Treatment adherence to pegvisomant in patients with acromegaly in Spain: PEGASO study.

PURPOSE: The burden of chronic daily subcutaneous administration of pegvisomant on adherence has not been previously studied. This study was aimed to determine the adherence to pegvisomant treatment in acromegaly patients in the real-world clinical practice setting in Spain. METHODS: Multicenter, observational, descriptive, cross-sectional study in patients with acromegaly treated with pegvisomant for at least 12 months. Patient adherence was indirectly determined by Batalla and Haynes-Sackett questionnaires and directly by prescription record review. Additionally, treatment satisfaction was assessed by the Treatment Satisfaction with Medicines Questionnaire (SATMED-Q) and treatment convenience by an ad-hoc Pegvisomant questionnaire. Errors in reconstitution and administration process were determined by direct observation. RESULTS: 108 patients were included in the analysis. Rates of adherence varied from 60.7 to 92.1% and did not correlate with disease control. Older patient age and alternative schedules other than daily pegvisomant dosing were associated with lower adherence. Treatment satisfaction and convenience was high, with a mean (SD) total SATMED-Q score of 74.6 ± 15.4 over 100 and a total ad-hoc Pegvisomant questionnaire score of 71.2 ± 15.2 over 100. 34.3% of patients made mistakes during the reconstitution /administration process. CONCLUSIONS: Patient adherence to pegvisomant was high (60.7-92.1%), but more than a third of the patients in the study made mistakes during the administration process, with a potential impact on disease control. Besides dosing compliance, correct administration of medication should be carefully assessed in these patients.

Effect of Treatment With Tabalumab, a B Cell-Activating Factor Inhibitor, on Highly Sensitized Patients With End-Stage Renal Disease Awaiting Transplantation.

B cell-activation factor (BAFF) is critical for B cell maturation. Inhibition of BAFF represents an appealing target for desensitization of sensitized end-stage renal disease (ESRD) patients. We conducted a Phase 2a, single-arm, open-label exploratory study investigating the effect of tabalumab (BAFF inhibitor) in patients with ESRD and calculated panel reactive antibodies (cPRAs) >50%. The treatment period duration was 24 weeks. Eighteen patients received tabalumab, at doses of 240-mg subcutaneous (SC) at Week 0 followed by 120-mg SC monthly for 5 additional months. Patients were followed for an additional 52 weeks. Immunopharmacologic effects were characterized through analysis of blood for HLA antibodies, BAFF concentrations, immunoglobulins, T and B cell subsets, as well as pre- and posttreatment tonsil and bone marrow biopsies. Significant reductions in cPRAs were observed at Weeks 16 (p = 0.043) and 36 (p = 0.004); however, absolute reductions were small (<5%). Expected pharmacologic changes in B cell subsets and immunoglobulin reductions were observed. Two tabalumab-related serious adverse events occurred (pneumonia, worsening of peripheral neuropathy), while the most common other adverse events were injection-site pain and hypotension. Three patients received matched deceased donor transplants during follow-up. Treatment with a BAFF inhibitor resulted in statistically significant, but not clinically meaningful reduction in the cPRA from baseline (NCT01200290, Clinicaltrials.gov).

Genetic and Environmental Influences on Retinopathy of Prematurity.

OBJECTIVE: The goals were to isolate and study the genetic susceptibility to retinopathy of prematurity (ROP), as well as the gene-environment interaction established in this disease. METHODS: A retrospective study (2000-2014) was performed about the heritability of retinopathy of prematurity in 257 infants who were born at a gestational age of ≤ 32 weeks. The ROP was studied and treated by a single pediatric ophthalmologist. A binary logistic regression analysis was completed between the presence or absence of ROP and the predictor variables. RESULTS: Data obtained from 38 monozygotic twins, 66 dizygotic twins, and 153 of simple birth were analyzed. The clinical features of the cohorts of monozygotic and dizygotic twins were not significantly different. Genetic factors represented 72.8% of the variability in the stage of ROP, environmental factors 23.08%, and random factors 4.12%. The environmental variables representing the highest risk of ROP were the number of days of tracheal intubation (p < 0.001), postnatal weight gain (p = 0.001), and development of sepsis (p = 0.0014). CONCLUSION: The heritability of ROP was found to be 0.73. The environmental factors regulate and modify the expression of the genetic code.

Diagnosis and management of antibody-mediated rejection: current status and novel approaches.

Advances in multimodal immunotherapy have significantly reduced acute rejection rates and substantially improved 1-year graft survival following renal transplantation. However, long-term (10-year) survival rates have stagnated over the past decade. Recent studies indicate that antibody-mediated rejection (ABMR) is among the most important barriers to improving long-term outcomes. Improved understanding of the roles of acute and chronic ABMR has evolved in recent years following major progress in the technical ability to detect and quantify recipient anti-HLA antibody production. Additionally, new knowledge of the immunobiology of B cells and plasma cells that pertains to allograft rejection and tolerance has emerged. Still, questions regarding the classification of ABMR, the precision of diagnostic approaches, and the efficacy of various strategies for managing affected patients abound. This review article provides an overview of current thinking and research surrounding the pathophysiology and diagnosis of ABMR, ABMR-related outcomes, ABMR prevention and treatment, as well as possible future directions in treatment.

Early hospital readmissions post-kidney transplantation are associated with inferior clinical outcomes.

Unplanned hospital readmissions are common early post-kidney transplantation. We investigated the relationship between early hospital readmissions and clinical outcomes in a single-center retrospective study that included all adult kidney transplant patients between 2004 and 2008 with follow-up to December 2012. The early hospital readmissions within the first 30 d were numbered and the diagnosis ascertained. Patients were grouped as none, once, and twice or more readmissions. Predictors of early readmissions were assessed, and clinical outcomes and patient and death-censored kidney survival were compared. Among 1064 patients, 203 (19.1%) patients had once and 83 (7.8%) patients had twice or more readmissions within 30 d. Surgical complications, infections, and acute kidney injuries/acute rejection were three most common diagnoses. The length of initial hospital stay and African American race were among the variables associated significantly with readmissions. Patients with early readmissions had lower baseline renal function (p < 0.01) and more early acute rejection (p < 0.01). During follow-up, only frequent readmissions, twice or more, within 30 d were associated with increased risk of death (AHR 1.75, p = 0.01) and death-censored kidney failure (AHR 2.20, p < 0.01). Frequent early hospital readmissions post-transplantation identify patients at risk for poor long-term outcomes, and more studies are needed to understand the mechanisms.

Management of acute stroke. Specific nursing care and treatments in the stroke unit.

OBJECTIVE: This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS: We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS: The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS: These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.

Solid-organ transplantation in older adults: current status and future research.

An increasing number of patients older than 65 years are referred for and have access to organ transplantation, and an increasing number of older adults are donating organs. Although short-term outcomes are similar in older versus younger transplant recipients, older donor or recipient age is associated with inferior long-term outcomes. However, age is often a proxy for other factors that might predict poor outcomes more strongly and better identify patients at risk for adverse events. Approaches to transplantation in older adults vary across programs, but despite recent gains in access and the increased use of marginal organs, older patients remain less likely than other groups to receive a transplant, and those who do are highly selected. Moreover, few studies have addressed geriatric issues in transplant patient selection or management, or the implications on health span and disability when patients age to late life with a transplanted organ. This paper summarizes a recent trans-disciplinary workshop held by ASP, in collaboration with NHLBI, NIA, NIAID, NIDDK and AGS, to address issues related to kidney, liver, lung, or heart transplantation in older adults and to propose a research agenda in these areas.

Evaluation of transjugular intrahepatic portosystemic shunt (TIPS) as a previous step to liver transplantation in pediatric patients. / Evaluación del shunt portosistémico intrahepático transyugular (TIPS) como puente terapéutico al trasplante hepático en pacientes pediátricos.

INTRODUCTION: Transjugular intrahepatic portosystemic shunt (TIPS) was designed to treat complications of portal hypertension (PH). The objective of this study was to analyze the results of the TIPS performed in pediatric patients in our institution as a previous step to liver transplantation (LT). MATERIAL AND METHODS: A retrospective, descriptive study of pediatric patients with liver cirrhosis undergoing TIPS prior to LT from 2015 to 2020 was carried out. RESULTS: TIPS was performed in 10 patients. The reason for TIPS was hard-to-control ascites in 7 patients (70%), upper gastrointestinal bleeding due to esophageal varices in 1 patient (10%), and portal hypoplasia in 2 cases (20%). No intraoperative complications were recorded. Stent patency was achieved in all cases. TIPS patency until LT was observed in 6 patients (60%). Indirect signs of patency were noted in 1 patient (10%). 2 patients (20%) required re-intervention, with patency being achieved in the second attempt. And finally, no patency was observed after 3 attempts in 1 patient (10%). A decrease in portocaval gradient (p = 0.001) and an increase in portal velocity (p = 0.006) were observed. No platelet count changes were found. A slight, non-significant increase in ammonia was noted. CONCLUSION: TIPS is a safe and effective procedure to reduce complications of hard-to-control PH in pediatric patients. It allows general condition to be optimized, deterioration to be avoided, and portal vein narrowing to be alleviated in cirrhosis patients as a previous step to LT.

INTRODUCCION: El shunt portosistémico intrahepático transyugular (TIPS) es un procedimiento para tratar las complicaciones de la hipertensión portal. El objetivo del estudio es analizar los resultados de los TIPS realizados en nuestro centro, a pacientes pediátricos como puente al trasplante hepático (TH). MATERIAL Y METODOS: Estudio retrospectivo y descriptivo de pacientes pediátricos con cirrosis hepática a los cuales se les ha realizado un TIPS previo al trasplante hepático entre los años 2015 y 2020. RESULTADOS: Se realizó el TIPS a 10 pacientes. El motivo fue en 7 por ascitis de difícil control (70%), un caso por hemorragia digestiva alta por varices esofágicas (10%) y en 2 por hipoplasia portal (20%). No hubo complicaciones intraoperatorias y en todos los casos se logró permeabilidad de la endoprótesis. En 6 pacientes (60%) se observó permeabilidad del TIPS hasta el TH, en un paciente se observaron signos indirectos de permeabilidad (10%), 2 casos requirieron reintervención, lográndose permeabilidad en el segundo intento (20%) y en otra paciente (10%) no se observó permeabilidad tras 3 intentos. Se apreció una disminución del gradiente portocava (p = 0,001) y un aumento en la velocidad portal (p = 0,006). No se evidenció cambios en la cifras de plaquetas y se produjo un ligero aumento del amonio, sin ser significativos. CONCLUSION: El TIPS es un procedimiento seguro y eficaz para paliar las complicaciones de la hipertensión portal de difícil control en pacientes pediátricos. Nos permite optimizar el estado general, evitar el deterioro y paliar el estrechamiento de la vena porta de los pacientes cirróticos como puente al TH.

Acromegaly disease activity according to ACRODAT®, a cross-sectional study in Spain: ACROVAL study.

OBJECTIVES: To evaluate disease activity status using the Acromegaly Disease Activity Tool (ACRODAT®) in a cohort of Spanish acromegaly patients, to assess the relationship between the level of disease activity according to both ACRODAT® and the physicians' clinical evaluation, and to study the potential discrepancies in the perception of symptoms between physicians and patients. DESIGN: Multicenter, observational, descriptive and cross-sectional study. METHODS: Disease activity was assessed in adult patients with acromegaly under pharmacological treatment during at least 6 months using ACRODAT®. RESULTS: According to ACRODAT®, 48.2%, 31.8% and 20.0% of a total of 111 patients were classified as having a stable disease (S), mild disease activity (M-DA) and significant disease activity (S-DA) respectively. ACRODAT® classification of disease activity significantly correlated with physicians' opinion, with a moderate inter-rater agreement and a specificity of 92.45% (PPV = 86.21%). No correlation was found between IGF-I levels and severity of symptoms or quality of life (QoL). A decision to take clinical action was significantly more frequent in S-DA and M-DA patients than S patients but no action was taken on 5 (22.7%) and 27 (77.1%) S-DA and M-DA patients, respectively CONCLUSIONS: ACRODAT® detected disease activity in 51.8% of patients. Interestingly, although M-DA and S-DA patients were likely to be in the process of being controlled, action was not always taken on these patients. ACRODAT® is a validated and highly specific tool that may be useful to routinely monitor acromegaly and to identify patients with non-obvious disease activity by incorporating "patient-centred" parameters like symptoms and QoL to the clinical evaluation of acromegaly.

Clinical utility of the maximum area of detrusor tracing measurement in the urodynamic studies in pediatric population diagnosed with neuropathic bladder: A pilot study.

INTRODUCTION: Neuropathic bladder (NB) is a lower urinary tract dysfunction (LUTD) that may lead to kidney failure. Urodynamic study is the gold standard for its diagnosis and follow-up. A classic prognostic parameter to predict the risk of upper urinary tract damage (UUTD) is the detrusor leak point pressure (DLPP) ≥  40 cmH2O, although this factor alone may lack prognostic value. The area under the curve (AUC) of the detrusor pressure tracing has been recently described as a prognostic factor. AIM: To analyze the clinical utility of the AUC of the detrusor pressure tracing in the pediatric population (<15 years). METHODS: Retrospective study of urodynamic recordings in pediatric population with NB from 2011 to 2020. The following variables were evaluated: detrusor leak point pressure ≥ 40 cmH2O, voiding dysfunction, bladder compliance and overactivity. The sample is classified according to clinical-radiological findings at the time of the UD. AUC is calculated using Newton-Cotes rules (trapezium, Simpson's rule) and its indexes are calculated according to bladder capacity (TI: Trapezium Index, SI: Simpson Index). Statistical significance: P < .05. RESULTS: Fifty-five recordings are analyzed. Unfavorable clinical condition was identified in 41.8% (n = 23) patients. Voiding dysfunction, low compliance and both indexes were associated with an unfavorable clinical condition (P < .05). ROC analysis showed the following AUC for the new indexes: TI (0.736, P = 0.0006), SI (0.755, P = .0001) with a cut-off value of 10,69 and 8 cmH2O·s/cc, respectively. We did not find differences in the diagnostic performance between them (P > .05). CONCLUSIONS: The analyzed indexes are useful in the diagnosis of patients with NB and unfavorable clinical condition.

Guidelines for the diagnosis of antibody-mediated rejection in pancreas allografts-updated Banff grading schema.

The first Banff proposal for the diagnosis of pancreas rejection (Am J Transplant 2008; 8: 237) dealt primarily with the diagnosis of acute T-cell-mediated rejection (ACMR), while only tentatively addressing issues pertaining to antibody-mediated rejection (AMR). This document presents comprehensive guidelines for the diagnosis of AMR, first proposed at the 10th Banff Conference on Allograft Pathology and refined by a broad-based multidisciplinary panel. Pancreatic AMR is best identified by a combination of serological and immunohistopathological findings consisting of (i) identification of circulating donor-specific antibodies, and histopathological data including (ii) morphological evidence of microvascular tissue injury and (iii) C4d staining in interacinar capillaries. Acute AMR is diagnosed conclusively if these three elements are present, whereas a diagnosis of suspicious for AMR is rendered if only two elements are identified. The identification of only one diagnostic element is not sufficient for the diagnosis of AMR but should prompt heightened clinical vigilance. AMR and ACMR may coexist, and should be recognized and graded independently. This proposal is based on our current knowledge of the pathogenesis of pancreas rejection and currently available tools for diagnosis. A systematized clinicopathological approach to AMR is essential for the development and assessment of much needed therapeutic interventions.

Pneumocystis jirovecii pneumonia is rare in renal transplant recipients receiving only one month of prophylaxis.

Prophylaxis against Pneumocystis jirovecii pneumonia (PCP) is recommended for at least 4-12 months after solid organ transplant. In our center, renal transplant recipients receive only 1 month of post-transplant trimethoprim-sulfamethoxazole, which also may provide limited protection against Nocardia. We identified only 4 PCP cases and 4 Nocardia cases in 1352 patients receiving renal and renal-pancreas transplant from 2003 to 2009 at the University of Michigan Health System. Two PCP cases were identified <1 year after transplant, and 2 PCP cases were identified >1 year after transplant (gross attack rate 4/1352, 0.3%). Two Nocardia cases were identified <1 year after transplant, and 2 cases were identified >1 year after transplant. All identified cases received induction therapy (7 of 8 with anti-thymocyte globulin), whereas about one-half of all renal transplant patients received induction therapy at our institution. No patient was treated for rejection within 6 months of PCP; 2 of 4 patients with PCP had recent cytomegalovirus infection. All patients with PCP and 3 of 4 patients with Nocardia survived. The benefits of prolonged PCP prophylaxis should be weighed against the adverse events associated with prolonged use of antimicrobials.

Influence of recipient race on the outcome of simultaneous pancreas and kidney transplantation.

Racial differences on the outcome of simultaneous pancreas and kidney (SPK) transplantation have not been well studied. We compared mortality and graft survival of African Americans (AA) recipients to other racial/ethnic groups (non-AA) using the national data. We studied a total of 6585 adult SPK transplants performed in the United States between January 1, 2000 and December 31, 2007. We performed multivariate logistic regression analyses to determine risk factors associated with early graft failure and immune-mediated late graft loss. We used conditional Kaplan-Meier survival and multivariate Cox regression analyses to estimate late death-censored kidney and pancreas graft failure and death between the groups. Although there was no racial disparity in the first 90 days, AA patients had 38% and 47% higher risk for late death-censored kidney and pancreas graft failure, respectively (p = 0.006 and 0.001). AA patients were twice more likely to lose the kidney and pancreas graft due to rejection (OR 2.31 and 1.86, p = 0.002 and 0.008, respectively). Bladder pancreas drainage was associated with inferior patient survival (HR 1.42, 95% CI 1.15, 1.75, p = 0.001). In the era of modern immunosuppression, AA SPK transplant patients continue to have inferior graft outcome. Additional studies to explore the mechanisms of such racial disparity are warranted.

Choice of induction regimens on the risk of cytomegalovirus infection in donor-positive and recipient-negative kidney transplant recipients.

BACKGROUND: Late occurrence of cytomegalovirus (CMV) infection remains a concern in CMV-seronegative kidney and/or pancreas transplant recipients of CMV-seropositive organs (donor positive/recipient negative, D+/R-) despite the use of prophylaxis. We investigated the impact of various antibody induction regimens on CMV infection in this group of patients. METHODS: A total of 254 consecutive D+/R- kidney and/or pancreas transplant patients were studied. The induction agents rabbit anti-thymocyte globulin (rATG) or basiliximab were used according to the center practice. All patients received prophylaxis with valganciclovir (VGCV) for either 3 or 6 months. The occurrence of CMV infection was confirmed by positive DNA viremia. Multivariate Cox regression analyses were performed to determine risk factors for CMV infection. RESULTS: The cumulative incidence of CMV infection was 58, 112, and 59 cases per 1000 patient-years for patients who received no antibody induction, induction with rATG, or basiliximab induction, respectively (P=0.02). The use of rATG but not basiliximab was associated with an increased risk for CMV infection (adjusted hazard ratio [AHR] 2.13, 95% confidence interval [CI] 1.24-3.54, P=0.006). Acute rejection and its treatment with rATG were not associated with an increased risk for CMV infection when an additional course of VGCV was given following the treatment. Longer duration of prophylaxis was associated with a reduced risk for CMV infection (AHR 0.54, 95% CI 0.33-0.87, P=0.011). CONCLUSIONS: Induction with rATG is associated with increased risk of CMV infection. Longer duration of prophylaxis is beneficial.

Ovarian transposition as a minimally invasive fertility preservation technique: ten years of experience in a pediatric center. / La transposición ovárica como técnica de preservación de la fertilidad en edad pediátrica: 10 años de experiencia en un centro de tercer nivel.

INTRODUCTION: Ovarian transposition is a surgical procedure allowing gonadal mobilization from a radiation spotlight to a safer, radiation therapy-free place in patients receiving abdominal or pelvic radiation therapy. And these patients can be managed using minimally invasive surgery. Although some authors have reported good results in fertility preservation with this technique, there are no long-term studies in the pediatric population. We present our results with this procedure in our oncological patients from the last decade. MATERIAL AND METHODS: Retrospective review of medical reports of patients who underwent laparoscopic ovarian transposition in our pediatric oncological surgery unit from 2008 to 2018. The technique varied depending on age, irradiation zone, and concomitant oncological resections. RESULTS: A total of 21 ovarian transpositions were successfully performed in 13 patients. Eight were bilateral, four were left and only one was right. An ovarian cortex cryopreservation was simultaneously carried out in all patients. Eleven procedures were completed laparoscopically, and the suspensory ovarian ligament was divided in sixteen cases. The Fallopian tube was divided in one case, and a simple ovarian transposition was conducted in five cases. Mean hospital stay was 2.4 days, and no complications in the immediate postoperative period were noted. CONCLUSION: Ovarian transposition is a feasible, safe technique. These patients require an extended follow-up to assess ovarian function after oncological treatment.

INTRODUCCION: La transposición ovárica es una técnica quirúrgica que permite alejar los ovarios de la zona de irradiación en pacientes que van a recibir radioterapia abdominal o pélvica. Se han descrito buenas tasas de conservación de función. Sin embargo, no existen estudios en pacientes pediátricos. Presentamos nuestra serie de pacientes intervenidas en nuestro centro. MATERIAL Y METODOS: Estudio retrospectivo de pacientes a las que se le realizó transposición ovárica en nuestra unidad de cirugía oncológica pediátrica entre los años 2008 y 2018. La técnica empleada dependió de la edad, la zona de la irradiación y de la asociación o no con la cirugía del tumor primario. RESULTADOS: Durante el periodo de estudio se realizaron un total de 21 transposiciones ováricas en 13 pacientes (8 bilaterales, 4 izquierdas y 1 derecha). En todos los casos se realizó criopreservación de corteza ovárica dentro del programa de preservación de fertilidad. Once de las 13 intervenciones fueron por laparoscopia, seccionándose el ligamento tubo-ovárico en 16 unidades y en 5 se realizó transposición ovárica simple. La estancia hospitalaria media fue de 2,4 días sin registrarse ninguna complicación en el postoperatorio. Actualmente 9 pacientes continúan seguimiento en sus unidades de oncología pediátrica de referencia, sin haberse notificado ninguna complicación. CONCLUSION: La transposición ovárica es una técnica segura y reproducible. Estas pacientes requieren un seguimiento prolongado para conocer el estado de los ovarios tras el tratamiento oncológico.

Surgical treatment of pulmonary aspergilloma in pediatric patients: report of 3 cases. / Tratamiento quirúrgico del aspergiloma pulmonar en pacientes pediátricos. A propósito de tres casos.

OBJECTIVE: To describe our experience in the surgical management of pulmonary aspergilloma (PA) and review surgery's role in PA treatment in pediatric patients. MATERIAL AND METHODS: A descriptive study of patients diagnosed with PA undergoing surgical resection from 2017 to 2019 was carried out. A review of pediatric studies mentioning "aspergilloma", "surgical", and "treatment" was performed. RESULTS: During the study period, 3 patients with single PA aged 18 months old, 3 years old, and 13 years old underwent surgery. All of them had leukemia and little or no response to aspergilloma medical treatment. In all patients, the procedure was initiated using the thoracoscopic route, but conversion into thoracotomy was required in two cases. In all three cases, pulmonary segmentectomy was carried out with complete PA removal, without severe intraoperative or postoperative complications. No pulmonary recurrence was observed after 30-, 34-, and 16-month follow-up, respectively. CONCLUSIONS: PA surgical resection is a feasible alternative in pediatric patients with a poor antifungal treatment response or related complications.

OBJETIVOS: El objetivo de este trabajo es describir la experiencia de nuestro centro en el manejo quirúrgico del aspergiloma pulmonar (AP) y la realización de una revisión sobre el papel de la cirugía en el tratamiento del AP en el niño. MATERIAL Y METODOS: Estudio descriptivo de los pacientes diagnosticados e intervenidos mediante resección del AP desde el 2017 hasta el 2019. Se realizó una revisión con los términos "aspergilloma", "surgical", "treatment", descartando los estudios no referidos a pacientes pediátricos. RESULTADOS: Durante el periodo de estudio se intervinieron 3 pacientes con AP único, de 18 meses, 3 y 13 años de edad respectivamente, los 3 afectos de leucemia y con poca o nula respuesta al tratamiento médico habitual del aspergiloma. En todos los pacientes se inició la intervención por vía toracoscópica, siendo necesaria la conversión a toracotomía en 2 casos. En los tres casos se realizó segmentectomía pulmonar con exéresis completa del AP, sin complicaciones intraoperatorias ni postoperatorias graves. No se observaron recidivas pulmonares tras un seguimiento de 30, 34 y 16 meses respectivamente. CONCLUSIONES: La resección quirúrgica del AP, se presenta como una alternativa factible en pacientes pediátricos con pobre respuesta a tratamiento antifúngico o con complicaciones derivadas de este.

Management of acute stroke. Specific nursing care and treatments in the stroke unit. / Manejo del ictus agudo. Tratamientos y cuidados específicos de enfermería en la Unidad de Ictus.

OBJECTIVE: This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS: We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS: The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS: These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.

BAFF is increased in renal transplant patients following treatment with alemtuzumab.

Alemtuzumab is a monoclonal antibody that depletes T and B cells and is used as induction therapy for renal transplant recipients. Without long-term calcineurin inhibitor (CNI) therapy, alemtuzumab-treated patients have a propensity to develop alloantibody and may undergo antibody-mediated rejection (AMR). In pursuit of a mechanistic explanation, we analyzed peripheral B cells and serum of these patients for BAFF (Blys) and BAFF-R, factors known to be integral for B-cell activation, survival, and homeostasis. Serum BAFF levels of 22/24 alemtuzumab-treated patients were above normal range, with average levels of 1967 pg/mL compared to 775 pg/mL in healthy controls (p = 0.006). BAFF remained elevated 2 years posttransplant in 78% of these patients. BAFF-R on CD19(+) B cells was significantly downregulated, suggesting ligand/receptor engagement. BAFF mRNA expression was increased 2-7-fold in CD14(+) cells of depleted patients, possibly linking monocytes to the BAFF dysregulation. Addition of recombinant BAFF to mixed lymphocyte cultures increased B-cell activation to alloantigen, as measured by CD25 and CD69 coexpression on CD19(+) cells. Of note, addition of sirolimus (SRL) augmented BAFF-enhanced B-cell activation whereas CNIs blocked it. These data suggest associations between BAFF/BAFF-R and AMR in alemtuzumab-treated patients.

[Dog bites, a current problem in our environment]. / Mordeduras de perro, un problema vigente en nuestro entorno.

AIMS: Dog bites are frequent reason for consultation in pediatrics emergency department. Despite in our environment dog bites are rarely lethal, some of these accidents can have serious aesthetics consequences. The main goal of this article is to analyze dog bites casuistry and their impact in our community. MATERIAL AND METHODS: Retrospective review of patients treated for dog bite in a tertiary pediatric center between 2013-2018. We studied patient's demographic variables, bite localization, dog-patient relationship, antibiotic therapy, need for admission, complications and secondary sequelae. RESULTS: 256 cases were analyzed (average age 6.4 years), 133 boys (51.9%) and 123 girls (48%). In 153 cases, the aggressor dog was from the patient's familiar environment (59.8%). The most frequent location of the wounds was head and neck (94.1%), followed by extremities (4.7%) and genitals (1.6%). In 227 cases (88.7%) antibiotics were administered. Wound infection was the most frequent complication, occurring in 5 patients (2%). 20 patients (7.8%) required hospital admission with a mean stay of 1.6 days. Aesthetic sequelae were described in 10 cases (3.9%), 7 of which required correcting surgery. CONCLUSIONS: Dog bites persist as a frequent reason for medical consultation, most of them are provoked by patient familiar dogs. Wound infection represents the major complication, and the facial aesthetic sequelae are the most frequent indication for surgical intervention. We consider due to the amount of dog bites and their sequelae, the inclusion of preventive measures against these accidents in home prevention guidelines could be useful to reduce the incidence of these injuries.

OBJETIVOS: Las mordeduras de perro son motivo de consulta habitual en urgencias pediátricas. Si bien en nuestro medio raramente son letales, algunas conllevan secuelas estéticas graves. El objetivo del trabajo es analizar la casuística de mordeduras de perro y su repercusión en nuestro entorno. MATERIAL Y METODOS: Revisión retrospectiva de pacientes atendidos por mordedura de perro en un centro pediátrico terciario entre 2013-2018. Estudiamos variables demográficas, localización de mordedura, relación perro-paciente, antibioterapia, necesidad de ingreso, complicaciones y secuelas derivadas. RESULTADOS: Se analizaron 256 casos (edad media 6,4 años), 133 niños (51,9%) y 123 niñas (48%). En 153 casos el perro agresor era del entorno del paciente (59,8%). La localización más frecuente de heridas fue cabeza y cuello (94,1%), seguida de extremidades (4,7%) y genitales (1,6%). En 227 casos (88,7%) se administró antibiótico. La complicación más frecuente fue la infección de herida en 5 pacientes (2%). Precisaron ingreso hospitalario 20 pacientes (7,8%) con estancia media de 1,6 días. Se describieron secuelas estéticas en 10 casos (3,9%), 7 precisaron cirugía correctora. CONCLUSIONES: Las mordeduras de perro persisten como motivo frecuente de consulta, produciéndose mayoritariamente por perros del entorno del paciente. La infección de herida representa la complicación más común, y la secuela estética facial supone la indicación más frecuente de intervención quirúrgica. Consideramos que por la cantidad de mordeduras y sus secuelas, la inclusión de medidas preventivas ante estos accidentes en guías de prevención del hogar, podría ser de utilidad para concienciar a la población y disminuir la incidencia de estas lesiones.