Reconstrucción de roturas inveteradas del tendón distal del biceps brachii con aloinjerto liofilizado de tendón de Aquiles

Objectivo: Las roturas inveteradas o crónicas del tendón distal del biceps brachii son infrecuentes. Su tratamiento es complejo por el grado de retracción y mala calidad del tendón lesionado, que no permiten una sutura directa. Describimos la reconstrucción con aloinjerto de tendón de Aquiles liofilizado mediante una nueva técnica y presentamos nuestra experiencia y resultados.

Material y método: Cuatro pacientes con actividades de alta demanda funcional, presentaban una rotura crónica (más de 3 meses de evolución) del tendón distal del biceps brachii. Se reconstruyó el tendón del biceps brachii con aloinjerto de Aquiles liofilizado mediante dos incisiones y reinserción en la tuberosidad bicipital con anclajes biodegradables.

Se valoran el arco de movilidad activo, resultado de la Mayo Elbow Performance Score (MEPS), dolor, fuerza y reincorporación laboral.

Resultados: A los 68 meses de seguimiento medio (rango: 36-88) todos los pacientes presentan un resultado satisfactorio, con un arco de movilidad activo completo, sin dolor y un resultado excelente de la MEPS. La fuerza en flexión y supinación fue similar con respecto al lado contralateral, si bien se objetivó un ascenso de la masa muscular y adelgazamiento del injerto en el caso con mayor seguimiento. Todos los pacientes se reincorporaron a su mismo puesto de trabajo sin restricciones a las 14 semanas. Un paciente presentó una neuroapraxia del nervio interóseo posterior que se recuperó de forma satisfactoria a los 3 meses. No existieron otras complicaciones ni se precisaron reintervenciones.

Conclusiones: La reconstrucción con aloinjerto de tendón de Aquiles liofilizado en las roturas crónicas del tendón distal del biceps brachii presenta resultados satisfactorios, siendo una alternativa válida en pacientes con alta demanda funcional.

[Effects of air pollution on daily mortality in the city of Zaragoza, Spain, 1991-1995]

OBJECTIVE

To analyze the short-term impact of air pollution on daily mortality in the City of Zaragoza (Spain).

MATERIAL AND METHODS

This ecologic study was conducted in Zaragoza, Spain, from 1991 to 1993. Poisson autoregressive models were constructed to assess the association between air particulate matter and sulphur dioxide SO2 and daily deaths. Four outcome variables were studied: overall mortality (excluding external deaths), mortality in subjects over 69 years of age, mortality due to respiratory disease, and mortality due to cardiovascular disease. A sample size was not obtained. Data analysis was conducted using the statistical software EGRET and SPSS.

RESULTS

SO2 levels were significantly associated with cardiovascular deaths (RR = 1.018 IC 95%: 1.001-1.036) and particulate matter levels with respiratory deaths (RR = 1.028 IC 95%: 1.006-1.051). During the warm season, a significant relationship was found between particulate mater and cardiovascular deaths (RR = 1.020 IC 95%: 1.001-1.040).

CONCLUSIONS

Low levels of air pollution were found in Zaragoza, with considerable variation in the concentration of air pollutant concentrations and daily respiratory and cardiovascular deaths, particularly during the warm season. The English version of this paper is available at: http://www.insp.mx/salud/index.html

Cost-analysis of high-dose chemotherapy and peripheral blood stem-cell support in patients with solid tumors

BACKGROUND

The use of High-dose chemotherapy (HDC) with peripheral blood stem cells (PBSC) rescue in the treatment of solid tumors is controversial, and may be an important determinant of HDC and PBSC use in the future. Until the use of these procedures is proven through disease-free survival and overall survival compared with standard-dose chemotherapy, the associated cost is also under discussion.

PATIENTS AND METHODS

We evaluate 27 consecutive patients with solid tumors who underwent HDC and PBSC rescue, through an accurate review of medical records and cost estimate for each patient.

RESULTS

Median age was 45 years. Fifteen had breast cancer, six non-Hodgkin's lymphoma and six other solid tumors. The mean hospital length of stay was 21 days and mean cost was 21,445 US dollars (21,232 euro). Mean cost was clearly lower for the 9 patients treated within phase III trials, 17,571 US dollars (17,747 euro) than for the remaining 18 patients, treated in phase I-II trials, 22,747 US dollars (22,975 euro) (P < 0.001). The distribution of costs shows that wages and pharmacy account for 72% of total cost. The distribution of pharmacy costs per patient shows that chemotherapy (56% of pharmacy costs) and antibiotics (26%) account for most of the cost of medication.

CONCLUSIONS

Our cost estimates agree with those of most countries with national health insurance programs, and are lower than those from the USA. As wages and pharmacy account for more than 70% of the costs, the great different among the costs estimates compared are due essentialy to doctors fees or salary and drugs utilization. Anyway, taking HDC with PBSC rescue as a model for a therapy that is more aggressive than standard, and that is associated to a possible survival improvement in indications such as relapsed high-grade non-Hodgkin's lymphoma, an adequate cost analysis is crucial both to measure cost-effectiveness and to establish payment to health care providers.

Human trichinellosis in Sourthern Spain: serologic and epidemiologic study

An outbreak of trichinellosis caused by wild boar meat occurred in the Iruela (Jaen) in southern Spain in February 1996. Thirty-five people were diagnosed on the basis of epidemiologic data, but only 24 patients agreed to participate in this study. Twenty-three (96%) had symptoms suggestive of trichinellosis. Immunofluorescent and Western blot test results for trichinellosis were positive in 18 persons, and 15 had circulating Trichinella spiralis antigens. These findings suggest that results of tests for circulating antigens in conjunction with clinical presentation are useful for the diagnosis of trichinellosis.

Laparoscopic versus open appendectomy: a prospective randomized trial

To study comparative results between laparoscopic and open appendectomy, all the patients with suspected acute appendicitis who presented between January 1992 and December 1994 (N = 210) were randomized into two groups: laparoscopic (LA, n = 106) and open appendectomy (OA, n = 104). Patient demographics, pathological findings, operative time, postoperative course, and cost were analyzed. Age, gender, previous laparotomy, intraoperative diagnosis, and perforated appendix rate were comparable between both groups. Mean operative time was longer in the LA group (p < 0.05). Earlier resumption of a regular diet, shorter postoperative stay, and less postoperative analgesia also were observed in the LA group (p < 0.05). Postoperative morbidity and hospital readmissions were similar in both groups (p > 0.05). Higher operative cost was observed in the LA group, but global cost was lower in this group (p < 0.05). Laparoscopic appendectomy shows a more comfortable postoperative course (oral resumption, postoperative stay, and analgesia) over open appendectomy, with similar postoperative morbidity. The LA group showed more operative but less global cost.

Choledochoduodenostomy and sphincterotomy in the treatment of choledocholithiasis

Over a 10-year period, 2610 patients underwent operation for biliary lithiasis. Exploratory choledochotomy was indicated in 591 patients (22.6 per cent). This was followed by simple choledochorrhaphy over a T tube in 240 patients (40.6 per cent), transduodenal sphincterotomy and choledochorrhaphy over a T tube in 126 (21.3 per cent), supraduodenal choledochoduodenostomy in 216 (36.5 per cent), and choledochoduodenostomy and transduodenal sphincterotomy in nine (1.5 per cent). Choledochoduodenostomy was performed if the bile duct was more than 12 mm in diameter. The indication for transduodenal sphincterotomy was the presence of a stone impacted in the papilla and/or papillary stenosis. Six patients developed abdominal abscess and three an external biliary fistula following choledochoduodenostomy. There were four abscesses and two episodes of acute pancreatitis in patients undergoing sphincterotomy. There was no difference in mortality rate between the two groups. After a mean follow-up of 5.6 years, 71.5 per cent of patients who underwent choledochoduodenostomy and 75.2 per cent of those who received transduodenal sphincterotomy were asymptomatic. The remainder suffered from dyspepsia, colicky pain or episodes of cholangitis. Nine patients underwent reoperation for residual calculi (six choledochoduodenostomies, three sphincterotomies).

Brain cysticercosis treated with praziquantel. Report of six cases

Cysticercosis is the most common parasitosis affecting the central nervous system and it is endemic in many countries. Although cysticercosis is nowadays a rare disease in Spain, three of such cases have been treated with Praziquantel at the Hospital "Princesa Sofía" of León and another three at the Hospital General de Galicia of Santiago, and the six of them are reported together. The six patients presented at CT scans cysts located at different levels in the brain parenchyma, subarachnoid space and ventricular system. Praziquantel was administrated at daily dosage of 50 mg per kilogram of body weight, by oral route, distributed in three doses during 15 days. Moderate hepatotoxic effect were detected in two cases. No significant neurological disfunction was observed in any case during the treatment. The therapeutic effect on the brain cysts was evaluated in the CT scans obtained after treatment. In four cases a positive effect on the cysts was observed, but no apparent effect was noticed in the other two.

Cerebral arteriovenous malformations. Comparative results of surgical vs conservative treatment in 112 cases

A group of 112 patients affected by cerebral arteriovenous malformations is reviewed. Sixty-six per cent of the cases presented with subarachnoid hemorrhage. Epilepsy was the main clinical feature in 20% of the cases. In 45 cases an intracerebral or intraventricular hematoma was diagnosed by CT-scan, angiography or was found during surgery. Seventy cases (62.5%) were operated upon and 42 cases were treated conservatively. In 57 operated cases, total excision of the AVM was confirmed by postoperative angiography. In this group there was no rebleeding during the follow-up period. Other 13 cases were submitted to partial excision of the AVM or clipping of the feeding vessels. In this latter group, 2 patients had later subarachnoidal rebleeding. Operative mortality was 11% in this series. Mortality caused by the AVM in the non-operated group was 20%. Comparing the morbidity in both groups, the operated group had a much better clinical evolution than the non-operated one. Regarding the final clinically results, an abnormal state of consciousness before surgery, a large size of the AVM and the presence of intracerebral hematoma appear to have a bad prognosis significance.

An unrecognized neurological syndrome: sixth-nerve palsy and Horner's syndrome due to traumatic intracavernous carotid aneurysm

An unclassified type of ophthalmoplegia, composed of sixth-nerve paresis and Horner's syndrome without facial anhidrosis, was studied in an 18-year-old woman following cranial trauma. Carotid angiography disclosed a traumatic intracavernous carotid aneurysm. According to previous anatomical reports, an important sympathetic nerve joins the sixth cranial nerve in the posterior part of the cavernous sinus. An expansive process into the cavernous sinus at this point may cause this unclassified neurological syndrome. A review of the literature and a detailed clinical study were made.