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Cet article présente les relations entre tous les éléments et les structures qui interagissent dans une ville qui cohabite avec ses euves. Les changements culturels et idéologiques et les nouvelles sensibilités ajoutent une complexité et mutabilité qui doivent aider a` une intégration entre éléments du passé, du présent tout en cherchant a` prévoir le futur de ses cours d’eau. C’est non seulement un dé passionnant, mais un nouveau paradigme pour la plani cation et l’aménagement des cours uviaux pour améliorer ses relations avec la ville de Saragosse. The interaction between Zaragoza and its rivers: evolution, conflicts and perspectives. is article demonstrates the relationships among the elements and structures of cities built on the banks of rivers. Cultural and ideological changes and new interests add complexity and mutability, which should help to inte- grate elements of the past and present in an attempt to predict water courses in the future. Apart from being an exciting challenge, it is a new paradigm in planning and managing water courses by improving their inter-action with the city of Zaragoza La intercacción entre Zaragoza y sus ríos : evolución, conflictos y perspectivas. Este artículo muestra las relaciones entre todos los elementos y estructuras que interactuan en una ciudad que cohabita con sus ríos. Los cambios culturales e ideológicos, y las nuevas sensibilidades, an~aden una complejidad y mutabilidad que deben de ayudar a una integración entre los elementos del pasado y del presente buscando prever el futuro de los cursos de agua. Además de un apasionante desafío, es un nuevo paradigma para la plani cación y la ordenación de los cursos uviales mejorando sus interacciones con la ciudad de Zaragoza.

The authors in this paper make a bibliographical revisión and comentary about the periglacial geomorphology on the inside of the Iberian Península.

Las variaciones cumbre-base de la textura de los depósitos de ladera en un ambiente semiárido de la Depresión Central del Ebro (NE España) difieren significativamente según la orientación topográfica. En las solanas las arenas gruesas y finas covarían negativamente con la distancia a la divisoria de aguas y positivamente con la pendiente (0.95). Las mismas relaciones se observan en los limos gruesos, pero con signo cambiado. No se observan relaciones significativas entre la pendiente y la distancia a la divisoria de aguas en las subfracciones de limos finos y arcillas. De la misma manera no se detectan relaciones significativas en cualquiera de las subfracciones analizadas en la umbría. Los resultados se discuten en función de los procesos de erosión hídrica superficial.

BACKGROUND AND OBJECTIVE: Clinical decision rules have reduced use of computed tomography (CT) to evaluate minor pediatric head injury in pediatric emergency departments (EDs). CT use remains high in community EDs, where the majority of children seek medical care. We sought to reduce the rate of CT scans used to evaluate pediatric head injury from 29% to 20% in a community ED. METHODS: We evaluated a quality improvement (QI) project in a community ED aimed at decreasing the use of head CT scans in children by implementing a validated head trauma prediction rule for traumatic brain injury. A multidisciplinary team identified key drivers of CT use and implemented decision aids to improve the use of prediction rules. The team identified and mitigated barriers. An affiliated children’s hospital offered Maintenance of Certification credit and QI coaching to participants. We used statistical process control charts to evaluate the effect of the intervention on monthly CT scan rates and performed a Wald test of equivalence to compare preintervention and postintervention CT scan proportions. RESULTS: The baseline period (February 2013–July 2014) included 695 patients with a CT scan rate of 29.2% (95% confidence interval, 25.8%–32.6%). The postintervention period (August 2014–October 2015) included 651 patients with a CT scan rate of 17.4% (95% confidence interval, 14.5%–20.2%, P CONCLUSIONS: We demonstrate that a Maintenance of Certification QI project sponsored by a children’s hospital can facilitate evidence-based pediatric care and decrease the rate of unnecessary CT use in a community setting.

El dolor abdominal crónico afecta a un alto porcentaje de niños en edad escolar, lo que la convierte en una de las patologías más frecuentes en nuestro medio. El objetivo es valorar si la cápsula endoscópica (CE) permite identificar lesiones intestinales en estos pacientes. Se han incluido 16 pacientes (9 niños y 7 niñas) con edades comprendidas entre los 5 y 16 años con dolor abdominal crónico de más de 12 meses de evolución. Todos tenían realizados hemograma, bioquímica, sedimento de orina, test de aliento para Helicobacter pylori y serología para enfermedad celíaca, que eran negativos. A todos se les había realizado una gastroscopia, y una colonoscopia que resultaron negativas, así como un tránsito gastrointestinal y una ecografía abdominal, sin hallazgos de interés. En el 43,75 % de los pacientes estudiados (7/16) la CE mostró imágenes compatibles con hiperplasia folicular linfoide localizadas en el íleon. En una niña se observaron oxiuros en ciego y en otra, lesiones aftosas ileales compatibles con enfermedad de Crohn.La CE muestra en la mayoría de los casos imágenes compatibles con hiperplasia nodular linfoide intestinal, con dudosa significación clínica, por lo que podemos concluir que la CE no aporta nada específico en niños con dolor abdominal crónico. : Chronic abdominal pain is highly prevalent in school-aged children and is one of the most frequent disorders in our environment. The aim of the present study was to evaluate the usefulness of capsule endoscopy (CE) in patients with chronic abdominal pain. Sixteen patients (nine boys and seven girls), aged between 5 and 16 years old, with chronic abdominal pain for at least 12 months were studied. In all patients the results of hemograms, biochemical investigations, urine sediment test, Helicobacter pylori breath test and celiac serology were normal. In all children, gastroscopy, small bowel follow-through, abdominal ultrasound and colonoscopy were normal. All patients received CE by mouth. In 43.75 % of the patients studied (7/16), the capsule showed evidence of nodular lymphoid hyperplasia, mainly located in the ileum. In one girl, oxyuriasis was observed in the cecum and in another girl aphthous lesions were observed in the ileum. These lesions suggested small bowel Crohn's disease.CE mainly showed images compatible with nodular lymphoid hyperplasia, with unknown clinical significance. Consequently, we conclude that CE does not provide useful information in patients with abdominal pain without other symptoms.

Background Non-compliance is a common cause of failed medical action, contributing to absence of regular check-ups. Our group has already published studies that analyse the level of non-compliance with appointments amongst patients attending our Allergology clinic, and we have made proposals for improvement. Objective This article evaluates the results obtained three years after setting up and launching telephone reminders for patients’ first appointments. Methods All patients who were given appointments for first and subsequent visits during 2005 were included. A total of 18215 appointments were studied (3115 first appointments and 15100 subsequent ones). Of these, there were 2479 missed appointments (438 first appointments and 2041 subsequent ones), corresponding to 2215 patients (412 first visits and 1803 subsequent ones), with a mean of 1.12 appointments/patient/year. Results The non-compliance rate was 13.61 %. The most common non-compliers were men (14.11 % missed appointments against 13.24% missed appointments in women) and in the age range 20-29 years and 30-39 years (16.46 % and 15.28 % non-compliance, respectively). The mean age of non-compliers was 34.55 ± 14.73 years. We observed a significant number of patients who missed more than one appointment (5.12 % of all non-compliers and 0.7 % of all patients). Differences were found in the degree of non-compliance depending on the type of appointment (14.06 % non-compliance with first visits and 13.52 % with subsequent visits). We observed a significant increase in missed appointments during the Summer holidays; July and August showed the highest percentage of missed appointments for both the first visit (20.62 % in July and 23.59 % in August) and subsequent visits alike (16.14 % in July and 14.23 % in August). Conclusions A slight reduction in non-compliance was observed after implementing the proposals made in our previous study. In view of the high costs incurred from missed appointments, the government should finance studies to reduce this problem. The causes of non-compliance may be difficult to control, including present access to the public health service. We must be alert to and/or take preventive measures in young patients and cases of previous non-compliance. The degree of non-compliance is a quality indicator, because it reduces the yield of appointments, and it evidences a lack of cohesion of patients with Primary Health Care Units for first appointments, and with Specialist Care Units for subsequent appointments. Once certain levels of attendance have been attained, it is difficult to achieve an effect on this point in order to improve attendance rates.

Sarcoidosis is a chronic multisystemic granulomatosis of unknown etiology that affects mainly young adults. It characterized by bilateral hiliar adenopathies interstitial pulmonary infiltrate, and cutaneous and ocular lesions. Localization in upper respiratory tract is infrequent. In the present report we describe a 26-year-old male with a three-month history of a globus sensation, hoarse voice, loud snoring and obstructive sleep apnoea, because of a laryngeal noncaseating granulomatous infiltration. The diagnosis is made through the history, the radiology and the pathological examination. Treatment is symptomatic, due to its tendency to a spontaneous regression. The treatment is based on corticosteroids by systemic or aerosol routes. Micro surgical excision and tracheotomy may be useful in selected patients.

Capsaicin is responsible for the pungent sensation produced by red peppers on the body's mucous membranes. This substance is found naturally in the gender Capsicum, widely used in the diet of different cultures in America, Asia, and Africa. In this paper we used the hot plate model (53 ± 0.5°C) to study the effect of acute thermonociceptive stimulus on escape response latency in the offspring of rats that were treated during gestation, either with an aqueous red pepper solution (Capsicum frutescens, approximately 2.75 mg of capsaicin in 1 ml/day, by gavage during the second week), or with capsaicin (0.5 mg/day SC, during the second week). These groups were compared with their respective controls. We found that the difference between the manipulated control group and the one given the aqueous red pepper solution was 41.33%, and between the vehicle control and the one treated with capsaicin was 30.59%. These increments on the escape response latency were statistically significant. Our results show that both treatments, the aqueous red pepper extract and low doses of capsaicin on pregnant rats, produce an increment on escape response latency due to a thermonociceptive stimulus.

A 36-year-old male with diarrhea and loss of weight underwent testing for blood chemistry, TSH, immunological parameters, celiac profile, and parasites in feces. All results were normal. C-reactive protein was elevated. Colonoscopy up to the cecum was normal, and a small-bowel follow-through with barium showed no alterations. Abdominal echography showed a left renal upper-pole mass about 4 cm in diameter, round, and isoechoic with hyperechoic areas inside consistent with necrotic areas (Fig. 1). CTA confirmed this lesion as 4.3 cm in size, hypodense, confined to the kidney and not affecting the perirenal fat or vascular pedicle. The patient was sent to the Urology Department and underwent a left laparoscopic nephrectomy -a mass could be macroscopically seen in a pole, with a complete Gerota’s capsule and no significant macroscopic changes. Cuts allowed identifying a rounded, well delimited lesion 4.8 x 4.5 cm in size in that pole, with a yellowish-brownish parenchyma with small millimetric cavities that was friable at the cut close to the renal capsule. The diagnosis was of papillary renal cell carcinoma, type 2 according to Delahunt and Eble (Fig. 2). The patient is now asymptomatic, and diarrhea is no longer present after surgery.

Radiation enteritis is a complex clinical entity secondary to the affectation of intestinal epithelial cells as a result of radiation in the management of pelvic malignancies that may occasionally cause intestinal strictures. We present the case of a 60 year-old woman who had been diagnosed ten years before with endometrial adenocarcinoma, and who underwent hysterectomy with double adnexectomy and subsequent radiation therapy. The patient consulted for abdominal pain and ferropenic anemia of several years' standing, and had negative results following radiographic and endoscopic conventional techniques, reason why she was subjected to a capsule endoscopy study that revealed the presence of an ulcerated ileal stricture, which caused the asymptomatic retention of the capsule within the ileum. A laparotomy was subsequently performed - the strictured segment was resected and the capsule retrieved. The histologic examination of the resected segment confirmed the capsule endoscopy-raised suspicion of radiation enteritis. This case shows the role capsule endoscopy may play in the diagnosis of this condition.

Objectives a) To determine the rate of H. pylori reinfection after successful eradication in a 4-year follow-up study; and b) To evaluate the contribution of different factors in the infection relapse. Patients and methods A total of 208 patients (age range 18-81 years; average 50 years; 87 women) who had been successfully treated for H. pylori infection were included. Annually, urea breath test was assessed to determine H. pylori status after eradication. Age, sex, rural/urban environment, smoking habit, treatment regimens against H. pylori and urea breath test values were evaluated. Results reinfection occurred in 9,6% of patients observed, 6,7% (14/208) in the first year, 1,9% (4/208) in the second year, 1% (2/208) in the third and 0% in the forth. Risk factors for infection recurrence were younger age and higher values of urea breath test in the multivariante analysis. Conclusions annual reinfection rate was 2,4 pacients-year. Younger patients and higher values of urea breath test were factors associated with a higher rate of reinfection relapse. Annually, urea breath test should be performed to detect reinfection in order to avoid ulcer complications.

Background and study aims The aim of the present study was to assess the value of capsule endoscopy in the diagnostic work-up of patients in whom there is a clinical suspicion of small bowel Crohn's disease that cannot be confirmed using traditional techniques. Patients and methods A total of 21 patients (14 men, seven women; mean age 43 +/- 8 years) with a clinical and biochemical suspicion of Crohn's disease were included in the study. Conventional imaging work-up, including upper and lower endoscopy, as well as a small-bowel follow-through, was carried out in all of the patients. Results Pathological findings were not observed in 12 of the 21 patients (57 %). In the other nine patients (43 %), lesions supporting the diagnosis of Crohn's disease were seen. The most frequent findings were located in the distal ileum and included aphthae, lineal and serpiginous ulcers, and fissures. Four patients had lesions in the jejunum. One patient showed erosions in the distal duodenum, jejunum, and ileum. No adverse effects of the technique were observed in any of the patients. Conclusions Capsule endoscopy is a valuable diagnostic tool in patients with suspected Crohn's disease that has not been confirmed using standard imaging techniques.

Sarcoidosis is a chronic multisystemic granulomatosis of unknown etiology that affects mainly young adults. It characterized by bilateral hiliar adenopathies interstitial pulmonary infiltrate, and cutaneous and ocular lesions. Localization in upper respiratory tract is infrequent. In the present report we describe a 26-year-old male with a three-month history of a globus sensation, hoarse voice, loud snoring and obstructive sleep apnoea, because of a laryngeal noncaseating granulomatous infiltration. The diagnosis is made through the history, the radiology and the pathological examination. Treatment is symptomatic, due to its tendency to a spontaneous regression. The treatment is based on corticosteroids by systemic or aerosol routes. Micro surgical excision and tracheotomy may be useful in selected patients.

Introducción: La Pancreatitis crónica es una enfermedad recurrente, frecuentemente asociada al consumo de alcohol y suele presentarse en la tercera y la cuarta décadas. Las estenosis y las litiasis del conducto pancreático principal producen obstrucción del mismo y consecuentemente dolor. Por tanto la descompresión quirúrgica o endoscópica, del conducto pancreático principal alivia el dolor. Sujetos y métodos: Revisión de nuestra experiencia en el manejo endoscópico en pacientes con pancreatitis crónica. Realizamos CPREs en 42 pacientes para el manejo de su pancreatitis crónica. Las opciones terapéuticas fueron la esfinterotomía, colocación de endoprótesis ó ninguna. El seguimiento medio fue 47,8 (27,2) meses. Resultados: 22 pacientes fueron sometidos a CPRE terapéutica. En ocho pacientes, realizamos esfinterotomía y en 14 pacientes, colocamos endoprótesis con esfinterotomía previa. 8 pacientes estaban asintomáticos, después de un seguimiento medio de 10,8 (11,6) meses. Dos de ellos, fueron sometidos a una esfinterotomía y en seis de ellos, colocamos endoprótesis, previa esfinterotomía. Conclusión: La CPRE es una herramienta que alivia el dolor en un quinto de pacientes con pancreatitis crónica.

Wireless endoscopy consists of a small-sized device which allows gastrointestinal tract images to be taken as it physiologically advances along its lumen after being orally ingested. Its primary contribution is the study of small bowel conditions, a gastrointestinal tract segment in which diagnosis difficulties still arise when using current tests, including enteroscopy. Preliminary studies in animals and healthy subjects have revealed data on image quality, sensitivity, specificity, and safety that demonstrate the benefits of this new technique. This review discusses technical aspects, indications and contraindications, as well as studies reported so far on this endoscopic diagnostic procedure.

1. The release mechanism of immunoreactive Met- and Leu-enkephalins was studied by radioimmunoassay (RIA) with highly specific antisera in whole perioesophageal ganglia of the snail Helix aspersa . 2. The release was measured under three different experimental situations: (a) basal release, (b) during a high potassium depolarizing pulse and (c) without Ca 2+ . 3. Our results show that IR-ME/IR-LE ratio, under a high potassium depolarizing pulse, was approximately 2:1. The release mechanism for enkephalins is enhanced by a depolarizing pulse and is Ca 2+ dependent. 4. This preparation provides a good model to investigate physiological or pathological conditions in which opioid peptides are involved.

A relevant percentage of patients with malignant biliary obstruction are not candidates for surgery when the diagnosis is made. Endoscopically placed biliary stents have shown their efficacy in the palliative management of these patients although they do not seem to increase their survival. We report on a retrospective analysis of 37 patients with malignant biliary obstruction treated with endoscopic biliary stents. The distal third (62%) of the main life duct was the most frequent common location for the obstruction, and pancreatic cancer was the most frequent cause of obstruction (64%). Twenty three plastic (13-7F and 10-10F) and 14 metallic stents were placed initially. Forty four percent of the plastic stents (all of them 7F, none 10F) were removed after 39 days against 30% of the metallic stents after a mean period of 60 days. Global survival was 153 days (110 in the plastic stents' group versus 195 in the metallic one, p: NS). We could only make a complete follow up in 52% of the patients.endoprotheses are a good palliative treatment for malignant biliary obstruction. When plastic stents are used they should have a wide calibre (10F or greater). Metallic stents result in an increase of survival time without statistical significance.

Pain in chronic pancreatitis is due to intraglandular neural affection and to pancreatic duct drainage obstruction with an increased intraductal pressure. To achieve pain relief, medical, surgical and endoscopic procedures have been developed.To evaluate the efficacy of pancreatic duct stenting in patients with narcotic-dependent pain due to chronic pancreatitis.From May-1994 to May-1996, ten patients (medium age: 47.5 yr) with alcoholic chronic pancreatitis were selected for this procedure. Pancreatography showed single or multiple Wirsung strictures in all cases. Papillotomy and pancreatic duct sphincterotomy were performed before stenting. Strictures were negotiated with a 7F dilating catheter over a guide wire, and intraductal calculi were removed as well. We used 7F plastic stents with variable lengths (5-10 cm), that were exchanged when the patient presented pain recurrence. Stent survival time was defined as the patient's pain-free time.In 6 of the 10 patients stent placement was carried out successfully. A single distal Wirsung stricture was diagnosed in 3 patients while in the remaining 3 there were several strictures associated to ductal lithiasis in two of them. Mean time to achieve pain relief was 3 days and mean stent survival time was 166.5 days. There were no complications due to the procedure.When placed through the stricture, endoscopic pancreatic stent drainage is effective in achieving pain relief. It is a safe procedure with no complications in our short series.

The Lesch-Nyhan syndrome (LNS) has been extensively studied from the genetic and biochemical point of view. The main characteristic of the syndrome is the self-mutilation feature, which has been poorly studied and understood. We propose a new hypothesis about the self-mutilation physiopathology, which is related to the supersensitivity of the dopaminergic D1 receptors in the neuromatrix found in the cingulum cortex region. The LNS shows an increase of uric acid levels as a result of the deficiency of hypoxanthine phosphoribosyltransferase enzyme. This increase could induce damage to dopaminergic neurons. As a consequence, a decrease in dopamine synthesis during gestation and the early postnatal period could occur, producing a functional dopaminergic denervation of the D1 receptors, located on the prefrontal cortex, specifically in the cingulum bundle projections. This phenomenon could induce a codification disturbance in the 'genetic body' of the neuromatrix, that could be expressed functionally as anosognosia, giving rise to self-mutilation. We suggest that this self-mutilation is a pain consciousness problem.

Many cases of hearing impairment are of genetic origin. Non-syndromic recessive transmission is the most frequent form. A genetic study was made of cases of non-syndromic familial hearing impairment seen in our service. The pattern of Mendelian inheritance was studied in the disorders associated with deafness. Four families had non-syndromic deafness and autosomal inheritance (3 dominant and one recessive) and one had a probable sex-linked inheritance. Genetic counseling was given and guidelines were created after reviewing the literature.

We report our experience of two years (February 1993-February 1995) in the endoscopic treatment with self-expanding prosthesis (Ultraflex) of 21 patients with inoperable malignant oesophageal stenosis. 23 prosthesis were implanted enabling swallowing in less than 24 h. There were no major complications. In two occasions the prosthesis was obstructed by tumoral growth needing replacement. The prosthesis was occluded by solid food in four cases, which were resolved endoscopically.

Infantile Cholesteatoma has been lately the aim of a large number of papers dealing with its natural history and optimal treatment. The outcome of 26 cases of ear surgery, done between 1990 and 1991, are reviewed. The etiology of Cholesteatoma was congenital in 2 cases, iatrogenic in an other one and unknown for the remainder (88%). Fifteen (15) closed surgical procedures and 11 open were carry out, achieving global removal of lesions in 76 percent of cases. Ninety-one (91%) of open tympanoplasties and 66 percent of closed procedures. Six cases evolved to recidivation (and later reoperatively reconverted in open cases) owing either to the erosion of the ossicular chain or encroachment of the recessus. Reconstructions of the ossicular chain was undertaken in 61.5 percent of cases and the hearing preserved in all instances and improved in 35 percent of reconstructions.

Distortion product otoacoustic emissions (DPEs) are a subtype of evoked otoacoustic emissions that represent a class of cochlear response. Because of their frequency specificity and the wide range of frequencies explored DPEs have a great potential for clinical use. DPEs studies include DP-audiograms and input/output functions. We recorded 27 DPEs, 24 of them from normal ears and 3 from pathological ears. This report resumes methods and results.

We present a case of 6-years-old male with an internal jugular phlebectasia, diagnosed at our Hospital. Review of the bibliography, and complementary examination, like doppler, echography and digital intravenous angiography subtraction (DIVAS) was made.