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Background: KRAS mutation is a negative prognostic factor for colorectal liver metastases. Several studies have investigated the resection margins according to KRAS status, with conflicting results. The aim of the study was to assess the oncologic outcomes of R0 and R1 resections for colorectal liver metastases according to KRAS status., Methods: All patients who underwent resection for colorectal liver metastases between 2010 and 2015 with available KRAS status were enrolled in this multicentric international cohort study. Logistic regression models were used to investigate the outcomes of R0 and R1 colorectal liver metastases resections according to KRAS status: wild type versus mutated. The primary outcomes were overall survival and disease-free survival., Results: The analysis included 593 patients. KRAS mutation was associated with shorter overall survival (40 vs 60 months; P = .0012) and disease-free survival (15 vs 21 months; P = .003). In KRAS-mutated tumors, the resection margin did not influence oncologic outcomes. In multivariable analysis, the only predictor of disease-free survival and overall survival was primary tumor location (P = .03 and P = .03, respectively). In KRAS wild-type tumors, R0 resection was associated with prolonged overall survival (74 vs 45 months, P < .001) and disease-free survival (30 vs 17 months, P < .001). The multivariable model confirmed that R0 resection margin was associated with prolonged overall survival (hazard ratio = 1.43, 95% confidence interval: 1.01-2.03) and disease-free survival (hazard ratio = 1.42; 95% confidence interval: 1.06-1.91)., Conclusions: KRAS-mutated colorectal liver metastases showed more aggressive tumor biology with inferior overall survival and disease-free survival after liver resection. Although R0 resection was not associated with improved oncologic outcomes in the KRAS-mutated tumors group, it seems to be of paramount importance for achieving prolonged long-term survival in KRAS wild-type tumors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Our aim is to analyze the differences between sporadic gastrointestinal stromal tumors and those associated with other tumors., Methods: Retrospective cohort study including patients with diagnosis of gastrointestinal stromal tumors operated at our center. Patients were divided into two groups, according to whether or not they had associated other tumors, both synchronously and metachronously. Disease free survival and overall survival were calculated for both groups., Results: 96 patients were included, 60 (62.5%) were male, with a median age of 66.8 (35-84). An association with other tumors was found in 33 cases (34.3%); 12 were synchronous (36.3%) and 21 metachronous (63.7%). The presence of mutations in associated tumors was 70% and in non-associated tumors 75%. Associated tumors were classified as low risk tumors based on Fletcher's stratification scale (p = 0.001) as they usually were smaller in size and had less than ≤5 mitosis per 50 HPF compared to non-associated tumors. When analyzing overall survival, there were statistically significant differences (p = 0,035) between both groups., Conclusion: The relatively high proportion of gastrointestinal stromal tumors cases with associated tumors suggests the need to carry out a study to rule out presence of a second neoplasm and a long-term follow-up should be carried out in order to diagnose a possible second neoplasm. Gastrointestinal stromal tumors associated with other tumors have usually low risk of recurrence with a good long-term prognosis., (Copyright © 2023 AEC. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To evaluate the feasibility, safety, and effectiveness of gastric conditioning using preoperative arterial embolization (PAE) before McKeown esophagectomy at a tertiary university hospital., Background: Cervical anastomotic leakage (AL) is a common complication of esophagectomy. Limited clinical evidence suggests that gastric conditioning mitigates this risk., Methods: This pilot randomized clinical trial was conducted between April 2016 and October 2021 at a single-center tertiary hospital. Eligible patients with resectable malignant esophageal tumors, suitable for cervical esophagogastrostomy, were randomized into 2 groups: one receiving PAE and the other standard treatment. The primary endpoints were PAE-related complications and incidence of cervical AL., Results: The study enrolled 40 eligible patients. PAE-related morbidity was 10%, with no Clavien-Dindo grade III complications. Cervical AL rates were similar between the groups (35% vs 25%, P = 0.49), even when conduit necrosis was included (35% vs 35%, P = 1). However, AL severity, including conduit necrosis, was higher in the control group according to the Clavien-Dindo ≥IIIb (5% vs 30%, P = 0.029) and Comprehensive Complication Index (20.9 vs 33.7, P = 0.01). No significant differences were found in other postoperative complications, such as pneumonia or postoperative mortality., Conclusions: PAE is a feasible and safe method for gastric conditioning before McKeown minimally invasive esophagectomy and shows promise for preventing severe AL. However, further studies are required to confirm its efficacy., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives: Hypertension (HT) is a key risk factor for stroke. We evaluated whether the importance of hypertension on the risk of ischemic stroke has increased in recent decades., Methods: Retrospective study of patients with ischemic stroke discharged from 3 hospitals in Seville (Spain), during the periods: 1999-2001, 2014-2016 and 2019-2020., Results: 1,379 patients were included, 42.6% women, mean age 69.1 (±11) years. HT was the most prevalent vascular risk factor in all periods, with a progressive increase in hypertensive patients (65.9% vs 69.6% vs 74%; P=.029). HT was especially frequent in patients≥80 years (73% vs 81.9% vs 85.2%; P=.029). At discharge, progressively more antihypertensive drugs were used (in 65% vs 85.1 vs 90.2% of patients; P=.0001), with a clear increase in the number of antihypertensive drugs used (mean 0.9±0.8 vs 1.5±1 vs 1.8±0.8 drugs, P=.0001). The use of diuretics (13.7%-39.3%-65.3%; p=0.0001), ACE inhibitors (35.5%-43.3%-53.4%; P=.0001) and angiotensin receptor blockers (12.2%-24%-32.4%; P=.0001) increased progressively. On the contrary, the use of calcium antagonists decreased (24%-19.9%-13.7%; P=.0001)., Conclusions: In the last 2 decades there has been a greater role for HT among patients with their first ischemic cerebrovascular event. Greater and better control of HT is necessary to reduce the enormous burden of cerebrovascular disease., (Copyright © 2023 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Population aging has caused an increase in strokes in very elderly patients (VEP). We assess how secondary prevention of ischemic stroke has changed in VEP in recent decades., Method: Retrospective study of discharges due to ischemic stroke in the Virgen Macarena, Virgen del Rocio and Valme hospitals in Seville (Spain), during the periods 1999-2001, 2014-16 and 2019-2020. VEP were considered those with ≥80 years., Result: We studied 1806 patients, 349 (19.3%) were VEP. Over the years, VEPs have doubled (13.5% vs. 25.9% and 28% p = 0.0001) and age has increased (83.3 ± 3 vs. 84.1 ± 3 vs. 85.2 ± 4 p = 0.001). Comparing the periods, the VEPs have more hypertension (69.9% vs. 84.8% vs. 84.6%; p = 0.0001) and dyslipidemia (12% vs. 41.7% vs. 52.3%; p = 0.0001) and have prescribed more antihypertensives (69.1% vs. 86.7% vs. 92.3%; p = 0.0001), statins (5.3% vs. 78% vs. 81.5%; p = 0.0001) and anticoagulants (16.5% vs. 19.4% vs. 53.1%; p = 0.001), increasing the number of antihypertensives (1 ± 0.9 vs. 1.6 ± 0, 9 vs. 1.9 ± 0.8 drugs p = 0.0001), and high-intensity statins (2.3% vs. 42.7 vs. 69.2% p = 0.0001). Comparing the VEPs with the younger ones, there were no differences in antihypertensive treatment in any period, there were differences in antithrombotic treatment in the first period, and with statins the differences were maintained until the end., Conclusions: In the last 20 years the number of VEPs has doubled, exceeding a quarter of the discharges. Although there is improvement in secondary stroke prevention in VEPs, there is room for improvement., (Copyright © 2023 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Introduction: The role of statins after ischaemic stroke changed with the publication of the SPARCL study in 2006. We analyse how this has influenced the prescription of statins in this patient population., Methods: We conducted a retrospective study of patients discharged with ischaemic stroke at the Virgen Macarena, Virgen del Rocío, and Valme hospitals in Seville (Spain) over two periods: 1999-2001 and 2014-2016., Results: The study included 1575 patients: 661 (42%) were women and mean age (standard deviation) was 69 (10) years. Patients from the later period are older (68 [10] vs 71 [11]; P = .0001); include a higher proportion of women; and present higher rates of dyslipidaemia, hypertension, and diabetes. At discharge, statins were used in 18.7% of patients (vs 86.9% in the first period; P = .0001), with high-intensity statins prescribed in 11.1% of cases (vs 54.4%; P = .0001). In both periods, atorvastatin was the most commonly prescribed statin (80 mg: 6% vs 42.7%; 40 mg: 5.1% vs 11.1%). In the first period, the use of statins and high-intensity statins was correlated with hypercholesterolaemia, and inversely correlated with age. In the second period, statin use was correlated with hypertension and hypercholesterolaemia, and high-intensity statin use was correlated with ischaemic heart disease and inversely correlated with age., Conclusion: There has been a clear change in the prescription of statins to patients with ischaemic stroke at discharge. However, many patients remain undertreated and the use of these drugs needs to be optimised., (Copyright © 2020 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: There is still debate regarding the principal role and ideal timing of perioperative chemotherapy (CTx) for patients with upfront resectable colorectal liver metastases (CRLM). This study assesses long-term oncological outcomes in patients receiving neoadjuvant CTx only versus those receiving neoadjuvant combined with adjuvant therapy (perioperative CTx)., Methods: International multicentre retrospective analysis of patients with CRLM undergoing liver resection between 2010 and 2015. Characteristics and outcomes were compared before and after propensity score matching (PSM). Primary endpoints were long-term oncological outcomes, such as recurrence-free survival (RFS) and overall survival (OS). Furthermore, stratification by the tumour burden score (TBS) was applied., Results: Of 967 patients undergoing hepatectomy, 252 were analysed, with a median follow-up of 45 months. The unmatched comparison revealed a bias towards patients with neoadjuvant CTx presenting with more high-risk patients (p = 0.045) and experiencing increased postoperative complications ≥Clavien-Dindo III (20.9% vs. 8%, p = 0.003). Multivariable analysis showed that perioperative CTx was associated with significantly improved RFS (hazard ratio [HR] 0.579, 95% confidence interval [CI] 0.420-0.800, p = 0.001) and OS (HR 0.579, 95% CI 0.403-0.834, p = 0.003). After PSM (n = 180 patients), the two groups were comparable regarding baseline characteristics. The perioperative CTx group presented with a significantly prolonged RFS (HR 0.53, 95% CI 0.37-0.76, p = 0.007) and OS (HR 0.58, 95% CI 0.38-0.87, p = 0.010) in both low and high TBS patients., Conclusions: When patients after resection of CRLM are able to tolerate additional postoperative CTx, a perioperative strategy demonstrates increased RFS and OS in comparison with neoadjuvant CTx only in both low and high-risk situations., (© 2022. Society of Surgical Oncology.)

Background: Data on the management of elderly patients with extensive colorectal liver metastases (CRLM) are scarce and conflicting. This study assesses differences in management and long-term oncological outcomes between older and younger patients with CRLM and a high Tumour Burden Score (TBS)., Methods: International multicentre retrospective study on patients with CRLM and a category 3 TBS, submitted to liver resection. Patients were divided into two groups according to their age (younger and older than 75) and were compared using propensity score matching (PSM) analysis and multivariable regression models. Differences in management and oncological outcomes including recurrence-free survival (RFS) and overall survival (OS) were assessed., Results: The study included 386 patients, median follow-up was 48 months. The unmatched comparison revealed a higher ASA score (p = 0.035), less synchronous CRLM (47% vs 68%, p = 0.003), a lower median number of lesions (1 vs 3, p = 0.004) and less perioperative chemotherapy (CTx) (66% vs 88%, p < 0.001) in the elderly group. Despite the absence of CTx being an independent predictor of decreased RFS and OS (HR 0.760, p = 0.044 and HR 0.719, p = 0.049, respectively), the elderly group still received less CTx (OR 0.317, p = 0.001) than the younger group. After PSM (n = 100 patients), the two groups were comparable, however, CTx administration was still significantly lower in the elderly group., Conclusion: Liver resection should be considered in patients aged 75 and older, even if they present with extensive liver disease. Despite CTx being associated with improved oncological outcomes, a large percentage of elderly patients with CRLM are undertreated., Competing Interests: Declaration of competing interest The Authors declare that there is no conflict of interest., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Diaphragmatic hernia (DH), congenital or traumatic, is uncommon but sometimes can lead to a serious surgical emergency. There are no clinical guidelines or approved recommendations for the management of this condition, and most data are from retrospective, single-institution series. The aim is to analyze the management of the DH at our institution and review the indications for laparoscopic repair., Methods: A retrospective serie of patients diagnosed of DH with surgical treatment at our institution between 2009 and 2019. Literature review was carried out to establish the current indications of laparoscopic repair in each type of DH., Results: Surgery was carried out in 15 patients with DH, 5 congenital and 10 traumatic hernias. Traumatic hernias were classified as acute (n = 2) and chronic (n = 8). 53.4% of all cases (8 patients) required urgent surgery using an abdominal approach (5 open and 3 laparoscopic) and elective surgery was performed in 46.6% of all cases (7 patients) with an abdominal approach (3 open and 4 laparoscopic) and 2 patients with a combined approach. Primary repair was performed in 4 patients (26.6%), closure and mesh reinforcement in 9 cases (60%) and only mesh placement in 2 patients (13.4%). Postoperative morbidity and mortality were 20% and 0%, respectively. No recurrences were detected., Conclusions: DH may pose different scenarios which require urgent or elective surgical treatment. Laparoscopic approach may be a first option in elective surgery; and in emergency setting taking into account hemodynamic stability and associated injuries., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: High morning BP surge (MBPS) has been associated with an increased risk of cardiovascular events. We evaluated the presence of a high MBPS in patients with recent ischaemic stroke., Material and Methods: A case-control study was carried out. One hundred patients with an ischaemic stroke in the previous 6 months and fifty hypertensive patients without cardiovascular disease were included as controls., Results: 61 lacunar (LAC) and 39 non-lacunar (NLAC) strokes were studied. The mean age was 65±11 years, and 60 (40%) patients were women. High MBPS was present in 9% of strokes (in 5 LAC and 4 NLAC) and in 8% of controls (p not significant [NS]), with a similar mean value of MBPS in both groups: 23.9±14mmHg and 24.9±15mmHg respectively (p=NS), although the control patients had a higher office BP (systolic [p=.008] and diastolic [p=.0001]), 24h systolic BP (p=.028) and daytime systolic BP (p=.022). Among the stroke patients, high MBPS was associated with previous coronary heart disease (p=.005), circadian BP pattern (p=.029), but not with the type of antihypertensive treatment prescribed. In multivariate analysis, elevated MBPS was only associated with previous coronary artery disease (p=.001)., Conclusions: Approximately one in ten patients with recent ischaemic stroke has a high MBPS. Strategies to detect and treat high MBPS after a stroke are needed., (Copyright © 2022 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: There is still uncertainty regarding the role of perioperative chemotherapy (CTx) in patients with resectable colorectal liver metastases (CRLM), especially in those with a low-risk of recurrence., Methods: Multicentre retrospective analysis of patients with CRLM undergoing liver resection between 2010-2015. Patients were divided into two groups according to whether they received perioperative CTx or not and were compared using propensity score matching (PSM) analysis. Then, they were stratified according to prognostic risk scores, including: Clinical Risk Score (CRS), Tumour Burden Score (TBS) and Genetic And Morphological Evaluation (GAME) score., Results: The study included 967 patients with a median follow-up of 68 months. After PSM analysis, patients with perioperative CTx presented prolonged overall survival (OS) in comparison with the surgery alone group (82.8 vs 52.5 months, p = 0.017). On multivariable analysis perioperative CTx was an independent predictor of increased OS (HR 0.705, 95%CI 0.705-0.516, p = 0.029). The benefits of perioperative CTx on survival were confirmed in patients with CRS and TBS scores ≤2 (p = 0.022 and p = 0.020, respectively) and in patients with a GAME score ≤1 (p = 0.006)., Conclusion: Perioperative CTx demonstrated an increase in OS in patients with CRLM. Patients with a low-risk of recurrence seem to benefit from systemic treatment., (Copyright © 2021 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: We aimed to investigate the prevalence of TOR1A, GNAL and THAP1 variants as the cause of dystonia in a cohort of Spanish patients with isolated dystonia and in the literature., Methods: A population of 2028 subjects (including 1053 patients with different subtypes of isolated dystonia and 975 healthy controls) from southern and central Spain was included. The genes TOR1A, THAP1 and GNAL were screened using a combination of high-resolution melting analysis and direct DNA resequencing. In addition, an extensive literature search to identify original articles (published before 10 August 2020) reporting mutations in TOR1A, THAP1 or GNAL associated to dystonia was performed., Results: Pathogenic or likely pathogenic variants in TOR1A, THAP1 and GNAL were identified in 0.48%, 0.57% and 0.29% of our patients, respectively. Five patients carried the variation p.Glu303del in TOR1A. A very rare variant in GNAL (p.Ser238Asn) was found as a putative risk factor for dystonia. In the literature, variations in TOR1A, THAP1 and GNAL accounted for about 6%, 1.8% and 1.1% of published dystonia patients, respectively., Conclusions: There is a different genetic contribution to dystonia of these three genes in our patients (about 1.3% of patients) and in the literature (about 3.6% of patients), probably due the high proportion of adult-onset cases in our cohort. As regards age at onset, site of dystonia onset, and final distribution, in our population there is a clear differentiation between DYT-TOR1A and DYT-GNAL, with DYT-THAP1 likely to be an intermediate phenotype., (© 2020 European Academy of Neurology.)

Background: The impact of laparoscopic appendectomy (LA) on the incidence of intra-abdominal abscess (IAA) remains controversial. We aimed to identify risk factors for postappendectomy IAA and assess the impact of appendectomy approach in postoperative morbidity., Methods: A retrospective single-center study including consecutive patients who underwent appendectomy for acute appendicitis between 2015 and 2018 was performed. Demographic, clinical, intraoperative, and perioperative variables were collected. Univariate and multivariate analyses was performed to detect independent risk factors for IAA. Comparison of LA and open appendectomy was conducted, and propensity score model (PSM) was used to overcome differences between groups. Independent risk factors for IAA were identified by univariate and multivariate analyses in the PSM cohort., Results: A total of 532 appendectomies were included. The median age was 35 years. Three hundred two patients (56.7%) underwent LA. The most frequent operative finding was American Association for the Surgery of Trauma (AAST) grade 1 appendicitis in 303 patients (57%). Peritonitis was found in 109 patients (20.5%). Postoperative morbidity and mortality were 14.4% and 0%, respectively. Intra-abdominal abscess rate was 6.2%. An AAST grade of ≥2, a preoperative C-reactive protein level of >100 mg/dL, and diabetes mellitus were identified as independent risk factors for IAA in the multivariate analysis. Comparing LA and open appendectomy, there were no differences in IAA rates. After PSM, LA showed lower morbidity and shorter hospital stay., Conclusions: Laparoscopic appendectomy is a safe approach and not related to a higher risk of IAA. Patients with an AAST grade of ≥2, a preoperative C-reactive protein level of >100, and diabetes mellitus have higher risk for postappendectomy IAA., Level of Evidence: Therapeutic/care management, level IV., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Parastomal evisceration is a very uncommon complication of stomas with only few cases reported in the literature. This complication can be developed in the early postoperative period due to technical aspects of stoma creation, but late parastomal evisceration appearing after 6 months from surgery is an exceptional condition. Herein, we present a rare case of a patient with late parastomal evisceration., Case Presentation: A 44-year-old man with sigmoid volvulus underwent a temporary end-terminal colostomy. The ostomy was complicated by a parastomal hernia and stoma prolapse 5 months postoperatively. He was brought into our emergency department having been found collapsed in the street. On physical examination, the patient presented signs of shock and evisceration of small bowel through the colostomy. Intraoperatively, a perforation of prolapsed colon was assessed as the point for intestinal evisceration. We discuss this case and all similar cases reported in the literature., Conclusion: Parastomal evisceration is a potentially life-threatening complication. Patients with parastomal hernia and stoma prolapse must be considered for surgical treatment to avoid this complication.

Background and Objectives: Postoperative complications (POCs) after hepatic resection for colorectal liver metastases (CRLM) adversely affect long-term survival. The aim of this study was to analyze the effect of POC etiology and severity on overall survival (OS) and disease-free survival (DFS)., Methods: A retrospective study of 254 consecutive hepatectomies for CRLM was performed. Univariate and multivariate analyses were performed to determine the effects of demographic, tumor-related and perioperative variables on OS and DFS. A 1:1 propensity score matching (PSM) was then used to compare patients with different POC etiology: infective (Inf-POC), noninfective (Non-inf POC), and no-complications (No-POC)., Results: Inf-POC, Non-inf POC, and No-POC patients represented 18.8%, 19.2%, and 62% of the sample, respectively. In univariate and multivariate analyses infectious POC were independent risk factors for decreased OS and DFS. After PSM, Inf-POC group presented decreased OS and DFS when compared with Non-inf POC (5-year OS 31.8% vs 51.6%; P = .05 and 5-year DFS 13.6% vs 31.9%; P = .04) and with No-POC (5-year OS 29.4% vs 58.7%; P = .03 and 5-year DFS 11.8% vs 39.7%; P = .03). There were no differences between Non-inf POC and No-POC patients. POC severity calculated using the Comprehensive Complications Index did not influence OS and DFS before and after PSM., Conclusion: The negative oncological impact of POCs after CRLM resection is determined by infective etiology not by severity., (© 2020 Wiley Periodicals, Inc.)

Introduction: The role of statins after ischaemic stroke changed with the publication of the SPARCL study in 2006. We analyse how this has influenced the prescription of statins in this patient population., Methods: We conducted a retrospective study of patients discharged with ischaemic stroke at the Virgen Macarena, Virgen del Rocío, and Valme hospitals in Seville (Spain) over two periods: 1999-2001 and 2014-2016., Results: The study included 1575 patients: 661 (42%) were women and mean age (standard deviation) was 69 (10) years. Patients from the later period are older (68 [10] vs 71 [11]; P=.0001); include a higher proportion of women; and present higher rates of dyslipidaemia, hypertension, and diabetes. At discharge, statins were used in 18.7% of patients (vs 86.9% in the first period; P=.0001), with high-intensity statins prescribed in 11.1% of cases (vs 54.4%; P=.0001). In both periods, atorvastatin was the most commonly prescribed statin (80mg: 6% vs 42.7%; 40mg: 5.1% vs 11.1%). In the first period, the use of statins and high-intensity statins was correlated with hypercholesterolaemia, and inversely correlated with age. In the second period, statin use was correlated with hypertension and hypercholesterolaemia, and high-intensity statin use was correlated with ischaemic heart disease and inversely correlated with age., Conclusion: There has been a clear change in the prescription of statins to patients with ischaemic stroke at discharge. However, many patients remain undertreated and the use of these drugs needs to be optimised., (Copyright © 2020 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Aim of the study was to describe characteristics and outcomes of Hartmann's procedure (HP) and subsequent intestinal restoration., Methods: Retrospective study including all patients who underwent HP over a period of 16 consecutive years. We propose a classification and regression tree for a more accurate view of the relationship between the variables related to intestinal restoration and their weighting in the decision to reverse HP., Results: 533 patients were included. Overall morbidity rate of HP was 53.5% and mortality 21.0%. Overall morbidity of the intestinal continuity reconstruction was 47.3% and mortality 0.9%. Patients with a benign disease, aged under 69 years and with low comorbidity, had an 84.4% probability of undergoing intestinal reconstruction., Conclusions: HP is associated with high morbidity and mortality. Restoration of intestinal continuity involves minor, but frequent, morbidity and a low mortality rate. Age and comorbidities can decrease, and even override, the decision to reverse HP., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays an important role in the modulation of plasma levels of low density lipoprotein cholesterol (LDLC). PCSK9 binds to the LDL receptor (LDLR), disrupts its endocytic recycling itinerary and directs it to lysosomal degradation. Activation of PCSK9 can thus decrease the expression of LDLR in the liver and inhibit LDL uptake, which leads to hypercholesterolaemia., Development: Currently we now know that different polymorphisms of PCSK9 are associated with the occurrence of ischaemic stroke. On the other hand, PCSK9 inhibitors prevent binding of PCSK9 to LDLR and inhibit degradation of LDLR, which results in increased hepatic uptake of LDL and lower LDL levels in blood. Different phase 2 and 3 studies, including OSLER and ODYSSEY LONG-TERM, have demonstrated the efficacy and safety of the new monoclonal antibodies against PCSK9 such as evolucumab and alirocumab, and the first exploratory analyses have shown evidence of their efficacy in decreasing vascular events, including stroke., Conclusions: Although few strokes have been reported by these studies, new ongoing trials examining the cardiovascular effects of evolucumab (FOURIER study), alirocumab (ODYSSEY OUTCOMES study), and bococizumab (SPIRE-1 and SPIRE-2 studies) will reveal the true potential of these drugs, particularly for the prevention of stroke., (Copyright © 2017 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Spigelian hernia (SH) is a rare entity, but its surgical treatment is essential because of its high complication risk. Laparoscopic approaches have become the option in elective surgery because it has less morbidity and requires a shorter stay. Several laparoscopic techniques have been employed, but there is no gold standard technique for this kind of hernia. We report, in this study, our experience with intraperitoneal onlay mesh (IPOM) repair., Materials and Methods: Fifteen patients underwent elective surgery for SH between 2008 and 2015 in a Short-Stay Surgical Unit. Laparoscopic IPOM technique was performed in all patients. The technique, epidemiological data, operative findings, hospital stay, morbidity, and follow-up are presented., Results: Fifteen patients (8 males) with a median age of 57 years were operated on. They commonly presented an abdominal mass in the flank (73.3%). Computed tomography was necessary in 4 patients to complete preoperative diagnosis. The mean operating time was 43 minutes. No closure of the defect was associated and we employed expanded polytetrafluoroethylene-coated and polyvinylidene fluoride-coated polypropylene meshes. There were no postoperative complications and early discharge was possible in all cases. No recurrences or complications related to the mesh have been detected so far, with a median follow-up of 4 years (1-8)., Conclusions: Our experience shows IPOM laparoscopic SH repair is a safe and effective technique with advantages that allow us to recommend it as the most advisable for SH treatment in Short-Stay Surgical Units. However, current controversies in the use of intraperitoneal meshes must be clarified.

Introduction and Objective: Hypertensive left ventricular hypertrophy (H-LVH) is a potentially modifiable vascular risk factor (VRF) often overlooked in clinical practice. We aimed to evaluate the frequency of H-LVH in patients with coronary heart disease (CHD) or ischemic stroke (IS)., Patients and Methods: We retrospectively assessed all the echocardiography studies of patients admitted with the diagnosis CHD or IS over a 4-year period., Results: We studied 533 patients, 330 with CHD and 203 with IS. Mean age was 69 (±11) years, 61.5% males. Hypertension was the most common RF: 362 patients (67.9%) (CHD vs. IS: 70 vs. 64.5%; P=NS). H-LVH was seen in 234 patients (43.9%) (CHD vs. IS: 44.8 vs. 42.3%; P=NS). Patients with H-LVH were older and received a greater number of antihypertensive drugs at discharge. Half of patients with hypertension presented H-LVH (184 patients; 50.8%), with similar frequency in both groups (CHD vs. IS: 50.6 vs. 51.1%; P=NS). Neither patients' characteristics nor VRF with the exception of hypertension (P=.0001) were associated with H-LVH., Conclusions: H-LVH is a major VRF in patients with ischemic events in the heart and brain. Nearly half the patients present H-LVH, with a similar frequency in both groups. It is important to identify H-LVH in these patients to optimize treatment and improve long-term prognosis., (Copyright © 2015 SEHLELHA. Published by Elsevier España, S.L.U. All rights reserved.)

The proportion of diabetic patients who are hospitalised for stroke has been increasing in recent years, currently reaching almost a third of all cases of stroke. In addition, about half of patients with acute stroke present hyperglycaemia in the first hours of the stroke. Although hyperglycaemia in the acute phase of stroke is associated with a poor prognosis, its treatment is currently a topic of debate. There is no evidence that the adminstration of intravenous insulin to these patients offers benefits in terms of the evolution of the stroke. New studies in development, such as the SHINE study (Stroke Hyperglycemia Insulin Network Effort), may contribute to clarifying the role of intensive control of glycaemia during the acute phase of the stroke. Ultimately, patients who have presented with stroke should be screened for diabetes., (Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Asymptomatic carotid stenosis (ACS) is a common problem in daily clinical practice, and its management is still the subject of controversy. In contrast to symptomatic carotid disease, the main studies on surgical treatment of patients with ACS have shown only a modest benefit in the primary prevention of stroke. In addition, current medical treatment has drastically decreased the risk of stroke in patients with ACS. Selecting patients amenable to endovascular treatment and determining how and when to conduct the ultrasound follow-up of these patients are issues that still need resolving. This article analyzes two new studies underway that provide evidence for better management of ACS in daily clinical practice., (Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Introduction: Post-stroke depression (PSD) is the most common mood disorder following a stroke, and also the main factor limiting recovery and rehabilitation in stroke patients. In addition, it may increase mortality by up to ten times., Development: PSD occurs in 1 in 3 stroke patients and more than half of all cases are neither diagnosed nor treated. Several mechanisms, including biological, behavioral, and social factors, are involved in its pathogenesis. Symptoms usually occur within the first three months after stroke (early onset PSD), and less frequently at a later time (late onset PSD). Symptoms resemble those of other types of depression, although there are some differences: PSD patients experience more sleep disturbances, vegetative symptoms, and social withdrawal. For PSD diagnosis, we recommended vigilance and use of specific diagnostic tools such as the Patient Health Questionnaire-2 (PHQ-2). The treatments of choice are selective serotonin reuptake inhibitors (SSRI). However, there are still many unanswered questions in the treatment of PSD, such as the best time to start treatment or the effects of antidepressants on cognition and motor function, among others., Conclusions: Neurologists play a pivotal role in the care and management of patients recovering from stroke. They must be familiar with methods for early detection and treatment of PSD, as this can facilitate a patient's functional recovery and social reintegration, and improve quality of life for patients and their families., (Copyright © 2012 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Background: A polymorphism in brain-derived neurotrophic factor (BDNF) (Val66Met) has been reported as a risk factor in primary dystonia. However, overall the results have been inconclusive. Our aim was to clarify the association of Val66Met with primary dystonia, and with the most prevalent clinical subtypes, cervical dystonia and blepharospasm., Methods: We conducted a Spanish multicenter case-control study (including 680 primary dystonia patients and 788 healthy controls) and performed a meta-analysis integrating our study and six previously published studies (including a total of 1,936 primary dystonia patients and 2,519 healthy controls)., Results: We found no allelic or genotypic association with primary dystonia, cervical dystonia, or blepharospasm risks, for the allele A (Met) from a BDNF Val66Met polymorphism in our case-control study. This was confirmed by results from our meta-analysis in white and mixed ethnic populations in any genetic model., Conclusion: We did not find any evidence supporting the association of the BDNF Val66Met polymorphism with primary dystonia., (© 2014 International Parkinson and Movement Disorder Society.)

Some patients with a recent ischemic stroke who are being treated with aspirin as an antiaggregant suffer a new ischemic stroke. These patients (15-25%) have been called unresponsive to aspirin or aspirin resistant. The aspirin-resistant patients have a four-time greater risk of suffering a stroke. Furthermore, these strokes are generally more severe, with increased infarct volume and greater risk of recurrence. There is currently no ideal laboratory test to detect the resistance to the antiaggregant effect of aspirin. The study of resistance to aspirin would only be indicated in selected cases. In these patients, one should first rule out any "pseudo-resistance" to aspirin (lack of compliance, concomitant treatments that interfere with the action of the aspirin)., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)

A 77-year old man who consulted due to left arm weakness and dysarthria. He reported having been diagnosed of high blood pressure and that he was taking enalapril/hydrochlorothiazide without adequate blood pressure control. He had smoked 2 packs of cigarettes a day and continues to smoke at present. He was admitted to the emergency service about 90 min after the onset of his symptoms. He did not report headache, nausea or vomiting. His BP was 182/104 mmHg, with irregular pulse at 88 beats per minute. The neurological examination revealed dysarthria, left homonymous hemianopsia, muscle weakness and hypoesthesia of the left limbs. How should this patient be evaluated and treated?, (Copyright (c) 2008 Elsevier España, S.L. All rights reserved.)

Background: A pathologically reduced or abolished circadian blood pressure variation has been described in acute stroke. However, studies on alterations of circadian blood pressure patterns after stroke and stroke subtypes are scarce. The objective of this study was to evaluate the changes in circadian blood pressure patterns in patients with acute ischaemic stroke and their relation to the stroke subtype., Aims: We studied 98 consecutive patients who were admitted within 24 h after ischaemic stroke onset. All patients had a detailed clinical examination, laboratory studies and a CT scan study of the brain on admission. To study the circadian rhythm of blood pressure, a continuous blood pressure monitor (Spacelab 90217) was used. Patients were classified according to the percentage fall in the mean systolic blood pressure or diastolic blood pressure at night compared with during the day as: dippers (fall> or =10-20%); extreme dippers (> or =20%); nondipper (<10%); and reverse dippers (<0%, that is, an increase in the mean nocturnal blood pressure compared with the mean daytime blood pressure). Data were separated and analysed in two groups: lacunar and nonlacunar infarctions. Statistical testing was conducted using the SSPS 12.0. Methods We studied 60 males and 38 females, mean age: 70.5+/-11 years. The patient population consisted of 62 (63.2%) lacunar strokes and 36 (36.8%) nonlacunar strokes. Hypertension was the most common risk factor (67 patients, 68.3%). Other risk factors included hypercholesterolaemia (44 patients, 44.8%), diabetes mellitus (38 patients, 38.7%), smoking (24 patients, 24.8%) and atrial fibrillation (19 patients, 19.3%). The patients with lacunar strokes were predominantly men (P=0.037) and had a lower frequency of atrial fibrillation (P=0.016) as compared with nonlacunar stroke patients. In the acute phase, the mean systolic blood pressure was 136+/-20 mmHg and diastolic blood pressure was 78.7+/-11.8. Comparing stroke subtypes, there were no differences in 24-h systolic blood pressure and 24-h diastolic blood pressure between patients with lacunar and nonlacunar infarction. However, patients with lacunar infarction showed a mean decline in day-night systolic blood pressure and diastolic blood pressure of approximately 4 mmHg [systolic blood pressure: 3.9 (SD 10) mmHg, P=0.003; diastolic blood pressure 3.7 (SD 7) mmHg, P=0.0001] compared with nonlacunar strokes. Nonlacunar strokes showed a lack of 24-h nocturnal systolic blood pressure and diastolic blood pressure fall. The normal diurnal variation in systolic blood pressure was abolished in 87 (88.9%) patients, and the variation in diastolic blood pressure was abolished in 76 (77.5%) patients. On comparing lacunar and nonlacunar strokes, we found that the normal diurnal variation in systolic blood pressure was abolished in 53 (85.4%) lacunar strokes and in 34 (94.4%) nonlacunar strokes (P=nonsignificant). In terms of diurnal variation in diastolic blood pressure, it was abolished in 43 (69.3%) lacunar strokes and in 33 (91.6%) nonlacunar strokes (P=0.026)., Conclusions: Our results show clear differences in the blood pressure circadian rhythm of acute ischaemic stroke between lacunar and nonlacunar infarctions by means of 24-h blood pressure monitoring. The magnitude of nocturnal systolic and diastolic blood pressure dip was significantly higher in lacunar strokes. Besides, patients with lacunar strokes presented a higher percentage of dipping patterns in the diastolic blood pressure circadian rhythm. Therefore, one should consider the ischaemic stroke subtype when deciding on the management of blood pressure in acute stroke.

Stroke represents a primary health problem in the elderly population. It is the first cause of mortality in women over 65 years, and that of men over 75 years in our country. Atheromatous carotid disease (ACD) is a fundamental etiological factor for the development of ischemic stroke. It is known that approximately 10% of the subjects with stroke have carotid stenosis of 50% or greater. Non-pharmacological management of the ACD in elderly subjects is an increasingly more frequent clinical problem in the daily practice and a subject that is traditionally under debate. The aim of this article is to review the current status of knowledge on this controversial subject and to be able to apply it to our clinical practice.

The role of lipids in stroke has been a traditionally debated subject. Many studies have recently demonstrated that reduction of cholesterol levels is associated to a lower stroke incidence. At present, statins play an essential role in both primary as well as secondary stroke prevention. More knowledge on the use of statins in stroke in order to be able to apply it in the daily clinical practice is needed.