Skin and sepsis: contribution of dermatology to a rapid diagnosis.

In patients who develop sepsis, whether due to primary, secondary or metastatic lesions, the skin is frequently affected. However, there are unresolved aspects regarding the general clinical manifestations in the skin or the prognosis and/or therapeutic implications. The main challenge in the approach to sepsis is its early diagnosis and management. In this review, we address the sepsis-skin relationship and the potential impact of early dermatological intervention on the septic patient through ten basic questions. We found little evidence of the participation of the dermatologist in sepsis alert programs. There are early skin changes that may alert clinicians on a possible sepsis, such as skin mottling or variations in acral skin temperature. In addition, the skin is an accessible and highly cost-effective tissue for etiological studies of some forms of sepsis (e.g., meningococcal purpura) and its involvement defines the prognosis of certain patients (e.g., infective endocarditis).

Larva migrans cutánea de adquisición ocupacional en Madrid / Occupational cutaneous larva migrans disease in Madrid

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Experiencia inicial con oxibutinina transdérmica en el tratamiento de la hiperhidrosis / Preliminary experience with transdermal oxybutynin patches for hyperhidrosis

INTRODUCCIÓN: La hiperhidrosis (HH) es una condición muy prevalente que supone una repercusión importante en la calidad de vida. Entre las opciones terapéuticas disponibles, la oxibutinina oral consigue buenas tasas de respuesta aunque con frecuentes efectos secundarios que condicionan en muchas ocasiones el abandono del tratamiento. Tras la comercialización en nuestro país de la oxibutinina en presentación transdérmica, realizamos un estudio preliminar para valorar el control de la HH y el perfil de efectos secundarios de este tratamiento. MATERIAL Y MÉTODOS: Se realizó un estudio prospectivo con 25 pacientes que recibieron tratamiento con 2 parches semanales de oxibutinina transdérmica durante 10 semanas. La respuesta terapéutica se valoró mediante 2 escalas subjetivas: Hyperhidrosis Disease Severity Scale (HDSS) y escala analógica visual (EAV). RESULTADOS: Un 60% de los pacientes consiguieron una reducción en la puntuación de la HDSS. Todos los casos obtuvieron una disminución en la puntuación de la EAV, siendo esta de 3 puntos o superior en el 68% de los pacientes. Solo 2 pacientes (8%) presentaron efectos adversos relacionados con el tratamiento, en ambos casos en forma de dermatitis irritativa en la zona de aplicación del parche. CONCLUSIONES: Aunque se trata de una experiencia limitada, los resultados de nuestro estudio sugieren que la oxibutinina transdérmica podría tener utilidad en el manejo de la HH, con un excelente perfil de seguridad y tolerancia

BACKGROUND AND OBJECTIVE: Hyperhidrosis is very common and has a considerable impact on patients' quality of life. While oral oxybutynin is associated with good response rates, adverse effects are common and frequently cause patients to stop treatment. Following the recent launch of oxybutynin in a transdermal patch formulation in Spain, we undertook a preliminary study to assess treatment response and adverse effects in patients with hyperhidrosis. MATERIAL AND METHODS: This prospective study of 25 patients treated twice weekly with transdermal oxybutynin patches over 10 weeks assessed treatment response on 2 subjective scales: the Hyperhidrosis Disease Severity Scale (HDSS) and a visual analog scale (VAS) for sweating. RESULTS: Sixty percent of patients showed an improvement in HDSS scores. VAS scores improved in all cases, and 68% of patients achieved a reduction of 3 points or more. Just 2 patients (8%) experienced treatment-related adverse effects (irritant dermatitis at the patch application site in both cases). CONCLUSIONS: Although our results are based on a small sample, they suggest that transdermal oxybutynin could be a useful option for the treatment of hyperhidrosis and that it has an excellent safety and tolerability profile

Preliminary Experience with Transdermal Oxybutynin Patches for Hyperhidrosis. / Experiencia inicial con oxibutinina transdérmica en el tratamiento de la hiperhidrosis.

BACKGROUND AND OBJECTIVE: Hyperhidrosis is very common and has a considerable impact on patients' quality of life. While oral oxybutynin is associated with good response rates, adverse effects are common and frequently cause patients to stop treatment. Following the recent launch of oxybutynin in a transdermal patch formulation in Spain, we undertook a preliminary study to assess treatment response and adverse effects in patients with hyperhidrosis. MATERIAL AND METHODS: This prospective study of 25 patients treated twice weekly with transdermal oxybutynin patches over 10 weeks assessed treatment response on 2 subjective scales: the Hyperhidrosis Disease Severity Scale (HDSS) and a visual analog scale (VAS) for sweating. RESULTS: Sixty percent of patients showed an improvement in HDSS scores. VAS scores improved in all cases, and 68% of patients achieved a reduction of 3 points or more. Just 2 patients (8%) experienced treatment-related adverse effects (irritant dermatitis at the patch application site in both cases). CONCLUSIONS: Although our results are based on a small sample, they suggest that transdermal oxybutynin could be a useful option for the treatment of hyperhidrosis and that it has an excellent safety and tolerability profile.

Lower-normal TSH is associated with better metabolic risk factors: A cross-sectional study on Spanish men.

BACKGROUND AND AIMS: Subclinical thyroid conditions, defined by normal thyroxin (T4) but abnormal thyroid-stimulating hormone (TSH) levels, may be associated with cardiovascular and metabolic risk. More recently, TSH levels within the normal range have been suggested to be associated with metabolic syndrome and cardiovascular risk. This work studies the linearity of the relationship between metabolic syndrome and TSH across the euthyroid range. METHODS AND RESULTS: We studied 3533 male participants of the Aragon Workers' Health Study (AWHS) with normal TSH and free T4 levels, across quintiles of these variables, after adjusting for age, alcohol intake, and smoking. Compared with the lowest TSH quintile, the odds ratios for metabolic syndrome at the higher quintiles, which indicate lower thyroid function, were 1.34 (1.04, 1.73), 1.56 (1.21, 2.01), 1.57 (1.22, 2.03), and 1.71 (1.32, 2.21). The lowest free T4 quintile also showed an odds ratio of 1.49 (1.16, 1.90) with respect to the highest quintile. In addition, spline models showed departures from linearity: the risk of metabolic syndrome mostly increases at TSH values below the median (sample half-closest to subclinical hyperthyroidism). Interestingly, glucose also increases with TSH primarily below the median TSH, diastolic blood pressure shows similar changes across the entire TSH range, whereas body mass index, triglycerides, and high-density lipoprotein (HDL)-cholesterol change only at the highest normal TSH values, which are associated with lower free T4 concentration. CONCLUSIONS: TSH and free T4 within the normal range are associated with the metabolic syndrome. The sample half-below the TSH median (with probably higher functional thyroid status) exhibited better metabolic and cardiovascular profiles.

[An analysis of pre-hospital delay times in stroke care]. / Análisis de la demora prehospitalaria en la asistencia al ictus.

INTRODUCTION: Delays in the treatment of a stroke constitute a factor that leads to a more unfavourable prognosis. Shortening the delay time in the health care of these patients is essential in order to reduce the morbidity and mortality rates of this disease. AIMS: Our aim was to analyse the causes that bring about delays in getting stroke patients to hospital. PATIENTS AND METHODS: A prospective analysis was conducted of 133 patients who visited the Emergency Department. A survey carried out during the first 48 hours collected information on the clinical characteristics and the steps followed by the patient before arriving at the hospital. We considered the time that elapsed to be adequate if patients arrived at the hospital in less than 2 hours. A univariate and multivariate analysis was performed to evaluate the factors that could extend this time. RESULTS: The mean time elapsed before the patient reached hospital was 502 minutes (interval: 11-5,700). A total of 42.5% arrived in less than 2 hours and 58.2% got there in less than 3 hours. The univariate analysis showed that females, those with a low cultural level, the most severe cases, those who went straight to hospital and those who used the emergency services all arrived more quickly. In the multivariate analysis only the more severe cases and those who went straight to hospital ran less risk of a delayed arrival. CONCLUSIONS: The time stroke patients take to reach hospital varies greatly. The main factors that influence the time that elapses before arrival are the severity of the symptoms and going straight to hospital.

[Familial multiple sclerosis in Canary Islands]. / Esclerosis múltiple familiar en Canarias.

INTRODUCTION: Multiple sclerosis (MS) is an autoimmune disease that occurs in genetically predisposed individuals. Its inheritance is polygenic. Genetic epidemiology studies have shown an increased familial aggregation. AIM. To determine the prevalence of familial MS (fMS) in a series of patients from the Canary Islands. PATIENTS AND METHODS: From a cohort of 266 patients with defined MS, during a 6-year period, we investigated prospectively by personal interviews the presence of MS on first and second degree relatives. We analysed as well the presence of HLA DRB1 in affected families, and also clinical and demographic characteristics in fMS and compared them with sporadic MS (sMS). RESULTS: fMS prevalence was 13.9% (27 non-related families with 50 affected individuals). The HLA DRB01*1501 allele were present in 51,8% of familial cases. We could not found either intrafamilial concordance in clinically affected regions and age of onset or clinical evolution. We have not found any phenotypic differences between familial and sMS. CONCLUSIONS: The prevalence of fMS in our series is comparable to that in other Mediterranean populations. Our results do not support that fMS was a different clinical entity of sMS and intrafamilial concordance in its clinical expression.

[Pain after anterior cruciate ligament reconstruction: detail and treatment]. / Douleurs après ligamentoplastie du ligament croisé antérier: démembrement et prise en charge.

OBJECTIVE: Several factors can influence the occurrence of pain after anterior cruciate ligament (ACL) ligamentoplasty, namely, factors linked to the selection of graft, the surgical technique and rehabilitation program. The aim of this research was to review the literature for different types of pain experienced after ACL reconstruction to illuminate better prevention and treatment. METHOD: We reviewed reports by searching the PUBMED* research engine using the key words pain, complication, and anterior cruciate ligament. RESULTS: We found an increasing incidence of anterior pain after use of the patellar tendon for ACL reconstruction. Some anterior pain can be mistakenly interpreted as donor site morbidity or patello-femoral problems, but it is in fact linked to graft impingement caused by bad placement of tunnels and/or proliferation of a fibrovascular nodule on the ACL graft ("cyclops syndrome"). Some posterior-external pain, sometimes associated, can occur under the same circumstances. Cartilage, ligament or meniscal lesions or saphenous nerve injuries can explain some occurrences of pain. Pain linked to loco-regional factors such as reflex sympathetic dystrophy appear to be rare with rehabilitation and surgery. CONCLUSION: The treatment of pain after ACL reconstruction lies first in the establishment of an etiologic diagnosis. Prevention, by controlling tendon-muscular and joint stress during rehabilitation, is essential and requires sound knowledge of biomechanical data.

[Guillain-Barré syndrome in the northern area of Gran Canaria and the island of Lanzarote]. / Sindrome de Guillain-Barré en el area norte de Gran Canaria e isla de Lanzarote.

AIMS: The objective of this study is to analyse the incidence and clinical characteristics of Guillain Barre syndrome (GBS) in the Canary Islands. PATIENTS AND METHODS: We conducted a retrospective study of GBS patients (according to diagnostic criteria from the National Institute of Neurological and Communicative Disorders and Stroke) treated in the Ntra. Sra. del Pino Hospital in Gran Canaria between 1983 and 1998. Annual incidence, seasonal distribution, preceding infection, clinical and electrophysiological data, and evolution were all evaluated. Prognostic factors were studied by means of a univariate analysis. RESULTS: A total of 81 patients were selected for the study. The raw incidence was 1.04/100,000 inhab./year (CI 95%: 0.83 1.29; adjusted for age to the European population: 1.5). The rates of incidence were higher in men and increased lineally with age in both sexes. We observed an upward tendency during the winter months. 48% of the patients displayed serious motor deficits in the nadir of the disease, and 17.8% required assisted ventilation. After one year s evolution 74% were seen to experience an excellent recovery. The mortality rate was 8.2% and 37% received immunomodulatory treatment. The main variables associated with a bad prognosis at 3 and 12 months were: serious deficits in muscular balance, the need for assisted ventilation and very reduced amplitude of evoked motor potential. CONCLUSIONS: GBS incidence in the Canary Islands is similar to that found in other countries. An increase with age and an upward tendency during the winter months was observed. No differences were found in the clinical data as compared with other series.

Síndrome de Guillain-Barré en el área norte de Gran Canariae isla de Lanzarote / Guillain-Barré syndrome in the northern area of Gran Canaria and the island of Lanzarote

Objetivo. Analizar la incidencia y características clínicas del síndrome de Guillain-Barré (SGB) en Canarias. Pacientes y métodos. Estudio retrospectivo de pacientes con SGB (criterios diagnósticos del National Institute of Neurological and Communicative Disorders and Stroke) atendidos en el H. Ntra. Sra. del Pino de Gran Canaria, entre 1983 y 1998. Se evaluaron la incidencia anual, distribución estacional, infección precedente, los datos clínicos y electrofisiológicos y la evolución. Se investigaron factores pronósticos mediante un análisis univariante. Resultados. Se seleccionaron 81 pacientes. La incidencia cruda fue 1,04/100.000 hab/año (IC 95 por ciento: 0,83-1,29) (ajustada por edad a la población europea: 1,5). Las tasas de incidencia fueron más altas en el hombre y aumentaban linealmente con la edad en ambos sexos. Observamos predilección por los meses de invierno. El 48 por ciento de los pacientes alcanzaron déficit motores graves en el nadir de la enfermedad, y un 17,8 por ciento precisó ventilación asistida. Al año de evolución, el 74 por ciento tuvo una excelente recuperación. La mortalidad fue del 8,2 por ciento. El 37 por ciento recibió tratamiento inmunomodulador. Las principales variables asociadas a mal pronóstico a los tres y 12 meses fueron: déficit graves en el balance muscular, necesidad de ventilación asistida y una amplitud muy reducida de potencial motor evocado. Conclusiones. La incidencia del SGB en Canarias es similar a la que se encontró en otros países. Observamos un aumento de la incidencia con la edad y predilección por los meses de invierno. No encontramos diferencias en los datos clínicos con otras series (AU)

[Neurosyphilis: forms of presentation and clinical management]. / Neurosífilis: formas de presentación y manejo clínico.

INTRODUCTION AND AIMS: Neurosyphilis results from the infection of the central nervous system by Treponema pallidum. It causes diverse clinical pictures which are occasionally similar to other, better known neurological diseases. In this paper our aim is to offer a global clinical vision of this entity by reviewing the different forms it can take and its diagnostic and therapeutic management. DEVELOPMENT: The forms of presentation of neurosyphilis can be grouped in two categories: early (asymptomatic, meningeal and meningovascular neurosyphilis) and late (progressive general paralysis and tabes dorsalis). Other less important forms, such as gummas, ocular forms, syphilitic amyotrophy or hypoacusis, have also been described. Diagnosis is complex and is based on the study of the cerebrospinal fluid. Given the difficulty involved in performing an accurate diagnosis, different criteria have been developed in which T. pallidum serology plays a key role. The most effective treatment is penicillin, although on occasions it may have no effect and we therefore recommend clinical and fluid analysis follow ups. Lastly, we describe the changes in incidence and clinical presentation, and the complications that may arise in diagnosis when HIV carrying patients also suffer from this disease. CONCLUSIONS: Neurosyphilis is a disease that still occurs nowadays and, due to its clinical polymorphism, must be borne in mind as a differential diagnosis in a number of neurological and psychiatric illnesses. This, together with the fact the serological tests are difficult to interpret and its irregular response to the usual treatment, makes it difficult to manage and means that the neurologist must have a thorough knowledge of the disorder.

[Evaluation of the pediatric aspects of the WHO document and meta-analysis of immunotherapy]. / Valoración de los aspectos pediátricos del documento de la OMS y del meta-análisis sobre inmunoterapia.

In spite of the existence of numerous scientific studies on the beneficial effect of immunotherapy with specific allergens in the treatment of allergic diseases, their results have not been easily accepted as the methodology and the valuation of the studies have been very heterogeneous. Over the last few years the meta-analysis technology has been developed as a useful tool to globally value the results on the different research studies related to a specific problem. When meta-analyse are carried out correctly, they are accepted as an optimum way to express the results obtained from the different studies from a common view point. In 1995 Abramson MJ, Puy RM and Weiner INI published the first meta-analysis on the efficiency of immunotherapy with specific allergens in the treatment of asthma. The same authors continued to carry out systematic reviews of this theme, and their results were published in the Cochrane Library Document. In october 1999 the latest meta-analysis on immunotherapy in asthma, also carried out by Abramson et al was published in Allergy. In this study 62 investigations published from 1954 to 1998 were included. None of the meta-analyses published to date have separately analysed the studies carried out on children, nor have special considerations been made with respect to the 105 patients who were of paediatric age. The first meta-analysis studies, as well as the ones carried out in 1999, only value random clinical tests, in which there is a valuation of the evolution of asthma and in which mite, pollen, animal, fungi or epithelial allergenic vaccinations are used. Only the subcutaneous administration of the vaccine was allowed. Although this meta-analysis has not been designed to obtain specific conclusions of the effectiveness of immunotherapy in children, probably of conclusions of some of the sections can be applied to the children and/or adolescent population. The authors point out, by valuing the results of the effect of immunotherapy on the clinical evolution, that the studies carried out on children were more homogenous than on adults, which means that their significance on this population is more important. Approximately 50% of the studies that evaluate the clinical evolution, the medicines taken and the specific BHR study with allergens, included children and/or adolescents. It is very probable that these conclusions can be applied to the population between 5 and 18 years old that suffer from allergic asthma, but it is clear that a meta-analysis of the efficiency of immunotherapy in paediatrics is needed. Recently regulations on immunotherapy have been published that appeared after the immunotherapy experts from the World Health Organisation met in Geneva in 1997 (1). The recommendations for immunotherapy in children are clear and similar to those applied to adults: 1. Rhonoconjunctivitis and allergic asthma mediated by IgE. 2. Serious anaphylactic reactions caused by hymenoptera bites. 3. The same diagnosis and treatment considerations recommended are applied to children as well as adults. It is not indicated for allergies to food substances and atopic dermatitis. The patients age is another factor to be considered and, except in the case of allergy to hymenoptera poison, when the patient is under 5 it is a relative counter indication to administer immunotherapy. In general it is admitted that immunotherapy is more efficient on children than on adults, but more studies need to be carried out on the efficiency and safety on children under 5. The early treatment with immunotherapy in children who suffer from allergic respiratory illnesses can have an important significance, as this type of treatment could have a preventive nature as it prevents the rhinitis developing into asthma, as well as the beneficial effect that has been shown on children with allergic asthma.

Postnatal development of NADPH-diaphorase activity in the superior colliculus and the ventral lateral geniculate nucleus of the rat.

We have studied the postnatal development of dihydronicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) activity in the superior colliculus (SC) and the ventral lateral geniculate nucleus (LGv) of the rat. We describe two different developmental patterns of NADPH-diaphorase activity. The first pattern, observed in the deep layers of the SC, shows a transient activity during the first week which progressively decreases during the following two weeks. The second pattern is observed in the superficial layers of the SC and in the LGv. They become positive during the first week, their NADPH-d activity increases progressively during the second and third weeks, reaching the adult pattern at the fourth week. On the whole, the developmental chronology of the laminar distribution of NADPH-d in the SC displays an inside-out pattern. Our results suggest that NADPH-d activity may play different roles at different stages of the developing nervous system.

Laminar distribution and morphology of NADPH-diaphorase containing neurons in the superior colliculus and underlying periaqueductal gray of the rat.

We have studied the laminar distribution of reduced nicotinamide dinucleotide phosphate diaphorase (NADPH-d) activity and the morphology of positive neurons in the superior colliculus (SC) and the underlying periaqueductal gray (PAG) of the rat. The morphology of NADPH-d-positive neurons has been compared to that of Golgi-impregnated cells. The highest activity occurs in the stratum zonale and stratum griseum superficiale, contrasting with the pale neuropil in the stratum opticum, where only a few positive neurons are found. In the stratum griseum intermedium positive neurons are grouped in patches separated by narrow, NADPH-d-negative bands. In the deeper layers, the neuropil is NADPH-d-negative, and few neurons show enzymatic activity. In contrast, numerous neurons in the dorsolateral part of the PAG are intensely positive. They are continuous with the positive neurons in the stratum album profundum, with no clear border between the two centers. In both SC and PAG, only small and medium sized neurons are NADPH-d-positive. In comparison with Golgi material, all types of small neurons in the superficial layers show NADPH-d activity; NADPH-d histochemistry, however, does not visualize the characteristic dendritic appendages of these neurons. The large neurons of the SC and PAG, probably representing the long-projecting neurons of these centers, do not contain the enzyme.