Results of the section of the filum terminale in 20 patients with syringomyelia, scoliosis and Chiari malformation.

BACKGROUND: Spinal cord traction caused by a tight filum terminale may be considered a pathogenic mechanism involved in the development of syringomyelia, the Chiari malformation (type I) and scoliosis. Section of the filum terminale is proposed as a useful surgical approach in these conditions. METHODS: Between April 1993 and July 2003, a total of 20 patients (8 men and 12 women) with a mean age of 33.5 years underwent section of the filum terminale with or without opening of the dural sac through a standard sacrectomy. Eight patients suffered from scoliosis, 5 from syringomyelia, 2 from Chiari malformation and 5 with a combination of these conditions. FINDING: After section of the filum terminale, patients with syringomyelia showed an early clinical improvement of dysaesthesia, thermo-anaesthesia, hypo-aesthesia and walking difficulties. Rising of the medullary conus was also observed. In patients with scoliosis, back pain improved dramatically and a curve reduction was noticed, although progression of the curve was observed in one case. In patients with Chiari malformation, headache, dysaesthesia and paraparesis disappeared. CONCLUSIONS: Section of the filum terminale is a useful strategy in the treatment of scoliosis, syringomyelia and the Chiari malformation, and offers a new aetiological basis for the understanding of these three disorders.

[Difficult patients in primary care: a quantitative and qualitative study]. / Pacientes de trato difícil en atención primaria: una aproximación cuantitativa y cualitativa.

AIM: To identify difficult (heartsink) patients (DP), describe their profile, and report the opinions and experiences they evoke in physicians who see them. DESIGN: Descriptive, cross-sectional study based on quantitative and qualitative methods. SETTING: Urban health care center. PARTICIPANTS: Difficult patients were selected daily from among all patients seen in six primary care practices during the period from March to May 2001. Patients were identified according to the diagnostic criteria of Ellis (patients who cause a knot in the stomach when their name appears on the list of patients with an appointment that day) and O'Dowd (patients who cause distress or discomfort). METHOD: Information was obtained on the number of DP seen, number of visits made by DP, age, sex, type of DP, level of education, occupation, family structure and comorbidity. Type of DP was determined with a modification of the Groves classification (dependent clinger, entitled demander, manipulative help-rejecter, self-destructive denier, somatizer, emotive seducer). We analyzed the opinions DP generated by examining the discourse produced during a discussion group session with 9 physicians from the participating health center and a moderator. RESULTS: A total of 82 DP were identified (prevalence.7%, i.e., 2.3% of all visits). Most (67.1%) were women. Mean age was 57.8 years (standard deviation 15.2 years). Dependent clinger patients predominated (41%). Most patients had primary-level education (62%), about one-third were retired (35%), and about one-third were married and had children (35%). Most had two or more medical diagnoses (74.4%), and many had at least one psychiatric diagnosis (40.2%).The feelings these patients evoked most often in physicians were irritability and frustration. Most physicians agreed that these patients are rare but have a severe emotional impact. Physicians believe that the skills and strategies they have to help them manage these patients are limited, and consider specific training necessary to improve them. CONCLUSIONS: Although DP are not a relevant problem in quantitative terms, they cause considerable emotional distress. Specific training in clinical interviewing is felt to be necessary given the difficulties in managing these patients.

Pacientes de trato difícil en atención primaria: una aproximación cuantitativa y cualitativa / Difficult patients in primary care: a quantitative and qualitative study

Objetivo. Identificar a los pacientes "de trato difícil" (PD), describir su perfil y las opiniones y vivencias que generan en los médicos que los atienden. Diseño. Estudio descriptivo transversal. Metodología cuantitativa-cualitativa. Emplazamiento. Centro de salud urbano. Participantes. Los PD seleccionados diariamente del total de pacientes atendidos en 6 consultas de atención primaria, entre marzo y mayo de 2001. Se identificaron mediante los criterios diagnósticos de Ellis (pacientes que provocan nudo en el estómago al leer su nombre en el listado) y O'Dowd (pacientes capaces de producir distrés, malestar).Método. Se recogió información sobre los PD visitados, número de visitas realizadas por PD, edad, sexo, clasificación, estudios, ocupación, estructura familiar y comorbilidad. Se utilizó la clasificación de Groves modificada (pasivo dependiente, exigente-agresivo, manipulador masoquista, negador-autodestructivo, somatizador, emotivo-seductor). Analizamos las opiniones que generan a partir del discurso producido en un grupo de discusión (9 médicos del centro y un moderador).Diseño. Se seleccionó a 82 pacientes (prevalencia del 0,7 por ciento [el 2,3 por ciento de las consultas realizadas]), de los que el 67,1 por ciento eran mujeres. La edad media era de 57,8 años (DE, 15,2). Predominó la paciente pasiva-dependiente (41 por ciento), con estudios primarios (62 por ciento), jubilada (35 por ciento), casada y con hijos (35 por ciento), con dos o más patologías médicas (74,4 por ciento) y al menos una psiquiátrica (40,2 por ciento).Los sentimientos que predominantemente generan en los médicos son irritabilidad y frustración. La mayoría coincide en que estos pacientes son escasos pero ocasionan un impacto emocional intenso, cree que sus habilidades y estrategias para manejarlos son limitadas y considera necesaria formación específica para mejorarlas. Conclusiones. Aunque cuantitativamente los PD no se consideran un problema relevante, provocan un gran desgaste emocional. Se consideran necesarios formación/entrenamiento específicos en entrevista clínica dadas las dificultades que presenta su manejo (AU)

Assessment of pathological gamblers who use slot machines.

The aim of the present study was to classify pathological gamblers based on their psychopathology as related to the variable sensation-seeking, and to check possible differences between the groups on the sociodemographic variables. The sample was composed of 110 male pathological gamblers using slot machines who requested treatment at the Pathological Gambling Unit at the Ciutat Sanitària i Universitària de Bellvitge. It was observed that pathological gamblers comprise three clusters, differentiated with differing severity depression, psychoticism, somatization, impulsiveness, interpersonal sensitivity, and phobic anxiety. Cluster 1, representing 46.7% of the sample, showed mean scores higher than or equal to T=63. On the subscales of Depression, Psychoticism, Interpersonal Sensitivity, Phobic Anxiety, and Obsessiveness-Compulsiveness the score was close to T=63 (the clinical cut-off score). Cluster 2, representing 23.8% of the sample, scored higher than Cluster 1 on the following subscales: Depression, Phobic Anxiety, Interpersonal Sensitivity, Psychoticism, Obsessive-Compulsive, and Somatization. On Cluster 3 highest mean scores were observed on all SCL-90-R dimensions relative to the other two groups. What distinguished these subgroups is not symptomatology but the severity of the psychopathology. On the other hand, sensation seeking was similar for the three clusters, and the slight differences depended on the subjects' psychopathology.

Diagnostic agreement between clinicians and the Diagnostic Interview for Children and Adolescents--DICA-R--in an outpatient sample.

The paper examines the diagnostic agreement between clinicians and the Diagnostic Interview for Children and Adolescents. One hundred and thirty-seven outpatients-children and adolescents, and their parents-were diagnosed independently following DSM-III-R criteria by clinicians and by the DICA-R. The diagnostic concordance between clinicians and DICA-R ranged from low to moderate in the majority of the categories. The only exception was Conduct Disorder. Differences depending on the informant and the quality of the information (cognitive vs. observable) were observed. Combining the information from the child/adolescent and their parents ameliorates the concordance. The reasons for the scanty agreement found could be due to the fact that clinicians and structured interviews differ in what they evaluate (conditions on which they focus), how they evaluate (strictness in the criteria application, use of different informants and different information etc.), and when they evaluate (present condition vs. lifespan). After analysing the pros and cons of both, the use of structured interviews is advisable for research purposes. There is a clear need for a variety of informants, and the combination of information from different sources is recommended, depending on the age of the children and the type of disorder.

Obesity, diet and restrained eating in a Mediterranean population.

OBJECTIVE: To evaluate links between obesity, gender and restrained eating in a representative sample of adolescents in Catalonia, Spain. DESIGN: Several surveys were conducted in which measurements were taken of a sample of adolescents living in the city of Barcelona. SUBJECTS: 610 subjects (57% girls and 43% boys) with ages ranging between 15-17, from 22 schools in Barcelona. MEASUREMENTS: Weight, height, Body Mass Index (BMI) as measurement of obesity, subscale "Diet' of the Eating Attitudes Test (EAT) as measurement of concern for dieting, and subjects' negative or affirmative responses to the questions as to whether they were following a diet at the time of the study. RESULTS: 15% of the sample was found to be obese (13.5% presented grade I obesity-BMI 25-29.9 kg/m2, 1.3% presented grade II obesity-BMI 30-40 kg/m2, 0.2% presented grade III obesity-BMI > 40 kg/m2). Dieting has a strong influence on normal-weight female adolescent populations in Spain. Such girls are more concerned about dieting and are more likely to follow a diet independent of the extent to which they are overweight. Obese subjects are more likely to show greater concern for their diet and to be on a diet than those of normal-weight. The restrained behaviour observed in obese subjects is not related to the type of restraint evaluated using instruments such as the "Diet' subscale of the EAT. CONCLUSION: Our results show a lower prevalence of obesity in Spain (a European sample) than in the United States. But the prevalence of obesity is not insignificant. It would appear that there is no linear relationship between the degree of excess weight and the restraint boundary. The prevalence of restrained eating behaviour among young adolescent girls in Spain is high. Given the dangers of such attitudes, it is becoming increasingly necessary to develop preventive programmes to combat them.

Prediction of therapeutic failure in patients with bleeding peptic ulcer treated with endoscopic injection.

Endoscopic injection therapy was performed in a consecutive series of 233 patients admitted for a bleeding peptic ulcer with active arterial hemorrhage or a nonbleeding visible vessel disclosed at emergency endoscopy. Further bleeding occurred in 57 cases (24.5%). The present study was conducted to evaluate whether any clinical or endoscopic features could identify the patients at high risk of therapeutic failure. Multiple logistic regression analysis showed that failure was significantly related to: (1) the ulcer location on the posterior wall (P = 0.004) or superior wall (P = 0.003) of the duodenal bulb, (2) the ulcer size (P = 0.011), and (3) the existence of associated diseases (P = 0.012). The validity of the prediction rule based on these factors was evaluated by receiver-operating characteristic curves and was confirmed and prospectively validated in an independent sample of 81 patients with a bleeding peptic ulcer treated by endoscopic injection. We conclude that once the initial control of bleeding has been achieved by injection therapy, the present prediction rule can be used to identify candidates for alternative treatment.

Rare origin of the obturator, inferior epigastric and medial circumflex femoral arteries from a common trunk.

Two cases of arterial variation are described in which the obturator, inferior epigastric and medial circumflex femoral arteries arose from a common trunk from the external iliac artery. A possible ontogenetic explanation is provided.

Peer Nomination Inventory of Depression: characteristics in a Spanish sample.

The Peer Nomination Inventory of Depression (PNID) was answered by 1,121 children from Barcelona in the fourth year of grammar school and by their teachers (n = 36) to analyze this questionnaire in a Spanish sample. The results indicated (1) high internal consistency; (2) discriminative power between depressed and nondepressed; (3) low concurrent validity; (4) convergent and discriminant validity; (5) a two-factor structure; and (6) that two discriminant functions could differentiate between depressed, dysthymic, and nondepressed subjects. The teacher's responses showed (1) moderate internal consistency; (2) discriminative power between depressed and nondepressed groups; (3) moderate concurrent validity; (4) and that two discriminant functions could differentiate between the diagnostic groups. The importance of the information given by the teacher to help detect severe depressive problems was pointed out.

A Golgi and electron microscope study of the ventral septum in the reptile, Podarcis hispánica.

The ventral septum of the reptile Podarcis hispánica has been studied using cytoarchitectonical and Golgi methods as well as electron microscopy techniques. The ventral septum is located in the medial wall of the telencephalon, just ventral to the dorsal septum. 2 different cell masses or nuclei can be easily appreciated in this structure: the Ventro-lateral Nucleus, located close to the ventricle, and the Ventro-medial Nucleus, located close to the medial hemispheric wall. Using Golgi methods, 3 classes of neurons have been distinguished: Big Polymorphic (BP) neurons, Small Polymorphic (SP) neurons and Horizontal (H) neurons. BP neurons are located within Ventro-medial Nucleus and they are characterized by a large dendritic 3 with numerous dendritic spines (50 spines per 100 microns). SP neurons are located within Ventro-lateral Nucleus and they are characterized by a small dendritic tree which is covered by numerous dendritic spines (48 spines per 100 microns). H neurons are located around both nuclei and they are characterized by a linear dendritic tree and a low number of dendritic spines. Using E.M. techniques 3 classes of neuronal cell bodies can be distinguished: big neuronal somata, small neuronal somata and spindle-like neuronal somata Big somata are located within Ventro-medial Nucleus. Small somata are located within Ventro-lateral Nucleus. Spindle-like somata are located either close to the lateral ventricle or close to the medial hemispheric wall. We have identified 4 different types of synaptic endings in the neuropil, depending on the vesicle morphology: A) endings with slightly pleomorphic vesicles; B) endings with big round vesicles; C) endings with dense core vesicles and D) endings with small round vesicles.

The circumflex branch of the left coronary artery in the human infant.

Coronary arterial vascularisation in the human infant in the first five weeks of life, was studied by radiological and injection-corrosion techniques. The main differences lay in the characteristics of the circumflex artery and its distribution over the myocardial wall. These differences were age-related. Coronary arterial anastomoses were detected in 61% of the hearts.

[Myocardial bridges. Incidence and relation to some certain coronary variables]. / Ponts myocardiques. Incidence et relation avec certaines variables coronariennes.

72 human hearts from necropsies of subjects with an age range from 27 to 83 years have been examined by dissection. The aim of this study was to know the percentage of myocardial bridges (intramural coronary arteries) and to compare with other studies carried on this subject, using the same or different techniques. Myocardial bridges were observed in 25% of cases. The main localization was the middle third of the anterior interventricular artery. The principal characteristics of the myocardial bridges were: The length, from 4 mm to 25 mm, and the thickness, from 0.3 mm to 1.7 mm. Chi-square test have been made in order to verify the relation between the coronary arterial preponderance and the incidence of myocardial bridges, showing the absence of statistical significance.

Angiogenic activity in fluid samples from tumoral patients.

Tests were performed to study the angiogenic activity in samples of pleural fluid, ascites and cerebrospinal fluid, in patients with solid tumors and non-neoplastic diseases such as cerebrovascular accidents, cirrhosis, and congestive heart failure. The measurement of the angiogenic activity was carried out on chorioallantoid chick embryo membrane. The cerebrospinal fluid showed angiogenic activity in patients with primitive tumors of the central nervous system and also in cases where the tumor had extended into other organs. The cerebrospinal fluid of controls without tumor revealed angiogenic activity in 28% of the cases. There was a direct correlation between positive assays and age. Sixty-two percent of the samples of ascites from cancer patients were positive. Only 25% of the controls were positive. Only 10% of the pleural fluid from cancer patients was negative, and 75% of the control samples were negative.

Thyrotrophin-releasing hormone responsiveness and degradation in children with chronic renal failure: effect of time of evolution.

In order to study the hypothalamic-pituitary-thyroid function in children with chronic renal failure (CRF), the serum levels of L-thyroxine (L-T4), L-triiodothyronine (L-T3), reverse T3 (rT3), thyrotrophin (TSH) and prolactin (Prl) were measured by radioimmunoassay (RIA). Values were compared with those of normal subjects. Low levels of L-T4 were present in CRF patients as compared to controls. L-T3 was also found to be low but less than L-T4, and rT3 was lower in patients with long evolution. No alterations were observed in TSH basal levels, whereas Prl values in patients were high. After thyrotrophin-releasing hormone (TRH) administration, TSH and Prl rose to similar levels in both groups, but high values were maintained throughout (120 min) in CRF. A significant negative correlation was found between the peak rise of the TSH response and the CRF evolution time. The L-T3 response to TRH administration (120 min) was similar in both CRF and controls. The rate of in vivo and in vitro exogenous TRH degradation was decreased in patients with CRF or by their sera, respectively. Our data seem to confirm that the hypothyroid syndrome described in CRF patients is of hypothalamic origin, and the low in vivo and in vitro TRH degradation rates are a consequence of this state.