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Complex distal femoral fracture (DFF) in the elderly patient is an infrequent but challenging scenario. In these fragile patients, DFF is associated with a high rate of medical complications and mortality. The optimum treatment remains controversial. Our aim is to propose our standard treatment, describe our results and discuss its clinical relevance. We describe three cases of elderly and fragile patients with multiple comorbidities who suffered a complex DFF after low energy trauma. They were successfully treated through a primary arthroplasty with distal femoral replacement (DFR). All the three patients presented early full weight-bearing mobilization (average time to first ambulation was five days), good functional outcome (mean knee range of motion was 103°) and short hospital length of stay (mean of ten days). According to our experience, primary arthroplasty with DFR could be a good therapeutic option for complex DFF in elderly patients. Resumen: La fractura femoral distal (FFD) compleja en el paciente anciano es infrecuente, pero su manejo es un desafío. En estos pacientes frágiles, la FFD se asocia a un elevado riesgo de complicaciones médicas y mortalidad. Su tratamiento óptimo sigue siendo controvertido. El objetivo del estudio es proponer nuestro tratamiento estándar, describir nuestros resultados y discutir su relevancia clínica. Reportamos 3 casos de pacientes ancianos y frágiles con múltiples comorbilidades que sufrieron una FFD compleja a causa de un traumatismo de baja energía. Fueron tratados con éxito mediante un reemplazo femoral distal (RFD). Los 3 pacientes presentaron una movilización precoz con carga completa (la media hasta la primera deambulación fue 5 días), buenos resultados funcionales (la media de rango de movimiento de la rodilla fue 103̊) y una estancia hospitalaria breve (media de 10 días). Según nuestra experiencia, la artroplastia primaria podría ser una buena elección terapéutica para las FFD complejas en los pacientes ancianos.

Resumen: La fractura femoral distal (FFD) compleja en el paciente anciano es infrecuente, pero su manejo es un desafío. En estos pacientes frágiles, la FFD se asocia a un elevado riesgo de complicaciones médicas y mortalidad. Su tratamiento óptimo sigue siendo controvertido. El objetivo del estudio es proponer nuestro tratamiento estándar, describir nuestros resultados y discutir su relevancia clínica. Reportamos 3 casos de pacientes ancianas y frágiles con múltiples comorbilidades que presentaron una FFD compleja a causa de un traumatismo de baja energía. Fueron tratadas con éxito mediante un reemplazo femoral distal. Las 3 pacientes presentaron una movilización precoz con carga completa (la media hasta la primera deambulación fue de 5 días), buenos resultados funcionales (la media de rango de movimiento de la rodilla fue de 103̊) y una estancia hospitalaria breve (media de 10 días). Según nuestra experiencia, la artroplastia primaria podría ser una buena elección terapéutica para las FFD complejas en los pacientes ancianos. Abstract: Complex distal femoral fracture (DFF) in the elderly patient is an infrequent but challenging scenario. In these fragile patients, DFF is associated with a high rate of medical complications and mortality. The optimum treatment remains controversial. Our aim is to propose our standard treatment, describe our results and discuss its clinical relevance. We describe 3 cases of elderly and fragile patients with multiple comorbidities who suffered a complex DFF after low energy trauma. They were successfully treated through a primary arthroplasty with distal femoral replacement. All the 3 patients presented early full weight-bearing mobilization (average time to first ambulation was 5 days), good functional outcome (mean knee range of motion was 103°) and short hospital length of stay (mean of 10 days). According to our experience, primary arthroplasty with distal femoral replacement could be a good therapeutic option for complex DFF in elderly patients.

Introduction and Objectives: Late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) allows noninvasive detection of left atrial fibrosis in patients with atrial fibrillation (AF). However, whether the same methodology can be used in the right atrium (RA) remains unknown. Our aim was to define a standardized threshold to characterize RA fibrosis in LGE-CMR., Methods: A 3 Tesla LGE-CMR was performed in 53 individuals; the RA was segmented, and the image intensity ratio (IIR) calculated for the RA wall using 1 557 767 IIR pixels (40 994±10 693 per patient). The upper limit of normality of the IIR (mean IIR+2 standard deviations) was estimated in healthy volunteers (n=9), and patients who had undergone previous typical atrial flutter ablation (n=9) were used to establish the dense scar threshold. Paroxysmal and persistent AF patients (n=10 each) were used for validation. IIR values were correlated with a high-density bipolar voltage map in 15 patients undergoing AF ablation., Results: The upper normality limit (total fibrosis threshold) in healthy volunteers was set at an IIR = 1.21. In the postablation group, 60% of the maximum IIR pixel (dense fibrosis threshold) was calculated as IIR = 1.29. Endocardial bipolar voltage showed a weak but significant correlation with IIR. The overall accuracy between the electroanatomical map and LGE-CMR to characterize fibrosis was 56%., Conclusions: An IIR > 1.21 was determined to be the threshold for the detection of right atrial fibrosis, while an IIR > 1.29 differentiates interstitial fibrosis from dense scar. Despite differences between the left and right atria, fibrosis could be assessed with LGE-CMR using similar thresholds in both chambers., (Copyright © 2023 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Magnetic resonance has become a first-line imaging modality in various clinical scenarios. The number of patients with different cardiovascular devices, including cardiac implantable electronic devices, has increased exponentially. Although there have been reports of risks associated with exposure to magnetic resonance in these patients, the clinical evidence now supports the safety of performing these studies under specific conditions and following recommendations to minimize possible risks. This document was written by the Working Group on Cardiac Magnetic Resonance Imaging and Cardiac Computed Tomography of the Spanish Society of Cardiology (SEC-GT CRMTC), the Heart Rhythm Association of the Spanish Society of Cardiology (SEC-Heart Rhythm Association), the Spanish Society of Medical Radiology (SERAM), and the Spanish Society of Cardiothoracic Imaging (SEICAT). The document reviews the clinical evidence available in this field and establishes a series of recommendations so that patients with cardiovascular devices can safely access this diagnostic tool., (Copyright © 2022 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: Total knee arthroplasty (TKA) is a surgery that aims to restore function and relieve pain in advanced osteoarthritis. The Educational Workshop (EW) for TKA is given to patients in the pre-surgery period to inform them and facilitating their participation in their health process (empowerment). The aim of this study was developing and validating a self-administered questionnaire to evaluate the acquired knowledge after the EW by the patients who will undergo the TKA procedure., Material and Methods: It was a longitudinal and prospective observational study with a sample of TKA candidate patients. The phases for the construction and validation of this ad hoc questionnaire were: Phase 1: A panel of experts who agreed on a final questionnaire of 20 items; Phase 2: Pilot test administered to 47 patients; Phase 3: Final test of 11 items administered to 50 patients, before and after the EW; Phase 4: Re-test, after the EW and 2 weeks after, administered to 58 patients., Results: One hundred and fifty five patients were included. The Cronbach's alpha coefficient for the item's internal consistency of the final questionnaire, 11 items, was 0.78. To reach the criterion validity, in pre-EW the mean number of hits was: 4.92 (SD=1.78) and in post-EW 10.68 (SD=0.55), a difference that had a statistical significance p<.0001, with no overlap in the 95% CI of the mean: 4.46-5.38/10.54-10.82. The test for stability and reliability, re-test, obtained a mean of right answers 10.87 (SD=0.33) and for the re-test of 10.70 (SD=0.59). The correlation of the interclass coefficient for the re-test was 0.99, which corresponds almost to a maximum concordance., Conclusions: The questionnaire developed in this study is a reliable and easy tool to evaluate the acquired knowledge in the EW for patients who will be TKA operated., (Copyright © 2021 FECA. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: Process indicators have been widely used to monitor the way trauma care is provided. We aimed to analyze whether data from a hospital's severe trauma register could facilitate the evaluation of aspects of the initial management of severe injuries., Material and Methods: Observational, retrospective population-based study. A working group of experts selected a set of trauma care process indicators relevant to some aspects of initial care, diagnosis, and treatment of severely injured patients. Four of the indicators referred to prehospital care and 5 to hospital care. We calculated the observed and expected compliance rates for all the indicators., Results: A total of 1526 cases (44.4%) were analyzed for 2013; 1908 (55.6%) were analyzed for 2014. We were able to evaluate 3 of the 4 prehospital process indicators: endotracheal intubation in patients with a score of 􀀀 8 on the Glasgow coma scale (GCS) (84% compliance), venous access established before hospital arrival (83.4%), and placement of a neck collar to immobilize the cervical spine (72.7%). Compliance for the hospital-phase indicators were as follows: performance of a computed tomography scan of the head within 60 minutes in cases with a GCS of 􀀀 13 (5.3% compliance, craniotomy in candidate patients within 2 hours of diagnosis (65%), diagnostic examination for abdominal injuries within 60 minutes in patients with systolic blood pressure 􀀀 90 mm Hg (89.3%), and therapeutic laparotomy or angiography within 4 hours of abdominal injury in candidate patients with systolic blood pressure 􀀀 90 mm Hg (51.7%). Compliance was 69.9% for the last process indicator: surgical treatment of open fractures within 8 hours of an accident., Conclusion: Our findings show that a hospital trauma register provides data about care process indicators that can allow us to monitor the quality of care of severely injured patients.

In recent years, rapid technological advances have allowed the development of new electrophysiological procedures that would not have been possible without the parallel development of imaging techniques used to plan and guide these procedures and monitor their outcomes. Ablation of atrial fibrillation is among the interventions with the greatest need for imaging support. Echocardiography allows the appropriate selection of patients and the detection of thrombi that would contraindicate the intervention; cardiac magnetic resonance imaging and computed tomography are also essential in planning this procedure, by allowing a detailed anatomical study of the pulmonary veins. In addition, in cardiac resynchronization therapy, echocardiography plays a central role in both patient selection and, later, in device adjustment and in assessing the effectiveness of the technique. More recently, ablation of ventricular tachycardias has been established as a treatment option; this would not be possible without planning using an imaging study such as cardiac magnetic resonance imaging of myocardial scarring., (Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

The development of myocardial fibrosis is a common process in the appearance of ventricular dysfunction in many heart diseases. Magnetic resonance imaging makes it possible to accurately evaluate the structure and function of the heart, and its role in the macroscopic characterization of myocardial fibrosis by late enhancement techniques has been widely validated clinically. Recent studies have demonstrated that T1-mapping techniques can quantify diffuse myocardial fibrosis and the expansion of the myocardial extracellular space in absolute terms. However, further studies are necessary to validate the usefulness of this technique in the early detection of tissue remodeling at a time when implementing early treatment would improve a patient's prognosis. This article reviews the state of the art for T1 mapping of the myocardium, its clinical applications, and its limitations., (Copyright © 2016 SERAM. Published by Elsevier España, S.L.U. All rights reserved.)

Cardiac magnetic resonance imaging is considered the reference technique for characterizing myocardial tissue; for example, T2-weighted sequences make it possible to evaluate areas of edema or myocardial inflammation. However, traditional sequences have many limitations and provide only qualitative information. Moreover, traditional sequences depend on the reference to remote myocardium or skeletal muscle, which limits their ability to detect and quantify diffuse myocardial damage. Recently developed magnetic resonance myocardial mapping techniques enable quantitative assessment of parameters indicative of edema. These techniques have proven better than traditional sequences both in acute cardiomyopathy and in acute ischemic heart disease. This article synthesizes current developments in T2 mapping as well as their clinical applications and limitations., (Copyright © 2014 SERAM. Published by Elsevier España, S.L.U. All rights reserved.)

Aim: The treatment of intertrochanteric fractures using a minimally invasive dynamic hip screw (MIDHS) technique has been reported to provide better results than the conventional technique (CDHS). The present study aims to determine whether there are any differences in terms of transfusion needs, morbidity, length of hospital stay, and economical costs, based on a study of two retrospective cohorts., Material and Method: Cohorts study of 80 patients with intertrochanteric femoral fractures (31-A1 and 31-A2.1) who underwent DHS procedure from July 2005 to September 2007; 40 of them were treated using the traditional technique (CDHS), and the other 40 using the minimally invasive technique (MIDHS)., Results: No differences were found in terms of blood loss, transfusion requirements or morbidity. Mean hospital stay for MIDHS group was 1.3 days lower, reducing the costs regarding the CDHS group by €306.3, but this difference was not statistically significant (P=.3). The time required to perform the surgery was shorter for the MIDHS group: 49.3 versus 78.8minutes (p=0.0001)., Discussion: Contrary to previous studies published, the present study did not show any advantage for the MIDHS technique, except for a shorter surgical time to perform the procedure. We consider that the MIDHS could help in improving operating room productivity and efficiency., (Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.)

Unlabelled: Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit., Intervention: collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions., Main Outcome Measures: frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)

Aim: Retrospective review of long term biphosphonates treated patients who sustained a subtrochanteric or diaphyseal femoral fracture with an atypical pattern. A literature review is presented as an update of the topic., Material and Methods: A retrospective study was conducted on 13 subtrochanteric or diaphyseal fractures in female patients treated with biphosphonates at our institution from September 2007 to March 2011., Results: Four cases of subtrochanteric fractures and 13 diaphyseal fractures were detected. Four patients had bilateral fractures. All cases but one (that affected only the lateral cortex) were complete fractures. Surgically, these kinds of fractures are demanding due to the hardness of the bones., Discussion: It is difficult to know if there is any relationship between bisphosphonates treatment and atypical femoral fractures. Nevertheless, current literature supports a greater benefit of their use in preventing vertebral and non-vertebral fractures. For this reason, biphosphonates continue being considered as a first choice in the prevention of osteoporotic fractures., Conclusions: Patients on long-term treatment with bisphosphonates may present atypical femoral fractures as a complication. It is considered that the maximum period for biphosphonates treatment should not exceed 5 years., (Copyright © 2012 SECOT. Published by Elsevier Espana. All rights reserved.)

Currently there is limited information on the indications for the use of cortical allograft for the treatment of periprosthetic fractures on a stable stem. The purpose of this study was to retrospectively evaluate the treatment and the results obtained in this type of fractures and propose a series of criteria for the use of cortical allograft. Between 2003 and 2008 a total of 31 periprosthetic femur fractures were treated at our institution. Twelve of them were classified as B1: 6 were treated with a Dall-Miles (Stryker) system plate and 6 with the same plate supplemented with a structural cortical allograft over the medial cortex of the femur (DM and DM-Allo groups, respectively). An evaluation of the clinical and radiologic results was performed in the latest follow-up available. A patient in the DM-Allo group had rupture of a screw and 10 degrees varization; the fracture healed despite this and the patient had a satisfactory clinical course. The Oxford Hip Score was 9 points lower in the DM group compared with the DM-Allo group, and the EQ-5D health scale was 0.10 better for the DM group. The DM-Allo group had a longer hospital stay and more transfusion-related requirements. We think that the patients with clinical or radiologic criteria of osteoporotic bone may benefit from the use of a cortical allograft to favor healing and increase the bone stock. However, those advantages should be weighed considering the higher risk of surgical-related morbidity associated with the surgical insult.

Background: Group A Streptococcal (GAS) infections have increased in frequency and severity worldwide. During April 1996, a nosocomial outbreak associated to GAS infections affected seven patients admitted to a pediatric burn unit. The causative organism was likely disseminated from the source patient to another child in the emergency room before he was transferred to the burn unit. Patients developed burn infections or invasive disease. One of them died due to a toxic shock syndrome and 3 other lost their skin grafts. Perineal and nasal microbiological surveillance of 42 related health care workers identified only one of them as carrier of S pyogenes., Aim: To report a molecular analysis of an apparently clonal outbreak., Material and Methods: The available isolates were analyzed by molecular methods including random amplified polymorphic DNA analysis (RAPD) with 4 different primers, Sma-I pulsed field gel electrophoresis (PFGE) analysis, and speA, speB and speC detection by polymerase chain reaction (PCR)., Results: Two phylogenetically distant and sequentially isolated bacterial groups were identified either by RAPD analysis with selected primers or by Smal-PFGE analysis. The first group involved isolates identified in two patients that included the lethal case. The second bacterial group comprised 5 clinical isolates and the perineal and nasal isolates obtained from a health care worker. Only strains belonging to the first group harbored the speA gene and were associated with invasive disease. The second group could be split further in two subgroups according to their speB profile., Conclusions: RAPD analysis with selected primers can reproduce the PFGE-discriminating ability on the epidemiological analysis of GAS infections.

Background: Spinal tuberculosis can produce kyphosis with neurologicaldeficit, despite antibiotic treatment. When there is no response to medical treatment, the recommended procedure is debridementand interbody fusion with bone autograft. The biological characteristicsof Mycobacterium tuberculosis do not prevent osteosynthesisof the infected bone from being performed., Patients and Method: Five patients with spinal tuberculosis and neurological deficitunderwent debridement, interbody fusion and anterior osteosynthesisin addition to medical treatment. In order to ensure stability, posterior fusion was also performed in three patients. All 5 patientsdisplayed weakness and paralysis of their lower extremities, two patients suffered an L4 radiculopathy, one developed paraparesiaand one was excluded due to a short follow-up. Mean value of vertebralkyphosis was 22,8 degrees and mean follow-up was 3,1 years., Results: No patient had septic loosening or progression of the disease. Correction of kyphosis was 104,5% postoperatively and 80,5% atthe end of follow-up. All patients, apart from one with an L4radiculopathy, exhibited neurological recovery., Conclusions: Anterior instrumentation allows spinal decompression, septic focusdebridement, deformity correction and autologous bone grafting. In severe kyphotic flattening, it is advisable to associate alimited posterior arthrodesis. When pathological fractures appearor there is no response to antibiotic treatment, the combinationof medical and surgical treatment improves patients' outcome.

Since 1994 an extensive epidemic of infections with Salmonella enteritidis (S. enteritidis) has affected Chile. In order to understand the diversity of infective sources, the possible origin of the epidemic, and the epidemiological relationships between clinical, food, and poultry isolates, we carried out phage typing of three groups of samples: 1) 310 S. enteritidis clinical samples collected between 1975 and 1996, 2) 47 food isolates obtained during S. enteritidis outbreaks, and 3) 27 strains isolated in surveillance studies of poultry-raising establishments. With the clinical samples, a total of 13 phage types were identified, 2 isolates could not be typed, and 1 was considered atypical. The phage types that were identified most frequently were 1 (56.8%) and 4 (31.3%), trailed by type 8 (4.8%) and type 28 (1.9%). Over time and in different regions of the country there were major changes in the distribution of the phage types. In the first years of collection the only phage types registered were 8 and 28, which disappeared around 1980 and then began reappearing sporadically in 1996. With the gradual S. enteritidis expansion that started in 1988, in the central and southern areas of the country phage type 4 began to appear; that type had not been found before in Chile. In 1991 in the northern area of the country phage type 1 began to predominate; it was another type that had not been reported before in Chile. In the food isolates the only phage types identified were 1 and 4, which were also the most common in the poultry isolates. Phage typing of S. enteritidis has proved to be useful in guiding the epidemiological analysis of the infections caused by this pathogen.

Background: Salmonella enteritidis (SE) is a frequent cause of diarrhea, and is transmitted mainly by SE contaminated eggs or poultry meat. The frequency of SE contaminated eggs or chicken meat and the risk for acquiring this pathogen is unknown in Chile., Aim: To measure SE contamination in eggs poultry meat and entrails offered in retail markets in the Metropolitan Area during two consecutive years (1998-1999)., Material and Methods: Samples were placed in sterile bags and transported to the laboratory before 4 hours at 4 degrees C. Microbiologic detection was done using a standard procedure and an immunodetection assay., Results: SE was found in one of 1081 egg samples (0.09%). The contaminated sample was offered in a supermarket under their own commercial name. Six percent of 1154 poultry meat samples were contaminated by SE and 2.3% by other Salmonella serotypes. Entrails had even higher rates with 10.2% of 370 samples harboring SE and 2.7% other serotypes. Total Salmonella sp. isolates and SE isolates declined during 1999. Nine SE phagotypes were identified, predominating types 4 and 7., Conclusions: Eggs and other avian products are contaminated by different SE phagotypes and other Salmonella serotypes, implicating a risk for the consumers (Rev Méd Chile 2000; 128: 1075-83).

Background: Salmonella enteritidis infections have increased worldwide in the last years. Isolation of this pathogen was remarkably rare in Chile until 1994, when the still ongoing outbreak emerged., Aim: To assess the main epidemiological characteristics of the Salmonella enteritidis epidemic in Chile., Materials and Methods: Cases of clinical infections by Salmonella enteritidis were recorded from bacteriological and demographic notifications obtained at The National Reference Laboratory for Enterobacteria. Infection rates were calculated using the total Chilean population and the population of the different Health Services along the country., Results: Until 1993, 13.67 Salmonella enteritidis strains per year were received at the Reference Laboratory. The figures increased to 478 and 432 in 1994 and 1995, respectively. National rates were 3.41 and 3.04 notifications/100,000 inhabitants in 1994 and 1995 respectively. Northern regions were the most affected and 90% of observed cases during 1994 came from Arica and Antofagasta. At the present time, 20% of cases are observed in Santiago, located in the mid-portion of the country. The outbreak has mainly affected children and young adults (70% of cases). Strains have been isolated from stool cultures, suggesting gastrointestinal infections as the main clinical presentation. More than 98% of strains are susceptible to chloramphenicol, ampicillin, tetracycline, sulfa-trimetroprim, cefotaxime or ciprofloxacin., Conclusions: The obtained data clearly indicate the existence of an epidemic outbreak of Salmonella enteritidis infections, with a geographic progression from North to South.

After a period of time of 5 years, we made a review of all the patients registered at our Center. Eight cases of closed traumatism at the scapulohumeral belt, with vascular injury associated (0.2% of all closed traumatisms at this level registered in our center during this time) were reported. Six patients presented also an osteoarticular injury associated. Three different vascular injuries were showed: three cases of complete arterial section, two arterial contusions and a partial arterial section. From the two cases without osteoarticular injuries, one of them showed a complete section and the other presented an arterial contusion. Polytraumatic patients showed multiple osteoarticular injuries. We registered one fracture-luxation at the shoulder, 3 diafisaric humeral fractures, one humeral neck fracture, one clavicle fracture, one fracture-luxation at the cervical column and one simple luxation of the shoulder.

Authors present their experience (32 patients affected by a traumatic femoropopliteal injury) with vascular traumatisms at the lower limb. Causes, treatment and successful results with the new technics and the early clinical management to the patients are commented.