Trans-arterial chemoembolization with doxorubicin-eluting particles versus conventional trans-arterial chemoembolization in unresectable hepatocellular carcinoma: A study of effectiveness, safety and costs.

OBJECTIVES: To compare the effectiveness, survival and cost in patients with unresectable hepatic cell carcinoma (HCC) treated with trans-arterial chemoembolization using doxorubicin-eluting beads (DEB-TACE) versus conventional TACE (cTACE) in clinical practice. MATERIAL AND METHODS: This single-centered retrospective observational study compared 60 consecutive HCC unresectable patients: 30 were treated with DEB-TACE and 30 used cTACE. Comparisons were with χ(2) test, Student t-test, and Kaplan Meier method. RESULTS: Of the 60 patients with HCC in non-curative stage, baseline characteristics were similar for both groups of treatment, and of these we observed lower survival in male patients and those who had hepatitis C virus (p=0.014 and p=0.003, respectively). No statistically significant differences were observed as a function of treatment employed with respect to overall survival (OS) at 5 years (29.99 months; 95%CI: 21.38-38.60 versus 30.67 months; 95%CI:22.65-38.70; p=0.626) and progression free survival (PFS) median of 11.57 months (95%CI: 0.97-22.18) versus 12.80 months (95%CI:0.00-32.37; p=0.618). The median length of hospital admission were 2.6 and 5.4 days (p<0.001) for DEB(-)TACE and cTACE, respectively. Toxicities grade 2-4 were higher in cTACE group (54 versus 31; p<0.001). The cost of the treatment was 1581 € for DEB(-)TACE and 514.63 € for cTACE. The overall mean cost of intervention was 3134 € and 3694.35 €, respectively (p=0.173). CONCLUSIONS: Chemoembolization in patients with unresectable HCC achieved OS close to 30 months at 5 years, independent of the technique employed. Similar overall costs but better tolerance of the DEB-TACE justified the higher costs of the procedure.

Formación en radiología vascular intervencionista. ¿Una carrera de obstáculos? / No disponible

No disponible

[Professional competencies: from conflict to opportunity]. / Competencias profesionales: del conflicto a la oportunidad.

The tough [correction of turf] battles with other specialties that tend to take control of the radiological practice and some of our areas of interest are one of the most important problems that Radiology must face at the present time. Interventional Radiology is the last one and the more recent example of this phenomenon that spreads world-wide. Far from defeatist attitudes, we must learn from our past mistakes to turn this scenario into an opportunity to evolve towards a more competitive and updated specialty according to our time. The authors review the present situation of the tough [correction of turf] batlles of Radiology with other specialties, pointing to their possible causes and proposing the resolution strategies.

Competencias profesionales: del conflicto a la oportunidad / Professional competencies: from conflict to opportunity

El conflicto con otras especialidades que tienden a apropiarse de la práctica radiológica y de algunas de nuestras áreas de interés es uno de los problemas más importantes con los que la Radiología y los radiólogos debemos enfrentarnos actualmente. La Radiología Vascular Intervencionista es el último y más reciente ejemplo de este fenómeno extendido a nivel mundial. Lejos de actitudes derrotistas, debemos aprender de los errores pasados, transformando este escenario actual en una oportunidad para evolucionar hacia una especialidad más competitiva y acorde con lo que de la imagen médica se debe demandar. Los autores revisan la situación actual de los conflictos de la Radiología con otras especialidades, incidiendo en sus posibles causas y proponiendo estrategias de resolución (AU)

The turf battles with other specialties that tend to take control of the radiological practice and some of our areas of interest are one of the most important problems that Radiology must face at the present time. Interventional Radiology is the last one and the more recent example of this phenomenon that spreads world-wide. Far from defeatist attitudes, we must learn from our past mistakes to turn this scenario into an opportunity to evolve towards a more competitive and updated specialty according to our time. The authors review the present situation of the turf batlles of Radiology with other specialties, pointing to their possible causes and proposing the resolution strategies (AU)

Microfracture and bone morphogenetic protein 7 (BMP-7) synergistically stimulate articular cartilage repair.

OBJECTIVE: Microfracture is used to treat articular cartilage injuries, but leads to the formation of fibrocartilage rather than native hyaline articular cartilage. Since bone morphogenetic protein 7 (BMP-7) induces cartilage differentiation, we hypothesized that the addition of the morphogen would improve the repair tissue generated by microfracture. We determined the effects of these two treatments alone and in combination on the quality and quantity of repair tissue formed in a model of full-thickness articular cartilage injury in adolescent rabbits. DESIGN: Full-thickness defects were made in the articular cartilage of the patellar grooves of forty, 15-week-old rabbits. Eight animals were then assigned to (1) no further treatment (control), (2) microfracture, (3) BMP-7, (4) microfracture with BMP-7 in a collagen sponge (combination treatment), and (5) microfracture with a collagen sponge. Animals were sacrificed after 24 weeks at 39 weeks of age. The extent of healing was quantitated by determining the thickness and the surface area of the repair tissue. The quality of the repair tissue was determined by grading specimens using the International Cartilage Repair Society Visual Histological Assessment Scale. RESULTS: Compared to controls, BMP-7 alone increased the amount of repair tissue without affecting the quality of repair tissue. Microfracture improved both the quantity and surface smoothness of repair tissue. Compared to either single treatment, the combination of microfracture and BMP-7 increased both the quality and quantity of repair tissue. CONCLUSIONS: Microfracture and BMP-7 act synergistically to stimulate cartilage repair, leading to larger amounts of repair tissue that more closely resembles native hyaline articular cartilage.

[The role of video-nystagmography in the diagnosis of acoustic neuroma]. / El papel de la videonistagmografía en el diagnóstico del neurinoma del acústico.

AIM: Schwannoma of the vestibular nerve represents 75% of all expansive processes affecting the pontocerebellosum angle. Hearing loss is the most frequent symptom at diagnosis (86%) with or without tinnitus, in the intracanalicular tumors. Vestibular symptoms are described in 60% of patients. MATERIAL AND METHOD: We study twenty cases of acoustic neuromas diagnosed between years 2000 and 2002 in both Otolaryngology and Neurosurgery Departments in our hospital. Videonystagmography (VNG) was performed in all of them. Videonystagmographic findings were analyzed statistically together with the tumoral size and hypoacusia level. DISCUSSION AND CONCLUSION: According to the medical literature reviewed for this paper, we conclude that caloric tests are the most frequently altered ones (77%), showing vestibular hyporreflexia or arreflexia.

[Stenting without prior dilatation in intracranial stenosis of the internal carotid artery: a case report]. / Colocación de endoprótesis vascular sin dilatacion previa en estenosis intracraneal de la carótida interna. A propósito de un caso.

INTRODUCTION: Recent reports have described the application of coronary stents for the treatment of intracranial stenosis of the internal carotid artery (ICA), above all in patients who do not respond to medical treatment and display advancing neurological symptoms. Stenting in intracranial vascular lesions of the carotid territory has been used almost exclusively in the treatment of the complications due to transluminal angioplasties with balloons. In selected cases and without prior dilatation of the stenosis it would be possible to place a stent. CASE REPORT: We describe a case of intracranial carotid stenting, without previous dilatation, in a 57 year old male patient with multiple arteriosclerotic risk factors. The patient presented neurological symptoms with no response to medical treatment, caused by a stenosis that affected over 70% of the cavernous segment of the right ICA, which was shown up by the arteriographic study. A favourable anatomy and the material used allowed the stent to pass through the stenosis without the need for dilatation. No immediate complications were observed and the carotid artery was seen to be of a normal calibre for stenosis. The brain angiogram also proved to be normal. The patient continues with the medical treatment and has remained neurologically stable throughout the 9 month clinical follow up. CONCLUSION: In certain selected cases, placing an intracranial carotid stent, without previous balloon dilatation, can give good results and prevent the complications that can accompany angioplasty (such as dissection, rupture or embolism)

[Non-benign paroxysmal positional vertigo]. / Vértigo posicional paroxístico no benigno.

Positional vertigo is a frequent clinical manifestation of vertigo of very different etiologies, being the benign paroxystic positional vertigo (BPPV) the most frequent one of them, representing in some series even the most found etiology of peripheral vertigo. Usually of severe entities, positional vertigo may appear in the context of severe entities and of difficult diagnosis. In these cases, the bearing of the symptoms in spite of the repositioning manoeuvers, the association with otological or neurological symptoms, and the atypical nystagmus evoked by Dix-Hallpike manoeuver, must take the otolaryngologist to suspect of a feasible non benign pathology. We report a case of positional paroxysmal vertigo caused by an intracranial tumour and we review the clinical signs that shoved help us to suspect of non benign pathologies that can mimic a positional vertigo.

Total knee replacement with interlocking stems: a preliminary report.

Revision total knee replacements or primary total knee replacements with large amounts of bone loss frequently require long-stemmed prostheses to stabilize the components. The hypothesis of the current study was that long-stemmed prostheses can be fixed with interlocking screws, provide a successful outcome, avoid extensive stress-shielding, and allow easy revision in the future. Ten patients with a minimum 2-year followup were studied. Outcomes were studied preoperatively and postoperatively using the Short Form-12 questionnaires, physical examinations, and radiographs. Complications were recorded. Ability to do activities of daily living, strenuous work, and sedentary work were recorded on a 10-point analog scale. Results indicated that 80% of stems well-fixed as shown on serial radiographs, functional outcome scores postoperatively improved significantly from preoperatively, pain was improved significantly, and positive bone remodeling without stress-shielding was seen in 80% of patients, but 20% had significant stress-shielding in the metaphysis. Complications included two periprosthetic fractures for which the patients did not require revision surgery, and one infection. Long-stemmed total knee components with interlocking fixation seem to be a reasonable alternative when large bone defects exist in the femur or tibia.

Microfracture: surgical technique and rehabilitation to treat chondral defects.

Full-thickness articular cartilage defects rarely heal spontaneously. Some patients may not have clinically significant problems from chondral defects, but most eventually have degenerative changes. Techniques to treat chondral defects include abrasion, drilling, autografts, allografts, and cell transplantation. The senior author (JRS) developed the microfracture technique to enhance chondral resurfacing by providing a suitable environment for new tissue formation and taking advantage of the body's own healing potential. Microfracture has been done in more than 1800 patients. Specially designed awls are used to make multiple perforations, or microfractures, into the subchondral bone plate. Perforations are made as close together as possible, but not so close that one breaks into another. They usually are approximately 3 to 4 mm apart. The integrity of the subchondral bone plate must be maintained. The released marrow elements (including mesenchymal stem cells, growth factors, and other healing proteins) form a surgically induced super clot that provides an enriched environment for new tissue formation. The rehabilitation program is crucial to optimize the results of the surgery. It promotes the ideal physical environment for the marrow mesenchymal stem cells to differentiate into articular cartilagelike cells, ultimately leading to development of a durable repair cartilage that fills the original defect.

A mechanistic model for internal bone remodeling exhibits different dynamic responses in disuse and overload.

Bone is a dynamic tissue which, through the process of bone remodeling in the mature skeleton, renews itself during normal function and adapts to mechanical loads. It is, therefore, important to understand the effect of remodeling on the mechanical function of bone, as well as the effect of the inherent time lag in the remodeling process. In this study, we develop a constitutive model for bone remodeling which includes a number of relevant mechanical and biological processes and use this model to address differences in the remodeling behavior as a volume element of bone is placed in disuse or overload. The remodeling parameters exhibited damped oscillatory behavior as the element was placed in disuse, with the amplitude of the oscillations increasing as the severity of disuse increased. In overload situations, the remodeling parameters exhibited critically sensitive behavior for loads beyond a threshold value. These results bear some correspondence to experimental findings, suggesting that the model may be useful when examining the importance of transient responses for bone in disuse, and for investigating the role fatigue damage removal plays in preventing or causing stress fractures. In addition, the constitutive algorithm is currently being employed in finite element simulations of bone adaptation to predict important features of the internal structure of the normal femur, as well as to study bone diseases and their treatment.

[Cordectomy in the surgical treatment of tumors T1 of the vocal cords. Review of our cases (1974-1990)]. / La cordectomía en el tratamiento quirúrgico de los tumores T1 de cuerda vocal. Revisión de nuestra casuística (1974-1990).

We decided to review the results of cordectomy in our surroundings over the 22 years of existence of our Service. 631 clinic histories of patients undergoing surgery for laryngeal cancer in our Department, between 1974 and 1990, were reexamined, and from those selected 56 pertaining to T1 tumors treated with cordectomy. In this reduced group were studied epidemiology, clinical and pathologic data, complications, survival and death causes as well. The 58 considered were of male sex, middle aged (58-86) excepting 9 patients under 50. Their relation with tobacco eas clear, although less than in our general series (87.93% smokers). Of the 58 patients group 4 of then disappear during the 5 years follow-up term (8.62%). Three died: one from ganglion disease, other from local recurrence and the last one from other condition. In brief, global survival are accounted for 94.34% and the adjusted survival was 96.1%.

[Surgery of cancer of the larynx. Analysis of the results of our cases]. / Cirugía del cáncer de laringe. Análisis de resultados de nuestra casuística.

After 20 years of existence of this Department we decided to carry out a review of the characteristics of our series and also of the results of treatment, according to the protocol elaborated and followed in agreement with the Tumour Committee if the Hospital. 631 medical histories of patients diagnosed and operated for cancer of larynx between 1974 and 1990 were reviewed. 83 of which (13.154%) disappeared during the 5 year follow-up period. Epidemiological, clinical, location, extension and treatment fdata were considered as well as the survival results and a single descriptive statistical analysis performed. The mean age of our study was 59.02 years, showing a clear relation to exposure to tobacco (91.44% were smokers and 63.39% of more than 20 cigarettes per day). The predominant location of the growth was supraglottic (64.05% of cases) followed by glottic in 33.76%. The most frequently used surgical technique was the total laryngectomy and total and extended to either the pharynx or tongue basis in 76.28%, followed by supraglottic laryngectomy in 13m5%. The stages were rather advanced with predominance of stage III /40.60%) and stage IV (21.17%). Global survive rate of our series accounted for 68.61% while the adjusted survival rate was 71.4%.

[Benign positional paroxysmal vertigo in the general ear, nose, and throat clinic]. / El vértigo posicional paroxístico benigno en la consulta de ORL general.

Benign positional paroxysmal vertigo is a common disease which may be caused by abnormal movement of utricular debris in the posterior semicircular canal. It is diagnosed by the Dix-Hallpike positional maneuver eliciting vertigo and nystagmus. Treatment generally consists of physical exercises with the Epley or Semont maneuvers. We review 43 consecutive patients diagnosed as BPPV in the last year and treated with physical therapy (Epley maneuvers). Results were very good, with a cure rate of 88.37% (53.5% after a single maneuver). Physical therapy is an effective treatment for BPPV.

[The microfracture technic in the management of complete cartilage defects in the knee joint]. / Die Technik der Mikrofrakturierung zur Behandlung von kompletten Knorpeldefekten im Kniegelenk.

Full thickness defects of the articular cartilage rarely heal spontaneously. While some patients do not develop clinically significant problems from chondral defects, most eventually develop degenerative changes associated with the cartilage damage over time. Techniques to treat chondral defects include abrasion, drilling, tissue autografts, allografts, and cell transplantation. The senior author has developed a procedure referred to as the "microfracture." This technique enhances chondral resurfacing by providing a suitable environment for tissue regeneration and by taking advantage of the body's own healing potential. This technique has now been used in more than 1400 patients. Specially designed awls are used to make multiple perforations, or "microfractures", into the subchondral bone plate. The perforations are made as close together as necessary, but not so close that one breaks into another. Consequently, the microfracture holes are approximately three to four millimeters apart (or 3 to 4 holes per square centimeter). Importantly, the integrity of the subchondral bone plate is maintained. The released marrow elements form a "super clot" which provides an enriched environment for tissue regeneration. Follow up with long term results of more than 8 years have been positive and very encouraging.

Treatment of articular cartilage defects in athletes: an analysis of functional outcome and lesion appearance.

This article characterizes chondral injuries and reviews the results of microfracture treatment in high-level competitive and recreational athletes. Thirty-eight high-level and 140 recreational athletes completed functional questionnaires preoperatively and yearly postoperatively, recording symptoms, function, and activity level. Second-look arthroscopy tapes were available in 26 high-level and 54 recreational athletes. The mean follow-up for the high-level athletes was 3.7 +/- 1.4 years. Chondral defects averaged 223 +/- 180 mm2. Lesion size and follow-up were not significantly different in the recreational group. Functional questionnaire responses demonstrated significant improvements from the time of microfracture to final follow-up. Improvement in function and symptoms was similar for the competitive and recreational athletes.

Adenosine 5'-triphosphate, uridine 5'-triphosphate, bradykinin, and lysophosphatidic acid induce different patterns of calcium responses by human articular chondrocytes.

Small calcium-mobilizing inflammatory mediators have been implicated in joint pathology. Here we demonstrate that bradykinin, adenosine 5'-triphosphate, uridine 5'-triphosphate, and lysophosphatidic acid raise the intracellular calcium concentration ([Ca2+]i) in human articular chondrocytes. Heterologous cross-desensitization experiments showed that the uridine 5'-triphosphate response was abolished by prior treatment with adenosine 5'-triphosphate and, conversely, that the adenosine 5'-triphosphate response was abolished by prior treatment with uridine 5'-triphosphate; this indicated competition for the same receptor site, whereas bradykinin and lysophosphatidic acid did not compete with other ligands. Pretreatment with thapsigargin abolished ligand-mediated Ca2+ responses but not vice versa; this confirmed that Ca2+ release occurred from intracellular stores. Single-cell analysis of Fura-2 acetoxymethyl ester loaded chondrocytes showed mediator-dependent patterns of oscillatory Ca2+ changes in a subset of cells when challenged with submaximal concentrations of bradykinin, adenosine 5'-triphosphate, or uridine 5'-triphosphate in the presence of extracellular Ca2+. However, no oscillatory responses were seen after a challenge with lysophosphatidic acid. Therefore, although a number of different Ca2+-mobilizing ligands activate chondrocytes, the differences that occur in the temporal patterning of Ca2+ responses may result in unique mediator-dependent changes in cellular activity.

[Mortality in laryngeal cancer surgery]. / Mortalidad en la cirugía del cáncer de laringe.

UNLABELLED: The causes of death were studied in a series of 171 patients who died in a 5-year follow-up period, out of a total of 631 patients who underwent different surgical techniques for cancer of the larynx. MATERIAL AND METHODS: The case histories of 631 patients who had undergone surgery between 1974 and 1990 were reviewed; 83 did not have a 5-year follow-up and were excluded from the study. A descriptive and inferential statistical study was made of the remaining cases to determine the relation between cause of death and tumoral extension, primary location, degree of tumoral differentiation, surgical technique and other data. RESULTS: Ninety-one patients died from local or regional recurrence, 50 from distant metastases, 20 from diseases other than the tumor, and 10 from postoperative complications. These findings were studied with regard to factors such as tumor extension, location, surgical technique, etc. CONCLUSIONS: The main cause of death in surgery for cancer of the larynx was recurrence, either local, on the tumor bed (62 patients) or regional (29 patients). The mortality rate was higher in older patients, patients with lymph-node involvement in the postoperative histological study, and patients with less differentiated histological forms.

Immune response to synthetic materials. Sensitization of patients receiving orthopaedic implants.

Metallic orthopaedic devices are composed of elements that are known to be skin sensitizers in the general population. There is concern about the possibility of sensitivity reactions in patients bearing these implants. Blood samples were drawn from 22 patients having primary total joint replacement and who had no known prior metal allergies or exposure. Repeat blood samples were drawn 3 months to 1 year later. All preoperative blood samples showed no immune reactions against titanium, cobalt, chromium, or nickel ion solutions in a leukocyte migration inhibition test. Thirty two percent (7 of 22) of the patients developed sensitivity to at least 1 of the antigens, but only 5 percent (1 of 22) developed a severe reaction. Review of the literature and these studies has indicated that such reactions can occur. However, the incidence seems to be very low.