Safety and efficacy of trastuzumab emtansine (TDM-1) in a patient on hemodialysis for renal failure.

HER2-positive metastatic breast cancer is an aggressive disease with a limited number of treatment options. In the last 15 years, new drugs such as trastuzumab, pertuzumab, lapatinib or trastuzumab emtansine (TDM-1) have sprouted for these patients. There is a huge lack of evidence on the use of some of these drugs in patients with chronic renal failure, who need hemodialysis. We have reviewed the use of TDM-1 in these type of patients in the literature with unsuccessful results. In this article we want to present a case report to illustrate the safety and efficacy of TDM-1 in a patient on hemodialysis.

Uniparental disomy of chromosome 21: A statistical approach and application in paternity tests.

Considering the overall frequency of paternity investigation cases including mutational events, there is a real possibility that at least a fraction of all inconsistencies reported in paternity cases are caused not by polymerase slippage mutations, but to chromosomic abnormalities, as Uniparental Disomy (UPD). We report here the investigation of a trio paternity case (mother, child and alleged father), with observed inconsistencies that can alternatively be explained by occurrence of maternal uniparental isodisomy of chromosome 21 (miUPD21). A total of 350 short tandem repeat (STR) and single nucleotide polymorphism (SNP) markers were tested, statistically suggesting true biological linkage within the trio. Additionally, we propose miUPD21 explains, with significantly greater probability, the occurrence of detected inconsistencies, when compared to alternative hypothesis of multiple and simultaneous slippage mutations. Similar cases could have their statistical conclusions improved or even altered by including unusual chromosomal segregation patterns in the hypothesis formulation, as well as in mathematical calculations. Such reports of allelic inconsistencies being explained by chromosomal alterations are common in clinical genetics, and such situations might have impact on forensic investigation.

Multimodality imaging features of desmoid tumors: a head-to-toe spectrum.

Desmoid tumors (DTs) are a rare and biologically heterogeneous group of locally aggressive fibroblastic neoplasm: their biological behavior spectrum ranges from indolent to aggressive tumors. DTs are classified as intra-abdominal, extra-abdominal, and within the abdominal wall lesions.It is well known that abdominal and extra-abdominal DTs are associated with familial adenomatous polyposis (FAP) and Gardner syndrome. Possible risk factors are prior trauma/surgery, pregnancy, and oral contraceptives.There was a real revolution in the management of DT: from aggressive first-line approach (surgery and radiation therapy) to a more conservative one (systemic treatment and "wait-and-see policy").In these clinical settings, radiologists play an important role for assessing lesion resectability, evaluating recurrence, monitoring the biological behavior if an expectant management is chosen, and assessing response to systemic treatment as well as to radiation therapy.Awareness of common locations, risk factors, and imaging features is fundamental for a correct diagnosis and an adequate patient management.

SEOM Clinical guidelines for the treatment of advanced colorectal cancer 2013

Colorectal cancer (CRC) is the most common malignant tumor in Western countries. Despite efforts made to implement screening programmes for early detection and treatment, still half of the patients present or will eventually develop distant metastasis. Management of advanced CRC should be discussed within an experienced multidisciplinary team, to adequately select the most appropriate systemic therapeutic option, as well as the optimal way to integrate it with surgical procedures when indicated. Disease localization and extent, resectability of primary and metastatic disease, tumor biology and dynamics, clinical symptoms, personal preferences and patient's ability to tolerate intensive chemotherapy or extensive surgical procedures are the key factors to properly design a customized treatment plan. The aim of the current manuscript is to provide synthetic practical guidelines regarding therapeutic options for advanced CRC (AU)

SEOM clinical guidelines for the treatment of advanced colorectal cancer 2013.

Colorectal cancer (CRC) is the most common malignant tumor in Western countries. Despite efforts made to implement screening programmes for early detection and treatment, still half of the patients present or will eventually develop distant metastasis. Management of advanced CRC should be discussed within an experienced multidisciplinary team, to adequately select the most appropriate systemic therapeutic option, as well as the optimal way to integrate it with surgical procedures when indicated. Disease localization and extent, resectability of primary and metastatic disease, tumor biology and dynamics, clinical symptoms, personal preferences and patient's ability to tolerate intensive chemotherapy or extensive surgical procedures are the key factors to properly design a customized treatment plan. The aim of the current manuscript is to provide synthetic practical guidelines regarding therapeutic options for advanced CRC.

Primary systemic amyloidosis and high levels of Angiotensin-converting enzyme: two case reports.

Infiltrative heart diseases are caused by a heterogeneous group of disorders; amyloidosis and sarcoidosis are two frequent causes of myocardial infiltration, which differ in clinical and biological outcome and treatment issues. The presence of high levels of angiotensin-converting enzyme (ACE) in a patient with infiltrative heart disease may increase suspicion of sarcoidosis. Nevertheless, no mention about increased ACE levels in extracerebral primary systemic amyloidosis is available. We present two cases of primary systemic amyloidosis, which are cardiac involvement and elevated ACE levels.

Microwave assisted liver resection: clinical feasibility study and preliminary results.

AIM: The main goal of liver resection for malignant tumors is nowadays represented by properly parenchymal transection and careful control of hemostasis. Applying the concept of precoagulation of liver transection line we developed a new technique that provides the pre coagulation of the resection line using microwaves technologies. The purpose of this study is to evaluate the feasibility of this new liver transection technique demonstrating the high performance of this procedure, the accuracy in terms of squeeze effect on veins and portal branch and in terms of reducing the intra operative blood loss. METHODS: From December 2010 to January 2012 a total of ten patients (6 men and 4 women) affected by liver metastatic disease from colon rectal cancer and primitive liver cancer were treated (five patients with metastatic colorectal cancer disease and five patient with hepatocellular carcinoma respectively): patients requiring major liver resection were excluded from the present study focusing attention on minor liver resection. RESULTS: The technique used for the parenchyma transection is similar to those previously described by our group for hepatic radiofrequency assisted liver resection. There was no need for vascular occlusive clamping while during each surgical procedure the underpass of the hepatic hilum was done for safety control of any kind of hepatic bleeding. There was no need for ties and clips excluding the main vascular an bile pedicles that were sutured between ties. CONCLUSION: In conclusion this study with a small group of patients suggest surgical advantages in terms of statement for best practice in oncologic resection of liver malignancy. It allows a complete resection obtaining a negative pathologic margin, no blood loss and need for blood transfusions factors predicting post operative morbidity and survival, and consistently reducing time of procedure and avoidance of parenchymal ischemia. Further studies should confirm this preliminary data extending surgical indication to major hepatic resection.

Unidades de gestión clínica en rehabilitación: gestión por planes y procesos / Clinical management units in rehabilitation: management by plans and procedures

ntroducción. Desde el año 2001, y promovido por la Consejera de Salud de Andalucía, se pone en marcha el abordaje integral de los problemas de salud mediante la implantación de los procesos asistenciales integrados (PAI) y los planes integrales. El objetivo de nuestro trabajo es analizar el papel del médico especialista en medicina física y rehabilitación (MFR) en los mismos. Material y métodos. Se han analizados los 61 PAI y los 7 planes integrales recogidos en la página web del Servicio Andaluz de Salud, dentro del apartado Gestión y Calidad (www.juntadeandalucia.es/servicioandaluzdesalud). Resultados. Las actuaciones del médico rehabilitador están contempladas en 13 de los 61 PAI, siendo colaborador activo en la elaboración de dicho proceso en la mayoría de ellos. Cabría destacar que mientras los PAI son líneas de acción y mejora en salud que dependen únicamente de la Consejería de Salud, los planes integrales son generados por la misma Consejería con carácter intersectorial. Conclusión. Los planes integrales y los PAI constituyen una línea estratégica fundamental de política sanitaria de nuestra comunidad, abiertos a modificaciones para mejorar su calidad. Una de las formas de hacerlos operativos es a través de las unidades de gestión. La nuestra ha permitido la mejora del PAI de ataque cerebrovascular y la dirección del Plan de Atención a la Accidentabilidad en Andalucía (AU)

Introduction. Since 2001, and sponsored by the Health Care Council of Andalusia, the integral approach to the health programs has been established through the establishment of the Integral Care Process and Integral Plans. The purpose of our work is to analyze the role of the medical specialist in Physical Medicine and Rehabilitation (PM&R) in them. Material and methods. The 61 PM&Rs and the 7 Integral Plans included on the web page of the Andalusian Public Health Service, within the Management and Quality section (www.juntadeandalucia.es/servicioandaluzdesalud) have been analyzed. Results. The actions of the rehabilitation physicians are contemplated in 13 of the 61 PM&Rs, in which they are active collaborators in the elaboration of the process in most of them. It could be stated that while the PM&Rs are lines of action and improvement in health that depend only on the Health Care Council, the Integral Plans are generated by the Council with an intersectorial character. Conclusion. The Integral Plans and PM&Rs constitute a fundamental strategical line of public health care policy in our community open to modifications to improve their quality. One of the ways of observing them is through the Management Unit. Ours has permitted the improvement of the PM&Rs of cerbrovascular accident and the direction of the Care Plan to Accidentability in Andalusia (AU)

La sesión clínica basada en evidencias: proceso de evaluación y mejora / Evidence Based Medicine clinical session: a process of evaluation and improvement

Introducción y objetivo. Ya desde finales de los años noventa nuestro Servicio se interesa por la medicina basada en evidencias (MBE), que promueve la búsqueda y valoración crítica de la literatura médica para la resolución de dudas en el ámbito profesional. De esta forma, comenzamos a aplicar la MBE en las sesiones clínicas del Servicio, siguiendo el formato de los Critically Appraised Topic (CAT). Se realiza un análisis crítico de esta metodología, valorando las mejoras introducidas y las que están todavía pendientes. Material y métodos. Análisis descriptivo retrospectivo de las sesiones realizadas en formato tipo CAT desde el 24 de junio de 2003 hasta el 13 de febrero de 2007. Los datos recogidos fueron: tema de la sesión, tipo de análisis realizado (tratamiento, etiología, diagnóstico y pronóstico), aporte de pruebas complementarias, definición de la pregunta clínica, bases de datos utilizadas, artículos analizados y respuesta concluyente o no. Resultados. Se analizaron 83 sesiones clínicas. El tema más frecuente fue la patología musculoesquelética. Setenta y tres sesiones investigaron una medida terapéutica y 30 aportaron pruebas complementarias; la base de datos más utilizada fue Medline y los artículos más frecuentemente analizados fueron ensayos clínicos aleatorizados, con nivel de evidencia A, y la respuesta fue concluyente en 35 sesiones. Discusión. Se analiza la implantación de la sesión tipo CAT basada en la evidencia, detectando los errores y las mejoras aplicadas para aumentar su calidad. Seguimos proponiéndonos nuevos retos, como la aplicación del programa de lectura crítica CASPe (Critically Appraisal Skills Programme) y el uso de número necesario a tratar como instrumento de medida epidemiológica, todo ello en el proceso de evaluación y continua mejora de la sesión clínica tipo CAT

Introduction. By the end of the 1990¿s, the Rehabilitation Service in our hospital was already interested in Evidence Based Medicine (EBM), which promotes the search and critical evaluation of medical information for the solving of doubts in the professional setting. In this way, we began to apply EBM in the clinical sessions of the Service, using the Critically Appraised Topic format (CAT). A critical analysis of this methodology is made, evaluating the improvements introduced and those which are still pending. Material and methods. This article provides a descriptive and retrospective analysis of the clinical sessions in the Rehabilitation Service between 24/06/2003 to 13/02/2007. We analyze the subject of the session, type of analysis made (treatment, etiology, diagnosis, prognosis), if there were complementary tests, definition of the clinical question, what database were consulted, the kind of articles analyzed, and if the answer to the question was conclusive. Results. We analyzed 83 clinical sessions. The most treated subject was skeletal muscle pathology. A total of 73 sessions provided information on one kind of treatment, 30 sessions provided complementary diagnostic tests. The most consulted database was Medline. The articles analyzed most frequently were randomized clinical trials with evidence level A and the answer was conclusive in 35 sessions. Discussion. This article analyzes the introduction of the Critically Appraised Topic format in the clinical session in our service, detecting some mistakes and their solutions which have increased the quality of the clinical session. We continue to propose new challenges, such as the application of CASPe tools (Critically Appraisal Skills Programme) and the number needed to treat as an epidemiologic index, all of this within the clinical session improvement process

¿Realmente infiltramos con toxina botulínica el músculo tibial posterior? / Do we really infiltrate the posterior tibial muscle with botulinum toxin?

Objetivo. Valorar la probabilidad de infiltrar el músculo tibial posterior (TP) mediante una punción "ciega" (guiados exclusivamente por referencias anatómicas) usando dos agujas de diferentes longitudes, 40 y 50 mm respectivamente, introducidas en toda su longitud. Material y método. Estudio prospectivo observacional de 27 pacientes con pie equinovaro espástico, a los que se aplica toxina botulínica tipo A (TB-A) en el músculo TP. La localización del punto de punción se realiza según referencias anatómicas y la localización de la aguja se comprueba mediante electroestimulación. Se realiza una medición de la profundidad a la cual se detecta el músculo TP y la distancia a la cual se deja de detectar, estableciéndose un intervalo teórico en el cual se localizaría el músculo TP. Resultados. En el 100 % de los pacientes de la muestra fue posible localizar el músculo TP mediante electroestimulación. En la punción "ciega", con agujas de 40 mm de longitud, la probabilidad que tenemos de inyectar la TB-A en el músculo TP es del 18,52 %; con agujas de 50 mm de longitud la probabilidad asciende a un 48,15 %. Discusión. La electroestimulación es una técnica sencilla y segura para localizar el músculo TP. La punción "a ciegas" presenta una probabilidad de error tan elevada que se desaconseja la infiltración de este músculo si no se dispone de una técnica complementaria que la guíe. Parte de los fracasos en el tratamiento del pie equinovaro con TB-A podría deberse a esta carencia técnica, y no a la ineficacia del fármaco

Objective. To evaluate the accuracy of intramuscular injection in the posterior tibial (PT) with two different length needles, 40 mm and 50 mm, using the manual technique following anatomic references. Material and methods. An observational, prospective study of 27 patients with spastic equinovarus foot who received botulinum toxin type A (BT-A) in PT. The injection site was measured by anatomical references and the needle location was checked by electrical stimulation. The depth in mm in which the PT was detected and the distance at which PT was not longer detected was measured, establishing a theoretical interval at which the PT would be located. Results. It was possible to locate the PT with electrical stimulation in 100 % of the patients. Using "free hand" or manual technique, the likelihood of injecting the PT was 18.52 % with a 40 mm length needle and 48.15 % with a 50 mm length needle. Discussion. Electrical stimulation is a simple and safe technique to locate the PT. The "free hand" or manual technique produces an elevated rate of errors. Thus, it is not advisable to infiltrate this muscle is the correct technique to find it is not available. Most of the failures in the treatment of spastic equinovarus foot with BT-A could be due to the use of an incorrect technique more than to drug inefficacy

[Related factors with the failed surgery of herniated lumbar disc]. / Factores relacionados con la cirugía fallida de hernia discal lumbar

INTRODUCTION: The surgery for herniated disc is the most common operation at the level of the lumbar spine. The failed surgery rates range between 10% and 40%, conforming what is known as Failed Back Surgery Syndrome (FBSS). Return to work after surgery occurs in 70-85% of the cases. There are a few studies analysing the quality of life after the operation. The aims of this study are to know the incidence of the herniated disc lumbar failed surgery in our area, identify those factors influencing its development, and study behavioural parameters as the return to work and the quality of life at a middle term after surgery, also its relation with the success or failure surgery. MATERIAL AND METHODS: A descriptive transversal study of 117 patients operated for herniated lumbar disc during the first six months of the year 2003 is reported. In order to evaluate the incidence of failed surgery and the related factors, the clinical records were retrospectively analyzed. Ninety one patients were interviewed by phone using the Health Questionnaire SF-36, in order to analyze the non clinical factors related to FBSS, such as labour reincorporation, satisfaction with surgery, realization of rehabilitation treatment and quality of life after surgery. For the statistical analysis of the results, we used the program SPSS 11.01. RESULTS: In a sample in which the proportion between both sexes was 1/1, and the middle age was over 45 years [35-54], in which the most frequent clinical symptom was right sciatica, lasting more than 6 months, correlated to disc herniation at L5-S1 level, 37.9% of the patients presented FBSS. Although there were a few patients with reoperation in our study, the incidence of FBSS in these patients was higher (52.9%) than in patients who suffered this surgery for first time (32%). The predictive clinical factors of an unfavourable result in patients operated on for first time were bilateral sciatica, the presence of stenosis associated to herniated disc and comorbidity factors. On the other hand the sociolabor factors identified were a low culture level and those working as drivers, building and service sectors. Return to work occurred in the 64% of the active workers before surgery. Only around 10% of patients were dissatisfied with surgical result and there was a significant relationship between this and the physical function, pain, vitality and emotional status in the SF-36 with the FBSS. CONCLUSIONS: One out of three patients operated of herniated lumbar disc in our area presented failed disc surgery and the return to work occurred in 2 out of three patients active before the operation. The failed surgery patient suffers from pain, that interferes and limits the labour and home activities. Furthermore, the patient presents frequent sensation of fatigue and exhaustion and also emotional problems that contribute to interfere with work and activities of the daily life.

Factores relacionados con la cirugía fallida de hernia discal lumbar / Related factors with the failed surgery of herniated lumbar disc

Introducción. La cirugía descompresiva de herniadiscal es la intervención quirúrgica más frecuente a nivel de la columna lumbar. La cirugía fallida oscila entre un 10 y un 40% de los casos, constituyendo el denominado Síndrome de la Cirugía Raquídea Fracasada (SCRF). La reincorporación laboral a medio plazo tras la cirugía se sitúa en torno al 70-85%, y existen pocos estudios que analicen la calidad de vida tras la intervención. Los objetivos de este estudio son conocerla incidencia de cirugía fallida de hernia discal lumbar en nuestro medio, identificando aquellos factores que puedan influir en su aparición; y estudiar factores ambientales como la reincorporación laboral y la calidad de vida a medio plazo tras esta cirugía, así como su relación con el éxito o fracaso quirúrgico. Material y métodos. Estudio descriptivo transversal de 117 pacientes intervenidos de hernia discal lumbar durante el primer semestre del 2003 en nuestro hospital. Para valorar la incidencia de cirugía fallida y factores relacionados se han recogido datos clínicos de la Historia Clínica de los pacientes de la muestra. Y, asimismo, se ha entrevistado telefónicamente a 91 de ellos -los que contestaron- para valorar factores no clínicos relacionados con el SCRF, tales como reincorporación laboral, satisfacción con la cirugía, realización de tratamiento rehabilitador y calidad de vida a través del Cuestionario de Salud SF-36. Para el análisis de resultados se ha empleado el programa estadístico SPSS 11.01. Resultados. En una muestra en la que la proporción ente ambos sexos es de 1/1 y la edad media de 45 [35-54]años, con una clínica más frecuente de ciática derecha, de más de 6 meses de evolución, correlacionada con el hallazgo radiológico de hernia L5-S1, un 37,9% ha presentado el SCRF. Aunque es escaso el número de pacientes que en nuestra serie afrontan una reintervención, se ha observado en ellos una incidencia del SCRF notablemente superior (52,2%) a los que se someten a una primera cirugía (32%). Los factores clínicos predictivos de resultados desfavorables en pacientes sometidos a primera cirugía han sido la clínica precirugía de ciática bilateral, el hallazgo de estenosis de canal asociada a hernia discal y la comorbilidad; mientras que los sociolaborales han sido pacientes sin estudios y aquellos que trabajan en los sectores de la conducción, construcción y hostelería. La reincorporación laboral se produjo en el 64 % de los trabajadores activos previamente. Sólo entorno al 10% se encuentran insatisfechos con la opción quirúrgica, relacionándose significativamente tanto estocomo las dimensiones de función física, dolor, vitalidad y rol emocional en el SF-36 con el SCRF. Conclusiones. Uno de cada 3 pacientes intervenidos de hernia discal lumbar en nuestro medio presenta cirugía fallida, reincorporándose laboralmente 2 de cada 3pacientes previamente activos. El paciente con cirugía fallida se encuentra afectado por dolor, hasta el punto de repercutir y limitar las actividades del hogar y las laborales. Además presenta frecuentemente sensación de cansancio o agotamiento, y problemas emocionales que interfieren tanto en las actividades de la vida diaria como en el trabajo

Introduction. The surgery for herniated disc is the most common operation at the level of the lumbar spine. The failed surgery rates range between 10% and 40%, conforming what is known as Failed Back Surgery Syndrome (FBSS). Return to work after surgery occurs in 70-85% of the cases. There are a few studies analysing the quality of life after the operation. The aims of this study are to know the incidence of the herniated disc lumbar failed surgery in our area, identify those factors influencing its development, and study behavioural parameters as the return to work and the quality of life at a middle term after surgery, also its relation with the success or failure surgery. Material and methods. A descriptive transversal study of 117 patients operated for herniated lumbar disc during the first six months of the year 2003 is reported. In order to evaluate the incidence of failed surgery and the related factors, the clinical records were retrospectively analyzed. Ninety one patients were interviewed by phone using the Health Questionnaire SF-36, in order to analyze the non clinical factors related to FBSS, such as labour reincorporation, satisfaction with surgery, realization of rehabilitation treatment and quality of life after surgery. For the statistical analysis of the results, we used the program SPSS 11.01. Results. In a sample in which the proportion between both sexes was 1/1, and the middle age was over 45 years [35-54], in which the most frequent clinical symptom was right sciatica, lasting more than 6 months, correlated to disc herniation at L5-S1 level, 37'9% of the patients presented FBSS. Although there were a few patients with reoperation in our study, the incidence of FBSS in these patients was higher (52,9%) than in patients who suffered this surgery for first time (32%). The predictive clinical factors of an unfavourable result in patients operated on for first time were bilateral sciatica, the presence of stenosis associated to herniated disc and comorbidity factors. On the other hand the socio-labor factors identified were a low culture level and those working as drivers, building and service sectors. Return to work occurred in the 64% of the active workers before surgery. Only around 10% of patients were dissatisfied with surgical result and there was a significant relationship between this and the physical function, pain, vitality and emotional status in the SF-36 with the FBSS. Conclusions. One out of three patients operated of herniated lumbar disc in our area presented failed disc surgery and the return to work occurred in 2 out of three patients active before the operation. The failed surgery patient suffers from pain, that interferes and limits the labor and home activities. Furthermore, the patient presents frequent sensation of fatigue and exhaustion and also emotional problems that contribute to interfere with work and activities of the daily life (AU)

Marcha y patrón podobarográfico en niños con pies zambos congénitos / Gait and podobarographic pattern in children with congenital clubfeet

Introducción. El objetivo del trabajo es conocer las alteraciones que presentan durante la bipedestación y la marcha los niños con pies zambos congénitos. Pacientes y métodos. Estudio prospectivo de casos y controles. Criterios de inclusión: niños con pie zambo congénito, en seguimiento regular, entre 3 y 14 años. Criterios de exclusión: pie zambo sindrómico, patología que altere la marcha, deseo de no participar. Estudio baropodográfico y análisis del paso en 44 niños divididos en dos grupos: pie zambo bilateral y pie zambo unilateral. En los niños con pie zambo unilateral se comparan los valores con los del pie sano contralateral. En los pacientes con pie zambo bilateral se comparan con un grupo control. Los parámetros se expresan en percentiles y la comparación estadística se hace con las pruebas no paramétricas de la U de Wilcoxon y la U de Mann-Whitney con una p < 0,05. Resultados. En el grupo unilateral encontramos diferencias en la estabilometría, la repartición de carga y la duración del paso. En los bilaterales las encontramos en la superficie plantar, las presiones máximas estáticas, la duración del paso y las presiones máximas dinámicas. Conclusiones. Los unilaterales presentan mayor carga sobre el pie sano y mayor área de oscilación de la carga sobre el zambo, lo cual dificulta el control postural. El aumento del tiempo de paso se relaciona con alteraciones en los momentos angulares y de fuerza del miembro. La marcha se afecta más en los casos bilaterales, lo que puede conducir a un mayor consumo energético

Introduction. The objective of this study is to know the alterations presented during orthostatism and walking in children with congenital clubfeet. Patients and methods. Prospective study of cases and controls. Inclusion criteria: children with congenital club foot, in regular follow-up, between 3 and 14 years of age. Exclusion criteria. syndromic clubfoot, pathology that alters walking, desire to not participate. Baropodographic study and analysis of gait in 44 children divided into two groups: bilateral clubfoot and unilateral clubfoot. In the children with unilateral clubfoot, the values are compared with the healthy contralateral foot. In patients with bilateral clubfoot, they are compared with a control group. Parameters are expressed in percentages and statistical comparison made with the non-parametric tests of Wilcoxon U and Mann-Whitney U test with a p < 0.05. Results. In the unilateral group, we found differences in the stabilometry, load distribution and step duration. In the bilateral group, we found them in the plantar surface, maximum static pressures, step duration and maximum dynamic pressures. Conclusions. The unilateral group had greater load on the healthy foot and greater area of oscillation of the load on the clubfoot, which made postural control difficult. The increased step time is related with alterations in the angular moments and limb force. Gait is more affected in the bilateral cases, which may lead to greater energy consumption

La sesión clínica basada en la evidencia. Temas valorados críticamente / Evidence based clinical session. Critically evaluated subjects

La medicina basada en la evidencia (MBE) se ha convertido en una herramienta útil para poder hacer frente a la numerosa literatura científica orientada a la resolución de problemas clínicos concretos. Son muchos los cursos orientados a la formación en MBE, pero su aplicación práctica es escasa. En nuestro Servicio hemos iniciado el proyecto de aplicación de la sistemática de la MBE a la realización de las sesiones clínicas. Presentamos el formato de la sesión clínica basado en los temas valorados críticamente (critical appraisal topics, CAT) que actualmente se emplea en nuestro Servicio. También aportamos recomendaciones para la realización de las sesiones y un ejemplo práctico. Es importante valorar este proyecto no sólo como una forma de trabajar, sino también como una oportunidad de aprendizaje (AU)

Valoración funcional y calidad de vida en pacientes intervenidos de un tumor óseo primario / Functional outcome and quality of life in patients after surgical treatment of a primary bone tumor

Fundamento. Valorar la funcionalidad y calidad de vida relacionada con la salud (CVRS) a largo plazo, en pacientes intervenidos de un tumor óseo primario y posibles factores que pudieran predecir un mejor resultado tanto funcional como de CVRS. Pacientes y métodos. Estudio transversal descriptivo de 57 pacientes que realizaron tratamiento rehabilitador entre los años 1990 y 2001, tras ser intervenidos quirúrgicamente como parte del tratamiento de un tumor óseo primario. Se utilizó la escala de Enneking para valorar los resultados funcionales y la Medical Outcomes Study Survey Form 36 (SF-36) para valorar la CVRS. Resultados. El 53 por ciento han alcanzado un buen o excelente resultado funcional. Estos resultados funcionales presentan una correlación inversa con la edad actual (p = 0,018) y la edad al diagnóstico (p = 0,049), de forma que a menor edad, mejor resultado. También se ha encontrado esa correlación inversa con 5 de las 8 dimensiones del SF-36. La afectación izquierda presenta mejores resultados que la afectación derecha en la puntuación de Enneking, el 66,6 frente al 53,3 (p = 0,046), y en las dimensiones del SF-36 de función física y limitaciones del rol por problemas físicos. Los pacientes que requirieron una reintervención por alguna complicación presentaron peores resultados funcionales y de calidad de vida. Conclusiones. En nuestro estudio, el 53 por ciento de los pacientes alcanzaron un buen o excelente resultado funcional. Los factores que se relacionaron con una mejor calidad de vida y/o resultado funcional fueron la menor edad al diagnóstico, afectación del lado izquierdo, aquellos pacientes a los que se les practicó cirugía reconstructiva y no requirieron reintervención (AU)