Utilidad de la ecografía en la punción retrógrada distal en la isquemia crítica de extremidades inferiores / Usefulness of ultrasound-guided tibio-pedal access in patients with critical limb ischemia

Introducción La punción retrógrada se puede realizar guiada mediante fluoroscopia o ecografía. Nuestro objetivo fue analizar la utilidad de la ecografía en la punción retrógrada distal de las extremidades inferiores. Métodos Estudio analítico observacional de diciembre del 2013 a junio del 2019. Se incluyeron todos los accesos retrógrados distales que fueron realizados guiados ecográficamente. Se analizaron datos demográficos y clínicos, vaso utilizado como acceso retrógrado, procedimiento efectuado, cantidad de contraste usada y tiempo de escopia, fallo en el acceso y complicaciones locales. Resultados De 715 procedimientos, se utilizó el acceso retrógrado ecoguiado en 25 pacientes (64% hombres). La edad media fue de 74,8 años (45 a 90), con un 92% de diabéticos y un 32% de insuficiencia renal crónica. La clínica inicial era estadio 4 de Rutherford en dos pacientes y estadios 5-6 en los restantes 23. En 24 (96%) pacientes la punción ecoguiada fue satisfactoria, mientras que en un caso (4%) no se consiguió entrar en el vaso diana. Posteriormente a la punción, el éxito técnico de la revascularización fue conseguido en 19 (79,2%) pacientes, con cinco (20,8%) en los que no se consiguió superar la lesión. Las arterias utilizadas como acceso retrógrado fueron: tibial anterior 11, tibial posterior 10 y peronea en cuatro. Se utilizó una media de 63mL (9 a 100 mL) de contraste con un tiempo medio de escopia de 43 minutos (15 a 76 min). No se observaron complicaciones relacionadas con el acceso retrógrado. Conclusiones El acceso retrógrado distal ecoguiado es un método seguro y efectivo, que supone un buen recurso en aquellos procedimientos endovasculares en los que no es posible su realización vía anterógrada (AU)

Introduction Retrograde access performed guided by fluoroscopy or ultrasound. We aimed to analyze the usefulness of ultrasound in retrograde access in patients with critical limb ischemia. Methods Observational analytical study. From December 2013 to June 2019. We included all retrograde accesses that were guided by ultrasound. Our register assesses demographic and clinical data, the vessel used as retrograde access, the procedure performed, the amount of contrast agent used and time of fluoroscopy, access failure, and local complications. Results On 715 procedures performed, was used ultrasound-guided retrograde access in 25 patients (64% men). The mean age was 74.8 years (45-90), with 92% of diabetics and 32% of chronic renal failure. Two patients with Rutherford stage 4 and 23 with stage 5-6. In 24 (96%) patients the ultrasound-guided puncture was successful, while in one (4%) of them, it was not possible to enter the target vessel. After the punch, was achieved the technical success of revascularization in 19 (79.2%) patients, with 5(20.8%) in whom did not the arterial injury was not overcome. The arteries used as retrograde access were: anterior tibial 11, posterior tibial 10, and peroneal in 4. The mean of contrast used was 63 mL (9-100 ml) with an average time of 43 minutes (15- 76 min). Complications related did not observe in retrograde access. Conclusions Ultrasound- guided retrograde distal access is an effective method that may use as a bailout method in those endovascular procedures in which it is not possible to cross the lesion anterogradely (AU)

Synchronous bilateral breast cancer treated with a 3-week hypofractionated radiotherapy schedule: clinical and dosimetric outcomes

Background and purpose Synchronous bilateral breast cancer (SBBC) accounts for 1–3.5% of breast cancer patients. The aim of this study was to evaluate dosimetric issues, clinical outcomes, and acute toxicities for SBBC patients receiving synchronous bilateral hypofractionated radiotherapy (SBHRT) and to compare them with patients treated with synchronous bilateral normofractionated RT schedule (SBNRT). Materials and methods From April 2016 to March 2020, 39 SBBC patients were referred to our institution. Patients were divided according to their prescription dose: Group A: 50 Gy/25fx (fractions), B: 60–64 Gy/25fx, C: 40.05 Gy/15fx; D: 48 Gy/15fx. Toxicity was evaluated using Common Terminology Criteria for Adverse Events (CTCAE)v.5.0. Results 34 patients were finally evaluated. Median follow-up was 24 months for NF schedule and 9 months for HF schedule. In the HF schedule, no acute side-effects > G2 were observed and no dermatitis was reported in 6th month´s assessments. 95% of patients have no evidence of disease and only 1 patient presented local relapse in the first mammography after RT. No distant failures or deaths were observed. Regarding dosimetric issues, the inter-patient average Dmean for the heart was: Group A: 5.0 Gy (4.6–5.5), Group B: 4.4 Gy (4.1–5.4), Group C: 4.8 Gy (4.5–5.1) and Group D: 5.3 Gy (4.4–5.6). For the lungs, the inter-patient average Dmean was: Group A: 10.8 Gy (9.8–12.2), Group B: 11.5 Gy (11.3–12), Group C: 9.8 Gy (9.3–10.5) and Group D: 10.5 Gy (10–11.3). Conclusions This is the first study reporting the safety, feasibility, and tolerability of 40.05 Gy/15fx over 3 weeks for the treatment of SBBC patients. Further study with larger accrual is mandatory (AU)

Synchronous bilateral breast cancer treated with a 3-week hypofractionated radiotherapy schedule: clinical and dosimetric outcomes.

BACKGROUND AND PURPOSE: Synchronous bilateral breast cancer (SBBC) accounts for 1-3.5% of breast cancer patients. The aim of this study was to evaluate dosimetric issues, clinical outcomes, and acute toxicities for SBBC patients receiving synchronous bilateral hypofractionated radiotherapy (SBHRT) and to compare them with patients treated with synchronous bilateral normofractionated RT schedule (SBNRT). MATERIALS AND METHODS: From April 2016 to March 2020, 39 SBBC patients were referred to our institution. Patients were divided according to their prescription dose: Group A: 50 Gy/25fx (fractions), B: 60-64 Gy/25fx, C: 40.05 Gy/15fx; D: 48 Gy/15fx. Toxicity was evaluated using Common Terminology Criteria for Adverse Events (CTCAE)v.5.0. RESULTS: 34 patients were finally evaluated. Median follow-up was 24 months for NF schedule and 9 months for HF schedule. In the HF schedule, no acute side-effects > G2 were observed and no dermatitis was reported in 6th month´s assessments. 95% of patients have no evidence of disease and only 1 patient presented local relapse in the first mammography after RT. No distant failures or deaths were observed. Regarding dosimetric issues, the inter-patient average Dmean for the heart was: Group A: 5.0 Gy (4.6-5.5), Group B: 4.4 Gy (4.1-5.4), Group C: 4.8 Gy (4.5-5.1) and Group D: 5.3 Gy (4.4-5.6). For the lungs, the inter-patient average Dmean was: Group A: 10.8 Gy (9.8-12.2), Group B: 11.5 Gy (11.3-12), Group C: 9.8 Gy (9.3-10.5) and Group D: 10.5 Gy (10-11.3). CONCLUSIONS: This is the first study reporting the safety, feasibility, and tolerability of 40.05 Gy/15fx over 3 weeks for the treatment of SBBC patients. Further study with larger accrual is mandatory.

Effectiveness of fentanyl pectin nasal citrate in controlling episodes of breakthrough cancer pain triggered by routine radiotherapy procedures.

PURPOSE: The aim of the study was to evaluate the effectiveness of fentanyl pectin nasal spray (FPNS) in controlling procedural breakthrough cancer pain (BTCP) in advanced cancer patients undergoing radiotherapy. MATERIALS AND METHODS: This study involved 62 advanced cancer patients, with well-controlled background pain, who presented BTCP associated to routine radiotherapy procedures, treated with FPNS according to our protocol of administration. The BPE intensity was measured using a visual analog scale (VAS). RESULTS: The BTCP was triggered during the computed tomography simulation (79.3%) or treatment delivery (20.7%). Patients indicated a mean VAS of 8.8 (range 7-10) when attempting the procedure. After 4.5 min (range 2-10) of the first FPNS dose, the majority of patients (85.5%) indicated a VAS of 4.3 (range 2-6). 15.5% of the patients did not respond after 15 min; requiring a second dose. All these patients responded, reporting a mean VAS of 4.2 (range 4-6) after 3.0 min (range 2-5) of the second dose. None of the patients required a third dose, nor reported an AE after the administration of FPNS. CONCLUSIONS: In our knowledge, our study is the one of highest recruitment, and with the fastest response of BTCP treated with FPNS reported in advanced cancer patients undergoing radiotherapy. FPNS has proven to be highly effective in reducing the intensity of procedural BTCP in a very short period of time.

Evaluación del riesgo de infecciones alimentarias en pacientes internados en un hospital pediátrico de alta complejidad y su sistema de prevención / Risk assesment of food infections in patient in a pediatric tertiary-care hospital and its prevention

The Garrahan Hospital is a tertiary-care center for pediatrics patients with complex diseases. Infections, including food-borne infections, contribute considerably to the morbidity and mortality in this population at risk. In order to prevent food-borne infections, the Foodservice Area has developed a preventive process approach system of Hazard Analysis and Critical Control Point (process approach HACCP) in food production and service. Objective: To conduct a thorough review and assessment of risk from food borne pathogens according to the pathology of patients or the therapeutic practice used, and to standardize food production and service. With the criterion "degree of safety at the time of service" preventive measures were standardized. The food was classified into four levels of process. One or more food levels are indicated according to risk, and if necessary individual adjustments are made.

El hospital Garrahan brinda asistencia a pacientes pediátricos con patologías complejas. Las infecciones, incluidas las alimentarias, contribuyen considerablemente en la morbilidad y mortalidad en esta población en riesgo. Con la finalidad de prevenir infecciones alimentarias, el Área de Alimentación desarrolla un Sistema Preventivo de Análisis de Peligros y Puntos Críticos de Control con enfoque en procesos (HACCP process approach) en la producción y servicio de alimentos. Objetivo: realizar una exhaustiva revisión y evaluación de los patógenos alimentarios de riesgo según patología o práctica terapéutica de los pacientes y estandarizar la producción y servicio de alimentos. Con el criterio "grado de inocuidad al momento del servicio" se estandarizaron las medidas preventivas. La alimentación fue clasificada en cuatro niveles de proceso. A cada grupo de población asistida, según riesgo, se le indica uno o más niveles de alimentación y se realizan los ajustes individuales necesarios.

Diffuse large B-cell lymphoma in the older.

The incidence of diffuse large B-cell lymphoma (DLCL) in the older is growing to the point of becoming a health priority in the next decades. Prognostic factors and the biology of the tumor are not very different between younger and older populations. Furthermore, it seems that the response rate is basically similar in both populations, provided an appropriate dose of chemotherapy is administered. However, there seem to be differences with regard to a lower tolerance to treatment and a higher relapse rate in responsive older patients. To analyze these problems we review the most important differences between young and older DLCL patients in terms of immunologic status, treatment toxicity and the presence of other concomitant diseases or organ dysfunctions. We also consider the most relevant clinical studies that may allow us to make the appropriate decisions regarding DLCL therapy in this older population.

Diagnóstico en Urgencias de la trombosis venosa de miembros inferiores: valor de los criterios clínicos unidos al dímero-D / The role of clinical signs in combination to the D-dimer in the diagnosis of deep vein thrombosis of lower limbs in an emergency room

Objetivo. Valorar la utilidad de criterios clínicos unidos a la determinación del dímero-D para el diagnóstico de la trombosis venosa profunda (TVP) de miembros inferiores (MMII) en un Servicio de Urgencias de un hospital de tercer nivel. Pacientes y métodos. Estudio retrospectivo-comparativo. Durante 6 meses (julio a diciembre de 2002) se examinaron 295 pacientes en el Servicio de Urgencias de nuestro centro por sospecha de TVP de MMII. Se les valoró siguiendo los criterios clínicos de Wells, y se estratificaron como pacientes de alta, media o baja probabilidad de TVP. Se les determinó el dímero-D. En todos se realizó eco-Doppler (ED) venoso de MMII como método de referencia diagnóstica. Analizamos los resultados obtenidos en función de sensibilidad, especificidad, valor pronóstico positivo (VPP) y negativo (VPN), y coeficiente kappa para comparar el grado de concordancia entre ambas pruebas diagnósticas, mediante sistema SPSS para Windows. Resultados. Sólo 53 (18%) casos tuvieron diagnóstico positivo de TVP según ED. Probabilidad alta/intermedia con dímero-D positivo: 49 con TVP, seis sin ella. Probabilidad baja o dímero-D negativo: 236 sin TVP, cuatro con TVP (los cuatro con dímero-D positivo). Sensibilidad 92%, especificidad 97%, VPP 89%, VPN 98%, con una exactitud de 96,6%, y el coeficiente kappa fue de 0,88, demostrando un alto grado de concordancia entre ambos procedimientos (p < 0,0001). Conclusiones. Los criterios clínicos de estratificación de Wells unidos a la determinación del dímero-D son muy útiles en un Servicio de Urgencias para el diagnóstico de TVP de MMII, permitiendo un inicio rápido de la terapéutica. En caso de baja probabilidad clínica y dímero-D negativo, se evita la realización de ED en un número elevado de casos, lo que agiliza la asistencia en Urgencias

Aim. To validate the role of clinical sings and D-dimer determination in evaluation of deep venous thrombosis (DVT) of lower limbs suspect in emergency room of high technology hospital. Patients and methods. Retrospective and comparative study since July 2002 to December 2002 about 295 patients looked after in emergency room in our hospital because of DVT of lower limbs suspect. We looked for Wells’ clinical signs, and stratified patients in high, middle and low probability of DVT. We determined D-dimer in all patients evaluated. We achieved venous duplex ultrasound of lower limbs like gold-standard diagnosis. We diagnosed 53 DVT with this method. We evaluated the results in sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV), and kappa coefficient, with program SPSS for Windows. Results. High and middle probability with D-dimer positive: 49 with DVT, 6 without. Low probability or D-dimer negative: 236 without DVT, 4 with it (these with D-dimer positive). Sensibility 92%, specificity 97%, PPV 89%, NPV 98%, with an exactitude of 96,6%, and kappa coefficient of 0,88. It was demonstrated a high degree of concordance between gold-standard and tests evaluated (p < 0,0001). Conclusions. Wells’ clinical signs and determination of D-dimer give good diagnosis approximation to DVT of lower limbs in emergency room. With low clinical probability of deep venous thrombosis and negative D-dimer determination is not necessary to achieve duplex for suspect deep venous thrombosis

Twenty-three years of Klebsiella phage typing: a review of phage typing of 12 clusters of nosocomial infections, and a comparison of phage typing with K serotyping.

OBJECTIVE: To review phage typing of 12 clusters of nosocomial Klebsiella infections which occurred between 1974 and 1997, and to compare phage typing and K serotyping. Materials and methods A total of 489 clinical and laboratory Klebsiella isolates were phage typed using 110 different phage preparations and K typed by counter current immunoelectrophoresis against 77 K antisera. RESULTS: A total of 152 phage types (PT) and 82 K types were found. Thirty-six phage types and 14 K types were represented only by the reference type strains. Of the remaining 68 K types, 60 could be subdivided into from two to 10 phage types. Ten out of 12 clusters of nosocomial Klebsiella infections could be verified as outbreaks by phage typing, whereas two clusters were found to be accumulations of sporadic cases. K typing performed retrospectively confirmed these results. In addition, for a subset of 104 epidemiologically unrelated isolates, O typing and pulsed field gel electrophoresis typing data were available. Based on these results the discriminative power of phage typing was found to be comparable with that of K typing, but phage types were less stable and reproducible. CONDITIONS: In an outbreak situation, phage typing was found to be very useful, although it seems less suitable for long-term surveillance purposes.

Somatic serogroups, capsular types, and species of fecal Klebsiella in patients with ankylosing spondylitis.

The purpose of the present study was to find out whether patients with ankylosing spondylitis (AS) carry fecal Klebsiella strains that belong to serotypes or species specific for AS. Somatic serotypes (O groups), capsular (K) serotypes, and biochemically identified species were determined for fecal klebsiellae isolated from 187 AS patients and 195 control patients. The controls were patients with fibromyalgia or rheumatoid arthritis. The 638 isolates of Klebsiella that were obtained represented 161 strains; 81 from AS patients and 80 from the controls. The average number of Klebsiella strains per patient was 1.7 for the AS group and 1.5 for the control group. The most common O group was O1, which was observed for isolates from 23 of 187 AS patients and 24 of 195 control patients. Next in frequency was group O2, which was observed for isolates from 17 AS patients and 15 control patients. Regarding the K serotypes, 59 different types were identified, revealing a heterogeneous representation of Klebsiella strains, without a predominance of any serotype. By biochemical identification, Klebsiella pneumoniae was the most frequently occurring species, being found in 45 AS patients and 45 control patients. Next in the frequency was K. oxytoca, which was observed in 26 AS patients and in 29 control patients. K. planticola and K. terrigena occurred in only a minority of patients. Altogether, when analyzed either separately or simultaneously according to O groups, K serotypes, and biochemically identified species, no evidence of the existence of AS-specific Klebsiella strains was obtained. These findings do not indicate participation of Klebsiella in the etiopathogenesis of AS.

Klebsiella pneumoniae lipopolysaccharide O typing: revision of prototype strains and O-group distribution among clinical isolates from different sources and countries.

We have previously described an inhibition enzyme-linked immunosorbent assay method for the O typing of O1 lipopolysaccharide from Klebsiella pneumoniae which overcomes the technical problems and limitations of the classical O-typing method. In this study, we have extended the method to all of the currently recognized O types. The method was validated by studying the prototype strains that have defined the O groups by the classical tube agglutinatination O-typing method. Based on these results, we confirmed the O types of 60 of 64 typeable strains, and we propose a revised O-antigenic scheme, with minor but necessary changes, consisting of serogroups or serotypes O1, O2, O2ac, O3, O4, O5, O7, O8, and O12. Application of this typing method to 638 K. pneumoniae clinical isolates from Denmark, Spain, and the United States from different sources (blood, urine, and others) showed that up to 80% of these isolates belong to serotypes or serogroups O1, O2, O3, and O5, independently of the source of isolation, and that a major group of nontypeable isolates, representing about 17% of the total, consists of half O+ and half O- strains. Differences were observed, however, in the prevalence of the lipopolysaccharide O types or groups, depending on the country and isolation source.