Trends and risk factors of hepatitis A in Catalonia after the introduction of a hepatitis A+B vaccination programme.

At the end of 1998, universal hepatitis A+B vaccination of 12 year olds was introduced in Catalonia. The aim was to examine trends in hepatitis A during 2005-2015 and assess risk factors by age group. We carried out an observational epidemiological study of the incidence and risk factors of hepatitis A reported to the surveillance system. Information on exposure was recorded for each case for the 2-6 weeks before symptom onset. Spearman's coefficient was used to evaluate the trends of rates. The chi-square test was used to compare categorical. We studied 2621 hepatitis A cases; the age mean was 26.6 years (SD=18.2), and >50% of cases were in the 20-49 years age group. The incidence decreased from 3.28/100 000 in 2005 to 1.50/100 000 in 2015. The rate for women decreased over time (P = .008), but the reduction was not significant in men (P = .234). Men consistently had higher rates than women with the biggest difference being in the 20-34 years age group (rate 8.8 vs 2.8). The greatest risk factor was travel to an endemic country (42.1%) in the 0-19 years age group and male-to-male sexual contact (18.6%) in the 20-49 years age group. The case fatality rate in adults aged >49 years was 0.4%. In conclusion, the vaccination programme of preadolescents resulted in a reduction in hepatitis A cases. However, a significant amount of cases still appear in immigrants and men who have sex with men. Hepatitis A in adults is an emerging health problem that will require new strategies.

[Long-term results of hypospadias surgery. Urinary and sexual function, and psychological impact]. / Resultados a largo plazo de la cirugía de hipospadias. Función urinaria, sexual e impacto psicológico.

OBJECTIVES: To determine the current status of the patients operated on for hypospadias in our region, in order to adapt the surgical technique to their real needs. MATERIAL AND METHODS: A descriptive and observational study. Interviews were conducted with hypospadias surgery patients in our hospital between 1976 and 1996, focusing on their urinary and sexual function and psychological impact. We performed a descriptive statistical analysis and comparisons between types of hypospadias (SPSSv19). RESULTS: 566 patients were operated on for hypospadias during the study period, interviewing 100 aged between 18 and 40 years. The 73% were distal and 27% proximal. Of all patients, 30% do not have an orthotopic meatus, 10% have fistula, 18% have some degree of stenosis and 52% have penile curvature. The 13% feel to have had disadvantages in their life. They consider they have a different penis in: size (19%), glans shape (17%), curvature (14%), scars (10%) and lowest hole (7%). Sexual satisfaction was valued at 8.9 on a scale of 1 to 10, with no differences between the types of hypospadias. Proximal hypospadias patients have more ejaculation problems: 42% versus 11% in distal hypospadias. The 68% of the proximal ones would like to improve compared to 20% of the distal in: appearance (17%), size (11%) and way to urinate (11%). CONCLUSIONS: Anatomic abnormalities are maintained but the aspects that values the adult patient differ from those persecuted by practiced surgeries. A significant percentage of patients would try to get another surgery. Keeping the size of the penis and natural appearance of the glans should be a priority in hypospadias surgery.

OBJETIVOS: Conocer el estado actual de los pacientes intervenidos por hipospadias en nuestra región, para adaptar la técnica quirúrgica a sus necesidades reales. MATERIAL Y METODOS: Estudio descriptivo y observacional. Se entrevistó a pacientes intervenidos de hipospadias en nuestro hospital entre 1976 y 1996, incidiendo en su función urinaria, sexual e impacto psicológico. Realizamos análisis estadístico descriptivo y comparaciones entre tipos de hipospadias (SPSSv19). RESULTADOS: 566 pacientes fueron intervenidos de hipospadias en el período estudiado, entrevistándose a 100, con edades entre 18 y 40 años. El 73% fueron distales y 27% proximales. En el 30% el meato no es ortotópico, 10% presenta fístula, 18% presenta algún grado de estenosis y 52% presenta curvatura. El 13% siente haber tenido desventajas en su vida. Consideran su pene diferente en: tamaño (19%), forma glande (17%), curvatura (14%), cicatrices (10%) y orificio más bajo (7%). La satisfacción sexual fue valorada en 8,9 en una escala del 1 al 10, sin diferencias entre los tipos de hipospadias. Los proximales presentan mayores problemas de eyaculación: 42% frente al 11% de los distales. El 68% de los proximales desearían mejorar frente al 20% de los distales, en apariencia (17%), tamaño (11%) y forma de orinar (11%). CONCLUSIONES: Se mantienen alteraciones anatómicas pero los aspectos que más valora el paciente adulto difieren de los perseguidos en las cirugías que se practicaban. Un porcentaje importante de pacientes se reoperaría de nuevo. Mantener el tamaño del pene y aspecto natural del glande debe ser un objetivo prioritario durante la cirugía de hipospadias.

Clinical characteristics and pertussis costs in cases reported to epidemiological services and cases detected in household contacts in Catalonia (Spain).

PURPOSE: To assess the clinical characteristics and direct health costs associated with pertussis cases reported to and confirmed by epidemiological services and cases detected among household contacts in Catalonia (Spain) in 2012-2013. METHODS: All pertussis cases confirmed by the epidemiological services (n = 641) and all cases detected among the household contacts (n = 422) were included in the study. The chi-square test and odds ratios were used to compare percentages and the t-test was used to compare mean pertussis costs, with p < 0.05 being considered statistically significant. RESULTS: Cases reported to epidemiological services had a higher percentage of hospitalizations (OR = 32.2, p < 0.001) and severe disease (OR = 27.7, p < 0.001) than cases detected among the household contacts. The total health costs associated with pertussis cases were €871,648, €799,704 (92 %) for cases reported to epidemiological services and €71,944 (8 %) for cases detected among the household contacts. Total treatment, detection, and quimiprophylaxis costs were € 809,702, € 44,312, and € 17,635, representing 92.5 %, 5.5 %, and 2 % of total pertussis costs respectively. The mean costs were significantly higher (p < 0.001) in cases reported to epidemiological services than in cases detected among the household contacts, for all cases (€1248 vs €170), and for severe (€4546 vs €1073), moderate (€204 vs €165), and mild (€153 vs €133) disease. CONCLUSIONS: The burden of pertussis in Catalonia was high in terms of health costs, especially in infants aged less than 1 year. Active epidemiological surveillance activities could prevent pertussis transmisison and reduce pertussis costs.

[Animated biofeedback for the dysfunctional voiding syndrome]. / Biofeedback animado para el tratamiento de la micción disfuncional.

OBJECTIVES: To analyze clinical and electromyographic treatment outcome of dysfunctional voiding (DV) with animated Biofeedback (Bfb). Clinical or electromyographic variables associated with higher success rate were checked. PATIENTS AND METHODS: Cross-sectional study of patients with DV, that in 2010- 2015 followed animated Bfb program. Efficacy was measured with Uroflowmetry, Electromyography (EMG) and validated clinical questionnaire. Inclusion criteria: no myelodysplasia, no anatomical malformations and a minumin of 3 Bfb sessions. Clinical variables: age, number of sessions, daytime leaks, nocturnal enuresis, constipation, UTI, VUR. Flow measurement variables: morphology of curves, electromyogram, flows, and elevated post void residual (PVR). RESULTS: Of 37 patients who received Bfb, 27 girls who met inclusion criteria were selected. Mean age: 7.8 years (2.5). Twelve (44%) had detrusor overactivity on urodynamics concomitantly. Globally, all clinical and flowmetry parameters improved. Clinically 33.5% had complete resolution of symptoms, 37% improved (> 50% of symptoms according to criteria ICCS) and 29% had no improvement. In EMG, 74% achieved normal perineal relaxation. Constipation at baseline is associated with lower rates of success (cure: 13 vs. 58%, p = 0.019; cure + improvement: 60% vs. 83% p> 0.05). The absence of RPM at the end of the study was associated with clinical improvement (cure: 66.7% vs. 0%, p = 0.012; cure + improvement: 89% vs. 60%, p> 0.05). CONCLUSIONS: Bfb in DV provides cure or improvement and electromyographic resolution are 69 and 74% respectively. The absence of constipation is associated with higher success rates. The High RPM correlates with persistence of clinics.

OBJETTIVOS: Se pretende analizar resultado clínico y electromiográfico del tratamiento de la micción disfuncional (MD) con Biofeedback (Bfb) animado. Además, se estudia si existen variables clínicas o electromiográficas asociadas a mayor tasa de éxito. PACIENTES Y METODOS: Se realizó corte transversal de pacientes con MD, que en 2010- 2015 siguieron programa de Bfb animado. El control post-tratamiento se realizó con Uroflujometría más Electromiografía y cuestionario validado. Se excluyeron los pacientes con mielodisplasia, malformaciones anatómicas, y a los que recibieron menos de 3 sesiones. Las variables clínicas estudiadas fueron: edad, número de sesiones, fugas diurnas, enuresis nocturna, estreñimiento, ITU, RVU. Las flujométricas fueron: morfología de curvas, electromiograma, flujos, y residuo postmiccional (RPM) elevado. RESULTADOS: De 37 pacientes que recibieron Bfb, se seleccionaron 27 niñas que cumplieron criterios de inclusión. Edad media: 7,8 años (DE: 2,5). Doce (44%) presentaron hiperactividad del detrusor asociado a la MD. De manera global, todos los parámetros clínicos y flujométricos mejoraron. Clínicamente 33,5% presentó resolución completa de síntomas y el 37% mejoraron (desaparecieron más del 50% de los síntomas según criterios ICCS). El 29% no presentó mejoría. Electromiográficamente el 74% logró flujometrías normales. El estreñimiento al inicio del estudio se asocia a tasas menores de éxito (curación: 13 vs. 58%, p= 0,019; curación + mejoría: 60% vs. 83% p > 0,05). La ausencia de RPM al final del estudio se relacionó con la mejoría clínica (curación: 66,7% vs. 0%, p= 0,012; curación + mejoría: 89% vs. 60%, p > 0,05). CONCLUSIONES: El Bfb en la micción disfuncional proporciona tasas de curación/mejoría clínica y de resolución electromiográfica del 69 y 74%, respectivamente. La ausencia de estreñimiento se asocia a mayores tasas de éxito. La persistencia de clínica se relaciona con RPM elevado post-tratamiento.

Oxidant/antioxidant effects of chronic exposure to predator odor in prefrontal cortex, amygdala, and hypothalamus.

The incidence of anxiety-related diseases is increasing these days, hence there is a need to understand the mechanisms that underlie its nature and consequences. It is known that limbic structures, mainly the prefrontal cortex and amygdala, are involved in the processing of anxiety, and that projections from prefrontal cortex and amygdala can induce activity of the hypothalamic-pituitary-adrenal axis with consequent cardiovascular changes, increase in oxygen consumption, and ROS production. The compensatory reaction can include increased antioxidant enzymes activities, overexpression of antioxidant enzymes, and genetic shifts that could include the activation of antioxidant genes. The main objective of this study was to evaluate the oxidant/antioxidant effect that chronic anxiogenic stress exposure can have in prefrontal cortex, amygdala, and hypothalamus by exposition to predator odor. Results showed (a) sensitization of the HPA axis response, (b) an enzymatic phase 1 and 2 antioxidant response to oxidative stress in amygdala, (c) an antioxidant stability without elevation of oxidative markers in prefrontal cortex, (d) an elevation in phase 1 antioxidant response in hypothalamus. Chronic exposure to predator odor has an impact in the metabolic REDOX state in amygdala, prefrontal cortex, and hypothalamus, with oxidative stress being prevalent in amygdala as this is the principal structure responsible for the management of anxiety.

Muscle enzyme and fiber type-specific sarcomere protein increases in serum after inertial concentric-eccentric exercise.

Muscle damage induced by inertial exercise performed on a flywheel device was assessed through the serum evolution of muscle enzymes, interleukin 6, and fiber type-specific sarcomere proteins such as fast myosin (FM) and slow myosin (SM). We hypothesized that a model of muscle damage could be constructed by measuring the evolution of serum concentration of muscle proteins following inertial exercise, according to their molecular weight and the fiber compartment in which they are located. Moreover, by measuring FM and SM, the type of fibers that are affected could be assessed. Serum profiles were registered before and 24, 48, and 144 h after exercise in 10 healthy and recreationally active young men. Creatine kinase (CK) and CK-myocardial band isoenzyme increased in serum early (24 h) and returned to baseline values after 48 h. FM increased in serum late (48 h) and remained elevated 144 h post-exercise. The increase in serum muscle enzymes suggests increased membrane permeability of both fast and slow fibers, and the increase in FM reveals sarcomere disruption as well as increased membrane permeability of fast fibers. Consequently, FM could be adopted as a fiber type-specific biomarker of muscle damage.

[Ultrasound markers in the follow up of pyeloplasty]. / Evolución de los parámetros ecográficos tras pieloplastia en la población infantil.

INTRODUCTION: There are few studies on the long term follow up of pyeloplasty. Is there a residual pelvis dilatation in all successful procedures? How is the long term evolution of the ecographic parameters and measures postoperatively (PO)? PATIENTS AND METHODS: We reviewed all successful Anderson-Hynes pyeloplasties performed on obstructed renal pelvis with an anterio-posterior diameter >15 mm during 2001-2010. Ultrasound controls were made at 3 and 6 months postoperatively and then yearly afterwards. We aimed to describe time course of hydronephrotic changes following unilateral pyeloplasties, using three parameters: pelvic anterior-posterior diameter (APD), pelvis/córtex ratio (P/C R) and the percentage of improvement in APD (PI-APD). RESULTS: 41 patientswereincluded. Age at intervention ranged from 2 months to 10.3 years (mean 13 months, 83% were operated in the first year of life). Median of follow up was 4 years (range 1-12 years). Mean APD preoperatively was 25 mm (range 16-54). At the third month PO, PI-APD was 28%. At the sixth month control, it was 51%, and remained stable during the next consecutive yearly controls, without statistically significant variations (50%, 57%, 60%, 51%, 39%, 46%, 38%, 42%). P/C R diminished significantly already in the third month control (4.6 vs. 1.8, p=0.03). We observed complete disappearance of hidronephrosis in 8 patients (19.5%). DISCUSSION: Although early postoperative ultrasound changes occur, the ultrasound parameters remain often stable during long term follow up. We documented the complete normalization of renal pelvis (no hydronephrosis) in one of every five patients.

INTRODUCCION: Hay pocos estudios sobre la evolución postquirúrgica a largo plazo de la estenosis de la unión pieloureteral (EUPU). ¿Existe una dilatación residual en todos los pacientes que presentan resultados satisfactorios tras la cirugía? ¿Cuál es la evolución en los parámetros ecográficos? PACIENTES Y METODOS: Revisión retrospectiva de pacientes con EUPU intrínseca, con diámetro anteroposterior (AP) de la pelvis >15 mm (e hidronefrosis grado III o superior), y seguidos tras pieloplastia de Anderson-Hynes en el periodo 2001-2010 (10 años), no reintervenidos, asintomáticos y con función renal normal. Los controles ecográficos se hicieron a los 3 y 6 meses postoperatorio (PO) y posteriormente anuales. Se midieron tres parámetros: diámetro AP, ratio pelvis/córtex (R P/C) y porcentaje de mejoría (PM). RESULTADOS: Se seleccionaron 41 pacientes, intervenidos entre 2 meses y 10,3 años (media 13 meses, 83% en primer año de vida), mediana de seguimiento: 4 años (rango: 1-12). El diámetro AP de la pelvis renal medio pre-quirúrgico fue de 25 mm (rango 16-54). A los 3 meses la disminución media del diámetro AP (o PM) fue del 28% (respecto a diámetro prequirúrgico). A los 6 meses PO, fue del 51%, permaneciendo estable durante los siguientes años: 50%, 57%, 60%, 51%, 39%, 46%, 38%, 42% (controles anuales durante los primeros 8 años). La relación pelvis/córtex disminuyó de manera significativa ya en las ecografías al tercer mes (4,6 vs. 1,8; p= 0,03). En 8 pacientes (19,5%) se pudo objetivar ausencia de dilatación piélica en la evolución. CONCLUSIONES: Aunque los cambios ecográficos tras la pieloplastia se pudieron objetivar desde los controles precoces, permanecieron a menudo sin cambios durante los controles posteriores. Sin embargo, en uno de cada cinco pacientes se objetivó la desaparición de la dilatación piélica.

[Neonatal surgical site infection: multicentric survey on prophylactic measures]. / Infección de herida quirúrgica neonatal: encuesta multicéntrica sobre medidas profilácticas.

OBJECTIVES: Surgical site infection (SSI) has a considerable impact on neonatal morbidity. There are known risk factors such type of surgery (clean/contaminated), prematurity, surgical length, hypoalbuminemia, previous infection, prolonged mechanical ventilation, and so on. Many perioperative factors have not been studied, opposite to adults. We have developed a survey on intraoperative attitudes and measures, as surgical wound management in Neonates among pediatric surgeons, to seek for a wider consense. METHODS: Multi-response survey with 22 items, based on the Surgical Infection Society NIH 2008 clinical guideline. Each item poses a question on perioperative attitudes, surgical aspects and wound management. Each question is subdivided in two categories, depending on urgency and type of surgery (clean/contaminated). RESULTS: 159 surveys were sent. Among those, we received back 51 (32%). 69% of the interviewed surgeons use clorhexidin to prepare surgical field, 25% use Iodine solutions. 69% never use diathermy to incise skin. There was no agreement on the use of sterile plastic adhesive drapes, intra-cavity lavage, changing surgical gloves/material, or wound irrigation during closure. 82% never use cyanocrilate dressing. Intracuticular skin suture and simple stitches were used indistinctly. Wound management and dressings were not uniform and depended on each pediatric unit. CONCLUSIONS: The survey reflects the lack of consensus regarding prophylactic measures and wound management among pediatric surgeons who care after surgical neonates.

OBJETIVOS: La infección de herida quirúrgica (IHQ) es una causa frecuente de morbimortalidad en Neonatología. Existen factores de riesgo conocidos: tipo de cirugía (sucia/contaminada/limpia), prematuridad, duración de intervención, hipoalbuminemia, infección previa, ventilación mecánica prolongada y contaminación de vía central. Otros factores perioperatorios no han sido estudiados en neonatos, sí en adultos. Desarrollamos una encuesta sobre las actitudes y las medidas, intraoperatorias y de manejo de herida. Pretendemos dilucidar si existe consenso sobre la profilaxis de IHQ neonatal. METODOS: Encuesta con 22 ítems, basada en la guía de prevención de la IHQ en adultos (Surgical Infection Society, 2008). Cada ítem cuestiona temas sobre hábitos perioperatorios, intra y postoperatorios, relacionados con el manejo de la herida quirúrgica en el neonato, y consta de dos preguntas, según sea cirugía sucia/urgente o limpia/contaminada. Las opciones de respuesta son 4: siempre, con frecuencia, raramente y nunca. Enviamos la encuesta a cirujanos pediátricos españoles mediante correo electrónico en el primer trimestre del 2012. RESULTADOS: Se enviaron 159 encuestas. 51 (32%) respondieron. 69% emplean clorhexidina para preparar campo, 25% usan povidona iodada. Solo el 51% refirió dejar actuar siempre un minuto el antiséptico. 69% nunca usan bisturí eléctrico en piel para ampliar herida. No hubo respuestas unánimes en cuanto al uso de paños adhesivos protectores del campo, la irrigación de planos con suero o antisépticos durante el cierre, el empleo de drenajes, cambio de guantes y/o material al iniciar el cierre (cirugía sucia). El 72% y el 82% nunca emplean cianocrilato como cierre o apósito en neonatos, respectivamente. En cirugía sucia, 43% suturan piel con intradérmica y 49% con puntos sueltos. CONCLUSIONES: La distribución de respuestas refleja la falta de consenso sobre los aspectos de la técnica quirúrgica y el manejo perioperatorio que podrían estar relacionados con la profilaxis de IHQ neonatal.

[Incidence of major lower limb amputation in Geneva: twenty-one years of observation]. / Incidence de l'amputation majeure des membres inférieurs à Genève: vingt-et-un ans d'observation.

Between 1990 and 2010 the incidence of major lowerlimb amputations (by definition any level of amputation above the foot) in the canton of Geneva was 10.02 per 100,000 inhabitants/ year. The analysis of various population groups revealed that the presence of diabetes increased the relative risk of amputation by a factor of 20, and age 65 years or older by a factor of 9. During this 21 years period we observed a gradual decline in the incidence of amputation and an increased age at the time of amputation, despite the increasing prevalence of diabetes and an aging population. This was a reflection on the efforts of primary and secon- dary prevention, initiated in the 1980s in which Geneva was a pioneer.

[Uroflowmetry values among asymptomatic children who underwent tubularized incised plate urethroplasty]. / Flujometría en varones asintomáticos intervenidos mediante la técnica de Snodgrass.

PURPOSE: Tubularized incised plate uretroplasty (TIPU) technique for hypospadias repair or Snodgrass procedure has become increasingly popular since its description in 1994. The elasticity of the neouretra is reduced and several studies have pointed out that flow parameters of the patients operated on this procedure show some grade of asymptomatic functional obstruction, although there are reports on the improvement of these parameters on the mid term. We evaluated the functional outcome in the form of urinary flow in asymptomatic children following uncomplicated TIPU. PATIENTS AND METHODS: We reviewed the urine flow rate of asymptomatic toilet trained children who underwent TIPU at our institution between 2005 and 2012. Uroflowmetries were performed in a serial fashion, during the follow up visits at the first months after the repair and yearly afterwards. Unfavourable values were plateau or interrupted curves and peak flow below the 5th percentile of a validated Nomogram for children (Gutiérrez-Segura). Statistical work up: SPSS 15.0. RESULTS: 85 patients were eligible. The mean age at surgery was 2.7 years. Median follow up was 29 months (6-82 months). Hypospadias was distal penile in 76 (89.5%) and mid penile in 9 (10.6%). We obtained 131 uroflowmetries (1.54 per patient) at a mean age of 5.1 years (2.5-8). 66.7% of the peak flow values and 55% of the average flow values were below the 5th percentile of the Nomogram. Flow curve was normal (bell- shaped) in 35 charts (26.5%), irregular in 38 (28.8%) and plateau in 56 (42.4%). Peak flow values improved in the second year after surgery (compared to the first year values): 7 ml/sgvs 8.09 ml/sg (p=0.07). The difference was significative in low volumes (<100 ml) (6.3 vs 7.8 ml/sg, p=0.04). Bell-shaped curve rate also grew: 21% (6/29) vs 28% (29/74), p> 0.05. We constructed a specific Nomogram for this population. CONCLUSIONS: Our data confirm that many asymptomatic patients who undergo TIPU repair present altered flow patterns. Spontaneous partial improvement is the norm after the first year of surgery.

[Update on the current role of plasma cholinesterase]. / Papel de las colinesterasas plasmáticas. Actualización.

The antagonism of steroidal nondepolarizing neuromuscular blockers (NDMBs) moved forward recently with the introduction of sugammadex, the only drug able to immediately reverse the effects of curarization produced by NDMBs. This advance has necessitated reflection on the future role of pseudocholinesterase. In spite of the side effects of succinylcholine and published opinions on its use, this NDMB continues to be used in clinical anesthesia. Pseudocholinesterase is mainly found in the liver, plasma, and nervous system. The enzyme is synthesized in the liver in greater amounts than required although certain conditions lead to deficiency, which is usually asymptomatic. The only clinical expression is the apnea which develops after administration of succinycholine because this NDMB cannot be metabolized. In some patients, slight reductions in the antagonism of succinylcholine lead to rising neuromuscular concentrations of the drug in accordance with the degree and duration of the blockade. We review the various forms of pseudocholinesterase deficiency, including a discussion of genetic variants, clinical manifestations, and management. In addition to discussing the diagnosis of this condition and the clinical implications, we highlight the importance of practice protocols and access to a referral laboratory if one is not available within the immediate hospital.

The beginnings of radiology in Malaga. / Los inicios de la radiología en Málaga.

On March 2, 1896, the local press in Malaga reported the discovery of X-rays, relating various news items about the use of X-rays and literature about Roentgen's discovery by journalists and other authors. Outstanding among these writings was a periodical directed at the administration and general public called Los Rayos X. Progressively, the first X-ray machines were installed in hospitals during this period, and the first installation in a private medical clinic took place in 1900. In Malaga, the assimilation and progression of the diagnostic and therapeutic use of radiology was slow and affected by peculiarities owing to the social, economic, and cultural circumstances of the period. Influential physicians willing to overcome resistance to advances were able to bring medical practice in Malaga to a level similar to that of other cities.

Factors influencing the case-fatality rate of Legionnaires' disease.

SETTING: The extent of the public health problem posed by Legionnaires' disease (LD) is not always well- appreciated. OBJECTIVE: To determine the characteristics and factors associated with the case fatality rate (CFR) of LD in Catalonia, Spain. DESIGN: Confirmed cases of LD reported during 1993-2004 were studied. Age, sex, hospitalisation, the type of diagnostic confirmation test and the personal risk factors for LD of cases were collected. Comparative bivariate and multivariate analyses according to origin (community-acquired or nosocomial) and nature (sporadic or outbreaks) were performed. RESULTS: Of 1938 cases reported, 164 died (case-fatality rate [CFR] 8.5%). The CFR fell from 35% in 1993 to 5.6% in 2004, and was higher in sporadic than in outbreak-associated cases (10% vs. 4.7%) and in nosocomial than community-acquired cases (31.7% vs. 6.8%). In community-acquired cases, the CFR was associated with age >70 years (OR 3.42, 95%CI 2.02-5.79), cancer (OR 4.58, 95%CI 2.36-8.90) and diagnostic confirmation methods other than Legionella urinary antigen test. The CFR of nosocomial cases was not associated with any of these factors. CONCLUSIONS: The CFR of LD fell during the study period due to the incorporation of new diagnostic techniques and improved detection of outbreaks.

[Long-term renal function in Wilms tumor survivors]. / Función renal a largo plazo en supervivientes de tumor de Wilms.

OBJETIVE: To evaluate long-term renal function and morbimortality in non-syndromic Wilms tumor (WT) survivors. METHODS: Retrospective study about WT patients treated in 1993-2017, according to SIOP protocols. Mortality, glomerular filtration rate (GFR), prevalence of hypertension and requirement of dialysis and renal transplant were evaluated. Chronic kidney disease (CKD) was defined as GFR <90 ml/min/1.73 m2. RESULTS: Thirty-nine children were treated in the 25 analyzed years. Median time of follow-up was 6 years (0.5-21 years). 48% (19 patients) debuted with stage I or II. Four cases had high-grade histo-logy. Mortality rate was 10%. GFR data were found in 37 patients. Chronic kidney disease (grade I-II) turned up in 6 patients (16%). No patient required renal replacement therapy or renal transplant. 16% of patients developed CKD in both unilateral and bilateral WT, (p>0.05); OR 1.04 (IC 95% 0.09-10.9). Identical results were obtained comparing patients treated with or without radiotherapy (16%). Children with stage I-III had CKD in 11% vs. 40% of patients with stage IV (p=0.12); OR 5.3 (IC 95% 0.61-45). None of them presented hypertension in addition. CONCLUSIONS: In the current study the prevalence of CKD was low but not negligible, although no patients required renal replacement therapy or renal transplant. Bilateral renal involvement and radiotherapy were not associated with CKD development. Metastatic disease determines a higher risk of CKD.

OBJETIVOS: Evaluar la función renal y la morbimortalidad a largo plazo, en supervivientes de tumor de Wilms (TW) no sindrómico. MATERIAL Y METODOS: Estudio retrospectivo de pacientes con TW entre 1993-2017 tratados según protocolos SIOP. Evaluamos mortalidad, filtrado glomerular (FG), prevalencia de hipertensión arterial (HTA), necesidad de diálisis y trasplante renal. Se definió enfermedad renal crónica (ERC) como FG <90 ml/min/1,73 m2. RESULTADOS: En los 25 años analizados se trataron 39 pacientes con edad media diagnóstica de 3,6 años (0,3-11 años). Mediana de seguimiento 6 años (0,5-21 años). El 48% (19 pacientes) debutaron con estadio I o II. Cuatro pacientes presentaron histología de alto riesgo (10%). La mortalidad fue del 10%. El 16% (6 pacientes) desarrolló ERC (grados I-II). Ningún paciente precisó terapia renal sustitutoria (TRS) o trasplante. La presencia de ERC tanto en enfermedad unilateral como bilateral fue del 16%, p>0,05; OR 1,04 (IC 95% 0,09-10,9). Se obtuvieron idénticos resultados (16%) comparando pacientes que recibieron radioterapia frente a aquellos que no. Los pacientes en estadio I, II y III presentaron una prevalencia de ERC del 11% vs. 40% en estadio IV (p=0,12); OR 5,3 (IC 95% 0,61-45). Ningún paciente asoció HTA crónica. CONCLUSIONES: En el presente estudio la prevalencia de ERC en supervivientes de TW no sindrómico es baja pero no desdeñable, aunque ninguno precisó trasplante renal o TRS. La presencia de enfermedad bilateral y la radioterapia no se asociaron al desarrollo de ERC. La enfermedad metastásica condiciona un riesgo mayor de ERC.

Epidemiology of hepatitis A before and after the introduction of a universal vaccination programme in Catalonia, Spain.

A universal vaccination program for preadolescents, aged 12 years, with the hepatitis A + B vaccine was introduced in 1998 in Catalonia (Spain) with the aim of protecting the whole population against hepatitis A. The hepatitis A + B vaccine program replaced the hepatitis B vaccination program for preadolescent started in 1991. The impact of the hepatitis A + B vaccination program was studied by assessment of the trend of reported cases of hepatitis A. All cases of viral hepatitis reported from 1992 to 2006 were included in the study. To evaluate changes in the epidemiology of hepatitis A, two periods were considered: a prevaccination period (1992-1998) and a post-vaccination period (2001-2006). The ratios of the rates were calculated according to age and sex. The comparison of rates and proportions was made by calculation of the normal z statistic. A total of 7536 cases of viral hepatitis were reported, of which 4109 (54.52%) were hepatitis A. The incidence rate of hepatitis A fell from 5.44 per 100 000 person-years in the prevaccination period to 3.02 in the post-vaccination period. In males, the rate fell from 6.85 to 3.89 and in females from 4.10 to 2.18. The male-female ratio of incidence rates was lower in the post-vaccination period. In males the global decline of incidence rate was 43.26% and in females 46.96%. The greatest decline occurred in the 15 to 19 years age group in both sexes (79.1% in men and 78.34% in women) but declines in the 10-14 years age group were also very important (69.21% and 67.88%, respectively). In conclusion, hepatitis A incidence fell in Catalonia in the post-vaccination period in vaccinated adolescents and also in other unvaccinated groups who have benefited from the indirect effects of the vaccination program.

[Endoscopic treatment of primary vesicoureteral reflux in childhood. Review of 989 cases in a 9 years period]. / Tratamiento endoscópico del reflujo vesicorrenal primario en la infancia. Revisión de 989 casos tratados en el Servicio Asistencial de Urología Pediátrica de la Comunidad Autónoma de Murcia en un periodo de 9 años.

PURPOSE: The primary vesicoureteral reflux (PVUR) is the most common urologic pathology during childhood and affects from 1 to 3% of newborn. It causes acute pyelonephritis (APN) and renal damage in addition to hospital visits with high economic and social costs. Nowadays the endoscopic treatment (ETR) seems to be the most suitable one for the reflux, due to its lower biological cost and its good results. We report our experience in the endoscopic treatment of the primary vesicoureteral reflux (ETR) in Murcia Pediatric Hospital from 1998 to 2007. PATIENTS AND METHODS: We present a retrospective study describing 989 patients (1498 ureters) treated by means of ETR. All patients were treated with chemoprophylaxis since the moment of the diagnosis. ETR was fulfilled by the surgeon in an ambulatory way and with Sevofluorano. Deflux, Macroplastique and Coaptite were used. Age, stade, number of ETR, material, chemoprophylaxis, ureterocistoneostomy and ETR costs were evaluated. RESULTS: One-thousand four-hundred and ninty-eight ureteral units, corresponding to 989 patients, (51,2% males), at ages from 4 months to 21-years-old, have been treated by means of ETR. The average age was 4-years-old. Grade III reflux was the most common of all, with 801 ureters affected. Deflux was used in 777 patients, Macroplastique in 203 and Coaptite in 9. No problems in early post-operation happened and the average length was shorter than 2 hours. Forty-eight hours after, 7 patients had to be treated due to APN. Four patients showed late litiasis related to ETR. Two suffered litotomy. The 89.9% of the patients were cured at first ETR. The 11.2% needed a second ETR, with 2.12% of failure (21 patients). Six cured with the third injection and 2 needed a fourth ETR. Thirteen children were treated with ureterocistoneostomy. Radiological correction have not relation with PVUR level and does not show significant differences. Failure regarding the used material was around 9% for Deflux, 11.8% for Macroplastique and 66.6% for Coaptite. The cost of ETR was 1.400 euros, the cost of ureterocistoneostomy 4.822 euros and of the chemoprophylaxis 4.158,7 euros per year. CONCLUSIONS: From our experience, ETR is a method as safe as surgery and with less morbility. It is, furthermore, much more predictable than chemoprophylaxis and implies lower economical, biological and social costs than those other methods. In case of failure, ETR does not prevent any other kind of treatment. We regard ETR as a first order therapeutic gesture when dealing with PVUR.

[Evaluation of the effect of hospital clown's performance about anxiety in children subjected to surgical intervention]. / Evaluación del efecto de la actuación de los payasos de hospital sobre la ansiedad, en los niños sometidos a una intervención quirúrgica.

OBJECTIVE: To be hospitalized is a highly distressing event for children. At present, a resort used in Spain and other countries to reduce children's anxiety in the health context are hospital's clown. We studied the effect of the hospital's clowns about the anxiety in children that going to be operated. METHODS: We recruited 60 children aged 6 to 10 years scheduled to undergo elective surgery. 30 children would have clowns before the surgery (case group) and 30 would not have them (control group). In the case group, two clowns performed for children. We measured the anxiety with several scales (STAIC, CCPH, faces scale), after the performance and until 7 days after the surgery. RESULTS: The outcomes show both groups a tendency to increase anxiety but the children of the case group showed less increase at the anxiety's score. In the control group is showed that the children are more alterated at seven days from the discharge. CONCLUSIONS: Children that receive the clown's care, have tendency to be less distressing and with less fear that another ones, measurement by STAIC and faces scale, and these results are maintained seven days after the discharge.

[Walking activity in prosthesis-bearing lower-limb amputees]. / Capacité de marche en milieu extra-hospitalier des amputés appareillés.

PURPOSE OF THE STUDY: A large body of literature has been devoted to gait analysis in amputees. Most studies have been conducted in the laboratory setting where numerous variables are analyzed: gait efficiency, energy cost, walking velocity. At the present time however, data are lacking on the real-life use of walking prostheses. Little is known about how long patients wear their prosthesis or how difficult it is for them to walk during different periods of the day. Currently, such information depends on the quality of the interview and the patient-physician relationship. A precise assessment of walking activity in amputees and use of prostheses would be a valuable source of information for therapists and would provide complimentary information to that collected from laboratory gait analysis. The purpose of this study was to study walking activity in home-dwelling prosthesis-bearing lower-limb amputees and to determine variables affecting walking performance. To our knowledge, this is the first published study on this topic. MATERIAL AND METHODS: The series included home-dwelling prosthesis-wearing lower-limb amputees (Syme amputation or more proximal) who were able to get up and go without assistance. A StepWatch3 recorder was implanted on the prosthesis for 15 consecutive days. Variables recorded were number of steps, total walking time, and walking velocity. Variables which might affect walking in prosthesis-wearing amputees were also recorded: body mass index, use of a walking aid, level and reason for amputation, age at amputation and at recording, time between amputation and recording. RESULTS: From June 2004 to May 2005, 43 patients wore the StepWatch3 for the scheduled 15 days during their daily activities. Mean age at amputation was 42 years (range 13-78 years) and at recording 52 years (range 25-85 years). Considered separately, gait parameters showed that all of the patients wore their prosthesis daily and that the best walking performance was significantly observed among below-knee amputees who did not use a walking aid and who underwent amputation for a non-vascular cause. Multivariate analysis revealed that above-knee amputees lost 93 minutes of walking time per day (21% loss), and that amputees who used a walking aid lost 58 minutes per day (13% loss). Daily walking time declined 2.5 minutes per year of age. Body mass index was not correlated with total daily walking time but had a direct significant effect on walking velocity.

[Total tubular colonic duplication in a neonate with rectal bleeding: value of the endoscopy in the diagnose and treatment]. / Duplicación cólica tubular total en un neonato con sangrado rectal: valor de la endoscopia en el diagnóstico y tratamiento.

Gastrointestinal duplication is an infrequent congenital abnormality. Colonic and tubular duplications are the least common. In neonates there are few described cases. It's difficult to identify the duplication preoperatively and a standard surgical approach has not been developped. We report a neonate with bleeding of the digestive tube who presented a colonic duplication who required multiple diagnostic test before the diagnosis was made for colonoscopy. Laparotomy showed a total tubular duplication of the right, transverse and left colon with proximal and distal communication. Exclusion of the duplicated segment was performed, but three months after the operation, subocclusion due to stenosis of the colonic distal loop was developed. This finding was confirmed by a second colonoscopy and septum was partially removed. The study implies that CD, though uncommon, should be included in the differential diagnosis of rectal bleeding and the importance of the colonoscopy in the diagnosis and treatment of this malformation.

Diagnostic yield of lumbosacral magnetic resonance imaging requested by paediatric urology consultations. / Rentabilidad diagnóstica de la resonancia magnética lumbosacra solicitada desde las consultas de urología pediátrica.

OBJECTIVES: In the historical series, the diagnostic yield of lumbosacral magnetic resonance imaging to rule out occult spinal dysraphism (or occult myelodysplasia), requested by paediatric urology, ranged from 2% to 15%. The aim of this study was to define our cost-effectiveness in children with urinary symptoms and to define endpoints that increase the possibility of finding occult spinal dysraphism. PATIENTS AND METHODS: A screening was conducted on patients with urinary dysfunction for whom an magnetic resonance imaging was requested by the paediatric urology clinic, for persistent symptoms after treatment, voiding dysfunction or other clinical or urodynamic findings. We analysed clinical (UTI, daytime leaks, enuresis, voiding dysfunction, urgency, renal ultrasonography, lumbosacral radiography, history of acute urine retention, skin stigma and myalgia) and urodynamic endpoints (hyperactivity or areflexia, voiding dysfunction, interrupted pattern, accommodation value and maximum flow). A univariate analysis was conducted with SPSS 20.0. RESULTS: We analysed 21 patients during the period 2011-2015. The median age was 6 years (3-10). Three patients (14.3%) had occult spinal dysraphism: one spinal lipoma, one filum lipomatosus and one caudal regression syndrome with channel stenosis. The endpoints with statistically significant differences were the myalgias and the history of acute urine retention (66.7% vs. 5.6%, P=.04; OR= 34; 95%CI: 1.5-781 for both endpoints). CONCLUSIONS: The diagnostic yield of magnetic resonance imaging requested for children with urinary dysfunctions without skin stigma or neuro-orthopaedic abnormalities is low, although nonnegligible. In this group, the patients with a history of acute urine retention and muscle pain (pain, «cramps¼) can experience a greater diagnostic yield or positive predictive value.