A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

Objective: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. Design: A secondary analysis derived from multicenter, observational study. Setting: Critical Care Units. Patients: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. Interventions: Corticosteroids vs. no corticosteroids. Main variables of interest: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. Results: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR = 0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. Conclusion: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

Objetivo: Evaluar si el uso de corticoesteroides (CC) se asocia con la mortalidad en la unidad de cuidados intensivos (UCI) en la población global y dentro de los fenotipos clínicos predeterminados. Diseño: Análisis secundario de estudio multicéntrico observacional. Ámbito: UCI. Pacientes: Pacientes adultos con COVID-19 confirmado ingresados en 63 UCI de España. Intervención: Corticoides vs. no corticoides. Variables de interés principales: A partir del análisis no supervisado de grupos, 3 fenotipos clínicos fueron derivados y clasificados como: A grave, B crítico y C potencialmente mortal. Se efectuó un análisis multivariado después de un propensity optimal full matching (PS) y una regresión ponderada de Cox (HR) y análisis de Fine-Gray (sHR) para evaluar el impacto del tratamiento con CC sobre la mortalidad en la población general y en cada fenotipo clínico. Resultados: Un total de 2.017 pacientes fueron analizados, 1.171 (58%) con CC. Después del PS, el uso de CC no se relacionó significativamente con la mortalidad en UCI (OR: 1,0; IC 95%: 0,98-1,15). Los CC fueron administrados en 298/537 (55,5%) pacientes del fenotipo A y no se observó asociación significativa con la mortalidad (HR = 0,85; 0,55-1,33). Un total de 338/623 (54,2%) pacientes del fenotipo B recibieron CC sin efecto significativo sobre la mortalidad (HR = 0,72; 0,49-1,05). Por último, 535/857 (62,4%) pacientes del fenotipo C recibieron CC. En este fenotipo, se evidenció un efecto protector de los CC sobre la mortalidad HR (0,75; 0,58-0,98). Conclusión: Nuestros hallazgos alertan sobre el uso indiscriminado de CC a dosis moderadas en todos los pacientes críticos con COVID-19. Solamente pacientes con elevado estado de inflamación podrían beneficiarse con el tratamiento con CC.

A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

OBJECTIVE: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. DESIGN: A secondary analysis derived from multicenter, observational study. SETTING: Critical Care Units. PATIENTS: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. INTERVENTIONS: Corticosteroids vs. no corticosteroids. MAIN VARIABLES OF INTEREST: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. RESULTS: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. CONCLUSION: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

The impulsiveness level influences the salivary cortisol response and social stress sensitivity in suicidal patients.

INTRODUCTION: Suicide attempters (SA) are more vulnerable to social stress and show disturbed cortisol response in stressful conditions compared with psychiatric and healthy controls. Recent data suggest that this dysregulation might be related to impulsivity traits. However, little is known about the emotional consequences of social stress in SA exposed to stress. OBJECTIVES: The aim of our study was to evaluate the cortisol and emotional responses to social stress in patients with depression with and without suicide attempt, by taking into account impulsivity traits and depression severity. METHODS: 67 adult women (41 SA and 26 affective controls (AC,i.e. without suicide attempt history)) with lifetime history of major depressive episode were included. Patients performed the Trier Social Stress Test (TSST), a well-validated social stress task. Patients provided seven saliva samples, to measure the cortisol response, and filled in questionnaires to assess psychological pain, positive and negative mood, and anxiety at different time points (from 10 min before to 120 min after the TSST). Moderated regression models were used including suicide attempt history, depression severity, and impulsivity as independent variables and their interactions. RESULTS: In patients with low depression and high impulsivity, salivary cortisol response during the TSST was higher in SA than in AC (p < .001). Psychological pain, negative mood, and anxiety were increased in all patients just after the TSST, followed by a decrease at 120 min. Positive mood recovery was slower in SA, and in patients with high impulsivity and low depression level (p < .001). CONCLUSIONS: Impulsivity traits have an important role in suicidal vulnerability in stress conditions. Impulsivity traits might help to differentiate patients at risk of suicide who are highly sensitive to stress when depression level is low. Higher impulsiveness may increase the sensitivity to emotional distress that translates into inadequate physiological responses.

Being an optimist or a pessimist and its relationship with morning cortisol release and past life review in healthy older people.

OBJECTIVE: Investigate the relationship between optimism and pessimism and the cortisol awakening response (CAR) and past life review in healthy older people. DESIGN: 76 older volunteers summarised their lives, highlighting the most important events, impressions and experiences. Cortisol saliva samples were collected on two consecutive weekdays. High and low optimism and pessimism groups were computed by mean split. MAIN OUTCOME MEASURES: Percentages of positive (PE) and negative events (NE) and positive (PCE) and negative cognitions and emotions (NCE) were obtained. Optimism and pessimism were measured with the Life Orientation Test Revised. The areas under the curve with respect to the ground and with respect to the increase were computed, with the latter understood as the CAR. RESULTS: The high pessimism group reported more NE and NCE and less PE and PCE (p's < 0.041). No significant differences in CAR were found between high and low optimism and pessimism groups after removing suspected non-adherent participants (p's > 0.116). Higher CAR was related to lower PCE, but higher NCE (both p < 0.008). CONCLUSION: Pessimism seems to increase the focus on negative aspects of the past, which may lead to a worse perception of life in ageing, whereas optimism contributes to a healthier CAR.

Searching for a job: Cardiac responses to acute stress and the mediating role of threat appraisal in young people.

Being unemployed and looking for a job has become a source of stress for many people in several European countries. However, little attention has been paid to the impact of this stressful situation on the individuals' psychophysiological stress responses. The aim of this study was to investigate the effect of being an unemployed job seeker on cognitive threat appraisal and cardiac responses to a psychosocial stressor. We exposed a group of unemployed job seekers (N = 42) and a matched group of unemployed non-job seekers (N = 40) to a standardized social stressor in form of job interview, the Trier Social Stress Test. Our results showed that unemployed job seekers manifest lower cardiac responses, along with a lower cognitive threat appraisal, compared to non-job seekers. Moreover, we observed a full mediating role of cognitive threat appraisal on the relationship between being an unemployed job seeker and cardiac responses to stress. These findings reveal that being unemployed and looking for a job has an effect on physiological responses to acute stress, as well as the importance of psychological process related to the situation. These responses might lead to negative health and motivational consequences. Theoretical and practical implications are discussed.

Environmental factors associated with Dictyocaulus viviparus and Fasciola hepatica prevalence in dairy herds from Costa Rica.

Dictyocaulosis and fasciolosis are parasitic diseases that cause considerable economic losses for owners of farm animals worldwide, with special relevance on fasciolosis because it is an emerging zoonosis. Indirect diagnosis of these diseases through analyses of bulk milk tank samples has allowed carrying out large-scale prevalence studies, while the use of geographical information systems has helped to visualize and determine those variables that affect distribution of these pathogens. This study is intended to describe the spatial distribution of Dictyocaulus viviparus and Fasciola hepatica in dairy herds from Costa Rica, as well as their associated environmental factors. Bulk milk tank samples from 526 dairy herds in the three most important dairy regions of Costa Rica were analyzed using enzyme immunoassays. Results from the farms were subjected to spatial analyses using Holdridge's life zones, relief and soil type environmental layers. Of the total bulk milk tank samples analyzed, 3.8% (n=20) and 3.6% (n=19) were positive for D. viviparus and F. hepatica, respectively. Moran's I analysis revealed the existence of potential cluster (Moran's I=1.789, z=12.726 p<0.05) for D. viviparus. Consequently, Getis-Ord General G analysis showed that the spatial distribution of positive farms in the dataset was clustered (Observed General G=0.015, variance=0.000001, z=12.823, p<0.05). No significant positive spatial autocorrelation (Moran's I=0.038, z=0.286, p>0.0.5) was observed for F. hepatica. Furthermore, a significant difference was detected in the spatial locations of both parasites (latitude p<0.05, longitude p<0.05), and about the spatial distribution of both D. viviparus negative and positive farms (latitude p<0.05, longitude p<0.05), as well as in F. hepatica negative and positive farms regarding on latitude (p<0.05), but not on longitude (p>0.05). In the case of environmental factors, significant differences were found for D. viviparus and F. hepatica with respect to types of soil, precipitation, altitudinal belts, life zones, biotemperature, and elevation.

Acute stress and working memory: The role of sex and cognitive stress appraisal.

Sex is considered a moderating factor in the relationship between stress and cognitive performance. However, sex differences and the impact of cognitive stress appraisal on working memory performance have not received much attention. The aim of this study was to investigate the role of physiological responses (heart rate and salivary cortisol) and cognitive stress appraisal in Working Memory (WM) performance in males and females. For this purpose, we subjected a comparable number of healthy young adult males (N=37) and females (N=45) to a modified version of the Trier Social Stress Test (TSST), and we evaluated WM performance before and after the stress task. Females performed better on attention and maintenance after the TSST, but males did not. Moreover, we found that attention and maintenance performance presented a negative relationship with cortisol reactivity in females, but not in males. Nevertheless, we observed that only the females who showed a cortisol decrease after the TSST performed better after the stress task, whereas females and males who showed an increase or no change in cortisol levels, and males who showed a cortisol decrease, did not change their performance over time. In females, we also found that the global indexes of cognitive stress appraisal and cognitive threat appraisal were negatively related to attention and maintenance performance, whereas the Self-concept of Own Competence was positively related to it. However, these relationships were not found in males.

Behavior and Inactivation of Enterotoxin-Positive Clostridium perfringens in Pork Picadillo and Tamales Filled with Pork Picadillo under Different Cooking, Storage, and Reheating Conditions.

This study analyzed the behavior of Clostridium perfringens in individual ingredients and tamales containing different pathogen concentrations upon exposure to different temperatures and methods of cooking, storage, and reheating. In ground pork, C. perfringens cells were inactivated when exposed to 95°C for 30 min. Three lots of picadillo inoculated with 0, 3, and 5 log CFU/g C. perfringens cells, respectively, were exposed to different storage temperatures. At 20°C, cell counts increased 1 log in all lots, whereas at 8°C, counts decreased by 2 log. Four lots of tamales prepared with picadillo inoculated with 0, 2, 3, and 7 log CFU/g prior to the final cooking step exhibited no surviving cells (91°C for 90, 45, or 35 min). Four lots of tamales were inoculated after cooking with concentrations of 0, 0.6, 4, and 6 log CFU/g of the pathogen and then stored at different temperatures. In these preparations, after 24 h at 20°C, the count increased by 1.4, 1.7, and 1.8 log in the tamales inoculated with 0.6, 4, and 6 log inoculum, respectively. When they were stored at 8°C for 24 h, enumerations decreased to <1, 2.5, and 1.9 log in the tamales inoculated with 0.6, 4, and 6 log of C. perfringens cells, respectively. However, when the lots were exposed to 20°C and then 8°C, 0.8, 1.8, and 2.4 log changes were observed for the tamales inoculated with 0.6, 4, and 6 log, respectively. Microwaving, steaming, and frying to reheat tamales inoculated with 6 log CFU/g C. perfringens cells showed that the pathogen was inactivated after 2 min of exposure in the microwave and after 5 min of exposure to steam. In contrast, no inactivation was observed after 5 min of frying. The tamales inoculated with spores (7 log most probable number [MPN]/g) showed a decrease of 2 log after steaming or frying, and no survival was observed after microwaving. Tamales inoculated with spores (7 log MPN/g) after cooking were susceptible to microwaves, but 2.4 and 255 MPN/g remained after frying and steaming, respectively.

Postoperative adjuvant treatment for gastric cancer improves long-term survival after curative resection and D2 lymphadenectomy. Results from a Latin American Center.

BACKGROUND: The benefits of adjuvant treatment in the context of a D2 lymph node dissection are controversial. The aim was to investigate the effects of postoperative adjuvant treatment on the survival of patients with a curative resection for gastric cancer and a D2 lymph node dissection. METHODS: We performed a retrospective cohort study. Patients operated from 1996 to 2013 were selected. We compared long term survival of patients treated with surgery alone and those with surgery plus postoperative adjuvant treatment. A multivariate analysis for survival was applied in every stage. RESULTS: The study included 580 patients. Two-hundred and four patients received postoperative adjuvant treatment (AD) and 376 patients were treated only with surgery (SU). Patients in the AD group were younger (60 versus 68, p < 0.001), had a lower rate of multiple organ resection (21% versus 39%, p < 0.001) and had less postoperative complications (14% versus 32%, p < 0.001). In the AD group, patients had more advanced disease (stage III; 77% versus 66%, p < 0.001). No difference was found in lymph nodes resected (31 versus 30, p = ns). The median survival with adjuvant treatment was 33 months (39% 5 year survival) and 22 months (31% 5 year survival) for patients without adjuvant treatment (p = 0.003). On multivariate analysis, patients with stage IIIB and IIIC had significantly better overall and disease specific long-term survival with adjuvant treatment. CONCLUSIONS: These results suggest that there is a long-term survival benefit for patients treated with postoperative adjuvant treatment for stages IIIB and IIIC gastric cancer after D2 lymph node dissection.

Pathophysiological Basis of Acute Respiratory Failure on Non-Invasive Mechanical Ventilation.

Noninvasive mechanical ventilation (NIMV) was created for patients who needed noninvasive ventilator support, this procedure decreases the complications associated with the use of endotracheal intubation (ETT). The application of NIMV has acquired major relevance in the last few years in the management of acute respiratory failure (ARF), in patients with hypoxemic and hypercapnic failure. The main advantage of NIMV as compared to invasive mechanical ventilation (IMV) is that it can be used earlier outside intensive care units (ICUs). The evidence strongly supports its use in patients with COPD exacerbation, support in weaning process in chronic obstructive pulmonary disease (COPD) patients, patients with acute cardiogenic pulmonary edema (ACPE), and Immunosuppressed patients. On the other hand, there is poor evidence that supports the use of NIMV in other pathologies such as pneumonia, acute respiratory distress syndrome (ARDS), and during procedures as bronchoscopy, where its use is still controversial because the results of these studies are inconclusive against the decrease in the rate of intubation or mortality.

Humidification on Ventilated Patients: Heated Humidifications or Heat and Moisture Exchangers?

The normal physiology of conditioning of inspired gases is altered when the patient requires an artificial airway access and an invasive mechanical ventilation (IMV). The endotracheal tube (ETT) removes the natural mechanisms of filtration, humidification and warming of inspired air. Despite the noninvasive ventilation (NIMV) in the upper airways, humidification of inspired gas may not be optimal mainly due to the high flow that is being created by the leakage compensation, among other aspects. Any moisture and heating deficit is compensated by the large airways of the tracheobronchial tree, these are poorly suited for this task, which alters mucociliary function, quality of secretions, and homeostasis gas exchange system. To avoid the occurrence of these events, external devices that provide humidification, heating and filtration have been developed, with different degrees of evidence that support their use.

Noninvasive Mechanical Ventilation in Acute Respiratory Failure Patients: A Respiratory Therapist Perspective.

Physiotherapist in Chile and Respiratory Therapist worldwide are the professionals who are experts in respiratory care, in mechanical ventilation (MV), pathophysiology and connection and disconnection criteria. They should be experts in every aspect of the acute respiratory failure and its management, they and are the ones who in medical units are able to resolve doubts about ventilation and the setting of the ventilator. Noninvasive mechanical ventilation should be the first-line of treatment in acute respiratory failure, and the standard of care in severe exacerbations of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, and in immunosuppressed patients with high levels of evidence that support the work of physiotherapist. Exist other considerations where most of the time, physicians and other professionals in the critical units do not take into account when checking the patient ventilator synchrony, such as the appropriate patient selection, ventilator selection, mask selection, mode selection, and the selection of a trained team in NIMV. The physiotherapist needs to evaluate bedside; if patients are properly connected to the ventilator and in a synchronously manner. In Chile, since 2004, the physioterapist are included in the guidelines as a professional resource in the ICU organization, with the same skills and obligations as those described in the literature for respiratory therapists.

Vasectomía sin bisturí: resultados de una cohorte de 309 pacientes / No-scalpel vasectomy

Introducción: La vasectomía es una técnica segura y efectiva para el control de la fertilidad masculina. A pesar de esto, en el mundo se realizan el doble de esterilizaciones femeninas respecto a vasectomías, lo cual es más acentuado en países en vías de desarrollo. Objetivos: El objetivo de este trabajo es presentar nuestra experiencia y resultados en pacientes sometidos a una vasectomía sin bisturí. Materiales y Métodos: Se incluyó un total de 309 pacientes sometidos a una vasectomía sin bisturí entre junio de 2009 y mayo de 2010. En cada caso se evaluó la edad, tiempo operatorio, espermiograma a los 3 y 6 meses (en caso de ser necesario) y la morbilidad perioperatoria. Resultados: 281 pacientes (91 por ciento) se controlaron con al menos un espermiograma. En 189 pacientes (67 por ciento) se evidenció azoospermia en el espermiograma a los 3 meses. En 81 pacientes (29 por ciento) se evidenció un recuento con < 100.000 espermatozoides 100 por ciento inmóviles. En 9 pacientes (3,2 por ciento) se necesitó un segundo espermiograma para obtener menos de 100.000 espermatozoides 100 por ciento inmóviles. Seis pacientes (2 por ciento) consultaron por complicaciones menores: orquialgia, epididimitos o hematoma del sitio operatorio. A 2 años de seguimiento, no se registraron embarazos. Conclusiones: La vasectomía sin bisturí es un método seguro y reproducible de anticoncepción masculina, presentando tasas de efectividad superiores al resto de los métodos anticonceptivos. Un espermiograma de control debe ser realizado a los 3 meses de realizado el procedimiento. La tasa de falla temprana se estima en 0,3 por ciento de los pacientes.

Introduction: Vasectomy is a safe and effective technique of male fertility control. Despite this, in the world are carried out more than double female sterilization in comparison with vasectomies, that is more pronounced in less developed countries. Aims: To present our experience and results in patients undergoing a no-scalpel vasectomy. Methods and Material: A total of 309 patients undergoing a no-scalpel vasectomy between June 2009 and May 2010 were included. For each case was record age, operative time, sperm count at 3 months post vasectomy and peri-operative morbidity. Results: 309 vasectomies were performed, 281 patients (91%) were controlled with at least one sperm count. Azoospermia was obtained in the first sperm count at 3 months in 189 patients (67%). In 81 patients (29%) were observed ≤ 100,000 sperm 100% immobile. 9 patients (3.2%) needed a second semen analysis and 2 patients a third one for less than 100,000 sperm that were 100% immobile. 6 patients (2%) consulted by minor complications such as postoperative pain, epididymitis or hematoma with spontaneous resolution. Conclusions: Vasectomy is a safe and reproducible method of male contraception, presenting an effectiveness rates higher than others contraceptive methods. There are no absolute contraindications for performing the procedure. A sperm count should be done at 3 months of the procedure. The early failure rate in our study is 0.3%.

Efectividad y satisfacción del tratamiento con dosis diaria de Tadalafilo 5 mg para la disfunción eréctil / Effectiveness and satisfaction of the treatment with daily dose of Tadalafil 5 mg for erectile dysfunction

La base del tratamiento de la disfunción eréctil (DE) son los inhibidores de la fosfodiesterasa 5, disponibles mayoritariamente para dosificación a demanda. En 2008 la FDA aprobó el Tadalafilo 5 mg de uso diario. OBJETIVO: Evaluar la efectividad del Tadalafilo 5 mg de uso diario para el tratamiento de la DE y la satisfacción de los pacientes frente a su uso. PACIENTES Y METODOS: Se reclutaron pacientes con DE entre Junio de 2011 y Mayo de 2012. Se registraron datos sociodemográficos, clínicos y andrológicos. La DE se clasificó según el puntaje del cuestionario IIEF. Todos los pacientes iniciaron tratamiento diario con Tadalafilo 5 mg y fueron reevaluados luego de un mes. La satisfacción y calidad de vida se evaluó con cuestionarios validados (EDITS, SEAR y GAQ). Para el análisis estadístico se consideró significativo un P<0.05.RESULTADOS: Se reclutaron 49 pacientes con edad promedio de 59,9 +/- 8,8 años. Un 14,3 por ciento presentaba DE severa, 36,7 por ciento moderada, 36,7por ciento leve-moderada y 12,2 por ciento leve. Al mes de tratamiento, el puntaje IIEF aumentó significativamente (P<0.0005), encontrándose un 18,4 por ciento sin DE, 53,1 por ciento con DE leve, 28,6 por ciento con DE leve-moderada y ninguno con DE moderada o grave. El 87,7 por ciento de los pacientes refirió mejores erecciones y el 81,6 por ciento una mejor capacidad para mantener la relación sexual. La satisfacción global con el tratamiento fue de 64,1 por ciento. CONCLUSIÓN: El tratamiento diario con Tadalafilo 5 mg es efectivo para el manejo de la DE y se asocia a niveles adecuados de satisfacción y confianza al cabo de un mes de tratamiento.

The base of the treatment of erectile dysfunction (ED) are the phosphodiesterase-5 inhibitors, mostly available for “on demand” dosing. In 2008, the FDA approved Tadalafil 5mg for daily use. OBJECTIVE: To evaluate the effectiveness of Tadalafil 5 mg daily dose for the treatment of ED and the patient’s satisfaction with its use. PATIENTS AND METHODS: Patients with ED were enrolled between June 2011 and May 2012. Sociodemographic, clinical and andrologic data was recorded. The severity of ED was classified according to the score of the IIEF questionnaire. All patients started daily treatment with Tadalafil 5 mg and were reevaluated after one month. Satisfaction and quality of life was assessed using validated questionnaires (EDITS, SEAR and GAQ). A P<0.05 was considered significant in all statistical analysis. RESULTS: A total of 49 patients were enrolled, with mean age of 59.9 +/- 8.8 years. A 14.3 ´percent suffered severe ED, 36.7 percent moderate, 36.7 percent mild-moderate and 12.2 percent mild. After one month, the IIEF score significantly increased (P<0.0005), finding a 18.4 percent of patients without ED, 53.1 percent with mild ED, 28.6 percent with mild-moderate ED and no cases with moderate or severe ED. 87.7 percent of patients reported better erections and 81.6 percent stated a better capacity to maintain erections during. The global satisfaction rate with the treatment was of 64.1 percent. CONCLUSION: The treatment with daily dose of Tadalafil 5 mg is effective for the management of ED and is associated with adequate levels of satisfaction and confidence after one month of use.

Síndrome de Cushing por ACTH ectópica: revisión a propósito de dos casos clínicos / Cushing syndrome caused by ectopic ACTH secretion: report of two cases

Twelve percent of Cushing syndromes (CS) are caused by ectopic ACTH secretion. We report two cases of the condition. A 57 years old woman with an ectopic CS caused by a bronchial carcinoid tumor. After the tumor excision, the patient had a favorable evolution. A 63 years old woman consulting for cough, dyspnea and weight loss causes by a small cell lung cancer. The patient presented hyperglycemia, hypokalemia and metabolic alcalosis. The laboratory showed a severe hypercortisolism with elevated ACTH levels. The metabolic condition did not subside after the first course of chemotherapy and the patient died due to an infectious complication...

Microbiological safety of domestic refrigerators and the dishcloths used to clean them in Guadalajara, Jalisco, Mexico.

Household refrigerators are a potential pathogen contamination source for foods. An evaluation of the microbiological safety of 200 refrigerators in Guadalajara, Jalisco, Mexico, was made by visual inspection, ATP-bioluminescence levels, indicator microorganisms including Escherichia coli and Staphylococcus aureus, and the presence of Listeria monocytogenes and Salmonella. Additionally, interviews of the owners of the refrigerators were carried out to determine relationships between food storage practices, demographic aspects, and microbiological status. Dishcloths used to clean refrigerators were also analyzed. Operational conditions (cleanliness, fullness, organization, frequency of cleaning, and temperature) were evaluated by trained observers. Results showed deficient cleanliness in 55% of refrigerators, 22% were completely full, 43% very disorganized, 28% were usually cleaned only once in 3 to 6 months, and 53% had internal temperatures >7.1°C. ATP-bioluminescence levels were >300 relative light units on 67 and 74% of shelves and drawers, respectively, indicating that surfaces were dirty according to the luminometer manufacturer. Psychrotrophic aerobic bacteria counts on shelves, drawers, and dishcloths were 6.3, 5.2, and 6.3 log CFU/cm(2); for coliform bacteria, 5.2, 3.9, and 4.7 CFU/cm(2); for E. coli, 3.7, 3.5, and 4.8 CFU/cm(2); and for Staphylococcus aureus, 2.1, 2.5, and 2.3 CFU/cm(2), respectively. L. monocytogenes and Salmonella were isolated from 59.5, 20.5, and 17% and 32.5, 8.0 and 12.5% of shelves, drawers, and dishcloths, respectively. Four Salmonella serotypes and nine serogroups (partially serotyped isolates) were identified. The most prevalent were Salmonella Anatum (39.5%), Salmonella group E1 (19.7%), and Salmonella group E1 monophasic (12.5%). Operational conditions and microbiological status were clearly deficient in sampled refrigerators, highlighting the consequent risk of foodborne disease among users. Educational programs are needed to improve the domestic food safety in Mexico.

Incidence of Salmonella, Listeria monocytogenes, Escherichia coli O157:H7, and Staphylococcal enterotoxin in two types of Mexican fresh cheeses.

Handcrafted fresh cheeses are popular among consumers in Mexico. However, unsafe raw materials and inadequate food safety practices during cheese manufacture and preservation make them a potential public health risk. The incidence of Salmonella, Listeria, Escherichia coli O157:H7, and staphylococcal enterotoxin was analyzed in two types of fresh cheese (panela and adobera) commonly marketed in Mexico. A total of 200 samples, 100 panela and 100 adobera, were acquired from 100 wholesale milk product distributors who supply small retailers in the Guadalajara metropolitan area, Jalisco State, Mexico. Pathogens were identified using culture and immunoassay (miniVidas) methods. The presence of staphylococcal enterotoxin was determined by an immunoassay method. Of the 200 analyzed samples, 92 were positive for at least one of the pathogens. The incidence in the panela samples was 56%: 34% Salmonella, 16% E. coli O157:H7, and 6% L. monocytogenes. In the adobera samples, incidence was 36%: 20% Salmonella, 4% E. coli O157:H7, and 12% L. monocytogenes. Staphylococcal enterotoxin was not detected in any of the 200 samples. Choice of technique had no effect on detection of pathogen incidence, although the immunoassay method identified more Salmonella serotypes than the culture method. Handcrafted panela and adobera fresh cheeses in Mexico frequently contain pathogenic bacteria and therefore pose a public health risk.

Patogenia y tratamiento médico de la orbitopatía de graves / Pathogenesis and medical treatment of graves' orbitopathy

La Orbitopatía de Graves se presenta clínicamente en aproximadamente 50 por ciento de los casos de Enfermedad de Graves. La mayoría de las veces es leve y sólo en menos del 5 por ciento pone en riesgo la visión, pese a lo cual deteriora significativamente la calidad de vida de los pacientes. Hasta el momento no se conoce totalmente la patogenia, siendo posiblemente el receptor de TSH el blanco de la autoinmunidad. En cuanto al tratamiento, las medidas preventivas como lograr el eutiroidismo y la suspensión del tabaco son útiles en los distintos grados de la enfermedad. Para los casos más severos se han investigado diferentes medicamentos pero ninguno ha demostrado ser superior a los Glucocorticoides. Actualmente los consensos concuerdan en que es imprescindible clasificar al paciente según grado de actividad y severidad para orientar la terapia con mayor eficacia. Las investigaciones en curso pretenden encontrar una droga que supere el rendimiento existente

Graves' orbitopathy occurs clinically in approximately 50 percent of Graves' Disease. Most often it is mild and only less than 5 percent can threaten vision, despite which it significantly impairs the quality of life of this patients. So far its pathogenesis is not completely understood, but possibly TSH receptor is the target of autoimmunity. In relation to treatment, preventive measures such as achieving euthyroidism and the suspension of tobacco are useful in varying degrees of the disease. For more severe cases, different drugs have been investigated but none has shown superior efficacy to that of Glucocorticoids. Currently, different consensus agrees that it is essential to classify the patient according to levels of activity and severity to guide therapy more effectively. Ongoing investigations aim to find a drug that exceeds the existing performance

Evaluación de la ventilación mecánica no invasiva en pacientes con insuficiencia respiratoria aguda / Evaluation of non-invasive ventilation in patients with acute respiratory failure

Antecedentes: Existe evidencia que avala la utilidad de la ventilación mecánica no invasiva (VMNI) en el manejo de la insuficiencia respiratoria aguda (IRA), no obstante, la definición de variables que permitan predecir el éxito o fracaso de este recurso terapéutico es controversial. Objetivo: Evaluar el comportamiento de parámetros clínicos y de laboratorio en relación con el éxito o fracaso de la VMNI en pacientes con IRA. Metodología: Estudio prospectivo de cohorte descriptivo que incluye pacientes consecutivos que cumplieron con criterios de conexión a VMNI e ingresaron a la UPC de Clínica Alemana de Santiago entre marzo de 2005 y julio de 2007. Los pacientes se dividieron en dos grupos, aquellos que fracasan con VMNI y requirieron intubación, grupo fracaso (GF) y los que no la requirieron, grupo éxito (GE). Se registraron variables demográficas, APACHE II, diagnóstico de ingreso. La mecánica respiratoria, gasometría arterial y hemodinámica se obtuvieron en tres momentos de la evolución evolución: previo a la conexión, a las dos horas y al término del uso de VMNI (preintubación y destete de VMNI). Resultados: De los 132 pacientes incluidos se logró evitar la intubación en 99 de ellos (75 por ciento), 33 fueron intubados (25 por ciento), de los cuales 1 falleció. El pH fue menor en el GF (7,42+/-0,06 v/s 7,39+/-0,08; p =0,04). La saturación de oxígeno por pulsioximetría (SpO2) también fue menor en el GF tanto a las dos horas (96+/-2 v/s 95+/-3; p=0,01) como al final del uso de VMNI (96+/-2 v/s 95+/-3; p =0,04). La PaO2/FiO2 fue menor en el mismo grupo, en los tres momentos de medición: previo a la conexión (196+/-66 v/s 144+/-59; p =0,001), a las dos horas (223+/-92 v/s 179+/-88;p =0,022) y al término del uso de VMNI (252+/-78 v/s 208+/-104; p =0,021). Al final del uso de VMNI, tanto la frecuencia cardiaca (FC) (86+/-16 v/s 94+/-20; p =0,03) como el nivel de IPAP (12+/-2 v/s 13+/-3; p =0,02) fueron mayores en el GF. Conclusiones: El GF muestra..

Background: There is evidence supporting the benefits of non-invasive ventilation (NIV) in the treatment of acute respiratory failure (ARF), however, the role of different variables in the evaluation of this technique’s success are controversial. Objective: To evaluate the performance of the different clinical parameters and relate them with the success and failure of NIV in patients with ARF. Methodology: Prospective study of descriptive cohort that includes consecutive patients who fulfilled criteria of connection to NIV and entered to the ICU (Intensive Care Unit)of Clínica Alemana de Santiago between March of 2005 to July 2007. These patients were divided into two groups, those presenting failure with NIV and required intubation, failure group (GF) and those that did not require it, success sgroup (GE). The demographic registered variables measured were APACHE II, diagnosis of entrance were registered. The respiratory mechanics, arterial gasometry and haemodynamics were obtained at three moments of the evolution: previous to the connection, the two hours and at the end of the use of NIV (pre-intubation and weaning of NIV). Results: From the 132 patients included, intubation was avoided in 99 of them (75 percent) 33 percent were entubated from which only 1 died. The pH was lower in the FG (7.42 +/- 0.06v/s 7.39 +/- 0.08; p = 0.04). The oxygen saturation by pulsometry (SpO2), was also lower in the GF after two hours (96+/-2 v/s 95+/-3; p =0.01) and at the end of NIV use (96+/-2 v/s 95+/-3; p =0.04). The PaO2/FiO2 was lower in the same group, at the three moments of measurement: previous to the connection (196+/-66 v/s 144+/-59; p =0.001), two hours post connection (223+/-92 v/s 179+/-88; p =0.022) and at the end of the NIV use (252+/-78 v/s 208+/-104; p =0.021). At the end of the NIV use both, the cardiac frequency (FC) (86+/-16 v/s94+/-20; p =0.03) and the IPAP level (12+/-2 v/s 13+/-3; p=0.02)...