Reactivity of Schiff base-[C,N,S] pincer palladacycles: hydrolysis renders singular trinuclear, tetranuclear, and heteropentanuclear Pd3W2 coordinated complexes.

Treatment of the Schiff base ligands a-f with Li2[PdCl4]/NaAcO in methanol under reflux gave the single nuclear palladacycles 1a-1f, with the metal atom bonded to a terdentate monoanionic [C,N,S] iminic ligand and to a chloride ligand that completes the palladium coordination sphere. Reaction of 1a-1c with silver perchlorate/triphenylphosphine in acetone at room temperature yielded the single nuclear complexes 2a-2c as the perchlorate salts, after substitution of the chloride ligand by a triphenylphosphine. However, reaction of a-c with Na2[PdCl4]/NaAcO in methanol at room temperature also gave compounds 1a-1c albeit contaminated with small amounts of the corresponding free aldehyde (mixture A). Reaction of mixture A with silver perchlorate/triphenylphosphine in acetone at room temperature gave analogously 2a-2c with some of the corresponding free aldehyde (mixture B). Attempts to purify mixtures A and B via recrystallization produced single crystals of 5 and 6 respectively: two serendipitously formed complexes, bearing thiomethyl aniline and/or acetate ligands, and void of aldehyde or iminic residue; the structures contain eight- and six-membered rings of alternating palladium and nitrogen atoms, respectively. To clarify this situation the aniline itself was reacted with palladium(II) acetate or with Na2[PdCl4]; in the latter case after recrystallization a unique behavior is revealed, giving rise to a tetranuclear complex containing a Pd4N4 ring with three differing coordination environments on the palladium atoms. Treatment of 1d with Ph2PCH2PPh2 (dppm)/AgClO4 or with Ph2PCH2(PPh2)W(CO)5/AgClO4 gave 3d, with a mono-coordinated dppm ligand, and 4d, respectively; complex 3d could not be converted into 4d by reaction with W(CO)5(THF). Recrystallization of 4d gave a still further noticeable species, complex 8: a pentanuclear trans-configured heterometallic mixed valent Pd(II)/W(0) linear complex with the palladium atoms supported by two acetate and two thiomethyl aniline bridging ligands. The complexes were fully characterized by microanalysis, IR, 1H, and 31P NMR spectroscopies, as appropriate. The X-ray single-crystal analyses for compounds 1b, 5, 6, 7 and 8 are described.

Sodium valproate treatment reverses endothelial dysfunction in aorta from rabbits with acute myocardial infarction.

Sodium valproate (VPA), a histone deacetylase (HDAC) inhibitor, could be a promising candidate to treat acute myocardial infarction (AMI). In this study, AMI was induced in New Zealand White rabbits by occluding the left circumflex coronary artery for 1 h, followed by reperfusion. The animals were distributed into three experimental groups: the sham-operated group (SHAM), the AMI group and the AMI + VPA group (AMI treated with VPA 500 mg/kg/day). After 5 weeks, abdominal aorta was removed and used for isometric recording of tension in organ baths or protein expression by Western blot, and plasma for the determination of nitrate/nitrite (NOx) levels by colorimetric assay. Our results indicated that AMI induced a reduction of the endothelium-dependent response to acetylcholine without modifying the endothelium-independent response to sodium nitroprusside, leading to endothelial dysfunction. VPA treatment reversed AMI-induced endothelial dysfunction and even increased NO sensitivity in vascular smooth muscle. This response was consistent with an antioxidant effect of VPA, as it was able to reverse the superoxide dismutase 1 (SOD 1) down-regulation induced by AMI. Our experiments also ruled out that the VPA mechanism was related to eNOS, iNOS, sGC and arginase expression or changes in NOx plasma levels. Therefore, we conclude that VPA improves vasodilation by increasing NO bioavailability, likely due to its antioxidant effect. Since endothelial dysfunction was closely related to AMI, VPA treatment could increase aortic blood flow, making it a potential agent in reperfusion therapy that can prevent the vascular damage.

Levamisole Impairs Vascular Function by Blocking α-Adrenergic Receptors and Reducing NO Bioavailability in Rabbit Renal Artery.

Levamisole is an anthelmintic drug restricted to veterinary use but is currently detected as the most widely used cocaine cutting agent in European countries. Levamisole-adulterated cocaine has been linked to acute kidney injury, marked by a decrease in glomerular filtration rate, which involves reduced renal blood flow, but data on the alteration of renovascular response produced by levamisole are scarce. Renal arteries were isolated from healthy rabbits and used for isometric tension recording in organ baths and protein analysis. We provide evidence that depending on its concentration, levamisole modulates renovascular tone by acting as a non-selective α-adrenergic receptor blocker and down-regulates α1-adrenoceptor expression. Furthermore, levamisole impairs the endothelium-dependent relaxation induced by acetylcholine without modifying endothelial nitric oxide synthase (eNOS) expression. However, exposure to superoxide dismutase (SOD) partially prevents the impairment of ACh-induced relaxation by levamisole. This response is consistent with a down-regulation of SOD1 and an up-regulation of NADPH oxidase 4 (Nox4), suggesting that endothelial NO loss is due to increased local oxidative stress. Our findings demonstrate that levamisole can interfere with renal blood flow and the coordinated response to a vasodilator stimulus, which could worsen the deleterious consequences of cocaine use.

Anatomical sphincteroplasty as a surgical treatment for faecal incontinence: proposal for a global anatomical reconstructive surgical procedure and results from a case series.

The aim of this study is to describe the technical details and clinical and functional results of anatomical sphincteroplasty as a global reconstructive surgery for the treatment of faecal incontinence caused by anal sphincter lesions. This was a prospective, longitudinal study that included patients who underwent the anatomical sphincteroplasty procedure described here to treat complete sphincter damage. We have described the different technical steps in detail. We evaluated the intraoperative and postoperative complications rate, Cleveland Clinic Score (CCS), a modification of the CCS that included soiling (mCCS), the Faecal Incontinence Quality of Life Scale (FIQLS), and patient satisfaction. An endoanal ultrasound and anorectal manometric study were performed in all the patients. Forty-four patients were included with a mean of 40.5 months follow-up. The CCS reduced from 15 to 3.3 points and the mCCS from 18.5 to 4.5 points over the study period; p < 0.001. Excellent or good results were achieved in 93% of cases. Endoanal ultrasounds showed a good sphincter repair in 66% of the cases. Anorectal manometry showed an increase in the mean maximal resting pressure from 27.6 mmHg to 41.7 mmHg and of the maximal squeeze pressure from 57.9 to 93 mmHg (p < 0.001) with respect to the preoperative values. Anatomical sphincteroplasty is a surgical proposal for the global anatomical reconstruction of anal sphincter lesions, even in cases of very severe damage. The procedure is safe and produced excellent clinical and functional results after a medium-term follow-up.

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology.

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Implicación de la isoforma antiangiogénica VEGF-A165b en la angiogénesis y la función sistólica tras un infarto de miocardio reperfundido / Role of antiangiogenic VEGF-A165b in angiogenesis and systolic function after reperfused myocardial infarction

Introducción y objetivos La angiogénesis participa en la restauración de la microcirculación después de un infarto agudo de miocardio (IAM). El objetivo de este estudio es explorar el papel que juega la isoforma anti-angiogénica del factor de crecimiento endotelial vascular (VEGF)-A165b y explorar su potencial como terapia coadyuvante a la reperfusión coronaria. Métodos Se realizaron dos modelos murinos de IAM: a) ligadura permanente de la arteria coronaria (IAM no reperfundido) y b) oclusión transitoria durante 45 minutos de la arteria coronaria seguida de reperfusión (IAM reperfundido); en ambos modelos, se realizó a los animales una ecocardiografía previa a la eutanasia el día 21 pos-IAM. Se determinaron los niveles séricos y miocárdicos de VEGF- A165b. En ambos modelos experimentales se evaluó la implicación funcional y estructural del bloqueo de esta isoforma. En una cohorte de 104 pacientes con IAM con elevación del segmento ST se cuantificaron los niveles circulantes de VEGF-A165b y se estudió su asociación con la fracción de eyección del ventrículo izquierdo determinada mediante resonancia magnética cardiaca a los 6 meses del IAM, así como con la aparición de eventos adversos (muerte, insuficiencia cardiaca o reinfarto) durante el seguimiento. Resultados En ambos modelos, los niveles séricos y tisulares de VEGF-A165b habían aumentado a los 21 días de la inducción del IAM. Además, existía una correlación negativa entre los valores circulantes de VEGF-A165b y la función sistólica evaluada mediante ecocardiografía. El bloqueo in vivo de VEGF-A165b se relacionó con una mayor densidad microvascular, menor tamaño de infarto y mejor fracción de eyección en el modelo de IAM reperfundido, pero no en el modelo de IAM no reperfundido. En la cohorte de pacientes, aquellos con unos niveles séricos elevados de VEGF-A165b presentaron una fracción de eyección deprimida y una mayor tasa de eventos adversos. Conclusiones ... (AU)

Introduction and objectives Angiogenesis helps to reestablish microcirculation after myocardial infarction (MI). In this study, we aimed to further understand the role of the antiangiogenic isoform vascular endothelial growth factor (VEGF)-A165b after MI and to explore its potential as a coadjuvant therapy to coronary reperfusion. Methods Two mice MI models were formed: a) permanent coronary ligation (nonreperfused MI); b) transient 45-minute coronary occlusion followed by reperfusion (reperfused MI); in both models, animals underwent echocardiography before euthanasia at day 21 after MI induction. We determined serum and myocardial VEGF-A165b levels. In both experimental MI models, we assessed the functional and structural role of VEGF-A165b blockade. In a cohort of 104 ST-segment elevation MI patients, circulating VEGF-A165b levels were correlated with cardiovascular magnetic resonance-derived left ventricular ejection fraction at 6 months and with the occurrence of adverse events (death, heart failure, and/or reinfarction). Results In both models, circulating and myocardial VEGF-A165b levels were increased 21 days after MI induction. Serum VEGF-A165b levels inversely correlated with systolic function evaluated by echocardiography. VEGF-A165b blockade increased capillary density, reduced infarct size, and enhanced left ventricular function in reperfused, but not in nonreperfused, MI experiments. In patients, higher VEGF-A165b levels correlated with depressed ejection fraction and worse outcomes. Conclusions In experimental and clinical studies, higher serum VEGF-A165b levels are associated with worse systolic function. Their blockade enhances neoangiogenesis, reduces infarct size, and increases ejection fraction in reperfused, but not in nonreperfused, MI experiments. Therefore, VEGF-A165b neutralization represents a potential coadjuvant therapy to coronary reperfusion. (AU)

Ataque cerebrovascular isquémico agudo de territorio anterior: Tratamiento endovascular / Acute ischemic stroke in anterior territory: endovascular treatment

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) ≤ 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS ≤ 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) ≤ 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS ≤ 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

Calidad de vida y balance sagital en la evolución de los pacientes con mieloma múltiple tratados con vertebroplastia percutánea / Quality of Life and Sagittal Balance in the Evolution of Patients with Multiple Myeloma Who Received Treatment

RESUMEN Introducción: El mieloma múltiple representa el 1 por ciento de las neoplasias y el 10 por ciento de las hemopatías malignas. La edad media de presentación es 65 años. El dolor óseo en columna vertebral y costillas constituye su manifestación inicial. El tratamiento quirúrgico del mieloma múltiple en la columna consiste en descompresión amplia y artrodesis. La vertebroplastia se considera técnica de elección porque restablece el balance sagital y coronal, contribuye al fortalecimiento del cuerpo vertebral, y disminuye el dolor asociado a fracturas. Objetivo: Evaluar el efecto de la vertebroplastia sobre la calidad de vida y el balance sagital, en la disminución del dolor. Métodos: Se estudiaron 192 pacientes con mieloma múltiple con fractura en la columna, 80 tratados con vertebroplastia y 112 en forma conservadora. Se utilizó el cuestionario de Oswestry y la escala de Karnosfky. Resultados: La vertebroplastia disminuyó 0,52 veces el uso de analgésicos opioides. Conclusiones: La vertebroplastia representa un mayor beneficio de la calidad de vida de los pacientes aquejados de mieloma múltiple con fractura vertebral; repercute en el mejoramiento del balance sagital, el nivel de discapacidad y la capacidad para realizar tareas cotidianas(AU)

ABSTRACT Introduction: Multiple myeloma accounts for 1 percent of neoplasms and for 10 percent of malignant hematomas. The mean onset age is 65 years. Bone pain in the spine and ribs is its initial manifestation. Surgical treatment for multiple myeloma in the spine consists in wide decompression and arthrodesis. Vertebroplasty is considered the choice technique because it restores sagittal and coronal balance, contributes to the strengthening of the vertebral body, and reduces pain associated with fractures. Objective: To assess the effect of vertebroplasty on quality of life and the effect of sagittal balance in reducing pain. Methods: 192 patients with multiple myeloma and spinal fracture were studied, 80 treated with vertebroplasty and 112 treated conservatively. The Oswestry questionnaire and the Karnofsky scale were used. Results: Vertebroplasty decreased the use of opioid analgesics by 0.52 times. Conclusions: Vertebroplasty represents a greater benefit for the quality of life of patients suffering from multiple myeloma with vertebral fracture. It affects the improvement of sagittal balance, the level of disability, and the ability to perform daily tasks(AU)

Retos, evidencia, ética y cirujanos. Lecciones aprendidas de la evolución reciente de la cirugía colorrectal / Challenges, evidence, ethics and surgeons: Lessons learned from the recent evolution of colorectal surgery

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Resultados oncológicos del Proyecto docente del Cáncer de Recto en España 10 años después de su inicio / Oncological results of the educational Rectal Cancer Project in Spain 10 years after its implementation

Introducción: El objetivo de este estudio observacional, prospectivo, multicéntrico y multinivel ha sido evaluar los resultados oncológicos (recidiva local, metástasis y supervivencia global) del Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos (AEC) 10 años después de su inicio, comparando los resultados con los registros escandinavos. Métodos: La base de datos del proyecto docente de la AEC incluye hasta la fecha a 17.620 pacientes, de los cuales 4.508 fueron operados con una resección potencialmente curativa entre marzo de 2006 y diciembre de 2010. Todos ellos son provenientes de los primeros 59 hospitales incluidos en el proyecto, y por tanto seguidos al menos durante 5 años, y constituyen el objeto del presente estudio. Resultados: La incidencia acumulada de recidiva local fue 7,3 (IC 95%: 8,2-6,5), la de metástasis fue 21,0 (IC 95%: 22,4-19,7) y la de supervivencia global, 72,3 (IC 95%: 80,3-77,6). El análisis de regresión multinivel, con la variable hospital como un efecto aleatorio, mostró una variación significativa entre los hospitales para las variables de resultado oncológico: supervivencia general, recidiva local y metástasis (Delta2=0,053). Conclusiones: Este estudio indica que los resultados observados en el Proyecto del Cáncer de Recto de la AEC son inferiores a los observados en los registros de Escandinavia a los que tratamos de emular y que ello es atribuible a la variabilidad de la práctica en algunos centros (AU)

Introduction: The objective of this observational, prospective, multicenter and multilevel study was to evaluate the oncological outcomes (local recurrence, metastasis and overall survival) of the Rectal Cancer Project of the Spanish Association of Surgeons (AEC) 10 years after its initiation, comparing the results with Scandinavian registries. Methods: The AEC teaching project database includes 17,620 patients to date, of which 4,508 were operated on with a potentially curative resection between March 2006 and December 2010. All of them come from the first 59 hospitals included in the project, and therefore followed for at least 5 years, and are the subject of the present study. Results: The cumulative incidence of local recurrence was 7.3 (95% CI: 8.2-6.5), metastasis 21.0 (CI 95%: 22.4-19.7) and overall survival 72.3 (CI 95%: 80.3-77.6). The multilevel regression analysis with the hospital variable as a random effect, showed a significant variation among the hospitals for the cancer outcome variables: general survival, local recurrence and metastasis (Delta2=0.053). Conclusions: This study indicates that the results observed in the AEC’ Rectal Cancer Project are inferior than those observed in the Scandinavian registries that we tried to emulate and that this is attributable to the variability of practice in some centers (AU)

Validación de la resonancia magnética pélvica como método de elección para determinar la distancia al margen anal en el cáncer de recto / Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer

Introducción: La altura exacta del tumor en el recto y sus relaciones anatómicas contribuyen a determinar la estrategia terapéutica multidisciplinar basada en la combinación de radio-quimioterapia y cirugía radical. Nuestro objetivo es valorar cuál es el método diagnóstico más preciso en la medición preoperatoria de la distancia al margen anal, y si la resonancia magnética pélvica (RM) puede sustituir a los métodos instrumentales clásicos. Métodos: Estudio prospectivo de precisión diagnóstica entre colonoscopia (CF), rectoscopia rígida (RRp) y RM en pacientes con indicación de cirugía radical. La RRp intraoperatoria fue considerada la prueba de referencia. Se analizaron las correlaciones entre las distintas técnicas y su coeficiente de determinación, así como el coeficiente de correlación intraclase y el grado de acuerdo entre los distintos test. Resultados: Se incluyeron 96 pacientes con edad media (DE) de 68 (14,1) años y predominio de varones (65%). Un 72% recibió tratamiento neoadyuvante. La distancia media al margen anal, medida mediante CF=103,5mm, fue significativamente mayor al resto, que obtuvieron valores similares: RRp=81,1, RM=77,4, RRp intraoperatoria=82,9mm (p<0,001). Se objetivó una significativa correlación intraclase y hubo un elevado acuerdo entre todas las mediciones pre e intraoperatorias a excepción de la realizada mediante CF, que sobreestimó el resultado. La RM aportó información más individualizada y precisa. Conclusiones: Existe variabilidad entre los métodos de medición, siendo la colonoscopia el menos fiable. La RM ofrece valores objetivos, comparables, precisos e individualizados que pueden sustituir a los obtenidos por RR en tumores de cualquier localización del recto. (AU)

Introduction: Distance from anal verge of rectal tumors and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumors and if the pelvic MRI can substitute the classical instrumental methods. Methods: Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. Results: 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC=103.5mm, was significantly greater than others, which had similar values: pRR=81.1; MRI=77.4; iRR=82.9mm (P<.001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. Conclusions: There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumors of any location in the rectum. (AU)

Enfermedad diverticular complicada: toma de posición sobre tratamiento ambulatorio, intervención de Hartmann, lavado-drenaje peritoneal y cirugía laparoscópica. Documento de consenso de la Asociación Española de Coloproctología y Sección de Coloproctología de la Asociación Española de Cirujanos / Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons

Desde la Asociación Española de Coloproctología (AECP) y la Sección de Coloproctología de la Asociación Española de Cirujanos (AEC), se propone un documento de consenso sobre la enfermedad diverticular complicada que pueda ser de utilidad en la toma de decisiones. En él se expone, principalmente, la actualidad en el tratamiento ambulatorio, la intervención de Hartmann, el lavado laparoscópico peritoneal, así como el papel del abordaje laparoscópico en la resección colónica (AU)

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed (AU)

Proyecto docente del cáncer de recto y concentración de procedimientos: comparación entre los resultados oncológicos en Cataluña con los obtenidos en el resto de comunidades autónomas / A teaching project on rectal cancer and concentration of procedures: a comparison of oncological results between Catalonia and the rest of autonomous communities

Introducción: el objetivo de este estudio es comparar los resultados oncológicos (recidiva local, metástasis y supervivencia global) del Proyecto Docente del Cáncer de Recto de la Asociación Española de Cirujanos (Proyecto Vikingo [PV]) en Cataluña con los obtenidos en el resto de comunidades autónomas (CC. AA.). Métodos: la base de datos del PV incluye 4.508 pacientes operados con una resección curativa entre marzo de 2006 y diciembre de 2010 (1.163 en Cataluña y 3.345 en el resto de España), provenientes de los primeros 59 hospitales incluidos en el PV con un seguimiento mínimo de cinco años. Resultados: la incidencia acumulada a cinco años de recidiva local en Cataluña fue del 8% (IC 95%: 6,4-9,9); de metástasis, del 17,7% (IC 95%: 15,4-20,2); y de supervivencia global, del 75% (IC 95%: 72,4-77,7). La incidencia de recidiva local en el resto de CC. AA. fue del 7% (IC 95%: 6,2-8,2); de metástasis, del 22,3% (IC 95%: 20,7-23,9); y de supervivencia global, del 71% (IC 95%: 69,4-72,9). La intervención de Hartmann, la perforación intraoperatoria y la afectación del margen circunferencial fueron las variables asociadas con recurrencia tumoral en el PV. Conclusión: los resultados observados en el Proyecto del Cáncer de Recto entre Cataluña y el resto de comunidades son homogéneos

Introduction: the goal of this study was to compare the oncological results (local recurrence, metastasis and overall survival) obtained by the Proyecto Docente del Cáncer de Recto of the Spanish Association of Surgeons (AEC) (Proyecto Vikingo, PV) in Catalonia versus the rest of Spanish autonomous communities. Methods: the PV database includes 4,508 patients who underwent a curative resection between March 2006 and December 2010, from the first 59 hospitals included in PV; 1,163 were from Catalonia and 3,345 were from the rest of Spain. There was a minimum follow-up of five years. Results: in Catalonia, the five-year cumulative incidence was 8% (95% CI: 6.4-9.9) for local recurrence, 17.7% (95% CI: 15.4-20.2) for metastasis and 75% (95% CI: 72.4-77.7) for overall survival. In the rest of autonomous communities, these figures were 7% (95% CI: 6.2-8.2) for local recurrence, 22.3% (95% CI: 20.7-23.9) for metastasis, and 71% (95% CI: 69.4-72.9) for overall survival. Variables associated with tumor recurrence in PV included Hartmann's procedure, intraoperative perforation and circumferential margin involvement. Conclusion: the results obtained by the Proyecto Docente del Cáncer de Recto were homogeneous between Catalonia and the rest of the autonomous communities

Pérdida de visión / Loss of sight

Paciente varón de 81 años que acude a urgencias refiriendo pérdida de visión en el campo visual superior izquierdo desde hace unos días. A la exploración oftalmológica, se evidenciaba ausencia de percepción de luz en el campo superior del ojo izquierdo. En el fondo de ojo aparecía una masa retiniana con origen a nivel nasal inferior. Se realiza una ecografía, donde se identifica una lesión ocupante de espacio (melanoma coroideo) con desprendimiento de retina asociado (AU)

81 year old male patient who went to the emergency department after beginning to suffer loss of sight in the upper left visual field two days earlier. On ophthalmic examination, absence of light perception was evident in the upper left eye field. At the back of the eye there was a a retinal mass originating at lower nasal level. An ultra sound was performed and a space occupying lesion (choroidal melanoma) with associated retinal detachment was identified (AU)

Utilidad de la presencia y el tipo de placa carotídea en la predicción de eventos cardiovasculares en pacientes de riesgo alto / Usefulnes of the Presence and Type of Carotid Plaque to Predict Cardiovascular Events in High-Risk Patients

Introducción La ateromatosis carotídea es una alteración temprana de la aterosclerosis subclínica que puede determinarse en forma rápida, económica, repetible y no invasiva. Su correlación anatómica y su asociación con los factores de riesgo y diferentes manifestaciones de aterosclerosis avanzada se han demostrado claramente. En la actualidad, la ateromatosis carotídea se utiliza con frecuencia creciente para caracterizar al paciente con factores de riesgo y para evaluar resultados terapéuticos mediante la determinación del grosor íntima-media carotídeo y de la presencia y el tipo de placas bulbares, ya que se ha demostrado su valor predictivo independiente para eventos isquémicos tanto coronarios como cerebrovasculares. Objetivos Determinar si la presencia y el tipo de placa carotídea (PC) agregan información para predecir futuros eventos cardiovasculares en pacientes de riesgo alto. Material y métodos Se estudiaron 502 pacientes de riesgo alto (múltiples factores de riesgo o antecedente de evento vascular) mediante la determinación del grosor íntima-media máximo (GIMmáx), la presencia (elevación localizada) y el tipo de PC según apariencia ecográfica (fibrocálcica o fibrolipídica), la reactividad humeral dependiente del endotelio (RDE, valor basal arteria humeral vs. a los 5 min de isquemia braquial). Se consideró anormalidad la presencia y el tipo de PC, el GIMmáx > 1,1 mm y la RDE < 5%. Los puntos finales incluyeron la ocurrencia de eventos vasculares o de muerte. Los marcadores de enfermedad vascular se analizaron junto con factores de riesgo (FR) clásicos (edad, diabetes, hipertensión, dislipidemia, tabaquismo y componentes del síndrome metabólico) por el método de riesgos proporcionales de Cox y curvas de Kaplan-Meier. Resultados Edad media 65,5 ± 8,8 años, 354 hombres, 43 eventos durante un seguimiento promedio de 21 meses. Fueron predictores de eventos la PC (RR 5,6; p < 0,001), la dislipidemia (RR 5,5; p < 0,005), el GIMmáx (RR 3,2; p < 0,005), la edad > 65 años (RR 2,7; p < 0,003), la hipertensión sistólica (RR 2,5; p < 0,025), el C-HDL < 50 mg/dl (RR 2,4; p < 0,01), el síndrome metabólico (RR 2,2; p < 0,02), la trigliceridemia > 130 mg/dl (RR 2,1; p < 0,02). Ajustado por los FR, el predictor más potente resultó la PC (RR 3,13; p < 0,05). Los individuos sin PC presentaron un 2,3% de eventos, con PC fibrolipídica un 8,8% y con PC fibrocálcica un 13,4% (p < 0,001). Conclusiones Marcadores de enfermedad vascular temprana, como la presencia y el tipo de PC y el GIMmáx, agregan información pronóstica independiente a los FR. La RDE no agregó información en este grupo. Una metodología simplificada de estudio no invasivo como la empleada puede ser de utilidad clínica en la evaluación del riesgo de eventos vasculares.

Background Carotid atheromatosis is an early manifestation of subclinical atherosclerosis that can be determined in a rapid, economic, repeatable and non-invasive fashion. The anatomic correlation and its association with risk factors and different manifestations of advanced atherosclerosis have been clearly demonstrated. The determination of the intima-media thickness and the presence and type of plaques in the carotid bulb are used to assess carotid atheromatosis in patients with risk factors and to evaluate response to treatment, as this method has an independent predictive value for ischemic coronary and cerebrovascular ischemic events. Objectives To determine whether the presence and type of carotid plaques (CPs) add any information to predict future cardiovascular events in high-risk patients. Material and Methods A total of 502 high-risk patients (with multiple risk factors or history of vascular event) underwent ultrasound evaluation of maximum intima-media thickness (IMTmax), presence (localized protrusion of the vessel wall) and type of (fibrocalcific plaque or fibrolipid plaque) CP, flow mediated dilation of the brachial artery (FMD, brachial artery diameter recorded at baseline and after 5 minutes of brachial ischemia). The following variables were considered abnormal: presence and type of CP, IMTmax >1.1 and FMD <5%. Endpoints included vascular events or mortality. Markers of vascular disease and traditional risk factors (RFs) (age, diabetes, hypertension, dyslipemia, smoking habits and components of the metabolic syndrome) were analyzed together using Cox proportional-hazards regression model and Kaplan-Meier curves. Results Mean age was 65.5±8.8 years and 354 were men; 43 events occurred during an average follow-up of 21 months. The presence of CP (RR 5,6; p <0.001), dyslipemia (RR 5.5; p <0.005), IMTmax (RR 3.2; p <0.005), age > 65 years (RR 2.7; p <0.003), systolic hypertension (RR 2.5; p <0.025), HDL-C <50 mg/dl (RR 2.4; p <0.01), metabolic syndrome (RR 2.2; p <0.02), and triglyceride levels >130 mg/dl (RR 2.1; p <0.02) were predictors of events. After adjusting for RFs, PC was the most powerful predictor (RR 3.13; p <0.05). The incidence of events was 2.3% in the absence of CP, 8.8% with fibrolipid plaque, and 13.4% with fibrocalcific plaque p <0.001). Conclusions The presence and type of CP anf IMTmax are markers of early vascular disease providing prognostic information independent of RFs. FMD did not provide additional information in this group. This simple, non-invasive method may be clinically useful in the evaluation of the risk of vascular events.

Cardiogenic shock due to citomegalovirus myocarditis: successful clinical treatment / Choque cardiogênico devido à miocardite por citomegalovírus: terapêutica clínica com sucesso

OBJECTIVE: Cytomegalovirus (CMV) systemic disease and myocarditis in healthy persons is infrequently reported in the literature, although in increasing numbers in recent years. The importance of the recognition of the syndrome that usually has an initial picture of a mononucleosis like infection in an otherwise healthy person, is the available therapeutic agent, ganciclovir, that can cure the infectious disease. METHODS: We analyzed the clinical result of pulsotherapy with steroids in a patient with CMV myocarditis after 7 days of etiological treatment, with ganciclovir, intravenous vasodilators, and the conventional treatment for congestive heart failure. RESULTS: The clinical condition of the patient improved accordingly to the better function of the left ventricle, and the ganciclovir was kept for 21 days, most of it in an out patient basis. The patient was dismissed from the hospital, with normal myocardial function. CONCLUSION: Potentially curable forms of myocarditis, like M pneumoniae and CMV, for example, can have an initial disproportionate aggression to the myocardium, by the acute inflammatory reaction, that can by itself make worse the damage to the LV function. In our opinion, the blockade of this process by pulsotherapy with steroids can help in the treatment of these patients. We understand that the different scenario of immunosuppressive treatments for the possible auto immunity of the more chronic forms of the presumably post viral cardiomyopathy has been in dispute in the literature, and has stolen the focus from the truly acute cases.

OBJETIVO: Doença sistêmica por citomegalovírus (CMV) com miocardite em pessoas saudáveis é raramente referida na literatura, apesar de em maior número em anos recentes. A importância do reconhecimento da síndrome, que usualmente tem um quadro inicial "mononucleosis like" em uma pessoa sadia é a disponibilidade do agente terapêutico ganciclovir, que pode curar a infecção. MÉTODOS: Nós analisamos o resultado da pulsoterapia com esteróides em um paciente com miocardite por CMV, após 7 dias de tratamento etiológico com ganciclovir, vasodilatadores intravenosos e o tratamento convencional para insuficiência cardíaca congestiva. RESULTADOS: A condição clínica do paciente melhorou com a melhor função do ventrículo esquerdo e o ganciclovir foi mantido por 21 dias após alta hospitalar.A função miocárdica retornou ao normal. CONCLUSÃO: Formas curáveis de miocardites como M pneumonia e CMV, por exemplo, podem ter uma agressão grave ao miocárdio por uma ação inflamatória que pode piorar a função cardíaca. Em nossa opinião, o bloqueio deste processo pela pulsoterapia com esteróides pode auxiliar no tratamento destes pacientes. Entendemos que existe um cenário diferente de tratamento com imunossupressores para possível agressão auto-imune das formas mais crônicas de cardiomiopatias dilatadas e isso está em disputa na literatura, talvez mudando o foco dos casos realmente agudos.

Experiência com transplante cardíaco heterotópico em pacientes com resistência pulmonar elevada: seguimento tardio / Experiencia con trasplante cardíaco heterotópico en pacientes con resistencia pulmonar elevada: seguimiento tardío / Experience with heterotopic heart transplantation in patients with elevated pulmonary vascular resistance: late follow-up

FUNDAMENTO: Nos últimos anos o numero de artigos sobre transplante cardíaco heterotópico tem sido escasso na literatura, inclusive internacional, e em particular do seguimento de longo prazo destes pacientes, o que levou ao presente relato. OBJETIVO: Relatar a experiência clínica inicial e evolução tardia de quatro pacientes submetidos a transplante cardíaco heterotópico, sua indicação e principais complicações. MÉTODOS: As cirurgias ocorreram entre 1992 e 2001, sendo que a indicação de transplante heterotópico, em todas, foi pela RVP, variável de 4,8UW a 6.5UW, com gradiente transpulmonar acima de 15mmHg. No 3º paciente, foi realizada uma anastomose direta entre as artérias pulmonares sem emprego de tubo protético e, no coração nativo, foi realizada uma valvoplastia mitral e aneurismectomia de ventrículo esquerdo (VE). O esquema imunossupressor imediato foi duplo com ciclosporina e azatioprina nos três primeiros pacientes e ciclosporina e micofenolato mofetil no 4º paciente. RESULTADOS: Um óbito imediato por falência do enxerto, um óbito após dois anos e meio por endocardite em trombo intraventricular no coração nativo, e um terceiro óbito seis anos após o transplante, por complicações pós-operatórias de cirurgia na valva aórtica do coração nativo. O remanescente, 15 anos após o transplante, encontra-se bem, em classe funcional II (NYHA), seis anos após a oclusão cirúrgica da valva aórtica do coração nativo. CONCLUSÃO: O transplante cardíaco heterotópico é um procedimento com resultado inferior ao transplante cardíaco ortotópico, por apresentarem maior RVP. Os trombos intraventriculares no coração nativo, que exigem anticoagulação prolongada, bem como as complicações de válvula aórtica, também no coração nativo, podem exigir tratamento cirúrgico. Entretanto, em um paciente, a sobrevida de 15 anos mostrou a eficácia de longo prazo desse tipo de alternativa, para pacientes selecionados.

BACKGROUND: Along the past few years the number of papers on heterotopic cardiac transplant has been very scarce in the medical literature, including at the international level; this is particularly true in reference to the long term follow-up of these patients and the reason which led to the presentation of our report. OBJECTIVE: To report the initial clinical experience and late evolution of 4 patients undergoing heterotopic heart transplantation, indications for this procedure and its major complications. METHODS: The surgeries were performed between 1992 and 2001, and all had as indication for heterotopic transplantation the PVR, which ranged from 4.8 WU to 6.5WU, with a transpulmonary gradient above 15mmHg. In the 3rd patient, a direct anastomosis between the pulmonary arteries was performed without the use of a prostetic tube, and a mitral valvuloplasty and a LV aneurysmectomy were performed in the native heart. The immediate immunosuppressive regimens were double, with cyclosporine and azathioprine in the first 3 patients, and cyclosporine and mycophenolate mofetil in the 4th patient. RESULTS: One immediate death occurred from graft failure, one death occurred after 2 ½ years, from endocarditis in an intraventricular thrombus in the native heart, and a third death occurred 6 years after transplantation, from post-operative complications of the aortic valve surgery in the native heart. The remaining patient is well, 15 years after the transplantation. This patient is in functional class II (NYHA), 6 years after a surgical occlusion of the native heart aortic valve. CONCLUSION: Heterotopic heart transplantation results are inferior to those of orthotopic heart transplantation because they present higher RVP. The intraventricular thrombi, in the native heart, which require prolonged anticoagulation, and aortic valve complications, also in the native heart, may require surgical treatment. However, a patient's 15-year survival has demonstrated ...

FUNDAMENTO: En los últimos años el número de artículos sobre trasplante cardíaco heterotópico y, en particular, del seguimiento a largo plazo de estos pacientes, ha sido escaso en la literatura, inclusive internacional, lo que llevó al presente relato. OBJETIVO: Relatar la experiencia clínica inicial y la evolución tardía de cuatro pacientes sometidos a trasplante cardíaco heterotópico, su indicación y principales complicaciones. MÉTODOS: Las cirugías se realizaron entre 1992 y 2001, y la indicación de trasplante heterotópico, en todas, fue mediante RVP, variable de 4,8 UW; a 6.5 UW, con gradiente transpulmonar superior a 15 mmHg. En el tercer paciente, se realizó una anastomosis directa entre las arterias pulmonares sin empleo de tubo prostético, y, en el corazón nativo, se realizó una valvuloplastia mitral y aneurismectomía de VI. El esquema inmunosupresor inmediato fue doble, con ciclosporina y azatioprina en los tres primeros pacientes y ciclosporina y micofenolato mofetil en el cuarto paciente. RESULTADOS: Un óbito inmediato por falla del injerto, un óbito luego de dos años y medio por endocarditis en trombo intraventricular en el corazón nativo, y un tercer óbito seis años después del trasplante, por complicaciones postoperatorias de una cirugía en la válvula aórtica del corazón nativo. El restante, 15 años después del trasplante, se encuentra bien, en clase funcional II (NYHA), seis años después de una oclusión quirúrgica de la válvula aórtica del corazón nativo. CONCLUSIÓN: El trasplante cardíaco heterotópico es un procedimiento con resultado inferior al trasplante cardíaco ortotópico, por presentar mayor RVP. Los trombos intraventriculares en el corazón nativo, que exige anticoagulación prolongada, así como las complicaciones de válvula aórtica, también en el corazón nativo, pueden exigir tratamiento quirúrgico. Sin embargo, en un paciente, la sobrevida de 15 años mostró la eficacia a largo plazo de este tipo de alternativa, ...

¿Hay neurogénesis en la médula espinal adulta?: del módelo animal al paciente / No disponible

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Transplante cardíaco em amiloidose primária / Heart transplantation in primary amyloidosis

A amiloidose cardíaca é doença altamente limitante da sobrevida, por morte súbita na maioria dos pacientes. Pela agressão contra outros órgãos, particularmente rins e sistema nervoso central, o transplante cardíaco tem sido opção questionável, face à escassez de órgãos. O objetivo é relatar a evolução, com sobrevivência de 7 anos, da paciente após transplante cardíaco por amiloidose, em boas condições. Um ano após o transplante cardíaco, houve indicação de transplante renal, também pela agressão da doença. Esta paciente contrasta com outros três pacientes de nosso serviço que foram a óbito, ainda na fase de avaliação. Apesar de sua natureza multisistêmica, a amiloidose cardíaca pode, em pacientes selecionados, justificar o transplante cardíaco, pela gravidade do seu potencial evolutivo após o início dos sintomas

Cardiac amyloidosis is a disease with a gloom life expectance after the beginning of the symptomatic phase, usually with sudden death as the final event. The aggression to other organs, although, can make heart transplantation a disputable form of treatment taking into consideration the shortage of donor organs. The aim is to report the evolution with a survival of seven years after heart transplantation and in very fair condition of a patient with amyloidosis. One year after the heart transplantation, there was indication of renal transplantation also from the aggression from the disease. This patient compares' favorable with three other patients also from our service, who died early after de diagnosis. Even considering the multi systemic nature of amyloidosis, we can accept that in peculiar patients justified the heart transplantation, taking in the consideration the very bad prognosis of the disease

Comprensión lectora y procesos ejecutivos de la memoria operativa / Reading comprehension and working memory's executive processes

En el presente trabajo se estudiaron las relaciones entre los procesos ejecutivos de la memoria operativa, lainteligencia fluida y la comprensión lectora en una muestra de 77 escolares de 3º de Educación Primaria.Asimismo, se analizó la capacidad predictiva de la MO y de la inteligencia fluida con respecto al rendimientoen comprensión lectora. Como se predijo, los resultados mostraron un patrón de correlaciones positivasy significativas: las medidas de comprensión lectora -en particular, inferencias e integración- correlacionaroncon las medidas de los procesos ejecutivos de la MO y de inteligencia fluida. Los análisis de regresiónmostraron que las habilidades cognitivas de alto nivel -actualización semántica en la MO e inteligenciafluida- contribuyen de manera independiente a explicar el 33 % de la varianza en comprensión lectora

The aim of this paper is focused on the relationship of executive processes of working memory and fluidintelligence with reading comprehension, in a group of 77 third-grade primary students. Moreover, westudied the predictive capacity of working memory and fluid intelligence on reading comprehension. Aspredicted, there was a pattern of positive and significant correlations: reading comprehension measures -particularly, inferences and integration- correlated with working memory´s executive processes and fluidintelligence measures. Regression analyses showed that this highest cognitive variables -particularly,semantic updating in working memory, and intelligence- contributed independently to explain a relevantamount of the variance ( 33 %) in reading comprehension measures