Cost of Treating Cutaneous T-Cell Lymphoma in Spain: Analysis of MICADOS Study Data by Disease Stage. / Evaluación de los costes asociados a la enfermedad de pacientes con linfoma cutáneo de células T en España: análisis en función del estadio clínico (estudio MICADOS).

BACKGROUND AND OBJECTIVE: The cost of treating cutaneous T-cell lymphoma (CTCL) in Spain is unknown. With the advent of new treatments, it is more important than ever to gain an accurate picture of the true costs involved. The MICADOS study had 2 primary objectives: 1)to evaluate the impact of CTCL on patient quality of life, and 2)to evaluate the costs associated with the disease. This article reports the results of the cost analysis. METHODS: We estimated the cost of treating CTCL over a period of 1year from the perspective of the Spanish National Health System. Twenty-three dermatologists and hematologists from 15 public hospitals analyzed data for adult patients with mycosis fungoides (MF) or Sézary syndrome (SS). RESULTS: A total of 141 patients (57.4% male) with a mean age of 63.6 years (95%CI: 61.4-65.7 years) were included. The mean direct annual cost of treating CTCL was €34,214 per patient. The corresponding costs by stage were €11,952.47 for stageI disease, €23,506.21 for stageII disease, €38,771.81 for stageIII disease, and €72,748.84 for stageIV disease. The total direct annual cost of treating MF/SS in public hospitals in Spain was estimated at €78,301,171; stageI disease accounted for 81% of all costs, stageII for 7%, and stagesIII andIV for 6% each. CONCLUSIONS: The MICADOS study offers an accurate picture of the direct cost of treating CTCL in patients with MF/SS in Spain and shows that costs vary significantly according to disease stage. Patient-borne and indirect costs should be analyzed in future studies.

[Translated article] Cost of Treating Cutaneous T-Cell Lymphoma in Spain: Analysis of MICADOS Study Data by Disease Stage.

BACKGROUND AND OBJECTIVE: The cost of treating cutaneous T-cell lymphoma (CTCL) in Spain is unknown. With the advent of new treatments, it is more important than ever to gain an accurate picture of the true costs involved. The MICADOS study had 2 primary objectives: 1)to evaluate the impact of CTCL on patient quality of life, and 2)to evaluate the costs associated with the disease. This article reports the results of the cost analysis. METHODS: We estimated the cost of treating CTCL over a period of 1year from the perspective of the Spanish National Health System. Twenty-three dermatologists and hematologists from 15 public hospitals analyzed data for adult patients with mycosis fungoides (MF) or Sézary syndrome (SS). RESULTS: A total of 141 patients (57.4% male) with a mean age of 63.6 years (95%CI: 61.4-65.7 years) were included. The mean direct annual cost of treating CTCL was €34,214 per patient. The corresponding costs by stage were €11,952.47 for stageI disease, €23,506.21 for stageII disease, €38,771.81 for stageIII disease, and €72,748.84 for stageIV disease. The total direct annual cost of treating MF/SS in public hospitals in Spain was estimated at €78,301,171; stageI disease accounted for 81% of all costs, stageII for 7%, and stagesIII andIV for 6% each. CONCLUSIONS: The MICADOS study offers an accurate picture of the direct cost of treating CTCL in patients with MF/SS in Spain and shows that costs vary significantly according to disease stage. Patient-borne and indirect costs should be analyzed in future studies.

Real-life data in 115 chronic migraine patients treated with Onabotulinumtoxin A during more than one year.

BACKGROUND: OnabotulinumtoxinA (OnabotA) is effective in Chronic Migraine (CM) during first year of treatment and longer. In real clinical setting, CM patients with acute Medication Overuse (MO) or concurrently receiving oral preventatives are treated with OnabotA. We aim to assess evolution of CM patients beyond first year on OnabotA. METHODS: Data were retrospectively collected in three headache units. We analyzed cases who had received at least five sessions of OnabotA according to PREEMPT protocol. We continued OnabotA therapy when a reduction of number of headache days of at least 30% was achieved. RESULTS: We included 115 patients (98 females, 17 males) who completed 7.6 ± 2.3 (5-13) OnabotA procedures. Previously they had not responded to topiramate and, at least, one other preventative. Age at inclusion was 45.3 ± 12 (14-74) years, and latency between CM onset and OnabotA therapy was 43.1 ± 38.2 (6-166) months. At first OnabotA session 92 patients (80%) fulfilled MO criteria and 107 (93%) received a concurrent oral preventative. In 42 cases (36.5%) OnabotA dose was increased over 155 units. After first year in 57 out of 92 patients (61.9%) MO was discontinued. Among those receiving preventatives, in 52 out of 107 they were retired (48.6%). In 22 cases (19.1%) OnabotA administration was delayed to the fourth or fifth month and in 12 (10.4%) it was temporally stopped. Finally, in 18 patients (15.7%) OnabotA was discontinued due to lack of efficacy beyond first year of treatment. CONCLUSION: Our results suggest that discontinuation of acute medication overuse and oral preventive therapies are achievable objectives in long-term using of OnabotA in CM patients.

Modelo hospitalario transversal: Mutua de Terrassa / A cross-disciplinary hospital model: The Mutua de Terrassa University Hospital

El objetivo del trabajo es describir nuestro modelo de gestión asistencial, analizar sus resultados y explicar propuestas innovadoras que desarrollamos en primaria ligadas a dicho modelo de gestión. Describimos nuestro servicio, su organización, recursos humanos y técnicos, gestión de calidad, coordinación con atención primaria, cartera de servicios y actividad de 2009. Analizamos el modelo de gestión, sus resultados y añadimos las propuestas innovadoras que estamos desarrollando. El Hospital Universitario Mutua de Terrassa está concertado con el sistema catalán de salud y su gestión es privada. La actividad asistencial se realiza de manera transversal en los diferentes niveles asistenciales. El modelo de gestión se basa en 3 puntos fundamentales: el continuum asistencial, el producto único y la gestión directa del jefe de servicio de los recursos humanos y técnicos, así como su participación activa en el proyecto. Ello ha requerido implementar una estructura física, recursos humanos y técnicos, estrechar la relación con primaria mediante la historia clínica informatizada y programas de tratamiento rehabilitador educacionales grupales multidisciplinarios. Un modelo transversal asegura el continuum asistencial y el producto único. Para ello, la gestión integral del proceso rehabilitador es fundamental. El hospital debe atender patologías complejas. Una sólida estructura en atención primaria es imprescindible y no menos importante es contar con medios a nivel sociosanitario y domiciliario. Debemos ser pioneros en la valoración del daño corporal y peritaje. La docencia estimula la calidad de la práctica clínica y la investigación (AU)

This article aims to describe our model of healthcare management, analyze its results and explain the innovative proposals we developed in primary care linked to this management model. We outline our service, its organization, human and technical resources, quality management, coordination with primary care, services’ portfolio and activity for 2009. The management model and its results, as well as the proposals we are currently developing in primary care are described. The Mutua de Terrassa University Hospital is linked to the Catalan health system but has private management. Healthcare activity is carried out across distinct levels of care. The management model is based on three main points: the continuum of care, the single product, and the direct management of human and technical resources by the departmental head, who also actively participates in the project. This model has required the implementation of a physical structure and human and technical resources and the establishment of closer links with primary care through computerized medical records and education programs in rehabilitation for multidisciplinary groups. A cross-disciplinary model ensures the continuum of care and the single product. Comprehensive management of the rehabilitation process is essential for this purpose. The hospital must address complex diseases. A strong primary care structure is essential. Equally important are geriatric and home-based services. The specialty of rehabilitation must move forward and education is crucial in stimulating the quality of clinical practice and research (AU)

Programa rehabilitador integral del raquis cervical. Descripción, resultados y análisis de costes / Integral rehabilitation neck program. Description, outcome and cost analysis

Introducción. La cervicalgia mecánica crónica es la segunda causa de consulta en nuestros centros de atención primaria. La alta demanda de recursos que genera nos plantea introducir estrategias de gestión que sean eficaces y eficientes. Para ello diseñamos un programa de tratamiento integral del raquis (PIR) cervical, que optimiza los recursos disponibles. El objetivo del estudio es demostrar su efectividad. Material y método. Estudio prospectivo y de costes de pacientes que han participado en el PIR cervical de septiembre de 2008 a enero de 2009. Son 208 pacientes, 33 hombres y 175 mujeres, de 25–89 años. El programa es multidisciplinario y consta de 14 sesiones grupales de 1h de duración, incluyendo 2 charlas educativas (psicólogo y médico rehabilitador). Las variables recogidas son edad, sexo, escala visual analógica de dolor pretratamiento y postratamiento, y cuestionario de Northwick Park pretratamiento y postratamiento. Resultados. Disminuye un 50% las visitas y un 40% las horas de tratamiento fisioterapéutico, aunque se ha necesitado una inversión inicial única en equipamiento. La disminución del dolor mediante escala visual analógica y la mejora de la funcionalidad mediante el cuestionario de Northwik Park han sido altamente significativas desde el punto de vista estadístico. Conclusión. El PIR cervical se ha demostrado útil en la gestión de los recursos disponibles para el tratamiento del dolor cervical crónico (AU)

Introduction. Chronic mechanical neck pain is the second cause of consultation in our primary care centers. The high demand for resources generated for it, leading us introduce management strategies that are effective and efficient. For this reason, we designed an integral neck program (PIR), which optimizes available resources, and the aim of this study is demonstrate their effectiveness. Material and methods. Prospective and cost analysis study of patients who have participated in the PIR cervical, from September 2008 to January 2009. Are 208 patients, 33 men and 175 women aged 25 to 89 years. The program is multidisciplinary and consists of 14 group sessions of 1h, including 2 educational lectures (psychologist and rehabilitation physician). As variables are set age, sex, pain Visual Analog Scale (VAS) pre-and post-treatment and Northwick Pack Neck Pain Questionnaire before and after treatment. Results. We have decreased visits by 50% and 40% the hours of physiotherapy, but has needed a single initial investment in equipment. The decrease in pain by VAS and improved functionality through the Northwik Park Neck Pain Questionnaire have been highly significant statistically. Conclusion. The integral rehabilitation Neck Program is useful in the management of the resources available for the treatment of chronic neck pain (AU)

Coledocotomía y coledocorrafia sobre el tubo en "T" de Kehr. Morbilidad y mortalidad en una serie de 243 pacientes operados / Choledochotomy and closure of the choledochus with "T"-tube drainage. Morbidity and mortality in a series of 243 surgical patients

Objetivo. Se presenta nuestra experiencia en el manejo de los pacientes sometidos a exploración quirúrgica de la vía biliar con drenaje sobre el tubo de Kehr. Pacientes y métodos. Estudio retrospectivo sobre 243 pacientes (1985-1997), a quienes se les practicó apertura de la vía biliar principal por presentar enfermedad o sospecha de enfermedad litiásica y en los que la intervención finalizó con colocación de un tubo de Kehr. Resultados. La morbilidad fue del 28,3 por ciento. Aparecieron complicaciones de tipo biliar en el 14,8 por ciento de los casos, todas resueltas en el mismo ingreso, sin necesidad de reintervención (19 litiasis residuales y 17 fugas biliares). La presentación de complicaciones de tipo biliar no supuso un aumento de la morbilidad general (p < 0,05). La colangiografía trans-Kehr intraoperatoria (CTK) disminuyó de forma significativa el riesgo de presentar litiasis residual (p < 0,001), al detectar casi la mitad en el quirófano. Apareció un 33,3 por ciento (3/9) de fugas cuando el Kehr se retiró el séptimo día y un 3,0 por ciento (7/230) cuando se retiró a partir del octavo día (p < 0,01). Fallecieron 4 pacientes (1,6 por ciento), pero ninguno de ellos presentó complicaciones de tipo biliar. Conclusiones. La CTK intraoperatoria redujo de forma significativa la incidencia de litiasis residual. Si la CTK de control es normal, el Kehr puede ser retirado de forma segura a partir del octavo día. En caso de litiasis residual, si no se prevé su expulsión espontánea, estará indicada su extracción mediante colangiopancreatografía retrógrada endoscópica (CPRE) tan pronto como se diagnostique (AU)

[Clinical analysis of unsuspected pulmonary thromboembolism at the emergency department]. / Análisis clínico de la tromboembolia pulmonar no sospechada en el servicio de urgencias.

OBJECTIVES: Evaluate the degree of suspicion of pulmonary embolism (PE) in the emergency department (ED). PATIENTS AND METHODS: We analyzed the cases of patients with TEP diagnosed during two years and compared group A (PE suspected) with group B (PE was not initially suspected). RESULTS: 57 cases of PE were admitted from ED. In 14 (25%) of them the PE was not suspected. There were statistically significant differences in the signs of deep venous thrombosis (more prevalent in group A), heart failure, and pleural effusion (more frequent in group B). The alternative diagnosis were mostly heart failure and pneumonia. CONCLUSIONS: The patients with unsuspected PE do not have a different clinical profile. The PE is most of the times confused with heart failure and pneumonia.

Paraganglioma extraadrenal retroperitoneal. Presentación de dos nuevos casos / Retroperitoneal extraadrenal paraganglioma. Report of two new cases

Presentamos 2 casos de paraganglioma retroperitoneal extraadrenal no diagnosticados preoperatoriamente, ya que simularon una tumoración hepática y pancreática, respectivamente. La ausencia de preparación preoperatoria adecuada y de diagnóstico originó en uno de nuestros pacientes importante labilidad tensional durante las maniobras de extirpación, que fue controlada de manera adecuada. Analizamos los principales aspectos clínicos, diagnósticos, terapéuticos y pronósticos de estos tumores poco frecuentes y realizamos una revisión de la bibliografía (AU)

[Brain stem involvement in eclampsia and HELLP syndrome]. / Afectación del tronco cerebral en la eclampsia y síndrome HELLP.

INTRODUCTION: Nowadays, eclampsia is a rare complication of pregnancy and the puerperium. However, it is still one of the main causes of maternal morbi-mortality. Systemic findings in eclampsia may sometimes include association with microangiopathic hemolytic anaemia, raised liver enzymes and thrombocytopenia. This clinical combination constitutes the HELLP syndrome (Hemolysis Elevated Liver enzymes Low Platelets). The commonest neurological findings in eclampsia are headache, visual alterations, convulsions and stupor or coma. The presence of clinical symptoms and signs due to brainstem disorders is unusual. CLINICAL CASE: We present the case of a thirty year old woman with eclampsia and associated HELLP syndrome, which briefly affected the brain stem. The patient showed progressive general and neurological improvement. Three months afterwards she still had paresia of the sixth right cranial nerve, due to what was presumed to be a right paramedian infarct of the pons. CONCLUSION: We consider it important not to forget this exceptional association so that suitable treatment may be given to such patients since prognosis is not invariably bad.

[Thoracic stab wounds]. / Heridas torácicas por arma blanca.

Stab wounds are the most common cause of open chest wounds in our setting, with an incidence far higher than either wounds caused by firearms or bull horns. We describe a series of 49 patients, 44 (89.8%) men and 5 (10.2%) women. Mean age was 31 years. The 49 patients had suffered 72 stab wounds to the chest, of which 30 (41.6%) were penetrating and 42 (58.3%) were non penetrating. The lesions observed were 11 (22.4%) cases of pneumothorax, 10 (20.4%) of hemopneumothorax, 6 pulmonary lesions, 2 heart wounds and 1 extensively damaged diaphragm. Twenty-four patients with non penetrating wounds and 8 with penetrating wounds were treated conservatively. It was subsequently necessary to drain the chest of only one. Of the remaining penetrating wounds, drains were inserted in six immediately and 11 underwent surgery. Complications developed in only 9 cases. One patient died as a result of abdominal lesions resulting from stab wounds directly to the abdomen. We are in favor of conservative management. Indications for more aggressive intervention are hypovolemic shock, cardiac tamponade or significant loss of fluid through the thoracic drain.

[Detection of bacteremia in patients discharged from an emergency unit: study of 61 cases]. / Detección de bacteriemia en los pacientes dados de alta en urgencias: estudio de 61 episodios.

BACKGROUND: To know the prevalence, the clinical and microbiological characteristics of bacteremia episodes detected on discharged patients at the emergency unit, as well as the accordance of diagnostics and the predicting factors. PATIENTS AND METHODS: We analysed the cases with bacteria detected on discharged patients during 2 years (1995-1996) in an university hospital. We reported: age, sex isolated organism in blood cultures, bacteremia source, leukocytes count, presence of underlying conditions, and accordance between initial and final diagnosis. We compared the characteristics of the groups with bacteremia without apparent origin and the ones with evident clinical source. RESULTS: We detected 61 cases, the mean age was 55 years (SD = 21), and 54% were males. The most commonly isolated agent was E. coli (50%). The leukocytes count was higher 10 x 10(9)/l in 15%. The source of bacteremia was: urinary tract infection (54%) no clinical focus (31%), respiratory tract (11%) and biliary duct (3%). The 90% of urinary tract and the 71% of respiratory infections were correctly diagnosed. However only the 5% of bacteremias without apparent source was correctly diagnosed. We found these differences statistically a significant (p < 0.001 and p = 0.002). Underlying conditions were detected in the 84% of cases in bacteremia without apparently source: AIDS (22%), cirrhosis (22%), parenteral drugs addiction (17%) and venous catheter (17%). Comparing both groups, with apparent focus and without it, we found that the presence of underlying condition is the only independent factor which predispose to bacteremia (p = 0.000; RR = 4.6; IC 95% = 1.9-11.8). CONCLUSIONS: The prevalence of bacteremia detected in discharged patients at the emergency unit seems acceptable. However those results suggest that we could decrease the number of patients with bacteremia without apparently source, because this group shows up to be the less successful in diagnosis. In patients with fever and no clinical focus in the emergency unit, it is useful to consider the presence of underlying factors to decide its management.

Electron microscopic microanalysis of bronchoalveolar lavage: a way to identify exposure to silica and silicate dust.

OBJECTIVES: The diagnostic implications of finding non-fibrous inorganic particles in bronchoalveolar lavage (BAL) fluid has not been fully assessed. The aim of this study has been to measure the silica and non-fibrous silicates in BAL fluid from populations with different exposures to inorganic dust, and to find whether such measurement is useful for diagnostic purposes. MATERIALS AND METHODS: BAL samples from 19 subjects with only environmental exposure to inorganic dust (group A, mean (SD) age 50.7 (15.2)), 23 subjects with normal chest x ray films exposed to silica or silicates at work (group B, mean (SD) age 52.0 (12.4)), and 15 subjects with a previous diagnosis of silicosis (group C, mean (SD) age 68.0 (6.5)) were studied. Absolute and relative cell counts were found, and the samples were prepared for microanalysis by electron microscopy (EM). Firstly, semiquantitative x ray microanalysis was performed to find the level of silicon (Si) (peak/background Si) and this was followed by microanalysis of individual particles by EM. Variables related to the level of Si detected were assessed with multivariate analysis. RESULTS: Detected levels were higher in group B (2.09, 95% confidence interval (95% CI) 1.56 to 2.82) and C (1.50, 95% CI 1.07 to 2.12) than in group A (0.87, 95% CI 0.66 to 1.16) (P < 0.05, Dunett t test). A first multivariate analysis showed that exposure to silica or silicates was the only determinant of the level of Si expressed as log peak/background Si, when adjusted for age, sex, smoking habit, and cell count. A second multivariate analysis with microanalysis of individual particles as an independent variable showed the silica count to be the main predictor of detected concentration of Si. Silica and non-aluminium silicates together explain 55.5% (R2) of the variation in detected levels of Si. CONCLUSIONS: Detected levels of Si in BAL fluid depend on silica count and are higher in subjects with exposure to inorganic dust at work, but will not discriminate between exposed subjects with and without silicosis. Because semiquantitative x ray microanalysis does not accurately define exposure to non-silica inorganic particles, this measurement must be followed by EM microanalysis of individual particles in most cases, especially when exposure to silicates or metal dust is suspected.

Bronchial stump aspergillosis four years after lobectomy.

Bronchial stump aspergillosis (BSA) is an unusual entity. We report a case presenting hemoptysis four years after right upper lobe resection because of lung cancer. Simple removal of the silk suture is most likely the treatment of choice. No additional local or systemic antifungal therapy is needed.

Treatment of Legionnaires' disease. Current recommendations.

Legionnaires' disease is a relatively common cause of community-acquired pneumonia and of some outbreaks of hospital-acquired pneumonia. Moreover, Legionella pneumophila is frequently involved in the aetiology of the subset of pneumonias that is characterised by severe clinical course and high mortality. No sure clinical, radiographical or analytical features are useful in differentiating Legionella infection from other aetiologies of pneumonia. On the basis of these data, a rational initial therapeutic approach to community-acquired pneumonia, as well as to nosocomial pneumonia in certain circumstances, has to include an antimicrobial agent that is clinically effective against Legionella spp. Clinical studies have provided evidence that erythromycin is the first-line treatment. An intravenous dosage of 1g every 6 hours as initial therapy will be effective in most cases. Parenteral treatment may be switched to oral administration only after clinical response is observed. In vitro susceptibilities and preliminary experimental and clinical results suggest that clarithromycin will most likely become the preferred treatment once an intravenous preparation is available worldwide. However, orally administered clarithromycin at the dosage of 500 mg every 12 hours may be recommended in those developing countries in which health systems cannot afford the costs of intravenous therapy. In the case of clinically severe illness or in seriously immunosuppressed hosts with confirmed legionellosis, a combined therapeutic approach is warranted. Rifampicin 600 mg every 12 hours intravenously or orally has to be added to the usual dosage of erythromycin. Other alternative therapies, but with less distinct clinical efficacy, that can be combined with erythromycin are doxycycline 100 mg every 12 hours intravenously or orally, and intravenous ciprofloxacin 200 mg every 6 hours.

Measurement of maximal expiratory pressure: effect of holding the lips.

BACKGROUND: Minor differences in technique may account for the wide range of published normal values of maximum expiratory and inspiratory pressures. The effects of holding the lips while the subject performed a maximal expiratory pressure manoeuvre were investigated in this study. METHODS: Maximum static expiratory pressures (PEmax) obtained with a cylindrical tube by means of lip compression by the subject and technician aided compression were compared in 20 men (mean age 27 years) and 20 women (mean age 28 years). RESULTS: Technician aided lip compression was associated with higher maximum expiratory pressure than compression by the subject in both men (195 v 110 cm H2O) and women (134 v 80 cm H2O). CONCLUSION: Compression of the lips and corners of the mouth should be performed by a trained technician for maximum expiratory pressure measurements when a cylindrical mouthpiece is used.

Postural variation of the maximum inspiratory and expiratory pressures in obese patients.

Evaluating whether weight is a factor responsible for the decrease of muscle force in the supine position with respect to the upright and sitting positions, we measured maximum inspiratory and expiratory pressures (PImax and PEmax) in these postures in ten obese patients (age 38.7 +/- 9.1 years; height 168.7 +/- 8.9 cm; and weight 139.3 +/- 28.4 kg) and ten normal control subjects (age 38.4 +/- 8.2 years; height 169.3 +/- 7.9 cm and weight 66.9 +/- 11.9 kg.) In both study groups, PImax and PEmax values decreased in the supine posture with respect to upright and sitting positions. Differences between pressures in the various postures were similar for both groups with the exception of PEmax in obese females. The decrease in PEmax values from the sitting to supine positions was greater in obese than control females. Weight, sex and postural changes can influence the generation of maximal expiratory force.