Tratamiento del enfisema subcutáneo masivo con drenaje aspirativo / Treatment of massive subcutaneous emphysema with aspiration drainage

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Stentoplasty effectiveness and safety for the treatment of osteoporotic vertebral fractures: a systematic review.

UNLABELLED: To assess the effectiveness and safety of stentoplasty in people with osteoporotic vertebral body fractures. A systematic search of databases including MEDLINE, EMBASE and Cochrane library, between others, was conducted to June 9, 2014. Clinical trials and observational studies that included alive adults with osteoporotic vertebral body fractures and the comparators were the intervention himself, vertebroplasty or balloon kyphoplasty were selected. Quality of evidence was graded according to the GRADE approach. Two review authors independently selected studies, assessed risk of bias and extracted data. Forty-two citations were identified during the search. After removing duplicates, five studies were included: two clinical trials and three observational studies. Stentoplasty, showed higher rate of adverse events related to material (P=0.043) and cuff pressure (P=0.014) in comparison to kyphoplasty. There was no difference between two procedures in terms of reduction of kyphosis, time of exposure to radiation or postoperative loss of cement. Stentoplasty in comparison to vertebroplasty, showed an improvement of restoration of vertebral height (P=0.042), kyphosis correction and volume of bone cement. No differences were found between two procedures in terms of loss of vertebral body volume. Based on observational studies, stentoplasty improved vertebral height, pain and functional disability at 6 and 12months follow-up, and corrected the angle vertebral fractures in patients with osteoporotic vertebral body. Stentoplasty was presented as a safe procedure in short-medium term, with a low complication rate, a reduced loss of cement and new vertebral body fractures lower rates. Stentoplasty improves vertebral height, reduces the pain and functional disability and correct the vertebral angle in patients with osteoporotic vertebral body fracture with minimum adverse events. Stentoplasty is comparable to kyphoplasty in terms of correction of kyphosis, time of exposure to radiation and cement postoperative loss, and comparable to vertebroplasty in terms of restoration of vertebral height correction and bone cement volume. LEVEL OF EVIDENCE: Level II systematic review.

Enseñando soporte vital básico a la población general. Análisis de las intervenciones de los alumnos / Teaching basic life support to the general population. Alumni intervention analysis

OBJETIVOS: Estudiar la tasa de detección e intervención en situaciones de urgencia extrahospitalaria por parte de los alumnos de cursos de soporte vital básico (SVB). Definir variables de los alumnos asociados a una mayor tasa de detección e intervención. Estudio de eficiencia de las intervenciones. DISEÑO: Estudio descriptivo transversal. Ámbito: Comarca del Poniente de Almería. PACIENTES: Alumnos de un plan de formación masiva en SVB a población general «Plan Salvavidas» desarrollado entre 2003 y 2009. Intervención: En 2010 se encuestó a los alumnos del «Plan Salvavidas» sobre si habían presenciado situaciones de urgencia y datos relacionados con dichas situaciones. Variables principales: Tasa de detección de situación de urgencias. Intervención en situaciones de urgencias. Perfil sociodemográfico de intervinientes. RESULTADOS: Tres mil ochocientos sesenta y cuatro alumnos formados fueron llamados por teléfono: obtuvimos respuestas de 1.098, el 63,9% fueron mujeres, la edad media fue 26,61 ± 10,6. Un 11,75% habían presenciado situaciones de urgencia, de media 3 años tras el curso. Un 23,3% de las urgencias fueron paradas cardíacas. Los alumnos intervinieron en un 98% de los casos posibles. La relación de los alumnos con la víctima era inexistente en el 63% de los casos, la mayoría se presenciaron fuera del domicilio. Se asoció a una mayor tasa de detección de situaciones de urgencia: ser trabajador del ámbito sanitario y ser mayor de 18 años. CONCLUSIONES: En nuestra serie la tasa de urgencias extrahospitalarias presenciadas tras los cursos de SVB fue del 11,75%. El intervencionismo fue alto. La población diana más eficiente fueron los trabajadores del ámbito sanitario

OBJECTIVES: The aim of this study was to investigate the rate at which the alumni of basic life support courses witnessed and intervened in out-of-hospital emergency situations, and to identify the variables characterizing those alumni associated with a greater number of witnessing events and interventions. An analysis of the efficiency of the courses was also carried out. DESIGN: A descriptive, cross-sectional study was made. SETTING: A district in the province of Almería (Spain). PATIENTS: Alumni of a mass basic life support training program targeted to the general population «Plan Salvavidas» conducted between 2003-2009. INTERVENTIONS: In 2010 the alumni were administered a telephone survey asking whether they had witnessed an emergency situation since attending the program, with the collection of information related to this emergency situation. Main variables of interest: Rate of out-of-hospital emergencies witnessed by the alumni. Rate of intervention of the alumni in emergency situations. Variables characterizing alumni with a greater likelihood of witnessing an emergency situation. RESULTS: A total of 3,864 trained alumni were contacted by telephone. Of 1,098 respondents, 63.9% were women, and the mean age was 26.61 ± 10.6 years. Of these alumni, 11.75% had witnessed emergency situations, an average of three years after completing the course. Of these emergencies, 23.3% were identified as cardiac arrest. The alumni intervened in 98% of the possible cases. In 63% of the cases, there was no connection between the alumni and the victim. The majority of the emergency situations occurred in the street and in public spaces. A greater likelihood of witnessing an emergency situation was associated with being a healthcare worker and with being over 18 years of age. CONCLUSIONS: The rate of out-of-hospital emergencies witnessed by these alumni after the course was 11.75%. The level of intervention among the alumni was high. The most efficient target population consisted of healthcare workers

[Teaching basic life support to the general population. Alumni intervention analysis]. / Enseñando soporte vital básico a la población general. Análisis de las intervenciones de los alumnos.

OBJECTIVES: The aim of this study was to investigate the rate at which the alumni of basic life support courses witnessed and intervened in out-of-hospital emergency situations, and to identify the variables characterizing those alumni associated with a greater number of witnessing events and interventions. An analysis of the efficiency of the courses was also carried out. DESIGN: A descriptive, cross-sectional study was made. SETTING: A district in the province of Almería (Spain). PATIENTS: Alumni of a mass basic life support training program targeted to the general population «Plan Salvavidas¼ conducted between 2003-2009. INTERVENTIONS: In 2010 the alumni were administered a telephone survey asking whether they had witnessed an emergency situation since attending the program, with the collection of information related to this emergency situation. MAIN VARIABLES OF INTEREST: Rate of out-of-hospital emergencies witnessed by the alumni. Rate of intervention of the alumni in emergency situations. Variables characterizing alumni with a greater likelihood of witnessing an emergency situation. RESULTS: A total of 3,864 trained alumni were contacted by telephone. Of 1,098 respondents, 63.9% were women, and the mean age was 26.61±10.6 years. Of these alumni, 11.75% had witnessed emergency situations, an average of three years after completing the course. Of these emergencies, 23.3% were identified as cardiac arrest. The alumni intervened in 98% of the possible cases. In 63% of the cases, there was no connection between the alumni and the victim. The majority of the emergency situations occurred in the street and in public spaces. A greater likelihood of witnessing an emergency situation was associated with being a healthcare worker and with being over 18 years of age. CONCLUSIONS: The rate of out-of-hospital emergencies witnessed by these alumni after the course was 11.75%. The level of intervention among the alumni was high. The most efficient target population consisted of healthcare workers.

Comparison of the accuracy of CT colonography and colonoscopy in the diagnosis of colorectal cancer.

AIM: The available evidence was reviewed to compare the effectiveness of CT colonography with that of colonoscopy for colorectal cancer (CRC) screening. METHOD: An electronic search was conducted using PubMed, EMBASE, the Cochrane Library and Centre for Reviews and Dissemination databases, from inception to July 2009. Studies were included if investigations used CT colonography for CRC screening in asymptomatic populations. Studies were excluded if investigations were conducted for the diagnosis of CRC or in elderly, high-risk or symptomatic populations. RESULTS: Of the 213 references identified, nine studies were included. The specificity of CT colonography in screening for CRC was high, although it decreased with decreasing diameter of polyp to be detected. The sensitivity of CT colonography for the detection of polyps < 6 mm in diameter was low and heterogeneous, although it was higher for polyps > 10 mm. The main factors contributing to a greater sensitivity of CT colonography were the inclusion of only populations with an average CRC risk and colonic insufflation with CO2 . The incidence of adverse effects was very low for both tests. CONCLUSION: CT colonography has high specificity but heterogeneous sensitivity, although in most cases it is not as sensitive or specific as conventional colonoscopy. CT colonography could therefore be useful as a screening test for populations with an average risk of CRC.

Complicaciones y preservación nerviosa de la prostatectomía en relación con el intervalo de tiempo desde la biopsia diagnóstica / Complications and Nerve Preservation in Prostatectomy According to the Time Interval from Diagnostic Biopsy

Objetivos: Sintetizar la evidencia disponible sobre las complicaciones y la capacidad de preservación nerviosa bilateral de la prostatectomía radical en pacientes con cáncer próstatico en función del tiempo transcurrido de la biopsia diagnóstica (superior o inferior a las seis semanas). Material y métodos: Se identificaron los estudios relevantes utilizando estrategias de búsqueda estructuradas y específicas para cada una de las bases de datos consultadas sin ninguna limitación. Se evaluó la calidad metodológica de cada uno de los estudios incluidos y se extrajeron los datos de forma independiente. Resultados: Para la prostatectomía radical abierta, dos de los estudios concluyeron que el intervalo de tiempo transcurrido entre la realización de la biopsia prostática y la cirugía inferior a las 4 o 6 semanas no influye en la tasa de complicaciones posquirúrgicas y la capacidad de preservación nerviosa durante la cirugía. En cuanto a la prostatectomía radical laparoscópica asistida por robot el estudio incluido concluye que la realización de este tipo de intervenciones dentro de un periodo de tiempo inferior a las cuatro o seis semanas posteriores a la biopsia diagnóstica, se asocia a un mayor riesgo de sufrir complicaciones postquirúrgicas. No obstante, estos estudios contaban con importantes limitaciones metodológicas. Conclusiones: El intervalo de tiempo entre la realización de la biopsia diagnóstica y la cirugía abierta no influye en la tasa de complicaciones o preservación nerviosa. En cambio, un periodo de tiempo inferior a las cuatro semanas entre la biopsia diagnóstica y la cirugía laparoscópica se asocia con mayor riesgo de complicaciones quirúrgicas (AU)

Objectives: To summarize the available evidence on complications and bilateral nerve preservation in radical prostatectomy in patients according to the time interval from diagnostic biopsy (more or less than six weeks). Material and methods: Relevant studies were identified by using structured and specific search strategies for each of the databases consulted, without limitations. The methodological quality of each of the studies included was evaluated and the data were extracted independently. Results: For open radical prostatectomy, two of the studies concluded that a time interval of less than 4 or 6 weeks between prostate biopsy and surgery had no influence on the postsurgical complications rate or on nerve preservation during surgery. For laparoscopic robotic-assisted radical prostatectomy, the study included concluded that performing this type of intervention in an interval of less than 4 or 6 weeks after diagnostic biopsy was associated with a higher risk of postsurgical complications. However, all these studies had major methodological limitations. Conclusions: The time interval between diagnostic biopsy and open surgery has no influence on the complications rate or nerve preservations. In contrast, an interval of less than 4 weeks between diagnostic biopsy and laparoscopic surgery is associated with a higher risk of surgical complications (AU)

[Complications and nerve preservation in prostatectomy according to the time interval from diagnostic biopsy]. / Complicaciones y preservación nerviosa de la prostatectomía en relación con el intervalo de tiempo desde la biopsia diagnóstica.

OBJECTIVES: To summarize the available evidence on complications and bilateral nerve preservation in radical prostatectomy in patients according to the time interval from diagnostic biopsy (more or less than six weeks). MATERIAL AND METHODS: Relevant studies were identified by using structured and specific search strategies for each of the databases consulted, without limitations. The methodological quality of each of the studies included was evaluated and the data were extracted independently. RESULTS: For open radical prostatectomy, two of the studies concluded that a time interval of less than 4 or 6 weeks between prostate biopsy and surgery had no influence on the postsurgical complications rate or on nerve preservation during surgery. For laparoscopic robotic-assisted radical prostatectomy, the study included concluded that performing this type of intervention in an interval of less than 4 or 6 weeks after diagnostic biopsy was associated with a higher risk of postsurgical complications. However, all these studies had major methodological limitations. CONCLUSIONS: The time interval between diagnostic biopsy and open surgery has no influence on the complications rate or nerve preservations. In contrast, an interval of less than 4 weeks between diagnostic biopsy and laparoscopic surgery is associated with a higher risk of surgical complications.

Eficacia de la colonografía por tomografía computarizada frente a la colonoscopia como prueba de cribado del cáncer colorrectal / Efficacy of CT colonography versus colonoscopy in screening for colorectal cancer

Objetivo. Determinar la eficacia y efectividad de la colonografía por tomografía computarizada (CTC) frente a la colonoscopia como pruebas de cribado para el cáncer colorrectal (CCR). Material y métodos. Se realizó una revisión sistemática de la literatura científica que incluyó todos los estudios que evaluaran la eficacia de la CTC como prueba de cribado del CCR. Quedaron excluidos aquellos artículos que analizaran la eficacia de otras técnicas de cribado para el CCR o los que utilizaran la CTC como técnica diagnóstica o en poblaciones sintomáticas. De las 213 referencias obtenidas se seleccionaron 9 estudios tras lectura crítica. Resultados. La especificidad demostrada para la CTC en el cribado del CCR fue alta y disminuía con el diámetro del pólipo a detectar. La sensibilidad para la CTC para detectar pólipos de diámetro igual o menor de 6mm resultó ser muy baja y heterogénea, aunque aumentaba para la detección de pólipos de más de 9mm de diámetro. Conclusión. La CTC demostró tener alta especificidad y una sensibilidad muy heterogénea, aunque en la mayoría de los casos no alcanzó los porcentajes de sensibilidad y especificidad logrados por la colonoscopia (AU)

Objective. To determine the efficacy and effectiveness of CT colonography in comparison with those of colonoscopy in screening for colorectal cancer. Material and methods. We systematically reviewed all the studies in the scientific literature that assessed the efficacy of CT colonography in screening for colorectal cancer. We excluded articles that assessed the efficacy of other screening techniques for colorectal cancer and those that used CT colonography in the diagnostic workup of suspected lesions or symptomatic patients. After a critical reading of the 213 references obtained, we selected nine studies. Results. The specificity of CT colonography in screening for colorectal cancer was high, although it decreased with the diameter of the polyp to be detected. The sensitivity of CT colonography in the detection of polyps less than or equal to 6mm in diameter was very low and heterogeneous, although it was higher for polyps greater than 9mm in diameter. Conclusion. CT colonography has high specificity but very heterogeneous sensitivity, although in most cases it was not as sensitive or specific as conventional colonoscopy (AU)

La vitamina K como profilaxis para la enfermedad hemorrágica del recién nacido / Prophylactic Vitamin K for Vitamin K Deficiency Bleeding of the Newborn

Objetivo La administración de vitamina K inmediatamente después del nacimiento ha demostrado un descenso significativo de la incidencia de hemorragias neonatales, pero no existe evidencia suficiente que determine la forma de administración más adecuada. El objetivo de esta revisión es determinar la eficacia de la vitamina K administrada por vía oral frente a la vía intramuscular en la prevención de la enfermedad hemorrágica del recién nacido. Métodos Se realizó una revisión sistematizada de las principales bases de datos (Medline, Embase y Cochrane), entre otras sin limitación por fecha, idioma ni tipo de estudio. Los estudios seleccionados evaluaban la eficacia de la vitamina K. Se excluyeron aquellos estudios realizados en embarazadas, niños pretérmino o en pacientes afectos de alguna enfermedad. La validez de estos estudios fue evaluada mediante herramientas CASPe para revisiones sistemáticas y ensayos clínicos. Resultados Los estudios incluidos fueron cuatro ensayos clínicos y una revisión sistemática. Únicamente dos estudios evaluaron aspectos clínicos en los cuales se observó un descenso en la incidencia de hemorragias en el recién nacido tras la profilaxis con vitamina K por vía intramuscular. Con respecto a la vía oral, diferentes estudios analizaron la eficacia de la vitamina K mediante la determinación de parámetros bioquímicos (factor X, índice y tiempo de protrombina, vitamina K1 en plasma y antígeno de protrombina, entre otros) con resultados poco concluyentes en cuanto a la vía de administración y al número de dosis. Conclusiones(..)(AU)

Background The administration of vitamin K immediately after birth has shown a significant decrease in the incidence of newborn bleeding, but there is not enough evidence to determine the most appropriate method of administration. The objective of this review is to determine the effectiveness of orally administered vitamin K compared to the intramuscular route in the prevention of haemorrhagic disease of newborn (HDN).Methods We conducted a systematic review of the main databases (Medline, Embase and Cochrane, among others) without limitation by date, language or type of study. Selected studies evaluated the efficacy and safety of vitamin K. Excluded were studies in pregnant women in preterm infants or patients with pathology. The validity of these studies was assessed by CASPe tools for systematic reviews and clinical trials. Results Only two studies evaluated clinical aspects. They showed a reduction in the incidence of bleeding in the newborn after intramuscular prophylaxis with vitamin K. With regard to the oral route, different studies examined the effectiveness of vitamin K by determining biochemical parameters (factor X, prothrombin time and index, vitamin K1 in plasma and prothrombin antigen, among others) with inconclusive results regarding the route of administration and the number of doses. Conclusions There is sufficient evidence to support the effectiveness of a single intramuscular dose of vitamin K to prevent the classic form of HDN. With regard to late HDN and oral route, the results are inconclusive because the studies used biochemical indicators of effectiveness, which cannot be correlated with the actual coagulation status of the newborn due to lack of scientific evidence(AU)

[Efficacy of CT colonography versus colonoscopy in screening for colorectal cancer]. / Eficacia de la colonografía por tomografía computarizada frente a la colonoscopia como prueba de cribado del cáncer colorrectal.

OBJECTIVE: To determine the efficacy and effectiveness of CT colonography in comparison with those of colonoscopy in screening for colorectal cancer. MATERIAL AND METHODS: We systematically reviewed all the studies in the scientific literature that assessed the efficacy of CT colonography in screening for colorectal cancer. We excluded articles that assessed the efficacy of other screening techniques for colorectal cancer and those that used CT colonography in the diagnostic workup of suspected lesions or symptomatic patients. After a critical reading of the 213 references obtained, we selected nine studies. RESULTS: The specificity of CT colonography in screening for colorectal cancer was high, although it decreased with the diameter of the polyp to be detected. The sensitivity of CT colonography in the detection of polyps less than or equal to 6mm in diameter was very low and heterogeneous, although it was higher for polyps greater than 9mm in diameter. CONCLUSION: CT colonography has high specificity but very heterogeneous sensitivity, although in most cases it was not as sensitive or specific as conventional colonoscopy.

[Prophylactic vitamin K for vitamin K deficiency bleeding of the newborn]. / La vitamina K como profilaxis para la enfermedad hemorrágica del recién nacido.

BACKGROUND: The administration of vitamin K immediately after birth has shown a significant decrease in the incidence of newborn bleeding, but there is not enough evidence to determine the most appropriate method of administration. The objective of this review is to determine the effectiveness of orally administered vitamin K compared to the intramuscular route in the prevention of hemorrhagic disease of newborn (HDN). METHODS: We conducted a systematic review of the main databases (Medline, Embase and Cochrane, among others) without limitation by date, language or type of study. Selected studies evaluated the efficacy and safety of vitamin K. Excluded were studies in pregnant women in preterm infants or patients with pathology. The validity of these studies was assessed by CASPe tools for systematic reviews and clinical trials. RESULTS: Only two studies evaluated clinical aspects. They showed a reduction in the incidence of bleeding in the newborn after intramuscular prophylaxis with vitamin K. With regard to the oral route, different studies examined the effectiveness of vitamin K by determining biochemical parameters (factor X, prothrombin time and index, vitamin K1 in plasma and prothrombin antigen, among others) with inconclusive results regarding the route of administration and the number of doses. CONCLUSIONS: There is sufficient evidence to support the effectiveness of a single intramuscular dose of vitamin K to prevent the classic form of HDN. With regard to late HDN and oral route, the results are inconclusive because the studies used biochemical indicators of effectiveness, which can not be correlated with the actual coagulation status of the newborn due to lack of scientific evidence.

Nevo lipomatoso cutáneo superficial / Nevus lipomatosus cutaneous superficialis

Se presenta el caso de un niño afectado por un nevo lipomatoso cutáneo superficial localizado en el muslo. Se describen los aspectos epidemiológicos, anatomopatológicos y clínicos de esta entidad y se revisan los casos pediátricos publicados en la bibliografía científica de nuestro país

We report the case of a child with a nevus lipomatosus cutaneous superficialis located on his thigh. The authors describe the epidemiological, pathological and clinical aspects and review the pediatric cases documented in the scientific literature published in Spain

Valoración clínica de la lesión pulmonar aguda / Clinical assessment of acute lung injury

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[Analysis of prognostic factors for mortality in bacteremia and fungemia at a university hospital. Experience of 10 years]. / Análisis de factores pronósticos de mortalidad de las bacteriemias y fungemias en un Hospital Universitario. Evolución en 10 años.

OBJECTIVE: The objective of this study was to determine the prognostic factors in relationship to evolution to death of bacteremia-fungemia (BF) episodes occurred in 1986 and to compare them with the results obtained ten years later in 1996. PATIENTS AND METHODS: Prospective study of all BF episodes observed at Hospital Universitario La Princesa, Madrid, during the 1985-1986 and 1996-1997 periods. The same definitions were used for the two study periods. The univariate analysis of results was performed with the chi square test and variables with statistical significance with p < 0.10 in the multivariate analysis with the logistic regression model. RESULTS: A total of 984 episodes were analyzed. There was an increased incidence per 1,000 admissions from 23.58 to 28.44. A change in the relationship of nosocomial acquisition (55.5%-42.6%) to community-acquired episodes (44.1%-57.4%) and an increase in gram-positive organisms (39%-48.6%) compared with gram-negative organisms (53.4%-41.8%) was observed. The organisms recovered most frequently in both periods were Escherichia coli and coagulase-negative Staphylococcus. An overall decrease of mortality rate from 26.2% down to 15.9% (OR: 4.52) was noted. Independent factors with poor prognosis in the first period included age over 60 years (OR: 4.52), underlying disease (OR: 2.79; more than one OR: 6.53), respiratory source (OR: 3.86), DIC (OR: 4.79), hypotension (OR: 3.19); as for the second period, the corresponding independent factors included age > 60 years (OR: 6.48), nosocomial acquisition (OR: 2.62), DIC (OR: 18.7), hypotension (OR: 3.07), and inadequate surgical treatment (OR: 7.61). CONCLUSIONS: In the last ten years the incidence of BF episodes has increased. In contrast, mortality rate has decreased. Factors with poor prognosis, including age > 60, DIC, and hypotension, still persist.

Análisis de factores pronósticos de mortalidad de las bacteriemias y fungemias en un Hospital Universitario. Evolución en 10 años / Analysis of prognostic factors of mortality from bacteremia and fungemia in a University Hospital. A ten-year evolution

Introducción. El objetivo de este estudio ha sido determinar los factores pronósticos, en relación con la evolución a muerte, de las bacteriemias-fungemias (BF) ocurridas en 1986 y comparar con los resultados obtenidos 10 años después, en 1996.Pacientes y métodos. Estudio prospectivo de todos los episodios de BF en el Hospital Universitario de La Princesa de Madrid en los períodos de 1985-1986 y 1996-1997. Se utilizaron las mismas definiciones en los dos períodos de estudio. El análisis univariado de los resultados se realizó con la prueba de Chi cuadrado y las variables con significación estadística con p 60 años (OR: 6,48), adquisición intrahospitalaria (OR: 2,62), CID (OR: 18,7), hipotensión (OR: 3,07) y el tratamiento quirúrgico inadecuado (OR: 7,61). Conclusiones. En los últimos 10 años la incidencia de episodios de BF ha aumentado con disminución de la mortalidad y persistiendo como factores de mal pronóstico la edad > 60 años, CID e hipotensión (AU)

[Urticaria pigmentosa]. / Urticaria pigmentosa.

The authors present three cases of urticaria pigmentosa (UP), one with a very early beginning and two with a late beginning. The clinical symptoms orient the diagnosis of the three cases in relation to maculopapular exanthema of a dark pink color, brown macules and, in all cases, the presence of Darier's sign. As normal, the clinical diagnosis was confirmed by the histopathological examination of the skin. The evolution of the three patients was favorable in all cases, with the disappearance of symptoms in one case. In the other two cases the process is stabilized, and at no time have systemic manifestations been found. The relative rareness of UP in infancy, an expression of a proliferation of the reticuloendothelial system (RES) on a mast cell level with different evolutional possibilities, has been the justifying factor in the presentation of these new cases.