Laparoscopic repair of an anterior perineal hernia: a video presentation.

Background: The perineal hernia is a condition that occurs as a result of a defect in the pelvic diaphragm. It is classified as anterior or posterior, and as either a primary or secondary hernia. The best management of this condition remains controversial. Objectives: To demonstrate the surgical steps of a laparoscopic repair with mesh of a perineal hernia. Materials and Methods: A video presentation showing the laparoscopic repair of a recurrent perineal hernia. Main outcome measures: A 46-year-old woman with a prior history of a primary perineal hernia repair had complaints of a symptomatic vulvar bulge. Pelvic magnetic resonance imaging showed a 5 cm hernia sac at the right anterior pelvic wall containing adipose tissue. A laparoscopic perineal hernia repair was performed by dissection of the space of Retzius, reduction of the hernial sac, closure of the defect and mesh fixation. Results: The laparoscopic repair with mesh of a recurrent perineal hernia is demonstrated. Conclusion: We showed that the laparoscopic approach can be an effective and reproducible treatment for perineal hernia. Learning objective: Understanding of the surgical steps involved in the laparoscopic repair with mesh of a recurrent perineal hernia.

Congenital knee dislocation. Therapeutic protocol and long-term functional results. / Luxación congénita de rodilla. Protocolo terapéutico y resultados funcionales a largo plazo.

BACKGROUND AND OBJECTIVE: Congenital knee dislocation is a very rare entity, characterised by deformity in knee recurvatum present at birth, and there is currently no consensus on the optimal treatment. The aim of the present study is to analyse the functional results and long-term complications after the application of a protocol of therapeutic action for the management of congenital knee dislocation (CKD) created in a reference centre for child orthopaedics. MATERIALS AND METHODS: Retrospective descriptive study of patients with congenital dislocation of the knee who followed CRPL between January 1997 and December 2010. Demographic variables, type of treatment, functional outcomes at the end of the follow-up, complications and relapses were studied. The conservative treatment consisted of serial casts, leaving the surgical treatment for cases in which passive flexion was not achieved above 30° or the conservative treatment failed. RESULTS: 9 patients (11 knees) met the inclusion criteria. The 66.7% were girls and the average follow-up was 15 years (9-22). In all cases, conservative treatment was initiated. Of the 11 knees treated, less than half (36%) required surgery. The average Lysholm questionnaire was 90.3 points, the WOMAC pain 0.4 (0-1), WOMAC stiffness 1.8 (0-6) and WOMAC function 3.8 (1-12). CONCLUSIONS: The existence and application of the PLCR protocol in a pathology as rare as congenital knee dislocation suggests good long-term functional results with few complications and no recurrences.

Estudio evolutivo de metabolitos porfirínicos de un caso de porfiria cutánea tardía / Porphyrins in a case of porphyria cutanea tarda: follow-up study

Resumen Las porfirias son errores congénitos poco frecuentes del metabolismo de las porfirinas. La porfiria cutánea tardía (PCT) es la más frecuente dentro de este grupo de enfermedades. Reportamos el estudio evolutivo de metabolitos porfirínicos de una paciente de 51 años con porfiria cutánea tardía, cuatro años después de su diagnóstico. Durante este período, se le indicó un esquema terapéutico de flebotomías en el Instituto de Hematología e Inmunología. Uno de los exámenes complementarios para su seguimiento fue la determinación de porfirinas totales en la orina, plasma y heces. Los resultados del estudio bioquímico de las porfirinas mostraron mejoría en todos los parámetros, lo que contribuyó a corroborar la utilidad del estudio de estos metabolitos como seguimiento de esta enfermedad y efectividad del tratamiento.

Abstract Porphyrias are rare congenital errors in the metabolism of porphyrins. Porphyria cutanea tarda is the most frequent among different types of porphyrias. We report the follow-up study of porphyrin metabolites of a 51-year-old patient with porphyria cutanea tarda four years later of her diagnosis. During this period, it was indicated a therapeutic scheme of phlebotomies in the Institute of Hematology and Immunology. One of the complementary examinations for its follow-up was the determination of total porphyrins in the urine, plasma and feces. Porphyrins in plasma decreased from 13 500 nmol/L at onset of disease to 250 nmol/L four years later. Although, porphyrins in feces and plasma could not quantify, we observed non-presence of peaks at 405 nm and 615.1 nm, respectively. These results contributed to corroborate the usefulness of the study of these metabolites for monitoring of this disease and effectiveness of the treatment.

Plant extracts as a natural treatment against the fish ectoparasite Neobenedenia sp. (Monogenea: Capsalidae).

The toxicity of water-ethanol extracts of garlic (Allium sativum), ginger (Zingiber officinale), basil (Ocimum basilicum), bitter chaparro (Castela tortuousa), onion (Allium cepa) and papaya (Carica papaya) against adults, eggs and oncomiracidia of Neobenedenia spp. parasites was examined. Parasites were exposed to continuous immersion and treated as follows: extracts were tested at three dilutions: 1:10, 1:50 and 1:100 made with filtered seawater (35 g l-1); ethanol (70%) was evaluated at the same dilutions of 1:10 (7% ethanol), 1:50 (1.4% ethanol) and 1:100 (0.07% ethanol) and a seawater (35 g l-1) control. The antiparasitic effect was measured on: (1) adult survival, egg production and time to detachment from the culture vessel; (2) egg development and cumulative egg hatching; and (3) oncomiracidia survival. All three dilutions of ginger and dilutions 1:100 and 1:50 of basil extract reduced adult survival in vitro, time to detachment from the surface of the culture vessel, egg production and oncomiracidia survival. Bitter chaparro extract reduced adult egg production and oncomiracidia survival. Hatching success was significantly reduced (P < 0.05) in basil extract (1:100) to 86.6% compared to the seawater control (100%). Dilutions 1:10 of ginger and basil exhibited the highest impact on the biological parameters of Neobenedenia sp. Our study demonstrates that water-ethanol extracts of ginger, basil and bitter chaparro are toxic against Neobenedenia sp. life stages.

Circulating autoantibodies against the NR2 peptide of the NMDA receptor are associated with subclinical brain damage in hypertensive patients with other pre-existing conditions for vascular risk.

Arterial hypertension (HT) and other vascular pre-existing conditions (PEC) generate asymptomatic brain damage which increases the occurrence of stroke and cognitive decline. The aim of this work was to explore if serum antibodies against the NR2 subunit of the NMDA receptor (NR2Ab) could predict subclinical brain damage (SBD) in hypertensive patients with PEC. Forty seven neurologically asymptomatic hypertensive subjects were classified according to the number of PEC (retinopathy, overweight/obesity, diabetes mellitus and dyslipidemia). NR2A/B Ab were measured in serum employing an ELISA method. 3.0-T Brain MRI imaging was performed, and visual ratings of white matter hyperintensities (WMH) and counts of dilated Virchow-Robin spaces (DVRS) and lacunes were obtained. Brain atrophy was evaluated with cortical thickness measurements and linear measures. Higher levels of NR2Ab were associated with more severe periventricular WMH (PWMH), more DVRS and more severe SBD; while greater frontal interhemispheric fissure width (IHFW), as a linear measure of frontal atrophy, was inversely related with NR2Ab. Overall and regional cortical thickness were not significantly associated with NR2 Ab. A multivariate analyses showed that IHFW and PWMH were the only variables independently associated with serum NR2Ab concentration. ROC analysis revealed that NR2Ab (cutoff: 1.7ng/ml) predicted PWMH with a sensitivity and specificity of 65% and 87% respectively. CONCLUSIONS: Serum NR2Ab levels may reflect SBD in HT subjects with PEC, especially in younger populations at risk, where age-related cortical atrophy has not yet been fully established.

Utilidad del campo magnético y el láser en el tratamiento de la parálisis facial periférica idiopática / Usefulness of magnetic field and laser for the treatment of idiopathic peripheral facial palsy

Objetivos: Determinar si la terapia combinada de campo magnético (CM) y láser con la terapia convencional (TC) es más beneficiosa para el proceso de recuperación de una parálisis facial periférica idiopática (PFPI) que la aplicación de cada uno de estos 2 agentes físicos por separado con la TC. Métodos Se realizó un estudio prospectivo, aleatorizado y controlado a simple ciego. Fueron incluidos 153 pacientes con PFPI que tuvieran menos de una semana de evolución desde la instalación de los síntomas y que no hubieran recibido tratamiento fisioterapéutico previo. Los pacientes se distribuyeron al azar en 4 grupos de estudio según el tratamiento: grupo A: TC; grupo B: láser + TC; grupo C: CM + TC, y grupo D: CT + láser + CM. La variable de salida que se utilizó para evaluar los resultados del tratamiento fue la escala de Sunnybrook. Los pacientes se evaluaron antes del tratamiento, al mes y a los 3 meses. Resultados Los pacientes de los grupos C y D mostraron una mejor recuperación que aquellos de los grupos A y B (mayor valor en la escala de Sunnybrook y menos sincinesias). Específicamente, los pacientes del grupo D tuvieron resultados más ventajosos en el proceso de recuperación a los 3 meses. Conclusiones La aplicación del tratamiento combinado de TC, láser y CM resultó más beneficiosa que la combinación de cada uno de estos 2 agentes físicos por separado con la TC (AU)

Objectives: To evaluate if the combination of magnetic field (MF) and laser therapy with conventional therapy (CT) is more beneficial for the recovery process of idiopathic peripheral facial palsy (IPFP) than the separate application of each one of these two physical agents with CT. Methods: A prospective, randomized and controlled simple blinded study was conducted. The study included 153 patients with IPFP having less than one week of evolution from symptom onset and no previous physiotherapy treatment. The patients were randomly distributed into4 study groups according to treatment: A) CT, B) laser + CT, C) MF + CT, and D) CT + laser+ MF. Outcome variable used to evaluate treatment was the Sunnybrook scale. Patients were evaluated before initiating treatment, and at one and 3 months after treatment. Results: Patients in groups C and D displayed a better outcome than those in groups A and B(higher Sunnybrook score and less syncinesia). Specifically, patients in group D exhibited the best overall recovery at 3 months. Conclusions: Combined treatment with CT+laser+MF was more beneficial than the separate combination of each one of these two physical agents with CT (AU)

Serum neuron-specific enolase and S100 calcium binding protein B biomarker levels do not improve diagnosis of acute stroke.

BACKGROUND: The high sensitivities and specificities reported for blood biomarkers as a supportive test in the diagnosis of acute stroke do not correspond with their performance for decision-making in emergency situations. METHODS: Seventy-two patients with suspected stroke were recruited: 44 with ischaemic stroke, 17 with haemorrhagic stroke and 11 stroke mimics, as well as a high-risk control group of 79 individuals. Serum neuron-specific enolase (NSE) and S100 calcium binding protein B (S100B) biomarker levels were determined on admission, using immunoassay kits. The sensitivities and specificities of NSE and S100B for distinguishing acute stroke from stroke mimics and high-risk controls were calculated. RESULTS: For cut-off values (NSE ≤ 14 micrograms per litre and S100B ≤130 nanograms per litre) the sensitivity was 53% and 55% respectively. Specificity was 64 for both versus the stroke mimic group. Specificity was higher (79% and 86% respectively) when calculated on the basis of the control group. CONCLUSIONS: This study supports the evidence indicating that serum levels of NSE and S100B do not improve the diagnosis of acute stroke.

Síndrome de Takotsubo: a propósito de un caso / Tako-tsubo syndrome: report of a case

Se presenta el caso de una mujer de 72 años de edad, ingresada en la UCI con diagnóstico de Síndrome Coronario Agudo Sin Elevación del ST (SCASEST). El cateterismo cardíaco demostró la integridad de su árbol coronario, siendo diagnosticada finalmente de Síndrome de Takotsubo (AU)

This report presents the case of a 72 years-old woman, who was admitted in ICU with a diagnostic of non-ST-segment elevation acute coronary syndrome (NST-ACS). Cardiac catheterization showed a normal coronary angiogram, and the final diagnostic was TakoTsubo Syndrome (AU)

High proportion of mannosidosis and fucosidosis among lysosomal storage diseases in Cuba.

Although lysosomal storage disorders (LSDs) are considered individually rare, as a group they present a non-negligible frequency. Few studies have been made of populational occurrence of LSDs; they have been conducted predominantly on Caucasian populations. We studied the occurrence of LSDs in Cuba. Data from individuals who had been referred to the Institute of Neurology and Neurosurgery in Havana from hospitals all over the country between January 1990 and December 2005 were analyzed. This institute was the only laboratory to provide enzyme-based diagnostic testing for 19 LSDs in Cuba during this period. Occurrence rates were calculated by dividing the number of postnatal diagnoses by the number of births during the study period. The combined occurrence of LSDs in Cuba was 5.6 per 100,000, lower than that reported in other studies conducted on Caucasian populations. The most frequent individual LSDs were: mucopolysaccharidosis type I (1.01 per 100,000) and, surprisingly, alpha-mannosidosis (0.72 per 100,000) and fucosidosis (0.62 per 100,000). These findings may be related to specific genetic characteristics and admixture of the Cuban population. This is the first comprehensive study of the occurrence of LSDs in Cuba. We conclude that the epidemiology of these diseases can vary regionally, and we stress the need for similar surveys in other Latin American countries.

Dolor torácico y disnea progresiva en varón joven / No disponible

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The effects of iPod and text-messaging use on driver distraction: a bio-behavioral analysis.

This study was designed to empirically examine the effects of iPod device and text-messaging activities on driver distraction. Sixty participants were asked to perform a driving simulation task while searching for songs using an iPod device or text messaging. Driving errors as measured by lane deviations were recorded and analyzed as a function of the distracters. Physiological measures (EEG) were also recorded during the driving phases in order to measure participant levels of cortical arousal. It was hypothesized that iPod use and text messaging would result in a profound effect on driving ability. The results showed a significant effect of iPod use and text-messaging on driving performance. Increased numbers of driving errors were recorded during the iPod and text-messaging phases than the pre- and post-allocation phases. Higher levels of Theta activity were also observed during the iPod and Text-messaging phase than the pre- and post-allocation phases. Implications for in-vehicle systems design, training, and safety are also discussed.

Leiomioma de la cápsula renal: presentación de un caso y revisión de la literatura / Leyomioma of the renal capsule: a case report and literature review

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Mucopolisacaridosis: diagnóstico enzimático de 20 años en Cuba / Mucopolysaccharidosis: 20-year enzymatic diagnosis in Cuba

Introduction. Mucopolysaccharidoses (MPS), which belong to the family of inborn errors of metabolism, are characterised by their severe clinical manifestations (skeletal, neurological and visceral) and a chronic, progressive course leading to death at early stages of life. Aim. To accomplish an enzymatic diagnosis and characterise MPS within the Cuban population. Subjects and methods. A total of 664 patients with a clinical suspicion of some type of MPS were referred to theInstitute of Neurology and Neurosurgery in Havana in order to determine a possible enzymatic deficiency and to classify the type of MPS involved in each case. Enzymatic determinations of alpha-L-iduronidasa, alpha-N- cetylglucosaminidase, betagalactosidase,arylsulphatase B and beta-glucuronidase were performed in leukocyte homogenate for MPS I, IIIB, IVB, VI andVII, respectively, in patients, parents and controls. Results. In all, 42 cases of MPS were diagnosed: MPS I (62%, n = 26), MPS VI (29%, n = 12), MPS IIIB (7%, n = 3) and MPS IVB (2%, n = 1). No patients with MPS VII were identified. The patients diagnosed with MPS were of both sexes and ages ranged between 4 months and 10 years. The specific activity of the enzymesthat were studied was deficient in patients with respect to parents and controls. The percentage of activity was lower in patients compared to parents. Conclusions. These studies made it possible to evaluate the enzymatic deficiencies and to establish thediagnosis of MPS I, MPS IIIB, MPS IVB, MPS VI and MPS VII in the Cuban population (AU)

Introducción. Las mucopolisacaridosis (MPS), dentro de los errores innatos del metabolismo, se caracterizan por sus manifestaciones clínicas graves (esqueléticas, neurológicas y viscerales), con un curso crónico y progresivo, que conducena la muerte en etapas tempranas de la vida. Objetivo. Diagnosticar enzimáticamente y caracterizar las MPS en la población cubana. Sujetos y métodos. Se remitió un total de 664 pacientes con sospecha clínica de algún tipo de MPS al Instituto de Neurología y Neurocirugía de La Habana para determinar la posible deficiencia enzimática y clasificar el tipo de MPS.Las determinaciones enzimáticas de alfa-L-iduronidasa, N-alfa- etilglucosaminidasa, beta-galactosidasa, arilsulfatasa B y beta-glucuronidasa se realizaron en homogenado de leucocitos para MPS I, IIIB, IVB, VI y VII, respectivamente, en pacientes,padres y controles. Resultados. Se diagnosticaron 42 casos de MPS: MPS I (62%, n = 26), MPS VI (29%, n = 12), MPS IIIB (7%, n = 3) y MPS IVB (2%, n = 1). No se identificó ningún paciente con MPS VII. Los pacientes con MPS diagnosticados fueron de ambos sexos, y el rango de edad osciló de 4 meses a 10 años. La actividad específica de las enzimas estudiadas fue deficitaria en pacientes respecto a padres y controles. El porcentaje de actividad resultó inferior en pacientes respecto apadres. Conclusión. Estos estudios permitieron valorar las deficiencias enzimáticas y establecer el diagnóstico de las MPS I, IIIB, IVB, VI y VII en la población cubana (AU)

[Mucopolysaccharidosis: 20-year enzymatic diagnosis in Cuba]. / Mucopolisacaridosis: diagnostico enzimatico de 20 anos en Cuba.

INTRODUCTION: Mucopolysaccharidoses (MPS), which belong to the family of inborn errors of metabolism, are characterised by their severe clinical manifestations (skeletal, neurological and visceral) and a chronic, progressive course leading to death at early stages of life. AIM. To accomplish an enzymatic diagnosis and characterise MPS within the Cuban population. SUBJECTS AND METHODS: A total of 664 patients with a clinical suspicion of some type of MPS were referred to the Institute of Neurology and Neurosurgery in Havana in order to determine a possible enzymatic deficiency and to classify the type of MPS involved in each case. Enzymatic determinations of alpha-L-iduronidasa, alpha-N-acetylglucosaminidase, beta-galactosidase, arylsulphatase B and beta-glucuronidase were performed in leukocyte homogenate for MPS I, IIIB, IVB, VI and VII, respectively, in patients, parents and controls. RESULTS. In all, 42 cases of MPS were diagnosed: MPS I (62%, n = 26), MPS VI (29%, n = 12), MPS IIIB (7%, n = 3) and MPS IVB (2%, n = 1). No patients with MPS VII were identified. The patients diagnosed with MPS were of both sexes and ages ranged between 4 months and 10 years. The specific activity of the enzymes that were studied was deficient in patients with respect to parents and controls. The percentage of activity was lower in patients compared to parents. CONCLUSIONS: These studies made it possible to evaluate the enzymatic deficiencies and to establish the diagnosis of MPS I, MPS IIIB, MPS IVB, MPS VI and MPS VII in the Cuban population.

Relapsing neuromyelitis optica: long term history and clinical predictors of death.

BACKGROUND: Relapsing neuromyelitis optica (RNMO) is an uncommon but devastating inflammatory disorder of the central nervous system. Long term history in a wide series of RNMO is required for better knowledge of the course of the disease and identification of patients at high risk of death. METHODS: Clinical features of patients with RNMO (88 women/eight men) obtained from the geographic Caribbean database (Cuba and French West Indies) were used to determine the progression of disability and to identify clinical predictors of death. RESULTS: Median age at onset of RNMO was 29.5 years (range 11-74). Median duration of disease was 9.5 years (1-40). Median relapse rate was 0.7 attack/patient/year (0.1-3). 66 patients experienced severe visual loss in at least one eye and 46 in both eyes. Median time from onset to unilateral and bilateral severe visual loss was 3 and 15 years, respectively. Median times to reach Kurtzke Disability Status Scale 3, 6 and 8 from onset of RNMO were 1, 8 and 22 years. There were 24 deaths (25%); within 5 years in 63% of cases. A higher attack frequency during the first year of disease (p = 0.009), blindness (p = 0.04) and sphincter signs at onset (p = 0.02) and lack of recovery of first attack (p = 0.003) were independently associated with a shorter time to death. CONCLUSION: RNMO is a very rapidly disabling disease affecting primarily young women. This study has identified clinical features that predict a poor outcome. These findings suggest that early and aggressive immunotherapy might be warranted in RNMO.

An appraisal of blood-cerebrospinal fluid barrier dysfunction during the course of Guillain Barré syndrome.

BACKGROUND: Elevated cerebrospinal fluid (CSF) total protein (TP) concentration (mainly due to a dysfunctional blood-CSF barrier (B-CSFB)) with normal cell count is a hallmark for the diagnosis of Guillain-Barriota syndrome (GBS). AIMS: This work presents the evaluation of B-CSFB dysfunction with respect to the course, severity, and clinical features of GBS. MATERIALS AND METHODS: A sample of CSF was collected on admission from 68 patients of both genders (15 children and 53 adults) diagnosed with GBS. A follow-up CSF sample was obtained approximately 15 days after admission. TP concentration was determined in the CSF and 7.5% polycrylamide gel electrophoresis was employed for serum and CSF protein fractioning. A low percentage of prealbumin fraction was considered a test of impaired B-CSFB. RESULTS: Elevated TP concentration and lower prealbumin were observed in almost 70% of the patients on admission, but this percentage was lower (52.4%) during the first week from onset of symptoms. Both variables were directly associated with the time of evolution of the disease and also with a greater clinical severity. Follow-up CSF studies showed higher CSF TP and lower prealbumin percentages, while deceased patients did not display this response pattern in the follow-up CSF. CONCLUSIONS: B-CSFB dysfunction was present in only half of the patients with GBS during the first week from onset and it was directly associated with progression and clinical severity; nevertheless, a low B-CSFB dysfunction response during follow-up was associated with a lethal outcome, suggesting it could also serve a 'protective' effect during regeneration.

Neuromyelitis optica positive antibodies confer a worse course in relapsing-neuromyelitis optica in Cuba and French West Indies.

BACKGROUND: In Caucasian populations neuromyelitis optica (NMO-IgG) antibody has been detected in 27.1% / 78.2% of patients with relapsing-NMO (R-NMO). The prevalence reported for the disease in the Caribbean is 3.1/100,000 in the French West Indies (FWI) and 0.52 /100,000 in Cuba, but the NMO antibody status is unknown. OBJECTIVE: To assess the NMO-IgG antibody status of Cuban/FWI RNMO patients, comparing with European cases tested at the same laboratories. METHODS: Serum NMO-IgG antibodies were assayed in 48 R-NMO patients (Wingerchucks 1999 criteria): Cuba (24)/FWI (24), employing Lennon et als method. We compared the demographic, clinical, disability and laboratory data between NMO-IgG +/- patients. All the data were reviewed and collected blinded to the NMO-IgG status. RESULTS: Seropositivity of the NMO-IgG antibody demonstrated a lower rate in the Caribbean (33.3%), as compared with Caucasian patients from Spain/Italy (62.5%) and France (53.8%). Caribbean patients with NMO-IgG (+) displayed more attacks, more spinal attacks and a higher EDSS than NMO-IgG (-) cases, while brain and spinal cord MRI lesions were more frequent during remission, with more vertebral segments, more gray, white matter and holocord involvement. CONCLUSIONS: NMO IgG positive antibodies in NMO patients had a lower rate in the Caribbean area - where the population has a predominant African ancestry - than in Caucasian Europeans, suggesting the influence of a possible ethnic factor in the pathogenesis of the disease, but they confer a worse course with more attacks, more disability and MRI lesions.

Robotic laparoscopic surgery: cost and training.

The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.

[Descriptive epidemiology of neuromyelitis optica in the Caribbean basin]. / Epidémiologie descriptive de la neuromyélite optique dans le bassin caraïbéen.

INTRODUCTION: Data on epidemiology of neuromyelitis optica (NMO) remained scarce in the last century, but the recent development of diagnostic criteria now enables inclusion of both monophasic and relapsing NMO in epidemiologic studies. Given the rarity of NMO, multicentric studies are needed to confirm a presumed higher frequency in women and in populations of black/Asian ancestry. The Caribbean basin is a suitable area for collecting a large NMO cohort and to assess the prevalence, incidence, and mortality of this disorder. PATIENTS AND METHODS: This population-based survey of the NMO spectrum in the French West Indies (FWI) and Cuba included 151 cases. RESULTS: Ninety-eight patients (female/male ratio: 9.8) had NMO. Age of onset in NMO patients was 30.9 years. Mean annual incidence of NMO in the French West Indies for the period July 2002 to June 2007 was 0.20/100,000 inhabitants (IC 95% 0.05-0.35). Incidence rates were steady in the FWI during the 1992 to 2007 period. Decreasing mortality in the FWI during the 1992 to 2007 period explained the increasing prevalence which was 4.20/100,000 inhabitants (IC 95% 3.7-5.7) in June 2007. The prevalence of NMO in Cuba on November302004 was 0.52/100,000 inhabitants. (IC 95% 0.39-0.67). Prevalence rates did not differ significantly by ethnic group in Cuba, however, black Cubans exhibited the highest prevalence. DISCUSSION: Epidemiologic studies on NMO in each population are needed to determine whether aggressive therapies can reduce the mortality of this devastating disorder. CONCLUSION: In the Caribbean basin, NMO involves almost exclusively young women; the epidemiologic data confirm its predilection for populations of African ancestry. In the FWI, recent and aggressive therapy has lowered mortality but with an increase in the prevalence of NMO.