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While relatively new, fetal surgery has become an indispensable part of the field of Obstetrics as it allows potentially life-threatening conditions to be corrected in utero. Imaging modalities such as ultrasound, magnetic resonance imaging, and computer tomography have become staples in fetal imaging, as they allow for comprehensive analysis of the fetal anatomy. Uses of these modalities can range from chromosomal diagnosis to surgical planning. Scientific development has not only allowed for visualization in the three-dimensional plane, but the implementation of virtual reality technology is also now a possibility. It is our belief that integrating virtual reality technology will help overcome hurdles currently faced by fetal surgeons including candidate selection and clearly observing fetal anatomy. Training opportunities are also probably, as surgeons and residents can use models created during these virtual reality experiences to study and prepare for complications that may arise during surgical intervention. This article is protected by copyright. All rights reserved.

Resumen La amiloidosis cardiaca relacionada con el deposito de transtirretina (ATTR) ha sido tradicionalmente considerada como una enfermedad rara, de dificil diagnostico y sin tratamiento. Sin embargo, en la actualidad sabemos que su prevalencia es mayor de la considerada, disponemos de metodos diagnosticos no invasivos y estan apareciendo tratamientos eficaces. En este contexto, la gammagrafia cardiaca (GC) con difosfonatos marcados con 99mTc ha alcanzado un inusitado interes al mostrar alta sensibilidad y especificidad para el diagnostico no invasivo y fiable de la ATTR. Este articulo, a modo de guia, pretende identificar los componentes criticos en la realizacion de la GC que resulten de utilidad en la practica clinica diaria y, asi, ayudar a los especialistas a utilizar los radiofarmacos idoneos, obtener las imagenes mas adecuadas, interpretar los resultados de estas y conocer los escenarios clinicos en los que resulta apropiado realizar la GC.

Transthyretin cardiac amyloidosis (ATTR) has traditionally been considered a rare, difficult-to-diagnose and untreatable disease. However, its prevalence is known to be greater than what was previously thought, non-invasive diagnostic methods are available, and that effective treatments are emerging. In this context, cardiac scintigraphy (CS) with 99mTc-labeled diphosphonates has aroused a noticeable surge in interest by demonstrating high sensitivity and specificity for the reliable, non-invasive diagnosis of ATTR. By way of a guide, this article aims to identify the critical components in the performance of CS that are useful in everyday clinical practice and, thus, help specialists use optimal radiopharmaceuticals, obtain the most appropriate images, interpret the results thereof, and acquaint themselves with those clinical scenarios in which it is convenient to perform CS.

espanolLa obtencion de imagenes de la inervacion simpatica cardiaca solo es posible mediante tecnicas de cardiologia nuclear, y su valoracion es de importancia decisiva en la evaluacion y en la toma de decisiones en pacientes en los que exista deterioro de inervacion simpatica. Se revisa el fundamento de la gammagrafia de inervacion simpatica cardiaca con 123I-metayodobencilguanidina (123I-MIBG), los protocolos recomendados para su realizacion, incluyendo preparacion del paciente, tecnicas de obtencion y cuantificacion de imagenes, reproducibilidad, consideraciones dosimetricas, etc., analizando las indicaciones clinicas de esta exploracion en pacientes cardiologicos, principalmente en insuficiencia cardiaca, arritmias, coronariopatia, cardiotoxicidad, contribucion a la indicacion y seguimiento de respuesta a dispositivos de estimulacion cardiaca, tratamiento farmacologico, trasplante cardiaco y otros. EnglishImaging of cardiac sympathetic innervation is only possible by nuclear cardiology techniques and its assessment is key in the evaluation of and decision-making for patients with cardiac sympathetic impairment. This review includes the basis of cardiac sympathetic scintigraphy with 123I-meta-iodobenzylguanidine (123I-MIBG), recommended protocols, patient preparation, image acquisition and quantification, reproducibility, dosimetry, etc., and also the clinical indications for cardiac patients, mainly with regard to heart failure, arrhythmia, coronary artery disease, cardiotoxicity, including its contribution to establishing the indication for and monitoring the response to implantable cardiac devices, pharmacological treatment, heart transplantation and other.

Imaging of cardiac sympathetic innervation is only possible by nuclear cardiology techniques and its assessment is key in the evaluation of and decision-making for patients with cardiac sympathetic impairment. This review includes the basis of cardiac sympathetic scintigraphy with 123I-meta-iodobenzylguanidine (123I-MIBG), recommended protocols, patient preparation, image acquisition and quantification, reproducibility, dosimetry, etc., and also the clinical indications for cardiac patients, mainly with regard to heart failure, arrhythmia, coronary artery disease, cardiotoxicity, including its contribution to establishing the indication for and monitoring the response to implantable cardiac devices, pharmacological treatment, heart transplantation and other.

Resumen La fuga urinaria en los pacientes trasplantados renales es una complicacion quirurgica relativamente frecuente que requiere un diagnostico e intervencion precoces. El renograma isotopico es un metodo no invasivo y efectivo para evaluar la perfusion y funcion del trasplante renal, y nos permite diagnosticar complicaciones urologicas como la fuga urinaria. En estos casos es de gran utilidad completar el estudio con imagenes planares y SPECT/TC tardio para precisar el diagnostico y localizar la fuga. Se exponen 2 casos diagnosticados de fuga urinaria tras realizar renograma con imagenes planares precoz y tardia y SPECT/TC tardio, a la semana de ser sometidos a trasplante. En ambos casos se coloco una sonda de nefrostomia percutanea, asi como un cateter ureteral doble J, resolviendose la complicacion quirurgica.

Urinary leakage in patients with kidney transplantation is a relatively common surgical complication that requires early diagnosis and intervention. The isotopic renogram is a non-invasive and effective method to evaluate the perfusion and function of kidney transplantation, and allows us to diagnose urological complications such as urinary leakage. In these cases, it is useful to complete the study with planar images and delayed SPECT/CT to specify the diagnosis and locate the leak. We expose two cases diagnosed with urinary leak after performing a renogram with early and delayed planar images and delayed SPECT/CT a week after transplantation. In both cases, a percutaneous nephrostomy catheter was placed, as well as a double J catheter, resolving the surgical complication.

The role of the selective sentinel node biopsy (SNB) is increasing in relevance in breast cancer women with indication of neoadjuvant chemotherapy (NAC). The Radiosurgery Working Group of the SEMNIM is aware of the necessity of establishing the need for SNB before or after NAC, and also how to manage patients with axillary node-negative or node-positive. There is sufficient data to assess that the SNB with radioisotope techniques are feasible and safe in all these scenarios. An adequate axilla evaluation prior to surgery and the possibility of marking prior to NAC the nodes infiltrated must be the two main pillars to guarantee the success of the SNB. It has been shown that to incorporate the SNB in breast cancer women with indication of NAC increases the rate of a conservative treatment of the axilla that will be a clear benefit for these patients.

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm.

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm.

Imaging of cardiac sympathetic innervation is only possible by nuclear cardiology techniques and its assessment is key in the evaluation of and decision-making for patients with cardiac sympathetic impairment. This review includes the basis of cardiac sympathetic scintigraphy with

Urinary leakage in patients with kidney transplantation is a relatively common surgical complication that requires early diagnosis and intervention. The isotopic renogram is a non-invasive and effective method to evaluate the perfusion and function of kidney transplantation, and allows us to diagnose urological complications such as urinary leakage. In these cases, it is useful to complete the study with planar images and delayed SPECT/CT to specify the diagnosis and locate the leak. We expose two cases diagnosed with urinary leak after performing a renogram with early and delayed planar images and delayed SPECT/CT a week after transplantation. In both cases, a percutaneous nephrostomy catheter was placed, as well as a double J catheter, resolving the surgical complication.

Background Elderly patients are fragile, pluripatologicsa, chronic, and polytechnic populations. These characteristics added to others such as physiological, pharmacokinetic and pharmacodynamic changes, the attention by various specialists and at levels of care, make them a group that requires special care. There are several criteria to improve the prescription quality in this group of patients, among which we find the STOPP/START criteria. The optimisation of treatments and their adequacy in this group of patients also contemplates aspects such as deprescription, monitoring, dose adjustments or conciliation. Purpose Analysis and determination of the degree of acceptance of pharmaceutical interventions (PI) performed in a third-level hospital in elderly patients. Material and methods Retrospective descriptive study of pharmaceutical interventions performed between January 2016 and August 2017 in patients over 65 years of age. The Farmatool® and Medora®programs have been used to classify the interventions and check the chronic medication prescribed for primary care. The variables recorded were: demographic data of the patient, service involved, drug involved and reason for PI. Interventions were classified as: therapeutic equivalent, conciliation, dose adjustment in elderly patients, allergies, interactions, duplications, pattern changes, adjustment in renal/hepatic insufficiency, conciliation, incomplete medical order and others. In addition, the interventions were analysed to show how many of them met STOPP/START criteria. Apart from that, the acceptance of the interventions was evaluated. Results During the study period, 1,127 PI were recorded in elderly patients with a mean age of 79 years. According to the classification, the following results were obtained: therapeutic equivalent: 158, conciliation: 39, dose adjustment in elderly patients: 159, allergies: 40, interactions: 228, duplicity: 102, renal/hepatic adjustment: 75, incomplete medical orders: 45, others: 281, STOPP/START criteria: 497. The degree of acceptance of the recommendations was 45%. The service with the most interventions was internal medicine. Conclusion There have been a large number of interventions that have helped to avoid medication errors and have increased the quality of care. The participation and intervention of the pharmacist is of great help in the detection and resolution of potential medication errors. References and/or Acknowledgements STOPP/START criteria. No conflict of interest

The role of the selective sentinel node biopsy (SNB) is increasing in relevance in breast cancer women with indication of neoadjuvant chemotherapy (NAC). The Radiosurgery Working Group of the SEMNIM is aware of the necessity of establishing the need for SNB before or after NAC, and also how to manage patients with axillary node-negative or node-positive. There is sufficient data to assess that the SNB with radioisotope techniques are feasible and safe in all these scenarios. An adequate axilla evaluation prior to surgery and the possibility of marking prior to NAC the nodes infiltrated must be the two main pillars to guarantee the success of the SNB. It has been shown that to incorporate the SNB in breast cancer women with indication of NAC increases the rate of a conservative treatment of the axilla that will be a clear benefit for these patients.

Resumen Objetivo Evaluar la influencia del subtipo molecular (SM) en la biopsia del ganglio centinela (BGC) tras quimioterapia neoadyuvante (QTN) en canceres de mama (CM) localmente avanzados y respuesta completa axilar (RCA). Material y metodos Estudio prospectivo de 70 CM tratadas con QTN para cirugia conservadora. Se realizo linfadenectomia axilar en 48 pacientes (fase validacion), y en caso de micro o macrometastasis (fase terapeutica). Clasificadas segun el SM: 14 luminal A, 16 luminal B HER2-, 13 luminal B HER2+, 10 HER2+ no-luminal, 17 triple-negativo. Resultados La BGC se realizo en el 98,6% de los casos, con un falso negativo en la fase de validacion (FN = 2%). El SM no influyo en la deteccion del GC. A pesar de existir RCA, al comparar los cN0 y cN+ preQTN, encontramos diferencias significativas en la proporcion de macrometastasis (16,7% vs. 35,7%, p = 0,043).La respuesta completa del tumor mamario tras QTN vario estadisticamente entre los SM, siendo la mas baja los luminal A (21,5%) y la mas alta los HER2+ no-luminal (80%). El HER2+ y el triple negativo fueron los grupos con mejor respuesta patologica axilar tanto si existia afectacion clinica previa o no. Conclusion El SM es un factor predictivo del grado de respuesta tumoral a la QTN en el CM pero no influye en la deteccion y la eficacia de la biopsia del ganglio centinela. Es seguro utilizar la biopsia del ganglio centinela tambien en mujeres con afectacion ganglionar previa siempre que se realice una completa evaluacion clinica y radiologica de la respuesta ganglionar a la QTN.

Radioguided surgery can be a useful technique in the localization of neuroendocrine tumors. It detects more and smaller lesions compared to pre-surgical imaging and intraoperative digital palpation by the surgeon. It detects residual lesions and also indicates the shortest access route to the lesion. Nevertheless, its use has not become widespread because of technical difficulties. There is a limited number of published series, a lack of standardized protocol because of the great variability regarding type of radiopharmaceutical, dose of radiotracer, timing between injection and surgery. In this paper, we review these issues, describing the experience of different authors in diverse tumors.

Radioguided surgery can be a useful technique in the localization of neuroendocrine tumors. It detects more and smaller lesions compared to pre-surgical imaging and intraoperative digital palpation by the surgeon. It detects residual lesions and also indicates the shortest access route to the lesion. Nevertheless, its use has not become widespread because of technical difficulties. There is a limited number of published series, a lack of standardized protocol because of the great variability regarding type of radiopharmaceutical, dose of radiotracer, timing between injection and surgery. In this paper, we review these issues, describing the experience of different authors in diverse tumors.

AimsA complete clinical response after neoadjuvant chemotherapy (NACT) in breast cancer patients hinders the localization of the residual lesion and the removal of a minimum amount of breast tissue. The aim of the present work is to report our single-centre experience with intraoperative ultrasound-guided (IOUS) excision performed by surgeons in these patients.Patients and methodsFrom January 2008 to December 2012, IOUS excisions were performed on 58 patients with a previous intralesional ultrasound-detectable metallic marker and non-palpable breast cancer after NACT. The specimen margins were estimated by ultrasonography and macroscopic pathologic examination. Successful lesion removal, specimen weight, and analysis of the results as regards margins were evaluated, and the need for breast-conserving re-excision and mastectomy was considered.ResultsAfter NACT the average ultrasound/mammography and MRI diameters were 11.7 mm (0–30) and 9.1 mm (0–40) respectively. In all cases, the residual lesion or tissue around the marker was removed. The average weight of the specimens was 26.4 g (6–84), being lower in cases of complete response according to ultrasound (p

Background Dimethyl fumarate(DMF; Tecfidera) is an oral drug approved in Spain since February 2014 for relapsing remitting multiple sclerosis (RRMS). Oral treatments allow patients a better quality of life than injectable treatments, but are not innocuous. Purpose To assess the safety profile of DMF in RRMS treatment in adult patients in a tertiary hospital. Material and methods This was an observational and retrospective study of patients from a tertiary hospital who began treatment with DMF between February 2015 and March 2016. The studied variables were: age, sex, previous treatment, safety profile (adverse reactions (AR), suspension or dose reduction) and alternative treatment in the event of suspension of DMF treatment. The information was obtained from outpatient dispensing programme registration (Farmatools). AR reported by patients after clinical interview were collected in each dispensation. Results Our study included 40 patients diagnosed with RRMS (9 men/31 women) with a mean age of 37.7 years. 15 were treated with DMF as the firstline treatment, and 25 had previously been treated with: intramuscular interferon-beta-1a (5), subcutaneous interferon-beta-1a (11); subcutaneous interferon-beta-1b (3); subcutaneous glatiramer acetate (6); and oral fingolimod (1). 14 patients did not show AR or these were not mentioned in the interview. 26 patients presented AR in the skin (flushing, itching, eczema) and gastrointestinal symptoms (nausea, vomiting, heartburn, stomach-aches) as well as fatigue and others. 69.23% of patients (18) reported skin disturbances (appearing after taking medication and remitting in 3–4 hours), 69.23% (18) gastrointestinal disorders and 19.23% (5) expressed fatigue, especially at the beginning of treatment. 5 patients suffered other AR: changes in blood glucose levels (2), lymphopenia (1), palpitations (1) and urinary tract infection (1). Several patients presented AR in multiple groups. 50% (13) had both skin and gastrointestinal AR, 15.38% (4) gastrointestinal and fatigue, 7.69% (2) had skin reactions and fatigue and 1 patient suffered three types of AR, which led to discontinuation of treatment. 8 patients required temporary dose reduction, mainly due to digestive AR. 1 patient continues with the reduced dose. The treatment was discontinued in 3 patients because of intolerance and in 1 because of failure. Conclusion DMF is well tolerated. Patients reported mild AR, being more intense as the dose was increased and disappearing with time. However, in some cases they were limiting and did not allow the full dose to be administered or treatment was discontinued. AR are in line with those described in the data sheet and other studies, although increased monitoring is necessary to assess effectiveness and long term safety. No conflict of interest

Background Teriflunomide (TRF) and dimethyl fumarate (DMF) are oral drugs authorised in Spain to treat relapsing remitting multiple sclerosis (RRMS). Purpose To compare the safety profile of both drugs in the treatment of RRMS in adults in a tertiary hospital. Material and methods An observational retrospective study was conducted in patients who began treatment with TRF and DMF from January 2015 to March 2016. Collected variables: age, sex, previous treatment, safety profile (adverse reactions (AR), suspension, reduction of dose) and subsequent treatment in case of withdrawal. The information was obtained from the clinical history and RA record in the Farmatools programme when they came to collect their medication. Results 53 patients were included, 12 men/41 women (mean age 40.59 years). 38 received DMF and 15 TRF. 15 were treated with firstline DMF and 4 with TRF. The main reasons for the change were: poor tolerance, AR at the site of injection and convenience of oral administration. 25 patients showed no AR (35% of patients with DMF and 73% of TRF), or were not mentioned. 26 patients treated with DMF presented AR: skin (redness/eczema), gastrointestinal (nausea/vomiting/burning), fatigue and others. 69.23% of patients (18) reported skin changes which appeared after taking medication and disappeared after 3–4 hours. 69.23% (18) had gastrointestinal disorders, and was the main reason for suspension/dose reduction. 19.23% (5) had fatigue/malaise, especially at the beginning of treatment. 5 patients had other AR, including changes in blood glucose (2), lymphopenia (1), palpitations (1) and possible urinary tract infection (1). 8 patients required dose reduction temporarily. Only 1 patient is continuing with reduced doses. Only 4 patients treated with TRF reported any AR: headache (1), gastrointestinal disorders (2) and alopecia (1). 3 of the 15 patients experienced moderate elevation of liver enzymes. 5 patients discontinued treatment, 3 due to intolerance (DMF) and 2 ineffectiveness (DMF+TRF). They are currently receiving treatment with natalizumab (1), teriflunomide (2) and PegIFN-B1a (2). Conclusion The AR that patients manifested were mild and the majority disappeared with withdrawal of the drugs. However, analysing the percentage of patients who presented AR, we consider that TRF has a better profile for frequency and severity of AR compared with DMF. AR were in line with those described in the data sheet and other studies, although increased monitoring is necessary to assess effectiveness and long term safety. References and/or acknowledgements Thanks to all colleagues who participated in the study. No conflict of interest

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm.

The sentinel lymph node (SLN) biopsy is currently the procedure of choice for axillary node staging in initial stages of breast cancer. The purpose of this study is to establish our false negative rate within a 5-year follow-up period in 258 patients with breast cancer staged with this procedure. Methods A retrospective study on 258 consecutive T1–T2 Results Of the 258 patients, 3 false negatives (1.1%) with axillary recurrence were detected at 10, 11 and 29 months of the surgery. This did not have a significant repercussion in the survival analysis on the contrary to the existence of breast recurrence or the appearance of distant metastasis in 4.7% and 6.2% patients, respectively. Global survival related with the cancer was 93.0 (240/258) and disease free survival was 89.1% (230/258). Conclusion The risk of developing axillary recurrence after a negative SLN without axillary node dissection is low enough to consider the SLN procedure to be the best approach for axilla staging in early breast cancer. This staging technique also makes it possible to achieve local disease control without diminishing the survival of the patients.

Aim To determine the clinical utility of the gated myocardial perfusion SPECT to detect silent ischemia in asymptomatic diabetic patients without previous coronary events and to evaluate the prognosis of this population. Material and methods A retrospective study of 56 asymptomatic diabetics referred for a gated myocardial perfusion SPECT for the diagnosis of ischemic disease was performed. The criteria for ischemia were: mild SDS 8. A multivariable statistical analysis was carried out to identify possible predictive variables of an abnormal SPECT. The cardiovascular events were recorded up to December-2010. Results A high proportion of the 56 patients had an abnormal perfusion study (46.4%), there being moderate–severe ischemia in 10.7%, necrosis with ischemia in 5.4% and necrosis in 7.1%. We found no statistical differences in the type of stress used (treadmill or dipyridamole). The patients had a high combination of cardiovascular risk factors. In the multivariate analysis, diabetic nephropathy was the only factor related to an abnormal SPECT ( p = 0.043). The events recorded in the follow-up were: 2 early revascularizations, 5 cardiology admissions, 10 non-cardiac related deaths. The existence of ischemia in the SPECT was significantly related to the appearance of cardiovascular events ( p Conclusion A gated myocardial perfusion SPECT in asymptomatic diabetics with high combination of cardiovascular risk factors detects silent ischemia in a significant proportion and this seems to be related to future coronary events. Diabetic nephropathy implies a greater likelihood of abnormal studies. However, the screening criteria in this population still need to be established for better performance and lower cost.

Resumen Objetivo Determinar la utilidad clinica de la gated-SPECT de perfusion miocardica en la deteccion de isquemia silente en pacientes diabeticos sin sintomas ni eventos cardiovasculares previos y evaluar implicaciones pronosticas. Material y metodos Estudio retrospectivo de 56 pacientes diabeticos asintomaticos tras una gated-SPECT de perfusion miocardica para diagnostico de enfermedad isquemica. El criterio de isquemia fue: ligera SDS 8. Se realizo un analisis estadistico multivariante para identificar variables predictoras de un estudio anormal y se registraron hasta diciembre de 2010 los eventos cardiovasculares. Resultados Una alta proporcion de los 56 pacientes presento un estudio de perfusion anormal (46,4%), existiendo isquemia moderada-severa en el 10,7%, necrosis con isquemia en el 5,4% y necrosis en el 7,1%. No encontramos diferencias en cuanto al tipo de esfuerzo (tapiz rodante o dipiridamol). Existio una alta combinacion de factores de riesgo cardiovascular. En el analisis multivariante, la nefropatia diabetica fue la unica que se relaciono con una SPECT anormal (p = 0,043). En el seguimiento, los eventos fueron: 2 revascularizaciones precoces, 5 ingresos en cardiologia, 10 muertes de no origen cardiaco. La existencia de isquemia en la SPECT se relaciono de forma significativa con la aparicion de eventos cardiovasculares (p Conclusion La SPECT de perfusion miocardica en diabeticos asintomaticos con alta asociacion de factores de riesgo detecta la existencia de isquemia silente, la cual parece relacionarse con futuros eventos cardiovasculares. La nefropatia diabetica sugiere mayor probabilidad de estudios anormales; sin embargo, es preciso establecer los criterios de cribado para un mayor rendimiento y un menor coste economico.

At present, the side effects associated with antiretroviral treatment are the main reasons for discontinuation of this kind of therapy, both in clinical trials and in regular clinical practise. On the other hand, due to the change of direction that our profession has suffered in recent years, we face the need to establish a different relationship with the patient, achieving direct and effective Pharmaceutical Care within a framework of shared responsibility for therapeutic results. Pharmacist interventions should be aimed at improving the quality of life of patients, which can only be achieved with a multidisciplinary approach and individualised and adjusted to new patterns of toxicity of the drugs currently used. The pharmacist who does this work must know how to interpret these side effects, giving accurate information to the patient about both pharmacological and non-pharmacological treatment and correct pharmaceutical follow-up which clearly sets forth the criteria for referral to medical appointments. The aim of this paper is to establish baselines so that the hospital pharmacist can perform clearly and uniformly in the prevention, identification and management of major side effects: gastrointestinal, cardiovascular, dermatological, at the central nervous system and kidney level, associated with antiretroviral therapy.

ResumenObjetivo Presentar nuestra experiencia en la aplicacion de la biopsia del ganglio centinela (GC) en la estadificacion axilar del cancer de mama de mas de 3 cm sin evidencia clinica de metastasis. Material y metodo Analisis retrospectivo de 393 casos entre enero-2001 y diciembre-2006 divididos en grupos: (A) 47 casos con tumores T2N0 entre 3 y 5 cm, y (B) 346 casos T 3 cm fue en la gammagrafia del 94 % y con la sonda gammadetectora del 96 %, sin diferencias estadisticamente significativas frente a los T 3 cm la estadificacion axilar final fue 45 % pN0, 8% pN1mi, 34 % pN1a, 11 % pN2a y 2% pN3a. Existieron diferencias significativas (p 3 cm (media 42,88 meses) no encontramos ningun caso con recaida a nivel axilar que pueda considerarse como falso negativo de la tecnica. Conclusiones La deteccion del GC es posible y segura en tumores de mas de 3 cm con axila clinicamente negativa, evitandose en un 45 % de los casos la linfadenectomia axilar, por lo que consideramos que es correcta su inclusion en los criterios de indicacion de la tecnica en el cancer de mama.

Objective To present our experience in the application of sentinel node (SN) biopsy in patients with breast cancer T > 3 cm without clinical evidence of axillary metastasis. Material and Method Retrospective study of 393 cases in the period 2001-2006, divided into group (A) 47 patients with 3-5 cm T2N0 tumours and group (B) 346 patients T 99m Tc-colloidal rhenium sulphide and isosulfan blue dye. Preoperative lymphoscintigraphy was performed and the SN was located intraoperatively with a gamma ray detection probe and the blue dye. Axillary lymph node dissection was completed only when the SN was positive for metastasis in the histopathology analysis or not located. Results The SN detection rate for T2 > 3 cm was 94% in the scintigraphy and 96% with the probe, with no statistically significant differences between T 3 cm, the final staging was 45% pN0, 8% pN1mi, 34% pN1a, 11% pN2a and 2% pN3a. We found statistically significant differences (p 3 cm (median 42.88 months) we did not find any axillary relapse which could be considered a false negative of the technique. Conclusion The detection of sentinel lymph nodes is feasible and safe in tumours larger than 3cm with clinically negative axilla. Axillary lymph node dissection can be avoided in 45% of these patients and therefore, we consider that they should be included as a general indication in breast cancer SN detection.

To present our experience in the therapeutic approach of the sentinel node biopsy (SNB) in patients with previous excision of the breast cancer, divided in non-palpable and palpable lesions, in comparison with time treatment and stagement of breast cancer. In the period 2001–2006, 138 patients with prior diagnostic excisional biopsy (96 non-palpable and 42 palpable breast cancer) and 328 without previous surgery (32 non-palpable; 296 palpable cancer) were treated. The combined technique (99mTc-colloidal rhenium and isosulfan blue dye) was the approach for sentinel lymph node (SLN) detection. Axillary lymph node dissection (ALND) was completed only when the SLN was positive for metastasis or not located. Detection rate, if there was prior surgery, was 95% for non-palpable and 98% for palpable cancer, and 99% for one-time treatment group. Metastasis rate in the SLN was 15% in non-palpable cancer (14/91), significantly smaller than in palpable breast cancer (39% if prior surgery and 37% in one-time surgery). According to tumoral size, ALND metastasis rate was similar for T1 and T2 tumors (43–44%). In the follow-up of the groups with prior diagnostic biopsy or surgery of the breast cancer we have not found any false negative in the axilla. The detection of the SLN is also feasible in patients with previous surgery of breast cancer. Because SLN metastasis rates are significantly smaller in non-palpable lesions, the effort in screening programs for early detection of breast cancer and also in improving histopathological confirmation of malignancy with ultrasound or stereotactic guided core biopsies must continue.

To assess perinatal outcomes and intrauterine complications following fetal intervention for congenital heart disease (CHD).A systematic review and meta-analysis were performed following an electronic search of PubMed and Scopus databases (last searched August 2015). Perinatal outcomes that were assessed included fetal death, live birth, preterm delivery 37 weeks' gestation and neonatal death. Intrauterine complications that were assessed included bradycardia requiring treatment and hemopericardium requiring drainage. Estimated proportions were reported as mean (95% CI). Inconsistency was assessed using the IAn electronic search identified 2279 records, of which 29 studies (11 retrospective cohort and 18 case reports) were considered eligible for analysis. Fetal death after treatment of CHD by aortic valvuloplasty was reported in three studies, with a rate of 31% (95% CI, 9-60%), after pulmonary valvuloplasty in one study, with a rate of 25% (95% CI, 10-49%), after septoplasty in one study, with a rate of 14% (95% CI, 6-28%) and after pericardiocentesis and/or pericardioamniotic shunt placement in 24 studies, with a rate of 29% (95% CI, 18-41%). Bradycardia requiring treatment was reported after aortic valvuloplasty in two studies, with a rate of 52% (95% CI, 16-87%), after pulmonary valvuloplasty in one study, with a rate of 44% (95% CI, 23-67%), and after septoplasty in one study, with a rate of 27% (95% CI, 15-43%).Current evidence on the effectiveness of prenatal intervention for CHD derives mostly from case reports and a few larger series; no study was randomized. Although the results of the meta-analysis are encouraging in terms of perinatal survival, they should be interpreted with caution when comparing with procedures performed after delivery. Copyright © 2016 ISUOG. Published by John WileySons Ltd.

Canadian First Nations are composed of 53 different cultures. Their key forces involve a sense of community, respect for elders, and deep values and religious beliefs promoting growth. Counselling issues include assimilation, post-traumatic stress, addictions, cultural identification, health, and issues caused by societal rupture. Non-Native counsellors may be seen as unhelpful or even potentially harmful to community strengths. Counselling methods need to be based on deep respect, benefit to the community, spirituality, and values. Skills include listening in a way that gives meaning to both verbal and nonverbal messages, growth from one’s own hardships, and being helpful versus using technique. . Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License. This article is available in Online Readings in Psychology and Culture: http://scholarworks.gvsu.edu/orpc/vol10/iss3/6

Acute maternal hyperoxygenation (AMH) results in increased fetal left heart blood flow. Our aim was to perform a pilot study to determine the safety, feasibility and direction and magnitude of effect of chronic maternal hyperoxygenation (CMH) on mitral and aortic valve annular dimensions in fetuses with left heart hypoplasia (LHH) after CMH.Gravidae with fetal LHH were eligible for inclusion in a prospective evaluation of CMH. LHH was defined as: sum of aortic and mitral valve annuli Z-scores -4.5, arch flow reversal and left-to-right or bidirectional atrial level shunting without hypoplastic left heart syndrome or severe aortic stenosis. Gravidae with an affected fetus and with ≥ 10% increase in aortic/combined cardiac output flow after 10 min of AMH at 8 L/min 100% fraction of inspired oxygen were offered enrollment. Nine gravidae were enrolled from February 2014 to January 2015. The goal therapy was ≥ 8 h daily CMH from enrollment until delivery. Gravidae who were cared for from July 2012 to October 2014 with fetal LHH and no CMH were identified as historical controls (n = 9). Rates of growth in aortic and mitral annuli over the final trimester were compared between groups using longitudinal regression.There were no significant maternal or fetal complications in the CMH cohort. Mean gestational age at study initiation was 29.6 ± 3.2 weeks for the intervention group and 28.4 ± 1.8 weeks for controls (P = 0.35). Mean relative increase in aortic/combined cardiac output after AMH was 35.3% (range, 18.1-47.9%). Median number of hours per day on CMH therapy was 9.3 (range, 6.5-14.6) and median duration of CMH was 48 (range, 33-84) days. Mean mitral annular growth was 0.19 ± 0.05 mm/week compared with 0.14 ± 0.05 mm/week in CMH vs controls (mean difference 0.05 ± 0.05 mm/week, P = 0.33). Mean aortic annular growth was 0.14 ± 0.03 mm/week compared with 0.13 ± 0.03 mm/week in CMH vs controls (mean difference 0.01 ± 0.03 mm/week, P = 0.75). More than 9 h CMH daily (n = 6) was associated with better growth of the aortic annulus in intervention fetuses (0.16 ± 0.03 vs 0.08 ± 0.02 mm/week, P = 0.014).CMH is both safe and feasible for continued research. In this pilot study, the effect estimates of annular growth, using the studied method of delivery and dose of oxygen, were small. Copyright © 2015 ISUOG. Published by John WileySons Ltd.

To present a single center experience of a standardized prenatal multidisciplinary management protocol for fetal lower urinary tract obstruction (LUTO) and to propose a classification of fetal LUTO based on disease severity.This was a retrospective cohort study of 25 consecutive fetal patients with prenatal diagnosis of primary LUTO. Fetal intervention was offered after evaluation by a multidisciplinary team. Analyses were conducted using Bayesian methodology to determine predictors of survival at 6 months postpartum. Odds ratios (ORs) with 95% credibility intervals are reported.Fifteen (60.0%) of the 25 patients referred for assessment survived to postnatal evaluation. Fetal vesicoamniotic shunt was placed in 14 (56.0%) patients with 12 survivors. Multivariable analysis suggested that fetal intervention (OR, 6.97 (0.88-70.16), Pr(OR 1) = 96.7%), anhydramnios (OR, 0.12 (0.04-0.35), Pr(OR 1) = 99.9%), favorable fetal urine analysis (OR, 3.98 (0.63-25.15), Pr(OR 1) = 92.7%) and absence of renal cortical cysts (OR, 3.9 (0.66-24.2), Pr(OR 1) = 93.3%) were predictors of survival.Fetal intervention and fetal renal function were independently associated with postnatal survival of fetuses with LUTO. A classification based on the severity of disease is proposed. Copyright © 2015 ISUOG. Published by John WileySons Ltd.