Describing post-polio syndrome.

INTRODUCTION: Patients presenting sequelae of poliomyelitis may present new symptoms, known as post-polio syndrome (PPS). OBJECTIVE: To identify the clinical and functional profile and epidemiological characteristics of patients presenting PPS. PATIENTS AND METHODS: We performed a retrospective study of 400 patients with poliomyelitis attended at the Institut Guttmann outpatient clinic, of whom 310 were diagnosed with PPS. We describe patients' epidemiological, clinical, and electromyographic variables and analyse the relationships between age of poliomyelitis onset and severity of the disease, and between sex, age of PPS onset, and the frequency of symptoms. RESULTS: PPS was more frequent in women (57.7%). The mean age at symptom onset was 52.4 years, and was earlier in women. Age at primary infection > 2 years was not related to greater poliomyelitis severity. The frequency of symptoms was: pain in 85% of patients, loss of strength in 40%, fatigue in 65.5%, tiredness in 57.8%, cold intolerance in 20.2%, dysphagia in 11.7%, cognitive complaints in 9%, and depressive symptoms in 31.5%. Fatigue, tiredness, depression, and cognitive complaints were significantly more frequent in women. Fifty-nine percent of patients presented electromyographic findings suggestive of PPS. CONCLUSIONS: While the symptoms observed in our sample are similar to those reported in the literature, the frequencies observed are not. We believe that patients' clinical profile may be very diverse, giving more weight to such objective parameters as worsening of symptoms or appearance of weakness; analysis of biomarkers may bring us closer to an accurate diagnosis.

Improvements in the radiochemical method for separating 226Ra in solid samples through coprecipitation with BaSO4.

The aim of this work was to improve the commonly used method for 226Ra determination in water and to establish its application in solid samples. This method is based on the coprecipitation of Ra with BaSO4 and gross alpha counting of the precipitate. An exhaustive study of the coprecipitation behaviour of the most abundant cations present in solid samples was performed to avoid incorrect radiochemical yields. As a result, it was considered necessary to introduce two new purification steps into the conventional method. Likewise, two nuclides, 241Am and 226Ra, were compared to obtain the mass efficiency curve given their different behaviour in the coprecipitation process. While Ra behaves similarly to Ba, Am coprecipitates, forming mixed crystals that may behave differently in the self-absorption process. The influence of the cations on the chemical yield with no precipitate purification was: Sr2+≫Fe3+>Mg2+≈Ca2+>K+≈Na+. The method was successfully applied to soil, sediment, and plant ash samples.

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). / Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP).

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

CONGENITAL GRANULAR CELL TUMOUR OF THE NEWBORN: A CASE REPORT OF THE RARE LESION.

Congenital granular cell tumour [CGCT], a benign soft tissue tumour was a surprise discovery to the parents as well as the obstretical staffs at birth. It developed in the maxillary left canine region causing oral disfigurement and feeding problems. Diagnosis was essentially clinical and confirmed by histology. Surgical excision was done. We describe a case of CGCT in a 3-week old female neonate in the paediatric dentistry unit of LASUTH.

Describing post-polio syndrome. / Describiendo el síndrome pospolio.

INTRODUCTION: Patients presenting sequelae of poliomyelitis may present new symptoms, known as post-polio syndrome (PPS). OBJECTIVE: To identify the clinical and functional profile and epidemiological characteristics of patients presenting PPS. PATIENTS AND METHODS: We performed a retrospective study of 400 patients with poliomyelitis attended at the Institut Guttmann outpatient clinic, of whom 310 were diagnosed with PPS. We describe patients' epidemiological, clinical, and electromyographic variables and analyse the relationships between age of poliomyelitis onset and severity of the disease, and between sex, age of PPS onset, and the frequency of symptoms. RESULTS: PPS was more frequent in women (57.7%). The mean age at symptom onset was 52.4 years, and was earlier in women. Age at primary infection >2 years was not related to greater poliomyelitis severity. The frequency of symptoms was: pain in 85% of patients, loss of strength in 40%, fatigue in 65.5%, tiredness in 57.8%, cold intolerance in 20.2%, dysphagia in 11.7%, cognitive complaints in 9%, and depressive symptoms in 31.5%. Fatigue, tiredness, depression, and cognitive complaints were significantly more frequent in women. Fifty-nine percent of patients presented electromyographic findings suggestive of PPS. CONCLUSIONS: While the symptoms observed in our sample are similar to those reported in the literature, the frequencies observed are not. We believe that patients' clinical profile may be very diverse, giving more weight to such objective parameters as worsening of symptoms or appearance of weakness; analysis of biomarkers may bring us closer to an accurate diagnosis.

Code stroke in Asturias.

BACKGROUND: Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. METHODS: We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. RESULTS: We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. CONCLUSIONS: Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible.

Strategies for overcoming chemotherapy resistance in enterohepatic tumours.

When considered together, enterohepatic tumours, i.e., those affecting the liver, the biliary tree and gallbladder and the intestine, constitute the first cause of death due to cancer. Although in many cases surgery and radiotherapy are efficacious, these therapeutic strategies cannot always be implemented. Moreover, even when the removal of tumours is possible, pre- and post-operative pharmacological adjuvant regimens are often needed. However, one important limitation to the use of cytostatic drugs to treat enterohepatic tumours is that they generally exhibit marked refractivity to currently available pharmacological approaches. In addition, most of them increase their chemoresistance during treatment. In view of the high refractivity of these tumours to anti-cancer drugs and the existence of undesirable side effects, both of which are drawbacks in the available chemotherapy, several novel therapeutic approaches have been devised. The purpose of the present review is to offer some insight into the different types of strategies that have already been evaluated and incorporated into clinical practice, such as therapies based on the use of molecular targets, as well as into the approaches that are still under experimental development, such as the chemosensitization of cancer cells, genetic manipulation of tumour or host cells, and cell-specific enhancement of intracellular concentrations of the active agent by efficient targeting of pro-drugs or by using inhibitors of efflux pumps.

[Project to improve the management of primary care complaints in Santiago de Compostela]. / Proyecto de mejora en la gestión de quejas de la Gerencia de Atención Primaria de Santiago de Compostela.

OBJECTIVE: To improve the quality of how Santiago's Primary Care Department manages complaints through two specific objectives: 1) Address patients' claims within a month or less; 2) Use an automated and data management tool to detect and record issues and activities of the health care centers. RESOURCES AND METHODS: The work consisted of improvements implemented in various phases: a) Quantifying the initial situation; b) Analyzing possible issues; c) Implementing corrective measures; d) Evaluating the implementation and monitoring; period of study 2007-2008. RESULTS: In 2008, 83% of claims were addressed in a month or less (79.36% in 2007), taking into account that the number of complaints received in 2008 increased 49.5% from 2007 levels. In 2008, it took 19.46 days to respond to a complaint (22.82 days in 2007). The implementation of the new complaints management protocol in the health care centers allowed 67.9% of all claims in 2008 to be received with all pertinent facts (31.1% in 2007). CONCLUSION: The application of new protocols and simple corrective measures to the identified issues allowed for a statistically significant improvement in the response rate to the user. The optimization of the automated tool for managing the claims facilitated the identification of breakdowns in the system and prospectively will help undertake improvement actions.

Delirium secondary to intrathecal baclofen.

STUDY DESIGN: Retrospective study based on a revision of the clinical histories of all patients carrying an intrathecal baclofen (ITB) infusion system between July 1988 and March 2007 in a neurorehabilitation hospital. OBJECTIVES: To describe the psychiatric manifestations due to intoxication or withdrawal of ITB and to explore the possible risk factors for the presentation of delirium secondary to baclofen. SETTING: Spinal Cord Injury Unit in Barcelona, Spain. METHODS: We selected patients who presented delirium related to baclofen treatment. We filtered these cases by the search of key words. All the compatible episodes were then reviewed and positive cases were confirmed to perform a descriptive analysis of the different variables. Control subjects were randomly selected for a comparative analysis of the aspects of interest. RESULTS: A total of 12 of the 126 patients carrying the intrathecal system in our hospital presented delirium related to baclofen. Eight cases due to intoxication (66.6%) and four due to withdrawal (33.3%) were found. We provide a description of the psychiatric symptoms. There were no fatal cases due to delirium. CONCLUSION: Delirium has a frequency of 9.5% in patients carrying the ITB infusion system, intoxication being more frequent than withdrawal.

[Shifting to subcutaneous infusion of apomorphine in advanced Parkinson's disease patients on an out-patient basis: experience and recommendations]. / Introducción ambulatoria de apomorfina en infusión subcutánea continua en pacientes con enfermedad de Parkinson avanzada: experiencia y recomendaciones.

INTRODUCTION: Shifting from oral medication to continuous subcutaneous infusion of apomorphine (CSIA) in Parkinson's disease (PD) may be complicated. It is unclear whether hospitalization is necessary. OBJECTIVE: To observe efficacy and side effects in advanced PD patients shifting to CSIA managed as out-patients with hospital-based support. MATERIAL AND METHODS: CSIA was started on 7 PD patients with uncontrollable on-off fluctuations on a waiting list for surgery. Two patients were initially admitted to hospital, all others being managed as out-patients. Awake off time was assessed with daily charts and motor function with UPDRS subscale and a scale for dyskinesias severity. Appropriate scales were applied for mood changes, neuropsychiatric complications and quality of life measures. Apomorphine dosage and oral antiparkinsonian medication were adjusted daily (mean: 6.1 days) according to motor responses. Follow-up visits were scheduled at 3 and 6 months. Patients were offered phone calls, unprogrammed visits, and 24 hours neurological care if required. RESULTS: All patients required phone calls (mean, 4.4), but unprogrammed visits were rare (1.5). Off-time was reduced in the overall group by a 68.1 %. Co-medication with levodopa was necessary in all patients, but all other antiparkinsonian medications could be discontinued. CONCLUSION: Shifting from oral dopaminergic therapy to CSIA is safe and effective in advanced PD managed on an out-patient basis in a hospital-based setting providing that daily in-person evaluation is available during the first week and follow-up by phone calls thereafter.

[Quality assessment in single-slice spiral brain CT examinations of patients with cerebrovascular accident]. / Evaluación de la calidad de los exámenes de tomografía computarizada de cerebro en la indicación de accidente cerebro-vascular agudo.

OBJECTIVES: Our objective was to apply quality criteria proposed by the European Commission (EC) Guidelines to the brain CT examinations for cerebrovascular accident (CVA) diagnosis at single-slice spiral CT scanners from five different hospitals in the Madrid area. MATERIAL AND METHODS: A sample of 100 brain CT examinations was collected and independently reviewed by five radiologists, to determine the degree of fulfilment of image quality criteria. Dose measurements were performed to estimate the values of the CT dose indexes (CTDIw, CTDIair), the dose length product (DLP), and the effective dose (E). RESULTS: Once the McNemar test was applied to the sample, the number of observers' readings was reduced to three. The quality criteria were, in general, fulfilled, since mean values of image quality score between 80% and 92% were deduced, with variation coefficients per centre in the range of 0.07-0.1. However, both visualization criteria 1.1.2 and 1.1.3 exhibited similar ranges of fulfilment (38% - 94%). The good compliance with critical reproduction criteria in the study reflected the capability of these CT scanners to create images of adequate quality, although optimisation should be achieved in some of the centres. Concerning radiation exposure, the mean values per centre of the dose quantities were in the range of 42-64 mGy for the weighted CTDI (CTDIw), 423-744 mGy x cm for DLP, and 1.1-1.9 mSv for E. CONCLUSIONS: The mean values at three centres were close to but above the reference value proposed by the EC Guidelines for CTDIw (60 mGy), and lower than the corresponding reference level for DLP (1050 mGy x cm). Dose optimisation techniques focused on the adjustment of the CTDIw-related examination parameters were proposed.

Image quality and dose evaluation in spiral chest CT examinations of patients with lung carcinoma.

A study was undertaken to assess the quality of general chest CT examinations for indication of lung carcinoma according to the criteria proposed in the European Commission (EC) Guidelines, and to investigate their usefulness in the optimization of this practice. The criteria were evaluated for a sample of 100 examinations from five radiology departments in the Madrid area featuring single slice helical CT scanners with special emphasis on radiation dose and image quality. To determine the degree of compliance with the image criteria considered, the examinations were independently evaluated twice by five radiologists from the participating centres. A subsequent selection of the observers was made according to the consistency and independence of their readings. Dose measurements carried out in parallel supplied data to estimate the values of the CT dose indices (CTDI), dose-length product (DLP) and effective dose (E). The results show good compliance with the image criteria used - between 93% and 98% on average at the different sites, with variable degrees of internal deviation. 10 out of a total of 16 criteria proposed in the EC guidelines were met by practically all the examinations in the sample. The average weighted CTDI (CTDI(w)) values per site were in the range of 13-19 mGy; those of DLP were between 263 mGy cm and 577 mGy cm, and those of effective dose between 4 mSv and 9 mSv. The highest mean DLP value was below but close to the reference value proposed in the EC Document (650 mGy cm). In general, a weak correlation or no correlation at all was found between image quality scores and patient dose (DLP).

[Multiple pulmonary nodules and posterior uveitis as unusual manifestation of pulmonary tuberculosis]. / Nódulos pulmonares múltiples y uveítis posterior como manifestación inusual de la tuberculosis pulmonar.

Pulmonar tuberculosis still being one of the diseases more frequent in our area, this producing different clinical and radiological presentation. A case with posterior uveitis and bilateral lungs nodules which required a thoracotomy to perform a diagnosis, is presented.

[Urethral diverticulum in women. Echographic diagnosis]. / Divertículos uretrales femeninos. Diagnóstico por ecografía.

Review of clinical, radiological and ecographical data observed in 11 cases of diverticulum of urethra in women. Mictional cystourethrography was performed to all patients and acography through suprapubic route to 7 of them. The results from the radiological study and ecography findings are discussed; also the differential diagnosis with other masses in the same location.

[In situ tumor excision of a renal neoplasm]. / Tumorectomía in situ de neoformación renal.

The present work reviews the conservative surgical options to treat renal tumor formation in patients who still have both kidneys, and tries to clarify the diagnostic aspects, indications and therapeutical alternatives. The controversial items are analyzed versus treatments advocating a radical surgical approach, establishing a parallelism with current trends of surgical non-intervention in renal traumatism of moderate to severe condition (grade II). A case is presented where these two pathological circumstances are concurrent: Renal traumatism with complete parenchymatous rexhis and contralateral solid renal mass, both treated conservatively. Pre-surgical diagnosis was left renal traumatism grade II and righ renal neoformation and was based in findings with CAT and arteriographia. Histology of the piece from tumorectomy was renal angiomyolipoma. After a post-surgical evolution of twelve months, therapeutical results were assessed as excellent, with no evidence of either immediate not late complications. Considering data recently communicated by most authors, the concept of simple tumorectomy or renal tumoral enucleation is suggested as valid. However, arguments both clinical and surgical, in order to confirm its indication, require very rigorous criteria and a careful selection of patients.

[Cysts of the seminal vesicles. Diagnosis and treatment]. / Quistes de vesículas seminales. Diagnóstico y tratamiento.

Congenital cysts in the seminal vesicle represent a rare by illustrative example of embryological malformation. They are often associated with ipsilateral urinary tract anomalies. We have analyzed the diagnostic and therapeutic schemes followed in the study of this uncommon pathology.

[Retrovesical pelvic masses: diagnosis]. / Masas pelvianas de localización retrovesical: diagnóstico.

We present two cases of pelvic masses with retrovesical localization: one consisting of a mature cystic teratoma and the other in a ganglionic metastasis of a subclinical prostate adenocarcinoma. We carry out an analysis of the clinical aspects as well as a review of the diagnostic guidelines to be followed in the light of the existence of a neoformation in this location. We analyse the possible differential diagnoses to be established with these tumours, which we should take into consideration despite their rare incidence and form of presentation.

[Leiomyoma of female urethra]. / Leiomioma de uretra femenina.

Smooth muscle tumours located in the female urethra represent a pathology that is not observed very often. We offer two new cases and analyse the clinical aspects, differential diagnosis and treatment of this entity.