In reply to the letter to the editor regarding "Palisade cartilage tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for transcanal endoscopic treatment of subtotal tympanic membrane perforations: a retrospective study".

This is a reply letter to the manuscript "The size and diameter of pieces of cartilage are not fixed for the palisade technique and one-piece technique", regarding the elevation of a tympanomeatal flap and keratin pearl formation in "Palisade cartilage tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for transcanal endoscopic treatment of subtotal tympanic membrane perforations: a retrospective study" ( https://doi.org/10.1007/s00405-020-05947-3 ).

Cross-cultural adaptation and validation of the Spanish version of the Paediatric Throat Disorders Outcome Test (T-14).

OBJECTIVES: The Paediatric Throat Disorders Outcome Test (T-14) is a disease-specific questionnaire that parents are requested to complete; it aimed to assess the quality of life related to tonsil and adenoid disease or its treatment in children with throat disorders. The aim of this study was to validate the Spanish adaptation of the T-14, thus allowing comparison across studies and facilitating international multicentre projects. DESIGN, SETTING AND PARTICIPANTS: This was a multicentre prospective instrument validation study. Guidelines for the cross-cultural adaptation process from the original English-language scale into a Spanish-language version were followed. The psychometric properties (reproducibility, reliability, validity, responsiveness) of the Spanish version ("T-14-s" for "T-14-Spanish") were assessed in 50 consecutive children undergoing adeno/tonsillectomy (both before and 6 months after surgery) and in a separate cohort of 50 unaffected children in a comparable age range. MAIN OUTCOME MEASURES AND RESULTS: Test-retest reliability (γ = 0.83) and internal consistency reliability (α = 0.94) were adequate. The T-14-s demonstrated satisfactory construct validity (r > 0.40). The instrument showed excellent between-group discrimination (P < .0001) and a high responsiveness to change (effect size = 2.09). CONCLUSIONS: The Spanish version of the T-14 (T-14-s) is a valid tool for measuring the subjective severity of throat disorders, and its use is recommended.

Evolution of the clinical profile of patients with acute heart failure treated in Spanish emergency departments. / Evolución del perfil clínico de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias españoles.

OBJECTIVE: To analyse the changes in epidemiology, outpatient and emergency department clinical care, and outcomes of patients treated for acute heart failure (AHF) in Spanish hospital emergency departments (HEDs) between 2007 and 2014. METHOD: A multicentre cohort study was conducted that consecutively included patients with AHF diagnosed in 9HEDs during 4 periods (2007, 2009, 2011 and 2014). The study analysed the changes observed in 20 variables corresponding to baseline data, outpatient care and emergency care data and outcome data. RESULTS: A total of 4,845 patients were included. There were significant changes in 13 variables: there was an increase in patients older than 80years (2007/2014: 45.9%/55.4%; P<.001) and a decrease in severe functional dependence (28.2%/19.7%; P<.001). In terms of long-term outpatient care, there was an increased use of beta-blockers (44.6%/57.8%; P=.002) and aldosterone antagonists (26.6%/37.7%; P<.05) among patients with reduced ejection fraction and an increase use of echocardiography (42.8%/56.2%; P=.001). The use of digoxin decreased (25.4%/16.9%; P=.005). In terms of emergency care, there was an increase in requests for troponins (54.6%/61.9%; P<.001), natriuretic peptides (7.8%/48.5%; P<.001) and the use of noninvasive ventilation (3.2%/6.9%; P=.004). Requests for endovenous perfusion drugs decreased (diuretics: 21.3%/10.4%; P<.001; nitrates: 21.3%/17.5%; P=.001; vasopressors: 4.2%/1.5%; P<.001). Finally, discharges directly from the emergency department without hospitalization increased (20.0%/25.9%; P<.001), and emergency department readmissions at 30days decreased (27.3%/17.6%; P=.007). Hospital mortality and mortality at 30days did not change. CONCLUSIONS: Changes in outcomes were detected during a 7-year period in patients with AHF treated in HEDs, with care that was more in line with the clinical guidelines. There are, however, areas for improvement. There was a noteworthy increase in outpatient follow-up without hospitalisation and a reduction in HED readmissions.

Simulación de alta fidelidad en España: de la ensoñación a la realidad / High fidelity simulation in Spain: from dreams to reality

La simulación clínica ha surgido como una potente herramienta para el aprendizaje y evaluación de las diferentes capacidades y actitudes en el ámbito de las Ciencias de la Salud, mediante el uso de tecnologías innovadoras, como los simuladores de alta fidelidad (HFS). Objetivo. Describir el estado actual de la dotación de equipos de simulación clínica de alta fidelidad en nuestro país e identificar sus características principales. Método. Estudio observacional descriptivo que analiza la información sobre los centros que poseen HSF en nuestro país. Resultados. Existen actualmente un total de 80 centros dotados de HFS en nuestro país, distribuidos principalmente en centros universitarios (43), centros hospitalarios y de urgencias (27), e institutos o centros de simulación (5), estando el resto (5) asociado a entidades de diversa titularidad. El desarrollo temporal de los HFS ha sido lentamente progresivo, experimentando un importante crecimiento en el último sexenio. En su mayoría (74%) cuentan con instalaciones específicas, equipos auxiliares (60%) y profesionales con dedicación compartida (80%). Está integrada ya en los programas de formación del 56% de los centros universitarios dotados de HFS. Conclusiones. Disponemos actualmente de un notable desarrollo de HFS en nuestro país, principalmente relacionados con la docencia médica pregrado universitaria y posgrado hospitalaria. Sería de utilidad diseñar una red de centros de formación en simulación de Ciencias de la Salud en España, que sea operativa, sostenible y reconocida, que permita optimizar la utilización de estos centros (AU)

Clinical simulation has emerged as a powerful new tool for the learning and assessment of different skills and attitudes in patient care, by using innovative technology such as high fidelity simulators (HFS). Objective. To describe the current state of high fidelity clinical simulation in Spain and its principal characteristics. Methods. Descriptive observational study that analyzes information on the clinical centers that have HFS in our country. Results. There are currently a total of 80 centers with HFS in our country, mainly distributed in university centers (43), hospital and emergency centers (27), simulation centers and institutes of simulation (5), and the rest (5) associated to entities of diverse ownership. The temporal development of HFS has been slowly progressive, with a significant growth in the last 6 years. The majority (74%) have specific facilities, auxiliary equipment (60%), and professionals with a shared commitment (80%). It is already integrated into the training programs in 56% of university centers with HFS. Conclusions. The development of HFS has been remarkable in our country, and is mainly related to university undergraduate and postgraduate clinical medical education. It would be useful to design a network of simulation training centers of Health Sciences in Spain, which would be operational, sustainable and recognized, to optimize the use of these facilities (AU)

[High fidelity simulation in Spain: from dreams to reality]. / Simulación de alta fidelidad en España: de la ensoñación a la realidad.

UNLABELLED: Clinical simulation has emerged as a powerful new tool for the learning and assessment of different skills and attitudes in patient care, by using innovative technology such as high fidelity simulators (HFS). OBJECTIVE: To describe the current state of high fidelity clinical simulation in Spain and its principal characteristics. METHODS: Descriptive observational study that analyzes information on the clinical centers that have HFS in our country. RESULTS: There are currently a total of 80 centers with HFS in our country, mainly distributed in university centers (43), hospital and emergency centers (27), simulation centers and institutes of simulation (5), and the rest (5) associated to entities of diverse ownership. The temporal development of HFS has been slowly progressive, with a significant growth in the last 6 years. The majority (74%) have specific facilities, auxiliary equipment (60%), and professionals with a shared commitment (80%). It is already integrated into the training programs in 56% of university centers with HFS. CONCLUSIONS: The development of HFS has been remarkable in our country, and is mainly related to university undergraduate and postgraduate clinical medical education. It would be useful to design a network of simulation training centers of Health Sciences in Spain, which would be operational, sustainable and recognized, to optimize the use of these facilities.

Aphysiologic performance on dynamic posturography in work-related patients.

It has been suggested that malingering should be suspected in patients suffering from dizziness or imbalance and who had a potential gain associated with insurance and worker's compensation claims. This study aimed to assess and compare the prevalence of aphysiologic performance on computerized dynamic posturography (CDP) in patients with the potential for secondary gain using a retrospective review of two groups of patients: work-related patients referred for dizziness and/or imbalance (Group 1) were compared against a group of patients with complaints of dizziness or imbalance, who had no history of work-related injury, or litigation procedures (Group 2). CDP and videonystagmography (VNG) were carried out in all patients. The Sensory Organization Test summaries were scored as normal, aphysiologic, or vestibular using the scoring method published by Cevette et al. in Otolaryngol Head Neck Surg 112:676-688 (1995). 24 out of 88 (27%) patients had aphysiologic CDP in Group 1 and 9 out of 51 (18%) in Group 2 but these differences were not significant (p > 0.05). Definite signs of vestibular dysfunction were found in 12 out of 24 (50%) of patients with aphysiologic performance in Group 1 although the presence of VNG abnormalities was significantly higher (p = 0.005) in Group 2. The hypothesis that the occupational group could show a significantly higher rate of aphysiologic results than a control group is not confirmed. Furthermore, VNG abnormalities were found in 50% of the work-related cases with non organic sway patterns. These results suggest that patient's complaints should be considered genuine in work-related cases and due caution exercised when evaluating aphysiologic CDP patterns.

Resultados de pruebas de control postural y función vestibular en 51 pacientes con antecedente de latigazo cervical y síntomas de vértigo e inestabilidad / Results of balance control and vestibular function tests in 51 patients with whiplash injury complaining of dizziness and imbalance

Introducción y objetivos. El vértigo y la inestabilidad tienen una importante implicación médico-legal en el paciente con antecedente de latigazo cervical (LC). En estos casos la posturografía dinámica computarizada (PDC) aporta información adicional a las pruebas vestibulares estándar y tiene descritos patrones compatibles con escasa colaboración o falta de sinceridad al esfuerzo, también denominados afisiológicos. El objetivo de este trabajo es valorar las características de las pruebas de equilibrio y función vestibular en pacientes con LC y especialmente, los resultados afisiológicos. Material y métodos. Estudio retrospectivo de pacientes con antecedente de LC con vértigo y/o inestabilidad. Se realizó videonistagmografía (VNG) y PDC. Los resultados de la prueba de organización sensorial (SOT) se valoraron como normales, vestibulares o afisiológicos usando el método de cálculo publicado por Cevette et al. en 1995. Resultados. Cincuenta y uno pacientes (24 varones, 27 mujeres); edad media: 42,2 años; tiempo de evolución medio: 3,8 m; PDC afisiológica: 13 (25,5%); PDC vestibular: 9 (17,6%); PDC normal: 29 (56,9%); VNG normal: 29 (56,9%); VNG alterada: 22 (43,1%); VNG vestibular: (n=11); VNG central: (n=6), y VNG cervical: (n=5). En el 46,2% de pacientes con PDC afisológica la VNG estaba alterada. Conclusiones. La prevalencia de pruebas afisiológicas en la PDC en el LC es relativamente elevada sin que deba suponerse simulación o exageración ya que en muchos casos existen signos objetivos de disfunción vestibular. Sería recomendable realizar pruebas de función vestibular a los pacientes con LC con síntomas vertiginosos. La rehabilitación vestibular podría ser de utilidad en estos casos (AU)

Introduction. The medical legal implications of dizziness and imbalance among patients with whiplash-associated disorders (WAD) are important. In these cases, Computerized Dynamic Posturography (CDP) provides information to standard vestibular tests and patterns consistent with scarce collaboration or lack of sincerity on efforts have been described. Objectives. This work has aimed to assess the prevalence of altered balance and vestibular function tests in patients with whiplash injury, and especially the aphysiologic results. Material and methods. A retrospective review of patients with whiplash injury referred for assessment of dizziness and/or imbalance was carried out. Standard videonistagmophgraphy (VNG) assessment including CDP was performed in all patients. The Sensory Organization Test (SOT) summaries were scored as normal, aphysiologic, or vestibular using the scoring method published by Cevette et al. in 1995. Results. The study included 51 patients (24 men, 27 women) with mean age: 42.2 years. Mean evolution time was 3.8 m. Aphysiologic CDP 13 (25.5%); vestibular CDP 9 (17.6%); normal CDP 29 (56.9%). Normal VNG 29 (56.9%); altered VNG in 22 (43.1%): vestibular VNG (n=11); central VNG (n=6); cervical VNG (n=5). VNG was altered in 46.2% of patients with aphysiologic CDP. Conclusions. The prevalence of aphysiologic results on CDP among whiplash injury patients is relatively high, however, this should not necessarily be consider to be related to malingering or exaggeration since objective signs of vestibular dysfunction are found in many cases. Thus, we recommend these tests should be done in whiplash injury patients complaining of dizziness and imbalance. Vestibular rehabilitation could be of interest in the recovery of these patients (AU)

Differential clinical characteristics and outcome predictors of acute heart failure in elderly patients.

OBJECTIVE: We determined the clinical-epidemiological characteristics and prognostic factors of early mortality and re-consultation in an elderly population attending the hospital emergency department (HED) for acute heart failure (AHF). PATIENTS AND METHODS: A prospective, observational, non interventional study including all the patients with AHF attended in the Spanish's HED. Two groups were defined: elderly (≥ 80 years) and controls (< 80 years). VARIABLES: demographic characteristics, comorbidity, degree of cardiac involvement, previous treatment, symptoms and signs of the AHF episode, precipitating factors, treatment in the HED and outcome. OUTCOME VARIABLES: mortality and re-consultation within 30 days. RESULTS: Of the 942 patients included, 455 of whom were elderly (48.3%). In this elderly population female sex, auricular fibrillation and a history of ictus and a poor functional status predominated. The type of ventricular dysfunction was unknown in 70%. No main differences in the presentation of AHF were found between the two groups. Mortality and re-consultation to the HED within 30 days were similar in both groups. While several factors were identified to be related to mortality or re-consultation in control group, in the elderly group it was more difficult to identify patients who will die or re-consult to the HED within the following 30 days. Only respiratory insufficiency on arrival to the HED was found to predict a greater probability of death (OR 3.55; CI95% 1.39-9.11). CONCLUSIONS: AHF in elderly patients presents some differential characteristics and, most importantly, it is more difficult to identify which of these patients will die or re-consult in the short-term.

[Intraoperative complications of corticosubcortical mapping]. / Complicaciones intraoperatorias del mapeo corticosubcortical.

By looking through our cases and literature, an analysis of the surgical complications derived from direct cerebral stimulation under general anesthesia and local anesthesia and sedation was made. A retrospective descriptive study was performed including patients who were intervened in our centre from 2004 to 2008 and had the cortico-subcortical mapping technique. Common pre-operation variables were as follow: Age, sex, tumor localization and tumor's pathology; On patients intervened while awake, we collected the ASA, BMI and duration of the intervention. Afterwards, variable like epileptic attacks and cerebral edema were included in two groups. In addition, on those awake, respiratory and circulatory complications, local anesthesia toxicity, poor level of sedation, nausea and vomiting, pain and feeling uncomfortable with body posture were collected as well. A total of 20 patients had surgery. 10 of them were operated under local anesthesia and sedation with a mean age of 41 years, mean BMI of 26.8 and a pre-operatory ASA score of I or II ( except one patient with ASA III). The mean time duration of the surgical procedure was 5 hours and 20 minutes. On the other side, 10 patients were intervened with general anesthesia with a mean age of 55 years. There were no cases of cerebral edema in either group, although in 4 patients had epileptic attacks which resolved with cold saline irrigation. Five patients with local anesthesia and sedation did not have any complication, 2 patients showed desaturation episodes without further complications, three manifested hypertension episodes and two signs of feeling uncomfortable with body posture. None of the intra-operatory complications registered interfered wit the overall surgical procedure. This is a safe technique if performed following recommended indications and parameters. Regarding complications, respiratory complications are the most common and the most dangerous, as they can influence in the surgical procedure for difficult cases.

Complicaciones intraoperatorias del mapeo corticosubcortical / Intraoperative complications of corticosubcortical mapping

Mediante una revisión de nuestra casuística y dela literatura analizamos las complicaciones intraoperatoriasderivadas del uso de las estimulaciones cerebralesdirectas bajo anestesia general y anestesialocal y sedación. Se realizó un estudio retrospectivodescriptivo de los pacientes intervenidos (2004-2008)en que se utilizó la técnica del mapeo corticosubcortical.Se determinaron como variables preoperatoriascomunes: edad, sexo, localización tumoral, anatomíapatológica, y en los pacientes operados despiertos, seregistró el ASA, IMC y duración de la intervención.En los dos grupos se constataron la aparición de edemacerebral o crisis comiciales. En los pacientes despiertosse registró además las complicaciones respiratorias,hemodinámicas, toxicidad por anestésico local, nivelinadecuado de sedación, náuseas/vómitos, dolor eincomodidad postural. Bajo anestesia local y sedaciónse operaron 10, de 41 años de edad media, IMC mediode 26,8 y un ASA preoperatorio de I o II . La duraciónmedia de la intervención fue de 5 horas y 20 minutos.Mediante anestesia general se intervinieron 10 pacientes,de 55 años de media. En ningún caso de los dosgrupos se constató edema cerebral, 4 pacientes presentaroncrisis comiciales (autolimitadas con irrigación desuero frío). En 5 pacientes con anestesia local y sedaciónno registramos ninguna complicación, 2 pacientes episodiosde desaturación sin complicaciones, 3 episodiosde hipertensión y 2 incomodidad postural. Ninguna delas complicaciones intraoperatorias que registramosinterfirió en el desarrollo de la cirugía. Es una técnicasegura si se realiza siguiendo las indicaciones y losparámetros recomendados. Las crisis y complicacionesrespiratorias son las complicaciones más frecuentes ya su vez las más temidas, puesto que pueden influir encasos problemáticos en el proceso de la cirugía (AU)

By looking through our cases and literature, ananalysis of the surgical complications derived fromdirect cerebral stimulation under general anesthesiaand local anesthesia and sedation was made. A retrospectivedescriptive study was performed includingpatients who were intervened in our centre from 2004to 2008 and had the cortico-subcortical mapping technique.Common pre-operation variables were as follow:Age, sex, tumor localization and tumor’s pathology; Onpatients intervened while awake, we collected the ASA,BMI and duration of the intervention. Afterwards,variable like epileptic attacks and cerebral edema wereincluded in two groups. In addition, on those awake,respiratory and circulatory complications, local anesthesiatoxicity, poor level of sedation, nausea and vomiting,pain and feeling uncomfortable with body posturewere collected as well. A total of 20 patients had surgery.10 of them were operated under local anesthesia andsedation with a mean age of 41 years, mean BMI of 26.8and a pre-operatory ASA score of I or II ( except onepatient with ASA III). The mean time duration of thesurgical procedure was 5 hours and 20 minutes. On theother side, 10 patients were intervened with generalanesthesia with a mean age of 55 years. There were nocases of cerebral edema in either group, although in 4patients had epileptic attacks which resolved with coldsaline irrigation. Five patients with local anesthesiaand sedation did not have any complication, 2 patientsshowed desaturation episodes without further complications,three manifested hypertension episodes and (..) (AU)

Light and immunoelectronmicroscopic study of Hodgkin's disease: evidence of immunoglobulin synthesis by tumor cells.

The direct immunoperoxidase technique with peroxidase-conjugated F(ab')2 fragments was used at the light and electron microscopic levels to identify intracytoplasmic immunoglobulin (CIg) components in malignant cells of Hodgkin's disease. In each of the 27 cases studied, Hodgkin and Reed-Sternberg cells contained either IgG or IgM, with both light chains often present simultaneously. The number of IgG-positive malignant cells was inversely related to changes in the lymphoid compartment, as defined by the Rye grading system. The evolution from lymphocytic predominance to lymphocytic depletion was paralleled by a decrease of IgM-positive cells and by a substantial increase (to exclusiveness) of IgG-containing cells. These immunoelectronmicroscopic studies disclosed definite morphologic evidence of CIg synthesis by Hodgkin, Reed-Sternberg and lacunar cells. The immunoglobulin components were also synthesized by lymphoid B cells at different levels of modulation. Immunoglobulin synthesis by malignant cells was localized in perinuclear zone, on free cytoplasmic ribosomes and profiles of rough endoplasmic reticulum. The results of this joint light and electron microscopic study support the view that Hodgkin, Reed-Sternberg and lacunar cells belong to the B-cell compartment within Hodgkin's disease.