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There is currently a degree of divergence among the main clinical practice guidelines on the management of risk factors for peripheral arterial disease (PAD). This project aims to gain understanding of the management of PAD risk factors in clinical practice and to reach a multidisciplinary consensus on the strategies to be followed in order to optimize its identification, treatment, and follow-up.A multidisciplinary consensus following the Delphi methodology.Professionals (n = 130) with extensive experience in PAD participated in this consultation. The results suggest that in order to optimize the control of risk factors, efforts should be aimed at: (1) promoting the involvement and awareness of all specialists in the identification of and screening for the disease; (2) guaranteeing the possibility of evaluating the ankle-brachial index (ABI) in all the medical specialties involved; (3) promoting strategies for patients to quit smoking through the use of drugs, programs, or referrals to specialized units; (4) promoting an appropriate Mediterranean-based diet and the prescription of daily exercise; (5) raising awareness of the importance of ensuring LDL cholesterol values below 70 mg/dL, especially in symptomatic but also in asymptomatic patients (55 mg/dL following the publication of the ESC/EAS guide); (6) recommending the use of antiplatelet therapy in asymptomatic patients with diabetes mellitus (DM) and/or a pathological ABI; and (7) protocolizing the annual evaluation of ABI in high-risk patients.This document presents the 22 agreed-upon strategies which are intended to help professionals optimize multidisciplinary management of PAD risk factors.

Greater population life expectancy and consistent improvement in diagnostic techniques have increased the diagnosis of abdominal aortic aneurysms (AAAs) in the elderly population. The aim was to study the natural history of small (55 mm) incidental AAAs in octogenarian and nonagenarian patients to assess the need for follow up and/or invasive treatment.This was a retrospective analysis of a prospective registry. Patients ≥ 80 years old at the time of diagnosis of a55 mm AAA in 1988-2018 were selected. Clinical and anatomical characteristics were registered. Patients were divided in three groups: 30 - 39 mm, 40 - 49 mm, and 50 - 54 mm AAA. The outcome variables were aorto-iliac rupture, AAA reaching a surgical threshold (≥ 55 mm), and death. A descriptive statistical analysis was performed and life tables, Kaplan-Meier curves, and uni- and multivariable Cox regression were used.Three hundred and ten patients were included, 256 (82.6%) men, with mean index age of 84.5 years (standard deviation [SD] 3.5), and median follow up of 37.9 months (interquartile range [IQR] 18.2 - 65.4). Eighteen (5.8%) AAAs ruptured; four of these patients were operated on and only one survived. Sixty-two (20%) AAA reached a surgical size; eight were repaired electively, with 0% early mortality. The survival rates were 81%, 70%, and 38% at one, two, and five years. The rupture rates were 1%, 2%, and 6% and the AAAs reaching surgical threshold were 1%, 4%, and 19% for the same time periods. AAA size40 mm was an independent protective factor from rupture (0.13; 95% confidence interval [CI] 0.03 - 0.48), reaching surgical threshold (0.08; 95% CI 0.04 - 0.16) and death (0.63; 95% CI 0.42 - 0.95).The risk of late rupture of small incidental AAA diagnosed in octogenarian and nonagenarian patients is very small, especially when the AAA is40 mm in diameter. In contrast, global mortality is high. Conservative management seems sensible, with strict selection of the patients who would benefit from follow up and eventual repair.

Oral immunotherapy is a common treatment in cow’s milk protein allergy. The Department of Pediatric Allergology at the Children’s Hospital of Zaragoza performed a retrospective analysis of 335 infants under 1 year of age diagnosed with IgE-mediated cow’s milk and early treated. Clinical evaluation, skin prick test, and serum-specific IgE level control were performed before starting and after finishing treatment. Upon completion of treatment, more than 98% of patients became tolerant to milk and no one presented serious adverse reactions. Nowadays, the remaining non-tolerant patients (1.8%) can take milk or derivatives daily—as prophylaxis—to a certain maximum dose and still remain asymptomatic. After immunotherapy, both positive skin prick tests and a progressive decrease in specific IgE levels were found, as desensitization to milk increased. Conclusion: Oral immunotherapy is a safe and effective treatment against allergy to cow’s milk proteins in infants. Such treatment should be offered to the children’s families from the first moment of diagnosis.

Ensayo clínico controlado diseñado con el objetivo de disminuir la elevada prevalencia de lesiones de ligamento cruzado anterior en el fútbol femenino. Se implementó un programa específico de prevención de lesiones, obteniéndose mejoras significativas en la capacidad funcional y en la incidencia de lesiones en las jugadoras.

Acute mastoiditis is an infection that affects the mastoid air-cell system, usually due to the progression of an acute otitis media. The bacteria most frequently isolated in acute mastoiditis are Streptococcus pneumoniae, Streptococcus pyogenes and Staphylococcus aureus. The mastoid infection can extend affecting contiguous structures and producing intra or extracranial complications. The most frequent ones are intracranial complications, including meningitis, temporal lobe or cerebellar abscess, epidural or subdural abscess and venous sinus thrombosis. We present the case of a 4-year-old girl who developed two intracranial complications (intracranial epidural abscess and transverse and sigmoid sinus thrombosis) initiated in an acute mastoiditis produced by Streptococcus pyogenes.

We present software routines for simulating the transport of thermal neutrons through materials relevant for neutron instrumentation. The elastic interactions in different types of textured polycrystals are modelled and implemented in the routines. Three limit cases of textures are explicitly considered: powder texture, with uniform distribution of grain orientations, mosaic single crystal texture, with a distribution of orientations sharply peaked about one direction, and ideal fibre textures. Sharp textures can be modelled as combinations of these three limit textures. For polycrystals with mild textures, a different method is used. The inelastic scattering is treated in the incoherent approximation, including multi-phonon terms of arbitrary large order. The routines have been implemented in the McStas software package., We acknowledge Grant No. PGC-2018-099024-B-I00 from Spanish Ministry of Science Innovation and Universities and funding from the project I-COOP B20319. This work was performed within the world class Science and Innovation with Neutrons in Europe 2020 (“SINE2020”) project, funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 654000.

The main clinical manifestation of human herpesvirus 6 is exanthema subitum (also known as roseola infantum) and febrile syndrome. Central nervous system manifestations are not unusual in herpesvirus 6 infection, and even though the pathophysiology is not clear, they need to be early diagnosed and treated in order to avoid potentially serious damage. We present the case of an immunocompetent 2-year-old girl with encephalitis as a complication of herpesvirus 6 infection. We want to emphasize the significance of an early diagnosis and treatment in order to prevent further complications due to the central nervous system extension.

Mutations in BRCA1 or BRCA2 define a subset of prostate cancer patients. Herein, we address the question whether BRCA1/2 mutations have a predictive impact on chemotherapy with docetaxel, a widely used drug in patients with metastatic castration resistant prostate cancer (mCRPC). Fifty-three men treated with docetaxel for mCRPC were tested for somatic BRCA1/2 mutations of the primary tumor. In a subgroup of patients, BRCA1/2 protein expression was tested as a potential surrogate marker for BRCA1/2 inactivation. Eight of 53 patients (15.1%) harbored a deleterious BRCA2 mutation. No BRCA1 mutation was found. Patients with a BRCA2 mutation showed a response rate of 25% to docetaxel in comparison to 71.1% in men with wildtype BRCA2 (p = 0.019). While the time to develop castration resistance was similar in both subgroups, the overall survival was significantly shorter in patients harboring a BRCA2 mutation. No correlation between the BRCA1/2 protein expression and the response to docetaxel was found. While the presence of a BRCA2 mutation does not preclude a response to docetaxel, there is overall a significant correlation between BRCA2 inactivation and a poor response rate. Our results suggest that a close oncological monitoring of patients with BRCA2 mutations for taxane resistance is warranted.

Das ultimative Ziel einer personalisierten onkologischen Therapie von Prostatakarzinompatienten beruht auf zwei wichtigen Voraussetzungen: zum einen der Entwicklung praklinischer (aber kliniknaher) Modellsysteme, zum anderen der Verfeinerung und Implementierung robuster und aussagekraftiger prognostischer und pradiktiver biologischer Marker. In den letzten Jahren konnten deutliche Fortschritte im grundlagenwissenschaftlichen Bereich gemacht werden, um diesen beiden Voraussetzungen naher zu kommen. Diese Entwicklungen sollen im Folgenden umrissen und anhand einiger herausragender Beispiele naher erlautert werden.

Gestational alloimmune liver disease, previously known as neonatal hemochromatosis, is characterized by severe liver disease in neonatal period, associated with intra and extrahepatic iron accumulation. It is postulated an alloimmune origin, which has opened new opportunities in the treatment and prevention during risk pregnancies, changing the prognosis of this pathology. We report the case of a newborn that presents early liver failure, with clinical and analytical features compatible with gestational alloimmune liver disease. Exchange transfusion was made and gamma globulins were given, with good clinical evolution.

SummaryBackgroundIf carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA.MethodsBetween 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3–2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6–11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392.Findings1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1% vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4–3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0–7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7–9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43–0·68, p

ANEURISMA DE LA VENA MESENTERICA SUPERIOR. CASO CLINICO Y REVISION DE LA BIBLIOGRAFIA Resumen. Introduccion. Los aneurismas venosos del sistema porta y mesenterico son extremadamente raros y, de estos, los de la vena mesenterica superior los mas infrecuentes. Caso clinico. Mujer de 77 anos de edad a quien se detecta, en un estudio ecografico abdominal, una dilatacion venosa abdominal que, mediante angiorresonancia, se confirma que corresponde a un aneurisma de la vena mesenterica superior. Se trata de forma expectante, con un seguimiento de dos anos, tras los cuales sigue asintomatica y sin cambios en el aneurisma de la vena mesenterica superior. Junto con el caso clinico, presentamos una revision bibliografica con todos los casos publicados. Conclusion. Consideramos que, dada su excepcionalidad, su historia natural es desconocida y que aunque la conducta expectante es la adoptada en la mayoria de los casos, los pacientes deben ser advertidos de las posibles complicaciones, es decir, la trombosis o la rotura del aneurisma venoso, a pesar de que no existe ningun dato objetivo en que basarse para predecir el riesgo de las complicaciones. [ANGIOLOGIA 2009; 61: 95–8]

Therapeutic hypothermia is the current standard treatment in newborns with moderate to severe hypoxic-ischemic encephalopathy, changing the outcome of these children. It is considered a safe technique with almost no side effects. A possible adverse side event is subcutaneous fat necrosis, which is an acute self-limiting panniculitis that develops during the first weeks of life. We report a case of a newborn at term suffering hypoxic-ischemic encephalopathy with a generalized multiform erythematous rash and firm and indurated plaques over the back, buttocks and extremities on his 12th day of life after being treated with therapeutic hypothermia. Histopathological study after skin punchbiopsy confirmed the suspicion of subcutaneous fat necrosis. The infant developed asymptomatic moderate hypercalcaemia within the first month of life, which was treated with intravenous fluids and diuretics. Serum calcium levels decreased and normalized in 3 months, with progressive disappearance of skin lesions.

BACKGROUND: Dermal analogue tumor of the salivary gland is a rare form of salivary gland adenoma. Cytologic and histologic findings of 1 case are presented. CASE: A 74-year-old female had a dermal analogue tumor in the parotid gland diagnosed by fine needle aspiration cytology (FNAC). Aspiration smears were characterized by aggregates of uniform epithelial cells, and cell groups bordered on thick, basement membrane-like material. The tumor was excised, and the histologic sections confirmed the cytologic diagnosis. CONCLUSION: Dermal analogue tumor of the salivary gland has a distinctive cytomorphologic appearance, and diagnosis of this neoplasm by FNAC is possible. Preoperative FNAC of salivary gland lesions is important in planning the most appropriate type of treatment.

Resumen Objetivo Estudiar la variacion a largo plazo del diametro de la aorta supra-anastomotica (ASA) y del cuerpo protesico (CP) implantado tras la reseccion de un aneurisma de aorta abdominal infrarrenal (AAA). Pacientes y metodos. Se estudiaron 91 pacientes, a los que se les realizo una reseccion de un AAA hasta diciembre de 1997. Se midio con TAC (tomografia axial computarizada) preoperatoriamente el diametro de la aorta infrarrenal distal a la arteria renal mas baja. Se midieron el diametro de la ASA y del CP a los 5, 10 y 15 anos de la intervencion. Se estudiaron los factores de riesgo que influyen habitualmente en el crecimiento aortico. Resultados La edad media al intervenirse fue de 67 anos, y eran varones 90 (98,9%). El tiempo de seguimiento medio fue de 99,1 meses ( r = 60-185); el diametro aortico preoperatorio (DAP) medio de 24,2 mm ( r = 18-30), las protesis implantadas tuvieron un diametro medio de 16,4 mm ( r = 14-20). A los 5, 10 y 15 anos, la aorta yuxtaanastomotica presento un crecimiento medio de 4,6 ( r = 0-22), 6,6 ( r = 0-25) y 11,8 mm ( r = 2-22), respectivamente. Solo el DAP influyo de forma significativa en el crecimiento aortico. Las protesis tuvieron un crecimiento medio a los 5, 10 y 15 anos de 6,2 mm ( r = 0-21), 7,1 mm ( r = 0-25) y 13,2 mm ( r = 3-15), respectivamente. No encontramos ningun factor que interviniese de forma significativa en el crecimiento del CP. Conclusion En este estudio solo el DAP interviene de forma significativamente en el crecimiento aortico tras la reseccion quirurgica.

Resumen Introduccion Debido a los buenos resultados obtenidos actualmente con la cirugia convencional o con la tecnica endovascular en el tratamiento de los aneurismas de aorta abdominal (AAA), pensamos que se esta ampliando en ocasiones la indicacion de dicho tratamiento a los AAA pequenos (AAAp). Intentando comparar nuestros resultados con los que consiguieron otros grupos, presentamos el siguiente trabajo. Objetivo Conocer la evolucion de los AAA pequenos, determinar su tasa de crecimiento, numero de roturas y mortalidad. Pacientes y metodos Estudiamos 297 pacientes con AAAp desde enero de 1988 hasta enero de 2000. El 93,3% eran varones y la edad media de 71 anos. Controlamos su crecimiento mediante ecografias periodicas. Dividimos a los pacientes en dos grupos: uno con AAA menores de 4 cm y otro con mayores. El seguimiento concluia cuando se resecaba el aneurisma, fallecian los pacientes o estos finalizaban el estudio. Resultados El seguimiento medio fue de 35,6 meses. La tasa de crecimiento de los AAA menores de 4 cm fue significativamente menor que la de los mayores (1,8 mm/ano frente a 3,5 mm/ano). Se resecaron 43 AAA (14,5%). Fallecieron 85 pacientes (28,6%), pero solo en un caso se debio a la rotura de un AAA pequeno (0,3%). Se perdieron cinco pacientes (1,7%) durante el seguimiento. Finalizaron el estudio 164 pacientes con su aneurisma intacto (55,2%). Conclusiones Los AAAp crecen poco y tienen escasas posibilidades de romperse, por lo que unicamente deben operarse los que dan sintomas, crecen rapidamente o sobrepasen los 5 cm de diametro. [ANGIOLOGIA 2002; 54: 434-45].

arXiv:1406.7743v2, The generation process of second-harmonic radiation from holes periodically arranged on a metal surface is investigated. Three main modulating factors affecting the far-field distribution and the transmission efficiency are identified: the near-field distribution at the wavelength of the driving source (fundamental harmonic), how second-harmonic light couples to the diffraction orders of the lattice, and its propagation properties inside the holes. It is shown that light generated at the second harmonic can excite electromagnetic modes otherwise inaccessible in the linear regime under normal incidence illumination, a singularity of second-harmonic fields that affects the radiation process. For instance, the least decaying transversal electric TE0;1 mode accessible to the external beam is able to generate a superposition of high-order modes (TE1;1 and TM1;1) at the second harmonic. It is demonstrated that the emission of second-harmonic radiation is only allowed along off-normal paths precisely due to that symmetry. In this work, two different regimes are studied in the context of extraordinary optical transmission, where enhanced linear transmission either occurs through localized electromagnetic modes or is aided by surface plasmon polaritons (SPPs). While localized resonances in metallic hole arrays have been previously investigated, the role played by surface plasmons in second-harmonic generation has not been addressed so far. In general, good agreement is found between our calculations (based on the finite difference time domain method) and the experimental results on localized resonances, even though no free-fitting parameters were used in describing the materials. It is found that second-harmonic emission is strongly modulated by enhanced fields at the fundamental wavelength (either localized or surface plasmon modes) on the glass–metal interface. This is so in the transmission side but also in reflection, where emission can only be explained by an efficient tunneling of secondharmonic photons through the holes from the output to the input side. Finally, the existence of a dark SPP at the fundamental field is identified through a noninvasive method for the first time, by analyzing the efficiency and far-field pattern distribution in transmission at the second harmonic., We acknowledge support from the Spanish Ministry of Science and Innovation under projects MAT2011-28581-C02 and CSD2007-046-Nanolight.es.

255 p. El fallo hepático fulminante es un síndrome clínico muy grave resultante de la necrosis hepática y del fallo funcional del parénquima hepático, de rápida progresión. La regeneración hepática es también una respuesta fundamental del hígado ante el daño tisular y se considera que el índice de regeneración hepática puede ser crítico en el pronóstico de estos pacientes. Sin embargo, no existen terapias disponibles capaces de estimular la regeneración. La melatonina es una molécula que posee una gran capacidad de atravesar membranas lipídicas por difusión simple y es un potente depurador de radicales libres. Sus efectos protectores han sido ampliamente estudiados en diferentes modelos experimentales de enfermedades hepáticas. Por todo ello, en este estudio el principal objetivo ha sido comprobar el posible efecto protector de la administración de melatonina en conejos infectados con el virus de la enfermedad hemorrágica del conejo, modelo animal de fallo hepático fulminante de etiología vírica. Para ello se ha tratado de estudiar sus efectos sobre el estrés oxidativo, la apoptosis y la inflamación en el FHF producido por el virus de la enfermedad hemorrágica del conejo, así como sobre la regeneración hepática en los conejos infectados

We present the case of a 77-year-old man with oral haemorrhage and blood clots, with no cough or vomiting. A varicose lesion in the valleculae was established as the source of bleeding. The condition of the patient was haemodynamically unstable. Bleeding was successfully controlled through suture and diathermy. From that time, there have been no further episodes of bleeding.

espanolObjetivos: Evaluar a largo plazo los resultados tensionales de la trabeculectomia en pacientes sin factores de riesgo previo y comparacion segun tipo de glaucoma y tratamiento medico previo. Metodos: Se realizo un estudio retrospectivo de 965 casos intervenidos de trabeculectomia simple sin factores de riesgo previos. Seguimiento de 3 a 20 anos. Los datos se recogieron al dia siguiente, semana, al mes, 3, 6 meses y cada ano despues de la intervencion hasta la ultima exploracion realizada. Se incluyeron pacientes con glaucoma primario de angulo abierto (GPAA) (671 ojos), pseudoexfoliativo (GPSX) (156 ojos), y cronico de angulo cerrado (GCAC) (138 ojos). Definimos exito absoluto: presion intraocular (PIO) ≤ 21 mm Hg sin tratamiento medico y exito relativo: PIO ≤ 21 mm Hg sin tratamiento medico o con 1 o 2 colirios (principios activos). Resultados: La presion intraocular media se mantuvo entre 15 y 17 mm Hg. El descenso tensional medio se encontro entre 8,87 y 10,57 mm Hg. El porcentaje de descenso medio se cifro entre un 30,70% y un 37,40%. El exito relativo a los 10 anos fue mejor para el GPAA y el exito absoluto fue similar para el GPAA y GPSX en el mismo tiempo. El grupo de pacientes que menor numero de colirios se administraba antes de la cirugia fue el que presento un mayor exito relativo y absoluto. Conclusion: La trabeculectomia simple es una tecnica quirurgica eficaz en el control tensional a largo plazo, mostrando una mejor resultado en pacientes con GPAA y con menor tratamiento medico previo. EnglishObjectives: To evaluate long-term intraocular pressure results after trabeculectomy in low risk patients. Therefore differences among glaucoma type and previous medical treatment will be evaluated. Methods: A retrospective follow-up study, ranging between 3 and 20 years, was carried out on 965 trabeculectomy surgeries without any surgical- failure factor. Follow-up was carried-out one day, one week, one month, three months, six months and annually after surgery until the last visit. Primary open angle (POAG) (671eyes), pseudoexfoliative (PSXG) (156 eyes) and chronic closure angle glaucomas (CCAG) (138 eyes) were included. IOP under 21 Hg mm without medical treatment was considered absolute success, relative success included those eyes with pressures under 21 and one or two daily antiglaucomatous drops. Results: Mean IOP ranged between 15 and 17 Hg mm. Mean IOP decreased from 30.7 to 37.4%. Relative success ten years after surgery was better in POAG; whereas absolute success resulted to be similar in POAG and PSXG. The group of patients less treated before surgery showed greater rate of absolute and relative success. Conclusions: Trabeculectomy alone is an efficient technique in long-term tensional control for uncomplicated eyes. The group of patients less treated before surgery and POAG showed greater rate success.

espanolCaso clinico: Paciente varon que con 30 anos tuvo el primer episodio de enfermedad de Coats y recurrencia 14 anos mas tarde. Clinicamente ambos episodios tienen como sintoma de inicio vision borrosa y exploracion tipica de exudacion masiva retiniana con corona de exudados duros. La angiografia presenta hallazgos caracteristicos de telangiectasia retiniana con dilatacion anormal de vasos con hiperfluorescencia precoz y fuga tardia. Discusion: Coats es una entidad clinica poco frecuente y con grado de severidad variable, que hacen dificiles los estudios randomizados prospectivos. Pese a los hallazgos caracteristicos, hay que descartar otros diagnosticos tanto en el nino como en el adulto causantes de esa misma clinica. EnglishCase report: A male diagnosed with Coats disease at the age of 30 years, had a relapse of this condition 14 years later. His first symptom of blurred vision occurred in both episodes and similar findings of unilateral retinal exudation and lipid deposition at boundary were seen. Angiography showed the characteristic early hyperfluorescence of the telangiectasias and late leakage of dye. Discussion: Coats disease is relatively uncommon and, as the degree of involvement varies from case to case, a randomized, prospective study of treatment would probably not be feasible. Despite the characteristic features of this disease, the differential diagnoses must be considered in both children and adults

Hemorrhage from the valleculae Abstract We present the case of a 77-year-old man with oral hemorrhage and blood clots, with no cough or vomiting. A varicose lesion in the valleculae was established as the source of bleeding. The condition of the patient was haemodynamically unstable. The bleeding was successfully controlled through suture and diathermy. From that time, there have been no further episodes of bleeding. & 2009 Elsevier Espana, S.L. All rights reserved.