[Neurorehabilitation, a highly complex process]. / La neurorrehabilitación, un proceso de alta complejidad.

TITLE: La neurorrehabilitación, un proceso de alta complejidad.

[Non-invasive brain and spinal cord stimulation for motor and functional recovery after a spinal cord injury]. / Estimulación no invasiva cerebral y medular para la recuperación motora y funcional tras una lesión medular.

INTRODUCTION: Spinal cord injury is a traumatic or non-traumatic event that causes an alteration of sensory, motor or autonomic functioning and ultimately affects the physical, psychological and social well-being of the person who suffers it. A comprehensive approach to spinal cord injury requires many health resources and can place a considerable financial burden on patients, their families and the community. AIM: To review the literature published to date on the use of non-invasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and transcutaneous non-invasive spinal cord stimulation (tcSCS), as therapeutic strategies to improve the functionality of patients with spinal cord injury. The studies were grouped as addressing either non-invasive brain stimulation or non-invasive spinal cord stimulation. DEVELOPMENT: Altogether 32 studies were identified: 21 involving brain stimulation (14 in rTMS and 7 in tDCS) and 11 with spinal cord stimulation (tcSCS). All the studies were conducted in adult patients who had undergone a spinal cord injury. Despite significant variability in treatment protocols, patient characteristics and clinical assessment, the changes observed were reported in almost all the studies without producing any side effects and with motor or functional improvement. CONCLUSION: Non-invasive brain stimulation, as well as spinal cord stimulation, are promising techniques for the rehabilitation of patients with spinal cord injury due to their novelty, effectiveness and minimal side effects.

TITLE: Estimulación no invasiva cerebral y medular para la recuperación motora y funcional tras una lesión medular.Introducción. La lesión medular es un evento traumático o no traumático que causa una alteración de la función sensorial, motora o autonómica y, en última instancia, afecta a las características físicas, psicológicas y el bienestar social de la persona que lo sufre. El abordaje integral de la lesión medular requiere muchos recursos de salud y puede representar una considerable carga financiera para los pacientes, sus familias y la comunidad. Objetivo. Revisar la bibliografía publicada sobre el uso de la estimulación cerebral no invasiva, incluida la estimulación magnética transcraneal repetitiva (EMTr), la estimulación de corriente continua directa transcraneal (tDCS), así como la estimulación medular no invasiva transcutánea (tcSCS), como estrategias terapéuticas para mejorar la funcionalidad de los pacientes con lesión medular. Los estudios se agruparon bien como de estimulación no invasiva cerebral, bien como de estimulación medular no invasiva. Desarrollo. Se identificaron 32 estudios: 21 de estimulación cerebral (14 en EMTr y 7 en tDCS) y 11 de estimulación medular (tcSCS). Todos los estudios se realizaron en pacientes adultos que sufrieron una lesión medular. A pesar de la variabilidad significativa en los protocolos de tratamiento, las características de los pacientes y la evaluación clínica, los cambios observados se describieron en casi todos los estudios sin producir efectos secundarios con mejoría motora o funcional. Conclusión. La estimulación cerebral no invasiva, así como la estimulación medular, son técnicas prometedoras para la rehabilitación de pacientes con lesión medular debido a su novedad, su efectividad y mínimos efectos secundarios.

[Spinal cord injury due to suicide attempt, psychiatric profile and functional disability]. / Lesion medular por intento de suicidio, perfil psiquiatrico y discapacidad funcional.

INTRODUCTION: Studies published in other countries indicate that 1.6-3% of spinal cord injuries are acquired due to suicide attempt, the majority being produced by precipitation in patients with previous psychiatric disorders. AIMS: To determine the frequency of attempted suicide as a cause of spinal cord injuries in a neurorehabilitation hospital and to describe the characteristics of these patients in psychiatric terms and functional disability. PATIENTS AND METHODS: Retrospective study in which all patients with spinal cord injuries due to suicide attempt in a period of 15 years in a neurorehabilitation hospital were reviewed. RESULTS: Suicide attempt caused 2% (n = 61) of spinal cord injuries in our population. Although 93% of the patients were diagnosed with psychiatric pathology, 60% were linked to mental health facilities and only three consulted for emergency the days before the precipitation. Six attempts were made in the context of psychiatric services and 26% of patients had made previous attempts. The most frequent medical diagnosis was paraplegia associated with fractures in the lower extremities and chest trauma. CONCLUSIONS: Precipitation due to suicide attempt causes 2% of spinal cord injuries, with depression and psychotic disorders being the most prevalent psychiatric disorders. After the rehabilitation period, this population requires special attention from the mental health teams since they combine risk factors to commit suicide such as the history of previous attempts and the presence of a chronic disabling condition.

TITLE: Lesion medular por intento de suicidio, perfil psiquiatrico y discapacidad funcional.Introduccion. Estudios realizados en otros paises señalan que el 1,6-3% de las lesiones medulares se adquieren por intento de autolisis, y la mayoria se producen por precipitacion. Objetivos. Determinar la frecuencia de intento de suicidio como causa de lesion medular en un hospital de neurorrehabilitacion y describir las caracteristicas de estos pacientes en terminos psiquiatricos y de discapacidad funcional. Pacientes y metodos. Estudio retrospectivo en el que se revisaron todos los pacientes con lesion medular por intento de autolisis en un periodo de 15 años en un hospital de neurorrehabilitacion. Resultados. El intento de autolisis ocasiono el 2% de las lesiones medulares en la muestra (n = 61). El 93% de los pacientes estaba diagnosticado de patologia psiquiatrica y el 26% habia realizado tentativas previas. Aunque el 60% estaba vinculado a salud mental, solo tres consultaron por urgencias dias antes de la precipitacion y seis realizaron la tentativa en el contexto de servicios psiquiatricos. El diagnostico mas frecuente fue la paraplejia asociada a fracturas en las extremidades inferiores y traumatismos toracicos. Conclusiones. La precipitacion por intento de autolisis provoca el 2% de las lesiones medulares, y la depresion y los trastornos psicoticos son las patologias psiquiatricas previas mas prevalentes. Tras el periodo de rehabilitacion, esta poblacion requiere especial atencion por parte de los equipos de salud mental, ya que combina factores de riesgo para cometer suicidio, como la historia de tentativas previas, y la presencia de una condicion cronica discapacitante.

[Transcranial direct current stimulation for the treatment of fibromyalgia: a systematic review]. / Estimulacion transcraneal por corriente directa en la fibromialgia: revision sistematica.

INTRODUCTION: Fibromyalgia is a multisymptomatic diffuse chronic musculoskeletal pain syndrome with evidence of central nervous system dysfunction. Accordingly, non-invasive brain stimulation techniques such as transcranial direct current stimulation (tDCS) may be a complementary therapeutic resource to reduce pain perception. AIMS: To review the potential effectiveness of tDCS to reduce pain in fibromyalgia, to identify the most effective neurostimulation parameters and to delimit its safety. PATIENTS AND METHODS: Systematic review of prospective studies reported in PubMed and Cochrane reviews. RESULTS: The anodal tDCS of the left primary motor cortex, at 2mA for 20 minutes with 35 cm2 electrodes on five consecutive days, provides better results in reducing pain (14-59%), and improving sleep quality, with greater accentuation on the fifth day. The clinical improvement persists up to a minimum of 60 days (11-20% reduction of pain). Adverse effects are well tolerated and few. CONCLUSIONS: The experience with tDCS in fibromyalgia is still limited. However, the anodal tDCS in the left primary motor cortex can be recommended with level B (probable therapeutic efficacy) and appears to act through the modification of the sensorial processing of the pain of thalamic inhibitory circuitry.

TITLE: Estimulacion transcraneal por corriente directa en la fibromialgia: revision sistematica.Introduccion. La fibromialgia es un sindrome de dolor cronico difuso musculoesqueletico multisintomatico, con evidencias de una disfuncion del sistema nervioso central. Consecuentemente, tecnicas de estimulacion cerebral no invasiva, como la estimulacion transcraneal con corriente directa (tDCS), pueden ser un recurso terapeutico complementario para reducir la percepcion de dolor. Objetivos. Revisar la potencial efectividad de la tDCS para reducir el dolor en la fibromialgia, identificar los parametros mas efectivos de neuroestimulacion y delimitar su seguridad. Pacientes y metodos. Revision sistematica de estudios prospectivos registrados en PubMed y revisiones Cochrane. Resultados. La tDCS anodica de la corteza motora primaria izquierda, a 2 mA durante 20 minutos con electrodos de 35 cm2 durante cinco dias consecutivos, es la que proporciona mejores resultados en la reduccion del dolor (14-59%) y mejora de la calidad del sueño, con mayor acentuacion en el quinto dia. La mejora clinica persiste hasta un minimo de 60 dias (11-20% de reduccion del dolor). Se tolera bien y tiene escasos efectos adversos. Conclusiones. La experiencia con la tDCS en fibromialgia es todavia limitada. No obstante, la tDCS anodica en la corteza motora primaria izquierda puede recomendarse con un nivel B (probable eficacia terapeutica) y podria actuar mediante la modificacion del procesamiento sensorial del dolor de circuitos inhibitorios talamicos.

Actualización de la Guía para el diagnóstico no invasivo de la insuficiencia venosa (II). Documento de consenso del capítulo de diagnóstico vascular de la Sociedad Española de Angiología y Cirugía Vascular / Update of the guidelines for the non-invasive diagnosis of venous insufficiency (II). Consensus document of the vascular diagnosis chapter of the Sociedad Española de Angiología y Cirugía Vascular

A pesar de que muchos estudios han pretendido cuantificar la insuficiencia venosa, tanto con eco-doppler como particularmente con pletismografía, en la práctica diaria sigue valorándose la insuficiencia venosa como presente o ausente. Una cuantificación simple como el diámetro safeniano que parece correlacionarse con el grado de insuficiencia venosa según publicación del servicio de cirugía vascular de Oviedo, se empieza a imponer como un parámetro de adquisición simple y reproducible. Esta segunda parte del documento de consenso de la insuficiencia venosa se centra en la insuficiencia venosa crónica, y en su diagnóstico con eco-doppler. Se repasan las maniobras de exploración remarcando la diferente información que puede aportar cada una. Se divide la información de la exploración en una parte anatómica y en otra hemodinámica. Finalmente, se hace un repaso actualizado de los diferentes tipos de shunts veno-venosos, cuyo desarrollo constituye un obstáculo para el fraccionamiento de la columna de sangre al caminar (defecto de fraccionamiento dinámico de la presión hidrostática)

Although many studies have tried to quantify venous insufficiency using either doppler ultrasound, and particularly with plethysmography, venous insufficiency continues to be evaluated as present or absent in daily practice. A simple quantification such as the diameter of the saphenous vein, which appears to correlate with the venous insufficiency grade (according to publication by the Oviedo Vascular Surgery Department), is starting to become a simple and reproducible parameter. This second part of the venous insufficiency consensus document focuses on chronic venous insufficiency and its diagnosis with doppler ultrasound. The investigation techniques are reviewed, commenting on the different information that each one of them can provide. The information from the exploration technique is divided into an anatomy part and a hemodynamic part. Finally, a current review is presented on the different types of veno-venous shunt, which prevents the fractionation of the blood column on walking (dynamic fractionating of the hydrostatic pressure column deficiency)

Risk factors for colonization with extended-spectrum beta-lactamase-producing enterobacteriaceae on admission to rehabilitation centres.

Patients newly admitted to rehabilitation centres are at high risk of colonization with multidrug-resistant bacteria because many of them have experienced prolonged stays in other healthcare settings and have had high exposure to antibiotics. We conducted a prospective study to determine the prevalence of and risk factors for colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in this population. Subjects were screened by rectal swab for ESBL-PE within 2 days of admission. Swabs were plated on chromagar ESBL plates and the presence of ESBL was verified by a central laboratory. A multilevel mixed effects model was used to identify risk factors for ESBL-PE colonization. Of 2873 patients screened, 748 (26.0%) were positive for ESBL-PE. The variables identified as independently associated with ESBL-PE colonization were: recent stay in an acute-care hospital for over 2 weeks (OR=1.34; 95% CI, 1.12, 1.6), history of colonization with ESBL-PE (OR=2.97; 95% CI, 1.99, 4.43), unconsciousness on admission (OR=2.59; 95% CI, 1.55, 4.34), surgery or invasive procedure in the past year (OR=1.49; 95% CI, 1.2, 1.86) and antibiotic treatment in the past month (OR=1.80; 95% CI, 1.45, 2.22). The predictive accuracy of the model was low (area under the ROC curve 0.656). These results indicate that ESBL-PE colonization is common upon admission to rehabilitation centres. Some risk factors for ESBL-PE colonization are similar to those described previously; however, newly identified factors may be specific to rehabilitation populations. The high prevalence and low ability to stratify by risk factors may guide infection control and empirical treatment strategies in rehabilitation settings.

A multinational study of colonization with extended spectrum ß-lactamase-producing Enterobacteriaceae in healthcare personnel and family members of carrier patients hospitalized in rehabilitation centres.

The study aims were: (i) to define the prevalence of and risk factors for colonization by extended spectrum ß-lactamase (ESBL) -producing Enterobacteriaceae (EPE) among healthcare workers (HCWs) and family members (FMs) of EPE-colonized patients in rehabilitation units and (ii) to compare EPE isolates from these three groups. The study included 286 FMs of 194 EPE-carrying patients identified in five rehabilitation units located in Israel, Italy, France and Spain. The EPE were detected in rectal swabs from 26 (9%) of 286 FMs screened. In multivariate analyses, older age of FM, greater mean number of hours spent with the patient, being a daughter or a female spouse of a patient, and chronic lung disease of the patient were significantly associated with carriage in the FM. Escherichia coli was the most common organism (76%), followed by Klebsiella pneumoniae (19%). Isolates were typed by pulsed field gel electrophoresis and multilocus sequence typing, and ESBLs were identified by PCR sequencing. A comparison of paired species isolates from FMs and their respective patient showed that 17 of 23 strains were indistinguishable. EPE were detected in 35 (3.5%, E. coli = 34) of the 1001 HCWs screened. Feeding patients was associated with EPE carriage by HCWs. Only 7 of 23 E. coli subclones cultured from HCWs were also represented among 376 patient-derived ESBL-producing E. coli isolates from the same rehabilitation units. In Spain, a higher proportion of HCWs and FMs were ESBL carriers than elsewhere (p <0.05). In conclusion, the molecular and epidemiological data suggest that FMs are at higher risk of EPE acquisition from their relative patients than HCWs.

Comparative population analysis of Klebsiella pneumoniae strains with extended-spectrum ß-lactamases colonizing patients in rehabilitation centers in four countries.

The international project MOSAR was conducted in five rehabilitation centers; patients were screened for rectal carriage of extended-spectrum ß-lactamase (ESBL)-producing members of the Enterobacteriaceae. Among 229 Klebsiella pneumoniae isolates, four clonal groups (CG) or complexes (CC) prevailed: CG17 in France, CG101 in Italy, CG15 in Spain, and CC147 in Israel. ESBLs, mainly CTX-Ms, were produced by 226 isolates; three isolates expressed AmpC-like cephalosporinases. High genetic diversity of K. pneumoniae populations was observed, with specific characteristics at each center.

Clonal structure, extended-spectrum ß-lactamases, and acquired AmpC-type cephalosporinases of Escherichia coli populations colonizing patients in rehabilitation centers in four countries.

The prospective project MOSAR was conducted in five rehabilitation units: the Berck Maritime Hôpital (Berck, France), Fondazione Santa Lucia (Rome, Italy), Guttmann Institute (GI; Barcelona, Spain), and Loewenstein Hospital and Tel-Aviv Souraski Medical Center (TA) (Tel-Aviv, Israel). Patients were screened for carriage of Enterobacteriaceae resistant to expanded-spectrum cephalosporins (ESCs) from admission until discharge. The aim of this study was to characterize the clonal structure, extended-spectrum ß-lactamases (ESBLs), and acquired AmpC-like cephalosporinases in the Escherichia coli populations collected. A total of 376 isolates were randomly selected. The overall number of sequence types (STs) was 76, including 7 STs that grouped at least 10 isolates from at least three centers each, namely, STs 10, 38, 69, 131, 405, 410, and 648. These clones comprised 65.2% of all isolates, and ST131 alone comprised 41.2%. Of 54 STs observed only in one center, some STs played a locally significant role, like ST156 and ST393 in GI or ST372 and ST398 in TA. Among 16 new STs, five arose from evolution within the ST10 and ST131 clonal complexes. ESBLs and AmpCs accounted for 94.7% and 5.6% of the ESC-hydrolyzing ß-lactamases, respectively, being dominated by the CTX-M-like enzymes (79.9%), followed by the SHV (13.5%) and CMY-2 (5.3%) types. CTX-M-15 was the most prevalent ß-lactamase overall (40.6%); other ubiquitous enzymes were CTX-M-14 and CMY-2. Almost none of the common clones correlated strictly with one ß-lactamase; although 58.7% of ST131 isolates produced CTX-M-15, the clone also expressed nine other enzymes. A number of clone variants with specific pulsed-field gel electrophoresis and ESBL types were spread in some locales, potentially representing newly emerging E. coli epidemic strains.

Carriage of methicillin-resistant Staphylococcus aureus on admission to European rehabilitation centres--a prospective study.

This study aimed to determine the prevalence of and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) carriage among patients newly admitted to rehabilitation centres. It is a prospective study examining MRSA carriage on admission to seven rehabilitation wards in four countries. Risk factors for MRSA carriage were analysed using univariate and multivariate analyses. A total of 1204 patients were studied. Among them, 105 (8.7%) had a positive admission MRSA screening result. The MRSA carriers were more likely to be male, to have had a recent stay in another long-term-care facility or >2 weeks acute-care hospital stay, history of colonization with MRSA, reduced level of consciousness, peripheral vascular disease and pressure sores. In multivariable logistic regression male gender (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.4-3.6, p 0.001), history of MRSA positivity (OR 6.8, 95% CI 3.8-12.3, p <0.001), peripheral vascular disease (OR 2.5, 95% CI 1.2-5, p 0.013), recent stay in another long-term-care facility (OR 2.1, 95% CI 1.3-3.5, p 0.004), or long (>2 weeks) acute-care hospital stay (OR 1.9, 95% CI 1.2-3, p 0.004), remained significant risk factors for MRSA carriage. MRSA carriage is common on admission to rehabilitation centres but less so, than previously described in long-term-care facilities. Male gender, history of MRSA positivity, previous hospitalization and peripheral vascular disease may predict MRSA carriage, and may serve as indicators for using pre-emptive infection control measures.

[Characteristics of chronic neuropathic pain and their relationship with psychological well-being in spinal cord injury patients]. / Características del dolor neuropático crónico y su relación con el bienestar psicológico en pacientes con lesión medular.

AIMS: To determine the prevalence of neuropathic pain (NP) in a sample of patients with spinal cord injury (SCI), to examine the relation between clinical, demographic and psychological characteristics with the prevalence of NP after SCI and the different types of NP, and to study predictive factors. PATIENTS AND METHODS: Transversal observational study of 260 patients who attended their annual revision. Main outcome measures included presence/absence of NP, psychological well-being index, detailed pain history and 0-10 numerical rating scale of average pain intensity. RESULTS: 93 patients (36%) with SCI had NP. Of the patients with NP, 35% showed pain at level, while 65% showed NP below the level of injury. The only variable with a predictive value on the prevalence of NP was older age at the time of SCI. Statistically significant differences were observed between the prevalence of NP and the perception of psychological well-being; patients with NP were the ones with more psychological distress. As for the different types of NP, the variables with predictive value on the classification of NP were early onset of pain at level, and incompleteness of the lesion in the below level NP. CONCLUSION: The results of this study show that NP appears frequently after SCI being more prevalent in patients who suffered the injury at more advanced ages. NP has a negative impact on the perception of psychological well-being.

Características del dolor neuropático crónico y su relación con el bienestar psicológico en pacientes con lesión medular / Characteristics of chronic neuropathic pain and their relationship with psychological well-being in spinal cord injury patients

Objetivos. Determinar la prevalencia del dolor neuropático (DN) en una muestra de pacientes con lesión medular (LM), examinar la relación entre las características clínicas, demográficas y psicológicas con la prevalencia del DN después de una LM y a su vez con los diferentes tipos de DN, y estudiar el valor predictivo de los factores más significativos. Pacientes y métodos. Estudio transversal observacional de un total de 260 pacientes que acudieron a una revisión anual. Las principales medidas de resultados incluyeron presencia/ausencia de DN, índice de bienestar psicológico, historia detallada del dolor y escala de puntuación numérica de 0-10 para la media de intensidad del dolor. Resultados. 93 pacientes (36%) con LM tenían DN. De los pacientes que presentaron DN, un 35% mostró dolor a nivel de la lesión, mientras que un 65% presentó DN por debajo. La única variable con capacidad predictiva sobre la prevalencia del DN fue la edad en el momento de la LM. Se observaron diferencias estadísticamente significativas entre la prevalencia del DN y la percepción de bienestar psicológico; el grupo de pacientes con DN fue el que tuvo proporcionalmente un malestar psicológico mayor. En cuanto a los diferentes tipos de DN, las variables con capacidad predictiva sobre la clasificación del DN eran el inicio temprano del dolor en el DN a nivel y el hecho de que la lesión sea incompleta en el DN por debajo. Conclusión. El DN aparece con frecuencia después de la LM y se da de forma más común en aquellos pacientes que han sufrido la lesión a edades más avanzadas. El DN tiene un impacto negativo en la percepción de bienestar psicológico

Aims. To determine the prevalence of neuropathic pain (NP) in a sample of patients with spinal cord injury (SCI), to examine the relation between clinical, demographic and psychological characteristics with the prevalence of NP after SCI and the different types of NP, and to study predictive factors. Patients and methods. Transversal observational study of 260 patients who attended their annual revision. Main outcome measures included presence/absence of NP, psychological wellbeing index, detailed pain history and 0-10 numerical rating scale of average pain intensity. Results. 93 patients (36%) with SCI had NP. Of the patients with NP, 35% showed pain at level, while 65% showed NP below the level of injury. The only variable with a predictive value on the prevalence of NP was older age at the time of SCI. Statistically significant differences were observed between the prevalence of NP and the perception of psychological well-being; patients with NP were the ones with more psychological distress. As for the different types of NP, the variables with predictive value on the classification of NP were early onset of pain at level, and incompleteness of the lesion in the below level NP. Conclusion. The results of this study show that NP appears frequently after SCI being more prevalent in patients who suffered the injury at more advanced ages. NP has a negative impact on the perception of psychological well-being

Tratamiento quirúrgico de las úlceras por presión Enis-Sarmiento grado III-IV en los lesionados medulares / Surgical treatment in Enis-Sarmiento grade III-IV pressure ulcers in spinal cord indury

Se describe el tratamiento quirúrgico que realizamos en las úlceras por presión Enis-Sarmiento grado III-IV en lesionados medulares, así como los cuidados preoperatorios y postoperatorios según los protocolos del Instituto Guttmann de Barcelona. Se han seleccionado 59 pacientes intervenidos entre junio de 1999 y julio de 2002, con úlceras por presión Enis-Sarmiento grado III-IV intervenidas ya en varias ocasiones. En todos los casos se practicó extirpación de la úlcera según técnica del “pseudo tumor de Guttmann”. Es fundamental que la cobertura cutànea se realice con un buen almohadillado y para ello utilizamos colgajos fasciocutaneos, musculares y miocutáneos. Consideramos que los cuidados pre y postoperatorios son de suma importancia para la obtención de resultados satisfactorios. El índice de complicaciones fue del 27%, pero las recidivas no sobrepasaron el 10 %. Como consecuencia de todo ello la estancia media hospitalaria por enfermo intervenido se ha reducido considerablemente (AU)

We describe the surgical treatment that we realice to the Enis-Sarmiento grade III-IV pressure ulcers in spinal cord injury, and the preoperative and postoperative cares acoording to Barcelona´s Guttmann Institute protocols. We review Fifty-nine patients with a good common health and Enis-Sarmiento grade III-IV pressure ulcer operated on before in several occasions. The excision was practised in all the cases with “Guttmann´s pseudo tumor’s technique. A propper cushioning for the covering is essential. That´s why we have used fascicutaneous, muscular and myocutaneous flaps. The pre and postoperative cares are really important to obtain satisfactory results. Complications come up in 27% of the cases, but the relapses are less than 7%. As a consequence, the average stay per partient in the hospital, was considerably reduced (AU)

Reproducibility of lateral excursive tooth contact in a semi-adjustable articulator depending on the type of lateral guidance.

The purposes of this study were (i) to compare the reproducibility of lateral tooth contacts of casts mounted in a semi-adjustable articulator when condylar guidance was set by different methods and (ii) to assess the margin of error of the variations of condylar guidance without changing lateral tooth contacts, depending on the type of lateral guidance. In subjects with different types of lateral guidance, intraoral lateral tooth contacts identified with occlusal registration strips were compared with those identified by use of a semi-adjustable articulator, setting the condylar guidance in four different ways: using protrusive wax wafers, by axiography and by adding and subtracting 5 degrees from the value of condylar guidance obtained by protrusive wax wafers. Tolerance to variations of condylar guidance without changing lateral tooth contacts was determined by increasing and decreasing the value of condylar guidance until lateral tooth contacts changed. Different ways of setting condylar guidance on a semi-adjustable articulator give rise to different values of condylar guidance in the same subject. The occlusal repercussions of these variations of condylar guidance values depend on the type of lateral guidance. Canine protection had the greatest tolerance to variations in the setting of condylar guidance without changing lateral occlusal contacts.

Specific aspects of erectile dysfunction in spinal cord injury.

According to preliminary studies, the overall incidence of spinal cord injury (SCI; traumatic and medical) in Spain is estimated to be between 12 and 20 per million inhabitants, and almost 80% of these injuries occur in young men. SCI causes organic changes in men leading to erectile dysfunction (ED), impaired ejaculation, and changes in genital orgasmic perception. A vast majority of men with both complete and incomplete SCI will require treatment for ED, and the therapeutic options should include sexual counseling so that the patient can be informed about his disorder and can adjust his sexual behavior accordingly. The first-line treatment of choice is oral drugs, such as phosphodiesterase inhibitors (sildenafil, tadalafil, and vardenafil). Sildenafil has been shown to be highly effective and well tolerated in men with ED of various etiologies, including SCI. Data are also presented on sublingual apomorphine, which has limited indications for the treatment of ED in SCI, and on constrictive rings and vacuum systems. Second-line treatments include intracavernous injections of prostaglandin E(1), papaverine, and phentolamine, alone or in combination, which have been shown to be highly effective in the treatment of ED in men with SCI. Finally, for third-line treatments, the indications for surgical methods are given, including penile prostheses and neuroprosthesis of anterior sacral roots. These devices should be reserved for the cases when the above-mentioned methods have repeatedly failed. Historically, the treatment of ED among patients with SCI has been managed by clinicians in physical medicine and rehabilitation. Thus, the criteria for referral and the competencies of these specialists are established, and they should be included as an integral part of the rehabilitation program.

Aplicación de la estrategia CHIVA. Estudio prospectivo a un año / Application of the chiva strategy. A prospective study at one year

Introducción. La cirugía tiende a ser cada vez menos invasiva. Podríamos englobar la estrategia CHIVA dentro del concepto de cirugía mínimamente invasiva. Objetivos. Evaluar de forma prospectiva los resultados clínicos a un año de la aplicación de la estrategia CHIVA en el tratamiento de las varices esenciales. Pacientes y métodos. Seguimiento durante un año de 225 pacientes (147 mujeres, 78 hombres). Clínicamente, 195 de ellos en estadio 2 (CEAP). Se les ha practicado un eco-Doppler previo a la cirugía. Posteriormente, al mes y al año se ha hecho una valoración clínica y clasificado el resultado en cuatro categorías. Además, al año se les ha hecho un nuevo eco-Doppler. El tipo de estrategia practicado ha sido en un sólo tiempo en el 97,8 por ciento de los casos. Resultados. Al año, la valoración clínica objetiva y subjetiva han sido buenas en el 87,6 y en el 90,7 por ciento de los casos, respectivamente. El diámetro medio de la safena interna ha pasado de 6,4 a 4,0 mm (t test; p = 0,001). Se han apreciado diferen cias significativas entre la valoración objetiva al mes y al año (p = 0,001), así como en la valoración subjetiva (p = 0,001), ya que un tercio de los pacientes con mala valoración al mes la tenían buena al año. Conclusión. La estrategia CHIVA en nuestra serie presenta unos buenos resultados a un año. La reducción significativa del diámetro de la safena indica que el componente hemodinámico en la fisiopatología de las varices es importante (AU)

Cirugía carotídea sin arteriografía.Tres años de experiencia en 116 pacientes / Carotid surgery without arteriography. Three years' experience with 116 patients

Introducción. En un trabajo previo realizado en nuestro servicio, se validó la utilización del eco-Doppler de troncos supraórticos en el diagnóstico e indicación terapéutica ante la lesión carotídea; se obtuvieron unas indicaciones en las que el eco-Doppler era suficiente para asentar la realización de la endarterectomía carotídea. Posteriormente, se inició la cirugía carotídea (CC) sin arteriografía sobre la base de los criterios previos del eco-Doppler. Objetivos. Determinar la morbimortalidad tanto inmediata como tardía y la incidencia de reestenosis a largo plazo de la CC en los grupos de CC sin arteriografía y con arteriografía. Comparación con la literatura y ambos grupos. Pacientes y métodos. Trabajo prospectivo no aleatorizado. Entre 1/1/ 1998 y 31/12/2000 se intervinieron en nuestro centro 215 pacientes con indicación de CC; de éstos, 116 (53,95 por ciento) se intervinieron sin arteriografía (grupo A) y 99 (46,05 por ciento) casos con arteriografía (grupo B). Se ha comparado la distribución hombre/mujer, los factores de riesgo, la clínica y la técnica quirúrgica en ambos grupos y los resultados de la cirugía. Resultados. No hay diferencias estadísticamente significativas en relación con factores de riesgo, TAC craneal, clínica, técnica quirúrgica. En el grupo A: la mortalidad global fue del 0,86 por ciento, morbilidad neurológica en sintomáticos 4,44 por ciento y en asintomáticos 2,81 por ciento. En el grupo B: mortalidad 0 por ciento, morbilidad en sintomáticos 5,12 por ciento y en asintomáticos 1,66 por ciento. La tasa de reestenosis (lesiones estenóticas superiores al 50 por ciento) a largo plazo (media de 2 años) fue del 4,3 por ciento en el grupo A y del 5,05 por ciento para el B, y no se obtuvieron diferencias estadísticas. Conclusiones. La morbimortalidad y tasa de reestenosis presentada en el grupo sin arteriografía se halla dentro de los límites admitidos por la literatura, tanto en pacientes sintomáticos como en asintomáticos. Consideramos que podemos realizar CC sin arteriografía en casos previamente seleccionados por nuestro Laboratorio de Diagnóstico Vascular, tanto en pacientes sintomáticos como en asintomáticos (AU)

Cirugía hemodinámica venosaen el tratamiento del síndrome varicoso / Venous haemodynamic surgery in the treatment of varicose syndrome

Objetivo. El presente trabajo de revisión pretende poner al día los diferentes aspectos del tema: justificación del método, terminología anatomicofuncional utilizada, principios estratégicos y modalidades de su aplicación. Finalmente, se analizan los resultados comunicados de las diferentes series disponibles. Desarrollo. La cura CHIVA (cura conservadora hemodinámica de la insuficiencia venosa ambulatoria) fue descrita por Franceschi en 1988. Tras una expansión inicial del procedimiento, su utilización disminuyó a causa de difundirse sin haberse testado adecuadamente. La estandarización posterior del método ha motivado que diferentes grupos adopten dicha estrategia con resultados satisfactorios. La terminología propuesta por la Asociación Europea de CHIVA en el año 2002 permite aplicar con precisión los distintos tipos de estrategias de este tratamiento. Se remarca que en el registro de actividad de la Sociedad Española de Angiología y Cirugía Vascular correspondiente al año 2002, una tercera parte de las varices intervenidas en unidades o servicios de Angiología y Cirugía Vascular en España se realizaron mediante cirugía hemodinámica venosa. Conclusiones. No existe una evidencia definitiva (se están desarrollando ensayos clínicos prospectivos aleatorizados) en favor de la cura CHIVA; sin embargo, los datos disponibles apoyan la alternativa de dicho procedimiento frente a la flebectomía en el tratamiento de las varices (AU)

[Diagnostic and therapeutic management of pseudo-occlusions of the carotid artery]. / Manejo diagnóstico y terapéutico de la pseudooclusién carotídea.

AIMS: The aim of this study was to evaluate the diagnostic attitude and the results obtained after surgery in cases of pseudo occlusions of the carotid artery. PATIENTS AND METHODS: Between 1995 and 2000, 13 cases of pseudo occlusion of the internal carotid artery were performed (3.06% of carotid surgery carried out). Diagnostic criteria were as follows. Echo Doppler: complete occlusion with its origin in the internal carotid artery, damped distal signal; arteriography: occlusion with its origin in the internal carotid artery, filiform distal part, string sign. Clinical presentation was: 53.84% cerebral infarction, 23.07% TIA and 23.07% were asymptomatic. The 13 patients were submitted to echo Doppler and nine were examined using arteriography. Two patients were operated on without arteriography because of unstable neurological clinical features. A surgical exploration was performed in 100% of the cases. RESULTS: In seven cases, revascularisation of the internal carotid artery was carried out (53.84%) and in six cases it was ligated (46.16%). Echographic monitoring (from 1 4 years, average 2 years) showed permeability in the seven revascularised cases; in one case restenosis was detected between 31 50% at 2 years follow up. In the clinical controls (from 2 months to 4 years, average 30 months), one patient who was not revascularised was seen to have symptoms of TIA at one year and two months. DISCUSSION: Since neither arteriography nor echo Doppler can predict when it will be possible to revascularise the internal carotid artery, and because we did not observe an increase in surgical morbidity mortality, we believe surgical exploration is useful. In our study 53.84% of the series were successfully revascularised.

Reestenosis carotídea tras endarterectomía: factores pronósticos / The stenosis recurrence after carotid endarterectomy: pronostic factors

Objetivo. Determinar la eficacia del eco-Doppler en el diagnóstico de las reestenosis precoces postendarterectomía carotídea, y hacer hincapié en las características ecográficas de las mismas. Determinar los predictivos de oclusión fueron la salida distal (p= 0,01), fibrinógeno (p= 0,001) y celularidad sanguínea (p= 0,001). La permeabilidad secundaria fue del 41 per cent y el salvamento de extremidad del 82 per cent a los cinco años. Conclusión. Cifras altas de fibrinógeno y celularidad sanguínea influyen negativamente en la permeabilidad de los injertos suprageniculares de PTFE (AU)