Practical document on the management of hyponatremia in critically ill patients. / Documento práctico del manejo de la hiponatremia en pacientes críticos.

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.

[Needle-knife sphincterotomy for biliary access: a prospective study]. / Esfinterotomía de aguja como técnica de acceso a la vía biliar: estudio prospectivo.

OBJECTIVE: Needle-knife sphincterotomy (NKS) is used to achieve biliary access when routine cannulation methods have been unsuccessful. The aim of this study was to analyze the results of NNS in patients with an inaccessible common bile duct (difficult cannulation) using standard techniques in endoscopic retrograde cholangiopancreatography and the factors associated with the success of this procedure and complications. MATERIAL AND METHODS: We performed a prospective study of 72 patients who underwent NKS performed by the same endoscopist (J.E.) because of difficult cannulation of the common bile duct between January 1998 and December 2004. The results were analyzed in terms of successful biliary access, whether this was achieved in one or more sessions, its possible association with the underlying disease, and the incidence and severity of complications. RESULTS: Seventy-two NKS were performed from a total of 1062 sphincterotomies (6.7%). A total of 77.7% of the patients underwent prior implantation of a pancreatic prosthesis (NKS-PP). The final diagnosis was: choledocholithiasis (31.9%), cancer of the pancreas (16.6%), cholangiocarcinoma (13.8%), benign stenosis (8.3%), dysfunction of the sphincter of Oddi (6.9%), normal (6.9%), and miscellaneous (13.8%). Cannulation was successful in 87.5% (63/72), and was achieved in the first session in 73% (46/63). Biliary access was achieved in 72.7% of patients (16/22) with biliopancreatic neoplasms versus 94% (47/50) of those with other diagnoses (p = 0.03). Eleven patients (15.2%) presented 12 complications (16.6%) (6 pancreatitis, 4 cholangitis, 1 papillary hemorrhage, and 1 portal vein filling). The use of a pancreatic prosthesis was related to a higher success rate and significantly fewer complications (p = 0.03). CONCLUSIONS: NKS-PP can be a safe procedure in patients with difficult cannulation of the common bile duct. The presence of biliopancreatic neoplasm is a risk factor for failure to achieve biliary access compared with other diagnoses. The complication rate was similar to that found in other studies. No cases of severe pancreatitis or perforations were found.

"The Effervescent Gallbladder": A Rare Ultrasonographic Finding that Reflects the Presence of Gas within the Gallbladder.

This article deals with the "effervescent gallbladder", a rare ultrasonographic finding indicative of the presence of gas within the gallbladder. 3 cases are described and illustrated with photographs. Possible causes are reviewed and discussed.

[A right atrial thrombus in transit: its echocardiographic diagnosis 72 hours before a pulmonary embolism]. / Trombo en tránsito en aurícula derecha: diagnóstico ecocardiográfico 72 horas antes de un embolismo pulmonar.

We report a case of a 72-year-old woman with coronary artery disease in whom a thrombus in transit in the right atrium was diagnosed accidentally. After 72 hours of treatment with intravenous anticoagulants she developed a pulmonary thromboembolism resolved with systemic fibrinolysis. This is a rare case in which such a diagnosis preceded an embolic event. This fact raises the controversy about the best therapeutic management of this unusual form of thromboembolic illness.

[Current status of endoscopic retrograde cholangiopancreatography. What is the effect of the introduction of magnetic resonance cholangiography?]. / Estado actual de la CPRE. Cómo se refleja la introducción de la colangiorresonancia magnética?

AIM: To determine the current status of endoscopic retrograde cholangiopancreatography (ERCP) and the effects of the introduction of magnetic resonance cholangiography (MRC) on ERCP and to evaluate the diagnostic yield of MRC since its introduction in obstructive biliary disease. MATERIAL AND METHODS: We performed a retrospective analysis of the ERCP carried out between January 1998 and December 2000 and of the MRC performed for suspected obstructive biliary disease from May 1999 to December 2000. When both techniques were performed, the diagnostic yield of MRC was evaluated. RESULTS: We performed 927 ERCP. A total of 45.3% of the patients were men. Mean age was 69.2 14.6 years. Treatment was performed on 688 occasions (77%), mainly sphincterotomy (69.9%) and placement of polyethylene (21.8%) or self-expanding (9.9%) prostheses. The number of ERCP performed each year was 261, 330 and 336 in 1998, 1999 and 2000, respectively; of these 76.6%, 80% and 76.9% were therapeutic. MRC was performed in 63 patients with suspected biliary disease. In 27 of 59 patients (45.8%) MRC was sufficient for diagnosis, avoiding the need for ERCP. In the 35 patients in whom both techniques (MRC and ERCP) were performed, the diagnostic yield of MRC compared with that of ERCP was: sensitivity 100%, specificity 50%, positive predictive value 87.1%, negative predictive value 100% and overall value 89%. The cases responsible for the low specificity (all due to choledocholithiases) were analyzed and a significant time lapse was found between the performance of MRC and ERCP (range: 7-35 days) during which choledocholithiasis probably resolved spontaneously. CONCLUSIONS: a) Contrary to what could be expected, the number of ERCP seems to be increasing with a high percentage of endoscopic treatment; b) Because of its diagnostic sensitivity, MRC is the ideal technique for eliminating the need for diagnostic ERCP, thus allowing greater development of the therapeutic aspect of ERCP.

Documento práctico del manejo de la hiponatremia en pacientes críticos / Practical document on the management of hyponatremia in critically ill patients

La hiponatremia es el trastorno electrolítico más prevalente en las Unidades de Cuidados Intensivos. Se asocia a un aumento de la morbilidad, mortalidad y estancia hospitalaria. La mayoría de los estudios publicados hasta el momento son observacionales, retrospectivos y no incluyen pacientes críticos, lo que dificulta la extracción de conclusiones sólidas. Además, debido a la escasa evidencia científica de calidad, incluso las recomendaciones realizadas por distintas sociedades científicas recientemente publicadas difieren en aspectos importantes como son el diagnóstico o el tratamiento de la hiponatremia. Los mecanismos etiopatogénicos en los pacientes críticos suelen ser complejos. Sin embargo, hay que profundizar en ellos para llegar al diagnóstico más probable y a la pauta de tratamiento más adecuada. Todo ello, ha motivado la realización de esta revisión práctica sobre aspectos útiles en el abordaje de la hiponatremia en las Unidades de Cuidados intensivos, con el objetivo de homogeneizar el manejo de esta entidad y disponer de un algoritmo diagnóstico a nivel nacional

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient

Evaluation of vitamin D endocrine system (VDES) status and response to treatment of patients in intensive care units (ICUs) using an on-line SPE-LC-MS/MS method.

Vitamin D deficiency is recognized as one of the most common chronic medical conditions in the world. Vitamin deficiency has been associated with increased mortality. The aim of the study here presented was to evaluate the vitamin D endocrine system (VDES) status in healthy blood donors and critically ill patients baseline and in response to treatment during a week with two doses of 1.5 mg of 25-hydroxyvitamin D3 and 2 microg calcitriol (1,25(OH)2D3) IV on alternate days, by monitoring levels in serum of major vitamin D metabolites in critically ill patients. Group 1: healthy blood donors (control group) (n=92), and group 2: critically ill subjects from an intensive care unit (ICU) (n=33). Critically ill patients were divided into three groups: group A (n=12) is the control group; group B (n=11), administration PO 1,5 mg of 25(OH)D3, in days 0 and 4 of treatment; and group C (n=11), administration IV of 2 microg 1,25(OH)2D3 on alternate days. Baseline serum levels of vitamin D2 and 25(OH)D2 were not detected. Vitamin D3 (9.8 vs 26.0 nM) (p<0.05), 25(OH)D3 (13.3 vs 52.3 nM) (p<0.001), and 1,25(OH)2D3 (53.8 vs 120.5 pM) (p<0.01) serum levels were significantly lower in critically ill subjects than in healthy donors. After treatment in group B: 25OHD3 increased to 46.0+/-16.5 ng/ml (p<0.0001) (22.2%<75 nM, 11.1% <50 nM). 1,25(OH)2D3 increased to 121.8+/-61.8 pM<0.01 whereas were slightly decreased in the other groups during the study. 24,25(OH)2D3 serum levels were increased in patients treated with calcitriol 8.5+/-5.3 vs 24.8+/-16.3 nM (p<0.05) while the levels kept stable in group A patients. In summary, critically ill patients have a severe vitamin D deficiency, which can be easily corrected by administration of high doses of 25OHD (PO). The VDES functional deficiency could be probably also corrected through administration of calcitriol (IV). Both treatments could produce an improvement in the general health and probably a reduction in overall mortality risk of the critically ill patients.

[Diagnostic accuracy and interobserver variability in the BI-RADS ultrasound system]. / Utilidad diagnóstica y variabilidad interobservador del sistema BI-RADS-ecografía.

OBJECTIVES: To determine the predictive values and the interobserver variability of the descriptors and diagnostic categories of the BI-RADS- Ultrasound system and its usefulness for predicting malignancy in solid breast nodules. MATERIAL AND METHODS: We evaluated 601 consecutive solid nodules in 554 patients studied with ultrasound. All ultrasound examinations were performed by one of the three radiologists that participated in the study and the static images were reviewed by all three radiologists independently; radiologists were blind to the clinical history and to the findings at mammography and at histological study. RESULTS: The descriptors that best predicted benignity were circumscribed margins and oval shape (NPV, > 96%), parallel orientation (NPV, 84%-91%), and abrupt interface (NPV, 81%-90%). The descriptors that best predicted malignancy were spiculated margins (PPV, 77%-85%), echogenic halo (PPV, 61%-71%), and nonparallel orientation (PPV, 53%-54%). Interobserver concordance was good for lesion shape (kappa=0.61), circumscribed margins (kappa=0.65), and calcifications (kappa=0.63). The descriptors that presented the highest prognostic values for malignancy were spiculated margins (OR=14.68-10.45) and nonparallel orientation (OR=3.95-6.17). Final assessment category 3 yielded an excellent NPV for all three radiologists (99%-100%). The interobserver concordance was good for category 5 (kappa=0.77) and for category 3 (kappa=0.68); it was moderate for category 4 (kappa=0.59). CONCLUSIONS: The BI-RADS- Ultrasound system helps differentiate benign breast lesions from malignant ones and has a good or moderate interobserver concordance. Final assessment category 3 yielded an excellent negative predictive value, making it possible to avoid biopsies in lesions in this category.

Mitral valve prolapse and sudden deafness.

To examine the association between MVP and Idiopathic Sudden Sensorineural Hearing loss (ISSNHL). 349 subjects, 86 with ISSNHL and 263 controls underwent a 2D-echocardiography. Patients with ISSNHL had higher rates of MVP (29.1% vs 2.7%, p<0.001), mitral leaflet thickening (15.1% vs 2.3%, p<0.001), mitral regurgitation (16.3% vs 6.5%, p=0.02) and left atrial enlargement (11.6% vs 3.8%, p=0.01). Our results support the hypothesis that MVP could be one of the etiological factors of ISSNHL.

Is magnetic resonance imaging safe in cardiac pacemaker recipients?

Magnetic resonance imaging (MRI) is currently contraindicated in cardiac pacemaker (PM) recipients. The objectives of this prospective study were to (1) reassess the risks of performing an MRI scan in patients with PM, (2) compared the pacing functions before and after the exposure to MRI, and (3) monitor the development of possible adverse effects. Thirteen patients implanted with an Affinity DR model 5330 PMs (St. Jude Medical) connected to a Tendril model 1388 leads (St. Jude Medical) underwent 2.0 T-MRI for a variety of indications. All patients displayed a stable spontaneous rhythm at the time of the MRI scan and were not considered to be PM-dependent. The sensing and pacing functions were analyzed and the impedance of both leads was measured before and after the scan. The MRI scan was performed with all PM programmed in DDD mode. The sensing configuration was bipolar. All patients were monitored utilizing a standard electrocardiographic monitor and direct verbal communication. PM Inhibition, asynchronous pacing, or inappropriately rapid pacing was not observed. No patient reported discomfort, heat, or motion sensation at the PM implant site. There were no significant differences in the sensing, stimulation, AutoCapture threshold, and lead impedance measurements before and after MRI. The results of this study suggest that performing 2.0 T-MRI scans in patients with Affinity DR model 5330 PM connected to a Tendril model 1388 lead is safe.

Utilidad diagnóstica y variabilidad interobservador del sistema BI-RADS-ecografía / Diagnostic accuracy and interobserver variability in the BI-RADS ultrasound system

Objetivos: Conocer los valores predictivos y la variabilidad interobservador de los descriptores y de las categorías diagnósticas del sistema BI-RADS- ecografía y su utilidad para predecir la malignidad de los nódulos sólidos mamarios. Material y métodos: Se seleccionaron consecutivamente 601 nódulos sólidos de 554 pacientes evaluados mediante ecografía. Todas las ecografías fueron realizadas por alguno de los 3 radiólogos participantes en el estudio y las imágenes estáticas revisadas independientemente por los 3, sin conocimiento de la historia clínica, de la mamografía ni de la anatomía patológica. Resultados: Los descriptores que mejor predijeron la benignidad fueron el margen circunscrito y la formal oval (valor predictivo negativo [VPN] > 96%), la orientación paralela (VPN, 84–91%) y la interfase abrupta (VPN, 81–90%). Los que mejor predijeron la malignidad fueron el margen espiculado (valor predictivo positivo [VPP], 77–85%), el halo ecogénico (VPP, 61–71%) y la orientación antiparalela (VPP, 53–54%). Resultados: La concordancia interobservador fue buena para la morfología (k=0,61), el margen circunscrito (k=0,65) y las calcificaciones (k=0,63). Resultados: Los descriptores que presentaron los valores pronósticos más altos para la malignidad fueron el margen espiculado (odds ratio [OR] =14,68–10,45) y la orientación antiparalela (OR=3,95–6,17). Resultados: La categoría 3 mostró un excelente VPN para los 3 radiólogos (99–100%). La concordancia interobservador fue buena para las categorías 5 (k=0,77) y 3 (k=0,68) y moderada para la 4 (k=0,59). Conclusiones: El sistema BI-RADS-ecografía ayuda a diferenciar las lesiones mamarias benignas de las malignas con una concordancia interobservador buena o moderada. La categoría 3 mostró un excelente VPN, lo que permitiría evitar las biopsias de las lesiones incluidas en ésta (AU)

Objectives: To determine the predictive values and the interobserver variability of the descriptors and diagnostic categories of the BI-RADS- Ultrasound system and its usefulness for predicting malignancy in solid breast nodules. Material and methods: We evaluated 601 consecutive solid nodules in 554 patients studied with ultrasound. All ultrasound examinations were performed by one of the three radiologists that participated in the study and the static images were reviewed by all three radiologists independently; radiologists were blind to the clinical history and to the findings at mammography and at histological study. Material and methods: The descriptors that best predicted benignity were circumscribed margins and oval shape (NPV, > 96%), parallel orientation (NPV, 84%-91%), and abrupt interface (NPV, 81%-90%). The descriptors that best predicted malignancy were spiculated margins (PPV, 77%-85%), echogenic halo (PPV, 61%-71%), and nonparallel orientation (PPV, 53%-54%).Material and methods: Interobserver concordance was good for lesion shape (k=0.61), circumscribed margins (k=0.65), and calcifications (k=0.63).Material and methods The descriptors that presented the highest prognostic values for malignancy were spiculated margins (OR=14.68–10.45) and nonparallel orientation (OR=3.95–6.17) (AU)

Dracunculiasis / Dracunculiasis

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Esfinterotomía de aguja como técnica de acceso a la vía biliar: estudio prospectivo / Needle-knife sphincterotomy for biliary access: a prospective study

Objetivo: La esfinterotomía de aguja es una técnica empleada para conseguir el acceso a la vía biliar, cuando los métodos de canulación habituales han fallado. El objetivo ha sido analizar los resultados de la realización de la esfinterotomía de aguja en pacientes con inaccesibilidad a la vía biliar (canulación difícil) mediante técnicas estándar en colangiopancreatografía retrógrada endoscópica, y los factores asociados con el éxito y complicaciones. Material y métodos: Estudio prospectivo que incluye a 72 pacientes entre enero de 1998 y diciembre de 2004, sometidos a esfinterotomía de aguja por canulación difícil de la vía biliar por el mismo endoscopista (J.E.). Los resultados se analizaron respecto al éxito en acceder a la vía biliar, su consecución en una o más sesiones, su posible relación con la enfermedad de base y la incidencia y gravedad de las complicaciones. Resultados: Se realizaron 72 esfinterotomías de aguja de un total de 1.062 esfinterotomías (6,7%). En el 77,7% de los pacientes se colocó previamente una prótesis pancreática. El diagnóstico final fue: coledocolitiasis en el 31,9%; cáncer de páncreas en el 16,6%; colangiocarcinoma en el 13,8%; estenosis benigna en el 8,3%; disfunción del esfínter de Oddi en el 6,9%; normal en el 6,9%, y miscelánea en el 13,8%. Se obtuvo éxito en la canulación en el 87,5% (63/72), y se consiguió en la primera sesión en el 73% (46/63). Se logró el acceso biliar en el 72,7% de los casos (16/22) de neoplasia biliopancreática, frente al 94% (47/50) en pacientes con otros diagnósticos (p = 0,03). Once pacientes (15,2%) presentaron 12 complicaciones (16,6%) (6 pancreatitis, 4 colangitis, 1 hemorragia papilar y 1 relleno de la vena porta). El uso de prótesis pancreática se relacionó con un porcentaje mayor de éxito y menor de complicaciones, alcanzando significación estadística en esta última (p = 0,03).Conclusiones: La esfinterotomía de aguja con prótesis pancreática puede ser un procedimiento seguro en pacientes con canulación difícil de la vía biliar. La presencia de neoplasia biliopancreática es un factor de riesgo de no consecución del acceso biliar frente a otros diagnósticos. La incidencia de complicaciones está en consonancia con otros estudios, y no se han hallado pancreatitis graves ni perforaciones

Objective: Needle-knife sphincterotomy (NKS) is used to achieve biliary access when routine cannulation methods have been unsuccessful. The aim of this study was to analyze the results of NNS in patients with an inaccessible common bile duct (difficult cannulation) using standard techniques in endoscopic retrograde cholangiopancreatography and the factors associated with the success of this procedure and complications. Material and methods: We performed a prospective study of 72 patients who underwent NKS performed by the same endoscopist (J.E.) because of difficult cannulation of the common bile duct between January 1998 and December 2004. The results were analyzed in terms of successful biliary access, whether this was achieved in one or more sessions, its possible association with the underlying disease, and the incidence and severity of complications. Results: Seventy-two NKS were performed from a total of 1062 sphincterotomies (6.7%). A total of 77.7% of the patients underwent prior implantation of a pancreatic prosthesis (NKS-PP). The final diagnosis was: choledocholithiasis (31.9%), cancer of the pancreas (16.6%), cholangiocarcinoma (13.8%), benign stenosis (8.3%), dysfunction of the sphincter of Oddi (6.9%), normal (6.9%), and miscellaneous (13.8%). Cannulation was successful in 87.5% (63/72), and was achieved in the first session in 73% (46/63). Biliary access was achieved in 72.7% of patients (16/22) with biliopancreatic neoplasms versus 94% (47/50) of those with other diagnoses (p = 0.03). Eleven patients (15.2%) presented 12 complications (16.6%) (6 pancreatitis, 4 cholangitis, 1 papillary hemorrhage, and 1 portal vein filling). The use of a pancreatic prosthesis was related to a higher success rate and significantly fewer complications (p = 0.03). Conclusions: NKS-PP can be a safe procedure in patients with difficult cannulation of the common bile duct. The presence of biliopancreatic neoplasm is a risk factor for failure to achieve biliary access compared with other diagnoses. The complication rate was similar to that found in other studies. No cases of severe pancreatitis or perforations were found

Estenosis distal de la uretra en las ninas. Estudio de 100 casos. / Distal urethral stenosis in girls. Study of 100 cases

En el hospital infantil docente "Pedro Borras Astorga" hemos sido motivados a estudiar un numero de 100 pacientes con diagnostico de estenosis distal de la uretra, entidad de gran importancia a la luz de los conocimientos actuales debido a las manifestaciones disuricas que produce. Estas pacientes las hemos estudiado desde el punto de vista clinico, bacteriologico y radiologico, obteniendose el diagnostico mediante el examen fisico y la cistografia miccional. El tratamiento que hemos utilizado en todos los casos ha sido la dilatacion uretral asociada a tratamiento antimicrobiano. En este trabajo analizaremos el resultado obtenido de 100 pacientes que han sido dignosticados de estenosis distal de la uretra

Estenosis distal de la uretra en las ninas. Estudio de 100 casos. / Distal urethral stenosis in girls. Study of 100 cases

En el hospital infantil docente "Pedro Borras Astorga" hemos sido motivados a estudiar un numero de 100 pacientes con diagnostico de estenosis distal de la uretra, entidad de gran importancia a la luz de los conocimientos actuales debido a las manifestaciones disuricas que produce. Estas pacientes las hemos estudiado desde el punto de vista clinico, bacteriologico y radiologico, obteniendose el diagnostico mediante el examen fisico y la cistografia miccional. El tratamiento que hemos utilizado en todos los casos ha sido la dilatacion uretral asociada a tratamiento antimicrobiano. En este trabajo analizaremos el resultado obtenido de 100 pacientes que han sido dignosticados de estenosis distal de la uretra

Lipoma gigante de colon como causa de dolor y masa abdominal / Giant lipoma in colon causing abdominal pain and mass

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