[Occipital dermal sinus associated to a cerebellar abscess. Case]. / Seno dérmico occipital asociado a absceso cerebeloso. Caso clínico.

Congenital dermal sinuses are tubular tracts which communicate the skin with deeper structures. It is a manifestation of defective separation of the ectoderm and neuroderm. The incidence is 1/2500-3000 births alive. Almost 10 % of congenital dermal sinuses are localized in the occipitocervical region. They are usually asymptomatic, unless an infectious process is concurrent (meningitis, abscess). We are presenting the case of a 12 months girl with unnoticed cutaneous stigmata in the occipital region, who was admitted with a meningeal syndrome and secondary neurological impairment. She had a cerebellar abscess and was treated with decompression by puncture of the abscess and antibiotics. When infection was resolved, congenital dermal sinus was excised. Process solves without morbidity. We reviewed the clinical and therapeutic features in cases reported previously in the literature.

Seno dérmico occipital asociado a absceso cerebeloso. Caso clínico / Occipital dermal sinus associated to a cerebellar abscess. Case

Los senos dérmicos son trayectos tubulares que comunican la piel con estructuras profundas. Ponen de manifiesto un defecto en la separación entre el ectodermo cutáneo y el neuroectodermo. Su incidencia es de 1/2500-3000 nacidos vivos. De todas las localizaciones en el neuroaxis, los occipito-cervicales suponen un 10 por ciento. Generalmente cursan de forma asintomática, siendo la infección su principal complicación (meningitis, absceso). Presentamos el caso de una niña de 12 meses de edad con un estigma cutáneo en la región occipital, que no fue valorado previamente, y que debutó con un síndrome meníngeo y un importante deterioro neurológico, presentando un absceso en fosa posterior que fue tratado mediante punción evacuadora, antibioterapia y, en un segundo tiempo, extirpación quirúrgica de un seno dérmico occipital, resolviéndose el proceso sin secuelas. Se revisa la literatura y se analizan las características clínicas y terapéuticas, tanto de los casos tratados de forma profiláctica como de las complicaciones (AU)

No disponible

[Growing skull fracture in childhood. Presentation of 12 cases]. / Fractura evolutiva de cráneo en la infacia. Presentación de 12 casos.

Growing skull fractures (GSF) are rare complications of head injury (HI) in childhood. This entity consists of a skull fracture with an underlying dural tear that courses with a progressive enlargement of the fracture to produce a cranial defect. The pathophysiology and some aspects of its management are still controversial. In this review we present 12 patients diagnosedd and treated for a GSF at our institution between 1980 and 2002. 11 patients were under the age of 3 years and one patient was 5 years old at the moment of HI. The most common cause of injury was a fall from height. In the initial plain x-rayfilms, 11 patients showed a diastatic skull fracture and one patient only had a linear fracture. At this time, CT scan showed cortical contussion underlying the fracture in every case. The mean time between injury and presentation of GSF was 11.6 weeks. Diagnosis was made by palpation of the cranial defect and confirmed with skull x-rayfilms. The most frecuent location of GSF was in the parietal region. Associated lesions like hydrocephalus, encephalomalacia, lepto-menigeal cysts, brain tissue herniation and ipsilateral ventricular dilatation, were found in the preoperative CT or MRI. All patients underwent a dural repair with pericranium or fascia lata. The cranial defect was covered with local calvarial bone fragments in every case. Only one patient needed a cranioplasty with titanium mesh. Every child with a skull fracture must be followed until the fracture heals. Patients under the age of 3 years with a diastatic fracture and a dural tear, demostrated by TC or MRI, are more prone to develop GSF. In these cases, early repair must be adviced in order to prevent progressive brain damage.

Fractura evolutiva de cráneo en la infancia. Presentación de 12 casos / Growing skull fracture in childhood. Presentation of 12 cases

La fractura evolutiva de cráneo (FEC) es una complicación poco frecuente del traumatismo craneoencefálico (TCE) en la infancia. Consiste en una fractura con un desgarro dural subyacente, que se ensancha progresivamente hasta constituir un defecto craneal. Su fisiopatología, así como algunos aspectos del manejo terapéutico, son todavía controvertidos. Se presenta una revisión retrospectiva de 12 casos diagnosticados y tratados entre los años 1980 y 2002 en nuestra institución. Once pacientes eran menores de 3 años y uno tenía 5 años en el momento del traumatismo. La causa más frecuente de TCE fue la caída. En la radiografía inicial, 11 pacientes tenían fracturas con diastasis y solamente un paciente tenía fractura lineal. El hallazgo tomográfico común a todos los casos fue contusión cortical subyacente a la fractura. El intervalo promedio entre traumatismo y presentación de las FEC fue de 11,6 semanas. La localización preferente de las FEC fue en la región parietal. El diagnóstico se hizo por palpación de un defecto craneal y se confirmó con radiografía. Se encontraron lesiones asociadas en la TAC y RMN preoperatoria, como hidrocefalia, encefalomalacia, quistes leptomeníngeos, herniatión de tejido encefálico y dilatación ventricular ipsilateral. Todos los pacientes fueron sometidos a reparación plástica de la duramadre y el defecto craneal se cubrió con fragmentos óseos. Sólo un paciente precisó craneoplastia con malla de titanio. Todas las fracturas de cráneo en edad pediátrica deben controlarse hasta constatar su reparación. Los pacientes menores de 3 años con fracturas inicialmente diastasadas y con evidencia en la TAC o RMN de laceración dural, tienen mayor probabilidad de desarrollar una FEC. En estos casos se recomienda el tratamiento precoz para evitar un daño cerebral progresivo (AU)

[Unusual abdominal complication of ventriculoperitoneal shunt]. / Complicación abdominal poco frecuente de las derivaciones ventrículoperitoneales. Caso clínico.

The most common complications after CSF shunting to treat hydrocephalus are shunt infection and obstruction. Although ventriculoperitoneal (VP) diversion of the CSF using artificial shunt devices is an accepted method for the management of hydrocephalus, high rates of various complications have been reported, ranging from 24% to 47%. Among these, abdominal complications account for approximately 25%. The incidence of bowel perforation by shunt-catheter is known to be as low as 0.1-0.7%. We describe a case of migration af a peritoneal catheter through a congenital hernia of Morgagni.

Complicación abdominal poco frecuente de las derivaciones ventrículoperitoneales. Caso clínico / Unusual abdominal complication of ventrículoperitoneal shunt

Las complicaciones más frecuentes de las derivaciones ventrículoperitoneales en el tratamiento de la hidrocefalia son la infección y la obstrucción, oscilando estas últimas entre 24 y 47 por ciento, y dentro de ellas, las complicaciones abdominales representan aproximadamente un 25 por ciento. La incidencia de perforación diafragmática es relativamente escasa, aceptándose entre un 0,1-0,7 por ciento La migración del catéter peritoneal a través de hernias inguinales es relativamente frecuente dada su mayor incidencia, mientras que en las hernias de Morgagni la frecuencia es mucho menor (aproximadamente 1/4000-5000).Presentamos un caso de migración del extremo distal del catéter peritoneal a través de una hernia congénita de Morgagni (AU)

No disponible

[First experiences in evaluating the clinical competence of family doctors in Catalonia]. / Primeras experiencias en evaluación de la competencia clínica de los médicos de familia de Catalunya.

OBJECTIVES: To construct a valid instrument to evaluate the clinical competence of family doctors and establish professional standards. DESIGN: Construction of an objective and structured clinical evaluation test by the Test Committee of the Catalan Society of Family and Community Medicine (SCMFiC) with 27 representative clinical situations of primary care practice. This used various evaluative instruments and lasted 5 hours and 30 minutes. SETTING: 2 Barcelona health districts for the two runnings of the test. PARTICIPANTS: Family doctors, SCMFiC members, who took part voluntarily after having been invited by letter. MEASUREMENTS AND MAIN RESULTS: 23 doctors took part in the first running of the test. Their average age was 36.6 (SD 6.9) and 52.2% of them were women. 46 doctors took part in the second test. Their average age was 30.9 (SD 2.1) and 76.1 were women. The test had an overall reliability coefficient (Cronbach's alpha) of 0.83 the first time and 0.65 the second time. The overall mean score of the participants the first time was 56.9 (SD 19.2), with 100 the top score possible, and 62.1 (SD 4.1) the second time. CONCLUSIONS: This SCMFiC experiment is the first time the clinical competence of family doctors has been assessed in our area. It was a reliable and valid test to assess the competence of our health professionals.

Pott's puffy tumour: still not an eradicated entity.

Pott's puffy tumour is an infrequent entity characterised by one or more subperiosteal abscesses associated with frontal bone osteomyelitis. Although cases in patients of all ages have been reported, teenagers are the most frequently affected. Early diagnosis and aggressive treatment are essential because of the high risk of severe neurological complications, such as epidural abscess, subdural empyema, and secondary septic thrombosis of the dural sinuses. This paper describes the case of a patient with a subperiosteal abscess resulting from sinusitis, with orbital and intracranial extension, and subsequent neurological complications. Despite modern methods of diagnosis and treatment, 13 new cases have been published in the last 5 years; in at least 3 (23%) of these cases there were serious neurological complications. Upper respiratory infections and sinusitis are leading causes of visits to the emergency department in the paediatric age group; however, no risk factors for poor outcome have so far been identified in any of these patients.

Primeras experiencias en evaluación de la competencia clínica de los médicos de familia de Catalunya / First experiences in evaluation of the clinical competence of family doctors in catalonia

Objetivo. Construir un instrumento válido para evaluar la competencia clínica de los médicos de familia y establecer el estándar de la profesión. Diseño. Construcción de una prueba de evaluación clínica objetiva y estructurada por parte del Comité de Prueba de la Societat Catalana de Medicina Familiar i Comunitària (SCMFiC) con 27 situaciones clínicas representativas de la práctica de atención primaria, utilizando diversos instrumentos evaluativos, con una duración total de 5 horas y 30 minutos. Emplazamiento. Dos áreas básicas de salud de Barcelona para la realización de las dos ediciones de la prueba. Participantes. Médicos de familia, miembros de la SCMFiC, que participaron voluntariamente tras haber sido invitados por carta. Mediciones y resultados principales. En la primera edición de la prueba participaron 23 médicos, con una edad media de 36,6 años (DE, 6,9), siendo un 52,2 por ciento mujeres. En la segunda edición participaron 46 médicos, con una edad media de 30,9 (DE, 2,1), siendo un 76,1 mujeres. La prueba tuvo un coeficiente global de fiabilidad, alfa de Cronbach, de 0,83 en su primera edición y 0,65 en su segunda. La puntuación media global de los participantes de la primera edición fue de 56,9 (DE, 19,2), siendo 100 la puntuación máxima obtenible y la de los participantes de la segunda edición, 62,1 (DE, 4,1). Conclusiones. La experiencia de la SCMFiC es la primera por lo que refiere a la evaluación de la competencia clínica de los médicos de familia en nuestro ámbito, y se trata de una prueba fiable y válida para valorar la competencia de nuestros profesionales (AU)

Choroid plexus papillomas of the III ventricle in infants. Report of three cases.

The III ventricle is an uncommon location for choroid plexus papilloma at any age. We describe three new cases of choroid plexus papillomas of the III ventricle (CPPs). All children were boys under 4 months of age and all presented with increased intracranial pressure, hydrocephalus and macrocephaly. The three were examined by preoperative computed tomography (CT) and ultrasonography. Two of them were investigated with magnetic resonance imaging (MRI). The first case was treated with a right corticofrontal transventricular approach and subtotal resection, so that he required a second operation through a transcallosal approach. In the other two cases a transcallosal approach was used. Two children needed permanent ventriculo-peritoneal shunts. The average follow-up of 4.3 years has revealed no neurological deficits in any case. The timing of and the need for shunting are major considerations. Clinical and imaging follow-up (CT and/or ultrasonography) are very helpful in controlling postoperative hydrocephalus and subdural effusion, avoiding unnecessary shunting in many cases. The operative approaches, transcortical and transcallosal, are discussed.

[Validation of a questionnaire for the diagnosis of urinary incontinence]. / Validación de un cuestionario para el diagnóstico de la incontinencia urinaria.

OBJECTIVE: To validate a questionnaire applied in the Primary Care (PC) clinic which enables urinary incontinence (UI) and its different types to be diagnosed. DESIGN: A descriptive crossover study. SETTING: A Urodynamics hospital out-patients clinic. PARTICIPANTS: Patients referred from PC to be tested for UI by Urodynamics. INTERVENTION: A self-filled questionnaire prior to the Urodynamics test to give a rough idea of the type of UI. Analysis of patients' characteristics and the internal validity of the questionnaire by comparing it with the Urodynamics test. MEASUREMENTS AND MAIN RESULTS: The sample was 59 men and 432 women. For the rough diagnosis of UI caused by straining in women, a five-question survey had a positive predictive value (PPV) of 77.2% for four affirmative replies, which went up to 83% if maximum exterior flow was included. For the UI group arising from anticholinergic treatment, a four-question survey had low PPV (57.6%), but this figure went up to 85.7% with a flowmeter. CONCLUSIONS: A questionnaire to study the type of UI, along with further tests, approached the aetiological diagnosis of incontinence in women. A Urodynamics study, however, always needs to be performed on men.

Traumatic extradural hematomas of the posterior fossa in children.

The most favorable type of traumatic intracranial bleeding in childhood is the extradural hemorrage (EDH). The posterior fossa location is less frequent than the supratentorial site. In the period from January 1989 to January 1994 we treated 2,372 patients with craniocerebral trauma; 31 had extradural hematomas (1.3%); 3 of them were located in the posterior fossa (9.7%): 1 boy and 2 girls aged from 6 to 16 years. The traumatic mechanism was an occipital fall in all cases. Diagnosis was made by computed tomography scan (CT). Two of them had a rapidly deteriorating course. The three patients were operated on without mortality and there was no morbidity. The role of CT in the early detection of lesions and prompt surgical evacuation may reduce the mortality and morbidity from this lesion. The interaction between these factors is discussed.

Meningiomas intracraneales en infancia y adolescencia: presentación de 6 casos clínicos / Meningiomas intracraneales in childhood and adolescence: presentation of 6 clinical cases

Revisa 6 casos de meningiomas intracraneales, 4 fueron del sexo masculino, yu dos del femenino. Las edades estaban comprendidas entre 8 meses y 13 años. El síntoma más frecuente fue crisis comicial en 3 pacientes (50xciento), otras presentaciones clínicas fueron: déficit neurológico 1 paciente (16.6xciento), enoftalmos 1 paciente (16.6xciento), y hallazgo casual 1 paciente (16.6xciento). En 5 casos se practicaron resección macroscópica total, y en uno resección subtotal se pudo comprobar progresión tumoral, con deterioro neurológico y muerte. De los 5 pacientes con resección macroscópica total en uno se comprobó recidiva tumoral. Revisamos la literatura sobre la etiopatogenia, y los criterios clínicos, radiológicos, hallazgos quirúrgicos, y pronóstico de esta infrecuente patología en este grupo de edad...