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Introduction: Pintomyia (Pifanomyia) longiflocosa is an endemic species from Colombia, found between the central and eastern Andes, and reported as one of the primary vectors of cutaneous leishmaniasis in coffee-growing zones of the country. This species is classified in the Townsendi series and can only be identified by the morphology of the male adults., Objective: To determine the potential use of the fourth larval stage of the vector Pi. longiflocosa in morphological taxonomy based on the description of its chaetotaxy., Materials and Methods: Pintomyia longiflocosa adults were captured in Campoalegre, Huila, and reared in the Entomology Laboratory at the Colombian Instituto Nacional de Salud. To identify the setae found in each corporal segment, 15 fourth-instar larvae were mounted on microscope slides using Canadian balm after being cleared with 10 % potassium hydroxide and saturated phenol. Additionally, five specimens were prepared for their observation by scanning electron microscopy., Results: Based on the description of Pi. longiflocosa, we established that all species of the subgenus Pifanomyia so far described have the same antennal morphology and clavate setae along their body. However, various setae present in Pi. longiflocosa are absent in Pi. youngi, suggesting differences among the larvae of the Townsendi series., Conclusions: These results support the potential importance of morphological characters from the fourth larval instar, such as antennal morphology and chaetotaxy, specifically in closely related species that are cryptic in their adult stages.

The main objective of the present study is to analyze the presence of cognitive impairment associated with alcohol consumption in patients with moderate or severe alcohol use disorder seeking outpatient treatment for their dependence. To do this, we compared a sample of 111 patients with active alcohol use disorder who initiated ambulatory treatment with 100 healthy controls. We compared sociodemographic and clinical variables associated with alcohol consumption, such as alcohol craving and impulsivity. A systematized battery of cognitive tests was also used in the comparison, which allowed the evaluation of the following functions: Attention, anterograde memory, processing speed, verbal fluency, executive function and implicit attitude towards alcoholic beverages. Compared with healthy controls, patients with moderate or severe alcohol use disorder performed significantly worse in all tests used, and therefore in all cognitive functions evaluated, but for two tests, the Iowa Gambling Test and the Implicit Association Test. The analysis through a correlation matrix of the patient group indicates that patients who report more impulsivity and more chronic alcohol abuse and with more addiction are those who suffer greater deterioration in their cognitive function. Cognitive damage associated with alcohol consumption was distributed heterogeneously among patients. The present study confirms the presence of cognitive deterioration associated with alcohol consumption in patients seeking outpatient treatment.

People with schizophrenia constitute a substantial part of the people who still smoke. Regarding cognitive performance, the self-medication hypothesis states that patients smoke to improve their cognitive deficits based on the stimulating effects of nicotine. The aim of this paper is to describe in detail the methodology used in the COGNICO study. A quasi-experimental, observational, prospective, multicenter study with follow-ups over 18 months was conducted in three cities in northern Spain (Oviedo, Ourense and Santiago de Compostela). A total of 81 outpatient smokers with schizophrenia were recruited with a mean age 43.35 years (SD = 8.83), 72.8% of them male. They were assigned to 3 groups: a) control group (smokers); b) patients who quit smoking using nicotine patches; c) patients who quit smoking with Varenicline. The MATRICS neuropsychological battery was applied as a primary measure. In addition, a comprehensive assessment of patients was performed, including the number of cigarettes per day, physical and psychological dependence on nicotine and CO expired. Clinical evaluation (PANSS, HDRS, CGI, C-SSRS), anthropometric measurements and vital signs assessment was also performed. The aim is to identify the relationship between the pattern of tobacco use and cognitive performance by comparing scores on the neuropsychological battery MATRICS during the follow-up periods (3, 6, 12 and 18months). The importance of this study lies in addressing a topical issue often ignored by clinicians: the unacceptably high rates of tobacco use in patients with severe mental disorders.

Introduction: In Colombia, periurban populations of Lutzomyia longipalpis , vector of the causative agent of visceral leishmaniasis in the upper and middle valley of the Magdalena River, may be exposed to insecticide applications with different purposes. Thus, it is important to begin a susceptibility surveillance of this species to insecticides., Objective: To determine indicators of susceptibility to three insecticides habitually used in public health, such as malathion, deltamethrin and lambda-cyhalothrin in an experimental strain of L. longipalpis ., Materials and Methods: We used the method proposed by the Centers for Disease Control and Prevention. Groups of 10 to 15 unfed females were exposed to different concentrations of the insecticides using 250 ml glass bottles as test chambers. Mortality was registered every five minutes for an hour. Diagnostic concentrations and lethal times for each insecticide were calculated., Results: In the evaluated L. longipalpis strain, the diagnostic concentrations and times were 75 µg/ml and 25 minutes for malathion, 10 µg/ml and 35 minutes for deltamethrin, and 15 µg/ml during 30 minutes for lambda-cyhalothrin., Conclusions: Baseline data over mortality response to three insecticides were established in a susceptibility strain of L. longipalpis vector. These indicators will allow establishing comparisons with populations of L. longipalpis exposed regularly or sporadically to chemical control measures to detect changes in their resistance to these insecticides.

Objective: To systematically assess the literature related to the occurrence of osteonecrosis of the jaw (ONJ) using bisphosphonates (BP) in the treatment of osteoporosis (OP)., Methods: We conducted a systematic literature search in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials up to July 2010, including terms relating to OP, ONJ, and BP (MeSH and free text). We selected meta-analysis, systematic reviews and clinical trials (CT), English or Spanish, including patients > 18 years of both sexes with OP treated with BF (intravenous and oral). Furthermore, studies should evaluate the occurrence of ONJ during treatment with BF. We excluded studies that included patients with cancer or diseases other than OP, animal studies and basic science. The selection of articles both by title and 2 independent reviewers conducted a detailed review of the abstracts. We used the modified Oxford Scale (version 2001) to assess the quality of the included studies., Results: We identified 1422 articles of which we included 18 (8 systematic reviews, 8 CT and 2 meta-analysis). Most studies were of good quality and examined the use of BF in middle-aged women with OP. Frequency of ONJ was low., Conclusions: We found insufficient evidence to affirm that intravenous or oral BF used exclusively for the treatment of OP lead to a significant risk of ONJ (evidence level 2a, grade B recommendation)., (Copyright © 2012 Elsevier España, S.L. All rights reserved.)

Background and Objective: Despite the beneficial effects of exercise training in chronic obstructive pulmonary disease (COPD) patients, several studies have revealed functional and biological abnormalities in their peripheral muscles. The objective was to determine whether exercise training of high intensity and long duration modifies oxidative stress levels and structure of respiratory and peripheral muscles of severe COPD patients, while also improving their exercise capacity and quality of life., Methods: Multicenter study (Warsaw and Barakaldo) in which 25 severe COPD out-patients were recruited from the COPD clinics. In all patients, lung and muscle functions, exercise capacity (walking test and cycloergometer) and quality of life (QoL) were assessed, and open muscle biopsies from the vastus lateralis and external intercostals (n=14) were obtained before and after an exercise training program of high intensity (respiratory rehabilitation area, 70% maximal tolerated load in a cycloergometer) and long duration (10 weeks). Oxidative stress and muscle structural modifications were evaluated in all muscle biopsies using immunoblotting and immunohistochemistry., Results: In all patients, after the training program, without any drop-outs, exercise capacity and QoL improved significantly, whereas oxidative stress, muscle damage and structure were not modified in their respiratory or limb muscles compared to baseline., Conclusions: In patients with severe COPD, exercise training of high intensity and long duration significantly improves their exercise capacity and QoL, without inducing significant modifications on oxidative stress levels or muscle structure in their respiratory or peripheral muscles. These results may have future clinical therapeutic implications., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Introduction: Culicoides pachymerus is a major pest species for the inhabitants of the western Boyacá province of Colombia., Objective: The effect of a repellent lotion based on p-menthane-3,8-diol (16%) and lemongrass oil (2%) was evaluated against the bites of C. pachymerus., Materials and Methods: The repellent lotion was compared simultaneously with a control (no treatment) by human landing catches of C. pachymerus on the forearms of paired volunteers situated near human dwellings. Protection percentage and protection time for 3 to 6 h after repellent application was calculated. The test was repeated ten times., Results: Only two females of C. pachymerus were collected on arms with the repellent treatment. In contrast, the mean biting rate in the untreated control was 47.7 midges/person/10 min. Mean protection percentage of the repellent was 100% up to 4 h and 99.5% up to 5 h. Protection time was 332.2 and 338.2 min in the two replicates where bites of C. pachymerus were confirmed. In the remaining eight replicates protection time exceeded the test duration., Conclusion: The repellent showed high efficacy against C. pachymerus, up to 5 h post-application.

Calcium and vitamin D supplements are one of the most widely used treatments in the field of bone metabolism and, especially due to its frequency, in the case of the osteoporosis. Sometimes the use of these treatments can be easily justified because there is plenty of evidence or because prescription is mandatory. But other times, not only because of the possibility of adverse events, the indication of these therapies is more controversial. Furthermore, and particularly in the context of osteoporosis, it may be suggested that prescribing calcium and vitamin D supplements to the general population may reduce the impact of disease., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Introduction: The interviewer-administered chronic respiratory questionnaire (CRQ-IA) is widely used and has demonstrated excellent properties for measuring health-related quality of life (HRQL) in patients with chronic obstructive pulmonary disease (COPD). However, the self-administered version (CRQ-SAS) in Spanish has not been validated. The aim of this trial was to evaluate the validity and the sensitivity of the Spanish version of the CRQ-SAS in patients with COPD., Material and Methods: We randomized 40 patients with COPD (33 treated with pulmonary rehabilitation and 7 with liquid oxygen therapy) to one of the two methods of administration of CRQ (SAS vs. IA) both before and 8 weeks after the treatment. In addition, patients completed the SF-36 questionnaire, pulmonary function tests, and six-minute walk test., Results: The CRQ-SAS demonstrated good longitudinal construct validity on all domains with a range of correlations, for the change scores, between 0.46 (P=.05) and 0.71 (P=.01). Regarding sensitivity to change, we observed a minimal clinically significant change in most domains (fatigue 0.71 [P=.02], emotional factor 0.62 [P=.04], control of the disease 0.83 [P=.06])., Conclusions: The Spanish version of CRQ-SAS is valid for evaluating HRQL in COPD patients. The correlations of the CRQ-SAS with other tools provide construct validity and show good sensitivity to change., (2010 SEPAR. Published by Elsevier Espana. All rights reserved.)

Objective: Due to the amount and quality variability regarding the use of biologic therapy (BT) in psoriatic arthritis (PsA) patients, the Spanish Society of Rheumatology (SER) has promoted the generation of recommendations based on the best evidence available. These recommendations should serve as reference to rheumatologists and those involved in the treatment of patients with PsA, who are using, or about to use BT., Methods: Recommendations were developed following a nominal group methodology and based on systematic reviews. The level of evidence and degree of recommendation was classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique., Results: We have produced recommendations for the use of TB currently available for PsA in our country. These recommendations include disease assessment, treatment objectives, therapeutic scheme and switching., Conclusions: We present an update on the SER recommendations for the use of BT in patients with PsA., (Copyright © 2010 Elsevier España, S.L. All rights reserved.)

Objective: Due to the amount and variability in quality regarding the use of biologic therapy (BT) in patients with spondyloarthritis (SpA), except for psoriatic arthritis (PsA) patients, the Spanish Society of Rheumatology has promoted the generation of recommendations based on the best evidence available. These recommendations should be a reference for rheumatologists and those involved in the treatment of patients with spondyloarthritis (SpA), except for psoriatic arthritis (PsA), who are using, or about to use BT., Methods: Recommendations were developed following a nominal group methodology and based on systematic reviews. The level of evidence and grade of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique., Results: We have produced recommendations on the use of BT currently available for SpA (but not PsA) in our country. These recommendations include disease assessment, treatment objectives, therapeutic scheme and switching., Conclusions: We present an update on the SER recommendations for the use of BT in patients with SpA, except for PsA., (Copyright © 2010 Elsevier España, S.L. All rights reserved.)

Background: The need for clinical practice guidelines for spondyloarthritis (SpA) comes from the complexity of its management and the great advances that both its treatment and its diagnosis have experiences, which come accompanied by a great variability in its management that exceeds what is considered acceptable. The objective of the ESPOGUIA is to reduce the variability in the management of SA, improving the quality of care through clinical recommendations adapted to their particular environment and based on the best available evidence., Methods: For the development of ESPOGUÍA the following methods have been employed: nominal group, systematic review and Delphi surveys. The expert panel is voluntary, with multiple disciplines participating and based on selection criteria. For the first time in a SER recommendation document, the opinion of the patient was included. In a meeting of the nominal group, the reach, objective, users, organization and needs of the systematic review were established. The elaboration of the guideline, along with its recommendations, was performed in parallel to the systematic reviews, with a meeting for agreement held afterward. The scoring of the degree of evidence and the level of the recommendation was established from the evidence levels proposed by the Oxford Center of Evidence-Based Medicine and the degree of agreement was obtained through a two-round Delphi exercise., Results: We have produced a clinical guideline that encompasses all of the SpA, although it has two sub-guidelines, one for ankylosing spondylitis and the other one for psoriatic arthritis. The target users are mainly rheumatologists, although other specialists and paramedical staff, such as nurses or patient associations, might benefit. Its content envelops all of the management aspects of SpA, from clinical suspicion to treatment, follow-up and day-to-day activities of the patient., Conclusions: ESPOGUIA can become a very useful instrument for the management of SA and an interactive reference., (Copyright © 2009 Elsevier España, S.L. All rights reserved.)

Objective: To provide a reference to rheumatologists and to those involved in the treatment of RA who are using, or about to use biologic therapy., Methods: Recommendations were developed following a nominal group methodology and based on systematic reviews. The level of evidence and grade of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique., Results: We have produced recommendations on the use of the seven biologic agents available for RA in our country. The objective of treatment is to achieve the remission of the disease as quickly as possible. Indications and nuances regarding the use of biologic therapy were reviewed as well as the evaluation that should be performed prior to administration and the follow up of patients undergoing this therapy., Conclusions: We present an update on the SER recommendations for the use of biologic therapy in patients with RA., (Copyright © 2009 Elsevier España, S.L. All rights reserved.)

Introduction: Although cases of leishmaniasis have been reported in the province of Guaviare, Colombia, no entomological studies were included to identify the Lutzomyia sand fly vector species in that area., Objective: Lutzomyia species were identified from four townships of Guaviare. Probable vectors were named based on those species involved in transmission in other areas., Materials and Methods: Sampling was undertaken with CDC light traps suspended at heights between 1.5 m and 9 m. Additional sand flies were collected with Shannon traps and by aspiration of adult flies from daytime resting sites., Results: Sand flies belonging to 37 different species were collected. 35 of them were recorded for the first time in Guaviare Province. Four species were new records for Colombia: Lutzomyia begonae, L. campbelli, L. sericea and L. nematoducta. The most abundant species were L. hirsuta 24.3% (148/610), L. yuilli 15.2% (93/610), L. davisi 10.3% (63/610), followed by L. fartigi, L. carrerai, L. antunesi, L. flaviscutellata and L. olmeca bicolor., Conclusion: Seven of these species of have been associated previously with endemic or epidemic transmission of leishmaniasis.

Introduction: Inhabitants in the western border of Boyacá province have reported high nuisance levels and dermatologic problems caused by the intensely irritating bites of the very small flies of the genus Culicoides., Objective: A survey was carried out to locate the affected area, identify the anthropophylic Culicoides species and estimate its abundance in Boyacá., Materials and Methods: Nuisance reports and clinical records of dermatologic cases associated with Culicoides bites were requested from health authorities in counties where nuisance reports had been received or which had geographical features apparently favorable for Culicoides infestations. An outdoors entomological survey using human landing catches was undertaken in areas reporting a pest problem., Results: Culicoides infestations were confirmed as a serious nuisance problem in the rural areas of nine counties located in the western foothills of the Eastern Range of the Colombian Andes. Although available epidemiological records were fragmented, it was established that in six counties 11.4% of the dermatitis cases (total=2,472 cases) reported between 2003 and 2005 were attributed to the Culicoides bites. The entomological survey identified Culicoides pachymerus as the dominant species, 99.3% of 3,389 caught females. Biting rates in the most intensely affected areas reach a geometric mean of 52 females/person per 5 minutes. Multivariate analysis indicated that abundance of C. pachymerus had a negative relationship with altitude., Conclusions: Based on its dominance and high biting rates, C. pachymerus is probably the species responsible for the high nuisance levels caused by Culicoides bites and the associated dermatological pathology, within the study area.

Introduction: Case records of leishmaniasis of the years 1997 to 2003 of the department of Boyaca showed that since the year 2000 the department experienced an unusual rise in the incidence of cutaneous leishmaniasis that might correspond to an epidemic outbreak in the western region of the department. Age and gender distribution of cases supported a domestic transmission., Objective: This research was designed to identify the vectors of cutaneous leishmaniasis in the municipalities of Otanche and Pauna through their presence in dwellings and their natural infection with the same species of Leishmania isolated from patients., Material and Methods: Sampling of sand flies was done with CDC traps in and around dwellings. Samples from patients and pooled females of the most abundant species of Lutzomyia were used to identify the parasite by PCR. Monoclonal antibody typing was also used to confirm the identification of the parasite in samples from patients., Results: In both municipalities L. trapidoi was the most abundant anthropophilic species of Lutzomyia indoors and around dwellings. L. hartmanni and L. yuilli were also abundant in Otanche, and L. gomezi and L. panamensis in Pauna. Leishmania (V) panamensis was identified both in patients and in the sand flies: L. yuilli, L. gomezi and L. panamensis.., Conclusion: Our findings prove the presence of infected vectors of Leishmania panamensis within dwellings in the towns of Otanche and Pauna in Western Boyacá. Since L. trapidoi was the most abundant species, it may be considered as the principal vector of Leishmania (V.) panamensis. The evidence of transmission within human dwellings warrants vector control at least in this environment.

Objectives: To analyse the emotional distress associated with ageing, and its prevalence among elderly people who suffer from heart disease., Design: Personal interviews with elderly people with and without heart problems., Setting: Interviews were conducted in public hospitals and old people's homes in the south of Galicia, Spain., Participants: The sample was made up of 130 elderly people (65 with heart problems and 65 without)., Main Measurements: The Inventory of Coping Strategies, of Halroyd and Reynolk (1984); Scheir, Caver, and Bridges Test (1984); the Life Satisfaction Scale of Diener, Emmuns, Larsen, and Griffen (1985); Rosenberg's Self-Esteem Scale (1965); and an instrument to measure Associated Symptoms (SCL-90; Derogatis, 1975)., Results: Elderly people with heart problems experienced greater anxiety and had lower self-esteem than those without such problems. Heart patients also tended to suffer more phobic anxiety and to retreat from social interaction more. With the passing of time, heart patients over 60 showed more anxiety, irritability and psychosomatic disorders., Conclusions: This study clearly shows the existence of emotional distress in elderly heart patients. This makes it particularly important to conduct risk-prevention programmes, since a lot of heart disease is brought on by unhealthy conduct.

Introduction: The applicability of the polymerase chain reaction (PCR) was evaluated for the detection and identification of parasites in sand fly vectors and thereby precluding the necessity of dissecting them. DNA was extracted from individual, laboratory infected sand flies, and subjected to PCR amplification using specific B1 and B2 primers for parasites of the Leishmania (Viannia) subgenus., Methodology: The sensitivity and specificity of the PCR primers were defined by means of serial dilutions of a Leishmania culture. Pooled samples of 1 to 5 sandflies were examined in association with the parasite dilutions to determine the point at which sensitivity became reduced. Experimentally infected sand flies were used to compare the sensitivity of the PCR with sand fly dissection and searching for flagellated parasites by microscopic examination., Results: As few as a single parasite was detected, and the sensitivity remained unaltered up to 3 female sand flies per pool. Detection rates were 33% for the traditional technique and 33.3% for PCR. The B1 and B2 primers were confirmed as specific for Leishmania (Viannia) parasites., Conclusion: The demonstrably high sensitivity and specificity of PCR warrant the use of PCR in assessing natural infection rates of Leishmania (Viannia) in field populations of sand fly vectors.

The Centers for Disease Control (CDC, USA) has proposed a simplified method for the determinations of insecticide resistance in adult mosquitoes, using 250 ml Wheaton bottles containing measured dosages. Insects are transferred into the bottle for 1 hour and monitored for mortality at regular intervals. In standardizing the CDC method for use with phlebotomine sand flies, effects of the solvent without insecticide were evaluated. Two colonized sand fly vector species were used: Lutzomyia longipalpis (F50 and F54) and Lutzomyia serrana (F17). Groups of 10 to 24 unfed females 1-3 days old were transferred for 1 h to Wheaton bottles with the following pretreatment: (1) without additive, (2) 0.5 ml of acetone, or (3) 1.0 ml of acetone. Three to 5 replicates were undertaken for each condition and each species. In the control bottles, the insects rested quietly and after 1 h appeared normal. In bottles with 0.5 and 1.0 ml acetone, a repellent effect was observed in L. longipalpis and L. serrana within the first 10 min. A small proportion of the L. serrana became prostrate, but recovered quickly after removal from the bottle. Field test performed with Lutzomyia quasitownsendi produced results simialar to those of the L. serrana colony flies. The insecticide bioassays were performed with L. longipalpis (F60) flies. Females were exposed to three graded doses of lambdacyhalothrin (10, 50 and 100 micrograms/bottle), and mortality was recorded at five-minute intervals. Regression lines for the 3 concentrations were compared within the context of the CDC method. The advantages of the CDC method over the WHO protocols were four: lower cost, fewer insects required, an entire group of insects exposed to the same surface, and ease of field use.

Ventricular assist devices have demonstrated their utility in patients with intractable cardiac failure, both as support until complete myocardial recovery and as a bridge to transplantation. Specific pediatric pneumatic paracorporeal systems can be applied even in infants. Long-term survival has been reported although experience is limited. We report the case of an 8-year-old boy with dilated cardiomyopathy awaiting cardiac transplantation. The patient developed profound cardiogenic shock with multiorgan failure while being evaluated for heart transplantation. He was given biventricular assistance with the MEDOS-HIA system (MEDOS-Helmholtz Institute). Maximum stroke volume ventricles of 25 and 22 ml were used, achieving a cardiac output of 2.2 l/min in both ventricles. The patient was supported with ventricular assistance for 9 days, but multiple organ failed to improve and transplantation became impossible. Progressive loss of peripheral circulatory resistance unresponsive to treatment developed and ventricular assistance was discontinued. The previous severe shock and advanced and progressive multiorgan failure could be responsible for the poor outcome of our patient despite maintenance of adequate cardiac output. Nevertheless, the use of ventricular assist devices is a real therapeutic alternative in children with severe cardiogenic shock, allowing them to recover completely or undergo heart transplantation. Patient selection, the choice of a system of appropriate size, and early implantation seem to be the cornerstones for obtaining good results.

The WHO method for determining insecticide resistance was standardized for several species of Lutzomyia sand flies under laboratory and field conditions. The biological assays were applied solely to optimize the conditions for the control, i.e., without insecticide, and to estimate mortality due to handling or other unfavorable conditions. Adult female flies from 3 laboratory colonies and one field strain were tested: two laboratory strains of Lutzomyia longipalpis, one laboratory strain of Lutzomyia serrana and one field-collected strain of Lutzomyia quasitownsendi. The WHO method was compared with one modified in which, during the post-exposure period, the recommended plain tube apparatus was replaced with a plastic container layered with damp plaster of Paris. Three paper substrate types were compared under each condition: olive oil additive, silicon oil additive and plain paper. The measured variable was percent mortality in 24 h. For the WHO protocol, the L. longipalpis strains indicated a 0-10% mortality, L. serrana 20-80% and L. quasitownsendi 10-50%. With the modified WHO apparatus, the average mortality was < 4% for all species. No significant differences were observed among the paper treatments. These results indicate a strong species-specific effect of post-exposure conditions on sand flies. To establish baseline levels of insecticide resistance in Lutzomyia sand flies, the WHO method is recommended only for L. longipalpis, and the modified method for L. serrana, L. quasitownsendi and closely related species.

We describe a case of a 10-year-old girl with myelomeningocele and type II Chiari malformation. She presented with an acute bulbar palsy requiring mechanical ventilation. Surgical decompression of the brainstem was performed and, because of a phrenic nerve palsy, surgical plication of the right diaphragm was also required. The patient s evolution was favourable. We discuss the various forms of clinical presentation of this pathology as well as its management. The importance of early diagnosis and surgical correction are also stressed as a key factor for favourable evolution.

Objective: The aim of this study was to analyze the postoperative progress and medical management in the Pediatric Intensive Care Unit (PICU) of patients that underwent bilateral lung transplant., Patients and Methods: From April 1997 to June 1998, 10 pediatric lung transplants were performed at the Hospital Reina Sofía (Córdoba, Spain). There were 4 males and 6 females (mean age 11.5 years, range 5 to 15 years). Indications for transplantation were cystic fibrosis (n = 9) and one pulmonary fibrosis secondary to viral infection. Before the transplant, two patients required mechanical ventilation for acute respiratory decompensation and one patient was ventilator-dependent. Immunosuppression consisted of corticosteroids, azathioprine and cyclosporine or tacrolimus. Post-transplantation management included early extubation, when possible, optimal fluid balance to prevent lung edema, low aggressive mechanical ventilation and adequate treatment of complications, such as rejection and infection., Results: There were no peri-operative mortalities. The mean stay in the PICU was 28 days (median: 17 days) and the mean time on mechanical ventilation was 19 days (median: 5.5 days). The most frequent complications were rejection (n = 8), hyperglycemia (n = 6), renal failure (n = 4), arterial hypertension (n = 4) and respiratory infections (n = 3). There were no airway complications., Conclusions: Even if the post-operative period in pediatric lung transplant patients is difficult, the results have been good with an important improvement in the quality of life of these patients has been achieved.

Objective: The purpose of this study was to analyze the etiology, evolution and predictive value of clinical variables and complementary explorations in children admitted to a PICU with hypoxic-ischemic coma., Patients and Methods: A retrospective review (1991-1996) of 24 children with hypoxic-ischemic coma admitted to the pediatric ICU of a reference hospital was performed. Clinical data on admission and results of complementary explorations (EEG and neuroimaging techniques) were collected and the findings compared according to the evolution and underlying pathophysiological mechanism., Results: Non-reactive and dilated pupils, existence of neurohypophyseal disorders and isoelectric EEGs were exclusively found in dead patients. A score of 3-4 on the Glasgow Coma Score was obtained more frequently in groups with the worse evolution (exitus and surviving with sequelae), as well as positive findings with neuroimaging techniques and the appearance of seizures, though without meaningful differences. More significant was the existence of associated problems, which was more frequent in groups with a negative evolution. The differences among the pathophysiological groups were not meaningful. Global mortality in the series studied was 41.6%, with 29.2% of the survivors having neurological sequelae and 29.2% being healthy., Conclusions: Hypoxic-ischemic coma in children has a high mortality and morbility. The prognosis for each patient is based on the clinical facts and complementary explorations. No isolated data allows the establishment of the final outcome with certainty.

After a long experience with transperitoneal laparoscopic surgery of the kidney, we have incorporated the Gaur balloon technique for dissection. We report our experience of 3 nephrectomy procedures performed via lumboscopy, with the patients lying in the lumbotomy position. A 12 mm skin incision is made in the axillary midline. Blunt dissection of the muscle planes is carried out and the retroperitoneal space is explored digitally. A 16 F balloon-tipped catheter is introduced and the balloon is distended with 720 ml saline solution. The catheter is removed and a Hasson trocar with optics and 3 accessory trocars are inserted. The kidney is dissected and the elements of the vascular pedicle are clipped or stapled independently. The kidney is fragmented inside a Lapsac and removed. In our view, this procedure is easier to perform and carries less morbidity than transperitoneal laparoscopic nephrectomy.

Based on the fact that the results obtained with extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy are uncertain in cases of complex lithiasis in horseshoe kidney, and counting on a wide laparoscopic experience as the most suitable solution in these cases, the authors present their initial experience in two cases of double lithiasis in right hemikidney. Approach was done through transperitoneal laparoscopy, after placement of a stent catheter and under the support of a radiological C-arc. After removal of the stones, the renal pelvis was closed with loose 4 zero reabsorbable suture with kots done intracorporeally. The post-operative had no complications with the exception of a transient leak of urine (5 days) that cause no further complications or subsequent sequelae. Monitoring at 6 months showed absence of residual lithiasis and good morphology and renal function of the sides operated.

The therapeutic indications for renal cysts, a pathology observed in more than 50% of subjects aged over fifty years, are currently limited to their symptomatic forms or those of uncertain diagnosis. The approach has changed from the unroofing procedure to percutaneous sclerotherapy and, thereafter, to percutaneous resection or endourological marsupialization to the urinary tract. Only a year ago, some isolated cases of laparoscopic treatment of renal cysts were reported. Our experience of 13 cases using this latter technique is described. The procedure is performed under general intravenous anesthesia (with intubation), using three or four laparoscopic ports (one of 11 mm and 5 mm for the rest), electric scissors, two grasping forceps and an aspiration/irrigation system. After opening the parietocolic space at the cyst level, a 4 cm window is dissected in the peritoneal tissue, on its wall. After punctioning and emptying the cyst, we explore it inside and dissect its free wall for complete excision. The early and late results (some cases have a follow-up of more than one year) are excellent. For this reason, we advocate the use of this procedure for symptomatic renal cysts over 8 cm in diameter that do not present an exclusively intrarenal development.

The results of a student screening program performed by the Primary Care Team of Gandía on 359 children (180 males and 179 females) that attended 1. EGB are presented. We reviewed the following: vision, hearing, dentition, somatometry, immunization, and urological and traumatological problems. Children with pathologies were referred to specialists to confirm the diagnosis. Of these children, 78% had some form of pathology. The most frequent system involved was hearing, followed by dentition and vision. The correlation of these results with those of the specialists was good (> 50%). The best results were obtained on vision screening results (100% correlation and 2/3 of the problems formerly detected). Twenty-four percent of the children had caries and this was not of major concern to the families. The worst results were obtained in auditive screening. Because the primary care examination model is not generalized, school screening is still a good method to detect previously undiagnosed pathologies in children.

Spurred by the development of laparoscopic lymphadenectomy and nephrectomy, laparoscopic surgery has gained acceptance in Urology, although not as rapidly as endourology. Laparoscopic access to the kidney is easier by the transperitoneal than by the retroperitoneal approach. Insertion of a trocar through the umbilicus for the optic and utilizing three to five accessory trocars is the standard practice. In some simple procedures two accessory trocars will suffice, four trocars and periumbilical trocar are required for nephrectomy, and an additional trocar is inserted in the hypogastrium for distal ureter release in nephroureterectomy. The procedure is performed using intravenous general anesthesia with endotracheal intubation and the patient is placed in the supine decubitus position with a 45 degrees lateral tilt or in the total lateral decubitus position (nephrectomy) with a slight anti-Trendelenburg. Exposure of the kidney is achieved by opening the posterior peritoneum along the line of Toldt and, in some cases, releasing the hepatic angle or the splenic colon. The kidney can be released partially or completely depending on the type of surgery. It is easier to perform an extended nephrectomy since dissection is performed better between the capsule of Gerota and the pararenal tissue. The renal vessels can be controlled with clips or an automatic stapling/cutting device. Laparoscopic access to the mid and upper ureter is very simple and the only difficulty encountered is in its correct identification. The current and future applications of laparoscopic renal surgery are discussed, including some original procedures that have been performed by the authors, such as in situ excision of a renal tumor and two pyelolithotomy procedures in solitary kidney.

19 cases of medical pericarditis admitted to the PICU from 1978 to 1989 were reviewed, to asses the diagnostic and therapeutical approach. The overall incidence is low, 0.32% of the patients admitted to the PICU in that time period. We have found neither tuberculous nor purulent pericarditis, with a 42% of idiopatic forms. Echocardiography was the best method for syndromic diagnosis. The ethiological diagnosis of pericarditis was made, in most cases, by means of non invasive methods or in association with the underlying disease. The cualitative analysis of the pericardial fluid was not useful for the ethiological diagnosis, therefore, we suggest pericardiocentesis should be performed mainly as a therapeutical tool. There were no correlation between the amount of fluid obtained on the first pericardiocentesis and the later incidence of the pericardial effusion. Biopsy brought no ethiological specificity in the cases it was performed.