Molecular signatures of atherosclerotic plaques: An up-dated panel of protein related markers.

Atherosclerosis remains the leading cause of ischemic syndromes such as myocardial infarction or brain stroke, mainly promoted by plaque rupture and subsequent arterial blockade. Identification of vulnerable or high-risk plaques constitutes a major challenge, being necessary to identify patients at risk of occlusive events in order to provide them with appropriate therapies. Clinical imaging tools have allowed the identification of certain structural indicators of prone-rupture plaques, including a necrotic lipidic core, intimal and adventitial inflammation, extracellular matrix dysregulation, and smooth muscle cell depletion and micro-calcification. Additionally, alternative approaches focused on identifying molecular biomarkers of atherosclerosis have also been applied. Among them, proteomics has provided numerous protein markers currently investigated in clinical practice. In this regard, it is quite uncertain that a single molecule can describe plaque rupture, due to the complexity of the process itself. Therefore, it should be more accurate to consider a set of markers to define plaques at risk. Herein, we propose a selection of 76 proteins, from classical inflammatory to recently related markers, all of them identified in at least two proteomic studies analyzing unstable atherosclerotic plaques. Such panel could be used as a prognostic signature of plaque instability.

Síndrome de Stewart-Bluefarb: caso clínico y revisión de la literatura / Stewart-Bluefarb Syndrome: Case Report and Review of the Literature

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Consenso sobre la profilaxis y tratamiento de la enfermedad tromboembólica venosa en la lesión medular y en el daño cerebral adquirido / Prevention and treatment of venous thromboembolism in spinal cord injury and acquired brain injury

La enfermedad tromboembólica venosa es un proceso patológico que abarca tanto la trombosis venosa profunda como el tromboembolismo pulmonar. Son muchos los estudios que recogen la alta incidencia de esta enfermedad en pacientes afectos de lesiones neurológicas como la lesión medular, el traumatismo craneoencefálico o el ictus, todos ellos pacientes susceptibles de ingreso en centros de rehabilitación. En la literatura publicada existe controversia acerca de la necesidad de screening de enfermedad tromboembólica venosa en estos pacientes, el tiempo de mantenimiento de la profilaxis o los fármacos a utilizar tanto en la profilaxis como una vez se establece la sospecha o el diagnóstico definitivo de dicha enfermedad. Con esta revisión de la literatura pretendemos hacer un consenso para intentar aclarar dudas y establecer unas directrices de sospecha, diagnóstico y tratamiento que nos ayuden en la práctica clínica diaria

Venous thromboembolism is a disease that includes both deep vein thrombosis and pulmonary embolism. Many studies reflect the high incidence of this disease in patients with neurological injuries such as, spinal cord injury, traumatic brain injury, or stroke, and all these patients are candidates for admission to rehabilitation centres. There is controversy in the published literature on the need for screening of deep vein thrombosis in these patients, time on prophylaxis drug maintenance or the drugs to use for prophylaxis once suspected or when the definite diagnosis of this disease is established. A review of the literature is presented in order to attempt to clarify these doubts and establish guidelines for suspicion, diagnosis and treatment to help us in daily clinical practice

Coste del tratamiento del aneurisma de aorta abdominal: cirugía abierta frente a tratamiento endovascular / Cost of abdominal aortic aneurysm treatment. Open repair compared to endovascular repair

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Thrombosed Popliteal Artery Pseudoaneurysm as Herald of Tibial Osteochondroma.

BACKGROUND: Osteochondroma is the most common non-malignant tumour of bone, accounting for approximately one third of benign lesions in the skeleton. They often develop around the knee in the distal femur and in the proximal tibia and fibula. They present as a painless slow growing mass during adolescence and have been reported to cause damage to adjacent structures such as blood vessels; arterial damage is more common than venous injury and is usually a result of compression, stretching, and rubbing of the arterial wall. Such lesions include stenosis, thrombosis, and pseudoaneurysm formation possibly causing lower limb claudication or acute limb ischemia. METHODS: An 18 year old male patient with a 4 week history of pain, hematoma, and oedema of the left calf without previous trauma is reported. A computed tomography scan (CT) revealed a large popliteal artery pseudoaneurysm and its close relationship to a protrusion of the proximal tibia. RESULTS: The popliteal artery was repaired by an external saphenous patch and the exostosis was removed. The patient had palpable popliteal and distal pulses after surgery and during the first year follow-up. CONCLUSIONS: Tibial osteochondroma should be considered in the differential diagnosis in young patients, among the potential causes of pseudoaneurysm of the femoral or popliteal artery. Surgical repair should be performed to restore normal blood flow with resection of the exostosis to prevent recurrence.

Morbimortalidad de los aneurismas de aorta abdominal rotos durante la implantación del tratamiento endovascular en nuestro centro / Morbidity and mortality of ruptured abdominal aortic aneurysms during endovascular treatment

OBJETIVO: Valorar la mortalidad y complicaciones postoperatorias durante el primer mes de los aneurismas de aorta abdominal rotos (AAAr), en función de la técnica quirúrgica empleada, reparación endovascular de aneurisma (EVAR). Analizar los factores pronósticos que influyen en la mortalidad. MATERIAL Y MÉTODOS: Estudio de cohortes históricas de los pacientes con AAAr infrarrenales y yuxtarrenales sometidos a tratamiento quirúrgico (EVAR o cirugía abierta) en nuestro centro. Los criterios de elección para EVAR son anatomía favorable y estabilidad hemodinámica. Las variables recogidas fueron características demográficas, factores de riesgo cardiovascular y patología asociada, técnica quirúrgica, lugar de procedencia, demora en la intervención, situación preoperatoria, complicaciones médico-quirúrgicas postoperatorias, estancia en unidad de reanimación posquirúrgica (URP) y en planta de hospitalización y mortalidad. RESULTADOS: Entre enero de 2011 y agosto del 2013 se intervinieron 31 varones con edad media de 71 años. La mortalidad global fue del 45% (mortalidad del 61% en cirugía abierta frente al 23% con EVAR, p 0,06). Hipotensión preoperatoria < 80 mmHg (p < 0,004), creatinina > 2,1 mg/dl (p 0,018) e inestabilidad hemodinámica en quirófano (p < 0,05) se asocian con la mortalidad de forma significativa, independientemente de la técnica quirúrgica empleada. La estancia media en URP fue de 10 días en cirugía abierta frente a 2 días en EVAR (p 0,04). La estancia media hospitalaria fue de 19 días en cirugía abierta frente a 6,5 días en EVAR. CONCLUSIONES: La introducción del EVAR para el tratamiento de los AAAr en nuestro centro ha disminuido la morbimortalidad, la estancia media en URP y en planta de hospitalización

OBJECTIVE: A study was conducted on the 30-day mortality and postoperative complications after endovascular repair (EVAR) and open surgery in patients with ruptured abdominal aortic aneurysms (rAAA). An analysis was made of the prognostic factors influencing the mortality. MATERIAL AND METHODS: A review was conducted on a cohort of patients with infrarenal and juxtarenal rAAA undergoing surgical treatment (EVAR and open surgery). The selection criteria used for EVAR were favourable anatomy and hemodynamic stability. The variables collected were demographic characteristics, cardiovascular risk factors and associated diseases, surgical technique, place of origin, delayed intervention, preoperative status, postoperative medical and surgical complications, postoperative stay in intensive care unit (ICU) and days of hospital stay, and mortality. RESULTS: A total of 31 males with a mean age of 71 years were operated on between January 2011 and August 2013. Mortality was 45% (a mortality of 61% in open surgery compared to 23% with EVAR, p = .06). Variables significantly associated with 30-day mortality were preoperative hypotension < 80 mmHg (p = 0.004), creatinine > 2.1 mg / dl (p = 0.018), and hemodynamic instability during surgery (p < 0.05), regardless of the surgical technique used. The average stay in the ICU was 10 days in open surgery versus 2 days for EVAR (p = 0.04). The average hospital stay was 19 days in open surgery versus 6.5 days for EVAR. CONCLUSIONS: EVAR for treatment of rAAA in this hospital has decreased morbidity and mortality rates, the average stay in ICU, and hospitalization stay

Pseudoaneurisma de troncos distales de miembros inferiores tras traumatismo. ¿Tratamiento de elección endovascular o abierto? / Pseudoaneurysm of the distal arteries of the lower limbs after injury. Endovascular or open treatment?

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Isquemia en mano por fístula arteriovenosa para hemodiálisis trombosada / Ischemia of the hand due to a thrombosed arteriovenous fistula for hemodialysis access

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Comportamiento del saco aneurismático después del tratamiento endovascular (EVAR). Revisión de una serie de casos (periodo 2009-2012) / Behaviour of the aneurysm sac after endovascular treatment. Review of a case series (2009-2012)

Introducción: La reparación endovascular de los aneurismas (EVAR) es una técnica cada vez más utilizada y que necesita evaluar sus resultados en cuanto a morbimortalidad y comportamiento del aneurisma. Pocos estudios señalan datos del comportamiento del saco aneurismático. Objetivo: Realizar un análisis de los cambios de diámetro del saco aneurismático después de EVAR. Material y métodos: Entre febrero de 2009 y febrero de 2012, tratamos mediante EVAR a 73 pacientes (77 procedimientos) con AAA y/o aneurismas ilíacos, seleccionados según edad (> 75 años) o riesgo quirúrgico. Todos fueron seguidos a 1, 6 y 12 meses y luego de forma anual mediante angio-TC. Analizamos los que tienen, al menos, una angio-TC al año realizada en el mismo hospital, en total 28 pacientes (100 angio-TC), excluyendo los pendientes del control anual, muerte y pérdidas, la mayoría por angio-TC realizadas en otro centro. Un único facultativo calculó las mediciones axiales bidimensionales en el mismo equipo informático. Se implantaron 4 dispositivos diferentes y se analizaron 8 Endurant, 11 Excluder, 8 Zenith y 1 Anaconda. Resultados: Obtuvimos en todos los pacientes reducción del saco aneurismático. La disminución media por tipo de endoprótesis ha sido: Endurant 10,6mm; Excluder 7,8mm; Zenith 7,83mm; Anaconda 1mm. Conclusiones: En este primer análisis, la técnica utilizada no se ha relacionado con roturas del aneurisma, así como la regresión del saco aneurismático está presente en todos los dispositivos de nuestro estudio, lo cual parece haber sido favorablemente influido por la nueva generación de materiales del injerto. La relación entre la morfología del aneurisma y los efectos a largo plazo sobre la endoprótesis aórtica está aún por determinar por lo cual debemos seguir analizando datos y resultados(AU)

Introduction: Endovascular aneurysm repair (EVAR) is an increasingly used technique, but its results need to be evaluated as regards morbidity, mortality and behavior of the aneurysm. There are few studies that examine the behavior of the aneurysm sac. Objective: To perform an analysis of the aneurysm sac changes after EVAR. Material and methods: Between February 2009-February 2012 a total of 73 patients, selected according to age (> 75 years) or surgical risk, received EVAR treatment for AAA and/or iliac aneurysms (77 procedures). All patients were followed up at 1, 6, 12 months, and then annually using CT angiography. Those patients who had at least one CT angiography at the end of one year and performed in the same hospital were analyzed. A total of 28 patients (100 AngioCTs) were included, and those still awaiting the 12 month follow up, deaths and losses (mainly performed in other AngioCT sites), were excluded. All axial measurements were made by the same practitioner and computer equipment. Four different devices (8 Endurant, 11 Excluder, Zenith 8 and 1 Anaconda) were implanted and analyzed. Results: A reduction in the aneurysm sac was observed in all patients. The average decrease by type of endoprosthesis was: Endurant 10.6mm, Excluder 7.8mm, Zenith 7.83mm, and Anaconda 1mm. Conclusions: In this first analysis, the technique has not associated with aneurysm rupture, and aneurysm sac reduction was present in all the devices studied, which seems to have been favorably influenced by the new generation of graft materials. The relationship between the morphology of the aneurysm and the long-term effects on aortic stents still has to be determined and we must continue to analyze the data and results(AU)

Long and short-term performance of a stabilized/solidified electric arc furnace dust.

The application of class F fly ash, cement and lime to the Stabilization/Solidification (S/S) of electric arc furnace dust containing hazardous metals such as Zn, Pb, Cd, and Cr is described. The aim of the study was to determine the influence of the setting conditions during the S/S treatment and to know the behaviour of an aged solidified and stabilized waste. In order to determine the efficiency attained by the S/S process, USEPA TCLP, and other leaching tests have been accomplished. In addition, the compressive strength of the solidified waste at different times has been determined. In order to study the influence of the environmental conditions in which setting occurs, experiments were carried out with samples of the same composition, under different setting conditions: laboratory environment, stove at a temperature of 40-60 degrees C and setting in a hermetically sealed plastic bag at room temperature. All the samples were subjected to the TCLP test at 28 days, and the metal content of the resulting leachates was analysed. The results show that in some cases the setting conditions of the mixtures have a noticeable influence on the characteristics of the leachate. The evolution with time of some S/S solids, one month after their manufacture and more than 9 years after that has also been evaluated, by means of their leaching behaviour. The results obtained in this work have shown, in all the laboratory cured samples that the leachate pH decrease in the course of time, and consequently the leaching behaviour is in general worse. This could be due to the carbonation of the S/S solid and the subsequent loss of alkalinity.

Antibioterapia empírica en el pie diabético y no diabético / Empirical antibiotic therapy for diabetic and non-diabetic foot

Introducción. La neuropatía, la isquemia y la infección son los tres factores directamente relacionados con la aparición y desarrollo de las úlceras en los pacientes diabéticos. La infección definida mediante parámetros clínicos y apoyada por cultivos microbiológicos es el principal factor pronóstico de la lesión. Objetivo. Estudiar la etiología infecciosa de las úlceras en pacientes diabéticos y no diabéticos, así como la sensibilidad in vitro a antimicrobianos de los microorganismos aislados, nos permitirá establecer la mejor pauta antibiótica empírica en nuestro medio asistencial. Pacientes y métodos. Estudio observacional, transversal y prospectivo de 200 pacientes consecutivos, diabéticos y no diabéticos, ingresados por la presencia de úlceras isquémicas o neuropáticas con signos locales de infección. Toma de tres muestras microbiológicas el día del ingreso previa administración del tratamiento empírico (ciprofloxacino + clindamicina) y valoración de su respuesta clínica y sus modificaciones a específico por resistencia de los microorganismos. Resultados. En la mayoría de los cultivos se aisló microbiota polimicrobiana con predominio de aerobios-anaerobios gramnegativos y aerobios grampositivos. Staphylococcus aureus (10,6%), Pseudomonas aeruginosa y Bacteroides fragilis fueron los microorganismos más frecuentemente aislados. La terapia empírica tuvo que modificarse en más del 50% de los casos por resistencia. La mayor sensibilidad in vitro para los microorganismos grampositivos fue para la vancomicina, seguida de cloxacilina y amoxicilina/clavulánico. En el caso de aerobios-anaerobios gramnegativos, fue para meropenem, tobramicina e imipenem, y para los anaerobios, imipenem, cefoxitina y amoxicilina/clavulánico. Conclusiones. La administración de amoxicilina/clavulánico solo o asociado a tobramicina constituye una pauta antibiótica con amplio espectro para los pacientes ambulatorios. En régimen de ingreso el antibiótico de elección sería imipenem, seguido de piperacilina/tazobactam

Introduction. Neuropathy, ischaemia and infection are the three factors directly related to the appearance and development of ulcers in diabetic patients. Infection defined by means of clinical parameters and backed up by microbiological cultures is the main prognostic factor of the lesion. Aims. To study the infectious causation of ulcers in diabetic and non-diabetic patients, in addition to the in vitro sensitivity to antimicrobials of the microorganisms that were recovered, in order to enable us to develop a better empirical antibiotic regimen in our health care area. Patients and methods. We conducted a prospective, cross-sectional, observational study involving 200 consecutive diabetic and non-diabetic patients who were admitted to hospital due to the presence of ischaemic or neuropathic ulcers with local signs of infection. Three microbiological samples were taken on the day of admission before administration of the empirical treatment (ciprofloxacin + clindamycin) and their clinical response and modifications in the specific due to resistance of the microorganisms were evaluated. Results. Polymicrobial microbiota were recovered from most of the cultures, with predominance of gram-negative aerobic-anaerobics and gram-positive aerobics. Staphylococcus aureus (10.6%), Pseudomonas aeruginosa and Bacteroides fragilis were the most frequently recovered micro-organisms. The empirical therapy had to be modified in over 50% of cases due to resistance. The highest sensitivity in vitro for the grampositive micro-organisms was to vancomycin, followed by cloxacillin and amoxicillin/clavulanic acid. In the case of gram-negative aerobic-anaerobics, it was found to be meropenem, tobramycin and imipenem, while the anaerobics were seen to be more sensitive to imipenem, cefoxitin and amoxicillin/clavulanic acid. Conclusions. Administration of amoxicillin/ clavulanic acid alone or in association with tobramycin constitutes a wide-spectrum antibiotic regimen for outpatients. If the patient is hospitalised, the preferred antibiotic would be imipenem, followed by piperacillin/ tazobactam

Proteína C reactiva como factor pronóstico de mortalidad en los aneurismas de aorta abdominal rotos / C-reactive protein as a prognostic factor for mortality in ruptures abdominal aortic aneurysms

Objetivo. Determinar si el valor plasmático preoperatorio de diversos marcadores biológicos de inflamación –proteína C reactiva (PCR), leucocitos y fibrinógeno– se asocia a la mortalidad de los pacientes con rotura de aneurisma de aorta abdominal (AAA). Pacientes y métodos. Estudio prospectivo de 37 pacientes intervenidos quirúrgicamente de AAA roto. Se extrajo una muestra de sangre periférica a cada uno de ellos para el estudio preoperatorio de los biomarcadores de inflamación. Además, se recogieron datos correspondientes a variables clínicas pre, intra y postoperatorias. Para el análisis de los valores plasmáticos de PCR se utilizó un test convencional (Tina-Quant). Resultados. De los marcadores biológicos de inflamación estudiados, sólo la PCR fue un factor pronóstico de mortalidad perioperatoria, y la mediana fue significativamente superior en los fallecidos en comparación con los supervivientes (p=0,021). Se categorizó la PCR en dos grupos con la utilización como punto de corte el valor obtenido en la curva ROC (3,2 mg/dL) para la máxima sensibilidad y especificidad de esta variable con relación a la mortalidad. Los pacientes cuya PCR al ingreso fue >=3,2 mg/dL tuvieron una mortalidad significativamente mayor que aquellos cuya cifra era < 3,2 mg/dL (71 frente a 10%) (p=0,002). En el análisis multivariante, las variables pronósticas de mortalidad fueron: valor preoperatorio de PCR, duración del pinzamiento aórtico e inestabilidad hemodinámica durante la intervención. Conclusiones. La elevación de la PCR preoperatoria es un factor pronóstico de mortalidad en los AAA rotos, por lo que puede ser, junto a otros factores previamente identificados, útil para la estratificación del riesgo quirúrgico de estos pacientes

Aim. To determine whether the preoperative plasma values of several biological markers of inflammation –C-reactive protein (CRP), leukocytes and fibrinogen– are linked with the mortality of patients with a ruptured abdominal aortic aneurysm (AAA). Patients and methods. We performed a prospective study of 37 patients who had undergone surgery to treat a ruptured AAA. A peripheral blood sample was taken from each of the patients for use in the preoperative study of biomarkers of inflammation. Additionally, data concerning pre, intra and postoperative clinical variables were also collected. A conventional (Tina-Quant) test was used to analyse the CRP values in plasma. Results. Of the biological markers of inflammation studied, only CRP was a prognostic factor for perioperative mortality, and the mean was significantly higher in those who died than in survivors (p=0.021). CRP was categorised in two groups using a cut-off point taken as the value obtained from the ROC curve (3.2 mg/dL) for the maximum sensitivity and specificity of this variable in relation to mortality. Mortality among patients with a CRP on admission >=3.2 mg/dL was significantly higher than among those with a figure < 3.2 mg/dL (71 versus 10%) (p=0.002). In the multivariate analysis, the prognostic variables for mortality were: preoperative CRP value, duration of aortic clamping and haemodynamic instability during the intervention. Conclusions. Elevation of preoperative CRP levels is a prognostic factor for mortality in ruptured AAA, which means that, together with other previously identified factors, it may be useful for the stratification of surgical risk in these patients

Solidification/stabilization of electric arc furnace dust using coal fly ash. Analysis of the stabilization process.

In this paper, the stabilization of electric arc furnace (EAF) dust containing hazardous metals such as Pb, Cd, Cr or Zn is described. The treatment involves a waste solidification/stabilization (S/S) process, using coal fly ash as the fundamental raw material and main binder. The article also contains a brief review of the most important recent publications related to the use of fly ash as S/S agents. The efficacy of the process has been evaluated mainly through leaching tests on the solidified products and compliance with some imposed leachate limits. The concentration of metals leaching from the S/S products was strongly leachate pH dependent; thus, the final pH of the leachate is the most important variable in reaching the limits and, therefore, in meeting the stabilization goals. In this study, the dependence relationship between the leachate pH and the concentrations of metals in the leachate are analyzed; in some cases, this allows us to estimate the speciation of contaminants in the S/S solids and to understand the mechanism responsible for reduced leachability of heavy metals from solidified wastes.

Estudio enzimático de la pared arterial en un modelo experimental de hiperplasia intimal y relación con la respuesta histológica / Enzymatic study of the arterial wall in an experimental model of intimal hyperplasia and relationship to the histological response

Objetivos: La proliferación de células musculares lisas responsables de la Hiperplasia Intima¡ origina en las placas arterioscleróticas una alteración en la actividad de enzimas musculares. Nosotros queríamos comprobar si en la hiperplasia intimal, producida en el modelo experimental ya descrito en anteriores trabajos, también habría modificaciones enzimáticas y, en tal caso, si guardan relación con el crecimiento intimal medido en la imagen histológica. Material y métodos: En ratas Wistar Albina hemos provocado una denudación en el endotelio de la aorta abdominal infrarrenal, comprobando en cada semana posterior a la lesión la respuesta histológica y los cambios bioquímicos, actividad enzimática de la laetato-deshidrogenasa (LD), creatín-kinasa (CK) y sus isoenzimas. Resultados: Obtenemos engrosamiento intimal claramente significativo desde la 2.ª semana tras la lesión endotelial, siendo mayor en ta 3.'-' y 4.-'. A nivel bioquímico destaca el predominio de las isoenzimas LD-5 y CK-BB en la pared de la aorta abdominal de las ratas, con un incremento de la LD-5, del cociente LD-5/LD-3 y de la CK-BB conforme aumenta la hiperplasia intima¡, siendo significativo para las isoenzimas de la LD (p<0.05).Conclusiones: La pared de la aorta de las ratas Wistar Albina tiene actividad de enzimas musculares específicas y el estímulo de las células musculares lisas origina variaciones evidentes de las isoenzimas de la laetato-deshidrogenasa y de la crea tín-kinasa, guardando estas variaciones una relación muy clara con la respuesta de hiperplasia intimal obtenida, de forma que son mayores en los grupos y las ratas con mayor proliferación intima¡. (AU)

Stabilization of a chromium-containing solid waste: immobilization of hexavalent chromium

This article describes the stabilization/solidification (S/S) of a steel industry waste, using a common type-F fly ash from a coal power station as the main binder. The waste, which contains hazardous levels of metals, may be stabilized by a conventional S/S to achieve permissible Pb, Cd, and Zn concentrations in the Toxicity Characteristic Leaching Procedure (TCLP) leachates of S/S solids. On the other hand, the stabilization of Cr(VI), also present in the waste, requires a reducing pretreatment stage with ferrous sulfate to attain TCLP leachates within limits. A bibliographic study on the stabilization of Cr(VI)-containing wastes is included in the paper, along with a discussion on the lowest Cr concentration in TCLP and aqueous (DIN) leachates.

Subperiosteal new bone formation in association with vascular graft sepsis.

Hypertrophic osteoarthropathy (HOA) is a clinical and radiologic syndrome that consists of periosteal new bone formation, synovitis, and digital clubbing. Secondary HOA has been reported confined to one or two extremities that are perfused by Dacron grafts that have become infected. Herein we include a report of a vascular graft infection that shares some of the clinical features with HOA and a brief review of pathophysiologic theories. We conclude emphasizing that periostitis and other HOA signs and symptoms may play a role as a clue to support the suspicion of vascular graft infection when confusing and vague clinical features are present.