Oscar Bielsa

Análisis de la tendencia en la letalidad, incidencia y mortalidad por infarto de miocardio en Girona entre 1990 y 1999

Introduccion y objetivos La incidencia por infarto de miocardio en Espana es baja y la mortalidad esta disminuyendo en las ultimas decadas. Hemos analizado las tendencies en las tasas de mortalidad, incidencia y ataque, y en la letalidad a 28 dias por infarto de miocardio entre 1990 y 1999 en la poblacion de 35 a 74 anos de Girona. Metodos Se incluyeron todos los casos de infarto de miocardio de Girona clasificados segun el algoritmo MONICA. Se calcularon las tasas de ataque, incidencia y mortalidad, y la letalidad, asi como el porcentaje de cambio annual en cada uno de los indicadores durante el periodo analizado. Resultados La tasa anual media de ataque fue de 258 (intervalo de confianza [IC] del 95%, 249-267) y 55 (IC del 95%, 51-59) por 100.000 habitantes para varones y mujeres, respectivamente, y la de mortalidad de 99 (IC del 95%, 93-104) por 100.000 en varones y de 25 (IC del 95%, 22-28) por 100.000 en mujeres. Las tasas de ataque, incidencia y recurrencia disminuyeron significativamente en varones de 35 a 64 anos durante el periodo 1990-1999, pero no en los de 65 a 74 anos ni en las mujeres. Conclusiones La incidencia y la mortalidad por IAM fueron bajas en la poblacion de 35 a 64 anos, y mejoraron en los varones de 35 a 64 anos durante el periodo 1990-1999, pero no en los de 65 a 74 anos, lo que indica que la combinacion de prevencion primaria y secundaria ha retrasado la edad de aparicion del infarto de miocardio o de las recurrencias. Las tasas en mujeres fueron inferiors y no cambiaron durante el periodo estudiado.

Influence of Comorbid Conditions on One-Year Outcomes in Non–ST-Segment Elevation Acute Coronary Syndrome

OBJECTIVE To investigate comorbid conditions with prognostic influence in non-ST-segment elevation acute coronary syndrome (NSTEACS). PATIENTS AND METHODS The study group consisted of a derivation cohort of 1017 patients (admitted from October 1, 2002, through October 1, 2008) and an external validation cohort of 652 patients (admitted from February 1, 2006, through September 30, 2009). Comorbid conditions, including risk factors and components of the Charlson comorbidity index (ChCI) and coronary artery disease-specific index, were recorded. The main outcome was one-year mortality. RESULTS During follow-up, 103 patients died. After adjusting for variables associated with NSTEACS characteristics (base model), 5 comorbid conditions predicted mortality: severe or mild renal failure (hazard ratio [HR], 2.9 and HR, 1.6, respectively), dementia (HR, 3.1), peripheral artery disease (HR, 2.0), previous heart failure (HR, 2.6), and previous myocardial infarction (HR, 1.4). A simple comorbidity index (SCI) was developed using these variables, (per point: HR, 1.6; 95% confidence interval, 1.4-1.8; P = .0001). Adding the SCI, Charlson comorbidity index, or coronary artery disease-specific index to the base model resulted in a gain of 6.58%, 5.00%, and 4.04%, respectively, in discriminative ability (P = .001), without significant differences among the 3 indices. In patients with comorbid conditions, the highest risk period was in the first weeks after NSTEACS. The strength of the association between SCI and mortality rate was similar in the external validation cohort (HR, 1.3; 95% confidence interval, 1.1-1.6; P = .001). CONCLUSION Renal dysfunction, dementia, peripheral artery disease, previous heart failure, and previous myocardial infarction are the comorbid conditions that predict mortality in NSTEACS. A simple index using these variables proved to be as accurate as the more complex comorbidity indices for risk stratification. In-hospital management of patients with comorbid conditions merits further investigation.

Massive renal infarction due to mucormycosis in an AIDS patient

SummaryIsolated renal infection byMucor spp. occurs very rarely, even in the immunocompromised host. The mortality of the different forms of mucormycosis reaches 75–100% in most series. Infection of the kidney is usually diagnosed post-mortem. Thus, when renal infection is recognized, aggressive treatment including surgery and amphotericin B is required. We present a case in which a massive left renal infarction was the unique manifestation of mucormycosis in an AIDS patient. Administration of amphotericin B and left nephrectomy were necessary to achieve satisfactory outcome.ZusammenfassungIsolierte Mucor-Infektionen der Niere sind auch bei abwehrgeschwächten Patienten eine Seltenheit. In den meisten Serien liegt die Letalität der verschiedenen Formen der Mucormykose bei 75 bis 100%. Meist wird die Infektion der Niere erst autoptisch diagnostiziert. Die Mucormykose der Niere erfordert eine aggressive Therapie mit Operation und Amphotericin B-Behandlung. Wir stellen einen AIDS-Kranken vor, bei dem sich die Mucormykose nur an der Niere manifestierte. Durch operative Entfernung der linken Niere und Behandlung mit Amphotericin B konnte ein zufriedenstellendes Ergebnis erzielt werden.

Effect of antibiotic treatment on serum PSA and percent free PSA levels in patients with biochemical criteria for prostate biopsy and previous lower urinary tract infections

BACKGROUND Controversy exists as to the influence of inflammatory foci on total and free prostate-specific antigen (PSA) concentrations. The objective was to analyze the biological variations of PSA and percent free PSA (%f-PSA) in patients with biochemical criteria for prostate biopsy (PSA higher than 4 ng/mL and normal rectal examination) and compare them with the variation induced by antibiotic treatment in a cohort of patients with a history of lower urinary tract infections and no clinical evidence of prostatitis. METHODS Ninety patients with a history of lower urinary tract infections, non-suspicious digital rectal examination and PSA between 4 and 20 ng/mL were analyzed. PSA concentration and %f-PSA were determined. Forty-five patients were treated with three weeks of ofloxacin, following which marker determination was repeated. All patients underwent ultrasound-controlled transrectal six-core prostate biopsy. RESULTS Sixty-seven patients presented benign prostatic hyperplasia (BPH) (30 with prostatitic foci) and 23 cancer. Significant variations in PSA (6.97 ng/mL vs. 5.82 ng/mL, p=0.001) and %f-PSA (14.84% vs. 17.53%, p=0.01) were found only in the treated patients. These differences were significant for patients with BPH-associated prostatitic foci and not for patients with BPH or cancer. The tendency was for PSA to decrease (15 treated patients with PSA <4 ng/mL vs. six non-treated patients) and for %f-PSA to increase. The median variation of %f-PSA was greater than that of PSA. When the cutoff for %f-PSA was set at 25%, 18.9% of unnecessary biopsies after the first determination and 20% after the second could be avoided. By associating the reduction in PSA, up to 46% could be avoided in treated patients. CONCLUSION Biochemical criteria for prostate biopsy may be modified in patients with a history of lower urinary tract infections due to variations greater than those explained by intraindividual biological variations, and may be influenced by the antibiotic treatment. These results suggest that subclinical inflammatory foci may influence PSA and %f-PSA.

Low-Grade Spindle Cell Carcinoma of the Kidney

The authors report a renal cell carcinoma composed largely of spindle cells of Fuhrmans nuclear grade II in which the bland appearance of the cells and low mitotic index were reminiscent of a benign or low-grade smooth muscle tumor. Keratin immunostaining was positive, but evidence of epithelial differentiation was obtained by electron microscopy. The tumor was an incidental finding and it did not invade the perirenal fat or the renal vein. Follow-up is only 24 months but the histological features suggest that the prognosis may be better than that of a classic sarcomatoid renal cell carcinoma.

Analysis of Trends in Myocardial Infarction Case-Fatality, Incidence, and Mortality Rates in Girona, Spain, 1990-1999

INTRODUCTION AND OBJECTIVES The incidence of myocardial infarction in Spain is low, and mortality has been decreasing over the last few decades. The objective of this study was to analyze trends in myocardial infarction mortality, incidence, attack rates, and 28-day case-fatality attack rates between 1990 and 1999 in the general population aged 35-74 years in Girona, Spain. METHODS The study included all myocardial infarction cases in Girona classified according to the MONICA algorithm. Attack, incidence, mortality rates and case-fatality were calculated. In addition, the annual percentage change in each of these indicators during the study period was also calculated. RESULTS The mean attack rate per 100,000 inhabitants was 258 (95% CI, 249-267) in men and 55 (95% CI, 51-59) in women. The mean mortality rate per 100,000 was 99 (95% CI, 93-104) in men and 25 (95% CI, 22-28) in women. Significant reductions in attack, incidence and recurrence rates were observed in men aged 35-64 years during the period 1990-1999, but not in men aged 65-74 years, nor in women. CONCLUSIONS Myocardial infarction incidence and mortality rates were low in the general population aged 35-64 years. Rates improved in men aged 35-64 years during the period 1990-1999, but not in those aged 65-74 years, which indicates that a combination of primary and secondary prevention has increased the age at which a myocardial infarction or its recurrence is observed. Rates in woman were lower and did not change during the study period.

Tratamiento de la fístula rectouretral tras prostatectomía radical mediante la exposición transesfinteriana posterior de York Mason

Resumen Introduccion La fistula rectouretral tras prostatectomia radical es una complicacion poco frecuente que ocurre en menos de un 2% de los casos. El objetivo es analizar nuestra experiencia en el tratamiento de la fistula rectouretral mediante la exposicion transesfinteriana posterior de York Mason. Pacientes y metodo Estudio retrospectivo. Se ha incluido a todos los pacientes intervenidos en nuestro hospital de fistula rectouretral tras prostatectomia radical. En todos los casos se realizo la tecnica de York Mason. Resultados Durante los ultimos 6 anos, 5 pacientes han precisado tratamiento quirurgico de fistula rectouretral tras prostatectomia radical. Los sintomas (fecaluria y/o emision de orina por ano) aparecieron entre el cuarto dia y las 7 semanas tras la intervencion, y la fistula fue confirmada mediante cistografia. En 3 pacientes se practico una colostomia sigmoidea derivativa en el momento del diagnostico, mientras que en los otros 2 el diagnostico fue tardio y se realizo la derivacion fecal mediante ileostomia en el momento de la reparacion de la fistula. La reparacion transesfinteriana posterior se realizo entre 5 y 10 meses despues del diagnostico. Dos pacientes presentaron infeccion de la herida que no afecto a la reconstruccion esfinteriana y otros 2 presentaron dehiscencia cutanea sin infeccion. Ninguno de los pacientes ha tenido recidiva tras un seguimiento medio de 22 (4-40) meses, y la continencia, una vez cerrados los estomas, es completa en todos los casos. Conclusiones La reparacion mediante la via de abordaje transesfinteriana posterior de York Mason proporciona excelentes resultados en el tratamiento de la fistula rectouretral.

Hypertension confirmation and blood pressure control rates in epidemiological surveys

Background Scarce knowledge about hypertension confirmation and control after a single blood pressure (BP) measurement is available. The objective of this study was to evaluate hypertension confirmation and control rates after 6-year follow-up in a population-based cohort. Methods A cohort of 1748 participants representative of a Spanish population received standardized BP measurements. Systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg was found in 617 participants. Three hundred and thirty-four of them had no history of hypertension and the remaining 283 had been previously diagnosed or received antihypertensive treatment. All were advised to consult their physicians. We discarded for follow-up 109 participants with already well-controlled hypertension (27.8% of all hypertensive participants). We followed 583 participants (94.5% of the cohort) for 6 years (14 died and 20 were lost to follow-up). Results The diagnosis of hypertension was confirmed during follow-up in 139 (44.4%) of those with no previously known hypertension, making the overall prevalence for the cohort equal to 30.4% (n = 531). The hypertension control rate at the end of follow-up was 50.1 %, whereas it was 27.9% at baseline. Diabetes was the only factor to be independently associated with good control of hypertension. Conclusion Six years after a single-occasion blood pressure measurement, hypertension was confirmed in almost half of the participants with systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg and no history of hypertension. Hypertension control achieved with this screening procedure is almost double that observed in the baseline examination, and is highest among diabetic participants.

A Longer Duration of Neo-Adjuvant Combined Androgen Blockade Prior to Radical Prostatectomy May Lead to Lower Tumour Volume of Localised Prostate Cancer

OBJECTIVES To analyse tumour volume (TV) in clinically localised prostate cancer patients treated with neo-adjuvant combined androgen blockade (CAB) therapy prior to radical prostatectomy. PATIENTS AND METHODS Two hundred consecutive patients treated between 1996 and 2000 were retrospectively analysed. Fifty patients underwent radical prostatectomy alone and 45 were treated with CAB for 1-3 months, 83 for 4-6 months and 22 for more than 6 months before surgery. Logistic regression analysis was performed to identify the strongest independent prognosticator of organ-confined disease. RESULTS No evidence of residual cancer was found in 11 specimens (5.6%). Regarding TV, 20 specimens showed less than 0.1cc, 33 between 0.1 and 0.49cc and 86 more than 0.5cc. Smaller TV was found in CAB-treated patients. Significant correlation was observed between treatment duration and TV. In logistic regression analysis, only CAB duration and TV were significantly correlated with organ-confined disease. CONCLUSIONS Prominent regressive features and lower TV were found after neo-adjuvant CAB. It seems that more prolonged treatment may lead to greater tumoural regression. Only tumour burden and length of CAB therapy were independent variables significantly correlated with pathologically localised prostate cancer.

Hemiscrotectomy With Contralateral Testicular Transposition for Scrotal Cancer

PURPOSE Wide excision of scrotal tumors results in serious defects to such an extent that in some cases the contents of the scrotum cannot be preserved. We describe a hemiscrotectomy technique with transposition of the testis to the contralateral hemiscrotum that facilitates closure of the surgical wound and allows preservation of the testis. MATERIALS AND METHODS Our procedure was used in 3 patients with scrotal neoplasia, including 2 with squamous cell carcinoma and 1 with extramammary Pagets disease. After excision of the hemiscrotum affected by the tumor, which includes all layers of the scrotal wall, the testis is transposed into the contralateral hemiscrotum through a slit made in the medial scrotal septum. The defect is easily closed by apposing the surgical wound edges. RESULTS The 3 men were disease-free 8, 7 and 4 years after surgery, respectively. After intervention they remained pain-free. None had hydrocele or epididymitis secondary to placement of the 2 testes in the same hemiscrotum. CONCLUSIONS In appropriate candidates this technique allows the scrotal defect to be easily reconstructed after tumor excision without any need for skin flaps or free skin grafts. The procedure makes it possible to preserve the scrotal content and perform more radical treatment since the scrotal wall is completely excised.