A new technique in the treatment of intestinal malrotation. / Una nueva técnica en el tratamiento de la malrotación intestinal.

INTRODUCTION: Intestinal malrotation is a congenital pathology with potentially catastrophic complications, such as volvulus, whose treatment has barely not changed in nearly 100 years (Ladd's procedure). Dr. Abu-Elmagd recently described a new technique that was applied in one of our patients. CLINICAL CASE: 12-year-old boy who had undergone Ladd's procedure as a result of intestinal volvulus secondary to malrotation when he was 2 days old. He had subocclusion and eventually obstruction, with intestinal volvulus compatible imaging. Intraoperative findings: duodenal subocclusion, volvulus and lymphangiectasias. Kareem's procedure: bowel positioning in normal rotation, duodenopexy (duodenal C posterior to the mesenteric vessels), formation of neo-Treitz, and fixation of the cecum, the ascending colon, and the mesenteric root. The patient was discharged on postoperative day 6 and remains asymptomatic after 1 year of follow-up. DISCUSSION: Kareem's procedure is a safe and effective malrotation repair technique. It can replace Ladd's procedure as it reduces the risk of re-volvulation and improves digestive symptoms.

INTRODUCCION: La malrotación intestinal es una patología congénita con complicaciones potencialmente catastróficas, destacando el vólvulo, cuyo tratamiento no ha variado significativamente en casi 100 años (procedimiento de Ladd). Recientemente el Dr. Abu-Elmagd describió una técnica que hemos aplicado en un paciente. CASO CLINICO: Varón de 12 años, intervenido con 2 días de vida por vólvulo intestinal secundario a malrotación realizándose procedimiento de Ladd. Presenta cuadros suboclusivos y finalmente obstructivo con imágenes compatibles con vólvulo intestinal. Hallazgos intraoperatorios: suboclusión duodenal, vólvulo y linfangiectasias. Procedimiento de Kareem: posicionando intestino en normorotación, duodenopexia (C duodenal posterior a vasos mesentéricos), formación de neoTreitz, fijación de ciego, colon ascendente y raíz mesentérica. Alta hospitalaria al 6º día postoperatorio, asintomático en 1 año de seguimiento. COMENTARIOS: El procedimiento de Kareem es una técnica segura y efectiva que corrige la malrotación, pudiendo reemplazar al procedimiento de Ladd al disminuir el riesgo de revolvulación y mejorar síntomas digestivos.

Una nueva técnica en el tratamiento de la malrotación intestinal / A new technique in the treatment of intestinal malrotation

Introducción: La malrotación intestinal es una patología congénitacon complicaciones potencialmente catastróficas, destacando el vólvulo,cuyo tratamiento no ha variado significativamente en casi 100 años(procedimiento de Ladd). Recientemente el Dr Abu-Elmagd describióuna técnica que hemos aplicado en un paciente.Caso clínico: Varón de 12 años, intervenido con 2 días de vidapor vólvulo intestinal secundario a malrotación realizándose procedimiento de Ladd. Presenta cuadros suboclusivos y finalmente obstructivo con imágenes compatibles con vólvulo intestinal. Hallazgosintraoperatorios: suboclusión duodenal, vólvulo y linfangiectasias.Procedimiento de Kareem: posicionando intestino en normorotación,duodenopexia (C duodenal posterior a vasos mesentéricos), formaciónde neoTreitz, fijación de ciego, colon ascendente y raíz mesentérica.Alta hospitalaria al 6º día postoperatorio, asintomático en 1 año deseguimiento. Comentarios: El procedimiento de Kareem es una técnica seguray efectiva que corrige la malrotación, pudiendo reemplazar al procedimiento de Ladd al disminuir el riesgo de revolvulación y mejorarsíntomas digestivos.(AU)

Introduction: Intestinal malrotation is a congenital pathology withpotentially catastrophic complications, such as volvulus, whose treatment has barely not changed in nearly 100 years (Ladd’s procedure). Dr. Abu-Elmagd recently described a new technique that was appliedin one of our patients. Clinical case. 12-year-old boy who had undergone Ladd’s procedure as a result of intestinal volvulus secondary to malrotation when hewas 2 days old. He had subocclusion and eventually obstruction, withintestinal volvulus compatible imaging. Intraoperative findings: duodenalsubocclusion, volvulus and lymphangiectasias. Kareem’s procedure:bowel positioning in normal rotation, duodenopexy (duodenal C posterior to the mesenteric vessels), formation of neo-Treitz, and fixationof the cecum, the ascending colon, and the mesenteric root. The patientwas discharged on postoperative day 6 and remains asymptomatic after1 year of follow-up. Discussion: Kareem’s procedure is a safe and effective malrotationrepair technique. It can replace Ladd’s procedure as it reduces the riskof re-volvulation and improves digestive symptoms.(AU)

Factors affecting the incidence of contrast-induced nephropathy in patients undergoing computed tomography. / Incidencia de nefropatía por contraste en pacientes sometidos a tomografía computarizada: ¿qué factores la condicionan?

OBJECTIVE: To analyze the incidence of contrast-induced nephropathy in a cohort of patients undergoing computed tomography (CT) with intravenous iodinated contrast material. To evaluate the efficacy of N-acetylcysteine in preventing contrast-induced nephropathy. PATIENTS AND METHODS: This prospective observational study was carried out in the months comprising March 2016 through July 2016. We selected the first five patients scheduled to undergo CT examination each day who agreed to participate and signed the informed consent form. We recorded patients' cardiovascular histories, chronic treatments, and indications for the CT examination. We measured blood levels of creatinine and urea before and after the CT examination. We used the Modification of Diet in Renal Disease (MDRD-4) equation to estimate the glomerular filtration rate. We analyzed the type and dose of contrast material. We recorded whether N-acetylcysteine was administered before the CT examination. We used SPSS 15.0® to compare means and proportions. Statistical significance was set at p < 0.05. RESULTS: No incidents of contrast-induced nephropathy were detected in any of the 202 patients included [mean age, 63.92 ± 12 years (range 22-87); 57.4% male; 21.8% diabetic; 39.6% hypertensive; 87.1% had MDRD4 ≥ 60 ml/min/1.73 m2 (89.45 ± 14, range 62.36-134.14) and 12.9% had MDRD4 < 60 ml/min/1.73 m2 (45.38 ± 11, range 9.16-58.90)]. The most common indication for CT examinations was oncologic (81.2%). The only contrast agent administered was iopamidol; the mean dose was 107.83 ± 11 ml (range 70-140). The mean interval between pre-CT and post-CT laboratory tests was 4.06 ± 1 days. Only 13 patients received N-acetylcysteine; 9 of these had MDRD < 60 ml/min/1.73 m2 and 4 had MDRD4 ≥ 60 ml/min/1.73 m2 (p = 0.000). CONCLUSIONS: The incidence of contrast-induced nephropathy was not significant in patients with glomerular filtration rates greater than 30 ml/min/1.73 m2: these favorable results might be due to analyzing only scheduled examinations and to using relatively low doses of a "nonionic" iodinated contrast agent.

El radiólogo invisible. Respuesta de los autores / The invisible radiologist. Response of the authors

No disponible

Detectores radiográficos digitales inalámbricos en una sala de radiología de urgencias. Una solución eficaz / Wireless digital radiography detectors in the emergency area: an efficacious solution

Objetivos. Evaluar la implantación de un sistema digital de pantalla plana (flat panel digital radiography [DR]) con tecnología WiFi, en una sala de radiología de urgencias que previamente estaba trabajado con un sistema de radiología computarizada (computed radiography [CR]). Se analizaron aspectos de calidad de imagen, reducción de dosis, flujo de trabajo y ergonomía. Material y métodos. Se estudiaron los resultados obtenidos con sistemas CR y DR-WiFi, relacionados con la calidad de imagen analizada en imágenes obtenidas en maniquí y tras la valoración de imágenes radiológicas por radiólogos, también se analizaron tiempos y flujo de trabajo en la realización de los estudios con ambos métodos y especialmente se estudiaron datos de reducción de dosis en grupos de pacientes antes y después de la instalación del nuevo equipamiento. Resultados. La calidad de imagen mejoró tanto en las pruebas realizadas sobre maniquí como en la evaluación por radiólogos, que aumentó de 3 a 4,5 en una escala máxima de 5; los tiempos de estudio disminuyeron un promedio de 25 segundos por cada imagen; se comprobó que se requiere utilizar menos radiación con el panel plano en prácticamente todas las técnicas llevadas a cabo con exposimetría automática, aunque el estudio solo ha mostrado diferencias estadísticamente significativas en algunas de las técnicas (tórax, columna dorsal y lumbar). Conclusiones. La instalación del sistema DR-WiFi ha sido beneficiosa. Se ha producido un incremento en la calidad de imagen con una reducción de la dosis en los pacientes, junto a ventajas en términos de funcionalidad, ergonomía y rendimiento (AU)

Objectives. To evaluate the implementation of a flat panel digital radiolography (DR) system with WiFi technology in an emergency radiology area in which a computed radiography (CR) system was previously used. We analyzed aspects related to image quality, radiation dose, workflow, and ergonomics. Material and methods. We analyzed the results obtained with the CR and WiFi DR systems related with the quality of images analyzed in images obtained using a phantom and after radiologists’ evaluation of radiological images obtained in real patients. We also analyzed the time required for image acquisition and the workflow with the two technological systems. Finally, we analyzed the data related to the dose of radiation in patients before and after the implementation of the new equipment. Results. Image quality improved in both the tests carried out with a phantom and in radiological images obtained in patients, which increased from 3 to 4.5 on a 5-point scale. The average time required for image acquisition decreased by 25seconds per image. The flat panel required less radiation to be delivered in practically all the techniques carried out using automatic dosimetry, although statistically significant differences were found in only some of the techniques (chest, thoracic spine, and lumbar spine). Conclusions. Implementing the WiFi DR system has brought benefits. Image quality has improved and the dose of radiation to patients has decreased. The new system also has advantages in terms of functionality, ergonomics, and performance (AU)

[Wireless digital radiography detectors in the emergency area: an efficacious solution]. / Detectores radiográficos digitales inalámbricos en una sala de radiología de urgencias. Una solución eficaz.

OBJECTIVES: To evaluate the implementation of a flat panel digital radiolography (DR) system with WiFi technology in an emergency radiology area in which a computed radiography (CR) system was previously used. We analyzed aspects related to image quality, radiation dose, workflow, and ergonomics. MATERIAL AND METHODS: We analyzed the results obtained with the CR and WiFi DR systems related with the quality of images analyzed in images obtained using a phantom and after radiologists' evaluation of radiological images obtained in real patients. We also analyzed the time required for image acquisition and the workflow with the two technological systems. Finally, we analyzed the data related to the dose of radiation in patients before and after the implementation of the new equipment. RESULTS: Image quality improved in both the tests carried out with a phantom and in radiological images obtained in patients, which increased from 3 to 4.5 on a 5-point scale. The average time required for image acquisition decreased by 25 seconds per image. The flat panel required less radiation to be delivered in practically all the techniques carried out using automatic dosimetry, although statistically significant differences were found in only some of the techniques (chest, thoracic spine, and lumbar spine). CONCLUSIONS: Implementing the WiFi DR system has brought benefits. Image quality has improved and the dose of radiation to patients has decreased. The new system also has advantages in terms of functionality, ergonomics, and performance.

Osteopatía estriada con esclerosis craneal / Osteopathia striata with cranial sclerosis

La osteopatía estriada con esclerosis craneal es una rara enfermedad con menos de 100 casos descritos en la literatura médica. Presenta unos hallazgos radiológicos característicos que una vez identificados llevan al diagnóstico. Las estriaciones escleróticas longitudinales en huesos largos y la osteoesclerosis de los huesos faciales y del cráneo deben hacer pensar en esta entidad. No se trata de una enfermedad grave, aunque frecuentemente se asocia a otro tipo de trastornos y malformaciones extraesqueléticas que con frecuencia condicionan el pronóstico. La afectación de los huesos craneales y faciales puede producir deformación facial y discapacidad funcional marcada al afectar a los nervios craneales. Se presenta un caso de esta enfermedad descubierto de forma casual en una paciente joven estudiada en una consulta de medicina por manifestaciones clínicas en principio ajenas a esta dolencia (AU)

Osteopathia striata with cranial sclerosis is a rare disease: fewer than 100 cases have been reported. The radiologic findings of osteopathia striata are characteristic, and once they are identified, they lead to the correct diagnosis. Longitudinal sclerotic striation in long bones and osteosclerosis in facial bones should raise suspicion of osteopathia striata with cranial sclerosis. This is not a serious disease, although it is often associated with other kinds of disorders and extraskeletal malformations that can affect the prognosis. Involvement of cranial and facial bones can lead to facial deformity and marked functional incapacity when the cranial nerves are affected. We present a case of osteopathia striata with cranial sclerosis discovered incidentally in a young woman studied for clinical manifestations unrelated to this disease (AU)

[Teleradiology in the emergency department: opportunity and danger]. / Telerradiología en la urgencia, oportunidad y amenaza.

Teleradiology is an established fact in developed countries. It has been the subject of intense professional and even legal debate in recent years because the quality of care and the role of the radiologist as a medical specialist are at stake. The opportunities and the dangers involved in teleradiology are discussed in this article. The use of teleradiology in certain circumstances in the emergency department can result in significant benefits when done right; however, it is evident that poorly implemented teleradiology services can lead to significant decreases in the quality of care (for example when the aim is to provide a low cost reporting service through outsourcing). Radiologists must use their knowledge and collaboration to ensure that they have the main role in the design, management, and performance of teleradiology services. The stance of our scientific societies together with the legal and regulatory frameworks must be the pillars that support teleradiology as a medical act.

Telerradiología en la urgencia, oportunidad y amenaza / Teleradiology in the emergency department: opportunity and danger

La telerradiología es una realidad implantada en los países desarrollados, y ha suscitado un debate profesional e incluso legal intenso en los últimos años, ya que están en juego la calidad asistencial y el papel del radiólogo como especialista médico. La oportunidad y la amenaza que suponen la telerradiología son los aspectos que desarrollamos en este artículo: su utilización en determinadas circunstancias en las urgencias puede aportar importantes beneficios cuando se realiza adecuadamente; pero es evidente que mal implantada puede suponer una importante merma de la calidad asistencial, por ejemplo cuando su objetivo es dar un servicio de informes a bajo precio recurriendo a la externalización. El radiólogo, desde el conocimiento y la colaboración, debe mantener un papel protagonista en su diseño, dirección y realización. El posicionamiento de nuestras sociedades científicas, el marco normativo y legal deben ser los pilares para la realización de la telerradiología como un acto médico (AU)

Teleradiology is an established fact in developed countries. It has been the subject of intense professional and even legal debate in recent years because the quality of care and the role of the radiologist as a medical specialist are at stake. The opportunities and the dangers involved in teleradiology are discussed in this article. The use of teleradiology in certain circumstances in the emergency department can result in significant benefits when done right; however, it is evident that poorly implemented teleradiology services can lead to significant decreases in the quality of care (for example when the aim is to provide a low cost reporting service through outsourcing). Radiologists must use their knowledge and collaboration to ensure that they have the main role in the design, management, and performance of teleradiology services. The stance of our scientific societies together with the legal and regulatory frameworks must be the pillars that support teleradiology as a medical act (AU)

[Osteopathia striata with cranial sclerosis]. / Osteopatía estriada con esclerosis craneal.

Osteopathia striata with cranial sclerosis is a rare disease: fewer than 100 cases have been reported. The radiologic findings of osteopathia striata are characteristic, and once they are identified, they lead to the correct diagnosis. Longitudinal sclerotic striation in long bones and osteosclerosis in facial bones should raise suspicion of osteopathia striata with cranial sclerosis. This is not a serious disease, although it is often associated with other kinds of disorders and extraskeletal malformations that can affect the prognosis. Involvement of cranial and facial bones can lead to facial deformity and marked functional incapacity when the cranial nerves are affected. We present a case of osteopathia striata with cranial sclerosis discovered incidentally in a young woman studied for clinical manifestations unrelated to this disease.

[Utility of Tc-99m labeled heat-denatured red blood cell scintigraphy in a case of hepatic splenosis]. / Utilidad de la gammagrafía selectiva con hematíes desnaturalizados Tc-99m en un caso de esplenosis hepática.

The term splenosis, first used in the medical literature in 1939, refers to the autotransplantation of splenic tissue in a heterotopic location. We report the case of a known hepatitis C carrier in whom computed tomography scanning revealed a hepatic lesion suggestive of hepatocarcinoma. Magnetic Resonance imaging was performed for suspected hepatic splenosis, which was confirmed by Tc-99m labeled heat-denatured red blood cell scintigraphy. In addition to confirming the suspected diagnosis, this technique showed several pathological foci in distinct abdominal locations compatible with splenosis that had not previously been identified.

[Intracranial haemorrhage secondary to a lightning strike: a case report]. / Hemorragia intracraneal secundaria a fulguración por rayo: presentación de un caso.

INTRODUCTION: The damage caused to the central nervous system by lightning can be immediate or delayed. Cerebrovascular accidents are usually an infrequent complication of lightning strikes. CASE REPORT: We report the case of a patient who was hit by lightning and then developed an acute bilateral intraparenchymatous haemorrhage in the basal ganglia and the left internal capsule. DISCUSSION: Few cases of intracranial haemorrhages secondary to lightning strikes have been reported. We carry out a review and analysis of the literature currently available on the subject. A number of theories have been put forward that attempt to explain the mechanism behind these haemorrhages in patients who have been hit by lightning. The reason why there is a predilection for the basal ganglia is unknown, although it could be linked to the particular features of the vascularisation of the area.

Comparison of the Etest and microdilution method for antifungal susceptibility testing of Cryptococcus neoformans to four antifungal agents.

We performed a prospective study to compare the Etest and the microdilution method (NCCLS guidelines) for determining the MICs of fluconazole, itraconazole, flucytosine and amphotericin B for 35 strains of Cryptococcus neoformans. For the microdilution method (MDM) RPMI 1640 medium with 2% glucose was used for fluconazole, itraconazole and flucytosine, and Antibiotic Medium 3 for amphotericin B. For the Etest, RPMI 1640 medium with 2% glucose and solidified with 1.5% agar was used for the four antifungal agents. Amphotericin B was also tested on Antibiotic Medium 3 solidified with 1.5% agar. Fluconazole and flucytosine MICs by the Etest showed good correlation with the broth MDM (81.1 and 89.2% agreement within two dilutions, respectively). With the tested population of itraconazole- and amphotericin B-susceptible isolates, the MIC agreement for itraconazole was 54%; amphotericin B showed the lowest agreement (8.1% on Antibiotic Medium 3 and 13.5% on RPMI).

[Incidence and natural history of hepatocellular carcinoma in patients with chronic hepatitis C virus infection]. / Incidencia e historia natural del carcinoma hepatocelular en los pacientes con infección crónica por el virus de la hepatitis C.

OBJECTIVE: To report the natural history of patients with hepatitis C virus (HCV) infection and hepatocarcinoma (HCC) and to define clinico-biological variables with prognostic and predictive value of this complication. MATERIALS AND METHODS: A total of 543 patients consecutively diagnosed of chronic infection with HCV were included and followed prospectively and observationally regarding the development of HCC by means of semestral abdominal ultrasonography and measurement of serum alpha-fetoprotein (AFP). To determine variables with predictive value of HCC, the parameters determined at the start were compared, and all subjects diagnosed of hepatoma during the first twelve months after admission were excluded from the analysis. The Kaplan-Meier method was used to evaluate both survival and accumulated probability of HCC. RESULTS: During a mean follow-up period of 28.9 months, an incidence density of HCC of 2.6 per 100 inhabitants-year was obtained (n = 35). 52.6% of those with HCC in the first year were asymptomatic. The only initial variables associated with further development of HCC were age (64.6 vs 58.4 years; p = 0.0039) and alkaline phosphatase (373.5 vs 259 U/l; p = 0.001). Patients with cirrhosis at the start of the study had a higher risk of developing hepatoma than non-cirrhotic patients (RR: 11.5; 95% CI: 4.25-29.9; p < 0.0001). The presence of HCC decreased the survival of patients with cirrhosis (median 20 vs 75 months; log rank < 0.0001), with the exception of patients in stage C of the Child-Pugh classification. CONCLUSIONS: a) In the chronic infection with HCV, HCC showed to be an oligosymptomatic complication affecting almost exclusively patients with long-lasting cirrhosis. b) Survival in patients in the stage C of the Child-Pugh classification is independently associated with the coexistence of hepatoma; therefore, the early diagnosis of this complication should be restricted to those with a better liver functional reserve.

Incidencia e historia natural del carcinoma hepatocelular en los pacientes con infección crónica por el virus de la hepatitis C / Incidence and natural history of hepatocellular carcinoma among patients with chronic infection with hepatitis C virus

Objetivo. Describir la historia natural de los pacientes infectados por el virus de la hepatitis C (VHC) que presentan hepatocarcinoma (HCC) y definir variables clínico-biológicas con valor pronóstico de esta complicación. Material y método. Se incluyeron 543 pacientes diagnosticados de forma consecutiva de infección crónica por VHC y se siguieron de forma prospectiva y observacional respecto al desarrollo de HCC mediante la realización semestral de ecografía abdominal y alfafetoproteína sérica (AFP). Para determinar variables con valor predictivo de HCC se compararon los parámetros determinados al inicio, eliminándose del análisis todos aquellos sujetos que fueron diagnosticados de hepatoma dentro de los doce meses posteriores al ingreso. Se utilizó el método de KaplanMeier tanto para evaluar la supervivencia como la probabilidad acumulada de HCC. Resultados. Durante un período medio de seguimiento de 28,9 meses obtuvimos una densidad de incidencia de HCC de 2,6 por 100 habitantes-año (n = 35). El 52,6 por ciento de los que presentaron HCC durante el primer año estaban asintomáticos. Las únicas variables iniciales que se asociaron al ulterior desarrollo de HCC fueron la edad (64,6 frente a 58,4 años; p = 0,0039) y la fosfatasa alcalina (373,5 frente a 259 U/l; p = 0,001).Los pacientes con cirrosis al inicio del estudio tenían mayor riesgo de desarrollar hepatoma que los no cirróticos (RR: 11,5; IC 95 por ciento: 4,5-29,9; p < 0,0001). La presencia de HCC disminuyó la supervivencia de los enfermos con cirrosis (mediana de 20 frente a 75 meses; log rank < 0,0001), salvo que se encontraran en el estadio C de Child-Pugh. Conclusiones. a) En la infección crónica por VHC el HCC se muestra como una complicación oligosintomática que afecta de forma casi exclusiva a los enfermos con cirrosis de larga duración. b) La supervivencia mostrada por los pacientes con cirrosis en estadio C de Child-Pugh es independiente de la coexistencia de hepatoma, por lo que el diagnóstico precoz de esta complicación debería restringirse a los que presenten mejor reserva funcional hepática (AU)

Correlation of fluconazole MICs with clinical outcome in cryptococcal infection.

We have correlated the in vitro results of testing the susceptibility of Cryptococcus neoformans to fluconazole with the clinical outcome after fluconazole maintenance therapy in patients with AIDS-associated cryptococcal disease. A total of 28 isolates of C. neoformans from 25 patients (24 AIDS patients) were tested. The MICs were determined by the broth microdilution technique by following the modified guidelines described in National Committee for Clinical Standards (NCCLS) document M27-A, e.g., use of yeast nitrogen base medium and a final inoculum of 10(4) CFU/ml. The fluconazole MIC at which 50% of isolates are inhibited (MIC(50)) and MIC(90), obtained spectrophotometrically after 48 h of incubation, were 4 and 16 microg/ml, respectively. Of the 25 patients studied, 4 died of active cryptococcal disease and 2 died of other causes. Therapeutic failure was observed in five patients who were infected with isolates for which fluconazole MICs were > or =16 microg/ml. Four of these patients had previously had oropharyngeal candidiasis (OPC); three had previously had episodes of cryptococcal infection, and all five treatment failure patients had high cryptococcal antigen titers in either serum or cerebrospinal fluid (titers, >1:4,000). Although 14 of the 18 patients who responded to fluconazole therapy had previously had OPC infections, they each had only a single episode of cryptococcal infection. It appears that the clinical outcome after fluconazole maintenance therapy may be better when the infecting C. neoformans strain is inhibited by lower concentrations of fluconazole for eradication (MICs, <16 microg/ml) than when the patients are infected with strains that require higher fluconazole concentrations (MICs, > or =16 microg/ml). These findings also suggest that the MICs determined by the modified NCCLS microdilution method can be potential predictors of the clinical response to fluconazole therapy and may aid in the identification of patients who will not respond to fluconazole therapy.