Dermatosis purpúricas pigmentadas. Revisión de la literatura científica / Pigmented Purpuric Dermatosis: A Review of the Literature

Las dermatosis purpúricas pigmentadas son un grupo de enfermedades benignas y de curso crónico. Las variantes descritas representan distintas formas clínicas de una misma entidad con unas características histopatológicas comunes para todas ellas. Exponemos a continuación un resumen de las variedades más frecuentes, sus características clínicas, dermatopatológicas y de epiluminiscencia. Al tratarse de una entidad clínica poco frecuente, benigna, y no conocerse claramente los mecanismos patogénicos de la misma, no existen tratamientos estandarizados. Se revisan los tratamientos publicados hasta el momento, la mayoría de ellos basados en casos aislados o pequeñas series de casos, sin poder establecer un nivel de evidencia suficiente como para ser recomendado ninguno de ellos como tratamiento de elección

The pigmented purpuric dermatoses are a group of benign, chronic diseases. The variants described to date represent different clinical presentations of the same entity, all having similar histopathologic characteristics. We provide an overview of the most common PPDs and describe their clinical, dermatopathologic, and epiluminescence features. PPDs are both rare and benign, and this, together with an as yet poor understanding of the pathogenic mechanisms involved, means that no standardized treatments exist. We review the treatments described to date. However, because most of the descriptions are based on isolated cases or small series, there is insufficient evidence to support the use of any of these treatments as first-line therapy

Pigmented Purpuric Dermatosis: A Review of the Literature. / Dermatosis purpúricas pigmentadas. Revisión de la literatura científica.

The pigmented purpuric dermatoses are a group of benign, chronic diseases. The variants described to date represent different clinical presentations of the same entity, all having similar histopathologic characteristics. We provide an overview of the most common PPDs and describe their clinical, dermatopathologic, and epiluminescence features. PPDs are both rare and benign, and this, together with an as yet poor understanding of the pathogenic mechanisms involved, means that no standardized treatments exist. We review the treatments described to date. However, because most of the descriptions are based on isolated cases or small series, there is insufficient evidence to support the use of any of these treatments as first-line therapy.

Intervención en ancianos con multimorbilidad y polimedicados: resultados en la prescripción y en la calidad de vida / Intervention in elderly patients with multiple morbidities and multiple medications: results of the prescription and the quality of life

Objetivo. Evaluar el efecto de una intervención a través de los criterios de STOPP/START y el algoritmo de Garfinkel sobre la prescripción y la calidad de vida relacionada con la salud (CVRS) en ancianos polimedicados con multimorbilidad. Material y método. Estudio de intervención antes-después en 381 pacientes mayores de 67 años polimedicados de 71 médicos de atención primaria. Intervención: se formó a los médicos en los criterios de STOPP/START y en el algoritmo de Garfinkel. Cada médico revisó todos los medicamentos de sus enfermos seleccionados, posteriormente los citó a una primera consulta para realizarles una valoración clínica, modificarles el tratamiento según los criterios y medirles la CVRS mediante el cuestionario Short-Form Health Survey-V2 (SF-12). A los 2 meses, en una segunda consulta, se les realizó una nueva valoración clínica y se midió la CVRS. Las dimensiones de la CVRS entre la primera y la segunda consulta fueron comparadas con la «t» de Student pareada. Resultados. La intervención supuso la retirada de 1,5 fármacos de promedio por enfermo. Se modificó la dosis en el 4% de fármacos; al 8,9% de los pacientes se les prescribió un fármaco nuevo. Los AINE, fármacos psicoactivos e inhibidores de la bomba de protones fueron los más modificados. Mejoraron significativamente (p < 0,05) la función social y el componente sumario físico de la CVRS tras la intervención. Conclusión. La intervención mediante el algoritmo de Garfinkel y los criterios de STOPP/START conllevó una mejora de la CVRS y redujo el número de fármacos prescritos (AU)

Objective. To evaluate the effect of an intervention using STOPP/START criteria and the Garfinkel algorithm on prescription and the health-related quality of life (HRQoL) in elderly patients with multimorbidity and prescribed multiple medications. Material and method. A before-after intervention study on 381 patients over 67 years old and prescribed multiple medications by 71 Primary Care doctors. Intervention: The doctors were trained in the STOPP / START criteria and Garfinkel algorithm. Each doctor then reviewed all the drugs of their selected patients and then made appointments with them for an initial medical consultation and clinical assessment. Treatment was modified according to the criteria and the HRQoL measured using the SF-12 questionnaire. Two months later, in a second medical consultation, a new clinical assessment was made and the HRQoL was measured. The dimensions of the HRQoL between the first and the second consultation were compared using the paired Student-t test. Results. The intervention involved the removal of a mean of 1.5 drugs per patient. The dose was modified in 4% of drugs, and 8.9% of patients were prescribed a new drug. Non-Steroidal Anti-inflammatory drugs (NSAID), psychoactive drugs and proton pump inhibitors were the most modified. Social Function and Physical Component Summary of the HRQOL improved significantly (P < .05) after intervention. Conclusion. The intervention using the Garfinkel algorithm and STOPP -START criteria improved HRQoL and reduced the number of prescribed drugs (AU)

[Intervention in elderly patients with multiple morbidities and multiple medications: results of the prescription and the quality of life]. / Intervención en ancianos con multimorbilidad y polimedicados: resultados en la prescripción y en la calidad de vida.

OBJECTIVE: To evaluate the effect of an intervention using STOPP/START criteria and the Garfinkel algorithm on prescription and the health-related quality of life (HRQoL) in elderly patients with multimorbidity and prescribed multiple medications. MATERIAL AND METHOD: A before-after intervention study on 381 patients over 67 years old and prescribed multiple medications by 71 Primary Care doctors. INTERVENTION: The doctors were trained in the STOPP / START criteria and Garfinkel algorithm. Each doctor then reviewed all the drugs of their selected patients and then made appointments with them for an initial medical consultation and clinical assessment. Treatment was modified according to the criteria and the HRQoL measured using the SF-12 questionnaire. Two months later, in a second medical consultation, a new clinical assessment was made and the HRQoL was measured. The dimensions of the HRQoL between the first and the second consultation were compared using the paired Student-t test. RESULTS: The intervention involved the removal of a mean of 1.5 drugs per patient. The dose was modified in 4% of drugs, and 8.9% of patients were prescribed a new drug. Non-Steroidal Anti-inflammatory drugs (NSAID), psychoactive drugs and proton pump inhibitors were the most modified. Social Function and Physical Component Summary of the HRQOL improved significantly (P<.05) after intervention. CONCLUSION: The intervention using the Garfinkel algorithm and STOPP -START criteria improved HRQoL and reduced the number of prescribed drugs.

[The appropriate use of pharmacological treatment in patients with chronic heart failure. A perspective from Primary Care]. / Grado de adecuación del tratamiento farmacológico en pacientes con insuficiencia cardíaca crónica. Visión desde atención primaria.

INTRODUCTION AND OBJECTIVE: The appropriate use of pharmacological treatment according to the indications in Clinical Guidelines reduces morbidity and mortality in patients with chronic heart failure (CHF). There are numerous studies regarding this in the hospital environment, but there are few studies done in Primary Care. The objective of this study is to evaluate the degree of compliance by Primary Care doctors to the Clinical Guidelines of the European Society of Cardiology in patients with CHF. METHODS: A descriptive, observational study on the use of indication-prescription drugs was conducted. POPULATION AND SAMPLE: Primary Care teams of the Leon Health Area (9 urban and 19 rural). The study population included patients with a diagnosis of New York Heart Association (NYHA) Grade II-IV chronic heart failure, from a register of 2047 with chronic heart failure patients treated by 97 Primary Care doctors. A proportional representative random sample of 474 patients from the urban and rural areas was studied. MAIN MEASUREMENTS: Adherence to the drugs recommended in the Clinical Guidelines was evaluated using two indicators; one overall, and another for drugs with a higher level of evidence (A1: angiotensin converting enzyme inhibitors-angiotensin II receptor antagonists [ACE-I/ARA-II], ß-blockers [BB] and spironolactone). RESULTS: A total of 456 patients were studied, with a mean age of 78.4 years, and 53.1% females. Arterial hypertension (AHT) and ischaemic heart disease were present in 64.7% of patients. The mean comorbidity rate, excluding CHF, was 2.9. Around 40% were diagnosed a NYHA Grade 11-1V. The overall compliance rate (diuretics, ACE-I/ARA-II, ß-blockers, spironolactone, digoxin, and oral anticoagulants) and rate of adherence to evidence-based ones was 55.2% and 44.6%, respectively. There was low compliance by 39.5%, and only 12.9% of patients showed perfect compliance with the drugs with a higher level of evidence, while to be less than 70 years-old, a history of ischaemia, AHT, and a hospital admission, were variables associated with better adherence to treatment. CONCLUSION: There is a low use of the drugs recommended by the Clinical Guidelines for heart failure, particularly of those with better evidence for reducing morbidity and mortality.

Grado de adecuación del tratamiento farmacológico en pacientes con insuficiencia cardíaca crónica. Visión desde atención primaria / The appropriate use of pharmacological treatment in patients with chronic heart failure. A perspective from Primary Care

Introducción y objetivo. La adecuación del tratamiento farmacológico a las indicaciones de las guías clínicas reduce la morbimortalidad en enfermos con insuficiencia cardíaca crónica (ICC). Numerosos estudios informan sobre esta adecuación en el ámbito hospitalario, mientras que en atención primaria son escasos. El objetivo es evaluar el grado de adecuación a la guía clínica de la Sociedad Europea de Cardiología en la ICC en los pacientes de médicos de atención primaria. Métodos. Diseño observacional descriptivo, de utilización de medicamentos, tipo indicación-prescripción. Población y muestra: equipos de atención primaria del Área Sanitaria de León (9 urbanos y 19 rurales). La población de estudio está formada por los pacientes con un diagnóstico de insuficiencia cardíaca crónica en grado II-IV de la New York Heart Association (NYHA), de un registro de 2.047 con insuficiencia cardíaca crónica, pertenecientes a 97 médicos de atención primaria. Mediante un muestreo aleatorio se seleccionaron 474 enfermos con afijación proporcional a los estratos rural y urbano. Mediciones principales: se evalúa la adherencia a los fármacos recomendados en la guía clínica mediante 2 indicadores, uno global y otro para fármacos con mayor grado de evidencia (A1: inhibidores de la enzima conversora de angiotensina/antagonistas de los receptores de angiotensina II [IECA/ARA-II], β-bloqueantes [BB] y espironolactona). Resultados. Se estudian 456 enfermos, con una edad promedio de 78,4 años, de los cuales son mujeres el 53,1%. La hipertensión arterial (HTA) y la isquemia cardíaca causan el 64,7%. La comorbilidad promedio, excluyendo la ICC, fue de 2,9. El 40,4% están en grado III-IV de la NYHA. El Índice de Adherencia Global (diuréticos, IECA/ARA-II, β-bloqueantes, espironolactona, digoxina y anticoagulantes orales) y el de Adherencia a la Evidencia A1 (IECA/ARA-II, BB y espironolactona) fueron del 55,2 y del 44,6%, respectivamente. El 39,5% tiene una baja adherencia, solo el 12,9% de los pacientes exhiben una perfecta adherencia a los medicamentos con el mejor grado de evidencia, mientras que tener menos de 70 años, los antecedentes de isquemia, HTA e ingreso hospitalario son variables asociadas a mejor adherencia. Conclusión. Existe una infrautilización de medicamentos recomendados por la guía clínica para la insuficiencia cardíaca, sobre todo de aquellos con mejores evidencias para reducir la morbimortalidad (AU)

Introduction and objective. The appropriate use of pharmacological treatment according to the indications in Clinical Guidelines reduces morbidity and mortality in patients with chronic heart failure (CHF). There are numerous studies regarding this in the hospital environment, but there are few studies done in Primary Care. The objective of this study is to evaluate the degree of compliance by Primary Care doctors to the Clinical Guidelines of the European Society of Cardiology in patients with CHF. Methods. A descriptive, observational study on the use of indication-prescription drugs was conducted. Population and sample: Primary Care teams of the Leon Health Area (9 urban and 19 rural). The study population included patients with a diagnosis of New York Heart Association (NYHA) Grade II-IV chronic heart failure, from a register of 2047 with chronic heart failure patients treated by 97 Primary Care doctors. A proportional representative random sample of 474 patients from the urban and rural areas was studied. Main measurements: Adherence to the drugs recommended in the Clinical Guidelines was evaluated using two indicators; one overall, and another for drugs with a higher level of evidence (A1: angiotensin converting enzyme inhibitors-angiotensin II receptor antagonists [ACE-I/ARA-II], β-blockers [BB] and spironolactone). Results. A total of 456 patients were studied, with a mean age of 78.4 years, and 53.1% females. Arterial hypertension (AHT) and ischaemic heart disease were present in 64.7% of patients. The mean comorbidity rate, excluding CHF, was 2.9. Around 40% were diagnosed a NYHA Grade 11-1V. The overall compliance rate (diuretics, ACE-I/ARA-II, β-blockers, spironolactone, digoxin, and oral anticoagulants) and rate of adherence to evidence-based ones was 55.2% and 44.6%, respectively. There was low compliance by 39.5%, and only 12.9% of patients showed perfect compliance with the drugs with a higher level of evidence, while to be less than 70 years-old, a history of ischaemia, AHT, and a hospital admission, were variables associated with better adherence to treatment. Conclusion. There is a low use of the drugs recommended by the Clinical Guidelines for heart failure, particularly of those with better evidence for reducing morbidity and mortality (AU)

Morphometric study of testis of Wistar rat after open-ended vasectomy.

The effects on the testis of open-ended vasectomy in the Wistar rat have been assessed morphometrically and evaluated statistically at 1, 4, 12, and 24 weeks after operation, and compared to those in sham-operated controls. The open-ended technique, ie, without ligation of the epididymal end of the cut ductus deferens, allowed drainage of sperm into the spermatic cord. During the period of our study, it did not affect the structure of the testis; although the germinal epithelium, basement membrane, and the stroma and cells of the interstitial space all showed variations when compared to the control group, these were not statistically significant.

The vasectomized testis.

We have performed a qualitative study on effects of vasectomy on the testicular structure. Vasectomy performed with the traditional technique changes testicular structure. At first, the injuries are slight and restricted, but gradually, and in a time-dependent manner, become more severe and extensive. Ultrastructure studies indicate that the spermatogonia and Sertoli's cells are the most resistant to vasectomy, and are even observed in some regenerating testes lacking a complete germinal epithelium. Morphometric studies revealed a decrease in epithelial depth, an increase in the thickness of the basement membrane and in surface of the interstitial space, all significant (P < 0.01) with respect to the control. However, the percentage of the interstitial tissue occupied by cells, did not show any significant difference. We propose that the increase of intraluminal pressure is the essential factor that provokes testicular atrophy.

[Effects of experimental vasectomy on testicular structure: ultrastructural study]. / Efectos de la vasectomía experimental sobre la estructura del testículo: estudio ultraestructural.

We have performed experimental vasectomies in dogs in order to study effects of vas deferens ligature with close technique, on the testicular ultrastructure. We point out the existence of alterations: structural changes of the seminiferous epithelium, great extracellular spaces which are generated for the premature exfoliation of germinal cells, degeneration of the germinal shock cells, the appearance of immature germinal cells and multinucleate spermatids in every stages of the spermatogenesis, the fall of mature spermatozoid number, thickening of basal membrane, relative increase in the Sertoli's cells size as well as their phagocytic function, and existence of spermaphagos unfasted into tubular lumen. The Leydig's interstitial islets show an absolutely normal cellular and vascular configuration.

[Experimental vasectomy: comparison of epididymal structure with various surgical techniques]. / Vasectomía experimental: comparación de la estructura del epidídimo mediante diferentes técnicas quirúrgicas.

OBJECTIVE: To analyze the effects of different surgical techniques of vasectomy on the epididymal structure. METHODS: Experimental vasectomies were performed in dogs using the conventional and open-ended techniques. The animals were orchidectomized 1 to 12 months after vasectomy and the epididymal structure was analyzed. RESULTS: The epididymal structure of dogs submitted to the conventional technique showed marked ectasia, reinforced basement membrane, loss of stereocilia in the principal cells, and formation of spermatic granulomas in interstitial tissue. At 12 months the principal cells showed signs of degenerative changes. In the different time periods analyzed in the study, no changes were observed in the epididymal structure of dogs submitted to the open-ended technique. CONCLUSIONS: The changes observed in the principal cells are ascribable to the increased intraluminal pressure produced by ligation of both ends of the vas deferens (conventional technique), since no changes were found in the epididymal structure of dogs submitted to the open-ended technique, at least in the different time periods analyzed in the study.

[Experimental vasectomy: comparison of the testicular structure with various surgical techniques]. / Vasectomia experimental: comparación de la estructura testicular mediante diferentes técnicas quirúrgicas.

We have performed experimental vasectomies in dog in order to study different repercussions of various surgical techniques on the testicular structure. The closed technique, with ligature of both cut ends of the sectioned vas deferens caused a severe tubular atrophy, which finally destroyed the architecture of the testis with compensating hypertrophy of the intertubular connective tissue. The technique of the "open cut end", leaving the proximal end free and allowing the normal drainage of the vas deferens into the interstitial space of the spermatic cord, had not any influence on the testicular-structure, at least in the studied period of time, now one year. We can't reject any long-term immunological phenomena. The conclusion of this study is that the peculiarities of the surgical techniques of vasectomy have a decisive influence on the preservation of the testicular structure.

[A morphological and morphometric study of the testicle in the rat vasectomized by electrocautery technics]. / Estudio morfológico y morfométrico del testículo de rata vasectomizado mediante técnicas con electrocauterio.

OBJECTIVE: To evaluate the influence of vasectomy by different fulguration methods on the rat testicular structure. METHODS: Experimental vasectomy was performed in Wistar rats by means of the Shapiro and Silber, and the Schmidt cauterization techniques. The animals were orchidectomized between 7 days and 9 months following vasectomy. A morphological and morphometric study of the rat testes was performed. RESULTS: We have observed that both cauterization techniques do not produce sequelae in the rat testicular structure and its morphology is compatible with the normal. The morphometric study showed that both techniques produced a significant decrease (p > 0.05) of the area occupied by seminiferous epithelium within one month post-vasectomy; however, these values returned to normal three months thereafter. CONCLUSIONS: Vasectomy by different fulguration methods does not change the rat testicular structure.

[Effects of vasectomy on the testicular structure of the dog]. / Efectos de la vasectomía sobre la estructura del testículo de perro.

Study of the effect on testis structure in the dog caused by a vasectomy. Emphasis is made on how in animals undergoing ligature of both ends of the ductus deferens, existence of structural changes, which are consistently present, are proportional to the time elapsed from performance of vasectomy. Such changes are revealed by: degeneration of germinal epithelium, thickening of basal membrane and hypertrophy of interstitial tissue at the expense of unspecific connective tissue. Changes were first seen as from the fourth month, but a full year has to elapse prior to noting a marked germinal hypoplasia. These experimental results cast doubts on the safety of such sterilization approach, although they cannot be entirely extrapolated to humans.

[The characteristics of lipid metabolism in children with primary arterial hypertension]. / Osobennosti lipidnogo obmena u detei s pervichnoi arterial'noi gipertenziei.

Overall 183 children with arterial hypertension (AH) were examined. Of these, 122 suffered from primary arterial hypertension (PAH). The lipid spectrum was defined in blood plasma of 95 children with PAH and in 30 normals. The same investigation was carried out in 109 parents of the children suffering from PAH. The lipid spectrum was established to be heterogeneous. 77.9% of the patients had dyslipidemia. A significant relationship was established between the stage of PAH and the nature of lipidemia as was a close interrelation between alterations in the lipid spectrum of blood plasma and hereditary load as regards essential hypertension.

The role of yohimbine for the treatment of erectile impotence.

A double-blind crossover study of yohimbine vs. placebo was carried out in 40 patients. Eleven of 33 patients (33%) who completed the study had subjective improvement of erection while taking yohimbine alone, five of 33 (15%) responded while taking both yohimbine and placebo, five of 33 (15%) responded to placebo alone, and 12 of 33 (36%) responded to neither. Of 215 impotent patients subsequently treated with yohimbine, 38% reported some subjective improvement, but only 5% were completely satisfied. The physiologic response of yohimbine appears to occur in the central nervous system. Recent experience suggests that the typical dose has little side effect and higher doses achieves better results, but this conclusion requires more evaluation.

On the Green's function for a one-dimensional random walk.

The Green's function of a random walk on a lattice is defined as the inverse of the operator K - z1, where K is the matrix of transition rates and z is an arbitrary complex parameter. The Green's function for a symmetrical random walk in one dimension is here explicitly given in closed form for reflecting, periodic, and absorbing boundaries, and also for an infinite lattice.