ABSTRACT
BACKGROUND: Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. METHODS: Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. RESULTS: 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. CONCLUSIONS: The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.
Subject(s)
Anesthesiology , Hemodynamic Monitoring , Transfusion Medicine , Adult , Humans , Consensus , Delphi Technique , Fluid Therapy , Critical Care , HemostasisABSTRACT
BACKGROUND: In situ follicular neoplasia (ISFN) is a t(14;18)(q32;q21)+ precursor lesion of follicular lymphoma (FL), which in turn can transform into diffuse large Bcell lymphoma (DLBCL). For DLBCL that arise de novo, no precursor lesion is known. Given the high frequency of the t(14;18) translocation in de novo DLBCL as well, we investigated whether they can also arise from ISFN without FL as an intermediate step. OBJECTIVES: To investigate the clonal evolution of ISFN to DLBCL - transformed from FL and de novo. MATERIALS AND METHODS: Identification of ISFN lesions in patients with DLBCL was performed by BCL2 staining of reactive lymphoid tissues. ISFN and DLBCL were subsequently analyzed by fluorescence in situ hybridization, clonality analyses, sequencing of the t(14;18) breakpoint, and targeted next-generation sequencing. RESULTS: 10 cases with paired ISFN and DLBCL samples were identified, 6 of which were de novo DLBCL and 4 transformed from FL. 3 DLBCL carried MYC-rearrangements in addition to the t(14;18) and were classified as high-grade Bcell lymphoma (HGBL). The clonal relationship of ISFN and DLBCL/HGBL was confirmed for all cases. CREBBP, KMT2D, EZH2, TNFRSF14, and BCL2 were the genes most frequently mutated, with the distribution of private and shared mutations pointing to 2 different scenarios of clonal evolution. In most cases, DLBCL/HGBL, ISFN, and, if also present, FL had evolved divergently from a common progenitor, whereas linear evolution was less frequent. CONCLUSION: We show for the first time that t(14;18)+ DLBCL/HGBL can arise directly from ISFN without FL as an intermediate step and that during this progression, divergent evolution is common.
Subject(s)
Lymphoma, Follicular , Lymphoma, Large B-Cell, Diffuse , Evolution, Molecular , Humans , In Situ Hybridization, Fluorescence , Lymphoma, Follicular/genetics , Lymphoma, Large B-Cell, Diffuse/genetics , Translocation, Genetic/geneticsABSTRACT
Introducción: Los tumores maxilofaciales representan un reto para los anestesiólogos dada la dificultad de controlar el dolor con terapias farmacológicas convencionales. El componente cervical alto del tracto espinomesencefálico y los pares craneales V, VII, IX y X, están involucrados en la fisiopatología del dolor cervicocefálico crónico refractario. Existen estudios que proponen el uso de bajas dosis de bupivacaína a nivel de la cisterna magna como tratamiento de este tipo de dolor con buenos resultados. Nosotros proponemos la asociación de morfina a este nivel con el fin de obtener resultados similares evitando los efectos indeseables derivados de la administración única del anestésico local. Caso clínico: Se trata de una paciente de 41 años sin antecedentes personales de interés salvo ulcus gástrico, diagnosticada de carcinoma epidermoide de suelo de boca en estadio evolutivo avanzado (invasión de ganglios regionales y metástasis laterocervicales), remitida a nuestra consulta por cervicalgia y cefalea intensas. Había seguido tratamiento durante un mes con fentanilo transdérmico 150 µg-h-1 asociado a paracetamol 3 g-24 h-1, metamizol 6 g-24 h-1 y metilprednisolona v.o., a pesar de lo cual mantenía una puntuación en la EVA de 8. Se decide realizar una prueba intradural cervical con 1 mg de morfina y de bupivacaína con resultados satisfactorios. Posteriormente se colocó un catéter intradural cervical, comprobando radiológicamente la ubicación intracisternal de la punta. Se administraron inicialmente bolos de 0,9 mg de morfina y 1,2 mg de bupivacaína cada 12 horas. Con estas dosis se consiguió una disminuir 3 puntos en la EVA en los primeros días. Las dosis se aumentaron semanalmente hasta 3,2 mg y 6,2 mg de morfina y bupivacaína diaria consiguiendo una analgesia satisfactoria (EVA=3). No se observaron efectos adversos salvo ligero prurito e inicialmente náuseas, controlados farmacológicamente. Conclusiones: La administración intracisternal de bupivacaína y morfina puede ser un método útil para el tratamiento del dolor crónico maligno de cabeza y cuello, aunque se necesitarán estudios más completos para establecer tanto indicaciones como la seguridad de dicho método (AU)
