Impacto del nivel socioeconómico sobre el perfil del paciente amputado de miembro inferior por causa no traumática

IntroductionTo analyse the influence of socioeconomic status on the clinical profile of patients undergoing non-traumatic lower-limb amputation.MethodsRetrospective study of 697 lower-limb amputee patients in an Angiology and Vascular Surgery Department during a 5-year period. Patients were classified according to their socioeconomic status (low, medium and high). We analysed demographic (age and gender) and clinical variables (cause of amputation, comorbidity, cardiovascular risk factors and amputation level).ResultsMean age was 70.5 ± 11.9 years, and the median was 72 years. The low socioeconomic status group presented a higher frequency of amputations in men. Cardiovascular risks factors were more frequent in this socioeconomic group, and the difference was statistically significant for diabetes (85.8% low, 69.3% medium, 65% high; P<.01) and obesity (31.4% low, 22.6% medium, 12.5% high, P<.01). Diabetic retinopathy was the only comorbidity with a significant association with low socioeconomic status (21.1% low, 15.3% medium, 12.5% high, P<.03). Regarding the cause for amputation, there was no difference in terms of socioeconomic status. The low socioeconomic level showed a higher frequency of major amputation, which was a significant difference (63.6% low, 41.2% medium, 55% high, P<.04) and a higher predisposition for this amputation level.ConclusionsThe low socioeconomic status has been shown to determine an unfavourable vascular risk profile in lower-limb non-traumatic amputees and a higher predisposition of a major amputation. This socioeconomic level demonstrates a negative influence on these patients’ diabetes, obesity and diabetic retinopathy.     

Osteosarcomatosis

A review of the 690 cases of osteosarcoma in the radiographic file of the Armed Forces Institute of Pathology revealed 29 cases of "osteosarcomatosis" (multiple skeletal sites of osteosarcoma). Fifteen of these patients were 18 years old and under and manifested rapidly appearing, usually symmetric, sclerotic metaphyseal lesions. The remaining 14 patients were more than 18 years old and had fewer, asymmetric sclerotic lesions. In most patients (28 of 29), a radiographically dominant skeletal tumor was seen. Pulmonary metastases occurred in the majority of patients and were detected at the same time as the bone lesions. These 29 patients were studied with regard to demographic data and skeletal distribution and radiographic appearance of their lesions. As a result of the findings, a metastatic origin from a primary dominant osteosarcoma is favored over a multifocal origin as the basis for osteosarcomatosis. Osteosarcomatosis is more commonly encountered in the mature skeleton than has been previously recognized.     

The use and effects of vital fluorescent dyes: observation of motor nerve terminals and satellite cells in living frog muscles

Summary Several different fluorescent mitochondrial dyes were tested as vital stains for motor nerve terminals and other cells in frog skeletal muscles. It was found that 3,3diethyloxadicarbocyanine iodide and 4-(4-diethylaminostyryl)-N-methylpyridinium iodide were most useful. Both dyes labelled motor nerve terminals with high reliability. Electrophysiological and morphological control experiments showed that these dyes could be used to repeatedly observe neuromuscular junctions in living animals without affecting synaptic growth or remodelling. The importance of appropriate controls was emphasized by the finding that illumination, if excessively intense or prolonged, can cause physiological and structural damage to nerve terminals. Additional observations indicated that these dyes may be useful for determining the mitochondrial content, and therefore oxidative capacity, of living muscle fibres. It was also found that the fluorescent dyes labelled cells identified as muscle satellite cells, and that these myoblast precursors could be visualized in fixed whole mounts with a nitroblue tetrazolium stain. Both methods were used to study reactive cells that were closely associated with muscle fibres in lesioned muscles. Mitochondrial dyes also labelled the microvasculature, associated axons and other cells.     

The prevalence of serological markers for the human immunodeficiency virus and the hepatitis B virus in a psychiatric hospital

OBJECTIVES: To estimate the prevalence of antibodies to human immunodeficiency virus (HIV), antibodies to hepatitis B core antigen (anti-HBc), hepatitis B surface antigen (HBsAg), and antibodies to delta virus (anti-DV). DESIGN: Cross-sectional (prevalence) study. A non-proportional (stratified by length of stay) random sample of 20% of admitted patients was selected. CLINICAL SETTING: The Hospital Psiquiátrico Nuestra Se?ora de Montserrat (Sant Boi de Llobregat, Barcelona, Spain) admits about 670 patients in its short-term, rehabilitation (mid-term) and long-term wards. SUBJECTS: 139 patients were selected: 91% were males, mean age was 55 years, and 10% belonged to an HIV risk group; mean length of hospitalization since last discharge was 13 years. MEASUREMENTS: Blood samples were drawn in October, 1988. Anti-HBc, HBsAg and anti-DV were determined by competitive enzyme immunoassay (EIA). Anti-HIV-1 were determined by sandwich EIA; negativity of results with high absorbency but below the cut-off point was confirmed by Western blot. RESULTS: None of the sampled patients had circulating anti-HIV-1 antibodies. Four cases showing high absorbency (below the "cut-off" point) were ruled out by Western-blot. Overall, the prevalence of anti-HBc was 52.8% (54.4% in long-term wards, 35.0% in mid-term wards, and 13.8% in short-term wards). The prevalence of HBsAg was 2.3%, of anti-DV 1.5%, and of HDAg 0%. CONCLUSIONS: Prevalence of anti-HIV is null in the studied institution. Current efforts to prevent HIV infection must continue; a hepatitis B vaccination program is highly warranted among patients and professionals of the studied hospital.     

Utilisation of organs proceeding from donors with heart failure: review of the pathogenesis of organic damage and the possible mechanisms of prevention

There is an evident imbalance between the number of patients awaiting a kidney transplant and the availability of organs proceeding from donors with brain death. A high number of patients die each day from heart failure, whose organs could be used for transplants if specific care is employed. Although centres do exist where these methods of extraction are established, the problems of organic damage have yet to be resolved, since one third of the organs are still lost, besides the increase in the need for early dialysis, and the number of dysfunctioning grafts two years after the transplant, when this type or organ is employed. There is increasingly detailed knowledge of the pathogenesis of organic damage following heart failure and reanimation, as well as of the damage following the conservation and reimplantation of the kidney. Knowledge of the maximum time of hot ischemic that an organ can withstand is of crucial importance if organs are not to be unduly discarded. Besides, the increasing understanding of the physiopathology of oxidative stress could make it possible for us, through the use of antioxidants, to attempt to improve the utilisation of the organs and diminish the incidence of dysfunctions and rejections.     

‘Hybrid’ Bariatric Surgery: Bilio-pancreatic Diversion and Duodenal Switch - Preliminary Experience

Background: Hybrid, combined or mixed bariatric surgery is the combination of a degree of ‘malabsorption’ (as achieved by the intestinal bypass) with a ‘rrestriction’ (as achieved by gastric bypass or gastroplasty), thereby simultaneously reducing the absorption of fats in the small bowel and decreasing the intake of food. Methods: A modification of the bilio-pancreatic diversion (BPD) with a duodenal switch procedure, vertical lineal gastrectomy and preservation of the pylorus, has been used in 23 patients. The antropyloric pump and 4 cm of the duodenum are left intact to preserve physiologic gastric emptying and to prevent anastomotic ulcer. The use of staplers and continuous running sutures reduces surgical risks and operative time. Results: One patient, converted from a vertical gastroplasty, had an intrathoracic esophageal perforation and died of multisystemic organ failure, a mortality rate of 4.5%. One patient had a partial dehiscence of the laparotomy wound. Three patients developed subcutaneous seromas. Mean weight losses during the first 4 months were 13, 11, 6 and 5 kg, with a loss of 70% of excess weight in patients approaching 1 year. No patient needs treatment for diarrhea. No serious secondary side-effects have been detected. Conclusion: This operation appears to result in very satisfactory weight loss, improved quality of life, and a low incidence of complications.     

Adult-derived neural precursors transplanted into multiple regions in the adult brain

Neural stem cells persist in the adult brain subventricular zone (SVZ). These cells generate a large number of new neurons that migrate to the olfactory bulb, where they complete their differentiation. Here, we transplanted cells carrying beta-galactosidase under the control of neuron-specific enolase promoter (NSE::LacZ) from the SVZ of adult mice into the striatum cortex and olfactory bulb, with or without an excitotoxin lesion. Between 2 and 8 weeks after transplantation, grafted cells were present in the recipient regions, but extensive migration and differentiation into mature neurons of grafted cells were only observed in the olfactory bulb. Clusters of graft-derived neuroblasts forming chain-like structures were observed within or close to the grated sites in the cortex and striatum; electron microscopy confirmed that graft-derived cells in the olfactory bulb and a small number in the striatum were neurons. Surprisingly, most of the cells expressing NSE::LacZ outside the olfactory bulb were astrocytes. We conclude that primary precursors from the SVZ migrate and differentiate effectively only within the environment of the olfactory bulb. Only limited survival and differentiation were observed in other brain regions studied.     

Laparoscopic versus open adrenalectomy in Cushing's syndrome and disease

BACKGROUND: Adrenalectomy in Cushing's syndrome and disease involves particular risks and complications. The aim of the study was to compare the open posterior and the flank laparoscopic approaches in this group of patients. METHODS: Forty patients who underwent unilateral or bilateral adrenalectomy for hypercortisolism between 1991 and 1999 were studied. Patients were divided as follows: adenoma--5 laparoscopic and 6 open; hyperplasia--17 laparoscopic and 12 open. Demographics, surgical details, outcome, and complications were comparatively analyzed. RESULTS: Patients undergoing laparoscopic or open adrenalectomy were comparable in terms of age, sex distribution, body mass index, respiratory status, and anesthetic risk. Operative time was longer in the laparoscopic group. One patient in the laparoscopic group died of upper gastrointestinal tract bleeding on postoperative day 17. Two patients in the open group and one in the laparoscopic group experienced postoperative complications. Cure of the disease occurred in all patients. Mild abdominal wall pain developed in one patient in each group. No abdominal wall weakness was identified in either group. CONCLUSIONS: Cure rate and operative and long-term morbidity were similar for laparoscopic and open adrenalectomies in this series. However, it is important to emphasize that late complications in our patients who underwent the posterior open procedure were rather infrequent.     

Hürthle cell (oxyphilic) papillary thyroid carcinoma: a variant with more aggressive biologic behavior.

The latest World Health Organization International Classification defines papillary thyroid carcinoma by its "follicular cell differentiation...as well as characteristic nuclear changes". However the oxyphilic (Hürthle cell) papillary carcinoma have nuclei which generally resemble the nuclei seen in oxyphilic follicular carcinomas, and such oxyphilic papillary tumors may behave more aggressively than typical papillary cancers. To further characterize these rare tumors, we identified during a 32-year period 22 patients with oxyphilic papillary cancer and compared them with 1,084 patients with typical papillary cancers and 57 patients with oxyphilic follicular cancers treated by the Mayo surgical group during the same time period. Although typical papillary and oxyphilic papillary cancers were comparable with regards to patient age, tumor size and extent, TNM stage, and prognostic score (AGES), there were significant differences. Compared to typical papillary tumors, oxyphilic papillary cancers had fewer neck nodal metastases at primary diagnosis (5% vs 40%, p less than 0.0001), were more often DNA non-diploid (71% vs 21%, p less than 0.001), and after 10 postoperative years had higher rates of both tumor recurrence (28% vs 11%, p less than 0.0001) and cause-specific mortality (1.7% vs 4%, p less than 0.0005). In these four important respects the oxyphilic papillary cancers more resembled the oxyphilic follicular cancers. For oxyphilic follicular cancers, the frequency of initial neck nodal metastases was 7% (cf 5%); 83% of the oxyphilic follicular tumors were non-diploid (cf 71%), and at 10 years postoperatively the tumor recurrence and cause-specific mortality rates were 28% and 18%, insignificantly different from 28% and 17% seen with the oxyphilic papillary cancers.(ABSTRACT TRUNCATED AT 250 WORDS)     

A new approach to public health. Strategies for its implementation]

Public Health System accepts "New Public Health" only in a theoretical way, since in the practice essential modifications to get "Health For All-2000" aims are not implemented. It is necessary to look "bridge-heads" that permit to introduce changes gradually to reorganize Health Services. In the present article, different alternatives are analyzed, all of them giving priority to the programmes that consider Health as a natural resource. These programmes can be "Governmental Programmes" so Health policies coming from the Health Department can be assumed by the others Public Administration Departments.