Oncological monitoring after transanal total mesorectal excision (TaTME) for rectal neoplasia.

BACKGROUND: The surgical treatment of choice for rectal neoplasia is total mesorectal excision (TME). The transanal approach enables a better approach in male and obese patients and/or those with a narrow pelvis and in patients with small tumors. Short-term results are comparable with those for laparoscopy or the open approach, but the medium- and long-term oncological data are sparse. The aim of the present study was to evaluate our early experience with transanal TME (TaTME). METHODS: This was a retrospective study conducted on patients who underwent TaTME at our center between August 2013 and April 2017 with a follow-up ≥ 3 years. Histopathology, complications, mortality, neoplastic recurrence and disease-free survival were analyzed. RESULTS: One hundred patients (68 men and 32 women,, median age 66.8 years [range 29.6-91.2 years]) were included. There were 67 T3 cases (67%) with 74 N0 cases (74%), the mesorectal quality was graded optimal for 87.6% and only 2 cases of radial margin involvement were detected (2%). The median follow-up period was 47.6 months (range 11.8-78.9 months). Eighteen cases of recurrence were diagnosed, of which 3 (3%) recurred locally with an average disease-free period of 43.1 months. Overall survival was 80% and mortality due to progression of disease was 13%. CONCLUSIONS: TaTME is a safe surgical procedure with surgical, anatomopathological and oncological results at 3 years (medium-term) comparable with those for the laparoscopic and open approaches. Better monitoring is required with studies of the long-term functional and quality of life outcomes, i.e., at 5 or 10 years.

A 2-year follow-up of a novel Fracture Liaison Service: can we reduce the mortality in elderly hip fracture patients? A prospective cohort study.

Osteoporosis is an underdiagnosed disease that results in bone fragility and risk of fractures. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of a FLS protocol showed an increase of anti-osteoporotic drug prescription and significant reduction of all-cause mortality. INTRODUCTION: Hip fractures are the most severe osteoporotic fracture due to their associated disability and elevated risk of mortality. FLS programs have enhanced the management of osteoporosis-related fractures. Our objective is to analyze the effect of the FLS model over survival and 2-year mortality rate following a hip fracture. METHODS: We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during 3 consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2018). Patients' information was withdrawn from our local computerized database. Patients were followed for 2 years after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model. RESULTS: A total of 1101 patients were included in this study (i.e., 357 before FLS implementation and 744 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (583 (78.4%) vs 44 (12.3%); p < 0.01). There was an increase of adherence to treatment after FLS implementation (227 (38.9%) vs 12 (3.3%); p = 0.03). A total of 222 (29.8%) patients after FLS implementation and 114 (31.9%) individuals before FLS implementation (p = 0.44) died during the follow-up period. A second fracture occurred in 49 (6.6%) patients after FLS implementation and in 26 (7.3%) individuals before FLS implementation (p = 0.65). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower all-cause 1-year and 2-year mortality compared with patients managed before the implementation of the FLS protocol (adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.59-0.96; HR 0.87, 95% CI 0.69-1.09, respectively). CONCLUSIONS: The implementation of a FLS protocol was associated with an increase of anti-osteoporotic treatment, higher adherence, and greater survival in elderly hip fracture patients. There was a significant reduction of all-cause mortality in the FLS patients treated with anti-osteoporotic. However, the application of the FLS did not affect the risk of suffering a second fragility fracture.

Fracture liaison service and mortality in elderly hip fracture patients: a prospective cohort study.

Osteoporosis is a metabolic disorder that results in increased bone fragility and risk of fractures. Hip fracture is the most important fragility fracture. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of an intensive FLS model could decrease 1-year-mortality of hip fracture patients. INTRODUCTION: Hip fractures are a clinical manifestation of osteoporosis, and these patients are at risk of premature death and suffering subsequent fractures. FLS is an approach for secondary facture prevention by identifying patients with fragility fractures and initiating the appropriate treatment. Our objective is to analyze the effect of the FLS model over the first-year mortality rates following a hip fracture. METHODS: We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during two consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2017). Patients' information was withdrawn from our local computerized database. Patients were followed for 1 year after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model. RESULTS: A total of 724 individuals were included in this study (i.e., 357 before FLS implementation and 367 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation [275 (74.9%) vs 44 (12.3%); p < 0.01]. A total of 74 (20.2%) patients after FLS implementation and 92 (25.8%) individuals before FLS implementation (p = 0.07) died during the follow-up period. A second fracture occurred in 17 (4.6%) patients after FLS implementation and 13 (3.6%) individuals before FLS implementation (p = 0.50). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower 1-year mortality compared with patients managed before the implementation of the FLS protocol (treated or not treated with anti-osteoporotic drugs) [adjusted hazard ratio (HR) 0.66; 95% confidence interval (CI) 0.47-0.94; p < 0.05]. CONCLUSIONS: We did not observe significant 1-year-mortality differences following a hip fracture between patients treated before the implementation of an FLS protocol and patients treated after its implementation. The application of the FLS did not affect the risk of suffering a second osteoporotic fracture. However, patients treated with anti-osteoporotic drugs in an FLS context had a lower mortality rate compared with patients managed before the implementation of the FLS. LEVEL OF CLINICAL EVIDENCE: 2.

Ripretinib in gastrointestinal stromal tumor: the long-awaited step forward.

Gastrointestinal stromal tumor (GIST) represents a paradigm for clinically effective targeted inhibition of oncogenic driver mutations in cancer. Five drugs are currently positioned as the standard of care for the treatment of advanced or metastatic GIST patients. This is the result of continuous, deep understanding of KIT and PDGFRA GIST oncogenic drivers as well as the resistance mechanisms associated to tumor progression. However, the complexity of GIST molecular heterogeneity is an evolving field, and critical questions remain open. Specifically, the clinical benefit of approved and/or investigated targeted agents is strikingly modest at advanced stages of the disease when compared with the activity of first-line imatinib. Ripretinib is a novel switch-pocket inhibitor with broad activity against KIT and PDGFRA oncoproteins and has recently demonstrated antitumoral activity across phase I to phase III clinical trials. Therefore, ripretinib has emerged as a new standard of care for advanced, multi-resistant GIST patients. Based on this data, the Food and Drug Administration has granted in 2020 the approval of ripretinib for GIST patients after progression to imatinib, sunitinib and regorafenib. This, in turn, constitutes a major breakthrough in sarcoma drug development, as there have not been new treatment approvals in GIST for nearly a decade. Herein, we provide a critical review on the preclinical and clinical development of ripretinib in GIST. Furthermore, we seek to assess the biological and clinical impact of this new standard of care on the course of the disease, aiming to provide an insight on future treatments strategies for the next coming years.

The impact of hip fracture on health-related quality of life and activities of daily living: the SPARE-HIP prospective cohort study.

PURPOSE: The medical morbidity and mortality associated with neck of femur fractures is well-documented, whereas there is limited data for patient-reported outcomes. The aim of this study was to characterize the impact of neck of femur fractures on activities of daily living and patient-reported health-related quality of life. METHODS: Design and participants: Multicentric prospective cohort study. Consecutive sample patients with fragility hip fracture over 50 years old admitted in 48 hospitals in Spain. OUTCOMES: daily living activity function (Barthel Index) and health-related quality of life (EQ-5D) pre-fracture, admission to hospital and at 1- and 4-month follow-up post-fracture. STATISTICS: Barthel and EQ-5D over time are described as mean (SD) and median (interquartile range). RESULTS: A total of 997 patients were recruited at baseline with 4-month outcomes available for, and 856 patients (89.5%). Barthel Index fell from 78.77 (23.75) at baseline to 43.62 (19.86) on admission to hospital with the fracture. Scores partially recovered to 54.89 (25.40) and 64.09 (21.35) at 1- and 4-month post-fracture, respectively. EQ-5D fell from a median of 0.75 (0.47-0.91) to - 0.01 (- 0.03 to 0.51) on admission. Partial recovery was observed again to (0.51 (- 0.06 to 0.67)) and (0.60 (0.10 to 0.80)) at 1- and 4-month post-fracture, respectively. CONCLUSIONS: Hip fracture results in a large decline in the ability to perform activities of daily living and patient-reported health-related quality of life with only partial recovery amongst survivors 4-month post-fracture.

Cutaneous metastatic adenocarcinoma of gallbladder origin: report of a case and review of the literature.

In the English literature, there have only been seven reports of metastasis from cancer of the gallbladder to the skin. This is the report of a 75-year-old woman who developed cutaneous metastasis from an adenocarcinoma of the gallbladder which was confirmed histologically. We report the uncommon metastatic potential of gallbladder carcinoma to the skin.

[Quality of professional life (QoPL) among primary care workers in area 7 of the Madrid Autonomous Region]. / Estudio de la Calidad de Vida Profesional en trabajadores de Atención Primaria del Área 7 de la Comunidad de Madrid.

OBJECTIVE: To describe the QoPL as perceived by Primary Care workers in the Primary Care Area 7 and to describe the progress since 2004. MATERIAL AND METHODS: Cross - sectional study carried out in the Primary Care Area 7 in June 2008. Participants were all primary care workers (n=1003). Main measurements were: the CVP-35 questionnaire (anonymous and self-administered) and socio-demographic and professional variables that could be associated with QoPL. Results were compared to those obtained in previous years (2004-2006). RESULTS: Positive answers: 47%. By dimension, average scores were: perception of demands: 6.09, managerial support: 5.10 and intrinsic motivation: 7.56. Nurses, physiotherapists, and nursing assistants had significantly higher scores in intrinsic motivation, managerial support and quality of life. The individuals who carried out management activities had higher scores in managerial support and intrinsic motivation items. Slight improvements were seen in perception of demands, managerial support and quality of life. CONCLUSIONS: Item analysis allows us to develop improvement plans and subsequently evaluate their results. In this sense, we observed slight improvements, according to planned strategies, based on perceived demands in previous years. Some of these strategies have been recently introduced, so future evaluations using the CVP-35 questionnaire are needed in order to analyse their effectiveness.

Gold(I) and silver(I) complexes containing a tripodal tetraphosphine ligand: influence of the halogen and stoichiometry on the properties. The X-ray crystal structure of two gold(I) dimeric aggregates.

Complexes of the type [Au2(micro-PP3)2]X2 [X=Cl (), Br (), I ()], [Ag2(micro-PP3)2](NO3)2 (), Ag(PP3)Cl (), M3(micro-PP3)X3 [M=Au, X=Cl (), Br (), I (); M=Ag, X=NO3 ()] and Au4(micro-PP3)X4 [X=Cl (), Br (), I ()] have been prepared by interaction between gold(I) or silver(I) salts and the ligand tris[2-(diphenylphosphino)ethyl]phosphine (PP3) in the appropriate molar ratio. Microanalysis, mass spectrometry, IR and NMR spectroscopies and conductivity measurements were used for characterization. and are ionic dinuclear species containing four-coordinate gold(i) and four/three coordinate silver(i), respectively. Solutions of behave as mixtures of complexes in a 2:1 [Au2(micro-PP3)X2; X=Cl(), Br(), I()] and 4:1 () metal to ligand ratio. and react with free PP(3) in solution to generate the ionic compounds and , respectively. Complexes and , with four linear PAuX fragments per molecule, were shown by X-ray diffraction to consist of dimeric aggregates via close intermolecular gold(I)gold(I) contacts of 3.270 A () and 3.184 A (). The resultant octanuclear systems have an inversion center with two symmetry-related gold(I) atoms being totally out of the aurophilic area and represent a new form of aggregation compared to that found in other halo complexes of gold(I) containing polyphosphines. The luminescence properties of the ligand and complexes, in the solid state, have been studied. Most of the gold systems display intense luminescent emission at room and low temperature. The influence of the halogen on the aurophilic contacts of compounds with a 4:1 metal to ligand ratio results in different photophysical properties, while and are luminescent complex is nonemissive. The luminescence increases with increasing the phosphine/metal ratio affording for complexes , without aurophilic contacts, the stronger emissions. Silver complexes and are nonemissive at room temperature and show weaker emissions than gold(I) species at 77 K.

Synthesis of luminescent gold(I) and gold(III) complexes with a triphosphine ligand.

We have synthesized and characterized a series of trinuclear gold(I) complexes [(AuX)(3)(mu-triphos)] (triphos = bis(2-diphenylphosphinoethyl)phenylphosphine; X = Cl 1, Br 2, I 3, C(6)F(5) 4) and di- and trinuclear gold(III) complexes [[Au(C(6)F(5))(3)](n)(mu-triphos)] (n = 2 (5), 3 (6)). The crystal structure of 6 [[Au(C(6)F(5))(3)](3)(mu-triphos)] has been determined by X-ray diffraction studies, which show the triphosphine in a conformation resulting in very long gold-gold distances, probably associated with the steric requirements of the tris(pentafluorophenyl)gold(III) units. Complex 6 crystallizes in the triclinic space group P(-1) with a = 12.7746(16) A, b = 18.560(2) A, c = 21.750(3) A, alpha = 98.215(3) degrees, beta = 101.666(3) degrees, gamma = 96.640(3) degrees, and Z = 2. Chloride substitutions in complex 1 afford trinuclear gold(I) complexes [(AuX)(3)(mu-triphos)] (X = Fmes (1,3,5-tris(trifluoromethyl)phenyl) 7, p-SC(6)H(4)Me 8, SCN 9) and [Au(3)Cl(3)(-)(n)()(S(2)CNR(2))(n)(mu-triphos)] (R = Me, n = 3 (10), 2 (12), 1 (14); R = CH(2)Ph, n = 3 (11), 2 (13), 1 (15)). The luminescence properties of these complexes in the solid state have been studied; at low temperature most of them are luminescent, including the gold(III) derivative 6, with the intensity and the emission maxima being clearly influenced by the nature and the number of the ligands bonded to the gold centers.

Synthesis and structural characterization of luminescent trinuclear gold(I) complexes with dithiocarbamates.

We have synthesized a series of trinuclear gold(I) complexes, namely, [Au3(mu-dpmp)(S2CNR2)nCl3-n] (n = 0-3; R = Me, CH2Ph), [Au3(mu-dpmp)(mu-S2CNR2)Cl](CF3SO3) (R = Me, CH2Ph), and [Au3(mu-dpmp)(mu-S2CNMe2)(C6F5)]X (X = Cl, CF3SO3), containing the triphosphine dpmp [bis(diphenylphosphinomethyl)phenylphosphine] and varying amounts of dithiocarbamate. NMR experiments show fluxional behavior in solution for most of these derivatives because several arrangements of the ligands are possible. The crystal structure of [(mu-dpmp)(AuCl)3] has been determined by X-ray diffraction studies; the molecule displays mirror symmetry and involves an angular arrangement of the gold atoms [Au-Au-Au 119.603(14) degrees, Au-Au 3.3709(4) A]. We have studied the optical properties of these derivatives in the solid state, finding a red shift as a function of the dithiocarbamate number and, for some derivatives, wavelength-dependent emission spectra at low temperature.

Symptomatic colonic lipoma: differential diagnosis of large bowel tumors.

Symptomatic colonic lipomas, although unusual, continue to present difficulties in the preoperative differential diagnosis between malignant and benign colonic neoplasm. Although new imaging techniques are available, they are frequently diagnosed at laparotomy, and definitive histology is required. Local excision is adequate treatment, but segmental excision may be necessary when there is doubt about the diagnosis, or when a complication occurs.

Hepatic involvement in pancreatitis-induced lung damage.

The role of liver in the respiratory dysfunction associated with acute pancreatitis has been evaluated. For this purpose, an experimental necrohemorrhagic pancreatitis was induced in rats by intraductal administration of 3.5% sodium taurocholate. Additionally, a portocaval shunt was performed before induction of acute pancreatitis to prevent the initial passage through the liver of substances released by the pancreas. Twelve hours after the induction of pancreatitis, increases in lung prostacyclin and thromboxane B2 synthesis, decreased lung superoxide dismutase activity, and increases in plasma phospholipase A2 activity were found. In addition, inflammatory injury was evidenced in lung by histopathological analysis. The portocaval shunt was able to prevent the metabolic changes and ameliorate the inflammatory process in the lung, suggesting that the liver plays an active role in the systemic inflammatory response to acute pancreatitis.

[Threatening hemoptysis. Results of treatment with arterial embolization]. / Hemoptisis amenazante. Resultados del tratamiento mediante embolización arterial.

OBJECTIVE: Retrospective analysis the immediate and long-term efficacy of embolization of bronchial and systemic arteries in the treatment of threatening or relapsing hemoptysis. MATERIALS AND METHODS: During the study period 122 arterial embolizations were performed in patients with hemoptysis over 100 ml in 24 hours, relapsing hemoptysis and/or presence of vital risk factors. Embolization was performed with polyvinyl alcohol particles, spongostan and metallic spirals. Seventy patients were included in the study and 47 were excluded as they came from other institutions. RESULTS: Angiographic changes were observed in 100% of patients. The immediate clinical success, defined as hemoptysis control, was obtained in the 70 patients. The mean follow-up time was 21.2 +/- 16.3 months. Relapsing hemoptysis occurred in 17.1% of patients (12 patients), of which 5.7% (4 cases) occurred in the first seven days and in 11.4% (8 patients) after 6 months. In five patients (7.1%) a new embolization was performed and 6 were operated after embolization (5 of them with bronchiectasis). The remarkable complications derived from the procedure included self-limited paraparesis of the lower limbs and severe chest pain. CONCLUSIONS: The embolization of bronchial arteries is an efficient technique for the treatment of threatening hemoptysis and relapses, is associated with a low morbidity rate, and the late relapse is relatively common among patiets with bronchiectasis.

Factores pronósticos de incapacidad funcional en pacientes con fractura de cadera / Prognostic factors of functional impairment in hip fracture patients

Objetivo. Conocer los factores que determinan la recuperación funcional tras haber sufrido una fractura de cadera. Método. Se ha realizado un estudio de cohortes sobre 333 fracturas de cadera en pacientes mayores de 65 años, que ingresaron en el Hospital Regional Universitario Carlos Haya entre febrero de 2004 y febrero de 2005. Hemos recogido datos epidemiológicos, clínicos y de actividad funcional de dichos pacientes mediante la aplicación de escalas de uso generalizado, para conocer la funcionalidad que presentan antes de la fractura y en el seguimiento posterior, mediante entrevistas telefónicas a los 6 meses tras la misma. Resultados. A los 6 meses de la fractura los factores pronósticos de incapacidad funcional son la edad, el hecho de estar institucionalizado, presentar una mala funcionalidad previa a la fractura, ser dependiente para las actividades básicas de la vida diaria y la circunstancia de haber presentado una fractura extracapsular o que haya sido sometida a osteosíntesis. Conclusiones. Podemos conocer el pronóstico del paciente con fractura de cadera al ingreso, el uso de sistemas de fijación extramedular no ha mostrado buenos resultados en nuestro trabajo frente a la artroplastia. La osteosíntesis intramedular (usada únicamente en 5 casos) junto a un inicio precoz de la rehabilitación podrían mejorar los resultados funcionales de estos pacientes, ya que ha demostrado ser superior en las fracturas pertrocantéreas inestables y en las subtrocantéreas (AU)

Aim. To determine the factors that affect functional recovery after a hip fracture. Methods. A study was conducted on a cohort of 333 patients aged 65 years or over with hip fractures who were admitted to Carlos Haya hospital between February 2004 and February 2005. Epidemiological, clinical and functional activity data were recorded by applying generally used scales to determine the patients’ functionality before and after the fracture, by means of telephone interviews 6 months after the fracture. Results. Prognostic factors of functional incapacity 6 months after the fracture were age, being institutionalised, having poor functionality before the fracture, being dependent for basic activities of daily living and having had an extracapsular fracture or undergoing osteosynthesis. Conclusions. It is possible to determine the prognosis of a hip fracture patient on admission. The use of extramedullary fixation systems failed to show good results compared with arthroplasty. Intramedullary osteosynthesis (used only in 5 patients), and an early start of rehabilitation could improve the functional results of these patients. In fact, intramedullary nailing has demonstrated better outcomes in unstable trochanteric and subtrochanteric femoral fractures vs Dynamic Screw and Plate (AU)

Estudio de la Calidad de Vida Profesional en trabajadores de Atención Primaria del Área 7 de la Comunidad de Madrid / Quality of Professional Life (QoPL) among primary care workers in the Area 7 of Madrid Autonomous Region

Objetivo. Conocer la percepción de los trabajadores de Atención Primaria del Área 7 respecto a su calidad de vida profesional (CVP) y describir su evolución desde el año 2004. Material y métodos. Estudio descriptivo transversal. Se realiza en junio de 2008, en el Área 7 de Atención Primaria. Los participantes son todos los profesionales del Área (n=1003). Las mediciones principales son: Cuestionario CVP-35, anónimo y autoadministrado y variables sociodemográficas y profesionales que pudieran tener relación con la CVP. Se estudió la variación de los resultados respecto a los años 2004 y 2006. Resultados. La tasa de respuesta fue del 47%, siendo las medias: percepción global de demandas=6,09, percepción del apoyo directivo=5,10 y motivación intrínseca=7,56. Por estamentos, enfermería-fisioterapeutas y auxiliares son los más motivados, con mejor percepción de apoyo directivo y mejor CVP sentida. Los sujetos que desempeñan tareas directivas puntúan mejor los ítems relacionados con percepción de apoyo directivo y presentan mayor motivación intrínseca. Se observa cierta mejoría en los resultados de percepción de apoyo directivo, demandas y calidad de vida. Conclusiones. El análisis por ítems nos permite, partiendo de los peor valorados, establecer líneas de mejora y evaluar sus resultados. Así pues, observamos cierta mejoría de los resultados, en consonancia con las intervenciones desarrolladas que daban respuesta a demandas percibidas en años previos. Algunas de las intervenciones han sido recientemente implantadas, siendo necesario seguir evaluando su efectividad a través de la aplicación de este cuestionario(AU)

Objective. To describe the QoPL as perceived by Primary Care workers in the Primary Care Area 7 and to describe the progress since 2004. Material and methods. Cross – sectional study carried out in the Primary Care Area 7 in June 2008. Participants were all primary care workers (n=1003). Main measurements were: the CVP-35 questionnaire (anonymous and self-administered) and socio-demographic and professional variables that could be associated with QoPL. Results were compared to those obtained in previous years (2004–2006). Results. Positive answers: 47%. By dimension, average scores were: perception of demands: 6.09, managerial support: 5.10 and intrinsic motivation: 7.56. Nurses, physiotherapists, and nursing assistants had significantly higher scores in intrinsic motivation, managerial support and quality of life. The individuals who carried out management activities had higher scores in managerial support and intrinsic motivation items. Slight improvements were seen in perception of demands, managerial support and quality of life. Conclusions. Item analysis allows us to develop improvement plans and subsequently evaluate their results. In this sense, we observed slight improvements, according to planned strategies, based on perceived demands in previous years. Some of these strategies have been recently introduced, so future evaluations using the CVP-35 questionnaire are needed in order to analyse their effectiveness(AU)

PET en una tumoración abdominal de origen desconocido / PET in an abdominal tumour of unknown origin

Propósito: Valorar la utilidad de la tomografía de emisión de positrones (PET) con 18-ftuoro-2 desoxi-D-glucosa (FDG) en una tumoración abdominal de origen desconocido. Material y métodos: Presentamos una paciente de 71 años de edad y antecedentes de carcinoma ductal infiltrante de mama izquierda, con un incremento progresivo de los marcadores tumorales (CEA, CA 15.3 y CA 125) y una masa pélvica localizada en el fondo del saco de Douglas. Resultados: Mediante PET 18-FDG se identificaron lesiones intrapévicas, adenopatías intraabdominales, mediastínicas, supraclavicular y sacroilíaca izquierda. Conclusión: Aunque la realización de la PET 18-FDG no permitió la localización del tumor primario, si que contraindicó un procedimiento quirúrgico agresivo, orientando al clínico en el manejo terapéutico posterior (AU)