Prostatectomía radical laparoscópica frente a prostatectomía radical abierta: comparación del tiempo quirúrgico, complicaciones y estancia postoperatoria / Laparoscopic radical prostatectomy compared to open radical prostatectomy: Comparison between surgical time, complications and length of hospital stay

INTRODUCCIÓN: Existen muy pocos estudios que comparen la prostatectomía radical abierta (PRA) con la prostatectomía radical laparoscópica (PRL). OBJETIVOS: Comparar el tiempo quirúrgico, las complicaciones postoperatorias y la estancia hospitalaria en los pacientes con cáncer de próstata clínicamente localizado tratados mediante PRA y PRL. MATERIAL Y MÉTODOS: Comparación de dos cohortes (312 con PRA y 206 con PRL) entre 2007 y 2015. Las complicaciones postoperatorias se recogieron siguiendo las recomendaciones de las guías clínicas de la EAU y se agruparon según la clasificación de Clavien-Dindo. Para el contraste de variables cualitativas se utilizó el test Chi-cuadrado y ANOVA para las cuantitativas. Análisis multivariable mediante regresión logística para variables dependientes cualitativas y mediante regresión lineal para las variables dependientes continuas. RESULTADOS: La mediana de duración fue de 3:05 horas para la PRA y de 4:35 para la PRL (p = 0,0001). El 26,4% de pacientes presentaron alguna complicación en el postoperatorio. El 31,2% de PRA y el 19,3% de PRL (p = 0,003). La mediana de estancia fue de 4 días. En el grupo de PRA fue de 4 días, mientras que en el de PRL fue de 3 (p = 0,008). La PRL (p = 0,0001), la realización de linfadenectomía (p = 0,02) y la conservación neurovascular (p = 0,01) fueron factores predictores independientes de prolongación del tiempo quirúrgico. La PRL fue un factor protector independiente de complicaciones (OR = 0,48 p = 0,007). El tipo de prostatectomía no influyó en la estancia hospitalaria. CONCLUSIONES: La prostatectomía laparoscópica consumió mayor tiempo quirúrgico, presentó menor porcentaje de complicaciones y no influyó en la estancia hospitalaria

INTRODUCTION: There are very few articles comparing open radical prostatectomy (OPR) with laparoscopic radical prostatectomy (LRP). Objetives: To compare the surgical time, the postoperative complications and the hospital stay in patients with localized prostate cancer treated with ORP or LRP. MATERIAL AND METHODS: Comparison between two patients cohorts (312 with ORP and with 206 LRP) between 2007-2015. Postoperative complications were collected as defined in to the EAU Guidelines recommendations and they were classified according to the Clavien-Dindo classification. To compare the qualitative variables, we employed the chi-squared test and ANOVA for quantitative variables. We performed a multivariate analysis using logistic regression with dependent qualitative variables and a lineal regression with dependent continuous variables. RESULTS: The mean duration of ORP was 3:05hours and 4:35hours for LRP (p = .0001). The 26.4% of the patients presented any postoperative complication.31.2% of ORP and 19.3% of LRP (p = .003). The mean of hospital stay was 4 days. In ORP group was 4 days in contrast to LRP with 3 days (p = .008). The LRP (p = .0001), lymphadenectomy (p = .02) and nerve-sparing (p = .01) were independent predictor factors of extension of surgical time. LRP was a protector independent factor of complications (OR = 0.48 p = .007). The type of prostatectomy didn't influence in the length of hospital stay. CONCLUSIONS: LRP showed higher surgical time, less complications and it didn't influence the hospital stay

Laparoscopic radical prostatectomy compared to open radical prostatectomy: Comparison between surgical time, complications and length of hospital stay. / Prostatectomía radical laparoscópica frente a prostatectomía radical abierta: comparación del tiempo quirúrgico, complicaciones y estancia postoperatoria.

INTRODUCTION: There are very few articles comparing open radical prostatectomy (OPR) with laparoscopic radical prostatectomy (LRP). OBJETIVES: To compare the surgical time, the postoperative complications and the hospital stay in patients with localized prostate cancer treated with ORP or LRP. MATERIAL AND METHODS: Comparison between two patients cohorts (312 with ORP and with 206 LRP) between 2007-2015. Postoperative complications were collected as defined in to the EAU Guidelines recommendations and they were classified according to the Clavien-Dindo classification. To compare the qualitative variables, we employed the chi-squared test and ANOVA for quantitative variables. We performed a multivariate analysis using logistic regression with dependent qualitative variables and a lineal regression with dependent continuous variables. RESULTS: The mean duration of ORP was 3:05hours and 4:35hours for LRP (p=.0001). The 26.4% of the patients presented any postoperative complication. 31.2% of ORP and 19.3% of LRP (p=.003). The mean of hospital stay was 4 days. In ORP group was 4 days in contrast to LRP with 3 days (p=.008). The LRP (p=.0001), lymphadenectomy (p=.02) and nerve-sparing (p=.01) were independent predictor factors of extension of surgical time. LRP was a protector independent factor of complications (OR=0.48 p=.007). The type of prostatectomy didn't influence in the length of hospital stay. CONCLUSIONS: LRP showed higher surgical time, less complications and it didn't influence the hospital stay.

Complicaciones posquirúrgicas en los pacientes con cáncer de vejiga tratados con cistectomía: Diferencias entre el abordaje abierto y laparoscópico / Post-surgical complications in patients with bladder cancer treated with cystectomy: Differences between open and laparoscopic approach

Introducción: La cirugía mínimamente invasiva en la cistectomía no ha tenido el mismo desarrollo que en otras cirugías urológicas, entre otros motivos por la falta de estudios publicados que definan las ventajas de este abordaje frente a la cirugía abierta. Objetivos: El principal objetivo de este estudio es establecer el papel de la cirugía mínimamente invasiva, laparoscopia, en la cistectomía radical frente a la cirugía abierta en un análisis de complicaciones perioperatorias. Material y método: Análisis de cohortes retrospectivo de complicaciones perioperatorias de 2series homogéneas de cistectomías: laparoscópica (n = 196) frente a abierta (n = 197). Identificación mediante análisis multivariante de factores independientes predictores de complicaciones perioperatorias. Resultados: En el análisis comparativo entre el abordaje laparoscópico y el abierto observamos una menor tasas de trasfusión perioperatoria (p < 0,0001), una menor tasa de complicaciones postoperatorias globales (p < 0,0001) así como en el subgrupo de complicaciones graves (Clavien > 3; p < 0,001). También una menor tasa de mortalidad en la serie de laparoscópica frente a la abierta (p<0,0001). Identificamos como factor independiente predictor de complicaciones al abordaje quirúrgico y la duración de la cirugía (p < 0,001). Conclusiones: En nuestro estudio identificamos el abordaje laparoscópico como protector de complicaciones en la cistectomía radical. El abordaje abierto casi triplica el riesgo de tener complicaciones

Introduction: Minimally invasive surgery regarding cystectomy has not had the same development as other urological surgeries. This could be due to the lack of published studies defining the advantages of this approach versus open surgery. Objectives: The main objective of this study is to establish the role of minimally invasive surgery, laparoscopic radical cystectomy, versus open surgery by analyzing their perioperative complications. Material and method: Retrospective cohort analysis of perioperative complications of 2 homogeneous series of cystectomies: laparoscopic (n=196) versus open (n = 197). Identification of independent predictors of perioperative complications by multivariate analysis. Results: In the comparative analysis between laparoscopic cystectomies and open cystectomies we observed a lower rate of perioperative blood transfusion (p < 0.0001), a lower rate of global postoperative complications (p < 0.0001) and a lower rate of serious complications (Clavien > 3; p < 0.001) in the LRC group. There was also a lower mortality rate in the laparoscopic series compared to open ones (p < 0.0001). Surgical approach and surgical time (p < 0.001) were identified as independent predictors of complications. Conclusions: We have identified the laparoscopic approach as a complication shield for radical cystectomy. The open approach almost triples the risk of complications

Influencia del acceso laparoscópico en la mortalidad cáncer-específica de los pacientes con cáncer de vejiga en un estadio pTa-2pN0R0 tratados con cistectomía radical / Influence of laparoscopic access in cancer-specific mortality of patients with pTa-2pN0R0 bladder cancer treated with radical cistectomy

Introducción y objetivo: La cirugía mínimamente invasiva representa un abordaje quirúrgico atractivo en la cistectomía radical. Sin embargo, a la espera de estudios definitivos todavía es controvertido el efecto que pudiera tener en los resultados oncológicos. El objetivo de este estudio es evaluar el efecto del abordaje laparoscópico sobre la mortalidad cáncer-específica. Material y método: Estudio de cohortes retrospectivo de dos grupos de pacientes en estadio pT0-2pN0R0 sometidos a cistectomía radical abierta (CRA) (n = 191) y laparoscópica (CRL) (n = 74). Se realizó un análisis mediante regresión de Cox para identificar primero las variables predictoras y posteriormente las variables predictoras independientes relacionadas con la supervivencia. Resultados: El 90,9% fueron varones; la mediana de edad fue de 65 años y la mediana de seguimiento, de 65,5 (IQR 27,75-122) meses. Los pacientes con acceso laparoscópico presentaron de forma significativa un mayor índice ASA (p = 0,0001), un mayor tiempo entre la resección transuretral (RTU) y la cistectomía (p = 0,04), una menor tasa de transfusión intraoperatoria (p = 0,0001), un menor estadio pT (p = 0,002) y una menor incidencia de infección asociada a herida quirúrgica (p = 0,04). Al analizar los distintos factores de riesgo asociados a mortalidad cáncer-específica, solo encontramos el abordaje mediante CRA frente a CRL como factor predictor independiente de mortalidad cáncer-específica (p = 0,007). El acceso abierto a la cistectomía multiplicó el riesgo de mortalidad por 3,27. Conclusiones: En nuestra serie, cuando limitamos los distintos factores identificados asociados a mortalidad cáncer-específica analizando pacientes pT0-2N0R0, el abordaje laparoscópico no representa un factor de riesgo frente al abordaje abierto

Introduction and objective: Minimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality. Material and method: A retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n = 191) and laparoscopic radical cystectomy (LRC) (n = 74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival. Results: 90.9% were males with a median age of 65 years and a median follow-up period of 65.5 (IQR27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P = .0001), a longer time between TUR and cystectomy (P = .04), a lower rate of intraoperative transfusion (P = .0001), a lower pT stage (P = .002) and a lower incidence of infection associated with surgical wounds (P = .04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P = .007). Open approach to cystectomy multiplied the risk of mortality by 3.27. Conclusions: In our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients

Post-surgical complications in patients with bladder cancer treated with cystectomy: Differences between open and laparoscopic approach. / Complicaciones posquirúrgicas en los pacientes con cáncer de vejiga tratados con cistectomía: Diferencias entre el abordaje abierto y laparoscópico.

INTRODUCTION: Minimally invasive surgery regarding cystectomy has not had the same development as other urological surgeries. This could be due to the lack of published studies defining the advantages of this approach versus open surgery. OBJECTIVES: The main objective of this study is to establish the role of minimally invasive surgery, laparoscopic radical cystectomy, versus open surgery by analyzing their perioperative complications. MATERIAL AND METHOD: Retrospective cohort analysis of perioperative complications of 2homogeneous series of cystectomies: laparoscopic (n = 196) versus open (n = 197). Identification of independent predictors of perioperative complications by multivariate analysis. RESULTS: In the comparative analysis between laparoscopic cystectomies and open cystectomies we observed a lower rate of perioperative blood transfusion (P < 0.0001), a lower rate of global postoperative complications (P < 0.0001) and a lower rate of serious complications (Clavien > 3; P < 0.001) in the LRC group. There was also a lower mortality rate in the laparoscopic series compared to open ones (P < 0.0001). Surgical approach and surgical time (P < 0.001) were identified as independent predictors of complications. CONCLUSIONS: We have identified the laparoscopic approach as a complication shield for radical cystectomy. The open approach almost triples the risk of complications.

Influence of laparoscopic access in cancer-specific mortality of patients with pTa-2pN0R0 bladder cancer treated with radical cistectomy. / Influencia del acceso laparoscópico en la mortalidad cáncer-específica de los pacientes con cáncer de vejiga en un estadio pTa-2pN0R0 tratados con cistectomía radical.

INTRODUCTION AND OBJECTIVE: Minimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality. MATERIAL AND METHOD: A retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n=191) and laparoscopic radical cystectomy (LRC) (n=74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival. RESULTS: 90.9% were males with a median age of 65years and a median follow-up period of 65.5 (IQR27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P=.0001), a longer time between TUR and cystectomy (P=.04), a lower rate of intraoperative transfusion (P=.0001), a lower pT stage (P=.002) and a lower incidence of infection associated with surgical wounds (P=.04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P=.007). Open approach to cystectomy multiplied the risk of mortality by 3.27. CONCLUSIONS: In our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.

Influencia del acceso laparoscópico en la mortalidad cáncer específica de los pacientes con cáncer de vejiga en un estadio pT3-4 tratados con cistectomía / Influence of the laparoscopic approach on cancer-specific mortality of patients with stage pt3-4 bladder cancer treated with cystectomy

Introducción y objetivo: El principal objetivo del estudio fue establecer la seguridad oncológica del abordaje laparoscópico en la cistectomía radical de tumores uroteliales de alto riesgo no órgano-confinados. Material y métodos: Estudio de cohortes retrospectivo de 216 cistectomías estadio patológico pT3-4 intervenidos entre 2003 y 2016; con acceso abierto (CRA, n = 108) y laparoscópico (CRL, n = 108). Resultados: Ambos grupos tuvieron similares características patológicas, excepto en grado G3 de la RTU, mayor número de linfadenectomías y con mayor pN+, y mayor número de quimioterapia adyuvante en el grupo de CRL. La mediana de seguimiento de la serie fue de 15 (IQR: 8-10,5) meses. Recidivó el 68,1% de la serie, sin diferencias entre ambos grupos (p = 0,11). La estimación de las diferencias para la supervivencia cáncer específica fue mayor en el grupo de CRL (p = 0,03), al igual que la supervivencia global (p = 0,009). No existieron diferencias entre ambos grupos en estimación de supervivencia libre de recidiva (p = 0,26). El tipo de acceso quirúrgico (p = 0,03), el estadio pTpN (p = 0,0001) y la administración de quimioterapia adyuvante (p = 0,003) se relacionaron con la mortalidad cáncer específica (MCE) en el análisis univariante. Solo el estadio pTpN (p = 0,0001) y la no administración de quimioterapia adyuvante (p = 0,003) se comportaron como factores predictores independientes de MCE. Conclusión: El tipo de acceso quirúrgico a la cistectomía (CRA vs. CRL) no influyó en la MCE. La afectación ganglionar y la ausencia de quimioterapia adyuvante se identificaron como factores predictores de MCE. Nuestro estudio avala la seguridad oncológica del abordaje laparoscópico de la cistectomía en los pacientes con tumores vesicales musculoinvasivos localmente avanzados

Introduction and aim: The main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours. Material and methods: A retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n = 108), and using a laparoscopic approach (LRC, n = 108). Results: Both groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8-10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p = .11). The estimated differences for cancer-specific survival was greater in the LRC group (p = .03), as was overall survival (p = .009). There were no differences between either group in estimated recurrence-free survival (p = .26). The type of surgical approach (p = .03), pTpN stage (p = .0001), and administration of adjuvant chemotherapy (p = .003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p = .0001), and not giving adjuvant chemotherapy (p =. 003) behaved as independent predictive factors of CSM. Conclusion: The type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours

Influence of the laparoscopic approach on cancer-specific mortality of patients with stage pt3-4 bladder cancer treated with cystectomy. / Influencia del acceso laparoscópico en la mortalidad cáncer específica de los pacientes con cáncer de vejiga en un estadio pT3-4 tratados con cistectomía.

INTRODUCTION AND AIM: The main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours. MATERIAL AND METHODS: A retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n=108), and using a laparoscopic approach (LRC, n=108). RESULTS: Both groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8-10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p=.11). The estimated differences for cancer-specific survival was greater in the LRC group (p=.03), as was overall survival (p=.009). There were no differences between either group in estimated recurrence-free survival (p=.26). The type of surgical approach (p=.03), pTpN stage (p=.0001), and administration of adjuvant chemotherapy (p=.003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p=.0001), and not giving adjuvant chemotherapy (p=.003) behaved as independent predictive factors of CSM. CONCLUSION: The type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours.

Femoral and sciatic nerve block for knee arthroscopy in a patient with acute intermittent porphyria / Bloqueo nervioso femoral y ciático para una artroscopia de rodilla en paciente con porfiria aguda intermitente

Acute intermittent porphyria is an autosomal dominant disorder that results from a partial deficiency of porphobilinogen deaminase and that causes very severe symptoms. Attacks may be triggered by a series of drugs and by other factors that the anesthesiologist should be aware of in order to reduce morbidity and mortality. Our objective is to review anesthetic considerations in acute intermittent porphyria. We present the case of a patient diagnosed with acute intermittent porphyria who was scheduled for knee arthroscopy. The anesthetic technique used was a femoral and sciatic nerve block under sedation with an infusion of remifentanil. The surgery proceeded without incident and the patient was discharged home after 24h. We consider the use of a peripheral plexus block of the lower limb to have been the safest anesthetic technique for this patient (AU)

La porfiria aguda intermitente es una enfermedad autosómica dominante que resulta de un déficit de porfobilinógeno deaminasa y que causa síntomas muy severos. Los ataques se pueden desencadenar por fármacos y otros factores que el anestesiólogo debe conocer para reducir la morbilidad y la mortalidad. Nuestro objetivo es revisar las consideraciones anestésicas en la porfiria aguda intermitente. Presentamos el caso de una paciente diagnosticada de que porfiria aguda intermitente programada para una artroscopia de rodilla. La técnica anestésica realizada fue bloqueo nervioso femoral y ciático bajo sedación con perfusión de remifentanilo. La cirugía transcurrió sin incidencias y la paciente fue dada de alta a domicilio a las 24 h. Consideramos que el bloqueo nervioso periférico de la extremidad inferior es la técnica anestésica más segura para esta paciente (AU)

Femoral and sciatic nerve block for knee arthroscopy in a patient with acute intermittent porphyria.

Acute intermittent porphyria is an autosomal dominant disorder that results from a partial deficiency of porphobilinogen deaminase and that causes very severe symptoms. Attacks may be triggered by a series of drugs and by other factors that the anesthesiologist should be aware of in order to reduce morbidity and mortality. Our objective is to review anesthetic considerations in acute intermittent porphyria. We present the case of a patient diagnosed with acute intermittent porphyria who was scheduled for knee arthroscopy. The anesthetic technique used was a femoral and sciatic nerve block under sedation with an infusion of remifentanil. The surgery proceeded without incident and the patient was discharged home after 24h. We consider the use of a peripheral plexus block of the lower limb to have been the safest anesthetic technique for this patient.

Velamiento del ventrículo izquierdo por bulla pulmonar gigante / No disponible

No disponible

Atención psicológica y psiquiátrica en Cuidados Paliativos (IV): 10 años de un programa de enlace / Psychological and psychiatric assistance in palliative care (IV): ten years of a consultation-liaison program

Se realiza un estudio descriptivo y de asociación simple con una serie clínica de 73 enfermos terminales atendidos entre 1995-2005 por la Unidad de Psiquiatría de Enlace del Hospital de Osuna. Los diagnósticos más frecuentes son los adenocarcinomas de colon (31,5%), mama (15,1%), tumores genitourinarios (13,7%) y pulmón (8,2%). El diagnóstico psiquiátrico más frecuente fue el de trastorno adaptativo (47,2%), seguido por “reacción emocional no patológica” (23,6%), síndrome confusional agudo (15,3%) y depresión (5,6%). La intervención de Enlace habitual fue mixta (fármacos + psicoterapia individual + intervención familiar + staff). Los pacientes tenían normalmente un bajo nivel de información diagnóstica, pronóstica y terapéutica sobre su proceso tumoral, demandando más información médica con frecuencia. No existieron diferencias de género en ninguna de las variables diagnósticas consideradas, así como en “tipo de intervencón terapéutica” o “nivel de información”. La intervención sobre el staff en aspectos de comunicación, emocionales, legales o bioéticos fue también habitual. Se necesita mejorar la atención psicosocial que se presta a los enfermos terminales en nuestro ámbito, así como cambiar actitudes médicas y familiares paternalistas e incrementar el flujo de información médico-paciente

A descriptive and association study using a clinical sample of n=73 hospitalized, terminal patients is played. Patients were assessed between 1995-2005 in the Consultation-Liaison Psychiatric Unit of Osuna Hospital, Seville, Spain. The most prevalent cancer diagnosis were colon (31.5%), breast (15.1%), genitourinary (13.7%) and lung (8.2%). Psychiatric and psychological assessment found adjustment disorders (47.2%), non-pathological emotional reaction (23.6%), acute confussional state (15.3%) and depression (5.6%). Usually, we play a combinated therapeutic intervention (psychoactive drugs plus individual and family psychotherapy plus intervention on staff). Patients had commonly a poor level of diagnostic, prognostic and therapeutic information about his/her cancerous disease, and they demanded a higher level of medical information. There were no gender differences in any of the variables considered in the association study, and also no differences were found in variables as “type of therapeutic intervention” or “level of information”. Intervention on staff included communicational, legal, emotional and bioethical aspects. Psychological assistance implemented and directed to terminal patients in hospitalary setting must be optimised. Medical and familial paternalistic attitudes must also be changed. Certainly, communication feed-back between and clinical must be improved

Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care.

OBJECTIVES: To compare the effectiveness and costs of a new domiciliary rehabilitation service for elderly stroke patients with geriatric day-hospital care. DESIGN: Randomized controlled trial. PARTICIPANTS: Stroke patients aged 55+ who required further rehabilitation after hospital discharge or after referral to geriatricians from the community. SETTING: Poole area, East Dorset, a mixed urban/rural area on the south coast of England. MAIN OUTCOMES: Primary-changes between hospital discharge and 6-month follow-up in physical function as measured by Barthel index. Secondary-changes over this period in Rivermead Mobility Index and mental state (Philadelphia Geriatric Centre Morale Scale) and differences in social activity (Frenchay Activities Index) and generic health status (SF-36). Health service and social service cost per patient were compared for the two groups. RESULTS: 180 patients were eligible and 140 (78%) were randomized. The groups were well balanced for age, sex, social class and initial Barthel index. We achieved follow-up in 88% of subjects who were alive at 6 months. We detected no significant differences in patient outcomes, although there was a non-significant improvement in measures of physical function and social activity in the domiciliary group. Domiciliary patients had more physiotherapy time per session and more district nurse time, and made greater use of social service day centres and home helps. Total cost per patient did not differ significantly between the two groups, with reduced health service costs in the domiciliary arm offset by higher social service costs. CONCLUSION: No significant differences were detected in the effectiveness of the two services. Neither service influenced patients' mental state, and their social activity remained low. Total costs were similar. A mixed model of day-hospital and domiciliary care may be most cost-effective for community stroke rehabilitation, but this requires further evaluation.

[Malignant Mediterranean boutonneuse fever. Septic shock of unknown origin?]. / Fiebre botonosa mediterránea maligna. Shock séptico de origen desconocido?

Mediterranean Botonous Fever (MBF) is an infectious disease which provokes multisystemic vasculitis due to endothelial proliferation of rickettsia conorii. Its incidence, in our environment, has greatly increased during the last years being endemic in many large cities and their surrounding suburbs. In some cases its evolution is specially malignant resulting in septic shock, adult respiratory distress syndrome, and multiorgan failure. The purpose of this communication is to present a new case of malignant MBF with a bad evolution factor which has not been previously referred to, which is the persistence of vector ticks in the inoculation spot.

Alfa-one antitrypsin phenotypes and inhalatory pulmonary pathology.

One hundred and twenty nine workers in the cork industry, 69 rural workers, 66 carpet makers, 58 workers in a granite quarry and 51 workers in a rice husking factory were studied from an epidemiologic point of view. All were submitted to a standard questionnaire planned to detect respiratory disease due to inhalatory causes. They were submitted to a clinical examination, summary ventilatory function tests, a 70 mm microradiograph, and blood was taken to determine alfa-one antitrypsin and its phenotypes and, in the cork industry workers and rice husking workers, the level of IgA, IgG and IgM. The results are presented and an attempt is made to correlate the various parameters among themselves, and namely alfa-one AT phenotypes with the existence of respiratory pathology. Finally the results are discussed.