Treatment of fractures of the distal radius with a remodellable bone cement: a prospective, randomised study using Norian SRS

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year. We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment.

Impact of protease inhibitor therapy on HIV-related oropharyngeal candidiasis

OBJECTIVE

To determine the relationship between antiretroviral therapy and changes in prevalence and amount of oropharyngeal candidiasis (OPC) and skin test reactivity for delayed type hypersensitivity.

DESIGN

Observational cohort.

SETTING

University-based public hospital AIDS clinic.

PATIENTS

Adults with advanced HIV infection who had been taking nucleoside transcriptase inhibitor drugs but had not taken a protease inhibitor and who started antiretroviral treatment with ritonavir.

MAIN OUTCOME MEASURES

OPC lesions score, oral candidal colonization, oral candidal quantification, skin test reactivity for delayed type hypersensitivity (purified protein derivative, candidal and streptokinase antigens), plasma HIV RNA and CD4 cell count at weeks 8, 16 and 48 weeks.

RESULTS

In the 99 patients who entered the study, there was a significant reduction in the HIV plasma RNA (mean log decrease from baseline at 48 weeks 0.88) and a significant increase in CD4 cell counts (mean CD4 cell increase from baseline at 48 weeks 128 x 10(6) cells/l). Only 17% of patients had < 200 copies/ml HIV RNA at 48 weeks. There were significant decreases in the prevalence of OPC lesions (31% at baseline to 1% at 48 weeks; P < 0.001), and in oral candidal loads [2226 to 811 colony-forming units (CFU)/ml; P = 0.0171]. The percentage of patients with at least one positive skin test increased significantly (6 to 28%; P < 0.05). Patients whose CD4 lymphocyte count was > 200 x 10(6) cells/l at 48 weeks had significantly lower oral candidal loads and were more likely to have a positive skin test than patients whose CD4 cell count was < 200 x 10(6) cells/l.

CONCLUSION

In patients with advanced HIV infection, antiretroviral treatment including a protease inhibitor has a positive impact in the natural history of OPC. This positive impact appears to be correlated with a better immunological function and occurs despite continuous HIV replication.

Predictive value of nuclear factor kappaB activity and plasma cytokine levels in patients with sepsis

The relationship between fluctuating cytokine concentrations in plasma and the outcome of sepsis is complex. We postulated that early measurement of the activation of nuclear factor kappaB (NF-kappaB), a transcriptional regulatory protein involved in proinflammatory cytokine expression, may help to predict the outcome of sepsis. We determined NF-kappaB activation in peripheral blood mononuclear cells of 34 patients with severe sepsis (23 survivors and 11 nonsurvivors) and serial concentrations of inflammatory cytokines (interleukin-6, interleukin-1, and tumor necrosis factor) and various endogenous antagonists in plasma. NF-kappaB activity was significantly higher in nonsurvivors and correlated strongly with the severity of illness (APACHE II score), although neither was related to the cytokine levels. Apart from NF-kappaB activity, the interleukin-1 receptor antagonist was the only cytokine tested whose level in plasma was of value in predicting mortality by logistic regression analysis. These results underscore the prognostic value of early measurement of NF-kappaB activity in patients with severe sepsis.

Determination of the percentage of free prostate-specific antigen helps to avoid unnecessary biopsies in men with normal rectal examinations and total prostate-specific antigen of 4-10 ng/ml

OBJECTIVE

To assess the usefulness of measuring the percentage of free prostate-specific antigen (PSA) in serum to reduce the number of prostate biopsies in men with serum PSA levels between 4 and 10 ng/ml and benign prostate examinations.

MATERIALS AND METHODS

The percentage of free PSA (Immulite((R))) in serum was analyzed prospectively in 180 men with benign digital rectal examinations and total PSA serum levels of between 4 and 10 ng/ml. All patients underwent ultrasound-guided sextant prostatic biopsies. Sensitivity, specificity and positive and negative predictive values were calculated as well as the percent of patients in which biopsies could have been avoided for various cutoff values of the percentage of free PSA as an indicator for biopsy. Influence of age in the determination of cut points was evaluated.

RESULTS

Cancer was detected in 22.2% (40/180) of the patients. Mean percentage of free PSA was 13.4% in patients with cancer and 18.9% in patients with benign prostatic hyperplasia (p = 0.001). Using a percentage of free PSA cutoff of 22% or less as a criterion for performing prostatic biopsy would have detected 95% of cancers, avoided 25% of benign biopsies and yielded a positive predictive value of 29% in patients who underwent biopsy. Mean percent of free PSA values increased as mean subject age increased, influencing the calculation of cut points, sensitivity and specificity. Leaving the cut point constant across all age groups will oblige older patients to undergo an increased number of unnecessary biopsies, although allowing for higher sensitivity in younger men.

CONCLUSIONS

Measurement of the percentage of free serum PSA improves specificity of prostate cancer detection in patients with elevated total serum PSA levels and benign prostate examinations. Subject age seemed to influence the determination of optimal cut points.

Loosening of the cup after low-friction arthroplasty in patients with acetabular protrusion

Between 1972 and 1990, we performed 168 primary low-friction arthroplasties in 125 patients with acetabular protrusion. Twelve hips were lost to follow-up within eight years and eight which became infected were excluded from the final study. Of the 148 hips remaining, 62 with a mild protrusion were classified as group 1, 54 with moderate or severe protrusion as group 2 and, after 1985, 32 with moderate and severe protrusion which required bone grafts as group 3. The mean follow-up was 18.3 years (3 to 24) for group 1, 17.4 years (8 to 22) for group 2 and ten years (8 to 13) for group 3.

There were 31 revisions of the cup, 12 in group 1 and 19 in group 2. According to the Kaplan-Meier analysis the overall rates at 20 years were 21 ± 10.79% in group 1 and 37 ± 11.90% in group 2. There have been 43 radiological loosenings: 22 in group 1, 21 in group 2 and none so far in group 3, at ten years. The overall loosening rates at 20 years were 42 ± 14.76% in group 1 and 49 ± 19.50% in group 2. The grafts were well incorporated in all group-3 hips, and the bone structure appeared normal after one year.

The distance between the centre of the head of the femoral prosthesis and the approximate true centre of the femoral head was less in group 3 than in groups 1 and 2 (p < 0.01). According to the Cox proportional-hazards regression this was the single most important factor in loosening of the cup (odds ratio 1.11; 95% CI 1.05 to 1.18/mm). Better results were obtained in moderate and severe protrusions reconstructed with bone grafting than in hips with mild protrusion which were not grafted.

Loosening of the cup after low-friction arthroplasty in patients with acetabular protrusion. The importance of the position of the cup

Between 1972 and 1990, we performed 168 primary low-friction arthroplasties in 125 patients with acetabular protrusion. Twelve hips were lost to follow-up within eight years and eight which became infected were excluded from the final study. Of the 148 hips remaining, 62 with a mild protrusion were classified as group 1, 54 with moderate or severe protrusion as group 2 and, after 1985, 32 with moderate and severe protrusion which required bone grafts as group 3. The mean follow-up was 18.3 years (3 to 24) for group 1, 17.4 years (8 to 22) for group 2 and ten years (8 to 13) for group 3. There were 31 revisions of the cup, 12 in group 1 and 19 in group 2. According to the Kaplan-Meier analysis the overall rates at 20 years were 21 +/-10.79% in group 1 and 37 +/- 11.90% in group 2. There have been 43 radiological loosenings: 22 in group 1, 21 in group 2 and none so far in group 3, at ten years. The overall loosening rates at 20 years were 42 +/-14.76% in group 1 and 49 +/- 19.50% in group 2. The grafts were well incorporated in all group-3 hips, and the bone structure appeared normal after one year. The distance between the centre of the head of the femoral prosthesis and the approximate true centre of the femoral head was less in group 3 than in groups 1 and 2 (p < 0.01). According to the Cox proportional-hazards regression this was the single most important factor in loosening of the cup (odds ratio 1.11; 95% CI 1.05 to 1.18/mm). Better results were obtained in moderate and severe protrusions reconstructed with bone grafting than in hips with mild protrusion which were not grafted.

Patency and flow of the internal jugular vein after functional neck dissection

OBJECTIVES

To assess the patency and flow of the internal jugular vein after functional neck dissection.

STUDY DESIGN

Prospective study of 54 internal jugular veins in 29 oncologic patients undergoing functional neck dissection between September 1994 and February 1997.

METHODS

Patency, presence of thrombosis, characteristics of the vein wall, compressibility, area of the vein both in rest and during Valsalva maneuver, expiratory flow speed, Valsalva flow speed, jugular flow in each side, and total jugular flow were assessed in all veins before and after dissection. All patients were evaluated before and after the procedure by means of duplex Doppler ultrasonography.

RESULTS

In no case was there thrombosis before or after the operation. Although total jugular flow decreases during the early postoperative period, it recovers to normal parameters within 3 months after surgery.

CONCLUSIONS

According to these results, the patency of the internal jugular vein remains unaltered after functional neck dissection. Ultrasonographically there is no thrombosis after this procedure.

Use of mammography among women residing in Spanish provinces with breast cancer screening programmes

The objective of this study was to measure use of mammography and associated factors among women living in Spanish provinces with breast cancer screening programmes. From a cross-sectional population survey in a representative sample of Spanish women aged 40-70 years, we selected all women aged 45-65 living in provinces with breast cancer screening programmes (336 women). The programmes invited women in this age group to have a mammogram every 2 years. Data were collected by oral interviews in 1994. Use of mammography was defined as having received at least one test in the previous 2 years. Factors associated with mammography were studied using a logistic regression model. In the three autonomous communities (totalling 11 provinces) with programmes, the percentage of women receiving the test was 41.1% in Castille-Leon, 41.7% in Castille-La Mancha and 87.6% in Navarre (mean: 55.4%). The programmes began in 1990 in Navarre and between 1992 and 1993 in the other two communities. The most important factors affecting mammography use in the multivariate analysis were: intention to have a mammogram [odds ratio (OR) = 5.52; 95% confidence interval (CI) = 3.17-9.63]; not rejecting the test for fear of cancer diagnosis (OR = 4.23; 95% CI = 1.64-10.9); and physician recommendation of the test (OR = 3.43; 95% CI = 1.88-6.24). In conclusion, although the more established screening programmes have higher mammography use than those more recently implemented, programmes alone may not guarantee that women receive the test. Women's attitudes about mammography, and the role of the physician, are fundamental factors in the use of mammography.

Relationship of plasma leptin to plasma cytokines and human survivalin sepsis and septic shock

Leptin production is increased in rodents by administration of endotoxin or cytokines. To investigate whether circulating leptin is related to cytokine release and survival in human sepsis, plasma concentrations of leptin, interleukin (IL)-6, IL-1beta, tumor necrosis factor (TNF)-alpha, soluble TNF receptor type I, IL-1 receptor antagonist (IL-1ra), and the inflammatory modulator IL-10 were measured as soon as severe sepsis (n=28) or septic shock (n=14) developed and every 6 h for 24 h. Patients with sepsis or septic shock had leptin concentrations 2.3- and 4.2-fold greater, respectively, than the control group. There was an independent association for leptin with IL-1ra and IL-10 in both patient groups. By discriminant analysis, leptin and IL-6 were independent predictors of death. These findings suggest that increases in leptin levels may be a host defense mechanism during sepsis.

Extracapsular spread and desmoplastic pattern in neck lymph nodes: two prognostic factors of laryngeal cancer

The influence of extracapsular spread (ECS) and a desmoplastic pattern (DP) of metastatic cervical lymph nodes in patients with laryngeal cancer is presented. The study includes 128 patients surgically treated between 1984 and 1992 for squamous cell carcinoma of the larynx with pathologically proven lymph node metastasis. The results were studied from 2 major standpoints: survival and recurrence. The 3-year survival rates were as follows: patients without ECS 73.4%, and with ECS 28.9% (p < .001); patients without a DP 76.9%, and with a DP 43.3% (p < .03). Also, the 3-year recurrence rates in the neck showed significant differences: patients without ECS 10.7%, and with ECS 49.6% (p < .001); patients without a DP 10%, and with a DP 31.6% (p = .1142). Postoperative radiotherapy did not appear to improve the outcome.

Time course and prognostic significance of hemostatic changes in sepsis: relation to tumor necrosis factor-alpha

OBJECTIVES

To describe the time course and prognostic significance of tumor necrosis factor-alpha (TNF-alpha) levels and hemostatic abnormalities in clinical sepsis.

DESIGN

Prospective, observational study with sequential measurements in an inception cohort.

SETTING

An emergency department in a university teaching hospital. Patients were followed up until they either left the hospital or died.

PATIENTS

During a 1-yr period, 43 adult patients were selected from all emergency department patients who met the established criteria for sepsis. Excluded were patients with either organ dysfunction or septic shock at the time of admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected serially (day of admission and on days 3, 5, and 7) to determine TNF-alpha, platelet count, fibrinogen, factor VII, antithrombin III, tissue-type plasminogen activator activity, plasminogen activator inhibitor activity, plasminogen, and alpha2-antiplasmin. Fibrinopeptide A was measured only on the day of admission. Data were analyzed to determine whether admission values or serially obtained values within 7 days were useful in predicting outcome. Thirteen patients died and 30 survived. On admission, assay values indicated that platelet count and antithrombin III were significantly lower than normal (as observed in 50 healthy adults). Fibrinogen, plasminogen activator inhibitor type 1, tissue-type plasminogen activator, fibrinopeptide A, and TNF-alpha were higher than normal, whereas concentrations of factor VII, plasminogen, and alpha2-antiplasmin were in the normal range. No differences were detected in the admission values between survivors and nonsurvivors, except for antithrombin III. However, subsequent values of some variables demonstrated a difference between survivors and nonsurvivors. Survivors showed increasing platelet count and antithrombin III values compared with nonsurvivors, in whom the values remained low, with no significant changes during the study period. High TNF-alpha levels were found in both groups, but only survivors experienced progressive decrease during the observation period.

CONCLUSIONS

Early clinical sepsis is characterized by high plasma levels of TNF-alpha and by activation of the coagulation and fibrinolysis systems. Longitudinal analysis of some variables (antithrombin III, platelet count, and TNF-ea) showed some differences with time between the survivor and nonsurvivor groups, but we feel that such differences were not large enough to be predictive in individual patients.

Seasonal patterns of idiopathic facial paralysis: a 16-year study

The annual frequency of Bell's palsy in 16 consecutive years was investigated in a 465,000-person health area in Madrid, Spain. The annual incidence of Bell's palsy per 100,000 population was found to be 24.1. The male-to-female ratio was 46:54. Seasonal difference in the incidence was noted in our series with fewer cases during summer. According to these results, the illness in Spain seems to have a similar incidence to that in Western countries. In addition to this, Bell's palsy does not have an infectious epidemiologic pattern in our country, but its frequency decreases in warm weather.

Plasmatic amino acids in kidney transplantation in children

We studied the evolution of plasma amino acid levels in children with chronic kidney failure after undergoing a renal transplantation. Plasma amino acid profile was studied in 10 children just before surgery, at admission in paediatric intensive care unit and 4, 8, 12, 24, 48 and 72 h after transplantation. Previous to the graft, plasma levels of glutamic acid (p < 0.01), hydroxyproline (p < 0.01), citrulline (p < 0.01) and arginine (p < 0.05) were significantly increased, whereas plasma levels of serine (p < 0.01), glutamine (p < 0.03), threonine (p < 0.01), tyrosine (p < 0.01), valine (p < 0.01), leucine (p < 0.01), tryptophan (p < 0.01), branched amino acids (BCAA) (p < 0.01), aromatic amino acids (AAA) (p < 0.01) and essential amino acids (EAA) (p < 0.01) were decreased in relation to control children. The amino acid profile evolution run parallel to the settle down of renal function parameters. Within 72 h after surgery, even before in some cases, all amino acids except tryptophan and arginine reached normal levels.

Infection and associated risk factors in the immediate postoperative period of pediatric liver transplantation: a study of 176 transplants

OBJECTIVE

To describe the characteristics of infections occurring in the immediate postoperative period of orthotopic liver transplantation (OLT) in children in a pediatric intensive care unit (PICU) and the associated risk factors.

DESIGN

Retrospective cohort study.

SETTING

Multidisciplinary 16-bed pediatric intensive care unit in a tertiary university hospital.

PATIENTS

One hundred and thirty-three pediatric patients (range 6M to 22 yr) who underwent 176 liver transplantations and were admitted to the pediatric intensive care unit for at least 48 h.

RESULTS

A total of 180 infectious episodes (IE) occurred in 78 (59%) patients who underwent 96 (54.5%) liver transplantations (1.35 IE/patient; 1.02 IE/transplantation). The mean stay was 15.4 +/- 1.1 d (mean +/- SD) and 22 patients died in the pediatric intensive care unit. One hundred and thirty-one IE (72.8%) were bacterial, 31 (17.2%) fungal, and 14 (7.8%) mixed bacterial and fungal. 39% of the IE appeared in the first postoperative week and 27% in the second postoperative week. The most common sites of infection were abdomen (48.3%) and blood stream (26.1%). Bacteria, alone or with fungi, were present in 145 IE (1.1 IE/patient). Gram-positive aerobic bacteria (63%) predominated over gram-negative bacteria (54%) and fungi. Fungi were present in 45 IE; 53.4% of the infections occurred in lung (73% yeasts). The risk factors for infection that were identified were related with younger age, lower body weight, longer cold ischemia time, partial graft, and the volume of packed red blood cell transfusions. Infected patients had more postoperative complications and longer stay in the PICU (21 +/- 16 vs. 8 +/- 6 d), but no increase in mortality. The risk of infection increased 2.38 times with partial grafts and 1.1 times with each intraoperative transfusion of 20 ml/kg of packed red blood cells (RBC).

CONCLUSIONS

Infection in the immediate postoperative period of pediatric OLT was related with a high morbidity but was not related significantly with increased mortality. The main risk factors for infection in the postoperative period of OLT were related essentially with small recipient size and the inherent complexity of the operation. Routine oropharyngeal decontamination is recommended, as well as early administration of oral nystatin in preoperative intestinal decontamination. The risk of infection increased 2.38 times with partial grafts and 1.1 times with the transfusion of every 20 ml of packed RBC.

The spectrum of acute renal failure in the intensive care unit compared with that seen in other settings. The Madrid Acute Renal Failure Study Group

Acute renal failure (ARF) is at a crossroads between nephrology and intensive care medicine. However, there seems to be wide differences between the ARF observed in the intensive care unit (ICU) compared to that observed in other areas of the hospital, particularly when examining the mortality rate. Among the ICU patients the 70% mortality rate is higher to the 50% found in an overall series of studies. Recently, Druml proposed that there is a changing trend in the clinical spectrum of ARF as a convincing reason to justify these differences. According to him, we are moving from an ARF seen as a mono-organ failure to another one observed in a multiorgan dysfunction syndrome (MODS) context. Although extremely coherent, this hypothesis has not been fully confirmed in a prospective study. In fact, most authors seem to look at the problem from opposite sides of the river, either from the critical medicine or the nephrological bank. To the best of our knowledge, only one retrospective study has dealt with this topic by comparing outcome of ARF in ICU and non-ICU patients. In this article we aim to overcome this problem by reviewing the data of the prospective epidemiological ARF study carried out in Madrid using two different approaches: (1) comparing the ARF cases observed in the ICU setting with those ARF studied outside the ICU, and (2) comparing the outcome of isolated ARF with the outcome of ARF as part of a MODS in patients treated in both settings.

Idiopathic facial paralysis: a randomized, prospective, and controlled study using single-dose prednisone versus acyclovir three times daily

In a prospective, controlled, and randomized study, we compared the outcome of 101 Bell's palsy patients treated with acyclovir (54 patients) or prednisone (47 patients). The acyclovir dosage was 2400 mg (800 mg three times a day) for 10 days, and prednisone was given as a single daily dose of 1 mg/kg of body weight for 10 days and tapered to 0 over the next 6 days. Minimum follow-up was 3 months in all patients. Patients in the prednisone group had better clinical recovery than those treated with acyclovir. Less degree of neural degeneration was observed in the prednisone group compared with acyclovir patients. The incidence of sequelae was the same in both groups. According to these results, in a 10-day treatment cycle acyclovir given 800 mg three times is not as useful as prednisone given 1 mg/kg of body weight once a day in patients with idiopathic facial nerve paralysis.

[Relationship between mixed venous saturation and cardiac index, hemoglobin and oxygen consumption in aortic surgery]

OBJECTIVE

Mixed venous oxygen saturation (SvO2) depends mainly on four variables: cardiac index (CI), hemoglobin concentration (Hb), arterial oxygen saturation (SpO2) and oxygen consumption (VO2). Our aim was to study the correlation between each of these variables and SvO2 during abdominal aortic surgery, a situation which is of special interest because of associated hemodynamic and metabolic variations and the high risk of cardiovascular events.

PATIENTS AND METHODS

Twelve patients undergoing intrarenal aortic surgery were monitored by pulmonary artery catheter (Opticath), pulse oximetry and indirect calorimetry (Deltatrac Metabolic Monitor). SvO2, CI (measured by thermodilution), SpO2 and VO2 at six moments: post-induction (baseline), 1 min before and 1 min after clamping (pre-C, post-C), 1 min (post-D) and 10 min after declamping and at the end of the surgery. Hemoglobin concentration was measured at all moments except 10 min after declamping.

RESULTS

All variables except SpO2 varied significantly (p < 0.001) during the study. SvO2 was associated with CI at all moments except post-D and at the end of surgery. Hemoglobin concentration was related to SvO2 at baseline and post-C. We found no correlation between SvO2 and VO2 or SpO2 at any moment.

CONCLUSION

Monitoring SvO2 in patients undergoing aortic surgery is useful for detecting potentially prejudicial variations in cardiac output or hemoglobin concentration.

Progression of radiolucent lines adjacent to the acetabular component and factors influencing migration after Charnley low-friction total hip arthroplasty

We analyzed the progression of radiolucent lines around the acetabular cup after 452 Charnley low-friction arthroplasties that had been performed in 392 patients between 1971 and 1976. The average duration of follow-up was twenty years (range, eleven to twenty-five years) for the 442 hips (382 patients) that had the original component in place at ten years. The demarcation of the bone-cement interface was classified according to the system of Hodgkinson et al. We sought to determine if there was a relationship between the progression of the radiolucent line and the age, gender, and weight of the patient; the level of activity; the preoperative diagnosis; or the amount of wear of the acetabular cup. The demarcation increased over time in 138 (31 per cent) of the 452 hips. Radiographs made at the time of the latest follow-up showed migration of eleven (5 per cent) of the 233 acetabular cups with no demarcation on the initial postoperative radiograph, eighteen (11 per cent) of the 167 cups with type-1 demarcation, twelve (35 per cent) of the thirty-four cups with type-2 demarcation, and thirteen of the eighteen cups with type-3 demarcation. Preoperative acetabular protrusion, inflammatory arthritis, and severe acetabular dysplasia as well as a previous operation were associated with the extent of the radiolucent line on the most recent radiograph (p < or = 0.05 for all). A high level of activity and more than two millimeters of wear of the acetabular cup also were related to the progression of the radiolucent line (p = 0.0004 and p < 0.0001, respectively). Kaplan-Meier survivorship analysis demonstrated that the greater the demarcation on the initial postoperative radiograph, the greater the risk of migration (p < 0.0001, Mantel-Cox test). Our data suggest that, after a Charnley low-friction arthroplasty, any cemented cup, even one with the least amount of demarcation (types 0 and 1), can migrate. As the type of the initial postoperative demarcation increases, so does the risk of migration of the cup, particularly when there is loss of the acetabular bone stock.

Femoral osteolysis after low-friction arthroplasty. A planimetric study and volumetric estimate

Sixty-three cases of femoral osteolytic cavities were analyzed in a consecutive series of 680 low-friction arthroplasties of the hip performed in 598 patients between 1971 and 1979. Follow-up evaluation averaged 15 years 9 months (range, 2-22 years). The total cumulative probability of osteolysis developing after 20 years was 11% according to survivorship analysis. The mean time of appearance of the osteolytic lesion was 9 years 3 months after operation. Most of the cavities were seen in Gruen zones 3, 5, and 7 in decreasing order. Osteolytic cavities were classified as follows: group 1, cavities in cases with radiographic definite stem loosening (20 cases); group 2, cavities in cases with an acetabular wear equal to or greater than 2 mm (22 cases); and group 3, cavities in cases combining both of the above-mentioned findings (21 cases). Cementing defects such as voids and thin mantles were less frequent in group 2 than in groups 1 and 3 (P < .005). Poor clinical results were more frequent in groups 1 and 3 (P < .05), in all instances). Focal cavities were more frequent in group 2, and multifocal and diffuse cavities were more frequent in groups 1 and 3 (P < .05). The average planimetric area on radiographic diagnosis was 0.81 cm2, and the average approximate volume was 1.86 cm3, with significant differences among the three groups of cavities. Progression of the cavity area and volume was linear over time (P < .001) and more aggressive in groups 1 and 3 than in group 2 (P < .05). Thus, loosening of the stem was a more deciding factor than acetabular wear in the progression of cavities.

Animal survival related to acute blood pressure response in global cerebral ischemia in rats

The increase in mean arterial blood pressure (MABP) during global cerebral ischemia constitutes a compensatory and protective mechanism, regulated by the Central Nervous System, in response to the accumulation of different toxic compounds in the brain stem. The relationship between MABP increases and improved tolerance by the animals to ischemia is discussed.

[Programs of early detection of breast cancer and access of mammography in Spain]

BACKGROUND

We studied availability to mammography among Spanish women aged 40 to 70 years, variation in use of the mammography by autonomous community, and the situation and importance of breast cancer screening programs among other factors, in the access to mammography.

SUBJECTS AND METHODS

A cross-sectional population survey was conducted in 1994 in a sample of 3,218 women. A questionnaire was used to collect data on the variable access (receipt of at least one mammogram in the last 2 years) as well as different access-related variables. Information on breast cancer screening programs was collected by contacting the responsible institutions. We considered that a program had total coverage if it included all the municipalities in the province and partial if it did not include all municipalities.

RESULTS

Twenty-eight percent of women had performed a mammogram. This proportion varied among autonomous communities (AACC) from 11.5 to 73.8%. Breast cancer screening programs existed in 8 AACC. The multivariant analysis revealed an association between access to mammography and the existence of a screening program, especially when the later had total coverage (OR = 7.64; 95% CI = 5.24-11.10). An association was also found between access to mammography and physician-related factors, place of residence and attitudes of women toward mammography.

CONCLUSIONS

Less than one third of women aged 40-70 have performed a mammography in the last 2 years, and this proportion varies among AACC. Gynecologist visits and the existence of breast cancer screening programs are fundamental factors in the access to mammography in Spain.

Analysis of costs in a pediatric ICU

OBJECTIVE

To analyze the actual cost of pediatric intensive care and its different components, particularly the differences between various patient groups, with special reference to the variable cost and the elements included in it.

DESIGN

Prospective, observational study.

SETTING

Multidisciplinary 12-bed pediatric intensive care unit (PICU) in a tertiary university hospital.

PATIENTS

495 admissions to the unit over 17 consecutive months; 64.2% were medical patients and 35.8% were surgical patients; the mean (SE) stay in the PICU was 6.6 +/- 0.4 days.

MEASUREMENTS AND RESULTS

The fixed cost per day per patient was calculated, including the costs of physicians, nurses, auxiliary and other personnel who worked during the study period, and the costs of structural depreciation, maintenance, consumption, and disposable material. The variable cost was individually calculated from the costs of routine procedures and also included expenditure on pharmaceuticals, blood products, biochemical, hematological, and bacteriologic tests, radiology, image diagnosis procedures, and other procedures. The Physiologic Stability Index (PSI) was obtained in the first 24 h after admission. The mean fixed cost per patient per day was u.s. $608, which represents 72% of the total patient cost during this study; 86% of this amount was for personnel (58% for nurses and auxiliary staff). Variable costs came to 28% of the total amount, and were $218 +/- 100 (M +/- SEM) per patient per day. In addition to the costs of their longer stay in the PICU, the daily variable costs of nonsurvivors were higher than those of survivors ($542 +/- 52 vs $179 +/- 7; p < 0.001). We classified the patients into four groups according to their PSI score in the first 24 h; variable daily costs increased (p < 0.05) in all comparisons with the PSI level: group I: < 4 points ($155 +/- 0.5), group II: 5-9 points ($210 +/- 13), group III: 10-14 points ($324 +/- 54), group IV: > 15 points ($480 +/- 42). However, this pattern was not found for all resources: the cost of treatment techniques and biochemical and hematological tests increased, but the consumption of antibiotics, parenteral nutrition, blood products, and bacteriologic tests reached their maximum level in groups I-III and radiology was not significantly influenced by PSI level.

CONCLUSIONS

The cost of personnel was the biggest factor in intensive care costs: 62.4% of the total costs. Nonsurvivors generated 3 times the mean variable daily expenditure on survivors and had longer stays in the PICU. The increase in PSI score on the first day was associated with a global increase in variable costs. The cost of treatment techniques significantly increased as the illness became more severe but consumption of antibiotics and parenteral nutrition and use of bacteriologic tests and radiology did not.

Equity in the access to mammography in Spain

The purpose of this study is to measure the access to mammography of women aged 40-70 in Spain and to analyze the factors related to access to the test. Women were considered to have access to mammography if they have received at least one mammogram in the preceding 2 years. Numerous studies have shown that breast cancer mortality is reduced in women receiving periodic mammography, although experts disagree about the most appropriate age range for screening. An equitable health care system should provide access to effective procedures to all persons who need them. A number of factors influencing the access to mammography have been described. We conducted a cross-sectional population-based survey of 3218 women residing in Spain who were between 40 and 70 years of age. The sample was selected using a multi-stage stratified cluster technique, with proportional assignment to each stratum. Data collection took place between March and May 1994 by means of individual oral interviews using a standardized questionnaire. The questionnaire included information on the dependent variable (mammography use) and the independent variable (those potentially associated with access to the test). Information on other independent variables was collected in official institutions or from existing publications. Data analysis consisted of univariate and multivariate analyses. Only about 28% of all women had received a mammogram in the last 2 years. According to the univariate analysis, access to mammography is most strongly associated with number of gynaecologist visits, residence in the autonomous community of Navarre, and physician referral for mammography. In the multivariate analysis, the factors most strongly associated with access to mammography are gynaecologist visits at least once in the last 2 years (OR = 8.71; CI = 6.84-11.10), existence of a breast cancer screening programme (OR = 7.64; CI = 5.24-11.10), and physician referral for testing (OR = 4.78; CI = 3.83-5.96). The multivariate analysis also showed a significant association with place of residence and with women's attitudes about testing. A small proportion of Spanish women who could potentially benefit from mammography have received the test in the last 2 years. Establishing breast cancer screening programs equitably throughout the nation, and carrying out educational interventions aimed at women and especially at physicians, will help to reduce inequalities and increase the access to mammography in Spain.