Sistema inteligente para la gestión de la demanda en atención primaria.

INTRODUCTION AND OBJECTIVES: The Galician Health Service designed a system to improve demand management in primary care known as "XIDE". In it, all professionals participate in an interdisciplinary manner and within their competence framework, to respond to a reason for consultation in a certain time and manner. This article evaluates the pilot phase of implementation of XIDE in primary care of the Galician Health Service. MATERIALS AND METHODS: Cross-sectional descriptive study carried out in 45 primary care centers selected opportunistically at the discretion of the management of the Galician Health Service. For each center, were included all on-demand appointments requested by the adult population in the administrative units in person or by telephone, between 11/2021-05/2022. The XIDE integrates an intelligent search engine that, through algorithms, guides the administrative staff to make an appointment on demand. It performed a descriptive analysis of all the variables, as well as a bivariate analysis with chi-square to identify the causes of the population's rejection of XIDE. RESULTS: The three most frequent reasons for consultation were: knowing the results of the analysis (11.2%), performing blood tests (11.2%) and prescriptions for drugs (10.9%). Family medicine and nursing professionals are the ones who received the most citations. 22.1% of the appointments required to be scheduled on the same day or immediately. The acceptance of the population to the XIDE system was 85.0%. The reason for consultation, response time, mode of care and the recipient professional had a significant influence (p<0.0001) on the rejection of the appointment. CONCLUSIONS: The XIDE adapts globally well to the appointment systems and the organization of primary care of the Galician Health Service, which could facilitate its extension to all health centers in Galicia. However, it is necessary to delve deeper into the causes of rejection in order to introduce improvements that guarantee its viability in the medium-long term.

Analysis of skull bone thickness during growth: an anatomical guide for safe pin placement in halo fixation.

PURPOSE: To assess skull bone thickness from birth to skeletal maturity at different sites to provide a reference for the correct selection of pin type and pin placement according to age. METHODS: 270 children and adolescents (age: 0-17 years) with a normal CT scan obtained at Emergency Department for other medical reasons were included. Skull thickness was measured on the axial plane CT scans at eight different sites of the vault: midline anterior (A) and posterior (P), right and left lateral (L), antero-lateral (AL), postero-lateral (PL). RESULTS: From birth to skeletal maturity, L thickness was increased significantly less (+ 58%) compared with AL (+ 205%), P (+ 233%), PL (+ 247%), and A (+ 269%) thickness (P < 0.01). At the end of growth, the thickest and thinnest points of the vault (absolute value) were found at the P and L measurement sites, respectively (P < 0.01). Children aged < 4 years exhibited the highest variability in AL and PL skull bone thickness, with thickness < 3 mm observed in 85% (64/75 patients) and 92% (69/75 patients) of cases, respectively. CONCLUSION: We recommend that the tip of the pin should not exceed 2-3 mm in children aged < 4, and 4 mm in children aged 4-6 years, to decrease the risk of inner table perforation. After the age of 7 years and 13 years, standard-sized pin tips (5 and 6 mm, respectively) may be safely used. Children aged < 4 years show significant variability in skull thickness, and therefore a CT scan may be required for this particular age group.

Correction to: Analysis of skull bone thickness during growth: an anatomical guide for safe pin placement in halo fixation.

Unfortunately, the author group has been incorrectly listed by the first name instead of the family name in the original publication. The complete correct author group should read as follows.

Marking petroglyphs with calcite and gypsum-based chalks: Interaction with granite under different simulated conditions and the effectiveness and harmfulness of cleaning methods.

Marking petroglyphs with chalk is a common practice to enhance them for documentation and reproduction. Although this procedure has started to be less frequently used, there is no knowledge about the interaction between the rock engravings nor about the effectiveness achieved by the common cleaning procedures of such markers considering the chalk extraction and the induced damage to the rock. This study evaluates the interaction between two chalks of different composition (calcite and gypsum) and a granite on which the majority of NW Iberian Peninsula-petroglyphs are carved. Granitic samples marked with these chalks were subjected to artificial rain events and high temperatures (700°C) related to fires. After each aging test, chemical and physical modifications on the rock were analysed by means of stereomicroscopy, x-ray diffraction, Fourier transform infrared spectroscopy, scanning electron microscopy and colour spectrophotometry. Moreover, the evaluation of the effectiveness and harmfulness of several mechanical and chemical cleaning procedures commonly used in the field of cultural heritage conservation was carried out. Both chalks remained at different extent on the surface after the artificial rain events. Water would promote a different penetration-depth of the chalks into the stone, depending on their solubility. High temperatures led to mineral phase transformations of the chalks influencing the interaction with the rock. Regarding cleaning effectiveness, despite a few chalk remains were found in all the cleanings, chemical methods showed higher effectiveness than mechanical procedures even though some of them leave chemical contamination. Benzalkonium chloride can be considered as the cleaner with the best results to extract both types of chalk on granite.

Síndrome de bazex: acroqueratosis paraneoplásica secundaria a cáncer de próstata / Bazex syndrome: paraneoplasic acroqueratosis secondary to prostatic cancer

La piel puede ofrecer el primer síntoma guía en el 1% de los pacientes con neoplasias internas. Las manifestaciones cutáneas de malignidades internas se pueden producir por invasión directa de la piel por el tumor y por diseminación metastásica, pero existen mecanismos indirectos que inducen la aparición de signos y síntomas cutáneos no relacionados con el tumor primitivo. El Síndrome de Bazex es una rara dermatosis descrita por Bazex y colaboradores en 1965. Se caracteriza por la presencia de placas eritematosas, psoriasiformes, que típicamente afectan a las manos, los pies, la nariz y los pabellones auriculares. La inexperiencia puede motivar retrasos en el diagnóstico, haciendo que la neoplasia asociada se encuentre en estadios avanzados en el momento del diagnóstico. Se discute un caso clínico de un paciente masculino de 53 años de edad, hipertenso, quien acude por presentar lesiones cutáneas tipo placas hipertróficas, hiperpigmentadas, descamativas y dolorosas con fondo eritematoso acompañados de secreción hialina amarillenta en regiones acrales y cuero cabelludo. La biopsia cutánea reportó granulocitosis y aumento del espesor de la capa córnea; en los cultivos bacteriano y micológico de tejido dérmico creció flora habitual. La biopsia prostática diagnosticó adenocarcinoma prostático Gleason 4/5, Se inició hormonoterapia y se realizó prostatectomía total, con mejoría clínica significativa posterior al inicio del tratamiento. La acroqueratosis de Bazex es un proceso muy infrecuente, con pocos casos descritos en la literatura. Su reconocimiento temprano podría permitir el diagnóstico de la neoplasia asociada en estadios más precoces y conducentes a un tratamiento más temprano(AU)

The skin can show the first symptom in 1% of patients with internal neoplasias. Cutaneous manifestations of internal malignancies can be caused by direct invasion of the skin by the tumor and by metastatic dissemination, but there are indirect mechanisms that induce the appearance of cutaneous signs and symptoms unrelated to the primitive tumor. Bazex Syndrome is a rare dermatosis described by Bazex et al. in 1965. It is characterized by the presence of erythematous, psoriasiform plaques, which typically affect the hands, feet, nose, and ear-lobes. The lack of experience may carry diagnostic delays and the associated neoplasia could be at advanced stages when diagnosed. We describe here the case of a 53-year-old male patient, who consulted for cutaneous lesions.These were hypertrophic, hyperpigmented, scaly and painful plaques with an erythematous background accompanied by a yellowish hyaline secretion in the hands, feet and scalp. A skin biopsy was done that reported granulocytosis and increased thickness of the corneal layer; in addition, bacterial and mycological culture of dermal tissue were negative. The prostate biopsy diagnosed a prostate adenocarcinoma, Gleason 4/5. Hormone therapy was started and total prostatectomy was performed, with significant clinical improvement .Bazex acroqueratosis is a very rare process, with few cases described in the literature. Its early recognition could allow the diagnosis of the associated neoplasia in earlier stages, leading to earlier treatment(AU)

Eficacia y seguridad de la embolización en pacientes con diagnóstico de varices pélvicas / Efficacy and safety of embolisation in patients diagnosed with pelvic varices

El síndrome de congestión pélvica (SCP) o varices pélvicas (VP) es una entidad que pueden sufrir millones de mujeres en el mundo, y su ocurrencia puede llegar hasta un 39%. Son múltiples los factores que contribuyen la patofisiología del SCP. Hasta un 15% de las mujeres entre las edades de 20 a 50 años tienen venas varicosas en la pelvis, aunque no todas experimentan síntomas. Objetivo: Determinar la eficacia y seguridad de la flebografía y embolización de las VP como noxa del SCP. Material y métodos: Se incluyeron, desde junio de 2014 hasta diciembre de 2015, 75 mujeres sintomáticas remitidas de otros centros con diagnóstico de SCP; de ellas 24 pacientes (edades comprendidas entre 26 a 55 años con una media de 37 años) reportaron presencia de VP confirmadas con ultrasonido transvaginal (UST), posteriormente a este grupo se le realizó una flebografía control para ratificar dicho diagnóstico e inmediata embolización si así lo requerían. Se estableció el score escala analógica visual para determinar clínicamente el éxito del procedimiento con seguimiento a los 3, 6, 9 y 12 meses, correlacionando con el de base previo al procedimiento; además se realiza UST a los 6 meses para determinar el cierre o recanalización, y una flebografía control a los 12 meses con el mismo objetivo. Estos parámetros se recogieron en una plantilla base. Resultados: La presencia de VP asociada a SCP en nuestra ciudad, por ser nuestra institución centro de referencia nacional, constituyó un 3,9% de la población femenina recibida durante el año 2015. El 100% (n=24) de nuestras pacientes fue sintomática, donde la dispareunia era uno de los factores mayormente referido (100%); además el 100% de la población estudiada presentó como factor de riesgo la multiparidad y solo un 37% de ellas mostró varices en los miembros inferiores; cuando se realizó la flebografía control solamente en el 83% (n=20) de las pacientes referidas por US transvaginal con VP se confirmó el diagnóstico. Posteriormente al procedimiento no tuvimos complicaciones, el 8,3% de pacientes presentó recurrencia de síntomas a los 9 meses de seguimiento, se les realizó una flebografía control y se embolizó los vasos venosos ectásicos dependientes de la vena iliaca interna derecha y gonadal derecha, respectivamente. Al seguimiento a los 12 meses no tuvimos recurrencia de síntomas en ninguna de ellas. No tuvimos diferencias en el éxito de oclusión con el uso de coils vs polidocanol. Conclusión: La flebografía es un método específico y con baja tasa de complicaciones para el diagnóstico de VP. La embolización de VP con uso de coils o polidocanol representa un método eficaz y seguro como tratamiento del SCP

Objective: Pelvic congestion syndrome (PCS), or pelvic varices (PV), is an entity suffered by millions of women worldwide, and its occurrence can reach up to 39%. Multiple factors contribute the pathophysiology of the PCS. Up to 15% of women between the ages of 20 and 50 years-old have varicose veins in the pelvis, although not all experience symptoms. The aim of this study was to determine the efficacy and safety of phlebography and embolisation of the PV as treatment for PCS. Material and methods: The study included 75 symptomatic women, who were enrolled from June 2014 to December 2015 after being referred from other centres with a diagnosis of PCS. Of these, 24 patients (aged 26-55 years with a mean of 37 years) were diagnosed with the presence of PV using transvaginal ultrasound. A venography was performed on this group to verify the diagnosis, and immediate embolisation was performed, if this was possible and required. The VAS score was measured to clinically determine the success of the procedure at 3, 6, 9, and 12 months of follow-up, correlating with prior to the procedure base. Transvaginal ultrasound was also performed at 6 months to determine the closure or rechannelling, as well as a phlebography at 12 months, with the same objective. These parameters were collected in a base template. Results: The presence of PV associated with PCS in our city, due to being a central institution of national reference, was 3.9% of the female population seen from June of 2014 to December 2015. All the 24 patients were symptomatic, with dyspareunia being one of the most referred to factors; 100%. All the study population presented with multiparity as risk factor, and only 37% of them showed varices in the lower limbs. When phlebography was performed the diagnosis was confirmed in only 83% (n=20) of patients referred due to PV observed in the transvaginal ultrasound. There were no complications during the follow-up of the procedure, 8.3% of patients had recurrence of symptoms at 9 months follow-up. A phlebography was performed and ectatic venous vessels dependent on the right internal iliac vein and gonadal right were embolised, respectively. There was no recurrence of symptoms in any of them after 12 months of follow-up. No differences were observed in the successful occlusion with the use of coils vs polidocanol. Conclusion: Phlebography is a specific test and with a low complication rate for the diagnosis of PV. Embolisation of pelvic varices using coils or polidocanol is an effective and safe method for the treatment of PCS

Occupational eye lens doses in interventional cardiology. A multicentric study.

New European regulation regarding radiological protection of workers and more specifically the new occupational dose limit for the eye lens recently reduced to 20 mSv yr(-1) may affect interventional cardiologists. This paper presents a set of measurements of occupational doses performed in five interventional cardiology centres and then compared with the new dose limit. The measurement of occupational doses was performed over the apron at chest level using electronic dosemeters recording H p(10). In one of the centres, scatter dose at goggles was also measured with optically stimulated luminescence dosemeters calibrated in terms of H p(0.07). An average H p(10) over the apron of 46 µSv/procedure was measured for cardiologists. Lower doses were noted in other professionals like second cardiologists, nurses or anaesthetists. Procedures for valvular and other structural heart diseases involved the highest occupational doses, averaging over 100 µSv/procedure. Important differences in occupational doses among centres may be indicative of different radiation protection habits. The new occupational dose limit for the eye lens is likely to be exceeded by those among the interventionalists who do not use protection tools (ceiling suspended screen and/or goggles) even with standard workloads.

Tumor necrosis factor haplotype diversity in Mestizo and native populations of Mexico.

The so-called tumor necrosis factor (TNF) block includes the TNFA, lymphotoxin alpha and beta (LTA and LTB) genes with single-nucleotide polymorphisms (SNP) and microsatellites with an allele frequency that exhibits interpopulation variability. To date, no reports have included both SNPs and microsatellites at the TNF block to study Mestizo or Amerindian populations from Mexico. In this study, samples of five Mexican Mestizo populations (Durango, Guadalajara, Monterrey, Puebla, and Tierra Blanca) and four native-Mexican populations (North Lacandonians, South Lacandonians, Tepehuanos, and Yaquis) were genotyped for two SNPs (LTA+252A>G and TNFA-308G>A) and four microsatellites (TNFa, d, e, and f), to analyze the genetic substructure of the Mexican population. Allele and haplotype frequencies, linkage disequilibrium (LD), and interpopulation genetic relationships were calculated. There was significant LD along almost all of the TNF block but the lowest D' values were observed for the TNFf-TNFd pair. Mestizos showed higher allele and haplotype diversity than did natives. The genetic differentiation level was reduced among Mestizos; however, a slightly, but significant genetic substructure was observed between northern and southern Mexican Mestizos. Among the Amerindian populations, the genetic differentiation level was significantly elevated, particularly in both North and South Lacandonians. Furthermore, among Southern Lacandonians, inhabitants of Lacanja town were the most differentiated from all the Mexicans analyzed. The data presented here will serve as a reference for further population and epidemiological studies including these TNF polymorphisms in the Mexican population.

A national programme for patient and staff dose monitoring in interventional cardiology.

A national programme on patient and staff dose evaluation in interventional cardiology made in cooperation with the haemodynamic section of the Spanish Society of Cardiology has recently been launched. Its aim is to propose a set of national diagnostic reference levels (DRLs) for patients as recommended by the International Commission on Radiological Protection and to initiate several optimisation actions to improve radiological protection of both patients and staff. Six hospitals have joined the programme and accepted to submit their data to a central database. First to be acquired were the quality control data of the X-ray systems and radiation doses of patients and professionals. The results from 9 X-ray systems, 1467 procedures and staff doses from 43 professionals were gathered. Provisional DRLs resulted in 44 Gy cm(2) for coronary angiography and 78 Gy cm(2) for interventions. The X-ray systems varied up to a factor of 5 for dose rates in reference conditions. Staff doses showed that 50 % of interventional cardiologists do not use their personal dosemeters correctly.

Intercurrent events and comorbid conditions influence hemoglobin level variability in dialysis patients.

BACKGROUND: To help identify factors contributing to intra-patient Hb variability, pooled records were analyzed from 5,592 patients undergoing hemodialysis (HD) in European, multicenter, open-label, single-arm Phase 3b trials. PATIENTS AND METHODS: Patients previously treated with recombinant human erythropoietin (rHuEPO) were switched to darbepoietin-alpha administered once a week (QW) or once every 2 weeks (Q2W), maintaining the same dosing schedule and route of ESA administration (intravenous or subcutaneous) up to and through the evaluation period. Patients were treated with darbepoietin-alpha to maintain Hb levels between 10 and 13 g/dl. Intrapatient variability was calculated using the SD model, taking all of an individual patient's Hb values during the evaluation period (Weeks 21 - 24 after conversion) and calculating the SD of these Hb values. Adverse events (AE) of infection or inflammation were recorded. RESULTS: Smaller variability was seen for patients 65 years of age or older compared with younger patients (p = 0.0044) and greater variability for patients less than 40 years of age compared with older patients (p < 0.01). Little difference in variability was seen in relation to sex overall or to the presence or absence of diabetes. Intra-patient Hb variability was greater in the presence of intercurrent conditions, including infection or inflammation (p = 0.0032), blood transfusion (p < 0.0001), hospitalization (p < 0.0001), or hospitalization for cardiovascular (CV) causes (p = 0.0012), than in their absence. Iron status differences had little detectable effect on intra-patient Hb variability. A larger number of changes made to the ESA dose during the evaluation period was also associated with greater Hb variability compared with fewer dose changes, but this association could not be proved as being causative. Although p values were calculated for some comparisons, statistical significance might not indicate clinical significance because of the large sample size. Multivariable analysis to assess the association between AE status and intra-patient Hb variability, adjusting for age, sex, diabetes status, number of dose changes and iron status showed that AE status was significantly associated with Hb variability. CONCLUSION: Additional studies would be needed to further investigate causes and effects of Hb variability and intercurrent events.

Importance of dose settings in the x-ray systems used for interventional radiology: a national survey.

The purpose of this work was to investigate the differences in dose settings among the X-ray units involved in a national survey of patient doses in interventional radiology (IR). The survey was promoted by the National Society of IR and involved 10 centers. As part of the agreed quality control for the survey, entrance doses were measured in a 20-cm-thick acrylic phantom simulating a medium-sized patient. A standard digital subtraction angiography (DSA) imaging protocol for the abdomen was used at the different centers. The center of the phantom was placed at the isocenter of the C-arm system during the measurements to simulate clinical conditions. Units with image intensifiers and flat detectors were involved in the survey. Entrance doses for low, medium, and high fluoroscopy modes and DSA acquisitions were measured for a field of view of 20 cm (or closest). A widespread range of entrance dose values was obtained: 4.5-18.6, 9.2-28.4, and 15.4-51.5 mGy/min in low, medium, and high fluoroscopy mode, respectively, and 0.7-5.0 mGy/DSA image. The ratios between the maximum and the minimum values measured (3-4 for fluoroscopy and 7 for DSA) suggest an important margin for optimization. The calibration factor for the dose-area product meter was also included in the survey and resulted in a mean value of 0.73, with a standard deviation of 0.07. It seems clear that the dose setting for the X-ray systems used in IR requires better criteria and approaches.

HLA-A and HLA-B allele frequencies in a mestizo population from Guadalajara, Mexico, determined by sequence-based typing.

HLA-A and HLA-B genes were typed by DNA sequencing in a mestizo population from Guadalajara, Jalisco, Mexico. Thirty-seven HLA-A and 51 HLA-B alleles were observed in 103 samples. The common typical Amerindian alleles (>5%) and haplotypes (>or=2.0%) found were A*02010101, *24020101, *310102, B*350101, and *4002, and A*310102-B*4002, A*240201-B*350101, and the typical European alleles were A*010101, *29010101, B*1402, B*180101, and A*020101-B*1402, A*020101-B*510101, and A*3002-B*180101. This reflects the blending of the two main parental populations of mestizos: Amerindian and Iberian. Mexicans were found to be relatively closer to the Portuguese than to Spaniards. This proximity may indicate a larger Portuguese influence in Mexicans than previously considered. Present data contribute to the understanding of the genetic structure in Mexico.

Rinoplastia: de la rinoplastia estática a la dinámica. Evolución de la técnica / Rhinoplasty: from extatic to dynamic. Evolution of the technique

Se describe en este artículo, la experiencia y la evolución en la forma de realizar rinoplastias por parte de los autores. Comenzamos nuestro entrenamiento en rinoplastia estética en la ciudad de México con el Dr. Ortiz Monasterio, y aprendimos una rinoplastia básica (5) que se aplica a todos los pacientes. En los pacientes de origen caucásico se obtienen unos fantásticos resultados simplemente con la rinoplastia básica, pero los pacientes cuya característica es tener una nariz mestiza, necesitan injertos de cartílago en punta nasal y en el ángulo columelo labial, para dar angularidad a una piel gruesa y lograr sensación de refinamiento (camuflaje). Posteriormente hemos evolucionado en nuestra forma de entender la nariz pasando de la visión clásica desde un punto de vista estático a una nueva visión dinámica, desarrollando técnicas para permitir la rotación cefálica de la punta nasal y disminuir el descenso de ésta al hablar o sonreír (AU)

In this paper the author’s experience in rhinoplasty is described, and their evolution in the way of performing it. Our training in aesthetic rhinoplasty started in Mexico D.F. with Dr. Ortiz Monasterio, and we learnt a basic rhinoplasty that is applied to every patient. In patients with a Caucasian origin excellent results are obtained with this technique, but in patients with an ethnic nose cartilage grafts are needed in the nasal tip and in the lip-columela angle in order to give sharper angles to the thicker skin. This way a sensation of refining is obtained (camouflage). Our way of understanding the nose has evolved from a classic, static vision to a new, dynamic one. We have developed surgical techniques to obtain cephalic rotation of the nasal tip and diminish the downward tilt during speaking or smiling (AU)

Epidemiología de la enfermedad de Meniere en Cantabria / Epidemiology of Meniere´s disease in Cantabria

Objetivos: Conocer las principales características epidemiológicas de la enfermedad de Meniere en Cantabria. Métodos: Se recogieron de forma prospectiva todos los enfermos diagnosticados de Enfermedad de Meniere "definitivo" según los criterios de la AAO-HNS entre los años 1992 y 2002 en el Hospital Sierrallana de Torrelavega (Cantabria). Se calculó la incidencia, prevalencia, distribución por sexos, edad de presentación y si afectaba a uno o ambos oídos. Resultados: Un total de 75 pacientes fueron diagnosticados de enfermedad de Meniere "definitivo" durante dicho periodo. La incidencia fue de 3 casos /100.000 habitantes/año, la prevalencia de 75/100.000 (29 en varones y 46 en mujeres). La edad de diagnóstico más frecuente fue entre los 40 y 60 años. Los casos bilaterales constituyeron el 5,3 por ciento. Conclusiones: La enfermedad de Meniere no es infrecuente en Cantabria. Es más habitual en mujeres entre los 40 y 60 años de edad afectando normalmente a un solo oído (AU)

OBJECTIVES: To know the main epidemiologic characteristics of Meniere's disease in Cantabria. METHODS: All the patients diagnosed of «definitive» Meniere's disease between 1992 and 2002 in Sierrallana Hospital of Torrelavega (Cantabria, Spain) were reviewed. Incidence, prevalence, presence of bilateral disease, age at diagnosis and gender were recorded. RESULTS: A total of 75 patients were diagnosed of «definitive» Meniere's disease during this time. The incidence was 3/100,000 people/year, the prevalence 75/100,000, male/female ratio was 0.38. Most frequent age at onset was between 40 and 60 years and bilateral cases were 5.3%. CONCLUSIONS: Meniere's Disease is not uncommon in Cantabria. It is more prevalent among middle aged women. Bilateral cases are rare (AU)

[Epidemiology of Menière's disease in Cantabria]. / Epidemiología de la enfermedad de Menière en Cantabria.

OBJECTIVES: To know the main epidemiologic characteristics of Meniere's disease in Cantabria. METHODS: All the patients diagnosed of "definitive" Meniere's disease between 1992 and 2002 in Sierrallana Hospital of Torrelavega (Cantabria, Spain) were reviewed. Incidence, prevalence, presence of bilateral disease, age at diagnosis and gender were recorded. RESULTS: A total of 75 patients were diagnosed of "definitive" Meniere's" disease" during this time. The incidence was 3/100,000 people/year, the prevalence 75/100,000, male/female ratio was 0.38. Most frequent age at onset was between 40 and 60 years and bilateral cases were 5.3%. CONCLUSIONS: Meniere's Disease is not uncommon in Cantabria. It is more prevalent among middle aged women. Bilateral cases are rare.

Submillimeter evidence for the coeval growth of massive black holes and galaxy bulges.

The correlation, found in nearby galaxies, between black hole mass and stellar bulge mass implies that the formation of these two components must be related. Here we report submillimeter photometry of eight x-ray-absorbed active galactic nuclei that have luminosities and redshifts characteristic of the sources that produce the bulk of the accretion luminosity in the universe. The four sources with the highest redshifts are detected at 850 micrometers, with flux densities between 5.9 and 10.1 millijanskies, and hence are ultraluminous infrared galaxies. If the emission is from dust heated by starbursts, then the majority of stars in spheroids were formed at the same time as their central black holes built up most of their mass by accretion. This would account for the observed demography of massive black holes in the local universe. The skewed rate of submillimeter detection with redshift is consistent with a high redshift epoch of star formation in radio-quiet active galactic nuclei, similar to that seen in radio galaxies.