Protocol for assessing mortality reduction with the early use of noninvasive ventilation in prehospital emergency services: A multicentre, observational cohort study in Madrid, Spain.

BACKGROUND: Acute respiratory failure (ARF) has become one of the most prevalent serious pathologies encountered in the emergency medical service (EMS). In hospital settings, noninvasive ventilation (NIV) therapy prevents complications from more aggressive treatments for that condition. However, the scarce evidence on the benefits of NIV in prehospital EMS (i.e., during transport to the hospital) is inconclusive. OBJECTIVES: To determine whether the administration of NIV during prehospital EMS in cases of ARF reduces in-hospital mortality compared with starting NIV on arrival to in-patient EMS. METHODS: This is a multicentre, observational, prospective cohort study. We recruited a total of 317 patients from the Madrid region (Spain) who were prescribed NIV for their ARF using a nonprobabilistic consecutive sampling method. Analyses of the main outcome (in-hospital mortality) and secondary outcomes (length of hospital stay, readmissions, percentage of intensive care unit admissions, and cost-effectiveness) will include descriptive analyses of patients' characteristics, as well as bivariate and multivariate analyses and cost-effectiveness analysis. DISCUSSION: This study will provide data on NIV management in prehospital and in-patient EMS in patients with ARF. Results will contribute to the existing evidence on the benefits of NIV in the context of prehospital EMS while underlining the importance of a standardized formal training for physicians and nurses working in prehospital and in-patient EMSs. CONCLUSION: The VentilaMadrid study will provide valuable data on the clinical factors of patients receiving NIV in prehospital EMS. Further, were our hypothesis to be confirmed, our results would strongly suggest that the administration of NIV in prehospital EMS by medical and nursing profesionals formally trained in the technique reduces mortality and improves prognoses.

A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the upper extremity.

BACKGROUND: No studies have identified which patients with upper-extremity deep vein thrombosis (DVT) are at low risk for adverse events within the first week of therapy. METHODS: We used data from Registro Informatizado de la Enfermedad TromboEmbólica to explore in patients with upper-extremity DVT a prognostic score that correctly identified patients with lower limb DVT at low risk for pulmonary embolism, major bleeding, or death within the first week. RESULTS: As of December 2014, 1135 outpatients with upper-extremity DVT were recruited. Of these, 515 (45%) were treated at home. During the first week, three patients (0.26%) experienced pulmonary embolism, two (0.18%) had major bleeding, and four (0.35%) died. We assigned 1 point to patients with chronic heart failure, creatinine clearance levels 30-60 mL min(-1) , recent bleeding, abnormal platelet count, recent immobility, or cancer without metastases; 2 points to those with metastatic cancer; and 3 points to those with creatinine clearance levels < 30 mL min(-1) . Overall, 759 (67%) patients scored ≤ 1 point and were considered to be at low risk. The rate of the composite outcome within the first week was 0.26% (95% confidence interval [CI] 0.004-0.87) in patients at low risk and 1.86% (95% CI 0.81-3.68) in the remaining patients. C-statistics was 0.73 (95% CI 0.57-0.88). Net reclassification improvement was 22%, and integrated discrimination improvement was 0.0055. CONCLUSIONS: Using six easily available variables, we identified outpatients with upper-extremity DVT at low risk for adverse events within the first week. These data may help to safely treat more patients at home.

Papel de la linfadenectomía tipo II en la supervivencia a largo plazo del cáncer gástrico / Evaluation long term of lymphadenectom y relevance in the surgery of gastric cancer prognosis

INTRODUCCIÓN Y OBJETIVOS. El tipo de linfadenectomía en la cirugía curativa del cácer gástrico sigue siendo tema de controversia.Nuestro objetivo fue analizar la influencia del tipo de linfadenectomía en la supervivencia a largo plazo en los pacientescon cáncer gástrico, sometidos a cirugía con intención curativa. MATERIAL Y MÉTODOS. Se realiza un estudio retrospectivo, con fases de prospectivo sobre 454 pacientes sometidos a cirugía por adenocarcinoma gástrico para analizar la influencia de la linfadenectomía tipo II en la supervivencia de los pacientes tratados con intención curativa. RESULTADOS. Se incluyeron 454 pacientes, 264 varones y 190 mujeres, con una edad media de 70 años. Se llevaron a cabo un 45,2% de gastrectomías subtotales, 35,3% de gastrectomías totales y un 19,6% cirugía paliativa. Del grupo de cirugía curativa, se realizaron un 65,3% de linfadenectomía tipo II y un 34,7% de linfadenectomía tipo I. En el análisis de regresiónlogística la linfadenectomía tipo II se comportó como un factor protector 0,3 (0,1-0,750), resultado similar si se aplica la regresión de Cox 0,5 (0,4-0,8). El sexo, la edad, los estadios III y IV, la localización y el número de adenopatías infiltradas se comportaron como factores de mal pronóstico en el cáncer gástrico. La supervivencia global de los pacientes tratados concirugía curativa fue de 34% a 5 años y 23% a 10 años. CONCLUSIONES. El pronóstico del cáncer gástrico sigue siendo a día de hoy bastante pobre. La supervivencia global a los 5años supera ligeramente el tercio de los pacientes intervenidos con intención curativa. La linfadenectomía tipo II se comportacomo un factor independiente que mejora la supervivencia a largo plazo (AU)

INTRODUCTION AND AIMS. The type of lymphadenectomy in the surgery of gastric cancer is not clearly defined. Our aim was to evaluate long term prognosis of patients with gastric cancer who underwent curative surgery and the influence of the type of lymphadenectomy. MATERIAL AND METHODS. We performed a retrospective study with prospective phases of 454 patients who underwent surgery for gastric adenocarcinoma to analyze the influence of type II lymphadenectomy in gastric cancersurvival in patients treated with curative intention. RESULTS. A total of 454 patients, 264 men and 190 women, averaging 70 years of age. It held 45.2% of subtotal gastrectomy. 35.3% of total gastrectomy and 19.6% palliative surgery. In curative surgery group, 65.3% were type II lymphadenectomyand 34.7% lymphadenectomy type I. In the logistic regression analysis type II lymphadenectomy acted as a protective factor 0.3 (0.1 to 0.750), similar results if applied Cox regression 0.5 (0.4-0.8). Sex, age, stage III and IV, the location and number of infiltrated lymph nodes behaved as a prognostic factors in gastric cancer. Overall survival of patients treated with curativesurgery was 34% at 5 years and 23% at 10 years. CONCLUSIONS. The prognosis of gastric cancer remains a very poor today. Overall survival at 5 years exceeds one third of thepatients operated with curative intent. Lymphadenectomy type II behaves as an independent factor which improves long-termsurvival (AU)

Análisis de la mortalidad postoperatoria en la cirugía del cáncer gástrico / Postoperative mortality analysisi in gastric cancer surgery

INTRODUCCIÓN. El cáncer gástrico sigue siendo hoy en día uno de los cánceres más frecuentes con aproximadamente 870.000 nuevos casos y 650.000 muertes cada año. OBJETIVO. El objetivo del trabajo es analizar la mortalidad en el postoperatorio inmediato y las variables asociadas. MATERIAL Y MÉTODOS. Estudio retrospectivo, con fases de prospectivo sobre 454 pacientes sometidos a cirugía por adenocarcinoma gástrico. RESULTADOS. Se incluyeron un total de 454 pacientes, 264 varones y 190 mujeres. Pico de mayor incidencia en la séptima década de la vida, con una media de 70 años y una desviación típica de 10 y rango de 30 a 92 años. En ella se expone que un 76% de los tumores presentaron localización baja (cuerpo-antro), frente a un 22% localización alta (cardias-fundus). Se realizaron 45,2% de gastrectomías subtotales. 35,3% de gastrectomías totales y un 19,6% (laparotomía y gastroyeyunostomía). Se encontró afectación ganglionar en 249 pacientes (54,8%), metástasis hepáticas en 8,1% y en un 15,4% metástasis peritoneales. En este estudio el porcentaje de exitus en el postoperatorio fue de 10,1% del total de pacientes frente a un 8,7% en el de cirugía curativa. La edad, la esplenectomía y el estadio IV obtuvieron resultados significativos en el análisis multivariante. CONCLUSIONES. El estadio IV, la realización de esplenectomía y la edad se asocian de forma independiente con mayor mortalidad en el postoperatorio inmediato. Estas tres variables son predictivas, de forma independiente, de la mortalidad en el postoperatorio (AU)

INTRODUCCIÓN. Gastric cancer remains today one of the most common cancers with approximately 870,000 new cases and 650,000 deaths each year. OBJECTIVE. The study aims to analyze mortality in the immediate postoperative period and associated variables. METHODS. Retrospective study with prospective phases of 454 patients undergoing surgery for gastric adenocarcinoma. RESULTS. A total of 454 patients, 264 men and 190 women. There is a higher incidence peak in the seventh decade of life, with an average of 70 years and a standard deviation of 10 and range 30 to 92 years. It shows that 76% of tumors had low location (body-antrum), compared with 22% upper localization (cardia-fundus). 45.2% were performed subtotal gastrectomy, total gastrectomy 35.3% and 19.6% (laparotomy and gastrojejunostomy). Lymph node was found in 249 patients (54.8%), liver metastases in 8.1% and peritoneal metastases in 15.4%. In this study, the percentage of exitus in the postoperative period was 10.1% of patients compared to 8.7% for curative surgery. Age, splenectomy and stage IV results were significant in the multivariate analysis. CONCLUSIONS. Stage IV, the performance of splenectomy and age were independently associated with increased mortality in the immediate postoperative period. These three variables are predictive, independently of mortality in postoperatory (AU)

Patología puerperal / Puerperal pathology

El puerperio es el periodo desde el final del partohasta la aparición de la primera menstruación. Las posiblespatologías acontecidas en este tiempo son la causamás frecuente de mortalidad materna incluso en nuestromedio. La patología de la lactancia incluye el fallo delactancia, grietas en el pezón, ingurgitación mamaria ymastitis puerperal.La infección puerperal es una complicación obstétricafrecuente aunque las pautas de profilaxis han disminuidomucho la incidencia de esta patología.La patología vascular del puerperio incluye cuadrosde gravedad importante, representando una de lasprincipales causas de mortalidad materna. Se incluye latrombosis venosa profunda y el tromboembolismo pulmonarcomo la complicación más grave de la primera.No parece que la patología psiquiátrica sea másfrecuente en el puerperio que en otra época de la vida,pero sí que se describen los cuadros relacionados coneste periodo, como son el “blues”, la depresión puerperaly la psicosis puerperal.Por último, otros cuadros poco frecuentes, peroque pueden constituir una emergencia médica en elpuerperio son el síndrome de Sheehan, la miocardiopatíaperiparto y la tiroiditis postparto(AU)

The puerperium is the period from the end of labourto the appearance of the first menstruation. Thepossible pathologies that can occur in this period oftime are the most frequent cause of maternal mortalityeven in our setting. The pathology of lactation includesfailure of breastfeeding, cracks in the nipple, mammaryingurgitation and puerperal mastitis.Puerperal infection is a frequent obstetric complicationalthough clinical guidelines for prophylaxis haveconsiderably reduced its incidence.The vascular pathology of the puerperium includesclinical features of great seriousness, representing oneof the main causes of maternal mortality. These includedeep vein thrombosis, of which pulmonary thromboembolismis the most serious complication.It does not appear that a psychiatric pathology ismore frequent in the puerperium than in other periodsof life, but the clinical features related to this period aredescribed, such as “blues”, puerperal depression andpuerperal psychosis.Finally, other clinical features which although infrequentcan constitute a medical emergency in the puerperiumare: Sheehan’s syndrome, peripartum cardiomyopathyand postpartum thyroids(AU)

[Puerperal pathology]. / Patología puerperal.

The puerperium is the period from the end of labour to the appearance of the first menstruation. The possible pathologies that can occur in this period of time are the most frequent cause of maternal mortality even in our setting. The pathology of lactation includes failure of breastfeeding, cracks in the nipple, mammary ingurgitation and puerperal mastitis. Puerperal infection is a frequent obstetric complication although clinical guidelines for prophylaxis have considerably reduced its incidence. The vascular pathology of the puerperium includes clinical features of great seriousness, representing one of the main causes of maternal mortality. These include deep vein thrombosis, of which pulmonary thromboembolism is the most serious complication. It does not appear that a psychiatric pathology is more frequent in the puerperium than in other periods of life, but the clinical features related to this period are described, such as "blues", puerperal depression and puerperal psychosis. Finally, other clinical features which although infrequent can constitute a medical emergency in the puerperium are: Sheehan's syndrome, peripartum cardiomyopathy and postpartum thyroids.

Hernia Obturatriz. Revisión de la enfermedad / Obturator Hernia. Disease Review

INTRODUCCIÓN: La hernia obturatriz es una entidad poco frecuente, siendo una causa rara de obstrucción de intestino delgado. Su diagnóstico requiere un alto índice de sospecha. CASO CLÍNICO: Se presenta el caso de una mujer de 85 años, que acude a urgencias por dolor abdominal junto con vómitos. A la exploración tenía el abdomen distendido, no se palpaban hernias y refería un dolor que se irradiaba desde la región inguinal hacia la cara interna del muslo. Se intervino de urgencia encontrando un asa de intestino delgado en el interior del orificio obturador. DISCUSIÓN: Las hernias obturatrices son más frecuentes en mujeres ancianas y debilitadas. La presencia del signo de Howship-Romberg en un paciente con clínica de oclusión intestinal deberá hacernos pensar en este diagnóstico. La TC junto con la radiología simple nos podrá ayudar a precisar el diagnóstico. El tratamiento requiere cubrir el orificio mediante el cierre simple o la colocación de un tapón de malla en la hernia obturatriz que es una técnica sencilla y eficaz. El acceso laparoscópico sobre todo se emplea en los casos con un diagnóstico etiológico preoperatorio (AU)

INTRODUCTION: The presence of an obturator hernia is not very usual and odd cause for obstruction in the small bowel. A high degree of suspicion is necessary for that diagnosis. CASE REPORT: An 85 year old female came to hospital emergency department, complaining of abdominal pain and vomiting. On physical examination she was presenting a tender abdomen, no hernias were found and the pain irradiated from the inguinal region to the inner face of the thigh. An emergency surgical procedure was taken on and a small bowel handle was found inside the obturator orifice. CONCLUSIONS: Obturator hernias are more frequent in aged and weaken females. The presence of Howship-Romberg sign in a patient with a clinical profile of bowel obstruction leads us to this diagnosis. Both CT scanning and a simple radiology will help us to specify the diagnosis. The treatment requires either a simple closing of the orifice or a mesh repair in the obturator hernia, which is an easy and effective technique. The laparoscopic access to the abdomen is used above all in cases with an etiologic diagnosis in the preoperatory phase (AU)

Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation.

BACKGROUND: Malignant gastrointestinal obstruction is a secondary complication of cancers in an advanced state. Treatment has consisted of gastrojejunostomy. However, the endoscopic placement of metallic stents has provided positive results. This study aimed to compare the efficiency of both therapeutic options. METHODS: A total of 41 patients with gastrointestinal obstruction caused by inoperable neoplasm were treated endoscopically with enteral stent (24 patients) or gastrojejunostomy (17 patients). RESULTS: In the endoscopic group (EG) 24 patients (100%) achieved efficient gastric emptying, as compared with 82.3% in the surgical group (SG). The difference was not significant. The average time for initiating oral food tolerance was 2.4 days for the EG and 5 days for the SG (p < 0.001). The average inpatient time was 7.1 days for the EG and 11.5 days for the SG (p < 0.001). Mortality at 30 days was lower in the EG (16.6%) than in the SG (29.4%) (p < 0.05). The survival time was 20 weeks for the EG and 21.6 weeks for the SG. The difference was not significant. The rate of complications was 4% in the (EG) and 17.6% in the (SG), with the difference was not significant. CONCLUSION: Endoscopic treatment of malignant gastrointestinal obstruction provides an adequate palliation of the symptoms. It is less invasive, avoids the morbidity associated with open gastrojejunostomy, and achieves a faster start to oral food and a shorter hospital stay, leading to a higher quality of life.

Is magnetic resonance imaging safe in cardiac pacemaker recipients?

Magnetic resonance imaging (MRI) is currently contraindicated in cardiac pacemaker (PM) recipients. The objectives of this prospective study were to (1) reassess the risks of performing an MRI scan in patients with PM, (2) compared the pacing functions before and after the exposure to MRI, and (3) monitor the development of possible adverse effects. Thirteen patients implanted with an Affinity DR model 5330 PMs (St. Jude Medical) connected to a Tendril model 1388 leads (St. Jude Medical) underwent 2.0 T-MRI for a variety of indications. All patients displayed a stable spontaneous rhythm at the time of the MRI scan and were not considered to be PM-dependent. The sensing and pacing functions were analyzed and the impedance of both leads was measured before and after the scan. The MRI scan was performed with all PM programmed in DDD mode. The sensing configuration was bipolar. All patients were monitored utilizing a standard electrocardiographic monitor and direct verbal communication. PM Inhibition, asynchronous pacing, or inappropriately rapid pacing was not observed. No patient reported discomfort, heat, or motion sensation at the PM implant site. There were no significant differences in the sensing, stimulation, AutoCapture threshold, and lead impedance measurements before and after MRI. The results of this study suggest that performing 2.0 T-MRI scans in patients with Affinity DR model 5330 PM connected to a Tendril model 1388 lead is safe.

Traumatismo abdominal cerrado con sección pancreática / Pancreatic lesions in closed abdominal trauma

Las lesiones traumáticas del páncreas son poco frecuentes pero se acompañan de una gran morbimortalidad, sobre todo si se demora el diagnóstico y consecuentemente el tratamiento, cosa relativamente habitual dada su escasa sintomatología. Por tanto, es muy importante valorar el mecanismo lesional que nos hará sospechar este tipo de lesión. La tomografía computarizada (TC) helicoidal es de gran utilidad diagnóstica. La actitud terapéutica está condicionada por la integridad o no del conducto pancreático. Presentamos el caso de un paciente con trauma abdominal cerrado en el que la TC de ingreso fue normal a pesar de tener una sección pancreática que se visualizó tres días después. Se complicó con una disfunción multiorgánica que evolucionó favorablemente

Traumatic lesions of the pancreas are not very common but accompanied by a high morbimortality rate, especially if diagnosis and subsequent treatment are delayed, which is relatively common given its poor symptomology. It is, therefore, very important to evaluate the lesional mechanism which would lead one to suspect this type of lesion. Spiral CAT is very useful diagnostic tool. Therapeutic approach is conditioned on pancreatic duct integrity. Herein is presented the case of a patient with closed abdominal trauma whose CT at admittance was normal in spite of having had a pancreatic lesion being observed three days later. It was further complicated by a multiorgan dysfunction which evolved favorably

Pólipo antrocoanal gigante / Giant antrochoanal polyp

No disponible

Expression of 27 kDa heat shock protein (Hsp27) in immature rat brain after a cortical aspiration lesion.

The 27 kDa heat shock protein (Hsp27) is a well-known member of the astroglial response to injury, playing a protective role against oxidative stress, apoptosis, and cytoskeletal destruction. Although several studies have been focused on the damaged adult brain, little is known about Hsp27 expression in the immature brain. In this work, we have examined the spatiotemporal pattern of Hsp27 expression in the normal postnatal rat brain following a cortical aspiration lesion at postnatal day 9. In the immature brain, Hsp27 is mainly observed in the internal capsule, although some scattered cells are also found in the ependyma, the corpus callosum, the septum, and hypothalamic glia limitans. In the internal capsule, Hsp27 expression is developmentally regulated, being significantly decreased from postnatal day 14. After a cortical aspiration lesion, de novo expression of Hsp27 is observed in cortical injured areas as well as in the secondary affected thalamus. In the cortex, expression of Hsp27 is first seen at day 1 postlesion (PL) surrounding the neurodegenerative area, becoming restricted to the glial scar at longer survival times. Although a pulse-like expression of Hsp27 is observed in some microglial cells at day 1 PL, most Hsp27-labeled cells are reactive astrocytes, which show GFAP overexpression and coexpress vimentin from day 3 PL. In the thalamus, astroglial Hsp27 expression is delayed, being first observed at day 5 PL. Thalamic Hsp27-labeled astrocytes do not show vimentin expression. Our observations demonstrate astroglial expression of Hsp27 in areas of tissue damage following postnatal traumatic injury, suggesting an involvement of this cytoskeleton-stabilizing protein in the remodeling processes following postnatal brain damage.

[Clinical profile and prognosis of patients with endocarditis and periannular pseudoaneurysms]. / Perfil clínico y pronóstico de los pacientes con endocarditis y seudoaneurismas perianulares.

INTRODUCTION AND OBJECTIVES: Little information is available on the clinical profile and prognosis of patients with endocarditis and periannular pseudoaneurysms because the presence of pseudoaneurysm itself is considered an indication albeit not an evidence-based indication, for surgery. METHODS: We followed 18 patients (11 males, mean age: 5 +/- 4) with endocarditis and pseudoaneurysm diagnosed by transesophageal echocardiography and/or at surgery over 14 +/- 5 months. RESULTS: Aortic (n = 14; 6 on native valve, 8 on prosthesis) was more frequent than mitral (n = 3; 3 prosthesis) or tricuspid location (n = 1). Auriculoventricular block developed in 6 patients, all with aortic pseudoaneurysm. The most frequently involved microorganisms were staphylococci (n = 5) and streptococci (n = 5). Abscesses were found in 5 patients. Pseudoaneurysm was not considered an indication for surgery. Eleven patients underwent surgery 5 died after surgery (45%), 1 had reinfection and 5 are asymptomatic. The remaining 7 patients received only medical treatment: two died (28%), one developed reinfection and 4 are asymptomatic. The size of the pseudoaneurysm remained stable after 24 months of follow-up in the 4 asymptomatic medically treated patients (maximal diameter: 21 +/- 5 at diagnosis versus 22 +/- 5 at latest follow-up; p = NS). CONCLUSIONS: We conclude that the presence of a pseudoaneurysm identifies a subset of endocarditis patients with a high mortality. Pseudoaneurysms are usually located in an aortic position and around prosthetic material. Medical treatment without surgery should be considered when no other surgical indications exist. Lastly the size of a pseudoaneurysm in medically treated patients does not increase over time

A prospective multicenter study on the safety of a pacemaker with automatic energy control: influence of the electrical factor on chronic stimulation threshold. PEACE Investigators.

The effectiveness and safety of a pacemaker with automatic control of capture was evaluated in 162 patients followed at 27 Spanish centers. The aim of our prospective, multicenter, and randomized trial was to determine the relationship between the voltage output of the pulse generator and the stimulation threshold. We randomized 162 patients (107 men, mean age 75 +/- 12 years). We implanted a ventricular pacemaker model Regency SR+ or SC+ with Pacesetter's low polarization bipolar leads Membrane E 1450. The patients were randomized to receive Autocapture or not; group I (81 patients) Autocapture On, pulse output automatically adjusted and group II (81 patients) Autocapture Off, fixed output parameters (3.9 V, 0.37 ms). We performed a 6-month follow-up measuring stimulation threshold by means of the VARIO test and Autocapture test, evoked response signal, and R wave signal. The mean R wave was 15.77 +/- 3.5 mV at the end of the follow-up for group I, and 14.91 +/- 6.8 mV for group II (P = NS). The measured evoked response at the end of the follow-up was 9.25 mV in Group I and 8.48 mV in Group II (P = NS). The stimulation threshold was not different between groups. The current density created with the voltage and pulse width used in this study (< or = 3.9 V and 0.37 ms) at the tip of this electrode during the maturation process had no influence on the development of the chronic detection and stimulation thresholds.

Prognostic factors in patients with idiopathic facial paralysis (Bell's palsy): A prospective study.

A prospective study was designed in order to objectively quantify the most important prognostic factors of idiopathic facial paralysis (Bell's palsy). Stepwise logistic regression was applied to data obtained from 178 patients evaluated between April 1994 and September 1995 at La Paz Hospital. Due to statistical requirements, the final number of cases analyzed was 124. In all cases, 28 variables were recorded. The 3 variables selected by the multivariate analysis were: age, maximal stimulation test and treatment employed (prednisone or acyclovir). With these data, a linear discriminant function was obtained with an overall accuracy of 70.8%. The correct prediction rate for complete facial recovery was 82.1% and for absence of complete facial recovery 50.0%.

[The prognostic value of dobutamine echocardiography after an uncomplicated acute myocardial infarct]. / Valor pronóstico de la ecocardiografía con dobutamina después de un infarto agudo de miocardio no complicado.

BACKGROUND AND PURPOSE: The identification of patients at risk for future events after an infarction is mandatory. The aim of this study was to assess the prognostic value of dobutamine stress echocardiography after an uncomplicated myocardial infarction. METHODS: One hundred and twenty five patients (mean age 65 +/- 11 years, males 82%) underwent dobutamine-echo within ten days after an uncomplicated myocardial infarction. Four myocardial responses were identified: a) negative; b) sustained improvement of myocardial contractility; c) initial improvement followed by worsening, and d) worsening at a distance or in the infarcted zone. RESULTS: Mean follow-up was 7.4 +/- 4.6 months. An adverse outcome occurred in 47 patients: non cardiac death in 3, cardiac death in 6, myocardial infarction in 5, angina in 21, congestive heart failure in 2, and in 10 patients revascularization. Cox regression analysis showed that worsening of contractility was the best predictor for adverse events (p < 0.0001, relative risk 2.8; 95% confidence interval: 1.7-4.5). Non-smoking and previous angina were also predictors of adverse events (p = 0.003 and p = 0.04, respectively). Similar results were obtained after excluding the revascularized patients. CONCLUSIONS: Sustained improvement of contractility in the infarcted region is not a predictor of adverse events. Asynergy at a distance or in the infarcted region during dobutamine echocardiography within ten days after an uncomplicated myocardial infarction predicts adverse cardiac events during follow-up. Therefore, dobutamine echocardiography could be used for risk stratification after acute myocardial infarction.

Clinical course, microbiologic profile, and diagnosis of periannular complications in prosthetic valve endocarditis.

Whether periannular extension of prosthetic valve endocarditis (abscesses, pseudoaneurysms, fistulas) is related to the etiologic agent, the clinical course and the prognosis is still unknown. Likewise, transesophageal echocardiographic accuracy in detecting periannular complications in prosthetic recipients remains unsettled. We retrospectively analyzed data from 87 patients with anatomically proven prosthetic valve endocarditis who underwent a transesophageal echocardiographic examination. Periannular complications (30 abscesses, 18 pseudoaneurysms, 8 fistulas; 8 with >1) were found in 46 patients; results were compared with the remaining 41 without complications. Transesophageal echocardiography correctly identified 27 abscesses (90%) and all pseudoaneurysms and fistulas. One diagnosis of pseudoaneurysm by echocardiography was not found at surgery. No statistical differences were found regarding age, sex, type of prosthesis (mechanical vs biologic), and etiologic agent. Periannular complications were more frequent in aortic location (70% vs 20% in mitral position; p <0.001) and in early (within 6 months after surgery) endocarditis (63% vs 38% in late endocarditis; p = 0.04). The same percentage of patients from both groups underwent surgery (98% with and 90% without complications). At discharge, 62% and 67% of patients were alive, respectively. Thus, periannular complications in prosthetic valve endocarditis are more frequent in aortic location and within 6 months after surgery. Neither the type of prosthesis nor the etiologic agent are related to the presence of periannular complications. Short-term prognosis in patients who underwent surgery is not affected by the presence of periannular complications.

Cu/Zn superoxide dismutase activity at different ages in sporadic amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive disorder resulting from degeneration of motor neurons in the brain and spinal cord. Sporadic ALS (SALS) accounts for the majority of patients and the familial form (FALS) represents fewer than 10% of all cases. Since it was found that there are Cu/Zn superoxide dismutase (SODI) gene mutations in 20% of FALS patients and that FALS and SALS patients show similar clinical features, it has been postulated that both may share a common physiopathological mechanism. We studied Cu/Zn SOD1 activity in cytosolic extracts of erythrocytes from 125 normal individuals and 40 SALS patients. We found that enzyme activity does not change with age in control subjects and tends to decrease in most SALS patients older than 60 years. A subpopulation of five SALS patients had significantly increased SOD1 activity; four of these patients over 70 years old. There was no correlation between enzyme activity and time of onset of the disease, or clinical forms of the illness. The variation in SOD1 activity in ageing SALS patients compared with younger patients suggests that they may undergo an oxidative disbalance contributing to the development of the disease.

[Chronic inflammatory demyelinating polyneuropathy. Findings in 30 patients]. / Neuropatía crónica desmielinizante inflamatoria. Hallazgos en 30 pacientes.

Chronic demyelinating inflammatory polineuropathy (CIDP) is a disease which was recognized several years ago. However, the mechanism underlying its pathogenesis remains poorly understood. Nevertheless, there are some clues which strongly suggest that it constitutes an autoimmune disease. Since 1992 we have studied 30 cases. All them were clinically assessed and submitted to laboratory investigations encompassing nerve conduction studies, sera proteins immunoelectrophoresis, spinal fluid analysis and sural nerve biopsies. Upon clinical examination the usual findings were weakness, muscle atrophy, absence or diminished tendon jerks, paresthesias and hyposthesias. Electrophysiological studies disclosed marked slowing of the nerve conduction velocities, suggesting demyelination. Sera immunoelectrophoresis detected monoclonal gammopathy in 17% of the studied patients, which was not associated with lymphoproliferative illnesses. Of the patients 79% had increased levels of spinal fluid proteins. Seventeen patients gave their consent for performing a sural nerve biopsy; all the samples showed demyelination. In conclusion, we think that CDIP is a disease which can be recognized when the clinical assessment, the nerve conduction studies and the spinal fluid findings suggest the diagnosis. Although nerve biopsy may be strongly supporting, we believe that it has to be performed only if doubts arise from the clinical, electrophysiological or spinal fluid observations. It is worth noting that its early detection may benefit the patient through the administration of the right therapy precluding the eventual sequelae of the disease.