[Opinions on the organisation of health care in strokes. A survey among hospital medical directors in Spain]. / Opinión sobre la organización asistencial en el ictus. Encuesta a directores médicos hospitalarios en España.

INTRODUCTION: Therapy to treat strokes has changed dramatically. Around 70 years ago, it could not be treated and today it is a medical emergency. Awareness of this change has still not reached many layers of the medical or health care professions or of society itself. AIM: To use a survey to evaluate the attitudes of medical directors and hospital specialists towards the problems involved in the inpatient care of stroke patients. Materials and methods. A survey was carried out by means of a pilot study in hospitals in Madrid with specific sub-surveys for medical managers in charge of neurology departments, neurosurgery services and stroke units. These surveys were sent out to 108 acute care hospitals with over 250 beds in 2003-2004. RESULTS: Only the results of the survey administered by medical directors are analysed. Finally, 52 surveys were obtained from 108 hospitals. Information was collected about several aspects of stroke patients, including care in hospital emergency department, admission to hospital, rehabilitation treatment and staffing in stroke units. Care of stroke patients was given a significantly more positive score (better stroke care) by medical directors than by hospital neurologists. CONCLUSIONS: The survey revealed a great care burden from stroke in hospital emergency departments and from hospital admissions, deficits in neurological duty services and in the capacity to perform fibrinolysis and, above all, in stroke units. The data obtained show that medical directors should improve their attitudes with regard to the care of stroke patients.

Opinión sobre la organización asistencial en el ictus. Encuesta a directores médicos hospitalarios en España / Opinions on the organisation of health care in strokes. A survey among hospital medical directors in Spain

Introducción. La terapia del ictus ha cambiado dramáticamente. Hace 70 años no tenía tratamiento y, en la actualidad, es una urgencia médica. La conciencia de este cambio no ha llegado a muchos estamentos médicos o sanitarios ni a la sociedad. Objetivo. Evaluar las actitudes, mediante encuesta, de directores médicos y de especialistas médicos hospitalarios hacia la problemática asistencial hospitalaria del paciente con ictus. Materiales y métodos. Se desarrolló una encuesta por medio de un estudio piloto en hospitales de Madrid con subencuestas específicas para directores médicos, responsables de los servicios de neurología, neurocirugía y de las unidades de ictus. Se remitieron estas encuestas a 108 hospitales de enfermos agudos mayores de 250 camas en 2003-2004. Resultados. Sólo se analizan los resultados de la encuesta a los directores médicos. Se obtuvieron 52 encuestas de 108 hospitales. Se obtuvo información sobre varios aspectos de los pacientes con ictus: atención en la urgencia hospitalaria, ingreso en el hospital, tratamiento de rehabilitación y dotación de unidades ictus. La atención al paciente con ictus mereció una valoración por parte de los directores médicos significativamente más positiva (mejor atención al ictus) que por parte de los neurólogos hospitalarios. Conclusiones. La encuesta mostró gran carga asistencial de ictus en urgencias hospitalarias y de ingresos hospitalarios, déficit de guardias neurológicas y de capacidad para la realización de fibrinólisis y, sobre todo, de unidades de ictus. Los datos obtenidos indican que los directores médicos deberían mejorar sus actitudes sobre la asistencia al paciente con ictus (AU)

Introduction. Therapy to treat strokes has changed dramatically. Around 70 years ago, it could not be treated and today it is a medical emergency. Awareness of this change has still not reached many layers of the medical or health care professions or of society itself. Aim. To use a survey to evaluate the attitudes of medical directors and hospital specialists towards the problems involved in the inpatient care of stroke patients. Materials and methods. A survey was carried out by means of a pilot study in hospitals in Madrid with specific sub-surveys for medical managers in charge of neurology departments, neurosurgery services and stroke units. These surveys were sent out to 108 acute care hospitals with over 250 beds in 2003-2004. Results. Only the results of the survey administered by medical directors are analysed. Finally, 52 surveys were obtained from 108 hospitals. Information was collected about several aspects of stroke patients, including care in hospital emergency department, admission to hospital, rehabilitation treatment and staffing in stroke units. Care of stroke patients was given a significantly more positive score (better stroke care) by medical directors than by hospital neurologists. Conclusions. The survey revealed a great care burden from stroke in hospital emergency departments and from hospital admissions, deficits in neurological duty services and in the capacity to perform fibrinolysis and, above all, in stroke units. The data obtained show that medical directors should improve their attitudes with regard to the care of stroke patients (AU)

[Lasegue's test as prognostic factor for patients undergoing lumbar disc surgery]. / El test de Lásegue postoperatorio como factor pronóstico de los pacientes intervenidos de hernia discal lumbar.

INTRODUCTION: In patients operated for herniated lumbar disc it could be very useful to develop physical examination criteria that would allow early prediction of medium or long term clinical outcomes. The result of the Lasegue test after surgery depends on the occurrence of recurrent herniated disc and/or scar formation around the nerve root. Previous studies have shown the association between the result of Lasegue test, assessed 4 months after surgery, and the short term functional outcome. OBJECTIVE: To determine the prognostic value of postoperative Lasegue test in relation with medium term functional and clinical outcomes which were estimated by analyzing the functional grade, employment status, quality of life, reoperation for recurrent disc herniation, and the number of clinical revisions and imaging studies needed during the follow-up. PATIENTS AND METHODS: 243 patients who underwent hemilaminectomy for lumbar herniated disc between 1996 and 2002 were studied. The Lasegue sign was tested 3 months after surgery. A modification of Spangfort's criteria (to measure the functional grade) and the 12-item Short-form health survey (SF-12) method (to measure the quality of life) were used to quantify outcomes at 12, 24 and 36 months after initial surgery. RESULTS: This investigation has proved the prognostic value of Lasegue test assessed 3 months after initial surgery. A statistically significant correlation was found between a positive straight leg raising test and a poor functional status at 24 and 36 months, and the risk do not return to work because of persistent pain at 12, 24 and 36 months. A statistically significant correlation was also found between the result of the test and the frequency of reoperation for recurrent disc herniation and the number of clinical revisions and imaging control studies needed through the follow-up. Likewise, the prognostic value of Lasegue test on different aspects of quality of life (health perception, functional performances, poor social interaction and severe pain) analyzed at 24 and 36 months after surgery were also confirmed. CONCLUSION: This study provides additional information about the predictive value of the straight leg raising tested 3 months after surgery on the clinical (diagnostic resources consumption, successive outpatient revisions, etc) and functional (quality of life, functional grade and return to work) outcomes assessed 24 and 36 months after initial surgery.

[Treatment in spontaneous intracerebral haemorrhage. Analysis of Spanish clinical series]. / Tratamiento de la hemorragia intracerebral espontánea. Análisis de las series clínicas españolas.

OBJECTIVE: In the spontaneous intracerebral hemorrhage (SICH) there are a small number of unequivocally indicators of surgical or conservative treatment. DEVELOPMENT: An extensive bibliographic revision of studies of patients with spontaneous ICH admitted to Spanish Hospitals has been completed. Later on, studies related to analyses and results of mortality and functional state of surgical and conservative treatments of ICH were gathered. Using the Cochrane Collaboration Manual the methodological quality of the studies has been evaluated. CONCLUSIONS: The chosen studies were 25 clinical series. Only two studies comparing the surgical against the conservative treatment of supratentorial ICH has been found. The intrinsic methodological quality associated to this type of studies does not allow to establish valid conclusions on the efficacy of one treatment over another. Nonetheless it has utility considering that it reveals the chosen treatment and the outcomes in the published studies. We did not found studies evaluating the efficacy of both treatments in Spain with a prospective randomised design, with an adequate size, analysing mortality, dependency and quality of life of the affected patients. Therefore, our final conclusion is that given the importance of the information that could be extracted from these studies in order to design the more efficient treatment of ICH no delay to complete them can be admitted.

Tratamiento de la hemorragia intracerebral espontánea. Análisis de las series clínicas españolas / Treatment in spontaneous intracerebral haemorrhage. Analysis of spanish clinical series

Objetivo. En la hemorragia intracerebral (HIC) espontánea sólo se definen claramente algunas indicaciones de tratamiento quirúrgico o conservador. Desarrollo. Se realiza una revisión sistemática de la bibliografía, de estudios de pacientes con HIC espontánea ingresados en hospitales españoles. Posteriormente, se analizan los estudios y se recogen los resultados de mortalidad y estado funcional de los tratamientos quirúrgico y conservador de la HIC. Se evalúa la calidad metodológica de los estudios mediante el Manual de Colaboración de la Cochrane. Conclusiones. Los estudios seleccionados son 25 series clínicas. Sólo se localizan dos estudios que comparan el tratamiento quirúrgico frente al conservador en la HIC supratentorial. La calidad metodológica intrínseca a este tipo de estudios no permite establecer conclusiones válidas sobre la eficacia de un tratamiento con respecto al otro; sin embargo, tienen utilidad, ya que reflejan el tratamiento de elección y los resultados obtenidos en los trabajos publicados. En España no se encuentran estudios que evalúen la eficacia de ambos tratamientos con un diseño prospectivo y aleatorizado, con un tamaño adecuado y que analicen la mortalidad, la dependencia y la calidad de vida de los pacientes. Dada la importancia de la información que podría obtenerse de estos estudios en el manejo más eficaz de la HIC, sería deseable su realización (AU)

Objective. In the spontaneous intracerebral hemorrhage (SICH) there are a small number of unequivocally indicators of surgical or conservative treatment. Development. An extensive bibliographic revision of studies of patients with spontaneous ICH admitted to Spanish hospitals has been completed. Later on, studies related to analysis and results of mortality and functional state of surgical and conservative treatments of ICH were gathered. Using the Cochrane Collaboration Manual the methodological quality of the studies has been evaluated. Conclusions. The chosen studies were 25 clinical series. Only two studies comparing surgical against conservative treatment of supratentorial ICH has been found. The intrinsic methodological quality associated to this type of studies does not allow to establish valid conclusions on the efficacy of one treatment over another. Nonetheless it has utility considering that it reveals the chosen treatment and the outcomes in the published studies. We did not found studies evaluating the efficacy of both treatments in Spain with a prospective randomised design, with an adequate size, analysing mortality, dependency and quality of life of the affected patients. Therefore, our final conclusion is that given the importance of the information that could be extracted from these studies in order to design the more efficient treatment of ICH no delay to complete them can be admitted (AU)

[Quality analysis and evaluation of surgery for herniated lumbar disk. I. Methodology]. / Análisis y evaluación de la calidad en la cirugía de la hernia discal lumbar I. Metodología.

A method for the analysis of the quality of the lumbar disc surgery was developed. The method assesses the important quality parameters such as scientific and technical quality (STQ), functional grades, quality of life, patients satisfaction and economic costs. The STQ related to the measurement of the care according to the available medical and technological knowledge was determined according to the performance of explicit criteria and standards in the clinic documentation (PEP method: Performance Evaluation Procedure). To measure the functional grade, a modification of Spanfort's criteria was used. To assess the quality of life a modification of 12-item Short Form health survey was applied. This form includes aspects like pain, social interaction, family characteristics, employment and psychological status. A questionnaire was used to measure satisfaction. The form was previously designed taking into account the patients and professionals criteria. In every stage care given, information issued, management and hosting, the patients and professionals opinions was considered and weighted. To calculate the cost three different systems were proposed i.e., Analytic economic management system (ABC-ABM), Weight related costs of DRGs (Diagnostic Related Groups) and Costs computed from price listing for consulting and hospitalization established by INSALUD.

[Evaluation of the surgical process for herniated lumbar disk. II. Approximation to scientific-technical quality]. / Evaluación del proceso quirúrgico de la hernia discal lumbar II. Una aproximación a la calidad científico técnica.

INTRODUCTION: The procedure of surgical treatment of lumbar disc herniation belongs to the group of clinical practice procedures that have a great repercussion on health care systems. The high prevalence of this disease, the management variability and the possibility of improvement, explain the great interest in the evaluation of the quality of both treatment procedure and outcomes. OBJECTIVE: To determine and analyze the scientific and technical quality (STQ) of lumbar disc disease surgery and its correlation with some outcome measurements (clinical efficacy-functional grade and quality of life). METHODS: 172 patients who underwent a hemilaminectomy for lumbar herniated disc between 1996 and 1999 were studied. To analyze the STQ, we used the PEP (Performance Evaluation Procedure) method. A modification of Spangfort's criteria: to measure the functional grade- and the 12-item Short-form health survey (SF-12) to measure the quality of life- were the methods used to quantify outcomes, assessed after 12, 24 and 36 months after surgery. RESULTS: The mean overall STQ score was 0.83 (0-1). The anamnesis was the stage with worse information quality. Though neurosurgeons usually consider the anamnesis and physical examination data as the most important factors for decision making, these were no the best collected in the clinical reports. Surprisingly, data considered not relevant by neurosurgeons were registered with higher fidelity. An statistically significant correlation was found between STQ score and employment status among other parameters associated to the quality of life. The highest STQ scores were found in patients who did not return to work because of persistent pain 12 or 24 months after surgery (p < 0.02 and p < 0.04) and in patients showing poor social interaction and severe pain 12 months after surgery. When analyzing the completeness of clinical history data, statistically significant differences were observed in relation to the type of employment and the degree of physical effort needed at work. Patients working in positions without high skill requirements (p < 0.002) and involving a great physical effort (p < 0.05) had better registered data. Patients with better registered information tended to show a lesser clear surgical indication as a common characteristic, i.e., negative straight leg raising test, length of the current episode lasting more than 6 months and absence of symptoms (p < 0.01) for more than one year since the initial visit to the physician from the beginning of symptoms (p < 0.01), etc. CONCLUSIONS: This method established a significant correlation between STQ and clinical and presurgical variables, as well as between STQ and pain and activity after surgery.

T lymphocyte signalling defects and immunodeficiency due to the lack of CD3 gamma.

A selective CD3 gamma defect, involving point mutations in both the paternal and the maternal genes, has been analyzed. The CD3 gamma defect affected two brothers of a four sibs family; one of them died at the age of 3 of a viral pneumonia with concomitant autoimmune features (Haemolytic anaemia and gut epithelial cell autoantibodies), whereas the other is still alive at the age of 10 with relatively mild infection episodes. In this work, the effects of the absence of the CD3 gamma chain in the structure and signal transduction of the T-cell receptor (TCR)/CD3 complex and in the selection and function of T lymphocytes were studied. The absence of CD3 gamma did not prevent the expression of certain amounts of TCR/CD3 complexes on the surface of T lymphocytes. This suggests the existence of at least two TCR/CD3 isoforms in T cells, either with or without CD3 gamma. A persistent low proportion of CD8+ T cells, not functional in vitro (they were unable to proliferate) and probably in vivo (associated to a lethal viral pneumonia), was observed. In contrast, the proportion of CD4+ T cells was not altered, and they were functional both in vitro (they showed a normal proliferation and a low, but detectable, increase of cytosolic Ca2+ in response to anti-TCR/CD3 stimuli, although the production of IL-2 was impaired) and in vitro (they normally helped B cells). These results show that the absence of CD3 gamma affects the selection and function of cytotoxic, but apparently not helper, T lymphocytes, although the possibility that the CD4+ T cells represent a specific subpopulation can not be ruled out. They also suggest that the interactions of the TCR/CD3 complex with its co-receptors during thymic selection and antigen recognition in the periphery may be asymmetrical, with CD8 interacting through CD3 gamma and, probably, CD4 through the homologous CD3 delta.

Combined total deficiency of C7 and C4B with systemic lupus erythematosus (SLE).

The first inherited combined total deficiency of C7 and C4B complement components associated with SLE is described in a young female. Functional C7 assays showed a homozygous C7 deficiency in the propositus and her sister, and an heterozygous one in their parents. C4 molecular analyses showed that both the propositus and her mother had two HLA haplotypes carrying only C4A-specific DNA sequences and a normal C4 gene number. Thus, only C4A proteins could be expressed, with resultant normal C4 serum levels. The coexistence of a combined complete C7 and C4B deficiency may therefore abrogate essential functions of the complement cascade presumably related to immune complex handling and solubilization despite an excess of circulating C4A. These findings challenge the putative pathophysiological roles of C4A and C4B and stress the need to perform both functional assays and C4 allotyping in patients with autoimmune pathology and low haemolytic activity without low serum levels of a classical pathway complement component.

C4 Chido 3 and 6 distinguish two diabetogenic haplotypes: HLA-B49, SC01,DR4,DQw8 and B8,SC01,DR3,DQw2.

The combination of the HLA complement allotypes BFS, C2C, C4AQ0 (deleted gene) and C4B1, termed SC01 complotype, usually present in the HLA-B8,DR3,DQw2 diabetogenic haplotype, has also been found in a novel "low frequency" HLA-B49,DR4,DQw8 haplotype associated with Spanish insulin-dependent diabetes mellitus (IDDM). Family studies of C4 antigenic determinants Rodgers/Chido and their specific C4d nucleotide sequences confirm that this novel haplotype bearing Chido -3, -6 is not due to a recent recombination from the common HLA-B8,DR3 haplotype bearing Chido 3,6; moreover, Chido analysis at the serological or DNA level is presently the only way to distinguish both SC01 complotypes, since BF, C2, steroid 21-hydroxylase and C4 genes do not reveal other differences by restriction fragment analysis. On the other hand, HLA-B49,SC01,DR4 is the first DR4-bearing IDDM-susceptible haplotype with a deleted C4 gene described so far and the only DR4-bearing haplotype found in the Spanish population. This report further supports the fact that extended haplotypes with deleted (or "not duplicated") genes in the class III region contain IDDM-susceptibility more often than non-deleted (or "duplicated") haplotypes in the Spanish and other Mediterranean populations.

Autoimmunogenic HLA-DRB1*0301 allele (DR3) may be distinguished at the DRB1 non-coding regions of HLA-B8,DR3,Dw24 and B18,DR3,Dw25 haplotypes.

A novel TaqI restriction fragment length polymorphism (RFLP) of 4.15 kb is reported using a DR beta probe (pRTV1). This fragment corresponds to the DRB1 locus and allows the subdivision at the DNA level of the DRB1*0301 allele (DR3 antigen), which had not previously been reported. Both splits also distinguish each of the two DR3-bearing extended haplotypes (HLA-B8,SCO1,DR3,DQw2,Dw24 and B18,F1C30,DR3,DQw2,Dw25) found associated to several autoimmune diseases as insulin-dependent diabetes mellitus (IDDM), systemic lupus erythematosus (SLE) and myasthenia gravis. The fact that no polymorphism in the DRB1*0301 coding DNA sequence has been detected indicates that DRB1*0301 intronic, regulatory of neighbouring sequences might also contribute to differential disease associations (and pathogenic mechanisms) found linked to each of the two DR3-bearing haplotypes, i.e. IDDM and B8,DR3,Dw24 in North European/American Caucasoids vs IDDM and B18,DR3,Dw25 in Mediterraneans; SLE and B8,DR3,Dw24 in children vs SLE and B18,DR3,Dw25 in Spanish adults.

Shared SstI RFLPs by HLA-Aw19, A23/24 and A3/11 crossreacting groups.

Three novel restriction fragment length polymorphisms (RFLPs) have been identified using a pan-HLA class I probe and the endonuclease SstI. This study, in conjunction with previously reported SstI RFLPs, now allows the identification of the HLA-crossreacting antigens Aw19 (A29/30/31/32/w33), A23/24 and A3/11 by specific hybridization patterns with a single enzyme/probe combination. Three of the corresponding polymorphic SstI restriction sites map within the HLA-A gene and generate two allelic RFLPs (5.06, 5.92 kb) and one single RFLP (5.92 kb) that show an absolute correlation with HLA-A23/24 and A29/32 crossreacting antigens, respectively. However, other SstI RFLPs (7.97, 9.4, 9.6, 9.8 and 13.34 kb), also linked to HLA-A crossreacting antigens, map outside the HLA-A gene and probably correspond to non-HLA-A,B,C class I genes in strong linkage disequilibrium with the HLA-A gene. These data show that HLA-A crossreacting antigens share more SstI RFLPs than neighboring non-HLA-A,B,C class I genes or pseudogenes; also, this has raised the possibility that some crossreacting HLA-A alloantisera might additionally recognize shared antigenic determinants in non-HLA-A,B,C proteins since the HLA-Aw19 crossreactivity cannot be fully explained by analyzing the HLA-A amino acid sequence.