[Red tape in psychiatry: on bureaucracy, bureaucratism, and our secret fondness for procedures]. / De paarse krokodil in de psychiatrie: over bureaucratie, bureaucratisme en onze heimelijke liefde voor procedures.

BACKGROUND: A frequent complaint in psychiatry is that the psychiatrist-patient relationship and the quality of care are hampered by bureaucratic processes. AIM: To provide an analysis of various types of bureaucracy in psychiatry that can serve as a starting-point for the improvement of care and the performance of qualitative studies. METHOD: We conducted an exploratory study using PubMed, Google, and various Dutch medical journals. RESULTS: Contemporary psychiatry is characterised by a bureaucratic organization structure. Mental, somatic, and social problems are translated in a standardised manner into medical jargon which gives rise to a DSM diagnosis, a cost-price, and outcome measures. This medical-bureaucratic system has important virtues, provided it is applied efficiently and the patient-psychiatrist relationship remains intact. In the Netherlands, however, this balance has been disturbed. Future research can be facilitated if distinctions are made between various types of bureaucracy (referred to here as Hippocratic, Weberian, and Kafkaesque bureaucracy). In addition, we discuss various national initiatives which aim to counter bureaucracy, including initiatives of the Dutch government. CONCLUSION: If the patient-psychiatrist relationship is to regain its central role, bureaucracy needs to be countered constantly. The government can facilitate this process, but healthcare providers can also play a key role and meanwhile help to bring about a substantial reduction in the costs of care.

Uso de la tomografía de coherencia óptica y la biomicroscopía ultrasónica en el diagnóstico de los quistes iridociliares / Use of optical coherence tomography and ultrasound biomicroscopy in the diagnosis of iridociliary cysts

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Hemovítreo secundario a quiste iridociliar / Vitreous hemorrhage secondary to iridociliary cyst

CASO CLÍNICO: Varón de 18 años, presentó un hemovítreo inferior de causa desconocida. Se realizan múltiples pruebas, entre ellas ecografía oftálmica y angiofluoresceingrafía (AFG), no encontrándose justificación al sangrado. Finalmente se decide realizar una biomicroscopía ultrasónica (BMU) donde se aprecia un quiste iridociliar. DISCUSIÓN: Los quistes iridociliares son únicos o múltiples, primarios o secundarios. Los primarios suelen tener carácter benigno, por lo que no requieren tratamiento. Cuando el quiste alcanza un tamaño importante puede producir un iris meseta focal con o sin cierre angular. Nuestro caso describe una complicación inusual que habría que tener en cuenta ante un hemovítreo de origen desconocido

CASE REPORT: An 18-year-old man, presented a lower vitreous hemorrhage of unknown cause. Multiple tests are performed, including Ophthalmic Ultrasound and Fluorescein Angioghaphy (FA), they did not find justification of bleeding. Finally, we decide to do a Biomocroscopía Ultrasonic (UBM) showing an iridociliary cyst. DISCUSSION: The iridociliary cysts are single or multiple, primary or secondary. The primaries are usually benign so, they do not require treatment. When the cyst has a considerable size, it may produce a focal plateau iris with or without angle-closure. Our case reveals an unusual complication that should take notice of when you have an unknown vitreous hemorrhage

Vitreous hemorrhage secondary to iridociliary cyst.

CASE REPORT: An 18-year-old man, presented a lower vitreous hemorrhage of unknown cause. Multiple tests are performed, including Ophthalmic Ultrasound and Fluorescein Angioghaphy (FA), they did not find justification of bleeding. Finally, we decide to do a Biomocroscopía Ultrasonic (UBM) showing an iridociliary cyst. DISCUSSION: The iridociliary cysts are single or multiple, primary or secondary. The primaries are usually benign so, they do not require treatment. When the cyst has a considerable size, it may produce a focal plateau iris with or without angle-closure. Our case reveals an unusual complication that should take notice of when you have an unknown vitreous hemorrhage.

Chemokine response induced by Chlamydia trachomatis in prostate derived CD45+ and CD45- cells.

The role of innate cells and their receptors within the male genital tract remains poorly understood. Much less is known about the relative contribution of different genital tract cells such as epithelial/stromal cells and resident leucocytes. In this study, we examined innate immune responses to Chlamydia trachomatis by prostate epithelial/stromal cells and prostate resident leucocytes. Murine prostate primary cultures were performed and leucocyte and epithelial/stromal cells were sorted based on surface protein expression of CD45 by magnetism-activated cell sorting or fluorescence-activated cell sorting. Prostate derived CD45- and CD45+ cells were infected with C. trachomatis and chemokine secretion assayed by ELISA. Similar experiments were performed using prostate CD45+ and CD45- cells from myeloid differentiation factor 88 (Myd88(-/-)) mice or toll-like receptor (Tlr2(-/-)) and Tlr4(mutant) double-deficient mice. Moreover, a TLR-signalling pathway array was used to screen changes in different genes involved in TLR-signalling pathways by real-time PCR. Prostate derived CD45- and CD45+ cells responded to chlamydial infection with the production of different chemokines. Both populations expressed genes involved in TLR signalling and required to respond to pathogen-associated molecular patterns and to C. trachomatis infection. Both populations required the adaptor molecule MYD88 to elicit chemokine response against C. trachomatis. TLR2-TLR4 was essential for chemokine production by CD45+ prostate derived cells, but in their absence, CD45- cells still produced significant levels of chemokines. We demonstrate that C. trachomatis is differentially recognised by prostate derived CD45+ and CD45- cells and suggest that diverse strategies are taking place in the local microenvironment of the host in response to the infection.

Resultados del afilamiento del oblicuo superior en el tratamiento del síndrome de Brown plus / Superior oblique sharpening surgery in the treatment of Brown syndrome plus

ObjetivoDescribir los resultados del afilamiento del oblicuo superior (OS) en el síndrome de Brown congénito plus.Material y métodosEstudio retrospectivo de 17 casos con síndrome de Brown operados con el afilamiento del OS desde 1997 a 2007. La desviación vertical (DV) en posición primaria de la mirada (PM) se clasificó de + a +++, el tortícolis en leve (< de 10°), moderado (10-20°) y severo (≥ 20°); y la limitación de la elevación en aducción (LEA) de -1 a -4. Se consideró buen resultado post-operatorio cuando la LEA fue nula o grado -1, sin tortícolis y sin DV en PM al final del periodo de seguimiento.ResultadosLa edad media de la cirugía fue de 4,9 años. La LEA fue de -3 en 8 casos (47,1%) y de -4 en 9 (52,9%), normalizándose por completo con la cirugía en 6 casos, y quedando en 9 una LEA de -1 y en 2 de -3. La hipotropía preoperatoria, presente en 15 casos (13 leves, una moderada y una severa), se corrigió con la cirugía en 13. El tortícolis inicial, presente en 14 casos (3 leves, 10 moderados y uno severo), se corrigió en 11. Un buen resultado se obtuvo en 14 pacientes (82,4%), 2 quedaron hipocorregidos (11,8%) y uno hipercorregido (5,88%). El tiempo medio de seguimiento fue de 60,71 meses.ConclusionesEl afilamiento del OS en el síndrome de Brown congénito plus ha obtenido buenos resultados. La incidencia de hipercorrecciones por paresias secundarias de OS ha sido muy escasa(AU)

PurposeTo describe superior oblique sharpening in congenital Brown syndrome plus.Material and methodsA retrospective study of 17 Brown syndrome cases that were treated with oblique superior sharpening from 1997 to 2007. Vertical deviation in primary position was classified as + to +++, head tilt as: mild (< 10°), moderate (10-20°) and severe (≥ 20°); elevation in adduction from -1 to -4. A good postoperative result was considered if last elevation limitation in adduction was zero or -1, without head tilt and vertical deviation in primary position.ResultsMean age was 4.9 years. Limitation elevation in adduction which was -3 in 8 cases (47.1%) and -4 in 9 (52.9%), which improved completely after surgery in 6, -1 in 9 and -3 in 2 patients. Preoperative hypotropia in 15 cases (13 mild, 1 moderate and one severe) was resolved in 13 after surgery. Of 14 patients with torticollis (3 mild, 10 moderate and one severe) it was surgically corrected in 11. Success was achieved in 14 (82.4%), 2 were under corrected (11.8%) and one was overcorrected (5.88%). Mean follow-up was 60.71 months.ConclusionsOblique superior sharpening as treatment for Brown syndrome plus is an effective procedure. The incidence of secondary oblique palsies has been very low(AU)

Hipercorrección secundaria a transposición muscular aumentada / Overcorrection secondary to augmented rectus muscle transposition

Caso clínico: Paciente con parálisis del VI N tratado con técnica de Foster previa inyecciónde toxina botulínica. En el postoperatorio se observa exotropia, limitación aducción, inversióndel tortícolis y diplopía. Se reinterviene realizando resección del recto medio y toxinaen recto lateral del ojo afectado por ser técnicamente imposible retirar la fijación escleral.Se obtiene un resultado aceptable. Dos años después reaparece la diplopía y un aumentode exotropía, por lo que se realiza nueva resección de recto medio.Conclusiones: La técnica de Foster es nuestra técnica de elección en las parálisis completasdel VI; sin embargo, no está exenta de complicaciones como las hipercorrecciones(AU)

Case report: Patient with abducens palsy treated with Foster technique after injection ofbotulinum toxin. Exotropia, adduction limitation, face-turn inversion and diplopia wereobserved during the post-operative period. He was reinterviened by performing a resectionon the medial rectus of the affected and toxin was injected into the lateral rectus, as it wastechnically impossible to remove the scleral fixation with an acceptable result. Two yearslater diplopia and increased exotropia reoccurred which again required resection.Conclusions: The Foster technique is our technique of choice in complete abducens palsy,however it is important to point out that there could be complications, such asovercorrections(AU)

[Superior oblique sharpening surgery in the treatment of Brown syndrome plus]. / Resultados del afilamiento del oblicuo superior en el tratamiento del síndrome de Brown plus.

PURPOSE: To describe superior oblique sharpening in congenital Brown syndrome plus. MATERIAL AND METHODS: A retrospective study of 17 Brown syndrome cases that were treated with oblique superior sharpening from 1997 to 2007. Vertical deviation in primary position was classified as + to +++, head tilt as: mild (< 10°), moderate (10-20°) and severe (≥ 20°); elevation in adduction from -1 to -4. A good postoperative result was considered if last elevation limitation in adduction was zero or -1, without head tilt and vertical deviation in primary position. RESULTS: Mean age was 4.9 years. Limitation elevation in adduction which was -3 in 8 cases (47.1%) and -4 in 9 (52.9%), which improved completely after surgery in 6, -1 in 9 and -3 in 2 patients. Preoperative hypotropia in 15 cases (13 mild, 1 moderate and one severe) was resolved in 13 after surgery. Of 14 patients with torticollis (3 mild, 10 moderate and one severe) it was surgically corrected in 11. Success was achieved in 14 (82.4%), 2 were under corrected (11.8%) and one was overcorrected (5.88%). Mean follow-up was 60.71 months. CONCLUSIONS: Oblique superior sharpening as treatment for Brown syndrome plus is an effective procedure. The incidence of secondary oblique palsies has been very low.

[Overcorrection secondary to augmented rectus muscle transposition]. / Hipercorrección secundaria a transposición muscular aumentada.

CASE REPORT: Patient with abducens palsy treated with Foster technique after injection of botulinum toxin. Exotropia, adduction limitation, face-turn inversion and diplopia were observed during the post-operative period. He was reinterviened by performing a resection on the medial rectus of the affected and toxin was injected into the lateral rectus, as it was technically impossible to remove the scleral fixation with an acceptable result. Two years later diplopia and increased exotropia reoccurred which again required resection. CONCLUSIONS: The Foster technique is our technique of choice in complete abducens palsy, however it is important to point out that there could be complications, such as overcorrections.

First Report of Diplodia Cane Dieback of Grapevine in Bolivia.

Grape (Vitis vinifera L.) is an important commercial crop in the temperate regions of Bolivia where it has been grown for hundreds of years. In October of 2001, diseased canes of grape (cv. Muscat of Alexandria) were collected in a vineyard in Yotala, Department of Chuquisaca in southern Bolivia. In this planting of more than 1,000 plants, more than 75% were exhibiting cane dieback symptoms and many were dead or dying. No disease was observed on grape berries. Symptoms of the disease were similar to those reported for Diplodia cane dieback (1). Cankers ranging from 2 to 10 cm long and 0.5 to 3 cm wide were observed. When diseased canes were placed in a moist chamber, conidia oozed from pycnidia in black cirri. Immature conidia were hyaline and one-celled, but mature conidia were dark brown (20 to 30 × 10 to 15 µm) with one median septum and longitudinal striations. The pathogen was tentatively identified as Lasiodiplodia theobromae (Pat.) Griffon & Maubl. (synonyms Diplodia natalensis Pole-Evans and Botryodiplodia theobromae Pat.), teleomorph Botryosphaeria rhodina (Cooke) Arx) (2). Fungi were isolated from cankers on diseased canes by surface disinfestation in 0.25% NaOCl for 5 min and placing small pieces of tissue on 2% water agar or potato dextrose agar (PDA). L. theobromae was isolated from these tissues. Koch's postulates were fulfilled by inoculating grape berries and canes with the pathogen. Five grape berries were surface disinfested and inoculated by wounding with a sterile scalpel and inserting a piece of fungal mycelium on PDA in the wounded sites. The same number of control berries was similarly treated with sterile PDA. Inoculated and control berries were placed in plastic, moist chambers in the laboratory at ambient temperature (15 to 28°C) in the dark. Five canes on two potted plants were inoculated with the same isolate of the pathogen in a similar manner as the berries. The inoculated and control sites on canes were wrapped with masking tape. Plants were placed in a moist chamber for 5 days. After 8 days, inoculated berries were rotting and the inoculated sites were covered with grayish mycelium. Within 12 days, cankers as much as 3 cm long developed on the inoculated canes, and in some lesions, black pycnidia were observed. No lesions developed in the wounded control canes. The pathogen was reisolated from inoculated berries and canes, but not from control berries or canes. The teleomorph was not observed on any naturally infected canes or on those inoculated with the anamorph. The pathogen was identified as L. theobromae based on symptoms (1), cultural and morphological characteristics (2), and pathogenicity tests. The disease poses a potential threat to the cultivation of grapevine in southern Bolivia. To our knowledge, this is the first report of Diplodia cane dieback of grapevine in Bolivia. References: R. C. Pearson and A. C. Goheen. Compendium of Grape Diseases. The American Phytopathological Society, St. Paul, MN, 1988. (2). E. Punithalingam. No. 519 in: Descriptions of Pathogenic Fungi and Bacteria. CMI, Kew, Surrey, England, 1976.

Detección precoz de la sordera mediante otoemisiones. Análisis de los resultados en 200 niños consecutivos explorados / Early hearing loss detection by otoemissions. Analysis of the results in 200 consecutive children reviewed

Presentamos un estudio retrospectivo de 200 niños consecutivos explorados en nuestro hospital entre noviembre del 2005 y abril del 2006 del programa o protocolo de Detección Precoz de Soderas establecido desde hace varios años en nuestra Comunidad. Aquellos niños con sospecha de hipoacusia tras la realización de las otoemisiones acústicas son sometidos a potenciales evocados auditivos de tronco cerebral (PEATC) 3 meses después

We present a retrospective study of 200 consecutive children explored in our hospital between november 2005 and april 2006, as a part of the protocole or program of early identification hearing loss stablished several years ago in our Comunity. In case of suspected hypoacusia after performing otoacoustic emissions, children must be sent to PEATC 3 months later

[Zenker's esophageal diverticulum as differential diagnosis of paratracheal cystic lesion]. / Divertículo esofágico de Zenker como diagnóstico diferencial de lesión quística paratraqueal.

We report the case of a 52 years old patient with clinic of food regurgitation and some dysphagia without other added symptoms who was sent to our ENT consulting rooms. It was performed a cervicothoracic CT which informed as a paratracheal cystic lesion with differential diagnosis between esophageal or tracheal diverticulum. The possibility of that last one was discarted by a normal bronchoscopy.

[Sphenoidal sinus polyp-cyst as casual finding in a patient with severe and sudden retrocochlear hearing loss]. / Pólipo-quiste del seno esfenoidal como hallazgo casual en paciente con hipoacusia brusca severa retrococlear.

We present the case of a 56 years old female controlled in our ENT Department because of right sudden hearing loss, tinnitus and vertigo. The endoscopic exam was normal. Audiogram showed a severe neurosensorial hypoacusia and PEATC confirmed the so called hypoacusia suggesting a retrocochlear origin of it. As imaging tests an otic-craneal CT and IRM were asked for, which informed of the presence of a cystic lesion versus polyp in sphenoidal sinus of 15 x 10 mm without other alterations or significant pathology.

[Facial and oropharyngeal angioedema in patient with alimentary fish allergy. Diagnosis and treatment]. / Angioedema facial y orofaríngeo en paciente con alergia alimentaria a pescado. Diagnóstico y tratamiento.

Vegetal or animal food can produce hipersensibility reactions IgE mediated of diverse intensity. We report the case of a 54 years old woman without previous allergic antecedents who after eating frozen fish had to go to Emergencies due to angioedema especially in face and oropharynx. The ENT exploration by fibroscopia descarted laryngeal edema but the patient showed initially respiratory symptoms so she was treated with SC adrenalina and then steroids during her admission. The diagnosis of alimentary alergia would be confirmed after by Allergology with cutaneous test prick type.

[Cholesterol cyst-granuloma on petrous apex. Report of a case and differential diagnosis]. / Quiste-granuloma de colesterol de la punta del peñasco. Presentación de un caso y diagnóstico diferencial.

Cholesterol granulomas and cysts located on the petrous apex can course of a silent way during years. We describe one case assisted in our consulting rooms which was discovered after performing CT and MRI (with and without paramagnetic contrast) in a patient with vertigo associated to conscience loss without other symptoms. In the discussion is exposed which must be the differential diagnosis of this pathology.

Divertículo Esofágico de Zenker como diagnóstico diferencial de lesión quística paratraqueal / Zenker´s esophageal diverticulum as differential diagnosis of paratracheal cystic lesion

Presentamos el caso de un paciente de 52 años con clínica de regurgitación de alimentos y cierta disfagia sin otra sintomatología añadida visto en nuestras consultas externas de ORL. Se le practicó una TC cérvicotorácico que informaba de una lesión quística paratraqueal compatible con divertículo esofágico o traqueal. La posibilidad de este último se descartó mediante broncoscopia que resultó ser normal

We report the case of 52 years old patient with clinica of food regurgitation and some dysphagia without other added symptoms who was sent to our ENT consulting romos. It was performed a cervicothoracic CT which informed as a paratracheal cystic lesion with differential diagnosis between esophageal or tracheal diverticulum. The possibility of that las one was discarded bya a normal bronchoscopy

Pólipo-quiste del seno esfenoidal como hallazgo casual en paciente con hipoacusia brusca severa retrococlear / Sphenoidal sinus-cyst as casual finding in a patient with severe and audden retrocochlear hearing loss

Presentamos el caso de una mujer de 56 años controlada en nuestro servicio de ORL, a causa de acúfenos y vértigo de aparición brusca. La exploración endoscópica fue normal. La audiometría mostraba una hipoacusia neurosensorial severa y los potenciales evocados auditivos (PEATC) confirmaron la citada hipoacusia apuntando un origen retrococlear de la misma. Como pruebas de imagen se solicitarion TC y RMN óticocraneal, en la que se informaba de la presencia de una lesión quística versus pólipo en seno esfenoidal de 15 por 10 mm sin otras alteraciones o patología significativa

We present the case of a 56 years old female controlled in our ENT Department because of right suden hearing loss, tinnitus and vertigo. The endoscopic exam was normal. Audiogram showed a severe neurosensorial hypoacusia and PEATC confirmed the so called hypoacusia suggesting a retrocochlear origin of it. As imaging tests and otic-craneal CT and IRM were asked for, which informed of the presence of a cystic lesion versus polyp in sphenoidal sinus of 15 x 10 mm without other alterations or significant pathology

Angioedema facial orofaríngeo en paciente con alergia alimentaria a pescado / Facial and oropharyngeal angioedema in patient with alimentary fish allergy

Los alimentos tanto de origen vegetal como animal pueden ocasionar reacciones de hipersensibilidad IgE mediadas de diversa intensidad. Presentamos el caso de una mujer de 54 años sin antecedentes alérgicos previos que tras ingesta de pescado congelado tuvo que acudir a Urgencias por angioedema de predominio en cara y orofaringe. La exploración ORL mediante fibroscopia descartó edema laríngeo pero la paciente presentó inicialmente clínica respiratoria por lo que fue tratada con adrenalina SC y posteriormente corticoides durante su ingreso. El diagnóstico de alergia alimentaria se confirmaría después por parte de Alergología mediante pruebas cutáneas tipo prick-test

Vegetal or animal food can produce hipersensibility reactions IgE mediated of diverse intensity. We report the case of a 54 years old woman without previous allergic antecedents who after eating frozen fish had to go to Emergencies due to angioedema especially in face and oropharynx. The ENT exploration by fibroscopia descarted laryngeal edema but the patient showed initially respiratory symptoms so she was treated with SC adrenalina and then steroids during her admission. The diagnosis of alimentary alergia would be confirmed after by Allergology with cutaneous test prick type

Quiste-granuloma de colesterol de la punta del peñasco. Presentación de un caso y diagnóstico diferencial / Colesterol cyst-granuloma on petrous apex. Report of a case and differential diagnosis

Los quistes y granulomas de colesterol localizados en la punta del peñasco pueden cursar de forma silente durante años. Describimos un caso atendido en nuestras consultas que fue descubierto tras realizar TC y RMN óticocraneal (con y sin contraste) en una paciente con vértigo asociado a pérdida de conocimiento sin otra sintomatología. Exponemos en la discusión cuál debe ser el diagnóstico diferencial de esta patología

Cholesterol granulomas and cysts located on the petrous apex can course of a silent way during years. We describe one case assisted in our consulting rooms which was discovered after performing CT and MRI (with and without paramagnetic contrast) in a patient with vertigo associated to conscience loss without other symptoms. In the discussion is exposed which must be the differential diagnosis of this pathology