Functional Surgery for Malignant Subungual Tumors: A Case Series and Literature Review. / Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura.

BACKGROUND AND OBJECTIVES: Amputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications. MATERIAL AND METHODS: Retrospective observational study of MSUTs treated with WLE of the nail unit between 2008 and 2017. The technique consisted of en bloc supraperiosteal excision of the nail unit with a margin of 5mm followed by repair with a full-thickness graft. RESULTS: Eleven MSUTs were treated in the study period: 7 SUMs (4 in situ; mean thickness, 1.17mm; range, 0-4mm) and 4 SUSCCs (mean thickness, 3.4mm; range, 1.6-6mm). WLE of the nail unit was performed in 9 patients and amputation in 2 patients with invasive SUM. Mean follow-up was 39 months (range, 12-96 months) and no local or regional recurrences were detected. One of the 2 patients who underwent amputation developed metastasis to the brain and died. In our review of the literature, we identified 5 series of patients with SUSCC treated with WLE of the nail unit (105 patients) and 14 series of patients with SUM (243 patients). Based on an analysis of these cases and ours, it would appear that WLE of the nail unit is associated with a very low rate of local recurrence (<7%) and offers better functional and cosmetic outcomes than amputation. CONCLUSIONS: WLE of the nail unit is the treatment of choice for SUSCC without bone involvement and for thin noninvasive SUM (Breslow depth <1mm). It is also feasible in intermediate-thickness SUMs when detailed histologic examination of the margins confirms complete resection. Amputation, by contrast, is the treatment of choice for SUSCCs with bone involvement, very thick SUMs (>4mm), and recurrent tumors.

Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura / Functional Surgery for Malignant Subungual Tumors: A Case Series and Literature Review

ANTECEDENTES Y OBJETIVOS: El tratamiento clásico de los tumores malignos subungueales (TMSU), carcinoma epidermoide (CESU) y melanoma (MSU), es la amputación. La cirugía funcional del aparato ungueal (CFAU) puede preservar la función sin modificar el pronóstico. Presentamos nuestra serie de TMSU manejados con CFAU, describimos la técnica y revisamos sus indicaciones. MATERIAL Y MÉTODOS: Estudio observacional retrospectivo de TMSU tratados con CFAU entre 2008 y 2017, con exéresis supraperióstica en bloque del aparato ungueal, margen a 5 mm, y cierre con injerto de piel total. RESULTADOS: Se trataron 11 TMSU, de los cuales 7 fueron MSU (4 in situ, espesor medio: 1,17mm; rango: 0-4mm) y 4 CESU (espesor medio: 3,4 mm; rango: 1,6-6 mm). Se realizó CFAU en 9 casos y 2 amputaciones en sendos MSU invasivos. El seguimiento medio fue 39 meses, con un rango de 12-96 meses. No hubo recidivas locales ni regionales. Solo un caso -una de las 2 amputaciones- tuvo metástasis (cerebrales) y muerte. La revisión de la literatura de CFAU en TMSU mostró 5 series (103 pacientes en total) con CESU y 14 series (243 pacientes en total) con MSU. El análisis de nuestros casos y de los casos publicados muestra muy escasas recurrencias locales (< 7%), y mejores resultados funcionales y estéticos frente a la amputación. CONCLUSIONES: La CFAU es de elección en CESU sin afectación ósea y MSU no invasivo o delgado (Breslow <1mm). Es factible en MSU de grosores intermedios siempre con detallado estudio histológico de márgenes que asegure una resección completa. Por el contrario, en CESU con afectación ósea, MSU muy grueso (>4mm) o recurrencias, la amputación debe ser habitualmente de elección

BACKGROUND AND OBJECTIVES: Amputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications. MATERIAL AND METHODS: Retrospective observational study of MSUTs treated with WLE of the nail unit between 2008 and 2017. The technique consisted of en bloc supraperiosteal excision of the nail unit with a margin of 5mm followed by repair with a full-thickness graft. RESULTS: Eleven MSUTs were treated in the study period: 7 SUMs (4 in situ; mean thickness, 1.17 mm; range, 0-4mm) and 4 SUSCCs (mean thickness, 3.4mm; range, 1.6-6 mm). WLE of the nail unit was performed in 9 patients and amputation in 2 patients with invasive SUM. Mean follow-up was 39 months (range, 12-96 months) and no local or regional recurrences were detected. One of the 2 patients who underwent amputation developed metastasis to the brain and died. In our review of the literature, we identified 5 series of patients with SUSCC treated with WLE of the nail unit (105 patients) and 14 series of patients with SUM (243 patients). Based on an analysis of these cases and ours, it would appear that WLE of the nail unit is associated with a very low rate of local recurrence (<7%) and offers better functional and cosmetic outcomes than amputation. CONCLUSIONS: WLE of the nail unit is the treatment of choice for SUSCC without bone involvement and for thin noninvasive SUM (Breslow depth <1mm). It is also feasible in intermediate-thickness SUMs when detailed histologic examination of the margins confirms complete resection. Amputation, by contrast, is the treatment of choice for SUSCCs with bone involvement, very thick SUMs (> 4 mm), and recurrent tumors

Facilitando el cierre de defectos faciales con puntos enterrados / Buried sutures to facilitate the closure of facial defects

No disponible

Neumotórax bilateral y neumomediastino tras microcirugía transoral con láser y traqueotomía / Bilateral and pneumomediastinal pneumothorax after transoral laser microsurgery and tracheotomy

La microcirugía transoral con láser CO2 se ha convertido en una alternativa cada vez más empleada para el tratamiento del cáncer de laringe y faringe. Entre las ventajas que aporta frente a la cirugía abierta y la radioterapia, se encuentran su menor invasividad, mayor precisión, mejor preservación funcional del órgano y menor morbilidad asociada al procedimiento. No obstante, esta técnica quirúrgica no está exenta de complicaciones, algunas hasta ahora poco frecuentes, pero de gran trascendencia clínica. Presentamos el caso de una paciente que en el contexto de una microcirugía con traqueotomía por cáncer de laringe sufrió un enfisema subcutáneo, neumomediastino y neumotórax bilateral precisando de las medidas pertinentes para su control y estabilización, que se describen. Además, se realiza una revisión actual en la literatura, sobre las consideraciones anestésicas y las principales complicaciones perioperatorias de la microcirugía con láser(AU)

Transoral laser CO2 microsurgery is becoming an increasing used treatment option for cancer of the larynx and the pharynx. Amongst the advantages it has compared to open surgery and radiotherapy are, it less invasiveness, greater precision, better functional preservation of the organ, and less procedure-associated morbidity. However, this surgical technique is not without its complication, some being rare up until now, but with great clinical importance. We present the case of a patient subjected to microsurgery with a tracheotomy due to cancer of the larynx, who suffered a subcutaneous emphysema, and a bilateral and pneumomediastinal pneumothorax, requiring the appropriate measures for its control and stabilisation, which are described. A review was also performed of the current literature as regards anaesthetic considerations and the main peri-operative complications of laser microsurgery(AU)

[Bilateral and pneumomediastinal pneumothorax after transoral laser microsurgery and tracheotomy]. / Neumotórax bilateral y neumomediastino tras microcirugía transoral con láser y traqueotomía.

Transoral laser CO2 microsurgery is becoming an increasing used treatment option for cancer of the larynx and the pharynx. Amongst the advantages it has compared to open surgery and radiotherapy are, it less invasiveness, greater precision, better functional preservation of the organ, and less procedure-associated morbidity. However, this surgical technique is not without its complication, some being rare up until now, but with great clinical importance. We present the case of a patient subjected to microsurgery with a tracheotomy due to cancer of the larynx, who suffered a subcutaneous emphysema, and a bilateral and pneumomediastinal pneumothorax, requiring the appropriate measures for its control and stabilisation, which are described. A review was also performed of the current literature as regards anaesthetic considerations and the main peri-operative complications of laser microsurgery.

Randomized controlled trial comparing store-and-forward teledermatology alone and in combination with web-camera videoconferencing.

BACKGROUND: Studies on the reliability of teledermatology have shown considerable variability in results. Only one study has compared asynchronous and synchronous methods. OBJECTIVES: This report describes DERMATEL, a prospective, randomized diagnostic-concordance study that sought to evaluate the relative advantages, in terms of reliability, of two remote consultation techniques. METHODS: Patients referred by 18 general practitioners were randomized (4 : 4 : 2) to three study groups: store and forward (SF), hybrid videoconferencing-SF (VC-SF), and a control group. In total, 457 patients were assigned: 192 to the SF group, 176 to the VC-SF group and 89 to the control group. High-quality still images were used throughout, with additional use of standard web-camera (webcam) videoconferencing in the VC-SF group. All patients were also seen by the same dermatologist in a face-to-face (FTF) consultation, considered the practical reference standard. Two different dermatologists assessed concordances between the teledermatology and FTF consultations. RESULTS: There were no significant differences in age, gender or diagnostic category between the three groups, and the images (82%), clinical history (91%) and diagnostic confidence (89%) were high-quality. Online management was possible for 70% of cases. Agreement between teledermatology and the FTF consultation was high for both diagnosis (> 0.85) and treatment (> 0.78). Concordance in diagnosis was influenced by image quality (P < 0.001), confidence in diagnosis (P < 0.001) and need for conventional consultation (P < 0.001), rather than by quality of clinical history (P = 0.58) or method of teleconsultation (P = 0.340). CONCLUSIONS: Intraobserver reliability is very high in teledermatology. When history taking and training in digital photography are standardised, a hybrid system with audio is no better than SF alone.

[Telemedicine and teledermatology (II): current state of research on dermatology teleconsultations]. / Telemedicina y teledermatología (II): estado actual de la investigación en teleconsulta dermatológica.

The rapid increase in the use of telemedicine makes a critical appraisal of these services essential. This article reviews the current evidence from studies of teledermatology with sufficiently rigorous methodology to allow reasonable conclusions to be drawn. The review is organized according to areas of research in teledermatology: reliability of diagnosis and management, accuracy, outcomes, costs, and satisfaction. The conclusion of this review is that teledermatology has been shown to be feasible and reliable but that it has a long way to go before maturing as a medical technology in daily practice. The largest body of evidence relates to the reliability of diagnosis and management, but although numerous studies have been performed, many have marked methodological shortcomings. Accuracy studies have been conducted in skin oncology with appropriate methodology that show an accuracy comparable to that of face-to-face consultations. Studies of health outcomes should be designed such that a faithful assessment of the final outcomes, costs, and satisfaction with teledermatology systems can be carried out.

Telemedicina y teledermatología (II): estado actual de la investigación en teleconsulta dermatológica / Telemedicine and Teledermatology (II): current state of research on dermatology teleconsultations

El rápido incremento en el desarrollo de los servicios en telemedicina hace crucial su evaluación crítica. Este artículo revisa la evidencia actual en artículos de investigación en teledermatología con la suficiente calidad metodológica como para alcanzar conclusiones razonables. La revisión se organiza analizando las áreas de investigación en teledermatología: fiabilidad en el diagnóstico y el manejo, validez, resultados, costes y satisfacción. Las conclusiones de la misma indican que la teledermatología ha demostrado ser factible y fiable pero que está lejos de alcanzar su madurez como tecnología médica para su práctica habitual. El cuerpo de evidencia con mayor desarrollo es el área de fiabilidad en el diagnóstico y el manejo, donde existen un gran número de estudios, aunque muchos de ellos adolecen de importantes defectos metodológicos. Existen estudios de validez en oncología cutánea con metodología correcta que muestran unos resultados comparables con la consulta presencial. Se hace preciso el diseño de estudios en resultados de salud que permitan un análisis fidedigno de resultados finales, costes y satisfacción de los sistemas de teledermatología (AU)

The rapid increase in the use of telemedicine makes a critical appraisal of these services essential. This article reviews the current evidence from studies of teledermatology with sufficiently rigorous methodology to allow reasonable conclusions to be drawn. The review is organized according to areas of research in teledermatology: reliability of diagnosis and management, accuracy, outcomes, costs, and satisfaction. The conclusion of this review is that teledermatology has been shown to be feasible and reliable but that it has a long way to go before maturing as a medical technology in daily practice. The largest body of evidence relates to the reliability of diagnosis and management, but although numerous studies have been performed, many have marked methodological shortcomings. Accuracy studies have been conducted in skin oncology with appropriate methodology that show an accuracy comparable to that of face-to-face consultations. Studies of health outcomes should be designed such that a faithful assessment of the final outcomes, costs, and satisfaction with teledermatology systems can be carried out (AU)

[Preliminary results of DERMATEL: prospective randomized study comparing synchronous and asynchronous modalities of teledermatology]. / Resultados preliminares de DERMATEL: estudio aleatorizado prospectivo comparando modalidades de teledermatología síncrona y asíncrona.

INTRODUCTION: There is considerable variability in the results of studies that evaluate diagnostic reliability in teledermatology. There are only two studies that compare the synchronous and asynchronous modalities of teleconsult in the same sample. We present the results of the pilot project DERMATEL, a study of diagnostic concordance that aims to increase the evidence of these aspects. MATERIAL AND METHODS: One-hundred-fifty.nine patients referred by the general practitioner in the first consult were randomized (algorithm 3:2:1) in three arms: asyncronous teledermatology (store-and-forward or SAF), synchronous teldermatology (real-time or VTC), and conventional consult (CC). We used high-quality, fixed digital images in all cases. The patients on the VTC teledermatology arm were also evaluated by videoconference. Finally all patients attended a face-to-face consult, considered the gold standard of patient care. A second dermatologist evaluated the diagnostic and management concordance between the teleconsults and the face-to-face consults. RESULTS: One-hundred.forty-seven patients completed the study as follows: 74 in the SAF teledermatology arm, 47 in the VTC teledermatology arm and 26 in the conventional consult (control group). The teledermatological (SAF and VTC) and face-to-face evaluations were identical in 100 of 121 patients (82.6%). The errors were mild in 14 cases (11.6%) and severe in 7 (5.8%). The diagnostic concordance was very high (kappa=0,813). The errors grouped by diseases were as follows: 6/54 (11%) for tumors, 10/30 (33.3%) for inflammatory conditions, 1/20 (5%) for infectious diseases, 3/12 (25%) for alopecia/acne and 1/5 (20%) for others. There were 15 errors in the SAF teledermatology arm (20.3%) and 6 in the VTC teledermatology arm (12.8%); these differences were not statistically significant (chi2 1.12; p=0.288). CONCLUSION: The reliability of dermatological teleconsult is very high, especially for tumoral or infectious diseases. The synchronous interaction with audio requires more resources, is difficult to coordinate and its diagnostic efficacy is not superior to SAF teledermatology.

Resultados preliminares de DERMATEL: estudio aleatorizado prospectivo comparando modalidades de teledermatología síncrona y asíncrona / Preliminary results of DERMATEL: prospective randomized study comparing synchronous and asynchronous modalities of teledermatology

Introducción. Los estudios de fiabilidad diagnóstica en teledermatología muestran considerable variabilidad en sus resultados. Sólo hay dos estudios que comparen las modalidades de teleconsulta síncrona y asíncrona en la misma muestra. Presentamos resultados del proyecto piloto DERMATEL, estudio de concordancia diagnóstica que pretende incrementar la evidencia acerca de estos aspectos. Material y métodos. Ciento cincuenta y nueve pacientes remitidos por médicos generales en primera consulta fueron aleatorizados (algoritmo 3:2:1) en tres ramas: teledermatología asíncrona (almacenamiento o TDA) o síncrona (tiempo real o TDTR) y consulta convencional (CC). Utilizamos imágenes digitales fijas de alta calidad en todos los casos. Los pacientes TDTR fueron evaluados además mediante videoconferencia. Finalmente todos los pacientes fueron atendidos en consulta de presencia considerada como estándar oro. Un segundo dermatólogo evaluó la concordancia diagnóstica y de manejo entre las teleconsultas y las consultas de presencia. Resultados. Ciento cuarenta y siete pacientes completaron el estudio, distribuidos como 74 TDA, 47 TDTR y 26 CC (grupo control). Del total de 121 pacientes evaluados por telemedicina (TDA + TDTR), la evaluación teledermatológica fue idéntica a la de presencia (no error) en 100 pacientes (82,6 %). Los errores fueron leves en 14 (11,6 %) y graves en 7 (5,8 %). La concordancia diagnóstica fue muy alta (kappa = 0,813). Los errores agrupados por patologías fueron: 6/54 tumoral (11 %), 10/30 inflamatoria (33,3 %), 1/20 infecciosa (5 %), 3/12 alopecia/acné (25 %) y 1/5 otros (20 %). Hubo 15/74 errores en el grupo TDA (20,3 %) y 6/47 en el TDTR (12,8 %), estas diferencias no fueron estadísticamente significativas (Chi cuadrado 1,12; p = 0,288). Conclusión. La fiabilidad de la teleconsulta dermatológica es muy elevada, especialmente para patología tumoral o infecciosa. La interacción sincrónica con audio consume más recursos, es difícil de coordinar y no es más eficaz en diagnóstico que la TDA

Introduction. There is considerable variability in the results of studies that evaluate diagnostic reliability in teledermatology. There are only two studies that compare the synchronous and asynchronous modalities of teleconsult in the same sample. We present the results of the pilot project DERMATEL, a study of diagnostic concordance that aims to increase the evidence of these aspects. Material and methods. One-hundred-fifty.nine patients referred by the general practitioner in the first consult were randomized (algorithm 3:2:1) in three arms: asyncronous teledermatology (store-and-forward or SAF), synchronous teldermatology (real-time or VTC), and conventional consult (CC). We used high-quality, fixed digital images in all cases. The patients on the VTC teledermatology arm were also evaluated by videoconference. Finally all patients attended a face-to-face consult, considered the gold standard of patient care. A second dermatologist evaluated the diagnostic and management concordance between the teleconsults and the face-to-face consults. Results. One-hundred.forty-seven patients completed the study as follows: 74 in the SAF teledermatology arm, 47 in the VTC teledermatology arm and 26 in the conventional consult (control group). The teledermatological (SAF and VTC) and face-to-face evaluations were identical in 100 of 121 patients (82.6 %). The errors were mild in 14 cases (11.6 %) and severe in 7 (5,8 %). The diagnostic concordance was very high (kappa = 0,813). The errors grouped by diseases were as follows: 6/54 (11 %) for tumors, 10/30 (33.3 %) for inflammatory conditions, 1/20 (5 %) for infectious diseases, 3/12 (25 %) for alopecia/acne and 1/5 (20 %) for others. There were 15 errors in the SAF teledermatology arm (20.3 %) and 6 in the VTC teledermatology arm (12.8 %); these differences were not statistically significant (**2 1.12; p = 0.288). Conclusion. The reliability of dermatological teleconsult is very high, especially for tumoral or infectious diseases. The synchronous interaction with audio requires more resources, is difficult to coordinate and its diagnostic efficacy is not superior to SAF teledermatology

Diclofenac sodium and cyclosporin A inhibit human lens epithelial cell proliferation in culture.

PURPOSE: To investigate the effect of diclofenac sodium salt and cyclosporin A (CsA) on human lens epithelial cell (HLEC) growth in culture. METHODS: Cultures of HLEC were obtained from anterior capsules from extracapsular cataract surgery. Third-passage cells were seeded in 96-well plates in 0.1 ml culture medium. Cytotoxicity was estimated by the tetrazolium test in confluent monolayers after 24 h exposure to a wide range of concentrations of diclofenac and CsA. The effect of subcytotoxic concentrations of diclofenac and CsA on HLEC proliferation in subconfluent cultures was evaluated after 24 and 72 h of exposure. To investigate the relationship between PGE2 synthesis and the inhibitory effect of these drugs, after 24 h of exposure to diclofenac and CsA the production of PGE2 was measured by radioimmunoassay. We also tested the effect of exogenous PGE2 addition to diclofenac 72-h-treated cultures. RESULTS: Diclofenac and CsA (at concentrations > or = 65 microM and > or = 2.5 microM, respectively) inhibited the proliferation of subconfluent cultures of HLEC in a dose-dependent fashion. Diclofenac inhibits PGE2 synthesis, while CsA at high doses stimulates PGE2 synthesis of cultured HLEC. Exogenous PGE2 addition reversed in part the inhibitory effect of diclofenac. CONCLUSIONS: Diclofenac and CsA at appropriate doses are effective in inhibiting cultured HLEC proliferation. This could be of interest to prevent posterior capsule opacification. Further in vivo experimental studies seem worthwhile.

Doppler-duplex ultrasound in renal colic.

OBJECTIVE: To determine the role of intrarenal Doppler ultrasound (US) in patients with renal colic and to establish the usefulness of this diagnostic method. MATERIALS AND METHODS: In 121 patients with renal colic and 70 healthy individuals, 382 kidneys were examined with color duplex US. Mean intrarenal-arterial resistive index (RI), and the difference of mean RIs (dRI) between both kidneys were determined. In 64 patients, RI and dRI were compared with urographic findings (time of delay pyelogram between both kidneys). RESULTS: In the 70 healthy individuals, RI was 0.62 +/- 0.045 and dRI 0.018 +/- 0.01. In the 121 patients with renal colic, RI (0.71 +/- 0.06) was significantly superior (P < 0.001) with respect to the opposite kidney, with a dRI of 0.09 +/- 0.055. In a correlation performed in 64 patients with urographic findings among color doppler US, with a RI > or = 0.70 and/or dRI > or = 0.06 as an indicative value of obstruction, sensitivity and specificity were 91.8% for patients with delayed pyelogram (n = 37 patients), and 48.1% for patients with nondelayed pyelogram (n = 27 patients) with a specificity of 92.8% with respect to the group of normal patients. In the group of patients with delayed pyelogram, RI was significantly superior (P < 0.05) in patients with an evolution time greater than 24 hours, in patients with proximal ureteral obstruction and in patients who had signs of pyelonephritis. There were no significant differences in the group of patients with nondelayed pyelograms. CONCLUSION: Color Doppler US is useful to fundamentally evaluate the consequences of the obstruction on renal function. Other factors such as evolution time of the symptomology, obstruction level, or existence of pyelonephritis can alter the US-Doppler values.

Prevention and early detection of tuberculosis.

1,570 subjects with known TB contacts (active TB, old TB and primary infection) and individuals with no known contacts but belonging to 'defined TB risk groups' were screened at the Department of Tuberculosis Prevention at the La Fe Hospital in Valencia. The total infection rate was 40.13% and active TBC was diagnosed in 2.23% of the population screened. Infection and disease rates were significant in all the groups examined, showing the need for correct screening not only for active TB contacts but also for child primary infection contacts, old TB cases not previously screened and subjects with no known contacts but belonging to a 'TB risk group'.

Dietary habits and geographic variation in stomach cancer mortality in Spain.

Following examination of the geographical pattern of stomach cancer incidence in Spain, the possible relationship between diet and stomach cancer has been assessed using an ecological model which looks into the relationship between the consumption of different foods and the nutrient intake in each of the 50 Spanish provinces during the period 1964-65, and the mortality rate for stomach cancer in these same 50 provinces during a period 20 years later (1984-86). The geographical pattern of stomach cancer mortality has been arrived at using the standardized mortality ratios (SMRs) calculated for each province. The per capita consumption of foods was obtained from the National Institute for Statistics and the calculation of nutrient intake was based on tables of nutritional composition. The results have been obtained using the statistical techniques of linear and Poisson regression. Stomach cancer mortality in Spain exhibits a stable and well-defined pattern, with less risk being apparent in the Mediterranean coastal provinces. The variability in the geographical distribution of stomach cancer mortality can, in large part (76%), be explained by the variation in the types of foods consumed between provinces, and this figure rises to 82% when one considers other socio-economic variables. A significant inverse association has been found between gastric cancer mortality and consumption of vegetables, fruits and vegetable oil as well as with vegetative growth and population density. From the multiple regression analysis, which considered both nutritional and socio-economic variables, the strongest inverse association with stomach cancer mortality was found in the consumption of green vegetables. The estimated relative risk (RR) of dying, for an increase in consumption of vegetables of 100 g per capita per day is 0.72, (95% CI: 0.53-0.91). These results are consistent with those of similar studies elsewhere.

The effectiveness of health systems in influencing avoidable mortality: a study in Valencia, Spain, 1975-90.

OBJECTIVES: To measure variations in the Holland and Charlton classifications of avoidable death causes and to estimate the effect of the Spanish national health system on avoidable mortality. DESIGN: Mortality in the Valencian Community was assessed between 1975 and 1990. The classifications of Holland and Charlton, used to assess avoidable causes of death, were compared. Holland's classification was then used to divide avoidable mortality into two groups--medical care indicators (MCI), which show the effectiveness of health care, and national health policy indicators (NHPI), which show the status of primary prevention. Comparisons were made with rates, group rates, and population rates. Trends and indices were also studied. SETTING: Valencia, Spain, 1975-90. RESULTS: During the study period, avoidable morality (only assessed by MCI) fell 63%, whereas the remainder of the mortality (non-MCI causes, that is all the non-avoidable causes together with the NHPI group) fell by 17%. If it is assumed that the mortality due to non-MCI causes indicates the overall effect of the environmental, social, nutritional, and genetic influences, then the difference between this and the MCI group would take us nearer the actual effect of the intervention of the health system. CONCLUSIONS: It is concluded that in this community, the health system has been responsible for approximately 47% of the total reduction in mortality from avoidable causes in the period studied.

[Latex allergy]. / Allergia al lattice.

In 1979 the first case of contact urticaria to rubber gloves was reported in a patient with a positive skin prick test to latex. The use of articles containing rubber is widespread and this can explain the increasing frequency of allergic reactions to natural rubber latex. The symptoms may be localized like contact urticaria or systemic like angioedema, generalized urticaria or anaphylactic shock. In this study we have considered 12 patients who presented clinical manifestations after direct contact with objects containing rubber. Three patients had eczema and pruritus after the use of household gloves, 4 subjects had lips and tongue oedema following the contact with rubber tube during a dental treatment, 5 patients suffered from urticaria and pruritus during the use of surgical gloves. Generalized angioedema was also present in 4 out of 12 patients. All the patients had positive Skin prick test and Rast to latex. Three out of 12 patients were atopic. Our study confirms the increasing frequency of immediate hypersensitivity reactions to latex. This phenomenon must be taken into account especially before surgery, since severe clinical manifestations such as anaphylactic shock may occur.