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Palma D, Hernández A, Picchio CA, Jodar G, Galbany-Estragués P, Simón P, Guillaumes M, Diez E, Rius C. Confidence in a Vaccine against COVID-19 among Registered Nurses in Barcelona, Spain across Two Time Periods. Vaccines (Basel) 2022; 10:873. [PMID: 35746481 PMCID: PMC9229357 DOI: 10.3390/vaccines10060873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To report the vaccine hesitancy (VH) for a vaccine against COVID-19 in registered nurses in Barcelona, with measurements taken at two stages, prior to the vaccination campaign and once 75% vaccination coverage had been reached. METHODS A self-completed online survey was administered in December 2020 and again in July 2021 through the College of Nurses of Barcelona. It measured the prevalence of VH against a government-approved vaccine recommended by their employer, their intention to be vaccinated, perceptions of disease risk and vaccine protection, attitudes and beliefs to vaccination and social norm. Bivariate analysis according to VH and application time are presented. RESULTS 2430 valid responses were obtained in the first measurement and 2027 in the second. At both times, 86% were women and 69% worked mainly in the public sector. Prior to the vaccine availability, VH was 34.2%, decreasing to 17.9%. Risk perceptions were significantly lower in those with VH compared to non-VH, in all groups studied and at both times, while safety and efficacy perceptions increased in all groups, significantly less in VH. The greatest benefit of the COVID-19 vaccine is perceived by pharmaceutical companies. VH nurses perceived a more hesitant social environment. CONCLUSION As the vaccination was rolled out, VH in nurses declined, with time improving the confidence in the safety and efficacy of the vaccines. Risk perceptions also decreased over time, except for the perception of severity in HCW where it increased. Trust in institutions impacts trust in vaccines.
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Affiliation(s)
- David Palma
- Servei d’Epidemiologia, Agència de Salut Pública de Barcelona, 08023 Barcelona, Spain; (A.H.); (P.S.); (M.G.); (E.D.); (C.R.)
- Consorcio de Investigació Biomèdica en Red en Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
- Department of International Health, Care and Public Health Research Institute—CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Anna Hernández
- Servei d’Epidemiologia, Agència de Salut Pública de Barcelona, 08023 Barcelona, Spain; (A.H.); (P.S.); (M.G.); (E.D.); (C.R.)
| | - Camila A. Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain;
| | - Glòria Jodar
- Col·legi Oficial d’Infermeres i Infermers de Barcelona, 08019 Barcelona, Spain; (G.J.); (P.G.-E.)
| | - Paola Galbany-Estragués
- Col·legi Oficial d’Infermeres i Infermers de Barcelona, 08019 Barcelona, Spain; (G.J.); (P.G.-E.)
| | - Pere Simón
- Servei d’Epidemiologia, Agència de Salut Pública de Barcelona, 08023 Barcelona, Spain; (A.H.); (P.S.); (M.G.); (E.D.); (C.R.)
| | - Montserrat Guillaumes
- Servei d’Epidemiologia, Agència de Salut Pública de Barcelona, 08023 Barcelona, Spain; (A.H.); (P.S.); (M.G.); (E.D.); (C.R.)
| | - Elia Diez
- Servei d’Epidemiologia, Agència de Salut Pública de Barcelona, 08023 Barcelona, Spain; (A.H.); (P.S.); (M.G.); (E.D.); (C.R.)
- Consorcio de Investigació Biomèdica en Red en Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
| | - Cristina Rius
- Servei d’Epidemiologia, Agència de Salut Pública de Barcelona, 08023 Barcelona, Spain; (A.H.); (P.S.); (M.G.); (E.D.); (C.R.)
- Consorcio de Investigació Biomèdica en Red en Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
- Department of Experimental and Health Sciences, Faculty of Health and Life Sciences, Universitat Pompeu Fabra (UPF), 08003 Barcelona, Spain
- Institut de Recerca de l’Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain
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Martínez-Pías E, García-Azorín D, Trigo-López J, Talavera B, Valle G, Hernández I, Simón P, Arenillas-Lara JF. [Effect of treatment with benzodiazepines on the hospital prognosis of Coronavirus disease 2019]. Rev Neurol 2021; 73:201-209. [PMID: 34515333 DOI: 10.33588/rn.7306.2021028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The consequences of the use of of benzodiazepines in coronavirus disease 2019 have not yet been studied. We compared the hospital prognosis of patients hospitalized for coronavirus disease 2019 in benzodiazepine users and non-users. PATIENTS AND METHODS Observational study with a retrospective cohort design. All consecutive patients admitted with a confirmed diagnosis of coronavirus disease 2019 were included. The patients under chronic treatment with benzodiazepines at the time of admission were studied and compared with non-users. The primary objective was to analyze the mortality of patients who used chronic benzodiazepines at the time of admission and compare them with those who did not use them. The secondary objective was to analyze the risk of severe disease due to coronavirus 2019, acute respiratory distress syndrome and admission to the Intensive Care Unit in both groups of patients. RESULTS We included 576 patients, 138 (24.0%) used benzodiazepines. After adjusting for sex, age, baseline situation and all the different variables between both groups, benzodiazepine users did not show a higher odds of mortality (OR: 1,1, IC 95%: 0,7-1,9, p = 0,682) or higher risk of severe disease due to coronavirus 2019 (OR: 1.2, 95% CI: 0.7-1.8, p = 0.523). They also did not have a higher risk of acute respiratory distress syndrome (OR: 1.2, IC 95%: 0.8-1.9, p = 0.315) or more admission to the Intensive Care Unit (OR: 0.8, 95% CI: 0.4-1.4, p = 0.433). CONCLUSION In our sample, treatment with benzodiazepines at the time of admission was not associated with a worse hospital prognosis in patients with coronavirus disease 2019.
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Affiliation(s)
- E Martínez-Pías
- Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - D García-Azorín
- Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - J Trigo-López
- Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - B Talavera
- Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - G Valle
- Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - I Hernández
- Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - P Simón
- Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - J F Arenillas-Lara
- Universidad de Valladolid, Valladolid, España.,Hospital Clínico Universitario de Valladolid, Valladolid, España.,Universidad de Valladolid-Consejo Superior de Investigaciones Científicas, Madrid, España
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Álamo-Junquera D, Politi J, Simón P, Dieli-Crimi R, Borrell RP, Colobran R, Martínez-Gallo M, Campins M, Antón A, Esperalba J, Andrés C, Codina MG, Polverino E, Narciso MR, Molinero E, Rius C. Coordinated Response to Imported Vaccine-Derived Poliovirus Infection, Barcelona, Spain, 2019-2020. Emerg Infect Dis 2021; 27:1513-1516. [PMID: 33900188 PMCID: PMC8084499 DOI: 10.3201/eid2705.204675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In 2019, the Public Health Agency of Barcelona, Spain, was notified of a vaccine-derived poliovirus infection. The patient had an underlying common variable immunodeficiency and no signs of acute flaccid paralysis. We describe the ongoing coordinated response to contain the infection, which included compassionate-use treatment with pocapavir.
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4
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Palma D, Mercuriali L, Figuerola J, Montalvo T, Bueno-Marí R, Millet JP, Simón P, Masdeu E, Rius C. Trends in the Epidemiology of Leishmaniasis in the City of Barcelona (1996-2019). Front Vet Sci 2021; 8:653999. [PMID: 33981743 PMCID: PMC8107217 DOI: 10.3389/fvets.2021.653999] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Leishmaniasis is a neglected zoonosis produced by 20 different flagellated parasites of the Leishmania genus, a protozoan transmitted to humans and other vertebrates by the bite of dipteran insects of the Phlebotominae subfamily. It is endemic in Mediterranean countries and the number of cases is expected to increase due to climate change and migration. Prioritizing public health interventions for prevention and control is essential. The objective was to characterize the epidemiology and temporal trends in the incidence of human leishmaniasis in the city of Barcelona, between the years 1996 and 2019. Methods: A population-based, analytical observational study among residents in the city of Barcelona was conducted of all the cases of leishmaniasis reported between 1996 and 2019 to the Public Health Agency. The epidemiological survey contains clinical, diagnostic, and epidemiological data, including contact with suspicious mammals or insects. Annual incidence-rates were calculated by sex, age, and country of origin. Chi-square tests were used to assess association between studied risk factors, periods of time and type of leishmaniasis. Results: During the study period a total of 177 cases of leishmaniasis were reported in Barcelona, being 74.6% (n = 132) of the total cases in Spanish born, although within the foreign-born population the incidence was higher. Median age was 34 years (IQR = 10-48) and 121 (66.8%) were male. The main type was cutaneous (46%) followed by visceral (35.1%). The cumulative incidence was 0.47 per 100,000 inhabitants, with the highest incidence found in 2017 (1.60 per 100,000 inhabitants). A higher incidence was observed in the 0-4-year-old group (1.73 per 100,000 inhabitants), but increased during the study period for all age groups. There was an increase of foreign origin cases, and a decrease in the number of cases associated to any immunosuppression. Conclusion: In Barcelona, leishmaniasis incidence continues to be higher in people under 5 years of age, and 25-64 years old males, but it has also increased in population from foreign country of birth. There is an increase of the cases since 2016, probably due to the changes in the notification system, increasing the diagnosis of cutaneous leishmaniasis. Improvements in the current surveillance system are needed. Notification of the disease, vector, and reservoir control activities are also essential for the control of the disease.
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Affiliation(s)
- David Palma
- Agència de Salut Pública de Barcelona (ASPB), Barcelona, Spain.,Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain
| | | | - Jordi Figuerola
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain.,Estación Biológica de Doñana (EBD-CSIC), Sevilla, Spain
| | - Tomás Montalvo
- Agència de Salut Pública de Barcelona (ASPB), Barcelona, Spain.,Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain
| | - Rubén Bueno-Marí
- Department of Research and Development (R&D), Laboratorios Lokímica, Valencia, Spain.,Parasitology Area, Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of Valencia, Valencia, Spain
| | - Joan-Pau Millet
- Agència de Salut Pública de Barcelona (ASPB), Barcelona, Spain.,Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain
| | - Pere Simón
- Agència de Salut Pública de Barcelona (ASPB), Barcelona, Spain
| | - Eva Masdeu
- Agència de Salut Pública de Barcelona (ASPB), Barcelona, Spain
| | - Cristina Rius
- Agència de Salut Pública de Barcelona (ASPB), Barcelona, Spain.,Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain
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Lizondo M, Fuentes-Raspall J, Soto A, Jornet N, Latorre-Musoll A, Delgado-Tapia P, Carrasco P, Pérez-Alija J, Gallego P, Simón P, Ruiz-Martínez A, Adrià M, Valverde-Pascual I, Barceló M, Garcia N, Ribas M. PO-0939: Structured prospective database:exploratory study about toxicity and progression in breast patients. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00956-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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6
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Lizondo M, Fuentes-Raspall J, Jornet N, Latorre-Musoll A, Delgado-Tapia P, Carrasco P, Pérez-Alija J, Gallego P, Simón P, Ruiz-Martínez A, Adrià M, Valverde-Pascual I, Barceló M, Garcia N, Ribas M. PO-1539: Predictive modelling of late fibrosis in breast cancer radiotherapy. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01557-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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7
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Lizondo M, Jornet N, Fuentes-Raspall J, Viladés-Mendel D, Leta R, Latorre-Musoll A, Delgado-Tapia P, Carrasco P, Pérez-Alija J, Gallego P, Simón P, Ruiz-Martínez A, Adria M, Valverde-Pascual I, Barceló M, Garcia N, Ribas M. PO-1708: Retrospective automatic detection of calcified plaque in heart on planning CT:viability and benefits. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01726-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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8
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Garriga C, Manzanares-Laya S, García de Olalla P, Gorrindo P, Lens S, Solà R, Martínez-Rebollar M, Laguno M, Navarro J, Torras X, Gurguí M, Barberá MJ, Quer J, Masdeu E, Simón P, Ros M, de Andrés A, Caylà JA. Evolution of acute hepatitis C virus infection in a large European city: Trends and new patterns. PLoS One 2017; 12:e0187893. [PMID: 29135988 PMCID: PMC5685589 DOI: 10.1371/journal.pone.0187893] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 10/27/2017] [Indexed: 12/15/2022] Open
Abstract
The aims of this study were to describe the evolution of acute hepatitis C virus (HCV) infections since 2004 and to determine its associated factors. Acute HCV infections diagnosed in Barcelona from 2004 to 2015 were included. Incidence ratios (IR) were then estimated for sex and age groups. Cases were grouped between 2004-2005, 2006-2011 and 2012-2015, and their incidence rate ratios (IRR) were calculated. In addition, risk factors for acute HCV infection were identified using multinomial logistic regression for complete, available and multiple imputed data. 204 new HCV cases were identified. Two peaks of higher IR of acute HCV infection in 2005 and 2013 were observed. Men and those aged 35-54 had higher IR. IRR for men was 2.9 times greater than in women (95% confidence intervals (CI): 1.8 ‒ 4.7). Factors related to the period 2012-2015 (versus 2006-2011) were: a) sexual risk factor for transmission versus nosocomial (relative-risk ratio (RRR): 13.0; 95% CI: 2.3 ‒ 72.1), b) higher educated versus lower (RRR: 5.4; 95% CI: 1.6 ‒ 18.7), and c) HIV co-infected versus not HIV-infected (RRR: 53.1; 95% CI: 5.7 ‒ 492.6). This is one of the few studies showing IR and RRRs of acute HCV infections and the first focused on a large city in Spain. Sexual risk for transmission between men, higher educational level and HIV co-infection are important factors for understanding current HCV epidemic. There has been a partial shift in the pattern of the risk factor for transmission from nosocomial to sexual.
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Affiliation(s)
- César Garriga
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
- Spanish Field Epidemiology Training Programme (FETP/PEAC), National Centre for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain
- * E-mail: (CG); (SM)
| | - Sandra Manzanares-Laya
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- * E-mail: (CG); (SM)
| | - Patricia García de Olalla
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Pilar Gorrindo
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - Sabela Lens
- Liver Unit, Hospital Clínic, Barcelona. IDIBAPS, Barcelona, Spain
- CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Ricard Solà
- Internal Medicine-Infectious Diseases, Hospital del Mar, Barcelona, Spain
| | - María Martínez-Rebollar
- Hospital Clinic- August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Montserrat Laguno
- Hospital Clinic- August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Jordi Navarro
- Infectious Diseases, Hospital Vall de Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Torras
- CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Mercè Gurguí
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María-Jesús Barberá
- Sexually Transmitted Infections Unit, Hospital Vall de Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep Quer
- Liver Unit, Internal Medicine, Laboratory of Malalties Hepàtiques, Vall d'Hebron Institut de Recerca-Hospital Universitari Vall d´Hebron, (VHIR-HUVH), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eva Masdeu
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - Pere Simón
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - Miriam Ros
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - Anna de Andrés
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - Joan A. Caylà
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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Solano R, Rius C, Simón P, Manzanares-Laya S, Ros M, Toledo D, Domíngez À, Caylà JA. Evaluation of reported cases of pertussis: epidemiological study in a large city in Spain. J Med Microbiol 2014; 63:1688-1695. [DOI: 10.1099/jmm.0.079756-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
We retrospectively analysed the incidence rate of reported cases of pertussis in Barcelona during 2009–2012 according to age, sex, type of medical centre and vaccination status. We included 748 confirmed or suspected cases, 613 (82.0 %) of which were confirmed by laboratory testing and the remaining 135 (18.0 %) by epidemiological evidence. The highest reported incidence of pertussis was amongst <1 year olds [96.1 per 100 000 person-years, 95 % confidence interval (CI): 84.3–109.1]. The majority of confirmed and suspected cases were reported in 2011 and 2012, and the total incidence (confirmed or suspected) was 6.3 (95 % CI: 5.6–6.9) and 4.2 (95 % CI: 3.6–4.7) per 100 000 person-years, respectively. Incidence increased significantly (P = 0.001) in 2011–2012 compared with 2009. Most confirmed cases occurred in children <1 year old (87.9 %). Cases were confirmed by real-time (RT)-PCR (87.5 %; 95 % CI: 81.3–87.6) and bacterial culture (13.7 %; 95 % CI: 11.0–17.1). We recommend performing RT-PCR in suspected cases with no epidemiological link to a confirmed case.
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Affiliation(s)
- Rubén Solano
- Epidemiology Department, Barcelona Public Health Agency, Barcelona, Spain
- CIBER Epidemiology and Public Health, Carlos III Health Institute (CIBERESP), Madrid, Spain
| | - Cristina Rius
- Epidemiology Department, Barcelona Public Health Agency, Barcelona, Spain
- CIBER Epidemiology and Public Health, Carlos III Health Institute (CIBERESP), Madrid, Spain
| | - Pere Simón
- Epidemiology Department, Barcelona Public Health Agency, Barcelona, Spain
| | | | - Miriam Ros
- Epidemiology Department, Barcelona Public Health Agency, Barcelona, Spain
| | - Diana Toledo
- Department of Public Health, University of Barcelona, Barcelona, Spain
| | - Àngela Domíngez
- Department of Public Health, University of Barcelona, Barcelona, Spain
- CIBER Epidemiology and Public Health, Carlos III Health Institute (CIBERESP), Madrid, Spain
| | - Joan A. Caylà
- Epidemiology Department, Barcelona Public Health Agency, Barcelona, Spain
- CIBER Epidemiology and Public Health, Carlos III Health Institute (CIBERESP), Madrid, Spain
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Solano R, Gómez-Barroso D, Simón F, Lafuente S, Simón P, Rius C, Gorrindo P, Toledo D, Caylà JA. Retrospective space-time cluster analysis of whooping cough, re-emergence in Barcelona, Spain, 2000-2011. Geospat Health 2014; 8:455-461. [PMID: 24893022 DOI: 10.4081/gh.2014.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A retrospective, space-time study of whooping cough cases reported to the Public Health Agency of Barcelona, Spain between the years 2000 and 2011 is presented. It is based on 633 individual whooping cough cases and the 2006 population census from the Spanish National Statistics Institute, stratified by age and sex at the census tract level. Cluster identification was attempted using space-time scan statistic assuming a Poisson distribution and restricting temporal extent to 7 days and spatial distance to 500 m. Statistical calculations were performed with Stata 11 and SatScan and mapping was performed with ArcGis 10.0. Only clusters showing statistical significance (P <0.05) were mapped. The most likely cluster identified included five census tracts located in three neighbourhoods in central Barcelona during the week from 17 to 23 August 2011. This cluster included five cases compared with the expected level of 0.0021 (relative risk = 2436, P <0.001). In addition, 11 secondary significant space-time clusters were detected with secondary clusters occurring at different times and localizations. Spatial statistics is felt to be useful by complementing epidemiological surveillance systems through visualizing excess in the number of cases in space and time and thus increase the possibility of identifying outbreaks not reported by the surveillance system.
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11
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Escudero D, Martínez K, Saralegui I, Simón P. [Further clarifications on the limitation of life-sustaining treatment and organ donation]. Med Intensiva 2014; 38:197-8. [PMID: 24485534 DOI: 10.1016/j.medin.2013.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 11/06/2013] [Accepted: 11/07/2013] [Indexed: 11/27/2022]
Affiliation(s)
- D Escudero
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, España.
| | - K Martínez
- Presidente de la Asociación de Bioética Fundamental y Clínica, Servicio de Medicina Intensiva, Hospital de Navarra, Pamplona, Navarra, España
| | - I Saralegui
- Presidente Comité Ética Asistencial, Unidad de Medicina Intensiva, Hospital Universitario Álava-Santiago, Vitoria, Álava, España
| | - P Simón
- Profesor de Bioética, Escuela Andaluza de Salud Pública, Granada, España
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12
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Escudero D, Cofiño L, Gracia D, Palacios M, Casares M, Cabré L, Simón P, Miranda P, Martínez K, Iribarren S, Saralegui I, Simó RM, de León B, Español V. Cranioplasty with bandaging. New forms of limitation of life support and organ donation. Med Intensiva 2013; 37:180-4. [PMID: 23473740 DOI: 10.1016/j.medin.2012.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 12/15/2012] [Accepted: 12/17/2012] [Indexed: 11/29/2022]
Abstract
Most of transplanted organs are obtained from brain death (BD) donors. In neurocritical patients with catastrophic injuries and decompressive craniectomy (DC), which show a dreadful development in spite of this treatment, DC could be a futile tool to avoid natural progress to BD. We propose if cranial compressive bandage (cranioplasty with bandage) could be an ethically correct practice, similar to other life-sustaining treatment limitation (LSTL) common methods. Based on a clinical case, we contacted with the Assistance Ethics Committee and some bioethics professionals asking them two questions: 1) Is ethically correct to perform a cranioplasty with bandage in those patients with LSTL indication? 2) Thinking in organ donation possibility, is this option preferable? Conclusions 1) Cranioplasty with bandage could be considered an ethically acceptable LSTL practice, similar to other procedures. 2) It facilitates organ donation for transplant, which provides value-added because of its own social good. 3) In these cases, it is necessary to know previous patient's will or, in absentia, to obtain family consent after a detailed procedure report.
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Affiliation(s)
- D Escudero
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo.
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Lafuente S, Bellido JB, Moraga FA, Herrera S, Yagüe A, Montalvo T, de Simó M, Simón P, Caylà JA. Salmonella paratyphi B and Salmonella litchfield outbreaks associated with pet turtle exposure in Spain. Enferm Infecc Microbiol Clin 2012; 31:32-5. [PMID: 22795887 DOI: 10.1016/j.eimc.2012.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 05/23/2012] [Accepted: 05/27/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Salmonellosis is an important public health problem. Turtles are increasingly involved in the role of transmitters of this infection to humans. METHODS Salmonella cases are reported to the local Surveillance Agency where interviews are carried out to address possible exposures. Molecular epidemiology techniques were used to identify species. RESULTS In this article we report two examples of this type of infection in two places, 300 km apart in Spain. In Barcelona a turtle transmitted the disease to a small baby via her mother, and in Castellón 5 related cases of Salmonella infections were detected, and all were transmitted by imported turtles. Molecular epidemiology techniques confirmed the turtle-person transmissions and showed strong relationships between cases in Castellón and Barcelona. DISCUSSION These examples represent the tip of the iceberg of what is happening with pet reptiles as regards transmission of this infection. We believe that it is important to assess the impact of this type of infection in each country, in order to subsequently promote prevention strategies such as: regulations for pet shops, and educating/informing families who buy reptiles as pets.
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Simón P, Barrio I, Sánchez C, Tamayo M, Molina A, Suess A, Jiménez J. Satisfacción de los pacientes con el proceso de información, consentimiento y toma de decisiones durante la hospitalización. An Sist Sanit Navar 2007. [DOI: 10.4321/s1137-66272007000300003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Simón P, Barrio IM, Sánchez CM, Tamayo MI, Molina A, Suess A, Jiménez JM. [Patient satisfaction with the process of computerisation, consent and decision making during hospitalisation]. An Sist Sanit Navar 2007; 30:191-8. [PMID: 17898814 DOI: 10.23938/assn.0222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
UNLABELLED The health organisations have moved from being centred on the professionals and are now centred on users and their expectations. The new health institutions want to know patients' perception of the quality of the care received, with particular respect to the information received, consent and decision making. It is necessary to have available measuring instruments that explore the different components of the process of information, consent and decision making. BACKGROUND To identify the dimensions related to the process of information, consent and decision making of most importance to patients and susceptible to evaluation by questionnaire. SUBJECTS AND METHODS Adult persons who have been hospitalised for at least two days. Qualitative study using semi-structured interviews. RESULTS The participants wish to be informed and to participate in decision making; they do not know the meaning of the charter of patients' rights; they wish to share the whole care process with their family; written information is incomprehensible to them; and they feel that their pain and discomfort do not receive appropriate attention. CONCLUSION It would be convenient to include the following dimensions in the questionnaires on satisfaction: a) the possibility of clarifying doubts; b) real knowledge of the rights and duties of patients; c) participation by the family in the care process; d) continuity of the same informer throughout hospitalisation; d) degree of understanding of the written information; e) involvement in decision making; and f) attention to pain and discomfort.
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Affiliation(s)
- P Simón
- Escuela Andaluza de Salud Pública, Granada
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Simón P. [Ten myths about informed consent]. An Sist Sanit Navar 2006; 29 Suppl 3:29-40. [PMID: 17308537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The author reviews ten myths that, in his opinion, make up the perspective of many professionals on informed consent (IC). A viewpoint, on the other hand, that is imprecise and of low ethical and juridical quality. The myths are: 1. IC is something foreign to the moral duties of doctors. 2. IC consists in getting the patients to sign the form authorising an intervention. 3. Good clinical practice consists in carrying out clinical actions well, from a scientific-technical point of view; IC has nothing to do with this. 4. The ethical foundation of IC is the principle of autonomy. 5. Obtaining IC is an obligation of the professionals who carry out interventions, but not of those who prescribe them. 6. IC is meaningless because the majority of patients do not want to be informed. 7. Patients have the right to refuse a course of treatment, but only before it is applied to them. Once it is started, the professionals cannot withdraw it. 8. The evaluation of the capacity of the patients to make decisions is the responsibility of the psychiatrists. 9. Respect for the requirements of IC can be satisfied without the health organisations investing additional resources in this. 10. Obtaining IC is a responsibility of the doctors but not of the nursing staff. The conclusion insists on the importance of exposing the hidden discourse of these myths in order to be able to change the practices concerning IC in our health organisations.
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Affiliation(s)
- P Simón
- Escuela Andaluza de Salud Pública, Granada.
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Abstract
Striated muscle is typically not mentioned in histology chapters of most dermatology and dermatopathology books. In others, authors only speak of its presence in the dermis or subcutis but do not provide any details about its quantity, distribution, or orientation. In the course of an investigation concerning regional histologic variations of the skin, the presence of striated muscle fibers (StrMFs) has been a noteworthy feature of many areas of the face. Striated muscle fibers are a normal constituent of the dermis of the eyebrow (few and deep fibers); eyelid and nose (excluding the nasal tip) (numerous and deep fibers); and lips and chin (numerous, vertical, and more superficial fibers). They are also found in the subcutis of all these areas with some differences in density and distribution among them. Striated muscle fibers form a compact layer beneath the subcutaneous fat on the forehead and cheek, but because of their deep location, they are rarely included in cutaneous biopsy specimens of the latter area. Mainly based on the presence of StrMFs in the dermis, an algorithm to accurately determine the location of biopsy specimens from the face has been elaborated. With the aid of other features such as the type of hair follicles and the presence and degree of solar elastosis, the sex and approximate age of the patient can be established in many cases. Some practical and scientific consequences of these findings are discussed.
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Affiliation(s)
- E S Yus
- Department of Dermatology, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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Abstract
To discuss the relation between solitary keratoacanthoma (KA) and crateriform squamous cell carcinoma (cSCC), the clinical and histologic features of cutaneous crateriform squamous cell proliferations were studied. Two hundred twenty cases of wholly excised crateriform squamous cell proliferations were studied both clinically (age, sex, location, and duration) and histologically (hematoxylin-eosin-stained sections). For comparison, we studied 100 consecutive cases of wholly excised noncrateriform squamous cell carcinoma (ncSCC). One hundred forty-four of the 220 cases of crateriform squamous cell proliferations were histologically classified as KA. In 47 other cases, a relatively large area of the KA showed frank histologic and cytologic malignant transformation (mKA); this event could happen during every stage of the KA. Twenty-nine lesions were cSCCs without remnants of KA. The patients in the KA group were significantly younger (p = 0.000) than those in the other three groups. The ages of the patients in these three groups were not significantly different (p = 1.0). More KAs (16%) were located in areas that are not usually exposed to the sun than was the case with the other groups of neoplasms considered (2%, 3%, and 3%, respectively), and this difference was statistically significant (p = 0.001). Regarding the duration of the lesion, only the differences between KA and cSCC, KA and ncSCC, and mKA and ncSCC were statistically significant. Not every cutaneous crateriform squamous cell proliferation is a KA; in KA, the crater must be multilocular, the "lips" must be perforated, and the cornified contents do not usually project out of the "mouth." At least a quarter of KAs undergo malignant transformation, which occurs more frequently in older patients and photoexposed areas. This transformation is a focal event and may happen at any stage of KA development. Consequently, a suspected KA must be wholly excised and studied in serial paraffin blocks so as to disclose any focus of malignant transformation.
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Affiliation(s)
- E Sánchez Yus
- Department of Dermatology, Hospital Clínico San Carlos, Madrid, Spain
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22
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Abstract
Two unrelated patients, a woman aged 44 and a man aged 56, with a type I neurofibromatosis, showed comedo-like formations at the top of some neurofibromas. One of them was excised in each case and they were studied histopathologically. The comedo-like formation of the first case mimicked the epithelial component of a fibrofolliculoma, and that of the second case had the structure of a primary late microcomedo and showed also anagen hair differentiation in the form of a follicular bulb and papilla. Both events are considered to be the result of a stimulation phenomenon and to reflect the essential role of the stroma in many cutaneous epithelial hyperplasias, hamartomas and possibly in some neoplasms.
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Affiliation(s)
- E del Río
- Division of Dermatology, Hospital de Conxo, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain.
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Abstract
OBJECTIVE To determine the distinction between a comedo and an infundibular cyst of Favre-Racouchot disease. SETTING A university hospital. PATIENTS From the 8 patients included in the study, 19 cysts and comedones were evaluated. MAIN OUTCOME MEASURE The distinguishing features between the cysts and comedones of Favre-Racouchot disease. RESULTS All lesions were histologically indistinguishable from the primary comedones of acne vulgaris, except for the presence of a marked actinic elastosis in the surrounding dermis. The presence of a variable number of hair shafts and an abundant amount of bacteria, which was positive in the results of Gram staining and periodic acid-Schiff reaction and intermingled with sebum and eosinophilic laminated horny material within the dilated infundibulum, characterizes a comedo and differentiates it from an infundibular cyst. CONCLUSIONS The cysts and comedones of Favre-Racouchot disease are closed and open comedones. They can be easily differentiated from an infundibular cyst by the histopathologic features rather than by the connection to the surface.
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Affiliation(s)
- E Sánchez-Yus
- Department of Dermatology, Hospital Universitario San Carlos, Madrid, Spain
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Affiliation(s)
- L Requena
- Department of Dermatology, Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain
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Abstract
Literature regarding neoplasms with sebaceous differentiation is confusing, particularly concerning the concept of sebaceous epithelioma, accepted by some observers as a specific neoplasm but defined by others as basal cell carcinoma with sebaceous differentiation and still others as sebaceous adenoma in which undifferentiated basaloid cells predominate. From our study of 19 benign sebaceous neoplasms within this spectrum and a critical review of the literature, we conclude that (a) "sebaceous epithelioma" is a nonuseful term; (b) the term "basal cell carcinoma with sebaceous differentiation" should be used only for an otherwise conventional basal cell carcinoma with histological evidence of sebaceous differentiation; (c) "sebaceous adenoma," as described by Troy and Ackerman, represent polar ends of the spectrum of a benign neoplasm with varying degrees of sebaceous differentiation, for which we propose the term "sebomatricoma"; and (d) sebomatricoma, so defined, embraces such diverse benign neoplasms with sebaceous differentiation as superficial epithelioma with sebaceous differentiation and previously "unclassifiable" sebaceous neoplasms, often found in patients with Muir-Torre syndrome or within nevus sebaceus of Jadassohn.
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Affiliation(s)
- E Sáchez Yus
- Department of Dermatology (Hospital Universitarío San Carlos, Madrid, Spain
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Abstract
The incidental finding of microscopic foci of acantholytic dyskeratosis, reproducing the histological pattern of Darier's disease, has been the subject of a number of papers in the last few years. In contrast, the incidental finding of other types of acantholysis has not been mentioned in the literature. In the last 5 years, we have noticed such a microscopic finding in 14 biopsy specimens (0.15% of our cutaneous specimens). they were from 13 patients (7 men and 6 women); their ages ranged from 37 to 79 years (mean, 63). Three lesions were located on the head, 7 on the trunk, and 4 on the limbs. The histological diagnoses were basal cell carcinoma (6 cases), keratoacanthoma (2 cases), psoriasis (2 cases), elastolytic granuloma, acral arteriovenous angioma, tinea corporis, and leukocytoclastic vasculitis (1 case each). The histological patterns of the acantholytic foci simulated pemphigus vulgaris (9 cases), superficial pemphigus (1 case), Hailey-Hailey disease (3 cases), and unclassifiable acantholysis (1 case). None of the patients had familial or personal history of acantholytic disorders. We propose a classification of the primary acantholytic disorders based on both their acantholytic pattern and their clinical extent.
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Affiliation(s)
- E Sánchez Yus
- Department of Dermatology, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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Abstract
Present knowledge of the histopathology of cutaneous changes seen in drug-induced coma is very incomplete: Only 1 of the 11 papers on this subject mentions follicular or sebaceous gland damage, with very little attention focused on vascular changes. We made a careful study of serial sections from eight cutaneous biopsy specimens from seven patients who suffered drug-induced coma with the following findings: (a) The secretory portion of the eccrine sweat coil is the epithelium most susceptible to necrosis. It is followed by, ex aequo, eccrine sweat duct, hair follicle, and sebaceous gland, and, lastly, the epidermis. (b) In the eccrine sweat duct, the outer root sheath of the hair follicle, and the epidermis, necrosis does not usually appear first in the outermost (basal cell) layer. (c) Necrosis of the outer root sheath of the telogen "club" follicle is usually more advanced than that of the secondary hair germ, and, at times, a spared anagen bulb can be seen in closest proximity. (d) Vascular changes correlate proportionately with epidermal damage and consist of a largely neutrophilic inflammatory infiltrate and blood vessel wall damage, mainly involving arterioles. Our findings contradict the widely accepted hypothesis that pressure is the main cause of the cutaneous changes in drug-induced coma.
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Affiliation(s)
- E Sánchez Yus
- Department of Dermatology, Hospital Universitario San Carlos, Madrid, Spain
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Abstract
Three cases of basal cell carcinoma showing shadow cells within basaloid islands have been described using the term basal cell carcinoma with matrical differentiation for this histologic variant. We present four new cases of basal cell carcinoma with evidence of matrical differentiation. Unlike the cases previously published, these lesions showed nests of shadow cells either within the lobules of basaloid cells or forming nests in the stroma. We also noted the presence of a foreign body reaction and calcification. These neoplasms illustrate the capability of basal cell carcinoma to differentiate toward hair matrix cells. Basal cell carcinoma with matrical differentiation must be added to the uncommon variants of basal cell carcinoma showing adnexal differentiation. A parallel between the degrees of differentiation of the cutaneous sebaceous neoplasms with those showing matrical differentiation is proposed.
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Affiliation(s)
- P Ambrojo
- Departamento de Dermatologia, Hospital Clinico San Carlos, Universidad Complutense, Madrid, Spain
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Sánchez Yus E, Requena L, Simón P, Sánchez M. Complex adnexal tumor of the primary epithelial germ with distinct patterns of superficial epithelioma with sebaceous differentiation, immature trichoepithelioma, and apocrine adenocarcinoma. Am J Dermatopathol 1992; 14:245-52. [PMID: 1510222 DOI: 10.1097/00000372-199206000-00011] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 60-year-old man came for treatment of a sharply outlined erythematous plaque on the gluteal area (45 x 20 mm) of 20 years' duration. Eccentrically located on the plaque was a nodule, 20 mm in diameter. Histological study of the plaque showed a superficial platelike tumor with basaloid bland cytology and sebaceous gland differentiation. Histologic study of the nodule found an undifferentiated adenocarcinoma whose ductlike glandular structures opened to the skin surface and infiltrated the whole depth of the dermis. Study of other areas of the lesion detected two more neoplasms. A nodule of squamous cell carcinoma was found within the superficial band of the benign sebaceous tumor. The fourth neoplastic pattern consisted of epithelial islands composed of basaloid cells within a fibroblastic stroma. There was prominent palisading of epithelial cell nuclei at the periphery of the islands, which usually were surrounded by a sheath of mesenchymal cells. In this complex adnexal tumor of the primary epithelial germ, sebaceous and follicular differentiation both simulate neoplastic patterns recently described as separate entities: superficial epithelioma with sebaceous differentiation and immature trichoepithelioma. The undifferentiated adenocarcinoma may represent differentiation toward the third component of the germ, that is, the apocrine gland.
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Affiliation(s)
- E Sánchez Yus
- Department of Dermatology, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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Simón P, Requena L, Sánchez Yus E. How rare is melanoacanthoma? Arch Dermatol 1991; 127:583-4. [PMID: 2006888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Sánchez Yus E, Simón P, Requena L, Ambrojo P. Basal cell carcinoma with follicular differentiation. Am J Dermatopathol 1989; 11:505-7. [PMID: 2802110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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de Diego JA, Molina LM, Buján J, Simón P, Gea M, Menchero A, Balibrea JL. Influence of the conjoint administration of insulin and glucagon upon hepatic regeneration. Surg Gynecol Obstet 1986; 163:443-7. [PMID: 3535136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In noneviscerated rats, the influence of the conjoint administration of insulin and glucagon in the regenerative response triggered by 70 per cent hepatectomy using the incorporation of tritiated thymidine by nuclear deoxyribonucleic acid as a parameter has been demonstrated. The response was earlier and more intense in relation to animals not hormonally stimulated and stimulated only with glucagon (previously reported by us). Such a response has been comparatively greater both in the nonparenchymal cells and in the hepatocytes, especially in the latter, which are the main cause of the early peak of thymidine incorporation in the periportal zones indicating a greater regenerative activity than in the intermediate and centrolobular zones. In our opinion, this indicates the importance of certain extrahepatic humoral agents in the manifestation of the regenerative process. Therefore, the results of our study ascertain the determining role and synergistic action of the pancreatic hormones--insulin and glucagon--in hepatic regeneration.
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De Diego JA, Molina LM, Bujan J, Simón P, Cañizo JF, Gea M, García Calvo M, Delgado I, Fernández Represa JA, Balibrea JL. [The effect of glucagon on the process of liver regeneration. Autoradiographic study]. Rev Esp Enferm Apar Dig 1982; 62:355-61. [PMID: 7167668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Molina LM, De Diego JA, Simón P, Bujan J, Cañizo JF, Gea M, García Calvo M, Delgado I, Fernández Represa JA, Balibrea JL. [Incorporation of tritiated thymidine into nuclear DNA in the rat liver during regeneration]. Rev Esp Enferm Apar Dig 1982; 62:273-8. [PMID: 7163585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Casais PL, Chermat R, Cuenca E, Simón P. [Effect of N-(4-picolyl)-3,5 dimethylbenzamide (M-14012-4) on stereotyped behavior induced by apomorphine and amphetamine in the rat and mouse]. Arch Farmacol Toxicol 1981; 7:65-72. [PMID: 7198897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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