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Background and aim Pharyngoesophageal reconstruction after laryngo-pharyngo-esophagectomy is challenging due to its high morbidity and mortality. There are different reconstructive flaps: visceral flaps (pedicle stomach and colon flaps and free jejunum or colon grafts) and myocutaneous flaps (pedicle local flaps or free grafts). The objective is to evaluate the morbidity and mortality and functional results of the reconstruction after laryngo-pharyngo-esophagectomy. Methods This is a retrospective study of patients who underwent laryngo-pharyngo-esophagectomy in our center, due to a benign cause (caustic ingestion) or malignant (larynx, pharynx, parathyroid and cervical esophagus cancer) with circumferential pharyngeal reconstruction with flap, from 2008 to 2020. Demographic variables, procedure performed and flap used for reconstruction, complications related to reconstruction (fistula, stenosis, necrosis), postoperative complications, days until adequate swallowing, flap’s functional result, hospital stay, recurrence and mortality were collected. Results Twelve patients, with 59 years (45–78) median age, underwent surgery. There were complications related to reconstruction in 42% of the patients (Table 1). Postoperative morbidity was 67%. The median hospital stay was 21 days (16–94). The median time to swallowing was 13 days (3–73). An optimal functional result (oral intake) was achieved in 75%. The median follow-up was 18 months (4–56), with a survival rate of 50%. 30-days mortality was 8%. Conclusion Our study shows a high morbidity and mortality after circumferential pharyngeal reconstruction, similar to literature published. We have observed a higher rate of reconstruction related complications and worse functional results in reconstructions performed with gastroplasty and coloplasty after total laryngo-pharyngo-esophagectomy, compared to less aggressive local resections with ALT free flap reconstruction. Table https://secure.sem-2000.it/semUpload/OLC/file/9203828791100911681076702/93727_Table.jpg.

Annual influenza vaccination is especially relevant for older people because of their high risk of complications caused by influenza virus infection. It is important to get the elderly and other groups at risk of influenza derived complications to be vaccinated before the onset of the epidemic activity. Vaccination administered too early or delayed will not allow for desired protection. In northern hemisphere countries, influenza vaccination campaign runs between mid-September and the first week of December, with marked variations across countries. Influenza vaccine has moderate effectiveness in its ability to produce a protective immune response, which is reached within 14 days of having received the vaccine. The immunity achieved is attenuated over time resulting in a marked decline in vaccine effectiveness. One strategy used in many countries to limit this decline is to delay the vaccination period by one to two weeks. This delay either compresses the period towards the onset when the epidemic wave usually begins, so that when it initiates the degree of protective immunity of individuals is high.

Aim Description of the technique of intrathoracic anastomosis in Ivor-Lewis esophagectomy in prone position with minimally invasive approach (MIE) by manual tobacco-bag suture and anastomosis with circular stapler and its results. Background & Methods Retrospective descriptive analysis of the intrathoracic anastomosis technique in prone of the cases performed in our Health Care Center by thoracoscopic and laparoscopic approach in Ivor-Lewis esophagectomy between April 2017 and December 2018. Patients who required conversion to thoracotomy due to pleural adhesions were excluded Results The median age of the 18 patients was 59 years (54-67 years). In the 18 analyzed (17 adenocarcinomas of 1/3 lower or gastro-esophageal junction and 1 benign stenosis post-RT) 12 were performed with mechanical anastomosis CEA 25, 2 with CEA 28 and 4 with Orvyl CEA 25. No leakage occurred during the postoperative period, performing in 16 a TEGD at 4-5º DPO. Three patients underwent feeding jejunostomy. In the postoperative period, 2 patients presented with ARDS, 2 with pneumonia, 2 with pleural effusion, and 1 with AF. In the follow-up performed until May 2019 1 patient presented stenosis of the anastomosis that was treated by endoscopic dilation. No leakage of the anastomosis has been recorded. The postoperative mortality ( Conclusion Compared with other technical variations, even with another type of anastomosis, the circular mechanical anastomosis, making the tobacco bag around the head by manual suture and reinforcing it by Endoloop is a safe and reproducible technique with a 0% leakage rate and stenosis of 5.88%. According to the literature, the rate of anastomotic leakage in the thoracoscopic approach is between 0-20% and that of anastomotic stenosis is 0-27.5%, without finding significant differences between the different types of anastomosis. It has been demonstrated in numerous series that the thoracoscopic approach is oncologically equal to or better than the approach by thoracotomy because it allows a better dissection with resection of a greater number of nodes and that provides benefits such as less postoperative pain, better patient ventilation, better ergonomics for the surgeon and better vision of the operative field. However, we believe that this new approach should not change the usual technique of performing the anastomosis or the indication of the Ivor-Lewis esophagectomy. Randomized studies with a larger number of cases are necessary to determine which anastomosis technique is safest and reproducible in MIE surgery of esophageal cancer.

Aim To evaluate the rate of complications and hospital stay length in patients undergoing esophagectomy in whom a descompressive tube was not utilized during the postoperative period. Background & Methods A descriptive and retrospective study was performed at our Health Care Center. All patients undergoing esophagectomy from March 2015 to April 2018, in which no decompressive tube was placed in the plasty during the postoperative period were included. We evaluated epidemiological variables, postsurgical morbidity -including nausea, vomiting or plasty emptying problems- postsurgical mortality, decompressive tube placement necessity and hospital stay lenght. Results A total of 41 patients were included, with an average age of 61.1 years. 82.9% were males. 43.9% were hypertensive, 63.4% were smokers and 13.1% were diabetics. 78% of patients had received neoadjuvant chemotherapy and / or radiotherapy prior to surgery. The surgical technique used was Mc Keown's esophagectomy in 23 patients (56.1%) and Ivor-Lewis tecnique in 18 (43.9%). In 85.4% of the cases, a thoracoscopic approach was used; and in 48.8% laparoscopy was utilized for abdominal approach. For the reconstruction, a gastroplasty was performed in 36 patients (87.8%) and a coloplasty was performed in 5 of them (12.2%). The anastomosis was performed manually in 53% of cases, and mechanically in 47%, by utilizing a circular stapler. The rate of complications was : 1 necrosis of the coloplasty (2,4%) who died because of a multiorganic failure; 2 stenosis of the anastomosis (4,8%) treated by endoscopic dilatations and 4 anastomosis leaks (9,8%). The mortality rate was 4,8%. 1 patient died due to coloplasty necrosis and the other one because of an acute respiratory distress syndrome (ARDS). Conclusion The non-use of a descompressive probe during the postoperative period of an esophagectomy does not entail a higher rate of complications compared to the available literature.This fact can improve the comfort of the patient and reduce hospital stay length.

Aim To present a case report where Kamikawa’s technique1 was used, as well as the patient’s postoperative evolution and results. Background and Methods Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence. This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer. Results A 55 year-old female with no relevant medical history, diagnosed with diffuse signet ring cell gastric adenocarcinoma. The tumor was 3 cm long, extending from the esophago-gastric junction to the subcardial region (cT3 N1 M0). After presentation in a Multidisciplinary Group, the patient underwent perioperative chemotherapy according to the FLOT-4 protocol, presenting partial clinical response. The surgical intervention took place 6 weeks after finishing chemotherapy, and a laparoscopic superior polar gastrectomy was performed, associating extended resection including 3-4 cm of distal esophagus and D1+ lymphadenectomy with periesophageal lymph node regions 110 and 111. Once the resection was finalized, an assistance laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of the cranial part of the gastric pouch and afterwards, two seromuscular flaps were dissected. Then, the gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis made with 2 running sutures of V-lock 3/0. Finally, the previously prepared seromuscular flaps were sewn overlapping the esophagus and the esophago-gastric anastomosis in order to prevent reflux. The patient presented a benign postoperative course, reintroducing oral intake and developing no heartburn, no dysphagia, nor vomiting and was discharged on the 9th postoperative day. The postoperative barium swallow radiography showed no leak of contrast nor any regurgitation. The pathology report showed pT3N1 (2/17) and confirmed tumor free resection margins. Conclusion The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.

Aim To describe a case report of a carotid-gastroplasty fistula post esophagectomy with a successful result. Background & Methods Upper gastrointestinal bleeding due to a fistula between esophagus or gastroplasty and carotid vessels is infrequent. It is usually due to malignant tumors, penetrating trauma, foreign bodies or radiotherapy. Results A 55-year-old man, with background of laryngeal squamous cell carcinoma that was treated with total laryngectomy and tracheostomy followed by radiotherapy, and posterior recurrence of squamous cell carcinoma at the upper esophagus required total esophagectomy with pharynguectomy and lymphadenectomy, and reconstruction with gastroplasty with anastomosis to the floor of the mouth and pectoralis muscle flap. During this second postoperative period, patient developed a left hemiplegia secondary to thrombosis of the right common carotid artery. After recovery, the patient had repeated episodes of hematemesis that required hospital admission and blood transfusion. After several episodes with conservative management, upper endoscopy revealed blood oozing close to the anastomosis with no other findings. Once again, the patient returned to the emergency department with massive hematemesis, being visualized by endoscopy a high-flow arterial bleeding close to the anastomosis of the floor of the mouth. Arteriography showed the already known thrombosis of the right common carotid artery and the origin of the bleeding distal to that occlusion, where it was repermeabilized by a branch of the right vertebral artery. Given the inability of selective embolization by interventional radiology, urgent surgical approach was decided, performing a right lateral cervicotomy and identifying a fistula that communicated the common carotid artery with gastroplasty. It proceeded to close the fistulous orifice of the arteria and the gastroplasty with a continuous suture. A partial sternocleidomastoid muscle flap was interposed between the two sutures. The postoperative evolution was satisfactory. Patient was discharged 16 days after surgery and being currently stable without signs of hemorrhagic neither oncological recurrence. Conclusion Carotid-gastroplasty fistula is a rare complication with high mortality rate due to its more frequent presentation: the massive hematemesis. Gastrointestinal endoscopy and angiography allow us to diagnose and treat this complication, however in massive and uncontrollable bleeding, surgical approach is indicated. Prognosis will depend on the early diagnosis and a therapeutic individualization is required.

Introduction Radical Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), has been proposed as the current standard of treatment for metastatic peritoneal disease by several tumors. Despite its widely utilization, there seems to be a great variability in their organization, clinical practice, and safety among centers. Aim of the study To obtain updated information on clinical practice in different perioperative areas of the CRS-HIPEC. Patients and methods All 25 members of the Spanish Surface Peritoneal Malignancy (GECOP), were invited to answer an online survey, to describe their usual practice in different perioperative areas of the CRS-HIPEC. Results Survey was responded by 100% of centers. This study represents more than 800 patients treated annually. Seventy per cent of respondents perform CRS-HIPEC for more than 5 years. The most frequent technique was Coliseum (88%). Routinely non-invasive monitoring of cardiac output is used by 92% of centers. More than 50% of centers administer oxaliplatin (74%), or mitomycin-C (65%) in colorectal cancer; cisplatin in gastric cancer (73%) and mesothelioma (74%). Ovarian cancer is treated with cisplatin and various combinations, in 64% or paclitaxel in 54.5%. Spillage protocol was available in 100% centers. Conclusions Data showed an important variability in volume of patients per center, selection of cytostatic agents, professional training and safety measures applied. The standardization of CRS/HIPEC procedures based on the best available evidence, the individualization of patients and the consensus among professionals, constitute an important part of the basis that will allow us to improve results of this complex procedure.

The prevalence of multiple sclerosis in the south of Europe seems to be higher than previously considered. This study aimed to probe a possible increase in the prevalence of multiple sclerosis (MS) in Osona over the past 17 years. This was a cross-sectional study including MS-confirmed cases from several sources of information. Crude and adjusted prevalence rates were obtained. One hundred and twenty patients fulfilled the study criteria. The crude prevalence of MS was 79.9 (95% CI: 66.3-95.6) per 100,000 inhabitants and 91.2 (95% CI: 75.5-109.2) per 100,000 among Spanish born individuals. The prevalence of multiple sclerosis cases in Osona has increased over the past 17 years to being one of the highest reported in Spain.

Resumen Introduccion La incidencia del dolor de miembro fantasma (DMF) tras la amputacion es elevada y existen frecuentes fracasos en su tratamiento. Seria importante un nuevo enfoque en el manejo de los pacientes amputados que incluya un modelo preventivo del dolor, especialmente cuando la cirugia se realiza de manera programada. Material y metodos Se trata de un estudio de cohortes ambispectivo que compara una cohorte historica de amputados vasculares (ano 2002) con una cohorte de intervencion prospective (ano 2003) tras la incorporacion de gabapentina, desde el preoperatorio, al protocolo analgesico quirurgico. Resultados El numero final de pacientes fue 28 en la cohorte en control y 30 en la cohorte de intervencion. La incidencia de DMF en el posoperatorio inmediato se registro en el 75% de los controles y en el 60 % del grupo intervencion, y a los 3 meses en el 75 % y el 40 % respectivamente (p = 0,001). Considerando como resultado una disminucion de la escala visual analogical (EVA) en un 30 %, las diferencias fueron significativas a los 3 meses y el numero necesario para tratar (NNT) fue de 2,63. Considerando como evento final una EVA inferior a 30 mm, las diferencias fueron significativas a los 90 dias y el NNT fue de 2,04. En el analisis multivariante (respuesta EVA Conclusion Los resultados obtenidos, con una disminucion de la incidencia y de la intensidad del dolor a los 3 meses, podrian convertir a la gabapentina preoperatoria en una alternativa terapeutica para el DMF, si bien para confirmar esta afirmacion, se estima necesaria la realizacion de estudios doble-ciego.

Introducción: En este estudio se revisan las evidencias científicas disponibles sobre la seguridad de la vacuna triple vírica convencional (cultivada en fibroblastos de embriones de pollo) en niños con alergia al huevo, y se evalúa la reactogenicidad vacunal en una serie amplia de niños con este tipo de alergia inmunizados con triple vírica en una unidad de vacunación hospitalaria. Material y métodos: Estudio observacional prospectivo, realizado en la Unidad de Vacunación Internacional del Servicio de Medicina Preventiva y Epidemiología del Hospital Universitario Vall d’Hebron, entre marzo de 2004 y diciembre de 2005. Se analizan variables demográficas, las relativas a los antecedentes de alergia y la reactogenicidad apreciada tras la observación directa del niño durante los 30 min posteriores a la vacunación. Resultados: Se han incluido en el estudio 140 pacientes (106 en primera dosis de vacuna triple vírica y 34 en segunda). El 75,7 % había presentado manifestaciones clínicas tras la ingesta de huevo o de alimentos que lo contenían (sólo siete niños habían presentado manifestaciones graves, en forma de dificultad respiratoria en 6 casos y de anafilaxia en uno). Se administró la vacuna convencional a 121 niños, y no se observó ninguna reacción adversa importante (el 17,8 % de ellos presentó reacción local leve en el punto de inyección). Conclusiones: Las evidencias científicas actuales, así como los datos del presente estudio, sustentan la seguridad de la vacuna triple vírica en personas con hipersensibilidad al huevo. : Introduction: We review the scientific evidence on the safety of the measles, mumps, and rubella (MMR) vaccine (produced in chicken embryo cell culture) in children with egg allergy. Data on the reactogenicity observed with this vaccine in a large series of children with this type of allergy immunized in an hospital immunization unit are presented. Material and methods: An observational prospective study was performed in the International Immunization Unit of the Epidemiology and Preventive Medicine Service of the Vall d’Hebron University Hospital from March 2004 to December 2005. Demographic variables, clinical history of allergy, and the adverse reactions observed 30 minutes after vaccine administration were analyzed. Result: A total of 140 patients (106 referred for the first MMR vaccine dose, and 34 for the second) were evaluated. Of these, 75.7 % showed clinical signs after egg ingestion (severe reactions were described in only seven patients: respiratory distress in six and systemic anaphylaxis in one). The MMR vaccine was administered to 121 children. No significant adverse reactions were observed (17.8 % of the vaccinated children developed mild local symptoms). Conclusions: According to current scientific evidence and the data obtained in this study, the MMR vaccine is safe in patients with egg allergy.

Background Recent studies show an increasing incidence of multiple sclerosis (MS) in southern Europe. Although by its geographical location and genetic characteristics Spain is expected to be similar to other southern European regions, data on incidence are scarce. The aim of this study was to determine the onset-adjusted incidence of MS in the Girona province in Catalonia (Spain). Methods A prospective incidence study pooling data from the population-based Catalonia MS Registry was performed. Incident cases were defined as patients who had the onset of symptoms compatible with a clinically isolated syndrome (CIS) suggestive of MS in 2009 and fulfilled McDonald-2005 criteria during follow-up. Age- and sex-specific incidence rates were obtained. Results The Registry included 182 patients residing in Girona that presented a CIS from January 2009 to December 2013. Fifty one patients had the onset of symptoms in 2009, of whom 27 patients fulfilled the diagnostic criteria, giving an incidence of 3.6 per 100,000 (CI 95% 2.4–5.3) inhabitants; 4.3 (CI 95% 2.5–7.1) for women and 2.9 (CI 95% 1.4–5.2) for men. The age-adjusted incidence rate for the European population was 3.29 (CI 95% 3.2–3.3). Conclusion The incidence estimation derived in this study is consistent with recent epidemiological data of MS in southern Europe suggesting an increase in incidence in this region.

Introducción: Los niños menores de 2 años y los afectos de patologías de base son los que presentan un mayor riesgo de complicaciones y hospitalizaciones a causa de la gripe. A pesar del amplio consenso en la literatura médica en la indicación de vacunación antigripal anual en estos pacientes, menos del 30 % de niños con condiciones de alto riesgo son inmunizados anualmente. El objetivo de este estudio es conocer la cobertura vacunal antigripal en los niños ingresados en un hospital de tercer nivel con patologías de riesgo. Pacientes y métodos: Estudio de prevalencia en pacientes de 6 meses a 18 años con patologías de riesgo ingresados entre enero y mayo de 2005 en el Hospital Universitario Vall d’Hebron de Barcelona. Se analizan las coberturas vacunales frente a la gripe, factores asociados a la inmunización, así como los motivos de no vacunación. Resultados: La cobertura vacunal global observada ha sido del 23,5 %. Los pacientes afectados de cardiopatías, enfermedad respiratoria crónica y asma son los que presentan coberturas de vacunación más elevadas (43,2, 42,9 y 28,6 %, respectivamente). El tipo de patología de base, el antecedente de vacunación en la temporada anterior, estar vacunado frente al neumococo y ser menor de 5 años son las variables más asociadas a la vacunación antigripal en estos pacientes. El principal motivo de no vacunación ha sido la falta de recomendación por parte de los profesionales sanitarios que atienden a estos pacientes (95,3 %). Conclusiones: La cobertura vacunal frente a la gripe en niños que tienen indicación es baja. Se requieren estrategias para aumentar la concienciación de los profesionales sanitarios sobre la importancia de recomendar esta vacunación. : Introduction: Children aged less than 2 years old and those with chronic diseases have a high risk of complications and hospitalization due to influenza. Despite the broad consensus in the literature on the indication for annual immunization of these patients, less than 30 % of the children with high-risk underlying conditions are immunized each year. The aim of this study is to determine the influenza vaccine coverage in children with high-risk underlying conditions admitted to a university hospital. Patients and methods: We performed a cross-sectional study of patients aged from 6 months to 18 years old with high-risk medical conditions and who had been hospitalized between January and May, 2005 in the Vall d’Hebron University Hospital (Barcelona). Influenza vaccine coverage, factors associated with immunization, and the reasons for nonvaccination were analyzed. Results: Overall vaccine coverage was 23.5 %. The highest vaccination coverage was found in patients with congenital heart disease, chronic respiratory disease, and asthma (43.2 %, 42.9 % and 28.6 %, respectively). The factors most frequently associated with influenza vaccination were the type of underlying disease, having been immunized against influenza in the previous season, having received the pneumococcal vaccine, and age younger than 5 years. The main reason for nonvaccination was the lack of influenza vaccine recommendation by health professionals (95.3 %). Conclusions: Influenza vaccine coverage in children with high-risk conditions is low. Strategies to increase awareness among health professionals on the importance of recommending influenza immunization are required.

Although closed urinary drainage systems (CUDS) reduce the risk of catheter-associated urinary tract infection (CAUTI), open systems are still used in Spain. The object of this work was to describe the progress of CUDS use and factors associated with the drainage system type used in Spanish hospitals. The databases of the EPINE study (Study of Prevalence of Nosocomial Infections in Spain) from 1990 to 2000 were used. The EPINE study includes hospitalized patients of all ages in acute-care Spanish hospitals. Seventy-six thousand, seven hundred and eighty-eight catheterized patients were studied, and the whole database was used for the trend analysis of global hospital-acquired infection (HAI). The patient and the hospital were the two units of observation used in the analysis. Full implementation was defined as 90% CUDS use. A logistic regression model was applied to study factors influencing the use of CUDS and to determine prevalence trend. An odds ratio (OR) >1 indicates an incremental trend. The Pearson correlation coefficient between annual percentage of CUDS use and CAUTI prevalence was calculated. Variables for the year 2000 were compared using the Mann-Whitney U test between hospitals with and without full implementation. The prevalence of urinary catheterized patients in Spain increased from 12.4% in 1990 to 15.2% in 2000 (OR 1.019, 95% CI 1.016-1.021). The proportion of CUDS used increased from 50.6% in 1990 to 70% in 2000 (OR 1.1, 95% CI 1.095-1.104) and correlated with a significant decrease of UTIs (r = 0.65, P = 0.03). In 1990, 28.5% of hospitals had full implementation of CUDS and by 2000 this had risen to 40.3% (OR 1.093, 95% CI 1.06-1.127). Patients in medium (200-500 beds) and large (>500 beds) hospitals, as well as those with three of more diagnoses and two or more intrinsic risk factors had an increased probability of having a CUDS, whereas being hospitalized in areas other than intensive care, being male and less than 65 years old were associated with a lower probability of CUDS use. The median prevalence of catheterized patients in hospitals with full implementation, was significantly lower than in those without it (P = 0.049). Although CUDS use is increasing, there is still much work required to reach full implementation. Keeping CUDS for more severely ill patients may reflect a higher concern over the consequences of UTI in these patients. Nevertheless, it is necessary to change a practice that exposes patients to a known UTI risk factor and reach a consensus on indications for catheter insertion.

Resumen Introduccion La infeccion por el virus de la hepatitis C (VHC) es un importante problema de salud publica por su elevada incidencia, el curso progresivo de la enfermedad y su asociacion con el carcinoma hepatico. La transmision nosocomial del VHC ha sido objeto de debate en nuestro medio. Este riesgo depende de la prevalencia de la infeccion en la poblacion atendida y en el personal sanitario, de los procedimientos realizados y de la adecuacion de las medidas de prevencion. Objetivo Determinar la prevalencia de la infeccion en las pacientes atendidas por un parto o intervenidas ginecologicamente en un hospital de tercer nivel, como parte de un estudio mas amplio dirigido a estimar el riesgo de transmision nosocomial del VHC. Material y metodos Se incluyeron en el estudio 1.649 pacientes atendidas en estos servicios entre octubre de 1999 y mayo de 2001. Antes de la intervencion, se realizo una encuesta epidemiologica sobre antecedentes y factores de riesgo de infeccion por VHC y una extraccion sanguinea para el estudio serologico (tecnicas de ELISA III y confirmacion por RIBA III). Resultados La prevalencia global de infeccion por el VHC fue del 0,97% (intervalo de confianza [IC] del 95%, 0,56–1,57), con cifras superiores en ginecologia (1,75%; IC del 95%, 0,96–2,92) que en obstetricia (0,24%; IC del 95%, 0,03–0,84) (p = 0,004). La edad fue la variable mas asociada a la presencia de infeccion. El 75% de los casos desconocian la presencia de la infeccion. Conclusion La prevalencia de infeccion por VHC en las pacientes intervenidas en los servicios de ginecologia y obstetricia en nuestro centro es similar a la de la poblacion general. Se ha observado un infradiagnostico importante de esta infeccion en la poblacion atendida.

Objective. To determine survival and mortality in a cohort of Spanish patients with scleroderma (systemic sclerosis, SSc) and to analyse whether survival is influenced by demographic, clinical or immunological variables or the extent of skin involvement. Methods. The study included 79 patients diagnosed with SSc and taking part in a study to determine the extent of sclerosis, visceral involvement and immunological alterations. We studied the number of observed and expected deaths (the expected number being based on age- and sex-specific rates in the background population) and derived standardized mortality ratios with their 95% confidence intervals (CI). Cumulative survival after onset of the first symptom was estimated according to the Kaplan–Meier method. The Cox method was used to identify the prognostic factors. Results. The mortality rate was 0.0249 deaths per person-year. Survival at 15 yr was 0.62 (95% CI 0.410–0.778). The standardized mortality ratio was 429.4% (95% CI 222–750). On crude analysis, lung involvement wforced vital capacity (FVC)

Resumen En este trabajo se estudian las complicaciones de la cirugia tiroidea, aportando tanto la experiencia personal de nuestro servicio como la de la bibliografia general. Estudiando todas estas complicaciones se observa que la experiencia del cirujano y una tecnica cuidadosa son los factores mas determinantes de la morbilidad de esta cirugia. La iatrogenia recurrencial, hemorragica y la hipocalcemia aumentan con la cirugia oncologica y de repeticion. Se insiste en la necesidad de la diseccion de los nervios recurrentes hasta su entrada en la laringe, y en la busqueda sistematica de las cuatro paratiroides. Existe una relacion directa entre el numero de paratiroides encontradas y el grado de hipocalcemia. La necesidad de drenajes es controvertida, pero estos son preferibles ante la agresividad de la cirugia tiroidea actual.

From 1990, a study on the prevalence of nosocomial infections has been carried out yearly in Spanish hospitals. Acute care hospitals with more than 50 beds were involved on a voluntary basis. In 1990, 123 hospitals participated and by 1997 the number of hospitals had reached 214. The objective of the study is to examine the situation in each hospital, and to collect data across the country, by means of a common protocol. The overall prevalence of nosocomial infections has significantly decreased in Spain. The prevalence of infected patients has been about 7% in the three last studies. The prevalences for urinary tract infections and surgical wound infections have decreased, while prevalences for lower respiratory tract infections and bacteraemia have increased. Urinary tract infections have occupied the first position over the eight surveys. Second place was taken by surgical wound infections from 1990 to 1995, and by lower respiratory tract infections in 1996-1997. With the exception of Intensive Care Units, the prevalence of nosocomial infections has been decreasing in all hospital areas. The mean age of hospitalized patients has increased, so has the proportion of patients with one or more intrinsic risk factors and the proportion of those with one or more instrumentations. The proportions of patients with a short or a very long hospital stay have increased, revealing a change that no doubt reduces nosocomial infection rates. The use of antimicrobial drugs has shown a significant increase, from 33.8% of patients in 1990 to 35.8% in 1997.

In a 5-year observational study we have compared sodium fluoride (NaF) with different treatments commonly used in the treatment of osteoporosis: calcium, estrogens, androgens, and calcitonin, referred to as non-NaF. We have looked at the incidence of vertebral and nonvertebral fractures. At baseline, the NaF group, consisting of 125 patients (89% females) aged 65 +/- 10 (X +/- SE) had more crush fractures (P0.0001) and more months since menopause (P = 0.004) than the non-NaF group, consisting of 127 patients (90% females) aged 63 +/- 10. Fractures were evaluated by X-ray. The entire follow-up of patients treated with NaF accounted for 361 person-years, of whom 43 patients suffered one or more new vertebral fractures (68 vertebral fractures in total) and 18 patients suffered one or more new nonvertebral fractures (22 complete peripheral fractures in total); follow-up of patients treated with non-NaF regimes accounted for 382 person-years, of whom 53 patients suffered one or more new vertebral fractures (69 vertebral fractures in total) and 20 patients suffered one or more new nonvertebral fractures (27 complete peripheral fractures in total). After adjusting for significant covariates at baseline, NaF proved to be a significant protector for vertebral fractures [odds ratio (OR) 0.48, 95% confidence interval (CI) 0.2-0.9], and for peripheral fractures (QR 0.41, 95% CI 0.2-0.9). On the other hand, the probability of suffering undesired effects was much higher with NaF treatment (OR 5.04, 95% CI 2.1-11.9). We conclude that in the treatment of osteoporosis, NaF has a protective effect against vertebral and nonvertebral fractures, does not increase the risk of femoral fractures, but has a higher incidence of untoward symptomatology.

Children aged less than 2 years old and those with chronic diseases have a high risk of complications and hospitalization due to influenza. Despite the broad consensus in the literature on the indication for annual immunization of these patients, less than 30 % of the children with high-risk underlying conditions are immunized each year. The aim of this study is to determine the influenza vaccine coverage in children with high-risk underlying conditions admitted to a university hospital.We performed a cross-sectional study of patients aged from 6 months to 18 years old with high-risk medical conditions and who had been hospitalized between January and May, 2005 in the Vall d'Hebron University Hospital (Barcelona). Influenza vaccine coverage, factors associated with immunization, and the reasons for nonvaccination were analyzed.Overall vaccine coverage was 23.5 %. The highest vaccination coverage was found in patients with congenital heart disease, chronic respiratory disease, and asthma (43.2 %, 42.9 % and 28.6 %, respectively). The factors most frequently associated with influenza vaccination were the type of underlying disease, having been immunized against influenza in the previous season, having received the pneumococcal vaccine, and age younger than 5 years. The main reason for nonvaccination was the lack of influenza vaccine recommendation by health professionals (95.3 %).Influenza vaccine coverage in children with high-risk conditions is low. Strategies to increase awareness among health professionals on the importance of recommending influenza immunization are required.

A series of annual surveys on the prevalence of infections in hospitalized patients in Spain was undertaken from 1993 to 2003 to describe clinical and demographic characteristics, trends and geographical variations in the proportion of meticillin-resistant Staphylococcus aureus (MRSA). A total of 8312 S. aureus infections in patients from 296 acute care hospitals pertaining to 17 regions in Spain were observed during the study period. Overall, 23.8% of these organisms were reported as meticillin resistant. The proportion of MRSA varied widely across regions and during the study period. Patients with nosocomial infections (NIs) had a two-fold higher prevalence of MRSA (31%) than patients with community-acquired infections (CAIs) (14%; P0.001). Nevertheless, there was an increasing trend in the prevalence of MRSA isolates, both in patients with NI (from 22% to 41%; P0.001) and with CAI (from 7% to 28%; P0.001) throughout the 11-year period. Geographical variations over the last three years (2001-2003) show a centripetal gradient, with the lowest MRSA prevalence in south-west Spain and the highest MRSA prevalence in the central regions. Almost five-fold differences in MRSA proportions were seen between regions (range 10.3-54.5%). Compared with bloodstream infections, infections in other sites were more likely to be caused by MRSA (adjusted odds ratios for surgical site, urinary tract, skin and respiratory infections of 1.2, 1.2, 1.5 and 2.1, respectively).

The aim of this paper was to analyze how public health functions are covered in large or medium-sized cities in Catalonia (Spain) by assessing the role, activities and structure of local services.Data were collected through a questionnaire with items on public health functions and activities and on the structure of municipal services. The study population comprised the 43 cities of Catalonia with a population above 25,000 (3% of towns and 70% of the population). Answers were obtained from 28 cities (65%), covering 60% of the population of Catalonia and all towns with a population above 50,000 inhabitants.The public health function in which local governments were least active was need assessment while they were more active in policy development and service delivery assurance. For public health activities, the role of local governments was relatively greater in health protection while few municipal services were active in epidemiological surveillance and substance abuse. Municipal public health expenditure per resident/year was estimated at 1,063 pesetas (approximately 6 Euros). Among the public health personnel, 72% worked full-time while the remaining (mainly members of the corps of health officers serving local administration) worked part-time. Local governments often mixed within the same structure public health services and services, mainly consumer affairs, environmental or social services.Local governments showed significant activity in public health. The volume of resources involved and management capacity were considerable. In some cities, some public health activities were perceived as not covered.

Clinical and epidemiological studies have established that malnutritionis a risk factor for infection in patients being submitted to surgery. To date no study has been carried out to establish the association between the nutritional condition and the incidence of hospital-acquired infections in patients in the medical area. We study the incidence of hospital-acquired infections in the elderly in an attempt to determine the rate of this infection and its association with protein-calorie malnutrition. Another aim of this study has been to determine the predictive value of the parameters used to evaluate the patient's state of nutrition and immunity.We included 240 patients over 64 years old, 118 males and 122 females, admitted to the medical area of a general hospital. The nutritional and immunity condition of the patients was evaluated through determinations of weight, height, body mass index, hypoalbuminemia and total lymphocyte count. The psichophisical degree of dependence was evaluated through of Norton scale. The details on the hospital infections came from a clinical and microbiological follow-up of patients, in accordance with the criteria of the Centers for Disease Control of Atlanta.The frequency of protein-calorie malnutrition was 12.5% and the accumulated incidence of hospital-acquired infections was 19.6%. Functional incapacity of the elderly prior to hospitalization (odds ratio,4.70; 95% CI: 1.1-19.0) as well as the presence of certain extrinsicrisk factors (odds ratio, 2.35; 95% CI: 1.1-5.1) were, in addition to hypoalbuminemia (odds ratio, 3.60; 95% CI: 1.3-10.2) and lymphocytopenia(odds ratio, 2.67; 95% CI: 1.3-5.7), the independent variables that showed the most significant association with the incidence of hospital-acquired infections.The nutritional parameters associated with the immune system determinedgreater risk of hospital-acquired infections among elderly patients admitted to the medical area of a hospital. The initial evaluation of elderly patients hospitalitzed in accordance whit the psychophysical degree of dependence based on the Norton scale is useful to evaluate those patients who were at greater risk for hospital infections.

From 1990, a study on the prevalence of nosocomial infections has been carried out yearly in Spanish hospitals. Acute care hospitals with more than 50 beds were involved on a voluntary basis. In 1990, 123 hospitals participated and by 1997 the number of hospitals had reached 214. The objective of the study is to examine the situation in each hospital, and to collect data across the country, by means of a common protocol. The overall prevalence of nosocomial infections has significantly decreased in Spain. The prevalence of infected patients has been about 7% in the three last studies. The prevalences for urinary tract infections and surgical wound infections have decreased, while prevalences for lower respiratory tract infections and bacteraemia have increased. Urinary tract infections have occupied the first position over the eight surveys. Second place was taken by surgical wound infections from 1990 to 1995, and by lower respiratory tract infections in 1996-1997. With the exception of Intensive Care Units, the prevalence of nosocomial infections has been decreasing in all hospital areas. The mean age of hospitalized patients has increased, so has the proportion of patients with one or more intrinsic risk factors and the proportion of those with one or more instrumentations. The proportions of patients with a short or a very long hospital stay have increased, revealing a change that no doubt reduces nosocomial infection rates. The use of antimicrobial drugs has shown a significant increase, from 33.8% of patients in 1990 to 35.8% in 1997.

The purpose of this study was to know the use of addictive substances by adolescents of the city of Barcelona (Catalonia, Spain).Data were obtained from an anonymous and self-administered questionnaire about tobacco use, alcohol use and non-institutionalized drug abuse. participants were students in 3 degrees BUP (16-17 years old) of twelve institutes that are representative of the different districts of the city. The survey was made during the 1991-1992 school year.Among the 426 individuals included, 32.2% reported use of tobacco, 59.2% alcohol, and 16.4% marijuana. Tobacco use was higher among females (p = 0.05), and that of alcohol (p0.0001) and other drugs (p = 0.02) higher among males. The parents' smoking behavior was significantly associated with the use of non-institutionalized drugs (p = 0.01). There was a positive and significant association among the use of all three kinds of addictive substances (p0.0001).The prevalence of tobacco, alcohol and non-institutionalized drug use by students in this age range is high. Compared with previous studies in this population we can appreciate a decreasing trend of use.

Severe alpha-1-antitrypsin (AAT) deficiency is caused by homozygous inheritance of gene Z, and is associated with a high risk of developing pulmonary emphysema. Determination of frequencies of different genes associated with the deficiency (especially S and Z) gives a clue to estimate the number of individuals homozygous PiZZ, carrying a high risk for pulmonary disease, in any given population.Pi phenotypes of 440 healthy individuals were determined by means of isoelectrofocusing in polyacrylamide gel. Seric values of AAT were determined by immunonephelometry. Mean age of participants was 30 years (range 18-49 yrs.). Results are compared with other published series.Distribution of phenotypes was: PiMM 333 individuals (75%), PiMS 84 (19%), PiMZ 14 (3%), PiSS 4 (0.9%), PiM 3 (0.6%), PiMF 1 (0.2%), PiMP 1 (0.2%). The corresponding gene frequencies were Pi*M 87%, Pi*S 10.4%, and Pi*Z 1.5%. Normal values of AAT (phenotype PiMM) established in our laboratory were 116-232 mg/dl (21-41 micromol/I) (mean +/- 2 SD). According to Hardy-Weinberger equation, expected frequency of PiZZ individuals in our area would be 225 per million.The frequency of Z gen individuals observed in our study is one of the highest in the Iberian Peninsula, but lower than the frequency in northern Europe. According to these results, AAT deficiency (PiZZ) is not a rare condition in contrast with the small number of patients diagnosed. The gen frequency of the S variant is higher than that of the rest of Europe, and similar to others found in some Spanish populations.

Iron deficiency is particularly common among women in child-bearing age. The early detection and institution of an appropriate therapy can prevent the development of anemia.To study the prevalence of iron deficiency among women in child-bearing age (in the setting of periodic health visits) and the associated risk factors.A cross-sectional observational study was undertaken with 322 women in child-bearing age. An hemogram and serum ferritin levels were obtained on the same day when an interview was carried out to obtain data on general personal details, gynecological-obstetrical antecedents, diet, sports, and blood donations. Iron deficiency was defined as a serum ferritin concentration lower than 25 ng/ml.The prevalence of iron deficiency was 47.5%. In the multivariate analysis, factors significantly influencing on prevalence were: a copious menstruation blood loss (OR = 4.64, CI 2.22-9.68), a body mass index higher than 25 (OR = 0.49; CI 0.27-0.89) and maternity (OR = 2.08; CI 1.12-3.84). The likelihood associated with chi square goodness-of-fit was 0.08.The prevalence of iron deficiency detected is high; although there are clear associated risk factors, the goodness-of-fit was poor; therefore, for predictive purposes it is not possible to delineate a group in a special risk for iron deficiency.

To determine trends in rates of nosocomial infections in Spanish hospitals.Prospective prevalence studies, performed yearly from 1990 through 1994.A convenience sample of acute-care Spanish hospitals.The number of hospitals and patients included were as follows: 1990, 125 hospitals and 38,489 patients; 1991, 136 and 42,185; 1992, 163 and 44,343; 1993, 171 and 46,983; 1994, 186 and 49,689. A core sample of 74 hospitals, which participated in all five surveys and included a mean of 23,871 patients per year, was analyzed separately.The overall prevalence rate of patients with nosocomial infections in the five studies was as follows: 1990, 8.5%; 1991, 7.8%; 1992, 7.3%; 1993, 7.1%; and 1994, 7.2%. The prevalence rate of patients with nosocomial infection in the core sample of 74 hospitals was 8.9%, 8.0%, 7.4%, 7.6%, and 7.6%, respectively (test for trend, P = .0001). Patients admitted to intensive-care units had a 22.8% prevalence rate of nosocomial infection in 1994. The most common nosocomial infections by primary site were urinary tract infection and surgical site infections, followed by respiratory tract infections and bacteremia. More than 60% of all infections were supported by a microbiological diagnosis.The EPINE project provides a uniform tool for performing limited surveillance of nosocomial infections in most Spanish acute-care hospitals. Its use helps to spread an accepted set of definitions and methods for nosocomial infection control in the Spanish healthcare system. The surveys indicated that the prevalence of nosocomial infections has been reduced over the last 5 years in a core sample of Spanish hospitals.

Recent seroepidemiologic studies have demonstrated a decrease in the prevalence of hepatitis A virus infection (HAV) in relation with an improvement in hygienic conditions. The prevalence of anti-HAV in a group of health care students was studied and a vaccination program initiated in this collective.Serum anti-HAV determination was performed by an enzymoimmunoanalysis method. A inactivated hepatitis A vaccine was administered.Only 18.5% of the subjects between 17-23 years-old presented anti-HAV antibodies. The prevalence of anti-HAV was related with age and the number of partners. All of the 129 immunized individuals responded to the HAV vaccine with protector antibody titles.The present study demonstrates the decrease in HAV infection among youths as well as the immunogenicity of the anti-hepatitis A vaccine.

Fertile-aged women are a population group at special risk for developing ferropenia. In the periodic health care examinations, hemogram, among other tests, are included to detect the most advanced state of iron deficity, ferropenic anemia. Likewise, preanemic ferropenia presents a certain morbidity. The aim of this study was to analyze the cost-effectiveness of screening serum ferritin determination in health care examinations of fertile-aged women.An observational transversal study was carried out in 322 women in whom hemogram and serum ferritin were determined. The effects of serum ferritin determination were simulated in a hypothetical cohort of 20-year old women annually examined up to the age of 50 years (mean age of menopause).The prevalence of preanemic ferropenia (serum ferritinor = ng/ml) was 44.1% and that of ferropenic anemica (Hb120 g/l and serum ferritinor = 25 ng/ml) was 3.4%. Hemogram sensitivity for detection of ferropenia was 7.2% (3.6-12.5). By means of the screening program with serum ferritin avoiding of one year with ferropenia costs 2,428 pesetas. Prolonging the program to longer than 35 years largely increases the marginal cost. Cost-effectiveness analysis is specially sensitive to the cost of the diagnostic tests and disease prevalence.Ferropenia in fertile-aged women is a frequent disorder. Avoiding ferropenia by early diagnosis may be performed at a relatively low cost.

Urinary catheterization constitutes the main risk factor in urinary infections or nosocomial origin. The use of closed urinary drainage systems is fundamental to decrease this risk. The prevalence of the use of a urethral catheter as well as the proportion of closed type drainage systems in the Spanish medium was studied with the aim of improving the degree of the adoption of control measures for this type of infections.The prevalence of patients submitted to urinary catheterization (distinguishing between open and closed systems) in an important sample of Spanish hospitals was determined from the data provided by the EPINE project (1990-1993). The evolution over 4 years in addition to distribution by hospitalization areas were studied. Likewise, the results corresponding to an intervention program carried out in the authors' hospital are presented.The global prevalence of urinary catheterization ranges from 13.1% to 14.6%. The proportion of closed systems did not surpass 56.4% of the total with this system being completely implemented only in one fourth of the hospitals studied. A significant variation was not observed in this phenomenon during the study period. In the authors' hospital, the increase observed in the prevalence of closed urinary catheterization was associated to a marked decrease in the prevalence of urinary infection with values ranging from 4.3% to 0.8%.The prevalence of the use of open type urinary catheterization in Spanish hospitals remains high. The efficacy of the implementation of control measures of the urinary drainage systems is clearly proved.

At present, regression methods are an essential component of the analysis of data of any medical study describing the relationship between an outcome variable, or dependent variable, and one or more explanatory independent variables.

The aim of this study was to determine the result of partial resection of the soft palate (SPR) as a treatment of the obstructive apnea syndrome during sleep (OASS).Fifty-seven patients diagnosed of OASS treated with SPR were studied. The clinical and polysomnographic results prior to surgery and after 6 months were compared.Prior to SPR the 57 patients had a mean index of apnea plus hypopnea per hour of 57 (IAH) and following surgery the same was of 19.2 (p0.0001). IAH improved more than 50% in 42 patients (74%), 30 of whom were cured (IAHor = 10). Daily hypersomnia and snoring disappeared in 58% of the patients and decreased in intensity in most of the remaining cases. The secondary effects observed following SPR were: rhinolalia, nasal fluid reflux, and oropharyngeal disturbances, being present in 32 patients (56%) and permanent, although slight, in only 13 (23%).Soft palate resection is a good surgical procedure for therapy of obstructive apnea during sleep, with only slight secondary effects.

The prognostic assessment of the acute myocardial infarction may be obtained through clinical criteria, particularly in patients who are symptomatic during admission, or with several studies in patients without complications. The "effectiveness" of such investigations has been long studied, but not so their "efficiency", which analyses the relationships between costs and outcomes. The goal of the present study is to report the results of a cost-effectiveness analysis of various combinations of diagnostic tests.One hundred and fifteen patients (age65) with uncomplicated first acute myocardial infarction were evaluated. In all patients exercise test, two-dimensional echocardiogram thallium-201 scintigraphy, radionuclide ventriculography, Holter monitoring and cardiac catheterization were performed. The effectiveness was calculated as the "global value" (rate of correctly diagnosed patients: complications prediction during the first year follow-up) of every of such tests combinations. We have used the direct differential costs estimated following the "Colegio Oficial de Médicos de Barcelona" standards. The index used in the cost-effectiveness analysis was the medium cost person/global value. The lowest index corresponded to the most efficient test combination.The highest effectiveness was found for the exercise test plus bidimensional echocardiography combination (global value = 0.64). At the same time it was the less expensive combination (medium cost = 14.444 ptas); therefore, its index was the lowest (21.724 ptas/patient).In patients with a first uncomplicated myocardial infarction, the performance of exercise test and echocardiogram is the less costly and most effective combination of studies for one year prognosis. In these patients, routine cardiac catheterization does not improve the results.

The magnitude of the problem of nosocomial infection in children has never been studied in Spain.In 1990, a nationwide cross-sectional study was conducted to determine the prevalence of nosocomial infection and associated risk factors.Among 38,489 patients surveyed, 4081 were pediatric patients. Three hundred forty-five patients (8.4%) had active nosocomial infection at the time of the survey. Pediatric intensive care units (29.7%), hematology (23%), and special units (22%) showed the highest rates. Infections were most common in patients younger than 1 year (prevalence, 12.3%). Frequencies of nosocomial infection by site were as follows: bloodstream, 22.1%; urinary tract, 13.1%; lower respiratory tract, 12.3%; postoperative wound, 8%; gastrointestinal tract, 7.6%; skin, 6.5%; eye, 5.8%; and others 24.6%. The factors most closely associated with a higher prevalence of nosocomial infection in pediatrics were as follows: age younger than 1 year, surgery, moderate and severe baseline risk, number of diagnoses, and all categories of extrinsic risk factors. The most frequent etiologic agents were gram-positive bacteria (45.8%).Although the overall prevalence is at an acceptable level, future efforts should be focused on developing more effective prevention strategies in specific areas.

To determine the prevalence of Raynaud's phenomenon (RP) in Spain, we studied a working population of 988 men and 479 women. The overall prevalence of RP was 3.7%, with a 3.2% rate for men and 4.7% for women. There was a statistically significant association between Raynaud's phenomenon and a personal or familial history of perniosis, acrocyanosis or migraine among women. The age at onset was significantly lower in women. RP was classified as primary in 89% of the cases and as secondary in 11%. Examination by capillaroscopy revealed no significant differences between primary Raynaud cases and controls.