Dermatomiositis en el paciente anciano: un reto diagnóstico

Dermatomyositis is a rare disease characterized by an inflammatory myopathy that follows up to a progressive weakness and dysphagia in a high percentage of patients. It can frequently lead to skin lesions that may help to conclude a final diagnosis. We present the case of an 88-year-old male that was admitted to the hospital because of muscular weakness in the lower extremities, dysphagia and erythematous scaly lesions on the neck and front face of the limbs. The importance of this case is to suspect causes whose characteristics can overlap with more prevalent problems in elder patients.La dermatomiositis es una enfermedad rara caracterizada por una miopatía inflamatoria que cursa con debilidad muscular progresiva y disfagia en un elevado porcentaje de los pacientes. Asocia frecuentemente lesiones dermatológicas que pueden ayudar a orientar el diagnóstico. Presentamos el caso de un varón de 88 años que ingresó por debilidad muscular en extremidades inferiores, disfagia y lesiones eritematodescamativas en cuello y cara anterior de las extremidades. La importancia de este caso es la de sospechar causas cuyas características pueden solaparse con problemas de mayor prevalencia en el paciente anciano

Influencia del remodelado intersticial en la caída en fibrilación auricular en pacientes sometidos a cirugía de revascularización coronaria o recambio valvular aórtico por estenosis aórtica

Objetivos Se considera que el remodelado auricular es un proceso continuo, presente en la mayoría de las enfermedades cardiovasculares, y que puede participar en el desarrollo de FA tras cirugía cardiaca. Se estudió la incidencia de FA en el postoperatorio de cirugía cardiaca. Se analizaron los factores preoperatorios y perioperatorios relacionados con esta arritmia tras la cirugía cardiaca. Se han determinado varios biomarcadores y estudiado su asociación con la aparición de FAP. Métodos y resultados Durante un periodo de 15 meses fueron estudiados un total de 100 pacientes intervenidos tanto de revascularización coronaria como de sustitución valvular aórtica por estenosis aórtica severa. Se valoró la caída en FA durante el periodo postoperatorio mediante registro Holter de 7 días. La aparición de este evento ocurrió en el 29% de los casos. El análisis mediante curva de ROC de pacientes coronarios y valvulares mostró significación para los valores de TnT us preoperatorios y el desarrollo de FAP. El mejor punto de corte para la TnT us fue de 11,86 ng/L con una sensibilidad de 0,76 y una especificidad de 0,54. Encontramos valores plasmáticos de FvW más elevados en pacientes isquémicos respecto a valvulares (200,2 ± 66,3 vs 157,2 ±84,3 UI/dl; p = 0,015). El grado de fibrosis se asoció a los niveles plasmáticos de FvW. Hemos observado que valores de FvW por encima del cuarto cuartil (232 UI/dl) fueron predictivos de FAP (OR 6,67; IC 95% 1,78-37,78; p = 0,032) en pacientes isquémicos. El análisis de regresión logística ajustado a distintas variables clínicas encontró significación estadística para el sexo femenino, valores de TnT us superiores a 11,86 ng/L, valores de FvW por encima del cuarto percentil y ausencia de terapia con beta bloqueantes. Conclusiones El presente trabajo ha permitido comprobar la asociación de determinadas variables con la aparición de FAP, tales como el sexo femenino y la ausencia de terapia con beta bloqueantes. Por otro lado, hemos identificado marcadores bioquímicos que podrían ser útiles en la predicción de pacientes que sufrirán de FA en el postoperatorio, como los valores de TnT us y FvW en el preoperatorio, lo que podría permitir aplicar medidas preventivas antes de la cirugía para minimizar sus efectos negativos. ABSTRACT Objectives Atrial fibrillation (AF) is considered a continuous process, present in most cardiovascular diseases and might participate in the development of Postoperative Atrial Fibrillation (PAF) after cardiac surgery. The incidence of AF has been studied after cardiac surgery. Preoperative and perioperative factors associated with this arrhythmia after surgery have been analyzed. Several biomarkers have been identified and their association with PAF has been studied. Methods and results Over 15-month period a total of 100 patients undergoing either coronary artery bypass surgery for coronary disease or aortic valve replacement for severe aortic stenosis has been studied. The incidence of AF was assessed during the postoperative period by seven days Holter. The event happened in 29% of cases. The ROC curve analysis for both coronary and aortic valve patients showed statistically significance for preoperative us TnT values and the development of PAF. The best cutoff point for us TnT was 11.86 ng / L with a sensitivity of 0.76 and specificity of 0.54. We found higher plasma levels of vWF in ischemic patients than in aortic valve patients (200.2 ± 66.3 vs 157.2 ± 84.3 IU / dl; p = 0.015). The degree of fibrosis was associated with plasma levels of VWF. We have observed that vWF values above the fourth quartile (232 IU / dl) were predictive of PAF (OR 6.67; 95% CI 1.78 to 37.78; p = 0.032) in ischemic patients. The logistic regression analysis adjusted for different clinical variables was statistically significant for female gender, preoperative us TnT values above 11.86 ng / L, preoperative vWF values above the fourth percentile and absence of preoperative beta blocker therapy. Conclusions This research demonstrates the association of certain variables with the appearance of PAF, such as female gender and the absence of preoperative beta blocker therapy. On the other hand, we have identified biochemical markers that may be useful to predict patients who will suffer from atrial fibrillation after surgery, as the preoperative values of us TnT and vWF, which could allow preventive measures before surgery to minimize PAF negative effects

Rotura de pared libre de ventrículo izquierdo tras infarto agudo de miocardio. A propósito de un caso

La rotura de la pared libre del ventrículo izquierdo es una rara complicación del infarto agudo de miocardio que ocurre habitualmente entre el 1º y 5º día postinfarto. Presentamos un nuevo caso de rotura cardiaca tratado con éxito mediante cirugía sin circulación extracorpórea. Consideramos que los departamentos de cirugía general y torácica de hospitales sin cirugía cardiaca, podrían asumir este tipo de intervención para evitar las consecuencias nefastas deun largo traslado intercentros.Palabras clave: infarto agudo de miocardio, rotura cardiaca, circulación extracorpórea

Rotura de pared libre de ventrículo izquierdo tras infarto agudo de miocardio. A propósito de un caso

La rotura de la pared libre del ventrículo izquierdo es una rara complicación del infarto agudo de miocardio que ocurre habitualmente entre el 1º y 5º día postinfarto. Presentamos un nuevo caso de rotura cardiaca tratado con éxito mediante cirugía sin circulación extracorpórea. Consideramos que los departamentos de cirugía general y torácica de hospitales sin cirugía cardiaca, podrían asumir este tipo de intervención para evitar las consecuencias nefastas deun largo traslado intercentros.Palabras clave: infarto agudo de miocardio, rotura cardiaca, circulación extracorpórea

Iridium(I) complexes with hemilabile N-heterocyclic carbenes: Efficient and versatile transfer hydrogenation catalysts

16 páginas, 5 figuras, 3 tablas, 3 esquemas.A series of neutral and cationic rhodium and iridium(I) complexes based on hemilabile O-donor- and N-donor-functionalized NHC ligands having methoxy, dimethylamino, and pyridine as donor functions have been synthesized. The hemilabile fragment is coordinated to the iridium center in the cationic complexes [Ir(cod)(MeImR)]+ (R = pyridin-2-ylmethyl, 3-dimethylaminopropyl) but remains uncoordinated in the complexes [MBr(cod)(MeImR)], [M(NCCH3)(cod)(MeImR)]+ (M = Rh, Ir; R = 2-methoxyethyl and 2-methoxybenzyl) and [IrX(cod)(MeImR)] (X = Br, R = pyridin-2-ylmethyl; X = Cl, R = 2-dimethylaminoethyl, 3-dimethylaminopropyl). The structure of [IrBr(cod)(MeIm(2-methoxybenzyl))] has been determined by X-ray diffraction. The iridium complexes are efficient precatalysts for the transfer hydrogenation of cyclohexanone in 2-propanol/KOH. A comparative study has shown that cationic complexes are more efficient than the neutral and also that complexes having O-functionalized NHC ligands provide much more active systems than the corresponding N-functionalized ligands with TOFs up to 4600 h–1. The complexes [Ir(NCCH3)(cod)(MeImR)]+ (R = 2-methoxyethyl and 2-methoxybenzyl) have been successfully applied to the reduction of several unsaturated substrates as ketones, aldehydes, α,β-unsaturated ketones, and imines. The investigation of the reaction mechanism by NMR and MS has allowed the identification of relevant alkoxo intermediates [Ir(OR)(cod)(MeImR)] and the unsaturated hydride species [IrH(cod)(MeImR)]. The β-H elimination in the alkoxo complex [Ir(OiPr)(cod)(MeIm(2-methoxybenzyl))] leading to hydrido species has been studied by DFT calculations. An interaction between the β-H on the alkoxo ligand and the oxygen atom of the methoxy fragment of the NHC ligand, which results in a net destabilization of the alkoxo intermediate by a free energy of +1.0 kcal/mol, has been identified. This destabilization facilitates the β-H elimination step in the catalytic process and could explain the positive effect of the methoxy group of the functionalized NHC ligands on the catalytic activity.Financial support from Ministerio de Ciencia e Innovación (MICINN/FEDER) is gratefully acknowledged (Projects: CTQ2010-15221, CSD2006-0015, and CSD2009-00050). J.F. T. thanks the Spanish MICINN for a predoctoral fellowship, and S.W. thanks the Eramus program (Univ. RWTH-Aachen, Germany).Peer reviewe

Iridium(I) Complexes with Hemilabile N-Heterocyclic Carbenes: Efficient and Versatile Transfer Hydrogenation Catalysts

A series of neutral and cationic rhodium and iridium(I) complexes based on hemilabile O-donor- and N-donor-functionalized NHC ligands having methoxy, dimethylamino, and pyridine as donor functions have been synthesized. The hemilabile fragment is coordinated to the iridium center in the cationic complexes [Ir(cod)(MeImR)]⁺ (R = pyridin-2-ylmethyl, 3-dimethylaminopropyl) but remains uncoordinated in the complexes [MBr(cod)(MeImR)], [M(NCCH₃)(cod)(MeImR)]⁺ (M = Rh, Ir; R = 2-methoxyethyl and 2-methoxybenzyl) and [IrX(cod)(MeImR)] (X = Br, R = pyridin-2-ylmethyl; X = Cl, R = 2-dimethylaminoethyl, 3-dimethylaminopropyl). The structure of [IrBr(cod)(MeIm(2-methoxybenzyl))] has been determined by X-ray diffraction. The iridium complexes are efficient precatalysts for the transfer hydrogenation of cyclohexanone in 2-propanol/KOH. A comparative study has shown that cationic complexes are more efficient than the neutral and also that complexes having O-functionalized NHC ligands provide much more active systems than the corresponding N-functionalized ligands with TOFs up to 4600 h^–1. The complexes [Ir(NCCH₃)(cod)(MeImR)]⁺ (R = 2-methoxyethyl and 2-methoxybenzyl) have been successfully applied to the reduction of several unsaturated substrates as ketones, aldehydes, α,β-unsaturated ketones, and imines. The investigation of the reaction mechanism by NMR and MS has allowed the identification of relevant alkoxo intermediates [Ir(OR)(cod)(MeImR)] and the unsaturated hydride species [IrH(cod)(MeImR)]. The β-H elimination in the alkoxo complex [Ir(O<i>i</i>Pr)(cod)(MeIm(2-methoxybenzyl))] leading to hydrido species has been studied by DFT calculations. An interaction between the β-H on the alkoxo ligand and the oxygen atom of the methoxy fragment of the NHC ligand, which results in a net destabilization of the alkoxo intermediate by a free energy of +1.0 kcal/mol, has been identified. This destabilization facilitates the β-H elimination step in the catalytic process and could explain the positive effect of the methoxy group of the functionalized NHC ligands on the catalytic activity