Disease risk estimates in V30M variant transthyretin amyloidosis (A-ATTRv) from Mallorca.

BACKGROUND: Variant transthyretin amyloidosis (A-ATTRv) is an autosomal dominant disease caused by a range of TTR gene variants which entail great phenotypical heterogeneity and penetrance. In Majorca, the A-ATTRv caused by the V30M gene variant (A-ATTRV30M) is the most common. Since asymptomatic carriers are at risk of developing the disease, estimating age of onset is vital for proper management and follow-up. Thus, the aim of this study was to estimate age-related penetrance in ATTRV30M variant carriers from Majorca. METHODS: The disease risk among carriers from ATTRV30M families from Majorca was estimated by Non-parametric survival estimation. Factors potentially involved in the disease expression, namely gender and parent of origin were also analysed. RESULTS: A total of 48 heterozygous ATTRV30M families (147 affected patients and 123 were asymptomatic carriers) were included in the analysis. Penetrance progressively increased from 6% at 30 years to 75% at 90 years of age. In contrast to other European populations, we observe a similar risk for both males and females, and no difference of risk according to the parent of origin. CONCLUSIONS: In this first study assessing the age-related penetrance of ATTRV30M variant in Majorcan families, no effect of gender or parent of origin was observed. These findings will be helpful for improving management and follow-up of TTR variant carrier individuals.

Expresiones y criterios mejorables en la redacción de informes de evaluación y posicionamiento terapéutico / Expressions and criteria that could be improved in the writing of reports for drug evaluation and therapeutic positioning

En la revisión de borradores de informes para evaluación y posicionamiento de nuevos fármacos en un entorno multidisciplinar, se observan determinados errores de expresión o criterio que se repiten con frecuencia. Principalmente, están relacionados con la consideración de “diferencias” o tendencias no significativas, abuso de la reducción relativa del riesgo, errores en la valoración de resultados por subgrupos sin calcular la interacción estadística, confusiones en la interpretación de las comparaciones indirectas, sobrevaloración de la relevancia clínica con variables subclínicas y afirmaciones sesgadas en el apartado de seguridad, entre otros. También se observa a menudo ambigüedad o inhibición en el posicionamiento, especialmente en situaciones de precariedad en la evidencia disponible. El presente trabajo expone de forma sintética tales errores, aclara algunos términos comunes y propone expresiones o criterios alternativos que se consideran preferibles, con el fin de ofrecer una evaluación para la toma de decisiones en beneficio de los pacientes. (AU)

In the review of reports for evaluation and positioning of new drugs in a multidisciplinary setting, some usual errors of expression or criteria are observed. Most of them are related to the consideration of «differences» or non-significant trends, abuse of the relative risk reduction, errors in the assessment of results by subgroups without calculating the statistical interaction, misinterpretation of indirect comparisons, excess in the assessment of clinical relevance with subclinical variables and biased statements in the safety section, among others. Ambiguity or inhibition in positioning is also often observed, especially in situations of precariousness in the available evidence. This work summarizes such errors, clarifies some common terms and proposes alternative expressions or criteria that are considered preferable, in order to offer evaluations for decision-making focused on the benefit of patients. (AU)

The ICD-11 developmental field study of reliability of diagnoses of high-burden mental disorders: results among adult patients in mental health settings of 13 countries.

Reliable, clinically useful, and globally applicable diagnostic classification of mental disorders is an essential foundation for global mental health. The World Health Organization (WHO) is nearing completion of the 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11). The present study assessed inter-diagnostician reliability of mental disorders accounting for the greatest proportion of global disease burden and the highest levels of service utilization - schizophrenia and other primary psychotic disorders, mood disorders, anxiety and fear-related disorders, and disorders specifically associated with stress - among adult patients presenting for treatment at 28 participating centers in 13 countries. A concurrent joint-rater design was used, focusing specifically on whether two clinicians, relying on the same clinical information, agreed on the diagnosis when separately applying the ICD-11 diagnostic guidelines. A total of 1,806 patients were assessed by 339 clinicians in the local language. Intraclass kappa coefficients for diagnoses weighted by site and study prevalence ranged from 0.45 (dysthymic disorder) to 0.88 (social anxiety disorder) and would be considered moderate to almost perfect for all diagnoses. Overall, the reliability of the ICD-11 diagnostic guidelines was superior to that previously reported for equivalent ICD-10 guidelines. These data provide support for the suitability of the ICD-11 diagnostic guidelines for implementation at a global level. The findings will inform further revision of the ICD-11 diagnostic guidelines prior to their publication and the development of programs to support professional training and implementation of the ICD-11 by WHO member states.

«Ateroembolismo» paradójico en paciente con síndrome de Paget-Schroetter / Paradoxical «atheromatous embolism» in a patient with Paget-Schroetter syndrome

No disponible

Results of Infrainguinal Bypass in Acute Limb Ischaemia.

OBJECTIVE/BACKGROUND: To assess the outcomes of infrainguinal bypass performed for acute limb ischaemia, as well as the predictors of patency, mortality, and amputation. METHODS: This was a retrospective cohort study of patients undergoing infrainguinal bypass between 1998 and 2014. The cohort was stratified according to the indication for surgery into two groups: group A (acute limb ischaemia) and group B (chronic lower extremity ischaemia). Comparative analysis was performed on comorbidities, surgical technique, and outcomes, as well as prognostic factors in group A. RESULTS: In total, 702 bypasses were performed (group A, n = 107; group B, n = 595). Differences between groups were detected in age (65.9 vs. 70.9 years; p = .03), diabetes (16% vs. 49%; p < .01), renal insufficiency (6% vs. 13%; p = .05), stroke (7% vs. 14%; p = .04), and coronary artery disease (13% vs. 28%; p < .01). Patients with acute limb ischaemia more often required general anaesthesia (47% vs. 12%; p < .01) and a short bypass was more often performed (32% vs. 7%; p < .01). Median follow up was 23 and 24 months for groups A and B, respectively. No differences were found in patency rates at 1, 12, and 24 months between groups, but group B had a higher re-intervention rate during follow up. Primary patency in group A was 84%, 63%, and 58%, and in group B it was 88%, 62%, and 53% at 1, 12, and 24 months, respectively (p = .77). Assisted primary patency in group A was 85%, 72%, and 67%, and in group B it was 90%, 74%, and 66% at 1, 12, and 24 months, respectively (p = .61). Secondary patency in group A was 90%, 78%, and 75%, and in group B it was 94%, 80%, and 74% at 1, 12, and 24 months, respectively (p = .80). The freedom from re-intervention rate in group A was 91%, 74%, and 68%, and in group B it was 92%, 76%, and 71%, respectively (p = .04). Acute limb ischaemia was an independent risk factor for amputation (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.74-14.09; p < .01) and mortality (OR 4.13, 95% CI 1.53-11.14; p = .01) at 30 days. In group A, female sex, prosthetic conduit, and need of distal thrombectomy were independently associated with worse patency rates. Poor intra-operative runoff was correlated with higher amputation rates. CONCLUSION: Among those undergoing infrainguinal bypass, patients who present with acute limb ischaemia constitute a subset showing higher early rates of amputation and death. In this subset of patients, worse outcomes may be expected for women, prosthetic conduits, need for distal thrombectomy, and patients with poor intra-operative runoff.

Evolución de la arteria ilíaca ectásica no tratada tras la reparación endovascular del aneurisma de aorta / Evolution of the untreated ectactic iliac artery after endovascular aortic aneurysm repair

OBJETIVOS: Determinar el crecimiento de la arteria ilíaca común (AIC) ectásica no tratada durante la reparación endovascular del aneurisma aórtico (EVAR), por existir zonas de anclaje proximales más favorables. MATERIAL Y MÉTODOS: Estudio de cohortes retrospectivo, incluyendo pacientes tratados por aneurisma de aorta abdominal de forma electiva, con un seguimiento de 5 años. Se estudiaron los casos con anclaje en AIC, registrando los diámetros máximos basales y a 1, 2, 3, 4 y 5 años en el segmento de AIC no tratado, excluyendo aquellos casos con anclaje en la arteria ilíaca externa. Se analizó la muestra en función de: A) Diámetro basal AIC: grupo 1 (G1) (n = 67): < 16 mm; grupo 2 (G2) (n = 23): ≥16 mm. B) Zona de anclaje: 2/3 proximales de AIC (n = 40); 1/3 distal (n = 50). RESULTADOS: Un total de 56 pacientes incluidos en el estudio, con 90 ilíacas analizadas. A) Los diámetros medios en G1 y G2 (basal, 3, 5 años) fueron: 12,8; 13,1; 13,3 vs. 18,0; 19,4; 20,3 mm, con un crecimiento 1,8 mm mayor a 5 años en G2 (p < 0,001). No se registraron fugas tipo IB durante el seguimiento. B) Existió una interacción significativa (p = 0,01) entre la localización del anclaje y el diámetro basal para el crecimiento ilíaco: en AIC ≥ 16 mm el anclaje en el tercio distal fue protector para crecimiento (p = 0,04). CONCLUSIONES: El crecimiento tras EVAR de la AIC no tratada es mayor en las AIC ectásicas. En estos casos, el anclaje en el tercio distal puede disminuir la tasa de crecimiento. No obstante, si el anclaje es más favorable en los 2/3 proximales de la AIC dicho crecimiento no se traduce en mayor número de complicaciones

OBJECTIVE: To assess the enlargement of ectatic common iliac arteries (CIA) which are not covered during endovascular aortic aneurysm repair (EVAR) due to the existence of more favorable proximal sealing zones. MATERIAL AND METHODS: Patients who underwent elective EVAR, with a 5 year follow up were included in a retrospective cohort study. Only cases with distal sealing zones in CIA were studied, recording a maximum basal diameter at the non-covered segment of CIA, and at 1, 2, 3, 4 and 5 years. Cases with distal sealing on external iliac artery were excluded. The sample was analyzed according to: A) CIA baseline diameter: group 1 (G1) (n = 67): < 16 mm; group 2 (G2) (n = 23): ≥16 mm. B) Sealing zone: proximal two thirds of CIA (n = 40); distal third (n = 50). RESULTS: A total of 56 patients were included in the study, with 90 CIA analyzed. A) Mean diameters in G1 and G2 (baseline, 3, 5 years) were: 12.8, 13.1, 13.3 versus 18.0, 19.4, 20.3 mm, respectively, with a 1.8 mm greater enlargement for G2 (P<.001) at 5 years. No type IB endoleaks were registered during follow up. B) A significant interaction was observed (P=.01) between the distal sealing zone and basal diameter for iliac enlargement: in CIA ≥16 mm distal sealing in the distal third of the CIA was protective for iliac enlargement (P=.04). CONCLUSIONS: Iliac enlargement in non-treated segments of CIA after EVAR is greater in ectatic arteries. In these cases, distal sealing on the distal third of the CIA can decrease enlargement rate. However, if a more favorable zone for sealing exists proximally, the enlargement of the ectatic CIA does not result in a higher rate of complications

Resultados del bypass infrainguinal protésico en isquemia crítica: factores asociados a permeabilidad y salvamento de la extremidad / Outcomes of prosthetic bypass grafts in critical limb ischemia: Predictors of patency and limb salvage

OBJETIVOS: Los objetivos de este estudio son analizar los resultados del bypass protésico en isquemia crítica, así como evaluar posibles factores asociados a la permeabilidad y el salvamento de la extremidad. MATERIAL Y MÉTODOS: Estudio de cohortes retrospectivo de pacientes con isquemia crítica de miembros inferiores tratados mediante bypass infrainguinal protésico entre 1997-2013 en nuestro centro. Registramos factores preoperatorios e intraoperatorios, dividiendo la muestra en 3 grupos según la localización de la anastomosis distal: primera porción de la arteria poplítea (POP1), tercera porción de la arteria poplítea (POP3) o vaso distal. Analizamos permeabilidad primaria, primaria asistida, secundaria, salvamento de la extremidad y supervivencia. El análisis estadístico de variables se realizó por grupos según test habituales, Kaplan-Meier para permeabilidad, salvamento de la extremidad y supervivencia. El análisis univariable y multivariable de factores asociados a los resultados se llevó a cabo mediante regresión de Cox. RESULTADOS: Se analizaron 154 bypass protésicos, divididos en POP1 36,4% (n = 56), POP3 50% (n = 77) y vaso distal 13,6% (n = 21). Encontramos diferencias en la edad media (POP1 68,9 años, POP3 77,2 años, distal 76,8 años; p < 0,001). Seguimiento mediano: 11 meses. Obtuvimos mejores resultados en POP1 y peores en vaso sural para permeabilidad y salvamento de la extremidad (Log Rank P1 0,004, P1A 0,001, P2 0,001 y SE 0,025), sin diferencias en la supervivencia (Log Rank 0,068). Identificamos cardiopatía isquémica y anastomosis en vaso distal como factores de riesgo independientes para permeabilidad y salvamento de la extremidad. Los pacientes con mayor edad y aquellos con insuficiencia renal crónica presentaron mayor mortalidad. CONCLUSIONES: El bypass infrainguinal protésico ofrece resultados aceptables en isquemia crítica, siendo esperable un peor pronóstico en pacientes con cardiopatía isquémica y en bypass realizado a vasos distales

OBJECTIVES: To assess the outcomes of prosthetic bypass grafts in critical limb ischemia, as well as to determine the predictors of patency and limb salvage. MATERIALS AND METHODS: Retrospective cohort study of patients with critical limb ischemia undergoing a prosthetic infrainguinal bypass graft between 1997 and 2013 in a single centre. The pre- and post-operative data were collected, and the cohort was divided into 3 groups according to the location of the distal anastomosis: Above-knee popliteal artery (POP1), below-knee popliteal artery (POP3), or femorodistal. An assessment was made of the primary patency, assisted primary patency, secondary patency, limb salvage, and survival. Stratified statistical analysis using the Kaplan-Meier for patency, limb salvage and survival. Univariate and multivariate analysis of risk factors associated with the results using Cox regression. RESULTS: A total of 154 prosthetic graft bypass, divided into POP1 36.4% (n = 56), POP3 50% (n = 77), and femorodistal 13.6% (n = 21). Differences were found in mean age (POP1 68.9 years, POP3 77.2 years, femorodistal 76.8 years; P < .001). Median follow-up was 11 months. The best outcomes were found in POP1, and the worse in femorodistal in terms of patency and limb salvage (Log Rank P1 0.004, P1A 0.001, P2 0.001 and SE 0.025), with no differences in survival time (Log Rank 0.068). Coronary artery disease and femorodistal bypass were independent risk factors in patency and limb salvage. Older patients and those with chronic renal failure had higher mortality rates. CONCLUSIONS: Prosthetic infrainguinal bypass graft has fairly good outcomes in critical limb ischemia. The worst outcomes may be expected in patients with coronary artery disease and femorodistal bypass

¿Es la carga de trombo y su localización en el saco un factor protector de endofugas tipo II ? / Is thrombus load and location a protection factor of type II endoleaks?

OBJETIVO: Las endofugas tipo II (EFII) pueden incrementar la tasa de complicaciones. Se evaluó la relación entre la cantidad de trombo en el saco con el desarrollo de EFII y el crecimiento del aneurisma. MATERIAL Y MÉTODO: Se estudió a 103 pacientes tratados mediante EVAR. El grosor máximo del trombo (GMT), los porcentajes del área (PAOT) y perímetro aórticos con trombo (PPCT, PTHP) y el grosor (GMHP) en la cara posterior se determinaron en la TC preoperatoria en: zona A (diámetro máximo), zona B (entre zona A y bifurcación) y zona C (entre inicio del aneurisma y zona A). Se cuantificó el número de ramas permeables y el diámetro del saco durante el seguimiento. RESULTADOS: Hubo 51 endofugas (49,5%). Los pacientes con EFII presentaron unos GMT (18,6 vs. 24 mm; p = 0,01) y GMHP (13,9 vs. 18,9 mm; p = 0,003) menores en la zona A y tenían un PAOT (49,7 vs. 65,4%; p < 0,001), PPCT (72,4 vs. 82,3%; p < 0,001) y PTHP (63,7 vs. 74,7%; p = 0,03). El número medio de ramas fue de 5 en los pacientes sin EFII frente a 6 en los que la tenían (p = 0,004). Se observó un riesgo de EFII menor con: PAOT (OR = 0,65 por cada aumento del 10%; IC 95%: 0,44-0,98; p = 0,03), PPCT en la zona B (OR = 0,69 por cada aumento del 10%; IC 95%: 0,50-0,95; p = 0,01) y C (OR = 0,68; IC 95%: 0,52-0,88; p = 0,002), GMHP en la zona A (OR = 0,71 por cada aumento de 5 mm; IC 95%: 0,49-0,99; p = 0,04) y PTHP en la B (OR = 0,81 por cada aumento del 10%; IC 95%: 0,67-0,9; p = 0,02). La arteria mesentérica inferior (AMI) permeable (OR = 3,1; IC 95%: 1,1-8,9; p = 0,033), el mayor número de ramas (OR = 4,6 con más de 4 vasos; IC 95%: 1,8-12,2; p = 0,024) y lumbares (OR = 1,9 por cada incremento en una lumbar; IC 95%: 1,1-3,5; p = 0,017) se asociaron a un mayor riesgo. Cuanto mayor era el PAOT, PPCT, GMHP y PTHP mayor era la tendencia a la regresión/estabilidad del saco. CONCLUSIONES: La cuantificación de la carga de trombo y número de ramas permeables permite determinar pacientes con mayor riesgo de EFII y crecimiento del saco durante el seguimiento

BACKGROUND: Type II endoleaks (ELII) may increase the complication rate. An evaluation was made of the association between thrombus load and development of ELII, and aneurysm sac growth. MATERIAL AND METHODS: A total of 103 endovascular aortic repair patients were analyzed. The maximum thrombus thickness (GMT), percentages of area (PAOT) and perimeter lined by thrombus (PPCT), and posterior thickness (GMHP) were determined from pre-operative CT at 3 levels: zone A (maximum diameter), zone B (from zone A to bifurcation), and zone C (from neck to zone A). The number of aortic side branches was recorded, and sac diameter was measured during follow-up. RESULTS: A total of 51 endoleaks (49.5%) were noted. Patients with ELII had significantly less GMT (24.0 vs. 18.6 mm, P=0.01) and GMHP (13.9 vs. 18.9 mm, P=0.003) in zone A, and PAOT (49.7 vs.65.4%, P<0.001), PPCT (72.4 vs. 82.3%, P<0.001), and PTHP (63.7 vs. 74.7%, P=0.03). The average number of side branches was 5 in patients without ELII versus 6 with (P=0.004). Lower risk of ELII was observed with: PAOT (OR = 0.65 for a 10% increase, 0.44-0.98, P=0.03), PPCT in zone B (OR = 0.69 for each 10% increase, 0.50-0.95, P=0.01), and C (OR = 0.68, 0.52-0.88, P=0.002), GMHP in zone A (OR = 0.71 for each 5 mm increase, 0.49-0.99, P=0.04), and PTHP in zone B (OR = 0.81for 10% increase, 0.67-0.99, P=0.02). The patent IMA (OR = 3.1, 1.1-8.9, P=0.033), the number of patent branches (OR = 4.6 with more than 4 branches, 1.8-12.2, P = 0.024), and lumbar branches (OR = 1.9 for each patent lumbar, 1.1-3.5, P=.017) were associated with an increased risk of ELII. The greater PAOT, PPCT, GMHP, and PTHP were, the higher regression/stability of the sac was. CONCLUSIONS: Quantification of the thrombus load and the number of patent side branches can be used to determine patients at increased risk of ELII and sac growth during follow-up

Revisión sistemática: evaluación de la adherencia del tratamiento de pacientes naive con hepatitis C / Systematic review: evaluation of adherence among treatment naïve patients with hepatitis C

Introducción: El VHC en los seres humanos puede causar diferentes enfermedades hepáticas. La característica más significativa de la enfermedad es su alta tendencia a cronificarse. Objetivo: Realizar una revisión sistemática de estudios que evalúan la adherencia en pacientes con hepatitis C tratados con PEG-IFN/RBV y si una mejor adherencia hace conseguir un mayor número de pacientes que obtengan una RVS. Métodos: Los datos se obtuvieron mediante la búsqueda en Pubmed de revisiones sistemáticas en inglés publicadas en los últimos 5 años, empleando como palabras claves: «VHC treatment adherence», «Sustained Virologic Response». Se seleccionaron los estudios que evalúan la adherencia al tratamiento antiviral en pacientes sin coinfección con otra viremia. En una segunda búsqueda se utilizaron «telaprevir and boceprevir review». Resultados: En especial, en los pacientes con genotipo 1, una buena adherencia aumenta significativamente RVS (63% vs 34%). Las tasas de RVS con los nuevos antivirales han logrado aumentar en relación con la terapia dual hasta un 70% en naives, 30% en no respondedores y 80% recurrentes. Conclusión: Los pacientes con genotipo 1 deben mantener una mejor adherencia que pacientes con genotipo no 1. La interrupción del tratamiento, falta de adherencia por pérdidas de dosis de PEG-INF/RBV y los efectos adversos son los principales obstáculos para alcanzar la RVS

Introduction: In human beings, HCV might cause different liver diseases. The most significant feature of this disease is its high tendency to become chronic. Objective: To do a systematic review of several studies evaluating adherence in patients with hepatitis C who are treated with Peg-IFN/RBV. In addition, it is important to know if a better adherence let get a greater number of patients who obtained an SVR. Methods: Data were obtained by looking for Pubmed systematic reviews published in English in the last 5 years, using the following keywords: «HCV treatment adherence» and «Sustained Virologic Response». The selected studies were the ones that evaluate the adherence to antiviral therapy in patients without co-infection with another viremia. In a second search, the keywords used were «telaprevir and boceprevir review». Results: Particularly, in patients with genotype 1, a good adherence increases significantly SVR (63% vs 34%). With the new antivirals, SVR rates have increased in relation with dual therapy up to 70% in naïve, 30% in non-responders and 80 % in recurrent patients. Conclusion: Patients with genotype 1 have to maintain a better adherence than patients with genotype no 1. Discontinuation of treatment, lack of adherence caused by PEG-INF/RBV missing doses and adverse effects are the main obstacles to achieving SVR

Guía en DVD en la Cirugía Mayor Ambulatoria. Análisis de los resultados iniciales / Ambulatory surgery DVD guide. Analysis of the initial results

Introducción: Con la intención de mejorar la calidad asistencial se ha producido colateralmente una mayor complejidad en los circuitos peroperatorios. Así, en nuestro centro hemos asistido en los últimos años a un incremento de los pasos que deben realizar los pacientes desde que son derivados al cirujano para ser valorado un posible tratamiento quirúrgico hasta la fecha de la operación. Todo ello puede ocasionar confusión y angustia al paciente, a pesar del soporte y de la información oral y escrita que recibe de los diferentes profesionales sanitarios que visita. Objetivos: Para paliar esta situación se realizó un DVD que es entregado al paciente en la primera visita del especialista. Dicho DVD da a conocer una visión general del circuito de la CMA de nuestro centro y detalla cada paso que deberá realizar. De esta forma, el paciente puede verlo en su domicilio todas las veces que considere oportunas. Su observación familiariza al paciente con nuestras instalaciones y el ambiente hospitalario, complementa las explicaciones orales y escritas entregadas para clarificar las dudas que todavía pudieran persistir y creemos ayuda a disminuir la ansiedad del enfermo ante este acontecimiento. Material y método: Voluntariamente, el paciente realiza na encuesta de satisfacción que es remitida varias semanas tras el alta. Los resultados se comparan con los de un grupo de control que han visualizado el DVD. Resultados: Actualmente el estudio no está finalizado. Se han recibido 35 encuestas de las entregadas a los pacientes de cirugía general, de las cuales solo a 13 pacientes se le había entregado el DVD. El 31% de los pacientes a los que se entregó el DVD no tuvieron interés en verlo, los que lo consultaron refieren que la información fue útil en el 100% de los casos. Comparando los que reciben DVD de los que no, referente a sus preferencias de ingreso, el 11% hubieran preferido ingresar en comparación al 14% del grupo a los que no se les entregó. El grado de satisfacción fue elevado en ambos grupos, 8,8 puntos sobre 10. Conclusiones: La información perioperatoria puede ser mejorada con la entrega de material audiovisual complementario. Esta herramienta sintetiza y aclara todas las etapas que debe realizar el paciente. Incrementa el grado de satisfacción y la calidad asistencial percibida del paciente de la CMA realizada en nuestro hospital (AU)

Introduction: Nowadays there is more complexity in the per-operative circuits as a collateral consequence of trying to improve the health care quality. In the last years, we have seen an increase in steps that patients should be at our hospital since they are derived to the surgeon to be valued a possible surgical treatment until the date of the operation. All this can cause confusion and distress to the patient, despite the support and the oral and written information received from different specialists visited. Objective: A DVD was made to remedy this situation that is delivered to the patient in the first surgeon's visit. This DVD gives a general vision of the circuit of the ambulatory surgery of our center and details of each step. In this way the patient can see it at his home every time he deems appropriate. Its observation familiarizes him with our facilities and the hospitable atmosphere, clarifies the doubts that could still persist and we believe helps to decrease his anxiety before this event. Material and method: The patient performs a satisfaction questionnaire and he returns it several weeks after discharge from hospital. The results are compared with those of a control group that not viewed the DVD. Results: Currently the study is not complete. There have been 35 surveys delivered to the general surgery patients, of which only 13 patients had been given the DVD. 31% of patients who gave the DVD had no interest in seeing it, those who report that looked at the information was useful in 100% of cases. Comparing those who received the DVD not concerning their preferences for income, 11% would have preferred to enter compared to 14% of the group to which they were not given. The degree of satisfaction was high in both groups, 8.8 ut of 10. Conclusions: The preoperative information can be improved with the delivery of additional audiovisual material. This tool summarizes and clarifies all the stages that the patient should perform, increases the degree of satisfaction and the perceived quality in the care of ambulatory surgery patient in our hospital (AU)

Evolución de la función renal en la cirugía del aneurisma de aorta abdominal con clampaje suprarrenal / Evolution of renal function in abdominal aortic aneurysm surgery with suprarenal cross-clamping

Objetivo: Analizar los efectos del clampaje suprarrenal (CSR) frente al clampaje infrarrenal (CIR) en la evolución de la función renal en la cirugía del aneurisma de aorta abdominal (AAA). Material y método: Estudio de cohortes retrospectivo de los AAA tratados mediante cirugía abierta electiva entre 1998 y 2011. Se analizó la creatinina sérica (mg/dl) preoperatoria y a las 24, 48, 72, 96 h postoperatorias y al alta. Se definió deterioro de la función renal como una creatinina > 2 mg/dl en los pacientes con una creatinina basal normal o un aumento del doble de la creatinina basal en los pacientes con IRC previa. Se definió deterioro del filtrado glomerular (FG) como una disminución > 25%. Análisis multivariable de la evolución de la función renal. Resultados: Se analizaron 464 AAA, 359 (77,4%) con CIR y 105 (22,6%) con CSR. La prevalencia de IRC preoperatoria fue similar entre ambos grupos. El tipo de clampaje no se asoció a deterioro de la función renal (CSR = 8,6% vs. CIR = 4,7%; p = 0,13) y sí al deterioro del FG (CSR = 27,6% vs. CIR = 13,4%; p = 0,001). El tiempo de clampaje, la pérdida sanguínea y la IRC preoperatoria fueron factores de riesgo independientes para deterioro de la función renal. El tipo de clampaje aumentó el riesgo de deterioro de la función renal a partir de los 30 min (p = 0,001), asociándose a deterioro del FG (OR 2,04; IC 95% 0,94-4,47) de forma independiente. Conclusión: Con CSR inferiores a 30 min, en pacientes con creatinina normal, no es previsible un deterioro de la función renal. Con IRC previa o si se espera un CSR prolongado, es esperable un deterioro de la función renal, por lo que deberían valorarse métodos de protección renal (AU)

Objective: To analyse the effects of suprarenal cross-clamping (SC) as opposed to the infrarenal position (IC) in the evolution of the renal function abdominal aorta aneurysm (AAA) surgery. Material and method: A retrospective cohort study of AAAs treated by elective open surgery between 1998 and 2011. The preoperative level of serum creatinine (mg/dL) was determined and compared to postoperative level at 24, 48, 72 and 96 hours, and on discharge. A deterioration in the renal function was defined as a creatinine > 2 mg/dL in patients with a normal baseline creatinine level or an increase of double the baseline creatinine in patients with a previous chronic renal insufficiency (CRI). A deterioration of the glomerular filtrate (GF) was defined as a > 25% decrease. Multivariable analysis was performed on the evolution of the renal function. Results: A total of 464 AAA’s were analysed, 359 (77.4%) with IC, and 105 (22.6%) with SC. The prevalence of preoperative CRI was similar in both groups. The type of clamp was not associated with a deterioration in the renal function (SC = 8.6% vs. IC = 5.7%; p = 0.13) but was associated with a deterioration of the GF (SC = 27.6% vs. IC = 13.4%; p = 0.001). The time the clamp was in place, the blood loss, and the preoperative CRI were independent risk factors for the deterioration of the renal function. The type of clamp increased the risk of deterioration of the renal function beyond 30 minutes (p = .001), being independently associated with a deterioration in the GF (OR 2.04; 95% CI: 0.94-4.47). Conclusion: With SC less than 30 min, in patients with a creatinine level, a deterioration in the renal function is not foreseeable. With prior CRI, or if a prolonged SC is foreseen, a deterioration in the renal function can be expected, thereby making it necessary to evaluate methods for renal protection (AU)

Paraplejía súbita por oclusión aguda de aorta abdominal / Sudden onset of paraplegia from acute abdominal aorta occlusion

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Stent-graft repair for blunt traumatic aortic injury: functional and survival outcomes.

AIM: Traumatic aortic injury is usually lethal, most often because of serious associated wounds. The short- and midterm outcome of endovascular exclusion was assessed as the current treatment of choice due to a lower mortality and morbidity than open surgical treatment. METHODS: We reviewed the cases of 8 patients (5 male, mean age 33 years) undergoing endovascular repair of a traumatic thoracic aortic lesion, confirmed by computed tomographic angiography, at our centre. Most patients showed a contained lesion limited to the aortic isthmus and severe associated injuries. RESULTS: Intrahospital mortality was 37.5% (N.=3) and mostly due to posttraumatic brain injury (N.=2). Most patients were hemodynamically stable at the time of endovascular repair (N.=6). The median time to surgery was 12 hours (3-48 hours). The endografts used were TAG® (W.L. Gore and Associates, Flagstaff) in three patients, and Valiant® (Medtronic, Santa Rosa, CA) in four. The technical success rate was 100%. In one case, the left subclavian artery was occluded without signs of arm ischemia. There were no cases of paraplegia or stroke related to treatment. No revision procedures were needed during follow-up. CONCLUSION: Endovascular repair shortly after injury seems to be effective and safe with a low associated morbidity and mortality.

Pseudoaneurisma postraumático tardío de aorta torácica / Delayed pseudoaneurysm after thoracic aortic injury

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Fístula arteriovenosa poplítea y aneurisma ilíaco gigante secundarios a traumatismo antiguo / Popliteal arteriovenous fistula and a giant iliac aneurysm due to an old injury

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Resultados de la reparación quirúrgica de los aneurismas inflamatorios de aorta abdominal: evolución de los reactantes de fase aguda y de la reacción inflamatoria periaórtica / Results of the surgery of inflammatory abdominal aortic aneurysms: evolution of the acute phase reactants and the periaortic inflammatory reaction

Objetivos: Presentar los resultados del tratamiento quirúrgico electivo de los aneurismas inflamatorios de aorta abdominal (AIAA) y analizar la evolución de la inflamación periaórtica (IPA) y de los reactantes de fase aguda (RFA) tras la intervención. Material y método: Se ha realizado un análisis retrospectivo de los AIAA intervenidos de forma electiva entre 1990 y 2010 mediante cirugía abierta. El seguimiento mediano ha sido de 71 meses y se ha analizado la evolución de la IPA y de los RFA tras la intervención. Resultados: Se han tratado 38 pacientes, de los cuales 12 (31,5%) eran sintomáticos. Se evidenció hidronefrosis en 7 casos (18,4%), siendo necesaria la colocación de doble-J preoperatorio en 5 (13,1%). Un paciente (2,6%) falleció en el postoperatorio inmediato y se realizaron 3 reintervenciones por sangrado (7,8%). Durante el seguimiento la hidronefrosis mejoró en 5 pacientes (71%), siendo la supervivencia a los 12, 36 y 72 meses del 92, 85 y 81% respectivamente. En cuanto a los RFA, se produjo una reducción significativa tanto de la velocidad de sedimentación globular (VSG) (p 0,01), como de la proteína C reactiva (PCR) (p 0,01) tras la cirugía. De igual forma, se redujo de forma significativa la IPA durante el seguimiento, fundamentalmente a partir de los 9 meses tras la intervención (p 0,02). Conclusiones: La cirugía electiva del AIAA ofrece unos buenos resultados a corto y largo plazo, asociándose a una disminución de los RFA y de la IPA, esta última fundamentalmente a partir del noveno mes postoperatorio(AU)

Objectives: To show the results of selective surgical treatment of inflammatory abdominal aortic aneurysms (IAAA), and to analyse the evolution of periaortic inflammation (PAI) and acute phase reactants (APR) after surgery. Patients and method: A retrospective analysis was made of the IAAA electively operated on between 1990 and 2010 by means of open surgery. The median follow-up period was 71 months and an analysis was made of the PAI and APR after surgery. Results: A total 38 patients underwent treatment, of which 12 (31.5%) were symptomatic. Hydronephrosis was evident in 7 cases (18.4%). The implantation of a pre-operative double-J catheter was necessary in 5 cases (13.1%). One patient (2.6%) died in the immediate post-operative period, and 3 were re-operated on due to bleeding (7.8%). During the follow-up period the hydronephrosis improved in 5 patients (71%), with a survival rate at 12, 36 and 72 months of 92%, 85% and 81%, respectively. With regard to the APR, a significant reduction was produced both in the erythrocyte sedimentation rate (ESR) (P=.01) and in the C-reactive protein (CRP) (P=.01) after surgery. Likewise, the PAI was significantly reduced during the follow-up period, mainly from the ninth month following the surgery (P=.02). Conclusions: Selective surgery of IAAA offers good results in the short and long term, associated with a decrease in the APR and PAI, the latter mainly from the ninth month of the post-operative period(AU)

Elaboración y caracterización de una suspensión oleosa de omeprazol para su administración en pediatría / Preparation and characterization of an oily suspension for administration of omeprazole in children

Objetivo: Desarrollar una suspensión de omeprazol oral destinada a la población pediátrica. Métodos: Para el desarrollo de la formulación se empleó el principio activo en polvo en lugar de pellets, que es lo que habitualmente se utiliza. Por la inestabilidad del fármaco en medio ácido, se desarrolló una preparación de carácter oleoso. Se realizaron estudios para caracterizar el vehículo oleoso, características organolépticas, volumen de sedimentación y se utilizó la técnica de calorimetría diferencial de barrido (DSC) para los estudios de viscosidad y compatibilidad fármaco-excipientes. Resultados: Los porcentajes donde la fórmula no emulsionó fueron: 1,54% de viscosizante y 4,1% de tensioactivo. En el termograma se observó que la temperatura de fusión de pico y los valores de alfaHf entalpía de omeprazol se vieron disminuidos por la presencia de aspartamo y también un cambio en el pico de fusión igual a 10 °C, indicando una posible interacción entre omeprazol y aspartamo. Conclusiones: Hasta donde llegó el estudio se consiguió estabilizar todos los componentes de la fórmula, salvo el edulcorante que debe ser sustituido por otro de potencia similar para llegar a la fórmula deseada(AU)

Aim: Develop an oral omeprazole suspension for use in the pediatric population. Methods: For the development of the formulation was used active ingredient in powder instead of pellets, which is usually used. By instability of the drug in acid medium, we developed a preparation of an oily character. Studies were conducted to characterize the oil vehicle, organoleptic characteristics, sedimentation volume and used the technique of differential scanning calorimetry (DSC) for studies of viscosity and drug-excipient compatibility. Results: The percentages in which the emulsified non formula were 1,54% and 4,1% surfactant agent. In the thermogram was observed that the peak melting temperature and enthalpy values of omeprazole were diminished by the presence of aspartame and also a change in the melting peak equal to 10ºC, indicating a possible interaction between omeprazole and aspartame. Conclusions: As far as the study did managed to stabilize all components of the formula, except the sweetener should be replaced by another similar power to reach the desired formula(AU)

Atención farmacéutica integral a los pacientes de un servicio de Cirugía Vascular / Comprehensive Pharmaceutical Care in a Vascular Surgery Department

Objetivo La actuación conjunta del farmacéutico con el resto del equipo sanitario durante todo el proceso asistencial es necesaria para el desarrollo de la atención farmacéutica y así mejorar la calidad de vida del paciente. En este estudio se presentan los resultados de un modelo continuo de atención farmacéutica en pacientes ingresados en un servicio de Angiología y Cirugía Vascular (ACV).Material y método Estudio prospectivo realizado durante 5 meses para evaluar el resultado de la actividad de un farmacéutico clínico en un servicio de ACV. El farmacéutico participa en el pase de visita de lunes a viernes y en la toma de decisiones con el equipo multidisciplinar, detectando y resolviendo errores de conciliación (EC) al ingreso y al alta y problemas relacionados con la medicación (PRM) durante la estancia hospitalaria. Resultados Se han detectado y resuelto 273 EC en 99 pacientes y 76 PRM en 46 pacientes. La aceptación global de las intervenciones farmacéuticas ha sido del 96%.ConclusionesUn 74% de los pacientes han presentado EC. La eficiencia de la actividad farmacéutica a lo largo del proceso hospitalario queda recogida en el alto grado de aceptación de las intervenciones realizadas (AU)

Objective The pharmacist must work with the clinical team across the continuum of care to develop and therefore improve the patient's quality of life. In this study, we present the results from a continuous pharmaceutical care programme for patients admitted to an angiology and vascular surgery department. Material and methods A 5-month prospective study to evaluate the results of a pharmaceutical care programme in an angiology and vascular surgery department. The pharmacist went on the rounds with the clinical team from Monday to Friday and helped make decisions on treatment, and detect and resolve conciliation discrepancies upon admission and discharge, and drug-related problems during the hospital stay. Results We detected and resolved 273 conciliation discrepancies in 99 patients and 76 drug-related problems in 46 patients. Global acceptance of pharmacist interventions was 96%.ConclusionsSeventy-four percent of patients presented conciliation discrepancies. Efficiency of pharmaceutical activity across the continuum of care is demonstrated by the high acceptance of the interventions (AU)

Prevalencia de enfermedad carotídea asintomática en pacientes con claudicación intermitente / Prevalence of asymptomatic carotid artery disease in patients with intermittent claudication

Introducción y objetivosDeterminar la prevalencia de estenosis-oclusión carotídea en pacientes remitidos a nuestro Servicio por claudicación intermitente de miembros inferiores desde mayo de 2007 hasta febrero de 2008, así como los factores asociados a mayor riesgo de enfermedad carotídea.Pacientes y métodosDiseño transversal. Criterios de exclusión: pacientes con clínica neurológica previa y pacientes con eco-doppler carotídeo (eco-TSA) previo. Se determinaron factores de riesgo cardiovascular, antecedentes personales de cardiopatía isquémica y presencia de soplo carotídeo. Se realizaron asimismo un índice tobillo-brazo (ITB) y eco-doppler carotídeo.ResultadosSe analizaron 173 pacientes, la mayoría varones (89,6%), con una edad media de 68,1 años. El 19,7% tenía soplo carotídeo. La prevalencia de estenosis > 30% y > 50% fue del 15 y del 9,8% respectivamente, y el ITB medio fue de 0,68. Se ha observado una asociación estadísticamente significativa entre el soplo y la presencia de cualquier grado de estenosis (OR=6; p=0,0001) y de estenosis > 50% (OR=5,9; p=0,0001). También ha habido diferencias significativas en el ITB de los pacientes con estenosis>50% y los que no la presentaban (0,59 vs 0,68; p=0,05). Los pacientes con un ITB menor de 0,7 tienen mayor prevalencia de estenosis severa-oclusión que los pacientes con un ITB mayor (10,6% vs 1,4%; p=0,029).ConclusionesLa presencia de estenosis carotídea asintomática no es infrecuente en pacientes con arteriopatía periférica. En nuestro estudio la presencia de soplo carotídeo y un ITB menor de 0,7 se comportan como marcadores de riesgo de enfermedad carotídea(AU)

Introduction and objectivesTo establish both the prevalence of carotid stenosis-occlusion in patients with lower limb intermittent claudication referred to our Department between May 2007 and February 2008, and the risk factors of carotid disease.Patients and methodsCross-sectional design. Exclusion criteria: patients with previous neurological symptoms and patients with previous carotid echographic Doppler (Echo-SAT). We recorded cardiovascular risk factors, personal history of ischaemic heart disease and the presence of carotid bruit. We also performed an ankle-brachial index (ABI) and a carotid echo-Doppler.ResultsWe analysed 173 patients, 89.6% of whom were male, with a mean age of 68.1 years and 19.7% of carotid bruit. The prevalence of >30 and >50% carotid stenosis was 15% and 9.8%, respectively, and the mean ABI was 0.68. We observed a statistically significant association between the presence of a carotid bruit and that of any degree of carotid stenosis (OR=6; P=.0001), or the diagnosis of >50% stenosis (OR=5.9; P=.0001). There were also significant differences in the ABI values of patients with carotid stenosis compared to patients without it (0.58 vs 0.69, P=.05). The patients with an ABI less than 0.7 had a higher prevalence of severe stenosis-occlusion than the patients with a higher ABI (10.6% vs 1.4%, P=.029).ConclusionsThe presence of asymptomatic carotid stenosis is not uncommon in patients with peripheral artery disease. In our study, the presence of a carotid bruit and an ABI <0.7 have shown to be markers of carotid disease(AU)