[Spanish validation of the Autonomic Standards Assessment Form in spinal cord injuries]. / Validación española del cuestionario Autonomic Standards Assessment Form en la lesión medular.

INTRODUCTION AND OBJECTIVES: Autonomic nervous system (ANS) dysfunction in patients with spinal cord injury (SCI) severely impacts morbidity and mortality. However, research initiatives aiming to gain insight into the direct impact of ANS dysfunction on health outcomes in persons with SCI are still lacking. Thus, this study had 2main objectives: 1) to translate into Spanish the revised edition of the International Standards on documentation of remaining Autonomic Function after SCI (ISAFSCI), and 2) to describe the impact of ANS dysfunction in a sample of SCI patients. MATERIAL AND METHODS: Cross-sectional observational pilot study in 51 traumatic SCI patients (> 1 year after injury). Demographic, medical and ISAFSCI data were studied. RESULTS: The Spanish version of the ISAFSCI showed that the most altered systems in the sample were sweating control (above-lesion hyperhidrosis in 33.3%; below-lesion hyperhidrosis in 17.6%; below-lesion hypohidrosis in 21.6%) and temperature control (hyperthermia in 76.5%). In addition, 74.5% of the sample had complete loss of control of the lower urinary tract, and 82.4% had no control of the bowel. Finally, genital arousal was reflex in 47.1% and orgasm and ejaculation were reduced or altered in most of the patients (92.2% and 84.3%, respectively). CONCLUSION: The Spanish version of the ISAFSCI is a useful and practical tool, and can be employed in clinical practice to assess ANS function in patients with SCI. Understanding the role of ANS in persons with SCI is crucial to improve their health status and reduce secondary complications post-SCI, and consequently help to improve the clinical management in these individuals.

Comorbidity and physical activity in people with paraplegia: a descriptive cross-sectional study.

STUDY DESIGN: Descriptive cross-sectional study. SETTING: The study was conducted in the Spinal Cord Injury Unit of the University Vall d'Hebron Hospital and in the Physical Education and Sports Department of the University of Valencia. OBJECTIVES: The aim of this study was to quantify the presence of comorbidities in spinal cord injury (SCI) subjects who did or did not perform regular physical activity (PA) and to identify the relationship between PA and the level of comorbidity. METHODS: The sample consisted of patients with complete motor SCI (T2-T12), who were fitted with an accelerometer attached to the non-dominant wrist for a period of 1 week. The clinical and blood analytic variables were selected by an expert panel. RESULTS: In the exploratory analysis, we have found differences in the total number of pathologies between active and inactive patients, with fewer total pathologies in the active patient group. An association was found between the PA level and diabetes mellitus (; P=0.047; φ=0.25). We also observed an association between the cardioprotector level of high-density lipoprotein (HDL)-cholesterol and PA level (; P=0.057; Φ0.24). CONCLUSIONS: Our results suggest that patients considered active showed lower total comorbidity than inactive patients and higher protection levels against developing cardiovascular comorbidity.

Physical and Psychosocial Functions of Adults with Lower Limb Congenital Deficiencies and Amputations in Childhood.

Objectives. (1) To describe the epidemiological and medical features of a sample with LLA and LLD in childhood and (2) to explore their relationship with subsequent physical and psychosocial functions in adulthood. Methods. Cross-sectional survey. Demographics, medical data, Locomotor Capabilities Index (LCI), and Discomfort-Engagement in Everyday Activities Involving Revealing the Body Scale (D-EEARB) were collected from thirty-two adults who suffered from LLA in childhood or LLD. Results. Most of the sample (53.1% males) was working (84.4%), living independently (75%), and single (75%). Mean age was 33.16 (SD = 7.64, range 18-50). Leading causes for LLA were traumatic (40.6%) and oncologic (25%). LLD was present in 6 cases (18.8%). LCI scores revealed a high performance among males (t 17,464 = 2.976, p = .008). D-EEARB scores showed that 56.25% stated feeling "quite" or "totally comfortable" in situations which involved revealing their body, but 43.75% stated the contrary ("uncomfortable" or "very uncomfortable"). LLD and traumatic LLA show higher scores in D-EEARB than vascular and oncological LLA (χ (2) = 7.744, df = 3, p = .05). Conclusions. Adults suffering from LLDs and LLAs during childhood seem to perform well once they are adults. However, 43.75% of patients express considerable discomfort in situations that involve revealing the body.

Toxicity and adherence to treatment for latent tuberculosis infection in patients with hematologic malignancies.

PURPOSE: Oncohematological patients undergoing chemotherapy who have latent tuberculosis infection (LTBI) are at a high risk of developing active tuberculosis (TB). The identification and treatment of these patients can prevent LTBI progressing to active TB. This study analyzed the degree of adherence with and safety of the treatment of latent tuberculosis infection (TLTBI) in oncohematological patients undergoing antineoplastic chemotherapy. METHODS: This is a retrospective study of a cohort of oncohematological patients receiving TLTBI and antineoplastic chemotherapy simultaneously, between January 2007 and June 2010. The proportions of toxicity and adherence to TLTBI in these patients were compared with a non-oncohematological control group, matched for age, sex, and year in which the TLTBI was started. In addition, a minimum 2-year follow-up was carried out for all patients. RESULTS: A total of 105 patients who received TLTBI were included, 21 of whom had received antineoplastic chemotherapy simultaneously. The mean age of the patients was 63 years. There were no significant baseline differences in transaminase values. The percentages of patients completing treatment were 76.2% in the control group and 71.4% in the oncohematological group [risk ratio (RR): 1.07, 95% confidence interval (CI): 0.79-1.43]. The voluntary dropout proportion was similar in both groups (12.3 vs. 11.8%, RR: 1.05, 95% CI: 0.25-4.42). Treatment was discontinued because of toxicity in three oncohematological patients and in 11 patients from the control group (RR: 1.14; 95% CI: 035-3.66). No patient developed TB during the follow-up period. CONCLUSION: The safety of TLTBI is not influenced by simultaneous antineoplastic chemotherapy in oncohematological patients.

Quantifying mesenchymal stem cells in the mononuclear cell fraction of bone marrow samples obtained for cell therapy.

AIMS: The use of bone marrow mononuclear cells (BMMNCs) as a source of mesenchymal stem cells (MSCs) for therapy has recently attracted the attention of researchers because BMMNCs can be easily obtained and do not require in vitro expansion before their use. This study was designed to quantify the MSC population in bone marrow (BM) samples obtained for cell therapy using flow cytometry to detect the CD271 antigen. MATERIAL AND METHODS: Autologous BM was obtained by posterior superior iliac crest aspiration under topical anesthesia. Mononuclear cells isolated from the BM aspirate on a Ficoll density gradient were used to treat patients with pressure ulcer (n = 13) bone nonunions (n = 3) or diabetic foot ulcers (n = 5). RESULTS: Our flow cytometry data revealed a low percentage as well as a high variability among patients of CD271(+)CD45(-) cells (range, 0.0017 to 0.0201%). All cultured MSC adhered to plastic dishes showing a capacity to differentiate into adipogenic and osteogenic lineages. CONCLUSIONS: Our findings suggested that the success of cell therapy was independent of the number of MSCs present in the BM aspirate used for autologous cell therapy.

New serum-derived albumin scaffold seeded with adipose-derived stem cells and olfactory ensheathing cells used to treat spinal cord injured rats.

Recent advances in spinal cord injury (SCI) research and cell culture techniques and biomaterials predict promising new treatments for patients with SCI or other nerve injuries. Biomaterial scaffolds form a substrate within which cells are instructed to form a tissue in a controlled manner. This study was designed to assess axon regeneration and locomotor recovery in rats with spinal cord injury treated with a novel serum-derived albumin scaffold seeded with adipose derived stem cells (ADSCs) and olfactory ensheathing cells (OECs). OECs are considered promising candidates for the treatment of SCI, and ADSCs have the ability to differentiate into neural lineages. In vitro experiments revealed that ADSCs and OECs adhered to the scaffold, remained viable and expressed specific markers of their cell types when cultured in the scaffold. Rats treated with scaffold plus cells showed locomotor skills at several time points from 45 days post-injury that were improved over those recorded in control injured, untreated animals. Astrocytic scars and tissue regeneration, identified using histological and immunohistochemical techniques, revealed that although the scaffold itself appeared to play a significant role in reducing glial scar formation and filling of the lesion cavity with cells, the presence of ADSCs and OECs in the scaffold led to the appearance of cells expressing markers of neurons and axons at the injury site. Our findings point to the clinical feasibility of an albumin scaffold seeded with ADSCs and OECs as a treatment candidate for use in spinal cord injury repair studies.

Descenso de la estancia media en la Unidad de Lesionados Medulares. Implicaciones éticas sobre la asistencia / Decrease in the mean stay in the spinal cord injury unit. Ethical implications on the care

La estancia media (EM) es un factor importante para determinar la actividad asistencial y un indicador para el pago en determinados sistemas de salud. Se ha demostrado que ha descendido drásticamente, durante los últimos años, en los pacientes ingresados en los Servicios de Rehabilitación. Hemos analizado la evolución de la EM y el grado de complejidad del proceso asistencial, en el período comprendido entre los años 1997 y 2009, determinando la tendencia que sigue y como se ha visto influida por los cambios en el modelo asistencial, para conocer las modificaciones que se han producido en la gestión del proceso lesión medular y las implicaciones éticas que puede tener sobre el modelo asistencial. El número de pacientes en el período 1997-2009, ha sido de 907 con una media anual de 69,7 pacientes/año. La edad media es de 44,8 años (DE: 18,2), con un rango que varía entre 15 y 84 años y una mediana de 41 años. La edad media se ha incrementado de forma significativa (p<0,001) cuando se comparan los períodos 1997-2002 y 2003-2009. La EM en la unidad de cuidados intensivos, en los pacientes que lo precisaron, antes del ingreso en la Unidad de Lesionados Medulares (ULM), ha sido de 12,3 días (DE: 18,2) para las tetraplejías y de 15 días (DE: 19,6) para los paraplejías. El promedio de EM en la ULM ha sido de 66,4 días, con un rango que varía de 85,2 en 1997 a 55,4 en 2003. Se observa una reducción significativa de la EM, ostensible a partir de 2001, con descensos progresivos hasta 2003, estabilizándose a partir de ese año, existiendo diferencias significativas (p<0,0001) entre el período 1997-2002 y el 2003-2009. El grado de complejidad del proceso leucemia mieloide agudase ha incrementado de forma notable a partir de 2004, teniendo una media los grupos relacionados por el diagnóstico (GRD)en el período estudiado, de 5,37, con un rango que varía entre 3,79 en 1997 y 9,4 en 2009. Más de un 40% de los pacientes tienen GRD elevados, superiores a 5 puntos y un 10% tienen valores excesivos, superiores a 20 puntos. Se ha objetivado correlación entre EM más altas y mayor número de lesiones asociadas y mayor gravedad de la lesión, con una correlación significativa (p<0,01; r=78) entre EM más alta y GRD más alto. En conclusión, los cambios detectados a través de este estudio en cuanto a la incidencia EM y morbilidad añadida a la lesión medular aguda, evaluada a través de los GRD, indica que es necesario trabajar con el gobierno y los compradores de la salud en las CC.AA., para demostrar que la reducción de la EM, tienen un límite situado en el equilibrio entre la atención eficiente y la tolerable éticamente y que no siempre representan una gestión más rentable, por lo que será preciso tener en cuenta el grado de discapacidad de los pacientes y el análisis continuo de los procesos (AU)

Mean stay (MS) is an important factor to determine the care activity and is an indicator for payment in some health care systems. It has been shown that it has dramatically decreased in patients admitted in rehabilitation services during the last years. We have analyzed the evolution of EM and the degree of complexity of the health care process from 1997 to 2009. We have determined the tendency it has been following and how it has been influenced by the changes in the care model in order to discover the modifications that have been made in the management of the spinal cord injury process and the ethical implications it may have on the care model. The number of patients in the period 1997-2009 was 907 with an annual average of 69.7 patients/year. Average age was 44.8 years (SD: 18.2), with a range that varied from 15 to 84 years and a median of 41 years. Mean age increased significantly (P<0.001) when the periods 1997-2002 and 2003-2009 are compared. Mean stay (MS) in the ICU was 12.3 days (SD: 18.2) for tetraplegia and 15 days (SD: 19.6) for paraplegia. Mean stay in the spinal cord injured unit (SCI) was 66.4 days, with a range varying from 85.2 in 1997 to 55.4 in 2003. We observed a significant reduction of MS, ostensibly from 2001, with a steady decline until 2003, it stabilizing after this year, and with significant differences (P<0.0001) between the period 1997-2002 and 2003-2009. The complexity degree of SCI has increased significantly since 2004, with an average 5.37 diagnostic related groups (DRG), during the period study, and a range that varied from 3.79 in 1997 to 9.4 in 2009. More than 40 percent of the patients have elevated GRDs, greater than 5 points, and 10 per cent of patients have excessive values, which are considered to be more than 20 points. Correlations have been observed between higher MS and increased number of associated lesions, and greater severity of the injury, with a significant correlation (P<0.01; r=78) between higher MS and higher DRG. In conclusion, the changes detected by this study in regards to incidence, MS and morbidity added to the acute spinal cord injury, evaluated through the GRD, indicate the need to work with the Government and health care purchasers in the Autonomous Communities to demonstrate that the reduction of MS has a limit. This limit is found within the balance between efficient and ethically tolerable care, which does not always mean a more profitable process. Thus, it will be necessary to take into account the degree of disability of patients and the continuous analysis of processes (AU)

Treatment of pressure ulcers with autologous bone marrow nuclear cells in patients with spinal cord injury.

CONTEXT: Pressure ulcers are especially difficult to treat in patients with spinal cord injury (SCI) and recurrence rates are high. Prompted by encouraging results obtained using bone marrow stem cells to treat several diseases including chronic wounds, this study examines the use of autologous stem cells from bone marrow to promote the healing of pressure ulcers in patients with SCI. OBJECTIVE: To obtain preliminary data on the use of bone marrow mononuclear cells (BM-MNCs) to treat pressure ulcers in terms of clinical outcome, procedure safety, and treatment time. PARTICIPANTS: Twenty-two patients with SCI (19 men, 3 women; mean age 56.41 years) with single type IV pressure ulcers of more than 4 months duration. INTERVENTIONS: By minimally invasive surgery, the ulcers were debrided and treated with BM-MNCs obtained by Ficoll density gradient separation of autologous bone marrow aspirates drawn from the iliac crest. RESULTS: In 19 patients (86.36%), the pressure ulcers treated with BM-MNCs had fully healed after a mean time of 21 days. The number of MNCs isolated was patient dependent, although similar clinical outcomes were observed in each case. Compared to conventional surgical treatment, mean intra-hospital stay was reduced from 85.16 to 43.06 days. Following treatment, 5 minutes of daily wound care was required per patient compared to 20 minutes for conventional surgery. During a mean follow-up of 19 months, none of the resolved ulcers recurred. CONCLUSIONS: Our data indicate that cell therapy using autologous BM-MNCs could be an option to treat type IV pressure ulcers in patients with SCI, avoiding major surgical intervention.

La infección del tracto urinario en los servicios de medicina interna / Urinary tract infections in internal medicine

Objetivos. Análisis de las características de los pacientes ingresados en servicios de medicina interna (MI) con el diagnóstico de infección tracto urinario (ITU). Pacientes y métodos. Estudio transversal, descriptivo, retrospectivo de pacientes ingresados y diagnosticados de ITU en los informes de alta de diversos servicios de MI de nuestro país (1 de octubre al 31 de diciembre de 2007). Se registraron variables de filiación, factores de riesgo para ITU complicada, criterios diagnósticos, resultados microbiológicos y antibióticos utilizados. Resultados. Se reclutaron 992 pacientes (61,8% mujeres), de 57 hospitales, con edad media de 75,3 años. Procedían de residencia el 18,1%. Presentaban dependencia física el 53,5%. El 78,3% tenía algún factor de riesgo (diabetes mellitus 33,6%, sondaje vesical 24,1%). El tipo sindrómico de ITU más frecuente fue «ITU no especificada» (38,1%). En el 46% se llegó al diagnóstico exclusivamente por alteraciones del sedimento y/o urocultivo positivo. E. coli fue el patógeno más frecuente (64,17%), mostrando sensibilidad intermedia o resistente el 22,8% a amoxicilina-clavulánico, el 34,8 % a levofloxacino y el 40,6% a ciprofloxacino. La amoxicilina-clavulánico fue el antibiótico más utilizado (30,9%). La ITU demoró el alta en un 13,3% de los pacientes. La infección intrahospitalaria (23%) fue estadísticamente más frecuente en los pacientes sondados (50,5 vs 16,2%) y la mortalidad (3,4%) en mayores (81,2 vs 75,1 años), pacientes con P. aeruginosa (11,8 vs 4,1%) y en aquellos con sepsis urinaria (41,4 vs 16,2%). Conclusiones. Los pacientes dados de alta con ITU en los servicios de MI son de edad avanzada y frecuentemente presentan factores de riesgo. En excesivas ocasiones el diagnóstico se basa en criterios no específicos. E. coli es el patógeno más frecuente. Las quinolonas no deberían ser utilizadas en el tratamiento de primera línea en los pacientes con ITU complicada o grave, dado el alto porcentaje de resistencias(AU)

Objectives. Analysis of characteristics of patients in internal medicine (IM) hospital wards in Spain with the diagnosis of urinary tract infection (UTI). Patients and methods. Observational, descriptive, retrospective study of a population of inpatients with UTI diagnosis (October-December, 2007). Recorded variables included personal data, risk factors for complicated UTI, diagnosis criteria, microbiological results and antibiotics used. Results. A total of 992 patients (61.8% women), from 57 hospitals, were recruited. Mean age was 75.3 years old (SD 16.5), with 18.1% from nursing homes and with some physical dependence in 53.5%. The majority (78.3 %) had some risk factors (diabetes mellitus 33.6%, vesical catheterization 24.1%). Non-specific UTI was the most frequent diagnosis (38.1%). UTI was diagnosed in 46%, based exclusively on urinary sediment alterations and/or positive cultures. E. coli was the most frequent pathogen (64.17%), with intermediate sensitivity or resistance of 22.8% to amoxicillin-clavunanic, 34.8% to levofloxacin and 40.6% to ciprofloxacin. Amoxicillin-clavulanic was the most used antibiotic (30.9%). UTI delayed hospital discharge in a 13.3%. Intrahospital-UTI was statistically more frequent (23%) with vesical catheterization (50.5 vs 16.2%) and mortality (3.4%) in older patients (81.2 vs. 75.1 years old.), in patients with P. aeruginosa cultures (11.8 vs 4.1%) and in those with urinary sepsis (41.4 vs 16.2%). Conclusions. Patients in internal medicine wards with a UTI diagnosis are older and with risk factors. Frequently, UTI is diagnosed based on non-specific criteria. E. coli is the most frequent pathogen. Quinolones should not be the first-line treatment in complicated or severe UTI, due to the high percentages of resistance(AU)

Conflictos éticos en el aprendizaje de los médicos internos residentes de Medicina Física y Rehabilitación / Ethical conflicts in training of the medical residents of physical medicine and rehabilitation

Objetivo. Intentar identificar el lugar que ocupa el concepto ético en la actuación diaria de los médicos internos residentes (MIR) de Medicina Física y Rehabilitación. Material y método. Se realizó un estudio prospectivo en el que participaron 13 MIR de Medicina Física y Rehabilitación con el objetivo de identificar los conflictos éticos que pueden producirse durante el aprendizaje de la especialidad. Realizamos un documento para el análisis de las habilidades éticas que consistía en 10 casos clínicos de situaciones habituales en rehabilitación. Todas las preguntas tenían cinco respuestas posibles en las que se incluían los indicadores para la evaluación de la ética médica. Las respuestas podían ser: a) respeto o actitud basada en los principios de autonomía, beneficencia, ausencia de maleficencia y justicia; b) evasión en la que se subroga el compromiso de actuar a una autoridad o a otros colegas, y c) falta de respeto, que es la ausencia de respeto a la autonomía del paciente, las actitudes no beneficientes, la maleficencia o la injusticia. Resultados. Sobre un rango máximo total de todos los participantes de 1.300 puntos se obtuvieron 1.008,5 puntos, lo que significa el 77,6% y está situado en el mejor cuartil. Resultados. La media del grupo fue de 25,2 puntos (desviación estándar de 2,8) con un rango situado entre 22,5–27,1 puntos. Las preguntas con resultados más inadecuados fueron la 8 y la 9, referidas a la falta de colaboración del paciente y a las actitudes inadecuadas de otros profesionales del equipo multidisciplinario de rehabilitación. Conclusión. El estudio indica la necesidad de institucionalizar programas de formación específicos para los MIR en el apartado ético(AU)

Objective. To attempt to identify the place occupied by the ethical concept in the daily performance of resident physicians (RP) of Physical Medicine and Rehabilitation (PMR). Material and methods. A prospective study involving 13 RP of PMR was performed in order to identify the ethical conflicts that may occur during the specialty training. We elaborated a document for the analysis of ethical skills, which consisted of 10 clinical cases of common situations in Rehabilitation. All the questions had 5 possible answers that included indicators for the evaluation of medical ethics. The answers could be: a) Respect or attitude based on the principles of autonomy, beneficence, non-malfeasance and justice, b) avoidance in which commitment to act is subrogated to an authority or other colleagues, c) lack of respect, which is the absence of respect of the patient's autonomy, non-beneficence, malfeasance or injustice attitudes. Results. On a total maximum range for all the participants of 1300 points, 1008.5 points were obtained. This accounts for 77.6%, which would be located in the best quartile. The group average was 25.2 points (SD 2.8), with a range located between 22.5 and 27.1 points. The questions having the most inadequate results were numbers 8 and 9, concerning lack of patient cooperation and inappropriate attitudes of other professionals in the multidisciplinary rehabilitation team. Conclusion. The study indicates the need to institutionalize specific training programs for the Resident Physician within the ethics section(AU)

[Urinary tract infections in internal medicine]. / La infección del tracto urinario en los servicios de medicina interna.

OBJECTIVES: Analysis of characteristics of patients in internal medicine (IM) hospital wards in Spain with the diagnosis of urinary tract infection (UTI). PATIENTS AND METHODS: Observational, descriptive, retrospective study of a population of inpatients with UTI diagnosis (October-December, 2007). Recorded variables included personal data, risk factors for complicated UTI, diagnosis criteria, microbiological results and antibiotics used. RESULTS: A total of 992 patients (61.8% women), from 57 hospitals, were recruited. Mean age was 75.3 years old (SD 16.5), with 18.1% from nursing homes and with some physical dependence in 53.5%. The majority (78.3 %) had some risk factors (diabetes mellitus 33.6%, vesical catheterization 24.1%). Non-specific UTI was the most frequent diagnosis (38.1%). UTI was diagnosed in 46%, based exclusively on urinary sediment alterations and/or positive cultures. E. coli was the most frequent pathogen (64.17%), with intermediate sensitivity or resistance of 22.8% to amoxicillin-clavunanic, 34.8% to levofloxacin and 40.6% to ciprofloxacin. Amoxicillin-clavulanic was the most used antibiotic (30.9%). UTI delayed hospital discharge in a 13.3%. Intrahospital-UTI was statistically more frequent (23%) with vesical catheterization (50.5 vs 16.2%) and mortality (3.4%) in older patients (81.2 vs. 75.1 years old.), in patients with P. aeruginosa cultures (11.8 vs 4.1%) and in those with urinary sepsis (41.4 vs 16.2%). CONCLUSIONS: Patients in internal medicine wards with a UTI diagnosis are older and with risk factors. Frequently, UTI is diagnosed based on non-specific criteria. E. coli is the most frequent pathogen. Quinolones should not be the first-line treatment in complicated or severe UTI, due to the high percentages of resistance.

Incidencia del dolor neuropático en el lesionado medular / Neuropathic pain in chronic SCI patients

Objetivo. Conocer la incidencia de dolor neuropático (DN), mediante el cuestionario DN4, en la población de lesionados medulares (LM) de nuestro medio, dado que existe poca información a este respecto. Material y método. Se efectúa estudio prospectivo, aleatorizado, de la muestra de pacientes con lesión medular crónica que ya finalizaron tratamiento rehabilitador, los que acudieron a consultas externas de Unidad de Lesionados Medulares, durante 01/06/2007–31/12/2007. Para valorar la incidencia del DN hemos utilizado el cuestionario DN4. Se realizó un estudio bivariable con SPSS(R) 15. Resultados. Noventa y cinco pacientes (65 varones y 30 mujeres), con una edad media 42,91 (DE 16,57). Cuarenta y seis eran lesiones completas sensitivas y 49 incompletas sensitivas. Treinta y dos cervicales, 22 dorsales altos, 24 dorsales bajos y 17 lumbares. El tiempo de evolución medio de la lesión era 98,33 meses (DE 98,80). La puntuación media DN4 fue 4,44 (DE 2,48). La incidencia de DN en la muestra es 66,3%. No existieron diferencias significativas entre DN y las variables sensibilidad (completo sensitivo o incompleto sensitivo), nivel de localización de la lesión, tiempo de evolución de la lesión y sexo. Únicamente existió asociación estadísticamente significativa entre la edad y el DN (36 vs 46,42). Existía correlación positiva entre edad y puntuación del DN4 (p<0,05). Conclusiones. El 66,3% de los LM crónicos presentan DN, siendo este más frecuente en las LM incompletas, está relacionado con la edad, pero no con el sexo ni el tiempo de evolución de la LM (AU)

Objective. To understand the incidence of neuropathic pain (DN), through the DN4 questionnaire, in the chronic SCI patients, as there is little information in this regard. Design. A prospective, randomized study. Participants. It was performed with 245 patients with SCI in chronic phase to knowing the incidence of neuropathic pain (DN). Interventions. DN4 test evaluated neurophatic pain. Methods. We used to analyze the results the statistic program SPSS(R) 15. Results. The sample was 95 patients, 67% males and 33% women, with an average age of 42.91 years (SD 16.6). The time of evolution of SCI was 98.3 months (range 15–360). The proportion of patients with ASIA A was 50%. The prevalence of DN was 66.3%. The most common form of presentation of DN was numbness to 55% and electric shocks for 40%. There are correlation between DN with age p=0,005, but not with sex or the time of evolution of SCI. Conclusions. 66,3% of patients with chronic LM presented DN. It is more frequent in the incomplete SCI, and it is correlated with age, but not with sex or the time of evolution of the SCI (AU)

Distribución de los pacientes con lesiones medulares agudas por grupos relacionados diagnósticos / Distribution of acute spinal cord injuries by diagnoses related groups

Introducción. La atención de la lesión medular (LM) se ha visto modificada desde la introducción de los grupos relacionados diagnósticos (GRD). Material y métodos. Estudio retrospectivo de los pacientes con LM aguda dados de alta por la Unidad de Lesionados Medulares del Hospital Vall d’Hebron en el período comprendido entre el 1 de enero de 1997 y el 31 de diciembre de 2006. Material y métodos. El objetivo es conocer con qué GRD se clasifican los pacientes con LM aguda, el peso relativo de los GRD y obtener unos indicadores que nos informen sobre el tipo de pacientes con LM aguda en nuestro medio a través de los GRD. Resultados. El número de pacientes con LM aguda dados de alta por la Unidad de Lesionados Medulares del Hospital Vall d’Hebron en los últimos 10 años ha sido de 698. La edad media de la muestra fue de 40,27 (DE: 18,85); la mediana fue de 36, con un rango de 73 años. La estancia media fue de 70,34 días (DE: 43,49); la mediana fue de 65 con un rango de 182 días. El peso medio del GRD fue de 4,658 (DE: 4,99) con un rango que variaba entre 0,51–20,04. El número de pacientes considerados outliers, según grupo GRD específico, fue de 302, con una media de 30,3 pacientes outliers anualmente. Resultados. Los pacientes con LM aguda se clasifican mayoritariamente con un GRD quirúrgico, siendo el más frecuente el de las intervenciones espinales. Pero el que mayor coste genera es el GRD de traqueotomía (GRD 483-541-542) con un peso 3,7 veces superior al peso medio de nuestra muestra. Conclusiones. Se suelen clasificar con GRD quirúrgicos, pero consideramos que esta clasificación no tiene en cuenta la funcionalidad que obtienen (AU)

Introduction. The care of spinal cord injury (LM) has been changed since the introduction of GRDs. Material and methods. Retrospective study of acute spinal cord injured patients discharged by the spinal injury unit at the Hospital Vall d’Hebron (ULM_HVH) in the period from January 1 1997 and December 31, 2006. Material and methods. The aim of this study was to know that GRD classify patients with acute LM, as well as the relative weight of GRDs and get some indicators that inform us about the type of patients with acute LM in our environment through the GRDS. Results. The number of patients with acute LM discharged by the ULM-HVH in the last 10 years was 698. The average age of the sample was 40.27 (of 18.85), median 36, with a range of 73 years. The mean (EM) was 70.34 days (43.49), 65 with a median rank of 182 days. The average weight of the DRG was 4.658 (4.99) with a range that varied between 0,51–20,04. The number of patients considered outliers, as specific DRG group was 302, with an average of 30.3 patients annually outliers. Results. Acute spinal cord injured patients are classified mostly with a surgical DRG, the most frequent spinal interventions. But the greatest cost is generated by tracheotomy GRD (GRD 483-541-542) with a mass 3.7 times the average weight of our sample. Conclusions. These are usually classified GRDs surgical. But we believe that this classification does not account for the functionality that these patients have (AU)

Análisis de los factores que influyen en el gasto sanitario de los lesionados medulares agudos mediante los grupos relacionados diagnósticos / Analysis to the factors influencing the health-care costs for acute spinal cord injury by diagnosis-related groups

Objetivo. Analizar los factores que influyen en el gasto sanitario de los pacientes con lesión medular en la última década valorado a través de los grupos relacionados diagnósticos (GRD). Material y métodos. Estudio retrospectivo de pacientes dados de alta por la unidad de lesionados medulares desde el año 1997 hasta el año 2006. Se utilizan los datos obtenidos de la base de datos de los GRD de dicho hospital, que incluye los pacientes dados de alta en la unidad de lesionados medulares (n=698). El estudio investiga el número de altas, la estancia media (EM) total y el peso relativo del GRD. Se agrupó según si tenían EM normalizadas o eran outliers (pacientes con una estancia hospitalaria mayor que la media), y se estudiaron las mismas variables. Se realizó un estudio bivariable con el paquete estadístico SPSS® 15. Resultados. La EM fue de 70,3 días. El peso del GRD era de 4,65. La comparación de la EM de los outliers y no outliers mostró diferencias significativas (p<0,05). Existe una correlación entre la EM y el peso del GRD anual (–0,75). Existen 302 outliers. En los últimos 2 años ha habido un descenso importante en el número de outliers. Conclusiones. Descenso de la EM en los últimos años sin cambios en cuanto a la incidencia de ingresos, pero sí en el modelo de atención de la lesión medular aguda. Se ha producido un incremento del peso del GRD anual. Ha habido un descenso importante en el número de outliers en los últimos años (AU)

Objective. To analyze the factors influencing the health-care costs of the patients spinal cord injury in the last decade, valued through the Diagnosis-Related Groups (DRG). Material and methods. A retrospective study of given discharged patients by Spinal Cord Unit following 1997 to 2006. The collected data of the data base of the DRG are used of this hospital, and that includes the given discharged patients in the Spinal Cord Injury unit (ULM) (N=698). The study investigates the number of discharges, the mean of long of stay (LOS) and relative weight DRG's. It was grouped according to if they had LOS standardized or they were outliers, and the same variables studied. It was analyzed using a bivariate study with the statistical package SPSS® 15. Results. The LOS was 70.3 days. Weight DRG was 4,65. The comparison of LOS between of outliers and not outliers patients did not show significant differences (p<0,05). It exists a correlation between the LOS and weight DRG. The outliers were 302. In the last 2 years there has been an important reduction in the number of outliers. Conclusions. Decrease LOS in the last years, without changes as far as the incidence of SCI, but in the model of attention of the SCI patients. An increase of the weight of the annual DRG has taken place. There were important reductions in the number of outliers in the last years (AU)

[Quality of life evaluation in spinal cord injured patients comparing different bladder management techniques]. / Evaluación de la calidad de vida en pacientes con lesión medular comparando diferentes métodos de vaciado vesical.

OBJECTIVES: This study examines quality of life among patients with spinal cord injury requiring bladder management techniques, according to the validated King s Health Questionnaire (KHQ). MATERIAL AND METHODS: Prospective and observational study of 91 spinal cord-injured patients (21 women 23% and 70 men 77%). Mean age was 40 years (SD 13.4) and average time since spinal injury was 11.4 (SD 10.4) years. Patients completed the KHQ quality of life instrument and 10 additional questions related to urinary disturbance developed for the study, and filled in a form to subjectively rank their main concerns related to spinal injury. Patients were divided according to the bladder management techniques they regularly used: intermittent catheterization, condom catheter or indwelling catheter, and differences between the mean groups were assessed with de SPSS 13.0 statistic package. RESULTS: The overall KHQ score for the sample was 39.9 (SD 54.4) with higher scores (poorer QoL) in patients using an indwelling catheter. A thorough analysis of the test showed no significant differences between the groups other than in the physical role limitation item (p

DNA methylation during sexual embryogenesis and implications on the induction of somatic embryogenesis in Castanea sativa Miller.

From anthesis to mature seed formation, burrs from cross-pollinated adult Castanea sativa Miller trees were characterized and seven developmental stages defined based on macro and micromorphological traits. In order to get an insight into the involvement of epigenetic mechanisms in sexual embryogenesis and to define somatic embryogenesis induction capability, global DNA methylation and the somatic embryogenic competence were quantified. On cross-pollinated trees once fertilization takes place, at least one ovule per ovary becomes dominant, and transient DNA demethylation occurs coinciding with the start of the sexual embryogenic programme. Unfertilized ovules from the same cluster, which maintain their prior size, increase their methylation level and undergo degeneration. These results were validated using non-cross-pollinated trees and the asynchrony of flower receptivity. When testing in vitro somatic embryogenesis response of isolated dominant ovules and axes from zygotic embryos under cross-pollinated conditions, the highest competence was found for reaching seed maturity. Thus, a "developmental window" of somatic embryogenesis in chestnut has been characterized. It includes from fertilization to embryo maturity, and a transient decrease in methylation is necessary after fertilization for the development of the somatic embryogenesis response.

Evaluación de la calidad de vida en pacientes con lesión medular comparando diferentes métodos de vaciado vesical / Quality of life evaluation in spinal cord injured patients comparing different bladder management techniques

Material y métodos: Estudio observacional y prospectivo con 91 pacientes (21 mujeres 23%, 70 hombres 77%) afectos de lesión medular que acudieron a la consulta durante marzo 2004 y diciembre del 2005, con media de edad 40 años (DS 13,4) y tiempo medio de evolución de la lesión 11,4 (DS 10,4) años. Los pacientes completaron el KHQ, así como una valoración subjetiva de los principales problemas relacionados con la lesión medular. Se clasificaron los pacientes en función del sistema de evacuación urinaria habitual en: Cateterismos Intermitentes (CI), Sondaje Vesical Permanente (SVP) y Colector Permanente (CP). Analizamos con el paquete estadístico SPSS 12.0 las diferencias entre las medias de las dimensiones del KHQ de los tres grupos. Resultados: La media de la puntuación total del KHQ fue de 39,9 puntos (DT 54,4), con mejor puntuación en el grupo portador de CP. Encontramos que no hay diferencias significativas, excepto en la dimensión de la limitación de los roles, donde obtienen mejor puntuación el grupo portador de CP que los de SVP y los CI (p=0,025).La sexualidad se presenta en primer lugar en la lista de problemas que más preocupa a los pacientes, seguidos de los trastornos de defecación y urinarios. Conclusión: El grupo con mejor puntuación global en el KHQ es el portador de CP, aunque no hay diferencias significativas entre los 3 grupos. Lo que más preocupa a nuestros pacientes son los problemas sexuales (AU)

Material and methods: Prospective and observational study of 91 spinal cord-injured patients (21 women 23% and 70 men 77%). Mean age was 40 years (SD 13.4) and average time since spinal injury was 11.4 (SD 10.4) years. Patients completed the KHQ quality of life instrument and 10 additional questions related to urinary disturbance developed for the study, and filled in a form to subjectively rank their main concerns related to spinal injury. Patients were divided according to the bladder management techniques they regularly used: intermittent catheterization, condom catheter or indwelling catheter, and differences between the mean groups were assessed with de SPSS 13.0 stadistic pakagge. Results: The overall KHQ score for the sample was 39.9 (SD 54.4) with higher scores (poorer QoL) in patients using an indwelling catheter. A thorough analysis of the test showed no significant differences between the groups other than in the physical role limitation item (p=0.025). Patients using a condom catheter reported lower physical limitation scores (better QoL) than patients using an indwelling catheter or intermittent catheterization. Sexuality was the main concern of most patients, followed by bowel dysfunction, urinary incontinence and ambulation or gait problems. Conclusion: Patients treated with condom catheters reported the best quality of life according to KHQ scores, although there were no significant differences versus the other urinary management techniques. The patients’ main concern was related to sexuality (AU)

Mapa de conflictos éticos intrahospitalarios en rehabilitación / Map of ethical conflicts at health care hospital in the medical rehabilitation

Objetivo: Analizar los principales problemas que la ciencia, la tecnología y los cambios organizativos han causado en la actividad profesional, social, asistencial, organizativa y legal de los profesionales de rehabilitación. Material y método: El estudio comprendió a 83 profesionales sanitarios que atienden a pacientes que precisan tratamiento de rehabilitación: 35 médicos de rehabilitación (24 médicos especialistas con régimen estatutario y 11 MIR [médicos internos residentes] de rehabilitación), 48 diplomadas en enfermería (DUE): 16 de la Unidad de Lesionados Medulares, 16 de la Unidad de Cuidados Intensivos y 16 de las plantas de hospitalización general, no de urgencias. Se diseñaron 2 cuestionarios de valoración, uno basado en los 10 dilemas o conflictos éticos acreditados como más habituales en el desarrollo de la actividad asistencial y otro segundo basado en los conflictos expresados en diferentes áreas: profesional, social, asistencial, organizativa y legal. Resultados: No existen diferencias significativas entre los 2 grupos (DUE versus médicos) en relación con las variables de las áreas profesional, social y legal, pero sí en la asistencial y organizativa donde se mostraron diferencias significativas entre los 2 grupos (p<0,05): los médicos presentaron más conflictos que las DUE. No existen diferencias significativas entre los 2 grupos estudiados, médicos y DUE, para la puntuación global de los 10 dilemas. Conclusiones: Antes, la solución de los problemas éticos era competencia sólo del médico, hoy lo es también del resto de los profesionales de la salud, porque todos interaccionan con el paciente, por eso la ética es una construcción social y cultural que debe revisarse constantemente en las organizaciones asistenciales, para que sus procesos conlleven a mejorar la calidad de vida de la persona con discapacidad y promover su independencia, que ha sido el objeto del presente estudio (AU)

Objective: To analyze the ethical problems in the health care of the medical and nursing rehabilitation. Materials and methods: The sample were 83 health workers, 35 doctors and 48 nurse specialists. Materials and methods: Using two assessment scales, one of the 10 ethical dilemmas and conflicts the most important during health care and a second questionnaire where was studied professionals problems, social, medical care, organizational and legal. Results: There are not significant differences between the two groups (Physician and nurse) in the variables of the areas professional, social and legal, but there were differences in the care and organizational (p<0.05), presenting doctors more conflicts than nurses. There are not significant differences between the two groups for the 10 ethical dilemmas. Conclusion: The resolution of ethical problems was only the responsibility of the physician before, but now it is also other health professional, because all of us interact with the patient. For this reason the ethics is social and cultural construction which has to constantly revise with organizations aid. For their processes improve the quality of life of people with disabilities and promote their independence, which has been the goal of this study (AU)