Estudio observacional del uso de etanercept biosimilar en el tratamiento de enfermedades reumáticas / Etanercept in rheumatic diseases: observational study

Objetivos: 1.- Conocer la respuesta a etanercept biosimilar (E-BS) en pacientes naive y en pacientes a los que se realizó cambio desde el de referencia (E-R), diagnosticados de enfermedades reumáticas. 2.- Evaluar el impacto económico de estas actuaciones.Métodos: Estudio observacional retrospectivo de 110 pacientes en tratamiento con etanercept (referencia y/o biosimilar). Se analizaron dos grupos de pacientes: 62 pacientes que iniciaron tratamiento con E-BS y 48 pacientes a los que se les realizó cambio desde E-R (switch), y se compararon con grupos control. Variables analizadas: edad, sexo, diagnóstico, tratamiento, unidades dispensadas, modificaciones del tratamiento, motivo de suspensión o cambio, fecha de suspensión y tiempo de seguimiento. Se comparó el coste de la utilización del biosimilar y del que hubiera supuesto el de referencia.Resultados: Las tasas de retención observadas fueron: 65% en los naive (p=0,002) y 90% en los switch. En pacientes naive, el principal motivo de cambio fue respuesta parcial o insuficiente (90%) y en switch posible efecto nocebo (60%). No se observaron reacciones adversas. Al comparar estos grupos con poblaciones control, la principal diferencia fue la proporción de pacientes en los que se mantuvo tratamiento con E-BS frente a E-R, en pacientes naive (65% vs 34%; p=0,003) y switch (90% vs 27%; p<0,0001). La utilización de E-BS supuso un ahorro de 653.668 €.Conclusiones: La utilización de E-BS no fue diferente del E-R en cuanto a resultados clínicos y, desde el punto de vista económico, supone un ahorro sustancial que se debe considerar como medida que ayude a la sostenibilidad del sistema. (AU)

Objetive: 1.- To know the response to biosimilar etanercept (E-BS) in naive patients and in patients who change from the reference (E-R), diagnosed with rheumatic diseases. 2.- To evaluate the economic impact of these actions.Methods: Retrospective observational study of 110 patients in treatment with etanercept (reference and/or biosimilar). Two groups of patients were analyzed: 62 patients who started with E-BS and 48 patients who change from E-R (switch), and they were compared with control groups. Variables analyzed: age, sex, diagnosis, treatment, units dispensed, treatment modifications, reason for suspension or change, date of suspension and follow-up time. The cost of using the biosimilar was compared with that of the reference one.Results: The retention rates observed were: 65% in the naive (p=0.002) and 90% in switch. In naive patients, the main reason for change was partial or insufficient response (90%) and a possible nocebo effect in switch (60%). No adverse reactions were observed. When comparing these groups with control populations, the main difference was the proportion of patients in whom treatment with E-BS was maintained versus ER, in naive patients (65% vs 34%; p=0.003) and in switch (90% vs 27%; p<0.0001). The use of E-BS meant a saving of € 653,668.Conclusions: The use of E-BS was not different from the E-R in terms of clinical results and, from the economic point of view, represents a substantial saving that should be considered as a measure that helps the sustainability of the system. (AU)

Impacto económico de las nuevas terapias orales en esclerosis múltiple / Economic impact of the new oral treatments for multiple sclerosis

INTRODUCCIÓN: La esclerosis múltiple (EM) es una enfermedad crónica del sistema nervioso central que se caracteriza por la existencia de inflamación, desmielinización, gliosis y daño axonal. La introducción de dimetilfumarato y teriflunomida ha supuesto un aumento de las alternativas terapéuticas en la primera línea de tratamiento de la EM. El objetivo de este estudio fue evaluar el impacto económico de la incorporación de estas nuevas terapias orales en la Unidad de Referencia (CSUR) del Hospital Universitario Puerta de Hierro Majadahonda. MATERIAL Y MÉTODOS: Se realizó un estudio observacional retrospectivo en la población de pacientes diagnosticados de EM, en tratamiento con fármacos modificadores de la enfermedad durante el año 2015, y su seguimiento se prolongó hasta obtener un seguimiento medio superior a un año de tratamiento. Los datos se recogieron de la historia clínica electrónica y del programa de dispensación de medicamentos a pacientes externos y ambulantes del Servicio de Farmacia. RESULTADOS: Evaluando el coste del cambio del tratamiento en 125 pacientes desde otros fármacos a dimetilfumarato o teriflunomida y comparando con el coste que habría supuesto el mantenimiento de los tratamientos previos, el ahorro total durante el periodo de observación fue de 169.107,31 (Euro). CONCLUSIONES: Dimetilfumarato y teriflunomida, además de aportar nuevas alternativas terapéuticas, no solo no han supuesto un incremento sino, por el contrario, una disminución en los costes del tratamiento de la EM en nuestro hospital

INTRODUCTION: Multiple sclerosis (MS) is a chronic disease affecting the central nervous system and is characterised by inflammation, demyelination, gliosis, and axonal damage. The introduction of dimethyl fumarate and teriflunomide has led to an increase in the number of alternative first-line therapies for MS. The objective of this study was to evaluate the economic impact of the incorporation of new oral therapies at the reference unit (CSUR) at Hospital Universitario Puerta de Hierro Majadahonda. MATERIALS AND METHODS: We performed a retrospective observational study including patients diagnosed with MS, who underwent treatment with disease-modifying drugs in 2015 and were followed up for a minimum mean time of one year. Data were collected from patients' electronic clinical histories and the pharmacy service's programme for dispensing drugs to outpatients. RESULTS: Evaluating the cost of changing 125 patients' treatment from other drugs to dimethyl fumarate and teriflunomide, and comparing this with the cost that would have resulted from maintaining their previous treatment, demonstrated a total saving of (Euro)169,107.31 over the study period. CONCLUSIONS: In addition to contributing new therapeutic alternatives, dimethyl fumarate and teriflunomide produced an economic saving in MS treatment at our hospital

Economic impact of the new oral treatments for multiple sclerosis. / Impacto económico de las nuevas terapias orales en esclerosis múltiple.

INTRODUCTION: Multiple sclerosis (MS) is a chronic disease affecting the central nervous system and is characterised by inflammation, demyelination, gliosis, and axonal damage. The introduction of dimethyl fumarate and teriflunomide has led to an increase in the number of alternative first-line therapies for MS. The objective of this study was to evaluate the economic impact of the incorporation of new oral therapies at the reference unit (CSUR) at Hospital Universitario Puerta de Hierro Majadahonda. MATERIALS AND METHODS: We performed a retrospective observational study including patients diagnosed with MS, who underwent treatment with disease-modifying drugs in 2015 and were followed up for a minimum mean time of one year. Data were collected from patients' electronic clinical histories and the pharmacy service's programme for dispensing drugs to outpatients. RESULTS: Evaluating the cost of changing 125 patients' treatment from other drugs to dimethyl fumarate and teriflunomide, and comparing this with the cost that would have resulted from maintaining their previous treatment, demonstrated a total saving of €169,107.31 over the study period. CONCLUSIONS: In addition to contributing new therapeutic alternatives, dimethyl fumarate and teriflunomide produced an economic saving in MS treatment at our hospital.

Classification of radiologically isolated syndrome and clinically isolated syndrome with machine-learning techniques.

BACKGROUND AND PURPOSE: The unanticipated detection by magnetic resonance imaging (MRI) in the brain of asymptomatic subjects of white matter lesions suggestive of multiple sclerosis (MS) has been named radiologically isolated syndrome (RIS). As the difference between early MS [i.e. clinically isolated syndrome (CIS)] and RIS is the occurrence of a clinical event, it is logical to improve detection of the subclinical form without interfering with MRI as there are radiological diagnostic criteria for that. Our objective was to use machine-learning classification methods to identify morphometric measures that help to discriminate patients with RIS from those with CIS. METHODS: We used a multimodal 3-T MRI approach by combining MRI biomarkers (cortical thickness, cortical and subcortical grey matter volume, and white matter integrity) of a cohort of 17 patients with RIS and 17 patients with CIS for single-subject level classification. RESULTS: The best proposed models to predict the diagnosis of CIS and RIS were based on the Naive Bayes, Bagging and Multilayer Perceptron classifiers using only three features: the left rostral middle frontal gyrus volume and the fractional anisotropy values in the right amygdala and right lingual gyrus. The Naive Bayes obtained the highest accuracy [overall classification, 0.765; area under the receiver operating characteristic (AUROC), 0.782]. CONCLUSIONS: A machine-learning approach applied to multimodal MRI data may differentiate between the earliest clinical expressions of MS (CIS and RIS) with an accuracy of 78%.

[Spanish versions of the Minimental State Examination (MMSE). Questions for their use in clinical practice]. / Versiones en español del Minimental State Examination (MMSE). Cuestiones para su uso en la practica clinica.

The Minimental State Examination (MMSE), created in 1975 as a tool for briefly evaluating the patient's mental state, has been widely used and is the most frequently cited cognitive test on Medline, as well as being the one with the most versions in different languages (over 70). Through a review of the Medline database, this paper aims to analyse its virtues and shortcomings, in addition to determining its current clinical usefulness, in both the original version and any of its modifications, although here we are mainly concerned with its Spanish adaptations. The MMSE (original or versions) is the most commonly used test for standardised cognitive assessment in the clinical setting, especially in the case of the elderly. It is the test with the most data for screening, staging and monitoring dementias. Yet, because filling it in may take over 10 minutes, it has to compete with shorter, more specific screening tests in the primary care and community setting. In the hospital and specialised setting, there is a need for broader standardised neuropsychological tests that make it possible to detect subtle cognitive disorders in patients with incipient dementia or mild cognitive impairment, as well as to establish a cognitive profile of the different subtypes of dementia. This study proposes a series of recommendations on the clinical use of the Spanish versions of the MMSE in different contexts of application.

TITLE: Versiones en español del Minimental State Examination (MMSE). Cuestiones para su uso en la practica clinica.El Minimental State Examination (MMSE), creado en 1975 como instrumento para la evaluacion breve del estado mental, ha tenido una gran difusion, y es el test cognitivo mas citado en Medline y con mayor numero de versiones idiomaticas (superiores a 70). Este articulo pretende, mediante una revision en la base de datos Medline, analizar sus virtudes y limitaciones, ademas de precisar su utilidad clinica actual, tanto de la version original como de sus modificaciones, principalmente de las adaptaciones al español. El MMSE (original o versiones) es el test mas utilizado para la evaluacion cognitiva estandarizada en el ambito clinico, sobre todo en el anciano. Es el que dispone de mas datos para el cribado, estadiaje y seguimiento de las demencias. Sin embargo, dado que su cumplimentacion puede requerir mas de 10 minutos, ha de competir con tests de cribado mas cortos y especificos en atencion primaria y el medio comunitario. En el ambito hospitalario y especializado, se precisan evaluaciones neuropsicologicas estandarizadas mas amplias que permitan detectar alteraciones cognitivas sutiles en pacientes con demencia incipiente o alteracion cognitiva leve, ademas de establecer un perfil cognitivo de los diferentes subtipos de demencias. Este trabajo realiza una serie de recomendaciones sobre el uso clinico de las versiones españolas del MMSE en diferentes contextos de aplicacion.

La epistaxis como efecto secundario del tratamiento con oxibutinina en la hiperactividad vesical / Epistaxis as a side effect of the treatment of bladder hyperactivity with oxybutynin

No disponible

Supplementation of University of Wisconsin solution with Nitroglycerin and Nicorandil in long-term myocardial preservation: effects on the oxidative state, endothelial function and morphology.

The purpose of this study was to assess the effects of the addition of Nitroglycerin or Nicorandil to University of Wisconsin solution in long-term myocardial preservation. In a model of heterotopic heart transplantation in pigs, the donor heart was preserved for 24 hours by means of continuous perfusion in this solution, in the presence or absence of these drugs. During this period, the oxygenation and pH of the solution were measured, as were lactate concentrations and enzyme release. At regular intervals following reperfusion we measured the concentrations of enzymes, antioxidants, glutathione peroxidase, glutathione reductase, malondialdehyde, endothelin and nitrite, and, two hours later, samples of both ventricles were taken for a morphological study. In the treated groups there was a higher lactate production during preservation and, during reperfusion, the signs of contracture and the elevation of enzyme levels were more marked than in the untreated groups. In contrast, the glutathione reductase concentrations did not decrease during the first phase of reperfusion and were directly correlated with those of antioxidants, endothelin levels increased less than in the untreated groups and, in the case of nitroglycerin, the nitrite concentration was significantly greater than in the remaining groups. We conclude that nitroglycerin and nicorandil improved the oxidative state and endothelial function and did not produce substantial morphological changes, but increased cell necrosis and contracture, possibly due to the duration of ischemia.

[Short term evaluation of transanal pull-through with automatic suture]. / Valoración a corto plazo del descenso transanal con sutura automática.

For the last ten years many centres have adopted transanal pull-through (TP) as the first choice technique for the treatment of Hirschsprung's Disease (HD) affected children. We present our experience, based on the endorectal pull-through with autosuture, which has not been reported up to now. According to our HD management programme, TP with autosuture should be performed in rectosigmoid forms of HD which are easily handled with outpatient care. Seven patients with HD whose ages ranged from 5-months-old to 5-years-old underwent EP with autosuture. We present the short term results of the evolution of our patients. Firstly, a laparoscopic procedure is carried out in order to obtain a biopsy from the transition zone. The second stage consists of the TP following the De La Torre technique, modified by the 21 mm circular autosuture. No new surgical operation was necessary. Passage of stools started between the second and fourth postoperative day. The most frequent complication was abdominal distention, found in an 85.7% of patients and resolved before being discharged. Hospital discharge took place between the fourth and the tenth postoperative day. Oral feeding was started in the 2nd-7th postoperative day. Medium term outcomes show a single case of complications: a patient Developer a skin stricture due to the low suture, which has been treated conservatively with rectal dilatations. Patients older than three (42.8%) are continent, although one presents occasional fecal soiling. The rest of the children present normal stools for their age. Automatic suture involves several advantages such as celerity and safety. We ought to point out that this method should not be used in children under 5 months because the autosuture size does not allow to do so.

Valoración a corto plazo del descenso transanal con sutura automática / Short term evaluation of transanal pull-through with automatic suture

En los últimos 10 años el descenso transanal (DT) se ha popularizado en muchos centros como técnica de elección para el tratamiento de la enfermedad de Hirschsprung (EH). Presentamos nuestra experiencia de DT con autosutura, inédita en la literatura. En nuestro programa de tratamiento de la EH aplicamos el DT para las formas de afectación recto-sigmoidea de fácil manejo ambulatorio. Hemos practicado un estudio retrospectivo de la evolución de 7pacientes con edades comprendidas entre 5 meses y 5 años a los que se les ha realizado un descenso transanal con autosutura en los dos últimos años. Nuestra técnica se desarrolla en dos pasos. En un primer tiempo practicamos una biopsia laparoscópica, en el segundo tiempo se realiza un descenso endorrectal según la técnica de De La Torre, modificado con autosutura circular de 21mm. En ningún caso se han precisado reintervenciones. Nuestros pacientes empezaron a realizar deposiciones entre el 2º y 4º día postoperatorio (DPO). La complicación más frecuente fue distensión abdominal en (..)

For the last ten years many centres have adopted transanal pull-through(TP) as the first choice technique for the treatment of Hirschsprung’s Disease (HD) affected children. We present our experience, based on the endorectal pull-through with autosuture, which has not been reported up to now. According to our HD management programme, TP with autosuture should be performed in rectosigmoid forms of HD which are easily handled with outpatient care. Seven patients with HD whose ages ranged from 5 months old to 5 years old underwent EP with autosuture. We present the short term results of the evolution of our patients. Firstly,a laparoscopic procedure is carried out in order to obtain a biopsy from the transition zone. The second stage consists of the TP following the De La Torre technique, modified by the 21 mm circular autosuture. No new surgical operation was necessary. Passage of stools started between the second and fourth postoperative day. The most frequent complication was abdominal distention, found in an 85.7% of patients and resolved before being discharged. Hospital discharge took place (..) (AU)

[Impact in our environment of a gastroschisis therapeutic management protocol]. / Impacto en nuestro medio de un protocolo de manejo terapéutico de la gastrosquisis.

INTRODUCTION: Continuous exposure to amniotic in fetus with gastroschisis, leads to inflammation and edema of intestinal loops, hindering intestinal return to abdomen and making staged repair necessary in many cases. Furthermore, intestinal loops are hipoperistaltic, which leads to oral toleration difficulties, large periods of parenteral nutrition and an increase of hospital stay. The objective of this study is to evaluate the results in our environment, of a new multidisciplinary management protocol in patients with a prenatal diagnosis of gastroschisis. PATIENTS AND METHODS: Between January 2003 and May 2006, six cases of prenatal diagnosis of gastroschisis were included in the protocol. This consisted in a weekly ultrasound monitorization of the gestants which showed prenatal diagnosis of gastroschisis and elective delivery by caesarean section on the 39th week and if early signs of intestinal suffering appear (bowel diameter > 17 mm or wall thickening > 3 mm), in order to prevent harm to intestinal loops and its consequences in the neonatal period. After birth, bowel reduction through the defect was performed under general anaesthesia in the operating room. Gestational age at delivery, bowel appearance, associated anomalies, incidence of sepsis and intestinal obstruction in the postoperative period, PN and hospital stay are analyzed in a prospective descriptive study. RESULTS: Mean gestational age at delivery was 36,3 weeks (range 35-38). In all the cases, except one, bowel loops presented a nearly normal appearance, without signs of chronic inflammation. As associated anomalies we found two cases of intraabdominal testis and one of hypertrophic pyloric stenosis. No evidence of intestinal atresia in any case. Mean time of PN was 28 days. Two patients developed sepsis with good outcome with intravenous antibiotics treatment. No cases of intestinal obstruction in the immediate or late postoperative period were observed. Mean time of hospital stay was 38,8 days, with mean stay in neonatal care unit of 4 days. CONCLUSIONS: . Weekly ultrasound monitorization assessment in cases of prenatally-diagnosed gastroschisis allows early detection of bowel suffering signs, before chronic inflammatory damage of the herniated intestinal loops. The application of this prenatal gastroschisis management protocol permits normal gestation without having to anticipate delivery in practically all cases, minimizing consequences of prematurity.

Impacto en nuestro medio de un protocolo de manejo terapéutico de la gastrosquisis / Impact in our environment of a gastroschisis therapeutic management protocol

Introducción. En la gastrosquisis, la exposición continuada al líquidoamniótico provoca edema e inflamación de las asas intestinales, dificultandosu reintroducción en el abdomen y haciendo necesario enmuchas ocasiones un cierre diferido. Por otra parte, las asas inflamadasson hipoperistálticas, lo que conlleva dificultad para la tolerancia oral,largos periodos de nutrición parenteral y aumento de la estancia hospitalaria.El objetivo del trabajo es evaluar los resultados en nuestro mediode un nuevo protocolo de manejo multidisciplinar en pacientes con diagnósticoprenatal de gastrosquisis.Pacientes y método. Entre enero 2003 y mayo 2006, seis casos condiagnóstico prenatal de gastrosquisis fueron incluidos en el protocolo.Éste consistió en la monitorización ecográfica semanal de las gestantescon diagnóstico prenatal de gastrosquisis, e indicación del parto mediantecesárea electiva a las 39 semanas o ante la aparición de signos precocesde sufrimiento intestinal (diámetro asa > 17 mm o engrosamientoparietal > 3 mm), con el fin de prevenir la lesión de las asas y susconsecuencias neonatales. Tras el nacimiento se llevó a cabo el cierreprimario del defecto en quirófano y bajo anestesia general. La edad gestacionalal nacimiento, estado de las asas, anomalías asociadas, necesidadde nutrición parenteral (NP), incidencia de sepsis y obstrucciónintestinal en el postoperatorio, y estancia hospitalaria se analizan en unestudio descriptivo prospectivo.Resultados. La edad gestacional media al nacimiento fue de 36,3semanas (rango 35-38). En todos los casos, excepto uno, las asas presentaronun aspecto casi normal, sin signos evidentes de inflamación crónica.Como anomalías asociadas encontramos dos casos de testes intraabdominales y uno de estenosis hipertrófica de píloro. No se evidenció atresia intestinal en ninguno de los casos. El tiempo medio de NP fue de28 días. Dos pacientes desarrollaron sepsis que se resolvió favorablemente con tratamiento antibiótico sistémico. Ningún paciente presentó obstrucción intestinal en el postoperatorio inmediato y tardío. El tiempo medio de estancia hospitalaria fueron 38,83 días, con una media de estancia en la unidad de cuidados intensivos neonatales de 4 días. Conclusiones. La monitorización ecográfica semanal a las gestantescon diagnóstico prenatal de gastrosquisis permite la detección de signos que indican el inicio de sufrimiento intestinal antes de que se produzcan lesiones inflamatorias crónicas de las asas intestinales herniadas. La aplicación de este protocolo de manejo prenatal de la gastrosquisis permite continuar la gestación sin necesidad de adelantar el nacimiento en la mayoría de los casos, minimizando las consecuencias derivadas de la prematuridad (AU)

Introduction. Continuous exposure to amniotic in fetus with gastroschisis, leads to inflammation and edema of intestinal loops, hindering intestinal return to abdomen and making staged repair necessary in many cases. Furthermore, intestinal loops are hipoperistaltic, which leads to oral toleration difficulties, large periods of parenteral nutrition and an increase of hospital stay. The objective of this study is to evaluate the results in our environment, of a new multidisciplinary management protocol in patients with a prenatal diagnosis of gastroschisis. Patients and methods. Between January 2003 and May 2006,six cases of prenatal diagnosis of gastroschisis were included in the protocol. This consisted in a weekly ultrasound motorization of the gestants which showed prenatal diagnosis of gastroschisis and elective delivery by caesarean section on the 39th week and if early signs of intestinal suffering appear (bowel diameter > 17 mm or wall thickening >3 mm), in order to prevent harm to intestinal loops and its consequences in the neonatal period. After birth, bowel reduction through the defect was performed under general anaesthesia in the operating room. Gestational age at delivery, bowel appearance, associated anomalies, incidence of sepsis and intestinal obstruction in the postoperative period, PN and hospital stay are analyzed in a prospective descriptive study. Results. Mean gestational age at delivery was 36,3 weeks (range35-38). In all the cases, except one, bowel loops presented a nearly normal appearance, without signs of chronic inflammation. As associated anomalies we found two cases of intraabdominal testis and one of hypertrophicpyloric stenosis. No evidence of intestinal atresia in any case. Mean time of PN was 28 days. Two patients developed sepsis with good outcome with intravenous antibiotics treatment. No cases of intestinal obstruction in the immediate or late postoperative period were observed. Mean time of hospital stay was 38,8 days, with mean stay in neonatal care unit of 4 days. Conclusions. Weekly ultrasound monitorization assessment in cases of prenatally-diagnosed gastroschisis allows early detection of bowel suffering signs, before chronic inflammatory damage of the herniated intestinal loops. The application of this prenatal gastroschisis management protocol permits normal gestation without having to anticipate delivery in practically all cases, minimizing consequences of prematurity (AU)

[Endoscopic treatment of recurrent tracheoesophageal fistula]. / Tratamiento endoscópico de la fístula traqueoesofágica recurrente.

UNLABELLED: Repermeabilization of the tracheoesophageal fistula (RTE) is one of the major complications of the esophageal atresia with tracheal fistula. We present the long term results of our technique based on broncoscopic treatment with fibrin glue and diathermia. MATERIAL AND METHODS: A retrospective study of 10 children with RTE treated from 1993 to 2006, their ages ranging from 14 days-old to 4 years-old; there were 4 patients from other hospitals. One of the patients involved had a superior congenital fistula that had not been noticed during open surgery. Broncoscopic procedure was performed using rigid instrumentation. The fistula was sealed with fibrin glue; the last seven patients in the series received previous diathermia with an uretheral catheter. Clinical and radiological follow up took place in all children. Endoscopic evaluation was performed in 6 of them. Follow-up time vary from 1 to 13 years and the number of sessions was limited to 3 per patient. RESULTS: Closure of the fistula was confirmed in 9 cases (90%) who required a whole number of 15 sessions (Mean: 1.5). The group who received diathermia needed 9 sessions (Mean: 1.2). There were no major complications. DISCUSSION: Surgery reparation of RTE is often related to serious complications. Therefore, many groups have tried to develop several broncoscopic techniques using different materials. Scientific reviews have not pointed out a definitive option since they involve isolated patients with no long term evolution. Taking this report into account we believe that the application of diathermia and fibrin glue ought to be considered the first choice treatment for the RTE.

Tratamiento endoscópico de la fístula traqueoesofágica recurrente / Endoscopic treatment of recurrent tracheoesophageal fistula

Una de las complicaciones más graves del tratamiento de la Atresia de Esófago (AE) con fístula traqueal, es la repermeabilización (RTE)de la misma. Presentamos los resultados a largo plazo de nuestra técnica de tratamiento broncoscópico con Adhesivo de Fibrina y Diatermia. Material y Métodos. Se presenta un estudio retrospectivo de 10pacientes con RTE tratados entre 1993 y 2006, en enfermos de 14 días a 2 años, cuatro de ellos de otros centros Un paciente asoció una fístula congénita superior, desapercibida en la intervención abierta. Se utilizó un procedimiento broncoscópico, utilizando instrumentación rígida. La fístula fue sellada con Adhesivo de Fibrina y en los últimos 7 se asoció al procedimiento Diatermia previa, con un catéter ureteral. En todos los casos se realizó seguimiento clínico y radiológico. Controlendoscópico en 6. El seguimiento incluye de 1 a 13 años y número de sesiones se limitó a 3 por paciente. Resultados. Es evidenció cierre de la fístula en 9 casos (90%), que precisaron un total de 15 sesiones (Media: 1,5). El grupo de asociación con Diatermia 70% necesitó 9 (Media: 1,2) No se presentaron complicacionesgraves. Conclusiones. La reparación quirúrgica de RTE comporta a menudo serias complicaciones, por lo algunos grupos han intentado desarrollar diferentes técnicas broncoscópicas, con diferentes materiales. La revisión de la literatura no aporta una opción concluyente, pues son pacientes aislados sin evolución a largo plazo. A la vista del presente estudio opinamos que la aplicación de Diatermia y Adhesivo de Fibrina debe considerarse en el tratamiento de la RTE, como opción de inicio (AU)

Repermeabilization of the tracheoesophageal fistula (RTE) is one of the major complications of the esophageal atresia with tracheal fistula. We present the long term results of our technique based on broncoscopictreatment with fibrin glue and diathermia. Material and methods: A retrospective study of 10 children with RTE treated from 1993 to 2006, their ages ranging from 14 days-old to4 years-old; there were 4 patients from other hospitals. One of the patients involved had a superior congenital fistula that had not been noticed during open surgery. Broncoscopic procedure was performed using rigid instrumentation. The fistula was sealed with fibrin glue ; the last seven patients in the series received previous diathermia with an uretheral catheter. Clinical and radiological follow up took place in all children. Endoscopic evaluation was performed in 6 of them. Follow-uptime vary from 1 to 13 years and the number of sessions was limited to3 per patient. Results: Closure of the fistula was confirmed in 9 cases (90%) who required a whole number of 15 sessions (Mean: 1.5). The group who received diathermia needed 9 sessions (Mean: 1.2). There were no majorcomplications. Discussion: Surgery reparation of RTE is often related to serious complications. Therefore, many groups have tried to develop several broncoscopic techniques using different materials. Scientific reviews have not pointed out a definitive option since they involve isolated patients with no long term evolution. Taking this report into account we believe that the application of diathermia and fibrin glue ought to be considered the first choice treatment for the RTE (AU)

[Laparoscopic Kasai portoenterostom: present and future of biliary atresia treatment]. / Intervención de Kasai por vía laparoscópica: presente y futuro del tratamiento de la atresia de vías biliares.

INTRODUCTION: Kasai's operation has proved its value in surgical treatment of biliary atresia (BA). Its laparoscopic approach is a new challenge for pediatric surgeons, with all the potential advantages of minimally invasive surgery. The aim of the present study has been to report our experience in laparoscopic management of five patients with biliary atresia. PATIENTS AND METHODS: The average of age of five patients with biliary atresia, three boys and two girls was 58 days (range 40-64). Pre and postoperative management included antibiotic prophylaxis and choleretic treatment. Laparoscopic procedure was accomplished using one umbilical 10-mm trocar and two additional 5-mm trocars. We carried out the same technique in all the patients except in one of them with a total situs inversus and who compelled us to modify the original procedure. RESULTS: All five patients underwent a laparoscopic procedure, conversion was not necessary. The mean surgical time was 3 hours and 40 minutes (range: 5:30 y 3:10). There were not intra operative complications and all of them had a satisfactory recovery, except for the patient with situs inversus, who suffered a small bowel volvulus 9 days after the operation, leading us to perform an extensive bowel resection. All the patients, except this one, showed signs of adequate bile flow, with disappearance of clinical cholestasis. Biochemistry test became normal. CONCLUSIONS: Besides the certain advantages compared with conventional surgical procedures (lower surgical damage, diminished post-operative recovery), laparoscopic management of BA, allows a better exposure of the porta hepatis without hepatic mobilization so it shows similar or better preliminary results than conventional techniques. The advantages of laparoscopic portoenterostomy are yet to be proved whenever liver transplantation is indicated.

Intervención de Kasai por vía laparoscópica: presente y futuro del tratamiento de la atresia de vías biliares / Laparoscopic Kasai portoenterostom: present and future of biliary atresia treatment

Introducción. La operación de Kasai ha demostrado su eficacia en el tratamiento de los pacientes con atresia de vías biliares (AVB).El abordaje laparoscópico de esta técnica es un nuevo desafío al que ahora nos enfrentamos con las potenciales ventajas que la cirugía mínimamente invasiva puede ofrecer a estos pacientes. Esta comunicación tiene por objeto presentar la técnica utilizada y los resultados obtenidos con la operación de Kasai laparoscópica en cinco pacientes afectos de AVB. Material y métodos. A cuatro pacientes consecutivos, tres niños y una niña, de edad media 58 días (rango 40-64),. se les aplicó el protocolo de manejo pre y postoperatorio de la AVB, que incluye profilaxis antibiótica y tratamiento colerético entre otras medidas. El abordaje laparoscópico se realizó mediante tres puertos: uno umbilical de 10 mm y dos de 5 mm, con instrumental de 5 y 3 mm, y se utilizó el mismo procedimiento técnico en todos los casos excepto en un paciente que presentaba sitos inversas completo y que obligó a modificar ligeramente el procedimiento. Resultados. En todos los pacientes se realizó el procedimiento laparoscópicos in necesidad de conversión. El tiempo medio operatorio fue de3 horas y 40 minutos (rango entre 5:30 y 3:10). No se registraron complicaciones intraoperatorias y todos los pacientes evolucionaron satisfactoriamente a excepción del paciente con situs inversus, que sufrió una ovulación de intestino medio al 9º día del postoperatorio que obligó a una amplia resección intestinal. En todos los pacientes, excepto en este último, se consiguió el reestablecimiento del flujo biliar y la desaparición de la colestasis clínica y analítica. Conclusiones. La aplicación de la cirugía mínimamente invasiva en la AVB, además de las indudables ventajas que ofrece frente a la cirugía convencional (menor agresión quirúrgica, mayor rapidez en la recuperación postoperatoria, etc) permite una mejor visión del porta hepatissin necesidad de movilización hepática y ofrece unos resultados preliminares similares o incluso superiores a la cirugía convencional.Queda pendiente demostrar en un futuro si este tipo de cirugía supondrá un beneficio en el caso de necesidad de trasplante hepático (AU)

Introduction. Kasai´s operation has proved its value in surgical treatment of biliary atresia (BA). Its laparoscopic approach is anew challenge for pediatric surgeons, with all the potential advantages of minimally invasive surgery. The aim of the present study has been to report our experience in laparoscopic management of five patients with biliary atresia. Patients and methods. The average of age of five patients with biliary atresia, three boys and two girls was 58 days (range 40-64). Pre and postoperative management included antibiotic prophylaxis and choleretictreatment. Laparoscopic procedure was accomplished using one umbilical10-mm trocar and two additional 5-mm trocars. We carried out the same technique in all the patients except in one of them with a total situsinversus and who compelled us to modify the original procedure. Results. All five patients underwent a laparoscopic procedure, conversion was not necessary. The mean surgical time was 3 hours and 40minutes (range: 5:30 y 3:10). There were not intra operative complications and all of them had a satisfactory recovery, except for the patient with situs inversus, who suffered a small bowel volvulus 9 days after the operation, leading us to perform an extensive bowel resection. All the patients, except this one, showed signs of adequate bile flow, with disappearance of clinical cholestasis. Biochemistry test became normal. Conclusions. Besides the certain advantages compared with conventional surgical procedures (lower surgical damage, diminished post-operative recovery), laparoscopic management of BA, allows a better exposure of the porta hepatis without hepatic mobilization so it shows similar or better preliminary results than conventional techniques. The advantages of laproscopic portoenterostomy are yet to be proved whenever liver transplantation is indicated (AU)

[Choledocal cyst: analysis of 29 cases and review or the literature]. / Nuestra experiencia en el diagnóstico y tratamiento del quiste de colédoco.

UNLABELLED: The aim of the present study has been to systematize the clinical presentation of the entity named choledochal cyst, in relation with its probable etiopathology and the intraoperative findings as well as its evolution after surgery, based on the revision of the literature and of our experience in 29 cases. MATERIAL AND METHODS: 29 cases of cystic dilatation of the biliar duct extra and/or intrahepatic are analyzed. In 4 cases the diagnosis was prenatal and two were excluded of the study after it has been confirmed they suffered biliary atresia type I. In the left 27 cases, 19 variables are analyzed retrospectively, like age, sex, weight, symptoms, ultrasonographic images, etc. Subsequently, intra-operative cholangiographic findings were correlated with the clinic presentation and the evolution of the patients after surgery. RESULTS: Of the 27 cases analyzed 16 (59,25%) were cystic dilatations from which 14 had a neonatal or early clinic presentation (before 2 years), however the fusiform dilatations were presented later on. From the analyzed symptoms, in relation with the age only the pain and the jaundice showed significant differences, being the pain most frequent in later presentation ande the jaundice in the early form. The two cases of type 3 of Todani or choledochocele were of later presentation. An anomaly in the bilionpacreatric junction was detected in 15 patients; the majority had a later presentation, associated to pancreatitis in 4 cases. Primary cyst excision and biliary Roux-en-Y reconstruction was the treatment of election in the majority of cases. In 3 cases we used the appendix to replace the choledocus, but all three cases were reconverted two years later because of permanent elevation of ALT and GGT. CONCLUSIONS: In favour of the literature and of our experience nowadays it would be possible to systematize this malformation and make a division in two groups, depending on the cholangiographic findings and clinical presentation: 1. Cystic dilatations with a clinical neonatal presentation or beneath 2 years. 2. Fusiform dilatations with a later clinical predominance and associated frequently to pancreatitis and anomalous pancreatobiliary junction. Choledochocele is an entity that must be considered not only for its etiology but for its clinical presentation and treatment. Primary cyst excision and biliary Roux-en-Y reconstruction is the treatment of election. Regular long-term review of these patients is mandatory in the surveillance of sub-clinic cholangitis and the risk of possible long-term malignance of this entity.

Consecuencias del retraso diagnóstico de la aspiración de cuerpo extraño / Consequences of diagnostic delay in foreign body aspiration

Objetivos: Analizar las características clínicas de los niños con aspiración de cuerpo extraño, sus complicaciones y su correlación con el retraso diagnóstico. Material y métodos: Estudio retrospectivo realizado en 136 niños con sospecha de aspiración de cuerpo extraño; el diagnóstico se confirmó en 118 casos tras su extracción con el broncoscopio. Se calculó la especificidad, sensibilidad, valor predictivo positivo y negativo de cada uno de los datos diagnósticos utilizados: antecedente de crisis de sofocación, sintomatología sugestiva de aspiración (tos, estridor) en niños previamente sanos, hallazgos de auscultación positivos (hipoventilación, sibilancias) y atrapamiento respiratorio en la radiografía de tórax. Resultados: La aspiración se debe, fundamentalmente, a cuerpos extraños orgánicos (84,7%), sobre todo frutos secos, con predominio por el árbol bronquial derecho (56,8%). Se produce casi siempre en el domicilio familiar mientras el niño come o juega. La crisis de sofocación es la prueba de mayor sensibilidad (91 %) y de mayor valor predictivo positivo (95%), aunque su especificidad (66%) y valor predictivo negativo (27%) sean menores. Los hallazgos clínicos y la radiología tienen mucha menos sensibilidad o especificidad y su utilidad se basa en la localización del cuerpo extraño. El diagnóstico se demoró más de 48 horas en más de la mitad de los casos. Conclusiones: El antecedente de crisis de sofocación en niños obliga a efectuar una broncoscopia. Las complicaciones durante (episodios de broncospasmo, edema subglótico y hemorragia bronquial por laceración) y tras la broncoscopia (atelectasias, neumonías y bronquiectasias) fueron mayores en pacientes con diagnóstico tardío

Objective: We analyze the clinical features and complications associated with foreign body aspiration in children, correlating them with delayed diagnosis. Methods: The records of 136 children who were admitted for suspected foreign body aspiration were reviewed retrospectively. Bronchoscopic retrieval of foreign bodies was successful in 118 children. We evaluated the sensitivity, specificity and positive and negative predictive values of the following diagnostic tools: history of choking episodes, symptoms (cough and stridor) in previously healthy children, positive auscultatory findings (hypoventilation, wheezing) and unilateral air trapping in chest radiography. Results: The aspirated material was organic (dried fruits) in most patients(84.7%), and right main bronchus was most often involved (56.8%). The aspiration almost always occurred at home, while the children were eating or playing. A choking episode is the most sensitive diagnostic Clue (91 %), and has the highest positive predictive value (95%), although its specificity (66%) and negative predictive value (27%) were lower. Clinical signs and symptoms and radiology are much less sensitive and specific, and their utility is mainly confined to the localization of the foreign body. The diagnosis was delayed more than 48 hours in over half of our patients. Conclusions: Bronchoscopy should by performed in all children who have had a choking episode. The complications during bronchoscopy(bronchospasm, subglottic edema and bleeding due to tracheal laceration) and afterwards( atelectasis, pneumonia and bronchiectasis) were related to the diagnostic delay

Nuestra experiencia en el diagnóstico y tratamiento del quiste de colédoco / Choledocal cyst: analysis of 29 cases and review or the literature

El objeto del presente estudio ha sido el sistematizar la forma de presentación clínica de esta entidad relacionándola con su probable etiopatogenia y los hallazgos colangiográficos y su evolución tras la cirugía, basándonos en la revisión de la literatura y en nuestra propia experiencia de 29 pacientes. Material y métodos. Se analizan 29 casos de dilatación quística de la vía biliar extra y/o intrahepática. En 4 casos, el diagnóstico fue prenatal, dos de los cuales se excluyeron del estudio al confirmarse atresia biliar tipo I. En los 27 casos restantes, se analizan retrospectivamente hasta un total de 19 variables, como la edad, sexo, peso, sintomatología, hallazgos ecográficos y colangiográficos, etc. Posteriormente se correlacionan los hallazgos colangiográficos con la presentación clínica y la evolución tras el tratamiento quirúrgico. Resultados. De los 27 casos analizados, 16 (59,25%) fueron formas quísticas de las que 14 tuvieron una presentación clínica neonatal o precoz (antes de los 2 años), mientras que las formas fusiformes se presentaron más tardíamente. De los síntomas analizados, en relación con la edad de presentación tan sólo el dolor y la ictericia mostraron diferencias significativas, siendo el dolor más frecuente en la presentación tardía y la ictericia en la forma precoz. Los dos casos de tipo III de Todani o coledococele fueron de presentación tardía. Se detectó anomalía del conducto biliopancreático en 15 pacientes, la mayoría de los cuales tuvieron una presentación tardía y asociada a pancreatitis en cuatro casos. El tratamiento quirúrgico de elección fue la quistectomía y derivación bilioentérica en Y de Roux. En 3 casos realizamos hepático- porto-apendicostomía, que se reconvirtieron a los dos años de seguimiento debido a episodios de colangitis subclínicas, detectados exclusivamente por una hipertransaminemia x2. Tras la reconversión (..) (AU)

The aim of the present study has been to systematize the clinical presentation of the entity named choledochal cyst, in relation with its probable etiopathology and the intraoperative findings as well as its evolution after surgery, based on the revision of the literature and of our experience in 29 cases. Material and Methods. 29 cases of cystic dilatation of the biliar duct extra and/or intrahepatic are analyzed. In 4 cases the diagnosis was prenatal and two were excluded of the study after it has been confirmed they suffered biliary atresia type I. In the left 27 cases, 19 variables are analyzed retrospectively, like age, sex, weight, symptoms, ultrasonographic images, etc. Subsequently, intra-operative cholangiographic findings were correlated with the clinic presentation and the evolution of the patients after surgery. Results. Of the 27 cases analyzed 16 (59,25%) were cystic dilatations from which 14 had a neonatal or early clinic presentation (before 2 years), however the fusiform dilatations were presented later on. From the analyzed symptoms, in relation with the age only the pain and the jaundice showed significant differences, being the pain most frequent in later presentation ande the jaundice in the early form. The two cases of type 3 of Todani or choledochocele were of later presentation. An anomaly in the bilionpacreatric junction was detected in 15 patients; the majority had a later presentation, associated to pancreatitis in 4 cases. Primary cyst excision and biliary Roux-en-Y reconstruction was the treatment of election in the majority of cases. In 3 cases we used the appendix to replace the choledocus, but all three cases were (..) (AU)

A new approach to qualitative analysis of organophosphorus pesticide residues in cucumber using a double gas chromatographic system: GC-pulsed-flame photometry and retention time locking GC-mass spectrometry.

A qualitative method for the screening of organophosphorus pesticides (OPs) that could present in different types of vegetables has been established and validated. A typical multi-residue extraction procedure of OPs using ethyl acetate and sodium sulphate has been applied. No clean-up was required after extraction, and concentrated extracts were analysed by gas chromatography with pulsed-flame photometric detection (GC-PFPD). Confirmation of compound identities was performed by gas chromatography with mass spectrometric detection (GC-MSD) in the electron impact (EI) mode with full scan acquisition. Retention time locking (RTL) software was used in order to improve the method capability of identification and confirmation. Spiked samples at pesticide concentrations equal to the maximum residue level (MRL) were used to check chromatographic performance and for validation studies. The proposed method allows a rapid and accurate identification of the studied OPs until the ng ml(-1) range for those whose use is forbidden, and above their MRL concentration for the rest.

Heart transplantation: influence of the surgical technique on sinus function.

This study analyzes the influence of the surgical technique on the development of sinus dysfunction. Cycle length, corrected sinus node recovery time, and sinoatrial conduction time were determined in 4 groups of dogs under the following conditions: group 1, controls; group 2, subjected to heterotopic heart transplantation with conservation of atrial anatomy; group 3, subjected to orthotopic heart transplantation by using a standard technique; and group 4, treated as in group 3, but with an ischemic time of 24 hours. The cycle length was prolonged in all the treated groups when compared with the controls (P < .01), an effect attributed to the disconnection of the autonomic nervous system during the transplantation procedure. The corrected sinus node recovery time and sinoatrial conduction time were significantly longer in all the animals in groups 3 and 4 when compared with those of groups 1 and 2 (P < .01); however, there were no significant differences between groups 3 and 4 or between groups 1 and 2. These results suggest that the atrial anatomy play a more relevant role than the ischemic time in the origin of sinus dysfunction occurring after orthotopic heart transplantation.