Prevalence of clinical manifestations and orthopedic alterations in patients with lipedema: A prospective cohort study.

Lipedema is a chronic disease seen frequently in women that causes abnormal fat deposition in the lower limbs and associated bruising and pain. Despite increasing knowledge concerning lipedema, there are still aspects of diagnosis that need further investigation. We performed a prospective, observational cohort study to describe prevalence of clinical characteristics present in patients with lipedema in an attempt to establish diagnostic criteria. Participants were consecutive patients with lipedema presenting at a public hospital in Spain from September 2012 to December 2019. Patients were examined for the following signs and symptoms of lipedema: symmetrical involvement; disproportion between the upper and lower part of the body; sparing of the feet; pain; bruising; Stemmer' sign; pitting test; fibrosis; venous insufficiency; upper limbs involvement; vascular spiders; skin coldness; and lymphangitis attacks. In addition, orthopedic alterations were examined in all patients. We recruited 138 patients (median age=47.6 years; mean BMI=29.9 Kg/m2). Using waist-to-height-ratio, 41.3% of the patients were slim or healthy. The most frequent type of lipedema was Type III (71%), and most were in stage 1 and 2. The features of lipedema with a prevalence >80% were symmetrical involvement, unaffected feet, pain, bruising, vascular spiders, and disproportion. Pain was nociceptive in 60.2% and neuropathic in 33.1%, and there was a reduced social or working activities in 37.9%. Orthopedic alterations including cavusfeet or valgus-knees were observed in 1/3 of the patients. X-ray of the knees was performed in 63 patients and knee osteoarthritis diagnosed in 37. We found that the most frequent manifestations of lipedema were bilateral involvement, unaffected feet, pain, easy bruising, vascular spiders, and disproportion between the upper and lower parts of the body. These should be considered as major criteria for diagnosis. In addition, our findings on the prevalence of orthopedic alterations in patients with lipedema highlights the need for a multidisciplinary and integrated approach.

Perspectives on the fellowship training in cardiac, thoracic, and vascular anesthesia and critical care in Europe from program directors and educational leads around europe

ABSTRACT:This article reviews fellowship training in adult cardiac, thoracic, and vascular anesthesia and critical care from the perspective of European program initiators and educational leaders in these subspecialties together with current training fellows. Currently, the European Association of Cardiothoracic Anaesthesiology (EACTA) network has 20 certified fellowship positions each year in 10 hosting centers within 7 European countries, with 2 positions outside Europe (São Paulo, Brazil). Since 2009, 42 fellows have completed the fellowship training. The aim of this article is to provide an overview of the rationale, requirements, and contributions of the fellows, in the context of the developmental progression of the EACTA fellowship in adult cardiac, thoracic, and vascular anesthesia and critical care from inception to present. A summary of the program structure, accreditation of host centers, requirements to join the program, teaching and assessment tools, certification, and training requirements in transesophageal electrocardiography is outlined. In addition, a description of the current state of EACTA fellowships across Europe, and a perspective for future steps and challenges to the educational program, is provided. (AU)

A comparison of sufentanil vs. remifentanil in fast-track cardiac surgery patients.

We retrospectively compared patients receiving remifentanil with patients receiving sufentanil undergoing fast-track cardiac surgery. After 1:1 propensity score matching there were 609 patients in each group. The sufentanil group had a significantly longer mean (SD) ventilation time compared with the remifentanil group; 122 (59) vs. 80 (44) min, p < 0.001 and longer mean (SD) length of stay in the recovery area; 277 (77) vs. 263 (78) min, p = 0.002. The sufentanil group had a lower mean (SD) visual analogue pain score than the remifentanil group; 1.5 (1.2) vs. 2.4 (1.5), p < 0.001 and consumed less mean (SD) piritramide (an opioid analgesic used in our hospital); 2.6 (4.7) vs. 18.9 (7.3) mg, p < 0.001. The results of our study show that although remifentanil was more effective in reducing time to tracheal extubation and length of stay in the recovery area, there was an increased requirement for postoperative analgesia when remifentanil was used.

Diagnosis and treatment of hepatocellular carcinoma. Update consensus document from the AEEH, SEOM, SERAM, SERVEI and SETH / Diagnóstico y tratamiento del carcinoma hepatocelular. Actualización del documento de consenso de la AEEH, SEOM, SERAM, SERVEI y SETH

Hepatocellular carcinoma is the most common primary malignancy of the liver and one of the most frequent causes of death in patients with liver cirrhosis. Simultaneously with the recognition of the clinical relevance of this neoplasm, in recent years there have been important developments in the diagnosis, staging and treatment of HCC. Consequently, the Asociación Española para el Estudio del Hígado has driven the need to update clinical practice guidelines, continuing to invite all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document (Sociedad Española de Trasplante Hepático, Sociedad Española de Radiología Médica, Sociedad Española de Radiología Vascular e Intervencionista y Sociedad Española de Oncología Médica). The clinical practice guidelines published in 2009 accepted as Clinical Practice Guidelines of the National Health System has been taken as reference document, incorporating the most important advances that have been made in recent years. The scientific evidence for the treatment of HCC has been evaluated according to the recommendations of the National Cancer Institute (www.cancer.gov) and the strength of recommendation is based on the GRADE system.

El carcinoma hepatocelular es la neoplasia primaria de hígado más común y una de las causas de muerte más frecuentes en los pacientes afectos de cirrosis hepática. Simultáneamente al reconocimiento de la relevancia clínica de esta neoplasia, en los últimos años han aparecido novedades importantes en el diagnóstico, estadificación y tratamiento del carcinoma hepatocelular. Por tal motivo, desde la Asociación Española para el Estudio del Hígado se ha impulsado la necesidad de actualizar las guías de práctica clínica, invitando de nuevo a todas las sociedades involucradas en el diagnóstico y tratamiento de esta enfermedad a participar en la redacción y aprobación del documento (la Sociedad Española de Trasplante Hepático, la Sociedad Española de Radiología Médica, la Sociedad Española de Radiología Vascular e Intervencionista y la Sociedad Española de Oncología Médica). Se ha tomado como documento de referencia las guías de práctica clínica publicadas en 2009 aceptadas como Guía de Práctica Clínica del Sistema Nacional de Salud, incorporando los avances más importantes que se han obtenido en los últimos años. La evidencia científica en el tratamiento del carcinoma hepatocelular se ha evaluado de acuerdo con las recomendaciones del National Cancer Institute (www.cancer.gov) y la fuerza de la recomendación se basa en el sistema GRADE.

Management of corrosive injuries of the upper gastrointestinal tract. Our experience in 58 patients.

BACKGROUND: The ingestion of caustic substances is one of the most difficult conditions to be treated in Emergency Department. PATIENTS AND METHODS: The medical records of patients with caustic ingestion and hospitalized from 2003 to 2008 at the Division of General Emergency Surgery with Polyspecialistic Observation of AORN "A. Cardarelli "in Naples, have been revalued. RESULTS: From 2003 to 2008, 58 patients with caustic ingestion were admitted to our Division. Ten of these patients (17.24%) underwent surgery. Six patients underwent oesophageal and gastric resection with cervical esophagostomy and alimentary digiunostomy in emergency; two underwent exploratory laparotomy, two had gastroenteroanastomosis for antropyloric stenosis. One patient underwent new operation for a complication. In total, three reconstructions of oesophagus with colon were performed . Of the six patients undergoing esofagogastrectomy, two died in the first postoperative day, but four have passed the acute phase. CONCLUSIONS: There is no universally accepted diagnostic and therapeutic procedure for the management of these patients, who are often left - as it appears in literature - to the personal experience of the surgeon who is dealing with this situation.

[Imaging diagnosis of hepatocellular carcinoma. Addendum to hepatocellular carcinoma: diagnosis, staging and treatment strategies]. / Diagnóstico por técnicas de imagen del carcinoma hepatocelular. Addendum de carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica.

This addendum is aimed to review and discuss the updated non-invasive diagnostic algorithm recently published by the American Association for the Study of Liver Diseases (AASLD).

Diagnóstico por técnicas de imagen del carcinoma hepatocelular. Addendum de carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica / Imaging diagnosis of hepatocellular carcinoma. Addendum to hepatocellular carcinoma: diagnosis, staging and treatment strategies

El objetivo de este addedndum es Revisar y comentar el nuevo algoritmo para el diagnóstico no invasivo del carcinoma hepatocelular publicado recientemente por la American Association for the Study of Liver Diseases (AASLD) (AU)

This addendum is aimed to review and discuss the updated non-invasive diagnostic algorithm recently published by the American Association for the Study of Liver Diseases (AASLD) (AU)

Evolving strategies for the management of intermediate-stage hepatocellular carcinoma: available evidence and expert opinion on the use of transarterial chemoembolization.

Transarterial chemoembolization (TACE) is considered the gold standard for treating intermediate-stage hepatocellular carcinoma (HCC). However, intermediate-stage HCC includes a heterogeneous population of patients with varying tumour burdens, liver function (Child-Pugh A or B) and disease aetiology. This suggests that not all patients with intermediate-stage HCC will derive similar benefit from TACE, and that some patients may benefit from other treatment options. Results of an extensive literature review into the treatment of unresectable HCC with TACE were combined with our own clinical experience to identify factors that may predict survival after TACE. We also report contraindications to TACE and propose a treatment algorithm for the repetition of TACE. In addition, we have constructed a number of expert opinions that may be used as a guide to help physicians make treatment decisions for their patients with intermediate-stage HCC. The data included in the literature review related almost exclusively to conventional TACE, rather than to TACE with drug-eluting beads. Therefore, the findings and conclusions of the literature review are only applicable to the treatment of HCC with conventional TACE. Treating physicians may want to consider other treatment options for patients with intermediate-stage HCC who are not suitable for or do not respond to TACE. By distinguishing those patients who represent good candidates for TACE from those where little or no benefit might be expected, it may be possible to make better use of current treatment options and improve outcomes for patients.

Carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica / Hepatocellular carcinoma: diagnosis, staging, and treatment strategy

El carcinoma hepatocelular es un tumor de elevada incidencia y alta mortalidad. Estos datos justifican los programas de detección precoz para poder aplicar los tratamientos considerados curativos, lo que implicará una mayor supervivencia. La detección precoz debe realizarse mediante ecografía semestral en la población con riesgo de padecer este tipo de tumor, fundamentalmente en pacientes con cirrosis hepática. Debido a sus características vasculares, actualmente se puede realizar el diagnóstico de carcinoma hepatocelular por técnicas de imagen dinámicas (ecografía con contraste/TC/RM). En caso que el patrón de captación no sea característico en estas técnicas de imagen debe efectuarse una biopsia de la lesión. Una vez diagnosticado, se realiza la estadificación del tumor, lo que junto al estado clínico del paciente, determinará la estrategia terapéutica más adecuada en cada caso (AU)

Hepatocellular carcinoma is a tumor with a high incidence and high mortality. These data justify screening programs to enable curative treatments to improve survival rates. Screening the population at risk (mainly patients with cirrhosis of the liver) should include ultrasonographic examination twice yearly. Given the vascular characteristics of hepatocellular carcinoma, it can be detected using dynamic techniques (contrast-enhanced ultrasonography, CT, and MRI). In cases in which the enhancement pattern is not characteristic, these techniques should be complemented with lesion biopsy. Once hepatocellular carcinoma is diagnosed, the tumor is staged, and together with the clinical condition of the patient, the stage will determine the most appropriate treatment strategy in each case (AU)

[Hepatocellular carcinoma: diagnosis, staging, and treatment strategy]. / Carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica.

Hepatocellular carcinoma is a tumor with a high incidence and high mortality. These data justify screening programs to enable curative treatments to improve survival rates. Screening the population at risk (mainly patients with cirrhosis of the liver) should include ultrasonographic examination twice yearly. Given the vascular characteristics of hepatocellular carcinoma, it can be detected using dynamic techniques (contrast-enhanced ultrasonography, CT, and MRI). In cases in which the enhancement pattern is not characteristic, these techniques should be complemented with lesion biopsy. Once hepatocellular carcinoma is diagnosed, the tumor is staged, and together with the clinical condition of the patient, the stage will determine the most appropriate treatment strategy in each case.

[Early diagnosis of primary liver cancer: imaging versus genetics]. / Diagnóstico precoz del cáncer primario de hígado: imagen versus genética.

Early diagnosis of hepatocellular carcinoma (HCC) in nodules smaller than 2 cm detected by screening ultrasounds becomes essential given that, at that stage, no vascular invasion is usually detected and treatment is associated with a high rate of long-term survival. Improvements in imaging techniques in the last few years have allowed a conclusive diagnosis of HCC in these small nodules without invasive procedures. However, a conclusive diagnosis of HCC by imaging is not always possible and, in more than half of cases, biopsy is needed. On the other hand, histological confirmation of HCC in such tiny nodules is very complex, and in most cases impossible because of the limited sample obtained. In addition, serum tumor markers currently available show low accuracy and are useless for early diagnosis. Progress in the knowledge of molecular mechanisms associated with malignant transformation will allow the use of new techniques that will facilitate diagnosis for HCC in very early stages.

Diagnóstico precoz del cáncer primario de hígado: imagen versus genética / No disponible

El diagnóstico precoz del carcinoma hepatocelular (CHC) es fundamental,especialmente si se consigue cuando los nódulos son menoresde 2 cm, dado que en esta fase la mayoría aún no han presentadoinvasión vascular y la aplicación de tratamientos radicales seacompaña de una alta tasa de supervivencia a largo plazo. Los avancesen las técnicas de imagen en los últimos años han permitido llegara un diagnóstico concluyente de CHC en algunos de estos nódulos depequeño tamaño sin necesidad de realizar procedimientos invasivos.Sin embargo, el número de CHC que pueden ser diagnosticados mediantepruebas de imagen es bajo y en más de la mitad de los casos siguesiendo necesaria la realización de una biopsia. Por otro lado, laconfirmación histológica de CHC en este tipo de nódulos es complejay en muchas ocasiones imposible, dado el posible error de muestreo yla dificultad para diferenciar CHC bien diferenciado de nódulos displásicosen una muestra habitualmente con escaso material. Además, losmarcadores tumorales séricos disponibles en la actualidad presentanun bajo rendimiento y carecen de utilidad en el diagnóstico precoz deCHC. Los progresos en el conocimiento de los mecanismos molecularesresponsables de la transformación maligna permitirán aplicaruna serie de técnicas de biología molecular para facilitar el diagnósticode CHC de forma precoz, con resultados iniciales prometedores

Early diagnosis of hepatocellular carcinoma (HCC) in nodulessmaller than 2 cm detected by screening ultrasounds becomes essentialgiven that, at that stage, no vascular invasion is usually detectedand treatment is associated with a high rate of long-termsurvival. Improvements in imaging techniques in the last few yearshave allowed a conclusive diagnosis of HCC in these small noduleswithout invasive procedures. However, a conclusive diagnosisof HCC by imaging is not always possible and, in more than halfof cases, biopsy is needed. On the other hand, histological confirmationof HCC in such tiny nodules is very complex, and in mostcases impossible because of the limited sample obtained. In addition,serum tumor markers currently available show low accuracyand are useless for early diagnosis. Progress in the knowledge ofmolecular mechanisms associated with malignant transformationwill allow the use of new techniques that will facilitate diagnosisfor HCC in very early stages

[Jejunal perforation from metastatic choriocarcinoma. Case report and review of the literature]. / Perforazione digiunale da coriocarcinoma metastatico. Caso clinico e revisione della letteratura.

Choriocarcinoma is a rare malignant genital tract tumor, arising in the uterus or in the testis. Primary or metastatic choriocarcinomas of the gastrointestinal tract are infrequent. We report a case of a testis choriocarcinoma presenting as jejunal metastasis with perforation. Histology revealed the origin of this metastatic tumor, allowing us to recognize the primary neoplasm of the testis. A review of literature with PubMed since 1964 and of the references of the papers retrieved was performed. Since 1933 only 30 cases of jejunal choriocarcinomas have been described in literature. In 13 cases jejunal choriocarcinoma presented gastrointestinal hemorrhage, in 4 intestinal intussusception and in 1 case upper abdominal pain and vomiting. Only 5 cases of jejunal perforation have been described. The case presented is the first in literature of jejunal perforation from a metastatic choriocarcinoma of the testis.

Trasplante hepático en el carcinoma hepatocelular. Validez de los criterios de Milán / No disponible

No disponible

Hepatocarcinoma y VHC / Hepatocarcinoma and HCV

No disponible

No disponible

New aspects of diagnosis and therapy of hepatocellular carcinoma.

Hepatocellular carcinoma is one of the major cancer killers. It affects patients with chronic liver disease who have established cirrhosis, and currently is the most frequent cause of death in these patients. The main risk factors for its development are hepatitis B and C virus infection, alcoholism and aflatoxin intake. If acquistion of risk factors is not prevented and cirrhosis is established, the sole option to improve survival is to detect the tumor at an early stage when effective therapy may be indicated. Early detection plans should be based on hepatic ultrasonography every 6 months, whereas determination of tumor markers is not efficient. Upon detection of a hepatic nodule, there is a need to establish unequivocal diagnosis, either through biopsy or through the application of non-invasive criteria based on the specific radiology appearance of the tumor: fast arterial uptake of contrast followed by venous washout. Effective treatment for liver cancer includes surgical resection, liver transplantation and percutaneous ablation. These options provide a high rate of complete responses and are assumed to improve survival that should exceed 50% at 5 years. If the tumor is diagnosed at an advanced stage, the sole option that improves survival is transarterial chemoembolization. Ongoing research should further advance the time at diagnosis and identify new and effective options targeting molecular pathways governing tumor progression.

Detección precoz del carcinoma hepatocelular en pacientes cirróticos / No disponible

No disponible