Hiperintensidad en secuencia FLAIR del LCR en el espacio subaracnoideo: diagnósticos diferenciales / FLAIR hyperintensity in the subarachnoid space: Main Differentials

La secuencia fluid attenuated inversion recovery (FLAIR) forma parte hoy en día de la gran mayoría de protocolos diagnósticos de RM cerebral. Esta secuencia de inversión-recuperación permite una supresión de la señal del líquido cefalorraquídeo, lo que facilita la detección de enfermedad que afecta al espacio subaracnoideo. Las causas de hiperintensidad del líquido cefalorraquídeo en esta secuencia pueden subdividirse en 2grandes grupos, las patológicas y las debidas a artefactos. Son bien conocidas la etiología tumoral, la inflamatoria, la vascular o las debidas a hipercelularidad del líquido cefalorraquídeo o a ocupación por contenido hemático. Sin embargo, existen numerosas condiciones no patológicas, principalmente debidas a artefactos, que se relacionan con este hallazgo constituyendo una potencial fuente de errores diagnósticos.(AU)

The fluid-attenuated inversion recovery (FLAIR) sequence forms part of the vast majority of current diagnostic protocols for brain MRI. This sequence enables the suppression of the signal from cerebrospinal fluid, facilitating the detection of disease involving the subarachnoid space. The causes of hyperintensity in the arachnoid space in this sequence can be divided into two main categories: hyperintensity due to disease and hyperintensity due to artifacts. Hyperintensity due to tumors, inflammation, vascular disease, or hypercellularity of the cerebrospinal fluid or hematic contents is well known. However, numerous other non-pathological conditions, mainly due to artifacts, that are also associated with this finding are a potential source of diagnostic errors.(AU)

FLAIR hyperintensity in the subarachnoid space: Main differentials.

The fluid-attenuated inversion recovery (FLAIR) sequence forms part of the vast majority of current diagnostic protocols for brain MRI. This sequence enables the suppression of the signal from cerebrospinal fluid, facilitating the detection of disease involving the subarachnoid space. The causes of hyperintensity in the arachnoid space in this sequence can be divided into two main categories: hyperintensity due to disease and hyperintensity due to artifacts. Hyperintensity due to tumors, inflammation, vascular disease, or hypercellularity of the cerebrospinal fluid or hematic contents is well known. However, numerous other non-pathological conditions, mainly due to artifacts, that are also associated with this finding are a potential source of diagnostic errors.

Differences in MRI measurements of lateral recesses and foramina in degenerative lumbar segments in upright versus decubitus symptomatic patients.

OBJECTIVE: To evaluate differences in measurements of the lateral recesses and foramina in degenerative lumbar segments on MR images in symptomatic patients obtained with the patient standing versus lying down and to analyze the relationship between possible differences and patients' symptoms. MATERIAL AND METHODS: We studied 207 disc levels in 175 patients aged between 17 and 75 years (median: 47 years) with low back pain. All patients underwent MRI in the decubitus position with their legs extended, followed by MRI in the standing position. We calculated the difference in the measurements of the lateral recesses (in mm) and in the foramina (area in mm2 and smallest diameter in mm) obtained in the two positions. To eliminate the effects of possible errors in measurement, we selected cases in which the difference between the measurements obtained in the two positions was ≥10%; we used Student's t-tests for paired samples to analyze the entire group and subgroups of patients according to age, sex, grade of disc degeneration, and postural predominance of symptoms. RESULTS: Overall, the measurements of the spaces were lower when patients were standing. For the lateral recesses, we observed differences ≥10% in 68 (33%) right recesses and in 65 (31.5%) left recesses; when patients were standing, decreases were much more common than increases (26% vs. 7%, respectively, on the right side and 24% vs. 7.5%, respectively, on the left side; p < 0.005). For the foramina, decreases in both the area and in the smallest diameter were also more common than increases when patients were standing: on the right side, areas decreased in 23% and increased in 4%, and smallest diameters decreased in 20% and increased 6%; on the left side, areas decreased in 24% and increased in 4%, and smallest diameters decreased in 17% and increased in 8% (p < 0.005). Considering the group of patients in whom the postural predominance of symptoms was known, we found significant differences in patients whose symptoms occurred predominantly or exclusively when standing, but not in the small group of patients whose symptoms occurred predominantly while lying. We found no differences between sexes in the changes in measurements of the recesses or foramina with standing. The differences between the measurements obtained in different positions were significant in patients aged >40 years, but not in younger groups of patients. Differences in relation to the grade of disc degeneration were significant only in intermediate grades (groups 3-6 in the Griffith classification system). CONCLUSION: MRI obtained with patients standing can show decreases in the lateral recesses and foramina related to the predominance of symptoms while standing, especially in patients aged >40 years with Griffith disc degeneration grade 3-6, thus providing additional information in the study of patients who have low back pain when standing in whom the findings on conventional studies are inconclusive or discrepant with their symptoms. Further studies are necessary to help better define the value of upright MRI studies for degenerative lumbar disease.

Neumomediastino en Pediatría. Experiencia en un centro terciario / Pneumomediastinum in Pediatrics. Tertiary school experience

Introducción: el neumomediastino se define como la presencia de aire dentro del mediastino. Es una patología infrecuente fuera del periodo neonatal, que generalmente acontece en varones jóvenes y de complexión delgada. Material y métodos: se diseña un estudio descriptivo de serie de casos, retrospectivo (2009-2016) y prospectivo (2016-2019). Se incluyeron todos los pacientes de entre seis meses y 18 años diagnosticados de neumomediastino en nuestro centro. Se incluyeron ocho pacientes y se analizaron las variables epidemiológicas, clínicas, diagnósticas y terapéuticas. Resultados: el 87% de nuestros casos fueron diagnosticados de neumomediastino espontáneo, el 37% de ellos presentaron factores predisponentes como consumo de tóxicos, viajes en avión, maniobra de Valsava o infecciones. El motivo de consulta más frecuente fue el dolor torácico (75%), seguido de disnea (37%), palpitaciones y fiebre (12,5%). En la exploración física, el signo más prevalente fue el enfisema subcutáneo (37%), seguido del signo de Hamman (12,5%). El diagnóstico se realizó en base a la clínica y las pruebas de imagen. Todos los casos se confirmaron con radiografía de tórax y solo uno requirió tomografía computarizada de confirmación. Ningún paciente requirió soporte respiratorio y la estancia media hospitalaria fue de dos días. Conclusiones: el neumomediastino es una condición habitualmente benigna y autolimitada. Es una patología que, a pesar de su baja incidencia, debe incluirse en el diagnóstico diferencial del dolor torácico dada su potencial gravedad al poder propagarse al tejido subcutáneo, endotorácico, peritoneal o raquídeo (AU)

Introduction: pneumomediastinum is defined as the presence of air inside the mediastinum. It is infrequent beyond the neonatal period and typically occurs in male youth with a slender build.Material and methods: we conducted a descriptive study of a case series with retrospective data collection in the 2009-2016 period and prospective collection in 2016-2019. We included all patients aged 6 months to 18 years given a diagnosis of pneumomediastinum in our hospital. The total sample included 8 patients, and we analysed epidemiological, clinical, diagnostic and therapeutic variables.Results: 87% of the patients received a diagnosis of spontaneous pneumomediastinum, and there were predisposing factors in 37% of them, such as substance use, air travel, Valsalva manoeuvres or infection. The most frequent reason for seeking care was chest pain (75%), followed by dyspnoea (37%), palpitations and fever (12.5%). The most prevalent sign in the physical examination was subcutaneous emphysema (37%) followed by Hamman’s sign (12.5%). The diagnosis was based on the clinical manifestations and imaging features. All cases were confirmed by chest radiography and only 1 required CT for confirmation. None of the patients required respiratory support, and the average length of stay was approximately 2 days.Conclusions: pneumomediastinum is usually a benign and self-limited condition. Despite its low incidence, it should be included in the differential diagnosis of chest pain due to its potential severity, as it can spread to subcutaneous, endothoracic, peritoneal or spinal tissue. (AU)

Utilidad de la telemedicina en la atención pediátrica urgente durante la pandemia por COVID-19 / Usefulness of telemedicine in urgent pediatric care during the COVID-19 pandemic

Introducción: nuestro sistema sanitario ha sufrido una reorganización sin precedentes priorizando la atención de los pacientes con sintomatología COVID-19. El uso de telemedicina se presenta como una alternativa útil en la era pos-COVID. El objetivo del estudio fue valorar la utilidad del servicio de mensajería de Twitter como herramienta de telemedicina para el cribado de patología urgente. Material y métodos: estudio descriptivo, retrospectivo y transversal de un programa de telemedicina desarrollado por un equipo de especialistas en Pediatría y sus Áreas Específicas durante el estado de alarma. Se recogieron datos demográficos, número y motivos de consultas según signos, síntomas y su forma de presentación (texto, foto o vídeo). Se analizó el número de consultas resueltas, derivaciones y el grado de satisfacción. Resultados: se atendió un total de 182 consultas realizadas en su mayoría por mujeres (71%), durante las primeras semanas del confinamiento (70%). El 100% fueron mensajes de texto, acompañados casi en un tercio de los casos de material audiovisual (27,2% fotos, 4,6% vídeos). La edad media de los pacientes atendidos fue de 2,72 ± 2,74 y los principales motivos de consulta: fiebre, exantemas y dificultad respiratoria. El 18,13% tuvo relación con la COVID-19, y solamente el 8,24% fue derivado. Conclusiones: aunque la telemedicina no puede reemplazar la valoración presencial y todavía existen limitaciones técnicas y legales, nuestros resultados sugieren que podría ser una alternativa prometedora para mejorar el acceso, reducir los tiempos de triaje, coordinar los recursos disponibles, y disminuir el riesgo de contagio y saturación de las instalaciones sanitarias (AU)

Introduction: our healthcare system has undergone an unprecedented reorganization, prioritizing the care of patients with COVID-19 symptoms. Telemedicine has emerged as a useful alternative in the post-COVID era. The aim of the study was to assess the usefulness of the Twitter® messaging service as a telemedicine tool for the screening of urgent pathology.Material and methods: cross-sectional, retrospective and descriptive study of a telemedicine programme developed by a team of specialists in paediatrics and its subspecialities during the state of alarm. We collected demographic data and the number and reasons for consultations based on the presenting signs and symptoms and how they were conveyed (text, photo and/or video). We analysed the number of resolved concerns, referrals and the degree of user satisfaction.Results: the service managed a total of 182 consultations, mostly made by women (71%) and during the first weeks of the survey (70%). All consultations included text, accompanied in almost 1/3 of the cases by audiovisual content (27.2% photo, 4.6% video). The average age of the managed patients was 2.72 ± 2.74 years and the main reasons for consultation were fever, exanthema and respiratory difficulty. Of all consultations, 18.13% were related to COVID-19, and only 8.24% led to referral.Conclusions: although telemedicine cannot replace face-to-face assessment and there are still technical and legal limitations, our results suggest that it could be a promising alternative to improve access, reduce triage times, coordinate available resources, and decrease the risk of contagion and the saturation of health care facilities. (AU)

[Internal validity of a rapid test for COVID-19 antigens in a nursing home]. / Validez interna de una prueba rápida de detección de antígenos COVID-19 en una residencia de mayores.

INTRODUCTION: RT-qPCR is the reference test for the detection of SARS-CoV-2 infection, however, rapid antigen detection tests (RADT) are now available. In this work, the internal validity of the RADT was evaluated in the context of an outbreak in a nursing home. METHODS: Nasopharyngeal exudate samples were analyzed by RADT and RT-qPCR from 61 residents of a nursing home. The sensitivity and specificity of RADT with respect to RT-qPCR was calculated. RESULTS: Specificity was 100% (95% CI 54.1-100.0), while sensitivity in asymptomatic people was 70.3% (95% CI 53.0-84.1) and in symptomatic people 83.3% (95% CI 51.6-97.9). CONCLUSIONS: The RADTs are sufficiently sensitive and specific to be used as screening tests in nursing homes, especially in situations of outbreaks or suspected outbreaks due to the presence of symptoms.

Differences in MRI measurements of lateral recesses and foramina in degenerative lumbar segments in upright versus decubitus symptomatic patients. / Cambios en recesos laterales y forámenes en segmentos degenerativos lumbares de pacientes sintomáticos estudiados mediante resonancia magnética en decúbito y bipedestación.

OBJECTIVE: To evaluate differences in measurements of the lateral recesses and foramina in degenerative lumbar segments on MR images in symptomatic patients obtained with the patient standing versus lying down and to analyze the relationship between possible differences and patients' symptoms. MATERIAL AND METHODS: We studied 207 disc levels in 175 patients aged between 17 and 75 years (median: 47 years) with low back pain. All patients underwent MRI in the decubitus position with their legs extended, followed by MRI in the standing position. We calculated the difference in the measurements of the lateral recesses (in mm) and in the foramina (area in mm2 and smallest diameter in mm) obtained in the two positions. To eliminate the effects of possible errors in measurement, we selected cases in which the difference between the measurements obtained in the two positions was ≥10%; we used Student's t-tests for paired samples to analyze the entire group and subgroups of patients according to age, sex, grade of disc degeneration, and postural predominance of symptoms. RESULTS: Overall, the measurements of the spaces were lower when patients were standing. For the lateral recesses, we observed differences ≥10% in 68 (33%) right recesses and in 65 (31.5%) left recesses; when patients were standing, decreases were much more common than increases (26% vs. 7%, respectively, on the right side and 24% vs. 7.5%, respectively, on the left side; p<0.005). For the foramina, decreases in both the area and in the smallest diameter were also more common than increases when patients were standing: on the right side, areas decreased in 23% and increased in 4%, and smallest diameters decreased in 20% and increased 6%; on the left side, areas decreased in 24% and increased in 4%, and smallest diameters decreased in 17% and increased in 8% (p<0.005). Considering the group of patients in whom the postural predominance of symptoms was known, we found significant differences in patients whose symptoms occurred predominantly or exclusively when standing, but not in the small group of patients whose symptoms occurred predominantly while lying. We found no differences between sexes in the changes in measurements of the recesses or foramina with standing. The differences between the measurements obtained in different positions were significant in patients aged>40 years, but not in younger groups of patients. Differences in relation to the grade of disc degeneration were significant only in intermediate grades (groups 3-6 in the Griffith classification system). CONCLUSION: MRI obtained with patients standing can show decreases in the lateral recesses and foramina related to the predominance of symptoms while standing, especially in patients aged>40 years with Griffith disc degeneration grade 3 to 6, thus providing additional information in the study of patients who have low back pain when standing in whom the findings on conventional studies are inconclusive or discrepant with their symptoms. Further studies are necessary to help better define the value of upright MRI studies for degenerative lumbar disease.

Estudio de coste-efectividad sobre la utilización de un tapón de hidrogel en las biopsias pulmonares guiadas por tomografía computarizada / Cost-effectiveness of hydrogel plugs in CT-guided lung biopsies

Objetivo: La utilización de un tapón de hidrogel reduce el número de neumotórax y la necesidad de tubos de drenaje pleural en las biopsias de pulmón guiadas por tomografía computarizada. Realizamos un estudio de coste-efectividad sobre su uso. Material y métodos: Se analizaron 171 biopsias de pulmón divididas en tres grupos: grupo 1 (n=22): punción aspirativa con aguja fina (PAAF) sin tapón de hidrogel; grupo 2 (n=89): PAAF con tapón, y grupo 3 (n=60): PAAF más biopsia con aguja gruesa (BAG) con tapón. Se calcularon costes totales (directos e indirectos) de los tres grupos. Se analizó el porcentaje de diagnósticos correctos, las ratios medias e incrementales y la opción más coste-efectiva. Resultados: Costes totales: grupo 1 = 1.261,28 + 52,65 = 1.313,93 Euros, grupo 2 = 1.201,36 + 67,25 = 1.268,61 euros, grupo 3 = 1.220,22 + 47,20 = 1.267,42 Euros. Porcentaje de diagnósticos correctos: grupo 1 = 77,3%, grupo 2 = 85,4% y grupo 3 = 95% (p = 0,04). Ratio medio de coste-efectividad: grupo 1 = 16,99, grupo 2 = 14,85 y grupo 3=13,34. Conclusiones: El grupo 3 fue la opción dominante, con la menor ratio media, lo cual demuestra que, en las biopsias de pulmón guiadas por TC, la opción más coste-efectiva es la realización de una PAAF y una BAG con la utilización del tapón de hidrogel deshidratado al final del procedimiento

Objective: Using a hydrogel plug decreases the number of cases of pneumothorax and reduces the need for pleural drainage tubes in CT-guided lung biopsies. We aimed to analyze the cost-effectiveness of using hydrogel plugs. Material and methods: We analyzed 171 lung biopsies divided into three groups: Group 1 (n=22): fine-needle aspiration cytology (FNAC) without hydrogel plugs; Group 2 (n=89): FNAC with hydrogel plugs; and Group 3 (n=60): FNAC plus core-needle biopsy (CNB) with hydrogel plugs. We calculated the total costs (direct and indirect) in the three groups. We analyzed the percentage of correct diagnoses, the average and incremental rations, and the most cost-effective option. Results: Total costs: Group 1 = 1,261.28 + 52.65 = euros 1,313.93; Group 2 = 1,201.36 + 67.25 = Euros 1,268.61; Group 3 = 1,220.22 + 47.20 = Euros 1,267.42. Percentage of correct diagnoses: Group 1 = 77.3%, Group 2 = 85.4%, and Group 3 = 95% (p = 0.04). Average cost-effectiveness ratio: Group 1 = 16.99; Group 2 = 14.85; and Group 3 = 13.34. Conclusions: Group 3 was the best option, with the lowest average cost-effectiveness ratio; therefore, the most cost-effective approach is to do FNAC and CNB using a dehydrated hydrogel plug at the end of the procedure

Cost-effectiveness of hydrogel plugs in CT-guided lung biopsies. / Estudio de coste-efectividad sobre la utilización de un tapón de hidrogel en las biopsias pulmonares guiadas por tomografía computarizada.

OBJECTIVE: Using a hydrogel plug decreases the number of cases of pneumothorax and reduces the need for pleural drainage tubes in CT-guided lung biopsies. We aimed to analyze the cost-effectiveness of using hydrogel plugs. MATERIAL AND METHODS: We analyzed 171 lung biopsies divided into three groups: Group 1 (n=22): fine-needle aspiration cytology (FNAC) without hydrogel plugs; Group 2 (n=89): FNAC with hydrogel plugs; and Group 3 (n=60): FNAC plus core-needle biopsy (CNB) with hydrogel plugs. We calculated the total costs (direct and indirect) in the three groups. We analyzed the percentage of correct diagnoses, the average and incremental rations, and the most cost-effective option. RESULTS: Total costs: Group 1 = 1,261.28 + 52.65 = € 1,313.93; Group 2 = 1,201.36 + 67.25 = € 1,268.61; Group 3 = 1,220.22 + 47.20 = € 1,267.42. Percentage of correct diagnoses: Group 1 = 77.3%, Group 2 = 85.4%, and Group 3 = 95% (p = 0.04). Average cost-effectiveness ratio: Group 1 = 16.99; Group 2 = 14.85; and Group 3 = 13.34. CONCLUSIONS: Group 3 was the best option, with the lowest average cost-effectiveness ratio; therefore, the most cost-effective approach is to do FNAC and CNB using a dehydrated hydrogel plug at the end of the procedure.

Prevalence of peripheral artery disease (PAD) and factors associated: An epidemiological analysis from the population-based Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study.

AIM: To describe the prevalence of Peripheral Artery Disease (PAD) in a random population sample and to evaluate its relationship with Mediterranean diet and with other potential cardiovascular risk factors such as serum uric acid and pulse pressure in individuals ranged 45 to 74 years. METHODS: Cross-sectional analysis of 1568 subjects (mean age 6.5 years, 43% males), randomly selected from the population. A fasting blood sample was obtained to determine glucose, lipids, and HbA1C levels. An oral glucose tolerance test was performed in non-diabetic subjects. PAD was evaluated by ankle-brachial index and/or having a prior diagnosis. RESULTS: PAD prevalence was 3.81% (95% CI, 2.97-4.87) for all participants. In men, PAD prevalence was significantly higher than in women [5.17% (95% CI, 3.74-7.11) vs. 2.78% (95% CI, 1.89-4.07); p = 0.014]. Serum uric acid in the upper quartile was associated with the highest odds ratio (OR) of PAD (for uric acid > 6.1 mg/dl, OR = 4.31; 95% CI, 1.49-12.44). The remaining variables more strongly associated with PAD were: Heart rate >90 bpm (OR = 4.16; 95%CI, 1.62-10.65), pulse pressure in the upper quartile (≥ 54 mmHg) (OR = 3.82; 95%CI, 1.50-9.71), adherence to Mediterranean diet (OR = 2.73; 95% CI, 1.48-5.04), and former smoker status (OR = 2.04; 95%CI, 1.00-4.16). CONCLUSIONS: Our results show the existence of a low prevalence of peripheral artery disease in a population aged 45-74 years. Serum uric acid, pulse pressure and heart rate >90 bpm were strongly associated with peripheral artery disease. The direct association between Mediterranean diet and peripheral artery disease that we have found should be evaluated through a follow-up study under clinical practice conditions.

Urgencias neurológicas en el paciente inmunosuprimido no VIH / Neurologic emergencies in HIV-negative immunosuppressed patients

Los pacientes inmunodeprimidos no VIH (ID-no-VIH) constituyen un grupo heterogéneo que incluye a pacientes trasplantados, en tratamiento inmunosupresor, urémicos, alcohólicos, desnutridos, diabéticos, dializados, de edad avanzada o diagnosticados de un proceso grave o neoplásico. Las crisis epilépticas, el síndrome neurológico focal o la meningoencefalitis son síndromes neurológicos que requieren una actuación urgente. En la mayoría de estas situaciones es necesaria la realización de una prueba de neuroimagen, pero los hallazgos pueden ser diferentes a los observados en el paciente inmunocompetente en función de la respuesta inflamatoria. La enfermedad infecciosa constituye la primera sospecha diagnóstica, y la identificación del patógeno oportunista debe orientarse en función del tipo y grado de inmunosupresión. Otras urgencias neurológicas son: el ictus isquémico, la hemorragia cerebral, los procesos neoplásicos o la neurotoxicidad farmacológica. En este artículo se revisa el papel de la neuroimagen en pacientes ID-no-VIH con una complicación neurológica de manejo urgente (AU)

HIV-negative immunosuppressed patients comprise a heterogeneous group including transplant patients, patients undergoing treatment with immunosuppressors, uremic patients, alcoholics, undernourished patients, diabetics, patients on dialysis, elderly patients, and those diagnosed with severe or neoplastic processes. Epileptic seizures, focal neurologic signs, and meningoencephalitis are neurologic syndromes that require urgent action. In most of these situations, neuroimaging tests are necessary, but the findings can be different from those observed in immunocompetent patients in function of the inflammatory response. Infectious disease is the first diagnostic suspicion, and the identification of an opportunistic pathogen should be oriented in function of the type and degree of immunosuppression. Other neurologic emergencies include ischemic stroke, cerebral hemorrhage, neoplastic processes, and pharmacological neurotoxicity. This article reviews the role of neuroimaging in HIV-negative immunodepressed patients with a neurologic complication that requires urgent management (AU)

Estudio de costo-efectividad de la biopsia mamaria asistida por vacío versus biopsia con aguja gruesa o arpón / The cost effectiveness of vacuum-assisted versus core-needle versus surgical biopsy of breast lesions

Objetivo. Realizar estudio de costo-efectividad de la biopsia por aspiración al vacío (BAV) (9 G) guiada por estereotaxia vertical o ecografía comparada con biopsia con aguja gruesa (BAG) (14 G) y biopsia con arpón. Material y métodos. Analizamos 997 biopsias mamarias (181 BAV, 626 BAG y 190 arpones). Calculamos costes totales (directos e indirectos) de los tres tipos de biopsia. No calculamos costes intangibles. El efecto a medir fue el "porcentaje de diagnósticos correctos" obtenidos con cada una de las técnicas. Calculamos los ratios medios de los tres tipos de biopsias e identificamos la opción dominante más costo-efectiva. Resultados. Costes totales de BAG 225,09 Euros, de BAV 638,90 Euros y de biopsia con arpón 1780,01 Euros. Porcentaje de diagnósticos correctos globales con BAG 91,81%, BAV 94,03% y biopsia con arpón 100%, sin diferencias significativas (p=0,3485). En microcalcificaciones, los porcentajes de diagnósticos correctos fueron con BAG 50% y con BAV 96,77%, p<0,0001. En nódulos tampoco hubo diferencias significativas. El ratio medio costo-efectividad considerando todas las lesiones en conjunto, fue para BAG 2,45, BAV 6,79 y arpón 17,80. Conclusión. La BAG fue la opción dominante para el diagnóstico de lesiones mamarias sospechosas de malignidad en general. En el caso de las microcalcificaciones, el bajo porcentaje de diagnósticos de la BAG (50%) desaconsejan su uso y colocan a la BAV como técnica de elección; la BAV es, además, más costo-efectiva que el arpón, que es la otra técnica indicada para biopsiar microcalcificaciones (AU)

Objectives. To determine the cost effectiveness of breast biopsy by 9G vacuum-assisted guided by vertical stereotaxy or ultrasonography in comparison with breast biopsy by 14G core-needle biopsy and surgical biopsy. Material and methods. We analyzed a total of 997 biopsies (181 vacuum-assisted, 626 core, and 190 surgical biopsies). We calculated the total costs (indirect and direct) of the three types of biopsy. We did not calculate intangible costs. We measured the percentage of correct diagnoses obtained with each technique. To identify the most cost-effective option, we calculated the mean ratios for the three types of biopsies. Results. Total costs were Euros 225.09 for core biopsy, Euros 638.90 for vacuum-assisted biopsy, and Euros 1780.01 for surgical biopsy. The overall percentage of correct diagnoses was 91.81% for core biopsy, 94.03% for vacuum-assisted biopsy, and 100% for surgical biopsy; however, these differences did not reach statistical significance (p=0.3485). For microcalcifications, the percentage of correct diagnoses was 50% for core biopsy and 96.77% for vacuum-assisted biopsy (p<0.0001). For nodules, there were no significant differences among techniques. The mean cost-effectiveness ratio considering all lesions was 2.45 for core biopsy, 6.79 for vacuum-assisted biopsy, and 17.80 for surgical biopsy. Conclusion. Core biopsy was the dominant option for the diagnosis of suspicious breast lesions in general. However, in cases with microcalcifications, the low percentage of correct diagnoses achieved by core biopsy (50%) advises against its use in this context, where vacuum-assisted biopsy would be the technique of choice because it is more cost-effective than surgical biopsy, the other technique indicated for biopsying microcalcifications (AU)

Neurologic emergencies in HIV-negative immunosuppressed patients. / Urgencias neurológicas en el paciente inmunosuprimido no VIH.

HIV-negative immunosuppressed patients comprise a heterogeneous group including transplant patients, patients undergoing treatment with immunosuppressors, uremic patients, alcoholics, undernourished patients, diabetics, patients on dialysis, elderly patients, and those diagnosed with severe or neoplastic processes. Epileptic seizures, focal neurologic signs, and meningoencephalitis are neurologic syndromes that require urgent action. In most of these situations, neuroimaging tests are necessary, but the findings can be different from those observed in immunocompetent patients in function of the inflammatory response. Infectious disease is the first diagnostic suspicion, and the identification of an opportunistic pathogen should be oriented in function of the type and degree of immunosuppression. Other neurologic emergencies include ischemic stroke, cerebral hemorrhage, neoplastic processes, and pharmacological neurotoxicity. This article reviews the role of neuroimaging in HIV-negative immunodepressed patients with a neurologic complication that requires urgent management.

The cost effectiveness of vacuum-assisted versus core-needle versus surgical biopsy of breast lesions. / Estudio de costo-efectividad de la biopsia mamaria asistida por vacío versus biopsia con aguja gruesa o arpón.

OBJECTIVES: To determine the cost effectiveness of breast biopsy by 9G vacuum-assisted guided by vertical stereotaxy or ultrasonography in comparison with breast biopsy by 14G core-needle biopsy and surgical biopsy. MATERIAL AND METHODS: We analyzed a total of 997 biopsies (181 vacuum-assisted, 626 core, and 190 surgical biopsies). We calculated the total costs (indirect and direct) of the three types of biopsy. We did not calculate intangible costs. We measured the percentage of correct diagnoses obtained with each technique. To identify the most cost-effective option, we calculated the mean ratios for the three types of biopsies. RESULTS: Total costs were €225.09 for core biopsy, €638.90 for vacuum-assisted biopsy, and €1780.01 for surgical biopsy. The overall percentage of correct diagnoses was 91.81% for core biopsy, 94.03% for vacuum-assisted biopsy, and 100% for surgical biopsy; however, these differences did not reach statistical significance (p=0.3485). For microcalcifications, the percentage of correct diagnoses was 50% for core biopsy and 96.77% for vacuum-assisted biopsy (p<0.0001). For nodules, there were no significant differences among techniques. The mean cost-effectiveness ratio considering all lesions was 2.45 for core biopsy, 6.79 for vacuum-assisted biopsy, and 17.80 for surgical biopsy. CONCLUSION: Core biopsy was the dominant option for the diagnosis of suspicious breast lesions in general. However, in cases with microcalcifications, the low percentage of correct diagnoses achieved by core biopsy (50%) advises against its use in this context, where vacuum-assisted biopsy would be the technique of choice because it is more cost-effective than surgical biopsy, the other technique indicated for biopsying microcalcifications.

Performance of the Finnish Diabetes Risk Score and a Simplified Finnish Diabetes Risk Score in a Community-Based, Cross-Sectional Programme for Screening of Undiagnosed Type 2 Diabetes Mellitus and Dysglycaemia in Madrid, Spain: The SPREDIA-2 Study.

AIM: To evaluate the performance of the Finnish Diabetes Risk Score (FINDRISC) and a simplified FINDRISC score (MADRISC) in screening for undiagnosed type 2 diabetes mellitus (UT2DM) and dysglycaemia. METHODS: A population-based, cross-sectional, descriptive study was carried out with participants with UT2DM, ranged between 45-74 years and lived in two districts in the north of metropolitan Madrid (Spain). The FINDRISC and MADRISC scores were evaluated using the area under the receiver operating characteristic curve method (ROC-AUC). Four different gold standards were used for UT2DM and any dysglycaemia, as follows: fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), HbA1c, and OGTT or HbA1c. Dysglycaemia and UT2DM were defined according to American Diabetes Association criteria. RESULTS: The study population comprised 1,426 participants (832 females and 594 males) with a mean age of 62 years (SD = 6.1). When HbA1c or OGTT criteria were used, the prevalence of UT2DM was 7.4% (10.4% in men and 5.2% in women; p<0.01) and the FINDRISC ROC-AUC for UT2DM was 0.72 (95% CI, 0.69-0.74). The optimal cut-off point was ≥13 (sensitivity = 63.8%, specificity = 65.1%). The ROC-AUC of MADRISC was 0.76 (95% CI, 0.72-0.81) with ≥13 as the optimal cut-off point (sensitivity = 84.8%, specificity = 54.6%). FINDRISC score ≥12 for detecting any dysglycaemia offered the best cut-off point when HbA1c alone or OGTT and HbA1c were the criteria used. CONCLUSIONS: FINDRISC proved to be a useful instrument in screening for dysglycaemia and UT2DM. In the screening of UT2DM, the simplified MADRISC performed as well as FINDRISC.

Hematoma espinal epidural espontáneo: estudio retrospectivo de una serie de 13 casos / Spontaneous spinal epidural haematoma: A retrospective study of a series of 13 cases

Introducción: El hematoma espinal epidural espontáneo (HEEE) tiene una incidencia estimada de un caso por millón de habitantes al año. Se considera espontáneo cuando no se logra relacionar ninguna causa de forma directa con su aparición. Objetivo: Describir una muestra de pacientes con HEEE y analizar las variables relacionadas con el pronóstico funcional del mismo. Pacientes y métodos: Estudio retrospectivo de pacientes diagnosticados de HEEE en nuestro centro entre 2001 y 2013. Resultados: Trece pacientes, 7 varones, con edad media de 71 años. El 62% presentaba hipertensión arterial (HTA) y el 54% utilizaba anticoagulantes orales, teniendo una razón normalizada internacional > 3 el 57% de ellos. La presentación clínica más frecuente fue dolor en columna vertebral (85%). El 92% asoció déficit neurológico en forma de síndrome sensitivo-motor (70%), motor puro (15%) o sensitivo puro (7%). Cinco pacientes recibieron tratamiento quirúrgico y 8 fueron tratados de forma conservadora. Al año, 3 de los pacientes tratados de forma quirúrgica y 4 de los de manejo conservador tenían una puntuación igual o menor de 2 en la Escala Rankin Modificada. Se observó peor pronóstico en pacientes anticoagulados, en hematomas de mayor extensión, en hematomas localizados en región lumbar y cuando el compromiso motor inicial era mayor. Conclusiones: La edad avanzada, la HTA y la anticoagulación son los principales factores asociados con el HEEE. La presentación típica consiste en dolor en la columna vertebral seguido de déficit motor. En pacientes con déficits motores establecidos, el tratamiento quirúrgico dentro de las primeras 24 h parece ser la mejor opción terapéutica

Introduction: Spontaneous spinal epidural haematoma (SSEH) has an estimated incidence of one per million inhabitants. It is classified as spontaneous when no identifiable cause can be linked to its onset. Objective: To describe a sample of patients with SSEH and analyse variables related to its functional prognosis. Patients and methods: Retrospective study carried out in patients diagnosed with SSEH between 2001 and 2013 in our hospital. Results: We included 13 subjects (7 men) with a mean age of 71 years. Of the total, 62% had hypertension and 54% were treated with oral anticoagulants; of the latter, 57% had an International Normalised Ratio above 3. The most frequent manifestation was spinal column pain (85%). Nearly all subjects presented an associated neurological deficit, whether sensory-motor (70%), pure motor (15%), or pure sensory (7%). Five patients underwent surgical treatment and 8 had conservative treatment. After one year, 3 of the patients treated surgically and 4 of those on conservative treatment had a score of 2 or lower on the modified Rankin Scale. Poorer prognosis was observed in patients with anticoagulant therapy, large haematomas, location in the lumbar region, and more pronounced motor disability at onset. Conclusions: Old age, hypertension, and anticoagulant therapy are the main risk factors for SSEH. The typical presentation consists of back pain with subsequent motor deficit. In patients with established motor symptoms, surgical treatment within the first 24 hours seems to be the best option

Spontaneous spinal epidural haematoma: a retrospective study of a series of 13 cases.

INTRODUCTION: Spontaneous spinal epidural haematoma (SSEH) has an estimated incidence of one per million inhabitants. It is classified as spontaneous when no identifiable cause can be linked to its onset. OBJECTIVE: To describe a sample of patients with SSEH and analyse variables related to its functional prognosis. PATIENTS AND METHODS: Retrospective study carried out in patients diagnosed with SSEH between 2001 and 2013 in our hospital. RESULTS: We included 13 subjects (7 men) with a mean age of 71 years. Of the total, 62% had hypertension and 54% were treated with oral anticoagulants; of the latter, 57% had an International Normalised Ratio above 3. The most frequent manifestation was spinal column pain (85%). Nearly all subjects presented an associated neurological deficit, whether sensory-motor (70%), pure motor (15%), or pure sensory (7%). Five patients underwent surgical treatment and 8 had conservative treatment. After one year, 3 of the patients treated surgically and 4 of those on conservative treatment had a score of 2 or lower on the modified Rankin Scale. Poorer prognosis was observed in patients with anticoagulant therapy, large haematomas, location in the lumbar region, and more pronounced motor disability at onset. CONCLUSIONS: Old age, hypertension, and anticoagulant therapy are the main risk factors for SSEH. The typical presentation consists of back pain with subsequent motor deficit. In patients with established motor symptoms, surgical treatment within the first 24hours seems to be the best option.

Experiencia preliminar en el tratamiento combinado de metástasis vertebrales mediante radiofrecuencia y cifoplastia en sesión única / No disponible

Objetivos: Describir nuestra experiencia preliminar en el tratamiento de metástasis vertebrales mediante radiofrecuencia y cifoplastia combinadas en sesión única. Material y métodos: Se trataron cuatro pacientes con metástasis vertebral única confirmada histológicamente (mama, próstata, pulmón y mieloma en D12, L1, L5 y D12, respectivamente). La indicación en todos los casos fue el dolor con una mala respuesta al tratamiento médico habitual. Todos los pacientes presentaban dolor en el rango 6-7 de la escala visual analógica (EVA). En dos casos existía lesión lítica del muro posterior. Tras la obtención del consentimiento informado se realizó el procedimiento bajo sedación e infiltración anestésica local. Se efectuó abordaje transpedicular bilateral con sistemas de punción ósea 11G. Se insertaron de forma coaxial dos agujas de radiofrecuencia para efectuar un ciclo de ablación por cada pedículo. Durante el ciclo de ablación la punta del dispositivo correspondiente se situó en la unión del tercio medio con el tercio anterior del cuerpo vertebral, empleando la segunda aguja como sensor térmico, con su extremo a la altura del muro posterior. La duración de cada ciclo de ablación fue de 8 minutos, alcanzando temperaturas intratumorales de 70-80 ºC. A continuación se realizó cifoplastia transpedicular. Resultados: No se registraron complicaciones intra-periprocedimiento, con alta domiciliaria en las 24 horas siguientes. En todos los pacientes hubo una mejoría inmediata del dolor tras el procedimiento (con dolor de intensidad 1-2 de la EVA). En tres pacientes se retiró progresivamente la medicación analgésica, sin evidencia en ninguno de ellos de progresión local de la enfermedad ni recurrencia-aumento del dolor en el seguimiento (dolor de intensidad 1 de la EVA en un seguimiento en el rango de 8-14 meses). En un paciente no se pudo efectuar seguimiento clínico-radiológico posterior al alta. Conclusión: El empleo de radiofrecuencia asociada a cifoplastia en la enfermedad metastásica vertebral puede contribuir al manejo del dolor refractario al tratamiento médico y al control local de la enfermedad (AU)

Objectives: Describe our preliminary experience in the treatment of vertebral metastases by radiofrequency and Kyphoplasty combined in one single session. Material and methods: Four patients with histologically confirmed single spinal metastasis (breast, prostate, lung and myeloma in L1, L5, D12, D12, respectively) were treated. The indication in all cases was pain with a poor response to medical treatment. All patients had pain in the range 6-7 visual analogue scale (VAS). In two cases there was a lytic lesion of the spinal posterior wall. After obtaining informed consent, and under sedation and local anesthetic the procedure took place. The transpedicular approach took place with a 11 G bone puncture system. Two radiofrequency needles were coaxially inserted to carry out an ablation cycle through each pedicle. During the ablation cycle the tip of the ablation neddle stood between the anterior and middle third of the vertebral body, while the second needle was used as thermal sensor with its end to the height of the vertebral posterior wall. The duration of each cycle of ablation was 8 minutes reaching intratumoral temperatures of 70-80 °C. Transpedicular Kyphoplasty was performed subsequently. Results: No complications were reported during or after the procedure and patients were discharged in the first 24 hours. There was an immediate improvement in pain after the procedure (with a VAS 1-2 intensity pain) in all patients. During follow up, analgesic medication was withdrawn in three patients, and there was no evidence of disease progression or recurrence of pain (pain intensity 1 (VAS) in a follow-up in the range of 8-14 months). Clinical and radiological follow-up after discharge could not be performed on a patient. Conclusion: The use of radio-frequency associated with Kyphoplasty in vertebral metastatic disease can contribute to the management of refractory pain to medical treatment (AU)

Estudio de la perfusión cerebral mediante técnicas de susceptibilidad magnética: técnica y aplicaciones / Studying cerebral perfusion using magnetic susceptibility techniques: technique and applications

Las técnicas de perfusión por resonancia magnética (PRM) permiten la valoración de la microvasculatura cerebral mediante los cambios de señal debidos al paso intravascular de un trazador. La técnica más empleada se basa en la susceptibilidad magnética del gadolinio en secuencias T2* y los parámetros más comúnmente valorados son: el volumen sanguíneo cerebral, el flujo sanguíneo cerebral y el tiempo de tránsito medio. En los estudios de PRM deben considerarse diversos aspectos técnicos como la secuencia empleada, la dosis o la velocidad de inyección del contraste. También debe valorarse la existencia de fuentes de error como las debidas a la fuga de contraste por alteración en la permeabilidad de la barrera hematoencefálica. Las aplicaciones clínicas más extendidas de la PRM incluyen la determinación del grado de agresividad de gliomas, la diferenciación de algunos tipos histológicos tumorales o de lesiones pseudotumorales y la valoración del área de penumbra en la isquemia aguda (AU)

Perfusion MRI makes it possible to evaluate the cerebral microvasculature through changes in signal due to a tracer passing through blood vessels. The most commonly used technique is based on the magnetic susceptibility of gadolinium in T2*-weighted sequences, and the most commonly evaluated parameters are cerebral blood volume, cerebral blood flow, and mean transit time. Diverse technical aspects, like the sequence used, and the dose and speed of contrast material injection, must be taken into account in perfusion MRI studies. It is also essential to consider possible sources of error like contrast material leaks due to changes in the permeability of the blood-brain barrier. The most widely used clinical applications of perfusion MRI include the determination of the degree of aggressiveness of gliomas, the differentiation of some histological types of tumors or pseudotumors, and the evaluation of the penumbral area in acute ischemia (AU)