[[Translated article]]Survival Analysis and Prognostic Factors in a Case Series of 148 Cutaneous T-Cell Lymphomas. / Análisis de supervivencia y factores pronósticos en una serie de 148 casos de linfomas cutáneos de células T.

BACKGROUND AND OBJECTIVE: Cutaneous T-cell lymphomas (CTCL) such as mycosis fungoides (MF) and Sézary syndrome (SS) are rare lymphomas with varying prognoses. The aim of the study was to describe the survival of a cohort of patients with MF/SS and evaluate the prognostic factors impacting disease survival. MATERIALS AND METHODS: All cases of MF/SS diagnosed from 2008 through 2022 were retrospectively analyzed. The demographic variables, histological parameters, and analytical data were analyzed too. Progression-free survival (PFS) and disease-specific survival (DSS) were calculated. RESULTS: A total of 148 cases were included. A total of 121 (82%) and 27 cases were diagnosed with MF, and SS, respectively. A total of 37 patients (25%) experienced progression at some point disease progression. The median PFS and median DSS were 127 and 135 months, respectively. Age > 60 years, diagnosis of SS, the presence of large cell transformation (LCT) at diagnosis, folliculotropism in early stages, high Ki-67 expression, the presence of the clonal T-cell receptor (TCR) in blood, elevated LDH and B2M levels, and advanced stages (IIB, IVA, T3, T4, N3/Nx) were associated with worse prognosis across the entire cohort. CONCLUSIONS: Stage IVA and the presence of LCT at diagnosis stood out as independent factors of unfavorable prognosis. LCT was the variable that most significantly impacted the patients' survival and was closely associated with tumor skin involvement and stage IIB.

Survival Analysis and Prognostic Factors in a Case Series of 148 Cutaneous T-Cell Lymphomas. / Análisis de supervivencia y factores pronósticos en una serie de 148 casos de linfomas cutáneos de células T.

BACKGROUND AND OBJECTIVE: Cutaneous T-cell lymphomas (CTCL) such as mycosis fungoides (MF) and Sézary syndrome (SS) are rare lymphomas with varying prognoses. The aim of the study was to describe the survival of a cohort of patients with MF/SS and evaluate the prognostic factors impacting disease survival. MATERIALS AND METHODS: All cases of MF/SS diagnosed from 2008 through 2022 were retrospectively analyzed. The demographic variables, histological parameters, and analytical data were analyzed too. Progression-free survival (PFS) and disease-specific survival (DSS) were calculated. RESULTS: A total of 148 cases were included. A total of 121 (82%) and 27 cases were diagnosed with MF, and SS, respectively. A total of 37 patients (25%) experienced progression at some point disease progression. The median PFS and median DSS were 127 and 135 months, respectively. Age >60 years, diagnosis of SS, the presence of large cell transformation (LCT) at diagnosis, folliculotropism in early stages, high Ki-67 expression, the presence of the clonal T-cell receptor (TCR) in blood, elevated LDH and B2M levels, and advanced stages (IIB, IVA, T3, T4, N3/Nx) were associated with worse prognosis across the entire cohort. CONCLUSIONS: Stage IVA and the presence of LCT at diagnosis stood out as independent factors of unfavorable prognosis. LCT was the variable that most significantly impacted the patients' survival and was closely associated with tumor skin involvement and stage IIB.

Papel pronóstico del volumen metabólico tumoral y de la glucólisis tumoral total en los estudios 18F-FDG PET/TC de estadificación del cáncer localmente avanzado de mama / Prognostic value of metabolic tumour volume and total lesion glycolysis in 18F-FDG PET/CT scans in locally advanced breast cancer staging

Objetivo. Conocer si el volumen metabólico tumoral (VMT) y la glucólisis tumoral total (GTT) pueden predecir el riesgo de recurrencia en cáncer localmente avanzado de mama (CLAM). Material y métodos. Estudio retrospectivo de pacientes con CLAM tratados con tratamiento neoadyuvante, local y adyuvante; en seguimiento. Se realizó una 18F-FDG PET/TC para estadificar la enfermedad, midiéndose diferentes parámetros metabólicos (VMT, GTT, SUVmáx y SUVmed), tanto en el tumor primario (T) como en los ganglios metastásicos (N) y en el cuerpo entero (CE). Resultados. Se incluyeron 40 mujeres entre enero de 2010-2011; seguimiento hasta enero de 2015. Con una mediana de seguimiento de 46 meses el 20% tuvieron recidiva, local (n=2) o a distancia (n=6); fallecieron 3 (38% de aquellas con recidiva y 7,5% del total). EL SUVmáx, VMT y GTT, tanto en T, como N y CE, fue mayor en aquellas que presentaron recidiva. En el T tanto el VMT como la GTT se relacionaron con la recidiva de la enfermedad (p=0,020 y p=0,028, respectivamente), mientras que en la N fue el SUVmáx (p=0,008). Los puntos de corte óptimos para predecir recurrencia fueron: VMT T≥19,3cm3, GTT T≥74,4g y SUVmáx N≥13,8, existiendo 10-12 veces más probabilidad de experimentar progresión tumoral cuando superaban estos umbrales. El grado tumoral fue la única variable clínico-patológica asociada con la recidiva (p=0,035). Conclusiones. En este estudio de CLAM los parámetros metabólicos que más se asocian con la tasa de recidiva son el VMT y la GTT en el tumor primario, el SUVmáx en la enfermedad ganglionar regional y los 3 índices PET en el cuerpo entero. Estos parámetros podrían utilizarse en la práctica asistencial para identificar a las pacientes con mayor riesgo (AU)

Objective. To determine whether metabolic tumour volume (MTV) and total lesion glycolysis (TLG) are able to predict recurrence risk in locally advanced breast cancer (LABC) patients. Material and methods. Retrospective study of LABC patients who undertook neoadjuvant, local and adjuvant treatment and follow up. A 18F-FDG PET/CT study for initial staging was performed analysing in this study different metabolic parameters (MTV, TLG, SUVmax and SUVmed) both in the primary tumour (T) as well as in axillary nodes (N) and whole-body (WB). Results. Forty females were included between January 2010-2011; follow up until January 2015 was completed. The average follow-up was 46 months. Twenty percent presented recurrence: local disease (n=2) and distant metastasis (n=6); 3 patients died (38% of the patients which recurred and 7.5% from the total). SUVmax, MTV and TLG, in T, N and WB, were higher in those patients with recurrence. The MTV and TLG parameters in the tumour (T) were related to the recurrence rate (P=.020 and P=.028, respectively); whereas SUVmax in the lymph nodes (N) was significantly related (P=.008) to the recurrence rate. The best cut-off points to predict recurrence where: MTV T ≥19.3cm3, TLG T≥74.4g and SUVmax N≥13.8, being 10-12 times more likely to recidivate when these thresholds where exceeded. Tumour grade was the only clinical-pathological variable which was related to recurrence probability (p=.035). Conclusions. In this study of LABC patients the metabolic parameters which have a better relationship with recurrence rate are: MTV and TLG in the primary tumour, SUVmax in the regional lymph node disease and whole-body PET data (AU)

Prognostic value of metabolic tumour volume and total lesion glycolysis in 18F-FDG PET/CT scans in locally advanced breast cancer staging. / Papel pronóstico del volumen metabólico tumoral y de la glucólisis tumoral total en los estudios 18F-FDG PET/TC de estadificación del cáncer localmente avanzado de mama.

OBJECTIVE: To determine whether metabolic tumour volume (MTV) and total lesion glycolysis (TLG) are able to predict recurrence risk in locally advanced breast cancer (LABC) patients. MATERIAL AND METHODS: Retrospective study of LABC patients who undertook neoadjuvant, local and adjuvant treatment and follow up. A 18F-FDG PET/CT study for initial staging was performed analysing in this study different metabolic parameters (MTV, TLG, SUVmax and SUVmed) both in the primary tumour (T) as well as in axillary nodes (N) and whole-body (WB). RESULTS: Forty females were included between January 2010-2011; follow up until January 2015 was completed. The average follow-up was 46 months. Twenty percent presented recurrence: local disease (n=2) and distant metastasis (n=6); 3 patients died (38% of the patients which recurred and 7.5% from the total). SUVmax, MTV and TLG, in T, N and WB, were higher in those patients with recurrence. The MTV and TLG parameters in the tumour (T) were related to the recurrence rate (P=.020 and P=.028, respectively); whereas SUVmax in the lymph nodes (N) was significantly related (P=.008) to the recurrence rate. The best cut-off points to predict recurrence where: MTV T ≥19.3cm3, TLG T≥74.4g and SUVmax N≥13.8, being 10-12 times more likely to recidivate when these thresholds where exceeded. Tumour grade was the only clinical-pathological variable which was related to recurrence probability (p=.035). CONCLUSIONS: In this study of LABC patients the metabolic parameters which have a better relationship with recurrence rate are: MTV and TLG in the primary tumour, SUVmax in the regional lymph node disease and whole-body PET data.

Respuesta patológica en la axila tras quimioterapia neoadyuvante en el cáncer de mama localmente avanzado con afectación axilar / Axillary pathologic response after neoadjuvant chemotherapy in locally advanced breast cancer with axillary involvement

Objetivo. Comparar la afectación axilar (N+) al diagnóstico en el cáncer de mama localmente avanzado (CMLA), con el resultado histopatológico en la axila tras el tratamiento quimioterápico neoadyuvante (QTN). Material y métodos. Estudio retrospectivo entre noviembre de 2011 y septiembre de 2013 de los CMLA tratadas con QTN basada en docetaxel (asociando trastuzumab en los casos HER2 positivos y carboplatino/adriamicina si HER2 negativos). Los casos con sospecha clínica/radiológica de N+ se confirmaron histológicamente. Si no existía sospecha, se estadificó con la técnica de biopsia radioguiada del ganglio centinela (BRGC), mediante la inyección de 99mTc-nanocoloide de albúmina, previa a la QTN. En los casos N+ se realizó linfadenectomía axilar (LA) tras QTN. Clasificamos la respuesta patológica final como completa (RCp) cuando no hubo evidencia de enfermedad tumoral y como no respuesta patológica (NRp) en caso contrario. Resultados. Revisamos 346 pacientes tratados con docetaxel, donde identificamos 105 CMLA. En 70 (67%) se evidenció infiltración tumoral axilar antes de iniciar la QTN. De estas, el 73% (n = 51) presentaban N+ por punción-aspiración con aguja fina (PAAF) y/o biopsia ganglionar, y las restantes 19 (27%) presentaban N+ oculta demostrada por la BRGC. La LA evidenció RCp axilar en el 56% (39/70); aumentando hasta un 84% cuando el estatus inicial N+ se alcanzó por BRGC, frente a un 45% cuando se llegó al diagnóstico de N+ por PAAF/biopsia ganglionar. Conclusión. Más de la mitad de las mujeres con cáncer de mama localmente avanzado con afectación tumoral axilar al diagnóstico presentan axilas libres de enfermedad metastásica tras el efecto terapéutico de la quimioterapia neoadyuvante. Esto aumenta hasta casi el 90% cuando se trata de axilas metastásicas ocultas detectadas mediante el ganglio centinela antes de iniciar la quimioterapia neoadyuvante (AU)

Aim. To compare axillary involvement (N+) at initial staging in locally advanced breast cancer (LABC) with axillary lymphadenectomy histologic results after neoadjuvant chemotherapy treatment (NeoChemo). Material and methods. Retrospective study between November 2011 and September 2013 of LABC cases treated with neoadjuvant chemotherapy based on docetaxel (associated with trastuzumab in HER2 positive cases and carboplatin/adriamycin in HER2 negative cases). Those clinically or radiologically suspected cases of axillary involvement were histologically confirmed. When there was no suspicion of axillary involvement, sentinel lymph node radioguided biopsy (SLNRB) was performed using intradermal injection of 99mTc-nanocolloid albumin prior to neoadjuvant treatment. Axillary lymphadenectomy after NeoChemo was undertaken in all cases with positive axilla. Final pathologic response was classified as complete (pCR) when there was no evidence of tumoral disease and as non-pathologic complete response (no pCR) in the opposite case. Results. A total of 346 patients treated with docetaxel were reviewed, identifying 105 LABC. Axillary involvement at initial staging was detected in 70 (67%) before starting NeoChemo. From these 70, 73% (n = 51) were N+ (fine needle biopsy and/or biopsy) and the remaining 19 (27%) were occult N+ detected by SLNRB. Axillary lymphadenectomy detected pCR in 56% (39/70), increasing up to 84% pCR when initial N+ status was reached using SNLB. On the other hand, when N+ was detected using fine needle biopsy/lymph biopsy, pCR was only 45%. Conclusion. More than 50% of women affected by locally advanced breast cancer with tumoral axillary involvement at initial diagnosis present free metastatic axilla after therapeutic neoadjuvant chemotherapy effect. This increases up to almost 90% in case of occult metastatic axilla detected with sentinel node biopsy prior starting neoadjuvant chemotherapy (AU)

[Axillary pathologic response after neoadjuvant chemotherapy in locally advanced breast cancer with axillary involvement]. / Respuesta patológica en la axila tras quimioterapia neoadyuvante en el cáncer de mama localmente avanzado con afectación axilar.

AIM: To compare axillary involvement (N+) at initial staging in locally advanced breast cancer (LABC) with axillary lymphadenectomy histologic results after neoadjuvant chemotherapy treatment (NeoChemo). MATERIAL AND METHODS: Retrospective study between November 2011 and September 2013 of LABC cases treated with neoadjuvant chemotherapy based on docetaxel (associated with trastuzumab in HER2 positive cases and carboplatin/adriamycin in HER2 negative cases). Those clinically or radiologically suspected cases of axillary involvement were histologically confirmed. When there was no suspicion of axillary involvement, sentinel lymph node radioguided biopsy (SLNRB) was performed using intradermal injection of (99m)Tc-nanocolloid albumin prior to neoadjuvant treatment. Axillary lymphadenectomy after NeoChemo was undertaken in all cases with positive axilla. Final pathologic response was classified as complete (pCR) when there was no evidence of tumoral disease and as non-pathologic complete response (no pCR) in the opposite case. RESULTS: A total of 346 patients treated with docetaxel were reviewed, identifying 105 LABC. Axillary involvement at initial staging was detected in 70 (67%) before starting NeoChemo. From these 70, 73% (n=51) were N+ (fine needle biopsy and/or biopsy) and the remaining 19 (27%) were occult N+ detected by SLNRB. Axillary lymphadenectomy detected pCR in 56% (39/70), increasing up to 84% pCR when initial N+ status was reached using SNLB. On the other hand, when N+ was detected using fine needle biopsy/lymph biopsy, pCR was only 45%. CONCLUSION: More than 50% of women affected by locally advanced breast cancer with tumoral axillary involvement at initial diagnosis present free metastatic axilla after therapeutic neoadjuvant chemotherapy effect. This increases up to almost 90% in case of occult metastatic axilla detected with sentinel node biopsy prior starting neoadjuvant chemotherapy.

El quién, cómo y dónde de la formación continuada de un área de salud / The who, how and where of continuing education in a health area

Introducción. El objetivo de nuestro estudio es describir el Plan de Formación Continuada de nuestra área en 2009 y el perfil académico de nuestros profesionales. Material y métodos. Estudio descriptivo transversal realizado en el Área 9 de Atención Primaria de Madrid. Las variables analizadas se obtuvieron del sistema de información del Plan de Formación Continuada 2009 y de una encuesta estructurada autocumplimentada diseñada por el grupo investigador. Se incluyeron los profesionales que solicitaron alguna actividad formativa en 2009 y los que contestaron la encuesta. La medida de asociación se calculó a través del test ji cuadrado. La magnitud del efecto se expresó a través de la razón de prevalencias (IC 95%). Resultados. Se gestionaron 1.557 inscripciones. El 94,9% de los profesionales del área han realizado al menos una actividad formativa. El 37,6% de las inscripciones se realizaron por enfermeras, 15,7% auxiliares administrativos y 15,4% médicos. El 61,7% (IC 95%; 59,2-64,1) recibieron el certificado. La mediana del número de participantes por curso fue 16 (rango intercuartílico [RI]=9-22,7) y del coste 500 € (RI=250-1.287,5). Por áreas temáticas, el 60% se forman en práctica asistencial y más del 50% realizan la formación en la institución. Hay diferencias significativas entre las profesiones en cuanto a experiencia docente (p=0,01) y pertenencia a grupo o sociedad (p<0,001). Conclusiones. Casi todos nuestros profesionales han realizado alguna actividad formativa, aunque un porcentaje considerable no llega a recibir certificado. Mayoritariamente se forman en práctica asistencial y a través de la organización sanitaria. Las enfermeras se inscriben más y reciben más la certificación (AU)

Introduction. The aim of our study is to describe the 2009 Continuing Education Plan in our area and the academic profile of our professionals. Material and methods Descriptive cross-sectional study performed in Primary Care Area 9 Madrid. The variables analysed were obtained from the information system of Continuing Education Plan 2009 and a self-completed structured questionnaire designed by the research team. We included professionals who applied for some education activity in 2009 and those who filled in the questionnaire. The measure of association was calculated by the chi-squared test. The magnitude of the effect was expressed as the prevalence ratio (95%). Results. A total of 1557 registrations were handled, and 94.9% of professionals had attended at least one training activity. Nurses accounted for 37.6% of registrations, followed by administrative assistants, 15.7% and physicians 15.4%. A continuing education certificate was received by 61.7% of the professionals (95% CI, 59.2-64.1). The median number of participants per course was 16 (RI=9 to 22.7) and cost 500 € (IR=250 to 1287.5). As regards the training location, 60% took place in the clinical practice and more than 50% reported training in the institution. There were significant differences between professions in terms of teaching experience (P=.01) and group or society membership (P<.001). Conclusions. Almost all of our professionals had completed a training activity, although a considerable percentage failed to receive a certificate. Most took place in clinical practice and through the health care organization. Nurses are enrolling more and received more certificates (AU)

Análisis coste-efectividad de vareniclina (Champix®) en el tratamiento del tabaquismo en España / Cost effectiveness analysis of varenicline (Champix®) for the treatment of smoking in Spain

Objetivos: Analizar la eficiencia de la vareniclina (Champix®) versus bupropion y TSN (terapia sustitutiva con nicotina) y tratamiento no farmacológico en España. Métodos: Se utilizó un modelo de Markov para analizar las consecuencias clínicas y económicas del tabaquismo y distintas intervenciones para dejar de fumar. Las probabilidades fueron tomadas de la literatura y ensayos clínicos, siendo utilizadas para estimar la efectividad de las opciones comparadas (vareniclina, bupropión, TSN y no tratamiento farmacológico), para distintos horizontes temporales. Los resultados se expresaron en años de vida (AV) ganado y coste por años de vida ajustados por calidad (AVAC) ganado de vareniclina vs comparadores. El análisis se realizó desde la perspectiva del Sistema Nacional de Salud, descontando los costes al 3,5% anual. Resultados: La mayor eficacia de vareniclina supone una reducción de la morbi-mortalidad asociada al tabaquismo, que a largo plazo, compensa totalmente el coste adicional del tratamiento respecto a los comparadores.Vareniclina se muestra como una opción dominante respecto a todas las alternativas en el análisis a largo plazo (toda la vida de los sujetos). Incluso tomando horizontes temporales más cortos (20 años) resulta coste efectivo, siempre menos de 9.000 €/AVAC ganado en comparación con cualquier alternativa. Conclusiones: Vareniclina es una opción dominante (más efectiva amenor coste) comparada con los demás tratamientos, cuando se considera toda la vida del sujeto. Vareniclina es una terapia coste-efectiva incluso cuando se consideran horizontes temporales más cortos (a partir de 20 años), con un coste efectividad incremental muy por debajo del umbral aceptado en nuestro entorno

Objective: To analyse the efficiency of varenicline compared with bupropion, NRT (nicotine replacement therapy) and no pharmacological treatment in Spain. Methods: A Markov model was developed to analyse the health and economic consequences of smoking cessation therapies. The transition probabilities were taken from published studies. The model allows cost effectiveness analyses for different time frames (10 years, 20 years and life time). Outcomes are measured in terms of incremental life years gained (LYG) and QALYs. Pharmacological costs and costs of medical visits with varenicline and bupropion were considered. Treatment costs of smoking associated morbidity were taken from Spanish studies. Results: The analyses were done under the perspective of the National Health System, discounting costs and health benefits at 3%. Results:The life time cost-effectiveness analysis shows that varenicline dominates all other smoking cessation interventions (more effective at a lower cost).This is due to the higher efficacy of varenicline associated with a reductionin smoking related morbimortality, which, in the long term, accounts for health care cost savings that overcome the extra cost of varenicline. Even when shorter time frames are considered (20 years), vareniclin is cost-effective in comparison with any other alternative. Conclusions: Varenicline is a dominant option (more effective at a lower cost) compared with all other smoking cessation treatments when the timeframe is the life span of the patient. Varenicline is cost-effective even when shorter timeframes are considered (20 years or more), withan estimated incremental cost per QALY far bellow any thresh old commonly accepted in our environment

[Cost effectiveness analysis of varenicline (Champix) for the treatment of smoking in Spain]. / Análisis coste-efectividad de vareniclina (Champix) en el tratamiento del tabaquismo en España.

OBJECTIVE: To analyse the efficiency of varenicline compared with bupropion, NRT (nicotine replacement therapy) and no pharmacological treatment in Spain. METHODS: A Markov model was developed to analyse the health and economic consequences of smoking cessation therapies. The transition probabilities were taken from published studies. The model allows cost effectiveness analyses for different time frames (10 years, 20 years and life time). Outcomes are measured in terms of incremental life years gained (LYG) and QALYs. Pharmacological costs and costs of medical visits with varenicline and bupropion were considered. Treatment costs of smoking associated morbidity were taken from Spanish studies. RESULTS: The analyses were done under the perspective of the National Health System, discounting costs and health benefits at 3%. The life time cost-effectiveness analysis shows that varenicline dominates all other smoking cessation interventions (more effective at a lower cost). This is due to the higher efficacy of varenicline associated with a reduction in smoking related morbimortality, which, in the long term, accounts for health care cost savings that overcome the extra cost of varenicline. Even when shorter timeframes are considered (20 years), vareniclin is cost-effective in comparison with any other alternative. CONCLUSIONS: Varenicline is a dominant option (more effective at a lower cost) compared with all other smoking cessation treatments when the timeframe is the life span of the patient. Varenicline is cost-effective even when shorter timeframes are considered (20 years or more), with an estimated incremental cost per QALY far bellow any threshold commonly accepted in our environment.

Restoration of facial contour in Romberg's disease and hemifacial microsomia: experience with 118 cases.

The experience with free flaps and conventional reconstructive procedures for 118 patients with Rombergapos;s disease and hemifacial microsomia over a 10-year period is presented. The groin free flap was used most frequently for patients with Rombergapos;s disease, whereas the scapular free flap was used for patients with hemifacial microsomia. The rectus abdominis or the latissimus dorsi free flap was chosen only when additional volume was required. To achieve better contour, secondary procedures, such as defatting the flap, pedicled temporal fascial flaps, cartilage and bone grafts, orthognathic surgery, and bone distraction were performed in severe cases. For patients with Rombergapos;s disease, excellent results were achieved in 35% (n = 28) of mild cases, in 72% (n = 27) out of 38 moderately and in 41% (n = 5) out of 12 severely affected patients. In hemifacial microsomia group (n = 40) excellent results were obtained in 66% of cases.

Free flaps for head and neck reconstruction in non-oncological patients: experience of 200 cases.

Two hundred free flaps for reconstructing the head and neck regions in 192 patients with non-oncological pathology were studied. Pathological entities included Romberg's disease, hemifacial microsomia, acquired facial palsy, trauma, and burn sequelae. Indications for selecting a specific free flap for reconstructing each case, details of anastomoses, reexploration, flap success, operative time, length of hospitalization, and complications were studied. The long-term results of cosmetic and function were also obtained. Patient age ranged from 6 to 40 years. The most common diagnosis was Romberg's disease 39% (n = 75), followed by hemifacial microsomia 20% (n = 40). The free flap most frequently used was the scapular 32% (n = 64), followed by the groin free flap 21% (n = 42). A total of 190 flaps (95%) were successful, whereas only 10 (5%) were lost. The mean operative time was 5:30 h and the average hospital stay was only 6 days. There were no major complications and no deaths in the study group. The patients were followed for at least 1 year in all cases. It is concluded that free flaps are safe and reliable procedures for reconstructing complex head and neck non-oncological defects.

Treatment of chronic ventilatory failure using a diaphragmatic pacemaker.

We present our series of patients with chronic ventilatory failure treated with electrophrenic respiration: 13 males and nine females with a mean age of 12 +/- 11.5 years. The etiology was, 13 tetraplegia, five sequelae of surgical treatment of intracranial lesions, and four central alveolar hypoventilation. The mean duration of the conditioning period were 3-4 months. Eighteen patients (81.8%) achieved permanent, diaphragmatically-paced breathing with bilateral stimulation and in four (18.2%) patients, pacing was only during sleep. Five patients died (22.7%): two during the hospital stay and three at home; two deaths had unknown cause and three were due respectively to, lack of at-home care, recurrence of an epidermoid tumor, and sequelae of accidental disconnection of the mechanical ventilation before beginning the conditioning period. Two cases were considered failures: One patient had transitory neurapraxia lasting 80 days, and the other had an ischemic spinal cord syndrome with progressive deterioration of the left-side response to stimulation. One patient had right phrenic nerve entrapment by scar tissue and four suffered infections. The follow-up periods since pacemaker implantation are currently: 1, 11 years; 4, 10 years, and 17, less than 5 years. The results of our experience demonstrate that complete stable ventilation can be achieved using diaphragmatic pacing and that it improves the prognosis and life quality of patients with severe chronic respiratory failure.

Surgical treatment of lagophthalmos in facial palsy: ear cartilage graft for elongating the levator palpebrae muscle.

Ocular exposure, conjunctival irritation and corneal keratitis are disturbing consequences of facial paralysis with lagophthalmos. Many techniques have been described for correcting this condition. A new method for decreasing the palpebral fissure is presented. An ear cartilage graft is interposed between the tarsal plate and the levator palpebrae superioris muscle. 12 patients with paralysis of the orbicularis oculi muscle, as assessed by electromyography, were treated with this technique. The palpebral fissure was decreased by 2-3 mm in all cases. 11 patients showed significant improvement of their eye symptoms. One patient, in whom the palpebral fissure could not be closed sufficiently to protect the eye, required additional lengthening by 4 mm of the cartilage graft and a lateral tarsorrhaphy.

Transdiaphragmatic pressure in quadriplegic individuals ventilated by diaphragmatic pacemaker.

BACKGROUND: Electrophrenic pacing can be used in the management of ventilatory failure in quadriplegic patients. A study was undertaken to determine the pattern of transdiaphragmatic pressure (PDI) during the conditioning phase of electrophrenic pacing to see if it had a possible role in optimising the process of conditioning. METHODS: The tidal volume (TV) and PDI were measured in a group of six quadriplegic patients commencing ventilation by low frequency pulse stimulation (7-10 Hz) and low respiratory rate stimulation (< 10 breaths/min). RESULTS: Tidal volume increased between baseline and month 1 (4.33 ml/kg, p < 0.001) and between months 1 and 2 (3.00 ml/kg, p < 0.05) and then stabilised. PDI was higher during bilateral diaphragmatic pacing (mean (SD) 1.73 (0.30) kPa) than with either left (1.15 (0.34) kPa) or right (0.86 (0.37) kPa) unilateral pacing. PDI varied throughout the observation period, probably by interaction between recovery of the diaphragmatic fibres and the pacing regimen. CONCLUSIONS: Patients with quadriplegia due to high spinal injury can be maintained with ventilation by continuous electrophrenic pacing. The control criteria used in this study for pacing were tidal volume and the patient's tolerance, and the PDI measurement did not contribute any additional information to help with managing the conditioning process.

Fatal fungaemia due to Sporothrix schenckii.

A clinical case is reported of a 78-year-old male with antecedents of diabetes and alcoholism who was hospitalized because he showed cutaneous lesions on the face and extremities suggesting cutaneous tuberculosis, but after a first histological study cutaneous leishmaniasis was erroneously diagnosed. Because of some unusual characteristics of the patient, the skin biopsies were carefully re-examined, as well as blood smears, which revealed elongated yeast form-like cells suggestive of Sporothrix schenckii. The diagnosis was confirmed when the fungus grew in mice and in Sabouraud cultures inoculated with blood samples from the patient. It is recommended that Sp. schenckii is included in the differential diagnosis of ulcerative cutaneous lesions in patients from Mexican humid areas.

Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury.

We have made a retrospective comparative study of patients with spinal cord injury, nine with a diaphragmatic pacemaker and 13 with mechanical ventilation. Clinical outcome, cost and subjective satisfaction with both modalities have been evaluated. The functional status was the same with both types of treatment. Proper management of an electric wheelchair and optimal phonation were attained, respectively, in 100% and 89% of pacers and in 77% and 77% of mechanically ventilated. The rate of hospital discharge and satisfaction with the treatment were significantly better for pacers. The time devoted to ventilatory assistance and cost were also more favourable in this group.

Incidence and risk factors in the appearance of heterotopic ossification in spinal cord injury.

Heterotopic ossification (HO) is a frequent complication in patients with a spinal cord injury (SCI), although the aetiology is unknown. A study was undertaken of 654 SCI patients with traumatic aetiology, admitted for the first time to the Hospital Nacional de Paraplejicos, Toledo, during 1988 and 1989. Of the total number of patients, 85 (13%) were diagnosed HO and 569 without HO. The diagnosis was mainly achieved by x-ray studies and clinical signs. From the 569 patients with traumatic aetiology without HO, 44 were selected at random, as were 44 of the 85 patients with HO. The mean time lapse between the occurrence of the accident and admission for patients with HO was 40.79 days (typical deviation (TD) = 45.2), and for patients without HO was 32.84 (TD = 38) days, resulting in a value of F = 0.796 through analysis of variance, which is not a statistically significant variation between the 2 groups. In both groups we have taken account of the following variables: age at time of lesion, lesion level, type of lesion (complete or incomplete), spasticity, urinary tract complications, deep vein thrombosis, important associated injuries occurring at the moment of lesion, time elapsed before admission and the existence of pressure sores. In those SCI patients with HO the number of ossifications and their localisations were also verified. By use of the chi square test (X2) over all 9 variables which were studied, we found that 3 variables (complete spinal lesion, presence of pressure sores and spasticity) were significantly related to HO formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Skeletal muscle necrosis induced by a phospholipase A2 isolated from the venom of the coral snake Micrurus nigrocinctus nigrocinctus.

1. The venom of the coral snake Micrurus nigrocinctus nigrocinctus was fractionated by reverse-phase high performance liquid chromatography and an acidic myotoxic phospholipase A2 was purified to homogeneity. 2. After intramuscular injection, the toxin induced rapid and drastic myonecrosis, as serum creatine kinase levels increased markedly, reaching their highest values by 1.5 hr. 3. Ultrastructural observations indicate that the plasma membrane was the first structure to be affected, with the presence of focal disruptions in its integrity. 4. Myofilaments were hypercontracted and formed dense clumps. Sarcoplasmic reticulum integrity was lost, as evidenced by the presence of many small vesicles in the cellular space. 5. Some mitochondria were swollen, whereas others contained dense intracristal spaces and flocculent densities. Moreover, some had only one membrane. 6. In conclusion, pathogenesis of myonecrosis induced by this phospholipase A2 is similar to that induced by crude Micrurus nigrocinctus nigrocinctus venom.

Pathogenesis of myonecrosis induced by coral snake (Micrurus nigrocinctus) venom in mice.

The mode by which coral snake (Micrurus nigrocinctus) venom affects skeletal muscle was studied using a combined approach. The venom induced early functional and structural alterations in the plasma membrane of muscle cells, suggesting that sarcolemma is the primary site of action of this venom. This was shown by the presence of wedge-shaped ('delta') lesions at the periphery of the cells, as well as by focal disruptions in the continuity of plasma membrane as early as 15 min after envenomation. After this initial alteration the rest of the organelles were severely affected. Myofilaments were hypercontracted leaving, as a consequence, areas of overstretched myofibrils as well as empty spaces. Eventually, myofilaments formed dense, clumped masses in which the striated structure was totally lost. At 24 h, myofilaments were still disorganized but they presented a more hyaline and homogeneous appearance. As early as 15 and 30 min mitochondria were swollen; later, by I, 3 and 24 h, they showed further alterations such as the presence of dense intracristal spaces and vesiculated cristae, as well as disruption in the integrity of their membranes. Sarcoplasmic reticulum was dilated and disorganized into many small vesicles randomly distributed throughout the cellular space. Moreover, the venom induced a rapid decrease in muscle levels of creatine and creatine-kinase (CK) and a calcium influx. Since the rates of efflux of creatine and CK were similar, it is suggested that the lesions produced in the membrane are large enough to allow the escape of these two molecules. As corroboration of the severe myotoxic effect, envenomated mice excreted reddish urine containing large quantities of myoglobin. Skeletal muscle cells are more susceptible to the action of the venom than erythrocytes, since coral snake venom induced only a mild direct haemolytic effect in vitro and haemolysis is not a significant effect in vivo. M. nigrocinctus venom induced a drastic increase in plasma levels of lactate dehydrogenase. Isozymes LDH-3, LDH-4, and LDH-5 increased markedly, suggesting that the systemic pathology of coral snake envenoming may be more complex than previously thought.

[Ultrastructural study of the local changes induced in the white rat by the venom of Bothrops picadoi of Costa Rica]. / Estudio ultraestructural de las alteraciones locales inducidas en ration blanco por el veneno de Bothrops picadoi de Costa Rica.

The pathogenesis of local lesions induced by Bothrops picadoi venom was studied at the electron microscopic level. White mice were injected i.m. with 100 micrograms of venom. A strong hemorrhagic action was the earliest and most prominent local effect observed in this study. In skeletal muscle fibers, rupture of the sarcolemma was observed and myofibril structure was drastically affected, showing amorphous masses of myofilaments. Myelin layers in many axons were disorganized.