Tratamiento médico y quirúrgico del estrabismo divergente primario / Medical and surgical treatment of primary divergent strabismus

PROPÓSITO: Evaluar a largo plazo la efectividad de las distintas terapias aplicadas en los últimos 30 años a estos pacientes, tanto médicas como quirúrgicas, y los resultados obtenidos, con el fin último de determinar qué criterios son los más adecuados a la hora de indicar y realizar tratamiento médico y quirúrgico sobre estos pacientes. MÉTODO: Se ha realizado un estudio retrospectivo aleatorizado de 198 pacientes con estrabismo divergente primario vistos por primera vez en nuestra consulta (IOC) en los últimos 36 años (1976-2012), con un seguimiento medio de 8,38 años. Se han recogido sus características demográficas y clínicas, así como los diversos tratamientos realizados y su resultado motor y sensorial. Por último, se han dividido en 3 grupos de 70, 71 y 56 pacientes respectivamente según la fecha en la que realizaron la primera consulta, para poder comparar las distintas terapias aplicadas. RESULTADOS: En el 50% de nuestros pacientes empezó antes de los 2 años de edad (P50 = 24 meses). El 26,3% presentó una visión binocular óptima al inicio de la exploración. El tratamiento médico funcionó como medida exclusiva en el 29,3% de los casos (oclusiones horarias, aplicación de lentes negativas, toxina botulínica), y un 70,7% precisaron cirugía (61,2% mediante doble retroinserción de rectos laterales y 38,8% de retrorresecciones monolaterales). El 26,7% de los pacientes experimentaron recidivas, con 40 reintervenciones (70% por recidiva del estrabismo divergente, 12,5% por hipercorrección quirúrgica excesiva y el 17,5% por otras causas). Al final del seguimiento, el 61,1% de los pacientes presentaban una visión binocular perfecta (TNO = 60''), cuya proporción fue mayor en pacientes en ortotropía espontánea antes de disociarles (p = 0,003), pero sin diferencias en otras variables estudiadas. Al estudiar a los pacientes divididos en 3 grupos, que son demográficamente comparables entre sí, se ha visto mayor utilización de toxina y lentes negativas en el grupo 3 (p < 0,001 y p = 0,003). Se ha intervenido a los pacientes más frecuentemente con cirugía bilateral en el tercer grupo (p = 0,032), buscando una mayor hipercorrección en el postoperatorio inmediato, logrando así disminuir el número de reintervenciones del 40,5 al 19%, aunque no pudo demostrarse su significación estadística (p = 0,093). También aumentó significativamente el número de inyecciones de toxina botulínica en el recto medio como tratamiento de la hipercorrección posquirúrgica excesiva (p = 0,028). No hemos encontrado diferencias en la visión binocular final entre los 3 grupos (p = 0,703). CONCLUSIONES: En casos de dominancia ocular clara debemos aplicar oclusión horaria 2 veces al día sobre el ojo dominado para fomentar el control del estrabismo divergente y así obtener un mejor resultado desde el punto de vista sensorial. Procuraremos esperar a los 4 años para intervenir quirúrgicamente, salvo en los casos en los que detectemos un empeoramiento significativo del componente sensorial o motor. A la hora de operar, y siempre que las características del paciente lo permitan, intentaremos realizar cirugía bilateral sobre ambos rectos laterales, buscando una ligera hipercorrección posquirúrgica en el postoperatorio inmediato, ya que en estos pacientes hemos disminuido el número total de reintervenciones. A la hora de actuar sobre un recto medio, conviene recordar que la elasticidad del mismo parece ser el factor clave para el resultado posquirúrgico, aunque por el momento no nos sea posible medirlo de forma fiable. La aplicación de toxina botulínica sobre rectos medios poco elásticos en caso de excesiva corrección posquirúrgica nos ha permitido disminuir el número de reintervenciones

PURPOSE: To evaluate the long-term effectiveness of different therapies applied in the past 30 years, both medical and surgical, and results, with the ultimate aim of determining which are the most appropriate criteria to indicate when and how to perform medical and surgical treatment in these patients. METHOD: A retrospective randomized study was conducted on 198 patients with primary divergent strabismus first seen in our clinic (IOC) in the last 36 years (1976-2012), with a mean follow-up of 8.38 years. Demographic and clinical characteristics, as well as the various treatments performed, and motor and sensory outcome were collected. They were finally divided into 3 groups of 70, 71 and 56 patients, respectively, according to their first visit, in order to compare the therapies applied. RESULTS: Half (50%) of our patients debuted before 2 years of age (P50 = 24 months), and 26.3% had optimal binocular vision at the beginning of the study. Medical treatment was used as exclusive therapy in 29.3% of cases (occlusion therapy, applying negative lenses, botulinum toxin), and 70.7% required surgery (61.2% by double retro-insertion of lateral rectus, and 38.8% monolateral retro-resection). There was a recurrence in 26.7% of patients, and 40 re-interventions were performed (70% due to recurrence of divergent strabismus, 12.5% due to surgical over-correction, and 17.5% for other reasons). In the end, 61.1% of patients had perfect binocular vision (TNO = 60''), and the proportion was higher in patients who showed proper control of their strabismus at the beginning (P=.003). However, no differences were found in the other variables studied. When the patients were divided into 3 groups (which are demographically comparable), an increased number of patients in Group 3 were found to be treated using negative lenses and botulinum toxin (P<.001 and P=.003). This group was found to have had a higher proportion of bilateral surgery (P=.032), seeking greater immediate postoperative over-correction, thus reducing the number of re-interventions from 40.5 to 19%, although it did not reach statistical significance (P=.093). It was also found that there was a significantly increased number of injections of botulinum toxin in the middle rectum for treatment of excessive postoperative overcorrection (P=.028). No other differences in final binocular vision was found between the 3 groups (P=.703). CONCLUSIONS: In cases of clear ocular dominance, occlusion therapy must be applied twice daily on the dominating eye, in order to encourage divergent strabismus control and improve sensoriality. An attempt should be made to wait until patients reach four years of age before indicating surgical treatment, except in cases of a significant worsening of motor or sensory component. Bilateral surgery on both lateral rectus should be attempted, provided that patient characteristics allow this. A slight post-surgical overcorrection should be looked for in the immediate postoperative period, as this, in our experience, reduces the total amount of re-operations. When working on the middle rectus, remember that the elasticity of this muscle is the key factor for obtaining a proper post-surgical outcome, but a reliable measurement of this still cannot be made. In cases of excessive post-surgical over-correction, an injection of botulinum toxin should be applied to these poor elasticity muscles, in order to reduce the number of reoperations

Medical and surgical treatment of primary divergent strabismus.

PURPOSE: To evaluate the long-term effectiveness of different therapies applied in the past 30 years, both medical and surgical, and results, with the ultimate aim of determining which are the most appropriate criteria to indicate when and how to perform medical and surgical treatment in these patients. METHOD: A retrospective randomized study was conducted on 198 patients with primary divergent strabismus first seen in our clinic (IOC) in the last 36 years (1976-2012), with a mean follow-up of 8.38 years. Demographic and clinical characteristics, as well as the various treatments performed, and motor and sensory outcome were collected. They were finally divided into 3 groups of 70, 71 and 56 patients, respectively, according to their first visit, in order to compare the therapies applied. RESULTS: Half (50%) of our patients debuted before 2 years of age (P50=24 months), and 26.3% had optimal binocular vision at the beginning of the study. Medical treatment was used as exclusive therapy in 29.3% of cases (occlusion therapy, applying negative lenses, botulinum toxin), and 70.7% required surgery (61.2% by double retro-insertion of lateral rectus, and 38.8% monolateral retro-resection). There was a recurrence in 26.7% of patients, and 40 re-interventions were performed (70% due to recurrence of divergent strabismus, 12.5% due to surgical over-correction, and 17.5% for other reasons). In the end, 61.1% of patients had perfect binocular vision (TNO=60"), and the proportion was higher in patients who showed proper control of their strabismus at the beginning (P=.003). However, no differences were found in the other variables studied. When the patients were divided into 3 groups (which are demographically comparable), an increased number of patients in Group 3 were found to be treated using negative lenses and botulinum toxin (P<.001 and P=.003). This group was found to have had a higher proportion of bilateral surgery (P=.032), seeking greater immediate postoperative over-correction, thus reducing the number of re-interventions from 40.5 to 19%, although it did not reach statistical significance (P=.093). It was also found that there was a significantly increased number of injections of botulinum toxin in the middle rectum for treatment of excessive postoperative overcorrection (P=.028). No other differences in final binocular vision was found between the 3 groups (P=.703). CONCLUSIONS: In cases of clear ocular dominance, occlusion therapy must be applied twice daily on the dominating eye, in order to encourage divergent strabismus control and improve sensoriality. An attempt should be made to wait until patients reach four years of age before indicating surgical treatment, except in cases of a significant worsening of motor or sensory component. Bilateral surgery on both lateral rectus should be attempted, provided that patient characteristics allow this. A slight post-surgical overcorrection should be looked for in the immediate postoperative period, as this, in our experience, reduces the total amount of re-operations. When working on the middle rectus, remember that the elasticity of this muscle is the key factor for obtaining a proper post-surgical outcome, but a reliable measurement of this still cannot be made. In cases of excessive post-surgical over-correction, an injection of botulinum toxin should be applied to these poor elasticity muscles, in order to reduce the number of re-operations.

Combined use of non-thoracotomy cardioverter defibrillators and endocardial pacemakers.

OBJECTIVE: To study the potential interactions in patients with endocardial permanent pacemakers and non-thoracotomy implantable cardioverter defibrillator (ICD) systems. DESIGN: Case series and cohort study. SETTING: Tertiary referral centre. PATIENTS: Fifteen consecutive patients with both endocardial pacemakers (12 dual chamber and three single chamber) and non-thoracotomy ICD systems. MAIN OUTCOME MEASURES: Detection inhibition of induced ventricular fibrillation; double counting; and pacemaker function after shocks. In the evaluation of detection inhibition, 124 VF inductions were analysed for detection duration compared with induced VF episodes in controls with an ICD but without a pacemaker. RESULTS: Two patients (13%) showed detection inhibition of VF and required pacemaker system change at the time of the ICD implant. With the final lead position, despite frequent pacemaker undersensing of VF, ICD detection of VF was not inhibited during any induction, and neither initial detection nor redetection times for VF were different from controls. Double/triple counting of pacemaker artefact and evoked electrogram was noted in three patients (20%). In two, this was remedied during the implantation procedure, and in the other it was abolished when amiodarone treatment was discontinued. Pacemaker function was affected by ICD discharges in two patients, one who showed postshock atrial undersensing and loss of capture, and another whose pacemaker reverted to VVI mode. CONCLUSIONS: When careful testing is performed at implantation to detect and remedy device interactions, non-thoracotomy ICD treatment and endocardial pacemakers can be used safely in combination.

[Excess mortality in an inner-city area: the case of Ciutat Vella in Barcelona]. / Excés de mortalitat en una àrea urbana cèntrica: el cas de Ciutat Vella a Barcelona.

The purpose of this study is to compare mortality indicators in the district of Ciutat Vella (the more socio-economically deprived in Barcelona) with the entire city, for the 1983-87 period. Crude death rates, as well as age, sex and cause-specific deaths rates were calculated from vital statistics data; life expectancy, years of potential life lost (YPLL), the Comparative Mortality Figure (CMF) and avoidable mortality rates were also computed. All indicators point out at an excess of mortality in Ciutat Vella, when compared to the whole city. Life expectancy was 73 years (4 years less than for Barcelona as a whole); infant mortality was 15.6 per 1,000 births (as opposed to 9 for Barcelona). The CMF was 129 (95% confidence interval: 126.2-131.8), while the YPLL ratio was 182.1 (95% confidence interval: 173.1-191.8), mainly attributed to excess mortality due to tuberculosis, cirrhosis and to homicides and drug-related deaths. The percentage of avoidable deaths was 9.5% in Ciutat Vella compared with 8.23% for Barcelona as a whole. These data confirm the need to actively pursue intervention programs to improve health in Ciutat Vella, although further small-area analysis at the level of neighbourhood and of health care areas would be advisable.

[Mortality by external causes among residents of Barcelona (1983-1987)]. / Mortalitat per causes externes en els residents a Barcelona (1983-1987) [corrected].

Mortality due to external causes (EC) is an increasing problem among young people in Spain, with little epidemiologic knowledge available at the small-area level in urban settings. The objective of the present study is the assessment of the magnitude and distribution of EC-related mortality among residents in Barcelona during the 1983-1987 time period. The main EC-related deaths were traffic injuries (9.3 deaths per 100,000), suicides (7.2 deaths per 100,000), and falls (6.9 deaths per 100,000). EC have been the main cause of death up to 35 years of age, contributing to 19% of the total number of years of potential life lost. Traffic-related deaths occurred mainly in the 15-24 age group for vehicle occupants (11.7 deaths per 100,000), while deaths among pedestrians occurred primarily among people older than 75 years (16.4 deaths per 100,000). The largest share of deaths due to suicide also occurred in this same group (19.6 deaths per 100,000), followed by people 25-34 years old. Expectedly, the higher death rates due to falls occurred among elderly people, older than 75 years of age (71.8 deaths per 100,000). These results indicate that patterns of mortality due to external causes in Barcelona are rather similar to those in European countries, suggesting that the strategies to achieve the prevention and control of such deaths among Barcelona residents should presumably be close to those presently being implemented in those countries.

[A historical view of cardiology in Chile 1930-1990]. / Visión histórica de la cardiología en Chile 1930-1990.

The most significant facts in the development of Chilean cardiology since 1930 are reviewed. The preeminence of great clinicians in the thirties was followed by the creation of Departments of Cardiology in University Hospitals. The emergence of powerful diagnostic tools and cardiac surgery allowed an accelerated development of this specialty in our country. Some of the problems faced by physicians and public in general as a consequence of the increasing use of sophisticated technology are discussed.

[Certification of main cause of death in Barcelona, 1985]. / Validación de la causa básica de defunción en Barcelona, 1985.

The aim of the present study was the validation of the underlying cause of death of the patients who died in Barcelona hospitals in 1985. A sample of deaths was stratified on the basis of the 17 categories of International Classification of Diseases (ninth revision), and the underlying cause as stated in the Statistical Death Certificate was compared with the cause that was considered to be "more likely" according to the available clinical documentation. The agreement index in the 17 ICD-9 categories was 71.8%. The groups with reliable rates were tumours, congenital defects and perinatal abnormalities. It is concluded that the fulfillment of the Statistical Death Certificate should be improved following the WHO recommendations; this could be achieved with training programs for clinicians.