Quality of sleep in patients undergoing cardiac surgery during the postoperative period in intensive care. / Calidad del sueño en pacientes sometidos a cirugía cardiaca durante el postoperatorio en cuidados intensivos.

OBJECTIVES: To describe the quality of sleep of patients undergoing cardiac surgery during the first two nights following surgery and identify some of the factors conditioning the nightly rest of these patients in the Intensive Care Unit. METHOD: Observational descriptive study based on applying the Richards-Campbell Sleep Questionnaire through a consecutive sample of patients undergoing cardiac surgery with Intensive Care Unit admission. Simultaneously, a questionnaire assessing different environmental factors existing in the unit as possible conditioning of the night's rest was applied. The association between consumption of opioid and sleep quality was studied. RESULTS: Sample of 66 patients with a mean age of 65±11.57 years, of which 73% were men (N=48). The Richards-Campbell sleep questionnaire garnered average scores of 50.33mm (1.st night) and 53.30mm (2.nd night). The main sleep disturbing factors were discomfort with the different devices, 30.91mm and pain, 30.18mm. The problems caused by environmental noise, 27.5mm or through the voices of the professionals, 26.53mm were also elements of nocturnal discomfort. No statistical association was found between sleep and the distance of the patient with respect to the nursing control area or related to opioid analgesics. CONCLUSIONS: The quality of sleep during the first two nights of Intensive Care Unit admission was "regular". The environmental factors that conditioned the night-time rest of patients were discomfort, pain and ambient noise.

Core Content for Undergraduate Medical Education in Spain: Recommendations of the Instructors' Group of the Spanish Academy of Dermatology and Venereology (AEDV).

BACKGROUND: Skin problems are among the most frequent reasons for seeking medical attention in primary care. In recent years, as a result of the process of adapting medical curricula to the requirements of the European Higher Education Area, the amount of time students spend learning the concepts of dermatology has been reduced in many universities. MATERIAL AND METHODS: In order to reach a consensus on core content for undergraduate education in dermatology, we sent a survey to the 57 members of the instructors' group of the Spanish Academy of Dermatology and Venereology (AEDV), asking their opinions on what objectives should be set for a dermatology course in Spain. A total of 131 previously selected objectives were listed. We then applied the Delphi method to achieve consensus on which ones the respondents considered important or very important (score≥4 on a Likert scale). RESULTS: Nineteen responses (33%) were received. On the second round of the Delphi process, 68 objectives achieved average scores of at least 4. The respondents emphasized that graduates should understand the structure and functions of the skin and know about bacterial, viral, and fungal skin infections, the most common sexually transmitted diseases (STDs), and the 4 main inflammatory dermatoses. Students should also learn about common complaints, such as itching and bald patches; the management of dermatologic emergencies; purpura and erythema nodosum as signs of internal disease; and the prevention of STDs and skin cancer. During clinical clerkships students should acquire the communication skills they will need to interview patients, write up a patient's medical history, and refer the patient to a specialist. CONCLUSIONS: The AEDV's group of instructors have defined their recommendations on the core content that medical faculties should adopt for the undergraduate subject of dermatology in Spain.

Adverse reaction to silicone simulating orofacial granulomatosis.

BACKGROUND: Granulomatous reactions to silicone facial fillers are well described in the literature. Clinically, these reactions present as nodules or pseudotumors that are frequently described as silicone granulomas or siliconomas. OBJECTIVE: We want to report a peculiar form of granulomatous reaction to injected silicone characterized by recurrent episodes of facial edema. METHODS: We collected silicone infiltrated patients with a similar clinical picture consisting of asymptomatic episodes of unilateral facial edema that had been recurring for months or years. RESULTS: We found four women with recurrent episodes of facial edema. They had been infiltrated with silicone in the face. Histology showed silicone deposits and a granulomatous infiltrate in all 4 cases. CONCLUSION: We describe and illustrate a new type of adverse reaction to injected silicone simulating orofacial granulomatosis. The reaction presents as recurrent, unilateral, asymmetric facial edema of the cheek in patients who have been injected with silicone in the face. Familiarity with this adverse reaction will help to prevent erroneous diagnoses such as idiopathic angioedema, Melkersson Rosenthal syndrome, and orofacial granulomatosis.

Dermatofibroma of the face: a clinicopathologic study of 20 cases.

INTRODUCTION: Dermatofibroma is one of the most common benign skin tumors. It typically develops on the lower limbs between the third and fifth decade of life and is more common in women. Clinical diagnosis is often straightforward. Dermatofibromas are associated with a very low rate of local recurrence following excision. OBJECTIVES: To describe the clinical and histologic features of dermatofibroma of the face based on our experience. MATERIALS AND METHODS: Descriptive retrospective study of the clinicopathologic features of dermatofibromas of the face diagnosed at the dermatology department of Hospital General Universitario de Valencia between 1990 and 2012. RESULTS: Twenty cases of dermatofibroma of the face (1.11% of all dermatofibromas diagnosed) were studied. The age at onset varied widely, from 28 to 84 years. The mean age at onset was 57.15 years and the median was 54 years. There were 11 women and 9 men. Mean follow-up was 83 months and there were no local recurrences. All the tumors were confined to the papillary and reticular dermis and the storiform pattern was the most common growth pattern observed. CONCLUSIONS: This study of facial dermatofibromas diagnosed at our hospital over a period of 22 years suggests that the face is an uncommon site but that dermatofibromas in this location behave similarly to those occurring elsewhere on the body.

Mitotic rate and subcutaneous involvement are prognostic factors for survival after recurrence in patients with only locoregional skin metastasis as the first site of recurrence from cutaneous melanoma.

BACKGROUND: Few reports on literature give detailed figures on prognostic factors of locoregional skin recurrence in cutaneous melanoma. OBJECTIVE: The aim of this study was to evaluate clinical and histological prognostic factors following development of locoregional cutaneous metastasis as the only progression site from melanoma. METHODS: Data from 1327 stage I and II melanoma patients who visited Instituto Valenciano de Oncología and Consorcio Hospital General Universitario de Valencia from 2000 to 2010 were documented in a prospective manner. During follow up, 112 (8.4%) of them developed recurrent disease. A retrospective analysis revealed a subset of 36 patients with locoregional cutaneous metastases as a first event. RESULTS: Significant prognostic factors in the univariate analysis were Breslow thickness, tumor mitotic rate and the presence subcutaneous involvement of the skin metastasis. After multivariate analysis the independent predictive factors for survival after recurrence were tumor mitotic rate (hazard ratio [HR]: 8.6; 95% CI: 1.0-77.2) and subcutaneous involvement of the skin metastasis (HR: 4.3; 95% CI: 1.0-18.5). CONCLUSION: The survival after recurrence of melanoma patients that has relapsed with only locoregional cutaneous metastasis depends on the mitotic rate of the primary tumor and the subcutaneous involvement of the metastasis.

Risk factors for the development of locoregional cutaneous metastases as the sole form of recurrence in patients with melanoma.

BACKGROUND: While locoregional cutaneous metastases (in transit and satellite) in melanoma have received little attention from researchers to date, they have pathogenic and prognostic features that distinguish them from other forms of locoregional recurrence. Identifying predictors of these metastases would be of great value for their prevention, early diagnosis, and treatment. The aim of this study was to identify the risk factors associated with locoregional cutaneous metastases as the first form of recurrence in the metastatic progression of melanoma. MATERIAL AND METHODS: Between 2000 and 2010, we prospectively collected the data of 1327 patients diagnosed with stage I and II melanoma. During follow up, 112 patients (8.4%) developed metastases. Of these, 36 had exclusively locoregional cutaneous metastases. The clinical and histological characteristics of this subgroup were evaluated. RESULTS: In the univariate analysis, significant predictors were patient age, primary tumor thickness, site, ulceration, mitotic index, and histological type. After multivariate analysis, the independent risk factors were tumor thickness (risk ratio [RR] 5.6; 95% CI: 2.7-11.5) and the location of the primary tumor on the lower limbs (RR 3.4; 95% CI: 1.0-11.5), on the head or neck (RR 4.8; 95% IC: 1.7-13.5), or in acral sites (RR 6.7; 95% IC: 2.2-20.8). CONCLUSION: Patients who have melanomas with a Breslow thickness of more than 2mm located on the lower limbs, head, neck, or acral sites have a higher risk of developing locoregional cutaneous metastases. These findings could be useful in the design of future guidelines for the monitoring and management of melanoma.

Syphilitic alopecia: a report of 5 cases and a review of the literature.

Syphilitic alopecia occurs in only 4% of patients with syphilis. We present 5 cases of this uncommon manifestation and review the corresponding literature. All of the patients in our series were men aged between 31 and 46 years. The lesions, which were located mainly in the parieto-occipital area of the scalp, manifested as multiple, irregular, nonscarring patches of alopecia that adopted a characteristic patchy moth-eaten pattern. One patient initially presented diffuse alopecia with multiple erythematous scaling lesions. Immunohistochemical staining revealed the presence of numerous spirochetes in the hair follicles in the 2 patients in whom skin biopsy was performed. The lesions improved with treatment in all the patients who attended follow-up. Dermatologists should maintain a high level of clinical suspicion for this uncommon manifestation of syphilis, particularly when it is the only symptom.

[Evaluation of the postoperative acute pain after heart surgery]. / Evaluación del dolor postoperatorio agudo tras cirugía cardiaca.

INTRODUCTION: Pain is one of the main symptoms reported by patients who have had heart surgery. OBJECTIVES: To describe the pain and explain the possible association among demographics, psychological and biological variables of the patients subjected to heart surgery with pain intensity during the postoperative in the ICU. PATIENTS AND METHOD: A descriptive, longitudinal study conducted between February 2008 and January 2009 on patients subjected to heart surgery with admission to the ICU of the Hospital of Navarra was conducted. A preoperatory interview was made with registration of sociodemographic, biological and psychological variables. Pain intensity was monitored during the first 48 hours of ICU stay with the Verbal Numeric Scale (VNS) of pain. Accepted level of significance was p<0.05. RESULTS: A sample of 69 patients with mean age of 62, 26% women and 74% men was included. A superior statistical association was found between postoperative pain levels for age<65 years, bypass grafting with internal mammary artery and preoperatory anxiety variables. There was a significant increase in analgesic consumption for incomes>1400 €/month, bypass grafting with internal mammary artery and preoperatory anxiety. CONCLUSIONS: Postoperative pain after heart surgery show significant individual variability. In our study, age, bypass grafting with internal mammary artery and preoperatory anxiety were shown as predictive variables of postoperative pain in patients undergoing heart surgery.

[Protein contact dermatitis: review of 27 cases]. / Dermatitis de contacto por proteínas. Revisión de 27 casos.

BACKGROUND: Protein contact dermatitis (PCD) is a rare and underdiagnosed condition that many dermatologists fail to recognize. Nevertheless, increasing awareness of the condition and the substances responsible has led to a rise in the number of published cases in recent years. OBJECTIVE: To determine the clinical characteristics and allergens implicated in PCD in our setting. MATERIAL AND METHODS: A retrospective observational study of all patients diagnosed with PCD in the last 10 years was undertaken in the Skin Allergies Unit of the Department of Dermatology at Hospital General Universitario in Valencia, Spain. All patients were assessed by skin-prick test with the standard GEIDAC allergen panel and by prick-by-prick test with foods or other products that were linked to immediate skin symptoms following handling. RESULTS: Twenty-seven patients (8 men and 19 women) were diagnosed with PCD, and 26 of the cases were occupational in origin. The mean age of the patients was 32.3 years and 51.8% had a history of atopy. The latency period varied from 2 months to 27 years. The most commonly affected areas were the backs of the hands and the forearms. Four patients had an oral allergy syndrome. In order of frequency, the substances responsible for PCD were fish (9 patients, 33.3%), latex (8 patients, 29.6%), potato (4 patients, 14.8%), chicken (3 patients, 11.1%), flour (3 patients, 11.1%), alpha amylase (2 patients, 7.4%), aubergine (2 patients, 7.4%), pork (1 patient, 3.7%), garlic (1 patient, 3.7%), and Anisakis (1 patient, 3.7%). CONCLUSIONS: PCD is a clinically relevant condition that dermatologists should include in the differential diagnosis of chronic dermatitis affecting the hands or forearms in patients at high occupational risk, particular those in the food preparation industry.

[Inflammatory myxohyaline tumor of the distal extremities]. / Tumor mixohialino inflamatorio de las zonas distales de las extremidades.

Inflammatory myxohyaline tumor of the distal extremities is an extremely rare low-grade sarcoma with a tendency to produce local recurrence after surgical excision, but with a low metastatic potential. We present the case of a 49-year-old woman with a slow-growing asymptomatic tumor on the right pretibial region that was initially considered to be a lipoma. Histopathology revealed the presence of a polymorphic inflammatory infiltrate within a myxoid and hyaline matrix. Interspersed between the inflammatory cells were 3 different populations of neoplastic cells: atypical spindle-shaped cells; bizarre epithelioid cells, some of which were multinucleated and resembled the virocytes or Reed-Sternberg cells; and cells with abundant, vacuolated cytoplasm, similar to lipoblasts. These clinical-pathologic findings led to a diagnosis of inflammatory myxohyaline tumor of the distal extremities. Although the tumor was excised with wide surgical margins, local recurrence developed after 3 months and was treated with re-excision and radiotherapy.

[Myocardial revascularization surgery: short and long-term survival analysis].

BACKGROUND: This study sets out to describe the survival and clinical evolution of patients who undergo myocardial re-vascularisation surgery, and identifies the short- and long-term predictive factors for surgical outcomes. METHODS: Study of a cohort of 175 patients undergoing pure or mixed coronary myocardial revascularisation surgery at a heart surgery unit, recruited between 2008 and 2010 and monitored for ten years. Descriptive and logistic regression (OR and 95%CI) analysis were carried out, along with an analysis of survival by Kaplan Meier and Cox uni- and multivariate regression (HR and 95%CI) in the short- (one year) and long-term (ten years). RESULTS: Predominantly male cohort (85.1%), mean age of 67 years (45-84), and mean EuroSCORE of 5.3%. Mortality was 6.8 and 26.9% at 1 and 10 years, respectively. Mean survival of deceased individuals was 40 months (32.2-47.8). In the short-term, a better NYHA =III preoperative functional level was not significantly associated with lower mortality (OR: 0.11; 95%CI: 0.01-1.08; p=0.058), while being female (OR: 2.94; 95%CI: 1.01-8.57; p=0.048) and having a EuroSCORE of >4% (OR: 4.94; 95%CI: 1.52-16.10; p=0.008) showed an increased risk of presenting adverse cardiac events. In the long-term, greater age (HR: 1.06; 95%CI: 1.01-1.10; p=0.026) and lower rates of body mass index after the first postoperative year (HR: 0.90; 95%CI: 0.81-0.99; p=0.040) were independent predictors of mortality. CONCLUSION: Age was an independent predictor of long-term mortality, while being female and a EuroSCORE >4% were associated with a higher risk of suffering from short-term cardiovascular events.

[Alzemon: a prospective follow-up study of eslicarbazepine acetate monotherapy in patients with newly diagnosed epilepsy]. / Alzemon: estudio de seguimiento prospectivo del acetato de eslicarbacepina en monoterapia en pacientes con epilepsia de diagnóstico reciente.

INTRODUCTION: Eslicarbazepine acetate is a novel sodium channel blocker for use in the treatment of focal onset seizures. Prospective studies on its effectiveness in monotherapy in patients with newly diagnosed partial epilepsy in routine clinical practice are scarce. AIM: To evaluate the effectiveness of eslicarbazepine as initial monotherapy in patients with newly diagnosed partial epilepsy in routine clinical practice. PATIENTS AND METHODS: A prospective, multicentre, post-authorisation study. Patients with newly diagnosed partial epilepsy aged 18 years or older without previous treatment were included. The efficacy variables were: percentage of seizure-free patients, responders and reduction in monthly frequency of seizures. The safety variables analyse the 12-month retention rate and the occurrence of adverse effects. RESULTS: Fifty-three patients were included. The retention rate was 77.4%. At the end of the observation period, 83% of patients were seizure-free and 92.5% had reduced their baseline frequency by 50% or more. In addition, 68% of the patients reported some adverse effect and 7.5% of them dropped out of the study for this reason. The effectiveness analysis of the subgroup of patients aged 65 years or more showed no differences with respect to the overall population. CONCLUSION: Eslicarbazepine monotherapy in patients with newly diagnosed partial epilepsy, both in the general population and in the population over 65 years old, is effective and safe in routine clinical practice.

TITLE: Alzemon: estudio de seguimiento prospectivo del acetato de eslicarbacepina en monoterapia en pacientes con epilepsia de diagnóstico reciente.Introducción. El acetato de eslicarbacepina es un nuevo bloqueante de los canales de sodio en el tratamiento de las crisis de inicio focal. Los estudios prospectivos sobre su efectividad en monoterapia en pacientes con epilepsia parcial de reciente diagnóstico en la práctica clínica habitual son escasos. Objetivo. Evaluar la efectividad de la eslicarbacepina en monoterapia de inicio en pacientes con epilepsia parcial de reciente diagnóstico en la práctica clínica habitual. Pacientes y métodos. Estudio postautorización prospectivo y multicéntrico. Se incluyó a pacientes con epilepsia parcial de reciente diagnóstico de 18 años o más sin tratamiento previo. Las variables de eficacia fueron: porcentaje de pacientes libres de crisis, respondedores y reducción en la frecuencia mensual de crisis. Las variables de seguridad analizan la tasa de retención a los 12 meses y la aparición de efectos adversos. Resultados. Se incluyó a 53 pacientes. La tasa de retención fue del 77,4%. Al final del período de observación, el 83% de los pacientes se encontraba libre de crisis y el 92,5% había reducido en un 50% o más su frecuencia basal. El 68% de los pacientes notificó algún efecto adverso y el 7,5% de ellos abandonó el estudio por este motivo. El análisis de efectividad del subgrupo de 65 años o más no mostró diferencias respecto a la población global. Conclusión. La eslicarbacepina en monoterapia en pacientes con epilepsia parcial de reciente diagnóstico, tanto en la población general como en la población de más de 65 años, es eficaz y segura en la práctica clínica habitual.

[Long-term safety and efficacy of etanercept in the treatment of psoriasis]. / Seguridad y eficacia de etanercept a largo plazo en el tratamiento de la psoriasis.

BACKGROUND: Clinical experience has shown that, in patients with psoriasis, suspending treatment with etanercept at week 24, as indicated in the prescribing information, may lead to a rebound effect. Several clinical trials support long-term use of etanercept, which was shown to have a good safety and efficacy profile. MATERIAL AND METHODS: This was a retrospective, observational study of 43 patients with moderate to severe plaque psoriasis, with and without joint involvement, who received continuous treatment with etanercept for more than 24 weeks. RESULTS: Etanercept was administered for a mean of 57 weeks. Overall, the Psoriasis Area and Severity Index (PASI) score decreased from a baseline value of 22.5 to 4.3 after treatment. In addition, with continuous treatment, most patients maintained decreases in PASI scores of 50% and even of 75%. Some patients without significant improvement in their PASI score in the first 24 weeks did manage to achieve significant results after prolonged treatment. These outcomes were achieved with a low incidence of adverse effects (reported in 13 patients [30.2%]), which were generally mild. CONCLUSION: We present our clinical experience with long-term etanercept treatment in patients with moderate to severe psoriasis, with and without associated joint involvement. The efficacy and safety profiles were found to be favorable.

[Health-related quality of life two years after myocardial revascularization surgery].

BACKGROUND: To describe the levels of health-related quality of life (HRQoL) attained and the magnitude of the effect of myocardial revascularization surgery. METHOD: Prospective descriptive study that, using the SF-12v2 health questionnaire and different socio-demographic and clinical variables, evaluated during a two-year follow-up the HRQoL of patients who had received myocardial revascularization surgery in the Cardiac Surgery service. RESULTS: One hundred and seventy-five patients were included with an average age of 67 years (range 45-84), 85.1% men. Seventy-two point five percent received complete revascularization surgery and 80.8% received a multiple bypass; the average EuroSCORE was 5.3%. The preoperative scores of the summary components of the SF-12v2 reflected a lower physical HRQoL (MHQ 49.4; SD: 23.4) than mental HRQoL (PHQ 74.8; SD: 20.2), and all the dimensions increased one year after surgery, especially those for physical health (PHQ increased 36.8%, p<0.001). Two years later all the dimensions decreased with respect to those of the first year (except Bodily Pain). Scores remained significantly above preoperative ones in the physical health dimensions (PHQ increased 23.9%, p<0.001) and the dimensions of Vitality and Emotional Role decreased significantly. Women showed significantly worse levels of HRQoL than men; no other determinant factors of postoperative HRQoL were found. CONCLUSIONS: HRQoL during the two-year follow-up after myocardial revascularization improved significantly but without reaching the levels of the general Spanish population. The female sex showed significantly lower levels of postoperative health.

[The Andalusia Epilepsy Society's Guide to Epilepsy Therapy 2005: IV. General principles of antiepileptic polytherapy and therapeutic strategies in refractory epilepsy]. / Guía terapéutica en epilepsia de la Sociedad Andaluza de Epilepsia 2005: IV. Principios generales de politerapia antiepiléptica y estrategias terapéuticas en epilepsia refractaria.

AIMS: The objective of this work was to produce a scientific evidence-based guide to clinical practice dealing with the basic questions concerning the treatment of epilepsy. DEVELOPMENT: A committee of 11 experts belonging to the Andalusia Epilepsy Society, made up of six neurologists, three neuropaediatricians, one neurosurgeon and a pharmacologist, all of whom were deeply involved and experienced in epilepsy, conducted a thorough review of the literature in search of all the evidence available on the proposed subject matter. The following databases were used: MEDLINE, Cochrane Library and the databases of several clinical practice guidelines (National Guideline Clearinghouse, National Institute of Clinical Excellence and the American Academy of Neurology's Clinical Guidelines). The Guide was set out in seven sections and was published in four parts. From a total number of 187 relevant documents, the committee found 63 examples of scientific evidence and 91 therapeutic recommendations. These were tabulated and classified according to the European Federation of Neurological Societies' criteria for producing Clinical Practice Guidelines. CONCLUSIONS: The results of this survey provide scientific evidence-based clinical guidelines that are useful, simple and applicable at different levels of health care.