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Pituitary Apoplexy: Comorbidities, Management, and Outcomes-A Spanish Observational Multicenter Study.
No full text20.500.12530/87909Pituitary apoplexy (PA) is the paradigm of endocrine and neurosurgical emergency. To evaluate the comorbidities, risk factors, clinical presentation, pituitary apoplexy score (PAS), and the outcomes of surgical vs conservative management of PA in Spain. Spanish multicenter, observational study of 301 patients with acute PA. Statistical analyses compared risk factors, clinical presentation, and outcomes between surgical and conservative treatment groups, adjusting for potential confounders. The prevalence of cardiovascular risk factors in patients with PA was compared with the Spanish population and with patients with nonfunctioning pituitary adenomas. Median age was 59.3 years, 201 (66.8%) were men; nonfunctioning adenomas (77.9%) were the most common tumor type. The prevalence of diabetes (20.3% vs 13.9%, P There is a high burden of cardiovascular risk factors among patients with PA, suggesting that metabolic factors may play a potential role in the development of PA. This underscores the need for comprehensive management of these conditions in addition to treating the apoplexy itself in this population. Surgical management has a relevant place in PA approach mainly in patients with higher PAS. However, it leads a permanent vasopressin deficit more frequently than a conservative approach
Multidisciplinary management strategies for recurrent brain metastasis after prior radiotherapy: An overview.
No full text20.500.12530/87857As cancer patients with intracranial metastatic disease experience increasingly prolonged survival, the diagnosis and management of recurrent brain metastasis pose significant challenges in clinical practice. Prior to deciding upon a management strategy, it is necessary to ascertain whether patients have recurrent/progressive disease vs adverse radiation effect, classify the recurrence as local or distant in the brain, evaluate the extent of intracranial disease (size, number and location of lesions, and brain metastasis velocity), the status of extracranial disease, and enumerate the interval from the last intracranially directed intervention to disease recurrence. A spectrum of salvage local treatment options includes surgery (resection and laser interstitial thermal therapy [LITT]) with or without adjuvant radiotherapy in the forms of external beam radiotherapy, intraoperative radiotherapy, or brachytherapy. Nonoperative salvage local treatments also range from single fraction and fractionated stereotactic radiosurgery (SRS/FSRS) to whole brain radiation therapy (WBRT). Optimal integration of systemic therapies, preferably with central nervous system (CNS) activity, may also require reinterrogation of brain metastasis tissue to identify actionable molecular alterations specific to intracranial progressive disease. Ultimately, the selection of the appropriate management approach necessitates a sophisticated understanding of patient, tumor, and prior treatment-related factors and is often multimodal; hence, interdisciplinary evaluation for such patients is indispensable
Protocol for the Humanization of End-of-Life Care in Neonatology
No full textProtocolo asistencial de cuidados al final de la vida y tras la muerte neonatal del Servicio de Neonatología del Hospital Universitario Clínico San Carlos (Madrid). Versión 1 revisada por la Comisión de Cuidados y aprobada por la Dirección de Enfermería
Hydrosalpinx treatment before in-vitro fertilization: systematic review and network meta-analysis.
No full text20.500.12530/87910To compare the safety and effectiveness of different methods, both ablative and non-ablative, to treat hydrosalpinx in infertile patients before in-vitro fertilization embryo transfer (IVF-ET) via a systematic review and network meta-analysis (NMA). A structured literature search was conducted in common citation databases. Eligibility criteria included peer-reviewed randomized controlled trials (RCTs) or cohort studies comparing the effectiveness and/or safety of different hydrosalpinx treatments, including salpingectomy, laparoscopic proximal tubal occlusion (LTO), insertion of an intratubal device (ITD), ultrasound-guided aspiration, sclerotherapy and expectant management. Primary outcomes were live birth, ongoing pregnancy and clinical pregnancy. Miscarriage, ectopic pregnancy and procedural complications were considered as secondary outcomes. The main NMA included only RCTs, while observational studies were included in a secondary aggregate NMA. Pooled effects were summarized as odds ratios (ORs) with 95% CI for direct and indirect comparisons, derived from random-effects models. Imprecision of NMA estimates was assessed by comparison of their 95% CIs with predefined thresholds for effect size considered to represent clinical relevance (OR 1.1). Heterogeneity for NMA findings was estimated using the variance of the distribution of the underlying treatment effects (τ2), expressed as a 95% prediction interval. Surface under the cumulative ranking curve (SUCRA) was used to predict relative treatment rankings for each outcome. The main analysis included nine RCTs, while an additional 17 observational studies were incorporated into the aggregate analysis. The NMA of RCTs revealed no significant differences in live birth rate between hydrosalpinx treatment methods, with LTO achieving the highest SUCRA value (0.9). Salpingectomy and ultrasound-guided aspiration significantly increased the ongoing pregnancy rate compared with no treatment (OR, 4.35 (95% CI, 1.70-11.14) and 2.80 (95% CI, 1.03-7.58), respectively), with salpingectomy having the highest SUCRA value (0.9). Clinical pregnancy rate was significantly higher following salpingectomy (OR, 2.24 (95% CI, 1.30-3.86)) and LTO (OR, 2.55 (95% CI, 1.20-5.51)) compared with no treatment, despite some heterogeneity; LTO had the highest SUCRA value (0.8). NMA showed no significant differences in secondary outcomes between treatments. Aggregate NMA indicated that sclerotherapy significantly increased the live birth rate compared with no treatment. Higher ongoing pregnancy rate was observed in patients treated with salpingectomy, ultrasound-guided aspiration and LTO compared to untreated patients, with salpingectomy having the highest SUCRA value (0.9). Except for ITD insertion, all interventions increased the clinical pregnancy rate compared with no treatment. LTO had a greater effect on clinical pregnancy rate compared to ultrasound-guided aspiration, with no significant differences in other pairwise comparisons. NMA ranked LTO as the most effective treatment for increasing the clinical pregnancy rate and reducing the miscarriage rate, while sclerotherapy was deemed safer with regard to the ovarian response to IVF stimulation. This NMA fails to support the effectiveness of any hydrosalpinx treatment to improve the live birth rate following IVF-ET, although the beneficial effect of salpingectomy and ultrasound-guided aspiration on ongoing pregnancy rate and of salpingectomy and LTO on clinical pregnancy rate reinforces current recommendations. Based on the aggregated analysis, sclerotherapy could be an effective alternative to conventional laparoscopic techniques, with a favorable safety profile. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology
The real-world use and effectiveness of avacopan in routine practice for the treatment of ANCA vasculitis. First experiences in Spain.
No full text20.500.12530/87852ANCA-associated vasculitis (AAV) is a group of chronic diseases with relapses that associate organic damage because of the disease and its treatment. Avacopan is a new treatment indicated for AAV. We present the first experiences with avacopan in Spain as part of an Early Access program. Patients with AAV who started avacopan between June 2022 and September 2023 were included. For comparison, a historical cohort of patients diagnosed with AAV around the same time and treated without avacopan was also included. Twenty-nine patients treated with avacopan were analysed. Twelve patients (41.4%) were male, and median age was 56 years. Most patients were ANCA MPO positive (21/29, 72.4%). The most frequently affected organ was the kidney (23/29, 79.31%), with a mean estimated glomerular filtration rate (eGFR) of 23.2 ml/min. Mean follow-up was 456.8 (±181.7) days with a remission rate of 86.2%. eGFR increased from 23.2 (11.2) to 38.38 (18.55) ml/min after 12 months of diagnosis. Two patients had adverse events related to avacopan (severe neutropenia and a gastrointestinal affectation), 13 infections were reported and one death. Patients treated with avacopan received a significantly lower cumulative dose of prednisone at 6 and 12 months (P-values of 0.02 and The combination of avacopan with standard immunosuppressive therapy presents a good safety profile and provides added value by contributing to the control of AAV activity, increase GFR and removal of steroids
Characterisation of LGP2 complex multitranscript system in humans: role in the innate immune response and evolution from non-human primates.
No full text20.500.12530/87908Retinoic acid inducible gene I (RIG-I)-like receptors (RLRs), including RIG-I, MDA5 and LGP2, recognize viral RNA to mount an antiviral interferon (IFN) response RLRs share three different protein domains: C-terminal domain, DExD/H box RNA helicase domain, and an N-terminal domain with two tandem repeats (CARDs). LGP2 lacks tandem CARD and is not able to induce an IFN response. However, LGP2 positively enhances MDA5 and negatively regulates RIG-I signaling. In this study, we determined the LGP2 alternative transcripts in humans to further comprehend the mechanism of its regulation, their evolutionary origin, and the isoforms functionallity. The results showed new eight alternative transcripts in the samples tested. The presence of these transcripts demonstrated that the main mechanisms for the regulation of LGP2 expression are both by insertion of introns and by the loss of exons. The phylogenetic analysis of the comparison between sequences from exon 1 to exon 3 of humans and those previously described in non-human primates showed three well-differentiated groups (lineages) originating from gorillas, suggesting that the transspecies evolution has been maintained for 10 million years. The corresponding protein models (isoforms) were also established, obtaining four isoforms: one complete and three others lacking the C-terminal domain or this domain and the partial or total He2 Helicase domain, which would compromise the functionality of LGP2. In conclusion, this is the first study that elucidate the large genomic organization and complex transcriptional regulation of human LGP2, its pattern of sequence generation, and a mode of evolutionary inheritance across species
Visual manifestations in giant cell arteritis: identification of risk factors from the ARTESER Registry.
No full text20.500.12530/87908To determine the prevalence and predictive factors of visual manifestations in a large registry of patients with GCA. ARTESER is a large Spanish multicentre registry supported by the Spanish Society of Rheumatology. It includes patients with GCA from across the entire country diagnosed between June 2013 and March 2019. The variables collected at diagnosis were demographics, clinical manifestations (including all visual manifestations), laboratory, temporal artery biopsy, and imaging findings (ultrasound, FDG-PET/CT, MRI angiography, CT angiography). Patients with and without visual involvement were compared in a bivariate analysis. Multivariate logistic regression was performed to determine potential predictive factors of visual manifestations. The study population comprised 1636 GCA patients, of whom 599 (36.6%) presented visual manifestations. Anterior ischemic optic neuropathy was the most frequent (n = 274 of 599; 45.7%) ocular complication. The independent predictors that increased the risk (OR; 95% confidence interval) of visual involvement were older age (1.027; 1.009-1.045) and jaw claudication (1.724; 1.325-2.243). The variables associated with a reduced risk were polymyalgia rheumatica (0.541; 0.414-0.708), fever (0.373; 0.264-0.527), longer symptom duration (0.946; 0.909-0.985) and higher erythrocyte sedimentation rate (ESR) (0.992; 0.988-0.997), common features of patients with large vessel GCA. One-third of GCA patients present visual manifestations at diagnosis. Older age and jaw claudication are independent predictors of visual manifestations, whereas polymyalgia rheumatica, fever, longer symptom duration and high ESR reduce the risk of visual involvement
Selection of initiatives to improve the management of patients with hereditary angioedema by the hospital pharmacy using the nominal group technique.
No full textTo identify and promote hospital pharmacy initiatives to improve the management of patients with hereditary angioedema (HAE) within the Spanish healthcare system. A panel of experts comprising hospital pharmacists, an allergist and a nurse/member of the Spanish Hereditary Angioedema Association (Asociación Española de Angioedema Familiar) highlighted initiatives to improve care for patients with HAE after identifying, evaluating and prioritising them. Prioritisation was assessed based on the impact on patient care and the feasibility of their implementation on a scale of 1-5. Seven key areas of activity for the role of hospital pharmacists in the management of patients with HAE were identified: evaluation and selection of medicines; hospital pharmacy dispensation and telepharmacy; pharmacotherapy follow-up and telemedicine; coordination with other healthcare teams involved in the care of patients with HAE; patient health education and training; research on HAE; and continuous education and training of hospital pharmacy service personnel. Ten initiatives with a mean impact score of 5 and a mean feasibility score of ≥4.1 were considered as high-priority initiatives. Half of the initiatives belong to the area concerning patient education and training (50%), followed by care coordination initiatives (30%) and continuous education and training (20%). Ten high-priority initiatives for the management of patients with HAE were identified by a panel of experts. The implementation of such initiatives by the hospital pharmacy service should enhance the management of patients with HAE in the Spanish healthcare system
Burden of incidental cerebral aneurysms on lifestyle and quality of life: a survey of patients in expectant management (the SPICE Study).
No full textThe increasing availability of neuroimaging tests has led to a rise in the identification of incidental unruptured intracranial aneurysms (UIAs). Their management is under debate, with no consensus on their follow-up strategy, which can cause anxiety in patients. Our aim is to evaluate the impact of diagnosis and imaging follow-up on daily activities and quality of life. A multicenter cross-sectional study was carried out in patients with UIAs undergoing watchful waiting. Exclusion criteria were history of stroke, renal polycystic disease, symptomatic aneurysms, intervention or scheduled for intervention. The patients completed an anonymous 36-question survey about their habits and perceived quality of life after diagnosis through a validated questionnaire (PROMIS). We obtained 73 responses from 183 patients identified in eight hospitals (40%), 68 of which were included in the study (50 women (74%), median (IQR) age 62 (55-70) years). Forty-nine patients (72%) underwent at least one imaging follow-up per year. Forty-two patients (63%) found follow-up tests reassuring and 12 (18%) experienced concern about the results. Nineteen patients (28%) reported adopting a healthier lifestyle since diagnosis, while 13 (19%) acknowledged a negative impact on their daily activities. Forty-six (68%) admitted avoiding or conditioning at least one activity or situation from a list. PROMIS scores were similar to those of the general reference population. Overall, 77% rated their quality of life as 'good' or better. The diagnosis of UIAs seems to influence the activities of the majority of patients. However, follow-up yielded more benefit in the form of healthier lifestyles than harm to daily activities, without detriment to their perceived quality of life
Cariprazine and Cognition in Patients with Schizophrenia and Bipolar Disorder: A Systematic Review.
No full text20.500.12530/87854Cariprazine (CAR), an antipsychotic with partial agonism at the D3 receptor and higher affinity than dopamine, has shown significant procognitive effects in preclinical animal studies. This study systematically reviews CAR's effects on cognitive measures in patients with schizophrenia and bipolar disorder. Two independent reviewers systematically searched PubMed, Web of Science, Scopus, and the Cochrane Library up to May 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Additional studies were found by hand searching the references of included studies. Eligible studies were randomized controlled trials (RCTs) in English that assessed CAR's effects on cognition in patients with schizophrenia or bipolar disorder. Quality was assessed using the Jadad scale. Out of 139 reports, 5 studies (involving 6,104 patients with schizophrenia or bipolar disorder) were included. In schizophrenia, CAR showed better cognitive outcomes (mainly indirect measures) than placebo (PBO) in both early and late stages. It also outperformed risperidone and aripiprazole in attention-related cognitive tests. In bipolar disorder, CAR improved cognition compared to PBO (also using indirect measures). Most studies found the greatest cognitive benefits with low doses of CAR (1.5-3 mg/d). CAR improved cognitive measures compared to PBO and other D2 antagonists or partial agonists in RCTs, especially in patients with greater baseline impairment. Thus, CAR may be a promising option for enhancing cognition in schizophrenic and bipolar patients; though, more trials using specific cognitive assessment tools are needed. PROSPERO CRD42023485028