Simulación clínica para la rehabilitación de la mano en un anestesiólogo después de una lesión ocupacional: un estudio de caso / Patient simulation for hand therapy in an anesthesiologist after an occupational injury: A case study

Describir el uso de la simulación clínica como terapia de rehabilitación de la mano de una paciente anestesióloga que sufrió atrapamiento del pulgar derecho con la mesa quirúrgica y se le realizó un autoinjerto parcial del dedo del pie a la mano.En la semana 14 tras la cirugía se introdujo la terapia de simulación con tareas anestésicas simuladas y escenarios clínicos en lugar de la rehabilitación habitual. Las variables cuantificadas, tanto físicas, como funcionales y psicológicas, indicaron una mejoría durante y después de la intervención con simulación, que se mantuvo un mes después de la vuelta al trabajo.El uso de la simulación clínica en la rehabilitación en una paciente anestesióloga después de una lesión en la mano contribuyó a mejorar la amplitud de movimiento, la fuerza, la sensibilidad y las pruebas funcionales, y jugó un papel determinante en la reincorporación laboral para asumir las demandas de la práctica de la anestesia.(AU)

We described the use of clinical simulation for hand therapy in an anesthesiologist that accidentally suffered from entrapment with the surgical table in the right thumb and underwent a partial toe-to-hand autograft.At week 14 after surgery, the patient practiced anesthetic tasks and clinical scenarios using a patient simulator instead undergoing a regular occupational therapy regimen. Quantifiable physical, functional and psychological measures improved during and after the simulation intervention, and there was no decline one month after the patient returned to work.The use of clinical simulation as part of the rehabilitation process of an anesthesiologist after hand injury contributed to improving the range of motion, strength, sensibility, and functional tests. Overall, it played an important role in determining the worker's potential to withstand the demands of anesthesia practice.(AU)

[Patient simulation for hand therapy in an anesthesiologist after an occupational injury: A case study]. / Simulación clínica para la rehabilitación de la mano en un anestesiólogo después de una lesión ocupacional: un estudio de caso.

We described the use of clinical simulation for hand therapy in an anesthesiologist that accidentally suffered from entrapment with the surgical table in the right thumb and underwent a partial toe-to-hand autograft. At week 14 after surgery, the patient practiced anesthetic tasks and clinical scenarios using a patient simulator instead undergoing a regular occupational therapy regimen. Quantifiable physical, functional and psychological measures improved during and after the simulation intervention, and there was no decline one month after the patient returned to work. The use of clinical simulation as part of the rehabilitation process of an anesthesiologist after hand injury contributed to improving the range of motion, strength, sensibility, and functional tests. Overall, it played an important role in determining the worker's potential to withstand the demands of anesthesia practice.

Student Misbehaviour and School Climate: A Multilevel Study

This study examines how teacher perceptions of student misbehaviour correlate with their perceptions of school climate and student self-reports, using multi-informant two-level multilevel modelling. School climate questionnaires completed by 4,055 teachers and 16,017 students (1rd to 4th year of compulsory secondary education from 187 schools) showed that teachers' characteristics are marginally related to perceived disruption. Fair rules and support of students' families acted as protective factors, while a lack of educational leadership was a risk factor. Furthermore, the student variable of pro-violence messages from parents acted as a moderator for leadership and rules, while perceived coercive treatment from teachers acted as a moderator for family support of teachers

Esta investigación examina en qué medida la percepción del profesorado sobre el comportamiento disruptivo correlaciona con la percepción del clima escolar y los autoinformes del alumnado, mediante una modelización multi-informante y multinivel. Los cuestionarios sobre el clima escolar, cumplimentados por 4,055 profesores y 16,017 estudiantes (de 1º a 4º curso de Educación Secundaria Obligatoria pertenecientes a 187 centros educativos), muestran que las características de los profesores se relacionan solo marginalmente con la disrupción percibida. La existencia de unas reglas justas y el apoyo de las familias de los estudiantes se mostraron como factores de protección, mientras que la ausencia de un adecuado liderazgo en el equipo directivo aparecía como factor de riesgo. Además, los mensajes que los alumnos reciben de sus padres a favor de la violencia actuaron como moderadores del liderazgo y las reglas, mientras que el trato coercitivo de los profesores que percibían los estudiantes actuó de moderador del apoyo de la familia hacia el profesorado

Stereotactic body radiation therapy (SBRT) delays the emergence of castration resistance in patients with oligometastatic prostate cancer.

PURPOSE: To investigate whether bon e metastases-directed stereotactic body radiation therapy (SBRT) delays the emergence of castration resistance in patients with oligometastatic prostate cancer (OPC). METHODS AND MATERIAL: OPC is usually managed with androgen deprivation therapy (ADT). Migration to castration-resistant prostate cancer will inevitably occur in the majority of these patients. There are several strategies aimed to delay the emergence of castration resistance including intermittent ADT, second generation antiandrogens (abiraterone, enzalutamide) or metastases-directed SBRT. The present report describes two cases of patients with OPC that received SBRT 24 Gy/3Rx to the solitary bony lesion after ADT failure. RESULTS: Both cases showed complete and durable biochemical response for 13 and 17 months, respectively. CONCLUSIONS: SBRT can be used to delay the emergence of castration resistance and the need for systemic therapy when used after ADT failure.

Síndrome de Jacobsen (deleción parcial 11q) asociado a trombocitosis: presentación de un caso y revisión de la literatura científica / Jacobsen syndrome (partial 11q deletion) associated to thrombocytosis: report of a case and literature review

Introducción: El síndrome de Jacobsen se debe a una deleción parcial del brazo largo del cromosoma 11. En un 85% de los casos, la deleción ocurre de novo. Los signos más comunes incluyen retraso en el crecimiento pre/posnatal, retraso psicomotor y malformaciones, así como una dismorfia facial característica. Con frecuencia, desde el nacimiento existe una función plaquetaria anormal, una trombocitopenia o una pancitopenia. Aproximadamente un 20% de los pacientes fallece durante los 2 primeros años de vida. Caso clínico: Recién nacida a término, sin antecedentes familiares de interés, que presenta un fenotipo peculiar (pabellones auriculares pequeños, de implantación baja, puente nasal ancho, hipertelorismo, fisuras palpebrales inclinadas hacia abajo, boca «en carpa», microrretrognatia), fisura palatina, lesiones de aspecto petequial en tórax y muslo derecho, asociado a himen imperforado. Cariotipo 46,XX,del(11)(q14.1q23.3)dn, el estudio de ambos progenitores fue normal. Desde las 2 semanas de vida, la niña presentó una importante trombocitosis, con nula adquisición de los ítems madurativos. La paciente falleció a los 3 meses de vida, tras un accidente cerebrovascular hemorrágico espontáneo. Conclusiones: Las manifestaciones clínicas se relacionan con el tamaño de la deleción. Generalmente, el punto de rotura se localiza en 11q23.3. Entre las alteraciones hematológicas, la más frecuente es la trombopenia, aunque no fue así en esta paciente, que presentaba una trombocitosis. Esto parece deberse a que cuando la deleción afecta a la banda 11q24 se produce la pérdida del gen FLI-1, entre otros genes, que desempeñan un papel fundamental en la megacariopoyesis (AU)

Introduction: Jacobsen syndrome is due to partial deletion of the long arm of chromosome11. A de novo deletion occurs in 85% of cases. Most common signs include pre- and postnatal growth retardation, psychomotor delay, malformations and characteristic facial dysmorphism. Abnormal platelet function thrombocytopenia or pancytopenia are frequent from birth. Approximately, 20% of patients die during the first 2 years of life. Case report: Newborn female born at term, without any family history of congenital anomalies, presenting with peculiar phenotype (small and low-set ears, broad nasal bridge, hypertelorism, downslanting palpebral fissures, micro-retrognathia), carp-like mouth, cleft palate, petechial-like lesion in thorax and right thigh, associated to imperforate hymen. Karyotype 46,XX,del(11)(q14.1q23.3)dn, being normal for both her parents. Since the age of 2 weeks she had a marked thrombocytosis, with no acquisition of developmental milestones. The patient died at 3 months after a spontaneous hemorrhagic cerebral-vascular accident. Conclusions: Clinical manifestations of the syndrome are related to the size of the deletion. Generally, the breakpoint is located at 11q23.3. Among the hematological alterations the most frequent one is thrombopenia, unlike our patient, who had thrombocytosis. This seems to be due to the loss of FLI-1, among other genes with a key role in megakaryopoiesis, when the deletion affects the band 11q24 (AU)

Prescripción de benzodiacepinas en el anciano en diferentes niveles asistenciales: características y factores relacionados / Benzodiazepine prescription in the elderly in different health care levels: Characteristics and related factors

Objetivos. Conocer la prevalencia de uso y los factores relacionados con la prescripción de benzodiacepinas (BZD) en ancianos en la comunidad, hospital de agudos (HA) y una unidad de convalecencia geriátrica (UCO). Material y métodos. Estudio retrospectivo de 334 pacientes ingresados en una UCO que procedían de un HA. Se realizó una valoración geriátrica integral que incluía situación funcional y cognitiva previa a la hospitalización, al ingreso y al alta de UCO (índice de Barthel, índice de Lawton y Mini-Mental de Folstein), así como la comorbilidad (índice de Charlson), polifarmacia y situación social. Se compararon las proporciones de prescripción de esta muestra a lo largo de diferentes niveles asistenciales y se valoraron los factores relacionados con dicha prescripción mediante el test de la chi al cuadrado. Resultados. La prevalencia de uso de BZD en la comunidad fue del 23,6%, siendo el sexo femenino y la polifarmacia factores relacionados con la prescripción. Durante el ingreso en HA esta proporción aumentó al 38,6% y tras la estancia en UCO descendió al 21,9%. Los factores asociados con la prescripción de BZD en el HA fueron el sexo femenino, la polifarmacia y el diagnóstico relacionado con un problema osteoarticular-fractura, y en la UCO el sexo femenino y la polifarmacia. Conclusiones. La prevalencia de uso de BZD fue alta entre la población anciana en todos los niveles asistenciales (domicilio, HA y UCO) y uno de los factores asociados significativamente a su prescripción fue la polifarmacia. Dicha prescripción se vio incrementada durante la hospitalización en unidades de agudos por procesos médicos y/o quirúrgicos (AU)

Objectives. To determine the prevalence of benzodiazepine (BZD) prescription and the factors related to prescribing them in the elderly in the community, in an acute general hospital (AH) and in a convalescence geriatric unit (CGU). Material and methods. Retrospective study of 334 CGU inpatients discharged from an AH. A comprehensive geriatric assessment included functional and cognitive evaluation before hospitalization, at admission and at discharge from CGU (Barthel index, Lawton index and Folstein Mini-Mental State Examination), as well as comorbidity (Charlson index), polypharmacy and social situation. The percentage of benzodiazepine prescriptions at the different healthcare levels was compared and their related factors were evaluated (Chi-squared test). Results. The prevalence of benzodiazepine prescriptions in the community was 23.6%, and being female and polypharmacy were related factors to prescribing at this level. During AH admission, this proportion increased up to 38.6%, and after CGU admission decreased to 21.,9%. Factors related to prescription in AH were, being female, polypharmacy and osteoarticular-fracture related diagnosis, and in CGU, being female and polypharmacy. Conclusions. The prevalence of benzodiazepine prescribing was high among elderly people at every healthcare level (community, AH and CGU), and polypharmacy was one of the significant factors associated with prescribing. This prescribing was increased during AH admission due to a medical or surgical process (AU)

[Benzodiazepine prescription in the elderly in different health care levels: characteristics and related factors]. / Prescripción de benzodiacepinas en el anciano en diferentes niveles asistenciales: características y factores relacionados.

OBJECTIVES: To determine the prevalence of benzodiazepine (BZD) prescription and the factors related to prescribing them in the elderly in the community, in an acute general hospital (AH) and in a convalescence geriatric unit (CGU). MATERIAL AND METHODS: Retrospective study of 334 CGU inpatients discharged from an AH. A comprehensive geriatric assessment included functional and cognitive evaluation before hospitalization, at admission and at discharge from CGU (Barthel index, Lawton index and Folstein Mini-Mental State Examination), as well as comorbidity (Charlson index), polypharmacy and social situation. The percentage of benzodiazepine prescriptions at the different healthcare levels was compared and their related factors were evaluated (Chi-squared test). RESULTS: The prevalence of benzodiazepine prescriptions in the community was 23.6%, and being female and polypharmacy were related factors to prescribing at this level. During AH admission, this proportion increased up to 38.6%, and after CGU admission decreased to 21.,9%. Factors related to prescription in AH were, being female, polypharmacy and osteoarticular-fracture related diagnosis, and in CGU, being female and polypharmacy. CONCLUSIONS: The prevalence of benzodiazepine prescribing was high among elderly people at every healthcare level (community, AH and CGU), and polypharmacy was one of the significant factors associated with prescribing. This prescribing was increased during AH admission due to a medical or surgical process.

Incipient post-zygotic barrier in a model system of ecological speciation with gene flow.

The role of post-zygotic isolation in nonallopatric ecological speciation is still mostly unknown and information on the nature and strength of these barriers in well-known speciation models is essential for a deeper understanding of such processes. The Galician ecotypes of the marine snail Littorina saxatilis represent one of the best studied cases of nonallopatric ecological speciation. Here, we test the existence of incipient post-zygotic isolation by comparing the fertility of male hybrids with that of both pure forms [ridged and banded (RB) and smooth and unbanded (SU) ecotypes]. We analysed the degree of sperm DNA fragmentation (SDF) of individuals morphologically classified as RB, SU and hybrids, sampled from two locations. SDF analyses were chosen to study sperm quality because, in other animal species, SDF rates correlate with important parameters for speciation research, such as fertilization and abortion rates and viability of adult progeny. In the present work, hybrids showed significantly higher SDF rates than RB and SU males in one location and significantly higher variances in both locations. These results suggest the existence of an incipient post-zygotic barrier, the strength of which may vary across the Galician shore, and highlight the potential of SDF analyses for speciation research.

Diagnóstico comunitario mediante técnicas cualitativas de las expectativas y vivencias en salud de una zona necesitada de transformación social / Community diagnosis using qualitative techniques of expectations and experiences in a health area in need of social transformation

Objetivo: Conocer las opiniones, vivencias y expectativas sobre la atención prestada por el Sistema Sanitario Público Andaluz (SSPA) de los usuarios de una zona urbana necesitada de transformación social (ZNTS). Diseño: Metodología cualitativa, estudio exploratorio. Emplazamiento: Zona básica de salud urbana (16.000 habitantes; 40% ZNTS). Participantes: Usuarios del SSPA mediante muestreo intencional de usuarios y líderes de la comunidad. Criterios de homogeneidad: edad. Criterios de heterogeneidad: sexo, frecuentación, activo/pensionista, nivel cultural/económico. Intervenciones principales: Técnicas conversacionales registradas mediante videograbación y moderadas por una socióloga (grupos de discusión para usuarios y entrevistas en profundidad para líderes sociales). Análisis con transcripción literal de los discursos, codificación, triangulación de categorías y obtención de resultados. Resultados: Siete grupos (43 participantes; 58% ZNTS) y 6 líderes sociales. Se desea continuidad en la atención y libre elección de profesionales, criticando cambios sin información previa y la discontinuidad atención primaria/hospitalaria. Hay mala accesibilidad física por el entorno urbano y críticas a los servicios de admisión y los trámites burocráticos; la cita previa y la receta electrónica son mejoras pero solicitan más derivaciones y revisiones hospitalarias. Hay buena valoración de los profesionales (atención primaria-mayor cercanía, hospital-mayor capacidad técnica). Se precisa mejorar la formación de enfermería y la rapidez de la asistencia urgente. Hay falta de liderazgo en la organización del SSPA, muy fragmentada. Se conoce una oferta de servicios centrada en la demanda asistencial, siendo poco difundidas otras actividades. Conclusión: El SSPA debe incorporar las opiniones y expectativas de las comunidades en riesgo social para una mejora real de la calidad asistencial (AU)

Objective: To know the views, experiences and expectations of care provided by the Andalusian Public Health System (SSPA) of users of an urban area in need of social transformation (ZNTS). Design: Qualitative methodology (exploratory study). Location: Urban basic health zone (16,000 inhabitants, 40% ZNTS). Participants: Purposive sampling of users of SSPA and community leaders. Homogeneity criteria: age. Heterogeneity criteria: sex, frequency, active/pensioner, level cultural/economic. Main interventions: Conversational techniques recorded by videotape and moderated by a sociologist (user dicussion groups and in-depth interviews for community leaders). Analysis: transcription of speeches, coding, categories triangulation and final outcome. Results: Seven groups (43 participants, 58% ZNTS) and 6 leaders. They want continuity of care and choice of professionals, but not the medical change without information and attention's discontinuity primary care/hospital. There's bad physical accesibility by the urban environment in the ZNTS and is criticized admission services and paperwork; the programmed appointment and the electronic prescriptions are improvements but asking more hospital referrals and reviews. There's good appreciation of the professionals (primary care-closer, hospital-greater technical capacity). It needs to improve nursing education and speed of emergency assistance. There's a lack of leadership in the system organization, very fragmented. They know a range of services focusing on the demand for care; other health activities not spread to the users. Conclusion; The SSPA should incorporate the views and expectations of communities in social risk to a real improvement in the quality of care (AU)

The role of local ecology during hybridization at the initial stages of ecological speciation in a marine snail.

Hybrid zones of ecologically divergent populations are ideal systems to study the interaction between natural selection and gene flow during the initial stages of speciation. Here, we perform an amplified fragment length polymorphism (AFLP) genome scan in parallel hybrid zones between divergent ecotypes of the marine snail Littorina saxatilis, which is considered a model case for the study of ecological speciation. Ridged-Banded (RB) and Smooth-Unbanded (SU) ecotypes are adapted to different shore levels and microhabitats, although they present a sympatric distribution at the mid-shore where they meet and mate (partially assortatively). We used shell morphology, outlier and nonoutlier AFLP loci from RB, SU and hybrid specimens captured in sympatry to determine the level of phenotypic and genetic introgression. We found different levels of introgression at parallel hybrid zones and nonoutlier loci showed more gene flow with greater phenotypic introgression. These results were independent from the phylogeography of the studied populations, but not from the local ecological conditions. Genetic variation at outlier loci was highly correlated with phenotypic variation. In addition, we used the relationship between genetic and phenotypic variation to estimate the heritability of morphological traits and to identify potential Quantitative Trait Loci to be confirmed in future crosses. These results suggest that ecology (exogenous selection) plays an important role in this hybrid zone. Thus, ecologically based divergent natural selection is responsible, simultaneously, for both ecotype divergence and hybridization. On the other hand, genetic introgression occurs only at neutral loci (nonoutliers). In the future, genome-wide studies and controlled crosses would give more valuable information about this process of speciation in the face of gene flow.

[Community diagnosis using qualitative techniques of expectations and experiences in a health area in need of social transformation]. / Diagnóstico comunitario mediante técnicas cualitativas de las expectativas y vivencias en salud de una zona necesitada de transformación social.

OBJECTIVE: To know the views, experiences and expectations of care provided by the Andalusian Public Health System (SSPA) of users of an urban area in need of social transformation (ZNTS). DESIGN: Qualitative methodology (exploratory study). LOCATION: Urban basic health zone (16,000 inhabitants, 40% ZNTS). PARTICIPANTS: Purposive sampling of users of SSPA and community leaders. Homogeneity criteria: age. Heterogeneity criteria: sex, frequency, active/pensioner, level cultural/economic. MAIN INTERVENTIONS: Conversational techniques recorded by videotape and moderated by a sociologist (user dicussion groups and in-depth interviews for community leaders). ANALYSIS: transcription of speeches, coding, categories triangulation and final outcome. RESULTS: Seven groups (43 participants, 58% ZNTS) and 6 leaders. They want continuity of care and choice of professionals, but not the medical change without information and attention's discontinuity primary care/hospital. There's bad physical accesibility by the urban environment in the ZNTS and is criticized admission services and paperwork; the programmed appointment and the electronic prescriptions are improvements but asking more hospital referrals and reviews. There's good appreciation of the professionals (primary care-closer, hospital-greater technical capacity). It needs to improve nursing education and speed of emergency assistance. There's a lack of leadership in the system organization, very fragmented. They know a range of services focusing on the demand for care; other health activities not spread to the users. CONCLUSION: The SSPA should incorporate the views and expectations of communities in social risk to a real improvement in the quality of care.

A highly specific coding system for structural chromosomal alterations.

The Spanish Collaborative Study of Congenital Malformations (ECEMC, from the name in Spanish) has developed a very simple and highly specific coding system for structural chromosomal alterations. Such a coding system would be of value at present due to the dramatic increase in the diagnosis of submicroscopic chromosomal deletions and duplications through molecular techniques. In summary, our new coding system allows the characterization of: (a) the type of structural anomaly; (b) the chromosome affected; (c) if the alteration affects the short or/and the long arm, and (d) if it is a non-pure dicentric, a non-pure isochromosome, or if it affects several chromosomes. We show the distribution of 276 newborn patients with these types of chromosomal alterations using their corresponding codes according to our system. We consider that our approach may be useful not only for other registries, but also for laboratories performing these studies to store their results on case series. Therefore, the aim of this article is to describe this coding system and to offer the opportunity for this coding to be applied by others. Moreover, as this is a SYSTEM, rather than a fixed code, it can be implemented with the necessary modifications to include the specific objectives of each program.

E2F1 loss induces spontaneous tumour development in Rb-deficient epidermis.

The specific ablation of Rb1 gene in epidermis (Rb(F/F);K14cre) promotes proliferation and altered differentiation but does not produce spontaneous tumour development. These phenotypic changes are associated with increased expression of E2F members and E2F-dependent transcriptional activity. Here, we have focused on the possible dependence on E2F1 gene function. We have generated mice that lack Rb1 in epidermis in an inducible manner (Rb(F/F);K14creER(TM)). These mice are indistinguishable from those lacking pRb in this tissue in a constitutive manner (Rb(F/F);K14cre). In an E2F1-null background (Rb(F/F);K14creER(TM); and E2F1(-/-) mice), the phenotype due to acute Rb1 loss is not ameliorated by E2F1 loss, but rather exacerbated, indicating that pRb functions in epidermis do not rely solely on E2F1. On the other hand, Rb(F/F);K14creER(TM);E2F1(-/-) mice develop spontaneous epidermal tumours of hair follicle origin with high incidence. These tumours, which retain a functional p19(arf)/p53 axis, also show aberrant activation of ß-catenin/Wnt pathway. Gene expression studies revealed that these tumours display relevant similarities with specific human tumours. These data demonstrate that the Rb/E2F1 axis exerts essential functions not only in maintaining epidermal homoeostasis, but also in suppressing tumour development in epidermis, and that the disruption of this pathway may induce tumour progression through specific alteration of developmental programs.

Motivaciones para el consumo de tabaco entre los adolescentes de un instituto urbano / Motivations for tobacco consumption among adolescents in an urban high school

Objetivo Conocer las motivaciones (actitudes, creencias y experiencias) de los adolescentes para el consumo de tabaco. Método Diseño cualitativo con videograbación de seis grupos de discusión (6-8 adolescentes, 50 minutos), curso escolar 2008/09. Muestreo intencional de adolescentes (12-18 años) de un instituto urbano de clase media (Jaén-España), usando el nivel educativo como criterio de homogeneidad y el sexo/consumo como criterio de heterogeneidad. Análisis de contenido: codificación, triangulación de categorías y obtención/verificación de resultados. Resultados Cuarenta y cuatro adolescentes, 54% varones. Fumar relaja y mejora la imagen personal: da seguridad (chicos) y mejora las relaciones con el sexo opuesto, además de controlar el peso (chicas). La familia favorece el tabaquismo por imitación de comportamientos, aunque no lo normaliza. Los amigos constituyen un grupo de presión para el inicio/mantenimiento del consumo. El inicio de la educación secundaria marca el principio del consumo experimental. La sociedad suele normalizar el consumo y es fácil para los menores de edad comprar tabaco. Los universitarios son un modelo a seguir, con libertad para el consumo. Piden ejemplo de abstinencia a progenitores y educadores/sanitarios, dicen estar bien informados, pero recuerdan sólo mensajes impactantes. De forma unánime indican que el tabaco provoca adicción, pero de manera proporcional al tiempo de consumo; sólo les preocupan los síntomas inmediatos provocados por el tabaquismo. Los adolescentes fumadores relacionan el policonsumo con los momentos de ocio. Conclusiones El estudio aporta motivos potencialmente útiles para mejorar la intervención antitabaco en los adolescentes. La influencia de los amigos, las actitudes parentales, la accesibilidad al tabaco y los síntomas de dependencia parecen ser los factores más relevantes(AU)

Objective To determine the motivations (attitudes, beliefs and experiences) for tobacco consumption among adolescents. Methods This study was based on qualitative methodology using six 50-minute discussion groups with 6-8 adolescents per group during the 2008/09 school year. Purposive sampling was performed of 12-18 year-old adolescents attending a middle-class urban school (Jaén, Spain). The sample was stratified by educational level as the homogeneity criterion and gender and tobacco consumption as the heterogeneity criterion. Content analysis consisted of coding, triangulation of categories and obtaining and verifying the results .Results There were 44 adolescents (54% male). The participants reported that smoking relaxed and improved self-image, providing security (boys) and improving relations with the opposite sex, as well as weight control (girls). The family encouraged smoking by providing a model to imitate, although many adolescents hid their smoking from their families. Friends constituted a pressure group to start or continue smoking. Starting secondary school marked the beginning of experimental use. Society tended to accept consumption and buying tobacco was easy for minors. University students were a role model and were free to smoke. The adolescents looked to their parents and educators/health workers to provide a model of abstinence and reported that they were well informed but only remembered powerful messages. Participants unanimously indicated that tobacco causes addiction, but in proportion to the duration of consumption, and were concerned only with the immediate symptoms caused by smoking. Teenage smokers associated multiple drug use with leisure time. Conclusions This study provides useful data on motivation that could be used to improve smoking prevention interventions among adolescents. The most important factors seem to be peer influence, parental attitudes, easy access to tobacco and symptoms of dependence (AU)

[Motivations for tobacco consumption among adolescents in an urban high school]. / Motivaciones para el consumo de tabaco entre los adolescentes de un instituto urbano.

OBJECTIVE: To determine the motivations (attitudes, beliefs and experiences) for tobacco consumption among adolescents. METHODS: This study was based on qualitative methodology using six 50-minute discussion groups with 6-8 adolescents per group during the 2008/09 school year. Purposive sampling was performed of 12-18 year-old adolescents attending a middle-class urban school (Jaén, Spain). The sample was stratified by educational level as the homogeneity criterion and gender and tobacco consumption as the heterogeneity criterion. Content analysis consisted of coding, triangulation of categories and obtaining and verifying the results. RESULTS: There were 44 adolescents (54% male). The participants reported that smoking relaxed and improved self-image, providing security (boys) and improving relations with the opposite sex, as well as weight control (girls). The family encouraged smoking by providing a model to imitate, although many adolescents hid their smoking from their families. Friends constituted a pressure group to start or continue smoking. Starting secondary school marked the beginning of experimental use. Society tended to accept consumption and buying tobacco was easy for minors. University students were a role model and were free to smoke. The adolescents looked to their parents and educators/health workers to provide a model of abstinence and reported that they were well informed but only remembered powerful messages. Participants unanimously indicated that tobacco causes addiction, but in proportion to the duration of consumption, and were concerned only with the immediate symptoms caused by smoking. Teenage smokers associated multiple drug use with leisure time. CONCLUSIONS: This study provides useful data on motivation that could be used to improve smoking prevention interventions among adolescents. The most important factors seem to be peer influence, parental attitudes, easy access to tobacco and symptoms of dependence.

Pautas de prevención de defectos congénitos con especial referencia a los niveles primario y secundario. Guías de actuación preventiva desde la atención primaria / Guidelines for the prevention of congenital defects, particularly at primary and secondary level. Prevention guidelines from Primary Care

La prevención de defectos congénitos (DC) no difiere en esencia de la que se sigue para cualquier otra enfermedad. En el primer nivel, el de la prevención primaria, se trata de impedir que se produzca el trastorno. El segundo nivel se aplica cuando el DC ya se ha producido, y consiste en curar la enfermedad o, cuando ello no es posible, como en la mayoría de los DC, evitar que se agrave. Este nivel se basa en el diagnóstico precoz y correcto de la enfermedad, y en instaurar inmediatamente el tratamiento adecuado y las medidas correctoras o paliativas. El tercer nivel se instaura una vez que han fracasado los 2 anteriores y se centra en medidas que mejoren la autonomía y la calidad de vida del paciente (integración social y laboral de los afectados, supresión de barreras arquitectónicas, etc.). Por último, existe un «cuarto nivel de prevención» que consiste en evitar toda sobreactuación médica, en la que se someta al paciente a pruebas innecesarias que no sólo no le ayudan sino que, además, pueden generarle efectos adversos añadidos incluyendo problemas psíquicos. En este artículo se resumen las medidas más relevantes que se deberían implantar desde el colectivo de médicos de atención primaria, para conseguir todos los niveles de prevención de DC y, especialmente, de prevención primaria (AU)

There is essentially no difference in the prevention of congenital defects (CD) from that of any other disease. Primary prevention consists of preventing the causes that produce the disease. Secondary prevention is applied when the CD has already occurred, and consists of curing the disease, or when this is not possible, as in the majority of CD, to prevent it getting worse. This level is based on the early and correct diagnosis of the disease, and initiating immediate and appropriate treatment and corrective or palliative measures. The third level is started when the previous ones fail, and is focussed on measures that improve independence and quality of life (social and occupational integration of those affected, removal of architectural obstacles, etc.). Lastly, there is a “fourth level of prevention”, which consists of avoiding over-medication, in which the patient is subjected to unnecessary tests, which not only do not help the patient, but can also produce added adverse effects, including psychiatric problems. This article summarises the most important measures that Primary Care doctors should introduce to achieve all levels of CD prevention, and particularly primary prevention (AU)

Ejemplos clínicos de alteraciones crípticas del ADN, y guías para sospechar que un niño pueda tener alguna alteración críptica o molecular / Examples of DNA cryptic alterations, and guidelines for suspecting a child may have cryptic genetic or molecular alterations

No siempre es posible establecer el diagnóstico de un recién nacido con defectos congénitos. En general esto se debe a varias causas fundamentales: a) porque el conjunto de manifestaciones clínicas que presentan son aún de causa desconocida; b) porque los síndromes que ya se conocen tienen una frecuencia tan baja que no son fáciles de reconocer cuando no se tiene experiencia previa; c) porque no existe especificidad alguna entre una causa y un defecto; d) porque algunos solo presentan rasgos dismórficos que solo con gran experiencia pueden ser evaluados, ya que la mayoría de esos rasgos se encuentran en la población general sana, y e) porque muchos de ellos son de aparición evolutiva siendo de apariencia normal al nacimiento. Sin embargo, hoy se sabe que algunos de estos síndromes son producidos por alteraciones debidas a pérdidas de porciones cromosómicas tan pequeñas que no se detectan por citogenética de alta resolución (son crípticas para estas técnicas) o a mutaciones conocidas de ciertos genes. Como muchos de estos niños van a ir presentando sus manifestaciones durante la infancia, van a ser atendidos por los médicos de atención primaria, por lo que es esencial que dispongan de unas pequeñas guías para su reconocimiento y su manejo adecuado. En este artículo se explican las diferentes formas de presentación, sus características, las técnicas con las que se pueden diagnosticar, así como los síntomas que pueden alertar sobre estos síndromes y forma de actuar. Porque de la identificación precoz depende mucho el pronóstico y la información a la familia (AU)

It is not always possible to establish the diagnosis of a newborn with congenital defects. In general, this is due to several main reasons: a) because the group of clinical signs that they show are still of an unknown cause; b) because the already known syndromes are such a low frequency that they are not easy to recognise when there is no previous experience; c) because there is no specificity between a cause and a defect; d) because some only present with dysmorphic characteristics that can only be assessed by someone with wide experience since the majority of these characteristics are found in the general healthy population; and e) because many of them appear over time, appearing normal at birth. However, it is now known that some of these syndromes are caused by changes due to the loss of chromosome portions so small that they are not detected by high resolution cytogenetics (they are cryptic for these techniques), or to known mutations in certain genes. As many of these children will present with their signs during childhood and are going to be seen by Primary Care doctors, it is essential that small guises are available to recognise them and manage them appropriately. This article explains the different forms of presentation, their technical characteristics by which they can be diagnosed, as well as the symptoms that may make us aware of these syndromes and how to act. The prognosis very much depends on early identification and information to the family (AU)

Resumen de la evolución de las técnicas de citogenética y genética molecular para la identificación de las alteraciones genéticas del desarrollo embrionario / Review of the development of molecular cytogenetic and genetic techniques for identifying genetic anomalies in embryonic development

Desde la última mitad del siglo xx se ha producido un espectacular progreso en el conocimiento sobre el material genético humano: se han caracterizado los cromosomas, se ha identificado la secuencia completa del genoma y se ha relacionado un gran número de alteraciones de la estructura y secuencia del ADN con todo tipo de enfermedades, tanto hereditarias como no hereditarias (especialmente asociadas a cáncer). Este desarrollo ha venido propiciado, y acompañado, por una gran cantidad de técnicas para su estudio, muchas de las cuales se han trasladado a la investigación y la caracterización de la carga genética de los seres humanos, y a su aplicación en la práctica clínica para el diagnóstico de ciertas patologías. Ello ha generado que, además de los estudios moleculares al nivel de identificación de la mutación de un gen, la citogenética convencional se haya ampliado a la detección de alteraciones extremadamente pequeñas de la estructura del cromosoma, dando lugar a una nueva área de diagnóstico denominada citogenética molecular. Esta incluye diversas técnicas que detectan alteraciones pequeñas en orden decreciente, desde las micro-deleciones y micro-duplicaciones detectables por sondas fluorescentes (FISH), hasta los arrays genómicos y los arrays basados en hibridación genómica comparada (CGH) que detectan cambios aun más pequeños. Sin embargo, debido a su alta resolución, los arrays son capaces de identificar variaciones en el ADN cuyo significado, en muchos casos, es aun incierto. Esto implica que incluso algunas de las técnicas que más se están utilizando en la actualidad, como la CGH array, precisen de una cuidadosa evaluación antes de ofrecer un diagnóstico (AU)

Spectacular progress has been made in the knowledge of human genetic material since the middle of the last century: the chromosomes have been characterised; the complete sequence of the genome has been identified. Also, all types of diseases hereditary and non-hereditary diseases (especially cancers) have been associated to changes in DNA structure and sequence. These developments have been accompanied by a great number of techniques, which have led to the investigation and characterisation of the human genetic load, and its application in clinical practice for the diagnosis of certain diseases. This has meant that, besides studies at molecular level for identifying a gene mutation, conventional cytology has extended to the detection of extremely small changes in the structure of the chromosome, giving rise to a new area of diagnosis called molecular cytogenetics. This includes various techniques that detect small changes, in decreasing order, from microdeletions and microduplications detectable by fluorescent probes (FISH), to genomic arrays and arrays based on compared genomic (CGH) which detect even smaller changes. However, due to their high resolution, arrays are capable of identifying variations in DNA, which in many cases its importance is still uncertain. This implies that even some of the most common techniques currently used, such as CGH, require a careful evaluation before offering a diagnosis (AU)

Resonancia magnética de la osteonecrosis espontánea de la rodilla: ¿existe un proceso agudo o crónico predisponente? / Can MRI determine whether acute or chronic processes predisposing conditions are present in spontaneous osteonecrosis of the knee?

Objetivo. Analizar la posible etiología subyacente de la osteonecrosis (ON) espontánea de la rodilla en adultos, según su comportamiento en la resonancia magnética (RM): lesión aguda (fracturas por insuficiencia) o crónica (degeneraciones artrósicas). Material y método. Se realizó un estudio retrospectivo en el que se evaluaron las RM de rodillas de 48 pacientes que cumplían criterios de ON espontánea. En total, se incluyeron 51 lesiones subcondrales, que se dividieron en 2 grupos según la presencia de imágenes lineales (grupo A) o no (grupo B). Recogimos la localización y el tamaño de las lesiones, su intensidad de señal, su relación con el edema óseo, la rotura meniscal ipsolateral y las anomalías del cartílago adyacente, así como la existencia de artrosis. Resultados. Estudiamos a 28 hombres y a 20 mujeres con una edad media de 55,1±18,0 años. La morfología más frecuente fue la lineal (grupo A) frente a la no lineal (grupo B) (el 58,8 y el 41,2%, respectivamente). En ambos grupos, la localización más frecuente fue el cóndilo femoral interno (el 56,7% en el grupo A y el 52,4% en el grupo B), y la intensidad de señal predominante (88,2%) fue hipointensa en T1 y DP con supresión grasa. El tamaño medio en milímetros de las lesiones en los diámetros anteroposterior y transversal fue en el grupo A de 11,9±3,6×9,4±3,9 y en el grupo B de 10,9±5,1 x 10,5±4,5. El edema óseo predominante fue grave (grado ii–iii) en el grupo A y leve (grado 0–i) en el grupo B (p=0,033). Los defectos del cartílago ipsolateral a la lesión subcondral fueron superiores en el grupo B que en el grupo A (el 76,2 y el 56,7%, respectivamente; p=0,33), mientras que la incidencia de rotura meniscal ipsolateral fue similar en ambos grupos (el 56,7% en el grupo A y el 57,1% en el grupo B; p=0,97). Conclusión: Al conocer los hallazgos de la ON espontánea de la rodilla en la RM y valorar otros datos (tipo de lesión, edema óseo, rotura meniscal y defectos del cartílago ipsolateral), podemos intentar determinar un proceso primario predisponente. Las lesiones lineales podrían relacionarse con un proceso agudo (fracturas por insuficiencia) y las no lineales con un proceso crónico (artrosis) (AU)

Objective. To analyze possible underlying causes of spontaneous osteonecrosis of the knee in adults in function of the lesion's behavior on magnetic resonance imaging (MRI): acute lesion (insufficiency fractures) or chronic lesion (osteoarthritic degeneration). Material and methods. We retrospectively evaluated knee MRI studies in 48 patients who fulfilled criteria for spontaneous osteonecrosis. A total of 51 subchondral lesions were included and classified in two groups: those in which linear images were present (Group A) and those in which linear images were not present (Group B). We recorded the location and size of the lesions, their signal intensity, their relation with bone edema, ipsilateral meniscal tear and abnormalities in the adjacent cartilage, as well as the presence of osteoarthritis. Results. We studied 28 men and 20 women (mean age, 55.1±18.0 years). Linear images were present in 58.5% of lesions (group A) and absent in 41.2% (group B). The most common location in both groups was the internal femoral condyle (56.7% in group A and 52.4% in group B), and 88.2% of lesions were hypointense on T1-weighted and fat suppressed proton density sequences. The mean size of the anteroposterior and transversal diameters was 11.9±3.6×9.4±3.9mm in group A and 10.9±5.1×10.5±4.5mm in group B. The predominant bone edema was severe (grade 2–3) in group A and mild (grade 0–1) in group B (p=0.033). Defects in the cartilage ipsilateral to the subchondral lesion were more common in group B than in group A, although this difference was not significant (76.2% and 56.7%, respectively; p=0.33). The frequency of ipsilateral meniscal tear was similar in the two groups (56.7% in group A and 57.1% in group B; p=0.97). Knowing the MRI findings for spontaneous osteonecrosis and evaluating other data (type of lesion, bone edema, meniscal tear, and ipsilateral cartilage defects) can help determine the primary predisposing process. Linear lesions might be related to an acute process (insufficiency fractures) and non-linear lesions might be related to a chronic process (osteoarthritis) (AU)