RESUMO
INTRODUCTION: The incidence of melanoma is rising in Spain. The prognostic stages of patients with melanoma are determined by various biological factors, such as tumor thickness, ulceration, or the presence of regional or distant metastases. The Spanish Academy of Dermatology and Venereology (AEDV) has encouraged the creation of a Spanish Melanoma Registry (REGESMEL) to evaluate other individual and health system-related factors that may impact the prognosis of patients with melanoma. The aim of this article is to introduce REGESMEL and provide basic descriptive data for its first year of operation. METHODS: REGESMEL is a prospective, multicentre cohort of consecutive patients with invasive cutaneous melanoma that collects demographic and staging data as well as individual and healthcare-related baseline data. It also records the medical and surgical treatment received by patients. RESULTS: A total of 450 cases of invasive cutaneous melanoma from 19 participant centres were included, with a predominance of thin melanomas≤1mm thick (54.7%), mainly located on the posterior trunk (35.2%). Selective sentinel lymph node biopsy was performed in 40.7% of cases. Most cases of melanoma were suspected by the patient (30.4%), or his/her dermatologist (29.6%). Patients received care mainly in public health centers (85.2%), with tele-dermatology resources being used in 21.6% of the cases. CONCLUSIONS: The distribution of the pathological and demographic variables of melanoma cases is consistent with data from former studies. REGESMEL has already recruited patients from 15 Spanish provinces and given its potential representativeness, it renders the Registry as an important tool to address a wide range of research questions.
Assuntos
Dermatologia , Melanoma , Sistema de Registros , Neoplasias Cutâneas , Humanos , Melanoma/epidemiologia , Melanoma/cirurgia , Melanoma/patologia , Espanha/epidemiologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Neoplasias Cutâneas/epidemiologia , Estudos Prospectivos , Masculino , Dermatologia/estatística & dados numéricos , Feminino , Pessoa de Meia-Idade , Idoso , Venereologia , Academias e Institutos/estatística & dados numéricos , Adulto , Biópsia de Linfonodo Sentinela/estatística & dados numéricos , Idoso de 80 Anos ou mais , Estadiamento de NeoplasiasRESUMO
BACKGROUND: Early identification of vasospasm prior to symptom onset would allow prevention of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH). Dynamic cerebral autoregulation (DCA) is a noninvasive means of assessing cerebral blood flow regulation by determining independence of low-frequency temporal oscillations of systemic blood pressure (BP) and cerebral blood flow velocities (CBFV). METHODS: Eight SAH patients underwent prospectively a median of 7 DCA assessments consisting of continuous measurements of BCFV and BP. Transfer function analysis was applied to calculate average phase shift (PS) in low (0.07-0.2 Hz) frequency range for each hemisphere as continuous measure of DCA. Lower PS indicated poorer regulatory response. DCI was defined as a 2-point decrease in Glasgow Coma Score and/or infarction on CT. RESULTS: Three subjects developed symptomatic vasospasm with median time-to-DCI of 9 days. DCI was significantly associated with lower PS over the entire recording period (Wald = 4.28; p = 0.039). Additionally, there was a significant change in PS over different recording periods after adjusting for DCI (Wald = 15.66; p = 0.001); particularly, a significantly lower mean PS day 3-5 after bleed (14.22 vs 27.51; p = 0.05). CONCLUSIONS: DCA might be useful for early detection of symptomatic vasospasm. A larger cohort study of SAH patients is currently underway.
Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Estudos de Coortes , Homeostase , HumanosRESUMO
BACKGROUND: The INTERMED was developed for the early identification of biological, psychological, social and health system factors considered interacting in health complexity. This is defined as the interference with the achievement of expected or desired health and service use outcomes when patients are exposed to standard care. OBJECTIVE: The aim of this study was to test the INTERMED's ability to identify 'case' and 'care' complexity, identifying patients that would especially benefit from integrated care. METHODS: Observational longitudinal study of Internal medicine in patients in two National Health System hospitals in Spain using the INTERMED (patients scoring ≥ 21 were considered to be 'complex'); the Cumulative Illness Rating Scale (CIRS), a severity of illness assessment; and standard clinical variables. RESULTS: Six hundred and fifteen consecutives were included, and the prevalence of health complexity was 27.6%. The greatest differences between patients with and without health complexity were observed in the non-biological domains. Eighty-five per cent of patients with health complexity had non-biological items considered to require timely (immediately or soon) assistance or intervention compared to 30% of those without, nearly a threefold difference. Complex patients had a significantly higher number of medical diagnoses (p = 0.002) and number of psychiatric referrals (p = 0.041), but there were no differences in CIRS scores or lengths of stay. CONCLUSION: The INTERMED has the potential to identify a considerable subset of complex internal medicine inpatients for which timely corrective action related to non-biological risk factors not typically uncovered during standard medical evaluations would be considered beneficial.
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Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Medicina Interna/estatística & dados numéricos , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde , Humanos , Tempo de Internação , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , EspanhaRESUMO
Lentigo maligna is a type of in situ melanoma. It develops mainly in middle-aged and elderly individuals on areas of the skin chronically exposed to sunlight. It progresses to its invasive form, lentigo maligna melanoma, in 5% to 50% of cases. Management of lentigo maligna is open to debate, with a notable lack of randomized trials and specific guidelines and protocols. Early diagnosis and treatment is necessary to achieve cure if possible and prevent progression to invasive melanoma with the corresponding risk of metastasis. The treatment of choice for lentigo maligna is surgery. When surgery is not possible, other alternatives are available although outcomes and rates of recurrence are variable. The objective of this study was to review the diagnostic methods and criteria for lentigo maligna, as well as the different surgical options and alternatives to surgery, in order to provide information on the best approach in each case.
Assuntos
Sarda Melanótica de Hutchinson , Neoplasias Cutâneas , Humanos , Sarda Melanótica de Hutchinson/patologia , Sarda Melanótica de Hutchinson/terapia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/terapiaRESUMO
BACKGROUND: The Woven EndoBridge device was originally approved to treat intracranial wide-neck saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of sidewall intracranial aneurysms with variable success. PURPOSE: Our aim was to evaluate the safety and efficacy of the Woven EndoBridge device for sidewall aneurysms using a meta-analysis of the literature. DATA SOURCES: We performed a systematic review of all studies including patients treated with the Woven EndoBridge device for sidewall aneurysms from inception until May 2022 on Scopus, EMBASE, MEDLINE, the Web of Science, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Ten studies were selected, and 285 patients with 288 sidewall aneurysms were included. DATA ANALYSIS: A random-effects meta-analysis of proportions using a generalized linear mixed model was performed as appropriate. Statistical heterogeneity across studies was assessed with I2 statistics. DATA SYNTHESIS: The adequate occlusion rate at last follow-up was 89% (95% CI, 81%-94%; I2, = 0%), the composite safety outcome was 8% (95% CI, 3%-17%; I2 = 34%), and the mortality rate was 2% (95% CI, 1%-7%; I2 = 0%). Aneurysm width (OR = 0.5; P = .03) was the only significant predictor of complete occlusion. LIMITATIONS: Given the level of evidence, our results should be interpreted cautiously until confirmation from larger prospective studies is obtained. CONCLUSIONS: The initial evidence evaluating the use of the Woven EndoBridge device for the treatment of wide-neck sidewall intracranial aneurysms has demonstrated high rates of adequate occlusion with low procedural complications. Our findings favor the consideration of the Woven EndoBridge device as an option for the treatment of sidewall aneurysms.
Assuntos
Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Resultado do Tratamento , Estudos Prospectivos , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Estudos RetrospectivosRESUMO
BACKGROUND AND PURPOSE: High-resolution MR imaging allows the identification of culprit symptomatic plaques after the administration of gadolinium. Current high-resolution MR imaging methods are limited by 2D multiplanar views and manual sampling of ROIs. We analyzed a new 3D method to objectively quantify gadolinium plaque enhancement. MATERIALS AND METHODS: Patients with stroke due to intracranial atherosclerotic disease underwent 7T high-resolution MR imaging. 3D segmentations of the plaque and its parent vessel were generated. Signal intensity probes were automatically extended from the lumen into the plaque and the vessel wall to generate 3D enhancement color maps. Plaque gadolinium (Gd) uptake was quantified from 3D color maps as gadolinium uptake = (µPlaque T1 + Gd -µPlaque T1/SDPlaque T1). Additional metrics of enhancement such as enhancement ratio, variance, and plaque-versus-parent vessel enhancement were also calculated. Conventional 2D measures of enhancement were collected for comparison. RESULTS: Thirty-six culprit and 44 nonculprit plaques from 36 patients were analyzed. Culprit plaques had higher gadolinium uptake than nonculprit plaques (P < .001). Gadolinium uptake was the most accurate metric for identifying culprit plaques (OR, 3.9; 95% CI 2.1-8.3). Gadolinium uptake was more sensitive (86% versus 70%) and specific (71% versus 68%) in identifying culprit plaques than conventional 2D measurements. A multivariate model, including gadolinium uptake and plaque burden, identified culprit plaques with an 83% sensitivity and 86% specificity. CONCLUSIONS: The new 3D color map method of plaque-enhancement analysis is more accurate for identifying culprit plaques than conventional 2D methods. This new method generates a new set of metrics that could potentially be used to assess disease progression.
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Arteriosclerose Intracraniana , Placa Aterosclerótica , Acidente Vascular Cerebral , Humanos , Gadolínio , Arteriosclerose Intracraniana/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Placa Aterosclerótica/diagnóstico por imagemRESUMO
The aim of this paper is to describe common complications during neurosurgical interventional procedures. We describe our experience and review the literature about how to avoid complications during diagnostic cerebral angiography and neurosurgical interventional procedures. Recent technological advances have expanded the therapeutic options of neuroendovascular interventions. However, with higher complexity there is also an increased risk of complications. Common complications include hematoma at the puncture site, arterial dissection and microembolism. Treatment of complex aneurysms and arteriovenous malformations involves a higher complication rate. Standardized training and operator's certification reduces the risk of complications. It is also important to work with specialized ancillary staff and to provide dedicated neurocritical care after the neuroendovascular intervention.
Assuntos
Angiografia Cerebral/efeitos adversos , Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/normas , Complicações Pós-Operatórias/prevenção & controle , Angiografia Cerebral/estatística & dados numéricos , Transtornos Cerebrovasculares/epidemiologia , Humanos , Incidência , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Fatores de RiscoRESUMO
The surgical plane is a plane of dissection that can be used to excise a tumor while preserving most of the neurovascular structures. The majority of skin tumors are situated on the head and neck, and dermatologic surgeons should therefore have detailed knowledge of the surgical anatomy of this region. Fear of damaging important structures may result in insufficient efficacy of the surgical treatment, with consequent risk of persistence or recurrence of the tumor. Knowledge of the superficial musculoaponeurotic system and its relationship to key neurovascular structures enables the operation to be planned and will help us to locate the appropriate plane and minimize postoperative complications. The objective of this article is to review the key anatomical features defining suitable planes of dissection in the head and neck, the use of which will ensure survival of flaps and grafts.
Assuntos
Neoplasias de Cabeça e Pescoço/cirurgia , Cabeça/anatomia & histologia , Pescoço/anatomia & histologia , Neoplasias Cutâneas/cirurgia , Dissecação , Músculos Faciais/anatomia & histologia , Músculos Faciais/irrigação sanguínea , Músculos Faciais/inervação , Cabeça/cirurgia , Humanos , Complicações Intraoperatórias/prevenção & controle , Ligamentos/anatomia & histologia , Pescoço/cirurgia , Músculos do Pescoço/anatomia & histologia , Músculos do Pescoço/irrigação sanguínea , Músculos do Pescoço/inervação , Retalhos CirúrgicosRESUMO
BACKGROUND AND PURPOSE: Aneurysm wall enhancement has been proposed as a biomarker for inflammation and instability. However, the mechanisms of aneurysm wall enhancement remain unclear. We used 7T MR imaging to determine the effect of flow in different regions of the wall. MATERIALS AND METHODS: Twenty-three intracranial aneurysms imaged with 7T MR imaging and 3D angiography were studied with computational fluid dynamics. Local flow conditions were compared between aneurysm wall enhancement and nonenhanced regions. Aneurysm wall enhancement regions were subdivided according to their location on the aneurysm and relative to the inflow and were further compared. RESULTS: On average, wall shear stress was lower in enhanced than in nonenhanced regions (P = .05). Aneurysm wall enhancement regions at the neck had higher wall shear stress gradients (P = .05) with lower oscillations (P = .05) than nonenhanced regions. In contrast, aneurysm wall enhancement regions at the aneurysm body had lower wall shear stress (P = .01) and wall shear stress gradients (P = .008) than nonenhanced regions. Aneurysm wall enhancement regions far from the inflow had lower wall shear stress (P = .006) than nonenhanced regions, while aneurysm wall enhancement regions close to the inflow tended to have higher wall shear stress than the nonenhanced regions, but this association was not significant. CONCLUSIONS: Aneurysm wall enhancement regions tend to have lower wall shear stress than nonenhanced regions of the same aneurysm. Moreover, the association between flow conditions and aneurysm wall enhancement seems to depend on the location of the region on the aneurysm sac. Regions at the neck and close to the inflow tend to be exposed to higher wall shear stress and wall shear stress gradients. Regions at the body, dome, or far from the inflow tend to be exposed to uniformly low wall shear stress and have more aneurysm wall enhancement.
Assuntos
Hemodinâmica/fisiologia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/patologia , Imageamento por Ressonância Magnética/métodos , Angiografia Cerebral/métodos , Humanos , Masculino , Estresse MecânicoRESUMO
BACKGROUND AND PURPOSE: There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome. MATERIALS AND METHODS: Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliberpost - Caliberpre) and the proportion of caliber change ([(Caliberpost - Caliberpre)/Caliberpre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold. RESULTS: Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change (P < .001), mean proportion of change (P = .002), maximal caliber difference (P = .004), and mean caliber difference (P = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%. CONCLUSIONS: Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change ≥32% has the best diagnostic performance.
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Vasodilatadores/farmacologia , Vasoespasmo Intracraniano/diagnóstico , Verapamil/farmacologia , Adulto , Angiografia Digital , Feminino , Humanos , Infusões Intra-Arteriais , Masculino , Pessoa de Meia-Idade , Vasoconstrição/efeitos dos fármacosRESUMO
Recent publication of the results of clinical trials in which lymph node dissection was not associated with any survival benefit in patients with sentinel node metastasis makes it necessary to reconsider the treatment of patients with melanoma. This article provides an update on the available evidence on the diverse factors (routes of metastatic spread, predictors, adjuvant therapy, etc.) that must be considered when treating patients with sentinel node-positive melanoma. The authors propose a decision-making algorithm for use in this clinical setting. The current evidence no longer supports lymph node dissection in patients with low-risk sentinel node metastasis (sentinel node tumor load ≤1mm).
Assuntos
Algoritmos , Excisão de Linfonodo , Melanoma/secundário , Melanoma/cirurgia , Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Tomada de Decisão Clínica , Medicina Baseada em Evidências , Humanos , Metástase Linfática , Guias de Prática Clínica como AssuntoRESUMO
Coronavirus disease (Covid-19) is characterized by an intense inflammatory response and coagulopathy that is associated to a high incidence of thrombotic events with in situ thrombosis of the microcirculation of the lungs and other organs, which is the key event in the pathogenesis of the respiratory and multi-organ failure. These observations have led to to the use of heparin, which has anticoagulant, antiinflammatory and anti-viral properties, as the best agent to treat these patients. Clinical guidelines recommend the use of heparin thromboprophilaxis in these patients, although there is no agreement in the indication, dose and duration of thromboprophylaxis due to lack of randomized studies. (AU)
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Humanos , Masculino , Feminino , Gravidez , Infecções por Coronavirus , Tromboembolia Venosa/prevenção & controle , Heparina/uso terapêutico , Tromboembolia Venosa/tratamento farmacológico , Anticoagulantes/uso terapêuticoRESUMO
In a randomized, double-blind, parallel group study, we compared the clinical efficacy of coumarin 90 mg/day (Group A) with 135 mg/day (Group B) in 77 women (age 35-65 years) with lymphedema of the upper limb secondary to surgery and irradiation for treatment of breast cancer. During 12 months of coumarin therapy, the arm volume of lymphedema and a clinical score (degree of arm edema, heaviness, hardness, and neuralgia/dysesthesia) were determined. In both groups, the volume of arm lymphedema decreased (14.9% in Group A and 13.2% in Group B) (N.S.), the overall clinical score improved (12.9 +/- 4.3 to 5.7 +/- 3.5 in Group A and from 11.7 +/- 3.7 to 4.7 +/- 3.9 in Group B) (N.S.), and the overall efficacy of coumarin was similarly good or excellent (71.9% in Group A and 68.6% in Group B) (N.S.). Only mild to moderate side effects of drug therapy were recorded. Coumarin prevents a spontaneous trend toward an increase in arm lymphedema after treatment of breast cancer, decreases the severity of local symptoms, and overall improves the quality of life. No difference was found between the apparent benefits of coumarin at 90 mg/day compared with 135 mg/day.
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Neoplasias da Mama/terapia , Cumarínicos/administração & dosagem , Linfedema/tratamento farmacológico , Braço , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Terapia Combinada/efeitos adversos , Cumarínicos/efeitos adversos , Cumarínicos/uso terapêutico , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Humanos , Linfedema/etiologia , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Blood flow is not constant during the day, not only due to cardiac output variation but to the variable blood flow fraction supplied to the organs. To what extent these variations could affect the relative drug concentration between two different tissues, is the purpose of this work. In order to study that, a device was designed which took into account different fluid flows towards two flasks. Connections between flasks and pump are shown in text (figure 1). At the bottom of each flask a non-miscible liquid (dichloromethane: CH2Cl2, 100 mL, places 2 and 3) with the circulating fluid (water, 1350 mL, places 1, A, B) was placed. Malachite Green (MG) was introduced as solute into the system (place 1, 5 mL, 700 mg/L aqueous solution). The pump output was set at 1080 mL/min, serving more fluid (five times) to flask A than to flask B. Samples were drawn from compartments 1, A and B, and from organic compartments, during experiences taking several hours. MG concentrations were colorimetrically measured at 619 nm. Room temperature was between 15-25 degrees C. CH2Cl2 MG concentration ratio([2]/[3]) was similar to fluid flow ratio (sigma/(1-sigma)) all over the experience time. Other experiences changing the stop time, room temperature, CH2Cl2 volumes and places, pump output distribution, led us to different evidences that supported a theoretical model. As a conclusion, the most important feature was that whereas MG concentrations in water (1, A, B) were close, in CH2Cl2 these were very different. So, is drug effect prediction reliable by monitoring free drug concentrations in blood?
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Débito Cardíaco/fisiologia , Modelos Biológicos , Preparações Farmacêuticas/metabolismo , Distribuição Tecidual/fisiologiaRESUMO
BACKGROUND AND PURPOSE: Recanalization is observed in 20-40% of endovascularly treated intracranial aneurysms. To further reduce the recanalization and expand endovascular treatment, we evaluated the safety and efficacy of closed-cell SACE. MATERIALS AND METHODS: Between 2007 and 2010, 147 consecutive patients (110 women; mean age, 54 years) presenting at 2 centers with 161 wide-neck ruptured and unruptured aneurysms were treated by using SACE. Inclusion criteria were wide-neck aneurysms (>4 mm or a dome/neck ratio ≤ 2). Clinical outcomes were assessed by the mRS score at baseline, discharge, and follow-up. Aneurysm occlusion was assessed on angiograms by using the RS immediately after SACE and at follow-up. RESULTS: Eighteen aneurysms (11%) were treated following rupture. Procedure-related mortality and permanent neurologic deficits occurred in 2 (1.4%) and 5 patients (3.4%), respectively. In total, 7 patients (4.8%) died, including 2 with reruptures. Of the 140 surviving patients, 113 (80.7%) patients with 120 aneurysms were available for follow-up neurologic examination at a mean of 11.8 months. An increase in mRS score from admission to follow-up by 1, 2, or 3 points was seen in 7 (6.9%), 1 (1%), and 2 (2%) patients, respectively. Follow-up angiography was performed in 120 aneurysms at a mean of 11.9 months. Recanalization occurred in 12 aneurysms (10%), requiring retreatment in 7 (5.8%). Moderate in-stent stenosis was seen in 1 (0.8%), which remained asymptomatic. CONCLUSIONS: This series adds to the evidence demonstrating the safety and effectiveness of SACE in the treatment of intracranial aneurysms. However, SACE of ruptured aneurysms and premature termination of antiplatelet treatment are associated with increased morbidity and mortality.