[Simulation as a tool to facilitate change in healthcare organisations]. / La simulación como herramienta para facilitar el cambio en las organizaciones sanitarias.

OBJECTIVE: To describe the use of simulation as a tool to support the strategic management of change in the Cantabrian Regional Health Service in Spain. METHODS: A working group was created to: 1) define the strategic areas of innovation and change; 2) establish criteria for the selection of proposals that can be addressed with simulation; 3) analyse and select the proposals; 4) design and implement the simulation programs, and 5) evaluate results. RESULTS: The constantly changing needs of the regional health system enabled 6 strategic areas to be identified during 2017-208: 1) efficient use of resources; 2) implementation of health plans of interest in the community; 3) patient safety improvement; 4) management of health personnel; 5) development of new professional skills, and 6) selection and implementation of new technology. CONCLUSIONS: Clinical simulation is a useful tool to promote innovation strategies in healthcare, facilitating the adaptation of professionals and patients to change.

Spanish Registry for Embolization of Small Intracranial Aneurysms with Cerecyte Coils (SPAREC) Study. Early Experience and Mid-Term Follow-up Results.

SUMMARY: This study aimed to report the results obtained in treating small ruptured and unruptured intracranial aneurysms using Cerecyte coils. A prospective, non-randomized multicenter registry operating in Spain with a reporting period between May 2005 and September 2007.We present clinical and angiographic results for 48 small aneurysms (26 ruptured, five with III cranial nerve paresis, and 17 incidental) that had undergone six months' follow-up. The volumetric percentage occlusion (VPO) achieved and percentage bioactive coils (PBC) used were assessed. No episodes of bleeding occurred during the follow-up period. The technical complication rate was 10.4% (five cases): four thromboembolic complications resolved with medication (8.3%) and one asymptomatic protrusion of a coil into the parent vessel. The clinical complication rate for the procedure was 2.1% (occlusion of the anterior choroidal artery in a ruptured anterior choroidal anaeurysm). Mean VPO was 25.2%. Balloon-assisted technique (BAT) was used in 60.4% of cases. The VPO was higher in the BAT-treated cases (P < 0.05). The overall six-month recanalization rate was 16.7% (12.5% minor and 4.2% major recanalizations). Neck size and VPO were unrelated to the recanalization rate. The PBC was higher in cases with progressive Deployment of the device is safe from the standpoint of periprocedural technical and clinical complications. No episodes of hemorrhage were recorded during follow-up. The sixmonth recanalization and retreatment rates compared favorably with most endovascular platinum and bioactive coil series.

Simultaneous Cerebral Aneurysms and Carotid Disease Should the Symptomatic Lesion always be the first to be Treated? A Case Report.

SUMMARY: Simultaneous presentation of carotid stenosis and cerebral aneurysms is rare and it is conventionally accepted that symptomatic lesions need to be treated first. Our purpose was to describe our experience in managing patients who simultaneously presented significant carotid stenosis and cerebral aneurysm.

Concurrent angiomyolipomas and renal cell carcinoma harboring metastatic foci of mammary carcinoma in the same kidney: an incidental autopsy finding in a patient with a follow-up of thirty years.

The synchronous occurrence of three different types of renal tumor in a patient is rare. We report a case of conventional (clear cell) renal cell carcinoma harboring metastatic foci of mammary carcinoma associated with two angiomyolipomas in the left kidney incidentally discovered at the autopsy. The patient was a 75-year-old woman, without the tuberous sclerosis complex, who had undergone left radical mastectomy and radiotherapy for an infiltrating duct carcinoma of breast 30 years before. This tumor was widely disseminated at autopsy, but the nontumorous renal parenchyma was free of metastases. To the best of our knowledge this combination of neoplasms has not been described before. This case shows the important role played by autopsy in the accurate investigation of interrelations among coexisting tumors.

Papillary adenoma of the kidney with mucinous secretion.

Although infrequently, mucin secretion has previously been reported in papillary renal cell carcinoma. We here investigate the presence of mucin in a series of 93 renal papillary adenomas in 58 patients. Acid mucin was present in four cases (4.3% of the tumors; 6.9% of the patients), in which basophilic mucin secretion was evident with hematoxylin-eosin. To the best of our knowledge mucin secretion has not been reported in renal papillary adenoma. We describe two different types of mucin secretion: intracytoplasmic and luminal. The secretion was intracellular in numerous scattered tumor cells in two cases, focal luminal in one case, and mixed intracellular and luminal in another case. Mucin production, despite its low frequency, can be considered as an additional feature of renal papillary adenoma. Mucin production suggests that renal papillary adenoma and papillary renal cell carcinoma are actually not two independent biological processes, but a continuum of one biological process.

Polypoid (pedunculated) subepicardial lipoma: a cardiac lesion resembling the epiploic appendage.

This report describes a 75-year-old woman with an asymptomatic pedunculated lipoma involving the epicardium of the right atrium. The lipoma was an incidental finding at autopsy. The twisted lesion showed many similarities with the infarcted epiploic appendages observed in the visceral peritoneum.

Long-term histopathologic findings in two cerebral aneurysms embolized with Guglielmi detachable coils.

We present gross pathologic autopsy findings of a patient who was treated for two aneurysms with Guglielmi detachable coils (GDCs), and who died 33 months after the procedure. Histologic findings are also presented. In both aneurysms, the coils were firmly attached to the aneurysmal wall, making it impossible to remove them from the sac. The ostium of one aneurysm was covered by collagenous tissue and a single layer of endothelium.

Papillary (chromophil) renal cell carcinoma with mucinous secretion.

We investigated the presence of mucin in a series of 20 papillary renal cell carcinomas. Acid mucin was present in three cases (15%), in which basophilic mucin secretion was evident with hematoxylin-eosin. This secretion reacted positively with Mayer's mucicarmine, Alcian blue and high-iron diamine, but was negative for PAS in all the cases, indicating the presence of sulphomucins. We describe two different types of mucin secretion: luminal and intracytoplasmic. The secretion was abundant, diffuse or extensive, luminal in two cases and intracellular in numerous scattered tumor cells in one case. All tumors were < 3 cm in diameter (low grade, stage I). In the three mucin-secreting papillary tumors mentioned above, the immunohistochemical and lectin studies indicate both a proximal and a distal tubular staining pattern. Mucinous secretion in these tumors can be ascribed either to modulation or direct metaplasia of the tumor epithelium. Mucin production, despite its low frequency, can be considered an additional feature of papillary renal cell carcinoma. Thus, the presence of luminal or intracytoplasmic mucin deposition does not exclude papillary renal cell carcinoma from the differential diagnosis in cases of intra- or extrarenal carcinomas.

Treatment of a Giant Aneurysm of the Right Middle Cerebral Artery with GDCs after Extracranial to Intracranial Bypass. A Technical Case Report.

SUMMARY: A case of a giant aneurysm of the right middle cerebral artery treated with Guglielmi detachable coils is reported. Extracranial to intracranial bypass had previously been performed and surgical trapping had been attempted. During the endovascular procedure, balloon test occlusion of the middle cerebral artery was performed in order to demonstrate clinical and angiographic tolerance to parent vessel occlusion. A previous occlusion test in the right common carotid artery did not show sufficient flow through the bypass to perform safe parent vessel occlusion. Diagnostic imaging, the endovascular procedure, and haemodynamic aspects in cases in which parent vessel occlusion is required after extracranial-intracranial bypass are described and the literature is reviewed.

Malignant mixed tumor of the skin: malignant chondroid syringoma.

Malignant tumors of sweat gland origin are rare. Probably one of the rarest types, still poorly understood, is the so-called malignant chondroid syringoma or malignant mixed tumor of the skin. A case of malignant chondroid syringoma is presented. Ultrastructural study proves very useful for the differential diagnosis with other chondroid or chordoid tumors.

Cavernous angiomas of the pineal region. Report of two cases.

Two cases of cavernous angiomas of the pineal region are presented. The possibility that a mass in the pineal region could be a cavernous angioma should be considered when deciding upon early surgery or a trial of radiotherapy.