Pulso pulmonar visualizado a través de derrame pleural como signo diagnóstico de atelectasia obstructiva completa del pulmón izquierdo en paciente crítico con insuficiencia respiratoria / Lung pulse visualized through pleural effusion as a diagnostic sign of complete obstructive atelectasis of the left lung in a critical patient with respiratory failure

La atelectasia obstructiva completa del pulmón es producida por un bloqueo de la conducción del aire a nivel de uno de los bronquios principales por secreciones o cuerpos extraños. Varios signos ecográficos pulmonares se han correlacionado con esta entidad. Describimos el caso de una paciente ingresada en la unidad de cuidados críticos posquirúrgicos en el que la ecografía pulmonar llevó al diagnóstico de esta complicación y en el que la presencia de derrame pleural permitió la visualización directa del pulso pulmonar, signo que previamente solo ha sido descrito mediante interpretación de artefactos ecográficos

Complete obstructive atelectasis occurs when mucous or a foreign body obstruct one of the main bronchi. Several lung ultrasound signs have been associated with this entity. We describe the case of a patient admitted to the surgical critical care unit in whom lung ultrasound led to a diagnosis of complete obstructive atelectasis, and the presence of pleural effusion provided direct visualization of lung pulse, a sign that has only previously been described by interpreting ultrasound artifacts

Respuesta a consideraciones sobre la reserva de precarga en la ventilación pulmonar selectiva / Response to considerations on ventricular preload reserve in selective lung ventilation

No disponible

Percepción del médico sobre las ayudas cognitivas para el manejo de la hipoxemia en anestesia y cuidados críticos / Physician's perception of cognitive aids for hypoxemia management in anesthesia and critical care

No disponible

Monitorización de la variación de la presión de pulso durante la cirugía de resección pulmonar / Monitoring pulse pressure variation during lung resection surgery

Antecedentes y objetivo: La variación de presión de pulso (VPP) es un parámetro dinámico eficaz y ampliamente empleado para predecir el aumento del gasto cardiaco tras la administración de fluidos en cirugía abdominal, sin embargo su uso en cirugía torácica es controvertido. Se diseñó un estudio para describir el comportamiento de la VPP durante cirugía de resección pulmonar. Pacientes y métodos: Estudio observacional prospectivo en pacientes adultos programados para cirugía de resección pulmonar. Se excluyeron los pacientes con sangrado mayor de 200cc o con necesidad de vasopresores durante la recogida de datos. Se recogieron los valores de la VPP durante diferentes fases: en ventilación bipulmonar (T1), tras el inicio de la ventilación unipulmonar y la apertura del tórax (T2), al finalizar el procedimiento previo a la reinstauración de la ventilación bipulmonar (T3) y tras el cierre del tórax en ventilación bipulmonar (T4). Se calculó el coeficiente de correlación de los valores de VPP en los diferentes momentos. Resultados: Se incluyeron 50 pacientes consecutivos. Los valores medios y desviaciones estándar de VPP en las diferentes fases fueron: T1: 11,14% (6,67); T2: 6,24% (3,21; T3: 5,68% (3,19) y T4: 7,84% (4,61). El ANOVA de medidas repetidas encontró diferencias significativas entre los valores medios de VPP en las diferentes fases (p <0,001). La correlación entre los valores de VPP durante T1 y T2 (VPPT1 y VPPT2) fue de r = 0,868 ([p <0,001], r2 = 0,753), mientras que entre T3 y T4 (VPPT3 y VPPT4) la correlación fue de r=0,616 ([p <0,001], r2=0,379) entre los valores de VPP en T3 y T4. Conclusiones: La VPP presenta un comportamiento predecible en el transcurso de cirugía de resección pulmonar, caracterizado por una disminución de casi el 50% al inicio de la ventilación unipulmonar y apertura del tórax y posteriormente se mantiene estable a lo largo de la cirugía cuando no hay cambios en la volemia

Background and objective: Although pulse pressure variation (PPV) is an effective dynamic parameter widely used to predict the increase in cardiac output after the administration of fluids in abdominal surgery, its use in thoracic surgery is controversial. A study was designed to describe the behaviour of PPV during lung resection surgery. Patients and methods: A prospective observational study was conducted on adult patients scheduled for lung resection surgery. Patients with bleeding greater than 200cc, or those who required vasopressors during data collection, were excluded. The PPV values were collected during different phases: in bipulmonary ventilation (T1), after the start of single lung ventilation, and the opening of the thorax (T2), at the end of the procedure prior to the restoration of the bipulmonary ventilation (T3), and after the closure of the thorax in bipulmonary ventilation (T4). The correlation coefficient of the PPV values at the different times was calculated. Results: The study included 50 consecutive patients. The mean values and standard deviations of PPV in the different phases were: T1, 11.14% (6.67); T2 6.24% (3.21, T3 5.68% (3.19), and T4 7.84% (4.61). The repeated ANOVA measurements found significant differences between the mean values of PPV in the different phases (P<.001). The correlation between the PPV values during T1 and T2 (PPVT1 and PPVT2) was r=0.868 ([P<.001], r2=0.753), while between T3 and T4 (PPVT3 and PPVT4) the correlation was r=0.616 ([P<.001], r2=0.379) between the PPV values in T3 and T4. Conclusions: PPV presents a predictable behaviour in the course of lung resection surgery, characterised by a decrease of almost half at the beginning of the unipulmonary ventilation and opening of the thorax. It then remains stable throughout the surgery when there are no changes in the intravascular blood volume

Estudio prospectivo comparativo entre cistectomía radical laparoscópica y abierta: resultados operatorios y oncológicos / Prospective study comparing laparoscopic and open radical cystectomy: Surgical and oncological results

Introducción La cistectomía radical laparoscópica con linfadenectomía y derivación urinaria es una cirugía de empleo creciente. Se necesitan estudios que avalen la efectividad oncológica y la seguridad de este abordaje mínimamente invasivo. Pacientes y métodos: Estudio prospectivo comparativo no aleatorizado entre cistectomía radical abierta (CRA) y laparoscópica (CRL) llevado a cabo en un hospital universitario. El objetivo principal fue comparar la supervivencia cáncer-específica, y el objetivo secundario comparar resultados operatorios y complicaciones según la escala Clavien-Dindo. Resultados: Ciento cincuenta y seis pacientes con cáncer vesical invasivo de alto grado fueron tratados mediante CRA (n = 70) o CRL (n = 86). El seguimiento medio fue 33,5 ± 23,8 (rango 12-96) meses. La edad media fue 66,9 + 9,4 años y la proporción hombre/mujer 19:1. Ambos grupos fueron equivalentes en edad, estadio, ganglios positivos, carcinoma in situ, uropatía obstructiva preoperatoria, quimioterapia adyuvante y tipo de derivación urinaria. No hubo diferencias entre grupos en supervivencia cáncer-específica (log-rank; p = 0,71). El estadio histopatológico fue la única variable independiente predictiva de pronóstico. La estancia hospitalaria (p = 0,01) y la tasa de transfusión operatoria (p = 0,002) fueron menores para CRL. La duración de la cirugía fue mayor para CRL (p < 0,001). No hubo diferencias en la tasa de complicaciones totales (p = 0,62) ni complicaciones mayores (p = 0,69). El riesgo de evisceración (p = 0,02), infección de herida quirúrgica (p = 0,005) y neumonía (p = 0,017) fue mayor en CRA. El riesgo de lesión rectal (p = 0,017) y fístula uretrorrectal (p = 0,065) fue mayor en CRL. Conclusión: La CRL es un tratamiento equivalente a la CRA en términos de eficacia oncológica, y ventajoso respecto a tasa de transfusión y estancia hospitalaria, pero no respecto a la ocupación de quirófano o a la seguridad global. Se necesitan estudios que definan mejor el perfil de seguridad específico de cada abordaje

Introduction: Laparoscopic radical cystectomy with lymphadenectomy and urinary diversion is an increasingly widespread operation. Studies are needed to support the oncological effectiveness and safety of this minimally invasive approach. Patients and methods: A nonrandomised, comparative prospective study between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) was conducted in a university hospital. The main objective was to compare cancer-specific survival. The secondary objective was to compare the surgical results and complications according to the Clavien-Dindo scale. Results: We treated 156 patients with high-grade invasive bladder cancer with either ORC (n = 70) or LRC (n = 86). The mean follow-up was 33.5 ± 23.8 (range 12-96) months. The mean age was 66.9 + 9.4 years, and the male to female ratio was 19:1. Both groups were equivalent in age, stage, positive lymph nodes, in situ carcinoma, preoperative obstructive uropathy, adjuvant chemotherapy and type of urinary diversion. There were no differences between the groups in terms of cancer-specific survival (log-rank; P = .71). The histopathology stage was the only independent variable that predicted the prognosis. The hospital stay (P = .01) and operative transfusion rates (P = .002) were less for LRC. The duration of the surgery was greater for LRC (P < .001). There were no differences in the total complications rate (p = .62) or major complications (P = .69). The risk of evisceration (P = .02), surgical wound infection (P=.005) and pneumonia (P = .017) was greater for ORC. The risk of rectal lesion (P = .017) and urethrorectal fistulae (P = .065) was greater for LRC. Conclusion: LRC is an equivalent treatment to ORC in terms of oncological efficacy and is advantageous in terms of transfusion rates and hospital stays but not in terms of operating room time and overall safety. Studies are needed to better define the specific safety profile for each approach

Teledermatología en Atención Primaria / Teledermatology in Primary Care

Las nuevas tecnologías son una herramienta cada vez más utilizada en el desarrollo de la asistencia clínica. La teledermatología pretende establecer una comunicación rápida y eficaz entre el facultativo de Atención Primaria y el especialista en Dermatología. Se expone una muestra del proyecto de calidad llevado a cabo entre los pediatras de un centro de salud del sector 1 de Zaragoza y un especialista en Dermatología del Hospital Royo Villanova. Se describe el cuadro clínico y las imágenes realizadas en la consulta de Atención Primaria de cinco pacientes en edad pediátrica, así como la respuesta por parte del especialista. La teledermatología es un proyecto con buena aceptación por parte de pacientes y profesionales; disminuye listas de espera, evita derivaciones innecesarias y fomenta el aprendizaje por parte del pediatra (AU)

New technologies are an increasingly used tool in the development of clinical care. Teledermatology aims to establish a fast and efficient communication between the primary care physician and the specialist in dermatology. We exposed a sample of the quality project carried out between the pediatricians at a health centre in sector 1 in Zaragoza and a specialist in dermatology of the Hospital Royo Villanova. Is describes the picture clinical and the images made in the consultation of attention primary of 5 patients in age Pediatric, as well as the response from the specialist. Teledermatology is a project with good acceptance by patients and professionals; decreases waiting lists, avoids unnecessary referrals and encourages learning by the pediatrician (AU)

Monitorización no invasiva transcutánea de la concentración de hemoglobina en pacientes críticos pediátricos con riesgo de sangrado / Noninvasive hemoglobin monitoring in critically ill pediatric patients at risk of bleeding

OBJETIVO: Determinar la validez y precisión de un método de medición continua transcutánea de la concentración de hemoglobina (Hb) en pacientes críticos con riesgo de sangrado. DISEÑO: Estudio observacional prospectivo comparando el estándar de referencia con la determinación transcutánea de hemoglobina (SpHb). Ámbito: Unidad de cuidados intensivos pediátricos de un hospital universitario de tercer nivel. PACIENTES: Muestra consecutiva de pacientes con peso >3kg y riesgo de sangrado. INTERVENCIONES: Medición de SpHb mediante el cooxímetro de pulso Radical7 (Masimo Corp., Irvine, CA) en cada extracción sanguínea con determinación de Hb analizada con estándar de referencia (Siemens ADVIA 2120i). VARIABLES: Variables epidemiológicas, índice de perfusión (IP), índice de variabilidad pletismográfica, frecuencia cardiaca, SaO2, temperatura rectal, baja calidad de señal, así como otros factores que pueden afectar a la medición. RESULTADOS: Se realizaron 284 mediciones (80 pacientes). La media de Hb por el analizador central fue de 11,7±2,05g/dl. La media de SpHb fue de 12,32±2g/dl (Pearson 0,72, R2 0,52). El índice de correlación intraclase fue de 0,69 (IC95%: 0,55-0,78), p < 0,001. El diagrama de Bland-Altman mostró una diferencia media entre ambos métodos de 0,66±1,46g/dl. Un menor IP y una mayor temperatura rectal incrementaron de forma independiente el riesgo de baja calidad de la señal (OR 0,531 [IC95%: 0,32-0,88] y 0,529 [IC95%: 0,33-0,85], respectivamente). CONCLUSIONES: La SpHb presenta buena correlación con la obtenida por el analizador central, aunque los límites de concordancia son amplios. Su principal ventaja es la posibilidad de monitorización continua en pacientes con riesgo de sangrado. La fiabilidad de este método es limitada en casos de mala perfusión periférica

OBJECTIVE: To determine the accuracy and usefulness of noninvasive continuous hemoglobin (Hb) monitoring in critically ill patients at risk of bleeding. DESIGN: An observational prospective study was made, comparing core laboratory Hb measurement (LabHb) as the gold standard versus transcutaneous hemoglobin monitoring (SpHb). SETTING: Pediatric Intensive Care Unit of a tertiary University Hospital. PATIENTS: Patients weighing >3kg at risk of bleeding. INTERVENTIONS: SpHb was measured using the Radical7 pulse co-oximeter (Masimo Corp., Irvine, CA, USA) each time a blood sample was drawn for core laboratory analysis (Siemens ADVIA 2120i). VARIABLES: Sociodemographic characteristics, perfusion index (PI), pleth variability index, heart rate, SaO2, rectal temperature, low signal quality and other events that can interfere with measurement. RESULTS: A total of 284 measurements were made (80 patients). Mean LabHb was 11.7±2.05g/dl. Mean SpHb was 12.32±2g/dl (Pearson 0.72, R2 0.52). The intra-class correlation coefficient was 0.69 (95%CI 0.55-0.78)(p < 0.001). Bland-Altman analysis showed a mean difference of 0.07 ±1.46g/dl. A lower PI and higher temperature independently increased the risk of low signal quality (OR 0.531 [95%CI 0.32-0.88] and 0.529 [95%CI 0.33-0.85], respectively). CONCLUSIONS: SpHb shows a good overall correlation to LabHb, though with wide limits of agreement. Its main advantage is continuous monitoring of patients at risk of bleeding. The reliability of the method is limited in cases with poor peripheral perfusion

Test de apnea en muerte encefálica. ¿Es seguro realizarlo con CPAP en respiradores convencionales? / Apnea test in brain death. Is it safe to perform with CPAP using conventional respirators?

No disponible

La cinética de la citrulina y la arginina y su valor como factor pronóstico en pacientes pediátricos críticamente enfermos / Citrulline and arginine kinetics and its value as a prognostic factor in pediatric critically ill patients

INTRODUCCIÓN: Se han documentado bajas concentraciones de citrulina y arginina plasmáticas en niños en diversas condiciones patológicas. Hipótesis: La cinética de citrulina y arginina plasmáticas durante la enfermedad crítica pediátrica se correlaciona con parámetros evolutivos clínicos y bioquímicos. PACIENTES Y MÉTODOS: Estudio observacional unicéntrico prospectivo en pacientes de 7 días a 14 años ingresados en Unidad de Cuidados Intensivos Pediátricos (PICU). Los datos bioquímicos y clínicos fueron recogidos al ingreso, a las 12 h, a las 24 h, al 3.er y al 7.° día. RESULTADOS: Un total de 44 pacientes críticamente enfermos fueron incluidos y un grupo control de 51 niños sanos. La citrulina desciende de forma significativa (p < 0,05) a las 12 h de ingreso con niveles bajos mantenidos hasta el día 7, comenzando un aumento progresivo después. La arginina ya está descendida a las 6h, aunque tiene una subida más precoz (día 3). La disminución de citrulina al tercer día se correlaciona directamente con la arginina. Hay correlación entre la elevación de la citrulina al 7.° día con menor duración de ventilación mecánica, menor estancia en PICU y menos complicaciones. Los niveles de citrulina bajos al 7° día aún descendidos el día 7 se asocian con un mayor aumento de PCR y procalcitonina en primeras 24 h. La disminución de arginina en las primeras 12 h se correlaciona inversamente con estancia más larga, mayor número de complicaciones y aumento de reactantes de fase aguda en día 3. CONCLUSIONES: Hay disminución de arginina y citrulina en los primeros días de la enfermedad crítica, con recuperación al 3.er y 7.° día, respectivamente, y existe una relación entre mayor disminución y peor evolución

INTRODUCTION: Low concentrations of plasma citrulline and arginine have been reported in children under various pathological conditions. Hypothesis: Plasma citrulline and arginine levels undergo different kinetics during the early days of critical illness in children according to the severity of symptoms and can be correlated with other clinical and laboratory parameters associated with the SIR. PATIENTS AND METHODS: A single-center prospective observational study in patients 7 days to 14 years admitted to pediatric intensive care unit (PICU). Citrulline and arginine blood levels (blood in dry paper, analysis by mass spectrometry in tandem), acute phase reactants and clinical data were collected on admission, at 12 h, 24 h, 3 and 7 days. RESULTS: A total of 44 critically ill patients were included and control group was formed by 42 healthy children. The citrulline and arginine kinetic analysis showed: 1) Citrulline falls significantly (P<.05) at 12 h of admission; levels remain low until day 7 and begin progressive increase again. 2) Arginine is already lowered at 6h, although an earlier rise occurs (3rd day). 3. The decrease of citrulline in the first 3 days of admission positively correlates with arginine kinetics. Bivariate analysis showed: 1) Correlation of elevated citrulline on the 7th day with shorter duration of mechanical ventilation, lower PICU stay and lower occurrence of complications. The levels of citrulline still descended at day 7 are associated with increased CRP/procalcitonin elevation at first 24 h. 2) The greatest decrease of arginine in the first 12 h is associated with a longer PICU stay and greater number of complications and increase of acute phase reactants at 3 days. CONCLUSIONS: There are decreased levels of arginine and citrulline in the first days at PICU, with recovery at the 3rd and 7th day respectively, and a relationship between a greater decrease and a worse outcome and between a longer income and a higher serum CRP/procalcitonin

On the prediction of Hodgkin lymphoma treatment response

Purpose. The cure rate in Hodgkin lymphoma is high, but the response along with treatment is still unpredictable and highly variable among patients. Detecting those patients who do not respond to treatment at early stages could bring improvements in their treatment. This research tries to identify the main biological prognostic variables currently gathered at diagnosis and design a simple machine learning methodology to help physicians improve the treatment response assessment. Methods. We carried out a retrospective analysis of the response to treatment of a cohort of 263 Caucasians who were diagnosed with Hodgkin lymphoma in Asturias (Spain). For that purpose, we used a list of 35 clinical and biological variables that are currently measured at diagnosis before any treatment begins. To establish the list of most discriminatory prognostic variables for treatment response, we designed a machine learning approach based on two different feature selection methods (Fisher’s ratio and maximum percentile distance) and backwards recursive feature elimination using a nearest-neighbor classifier (k-NN). The weights of the k-NN classifier were optimized using different terms of the confusion matrix (true- and false-positive rates) to minimize risk in the decisions. Results and conclusions. We found that the optimum strategy to predict treatment response in Hodgkin lymphoma consists in solving two different binary classification problems, discriminating first if the patient is in progressive disease; if not, then discerning among complete and partial remission. Serum ferritin turned to be the most discriminatory variable in predicting treatment response, followed by alanine aminotransferase and alkaline phosphatase. The importance of these prognostic variables suggests a close relationship between inflammation, iron overload, liver damage and the extension of the disease (AU)

No disponible

Pensando en la dermatitis perianal / Thinking of perianal dermatitis

Introducción: la dermatitis perianal es una entidad infradiagnosticada, habitualmente producida por el estreptococo β-hemolítico del grupo A (EBHGA). La epidemiología, clínica y complicaciones están ampliamente descritas en la bibliografía. El diagnóstico es microbiológico y el tratamiento de elección asocia antibioterapia oral y tópica. Objetivo: describimos el cuadro clínico y manejo de seis pacientes para mejorar el índice de sospecha clínico. Serie de casos: seis pacientes (cinco varones). Edades: de nueve meses a cinco años (media de tres años). Clínica: seis con eritema perianal, tres con dolor defecatorio, dos con prurito, una con vaginitis. Se realizó una detección rápida de antígeno estreptocócico en cinco pacientes, de los que cuatro eran positivos inicialmente. En todos se recogió frotis rectal y en todos los cultivos creció EBHGA. Recibieron todos antibiótico oral (cinco penicilina y uno amoxicilina), asociando en cuatro mupirocina y en tres clotrimazol tópicos. Evolución satisfactoria. Discusión: los casos descritos concuerdan clínica y epidemiológicamente con la bibliografía. Es necesaria la sospecha clínica y el test rápido para el diagnóstico y tratamiento precoces (AU)

Introduction: perianal dermatitis is a misdiagnosed entity usually caused by group A beta-hemolytic streptococci (GABHS). Epidemiology, symptoms and complications are widely described in literature. The diagnosis is microbiological and the association of oral and topic antibiotic is the first choice of treatment. Objectives: we report the symptoms and management of six patients in order to improve the degree of clinical suspicion. Case-Series: patients: 6 (5 males). Ages: 9 months to 5 years (mode 3 years). Clinical presentation: 6 perianal rash, 3 rectal pain, 2 itching, 1 vaginitis. A rapid streptococcal test was done in 5 patients, 4 were initially positive. A rectum smear was taken in all patients, all of them showed GABHS growing. All patients were treated with oral antibiotic (5 penicillin, 1 amoxicillin), topic mupirocine was associated in 4 and clotrimazol in 3 patients. Satisfactory evolution. Discussion: the cases showed are clinical and epidemiologically concordant with the literature. Clinical suspicion and a rapid streptococcal test are necessary to get an early diagnosis and treatment (AU)

Injuries and illnesses during the 2011 Paris European Athletics Indoor Championships.

This study aimed to record and analyse incidence and characteristics of injuries and illnesses incurred during the Indoor Athletics Championships. During the 2011 European Indoor Athletics Championships in Paris, incidence and characteristics of new injuries and illnesses were recorded prospectively by physicians and physiotherapists from national teams and local organizing committee in 631 registered athletes. Around 70% of athletes were covered by the medical teams (response rate: 84%). Thirty injuries, including eight time-loss injuries, were reported, representing an incidence of 47.5 injuries and 29.4 time-loss injuries per 1000 registered athletes. Injury and time-loss injury risk were highest in heptathlon and hurdles. Three-quarters of injuries affected the lower extremity. Thigh strain was the most common diagnosis (n = 7; 23%). Noncontact trauma (n = 9; 30%) was the predominant cause. A total of 18 illnesses were reported. Incidence of illnesses was 28.5 per 1000 registered athletes, with 17% resulting in time lost from sport. Upper respiratory tract infection was the most common diagnosis (n = 8; 44%) followed by upper respiratory tract allergy (n = 3; 17%) and gastroenteritis (n = 3; 17%). Injury and illness incidence and severity were lower during the 2011 European Indoor Athletics Championships than during outdoor championships, probably due to the shorter duration, the fewer number of events, and shorter sprint distances.

Rentabilidad diagnóstica de los estudios PET/TC basal y de seguimiento en la terapia ablativa del cáncer de pulmón de células no pequeñas / Diagnostic yield of baseline and follow-up PET/CT studies in ablative therapy for non-small cell lung cancer

Aunque con efectividad probada, las técnicas de ablación por radiofrecuencia y microondas presentan un elevado índice de respuestas parciales. Es imprescindible contar con estudios diagnósticos que se anticipen a los cambios morfológicos para una detección más temprana del tejido tumoral residual viable o de recurrencias locales para determinar los pacientes que serán beneficiados de un nuevo tratamiento. Determinamos mediante nuestro estudio la rentabilidad diagnóstica de los estudios de PET/CT basal y de seguimiento y el tiempo adecuado entre estos y la intervención por ablación. Incluimos 7 pacientes con lesión tumoral única con un total de 8 ablaciones. Hemos realizado estudios CT y PET/CT basales y de seguimiento tras ablación. Los tiempos medios entre estudios PET basales y de seguimiento y la terapia ablativa fueron 1,8 y 3,4 meses respectivamente. Las cuentas medias en actividades metabólicas de los PET basales y de seguimiento han sido de 7,6 y 4,3g/ml de SUVmax respectivamente. La técnica de Dual Time Point ayudó en 3 casos a identificar tejido viable tras ablación. Los estudios de seguimiento PET/CT han condicionado las diversas estrategias terapéuticas adoptadas por los oncólogos clínicos. El alto rendimiento del estudio PET/CT incluyendo la técnica de Dual Time Point puede plantearse como estudio de sustitución de los CT con CIV basales y de seguimiento previo y posterior al tratamiento con ARF o AMO logrando reducir de manera considerable la exposición a altas cifras de radiación. Proponemos realizar el primer estudio PET/CT de seguimiento a los 3 meses de realizada la ARF o AMO(AU)

Although they have proven effectiveness, radiofrequency and microwave ablation techniques have a high rate of partial responses. Diagnostic studies that anticipate the changes in morphology are essential for earlier detection of residual viable tumor tissue or local recurrences to identify patients who will benefit from a new treatment. Our study has determined the diagnostic yield of PET/CT studies at baseline and follow-up and adequate time between them and the ablation intervention. Seven patients with single tumor lesion with a total of 8 ablations were included. CT and PET/CT studies were performed at baseline and follow-up after ablation. Average times between PET studies at baseline and follow-up and the ablative therapy were 1.8 and 3.4 months, respectively. Mean scores in metabolic activities of the PET at baseline and follow-up were 7.6 and 4.3g/ml of SUVmax, respectively. The Dual Time Point technique helped to identify viable tissue after ablation in 3 cases. Follow-up PET/CT studies have conditioned the various treatment strategies adopted by clinical oncologists. The high yield of the PET/CT study including the Dual Time Point technique may be considered as a study replacement of initial and follow-up Contrast-Enhanced CT before and after treatment with RFA and AMO, this achieving considerable reduction in the exposure to high radiation levels. We propose conducting the first PET/CT follow-up study at 3 months of the RFA and AMO(AU)

18F-FDG-PET/TC en linfoma: dos décadas de experiencia / 18F-FDG-PET/CT in lymphoma: two decades of experience

El uso del 18F-FDG-PET/TC ha introducido cambios relevantes en el manejo de los pacientes con linfoma en las últimas dos décadas. Esta técnica de imagen funcional permite mejorar la estadificación inicial de la enfermedad, realizar una aproximación pronóstica y planificar un tratamiento adecuado, monitorizar la respuesta a las terapias instauradas y hacer un seguimiento para el diagnóstico de recidiva y reestadificación del linfoma. Sin embargo, aún existen controversias sobre el tema en la literatura médica que repercuten en la práctica diaria. Esta profunda revisión bibliográfica resume la información actual sobre el uso potencial de 18F-FDG-PET/TC en pacientes con linfoma, destacando sus principales aplicaciones y los dilemas que se presentan al evaluar este tipo de estudios, intentando estandarizar criterios para su valoración, particularmente en la reestadificación y monitorización de la terapia(AU)

The use of 18F-FDG-PET/CT has changed the management of patients with lymphoma for the last two decades. This technique improves initial staging of the disease, making a prognostic approach and appropriate treatment planning, as well as monitoring therapy response of lymphoma. However, there are still controversial issues in medical literature that impact on daily clinical practice. This comprehensive literature review summarizes the current information regarding the potential use of 18F-FDG-PET/CT in patients with lymphoma, highlighting the main applications and the current dilemmas for the nuclear medicine physicians at the time of the evaluation of these studies, trying to standardize criteria for its assessment, particularly in restaging and therapy monitoring(AU)

Estenosis hipertrófica de píloro y anestesia espinal / Hypertrophic pyloric stenosis and spinal anesthesia

Introducción: La realización de la piloromiotomía extramucosa con abordaje umbilical o supraumbilical bajo anestesia espinal puede contribuir a la disminución de la morbimortalidad potencial asociada al tratamiento quirúrgico de la estenosis hipertrófica de píloro (EHP).Pacientes y métodos: Se realizó un estudio retrospectivo de 60 pacientes con EHP. Se analizaron la edad al diagnóstico, clínica, tipo de anestesia y evolución postoperatoria. En 50 pacientes se indujo anestesia general con atropina,fentanilo, propofol, succinil-colina y sevoflurano. En 10pacientes se realizó bloqueo espinal con bupivacaína 0,5%hiperbárica espinal y sedación con bolos de propofol. Resultados: La edad media al diagnóstico fue de 34,07días. Todos presentaron vómitos proyectivos, y se asociaron a pérdida de peso (33,3%), irritabilidad (15%), deshidratación(6,6%), ictericia (5%) y estreñimiento (5%). El tiempo medio de evolución fue de 4,8 días. El diagnóstico se realizó mediante ecografía abdominal en todos los casos. En los casos de anestesia espinal, el bloqueo se instauró en menos de 10 minutos, los niveles sensitivos alcanzados oscilaron entre T3-T5 y el tiempo medio de duración fue de 60minutos. En ningún caso se registró bradicardia <100 latidos/minuto, saturación <95%, apneas >15 segundos, ni cambios en la tensión arterial >15%. El inicio medio de la tolerancia oral fue de 18,7 horas para los pacientes intervenidos con anestesia general, y de 9,5 horas para el grupo de anestesia espinal. Un paciente precisó ingreso postoperatorio en la UCI pediátrica por necesidad de intubación prolongada. Conclusiones: La anestesia espinal en la piloromiotomía extramucosa es una alternativa segura a la anestesia general. El acceso y las condiciones quirúrgicas son iguales a los realizados bajo anestesia general. Nuestros resultados sugieren que puede disminuir el tiempo de inicio de toleranci aoral y de ingreso hospitalarios (AU)

Background: The pyloromyotomy procedure with umbilicalor supraumbilical incision is generally performed undergeneral anesthesia. Potential morbimortality is associated with postoperative apnoea and pulmonary aspiration. Spinal anesthesia may contribute to decrease these complications. Patients and methods: We report a retrospective study of60 patients with congenital pyloric stenosis (CPS). We analyzed the age at diagnosis, symptoms, anesthesia and postoperative outcome. Fifty patients received general anesthesia with atropine, fentanyl, propofol, succinylcholine and sevoflurane. Ten patients underwent spinal anesthesia with hyperbaricbupivacaine 0,5% and bolus of propofol for sedation. Results: Mean age at diagnosis was 34,07 days. All the patients were admitted because of projectile vomiting, with weight loss (33,3%), irritability (15%), dehydratation (6,6%),jaundice (5%) and constipation (5%). Mean time of symptoms was 4,8 days. The diagnosis was made with abdominal ultrasounds in all patients. In case of spinal anesthesia, the blockade was effective in less than 10 minutes, the sensory level was between T3-T5 and it lasted a medium time of 60 minutes. In no case we registered bradycardia <100beats/minute, saturation <95%, apnoeas >15 seconds, or changes in arterial pressure >15%. Start of oral intake began18,7 hours postsurgery in the general anesthesia group, and9,5 hours in the spinal anesthesia group, although there was no statistically significant differences. One patient of the general anesthesia group was admitted in the pediatric intensive care unit for prolonged apnoea. Conclusions: Spinal anesthesia for pyloromyotomy is a safe alternative to general anesthesia. The surgical incision and conditions are the same as those related to general anesthesia. Our results suggest that the beginning of oral intake and total hospital stay could be reduced (AU)

[Immunity and pathophysiology of respiratory tract infections]. / Immunité et physiopathologie des infections de l'arbre respiratoire.

The respiratory tract is permanently exposed to infections that may remain localized (bronchitis, pneumonias) or become potentially invasive (bacteremia and meningitis). It can be considered as an immunologic organ the upper part of which, the tracheobronchial tree, has the same secretory epithelium as the naso-oropharynx and shares bronchial associated lymphoid tissue (BALT). In this tissue, secretory IgA are more abundant than IgG. It is colonized by a commensal bacterial flora, including some potentially pathogenic species (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis). The pulmonary compartment includes the bronchioles and the alveoli, the wall of which is made of pneumocytes, resident macrophages, plasmocytoid dendritic cells and T cells. This wall is protected by a film that contains microbicidal agents, such as surfactant and phospholipase A2. Immune defenses of the respiratory tract involve mechanical factors, mucociliary escalator, receptor and effector molecules of the innate immune system and, by the proximity of lymph and blood vessels, humoral and cellular effectors of adaptative immunity. However, this sophisticated respiratory tract immune system can be bypassed in the non immunized host by infections due to primary pathogens (tuberculosis, plague, whooping cough, influenza) and may be impaired by endogenous factors (genetic defects, iatrogenic disorders) or exogenous factors (chemical pollutants, respiratory viruses) making the host susceptible to occasional pathogens, including commensal organisms.

Hyperinvasive genotypes of Neisseria meningitidis in France.

Clinical isolates of Neisseria meningitidis from cases of meningococcal disease, collected between January 2000 and December 2004, were identified and typed at the French National Reference Centre. A representative subset of 546 isolates from among 2882 isolates was further genotyped by multilocus sequence typing to determine their genetic lineages (clonal complexes) and the degree of diversification among different clonal complexes. Representative isolates of the main clonal complexes were tested for their virulence in mice and for proapoptotic effects on human epithelial cells. High genetic diversity in some genetic lineages (ST-32 and ST-41/44) was correlated with heterogeneity in virulence in mice and proapoptotic effects on human epithelial cells. In contrast, the homogeneous genetic structure of isolates of the ST-11 clonal complex, regardless of their serogroup, correlated positively with a fatal outcome of the infection, increased virulence in mice and increased proapoptotic effects on human epithelial cells.

[Characteristics of meningococcal meningitis in children in France]. / Caractéristiques des méningites à méningocoque de l'enfant en France.

BACKGROUND: In France, meningococcal meningitis account for 50% of bacterial meningitis in children. The GPIP/ACTIV (Groupe de Pathologie Infectieuse Pédiatrique and Association Clinique et Thérapeutique Infantile du Val de Marne) set up an active surveillance network to analyze the epidemiological, clinical and biological features of meningococcal meningitis. METHODS: From 2001 to 2007, 252 French paediatric wards working with 166 microbiology laboratories enrolled all children (0-18 years old) with bacterial meningitis. Risk factors, signs and symptoms, vaccination status, cerebrospinal fluid analysis, treatments and case fatality rate were recorded. RESULTS: During the period of the study, 1344 meningococcal meningitis were reported among 2951 (45.5%) bacterial meningitis. Mean age was 4.4 years (+/-4.7, median 2.5) and 2/3 cases occurred in children under 5 years (68.5%). Serogroup B (59.1%) was preponderant following by serogroup C (28.9%). 25% of children had received an antibiotic treatment 24hours before lumbar puncture. A shock was reported in 31.3% of cases. Cerebrospinal fluid culture was positive in 73% of cases. All N. meningitidis isolates were susceptible to cefotaxime and ceftriaxone while 41.6% and 25.7% showed reduced susceptibility to penicillin and amoxicillin respectively. Two cases of meningitis due to isolates of serogroups C and B were reported in two children that were respectively vaccinated using A+C plain saccharide vaccine or two doses of MenBvac vaccine. All patients had received beta-lactamin. Global case fatality rate was 6.6% but was higher (9.9%) for serogroup C than for serogroup B (5.5%) (p=0,007). CONCLUSION: This study is among the largest series of microbiologically documented meningococcal meningitis to date (more than 1300 cases). In France, meningococal is responsible for 50 % of meningitis. Effective meningococcal serogroup B vaccine and serogroup C vaccination recommendation could lessen considerably the burden of meningococal meningitis.

Retinogeniculate connections: A balancing act between connection specificity and receptive field diversity.

Retinogeniculate connections are one of the most striking examples of connection specificity within the visual pathway. In almost every connection there is one dominant afferent cell per geniculate cell, and both afferent and geniculate cells have very similar receptive fields. The remarkable specificity and strength of retinogeniculate connections have inspired comparisons of the lateral geniculate nucleus (LGN) with a simple relay that connects the retina with the visual cortex. However, because each retinal ganglion cell diverges to innervate multiple cells in the LGN, most geniculate cells must receive additional inputs from other retinal afferents that are not the dominant ones. These additional afferents make weaker connections and their receptive fields are not as perfectly matched with the geniculate target as the dominant afferent. We argue that these 'match imperfections' are important to create receptive field diversity among the cells that represent each point of visual space in the LGN. We propose that the convergence of dominant and weak retinal afferents in the LGN multiplexes the array of retinal ganglion cells by creating receptive fields that have a richer range of positions, sizes and response time courses than those available at the ganglion cell layer of the retina.