Variabilidad interregional en el uso de tecnologías cardiovasculares (2011-2019). Correlación con índices económicos y frecuentación y mortalidad hospitalarias / Interregional variability in the use of cardiovascular technologies (2011-2019). Correlation with economic indicators, admissions, and in-hospital mortality

Introducción y objetivos La igualdad de oportunidades para acceder a avances técnicos de reconocido valor clínico debe ser una prioridad del sistema público de salud. Se analizó la variabilidad entre todas las comunidades autónomas españolas en el uso de técnicas cardiológicas con indicación ya establecida y su relación con indicadores económicos, carga de enfermedad y mortalidad hospitalaria. Métodos Se analizaron los registros de actividad de las asociaciones de la Sociedad Española de Cardiología desde 2011 a 2019 en coronariografía, intervención coronaria percutánea (ICP) general, ICP primaria, desfibrilador automático implantable (DAI), terapia de resincronización cardiaca e implante percutáneo de válvula aórtica (TAVI). Se obtuvieron índices económicos (producto interior bruto y gasto sanitario per cápita) y datos sobre frecuentación y mortalidad hospitalarias reportados en los informes RECALCAR (Recursos y Calidad en Cardiología) de la Sociedad Española de Cardiología. Se analizó el coeficiente de variación en la actividad y la correlación de esta con los índices regionales económicos, de frecuentación y la razón de mortalidad hospitalaria estandarizada por riesgo. Resultados Existe una variación notable en el uso de las tecnologías, especialmente ICP primaria (18%), DAI (22%), terapia de resincronización cardiaca (36%) y TAVI (42%). Solo se observó cierta correlación con la frecuentación de la ICP general y el DAI. No se encontró una correlación significativa entre la penetración de las técnicas y los índices económicos de riqueza y gasto. La correlación con la mortalidad hospitalaria no mostró resultados significativos, aunque es el análisis con más limitaciones, ya que estas técnicas tienen mayor impacto en la supervivencia en el medio y largo plazo. Conclusiones Los resultados del estudio, con sus limitaciones inherentes (AU)

Introduction and objectives Equal opportunities to access technical advances with recognized clinical value should be a priority of the publicly-funded health system. We analyzed variability among all the Spanish autonomous communities in the use of cardiovascular techniques with an established indication and its relationship with economic indicators, burden of disease, and hospital mortality. Method The activity registries of various Associations of the Spanish Society of Cardiology from 2011 to 2019 were analyzed for coronary angiography, overall percutaneous coronary intervention (PCI), primary PCI, implantable cardioverter-defibrillators (ICD), cardiac resynchronization therapy, and transcatheter aortic valve replacement (TAVR). Economic indices (gross domestic product and per capita health care expenditure) were obtained from public sources and data on attendance rates and mortality from the Resources and Quality in Cardiology (RECALCAR) reports of the Spanish Society of Cardiology. We analyzed the coefficient of variation for activity and the correlation of activity with regional economic indices, attendance rates, and risk-adjusted rates of in-hospital mortality. Results We identified wide variability in the use of technologies, especially for primary PCI (18%), ICD (22%), cardiac resynchronization therapy (36%), and TAVR (42%). A certain correlation with attendance rates was seen only for overall PCI and ICD. In general, no significant correlation was found between the use of the techniques and the economic indices of wealth and expenditure. The correlation with in-hospital mortality showed no significant results, although this was the analysis with the greatest limitations because the impact of these techniques on survival is exerted more in the mid- and long-term Conclusions The results of this study, despite its inherent limitations, show marked variability between autonomous communities in the use of cardiovascular technologies (AU)

Resultados clínicos tempranos tras el implante percutáneo de válvula aórtica por acceso transaxilar comparado con el acceso transfemoral. Datos del registro español de TAVI / Early clinical outcomes after transaxillary versus transfemoral TAVI. Data from the Spanish TAVI registry

Introducción y objetivos: El acceso transaxilar (ATx) se ha convertido en el acceso alternativo al transfemoral (ATF), más utilizado en pacientes sometidos a implante percutáneo de válvula aórtica (TAVI). El objetivo principal de este estudio es comparar la mortalidad total hospitalaria y a los 30 días de los pacientes incluidos en el registro español de TAVI a los que se trató por acceso ATx frente a ATF. Métodos: Se analizó a todos los pacientes incluidos en el registro español de TAVI tratados por ATx o ATF. Los eventos hospitalarios y a los 30 días de seguimiento se definieron según las recomendaciones de la Valve Academic Research Consortium. Se evaluó el impacto de la vía de acceso mediante emparejamiento por puntuación de propensión según las características clínicas y ecográficas. Resultados: Se incluyó a 6.603 pacientes, 191 (2,9%) tratados por ATx y 6.412 con ATF. Después del ajuste (grupo de ATx, n=113; grupo de ATF, n=3.035), el éxito del dispositivo fue similar entre ambos grupos (el 94% en el grupo de ATx frente al 95% en el de ATF; p=0,95); sin embargo, se observó un incremento en la tasa de infarto agudo de miocardio (OR=5,3; IC95%, 2,0-13,8; p=0,001), complicaciones renales (OR=2,3; IC95%, 1,3-4,1; p=0,003) e implante de marcapasos (OR=1,6; IC95%, 1,01-2,6; p=0,03) en el grupo de ATx comparado con el de ATF. De mismo modo, la mortalidad hospitalaria y a los 30 días fueron superiores en el grupo de ATx (respectivamente, OR=2,2; IC95%, 1,04-4,6; p=0,039; y OR=2,3; IC95%, 1,2-4,5; p=0,01). Conclusiones: El ATx se asocia con un aumento en la mortalidad total tanto hospitalaria como a los 30 días frente al ATF. Ante estos resultados, el ATx debe considerarse solo en caso de que el ATF no sea posible (AU)

Introduction and objectives: Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access. Methods: We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics. Results: A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n=113 TXA group and n=3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P=.95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P=.001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P=.003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P=.03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P=.039 and OR, 2.3; 95%CI, 1.2-4.5; P=.01, respectively). Conclusions: Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA (AU)

Fasciola hepatica in Brazil: genetic diversity provides insights into its origin and geographic dispersion.

Fasciola hepatica is a trematode parasite that affects mammals, including humans. In Brazil, fascioliasis, a disease caused by the parasite, is of great importance. The disorder affects the welfare of the Brazilian population through impairing the agricultural production of cattle, where the disease causes weight loss as a result of liver damage. This study aimed to evaluate the genetic diversity of F. hepatica throughout Southern Brazil to determine its geographic origin and estimate the colonization route of the parasite. To accomplish these aims, flukes were collected from slaughterhouses in three endemic areas of Rio Grande do Sul and Paraná states. DNA was isolated using the phenol-chloroform protocol from single flukes and two mitochondrial genes, cytochrome oxidase subunit I (COI) and nicotinamide dehydrogenase subunit 1 (Nad1), were amplified and sequenced. Ten haplotypes of COI were found from 75 isolated parasites and the total haplotype and nucleotide diversity observed were 0.475 and 0.002, respectively. Using the Nad1 gene, we found 24 haplotypes from 79 samples, resulting in haplotype and nucleotide diversity values of 0.756 and 0.004, respectively. An analysis of molecular variance showed that 57.4% and 77.5% of variation was within populations (FST), while 9.0 and 36.8% of variation was among groups (FCT) when considering COI and Nad1 genes, respectively. For COI, the fixation index values of 0.425 and 0.368 were obtained for FST and FCT, respectively, while analysis of Nad1 0.225 and 0.089 index values were obtained for FST and FCT, respectively. We have determined that F. hepatica found in the two distinct areas originated from several geographical regions, since we found haplotypes that were shared with at least three different continents. These data are in accordance with the recent colonization of Brazil, and the recent import of cattle from South American, European and, possibly, some African countries. The observed FST and FCT values for COI and Nad1 genes of F. hepatica may be a result of limited movement of animals within states and support the lack of geographical structure of the parasite in Brazil, which are in agreement with the observed cattle production systems in this region.

Rationale and study design of the RESERVOIR trial: a randomized trial comparing reservoir-based polymer-free amphilimus-eluting stents versus everolimus-eluting stents with durable polymer in patients with diabetes mellitus.

BACKGROUND: Patients with diabetes mellitus (DM) remain at high risk for stent restenosis and adverse cardiovascular events in the drug-eluting stent era. The amphilimus-eluting stent (AES) is a third generation reservoir-based polymer-free drug-eluting stent that has shown promising preliminary results in patients with DM. It has been suggested that the formulation of the drug with fatty acids could not only modulate the drug release in a timely manner but also achieve convenient levels of drug concentration in diabetic cardiac cells. The aim of this trial is to assess the efficacy of the AES in patients with DM compared with the cobalt chromium everolimus-eluting stent with non-erodible polymer (EES). STUDY DESIGN: This is an investigator-initiated, multicenter, randomized clinical trial, performed in patients with DM. A total of 112 diabetic patients receiving glucose-lowering agents and requiring percutaneous revascularization of a de novo lesion will be randomized in a 1:1 fashion to receive AES or EES. The primary endpoint is the neointimal volume obstruction at 9 months, evaluated by optical coherence tomography. Secondary endpoints will include strut coverage, angiographic in-stent late loss and clinical endpoints such as target vessel revascularization or probable/definite stent thrombosis. This study completed the inclusion in October 2013. CONCLUSIONS: The RESERVOIR trial is an investigator-initiated trial that will evaluate whether the polymer-free AES is not inferior to the EES inhibiting the neointimal hyperplasia in patients with DM. These results are also expected to improve our knowledge of the neointimal healing process in this population (Clinicaltrials.gov number NCT01710748).

Predictors and impact of myocardial injury after transcatheter aortic valve replacement: a multicenter registry

BACKGROUND:Cardiac biomarker release signifying myocardial injury post-transcatheter aortic valve replacement (TAVR) is common, yet its clinical impact within a large TAVR cohort receiving differing types of valve and procedural approaches is unknown.OBJECTIVES:This study sought to determine the incidence, clinical impact, and factors associated with cardiac biomarker elevation post TAVR.METHODS:This multicenter study included 1,131 consecutive patients undergoing TAVR with balloon-expandable (58%) or self-expandable (42%) valves. Transfemoral and transapical (TA) approaches were selected in 73.1% and 20.3% of patients, respectively. Creatine kinase-myocardial band (CK-MB) measurements were obtained at baseline and at several time points within the initial 72 h post TAVR. Echocardiography was performed at baseline and at 6- to 12-month follow-up.RESULTS:Overall, 66% of the TAVR population demonstrated some degree of myocardial injury as determined by a rise in CK-MB levels (peak value: 1.6-fold [interquartile range (IQR): 0.9 to 2.8-fold]). A TA approach and major procedural complications were independently associated with higher peak of CK-MB levels (p < 0.01 for all), which translated into impaired systolic left ventricular function at 6 to 12 months post TAVR (p < 0.01). A greater rise in CK-MB levels independently associated with an increased 30-day, late (median of 21 [IQR: 8 to 36] months) overall and cardiovascular mortality (p < 0.001 for all)...

Isolation and pathogenicity of Toxoplasma gondii in naturally infected (rustic farm) pigs in southern Brazil.

This study reported a serological test for Toxoplasma gondii infection in 100 pigs from 58 rural farms in the state of Rio Grande do Sul, Brazil. Thirty-six pigs were seropositive (IFAT≥1:64). Bioassays were performed for all 36 seropositive pigs, and 17 isolates were obtained (47.2%). Seven of these isolates (41.2%) were highly pathogenic to mice, as clinical signs of acute infection were observed, and tachyzoites were found in the peritoneal exudates, livers, and lungs. The remaining 10 isolates were able to establish a chronic infection in mice, therefore, they were not highly virulent. The results of this study indicate that pork is a potential source of T. gondii transmission to humans.

Retrospective study assesing the role of MRI in the diagnostic procedures for early breast carcinoma: a correlation of new foci in the MRI with tumor pathological features

BACKGROUND: Use of breast magnetic resonance imaging (MRI) to detect breast cancer has generated significant debate. We analyze the role of breast MRI in the detection of additional disease and the need to perform additional biopsies in early breast carcinoma patients. In addition, we correlate the detection of new foci with tumor pathological features. METHODS: Early breast carcinoma patients that had undergone an MRI as well as a mammography as diagnostic procedures were included in the study. The following pathologic features were studied: carcinoma type, histological grade, estrogen receptors (ER), progesterone receptors (PR), HER2 and Ki67. Univariate analysis was conducted to ascertain significant correlation among detection of new foci and each of the tumor pathological features. RESULTS: Data from 98 patients have been analyzed: median age 49 years (range 35-79); carcinoma type: (a) infiltrative ductal carcinoma (n = 73, 74 %), (b) infiltrative lobular cancer (n = 12, 12 %), (c) ductal carcinoma in situ (n = 6, 6 %); amplified HER2 (n = 18, 18 %); grade III (n = 33, 33 %); Ki67 ≥ 25 % (n = 33, 33.67 %); positive ER and PR (n = 79, 80 %); triple negative tumors (n = 8, 8 %). MRI detected additional disease in 38 cases (39.58 %), and 20 led to an additional biopsy (20.4 %). Thirty-eight patients (39 %) underwent mastectomy. We found a statistically significant correlation between new foci in MRI and high Ki67 ≥ 25 % (p < 0.005). No other statistically significant correlation was established. CONCLUSION: MRI detected additional disease in 39 % cases, requiring an additional biopsy 20 %. Tumors with high proliferative index were significantly correlated with the detection of new foci in MRI (AU)

Retrospective study assessing the role of MRI in the diagnostic procedures for early breast carcinoma: a correlation of new foci in the MRI with tumor pathological features.

BACKGROUND: Use of breast magnetic resonance imaging (MRI) to detect breast cancer has generated significant debate. We analyze the role of breast MRI in the detection of additional disease and the need to perform additional biopsies in early breast carcinoma patients. In addition, we correlate the detection of new foci with tumor pathological features. METHODS: Early breast carcinoma patients that had undergone an MRI as well as a mammography as diagnostic procedures were included in the study. The following pathologic features were studied: carcinoma type, histological grade, estrogen receptors (ER), progesterone receptors (PR), HER2 and Ki67. Univariate analysis was conducted to ascertain significant correlation among detection of new foci and each of the tumor pathological features. RESULTS: Data from 98 patients have been analyzed: median age 49 years (range 35-79); carcinoma type: (a) infiltrative ductal carcinoma (n = 73, 74 %), (b) infiltrative lobular cancer (n = 12, 12 %), (c) ductal carcinoma in situ (n = 6, 6 %); amplified HER2 (n = 18, 18 %); grade III (n = 33, 33 %); Ki67 ≥ 25 % (n = 33, 33.67 %); positive ER and PR (n = 79, 80 %); triple negative tumors (n = 8, 8 %). MRI detected additional disease in 38 cases (39.58 %), and 20 led to an additional biopsy (20.4 %). Thirty-eight patients (39 %) underwent mastectomy. We found a statistically significant correlation between new foci in MRI and high Ki67 ≥ 25 % (p < 0.005). No other statistically significant correlation was established. CONCLUSION: MRI detected additional disease in 39 % cases, requiring an additional biopsy 20 %. Tumors with high proliferative index were significantly correlated with the detection of new foci in MRI.

Comunicación especial: pene enterrado / Special communication: penis buried

En el pene oculto, embutido o enterrado es aquel falo de tamaño normal, oculto en la grasa prepubica debido a la falta de fijación de la piel del pene alcuerpo del mismo; la piel del prepucio es redundante y en muchos casos estrecha; lo que dificulta la exposición del glande.

Manejo de la patología hepatobiliar por radiología intervencional / Hepatobiliary pathology management for interventional radiology

Developing procedures that determine lower associated morbimortality has been medicine tendency of last years. There is possible with coming of better imaging techniques, together with appearance of better materials have permitted developing more complex procedures, which have been gradually replacing the traditional surgical resolution of many pathologies. Being one of the most important hepatobiliary pathology.

Incisión pre-escrotal: una alternativa quirúrgica para la corrección de los trastornos inguino-escrotales / Pre scrotal access: a surgical alternative for inguino-scrotal disorders correction

La incisión inguinal ha sido la vía de acceso para la mayoría de los trastornos inguino-escrotales. Presentamos nuestra experiencia con el uso de la incisión pre-escrotal para el abordaje quirúrgico de los trastornos que atañen el canal inguinal y los testículos. La incisión inguinal para el tratamiento quirúrgico de los trastornos inguino-escrotales ha sido el acceso clásico; los elementos del cordón inguinal pueden ser de fácil identificación y rápida corrección. Con el uso de esta técnica, en la corrección de los TNDPs hay necesidad de una segunda incisión para garantizar que los testículos alcancen el escroto.

Diabetes mellitus and percutaneous coronary revascularization.

Diabetes mellitus is a complex metabolic disorder with aggressive and progressive cardiovascular expression. This article reviews the main percutaneous techniques and their results in the diabetic population, from the early days of balloon angioplasty to the recently advent of drug eluting stents. As the latter devices may eradicate restenosis, plaque progression will remain the cornerstone for interventional cardiologists and the medical community. Attempts to modify life habits, and a more accurate control of the components of the metabolic syndrome should be the main therapeutic objective to slow down the progression and expansion of the disease.

Uretroplastía por la técnica de Snodgrass combinado con colgajo vascularizado de dartos en la reparación de hipospadias / Snodgrass urethroplasty technique with vascularized dartos flaps for Hypospadia´s repair

Objetivo: Mostrar en nuestra comunidad médica la utilidad y las ventajas de la técnica de Snodgrass combinada con colgajo vascularizado de dartos para corregir hipospadias. Material y métodos: De julio de 2001 a julio de 2004 se llevo a cabo en el Servicio de Cirugía Pediátrica del Hospital Universitario Japonés un estudio prospectivo con el uso de la técnica de Snodgrass combinado con colgajo subcutáneo vascularizado de dartos para la corrección de hipospadias proximales y dístales. Se realizó en un total de 11 pacientes (8 hipospadias dístales y 3 proximales) con una media de edad de 2,5 años al momento de la cirugía. Se usó catéter de molde 10 o 12 Fr. en todos los casos durante un espacio de 7 días para las uretroplastías dístales y 10 días para las proximales. Resultados: De los 8 pacientes con hipospadia distal en ninguno se documentó la presencia de fístula uretrocutánea, hubo dos casos de dehicencia parcial de la sutura del glande y en un caso una estenosis de meato uretral. En las hipospadias proximales se documentaron 2 fístulas (de pequeño calibre) en el área de la anastomosis entre el meato uretral primitivo y la neouretra, ambas se corrigieron espontáneamente. Conclusión: Mostramos la experiencia del servicio de Cirugía Pediátrica del H.U.J. con la técnica Snodgrass combinado con colgajo vascularizado de dartos para la corrección hipospadias. Se presentó un bajo porcentaje de complicaciones, las mismas que tuvieron fácil resolución, no hubo repercusión ostensible en la morbidad de nuestros pacientes.

Objective: To show our experience and the utility of the Snodgrass technique with darto´s flap in the correction of Hypospadias. Methods: From July 2001 to July 2004, the paediatric surgical service of the Japanese University Hospital did a prospective study using the Snodgrass technique combined with dartos flap in the correction of distal and proximal hypospadias. We operated 11 patients (8 distal hipospadias and 3 proximal hipospadias); a medium age at the time of surgery was 2,5 years old. The neourethras was stented using catheter 10 or 12 Fr., 7 days for distal hipospadias and 10 days for proximal cases. Results: The patients with distal hipospadias nobody had urethrocutaneous fistula; two cases reported glandar dehiscence and another one meatal stenosis this required meatotomy. In patients with proximal hipospdias we have two cases with minor urethrocutaneous fistula, these resolved with observation and any surgical correction. Conclusion: We report the experience of the J.U.H. Paediatric Surgery Service with the Snodgrass technique and dartos flap for hypospadia´s repair. This technique shows to be a good alternative for hipospadias correction for the low incidence of complications and almost any morbidity of the patients.

Tumores adrenocorticales: a propósito de dos casos / Adrenocortical tumors: Report of two cases

Los tumores adrenocorticales son poco frecuentes en la población infantil. En esta comunicación se describen dos pacientes atendidos en el Servicio de Cirugía Pediátrica del Hospital Universitario Japonés, de la ciudad de Santa Cruz de la Sierra, Bolivia, presentando precozmente vello pubiano. La tomografía abdominal contrastada, reveló en ambos casos, tumor adrenocortical y el tratamiento efectuado fue la extirpación de la masa tumoral. Se confirmó el diagnóstico por Anatomía patológica concluyendo tratarse de un carcinoma adrenocortical y de otro adenoma adrenocortical.

The adrenocortical tumors are not very frequent in the infantile population. We describe two cases attended in the ward of Pediatric Surgery of the Hospital Universitario Japonés, at Santa Cruz de la Sierra, Bolivia. The patients, a three years-old girl and a four years-old boy had a precocious pubic body hair. The CT revealed in both cases adrenocortical tumors, and they were treated with the extirpation of the tumoral mass. Their diagnosis were confirmed by pathological reports: an adrenocortical carcinoma in the girl and an adrenocortical adenoma in the boy.

Stenosis of the inferior vena cava after liver transplantation: treatment with Gianturco expandable metallic stents.

PURPOSE: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). METHODS: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. RESULTS: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. CONCLUSIONS: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.