Nos describen el caso de un paciente con una emergencia hiperkalémica (potasio >6,5 mmol/l con alteraciones en el ECG). El primer paso es la administración de gluconato cálcico iv para contrarrestar la toxicidad cardíaca de la hiperpotasemia (opción 3 correcta), dándonos más tiempo para iniciar los tratamientos hipokalemiantes (inicialmente suero glucosado con insulina, salbutamol, furosemida, y valorando diálisis si no hay buena respuesta).

Nos describen el caso de un paciente con una emergencia hiperkalémica (potasio >6,5 mmol/l con alteraciones en el ECG). El primer paso es la administración de gluconato cálcico iv para contrarrestar la toxicidad cardíaca de la hiperpotasemia ([HIDDEN]), dándonos más tiempo para iniciar los tratamientos hipokalemiantes (inicialmente suero glucosado con insulina, salbutamol, furosemida, y valorando diálisis si no hay buena respuesta).

Ante un paciente con enfermedad renal crónica avanzada (ERC G4, FGe 20 ml/min) conocida, que acude a urgencias por debilidad general y se le detecta una hiperpotasemia grave (K 7 mEq/l) con alteraciones electrocardiográficas. ¿Cuál sería la primera medida a tomar?:

Administración de resinas de intercambio catiónico.

Colocación de un catéter para iniciar diálisis.

Administración de gluconato cálcico endovenoso.

Objetivo. Identificar factores demográficos y clínicos asociados con la mortalidad por dengue grave en cinco de-partamentos de Colombia. Material y métodos. Análisis secundario de un estudio de casos y controles basado en pa-cientes admitidos de 2009 a 2013. Los casos fueron pacientes que murieron por dengue y los controles fueron pacientes con dengue grave sobrevivientes a la enfermedad. Se utilizó el procedimiento de Mantel-Haenszel para identificar los factores. Resultados. Analizando 58 casos y 121 controles, cuatro factores fueron asociados con la mortalidad por den-gue: administración hospitalaria de dipirona (RMa=6.38 IC95% 2.41-16.86) y de acetaminofén (RMa=0.25 IC95% 0.10-0.61), presencia de comorbilidad (RMa=3.52 IC95% 1.51-8.18) y consulta previa por el mismo padecimiento (RMa=3.99 IC95% 1.63-9.77). Conclusiones. La administración de dipirona en pacientes con dengue grave se asoció con un aumento del riesgo de mortalidad. Si se considera que la dipirona fue retirada del mercado en 20 países por sus efectos secunda-rios, se puede desaconsejar su uso en el manejo del dengue.

[Hemodialysis with bicarbonate 30 mEq/l versus 34 mEq/l and acetate: better hemodynamic tolerance and electrolyte and acid-base homeostasis].

The use of bicarbonate buffer in dialysis is more physiological than acetate. The aim of this prospective study was to compare the hemodynamic stability, acid-base and electrolyte balance changes in a group of 5 hospital hemodialysis (HD) patients, with 3 different dialysis fluids: one with 30 mEq/l of bicarbonate (B30), another with 34 mEq/l of bicarbonate (B34) and the last with acetate (ACE). All the patients had more than 12 months in HD. Each patient had HD treatment with one of the 3 different dialysis fluids: ACE, B30, B34. Each HD had a duration of 4 hours, with less than 5% dry weight ultrafiltration (UF) and continuous cardiac monitoring. The following clinical and laboratory data were evaluated: arterial blood pressure (BP), cardiac rate (CR), respiratory rate (RR), cardiac arrhythmias, blood urea, creatinine, sodium, potassium, magnesium, total calcium (Ca), ionised calcium (Ca++), pH, bicarbonate (HCO3-) and pCO2. Statistic analysis was performed using Student's paired t test and ANOVA with Bonferroni correction. Clinical evaluation showed a CR increase only in the ACE group (pre X = 78.4 to 4 degrees h X = 102.6 p < 0.001). Analytical results demonstrated, at the 1st h, Ca++ stability in the B30 group; in the first 30' the pH decreased in the ACE group (pre X = 7.35 to 30' X = 7.34); during HD, HCO3- was not corrected in the ACE group (pre X = 19.4 to 4th h X = 20.0); at 4th, pCO2 also decreased in this group (pre X = 34.5 to 4th h X = 28.4 p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Acceso vascular en apoyo renal agudo].

El acceso vascular es el primer eslabón para la terapia de apoyo extracorpórea renal. A diferencia de la terapia de reemplazo renal para pacientes con enfermedad renal crónica donde la fístula arteriovenosa es la primera opción, seguida del catéter tunelizado, en pacientes con lesión renal aguda el acceso vascular de elección es el catéter temporal. El presente estudio constituye una revisión narrativa de resumen de los estudios que analizan la elección, colocación y cuidados del acceso vascular temporal para apoyo renal agudo. En pacientes que cuentan con fístula arteriovenosa preexistente, su punción en pacientes con inestabilidad hemodinámica conlleva riesgos y no puede ser recomendada. El uso del catéter tunelizado de primera intención implica una destreza, tiempo y costos que limitan igualmente su recomendación. El cambio de catéteres por guía metálica ha mostrado ser un método seguro en ausencia de infección del catéter a retirar. El acceso femoral ha mostrado no ser inferior al acceso yugular derecho, mientras el acceso yugular izquierdo reduce la vida del circuito y debe ser considerado como cuarta opción después del yugular derecho, el femoral derecho y el femoral izquierdo. La longitud del acceso debe evaluarse de acuerdo con el sitio de inserción, mientras que los catéteres de 20 cm suelen ser adecuados para punción de la yugular derecha, la yugular izquierda suele requerir 25 cm para su llegada a la aurícula derecha. Por su parte, el acceso femoral incrementa su desempeño con longitudes de 25 a 35 cm. La punción yugular posterior baja derecha es considerada una técnica de abordaje sencilla, segura y que permite una aproximación de hasta 5 cm más caudal hacia la aurícula derecha. La interacción entre catéteres centrales debe ser anticipada o evaluada ante el riesgo de aspiración de infusiones por el circuito extracorpóreo. En el cuidado del catéter, la aplicación de heparina 1,000 U/ml reduce el riesgo de sangrado al sellar los puertos comparada con heparina 5,000 U/ml. Por último, se presenta información sobre la elección de dispositivos de cobertura, el método de fijación, los materiales de recubrimiento de catéteres y el empleo de antibióticos, incluyendo las posturas de las guías del Kidney Dialysis Improving Global Outcomes (KDIGO) y la European Renal Best Practice (ERBP), además de la información disponible en el consenso del Acute Dialysis Quality Initiative, revisiones sistemáticas, metaanálisis y ensayos clínicos controlados. Vascular access is the first link for renal extracorporeal support therapy. Unlike renal replacement therapy for patients with end-stage renal disease where the arteriovenous fistula is the first option, followed by the tunneled catheter, in patients with acute kidney injury a temporary catheter is the first choice. The present article constitutes a narrative review summarizing the studies that analyze the choice, placement and care of temporary vascular access for acute renal support. In patients who have a pre-existing arteriovenous fistula, their puncture in patients with hemodynamic instability carries risks and cannot be recommended. The use of tunneled catheter as first option implies a complex, time-consuming procedure with higher cost that also limits its recommendation. The change of catheters by metal guide has shown to be a safe method in the absence of infection. Femoral access has been shown not to be inferior to right jugular access, while left jugular access reduces the life of the circuit and should be considered as a fourth option after right jugular, right femoral and left femoral sites. The length of the access should be evaluated according to the insertion site, while 20 cm catheters are usually suitable for right jugular puncture, the left jugular usually requires 25 cm for achieving the position inside the right atrium. On the other hand, the femoral access increases its performance with lengths of 25-35 cm. The low posterior jugular approach is considered a simple, safe technique that allows up to 5 cm further towards the right atrium. The interaction between central catheters must be anticipated or evaluated because of the risk of aspiration of infusions by the extracorporeal circuit. The use of heparin 1000 U/ml for sealing the ports reduces the risk of bleeding compared to heparin 5000 U/ml. The reasoning on the evolution of catheters in structural coating materials, the decision on using a suture, the differences among dressings or securement devices, and the controversy over the use of antibiotics for sealing ports and for dressings are also discussed. The review includes the positions of the guidelines by the Kidney Dialysis Improving Global Outcomes and the European Renal Best Practice, in addition to the information available mainly on the consensus of the acute dialysis quality initiative, systematic reviews, meta-analysis and controlled clinical trials.

[Analysis of the efficacy and factors influencing the response of secondary hyperparathyroidism patients on hemodialysis to cinacalcet].

Treatment of secondary hyperparathyroidism with cinacalcet improves control of PTH, phosphorus, calcium and Ca x P product, enabling to achieve targets recommended by K/DOQI guidelines for PTHi in only 30-50% of patients, in studies with a very selected population. The aim of this study was to analyze its effectiveness in real clinical practice, comparing results with targets recommended by K/DOQI and KDIGO guidelines and to investigate factors having influence on PTH responsiveness to cinacalcet. We collected data of evolution of 74 patients on hemodialysis with secondary hyperparathyroidism who were treated with cinacalcet for at least 6 months. According K/DOQI targets we observed a reduction of proportion of patients with PTHi > 300 pg/ml to 50%, a decrease of hyperphosphoremia from 38.4% to 23.3% and proportion of patients with Ca x P product > 55 mg2/dl2 from 37.8% to 15.1%. By contrast, presence of hypocalcemia increases from 2.7% to 12.3%. Comparing with KDIGO targets, proportion of patients with PTHi > 600 pg/ml decreased from 41.1% to 16.4% and with hyperphosphoremia from 68.5% to 52.1%. However, when considering patients with baseline PTHi > 600 pg/ml prevalence of P > 4.5 mg/dl decreased from 83.3% to 55.2%. We observed significant changes of phosphate binders after cinacalcet treatment with an increase in calcium carbonate doses (pre 0.61 +/- 1.53 g of calcium/day vs post-cinacalcet 0.95 +/- 1.98 g of calcium/day; p = 0.03) that was prescribed to prevent hypocalcemia and not as phosphate binder. Responsiveness were lower in patients who were taking higher doses of sevelamer at baseline, showing at the end of the study higher PTHi (no-sevelamer: 312 +/- 245 pg/ml; sevelamer < 6.4 g/day: 510 +/- 490 pg/ml; sevelamer > 6.4 g/day: 526 +/- 393 pg/ml; p = 0.04) and phosphorus (no-sevelamer: 4.5 +/- 1.2 mg/dl; sevelamer < 6.4 g/day: 4.2 +/- 1.5 mg/dl; sevelamer > 6.4 g/day: 5.7 +/- 0.9 mg/dl; p=0.01) serum levels. Use of paricalcitol did not show any influence on PTH response. Patients achieving targets for PTH at the end of the study showed a good response early, with a significant decrease of PTHi levels at three months (159 +/- 84 vs 630 +/- 377 pg/ml; p < 0.001) with significantly lower doses of cinacalcet (33.8 +/- 22.5 vs 51.1 +/- 25.1 mg/day; p = 0.003). Using multivariate analysis we found that percent of PTHi reduction was related with baseline PTHi levels and taking sevelamer as phosphate binder at baseline. Use of cinacalcet improves grade of control of secondary hyperparathyroidism in non-selected patients in hemodialysis, showing poor response in population with higher PTHi levels and who takes higher doses of sevelamer at baseline. By contrast, a reduction of PTHi levels at 3 months of treatment with relatively lower doses is a pronostic marker of good response to cinacalcet treatment.

Incidence and Characterization of Rectal Complications From Fecal Management Systems.

Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature. The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications. This was a retrospective cohort study. The study was conducted at a large academic medical center. All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included. We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy. A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy. The study was limited by its retrospective design and single institution. This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698. ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.

[Safe treatment of acute hyperkalemia : The 1:4 and other principles].

Acute hyperkalemia is a dangerous electrolyte disorder, which must be treated immediately. It can lead to cardiac arrhythmia and death due to alterations in cell membrane potentials. The resulting alterations in the electrocardiogram (ECG) are multifarious and need to be rapidly recognized. Treatment consists of various stages. In addition to membrane stabilization, which is always necessary, potassium must be displaced into the intracellular space and then eliminated from the body. A commonly applied method for displacement of potassium into the intracellular space involves the administration of insulin-glucose mixtures, which is associated with many complications. In the clinical routine many prescription variations are applied, which do not always appear to be ideal with respect to the individual risk-benefit ratio. A practically useful and easily memorized insulin-glucose mixture has a relationship of 1IU insulin to 4g glucose. The therapeutic elimination from the body is carried out using an enhanced diuresis or the utilization of renal replacement procedures. Special attention must be paid to the continous monitoring of potassium and blood sugar levels. After overcoming the acute situation, attention must be paid to treatment of the underlying disorder and if necessary to readjustment of the long-term medication of the patient.

[Experiencia en el tratamiento de la hemorragia uterina anormal en adolescentes con enfermedad renal crónica].

La enfermedad renal crónica (ERC) se asocia con alteraciones menstruales, y el manejo del sangrado uterino suele ser complejo por las condiciones de este grupo de pacientes. El objetivo de este trabajo fue describir la respuesta clínica al tratamiento hormonal de las alteraciones menstruales de adolescentes con ERC. Se presentan los datos de una serie de casos de pacientes adolescentes con ERC que cursaron con alteraciones menstruales y que recibieron tratamiento desde el año 2008 al 2012. Se identificaron las características del trastorno menstrual, del tratamiento hormonal recibido y de la respuesta al mismo. El análisis estadístico fue descriptivo. Se estudiaron 11 pacientes de sexo femenino con edad promedio de 14.5 años, que se encontraban en prediálisis (n = 1), diálisis peritoneal (n = 7) y hemodiálisis (n = 3). Las pacientes presentaron hiperpolimenorrea asociada a la opsomenorrea (n = 3), en su mayoría clasificadas como hemorragia uterina anormal secundaria. El tratamiento, en general, fue con progestágenos de manera inicial (clormadinona con o sin medroxiprogesterona) o bien con anticonceptivos combinados. En la mayoría de las pacientes se obtuvo una respuesta favorable; sin embargo, hubo casos en los que fue necesario modificar la dosis y el tiempo de tratamiento. La mayor parte de las adolescentes con ERC que han sido tratadas por hemorragia uterina anormal en nuestro estudio tuvieron una respuesta favorable al tratamiento hormonal. Chronic kidney disease (CKD) is associated with menstrual abnormalities and management of uterine bleeding is often complex because of the conditions in this group of patients. The aim of this study was to describe the clinical response to hormonal treatment of menstrual alterations in adolescents with CKD. We present data of cases of adolescent patients with CKD who had undergone menstrual changes and received treatment during the period 2008 to 2012. The characteristics of the menstrual disorder, hormone treatment received, and response to treatment were evaluated. The statistical analysis aplicated to analyze the results was descriptive. We studied 11 patients with a mean age of 14.5 years, who were in predialysis (n = 1), peritoneal dialysis (n = 7), hemodialysis (n = 3). Patients had hyperpolymenorrhea associated with opsomenorrhea (n = 3), mostly classified as secondary abnormal uterine bleeding. Treatment, in general, was with progestins initially (chlormadinone with or without medroxyprogesterone) or combined contraceptives. In the majority of the patients, a favorable response was obtained; however, there were cases where it was necessary to modify the dose and time of treatment. The majority of adolescents with CKD who have been treated for abnormal uterine bleeding in our study had a favorable response to hormonal treatment.

[Comparison of extra renal potassium management in hypertensive, diabetic and normal subjects].

Sodium and potassium ions are involved in the regulation of blood pressure and the genesis of hypertension. To assess internal potassium balance, as a measure of sodium pump activity, in subjects with essential hypertension and diabetic patients. Eleven hypertensive subjects, 5 non-insulin-dependent diabetics and 16 age matched controls were studied. An acute oral load of 0.8 mEq/Kg body weight of KCl was administered and blood samples were drawn every 30 min thereafter, until 120 min, to measure plasma K+ levels. Urinary K+ excretion during this period was also measured. In eight hypertensive patients, the test was repeated after two week of supplementation with 60 mEq/day of KCl. The maximal increase in plasma potassium levels and the time required to achieve the maximum concentration was recorded. All patients had normal serum creatinine levels. Mean fasting blood glucose of diabetic patients was 133 +/- 15.1 mg/dl. No difference between patients and controls in maximal increase plasma potassium increase, was observed. In hypertensive patients the lapse to achieve the maximal potassium concentration was longer than in controls. After the period of potassium supplementation in hypertensive patients, there was a significant increase in basal plasma K+ levels and the temporal pattern of plasma potassium increase was similar to that of controls. Between 63 and 68% of retained K+ load was translocated to the intracellular space at 120 min in all study groups. Internal potassium balance is not significantly altered in subjects with essential hypertension or in non-insulin-dependent diabetics.

Self-Expanding Metal Stents Do Not Adversely Affect Long-term Outcomes in Acute Malignant Large-Bowel Obstruction: A Retrospective Analysis.

Self-expanding metal stents as a bridge to surgery in acute malignant large-bowel obstruction has gained popularity. However, long-term oncologic outcomes have not been well established. To investigate long-term oncologic outcomes of patients undergoing curative resection after the placement of a colonic stent compared with emergency surgery for acute malignant large-bowel obstruction. This is a retrospective study. All patients presenting at 3 tertiary care centers between April 2002 and December 2012 with a diagnosis of complete malignant large-bowel obstruction were reviewed. Patients with disease distal to the hepatic flexure were selected for analysis. One hundred twenty-two patients who underwent either emergency surgery or placement of a colonic stent with curative intent were included. Patients receiving emergency surgery within 24 hours of presenting with obstructive symptoms, including those with failed stents, were included in the emergency surgery group. All patients with clinically successful stent deployment before surgery were included in the stent group. Overall survival and disease-free survival were calculated using the Kaplan-Meier method. Sixty-four patients underwent emergency surgery, and 58 patients underwent placement of a self-expanding metal stent. Groups were similar in terms of sex, tumor stage and grade, and Charlson and Charlson-Age Comorbidity Index scores. Patients in the surgery group were older than patients in the stent group. There were no differences in the number of lymph nodes harvested, positive nodes, rates of vascular and perineural invasion, or utilization of chemotherapy. Thirty-day mortality after resection was similar between groups (7.41% vs 4.41%; p > 0.05). Patients who underwent colonic stenting as a bridge to surgery had similar 10-year overall survival (40.5% vs 32.7%; p = 0.13) and 10-year disease-free survival (40.2% vs 33.8%; p = 0.26) compared with those who underwent emergency surgery. Similar results were seen on intention-to-treat analysis. This was a small retrospective study. Stent insertion followed by oncologic resection is associated with similar overall survival and disease-free survival compared with emergency resection. Stent insertion as a bridge to surgery should be considered in patients presenting with malignant colorectal obstruction. See Video Abstract at http://links.lww.com/DCR/B714Los Stents Metálicos Autoexpandibles No Afectan Negativamente Los Resultados A Largo Plazo En La Obstrucción Maligna Aguda Del Colon: Un Análisis Retrospectivo. Los stents metálicos autoexpandibles como puente a una cirugía en la obstrucción maligna aguda del colon han ganado popularidad. Sin embargo, no se han establecido bien los resultados oncológicos a largo plazo. Investigar los resultados oncológicos a largo plazo de los pacientes sometidos a resección curativa después de la colocación de un stent colónico en comparación con la cirugía de urgencia para la obstrucción maligna aguda del colon. Estudio retrospectivo. Entre abril de 2002 y diciembre de 2012, se revisaron todos los pacientes que acudieron a tres centros de tercer nivel con un diagnóstico de obstrucción maligna completa del colon. Se seleccionaron para el análisis los pacientes con enfermedad distal al ángulo hepático. Se incluyeron 122 pacientes que fueron operados de urgencia o a una colocación de un stent colónico con intención curativa. Los pacientes que se sometieron a cirugía de urgencia dentro de las 24 horas posteriores a la presentación de síntomas obstructivos; se incluyeron aquellos con stents fallidos en el grupo de cirugía de urgencia. Todos los pacientes con colocación clínicamente exitosa del stent antes de la cirugía se incluyeron en el grupo de stent. La sobrevida global y la sobrevida libre de enfermedad se calcularon mediante el método de Kaplan-Meier. Sesenta y cuatro pacientes fueron llevados a cirugía urgente y en 58 pacientes se colocó de un stent metálico autoexpandible. Los grupos fueron similares en relación a sexo, estadio y grado del tumor, puntuación de comorbilidad de Charlson y Charlson-Age. Los pacientes del grupo de cirugía eran mayores que los del grupo de stents. No hubo diferencias en el número de ganglios linfáticos recolectados, ganglios positivos, tasas de invasión vascular y perineural o utilización de quimioterapia. La mortalidad a los 30 días después de la resección fue similar entre los grupos (7,41% frente a 4,41%; p> 0,05). Los pacientes que se sometieron a la colocación de un stent colónico como puente a la cirugía tuvieron una sobrevida general a diez años similar (40,5% vs 32,7%; p = 0,13) y una sobrevida libre de enfermedad a diez años (40,2% vs 33,8%, respectivamente; p = 0,26) en comparación a los operados de urgencia. Se observaron resultados similares en el análisis por intención de tratamiento. Estudio retrospectivo reducido. La utilización de un stent y posteriormente la resección oncológica se asocia a una sobrevida general y una sobrevida libre de enfermedad similar en comparación con la resección de urgencia. La utilización de un stent como puente a la cirugía debe considerarse en pacientes que presentan obstrucción colorrectal maligna. Consulte Video Resumen en http://links.lww.com/DCR/B714. (Traducción-Dr. Lisbeth Alarcon-Bernes).

[The renin-angiotensin-aldosterone system in compensated and uncompensated cardiac insufficiency].

Renin Activity (PRA), Aldosterone (PA), Sodium (PNa) and Potassium (PK) in plasma and Aldosterone (UA), Sodium (UNa) and Potassium (UK) in 24 hrs urine were measured in 11 cases of heart failure compensated with treatment (HFCT) consisting in digoxin 0.25 mg daily, furosemide 40 to 80 mg daily, potassium chloride 1.5 g daily and low salt diet and in 12 cases of refractory heart failure (RHF). Mean and standard deviation of PRA, PA, PNa, PK, UA, UNa and UK were 9.7 +/- 8.2 mg/cc/hr. 24.2 +/- 14.0 mg/100 cc, 142.2 +/- 4.7 mEq/1, 4.9 +/- 0.3 mEq/1, 8.7 +/- 9.1 ug/24 hrs, 89.3 +/- 50.0 mEq/24 hrs and 50.0 +/- 26.7 mEq/24 hrs, respectively for cases with HFCT and 61.7 +/- 37.5, 120.3 +/- 125.8, 133.1 +/- 4.3, 4.9 +/- 0.4, 21.3 +/- 19.2, 9.9 +/- 19 and 33.3 +/- 12.0 respectively for subjects with RHF. The statistical analysis of PRA, PA, PNa and UNa, revealed differences between the two groups with p values of less than or equal to 0.05, less than or equal to 0.001, less than or equal to 0.001, less than or equal to 0.001, respectively. The other values were statistically non significant. These data suggest the existence of an stimulatory state of the renin-angiotensin-aldosterone system (RAAS) in the RHF and a normal state in HFCT. The lack of electrolytic changes suggestive of aldosteronism in RHF may be due to an alteration of aldosterone receptors or to hemodynamic renal factors. In heart failure hemodynamic changes rather than humoral factor seems to control RAAS.

The experience of bedaquiline implementation at a decentralised clinic in South Africa.

Multidrug-resistant tuberculosis (MDR-TB) is a serious public health problem, but the new drugs bedaquiline (BDQ) and delamanid offer hope to improve outcomes and minimise toxicity. In Khayelitsha, South Africa, patients are routinely started on BDQ in the out-patient setting. This report from the field describes BDQ use in the out-patient setting at the Nolungile Clinic. The clinic staff overall report a positive experience using the drug. Challenges have been based largely on the logistics of drug supply and delivery. BDQ can be started successfully in the out-patient setting, and can be a positive experience for both patients and providers. La tuberculose multirésistante (TB-MDR) est un problème de santé publique grave, mais les nouveaux médicaments que sont la bédaquiline (BDQ) et le délamanide apportent un espoir d'améliorer les résultats tout en réduisant la toxicité. A Khayelitsha, Afrique du Sud, les patients démarrent leur traitement par BDQ en consultation externe en routine. Ce rapport du terrain décrit l'utilisation de la BDQ à la consultation externe du dispensaire Nolungile. Dans l'ensemble, le personnel du centre de santé exprime une expérience positive du médicament. Les défis ont surtout été liés à la logistique de l'approvisionnement et de la distribution du médicament. La BDQ peut être mise en route avec succès dans le cadre d'une consultation externe et peut constituer une expérience positive pour les patients et les prestataires de soins. La tuberculosis multirresistente (TB-MDR) representa un grave problema de salud pública, pero la utilización de nuevos medicamentos como la bedaquilina (BDQ) y el delamanid ofrece perspectivas de mejores desenlaces terapéuticos y disminución de la toxicidad asociada. En Khayelitsha, Suráfrica, se inicia de manera sistemática el tratamiento ambulatorio con BDQ. En el presente informe del terreno, se describe la utilización de BDQ en tratamiento antituberculoso ambulatorio en el centro de atención Nolungile. En general, los miembros del personal del centro refirieron una experiencia positiva con la administración del medicamento. Las dificultades surgieron en gran parte con respecto a aspectos logísticos del suministro y la administración del medicamento. Es posible iniciar un tratamiento eficaz con BDQ en condiciones ambulatorias, y represente una experiencia positiva para los pacientes y los profesionales de salud.

[The electrical impedance indicator dilution method in studying the basic hemodynamic parameters during dialysis].

The procedure for measuring cardiac output and circulating blood volume is based on blood ability to modify its electrical conductance due to the amount of introduced ions (0.9% sodium chloride solution) or undissociated molecules (5% glucose solution). The cardiac output and circulating blood volume were calculated after measuring an area under the electrical impedance indicator dilution curve using the given formulas. With the described and thermodilution methods, the cardiac output was compared (r = 0.95). The correlation factor with the radioisotopic method in measuring the circulating blood volume was 0.88. Clinical investigations carried out in 47 patients on a programmed hemodialysis showed a significant decrease in cardiac output approximately by 700 ml/mi (7.9%) and circulating blood volume by an average of 900 ml (15.2%) by the end of a hemodialysis session, the rate of the circulating blood volume to body weight being also decreased. There was a predominant fluid "release" from the vascular bed.

Management, Functional Outcomes, and Quality of Life After Development of Pelvic Sepsis in Patients Undergoing Re-Do Ileal Pouch Anal Anastomosis.

The data on management and outcomes of pelvic sepsis after re-do IPAA are scarce. The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do IPAA and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no sepsis control group. This is a retrospective cohort study. This investigation is based on a single academic practice group experience on re-do IPAA. Patients who underwent re-do IPAA for ileal pouch failure between September 2016 and September 2020 were included in the study. Management of pelvic sepsis was reported. Functional outcomes, restrictions, and quality-of-life scores were compared between the sepsis and no sepsis groups. One-hundred ten patients were included in our study, of whom 25 (22.7%) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure, and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included interventional radiology abscess drainage (n = 7), IV antibiotics alone (n = 5), interventional radiology drainage and mushroom catheter placement (n = 1), mushroom catheter placement (n = 1), and endoluminal vacuum-assisted closure (n = 1). Average number of bowel movements, urgency, incontinence, pad use, and seepage were comparable between the pelvic sepsis and no pelvic sepsis groups ( p > 0.05). Lifestyle alterations, Cleveland Global Quality of Life scores, and happiness with the results of the surgery were similar ( p > 0.05). This study is limited by its low study power and limited follow-up time. Pelvic sepsis is common after re-do IPAA, and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823 . ANTECEDENTES:Los datos sobre el tratamiento y los resultados de la sepsis pélvica después de reconfección de anastomosis anal, de la bolsa ileal son escasos.OBJETIVO:El objetivo de este estudio es informar nuestro algoritmo de manejo de la sepsis pélvica en el contexto de reconfección de anastomosis anal de la bolsa ileal y comparar los resultados funcionales y la calidad de vida después del manejo exitoso de la sepsis pélvica con un grupo de control sin sepsis.DISEÑO:Este es un estudio de cohorte retrospectivo.AJUSTES:Esta investigación se basa en una experiencia de un solo grupo de práctica académica sobre reconfección de IPAA.PACIENTES:Se incluyeron en el estudio pacientes que se sometieron a una nueva anastomosis anal, del reservorio ileal por falla del reservorio ileal entre el 09/2016 y el 09/2020.PRINCIPALES MEDIDAS DE RESULTADO:Se informó el manejo de la sepsis pélvica. Los resultados funcionales, las restricciones y las puntuaciones de calidad de vida, se compararon entre los grupos con sepsis y sin sepsis.RESULTADOS:Se incluyeron 110 pacientes en nuestro estudio, de los cuales 25 (22,7) desarrollaron sepsis pélvica. Veintitrés pacientes presentaron sepsis pélvica antes del cierre de la ileostomía y 2 pacientes presentaron sepsis pélvica después del cierre de la ileostomía. Hubo 6 fallas de la bolsa en el período de estudio debido a sepsis pélvica. Nuestro manejo fue exitoso en el 79% de los pacientes con una mediana de seguimiento de 26 meses. Los tratamientos incluyeron drenaje de abscesos IR (n = 7), antibióticos intravenosos solos (n = 5), drenaje IR y colocación de catéter en forma de hongo (n = 1), colocación de catéter en forma de hongo (n = 1) y cierre endoluminal asistido por vacío (n = 1). El número promedio de evacuaciones intestinales, urgencia, incontinencia, uso de almohadillas y filtraciones fueron comparables entre los grupos con sepsis pélvica y sin sepsis pélvica ( p > 0,05). Las alteraciones del estilo de vida, las puntuaciones de la Calidad de vida global de Cleveland y la felicidad con los resultados de la cirugía fueron similares ( p > 0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:La sepsis pélvica es común después de la reconfección de anastomosis anal de la bolsa ileal y el manejo varía según la ubicación y el tamaño del absceso / seno. Si se detecta temprano, nuestra estrategia de manejo se asoció con altas tasas de recuperación de la bolsa. Consulte Video Resumen en http://links.lww.com/DCR/B823 . (Traducción-Dr. Mauricio Santamaria ).

[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.

The Impact of Transversus Abdominis Plane Block Within an Enhanced Recovery After Surgery Protocol on Length of Stay.

Multimodal, narcotic-sparing analgesic strategies are an important part of enhanced recovery after surgery protocols. Within such protocols, regional anesthetics have proven to be superior to narcotics. This study aimed to evaluate the impact of the transversus abdominis plane block within an enhanced recovery after surgery protocol on length of stay. A retrospective analysis of patients who underwent colorectal surgery in 2015 to 2016 was completed. The primary end points for this analysis were total length of stay and total narcotics consumed during hospitalization. Length of stay and total narcotic use were compared for patients who received a transversus abdominis plane block versus those that did not. The data were obtained from the data warehouse of a university teaching hospital. This study took place at a university teaching hospital. The patients were 18 years or older. The primary outcomes measured were length of stay and the total narcotics used. A total of 347 patients underwent colorectal procedures under the enhanced recovery protocol. Among these, 186 (54%) received a transversus abdominis plane block. Overall, the mean length of stay was 5.8 days (SD ±5.6), and median length of stay was 4 days. These values compare to a mean length of stay of 9.6 days and median length of stay of 7 days before implementing the enhanced recovery protocol. Patients who received a transversus abdominis plane block had a mean length of stay of 5.1 days compared to 6.6 days for those who did not receive one (p < 0.01). Patients who received a transversus abdominis plane block consumed 736.5 morphine milligram equivalents of opioids compared to 1150.3 morphine milligram equivalents of opioid consumed by those without a transversus abdominis plane block (p < 0.05), a 36% decrease in opioid use. When comparing patients who had a mean length of stay of 4 days with those whose length of stay was >4 days, there was an 80% decrease in opioid use. The readmission rate was 7.8%. The lack of randomization of patients was a limitation of this study. The use of transversus abdominis plane block in the setting of a well-structured enhanced recovery protocol was associated with a statistically significant decrease in length of stay by 1.5 days and a 36% decrease in narcotic use. See Video Abstract at http://links.lww.com/DCR/B432. ANTECEDENTES:La estrategia analgésica multimodal que consume poco medicamento de tipo narcótico es parte importante en los protocolos de recuperación mejorada postoperatoria. Dentro de dichos protocolos, los anestésicos regionales han demostrado ser superiores a la administración de medicamentos narcóticos.OBJETIVO:Estudiar el impacto del bloqueo del plano muscular de los transversos del abdomen sobre la duración de la estadía dentro de un protocolo de recuperación mejorada postoperatoria.DISEÑO:Se realizó un análisis retrospectivo de los pacientes que se sometieron a cirugía colorrectal entre 2015-2016. Los criterios principales de valoración en el presente análisis fueron la duración total de la estadía y el total de medicamentos narcóticos consumidos durante la hospitalización. Se comparó la duración de la estadía y el uso total de narcóticos en los pacientes que recibieron un bloqueo anestésico del plano muscular de los transversos del abdomen con los que no lo recibieron.FUENTE DE DATOS:Banco de datos de un hospital universitario docente.AMBIENTE:Hospital Universitario Docente.PACIENTES:Adultos desde los 18 años o mayores.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estadía, cantidad total de medicamentos narcóticos administrados.RESULTADOS:Un total de 347 pacientes se sometieron a procedimientos colorrectales bajo el protocolo ERAS. Entre ellos, 186 (54%) recibieron un bloqueo del plano muscular de los transversos del abdomen. En la globalidad, la duración media de la estadía fué de 5,8 días (DE ± 5,6) y la duración media de la estadía fué de 4 días. Estos resultados fueron comparados con la estadía media de 9,6 días y una estadía media de 7 días antes de implementar el protocolo ERAS. Los pacientes que recibieron un bloqueo del plano muscular de los transversos del abdomen tuvieron una estadía media de 5,1 días en comparación con los 6,6 días de los que no recibieron el mencionado bloqueo (p <0,01). Los pacientes que recibieron el bloqueo del plano muscular consumieron 736,5 miligramos de morfina o su equivalente en opioides, comparados con los 1150,3 de aquellos sin bloqueo del plano muscular (p <0,05) lo que significó una disminución del 36% en la administración de opioides. Al comparar los pacientes que tuvieron una estadía media de 4 días con aquellos cuya estadía fue mayor a 4 días, se evidenció una disminución en el 80% de la administración de opioides. La tasa de reingreso fue del 7,8%.LIMITACIONES:Estudio sin sin aleatorización de pacientes.CONCLUSIÓN:El bloqueo anestésico del plano muscular de los transversos del abdomen dentro un contexto protocolar tipo ERAS o de recuperación mejorada bien estructurada, se asoció con la disminución estadísticamente significativa de la duración de la estadía en 1,5 días y una disminución del 36% en la administración de medicamentos narcóticos. Consulte Video Resumen en http://links.lww.com/DCR/B432.

[Evaluation of the treatment efficacy of secondary hyperparathyroidism with oral pulse doses of alphacalcidol].

The purpose of the study was to evaluate the effectiveness of the oral pulse therapy with high doses of alphacalcidol (1 alpha(OH)D3) in secondary hyperparathyroidism. 16 hemodialysis patients with 4 to 9-fold iPTH serum elevation were given ones in week oral 1 alpha(OH)D3 in doses from 5.0 to 7.0 micrograms (0.1 microgram/b.m.) according to serum levels of calcium, phosphate, activity of alkaline phosphatase with its bone fraction. Serum iPTH levels were measured every 3rd month of the treatment. The dialysate calcium was reduced to 1.25 mmol/l. CaCO3 was used as a main phosphate binder in doses from 3.0 to 9.0 g/day. After first three months of treatment the serum iPTH levels decreased from 486.0 +/- 200 pg/ml to 218.0 +/- 117 pg/ml (p = 0.0001). Calcium levels increased from 2.39 +/- 0.2 mmol/l to 2.52 +/- 0.29 mmol/l (p > 0.05). Phosphate levels increased from 2.15 +/- 0.67 mmol/l to 2.17 +/- 0.62 mmol/l (p > 0.05). Alkaline phosphatase levels decreased from 35.2 +/- 17.3 IU/l to 31.1 +/- 7.78 IU/l (p > 0.05). Bone isoenzyme of alkaline phosphatase decreased from 19.2 +/- 13.4 IU/l to 15.5 +/- 7.51 IU/l (p > 0.05). Because of early serum hypercalcemia, doses of 1 alpha(OH)D3 had to be reduced in 2 patients. In 8 patients (50%) demonstrating decrease of serum iPTH levels (below 200 pg/ml) after first 3 months of treatment doses of 1 alpha(OH)D3 were reduced in the following months. We conclude that oral 1 alpha (OH)D3 pulse therapy is effective for parathyroid activity suppression in patients with severe hyperparathyroidism. To avoid dangerous hypercalcemia and adynamic bone disease serum iPTH and calcium levels should be strictly monitored.

Introducción: Chile en las últimas décadas ha experimentado un cambio en su perfil epidemiológico nutricional, pasando de una situación caracterizada por una elevada prevalencia de desnutrición y enfermedades infecciosas/parasitarias a otro completamente distinto, en donde las enfermedades crónicas y degenerativas presentan una elevada prevalencia.Objetivo: el objetivo del estudio es elaborar tablas de referencia de aspectos antropométricos y de condición física en estudiantes varones de 10 a 14 años de la ciudad de Chillán.Método: estudio descriptivo de corte transversal. La muestra se compone de 1250 varones con edades entre los 10 y 14 años. Para la confección de las tablas de referencia se utilizó estadística descriptiva y estas fueron divididas en cinco clasificaciones desde muy malo, malo, media, bueno y muy bueno, teniendo como parámetro la edad.Resultados: observamos niveles importantes de sobrepeso que se asociaron con bajo desempeño físico, lo que plantea la urgencia de realizar un seguimiento en el tiempo con herramientas de fácil aplicación como la presente batería; con el fin de detectar a tiempo a los niños que tienen bajos niveles de condición física y tomar medidas orientadas a estimular o mejorar la capacidad física como factores protectores de promoción de la salud y como ayuda en la prevención de enfermedades crónicas relacionadas con el sobrepeso u obesidad.Conclusión: en este trabajo se han establecido valores de referencia para posteriores estudios en cuanto a la condición física orientada a la salud en estudiantes varones de 10 a 14 años de la ciudad de Chillán, que permitirán evaluar e interpretar correctamente la condición física orientada a la salud de este grupo etario.

[Treatment of hyperkalemia: 2.0 version].

Hyperkaliaemia is a serious electrolyte disorder that is favored by many comorbidities, such as chronic renal failure or some treatments such as renin-angiotensin-aldosterone system blockers. The new oral treatments by chelation of intestinal potassium have demonstrated : 1) their effectiveness in the management of serum potassium by maintaining the treatments at optimal dosages ; 2) their safety of use by the absence of serious side effect and 3) the ease of use with a daily intake.

Age Determines Adjuvant Chemotherapy Use in Resected Stage II Colon Cancer.

The role of adjuvant chemotherapy in resected stage II colon cancer remains controversial. Treatment recommendations rely largely on the presence of certain high-risk features for recurrence. We sought to define patient and clinicopathologic differences between early-onset and late-onset colorectal cancer and determine whether these differences impact treatment. We hypothesized that high-risk features in stage II colorectal cancer differed between age groups and would most strongly influence administration of adjuvant chemotherapy. This was a retrospective cohort study. The study was conducted at a Commission on Cancer designated hospital as well as the National Cancer Institute Intramural Research Program. Patients with resected stage II colon cancer were identified in the National Cancer Database, and clinicopathologic characteristics were recorded. Patients were stratified into young (≤45), middle-aged (50-75), and older (>75) age groups. Incidence of high-risk clinicopathologic features and receipt of adjuvant chemotherapy were measured. A total of 14,966 patients met inclusion criteria. Young patients were found to have had at least one high-risk feature ( n = 489, 44%) slightly more often than both middle-aged ( n = 3734, 40%) and older patients ( n = 1890, 42%). A total of 332 (7%) older patients received adjuvant chemotherapy compared to 627 (56%) young patients and 2854 (30%) middle-aged patients. Age group was independently associated with receipt of adjuvant chemotherapy when controlling for relevant clinicopathologic factors. This was a retrospective study without granular detail on treatment decisions. Young patients are frequently prescribed adjuvant chemotherapy for both high- and low-risk tumors despite questionable benefit in the latter. Older patients rarely receive adjuvant therapy. Both medical and surgical oncologists should be aware of disparities in cancer treatment and remain conscientious about making treatment decisions solely based on age. See Video Abstract at http://links.lww.com/DCR/B846 . ANTECEDENTES:El papel de la quimioterapia adyuvante en el cáncer de colon resecado en estadio II sigue siendo controversial . Las recobmendaciones para el tratamiento dependen en gran medida de la presencia de ciertas características de alto riesgo de recurrencia.OBJETIVO:Buscamos definir las diferencias clínico-patológicas del paciente entre el CCR de inicio temprano y tardío; y determinar si estas diferencias afectan el tratamiento. Hipotetizamos que las características de alto riesgo del cáncer colorrectal en estadio II difieren entre los grupos de edad y que influyen fuertemente en la administración de quimioterapia adyuvante.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLINICO:El estudio se llevó a cabo en un hospital designado por la Comisión sobre el Cáncer, así como el Programa de Investigación Intramural del Instituto Nacional del Cáncer.PACIENTES:Se identificaron los pacientes con cáncer de colon resecado en estadio II en la Base de datos nacional del cáncer y se registraron las características clínico-patológicas. Los pacientes se estratificaron en grupos de edad jóvenes (≤45), de mediana edad (50-75) y mayores (> 75).PRINCIPALES MEDIDAS DE RESULTADO:Se estudiaron la incidencia de las características clínico-patológicas de alto riesgo y la recepción de quimioterapia adyuvante.RESULTADOS:Un total de 14.966 pacientes cumplieron con los criterios de inclusión. Se encontró que los pacientes jóvenes tenían al menos una característica de alto riesgo (n = 489, 44%) un poco más frecuente que los pacientes de mediana edad (n = 3734, 40%) y los pacientes mayores (n = 1890, 42%). Un total de 332 (7%) de los pacientes mayores recibieron quimioterapia adyuvante en comparación con 627 (56%) de los pacientes jóvenes y 2854 (30%) de los pacientes de mediana edad. El grupo de edad se asoció de forma independiente con la recepción de quimioterapia adyuvante al controlar los factores clínico-patológicos relevantes.LIMITACIONES:Este fue un estudio retrospectivo sin detalles granulares sobre las decisiones de tratamiento.CONCLUSIONES:A los pacientes jóvenes se les prescribe con frecuencia quimioterapia adyuvante para tumores de alto y bajo riesgo, a pesar de los cuestionables beneficios en estos últimos. Los pacientes de edad avanzada rara vez reciben terapia adyuvante. Tanto los oncólogos clínicos como los quirúrgicos deben ser conscientes de las disparidades en el tratamiento del cáncer y ser conscientes de tomar decisiones de tratamiento basadas únicamente en la edad. Consulte Video Resumen en http://links.lww.com/DCR/B846 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

[Incidence of contrast induced nephropathy in patients who underwent an aortic endovascular repair].

Intravascular iodinated contrasts are essencial in endovascular therapy. One of their major inconveniences is contrast-induced nephropathy (CIN), which has been associated with an increase in complications and prolonged hospital stay. To analyze the incidence of CIN in patients undergoing endovascular aneurysm repair (EVAR) in our hospital. A retrospective study including patients (n=129) treated with EVAR between January 2014 - September 2015. Information was gathered concerning age, history of diabetes, hypertension, pre-existing chronic kidney disease and previous treatment with diuretics or metformin. We analyzed serum levels of urea, creatinine, sodium, potassium and glomerular filtrate (GF), at baseline, at 24hours, peak levels during post-operative period and before discharge. The amount of intravascular contrast and periprocedureral hydration were correlated to creatinine and GF to determine their effect on CIN. Of 129 patients, 11 (8.53%) developed CIN. A significant difference was found between preoperative and postoperative levels of urea and sodium, both p<0.001.Volume of contrast was the only variable that presented a statistically significant association with increase of creatinine levels in postoperative period (p=0.032). Worsening of glomerular filtrate showed a statistically significant association with preoperative levels of urea (p=0.036) and GF (p= 0.019). Fluid-therapy before or after exposure to contrast did not show any influence on the outcome. The incidence of CIN depends mainly on baseline GF and amount of contrast, and it is barely associated with hydration during the perioperative period. Since there is no specific treatment for CIN, the best practice is its prevention.

Diverting Loop Ileostomy in the Management of Medically Refractory Constipation Cases Not Falling Into Classical Categories.

The approach to constipation refractory to medical management does not necessarily follow classical teaching and is challenging. Although the role of surgery is unclear, diverting loop ileostomy may be offered to gauge symptom response followed by colectomy for appropriate patients. Our goal was to examine outcomes in patients with constipation not falling into classical subtypes who underwent diverting loop ileostomy creation as the initial surgical intervention. Our secondary aim was to offer patients colectomy and anastomosis and examine their outcome if they improved after ileostomy. The study design was a retrospective review. This study was conducted in the pelvic floor center of our colorectal surgery department from January 2006 to December 2018. Patients with medically refractory constipation referred for surgical consideration and not falling into classical constipation categories (slow transit, normal transit, or pelvic floor dysfunction) underwent evaluation with transit marker study, cinedefecography, and anal physiology and were offered ileostomy as initial surgical management. The primary measures were symptom improvement and self-reported quality of life improvement with increased patient satisfaction. Eighty-seven patients underwent diverting loop ileostomy as initial surgical therapy. Group 1 had 54 (62%) patients who self-reported symptom improvement, discontinued anticonstipation medication, and had ileostomy output >200 mL/day. Of these 54 patients, 25 had colectomy with anastomosis, 16 (64%) of whom had symptom improvement, stayed off bowel medication, and had >1 bowel movement daily. Group 2 had 33 patients who did not meet the above criteria after initial ileostomy. Nine patients in group 2 elected colectomy with anastomosis after intensive counseling; 6 (66%) reported the same positive results above. The study limitations included: 1) no objective outcome measures of patient's perceived symptom improvement and satisfaction and 2) retrospective review. Initial creation of diverting loop ileostomy may be offered to a subset of refractory constipation patients not falling into classical categories after thorough workup. Patients who self-report symptom improvement, have ileostomy output >200 mL/day, and do not require bowel medication may have acceptable results with subsequent colectomy and ileorectal anastomosis. See Video Abstract at http://links.lww.com/DCR/B854. ANTECEDENTES:El enfoque del estreñimiento refractario al tratamiento médico, que no siempre se presenta como las formas descritas clasicamente, es un desafío. Si bien el papel de la cirugía no está claro, se puede ofrecer una ileostomía en asa para medir la respuesta de los síntomas, seguida de colectomía en pacientes seleccionados.OBJETIVO:Evaluar los resultados de pacientes con estreñimiento, que no pertenecen a las formas clásicas de presentación, que se les realizó una ileostomía en asa de derivación, como intervención quirúrgica inicial. El objetivo secundario fue ofrecer a los pacientes una colectomía con anastomosis primaria y evaluar si mejoraban sus resultados después de la ileostomía.DISEÑO:El diseño del estudio fue una revisión retrospectiva.MARCO:Este estudio se realizó en el centro del piso pélvico de nuestro departamento de cirugía colorrectal, e incluyo los pacientes atendidos entre enero de 2006 y diciembre de 2018.PACIENTES:Se incluyeron los pacientes con estreñimiento refractario al tratamiento médico, derivados para evaluación quirúrgica, que no presentaban las formas clásicas de presentación (tránsito lento, tránsito normal, disfunción del suelo pélvico). Estos se sometieron a evaluación con estudio de tránsito colónico, cinedefecografía y fisiología anal, y se les ofreció una ileostomía en asa como tratamiento quirúrgico inicial.PRINCIPALES MEDIDAS DE RESULTADO:Las primeras medidas fueron la mejora de los síntomas y la calidad de vida informado por el paciente.RESULTADOS:Ochenta y siete pacientes fueron sometidos a ileostomía en asa como tratamiento quirúrgico inicial. El grupo 1 tenía 54 (62%) pacientes que informaron mejoría de los síntomas, interrumpieron la medicación proquinética y tuvieron un débito por la ileostomía >200 cc/día. De estos 54 pacientes, 25 se sometieron a colectomía más anastomosis primaria y 16 (64%) tuvieron una mejoría de los síntomas, dejaron de tomar medicamentos proquinéticos y tuvieron más de una evacuación al día. El grupo 2 tenía 33 pacientes que no cumplían con los criterios de mejoría de los síntomas después de la ileostomía inicial. Nueve pacientes del grupo 2 eligieron colectomía con anastomosis después de un asesoramiento intensivo, 6 (66%) informaron resultados positivos de mejoría de los síntomas.LIMITACIONES:Las limitaciones del estudio incluyeron 1) ninguna medida de resultado objetiva de la mejora y satisfacción de los síntomas percibidos por el paciente 2) revisión retrospectiva.CONCLUSIÓNES:La creación inicial de una ileostomía en asa de derivación se puede ofrecer a un subgrupo de pacientes con estreñimiento refractario que no entran en las categorías clásicas después de un estudio exhaustivo. La mejoría de los síntomas, informado por los pacientes, producción de ileostomía >200 cc/día y que no requieren medicación proquinética, pueden tener resultados aceptables con colectomía y anastomosis ileorrectal. Consulte Video Resumen en http://links.lww.com/DCR/Bxxx. (Traducción-Dr. Rodrigo Azolas).

[Underestimated frequency of resistant hypertension in predialysis nondiabetic patients].

The real prevalence of resistant hypertension (RH) is unknown. Studies suggest that it affects 10%-15% of patients treated for hypertension by primary care physicians. RH is defined as blood pressure (BP) remaining above the goal despite the use of optimal doses of 3 or more medicines of different classes (including a diuretic). It means BP >140/90 mm Hg for the general population and >130/80 mm Hg for patients with diabetes or kidney disease. Prior to diagnosing a patient as having RH, it is important to document medication compliance and exclude white-coat hypertension, inaccurate BP measurement, and secondary causes. The role of aldosterone in RH has gained increasing recognition. There is strong evidence for the use of spironolactone as a highly effective antihypertensive agent. Aldosterone plays a significant role in RH pathogenesis, primarily due to its vasoconstrictive effects and the possibility of altering vascular compliance. In RH, there is a high prevalence of cardiac and extra-cardiac target organ damage. It is known that BP control in chronic kidney disease is the key factor for reducing cardiovascular risk and renal disease progression. The objective of the study was to evaluate the prevalence of RH in predialysis nondiabetic (CKD stage I-IV) patients.

[Not Available].

Introducción:la nutrición parenteral (NP) a largo plazo puede asociarse a complicaciones graves, con un deterioro importante de la calidad de vida de los pacientes con síndrome de intestino corto (SIC). Teduglutida, un análogo del péptido-2 similar al glucagón, pertenece a una nueva familia terapéutica y representa el primer abordaje no sintomático del SIC. Objetivos: revisar los datos preclínicos y clínicos en cuanto a eficacia y seguridad de teduglutida. Resultados: la aprobación de teduglutida se basó en los resultados de un estudio en fase III de 24 semanas, doble ciego, controlado con placebo (STEPS). Pacientes con fallo intestinal por SIC dependientes de NP ≥ 3 veces/semana durante ≥ 12 meses recibieron 0,05 mg/kg de teduglutida (n = 43) o placebo (n = 43) 1 vez/día. En la semana 24 hubo significativamente más respondedores en el grupo de teduglutida que en el de placebo (63 vs.30%; p = 0,002). La reducción absoluta media del volumen de NP frente al valor basal en la semana 24 fue significativamente mayor con teduglutida (4,4 vs.2,3 l/semana; p < 0,001). La necesidad de NP se redujo ≥ 1 día en la semana 24 en el 54% de pacientes tratados con teduglutida vs.23% con placebo. Del total de pacientes que recibieron teduglutida en los ensayos en fase III (n = 134), el 12% consiguió una autonomía completa de la NP. Por lo general, la administración subcutánea de teduglutida se toleró bien. Conclusiones: se ha demostrado que teduglutida recupera la absorción intestinal y reduce significativamente la dependencia de la NP, consiguiendo incluso la independencia en algunos pacientes.

[Acute response to calcium inhibitors in secondary arterial hypertension: does renin play a role?].

Calcium channel blocking agents are considered to be particularly effective in reducing blood pressure (BP) in low renin essential hypertension and in primary aldosteronism. The aim of this study was to compare the acute BP response to nicardipine in 2 opposite situations of stimulation of the renin angiotensin system: eight patients (49 +/- 13 years, mean arterial BP (MAP) 123 +/- 8 mmHg) with primary aldosteronism (active renin less than 5 pg/ml, group 1) and nine patients (38 +/- 17 years, MAP: 107 +/- 13 mmHg) with renovascular hypertension and high level of active renin (greater than 25 pg/ml, group 2). They had not taken any antihypertensive treatment since at least one week. After 60 minutes in the supine position (T0) nicardipine was infused at a rate of 7.5 mg/h during 10 minutes (T10), 15 mg/h from the 10th to 20th minute (T20) and 30 mg/h during the last ten minutes (T30). Thus, a total cumulative dose of 8.75 mg was administrated in 30 minutes. BP was recorded by an indirect oscillometric method (Sentrom) every 2 minutes and renin was assayed through an immuno-radiometric procedure (IRMA). There was an important and similar BP fall in the 2 groups (Gr 1: T10-6 p. 100, T20-17 p. 100, T30-25 p. 100; Gr 2: T10-7 p. 100, T20-13 p. 100, T30-18 p. 100) with a very significant dose-effect relation (r = 0.67, p less than 0.001). There was also an important increase in heart rate similar in the 2 groups (+35 p. 100, +25 p. 100, ns).(ABSTRACT TRUNCATED AT 250 WORDS)

Objetivo. Resumir la evidencia científica sobre las altera-ciones renales asociadas con la infección por SARS-CoV-2. Material y métodos. Se realizó una revisión rápida con la metodología Cochrane. Resultados. La enfermedad renal crónica (ERC) preexistente en pacientes con SARS-CoV-2 varió de 1 a 38% y la lesión renal aguda (LRA), de 2.9 a 86.4%. El pronóstico de la infección fue peor en pacientes con ERC y en aquellos con reserva renal remanente (RRR) intacta que desarrollaron LRA. El riesgo de muerte fue mayor (riesgo relativo combinado = 1.49; IC95%: 1.09-2.04) en pacientes infectados por SARS-CoV-2 con ERC preexistente. Los mar-cadores de RRR mostraron alteraciones en pacientes con SARS-CoV-2 graves y fatales; el marcador más utilizado fue la creatinina sérica. Conclusiones. La evidencia científica muestra la relevancia de la evaluación y monitoreo perma-nente de la RRR en pacientes hospitalizados por SARS-CoV-2 para mejorar el pronóstico de aquellos con ERC preexistente, así como de aquellos sin ERC que desarrollan LRA.

[Hyperglycemia controlled with GIK solution in non-diabetic patients subjected to heart surgery].

We prospectively compared, the glucose-insulin-potassium (GIK) solution 1,000 mL 10% glucose, 20 units of fast acting insulin and 60 mEq of potassium chloride, against a GIK solution with 1,000 mL of glucose, 40 units of fast acting insulin an 120 mEq of chloride, in the hyperglycemic control of non-diabetic patient subjected to cardiac surgery. We divided 40 patients in four groups ten patients each. Group A was the control they received 1,000 mL of 10% glucose in water, 20 units of fast acting insulin and 60 mEq of potassium chloride in a drops/ hour dose without an infusion pump. Group B received the same solution in a 50 mL/hour dose. Group C received 1,000 mL of 10% glucose in water, 40 units of fast acting insulin plus, 120 mEq of potassium chloride at the same infusion rate as Group A. Group D 2 1,000 mL of 10% of glucose in water, 40 units of fast acting insulin in the same rate as Group B. The GIK solution was started after anesthesia induction and maintained all along the extracorporeal circulation, the study continued until the patient was transferred to the intensive care unit. We measured blood glucose, circulating insulin and seric levels of potassium three times; basal before the anesthetic induction, during the extracorporeal circulation and at the intensive care unit arrival. The data were analyzed with measure of central tendency, dispersion and multivariate analysis. Among the four groups no statistically significant differences existed in demographic data. In Group A, glucose and potassium levels were higher as compared with the rest of the groups (p <0.05) in all measurements; Group D was less hyperglycaemic as compared with Groups A, B, and C. The solution with low insulin dose does useful plasmatic insulin levels in the hyperglycemia in non diabetic patients subjected to cardiac surgery.

A call for implementation of the Law 2120 against junk food during pandemic times in Colombia

Durante dos años y medio, tanto en Colombia como en el resto del mundo, hemos enfrentado la pandemia generada por el SARS-CoV-2, agudizando los múltiples problemas de salud pública que venían cursando a manera de sindemias. Tal es el caso de las enfermedades crónicas no transmisibles asociadas, entre otros factores, a los malos hábitos alimenticios, especialmente por el gran consumo de alimentos ultraprocesados y bebidas azucaradas. En julio del 2021, se aprobó la Ley 2120, por medio de la cual se adoptaron medidas para fomentar entornos alimentarios saludables. Entre estas medidas, también se promueve que los alimentos empacados, procesados y que afectan negativamente la salud humana, tengan un sello que identifique sus componentes y valor nutricional para informar a los consumidores sobre el producto que están comprando o consumiendo. Entre las enfermedades más prevalentes en Colombia que afectan la salud bucal, se encuentran las caries y las periodontitis, ambas con factores de riesgo comunes con las enfermedades crónicas no transmisibles. Dados sus costos y prevalencia, dichas enfermedades crónicas no transmisibles resultan primordiales desde un enfoque de gestión del riesgo en salud pública, siendo, quizá, su gravedad mayor durante la pandemia generada por el SARS CoV-2. Asimismo, se especula que la población confinada pudo llegar a consumir más comida chatarra durante la pandemia del COVID-19 en comparación con otros períodos, además, porque en aquellos con enfermedades crónicas no transmisibles, el confinamiento obligado se asocia con mayor sedentarismo y con un menor número de controles médicos regulares, asuntos que se han reportado previamente. La promulgación de la ley de comida chatarra no va a cambiar los hábitos de alimentación de los colombianos "de la noche a la mañana" y, por esto, se necesita con urgencia implementar procesos de educación y sensibilización frente a los efectos adversos de los alimentos procesados y ultraprocesados en la salud.

[Restoration of insulin sensitivity after correction of hypokalemia due to chronic tubulopathy in a diabetic patient].

In a type II diabetic patient presenting with chronic hypokaliemia secondary to a selective renal tubulopathy, insulin sensitivity was explored three times during a euglycemic hyperinsulinemic clamp procedure at two rates of insulin infusion: 1 and 10 mU/kg/min: once before treatment of hypokaliemia and once after successful correction of hypokaliemia with indomethacine or spironolactone. During insulin infusion, a 20% dextrose solution was infused by a Biostator in order to maintain the patient's glycemia at 90 mg/dl. Amounts of glucose infused during the last 20 min of each 2 hour insulin infusion were (at 1 and 10 m/kg/min respectively): before treatment (K+ = 2.7 mmol/l): 2.4 and 8.4 mg/kg/min; after spironolactone (K+ = 3.9 mmol/l): 3.3 and 15.4 mg/kg/min; after indomethacine (K+ = 3.7 mmol/l): 5 and 19 mg/kg/min after stopping drugs (K+ = 2.9 mmol/l): 2.5 and 5.3 mg/kg/min. These data suggest that potassium metabolism plays a critical role in the mechanisms of insulin sensitivity.

Topical Versus Oral Metronidazole After Excisional Hemorrhoidectomy: A Double-Blind Randomized Controlled Trial.

Both topical and oral metronidazole have been shown to reduce pain after excisional hemorrhoidectomy. Although recent meta-analyses have demonstrated efficacy against placebo, there has been no comparison between the 2 routes. This study aims to investigate whether topical or oral metronidazole provides the most analgesic properties after excisional hemorrhoidectomy. A prospective, double-blind, randomized controlled trial was performed. This trial was conducted at 2 hospitals in New Zealand between March 2019 and February 2020. Adults undergoing elective excisional hemorrhoidectomy for grade III/IV hemorrhoids were randomized. Participants were randomized to receive either topical metronidazole ointment and an oral placebo versus oral metronidazole with a placebo ointment for 7 days. The primary outcome was daily pain scores for 7 days, estimated using a generalized linear mixed model fitted with time and treatment arm and tested for interaction with time and treatment arm. Secondary outcomes included additional analgesia, return to normal activity, recovery scores, and adverse effects. A total of 120 participants were included, with 60 in each group. A unimodal peak of pain was recorded with the maximum at days 3 and 4, but there was no significant difference in resting pain scores, with a mean difference at day 3 of 0.47 (-0.48, 1.42). There were no significant differences for secondary outcomes. Fourteen (11.7%) participants were readmitted, without significant difference between groups. Fifty-nine percent of participants preferred topical analgesic compared with 31% who preferred oral and 9.7% who had no preference. This was a pragmatic study in which we could not have stopped participants seeking other analgesics and with less than perfect complete compliance. Postoperative oral and topical metronidazole provide similar analgesia after excisional hemorrhoidectomy. The route should depend on patient preference, with topical administration potentially benefiting from improved antimicrobial stewardship and having less effect on the gut microbiome. See Video Abstract at http:/links.lww.com/DCR/B853 .METRONIDAZOL TÓPICO VERSUS ORAL DESPUÉS DE UNA HEMORROIDECTOMÍA POR ESCISIÓN: UN ENSAYO CONTROLADO ALEATORIO DOBLE CIEGO. Se ha demostrado que tanto el metronidazol tópico como el oral reducen el dolor después de una hemorroidectomía por escisión. Aunque los metaanálisis más recientes han demostrado eficacia frente al placebo, no ha habido comparación entre las dos vías. Este estudio tiene como objetivo investigar si el metronidazol tópico u oral proporciona las propiedades más analgésicas después de una hemorroidectomía por escisión. Se realizó un ensayo prospectivo, controlado, aleatorio, a doble ciego. Este ensayo fue realizado en dos hospitales de Nueva Zelanda entre marzo de 2019 y febrero de 2020. Se asignaron al azar pacientes adultos sometidos a hemorroidectomía por escisión electiva por hemorroides de grado III / IV. Los participantes fueron asignados al azar para recibir un ungüento de metronidazol tópico y un placebo oral versus metronidazol oral con un ungüento de placebo durante siete días. El resultado primario fueron las puntuaciones diarias de dolor durante siete días, estimadas mediante un modelo lineal mixto generalizado ajustado tanto con el tiempo y el brazo de tratamiento y probado para la interacción con el tiempo y el brazo de tratamiento. Los resultados secundarios incluyen analgesia adicional, retorno a la actividad normal, puntuaciones de recuperación y efectos adversos. Se incluyó un total de 120 participantes, 60 en cada grupo. Se registró un pico de dolor unimodal con el máximo en los días 3 y 4, pero no hubo diferencias significativas en las puntuaciones de dolor en reposo, con una diferencia media en el día 3 de 0,47 (-0,48, 1,42). No hubo diferencias significativas para los resultados secundarios. Catorce (11,7%) participantes fueron readmitidos, sin diferencias significativas entre los grupos. El cincuenta y nueve por ciento de los participantes prefirió el tópico, en comparación con el 31% por vía oral y el 9,7% sin preferencia. Este fue un estudio pragmático en el que no pudimos haber impedido que los participantes buscaran otros analgésicos, con un cumplimiento completo menos que perfecto. El metronidazol posoperatorio por vía oral o tópica proporciona una analgesia similar después de una hemorroidectomía por escisión. La vía debe depender de la preferencia del paciente, y la administración tópica se beneficia potencialmente por una mejor protección de los antimicrobianos y un menor efecto sobre el microbioma intestinal. Consulte Video Resumen en http://links.lww.com/DCR/B853 . (Traducción-Dr Osvaldo Gauto).

[Perioperative management of the diabetic patient in cardiac surgery with extracorporeal circulation].

The hyperglycemia usually observed in patients undergoing heart surgery with extracorporeal circulation (EC) represents a difficult therapeutic problem. We studied the effects of several regimens of insulin therapy on serum glucose (SG) in 24 noninsulin dependent diabetic patients (NIDDs). The patients were randomly divided in five groups; group A received on IV bolus of 10.0-50.0 U/h according to glycosuria; groups B, C, D and E were given a continuous iv insulin infusion of 2.5, 5.0, 7.5 and 10.0 U/h respectively. In 10 non-diabetic patients (NDP) SG levels were also measured, but insulin was not given. A mean of 5.0 l/m2 of body surface of fluids containing 300 g of glucose were administered to all patients during surgery. At the operations SG levels rose progressively soon after the anesthesia was started, reached the highest values during the period of EC, and decreased slowly in blood samples taken after the EC phase and by 24h. This patterns was shown by all groups studied statistically significant lower SG levels, however, were observed in patients of group C, whose values were similar to those seen in the NDP group. Groups D and E had slightly higher SG levels than those of group C. An additional NIDDM patient with advanced chronic renal failure (CRF), had a tendency to hypoglycemia even during the EC period in response to relatively low doses of insulin (2.5 U/h), given by a continuous iv infusion and, although the insulin administration was stopped, his SG levels remained well below the mean values of the other patients for the rest of the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Implementation of an Enhanced Recovery Protocol Is Associated With On-Time Initiation of Adjuvant Chemotherapy in Colorectal Cancer.

Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. The study was conducted at a large academic medical center. All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). The study was limited by its retrospective and nonrandomized before-and-after design. Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACIÓN DE UN PROTOCOLO DE RECUPERACIÓN ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CÁNCER COLORRECTAL:: El inicio tardío de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cáncer colorrectal. Los protocolos de recuperación acelerada colorrectales dan lugar a una disminución de las complicaciones y la duración de estancia hospitalaria; sin embargo, el impacto de la recuperación acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administración a tiempo de la quimioterapia adyuvante después de la cirugía de cáncer colorrectal, con la hipótesis de que la implementación de un protocolo de recuperación acelerada daría lugar a que más pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administración de quimioterapia adyuvante a tiempo después de la resección del cáncer colorrectal antes y después de la implementación de un protocolo de recuperación acelerada.Centro médico académico grande.Todos los pacientes que se sometieron a resecciones de cáncer colorrectal no emergentes con intención curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenían indicación de quimioterapia adyuvante, que recibieron quimioterapia sistémica preoperatoria o no tenían registros médicos de oncología disponibles.Los pacientes se compararon antes y después de la implementación de la recuperación acelerada, con la tasa de administración de quimioterapia adyuvante a tiempo como el resultado primario. La administración de quimioterapia adyuvante se consideró a tiempo si se inició ≤8 semanas después de la operación, y el tratamiento se consideró retrasado / omitido si se inició> 8 semanas después de la operación (retrasado) o nunca fue recibido (omitido). La regresión logística multivariable identificó predictores de administración de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusión, con 189 (52.1%) pacientes sometidos a cirugía después de la implementación de recuperación acelerada. Los grupos difirieron en el abordaje laparoscópico y la duración media del procedimiento; ambos factores fueron mayores después de la recuperación acelerada. Significativamente más pacientes recibieron quimioterapia a tiempo después de la implementación de recuperación acelerada (p = 0.007). La recuperación acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseño retrospectivo, tipo ¨antes y después¨ no aleatorizado.La recuperación acelerada se asoció con la recepción de quimioterapia adyuvante a tiempo. Debido a que el inicio rápido de la quimioterapia adyuvante mejora la supervivencia en el cáncer colorrectal, en el futuro será necesario investigar los resultados oncológicos a largo plazo para evaluar el impacto potencial de la recuperación acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

[Intravenous calcitriol in the treatment of the refractory secondary hyperparathyroidism of terminal chronic kidney failure].

In advanced cases of secondary hyperparathyroidism (HPT) in terminal chronic renal failure, the oral treatment of calcitriol is not possible due to the development of hypercalcemia. It has been demonstrated that calcitriol directly inhibits the secretion of parathormone (PTH), independently of calcium. Therefore the intravenous administration of high and intermittent doses of calcitriol (ivVD) has been proposed as an alternative treatment for resistant HPT. The response of PTHi to treatment over 6 months with ivVD was evaluated in 18 patients with moderate-severe HPT resistant to the classical schedules. An important decrease was observed in the PTHi values (basal: 698 +/- 277 pg/ml, end of treatment: 272 +/- 200; p < 0.05). Alkaline phosphatase values followed a parallel course (basal: 476 +/- 286 U/l, end of treatment: 301 +/- 276 U/l, p < 0.05). Fifty-five percent of the patients presented hypercalcemia at some time (Ca > or = 11.5 mg/dl) being controlled by a decrease in the doses of calcitriol or calcium in dialysis fluid. No response was observed in 3 patients (17%) with treatment being discontinued due to presentation of uncontrollable hypercalcemia. The administration of intravenous calcitriol at high and intermittent doses is effective in a considerable number of patients with hyperparathyroidism resistant to the classical oral schedules. Its use may avoid surgical parathyroidectomy in some cases.