Clínica Girona

OBJETIVO. Conocer la eficacia, en términos de resultados en salud, de un programa de desfibrilación de acceso público (DAP) implementado en un área escasamente poblada, en España. MATERIAL Y MÉTODOS. Registro prospectivo, entre 2012 y 2022, de supervivientes de una PCE por primer ritmo desfibrilable que, tras recuperación de circulación espontánea, ingresaron en un centro terciario, en la provincia de Girona, España. Se consideraron dos grupos de supervivientes: los que inicialmente fueron desfibrilados mediante DAP y los que lo fueron por el Sistema de Emergencias Médicas (SEM). Se evaluó la situación neurológica al alta hospitalaria, mortalidad intrahospitalaria y en el seguimiento. El estado neurológico se evaluó mediante la escala Cerebral Performance Category (CPC). RESULTADOS. De los 457 supervivientes, 152 tuvieron un primer ritmo desfibrilable, siendo 88 desfibrilados por los SEM y 64 mediante el programa de DAP. En cuanto a la situación neurológica al alta, un 73 % de los pacientes estaban en CPC 1-2 en el grupo de DAP y un 52 % en el grupo SEM (p = 0,005). Fallecieron en el ingreso el 22,2 % en el grupo DAP y el 39,8 % en el grupo SEM (p = 0,036). En el seguimiento la tasa de exitus fue de 32,1 % vs 65,3 % respectivamente (p < 0,001). CONCLUSIONES. En un área de baja densidad poblacional, los supervivientes a una PCE por ritmo desfibrilable que inicialmente fueron atendidos con DAP presentaron mejor estado neurológico al alta y menor mortalidad en el seguimiento.

Cryotherapy (CT) is increasingly used as a primary treatment for prostate cancer (PC), though guideline recommendations remain limited. This study evaluates toxicity, including the use of hypofractionation, as well as local and biochemical control, and survival outcomes in patients treated with salvage radiotherapy (sRT) after recurrence following CT. We retrospectively analyzed 21 patients with recurrent PC after CT treated with sRT at our institution between 2013 and 2023. Toxicity was assessed with the RTOG scale, fractionation-related toxicity was compared with chi-square test. Biochemical recurrence was defined using Phoenix criteria. Survival and local control were analyzed with Kaplan-Meier method. Median follow-up was 56months (4.4-136.6). Median age at diagnosis was 73years (55-80), and median interval from CT to sRT was 45.5months (14.2-189.23). Median radiation dose was 73.14Gy (70-78); 86% received hormonal therapy, and 52% underwent hypofractionation. Acute grade 2 genitourinary (GU) toxicity occurred in 23.8%. Chronic GU grade 2 and 3 toxicities were 28.6% and 9.5%, respectively. Gastrointestinal (GI) toxicity included one case (4.76%) of acute G2 and one case each of chronic G3 and G4. No difference between conventional fractionation and hypofractionation was found. Median overall survival (OS) after sRT was 108.45months (22.44-194.46). Mean OS was 98months with 90.4% local control. sRT after CT can provide durable local and biochemical control in selected patients, but severe late toxicity may occur in a small proportion of cases. Hypofractionation was not associated with increased toxicity in this cohort and appears to be a feasible option.

Involvement of the bone marrow by metastases fromsolid tumors or multiple myeloma (MM) is a critical challenge in oncologic imaging. Lesion detection and staging, as well as accurate assessment of treatment response, disease recurrence, and complications, are key to optimal patient management. This article provides recommendations for performing and interpreting bone marrow MRI in cancer patients. MRI should be the primary imaging modality for patients suspected of having skeletal bone metastases or MM, and should replace radiography, bone scintigraphy, and CT for these indications. Protocols must be tailored to the clinical context and to each specific cancer. Whole-body MRI (WB-MRI) is preferred for a comprehensive assessment, while axial skeleton MRI (AS-MRI) is a fast and reliable alternative for targeted or follow-up evaluations. We recommend standardized protocols that incorporate anatomical sequences (preferably fast spin echo T2 Dixon) and diffusion-weighted imaging (DWI). Quantitative biomarkers, e.g., apparent diffusion coefficient (ADC) and fat fraction (FF), should be implemented to improve diagnostic accuracy and evaluate treatment response. Radiologists must be familiar with the typical patterns of bone marrow replacement by cancer cells, response assessment principles, and common imaging pitfalls. Every medical imaging facility should offer optimal bone marrow MRI and implement these recommendations using available MRI systems and existing disease-oriented guidelines. This ESR Essentials illustrates when, how, and why to perform bone marrow MRI to improve diagnostic precision and oncologic care across a broad range of indications. KEY POINTS: Prefer MRI of the bone marrow over radiographs, bone scintigraphy, or CT for suspected bone metastases of solid cancers and for myeloma staging. Use MRI for diagnosis of bone involvement, disease staging, assessment of lesion response to treatment, detection of recurrence, and assessment of osseous complications. Tailor MRI protocol to cancer type following existing guidelines, targeting either the axial skeleton or the "whole body," and using a panel of sequences with fat-sensitive, fast spin echo T2 Dixon and diffusion-weighted sequences as the fundamental components.

Abstract Background There is little evidence regarding the predictive factors associated with mucosal healing in patients with moderate ulcerative colitis (UC) treated with steroids. The aim of this study was to analyse the association between the speed of improvement in clinical variables with calprotectin levels and endoscopic mucosal healing once a conventional course of steroids has been completed. Methods All patients in the GETECCU prospective randomised CECUM clinical trial who completed the endoscopic assessment at eight weeks were included. Clinical variables were collected at 7 days, and at 4 and 8 weeks: presence of rectal bleeding, urgency and nocturnal stools, Mayo and Walmsley sub-scores, and faecal calprotectin levels. Endoscopic mucosal healing at week 8 was defined as an endoscopic Mayo score of 0. Group differences were compared and the association between early clinical response and final mucosal healing was analysed using descriptive statistics and logistic regression models adjusted for baseline clinical variables. Results Of the 75 patients included in the CECUM study, 58 underwent endoscopy at week 8. Forty-eight per cent were women with a median age of 49 (range 19–79), 98 per cent were non-smokers, 52 per cent had extensive colitis and 32 per cent had previously received steroids. The mucosal healing rate at eight weeks was 29% (17 of 58). In the univariate analysis, disappearance of rectal bleeding at week 4, use of topical therapy and calprotectin levels <250 at day 7 and <150 at 4 weeks were associated with mucosal healing (p < 0.05). In the multivariate logistic regression, independent factors associated with mucosal healing were topical treatment at 7 days (OR 9.96; 95% CI 1.51–65.83; p = 0.017), faecal calprotectin levels <250 µg/g at 7 days (OR 5.48; 95% CI 1.28–23.45; p = 0.022) and calprotectin levels <150 µg/g at 4 weeks (OR 5.15; 95% CI 1.13–23.32; p = 0.034). Conclusion Early normalisation of calprotectin and the use of topical treatment during the first week are independent predictors of mucosal healing in steroid-treated UC with moderate activity. These results reinforce the value of calprotectin as a non-invasive clinical decision marker and, furthermore, support the use of combined topical treatment when initiating oral steroids. Conflict of interest: Mañosa Ciria, Miriam: Personal Fees: Abbvie, FAES Pharma, Ferring, Jannsen, MSD, Pfizer, Tillots and Lilly Llao Guardia, Jordina: I have received financial support from AbbVie, Tillots, Adacyte, Jansen, Alfasigma and Lilly for educational activities. Piñero, Gisela Soledad: GP has served as a speaker or has received education funding or advisory fees from Adacyte, AbbVie, Kern Pharma, Ferring, Alfasigma. Calafat Sard, Margalida: No conflict of interest Martin Arranz, Eduardo: Personal Fees: Olympus and Janssen Non-financial Support: Support for conference attendance, education or research from Abbvie, Pfizer, Janssen Zabana, Yamile: Personal Fees: AbbVie, Adacyte Therapeutics, Alfa-Sigma, Amgen, Boehringer Ingelheim, Dr Falk Pharma, FAES Pharma, Fresenius Kabi, Ferring, Galapagos, Janssen-J & J, Kern Pharma, Lilly, MSD, Pfizer, Sanofi, Sandoz, Takeda, Tillots Pharma Non-financial Support: Shire, Otsuka, Almirall Navarro Llavat, Mercedes: No conflict of interest Teller, Marta: No conflict of interest Garcia Planella, Esther: No conflict of interest Busquets Casals, David: No conflict of interest Monfort Miquel, David: No conflict of interest Juan-Ramón , Pineda: No conflict of interest Gutiérrez Casbas, Ana: No conflict of interest Villoria Ferrer, Alberto: No conflict of interest Menchen Viso, Luis Alberto: No conflict of interest Bastida Paz, Guillermo: No conflict of interest Garcia Alonso, Francisco Javier: I have acted as a speaker for Abbvie, Lilly and Johnson and Johnson Rivero Tirado, Montserrat: No conflict of interest Chaparro, María: Grants: Pfizer, Janssen, Biogen, Abbvie, Lilly Personal Fees: Pfizer, Faes, Lilly, Abbvie, Janssen Riestra Menéndez, Sabino: No conflict of interest Merino Ochoa, Olga: No conflict of interest Rodríguez-Lago, Iago: No conflict of interest Barreiro-de Acosta, Manuel: MBA has been speaker, consultant and advisory member for or has received research funding from MSD, AbbVie, Janssen, Kern Pharma, Celltrion, Takeda, Alphasigma, Lilly, Pfizer, Sandoz, Biocon, Abivax, Fresenius, Faes Farma, Ferring, Tillots, Chiesi, Adacyte, Diasorin, Oncostellae and SunRock. Rodríguez-Fortúnez, Patricia: No conflict of interest Domènech Moral, Eugeni: Personal Fees: I have served as a speaker, or has received research or education funding or advisory fees from AbbVie, Adacyte Therapeutics, Biogen, Celltrion, Gilead, Janssen, Kern Pharma, MSD, Pfizer, Roche, Samsung, Takeda, Tillots. Other: I have served as a speaker, or has received research or education funding or advisory fees from AbbVie, Adacyte Therapeutics, Alfasigma/Galapagos Biogen, Celltrion, Ferring, Gilead, GoodGut, Imidomics, Janssen, Kern Pharma, Lilly, MSD, Pfizer, Roche, Takeda, Tillots.

Mandibular osteoradionecrosis (ORN) is a severe late complication affecting patients with head and neck cancer (HNC) treated with radiation therapy (RT) that significantly impacts patients' quality of life and can require costly interventions. Although radiation dose is a key factor, other clinical and demographic risk factors also influence ORN development. Previous predictive models have primarily been single-institutional, limiting their generalizability. In this first analysis from the PREDMORN Consortium, we have aimed to reproduce existing statistical association and modeling analyses on the largest and most diverse mandibular ORN cohort worldwide to allow comparison with previous studies. This retrospective multi-institutional study included 3928 patients with HNC (622 ORN cases) from 8 institutions. Clinical, demographic, and dosimetric variables were analyzed to develop a prediction model (any grade ORN vs no ORN) using forward stepwise logistic regression with correlation-based variable preselection. The ORN normal tissue complication probability (NTCP) model was developed on 80% of data from 6 institutions, tested on the remaining unseen 20%, and externally validated on a matched cohort (58 patients, 19 ORN cases) and a large population-based cohort (2687 patients, 215 ORN cases). Key predictors of ORN were D30%, V70Gy, pre-RT dental extractions, and smoking status. The ORN NTCP model demonstrated very good calibration on the population-based external cohort (Brier score, 0.077; Log Loss, 0.281). Model discrimination improved on a subcohort including oropharyngeal and locally advanced larynx/hypopharynx cancer cases only (AUC from 0.69 to 0.75 and from 0.65 to 0.67 on the matched and the population-based external cohorts, respectively). The PREDMORN NTCP model is the largest multi-institutional effort to date aimed at predicting ORN risk in patients with HNC using real-world data. The model demonstrated good generalizability when externally validated to a large population-based cohort. Our observations align with current guidelines and corroborate findings from smaller single-institution studies.

ABSTRACTBackground and AimsChildren with cerebral palsy (CP) are vulnerable to respiratory infections and chronic airway inflammation, which leads to diminished respiratory function. This decline is exacerbated by muscle tone abnormalities and reduced strength, worsening as CP progresses. Traditional lung function tests are often impractical for those with severe cognitive and motor impairments. Diaphragm evaluation through ultrasound imaging emerges as a non‐invasive, easy‐to‐apply technique for assessing respiratory function in CP children. This study aimed to evaluate diaphragm function in CP and typically developing (TD) children using ultrasound, focusing on diaphragm thickness and excursion parameters. The study also explored factors influencing respiratory function, particularly the number of lower respiratory tract infections (LRTI).MethodsThe study included 10 CP (11.2; range 4–17 years) and 12 TD children (8.9 years; range 4–13 years). M‐mode ultrasound assessed diaphragm thickness, thickening fraction (TF), and inspiratory slope (IS). Additionally, data on demographics, anthropometrics, medical history, and physical examination were collected.ResultsThe intra‐operator reliability for diaphragm ultrasound measurements showed good to excellent consistency (over 0.86). Significant differences were found between CP and TD children; CP children exhibited lower excursion and IS, with a non‐significant trend towards reduced diaphragm thickness. LTRI were associated to decreased excursion and IS, and increased TF in CP children.ConclusionsDiaphragmatic ultrasound is a non‐invasive, reproducible tool for assessing respiratory function in both CP and TD children, even in cases of severe cognitive and motor impairment. It effectively identifies diaphragm dysfunction associated with LRTI.

ABSTRACTIntroductionIndividuals who attempt suicide are at high risk of recurrence and mortality, particularly in the first year. Nurse‐led follow‐up programmes can mitigate this risk through structured, therapeutic engagement.AimTo examine adherence to a nurse‐led mental health follow‐up programme and its association with the recurrence of suicidal behaviours.MethodThis cohort study included 306 adults who had attempted suicide, who were enrolled in a one‐year suicidal behaviour case management programme (SBCMP) led by mental health nurses. Outcomes for programme completers were compared with non‐completers. Adherence was assessed at 12 months, while suicide attempts and mortality were tracked over 24 months.ResultsAll five scheduled SBCMP visits were completed by 48% of patients. Programme adherence was associated with significantly lower rates of psychiatric hospitalisation (4.8% vs. 11.3%; p = 0.036) and of repeated suicide attempts at 6 months (3.4% vs. 10.1%; p = 0.02) and 12 months (8.2% vs. 15.9%; p = 0.039). No suicides occurred in the first year; however, a suicide (1%) was recorded in the second year.DiscussionThis study highlights the role of structured follow‐up programmes led by mental health nurses in improving treatment adherence and reducing suicidal behaviour.Implications for PracticeIntegrating suicide prevention interventions in clinical practice is a cost‐effective strategy to support high‐risk individuals and improve outcomes.

Primary empty sella (PES) consists of herniation of the suprasellar subarachnoid space within the sella turcica in patients with no history of sellar pathology. Diagnosis is mostly made incidentally. Describe the characteristics of patients with PES. Patients with PES from 6 Argentine centers specialized in Neuroendocrinology in Buenos Aires diagnosed between 1997-2021 were included. Diagnosis was based in sellar magnetic resonance, pituitary functional evaluation by baseline hormonal measurement and visual function assessed by neuro-ophthalmological evaluation and campimetry. Sixty-three patients with a mean age of 52.3 ± 13.2 years and a predominance of female gender (79%, 4:1 ratio) were included. The average BMI was 32.7 ± 8.13 kg/m2 and 68% were overweight or obese. HTA was also found in 59%. Among women, the parity frequency was 78%: 92% had multiple pregnancies. The diagnosis was incidental in 22%. In symptomatic patients (n= 49), the reasons for consultation were headache in 61%, symptoms of endocrine dysfunction in 51% and visual disturbances in 33%: 43% of the patients presented multiple symptoms. MRI showed partial PES in 63% and total PES in 37% of the patients. In the biochemical evaluation, hypopituitarism was observed in 46%. Although the diagnosis of PES can be made incidentally, in our series most of the patients presented symptoms. Most of them were multiparous women, obese and hypertensive patients. Biochemical evaluation should be carried out to investigate isolated or multiple pituitary deficits in order to indicate the corresponding replacement treatment.