Voxel-wise analysis: A powerful tool to predict radio-induced toxicity and potentially perform personalised planning in radiotherapy.

Dose - volume histograms have been historically used to study the relationship between the planned radiation dose and healthy tissue damage. However, this approach considers neither spatial information nor heterogenous radiosensitivity within organs at risk, depending on the tissue. Recently, voxel-wise analyses have emerged in the literature as powerful tools to fully exploit three-dimensional information from the planned dose distribution. They allow to identify anatomical subregions of one or several organs in which the irradiation dose is associated with a given toxicity. These methods rely on an accurate anatomical alignment, usually obtained by means of a non-rigid registration. Once the different anatomies are spatially normalised, correlations between the three-dimensional dose and a given toxicity can be explored voxel-wise. Parametric or non-parametric statistical tests can be performed on every voxel to identify the voxels in which the dose is significantly different between patients presenting or not toxicity. Several anatomical subregions associated with genitourinary, gastrointestinal, cardiac, pulmonary or haematological toxicity have already been identified in the literature for prostate, head and neck or thorax irradiation. Voxel-wise analysis appears therefore first particularly interesting to increase toxicity prediction capability by identifying specific subregions in the organs at risk whose irradiation is highly predictive of specific toxicity. The second interest is potentially to decrease the radio-induced toxicity by limiting the dose in the predictive subregions, while not decreasing the dose in the target volume. Limitations of the approach have been pointed out.

El valor añadido de los servicios profesionales farmacéuticos asistenciales. Un caso de SFT / The added value of Professional Pharmaceutical Assistance Services. A case of pharmaceutical care

Presentación del caso: paciente de 62 años, dependiente, con buena adherencia terapéutica y presencia de enfermedades psiquiátricas que limitan su calidad de vida. Su hijo, cuidador desde que le diagnosticaron el trastorno de la personalidad, acude a la farmacia solicitando ayuda para abordar la situación. Estudio y evaluación del caso: se evaluó el estado de salud de la paciente y se detectaron posibles resultados negativos asociados a la medicación (RNM) que limitaban su calidad de vida. Intervención: se derivó a su médico de atención primaria con un informe de interconsulta multidisciplinar indicado los posibles RNM y las posibles modificaciones. Resultados: el médico de atención primaria aceptó la intervención y comenzó con una deprescripción progresiva de benzodiacepinas, con respecto a la sintomatología extrapiramidal se confirmó el RNM y se derivó a su especialista en psiquiatría. Tras mejorar significativamente su calidad de vida, se abordaron sus enfermedades cardiovasculares. Para ello se indicaron medidas higiénico- sanitarias que disminuyeran su riesgo cardiovascular. Conclusiones: la coordinación de los diferentes profesionales sanitarios permite un aumento de la autonomía del paciente, una deprescripción de medicamentos y una optimización de recursos sanitarios, traduciéndose como una mejora en su calidad de vida (AU)

Atención multidisciplinar: farmacia comunitaria y medicina familiar / Multidisciplinary care: community pharmacy and family medicine

Presentación del caso: paciente de 67 años, con una mala adherencia terapéutica. Se le ofrece formar parte del servicio de Sistema Personalizados de Dosificación (SPD); servicio que se convierte en la puerta de entrada para otro servicio asistencial de la farmacia comunitaria, el seguimiento farmacoterapéutico. Estudio y evaluación del caso: la evaluación del estado inicial de salud demuestra que algunos de los problemas de salud podrían estar relacionados con un Resultado Negativo Asociado a la Medicación (RNM). Se detectan fallos de inefectividad al tratamiento antihipertensivo y de seguridad al tratamiento antipsicótico. Intervención: se deriva al equipo de atención primaria con un informe de los resultados del servicio de seguimiento farmacoterapéutico y una propuesta de modificación de la farmacoterapia. Resultados: se añadió un nuevo principio activo para controlar la presión arterial, que provocó una reacción adversa, lo que derivó en su sustitución por otro. Por otro lado, se confirmaron reacciones adversas asociadas al tratamiento antipsicótico, por lo que se inició una deprescripción gradual del tratamiento. Conclusiones: la coordinación entre los diferentes profesionales de salud resultó esencial. El farmacéutico comunitario detectó Problemas Relacionado con los Medicamentos (PRM) y RNM que afectan negativamente a la calidad de vida de los pacientes polimedicados. (AU)

Development and psychometric validation of a brief comprehensive health status assessment scale in older patients with hematological malignancies: The GAH Scale.

OBJECTIVES: The purpose of this study was to develop a new brief, comprehensive geriatric assessment scale for older patients diagnosed with different hematological malignancies, the Geriatric Assessment in Hematology (GAH scale), and to determine its psychometric properties. MATERIALS AND METHODS: The 30-item GAH scale was designed through a multi-step process to cover 8 relevant dimensions. This is an observational study conducted in 363 patients aged≥65years, newly diagnosed with different hematological malignancies (myelodysplasic syndrome/acute myeloblastic leukemia, multiple myeloma, or chronic lymphocytic leukemia), and treatment-naïve. The scale psychometric validation process included the analyses of feasibility, floor and ceiling effect, validity and reliability criteria. RESULTS: Mean time taken to complete the GAH scale was 11.9±4.7min that improved through a learning-curve effect. Almost 90% of patients completed all items, and no floor or ceiling effects were identified. Criterion validity was supported by reasonable correlations between the GAH scale dimensions and three contrast variables (global health visual analogue scale, ECOG and Karnofsky), except for comorbidities. Factor analysis (supported by the scree plot) revealed nine factors that explained almost 60% of the total variance. Moderate internal consistency reliability was found (Cronbach's α: 0.610), and test-retest was excellent (ICC coefficients, 0.695-0.928). CONCLUSION: Our study suggests that the GAH scale is a valid, internally reliable and a consistent tool to assess health status in older patients with different hematological malignancies. Future large studies should confirm whether the GAH scale may be a tool to improve clinical decision-making in older patients with hematological malignancies.

Tratamiento quirúrgico del síndrome de sobrecarga en valgo y extensión en atletas / Traitement chirurgical du syndrome de surcharge en valgus et en extension chez les athlètes / Surgical treatment of valgus extension overload syndrome in athletes

Introducción: la sobrecarga en valgo y extensión (choque posteromedial) es una lesión que se presenta con cierta frecuencia en atletas de lanzamiento, que en ocasiones puede requerir de cirugía para que el atleta pueda seguir compitiendo. Objetivos: realizar el diagnóstico y tratamiento del síndrome de sobrecarga en valgo y extensión en atletas, hacer diagnóstico precoz y el tratamiento adecuado. Métodos: se realizó un estudio longitudinal prospectivo de intervención que incluyó a deportistas de alto rendimiento operados por síndrome de sobrecarga en valgo y extensión. La muestra estuvo formada por 8 pacientes, todos masculinos, edad media 26 años (rango entre 22 y 29), deportes que practicaban: 6 béisbol (5 lanzadores y uno jardinero), un paciente de pesas y otro de jabalina. El tiempo de seguimiento mínimo fue de 6 meses y máximo de 4 años y una media de 2.3 años. Resultados: fueron operados ocho pacientes, de ellos cuatro presentaban neuropatía por compresión del nervio cubital a nivel del codo, a cuatro se les realizó además transferencia del nervio cubital, dos subcutáneo y en dos se le realizó una polea con fascia flexora pronadora. Las complicaciones que se presentaron fueron: recidiva del dolor por insuficiencia del ligamento colateral medial (1/8) pacientes. Los resultados funcionales según escala de Conway fueron excelentes (5/8), bueno (2/8) y pobre (1/8). Conclusiones: el estrés repetido, la insuficiencia de los flexores pronadores y del ligamento colateral medial son las causas desencadenantes del síndrome de sobrecarga en valgo y extensión. La cirugía favorece el retorno a la actividad deportiva en la mayoría de los atletas(AU)

Introduction: valgus extension overload (posteromedial shock) is a type of injure that is relatively frequent in throwing athletes and may require surgical procedures to be performed so that the athlete can keep on competing. Objective: To early diagnose and adequately treat the valgus extension overload syndrome in athletes. Methods: a prospective, longitudinal and intervention study was conducted in high performance athletes operated on for valgus extension overload syndrome. The sample was made up of 8 male athletes aged 26 years as average (range of 22 to 29 years), who practiced baseball (five pitchers and one outfielder), weightlifting (one) and javelin throw (one). The minimal follow-up was 6 months and the maximum was 4 years, for a mean of 2.3 years. Results: eight patients were operated on, four of them presented with neuropathy from compressed cubital nerve at the elbow; four underwent transfer of their cubital nerve, two subcutaneous and two with a pulley with flexor pronator fascia. The most observed complication was pain relapse due to medial collateral ligament insufficiency in one patient. The functional results according to Conway's scale were excellent in 5 patients, good in two and unsatisfactory in just one patient. Conclusions: repeated stress, insufficiency in flexor pronators and in the medial collateral ligament were the causes that unleash the valgus extension overload syndrome. The surgical procedure helps most of the athletes to come back to their normal sports activity(AU)

Introduction: la surcharge en valgus et en extension (choc postéro-médial) est une lésion assez fréquente chez les sportifs de lancers exigeant parfois un traitement chirurgical pour qu'ils puissent retourner aux compétitions. Objectifs: cette étude a été visée à déterminer un diagnostic précoce et un traitement approprié du syndrome de surcharge en valgus et en extension chez des athlètes. Méthodes: une étude longitudinale prospective interventionnelle comprenant des sportifs de haut niveau, traités chirurgicalement pour syndrome de surcharge en valgus et en extension, a été effectuée. L'échantillon est composé de 8 patients, tous du sexe masculin, âge moyen de 26 ans (22-29 ans), pratiquant baseball (5 lanceurs et 1 joueur de champ), haltérophilie (1), et lancer du javelot (1), avec un suivi de 6 mois au minimum et 4 ans au maximum, et une médiane de 2.3 ans. Résultats: sur 8 patients opérés, quatre étaient atteints d'une neuropathie par pincement du nerf cubital au niveau du coude, quatre ont subi une chirurgie de transfert du nerf cubital, 2 sous-cutanés, et 2 ont subi la reconstruction de poulie par plastie autologue de fascia des fléchisseurs-pronateurs. Dans un seul cas, une complication est survenue: douleur récidivante due à un trouble du ligament collatéral médial. Selon l'échelle de Conway, les résultats sont excellents (5 patients), bons (2 patients) et faibles (1 patient). Conclusions: on conclut que le stress persistant et les troubles des fléchisseurs pronateurs et du ligament collatéral médial entraînent un syndrome de surcharge en valgus et en extension, et c'est le traitement chirurgical qui permet le retour de la plupart des athlètes affectés à la pratique de leur sport respectif(AU)

Tratamiento quirúrgico del síndrome de sobrecarga en valgo y extensión en atletas / Surgical treatment of valgus extension overload syndrome in athletes

Introducción: la sobrecarga en valgo y extensión (choque posteromedial) es una lesión que se presenta con cierta frecuencia en atletas de lanzamiento, que en ocasiones puede requerir de cirugía para que el atleta pueda seguir compitiendo. Objetivos: realizar el diagnóstico y tratamiento del síndrome de sobrecarga en valgo y extensión en atletas, hacer diagnóstico precoz y el tratamiento adecuado. Métodos: se realizó un estudio longitudinal prospectivo de intervención que incluyó a deportistas de alto rendimiento operados por síndrome de sobrecarga en valgo y extensión. La muestra estuvo formada por 8 pacientes, todos masculinos, edad media 26 años (rango entre 22 y 29), deportes que practicaban: 6 béisbol (5 lanzadores y uno jardinero), un paciente de pesas y otro de jabalina. El tiempo de seguimiento mínimo fue de 6 meses y máximo de 4 años y una media de 2.3 años. Resultados: fueron operados ocho pacientes, de ellos cuatro presentaban neuropatía por compresión del nervio cubital a nivel del codo, a cuatro se les realizó además transferencia del nervio cubital, dos subcutáneo y en dos se le realizó una polea con fascia flexora pronadora. Las complicaciones que se presentaron fueron: recidiva del dolor por insuficiencia del ligamento colateral medial (1/8) pacientes. Los resultados funcionales según escala de Conway fueron excelentes (5/8), bueno (2/8) y pobre (1/8). Conclusiones: el estrés repetido, la insuficiencia de los flexores pronadores y del ligamento colateral medial son las causas desencadenantes del síndrome de sobrecarga en valgo y extensión. La cirugía favorece el retorno a la actividad deportiva en la mayoría de los atletas(AU)

Introduction: valgus extension overload (posteromedial shock) is a type of injure that is relatively frequent in throwing athletes and may require surgical procedures to be performed so that the athlete can keep on competing. Objective: To early diagnose and adequately treat the valgus extension overload syndrome in athletes. Methods: a prospective, longitudinal and intervention study was conducted in high performance athletes operated on for valgus extension overload syndrome. The sample was made up of 8 male athletes aged 26 years as average (range of 22 to 29 years), who practiced baseball (five pitchers and one outfielder), weightlifting (one) and javelin throw (one). The minimal follow-up was 6 months and the maximum was 4 years, for a mean of 2.3 years. Results: eight patients were operated on, four of them presented with neuropathy from compressed cubital nerve at the elbow; four underwent transfer of their cubital nerve, two subcutaneous and two with a pulley with flexor pronator fascia. The most observed complication was pain relapse due to medial collateral ligament insufficiency in one patient. The functional results according to Conway's scale were excellent in 5 patients, good in two and unsatisfactory in just one patient. Conclusions: repeated stress, insufficiency in flexor pronators and in the medial collateral ligament were the causes that unleash the valgus extension overload syndrome. The surgical procedure helps most of the athletes to come back to their normal sports activity(AU)

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Severe anxiety symptomatology and HIV risk behavior among Hispanic injection drug users in Puerto Rico.

Despite an overall decrease in AIDS incidence in Puerto Rico, our studies continue to show high prevalence of HIV risk behaviors among injection drug users (IDUs). This study seeks to evaluate whether the occurrence of injection-related and sex-related HIV risk behaviors among IDUs in Puerto Rico varies with the presence of anxiety symptomatology. Subjects included 557 IDUs, recruited from street settings in poor neighborhoods in Puerto Rico. Symptoms of severe anxiety were reported by 37.1% of the study sample. Participants with severe anxiety symptoms were more likely to share needles, cotton, and rinse water; to pool money to buy drugs; and to engage in backloading, than those without severe anxiety symptoms. Participants with severe anxiety symptomatology were also more likely to practice unprotected vaginal or oral sex. The findings from this study alert HIV prevention and treatment programs to the need to address anxiety disorders within their programs.

Alcohol use among adolescents in Puerto Rico: the influence of physical and social neighborhood disorder.

INTRODUCTION: The characteristics of social settings are increasingly being recognized as important factors influencing the health of individuals. This study examines the association of neighborhood physical and social disorganization with alcohol consumption in a sample of adolescents 12- to 15-years-old residing in communities of the San Juan metropolitan area with high availability of illicit drugs. METHODS: The sampling frame was developed encompassing all census sectors in three municipalities of the San Juan metropolitan area with outdoor illegal drug-selling areas operating within them. Consent from parents and their adolescent offspring was obtained from 691 of these households for a response rate of 96%. Alcohol use was measured by asking adolescents if they had consumed alcohol during the last 12 months. Neighborhood social disorganization included hearing gunfire in the neighborhood, seeing neighbors selling stolen merchandise and drugs, vandalism, neighbors using alcohol and drugs, and seeing persons carrying weapons. Neighborhood physical disorganization included the presence of abandoned vehicles and buildings in the neighborhood, graffiti, and places where people go to inject drugs. RESULTS: Multiple logistic regression analysis revealed that older participants were more likely to use alcohol. Neighborhood social disorder was significantly associated with alcohol use. The strong positive gradient between neighborhood social disorder and alcohol use remained highly significant after controlling by sociodemographic characteristics. In contrast, neighborhood physical disorder was not significantly associated with alcohol use. CONCLUSION: These findings suggest that social signs of neighborhood disorganization have a more direct influence over adolescents' behaviors than the physical signs. Health professionals need to be cognizant of the strong effects that social environments have on adolescents and develop strategies to address these when intervening with adolescents.

[Intraventricular meningioma: case report in infancy]. / Meningioma intraventricular. Presentación de un caso en la infancia

Meningiomas are infrequent tumours in infancy but when they appear in this age group, the intraventricular location is more frequent than in adults. We report the case of a 5-year-old girl with intracranial hypertension and a VI nerve palsy. Computed tomography and magnetic resonance imaging of the brain revealed a tumoral lesion involving the right lateral ventricle with intense enhancement after contrast administration. It was completely resected through a mean temporal circunvolution route. Histological diagnosis was of atypical meningioma.

Meningioma intraventricular. Presentación de un caso en la infancia / Intraventricular meningioma: case report in infancy

Los meningiomas son tumores poco frecuentes en la infancia, pero, de presentarse en este grupo de edad, la localización intraventricular es más prevalente que en adultos. Presentamos el caso de una paciente de 5 años que debutó clínicamente con síndrome de hipertensión intracraneal con parálisis del VI par izquierdo. En la tomografía computarizada y en las imágenes de resonancia magnética se detectó una masa bien delimitada localizada en el interior del ventrículo lateral derecho. En ambas pruebas diagnósticas la tumoración captaba contraste de forma intensa y homogénea. La lesión se abordó quirúrgicamente a través de la circunvolución temporal media y fue extirpada totalmente. El studio anatomopatológico tipificó el tumor como meningioma atípico

Meningiomas are infrequent tumours in infancy but when they appear in this age group, the intraventricular location is more frequent than in adults. We report the case of a 5-year-old girl with intracranial hypertension and a VI nerve palsy. Computed tomography and magnetic resonance imaging of the brain revealed a tumoral lesion involving the right lateral ventricle with intense enhancement after contrast administration. It was completely resected through a mean temporal circunvolution route. Histological diagnosis was of atypical meningioma

Psychometric field study of the new haemophilia quality of life questionnaire for adults: the 'Hemofilia-QoL'.

Although there is a worldwide interest in the assessment of health-related quality-of-life (HRQoL) in haemophilia patients, no non-disease specific instruments (for adults) are readily available. In this paper, a haemophilia-specific quality-of-life assessment measure for adults (the Hemofilia-QoL questionnaire) has been developed and tested for psychometric properties in 121 adults with haemophilia living in Spain. The Hemofilia-QoL questionnaire is a self-report modular instrument that assesses nine relevant HRQoL domains for patients with haemophilia (e.g. physical health, daily activities, joint damage, pain, treatment satisfaction, treatment difficulties, emotional functioning, mental health, relationships and social activity). Psychometric examination involved the assessment of data quality, scaling assumptions, reliability (internal consistency and test-retest) and validity (concurrent; external clinical criterion and sensitivity). The Hemofilia-QoL 36-item version questionnaire had acceptable internal consistency and retest reliability values. The questionnaire shows excellent concurrent validity (with the SF-36 Health Survey) and external clinical criterion validity (haemophilia clinical status) and sensitivity (health status changes) as well. The Hemofilia-QoL is now available for adult assessment and is ready for use in clinical research in Spain.

Homelessness and HIV risk behaviors among drug injectors in Puerto Rico.

This report examines associations between homelessness and HIV risk behaviors among injection drug users (IDUs) in Puerto Rico. The study sample consisted of 557 IDUs who were not in treatment, recruited in inner-city neighborhoods of the North Metro Health Care Region. Subjects were categorized into three groups by residential status (last 30 days): housed, transitionally housed (living with friends, family, or others but considering themselves homeless), and on-the-street homeless (living on the street or in a shelter). Multiple logistic regression models were fitted to assess effects of residential status on each HIV risk behavior after adjusting for sociodemographic and drug-use related covariates. Transitionally housed and on-the-street homeless subjects made up 16% of the total sample. On-the-street homeless IDUs were more likely to test positive for HIV than were transitionally housed and housed IDUs. In the adjusted analysis, on-the-street homeless subjects were significantly more likely to share needles, share rinse water, and practice back loading than the other two groups. Sexual risk behaviors (last 30 days) were not significantly associated with residential status after adjustment. Findings from this study present an added challenge to drug treatment and HIV prevention and treatment programs, to provide services that can address the additional needs of drug users suffering the stressors of homelessness.

Factors associated with drug treatment dropout among injection drug users in Puerto Rico.

This study examined factors associated with drug treatment dropout among injection drug users (IDUs) in Puerto Rico, a group that has contributed significantly to the self-sustaining AIDS epidemic in the island since the mid-1980s. A total of 557 IDUs were recruited from communities in a semirural region of Puerto Rico, as part of a longitudinal study testing the efficacy of a two-facet intervention model, based on motivational interviewing. Of 124 IDUs who had entered drug treatment at follow-up, 33 (26.6%) dropped out before completing all recommended sessions. Multiple logistic regression analysis showed that age, homelessness, and speedball use were significantly associated with drug treatment dropout. Conversely, participants who received the two-facet intervention were significantly less likely to drop out of drug treatment. Receiving psychiatric services also reduced the odds of treatment dropout. Improving adherence to drug treatment and reducing dropout rates are complex processes that need to be addressed at the individual behavioral and social support levels, as well as the program process and resource levels.

HIV risk behaviors and alcohol intoxication among injection drug users in Puerto Rico.

This paper reports results of an analysis of the association between alcohol intoxication and injection and sexual HIV risk behaviors among 557 Hispanic heroin and cocaine injectors, not in treatment, who were recruited in poor communities in Puerto Rico. Subjects were part of a longitudinal prevention-intervention study aimed at reducing drug use and HIV risk behaviors. Participants reported a high prevalence of co-occurring conditions, particularly symptoms of severe depression (52%) and severe anxiety (37%), measured by Beck's Depression Index and Beck's Anxiety Index, respectively. Alcohol intoxication during the last 30 days was reported by 18% of participants. Associations were found between alcohol intoxication and both injection and sexual risk behaviors. In the bivariate analysis, subjects reporting alcohol intoxication were more likely to inject three or more times per day, pool money to buy drugs, share needles, and share cotton. They were also significantly more likely to have a casual or paying sex partner and to have unprotected sex with these partners. After adjustment, sharing needles and cotton, having sex with a paying partner or casual partner, and exchanging sex for money or drugs were significantly related to alcohol intoxication. HIV prevention programs, to be effective, must address alcohol intoxication and its relation to injection and sexual risk behaviors as a central issue in HIV prevention among drug injectors.

Effects of combined counseling and case management to reduce HIV risk behaviors among Hispanic drug injectors in Puerto Rico: a randomized controlled study.

This study examined the effectiveness of a combined counseling and case management behavioral intervention, using motivational interviewing strategies, in engaging Hispanic injection drug users in treatment and reducing drug use and injection-related HIV risk behaviors. Follow up data are presented on 440 (79.0%) of 557 randomized participants, 6 months after the initial interview. Subjects in the experimental arm were significantly less likely to continue drug injection independent of entering drug treatment, and were also more likely to enter drug treatment. Subjects in both arms who entered drug treatment were less likely to continue drug injection. Among subjects who continued drug injection, those in the experimental arm were significantly less likely to share needles. Confirming the outcomes of this study in other Hispanic sites and populations could be a critical step towards reducing factors that contribute to the self-sustaining HIV/AIDS epidemic in Puerto Rico and communities in the U.S. mainland.

Development of a new disease-specific quality-of-life questionnaire to adults living with haemophilia.

A haemophilia-specific health-related quality-of-life questionnaire (named 'Hemofilia-QoL') was developed to assess quality-of-life in adults with haemophilia, and was psychometrically tested. Seventy-three interviews with haemophilia patients and health care professionals were used to generate the items included in the questionnaire, and expert ratings on the items formulated were used to screen them for potential omission. This was followed by psychometric testing in a sample of 35 patients. Preliminary psychometric testing of the revised questionnaire version, which contains 10 domains (physical health, physical role, joint damage, pain, treatment satisfaction, emotional role, mental health, social support), showed acceptable reliability (alpha = 0.94 for the Hemofilia-QoL total score) and validity, and this will be examined in a subsequent study with a larger patient sample.

Determinants of health care use among Puerto Rican drug users in Puerto Rico and New York City.

This study was conducted to identify factors accounting for differences in health care and drug treatment utilization between Puerto Rican drug users residing in 2 separate locations. Survey findings from 334 drug users in Puerto Rico and 617 in New York City showed that those in Puerto Rico were 6 times less likely than their counterparts in New York to have used inpatient medical services and 13 to 14 times less likely to have used outpatient medical services or methadone. They also were less likely to have health insurance or past drug treatment. After site was controlled for, health insurance and previous use of physical or mental health services remained significant predictors of health care and drug treatment utilization during the study period. Although Puerto Rican drug users in Puerto Rico are not an ethnic minority, they reported significant disparities in health services use compared with Puerto Rican drug users in New York.