Encuesta de satisfacción del paciente con secuelas de parálisis facial periférica en tratamiento con toxina botulínica A / Satisfaction survey of patients with sequels of peripheral facial palsy treated with botulinum toxin A

INTRODUCCIÓN: El tratamiento de la parálisis facial periférica con toxina botulínica es seguro y eficaz. Si bien es conocido su impacto beneficioso sobre la calidad de vida de los pacientes, hasta ahora no se ha estudiado específicamente su percepción subjetiva. Nuestro objetivo ha sido conocer los resultados del tratamiento con toxina botulínica centrándonos en la opinión del paciente. PACIENTES Y MÉTODOS: Estudio prospectivo realizado en una muestra aleatoria de pacientes con secuelas de parálisis facial periférica, que estaban siendo tratados con toxina botulínica en el Servicio de Medicina Física y Rehabilitación de nuestro hospital. Creamos un cuestionario sencillo para evaluar tanto la satisfacción como la percepción subjetiva de mejoría después del tratamiento con toxina botulínica. RESULTADOS: Después de la infiltración, el 95% de los pacientes se sentía bien o muy bien. Más del 80% de ellos notó mejoría respecto a la sensación de tirantez en la mejilla y el cuello. Alrededor de 3/4 partes de los pacientes percibieron mejoría en el rango de movilidad voluntaria y en aproximadamente el 80% mejoraron las sincinesias. Casi todos ellos volverían a tratarse si se les propusiera de nuevo y el 100% recomendaría la infiltración con toxina botulínica a otros pacientes con parálisis facial. CONCLUSIONES: El tratamiento con toxina botulínica proporciona una mejora subjetiva importante en los pacientes con secuelas de parálisis facial periférica, tanto en reposo como respecto al control de sincinesias. El grado de satisfacción es superior a 8/10 en el 99% de los pacientes estudiados

INTRODUCTION: Treatment of peripheral facial palsy with botulinum toxin A is safe and effective. Although its beneficial impact on patients' quality of life is known, to date, there have been no studies specifically analysing patients' subjective perceptions. PATIENTS AND METHOD: We performed a prospective study in a random sample of patients with sequels of peripheral facial palsy treated with botulinum toxin in the Physical Medicine and Rehabilitation Service of our hospital. We created a simple questionnaire to assess both patient satisfaction and subjective perception of improvement after botulinum toxin treatment. RESULTS: After infiltration, 95% of the patients felt good or very good. More than 80% noted improvement in the sensation of tightness in the cheek and neck. Around 75% of patients perceived an improvement in the range of voluntary movement and approximately 80% reported improvement in synkinesis. Almost all the patients would repeat the treatment, if proposed, and 100% would recommend botulinum toxin infiltration to other patients with facial palsy. CONCLUSIONS: Patients treated with botulinum toxin experience substantial subjective improvement in the sequels of peripheral facial palsy, both in repose and in the control of synkinesis. Satisfaction was higher than 8/10 in 99% of patients in this study

[Satisfaction survey of patients with sequels of peripheral facial palsy treated with botulinum toxin A]. / Encuesta de satisfacción del paciente con secuelas de parálisis facial periférica en tratamiento con toxina botulínica A.

INTRODUCTION: Treatment of peripheral facial palsy with botulinum toxin A is safe and effective. Although its beneficial impact on patients' quality of life is known, to date, there have been no studies specifically analysing patients' subjective perceptions. PATIENTS AND METHOD: We performed a prospective study in a random sample of patients with sequels of peripheral facial palsy treated with botulinum toxin in the Physical Medicine and Rehabilitation Service of our hospital. We created a simple questionnaire to assess both patient satisfaction and subjective perception of improvement after botulinum toxin treatment. RESULTS: After infiltration, 95% of the patients felt good or very good. More than 80% noted improvement in the sensation of tightness in the cheek and neck. Around 75% of patients perceived an improvement in the range of voluntary movement and approximately 80% reported improvement in synkinesis. Almost all the patients would repeat the treatment, if proposed, and 100% would recommend botulinum toxin infiltration to other patients with facial palsy. CONCLUSIONS: Patients treated with botulinum toxin experience substantial subjective improvement in the sequels of peripheral facial palsy, both in repose and in the control of synkinesis. Satisfaction was higher than 8/10 in 99% of patients in this study.

Trasplante autólogo de limbo como nuevo tratamiento de la distrofia corneal epitelial de Lisch / Keratolimbal autograft transplantation as a possible new treatment of Lisch epithelial corneal dystrophy

CASO CLÍNICO: Presentamos el caso de una mujer de 64 años con agudeza visual de 20/40 en su ojo derecho, debida a una opacificación grisácea y plumosa con microquistes en el epitelio corneal, compatible con una distrofia epitelial de Lisch. Se trató secuencialmente con varios desbridamientos epiteliales, lente de contacto y mitomicina C, a pesar de los cuales, recidivaba. La extirpación de un sector limbar y el trasplante de limbo autólogo obtuvieron buenos resultados y sin recurrencia. CONCLUSIÓN: El trasplante autólogo de limbo tras extirpar la zona de limbo afectado puede ser considerado como una nueva opción terapéutica en el tratamiento de la distrofia epitelial de Lisch asimétrica, cuando otros tratamientos han fallado

CASE REPORT: The case concerns 64-year-old woman with visual acuity of 20/40 in the right eye. Slit-lamp examination revealed a grey, feathery corneal opacification with intraepithelial microcysts compatible with Lisch epithelial corneal dystrophy (LECD). It was treated with epithelial debridements, contact lenses and mitomycin C, but the opacification recurred within months. The removal of limbus sector and autologous limbal transplantation (KLAT) were used successfully without recurrence. Conclusions: After removal of damaged limbus, KLAT should be considered as a treatment option for asymmetric LECD when other treatments have failed

Keratolimbal autograft transplantation as a possible new treatment of Lisch epithelial corneal dystrophy. / Trasplante autólogo de limbo como nuevo tratamiento de la distrofia corneal epitelial de Lisch.

CASE REPORT: The case concerns 64-year-old woman with visual acuity of 20/40 in the right eye. Slit-lamp examination revealed a grey, feathery corneal opacification with intraepithelial microcysts compatible with Lisch epithelial corneal dystrophy (LECD). It was treated with epithelial debridements, contact lenses and mitomycin C, but the opacification recurred within months. The removal of limbus sector and autologous limbal transplantation (KLAT) were used successfully without recurrence. CONCLUSIONS: After removal of damaged limbus, KLAT should be considered as a treatment option for asymmetric LECD when other treatments have failed.

[End-of-life care in a Spanish Pediatric Intensive Care Unit: staff and parental evaluation]. / Cuidados al final de la vida en una unidad de cuidados intensivos pediátricos: evaluación por parte del personal y de los padres.

OBJECTIVES: To evaluate end-of-life care in a Paediatric Intensive Care Unit (PICU). METHODS: Retrospective study developed in a PICU. SUBJECTS: 41 workers from the PICU and parents of 26 deceased children (from 2001 to 2005). A questionnaire was designed to investigate end-of-life care. RESULTS: An age < 1-year old and a chronic or congenital disease correlated with a perceived lack of consistency in information. Nearly 38 % parents were with their children at the time of death; 64 % of all parents consider this "positive", and 13 % consider it "negative". Forty per cent of staff stated that it is "positive" for parents to be by the side of their child at the time of death, and 52 % do not know. Seventy-three per cent of staff, but only 29 % of parents want further professional psychological support for parents. Twenty per cent of children died following withdrawal of life support. The most important factors for this decision were the possibility of survival and quality of life. The majority (73 %) of caregivers express the view that often, this decision should be taken earlier. CONCLUSIONS: Analysis of staff opinions underlines the importance of the way news is communicated, the timing of withdrawal of life support, and the need for psychological support. Parents emphasized the role of the family during time spent in a PICU and during the last moments.

Cuidados al final de la vida en una unidad de cuidados intensivos pediátricos: evaluación por parte del personal y de los padres / End-of-life care in a Spanish Pediatric Intensive Care Unit: staff and Parental Evaluation

Objetivos: Evaluar los cuidados al final de la vida en una unidad de cuidados intensivos pediátricos (UCIP). Métodos: Estudio retrospectivo desarrollado en una UCIP. Los sujetos fueron 41 trabajadores de la UCIP y los padres de 26 niños fallecidos entre 2001 y 2005. Se diseñó un cuestionario para evaluar los cuidados al final de la vida proporcionados en este período. Resultados: La edad inferior a 1 año y las enfermedades crónicas o congénitas son las variables que se correlacionaron con una mayor percepción de incoherencia en la información. Cerca del 38 % de los padres estuvieron junto a sus hijos en el momento del fallecimiento; el 64 % de ellos consideran estar presentes algo positivo, y el 13 %, algo negativo. El 40 % del personal declaró que es positivo para los padres estar al lado de sus hijos en el momento del fallecimiento, y el 52 % no sabía si era positivo o negativo. El 73 % del personal, pero sólo el 29 % de los padres, desearía apoyo psicológico profesional para los padres. El 20 % de los niños fallecieron tras la retirada del soporte vital. Los factores más importantes para esta decisión fueron la posibilidad de supervivencia y la calidad de vida. La mayoría de los sanitarios expresaron que, a menudo, esta decisión debería haber sido tomada antes. Conclusiones: El análisis del personal subraya la importancia del cómo las noticias son comunicadas, del momento de retirada del soporte vital y la necesidad del apoyo psicológico. Los padres enfatizan más el papel de la familia en la UCIP y durante los últimos momentos (AU)

Objectives: To evaluate end-of-life care in a Paediatric Intensive Care Unit (PICU). Methods: Retrospective study developed in a PICU. Subjects: 41 workers from the PICU and parents of 26 deceased children (from 2001 to 2005). A questionnaire was designed to investigate end-of-life care. Results: An age < 1-year old and a chronic or congenital disease correlated with a perceived lack of consistency in information. Nearly 38 % parents were with their children at the time of death; 64 % of all parents consider this "positive", and 13 % consider it "negative". Forty per cent of staff stated that it is "positive" for parents to be by the side of their child at the time of death, and 52 % do not know. Seventy-three per cent of staff, but only 29 % of parents want further professional psychological support for parents. Twenty per cent of children died following withdrawal of life support. The most important factors for this decision were the possibility of survival and quality of life. The majority (73 %) of caregivers express the view that often, this decision should be taken earlier. Conclusions: Analysis of staff opinions underlines the importance of the way news is communicated, the timing of withdrawal of life support, and the need for psychological support. Parents emphasized the role of the family during time spent in a PICU and during the last moments (AU)

[Anterior approach in low cervical fractures prodited by hyperflexion or tear drop]. / Abordaje anterior de las fracturas cervicales bajas por mecanismo de hiperflexión o en gota de lágrima.

Hyperflexion or teardrop fracture of low cervical vertebrae is characterised by ligament affectation of the entire intervertebral segment, the vertebral body, primarily its anteroinferior third and, frequently, spinal medullar affectation. This series presents the clinical symptoms, diagnosis, surgical approach, and post surgical evolution in 30 patients with tear drop fractures. Over the last 30 years, thirty patients with tear drop fractures at the low cervical spine (C3-C7) were admitted to our Neurosurgical Service. Diagnostic studies included simple radiographs, computerised axial tomography (CT), and magnetic resonance imaging (MRI), all of which evidenced the instability of the damaged segment due to osteoligamentous affectation, and a primarily vertebral body fracture. Patients' neurological status was according to the Frankel' scale adapted to the American Spinal Injury Association scale (ASIA). 11 patients were included in grade A, 5 in B, 3 in grade C, 2 in grade D and 9 grade E of neurological affectation. Surgery through an anterior approach was performed, an average of 5 days after placement of halo traction, which had been placed on admission to the hospital. Surgery consisted in vertebral corporectomy and placement of a plate and a graft from the iliac crest. The patients' neurological evolution was favourable in all cases with incomplete medullar lesions. There were 11 patients with complete lesions, or Frankel grade A affectation; two died due to other associated lesions and the other nine showed no neurological improvement after surgery. The degree of arthrodesis was good and only one patient required an a combined anterior-posterior approach. We conclude that teardrop fractures were associated with severe neurological affectation in more than 50% of our patients, and that these fractures provoke instability requiring arthrodesis, generally via an anterior approach.

Posterior approach for low cervical fractures with unilateral or bilateral facet dislocation.

We evaluated treatment by posterior approach and its results for unilateral and bilateral facet dislocation of the lower cervical spine. Fracture reduction and ultimate stabilization of low cervical fractures located between C3 and C7 depend on the mechanism of the lesion and the resulting affectation of the osteoligamentary structures. The varied surgical approaches to fractures with unilateral or bilateral luxation include anterior, posterior, and combined. No surgery is performed if a conservative approach is used. Of the 71 low cervical fractures treated in our service in 10 years, 42 were facetary luxations (unilateral in 24 patients and bilateral in 18). Radiological studies included X-ray, CT and, in some cases, MRI. Once cervical fracture was diagnosed, halo traction was initiated and the decision to operate (34 cases) or continue conservative treatment (eight cases) was made a week after admittance. Surgery consisted of the posterior approach (27 bilateral clamps with bone graft, 5 wires with bone graft, and two posterior plates). Average patient follow-up was 7 (range 2-12) years. The patients' neurological status improved in 30 cases (71.42%) and was unchanged in 12 (28.57%). Three of eight patients initially treated conservatively developed radicular pain and instability and underwent surgery. Clamps were placed via a posterior approach in one case and the other two cases required a combined posterior and anterior approach. No instrumentation has required removal, although one patient developed a wall abscess. We found a posterior approach provides good stability for placing an arthrodesis in patients with a unilateral or bilateral cervical dislocation. In most of our cases we used clamps, and there was no worsening of any patient's neurological condition.

[Health-related quality of life of elderly patients in primary care]. / Calidad de vida relacionada con la salud en pacientes ancianos en atención primaria.

OBJECTIVES: To study the quality of life of the consultant elderly people and the associated factors to them. DESIGN: A transversal and observational study. SETTING: Primary care. An urban health center. PARTICIPANTS: Patients over 64 years without any physical or psiquical limitation that disturb the communication between patient and doctor, that ask for a consultation. Election of a necessary sample trough consecutive sampling, to precision of 0,05 points and 95% CI. OPERATIONS: The patients filled out the valid version to Spanish of the Nottinghan Health Profile. The social demographics and the morbility variables were taken through clinical histories or in other case, through the patients interviews. MEASUREMENTS AND MAIN RESULTS: The questionnaire was answered for 386 patients with a global mid punctuation of 9166 points (25,5% of deterioration; 95% CI, 23,8-27,1%), being the deterioration in each one of following sizes: <> (22%; 95% CI, 25,3-18,7%); <> (22,5%; 95% CI, 24,9-20,1%); <> (31,7%; 95% CI, 34,8-28,6%), <> (16,5%; 95% CI, 18,9-14%); <> (27,9%; 95% CI, 30,5-25,8%) and <> (28,3%; 95% CI, 30,7-25,9%). It was presented with a high level of deterioration and with differences statistically significant, women (28,7% versus 19,0%; p < 0,001), except in <> sphere, patients with elevated age (23,1%, 21,1%, 24,4%, 30,5% y 35,9% in 65-69, 70-74, 75-79, 80-84 and > 84 years old respectively; p < 0,001), except in <> and <> sphere), those who lived alone or without partner, those who were included in the house attention program 42,8% frente a 23,3%; p < 0,001), those who had a major number of chronic disease and those who took a great number of drugs. CONCLUSION: There are an important deterioration in the quality of life of our elderly people, associated to different social demography factors and morbidity. The assessment of the quality of life should be an habitual tool in our clinical practice.

Calidad de vida relacionada con la salud en pacientes ancianos en atención primaria / Health-related quality of life of elderly patients in primary care

Objetivos. Estudiar la calidad de vida relacionada con la salud de los pacientes ancianos consultantes y los factores asociados a aquélla. Diseño. Observacional, transversal. Ámbito. Atención primaria. Centro de salud urbano. Sujetos. Pacientes mayores de 65 sin limitación física ni psíquica que alterase la comunicación médico-paciente que solicitasen consulta. Elección de muestra necesaria, por muestreo consecutivo, para precisión de 0,05 puntos y nivel de confianza del 95 por ciento (número necesario, 386).Intervención. Los pacientes cumplimentaron la versión validada al castellano del Nottinghan Health Profile. Las variables sociodemográficas y de morbilidad fueron recogidas de la historia clínica o, en su defecto, de la entrevista al paciente. Mediciones y resultados. El cuestionario fue contestado por 386 pacientes, con una puntuación media global de 9,166 puntos (25,5 por ciento de porcentaje de deterioro; IC del 95 por ciento, 23,8-27,1 por ciento), siendo el deterioro en cada una de las dimensiones del cuestionario de: 'energía' (22 por ciento; IC del 95 por ciento, 25,318,7 por ciento), 'dolor' (22,5 por ciento, IC del 95 por ciento, 24,9-20,1 por ciento), 'sueño' (31,7 por ciento; IC del 95 por ciento, 34,8-28,6 por ciento), 'aislamiento social' (16,5 por ciento; IC del 95 por ciento, 18,9-14,1 por ciento), 'estado emocional' (27,9 por ciento; IC del 95 por ciento, 30,525,8 por ciento) y 'movilidad' (28,3 por ciento; IC del 95 por ciento, 30,7-25,9 por ciento). De forma estadísticamente significativa, presentaron mayor grado de deterioro las mujeres que los varones (28,7 por ciento frente a 19,0 por ciento; p 84 años; p < 0,001), excepto en las esferas 'dolor' y 'sueño', los que vivían solos o sin su pareja, los incluidos en el programa de atención domiciliaria (42,8 por ciento frente a 23,3 por ciento; p < 001), los que presentaban mayor número de patologías crónicas y los que consumían mayor número de fármacos. Conclusiones. Existe un deterioro importante de la calidad de vida de nuestros ancianos, asociándose a distintos factores sociodemográficos y de morbilidad. La valoración de la calidad de vida subjetiva debería convertirse en una herramienta de uso habitual en la práctica clínica (AU)

Efficacy, safety and predictive factors of therapeutic success with sildenafil for erectile dysfunction in patients with different spinal cord injuries.

STUDY DESIGN: Multicenter, open, prospective, before-after study. OBJECTIVE: To assess the efficacy and safety of sildenafil therapy for erectile dysfunction in patients with spinal cord injury, and the association between the response to sildenafil and factors such as causes and levels of spinal cord injury, grade of ASIA deficit, time since injury, orgasmic perception, and degree of baseline erection. SETTING: Homes of outpatients of 16 spinal cord injury units in Spain. METHOD: One hundred and seventy patients with erectile dysfunction secondary to spinal cord injury, from whom baseline data were collected on their sexual function, and who started treatment with sildenafil 50 mg. An efficacy assessment was made by the patient and his partner, and the score of the International Index of Erectile Function (IIEF) was recorded. RESULTS: It was reported by 88.2% of the patients and 85.3% of their partners that treatment with sildenafil had improved their erections, regardless of the baseline characteristics of the spinal cord injury and erectile function. In responders, this improvement was confirmed by an increase from 12.5 to 24.8 points (P<0.001) of the Erectile Function Domain of IIEF. A significant improvement was also seen in patients' satisfaction with sexual activity and general satisfaction derived from sexual life. Preservation of orgasmic perception and a baseline degree of erection of 3 or 4 (P=0.006) were predictors of therapeutic success. No serious adverse events occurred. CONCLUSION: Sildenafil is an effective, well-tolerated treatment for erectile dysfunction caused by spinal cord injury, regardless of the cause, neurological level, ASIA grade, and time since injury. SPONSORSHIP: Spanish Society of Paraplegia.

Phrenic nerve conduction study in demyelinating neuropathies and open-heart surgery.

OBJECTIVES: The aim of this study was to determine normal values of phrenic nerve conduction (PNC) in healthy individuals; to evaluate the subclinical extent of phrenic nerve involvement in Guillain-Barré syndrome (G-B) and hereditary motor and sensory neuropathy-I (HMSN-I), and to evaluate phrenic nerve damage after cardiac surgery. MATERIALS AND METHODS: PNC was performed by transcutaneous stimulation in the neck and recording the diaphragmatic potential from surface electrodes placed at the seventh and eight intercostal spaces. PNC was performed bilaterally in 25 healthy volunteers and 25 patients before and after open-heart surgery. Right PNC was also performed in 5 cases with G-B and 5 patients with HMNS-I. RESULTS: Latency and amplitude of the diaphragmatic potential were the same in controls and in patients with cardiac disease before surgery. After surgery, 28% of patients had left phrenic nerve inexcitability, and 8% had reduced amplitude of the response. These 9 patients demonstrated elevation of the left hemidiaphragm on chest radiography. Left PNC performed 1 year after the operation showed improvement in latency and amplitude of the responses in all except one patient. PNC was prolonged in 4 out of 5 cases with G-B and in all patients with HMNS-I. CONCLUSIONS: PNC is an easy and reliable method in evaluating phrenic nerve damage due to hypothermia or primary stretch injury in patients after cardiac surgery. PNC may be helpful in detecting diaphragmatic involvement before clinical ventilatory insufficiency in demyelinating neuropathies such as G-B and HMNS-I.

Cavernous angioma of the conus medullaris as a cause of paraplegia.

Cavernous angiomas of the conus medullaris are unusual lesions, representing about 3% of all intramedullary cavernomas. Most are asymptomatic. Magnetic resonance imaging (MRI) is the best diagnostic tool for the detection. We report a case of a 74-year-old man who initially developed low back pain and numbness of the right leg and subsequently paraplegia, ASIA impairment scale 'c'. MRI revealed a cavernous angioma of the conus medullaris with perilesional oedema and signs of acute bleeding. Clinical improvement was associated with changes in the MRI.