Diagnosis and treatment of trigeminal neuralgia: Consensus statement from the Spanish Society of Neurology's Headache Study Group.

INTRODUCTION: Trigeminal neuralgia (TN) is a chronic neuropathic pain disorder affecting one or more branches of the trigeminal nerve. Despite its relatively low global prevalence, TN is an important healthcare problem both in neurology departments and in emergency departments due to the difficulty of diagnosing and treating the condition and its significant impact on patients' quality of life. For all these reasons, the Spanish Society of Neurology's Headache Study Group has developed a consensus statement on the management of TN. DEVELOPMENT: This document was drafted by a panel of neurologists specialising in headache, who used the terminology of the International Headache Society. We analysed the published scientific evidence on the diagnosis and treatment of TN and establish practical recommendations with levels of evidence. CONCLUSIONS: The diagnosis of TN is based on clinical criteria. Pain attributed to a lesion or disease of the trigeminal nerve is divided into TN and painful trigeminal neuropathy, according to the International Classification of Headache Disorders, third edition. TN is further subclassified into classical, secondary, or idiopathic, according to aetiology. Brain MRI is recommended in patients with clinical diagnosis of TN, in order to rule out secondary causes. In MRI studies to detect neurovascular compression, FIESTA, DRIVE, or CISS sequences are recommended. Pharmacological treatment is the initial choice in all patients. In selected cases with drug-resistant pain or poor tolerance, surgery should be considered.

COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer.

INTRODUCTION: Laparoscopic resection of rectal cancer has been proven efficacious but morbidity and oncological outcome need to be investigated in a randomized clinical trial. TRIAL DESIGN: Non-inferiority randomized clinical trial. METHODS: The COLOR II trial is an ongoing international randomized clinical trial. Currently 27 hospitals from Europe, South Korea and Canada are including patients. The primary endpoint is loco-regional recurrence rate three years post-operatively. Secondary endpoints cover quality of life, overall and disease free survival, post-operative morbidity and health economy analysis. RESULTS: By July 2008, 27 hospitals from the Netherlands, Belgium, Germany, Sweden, Spain, Denmark, South Korea and Canada had included 739 patients. The intra-operative conversion rate in the laparoscopic group was 17%. Distribution of age, location of the tumor and radiotherapy were equal in both treatment groups. Most tumors are located in the mid-rectum (41%). CONCLUSION: Laparoscopic surgery in the treatment of rectal cancer is feasible. The results and safety of laparoscopic surgery in the treatment of rectal cancer remain unknown, but are subject of interim analysis within the COLOR II trial. Completion of inclusion is expected by the end of 2009. TRIAL REGISTRATION: Clinicaltrials.gov, identifier: NCT00297791 (www.clinicaltrials.gov).

[Erythema nodosum becoming a pheochromocytoma]. / Eritema nodoso como presentación de feocromocitoma.

The erythema nodosum is a septal panniculitis of several etiologies: infectious, medicamentous, secondary to systemic disease or idiopathic cause. The patient is a 47 year-female with a hypertension history of several years of evolution, who shows the following set of symptoms: successive rashes of erythematous and pruriginous cutaneous lesions in inferior members, which are diagnosed by a cutaneous biopsy of erythema nodosum. In the etiology study, an abdominal echographia is made, finding a hypodense 7 x 5 cm solid mass placed in the left adrenal gland. Determinations of catecholamines and their metabolites are found to be increased in plasma and urine, with a final diagnosis of pheochromocytoma. The pheochromocytoma is an adrenal marrow tumour of chromaffin cells derived of the neural crest, which secrete catecholamines. It is an unusual tumour, with no gender differences and with a higher incidence between the third and fourth decade of life. Ninety per cent of the cases are rather sporadic. It causes arterial hypertension just in the 0.1 and 0.2% of total cases. The appearance of erythema nodosum as one more symptom in the evolutionary context of a pheochromocytoma is a relation poorly documented in the examined literature. We could think it is just a possible coincidence, as searching with Medline we just find out one international bibliographic reference.

Retroperitoneal pelvic hemangiopericytoma. Combined abdominoperineal resection.

We report a case of large-size pelvic hemangiopericytoma (HPC) incidentally discovered in a 32-year-old woman. Prior to surgery the patient was studied using a CT scan and magnetic resonance imaging (MRI). Because of the size and scarce extent of the tumour (it expanded downwards, into the right ischiorectal fossa) a combined abdomino-perineal approach was needed for complete resection. Seventy-two months after initial surgery the patient remains asymptomatic, with no signs of local recurrence or distant metastasis.

Heart surgery with cardiopulmonary bypass in pregnant women.

OBJECTIVE: Definite data in heart surgery with extracorporeal circulation during pregnancy is limited. This report analyzes our experience in this area. METHODS: Fifteen women underwent open heart surgery under cardiopulmonary bypass during pregnancy at our institution between 1972 and 1998. Surgical procedures included valve replacement in 13 patients (12 mitral, 1 aortic), declotting of a tilting disk mitral prosthesis in one and closure, of an atrial septal defect in the remaining patient. RESULTS: Thirteen patients were in New York Heart Association functional class III to IV and were operated on urgently. Eight of these women had severe acute dysfunction of either a mechanical or a biological mitral prosthesis. There were 2 maternal operative deaths for a rate of 13.3%. Fetal losses resulted at the time of these maternal deaths. Fetal deaths occurred in 5 of the 13 pregnancies (38.5%) in women who survived the surgical procedure. CONCLUSIONS: Because of the fetal risks, open heart surgery during pregnancy should be advised only in extreme emergencies. Although pregnancy per se does not increase the maternal risk, a high maternal mortality results from the emergency nature of the surgical intervention. Fetal mortality remains high.

[Cytomegalovirus diarrhea as a diagnostic index for AIDS]. / Diarrea por citomegalovirus (CMV) como primera manifestación de SIDA.

We report a case of a male 49 years old, without clinical history, excepting rape in 1996, that was admitted to the Emergency Room of HGUGM because of diarrhea 6 months duration, plus fever (39 degrees C) in the last 2 months. He was diagnosed of infection by the Human Immunodeficiency Virus (HIV), with serum antigenemia (70 cells), and colonic biopsy positives for Cytomegalovirus, and a normal colonoscopy. Cytomegalovirus colitis is the major etiologic infectious agent in patients with AIDS-associated diarrhea, although it can be the diagnostic index for AIDS in a few cases.

[Crohn's disease and pregnancy. A case report]. / Enfermedad de Crohn y embarazo. Informe de un caso.

The name "Inflammatory Bowel Disease", of Anglo-Saxon origin, has been worked wide used in the medical language to name two nosologic entities: "Ulcerative colitis" (CU) and "Crohn's Disease" (EC). Both affect primarily young people, with approximately equal male to female ratio, although there is slight preponderance of females. In early as 90's, the development of ulcerative colitis during pregnancy had been described as potentially fatal complication, based on this observation therapeutic abortion was frequently recommended; now a days five questions in these patients with Inflammatory Bowel Disease (EII) that want to become pregnant have to be made: 1. Will the patient have more trouble getting pregnant? 2. Will the same (EC) affect the prognosis of pregnancy? 3. Will pregnancy affect the disease? 4. Which will be the treatment of the (EC) in pregnant women? 5. Will the treatment affect the fetus of the pregnancy? The authors present a case of Crohn's disease of the colon, in a patient of 24 years old with her first pregnancy. This case offered the opportunity to discuss problems and questions that took place in this kind of circumstances as mentioned earlier.

Primary colorectal lymphoma.

OBJECT: To analyze our experience in the treatment of primary colorectal lymphomas. PATIENTS: During the recent period from 1989 to 1995, a total number of 406 cases of malignant neoplasms of large intestine were treated at Department of Surgery, Hospital del S.A.S de Jerez de la Frontera. There were 5 cases of primary colorectal Non-Hodgkin's lymphomas, constituting 1.2% of all colorectal malignancies. METHODS: Medical records of all five patients were carefully reviewed. Surgical pathology specimens were retrospectively reexamined to confirm the diagnosis, and immunohistochemistry staining methods were performed. Dawson, Cornes and Morson criteria were used to distinguish primary colonic lymphoma. For tumor staging, a modification of the Ann-Arbor system for gastrointestinal lymphoma proposed by Musshoff and Schmidt-Vollmer was used. RESULTS: All cases were Non-Hodgkin's lymphomas. There were no cases of lymphoma of the rectum. There were 2 males and 3 females. Their ages ranged from 12 to 73 years, with an average age of 31 years. The cecum was the site of the lesions in 4 patients and the other was located in the sigmoid colon. Acute abdomen in three cases, undiagnosed abdominal mass in one and intussusception in the other one were the clinical presentation. Inmunohistochemical studies showed B-cell phenotype in 4 and non-B non-T Ki-1-positive phenotype in 1 patient. Chemotherapy was administered following resection in 100% of patients. CONCLUSIONS: Intraoperative diagnosis of lymphoma was not suspected in all cases but the malignancy was always present. The cecum is the commonest site of involvement. Both of our two patients presented with perforated lymphoma were associated with a poor short term prognosis. It is necessary to unify the staging system and the histologic classifications enabling a comparison of several studies.

Agripnianalgesia. / Agrypnianalgesia

Por mecanismos ainda nao elucidados, existe um paralelismo entre depressao e dor.Como tratamento do segundo sintoma se tem utilizado uma tecnica denominada "agripnianalgesia" que significa analgesia em estado de vigilia que se baseia na utilizacao de um agente antidepressivo e de um derivado das fenotiazinas. A mesma e descrita neste trabalho assim como os resultados obtidos. Mencionam-se as teorias sobre o mecanismo de acao dos neurotransmissores e o dos antidepressivos triciclicos