Interobserver reliability of classifying shoulder calcific tendinopathy on plain radiography and ultrasound.

INTRODUCTION: Shoulder calcific tendinopathy is a frequent cause of shoulder pain. Diagnosis is usually based on ultrasound (US) and/or X-ray. US is considered an inherently operator-dependent imaging modality and, interobserver variability has previously been described by experts in the musculoskeletal US. The main objective of this study is to assess the interobserver agreement for shoulder calcific tendinopathy attending to the size, type, and location of calcium analyzed in plain film and ultrasound among trained musculoskeletal radiologists. MATERIAL AND METHODS: From June 2018 to May 2019, we conducted a prospective study. Patients diagnosed with shoulder pain related to calcific tendinopathy were included. Two different experienced musculoskeletal radiologists evaluated independently the plain film and the US. RESULTS: Forty patients, with a mean age of 54.6 years, were included. Cohen's kappa coefficient of 0.721 and 0.761 was obtained for the type of calcium encountered in plain film and the US, respectively. The location of calcification obtained a coefficient of 0.927 and 0.760 in plain film and US, respectively. The size of the calcification presented an intraclass correlation coefficient (ICC) of 0.891 and 0.86 in plain film and US respectively. No statistically significant differences were found in either measurement. CONCLUSION: This study shows very good interobserver reliability of type and size measurement (plain film and US) of shoulder calcifying tendinopathy in experienced musculoskeletal radiologists.

Hipotensión arterial postoperatoria: el enemigo inadvertido / Postoperative arterial hypotension: The unnoticed enemy

La hipotensión postoperatoria es un problema de salud frecuentemente subestimado, asociado a una elevada morbimortalidad y a un mayor uso de recursos sanitarios. También plantea importantes retos clínicos, tecnológicos y humanos para la asistencia sanitaria. Al tratarse de un factor de riesgo modificable y evitable, este documento pretende aumentar su visibilidad, definiendo su impacto clínico y los retos tecnológicos que conlleva la optimización de su manejo, teniendo en cuenta aspectos clínico-tecnológicos, humanísticos y económicos.(AU)

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.(AU)

Postoperative arterial hypotension: the unnoticed enemy.

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.

Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes.

OBJECTIVES: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS: Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

Protocolo de extubación ultra-fast track tras cirugía cardiovascular: predictores de fracaso y resultados / Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes

Objetivos: Identificar los factores predictores independientes de fracaso de la extubación ultra-fast track (UFT) y comparar los resultados hospitalarios de la extubación UFT frente a la extubación fast track en pacientes adultos sometidos a cirugía cardiovascular. Material y métodos: Análisis retrospectivo de 1.498 pacientes consecutivos mayores de 18 años sometidos a cirugía cardiovascular en un solo centro. Entre diciembre 2014 y diciembre 2016 se utilizó la extubación fast track (n=713), mientras que, entre diciembre 2016 y diciembre 2018 todos los pacientes fueron considerados preoperatoriamente aptos para extubación UFT (n=785). En este caso se empleó el mismo protocolo anestésico estandarizado en todos los pacientes. La decisión de extubar o no en quirófano se basó exclusivamente en parámetros hemodinámicos y ventilatorios. Resultados: La extubación en quirófano fue posible en 699 (89%) pacientes. Los factores predictores independientes de fracaso de la extubación UFT fueron: clase funcional preoperatoria iii-iv de la NYHA, infarto agudo de miocardio dentro de los 2 días previos a la cirugía, balón de contrapulsación intraaórtico preoperatorio, cirugía urgente o emergente, transfusión intraoperatoria de plaquetas y soporte intraoperatorio con fármacos inotrópicos y vasopresores. La extubación UFT se asoció con una menor tasa de complicaciones cardiovasculares, como insuficiencia cardiaca congestiva (OR: 1,57; IC 95%: 1,13-2,19; p=0,008) y fibrilación auricular postoperatoria de novo (OR: 1,40; IC 95%: 1,06-1,86; p=0,020). Los pacientes extubados en quirófanos presentaron un menor riesgo de complicaciones globales, menor estancia en la UCI y mayor supervivencia a corto plazo, aunque no se encontraron diferencias estadísticamente significativas al realizarse el ajuste multivariante. Conclusiones: La extubación inmediata rutinaria en quirófano tras cirugía cardiovascular en adultos es una...(AU)

Objectives: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. Material and methods: Retrospective analysis of 1,498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N=713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N=785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. Results: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; P=0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; P=0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. Conclusions: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.(AU)

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). / Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP).

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

Terapia robótica con el exoesqueleto H2 en la rehabilitación de la marcha en pacientes con lesión medular incompleta. Una experiencia clínica / Robot therapy with the H2 exoskeleton for gait rehabilitation in patients with incomplete spinal cord injry. A clinical experience

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[Robot therapy with the H2 exoskeleton for gait rehabilitation in patients with incomplete spinal cord injry. A clinical experience]. / Terapia robótica con el exoesqueleto H2 en la rehabilitación de la marcha en pacientes con lesión medular incompleta. Una experiencia clínica.

BACKGROUND AND OBJECTIVE: Robotic exoskeletons have emerged as a promising tool in gait rehabilitation in patients with a spinal cord injury. The aim of this study was to assess the clinical applicability of a new robotic exoskeleton model (Exo H2) in the rehabilitation of people with incomplete spinal cord injury. MATERIAL AND METHODS: Exo H2 exoskeleton training was performed for 15 sessions in patients with incomplete subacute spinal cord injury. We analysed the appearance of undesirable events and the patient's perception of pain, fatigue and comfort. In addition, a pilot test was carried out on the possible effectiveness of the device by analysing gait characteristics before and after treatment measured by the 10mWT, the 6mWT, the TUG, the WISCI-II, and the impact on the SCIM III scale. RESULTS: Of a group of 8 patients recruited, we were able to analyse data from 4. No undesirable effects were reported. The VAS value was 2.28±1.55 for pain, 3.75±1.55 for fatigue and 4.17±1.68 for comfort. All values improved on the WISCI-I and the TUG and almost all in the 10MWT and in the 6MWT. CONCLUSIONS: The performance of the Exo H2 exoskeleton was robust during a clinical protocol for gait rehabilitation. The treatment was safe, without undesirable effects and with good patient tolerance. These results might justify the performance of clinical trials with an adequate sample size.

Hacia un uso juicioso de los opioides en España / Towards the judicious use of opioids in Spain

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Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto / Scimitar syndrome: anaesthetic management for pulmonary resection of the unaffected lung

El síndrome de la cimitarra es una rara anomalía congénita caracterizada por drenaje anómalo de las venas pulmonares derechas en cava inferior, asociado frecuentemente a hipoplasia del pulmón y arteria pulmonar derecha, dextrocardia y aporte arterial sistémico anómalo al lóbulo inferior. La resección sobre el pulmón sano resulta excepcional, y no conocemos antecedentes publicados. Un varón con síndrome de la cimitarra es diagnosticado de nódulo pulmonar maligno del pulmón contralateral. Esta situación conlleva una enorme complejidad anestésica, fundamentalmente para la ventilación intraoperatoria. Aunque la espirometría y la prueba de esfuerzo no contraindicaban la lobectomía prevista, la gammagrafía objetivó un pulmón derecho hipoplásico con captación por debajo del 15%. Descartamos la ventilación selectiva del pulmón derecho, ya que el shunt lo hacía funcionalmente inexistente, y planteamos 4 posibilidades anestésicas. Tras la colocación de un catéter epidural e intubación selectiva izquierda, la toracoscopia con apneas intermitentes fue nuestra primera elección (AU)

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity (AU)

Scimitar syndrome: Anaesthetic management for pulmonary resection of the unaffected lung. / Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto.

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity.

Neuroprotective effect of 2-hydroxy arachidonic acid in a rat model of transient middle cerebral artery occlusion.

Stroke modifies the composition of cell membranes by eliciting the breakdown of membrane phospholipids whose products, such as arachidonic acid (AA), are released in the cytosol. The action of enzymes such as cyclooxygenases on AA leads to inflammatory stimuli and increases the cell oxidative stress. We report here the neuroprotective effect of 2-hydroxyarachidonic acid (2OAA), a cyclooxygenase inhibitor derived from AA, as a promising neuroprotective therapy against stroke. The effect of a single dose of 2OAA, administered intragastrically 1h after the ischaemic insult, in a rat model of transient middle cerebral artery occlusion (tMCAO) was tested after 24h of reperfusion. Infarct volume was measured by TTC method to evaluate the neuroprotective effect. Levels of phospholipids and neutral lipids were measured by thin-layer chromatography. The expression of cPLA2 and sPLA2 phospholipases responsible for the cleavage of membrane phospholipids, as well as the expression of antioxidant enzymes, was measured by qPCR. Lipid peroxidation was measured as the concentration of malondialdehyde and 4-hydroxynonenal. The treatment with 2OAA reduced the infarct volume and prevented ischaemia-induced increases in transcription levels of free fatty acid (FFAs), as well as in both phospholipases A2 (cPLA2 and sPLA2). The lipid peroxidation and the transcription levels of antioxidant enzymes induced by ischaemia were also decreased by this treatment. We conclude that 2OAA treatment results in a strong neuroprotective effect that seems to rely on a decrease in PLA2 transcriptional activity. This would reduce their action on the membrane phospholipids reducing reactive oxygen and nitrogen species generated by FFAs. Based on the transcriptional activity of the antioxidant enzymes, we conclude that the treatment prevents oxidative stress rather than promoting the antioxidant response. This article is part of a Special Issue entitled: Membrane Lipid Therapy: Drugs Targeting Biomembranes edited by Pablo V. Escribá.

Anesthetic management for thoracic surgery in Rubinstein-Taybi syndrome / Manejo anestésico en cirugía torácica en el síndrome de Rubinstein-Taybi

Rubinstein-Taybi syndrome (RTS) is a chromosomopathy associated to molecular mutations or microdeletions of chromosome 16. It has an incidence of 1:125,000-700,000 live births. RTS patients present craniofacial and thoracic anomalies that lead to a probable difficult-to-manage airway and ventilation. They also present mental retardation and comorbidity, such as congenital cardiac defects, pulmonary structural anomalies and recurrent respiratory infections, which increase the risk of aspiration pneumonia. Cardiac arrhythmias have been reported after the use of certain drugs such as succinylcholine and atropine, in a higher incidence than in general population. There is an increased risk of postoperative apnea-hypopnea in these patients. We report the anesthetic management in a RTS patient undergoing emergent thoracic surgery due to oesophageal perforation and mediastinitis. Lung isolation was achieved with a bronchial blocker guided with a fiberoptic bronchoscope and one-lung ventilation was performed successfully (AU)

El síndrome de Rubinstein-Taybi es una enfermedad de baja incidencia (1:125.000-700.000 RN vivos) asociada a mutaciones o microdeleciones del cromosoma 16. Los pacientes afectos presentan frecuentemente anomalías craneofaciales y torácicas que condicionan una vía aérea y ventilación dificultosas. Asimismo, asocian retraso mental y comorbilidades, entre las que cabe destacar cardiopatías congénitas, infecciones respiratorias de repetición y enfermedad por reflujo gastroesofágico, que aumenta el riesgo de broncoaspiración. En estos pacientes se ha descrito una mayor incidencia de arritmias tras la administración de fármacos, como la succinilcolina y atropina, así como una mayor incidencia de apnea e hipopnea en el postoperatorio. Presentamos el manejo anestésico de un paciente afecto de síndrome de Rubinstein–Taybi sometido a cirugía torácica urgente por perforación esofágica y mediastinitis, con exclusión pulmonar llevada a cabo con bloqueador bronquial (AU)

Anesthetic management for thoracic surgery in Rubinstein-Taybi syndrome.

Rubinstein-Taybi syndrome (RTS) is a chromosomopathy associated to molecular mutations or microdeletions of chromosome 16. It has an incidence of 1:125,000-700,000 live births. RTS patients present craniofacial and thoracic anomalies that lead to a probable difficult-to-manage airway and ventilation. They also present mental retardation and comorbidity, such as congenital cardiac defects, pulmonary structural anomalies and recurrent respiratory infections, which increase the risk of aspiration pneumonia. Cardiac arrhythmias have been reported after the use of certain drugs such as succinylcholine and atropine, in a higher incidence than in general population. There is an increased risk of postoperative apnea-hypopnea in these patients. We report the anesthetic management in a RTS patient undergoing emergent thoracic surgery due to oesophageal perforation and mediastinitis. Lung isolation was achieved with a bronchial blocker guided with a fiberoptic bronchoscope and one-lung ventilation was performed successfully.

Clinical Evolution After Enzyme Replacement Therapy in Twins with the Severe Form of Maroteaux-Lamy Syndrome.

Mucopolysaccharidosis type VI (MPS VI) is a progressive, autosomal, recessive lysosomal disorder. This disorder, due to a deficiency in N-acetylgalactosamine-4-sulfatase (ASB), results in an accumulation of glycosaminoglycan (GAG), causing multiple organ failures. In this study, monochorionic biamniotic twins with the severe form of MPS VI underwent enzyme replacement therapy (ERT) with weekly infusions of recombinant human ASB (galsulfase) at 1 mg/kg. After 9 years of ERT, a comprehensive clinical examination was performed. Several types of biochemical, immunological, and genetic investigations were also conducted. Both twins showed the typical symptoms and signs of MPS VI at baseline, including short stature, progressive dysmorphic facial features, and dysostosis multiplex. Twin 2 presented stronger multisystemic involvement, with marked musculoskeletal, neurological, and odontological components. She also developed an ischemic spinal cord lesion after surgery, which is the first case described in the literature in Maroteaux-Lamy syndrome. However, the extent of disease was found to be equally stabilized in the two sisters, concretely the cardiac and respiratory functions and body length. The early diagnosis and treatment of MPS VI are critical for an optimal clinical outcome, and further evidence for the new treatment strategies is needed.

Glutamate receptor and transporter modifications in rat organotypic hippocampal slice cultures exposed to oxygen-glucose deprivation: the contribution of cyclooxygenase-2.

Meloxicam is a non-steroidal anti-inflammatory drug which has been reported to lessen the ischemic transcriptional effects in some of the glutamatergic system genes as well as to decrease the infarct volume in in vivo assays. In this study, we show how the presence of meloxicam decreases cell mortality in assays of oxygen-glucose deprivation (OGD) in rat organotypic hippocampal slices culture. Mortality was measured using propidium iodide. Transcript levels of some glutamatergic system genes, including vesicular and membrane glutamate transporters (VGLUT1, VGLUT2, GLAST-1A, GLT-1, and EAAC-1) and some glutamatergic receptor subunits (NMDA receptor, GluN1, GluN2A and GluN2B subunits and AMPA receptor, GluA1 and GluA2 subunits) were measured by real-time PCR (qPCR). The transcription of vesicular glutamate transporters and glutamatergic receptor subunits, but not membrane glutamate transporters, was modified by the presence of meloxicam. The study demonstrates the neuroprotective role of meloxicam in organotypic hippocampal slice cultures and shows how meloxicam is able to selectively increase or decrease the OGD-induced changes in the expression of the different glutamatergic system genes studied here. We suggest that the neuroprotective role of meloxicam could be due to a modification in the balance of the expression of some glutamatergic receptor subunits, leading to a different stoichiometry of receptors such as NMDA or AMPA. Thus, meloxicam would decrease the excitotoxicity induced by OGD.