Emphysematous osteomyelitis: a rare and aggressive disease.

Emphysematous osteomyelitis is an extremely rare entity consisting of the presence of intraosseous gas that can extend to the joints and adjacent soft tissues. It is an aggressive infectious process associated with high mortality, especially in patients with risk factors such as tumors or diabetes mellitus. Because early diagnosis and immediate treatment are crucial to prevent the potentially devastating consequences of this condition, imaging tests such as computed tomography play a fundamental role in its diagnosis and management. Therefore, radiologists must be aware that intraosseous gas is a rare but alarming sign that is pathognomonic of emphysematous osteomyelitis, especially in the axial skeleton.

Ventral Approach for the Non-transecting Bulbar Urethroplasty.

BACKGROUND: Nowadays, short bulbar strictures refractory to one endoscopic treatment attempt could be managed with non-transecting urethroplasty technique as a first option.1 Jordan et al2 and Bugeja et al3 described a dorsal approach, sparing vessels, and spongiosum in the hope of a decrease of surgical side effects. OBJECTIVE: To describe the step-by-step technique of the ventral approach for the non-transecting bulbar urethroplasty in distal and mid short bulbar strictures. MATERIALS AND METHODS: We performed a prospective observational study of a cohort of patients who underwent a ventral non-transecting bulbar urethroplasty for short mid or distal bulbar strictures from January 2016 to December 2018. We included 10 patients. SURGICAL TECHNIQUE: A ventral midline urethrotomy is made and extended to assure a good caliber lumen both distally and proximally (20 Fr). The mucosal scar tissue is marked and a mucosectomy is performed, preserving the spongiosum.We bring the distal and proximal edges of healthy mucosa together without tension with a 5/0 absorbable monofilament. Ventral stricturotomy is closed over a 20F catheter, in a Heinike-Mikulics fashion, with 5/0 absorbable monofilament for the mucosal anastomosis and a 4/0 absorbable monofilament for the spongioplasty. RESULTS: Mean age was 56,50 years (+/-17,27) and mean stricture length was 1,06cm (+/-1,82). The majority of strictures (90%) were located in the mid bulb. After a mean follow up of 27,25 months (+/-12,12), 9 patients remain recurrence-free (87,5%). A significant mean increase in Qmax was observed (12+/-4,53 ml/s, p=0,04). Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROMS), items (Questions 1-6) related to urinate symptoms also showed a significant improvement(p=0,03). We didn't find any significant decrease in erectile function with this technique. CONCLUSION: The ventral approach for mid and distal short bulbar strictures is a feasible and reproducible technique with a significant increase in Qmax and improvement in USS-PROMS. Preliminary results show no decrease in erectile function.

Evolution of male patients with detrusor underactivity and conservative treatment. Five-year follow-up. / Evolución de pacientes varones con detrusor hipoactivo y tratamiento conservador. Seguimiento a cinco años.

INTRODUCTION: The objective of the study was to compare the evolution of male patients with neurogenic detrusor underactivity (NDU) versus non-neurogenic DU (NNDU) and to establish risk factors to predict the need for clean intermittent catheterization (CIC) during the follow-up period. MATERIAL AND METHODS: Longitudinal, descriptive study of a cohort of patients diagnosed with DU, and 2,496 urodynamic studies (2008-2018) were reviewed. Patients with DU (ICS 2002 and/or Bladder contraction index (< 100)) without treatment were included. Patients with CIC or interventional treatment were excluded. Follow-up included flowmetry every six months. CIC was indicated in cases of high residual volume (PVR) > 200 mL or voiding efficiency (VE)<50%. The need for CIC during follow-up or the appearance of complications (urinary tract infections (UTI), bladder lithiasis) were compared. RESULTS: DU was found in 172 (6.89%) men. Neurological causes were observed in 106 (61,6%) cases. Finally, 62 patients were included with a mean follow-up of 4.9 years (+/- 2.6). Of these patients, 33 (53%) presented NDU and 29 (47%) NNDU. Six patients with NDU needed CIC versus none with NNDU (p = 0.04). Patients requiring CIC had higher PVR (p = 0.009) and lower VE (p = 0.017)), and there were also differences in terms of time until the need for CIC (log Rank: 0.009), which was 15.1 months [4-38]. In the multivariate analysis, none of the variables showed to be predictive of the need for CIC. CONCLUSIONS: The most common cause of DU is neurologic injury. Patients with NDU remain stable without requiring CIC. We have not detected any risk factors that identify patients at risk of needing CIC.

Primary lymph-node staging with 68Ga-PSMA PET in high-risk prostate cancer: pathologic correlation with extended pelvic lymphadenectomy specimens.

AIM OF THE STUDY: This study aims to assess the diagnostic efficacy of Gallium-68-prostate-specific membrane antigen positron emission tomography (PET)/computed tomography (CT) (68Ga PSMA PET-CT) in primary nodal staging of high-risk prostate cancer (PCa) when compared to pathologic findings of extended pelvic lymph-node dissection (eLND). MATERIALS AND METHODS: The records of high-risk PCa patients who were preoperatively staged through 68Ga PSMA PET-CT and who underwent robot-assisted radical prostatectomy with eLND either alone or as part of multimodal definitive therapy between August 2016 and November 2019 were retrospectively reviewed. Surgeons were not blinded to the results of the 68Ga PSMA PET-CT scan. Pathologic uptake was defined as any anomalous uptake which was not better explained by another cause and was suggestive of PCa. The reference standard for this study was the pathologic confirmation using a node-based analysis. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for 68Ga PSMA PET-CT were calculated in a per-patient analysis using IBM SPSS Statistics version 25. RESULTS: Seventeen patients met the selection criteria. Mean age was 63 years (range 44-77) and mean and median preoperative serum prostate specific antigen was 19.25 and 9 ng/ml (range 6-131), respectively. The most common pathologic Gleason score was 8 (52.9% of cases). Seven patients (41%) had positive surgical margins and were submitted to adjuvant radiotherapy. Mean number of per patient removed lymph-nodes was 13 (±2.19). 68Ga PSMA PET-CT showed findings compatible with lymph node metastases in 4/17 patients and with locally-confined disease in 13/17 patients. Following pathologic confirmation, the per-patient sensibility of the 68Ga PSMA PET-CT was calculated at 75% (1 false negative) and the specificity at 92.3% (1 false positive) for detection of lymph node metastasis on primary staging of high-risk PCa patients. Positive and negative predictive value were 75% and 92.3%, respectively; accuracy of the test was calculated at 88.2%. All patients were submitted to 68Ga PSMA PET-CT re-evaluation 6 months after surgery and tested negative for local, nodal, or distant recurrence of disease. CONCLUSIONS: 68Ga PSMA PET-CT appears to have a high negative predictive value for local lymph node metastases in high-risk primary PCa when compared to pathologic findings of eLND. Its role in the primary nodal staging of high-risk PCa patients worths further evaluation.

Redescription and DNA barcoding of diurnal moth Athroolopha latimargoRothschild, 1914 bona sp., stat. rev. from the southern Iberian Peninsula (Lepidoptera: Geometridae: Ennominae).

The rare and diurnal geometrid moth Athroolopha latimargo Rothschild, 1914 bona sp., stat. rev. is re-discovered and redescribed from the furthest point of the south of the Iberian Peninsula, for the first time since its original description as a subspecies of Athroolopha chrysitaria (Hübner, 1813) from North Africa. The range of this taxon is questioned. A mitochondrial COI barcode sequence was generated for the specimens and compared with Iberian and Sicilian Athroolopha species.

miR-146a rs2431697 identifies myeloproliferative neoplasm patients with higher secondary myelofibrosis progression risk.

Myelofibrosis (MF) occurs as part of the natural history of polycythemia vera (PV) and essential thrombocythemia (ET), and remarkably shortens survival. Although JAK2V617F and CALR allele burden are the main transformation risk factors, inflammation plays a critical role by driving clonal expansion toward end-stage disease. NF-κB is a key mediator of inflammation-induced carcinogenesis. Here, we explored the involvement of miR-146a, a brake in NF-κB signaling, in MPN susceptibility and progression. rs2910164 and rs2431697, that affect miR-146a expression, were analyzed in 967 MPN (320 PV/333 ET/314 MF) patients and 600 controls. We found that rs2431697 TT genotype was associated with MF, particularly with post-PV/ET MF (HR = 1.5; p < 0.05). Among 232 PV/ET patients (follow-up time=8.5 years), 18 (7.8%) progressed to MF, being MF-free-survival shorter for rs2431697 TT than CC + CT patients (p = 0.01). Multivariate analysis identified TT genotype as independent predictor of MF progression. In addition, TT (vs. CC + CT) patients showed increased plasma inflammatory cytokines. Finally, miR-146a-/- mice showed significantly higher Stat3 activity with aging, parallel to the development of the MF-like phenotype. In conclusion, we demonstrated that rs2431697 TT genotype is an early predictor of MF progression independent of the JAK2V617F allele burden. Low levels of miR-146a contribute to the MF phenotype by increasing Stat3 signaling.

Oral quality of life after buccal mucosal graft harvest for substitution urethroplasty. More than a bite?

INTRODUCTION: The aim of our study was to analyze the oral quality of life (QoL) in patients with urethral stricture treated with BMG by using a validated questionnaire (OIDP). MATERIALS AND METHODS: A prospective, single-arm, observational single-centre study of a cohort of patients scheduled for BMG Urethroplasty was conducted. OIDP assesses the impact of oral conditions on daily activities including an oral QoL question (0-10). The questionnaire was self-administered before, 3 months postoperatively and at the end of the study. Means, pre- and postoperatively, were compared. Multivariate analysis was performed to analyze the risk factors for a low quality of life (<8) after surgery. RESULTS: We included 41 patients (2013-2017). The mean preoperative oral QoL was 9.33 points (SD1.16). Preoperative mean OIDP dimensional score and global score were 0,5 (SD:0.02) and 0,8%. The most frequently preoperative altered aspect was hygiene. Mean oral QoL, 3 months after surgery, was 8,56 (SD1.89) and OIDP dimensional score and global score were 0,67 (SD0.21) and 1,1%. Mean oral QoL at the end of the study (mean 3,12 years) was 8,50 (SD1.13). OIDP dimensional score and global score were 0,7 (SD 0.16) and 1,1%.The most frequently altered aspect at the end of the study was eating. No statistical (p = 0.07) decrease in oral QoL was found. The increase in OIDP dimensional and global score was also not statistically significant. Neither age nor smoking, diabetes mellitus, cardiovascular morbidity, previous OIDP score, width, length of the graft, or surgery success could explain a low oral QoL alter graft harvesting. CONCLUSIONS: BMG harvesting is not free of problems at the donor site. Eating seems to be the most affected aspect after surgery. Nevertheless, those sequelae do not induce a reduction in oral QoL.

Adaptation to Spanish of the ICS Good Urodynamic Practices. / Adaptación al español de las Good Urodynamic Practices de la International Continence Society.

The standardisation working group of the International Continence Society has updated the Good Urodynamic Practice directives. This evidence-based ICS-GUP2016 has defined the terminology and standards of Urodynamic practice, for the laboratory and for individual practice, in quality control during cystometry and pressure-flow analysis. In addition, the working group included recommendations prior to the test and information about how to prepare the patient, as well as recommendations for the reporting of urodynamics. Based on earlier International Continence Society standardisations and current evidence, the practice of uroflowmetry, cystometry and pressure-flow study have been detailed with a view to ensuring that this Good Urodynamic Practice update contributes towards improving clinical and research quality in urodynamics.

Bilateral testicular torsion in an adolescent: a case with challenging diagnosis

ABSTRACT Bilateral testicular torsion is a very uncommon emergency, with a challenging differential diagnosis. We describe the case of a 15-year-old patient with a left testicular torsion of 48 hours of duration and a sudden onset of right scrotum pain during his stay at the emergency area. Bilateral testicular torsion was diagnosed after repeat physical examination and doppler ultrasound, which had been normal for right testis in a first evaluation. Surgical exploration was performed with orchiectomy in left testis and fixation in right testis. In previous literature, there are reported bilateral torsion only in four adolescents and five adults. With this case, we demonstrate that bilateral spermatic cord torsion may be easily overlooked in a patient with acute scrotum and we emphasize the importance of bilateral exploration in testicular torsion.

Bilateral testicular torsion in an adolescent: a case with challenging diagnosis.

Bilateral testicular torsion is a very uncommon emergency, with a challenging differential diagnosis. We describe the case of a 15-year-old patient with a left testicular torsion of 48 hours of duration and a sudden onset of right scrotum pain during his stay at the emergency area. Bilateral testicular torsion was diagnosed after repeat physical examination and doppler ultrasound, which had been normal for right testis in a first evaluation. Surgical exploration was performed with orchiectomy in left testis and fixation in right testis. In previous literature, there are reported bilateral torsion only in four adolescents and five adults. With this case, we demonstrate that bilateral spermatic cord torsion may be easily overlooked in a patient with acute scrotum and we emphasize the importance of bilateral exploration in testicular torsion.

Cultural adaptation to Spanish (Spain) of the "Overactive Bladder - Family Impact Measure (OAB-FIM)" questionnaire. / Adaptación cultural al español (España) del cuestionario Overactive Bladder Family Impact Measure (OAB-FIM).

OBJECTIVE: The OAB-FIM was developed as a measure of the impact of an overactive bladder (OAB) on relatives who live with the patient. The objective of this study was conduct a cultural adaptation to Spanish (Spain) of the OAB-FIM questionnaire. METHODS: The adaptation included a conceptual and linguistic validation phase, as well as a phase for measuring the psychometric properties in 25 relatives [mean age, 63.0 years (SD, 14.3); 44% women] who regularly live with patients with OAB, who are of either sex and 18 years of age or older. We measured conceptual and linguistic equivalence, internal reliability, construct validity and content validity. We assessed the applicability and administration load. RESULTS: The OAB-FIM was conceptually and linguistically equivalent to the original, maintaining its 6 domains: social, travel, worry, irritability, sleep and sex. The interagreement correctly placed all items in their domain, except for number 10, which was placed more in worry than in irritability, motivates its reformulation. Some 2.95% of the items were missing. The floor and ceiling effects of the items varied, respectively, between 20-28%, and 0-16%. The mean time for completing the questionnaire was 5.2minutes (SD, 2.8), and 24% of the participants required some type of assistance. The α-Cronbach coefficient varied between 0.948-0.839. The correlations with similar scales in the family were moderate-high (0.407-0.753) or small-moderate with those administered to the patient (0.004-0.423). CONCLUSION: We obtained a Spanish (Spain) version of the OAB-FIM that was conceptually and linguistically equivalent to the original. The questionnaire showed good internal consistency, content and construct validity and applicability.

Hydrodistension plus Onabotulinumtoxin A in bladder pain syndrome refractory to conservative treatments. / Hidrodistensión bajo anestesia más inyección de Onabotulinumtoxin A en pacientes con síndrome de dolor vesical refractario a tratamiento conservador.

INTRODUCTION: For bladder pain syndrome (BPS) refractory to conservative treatment, the European guidelines consider bladder hydrodistention (HD) under anaesthesia and the injection of Onabotulinumtoxin A (OnabotA) jointly. The objective of this study was to assess our experience in implementing this technique. MATERIAL AND METHODS: A prospective study of 25 patients with BPS who underwent HD plus a submucosal injection of 100 U of OnabotA in trigone. The Hunner lesions were treated endoscopically using resection or electrocoagulation. Thirty-eight procedures were performed (25 first interventions and 13 reoperations). To study the clinical change, we evaluated the subjective improvement (Treatment Benefit Scale [TBS] and Patient Global Impression of Change [PGIC] scales), the visual analogue scale (VAS) for pain, the Bladder Pain/Interstitial Cystitis Symptom Score (BPIC-SS) questionnaire and the voiding diary for 3 days. For the data analysis, we employed the Wilcoxon, Kruskal-Wallis, Kaplan-Meier and log-rank tests. RESULTS: We observed subjective improvement in 21 patients (84%), which was significant in 47% of these patients, moderate in 41.2% and slight in 11.8%. Four patients did not improve. A post-treatment reduction in the pain VAS (from 7.1 to 1.8 points; P=.001), in daytime (from 11.8 to 7.5; P=.012) and night-time (from 5.9 to 3.6; P=.003) voiding frequency and in the BPIC-SS (from 27.9 to 11.2 points; P=.042). The degree of improvement was not related to age, the presence of bladder lesions or the treatment of relapses. The median duration of improvement was 7 months (95% CI 5.69-8.31), although this duration was somewhat longer for the patients younger than 65 years. Mild complications occurred in 23.7% of the cases. CONCLUSIONS: The joint implementation of HD plus OnabotA is a valid therapeutic option in refractory BPS, which provides good clinical results and maintains its effectiveness in retreatments.

[Continuous spinal anesthesia in obstetrics]. / Anestesia subaracnoidea continua en obstetricia.

Despite the theoretical advantages of continuous anesthesia in obstetric patients (good-quality blockade at low doses, good hemodynamic stability, rapid onset of effect, and no risk of toxicity), little has been published on this technique and its use in pregnancy. Moreover, few descriptive studies or comparative trials have evaluated the efficacy and safety of continuous spinal anesthesia, probably because of concerns about potential adverse effects-principally neurologic complications and postdural puncture headache. We review the literature on the use of continuous spinal anesthesia in obstetric patients, analyzing the advantages and disadvantages, indications, and adverse effects of this technique.

Comparative analysis between laparoscopic (UCL) and open (UCO) technique for the treatment of ulcerative colitis in pediatric patients.

PURPOSE: The aim of this study is to compare laparoscopic with open approach in the surgical treatment of ulcerative colitis (UC) MATERIAL AND METHODS: Between July 1991 and August 2009, 32 consecutive unselective patients with UC received surgical treatment. The population analyzed was divided into three groups: subtotal colectomy + ileocolostomy (Group 1), proctectomy + ileoanal pouch (Group 2), one-step proctocolectomy + ileoanal pouch (Group 3). We analyzed the mean operating time, postoperative oral intake, use of opiates, the length of hospital stay and postoperative morbidity in each group. Open and laparoscopic approaches were compared in each group retrospectively. RESULTS: In Group 1 the mean operating time was longer for the laparoscopic group (301 vs. 197 min; p < 0.01). The length of postoperative stay was longer for the open group (8 vs. 19 days; p < 0.05) and the oral intake started earlier in the laparoscopic group (3, 5 vs. 6, 2 days; p = 0.05). No significant difference was found in the use of opiates (p = ns). A total of four major complications occurred in the laparoscopic group and another four in the open approach. In Group 2, there was no significant difference in operating time between laparoscopic and open approach. The laparoscopic group started earlier to tolerate (p < 0.05) and there were significantly differences in the use of narcotics and hospital stay (p < 0.05). General complications were related to the pouch. In Group 3 the mean operating time was longer for the laparoscopic group (470 vs. 330 min p < 0.05). Patients with a laparoscopic approach had a shorter hospital stay (5, 6 vs. 10 days; p < 0.05) and postoperative narcotic use and they started earlier to tolerate (p < 0.05). One major complication was presented in the laparoscopic procedure and two in the open approach. CONCLUSIONS: Of the 165 patients with UC in our hospital, 32 underwent surgery. The laparoscopic approach seems feasible and safe. A single staged approach (Group 1 + Group 2) remains the most reasonable choice for most patients. One-step approach was done only in selected cases (Group 3). The advantages of laparoscopy, such as improved cosmetic aspects, shorter postoperative ileus and hospital stay, were observed in the laparoscopic colectomy, proctectomy and ileoanal pouch in our study.

[Historical approach to reserpine discovery and its introduction in psychiatry]. / Aproximación histórica al descubrimiento de la reserpina y su introducción en la clínica psiquiátrica.

Reserpine, an alkaloid of the Rauwolfia serpentina plant isolated during the middle of the 20th Century, represented a highly important clinical advance in the treatment of schizophrenia whose pharmacological tools were limited to chlorpromazine that was introduced in the clinical area two years before. Both agents would come into the history as the drugs that made possible the beginning of the psychopharmacological era. In the present article, a revision is made of the complicated process leading to the isolation and synthesis of reserpine, by the Swiss pharmaceutical company Ciba (Schlittler and Müller) and how its pharmacological properties (Bein) were discovered and studied, in the animals laboratory, mainly, the "tranquillizers". The introduction of this antipsychotic in psychiatry, which was initiated in 1954 (half a century ago), and the results obtained in the first clinical studies, as well as the role played by researchers such as Kline, Delay, Noce, Hollister, Altschule, etc. are then described. In addition, and from a historical perspective, the discovery of the adverse effects of this drug, especially those of extrapyramidal nature (dyskinesia and akathisia), are studied, concluding with the reasons that produced its rapid clinical decline, among which the genesis of depressive pictures (phenomenon presently questioned) may be emphasized. Finally, the conclusion reached was that, although the clinical relevance of reserpine was not as evident and long lasting as chlorpromazine, its initial contribution to the treatment of schizophrenic patients was of maximum importance.

[Twelve years of the child oral care program (PADI) in Navarra (1991-2002). Utilisation and health indicators]. / Doce años de programa de asistencia dental infantil (PADI) en Navarra (1991-2002). Utilización e indicadores de Salud.

BACKGROUND: In 1991, with an incremental character, the Infant Oral Care Program (PADI) was set up in Navarra, which covers the population of 6 to 15 years of age, and which has a mixed provision, public and private-arranged, the latter with a payment system by capitation. The aim of this article is to analyse the possible impact of the program on the use of services and to analyse the evolution of the dental health of Navarra schoolchildren in the 1991-2002 period. MATERIALS AND METHODS: Data was collected on the network of providers and the utilisation of the PADI made available by the Directorate of Primary Care of the Navarra Health Service - Osasunbidea, and data was analysed from the surveys of dental health for 1987, 1997 and 2002, whose methodology has been published. The data was exploited statistically with the SPSS program for Windows, v10. RESULTS: The number of dentists-providers of the program increased from 28 in 1991 to 161 in 2002; in the same period the indexes of participation rose from 37.4 to 67.2%. There is a positive, statistically significant correlation between the growth of the network (r: 0.941) and its geographical extension (r: 0.933), and the index of utilisation. The percentage of schoolchildren aged 14 years who state that they have been to the dentists in the last year rises from 55.1% in 1987 to 88.2% in 2002. More than 70% of the schoolchildren between 6 and 12 years of age state that they have been to a PADI dentist. The prevalence of caries continues to fall in all age groups and becomes stabilised at 14 years. Between 44 and 79.2% of the caries are treated. The schoolchildren who regularly visit the PADI show more preventive and restorative treatment (sealed) than those who do not. CONCLUSION: The setting up of the PADI seems to have brought an increase in the utilisation of the dental services, together with an improvement in the dental health of the infant and adolescent population of Navarra.

Prevalencia de enteroparásitos en niños inmunocomprometidos e inmunocompetentes / Prevalence of enteroparasites in inmunocompromised and immnunocompetent children

Determinar la prevalencia de enteroparásitos en niños inmunocomprometidos e inmunocompetentes del Etado Zulia, Venezuela. Materiales y métodos: se analizó una muestra fecal de 78 niños de ambos sexos, en edades comprendidas entre 2 meses y 12 años, distribuidos en 4 grupos: Desnutridos (20), Oncología (20), con infección HIV/SIDA (18) y Control (20); practicándose examen coproparasitológico, coloraciones de lugol, Nair y Kinyoun, técnicas de concentración de Ritchie y técnica de Arakaki (agar en placa). Resultados: 29 (37,2 por ciento) niños presentaron una o varias especies de enteroparásitos, distribuidos así: 7/20 (35,0 por ciento) en los grupos de Desnutrición y control respectivamente, 8/20 (40,0 por ciento) en Oncología y 7/18 (38,9 por ciento) en los niños con infección HIV/SIDA. Los menores o iguales a 2 años fue el grupo etario más parasitado tanto en el grupo Desnutridos como en los Controles; en Oncología fueron los de 3 a 6 años, y en los niños con infección HIV/SIDA los de 7 a 12 años. Los parásitos más prevalentes fueron: Ascaris lumbricoides (14,3 por ciento) y Blastocystis hominis (24,5 por ciento). Conclusiones: La condición de inmunocomprometidos de los niños bajo estudio (Desnutridos, Cáncer y HIV/SIDAS) no fue determinante en la presencia de enteroparásitos. El monoparasitismo predominó en los grupos de Desnutrición, Oncología y Control, y el poliparasitismo en el grupo de niños con infección HIV/SIDA. Los resultados obtenidos en el presente estudio, representan un aporte más al conocimiento de las enteroparasitosis en nuestra región.

Evolution of the management of depression in Spain from the psychiatrist's perspective. A comparative analysis: 1997 vs 1982.

The main problem of depression is not only the high prevalence of the disorder but also its serious consequences on the patient's quality of life and the associated social costs in terms of health care resource utilization and productivity losses. In recent years, there has been a considerable improvement in the knowledge of depression from the pathogenic, clinical and therapeutic perspectives. The present study analyzes whether such advances are reflected in a positive evolution of the treatment of depression in Spain. To this effect we have contrasted the results of two socio-sanitary studies published in this country: the White Book editions of 1982 and 1997 (WB82 and WB97, respectively). From the methodological perspective, the physician selection criteria employed were very uniform (structured questionnaires delivered to 128 (WB82) and 300 (WB97) randomly selected psychiatrists). The origin of patients consulting for specialized care has varied over this 15-year period. In effect, WB82 patients were essentially referred by friends (87.5%) and from the primary care setting (44.5%), whereas in the WB97 study referral from primary care predominated (50.1%), followed by the patient's personal decision (24.8%). In turn, 40.7% and 51.7% of the psychiatrists in WB97 respectively considered the diagnostic and therapeutic means available in primary care to be insufficient. The priorities for improving patient quality of life, as reflected by both editions of the study, were the training of primary care physicians and the adequate provision of means in the mental health care centers. On the other hand, fewer problems for establishing a correct diagnosis were referred in the 1997 edition of the study (28.7%) than in 1982 (48.4%). In this sense, the main problem reported in WB82 was the lack of specialized training, whereas the masking of depression by some other disease process or symptoms was the main problem in WB97 (67.6% vs 21.1% according to WB82). The main symptoms upon which the diagnosis of depression are based do not seem to have evolved much in the past 15 years. The most frequently cited manifestations were a worsening of mood, loss of interest and leisure capacity, sleep alterations and diminished vitality. A comparative analysis of the therapeutic resources used was not possible, for prior to 1982 the only drugs available to physicians were the classical tricyclic agents and some MAO inhibitors; the selective serotonin reuptake inhibitors (SSRIs) - possibly the greatest advance in the treatment of depression in these 15 years - had not yet been introduced. Nevertheless, it should be pointed out that 98% of the psychiatrists consulted in WB97 considered pharmacologic treatment to be the most widely adopted form of management once depression has been diagnosed.