Papilomatosis juvenil: revisión a propósito de 2 casos / Juvenile papillomatosis: Review of 2 cases

La papilomatosis juvenil (PJ) es una lesión mamaria benigna, poco frecuente y de carácter proliferativo. Se caracteriza por ser una proliferación exofítica multifocal de varios papilomas dentro de un segmento mamario. Generalmente afecta a mujeres jóvenes de menos de 30 años de edad. Suele presentarse como una tumoración mamaria indolora, simulando un fibroadenoma. La biopsia percutánea guiada por ecografía permitirá detectar la naturaleza de la lesión y descartar patología maligna asociada. Se describe una serie de 2 casos con similar presentación clínica pero difiriendo en el manejo una vez analizados los antecedentes familiares y las circunstancias individuales de cada uno de ellos

Juvenile papillomatosis (JP) is a rare breast lesion of a proliferative and benign nature. It is noted for being a multifocal exophytic proliferation of several papillomas within a breast segment. It usually affects young women under 30 years of age, and usually presents as a painless breast mass, simulating a fibrous adenoma. The ultrasound guided percutaneous biopsy will enable the diagnosis to be confirmed, as well as to rule out any associated malignant disease. A description is presented on series of 2 cases with similar clinical presentation, but differing in management after analysing the family history and the individual circumstances of each of them

Next Generation Flow for highly sensitive and standardized detection of minimal residual disease in multiple myeloma.

Flow cytometry has become a highly valuable method to monitor minimal residual disease (MRD) and evaluate the depth of complete response (CR) in bone marrow (BM) of multiple myeloma (MM) after therapy. However, current flow-MRD has lower sensitivity than molecular methods and lacks standardization. Here we report on a novel next generation flow (NGF) approach for highly sensitive and standardized MRD detection in MM. An optimized 2-tube 8-color antibody panel was constructed in five cycles of design-evaluation-redesign. In addition, a bulk-lysis procedure was established for acquisition of ⩾107 cells/sample, and novel software tools were constructed for automatic plasma cell gating. Multicenter evaluation of 110 follow-up BM from MM patients in very good partial response (VGPR) or CR showed a higher sensitivity for NGF-MRD vs conventional 8-color flow-MRD -MRD-positive rate of 47 vs 34% (P=0.003)-. Thus, 25% of patients classified as MRD-negative by conventional 8-color flow were MRD-positive by NGF, translating into a significantly longer progression-free survival for MRD-negative vs MRD-positive CR patients by NGF (75% progression-free survival not reached vs 7 months; P=0.02). This study establishes EuroFlow-based NGF as a highly sensitive, fully standardized approach for MRD detection in MM which overcomes the major limitations of conventional flow-MRD methods and is ready for implementation in routine diagnostics.

¿Qué hacer ante una complicación hemorrágica en pacientes tratados con nuevos anticoagulantes orales? / What can be done when faced with a hemorrhagic complication in patients on the novel oral anticoagulants?

Los nuevos anticoagulantes orales (NACO) representan una alternativa eficaz a las antivitaminas K, con menor riesgo de complicaciones hemorrágicas, especialmente hemorragia intracraneal, que pueden ser manejadas de manera satisfactoria con la interrupción del fármaco y medidas de soporte. Estas características favorecen su progresiva utilización en la práctica clínica habitual. Esta revisión trata de resumir el mecanismo de acción y la farmacocinética de estos fármacos junto con la información disponible para elaborar una posible estrategia en el manejo de las complicaciones hemorrágicas en los pacientes que reciben NACO

Novel oral anticoagulants (NOACs) represent an effective alternative to vitamin K antagonists, with a lower risk of hemorrhagic complications, especially intracranial bleeding, which can be successfully managed with drug withdrawal and supportive measures. These characteristics favor their progressive use in routine clinical practice. This review aims to summarize the mechanism of actions and pharmacokinetics of these drugs, as well as the available information to develop a possible strategy in the management of bleeding complications in those patients receiving NOACs

Diagnostic utility of bone marrow examination for the assessment of patients with fever of unknown origin: a 10-year single-centre experience.

Bone marrow (BM) examination is included in the diagnostic algorithm of fever of unknown origin (FUO), although its role is not clearly determined. The purpose of this study was to assess the role of BM studies in patients with FUO. We retrospectively reviewed 45 consecutive patients (25% human immunodeficiency virus-positive) with FUO who underwent a BM study in the University Hospital of Salamanca from 2000 to 2010. We analysed the diagnostic role of BM smears, multiparameter flow cytometry analysis, histology and microbiological cultures. Five patients (11%) were finally diagnosed by BM study (three had an infectious disease and two were found to have haematological malignancies), all of whom were immunocompetent patients. Histology was the most useful study (diagnosis was obtained in 4/5 patients), while BM cultures did not establish the final diagnosis in any patient. Flow cytometry established the diagnosis in one patient, although this patient was also diagnosed by histology. In conclusion, BM study is useful for establishing the aetiology of FUO. BM biopsy for histological examination should be always mandatory if a BM examination is performed.

Risk factors for thrombotic microangiopathy in allogeneic hematopoietic stem cell recipients receiving GVHD prophylaxis with tacrolimus plus MTX or sirolimus.

Transplantation-associated thrombotic microangiopathy (TA-TMA) is a feared complication of allogeneic hematopoietic SCT (HSCT) owing to its high mortality rate. The use of calcineurin inhibitors or sirolimus (SIR) for GVHD prophylaxis has been suggested as a potential risk factor. However, the impact of tacrolimus (TAC) and SIR combinations on the increased risk of TA-TMA is currently not well defined. We retrospectively analyzed the incidence of TA-TMA in 102 allogeneic HSCT recipients who consecutively received TAC plus SIR (TAC/SIR) (n=68) or plus MTX (TAC/MTX)±ATG (n=34) for GVHD prophylaxis. No significant differences were observed in the incidence of TA-TMA between patients receiving TAC/SIR vs TAC/MTX±ATG (7.4% vs 8.8%, P=0.8). Only grade III-IV acute GVHD, previous HSCT and serum levels of TAC >25 ng/mL were associated with a greater risk of TA-TMA. Patients developing TA-TMA have significantly poorer survival (P<0.001); however, TA-TMA ceased to be an independent prognostic factor when it was included in a multivariate model. In conclusion, the combination of TAC/SIR does not appear to pose a higher risk of TA-TMA. By contrast, we identified three different risk groups for developing TA-TMA.

Inter-comparison of hemispherical conical reflectance factors (HCRF) measured with four fibre-based spectrometers.

We describe the results of an experiment designed to compare the radiometric performance of four different spectroradiometers in ideal field conditions. A carefully designed experiment where instruments were simultaneously triggered was used to measure the Hemispherical Conical Reflectance Factors (HCRF) of four targets of varying reflectance. The experiment was in two parts. Stage 1 covered a 2 hour period finishing at solar noon, where 50 measurements of the targets were collected in sequence. Stage 2 comprised 10 rapid sequential measurements over each target. We applied a method for normalising full width half maximum (FWHM) differences between the instruments, which was a source of variability in the raw data. The work allowed us to determine data reproducibility, and we found that lower-cost instruments (Ocean Optics and PP Systems) produced data of similar radiometric quality to those manufactured by Analytical Spectral Devices (ASD -here we used the ASD FieldSpec Pro) in the spectral range 400-850 nm, which is the most significant region for research communities interested in measuring vegetation dynamics. Over the longer time-series there were changes in HCRF caused by the structural and spectral characteristics of some targets.

Multiple cranial neuropathy and intracranial hypertension associated with all-trans retinoic acid treatment in a young adult patient with acute promyelocytic leukemia.

All-trans retinoic acid (ATRA) induces complete remission in 64-100 % of patients with acute promyelocytic leukemia (APL), and is considered to be a safe agent. Pseudotumor cerebri is a neurological side effect of ATRA reported in pediatric patients, and which is characterized by raised cerebrospinal fluid pressure in the absence of any intracranial pathology or secondary causes of intracranial hypertension. Involvement of cranial nerves other than II and VI is very uncommon in idiopathic intracranial hypertension (IIH); peripheral facial nerve palsy is exceptional and has rarely been described in the context of treatment with ATRA. We describe the case of a 15-year-old female patient with APL who developed an IIH and involvement of cranial nerves (bilateral papilledema, left facial and right sixth nerves) after receiving induction therapy including ATRA. Viral infections and other causes of secondary cranial nerve lesions were excluded. Symptoms completely subsided with the temporary withdrawal of ATRA and did not recur after reintroducing the drug. To date, the patient has managed to receive the treatment as per protocol. In conclusion, we report an atypical presentation of IIH that merits consideration, especially with respect to young patients with APL receiving ATRA; our most important observation is that the drug could be safely reintroduced once the symptoms had resolved.

Análisis envolvente de datos para la determinación de la eficiencia relativa de 8 servicios de 31 hospitales del Sistema Nacional de Salud (SNS) / Data envelopment analysis for determining the relative efficiency of eight services of 31 hospitals in the National Health System (NHS)

La investigación llevada a cabo ha tenido dos objetivos principales: 1) descriptivo, para determinar el nivel de eficiencia relativa en unidades productivas clínicas hospitalarias públicas, mediante la aplicación del Análisis Envolvente de Datos; 2) metodológico, en búsqueda de hallazgos de interés relacionados con la modelización. Los sujetos de estudio son ocho servicios de cada una de las 31 instituciones sanitarias participantes. Las variablesrelevantes han sido tratadas mediante el software “Frontier Analyst”, habiéndose obtenido información de utilidad para el análisis de unidades asistenciales, lo cual permite avanzar en el empeño de llevar a cabo evaluaciones específicas por servicios (AU)

The research carried out has had two main objectives. One descriptive, to determine the level of relative efficiency in public hospital clinics production units through the application of data envelopment analysis and, second, for methodological findings of interest related to modeling (AU)

Histoplasmosis pulmonar diseminada (enfermedad de Darling): a propósito de un caso / Disseminated pulmonary histoplasmosis (Darling's disease): a purpose of a case

La histoplasmosis es una micosis sistémica que afecta al hombre y a los animales, causada por el Hongo Histoplasma capsulatum, se relaciona especialmente con el guano de las aves, y las cuevas habitadas por murciélagos. La infección se produce habitualmente por vía respiratoria, raramente la puerta de entrada es cutánea. El mecanismo de contagio es a través de la inhalación de esporas en el polvo del aire; la población más afectada es la que vive en zonas rurales, especialmente los granjeros; este padecimiento también se ha presentado en forma epidémica. Es una enfermedad de variada, manifestación clínica que puede ir de una simple infección respiratoria asintomática, hasta una enfermedad diseminada, caracterizada por fiebre, anemia progresiva, hepatoesplenomegalía, linfadenopatías, úlceras en el aparato digestivo y necrosis de suprarrenales. Ocurre con mayor frecuencia en individuos del sexo masculino sin distinción de raza. El tratamiento es a base de derivados del imidazol: ketoconazol, itraconazol, fluconazol y anfotericina B.

Rotura espontánea de aneurisma de la arteria esplénica / Spontaneous rupture of an aneurysm in the splenic artery

Introducción. Los aneurismas de la arteria esplénica son lesiones vasculares infrecuentes, aunque representanel 60% de todos los aneurismas viscerales. Suelen ser clínicamente asintomáticos, pero en caso de rotura espontánease manifiestan como un cuadro de abdomen agudo y shock, requiriendo un diagnóstico temprano y una actitud quirúrgicainmediata. Caso clínico. Varón de 64 años de edad con una rotura de un aneurisma de la arteria esplénica que precisóintervención quirúrgica urgente con su resección y esplenectomía

Introduction. Aneurysms in the splenic artery are rare vascular lesions, although they account for 60% of allvisceral aneurysms. They are usually clinically asymptomatic, but when spontaneous rupture occurs they manifest in theform of acute symptoms in the abdomen and shock, and therefore require an early diagnosis and immediate surgicalintervention. Case report. A 64-year-old male with a ruptured aneurysm in the splenic artery that required urgent surgeryto excise it and a splenectomy

Enfermedad renal oculta. Una cuestión de decimales / Hidden chronic kidney disease. A matter of decimals

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Insuficiencia renal oculta en atención primaria. ¿Un problema exclusivo de mujeres? / Occult renal failure in primary care, a women problem ?

Introducción: La insuficiencia renal crónica se está convirtiendo en un problema de salud pública. La estimación del filtrado glomerular (FG) mediante fórmulas permite detectar las personas con daño renal. Objetivo: Conocer el porcentaje de personasatendidas en atención primaria con insuficiencia renal (IR) oculta definida por presentar un FG estimado < 60 mL/min/1,73 m2, con niveles de creatinina séricadentro de los límites de referencia del laboratorio (< 1,3 mg/dL en hombres y < 1,2 mg/dL en mujeres), que hubiesen pasado desapercibidas. Método: Personas mayores de 18 años atendidas en Atención Primaria del Área de Salud de Plasencia (Cáceres) a las que su médico de atención primaria solicitó la medición de niveles de creatinina, entre el 1 de marzo y el 31 de julio de 2006 (5 meses). Se estimó el FG usando la fórmula MDRD-4 y se clasificó el grado de IR de acuerdo con las guías DOQI de la NKF. Resultados: Se realizaron 13.784 mediciones de creatinina sérica en mayores de 18 años. 1.042 presentaron FG < 60 mL/min/1,73 m2, correspondientesa 960 personas (6,96%). Edad media 76,8 años (rango 40-98). De ellas, 418 (43,5%) presentaban IR «oculta», todas mujeres, con edad media 76,5 años y Crmedia 1 mg/dL. Conclusiones: Existe un elevado porcentaje de pacientes atendidos en atención primaria con FG < 60 mL/min/1,73 m2 que mantiene niveles de creatinina en los límites normales. La estimación del FG de forma sistemática permite detectar dichos pacientes, fundamentalmente mujeres mayores de 65 años, que pasarían desapercibidos, lo que se ha denominado IR «oculta»

Background: Chronic renal failure is becoming a public health problem. The estimation of glomerular filtration rate (GFR) using the MDRD-4 equation is importantto find out patients with impaired renal function. The aim of this study was to determinate the rate of patients took care in Primary Care with «occult» renal failure, defined as a GFR less than 60 mL/min/1.73 m2, and serum creatinine levels in the normal range of the laboratory (< 1.3 mg/dL for men, and < 1.2 mg/dL for women).Methods: Patients over 18 years-old took cared in Primary Care of the health area of Plasencia (Caceres), who were measured serum creatinine level between march to july 2006. We estimated GFR using MDRD-4 formula and classified the level of kidney function according to the NKF-DOQI guidelines.Results: We estimated GFR in 13.784 analyses. In 1.042 the GFR was less than 60 mL/min/1.73m2, from 960 patients(6.96%). Mean age 76.8 years (range 40-98 years). 418 keep normal serum creatinine levels (43.5%). Conclusion: Renal impairment seems to be prevalent in the general population took care in Primary Care. An elevated rate of patients with renal failure present serum creatinine levels in the laboratory normal range, «occult» renal failure. The systematic estimation of GFR using MDRD formula is necessary to detect this patients with renal impairment

Evaluación de desempeños eficientes en unidades productivas hospitalarias / An assessment of efficient performances in productive units in hospitals

El objetivo de este artículo es explicar de forma sencilla y práctica cuales son los procedimientos y las metodologías mediante las que es posible evaluar desempeños eficientes en unidades productivas hospitalarias públicas. Para ello, se comentan varios ejemplos prácticos, desde los más sencillos (uno o dos inputs y outputs), hasta lo más complicados que requieren la aplicación de técnicas más sofisticadas como el Análisis Envolvente de Datos (AED). Finalmente se mencionan las variables susceptibles de ser empleadas o que han sido ya utilizadas a este propósito, citándose a título de ejemplo las concernientes a tres servicios hospitalarios, que están siendo estudiados en un proyecto de investigación en curso (AU)

The objective of this article is to explain in a simple and practical way the procedures and methodologies for assessing efficient performances in productive units in public hospitals. Some examples are referred to and the employment variables are mentioned, presenting the cases of three hospital services which are being studied in a research project underway (AU)