Trends in stroke hospitalisation rates and in-hospital mortality in Aragon, 1998-2010. / Tendencia de las tasas de hospitalización y de letalidad hospitalaria de la enfermedad cerebrovascular aguda en Aragón en el periodo 1998-2010.

INTRODUCTION: Despite the impact of cerebrovascular disease (CVD) on global health, its morbidity and time trends in Spain are not precisely known. OBJECTIVE: The purpose of our study was to characterise the epidemiology and trends pertaining to stroke in Aragon over the period 1998-2010. METHODS: We conducted a retrospective, descriptive study using the data of the Spanish health system's Minimum Data Set and included all stroke patients admitted to acute care hospitals in Aragon between 1 January 1998 and 31 December 2010. We present data globally and broken down by stroke subtype, sex, and age group. RESULTS: The number of cases increased by 13% whereas age- and sex-adjusted hospitalisation rates showed a significant decrease for all types of stroke (mean annual decrease of 1.6%). Men and women in younger age groups showed opposite trends in hospitalisation rates for ischaemic stroke. Case fatality rate at 28 days (17.9%) was higher in patients with intracerebral haemorrhage (35.8%) than in those with subarachnoid haemorrhage (26.2%) or ischaemic stroke (13%). CVD case fatality showed a mean annual decline of 2.8%, at the expense of the fatality rate of ischaemic stroke, and it was more pronounced in men than in women. DISCUSSION: Understanding stroke epidemiology and trends at the regional level will help establish an efficient monitoring system and design appropriate strategies for health planning.

Prevalence of orthostatic hypotension in non-institutionalised elderly aged 80 and over. A diagnostic study using an oscillometric device.

BACKGROUND: Orthostatic hypotension (OH) is a common disorder, and possibly underdiagnosed. In the elderly, OH has been considered a common cause of falls, fractures, and fear of falling. Its prevalence increases with age, probably related to the number of drug treatments, decreased fluid intake, and the progressive dysfunction of the autonomic nervous system. OBJECTIVES: To evaluate the prevalence of OH in a non-institutionalised population ≥80 years, according to different criteria based on sequential measurements taken at minute 0, 1, 3 and 5 of standing. METHODS DESIGN: A diagnostic accuracy study using an oscillometric device. SETTING AND PARTICIPANTS: Convenience sampling of 176 people ≥80 years attended in an urban Primary Health Care Centre. MEASUREMENTS: Supine and standing blood pressure (BP) measurements, at minutes 0, 1, 3 and 5 using the OMRON 705-CP blood pressure device. OH definition: decrease ≥20mmHg in systolic BP (SBP) and/or ≥10mmHg in diastolic BP (DBP). RESULTS: Mean age (Standard Deviation) was 85.2 (3.7) years, and 60.2% were women. Prevalence of OH: 30.7% at minute 0; 19.3% at minute 1; 18.2% at minute 3; and 20.5% at minute 5. Age, sedentary life, smoking, diabetes and SBP values were significantly associated with a greater BP decrease at minute 0. CONCLUSION: A third of the sample had OH, with a maximum prevalence at minute 0. From a clinical point of view, it is suggested that the definition of OH is prioritized according to the BP at minute 0.

Global health care use by patients with type-2 diabetes: Does the type of comorbidity matter?

AIM: To identify patterns of health care use among diabetic patients with multimorbidity across primary, specialised, hospital and emergency care, depending on their type of chronic comorbidity. METHODS: Longitudinal study of a population-based retrospective cohort conformed by adult patients with type-2 diabetes assigned to any of the primary care centres in Aragon during 2010 and 2011 (n=65,716). Negative binomial regressions were run to model the effect of the type of comorbidity on the number of visits to each level of care. Comorbidities were classified as concordant, discordant or mental based on expert consensus and depending on whether they shared the same overall pathophysiologic risk profile and disease management plan designed for type-2 diabetes. RESULTS: Mental comorbidity was independently associated with total and unplanned admissions (incidence rate ratio [IRR]:1.25; 95% confidence interval [CI]:1.12-1.39, IRR:1.21; 95% CI:1.06-1.39), average length of stay (IRR:1.47; 95% CI:1.25-1.73), and total and priority emergency room visits (IRR:1.26; 95% CI:1.17-1.35, IRR:1.30; 95% CI:1.18-1.42). Patients with discordant comorbidities showed the strongest associations with the number of visits to specialists (IRR:1.38; 95% CI:1.33-1.43) and to different specialties (IRR:1.36; 95% CI:1.32-1.39). Differences regarding GP visits were lower but still significant for patients with discordant comorbidity (IRR:1.08; 95% CI:1.06-1.11), but especially for those with mental comorbidity (IRR:1.17; 95% CI:1.14-1.21). CONCLUSION: In patients with type-2 diabetes, the coexistence of mental comorbidity significantly increases the use of unplanned hospital services, and discordant comorbidities have an important effect on specialised care use. Differences with respect to primary care use are not as prominent.

Prevalence of atrial fibrillation and its associated factors in Spain: An analysis of 6 population-based studies. DARIOS Study. / Prevalencia de fibrilación auricular y factores asociados en España, análisis de seis estudios de base poblacional. Estudio DARIOS.

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) is the most common type of arrhythmia. The purpose of this study was to determine the prevalence of atrial fibrillation and its relationship with cardiovascular risk factors in Spain. METHODOLOGY: Cross-sectional study based on a grouped analysis of 17,291 randomized individuals recruited in 6 population studies. RESULTS: The prevalence of atrial fibrillation was 1.5% (95% CI:1.3-1.7%). Men had a greater prevalence of the disease than women (1.9 vs. 1.1%, respectively). The prevalence of atrial fibrillation progressively increased with age: 0.05% for patients younger than 45 years, 0.5% for those between 45-59 years of age, 2.3% for those between 60-74 years of age and 6.3% for those older than 75 years. The percentage of individuals who were underwent anticoagulant treatment was 74.3%. The risk factors significantly associated with arrhythmia were an age older than 60 years (odds ratio [OR]: 7.6; 95% CI: 5.1-11.2), the male sex (OR:1.8; 95% CI: 1.4-2.4), arterial hypertension (OR:1.6; 95% CI: 1.2-2.1), obesity (OR:1.5; 95% CI:1.2-2.1) and a history of coronary artery disease (OR:1.9; 95% CI: 1.3-3.0). CONCLUSION: Atrial fibrillation is a common disease in elderly individuals, while its prevalence is low in individuals younger than 60 years. Most individuals with atrial fibrillation were on anticoagulant treatment. The risk factors for this type of arrhythmia are age, the male sex, hypertension, obesity and a history of coronary artery disease.

Un método de detección de gammapatías monoclonales de IgM en un analizador / A method for detect Ig M monoclonal gammopathies in an autoanalyzer

Introducción. Frecuentemente el mieloma múltiple es precedido de una gammapatía monoclonal de significado incierto. Este estudio analiza la utilidad de una lipidemia falsamente positiva como un método rutinario y barato de detección de gammapatías monoclonales de IgM. Material y métodos. Se examinaron los sueros de 244 pacientes consecutivos con un índice lipidémico falso positivo (n=34) o negativo (n=210) y triglicéridos < 1,7mmol/L. Las concentraciones de inmunoglobulinas se estudiaron mediante un autoanalizador AU-5430. Los test de lipidemia fueron realizados con una concentración salina de 0,038M y los proteinogramas mediante una electroforesis capilar de la zona. Resultados. Con el diagnóstico de banda monoclonal la lipidemia falsa positiva tuvo una sensibilidad del 97% (95% CI: 91-100) y especificidad del 94% (95% CI: 91-97). El valor predictivo positivo y negativo fue de 72% (95% CI: 59-85) y 99% (95% CI: 99-100), respectivamente. Para el diagnóstico de IgM elevada la sensibilidad fue del 71% (95% CI: 55-86), la especificidad del 99% (95% CI: 98-100) y el valor predictivo positivo y negativo del 92% (95% CI: 82-103) y 95% (95% CI: 93-98), respectivamente. El OR ajustado por edad y sexo de la lipidemia falso positivo fue de 768,0 (95% CI: 75,8-7.799,3) para la IgM elevada y de 219,4 (95% CI: 42,9-1.120,5) para la banda monoclonal. Conclusiones. La lipidemia falsamente positiva se asoció a la IgM elevada y particularmente a la gammapatía monoclonal. Es una herramienta barata, sensible y específica para detectar una gammapatía monoclonal de IgM en los índices de interferencia rutinarios en analizadores (AU)

Introduction. Most patients with multiple myeloma have a previous monoclonal gammopathy of undetermined significance. This study analyzes the possible clinical usefulness of a false positive lipemia as a routine, inexpensive screening tool for IgM monoclonal gammopathies. Material and methods. Serum samples from 244 consecutive patients with a false positive (n=34) or negative lipemia test (n=210), with triglycerides <1.7mmol/L were studied. Immunoglobulin levels were quantified in an AU-5430 autoanalyzer. Lipemia tests were performed in a final saline concentration of 0,038M, and proteins by capillary-zone electrophoresis. Results. Sensitivity for monoclonal band detection was 97% (95% CI 91-100) for false lipemia, with 94% (95% CI: 91-97) specificity. The positive and negative predictive values were 72% (95% CI: 59-85) and 99% (95% CI: 99-100), respectively. Its sensitivity for elevated IgM detection was 71% (95% CI: 55-86) and 99% (95% CI: 98-100) specificity, positive and negative predictive values of 92% (95% CI: 82-100) and 95% (95% CI: 93-98), respectively. Age and sex-adjusted odds ratio of elevated IgM for false lipemic serum patients was 768.0 (95% CI: 75.8-7799.3), and 219.4 (95% CI: 42.9-1120.5) for the monoclonal band. Conclusions. A false positive lipemic test was associated with elevated IgM, and particularly with monoclonal gammopathy. This finding offers an inexpensive, sensitive and specific screening tool to detect IgM monoclonal gammopathy processes in routine autoanalyzer interference tests (AU)

Percepciones de pacientes y profesionales sanitarios sobre la calidad de la atención a personas diabéticas / Patient and health professional perceptions on the quality of care provided to diabetic patients

Objetivo. Describir la percepción y el conocimiento de pacientes y profesionales sanitarios (PS) sobre los factores que influyen en la calidad y continuidad asistencial de los cuidados prestados en atención primaria a personas diabéticas. Material y métodos. Estudio cualitativo de trayectoria fenomenológica. Participantes: profesionales médicos y de enfermería que trabajan en diferentes centros de atención primaria de Zaragoza y pacientes con diabetes atendidos en esos centros. Entre febrero y marzo de 2010 se realizaron 2 entrevistas grupales (grupos de discusión) y 6 individuales. Se siguió un guión preestablecido con las variables a explorar. Resultados. Los pacientes y profesionales entrevistados identificaron dificultades para asumir la diabetes como una enfermedad crónica. Se observaron como factores relacionados con problemas en el cambio de hábitos y estilos de vida el sexo (las mujeres mostraron mayores dificultades para el cambio), el tipo de trabajo y la situación de actividad laboral. Por parte de los profesionales entrevistados, se identificaron como factores favorecedores la existencia de guías y protocolos y la motivación personal, y como factores que dificultan la asistencia, la falta de tiempo y los sistemas de información existentes. Hay discrepancias entre los profesionales respecto al papel de grupos de pacientes y asociaciones. Conclusiones. En el diseño de intervenciones para la modificación de estilos de vida de los pacientes diabéticos se deben tener en cuenta las dificultades para el cambio ligadas al sexo y la situación laboral de los pacientes(AU)

Objective. To describe the knowledge and perceptions of patients and health professionals on the factors that influence the quality and continuity of care of diabetic patients provided in Primary Care. Material and methods. A qualitative study using a phenomenological perspective. Participants. Medical and nursing professionals working in Primary Care Centres in the city of Zaragoza, and patients with diabetes mellitus attended in the same centres. Two group (focus group) and 6 individual interviews were carried out in February and March 2010. A predetermined script, with the variables to explore, was used. Results. The patients and health professionals interviewed identified problems in assuming diabetes as a chronic disease. Among the factors related to success in changing habits and lifestyles, were gender (women showed greater difficulties to change), type of job and work situation. Health professionals identified the availability of guidelines and protocols, and personal motivation as factors that work in favour; and lack of time and current information systems as factors that hamper the provision of good quality care. There were discrepancies among health professionals as regards the role played by patient groups and associations. Conclusions. It is important to take into account the factors that make changes in habits and lifestyles difficult, such as gender and the employment situation, when designing actions aimed at modifying risk factors in diabetic patients(AU)

[Patient and health professional perceptions on the quality of care provided to diabetic patients]. / Percepciones de pacientes y profesionales sanitarios sobre la calidad de la atención a personas diabéticas.

OBJECTIVE: To describe the knowledge and perceptions of patients and health professionals on the factors that influence the quality and continuity of care of diabetic patients provided in Primary Care. MATERIAL AND METHODS: A qualitative study using a phenomenological perspective. PARTICIPANTS: Medical and nursing professionals working in Primary Care Centres in the city of Zaragoza, and patients with diabetes mellitus attended in the same centres. Two group (focus group) and 6 individual interviews were carried out in February and March 2010. A predetermined script, with the variables to explore, was used. RESULTS: The patients and health professionals interviewed identified problems in assuming diabetes as a chronic disease. Among the factors related to success in changing habits and lifestyles, were gender (women showed greater difficulties to change), type of job and work situation. Health professionals identified the availability of guidelines and protocols, and personal motivation as factors that work in favour; and lack of time and current information systems as factors that hamper the provision of good quality care. There were discrepancies among health professionals as regards the role played by patient groups and associations. CONCLUSIONS: It is important to take into account the factors that make changes in habits and lifestyles difficult, such as gender and the employment situation, when designing actions aimed at modifying risk factors in diabetic patients.

Validity of a short diet-quality index to predict changes in anthropometric and cardiovascular risk factors: a simulation study.

Coronary heart disease prevention in the primary care setting, where time is extremely limited, requires valid instruments that efficiently screen for unhealthy lifestyle habits. Identification of the individuals who would most benefit from dietary intervention is particularly important in this context. We used dietary intake data derived from a full-length food frequency questionnaire to simulate responses to our previously validated short dietary quality screener. We determined the prospective association of the resulting diet-quality index (DQI) with changes in anthropometric and cardiometabolic risk variables in 2181 men and women in a 10-year follow-up. Multiple linear regression analyses revealed that a higher DQI score at baseline related directly (P=0.002) to high-density lipoprotein cholesterol (HDL-C) and inversely (P<0.016) to waist circumference (WC), triacylglycerides (TG), the TG to HDL-C ratio and the total cholesterol to HDL-C ratio at follow-up. A low DQI score is predictive for an increase in WC and the development of an unfavourable cardiometabolic profile.

Resultados funcionales tras la reparación artroscópica de roturas masivas del manguito rotador: influencia de la aplicación de plasma rico en plaquetas asociado a fibrina / Functional results after arthroscopic repair of massive rotator cuff tears; influence of the application platelet-rich plasma combined with fibrin

Objetivo. El objetivo de este trabajo es investigar si la aplicación de plasma rico en plaquetas con alto contenido en fibrina a la zona de reparación de roturas masivas del manguito de los rotadores tratadas mediante técnicas artroscópicas mejora los resultados funcionales y disminuye el índice de reroturas. Material y método. 28 enfermos (20 mujeres y 8 varones) con una edad media de 65 años (rango: 53 a 78) diagnosticados de una rotura masiva del manguito rotador (dos tendones afectados>5cm) fueron incluidos en este estudio prospectivo y aleatorizado. En todos los enfermos se realizó una reparación completa artroscópica del manguito rotador con técnica de una hilera. En 14 pacientes una vez finalizada la reparación se aplicó en la zona de transición osteotendinosa un concentrado de plasma rico en plaquetas y alto contenido de fibrina, mientras que en 14 enfermos se realizó la reparación sin ningún aporte de factores de crecimiento. Se evaluaron los resultados funcionales con la escala de Constant al año de la intervención, así como una artro-RM para comprobar la integridad del tendón reparado. Resultados. No hubo complicaciones ni reoperaciones en ninguno de los dos grupos. El Constant preoperatorio mejoró 30 puntos en el grupo sin PRP y 26 puntos en el grupo con PRP, sin diferencias entre ambos grupos. En el estudio de artro-RM 9 pacientes mostraban integridad de la reparación (32%), 4 presentaban una fuga de contraste y 15 una rerotura franca. No se encontraron diferencias en índice de reroturas entre el grupo en el que se aplicó plasma rico en plaquetas y en el que no. Conclusiones. La reparación artroscópica de roturas masivas del manguito rotador ofrece unos resultados clínicos satisfactorios a pesar de un elevado índice de nuevas roturas. La aplicación de plasma rico en plaquetas no mejora los resultados clínicos ni disminuye el índice de reroturas (AU)

Objective. The aim of this work is to investigate whether the application of platelet-rich plasma (PRP) with a high fibrin content in the repair area of massive rotator cuff tears treated using arthroscopic techniques improves the functional results and decreases the number of re-tears. Material and method. This prospective, randomised study included 28 patients (20 females and 8 males) with a mean age of 65 years (range: 53 to 78) and diagnosed with a massive rotator cuff tear (two tendons affected, >5cm). A complete single row arthroscopic repair of the rotator cuff was performed on all patients. A concentrate of platelet rich plasma with a high fibrin content was applied to the osteotendinous transition area in 14 patients after the operation, whilst in the other 14 patients the repair was performed without any growth factor support. The functional results were evaluated with the Constant scale, as well as an arthro-MRI to check the integrity of the repaired tendon one year after the operation. Results. There were no complications or repeat operations in any of the two groups. The pre-operative Constant results improved 30 points in the group without PRP and 26 points in the group with PRP, with no significant differences between both groups. In the arthro-MRI study, integrity of the repair was observed in 9 (32%) patients, whilst 4 had a contrast leak and 15 a clear re-tear. No differences were found in the number of re-tears between the group in which the platelet-rich plasma was applied and in the one where it was not applied. Conclusions. The arthroscopic repair of massive rotator cuff tears gives clinically satisfactory results, despite a high rate of new tears. The application of platelet-rich plasma did not improve the clinic results or decrease the number of re-tears (AU)

Dexamethasone treatment in chronic subdural haematoma.

INTRODUCTION: Neurosurgeons are familiar with chronic subdural haematoma (CSH), a well-known clinical entity, which is usually treated by some modality of trepanation. Despite the excellent outcomes obtained by surgery, complications may occur, some of which may be potentially severe or fatal. Furthermore, up to 25% recurrence rate is reported. The authors present a novel approach to the management of CSH based on the use of dexamethasone as the treatment of choice in the majority of cases. PATIENTS AND METHODS: Medical records of 122 CSH patients were retrospectively reviewed. At admission, symptomatic patients were classified according to the Markwalder Grading Score (MGS). Those scoring MGS 1-2 were assigned to the Dexamethasone protocol (4 mg every 8h, re-evaluation after 48-72 h, slow tapering), and those scoring MGS 3-4 were, in general, assigned to the Surgical protocol (single frontal twistdrill drainage to a closed system, without irrigation). Patients were followed in the Outpatient Office with neurological assessment and serial CT scans. RESULTS. Between March 2001 and May 2006, 122 consecutive CSH patients (69% male, median aged of 78, range 25-97) were treated. Seventy-three percent of the patients exhibited some kind of neurological defect (MGS 2-3-4). Asymptomatic patients (MGS 0) were left untreated. Initial treatment assignment was: 101 dexamethasone, 15 subdural drain, 4 craneotomy and 2 untreated. Twenty-two patients on dexamethasone ultimately required surgical drain (21.8%). Favourable outcome (MGS 0-1-2) was obtained in 96% and 93.9% of those treated with dexamethasone and surgical drain, respectively. Median hospital stay was 6 days (range 1- 41) for the dexamethasone group and the whole series, and 8 days (range 5-48) for the surgical group. Overall mortality rate was 0.8% and re-admissions related to the haematoma reached 14.7% (all maintained or improved their MGS). Medical complications occurred in 34 patients (27.8%), mainly mild hyperglycemic impairments. Median outpatient follow up was 25 weeks (range 8-90), and two patients were lost. DISCUSSION: The rationale for the use of dexamethasone in CSH lies in its anti-angiogenic properties over the subdural clot membrane, as it is derived from experimental studies and the very few clinical observations published. Surgical evacuation of CSH is known to achieve excellent results but no well-designed trials compare medical versus surgical therapies. The experience obtained from this series lets us formulate some clinical considerations: dexamethasone is a feasible treatment that positively compares to surgical drain (and avoided two thirds of operations); the natural history of CSH allows a 48-72 h dexamethasone trial without putting the patient at risk of irreversible deterioration; eliminates all morbidity related to surgery and recurrences; does not provoke significant morbidity itself; reduces hospital stay; does not preclude ulterior surgical procedures; it is well tolerated and understood by the patient and relatives and it probably reduces costs. The authors propose a protocol that does not intend to substitute surgery but to offer a safe and effective alternative. CONCLUSION: Data obtained from this large retrospective series suggests that dexamethasone is a feasible and safe option in the management of CSH. In the author's experience dexamethasone was able to cure or improve two thirds of the patients. This fact should be confirmed by others in the future. The true effectiveness of the therapy as compared to surgical treatment could be ideally tested in a prospective randomized trial.

Elimination capacity of a TSE-model agent in the manufacturing process of Alphanate/Fanhdi, a human factor VIII/VWF complex concentrate.

The variant Creutzfeldt-Jakob disease (vCJD) is a transmissible spongiform encephalopathy (TSE), mainly present in the UK and is associated with the ingestion of bovine products affected with bovine spongiform encephalopathy. Manufacturers of biological products must investigate the ability of their production processes to remove TSE agents. We studied the purification steps in the manufacturing process of two FVIII/VWF concentrates (Alphanate) and Fanhdi in their ability to eliminate an experimental TSE-model agent. Hamster scrapie strain 263K brain-derived materials were spiked into samples of the solutions taken before various stages during its production: 3.5% polyethylene glycol (PEG) precipitation, heparin affinity chromatography and saline precipitation/final filtrations. PEG precipitation and affinity chromatography were studied both as isolated and combined steps. TSE agent removal was determined using a laboratory scale model representative of the industrial manufacturing process. The prion protein (PrP(Sc)) was measured with Western blot and TSE infectivity was measured with bioassay. Western blot results were in agreement with those obtained by bioassay, showing a significant removal capacity in the production process: 3.21-3.43 log(10) for the PEG precipitation; about 3.45 log(10) for the affinity chromatography; and around 2.0 log(10) for the saline precipitation plus final filtrations. PEG precipitation and heparin affinity chromatography were demonstrated to be two complementary TSE-model agent removal mechanisms with total removal being the sum of the two. An overall reduction factor of around 8 log(10) can be deduced. The tests from the production process of FVIII/VWF complex concentrates have demonstrated their potential for eliminating TSE agents.

Preservation of bone flap after craniotomy infection.

INTRODUCTION: The estimated incidence of craniotomy infection is 5%, ranging from 1-11% depending on the presence of certain risk factors, such as, prior radiation therapy, repeated surgery, CSF leak, duration of surgery over 4h, interventions involving nasal sinuses and emergency surgeries. The standard treatment for infected craniotomies is bone flap discarding and delayed cranioplasty. Adequate cosmetic results, unprotected brain and disfiguring deformity until cranioplasty are controversial features following bone removal. We present a limited series of five patients with craniotomy infection, that were successfully treated with wound debridement, in situ bone sterilization, reposition of the bone flap and antibiotic irrigation through a wash-in and wash-out draining system, all in the same surgical procedure. All infections cleared and every patient saved his/her bone flap. PATIENTS AND METHODS: We retrospectively reviewed the records of 5 patients with craniotomy infection that presented with wound swelling, purulent discharge and fever. The operative technique consisted on three manoeuvres: wound debridement, bone flap sterilization (either autoclaved or soaked in a sterilizing solution), and insertion of subgaleal/epidural drains for non-continuous antibiotic irrigation (vancomycin 50mg in 20cc of saline every 12h alternating with cephotaxime 100mg in 20cc of saline every 12h). Also, patients received equal systemic endovenous antibiotherapy and oral antibiotics after discharge, until complete resolution of infection and wound healing. RESULTS: Patients in the series (2 women and 3 men) ranged in age from 36 to 77. No patient had received prior radiation therapy and only one had undergone surgery involving nasal sinuses. The initial operations correspond to craniotomies performed for two intracranial tumours (meningiomas), one arteriovenous malformation and two decompressive craniotomies (haemorrhagic contusions and acute subdural haematoma). The duration of surgeries ranged from 1h30' to 5h30', only two operations extending over 4 hours. The interval between the initial surgery and the reintervention ranged from 11 to 227 days. Staphyloccocus spp were cultured in all patients. For bone sterilization povidone scrubbing was used in all patients, autoclave in two and soaking the flap in a sterilizing solution in three. All patients cleared infection and achieved complete wound healing in 2-3 weeks after the re-operation. Follow up ranged from 4 to 18 months. One patient died as a consequence of sepsis in the context of pneumonia some weeks after wound healing. DISCUSSION: Recent multivariate analyses have demonstrated that the presence of a CSF leak and the performance of repeated operations are the most important independent risk factors for craniotomy infection, with associated odds ratios for infection as high as 145 and 7, respectively. Regular antibiotic administration at anaesthesia induction seems to decrease the rate of craniotomy infection by half, both in the entire population and in low-risk subsets. Organisms involved in craniotomy infections are common pathogens usually contaminating neurosurgical procedures or normal skin flora germs. Auguste and McDermott have recently presented a case series of 12 patients in which successful salvage procedures for infected craniotomy bone flaps were performed using a continuous wash-in, wash-out indwelling antibiotic irrigation system, that needed close observation of the neurological status since obstruction of the outflow system could precipitate brain herniation. The method we present is as effective as theirs and avoids such complication since only small quantities of antibiotic solutions (20 cc) are instilled during each dose administration.

La glucemia basal alterada es un factor de riesgo para el infarto cerebralaterotrombótico o lacunar. Estudio de casos y controles / Impaired fasting glucose as a risk factor for atherothrombotic or lacunar cerebral infarction. A case-control study

Introducción. Los factores de riesgo vasculares modificables(FRVM) para los infartos cerebrales aterotrombóticos y lacunares sonbien conocidos, pero hay pocos estudios poblacionales y desconocemosel riesgo de estados glucémicos previos a la diabetes mellitus(DM). El objetivo del trabajo es estudiar la relación entre la glucemiabasal alterada (GBA) y otros FRVM con los infartos cerebrales aterotrombóticosy lacunares.Métodos. Estudio de casos y controles de base poblacional realizadoen dos centros de salud urbanos. Casos: 236 pacientes con infartoscerebrales aterotrombótico o lacunar diagnosticados mediante tomografíacomputarizada o resonancia magnética. Se excluyeron los infartoscerebrales cardioembólicos de causa infrecuente o indeterminada ylas hemorragias intracerebrales. Controles: 441 pacientes sin infartocerebral, apareados por edad y sexo, seleccionados por muestreo aleatoriosimple. Mediante regresión logística se estudiaron las odds ratio(OR) de los factores de riesgo GBA, DM, tabaquismo, hipertensión arterial(HTA), hipercolesterolemia, hipertrigliceridemia y obesidad.Resultados. La edad media fue de 71,1 años, con un 62% devarones. La prevalencia en los casos de los FRVM fue: GBA, 32,9%;DM, 49,6%; tabaquismo, 26,3%; HTA, 78,8%; hipercolesterolemia,29,3%; hipertrigliceridemia, 18,2 %, y obesidad, 63,5%. Todos losFRVM se asociaron en el análisis crudo con un aumento del riesgo deinfarto cerebral. En el análisis multivariante se asociaron de manerasignificativa la GBA (OR: 3,2; intervalo de confianza [IC] del 95%:1,1-7,9), la DM (OR: 4,5; IC 95%: 1,4-14,9), la HTA (OR: 2,6; IC 95%:1,5-4,5), la hipercolesterolemia (OR: 2,3; IC 95%: 1,4-3,9) y la obesidad(OR: 1,7; IC 95%: 1,0-2,9).Conclusiones. Las alteraciones del metabolismo de la glucosaGBA y DM son un importante FRVM para el IC aterotrombótico ylacunar por la elevada magnitud de la OR y elevada prevalencia en lapoblación con infarto cerebral (AU)

Introduction. Modifiable vascular risk factors (MVRF) foratherotrombotic or lacunar cerebral infarction have been clearlyestablished, even though only a few population studies havebeen conducted and we do not know the risk of glycemic statusprior to the diabetes mellitus (DM). This study has aimed todetermine the relationship between impaired fasting glucose(IFG) and others MVRF with atherothrombotic or lacunar cerebralinfarctions.Methods. A population based case-control study was conductedin two urban health care centers. Cases: 236 patientswith atherothrombotic or lacunar CI, diagnosed by computedtomography scan magnetic resonance imaging. Unusual, indeterminateand cardioembolic cerebral infarction and cerebralhemorrhage were excluded. Controls: 441 patients withoutcerebral infarction, matched by age and gender, selected bymeans of simple random sampling. The odds ratios (OR) of IFG,DM, smoking, high blood pressure, hypercholesterolemia,hypertriglyceridemia, and obesity were measured with logisticregression.Results. Mean age was 71.1 years old, 62 % being male.Prevalence in cases of MVRF was: IFG, 32.9%; DM, 49.6 %;smoking, 26.3%; high blood pressure, 78.8%; hypercholesterolemia,29.3%; hypertriglyceridemia, 18.2%, and obesity, 63.5%.All MVRFs were associated in the crude analysis with increasedrisk of cerebral infarction. In the multivariate analysis, significantassociations were found for IFG (OR: 3.2; 95 % confidenceinterval [CI]:1.1-7.9), DM (OR: 4.5; 95 % CI: 1.4-14.9),high blood pressure (OR: 2.6; 95 % CI: 1.5-4.5), hypercholesterolemia(OR: 2.3; 95 % CI: 1.4-3.9), and obesity (OR: 1.7; 95%CI: 1.0-2.9).Conclusions. Alterations of the glucose metabolism IFG andDM are important MVRF for atherothrombotic or lacunar cerebralinfarction as seen by the high rate of OR and high prevalence inthe population with cerebral infarction (AU)

[Impaired fasting glucose as a risk factor for atherothrombotic or lacunar cerebral infarction. A case-control study]. / La glucemia basal alterada es un factor de riesgo para el infarto cerebral aterotrombótico o lacunar. Estudio de casos y controles.

INTRODUCTION: Modifiable vascular risk factors (MVRF) for atherotrombotic or lacunar cerebral infarction have been clearly established, even though only a few population studies have been conducted and we do not know the risk of glycemic status prior to the diabetes mellitus (DM). This study has aimed to determine the relationship between impaired fasting glucose (IFG) and others MVRF with atherothrombotic or lacunar cerebral infarctions. METHODS: A population based case-control study was conducted in two urban health care centers. CASES: 236 patients with atherothrombotic or lacunar CI, diagnosed by computed tomography scan magnetic resonance imaging. Unusual, indeterminate and cardioembolic cerebral infarction and cerebral hemorrhage were excluded. CONTROLS: 441 patients without cerebral infarction, matched by age and gender, selected by means of simple random sampling. The odds ratios (OR) of IFG, DM, smoking, high blood pressure, hypercholesterolemia, hypertriglyceridemia, and obesity were measured with logistic regression. RESULTS: Mean age was 71.1 years old, 62 % being male. Prevalence in cases of MVRF was: IFG, 32.9%; DM, 49.6 %; smoking, 26.3%; high blood pressure, 78.8%; hypercholesterolemia, 29.3%; hypertriglyceridemia, 18.2%, and obesity, 63.5%. All MVRFs were associated in the crude analysis with increased risk of cerebral infarction. In the multivariate analysis, significant associations were found for IFG (OR: 3.2; 95 % confidence interval [CI]:1.1-7.9), DM (OR: 4.5; 95 % CI: 1.4-14.9), high blood pressure (OR: 2.6; 95 % CI: 1.5-4.5), hypercholesterolemia (OR: 2.3; 95 % CI: 1.4-3.9), and obesity (OR: 1.7; 95% CI: 1.0-2.9). CONCLUSIONS: Alterations of the glucose metabolism IFG and DM are important MVRF for atherothrombotic or lacunar cerebral infarction as seen by the high rate of OR and high prevalence in the population with cerebral infarction.

Large chondroma of the dural convexity in a patient with Noonan's syndrome. Case report and review of the literature.

INTRODUCTION: Intracranial chondromas are extremely rare intracranial tumours that usually arise from the skull base synchondrosis. Exceptionally, they may grow from cartilage rests within the dura mater of the convexity or the falx. They may be part of Ollier's multiple enchondromatosis or Maffuci's syndrome. We describe the case of a young male diagnosed of Noonan's syndrome that underwent resection of a large intracranial chondroma arising from the dural convexity. To our best knowledge this is the first report of such association. CASE REPORT: An 18-year-old male presented with a single generalized seizure. The patient was previously diagnosed of Noonan's syndrome on the basis of his special phenotype (Turner-like), low stature, cardiac malformation, retarded sexual and bone development and normal karyotype. He harboured mild psychomotor retardation. Physical and neurological examinations were unremarkable. Brain Magnetic Resonance image showed a large well-circumscribed intracranial mass in the dural convexity of the left frontal-parietal lobes, with heterogeneous contrast enhancement and no peritumoural oedema. The patient was initiated on valproic acid and underwent craniotomy and complete excision of the tumour. The tumour was firm, white-greyish, avascular and could be finely dissected away from the cortex. Postoperative seizures required additional anticonvulsant therapy. He was discharged uneventfully. The pathological study revealed a mature chondroma. Subsequent brain MRI studies have shown no evidence of recurrence after 33 months of follow up. DISCUSSION: Chondromas comprise less than 0.3% of intracranial tumours. Only twenty-five cases of intracranial dural convexity chondromas are reported in the literature. Several hystopathogenetic theories have been proposed: metaplasia of meningeal fibroblasts and perivascular meningeal tissue, traumatic or inflammatory cartilaginous activation of fibroblasts and growth of aberrant embryonal cartilaginous rests in the dura mater. Chondromas present clinical features similar to meningiomas. CT scan imaging shows a mass of variable density due to different degrees of calcification with minimum to moderate contrast enhancement. MRI studies show a well-circumscribed lesion without surrounding tissue oedema, that exhibit heterogeneous signal with intermediate to low intensity on T1-weighted images and mixed intensity on T2-weighted images with minimum enhancement. Angiogram is clue to differentiate from meningiomas since chondromas are completely avascular. Complete tumour resection including its dural attachment is the treatment of choice. Long-term prognosis is favourable. Radiation therapy is currently not recommended for residual tumours or inoperable patients due to risk of malignization. Noonan's syndrome (also known as pseudo-Turner syndrome) is a complex familial genetic disorder with a phenotype that resembles that of Turner's syndrome but exhibits no chromosomal defect. No predisposition of Noonan's syndrome for tumoural development is reported in the literature. Association of a dural convexity chondroma with Noonan's syndrome is unique as far as the literature is concerned.

Large chondroma of the dural convexity in a patient with Noonan’s syndrome. Case report and review of the literature

Introducción. Los condromas intracraneales sontumores extremadamente raros que suelen surgir dela sincondrosis de la base craneal. Excepcionalmente,puede crecer a partir de restos cartilaginosos en laduramadre de la convexidad o en la hoz. Se han relacionado con la encondromatosis múltiple de Ollier y con el síndrome de Maffuci. Describimos el caso de unvarón joven diagnosticado de síndrome de Noonan enel que se resecó un condroma gigante de la convexidad.Esta asociación no está descrita en la literatura hasta el momento. Caso clínico. Varón de 18 años de edad que presenta una única crisis comicial generalizada comodebut clínico. Estaba previamente diagnosticado desíndrome de Noonan basándose en su fenotipo especial(Turner-like), baja estatura, presencia de malformacióncardíaca, retraso en la maduración ósea y sexual, ycariotipo normal. No presentaba alteraciones significativas en la exploración física y neurológica salvo un leve retraso mental. El estudio de resonancia magnética cerebral mostró una masa intracraneal de gran tamaño, bien circunscrita, dependiente de la convexidad dural frontoparietal izquierda, con captación heterogéneade contraste y sin edema perilesional. Comenzó tratamiento con ácido valproico y se realizó una resección completa de la lesión. El tumor era de consistencia dura, blanco-grisáceo, avascular y pudo disecarse por completo de la corteza. Presentó crisis comiciales postoperatorias que precisaron tratamiento combinado con un segundo anticomicial. Anatomía patológica: condroma maduro. Las RM de control han mostrado ausencia de recidiva tras 33 meses de seguimiento. Discusión. Los condromas comprenden menos del 0,3% de los tumores intracraneales. Hasta la fecha, sólo se han descrito veinticinco casos de condromas de convexidad dural en la literatura. Se han propuesto diversas teorías histopatogénicas: metaplasia de fibroblastos meníngeos y tejido meníngeo perivascular, activación traumática o inflamatoria de fibroblastos hacia cartílago, y crecimiento de restos cartilaginosos embrionarios aberrantes en la duramadre. Los condromas presentan características clínicas similares a los meningiomas. La imagen de TAC muestra una masa de densidad variable debido a los diferentes grados de calcificación con mínima a moderada captación de contraste. Los estudios de RM evidencian una masa bien circunscrita sin edema perilesional, de señal heterogénea, hipointensa en T1 y de intensidad mixta en T2, y con captación mínima de contraste. La angiografía los diferencia perfectamente de los meningiomas pues aquéllos son totalmente avasculares. El tratamiento de elección es la resección completa incluyendo la duramadre adyacente. El pronóstico a largo plazo es excelente. El tratamiento con radioterapia no se recomienda ni en los restos tumorales ni en los pacientes inoperables, debido al riesgo de malignización. El síndrome de Noonan (tambiénconocido como pseudo-Turner) es una enfermedadgenética familiar compleja cuyo fenotipo se asemejaal del síndrome de Turner pero no presenta defectocromosómico. Hasta la fecha, no se ha descrito en laliteratura una predisposición al desarrollo de tumoresen los pacientes con Noonan ni tampoco la asociaciónde este síndrome con un condroma de convexidad cerebral

Introduction. Intracranial chondromas are extremelyrare intracranial tumours that usually arise fromthe skull base synchondrosis. Exceptionally, they maygrow from cartilage rests within the dura mater of theconvexity or the falx. They may be part of Ollier's multiple enchondromatosis or Maffuci's syndrome. We describe the case of a young male diagnosed of Noonan'ssyndrome that underwent resection of a large intracranialchondroma arising from the dural convexity. To our best knowledge this is the first report of such association.Case report. An 18-year-old male presented with asingle generalized seizure. The patient was previouslydiagnosed of Noonan's syndrome on the basis of hisspecial phenotype (Turner-like), low stature, cardiacmalformation, retarded sexual and bone developmentand normal karyotype. He harboured mild psychomotorretardation. Physical and neurological examinationswere unremarkable. Brain Magnetic Resonance imageshowed a large well-circumscribed intracranial massin the dural convexity of the left frontal-parietal lobes, with heterogeneous contrast enhancement and no peritumoural oedema. The patient was initiated on valproic acid and underwent craniotomy and complete excision of the tumour. The tumour was firm, white-greyish, avascular and could be finely dissected away from the cortex. Postoperative seizures required additional anticonvulsant therapy. He was discharged uneventfully. The pathological study revealed a mature chondroma. Subsequent brain MRI studies have shown no evidence of recurrence after 33 months of follow up.Discussión. Chondromas comprise less than 0.3% ofintracranial tumours. Only twenty-five cases of intracranial dural convexity chondromas are reported inthe literature. Several hystopathogenetic theories havebeen proposed: metaplasia of meningeal fibroblasts andperivascular meningeal tissue, traumatic or inflammatorycartilaginous activation of fibroblasts and growthof aberrant embryonal cartilaginous rests in the duramater. Chondromas present clinical features similar tomeningiomas. CT scan imaging shows a mass of variabledensity due to different degrees of calcification withminimum to moderate contrast enhancement. MRI studiesshow a well-circumscribed lesion without surroundingtissue oedema, that exhibit heterogeneous signalwith intermediate to low intensity on T1-weightedimages and mixed intensity on T2-weighted images withminimum enhancement. Angiogram is clue to differentiatefrom meningiomas since chondromas are completelyavascular. Complete tumour resection including itsdural attachment is the treatment of choice. Long-termprognosis is favourable. Radiation therapy is currentlynot recommended for residual tumours or inoperablepatients due to risk of malignization. Noonan's syndrome(also known as pseudo-Turner syndrome) is a complex familial genetic disorder with a phenotype that resembles that of Turner's syndrome but exhibitsno chromosomal defect. No predisposition of Noonan'ssyndrome for tumoural development is reported in theliterature. Association of a dural convexity chondromawith Noonan's syndrome is unique as far as the literatureis concerned