Melanoma subungueal: un reto diagnóstico para los médicos / Subungual melanoma: a diagnostic challenge for doctors

El melanoma subungueal es un subgrupo del melanoma acral lentiginoso. Con frecuencia se diagnostica en etapa avanzada, dada la escasez de síntomas; de ahí que la evaluación y el tratamiento oportuno mejoran el pronóstico. Se presenta el caso de un paciente de 44 años de edad, que acude a consulta de Ortopedia con melanoniquia de tres meses de evolución. Había sido tratado en la atención primaria de salud por un hematoma secundario a un trauma directo sobre la falange distal del primer artejo del pie izquierdo. Fue seguido por consulta externa de Ortopedia y, al no experimentar una evolución adecuada, fue evaluado por la Comisión Provincial de Tumores Periféricos. Se le realizó una biopsia por punch (sacabocado), que arrojó el resultado de melanoma subungueal. Se realizó la amputación del primer artejo y del proximal del primer metatarsiano, una vez verificada la no existencia de lesiones metastásicas, con excelente resultado estético y funcional, sin mostrar recidiva en su seguimiento, a dos años de su intervención(AU)

Subungual melanoma is a subgroup of lentiginous acral melanoma. It is often diagnosed in an advanced stage by a shortage of symptoms, so timely evaluation and treatment improve prognosis. This is the case of a 44-year-old patient who goes to orthopedics with melanonichia 3 months of evolution. He had been treated for a bruise secondary to direct trauma to the distal phalanx of the first left foot ailre in primary health care. It was followed by external orthopedic consultation and by not following an adequate evolution was evaluated by the provincial commission of peripheral tumors. He was given a punch biopsy resulting in a subungual melanoma. The amputation of the first artejo and proximal first metatarsal was carried out, once verified the non-existence of metastatic lesions, with excellent aesthetic and functional result, without showing relapse in its follow-up to two years(AU)

Revisión del diagnóstico de mano catastrófica a lo largo de 15 años en un hospital terciario: ¿hacemos un uso adecuado del término? / Review of catastrophic hand diagnosis over 15 years in a tertiary hospital: do we make proper use of the term?

Objetivo: Describir las características de los pacientes diagnosticados de «mano catastrófica» por el Servicio de Cirugía Plástica en un hospital de tercer nivel en el periodo comprendido entre 2000 y 2015; analizar la evolución del uso del término «mano catastrófica», y realizar una revisión bibliográfica con el objetivo de proponer la definición más óptima de dicha expresión. Material y método: Realizamos un estudio descriptivo y retrospectivo de los pacientes diagnosticados de «mano catastrófica» que requirieron atención hospitalaria por el Servicio de Cirugía Plástica de un hospital terciario en el periodo comprendido entre 2000 y 2015. Efectuamos una revisión bibliográfica acerca del uso del término «mano catastrófica» y aplicamos a nuestros resultados las clasificaciones propuestas en las publicaciones consultadas. Resultados: El número de diagnósticos de «mano catastrófica» fue de 133. Objetivamos una tendencia descendente en el empleo del mencionado término con el transcurso de los años. Aplicando clasificaciones basadas en la imposibilidad de recuperación de una mano aceptable (presencia de 3 dedos largos y pulgar) mediante procedimientos reconstructivos, tan solo 9 de 133 pacientes podían ser considerados «manos catastróficas», constituyendo un 6,7% del total de casos. Discusión: El término «mano catastrófica» posee diferentes acepciones, generando ambigüedad. El uso de una clasificación basada en la posibilidad de obtener una mano aceptable disminuye su utilización y mejora el abordaje de dichas lesiones. Conclusión: Abogamos por limitar el uso de «mano catastrófica» a los casos que cumplan criterios de «mano mutilada» y «mano metacarpiana» para evitar su uso indiscriminado y optimizar su manejo terapéutico

Objective: To describe the characteristics of patients diagnosed with 'catastrophic hand' by the plastic surgery department in a tertiary hospital in the period between 2000-2015, analyse the evolution of the use of the term 'catastrophic hand' and conduct a review of the literature with a view to proposing the optimal definition for said expression. Material and method: We conducted a descriptive and retrospective study of patients diagnosed with 'catastrophic hand' who required hospital care by the plastic surgery department of a tertiary hospital in the period between 2000-2015. We conducted a literature review on the use of the term 'catastrophic hand' and we applied the classifications proposed in the publications consulted to our results. Results: The number of 'catastrophic hand' diagnoses was 133. We observed a downward trend in the use of the term over the years. Applying classifications based on the impossibility of recovery of an acceptable hand (presence of three long fingers and thumb) by reconstructive procedures, only 9 out of 133 patients could be considered to have 'catastrophic hands', constituting 6.7% of the total cases. Discussion: The term 'catastrophic hand' has different meanings, and this generates ambiguity. The use of a classification based on the possibility of obtaining an acceptable hand diminishes its use and improves the approach for such injuries. Conclusion: We advocate limiting the use of 'catastrophic hand' to cases that meet criteria of 'mutilated hand' and 'metacarpal hand' to avoid indiscriminate use of the term and optimise therapeutic management

Estudio clínico-epidemiológico y molecular de metapneumovirus humano en pacientes con infecciones respiratorias agudas (IRA) en Venezuela / Clinical and epidemiological and molecular study of human metapneumovirus in patients with acute respiratory infections (ARI) in Venezuela

El Metapneumovirus Humano (MPVh) ha sido asociado con Infecciones Respiratorias Agudas (IRA) en pacientes de todas las edades. Estudios epidemiológicos indican la prevalencia del MPVh alrededor del mundo, sin embargo, en Venezuela poco se conoce sobre su comportamiento en la población. Este estudio pretende describir el comportamiento epidemiológico de la infección por MPVh en pacientes venezolanos. Se evaluaron por RT-PCR multiplex 1812 hisopados nasales (HN) provenientes de pacientes con diagnóstico de IRA e IRA grave (IRAG) con resultados negativos a virus Influenza, referidos al INHRR entre los años 2010 y 2013. De los Virus Respiratorios no Influenza (VRnI), el MPVh resultó ser el cuarto virus mas detectado con una frecuencia de 9,1%. El 42,02 % de los casos positivos a MPVh fueron niños ≤ 5 años con 29 casos (29/69). Los pacientes positivos a MPVh cursaron IRA alta con fiebre, tos, congestión nasal, disnea/tiraje/rinorrea, malestar general y estridor; e IRAG con hospitalización (58%), neumonía (36,2%), bronquitis aguda (10,1%), bronconeumonía (2,8%), rinofaringitis y laringotraqueobronquitis en el 1,4%. El análisis filogenético de los MPVh demostró la aparente relación de los genotipos A2 y B2 con IRAG. Este estudio permite demostrar la importancia de la detección de otros agentes virales respiratorios y su posible relación con el desarrollo de IRA/IRAG, así como fortalece la vigilancia epidemiológica de las enfermedades respiratoria en Venezuela.

Human metapneumovirus (hMPV) has been associated with acute respiratory infections (ARI) in patients of all ages. Epidemiological studies indicate hMPV prevalence around the world, but in Venezuela little is known about its behavior in the population. This study aims to describe the epidemiological behavior of hMPV infection in Venezuelan patients. Were evaluated by RT-PCR multiplex 1812 nasal swabs (HN) from patients diagnosed with ARF and severe ARI (SARI) Influenza virus with negative results, referring to INHRR between 2010 and 2013. Of the non Respiratory Influenza Virus ( VRNI), the fourth hMPV virus proved more detected at a frequency of 9.1%. The 42.02% of hMPV positive cases were children ≤ 5 years with 29 cases (29/69). HMPV positive patients were enrolled IRA with high fever, cough, nasal congestion, dyspnea/ printing / rhinorrhea, malaise and stridor; and SARI inpatient (58%), pneumonia (36.2%), acute bronchitis (10.1%), bronchopneumonia (2.8%), nasopharyngitis and croup at 1.4%. Phylogenetic analysis of the hMPV showed the apparent relationship of the A2 and B2 genotypes with SARI. This study can prove the importance of the detection of other respiratory viral agents and their possible relationship with the development of IRA / SARI and strengthens epidemiological surveillance of respiratory diseases in Venezuela.

Diagnosis and classification of the antiphospholipid syndrome.

The antiphospholipid syndrome (APS) is defined by the occurrence of venous and arterial thromboses, often multiple, and recurrent fetal losses, frequently accompanied by a moderate thrombocytopenia, in the presence of antiphospholipid antibodies (aPL). Some estimates indicate that the incidence of the APS is around 5 new cases per 100,000 persons per year and the prevalence around 40-50 cases per 100,000 persons. The aPL are positive in approximately 13% of patients with stroke, 11% with myocardial infarction, 9.5% of patients with deep vein thrombosis and 6% of patients with pregnancy morbidity. The original classification criteria for the APS were formulated at a workshop in Sapporo, Japan, in 1998, during the 8th International Congress on aPL. The Sapporo criteria, as they are often called, were revised at another workshop in Sydney, Australia, in 2004, during the 11th International Congress on aPL. At least one clinical (vascular thrombosis or pregnancy morbidity) and one laboratory (anticardiolipin antibodies, lupus anticoagulant or anti-ß2-glycoprotein I antibodies) criterion had to be met for the classification of APS.

Criteria for a catastrophically disabled determination for purposes of enrollment. Final rule.

The Department of Veterans Affairs (VA) is amending its regulation concerning the manner in which VA determines that a veteran is catastrophically disabled for purposes of enrollment in priority group 4 for VA health care. As amended by this rulemaking, the regulation articulates the clinical criteria that identify an individual as catastrophically disabled, instead of using the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Current Procedural Terminology (CPT[registered trademark]) codes. The revisions ensure that the regulation is not out of date when new versions of those codes are published. The revisions also broaden some of the descriptions for a finding of catastrophic disability. Additionally, the final rule does not rely on the Folstein Mini Mental State Examination (MMSE) as a criterion for determining whether a veteran meets the definition of catastrophically disabled, because we have determined that the MMSE is no longer a necessary clinical assessment tool.

Comparisons of medical utilizations and categorical diagnoses of emergency visits between the elderly with catastrophic illness certificates and those without.

BACKGROUND: In Taiwan, the policy of catastrophic illness certificates has benefited some populations with specific diseases, but its effect on the use of medical services and the sequence of public health has not been examined. As a pilot of a series of studies, focused on emergency department (ED) visits, the present study aimed to compare medical utilization and various diagnostic categories at EDs between the elderly with an identified catastrophic illness and the elderly without. METHODS: A cross-sectional study, based on a large-sample nationwide database (one million of the population, randomly sampled from Taiwan's National Health Insurance Research Database (NHIRD)), was performed in Taiwan. The 2008 insurance records of ambulatory medical services for subjects aged 65 years or more among the above one million of the population were further selected and analyzed. Taiwan's registered catastrophic illness dataset for 2008 was linked in order to identify the target subgroup. RESULTS: The prevalence of certificated catastrophic illness in Taiwan's elderly utilizing ambulatory medical services was 10.16%. On average, 61.62 emergency department (ED) visits/1,000 persons (95% CI: 59.22-64.01) per month was estimated for the elderly Taiwanese with catastrophic illness, which was significantly greater than that for the elderly without a catastrophic illness (mean 33.53, 95% CI: 32.34-34.71). A significantly greater total medical expenditure for emergency care was observed in the catastrophic illness subgroup (US$145.6 ± 193.5) as compared with the non-catastrophic illness group (US$108.7 ± 338.0) (p < 0.001). The three most common medical problems diagnosed when visiting EDs were injury/poisoning (14.22%), genitourinary disorders (11.26%) and neoplasm-related morbidity (10.77%) for the elderly population with a catastrophic illness, which differed from those for the elderly without a catastrophic illness. CONCLUSIONS: In Taiwan, the elderly with any certificated catastrophic illness had significantly more ED visits and a higher ED medical cost due to untypical medical complaints.

Update on the catastrophic antiphospholipid syndrome and the "CAPS Registry".

Although less than 1% of patients with the antiphospholipid syndrome (APS) develop the catastrophic variant known as catastrophic antiphospholipid syndrome (CAPS), its potentially lethal outcome emphasizes its importance in clinical medicine today. However, the rarity of this variant makes it extraordinarily difficult to study in any systematic way. To collate all the published case reports as well as the newly diagnosed cases from all over the world, an international registry of patients with CAPS ("CAPS Registry") was created in 2000 by the European Forum on Antiphospholipid Antibodies (www.med.ub.es/MIMMUN/FORUM/CAPS.HTM). Currently, this database documents the entire clinical, laboratory, and therapeutic data of more than 350 fully registered patients.

Validation of the preliminary criteria for the classification of catastrophic antiphospholipid syndrome.

OBJECTIVE: To describe the characteristics of patients with catastrophic antiphospholipid syndrome (APS) included in the International Registry of patients with this condition (CAPS registry) and to analyse the value of the recently proposed preliminary criteria for the classification of catastrophic APS. METHODS: A review of the first 220 patients included in the website based CAPS registry was undertaken and the preliminary criteria for their classification were tested; 175 unselected patients with systemic lupus erythematosus or APS, or both, acted as controls. RESULTS: The mean age of the patients was 38 (14) years (range 7 to 74), with a female preponderance (F/M, 153/67). The main clinical manifestations included renal involvement in 154 (70%), pulmonary in 146 (66%), cerebral in 133 (60%), cardiac in 115 (52%), and cutaneous in 104 (47%); 114 patients (52%) recovered after the catastrophic APS event (mortality 48%). Patients who received the combination of anticoagulation plus steroids plus plasma exchange or intravenous immunoglobulins had the best survival rate (63%, p = 0.09). Sufficient data could be analysed for application of the classification criteria in 176 patients. According to the preliminary criteria, 89 patients (51%) could be classified as having "definite" and 70 (40%) as having "probable" catastrophic APS, thus given a sensitivity of 90.3% with a specificity of 99.4%. Positive and negative predictive values were 99.4% and 91.1%, respectively. CONCLUSIONS: The preliminary criteria for the classification of catastrophic APS and the CAPS registry are useful tools for epidemiological studies.

Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled.

OBJECTIVE: To characterize hospital diagnoses, procedures and charges, and nursing home admissions in the year when older persons become severely disabled, comparing those in whom severe disability develops rapidly with those in whom disability develops gradually. DESIGN: A prospective, population-based cohort study with at least 6 annual interviews beginning in 1982. SETTING: A total of 3 communities: East Boston, Mass, New Haven, Conn, and Iowa and Washington counties in Iowa. SUBJECTS: A total of 6070 persons at least 70 years old with at least 1 interview after the fourth annual follow-up and without evidence of previous severe disability, defined as disability in 3 or more activities of daily living (ADLs). MAIN OUTCOME MEASURES: Characteristics associated with development of severe disability after the fourth annual follow-up, in which the disability is classified as catastrophic disability if the individual did not report any ADL disability in the 2 interviews prior to severe disability onset or as progressive disability if the individual had previous disability in 1 or 2 ADLs. RESULTS: In the year during which severe disability developed, hospitalizations were documented for 72.1% of those developing catastrophic disability and for 48.6% of those developing progressive disability. In the corresponding year, only 14.7% of those who were stable with no disability and 22.3% of those with some disability were hospitalized. The 6 most frequent principal discharge diagnoses included stroke, hip fracture, congestive heart failure, and pneumonia in both severe disability subsets; coronary heart disease and cancer in catastrophic disability; and diabetes and dehydration in progressive disability. These diagnoses occurred in 49% of those with catastrophic disability and 25% of those with progressive disability. In both severe disability subsets, the oldest patients received less intensive hospital care as indicated by charges for surgery, diagnostics, and rehabilitation and by the percentage who received major diagnostic procedures; they were also more often admitted to nursing homes. CONCLUSIONS: In the year when they become severely disabled, a large proportion of older persons are hospitalized for a small group of diseases. Hospital-based interventions aimed at reducing the severity and functional consequences of these diseases could have a large impact on reduction of severe disability.

Identifying clinical appropriateness in the catastrophic psychiatric case.

Catastrophic psychiatric illness has been commonly identified by demographic factors such as cost (greater than $10,000) and length of treatment (greater than 30 days). In order to determine which cases could have been better managed in order to prevent the high cost and long length of treatment, clinical identifiers were formulated by the authors. The authors examined reviews of cases identified by third-party payors and reviewed by psychiatrist reviewers. They found that the majority of the catastrophic cases were not truly clinically catastrophic but were catastrophic in terms of resource utilization. This was due to patient non-compliance, poor treatment management and poor benefit management. The authors conclude that catastrophic costs and extended treatment could be prevented, in some cases, through the use of better practice patterns and case management.

Quantitative evaluation of clinical course in surgical ICU patients: the data conform to catastrophe theory.

A response surface for critically ill patients is described. The coordinates of the three-dimensional response surface are two control variables, or state variables, related to aerobic and anaerobic metabolism, and a response variable, the A-VO2 difference. The data conform to a cusp catastrophe manifold. Cardiac insufficiency, adaptive response to stress, and sepsis may be distinguished by this model. The distinction between control and response variables is discussed.