25-OH-vitamina D y reversión de comorbilidades metabólicas asociadas a la obesidad tras la cirugía bariátrica / 25-OH-vitamin D and reversal of obesity-associated metabolic comorbidities after bariatric surgery

Introducción: La obesidad es un problema de salud pública en el que se producen defectos en el sistema endocrino generando en consecuencia enfermedades metabólicas. La cirugía bariátrica (CB) ha demostrado mayor eficacia en la pérdida de peso y reversión de las comorbilidades (especialmente inflamatorio y metabólico). Los mecanismos subyacentes relacionados con la reversión de comorbilidades son aún poco conocidos. Los pacientes sometidos a CB reciben de forma rutinaria suplementos de vitamina D, por lo que su papel en la reversión de comorbilidades puede ser relevante.Objetivos: Determinar la relación entre los niveles de 25-OH-vitamina D, la prevalencia de comorbilidades metabólicas antes de la CB y 6 meses tras la misma.Resultados: Se evaluaron 328 pacientes, los cuales mostraron pérdida significativa de peso y masa magra a los 6 meses de la CB. Los niveles séricos de 25-OH-vitamina D se incrementaron de forma paralela a un aumento en la suplementación, sin embargo, no se observaron correlaciones con la presencia de comorbilidades metabólicas basales ni a los 6 meses de la CB. Los niveles séricos de 25-OH-vitamina D se correlacionaron con algunos parámetros de la composición corporal de forma independiente a la reversión de las comorbilidades.Conclusiones: La CB se asoció a mejoría significativa de comorbilidades metabólicas en los pacientes estudiados de forma independiente a los niveles séricos de 25-OH-vitamina D. (AU)

Serum vitamin B12 and related 5-methyltetrahydrofolate-homocysteine methyltransferase reductase and cubilin genotypes predict neural outcomes across the Alzheimer's disease spectrum.

Epidemiological studies show mixed findings for serum vitamin B12 (B12) and both cognitive and regional volume outcomes. No studies to date have comprehensively examined, in non-supplemented individuals, serum B12 level associations with neurodegeneration, hypometabolism and cognition across the Alzheimer's disease (AD) spectrum. Serum B12 was assayed from the Alzheimer's Disease Neuroimaging Initiative (ADNI) and the Australian Imaging, Biomarker & Lifestyle Flagship Study of Ageing (AIBL). Voxel-wise analyses regressed B12 levels against regional grey matter (GM) volume and glucose metabolism (P < 0·05, family-wise corrected). For ADNI GM, there were thirty-nine cognitively normal (CN), seventy-three mild cognitive impairment (MCI) and thirty-one AD participants. For AIBL GM, there were 311 CN, fifty-nine MCI and thirty-one AD participants. Covariates were age, sex, baseline diagnosis, APOE4 status and BMI. In ADNI, higher B12 was negatively associated with GM in the right precuneus and bilateral frontal gyri. When diagnostic groups were examined separately, only participants with MCI, or above an established cut-off for cerebrospinal fluid (CSF) total tau showed such associations. In AIBL, higher B12 was associated with more GM in the right amygdala and right superior temporal pole, which largely seemed to be driven by CN participants that constituted most of the sample. Our results suggest that B12 may show different patterns of association based on clinical status and, for ADNI, AD CSF biomarkers. Accounting for these factors may clarify the relationship between B12 with neural outcomes in late-life.

Primary hyperparathyroidism in pregnancy: a two-case report and literature review.

Primary hyperparathyroidism (PHPT) in pregnant women is an uncommon disease. It could be easily misdiagnosed because of physiologic changes during pregnancy; in some cases, patients could remain asymptomatic maintaining elevated calcium serum levels, and this situation represents a threat to the health of both mother and fetus. We present two cases of PHPT during pregnancy and their evolution after surgical treatment in the second trimester; there were no observed complications during pregnancy or delivery in our patients. Early diagnosis and medical/surgical treatment in PHPT are necessary for avoiding maternal and fetal complications which could not be predicted based on duration or severity of hypercalcemia. An appropriate management of PHPT during pregnancy is necessary for preserving the health of both the woman and the fetus.

Conversion from clinically isolated syndrome to multiple sclerosis: A large multicentre study.

BACKGROUND AND OBJECTIVE: We explored which clinical and biochemical variables predict conversion from clinically isolated syndrome (CIS) to clinically definite multiple sclerosis (CDMS) in a large international cohort. METHODS: Thirty-three centres provided serum samples from 1047 CIS cases with at least two years' follow-up. Age, sex, clinical presentation, T2-hyperintense lesions, cerebrospinal fluid (CSF) oligoclonal bands (OCBs), CSF IgG index, CSF cell count, serum 25-hydroxyvitamin D3 (25-OH-D), cotinine and IgG titres against Epstein-Barr nuclear antigen 1 (EBNA-1) and cytomegalovirus were tested for association with risk of CDMS. RESULTS: At median follow-up of 4.31 years, 623 CIS cases converted to CDMS. Predictors of conversion in multivariable analyses were OCB (HR = 2.18, 95% CI = 1.71-2.77, p < 0.001), number of T2 lesions (two to nine lesions vs 0/1 lesions: HR = 1.97, 95% CI = 1.52-2.55, p < 0.001; >9 lesions vs 0/1 lesions: HR = 2.74, 95% CI = 2.04-3.68, p < 0.001) and age at CIS (HR per year inversely increase = 0.98, 95% CI = 0.98-0.99, p < 0.001). Lower 25-OH-D levels were associated with CDMS in univariable analysis, but this was attenuated in the multivariable model. OCB positivity was associated with higher EBNA-1 IgG titres. CONCLUSIONS: We validated MRI lesion load, OCB and age at CIS as the strongest independent predictors of conversion to CDMS in this multicentre setting. A role for vitamin D is suggested but requires further investigation.

Chondrocytes extract from patients with osteoarthritis induces chondrogenesis in infrapatellar fat pad-derived stem cells.

OBJECTIVE: Infrapatellar fat pad of patients with osteoarthritis (OA) contains multipotent and highly clonogenic adipose-derived stem cells that can be isolated by low invasive methods. Moreover, nuclear and cytoplasmic cellular extracts have been showed to be effective in induction of cell differentiation and reprogramming. The aim of this study was to induce chondrogenic differentiation of autologous mesenchymal stem cells (MSCs) obtained from infrapatellar fat pad (IFPSCs) of patients with OA using cellular extracts-based transdifferentiation method. DESIGN: IFPSCs and chondrocytes were isolated and characterized by flow cytometry. IFPSCs were permeabilized with Streptolysin O and then exposed to a cell extract obtained from chondrocytes. Then, IFPSCs were cultured for 2 weeks and chondrogenesis was evaluated by morphologic and ultrastructural observations, immunologic detection, gene expression analysis and growth on 3-D poly (dl-lactic-co-glycolic acid) (PLGA) scaffolds. RESULTS: After isolation, both chondrocytes and IFPSCs displayed similar expression of MSCs surface makers. Collagen II was highly expressed in chondrocytes and showed a basal expression in IFPSCs. Cells exposed to chondrocyte extracts acquired a characteristic morphological and ultrastructural chondrocyte phenotype that was confirmed by the increased proteoglycan formation and enhanced collagen II immunostaining. Moreover, chondrocyte extracts induced an increase in mRNA expression of chondrogenic genes such as Sox9, L-Sox5, Sox6 and Col2a1. Interestingly, chondrocytes, IFPSCs and transdifferentiated IFPSCs were able to grow, expand and produce extracellular matrix (ECM) on 3D PLGA scaffolds. CONCLUSIONS: We demonstrate for the first time that extracts obtained from chondrocytes of osteoarthritic knees promote chondrogenic differentiation of autologous IFPSCs. Moreover, combination of transdifferentiated IFPSCs with biodegradable PLGA 3D scaffolds can serve as an efficient system for the maintenance and maturation of cartilage tissue. These findings suggest its usefulness to repair articular surface in OA.

Induction and exacerbation of psoriasis with Interferon-alpha therapy for hepatitis C: a review and analysis of 36 cases.

BACKGROUND: Interferon-alpha (IFN-α) therapy is used to treat hepatitis C infection. The exacerbation and occurrence of psoriasis in hepatitis C patients treated with IFN-α is increasingly recognized, but the distinct associated features, aetiology and management have not been reviewed. OBJECTIVE: To review all published cases of hepatitis C patients who developed psoriasis while receiving IFN-α therapy. METHODS: The review was conducted by searching the PubMed database using the keywords 'hepatitis C' AND 'psoriasis.' In addition, references to additional publications not indexed for PubMed were followed to obtain a complete record of published data. RESULTS: We identified 32 publications describing 36 subjects who developed a psoriatic eruption while receiving IFN-α therapy for hepatitis C. Topical therapies were a commonly employed treatment modality, but led to resolution in only 30% of cases in which they were employed solely. Cessation of IFN-α therapy led to resolution in 93% of cases. Hundred per cent of those who developed psoriasis while on IFN-α therapy responded to systemic therapy and were able to continue the drug. CONCLUSION: Further studies and analysis of IFN-α-induced lesions are necessary to clarify the role of IFN-α and the hepatitis C virus in the development of psoriatic lesions.

Integrated internist - addiction medicine - hepatology model for hepatitis C management for individuals on methadone maintenance.

Despite a high prevalence of hepatitis C virus (HCV) among drug users, HCV evaluation and treatment acceptance are extremely low among these patients when referred from drug treatment facilities for HCV management. We sought to increase HCV treatment effectiveness among patients from a methadone maintenance treatment program (MMTP) by maintaining continuity of care. We developed, instituted and retrospectively assessed the effectiveness of an integrated, co-localized care model in which an internist-addiction medicine specialist from MMTP was embedded in the hepatitis clinic. Methadone maintenance treatment program patients were referred, evaluated by the internist and hepatologist in hepatitis clinic and provided HCV treatment with integration between both sites. Of 401 evaluated patients, anti-HCV antibody was detected in 257, 86% of whom were older than 40 years. Hepatitis C virus RNA levels were measured in 222 patients, 65 of whom were aviremic. Of 157 patients with detectable HCV RNA, 125 were eligible for referral to the hepatitis clinic, 76 (61%) of whom accepted and adhered with the referral. Men engaged in MMTP <36 months were significantly less likely to be seen in hepatitis clinic than men in MMTP more than 36 months (odds ratio = 7.7; 95% confidence interval 2.6-22.9) or women. We evaluated liver histology in 63 patients, and 83% had moderate to advanced liver disease. Twenty-four patients initiated treatment with 19 completing and 13 (54%) achieving sustained response. In conclusion, integrated care between the MMTP and the hepatitis clinic improves adherence with HCV evaluation and treatment compared to standard referral practices.

Low-energy spontaneous femoral fractures in patients with long-term bisphosphonate therapy.

Long-term bisphosphonate therapy has been associated with low-energy subtrochanteric and femoral diaphyseal fractures in recent reports. We report three cases of a characteristic pathologic fracture of the subtrochanteric part of femoral, one of them bilateral.

Tendinopatías / Tendinopathies

Objetivo: Realizar una revisión bibliográfica, sobre la etiología, etiopatogenia y tratamiento de las tendinopatías, así como revisar la terminología utilizada. Material y método: Se consultaron diversas fuentes electrónicas y en papel. Se utilizó Pub-med como motor de búsqueda. Resultados: Estructuralmente, la lesión se caracteriza por una alteración de los tenocitos, una desorganización del colágeno, un aumento de la sustancia fundamental y un aumento de los vasos sanguíneos. Junto a todo ello, aparece una alteración de las metaloproteasas y sus inhibidores. Estas sustancias forman parte de la homeostasis normal del tendón, pero determinados factores de riesgo pueden alterar la regulación normal de estas sustancias y podrían contribuir a iniciar y mantener el proceso de forma indefinida. También se ha descrito que el proceso de apoptosis o muerte celular programada iniciada por un citocromo y una enzima podrían estar en su origen patogénico. Conclusiones: Persiste un desconocimiento del proceso que origina y mantiene la lesión. Debido a ello, en la actualidad se han propuesto diversas opciones terapéuticas con más o menos éxito, pero ninguna con una eficacia totalmente satisfactoria. Desde el punto de vista terminológico, el término usado de tendinitis no es adecuado (AU)

Objetive: To extensively review all publicated data regarding etiology, pathogenesis and treatment of this disease and, review the terminology that was used in these processes. Material y Methods: We consulted some electronic and paper knowledge sources and Pubmed was used as a search engine. Results: Morphologically, the basic lesion is a cellular alteration of tenocytes, collagen disorganization, and an increase in matrix content and blood vessels. Moreover, metalloproteases and its inhibitors are disturbed. A programmed apoptosis of cells initiated by a cytocrom has been suggested as the origin of the disease. Conclusions: Due to ignorance of it origin, no real effective treatment has been yet achieved. Some therapeutic interventions have been proposed, with variable degree of success. From the standpoint of terminology, the term most used of tendinitis is not suitable (AU)

La Ortopedia infantil para pediatras de Atención Primaria / No disponible

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Transporte óseo en defecto óseo femoral. A propósito de un caso / Bone Transport for bone reconstruction. A case report

Objetivo: El transporte óseo es una técnica terapéutica que crea hueso en situaciones en las que la pérdida del mismo hace inviable la consolidación de los extremos. Esta técnica se basa en el concepto de osteogénesis en distracción. Material y método: Presentamos el caso de un varón de 31 años, que tras sufrir una fractura del tercio medio del fémur derecho, no se obtuvo la consolidación debido a la infección del foco tras varios intentos de osteosíntesis. Presentaba una pérdida de hueso severa con mal estado general. Resultados: Tras un tratamiento previo fallido, de unos dos años, se limpió el foco y, con la técnica de transporte óseo, se restauró la longitud inicial del hueso consolidándolo finalmente sin secuelas relevantes. Conclusión: El caso demuestra la validez de este método de transporte óseo para restaurar la longitud ósea en caso de grandes defectos diafisarios (AU)

Objetive: Bone transport is a therapeutic technique that generates bone in situations where bone loss makes consolidation of the extremities non-viable. This technique is based on the concept of distraction osteogenesis. Material and method: Following fracture of the middle third of the right femur in a 31-year-old male, consolidation was not achieved, due to focus infection after several osteosynthesis attempts. The patient presented severe bone loss with a poor general condition. Results: Following the previous failed treatment lasting about two years, the affected zone was cleaned, and the bone transport technique was used to restore the original length of the bone, which was finally consolidated without relevant sequelae. Conclusion: This case shows the validity of the bone transport technique in restoring bone length in the case of large diaphyseal defects (AU)

Abordajes quirúrgicos en la artroplastia de superficie de la cadera / Surgical approaches in hip resurfacing surgery

La artroplastia de superficie de la cadera, al retener la cabeza femoral, presenta una serie de problemas con el abordaje quirúrgico que no tiene la artroplastia convencional. Estos problemas derivan de la necesidad de conservar la vascularización y de una exposición quirúrgica más amplia para colocar adecuadamente los componentes. Se analiza la vascularización de la cabeza del fémur y su relación con los diferentes abordajes y las técnicas quirúrgicas empleadas y también los principales abordajes empleados para realizarla, y se indican las principales ventajas e inconvenientes de cada vía (AU)

By preserving the femoral head, hip resurfacing arthroplasty is associated with a series of problems specifically related to the surgical approach that are not present in conventional hip replacement. These problems are attributable to the need to preserve blood supply and to allow a wider surgical exposure in order to place the different components appropriately. In this study, we analyze the blood supply to the femoral head and its relationship with the different approaches and surgical techniques used. We also review the different approaches used to perform hip resurfacing surgery, indicating the main advantages and disadvantages of each of them (AU)

Comentario / No disponible

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Effect of vitamin C on fracture healing in elderly Osteogenic Disorder Shionogi rats.

We studied the effect of vitamin C on fracture healing in the elderly. A total of 80 elderly Osteogenic Disorder Shionogi rats were divided into four groups with different rates of vitamin C intake. A closed bilateral fracture was made in the middle third of the femur of each rat. Five weeks after fracture the femora were analysed by mechanical and histological testing. The groups with the lower vitamin C intake demonstrated a lower mechanical resistance of the healing callus and a lower histological grade. The vitamin C levels in blood during healing correlated with the torque resistance of the callus formed (r = 0.525). Therefore, the supplementary vitamin C improved the mechanical resistance of the fracture callus in elderly rats. If these results are similar in humans, vitamin C supplementation should be recommended during fracture healing in the elderly.

Dietary fat intake and the risk of osteoporotic fractures in the elderly.

OBJECTIVE: To explore the association between fat intake, serum lipids and the risk of osteoporotic fractures in the elderly. DESIGN: A hospital-based case-control study. SETTING: The study was conducted at a tertiary centre and referral hospital for the province of Jaén (Spain). SUBJECTS: Cases (n=167) were patients aged 65 years or more with a low-energy fracture selected from the population attended at the hospital. Controls (patients without antecedents of any fracture) were 1:1 matched to cases by sex and age (n=167). METHODS: Diet was assessed by a semiquantitative food frequency questionnaire. Serum total cholesterol and high-density lipoprotein (HDL) cholesterol were also measured. RESULTS: Participants in the two upper quartiles of polyunsaturated fat (PUFA) intake showed an increased risk of fracture, with statistically significant differences with respect to the first quartile in the adjusted model (odds ratio (OR)=3.59; 95% confidence interval (CI)=1.06-12.1 and OR=5.88; 95% CI=1.38-25.02); P=0.01 for the trend test). A higher ratio of monounsaturated fat (MUFA) to PUFA was associated with a reduced risk of fracture (OR=0.20; 95% CI=0.07-0.60 for the fourth quartile; P=0.002 for the trend test). The intake of omega-6 fatty acids was associated with an elevated risk of fracture (OR=3.41; 95% CI=1.05-11.15 for the fourth quartile; P=0.01 for the trend test). HDL-cholesterol levels were inversely associated with the risk of fracture (test for trend P=0.03 across quartiles). CONCLUSIONS: PUFA intake was associated with an increased risk of osteoporotic fractures in the elderly, whereas a high ratio of MUFA:PUFA was associated with decreased risk.

Variabilidad interobservador en las mediciones de radiografías de prótesis totales de rodilla / Inter-observer variability in measurements of X-rays of total knee replacements

Objetivo. Valorar la reproducibilidad de las medidas consideradas estándar por la Knee Society en la valoración de una prótesis total de rodilla. Material y método. Tres observadores midieron en veinte rodillas protésicas los ángulos alfa, beta femorotibial, sagital femoral, sagital tibial y de lateralidad patelar. Estas mediciones se obtuvieron de radiografías simples en las proyecciones anteroposterior, lateral y axial de rótula a 30°. Se calculó el coeficiente de correlación intraclase (ICC) para valorar la variabilidad interobservador de estas mediciones. Resultados. Todos los ángulos estudiados tienen una reproducibilidad excelente (ICC > 0,75), excepto el ángulo alfa y sagital tibial, que se encuentran de todas formas muy cercanos a este límite (0,74 y 0,76, respectivamente). Conclusiones. Las mediciones sobre radiografías de prótesis de rodilla antes descritas son similares entre distintos observadores con una reproducibilidad buena o muy buena, por lo que se podrían utilizar con objeto de unificar resultados en los distintos trabajos de los diferentes investigadores. Además se realizan sobre radiografías simples en proyecciones comunes en los estudios realizados en las rodillas, y por tanto son asequibles para la mayoría de los centros sanitarios, a diferencia de otros medios como la tomografía axial computarizada (TAC) o la resonancia magnética nuclear (RMN). La Knee Society considera como estándar las líneas radiolucentes en la valoración de las prótesis totales de rodilla que, al haber sido demostrada en otros estudios la no reproducibilidad, se han desestimado en el presente trabajo

Aim. To determine how reproducible Knee Society standard measurements are when evaluating total knee replacement. Materials and methods. In 20 cases of knee replacement three observers measured different angles: alpha angle, beta tibiofemoral angle, sagittal femoral angle, sagittal tibial angle and lateral patellar angle. These measurements were done on simple X-rays in the following projections: anteroposterior (AP), lateral and axial of the patella at 30°. The intra-class correlation coefficient (ICC) was calculated to assess inter-observer variability of these measurements. Results. All the angles studied have excellent reproducibility (ICC > 0.75) except for the alpha angle and the sagittal tibial angle, although these are very close to the above mentioned coefficient (0.74 and 0.76, respectively). Conclusions. measurements of knee prosthesis performed on simple X-rays are similar when taken by different observers with a degree of reproducibility of good to very good. Therefore, these measurements can be used with the aim of unifying the results of work carried out by different researchers. Moreover, they are performed on plain knee X-rays taken during ordinary knee studies and can therefore be obtained by most health centres, which is not the case for CAT scans or MRIs. The Knee Society considers the radiolucent lines as standards for assessment of total knee replacement prostheses, but as other studies have demonstrated that they are not reproducible they have not been considered in this study

Prevalencia del síndrome de burnout o desgaste profesional en los cirujanos ortopédicos de España / Prevalence of burnout syndrome in orthopedic surgeons in Spain

Objetivo. Determinar el grado de desgaste profesional en los cirujanos ortopédicos de España y la influencia de diversos factores sobre éste. Material y método. Se trata de un estudio transversal descriptivo. Se envió a 435 cirujanos ortopédicos en activo de toda España un cuestionario auto administrado y anónimo, que incluía: a) el Maslasch Burnout Inventory, que valora despersonalización (DP), logros personales (autoestima) (LP) y cansancio emocional (CE); b) variables sociodemográficas y c) propuesta de medidas a adoptar si hay estrés laboral. Resultados. Contestaron el cuestionario 169 cirujanos ortopédicos (38,85%), varones el 93,3% y con una media de edad de 49 años, el 60,4% realizaba guardias. El tipo de contrato es fijo en 117 casos (78,5%), interino en 22 (14,8%) y temporal en 6 (4%). Un 44,1% de los participantes presentó un alto desgaste profesional en cansancio emocional, un 64,6% en despersonalización y un 24,5% en realización personal. Tener varios hijos, un contrato fijo y trabajar en el sector privado son factores que se asocian con mejores puntuaciones en las escalas de burnout (p < 0,05). Como sugerencias para mitigar el burnout destacan la petición de una renumeración económica más satisfactoria, disminuir el número de pacientes por día en la consulta y un aumento del prestigio profesional. Conclusiones. Los niveles de desgaste profesional entre los cirujanos ortopédicos españoles son superiores a los encontrados en otros países, sobre todo en despersonalización y cansancio emocional. La prevalencia de burnout es superior en el ámbito público frente al privado. Se necesitan intervenciones en política sanitaria para paliar y prevenir esta situación

Purpose. To determine the degree of professional burnout in Orthopedic Surgeons in Spain and the influence of different factors affecting this condition. Materials and methods. This is a transverse descriptive study. We posted an anonymous self-administered questionnaire to 435 practicing orthopedic surgeons throughout Spain. The questionnaire included: a) the Maslach Burnout Inventory (MBI), that assesses Depersonalization (DP), Personal Accomplishment (PA), and Emotional Exhaustion (EE); b) social and demographic variables; and c) proposals of measures to decrease work related stress. Results. The questionnaire was answered by 169 orthopedic surgeons (38.85%), of which 93.3% were male, the average age of the respondents was 49, and 60.4% did emergency shifts. Work contracts were permanent in 117 cases (78.5%), interim in 22 cases (14.8%) and temporary in 6 cases (4%). Of the respondents, 44.1% had high levels of Emotional Exhaustion burnout, 64.6% had high levels of depersonalization burnout and 24.5% had high levels of Personal Accomplishment burnout. Having several children, a permanent contract, and working in the private sector were variables associated with a better score in the burnout scale (p<0.05). Different suggestions put forward to decrease burnout were: improvement in salary, decrease in the number of patients seen per day, and an increase of professional prestige. Conclusion. The degree of professional burnout in Spanish orthopedic surgeons is greater than that found in other countries, especially as far as rates of Depersonalization and Emotional Exhaustion are concerned. There is a greater prevalence of burnout in orthopedic surgeons working in the public sector in comparison with those working in the private sector. Health Policy measures are necessary to prevent professional burnout and improve the current situation

Síndrome de edema transitorio del cuboides / Transient osteoporosis of the cuboid bone

El edema transitorio de médula ósea es un síndrome infrecuente. Apenas existen 7 casos descritos en la bibliografía con localización en el hueso cuboides. Se presenta un caso en dicha localización, que se resolvió espontáneamente. Se discute el diagnóstico y las posibilidades terapéuticas (AU)

Manguito de isquemia en el tobillo para la cirugía del antepié / Tourniquet placed at the ankle for forefoot surgery

Objetivos: El manguito de isquemia para la cirugía del antepié se ha colocado tradicionalmente en el muslo o en la pantorrilla. El objetivo de este trabajo es valorar si el manguito colocado a este nivel es indoloro, efectivo (capaz de producir un campo exangüe), y seguro (sin complicaciones).Material y método: 20 pacientes (23 pies) programados para la realización de una intervención en el antepié se incluyeron de forma prospectiva. En todos los casos se realizó una anestesia troncular de tobillo con mepivacaína 1 por ciento (scandinibsa® 1 por ciento). El manguito se colocó sobre ambos maléolos, a una presión 100 mmHg superior a la presión sistólica del enfermo. Los resultados se valoraron mediante la escala analógico-visual del dolor (VAS: 0-10). Durante la intervención, la isquemia se valoró en 4 grados. A las 43,5 semanas de la intervención se revisaron 20 pies, anotando las zonas de dolor, parestesias, alteraciones vasculares y tumefacción. Resultados: Dolor: en ningún caso molestó el manguito durante el tiempo que duró la intervención. El dolor medio fue de 0,3 ñ 0,8. Isquemia: se valoró como excelente en 21 pies. Complicaciones: durante la intervención sólo apareció una bradicardia transitoria que se resolvió sin tratamiento. En la revisión posterior, no se encontró ninguna alteración neurológica o vascular debida al manguito de isquemia. Conclusiones: El manguito de isquemia en el tobillo es una técnica muy bien tolerada por el paciente, que proporciona un excelente campo quirúrgico, y que prácticamente está libre de complicaciones. Toda la cirugía del antepié se puede realizar con esta técnica (AU)

Las lesiones de la mano en urgencias

Las lesiones de la mano son muy frecuentes. La clave de un tratamiento adecuado en urgencias es una correcta exploración clínica. En este artículo se presentan los detalles anatómicos de mayor trascendencia clínica, así como la forma de realizar una exploración adecuada de la misma. También se indica el tratamiento básico de aquellas lesiones que pueden ser tratadas por el médico de atención primaria (AU)