Ventromedial prefrontal spectroscopic abnormalities over the course of depression: a comparison among first episode, remitted recurrent and chronic patients.

Structural and neuropathological alterations in the ventromedial prefrontal cortex (vmPFC) described in depression (MDD) might become even more pronounced over the course of illness. Measurement of brain metabolites by means of Magnetic Resonance spectroscopy (MRS) can indirectly deliver information about glial and neuronal integrity or potential cellular loss. The aim of this study was to investigate whether Glutamate (Glu), Choline (Cho) and total N-acetylaspartate (total-NAA) levels in the vmPFC differed among MDD patients in distinct stages of illness and healthy controls. We hypothesized that high-past illness-burden would represent more metabolite abnormalities independently of mood state. A 3-Tesla MR facility was used to measure these metabolites in vmPFC of 45 depressive patients (10 first-episode-MDD, 16 remitted-recurrent-MDD and 19 chronic-MDD) and 15 healthy controls. Multivariate and correlation analyses were carried out to explore the influence of duration of illness, age at onset and mood-state. Levels of Glu were significantly decreased in remitted-recurrent and chronic patients compared with both first-episode and controls (up to 28% mean reduction; p < 0.001, Cohen's d = 2.88) and were negatively correlated with illness duration (r = -0.56; p < 0.001). Cho levels showed an opposite pattern: highest values were detected in chronic patients, correlating positively with duration of illness (r = 0.32; p = 0.03). Total-NAA levels were significantly lowered in remitted-recurrent and chronic patients, which were associated with an earlier age at onset (r = 0.50; p = 0.001). Our data suggest that abnormalities in Glu, Cho and total-NAA levels are consistently related to the course of MDD, supporting the hypothesis that cellular changes would take place in vmPFC over time.

Multicenter, double-blind, randomized, intra-individual crossover comparison of gadobenate dimeglumine and gadopentetate dimeglumine in MRI of brain tumors at 3 tesla.

PURPOSE: To prospectively compare 0.1 mmol/kg doses of gadobenate dimeglumine and gadopentetate dimeglumine for contrast-enhanced MRI of brain lesions at 3 Tesla (T). MATERIALS AND METHODS: Forty-six randomized patients underwent a first examination with gadobenate dimeglumine (n = 23) or gadopentetate dimeglumine (n = 23) and then, after 2-7 days, a second examination with the other agent. Contrast administration (volume, rate), sequence parameters (T1wSE; T1wGRE), and interval between injection and image acquisition were identical for examinations in each patient. Three blinded neuroradiologists evaluated images qualitatively (lesion delineation, lesion enhancement, global preference) and quantitatively (lesion-to-brain ratio [LBR], contrast-to-noise ratio [CNR], % lesion enhancement). Differences were assessed using Wilcoxon's signed-rank test. Reader agreement was determined using kappa (kappa) statistics. RESULTS: There were no demographic differences between groups. The three readers preferred gadobenate dimeglumine globally in 22 (53.7%), 21 (51.2%), and 27 (65.9%) patients, respectively, compared with 0, 1, and 0 patients for gadopentetate dimeglumine. Similar significant (P < 0.001) preference was expressed for lesion border delineation and enhancement. Reader agreement was consistently good (kappa = 0.48-0.64). Significantly (P < 0.05) higher LBR (+43.5- 61.2%), CNR (+51.3-147.6%), and % lesion enhancement (+45.9-49.5%) was noted with gadobenate dimeglumine. CONCLUSION: Brain lesion depiction at 3T is significantly improved with 0.1 mmol/kg gadobenate dimeglumine.

Una nueva concepción de urgencias: el complejo de urgencias, emergencias y críticos del hospital de la santa cruz y san pablo / A new mergency conception: the urgency, emergency and critical comples at Hospital de la Santa Creu y San Pablo

Objetivo: Describir la metodología de trabajo y los resultados funcionales obtenidos al rediseñar un servicio de urgencias de un hospital terciario. Metodología: Se ha trabajado con la metología de las técnicas de mejora de la calidad, detectando los grupos de trabajo las siguientes áreas de mejora: 1. reordenación de los recursos aportados por cada servicio participante 2. reestructuración física del servicio 3. mejora de su competencia técnica mediante la renovación de equipos tecnológicos, y 4. informatización del servicio. Resultados: Se han creado 3 circuitos diferenciados para atender a los pacientes según su nivel de riesgo vital: 1. pacientes críticos que requieren soporte cardiovascular avanzado (nivel I de riesgo). Su circuito asistencial se apoya en cubículos de reanimación avanzada, quirófanos y UCI. 2. emergencias o pacientes con riesgo vital potencial (nivel II de riesgo) cuyo circuito se apoya en cubículos monitorizados zona de observación, quirófanos y salas de alta rápida y salas de semicríticos, y 3. urgencias o pacientes sin riesgo vital (nivel III de riesgo), con un circuito que se apoya en cubículos no monitorizados y área de terapéuticas cortas. Para dar soporte a todos estos circuitos se modificó la estructura del servicio de urgencias que pasó de 420 m2 a 1.750m2; para agilizar estos circuitos se ha integrado con una doctrina asistencial común a todas las áreas implicadas en la asistencia de estos pacientes. La informatización del complejo, los equipos de imagen de última generación, junto las guías de práctica clínica consensuada complementaron la competencia técnica de médicos/enfermeros. Conclusión: La reforma del servicio de urgencias se ha basado en el trabajo de los grupos de mejora y sus propuestas de intervenciones, la integración de áreas tales como las Salas de Alta Rápida, y la Unidad de Semicríticos junto con las áreas propiamente de urgencias y su coordinación a través de circuitos definidos por el nivel de riesgo del paciente constituye una de las aportaciones relevantes de la reforma del servicio de urgencias, que ha pasado a denominarse Complejo de Urgencias, Emergencias y Críticos para reflejar el cambio de filosofía que suponen las medidas aplicadas, con respecto a la etapa anterior (AU)