Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

Clinical features and prognosis of malignant small bowel tumors: experience from a university hospital in Chile

BACKGROUND

Small bowel tumors (SBT) are infrequent and represent a small proportion of digestive neoplasms. There is scarce information about SBT in Latin America.

AIM

To describe the epidemiology, clinical characteristics, diagnostic methods, and survival of malignant SBTs.

METHODS

Retrospective observational study of adult patients with histopathological diagnosis of SBT between 2007-2021 in a university hospital in Chile.

RESULTS

A total of 104 patients [51.9% men; mean age 57 years] with SBT. Histological type: neuroendocrine tumor (NET) (43.7%, n=38), gastrointestinal stromal tumors (GIST) (21.8%, n=19), lymphoma (17.2%, n=15) and adenocarcinoma (AC) (11.5%, n=10). GIST was more frequent in duodenum (50%; n=12) and NET in the ileum (65.8%; n=25). Metastasis was observed in 17 cases, most commonly from colon and melanoma. Nausea and vomiting were significantly more often observed in AC (p=0.035), as well as gastrointestinal bleeding in GIST (p=0.007). The most common diagnostic tools were CT and CT enteroclysis with an elevated diagnostic yield (86% and 94% respectively). The 5-year survival of GIST, NET, lymphoma and AC were 94.7% (95%CI: 68.1-99.2), 82.2% (95%CI: 57.6-93.3), 40.0% (95%CI: 16.5-82.8) and 25.9% (95%CI: 4.5-55.7%), respectively. NET (HR 6.1; 95%CI:2.1-17.2) and GIST (HR 24.4; 95%CI:3.0-19.8) were independently associated with higher survival compared to AC, adjusted for age and sex.

CONCLUSIONS

Malignant SBT are rare conditions and NETs are the most common histological subtype. Clinical presentation at diagnosis, location or complications may suggest a more probable diagnosis. GIST and NET are associated with better survival compared to other malignant subtypes.

The Clinical Impact and Cost-Effectiveness of Surveillance of Incidentally Detected Gastric Intestinal Metaplasia: A Microsimulation Analysis

BACKGROUND & AIMS

Gastric intestinal metaplasia (GIM) is associated with a higher risk of noncardia intestinal gastric adenocarcinoma (GA). The aim of this study was to estimate lifetime benefits, complications, and cost-effectiveness of GIM surveillance using esophagogastroduodenoscopy (EGD).

METHODS

We developed a semi-Markov microsimulation model of patients with incidentally detected GIM, to compare the effectiveness of EGD surveillance with no surveillance at 10-year, 5-year, 3-year, 2-year, and 1-year intervals. We modeled a simulated cohort of 1,000,000 US individuals aged 50 with incidental GIM. Outcome measures were lifetime GA incidence, mortality, number of EGDs, complications, undiscounted life-years gained, and incremental cost-effectiveness ratio with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY).

RESULTS

In the absence of surveillance, the model simulated 32.0 lifetime GA cases and 23.0 lifetime GA deaths per 1000 individuals with GIM, respectively. Among surveilled individuals, simulated lifetime GA incidence (per 1000) decreased with shorter surveillance intervals (10-year to 1-year, 11.2-6.1) as did GA mortality (7.4-3.6). Compared with no surveillance, all modeled surveillance intervals yielded greater life expectancy (87-190 undiscounted life-years gained per 1000); 5-year surveillance provided the greatest number of life-years gained per EGD performed and was the cost-effective strategy ($40,706/QALY). In individuals with risk factors of family history of GA or anatomically extensive, incomplete-type GIM intensified 3-year surveillance was cost-effective (incremental cost-effectiveness ratio $28,156/QALY and $87,020/QALY, respectively).

CONCLUSIONS

Using microsimulation modeling, surveillance of incidentally detected GIM every 5 years is associated with reduced GA incidence/mortality and is cost-effective from a health care sector perspective. Real-world studies evaluating the impact of GIM surveillance on GA incidence and mortality in the United States are needed.

Telemedicine in the management of patients with headache: current situation and recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations.

METHOD

The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain.

RESULTS

COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools.

CONCLUSIONS

The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.

Implementation of the updated Sydney system biopsy protocol improves the diagnostic yield of gastric preneoplastic conditions: Results from a real-world study

BACKGROUND

The updated Sydney system biopsy protocol (USSBP) standardizes the sampling of gastric biopsies for the detection of preneoplastic conditions (e.g., gastric intestinal metaplasia [GIM]), but the real-world diagnostic yield is not well-described.

AIM

To determine whether regular application of USSBP is associated with higher detection of chronic atrophic gastritis (CAG), GIM and autoimmune gastritis (AIG).

METHODS

We performed a real-world retrospective study at an academic urban tertiary hospital in Chile. We manually reviewed medical records from consecutive patients undergoing esophagogastroduodenoscopy (EGD) from January to December 2017. Seven endoscopists who performed EGDs were categorized into two groups (USSBP 'regular' and USSBP 'infrequent') based on USSBP adherence, using minimum 20% adherence as the prespecified threshold. Multivariable logistic regression models were used to estimate the odds ratios (aOR) and 95% confidence intervals (CI) for the association between endoscopist groups and the likelihood of diagnosing CAG, GIM or AIG.

RESULTS

1206 patients were included in the study (mean age: 58.5; 65.3% female). The USSBP regular group demonstrated a higher likelihood of detecting CAG (20% vs. 5.3%; aOR 4.03, 95%CI: 2.69-6.03), GIM (12.2% vs. 3.4%; aOR 3.91, 95%CI: 2.39-6.42) and AIG (2.9% vs. 0.8%; aOR 6.52, 95%CI: 1.87-22.74) compared to infrequent group. Detection of advanced-stage CAG (Operative Link for Gastritis Assessment stage III/IV) was significantly higher in the USSBP regular vs. infrequent group (aOR 5.84, 95%CI: 2.23-15.31).

CONCLUSIONS

Routine adherence to USSBP increases the detection rates of preneoplastic conditions, including CAG, GIM and AIG. Standardized implementation of USSBP should be considered in high gastric cancer risk populations.

Diagnosis and treatment of trigeminal neuralgia: consensus statement from the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Trigeminal neuralgia (TN) is a chronic neuropathic pain disorder affecting one or more branches of the trigeminal nerve. Despite its relatively low global prevalence, TN is an important healthcare problem both in neurology departments and in emergency departments due to the difficulty of diagnosing and treating the condition and its significant impact on patients' quality of life. For all these reasons, the Spanish Society of Neurology's Headache Study Group has developed a consensus statement on the management of TN.

DEVELOPMENT

This document was drafted by a panel of neurologists specialising in headache, who used the terminology of the International Headache Society. We analysed the published scientific evidence on the diagnosis and treatment of TN and establish practical recommendations with levels of evidence.

CONCLUSIONS

The diagnosis of TN is based on clinical criteria. Pain attributed to a lesion or disease of the trigeminal nerve is divided into TN and painful trigeminal neuropathy, according to the International Classification of Headache Disorders, third edition. TN is further subclassified into classical, secondary, or idiopathic, according to aetiology. Brain MRI is recommended in patients with clinical diagnosis of TN, in order to rule out secondary causes. In MRI studies to detect neurovascular compression, FIESTA, DRIVE, or CISS sequences are recommended. Pharmacological treatment is the initial choice in all patients. In selected cases with drug-resistant pain or poor tolerance, surgery should be considered. [[es]]Resumen INTRODUCCIóN: la neuralgia del trigémino (NT) es un tipo de dolor neuropático que afecta a una o más ramas del nervio trigémino. Aunque su prevalencia poblacional es relativamente baja, la NT supone un problema muy importante tanto en las consultas de neurología como en las urgencias por la dificultad para el diagnóstico y tratamiento y el elevado impacto sobre la calidad de vida de las personas que la padecen. Por estos motivos, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología ha elaborado un documento de consenso sobre el manejo de esta patología. DESARROLLO: este documento ha sido redactado por un comité de expertos utilizando la nomenclatura de la clasificación de la International Headache Society (IHS), analizando la evidencia científica publicada sobre diagnóstico y tratamiento y estableciendo unas recomendaciones prácticas con niveles de evidencia.

CONCLUSIONES

El diagnóstico de la NT es clínico. La International Classification of Headache Disorders en su tercera edición (ICHD-3) clasifica el dolor atribuible a una lesión o enfermedad del nervio trigémino en NT y neuropatía trigeminal dolorosa. A su vez la NT puede dividirse en tres tipos principales según la etiología del dolor: clásica, idiopática y secundaria. Es recomendable la realización de una resonancia magnética (RM) craneal a todo paciente con diagnóstico clínico de NT para descartar causas secundarias. Para estudiar la presencia de una compresión neurovascular con RM se recomienda la aplicación de los protocolos de imagen FIESTA, DRIVE o CISS. El tratamiento inicialmente será farmacológico y en pacientes seleccionados con respuesta insuficiente o mala tolerancia a fármacos se debe valorar el tratamiento quirúrgico.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment

INTRODUCTION

It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity.

DEVELOPMENT

The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics.

CONCLUSIONS

The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment

INTRODUCTION

It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity.

DEVELOPMENT

The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics.

CONCLUSIONS

The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

Telemedicine in the management of patients with headache: current situation and recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations.

METHOD

The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain.

RESULTS

COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools.

CONCLUSIONS

The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.

Standard headache and neuralgia treatments and SARS-CoV-2: opinion of the Spanish Society of Neurology’s Headache Study Group

Introduction

In recent months, doubts have arisen among patients, general practitioners, and neurologists as to whether some drugs commonly used in patients with headaches and neuralgia may favour or complicate the disease caused by SARS-CoV-2.

Material and methods

We collected information on the opinions of scientific societies and medicines agencies (American, European, and Spanish) to clarify doubts regarding the use of drugs such as lisinopril, candesartan, ibuprofen, corticosteroids, carbamazepine, and monoclonal antibodies targeting the calcitonin gene–related peptide in the context of the COVID-19 pandemic.

Results

We make recommendations about the use of standard headache treatments in the context of the COVID-19 pandemic, based on the current scientific evidence.

Conclusions

At present, there is no robust scientific argument to formally contraindicate any of the standard treatments employed for headaches and neuralgias.

[Standard headache and neuralgia treatments and SARS-CoV-2: opinion of the Spanish Society of Neurology's Headache Study Group]

Introduction

In recent months, doubts have arisen among patients, general practitioners, and neurologists as to whether some drugs commonly used in patients with headaches and neuralgia may favour or complicate the disease caused by SARS-CoV-2.

Material and methods

We collected information on the opinions of scientific societies and medicines agencies (American, European, and Spanish) to clarify doubts regarding the use of drugs such as lisinopril, candesartan, ibuprofen, corticosteroids, carbamazepine, and monoclonal antibodies targeting the calcitonin gene-related peptide in the context of the COVID-19 pandemic.

Results

We make recommendations about the use of standard headache treatments in the context of the COVID-19 pandemic, based on the current scientific evidence.

Conclusions

At present, there is no robust scientific argument to formally contraindicate any of the standard treatments employed for headaches and neuralgias.

Neuromodulation in headache and craniofacial neuralgia: guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery

INTRODUCTION

Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions.

METHODS

Neurologists from the Spanish Society of Neurology's (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia.

RESULTS

We present an updated review and establish the first set of consensus recommendations of the SEN and SENC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition.

CONCLUSIONS

Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality.

Impact of the COVID-19 pandemic on headache management in Spain: an analysis of the current situation and future perspectives

Introduction

The COVID-19 pandemic has had a great impact on healthcare systems. Spain, where headache is the main reason for outpatient neurology consultation, is one of the countries with the most reported cases of the disease.

Objectives

This study aimed to analyse the impact of the COVID-19 pandemic on headache units in Spain and to evaluate how neurologists see the future of these units.

Methods

We conducted a cross-sectional online survey of headache units during the sixth week of the state of alarm declared in Spain in response to the pandemic.

Results

The response rate was 74%, with the participation of centres with different characteristics and from all Autonomous Communities of Spain. Limitations in face-to-face activity were reported by 95.8% of centres, with preferential face-to-face consultation being maintained in 60.4%, and urgent procedures in 45.8%. In 91.7% of centres, the cancelled face-to-face activity was replaced by telephone consultation. 95.8% of respondents stated that they would use personal protection equipment in the future, and 86% intended to increase the use of telemedicine. The majority foresaw an increase in waiting lists (93.8% for initial consultations, 89.6% for follow-up, and 89.4% for procedures) and a worse clinical situation for patients, but only 15% believed that their healthcare structures would be negatively affected in the future.

Conclusions

As a consequence of the pandemic, headache care and research activity has reduced considerably. This demonstrates the need for an increase in the availability of telemedicine in our centres in the near future.

[Educational impact after 10 years of implementation of a portfolio for undergraduate medical students]

BACKGROUND

A portfolio is a compilation of academic work that demonstrates student's knowledge, reflection and critical thinking.

AIM

To describe the development and implementation of an undergraduate portfolio in the School of Medicine at the Pontificia Universidad Católica de Chile, its temporal evolution and its educational impact after 10 years of experience.

MATERIAL AND METHODS

The development and implementation of a portfolio for 4th-year undergraduate medical student was analyzed. Its design, teaching and learning methodologies, results and perceptions of students and teachers were assessed. The educational impact was measured using Kirkpatrick's levels.

RESULTS

A total of 1,320 students participated between 2007 and 2017, supported by six teachers and 190 assistant-students. The portfolio included clinical cases, narrative medicine, palliative care and evidence-based medicine (EBM). The overall student's perception was positive, highlighting the development of critical analysis, clinical reasoning and professionalism. The delivery of feedback and learning assessment, allowed students to obtain excellent grades. There were only two cases of plagiarism reported. Fifteen EBM articles and two books with 52 narrative medicine essays were published. The greatest organizational impact of this teaching innovation, was that it evolved to become an established and continuous assessment instrument in 10 consecutive years.

CONCLUSIONS

This portfolio is a project with a high educational impact, with a favorable perception by students and tutors, excellent results related to grades, stimulating both scientific writing and reflective practice.

Autoimmune Diseases and Gastric Cancer Risk: A Systematic Review and Meta-Analysis

Purpose

Autoimmunity is an alternative etiology of gastric inflammation, the initiating event in the gastric carcinogenic cascade. This mechanism may be an increasingly important cause of gastric cancer with the waning prevalence of its primary etiologic factor, chronic Helicobacter pylori infection.

Materials and Methods

PubMed and EMBASE were searched up to September 2018. Autoimmunity and 96 specific manifestations were considered for associations with gastric cancer risk. Random effects analysis was used to calculate pooled relative risk estimates (RR) and 95% confidence intervals (CI).

Results

We found a total of 52 observational studies representing 30 different autoimmune diseases. Overall, the presence of an autoimmune condition was associated with a gastric cancer pooled RR of 1.37 (95% CI, 1.24 to 1.52). Among the 24 autoimmune conditions with two or more independent reports, nine were significantly associated with increased gastric cancer risk: dermatomyositis (RR, 3.69; 95% CI, 1.74 to 7.79), pernicious anemia (RR, 2.84; 95% CI, 2.30 to 3.50), Addison disease (RR, 2.11; 95% CI, 1.26 to 3.53), dermatitis herpetiformis (RR, 1.74; 95% CI, 1.02 to 2.97; n=3), IgG4-related disease (RR, 1.69; 95% CI, 1.00 to 2.87), primary biliary cirrhosis (RR, 1.64; 95% CI, 1.13 to 2.37), diabetes mellitus type 1 (RR, 1.41; 95% CI, 1.20 to 1.67), systemic lupus erythematosus (RR, 1.37; 95% CI, 1.01 to 1.84), and Graves disease (RR, 1.27; 95% CI, 1.06 to 1.52).

Conclusion

Our analysis documents the wide range of autoimmune diseases associated with gastric cancer. These associations may reflect unreported links between these conditions and autoimmune gastritis. Further studies are warranted to investigate potential causal mechanisms.

OnabotulinumtoxinA in chronic migraine: predictors of response. A prospective multicentre descriptive study

BACKGROUND AND PURPOSE

OnabotulinumtoxinA is a treatment specifically approved for the prophylaxis of chronic migraine in adults. The aim of this study was to assess the effectiveness of OnabotulinumtoxinA in chronic migraine after 1 year of treatment in a real-life setting and to identify clinical predictors of outcome.

METHODS

We designed a prospective multicentre study performed in 13 hospitals in Spain. Patients underwent a complete medical history and examination. They were treated with OnabotulinumtoxinA every 12 weeks for 1 year. Data about outcome, adverse events, abortive medication use, emergency room use and disability were collected at 3 and 12 months.

RESULTS

A total of 725 subjects completed the study. At 12 months, 79.3% showed >50% reduction in number of headaches per month and 94.9% reported no adverse events. Unilaterality of pain, fewer days of disability per month and milder headache at baseline were correlated with good outcome. Duration of disease <12 months increased the chances of response to treatment with OnabotulinumtoxinA (odds ratio, 1.470; 95% confidence interval, 1.123-2.174; P = 0.045).

CONCLUSIONS

This study confirmed the effectiveness of treatment with OnabotulinumtoxinA after 1 year of treatment. The chances of a good outcome may be increased by starting treatment in the first 12 months after chronic migraine diagnosis.

Early pregnancy thyroid hormone reference ranges in Chilean women: the influence of body mass index

OBJECTIVE

Thyroid dysfunction and obesity during pregnancy have been associated with negative neonatal and obstetric outcomes. Thyroid hormone reference ranges have not been established for the pregnant Hispanic population. This study defines thyroid hormone reference ranges during early pregnancy in Chilean women and evaluates associations of body mass index (BMI) with thyroid function.

DESIGN, PATIENTS, MEASUREMENTS

This is a prospective observational study of 720 healthy Chilean women attending their first prenatal consultation at an outpatient clinic. Thyroid function [TSH, Free T4, Total T4 and antithyroid peroxidase antibodies (TPOAb)] and BMI were assessed at 8·8 ± 2·4 weeks of gestational age.

RESULTS

Median, 2·5th percentile (p2·5), and 97·5th percentile (p97·5) TSH values were higher, while median, p2·5, and p97·5 free T4 values were lower in obese patients compared with normal weight patients. Obesity was associated with a median TSH 16% higher (P = 0·035) and a median free T4 6·5% lower (P < 0·01) than values from patients with normal weight. BMI had a small, but statistically significant effect on TSH (P = 0·04) and free T4 (P < 0·01) when adjusted by maternal age, TPO antibodies, parity, sex of the newborn, gestational age and smoking. In all TPOAb (-) patients, median (p2·5-p.97·5) TSH was 1·96 mIU/l (0·11-5·96 mIU/l) and median (p2·5-p.97·5) free T4 was 14·54 pmol/l (11·1 - 19·02 pmol/l). Applying these reference limits, we found a prevalence of overt and subclinical hypothyroidism of 0·9% and 3·05% respectively.

CONCLUSIONS

TSH distributes at higher values and free T4 at lower values in obese pregnant women compared to normal weight pregnant women. Thyroid hormone reference ranges derived from Chilean patients with negative TPOAb are different from the fixed internationally proposed reference ranges and may be used in the Hispanic population.

[Development of MEDUC-PG14 survey to assess postgraduate teaching in medical specialties]

BACKGROUND

Feedback is one of the most important tools to improve teaching in medical education.

AIM

To develop an instrument to assess the performance of clinical postgraduate teachers in medical specialties.

MATERIAL AND METHODS

A qualitative methodology consisting in interviews and focus-groups followed by a quantitative methodology to generate consensus, was employed. After generating the instrument, psychometric tests were performed to assess the construct validity (factor analysis) and reliability (Cronbach’s alpha).

RESULTS

Experts in medical education, teachers and residents of a medical school participated in interviews and focus groups. With this information, 26 categories (79 items) were proposed and reduced to 14 items (Likert scale 1-5) by an expert’s Delphi panel, generating the MEDUC-PG14 survey, which was answered by 123 residents from different programs of medical specialties. Construct validity was carried out. Factor analysis showed three domains: Teaching and evaluation, respectful behavior towards patients and health care team, and providing feedback. The global score was 4.46 ± 0.94 (89% of the maximum). One teachers’ strength, as evaluated by their residents was “respectful behavior” with 4.85 ± 0.42 (97% of the maximum). “Providing feedback” obtained 4.09 ± 1.0 points (81.8% of the maximum). MEDUC-PG14 survey had a Cronbach’s alpha coefficient of 0.947.

CONCLUSIONS

MEDUC-PG14 survey is a useful and reliable guide for teacher evaluation in medical specialty programs. Also provides feedback to improve educational skills of postgraduate clinical teachers.

Prevalence of lactose intolerance in Chile: a double-blind placebo study

BACKGROUND AND STUDY AIMS

Lactase non-persistence (LNP), or primary hypolactasia, is a genetic condition that mediates lactose malabsorption and can cause lactose intolerance. Here we report the prevalence of lactose intolerance in a double-blind placebo study.

METHODS

The LCT C>T-13910 variant was genotyped by RT-PCR in 121 volunteers and lactose malabsorption was assessed using the hydrogen breath test (HBT) after consuming 25 g of lactose. Lactose intolerance was assessed by scoring symptoms (SS) using a standardized questionnaire following challenge with a lactose solution or saccharose placebo.

RESULTS

The LNP genotype was observed in 57% of the volunteers, among whom 87% were HBT⁺. In the HBT⁺ group the median SS was 9 and in the HBT⁻ group the median SS was 3 (p < 0.001). No difference was observed in the SS when both groups were challenged with the placebo. The most common symptoms included audible bowel sounds, abdominal pain and meteorism. In the ROC curve analysis, an SS ≥ 6 demonstrated 72% sensitivity and 81% specificity for predicting a positive HBT. To estimate prevalence, lactose intolerance was defined as the presence of an SS ≥ 6 points after subtracting the placebo effect and 34% of the study population met this definition.

CONCLUSIONS

The LNP genotype was present in more than half of subjects evaluated and the observed prevalence of lactose intolerance was 34%.

Orthodontic treatment timing in growing patients

AIM

The aim of the study is to estimate the orthodontic treatment timing for the main occlusal problems in growing patients.

STUDY DESIGN

a cross-sectional study was carried out in Italian primary and secondary schools from 2008 to 2011; 1375 males and 1642 females, aged between 8 and 13 years, were visited. The sample is divided into two main groups: primary school and secondary school. Selected malocclusion signs were registered according to an occlusal index (ROMA index) by trained and calibrated operators. Prevalence of increased overjet, Class III malocclusion, crossbite, deep bite and open bite observed in each group are compared. A significant decrease of prevalence with age is considered a sign of spontaneous improvement of the malocclusion.

RESULTS

Descriptive analyses were performed using frequencies, percentages and chi-square tests to evaluate differences for categorical variables. The level of significance was set at p ≤0.05. Data were analysed with the software SPSS 19.0 for Windows. Class III malocclusion, moderate or severe crossbite and severe increased overjet and overbite seem not to improve spontaneously.

CONCLUSION

Early treatment of orthodontic problems that do not improve with age may be helpful to avoid worsening of the condition in permanent dentition. Moderate Class II malocclusion and crossbite treatment can be postponed.

Early low-dose hydrocortisone in very preterm infants: a randomized, placebo-controlled trial

BACKGROUND

Several reports indicate a decreased cortisol response to adrenocorticotropic hormone in preterm infants developing chronic lung disease and in preterm infants with refractory hypotension. Low-dose hydrocortisone (HC) may allow for beneficial effects.

OBJECTIVE

Our aim was to assess whether HC is able to increase survival without chronic lung disease.

METHODS

We performed a double-blind, randomized, placebo-controlled trial. Fifty mechanically ventilated infants (birth weight: 500-1,249 g) were randomized to receive treatment (HC 0.5 mg/kg/12 h for 9 days, then HC 0.5 mg/kg/24 h for 3 days) or placebo. Major outcome was survival without oxygen dependence at 36 weeks of postconceptional age (O(2)-free survival).

RESULTS

The basic characteristics were similar between the two groups. O(2)-free survival was higher in the HC group (64 vs. 32%). The advantage was particularly evident among infants without antenatal steroids. The mortality rate was 16% in the HC group versus 40% in the control group (difference not significant). Hypotension after recruitment was reduced by HC (0 vs. 30%). The incidence of gastrointestinal perforation and other adverse effects was similar between the two groups.

CONCLUSIONS

HC prophylaxis improved O(2)-free survival and early cardiocirculatory function in our population, without important short-term effects. The neurodevelopmental outcome will be assessed at 2 years.

Aortic valve replacement with bioprostheses in liver transplant recipients

Three cases of aortic valve replacement with porcine bioprostheses are reported in liver transplant recipients at two to six years after transplantation. Indications for aortic valve replacement (AVR) were aortic stenosis (n = 2) and aortic regurgitation (n = 1). The use of bioprostheses was recommended because of patient age, the need for multiple liver biopsies, and contraindication to the use of anticoagulation therapy. The patient who underwent AVR because of aortic regurgitation developed structural valve deterioration (SVD) during the next five years after surgery, and thus replacement of the bioprosthetic valve was required. Recipients of liver transplant who undergo valve replacement with tissue valves should be carefully followed up because of the risk of early SVD. AVR may be performed safely after liver transplantation.

[Severe hepatotoxicity caused by amiodarone: description of a case]

Amiodarone is useful for the treatment of ventricular and supraventricular arrhythmias, but it has been associated with several adverse effects. Amiodarone-induced hepatotoxicity is a frequent complication and often consist in a mild and asymptomatic elevation of liver function tests, although severe cases have been described. A case of severe amiodarone-induced hepatotoxicity slowly resolving after discontinuation of the drug and in which liver biopsy was crucial for diagnosis is reported. Although there are no pathognomonic histopathological findings, phospholipidosis is the morphologic hallmark of amiodarone hepatotoxicity.

[Chlamydia pneumoniae pneumonia]

Chlamydia pneumoniae causes respiratory tract infections, and it is transmitted by air and fomites. It is probably more frequent than it is described, due to asymptomatic or mild symptomatic patients. They respond to macrolides, tetracyclines and quinolones, though patients may recover slowly. An increase of the incidence of pneumonia, caused by Chlamydia pneumoniae, is shown in recent multicenter surveys, being even more frequent than Streptococcus pneumoniae and Mycoplasma pneumoniae. Recently it has been demonstrated an association between coronary artery disease and atherosclerosis with Chlamydia pneumoniae infection. Special attention must be paid to the cardiovascular complications of Chlamydia pneumoniae. We describe six clinical cases of Chlamydia pneumoniae pneumonia in which two of them suffered from ischemic artery disease as a complication of the infection.

[Atopic manifestations, growth and nutritional data in newborns at high risk for allergy fed serum protein hydrolysate: 2-year follow-up]

Authors have studied, in high risk for atopy newborns, with a follow-up of two years, the effect of feeding whey hydrolysate, evaluating the incidence of atopic manifestations, the growth pattern and different biochemical nutritional parameters, comparing the results to those observed in breast fed newborns. No significative differences have been shown suggesting that whey protein hydrolysate could be a good alternative to breast milk, when this is not available.

In vitro measurement of silicone bleed from breast implants

A method to measure gel bleed from intact silicone gel-filled breast implants was developed. This nondestructive technique permits accurate and reproducible serial measurements of silicone bleed from smooth wall breast implants (n=10) under simulated physiologic conditions in vitro. Gel bleed rates from new low bleed gel-filled implants and intact explants (unbarriered, low bleed, double lumen) were determined. These results demonstrate the reliability of this method to quantify silicone gel bleed and may permit a meaningful comparison of bleed rates from implants in the future.

[A chondroameloblastic embryoma of the jaw. A case report]

A case of chondro-ameloblastic embryoma, on the posterior third of the palatine bone is reported. The report emphasises the importance of the neuromesenchymal origin of the ameloblastic cells and cartilaginous, fibro-connective and fibro-myxoid tissue, that usually form the structure of the neoplasm.

[Malignant fibrous histiocytoma of the gums. Anatomo-clinical study of a case]

A case of malignant fibrous histiocytoma occurring in the gingival tissue on the site of the mandibular right canine is reported. The histological, histochemical, immunohistochemical and ultrastructural features are discussed and compared with the recent literature on malignant fibrous histiocytomas.