Dual-energy CT in the differentiation between adrenal adenomas and metastases: Usefulness of material density maps and monochromatic images.

OBJECTIVE: To evaluate the behavior of adrenal adenomas and metastases with dual-energy CT, analyzing the attenuation coefficient in monochromatic images at three different levels of energy (45, 70, and 140 keV) and the tissue concentrations of fat, water, and iodine in material density maps, with the aim of establishing optimal cutoffs for differentiating between these lesions and comparing our results against published evidence. MATERIALS AND METHODS: This retrospective case-control study included oncologic patients diagnosed with adrenal metastases in the 6-12 months prior to the study who were followed up in our hospital between January and June 2020. For each case (patient with metastases) included in the study, we selected a control (patient with an adrenal adenoma) with a nodule of similar size. All patients were studied with a rapid-kilovoltage-switching dual-energy CT scanner, using a biphasic acquisition protocol. We analyzed the concentration of iodine in paired water-iodine images, the concentration of fat in the paired water-fat images, and the concentration of water in the paired iodine-water and fat-water images, in both the arterial and portal phases. We also analyzed the attenuation coefficient in monochromatic images (at 55, 70, and 140 keV) in the arterial and portal phases. RESULTS: In the monochromatic images, in both the arterial and portal phases, the attenuation coefficient at all energy levels was significantly higher in the group of patients with metastases than in the group of patients with adenomas. This enabled us to calculate the optimal cutoffs for classifying lesions as adenomas or metastases, except for the arterial phase at 55 KeV, where the area under the receiver operating characteristic curve (AUC) for the estimated threshold (0.68) was not considered accurate enough to classify the lesions. For the arterial phase at 70 keV, the AUC was 0.76 (95% CI: 0.663‒0.899); the optimal cutoff (42.4 HU) yielded 92% sensitivity and 60% specificity. For the arterial phase at 140 keV, the AUC was 0.94 (95% CI: 0.894‒0.999); the optimal cutoff (18.9 HU) yielded 88% sensitivity and 94% specificity). For the portal phase at 55 keV, the AUC was 0.76 (95% CI: 0.663‒0.899); the optimal cutoff (95.4 HU) yielded 68% sensitivity and 84% specificity. For the portal phase at 70 keV, the AUC was 0.82 (95% CI: 0.757‒0.955); the optimal cutoff (58.4 HU) yielded 80% sensitivity and 84% specificity. For the portal phase at 140 keV, the AUC was 0.9 (95% CI: 0.834‒0.987); the optimal cutoff (16.35 HU) yielded 96% sensitivity and 84% specificity. In the material density maps, in the arterial phase, significant differences were found only for the iodine-water pair, where the concentration of water was higher in the group with metastases (1018.8 ±â€¯7.6 mg/cm3 vs. 998.6 ±â€¯8.0 mg/cm3 for the group with adenomas, p < 0.001). The AUC was 0.97 (95% CI: 0.893‒0.999); the optimal cutoff (1012.5 mg/cm3) yielded 88% sensitivity and 96% specificity. The iodine-water pair was also significantly higher in metastases (1019.7 ±â€¯12.1 mg/cm3 vs. 998.5 ±â€¯9.1 mg/cm3 in adenomas, p < 0.001). The AUC was 0.926 (95% CI: 0.807‒0.977); the optimal cutoff (1009.5 mg/cm3) yielded 92% sensitivity and 92% specificity. Although significant results were also observed for the fat-water pair in the portal phase, the AUC was insufficient to enable a sufficiently accurate cutoff for classifying the lesions. No significant differences were found in the fat-water maps or iodine-water maps in the arterial or portal phase or in the water-fat map in the arterial phase. CONCLUSIONS: Monochromatic images show differences between the behavior of adrenal adenomas and metastases in oncologic patients studied with intravenous-contrast-enhanced CT, where the group of metastases had higher attenuation than the group of adenomas in both the arterial and portal phases; this pattern is in line with the evidence published for adenomas. Nevertheless, to our knowledge, no other publications report cutoffs for this kind of differentiation in contrast-enhanced monochromatic images obtained in rapid-kilovoltage-switching dual-energy CT scanners, and this is the first new contribution of our study. Regarding the material density maps, our results suggest that the water-iodine pair is a good tool for differentiating between adrenal adenomas and metastases, in both the arterial and portal phases. We propose cutoffs for differentiating these lesions, although to our knowledge no cutoffs have been proposed for portal-phase contrast-enhanced images obtained with rapid-kilovoltage-switching dual-energy CT scanners.

Pharmacokinetics/pharmacodynamics and therapeutic drug monitoring of ceftazidime/avibactam administered by continuous infusion in patients with MDR Gram-negative bacterial infections.

BACKGROUND: Therapeutic drug monitoring (TDM) of ß-lactams in critically ill patients has been correlated with better clinical outcomes. Evidence on TDM of newer ß-lactams such as ceftazidime/avibactam administered by continuous infusion (CI) is very limited. OBJECTIVES: To describe our experience with TDM of ceftazidime/avibactam and pharmacokinetic/pharmacodynamic (PK/PD) target attainment in patients with MDR bacterial infections. Clinical outcomes of ceftazidime/avibactam administered by CI were also assessed. METHODS: Patients treated with ceftazidime/avibactam administered by CI and undergoing TDM of ceftazidime plasma concentrations were included. Blood samples were obtained as part of the TDM program. The PK/PD therapeutic target of ceftazidime/avibactam was defined as 100%fT > 4 × MIC of the causative pathogen, and 100%fT > 10 × MIC was considered overexposure. Dose changes were made according to the TDM results. RESULTS: Thirty-one patients were included. Ceftazidime/avibactam total daily doses ranged from 1 g/0.25 g to 6 g/1.5 g. Twenty-six patients (83.9%) achieved a 100%fT > 4 × MIC, 15 (48.4%) of which were overexposed (100%fT > 10 × MIC). Dose reduction was suggested in 16/28 (57.1%) patients and dose maintenance in 12/28 (42.9%). Overall clinical cure was observed in 21 (67.7%) patients, and 18 of these (85.7%) achieved a 100%fT > 4 × MIC. CONCLUSIONS: Administering ceftazidime/avibactam by CI enabled the desired PK/PD target to be achieved in a large proportion of patients, even at lower doses than those recommended for a 2 h extended infusion. We suggest that the use of CI with TDM may be a useful tool for reducing initial doses, which could help to reduce antimicrobial-related adverse effects and treatment costs.

[Comprehensive post-stroke rehabilitation: its long-term effects and the socio-environmental factors conditioning access to it]. / Rehabilitación integral postictus: efectos a largo plazo y factores socioambientales condicionantes del acceso.

INTRODUCTION: Recovery of all brain functions affected after stroke is essential for the patient's quality of life, with comprehensive rehabilitation key. OBJECTIVES: Identify social and environmental factors affecting access to comprehensive post-ictus rehabilitation, and assess long-term effects of comprehensive rehabilitation on patient functionality. PATIENTS AND METHOD: 171 consecutive patients (84 women and 87 men) hospitalized in 2015 in Neurology Service with first ischemic stroke, without prior functional dependence, candidates for comprehensive rehabilitation are studied. Various socio-environmental and clinical variables potentially associated with access to it are analyzed. The long-term prognostic impact (average period of 54 months) on the functional situation is studied using the Barthel index. RESULTS: The average age of patients is 69 years. Only 53% were able to access the recommended comprehensive rehabilitation. Predictor variables of access were resulted: residence in urban environment (OR: 2,957; 95% CI: 1,067-8,199; p = 0.037), complement with private rehabilitation (OR: 2,89; 95% CI: 1,130-7,392; p = 0.027), best Rankin to high (OR: 22,437; 95% CI: 3,247-155,058; p = 0.014). After average follow-up for 54 months, of the 137 survivors, access to comprehensive post-ictus rehabilitation was independently associated with better long-term functional situation (OR: 12,441; 95% CI: 4.7-32.5; p < 0.001). CONCLUSIONS: Comprehensive post-ictus rehabilitation is associated with better long-term prognosis, but access to it is conditioned by environmental and social factors such as the place of residence and the possibility of contracting private services.

TITLE: Rehabilitación integral postictus: efectos a largo plazo y factores socioambientales condicionantes del acceso.Introducción. La recuperación de todas las funciones cerebrales afectadas tras un ictus es esencial para la calidad de vida del paciente y la rehabilitación integral resulta clave. Objetivos. Identificar los factores sociales y ambientales condicionantes del acceso a la rehabilitación integral postictus, y valorar los efectos a largo plazo de la rehabilitación integral en la funcionalidad del paciente. Pacientes y método. Se estudia a 171 pacientes consecutivos (84 mujeres y 87 hombres) hospitalizados en 2015 en el servicio de neurología con un primer ictus isquémico, sin dependencia funcional previa, candidatos a rehabilitación integral. Se analizan diversas variables socioambientales y clínicas potencialmente asociadas al acceso a ésta. Se estudia el impacto pronóstico a largo plazo (período medio de 54 meses) sobre la situación funcional mediante el índice de Barthel. Resultados. La edad media de los pacientes era de 69 años. Sólo el 53% pudo acceder a la rehabilitación integral recomendada. Resultaron variables predictoras del acceso: residencia en medio urbano ­odds ratio (OR): 2,957; intervalo de confianza al 95% (IC 95%): 1,067-8,199; p = 0,037­, complemento con rehabilitación privada (OR: 2,89; IC 95%: 1,13-7,392; p = 0,027) y mejor Rankin en el momento del alta (OR: 22,437; IC 95%: 3,247-155,058; p = 0,014). Tras un seguimiento medio durante 54 meses de los 137 supervivientes, el acceso a rehabilitación integral postictus se asoció independientemente a mejor situación funcional a largo plazo (OR: 12,441; IC 95%: 4,7-32,5; p menor de 0,001). Conclusiones. La rehabilitación integral postictus está asociada a un mejor pronóstico a largo plazo, pero su acceso está condicionado por factores ambientales y sociales, como el lugar de residencia y la posibilidad de contratar servicios privados.

Essential Subcortical Tracts in Language and Reading. 3D-Tractography for Clinical Practice and Anatomic Correlation with Intraoperative Subcortical Electrostimulation.

Diffusion tensor imaging (DTI) and tractography provide the neurosurgeon with a valid 3D view of the white matter tracts of the brain for the presurgical planning of the treatment of lesions close to eloquent areas, this being one of the principal clinical applications of this technique. In this article, we describe through practical cases the anatomic relationships of white matter tracts that are essential for language and reading, based on DTI studies and the excellent anatomic correlation with the intraoperative subcortical map.

Effects of dietary antioxidant of tomato extract and lycopene on Carassius auratus and Xiphophorus maculatus / Efecto antioxidante de un extracto de jitomate y licopeno en Carassius auratus y Xiphophorus maculatus

Objective. Evaluate the effect on tegument pigmentation, survival, growth and antioxidant capacity in diets supplemented with tomato extract and lycopene as additives in experimental feed for Carassius auratus and Xiphophorus maculatus. Materials and methods. The additives were added in different concentrations to a basic diet. We performed beginning and an ending biometrics for 100% of the population in each bioassay. The growth and survival of organisms were evaluated. The antioxidant capacity was analyzed by ABTS assay, both in the tomato extract sample as well as in foods used in different bioassays. The concentration of lycopene was determined in food and liver and muscle samples of fish fed with it. Acquired pigmentation of fish was assessed through photographs analyzed with Adobe Photoshop®. The results were evaluated by analysis of variance, and when differences were found (p<0.05) the means were compared by the Tukey test. Results. No significant effect (p>0.05) on pigmentation and growth of the organisms under the established experimental conditions was obtained. Significant differences in antioxidant capacity (p<0.05) were obtained in foods with added lycopene. Conclusions. The inclusion of lycopene or tomato extract in food for the organisms used is not recommended to improve pigmentation, but further studies are needed to demonstrate antioxidant effect.

Objetivo. Evaluar el efecto sobre la coloración de la piel, la sobrevivencia, el crecimiento y la capacidad antioxidante por dietas suplementadas con extracto de jitomate y licopeno como aditivos en la alimentación de Carassius auratus y de Xiphophorus maculatus. Materiales y métodos. Los aditivos se añadieron en diferentes concentraciones a una dieta base. Se realizó una biometría inicial y una final del 100% de la población en cada bioensayo. Se evaluó el crecimiento y supervivencia de los organismos. La capacidad antioxidante se analizó a través del ensayo ABTS, tanto a la muestra de extracto de jitomate como a los alimentos utilizados en diferentes bioensayos. Se determinó la concentración de licopeno a los alimentos y en muestras de hígado y músculo de peces alimentados con ellos. La pigmentación adquirida por los peces se evaluó a través de fotografías analizadas con el programa de Adobe Photoshop®. Los resultados fueron evaluados con análisis de varianza, cuando se encontraron diferencias (p<0.05) las medias fueron comparadas mediante la prueba de Tukey. Resultados. No se obtuvo un efecto significativo (p>0.05) sobre la pigmentación y el crecimiento de los organismos en estudio bajo las condiciones experimentales establecidas. Se obtuvieron diferencias significativas (p<0.05) en la capacidad antioxidante en los alimentos adicionados con licopeno. Conclusiones. La inclusión de licopeno o de extracto de jitomate en alimentos para los organismos utilizados no es recomendable con el fin de mejorar la pigmentación, aunque se requieren otros estudios para demostrar su efecto antioxidante.

Antioxidant enrichment and antimicrobial protection of fresh-cut fruits using their own byproducts: looking for integral exploitation.

Fresh-cut fruit consumption is increasing due to the rising public demand for convenience and awareness of fresh-cut fruit's health benefits. The entire tissue of fruits and vegetables is rich in bioactive compounds, such as phenolic compounds, carotenoids, and vitamins. The fresh-cut fruit industry deals with the perishable character of its products and the large percentage of byproducts, such as peels, seeds, and unused flesh that are generated by different steps of the industrial process. In most cases, the wasted byproducts can present similar or even higher contents of antioxidant and antimicrobial compounds than the final produce can. In this context, this hypothesis article finds that the antioxidant enrichment and antimicrobial protection of fresh-cut fruits, provided by the fruit's own byproducts, could be possible.

La necesidad de una guía clínica kinésica para la atención del linfedema en Complejo Asistencial Barros Luco / The need of a clinical guidelines in physical therapy for the lymphedema treatment: Complejo Asistencial Barros Luco experience

Información previa: El desconocimiento, tanto de la incidencia de linfedema como del tratamiento y cuidados pertinentes del linfedema, hace de éste, una patología de alto impacto psicosocial en el Complejo Asistencia Barros Luco (CABL). Objetivo: Dar a conocer la realidad de los pacientes con linfedema en el CABL; proveer información y recomendaciones para tratantes y pacientes, en cuanto al manejo, de linfedema en CABL. Opciones: Drenaje linfático manual, sistema elástico compresivo, bombas de compresión neumáticas, terapias físicas, tratamiento farmacéutico, educación. Resultado: Obtención de datos reales de la población afectada por linfedema en el CABL, optimización de recursos dentro de la Institución, prevenir y/o mejorar las alteraciones funcionales del paciente, calidad de vida, mayor acceso a tratamiento. Evidencia: Revisiones sistemáticas de la literatura en inglés y español obtenida principalmente desde MEDLINE (Octubre - Diciembre 2006). Conclusiones: El linfedema continúa siendo un problema de larga duración para los pacientes que sobreviven al cáncer. El tratamiento conservador ha demostrado ser efectivo para diferentes casos de linfedema. El CABL es un centro "en potencia" para desarrollar protocolos o guías clínicas para pacientes post tratamiento de cáncer. Dada la complejidad del tratamiento, este debe ser realizado por kinesiólogos con formación en el área. Proyecciones: promover la formación de un equipo transdisciplinario que apunte a una rehabilitación integral del paciente portador de linfedema, lograr la creación de una guía clínica que se ajuste a la realidad del CABL.

Background: The lack of knowledge of the incidence, treatment and appropriate care of Iymphedema has a high psicosocial impact at the CABL. Objective: To provide information about the reality of the patients with Iymphedema at the CABL; to provide information and recommendations for patients and their physicians when making decisions about the management of Iymphedema at the CABL. Options: Manual Lymphatic drainage, Compression garments, pneumatic compression pumps, physical therapies, pharmaceutical treatments and education. Results: To obtain real data of the Iymphedema affected population at the CABL, resource optimization at CABL, to prevent and/or improve the functional impairments of the patient, quality of life and more access to treatment. Evidence: Systematic review of English / Spanish - language literature retrieved primarily from MEDLINE (October - December 2006). Conclusions: The Iymphedema continues to be a long term issue for patient who survives cancer. The conservative treatment has been proven effective for different cases of Iymphedema. The CABL is a potential Medical Centre to develop protocols or Clinical practice guidelines for patients post cancer treatment. Because this is a complex treatment it must be developed by physical therapist with extensive preparation in the field. Future projections: To encourage the formation of an Transdisciplinary health team, which will offer a holistic rehabilitation to the patient with Iymphedema, to achieve the creation of a clinical practice guideline that fits the reality of the CABL.

Drenaje linfático manual en el linfedema facial / Manual lymph drainage in facial lymphedema

Presentamos la evolución de una paciente de 19 años de edad con un adenoma pleomorfo de parótida que tras varios tratamientos, incluyendo vaciamiento ganglionar cervical y radioterapia, desarrolló linfedema facial. Debido a la repercusión de tipo emocional que originó en la paciente, se planificó tratamiento físico rehabilitador con drenaje linfático manual con el que mejoró tanto subjetiva como objetivamente (AU)

[A new milk formula: iron bioavailability and effect on prevention of iron deficiency in infants]. / Nueva fórmula láctea: biodisponibilidad del hierro y efecto en la prevención de su deficiencia en lactantes.

Iron bioavailability from a modified cow milk, formula (LPM) (which included additional iron as 5 mg/l ferrous sulfate and ascorbic acid, 50 mg/l) was examined in 11 adult women using the extrinsic radioactive tag method. The geometric mean absorption from LPM was 13% (reference dose absorption = 26%). The effect of this formula on iron nutrition of infants was studied in 43 healthy term infants weaned spontaneously before 3 months of age which were given LPM until 9 months of age. Another 45 infants (controls) were fed full fat, non fortified powdered cow's milk (LP) as delivered through the National Complementary Food Program (PNAC-Chile) and additional 45 infants were given fortified a cow's milk formula (LF) with ferrous sulfate (iron: 15 mg/l and ascorbic acid: 100 mg/l). Solid foods (vegetables and meat) were introduced to all these babies from age 4 months. At 9 months of age 4% infants fed LPM had evidence of anemia vs. 2% and 20% of infants given LF and LP formulae respectively. This results suggests that LPM is effective in preventing iron deficiency anemia in infants.

[Iron-deficiency anemia in the nursing infant: its elimination with iron-fortified milk]. / Anemia ferropriva en el lactante: erradicación con leche fortificada con hierro.

We evaluated the effect of iron-supplemented milk on 86 healthy infants who were followed from 3 to 12 months of age. Whole milk was supplemented with 15 mg elementary iron as ferrous sulphate and 100 mg ascorbic acid per 100 g powder. 104 infants received the same milk with no supplement and served as control. All iron nutritional parameters were higher in the supplemented group at 9 and 12 months of treatment (p < 0.01). Iron-deficiency anemia was shown in 34% of the control as compared to 0% of the treatment group. The product exhibited excellent tolerance and could therefore be used to eradicate iron-deficiency anemia of the infant.

Hemoglobin-fortified biscuits: bioavailability and its effect on iron nutriture in school children.

School-age children in Chile received 30 g of wheat-flour biscuits daily through a National School Lunch Program. To improve iron nutrition, these biscuits were fortified with 6% of a bovine hemoglobin concentrate. Hemoglobin iron bioavailability, measured with a double isotope technique, showed that heme-iron absorption in fortified biscuits was high (19.7%). In a pilot field trial, a cohort of 215 school-children received fortified biscuits (30 g) daily during two school periods, and their iron nutrition status was compared with that of children who received non-fortified biscuits (n = 212). Acceptability of both types of biscuits was excellent. Initially, both groups had comparably good iron nutrition. The fortified children presented higher mean ferritin values at the end of the first and second school periods. Good iron stores (serum ferritin greater than or equal to 20 micrograms/lt) were present in 92% and 79% of the fortified and control subjects, respectively (P less than 0.004). The high-iron bioavailability, the good organoleptic characteristics and the biological effect on iron nutriture make this product an appealing alternative to combat iron deficiency.