Costes indirectos asociados al glioblastoma. Experiencia en un centro / Indirect costs associated with glioblastoma: Experience at one hospital

Introducción: El glioblastoma es el tumor cerebral más frecuente. A pesar de los avances en su tratamiento, el pronóstico sigue siendo pobre, con una supervivencia media en torno a los 14 meses. Los costes directos, aquellos asociados al diagnóstico y el tratamiento de la enfermedad, han sido descritos ampliamente. Los costes indirectos, aquellos derivados de la pérdida de productividad debido a la enfermedad, han sido descritos en escasas ocasiones. Material y método: Realizamos un estudio retrospectivo, incluyendo a los pacientes diagnosticados entre el 1 de enero del 2010 y el 31 de diciembre del 2013 de glioblastoma en el Hospital Universitario Donostia. Recogimos datos demográficos, relativos al tratamiento ofertado y la supervivencia. Calculamos los costes indirectos a través del método del capital humano, obteniendo datos de sujetos comparables según sexo y edad, y de mortalidad de la población general a través del Instituto Nacional de Estadística. Los salarios pasados fueron actualizados a euros de 2015 según la tasa de inflación interanual y los salarios futuros fueron descontados en un 3,5% anual en forma de interés compuesto. Resultados: Revisamos a 99 pacientes, 46 mujeres (edad media 63,53 años) y 53 hombres (edad media 59,94 años). En 29 pacientes se realizó una biopsia y en los 70 restantes se realizó una cirugía resectiva. La supervivencia global media fue de 18,092 meses. Los costes indirectos totales fueron de 11.080.762 Euros (2015). El coste indirecto medio por paciente fue de 111.926 Euros (2015). Discusión: A pesar de que el glioblastoma es un tipo relativamente poco frecuente de tumor, que supone el 4% de todos los tipos de cáncer, su mal pronóstico y sus posibles secuelas generan una mortalidad y morbilidad desproporcionadamente altas. Esto se traduce en unos costes indirectos muy elevados. El clínico debe ser consciente del impacto del glioblastoma en la sociedad y los costes indirectos deben ser tenidos en cuenta en los estudios de coste-efectividad para conocer las consecuencias globales de esta enfermedad (AU)

Introduction: Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described. Material and method: We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries. Results: We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was Euros11 080 762 (2015). Mean indirect cost per patient was Euros 111 926 (2015). Discussion: Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease (AU)

Indirect costs associated with glioblastoma: Experience at one hospital. / Costes indirectos asociados al glioblastoma. Experiencia en un centro.

INTRODUCTION: Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described. MATERIAL AND METHOD: We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries. RESULTS: We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was €11 080 762 (2015). Mean indirect cost per patient was €111 926 (2015). DISCUSSION: Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease.

Vacunación en viajeros internacionales / Vaccination for international travelers

La vacunación del viajero es una de las estrategias fundamentales para la prevención de las enfermedades infecciosas durante un viaje internacional. El riesgo de adquisición de una determinada enfermedad infecciosa viene condicionado en cada caso por las características del viajero y del viaje, por lo que el consejo del viajero y la indicación de las vacunas tendrán que hacerse de forma individualizada. La Organización Mundial de la Salud clasifica las vacunas que se pueden utilizar en viajeros en tres grupos.- Vacunas de uso rutinario en los programas nacionales de inmunización: Haemophilus influenzae tipo b, hepatitis B, poliomielitis, sarampión-parotiditis-rubéola, tétanos-difteria-tos ferina y varicela. - Vacunas exigidas por Ley en ciertos países para entrar en ellos: fiebre amarilla, enfermedad meningocócica y poliomielitis. -Vacunas recomendadas antes del viaje según las circunstancias: cólera, encefalitis japonesa, encefalitis por mordedura de garrapata, enfermedad meningocócica, fiebre tifoidea, gripe, hepatitis A, hepatitis B, rabia y BCG. Esta revisión tiene el propósito de introducir al lector en el campo de la vacunación internacional

Traveler's vaccination is one of the key strategies for the prevention of infectious diseases during international travel. The risk of acquiring an infectious disease is determined in each case by the characteristics of the traveler and the travel, so the pre-departure medical advice of the traveler must be individualized. The World Health Organization classifies travelers' vaccines into three groups. - Vaccines for routine use in national immunization programs: Haemophilus influenzae type b, hepatitis B, polio, measles-mumps-rubella, tetanus-diphtheria-whooping a cough, and chickenpox. - Vaccinations required by law in certain countries before to enter them: yellow fever, meningococcal disease and poliomyelitis. - Vaccines recommended depending on the circumstances: cholera, japanese encephalitis, tick-borne encephalitis, meningococcal disease, typhoid fever, influenza, hepatitis A, hepatitis B, rabies and BCG. This review is intended to introduce the reader to the field of international vaccination

[Vaccination for international travelers]. / Vacunación en viajeros internacionales.

Traveler's vaccination is one of the key strategies for the prevention of infectious diseases during international travel. The risk of acquiring an infectious disease is determined in each case by the characteristics of the traveler and the travel, so the pre-departure medical advice of the traveler must be individualized. The World Health Organization classifies travelers vaccines into three groups. - Vaccines for routine use in national immunization programs: Haemophilus influenzae type b, hepatitis B, polio, measles-mumps-rubella, tetanus-diphtheria-whooping a cough, and chickenpox. - Vaccinations required by law in certain countries before to enter them: yellow fever, meningococcal disease and poliomyelitis. - Vaccines recommended depending on the circumstances: cholera, japanese encephalitis, tick-borne encephalitis, meningococcal disease, typhoid fever, influenza, hepatitis A, hepatitis B, rabies and BCG. This review is intended to introduce the reader to the field of international vaccination.

[Multiple extraneural metastasis of glioblastoma multiforme].

INTRODUCTION: Glioblastoma multiforme is the most frequent primary tumor in the brain. Despite improvements in its surgical, chemotherapy and radiotherapy treatment, prognosis remains poor. Extracranial metastases of glioblastoma are a rare complication in this disease. Its appearance has been described in lung, liver, bone or lymph nodes. CASE REPORT: We describe the case of a 20 year-old patient who complained of a subacute-onset headache. In the MRI an enhancing right temporal lesion was detected suggesting a high grade glioma as first diagnosis. Surgery was performed, obtaining a gross total resection of the lesion. Our patient underwent adjuvant radiotherapy and chemotherapy treatment, according to our hospital's protocol. Five months after initial surgery our patient complained of chest pain and a hacking cough. A thoracic-abdominal-pelvic CT scan was obtained, which showed bilateral lung infiltrates with pleural effusion, a pancreatic nodule and several vertebral lytic lesions. The lung lesions were biopsied. The pathologic diagnosis was metastatic glioblastoma multiforme. The patient died eight months after initial diagnosis. CONCLUSION: Extracranial metastases of glioblastoma remain a rare event although its incidence is increasing, probably due to the improvement in survival among these patients and better imaging techniques. The mechanisms for extracranial dissemination of glioblastoma are not entirely known, as several theories exist in this regard. Physicians must be aware of this complication and keep it in mind as a differential diagnosis to improve the quality of life of our patients.

Multiple extraneural metastasis of glioblastoma multiforme / Metástasis extraneurales múltiples de glioblastoma multiforme

Introduction: Glioblastoma multiforme is the most frequent primary tumor in the brain. Despite improvements in its surgical, chemotherapy and radiotherapy treatment, prognosis remains poor. Extracranial metastases of glioblastoma are a rare complication in this disease. Its appearance has been described in lung, liver, bone or lymph nodes. Case report: We describe the case of a 20 year-old patient who complained of a subacute-onset headache. In the MRI an enhancing right temporal lesion was detected suggesting a high grade glioma as first diagnosis. Surgery was performed, obtaining a gross total resection of the lesion. Our patient underwent adjuvant radiotherapy and chemotherapy treatment, according to our hospital’s protocol. Five months after initial surgery our patient complained of chest pain and a hacking cough. A thoracicabdominal-pelvic CT scan was obtained, which showed bilateral lung infiltrates with pleural effusion, a pancreatic nodule and several vertebral lytic lesions. The lung lesions were biopsied. The pathologic diagnosis was metastatic glioblastoma multiforme. The patient died eight months after initial diagnosis. Conclusion: Extracranial metastases of glioblastoma remain a rare event although its incidence is increasing, probably due to the improvement in survival among these patients and better imaging techniques. The mechanisms for extracranial dissemination of glioblastoma are not entirely known, as several theories exist in this regard. Physicians must be aware of this complication and keep it in mind as a differential diagnosis to improve the quality of life of our patients (AU)

Fundamento: Los glioblastomas multiformes son los tumores cerebrales primarios más frecuentes. A pesar de los avances en su tratamiento quirúrgico, quimioterápico y radioterápico su pronóstico sigue siendo pobre. Las metástasis extracraneales de glioblastoma multiforme suponen una rara complicación dentro del curso de la enfermedad y ha sido descrita su aparición en distintas localizaciones como pulmón, hígado, hueso o ganglios linfáticos. Caso clínico: Presentamos el caso de una paciente de 20 años que consultó por un cuadro de evolución subaguda. Se obtuvo una RMN cerebral que demostró la presencia de una lesión temporal derecha, que sugería un glioma de alto grado como primera posibilidad diagnóstica. Se intervino a la paciente, realizando una resección macroscópicamente completa de la lesión. Se administró tratamiento radioterápico y quimioterápico adyuvante, de acuerdo con el protocolo de nuestro centro. Cinco meses después de la cirugía la paciente consultó por dolor torácio y tos seca. Se realizó un TAC toraco-abdomino-pélvico, que mostró la presencia de infiltrados pulmonares bilaterales con derrame pleural asociado, un nódulo pancreático y varias lesiones vertebrales líticas. Las lesiones pulmonares fueron biopsiadas. El diagnóstico anatomopatológico fue de metástasis de glioblastoma multiforme. La paciente falleció ocho meses después del diagnóstico inicial. Conclusiones: Las metástasis extracraneales de glioblastoma multiforme son un suceso poco frecuente, aunque su incidencia está aumentando en posible relación con el aumento de la supervivencia de nuestros pacientes. La aparición de esta complicación se asocia a un estado terminal de la enfermedad. A pesar de su baja frecuencia se debe mantener un alto nivel de sospecha en su diagnóstico para poder mejorar la calidad de vida de estos pacientes (AU)

Impact of squalene-based adjuvanted influenza vaccination on graft outcome in kidney transplant recipients.

BACKGROUND: Safety concerns have been raised about the use of adjuvanted vaccines after kidney transplantation. METHODS: We retrospectively analyzed 65 kidney transplant (KT) recipients who received ≥1 dose of influenza vaccine (pandemic or seasonal) during the 2009-2010 campaign. Participants were classified into 2 groups: those who received a squalene-based AS03- or MF59-adjuvanted vaccine ("adjuvanted vaccination" [AV] group, n = 37) and those who exclusively received non-adjuvanted vaccines ("non-adjuvanted vaccination" [NAV] group, n = 28). Primary outcomes included occurrence of biopsy-proven acute graft rejection (BPAR) and graft function at months 6 and 12 after vaccination. Patients were followed up until graft loss, death, or October 2010. RESULTS: Four episodes of BPAR occurred during post-vaccination follow-up, with no differences between the AV and NAV groups, in terms of cumulative incidence (5.4% vs. 7.1%, respectively; P = 0.581), incidence rate (0.22 vs. 0.18 episodes per 1000 transplant-days; P = 0.950), or occurrence of severe episodes (T-cell-mediated BPAR of grade ≥2a) (2.7% vs. 3.6%; P = 0.680). No between-group differences were seen in graft function after vaccination. CONCLUSION: Adjuvanted influenza vaccination in KT recipients seems to be safe regarding graft outcome.

[Multicentre study of infection incidence in knee prosthesis]. / Estudio multicéntrico sobre la incidencia de infección en prótesis de rodilla.

OBJECTIVE: To determine the incidence of surgical site infection in knee prosthesis surgical procedure for a follow-up period of one year in twelve hospitals in Madrid region. MATERIAL AND METHOD: A prospective study was carried out from January to December 2009 using a national surveillance system called Indicadores Clínicos de Mejora Continua de Calidad. Primary and revision knee joint replacements in patients operated on in the previous year were included. Criteria used to define surgical site infection and patient risk index categories were those established by the Centers for Disease Control and Prevention and National Nosocomial Infections Surveillance. The incidence rates were worked out crude and adjusted by hazard ratio. RESULTS: 2,088 knee prosthesis procedures were analyzed. The overall incidence of surgical site infection was 2.1%. Sixty-five percent of the infections were organ/space. Sixty percent of the infections were identified in the early postoperative period. Of all surgical site infections, 41.9% were microbiologically confirmed. Antibiotic prophylaxis was implemented correctly in 63.3% of the cases. The most important cause of inappropriate prophylaxis was an unsuitable duration in 85.7% of the cases. The presurgical preparation was carried out correctly in 50.3% of surgical operations. The incidence of knee arthroplasty infection was twice as high as in the National Healthcare Safety Network and similar to national rates. DISCUSSION: In this study, the incidence of infection was within the range of infection rates in other published European studies. Surveillance and control strategies of health care for associated infections allow us to assess trends and the impact of preventive measures.

Estudio multicéntrico sobre la incidencia de infección en prótesis de rodilla / Multicentre study of infection incidence in knee prosthesis

Objetivo. Determinar la incidencia de infección de localización quirúrgica en el procedimiento prótesis de rodilla, durante un año de seguimiento en 12 hospitales madrileños. Material y método. Estudio prospectivo de enero a diciembre de 2009, utilizando el programa Indicadores Clínicos de Mejora Continua de Calidad. Se incluyeron prótesis de rodilla primarias y de revisión intervenidas el año previo. Se utilizaron criterios de infección de localización quirúrgica y categorías por índice de riesgo de los Centros para el Control y Prevención de Enfermedades y del National Nosocomial Infections Surveillance. Se calcularon tasas crudas y ajustadas por índice de riesgo. Resultados. Se analizaron 2.088 procedimientos quirúrgicos de prótesis de rodilla. La tasa global de infección de localización quirúrgica fue del 2,1%. El 65% de las infecciones fueron de órgano/espacio. El 60% de las infecciones se identificaron precozmente. Se obtuvo confirmación microbiológica en el 41,9% de los casos. La profilaxis quirúrgica fue adecuada en el 63,3%, siendo la principal causa de inadecuación su duración en el 85,7%. La preparación prequirúrgica fue correcta en el 50,3% de los pacientes. La tasa de infección en artroplastias de rodilla fue dos veces superior a la esperada según el National Healthcare Safety Network y similares a las tasas nacionales. Discusión. La tasa de infección de nuestro estudio se encuentra dentro del rango de las tasas de infección descritas en otros estudios europeos ya publicados. Las estrategias de vigilancia y control de las infecciones asociadas a la asistencia sanitaria permiten evaluar tendencias y el impacto de las medidas de prevención (AU)

Objective. To determine the incidence of surgical site infection in knee prosthesis surgical procedure for a follow-up period of one year in twelve hospitals in Madrid region. Material and method. A prospective study was carried out from January to December 2009 using a national surveillance system called Indicadores Clínicos de Mejora Continua de Calidad. Primary and revision knee joint replacements in patients operated on in the previous year were included. Criteria used to define surgical site infection and patient risk index categories were those established by the Centers for Disease Control and Prevention and National Nosocomial Infections Surveillance. The incidence rates were worked out crude and adjusted by hazard ratio. Results. 2,088 knee prosthesis procedures were analyzed. The overall incidence of surgical site infection was 2.1%. Sixty-five percent of the infections were organ/space. Sixty percent of the infections were identified in the early postoperative period. Of all surgical site infections, 41.9% were microbiologically confirmed. Antibiotic prophylaxis was implemented correctly in 63.3% of the cases. The most important cause of inappropriate prophylaxis was an unsuitable duration in 85.7% of the cases. The presurgical preparation was carried out correctly in 50.3% of surgical operations. The incidence of knee arthroplasty infection was twice as high as in the National Healthcare Safety Network and similar to national rates. Discussion. In this study, the incidence of infection was within the range of infection rates in other published European studies. Surveillance and control strategies of health care for associated infections allow us to assess trends and the impact of preventive measures (AU)

Early mortality in spontaneous supratentorial intracerebral haemorrhage.

BACKGROUND: Spontaneous supratentorial intracerebral haemorrhage is a severe, frequent, and poorly understood condition. Despite the publication of 12 randomised controlled trials on this subject, the role of surgery remains controversial and no treatment has proved to be effective. We report on a ten year prospective cohort study based on a defined population treated with or without surgery and their outcome in terms of early survival. METHODS: Population based, ten year prospective observational study directed to patients consecutively admitted to the Intensive Care Unit (ICU) in a tertiary centre with spontaneous supratentorial intracerebral haemorrhage. Patients were distributed in five groups according to the Glasgow Coma Score (GCS) at admission. Haemorrhages were classified as deep-seated or superficial. All patient received standard medical care, and additionally surgery if it was found indicated by the duty neurosurgeon. Primary endpoint was early mortality defined as dead occurred by any cause during the admission in the ICU. FINDINGS: During the ten year period, 1.485 patients were admitted to our centre with primary intracerebral haemorrhage. Of these, 376 were admitted to the intensive care unit and 285 sustained supratentorial haemorrhages. Low GCS was strong predictor of early mortality. Despite the larger size of haematomas in patients undergoing surgical evacuation, surgery was associated with lower early mortality in all GCS subgroups. Maximal benefit was observed in patient with admission GCS of 4-8. Superficial haematomas were operated on more often, and were associated with lower mortality rate than deep-seated cases. CONCLUSIONS: Our findings suggest that craniotomy for haematoma evacuation may reduce early mortality in patients with primary supratentorial intracerebral haemorrhage. Surgery seems specially useful in patients with admission GCS between 4 and 8, and in those with superficial haemorrhages.

Early mortality in spontaneous supratentorial intracerebral haemorrhage

Background. Spontaneous supratentorial intracerebralhaemorrhage is a severe, frequent, and poorlyunderstood condition. Despite the publication of 12 randomisedcontrolled trials on this subject, the role of surgeryremains controversial and no treatment has proved to beeffective. We report on a ten year prospective cohort studybased on a defined population treated with or without surgeryand their outcome in terms of early survival.Methods. Population based, ten year prospective observationalstudy directed to patients consecutively admittedto the Intensive Care Unit (ICU) in a tertiary centre withspontaneous supratentorial intracerebral haemorrhage.Patients were distributed in five groups according to theGlasgow Coma Score (GCS) at admission. Haemorrhageswere classified as deep-seated or superficial. All patientreceived standard medical care, and additionally surgeryif it was found indicated by the duty neurosurgeon. Primaryendpoint was early mortality defined as dead occurredby any cause during the admission in the ICU.Findings. During the ten year period, 1.485 patientswere admitted to our centre with primary intracerebralhaemorrhage. Of these, 376 were admitted to theintensive care unit and 285 sustained supratentorialhaemorrhages. Low GCS was strong predictor of earlymortality. Despite the larger size of haematomas inpatients undergoing surgical evacuation, surgery wasassociated with lower early mortality in all GCS subgroups.Maximal benefit was observed in patient withadmission GCS of 4-8. Superficial haematomas wereoperated on more often, and were associated with lowermortality rate than deep-seated cases.Conclusions. Our findings suggest that craniotomyfor haematoma evacuation may reduce early mortalityin patients with primary supratentorial intracerebralhaemorrhage. Surgery seems specially useful in patientswith admission GCS between 4 and 8, and in those withsuperficial haemorrhages (AU)

Introducción. La hemorragia intracerebral supratentorialespontánea es un proceso frecuente, gravey poco comprendido. A pesar de la publicación de 12ensayos clínicos controlados sobre el tema, la indicaciónquirúrgica es controvertida y ningún tratamiento se hamostrado efectivo. Presentamos los resultados de unestudio prospectivo de cohortes desarrollado a lo largo dediez años en una población definida. Los pacientes recibierontratamiento quirúrgico o conservador y su evoluciónse describe en términos de mortalidad temprana.Material y métodos. Estudio prospectivo y observacionalbasado en una población definida en el que se incluyeronconsecutivamente todos los pacientes que ingresaron a lolargo de diez años en la Unidad de Cuidados Intensivos(UCI) de un centro terciario. Los pacientes fueron clasificadosen cinco grupos de acuerdo al puntaje en la escalade coma de Glasgow (GCS) al ingreso. Las hemorragiasfueron clasificadas en superficiales y profundas. Todoslos pacientes recibieron el tratamiento médico estándary cirugía de acuerdo con la indicación del neurocirujanode guardia. El punto final del análisis fue la mortalidadtemprana, definida como muerte por cualquier causaocurrida durante el ingreso en UCI.Resultados. Un total de 1.485 pacientes con hemorragiaintracerebral espontánea fueron ingresados ennuestro centro durante los diez años del estudio. De (..) (AU)

[Skull-base plasmacytoma with craniocervical instability]. / Plasmocitoma de base craneal con inestabilidad cráneo-cervical.

INTRODUCTION: Cranio-cervical instability is, in some cases, the main surgical concern in posterior skull base tumors. We report on a case in which a solitary plasmacytoma of the skull base presented with cranio-cervical instability. Vertebral artery was injured during surgery. The surgical anatomy is reviewed, with emphasis in vascular complications avoidance. CASE REPORT: A 66 year-old woman was diagnosed of a cranial base solitary plasmacytoma and treated with radio and chemotherapy with complete remission. After receiving that treatment, she presented with tetraparesis and a cranio-cervical instability was diagnosed. She was operated on, under cranial traction, of posterior occipito-cervical instrumentation with C1 to C2 transarticular Magerl screws. The right vertebral artery was injured during surgery without additional neurological deficit. Two years after the operation she remains independent for daily activities. CONCLUSIONS: Transarticular screws at the C1 to C2 level of the cervical spine may provide rigid fixation in posterior cranio-cervical instrumentation for osteolytic lesions, but there is a risk of injury to the vertebral artery, specially when some variations in the surgical anatomy exist.

Plasmocitoma de base craneal con inestabilidad cráneo-cervical / Skull base plasmacytoma with craniocervical instability

Introducción. La inestabilidad cráneo-cervicalconstituye, en ocasiones, el principal problema neuroquirúrgicoen la patología tumoral de la base cranealposterior. Presentamos un caso clínico en el que unplasmocitoma solitario originó inestabilidad cráneocervical.Durante la cirugía de estabilización, se lesionóla arteria vertebral. Revisamos la anatomía quirúrgicadesde el punto de vista de la prevención de las complicacionesvasculares.Caso clínico. Mujer de 66 años diagnosticada deplasmocitoma solitario de base craneal, tratada conradio y quimioterapia con remisión completa, quepresenta tetraparesia y disfagia. Tras el diagnóstico deinestabilidad cráneo-cervical, se indica estabilizaciónmediante instrumentación occipito-cervical. Es intervenidabajo tracción craneal con atornillado C1-C2 segúntécnica de Magerl y extensión occipital. Durante lacirugía se lesionó la arteria vertebral derecha sin repercusiónclínica. Dos años más tarde, la paciente es capazde llevar una vida independiente.Conclusiones. La instrumentación cráneo-cervicalcon tornillos transarticulares C1-C2, como parte delsistema de fijación C0-C1-C2, parece eficaz para corregirla inestabilidad en lesiones osteolíticas, a expensasde un riesgo considerable de lesión de la arteria vertebral,especialmente en presencia de algunas variacionesanatómicas (AU)

Introduction. Cranio-cervical instability is, in somecases, the main surgical concern in posterior skull basetumors. We report on a case in which a solitary plasmacytomaof the skull base presented with cranio-cervicalinstability. Vertebral artery was injured during surgery.The surgical anatomy is reviewed, with emphasis invascular complications avoidance.Case report. A 66 year-old woman was diagnosedof a cranial base solitary plasmacytoma and treatedwith radio and chemotherapy with complete remission.After receiving that treatment, she presented withtetraparesis and a cranio-cervical instability was diagnosed.She was operated on, under cranial traction, ofposterior occipito-cervical instrumentation with C1 toC2 transarticular Magerl screws. The right vertebralartery was injured during surgery without additionalneurological deficit. Two years after the operation sheremains independent for daily activities.Conclusions. Transarticular screws at the C1 to C2level of the cervical spine may provide rigid fixation inposterior cranio-cervical instrumentation for osteolyticlesions, but there is a risk of injury to the vertebralartery, specially when some variations in the surgicalanatomy exist (AU)

[Spinal cord compression due to a epidural lipoma]. / Compresión medular por lipoma epidural dorsal.

INTRODUCTION: The spinal extradural space is normally occupied by adipose tissue and a venous plexus, so it should be not surprising that lipomas arise and reach sufficient size to compress symptomatically the spinal cord. Nevertheless, the spinal epidural lipomas are rare and benign tumours may present as a progressive spinal cord compression syndrome. Magnetic resonance imaging is useful in demonstrating the full extent and characteristics of these lesions, the severity of cord compression and the location in the canal. Usually, the lesion is amenable to total surgical extirpation and the functional prognosis is good. Histopathologically the tumour consists of a mature adipose cells matrix intermixed with vascular endothelial channels, that is the reason why it is also named angiolipomas. CASE REPORT: A 47 year-old woman complained of dorsal and bilateral submamarian pain lasting two years and progressive loss of sensibility and weakness in her legs. Following magnetic resonance studies a posterior spinal cord compression by an extradural tumour at T3-T7 levels was observed. She was operated on and we found an extradural yellow tumour easily to dissect and it was completely removed. One year later she is asymptomatic. CONCLUSIONS: Spinal epidural lipoma is a benign tumour which initially presents itself with local or radicular pain accompanied by progressive spinal cord compression syndrome. The choice treatment is laminectomy and total excision. Probably, this is one of the easiest tumours to remove of the spinal canal and a source of satisfaction because a complete recovery can usually be achieved.

Compresión medular por lipoma epidural dorsal / Spinal cord compression due to a epidural lipoma

Introducción. El espacio extradural raquídeo se encuentra normalmente ocupado por tejido adiposo y por un rico plexo venoso, por lo que no es sorprendente que sea el asiento de tumores de estirpe lipídica que pueden al cazar un tamaño suficiente como para comprimir la médula espinal. Los lipomas epidurales son infrecuentes y se manifiestan clínicamente con un síndrome de compresión medular y/o radicular progresivo. La resonancia magnética del raquis suele serla clave en el diagnóstico, pues demuestra con claridad tanto la naturaleza como la localización del tumor y su extensión en relación al cordón medular. Con frecuencia se trata de lesiones accesibles para la extirpación quirúrgica y tienen un excelente pronóstico en cuanto a la recuperación funcional. Desde el punto de vista histopatológico se las describe como lesiones de aspecto similar al tejido graso maduro mezclados con numerosos canales vasculares, razón por la cual se los ha denominado angiolipomas. Caso ilustrativo. Mujer de 47 años que consulta por dolor submamario bilateral de dos años de duración acompañado de pérdida progresiva de sensibilidad y debilidad en las extremidades inferiores. El estudio por resonancia magnética llevó al diagnóstico de una compresión medular por una masa epidural a nivelD3-D7. Durante la intervención quirúrgica se identificó un tumor amarillento fácilmente disecable que se extirpó completamente. Un año más tarde la paciente se encuentra asintomática. Conclusión. Los lipomas extradurales raquídeos son tumores benignos que suelen presentarse como un síndrome radicular seguido de síndrome de compresión medular. El tratamiento de elección es la extirpación quirúrgica a través de una laminectomía. Probablemente se trata de los tumores técnicamente más fáciles de extirpar del raquis y que más satisfacciones produce al neurocirujano y al paciente ya que la recuperación funcional suele ser completa

Introduction. The spinal extradural space is normally occupied by adipose tissue and a venous plexus, so it should be not surprising that lipomas arise and reach sufficient size to compress symptomatically the spinal cord. Nevertheless, the spinal epidural lipomas are rare and benign tumours may present as a progressive spinal cord compression syndrome. Magnetic resonance imaging is useful in demonstrating the full extent and characteristics of these lesions, the severity of cord compression and the location in the canal. Usually, the lesion is amenable to total surgical extirpation and thefunctional prognosis is good. Histopathologically the tumour consists of a mature adipose cells matrix intermixed with vascular endothelial channels, that is the reason why it is also named angiolipomas. Case report. A 47 year-old woman complained of dorsal and bilateral submamarian pain lasting two years and progressive loss of sensibility and weakness in her legs. Following magnetic resonance studies a posterior spinal cord compression by an extradural tumour at T3-T7 levels was observed. She was operated on and we found an extradural yellow tumour easily to dissect and it was completely removed. One year later she is asymptomatic. Conclusions. Spinal epidural lipoma is a benign tumour which initially presents itself with local orradicular pain accompanied by progressive spinal cord compression syndrome. The choice treatment is laminectomy and total excision. Probably, this is one of the easiest tumours to remove of the spinal canal and a source of satisfaction because a complete recovery can usually be achieved

Influenza vaccination coverage among hospital personnel over three consecutive vaccination campaigns (2001-2002 to 2003-2004).

This study was carried out to assess influenza vaccination coverage among hospital personnel and the impact of health promotion campaigns, within the hospital, designed to increase vaccination coverage over three consecutive vaccination campaigns (2001-2002 to 2003-2004). The health promotion tool used in the 2001-2002 and 2002-2003 were informative posters distributed throughout the hospital. In the 2003-2004 season, the recommendation was also published in the internal bulletin and Web site of the hospital. In addition, a physician and a nurse from the Department of Preventive Medicine visited all departments offering vaccination in the work place. The overall vaccination coverage in the 2001-2002 campaign was 16% with coverage of 11.5% in nurses and 15% in physicians. In the 2002-2003 and 2003-2004 campaigns the overall vaccination coverage was 21% and 40%, respectively (p<0.01). Staff physicians and resident physicians reached 60 and 42% coverage rates in the 2003-2004 campaign, but coverage in nurses and nursing assistant remained around 30% (p<0.01). In summary, influenza vaccination coverage among hospital based healthcare personnel increased significantly during the last three seasons, however, it still remains low despite active attempts at promoting influenza vaccination.

Gestión de residuos biosanitarios y citotóxicos en un centro hospitalario / Management of bio-sanitary and cytotoxic wastes at a hospital centre

Los residuos sanitarios generados diariamente, van en aumento y la innovación en las actividades hospitalarias han traído consigo un gran incremento del volumen de desechos clínicos. A una pequeña fracción de éstos, se le atribuyen riesgos asociados a la salud pública y precisarán una gestión diferenciada. El interés por la correcta gestión de estos residuos es creciente y, sin embargo, hay dificultad en la aplicación del sistema de gestión y en el cumplimiento del marco legal. El plan de gestión de residuos es una herramienta para promover una adecuada gestión de residuos en los centros sanitarios. Los profesionales sanitarios y no sanitarios deben ser partícipes, del mismo modo que la información y formación es clave en nuestro trabajo diario, para garantizar un entorno seguro y en mejores condiciones técnicas e higiénicas (AU)

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[Anatomical landmarks and surgical limits in the suboccipital transmeatal approach to the acoustic neuroma]. / Referencias anatómicas y límites quirúrgicos en el abordaje suboccipital transmeatal del neurinoma acústico.

INTRODUCTION: To completely remove the intracanalicular portion of the acoustic neuroma through the retrosigmoid approach, we must open the posterior wall of the internal auditory canal (IAC). Therefore, drilling the IAC is one of the key steps we need to take in the transmeatal surgical approach. Nevertheless, there are no clear anatomical landmarks to identify structures such as the semicircular canals, the jugular bulb or air cells. The individual anatomical variations and those caused by the tumour itself make preoperative evaluation essential if we wish to avoid complications such as deafness, cerebrospinal fluid leakage, bleeding and air embolism. OBJECTIVE: We describe here the personal experience of the senior author (EU) in drilling the posterior wall of the IAC, with special reference to the anatomical landmarks and surgical limits in the suboccipital approach to the intracanalicular portion of the acoustic neuromas. MATERIAL AND METHODS: This work is based on anatomical data obtained from drilling human temporal bones obtained from cadavers, along with our experience with 20 patients who were operated on for acoustic neuroma using Samii's technique. RESULTS: We did not operate on any purely intracanalicular neurinomas using this approach. Two tumors were grade II (up to 20mm in diameter), 12 were grade III and 6 were grade IV. We did not drill far enough in any of these cases to be able to see the fundus of the IAC, which was confirmed by postoperative CT. Despite this, the tumor was considered to be completely removed in 17 cases. There was no mortality and we has no major complications as a result of drilling the IAC such as cerebrospinal fluid leakage or air embolism. we cannot guarantee that hearing loss of postoperative deafness, which were the norm except in one case of grade II, were caused by nervous, ischemic or labyrinthine lesions. CONCLUSION: In our material it was not possible to completely expose the IAC fundus using a retrosigmoid approach without injury to labyrinth. The areas in which the risk of secondary complications is greatest when drilling are the inferior wall and the IAC fundus. The medial extension of the suboccipital craniotomy makes drilling the intrameatal tumor exposure easier. There are no intraoperative landmarks to locate the petrous structures while drilling the IAC except for those provided by the surgeon's own experience.