Tratamiento de la estenosis traqueobronquial con prótesis: factores de buena respuesta / Treatment of tracheobronchial stenosis with stents: good response factors

OBJETIVO: Determinar predictores de buena respuesta con el uso de prótesis en la estenosis traqueobronquial. MATERIALES Y MÉTODO: Estudio retrospectivo descriptivo de una serie de casos entre junio de 2014 y junio de 2016. Se revisaron registros clínicos, protocolos operatorios, estudios histopatológicos y de imagen. Se consignaron antecedentes demográficos y clínicos al ingreso y luego del procedimiento, etiología de la estenosis traqueal, necesidad de oxígeno en litros, estadía hospitalaria, morbilidad asociada al procedimiento, indicación de terapia complementaria posterior y sobrevida. Se analizaron los datos con estadística descriptiva y analítica. RESULTADOS: Se realizaron 68 procedimientos, en 44 pacientes, 24 mujeres, el diagnóstico principal fue estenosis traqueal con 40 casos. La etiología neoplásica fue el 88% de los casos. El Performance status (PS) de ingreso fue mayor o igual a 2 en el 68% y posterior al procedimiento disminuyó a 22% p < 0,05. En 36 casos los pacientes requerían al menos 1 L de oxígeno lo que disminuyó en 13 casos posterior a la intervención p < 0,05. El tiempo de hospitalización promedio fue 6,2 días (1-60). En 13 pacientes con patología neoplásica se indicó terapia paliativa complementaria. La morbilidad asociada al procedimiento fue de 2,9% dado por prótesis desplazada y lesión iatrogénica. La sobrevida fue de 27% a un año. CONCLUSIONES: La etiología benigna, el PS previo a la intervención menor o igual a 3, requerimiento de oxígeno de 1 litro y obstrucción tumoral menor al 70% del lumen fueron elementos de buena respuesta.

AIM: Determine good response predictors in use of stent in benign and malignant tracheobronchial stenosis. MATERIAL AND METHODS: We retrospectively reviewed medical records of patients submitted to the procedure in the period 2014 to 2016. Clinical records, operative protocols, and histopathological and imaging studies were reviewed. Demographic and clinical data, performance status (PS) at admission and after the procedure, etiology of tracheal stenosis, need for oxygen in liters (L) Post-intervention, hospital stay, procedure-related morbidity, indication of therapy (Chemotherapy and/or Radiotherapy) and survival. Data were analyzed with descriptive and analytics statistics. RESULTS: A total of 68 procedures were performed in 44 patients, 24 women. Tracheal stenosis 40 cases were diagnosed. The malignant etiology was 88%. The admission PS was greater than or equal to 2 in 68% and 22% after the procedure. The oxygen requirements prior to the procedure were at least 1 L in 36 cases and decreased in 13 cases after the procedure. The average hospitalization period was 6.2 days (1-60). Complementary therapy was indicated in 13 patients; the morbidity associated with the procedure was 2.9%, displaced installation and iatrogenic injury. The one year survival was 27%. CONCLUSIONS: Benign etiology, el PS minor than or equal to 3, oxygen requirements prior to the procedure of 1 L and tumoral obstruction less than 75% were good response predictors in our study.

Uso del cannabis en 16 pacientes con epilepsia refractaria / Use of cannabis in 16 patients with refractory epilepsy

INTRODUCCIÓN: En la actualidad, el 30 a 40% de los pacientes epilépticos son refractarios a los fármacos anticonvulsivantes. En relación a esto, en los últimos años el uso de marihuana medicinal se ha convertido en un tema controversial tanto en la comunidad médica como en la población general. Se ha descripto que el sistema endocannabinoide del cerebro proporciona protección contra la actividad convulsiva, desempeñando un papel importante en la regulación del sistema nervioso central y equilibrando la interacción sináptica excitadora e inhibidora para una función cerebral normal. El mismo está compuesto principalmente de dos receptores cannabinoides: CB1R (Receptor cannabinoide tipo 1) y CB2R (Receptor Cannabinoide tipo 2). Los receptores CB1R se expresan predominantemente en sistema nervioso central, y el receptor CB2R se localiza principalmente en el sistema inmune humano y hematopoyético. La marihuana tiene dos componentes principales que influyen en el sistema endocannabinoide: delta-9-tetrahidrocannabinol (THC) y el cannabidiol (CBD). El THC a través del CB1R CBD presenta baja afinidad y es antagonista de CB1R y CB2R. Algunos estudios en animales muestran que los antagonistas de CB1R pueden reducir el umbral de las convulsiones. El CBD actúa a través de múltiples mecanismos. Estos incluyen efectos sobre los canales Potasio, Calcio, y funciones antagónicas en el receptor acoplado a proteína G, mediante el cual puede disminuir la liberación pre sináptica de glutamato, excitador del sistema nervioso central. Con todo, los mecanismos exactos subyacentes a los efectos antiepilépticos del CBD no están bien definidos. En estudios iniciales, realizados con utilización del extracto de aceite de cáñamo (con concentraciones de THC< 0,3%), en pacientes con Síndrome de Dravet y Epilepsia tipo Lennox Gastaut, se reportó una franca mejoría en la frecuencia de las crisis y en la calidad de conexión con el entorno del paciente. Asimismo, se objetivó alrededor de un 10% de efecto placebo debido a una escasa confiabilidad en el diseño de dichos estudios, mayormente basados en encuestas. Actualmente, los últimos estudios son realizados con CBD sintetizado, sin contener THC y a dosis mayores, con resultados prometedores. (AU)

INTRODUCTION: Currently, 30 to 40% of epilepsy patients are refractory to anti - convulsant drugs. In recent years, the use of medical marijuana has become a controversial issue not only within the medical community but also in the general population. Cannabidiol it would be responsible for the anticonvulsant effect through modulation of the endocannabinoid system. OBJECTIVE: To evaluate the efficacy of adjuvant treatment cannabis in patients with refractory epilepsy. MATERIALS AND METHODS: A descriptive retrospective study was performed from August 2016 to August 2017. Patients with a diagnosis of refractory epilepsy of various etiologies, to which was indicated as adjunctive therapy cannabidiol drops Everyday Advanced 5000 at a dose of 0.25 mg/lb/day. STATISTICALS ANALYSIS: Descriptive statistics was performed. For variables a chi-square test was used. Statistical significance p <0.05 was considered. RESULTS: The total sample (n = 16), 19% (3 patients) had a reduction equal to or greater than 50% in the seizure frequency (p = 1). Nine patients had electroencephalogram control, of which two patients showed improvements in drawn. By linking patients with EEG control and seizure frequency during treatment, a correlation statistically signific observed, with p <0.01. The 31% showed other positive effects reported by the family, the most common, improvements in connection with the environment. In 6 patients (37.5%) the adverse reaction was irritability. Five patients (31%) decidie rum discontinue treatment in less than 4 months, seeing no significant changes in the frequency of crisis. (AU)

Hipertensión endocraneana idiopática: respuesta al tratamiento Topiramato vs Acetazolamida / Endocranial idiopathic hypertension: response to treatment Topiramate vs. Acetazolamide

INTRODUCCIÓN: El término pseudotumorcerebri se reserva para denominar aquellas hipertensiones endocraneanas (HE) que clínicamente asemejan la existencia de un tumor cerebral, debido a la alteración de la circulación del líquido cefalorraquídeo (LCR). Para su diagnóstico se describen los criterios de Dandy-Smith. OBJETIVOS: Objetivo Primario: Determinar el beneficio del uso de Azetazolamida (ACZ) o Topiramato (TPM) en el tratamiento de la hipertensión endocraneana idiopática. Objetivos Secundarios: Uso de Presión de apertura como parámetro indicador para uso de ACZ o TPM. MATERIALES Y MÉTODOS: Tipo de estudio: Descriptivo Retrospectivo Observacional. RESULTADOS: La media de seguimiento fue de 11 meses, con un rango entre 6-12 meses Se estudiaron 5 pacientes con diagnóstico de Hipertensión Endocraneana Idiopática. Del total de los pacientes 5 (100%) tenían F.O patológico y como síntoma cardinal cefalea, 2 (40%) además vómitos. 3 (60%) fue tratado con Topiramato (TPM) mientras que 2 (40%) recibió acetazolamida (ACZ), ambos sin complicaciones (p= 0,07) Del total de los pacientes 3(60%) presento presión de apertura menor de 40 mmHg mientras que en los restantes 2 (40%) fue mayor a 40 mmHg. De estos últimos el 1 paciente recibió TPM y 1 paciente ACZ. Dos pacientes (40%) presentaron en el seguimiento una recaída sintomática, al intentar descender la medicación. No se pudo definir como parámetro de decisión la presión de apertura en del uso de uno u otro medicamento ya que al evaluar el uso de TPM y ACZ en pacientes con presión de apertura mayor a 41 mmHg solo se detallaron 2 pacientes cada uno tratado con un medicamento de los anteriormente descriptos. (Chi cuadrado p= 0.44). Ninguno de los pacientes tratados requirió otro tratamiento complementario como PL seriadas o válvula de derivación ventrículo peritoneal. CONCLUSION: No se logró determinar beneficio en el uso de un medicamento sobre otro en el tratamiento de la hipertensión endocraneana idiopática (p=0,07), pese al tamaño muestral, el cual podría ser un limitante. Coincidentemente con la literatura sigue sin haber evidencia suficiente. No existe un algoritmo de consenso en cuanto al correcto manejo terapéutico y farmacológico de esta entidad. El uso de TPM o ACZ no condiciona la posterior aparición de complicaciones (p= 0.45) El estudio oftalmológico es esencial para diagnóstico y seguimiento. No se pudo establecer correlación entre el valor obtenido en la medición de la presión de apertura y el tratamiento instaurado. (AU)

INTRODUCTION: The term Pseudotumor cerebri is reserved for those endocranial hypertensio (EH) that resemble clinically the existence of a brain tumor, due to alteration of the circulation of the cerebrospinal fluid (CSF). Classically, the Dandy-Smith criteria for diagnosis are described. TYPE OF STUDY: Descriptive observational. OBJECTIVE: Primary Objective: To determine the benefit of the use of Azetazolamide (ACZ) or Topiramate (TPM) in the treatment of idiopathic endocranial hypertension Secondary Objectives: Use of Opening Pressure as indicator parameter for use of ACZ or TPM. MATERIALS AND METHODS: Observed patients(N:5) per clinic with diagnosis of EIH by criteria of Dandy-Smith in the period 2013-2017. I was performed in all patients: RMNC s/contrast Fundus oculi Lumbar puncture + opening pressure. RESULTS: Of the total of patients (5) 100% had F.O pathological and as cardinal symptom headache, and 40% also vomiting. The mean follow-up was 11 months 60% of the patients was treated with topiramate (TPM) while 40% received acetazolamide (ACZ), both without complications. Of the total of patients 60% presented less than 40 opening pressure mmHg, while that in the remaining 40% was greater than 40 mmHg, of which 50% received TPM and 50% ACZ. 40% presented in tracking a symptomatic relapse, trying to get off the medication. None of the treated patients required other adjunctive therapy such as serial PL or ventricleperitoneal shunt. CONCLUSIONS: It was not possible to determine benefit in the use of one drug over another in the treatment of idiopathic intracranial hypertension (p = 0.07), despite the sample size, which could be a limitation. Coincidentally with the literature there is still not enough evidence. There is no consensus algorithm regarding the correct therapeutic and pharmacological management of this entity. The use of TPM or ACZ does not condition the subsequent appearance of complications (p = 0.45) The ophthalmological study is essential for diagnosis and follow-up. No correlation could be established between the value obtained in the measurement of the opening ression and the treatment established. (AU)

Evaluación de calidad de vida relativa a salud mediante KINDL en niños y adolescentes de 4 a 16 años asistentes al Programa de Alta Motivación en Teletón Santiago: años 2008-2009 / Quality of life evaluation in health using KINDL in children and teenagers from 4 to 16 years who assist to the High Motivation Program in Teleton Santiago: years 2008-2009

The therapy through the arts included in the high motivation program (HMP), achieves to explore and develop the expressive and communicative potentials, to integrate the affective, cognitive and motor areas of the patient, in an essentially sensory experience, in order to improve quality of life related to health (QLRH). Objectives: To estimate QLRH by using Kindl in children and adolescents attending the HMP in Teletón Santiago between 2008 and 2009, and to analyze the effect of parallel therapeutic treatments. Patients and Methods: We studied a cohort of 84 patients from 4 to 16 years old, who met the selection criteria, we administered the Kind questionnaire in their Kiddy (4-7 years, n = 22), Kid (8-11 years; n = 26) and Kiddo (12-16 years, n = 32) versions to measure QLRH before and after participating in the HMP. Results: The global QLRH increases in the Kid and Kiddy groups except in the school dimension; in Kiddo, there is a significant difference for global QLRH, emotional wellbeing and self-esteem; in Kid we find significant differences for physical and emotional wellbeing, self-esteem and friends (p < 0.05). Conclusions: The QLRH median score measured with Kindl, significantly increases after HMP intervention in the selected study groups. The perception of changes in QLRH reported by the parents and their children from 4 to 7 years old doesn't differ at the end of the intervention between them. Using therapy through the arts helps to enhance the global QLRH in all the Kindl groups and the self-esteem dimension in the Kiddo and Kind groups.

La terapia a través de las artes contenida en el programa de alta motivación (PAM), postula explorar y desarrollar los potenciales expresivos y comunicacionales, integrar las áreas afectivas, cognitivas y motora del paciente, en una experiencia esencialmente sensitiva, a fin de mejorar la calidad de vida relacionada a salud (CVRS). Objetivos: Estimar la CVRS mediante Kindl en niños y adolescentes asistentes al PAM en Teletón Santiago 2008-2009 y, analizar el efecto de tratamientos terapéuticos paralelos. Pacientes y Métodos: Se estudia una cohorte de 84 pacientes de 4 a 16 años, que cumplieron con requisitos de inclusión; se administra cuestionario Kindl en sus versiones Kiddy (4-7 años, n = 22), Kid (8-11 años; n = 26) y Kiddo (12-16 años; n = 32) para medir CVRS antes y después de participar en el PAM. Resultados: La CVRS global aumenta en los grupos Kiddy y Kid excepto en dimensión escuela; en Kiddo, se registra diferencia significativa para CVRS global, bienestar emocional y autoestima; en Kid las diferencias significativas se verifican para bienestar físico, emocional, autoestima y amigos (p < 0,05). Conclusiones: El puntaje mediano de CVRS medido con Kindl, aumenta significativamente después del PAM en los grupos considerados. La percepción de mejoría en CVRS es similar entre padres e hijos de 4 a 7 años al término de la intervención. La terapia a través de las artes, ayuda a potenciar la CVRS global en todos los grupos Kindl y la dimensión autoestima en grupos Kiddo y Kind.

Tratamiento del aneurisma aórtico abdominal por vía endovascular: experiencia inicial / Endovascular treatment of abdominal aortic aneurysm: initial experience

Background: Thirty day mortality of current surgical treatment of abdominal aortic aneurysm is 0.7 to 5 percent. Coronary artery disease is the main risk factor in this elderly population. An alternative procedure based on the transfemoral deployment of self expandable prostheses to exclude the aneurysm, avoids a laparotomy and major surgical trauma, reducing the risks of the conventional operation. Aim: To report our experience on endovascular repair of abdominal aortic aneurysms. Patients and methods: Nine consecutive patients aged 66 to 82 years old, possible candidates for the procedure, were studied. Results: Only four patients fulfilled the requirements for the procedure, which was technically successful in three. One patient was converted to an open surgical repair. Patients were discharged 72-96 hours after graft implantation. The postoperative CAT scan confirmed total exclusion of the aneurysm by the endovascular graft. All nine patients are alive at the time of this report. Conclusions: Given certain anatomical conditions, endovascular treatment of abdominal aortic aneurysms is an attractive alternative for high risk patients

[Electrophysiologic evaluation of athletes with Wolff-Parkinson-White syndrome: induction of supraventricular arrhythmia at rest and under exertion with transesophageal atrial electrostimulation]. / La valutazione elettrofisiologica degli atleti con Wolff-Parkinson-White: induzione di tachiaritmia sopraventricolare di base e sotto sforzo con elettrostimolazione atriale transesofagea.

The most suitable approach to the athletes with WPW is controversial. Therefore 66 symptom-free athletes with WPW and without heart disease (53 M, 13 F, mean age 21.98 yrs, min 12--max 44) underwent a study protocol whose end-point was the induction of supraventricular tachyarrhythmia, i.e. atrial fibrillation or, if not possible, atrial flutter or atrial tachycardia at rest and during ergometric stress test. The athletes with shortest R-R interval between preexcited beats less than or equal to 240 ms at rest and/or less than or equal to 210 ms during exercise were judged as being at risk i.e. no fit for sport activity. The end-point was reached in 64/66 athletes (in 62 atrial fibrillation). In 4 athletes with life threatening arrhythmia induced at rest the evaluation during exercise was not performed. According to the evaluation at rest we were able to identify only 18 athletes (28.1%) as being at risk, while according to the complete study protocol 26 athletes (40.6%) were judged as such. In 23/64 athletes (36%) this judgement was discordant with the usual non invasive evaluation (i.e. Holter monitoring, ergometric stress test, ajmaline test). During induced atrial fibrillation no significant difference, was found between the percentage of preexcited beats at rest and during exercise. On the average, 40 min. are required for performance of this study protocol (if the induced arrhythmia lasts less than 5 min.). According to our results we conclude: a) the non invasive assessment of the WPW athletes is unsatisfactory; b) the induction of atrial fibrillation during exercise gives a remarkable increase of the diagnostic power with respect to the assessment only at rest; c) since it is simple to perform and not expensive (in time, staff and cost) and because of its high diagnostic yield, we regard this protocol as fundamental for the electrophysiological evaluation of WPW athletes and also suitable for systematic study of WPW patients.

Overdrive and programmed atrial electrostimulation in the study of the electrogenetic mechanism of atrial flutter in man.

The response of atrial flutter (AF) to programmed atrial stimulation (PAS) (13 cases) and overdrive atrial pacing (OAP) ws studied in a total of 18 patients. During PAS the return cycle was equal to the basic cycle of AF in six patients, shorter in one patient, and slightly longer in six; it was never compensatory. ATrial flutter terminated in two patients by PAS and by OAP in three. In 4 patients, PAS resulted in an acceleration of the AF rate, followed by spontaneous interruption within 2 seconds. In the remaining patients, the stimulation either converted the AF into an uncommon type of AF (two patients) or into atrial fibrillation that was followed by spontaneous return to sinus rhythm. In two patients it was possible to reproduce the AF with PAS; in one of the patients another type of AF was induced. Some of the data observed suggest a re-entry circuit as the electrogenetic mechanism responsible for AF in man.

[Effects of amiodarone on atrio-ventricular and ventriculo-atrial conduction in the Wolff-Parkinson-White syndrome (author's transl)]. / Effetti dell'amiodarone sulla conduzione atrio-ventricolare e ventricolo-atriale nella sindrome di Wolff-Parkinson-White

In 10 patients with the Kent's bundle W.P.W. syndrome, the action of amiodarone (5 mg/kg i.v.) on conduction along the normal and anomalous pathways was studied. The drug actions were: 1) constant increase of the anomalous pathway E.R.P., in one case with antegrade functional block; 2) constant reduction of antegrade conduction velocity along the anomalous pathway, in one case with antegrade functional block; 3) reduction of retrograde conduction velocity along the anomalous pathway in 6 cases out of 8, including one with retrograde functional block; 4) constant increase of the A-V node E.R.P.; 5) reduction of sub Hisian A-V conduction velocity in 3 cases out of 7. Episodes of reciprocating tachycardia could be initiated by atrial electrostimulation in 5 patients before administration and in 3 following administration of the drug. In connection with the electrophysiological properties of the two atrio-ventricular pathways and on the mechanism of tachycardia, the use of this drug in prevention of the circus movement tachycardia in patients with the W.P.W. syndrome is discussed.