Outcomes after endovascular repair of arterial trauma.

BACKGROUND: Endovascular repair of peripheral arterial trauma using covered stent grafts is a minimally invasive alternative to open surgery in selected patients. Although the technical feasibility of endovascular repair has been established, there are a paucity of data regarding outcomes. The purpose of this study was to evaluate the short-term outcomes of endovascular repair in patients with peripheral arterial trauma. METHODS: A review of a prospectively collected institutional trauma registry captured all patients with peripheral arterial injury who underwent endovascular repair from August 2004 to June 2012. Data collected included demographics, Injury Severity Score (ISS), mechanism, location and type of injury, imaging modality, intervention type, complications and reintervention, length of stay, and follow-up. Descriptive statistics were used for analysis. RESULTS: During the study period, we performed endovascular repair in 28 patients with peripheral arterial injuries. There were 20 male patients (71%) with a median age of 39 years (range, 13-88 years). The mean ISS was 17.2 (range, 9-41). The mechanism of injury was penetrating in 21 (75%) and blunt in seven (25%). The anatomic locations of the 28 arterial injuries were carotid (3 [11%]), subclavian (7 [25%]), axillary (6 [22%]), iliac (3 [11%]), and femoral/popliteal (9 [32%]). Findings consistent with injury on imaging included pseudoaneurysms (9 [32%]), extravasations (9 [32%]), occlusions (6 [22%]), and arteriovenous fistulas (4 [14%]). Technical success was achieved in all patients. The overall complication rate was 21%, with six patients requiring a secondary procedure. Two patients underwent a planned, elective conversion to open repair during the initial hospitalization. Four patients required conversion secondary to stent graft thrombosis. Three conversions were early (<30 days) and one was late (>30 days). The mean length of stay was 18.4 ± 22.9 days (range, 1-93 days), with a median follow-up of 13 months (range, 1-60 months). The overall limb salvage rate was 92% at 45 days and 79% at 93 days. CONCLUSIONS: The present study outlines our early experience with endovascular repair of peripheral arterial injuries in a variety of anatomic locations. Overall complication rates are appreciable but can be effectively detected and managed with additional intervention. The inclusion of endovascular modalities in algorithms of trauma care holds considerable promise. The need to better define optimal algorithms for utilization and determine long-term outcomes of intervention requires significant additional study.

We advance in health thanks to the PAPI children's health application.

INTRODUCTION: The family structure and parenting are changing in society, sedentary lifestyle, the use of screens and social networks is increasing. Families and health professionals must learn to educate, adapting their health advice to the new social and digital environment. MATERIALS AND METHODS: A survey was sent to the representatives of more than 5000 paediatricians to renew the Well Child Visits Programme of the Spanish Association of Primary Care Paediatrics (AEPap). Contributions from preventive programmes from Andalusia, the Balearic Islands and Asturias were incorporated. The different interventions and advice were distributed in nine age groups. RESULTS: Part of the recommendations are based on the work of the PrevInfad group. It uses the methodology of evidence-based medicine and performs the evaluation and synthesis of the evidence in the proposed preventive activities. The AEPap considers that the Well Child Programme should be carried out by the paediatric team: the paediatrician and the nurse, thus enhancing specific skills. The WHO considers it essential to empower individuals, families, and communities to optimize their health by making them caretakers of themselves and others, equipping them with tools that protect their well-being. CONCLUSION: Hence, it was decided to capture the Well Child Programme in the format of a free APP for mobile devices, as an innovative and affordable method of disseminating child and adolescent health. Information is given on parenting advice for family members, for children and adolescents and describes health check-ups for health workers.

Patients Age 40 Years and Younger With Multiple Myeloma Have the Same Prognosis as Older Patients: An Analysis of Real-World Patients' Evidence From Latin America.

PURPOSE: Multiple myeloma (MM) is a highly heterogeneous, incurable disease most frequently diagnosed in the elderly. Therefore, data on clinical characteristics and outcomes in the very young population are scarce. PATIENTS AND METHODS: We analyzed clinical characteristics, response to treatment, and survival in 103 patients with newly diagnosed MM age 40 years or younger compared with 256 patients age 41-50 years and 957 patients age 51 years or older. RESULTS: There were no statistical differences in sex, isotype, International Scoring System, renal involvement, hypercalcemia, anemia, dialysis, bony lesions, extramedullary disease, and lactate dehydrogenase (LDH). The most used regimen in young patients was cyclophosphamide, bortezomib, dexamethasone, followed by cyclophosphamide, thalidomide, dexamethasone and bortezomib, thalidomide, dexamethasone. Of the patients age 40 years or younger, only 53% received autologous stem-cell transplant (ASCT) and 71.1% received maintenance. There were no differences in overall survival (OS) in the three patient cohorts. In the multivariate analysis, only high LDH, high cytogenetic risk, and ASCT were statistically associated with survival. CONCLUSION: In conclusion, younger patients with MM in Latin America have similar clinical characteristics, responses, and OS compared with the elderly.

Endovascular treatment of hemodialysis access pseudoaneurysms.

OBJECTIVE: Pseudoaneurysm (PSA) formation is a complication of hemodialysis access. Open repair requires PSA resection, interposition graft placement, and insertion of a catheter as a bridge. Endovascular stent graft repair is an alternative that permits immediate use of the access site. The objective of this study was to determine the efficacy of stent grafts for repair of arteriovenous fistula and arteriovenous graft PSA. METHODS: A retrospective review of medical records from October 2007 to March 2011 revealed 24 patients with a PSA who underwent endovascular repair using a stent graft. Indications for repair included PSA with symptoms (n = 11), PSA with skin erosion (n = 8), PSA with failed hemodialysis (n = 3), and PSA after balloon angioplasty of a stenosis (n = 2). Outcome measures were technical success, 30-day and 180-day patency, secondary interventions, and complications. All the statistical analyses were conducted by using software SAS 9.1 (SAS, SAS Institute, Gary, NC). RESULTS: Twenty-seven self-expanding stent grafts (Viabahn, W. L. Gore, n = 25; Fluency, Bard, n = 2) were used to treat hemodialysis access (arteriovenous graft, n = 13; arteriovenous fistula, n = 11) PSA in 24 patients (16 females; mean age, 55.7 years; mean body mass index, 28.4; mean PSA diameter, 19.5 mm). Comorbidities included hypertension (n = 22; 91.7%), diabetes mellitus (n = 8; 33.3%), and coronary artery disease (n = 4; 16.67%). The median time from access creation to repair was 455 days. The technical success rate was 100%. Balloon angioplasty of an outflow stenosis was performed in 56% of stent grafts. The 30- and 180-day patency rate was 100% and 69.2%, respectively. Three secondary interventions were performed for treatment of unrelated stenosis. Treatment failure occurred in five (18.5%) stent grafts due to infection (n = 3) and thrombosis (n = 2). Treatment of PSA with skin erosion was associated with failure due to infection (odds ratio, 5.0; 95% confidence interval, .38, 66.01). The remaining 22 (81.5%) stent grafts remain patent. The mean follow-up time was 268.9 days (median, 97.5). CONCLUSIONS: Endovascular therapy is an effective and durable treatment option for patients with dialysis access PSAs. This technique permits immediate use of the hemodialysis access site as well as identification and treatment of associated stenosis. It may be considered as an alternative to open repair in patients who are anatomically suitable candidates.

[Main changes in the «COVID-19 in paediatrics¼ clinical practice guideline]. / Principales modificaciones en la guía de práctica clínica «COVID-19 en pediatría¼.

We present a summary of the main modifications to the «COVID-19 in Paediatrics¼ clinical practice guideline made from its initial version, published in 2021, and the version published in 2022. The document was developed following the structured steps of evidence-based medicine and applying the GRADE system to synthesize the evidence, assess its quality and, when appropriate, issue graded recommendations (based on the quality of the evidence, values and preferences, the balance between benefits, risks and costs, equity and feasibility). This update also includes the modifications proposed by external reviewers.We summarised the main modifications in the following sections: epidemiology, clinical features, diagnosis, prevention, treatment and vaccines. In relation to the body of knowledge achieved in the first year of the pandemic, the literature published in the second year contributed additional data, but without substantial modifications in many of the areas. The main changes took place in the field of vaccine research. This update was completed in December 2021, coinciding with the emergence of infections by the omicron variant, so the document will need to be updated in the future.

Main changes in the "COVID-19 in paediatrics" clinical practice guideline.

We present a summary of the main modifications to the "COVID-19 in Paediatrics" clinical practice guideline made from its initial version, published in 2021, and the version published in 2022. The document was developed following the structured steps of evidence-based medicine and applying the GRADE system to synthesize the evidence, assess its quality and, when appropriate, issue graded recommendations (based on the quality of the evidence, values and preferences, the balance between benefits, risks and costs, equity and feasibility). This update also includes the modifications proposed by external reviewers. We summarised the main modifications in the following sections: epidemiology, clinical features, diagnosis, prevention, treatment and vaccines. In relation to the body of knowledge achieved in the first year of the pandemic, the literature published in the second year contributed additional data, but without substantial modifications in many the areas. The main changes took place in the field of vaccine research. This update was completed in December 2021, coinciding with the emergence of infections by the omicron variant, so the document will need to be updated in the future.

Incidence and Prognostic Significance of High-Risk Cytogenetically Abnormalities in Multiple Myeloma Patients in Colombia.

INTRODUCTION: Multiple Myeloma (MM) is the second most common hematological cancer, several cytogenetics abnormalities such as t(4;14), del (17p), and t(14;16) were identified as a high-risk for survival, in Latin America, we have very little data on cytogenetic alterations in MM. This study describes the incidence of high-risk cytogenetically abnormalities in a Colombian population and prognostic significance. METHODS: In a retrospective cohort of new diagnostic Multiple Myeloma between 2016 and 2020, we identified a high-risk cytogenetically abnormalities t(4;14), t(14;16), and 17p deletions by FISH techniques and described incidence. We followed patients until progression or death and comparing progression free survival (PFS) and overall survival (OS), according with high- risk cytogenetically features. RESULTS: We included 135 newly diagnosed MM patients, the incidence of high-risk cytogenetically abnormalities were 30.3%, with 17.1% of 17p deletions, 14.1% of t(4;14) and 2.25% of t(14;16). According to the high risk cytogenetically abnormalities, the median PFS for the group of no abnormalities were 50.2 months 95% CI [25.2-62.4] and for the group of high-risk cytogenetic abnormalities 33.9 months 95% CI [23.6-NA] (P = .2). For OS the median were 76.9 months, 95% CI [67.5-NA] and 42.7 months 95% CI [33.3-NA], respectively (P = .009). CONCLUSION: High-risk cytogenetically abnormalities were independent risk factor for OS but not PFS in this cohort of patients, and the incidence of del (17p) was slightly higher than the literature reports.  MICROABSTRACT: Prognostic significance of high-risk cytogenetic abnormalities in Multiple Myeloma in Colombia is unknown. In a retrospective cohort study of 135 newly, diagnostic Multiple Myeloma we found incidence of high-risk cytogenetic abnormalities was 30.3%. The hazard ratio (HR) for disease progression or death compared high-risk cytogenetic group vs. control was 1.22, (95% CI, 0.73-2.05) (P = .2), and The HR for death for the group of high-risk cytogenetic abnormalities was 2.17, (95% CI, 1.19-3.97). In the group of high-risk cytogenetic abnormalities, if the patient received VRD as induction treatment the median PFS were 41.2 months 95% CI [13.3-NA] and 33.9 months 95% CI [24.9-NA] for patients with different induction treatment (P = .56).

The utility of intravascular ultrasound compared to angiography in the diagnosis of blunt traumatic aortic injury.

BACKGROUND: Blunt traumatic aortic injury (TAI) refers to a spectrum of pathology that ranges from intimal tears to aortic rupture. Computed tomography angiography (CTA) has been widely used as a diagnostic tool in this setting. Additional imaging is required when CTA studies are equivocal. The purpose of this study is to evaluate the utility of intravascular ultrasound (IVUS) versus angiography in the diagnosis of TAI. METHODS: We performed an analysis of prospectively collected trauma registry data. CTA was used as the initial screening test. Patients with a positive or equivocal CTA underwent angiography and IVUS. Injuries were classified into Grades 1 to 4 (intimal tear, intramural hematoma, pseudoaneurysm, and rupture). Patients with Grade 1 injuries were managed medically. Patients with Grade 2 to 4 injuries underwent repair. A blinded randomized retrospective review of positive and equivocal imaging studies was performed. Standard screening test assessments (sensitivity, specificity), inter-rater agreement (Kappa), and frequency (Chi-square for the difference) were computed to evaluate the measurement characteristics of the multiple imaging techniques. RESULTS: Between May 2008 and August 2009, 7961 patients were admitted to our trauma center, and 2153 (27%) underwent a chest CTA. Twenty-five (0.3%) patients (21 males, mean age 21.9 years) had a positive or equivocal study for TAI. The mean Injury Severity Score was 33.9. Ten patients underwent repair (nine endovascular, one open), and 15 patients were managed medically. The 30-day mortality, paraplegia, and stroke rates were zero. Equivocal results were more common with CTA images than with either IVUS or angiography (27% vs 2.5 and 5%, respectively; overall P = .0002). Compared with angiography, IVUS changed the diagnosis in 13% of cases; identifying injuries in 11% and ruling them out in 2%. Sensitivity and specificity of angiography with respect to IVUS was 38% and 89%, respectively. CONCLUSIONS: CTA is useful as a screening test in suspected TAI. When additional imaging is required after an equivocal CTA, IVUS is better than angiography. Therefore, we advocate the use of IVUS in potential TAI patients in whom angiography is being considered.

Measurable Residual Disease Assessment and Allogeneic Transplantation as Consolidation Therapy in Adult Acute Lymphoblastic Leukemia in Colombia.

INTRODUCTION: Detectable minimal residual disease (MRD) after therapy for acute lymphoblastic leukemia (ALL) is the strongest predictor of hematologic relapse. The objective of the study was to assess disease-free survival (DFS) and overall survival (OS) of patients with ALL according with MRD status at the end of induction therapy in a Colombian population. PATIENTS AND METHODS: We assessed a retrospective cohort to compare DFS and OS in adults with de novo ALL according to MRD status at the end of induction chemotherapy, and the type of postinduction consolidation strategy used. RESULTS: A total of 165 adults with ALL were included in the MRD part of the study, 73 patients in the MRD-negative group and 92 in the MRD-positive group. Median DFS for the MRD-positive group was 11 months (95% confidence interval, 11.7-22.2) and was not reached for the MRD-negative group (P < .001). At 3 years, DFS was 18% and 55%, respectively (P < .001). The median OS for MRD-positive patients was 16 months (95% confidence interval, 8.8-23.15) and was not reached in the MRD-negative group. At 3 years, OS was 26% and 51% for the former and latter group, respectively. Among subjects who did not receive a transplant, median DFS was 21 months for MRD-negative patients and 9 months for MRD-positive patients (P < .001). The median DFS was not reached in either group, whereas 3-year DFS was 64% for MRD-negative and 70% for MRD-positive patients who underwent transplantation in first remission (P = .861). CONCLUSION: MRD status at the end of induction is an independent prognostic factor for DFS and OS in adult ALL. Allogeneic transplantation in first remission could overcome the adverse prognostic impact of MRD.

Bradicardia y convulsiones: una relación multicausal / Bradycardia and seizures: a multi-causal relationship

La disfunción del nodo sinusal consiste en una alteración en la generación del impulso en el nodo sinusal. Su principal causa es la degeneración fibrosa del tejido sinusal. Los casos asociados a convulsiones son multicausales y se deben a los efectos cardiodepresores de los anticonvulsivantes o de sus diluyentes; así mismo se pueden presentar casos de bradicardia y asistolia inducidos por las descargas epilépticas. Se expone el caso de una paciente con status epiléptico tratada con fenitoína endovenosa, quien recibía previamente carbamazepina y desarrolló disfunción del nodo sinusal considerada como un efecto secundario tóxico de su medicación anticonvulsivante.

Sinus node dysfunction is an alteration in the impulse generation in the sinus node. Its main cause is the fibrous degeneration of the sinus tissue. Cases associated with seizures have multiple causes and are due to the cardio-depressant effects of anticonvulsants or its diluents. Likewise, there may be cases of bradycardia and asystole induced by epileptic discharges. Here is presented the case of a female patient with status epilepticus who was treated with intravenous phenytoin and was previously receiving and developed sinus node dysfunction which was considered as a toxic side effect of her anticonvulsant medication.

Polimiositis y compromiso cardiaco / Cardiac involvement in polymyositis

Las miopatías idiopáticas son enfermedades que se caracterizan por cursar con una lesión muscula de tipo inflamatorio, sin embargo, también se ha encontrado que presentan compromiso del músculo cardiaco de forma importante, inclusive con desarrollo de falla cardiaca. Lo anterior constituye una causa frecuente de morbilidad y mortalidad en este grupo de pacientes. Al respecto, se presenta el caso de una paciente de 54 años con sospecha inicial de síndrome coronario agudo, quien cursó con polimiositis, dolor torácico y compromiso de la fracción de eyección.

Idiopathic myopathies are disorders characterized by inflammatory muscle damage. However, it has also been found that they may present significant muscle heart engagement, even with the development of heart failure. This is a frequent cause of morbidity and mortality in this group of patients. In this regard, the case of a 54 year old female patient with initial suspicion of acute coronary syndrome accompanied by polymyositis, chest pain and commitment of the ejection fraction, is presented.

Enfermedad cerebrovascular: doce años de experiencia en el tratamiento quirúrgico de la obstrucción carotídea / Cerebrovascular disease: a 12 year experience in the surgical treatment of carotid obstruction

Introducción: se consideró prudente revisar el tema y la casuística de doce años por los autores en pacientes con infarto cerebral por enfermedad carotídea, por la elevada morbilidad y mortalidad así como la frecuencia de secuelas incapacitantes.Material y método: presentamos nuestra experiencia en el Hospital ABC de junio de 1988 a junio del 2000, en el tratamiento quirúrgico de la obstrucción carotídea en 63 pacientes (33 Fem. y 30 Masc.), con edad promedio de 70 años, que requirieron 68 endarterectomías. Sus factores de riesgo incluían: hipertensión arterial 40 Ptes., tabaquismo 40, cardiopatía isquémica 22, neumopatía 12 y diabetes m. 10. Fueron 40 endarterectomías izquierdas y 28 derechas; 61 por estenosis sintomática y 7 asintomáticas. Los principales síntomas fueron: ataques de isquemia cerebral transitoria 39, infarto cerebral previo 13 y amaurosis fugax 9. El porcentaje promedio de estenosis en las lesiones sintomáticas fue de 86.47 por ciento y en las asintomáticas de 82 por ciento. Resultados: todos los pacientes fueron operados bajo anestesia general endotraqueal, con protección cerebral farmacológica, monitorización electroencefalográfica y de potenciales evocados somatosensoriales. Nueve casos (13.23 por ciento) requirieron la colocación de una derivación (shunt) transoperatoria. El tiempo promedio de pinzamiento carotídeo fue en los pacientes sin derivación 35.8 minutos y con derivación 4 minutos. Siete casos, todos del sexo femenino, requirieron arteriorrafia con parche; 4 con dacrón, 2 con PTFE y 1 con vena safena. El tiempo promedio de cirugía fue de 2 horas 37 minutos. Mortalidad operatoria 1 caso (1.47 por ciento) por fibrilación ventricular secundaria a infarto agudo del miocardio. Morbilidad neurológica central 1 caso. Morbilidad neurológica periférica 2 casos por lesión neuropráxica del recurrente laríngeo y del facial con recuperación completa. Morbilidad no neurológica 9 casos (13.23 por ciento): HTA postoperatoria 4, hipotensión arterial postoperatoria 3, hematoma 1 e IAM 1.El tiempo promedio de estancia hospitalaria fue de 4.52 días. Discusión: los resultados de esta serie de endarterectomías carotídeas con pacientes cuya edad promedio fue la 8a. década de la vida, con ASA III en 47 por ciento de los casos, donde 89.7 por ciento presentaba estenosis sintomáticas de 86.47 por ciento promedio, muestran baja mortalidad operatoria y morbilidad neurológica central, equiparables a los resultados de los estudios NASCET y ACAS.

La histerosalpingografia en el diagnostico de esterilidad / The hysterosalpingography in the diagnosis of sterility

Se dan a conocer histerosalpingografias atipicas y anormales de los expedientes de mujeres esteriles registradas en el Departamento de Esterilidad del Hospital de Clinicas de La Paz. A Partir de ellas se concreta el valor diagnostico y terapeutico de la histerosalpingografia (H.S.G.). Tambien, el porcentaje de los problemas tubaricos y uterinos como causa de esterilidad.