[Avascular necrosis of the hip secondary to long-standing COVID]. / Necrosis avascular de cadera secundaria a COVID de larga duración.

Long COVID is a term used to describe the long-terms effects of COVID-19 infection that continue for weeks or months after the patient has recovered from COVID-19. Long COVID is defined by the persistence of symptoms beyond 12 weeks from the onset of the disease. Corticosteroids are part of the treatment in this period with good results in controlling the disease; however, it is a predisposing factor for the development of avascular necrosis. We present a clinic case of a young man of 39 years old with diagnosis of avascular necrosis in his left hip, before the administration of corticosteroids for the treatment of COVID-19. There is a lack of consensus about the dosage and duration of steroids required to develop avascular necrosis. Some authors have reported that cumulative dose of 2,000 mg prednisone (or its equivalent) was required for avascular necrosis development. For patients with advanced avascular necrosis stages total hip arthroplasty is an attractive option with excellent outcomes in terms of pain relief and survivorship.

El COVID de larga duración es un término que describe la enfermedad en pacientes que se recuperaron de una infección por COVID-19 y reportan síntomas por más de 12 semanas. Los corticosteroides forman parte del tratamiento en este período con buenos resultados en el control de la enfermedad; sin embargo, el uso de este grupo de medicamentos se ha descrito como un factor de riesgo para el desarrollo de necrosis avascular. Se describe el caso clínico de un paciente masculino de 39 años con diagnóstico de necrosis avascular de la cadera izquierda posterior a la administración de corticosteroides para el tratamiento de COVID-19. La dosis de esteroides capaz de provocar necrosis avascular no está clara o bien descrita; sin embargo, existen reportes en la literatura donde se habla de dosis de 2,000 mg de prednisona (o equivalentes) para su desarrollo. El tratamiento de la necrosis avascular tiene como objetivo el alivio del dolor, retardar la progresión del cuadro, prevenir el colapso en etapas tempranas y restaurar la función articular. La artroplastía o recambio total de cadera parece ser una excelente opción de tratamiento quirúrgico para aquellos pacientes en etapas avanzadas.

Willingness toward post-mortem body donation to science at a Mexican university: an exploratory survey.

BACKGROUND: Voluntary post-mortem donation to science (PDS) is the most appropriate source for body dissection in medical education and training, and highly useful for biomedical research. In Mexico, unclaimed bodies are no longer a legal source, but PDS is legally possible, although scarcely facilitated, and mostly ignored by the general population. Therefore, we aimed to evaluate the attitude and willingness for PDS and to identify a sociodemographic profile of people with willingness toward PDS. METHODS: A validated on-line survey was distributed by the convenience method via the social networks of a Catholicism-inspired, private university in northern Mexico. Frequency analyses of all variables and coded free comments were complemented with association studies. RESULTS: Although the responder cohort (n = 143) was too small and biased to be representative of the university community (n = 13,500), willingness to post-mortem organ donation was 90.7% and to PDS 70.7%. In this cohort, PDS willingness had the strongest association with mature age (> 40 years old; P, 0.0008). Among young adults, willingness to PDS was the lowest among volunteers from technical and business schools and the highest among those from the social sciences (P, 0.009). Respondents from the social sciences were also the most consistent between attitude and behavior with respect to organ donation. A free comment option revealed respondents were interested in the unusual taboo topic. CONCLUSIONS: A small, but sufficiently large proportion expressed willingness toward PDS. In our university cohort, which was biased in higher education and altruism, mature age and social interest were associated with PDS willingness.

Challenges in Occupational Dosimetry for Interventional Radiologists.

This review presents the challenges met by interventional radiologists in occupational dosimetry. The issues mentioned are derived from the recommendations of the International Commission on Radiological Protection, the CIRSE guidelines on "Occupational radiation protection in interventional radiology" and the requirements of the European directive on Basic Safety Standards. The criteria for a proper use of personal dosimeters and the need to introduce optimization actions in some cases are set out in this review. The pros and cons of the electronic real-time dosimeters are outlined and the potential pitfalls associated with the use of personal dosimeters summarized. The electronic dosimeters, together with the appropriate software, allow an active optimization of the interventional procedures.

[Membrane induction and transposition of non-vascularized ipsilateral fibula in posttraumatic bone neoformation. Case report]. / Inducción de membrana y trasposición de peroné ipsolateral no vascularizado en neoformación ósea postraumática. Reporte de caso.

OBJECTIVE: To demonstrate the outcome of tibial bone neo formation, using induced-membrane technique and non-vascularized ipsolateral fibular graft transposition. CASE REPORT: A 25 years old male with a 2 years ago firearm injury in left leg, presenting an initial diagnosis of open fracture Gustilo IIIB AO 42C3 IO4NV1MT2 with a 7cm tibial diaphyseal bone defect. During his hospital evolution multiple interventions were made including surgical debridement and skin grafts placement, with unfavorable results. Therefore, we decided to use the induced-membrane technique and non-vascularized ipsolateral fibular graft transposition, resulting in a cane dependent ambulation, in 4 months evolution after last intervention. CONCLUSION: Induced-membrane technique and non-vascularized ipsolateral fibular graft transposition could be a successful alternative for the management of patients with severe bone loss.

OBJETIVO: Demostrar los resultados en la neoformación ósea de tibia utilizando la técnica de inducción de membrana más la transposición de peroné ipsolateral no vascularizado. CASO CLÍNICO: Masculino de 25 años, antecedente de sufrir impacto por arma de fuego en pierna izquierda dos años antes, presentó un diagnóstico inicial de fractura expuesta Gustilo IIIB AO 42C3 IO4NV1MT2 con pérdida ósea de 7 cm de diáfisis tibial. Durante su evolución se realizaron múltiples aseos quirúrgicos y colocación de injertos cutáneos con resultados no favorables, por lo que se emplea la técnica de membrana inducida más colocación de peroné ipsolateral no vascularizado, teniendo una evolución a los cuatro meses posterior a su última intervención con deambulación dependiente de bastón. CONCLUSIÓN: La técnica de inducción de membrana con transposición de peroné ipsolateral no vascularizado podría ser una alternativa adecuada para el manejo de pérdidas óseas en los pacientes.

Diagnostic reference levels and complexity indices in interventional radiology: a national programme.

OBJECTIVES: To propose national diagnostic reference levels (DRLs) for interventional radiology and to evaluate the impact of the procedural complexity on patient doses. METHODS: Eight interventional radiology units from Spanish hospitals were involved in this project. The participants agreed to undergo common quality control procedures for X-ray systems. Kerma area product (KAP) was collected from a sample of 1,649 procedures. A consensus document established the criteria to evaluate the complexity of seven types of procedures. DRLs were set as the 3rd quartile of KAP values. RESULTS: The KAP (3rd quartile) in Gy cm2 for the procedures included in the survey were: lower extremity arteriography (n = 784) 78; renal arteriography (n = 37) 107; transjugular hepatic biopsies (THB) (n = 30) 45; biliary drainage (BD) (n = 314) 30; uterine fibroid embolization (UFE) (n = 56) 214; colon endoprostheses (CE) (n = 31) 169; hepatic chemoembolization (HC) (n = 269) 303; femoropopliteal revascularization (FR) (n = 62) 119; and iliac stent (n = 66) 170. The complexity involved the increases in the following KAP factors from simple to complex procedures: THB x4; BD x13; UFE x3; CE x3; HC x5; FR x5 and IS x4. CONCLUSIONS: The evaluation of the procedure complexity in patient doses will allow the proper use of DRLs for the optimization of interventional radiology. KEY POINTS: • National DRLs for interventional procedures have been proposed given level of complexity • For clinical audits, the level of complexity should be taken into account. • An evaluation of the complexity levels of the procedure should be made.

Benefits of an automatic patient dose registry system for interventional radiology and cardiology at five hospitals of the Madrid area.

The purpose of this article is to present the results of connecting the interventional radiology and cardiology laboratories of five university hospitals to a unique server using an automatic patient dose registry system (Dose On Line for Interventional Radiology, DOLIR) developed in-house, and to evaluate its feasibility more than a year after its introduction. The system receives and stores demographic and dosimetric parameters included in the MPPS DICOM objects sent by the modalities to a database. A web service provides a graphical interface to analyse the information received. During 2013, the system processed 10 788 procedures (6874 cardiac, 2906 vascular and 1008 neuro interventional). The percentages of patients requiring clinical follow-up due to potential tissue reactions before and after the use of DOLIR are presented. The system allowed users to verify in real-time, if diagnostic (or interventional) reference levels are fulfilled.

Automatic patient dose registry and clinical audit on line for mammography.

The use of automatic registry systems for patient dose in digital mammography allows clinical audit and patient dose analysis of the whole sample of individual mammography exposures while fulfilling the requirements of the European Directives and other international recommendations. Further parameters associated with radiation exposure (tube voltage, X-ray tube output and HVL values for different kVp and target/filter combinations, breast compression, etc.) should be periodically verified and used to evaluate patient doses. This study presents an experience in routine clinical practice for mammography using automatic systems.

Five new records of Luvarus imperialis (Acanthuroidei: Luvaridae) in the south-west Atlantic Ocean.

Five new records of louvars Luvarus imperialis are documented for the south-west Atlantic Ocean, extending its distribution range in this ocean. The presence of one ripe specimen, associated with the previous records of larvae and juveniles, suggests that L. imperialis spawn in this region. The possible association of juveniles with shoals of skipjack tuna Katsuwonus pelamis is discussed.

Niveles de referencia de dosis en radiología intervencionista / Diagnostic reference levels in interventional radiology

Se describe el concepto de los niveles de referencia de dosis para diagnóstico («diagnostic reference levels») propuestos por la Comisión Internacional de Protección Radiológica (ICRP) como ayuda para la aplicación del criterio de optimización en radiodiagnóstico y en procedimientos intervencionistas. Dichos niveles se establecen habitualmente como el tercer cuartil de las distribuciones de dosis a pacientes en una muestra amplia de centros y se supone que son valores representativos de buena práctica desde un punto de vista de la protección del paciente. Durante su determinación, se debe evaluar también la calidad de las imágenes para asegurar que es suficiente para el diagnóstico. Cuando los valores de las dosis a los pacientes resultan ser sistemáticamente mayores o mucho más bajos que los valores de referencia, procede realizar una investigación para la posible aplicación de medidas correctoras. Las normativas europea y española de protección del paciente obligan a utilizar los valores de referencia en los programas de calidad. Para los procedimientos intervencionistas se suelen utilizar como valores de referencia el producto dosis área (o producto kerma área) junto con el tiempo de fluoroscopia y el número total de imágenes adquiridas. En los equipos más modernos, se puede también utilizar el valor de la dosis acumulada a la entrada del paciente para optimizar la distribución de la dosis en la piel. La ICRP recomienda que se tenga en cuenta la complejidad de los procedimientos intervencionistas cuando se establecen los valores de referencia. Los servicios de diagnóstico por imagen dispondrán en el futuro de sistemas automáticos de gestión de datos dosimétricos a pacientes que permitirán la auditoría continua de las dosis y recibir alertas sobre procedimientos individuales que puedan registrar dosis varias veces por encima de los valores de referencia. Se presentan también los aspectos que requieren aclaraciones para el mejor aprovechamiento de los niveles de referencia en intervencionismo (AU)

This article discusses the diagnostic reference levels for radiation exposure proposed by the International Commission on Radiological Protection (ICRP) to facilitate the application of the optimization criteria in diagnostic imaging and interventional procedures. These levels are normally established as the third quartile of the dose distributions to patients in an ample sample of centers and are supposed to be representative of good practice regarding patient exposure. In determining these levels, it is important to evaluate image quality as well to ensure that it is sufficient for diagnostic purposes. When the values for the dose received by patients are systematically higher or much lower than the reference levels, an investigation should determine whether corrective measures need to be applied. The European and Spanish regulations require the use of these reference values in quality assurance programs. For interventional procedures, the dose area product (or kerma area product) values are usually used as reference values together with the time under fluoroscopy and the total number of images acquired. The most modern imaging devices allow the value of the accumulated dose at the entrance to the patient to be calculated to optimize the distribution of the dose on the skin. The ICRP recommends that the complexity of interventional procedures be taken into account when establishing reference levels. In the future, diagnostic imaging departments will have automatic systems to manage patient dosimetric data; these systems will enable continuous dosage auditing and alerts about individual procedures that might involve doses several times above the reference values. This article also discusses aspects that need to be clarified to take better advantage of the reference levels in interventional procedures (AU)

[Diagnostic reference levels in interventional radiology]. / Niveles de referencia de dosis en radiología intervencionista.

This article discusses the diagnostic reference levels for radiation exposure proposed by the International Commission on Radiological Protection (ICRP) to facilitate the application of the optimization criteria in diagnostic imaging and interventional procedures. These levels are normally established as the third quartile of the dose distributions to patients in an ample sample of centers and are supposed to be representative of good practice regarding patient exposure. In determining these levels, it is important to evaluate image quality as well to ensure that it is sufficient for diagnostic purposes. When the values for the dose received by patients are systematically higher or much lower than the reference levels, an investigation should determine whether corrective measures need to be applied. The European and Spanish regulations require the use of these reference values in quality assurance programs. For interventional procedures, the dose area product (or kerma area product) values are usually used as reference values together with the time under fluoroscopy and the total number of images acquired. The most modern imaging devices allow the value of the accumulated dose at the entrance to the patient to be calculated to optimize the distribution of the dose on the skin. The ICRP recommends that the complexity of interventional procedures be taken into account when establishing reference levels. In the future, diagnostic imaging departments will have automatic systems to manage patient dosimetric data; these systems will enable continuous dosage auditing and alerts about individual procedures that might involve doses several times above the reference values. This article also discusses aspects that need to be clarified to take better advantage of the reference levels in interventional procedures.

Spanish experience in education and training in radiation protection in medicine.

In most of its publications, the International Commission on Radiological Protection has highlighted the importance of education and training in radiation protection (RP) for medical exposures. Spain, like other Member States of the European Union, has implemented the Directive and the Guidelines in the medical area. The purpose of this paper is to present the Spanish experience in RP education and training in medicine, the different objectives established according to professional levels, existing regulations and feedback obtained from various RP actions.

Association of Toll-like receptor 10 and susceptibility to Crohn's disease independent of NOD2.

Impaired innate inflammatory response has a key role in the Crohn's disease (CD) pathogenesis. The aim of this study was to investigate the possible role of the TLR10-TLR1-TLR6 gene cluster in CD susceptibility. A total of 508 CD patients (284, cohort 1 and 224, cohort 2) and 576 controls were included. TLR10-TLR1-TLR6 cluster single-nucleotide polymorphisms genotyping, NOD2 mutations and TLR10 mRNA quantification were performed using TaqMan assays. Nucleotide-binding oligomerization domain containing 2 (NOD2) and Toll-like receptor (TLR) loci interaction was analyzed by logistic regression and multifactor-dimensionality reduction (MDR). Entropy-based analysis was used to interpret combination effects. One TLR10 haplotype (TLR10(GGGG)) was found associated with CD susceptibility in both cohorts, individuals with two copies had approximately twofold more risk of CD susceptibility than individuals having no copies (odds ratio=1.89, P-value=0.0002). No differences in the mRNA levels were observed among the genotypes. The strongest model for predicting CD risk according to the MDR analysis was a two-locus model including NOD2 mutations and TLR10(GGGG) haplotype (P(c)<0.0001). The interaction gain attributed to the combination of both genes was negative (IG=-2.36%), indicating redundancy or independent effects. Our results support association of the TLR10 gene with CD susceptibility. The effect of TLR10 would be independent of NOD2, suggesting different signaling pathways for both genes.

Optimising the use of computed radiography in pediatric chest imaging.

The objective of this study was to analyze image quality of chest examinations in pediatric patients using computed radiography (CR) obtained with a wide range of doses to suggest the appropriate parameters for optimal image quality. A sample of 240 chest images in four age ranges was randomly selected from the examinations performed during 2004. Images were obtained using a CR system and were evaluated independently by three radiologists. Each image was scored using criteria proposed by the European Guidelines on Quality Criteria in Pediatrics. Mean global scoring and scoring of individual criteria more sensitive to noise were used to evaluate image quality. Agfa dose level (DL) was in the range 1.20 to 2.85. It was found that there was not significant correlation (R < 0.5) between image quality and DL for any of the age ranges for either global score or for individual criteria more related to noise. The mean value of DL was in the ranges 1.9-2.1 for the four age bands. From this study, a DL value of 1.6 is proposed for pediatric CR chest imaging. This could yield a reduction of approximately a factor of 2.5 in mean patient entrance surface doses.

In situ detection and distribution of inflammatory cytokines during the course of infection with Nocardia brasiliensis.

Actinomycetoma, caused by the intracellular bacterium Nocardia brasiliensis, is characterized by an infiltration of several inflammatory cell populations. To explore aspects of the immune response in the pathogenesis of these bacteria we injected 10(6) CFU in footpads of BALB/c mice. After 1, 2, 3, 4, 7, 30 and 90 days immunohistochemistry was performed to compare presence and distribution of the inflammatory cytokines TNF-alpha, IL-1 beta, IL-6, IFN-gamma, IL-4, IL-10, and TGF-beta. Analysis of serial paraffin tissue sections showed strong participation and differences in distribution of cytokine-producing cells during the course of infection. Several TNF-alpha immunoreactive lymphocytes of the dermis were present during the course of the infection, but absent in the site of inflammation. During the first 4 days, IL-1 beta immunoreactivity was observed in dendritic epidermal cells and in cells surrounding the neutrophils around the grain. In later stages of infection, immunoreactive cells to this cytokine were mainly in the periphery of the microabscesses. Strong immunoreactivity was observed with IL-6 during the course of infection. Some cells in the epidermis and dermis, as well as muscle cells and several cells at the periphery of the microabscesses, showed strong IL-6 immunoreactivity. Cells immunoreactive to IL-4, IL-10, IFN-gamma and TGF-beta were present at the site of infection and, in later stages, in cells at the periphery of the microabscesses. In conclusion a mix of proinflammatory and antiinflammatory cytokines are produced at the same time by host cells. According to their distribution, inflammatory cytokines seems to have different functions during the course of infection with the intracellular bacterium N. brasiliensis.

Evaluation of surgical and non-surgical periodontal therapies, and immunological status, of young Down's syndrome patients.

BACKGROUND: Individuals with Down's syndrome (DS) differ in their oral condition compared with the healthy population. Periodontal disease in persons with DS under the age of 30 years is very high. Immune deficiencies are also present. For dental practitioners it is difficult to decide on a particular course of treatment. In this study, patients with DS were selected in order to 1) evaluate the effectiveness of surgical and non-surgical periodontal therapies and 2) assess their immunological status. METHODS: The population consisted of 14 DS patients (14 to 30 years old). Surgical and non-surgical periodontal therapies were compared in a split-mouth design. Clinical measurements of plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment levels (CAL) were taken at baseline, posttreatment, 6 months, and 1 year. Immunomodulatory activity of neutrophils was analyzed in vitro by chemotaxis (Boyden migration chamber), phagocytic activity, and production of super-oxide anion (NBT reduction) tests and compared between DS patients and healthy controls. RESULTS: Both surgical and non-surgical therapies showed a significant improvement in all the clinical parameters compared to baseline. There were no differences between surgical and nonsurgical therapy in PI or GI. There was a significant PD reduction with the non-surgical therapy at 1 to 3 mm PD. However in PD >3 mm the surgical therapy, although not statistically significant, showed better results. Neutrophil chemotaxis, phagocytic activity, and production of super-oxide anion were significantly decreased in the DS patients. CONCLUSIONS: After a year, both surgical and non-surgical therapies have similar periodontal clinical improvement in DS patients. There is partial impairment of immunological functions in DS individuals which does not seem to affect the clinical response to therapy.

A survey of patient dose and clinical factors in a full-field digital mammography system.

In this work, we analyse the dose to 5034 patients (20 137 images) who underwent mammographic examinations with a full-field digital mammography (FFDM) system over a 2-y period. The information relevant to this study has been extracted from the image Digital Imaging and Communications in Medicine (DICOM) headers. Entrance surface air-kerma (ESAK) without backscatter and average glandular dose (AGD) were estimated following the methodology proposed in the European Protocol on Dosimetry in Mammography. Mean values for patient age and compressed breast thickness were 56 +/- 11 y and 52 +/- 13 mm, respectively. The mean ESAK value was 8.1 mGy and the mean AGD was 1.9 mGy. In addition, the dose values from both FFDM and screening-film mammographic (SFM) examinations were compared. The third quartile (TQ) of the ESAK values delivered by the FFDM system was 33% lower and 32% higher than the TQ for SFM with slow and fast screen/film receptors. Differences between dose values for cranio-caudal (CC) and medio-lateral oblique (MLO) images (about 27% for SFM) decreased to 11% for FFDM.

Estado clínico y psicosocial de reclusos en tratamiento con antirretrovirales / Clinical and psychosocial state of inmates in treatment with antiretrovirals

Introducción: La mayoría de los estudios realizados en prisiones se han centrado en el estudio de la infección por VIH, la adherencia o la TBC. Sin embargo, llama la atención la escasez de estudios sobre las características psicosociales de esta población, como son por ejemplo la morbilidad psíquica, el apoyo social o el consumo de drogas. Objetivos: Describir el estado clínico y psicosocial de los reclusos en tratamiento con antirretrovirales en tres prisiones andaluzas (Córdoba, Granada y Huelva). Material y métodos: Mediante una encuesta transversal, con un cuestionario administrado por entrevistador, se entrevistaron a todos los reclusos en tratamiento con antirretrovirales de los tres centros. Las variables estudiadas fueron: datos sociodemográficos, variables del medio penitenciario, variables sobre la adherencia al tratamiento, variables de salud y variables de apoyo. Resultados: La frecuencia de morbilidad psíquica fue del 42% y el 64,4% refirió tener algún tipo de enfermedad crónica; de éstos, el 12,7% afirmó padecer tuberculosis. El 46,6% afirmaron contar con apoyo social dentro de la prisión, recibiéndolo de otros internos el 45% y de los profesionales de la prisión el 36,6%. El 54,8% fueron considerados no adherentes al tratamiento con antirretrovirales. El 89% consideraba que la comida era mala, y sólo al 29,9% se le facilitaban suplementos de comida. Por último, el 33,8% refería no tener flexibilidad para que le abrieran la celda en caso de olvido del tratamiento. El 31% refería peor salud autopercibida (AU)

Introduction: Most studies conducted in prisons have focused on the study of HIV infection, adherence to treatment or TBC. However, there is a surprisingly small number of studies on the psychosocial characteristics of this population, such as psychic morbidity, social support or drug use. Objective: To describe the clinical and psychosocial status of inmates in treatment with antiretrovirals in three Andalusian prisons (Córdoba, Granada and Huelva). Materials and method: All inmates in treatment with antiretrovirals in the three correctional facilities were interviewed using a heteroadministered questionnaire, with a cross-sectional design. The sociodemographic data, penitentiary, adherence to treatment, health and social support variables were studied. Results: The frequency of psychic morbidity was 42%, and 64,4% of the interviewed sample mentioned having some kind of chronic disease; of these, 12,7% admitted to suffering from tuberculosis. 46,6% stated that they had social support within the prison, receiving it from other inmates in 45% of the cases and 36,6% from professionals of the prison. 54,8% were considered non-adherent to antiretroviral treatment. 89% of the sample considered that the food was of bad quality, and only 29,9% were provided with food supplements. Finally, 33,8% stated that they were not able to have their cells opened if their medication was forgotten. 31% mentioned worse self-perceived health when compared with the previous year (AU)