Nervio mediano trífido. Una variante anatómica infrecuente en la exploración ecográfica del túnel del carpo / Trifid median nerve. A rare anatomical variant in sonographic evaluation of carpal tunnel

El estudio ecográfico para el diagnóstico del síndrome del túnel del carpo puede ponernos de manifiesto distintas variantes anatómicas. Una variante poco común es la presencia de un nervio mediano trífido, que puede ser de importancia en una posterior planificación quirúrgica. Varón de 52 años, con clínica compatible con síndrome del túnel del carpo bilateral. Se realiza una evaluación ecográfica, visualizándose un nervio mediano bífido en la muñeca derecha y un nervio mediano trífido en la izquierda como variantes de la normalidad. La aparición de un tercer elemento nervioso en el túnel del carpo debe ser diferenciado de una persistencia de la arteria mediana a nivel del túnel del carpo junto a un nervio mediano bífido, mucho más habitual. Para ello, es fundamental la visualización ecográfica de la zona de estudio mediante la utilización de la función Doppler, como vemos en el caso clínico que presentamos.(AU)

The ultrasound study for the diagnosis of carpal tunnel syndrome can reveal different anatomical variants. A rare variant is the presence of a trifid median nerve. The visualization of this anatomical variant may be of importance in the surgical planning of carpal tunnel syndrome. Fifty-two-year-old male, with a clinic compatible with bilateral carpal tunnel syndrome. In the ultrasound examination, a bifid median nerve appears as a finding in the right wrist and a trifid median nerve in the left wrist as anatomical variants. It is important to distinguish a trifid median nerve from a persistent median artery at the level of the carpal tunnel, much more frequent than the first. For this, the ultrasound visualization of the study area using the Doppler function is essential.(AU)

[Trifid median nerve. A rare anatomical variant in sonographic evaluation of carpal tunnel]. / Nervio mediano trífido. Una variante anatómica infrecuente en la exploración ecográfica del túnel del carpo.

The ultrasound study for the diagnosis of carpal tunnel syndrome can reveal different anatomical variants. A rare variant is the presence of a trifid median nerve. The visualization of this anatomical variant may be of importance in the surgical planning of carpal tunnel syndrome. Fifty-two-year-old male, with a clinic compatible with bilateral carpal tunnel syndrome. In the ultrasound examination, a bifid median nerve appears as a finding in the right wrist and a trifid median nerve in the left wrist as anatomical variants. It is important to distinguish a trifid median nerve from a persistent median artery at the level of the carpal tunnel, much more frequent than the first. For this, the ultrasound visualization of the study area using the Doppler function is essential.

Implantación de un nuevo modelo organizativo en la atención al proceso musculoesquelético: ¿mejora la capacidad de resolución de los procesos? / Implementation of a new referral model for the musculoskeletal care pathway: does it improve healthcare outcomes?

OBJETIVO: Evaluar el impacto de un cambio organizativo en la gestión del proceso musculoesquelético en nuestra Área de Gestión Sanitaria (AGS) estudiando los cambios en la capacidad de resolución de estos procesos mediante la derivación a la especialidad útil. DISEÑO: Estudio descriptivo prospectivo para evaluar las tendencias de las derivaciones de atención primaria (PAP) y atención hospitalaria (PAE) con procesos musculoesqueléticos en el periodo 2012-2018. MATERIAL Y MÉTODO: Se incluye a toda la población de referencia de nuestra AGS derivada a alguna de las 3 especialidades hospitalarias que atienden procesos musculoesqueléticos, sin determinación del tamaño muestral. Variables estudiadas: PAP, PAE, servicio de procedencia y de destino. Para el análisis estadístico se utilizó el programa SPSS; se presenta la evaluación de frecuencias absolutas. RESULTADOS: Las derivaciones totales realizadas desde atención primaria han pasado de 25.575 en 2012 a 24.871 en 2018. Las derivaciones PAE han pasado de 17.207 en 2012 a 9.803 en 2018. De las derivaciones PAP, el de mayor impacto ha sido el Servicio de Rehabilitación, que ha pasado de recibir el 8,2% de PAP en 2012 al 47% en 2018. De las derivaciones PAE por especialidad, la mayor reducción ha sido la del Servicio de Traumatología, que pasó de recibir 10.587 PAE en 2012 a 3.911 en 2018. CONCLUSIONES: El rediseño organizativo de la atención al proceso musculoesquelético ha conseguido mejorar la resolución de los procesos musculoesqueléticos. En este cambio organizativo, el Servicio de Rehabilitación ha asumido el liderazgo desde el punto de vista asistencial y de gestión del proceso musculoesquelético, lo que ha colaborado en la mejora de la resolución de estos procesos

OBJECTIVE: To evaluate the impact of an organisational change in the musculoskeletal referral pathway in our health management area (HMA) by identifying changes in the ability to improve healthcare outcomes by facilitating referral to the most suitable specialty. DESIGN: This prospective descriptive study aimed to evaluate referral trends from primary care services (PCS) and hospital care (PHS) to musculoskeletal services from 2012 to 2018. MATERIALS AND METHODS: We included all patients who were referred to any of the 3 musculoskeletal services from our HMA catchment area, without specifying sample size. The variables studied were PCS, PHS, service of origin and destination. We used the SPSS programme for the statistical analysis and obtained absolute frequency data. RESULTS: The total number of referrals from PCS increased from 25,575 in 2012 to 24,871 in 2018. PHS referrals decreased from 17,207 in 2012 to 9,803 in 2018. With regards to PCS referrals, the service most increasing the number of referrals to the musculoskeletal team was the Rehabilitation Service, from 8.2% in 2012 to 47% in 2018. Regarding PHSs referrals by specialty, the service that most reduced the number of referrals to the musculoskeletal team was the Traumatology Service, from 10,587 in 2012 to 3,911 in 2018. CONCLUSIONS: The redesign of the musculoskeletal referral pathway improved healthcare outcomes by improving the quality of the referral process. In this organisational change, the Rehabilitation Service took the leadership from the point of view of healthcare and management of the musculoskeletal process, collaborating in the improvement of the healthcare outcomes of these processes

[Implementation of a new referral model for the musculoskeletal care pathway: Does it improve healthcare outcomes?] / Implantación de un nuevo modelo organizativo en la atención al proceso musculoesquelético: ¿mejora la capacidad de resolución de los procesos?

OBJECTIVE: To evaluate the impact of an organisational change in the musculoskeletal referral pathway in our health management area (HMA) by identifying changes in the ability to improve healthcare outcomes by facilitating referral to the most suitable specialty. DESIGN: This prospective descriptive study aimed to evaluate referral trends from primary care services (PCS) and hospital care (PHS) to musculoskeletal services from 2012 to 2018. MATERIALS AND METHODS: We included all patients who were referred to any of the 3 musculoskeletal services from our HMA catchment area, without specifying sample size. The variables studied were PCS, PHS, service of origin and destination. We used the SPSS programme for the statistical analysis and obtained absolute frequency data. RESULTS: The total number of referrals from PCS increased from 25,575 in 2012 to 24,871 in 2018. PHS referrals decreased from 17,207 in 2012 to 9,803 in 2018. With regards to PCS referrals, the service most increasing the number of referrals to the musculoskeletal team was the Rehabilitation Service, from 8.2% in 2012 to 47% in 2018. Regarding PHSs referrals by specialty, the service that most reduced the number of referrals to the musculoskeletal team was the Traumatology Service, from 10,587 in 2012 to 3,911 in 2018. CONCLUSIONS: The redesign of the musculoskeletal referral pathway improved healthcare outcomes by improving the quality of the referral process. In this organisational change, the Rehabilitation Service took the leadership from the point of view of healthcare and management of the musculoskeletal process, collaborating in the improvement of the healthcare outcomes of these processes.

[Enterocystoplasty in the treatment of interstitial cystitis]. / La enterocistoplastia en el tratamiento de la cistitis intersticial.

OBJECTIVE: To evaluate supratrigonal cystectomy and enterocystoplasty in patients with interstitial cystitis. METHODS: We reviewed four women with interstitial cystitis with infructuos conservative treatment and performed supratrigonal cystectomy and enterocystoplasty. All the patients fulfilled the NHI criteria with increased voiding frequency by night (mean 7.3 times). In 3 cases urodynamic study was available. We used is the four patients ileon as segment for the enterocystoplasty. RESULTS: Mean postoperative follow up was 60 months. In all cases the suprapubic pain disappeared and night voiding frequency reduced (mean 2.2 times). We don't have mayor complications. One patient needs self catheterism 3 years after surgery. CONCLUSION: In patients with interstitial cystitis to be operated supratrigonal cystectomy and enterocystoplasty is the most effective method.

La enterocistoplastia en el tratamiento de la cistitis intersticial / The ehterocystoplasty in the management of the interstitial cystitis

OBJETIVO: Analizar la cistectomía supratrigonal con enterocistoplastia en los pacientes con cistitis intersticial. MÉTODO: Se revisaron cuatro mujeres diagnosticadas de cistitis intersticial en las que fracasaron los tratamientos conservadores y fueron sometidas a cistectomía supratrigonal con enterocistoplastia. Todas las pacientes cumplían los criterios diagnósticos de la NIH con un aumento de frecuencia miccional nocturna (media 7,3 micciones/noche). Se realizó estudio urodinámico en tres casos. En las cuatro pacientes se empleó íleon para la enterocistoplastia. RESULTADOS: El seguimiento medio post-operatorio es de 60 meses. En todos los casos desapareció el dolor suprapúbico y la frecuencia miccional nocturna descendió (media 2,2 micciones/ noche). No tuvimos complicaciones quirúrgicas mayores. Una paciente requirió cateterismo intermitente a los tres años de la intervención. Alguna paciente ha presentado episodio de infección urinaria. CONCLUSIONES: Consideramos que en los pacientes con cistitis intersticial que deben ser opera-dos la cistectomía supratrigonal con enterocistoplastia es el método quirúrgico más efectivo (AU)

[Endoscopic resolution of complications caused by urethrovesical suspension]. / Resolución endoscópica de complicaciones en suspensión uretrovesical.

We presented a total of ten women which referred a varied syntomatology secondary to a bladder foreign body due to the suture employed in the stress incontinence surgery in which urethrovesical suspension techniques were performed. In these patients, to six a Marshall-Marchetti-Krantz technique was practised, to three modified Burch procedure and to the left a suspension according to Raz method. It is described the varied clinic they presented, the necessity of endoscopic study to confirm and the results after solving the 90% of these cases using endoscopic techniques. It is concluded that is not mandatory the employment of non absorbable suture to perform the suspension techniques and in the opposite of the usual tendency of the authors recurring to open surgery, this complication can be solved endoscopically and in ambulatory regime in the most of these cases.

Resolución endoscópica de complicaciones en suspensión uretrovesical / Endoscopic resolution of complications in urethrovesical suspension

Presentamos un total de diez mujeres que referían una sintomatología diversa por cuerpo extraño intravesical, debido a la sutura empleada en la cirugía de incontinencia de estrés en las que se realizaron diversas técnicas de suspensión uretrovesical. En estas pacientes, a seis se les había practicado la técnica de Marshall-Marchetti-Krantz 1 , a tres el procedimiento modificado de Burch 2,3 , y a la restante una suspensión según el método de Raz 4 .Se describe la clínica tan variada que presentaron,la necesidad de estudio endoscópico para la confirmación y resultados tras la resolución del 90 por ciento de estos casos mediante técnicas endoscópicas. Se concluye que no es obligado el empleo de sutura irreabsorbible para realizar la técnica de suspensión y que, en contra de la tendencia general de los autores empleando la cirugía abierta, esta complicación se resuelve endoscópicamente y de modo ambulatorio en la mayoría de los casos (AU)

[A fibroepithelial myxoid polyp of the renal pelvis in a patient with horseshoe kidneys. Apropos a case]. / Pólipo fibroepitelial mixoide de la pelvis renal en paciente con riñones en herradura. A propósito de un caso.

Tumours of the renal pelvis are usually urothelial carcinomas. The benign tumors are extremely rare. Fibroepithelial polyps are the most common mesodermal tumors of the upper urinary tract. They are found most commonly in the ureter but several have been reported in the renal pelvis. Patients usually present with pain and less commonly hematuria. Grossly, these polypoid structures are smooth nodules or filiform projections varying is size from a few millimeters to several centimetres. Histologically, they consist of a thick fibrous stalk with numerous vascular channels covered by a layer of normal or hyperplastic transitional epithelium. The etiology of these tumors is unknown but congenital, obstruction, allergy and trauma have been implicated. Conservative treatment is recommended when the diagnosis is certain. To our knowledge, this is the first report of fibroepithelial polyp of the renal pelvis in a patient with horseshoe kidney.

[Staghorn calculi. Combined treatment with percutaneous nephrolithotripsy and extracorporeal lithotripsy]. / Litiasis coraliforme. Tratamiento combinado con nefrolitotricia percutánea y litotricia extracorpórea.

We present our experience in 61 patients with partial or complete staghorn stone who underwent combined treatment with PCN and ESWL. We excluded the cases with an additional factor complicating staghorn stone, such as horseshoe kidney, severe ectopic, mal-rotated or high, with pyeloureteral junction stricture, etc. The patients were submitted to 72 PCN and 113 ESWL sessions, 5 percutaneous nephrostomies prior to PCN and 5 ureteroscopy procedures to remove post-ESWL obstruction. Complications were observed in 24.5%; acute urinary infection post-PCN (13 patients, 21.3%), massive absorption of liquid (1 case) and arteriovenous fistula (1 case). One year following treatment 83.6% of the patients are stone free and 14.9% have residual stone fragments. No patients developed arterial hypertension and one patient was submitted to nephrectomy due to pyelonephritic atrophy. Our criteria concerning the indications for the different therapeutic methods are discussed. In our view, the role of each method must be reviewed in the light of current clinical experience and investigative data.

Imbalance of the CD4+ subpopulations expressing CD45RA and CD29 antigens in the peripheral blood of adults and children with Down syndrome.

Peripheral blood lymphoid subsets expressing either CD45RA or CD29 antigens, were quantified in 30 children and 59 adults with Down Syndrome and appropriate age-matched controls, by dual immunofluorescence and flow cytometry. Down's patients, both adults and children, displayed a significant decrease of CD4+CD45RA+ cells in comparison with the observed in their age-matched controls, but no difference was found in the CD4+CD29+ subset. These results show clearly the imbalance of these subpopulations in the peripheral blood of individuals with Down syndrome that result in the inversion of the CD45RA/CD29 ratio, due to a major reduction of the CD45RA subset. No obvious difference was found in the CD45RA/CD29 ratio within the CD4 negative cells. Abnormalities of these subpopulations could be indicative of early senescence of the immune system, since age-related changes in Down's persons were in parallel with those observed in normal individuals and the proportion of both subpopulations were roughly similar in Down's children and normal adults.

[Percutaneous nephrostomy associated with extracorporeal shockwave lithotripsy in the treatment of renoureteral lithiasis]. / Nefrostomía percutánea asociada a litotricia extracorpórea por ondas de choque en el tratamiento de la litiasis renoureteral.

From a series of 5000 cases that had undergone extracorporeal shock wave lithotripsy at the Hospital Clinico Quirúrgico "Hermanos Ameijeiras" from March, 1986 to April, 1988, 220 cases that required percutaneous nephrostomy due to obstructive hydronephrosis from stone fragments were studied. We analyzed the clinical, radiological and ultrasound features of these cases, as well as the criteria for performing percutaneous nephrostomy. We identified the risk factors that made the procedure necessary, particularly urinary tract infection. No important complications ascribable to the foregoing procedure were observed. Performing the procedure early improved patient clinical course and reduced cost of treatment. To eliminate stone fragments completely, percutaneous nephrostomy was combined with other procedures in 198 cases (90%). The stone fragments were passed spontaneously in 10 cases (4.5%) following diversion. At 2 months 190 cases (86%) were completely stone free, 18 (8%) had residual stones and 12 (6%) required open surgery. The foregoing results show that percutaneous nephrostomy is a very useful procedure in septic-obstructive complications following extracorporeal shock wave lithotripsy and acquiring the skill to perform it is essential.

Differential expression of lymphocyte function-associated antigen (LFA-1) on peripheral blood leucocytes from individuals with Down's syndrome.

We analysed the expression of lymphocyte function-associated antigen LFA-1 on the cell surface of peripheral blood lymphocytes, monocytes and granulocytes from 20 children with Down's syndrome. No differences in LFA-1 expression was found within monocytes or granulocytes from either normal or Down's syndrome children; however, a clear-cut difference was observed on lymphoid cells. Both normal and Down's syndrome lymphocytes displayed a bimodal pattern of LFA-1 staining by flow cytometry, with a predominance of cells with low expression in normal population, and an increased proportion of lymphocytes with high level of LFA-1 expression in Down's syndrome children. This difference correlates well with the abnormal proportion of T cell subsets and inversion of CD4/CD8 observed in a majority of our cases, and therefore, it could merely reflect the increase of certain T cell subsets normally expressing higher number of LFA-1 molecules. Taken together, our results do not support an abnormally increased expression of leucocytes integrins in trisomy 21 cells, and raise some doubt about the suggested role of the abnormal cellular expression of LFA-1 in the pathogensis of secondary immunodeficiency associated to Down's syndrome.

[Percutaneous nephrolitholapaxy combined with extracorporeal shockwave lithotripsy in the treatment of staghorn lithiasis]. / Nefrolitotricia percutánea asociada a litotricia extracorpórea por ondas de choque en el tratamiento de la litiasis coraliforme.

From December, 1988 to July, 1989, 41 patients with renal or juxtapyelic ureteral calculi were submitted to percutaneous litholapaxy (PCN) at the Stone Center of the Hermanos Amerijeiras Hospital in Havana. This series comprise our early experience utilizing this procedure. PCN was initially limited to pelvic and juxtapyelic ureteric calculi with dilated renal cavities. It was subsequently used in combination with extracorporeal lithotripsy (ESWL) in the treatment of staghorn stones. The present study analyzed the results achieved with PCN in 30 patients with staghorn calculi; 21 (70%) incomplete staghorns and 9 (30%) complete staghorns. Posteriorly, 6 additional borderline staghorns were completely removed by PCN and are not included in the present study. PCN was performed to reduce stone mass and for placement of a large renal drain to permit subsequent ESWL. At two months following treatment, 86.6% of the patients were completely stone-free. The remaining 13.4% with stone remnants presented anatomic and functional renal conditions that allow us to predict complete elimination within a short period of time. Since 6 months had not elapsed in these cases, these were not considered as residual fragments. One patient presented massive absorption of fluids. This was the only observed major and non-lethal complication. Episodes of fever were observed in 23% post-PCN. No patient presented severe sepsis. In our view, PCN combined with ESWL is one of the currently available therapeutic options in the treatment of staghorn calculi. This approach permits adequate resolution of cases that would have otherwise required surgery.

[Treatment of renoureteral lithiasis using extracorporeal shockwave lithotripsy. Experience in Cuba]. / Tratamiento de la litiasis renoureteral mediante litotricia extracorpórea por ondas de choque. Experiencia en Cuba.

Herein we present our experience in 5,000 cases of reno-ureteral lithiasis submitted to treatment at the Extracorporeal Lithotripsy Unit of Hermanos Ameijeiras Hospital in Havana, Cuba, from April 1986 and during a period spanning 30 months. Treatment was exclusively by extracorporeal shock wave lithotripsy (ESWL) in 85.5% of the patients and in combination with other procedures in 14.5% (endoscopic maneuvers in 5.9%, percutaneous nephrostomy 4.4%, open surgery 3.6%, and percutaneous nephrolithotripsy 0.6%). Complications were observed in 7% of the cases: ureteric obstruction (6.4%) with or without infection, perirenal hematoma (0.4%), and obstructive anuria (0.2%); acute urinary infection of different clinical types, some of which were very severe, were observed concomitantly in 2.6% of these patients. Two months following treatment, 86% of the cases were completely stone-free. At 6 months 96.2% were completely stone-free; the remaining 3.8% were classed as residual lithiasis. The pathologic conditions that put patients at high therapeutic risk and the possible complications that could arise were identified. The efficacy of the Dornier HM-3 lithotripter and the health care system that permits its extensive use are highlighted.