Mineralcorticoid receptor blockers in chronic kidney disease.

There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage. Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin-angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events. In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent/decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers. The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits. Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.

[Mineralcorticoid receptor blockers in chronic kidney disease]. / Bloqueantes del receptor mineralcorticoide en la enfermedad renal crónica.

There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage. Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin- angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events. In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent / decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers. The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits. Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.

Clinical and radiologic features of pigmented villonodular synovitis of the foot: report of eight cases.

Pigmented villonodular synovitis, a rare proliferative disease of unknown etiology, is rare in the foot (2% of these lesions). A retrospective review was undertaken of the case histories, radiographs, and imaging results of eight patients treated for pigmented villonodular synovitis of the foot. Pigmented villonodular synovitis was located in the rearfoot in five patients and in the forefoot in the other three. Radiographs in six patients showed bone involvement. Affected bones included the talus, first cuneiform, first and fifth metatarsals, and second phalanx. Treatment was surgical, and only one recurrence was recorded after 24 months. Pigmented villonodular synovitis should be considered in the differential diagnosis of foot tumors.

Implante de un dispositivo de asistencia ventricular izquierda definitivo y circulación asistida en cuidados intensivos como terapia puente. Cuidados enfermeros: caso clínico / Permanent left ventricular assistance internal device implantation and assisted circulation in intensive care as bridge therapy. Nursing care: case report

A lo largo de los últimos años la implantación de Dispositivos de Asistencia Ventricular (DAV) está tomando un papel más relevante en el tratamiento de la Insuficiencia Cardíaca (IC). El uso de los DAV también está cambiando hacia la Terapia Definitiva (TD), conformándose como alternativa clara al trasplante cardíaco. La implantación de un DAV, en ocasiones, requiere previamente tratamiento emergente con otros dispositivos de Asistencia Circulatoria Mecánica (ACM) como Circulación Extracorpórea con Membrana de Oxigenación (ECMO) o Asistencia Ventricular paracorpórea Izquierda o Derecha. Por tanto, es necesario el ingreso en Unidades de Cuidados Intensivos (UCI) especializadas en estas terapias hasta la estabilización del paciente y toma de la decisión correcta. Se expone un caso clínico reciente de una persona que requiere asistencia inicial con ECMO V-A emergente en el hospital de origen y su traslado al centro de referencia para posterior asistencia biventricular paracorpórea e implantación definitiva de un DAVI (Dispositivo de Asistencia Ventricular Izquierda). Se exponen la secuencia de decisiones, complicaciones y el plan de cuidados de enfermería inicial en UCI con taxonomía NANDA. Es el primer implante de un DAVI, realizado en nuestro hospital. En él ha intervenido un enorme equipo multidisciplinar.

Over the past few years, the Ventricular Assist Devices (VADs) implementation is taking a relevant role in the Heart Failure (HF) treatment. VADs ́s use is also shifting towards Definitive Therapy (TD), being a clear alternative to heart transplantation. The implantation of a VAD, sometimes, requires a previous emergent treatment with other Mechanical Circulatory Assistance (ACM) devices such as Extracorporeal Circulation with Oxygenation Membrane (ECMO) or Left or Right Paracorporeal Ventricular Assistance. So is necessary of a mobile team for emergency assistance with ECMO and transfer to Intensive Care Units (ICU) which is specialized in these therapies until the patient stabilizes and doctors takes the right decision. A recent clinical case of a patient is exposed. This person required assistance with emergent ECMO V-A (Venous-Arterial) in the hospital of origin and his transfer to the reference center for subsequent biventricular paracorporeal assistance and to the definitive implantation of LVAD (Left Ventricular Assist Device). The sequence of decisions, complications and the initial nursing care plan at ICU with NANDA taxonomy, are presented here. This is the first implant of a LVAD in our hospital. A huge multidisciplinary team has been involved in the project.

Prevalence of osteoporotic vertebral fracture in Spanish women over age 45.

The aim of this work is to study the prevalence of osteoporotic vertebral fractures in Spanish women over 45 years of age, based on the selection of a nationwide sample. An observational, cross-sectional, multicenter study was conducted during 2006, in all of Spain's regions. The sample analyzed was of 5000 individuals, representative of the female population over age 45 in Spain. A questionnaire was used to determine which factors are most often associated with vertebral fractures. We also assessed whether the Prevalent Vertebral Fracture Index, proposed by Vogt, is useful in indicating a possible osteoporotic vertebral fracture. Five hundred orthopedic surgeons, from various Spanish regions, were trained in different aspects of the study: inclusion and exclusion criteria, management of the risk factor questionnaire, and implementation of the Vogt questionnaire. The number of fracture cases was 1549 (31.79%). 528 Women (34.08%) had a single vertebral fracture, and 1021 (65.92%) had multiple vertebral fractures. The following factors were statistically significantly associated with vertebral fracture: age, late menarche, early menopause, diabetes mellitus, hyperparathyroidism, rheumatoid arthritis, height loss, daily physical activity, corticosteroid therapy, personal history of osteoporotic fracture and previous diagnosis of osteoporosis. The differences in Vogt score according to age and fracture status were statistically significant. The conclusion of the study is that vertebral osteoporotic fracture in the female Spanish population is frequent. The high prevalence in the Spanish population older than 60 years is probably related to malnutrition in the period from 1936 to 1952.

Complications of hip fractures: A review.

Nowadays, fracture surgery represents a big part of the orthopedic surgeon workload, and usually has associated major clinical and social cost implications. These fractures have several complications. Some of these are medical, and other related to the surgical treatment itself. Medical complications may affect around 20% of patients with hip fracture. Cognitive and neurological alterations, cardiopulmonary affections (alone or combined), venous thromboembolism, gastrointestinal tract bleeding, urinary tract complications, perioperative anemia, electrolytic and metabolic disorders, and pressure scars are the most important medical complications after hip surgery in terms of frequency, increase of length of stay and perioperative mortality. Complications arising from hip fracture surgery are fairly common, and vary depending on whether the fracture is intracapsular or extracapsular. The main problems in intracapsular fractures are biological: vascularization of the femoral head, and lack of periosteum -a major contributor to fracture healing- in the femoral neck. In extracapsular fractures, by contrast, the problem is mechanical, and relates to load-bearing. Early surgical fixation, the role of anti-thromboembolic and anti-infective prophylaxis, good pain control at the perioperative, detection and management of delirium, correct urinary tract management, avoidance of malnutrition, vitamin D supplementation, osteoporosis treatment and advancement of early mobilization to improve functional recovery and falls prevention are basic recommendations for an optimal maintenance of hip fractured patients.