[Impact of Spanish Public Health Measures on Emergency Visits and COVID- 19 diagnosed cases during the pandemic in Madrid].

OBJECTIVE: Changes in Public Health recommendations may have changed the number of emergency visits and COVID-19 diagnosed cases in an Emergency Department in Madrid. METHODS: This retrospective case series study included all consecutive patients in a tertiary and urban ED in Madrid from 1st to 31st March. The sample was divided: NonCOVID-19, Non-investigated COVID-19, Possible COVID-19, Probable COVID-19, Confirmed COVID-19. Differences between public health periods were tested by ANOVA for each cohort, and by ANCOVA including the number of PCR tests (%) as covariate. RESULTS: A total of 7,163 (4,071 Non-COVID-19, 563 Non-investigated COVID-19, 870 Possible, 648 Probable and 1,011 Confirmed COVID-19) cases were included. Public Health measurements applied during each period showed a clear effect on the case proportion for the five cohorts. CONCLUSIONS: The variability of case definitions and diagnostic test criteria may have impact on the number of emergency visits and COVID-19 diagnosed cases in Emergency Department.

The impact of perimenopausal symptomatology, sociodemographic status and knowledge of menopause on women's quality of life.

BACKGROUND: A high percentage of menopausal and perimenopausal women suffer symptoms that deteriorate their quality of life (QoL) significantly. Many studies have focused on the relationship between perimenopausal symptoms and QoL, yet the results obtained have been inconclusive. The aim of this study is to evaluate the relationships among the symptoms of menopause, sociodemographic variables, knowledge of menopause and QoL. METHOD: Sociodemographic and clinical data was collected from interviews of 453 women in Madrid, and they also completed questionnaires related to perimenopausal symptomatology (MRS, MENQOL), knowledge of menopause and QoL. RESULTS: Although dependent on the assessment techniques, all the tools used indicated that more than half of the women studied suffered perimenopausal symptomatology: interview (59.1%), MENQOL (69.2%) and MRS (65.1%). Stronger symptoms were related to a worse QoL (R2 = 0.287 for MENQOL; R2 = 0.390 for MRS), being psychosocial/psychological and urogenital/sexual symptomatology, and educational level and knowledge about menopause the most strongly related to this parameter. Taking into account the main perimenopausal symptoms in Europe, psychosocial and sexual symptoms are also found to be strongly related to QoL. CONCLUSION: Perimenopausal symptomatology is frequent and intense, deteriorating women's QoL. While psychosocial and somatic/physical symptoms are the most frequent and intense, psychosocial/psychological and urogenital/sexual are those that best predict the individual's QoL. Educational level and knowledge about menopause are also related to a better QoL.

Carta al director sobre «Eficacia y seguridad de la aplicación del ácido tranexámico tópico en la artroplastia primaria no cementada de cadera: estudio prospectivo, aleatorizado, doble ciego y controlado» / Letter to the Editor on «Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: prospective, randomised, double-blind and controlled study»

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Efficacy and safety of administering oral misoprostol by titration compared to vaginal misoprostol and dinoprostone for cervical ripening and induction of labour: study protocol for a randomised clinical trial.

BACKGROUND: Among the various methods available, the administration of prostaglandins is the most effective for inducing labour in women with an unfavourable cervix. Recent studies have compared treatment with various titrated doses of oral misoprostol with vaginal misoprostol or dinoprostone, indicating that the use of an escalating dose of an oral misoprostol solution is associated with a lower rate of caesarean sections and a better safety profile. The objective of this study is to assess which of these three therapeutic options (oral or vaginal misoprostol or vaginal dinoprostone) achieves the highest rate of vaginal delivery within the first 24 h of drug administration. METHODS: An open-label randomised controlled trial will be conducted in Araba University Hospital (Spain). Women at ≥41 weeks of pregnancy requiring elective induction of labour who meet the selection criteria will be randomly allocated to one of three groups: 1) vaginal dinoprostone (delivered via a controlled-release vaginal insert containing 10 mg of dinoprostone, for up to 24 h); 2) vaginal misoprostol (25 µg of vaginal misoprostol every 4 h up to a maximum of 24 h); and 3) oral misoprostol (titrated doses of 20 to 60 µg of misoprostol following a 3 h on + 1 h off regimen up to a maximum of 24 h). Both intention-to-treat analysis and per-protocol analysis will be performed. DISCUSSION: The proposed study seeks to gather evidence on which of these three therapeutic options achieves the highest rate of vaginal delivery with the best safety profile, to enable obstetricians to use the most effective and safe option for their patients. TRIAL REGISTRATION: NCT02902653 Available at: https://clinicaltrials.gov/show/NCT02902653 (7th September 2016).

Determination of Perioperative Blood Loss: Accuracy or Approximation?

BACKGROUND: Various different interventions can be used to reduce surgical blood loss; however, there is no "gold standard" for accurately measuring the volume of perioperative blood loss, and this makes it difficult to assess the efficacy of these interventions. METHODS: We used data from a previous multicenter double-blind randomized clinical trial in patients undergoing total hip arthroplasty in which we compared 2 regimens for administering tranexamic acid versus placebo. We assessed direct measures (external blood loss) and indirect estimates (using the formulas of Bourke, Gross, Mercuriali, and Camarasa and a new formula we have developed) using analysis of variance to compare estimated volumes of blood loss among the study groups. In addition, intraclass correlation coefficients (ICCs) and Bland-Altman diagrams were used to compare the estimated volumes of blood loss obtained with each formula. RESULTS: The mean estimated external blood loss was 909 ± 324 mL, and the mean estimates of blood loss calculated using the formulas of Gross, Bourke and Smith, and Camarasa were 1308 ± 555, 1091 ± 454, and 1641 ± 945 mL, respectively, whereas we obtained a value of 1511 ± 919 mL with the new formula at day 2. In all cases, the results favored the use of tranexamic acid (P < .0001). Comparing results of the new and other formulas, we found moderate-to-low agreement (in terms of ICCs) except for that of Camarasa (ICC: 0.992). The limits of agreement with the new formula ranged from -378 to 93 in the case of the comparison with Camarasa's formula and from -2226 to 959 for external blood loss, the difference depending on the magnitude of the estimate to a large extent. CONCLUSIONS: Formulas that take into account both anthropometric and laboratory parameters are useful for evaluating the efficacy of interventions aiming to decrease blood loss but do not ensure that the values obtained are sufficiently accurate for absolute measuring.

Growing teratoma syndrome after ovarian inmature teratoma: a case report and review of the literature.

Growing teratoma syndrome is an uncommon complication of malignant germ cell cancer, characterised by the development of large tumours during or after chemotherapy, despite normalisation of tumour marker levels and metastasis, which contain only mature teratoma. Given its low incidence, little is data available. The authors present the case of a 15-year-old girl with a growing teratoma and the literature review outlines the current knowledge of its pathogenesis, common sites, diagnosis, natural course, treatment, and prognosis.

Valoración de la implementación de programa de ahorro de sangre en cirugía ortopédica / Assessment of the introduction of a blood management program in orthopaedic surgery

Objetivo. Describir el impacto de la introducción de un programa de ahorro de sangre (PAS) en las transfusiones, estancias hospitalarias y complicaciones debidas a la artroplastia total de cadera (ATC) y artroplastia total de rodilla (ATR). Material y métodos. Estudio observacional retrospectivo en el Hospital Universitario Araba, de 2006 a 2011. Se recogieron todas las ATR y ATC. La variable principal fue el porcentaje de pacientes transfundidos con sangre alogénica. Como variables secundarias se recogió la media de bolsas transfundidas, transfusiones totales (alogénica y/o autóloga), las complicaciones (totales y específicas), la edad y el sexo de los pacientes, hemoglobina prequirúrgica y al alta y la estancia hospitalaria. Resultados. Se incluyeron un total un total de 825 ATC y 875 ATR. Tanto en ATC (47,6% en 2006 y 30,6% en 2011; p = 0,013) como ATR (33,6% en 2006 y 16,2% en 2011; p < 0,001) se produjo una disminución significativa en las transfusiones alogénicas. Las transfusiones totales también disminuyeron en ATC (65,7% en 2006 y 39,5% en 2011; p < 0,001) y ATR (38,3% en 2006 y 17,2% en 2011; p < 0,001). La estancia disminuyó en ambas cirugías (p = 0,038 en ATC y p < 0,0001 en ATR). En 2006 fue de 9,2 ± 2,9 días en ATC y 11,1 ± 4,7 días en ATR, mientras que en 2011 fue de 8,7 ± 4,2 y 9,5 ± 3,4 días para ATC y ATR respectivamente. Conclusiones. La implementación del PAS, y sus aportaciones consecutivas, ha reducido significativamente el porcentaje de pacientes que requieren transfusiones, tanto alogénicas como autólogas. La estancia media disminuyó aunque no pueda establecerse el impacto del PAS en las mismas (AU)

Objective. To assess the impact of implementing a Patient Blood management program (PBM) on transfusion rates, hospital stay, and complications for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Material and methods. A retrospective, observational study was conducted in Araba University Hospital from 2006 to 2011. All THA and TKA were included. The percentage of patients transfused with allogeneic blood was the primary endpoint. The mean of transfused blood bags, overall transfusion, complications (both overall and specific), patient age and sex, pre-operative and discharge hemoglobin, and hospital stay were recorded. Results. A total of 825 THA and 875 TKA were included. Both THA (47.6% in 2006 and 30.6% in 2011; P = .013) and TKA (33.6% in 2006 and 16.2% in 2011; P < .001) showed a significant decrease of allogeneic transfusion. The overall transfusion rate was also reduced in THA (65.7% in 2006 and 39.5% in 2011; P < .001) and TKA (38.3% in 2006 and 17.2% in 2011; P < .001). Hospital stay was reduced in both types of surgeries (P < .038 in THA and P < .0001 in TKA). In 2006 it was 9.2 ± 2.9 days for THA and 11.1 ± 4.7 days for TKA, whereas in 2011 it was 8.7 ± 4.2 and 9.5 ± 3.4 days for THA and TKA, respectively. Conclusions. Our patient blood management has decreased the percentage of patients that need both allogeneic and autologous transfusion in a statistically significant way. Although the mean hospital stay decreased, the impact of the PBM cannot be established (AU)

Assessment of the introduction of a blood management program in orthopaedic surgery.

OBJECTIVE: To assess the impact of implementing a Patient Blood management program (PBM) on transfusion rates, hospital stay, and complications for total hip arthroplasty (THA) and total knee arthroplasty (TKA). MATERIAL AND METHODS: A retrospective, observational study was conducted in Araba University Hospital from 2006 to 2011. All THA and TKA were included. The percentage of patients transfused with allogeneic blood was the primary endpoint. The mean of transfused blood bags, overall transfusion, complications (both overall and specific), patient age and sex, pre-operative and discharge hemoglobin, and hospital stay were recorded. RESULTS: A total of 825 THA and 875 TKA were included. Both THA (47.6% in 2006 and 30.6% in 2011; P=.013) and TKA (33.6% in 2006 and 16.2% in 2011; P<.001) showed a significant decrease of allogeneic transfusion. The overall transfusion rate was also reduced in THA (65.7% in 2006 and 39.5% in 2011; P<.001) and TKA (38.3% in 2006 and 17.2% in 2011; P<.001). Hospital stay was reduced in both types of surgeries (P<.038 in THA and P<.0001 in TKA). In 2006 it was 9.2±2.9 days for THA and 11.1±4.7 days for TKA, whereas in 2011 it was 8.7±4.2 and 9.5±3.4 days for THA and TKA, respectively. CONCLUSIONS: Our patient blood management has decreased the percentage of patients that need both allogeneic and autologous transfusion in a statistically significant way. Although the mean hospital stay decreased, the impact of the PBM cannot be established.

Respuesta de los autores a la Carta al Director en relación con el artículo «Osteoporosis posmenopáusica: prevención primaria o medicación excesiva» / Authors’ response to the Letter to the Editor as regards the article ‘‘Post-menopausal osteoporosis: Primary prevention or excessive medication’’

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Remifentanil versus placebo for analgesia during external cephalic version: a randomised clinical trial.

BACKGROUND: Breech presentation occurs in up to 3% of pregnancies at term and may be an indication for caesarean delivery. External cephalic version can be effective in repositioning the fetus in a cephalic presentation, but may be painful for the mother. Our aim was to assess the efficacy of remifentanil versus placebo for pain relief during external cephalic version. METHODS: A randomized, double-blind, controlled trial that included women at 36-41 weeks of gestation with non-cephalic presentations was performed. Women were randomized to receive either a remifentanil infusion at 0.1 µg/kg/min and demand boluses of 0.1 µg/kg, or saline placebo. The primary outcome was the numerical rating pain score (0-10) after external cephalic version. RESULTS: Sixty women were recruited, 29 in the control group and 31 in the remifentanil group. There were significant differences in pain scores at the end of the procedure (control 6.5 ± 2.4 vs. remifentanil 4.7 ± 2.5, P = 0.005) but not 10 min later (P = 0.054). The overall success rate for external cephalic version was 49% with no significant differences between groups (remifentanil group 54.8% vs. control group 41.3%, P = 0.358). In the remifentanil group, there was one case of nausea and vomiting, one of drowsiness and three cases of fetal bradycardia. In the control group, there were three cases of nausea and vomiting, one of dizziness and nine cases of fetal bradycardia. CONCLUSION: Intravenous remifentanil with bolus doses on demand during external cephalic version achieved a reduction in pain and increased maternal satisfaction. There were no additional adverse effects, and no difference in the success rate of external cephalic version or the incidence of fetal bradycardia.

Nueva técnica en el estudio del ganglio centinela: one step nucleic acid amplification. Nuestra experiencia / New tecniques in the study of the sentinel node: our experience of the one step nucleic acid amplification assay

Objetivo Describir la experiencia de nuestra Unidad de Patología Mamaria tras la implantación de la técnica molecular OSNA para la detección del ganglio centinela axilar en pacientes con carcinoma de mama y comparar los datos obtenidos con la técnica previa mediante estudio histológico de rutina. Material y métodos Se compararon de manera retrospectiva 2 grupos de mujeres, uno de ellos de 148 pacientes con aplicación de técnica OSNA y el otro de 155 con estudio histológico habitual. Resultados El número de ganglios axilares afectados con el método OSNA es comparable con el método anatomopatológico de rutina utilizado previamente (36,1% en HE y 36,5% en OSNA). La sensación subjetiva de mayor número de micrometástasis con OSNA se descarta tras el estudio retrospectivo de ambos grupos (11,6% en HE y 12,2% en OSNA). Conclusión Se puede aceptar la implantación del método OSNA como una técnica sensible, segura y reproducible para el estudio intraoperatorio del ganglio centinela en el proceso del tratamiento quirúrgico del cáncer de mama. La necesidad o no de linfadenectomía axilar en el caso de micrometástasis sigue siendo una incógnita (AU)

Objective: To describe the experience of our Breast Pathology Unit after implementation of the OSNA assay for the detection of axillary sentinel nodes in patients with breast carcinoma and to compare the data obtained with those obtained by the previously used method of routine histological analysis. Material and methods: Two groups of women were retrospectively compared. One group included148 patients diagnosed by using the OSNA assay and another group comprised 155 patients diagnosed by routine histology. Results: The number of metastatic axillary nodes detected by OSNA was similar to that detected by the previously used routine histological method (36.1% using H&E and 36.5% by OSNA). The subjective feeling of an increased number of micrometastases detected by OSNA was excluded after retrospective study of the two groups (11.6% using H&E and 12.2% by OSNA).Conclusion: The OSNA assay can be accepted as a sensitive, reliable and reproducible method for the intraoperative evaluation of sentinel nodes during surgical treatment of breast cancer. The need for axillary lymph node dissection in cases of micrometastases remains unclear (AU)

[Postmenopausal osteoporosis: Primary prevention or excessive use of medications]. / Osteoporosis posmenopáusica: prevención primaria o medicación excesiva.

OBJECTIVE: [corrected] Estimate the percentage of excessive use of medicines (bisphosponates, strontium ranelate and raloxifene) in the prevention of fragility fractures in postmenopausal women. MATERIAL AND METHODS: A descriptive study conducted in an urban health centre in Vitoria-Gasteiz. The participants were women aged between 50 and 70, treated during 2010 with some of aforementioned medicines. Out of the 253 women included, three died, two moved, one did not want to sake part, and another one could not be found, leaving 246 participants. It was determinated if the treatment was or not indicated, as recommended in the ESCEO, NAMS and NOF clinical practice guides. A data search, including fragility fracture history, densitometry performed, densitometry diagnoses, prescribed medicines and prescribing doctor, was carried out by looking in the Osabide and Global Clinic digital clinic records. Interviews were carried out with 72 patients for a more complete information. RESULTS: The mean patient age was 60.5 ± 4.9 years, and 91,5% of them (225) had undergone a densitometry. Three-quarters (75.1%, 169) had a diagnosis of osteoporosis and 4,4% (11) had previous history of fractures. More than a quarter (27.0%, 68) of treatments had no indication, and varied depending of the prescribing doctor (family doctors: 8.5%/ traumatologists: 58.5%) (p<0.001). The use of the medicine of choice, alendronate in 29.7% of cases, Was significantly higher (59.3%) in Primary Care than in other specialties. CONCLUSIONS: A high percentage of women are given excessive medication, exposing them to potentially severe secondary damages. Family doctors deal correctly with osteoporosis, with a high percentage of indicated treatments and a rational use of medicines, with alendronate as the first choice in the majority of cases.

Osteoporosis posmenopáusica: prevención primaria o medicación excesiva / Postmenopausal osteoporosis: primary prevention or excessive use of medications

Objetivo. Estimar el porcentaje del uso excesivo de fármacos (bifosfonatos/ranelato de estroncio/raloxifeno) en la prevención de fracturas por fragilidad en las mujeres posmenopáusicas. Material y métodos. Estudio descriptivo transversal en un centro de salud urbano en Vitoria. Las participantes fueron mujeres de entre 50 y 70 años tratadas con alguno de los fármacos en estudio en el año 2010 (253). Cinco excluidas (3 fallecidas, 2 traslados), una no colaboró y otra no pudo ser localizada (246 mujeres). Se determinó si el tratamiento estaba indicado o no según las indicaciones de las guías de práctica clínica (ESCEO, NAMS, NOF). Los datos (antecedentes de fracturas por fragilidad, densitometría realizada, diagnósticos densitométricos, fármaco prescrito, médico prescriptor) se buscaron en las historias clínicas informatizadas Osabide y Global Clinic. En 72 casos se realizaron entrevistas para completar la información. Resultados. La edad media de las pacientes fue de 60,5±4,9 años y al 91,5% (225) se les había realizado densitometría. El 75,1% (169) tenía diagnóstico de osteoporosis y el 4,4% (11) presentaba historia personal de fracturas. El 27,6% (68) de los tratamientos no tenían indicación, variando según el médico prescriptor (8,5% médicos de familia/58,5% traumatólogos) (p<0,001). Uso del fármaco de elección (alendronato) en un 29,7%, con claras diferencias entre atención primaria (59,3%) y el resto. Conclusiones. Un alto porcentaje de mujeres está excesivamente medicada, exponiéndose a efectos secundarios potencialmente graves. Los médicos de familia manejan correctamente la osteoporosis, con un gran porcentaje de tratamientos indicados, y un uso racional del medicamento, optando mayoritariamente por el alendronato como primera opción (AU)

Objetive. Estimate the percentage of excessive use of medicines (bisphosponates, strontium ranelate and raloxifene) in the prevention of fragility fractures in postmenopausal women. Material and methods. A descriptive study conducted in an urban health centre in Vitoria-Gasteiz. The participants were women aged between 50 and 70, treated during 2010 with some of aforementioned medicines. Out of the 253 women included, three died, two moved, one did not want to sake part, and another one could not be found, leaving 246 participants. It was determinated if the treatment was or not indicated, as recommended in the ESCEO, NAMS and NOF clinical practice guides. A data search, including fragility fracture history, densitometry performed, densitometry diagnoses, prescribed medicines and prescribing doctor, was carried out by looking in the Osabide and Global Clinic digital clinic records. Interviews were carried out with 72 patients for a more complete information. Results. The mean patient age was 60.5 ± 4.9 years, and 91,5% of them (225) had undergone a densitometry. Three-quarters (75.1%, 169) had a diagnosis of osteoporosis and 4,4% (11) had previous history of fractures. More than a quarter (27.0%, 68) of treatments had no indication, and varied depending of the prescribing doctor (family doctors: 8.5%/ traumatologists: 58.5%) (p<0.001). The use of the medicine of choice, alendronate in 29.7% of cases, Was significantly higher (59.3%) in Primary Care than in other specialties. Conclusions. A high percentage of women are given excessive medication, exposing them to potentially severe secondary damages. Family doctors deal correctly with osteoporosis, with a high percentage of indicated treatments and a rational use of medicines, with alendronate as the first choice in the majority of cases (AU)

Embolismo del líquido amniótico: caso clínico y revisión de la literatura / No disponible

El embolismo de líquido amniótico (ELA) es un síndrome poco frecuente pero con fatales resultados que se produce principalmente durante el parto o en el posparto inmediato. Se presenta un caso de una paciente de 33 años sin antecedentes médicos importantes. Coincidiendo rotura de la bolsa amniótica, comienza con sensación de mareo, que mejora con decúbito lateral izquierdo y sueroterapia. Tras el nacimiento del recién nacido, la paciente presenta parada cardiorrespiratoria de la que tras 45min de reanimación cardiopulmonar se recupera pero presenta hemorragia posparto por atonía que revierte parcialmente con la administración de metilergometrina y misoprostol ni con la colocación de balón de Bakri. Debido a la sospecha de coagulación intravascular diseminada se transfunden 8 concentrados de hematíes, 3 concentrados de plasma y 2.000 UI de octaplex; y se la traslada a la UCI de nuestro hospital con el diagnóstico de sospecha de embolismo de líquido amniótico. Al llegar a nuestro centro presenta metrorragia activa y orina hematúrica; con una hemoglobina de 7,9, trombopenia y coagulopatía, precisando transfusión de concentrados de hematíes, un pool de plaquetas, 750 cc de plasma, fibrinógeno y factor vii de la coagulación. Tras la corrección de la coagulopatía, cesa el sangrado y la paciente evoluciona, y es dada de alta a los 6 días (AU)

Amniotic fluid embolism (AFE) is a rare but fatal syndrome occurring mostly during delivery or immediately postpartum. We report the case of a 33-year-old patient with no (..) (AU)