Electroporación percutánea irreversible de un tumor renal: manejo anestésico / Percutaneous irreversible electroporation of a renal tumor: anesthetic management

La electroporación percutánea irreversible (EPI) es un novedoso método de ablación tumoral. Mediante la aplicación al tumor y tejidos adyacentes de breves pulsos eléctricos de alto voltaje se generan alteraciones en la permeabilidad de la membrana de sus células, lo cual termina provocando su muerte. Este alto voltaje aplicado precisa la actuación del anestesiólogo, ya que existe riesgo de desarrollar importantes complicaciones, como arritmias cardíacas o convulsiones. Presentamos el caso de un varón de 66 años diagnosticado de adenocarcinoma renal y sometido a EPI para su ablación con intención curativa bajo anestesia general. Se trata del primer caso en el que se realiza esta técnica en España (AU)

Percutaneous irreversible electroporation (IRE) is a novel tumour ablation method. The application of short and high-voltage electrical pulses to the target lesion induces alterations in cell membrane permeability, finally causing tumour cell death. The extremely high-voltage that is needed in this technique requires the surveillance and management of an experienced anaesthesiologist, as it involves a significant risk of complications, such as cardiac arrhythmias or seizures. The case is presented of a 66 year-old patient diagnosed with a renal adenocarcinoma, and who received without intention-to-cure IRE under general anaesthesia. This case represents the first time this type of technique is used in Spain (AU)

Percutaneous irreversible electroporation of a renal tumor: Anesthetic management. / Electroporación percutánea irreversible de un tumor renal: manejo anestésico.

Percutaneous irreversible electroporation (IRE) is a novel tumour ablation method. The application of short and high-voltage electrical pulses to the target lesion induces alterations in cell membrane permeability, finally causing tumour cell death. The extremely high-voltage that is needed in this technique requires the surveillance and management of an experienced anaesthesiologist, as it involves a significant risk of complications, such as cardiac arrhythmias or seizures. The case is presented of a 66 year-old patient diagnosed with a renal adenocarcinoma, and who received without intention-to-cure IRE under general anaesthesia. This case represents the first time this type of technique is used in Spain.

Helicobacter pylori second-line rescue therapy with levofloxacin- and bismuth-containing quadruple therapy, after failure of standard triple or non-bismuth quadruple treatments.

BACKGROUND: The most commonly used second-line Helicobacter pylori eradication regimens are bismuth-containing quadruple therapy and levofloxacin-containing triple therapy, both offering suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens. AIMS: To evaluate the efficacy and tolerability of a second-line quadruple regimen containing levofloxacin and bismuth in patients whose previous H. pylori eradication treatment failed. METHODS: This was a prospective multicenter study including patients in whom a standard triple therapy (PPI-clarithromycin-amoxicillin) or a non-bismuth quadruple therapy (PPI-clarithromycin-amoxicillin-metronidazole, either sequential or concomitant) had failed. Esomeprazole (40 mg b.d.), amoxicillin (1 g b.d.), levofloxacin (500 mg o.d.) and bismuth (240 mg b.d.) was prescribed for 14 days. Eradication was confirmed by (13) C-urea breath test. Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by questionnaires. RESULTS: 200 patients were included consecutively (mean age 47 years, 67% women, 13% ulcer). Previous failed therapy included: standard clarithromycin triple therapy (131 patients), sequential (32) and concomitant (37). A total of 96% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 91.1% (95%CI = 87-95%) and 90% (95%CI = 86-94%). Cure rates were similar regardless of previous (failed) treatment or country of origin. Adverse effects were reported in 46% of patients, most commonly nausea (17%) and diarrhoea (16%); 3% were intense but none was serious. CONCLUSIONS: Fourteen-day bismuth- and levofloxacin-containing quadruple therapy is an effective (≥90% cure rate), simple and safe second-line strategy in patients whose previous standard triple or non-bismuth quadruple (sequential or concomitant) therapies have failed.

The pathogenesis of primary biliary cirrhosis.

Primary biliary cirrhosis (PBC) would develop when the immune system comes across a microorganism with proteins similar to those in the piruvate dehydrogenase complex E2 (PDC-E2), or a neoantigen resulting from a xenobiotic-modified autoantigen. This would lead to an innate immune response where TLRs would play a pivotal mediating role, which would give rise to a local microenvironment favoring an adaptive immune response. Such response would be particularly strong in individuals with selected genetic characteristics. The genetic characteristics underlying this predisposition remain unknown, but they likely entail small numbers of scarcely-active regulatory T cells. The AE2 anion exchanger, which is deficient in patients with PBC, may reduce the number and activity of regulatory T cells. NK cells are also pivotal in the preparation of an adaptive response, as they release a number of cytokines and chemokines that favor and recruit antigen-presenting cells to activate B and T cells - CD4+ Th1 and CD8+. An activation of the former would increase the production of IgM and anti-mitochondrial IgG and IgA antibodies against PDC-E2. An activation of CD8+ cells, also sensitive to PDC-2 as aberrantly expressed on the surface of BECs and SECs, would result in apoptosis for these epithelial cells, and in small bile-duct destruction. Immune response is likely inadequately suppressed because of the small numbers of scarcely-active regulatory T cells, the latter resulting from low genetic expression and activity of the AE2 transporter.

Melatonin and oxidative stress

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Chronic intestinal pseudo-obstruction: a diagnosis to be considered.

Chronic intestinal pseudoobstruction (CIPO) is a rare entity characterized by recurrent clinical episodes of intestinal obstruction in which no mechanical cause is identified. There are multiple causes for this syndrome but two main groups can be distinguished: a) secondary to a systemic non-gastrointestinal disease; and b) primary or idiopathic originated from alterations in the components of the intestinal wall. The latter forms are the most uncommon and their diagnosis is generally difficult. In the present article, we describe nine patients with CIPO that were diagnosed in our center over the last six years. Four of them were diagnosed with primary or idiopathic form of CIPO and another four were clearly secondary to a systemic disease. The ninth case, which was initially diagnosed as secondary, is probably also a primary form of the disease. The number of patients diagnosed in our center, even thought small, makes us to hypothesize that the prevalence of CIPO is probably greater than is generally believed and that the reasons of its rarity are the incomplete understanding of its physiopathology and the difficulties to achieve a correct diagnosis.

The pathogenesis of primary biliary cirrhosis

Primary biliary cirrhosis (PBC) would develop when the immunesystem comes across a microorganism with proteins similarto those in the piruvate dehydrogenase complex E2 (PDC-E2), ora neoantigen resulting from a xenobiotic-modified autoantigen.This would lead to an innate immune response where TLRswould play a pivotal mediating role, which would give rise to a localmicroenvironment favoring an adaptive immune response.Such response would be particularly strong in individuals with selectedgenetic characteristics. The genetic characteristics underlyingthis predisposition remain unknown, but they likely entailsmall numbers of scarcely-active regulatory T cells. The AE2 anionexchanger, which is deficient in patients with PBC, may reducethe number and activity of regulatory T cells. NK cells arealso pivotal in the preparation of an adaptive response, as they releasea number of cytokines and chemokines that favor and recruitantigen-presenting cells to activate B and T cells – CD4+ Th1 andCD8+. An activation of the former would increase the productionof IgM and anti-mitochondrial IgG and IgA antibodies againstPDC-E2. An activation of CD8+ cells, also sensitive to PDC-2 asaberrantly expressed on the surface of BECs and SECs, would resultin apoptosis for these epithelial cells, and in small bile-duct destruction.Immune response is likely inadequately suppressed becauseof the small numbers of scarcely-active regulatory T cells,the latter resulting from low genetic expression and activity of theAE2 transporter(AU)

Chronic intestinal pseudo-obstruction: a diagnosis to be considered

Chronic intestinal pseudoobstruction (CIPO) is a rare entitycharacterized by recurrent clinical episodes of intestinal obstructionin which no mechanical cause is identified. There are multiplecauses for this syndrome but two main groups can be distinguished:a) secondary to a systemic non-gastrointestinal disease;and b) primary or idiopathic originated from alterations in thecomponents of the intestinal wall. The latter forms are the mostuncommon and their diagnosis is generally difficult. In the presentarticle, we describe nine patients with CIPO that were diagnosedin our center over the last six years. Four of them were diagnosedwith primary or idiopathic form of CIPO and another four wereclearly secondary to a systemic disease. The ninth case, whichwas initially diagnosed as secondary, is probably also a primaryform of the disease. The number of patients diagnosed in our center,even thought small, makes us to hypothesize that the prevalenceof CIPO is probably greater than is generally believed andthat the reasons of its rarity are the incomplete understanding ofits physiopathology and the difficulties to achieve a correct diagnosis(AU)

Enfermedad de Wilson. Una enfermedad rara pero presente / Wilson's disease. A rare thought present condition

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Factores genéticos en la enfermedad grasa del hígado no alcohólica / Genetic factors in non-alcoholic fatty liver disease

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Manifestaciones hepatobiliares en la enfermedad inflamatoria intestinal / Hepatobiliary manifestations in inflammatory bowel disease

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