Isquemia de mão de pacientes em terapia renal substitutiva: avaliação por termografia / Isquemia de mano de pacientes en terapia de reemplazo renal: evaluación por termografía / Hand ischemia in patients undergoing renal replacement therapy: assessment by thermography

Resumo Objetivo Avaliar a presença de isquemia na porção distal das mãos dos membros superiores com Fistula Arteriovenosa (FAV) de pacientes em Terapia Renal Substitutiva (TRS) através da termografia por infravermelho. Método Amostra composta por 15 pacientes em TRS por hemodiálise por meio de FAV que responderam um questionário elaborado pelos próprios autores com as seguintes variáveis: dados sociodemográficos, diagnóstico, sinais vitais e dados sobre a FAV. Para obtenção dos termogramas das mãos com e sem FAV foi utilizado uma câmera termográfica por infravermelho C5, FLIR Systems, fixada a 50 cm das mãos dos participantes, privilegiando o enquadramento bilateral enquadrando ambas as mãos. Os dados obtidos foram organizados em planilha de Excel 2011® e comparados estatisticamente utilizando o programa Microcal Origin 6.0, para avaliar se existia diferença entre as médias de temperatura. Resultados Com relação as variáveis sociodemográficas, o gênero masculino foi o predominante, faixa etária com média de 45 anos, ensino fundamental (incompleto/completo), casados e provenientes de outros municípios. A termografia demonstrou que há diferença de temperatura entre as mãos com FAV e sem FAV, com variação na temperatura de 1,78°C (± DP 1,99°C), menor para as mãos com FAV. Conclusão A análise da distribuição do sangue das mãos por meio da termografia pode fornecer evidências sobre a microcirculação periférica e orientar o diagnóstico precoce e o tratamento da isquemia induzida por FAV em indivíduos em TRS, como ferramenta inovadora de diagnóstico auxiliar das complicações dos acessos venosos de pacientes em hemodiálise.

Resumen Objetivo Evaluar la presencia de isquemia en la parte distal de las manos de los miembros superiores con fístula arteriovenosa (FAV) de pacientes en terapia de reemplazo renal (TRR) a través de la termografía infrarroja. Métodos Muestra compuesta por 15 pacientes en TRR por hemodiálisis mediante FAV que respondieron un cuestionario elaborado por los propios autores con las siguientes variables: datos sociodemográficos, diagnóstico, signos vitales y datos sobre la FAV. Para obtener los termogramas de las manos con y sin FAV, se utilizó una cámara termográfica infrarroja C5, FLIR Systems, ubicada a 50 cm de las manos de los participantes, favoreciendo el encuadramiento bilateral y encuadrando ambas manos. Los datos obtenidos se organizaron en una planilla de Excel 2011® y se compararon estadísticamente con el programa Microcal Origin 6.0, para evaluar si había diferencia entre los promedios de temperatura. Resultados Con relación a las variables sociodemográficas, el género masculino fue predominante, grupo de edad promedio de 45 años, educación primaria (incompleta/completa), casados y provenientes de otros municipios. La termografía demostró que hay diferencia de temperatura entre las manos con FAV y sin FAV, con una variación de temperatura de 1,78°C (± DP 1,99°C), menor en las manos con FAV. Conclusión El análisis de la distribución de la sangre de las manos por medio de termografía puede ofrecer evidencias sobre la microcirculación periférica y guiar el diagnóstico temprano y el tratamiento de la isquemia inducida por FAV en individuos en TRR, como una herramienta innovadora de diagnóstico auxiliar de las complicaciones de los accesos vasculares de pacientes en hemodiálisis.

Abstract Objective To assess the presence of ischemia in the distal portion of the hands of the upper limbs with arteriovenous fistula (AVF) in patients undergoing renal replacement therapy (RRT) using infrared thermography. Method The sample consisted of 15 patients on RRT via hemodialysis using an AVF who answered a questionnaire prepared by the authors themselves with sociodemographic data, diagnosis, vital signs and data on AVF. To obtain thermograms of hands with and without AVF, a C5 infrared thermographic camera, FLIR Systems, was used, fixed 50 cm from participants' hands, favoring bilateral framing of both hands. The data obtained were organized in an Excel 2011® spreadsheet and statistically compared using the Microcal Origin 6.0 program to assess whether there was a difference between temperature averages. Results Regarding sociodemographic variables, males were predominant, with a mean age of 45 years, (incomplete/complete) elementary school, married and from other municipalities. Thermography demonstrated that there is a difference in temperature between hands with AVF and without AVF, with a temperature variation of 1.78°C (± SD 1.99°C), lower for hands with AVF. Conclusion The analysis of hand blood distribution using thermography can provide evidence on peripheral microcirculation and guide the early diagnosis and treatment of AVF-induced ischemia in individuals undergoing RRT as an innovative auxiliary diagnostic tool for complications of venous access in hemodialysis patients.

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm / Revascularização aberta na isquemia mesentérica crônica durante a era endovascular: experiência de um centro quaternário e um algoritmo de tratamento

Abstract Background Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR). Objectives To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition. Methods Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature. Results All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years. Conclusions Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Resumo Contexto A isquemia mesentérica crônica (IMC) é uma doença debilitante, com grave impacto na qualidade de vida. A literatura recomenda a angioplastia com stent da artéria mesentérica superior (AMS) como primeira opção de tratamento, mas há falta de consenso que defina indicações precisas para a revascularização aberta. Objetivos Descrever uma série de quatro pacientes com IMC, tratados com revascularização aberta, e apresentar um algoritmo para o manejo dessa condição. Métodos Três pacientes apresentaram angina intestinal típica e perda ponderal. Uma paciente foi submetida a reparo aberto de aneurisma da aorta abdominal e apresentava obstrução da AMS, que foi revascularizada profilaticamente. As técnicas cirúrgicas incluíram: 1) enxerto entre a aorta infrarrenal e a AMS; 2) enxerto entre o dácron utilizado em um enxerto aortobifemoral e a AMS; 3) enxerto entre a artéria ilíaca comum direita e a AMS; e 4) enxerto entre o ramo direito do dácron utilizado em um enxerto aorto-biilíaco e a artéria cólica média (ao nível da arcada de Riolan). Todos os enxertos foram feitos utilizando politetrafluoretileno em uma configuração retrógrada, tunelizados abaixo da veia renal esquerda, fazendo uma alça em C. Resultados Todos os pacientes demonstraram resolução dos sintomas e ganho ponderal. Todos os enxertos se mantiveram pérvios durante um seguimento médio de 2 anos. Conclusões A revascularização aberta para IMC utilizando-se a alça em C é uma técnica valiosa e pode ser considerada em pacientes selecionados. O algoritmo proposto pode auxiliar na decisão terapêutica em centros quaternários.

Correlação entre o índice de resistência vascular e a arteriografia na avaliação do leito arterial distal na isquemia crítica dos membros inferiores / Correlation between the vascular resistance index and arteriography for assessment of the distal arterial bed in chronic limb threatening ischemia

Resumo Contexto Pacientes com isquemia crítica (IC) dos membros inferiores (MMII) precisam de arteriografia para o planejamento da cirurgia de revascularização. A ultrassonografia Doppler (UD) não é invasiva e, através da aferição do índice de resistência (IR), pode fornecer informações sobre as artérias distais. Objetivos Correlacionar a Classificação Angiográfica de Rutherford com o IR na avaliação do leito arterial distal dos MMII. Métodos Estudo transversal, realizado em hospital público terciário, com 120 pacientes portadores de IC dos MMII, entre setembro de 2019 a abril de 2022. Foi comparado o IR das artérias da perna passíveis de serem receptoras de revascularização com a imagem obtida através da arteriografia dessas artérias em acordo com a Classificação Angiográfica de leito distal de Rutherford. Resultados Foram avaliados 120 MMII em 120 pacientes com idade média de 68,6 anos. A amostra foi composta de 50,0% de pacientes do sexo masculino. Na amostra, 90,0% pacientes encontravam-se na classe cinco de Rutherford. Os valores do IR encontrados para as artérias de perna apresentaram uma correlação positiva, estatisticamente significativa, quando comparados com a Classificação de Rutherford (tibial anterior, p< 0,01; tibial posterior, p = 0,012 e fibular, p = 0,034 e artéria dorsal do pé, p < 0,001). Conclusões Neste estudo, os IRs das artérias da perna obtidos através da ultrassonografia Doppler apresentaram uma correlação positiva quando comparados à classificação de Rutherford. Em pacientes com isquemia crítica, esse índice pode ser útil na avaliação do leito arterial distal dos membros inferiores.

Abstract Background Patients with chronic limb threatening ischemia (CLTI) of the lower limbs (LL) undergo arteriography for revascularization surgery planning. Doppler ultrasound (DU) is non-invasive and can provide information about the distal arteries through measurement of the resistance index (RI). Objectives To correlate the Rutherford Angiographic Classification with the RI for assessment of the distal arterial bed of the LL. Methods A cross-sectional study, conducted at a public tertiary hospital with 120 patients with LL CLTI, from September 2019 to April 2022. The RI of arteries that were candidates for revascularization was compared with the images of the same arteries obtained using arteriography, using the Rutherford Angiographic Classification of the distal bed. Results A total of 120 LL were assessed in 120 patients with a mean age of 68.6 years. The sample was 50.0% male and 90.0% of the patients in the sample were classified as Rutherford category five. The RI values found for the arteries of the leg exhibited a statistically significant positive correlation with the Rutherford Classification (anterior tibial, p< 0.01; posterior tibial, p = 0.012 fibular, p = 0.034; and dorsalis pedis, p < 0.001). Conclusions In this study, RIs for the arteries of the leg measured using Doppler ultrasound exhibited a positive correlation with the Rutherford Classification. This index could be useful for assessment of the distal arterial bed of the lower limbs of patients with chronic limb threatening ischemia.

Arterialização venosa superficial com veia safena magna in situ: a experiência de um único centro / Superficial venous arterialization with the great saphenous vein in situ: a single-center experience

Resumo Contexto A arterialização do arco venoso dorsal do pé é uma técnica indicada em casos de isquemia crítica de membros inferiores sem leito distal adequado que possibilite tratamento convencional, como revascularização, angioplastia ou tratamento clínico. Objetivos O propósito do trabalho foi apresentar o resultado da arterialização do arco venoso do pé em 16 pacientes submetidos a essa técnica. Métodos Tratou-se de um estudo analítico descritivo retrospectivo transversal, baseado na revisão de prontuários de 16 pacientes submetidos à arterialização do arco venoso dorsal do pé para salvamento de membro, entre janeiro de 2016 a janeiro de 2021. Resultados Dos 16 pacientes submetidos à arterialização do arco venoso do pé, 25% (4) evoluíram para amputação maior durante a mesma internação, e 6,25% (1) pacientes evoluíram para amputação maior após 6 meses. Os demais pacientes (68,75%, 11) tiveram seus membros preservados, sendo que 10 foram submetidos a amputações menores (pododáctilos e antepé), e 1 paciente não necessitou de procedimento adicional. Conclusões A técnica de arterialização do arco venoso dorsal do pé deve ser considerada em casos selecionados. Trata-se de uma alternativa válida para a preservação do membro na impossibilidade de tratamento convencional.

Abstract Background Arterialization of the dorsal venous arch of the foot is a technique indicated in cases of critical lower limb ischemia that do not have a distal bed that is adequate to enable conventional treatment such as revascularization, angioplasty, or clinical treatment. Objectives The purpose of this study is to present the result of arterialization of the venous arch of the foot in 16 patients who underwent treatment with this technique. Methods This is a cross-sectional retrospective descriptive analytical study based on a review of the medical records of 16 patients who underwent arterialization of the dorsal venous arch of the foot for limb salvage from January 2016 to January 2021. Results Four (25%) of the 16 patients who underwent arterialization of the venous arch of the foot underwent a major amputation during the same hospital stay and one patient (6.25%) had a major amputation within 6 months. The other 11 patients (68.75%) had their limbs preserved, with 10 undergoing minor amputations (toes and forefoot) and one patient having no additional procedures. Conclusions We conclude that the technique of arterialization of the dorsal venous arch of the foot should be considered in selected cases. It is a valid alternative for limb salvage when conventional treatment is impossible.

Isquemia mesentérica aguda: un desafío de la medicina. Reporte de un caso

La isquemia intestinal aguda es una emergencia vascular provocada por fenómenos oclusivos y no oclusivos de la circulación mesentérica arterial y venosa, de difícil diagnóstico y pronóstico ominoso. Su incidencia va en aumento paulatino con el decurso de los años, asociada fundamentalmente al envejecimiento de la población. La tasa de mortalidad es elevada a pesar de los avances en el campo de la imagenología. Suele diagnosticarse de forma tardía, cuando está establecido el daño isquémico intestinal de carácter irreversible. El elemento imprescindible e indispensable lo constituye el tiempo que trascurre hasta la cirugía, por lo que su diagnóstico sigue siendo un reto clínico. El tratamiento exige medidas médicas intensivas, al igual que cirugía de revascularización y resección del intestino necrosado. Por desdicha, el examen físico y los hallazgos de laboratorio no son sensibles ni específicos para su diagnóstico. Teniendo en cuenta estos elementos, se presenta el caso de una paciente de 38 años con clínica difusa de vómitos, diarrea y dolor abdominal progresivo, que requirió intervención quirúrgica de urgencia con diagnóstico transoperatorio de isquemia mesentérica aguda. Durante su estancia hospitalaria se relaparotomizó en dos ocasiones, mantuvo soporte ventilatorio e inotrópico por fallo multiorgánico en la Unidad de Cuidados Intensivos, mostrando una adecuada evolución posquirúrgica. El objetivo de esta presentación es enfatizar en la clínica como elemento fundamental para abordar de forma correcta esta entidad en un medio hospitalario de limitados recursos diagnósticos imagenológicos, al abordar conceptos teóricos recientes y facilitar una adecuada actuación en la toma de decisiones.

Acute intestinal ischemia is a vascular emergency caused by occlusive and non-occlusive phenomena of the mesenteric arterial and venous circulation of difficult diagnosis and ominous prognosis. Its incidence is gradually increasing over the years, mainly associated with the ageing of the population. The mortality rate is high despite advances in the field of imaging. It is usually diagnosed late, when irreversible ischemic intestinal damage is established. The essential and indispensable element is the time that elapses until surgery, so its diagnosis continues to be a clinical challenge. Treatment requires intensive medical measures, as well as revascularization surgery and resection of the necrotic intestine. Unfortunately, physical examination and laboratory findings are neither sensitive nor specific for its diagnosis. Taking these elements into account, the authors present the case of a 38-year-old female patient with diffuse symptoms of vomiting, diarrhea and progressive abdominal pain that required emergency surgery with intraoperative diagnosis of acute mesenteric ischemia. During her hospital stay, she underwent re-laparotomy twice, maintained ventilatory and inotropic support due to multi-organ failure in the Intensive Care Unit, showing an adequate post-surgical evolution. The objective of this presentation is to emphasize in the clinic as a fundamental element to correctly address this entity in a hospital environment with limited imaging diagnostic resources by addressing recent theoretical concepts and facilitating adequate action in decision-making.

Trombosis venosa mesentérica y portal como causa infrecuente de obstrucción e isquemia intestinal en paciente joven. Reporte de caso / Mesenteric and Portal Venous Thrombosis as an infrequent cause of intestinal Obstruction and Ischemia in young patients. A case report

Resumen La isquemia mesentérica aguda se asocia a una mortalidad de entre el 50 y el 100%, la causa más rara de esta es la trombosis venosa de los vasos mesentéricos (5%) y portal (1%). Las manifestaciones clínicas son diversas, siendo el dolor abdominal el principal síntoma. La tomografía computarizada con contraste intravenoso en fase portal es la imagen más precisa para el diagnóstico. El tratamiento en fase aguda se basa en anticoagulación, fluidos intravenosos, antibióticos profilácticos, descanso intestinal y descompresión. La laparotomía de control de daños, incluida la resección intestinal y el abdomen abierto, pueden estar justificados en última instancia para pacientes con necrosis intestinal y sepsis. Caso clínico: Hombre de 35 años, sin antecedentes de importancia, solo tabaquismo desde hace 15 años. Refirió que 5 días previos comenzó a presentar dolor en el epigastrio tipo cólico, de intensidad moderada, posteriormente refirió que el dolor se generalizó y aumentó de intensidad, acompañado de náusea, vómito, intolerancia a la vía oral y alza térmica. Al examen físico tuvo datos de respuesta inflamatoria sistémica, estaba consciente y orientado, con abdomen doloroso a la palpación superficial y profunda a nivel generalizado, pero acentuado en el flanco derecho, rebote positivo con resistencia, timpanismo generalizado, peristalsis ausente. Se ingresó a quirófano a laparotomía exploradora, encontrando lesión a intestinal isquémica-necrótica a 190-240 cm del ángulo de Treitz, y 400 cc de líquido hemático; se realizó resección de la parte intestinal afectada, con entero-enteroanastomosis término-terminal manual. Se envió pieza a patología, y se reportó un proceso inflamatorio agudo con necrosis transmural y congestión vascular. Ante estos hallazgos se realizó angiotomografía abdominal que reportó defecto de llenado en la vena mesentérica superior, secundario a trombosis que se extendía hasta la confluencia y la vena porta. Conclusión: La trombosis venosa mesentérica y portal es una patología muy infrecuente en pacientes jóvenes sin factores de riesgo en los que se presenta dolor abdominal. El diagnóstico es complejo debido a que los datos clínicos y de laboratorio son poco específicos. Sin embargo, debemos tenerla en cuenta en el diagnóstico diferencial de etiologías de dolor abdominal.

Abstract Acute Mesenteric Ischemia is associated with a mortality rate between 50% and 100%; the rarest cause of this is venous thrombosis of the mesenteric (5%) and portal (1%) vessels. The clinical manifestations are diverse, with abdominal pain being the main symptom. Computed tomography with intravenous contrast in the portal phase is the most accurate image for diagnosis. Treatment in the acute phase is based on anticoagulation, intravenous fluids, prophylactic antibiotics, intestinal rest, and decompression. Damage control laparotomy, including bowel resection and open abdomen, may ultimately be warranted for patients with bowel necrosis and sepsis. Clinical case: 35-year-old man, with no significant history, only smoking for 15 years. For 5 days before, he reported crampy epigastric pain of moderate intensity. He subsequently reported that the pain became generalized and increased in intensity, accompanied by nausea, vomiting, oral intolerance, and temperature rise. The physical examination showed signs of a systemic inflammatory response, conscious and oriented, abdomen painful on superficial and deep palpation at a generalized level but accentuated on the right flank, positive rebound with resistance, generalized tympanism, absent peristalsis. The operating room was entered for exploratory laparotomy, finding an ischemic-necrotic intestinal lesion at 190 - 240 cm from the angle of Treitz, and 400cc of blood fluid. Resection of the affected intestinal part is performed, with entire manual terminal end anastomosis. The specimen was sent to pathology, reporting an acute inflammatory process with transmural necrosis and vascular congestion. Given these findings, abdominal CT angiography was performed, which reported a filling defect in the superior mesenteric vein, secondary to thrombosis that extended to the confluence and the portal vein. Conclusion: Mesenteric and portal venous thrombosis is a very rare pathology in young patients without risk factors in whom abdominal pain occurs. The diagnosis is complex because the clinical and laboratory data are not very specific. However, we must take it into account in the differential diagnosis of abdominal pain etiologies.

Prediction of Preterm Delivery Using Serum Ischemia Modified Albumin, Biglycan, and Decorin Levels in Women with Threatened Preterm Labor / Previsão de parto prematuro usando albumina modificada por isquemia sérica, biglicano e níveis de decorina em mulheres com ameaça de trabalho de parto prematuro

Abstract Objective The serum ischemia modified albumin (IMA), biglycan, and decorin levels of pregnant women who were hospitalized for threatened preterm labor were measured. Methods Fifty-one consecutive pregnant women with a single pregnancy between the 24th and 36th weeks with a diagnosis of threatened preterm labor were included in the present prospective cohort study. Results As a result of multivariate logistic regression analysis for predicting preterm delivery within 24 hours, 48 hours, 7 days, 14 days, ≤ 35 gestational weeks, and ≤ 37 gestational weeks after admission, area under the curve (AUC) (95% confidence interval [CI[) values were 0.95 (0.89-1.00), 0.93 (0.86-0.99), 0.91 (0.83-0.98), 0.92 (0.85-0.99), 0.82 (0.69-0.96), and 0.89 (0.80-0.98), respectively. In the present study, IMA and biglycan levels were found to be higher and decorin levels lower in women admitted to the hospital with threatened preterm labor and who gave preterm birth within 48 hours compared with those who gave birth after 48 hours. Conclusion In pregnant women admitted to the hospital with threatened preterm labor, the prediction preterm delivery of the combined model created by adding IMA, decorin, and biglycan in addition to the TVS CL measurement was higher than the TVS CL measurement alone. Clinical trial registration The present trial was registered at ClinicalTrials.gov, number NCT04451928.

Resumo Objetivo Medir os níveis séricos de albumina modificada por isquemia (IMA), biglicano e decorina de gestantes hospitalizadas por ameaça de parto prematuro. Métodos Cinquenta e uma mulheres grávidas consecutivas com uma única gravidez entre a 24ᵃ e a 36ᵃ semanas com diagnóstico de ameaça de trabalho de parto prematuro foram incluídas no presente estudo de corte prospectivo. Resultados Como resultado da análise de regressão logística multivariada para prever parto prematuro dentro de 24 horas, 48 horas, 7 dias, 14 dias, ≤ 35 semanas gestacionais e ≤ 37 semanas gestacionais após a admissão, área sob a curva (AUC) (95% de confiança os valores de intervalo [CI[) foram 0,95 (0,89-1,00), 0,93 (0,86-0,99), 0,91 (0,83-0,98), 0,92 (0,85-0,99), 0,82 (0,69-0,96) e 0,89 (0,80-0,98), respectivamente. No presente estudo, os níveis de IMA e biglican foram maiores e os níveis de decorin menores em mulheres admitidas no hospital com ameaça de trabalho de parto prematuro e que tiveram parto prematuro em 48 horas em comparação com aquelas que deram à luz após 48 horas. Conclusão Em gestantes admitidas no hospital com ameaça de trabalho de parto prematuro, a predição de parto prematuro do modelo combinado criado pela adição de IMA, decorin e biglican, além da medição do TVS CL, foi maior do que a medição do TVS CL isoladamente. Registro do ensaio clínico O presente ensaio foi registrado em ClinicalTrials.gov, número NCT04451928.

Precondicionamiento Isquémico Remoto: bases de la protección y resultados clínicos

El precondicionamiento isquémico remoto es una manera eficaz de disminuir el daño por isquemia y reperfusión en el corazón y otros órganos como cerebro o riñón, en modelos experimentales. Este consiste en realizar entre 3 y 5 ciclos de 5 minutos de isquemia seguidos del mismo tiempo de reperfusión, en un tejido alejado del que se quiere proteger, normalmente una extremidad. Estudios preclínicos en animales indican que la isquemia precondicionante inicia señales nerviosas y humorales en el tejido isquémico remoto, que en el corazón activan mecanismos de protección. La señal nerviosa se origina en fibras sensoriales que a nivel cerebral producen una activación del sistema parasimpático. El nervio vago activa ganglios cardíacos intrínsecos del corazón lo que induce protección. Además, desde el tejido isquémico se liberan a la circulación diferentes mediadores que viajan en forma libre o en vesículas lipídicas (exosomas) que inician vías de señalización protectoras en el corazón. A pesar del éxito del precondicionamiento isquémico remoto en animales de experimentación, su aplicación en seres humanos no ha tenido resultados claros. Esta discrepancia puede deberse a una diversidad de factores tales como la edad, la existencia de otras patologías, uso de fármacos u otros tratamientos que afectan la respuesta de los pacientes. Se requiere un mayor conocimiento de las bases moleculares de este mecanismo de protección para que su aplicación en clínica sea exitosa.

In experimental models, remote ischemic preconditioning effectively decreases ischemia reperfusion injury to the heart and other organs such as the brain or kidney. It consists of 3 to 5 cycles of 5 minutes of ischemia followed by 5 minutes of reperfusion, in a remote tissue, usually a limb. Preclinical studies in animals indicate that preconditioning ischemia initiates neural and humoral signals in the remote ischemic tissue, which activate protective mechanisms in the heart. The nervous signal originates in sensory fibers that activate the parasympathetic system in the brain. The vagus nerve activates the intrinsic cardiac ganglia of the heart, leading to protection from ischemic injury. Furthermore, mediators are released from the ischemic tissue into the circulation that travels freely or in lipid vesicles (exosomes) to the heart where they initiate protective signaling pathways. Despite the success of remote ischemic preconditioning in experimental animals, its application in humans has not produced clear results. This discrepancy may be due to a variety of factors such as age, the existence of other pathologic processes, or the use of drugs or other treatments that affect the patient´s response. An increased knowledge of the molecular bases of this protective mechanism is required for its clinical application to be successful.

Encefalopatia hipoxica isquemica neonatal avances y nuevos tratamientos basados en las bases patofisiologicas de la injuria / Neonatal hypoxic ischemic encephalopathy: Progress and new treatments according to the pathophysiological basis of the injury

Resumen La encefalopatía hipóxica isquémica del neonato (EIH) es un tipo de injuria causada por la falta de oxí geno en el cerebro durante el periodo neonatal. Es un síndrome clínico claramente reconocible en recién na cidos a término y prematuros debido a asfixia fetal en el momento del nacimiento. Se estima que EHI ocurre a una frecuencia de1 a 3 por cada 1000 nacimientos vivos al año en países desarrollados. En países de bajo o mediano ingreso, la incidencia es hasta 10-20 veces más alta, equivalente a 1-8 nacidos vivos por cada 1000. El impacto social y económico ha sido estimado en cerca de 50.2 millones de dólares por año de vida ajustados a discapacidad. Así mismo, se estima que 7 es el número necesario de pacientes a tratar con hipotermia corporal terapéutica (HCT) para evitar un caso de muerte o minusvalía severa. La etiología es multifactorial e incluye factores prenatales, perinatales o post natales. El diagnóstico se basa en la incapacidad para respirar en el momento del nacimiento requirien do ventilación asistida, Apgar menos de 5 a los 5 y 10 minutos, alteración del estado normal de conciencia, reflejos neonatales y de tono muscular. Este artículo revisa los avances y estrategias terapéuticas estableci das y emergentes basadas en las fases pato-fisiológicas de este proceso.

Abstract Neonatal hypoxic ischemic encephalopathy (HIE) is a type of injury caused by lack of oxygen in the brain during the neonatal period. It is a clinical syndrome clearly rec ognizable in term and premature newborns secondary to asphyxia at the time of delivery. HIE is estimated to occur at a frequency of 1-3 for each 1000 alive newborns per year in developed countries. In countries of low or medium income, the incidence is up to 10-20 times higher, equivalent to 1-8 alive newborns per each 1000. The social and economic impact has been estimated near US$ 50.2 million per year of life adjusted to disability. At the same time, it is estimated in 7, the number of patients needed to treat with corporal cooling therapy (CCT) to prevent one case of death or se vere disability. The etiology is multifactorial and includes prenatal, perinatal and postnatal factors. The diagnosis is based in the inability to support spontaneous breath at the time of delivery requiring assisted ventilation, Apgar less than 5 at 5 and 10 minutes, altered level of consciousness, neonatal reflexes and muscle tone. This article is a review of the stablished and emergent therapeutic strategies based on the pathophysiological disease process.

Clinical impact of the infrapatellar location in symptomatic peripheral arterial disease patients / Impacto clínico de la localización infrapatelar en pacientes con enfermedad arterial periférica sintomática

Abstract Background: Peripheral artery disease (PAD) frequently affects multiple segments of the limbs. Contradictory data have reported worse prognosis in aortoiliac lesions, nevertheless, diabetes and chronic limb ischemia frequently affects the infrapatellar territory. Our aim was to assess the impact of infrapatellar disease in cardiovascular outcomes. Methods: We performed a retrospective, observational cohort study at a university hospital in Argentina. Electronic health records were retrospectively reviewed including symptomatic PAD patients requiring revascularization. A multivariable regression model was performed to account for confounders. The primary endpoint was a composite of hospitalizations due to chronic limb threatening ischemia (CLTI) and major amputation events between infrapatellar and suprapatellar patients. Minor amputation events, all-cause death, myocardial infarction (MI), stroke, and major cardiovascular events (MACE) were secondary endpoints. Results: From January 2014 through July 2020, a total of 309 patients were included in the analysis. 151 patients had suprapatellar disease, and 158 had infrapatellar disease. The primary composite endpoint occurred in 35 patients (22.2%) in the infrapatellar patients and 18 patients (11.9%) in the suprapatellar patients (HR = 2.16; 95% confidence interval [CI] = [1.22-3.82]; p = 0.008). Both components of the primary outcomes occurred more frequently in infrapatellar patients. Minor amputation events were more prevalent in infrapatellar patients (HR = 5.09; 95% CI = [1.47-17.6]; p = 0.010). Death, MI, stroke, and MACE events were not different among groups (all p > 0.05). Conclusion: Infrapatellar disease was an independent factor for increased hospitalization of CLTI, major and minor amputations events, compared to suprapatellar disease in symptomatic revascularized PAD patients.

Resumen Objetivo: La enfermedad vascular periférica (EVP) afecta generalmente múltiples segmentos de los miembros. Existe información contradictoria con respecto al pronóstico de pacientes con enfermedad aortoilíaca, sin embargo, la diabetes y la enfermedad critica de miembros inferiores habitualmente afecta el territorio infrapatelar. Nuestro objetivo es determinar el impacto de la afectación infrapatelar en eventos cardiovasculares. Métodos: Estudio retrospectivo, observacional en un hospital universitario de Argentina. Se revisó la historia clínica electrónica de pacientes con EVP con requerimiento de revascularización. Se generó un modelo de regresión multivariado incluyendo variables clínicamente relevantes. El punto final primario fue un combinado de hospitalización por isquemia crítica y amputaciones mayores entre pacientes con afectación infrapatelar y suprapatelar. Amputaciones menores, muerte por todas las causas, infarto agudo de miocardio (IAM), accidente cerebrovascular (ACV) y un combinado de eventos cardiovasculares (MACE) fueron los puntos secundarios. Resultados: Se reclutó un total de 309 pacientes desde enero de 2014 hasta julio de 2020. 151 pacientes presentaron enfermedad suprapatelar y 158 infrapatelar. El punto final primario ocurrió en 35 pacientes (22.2%) en el grupo infrapatelar y en 18 pacientes (11.9%) en suprapatelares (HR 2.16; intervalo de confianza 95% [1.22-3.82]; p = 0.008). Ambos componentes ocurrieron con mayor frecuencia en pacientes con afectación infrapatelar. Los eventos de amputación menor fueron mas prevalentes en pacientes con afectación infrapatelar (HR 5.09; IC95% [1.47-17.6]; p = 0.010) La mortalidad por todas las causas, IAM, ACV y MACE no fueron diferentes entre los grupos (p > 0.05). Conclusión: La enfermedad infrapatelar fue un factor independiente para mayor riesgo de hospitalización por isquemia critica, amputación mayor y menor comparado con pacientes con afectación suprapatelar en EVP sintomática revascularizada.

Animal Model Standardization for Studying Avascular Necrosis of the Femoral Head in Legg-Calvé-Perthes Disease / Padronização de modelo animal para o estudo da necrose isquêmica da cabeça femoral na doença de Legg-Calvé-Perthes

Abstract Objective Testing an experimental model for ischemic necrosis of the femoral head in Legg-Calvé-Perthes disease by evaluating gait, imaging and morphohistology. Methods The operation was done in 11 piglets. Necrosis by cerclage in the right femoral neck was induced. Piglets were divided into group A, with 8 animals, euthanizing two in the 2nd, 4th, 6th, and 8th weeks, respectively; and group B, with 2 animals (sham), submitted to the surgical procedure without cerclage of the right femoral neck. The gait classification used was that of Etterlin. The frozen femurs were submitted to digital radiography and computed tomography. The height and width of the epiphysis and epiphysary coefficient were measured at study times. Light microscopy and immunohistochemistry with TGF-β1 were performed. Results One animal died of sepsis in Group A. In this group, claudication was observed in all animals. On digital radiography and computed tomography, bone sclerosis, enlargement of the right femoral neck, flattening, collapse, and fragmentation of the right femoral head were observed. All epiphysis height and epiphysary coefficient values of the right femoral head were lower than the contralateral ones, in which were observed chondrocytes disordered and separated by gaps. A reduction in TGF-β1 expression was observed at 2 and 6 weeks in the right femoral head and at eight in the left. In group B, there were no signs of necrosis and gait was normal. Conclusions The model presented reproduced macroscopic necrosis on digital radiography, computed tomography, and microscopy. Gait evaluation showed a good correlation with other ischemia findings. Level of EvidenceV. Diagnostic studies.

Resumo Objetivo Testar um modelo experimental para necrose isquêmica da cabeça femoral na doença de Legg-Calvé-Perthes avaliando a marcha, exames de imagens e morfohistologia. Métodos Operaram-se 11 leitões. Induziu-se a necrose por cerclagem no colo femoral direito. Dividiram-se os leitões em grupo A com 8 animais, sacrificando-se dois na 2ª, 4ª, 6ª e 8ª semanas, respectivamente; e grupo B, com 2 animais (sham), submetidos ao procedimento cirúrgico sem a cerclagem do colo femoral direito. A classificação da marcha utilizada foi a de Etterlin. Os fêmures congelados foram submetidos à radiografia digital e tomografia computadorizada. Mediram-se a altura e largura da epífise e o coeficiente epifisário nos tempos de estudo. Realizou-se, microscopia de luz e imunohistoquímica com TGF-β1. Resultados Um animal morreu por sepse no grupo A. Neste grupo, observou-se claudicação em todos os animais. Na radiografia digital e tomografia computadorizada observaram-se: esclerose óssea, alargamento do colo femoral direito, achatamento, colapso e fragmentação da cabeça femoral direita. Todos os valores da altura da epífise e coeficiente epifisário da cabeça femoral direita foram menores que os contralaterais, nos quais observaram-se condrócitos desordenados e separados por lacunas. Observou-se redução da expressão do TGF-β1 com 2 e 6 semanas nas cabeças femorais direitas e nas esquerdas com oito. No grupo B, não ocorreram sinais de necrose e a marcha foi normal. Conclusões O modelo apresentado reproduziu a necrose macroscopicamente, na radiografia digital, tomografia computadorizada e microscopia. A avaliação da marcha demonstrou boa correlação com os demais achados de isquemia. Nível de EvidênciaV. Estudos diagnósticos.

Correlation between tomographic scales and vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage / Correlación entre escalas tomográficas y vasoespasmo e isquemia cerebral diferida en la hemorragia subaracnoidea aneurismática

ABSTRACT Objective: To determine the prevalence of sonographic vasospasm and delayed ischemic deficit in patients with aneurysmal subarachnoid hemorrhage, to evaluate the correlation between different tomographic scales and these complications, and to study prognostic factors in this group of patients. Methods: This was a prospective study of patients admitted to the intensive care unit with a diagnosis of aneurysmal subarachnoid hemorrhage. The prevalence of sonographic vasospasm and radiological delayed cerebral ischemia was analyzed, as was the correlation between different tomographic scales and these complications. Results: A total of 57 patients were studied. Sixty percent of the patients developed sonographic vasospasm, which was significantly associated with delayed cerebral ischemia and mortality. The Claassen and Hijdra scales were better correlated with the development of cerebral vasospasm (areas under the curve of 0.78 and 0.68) than was Fisher's scale (0.62). Thirty-two patients (56.1%) developed cerebral infarction on CT; the significantly associated factors were poor clinical grade at admission (p = 0.04), sonographic vasospasm (p = 0.008) and severity of vasospasm (p = 0.015). Only the semiquantitative Hijdra scale was significantly correlated with the development of radiological delayed cerebral ischemia (p = 0.009). The patients who presented cerebral infarction had worse neurological evolution and higher mortality. Conclusion: This is the first study in our environment on the subject. The Claassen and Hijdra tomographic scales showed better prognostic performance than the Fisher scale for the development of cerebral vasospasm. The finding of sonographic vasospasm could be a noninvasive criterion for the early detection of delayed cerebral ischemia and neurological deterioration in patients with aneurysmal subarachnoid hemorrhage.

RESUMO Objetivo: Determinar la prevalencia de vasoespasmo sonográfico y déficit isquémico diferido en pacientes con hemorragia subaracnoidea aneurismática, evaluar la correlación entre las diferentes escalas tomográficas con dichas complicaciones, así como estudiar los factores pronósticos en este grupo de pacientes. Métodos: Estudio prospectivo de pacientes ingresados a la unidad de cuidados intensivos con diagnóstico de hemorragia subaracnoidea aneurismática. Se analizó la prevalencia de vasoespasmo sonográfico e isquemia cerebral diferida radiológica, así como la correlación entre diferentes escalas tomográficas con dichas complicaciones. Resultados: Se estudiaron 57 pacientes. El 60% de los pacientes desarrollaron vasoespasmo sonográfico, el cual se asoció significativamente con isquemia cerebral diferida y mortalidad. Las escalas de Claassen y de Hijdra tuvieron una mejor correlación con el desarrollo de vasoespasmo cerebral (área bajo la curva de 0,78 y 0,68) que la de Fisher (0,62). Treinta y dos pacientes (56,1%) desarrollaron infarto cerebral en la TC, siendo los factores que se asociaron en forma estadísticamente significativa al mismo: pobre grado clínico al ingreso (p = 0,04), vasoespasmo sonográfico (p = 0,008) y severidad del vasoespasmo (p = 0,015). Solamente la escala semicuantitativa de Hijdra se correlacionó significativamente con el desarrollo de isquemia cerebral diferida radiológica (p = 0,009). Los pacientes que presentaron infarto cerebral tuvieron peor evolución neurológica y mayor mortalidad. Conclusion: Se presenta el primer estudio en nuestro medio sobre el tema. Las escalas tomográficas de Claassen y Hijdra presentaron un mejor rendimiento pronóstico que la de Fisher para desarrollo de vasoespasmo cerebral. El hallazgo de vasoespasmo sonográfico podría ser un criterio no invasivo de detección temprana de isquemia cerebral diferida y peoría neurológica en los pacientes con hemorragia subaracnoidea aneurismática.

Dolor tóraco-abdominal: "Si miras el corazón, encontrarás la razón". Serie de casos

La isquemia miocárdica es un fenómeno secundario a la perfusión insuficiente del músculo cardíaco que en algunos casos puede ocurrir de forma aguda llevando a la necrosis celular y constituyendo el infarto agudo al miocardio (IAM). A pesar de que el diagnóstico de IAM es principalmente clínico, en ciertos casos en que no se sospeche de forma activa por presentar síntomas no típicos de isquemia miocárdica, el diagnóstico puede sugerirse por la Tomografía Computarizada (TC), que puede mostrar hallazgos sugerentes de IAM. A continuación, se comunica una serie de 4 casos clínicos con diagnóstico imagenológico incidental de IAM.

Myocardial ischemia is secondary to myocardial under perfusion. It can develop acutely leading to cell necrosis and myocardial infarction (AMI), or have a chronic course. Though the diagnosis of AMI is mainly clinical, in certain cases the symptoms may be atypical and the diagnosis can be suggested by images such as Computed Tomography (CT). Herein we report a series of 4 clinical cases with diagnosis of AMI following incidental CT imaging. There was an abdominal pain in 3 patients and a cervical pain in the remaining one. CT scan showed a hypodense myocardial image. The final diagnosis was confirmed by the appropriate laboratory and angiographic methods.

Recurrent acute coronary syndrome after infliximab infusion in a patient with rheumatoid arthritis: Case report

Case description: A 61-year-old male patient with uncontrolled rheumatoid arthritis presented acute coronary syndrome on three occasions, less than 48 hours after infliximab infusion. Clinical findings: He presented with ST-elevation myocardial infarction on two occasions and non-ST-elevation acute coronary syndrome on one, with the identification of multivessel coronary disease. Treatment and outcome: Coronary intervention was performed with thrombus aspiration, medicated stent implantation, medicated balloon angioplasty, discontinuation of infliximab, and modification and optimization of cardiovascular pharmacological management. Clinical relevance: Patients with rheumatoid arthritis have subclinical cardiovascular disease and increased cardiovascular risk. The evidence regarding the relationship between infliximab and ischemic heart disease is controversial. A wide clinical spectrum of cardiac involvement with infliximab infusion is found in case reports, ranging from stable angina to ST-segment elevation acute coronary syndrome. The pathophysiology is not elucidated, with hypotheses proposing plaque rupture, allergic reactions, and vasoconstriction as possible disease mechanisms. The direct association between infliximab infusion and acute coronary syndrome needs more clinical research to optimize the management and prognosis of patients presenting with this type of complication.

Descripción del caso: Paciente masculino de 61 años con artritis reumatoide no controlada, en manejo con infliximab, quién presentó en tres oportunidades síndrome coronario agudo menos de 48 horas posterior a la aplicación del medicamento. Hallazgos clínicos: Presentó infarto con elevación del ST en dos ocasiones y síndrome coronario agudo sin elevación del ST en una oportunidad, encontrándose enfermedad coronaria multivaso. Tratamiento y resultado: Se realizó intervención coronaria con tromboaspiración, implante de stents medicados y angioplastia con balón medicado, suspensión del infliximab y modificación y optimización de manejo farmacológico cardiovascular. Relevancia clínica: Los pacientes con artritis reumatoide tienen enfermedad cardiovascular subclínica y mayor riesgo cardiovascular. La evidencia respecto a la relación entre infliximab y cardiopatía isquémica es controversial. En reportes de caso se encuentra un amplio espectro clínico de compromiso cardíaco con la infusión de infliximab, que va desde la angina estable hasta el síndrome coronario agudo con elevación del segmento ST. La fisiopatología no está claramente dilucidada, con hipótesis que proponen la ruptura de placa, reacciones alérgicas y la vasoconstricción como posibles mecanismos de enfermedad. La asociación directa entre la infusión de infliximab y el síndrome coronario agudo necesita más investigación clínica con el fin de optimizar el manejo y pronóstico de los pacientes que presentan este tipo de complicaciones.

Trombo flotante en el arco aórtico, una causa poco frecuente de isquemia de miembros inferiores / Floating thrombus in the aortic arch, a rare cause of lower limb ischemia

Resumen La oclusión arterial aguda de los miembros inferio res es una urgencia médica y quirúrgica por su morbi mortalidad. Presentamos el caso de un hombre de 59 años que ingresó al servicio de urgencias por un dolor agudo y difuso del miembro inferior izquierdo causado por extensos coágulos obstructivos en las arterias del miembro inferior izquierdo. Siendo improbable la cau sa ateromatosa tras realización de la angioscopia de miembros inferiores, se sospechó un origen cardíaco. La ecografía cardiaca no mostró anomalías, sin embargo, la angiotomografía torácica reveló un trombo flotante en el arco aórtico. El paciente fue tratado quirúrgica mente con colocación de una endoprótesis aórtica sin complicaciones.

Abstract Acute arterial occlusion of the lower limbs is a medi cal and surgical emergency due to its morbi-mortality. We present the case of a 59-year-old man admitted to the emergency department for acute and diffuse pain in the left lower limb caused by extensive obstructive clots in the arteries of this limb. Since atheromatous cause was unlikely after angioscopy of the lower limbs, a car diac origin was suspected. Echocardiogram was normal, however, thoracic angiotomography revealed a floating thrombus in the aortic arch. The patient was treated surgically with placement of an aortic endoprosthesis without complications.

Estrategia de apropiación social del conocimiento en la isquemia cardiaca / Strategy for the social appropriation of knowledge in myocardial ischemia

Introducción: La construcción de conocimiento a partir del intercambio de saberes entre pacientes, familias y equipo de salud es una necesidad sentida que puede impactar en la educación en salud y la adherencia a los tratamientos. Objetivo: Desarrollar una estrategia de apropiación social que permita innovar en el cuidado de la salud de las personas con enfermedad isquémica cardiaca y sus familias mediante el uso de la herramienta MHealth. Materiales y Métodos: Estudio exploratorio que permitió el diseño de una estrategia de apropiación social de conocimiento para mejorar la salud cardiovascular de personas que sufren isquemia cardiaca. Participaron 31 personas entre pacientes, familiares, profesionales de la salud. Se desarrollaron dos talleres virtuales en el mes de junio y seguimientos telefónicos entre agosto y septiembre. Las experiencias y saberes de los participantes, permitió la construcción de la herramienta MHealth. Resultados: La reflexión crítica entre los actores facilitó la construcción y desarrollo de la herramienta tipo MHealth (página web/app) titulada "Cuidando tu corazón", que permite el acceso a información relacionada con el cuidado durante la isquemia cardiaca y articula información a partir del diálogo de saberes y la evidencia reportada en la literatura. Discusión: Las estrategias de apropiación social son una herramienta relevante para la generación de conocimiento en el área de la salud. Conclusiones: La estrategia implementada permitió reconocer la importancia de contar con herramientas para el cuidado de la salud cardiovascular elaboradas desde las necesidades, perspectivas y creencias de sus actores para mejorar la educación y el cuidado.

Introduction: The construction of knowledge from the exchange of knowledge between patients, families, and healthcare teams is a felt need that can impact health education and adherence to treatment. Objective: To develop a social appropriation strategy that enables innovation in the health care of people with ischemic heart disease and their families through the use of an MHealth tool. Materials and methods: Exploratory study that allowed the design of a strategy for the social appropriation of knowledge to improve the cardiovascular health of people suffering from myocardial ischemia. Thirty-one people participated, including patients, family members, and health professionals. Two virtual workshops were held in June, and follow-up phone calls were made between August and September. The participant's experiences and knowledge enabled the construction of the MHealth tool. Results: The critical reflection of the stakeholders facilitated the construction and development of the MHealth tool (webpage/app) named "Cuidando tu corazón" (Taking care of your heart). Discussion: Social appropriation strategies are a relevant tool for knowledge creation in health. Conclusions: The strategy implemented made it possible to recognize the importance of developing cardiovascular healthcare tools from stakeholders' needs, perspectives, and beliefs to improve education and care.

Introdução: A construção do conhecimento a partir da troca de conhecimentos entre pacientes, familiares e equipe de saúde é uma necessidade sentida que pode impactar na educação em saúde e na adesão aos tratamentos. Objetivo: Desenvolver uma estratégia de apropriação social que permita inovar na atenção à saúde de pessoas com doença isquêmica do coração e seus familiares por meio do uso da ferramenta MHealth. Materiais e Métodos: Estudo exploratório que permitiu desenhar uma estratégia de apropriação social do conhecimento para melhorar a saúde cardiovascular de pessoas com isquemia cardíaca. Participaram 31 pessoas, entre pacientes, familiares e profissionais de saúde. Foram realizadas dois seminários virtuais em junho e acompanhamentos por telefone entre agosto e setembro. As experiências e conhecimentos dos participantes permitiram a construção da ferramenta MHealth. Resultados: A reflexão crítica entre os atores facilitou a construção e desenvolvimento da ferramenta do tipo MHealth (página web/ aplicativo) intitulada "Cuidando do seu coração", que permite o acesso às informações relacionadas aos cuidados durante a isquemia cardíaca e articula as informações a partir do diálogo de conhecimento e as evidências relatadas na literatura. Discussão: As estratégias de apropriação social são uma ferramenta relevante para a geração de conhecimento na área da saúde. Conclusões: A estratégia implementada possibilitou reconhecer a importância de ter ferramentas para o cuidado à saúde cardiovascular elaboradas a partir das necessidades, perspectivas e crenças de seus atores para melhorar a educação e o cuidado.

Isquemia arterial aguda trombótica de los miembros inferiores / Acute thrombotic arterial ischemia of the lower limbs

Introducción: La enfermedad arterial periférica es una de las afecciones más prevalentes. Resulta habitual su coexistencia con la enfermedad vascular en otras localizaciones. El diagnóstico precoz tiene importancia para mejorar la calidad de vida del paciente y reducir el riesgo de eventos secundarios mayores, como el infarto agudo de miocardio o el ictus. Objetivo: Caracterizar el comportamiento de la isquemia arterial aguda trombótica en miembros inferiores en pacientes que ingresaron en el Instituto Nacional de Angiología y Cirugía Vascular. Métodos: Se realizó un estudio observacional, descriptivo y retrospectivo, con el fin de determinar factores pronósticos en la evolución final del tratamiento quirúrgico de la isquemia arterial aguda trombótica en miembros inferiores, en pacientes que ingresaron en los servicios de Arteriología y Angiopatía Diabética del Instituto Nacional de Angiología y Cirugía Vascular durante un período de cuatro años. Resultados: El grupo de edades más afectado estuvo entre 40 y 59 años, con un predomino del sexo masculino. El hábito de fumar fue el factor de riesgo vascular más frecuente; y la amputación mayor, el procedimiento quirúrgico más empleado, por lo que el patrón oclusivo femoropoplíteo resultó el más prevalente. Conclusiones: Predominaron el sexo masculino, el hábito de fumar, la amputación mayor y el patrón oclusivo femoropoplíteo(AU)

Introduction: Peripheral arterial disease is one of the most prevalent conditions. Its coexistence with vascular disease in other locations is common. Early diagnosis is important to improve the patient's quality of life and reduce the risk of major secondary events, such as acute myocardial infarction or stroke. Objective: To characterize the behavior of acute thrombotic arterial ischemia in lower limbs in patients admitted to the National Institute of Angiology and Vascular Surgery. Methods: An observational, descriptive and retrospective study was conducted in order to determine prognostic factors in the final evolution of surgical treatment of acute thrombotic arterial ischemia in the lower limbs in patients admitted to the Arteriology and Diabetic Angiopathy services of the National Institute of Angiology and Vascular Surgery for a period of four years. Results: The most affected age group was the one of 40 to 59 years, with a predominance of males. Smoking was the most frequent vascular risk factor; and major amputation, the most used surgical procedure, so the femoropopliteal occlusive pattern was the most prevalent. Conclusions: Male sex, smoking habit, major amputation and femoropopliteal occlusive pattern predominated(AU)

Diacerein mitigates renal ischemia/reperfusion injury via inhibition of renal inflammation, dendritic cells maturation and apoptosis: the role of TLR4/NF-kB/NLRP3/IL-1beta signaling pathway / La diacereína mitiga la lesión por isquemia/reperfusión renal a través de la inhibición de la inflamación renal, la maduración de las células dendríticas y la apoptosis: el papel de la vía de señalización TLR4/NF-kB/NLRP3/IL-1beta

SUMMARY: One of the reasons for acute kidney damage is renal ischemia. Nevertheless, there are limited protective and therapeutic approaches for this problem. Diacerein is an anti-inflammatory drug characterized by numerous biological activities. We aimed to determine the ameliorative impact of diacerein on renal ischemia/reperfusion injury (I/R) condition, exploring the underlying mechanisms. Twenty-four male rats were allotted into four groups (n= 6): sham group; Diacerein (DIA) group; I/R group, in which a non-crushing clamp occluded the left renal pedicle for 45 min, and the right kidney was nephrectomized for 5 min before the reperfusion process; I/R + diacerein group, injected intraperitoneally with 50 mg diacerein/kg i.m 30 minutes prior to I/R operation. Ischemia/ reperfusion was found to affect renal function and induce histopathological alterations. The flow cytometry analysis demonstrated an elevated expression of innate and mature dendritic cells in I/R renal tissues. Moreover, upregulation in the expression of the inflammatory genes (TLR4, Myd88, and NLRP3), and overexpression of the pro-inflammatory cytokines (IL-1β), apoptotic (caspase-3) and pyroptotic (caspase-1) markers were observed in I/R-experienced animals. The aforementioned deteriorations were mitigated by pre-I/R diacerein treatment. Diacerein alleviated I/R-induced inflammation and apoptosis. Thus, it could be a promising protective agent against I/R.

La isquemia renal es una de los motivos del daño renal agudo. Sin embargo, los enfoques protectores y terapéuticos para este problema son limitados. La diacereína es un fármaco antiinflamatorio caracterizado por numerosas actividades biológicas. Nuestro objetivo fue determinar el impacto de mejora de la diacereína en la condición de lesión por isquemia/ reperfusión renal (I/R), explorando los mecanismos subyacentes. Veinticuatro ratas macho se distribuyeron en cuatro grupos (n= 6): grupo simulado; grupo de diacereína (DIA); grupo I/R, en el que una pinza no aplastante ocluyó el pedículo renal izquierdo durante 45 min, y el riñón derecho fue nefrectomizado durante 5 min antes del proceso de reperfusión; Grupo I/R + diacereína, inyectado por vía intraperitoneal con 50 mg de diacereína/kg i.m. 30 min antes de la operación I/R. Se encontró que la isquemia/ reperfusión afecta la función renal e induce alteraciones histopatológicas. El análisis de citometría de flujo demostró una expresión elevada de células dendríticas innatas y maduras en tejidos renales I/R. Además, se observó una regulación positiva en la expresión de los genes inflamatorios (TLR4, Myd88 y NLRP3) y una sobreexpresión de las citoquinas proinflamatorias (IL-1β), marcadores apoptóticos (caspasa-3) y piroptóticos (caspasa-1) en animales con experiencia en I/R. Los deterioros antes mencionados fueron mitigados por el tratamiento previo a la diacereína I/R. La diacereína alivió la inflamación y la apoptosis inducidas por I/R. Por lo tanto, podría ser un agente protector prometedor contra I/R.

Vitamin A could be a Therapeutic Agent in Ischemia/Reperfusion Induced Kidney Injury / La vitamina A podría ser un agente terapéutico en la lesión renal inducida por isquemia/reperfusión

ABSTRACT Introduction: Renal ischemia (I) could develop due to decreased or ceased blood flow to the kidney in some clinical conditions such as shock, sepsis, and kidney transplantation. The re-supply of blood to the kidney is called reperfusion (R). Ischemia and reperfusion periods can cause severe kidney damage. Objectives: When we examined the I/R molecular progression, antioxidant molecules such as vitamin A seem promising treatment agents. This study aimed to investigate the effects of vitamin A on renal I/R injury. Material and Methods: In the study, 40 Sprague-Dawley male rats were divided into five groups (n=8): the control group, only I/R, I/R+1000, I/R+3000, and I/R+9000 IU/kg of Vitamin A groups. Vitamin A was administrated to each group for seven days via oral gavage. Blood and kidney tissue samples were collected at the end of the experiment. We took blood samples for Superoxide dismutase (SOD), malondialdehyde (MDA), catalase (CAT), blood urea nitrogen (BUN), and creatinine (Cr) levels, and determined their values. The tissue samples were stained with hematoxylin/eosin to examine the renal changes histopathologically and stereologically under a light microscope. Results: Histopathological changes caused by I/R were decreased with vitamin A administration in a dose-dependent manner (p<0.05). Vitamin A administration decreased MDA levels and increased SOD and CAT activities (p<0.05). The most effective dose among treatment groups was 9000 IU/kg. There was no significant difference between the controls and all other groups regarding BUN and Cr concentrations. Conclusions: Consequently, administration of vitamin A after renal I/R reduced the histological damage and ameliorated the antioxidant state. These results showed that vitamin A could be a promising agent in treating I/R-induced acute kidney injury.

RESUMEN Introducción: La isquemia renal (I) puede desarrollarse debido a la disminución o interrupción del flujo sanguíneo al riñón en algunas condiciones clínicas como shock, sepsis y trasplante renal. El reabastecimiento de sangre al riñón se denomina reperfusión (R). Tanto la isquemia como los períodos de reperfusión pueden causar graves daños renales. Objetivos: Cuando examinamos la progresión molecular I/R, las moléculas antioxidantes como la vitamina A parecen agentes de tratamiento prometedores. El objetivo de este estudio fue investigar los efectos de la vitamina A sobre la lesión renal I/R. Material y Métodos: En el estudio, 40 ratas macho Sprague-Dawley se dividieron en 5 grupos (n=8) como: control, solo I/R, I/R+1000, I/R+3000 e I/R+9000 UI/kg de la Vitamina A. La vitamina A se administró a cada grupo durante 7 días por vía oral forzada. Al final del experimento se recolectaron muestras de sangre y tejido del riñón. A partir de muestras de sangre se determinaron los niveles de superóxido dismutasa (SOD), malondialdehído (MDA), catalasa (CAT), nitrógeno ureico en sangre (BUN) y creatinina (Cr). Las muestras de tejido se tiñeron con hematoxilina/eosina y los cambios en la histología renal se examinaron histopatológicamente y estereológicamente al microscopio de luz. Resultados: Los cambios histopatológicos causados por I/R disminuyeron con la administración de la vitamina A de manera dependiente de la dosis (p<0,05). La administración de la vitamina A disminuyó los niveles de MDA, aumentó las actividades de SOD y CAT (p<0,05). La dosis más eficaz entre los grupos del tratamiento fue de 9000 UI/kg. No hubo una diferencia significativa entre el grupo control y todos los demás grupos con respecto a las concentraciones de BUN y Cr. Conclusiones: Consiguientemente, la administración de la vitamina A, después de I/R renal, redujo el daño histológico y mejoró el estado antioxidante. Estos resultados mostraron que la vitamina A puede ser un agente promisorio en el tratamiento de la lesión renal aguda (LRA) inducida por I/R.