Development and validation of clinical scores for visual outcomes after cataract surgery.

PURPOSE: To develop and validate a clinical score to predict visual acuity (VA) and functional changes after phacoemulsification on the basis of readily obtainable preoperative history data and patient assessment. DESIGN: Prospective follow-up study. PARTICIPANTS: A sample of 5512 patients on waiting lists for phacoemulsification at 17 hospitals in Spain. METHODS: Data were obtained at the baseline examination from the 5512 patients. The patients were divided randomly into 2 subgroups: derivation (n = 3285; 60%) and validation (n = 2227; 40%). The preoperative predictors of postoperative gains in VA and visual function index 14 (VF-14) were determined by multivariate logistic regression analysis and implemented using a prediction score. MAIN OUTCOME MEASURES: Probability of postoperative improvement in VA and VF-14 scores. The cutoff points were established for each outcome on the basis of the minimal clinically important difference values. RESULTS: The predictive variables for VA gain were the baseline VA, patient age, ocular comorbidity, and surgical complexity. Regarding the VF-14, the predictive factors were the preoperative VF-14, the eye with the better VA, and the surgical complexity. In the multivariate logistic model in the derivation sample, the final VA and VF-14 scores ranged from 0 to 44 and from 0 and 24, respectively. Receiver operating characteristic curves were developed in the derivation and validation samples, and no statistical significance was found when their areas under the curve were compared. Areas under the curve ranged from 65% to 80%. Both scores had a positive predictive value from 74% to 85%. CONCLUSIONS: Newly developed and validated clinical prediction scores may assist physicians and patients in decision making about the expected outcomes and benefits of cataract surgery.

Variability in the prioritization of patients for cataract extraction.

OBJECTIVE: The aim of this study was to compare time spent waiting for cataract extraction across various hospitals and to determine if it was influenced by severity of disease or patient characteristics. DESIGN: Ambispective cohort study. Clinical, sociodemographic, and health-related quality of life data were collected along with time spent on the waiting list. SETTING: Twelve hospitals in four regions of Spain. PARTICIPANTS: A total of 4043 patients who were waiting for being intervened on cataracts in the participant centres were recruited prospectively. Exposition variables Priority was assigned retrospectively using a previously validated scoring system. MAIN OUTCOME MEASURE: Time spent on waiting list. RESULTS: Statistically significant differences in time spent on the waiting list (P < 0.0001) were observed across the hospitals, even after adjusting for pathology, age, social dependency, laterality of the cataract and number of inappropriate interventions in each centre. Waiting time was not correlated with preintervention visual acuity, preintervention visual function measured by the VF-14 or priority score. CONCLUSIONS: Allocation of cataract surgery does not appear to be correlated with the need for surgery or the likely benefit to be derived from it in the Spanish participant centres. The use of explicit and standardized priority criteria could provide a fairer, more rational way to manage waiting lists for this procedure and may help to reduce unnecessary variation on access to health care.

Solitary osteochondroma long-term follow-up.

A series of 113 osteochondromas were treated in our institution with a long-term follow-up. A retrospective study of the cases of solitary osteochondroma diagnosed and treated in our center from 1970 to 2002 was done. A diagnosis for clinical findings in 73% of the patients was made. The most frequent location was the distal femur. Six patients had a recurrence and in two patients the lesions became malignant and chondrosarcoma developed. Relapse of the exostosis is rare, occurring in an estimated 2% of the resections. The growth of an osteochondroma and/or the presence of pain in older patients suggest possible malignancy.

Metal levels in corrosion of spinal implants.

Corrosion affects spinal instrumentations and may cause local and systemic complications. Diagnosis of corrosion is difficult, and nowadays it is performed almost exclusively by the examination of retrieved instrumentations. We conducted this study to determine whether it is possible to detect corrosion by measuring metal levels on patients with posterior instrumented spinal fusion. Eleven asymptomatic patients, with radiological signs of corrosion of their stainless steel spinal instrumentations, were studied by performing determinations of nickel and chromium in serum and urine. Those levels were compared with the levels of 22 patients with the same kind of instrumentation but without evidence of corrosion and to a control group of 22 volunteers without any metallic implants. Statistical analysis of our results revealed that the patients with spinal implants without radiological signs of corrosion have increased levels of chromium in serum and urine (P < 0.001) compared to volunteers without implants. Corrosion significantly raised metal levels, including nickel and chromium in serum and urine when compared to patients with no radiological signs of corrosion and to volunteers without metallic implants (P < 0.001). Metal levels measured in serum have high sensibility and specificity (area under the ROC curve of 0.981). By combining the levels of nickel and chromium in serum we were able to identify all the cases of corrosion in our series of patients. The results of our study confirm that metal levels in serum and urine are useful in the diagnosis of corrosion of spinal implants and may be helpful in defining the role of corrosion in recently described clinical entities such as late operative site pain or late infection of spinal implants.

Corrosion and late infection causing delayed paraparesis after spinal instrumentation.

A 28-year-old female patient came to our hospital 14 years after surgical correction of adolescent idiopathic scoliosis with a 316L stainless-steel instrumentation. She presented progressive paraparesis during the last 2 months. Plain radiography, computed tomography scan and computed tomography-scan-guided needle biopsy revealed that a metallotic mass penetrated into the spinal canal, causing compression of the spinal cord at the T5-T6 level. The patient's symptoms were related to corrosion of the implant and infection by Propionibacterium acnes. Through a posterior approach, the instrumentation was retrieved and the metallotic mass and tissues were excised. Six months after the surgery, the patient is completely asymptomatic. Corrosion of stainless-steel implants is a finding more common than supposed. Biocorrosion--or microbially influenced corrosion--is a concept to be taken into account. It is possible that bacteria may modify the rate of corrosion of metals. Early diagnosis of corrosion is essential in order to prevent cases like the one we report, and perhaps, as suggested for total hip arthroplasties, metal levels could be useful to monitor spinal implants.

[Singularization processes: a proposal for continuity between clinical activity and health policy objectives]. / Singularizar procesos: una propuesta de continuidad entre la actividad clínica y los objetivos de salud de las políticas sanitarias.

BACKGROUNDS AND OBJECTIVES: In 1996 the Gipuzkoa Territorial Health Agency (Basque Country, Spain) created the Health Plan Service. The aim was to transform the health objectives prioritized by the Health Department into intervention strategies to be incorporated into the local contract services. PROCESS AND RESULTS: One of the procedures the service uses for this purpose, known as <>, involves selecting a process linked to a prioritized health problem, and analyzing and reconstructing it so that the related activity, expected results, financial costs and its impact on the population's health can be identified. After this process the service provides the Territorial Health Agency, which is responsible for service purchase for the public and private sectors, with information about contract conditions for the process reviewed. Annual assessment of contract services monitors the extent to which the agreements made have been carried out and their consequences on the population's health. The present article deals with the process through which this <> is carried out.

Singularizar procesos: una propuesta de continuidad entre la actividad clínica y los objetivos de salud de las políticas sanitarias / Singularization processes: a proposal for continuity between clinical activity and health policy objectives

Antecedentes y objetivos: La Dirección Territorial de Sanidad de Gipuzkoa creó en 1996 el servicio del Plan de Salud con la finalidad de transformar los objetivos de salud priorizados por el Departamento de Sanidad en estrategias de intervención a incorporar a los contratos programa. Proceso y resultados: el procedimiento que el servicio está utilizando para cumplir este objetivo se denomina singularización y consiste en seleccionar un proceso vinculado a un problema de salud prioritario, analizarlo y reconstruirlo de forma que se conozca la actividad relacionada con él, los resultados, el coste económico y su impacto en la salud de la población. El procedimiento permite a la Dirección Territorial de Sanidad, responsable de la compra de servicios al sector público y privado, disponer de información sobre las condiciones de contratación para el proceso revisado. La evaluación anual de los Contratos programa y Conciertos controla el grado de consecución de los pactos realizados y de sus consecuencias sobre la salud de la población. El artículo que se presenta recoge la forma en la que se realiza esta singularización

Backgrounds and objectives: In 1996 the Gipuzkoa Territorial Health Agency (Basque Country, Spain) created the Health Plan Service. The aim was to transform the health objectives prioritized by the Health Department into intervention strategies to be incorporated into the local contract services. Process and results: One of the procedures the service uses for this purpose, known as «singularization», involves selecting a process linked to a prioritized health problem, and analyzing and reconstructing it so that the related activity, expected results, financial costs and its impact on the population's health can be identified. After this process the service provides the Territorial Health Agency, which is responsible for service purchase for the public and private sectors, with information about contract conditions for the process reviewed. Annual assessment of contract services monitors the extent to which the agreements made have been carried out and their consequences on the population's health. The present article deals with the process through which this «singularization» is carried out

Spondylolisthesis in pre-school children.

Although the natural history of spondylolisthesis is poorly described, we know that it is rare to see the condition in children before they are 5 or 6 years old. Treatment in these patients may be confusing because there is very little literature on the subject, and most papers are case reports. We present a series of eight pre-school patients (mean age 3.5 years; range 9 months to 5 years) with spondylolisthesis with an average follow up of 11.5 years (range 9-14 years). In our experience, general guidelines for treatment as given by Wiltse and Jackson are useful in patients younger than 5 years. Nowadays we have to keep strict control of these patients due to their important capacity for growth that increases the possibility of further slippage.

Physical sports activity during leisure time and dietary intake of foods and nutrients in a large Spanish cohort.

This study evaluated the dietary pattern of foods and nutrients according to levels of vigorous leisure time physical activity (PA) assessed at recruitment within the Spanish cohort of the European Prospective Investigation on Cancer (EPIC) study (37,287 healthy volunteers with complete information). We used a validated PA questionnaire (PAQ) to measure the weekly frequency and duration of different kinds of sport activities. For dietary assessment, we used a validated diet history questionnaire that included all items consumed with a frequency of at least twice a month. We tested differences in food and nutrient intake according to PA duration by means of both an analysis of variance and an analysis of covariance adjusted for confounding factors. Linear increases or decreases in food and nutrient intake across PA levels were tested by means of a regression analysis. Only 11% of men and 6% of women performed at least 3 hours/week of intense PA, which is similar to current recommendations. Overall, main nutrient and total energy intakes were similar across different PA levels (<2% change in total energy intake between extreme PA categories). However, the intake of some foods and vitamins did significantly (p .05) increase as PA increased. The average gender-weighted percentage change in the intake of food and vitamins increased when moving from the lowest levels of PA to the highest. There was an increase in the intake of the following: 15.9% in vegetables, 6.7% in fruit, 9% in fish, 5.6% in dairy products, 10% in vitamin C, 5.9% in vitamin E, 7.2% in retinol, 19.7% in total carotene, 40.1% in alpha-carotene, 20.4% in beta-carotene, 11.2% in licopene, and 26.1% in lutein. BMI, which was above average for the cohort (mean +/- SD: 28.4 +/- 4.2), decreased steadily when PA increased. To sum up, in this large Spanish cohort, the differences in dietary intake relative to levels of PA were not found either in the amount of total energy consumed nor in the number of main macronutrients but rather in the intake of certain foods which, while having very little or moderate caloric content, are very rich in highly bioactive elements such as vitamins and provitamins.

Nail-patella syndrome: long term evolution.

Nail-patella syndrome is a rare dysplasia characterized by a typical tetrad: hypoplasic nails, hypoplasic or absent patella, radial head dislocation and iliac horns. We review eight patients, four men and four women, aged from 20 to 70 years. The main complaint at consultation was with their knees due to patellar instability and pain. Five of them required surgical treatment due to patellar dislocation and three patients were not treated. The Krogius-Lecène procedure was performed in four patients with a good result following the Insall classification of pain and instability and with an average follow-up of 24 years (range, 18-28 years). Patellectomy was performed in the eldest patient due to femoropatellar arthritis present at first consultation. No patients presented with elbow or nail disorders or with iliac horns.

Factores asociados a la acumulación de grasa abdominal estimada mediante índices antropométricos / Association of lifestyle factors and dietary intake with abdominal obesity measured by anthropometric variables

Fundamento: Describir los hábitos de vida, antecedentes personales y hábitos alimentarios asociados a la acumulación de grasa abdominal estimada mediante indicadores antropométricos. Sujetos y método: Se realiza un estudio transversal sobre 23.228 mujeres y 14.332 varones entre 29 y 69 años de edad, miembros de la cohorte española del estudio EPIC, voluntarios sanos de diversos sectores sociales, seleccionados entre 1992 y 1996 en Asturias, Granada, Murcia, Navarra y Guipúzcoa. La información sobre consumo alimentario y otros factores fue recogida mediante entrevista, y la de circunferencia de la cintura y cadera, peso y altura por medición realizada por personal adiestrado. Resultados: En el análisis por regresión lineal múltiple ajustando por el conjunto de factores estudiados, la práctica de deportes y el nivel educacional se encuentran inversamente asociados a la acumulación de grasa abdominal, mientras que el índice de masa corporal y la edad, el consumo de alcohol, tabaco, grasas saturadas y antecedentes de diabetes, hipertensión e infarto agudo de miocardio se encuentran asociados de forma positiva. El conjunto de las variables explica el 22 y el 27 por ciento de la variabilidad de la razón cintura cadera, y el 74 y el 66 por ciento de la variabilidad de la circunferencia de la cintura en mujeres y varones, respectivamente. Conclusión: El índice de masa corporal y la edad son los factores principales asociados a la acumulación de grasa abdominal en ambos sexos, mientras que los hábitos alimentarios y otros factores parecen tener un efecto muy débil. (AU)