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Fernandez-Jimenez R.,Hospital Universitario Clinico San Carlos | Sanchez-Gonzalez J.,Philips | Fernandez-Friera L.,Hospital Universitario Monteprincipe | Pizarro G.,European University at Madrid | And 5 more authors.
Journal of the American College of Cardiology | Year: 2015

Background It is widely accepted that edema occurs early in the ischemic zone and persists in stable form for at least 1 week after myocardial ischemia/reperfusion. However, there are no longitudinal studies covering from very early (minutes) to late (1 week) reperfusion stages confirming this phenomenon. Objectives This study sought to perform a comprehensive longitudinal imaging and histological characterization of the edematous reaction after experimental myocardial ischemia/reperfusion. Methods The study population consisted of 25 instrumented Large-White pigs (30 kg to 40 kg). Closed-chest 40-min ischemia/reperfusion was performed in 20 pigs, which were sacrificed at 120 min (n = 5), 24 h (n = 5), 4 days (n = 5), and 7 days (n = 5) after reperfusion and processed for histological quantification of myocardial water content. Cardiac magnetic resonance (CMR) scans with T2-weighted short-tau inversion recovery and T2-mapping sequences were performed at every follow-up stage until sacrifice. Five additional pigs sacrificed after baseline CMR served as controls. Results In all pigs, reperfusion was associated with a significant increase in T2 relaxation times in the ischemic region. On 24-h CMR, ischemic myocardium T2 times returned to normal values (similar to those seen pre-infarction). Thereafter, ischemic myocardium-T2 times in CMR performed on days 4 and 7 after reperfusion progressively and systematically increased. On day 7 CMR, T2 relaxation times were as high as those observed at reperfusion. Myocardial water content analysis in the ischemic region showed a parallel bimodal pattern: 2 high water content peaks at reperfusion and at day 7, and a significant decrease at 24 h. Conclusions Contrary to the accepted view, myocardial edema during the first week after ischemia/reperfusion follows a bimodal pattern. The initial wave appears abruptly upon reperfusion and dissipates at 24 h. Conversely, the deferred wave of edema appears progressively days after ischemia/reperfusion and is maximal around day 7 after reperfusion. © 2015 American College of Cardiology Foundation.

Fernandez-Jimenez R.,Hospital Universitario Clinico San Carlos | Sanchez-Gonzalez J.,Philips | Fuster V.,Mount Sinai School of Medicine | Ibanez B.,Hospital Universitario Clinico San Carlos
Journal of the American College of Cardiology | Year: 2015

Background Post-ischemia/reperfusion (I/R) myocardial edema was recently shown to follow a consistent bimodal pattern: an initial wave of edema appears on reperfusion and dissipates at 24 h, followed by a deferred wave that initiates days after infarction, peaking at 1 week. Objectives This study examined the pathophysiology underlying this post-I/R bimodal edematous reaction. Methods Forty instrumented pigs were assigned to different myocardial infarction protocols. Edematous reaction was evaluated by water content quantification, serial cardiac magnetic resonance T2-mapping, and histology/immunohistochemistry. The association of reperfusion with the initial wave of edema was evaluated in pigs undergoing 40-min/80-min I/R and compared with pigs undergoing 120-min ischemia with no reperfusion. The role of tissue healing in the deferred wave of edema was evaluated by comparing pigs undergoing standard 40-min/7-day I/R with animals subjected to infarction without reperfusion (chronic 7-day coronary occlusion) or receiving post-I/R high-dose steroid therapy. Results Characterization of post-I/R tissue changes revealed maximal interstitial edema early on reperfusion in the ischemic myocardium, with maximal content of neutrophils, macrophages, and collagen at 24 h, day 4, and day 7 post-I/R, respectively. Reperfused pigs had significantly higher myocardial water content at 120 min and T2 relaxation times on 120 min cardiac magnetic resonance than nonreperfused animals. Permanent coronary occlusion or high-dose steroid therapy significantly reduced myocardial water content on day 7 post-infarction. The dynamics of T2 relaxation times during the first post-infarction week were altered significantly in nonreperfused pigs compared with pigs undergoing regular I/R. Conclusions The 2 waves of the post-I/R edematous reaction are related to different pathophysiological phenomena. Although the first wave is secondary to reperfusion, the second wave occurs mainly because of tissue healing processes. © 2015 American College of Cardiology Foundation.

Alfonso F.,Hospital Universitario Of La Princesa | Perez-Vizcayno M.J.,Hospital Universitario Clinico San Carlos | Cardenas A.,Hospital Universitario Clinico San Carlos | Garcia Del Blanco B.,Hospital Universitario Vall dHebron | And 17 more authors.
Journal of the American College of Cardiology | Year: 2015

Background Treatment of patients with drug-eluting stent (DES) in-stent restenosis (ISR) remains a major challenge. Objectives This study evaluated the comparative efficacy of drug-eluting balloons (DEB) and everolimus-eluting stents (EES) in patients presenting with DES-ISR. Methods The study design of this multicenter randomized clinical trial assumed superiority of EES for the primary endpoint, in-segment minimal lumen diameter at the 6- to 9-month angiographic follow-up. Results A total of 309 patients with DES-ISR from 23 Spanish university hospitals were randomly allocated to DEB (n = 154) or EES (n = 155). At late angiography (median 247 days; 90% of eligible patients), patients in the EES arm had a significantly larger minimal lumen diameter (2.03 ± 0.7 mm vs. 1.80 ± 0.6 mm; p < 0.01) (absolute mean difference: 0.23 mm; 95% CI: 00.7 to 0.38), net lumen gain (1.28 ± 0.7 mm vs. 1.01 ± 0.7 mm; p < 0.01), and lower percent diameter stenosis (23 ± 22% vs. 30 ± 22%; p < 0.01) and binary restenosis rate (11% vs. 19%; p = 0.06), compared with patients in the DEB arm. Consistent results were observed in the in-lesion analysis. At the 1-year clinical follow-up (100% of patients), the main clinical outcome measure (composite of cardiac death, myocardial infarction, and target vessel revascularization) was significantly reduced in the EES arm (10% vs. 18%; p = 0.04; hazard ratio: 0.58; 95% CI: 0.35 to 0.98), mainly driven by a lower need for target vessel revascularization (8% vs. 16%; p = 0.035). Conclusions In patients with DES-ISR, EES provided superior long-term clinical and angiographic results compared with DEB. (Restenosis Intra-Stent of Drug-Eluting Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent [RIBS IV]; NCT01239940) © 2015 American College of Cardiology Foundation.

Garcia M.E.,Hospital Universitario Clinico San Carlos | Garcia-Morales I.,Hospital Universitario Clinico San Carlos | Garcia-Morales I.,Hospital Ruber Internacional | Gil-Nagel A.,Hospital Ruber Internacional
Epilepsy Research | Year: 2015

Background: Drug-resistant epilepsy (DRE) is usually related to focal epilepsy (FE) and is present in up to 30% of patients. Several studies have found high rates of depressive symptoms and poor health related quality of life (HRQOL) in DRE patients but little information is available on these aspects for Spain. Objective: To determine the prevalence of depressive symptoms in a cohort of Spanish patients with DRE and evaluate their HRQOL in comparison with patients with controlled FE (CFE). Methods: This observational cross-sectional study analyzed FE patients, with and without DRE, recruited from different Spanish neurology outpatient clinics. Presence of depressive symptoms was assessed using the Montgomery-Asberg Depression Rating Scale (MADRS) and the Beck Depression Inventory-II (BDI-II). HRQOL was evaluated using the Quality of Life in Epilepsy Inventory (QOLIE-31). Results: 515 patients (DRE. =. 248) were included. Mean (SD) age was 44.3 (15.4) years and 50.5% were male. Overall, 15.9% had a previous diagnosis of depressive symptoms (DRE. =. 22.6%; CFE. =. 9.7%, p<. 0.001). Depressive symptoms was observed in 62.1% [95% CI 56.1-68.1] and 64.8% [58.8-70.7] of DRE patients using MADRS and BDI-II, respectively, compared to 32.6% [27.0-38.2] and 37.2% [31.4-43.0] in the CFE group (. p<. 0.001). Depressive symptoms was associated with poorer HRQOL. Multivariate modeling showed that presence of depressive symptoms on the MADRS or BDI-II had the greatest impact on mean QOLIE-31 scores. Conclusions: Compared to other studies, the rate of depressive symptoms was high (60% in DRE and 30% in CFE patients). MADRS and BDI-II showed a positive correlation. Prior to the study, depressive symptoms were underdiagnosed in a large proportion of patients. Clinical diagnosis of depressive symptoms and not seizure frequency was associated with poorer mean QOLIE-31 scores. © 2014.

Gutierrez-Gonzalez R.,Hospital Universitario Clinico San Carlos | Boto G.R.,Hospital Universitario Clinico San Carlos
Journal of Infection | Year: 2010

Cerebrospinal fluid shunting devices are foreign bodies internally or externally placed in a patient with the aim of improving the prognosis. Device-related infection is the most serious complication. Its importance arises from the high frequency of occurrence and the consequences that it implies in terms of morbidity and mortality. As a result, the presence of these two factors increases significantly hospital costs.Among many primary prevention measures investigated, one of those that has gained in importance over the last years is the use of antibiotic-impregnated catheters. Although their experimental development dates back to the 1970s, experience in clinical practice has not been settled until the last decade. This is the reason why only 22 studies on the usefulness of AICs in CSF shunting procedures in clinical practice have been published in the literature since their commercialization.Although experience with antibiotic-impregnated shunts continues growing, practice with antibiotic-impregnated external ventricular drains is much shorter. The present study reviews and analyses the different investigations performed in order to determine the efficacy of antibiotic-impregnated shunts and external ventricular drains with the aim of reducing device-related infectious complications. The results suggest that AICs reduce device-related infection as well as hospital costs. However, evidence is not enough to state categorical conclusions, and further large, prospective, randomized and double-blind studies must be performed in order to confirm these results and the efficacy of other antibiotic-impregnated devices. Further economic evaluation is required to confirm the benefit in terms of cost-effectiveness as well. © 2010 The British Infection Society.

Gonzalez del Castillo J.,Hospital Universitario Clinico San Carlos
European Journal of Emergency Medicine | Year: 2015

OBJECTIVE: To determine the validity of the classic sepsis criteria or systemic inflammatory response syndrome (heart rate, respiratory rate, temperature, and leukocyte count) and the modified sepsis criteria (systemic inflammatory response syndrome criteria plus glycemia and altered mental status), and the validity of each of these variables individually to predict 30-day mortality, as well as develop a predictive model of 30-day mortality in elderly patients attended for infection in emergency departments (ED). METHODS: A prospective cohort study including patients at least 75 years old attended in three Spanish university ED for infection during 2013 was carried out. Demographic variables and data on comorbidities, functional status, hemodynamic sepsis diagnosis variables, site of infection, and 30-day mortality were collected. RESULTS: A total of 293 patients were finally included, mean age 84.0 (SD 5.5) years, and 158 (53.9%) were men. Overall, 185 patients (64%) fulfilled the classic sepsis criteria and 224 patients (76.5%) fulfilled the modified sepsis criteria. The all-cause 30-day mortality was 13.0%. The area under the curve of the classic sepsis criteria was 0.585 [95% confidence interval (CI) 0.488–0.681; P=0.106], 0.594 for modified sepsis criteria (95% CI: 0.502–0.685; P=0.075), and 0.751 (95% CI: 0.660–0.841; P<0.001) for the GYM score (Glasgow <15; tachYpnea>20 bpm; Morbidity–Charlson index ≥3) to predict 30-day mortality, with statistically significant differences (P=0.004 and P<0.001, respectively). The GYM score showed good calibration after bootstrap correction, with an area under the curve of 0.710 (95% CI: 0.605–0.815). CONCLUSION: The GYM score showed better capacity than the classic and the modified sepsis criteria to predict 30-day mortality in elderly patients attended for infection in the ED. © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Alfonso F.,Hospital Universitario Clinico San Carlos
Archivos de Cardiologia de Mexico | Year: 2010

The main objective of biomedical journals is to publish high-quality scientific studies and to ensure a widespread dissemination of their contents. Journals compete for the best science generated in their respective disciplines and, therefore, they critically scrutinize the scientific quality of all submitted papers in order to identify and select only those that merit publication. The "peer review" system represents the cornerstone of the scientific process. It provides a critical appraisal, by external independent experts, of the studies under consideration. The system is intended to improve the quality of the submitted papers but also to help the Editors in their decision-making process. The process has been widely embraced by the scientific and editorial international community but it is not free from caveats. In fact, although several strategies have been implemented to improve its quality and the results obtained, limitations still persist. Accordingly, its quality should be closely monitored to ensure excellence. Surprisingly, although the "peer review" process is universally accepted to validate the science, limited scientific information exists on its real value. In this review we will critically analyze the "peer review" process and we will advance some ideas that may help to understand why, in spite of its limitations, it remains the "gold standard" for the selection of scientific manuscripts by biomedical journals. © 2010 Instituto Nacional de Cardiología Ignacio Chávez.

Biomedical journals must adhere to strict standards of editorial quality. In a globalized academic scenario, biomedical journals must compete firstly to publish the most relevant original research and secondly to obtain the broadest possible visibility and the widest dissemination of their scientific contents. The cornerstone of the scientific process is still the peer-review system but additional quality criteria should be met. Recently access to medical information has been revolutionized by electronic editions. Bibliometric databases such as MEDLINE, the ISI Web of Science and Scopus offer comprehensive online information on medical literature. Classically, the prestige of biomedical journals has been measured by their impact factor but, recently, other indicators such as SCImago SJR or the Eigenfactor are emerging as alternative indices of a journal's quality. Assessing the scholarly impact of research and the merits of individual scientists remains a major challenge. Allocation of authorship credit also remains controversial. Furthermore, in our Kafkaesque world, we prefer to count rather than read the articles we judge. Quantitative publication metrics (research output) and citations analyses (scientific influence) are key determinants of the scientific success of individual investigators. However, academia is embracing new objective indicators (such as the "h" index) to evaluate scholarly merit. The present review discusses some editorial issues affecting biomedical journals, currently available bibliometric databases, bibliometric indices of journal quality and, finally, indicators of research performance and scientific success. © 2010 SEEN.

Mateos Rodriguez A.A.,SUMMA112 | Navalpotro Pascual J.M.,SUMMA112 | Del Rio Gallegos F.,Hospital Universitario Clinico San Carlos
American Journal of Emergency Medicine | Year: 2013

Non-heart-beating donors (NHBDs) have to meet the predefined criteria for organ donation including death from irreversible cessation of the beating heart. The Maastricht conference defined 4 NHBD categories to differentiate their viability and ethical-legal support. In Spain, NHBDs who originate from an out-of-hospital setting correspond to type II donors. These are patients who have had a cardiac arrest outside hospital and, after failed CPR attempts, are transferred with hemodynamic support measures to the hospital for organ donation. The Hospital Clínico San Carlos also has a lung donation program in collaboration with the Hospital Puerta de Hierro in Madrid and the Hospital Marques de Valdecilla in Santander. The objective of this study is to describe the results of lung transplantation of after cardiac death program, specifically the section regarding lung extraction donation. Twenty potential lung donors were obtained during the study. Most patients were male (19 cases), with a mean age of 42 years (36.5-49.5 years). A total of 33 lungs were donated (18 right and 15 left lungs). Most extractions were multiorganic (19 cases). One liver, 19 kidneys, 2 pancreas, and 19 corneas were obtained from these donors; bone tissue was obtained from all donors. The transplantation was bipulmonary in 13 cases and unipulmonary in 7. Thirty days after transplantation, 2 recipients died, 1 died of stroke associated with bilateral pneumonia and 1 died of hypovolemic shock resulting from hemothorax. The remaining 18 patients were progressing well at 30 days. Our data suggest that lung transplantation from patients after extrahospitalary cardiac death is feasible. © 2013 Elsevier Inc.

The " peer-review" system is used to improve the quality of submitted scientific papers and provides invaluable help to the Editors in their decision-making process. The " peer-review" system remains the cornerstone of the scientific process and, therefore, its quality should be closely monitored. The profile of the " elite" reviewers has been described, but further studies are warranted to better identify their main characteristics. A major challenge, not only for Editors but also for medical scientific societies as a whole, is to continue to guarantee the excellence in the " peer-review" process and to ensure that it receives adequate academic recognition. © 2010 Sociedad Española de Neurología.

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