Mobile thrombus in right atrium during cannulation of veno-venous extracorporeal membrane oxygenation / Trombo móvil en la aurícula derecha durante la canulación de una membrana de oxigenación estracorpórea veno-venosa

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Improvement of renal function after conversion to mycophenolate mofetil combined with low-level calcineurin inhibitor in liver transplant recipients with chronic renal dysfunction.

INTRODUCTION: Calcineurin inhibitors (CNI) are the main pathogenic factors for renal dysfunction in solid organ transplant recipients. Introduction of non-nephrotoxic immunosuppressive drugs, such as mycophenolate mofetil (MMF), may allow discontinuation or reduction of CNI treatment, thereby improving renal function. The aim of this study was to assess the feasibility, efficacy and safety of MMF introduction and CNI dosage reduction in the maintenance immunosuppressive protocol to improve renal function in liver transplant recipients with chronic renal dysfunction. PATIENTS AND METHODS: We prospectively included 88 liver transplant recipients including 74 men and an overall mean age of 58.8 +/- 10.3 years who all displayed chronic renal dysfunction (creatinine >1.4 mg/dL) and proteinuria <1 g/d. They were subdivided into 3 groups according to the basal creatinine value 1.4-1.7 mg/dL (group I; n = 41); 1.8-2.0 mg/dL (group II; n = 28); and >2 mg/dL (group III; n = 19). MMF was initiated at 1.5-2.0 g/d. Reduction of tacrolimus or cyclosporine dosage was performed to achieve respective target trough levels of <5 ng/mL or <50 ng/mL. We performed periodic determinations of arterial pressure, liver function tests, serum creatinine, blood cells count, CNI levels, and proteinuria. RESULTS: Creatinine values after conversion were 1.4 +/- 0.5 mg/dL in the overall group. Improvement of renal function was more frequent among groups I (80.4%) and II (92.8%) versus III (73.6%). Normalization of creatinine values was more frequent in group I (68.2%) with respect to cohorts II (21.4%) and III (10.5%). Rejection was not detected. CONCLUSION: Application of an immunosuppressive protocol with MMF and low-level CNI in liver transplant recipients with chronic renal dysfunction was associated with improvement or normalization of creatinine, without an increased risk of rejection. Early conversion is needed to achieve the best results.

Evolution of hepatorenal syndrome after orthotopic liver transplantation: comparative analysis with patients who developed acute renal failure in the early postoperative period of liver transplantation.

OBJECTIVE: The purpose of this study was to ascertain the prognosis of patients with hepatorenal syndrome (HS) prior to orthotopic liver transplantation (OLT) by comparisons with a group of selected patients with normal renal function (NRF) pretransplantation who developed acute renal failure (ARF) in the early postoperative period. MATERIALS AND METHODS: Fifty-two OLT cases developed ARF in the early postoperative period between March 1999 and October 2004; 17 cases experienced HS prior to OLT. ARF was defined as serum creatinine level (Cr) >1.5 mg/dL or a creatinine clearance (CrCl) <50 mL/min. The immunosuppressive therapy was the same in both groups: low doses of tacrolimus were prescribed to reach trough levels of 5 ng/mL in the first week after OLT, where patients were administered monoclonal antibodies and corticosteroids. RESULTS: No differences were observed between the groups for gender, age or APACHE II Score in the first 24 hours after OLT. Patients with HS pretransplantation showed higher Cr and urea (U) levels than the other group (Cr: 2.1 +/- 0.8 HS vs 0.9 +/- 0.2, P = .000; U: 93.6 +/- 51.9 HS vs 42.1 +/- 19.3, P = .001). The ICU days of stay were similar (12.8 +/- 0.5 HS vs 19.7 +/- 15.2, P = .053). At the end of 1 year follow-up after OLT there were no differences in mortality (35% HS vs 26%), need for renal replacement therapy (23% HS vs 34%), infection (59% HS vs 51%), or rejection (6% HS vs 29%, P = .06). CONCLUSIONS: Patients with HS prior to OLT showed a similar prognosis to a group of selected patients with NRF pretransplantation, but developed ARF in the early postoperative period which was treated with monoclonal antibodies and low doses of tacrolimus.

Disección coronaria espontánea: aspectos diagnósticos y terapéuticos / Spontaneous coronary dissection: diagnostic and therapeutic approach

Presentamos dos casos de disección espontánea coronaria, que corresponden a dos mujeres sin factores de riesgo que presentaron un síndrome coronario agudo que cursó con importantes cambios electrocardiográficos. Se realizó en ambos casos una coronariografía urgente, que demostró una disección del tronco de la coronaria izquierda en el primer caso y una disección del segmento proximal de la arteria descendente anterior en el segundo. Ambos casos fueron revascularizados quirúrgicamente. (AU)

[Paraquat poisoning and hemoperfusion with activated charcoal]. / Envenenamiento por Paraquat y hemoperfusión con carbón activado.

Paraquat is a common herbicide in Spain. In our country there are a few cases of this intoxication and it presents a high mortality even if the patients ingest a minimal amount. We present two cases of accidental poisoning with paraquat. These patients were admitted three hours after ingestion of toxin. They were treated with with orogastric lavage, activated charcoal, N-acetylcysteine, Fuller's earth, cathartics, support measures and hemoperfusion with activated charcoal. With these treatments both patients had a undetectable levels of paraquat 48 hours after and improvement of their symptoms, gastric and intestinal predominantly . We present the graphics of evolution of the plasma and urine levels of paraquat in both patients. We review the different aspects of treatment and update of this poisoning.

Envenenamiento por paraquat y hemoperfusión con carbon activado / Paraquat intoxications and hemoperfusion with activated charcoal

El Paraquat es un herbicida del grupo de los biperidilicos, de los más utilizados en nuestro pais.En España existen muy pocos casos descritos de esta intoxicación y presenta una alta mortalidad incluso con la ingestión de mínimas cantidades.Presentamos dos casos de intoxicación por ingesta accidental de este producto, que llegan a nuestro hospital en las tres horas posteriores. Se instaura tratamiento con lavado gástrico, carbón activado, N acetil cisteina, tierra de Fuller, catárticos, medidas de apoyo y hemoperfusión con carbón activado; consiguiendose niveles indetectables del tóxico 48 horas después y mejorando su sintomatología, predominantemente gastrointestinal.Se comentan los casos clínicos durante su estancia en U.C.I así como aspectos clínicos de estas intoxicaciones, su tratamiento actual y últimas tendencias y factores pronósticos (AU)

The Paraquat is a herbicide more using in Spain. In our country there are a few cases this intoxication and it presents a hight mortality even if the patients ingest a minimal amount. We present two cases of casual poisoning with paraquat. These patients were admited three hours after ingestion of toxic. They were treated with with orogastric lavage, activated charcoal, N-acetil-cysteina, Fuller´s earth, catartics, support measuring and hemperfusion with activated charcoal, with this treatments both patients had a indetectable levels of paraquat 48 hours after and yours symptoms that was gastric and intestinal predominantly had missing. We present the graphics of evolution the plasmatic and urine levels of paraquat the both patients. We review the differents aspects of treatment and update of this intoxication (AU)

[Coronary ischemia caused by pseudoxanthoma elasticum and myocardial revascularization with double arterial graft]. / Isquemia coronaria producida por seudoxantoma elástico y revascularización miocárdica con doble injerto arterial.

We present a case of an 18 year-old woman with pseudoxanthoma elasticum, who had a biopsy taken from a lesion. Although she was asymptomatic, we tried to rule out myocardial ischemia with a treadmill and cardiac gammagraphy with Talio. The isotopic studies and the ergometry were positive and the patient underwent coronariography. This study showed a severe triple-vessel disease. We did an angiography of the supraaortic arteries, mamarian artery, and mesenteric artery. These studies showed no obstructive lesions. The treatment of patient was a double by-pass with internal mammary artery and one by-pass with safena vein grafts with satisfactory results.

Infarto agudo de miocardio y trombosis coronaria inducidos por cocaína / Acute myocardial infarction and coronary thrombosis induced by cocaine

Un joven de 28 años con antecedentes de ulcus gástrico sufre un infarto agudo de miocardio anterolateral después de haber consumido en los días previos gran cantidad de cocaína. La coronariografía evidenció la presencia de un trombo oclusivo en el segmento proximal de la arteria descendente anterior, que se extendía hacia la porción distal del tronco de la coronaria izquierda. Se decidió realizar trombolisis intracoronaria con urocinasa. El trombo fue parcialmente lisado y la evolución posterior fue satisfactoria. En el control angiográfico se observaron unas arterias coronarias epicárdicas sin lesiones obstructivas (AU)

[Angiosarcoma of gingival presentation]. / Angiosarcoma de presentación gingival.

We present the case of a woman of 62 years old with changes history in the intestinal habit, weak, thing, anemia, violet injuries in the gums and hemoptysis of small quantity. After the various tests accomplishment of image and biopsy of the injuries gingival and of lymphadenopathy supraclavicular was demonstrated the existence of a angiosarcoma of high degree of malignity. This neoplasm is originated in the cells of vascular endothelium and constitutes 1% of all the sarcomas and solely 4% appear the the oral cavity. These tumors has a high mortality (superior to the 20%) to five years. Once diagnosed its manage must be aggressive in spite of its wrong therapeutic response.

[Influence of systemic arterial hypertension on mid-term survival of patients with acute myocardial infarction treated with fibrinolytic agents]. / Influencia de la hipertensión arterial sistémica en la supervivencia a medio plazo de los pacientes con infarto agudo de miocardio que han recibido tratamiento fibrinolítico.

BACKGROUND: The purpose of this study to asses the effect of systemic arterial hypertension on mid-term survival of patients with acute myocardial infarction who received thrombolytic treatment. PATIENTS AND METHOD: We studied 202 consecutive patients with acute myocardial infarction, admitted in the Coronary Care Unit of the Hospital Xeral de Galicia who received intravenous thrombolytic therapy within six hours from the onset of symptoms. The thrombolytics used were: urokinase (79.7%), rt-PA (9.9%), streptokinase (4.9%) and APSAC (5.5%). Left heart catheterization with coronary angiography was performed in 162 patients at 2 weeks after infarction. Patency of the infarction-related artery (IRA) was classified according to Thrombolysis in Myocardial Infarction (TIMI) criteria. A patent artery weas defined as having TIMI grades 2 or 3 antegrade flow. RESULTS: Systemic arterial hypertension was found in 34.7% of patients. IRA patency (TIMI 2-3) was demonstrated in the 75.3% of the patients. Early mortality (first month) was 5.4%. Multivariate analysis identified cardiogenic shock as the only variable with independent predictive value for early mortality. Mean follow-up was for 24 +/- 19 months. Late mortality was 5.2% and cardiac death occurred in 4.2% of patients. Reinfarction occurred in 3.1% of patients. Congestive heart failure, arterial hypertension and reinfarction adversely affected prognosis. Actuarial survival at the end of follow-up period was significantly lower in patients with systemic arterial hypertension (70.4% vs 85.9%; p < 0.05). CONCLUSIONS: These data suggest that systemic arterial hypertension adversely affects mid-term prognosis in patients with acute myocardial infarction who received thrombolytic treatment.