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Marfan's syndrome is a disease associated with reduced structural integrity of connective tissues. We report a 36-year-old patient with Marfan's syndrome who presented with rhinorrhoea, occipital headache and vomiting. Physical examination revealed typical Marfan's syndrome features including dolicocephalous, mandibular micrognathia, tall stature, disproportionately long limbs and digits, and hypermobility of the joints. A high-resolution CT scan demonstrated pneumoencephalous, cerebrospinal fluid (CSF) filling the sphenoidal sinus, and a small bone defect of the clivus. Surgery performed through a transsphenoidal approach revealed the sphenoid sinus to be filled with CSF and a small fenestration in the clivus. The arachnoid diverticulum and the fenestration were repaired and covered with a graft of abdominal fat. In this patient, a deficiency in bone development associated with Marfan's syndrome gave rise to a clival fenestration and a transclival CSF fistula. Although abnormalities of the spinal meningeal membranes have been reported in Marfan's syndrome, to our knowledge, this is the first report of a fistula located in the cranial base in this condition.

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En el momento actual, el tratamiento electivo de la acromegalia consiste en la resección quirúrgica del adenoma productor de hormona del crecimiento con conservación de la función hipofisaria. La mayoría de los casos son intervenidos mediante un abordaje transesfenoidal, que puede ser sublabial o intranasal. El endoscopio puede mejorar la visión de algunos aspectos de la resección quirúrgica realizada con un microscopio y es útil como adyuvante de la microcirugía. La resección quirúrgica de un adenoma con técnica endoscópica exclusiva puede presentar serias limitaciones en los campos quirúrgicos con hemorragia, lo que añade riesgo y en ningún caso mejora los resultados endocrinológicos que ofrece la microcirugía. Estos resultados guardan relación con el tamaño del tumor y los criterios de curación utilizados, así como con el tiempo de evolución postoperatoria. En general se puede esperar una remisión de la enfermedad en más del 90% de los casos intervenidos por tumores < 1 cm de diámetro, pero también se puede obtener la remisión de la enfermedad en al menos un 15% de los casos con adenomas invasivos. El porcentaje de complicaciones es bajo, con insuficiencia de la función hipofisara secundaria al acto quirúrgico en alrededor del 1% de los casos (AU)

Transsphenoidal microsurgery remains the most valid and widely used method of treating acromegaly. This procedure that has been proved relatively safe, achieves selective adenomectomy in a great number of cases and a successful outcome in about 90% of patients with microadenomas. Pituitary insuficiency surgically realated in less than 1% of the cases. 90% of all pituitary adenomas can be treated via the transphenoidal approach using different entry sites: sublabial, pernasal, endonasal. The use of endoscopes is very helpful for better visualization within the sphenoid sinus, especially within the sella, but does not seem to improve the final endocrinological results. Acurate endocrinological diagnosis and early surgical treatment lead to prevent tumor growth and possible focal or general invasion. An other surgical point, is the the prevention of the possibility of pituitary apoplexy rare but life threatening (AU)

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OBJECTIVES: In this study it was our intention to evaluate the relation between the reabsorption of irrigating fluid and three variables: time of the intervention, volume of solution of glicina employee and weight of the fragments, during the RTU of prostate fulfilled to low hydraulic pressure. MATERIAL AND METHOD: We study 74 patients that RTU of prostate was performed with suprapúbica derivation with Amplatz's pod 30 ch. The ethanol was monitored in expired air every 15 minutes during the intervention. Likewise we annotated the time of the intervention, the volume of glicina used and the weight of the fragments extracted. Statistically Anova's text was in use for comparison of averages. RESULTS: 13,6% of the patients absorbed irrigating fluid in some quantity. The range of absorption belongs to 100 cc until 2.000 cc. We did not find a statistically significant difference in the averages of time of resection, volume of glicina and weight of the fragments between the group of patients that had absortion of irrigating fluid and they that didn't had. CONCLUSIONS: Our data show that the operative time, the volume of irrigating fluid and the weight of the resected fragments do not influence the reabsorption of liquid of irrigation when a RTU is realized to low hydraulic pressure.

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OBJECT: The indications for additional radiotherapy (RT) after surgery for non-functioning pituitary adenoma are controversial. The goal of this retrospective study was to evaluate the outcome of surgically treated patients, with or without post- operative irradiation. METHODS: Review of cases treated for non-functioning pituitary adenoma. Fifty-one patients were identified, with a mean post-operative follow-up of 6.4+/-3.5 yr. Twenty-nine patients showed residual tumor after surgery and 22 did not. Serial endocrine, visual and radiological evaluations were made after treatment to assess the efficacy and toxicity of surgery and RT. Twenty-seven patients with residual tumor after surgery received RT (22 of them during the post-operative period and 5 after an interval of several yr: 3 because of increased tumor size and 2 with stable residual lesion); tumors in 14 of these patients decreased in size, 11 appeared to be stable on imaging and one patient showed some increase in tumor size (one patient was not followed-up). The residual tumors of the 2 non-irradiated patients remained stable after 5 and 7 yr, respectively. Twenty-two patients without residual disease after surgery (11 with post-operative irradiation, 1 with RT 5 yr after transsphenoidal surgery because of tumor recurrence, and 10 without RT) have shown no evidence of tumor regrowth on serial images. CONCLUSIONS: Radiotherapy can be avoided in patients with complete macroscopic resection and absence of residual tumor in post-operative images; they must be carefully followed using imaging techniques and, in the case of recurrence, they should be re-operated and/or irradiated.

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INTRODUCTION AND OBJECTIVES: Studies about quality in thesis and investigation projects in biomedical sciences are unusual, but very important in university teaching because is necessary to improve the quality elaboration of the thesis. The objectives the study were to determine the project's quality of thesis in our department, according to the fulfillment of the scientific methodology and to establish, if it exists, a relation between the global quality of the project and the statistical used resources. MATERIAL AND METHODS: Descriptive study of 273 thesis projects performed between 1995-2002 in surgery department of the Zaragoza University. The review realized for 15 observers that they analyzed 28 indicators of every project. Giving a value to each of the indicators, the projects qualified in a scale from 1 to 10 according to the quality in the fulfillment of the scientific methodology. RESULTS: The mean of the project's quality was 5.53 (D.E: 1.77). In 13.9% the thesis projects was concluded with the reading of the work. The three indicators of statistical used resources had a significant difference with the value of the quality projects. DISCUSSION: The quality of the statistical resources is very important when a project of thesis wants to be realized by good methodology, because it assures to come to certain conclusions. In our study we have thought that more of the third part of the variability in the quality of the project of thesis explains for three statistical above-mentioned articles.

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Several matrix metalloproteinases (MMPs) have been implicated in intestinal inflammation, mucosal wound healing, and cancer progression. The purpose of this study was to examine the cellular location and putative function of MMP-19, MMP-26 (matrilysin-2), and MMP-28 (epilysin), in normal, inflammatory, and malignant conditions of the intestine. Peroperative tissue specimens from patients with ulcerative colitis (UC) (n = 16) and archival tissue samples of ischemic colitis (n = 9), Crohn's disease (n = 7), UC (n = 8), colon cancer (n = 20), and healthy intestine (n = 5) were examined using immunohistochemical analyses with polyclonal antibodies. Unlike many classical MMPs, MMP-19, MMP-26, and MMP-28 were all expressed in normal intestine. In inflammatory bowel disease (IBD), MMP- 19 was expressed in nonmigrating enterocytes and shedding epithelium. MMP-26 was detected in migrating enterocytes, unlike MMP-28. In colon carcinomas, MMP-19 and MMP-28 expression was downregulated in tumor epithelium. Staining for MMP-26 revealed a meshwork-like pattern between cancer islets, which was absent from most dedifferentiated areas. Our results suggest that MMP-19 is involved in epithelial proliferation and MMP-26 in enterocyte migration, while MMP-28 expression is not associated with inflammatory and destructive changes seen in IBD. In contrast to many previously characterized MMPs, MMP-19 and MMP-28 are downregulated during malignant transformation of the colon and may play a prominent role in tissue homeostasis.

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UNLABELLED: FUNDAMENTAL: [corrected] To show our initial experience in the TUR of prostate with bipolar axipolar bistoury. MATERIAL AND METHODS: Five patients with an average age of 72 years old, were operated between may and june 2002. They showed important increased in questionnaire symptoms (IPSS). The average ecographic volume has been 57.4 g. We employed Gyrus resector and physiological salt solution for continue irrigation. RESULTS: The average operative time was 70 minutes. None of the patients showed hyponatremia needed blood transfusion. In all the cases the sound was removed 48 hours after operation, one of them have urinary retention (UR) and need sound tow more days. Hospital stay was tree days except the patient how had UR. At 1 and 6 month there is improvement in the IPSS. CONCLUSIONS: TUR of prostate with bipolar axipolar bistoury can avoid the secondary effects of glicine and allows us to work with prostates of bigger volumes due to we have more time to do it. Nevertheless bigger and better studies are required to value the effectiveness of this new technology opposite the TUR of prostate with monopolar bistoury which keeps being the gold standard.

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The determination of five volatile organochlorine compounds, VOX (chloroform, 1,1,1-trichloroethane, carbon tetrachloride, trichloroethene and tetrachloroethene) in raw landfill leachates and biologically cleansed leachates by GC-MS is investigated. Two extraction and preconcentration procedures were evaluated for recovery of such analies from the samples, including static headspace (HS) and solid phase microextraction by sampling the headspace above the sample (HS-SPME). Optimisation of operating parameters for the best performance of both, sampling and preconcentration techniques was described. Detection limits, time of analysis, precision and linear ranges of both introduction techniques have been established. Application of proposed methods to the determination of the five VOX under study in the above referred samples revealed the absence of such analytes in both leachates. Then both methods were applied to the determination to the five organochlorine compounds under study on spiked leachates samples. While HS-GC-MS offered better analytical precision than HS-SPME-GC-MS, this last technique gave a faster analytical response because no dilution must be done for a reliable VOX determination in landfill leachates. In any case, both sample introduction techniques tested provides excellent recoveries and good analytical precision (ranged from 1 to 3%).

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PURPOSE: To establish a technique for transurethral resection of the prostate (TURP), combining the use of local anaesthesia with an Amplatz suprapubic tube, in patients at high surgical risk. MATERIALS AND METHOD: A study was carried out in 32 patients who underwent TURP with a 30 F Amplatz suprapubic tube following local anaesthesia. This technique was indicated where surgery presented a general risk, in elderly patients, and for patients refusing to undergo spinal intradural or general anaesthesia. The mean age of the patients was 70 years (61-82 years). The risk of surgery was assessed according to the ASA classification. RESULTS: According to the ASA classification, 7 patients were ASA III (21.9%), and 25 patients were ASA IV (78.1%). In 31 of the 32 patients the operation was completed in one session. When questioned about the pain they felt, 11 patients reported no pain, 12 slight discomfort and 3 occasional pain. In the latter three patients, intravenous sedation was enhanced with 0.1 mg etomidate per kg body weight. The volume of the resected fragments ranged from 18 to 120 ml, with a mean of 47 ml, except in one patient with 205 ml who required two treatment sessions. CONCLUSIONS: Large prostate resection in patients at high surgical risk was performed comfortably using a combination of local anaesthesia and an Amplatz suprapubic tube. This procedure is one possible option to be considered as an alternative to other treatments.

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At this moment in time, endourology is incorporating extraluminal endoscopic techniques (laparoscopy, lumboscopy, retziuscopy), which the urologist is expected to master. The current advanced stage of development of intraluminal endoscopic surgery is mainly due to the most recent technological achievements (miniaturization of the lens, the use of more versatile materials and new energy sources). In the current cystourethroscopic procedures, compact endoscopes and flexible cystoscopes play an important role. The most important of these new techniques include tissue vaporisation procedures, interstitial application of substances or energies, low-pressure transurethral resection and percutaneous vesical surgery. Upper endoluminal procedures have been the ones to most benefit from modern technological developments. The most important features of present day ureterorenoscopes and their clinical applications are studied and also those of percutaneous nephroscopy (lithiasis, neoformations and others). In a review on the current situation of extraluminal endoscopy, a wide range of laparoscopic techniques--applicable to adrenal regions, kidneys, ureters, retroperitoneal and lymphatic systems, testicles and sperm ducts, bladder and prostrate gland--are discussed as well as the indications, advantages and drawbacks involved and the preferential surgical approaches.

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In this study, we have investigated the effect of combined treatment using two somatostatin analogs, lanreotide or octreotide, with bromocriptine on GH release in cultures of GH-secreting pituitary tumors. Sixteen acromegalic patients were included in the study. All patients had been treated with lanreotide prior to the surgery. Five patients (31.2 %) reached GH levels below 2.0 microg/l and normal IGF-I levels according to age and sex after lanreotide treatment. A positive correlation was observed between the lanreotide-induced inhibition of GH release in vitro and serum GH decrease after lanreotide treatment (r = 0.52; p = 0.03). Combined treatment significantly inhibited GH release in vitro in 8 of the 16 tumors (50 %). However, only 5 (31.2 %) of the respective patients had been resistant to presurgical treatment with lanreotide. Three of these 5 patients (18.7 %) responded to a BC concentration similar to that achieved with therapeutic doses, and in 2 patients only when a pharmacological dose of BC was used in the combined treatment. The additive effect was observed with the combination of lanreotide and BC in 6 tumors and with octreotide and BC in 3. Only one tumor showed simultaneous response to both types of combination. These results suggest that the additive effect under the combined treatment might be found between 18 and 30 % of patients who are resistant to these drugs, and that different combinations of somatostatin analogs and dopamine agonists should be tested in resistant patients.

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En el presente trabajo se presentan casos clínicos que ilustran situaciones de impactación de incisivos, tanto debidas a ectopia del germen como a obstáculos en el camino de erupción, y de retención primaria y la forma en que fueron resueltos. También se presenta un caso en que la erupción ectópica de un incisivo se resolvió casi de manera espontánea. Todos ellos mueven a la reflexión acerca de cuáles son los planteamientos ortodóncicos y periodentales más adecuados para la resolución de este tipo de problemas, destacándose además la importancia fundamental de la comunicación entre el periodoncista o cirujano y el ortodoncista para conseguir los mejores resultados. (AU)

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MAIN OBJECTIVES: to know the proportion of induced prescription (IP) in Area Bilbao and its source, the proportion of cost IP accounts for, the proportion of IP in the main therapeutic groups, the attitude of GP when requested for prescription and its influence on cost, the proportion of disagreement with requested prescription, the reasons for disagreement, and the proportion with letter from specialist. SECONDARY OBJECTIVES: to know the proportion of IP in the remaining therapeutic groups, in drugs of low clinical value, in generic drugs and in new drugs with low or no therapeutic improvement. DESIGN: A descriptive cross-sectional study.Setting. Primary health care. PARTICIPANTS: Drugs prescribable under National Health Service prescribed by and/or requested to GPs. Main results. 7.922 drugs were analysed. Type of prescription: IP, 48.3% (95% CI, 47.2-49.4); GP prescription (GPP), 50.6% (95% CI, 49.5-51.7); unknown source, 1,1% (95% CI, 0.9-1.3). Main source, public specialist (72.2%), private specialist (16.6%). IP accounted for 62.5% of cost. In the most prescribed therapeutic group, central nervous system (24.2%), IP, 39.8%; GPP, 58.9%; in cardiovascular system (19.1%), IP, 56.2%; GPP, 43.1%. 98.4% of requested prescription was actually prescribed, 1.2% was changed and 0.4%, suppressed. Proportion of disagreement, 11%; reasons for disagreement, no need for medical treatment (23.9%), therapeutic group (34.4%), active ingredient (13.2%), brand name (28.5%). There was a 62.4% with letter from specialist. CONCLUSIONS: Primary care is not accountable for a substantial proportion of prescription. GP prescribes a considerable proportion of drugs without agreement. It would be necessary a system that allows to separate the cost by care levels and also improve their communication.

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Objetivos. Principales: conocer la proporción de prescripción inducida (PI) en Comarca Bilbao y su procedencia, la proporción de gasto correspondiente a la PI, la proporción de PI en los principales grupos terapéuticos, la actitud del médico de atención primaria ante la prescripción solicitada y su influencia en el gasto, la proporción de desacuerdo con dicha prescripción y los motivos de desacuerdo, y la proporción con informe del especialista. Secundarios: conocer la proporción de PI en los demás grupos terapéuticos, en fármacos VINE, EFG y en los de nula o baja mejora terapéutica. Diseño. Estudio transversal, descriptivo. Emplazamiento. Atención primaria. Participantes. Fármacos financiables prescritos por y/o solicitados a los médicos de familia de EAP. Resultados principales. Se estudiaron 7.922 fármacos. Tipo de prescripción: PI, 48,3 por ciento (IC del 95 por ciento, 47,2-49,4); del médico de atención primaria (PRO), 50,6 por ciento (IC del 95 por ciento, 49,5-51,7); desconocida, 1,1 por ciento (IC del 95 por ciento, 0,9-1,3). Procedencia principal: especialista público (72,2 por ciento), especialista privado (16,6 por ciento). Un 62,5 por ciento del gasto correspondió a la PI. En el grupo terapéutico más prescrito, sistema nervioso central (24,2 por ciento), PI, 39,8 por ciento; PRO, 58,9 por ciento; en aparato cardiovascular (19,1 por ciento), PI, 56,2 por ciento, PRO, 43,1 por ciento. Se prescribió el fármaco solicitado en un 98,4 por ciento de los casos, se cambio en el 1,2 por ciento y se suprimió en un 0,4 por ciento. Proporción de desacuerdo, 11 por ciento; motivos de desacuerdo, no hay necesidad de tratar (23,9 por ciento), grupo terapéutico (34,4 por ciento), principio activo (13,2 por ciento), marca comercial (28,5 por ciento). Hubo informe de especialista en un 62,4 por ciento de los casos. Conclusiones. Se detecta una proporción considerable de prescripción no atribuible a atención primaria y una proporción importante de fármacos que el médico de primaria prescribe sin estar de acuerdo. Sería necesario un sistema que permitiera separar el gasto por niveles, así como mejorar la comunicación entre éstos (AU)

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Transsphenoidal microsurgery is the standard treatment for patients with Cushing's disease. However, there is general lack of agreement regarding the definition of cure. We studied 58 patients with corrected hypercortisolism after transsphenoidal surgery for Cushing's disease. Plasma and urinary cortisol levels were measured after surgery. After the postsurgical hypocortisolism stage (or periodically in patients without hypocortisolism), urinary free cortisol, plasma cortisol at 0800 h and 2300 h, morning cortisol after 1 mg dexamethasone, and cortisol response to insulin-induced hypoglycemia were performed. Patients were classified in 3 groups: group I, patients with transient hypocortisolism and normal hypothalamus-pituitary-adrenal axis afterwards; group II, patients with transient hypocortisolism and abnormalities in the circadian rhythm or the stress response afterwards; and group III, patients without postoperative hypocortisolism. Thirty-three patients were included in group I, 8 in group II, and 17 in group III. Groups I and II were similar in postsurgical plasma cortisol (46.9 +/- 30.3 vs. 60.7 +/- 38.6 nM) and mean follow-up (69.8 vs. 68.8 months) but were significantly different in their recurrence rate (3.4% vs. 50%, P < 0.001). Patients in group III had normal postsurgical plasma and urinary cortisol but persistent abnormalities in circadian rhythm and stress response. After a mean follow-up of 39.1 months, their recurrence rate was similar to that of group II (64.7% vs. 50%). The complete normalization of the adrenocortical function, which is always preceded by postsurgical hypocortisolism, is associated with a very low recurrence risk and should be considered, in our opinion, the main criterion of surgical cure in Cushing's disease.

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Fetal development and tumor progression both require a complex system of extracellular matrix (ECM) synthesis and breakdown, which is mediated by, for instance, the matrix metalloproteinases (MMPs). Human metalloelastase (MMP-12) is an MMP, the expression of which has so far been documented in macrophages associated with atherosclerosis, wound repair, and certain cancers. In this study we first examined the expression of MMP-12 during human fetal development. By in situ hybridization MMP-12 transcripts were detected in chondrocytes of hypertrophic cartilage in vertebrae of the spinal column, in ribs, and in extremities undergoing ossification, beginning at the gestational age of 8 weeks. Also, periosteal cells expressed MMP-12 at 11 weeks. No expression of MMP-12 mRNA could be noted in other fetal tissues, including the skin, lungs, intestine, kidney, and liver. Expression of MMP-12 mRNA could not be detected in adult normal cartilage or osteosarcomas, but in chondrosarcomas both macrophages (8 of 19 samples) (identified by CD68 immunostaining) and chondrosarcoma cells (8 of 19) were positive. MMP-12 was also demonstrated in the tumors by western blotting and it was expressed in the same regions as MMP-13 mRNA. By immunostaining, MMP-12 mRNA colocalized with the protein in both fetal and chondrosarcoma specimens. Unlike basic fibroblast growth factor (bFGF) and transforming growth factor-beta (TGF-beta), tumor necrosis factor-alpha (TNF-alpha) induced MMP-12 mRNA production in chondrosarcoma-derived HTB-94 cells. Our results suggest that MMP-12 plays an important role in ECM remodeling during fetal bone development and is induced when chondrocytes undergo malignant transformation.

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AIM: We report our experience of the endoscopic treatment of vesicoureteric reflux in children by submucosal injection of polytetrafluoroethylene (Teflon). PATIENTS AND METHODS: From April 1995 to September 1999 we treated 30 cases of vesicoureteric reflux in 22 children aged 19 months to 8 years. All the children underwent general anesthesia and subureteric injection of polytetrafluoroethylene paste with a pediatric cystoscope. Patients were discharged the day of the operation and were followed-up 15 days, six months and one year postoperatively with ultrasound and radionuclide cystography. When reflux persisted, the treatment was repeated. RESULTS: Open surgery was performed in one patient with reflux after two repeat injections. Another patient underwent a second, successful, injection. The overall success rate with endoscopic treatment was 96.5% and only one injection was required in 93.1%. None of the patients required hospitalization because of complications due to the operation or the endoscopic technique. CONCLUSIONS: We consider submucosal injection of Teflon to be a first-line technique in the treatment of vesicoureteric reflux in children. The success rate is similar to that of open surgery but with endoscopic treatment morbidity and costs are lower and hospital stay is shorter.

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We have identified a human placenta cDNA coding for a new member of the matrix metalloproteinase (MMP) family. The isolated cDNA encodes a polypeptide of 261 amino acids, the smallest MMP identified to date, which contains several structural features of MMPs including the signal sequence, the prodomain involved in enzyme latency, and the catalytic domain with the zinc-binding site. However, it lacks the hinge region and hemopexin-domain present in most MMPs. According to these structural characteristics, the human MMP described herein has been called matrilysin-2 (MMP-26), because it exclusively shares with matrilysin this minimal domain organization required for secretion, latency, and activity. The amino acid sequence of matrilysin-2 also contains a threonine residue adjacent to the Zn-binding site that has been defined as a specific feature of matrilysin. Chromosomal location of the matrilysin-2 gene showed that it maps to the short arm of chromosome 11, a location distinct to that of other MMP genes. Matrilysin-2 was expressed in Escherichia coli, and, after purification and refolding, the recombinant protein was found to degrade synthetic substrates commonly used for assaying MMPs. Furthermore, this protein hydrolyzed type IV collagen, fibronectin, fibrinogen, and gelatin, which indicated that matrilysin-2 is a potent enzyme with a wide substrate specificity. In addition, it was found that matrilysin-2 is able to activate progelatinase B. Proteolytic activity of matrilysin-2 against all of these substrates was abolished by synthetic inhibitors and by tissue inhibitors of metalloproteinases. Expression analysis revealed that matrilysin-2 is detected not only in placenta and uterus but is widely expressed in malignant tumors from different sources as well as in diverse tumor cell lines. These data together with its broad spectrum of proteolytic activity, suggest that matrilysin-2 may play a role in some of the tissue-remodeling events associated with tumor progression.

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