GECOP-MMC: phase IV randomized clinical trial to evaluate the efficacy of hyperthermic intraperitoneal chemotherapy (HIPEC) with mytomicin-C after complete surgical cytoreduction in patients with colon cancer peritoneal metastases.

BACKGROUND: The French PRODIGE 7 trial, published on January 2021, has raised doubts about the specific survival benefit provided by HIPEC with oxaliplatin 460 mg/m2 (30 minutes) for the treatment of peritoneal metastases from colorectal cancer. However, several methodological flaws have been identified in PRODIGE 7, specially the HIPEC protocol or the choice of overall survival as the main endpoint, so its results have not been assumed as definitive, emphasizing the need for further research on HIPEC. It seems that the HIPEC protocol with high-dose mytomicin-C (35 mg/m2) is the preferred regime to evaluate in future clinical studies. METHODS: GECOP-MMC is a prospective, open-label, randomized, multicenter phase IV clinical trial that aims to evaluate the effectiveness of HIPEC with high-dose mytomicin-C in preventing the development of peritoneal recurrence in patients with limited peritoneal metastasis from colon cancer (not rectal), after complete surgical cytoreduction. This study will be performed in 31 Spanish HIPEC centres, starting in March 2022. Additional international recruiting centres are under consideration. Two hundred sixteen patients with PCI ≤ 20, in which complete cytoreduction (CCS 0) has been obtained, will be randomized intraoperatively to arm 1 (with HIPEC) or arm 2 (without HIPEC). We will stratified randomization by surgical PCI (1-10; 11-15; 16-20). Patients in both arms will be treated with personalized systemic chemotherapy. Primary endpoint is peritoneal recurrence-free survival at 3 years. An ancillary study will evaluate the correlation between surgical and pathological PCI, comparing their respective prognostic values. DISCUSSION: HIPEC with high-dose mytomicin-C, in patients with limited (PCI ≤ 20) and completely resected (CCS 0) peritoneal metastases, is assumed to reduce the expected risk of peritoneal recurrence from 50 to 30% at 3 years. TRIAL REGISTRATION: EudraCT number: 2019-004679-37; Clinicaltrials.gov: NCT05250648 (registration date 02/22/2022, ).

COVID 19 comprehensive management in a regional hospital of Northwestern Spain.

INTRODUCTION: The COVID-19 pandemic has brought about a paradigm shift in healthcare. OBJECTIVE: To evaluate the utility of a strategy to comprehensively address the pandemic in a health area that covers 42,000 people. METHOD: Between March 10 and May 15, 2020, the COVID Unit was created in the corresponding regional hospital, and an independent circuit was established for the diagnosis and management of patients with suspected or confirmed COVID-19; social health centers were monitored with PCR testing. RESULTS: Eighteen COVID-19-positive patients (age 72.9 ± 13.2 years) were admitted, out of which 66% were males. All these patients had pneumonia and 67% had respiratory distress syndrome; no one required mechanical ventilation. Mean hospital stay was 9.4 ± 5.3 days, and mortality, 11%. PCR tests were applied to all hospital residents (n = 827) and workers (n = 519), 1,044 phone calls were made and 36 hospital admissions were avoided. Only 50 patients required close follow-up, out of which four (0.48%) were positive for COVID-19. CONCLUSION: Clinical monitoring at the hospital and social health centers showed that patient profile was like that documented in the literature and that the incidence of COVID-19 was low in social health centers.

INTRODUCCIÓN: La pandemia de COVID-19 provocó un cambio de paradigma en la atención médica. OBJETIVO: Evaluar una estrategia para abordar integralmente la pandemia en un distrito de salud que comprende 42 000 personas. MÉTODO: Entre el 10 de marzo y 15 de mayo de 2020 se creó la Unidad COVID en un hospital regional correspondiente al distrito y se estableció un circuito independiente para el diagnóstico y manejo de pacientes con sospecha o confirmación de COVID-19; los centros de salud social fueron monitoreados mediante PCR. RESULTADOS: Ingresaron 18 pacientes positivos a COVID-19 (edad de 72.9 ± 13.2 años), 66 % eran hombres; todos presentaron neumonía, 67 % desarrolló síndrome de dificultad respiratoria y ninguno requirió ventilación mecánica. La estancia hospitalaria fue de 9.4 ± 5.3 días y la mortalidad, de 11 %. Se realizaron pruebas de PCR a todos los residentes (n = 827) y trabajadores (n = 519) del hospital, se realizaron 1044 llamadas telefónicas y se evitaron 36 hospitalizaciones. Solo 50 pacientes necesitaron seguimiento cercano, cuatro (0.48 %) positivos a COVID-19. CONCLUSIÓN: El monitoreo clínico en el hospital y centros de salud social mostró que el perfil de los pacientes fue similar al documentado en la literatura y que la incidencia de COVID-19 fue baja en los centros sociales de salud.

Clipping for endoscopic perforations: initial success but late complication requiring surgery.

INTRODUCTION: This response discusses the article by Kim and colleagues entitled "endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients". Iatrogenic colonoscopic perforation, although uncommon, implies serious management problems for endoscopists and surgeons. Nonoperative treatment currently is recommended under certain conditions, and endoscopic clips can primarily close iatrogenic perforations, helping to avoid surgery. Of the 27 colonoscopic perforation cases presented in the article by Kim and colleagues, 16 were managed by endoscopic clipping closure and 11 by primary surgery. Conservative treatment failed for three patients. Only perforation size obtained statistical significance among the nine variables contrasted between the 11 cases with primary surgery and the 13 cases with successful endoscopic clipping. The results for the three patients whose endoscopic closure failed are not reported. AUTHORS' OPINION: The authors of this letter think it would have been interesting if these three patients had been included in the analysis due to the high importance of discovering factors that can predict failure of endoscopic clipping for perforations. CONCLUSIONS: To call attention to possible late complications requiring surgery even when initial conservative management of endoscopic perforation succeeds, the authors of this letter present a case of a colocutaneous (actually, sigmoid-scrotal) fistula in a patient 2 weeks after an apparently successful closure of colonoscopic perforation with an "over-the-scope" clip.

Treatment of Peritoneal Surface Malignancies by Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Spain: Results of the National Registry of the Spanish Group of Peritoneal Oncologic Surgery (REGECOP).

INTRODUCTION: Treatment of Peritoneal Surface Malignancies (PSM) with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has achieved results never seen before in these patients, which classically have a poor prognosis. The possibility of conducting clinical trials in these diseases is complicated, since some of them are rare, so the analysis of large databases provides very valuable scientific information. The aim of this study is to analyze the global results of the National Registry of the Spanish Group of Peritoneal Oncologic Surgery (REGECOP), whose objective is to register all patients scheduled for HIPEC nationwide. METHODS: This is a retrospective analysis of the data recorded in the REGECOP from 36 Spanish hospitals from 2001 to 2021. There were 4159 surgical interventions in 3980 patients. RESULTS: 66% are women and 34% are men with a median age of 59 years (range 17-86). 41.5% of the patients were treated for Peritoneal Metastases (PM) of colorectal cancer (CRC); 32.4% were women with ovarian cancer (OC) with PM; 12.8% were treated for pseudomyxoma peritonei (PMP); 6.2% had PM from gastric cancer (GC); 4.9% had PM of non-conventional origin; and, finally, 2.1% of cases were patients diagnosed with peritoneal mesothelioma. The median Peritoneal Cancer Index (PCI) was 9 (0-39), and complete cytoreduction was achieved in 81.7% of the procedures. Severe morbidity (Dindo-Clavien grade III-IV) was observed in 17.7% of surgeries, with 2.1% mortality. Median hospital stay was 11 days (0-259). Median overall survival (OS) was 41 months for CRC patients, 55 months for women with OC, was not reached in PMP patients, was 14 months for GC patients, and 66 months in mesothelioma patients. CONCLUSIONS: large databases provide extremely useful data. CRS with HIPEC in referral centers is a safe treatment with encouraging oncologic results in PSM.

Feasibility analysis of wind and solar powered desalination plants: An application to islands.

Economic surveillance for securing water projects driven by non-conventional energy sources is a challenge. The carrying out of these initiatives in economies based on liberalized markets faces governments against the need for guaranteed profits. As water availability has become a relevant global problem, and desalination an energy-intensive demand solution, it is common to combine both kinds of technologies, renewable energy systems and desalination plants. This research investigates the influence of grants, investment rates, and energy and water sales on the commercialization of two desalination technologies. A performance analysis has been carried out taking into account different scenarios. Following this approach, a simulated reverse osmosis desalination plant has been compared with respect to an already granted novel pilot plant. Results show a better fulfilment of the non-economic objectives, and economically profitable not only under certain conditions of conceded grants, and investor's expected benefits but also of sales of water-energy, that highlighted as a limiting factor. The Levelized Cost of Energy might be similar than the Spanish generation means, depending on the cost escalation rate of the loans, and conceded grants. It was found a reduction of 11 euro cents under the average price that could be achieved, for the standard scenario.

Recommendations for the measurement of the QT interval during the use of drugs for COVID-19 infection treatment. Updatable in accordance with the availability of new evidence.

COVID-19 infection has shown rapid growth worldwide, and different therapies have been proposed for treatment, in particular, the combination of immune response modulating drugs such as chloroquine and hydroxychloroquine (antimalarials) alone or in combination with azithromycin. Although the clinical evidence supporting their use is scarce, the off label use of these drugs has spread very quickly in face of the progression of the epidemic and the high mortality rate in susceptible populations. However, these medications can pathologically prolong the QT interval and lead to malignant ventricular arrhythmias such that organized guidance on QT evaluation and management strategies are important to reduce morbidity associated with the potential large-scale use.

Clinical experience and practical skills: results from Mexico City's paramedic registry.

INTRODUCTION: Trauma is a leading cause of death and disability in Mexico. Unintentional injuries, along with diabetes and heart disease, contribute to > 35% of the country's total mortality. Effective and efficient prehospital care of the conditions may improve outcomes. OBJECTIVE: The objective of this paper was to determine if prehospital field experience (PFE) correlated with higher passing rates among candidates for the paramedic registry in Mexico City. METHODS: This was a retrospective, cohort study using data from the Voluntary Registry of Prehospital Care Professionals (VRPHP) in Mexico City. RESULTS: The mean value for candidate age was 30.6 years and mean value for the years of PFE was 6.8 years (CI = 9-13 years). Most of the applicants were male and almost 90% were basic emergency medical services providers. Sixty-five percent of the candidates were from private, non-profit organizations, 73% were volunteers, and 19% had obtained a university degree. More than 57% had > 5 years of PFE, but the experience level did not correlate significantly with higher passing rates for the registry evaluation (chi2 = 1.66, p = 0.43). The results differed between the two years that the examination was offered (chi2 = 32.98, df = 1, p < 0.001, gamma = 0.54), regardless of gender, education, and years of experience. CONCLUSIONS: Previous field experience showed no correlation with passing rates, although the correlations improved between examination periods. The results may be used to support appropriate implementation of future health policies for prehospital emergency services.

[Current concepts on sudden death]. / Conceptos actuales sobre la muerte súbita.

Sudden death is defined as the death occurring less than one hour before the onset of the patient's symptoms. It is a severe condition considered a public health issue in several countries and in ours, it accounts for 33 000 to 53 000 annual deaths mainly related to ischemic heart disease. The main cause of sudden death are severe ventricular arrhythmias, but determining what patients are at risk for such an episode is complex, that is why risk stratification is usually a low cost-effective intervention. In the present study, we describe different sudden death risk-stratification strategies. Different sudden death treatment strategies regarding general population have different success rates in different countries, nevertheless, among select high risk populations; the best therapy currently available is the automatic implantable cardioverter-defibrillator. We also discuss other treatment options. In Mexico it is deemed necessary to do an important effort for the early detection, prevention and treatment of sudden death in order to limit the consequences of this problem.

Postprandial hypotension in the elderly: Findings in a Mexican population.

OBJECTIVE: Postprandial hypotension is a known cause of syncope in the elderly. Its prevalence is unknown in our country. METHODS: A prospective cross-sectional study was performed to determine PPH's Prevalence in elderly adults of both an urban and a rural Community in the State of Queretaro. Blood pressure measurements included a basal pre-prandial record, minute 0 recording at the moment they finished the meal and every 10 min until a 90 min record was complete. We included a medical history, a mental state test for cognitive evaluation (Minimental) and Minnesota Quality of life score and a food macronutrient composition analysis. RESULTS: We included 256 subjects, 78.1 ± 8.8 years old, 195 (76.2%) female. Two-hundred and five subjects (80.1%) had Postprandial hypotension after one or both analyzed meals, with non-significant differences in the studied items. Sixty-six (26.2%) patients had "significant postprandial hypotension". Patients living in a special care facility had more postprandial hypotension than people at the family home (87-3% vs 69.8% respectively, p<0.0001). CONCLUSIONS: Post-prandial hypotension is a common finding in this elderly population. We did not find distinctive conditions or markers that allow identification of subjects at risk for postprandial hypotension and its complications. This should prompt for routine screenings in specialized facilities to prevent complications.

Ambulatory postural blood pressure changes and history allow a better selection of patients that should undergo a head-up tilt test.

BACKGROUND: Syncope is a common symptom and in most cases it is of a neurally mediated origin. Such patients have to be studied with a careful history and a physical exploration that should include simple maneuvers such as blood pressure (BP) recordings in decubitus and standing position. These tools can suggest diagnosis in a good percentage of patients without the need for expensive or invasive testing. METHODS: We carried out a prospective observational study measuring BP and heart rate (HR) with the patients in decubitus and just as they stood up. The patients were sent for a tilt table test in different specialized centers. The BP changes were compared to the results of the tilt test. RESULTS: We included 215 patients, 36.1 ± 18.8 years old, 118 (54.9%) feminine, of which 143 (66.5%) had a positive tilt test. Patients with a positive test showed a rise in systolic BP (SBP) (121.7 ± 19.1 vs. 124.2 ± 20, p < 0.005) and in diastolic BP (DBP) (75 ± 11 vs. 78 ± 11.3, p < 0.005) when compared to people with a negative one. On the other hand, percentage BP changes were significantly different (SBP 2.24% vs. 0.48%, p = 0.02; DBP 4.1% vs. 1.2%, p = 0.009). Patients with a positive test had also a lower HR on standing up (72.1 ± ± 11.1 vs. 78.3 ± 17.2, p = 0.01). CONCLUSIONS: Patients with neurally mediated syncope showed an elevation of SBP and DBP when standing up actively, unlike subjects with a negative tilt test.

COVID 19 comprehensive management in a regional hospital of Northwestern Spain / Gestión integral de COVID 19 en un hospital regional en el noroeste de España

Abstract Introduction: The COVID-19 pandemic has brought about a paradigm shift in healthcare. Objective: To evaluate the utility of a strategy to comprehensively address the pandemic in a health area that covers 42,000 people. Method: Between March 10 and May 15, 2020, the COVID Unit was created in the corresponding regional hospital, and an independent circuit was established for the diagnosis and management of patients with suspected or confirmed COVID-19; social health centers were monitored with PCR testing. Results: Eighteen COVID-19-positive patients (age 72.9 ± 13.2 years) were admitted, out of which 66% were males. All these patients had pneumonia and 67% had respiratory distress syndrome; no one required mechanical ventilation. Mean hospital stay was 9.4 ± 5.3 days, and mortality, 11%. PCR tests were applied to all hospital residents (n = 827) and workers (n = 519), 1,044 phone calls were made and 36 hospital admissions were avoided. Only 50 patients required close follow-up, out of which four (0.48%) were positive for COVID-19. Conclusion: Clinical monitoring at the hospital and social health centers showed that patient profile was like that documented in the literature and that the incidence of COVID-19 was low in social health centers.

Resumen Introducción: La pandemia de COVID-19 provocó un cambio de paradigma en la atención médica. Objetivo: Evaluar una estrategia para abordar integralmente la pandemia en un distrito de salud que comprende 42 000 personas. Método: Entre el 10 de marzo y 15 de mayo de 2020 se creó la Unidad COVID en un hospital regional correspondiente al distrito y se estableció un circuito independiente para el diagnóstico y manejo de pacientes con sospecha o confirmación de COVID-19; los centros de salud social fueron monitoreados mediante PCR. Resultados: Ingresaron 18 pacientes positivos a COVID-19 (edad de 72.9 ± 13.2 años), 66 % eran hombres; todos presentaron neumonía, 67 % desarrolló síndrome de dificultad respiratoria y ninguno requirió ventilación mecánica. La estancia hospitalaria fue de 9.4 ± 5.3 días y la mortalidad, de 11 %. Se realizaron pruebas de PCR a todos los residentes (n = 827) y trabajadores (n = 519) del hospital, se realizaron 1044 llamadas telefónicas y se evitaron 36 hospitalizaciones. Solo 50 pacientes necesitaron seguimiento cercano, cuatro (0.48 %) positivos a COVID-19. Conclusión: El monitoreo clínico en el hospital y centros de salud social mostró que el perfil de los pacientes fue similar al documentado en la literatura y que la incidencia de COVID-19 fue baja en los centros sociales de salud.

Clinical findings as predictors of positivity of head-up tilt table test in neurocardiogenic syncope.

BACKGROUND: Neurocardiogenic (vasovagal) syncope occurs frequently and can be diagnosed with the head-up tilt table (HUTT) test. Our objective in this study was to identify clinical predictors of the positivity of HUTT test in neurocardiogenic syncope. METHODS: We conducted a prospective study of 117 cases (81 women and 36 men, 13-85 years of age) referred to our Institution for HUTT testing. The ability of 10 symptoms and signs of clinical history to predict HUTT positivity were evaluated using logistic regression analysis. RESULTS: We observed a low rate of test-negative cases (24%) and 89 positives. Nearly all positives (87/89) were neurocardiogenic, principally of vasodepressor and mixed types (43 and 34 cases, respectively) and a few were cardioinhibitory (10, mostly young males). Regression analysis established that dizziness, nausea, and diaphoresis in past history were associated with HUTT positivity nearly 25 times more frequently than when absent. CONCLUSIONS: Our three conclusions are that syncope in absence of heart disease accompanied by dizziness, nausea, and diaphoresis may be treated as neurocardiogenic in settings where no HUTT is available. In addition, our low rate of negative tests may have been the result of our reexamining referrals prior to deciding test performance, and high frequency of young males in cardioinhibitory syncope needs further research.

[Impact of optimal medical therapy on the arrhythmias and heart rate variability detected with 24 hour Holter in a series of patients from a heart failure clinic]. / Impacto de la terapia médica en las arritmias y variabilidad de la frecuencia cardiaca detectadas por Holter de 24 horas en una serie de pacientes de una clínica de insuficiencia cardiaca.

UNLABELLED: Pharmacological treatment of heart failure (HF) patients usually induces improvements in their functional class (FC). Heart rate variability and Holter-detected arrhythmias are sudden cardiac death predictors and should be evaluated in the presence of optimal medical treatment. METHODS: We conducted a prospective, observational and linear study to evaluate ventricular arrhythmia presence and heart rate variability through 24-hr Holter. A first recording was made upon admission to the HF clinic and the second was obtained when a stable FC was reached or optimal medication doses where attained. RESULTS: We have controls among 47 patients 11.6 +/- 8.1 months after the enrollment Holter. We have 26 (55.3%) men, with an average age of 60.2 +/- 13.9 years. The main ejection fraction (EF) went from 31.9 to 37.4% during follow-up (p = 0.01). At enrollment, 44.7% of our patients were in a FC I, 27.7% in FC II and 27.7% in FC III. At the end of follow-up, 67.4% were in FC I, 27.9% in FC II and 4.7% in FC III. Time-domain variability did not show significant changes and remained in normal average values. Premature atrial contractions diminished (324.1 +/- 811.1 vs. 316 +/- 809.2) but the ventricular ones went from 1,493.6 +/- 3,530.9 in 24 hours, to 1,582.4 +/- 4,394.5 (p = ns) during control, among those with an EF < 40% and SDNN < 100 ms, we found an increase from 7,026.6 +/- 12,168.8 to 9,336 +/- 16,137.8 PVC's in 24-hours (p = 0.008). CONCLUSION: Optimal medical therapy for heart failure can positively change certain aspects of these patients, but it does not improve the arrhythmic sudden death risk profile.

Detection of myocardial viability could be improved by rest GIK (glucose-insulin-potassium solution)-Tc 99m sestamibi compared with TL-201 reinjection, in post myocardial infarction patients.

UNLABELLED: GIK solutions improve detection of myocardium viability after acute infarction because they could change the metabolic conditions, improving myocardial perfusion defects. METHODS AND RESULTS: Seventy four patients (52 men, 22 women, mean age 53.3.08 +/- 12.14 years) with previous myocardial infarction (evolution time, 4.2 +/- 3.1 months) underwent pharmacological stress (dipyridamole), rest redistribution and reinjection Tl-201 image as well rest/stress Tc-99m Sestamibi, after the intravenous administration of GIK (200 g glucose +/- 30 UI regular insuline +/- 40 mEq potassiumchloride/500 mL in continuous infusion during 3 hours), Group A (N = 22) or oral administration of 70 g of glucose+/- 40 mEq of potassium chloride taking in advantage the endogenous insulin secretion, to non-diabetic patients (group B = GB, N = 26) and group C (GC, diabetic patients N = 26). All of the 74 patients received 10 mg of sublingual Isorbide previous to 25 mCi of Tc99m Sestamibi administration in a different 2 days protocol. A total of 1,480 myocardial segments were assessed and numbered, and the severity of perfusion defects in the segments involved, were compared between Thallium 201 rest reinjection and GIK-MIBI as the main objective of the study. Involved territories number: 4.02 +/- 2.50 vs. 6.88 +/- 2.12, p = 0.005 for AD; 5.2 +/- 1.44 vs. 6.35 +/- 1.11, p = 0.05 for RC and 1.58 +/- 1.01 vs. 2.05 +/- 1.05, p = 0.05 Cx. For GIK-MIBI vs. Tl-201 reinjection respectively, and defect severity: 8.2 +/- 6.04 vs. 13.22 +/- 5.38, p = 0.01 for LAD; 11.72 +/- 5.08 vs. 15.13 +/- 4.42, p = 0.005 for RC and 2.66 +/- 2.09 vs. 4.69 +/- 3.58, p = 0.003 Cx . For GIK-MIBI vs. Tl-201 reinjection respectively, were found. CONCLUSION: Our data suggest that GIK-MIBI protocol is a safe and easy procedure which improves the detection of perfusion reversible defects compared with Tl-201 reinjection, obtaining better information regarding myocardial viability, with lower acquisition time and less cost.

[Description of the resting electrocardiogram in a series of patients with myasthenia gravis]. / Descripción del electrocardiograma en reposo de una serie de pacientes con miastenia gravis.

UNLABELLED: Myasthenia gravis (MG) is a disease characterized by the presence of acetylcholine receptor-directed autoantibodies. Functional cardiac disorders are the most common since there is no neuro-muscular plate in the heart. Autonomic nervous system is involved in MG, but the cardiac manifestations of such an involvement remain unclear. Previous EKG studies in patients with MG show heterogeneous results. MATERIAL AND METHODS: A retrospective, descriptive and observational study was performed to know the main electrocardiographic characteristics and some autonomic nervous function in a series of patients with MG. RESULTS: One-hundred seventeen patients with EKG were analyzed. Twenty-eight were 47.9 +/- 20 years-old males, and 89 were women of 35.2 +/- 7.7 years (p = 0.001). 49 (41.9%) EKG had no changes, while 68 (58.1%) did. The main QT dispersion was 35.5 +/- 18.4 ms among those with some anomaly (p = 0.27). In 54 (78.3%) patients with an abnormal EKG there was T wave alternans, which was also present in 35 (71.4%) (p = 0.32) patients with normal EKG. CONCLUSIONS: MG is frequently associated to unspecific EKG changes. Dynamic electrocardiography allows a precise evaluation of the kind of cardiac involvement derived from MG, specifically the one related to the autonomic function, that is apparently affected in both the sympathetic and parasympathetic arms.

Abnormal SPECT myocardial perfusion imaging during periods of obstructive sleep apnea in morbid obese patients without known heart disease.

OBJECTIVE: Determine the myocardial perfusion characteristics in obstructive sleep apnea and its possible role in cardiovascular damage. METHODS AND PROCEDURES: Fourteen patients from the Obesity Clinic weighing less than 130 kg underwent myocardial perfusion studies using single photon emission computed tomography with technetium 99m-labeled sestamibi during nighttime polysomnographic recordings. Coronary angiograms were performed on patients with suspect of severe coronary obstruction according nighttime myocardial perfusion studies or pharmacological stress carried out during waking hours. RESULTS: All 14 patients manifested myocardial perfusion defects during sleep, affecting an average of 5.5 segments/patient, although only 8 presented ischemic ST segment changes and none demonstrated rhythm or conduction disturbances. Angiographic examination of the 10 patients with the most severe perfusion defects did not reveal significant coronary obstruction, and fewer perfusion defects were documented during daytime scintigraphy. DISCUSSION: In obese patients with obstructive sleep apnea, myocardial perfusion defects appear to occur with highest frequency and severity during nighttime sleep, justifying further investigation in a larger number of patients with obstructive sleep apnea and more significant obesity.

[Biliopancreatic diversion and simultaneous resection of a giant ulcerated fatty mass in a patient with body mass index: 75]. / Derivación biliopancreática y resección simultánea de masa adiposa ulcerada gigante en paciente con índice de masa corporal de 75.

Bariatric Surgery is currently the best treatment option for patients with Morbid Obesity and a Body Mass Index ≥ 40 kg/m2. Despite its high rate of postoperative and nutritional complications, biliopancreatic diversion (Scopinaro s procedure) has shown best results in terms of excess weight loss and improving obesity-associated diseases. This technique was performed on a 52-year-old woman (weight = 174 Kg, height = 152 cm, BMI= 75.3 kg/m2), with a classic open access due to anaesthesiologist's indication. During this procedure it was also performed a resection of a giant fatty mass on the inner side of left lower limb, which was ulcerated and infected. Postoperative period was uneventful, excepting wound dehiscence of the leg, requiring re-suturing. Six months after hospital discharge, the patient's percent excess weight loss was 36.98%. In our bariatric surgery series, with more than 400 patients since 2002, this patient was the one with the highest BMI.

Radiofrequency ablation of a hepatic neoplasm in a patient with an abdominal pacemaker.

We present the case of a 52 year-old male with a history of C-hepatitis and two liver neoplastic lesions treated by radiofrequency (RF) ablation. The patient wears an abdominally-implanted unipolar VVI pacemaker that did not show any signs of interference during RF pulses. We describe the procedure performed and discuss the present knowledge regarding the possibilities of RF interference with the normal pacemaker functioning in several settings related to abdominal RF treatments.

Miocardiopatía del atleta / Athlete's cardiomyopathy

La práctica de los deportes de alto nivel es cada vez más común. En el presente trabajo se revisa una serie de conceptos sobre la muerte súbita en atletas y cómo se puede incluir el concepto de "miocardiopatía del atleta" en el conocimiento disponible hasta la fecha. La prevalencia de muerte súbita en atletas es mayor que en la población general (1.5:100,000 contra 0.2:100,000 respectivamente). Esta diferencia puede ser secundaria a ciertos cambios miocárdicos derivados del ejercicio de resistencia. Consistentemente se han estado describiendo cambios anatómicos y funcionales de predominio ventricular derecho que semejan a una displasia arritmogénica, lo que da lugar a la hipótesis de que el ejercicio de resistencia de alto nivel puede inducir una forma de miocardiopatía que explica un cierto número de casos de muerte súbita en atletas. Los profesionales de la salud deben conocer esta posibilidad de riesgo en atletas entrenados, al tiempo que deben estimular la realización de ejercicio moderado regular como una práctica saludable en la población general.

High performance sports practice is more common every day. In the present work we evaluate several concepts regarding sudden death among athletes and the recently described "Athlete's cardiomyopathy". The prevalence of sudden death among athletes is higher than among the general population (1.5:100,000 versus 0.2:100,000 respectively). This difference can be related to myocardial changes derived from endurance exercise. There are consistent descriptions of anatomical and functional changes, more specific to the right ventricle that simulate an arrhythmogenic right ventricular dysplasia/cardiomyopathy. This can originate the hypothesis that such a cardiomyopathy can explain a certain number of sudden deaths among athletes. As healthcare professionals we have to be aware of this possibility among trained athletes, although we must continue to encourage moderate physical activity as a healthy behaviour among the general population.

Conceptos actuales sobre la muerte súbita / Current concepts on sudden death

La muerte súbita se define como aquella que ocurre antes de una hora de la aparición de los síntomas. Es una condición grave que en diversos países supone un problema de salud pública y que en México implica entre 33 y 53 mil muertes anuales, en su mayoría ligadas a enfermedad isquémica del corazón. La causa primordial de la muerte súbita son las arritmias ventriculares graves, sin embargo determinar qué sujetos son susceptibles de tener un episodio arrítmico es complejo y por ello la relación costo efectividad de las medidas de estratificación de riesgo suele ser mala. En el presente trabajo se revisan las diferentes estrategias para determinar el riesgo de muerte súbita. Las estrategias para el tratamiento oportuno de la muerte súbita relativas a la población general utilizadas en diversos países tienen impactos variables en la supervivencia, sin embargo, en las poblaciones seleccionadas con alto riesgo de padecer un evento arrítmico ventricular, la mejor terapia disponible actualmente es el desfibrilador automático implantable, aunque en el trabajo se discuten otras opciones de tratamiento. En nuestro país es necesario hacer un importante esfuerzo de detección prevención y tratamiento oportuno para limitar las consecuencia de este problema.

Sudden death is defined as the death occurring less than one hour before the onset of the patient's symptoms. It is a severe condition considered a public health issue in several countries and in ours, it accounts for 33 000 to 53 000 annual deaths mainly related to ischemic heart disease. The main cause of sudden death are severe ventricular arrhythmias, but determining what patients are at risk for such an episode is complex, that is why risk stratification is usually a low cost-effective intervention. In the present study, we describe different sudden death risk stratification strategies. Different sudden death treatment strategies regarding general population have different success rates in different countries, nevertheless, among select high risk populations; the best therapy currently available is the automatic implantable cardioverter defibrillator. We also discuss other treatment options. In Mexico it is deemed necessary to do an important effort for the early detection, prevention and treatment of sudden death in order to limit the consequences of this problem.