[Prognosis of patients with COVID-19 presenting acute ischaemic stroke and receiving interventional treatment]. / Pronóstico de pacientes COVID-19 con ictus isquémico y tratamiento neurointervencionista.

Objetivo: Presentar nuestra experiencia y analizar el pronóstico de pacientes COVID-19 con ictus isquémico agudo por oclusión de grandes vasos tratados con neurointervencionismo (NIV) en la unidad de ictus. Material y métodos: Se incluyeron todos los pacientes consecutivos con ictus isquémico agudo debido a oclusión de grandes vasos tratados por NIV en nuestra institución entre marzo y abril de 2020, durante el brote de COVID-19. Se realizó una comparación entre pacientes con COVID-19 y pacientes sin infección por coronavirus. Se comunican los resultados clínicos iniciales y a corto plazo. Resultados: Del 1 de marzo al 30 de abril se realizaron 25 procedimientos de NIV por ictus isquémico agudo en nuestra institución. Ocho pacientes eran COVID-19 y 17 eran pacientes no COVID-19. La edad media de los pacientes con COVID-19 fue de 70,1 ± 12,23 años, y 7 fueron hombres (87,5%, p = 0,006). Mientras que todos los pacientes sin COVID procedían de urgencias, solo 5 pacientes con COVID-19 (62,5%) fueron atendidos desde urgencias por ictus (p = 0,01). Tres pacientes procedían de hospitalización. La tasa de mortalidad en pacientes sin COVID-19 fue del 5,8%, pero en pacientes con COVID-19 fue considerablemente alta (50%). Ningún parámetro analítico difirió entre ambos grupos. No se registraron hemorragias en esta serie.En comparación con el mismo período del año pasado, se observó una disminución de la actividad neurointervencionista del 39%. Conclusiones: La mejor terapia médica y de NIV desembocó en malos resultados y una mortalidad dramática. La pandemia de COVID-19 dificultó significativamente el funcionamiento normal de los servicios de urgencias y la atención de estos pacientes con ictus.

Endovascular treatment of intracranial aneurysms using the Pipeline Flex embolization device: a case series of 30 consecutive patients.

BACKGROUND: The Pipeline Flex embolization device has some peculiarities in comparison with the previous generation device. Despite recent reports of the modified delivery system, its safety is still unknown. OBJECTIVE: To illustrate the intraprocedural and periprocedural complication rate with this new device in 30 consecutive patients. MATERIAL AND METHODS: Clinical, procedural, and angiographic data, including aneurysm size and location, device or devices used, angiographic and clinical data were analyzed. RESULTS: 30 patients harboring 30 aneurysms were analyzed. 39 devices were placed properly. Multiple Pipeline embolization devices (PEDs) were used in 7 cases. In 28 devices the distal end opened fully from the beginning with a complete wall apposition. In the remaining 11 devices, distal-end opening of the devices was instant but partial, but fully opened easily after recapture. Among the 30 procedures, recapture and reposition of the Pipeline Flex was performed four times owing to proximal migration/malposition of the device during delivery. Four intraprocedural/periprocedural complications occurred, of which 2 resulted in major complications, with neurologic deficits persisting for longer than 7 days. The 30-day morbidity rate was 6.6%, with no deaths. No aneurysm rupture or parenchymal hemorrhage was seen. CONCLUSIONS: The Pipeline Flex embolization device allows more precise and controlled deployment than the first-generation device. The number of devices and the complication rate during the learning curve are lower than reported with the first-generation PED. The new delivery system and the resheathing maneuvers do not seem to increase the intraprocedural complication rate in comparison with the first-generation PED.

Optimizing CIGB-300 intralesional delivery in locally advanced cervical cancer.

BACKGROUND: We conducted a phase 1 trial in patients with locally advanced cervical cancer by injecting 0.5 ml of the CK2-antagonist CIGB-300 in two different sites on tumours to assess tumour uptake, safety, pharmacodynamic activity and identify the recommended dose. METHODS: Fourteen patients were treated with intralesional injections containing 35 or 70 mg of CIGB-300 in three alternate cycles of three consecutive days each before standard chemoradiotherapy. Tumour uptake was determined using (99)Tc-radiolabelled peptide. In situ B23/nucleophosmin was determined by immunohistochemistry. RESULTS: Maximum tumour uptake for CIGB-300 70-mg dose was significantly higher than the one observed for 35 mg: 16.1 ± 8.9 vs 31.3 ± 12.9 mg (P = 0.01). Both, AUC24h and biological half-life were also significantly higher using 70 mg of CIGB-300 (P < 0.001). Unincorporated CIGB-300 diffused rapidly to blood and was mainly distributed towards kidneys, and marginally in liver, lungs, heart and spleen. There was no DLT and moderate allergic-like reactions were the most common systemic side effect with strong correlation between unincorporated CIGB-300 and histamine levels in blood. CIGB-300, 70 mg, downregulated B23/nucleophosmin (P = 0.03) in tumour specimens. CONCLUSION: Intralesional injections of 70 mg CIGB-300 in two sites (0.5 ml per injection) and this treatment plan are recommended to be evaluated in phase 2 studies.

Recombinant streptokinase suppositories in the treatment of acute haemorrhoidal disease. Multicentre randomized double-blind placebo-controlled trial (THERESA-2).

AIM: A four-arm multicentre randomized double-blind placebo-controlled trial was undertaken to assess the effect and safety of suppositories containing recombinant streptokinase (rSK) at two dose levels (100,000 IU and 200,000 IU) with sodium salicylate (SS) compared with placebo and SS for the treatment of acute haemorrhoidal disease. METHOD: Patients with acute symptoms of haemorrhoids were randomized to four treatment groups: (I) placebo, (II) SS, (III) SS + rSK 100,000 IU and (IV) SS + rSK 200,000 IU per suppository. Inpatient treatment was by four suppositories given every 6 h to discharge at 24 h. Evaluations were made at the time of discharge (24 h) and at 3, 5 and 20 days later. The main end-point was the degree of relief of pain, oedema and reduction in the size of the lesion by 90% on day 5. Adverse events and the occurrence of anti-SK antibodies were also determined. RESULTS: Eighty patients were included. Respective response rates in the four groups were 16%, 30%, 25% and 52%. In the last group there was a significant difference (36.8%) compared with control (95% CI 7.0-58.4%). The time to response was significantly shorter (median 5 days) in the 200,000 IU rSK group with respect to the others. There were no adverse events attributable to the treatment. No increase in anti-SK antibodies was detected 20 days after treatment. CONCLUSION: Suppositories with 200,000 IU rSK showed a significant improvement in symptoms of acute haemorrhoids, with an adequate safety profile.

[Methaemoglobinaemia in a healthy patient after using topical anaesthetic cream, for laser depilation]. / Metahemoglobinemia en una paciente sana tras administración tópica de anestésicos locales para depilación con láser.

Methaemoglobin is the oxidised form of haemoglobin containing iron in ferric state (Fe3+) that impairs oxygenation and produces metabolic acidosis. It may be hereditary or acquired (contact with external oxidising agents). Cyanosis, is the main symptom and itr does not respond to the external administration of oxygen. Co-oximetry helps in the final diagnosis. Methylene blue is the treatment of choice. We present the case of a 21 year old female with methaemoglobinemia after using topical lidocaine and prilocaine anaesthetic cream for laser depilation.

Y-stent-assisted coil embolization of anterior circulation aneurysms using two Solitaire AB devices: a single center experience.

Wide-neck intracranial aneurysms remain a challenge to endovascular treatment. We describe our experience in repairing wide-neck aneurysms of the anterior circulation located at arterial branch points using coil embolization assisted by Y-stenting using two Solitaire(®) stents.Six wide-neck intracranial aneurysms located on the middle cerebral artery bifurcation( 3), pericallosal artery( 1), and anterior communicating artery( 2) were repaired by Y-stent-assisted coil embolization using two Solitaire(®) stents. Four cases were incidental findings of aneurysm and two cases were previously treated ruptured aneurysms that had undergone recanalization. All the cases were successfully treated without complications. Follow-up by digital subtraction angiography and magnetic resonance angiography at six months showed the stents to be patent with no recanalization of the aneurysm sacs. Repairing wide-neck aneurysms of the anterior circulation by Y-stent-assisted coil embolization using two Solitaire(®) stents is a simple and safe method of treating complex aneurysms. While the results are promising, larger series with longer term follow-ups are needed to corroborate that this treatment method is superior to other techniques.

[Utility of the detection of nasal flaring in the assessment of severity of dyspnea]. / Utilidad de la detección del aleteo nasal en la valoración de la gravedad de la disnea.

OBJECTIVE: To determine if the presence of nasal flaring is indicative of severe respiratory insufficiency. METHODS: Prospective observational study of patients consulting in the Emergency Department because of dyspnea whose triage level is II or III in the Spanish Triage System (MAT-SET). Vital signs, SpO2, arterial blood gases and nasal flaring presence were recorded, as well as the need for hospital admission and length of hospital stay. Data are presented as median (25-75th percentile). RESULTS: A total of 43 patients were analyzed (70% men, aged 77 (67-82) years), 7 of whom showed nasal flaring. Those having flaring had higher respiratory rate (36 (34-40) vs. 25 (20-28) vs., p=0.001) and were more acidotic (pH 7.34 [7.23-7.40] vs. 7.42 [7.39-7.46] vs., p=0.03) than patients without this sign. There were no differences between groups in SpO2, PaCO2, heart rate and arterial pressure. There were no differences in the rate of hospital admission-(6 patients [85.7%] in nasal flaring group vs 29 patients [80.5%] in the non nasal flaring group [p=0,06], or in the length of the hospital stay-3 days [1-16] in nasal flaring group vs. 6 days [1-10] in the non nasal flaring group, p=0.6). All patients with nasal flaring had tachypnea. CONCLUSION: In our study, nasal flaring does not indicate severity in dyspneic patients in spite of its association with tachypnea and acidosis.

Treatment with type I interferons induces a regulatory T cell subset in peripheral blood mononuclear cells from multiple sclerosis patients.

Type I Interferon (IFN-alpha/beta) therapy has altered the natural course of multiple sclerosis. In this paper we evaluate the possible molecular mechanisms involved in the in vitro effects of IFN-alpha/beta on peripheral blood mononuclear cells from patients with clinically definite Relapsing-Remitting Multiple Sclerosis. The total RNA from IFN-alpha, IFN-beta treated cells and untreated cells was extracted and amplified for CD86, CD28, CTLA-4, TNF-alpha, IFN-gamma, CCL2, CCR5, IL-13, MMP-9, TIMP-1, CD25, TGF-beta, IL-10 and the transcriptional factor Foxp3 by Reverse Transcription-Polymerase Chain Reaction and the CD4+CD25high subset was evaluated using flow cytometry. In general, there were no significant differences concerning the modulation of the genes studied in the response to IFN-alpha and IFN-beta treatments, which suggest a similar mechanism of action for both interferons. However, we found a significant increment in IFN-gamma expression after IFN-alpha but not after IFN-beta treatments. The in vitro treatment of mononuclear cells from multiple sclerosis patients with both interferons significantly increased the CD25 mRNA. Furthermore, we observed a CD25/Foxp3 correlation and an increment of the CD4+CD25high subset, indicating that the induction of regulatory T cells could be a crucial mechanism involved in the type I interferon effects.

[Costs of spirometry as a screening test for chronic obstructive pulmonary disease in primary care]. / Costes de la espirometría como prueba de cribado en atención primaria de la enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To calculate the costs of COPD screening by simple spirometry, conducted in primary care, in smokers and ex-smokers over 40 years old. DESIGN: Descriptive study. Cost analysis. SETTING: Semi-rural health district covering some 6000 inhabitants. PARTICIPANTS: Randomised sample of 350 smokers and ex-smokers over 40 allocated to the centre. 73 were excluded on SEFAR criteria. INTERVENTIONS AND MEASUREMENTS: Simple spirometry was conducted with an automatic, portable, dry spirometer. Costs were calculated from the time needed, the material, human resources and the number of valid spirometer readings. RESULTS: 85% of 277 had a spirometry test. 18% of the spirometry readings were not valid. 3 spirometries an hour could be done: at least 1 was pathological and a bronchodilator test was needed. The cost of a spirometry, if a professional devotes 2 hours a day for 5 years, was 10.57 euros or 8.54 euros, for doctor or nurse, respectively. Modifying the number of spirometries per year or the number of professionals trained for such a technique causes only minor changes in cost. CONCLUSIONS: Optimal cost: 9000 spirometries a year by a single nurse. However, this would entail one nurse's almost exclusive dedication. Two trained professionals raises the cost slightly and distributes the work load better, enabling more hours to be covered. Before advising any COPD screening, its costs and its real possibility of affecting active smokers (the sole preventive possibility) should be carefully assessed.

Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of Sequential Organ Failure Assessment scores in decision making.

OBJECTIVE: This study examined the incidence and mortality of multiple organ dysfunction syndrome (MODS) in intensive care units, evaluated the limitation of life support in these patients, and determined whether daily measurement of the Sequential Organ Failure Assessment (SOFA) is useful for decision making. DESIGN AND SETTING: Prospective, observational study in 79 intensive care units. PATIENTS AND PARTICIPANTS: Of the 7,615 patients admitted during a 2-month period we found 1,340 patients to have MODS. MEASUREMENTS AND RESULTS: We recorded mortality and length of stay in the intensive care unit and the hospital and the maximum and minimum total SOFA scores during MODS. Limitation of life support in MODS patients was also evaluated. Stepwise logistic regression was used to determine the factors predicting mortality. The in-hospital mortality rate in patients with MODS was 44.6%, and some type of limitation of life support was applied in 70.6% of the patients who died. The predictive model maximizing specificity included the following variables: maximum SOFA score, minimum SOFA score, trend of the SOFA for 5 consecutive days, and age over 60 years. The model diagnostic yield was: specificity 100%, sensitivity 7.2%, positive predictive value 100%, and negative predictive value 57.3%; the area under the receiver operating characteristic curve was 0.807. CONCLUSIONS: This model showed that in our population with MODS those older than 60 years and with SOFA score higher than 9 for at least 5 days were unlikely to survive.

[Management of osteoporosis at a primary care center]. / Abordaje de la osteoporosis en un centro de atención primaria.

OBJECTIVES: To find how suitable a semFYC guide is for the indication of bone densitometry in menopausal women; and how appropriate their Osteoporosis treatment is. DESIGN: Cross-sectional study.Setting. Girona-3 Health District. PARTICIPANTS: Women between 50 and 80 allocated to the Girona-3 Health District. Suffering a grave psychiatric disorder or a terminal illness were considered criteria for exclusion. 409 out of the 420 women envisaged were included, to achieve a 5% accuracy and a 0.05% alpha error. MAIN MEASUREMENTS: Whether bone densitometry took place or otherwise, other diagnostic tests, risk factors for osteoporosis recorded and drug treatment prescribed. RESULTS: Of the 125 women with risk factors for osteoporosis, 12 (9.6%) had had a bone densitometry. 20% of all bone densitometries done showed pathology. Only in 3 cases (0.7%) of the pathological cases was any recommendation on life-style recorded. 19.8% of the women took drug treatment. In 8% this was justified. The most common treatment prescribed was calcium, on its own or linked to vitamin D. 20% of cases had a bone densitometry to monitor them after 2 years. CONCLUSIONS: The indication for bone densitometry is low and its use could be improved. In those cases in which bone densitometry is requested, a pharmacological intervention is more common than a life-style one.