[Treatment of intrinsic brain tumors located in motor eloquent areas. Results of a protocol based in navigation, tractography and neurophysiological monitoring of cortical and subcortical structures]. / Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes. Resultados de un protocolo basado en la navegación, tractografía y monitorización neurofisiológica de estructuras corticales y subcorticales.

OBJECTIVES: The role of the microsurgical management of intrinsic brain tumors is to maximize the volumetric resection of the tumoral tissue minimizing the postoperative morbidity. The purpose of our paper has been to study the benefits of an original protocol developed for the microsurgical treatment of tumors located in eloquent motor areas where the navigation and electrical stimulation of motor subcortical pathways have been implemented. MATERIALS AND METHODS: A total of 17 patients operated on for resection of cortical or subcortical tumors in motor areas were included in the series. Preoperative planning for multimodal navigation was done integrating anatomic studies, motor functional MRI (f-MRI) and subcortical pathways volumes generated by diffusion tensor imaging (DTI). Intraoperative neuromonitorization included motor mapping by direct cortical and subcortical electrical stimulation (CS and sCS) and localization of the central sulcus using cortical multipolar electrodes and the N20 wave inversion technique. The location of all cortical and subcortical stimulated points with positive motor response was stored in the navigator and correlated with the cortical or subcortical motor functional structures defined preoperatively. RESULTS: The mean tumoral volumetric resection was 89.1±14.2% of the preoperative volume, with a total resection (≥100%) in twelve patients. Preoperatively a total of 58.8% of the patients had some motor deficit, increasing 24 hours after surgery to 76.5% and decreasing to 41.1% a month later. There was a great correlation between anatomic and functional data, both cortically and subcortically. However, in six cases it was not possible to identify the central sulcus and in many cases fMRI gave contradictory information. A total of 52 cortical points submitted to CS had positive motor response, with a positive correlation of 83.7%. Also, a total of 55 subcortical points had positive motor response, being in these cases 7.3±3.1 mm the mean distance from the stimulated point to the subcortical tract. CONCLUSIONS: The integration of preoperative and intraoperative anatomic and functional studies allows a safe functional resection of the brain tumors located in eloquent areas, compared to the tumoral resection based on anatomic imaging studies. Multimodal navigation allows the integration and correlation among preoperative and intraoperative anatomic and functional data. Cortical motor functional areas are anatomically and functionally located preoperatively thanks to MRI and fMRI and subcortical motor pathways with TDI and tractography. Intraoperative confirmation is done with CS and N20 inversion wave for cortical structures and with sCS for subcortical pathways. With this protocol we achieved a mean of 90% of volumetric resection in cortical and subcortical tumors located in eloquent motor areas with an increase of neurological deficits in the immediate postoperative period that significantly decreased one month later. Ongoing studies will define the safe limits for functional resection taking into account the intraoperative brain shift. Finally, it must be demonstrated if this protocol has any benefit for patients concerning disease free or overall survival.

A multicenter and observational study of the Ambu™ AuraGain™ laryngeal mask in adult patients. / Estudio multicéntrico observacional de la mascarilla Ambu® AuraGain® en pacientes adultos.

PURPOSE: The main objective of this study was to evaluate the performance of the Ambu™ AuraGain™ device by determining its main parameters of use and complications. METHODS: A total of 250 adult ASA physical status i to iii patients from five hospitals in Spain who received general anaesthesia with a supraglottic airway (SGA) device were enrolled in this study. RESULTS: The primary outcome was analysed for 244 patients and a median OLP of 32 cm H2O (IQR 28-36 cm H2O) was obtained. Insertion was achieved at first attempt in 85% of cases, and overall in 98% of cases, in a median time of 15 s (12-22.5). We applied manoeuvres in 61% of patients to facilitate the process. Ventilation was effective in 97.2% of the interventions (95% CI 0.99-0.94) throughout the procedure. Insertion of the gastric tube was easily performed in 99.6% of the patients, and the vocal cords were viewed by fibrobronchoscopy in 96.3% of cases. Logistic regression analysis identified the use of sizes smaller than those recommended as a risk factor for low OLP (< 25 cm H2O). The main complication recorded was the presence of blood when withdrawing the SGA device (15%). CONCLUSIONS: Our results confirm that the use of AuraGain allows airway management in a reliable and effective way achieving high OLP and low incidence of associated complications, establishing it as a useful alternative in the routine clinical setting of anaesthesiologists. AuraGain performance was consistent in all five centres.

The inaccuracy of LaFarge equations estimating the oxygen consumption in children under 3 years age. / La inexactitud de las ecuaciones predictivas de LaFarge para la estimación del consumo de oxígeno en niños menores de 3 años.

Accurate oxygen consumption measurement (VO2), is essential to obtain a reliable hemodynamic assessment, particularly in patients with congenital heart diseases undergoing cardiac catheterization. LaFarge equations can be unreliable in predicting VO2, particularly in the pediatric population. In a clinical setting, these inaccurate estimates can lead to important hemodynamic parameter miscalculations, with possible therapeutic or diagnostic consequences. Our aim is to validate LaFarge equations (the most widely used for estimating VO2) and compare them with direct measurement in children during cardiac catheterization in the cath lab. We performed a prospective observational study in 21 patients (0-3 years of age) with different congenital cardiac diseases, scheduled for diagnostic cardiac catheterization. Under general anesthesia and mechanical ventilation, VO2 was measured directly with a metabolic module in our cath lab, and also estimated using LaFarge equations. Statistical analysis included Bland-Altman plots, Pearson coefficient and percentage error, among others. LaFarge equations overestimated VO2 values in all study patients. Therefore, in pediatric patients under 3 years of age, the use of direct VO2 measurement methods are more accurate and acceptable than LaFarge equations.

Experience of a fungal infection after cardiac surgery. / Infección fúngica tras cirugía cardiaca. Nuestra experiencia.

INTRODUCTION AND OBJECTIVES: Patients undergoing cardiac surgery can have post-operative complications, including infections. The aim of this article was to study the incidence, severity and risk factors of invasive candidiasis in these patients, based on the hypothesis that several factors (multiple transfusions and time on extracorporeal circulation) are related to invasive candidiasis. MATERIAL AND METHODS: The study included a prospective analysis of 669 patients undergoing scheduled cardiac surgery from April 2016 to December 2017. Control cultures were collected on admittance to the Surgical Intensive Care Unit. RESULTS: The incidence of invasive candidiasis was 2.69%, being confirmed in 1.79% of cases. The most frequently isolated Candida species was Candida auris. Mortality rate in the invasive candidiasis group was 11% in the immediate post-operative period and 22% at 30 days. After the univariate study, a statistically significant relationship was found between invasive candidiasis and multiple transfusions (OR 15.86; 95% CI: 5.15-69.4; p<.001). A statistically significant relationship was also found with other known risk factors in hospitalised patients. CONCLUSIONS: Multiple transfusions are associated with an increased risk of invasive candidiasis. Surveillance measures for fungal infection in patients with risk factors undergoing cardiac surgery should be implemented in hospitals with a high incidence of candidiasis.

[Clinical response of gabapentin for glossopharyngeal neuralgia]. / Respuesta clínica a la gabapentina en la neuralgia del glosofaríngeo.

INTRODUCTION: The analgesic effect of the antiepileptic drug gabapentin makes it useful as an alternative for neuropathic pain. Its structural resemblance to other GABAergic antiepileptic drugs does not explain its mechanism of action, which seems not to depend on the activation of GABA receptor. Glossopharyngeal neuralgia is a rare entity which presents paroxystic crisis of pain, often with unknown etiology and poor response to treatment. CLINICAL CASES: Nine patients bearing of IX root neuralgia resistant to other therapies and ages ranged from 43 to 71 years old are being treated with gabapentin at doses between 800 and 3,600 mg daily in a period of time between two and sixteen months. Four cases in which magnetic resonance detected a compression of the nerve by posterior inferior cerebellar artery were submitted to a decompression surgery, but it was not effective. Gabapentin, alone or in association to carbamazepine, reduced the frequency and severity of crisis in seven patients, but in those with vascular compression the response was poorer. CONCLUSION: Gabapentin can be considered as an useful option for the management of glossopharyngeal neuralgic crisis, associated or not to other agents, for a short and long time, because of its good tolerance and lack of interactions.

[Use of gabapentin in glossopharyngeal neuralgia]. / Empleo de gabapentina en la neuralgia del glosofaríngeo.

Anticonvulsant drugs, especially carbamazepine, are the treatment of choice for glossopharyngeal neuralgia. If no clinical response is obtained, surgical treatment, including nerve section or decompression, may be required. We report the results obtained with a new anticonvulsant, gabapentin, as an alternative for cases of carbamazepine failure. In 7 patients with bouts of glosso-pharyngeal neuralgia refractory to the usual medical treatment, gabapentin produced improvement in 5 patients. Response was poor in patients who had undergone surgical nerve decompression. Gabapentin was concluded to be an effective therapeutic option for neuralgia of the IXth cranial nerve before surgery.

In vitro activity of the newer quinolones compared with the classic ones and tobramycin.

The halogenated substitution of quinolone derivatives has given rise to a new group of substances called newer quinolones, which possess extraordinary antibacterial activity in vitro. The aim of our study was to compare the effect of the newer quinolones ciprofloxacin (CIP), norfloxacin (NOR) and enoxacin (ENO) with that of the classical ones nalidixic acid (NA), oxolinic acid (OX) and pipemidic acid (PIP) and with a widely-used aminoglycoside tobramycin (TBR). This was tested on 2,263 strains from clinical isolations. Evaluating the effect of the least active substances as a unit, we generally found the MIC90s to be of the following order: (Formula: see text). The remaining groups among the antibiotics studied are ordered identically, the most potent being the newer quinolones in the following order: CIP is at least four times superior to NOR, which in turn is at least twice as effective as ENO for gram-positive organisms, but only 1.2 times for gram-negative bacilli.

[The role of E. coli adhesins in the pathogenesis of urinary infection]. / Papel de las adhesinas de E. coli en la patogénesis de la infección urinaria.

One thousand five hundred strains obtained from patients suffering from different clinical forms of urinary infections (UI) and dependent glands have been studied with the aim of establishing the pathogenic responsibility of E. coli adhesion protein (ADH) in urinary infections (UI). ADH were determined using agglutination techniques with guinea pig and human red cells, C. albicans and S. cerevisiae spores and GAL-GAL sensitized latex. In non complicated UI, the presence of ADH is the main invasion mechanism for E. coli. The frequency of adherent strains is very high (569/648) in acute cases (207/247 cystitis + 69/98 recurrent cystitis + 108/114 pyelonephritis + 140/154 prostatitis + 28/35 orchyepidimitis and scarce (14/184) in asymptomatic or chronic cases (6/107 bacteriurias + 7/67 prostatitis + 1/10 orchyepidimitis). A close relationship is established between the presence of ADH and clinical symptoms. The acute cases with general symptoms are caused in 85% of cases (188/216) by strains with ADH type MR specially subtype P. The acute cases with local symptoms (only urinary syndrome) are caused in 77% of cases (297/387) by strains with ADH type Ms. In complicated UI the expression of adhesion proteins does not constitute and essential requisite in order to invade the urinary tract. It is suggested that males are significantly more resistant the females to UI both parenchymal and urinary tract. It is deduced that underlying factors are more predisposing to UI the smaller the adherence rate of isolated strains is. Thus, reflux and neurogenic bladder probes are by far more aggressive alterations than prostatic adenoma, bladder tumor and lithiasis.