Present and future of subthalamotomy in the management of Parkinson´s disease: a systematic review.

Introduction: The subthalamic nucleus (STN) is known to be involved in the pathophysiology of Parkinson´s disease and by reducing its abnormal activity, normal output of basal ganglia can be restored along with improvement in PD cardinal motor features. Deep brain stimulation of the STN is currently the main surgical procedure for PD with motor complications, but lesioning can be an alternative.Areas covered: Here, the authors systematically review the current evidence regarding subthalamotomy both with radiofrequency and, more recently, with focused ultrasound (FUS) for the treatment of PD.Expert opinion: Unilateral subthalamotomy for the treatment of PD motor features can be considered a viable option in asymmetric patients, particularly with FUS which allows a minimally invasive safe and effective ablation of the STN. Risk of inducing dyskinesia (i.e., hemichorea/ballism) may be strikingly reduced when lesions enlarge dorsally to impinge on pallidothalamic fibers.

[Clinical experience in the treatment of motor fluctuations in Parkinson's disease. Delphi consensus of a group of experts in movement disorders]. / Experiencia clínica en el tratamiento de las fluctuaciones motoras en la enfermedad de Parkinson. Consenso Delphi de un grupo de expertos en trastornos del movimiento.

INTRODUCTION: Motor fluctuations are one of the most common complications of Parkinson's disease and their treatment is still a complex matter. Therefore, from the Neurology Movement Disorders Group we present our clinical experience in the treatment of these complications, with the intention of it being useful in decision-making in daily clinical practice. DEVELOPMENT: Nineteen questions were developed based on a literature review and an open survey answered by members of this group. These issues were discussed in two phases, using the Delphi methodology. Considering the results of the survey, levodopa dose adjustment and dopamine agonists are the option with the best efficacy/tolerability ratio in the treatment of motor fluctuations. Rotigotine is useful in the motor fluctuations associated with gastroparesis, and intermittent subcutaneous apomorphine has positive effects in patients with unpredictable off periods. The most relevant adverse effect associated with dopamine agonists is impulse control disorder. Catechol-O-methyltransferase inhibitors are useful in the initial stages of motor fluctuations, especially in wearing off. Monoamine oxidase inhibitors are generally drugs that are well-tolerated and useful in motor fluctuations. If these measures are not effective, second-line treatments should be indicated on a case-by-case basis. CONCLUSION: The clinical profile of patients with Parkinson's disease is paramount in deciding the most appropriate therapy for the treatment of motor fluctuations.

TITLE: Experiencia clínica en el tratamiento de las fluctuaciones motoras en la enfermedad de Parkinson. Consenso Delphi de un grupo de expertos en trastornos del movimiento.Introducción. Las fluctuaciones motoras son una de las complicaciones más frecuentes en la enfermedad de Parkinson y su tratamiento sigue siendo complejo. Por ello, desde el Grupo de Trastornos del Movimiento de la Asociación Madrileña de Neurología presentamos nuestra experiencia clínica en el tratamiento de estas complicaciones, con la intención de que sea de utilidad en la toma de decisiones en la práctica clínica diaria. Desarrollo. Se elaboraron 19 preguntas a partir de una revisión bibliográfica y una encuesta abierta respondida por los miembros de dicho grupo. Dichas cuestiones se debatieron en dos fases, utilizando la metodología Delphi. Considerando los resultados de la encuesta, el ajuste de la dosis de levodopa y los agonistas dopaminérgicos son la opción con mejor relación eficacia/tolerabilidad en el tratamiento de las fluctuaciones motoras. La rotigotina es útil en las fluctuaciones motoras asociadas a gastroparesia, y la apomorfina subcutánea intermitente, en pacientes con off impredecible. El efecto adverso más relevante asociado a los agonistas dopaminérgicos es el trastorno del control de impulsos. Los inhibidores de la catecol-O-metiltransferasa son útiles en las fluctuaciones motoras de inicio, especialmente en el wearing off. Los inhibidores de la monoaminooxidasa son fármacos, en general, bien tolerados y útiles en las fluctuaciones motoras. En caso de que estas medidas no resulten eficaces, se deben indicar terapias de segunda línea de manera individualizada. Conclusión. El perfil clínico del paciente con enfermedad de Parkinson es primordial para decidir la terapia más adecuada en el tratamiento de las fluctuaciones motoras.

[A protocol for the treatment of retinopathy of prematurity in Spain]. / Protocolo de tratamiento de la retinopatía del prematuro en España.

OBJECTIVE: To prepare a protocol for the treatment of retinopathy of prematurity (ROP) agreed by the majority of Spanish ophthalmologists dedicated to this topic. MATERIAL AND METHOD: A draft of the protocol was produced taking into account the experience of the participants and up to date publications. This draft was corrected by all the ophthalmologists participating in the project, and the final document was agreed by all of them. RESULTS: We present general guidelines as an aid for the treatment of ROP, including treatment criteria, treatment methods, a calendar of action, and follow-up. CONCLUSIONS: It is important to have a common working protocol for the treatment of ROP to improve care and to avoid mistakes. Although individual Hospitals may adapt the protocol to their daily activity, it is recommended that there is a minimal working protocol agreed by most of professionals dedicated to pediatric ophthalmology in Spain.

Protocolo de tratamiento de la retinopatía del prematuro en España / A protocol for the treatment of retinopathy of prematurity in Spain

Objetivo: Realizar un protocolo de tratamiento de la retinopatía del prematuro (ROP) consensuado por la mayor parte de oftalmólogos españoles dedicados al tema. Material y método: Se realizó un borrador del protocolo según la experiencia de los participantes y las publicaciones actualizadas. Este borrador fue corregido por los participantes en el protocolo y se llegó al documento final consensuado por todos los participantes. Resultados: Se presentan las directrices generales para realizar el tratamiento de la ROP, incluyendo criterios de tratamiento, metodología de actuación, calendario de actuación y seguimiento. Conclusiones: Es importante disponer de un protocolo de actuación común en el tratamiento de la ROP para mejorar la actuación y evitar errores. Aunque cada centro hospitalario deba adaptar el protocolo a su actividad clínica, es recomendable que existan un mínimo de procedimientos consensuados por todos los oftalmólogos dedicados a la ROP (AU)

Objective: To prepare a protocol for the treatment of retinopathy of prematurity (ROP) agreed by the majority of Spanish ophthalmologists dedicated to this topic. Material and method: A draft of the protocol was produced taking into account the experience of the participants and up to date publications. This draft was corrected by all the ophthalmologists participating in the project, and the final document was agreed by all of them. Results: We present general guidelines as an aid for the treatment of ROP, including treatment criteria, treatment methods, a calendar of action, and follow-up. Conclusions: It is important to have a common working protocol for the treatment of ROP to improve care and to avoid mistakes. Although individual Hospitals may adapt the protocol to their daily activity, it is recommended that there is a minimal working protocol agreed by most of professionals dedicated to pediatric ophthalmology in Spain (AU)

Programa de cribado para la retinopatía del prematuro en España / Screening program for retinopathy of prematurity in Spain

Objetivo: Realizar un protocolo de cribado de la retinopatía del prematuro (ROP), consensuado por la mayor parte de oftalmólogos españoles dedicados al tema. Material y método: Se realizó un borrador del protocolo según la experiencia de los participantes y las publicaciones actualizadas. Este borrador fue corregido por los participantes en el protocolo y se llegó al documento final consensuado por todos los participantes. Resultados: Se presentan las directrices generales para realizar el cribado de la ROP, incluyendo criterios de inclusión y exclusión, metodología de exploración y calendario de actuación. Conclusiones: Es importante disponer de un protocolo de actuación común en el cribado de la ROP para mejorar la actuación y evitar errores. Aunque cada centro hospitalario deba adaptar el protocolo a su actividad clínica es recomendable que existan un mínimo de procedimientos consensuados por todos los oftalmólogos dedicados a la ROP (AU)

Objective: To prepare a retinopathy of prematurity (ROP) screening program as agreed by most of Spanish ophthalmologists dedicated to this topic. Material and method: A draft of the protocol was produced taking into account the experience of the participants and current publications. This draft was corrected by all the ophthalmologists participating in the project and the final document produced was agreed by all of them. Results: We present general guidelines to help in the screening of ROP, including treatment criteria, treatment methods, and a calendar of action. Conclusions: It is important to have a common working protocol in the screening of ROP to improve the action and to avoid mistakes. Although individual Hospitals may adapt the protocol to their daily activity, it is recommended that there is a minimal working protocol agreed by most of professionals dedicated to pediatric ophthalmology in Spain (AU)

Screening program for retinopathy of prematurity in Spain.

OBJECTIVE: To prepare a retinopathy of prematurity (ROP) screening program as agreed by most of Spanish ophthalmologists dedicated to this topic. MATERIALS AND METHODS: A draft of the protocol was produced taking into account the experience of the participants and current publications. This draft was corrected by all the ophthalmologists participating in the project and the final document produced was agreed by all of them. RESULTS: We present general guidelines to help in the screening of ROP, including treatment criteria, treatment methods, and a calendar of action. CONCLUSIONS: It is important to have a common working protocol in the screening of ROP to improve the action and to avoid mistakes. Although individual Hospitals may adapt the protocol to their daily activity, it is recommended that there is a minimal working protocol agreed by most of professionals dedicated to pediatric ophthalmology in Spain.

[X linked retinoschisis, unusual presentation: strabismus]. / Retinosquisis ligada al cromosoma X, presentación inusual: estrabismo.

CASE REPORT: X linked retinoschisis is a recessively inherited degenerative retinopathy. We report two cases that debuted with an unusual presentation (strabismus) in early childhood (months). Both of them presented with vitreous veils in the retinal periphery. Mutation in the XLRS1 gene was detected in both cases. DISCUSSION: X linked retinoschisis is one of the leading causes of macular degeneration in male children. Clinical features include a stellate foveal schisis, with or without peripheral retinoschisis. Clinical diagnosis is often difficult because of a high degree of phenotype variability. Furthermore, ERG and OCT may be normal in early stages of the disease. In our opinion, the XLRS1 gene mutation screening provides a powerful clinical tool for evaluating clinically ambiguous cases of X linked retinoschisis.

Retinosquisis ligada al cromosoma X, presentación inusual: estrabismo / X linked retinoschisis, unusual presentation: strabismus

Caso clínico: La retinosquisis ligada al cromosoma X es una retinopatía degenerativa de carácter recesivo. Presentamos dos casos clínicos que debutaron con una presentación atípica (estrabismo) en la infancia precoz (lactancia). Ambos niños presentaban velos vítreos en retina periférica. Se encontró una mutación en el gen XLRS1 en ambos casos. Discusión: La retinosquisis ligada al cromosoma X es una de las causas principales de degeneración macular en niños varones. Se caracteriza por una esquisis foveal estrellada, asociada o no a retinosquisis periférica. El diagnóstico clínico puede ser difícil por la alta variabilidad fenotípica del cuadro. Además, el ERG y la OCT pueden ser normales en fases precoces de la enfermedad y de difícil realización en niños pequeños. Consideramos que el cribado para la mutación del gen XLRS1 es útil para evaluar casos con presentación atípica de retinosquisis ligada al cromosoma X y/o en niños en los que otras pruebas complementarias no son realizables(AU)

Case report: X linked retinoschisis is a recessively inherited degenerative retinopathy. We report two cases that debuted with an unusual presentation (strabismus) in early childhood (months). Both of them presented with vitreous veils in the retinal periphery. Mutation in the XLRS1 gene was detected in both cases. Discussion: X linked retinoschisis is one of the leading causes of macular degeneration in male children. Clinical features include a stellate foveal schisis, with or without peripheral retinoschisis. Clinical diagnosis is often difficult because of a high degree of phenotype variability. Furthermore, ERG and OCT may be normal in early stages of the disease. In our opinion, the XLRS1 gene mutation screening provides a powerful clinical tool for evaluating clinically ambiguous cases of X linked retinoschisis(AU)

Use of fully covered self-expanding metal stents for the management of benign biliary conditions.

BACKGROUND AND AIM: biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. PATIENTS AND METHODS: in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. RESULTS: twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36-270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). CONCLUSIONS: in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions.

Utilización de prótesis metálicas autoexpandibles totalmente recubiertas en procesos biliares benignos / No disponible

Introducción y objetivo: las prótesis metálicas autoexpandibles biliares (PMAB) tienen la ventaja de introducirse plegadas con calibres muy pequeños y proporcionar, al abrirse completamente, diámetros grandes para el drenaje biliar. Su utilización en procesos benignos ha estado muy limitada, fundamentalmente por la dificultad en su extracción. Presentamos nuestra experiencia inicial con una PMAB totalmente recubierta (Wallflex) para tratar patología benigna de la vía biliar. Pacientes y métodos: en un estudio descriptivo prospectivo se insertaron por CPRE prótesis de 8 mm de diámetro y 4, 6 u 8 cm de longitud, cuando se consideró que para el drenaje biliar eran precisos diámetros superiores a 10 french (3,3 mm). Las prótesis se retiraron también por endoscopia varios meses después según se consideró oportuno clínicamente. Resultados: se insertaron 20 PMAB. Los motivos fueron: gran fístula biliar intrahepática tras cirugía de quiste hidatídico (1), perforación del área papilar por esfinterotomía endoscópica (2), recanalización de prótesis no recubiertas insertadas en procesos benignos (3), estenosis benignas (7), coledocolitiasis múltiples y de gran tamaño con afilamiento-estenosis del colédoco distal que no pudieron extraerse (7). En todos los casos se logró un drenaje biliar satisfactorio y no se produjeron complicaciones por la inserción. Las prótesis se extrajeron con facilidad a los 132 días de media (36-270). La resolución completa de los procesos se obtuvo en 14 pacientes (70%). Conclusiones: en nuestra experiencia inicial, la prótesis Wallflex biliar totalmente recubierta pudo extraerse sin complicaciones tras permanecer en el colédoco hasta una media de más de cuatro meses, por lo que podría utilizarse en el tratamiento de procesos biliares benignos(AU)

Background and aim: biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. Patients and methods: in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. Results: twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36- 270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). Conclusions: in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions(AU)

Endarterectomía carotídea: descripción, resultados y evolución clínica en 100 pacientes sintomáticos consecutivos / Carotid endarterectomy: description, results and clinic evolution in 100 consecutive symptomatic patients

Introducción. La endarterectomía carotídea (EC) ha demostrado ser eficaz en la prevención secundaria de ictus isquémico en pacientes con estenosis sintomática de arteria carótida interna (ACI) mayor del 70%. Este beneficio está condicionado por la morbimortalidad perioperatoria del centro. Pese a la recomendación de analizar y comunicar los resultados de la EC en centros que la realizan de forma habitual, son muy escasas las publicaciones al respecto. El objetivo de nuestro estudio fue analizar el perfil de pacientes intervenidos y riesgo quirúrgico asociado a la EC en nuestro hospital. Material y métodos. Se incluyeron 100 pacientes consecutivos intervenidos entre 2002 y 2006. Se recogieron datos sobre antecedentes patológicos, clínica de inicio, hallazgos ultrasonográficos (incluido Doppler transcraneal y carotídeo), neuroimagen, complicaciones intra y postoperatorias y evolución clínica a los 3 meses. Se compararon con resultados de los estudios previos, incluidos los ensayos clínicos NASCET, ECST y series publicadas en nuestro país. Resultados. En nuestra serie destaca el elevado perfil de riesgo de los pacientes. Hubo predominio masculino (74% frente a 26 %), con una edad media de 70 (8,5) años, un 36% de pacientes mayores de 75 años. En un 42% la estenosis de ACI fue >90% y en un 14% existía una estenosis crítica u oclusión de ACI contralateral. La clínica de presentación más frecuente fue el infarto cerebral establecido (67%). La complicación intra y postoperatoria más frecuente fue la alteración hemodinámica subclínica (67 y 45%, respectivamente). Un 4% de los pacientes presentaron recidiva del ictus y uno un síndrome de reperfusión. Dos pacientes fallecieron. La tasa de ictus-mortalidad a 3 meses se situó en el 5%. Conclusión. Nuestros pacientes presentan un perfil de alto riesgo con una morbimortalidad asociada a la EC dentro de los rangos de seguridad recomendados. Pese a las recomendaciones vigentes, son escasas las auditorías internas evaluando el riesgo quirúrgico en cada centro (AU)

Introduction. The efficacy of endarterectomy in symptomatic carotid stenosis greater than 70% in secondary stroke prevention has been demonstrated although the benefit is dependent upon the perioperative morbidity and mortality risk. Despite the recommendation that the results of centres regularly practicing endarterectomies be analysed and reported, few studies have in fact been published. The aim of our study was to analyze the incidence of surgical complications from carotid endarterectomy at our hospital and to describe the stroke profile of the operated patients. Material and methods. 100 consecutive patients submitted to carotid endarterectomy between 2002 and 2006 were included. We recorded stroke risk factors, clinical presentation, ultrasonography findings including transcranial and carotid eco-Doppler, neuroimaging, intra and perioperative complications including mortality- stroke rate, and clinical outcome at three months. We compare our results with the NASCET, ECST and Spanish published series. Results. Males predominated (74 % vs 26 %). The mean age was 70±8.5 years with 36 % of patients older than 75 years. Arterial hypertension was the most common vascular risk factor (74%), 14% had a critical contralateral carotid stenosis or occlusion. Stroke was the most frequent clinical presentation (67 %). The most commonly detected intraoperatory and postoperatory complication was subclinical haemodynamic changes (67% and 45% respectively). Cranial nerve lesions were the most usual local complication. Four patients suffered stroke recurrence, leading to death in one. A further patient died due to a reperfusion syndrome. The rate of stroke-mortality at three months was 5%. Conclusions. Morbidity and mortality related to carotid endarterectomy for symptomatic stenosis greater than 70 % was within guideline ranges. Surgical risk at every centre should be periodically evaluated in order to guarantee that acceptable standards are maintained (AU)

Biliary sphincterotomy dilation for the extraction of difficult common bile duct stones

Background and aim: endoscopic retrograde cholangiopancreatography(ERCP) with biliary sphincterotomy (BS) is the usualmethod for extracting common bile duct stones. However, followingBS and by means of extraction balloons and Dormia baskets acomplete bile duct clearance cannot be achieved in all cases. Wepresent a study on the impact that hydrostatic balloon dilation of aprevious BS (BSD) may have in the extraction rate of choledocholithiasis.Patients and methods: a prospective study which included 91consecutive patients diagnosed with choledocholithiasis who underwentERCP. For stone removal, extraction balloons and Dormia basketswere used, and when necessary BSD was employed.Results: complete bile duct clearance was achieved in 86/91(94.5%) patients. BSD was used in 30 (33%) cases. In these cases,extraction was complete in 29/30 (97%); 23 (76%) patients in theBSD group had anatomic difficulties or bleeding disorders. Themost frequently used hydrostatic balloon diameter was 15 mm(60%). There were 7 (7.6%) complications: two self-limited hemorrhageepisodes in the BSD group and one episode of cholangitis,one of pancreatitis, and three of bleeding in the group inwhich BSD was not used.Conclusions: BSD is a very valuable tool for extracting commonbile duct stones. In our experience, there has been an increasein the extraction rate from 73% (Rev Esp Enferm Dig2002; 94: 340-50) to 94.5% (p = 0.0001, OR 0.1, CI 0.05-0.45), with no increase in complications(AU)

[Palliative management of malignant gastric outlet obstruction with endoscopically inserted self-expanding metal stents].

AIM AND BACKGROUND: the insertion of self-expanding metal stents to palliate malignant gastric outlet obstruction is a minimally invasive procedure that is being increasingly used. We discuss experience with this technique in a level-II hospital in the Spanish National Health System. PATIENTS AND METHODS: a retrospective five-year study (2003-2007) was conducted in 23 patients who underwent 27 procedures aimed at resolving malignant gastric outlet obstruction (mean, 0.45 procedures per month) using endoscopically inserted noncovered stents (Wallstent and Wallflex). RESULTS: insertion was technically feasible in all 27 (100%) attempts, with satisfactory clinical results in 25 cases (92.5%). Endoscopy alone was used 10 times (37%), and both endoscopy and fluoroscopy on 17 (63%) occasions. After stent insertion, one patient was intervened for treatment, and a patient with an unsuccessful prosthesis received a palliative surgical bypass. Four stents became obstructed by tumoral ingrowth, and patency was reestablished by inserting a new stent. Obstructive jaundice caused by stents covering the papilla of Vater occurred in three cases. There were no other complications or mortality due to the procedure. Mean survival was 104 days (range 28-400, SD +/- 94). CONCLUSIONS: in our experience endoscopic insertion of self-expanding metal stents appears to be a safe and efficient palliative method for malignant gastric outlet obstruction, and can be performed successfully in a center with our characteristics.

Tratamiento paliativo de la obstrucción tumoral del vaciamiento gástrico con prótesis metálicas autoexpandibles insertadas endoscópicamente / No disponible

Antecedentes y objetivo: la inserción de prótesis metálicas autoexpandiblespara paliar la obstrucción tumoral del vaciamiento gástricoes un procedimiento mínimamente invasivo, que cada vez seutiliza con más frecuencia. Presentamos la experiencia de esta técnicaen un hospital de nivel II del Sistema Nacional de Salud.Pacientes y métodos: estudio retrospectivo de un periodo decinco años (2003-2007), en los que se trató de resolver la obstruccióntumoral del vaciamiento gástrico en 27 ocasiones a 23 pacientes(media de 0,45 procedimientos por mes), mediante la inserciónendoscópica de prótesis no recubiertas (Wallstent® y Wallflex®).Resultados: la inserción fue técnicamente posible en el 100%de los 27 intentos. Se obtuvo un buen resultado clínico en 25 ocasiones(92,5%). Se utilizó sólo endoscopia 10 (37%) veces y en lasotras 17 (63%) también fluoroscopia. Tras la inserción de la prótesisse intervino a un paciente con intención curativa y a otro, enel que la prótesis no funcionó, para realizar una derivación paliativa.Cuatro prótesis se obstruyeron por crecimiento tumoral, recanalizándosemediante la inserción de nuevas prótesis. En tres ocasionesse produjo ictericia obstructiva en prótesis que cubrían lapapila de Vater. No hubo otras complicaciones. Tampoco mortalidadderivada del procedimiento. La media de supervivencia fuede 104 días (rango 28-400, DE ± 94).Conclusiones: en nuestra experiencia, la inserción endoscópicade prótesis metálicas autoexpandibles parece un método seguroy eficaz en el tratamiento paliativo de la obstrucción tumoraldel vaciamiento gástrico y puede llevarse a cabo con éxito en uncentro de nuestras características

Aim and background: the insertion of self-expanding metalstents to palliate malignant gastric outlet obstruction is a minimallyinvasive procedure that is being increasingly used. We discussexperience with this technique in a level-II hospital in the SpanishNational Health System.Patients and methods: a retrospective five-year study(2003-2007) was conducted in 23 patients who underwent 27procedures aimed at resolving malignant gastric outlet obstruction(mean, 0.45 procedures per month) using endoscopically insertednoncovered stents (Wallstent® and Wallflex®).Results: insertion was technically feasible in all 27 (100%) attempts,with satisfactory clinical results in 25 cases (92.5%). Endoscopyalone was used 10 times (37%), and both endoscopy andfluoroscopy on 17 (63%) occasions. After stent insertion, one patientwas intervened for treatment, and a patient with an unsuccessfulprosthesis received a palliative surgical bypass. Four stentsbecame obstructed by tumoral ingrowth, and patency was reestablishedby inserting a new stent. Obstructive jaundice caused bystents covering the papilla of Vater occurred in three cases. Therewere no other complications or mortality due to the procedure.Mean survival was 104 days (range 28-400, SD ± 94).Conclusions: In our experience endoscopic insertion of selfexpandingmetal stents appears to be a safe and efficient palliativemethod for malignant gastric outlet obstruction, and can be performedsuccessfully in a center with our characteristics

[Prognostic factors in patients admitted with type 2 diabetes in Internal Medicine Services: hospital mortality and readmission in one year (DICAMI study)]. / Factores pronósticos en pacientes con diabetes mellitus tipo 2 ingresados en Servicios de Medicina Interna: mortalidad y reingreso hospitalario en un año (estudio DICAMI).

INTRODUCTION: Type II diabetes mellitus (T2DM) is a prevalent Public Health Care problem that causes an increase in morbidity, mortality and number of hospital admissions as well as increased costs in care services in this population group. The clinical indicator that determine readmission and/or death are analyzed in a 12 month follow-up period. METHODS: All T2DM patients admitted in Spanish Internal Medicine Services between two different periods (june 1-15, 2003 and november 1-15) were enrolled in a prospective cohort study. Primary endpoint were readmission and/or death in the year following the first admission. RESULTS: Population of the study (n = 482) was distributed in 229 males (47.5%) and 253 females (52.5%). Mean age was 73.48 +/- 8.86 years. A total of 210 (43.6%) were not readmitted to the hospital and/or died in the follow-up and 272 (56.4%) were readmitted and/or died. The latter 272 patients had a significantly greater percentage of heart failure (odds ratio [OR] 1.760; 1.073-2.886), atrial fibrillation (OR 1.747; 1.010- 3.022) and previous history of systolic blood pressure (OR 0.400; 0.241-0.666). They also showed increased levels of plasma glucose (OR 1.004; 1.001-1.007), and lower concentration of plasma hemoglobin (OR 0.756; 0.677-0.845) and creatinine clearance (OR 0.985; 0.976-0.994). CONCLUSIONS: T2DM patients who are admitted to the Internal Medicine Services in Spain are elderly patients with elevated indices of readmission and death in a short follow-up period (one year). The coexistence of heart failure, atrial fibrillation, renal dysfunction deterioration and decrease in hemoglobin levels may predict this worse outcome.

Factores pronósticos en pacientes con diabetes mellitus tipo 2 ingresados en Servicios de Medicina Interna: mortalidad y reingreso hospitalario en un año (estudio DICAMI) / Prognostic factors in patients admitted with type 2 diabetes in Internal Medicine Services: hospital mortality and readmission in one year (DICAMI study)

Introducción. La diabetes mellitus tipo 2 (DMT2) constituye un problema de Salud Pública que determina un incremento de la mortalidad y del número de ingresos hospitalarios, con un aumento de los costes sanitarios en este grupo de población. Se analizan los indicadores clínicos que determinan el reingreso y/o muerte en un año de seguimiento. Métodos. Estudio de cohorte prospectivo de pacientes ingresados en Servicios de Medicina Interna con el diagnóstico de DMT2 en dos períodos diferentes (1-15 de junio y 1-15 de noviembre de 2003). Como variable resultado se consideraron el reingreso hospitalario y/o la muerte en un año de seguimiento. Resultados. El grupo de estudio lo constituyen 482 pacientes, 229 varones (47,5%) y 253 mujeres (52,5%) con 73,48 ± 8,86 años de edad. Doscientos diez (43,6%) no reingresaron y/o fallecieron en el seguimiento y 272 (56,4%) reingresaron y/o fallecieron. Estos 272 pacientes presentaron de forma significativa un porcentaje mayor de insuficiencia cardíaca (odds ratio [OR] 1,760; 1,073-2,886), fibrilación auricular (OR 1,747; 1,010-3,022), historia previa de presión arterial sistólica (PAS) > 130 mmHg (OR 0,400; 0,241-0,666), niveles superiores de glucemia al ingreso (OR 1,004; 1,001-1,007), niveles más bajos de hemoglobina (OR 0,756; 0,677-0,845) y aclaramiento de creatinina (OR 0,985; 0,976-0,994). Conclusiones. La DMT2 que ingresa en los Servicios de Medicina Interna se da en pacientes de edad avanzada y elevados índices de reingreso hospitalario y/o muerte en períodos de seguimiento cortos (un año). La coexistencia de insuficiencia cardíaca, fibrilación auricular, deterioro de función renal y descenso de cifras de hemoglobina pudiera predecir está peor evolución (AU)

Introduction. Type II diabetes mellitus (T2DM) is a prevalent Public Health Care problem that causes an increase in morbidity, mortality and number of hospital admissions as well as increased costs in care services in this population group. The clinical indicator that determine readmission and/or death are analyzed in a 12 month follow-up period. Methods. All T2DM patients admitted in Spanish Internal Medicine Services between two different periods (june 1-15, 2003 and november 1-15) were enrolled in a prospective cohort study. Primary endpoint were readmission and/or death in the year following the first admission. Results. Population of the study (n = 482) was distributed in 229 males (47.5%) and 253 females (52.5%). Mean age was 73.48 ± 8.86 years. A total of 210 (43.6%) were not readmitted to the hospital and/or died in the follow-up and 272 (56.4%) were readmitted and/or died. The latter 272 patients had a significantly greater percentage of heart failure (odds ratio [OR] 1.760; 1.073-2.886), atrial fibrillation (OR 1.747; 1.010- 3.022) and previous history of systolic blood pressure (OR 0.400; 0.241-0.666). They also showed increased levels of plasma glucose (OR 1.004; 1.001-1.007), and lower concentration of plasma hemoglobin (OR 0.756; 0.677-0.845) and creatinine clearance (OR 0.985; 0.976-0.994). Conclusions. T2DM patients who are admitted to the Internal Medicine Services in Spain are elderly patients with elevated indices of readmission and death in a short follow-up period (one year). The coexistence of heart failure, atrial fibrillation, renal dysfunction deterioration and decrease in hemoglobin levels may predict this worse outcome (AU)

[Ocular manifestations in Proteus syndrome]. / Manifestaciones oculares en el síndrome de Proteus.

CASE REPORT: Congenital disfiguring malformations are rare and usually have a multifactorial aetiology. Here we report on the ocular manifestations seen in a patient with Proteus syndrome. The retina showed retinal dysgenesia, retinal pigmentary abnormalities and optic nerve hypoplasia. Other abnormalities included strabismus and high myopia. DISCUSSION: Proteus syndrome is a complex hamartomatous disorder defined by local overgrowth, subcutaneous tumours and various bone, cutaneous and/or vascular anomalies. The incidence of ocular malformations in Proteus syndrome is unknown, however a meticulous cranio-facial examination and a systematic study of the eye is required to improve the medical care of these patients.

Manifestaciones oculares en el síndrome de Proteus / Ocular manifestations in proteus syndrome

Caso clínico: Las malformaciones congénitas deformantes son raras y tienen una etiología multifactorial. Presentamos las manifestaciones oculares de un caso clínico de Síndrome de Proteus. La retina mostraba una desorganización difusa, alteraciones pigmentarias e hipoplasia de nervio óptico. Otras alteraciones eran estrabismo y alta miopía. Discusión: El Síndrome de Proteus es un complejo trastorno hamartomatoso caracterizado por un crecimiento local exagerado, tumores subcutáneos y diversas malformaciones óseas, cutáneas y/o vasculares. La incidencia de las malformaciones oculares en el Síndrome de Proteus es desconocida, precisando un examen craneofacial minucioso y un estudio sistemático ocular en estrecha relación multidisciplinaria para mejorar la asistencia de estos pacientes (AU)

Case report: Congenital disfiguring malformations are rare and usually have a multifactorial aetiology. Here we report on the ocular manifestations seen in a patient with Proteus syndrome. The retina showed retinal dysgenesia, retinal pigmentary abnormalities and optic nerve hypoplasia. Other abnormalities included strabismus and high myopia. Discussion: Proteus syndrome is a complex hamartomatous disorder defined by local overgrowth, subcutaneous tumours and various bone, cutaneous and/or vascular anomalies. The incidence of ocular malformations in Proteus syndrome is unknown, however a meticulous cranio-facial examination and a systematic study of the eye is required to improve the medical care of these patients