[Sex differences in the integrated stroke management in a rural healthcare area in Asturias]. / Diferencias de sexo en el abordaje integral del ictus en un area sanitaria rural de Asturias.

INTRODUCTION: Sex differences and the (rural or urban) nature of populations largely determine the integrated management of time-dependent pathologies such as strokes, which is the main cause of female hospitalisation and mortality in our setting. AIM: To determine whether any differential characteristics can be observed between male and female stroke patients in a rural healthcare area in the Principality of Asturias. PATIENTS AND METHODS: A descriptive retrospective study was conducted at the Jarrio Hospital. Different variables were reviewed using the computerised medical records of patients who suffered a stroke in 2013. RESULTS: Altogether 126 patients were discharged, 53.2% among females, who suffered the disease with a five-year delay (p < 0.008) with respect to males. These latter smoked more and also drank harmful amounts of alcohol (p < 0.000). The pre-hospital delay did not yield any significant sex differences. Language disorder was the main symptom in the female group (p < 0.008), who scored higher on the National Institute of Health Stroke Scale (p < 0.046). Complementary studies, such as Holter monitoring (p < 0.04) and ultrasound scanning of the supra-aortic trunks (p < 0.02), are conducted less often in females, who mainly received conservative treatment with greater parenteral hydration (p < 0.017) and rest. The female group suffered more complications, disability at discharge (p < 0.001) and at three months (p < 0.004), and recorded higher percentages of subsequent institutionalisation (p < 0.005). CONCLUSIONS: There are demographic sex differences in the cerebrovascular risk profile, clinical presentation, hospital management and comorbidity of stroke in this rural population, which suggest that there are areas where there is room for improvement.

TITLE: Diferencias de sexo en el abordaje integral del ictus en un area sanitaria rural de Asturias.Introduccion. Las diferencias de sexo y el caracter (rural o urbano) de las poblaciones determinan en gran medida el abordaje integral de patologias dependientes del tiempo, como el ictus, principal causa de hospitalizacion y mortalidad femenina en nuestro medio. Objetivo. Determinar si en un area sanitaria rural del Principado de Asturias se ponen de manifiesto las caracteristicas diferenciales entre mujeres y hombres con ictus. Pacientes y metodos. Estudio descriptivo retrospectivo realizado en el Hospital de Jarrio. Se revisaron variables a traves de las historias clinicas informatizadas de los pacientes que sufrieron ictus en 2013. Resultados. Se produjeron 126 altas totales, el 53,2% en las mujeres, que sufrieron la enfermedad con un retraso de cinco años (p < 0,008) en relacion con los varones, los cuales fueron mas fumadores y consumidores perjudiciales de alcohol (p < 0,000). La demora prehospitalaria no arrojo diferencias de sexo significativas. El trastorno del lenguaje fue el sintoma principal en el grupo femenino (p < 0,008), que registro una puntuacion superior en la National Institute of Health Stroke Scale (p < 0,046). Los estudios complementarios, como el Holter (p < 0,04) y la ecografia de troncos supraaorticos (p < 0,02), se realizaron menos en las mujeres, que recibieron un tratamiento principalmente conservador con mayor hidratacion parenteral (p < 0,017) y reposo. El grupo femenino sufrio mas complicaciones, discapacidad al alta (p < 0,001) y a los tres meses (p < 0,004), y registro porcentajes mas elevados de institucionalizacion posterior (p < 0,005). Conclusiones. Existen diferencias de sexo demograficas, en el perfil de riesgo cerebrovascular, la presentacion clinica, el manejo hospitalario y la comorbilidad del ictus en esta poblacion rural, que sugieren areas de mejora.

Pulmonary valve endocarditis: mid-term follow up of pulmonary valvectomies.

Four males aged 20-37 years (three drug addicts and one with a congenital mixed pulmonary valve lesion) were diagnosed in 1989, 1991 and 1993 with pulmonary valve endocarditis without tricuspid infection. Three patients were positive for hepatitis B, C or both, and one patient was HIV-positive. The predominant organism in blood cultures was Staphylococcus aureus. Antibiotic treatment of pulmonary valve endocarditis had failed; thus partial or total valvectomies were performed. Postoperatively, all patients were cured of infection and initial recovery was good. At mid-term follow up (5-10 years) there were no recurrences, and tolerance of the resultant pulmonary insufficiency was good. Slight to severe tricuspid valve insufficiency developed, together with right ventricular dilatation, in all cases. Hepatomegaly was apparent in two cases and peripheral edema in one. Despite treatment, the latter patient remained in moderate right ventricular failure, and may require homograft valve replacement. The other three patients remained in good clinical condition. Eradication of the infection was achieved in all patients. It is concluded that pulmonary valve resection is the treatment of choice for pulmonary valve endocarditis when antibiotic treatment has failed. Complete resection of all affected tissue should be performed in these cases. Analysis of preoperative data did not permit differentiation of those patients likely to develop right heart failure.

Primary lymphomas of the heart in immunocompetent patients. Presentation of two cases with one 12 year survival. Analysis of surgical implications.

Two primary malignant lymphomas originating in the right heart cavities have been diagnosed and treated in our department: one, with additional right atrial and inferior vena cava thrombosis required emergency thrombectomy, incomplete excision and chemotherapy and survived 12 years, the other with extensive right ventricular infiltration and failure, died from mediastinitis and aplastic anaemia following surgery and chemotherapy. Quick diagnosis and treatment are indicated. If possible, surgery should be avoided.

Analysis of cocaine and cocaethylene in blood and tissues by GC-NPD and GC-ion trap mass spectrometry.

Cocaethylene, the ethyl homolog of cocaine, is an active cocaine metabolite found in cocaine users who simultaneously consume cocaine and ethanol. To study the combined incidence of cocaine and cocaethylene, an analytical method was devised that would simultaneously quantify both drugs in whole blood or tissues. The method includes a quantitative procedure by GC-NPD with a confirmation by ion trap mass spectrometry. Propylbenzoylecgonine, the propyl homolog of cocaine, was used as the internal standard. The quantitative method was linear from 0.05 to 10.0 mg/L with a limit of detection of 0.02 mg/L. Cocaethylene and propylbenzoylecgonine were synthesized in the laboratory. The complete analytical procedure and the method of synthesis are presented, along with brief descriptions of medical examiner cases where both cocaine and cocaethylene were quantified and where cocaethylene may have played a part in the cause of death. In the five cases presented, the cocaine concentration ranged from 0.03 to 1.4 mg/L and cocaethylene ranged from 0.03 to 0.53 mg/L in the blood.

Cocaethylene: a unique cocaine metabolite displays high affinity for the dopamine transporter.

Concurrent cocaine and alcohol use is common practice in the general population, as indicated by recent prevalence studies. In the presence of ethyl alcohol, cocaine is metabolized to its ethyl homolog, cocaethylene. The transesterification of cocaine and ethanol to cocaethylene takes place in the liver and represents a novel metabolic reaction. Cocaethylene was detected in postmortem blood, liver, and neurological tissues in concentrations equal to and sometimes exceeding those of cocaine. In vitro binding studies demonstrate that cocaethylene has a pharmacological profile similar but not identical to that of cocaine at monoamine transport sites assayed in the human brain. Cocaethylene was equipotent to cocaine at inhibiting [3H]mazindol binding to the dopamine transporter. The blockade of dopamine reuptake in the synaptic cleft by cocaethylene may account for the enhanced euphoria associated with combined alcohol and cocaine abuse.

Tissue distribution of cocaine in a pregnant woman.

Reports of cocaine-related obstetrical problems, including abruptio placentae and spontaneous abortion, have become increasingly evident in the medical literature; however, little is known about tissue distribution of cocaine in the pregnant woman. We report the toxicologic results of distribution studies performed on a pregnant woman and her fetus. Maternal/fetal cocaine concentration ratios were high when comparing blood (9:1), brain (6:5), and kidney (10:6). Possible explanations of the mechanism for lower fetal cocaine concentrations may include uterine vasoconstriction, incomplete maternal/fetal equalibration, or rapid placental/fetal clearance.

Isolated mitral valve replacement and ventricular rupture: presentation of 6 patients.

The cases of 6 patients who had ventricular wall rupture after isolated mitral valve replacement and were seen in our service are reviewed. In the first 2, the main lesion was mitral stenosis and calcification was severe. Injury to the ventricular myocardium during removal of the valve was the causative factor in 1 and the most likely explanation in the other. In the other 4 patients, the dominant lesion was insufficiency. Calcium was absent, and fibrosis of the valves was minimal. Defects of technique were not obvious. All perforations were beneath the annulus. The first of these 4 latter patients underwent operation just after cardioplegic solutions were introduced for myocardial protection in our service. During that period, the incidence of ventricular wall rupture was 7.3% for mitral valve replacement (55 patients). Causing 3 deaths, it became the most important mortality factor. After reviewing the problem, we decided to change our technique by leaving practically all the posterior leaflet and most of the chords intact and placing sutures through fibrous tissue only, never into muscle, as had already been suggested. Since then, we have not seen another rupture in 23 valve replacements.

[Congenital cystic adenomatoid malformation of the lung with systemic circulation (author's transl)]. / Malformación adenomatoidea quística pulmonar congénita con circulación sistémica.

A new observation of CCAML which systemic circulation is presented. At this occasion authors update literature review published in 1973. The total number of cases reported is 78 which our case has to be added. The existence of a systemic artery has only been demonstrated previously in three patients.

Removal of infected epicardial electrodes by traction.

Five patients who had infected cardiac pacemakers with epicardial electrodes have been managed by exteriorization of the pulse generator and placement of an endocardial unit. In each case the remaining electrode leads where detached from the myocardium and removed by simple traction, avoiding a surgical procedure. In 4 patients, sets of cables had been sutured to the myocardium through an anterior thoracotomy, in some instances using Teflon pledgets as buttresses. In one of these procedures a pericostal suture had been used to secure the leads from the thoracic cavity against the ribs. The remaining patient had received a subxiphoid pacemaker also implanted with sutures. This is a consecutive series, and we have had no failures so far. All pulse generator units were bipolar and located beneath either the pectoral or the rectus muscle. All of them were functioning properly when infection was diagnosed. This procedure constitutes an alternative method of management when more conservative techniques, such as closed irrigation and debridement, cannot be utilized.

Retroclavicular route for electrode placement in endocardial pacemakers.

In order to avoid skin erosion and electrode infection in endocardial pacemakers placed through the external jugular vein, we direct the wires from their point of entry into the vessel to the pacing unit placed in the pectoral region by dissecting a retroclavicular tunnel. This can be done under general or local anesthesia, and so far we have not seen any injuries to the subclavian vein. In this way the entire pathway of the cables is deep enough so that they cannot be palpated through the skin, and the dangers of exposure through erosion are minimized.