Actitudes de los pacientes de atención primaria ante los momentos finales de la vida / No disponible

Objetivo: conocer las actitudes de los pacientes de atención primaria ante su futura asistencia sanitaria en los momentos finales de la vida. Material y método: Diseño: estudio descriptivo transversal mediante encuesta. Emplazamiento: zona básica de salud urbana. Participantes:selección de 300 pacientes de atención primaria, por muestreo consecutivo no probabilístico, según el orden de citación en consulta. Mediciones principales: cuestionario anónimo autoadministrado de preguntas cerradas. Resultados: el número de respuestas fue de 131 (43%), con una media de edad de 53,3 años (DE: 17,7). El 96,1% considera útil el documento de voluntades anticipadas (DVA). El 61,9% comentaría el DVA solamente con sus seres queridos, el 13,5% con el médico únicamente, y el 24,6% con ambos. Respecto a una futura situación de incapacidad para tomar decisiones por una enfermedad grave e irreversible, el 52% cree que serían sus seres queridos quienes velarían mejor para que se respetasen sus deseos, mientras un 32,3% confía exclusivamente en el DVA. Existe una asociación estadísticamente significativa (p = 0,045) entre un más alto nivel de estudios y una mayor preferencia por morir fuera de un hospital. Conclusiones: los pacientes que han participado en la encuesta piensan que el DVA es útil, y no tienen inconveniente en hablar con su médico de la futura asistencia sanitaria en los momentos finales de su vida. Al mismo tiempo, manifiestan querer incluir en ese diálogo, y de un modo preferente, a sus seres queridos. El impacto del nivel de estudios de los pacientes sugiere que el futuro abordaje de las cuestiones acerca de los momentos finales de la vida se desarrolle de una forma asequible para quienes tienen menos formación académica (AU)

Objective: to explore attitudes towards end-of-life issues among primary-care patients. Material and method: Design: a cross-sectional descriptive study by means of a survey. Setting: an urban primary healthcare center. Participants: the survey protocol was designed so that 300 primary-care patients were selected by consecutive sampling. Main measurements: anonymous self-administered questionnaire with closed questions. Results: respondents were 43% (131/300). Mean age was 53.3 (SD17.7). Most respondents (96.1%) had a positive attitude toward the living wills document (LWD); 61.9% would deal with the LWD only with their loved ones, 13.5% with their physician, and 24.6% with both; 52% believed that their loved ones would ensure that their wishes be respected in case they became mentally handicapped later in life, and 32.3% confided exclusively in the LWD. Higher levels of education were associated with dying out of hospital (p = 0.045). Conclusions: patients find LWD useful in dealing with end-of-life issues, but prefer to implicate loved ones in making decisions. The consistent impact of education suggests that future efforts about end-of-life issues should include efforts to access elders with less education, and should include educational materials that could be readily understood by persons with lower education levels (AU)

Basal cell carcinoma in a girl after cobalt irradiation to the cranium for acute lymphoblastic leukemia: case report and literature review.

A 12-year-old girl had a lesion located on the upper part of the scalp that was clinically interpreted as a melanocytic nevus and corresponded histologically to a basal cell carcinoma. At age 2 years she had been diagnosed as having acute lymphoblastic leukemia L1, for which she was treated with systemic chemotherapy. She also received telecobalt therapy to the whole cranium for prophylaxis of meningeal leukosis. Having rejected other possible causes that can favor the appearance of basal cell carcinoma during childhood (basal cell nevus syndrome, nevus sebaceus, albinism, etc.), we believe that this case should be added to the five previously reported in the literature as basal cell carcinoma developing at an early age in cranial radiation portals with megavoltage radiotherapy. We draw attention to the need to explore radiated areas of skin as part of the long-term follow-up of these patients, and to the advisability of obtaining a biopsy from any persistent lesion in these areas.

Delayed childbearing and pregnancy outcome.

This study is to analyze the effect of delayed childbearing on pregnancy outcome among nulliparous women. A hospital-based study was conducted with prospectively collected data from the computerized perinatal data base that includes information about all patients delivered in our Hospital. We studied 17,230 nulliparous women who were > or = 20 years of age with a singleton gestation delivered between 1987 and 1992. We assessed the rates of low birth weight (< 2500 g), preterm delivery (< 37 weeks), small for gestational age, perinatal death (> 500 g and 28 days of life), and selected complications of pregnancy and delivery (ante partum complications, meconium, labor abnormal fetal heart rate, cesarean section, breech presentation, Apgar score, umbilical cord-pH, and rates of neonatal admission). Compared with women aged 20-29 years, women aged > or = 35 years had no significantly higher odds ratio (OR) of low birth weight < 2500 g (OR = 1.3); preterm delivery < 37 weeks (OR = 1.2); small for gestational age (OR = 1.0); and perinatal death (OR = 1.7). In contrast, we found a significantly higher rates of specific antepartal complications (OR = 1.9); cesarean section (OR = 2.5); breech presentation (OR = 1.4); and higher rates of admission to the newborn intensive care unit (OR = 1.4); but excluding infants delivered before 37 weeks of gestation, we found no significantly higher odds ratio of neonatal admission (OR = 1.4). Delayed childbearing is associated with an increased risk of complications of pregnancy and delivery although neonatal outcomes were not appreciably different from those among infants of younger women.

Primary syphilis with multiple chancres and porphyria cutanea tarda in an HIV-infected patient.

A 51-year-old promiscuous heterosexual man with no history of venereal diseases or porphyria had a large genital chancre and deep erosions on the hands. The HIV serology was positive; the CD4 lymphocyte count was 187/mm3, but the patient did not fulfill the CDC criteria for AIDS. Five months later he developed a clinical and biochemically typical porphyria cutanea tarda.

Factors associated with premature chromosome condensation (PCC) following in vitro fertilization.

From January 1989 to July 1990 a total of 562 oocytes was fixed in our In Vitro Fertilization Program, while cytogenetic data were collected in the case of 433. Forty-eight of these (11%) had a set of oocyte chromosomes in metaphase II, and at least one other set of sperm chromosomes prematurely condensed in the form of single chromatids. In the literature this phenomenon, frequent in our experience, has not been separately studied by many authors. Comparative studies with diverse parameters have shown a significant correlation between the same phenomenon and the use of follicle-stimulating hormone supplementation in ovarian stimulation protocols. Also, in some cases we found a high percentage of repetition of the phenomenon in one patient.

Chromosome studies in human unfertilized oocytes and uncleaved zygotes after treatment with gonadotropin-releasing hormone analogs.

OBJECTIVE: To determine the frequency of the anomalies from the cytogenetic point of view in the oocytes remaining from our in vitro fertilization (IVF) program. Two gonadotropin-releasing hormone analogs (GnRH-a) were used (buserelin acetate and leuprolide acetate) in the superovulation treatment. DESIGN: A prospective study was planned in January 1989. Deadline for data and quantitative analysis was to be July 1990. SETTING: Hospital de Cruces, a public and tertiary institute. PATIENTS: One hundred thirty-nine IVF patients, yielding 433 oocytes. Selected on the basis of availability of oocytes and staff. RESULTS: Two hundred thirty-eight oocytes (71.25%) exhibited the normal number of metaphase II chromosomes; 64 (19.16%) exhibited aneuploidy; 13 (3.89%) were diploid, hyperdiploid, or hypodiploid; and 19 (5.68%) showed parthenogenetic activation. Of the 99 zygotes, 17 were polyploid and 48 showed prematurely condensed chromosomes, whereas in 31 cases the male and female pronuclei remained separate. CONCLUSIONS: It would not appear that the rate of chromosomal anomalies is affected after pituitary suppression with GnRH-a.

Deletion of chromosome 4: 46,XY, del(4) (q31.3) after gamete intrafallopian transfer and in vitro fertilization-embryo transfer.

It seems that assisted reproduction technology does not increase the rate of chromosome abnormalities, and up to now, a few cases have been reported. The case we describe here is the first one of monosomy 4q31 in a full-term liveborn after a combined GIFT-IVF procedure. Once more, this case raises the question of whether pregnancies resulting from IVF should be monitored for chromosome abnormalities or not.

Does minimal endometriosis reduce fecundity?

Twenty-one patients with minimal endometriosis treated with artificial insemination with donor semen (AID) because of male sterility were compared with 40 patients with the same degree of endometriosis treated by "expectant management" (EM). The conception response of both groups was analyzed with the life-table method calculating the monthly fecundity rate (MFR), and the cumulative pregnancy rate (CPR). Both groups were similar in terms of woman's age and length of infertility before diagnosis. The results obtained after the 12th month showed that the group treated with AID had a CPR of 80.9% and an MFR of 0.201, much higher than the group treated with EM, in which the CPR was 47.5% and the MFR 0.060. The results of the fecundity rate of the AID-treated group was comparable to that of normal population.

Familial 46,XX gonadal dysgenesis.

Two sisters, ages 18 and 25, presented with primary amenorrhea and underwent clinical, hormonal, cytogenetic, and pathologic evaluation. Both were of normal stature and lacking of somatic stigmata. Both patients had normal 46,XX karyotype on peripheral blood. Streak gonads were seen in both patients and a rather scanty number of primordial follicles was found in one patient. FSH, LH, and urinary estrogens were consistent with streak gonad syndrome. Autosomal recessive inheritance has been suggested in familial aggregates with XX gonadal dysgenesis.

Management of phenotypic female patients with an XY karyotype.

Nine phenotypic female patients with XY karyotype were evaluated through a clinical, cytogenetic, hormonal, endoscopic and histologic diagnostic protocol. Seven patients complained of primary amenorrhea and two patients of abnormal puberal development. The final diagnosis was XY gonadal dysgenesis (n = 5) and testicular feminization syndrome (n = 4). Two patients were less than 155 cm tall, and the remainder were over 155. Minor somatic anomalies were found in two patients with XY gonadal dysgenesis. Patient with testicular feminization syndrome had FSH and LH within the normal range, and patients with XY gonadal dysgenesis had elevated FSH and LH levels. Gonadoblastomas were found in two patients with XY gonadal dysgenesis (one patient with XO/XX/XY mosaicism). Laparoscopy and gonadal biopsy might be useful in some patients to avoid confusion between XY gonadal dysgenesis and testicular feminization syndrome. Early diagnosis of XY gonadal dysgenesis is always desirable, and bilateral gonadectomy is indicated as soon as the diagnosis is made in patients with a Y chromosome and elevated FSH levels. Surgical removal of the gonads from patients with testicular feminization should be delayed until the completion of puberty because of the low risk of malignancy.

Laparoscopy, ovarian and endometrial biopsies in secondary amenorrhea.

A series of 114 patients complaining of secondary amenorrhea underwent laparoscopy and ovarian biopsy to evaluate ovarian function. Endometrial biopsy were performed on 81 patients. Smooth-inactive and polycystic-sclerocystic ovaries are the two more frequent gross ovarian findings. Normal ovarian histology was found in 61% of the series, Stein-Leventhal in 17% and ovarian fibrosis in 22%. Atrophic wrinkled ovaries should be biopsied to identify possible ovarian failure. Sclerocystic-polycystic, smooth-inactive, and normally active ovaries are not recommended for biopsy, since equally valuable information may be obtained from the gross ovarian appearance. Proliferative and atrophic endometrium are the two most frequent pathologic reports in secondary amenorrhea patients. Laparoscopic gross ovarian appearance, ovarian biopsy and endometrial biopsy should be considered as an alternative in the diagnostic management with secondary amenorrhea, when sophisticated laboratory assays are not readily available.

Indications for and limitations of laparoscopic ovarian biopsy.

A series of 213 patients with different menstrual patterns underwent laparoscopic visualization of the ovaries and ovarian biopsy in order to evaluate ovarian function. Menstrual patterns were classified in four groups: regular menstrual cycles, oligoamenorrhea, secondary amenorrhea and primary amenorrhea. Laparoscopic gross ovarian appearance was classified in four groups, also. Microscopic picture of the ovaries was also placed in four categories. Laparoscopic vision of the ovaries is not justified in regular menstrual cycle patients. Laparoscopic vision of the ovaries might be useful when menstrual disorders exist, especially in secondary amenorrhea. There is some controversy about whether primary amenorrhea patients should be biopsied. Histology may be important in x,y karyotype primary amenorrhea. Biopsy should be avoided in oligoamenorrhea patients. Premature menopause might be diagnosed histologically in patients with secondary amenorrhea. Gross ovarian appearance may help in the selection of patients for ovarian biopsy. Sclerocystic polycystic ovaries should be biopsied, but the procedure must be bloodless and correctly performed. Streak gonad biopsy is not without hazard, and ureteral injury has been reported. The diagnostic, prognostic and therapeutic value of ovarian biopsy should be balanced against the risk and expense of the procedure.

Verapamil to inhibit the cardiovascular side effects of ritodrine.

Side effects of beta-sympathomimetic drugs are of primary interest in the treatment of preterm labor. Incidence of side effects are dose-dependent, as is the efficacy of the beta-agonist in uterine relaxation. the effect of verapamil (Ca2+) inhibitor with antiarrhythmic action) on ritodrine does not modify the value of ritodrine in prolonging pregnancy, but clearly diminishes the incidence of maternal tachycardia and hypotension. The authors suggest that in the treatment of preterm labor with ritodrine infusion above 200 micrograms/min, the addition of verapamil (dosage, 80-120 micrograms/min) is useful because it substantially reduces the cardiovascular side effects associated with ritodrine hydrochloride.

Gonadal dysgenesis (46,XY) and gonocytoma.

A case of 46,XY gonadal dysgenesis with a type III Teter's gonocytoma occurred in the left ovary of a 22-year-old woman. Hormonal, genetic and laparoscopic studies were performed before the diagnosis of gonadal dysgenesis was made. Gonadal neoplasm was found after bilateral gonadectomy.

Epidemiologic study of dermatophytoses in Salamanca (Spain).

An epidemiologic study of the dermatophytoses in Salamanca (Spain) from 1973 to 1976 was performed. Dermatophyte species were identified in 224 patients with clinical tinea infections; 31 bovines, 18 rodents and 70 soil samples. The prevalence of Trichophyton verrucosum and Epidermophyton floccosum was strikingly high in relation to other statistics. The most common clinical forms were tinea corporis and tinea cruris. Tinea capitis by anthropophilic species was uncommon.