Textbook outcome in colon carcinoma: implications for overall survival and disease-free survival.

BACKGROUND: Textbook outcome (TO) is a multidimensional quality management tool that uses a set of traditional surgical measures to reflect an "ideal" surgical result for a particular pathology. The aim of the present study is to record the rate of TO in patients undergoing elective surgery for colon cancer (CC). MATERIAL AND METHODS: Retrospective study of all patients undergoing scheduled CC surgery at a Spanish university hospital from September 2012 to August 2016. Patients with rectal cancer were excluded. The variables included in the definition of TO were: R0 resection, number of isolated nodes ≥ 12, no Clavien-Dindo ≥ IIIa complications, no prolonged stay, no readmissions, and no mortality in the first 30 days. The main objective of this study is to analyse the achievement of TO in these patients and to assess the relationship between TO and overall and disease-free survival. RESULTS: Five hundred and sixty-four patients were included in the study. TO was achieved in 49.8%. The sample had a mean age of 69 ± 11 years, and 60% were male. Female sex (OR 1.61; 95% CI 2.30-1.13), T3 and T4 classification (OR 2.50, 95% CI 4.59-1.36, and OR 2.55, 95% CI 5.21-1.24 respectively) and laparoscopic approach (OR 1.53, 95% CI 2.33-1.00) were independent factors that were significantly associated with achieving a TO. Patients who achieved TO had higher overall survival (p = 0.008) than those who did not. However, with regard to disease-free survival, no statistically significant differences were found (p = 0.303). CONCLUSION: TO is a useful, easy-to-interpret management tool for measuring oncological results and for predicting patient survival.

Individually tailored vs. standardized substrate modification during radiofrequency catheter ablation for atrial fibrillation: a randomized study.

Aims: This randomized single-centre study sought to compare the efficacy and safety of pulmonary vein isolation (PVI) plus voltage-guided ablation vs. PVI with or without linear ablation depending on the type of atrial fibrillation (AF). Methods and results: Overall, 124 ablation-naive patients with paroxysmal or persistent AF were randomized to PVI with (persistent AF) or without (paroxysmal AF) additional linear ablation (control group) vs. PVI plus ablation of low-voltage areas (LVAs) irrespective of AF type. Bipolar voltage mapping was performed during stable sinus rhythm. An LVA consisted of ≥ 3 adjacent mapping points that each had a peak-to-peak amplitude ≤0.5 mV. After a mean follow-up of 12 ± 3 months, significantly more patients in the LVA ablation group were free from atrial arrhythmia recurrence >30 s off antiarrhythmic drugs (AADs) after a single procedure (primary endpoint) compared with control group patients [40/59 (68%) vs. 25/59 (42%), log-rank P = 0.003]. Arrhythmia-free survival on or off AADs was found in 33/59 control group patients (56%) and in 41/59 LVA ablation group patients (70%) (adjusted log-rank P = 0.10). During the 7 day Holter monitoring period at 12 months, significantly more patients in the LVA ablation group were free from arrhythmia recurrence on or off AADs [45/50 (90%) vs. 33/46 (72%), P = 0.04]. No between-group differences were observed regarding procedure duration, fluoroscopy time, and major complications. Conclusion: In this single-centre study, individually tailored substrate modification guided by voltage mapping was associated with a significantly higher arrhythmia-free survival rate compared with a conventional approach applying linear ablation according to AF type.

Mapping-guided characterization of mechanical and electrical activation patterns in patients with normal systolic function using a sensor-based tracking technology.

AIMS: In times of evolving cardiac resynchronization therapy, intra-procedural characterization of left ventricular (LV) mechanical activation patterns is desired but technically challenging with currently available technologies. In patients with normal systolic function, we evaluated the feasibility of characterizing LV wall motion using a novel sensor-based, real-time tracking technology. METHODS AND RESULTS: Ten patients underwent simultaneous motion and electrical mapping of the LV endocardium during sinus rhythm using electroanatomical mapping and navigational systems (EnSite™ NavX™ and MediGuide™, SJM). Epicardial motion data were also collected simultaneously at corresponding locations from accessible coronary sinus branches. Displacements at each mapping point and times of electrical and mechanical activation were combined over each of the six standard LV wall segments. Mechanical activation timing was compared with that from electrical activation and preoperative 2D speckle tracking echocardiography (echo). MediGuide-based displacement data were further analysed to estimate LV chamber volumes that were compared with echo and magnetic resonance imaging (MRI). The lateral and septal walls exhibited the largest (12.5 [11.6-15.0] mm) and smallest (10.2 [9.0-11.3] mm) displacement, respectively. Radial displacement was significantly larger endocardially than epicardially (endo: 6.7 [5.0-9.1] mm; epi: 3.8 [2.4-5.6] mm), while longitudinal displacement was significantly larger epicardially (endo: 8.0 [5.0-10.6] mm; epi: 10.3 [7.4-13.8] mm). Most often, the anteroseptal/anterior and lateral walls showed the earliest and latest mechanical activations, respectively. 9/10 patients had concordant or adjacent wall segments of latest mechanical and electrical activation, and 6/10 patients had concordant or adjacent wall segments of latest mechanical activation as measured by MediGuide and echo. MediGuide's LV chamber volumes were significantly correlated with MRI (R2= 0.73, P < 0.01) and echo (R2= 0.75, P < 0.001). CONCLUSION: The feasibility of mapping-guided intra-procedural characterization of LV wall motion was established. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov; Unique identifier: CT01629160.

In vitro modulation of Drimys winteri bark extract and the active compound polygodial on Salmo salar immune genes after exposure to Saprolegnia parasitica.

The rapid development of the aquaculture industry has global concerns with health management and control strategies to prevent and/or treat diseases and increase sustainability standards. Saprolegniosis is a disease caused by Saprolegnia parasitica, and is characterized by promoting an immunosuppression in the host. This study evaluated in vitro the extract and one active compound (polygodial) of Drimys winteri, a Chilean medicinal tree as a potential early immunostimulatory aid in Saprolegniosis control. Atlantic salmon (Salmo salar) head kidney cells (ASK-1) were incubated with both extract and pure polygodial before exposure to S. parasitica mycelium, and the expression of the immune-related genes interleukin 1ß (IL-1ß), interferon α (IFNα), and major histocompatibility complex II (MHCII) was evaluated. Both evidenced immunomodulatory capacities by increasing gene expressions. This immunomodulation related to a mitigatory action counteracting the immunosuppressing effects of S. parasitica. Despite that most immune-related genes were up-regulated, the down-regulation of MHCII, characteristic of S. parasitica infection, was lessened by pre-incubation with the compounds. This study provides the first insight on the potential of D. winteri bark extract as a possible immunomodulatory and defensive strategy against this oomycete infection in fish.

Patient discomfort following catheter ablation and rhythm device surgery.

AIMS: Proper management of post-interventional pain relieves unwarranted patient distress and enhances patient satisfaction. There have been only a limited number of investigations into patient discomfort following electrophysiological interventions. This study aims to quantify pain after interventional procedures, including ablation of atrial fibrillation (AF) or ventricular tachycardia (VT), as well as implant or explant of pacemakers or implantable cardioverter defibrillators. METHODS AND RESULTS: One-hundred and two consecutive patients (mean age 66 years, 70 men) were asked to quantify post-interventional pain on a numeric rating scale (NRS 0-10) every 2 h during a period of 24 h after their intervention (49 ablations in deep propofol sedation, 53 device surgeries in local anaesthesia with mepivacaine 1%) and to specify the type of pain. Pain was classified as moderate to severe in case of NRS > 3. Post-operative pain medication included non-opioid and opioid analgesics as per the treating physicians' discretion. Sixty-one patients (60%) suffered from moderate-to-severe pain within the first 24 h after the procedure, despite the use of analgesics in 47 patients (46%). Pain was present in an early period (0-6 h) in 54% and in a late period (8-24 h) in 40% of patients. Patients complained of back pain (44%), pain at the site of the device pocket (39%), pain at the groin after puncture (7%), and pericarditic pain (5%). Multivariate analysis identified female gender (P = 0.046) associated with early post-interventional pain while age, diabetes mellitus, body mass index, type of intervention, and procedure time were not related to early or late post-interventional pain. CONCLUSION: The findings highlight the high prevalence and the poor predictability of moderate-to-severe post-interventional pain within the first 24 h after catheter ablation and cardiac device surgery procedures, despite the use of peri-interventional analgesics. These findings highlight the need for more careful pain assessment and management programmes.

Treatment with novel oral anticoagulants in a real-world cohort of patients undergoing cardiac rhythm device implantations.

AIMS: The safety and efficacy of novel oral anticoagulants in patients with atrial fibrillation undergoing pacemaker or implantable cardioverter-defibrillator interventions have not been clearly defined. Therefore, we compared the incidence of bleeding and thrombo-embolic complications following cardiac rhythm device (CRD) implantations under dabigatran vs. rivaroxaban in a real-world cohort. METHODS AND RESULTS: We analysed 176 consecutive procedures performed in 93 patients treated peri-interventionally with dabigatran and 83 patients with rivaroxaban, respectively. Post-operative bleeding complications and thrombo-embolic events occurring within 30 days were compared. There were no significant differences in baseline characteristics between patients in the dabigatran and the rivaroxaban group. Most of the patients in both the groups received dual chamber or cardiac resynchronization devices (71 vs. 78%) as opposed to single-chamber systems (29 vs. 22%). In the dabigatran group, two (2%) bleeding complications (two pocket haematomas) were observed in comparison with four (5%, three pocket haematomas and one pericardial effusion) in the rivaroxaban group (P = 0.330). Three complications in the rivaroxaban group necessitated surgical intervention as opposed to none in the dabigatran group (P = 0.064). One case of a transient ischaemic attack occurred in the dabigatran group (P = 0.343). CONCLUSION: Bleeding and thrombo-embolic complications in patients treated with dabigatran or rivaroxban are rare. Further and larger studies are warranted to define the optimal anticoagulation management in patients with a need for oral anticoagulation and CRD interventions.

The predictive value of echocardiographic parameters associated with left ventricular diastolic dysfunction on short- and long-term outcomes of catheter ablation of atrial fibrillation.

AIMS: Recurrence of atrial fibrillation (AF) is frequently observed after AF catheter ablation. However, the predictive value of echocardiographic parameters associated with left ventricular diastolic dysfunction (LVDD) has not been well studied. METHODS AND RESULTS: In 124 consecutive patients (mean age 61 ± 10 years, 60% male) with paroxysmal (n = 70) or persistent AF (n = 54) undergoing AF catheter ablation, mitral early diastolic peak (E-wave) and late peak (A-wave) velocities, E/A ratio, deceleration time (DT) of mitral early velocity, early diastolic mitral annulus peak velocity (e'), and E/e' ratio were determined by transthoracic echocardiography. Early (ERAF) and late AF recurrence (LRAF) were monitored with 7-day Holter electrocardiograms directly after catheter ablation and after 6 and 12 months. Early AF recurrence occurred in 34% of the patients, while LRAF was observed in 27% of the patients. Patients with ERAF had higher E-wave (0.9 ± 0.2 vs. 0.8 ± 0.2 m/s, P = 0.035) and lower A-wave velocity (0.5 ± 0.2 vs. 0.6 ± 0.2 m/s, P = 0.038), higher E/A ratio (1.8 ± 0.9 vs. 1.5 ± 0.9, P = 0.089), and slower DT (214 ± 67 vs. 243 ± 68 ms, P = 0.073), while E/e', left atrial diameter, and left ventricular ejection fraction were similar. In multivariable regression analysis, the E/A ratio was the only independent predictor of ERAF (odds ratio 2.905, 95% confidence interval 1.072-7.870, P = 0.036). None of the echocardiographic parameters influenced the late therapy outcome. CONCLUSION: Early results of the catheter ablation, but not the late rhythm outcome, are influenced by an impaired mitral inflow pattern, which is associated with LVDD.

Additional diagnostic and prognostic value of copeptin ultra-sensitive for diagnosis of non-ST-elevation myocardial infarction in older patients presenting to the emergency department.

BACKGROUND: Identifying older patients with non-ST- elevation myocardial infarction (NSTEMI) within the very large proportion with elevated high-sensitive cardiac troponin T (hs-cTnT) is a diagnostic challenge because they often present without clear symptoms or electrocardiographic features of acute coronary syndrome to the emergency department (ED). We prospectively investigated the diagnostic and prognostic performance of copeptin ultra-sensitive (copeptin-us) and hs-cTnT compared to hs-cTnT alone for NSTEMI at prespecified cut-offs in unselected older patients. METHODS: We consecutively enrolled 306 non-surgical patients ≥70 years presenting to the ED. In addition to clinical examination, copeptin-us and hs-cTnT were measured at admission. Two cardiologists independently adjudicated the final diagnosis of NSTEMI after reviewing all available data. All patients were followed up for cardiovascular-related death within the following 12 months. RESULTS: NSTEMI was diagnosed in 38 (12%) patients (age 81±6 years). The combination of copeptin-us ≥14 pmol/L and hs-cTnT ≥0.014 µg/L compared to hs-cTnT ≥0.014 µg/L alone had a positive predictive value of 21% vs. 19% to rule in NSTEMI. The combination of copeptin-us <14 pmol/L and hs-cTnT <0.014 µg/L compared to hs-cTnT <0.014 µg/L alone had a negative predictive value of 100% vs. 99% to rule out NSTEMI. Hs-cTnT ≥0.014 µg/L alone was significantly associated with outcome. When copeptin-us ≥14 pmol/L was added, the net reclassification improvement for outcome was not significant (p=0.809). CONCLUSIONS: In unselected older patients presenting to the ED, the additional use of copeptin-us at predefined cut-offs may help to reliably rule out NSTEMI but may not help to increase predicted risk for outcome compared to hs-cTnT alone.

[Intussusception in the adult: a rare cause of mechanical obstruction]. / Invaginación intestinal en el adulto. Una causa infrecuente de obstrucción mecánica.

Intussusception is an infrequent cause of mechanical intestinal obstruction in the adult. We present herein two clinical cases of intussusception with different etiologies. In the first case, the underlying cause was a lipoma, and in the second, it was metastasis from melanoma. In both cases the intussusception was identified through computed tomography and treatment was intestinal resection. Pathologic anatomy provided the definitive diagnosis. Etiology is diverse and it is more common for obstruction to be due to organic lesions that are malignant at the level of the colon and benign at the level of the small bowel. Currently there are more preoperative diagnoses thanks to the advances made in imaging study techniques. Intestinal resection continues to be the treatment of choice in the majority of cases, because of the high percentage of malignant lesions as the underlying cause.

How-to: Focus Cardiac Ultrasound in acute settings.

Focus cardiac ultrasound (FoCUS) provides vital information at at the bedside which has the potential of improving outcomes in the acute settings. FoCUS could help the clinicians in their daily clinical decision-making while applied within the clinical context as an extension of bedside clinical examination. FoCUS practitioners should be aware of their own limitations with the importance of the timely referral for comprehensive Echocardiography whenever required.

Burden of acute gastrointestinal illness in the Metropolitan region, Chile, 2008.

The purpose of this study was to determine the magnitude and distribution of acute gastrointestinal illness (GI) in the Chilean population, describe its burden and presentation, identify risk factors associated with GI and assess the differences between a 7-day, 15-day and a 30-day recall period in the population-based burden of illness study design. Face-to-face surveys were conducted on 6047 randomly selected residents in the Metropolitan region, Chile (average response rate 75·8%) in 2008. The age-adjusted monthly prevalence of GI was 9·2%. The 7-day recall period provided annual incidence rate estimates about 2·2 times those of the 30-day recall period. Age, occupation, healthcare system, sewer system, antibiotic use and cat ownership were all found to be significant predictors for being a case. This study expands on the discussion of recall bias in retrospective population studies and reports the first population-based burden and distribution of GI estimates in Chile.

Level 1 of Entrustable Professional Activities in adult echocardiography: a position statement from the EACVI regarding the training and competence requirements for selecting and interpreting echocardiographic examinations.

The goal of Level 1 training in echocardiography is to enable the trainee to select echocardiography appropriately for the evaluation of a specific clinical question, and then to interpret the report. It is not the goal of Level 1 training to teach how to perform the examination itself-that is the goal of higher levels of training. However, understanding the principles, indications, and findings of this crucial technique is valuable to many medical professionals including outside cardiology. This should be seen as part of a general understanding of cardiac imaging modalities. The purpose of this position statement is to define the scope and outline the general requirements for Level 1 training and competence in echocardiography. Moreover, the document aims to make a clear distinction between Level 1 competence in echocardiography and focus cardiac ultrasound (FoCUS).

Echocardiography in aortic diseases: EAE recommendations for clinical practice.

Echocardiography plays an important role in the diagnosis and follow-up of aortic diseases. Evaluation of the aorta is a routine part of the standard echocardiographic examination. Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly the aortic root and proximal ascending aorta. Transoesophageal echocardiography (TOE) overcomes the limitations of TTE in thoracic aorta assessment. TTE and TOE should be used in a complementary manner. Echocardiography is useful for assessing aortic size, biophysical properties, and atherosclerotic involvement of the thoracic aorta. Although TOE is the technique of choice in the diagnosis of aortic dissection, TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade, and left ventricular function can be easily visualized by TTE. However, a negative TTE does not rule out aortic dissection and other imaging techniques must be considered. TOE should define entry tear location, mechanisms and severity of aortic regurgitation, and true lumen compression. In addition, echocardiography is essential in selecting and monitoring surgical and endovascular treatment and in detecting possible complications. Although other imaging techniques such as computed tomography and magnetic resonance have a greater field of view and may yield complementary information, echocardiography is portable, rapid, accurate, and cost-effective in the diagnosis and follow-up of most aortic diseases.

Outbreak of 2009 pandemic influenza A(H1N1), Los Lagos, Chile, April-June 2009.

On 17 May 2009, the first two cases of 2009 pandemic influenza A(H1N1) were confirmed in the Metropolitan region (Santiago, Chile). On 6 June 2009, Chile reported 500 confirmed cases, seven severe and two fatal. Because six of the severe cases and the two deaths occurred in the region of Los Lagos in southern Chile, a retrospective study was conducted using data on emergency room visits as well as laboratory viral surveillance, during the period from 1 April to 31 May, in order to establish the date of the beginning of the outbreak. From 1 to 27 June, data were collected in real time, to establish the real magnitude of the outbreak, describe its transmission, clinical severity and secondary attack rates. Confirmed cases, their household contacts and healthcare workers were interviewed. This analysis showed that the outbreak in Los Lagos started on 28 April. By 27 June, a total of 14.559 clinical cases were identified, affecting mostly 5-19 year-olds. The effective reproduction number during the initial phase (20 days) was 1.8 (1.6-2.0). Of the 190 confirmed cases with severe acute respiratory infection, 71 (37.4%) presented a risk condition or underlying illness.

[Low back pain as a manifestation of an intra-abdominal desmoplastic small round cell tumor]. / Dolor lumbar como manifestación de un tumor intra-abdominal desmoplásico de células pequeñas y redondas.

The desmoplastic small round cell tumor is infrequent.That mainly affects male youngsters and is normally located at the abdomino-pelvic cavity, being its clinic unspecific. The diagnosis is confirmed by the presence of a specific chromosomal translocation: t (11; 22), (p13; q12). As to its treatment, it is mostly recommended to follow a multimodal aggressive one. We present the case of a man, whose atypicality is due to his advanced age (63 years old) and the symptoms he presents (lumbar ache).

Association of NT-proBNP with severity of heart valve disease in a medical patient population presenting with acute dyspnea or peripheral edema.

BACKGROUND AND AIM OF THE STUDY: The study aim was to perform a comprehensive evaluation of the association between N-terminal pro B-type natriuretic peptide (NT-proBNP) and the severity of heart valve diseases in a typical clinical population presenting with acute dyspnea or peripheral edema. METHODS: Among 401 eligible patients, 210 demonstrated evaluable complete echocardiographic examinations. Plasma levels of NT-proBNP were measured after the initial clinical evaluation. RESULTS: Patients with a prior valve replacement had higher plasma levels of NT-proBNP (median 3,366 pg/ml; n = 10) compared to all other patients (median 931 pg/ml; n = 200) (p < 0.05). In univariable analyses, NT-proBNP levels correlated with multiple valve diseases (r = 0.5; p < 0.001) and the severities of specific heart valve diseases, including aortic valve stenosis (AS) and regurgitation (AR), tricuspid (TR) and mitral valve regurgitation (MR) (p < 0.001). Within multivariable linear regression models, multiple heart valve diseases (Beta = 0.21; T = 3.56; p = 0.0001) and specifically valve regurgitations (AR (Beta = 0.16; T = 2.54; p = 0.012), MR (Beta = 0.36; T = 5.55; p = 0.0001), TR (Beta = 0.17; T = 2.55; p = 0.012)) were associated with increasing plasma levels of NT-proBNP. Patients with NT-proBNP plasma levels > 1,100 pg/ml showed the highest risk for future clinical events (odds ratio (OR) 4.86; p = 0.02), followed by patients with TR (OR 3.17; p = 0.03) and AS (OR 3.49; p = 0.06). CONCLUSION: In addition to clinical assessment and echocardiographic evaluation, the measurement of plasma NT-proBNP levels may serve as a valuable additional indicator of the severity of heart valve disease in individual patients.