Diagnóstico de lesiones anexiales por residentes de ginecología mediante valoración subjetiva, LR2 y Simple rules / Diagnosis of adnexal lesions by gynaecology residents using subjective assessment, logistic regression, and Simple Rules

OBJETIVO: Evaluar y comparar la precisión diagnóstica de las Simple rules, el sistema de regresión logística LR2 de IOTA y la valoración subjetiva aplicados por residentes de ginecología en la clasificación de benignidad o malignidad de lesiones anexiales. MATERIAL Y MÉTODOS: Fueron evaluadas las imágenes ecográficas de 94 lesiones anexiales por 3residentes de ginecología con un año de experiencia y con un entrenamiento teórico y práctico previo similar. La benignidad o malignidad fue determinada mediante 3 métodos: valoración subjetiva, Simple rules y modelo LR2. El grado de precisión en la clasificación de las lesiones se valoró mediante la sensibilidad, la especificidad, el valor predictivo positivo y negativo y la likelihood ratio positiva y negativa. Fue aportado también un diagnóstico de presunción histológica por cada ecografista. RESULTADOS: De las 94 lesiones, 73 resultaron benignas y 21 malignas. Los resultados estadísticos fueron los siguientes: Simple rules, sensibilidad 84,2% y especificidad 79,7%; LR2, sensibilidad 71,4% y especificidad 74%; valoración subjetiva, sensibilidad 65% y especificidad 76,1%. CONCLUSIONES: Los sistemas ecográficos de clasificación objetiva de lesiones anexiales han mostrado en la bibliografía mejores resultados diagnósticos que la valoración subjetiva aplicados por ecografistas no expertos. Las Simple rules y el LR2 se han descrito como 2de los más precisos y de más sencilla aplicación, por lo que podrían incorporarse en la evaluación ecográfica de masas anexiales por residentes de ginecología. En nuestro estudio observamos esta tendencia de una mayor precisión diagnóstica de estos sistemas predictivos respecto a la valoración subjetiva por residentes de ginecología, aunque sin que resultara estadísticamente significativa

OBJECTIVE: To evaluate and compare the diagnostic accuracy of the Simple Rules, the second logistic regression system of IOTA (LR2) and the subjective assessment used by gynaecology residents in the classification of benign or malignant adnexal lesions. MATERIAL AND METHODS: The ultrasound images of 94 adnexal lesions were evaluated by 3gynaecology junior doctors with one year of experience and with similar theoretical and practical training. The benignity or malignancy was determined by 3methods: subjective assessment, Simple Rules, and model LR2. The assessment of the degree of accuracy in the classification of the lesions was made by determining sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio. A diagnosis of histological presumption was also provided by each ultrasound operator. RESULTS: Of the 94 lesions, 73 were benign and 21 malignant. The statistical results were the following: Simple rules sensitivity 84.2% and specificity 79.7%; LR2 sensitivity 71.4% and specificity 74%; subjective assessment 65% sensitivity and specificity 76.1%. CONCLUSION: The ultrasound systems for objective classification of adnexal lesions have shown better diagnostic results in the literature than subjective assessment applied by non-expert sonographers. The Simple Rules and the LR2 have been described as 2of the most precise and simplest to apply, so they could be incorporated into the ultrasound evaluation of adnexal masses by gynaecology junior doctors. In this study, this trend of greater diagnostic accuracy was observed in these predictive systems regarding subjective assessment by gynaecology junior doctors, although without being statistically significant

Del vasoespasmo a la lesión cerebral precoz: una nueva frontera en la investigación de la hemorragia subaracnoidea / From vasospasm to early brain injury: new frontiers in subarachnoid haemorrhage research

Introducción: El vasoespasmo (VSP) ha sido tradicionalmente considerado como el principal determinante de mal pronóstico tras sufrir una hemorragia subaracnoidea (HSA). Como consecuencia, la mayoría de las líneas de investigación y los tratamientos están dirigidos hacia la reducción de la incidencia de dicho VSP. Hasta la fecha, sin embargo, los resultados de los ensayos clínicos basados en esta estrategia no se han traducido en un tratamiento definitivo capaz de prevenir o mejorarla lesión cerebraltras unaHSA. Este hecho ha provocado un cambio de paradigma en el interés investigativo, focalizándolo hacia la lesión cerebral precoz (LCP), que se produce en las primeras 72 h tras la HSA. Así mismo, ha modificado la visión que se tenía de la responsabilidad del VSP sobre el dano˜ cerebral y sugiere la necesidad de una re-evaluación del proceso fisiopatológico de la HSA. Desarrollo: Esta revisión examina el estado actual del conocimiento de los mecanismos fisiopatológicos relacionados con la LCP y resume las opciones diagnósticas disponibles en la actualidad. Conclusión: Parece necesario cambiar la dirección en la investigación de esta enfermedad, centrándose en la prevención de la LCP, la reducción de las complicaciones cerebrales secundarias y en última instancia, la optitimización de los resultados neurológicos (AU)

Introduction: Delayed vasospasm has traditionally been considered the mostimportant determinant of poor outcome after subarachnoid haemorrhage (SAH). Consequently, most of the research and therapies are directed towards reducing the incidence of vasospasm (VSP). To date, however, clinical trials based on this strategy have not delivered a definitive treatment for preventing or reducing brain injury after SAH. This fact has caused a paradigm shift in research, which now focuses on early brain injury (EBI) occurring in the first 72hours after SAH. It has also changed the idea of VSP’s role in brain damage, and suggests the need for re-evaluating the pathophysiological process of SAH. Development: This review examines the current state of knowledge on the pathophysiological mechanisms associated with EBI and summarises the diagnostic options currently available. Conclusion: It seems that the research approach needs to be changed so that investigators will focus on prevention of EBI,reduction of secondary brain complications and ultimately,the optimisation neurological outcome (AU)

From vasospasm to early brain injury: new frontiers in subarachnoid haemorrhage research.

INTRODUCTION: Delayed vasospasm has traditionally been considered the most important determinant of poor outcome after subarachnoid haemorrhage (SAH). Consequently, most of the research and therapies are directed towards reducing the incidence of vasospasm (VSP). To date, however, clinical trials based on this strategy have not delivered a definitive treatment for preventing or reducing brain injury after SAH. This fact has caused a paradigm shift in research, which now focuses on early brain injury (EBI) occurring in the first 72 hours after SAH. It has also changed the idea of VSP's role in brain damage, and suggests the need for re-evaluating the pathophysiological process of SAH. DEVELOPMENT: This review examines the current state of knowledge on the pathophysiological mechanisms associated with EBI and summarises the diagnostic options currently available. CONCLUSION: It seems that the research approach needs to be changed so that investigators will focus on prevention of EBI, reduction of secondary brain complications and ultimately, the optimisation neurological outcome.

Biopsia guiada por TC de tumores sacros agresivos. ¿Es siempre diagnóstica? / Is CT-guided biopsy of aggressive sacral tumors always able to reach a diagnosis?

Objetivos. Presentar una serie de 8 casos de tumores sacros infrecuentes, que representan un amplio espectro de la patología agresiva que asienta en este hueso y discutir la eficacia de la técnica de biopsia guiada por TC. Material y métodos. Se revisó retrospectivamente a todos los pacientes con tumoraciones sacras a los que se hizo biopsia guiada por TC en nuestro servicio, durante los últimos 2 años. Antes de realizar la biopsia, se analizaron las imágenes previas de TC y RM para dirigir correctamente la biopsia. Se realizó una TC dirigida a la lesión con cortes de 3mm, para determinar la localización de la zona diana y el trayecto de la aguja. Se utilizó en todos los casos aguja de 11G y aguja coaxial de 15G. Resultados. Se biopsiaron 8 lesiones sacras, de las cuales, en 4 se consiguió el diagnóstico con biopsia guiada con TC. En 3 de ellas solo fue necesaria una sesión, con los diagnósticos de cordoma, plasmocitoma y metástasis de melanoma, mientras que en otro caso se tuvieron que realizar 3 sesiones, llegando al diagnóstico de sarcoma de Ewing. En los otros 4 casos fue necesaria la biopsia quirúrgica por distintos motivos. En ellos los diagnósticos definitivos fueron condrosarcoma, granuloma eosinófilo y en 2 pacientes linfoma óseo primario. La eficacia diagnóstica de la técnica fue del 36%. Conclusión. Nuestros resultados sugieren que la biopsia guiada por TC es menos útil en la caracterización de tumores primarios que en metástasis, siendo especialmente complicado el diagnóstico de linfomas óseos primarios. La repetición del procediendo tras resultados no diagnósticos, probablemente no aporte información adicional, por lo que es recomendable recurrir a biopsia quirúrgica (AU)

Objectives. To present a series of eight cases of rare sacral tumors that represent a wide spectrum of the aggressive disease involving the sacrum and to discuss the efficacy of CT-guided biopsy in these cases. Material and methods. We reviewed all cases of sacral tumors biopsied under CT guidance in the last two years. Prior CT and MR images were analyzed before biopsy, and 3mm CT slices of the lesion were obtained to determine the location of the target area and the path of the needle. All biopsies were performed using 11G needles and 15G coaxial needles. Results. Eight sacral lesions were biopsied under CT guidance, and a diagnosis was reached in four. In three of these, the diagnosis (chordoma, plasmocytoma, and metastasis from melanoma) was reached in a single session. In the fourth case, three sessions were necessary to reach the diagnosis of Ewing's sarcoma. For various reasons, the remaining four cases required surgical biopsy to reach the diagnoses of chondrosarcoma, eosinophilic granuloma, and primary bone lymphoma in two patients. The diagnostic efficacy of CT-guided biopsy was 36%. Conclusion. Our results suggest that CT-guided biopsy is less useful in the characterization of primary tumors than in metastases. The diagnosis of primary bone lymphomas is especially complicated. Repeating the procedure after inconclusive results probably will not provide additional information, and it is recommendable to perform surgical biopsy in these cases (AU)

[Is CT-guided biopsy of aggressive sacral tumors always able to reach a diagnosis?]. / Biopsia guiada por TC de tumores sacros agresivos. ¿Es siempre diagnóstica?

OBJECTIVES: To present a series of eight cases of rare sacral tumors that represent a wide spectrum of the aggressive disease involving the sacrum and to discuss the efficacy of CT-guided biopsy in these cases. MATERIAL AND METHODS: We reviewed all cases of sacral tumors biopsied under CT guidance in the last two years. Prior CT and MR images were analyzed before biopsy, and 3 mm CT slices of the lesion were obtained to determine the location of the target area and the path of the needle. All biopsies were performed using 11 G needles and 15 G coaxial needles. RESULTS: Eight sacral lesions were biopsied under CT guidance, and a diagnosis was reached in four. In three of these, the diagnosis (chordoma, plasmocytoma, and metastasis from melanoma) was reached in a single session. In the fourth case, three sessions were necessary to reach the diagnosis of Ewing's sarcoma. For various reasons, the remaining four cases required surgical biopsy to reach the diagnoses of chondrosarcoma, eosinophilic granuloma, and primary bone lymphoma in two patients. The diagnostic efficacy of CT-guided biopsy was 36%. CONCLUSION: Our results suggest that CT-guided biopsy is less useful in the characterization of primary tumors than in metastases. The diagnosis of primary bone lymphomas is especially complicated. Repeating the procedure after inconclusive results probably will not provide additional information, and it is recommendable to perform surgical biopsy in these cases.

Seguimiento mediante angio-resonancia magnética de aneurismas cerebrales embolizados: concordancia entre lectores / MR angiography follow-up of embolized cerebral aneurysms: interobserver agreement

Objetivo: valorar el grado de concordancia entre lectores en los estudios de angio-resonancia magnética (angio-RM) realizados como seguimiento de aneurismas intracraneales embolizados. Asimismo, comprobar si el uso de contraste paramagnético mejora el grado de concordancia. Material y métodos: se recogen los estudios de angio-RM realizados desde julio de 2004 a diciembre de 2006 como seguimiento de aneurismas cerebrales embolizados. Estas exploraciones se analizaron de forma independiente por 2 neurorradiólogos con experiencia en RM. Se obtuvieron 2 secuencias para cada paciente, una sin contraste, mediante parámetros 3D time-of-flight, y otra con contraste paramagnético. Los hallazgos se dividieron en: a) invalorable; b) oclusión completa, y c) resto aneurismático. El grado de concordancia entre lectores para las angio-RM sin y con contraste se midió mediante el cálculo del coeficiente kappa y se clasificó en: k<0,2 insignificante; k=0,21–0,4 bajo; k=0,41–0,6 moderado; k=0,61–0.8 bueno, y k>0,81 excelente. Resultados: se obtuvieron 200 angio-RM, 100 realizadas sin contraste y 100 con contraste, en un total de 48 pacientes a los 6, 12 y/o 24 meses tras la embolización. El grado de concordancia entre lectores fue bueno, tanto para las angio-RM sin contraste como para las con contraste, si bien fue superior para los estudios con contraste (k=0,660, p<0,001 y k=0,779, p<0,001, respectivamente). Conclusiones: la angio-RM presenta una buena concordancia entre lectores en el seguimiento de aneurismas intracraneales embolizados. El uso de contraste paramagnético ha supuesto un mayor grado de concordancia observado (AU)

Objective: To determine the interobserver agreement in the interpretation of MR angiography (MRA) studies for surveillance of embolized intracranial aneurysms. To determine whether contrast administration improves interobserver agreement. Material and methods: Two experienced neuroradiologists independently reviewed all follow-up MRA studies performed between July 2004 and December 2006 of cerebral aneurysms embolized with coils. All MRA studies included both unenhanced 3D time-of-flight (3D TOF) and contrast-enhanced MRA (CE-MRA) images. Studies were classified as: a) not assessable; b) complete occlusion; c) residual aneurysm. Interobserver agreement for unenhanced and enhanced MRA studies was determined using the kappa statistic. Kappa values were considered insignificant when<0.2, low when between 0.21 and 0.4, and moderate when between 0.41–0.6; values >0.6 were considered good agreement and >0.8 excellent agreement. Significance was set at p<0.005. Results: We reviewed a total of 200 MRA studies (100 3D TOF studies and 100 CE-MRA studies) performed in 48 patients (25 women, 23 men) at 6, 12, and/or 24 months after embolization. Interobserver agreement was good in both 3D TOF and CE-MRA studies, although it was better in CE-MRA studies (k=0.660, p<0.001 and k=0.779, p<0.001, respectively). Conclusions: Interobserver agreement is good for follow-up MRA studies of embolized intracranial aneurysms. Gadolinium administration improves interobserver agreement (AU)

[MR angiography follow-up of embolized cerebral aneurysms: interobserver agreement]. / Seguimiento mediante angio-resonancia magnética de aneurismas cerebrales embolizados: concordancia entre lectores.

OBJECTIVE: To determine the interobserver agreement in the interpretation of MR angiography (MRA) studies for surveillance of embolized intracranial aneurysms. To determine whether contrast administration improves interobserver agreement. MATERIAL AND METHODS: Two experienced neuroradiologists independently reviewed all follow-up MRA studies performed between July 2004 and December 2006 of cerebral aneurysms embolized with coils. All MRA studies included both unenhanced 3D time-of-flight (3D TOF) and contrast-enhanced MRA (CE-MRA) images. Studies were classified as: a) not assessable; b) complete occlusion; c) residual aneurysm. Interobserver agreement for unenhanced and enhanced MRA studies was determined using the kappa statistic. Kappa values were considered insignificant when<0.2, low when between 0.21 and 0.4, and moderate when between 0.41-0.6; values >0.6 were considered good agreement and >0.8 excellent agreement. Significance was set at p<0.005. RESULTS: We reviewed a total of 200 MRA studies (100 3D TOF studies and 100 CE-MRA studies) performed in 48 patients (25 women, 23 men) at 6, 12, and/or 24 months after embolization. Interobserver agreement was good in both 3D TOF and CE-MRA studies, although it was better in CE-MRA studies (kappa=0.660, p<0.001 and kappa=0.779, p<0.001, respectively). CONCLUSIONS: Interobserver agreement is good for follow-up MRA studies of embolized intracranial aneurysms. Gadolinium administration improves interobserver agreement.

[Primary cardiac tumours in infancy]. / Tumores cardíacos primarios en la infancia.

INTRODUCTION: Primary cardiac tumours are very rare in the paediatric age, their incidence varies from 0.0017 % to 0.28 %. More than 90 % are benign in nature. The most common variety is the rhabdomyoma, present in over 60 % of cases with tuberous sclerosis. MATERIAL AND METHODS: We performed a retrospective analysis of medical records with a diagnosis of primary cardiac tumor between March 1977 and March 2007, finding a total of 27 patients. RESULTS: The age of initial diagnosis is more prevalent in the neonatal period, beginning with the discovery of a heart murmur (11 cases). There was no difference in gender distribution. In 14 patients were found cardiomegaly on chest radiograph. According to the echocardiography characteristics there were diagnosed 20 rhabdomyomas, 2 fibromas, 2 pericardial teratomas and 3 non classifiable tumours. Most were located in the left ventricle. Echocardiography, cardiac catheterization was also performed in 3 cases and angioresonance in 5 cases. During their evolution, episodes of arrhythmias were observed in 11 patients, 5 patients required some sort of surgical procedure, which confirmed the histopathology diagnosis. In 3 patients the initial cause of death was cardiological. The 75 % of cases with rhabdomyomas presented or developed tuberous sclerosis. In most of the rhabdomyomas (13 cases), there was a spontaneous regression. CONCLUSIONS: Firstly, there is shown to be a low prevalence of this disorder in children. Rhabdomyoma is the most common primary cardiac tumour in our study and it was associated in 75 % of cases with tuberous sclerosis. The diagnosis is more common in the early neonatal period after auscultation of a cardiac murmur and echocardiography, the diagnostic technique of choice, other imaging techniques, such as angioMRI not being of much for diagnosis in children. The emergence of foetal echocardiography allows early detection. The course is benign in most tumours, rhabdomyomas tending to regress spontaneously. It must be monitored as the occurrence of arrhythmias during its evolution will require medical treatment. Surgery is needed in cases with severe symptoms, due to obstruction in the ventricular output tracts. One option is the surgical cardiac transplant in non-resectable life-threatening tumours.

Tumores cardíacos primarios en la infancia / Primary cardiac tumours in infancy

Introducción: Los tumores cardíacos primarios son muy poco frecuentes en la edad pediátrica, y su incidencia varía entre el 0,0017 y el 0,28 %. Más del 90 % son de naturaleza benigna. La variedad más frecuente es el rabdomioma, asociado en más del 60 % de los casos con esclerosis tuberosa. Material y métodos: Se realizó un análisis retrospectivo de historias clínicas con diagnóstico de tumor cardíaco primario entre marzo de 1977 y marzo de 2007, y se encontró a un total de 27 pacientes. Resultados: La edad de diagnóstico inicial es más frecuente en el período neonatal, a partir del hallazgo de un soplo cardíaco (11 casos). No hubo diferencias en la distribución por sexos. En 14 pacientes se encontró cardiomegalia en la radiografía de tórax. De acuerdo con las características ecocardiográficas, se diagnosticaron 20 rabdomiomas, 2 fibromas, 2 teratomas pericárdicos y 3 tumores no clasificables. La mayor parte se localizaron en el ventrículo izquierdo. Además de la ecocardiografía, se realizó cateterismo cardíaco en 3 casos y angiorresonancia en 5 casos. Durante su evolución se constataron episodios de arritmias en 11 pacientes. En 5 se requirió algún tipo de procedimiento quirúrgico, en los que se obtuvo el diagnóstico anatomopatológico. La mortalidad inicial de causa cardiológica fue de 3 pacientes. El 75 % de casos con rabdomiomas presentaba o desarrolló esclerosis tuberosa. En la mayoría de los rabdomiomas (13 casos) se produjo regresión espontánea. Conclusiones: En primer lugar, se evidencia la baja prevalencia de esta patología en la infancia. El rabdomioma es el tumor cardíaco primario más frecuente y en nuestro estudio se asoció en el 75 % de los casos a esclerosis tuberosa. El diagnóstico es más frecuente en el período neonatal precoz tras la auscultación de un soplo cardíaco y la ecocardiografía, la técnica diagnóstica de elección, mientras que no se ha encontrado utilidad de otras técnicas de imagen, como la angiorresonancia, para su diagnóstico en la población infantil. La aparición de la ecocardiografía fetal permite descubrirlos precozmente. El curso es benigno en la mayoría de los tumores, con tendencia a la regresión espontánea en los rabdomiomas. Debe vigilarse la aparición de arritmias durante su evolución, que precisará tratamiento médico. La cirugía es necesaria en los casos con síntomas graves, debidos a obstrucción en los tractos de salida ventricular. Una opción quirúrgica es el transplante cardíaco en caso de tumores irresecables con riesgo vital (AU)

Introduction: Primary cardiac tumours are very rare in the paediatric age, their incidence varies from 0.0017 % to 0.28 %. More than 90 % are benign in nature. The most common variety is the rhabdomyoma, present in over 60 % of cases with tuberous sclerosis. Material and methods: We performed a retrospective analysis of medical records with a diagnosis of primary cardiac tumor between March 1977 and March 2007, finding a total of 27 patients. Results: The age of initial diagnosis is more prevalent in the neonatal period, beginning with the discovery of a heart murmur (11 cases). There was no difference in gender distribution. In 14 patients were found cardiomegaly on chest radiograph. According to the echocardiography characteristics there were diagnosed 20 rhabdomyomas, 2 fibromas, 2 pericardial teratomas and 3 non classifiable tumours. Most were located in the left ventricle. Echocardiography, cardiac catheterization was also performed in 3 cases and angioresonance in 5 cases. During their evolution, episodes of arrhythmias were observed in 11 patients, 5 patients required some sort of surgical procedure, which confirmed the histopathology diagnosis. In 3 patients the initial cause of death was cardiological. The 75 % of cases with rhabdomyomas presented or developed tuberous sclerosis. In most of the rhabdomyomas (13 cases), there was a spontaneous regression. Conclusions: Firstly, there is shown to be a low prevalence of this disorder in children. Rhabdomyoma is the most common primary cardiac tumour in our study and it was associated in 75 % of cases with tuberous sclerosis. The diagnosis is more common in the early neonatal period after auscultation of a cardiac murmur and echocardiography, the diagnostic technique of choice, other imaging techniques, such as angioMRI not being of much for diagnosis in children. The emergence of foetal echocardiography allows early detection. The course is benign in most tumours, rhabdomyomas tending to regress spontaneously. It must be monitored as the occurrence of arrhythmias during its evolution will require medical treatment. Surgery is needed in cases with severe symptoms, due to obstruction in the ventricular output tracts. One option is the surgical cardiac transplant in non-resectable life-threatening tumours (AU)

Endocarditis neumocócica: revisión a propósito de un caso y nueva pauta de tratamiento asociada a fosfomicina / Pneumococcal endocarditis: report of a case involving a novel treatment with association of fosfomycin and a review of the literature

Se presenta un interesante caso de endocarditis bacteriana en un varón de 12 años de edad, que asociaba como patología de base una comunicación interventricular membranosa, que presentó buena respuesta al tratamiento asociado con penicilina en altas dosis, gentamicina y fosfomicina. Se adjunta una revisión bibliográfica acerca de los distintos tratamientos antibióticos descritos, incluidas las pautas menos habituales. Se incluye en la discusión una extensa explicación de la asociación al tratamiento antibiótico de fosfomicina

The authors present an interesting case of bacterial endocarditis in a 12 year-old boy, the underlying cause of which was a membranous ventricular septal defect. The infection responded well to treatment with high-dose penicillin, in combination with gentamycin and fosfomycin. A review of the literature dealing with the different types of antibiotic therapy, including less conventional approaches, is provided, and the reasons for administering combination treatment involving fosfomycin are explained in detail

[Magnetic resonance diagnosis of ankylosing spondylitis and evaluation of the response to treatment]. / Diagnóstico y valoración de la respuesta al tratamiento mediante resonancia magnética en la espondilitis anquilosante.

OBJECTIVE: To show the role of magnetic resonance imaging in the early diagnosis of ankylosing spondylitis and discuss its possible usefulness in evaluating the response to treatment. MATERIAL AND METHODS: We describe the findings on magnetic resonance images using STIR and contrast-enhanced T1-weighted sequences in 13 patients diagnosed with ankylosing spondylitis receiving adalimumab treatment. Magnetic resonance images were acquired at baseline and after six months. We describe the findings obtained and the results of the quantitative analysis of vertebral affection (using the ASspiMRI-a score), and sacroiliac and hip joint affection. RESULTS: Inflammatory effects were demonstrated in 12 patients as signal hyperintensity in STIR sequences and as contrast enhancement in T1-weighted sequences. After treatment, 12 patients showed decreased ASspiMRI-a score and less affection in the sacroiliac and hip joints. No changes were observed in the remaining patient. Two patients showed posterior vertebral element involvement and disc involvement was seen in three. CONCLUSIONS: MRI opens up new possibilities for the management of patients with ankylosing spondylitis. On the one hand, it enables early diagnosis, saving the patient years of trial treatments and saving the healthcare system the cost of multiple diagnostic tests to try to explain the symptoms these patients present. On the other hand, it enables the rapid, objective evaluation of the response to therapy, thus making it possible to step up to a new, more aggressive therapy quickly and avoid treatments that are not very effective.

Diagnóstico y valoración de la respuesta al tratamiento mediante resonancia magnética en la espondilitis anquilosante / Magnetic resonance diagnosis of ankylosing spondylitis and evaluation of the response to treatment

Objetivo. Mostrar el papel de la resonancia magnética en el diagnóstico precoz de la espondilitis anquilosante y su posible utilidad en la valoración de la respuesta al tratamiento.Material y métodos. Se describen los hallazgos en resonancia magnética (secuencias STIR y T1 con contraste paramagnético) en 13 pacientes diagnosticados de espondilitis anquilosante que reciben tratamiento con adalimumab. Se realiza una resonancia magnética basal al comienzo del estudio y otra a los seis meses, describiendo los hallazgos obtenidos y valorando cuantitativamente la afectación vertebral (con el sistema de puntuación ASspiMRI-a), la afectación sacroilíaca y de la articulación coxofemoral.Resultados. La afectación inflamatoria se demostró en 12 pacientes en forma de hiperintensidad de señal en STIR y captación de contraste en secuencias T1. Tras la administración del tratamiento 12 pacientes mostraron una disminución de la puntuación ASspiMRIa, y una menor afectación en ASI y coxofemorales. En el paciente restante la puntuación no se modificó. Dos pacientes presentaban afectación de elementos posteriores vertebrales y en tres pacientes se apreció afectación discal.Conclusiones. La resonancia magnética abre nuevas posibilidades para el manejo de los pacientes con espondilitis anquilosante. Por un lado, permite el diagnóstico precoz, ahorrando al paciente años de tratamientos de prueba y ahorrando al sistema sanitario el coste de múltiples pruebas diagnósticas para intentar explicar los síntomas que presentan dichos enfermos. Por otro lado, permite una valoración rápida y objetiva de la respuesta al tratamiento, por lo que el paso a un nuevo escalón terapéutico más agresivo se podrá realizar con mayor celeridad, evitando tratamientos poco efectivos

Objective. To show the role of magnetic resonance imaging in the early diagnosis of ankylosing spondylitis and discuss its possible usefulness in evaluating the response to treatment.Material and methods. We describe the findings on magnetic resonance images using STIR and contrast-enhanced T1-weighted sequences in 13 patients diagnosed with ankylosing spondylitis receiving adalimumabtreatment. Magnetic resonance images were acquired at baseline and after six months. We describe the findings obtained and the results of the quantitative analysis of vertebral affection (using the ASspiMRI-a score), and sacroiliac and hip joint affection.Results. Inflammatory effects were demonstrated in 12 patients as signal hyperintensity in STIR sequences and as contrast enhancement in T1-weighted sequences. After treatment, 12 patients showed decreasedASspiMRI-a score and less affection in the sacroiliac and hip joints. No changes were observed in the remaining patient. Two patients showed posterior vertebral element involvement and disc involvementwas seen in three.Conclusions. MRI opens up new possibilities for the management of patients with ankylosing spondylitis. On the one hand, it enables early diagnosis, saving the patient years of trial treatments and saving the healthcare system the cost of multiple diagnostic tests to try to explain the symptoms these patients present. On the other hand, it enables the rapid, objective evaluation of the response to therapy, thus making it possible to step up to a new, more aggressive therapy quickly and avoid treatments that are not very effective

[Ibuprofen versus indomethacin in the treatment of patent ductus arteriosus in preterm infants]. / Ibuprofeno frente a indometacina en el tratamiento del conducto arterioso persistente del prematuro.

INTRODUCTION: Persistent patent ductus arteriosus (PDA) is a common entity in preterm infants. The most commonly used pharmacological treatment to close the ductus is indomethacin but it can affect cerebral, renal and mesenteric blood flow. Ibuprofen has recently been shown to be effective in closing PDA with fewer hemodynamic effects. In this study we compared the safety and efficacy of ibuprofen and indomethacin in the treatment of PDA in preterm infants. MATERIAL AND METHODS: A randomized trial was performed. Premature infants with symptomatic PDA confirmed by echocardiography in the first week of life and who required respiratory support were included. The patients were randomly assigned to receive either intravenous indomethacin or ibuprofen. The rate of ductal closure, need for additional treatment, complications, and clinical course were evaluated. RESULTS: Twenty-four patients were treated with indomethacin and 23 with ibuprofen. The clinical characteristics before treatment were similar in both groups. Both treatments were effective in closing PDA (87.5% in the indomethacin group and 82.6% in the ibuprofen group). The two cohorts did not differ in the rate of reopening, need for a second pharmacologic treatment, or surgical ductal ligation. No patient in the ibuprofen group developed gastrointestinal adverse effects, but two infants in the indomethacin group had isolated bowel perforation and one had necrotizing enterocolitis. Transient renal dysfunction developed in seven patients (29%) in the indomethacin group versus two (9%) in the ibuprofen group. Transient renal insufficiency was found in one patient in the indomethacin group and in none in the ibuprofen group. The rate of other complications was similar in both groups. CONCLUSIONS: In our trial ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications but fewer renal complications and no gastrointestinal complications were found in the ibuprofen group.

Ibuprofeno frente a indometacina en el tratamiento del conducto arterioso persistente del premature / Ibuprofen versus indomethacin in the treatment of patient ductus arteriosus in preterm infants

Introducción. El conducto (ductus) arterioso persistente (DAP) es una enfermedad frecuente en el prematuro. La indometacina es el tratamiento más utilizado en su cierre, pero puede alterar el flujo cerebral, renal y mesentérico. Recientemente el ibuprofeno ha mostrado ser eficaz en el cierre del DAP con menores efectos hemodinámicos. Este estudio se realizó para comparar la eficacia y seguridad del ibuprofeno frente a la indometacina en el cierre del DAP en el prematuro. Material y métodos. Estudio aleatorizado que incluyó prematuros con DAP sintomáticos, diagnosticados mediante ecografía en la primera semana de vida, que precisaron soporte ventilatorio. Los pacientes fueron asignados aleatoriamente a indometacina o ibuprofeno por vía intravenosa. Se evaluó la tasa de cierre ductal, la necesidad de tratamiento adicional, las complicaciones y la evolución clínica. Resultados. Se trataron 24 pacientes con indometacina y 23 con ibuprofeno. Sus características clínicas previas al diagnóstico fueron similares. Ambos tratamientos se mostraron eficaces en el cierre, 87,5 % para la indometacina y 82,6 % para el ibuprofeno. Las dos cohortes no se diferenciaron en la frecuencia de reaperturas, necesidad de dos tandas de fármaco, ni proporción de ligaduras quirúrgicas. Ningún paciente tratado con ibuprofeno presentó enfermedad abdominal que sí apareció en el grupo de indometacina (dos perforaciones intestinales y una enterocolitis necrosante). Siete pacientes (29 %) del grupo de indometacina desarrollaron disfunción renal transitoria frente a 2 casos (9 %) en el de ibuprofeno. En el grupo de indometacina un paciente experimentó insuficiencia renal transitoria y ninguno en el de ibuprofeno. El resto de complicaciones fue similar en ambos grupos. Conclusiones. En nuestra serie el ibuprofeno se mostró igual de eficaz que la indometacina en el cierre del DAP. No hubo diferencias significativas en la incidencia de complicaciones entre ambos grupos, aunque los tratados con ibuprofeno tuvieron menos complicaciones renales y ninguna intestinal

Introduction. Persistent patent ductus arteriosus (PDA) is a common entity in preterm infants. The most commonly used pharmacological treatment to close the ductus is indomethacin but it can affect cerebral, renal and mesenteric blood flow. Ibuprofen has recently been shown to be effective in closing PDA with fewer hemodynamic effects. In this study we compared the safety and efficacy of ibuprofen and indomethacin in the treatment of PDA in preterm infants. Material and methods. A randomized trial was performed. Premature infants with symptomatic PDA confirmed by echocardiography in the first week of life and who required respiratory support were included. The patients were randomly assigned to receive either intravenous indomethacin or ibuprofen. The rate of ductal closure, need for additional treatment, complications, and clinical course were evaluated. Results. Twenty-four patients were treated with indomethacin and 23 with ibuprofen. The clinical characteristics before treatment were similar in both groups. Both treatments were effective in closing PDA (87.5 % in the indomethacin group and 82.6 % in the ibuprofen group). The two cohorts did not differ in the rate of reopening, need for a second pharmacologic treatment, or surgical ductal ligation. No patient in the ibuprofen group developed gastrointestinal adverse effects, but two infants in the indomethacin group had isolated bowel perforation and one had necrotizing enterocolitis. Transient renal dysfunction developed in seven patients (29 %) in the indomethacin group versus two (9 %) in the ibuprofen group. Transient renal insufficiency was found in one patient in the indomethacin group and in none in the ibuprofen group. The rate of other complications was similar in both groups. Conclusions. In our trial ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications but fewer renal complications and no gastrointestinal complications were found in the ibuprofen group

Servicios Hospitalarios en Medicina Legal / Legal Medicine hospital services

Este artículo revisa los servicios hospitalarios de Medicina Legal, señalando que estos servicios son costo-eficientes para el Sistema Sanitario, que el profesional idóneo es el especialista en Medicina Legal con experiencia clínica y formando Bioética, haciendo énfasis en que es imprescindible la incorporación de los valores a los objetos del hospital (AU)

This article reviews the Legal Medicine hospital services, indicating that these services are cost-efficient for the Health System, that the ideal professional is the specialist in Legal Medicine with clinical experience and Bioethical training, and emphasising that it is essential to incorporate the values into the objective of the hospital (AU)