Ultrasound functional evaluation of fetuses with myelomeningocele: study of the interpretation of results.

OBJECTIVE: To assess the reliability of the interpretation of a new technique for the ultrasound evaluation of the level of neurological lesion in fetuses with myelomeningocele. METHODS: Observational study including myelomeningocele fetuses, referred to our center for the sonographic assessment of the fetal lower-limb movements, made and recorded by an expert in Maternal-fetal medicine and a specialist in Rehabilitation. Two observers, with different levels of expertise and blinded to each other's results, interpreted each recorded scan two different times. The agreement for the segmental levels assigned between the observers and the gold standard, the inter-observer and intra-observer reproducibility were tested using the weighed Kappa (wκ) index. RESULTS: Twenty-eight scans were recorded and evaluated. The agreement between the observers and the gold standard remained constant for the expert observer (wκ = 0.82) and increased (wκ = 0.66-wκ = 0.72) for the other one. The inter-observer and the intra-observer variability for the expert observer were wκ = 0.72 and wκ = 0.94, respectively. DISCUSSION: The agreement for the prenatal evaluation of the segmental neurological level was excellent, after a short training period, for observers with different degrees of expertise. The interpretation of this technique is reproducible enough and this supports its value for the prediction of postnatal motor function in myelomeningocele fetuses.

Prenatal ultrasound evaluation of segmental level of neurological lesion in fetuses with myelomeningocele: development of a new technique.

OBJECTIVES: To report our preliminary experience in the use of prenatal ultrasound examination to assess lower-limb movements in fetuses with myelomeningocele. We aimed to determine the accuracy of this method to establish the segmental level of neurological lesion, as this is the best known predictor of the future ability to walk. METHODS: This was a preliminary, observational study including fetuses with myelomeningocele operated on prenatally. The patterns of movements present and absent in the affected fetuses' lower limbs were evaluated systematically by ultrasound examination. According to the known nerve function associated with each muscle group, the segmental level of neurological lesion was established before birth. The agreement for the segmental levels assigned, between the prenatal ultrasound technique and the classical neurological clinical examination after birth (gold standard), was tested using the weighed kappa (wκ) index. RESULTS: Seventy-one fetuses with myelomeningocele were evaluated at the Hospital Universitari Vall d'Hebron. After counseling, the parents opted for prenatal surgery (26 cases), termination of pregnancy (43 cases) or postnatal repair (two cases). Five patients did not fulfil the inclusion criteria for prenatal surgery and three were excluded after birth. In the 18 fetuses that underwent surgery and were analyzed, the agreement between prenatal and postnatal segmental levels assigned was 91.7% for the right limb (wκ = 0.80) and 88.9% for the left limb (wκ = 0.73). CONCLUSIONS: The agreement found between prenatal and postnatal assignment of level of lesion in this preliminary study suggests that neurological sonographic evaluation is feasible before birth. This may provide accurate individualized information about the motor function and future ambulation prognosis of fetuses with myelomeningocele.

La difusión de estudios de coste-efectividad sobre actuaciones médicas en medios generales de comunicación debería realizarse con cautela / The diffusion of cost-effective studies on medical actions in the general media of communication should be done with caution

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Exposure to medicines among patients admitted for hip fracture and the case-fatality rate at 1 year: a longitudinal study.

PURPOSE: To describe the demographic and clinical characteristics and the pre-fracture exposure to medicines of patients admitted for a hip fracture, and to explore their association with fatal outcome 1 year after the fracture. METHODS: All patients ≥ 65 years old admitted for a hip fracture in a tertiary hospital in Barcelona between January 1 and December 31 2007 were included. Data on the patients' clinical characteristics before and during hospital admission and on pre-fracture exposures to medicines were collected from the clinical records. One-year mortality was checked by approaching the patients and their families and was cross-checked with the national mortality statistics database. A Cox proportional hazards analysis was carried out. RESULTS: Four hundred and fifty-six patients [mean age (SD) 82.9 (7.2) years, 73.5 % female], were admitted with hip fracture during the study period. Almost 80 % of the patients (363, 79.6 %) had three or more associated conditions, and 41.7 % received pre-fracture treatment with five or more drugs. The case-fatality rate during hospital admission was 4.6 % (21 patients). One hundred and seven patients died within 1 year (23.5 %). Advanced age, male gender, two or more associated chronic conditions, cancer, severe cognitive impairment, and treatment with opiates before fracture were significantly associated with the risk of dying. An inverse association was recorded between mortality and pre-hospital exposure to medicines for osteoporosis. CONCLUSIONS: One-quarter of patients admitted for hip fracture died within 1 year after the fracture. Exposure to opiates before hip fracture was associated with an increased 1-year death rate, whereas treatment with drugs for osteoporosis was associated with a decrease in death rate. These results should be confirmed in studies with detailed prospective collection of information on exposure to medicines.

Roturas tendinosas bilaterales del aparato extensor de la rodilla: serie de casos / Bilateral tendon tears of the extensor mechanism of the knee: a series of cases

Las roturas bilaterales del aparato extensor de la rodilla son infrecuentes y se asocian clásicamente a enfermedades sistémicas. Estas lesiones pueden ser óseas, de patela o tuberosidad tibial anterior, musculares o tendinosas. Las más comunes de todas son las fracturas de rótula, seguidas de roturas del tendón cuadricipital o rotuliano. Las roturas bilaterales tanto del tendón rotuliano como cuadricipital, al ser infrecuentes, pueden ser infradiagnosticadas retrasando el tratamiento quirúrgico y la posterior rehabilitación; suelen ser traumáticas. En la literatura existen publicaciones sobre algunos casos de roturas tendinosas bilateral del aparato extensor de la rodilla asociadas a enfermedades sistémicas como isuficiencia renal, diabetes mellitus o artritis reumatoide o al uso prolongado de quinolonas o corticoides. En este trabajo describimos 4 casos clínicos de roturas tendinosas bilaterales del aparato extensor, sin y con enfermedades sistémicas asociadas (AU)

Bilateral injuries of the knee extensor mechanism are uncommon and are generally related to systemic diseases. Such injuries may be muscle tears, bone fractures (patella and tibial tubercle) and tendinous disruptures. Patella fractures are described as being the most common of these, followed by injuries of the quadriceps and patellar tendons. As bilateral disruption of either patellar and/or quadricipital tendons is uncommon, it may be underdiagnosed, thus delaying the surgical treatment and subsequent rehabilitation. They are generally traumatic. There are publications in the literature on some cases of bilateral tendinous disruptions of the knee extensor complex associated to systemic diseases such as renal failure, diabetes mellitus or rheumatoid arthritis or the continued use of steroids or fluoroquinolones. We report four cases of bilateral knee tendon disruption in patients with and without systemic disease (AU)

Artroplastia de cadera / Hip arthroplasty

La artroplastia total de cadera (ATC) es una intervención coste-efectiva para disminuir el dolor, mejorar la función y la calidad de vida de los pacientes con patología degenerativa o inflamatoria de la cadera. La mayoría de sistemas disponibles actualmente son modulares y la fijación de los componentes protésicos al hueso puede conseguirse mediante dos técnicas: la cementación y la osteointegración. Tanto los vástagos cementados como los no cementados pueden ser considerados el patrón oro para la supervivencia a largo plazo; sin embargo, las técnicas no cementadas son hoy en día el método preferido para la mayoría de reemplazos acetabulares. Actualmente la superficie de carga con par de fricción metal-polietileno entrelazado es la más utilizada. La mayoría de complicaciones después de una ATC son infrecuentes, y pueden ser prevenidas y tratadas fácilmente. El objetivo inmediato de la rehabilitación en la fase aguda se centra en reducir el dolor, mejorar la movilidad, restaurar la función e identificar y prevenir las complicaciones postoperatorias inmediatas. Las guías clínicas para los pacientes intervenidos de una prótesis de cadera, y más específicamente los protocolos de ejercicios terapéuticos, varían dependiendo de las instituciones u hospitales y del ámbito de actuación. Una adecuada valoración de los resultados de la artroplastia requiere el uso de instrumentos genéricos de medición de la calidad de vida, siendo el más utilizado el Medical Outcomes Study-Short Form 36, y de instrumentos específicos que sean lo suficientemente sensibles para detectar los cambios clínicos de interés, como la escala de cadera de Harris (Harris Hip Score). Los resultados publicados demuestran una mejoría excelente tanto clínica, como funcional y radiográfica después de la ATC y aproximadamente el 90 % de las ATC tienen éxito, en términos de no dolor ni complicaciones a los 10-15 años de la cirugía

Total hip arthroplasty (THA) is a cost-effective intervention to decrease pain, improve function and quality of life of the patients with degenerative or inflammatory disease of the hip. Most of the currently available systems are modular and fixation of the prosthetic components to the bone may be achieved with two techniques: cementation and osteointegration. Both the cemented stems and non-cemented ones may be considered the gold standard for long term survival. However, the non-cemented techniques are presently the preferred method for most of cetabular replacements. Currently friction of metal on polyethylene bearing surface is used most. Most of the complications after a THA are uncommon and may be easily prevented and treated. The immediate objective of rehabilitation in the acute phase is focused on reducing pain, improving mobility, restoring function and identifying and preventing immediately postoperative complications. Clinical guidelines for the patients operated on for a hip prosthesis and more specifically the therapeutic exercise protocols, vary according to the institutions or hospitals and action setting. An adequate assessment of the results of the arthroplasty requires the use of generic instruments of measurement of quality of life. That used most is the Medical Outcomes Study-Short Form 36. It is also necessary to use specific instruments that are sufficiently sensitive to detect clinical changes of interest, such as the Harris Hip Score. The results published show excellent clinical, functional and radiological improvement after the THA. Approximately 90 % of the THAs are successful in terms of no pain or complications at 10 to 15 years of the surgery (AU)

Sow porcine circovirus type 2 (PCV2) status effect on litter mortality in postweaning multisystemic wasting syndrome (PMWS).

Previous studies have described a "litter effect" associated with mortality in postweaning multisystemic wasting syndrome (PMWS) affected farms. The main objective of this study was to evaluate litter mortality in different PMWS affected farms and to characterize it in relation to three variables of the sow: parity, porcine circovirus type 2 (PCV2) infectious status and PCV2 antibody titres. The study was performed in seven farms that experienced PMWS in nurseries and/or fattening areas. Fifteen sows from each farm were randomly selected from the same farrowing batch. Serum samples were analyzed for antibodies to PCV2 and for genomic detection of PCV2. Four piglets from each sow (60 piglets per farm) were selected and ear-tagged at birth. Out of 420 initial piglets, 104 (25%) died. Sixty three of them (60%) were necropsied, and 40 (63%) diagnosed as PMWS based on case definition criteria. Our results show that sow PCV2 viremia was significantly related to piglet mortality since more piglets per litter died from viremic than from non-viremic sows. Additionally, a significantly greater proportion of animals died from sows that had low antibody titres against PCV2 (39% vs. 18% from sows with medium to high antibody titres). The present study, of exploratory nature, confirms previous results and further characterizes the so called "litter effect" by establishing that the sow PCV2 status had a significant effect on litter mortality in PMWS affected farms.

Artroplastia de cadera / Hip arthroplasty

La artroplastia total de cadera (ATC) es una intervención coste-efectiva para disminuir el dolor, mejorar la función y la calidad de vida de los pacientes con patología degenerativa o inflamatoria de la cadera. La mayoría de sistemas disponibles actualmente son modulares y la fijación de los componentes protésicos al hueso puede conseguirse mediante dos técnicas: la cementación y la osteointegración. Tanto los vástagos cementados como los no cementados pueden ser considerados el patrón oro para la supervivencia a largo plazo; sin embargo, las técnicas no cementadas son hoy en día el método preferido para la mayoría de reemplazos acetabulares. Actualmente la superficie de carga con par de fricción metal-polietileno entrelazado es la más utilizada. La mayoría de complicaciones después de una ATC son infrecuentes, y pueden ser prevenidas y tratadas fácilmente. El objetivo inmediato de la rehabilitación en la fase aguda se centra en reducir el dolor, mejorar la movilidad, restaurarla función e identificar y prevenir las complicaciones postoperatorias inmediatas. Las guías clínicas para los pacientes intervenidos de una prótesis de cadera, y más específicamente los protocolos de ejercicios terapéuticos, varían dependiendo de las instituciones u hospitales y del ámbito de actuación. Una adecuada valoración de los resultados de la artroplastia requiere el uso de instrumentos genéricos de medición dela calidad de vida, siendo el más utilizado el Medical Outcomes Study-Short Form 36, y de instrumentos específicos quesean lo suficientemente sensibles para detectar los cambios clínicos de interés, como la escala de cadera de Harris (Harris Hip Score).Los resultados publicados demuestran una mejoría excelente tanto clínica, como funcional y radiográfica después dela ATC y aproximadamente el 90 % de las ATC tienen éxito, en términos de no dolor ni complicaciones a los 10-15 años de la cirugía (AU)

Total hip arthroplasty (THA) is a cost-effective intervention to decrease pain, improve function and quality of life of the patients with degenerative or inflammatory disease of the hip. Most of the currently available systems are modular and fixation of the prosthetic components to the bone may beachieved with two techniques: cementation and osteointegration. Both the cemented stems and non-cemented ones may be considered the gold standard for long term survival. However, the non-cemented techniques are presently the preferred method for most of cetabular replacements. Currently friction of metal on polyethylene bearing surface is used most. Most of the complications after a THA are uncommon and may be easily prevented and treated. The immediate objective of rehabilitation in the acute phase is focused on reducing pain, improving mobility, restoring function and identifying and preventing immediately postoperative complications. Clinical guidelines for the patients operated on for a hip prosthesis and more specifically the therapeutic exercise protocols, vary according to the institutions or hospitals and action setting. An adequate assessment of the results of the arthroplasty requires the use of generic instruments of measurement of quality of life. That used most is the Medical Outcomes Study-Short Form 36. It is also necessary to use specific instruments that are sufficiently sensitive to detect clinical changes of interest, such as the Harris Hip Score. The results published show excellent clinical, functional and radiological improvement after the THA. Approximately 90 % of the THAs are successful in terms of no pain or complications at 10 to 15 years of the surgery (AU)

Prótesis total de rodilla estándar. Análisis de supervivencia del implante a los 5 años / Standard total knee replacement. Analysis of 5-year implant survival rates

El objetivo de este estudio es realizar un análisis de supervivencia del implante en las artroplastias totales de rodilla estándar a los 5 años de la intervención, así como el estudio de los factores relacionados con dicha supervivencia. Pacientes y métodos. Se ha realizado un estudio prospectivo que incluye 271 pacientes que fueron intervenidos de prótesis total de rodilla estándar en el período comprendido entre 1988 y 1993 y posteriormente trasladados al servicio de Rehabilitación. Para la recogida de datos utilizamos el cuestionario modificado de la British Orthopaedic Association. Para el análisis de supervivencia hemos utilizado la función de Kaplan-Meier y consideramos como evento o acontecimiento final para la supervivencia la retirada de la prótesis. Resultados. El porcentaje de supervivencia de esta serie a los 5 años es del 94,98 por ciento. Los factores asociados significativamente con la supervivencia a los 5 años han sido: valgo al alta hospitalaria (p < 0,001), luxación de rótula (p < 0,001; supervivencia 70,59 por ciento), infección (p < 0,001; supervivencia 28,57 por ciento), descementación (p < 0,001; supervivencia 50 por ciento), inestabilidad (p < 0,001; supervivencia 25 por ciento) y dolor de etiología desconocida (p < 0,001; supervivencia 92 por ciento). Los resultados funcionales y de impresión subjetiva a los 5 años han sido excelentes o buenos en el 72,2 por ciento de los casos. Conclusiones. En esta serie los resultados de las prótesis totales de rodilla estándar a los 5 años de la cirugía son predecibles, constatándose una alta supervivencia del implante y unos resultados funcionales y de impresión subjetiva excelentes o buenos en la gran mayoría de los casos (AU)

Prótesis total de rodilla. Estudio de los factores determinantes del alta hospitalaria en rehabilitación / Total knee prosthesis. Study of the determining factors of hospital discharge in rehabilitation

Introducción: El objetivo de este estudio es analizar qué factores son determinantes del alta hospitalaria en la rehabilitación de los pacientes intervenidos de prótesis total de rodilla. Pacientes y métodos: Se ha realizado un estudio prospectivo que incluye 162 pacientes que fueron intervenidos consecutivamente de prótesis total de rodilla en el período de tiempo comprendido entre junio de 1999 y junio de 2000 y posteriormente trasladados al Servicio de Rehabilitación para realizar tratamiento médico rehabilitador en régimen de hospitalización. Para la recogida de datos utilizamos el cuestionario modificado de la British Orthopaedic Association. Se ha realizado un análisis de regresión lineal múltiple, para estudiar qué variables están asociadas con la estancia hospitalaria en rehabilitación (variable dependiente), ajustando por el efecto de las demás. Resultados: En el análisis bivariable han sido factores asociados con una menor estancia hospitalaria en rehabilitación: la edad avanzada (p<0,05), el índice de masa corporal elevado (p<0,0002), la no presencia de complicaciones quirúrgicas (p<0,01), el mayor balance articular en flexión a la semana del postoperatorio (p<0,004) y la menor media de días de movilización pasiva continua (p<0,02); pero en el análisis multivariable, los dos únicos factores determinantes del alta hospitalaria con correlación inversa, son la edad (p<0,001; IC 95 por ciento 1,86-2,06) y el balance articular en flexión a la semana del postoperatorio (p<0,01; IC 95 por ciento 1,92-1,99).Conclusiones: La edad y el balance articular en flexión a la primera semana son las dos únicas variables determinantes del alta hospitalaria (AU)

Prótesis total de rodilla. Valoración funcional y satisfacción personal del paciente a los cinco años / Total knee prosthesis. Funcrional assessment and personal satisfaction of the patient at five years

Objetivo: El objetivo de este estudio ha sido determinar el nivel funcional de los pacientes intervenidos de prótesis total de rodilla en nuestro medio a los cinco años de dicha intervención, valorando individualmente el dolor, la marcha, las actividades de la vida diaria y la satisfacción personal. Asimismo hemos intentado identificar las variables responsables o asociadas a una satisfacción personal mala o regular. Pacientes y métodos: Se ha realizado un estudio prospectivo que incluye 311 pacientes que fueron intervenidos de prótesis total de rodilla entre 1988 y 1993. Posteriormente fueron trasladados al Servicio de Rehabilitación para realizar tratamiento médico rehabilitador en régimen de hospitalización. Para la recogida de datos utilizamos el cuestionario modificado de la British Orthopaedic Association. La encuesta de valoración funcional y de satisfacción personal se realizó a los cinco años de la cirugía. Se ha realizado un análisis de regresión logística múltiple para identificar las variables responsables o asociadas a una satisfacción personal mala o regular. Resultados: La mayoría de pacientes portadores de la prótesis a los cinco años presentaron un buen resultado en cuanto a balance articular [extensión media -2,6º (ñ5,9) y flexión media 97,89º (ñ17)], dolor inexistente o ligero (88,5 por ciento), y perímetro de marcha de al menos un kilómetro (73,57 por ciento). La satisfacción personal fue excelente o buena en el 75,4 por ciento del total de pacientes. En el análisis multivariable sólo el dolor (OR=8,16; IC 95 por ciento=3,59-18,5) y las ayudas para la marcha (OR=2,52; IC 95 por ciento=1,41-4,49) son factores determinantes de tener una satisfacción personal regular o mala en los pacientes portadores de la prótesis a los cinco años (AU)

Increased intracranial pressure in myelomeningocele (MMC) patients never shunted: results of a prospective preliminary study.

STUDY DESIGN: In some young adults non-shunted myelomeningocele (MMC) patients without symptoms or with unspecific clinical findings, moderate or severe stabilised ventriculomegaly are observed in control CT scans. Physicians are then faced with the so-called 'Arrested Hydrocephalus' (AH) syndrome. The present study is part of a prospective protocol in which patients with hydrocephalus associated with MMC and long-term clinical diagnosis of AH were included. OBJECTIVES: To evaluate myelomeningocele patients never shunted with clinical and/or CT scan criteria compatible with AH. SETTING: Multidisciplinary Spina Bifida Unit in a tertiary university hospital in Barcelona, Spain. METHODS: Fourteen MMC patients were selected, in all of them, continuous intracranial pressure (ICP) monitoring was performed. Analysis of the ICP records was done using the method described by Borgesen in mmHg. All patients were also studied by intelligence quotient (IQ) testing before and after shunting. RESULTS: The CT in all the study cases showed an Evans ratio

Prótesis total de rodilla. Evolución del tratamiento rehabilitador intrahospitalario durante el decenio 1988-1998 / Total knee prosthesis. evolution of the intra-hospital rehabilitation treatment during the decade of 1988-1998

Objetivo: Realizar un análisis descriptivo de la evolución del tratamiento rehabilitador intrahospitalario tras la artroplastia de sustitución de rodilla en nuestra sección durante el último decenio.Pacientes y métodos: Se ha realizado un estudio descriptivo que incluye 1.050 pacientes intervenidos de prótesis total de rodilla por el Servicio de Cirugía Ortopédica y Traumatología de nuestro hospital en el período comprendido entre 1988 y 1998. Posteriormente fueron trasladados al Servicio de Rehabilitación para realizar tratamiento rehabilitador en régimen de hospitalización.Resultados: La media de edad de los pacientes ha ido aumentando de 66,5 a 69,7 años, manteniéndose en el tiempo un mayor porcentaje de mujeres intervenidas, con un elevado índice medio de masa corporal. El 94,9 por ciento de los pacientes han sido intervenidos por presentar gonartrosis.La estancia hospitalaria ha ido disminuyendo durante este decenio desde una media de 42,5 (ñ16,3) días en el hospital y 26,9 (ñ13,4) días en rehabilitación, hasta una media de 20,9 (ñ8,5) días en el hospital y de 16,5 (ñ4,9) días en rehabilitación. El diseño de las prótesis se ha ido modificando y en la actualidad se utilizan con mayor frecuencia la estabilizada posterior cementada con recambio patelar.En el programa de tratamiento rehabilitador, se ha universalizado el uso del sistema de movilización pasiva continua de la rodilla como coadyuvante de la fisioterapia. El balance articular medio en flexión al alta hospitalaria se mantiene sobre 92º, el de extensión sobre -6º y el eje mecánico de alineación del miembro se mantiene en valores normales. El balance muscular medio al alta hospitalaria es de tres. Finalmente el 75 por ciento de los pacientes no presenta ninguna complicación médica ni quirúrgica en el postoperatorio inmediato (AU)

Cognitive changes after cerebrospinal fluid shunting in young adults with spina bifida and assumed arrested hydrocephalus.

OBJECTIVES: To establish whether surgery can improve the neuropsychological functioning of young adult patients with spina bifida and apparent clinically arrested hydrocephalus showing abnormal intracranial pressure. METHODS: Twenty three young adults with spina bifida and assumed arrested hydrocephalus (diagnosed as active or compensated by continuous intracranial pressure monitoring) underwent surgery. All patients received neuropsychological examination before surgery and 6 months later. Neuropsychological assessment included tests of verbal and visual memory, visuospatial functions, speed of mental processing, and frontal lobe functions. RESULTS: Shunt placement in this subgroup of patients improves neuropsychological functioning, especially in verbal and visual memory and attention and cognitive flexibility. CONCLUSIONS: Young adults with spina bifida and suspected non-functioning shunt or non-shunted ventriculomegaly should be carefully monitored to identify those who could benefit from shunting.

Evaluación de dos técnicas de rehabilitación tras la prótesis total de rodilla / Evaluation of two rehabilitation techniques after total knee prosthesis

Objetivo: Comparar dos técnicas de rehabilitación tras la artroplastia total de rodilla: movilización pasiva continua (MPC) más un programa estándar de fisioterapia frente al programa estándar de fisioterapia únicamente. Pacientes y métodos: Se ha realizado un estudio retrospectivo de 242 pacientes intervenidos de prótesis total de rodilla primaria en el período comprendido entre 1988 y 1998. Todos fueron trasladados al Servicio de Rehabilitación en las primeras 24-48 horas postoperatorias para realizar tratamiento médico rehabilitador en régimen de hospitalización. Para la recogida de datos utilizamos el cuestionario modificado de la British Orthopaedic Association. El análisis estadístico se ha realizado mediante las pruebas de la Ji al cuadrado, t de Student o U de Mann-Whitney. Resultados: No hay diferencias significativas entre los dos grupos en cuanto a la duración del tiempo de hospitalización. A la semana de la intervención los pacientes del grupo de MPC presentan una mejor, y estadísticamente significativa, flexión de rodilla (p<0,001), pero esta diferencia desaparece al alta hospitalaria y a los seis meses. No existen diferencias entre los dos grupos estudiados en relación con la pérdida hemática, el número de complicaciones médicas o quirúrgicas y el número de pacientes que presentaron rigidez de rodilla (AU)

Neurological abnormalities, major orthopaedic deformities and ambulation analysis in a myelomeningocele population in Catalonia (Spain).

UNLABELLED: The aim of the study was to analyze the present status of neurologic abnormalities, major orthopaedic deformities and ambulatory status in a large myelomeningocele population. PATIENTS AND METHODS: Cross-sectional study based on the clinical and radiographic records of 322 patients treated and followed-up from 1967-1995. The setting was a multidisciplinary spina bifida unit within a third-level university hospital, which serves as the referral centre for these patients in Catalonia (Spain). We collected information on diagnosis, central nervous system, musculoskeletal system (spinal and hip deformities) and functional level in each patient. To study relationships among the variables, the Mann-Whitney U and the Chi-squared tests were applied. Results were considered to be statistically significant at P levels of < or = 0.05. RESULTS: Mean age was 15.9 years. 78.1% of patients had mid-lumbar, low-lumbar or sacral neurological levels; 97.5% had hydrocephalus and 68.8% were shunted. Prevalence of spine deformities was 45.3%; 38.8% had dislocation of one or both hips. Median age of walking onset was 37.1 months and 74.8% of patients were ambulatory. Median age at which ambulation ceased was 128 months (10 years and 8 months). The bivariate analysis showed statistically significant relationships between neurological level and all the variables studied (P<0.001, P<0.02) except body mass indexes and intelligence quotient. CONCLUSIONS: Neurological level was the main factor that determined neurological abnormalities, major orthopaedic deformities and ambulatory status.

[Factors associated with mortality and gait impairment in elderly patients with hip fractures]. / Fracturas de cadera en el anciano determinantes de mortalidad y capacidad de marcha.

BACKGROUND: Hip fractures are a major source of mortality and morbidity among the elderly. The aim of the present study is to try to identify predictors of death and of non-deambulation during the period of acute treatment. PATIENTS AND METHODS: Consecutive prospective study of 459 patients older than 65 years admitted to our hospital with acute proximal femoral fractures with 12 months follow-up. RESULTS: The mean length of hospital stay was 26.6 days, it exists a highly percentage of non-ambulatory patients at discharge from hospital (44.3%), a low percentage of mortality in the immediate postoperative period (6.1%) and a larger percentage of mortality at 6 months (26.15%). Factors associated with risk of death at hospital are male sex (OR = 2.38; 95% CI = 1.04-5.47), deteriorated mental status (OR = 2.62; 95% CI = 1.01-6.76) and no previous personal independence (OR = 3.16; 95% CI = 1.19-8.38). Age over 80 years (OR = 2.27; 95% CI = 1.43-3.60), deteriorated mental status (OR = 7.90; 95% CI = 3.83-16.3), no walking ability before fracture (OR = 3.72; 95% CI = 2.33-5.91) and type of fracture (OR = 1.84; 95% CI = 1.15-2.95) are shown as the determinants of gait capacity. CONCLUSIONS: Mortality in the immediate postoperative period is associated with sex, dementia and previous personal independence. The hospital stay is extended and functional recovery at discharge is low, therefore, new programs for these patients should be considered.

Relationship between ANCA and clinical activity in inflammatory bowel disease: variation in prevalence of ANCA and evidence of heterogeneity.

Antineutrophil cytoplasmic antibodes (ANCA) are markers of necrotizing vasculitis. ANCA have been recently detected in the two forms of inflammatory bowel disease (IBD), ulcerative colitis (UC) and Crohn's disease (CD). To assess the possible role of ANCA in the diagnosis and management of IBD we studied the prevalence of ANCA at diagnosis and during follow-up in a group of 89 IBD patients. The relationship between ANCA and clinical features of IBD was investigated. ANCA assayed by indirect immunofluorescence were detected in 38/52 (73%) of the UC patients but only 6/37 (16.6%) of the CD patients (P<0.005) and in none of the controls. In the UC group, but not in the CD group, there was a positive correlation between ANCA and disease activity. The sensitivity and specificity of ANCA for the diagnosis of UC were 73 and 83.7% respectively. The most commonly observed pattern of ANCA in IBD patients was perinuclear: in 84% of the UC and 66.6% of the CD patients positive for ANCA, respectively. However, careful comparison of IFL patterns revealed some distinct features of IBD-associated ANCA when compared to vasculitis-associated ANCA. In addition, most ANCA positive sera from IBD patients were negative for antibodies to proteinase 3 and myeloperoxidase by ELISA. These results suggest that the autoantigens recognized by ANCA are different in patients with IBD from those with necrotising vasculitis.

Platelet count and the risk of bleeding in hospitalized patients with venous thromboembolism starting anticoagulant therapy.

In a series of patients with pulmonary embolism (PE) we have previously demonstrated that the risk of recurrent PE was inversely correlated to platelet count (PlC) levels. To find out whether PlC levels were also associated to a different incidence of heparin-related bleeding complications, we report our experience with 1,103 consecutive patients with venous thromboembolism (VTE) receiving full-dose heparin therapy. Six points of clinical and laboratory information were recorded on admission and then compared to the development of bleeding: the patient's age and sex; the etiology of VTE; the type of heparin used (unfractioned, UFH, vs. low-molecular-weight, LMWH), the presence or lack of PE findings on lung scan, and the PC levels on admission. Bleeding occurred in 64/1,103 patients (6%). Patients who bled were significantly older than those who did not (72 +/- 11 vs. 64 +/- 17 years; p = 0.0005). There were no significant differences in bleeding rate according to any of the risk factors that could have predisposed to VTE, but patients treated with UFH bled significantly more frequently than those on LMWH (48/636 vs. 16/467; odds ratio: 2.30; 95% confidence interval: 1.25-4.28). Finally, mean PlC levels were significantly lower at VTE diagnosis in patients who subsequently bled (227 +/- 112 vs. 262 +/- 110 x 10(9) liters-1; p = 0.01). The logistic regression analysis confirmed that all three variables were independent risk factors for bleeding complications. This is the first study to demonstrate that PlC levels (within the normal range) are inversely correlated with the risk of heparin-related bleeding. These findings may be interest not only from the point of view of pathogenesis but also clinically, as they may be used in the decision as to which VTE patients could receive heparin therapy at home.

[Diagnostic approach to neoplasms at an internal medicine service]. / Análisis de la conducta diagnóstica de las neoplasias en un servicio de medicina interna.

BACKGROUND: The aim of this study was to investigate the diagnostic behavior of different members of a department of internal medicine towards some neoplasms, analyzing the study times, reasons for suspicion and the number of tests performed and their results. PATIENTS AND METHODS: A retrospective review of the clinical histories of the patients admitted from January 1, 1992 to June 30, 1994 whose diagnosis was a new neoplasm of the digestive tract, lung cancer, cancer of unknown origin or lymphoma was carried out. The total diagnostic study time and the different partial times were measured and confirmed. The causes leading to suspicion of the neoplasms were also analyzed by groups, and finally the efficacy of the different diagnostic tests; either non invasive, oriented at the decision of the definitive test, or invasive (biopsies and fine needle aspiration puncture). RESULTS: The median total study time was 13 days with no differences between the groups. The median time until clinical suspicion was 0 days (interquartile range 0-2), being significantly greater in the digestive neoplasms. Less than half of the total study time corresponded to the clinical work itself (5 vs. 8 days). Suspicion of neoplasms in 49% of the cases arose from radiographic alteration and in 30% from clinical alterations. With regards to diagnostic tests, the value of thorax X-ray as the first exploration, mainly in the lung neoplasms (82.5% of the radiographies showed alterations), the elevated efficacy of computerized tomography, among the non invasive tests and fine needle aspiration puncture among the invasive tests were of note. Definitive diagnosis was achieved in 62% of the cases by biopsy and in 31% by fine needle aspiration puncture. CONCLUSIONS: Not all the time spent in achieving diagnosis of neoplasms is attributable to clinical work, although this may be shortened. To do so, a faster and more adequate use of the tests of greater performance (thorax X-ray, computerized tomography and fine needle aspiration puncture) should be used and performed with greater coordination and cooperation among the clinical technicians and physicians of the different departments.