[Coordination of general and specialized medicine. Evaluation in the Burgos area]. / Coordinación medicina general-especializada. Evaluación en el área de Burgos.

OBJECTIVE: To evaluate the coordination between General and Specialist Medicine, its development and the causes of breakdowns. DESIGN: Descriptive at two periods. SETTING: Burgos Health Area. PARTICIPANTS: All the consultation request reaching Specialist Care (SC) in January 1993 and January 1995 from all the Primary Care Centres running the Mostrador programme (23); random sample of these requests in order to evaluate the proportion of return six months after the requests and to study the data found in the interconsultation notes (ICN) returned to Primary Care (PC). MAIN RESULTS: The percentage of requests without and appointment being made was similar. 1.21% (1993) and 1.30% (1995); the most common cause was error/lack of data. The percentage of ICN returned to PC 6 months after the requests was also similar: 24.10% (1993) and 22.03% (1995). The most frequent reason for the failure in the circuit was that the specialist "retained" the ICNs. CONCLUSIONS: General Medical and Specialist coordination was similar in the two periods evaluated. It was adequate for the appointment-making process, but there were break-downs in communication between doctors using the ICN. The most important reasons for these failures were identified.

Cystic craniopharyngioma treated by 90yttrium silicate colloid.

UNLABELLED: Fourteen children and 3 adults with cystic craniopharyngiomas were treated with intracavitary 90Y, by the procedure described by Backlund. Their ages ranged from 2 to 65 years and postoperative follow-up ranged from 6 to 40 months. Leksell's stereotactic technique was employed to determine coordinates by CAT. Cyst volume was quantified both geometrically and isotopically with 99Tc, values differing by 7%. Dosimetry was determined by applying the formula developed by Loevinger et al., and 20,000 rads were administered throughout to the cystic wall. All 17 patients, except for 4 children, had previously received surgery, shunts or radiotherapy, alone or combined. In 4 cases, 90Y injection was the only treatment, while in 6, the cyst was evacuated at 10 days following radiocolloid injection. Skull and spinal column gamma chamber studies were carried out on all patients at 24, 48, and 72 hours post injection, but no isotope leakage could be detected. The patients returned to normal activities except one with multiple cysts who died. There were no changes in the endocrinologic profile. In one case, a decrease in visual acuity 18 months after treatment, improved following corticoid administration. CONCLUSIONS: Though preliminary, these results are encouraging since it seems that the severe neuro-endocrinologic sequelae of open surgery may be avoided.

Bacterial adhesion to cerebrospinal fluid shunts.

Bacterial adherence to cerebrospinal fluid (CSF) shunts was analyzed in vivo and in vitro. Scanning electron micrographs (SEM's) of catheters removed from pediatric patients with shunts infected by Staphylococcus aureus or Klebsiella pneumoniae revealed numerous bacterial cells and microcolonies, leukocytes, and erythrocytes attached to the CSF catheters' inner walls, as well as the existence of surface irregularities, such as fissures, rugosities, and holes. Permeability analyses and SEM's demonstrated that catheters develop physical alterations over the period of implantation. Different bacterial strains presented a different in vitro adherence to CSF shunts, suggesting that this attachment may be affected by specific properties of the outer structures of each strain. The attachment of microbial pathogens to CSF shunts seems to contribute to the persistence of bacterial cells within a catheter and the onset of recurrent shunt infection. This study demonstrated that some bacteria can remain attached within shunts in vitro despite a CSF flow at rates up to 200 times higher than those normally demonstrated in vivo. Furthermore, surface irregularities found throughout this study may help to anchor and hide bacterial microcolonies. Based on these findings, it seems advisable to remove an infected shunt and to replace it with a new one after proper antimicrobial therapy, in order to prevent recurrent infections.

Microscopic studies in shunts for hydrocephalus.

Valve-regulated systems, used for the treatment of hydrocephalus, were studied with the scanning electron microscope. The study was performed on unused systems of shunt replaced after different pathologies and on systems removed due to cerebrospinal fluid infection. Defects in the material, such as holes and protrusions, were systematically found in new systems. Aged shunts (1--8 years of implantation) as well as those removed in cases of cerebrospinal fluid infections showed important changes in the structure of the material too; it was also found that biological material, such as fibrin, red blood cells and bacteria, were able to adhere to the walls of the catheter tubing. These results indicate that the scanning electron microscope could be a complementary tool to be used in research, diagnosis, and quality control of silicone rubber prosthesis.

Surgical treatment of hydatid cysts of the central nervous system in the pediatric age (Dowling's technique).

Single hydatid cysts of the brain are rarely seen by pediatric neurosurgeons who do not reside in certain countries, i.e. Australia, Uruguay, and Argentina. It is, however, of considerable importance that every pediatric neurosurgeon be aware of the manner of diagnosis of this condition and surgical management of these patients. Out of 35 cases of hydatidosis of the CNS and its covering observed over a 42-year period, there were 29 hydatid cysts of the brain and one of the spinal cord. Emphasis is placed on the former. Surgically, the hydatid cyst can be removed intact. The essential steps of the technique are: (1) a large flap; (2) careful handing during all the operative steps avoiding monopolar coagulation; (3) opening of the atrophic cortex overlying the cyst over an area whose diameter should be no less than three quarters of the diameter of the cyst, and (4) letting the cyst come out by just lowering the head of the operating table and instillating warm saline between the cyst and surrounding brain. In this series of hydatid cysts of the CNS, there was no operative mortality. The 20 cases in which the cyst was removed unbroken with Dowling's technique are alive and only two have sequelae of the preoperative lesion (blind). In the 11 cases in which Dowling's technique was not used and the cyst broke during ventriculography (3) or surgery (7, one broke spontaneously), only 7 are alive and well and there were 4 late deaths.