In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale.

INTRODUCTION: Patent foramen ovale (PFO) is present in a significant proportion of young patients with stroke of undetermined etiology, but is not always causal. Therefore, classifications (RoPE, PASCAL) have been developed to determine the probability that PFO is the stroke cause. However, the presence of an initial arterial occlusion as a prediction factor was not studied when these classifications were built. Our aim was to evaluate the presence of arterial occlusion in young patients with stroke of undetermined etiology with/without high-risk PFO. METHODS: From a prospectively-built monocentric database, we identified patients aged≥18 to<60-years with strokes of undetermined etiology and complete etiological work-up, including transesophageal echocardiography. We divided patients in two groups: (i) with high-risk PFO [i.e. PFO with large interatrial shunt (>30 microbubbles) or associated with atrial septal aneurysm] and (ii) with low-risk/without PFO. We recorded the presence of arterial occlusion and large vessel occlusion (LVO) in the acute phase. RESULTS: We included 96 patients; 55 (57%) had high-risk PFO. Their median age was 48 (40-52) years, and 28 (29%) were women. The percentages of patients with arterial occlusion and with LVO were lower in the high-risk PFO group than in the low-risk/without PFO group: 11 (20%) versus 19 (46%) (P=0.008), and 5 (9%) versus 15 (37%) (P=0.002), respectively. There was no difference in the median RoPE score between groups (P=0.30). CONCLUSION: The presence of LVO could represent a "red flag" of PFO causality in stroke of undetermined etiology, and could be implemented in future PFO-related stroke classifications.

Nasal lavage technique reveals regular inhalation exposure of microplastics, not associated from face mask use.

During the COVID-19 pandemic, the use of face masks has been a worldwide primary protection measure to contain the spread of the virus. However, very little information is known about the possible inhalation of microplastics (MP) from wearing masks. This pilot study evaluates the presence of MP accumulated in nasal cavities through the nasal lavages technique. Six different commercial face masks were tested in 18 participants during five working days (8 h use/day). Eight different polymers (polystyrene, polyamide, poly(ethylene - propylene) diene monomer, polyester, polyethylene, polyvinylidene fluoride, polypropylene, and polyvinyl chloride) predominantly within the 20-300 µm size were detected in nasal lavages, with an average concentration of 28.3 ± 15.6 MP/5 mL nasal solution. Results demonstrate that MP in the nasal cavity are not associated to face mask use but rather to general exposure to airborne MP. We highlight the use of nasal lavages to evaluate human inhalation of MP and associate it to potential sources and risks.

Airborne microplastic particle concentrations and characterization in indoor urban microenvironments.

Airborne microplastics (MPs) have recently drawn the attention of the scientific community due to their possible human inhalation risk. Indoor environments are of relevance as people spend about 90% of their time indoors. This study evaluated MPs concentrations in three indoor environments: houses, public transport and working places, which are representative of urban life. Sampling involved the collection of airborne particulate matter on nylon 20 µm pore size filters. Samples were first visually inspected, and particles were characterized (colour, length or area). Polymer identification was performed through µFTIR analysis. Working conditions were controlled to guarantee quality assurance and avoid background contamination. Limits of detection, recovery tests and repeatability were performed with home-made polyethylene (PE), polypropylene (PP), and polystyrene (PS) standards. The highest average MP concentrations were found in buses (17.3 ± 2.4 MPs/m3) followed by 5.8 ± 1.9 MPs/m3 in subways, 4.8 ± 1.6 MPs/m3 in houses, and 4.2 ± 1.6 MPs/m3 in the workplaces. Polyamide, PA (51%), polyester PES (48%) and PP (1%) were the polymers identified and most common in personal care products and synthetic textiles. Most of these polymers were below 100 µm in size for both fibres (64 ± 8%) and fragments (78 ± 11%). The frequency of MP particles in our study decreased with increasing size, which points to their potential as an inhalation hazard.

Overview on the occurrence of microplastics in air and implications from the use of face masks during the COVID-19 pandemic.

Environmental pollution from microplastics (MPs) in air is a matter of growing concern because of human health implications. Airborne MPs can be directly and continuously inhaled in air environments. Especially high MPs contributions can be found in indoor air due to the erosion and breakage of consumer, domestic and construction products, although there is little information available on their sources and concentrations and the risks they might pose. This is in part due to the fact that sampling and analysis of airborne MPs is a complex and multistep procedure where techniques used are not yet standardized. In this study, we provide an overview on the presence of MPs in indoor air, potential health impacts, the available methods for their sampling and detection and implications from the use of face masks during the COVID-19 pandemic.

Análisis de las derivaciones a la Atención Especializada desde la consulta de Atención Primaria / Analysis of referrals to Specialized Care from Primary Care

Introducción: la derivación a una consulta especializada forma parte de la práctica diaria en Atención Primaria. La cuantificación y valoración de los motivos de derivación plantean una reflexión sobre los recursos humanos y materiales de los que disponemos, y sobre si los circuitos de relación entre los diferentes niveles asistenciales son los más adecuados para los pacientes y los profesionales. Objetivo: determinar, a partir de las derivaciones realizadas desde un equipo de Pediatría de Atención Primaria, los servicios a los que se derivan más pacientes y los motivos de las derivaciones. Material y métodos: estudio descriptivo transversal de las derivaciones realizadas a la Atención Especializada desde los centros de salud de Vallirana y Cervelló (Barcelona), con una población de 3375 niños de0 a 14 años, a partir del registro de la historia clínica informatizada, durante los años 2007, 2008 y 2009. Resultados: en este periodo se han realizado 1460 derivaciones en una población atendida de 3375 menores de 15 años de edad. Se presentan los resultados del análisis de 1422 derivaciones, ya que de las restantes no disponemos de todos los datos. La especialidad a la que se han derivado más casos es Oftalmología (27,65%), seguida de Traumatología (16,88%), Dermatología (14,84%) y Otorrinolaringología (12,52%). Conclusiones: las especialidades más demandadas son Oftalmología, Traumatología, Dermatología y Otorrinolaringología. Estas especialidades son una constante en cada grupo de edad. Los resultados obtenidos podrían ser de ayuda para planificar la relación entre los diferentes niveles asistenciales (AU)

Introduction: children referral to specialized consultation is part of the Primary Care daily work. Quantification and evaluation of the referral reasons make us think about the human and material resources available and also consider if the relationship between the different care levels are the best for patients as well as for health staff. Objective: to determine which are the specialist areas that receive more referrals from the Primary Care pediatric team and their motives. Material and methods: transversal descriptive study of the specialized care referrals made by the Vallirana’s and Cervello’s Primary Care pediatricians. Vallirana and Cervelló villages (Barcelona) have 3375 children younger than 15 years old. Data were obtained from the electronic medical record between 2007 and 2009. Results: during this three years period, 1460 referrals have been done for 3375 children younger than 15 years old attended in the Primary care centres. Thirty-eight of them haven’t been analysed because of lack of complete information. Ophthalmology is the most referred specialization (27.65%) followed by Orthopaedics (16.88%), Dermatology (14.84%) and Otolaryngology (12.52%) as the more required specializations. Conclusions: Ophthalmology, Orthopaedics, Dermatology and Otolaryngology are the most referred specialities. These specialities are constant in each year group. These results could help to organize the relationship between the different care levels (AU)

Implementation and assessment of a fast-track programme to improve communication between primary and specialized care in patients with suspected cancer: how to shorten time between initial symptoms of cancer, diagnosis and initiation of treatment

Purpose. This study aims to asses a cancer fast-track programme (CFP) to shorten the time since a patient with suspicion of cancer is referred by the primary care (PC) physician to the specialized medical team. Methods. Guidelines for main suspected tumours were designed to help PC physicians to detect and rapidly refer cases to the CFP oncology coordinator, who sent them to the appropriate department to accelerate diagnosis, staging and therapy. All patients analysed in this report were referred from June 2009 to July 2012. Results. A total of 897 suspected cancer cases were submitted and finally 705 were studied. In 205 (29 %) a cancer diagnosis was confirmed within 23 days (median). Therapy was initiated within 46 days after referral (median). Early diagnoses with a potential curative approach were made in 166 (82 %). Conclusions. This CFP decreased the waiting time for cancer diagnosis, by improving communication between PC physician and specialized care teams. Most patients included in this program could get therapy with curative intent (AU)

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Implementation and assessment of a fast-track programme to improve communication between primary and specialized care in patients with suspected cancer: how to shorten time between initial symptoms of cancer, diagnosis and initiation of treatment.

PURPOSE: This study aims to asses a cancer fast-track programme (CFP) to shorten the time since a patient with suspicion of cancer is referred by the primary care (PC) physician to the specialized medical team. METHODS: Guidelines for main suspected tumours were designed to help PC physicians to detect and rapidly refer cases to the CFP oncology coordinator, who sent them to the appropriate department to accelerate diagnosis, staging and therapy. All patients analysed in this report were referred from June 2009 to July 2012. RESULTS: A total of 897 suspected cancer cases were submitted and finally 705 were studied. In 205 (29 %) a cancer diagnosis was confirmed within 23 days (median). Therapy was initiated within 46 days after referral (median). Early diagnoses with a potential curative approach were made in 166 (82 %). CONCLUSIONS: This CFP decreased the waiting time for cancer diagnosis, by improving communication between PC physician and specialized care teams. Most patients included in this program could get therapy with curative intent.

Determination of total cadmium, lead, arsenic, mercury and inorganic arsenic in mushrooms: outcome of IMEP-116 and IMEP-39.

The Institute for Reference Materials and Measurements (IRMM) of the Joint Research Centre (JRC), a Directorate General of the European Commission, operates the International Measurement Evaluation Program (IMEP). IMEP organises inter-laboratory comparisons in support of European Union policies. This paper presents the results of two proficiency tests (PTs): IMEP-116 and IMEP-39, organised for the determination of total Cd, Pb, As, Hg and inorganic As (iAs) in mushrooms. Participation in IMEP-116 was restricted to National Reference Laboratories (NRLs) officially appointed by national authorities in European Union member states. IMEP-39 was open to all other laboratories wishing to participate. Thirty-seven participants from 25 countries reported results in IMEP-116, and 62 laboratories from 36 countries reported for the IMEP-39 study. Both PTs were organised in support to Regulation (EC) No. 1881/2006, which sets the maximum levels for certain contaminants in food. The test item used in both PTs was a blend of mushrooms of the variety shiitake (Lentinula edodes). Five laboratories, with demonstrated measurement capability in the field, provided results to establish the assigned values (Xref). The standard uncertainties associated to the assigned values (uref) were calculated by combining the uncertainty of the characterisation (uchar) with a contribution for homogeneity (ubb) and for stability (ust), whilst uchar was calculated following ISO 13528. Laboratory results were rated with z- and zeta (ζ)-scores in accordance with ISO 13528. The standard deviation for proficiency assessment, σp, ranged from 10% to 20% depending on the analyte. The percentage of satisfactory z-scores ranged from 81% (iAs) to 97% (total Cd) in IMEP-116 and from 64% (iAs) to 84% (total Hg) in IMEP-39.

Mastopatía diabética: diagnóstico y tratamiento / Diabetic mastopathy: diagnosis and treatment

La mastopatía diabética abarca una serie de alteraciones estructurales de la glándula mamaria que hace años no estaban bien identificadas y que se describían, junto con otras entidades, bajo un epígrafe común: las llamadas «mastitis granulomatosas». Es una entidad infrecuente, que suele afectar a mujeres premenopáusicas con antecedente de diabetes mellitus tipo 1 de larga evolución. Se trata de una lesión histológicamente benigna, no progresiva y que no predispone a la malignización. Debe considerarse como una complicación crónica adicional de la diabetes de larga duración, al igual que lo son, por ejemplo, la nefropatía diabética o la retinopatía diabética. Conocer su existencia es importante para poder establecer el diagnóstico diferencial con el cáncer de mama. La etiología de la mastopatía diabética no está aclarada, y se invoca cierta asociación con enfermedades autoinmunitarias

Diabetic mastopathy includes a number of structural alterations of breast gland, no well identified since many years and which has been described besides other entities with the name of «granulomatous mastitis». It is an infrequent disease, which affects usually premenopausal women with type 1 diabetes of long duration. It is a benign lesion, non progressive and which will not predispose to breast cancer. The diabetic mastopathy should be considered as an additional chronic complication of diabetes of long duration as diabetic nephropathy, diabetic retinopathy, etc. The major interest remains to establish the differential diagnosis against breast cancer. The etiology of the diabetic mastopathy is not clarified enough, although an association with other autoimmune diseases has been suggested

Mastopatía diabética en una mujer con diabetes mellitus tipo 1 de larga evolución: descripción de una entidad poco conocida / Diabetic mastopathy in a woman with long-standing type 1 diabetes: a description of a poorly characterized entity

La mastopatía diabética es una forma poco frecuente de mastitis linfocitaria que aparece preferentemente en mujeres con una diabetes mellitus tipo 1 (DM1) de larga evolución. Esta entidad, con una característica proliferación fibrosa del estroma, se encuadra dentro de las lesiones mamarias fibrosas benignas, pero clínicamente puede confundirse con lesiones malignas. En este caso clínico se describe un proceso de mastopatía diabética en una paciente con DM1 de larga duración y complicaciones crónicas microvasculares conocidas, aunque controladas. Tras la detección de la lesión en una ecografía de control, fue remitida al cirujano de mama para su valoración. El diagnóstico se realizó mediante biopsia, y se descartó la presencia de lesiones malignas. El tratamiento de la mastopatía diabética fue conservador

Diabetic mastopathy is an uncommon form of lymphocytic mastitis that typically occurs in women with long-standing type 1 diabetes. This entity, which presents with a characteristic stromal fibrosis, is a benign fibrous lesion, but may clinically mimic a malignant lesion. The authors report a case involving the development of diabetic mastopathy, diagnosed in a woman with long-standing type 1 diabetes and known controlled chronic microvascular complications. After the detection of a breast lump in a routine ultrasound scan, she was referred to a breast surgeon for evaluation. The diagnosis of diabetic mastopathy was confirmed by biopsy, which ruled out the presence of malignant lesions. The management was conservative

Low number of examined lymph nodes in node-negative breast cancer patients is an adverse prognostic factor.

BACKGROUND: The aim of the study was to determine whether the number of lymph nodes removed at axillary dissection is associated with recurrence and survival in node-negative breast cancer (NNBC) patients. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 1606 women with pathologically node-negative T1-T3 invasive breast cancer. Median follow-up was 61 months (range 2-251). Potential prognostic factors assessed included: number of axillary lymph nodes examined, age, menopausal status, tumor size, histological type, tumor grade, estrogen receptor(ER), progesterone receptor (PR) and HER2. RESULTS: At 5 years, relapse-free survival (RFS) rate was 85% and breast cancer-specific survival (BCSS) rate was 94%. In univariate analysis, factors significantly associated with lower RFS and BCSS were: fewer than six lymph nodes examined (RFS, P = 0.01; BCSS, P = 0.007), tumor size >2 cm, grade III, negative ER or PR. Statistically significant factors for lower RFS and BCSS in multivariate analysis were: fewer than six lymph nodes examined [RFS, hazard ratio (HR) 1.36, P = 0.029; BCSS, HR 1.87, P = 0.005], tumor size >2 cm, tumor grade III and negative PR. CONCLUSIONS: Examination of fewer than six lymph nodes is an adverse prognostic factor in NNBC because it could lead to understaging. Six or more nodes need to be examined at axillary dissection to be confident of a node-negative status. This may be useful, in conjunction with other prognostic factors, in the assessment of NNBC patients for adjuvant systemic therapy.

A comparative study of the accuracy of Ranawat's and Pierchon's methods to determine the centre of rotation in bilateral coxopathy.

OBJECTIVE: The objective of the study was to compare two methods (Ranawat's and Pierchon's) used to determine the centre of rotation of the hip and establish which method calculates a position nearer to the real centre of rotation. PATIENTS AND DESIGN: We selected 24 patients with unilateral osteoarthritis of the hip. The centre of rotation of the healthy hip was determined in two consecutive radiographic studies by superimposing a template of circles and using two axes as the reference lines (X-axis=teardrop line; Y-axis=a line perpendicular to the X-axis, drawn from the intersection of the ilio-ischiatic line and the teardrop line). After ensuring the stability of these references, both methods were applied to the same radiograph to determine which one established a centre of rotation nearer to the anatomical centre identified by the template of circles. RESULTS: When the values for the healthy hip are compared with those obtained using Ranawat's method, highly significant differences are observed for both X (P<0.0001) and Y (P<0.0001). When the results for the healthy hip are compared with the values obtained using Pierchon's method, neither the X (P=0.722 ) nor the Y values (P=0.112) show any significant differences. It would be advisable to use Pierchon's method to determine the centre of rotation during the preoperative planning for a total hip arthroplasty when the anatomical alteration is bilateral.

Prognostic factors predicting survival from first recurrence in patients with metastatic breast cancer: analysis of 439 patients.

We have analyzed retrospectively 439 women with recurrent breast cancer, followed at a single institution, in order to define potential prognostic factors for survival at the time of first recurrence. Median age at the time of first recurrence was 58 and the median disease free interval (DFI) from initial diagnoses to recurrence was 33 months. Thirteen percent of the patients did not receive any adjuvant therapy while 87% received different combinations of chemotherapy, radiotherapy and hormone therapy as adjuvant treatment. With a median follow-up of 44 months from the time of recurrence the median survival (MSR) was 24 months (SE 1.24) and five-year overall survival was 18% (SE 2.02). On the univariate analysis, pathological tumor size (pT) at diagnosis (p < 0.0006), axillary lymph node status at diagnosis (p < 0.00001), negative estrogen receptor (ER) status (p < 0.0001), negative progesterone receptor (PgR) status (p < 0.0001), adjuvant chemotherapy (p < 0.001), disease free interval (p < 0.00001), location of recurrence (p < 0.0002) and number of metastatic sites (> or = 3: p < 0.0003), were significantly associated with shorter survival from first relapse. On the multivariate analysis, only the site of recurrence, axillary lymph node status at diagnosis, ER status and DFI remained independently associated with decreased MSR after first relapse.

Prognostic factors in patients with isolated recurrences of breast cancer (stage IV-NED).

BACKGROUND: One to 10% of women with metastatic breast cancer have a recurrence of their disease as an isolated lesion (local, regional, or distant) which may be treated by surgical resection, irradiation, or both. These are patients with stage IV breast cancer with no evidence of disease, or stage IV-NED. Because natural history and prognostic factors for patients with stage IV-NED are poorly determined, we decided to evaluate a group of patients with stage IV-NED treated at a single institution. PATIENTS AND METHODS: Ninety-six patients with isolated recurrence of stage IV breast cancer were analyzed retrospectively. Treatment of loco-regional or distant recurrence was surgery in 18 patients and surgery plus irradiation in 78 patients. Seventy-nine patients received systemic therapy after loco-regional treatment (24 chemotherapy and 55 hormonotherapy). Prognostic factors were analyzed and correlated with disease-free survival (DFS) and overall survival (OS). RESULTS: Five-year DFS and OS for the whole group were 29% and 49%, respectively. On the univariate analysis, patients without axillary nodal involvement at the time of mastectomy had significantly greater 5-year DFS and OS than patients with nodal involvement (51% vs. 14% and 70% vs. 34%, respectively, p < 0.05). DFS was also significantly better for patients receiving systemic therapy after local treatment (31% vs. 19%). On the multivariate analysis, absence of nodal involvement and systemic therapy were associated with longer DFS (p = 0.044 and p = 0.008, respectively) and OS (p = 0.009 and p = 0.011, respectively). None of the other factors analyzed including menopausal status, T-stage, number of involved nodes, receptor status, adjuvant therapy, sites of first recurrence, or time from mastectomy to first recurrence had a predictive value for DFS and OS. CONCLUSION: Patients with stage IV-NED have poor prognosis due to early development of metastatic disease. Absence of axillary nodal involvement at the time of mastectomy and systemic therapy following local management is associated with improved DFS and OS. These results suggest that systemic therapy after local treatment in stage IV-NED is indicated. Poor prognosis in patients with previous nodal involvement warrants new approaches.

[Congenital diaphragmatic hernia: evaluation of two ways of management]. / Hernia diafragmática congénita: análisis de dos formas de tratamiento.

OBJECTIVE: The aim of this study was to analyze the treatment and evolution of congenital diaphragmatic hernia in the last 16 years, distinguishing two ways of management, and to look for parameters that can predict the evolution. MATERIALS AND METHODS: Between 1978 and 1994, 29 cases of congenital diaphragmatic hernia were treated in our NICU. During the first period (1978-1988) 17 cases (group 1) were treated after birth as a surgical emergency. In the second period (1989-1994), preoperative stabilization was performed before surgery (12 cases, group 2). Two cases of group 2 were excluded because of the association of other malformations that were the cause of death. RESULTS: Both groups were similar in gestational age, birth weight and Apgar score at 5 minutes. Overall mortality was 48.1% (47.0% in group 1 and 50.0% in group 2). No infants with PaCO2 greater than 40 mmHg and OI greater than 40 or VEI over 1,000 survived. CONCLUSION: Despite preoperative stabilization, there is no difference in the mortality rate of the two groups. With congenital diaphragmatic hernia, as with other entities of low incidence, collaborative studies are needed to obtain enough cases to analyze the results more precisely.

[Routes of endotracheal colonization in patients with mechanical ventilation]. / Rutas de colonización traqueal en pacientes sometidos a ventilación mecánica.

OBJECTIVE: We prospectively evaluated the frequency and route of endotracheal colonization in intubated children in order to know what microorganisms, either by primary infection or through previous colonization of oropharynx and/or stomach and progression towards the lower respiratory tract, are responsible for these infections. PATIENTS AND METHODS: Oropharyngeal, tracheal and gastric samples of 43 patients were collected for culture at the moment of intubation and at 24-h intervals for 4 days. The colonization route for each endotracheal microorganism was classified depending on the initial isolation site. Isolated microorganisms were considered as belonging to the same strain if the biochemical pattern and antibiogram were identical. RESULTS: Of the patients studied, 84% presented positive cultures the first day. Tracheal colonization was detected at day 1 in 22 patients (51%) and in 35 (82%) at the end of the study. A colonization sequence was seen in 18 patients (41%). The microorganisms most frequently isolated were S. aureus, P. aeuruginosa and C. albicans. CONCLUSIONS: The mechanisms of tracheal colonization in intubated children is similar to adults. Oropharynx colonization is the key antecedent. Prophylaxis measures should avoid the proliferation at the oropharyngeal and/or gastric level.

[Acute ethmoiditis. A review of 38 cases]. / Etmoiditis aguda. Revisión de 38 casos.

OBJECTIVE: The purpose of this study was to assess the usefulness of computerized tomography (CT) scan in the diagnosis and management of the complications of acute ethmoiditis in children. MATERIALS AND METHODS: A retrospective revision of the records of pediatric patients admitted to Sant Joan de Déu Hospital from January 1985 to June 1994 was performed. RESULTS: Thirty-eight children (22 males and 16 females) between the ages of 18 months and 15 years (mean age 6.5 years) were studied. All of the patients had eyelid afflictions; 5 (13.2%) with eyelid edema and 33 (86.8%) with periorbital cellulitis. All of them were unilateral without side predominance. The signs and symptoms included fever (37) and orbital pain and headache (24), with 28 patients presenting other forms of sinusitis. CT scan was applied in 24 children (63%). Thirteen of these patients demonstrated complications of the orbit, 6 with orbital cellulitis, 4 subperiosteal abscess and 3 orbital abscesses. Surgery was performed in 3 cases. CONCLUSIONS: We conclude that the CT scan is a radiological procedure that must be applied when there are signs or symptoms compatible with orbital complications. Patients should also be scanned if their exam is worse or unchanged after 24-48 hours of antibiotic therapy. Early diagnosis and antibiotic treatment can prevent complications subsidiary of surgery.