Derrame pericárdico en un caso de linfohistiocitosis hemofagocítica secundaria a leishmaniasis / Pericardial effusion in a case of hemophagocytic lymphohistiocytosis secondary to leishmaniasis

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Parálisis frénica tras vaciamiento ganglionar cervical radical en un paciente EPOC y con síndrome de apnea-hipopnea del sueño / No disponible

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Successful major and minor surgery using factor VIII inhibitor bypassing activity in patients with haemophilia A and inhibitors.

Surgeries are being increasingly performed in patients with haemophilia A and high-titre inhibitors. Optimal bypassing agent regimens need further delineation. Data pertaining to surgeries from 1989 to 2004 at a single centre were retrospectively analysed. Patients received a standardized factor eight inhibitor bypassing activity (FEIBA) dose for both major and minor elective or emergency surgeries. The standard FEIBA dose was 70 U kg(-1) per infusion. FEIBA was infused at 9 and 1 h before and 8 h after operation. Infusions were routinely repeated every 8 h afterward. Haemostatic efficacy was assessed on the basis of blood loss, occurrence of haematoma and transfusion requirements. Seven adult patients underwent a total of 12 operations: 10 major and two minor. Ten procedures were elective. The median cumulative numbers of infusions and days of therapy were 46 and 17, respectively. Cumulative total FEIBA consumption was a median of 3185 U kg(-1). Observed blood losses, haematoma incidence and transfusion requirements were comparable to those expected for noncoagulopathic patients undergoing similar procedures. The only large haematoma occurred after a hip prosthesis operation and resolved under continuing FEIBA treatment. There were no cases of disseminated intravascular coagulation or other thromboembolic complications. FEIBA provides an effective and safe first-line peri- and postoperative haemostatic therapy for patients with haemophilia A and inhibitors, allowing both major and minor operations to be successfully performed.

Acute myeloid dendritic cell leukaemia with specific cutaneous involvement: a diagnostic challenge.

Myeloid or type 1 dendritic cell leukaemia is an exceedingly rare haematopoietic neoplasm characterized by a specific immunophenotypic profile close to plasmacytoid dendritic cell and acute myelogenous leukaemia. A 77-year-old man presenting specific cutaneous infiltration by myeloid dendritic cell leukaemia is reported. The clinical features as well as the cutaneous histopathological and immunohistochemical features led to the initial diagnosis of CD4+/CD56+ haematodermic neoplasm. However, extensive immunophenotypic studies performed from peripheral blood blasts disclosed that leukaemic cells expressed myeloid dendritic cell markers, confirming the diagnosis. The diagnostic difficulties of specific cutaneous involvement by myeloid dendritic cell leukaemia on the basis of routine histopathological and immunohistochemical features are highlighted.

[Is a preanesthetic interview by a team including nurses effective, safe, and efficient?]. / Es eficaz, segura y eficiente una consulta preanestésica en equipo con enfermería?

OBJECTIVE: To analyze the effectiveness, safety, and performance of anesthetist-led preanesthetic interviews in which specifically trained nurses exercise defined roles under supervision. MATERIAL AND METHODS: This descriptive study analyzed preanesthetic interviews performed by a team of anesthesiologists and nurses in surgically treated patients over a 1-year period. We assessed the impact of those interviews on the rate of procedures canceled due to errors in presurgical assessment. Study variables were the percentage of procedures canceled due to failure of presurgical assessment and the difference in the cancellation rate according to whether the interviews were undertaken by anesthesiologists or nurses, number of preanesthetic assessments made by nurses; number of consultations made by nurses to anesthesiologists, number of patients referred for a second interview with an anesthesiologist after assessment by a nurse, rate of substitution by nurses of anesthesiologists, and time dedicated daily by anesthesiologists responding to nurses' consultations. The results were analyzed using descriptive statistics. RESULTS: A total of 7343 preoperative assessments were performed. Of those, 28.6% were undertaken by nurses. Surgery was canceled because of errors in presurgical assessment in 78 cases (1.06%), corresponding to 1.0% of the preoperative evaluations performed by anesthesiologists and 0.7% of those performed by nurses. In 317 (18.2%) nurse-led preoperative assessments the anesthesiologist was consulted, and in another 121 cases (6.9%) a second preanesthetic interview was required. The rate of substitution of anesthesiologists by nursing staff was 26.5% and the time anesthesiologists dedicated daily to consultation during nurse-led assessments was 17.7 minutes. CONCLUSIONS: The involvement of nurses in preanesthesia assessments of surgical patients is a clinically safe and effective initiative.

¿Es eficaz, segura y eficiente una consulta preanestésica en equipo con enfermería? / Is a preanesthetic interview by a team including nurses effective, safe, and efficient?

OBJETIVO: Analizar la eficacia, seguridad y rendimientode una consulta preanestésica, liderada por anestesiólogos,en la que participa, por delegación de funciones, supervisaday previo entrenamiento específico enfermería.MATERIAL Y MÉTODOS: Estudio descriptivo de las evaluacionespreanestésicas de pacientes sometidos a intervencionesquirúrgicas durante el período de un año porun equipo compuesto por anestesiólogos (CAnest) y enfermería(CEnfAnest) y su impacto sobre el índice de suspensionesquirúrgicas por fallo del Circuito Preoperatorio(CP). Variables del estudio: Porcentaje de suspensionesquirúrgicas por fallo del CP; relación de las mismas conCAnest y CEnfAnest. Número de evaluaciones preanestésicasrealizadas por enfermería, número de consultas desdeCEnfAnest a CAnest, número de pacientes derivadoscomo segunda visita a CAnest tras visita en CEnfAnest,índice de sustitución (IS) de CEnfAnest, tiempo del anestesiólogodedicado diariamente a las consultas de CEnfAnest(TAnest). Estudio estadístico: estadística descriptiva.RESULTADOS: Total de evaluaciones preoperatorias:7.343. El 28,6% de las mismas fueron realizadas porCEnfAnest. Suspensiones quirúrgicas por fallo del CP:78 casos (1,06%); correspondieron al 1% de las evaluacionespreoperatorias realizadas en CAnest y al 0,7% delas realizadas en CEnfAnest. En 317 (18,2%) evaluacionespreoperatorias de CEnfAnest se consultó al anestesiólogoy en otros 121 casos (6,9%) se requirió nuevavisita preanestésica. El IS de CEnfAnest fue del 26,5%;el TAnest de 17,7 minutos.CONCLUSIONES: La participación de enfermería en lasvaloraciones preanestésicas de los pacientes quirúrgicoses una iniciativa eficaz y segura desde el punto de vistaclínico

OBJETIVE: To analyze the effectiveness, safety, and performance of anesthetist-led preanesthetic interviews in which specifically trained nurses exercise defined roles under supervision. MATERIAL AND METHODS: This descriptive study analyzed preanesthetic interviews performed by a team of anesthesiologists and nurses in surgically treated patients over a 1-year period. We assessed the impact of those interviews on the rate of procedures canceled due to errors in presurgical assessment. Study variables were the percentage of procedures canceled due to failure of presurgical assessment and the difference in the cancellation rate according to whether the interviews were undertaken by anesthesiologists or nurses, number of preanesthetic assessments made by nurses; number of consultations made by nurses to anesthesiologists, number of patients referred for a second interview with an anesthesiologist after assessment by a nurse, rate of substitution by nurses of anesthesiologists, and time dedicated daily by anesthesiologists responding to nurses’ consultations. The results were analyzed using descriptive statistics. RESULTS: A total of 7343 preoperative assessments were performed. Of those, 28.6% were undertaken by nurses. Surgery was canceled because of errors in presurgical assessment in 78 cases (1.06%), corresponding to 1.0% of the preoperative evaluations performed by anesthesiologists and 0.7% of those performed by nurses. In 317 (18.2%) nurse-led preoperative assessments the anesthesiologist was consulted, and in another 121 cases (6.9%) a second preanesthetic interview was required. The rate of substitution of anesthesiologists by nursing staff was 26.5% and the time anesthesiologists dedicated daily to consultation during nurse-led assessments was 17.7 minutes. CONCLUSIONS: The involvement of nurses in preanesthesia assessments of surgical patients is a clinically safe and effective initiative

Réplica al comentario al caso clínico titulado “Síndrome neurológico transitorio tras bupivacaína hiperbara intradural. Un nuevo caso” / Reply. On the case report: "Transient neurological syndrome after spinal hyperbaric bupivacaine: a new case"

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Polirradiculitis bilateral tras bloqueo epidural, una complicación grave poco frecuente / Bilateral polyradiculitis after an epidural block: a rare, serious complication

Las complicaciones neurológicas permanentes asociadasa técnicas neuroaxiales son poco frecuentes. Presentamosun caso clínico en el que la realización de la técnicaregional así como la intervención cursaron sinincidencias reseñables. El dolor postoperatorio fue controladomediante analgesia multimodal. El catéter epiduralfue retirado en planta a las 24 horas. A las 72horas el paciente comenzó con un cuadro de impotenciafuncional en miembros inferiores, de predominio derechoy, parestesias asociadas. En la exploración neurológicase objetivó una paraparesia flácida con afectacióna nivel de la segunda vértebra lumbar, de predominioproximal en miembro inferior derecho, sin alteracionesesfinterianas. La resonancia magnética (RM) realizadade urgencia fue negativa para masas ocupantes de espacioen canal medular. Tras estudios complementariosrealizados en días sucesivos (electromiografías seriadas(EMG), punción lumbar y nueva RM), se diagnosticófinalmente una polirradiculitis bilateral asociada aanalgesia epidural. La evolución ha sido lenta pero favorable.La EMG realizada a los 8 meses mostró unamejoría clara de las lesiones. Después de un año de evolución,el paciente continúa en programa de rehabilitacióny utiliza apoyo ocasional de bastón para la deambulación

Permanent neurological complications related to neuraxialtechniques are rare. We report a case in whichperformance of the regional block and the interventionwere free of noteworthy incidents. Postoperative painwas controlled by use of multimodal analgesia. The epiduralcatheter was removed on the ward after 24 hours.However, 72 hours after the intervention, the patientdeveloped lower limb weakness and associated paresthesiamainly on the right side. Examination disclosed flaccidparalysis from the second lumbar vertebra affectingmainly the right lower extremity with no involvement ofthe sphincters. Emergency magnetic resonance imagingwas negative for masses occupying the spinal canal.After a battery of tests over the following days (electromyography,lumbar puncture, and magnetic resonanceimaging), bilateral polyradiculitis related to epiduralanalgesia was diagnosed. The clinical course was satisfactory,though resolution was slow. Electromyographyat 8 months confirmed clear improvement in lesions.After a year, the patient continued rehabilitation andoccasionally still used a cane

CD4+/CD56+ haematodermic neoplasm: a preculsor haematological neoplasm that frequently first presents in the skin.

CD4+/CD56+ hematodermic neoplasm, formerly known as blastic NK cell lymphoma, is an aggressive and rare preculsor hematologic neoplasm recently recognized by the WHO-EORTC classification consensus for cutaneous lymphomas. The neoplasm tends to affect elderly patients, who usually present with skin lesions but often have a disseminated disease, including bone marrow involvement. Although the lesions are composed of cells with a lymphoblast-like morphology and an NK-cell phenotype, exhibiting a CD4+, CD56+ positive immunophenotype, recent studies support a relationship to plasmacytoid dendritic cells. Because of the rarity of this disease, we describe two patients suffering a CD4+/CD56+ hematodermic neoplasm.

[Transient neurological syndrome after spinal hyperbaric bupivacaine: a new case]. / Síndrome neurológico transitorio tras bupivacaína hiperbara intradural. Un nuevo caso.

A 47-year-old woman underwent hysteroscopy and removal of an endometrial polyp because of irregular, acyclic bleeding of 6 months' duration. The procedure was carried out under spinal anesthesia. No adverse events occurred during puncture or surgery, or in the immediate postoperative recovery period. Recovery from the sensory and motor block was normal. Twenty-four hours after surgery gluteal and lower limb pain and paresthesia developed, with no sensory or motor deficit. The symptoms suggested transient neurological syndrome. This syndrome has been defined by pain in the lower limbs, buttocks, thighs and calves after uncomplicated spinal anesthesia and full recovery from the sensorimotor block during the immediate postoperative period (first 24 hours). The condition is self-limiting and does not leave permanent neurological sequelae. Recent studies have demonstrated biochemical and anatomical changes that provide a structural basis for this clinical entity. According to this literature, transient neurological syndrome might be a mild expression of local anesthetic toxicity. Recent findings show that the initial injury to the nerve cell membrane, induced by high concentrations of local anesthetic could lead to permanent neuronal damage.

Síndrome neurológico transitorio tras bupivacaína hiperbara intradural. Un nuevo caso / Transient neurological syndrome after spinal hyperbaric bupivacaine: a new case

Paciente de 47 años sometida a histeroscopia y exéresisde pólipo endometrial por metrorragias de seis mesesde evolución. El procedimiento se llevó a cabo bajo anestesiaintradural. No hubo incidencias durante la punción,el intra ni el postoperatorio inmediato. La recuperacióndel bloqueo sensitivo y motor fue normal. A las 24horas de la cirugía comenzó con dolor y disestesias englúteos y miembros inferiores, sin déficit sensitivo nimotor. La clínica era sugerente de síndrome neurológicotransitorio.El síndrome neurológico transitorio (TNS) ha sidodefinido como dolor en los miembros inferiores, nalgas,muslos y piernas tras una anestesia espinal sin complicacionesy tras una recuperación completa del bloqueosensitivo-motor durante el periodo postoperatorio inmediato(antes de las primeras 24 horas). El curso es autolimitadoy no permanece secuela neurológica alguna.Los últimos estudios han demostrado cambios bioquímicosy anatomopatológicos que aportan una baseestructural a la entidad clínica de TNS. Según algunosautores TNS podría ser la menor expresión de la toxicidadpor anestésicos locales. Hallazgos recientes demuestranque el daño inicial en la membrana de la célula nerviosa,inducida por altas concentraciones de anestésicolocal, podría desembocar en un daño neuronal permanente

A 47-year-old woman underwent hysteroscopy andremoval of an endometrial polyp because of irregular, acyclicbleeding of 6 months’ duration. The procedure wascarried out under spinal anesthesia. No adverse eventsoccurred during puncture or surgery, or in the immediatepostoperative recovery period. Recovery from the sensoryand motor block was normal. Twenty-four hours after surgerygluteal and lower limb pain and paresthesia developed,with no sensory or motor deficit. The symptoms suggestedtransient neurological syndrome.This syndrome has been defined by pain in the lowerlimbs, buttocks, thighs and calves after uncomplicatedspinal anesthesia and full recovery from the sensorimotorblock during the immediate postoperative period(first 24 hours). The condition is self-limiting and doesnot leave permanent neurological sequelae.Recent studies have demonstrated biochemical andanatomical changes that provide a structural basis forthis clinical entity. According to this literature, transientneurological syndrome might be a mild expression oflocal anesthetic toxicity. Recent findings show that theinitial injury to the nerve cell membrane, induced byhigh concentrations of local anesthetic could lead to permanentneuronal damage

[Bilateral polyradiculitis after an epidural block: a rare, serious complication]. / Polirradiculitis bilateral tras bloqueo epidural, una complicación grave poco frecuente.

Permanent neurological complications related to neuraxial techniques are rare. We report a case in which performance of the regional block and the intervention were free of noteworthy incidents. Postoperative pain was controlled by use of multimodal analgesia. The epidural catheter was removed on the ward after 24 hours. However, 72 hours after the intervention, the patient developed lower limb weakness and associated paresthesia mainly on the right side. Examination disclosed flaccid paralysis from the second lumbar vertebra affecting mainly the right lower extremity with no involvement of the sphincters. Emergency magnetic resonance imaging was negative for masses occupying the spinal canal. After a battery of tests over the following days (electromyography, lumbar puncture, and magnetic resonance imaging), bilateral polyradiculitis related to epidural analgesia was diagnosed. The clinical course was satisfactory, though resolution was slow. Electromyography at 8 months confirmed clear improvement in lesions. After a year, the patient continued rehabilitation and occasionally still used a cane.

Cerebral hemodynamic effects of 7.2% hypertonic saline in patients with head injury and raised intracranial pressure.

The aim of the present study was to investigate the acute effects of 7.2% hypertonic saline (HS) on intracranial pressure (ICP), cerebral and systemic hemodynamics, serum sodium, and osmolality in 14 patients with moderate and severe traumatic brain injury (Glasgow Coma Scale < or =13) and raised ICP (>15 mm Hg) within the first 72 h postinjury. After CO2 reactivity and autoregulation were tested, each patient received a 15-min infusion of 7.2% HS (1,232 mEq/L, volume 1.5 mL/kg). ICP, serial hemodynamics, cerebral blood flow (CBF) estimated from cerebral arteriovenous oxygen content difference (AVDO2), and laboratory variables, including serum osmolality, electrolytes, urea, and creatinine were collected before infusion (T0) and at 5, 30, 60, and 120 min after (T5, T30, T60, T120). Urine output was measured 2 h before infusion and at T120. While CO2 reactivity was preserved in all patients, autoregulation was preserved in only four. ICP decreased to about 30% of base line (p = 0.0001) during the whole study period. During the first hour after infusion, cerebral perfusion pressure (p< or =0.04) and cardiac index (CI; p< or =0.01) increased, while systemic vascular resistance index fell (p< or =0.05). Heart rate increased (p< or =0.04) during the first 30 min. Pulmonary artery occlusion pressure (PAOP) increased (p = 0.004) at T5. There were no significant changes in mean arterial blood pressure (MABP), urine output, and estimated CBF. A significant positive correlation (r = 0.75; p = 0.02) between ICP and serum osmolality was found at T5. The administration of 7.2% HS in patients with traumatic brain injury significantly reduces ICP without significant changes in relative global CBF (expressed as 1/AVDO2), increases CI and transiently increases PAOP, without changing MABP and urine output. The correlation between changes in osmolality and ICP supports the hypothesis that HSS may in part decrease ICP by means of an osmotic mechanism.

Latency and reactivation of JC virus in peripheral blood of human immunodeficiency virus type 1-infected patients.

JC virus (JCV) acts as an opportunistic virus in immunocompromised human immunodeficiency virus type 1 (HIV-1)-infected patients. The role of peripheral blood cells in central nervous system invasion, before the onset of progressive multifocal leukoencephalopathy (PML), remains controversial. In order to clarify JCV latency or reactivation status in peripheral blood, 72 HIV-1-infected patients were studied, together with 7 HIV-1-positive PML patients and 50 blood donors. Blood leukocytes, plasma, and B lymphocytes were investigated by two complementary DNA amplification procedures within the early T and late VP1 JCV genes and two reverse transcription techniques for the detection of corresponding early transcripts and mRNAs. JCV DNA was detected in 40.3% of the HIV-1-infected patients but only 8% of the blood donors (P < 0.001). Leukocytes represented 82.7% of the positive samples, but plasma from 12 patients (41.4%) contained JCV DNA. B lymphocytes seemed to be involved in the natural history of JCV but did not represent the unique cell target. JCV DNA was intermittently found in blood, and JCV mRNAs for VP1 capsid protein were detected exclusively in one PML patient. Such observations demonstrate that JCV, when detected in blood, does not undergo active multiplication. They support the JCV hematogenous spread hypothesis, but do not indicate any direct link between peripheral virus and dissemination in the central nervous system at the time of immunodepression.

Peripheral blood progenitor cell transplantation in 118 patients with hematological malignancies: analysis of factors affecting the rate of engraftment.

We retrospectively studied the factors affecting the rate of hematopoietic reconstitution (HR) in 118 patients with hematological malignancies who underwent peripheral blood progenitor cell (PBPC) transplantation at a single institution. The patients received a median number of 6.6 x 10(8) nucleated cells/kg corresponding to 9.5 x 10(4) (0.5-578) CFU-GM/kg and 6.8 x 10(6) (0.2-161) CD34-positive cells/kg. The median number of days to reach 500 polymorphonuclear cells/mm3 and 50,000 platelets/mm3 was 12.5 (6-93) and 14.5 (6-440) days, respectively. No patient died from infection during the aplastic phase. By multivariate analysis, we found that the dose of CFU-GM infused was the only factor that significantly affects the HR rate (p < 0.0001). Moreover, patients with acute myelogenous leukemia or those transplanted after busulfan or total-body irradiation conditioning regimens had a slower engraftment (p < 0.08). These results could lead to identifying patients who need growth factors posttransplantation and/or the reinfusion of "back-up" marrow together with PBPC.

Collection of peripheral blood stem cells in multiple myeloma following single high-dose cyclophosphamide with and without recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF).

High-dose cyclophosphamide (HD-CY; 7 g/m2) was administered to patients suffering from high risk multiple myeloma (MM). The safety of this procedure, the recirculation and collection of peripheral blood stem cells (PBSC) and the effect of rhGM-CSF and HD-CY were studied. Group I patients (n = 21) were treated with HD-CY alone. Group II patients (n = 10) received 5 micrograms/kg/day rhGM-CSF iv after HD-CY. Neutropenia was shorter in group II (p = 0.01). In group II, the number of circulating colony forming units (CFU-GM) after 14 days was correlated with the number of circulating CFU-GM after 7 days (r = 0.85, p < 0.0001) and with the number of CD34+ cells (r = 0.839, p = 0.01). The total number of mononuclear cells (MNC) and CFU-GM collected per patient was two and seven-fold higher, respectively, in group II (p = 0.01 and p = 0.03). Recovered MNC and CFU-GM were 1.7 and 7-fold higher, respectively, in group II (p = 0.01 and p = 0.004). Our data show that HD-CY is an efficient means of collecting functional PBSC in MM. We suggest that rhGM-CSF is able to further enhance this yield in MM.

Malignant infiltration of peripheral nerves in the course of acute myelomonoblastic leukaemia: neuropathological study of two cases.

Two patients suffering from acute myelomonoblastic leukaemia developed clinical evidence of peripheral nerve involvement. In both cases, a peripheral nerve biopsy revealed endoneurial cellular infiltrates which were identified as leukaemic cells by immunocytochemistry. Ultrastructural studies showed mainly axonal damage. Moreover, in one patient, a few features of active demyelination were also observed.