Patients with severe polytrauma: management and imaging protocols.

Traumatic injuries can be severe and complex, requiring the coordinated efforts of a multidisciplinary team. Imaging tests play a fundamental role in rapid and accurate diagnosis. In particular, whole-body computed tomography (CT) has become a key tool. There are different CT protocols depending on the patient's condition; whereas dose-optimized protocols can be used in stable patients, time/precision protocols prioritizing speed at the cost of delivering higher doses of radiation should be used in more severe patients. In unstable patients who cannot be examined by CT, X-rays of the chest and pelvis and FAST or e-FAST ultrasound studies, although less sensitive than CT, enable the detection of situations that require immediate treatment. This article reviews the imaging techniques and CT protocols for the initial hospital workup for patients with multiple trauma.

Update on acute appendicitis: Typical and untypical findings.

Acute appendicitis is the most common indication for emergency abdominal surgery throughout the world and a common reason for consultation in emergency departments. In recent decades, diagnostic imaging has played a fundamental role in identifying acute appendicitis, helping to reduce the rate of blind laparotomies and hospital costs. Given the results of clinical trials supporting the use of antibiotic therapy over surgical treatment, radiologists need to know the diagnostic criteria for complicated acute appendicitis to be able to recommend the best treatment option. This review aims not only to define the diagnostic criteria for appendicitis in different imaging modalities (ultrasonography, computed tomography, and magnetic resonance imaging), but also to explain the diagnostic protocols, atypical presentations, and other conditions that can mimic appendicitis.

The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: A retrospective study.

OBJECTIVE: To analyze the evolution of the use of imaging tests (ultrasonography and computed tomography (CT)) in the diagnosis of acute appendicitis. To determine the positive predictive value of these tests and the percentage of negative and complicated appendectomies. MATERIAL AND METHODS: This retrospective study compared adults who underwent appendectomy for suspected acute appendicitis at our tertiary hospital during 2015 versus similar patients at our center during 2007. RESULTS: A total of 278patients were included. The rate of negative appendectomies descended to 5%. The positive predictive value of ultrasonography increased to 97.4% in 2015, and the positive predictive value of CT and combined CT and ultrasonography was 100%. The rate of complicated appendicitis increased (23% in 2015). CONCLUSIONS: The use of imaging tests increased, and the rate of "blind" laparotomies decreased. Nevertheless, the rate of complicated appendicitis increased.

Radiologic diagnosis of patients with COVID-19. / Diagnóstico radiológico del paciente con COVID-19.

The pandemia caused by the SARS-CoV-2 virus has triggered an unprecedented health and economic crisis. Although the diagnosis of infection with SARS-CoV-2 is microbiological, imaging techniques play an important role in supporting the diagnosis, grading the severity of disease, guiding treatment, detecting complications, and evaluating the response to treatment. The lungs are the main organ involved, and chest X-rays, whether obtained in conventional X-ray suites or with portable units, are the first-line imaging test because they are widely available and economical. Chest CT is more sensitive than plain chest X-rays, and CT studies make it possible to identify complications in addition to pulmonary involvement, as well as to suggestive alternative diagnoses. The most common radiologic findings in COVID-19 are airspace opacities (consolidations and/or ground-glass opacities), which are typically bilateral, peripheral, and located primarily in the lower fields.

Puerperal complications: pathophysiological mechanisms and main imaging findings. / Complicaciones del puerperio: mecanismos fisiopatológicos y principales hallazgos radiológicos asociados.

OBJECTIVE: Puerperium is the period during which the physiological changes that have taken place during pregnancy revert and the uterus involutes until it reaches its normal size. This is a period of intense systemic changes, and diagnosing complications in this period is a challenge for both gynecologists and radiologists. This paper reviews the complications that can occur during puerperium, classifying them according to the pathophysiological mechanisms involved: the prothrombotic state, hemodynamic and hormonal changes, rapid uterine growth, changes associated with endothelial damage (preeclampsia, eclampsia, and HELLP syndrome), and postoperative complications in patients undergoing cesarean sections. CONCLUSION: Puerperal complications represent a diagnostic challenge. Understanding the pathophysiological mechanisms underlying these complications is fundamental for choosing the most appropriate imaging technique to ensure the correct diagnosis in each case.

Pulmonary embolisms in patients with COVID-19: a prevalence study in a tertiary hospital. / Tromboembolismo pulmonar en pacientes con COVID-19: estudio de prevalencia en un hospital terciario.

INTRODUCTION: SARS-CoV-2, the virus responsible for the current pandemic, predominantly affects the respiratory tract, and a growing number of publications report the predisposition of patients with COVID-19 to develop thrombotic phenomena. OBJECTIVE: To determine the prevalence of pulmonary embolism in patients with COVID-19; to determine the possible relationship between the severity of pulmonary involvement and D-dimer levels; to analyze the location of pulmonary embolisms in patients with COVID-19 and to compare it with the location in patients without COVID-19. METHODS: This retrospective study analyzed all CT angiograms of the pulmonary arteries done in patients with suspected pulmonary embolisms between March 15 and April 30, 2020 and compared them with studies done in the same period one year earlier. RESULTS: We included 492 pulmonary CT angiograms (342 (69.9%) in patients with COVID-19 and 147 (30.1%) in patients without COVID-19). The prevalence of pulmonary embolisms was higher in patients with COVID-19 (26% vs. 16.3% in patients without COVID-19, p=0.0197; relative risk=1.6). The prevalence of pulmonary embolisms in the same period in 2019 was 13.2%, similar to that of the group of COVID-19-negative patients in 2020 (p=0.43). There were no significant differences in D-dimer levels or the location of pulmonary embolisms between the two groups. CT showed moderate or severe pulmonary involvement in 78.7% of the patients with COVID-19. CONCLUSIONS: Patients with COVID-19 have an increased prevalence of pulmonary embolisms (26%), and most (78.7%) have moderate or severe lung involvement on CT studies. The location of pulmonary embolisms and the degree of elevation of D-dimer levels does not differ between patients with COVID-19 and those without.

Synthesis and evaluation of new heteroaryl nitrones with spin trap properties.

A new series of heteroaryl nitrones were synthesized and evaluated as free radical traps due to the results showed in our previous report. The physicochemical characterization of these new nitrones by electron spin resonance (ESR) demonstrated their high capability to trap and stabilize different atom centered free radicals generated by the Fenton reaction. Additionally, we intensely studied them in terms of their physicochemical properties. Kinetic studies, including the use of a method based on competition and the hydroxyl adduct decay, gave the corresponding rate constants and half-lives at the physiological pH of these newly synthesized nitrones. New nitrones derived from quinoxaline 1,4-dioxide heterocycles were more suitable than DMPO to trap hydroxyl free radicals with a half-life longer than two hours. We explain some of the results using computational chemistry through density functional theory (DFT).

The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: a retrospective study. / Estudio retrospectivo y comparativo de la utilidad y del valor predictivo positivo de la ecografía y la tomografía computarizada en el diagnóstico de apendicitis aguda en adultos.

OBJECTIVE: To analyze the evolution of the use of imaging tests (ultrasonography and computed tomography (CT)) in the diagnosis of acute appendicitis. To determine the positive predictive value of these tests and the percentage of negative and complicated appendectomies. MATERIAL AND METHODS: This retrospective study compared adults who underwent appendectomy for suspected acute appendicitis at our tertiary hospital during 2015 versus similar patients at our center during 2007. RESULTS: A total of 278 patients were included. The rate of negative appendectomies descended to 5%. The positive predictive value of ultrasonography increased to 97.4% in 2015, and the positive predictive value of CT and combined CT and ultrasonography was 100%. The rate of complicated appendicitis increased (23% in 2015). CONCLUSIONS: The use of imaging tests increased, and the rate of "blind" laparotomies decreased. Nevertheless, the rate of complicated appendicitis increased.

Aortoenteric fistulas: spectrum of MDCT findings. / Fístula aortoentérica: Espectro de hallazgos en tomografía computarizada multidetector.

An aortoenteric fistula is an abnormal communication between the aorta and the gastrointestinal tract wall. The high mortality associated with this rare entity means it requires early accurate diagnosis. Aortoenteric fistulas are classified as primary when they develop on a native aorta that has not undergone an intervention and as secondary when they develop after vascular repair surgery. All radiologists need to be able to recognize the direct and indirect signs that might suggest the presence of an aortoenteric fistula. This article reviews the types of aortoenteric fistulas and their clinical and pathophysiological correlation, as well as the diagnostic algorithm, illustrating the most characteristic findings on multidetector computed tomography.

Ewing sarcoma, analysis of survival at 6 years with multidisciplinary therapy. / Sarcoma de Ewing, análisis de supervivencia a los 6 años con terapia multidisciplinar.

PURPOSE: The purpose of this study is to present our series of Ewing sarcoma cases and the survival data obtained in the medium term, using a multidisciplinary therapy protocol. MATERIAL, METHODS AND RESULTS: Forty-one Ewing sarcomas were diagnosed, treated and followed-up in our hospital between 2004 and 2009 with an average age of 18.29 years. Seventy-eight percent were to Ewing sarcoma of the bone, the femur being the most frequent location. Sixty-eight percent had a localized stage at the time of diagnosis. At the end of follow-up, 40% of the patients did not survive, most died within the first 5 years of follow-up. DISCUSSION: In Spain, Ewing sarcoma is the most common primary malignant bone tumour in childhood, ahead of osteosarcoma. Its survival rate has increased greatly in the last 40 years, improvement attributable mainly to the aggressive use of chemotherapy and to multidisciplinary treatment, but its prognosis remains very poor, especially for those with metastasis at diagnosis, the main adverse prognostic factor. Because of its high mortality, many authors consider it a disseminated disease from the beginning, with non- detectable micrometastasis that condition final survival. CONCLUSIONS: Early diagnosis and multidisciplinary therapy in referral centres are the best strategies currently available to us to provide these patients the maximum possibilities of cure of this disease.

Universal mathematical identities in density functional theory: results from three different spin-resolved representations.

This paper supersedes previous theoretical approaches to conceptual DFT because it provides a unified and systematic approach to all of the commonly considered formulations of conceptual DFT, and even provides the essential mathematical framework for new formulations. Global, local, and nonlocal chemical reactivity indicators associated with the "closed-system representation" ([N(alpha),N(beta),nu(alpha)(r),nu(beta)(r)]) of spin-polarized density functional theory (SP-DFT) are derived. The links between these indicators and the ones associated with the "open-system representation" ([mu(alpha),mu(beta),nu(alpha)(r),nu(beta)(r)]) are derived, including the spin-resolved Berkowitz-Parr identity. The Legendre transform to the "density representation" ([rho(alpha)(r),rho(beta)(r)]) is performed, and the spin-resolved Harbola-Chattaraj-Cedillo-Parr identities linking the density representation to the closed-system and open-system representations are derived. Taken together, these results provide the framework for understanding chemical reactions from both the electron-following perspective (using either the closed-system or the open-system representation) and electron-preceding perspective (density representation). A powerful matrix-vector notation is developed; with this notation, identities in conceptual DFT become universal. Specifically, this notation allows the fundamental identities in conventional (spin-free) conceptual DFT, the [N(alpha),N(beta)] representation, and the [N=N(alpha)+N(beta),N(S)=N(alpha)-N(beta)] representation to be written in exactly the same forms. In cases where spin transfer and electron transfer are coupled (e.g., radical+molecule reactions), we believe that the [N(alpha),N(beta)] representation may be more useful than the more common [N,N(S)] representation.

Dual descriptors within the framework of spin-polarized density functional theory.

Spin-polarized density functional theory (SP-DFT) allows both the analysis of charge-transfer (e.g., electrophilic and nucleophilic reactivity) and of spin-polarization processes (e.g., photophysical changes arising from electron transitions). In analogy with the dual descriptor introduced by Morell et al. [J. Phys. Chem. A 109, 205 (2005)], we introduce new dual descriptors intended to simultaneously give information of the molecular regions where the spin-polarization process linking states of different multiplicity will drive electron density and spin density changes. The electronic charge and spin rearrangement in the spin forbidden radiative transitions S(0)-->T(n,pi(*)) and S(0)-->T(pi,pi(*)) in formaldehyde and ethylene, respectively, have been used as benchmark examples illustrating the usefulness of the new spin-polarization dual descriptors. These quantities indicate those regions where spin-orbit coupling effects are at work in such processes. Additionally, the qualitative relationship between the topology of the spin-polarization dual descriptors and the vertical singlet triplet energy gap in simple substituted carbene series has been also discussed. It is shown that the electron density and spin density rearrangements arise in agreement with spectroscopic experimental evidence and other theoretical results on the selected target systems.

Diaphyseal forearm fractures, 20 years after surgical treatment. Is there still an indication for percutaneous fixation? / Fracturas diafisarias de antebrazo, 20 años después. ¿Está indicada la osteosíntesis percutánea?

OBJECTIVE: This is a retrospective study of 98 diaphyseal forearm fractures in adults, treated by a percutaneous technique with intramedullar Kirchner wires. MATERIALS AND METHOD: We reviewed 64 patients with 98 forearm fractures with a radiographic follow-up, assessing the presence of pseudarthrosis or delayed bone union and evaluating functional outcomes with the Anderson and the Disability of the Arm, Shoulder and Hand scale. RESULTS: Clinical and radiological bone union was achieved in an average of 12 weeks. We obtained 77% of excellent and good results following Anderson's scale. There were 4 cases of pseudarthrosis and 6 cases of delayed bone union. CONCLUSION: This surgical technique provides several advantages, such as a low incidence of complications and a total absence of infections, refractures and iatrogenic neurovascular injuries. It allows a lower hospital stay and a shortening of the surgery time compared with other techniques such as plates and intramedullary nails, that have similar results, in terms of bone union and functional outcomes, as we have verified from the published literature.

Short-term Results From a Training Program to Improve Organ Donation in Uncontrolled Donation After Circulatory Death.

BACKGROUND: In all organ transplantation programs, election of the proper protocol relies primarily on the professionals involved in the detection of potential donors. The objective of our study was to assess the impact of a series of prehospital training sessions, as well as to develop several positive feedback strategies within the uncontrolled organ donation after circulatory death (uDCD) program in our city. METHODS: A before-after intervention study was carried out in 3 steps. First, professionals enrolled in the Emergency Health Services Agency-061 (EPES-061) program underwent specific training to identify potential donors. Second, a specific logotype was designed to alert emergency health care professionals that in cases where cardiopulmonary resuscitation was ineffective and after treatment of all potentially reversible causes, the "chain of survival" should be considered a "chain of opportunities." Third, a positive feedback strategy was put in place, whereby each time a donation was procured, the EPES-061 personnel that had identified the potential donor were notified by phone and in a personal letter. RESULTS: The mean age for donors was 50.5 years of age (interquartile range 37-52.5), and 89.5% of all donations came from male subjects. Positive feedback letters and phone calls, including information on final outcome, were provided to the appropriate personnel in 100% of the cases. Postintervention information showed an increase in both eligible and utilized donors. CONCLUSIONS: Interventions outside the hospital setting that facilitate optimal implementation of the uDCD program are an essential part of this strategy to increase the donor pool and make the wait shorter for transplant patients.

[APACHE II and SAPS II as predictors of brain death development in neurocritical care patients]. / APACHE II y SAPS II como predictores de evolucion a muerte encefalica en pacientes neurocriticos.

AIM: To assess the prognostic value of APACHE II and SAPS II scales to predict brain death evolution of neurocritical care patients. PATIENTS AND METHODS: Retrospective observational study performed in a tertiary hospital. Include 508 patients over 16 years old, hospitalized in ICU for at least 24 hours. The variables of interest were: demographic data, risk factors, APACHE II, SAPS II and outcome. RESULTS: Median age: 41 years old (IR: 25-57). Males: 76.2%. Most frequent reason for admission: trauma (55.3%). Medians: Glasgow Coma Scale (GCS), 10 points; APACHE II, 13 points; SAPS II, 31 points; and ICU stay, 5 days. Mortality in the ICU was 28.5% (n = 145) of whom 44 (8.7%) evolved to brain death. Univariate logistic regression analysis showed that GCS, APACHE II and SAPS II scores, as well as ICU stay days behaved as predictors of brain death evolution. However, the multivariate analysis performed including APACHE II and SAPS II scores showed that only APACHE II maintained statistical significance, despite the good discrimination of both scores. CONCLUSION: Transplant coordinators might use the APACHE II score as a tool to detect patients at risk of progression to brain death, minimizing the loss of potential donors.

TITLE: APACHE II y SAPS II como predictores de evolucion a muerte encefalica en pacientes neurocriticos.Objetivo. Evaluar si las escalas pronosticas APACHE II (Acute Physiology and Chronic Health Evaluation II) y SAPS II (Simplified Acute Physiology Score II) son capaces de predecir la evolucion a muerte encefalica en pacientes neurocriticos. Pacientes y metodos. Estudio retrospectivo, observacional, realizado en un hospital de tercer nivel. Se incluyo a 508 pacientes mayores de 16 años, ingresados con patologia neurocritica aguda, con estancia en la unidad de cuidados intensivos de al menos 24 horas. Las variables de interes fueron: datos demograficos, factores de riesgo, APACHE II, SAPS II y resultado pronostico. Resultados. Mediana de edad: 41 años (rango intercuartilico: 25-57). Varones: 76,2%. Motivo de ingreso mas frecuente: traumatismo (55,3%). Medianas: escala de coma de Glasgow (GCS), 10 puntos; APACHE II, 13 puntos; SAPS II, 31 puntos; y estancia en cuidados intensivos, cinco dias. La mortalidad en la unidad de cuidados intensivos fue de 145 (28,5%). De ellos, 44 (8,7%) evolucionaron a muerte encefalica. El analisis de regresion logistica univariante mostro que la GCS, las escalas APACHE II y SAPS II, y los dias de estancia en la unidad de cuidados intensivos se comportaron como variables predictoras de evolucion a muerte encefalica. Sin embargo, en el analisis multivariante realizado con APACHE II y SAPS II, se evidencio que solo APACHE II mantiene significacion estadistica, a pesar de la buena discriminacion de ambas escalas. Conclusion. Los coordinadores de trasplantes podrian usar la escala APACHE II como una herramienta para detectar pacientes con riesgo de evolucion a muerte encefalica, minimizando la perdida de potenciales donantes.

[And if it happened to children? Adapting medical care during terrorist attacks with multiple pediatric victims]. / Et si c'était des enfants ? Adaptation de la prise en charge médicale en cas d'attentats terroristes avec de nombreux enfants victimes.

In light of the recent terrorist attacks in Europe, we need to reconsider the organization of rescue and medical management and plan for an attack involving multiple pediatric victims. To ensure quick surgical management, but also to minimize risk for on-site teams (direct threats from secondary terrorist attacks targeting deployed emergency services), it is crucial to evacuate patients in a swift but orderly fashion. Children are vulnerable targets in terrorist attacks. Their anatomical and physiological characteristics make it likely that pediatric victims will suffer more brain injuries and require more, often advanced, airway management. Care of multiple pediatric victims would also prove to be a difficult emotional challenge. Civilian medical teams have adapted the military-medicine principles of damage control in their medical practice using the MARCHE algorithm (Massive hemorrhage, Airway, Respiration [breathing], Circulation, Head/Hypothermia, Evacuation). They have also learned to adapt the level of care to the level of safety at the scene. Prehospital damage control principles should now be tailored to the treatment of pediatric patients in extraordinary circumstances. Priorities are given to hemorrhage control and preventing the lethal triad (coagulopathy, hypothermia, and acidosis). Managing hemorrhagic shock involves quickly controlling external bleeding (tourniquets, hemostatic dressing), using small volumes for fluid resuscitation (10-20ml/kg of normal saline), quickly introducing a vasopressor (noradrenaline 0.1µg/kg/min then titrate) after one or two fluid boluses, and using tranexamic acid (15mg/kg over 10min for loading dose, maximum 1g over 10min). Prehospital resources specifically dedicated to children are limited, and it is therefore important that everyone be trained and prepared for a scene with multiple pediatric patients.

Cisplatin plus continuous infusion vinorelbine for the treatment of advanced non-small cell lung cancer: a phase I-II study.

BACKGROUND: In this Phase I/II trial, the maximumtolerated dose (MTD) and activity of cisplatin plus vinorelbine (VRL) administered in continuous infusion as first-line treatment of advanced non small cell lung cancer (NSCLC) was determined in 12 consecutive chemotherapy-naive patients with advanced NSCLC. PATIENTS AND METHODS: The dose of cisplatin was 100 mg/m(2) in all patients, and vinorelbine was administered as an initial intravenous (iv) bolus of 8 mg/m(2) on day 1 followed by a 4-day continuous iv infusion at 4 different 24 h dose levels (DLs) to be repeated every 21 days. All 12 patients (47 cycles) were evaluable for response and toxicity. RESULTS: The MTD was 8 mg/m(2) bolus followed by a continuous iv infusion of 8 mg/m(2) per day over 4 days. The dose limiting toxicities (DLT) were febrile neutropenia in 4 patients and grade 3 mucositis in 1 patient. There was less neuro-toxicity and compared to the weekly bolus scheme. There was no significant cumulative toxicity after 3 cycles. Partial responses were observed in 6 patients; an overall response rate of 50% (95% CI: 30-65%). Median time to progression was 5,5 months (95% CI: 1,5-11 months) and median survival was 11 months (95% CI: 5-20 months). CONCLUSIONS: The results demonstrate that, in this setting of first-line treatment of NSCLC, cisplatin plus vinorelbine at 8 mg/m(2) bolus followed by a continuous infusion of 8 mg/m(2) per day over 4 days is the recommended schedule. Further trials would be useful to establish activity of this combination.