Guía de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) para el manejo de la vía aérea difícil. Parte I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II.

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I.

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

The Vortex model: A different approach to the difficult airway. / El modelo del Vórtex: una aproximación diferente a una vía aérea difícil.

Airway management is an essential area in anaesthesia, and anaesthesiologists are considered the most expert professionals to manage airway tasks. However, complications related to inadequate airway management remain the most frequent cause of morbidity and mortality. Algorithmic strategy to solve difficulties fails, due to several factors related to its structure and clinical application. The Vortex Approach has emerged as a response to the limitations found in the algorithmic strategy of managing the difficult airway, by using a cognitive aid strategy to reduce cognitive load and fixation error. This new strategy may represent a solution to the elusive problem of the challenging airway and reduce the complications rate.

Approach of clinicians to candiduria and related outcome in the elderly.

OBJECTIVE: Candiduria is increasingly frequent in hospitalized debilitated patients. We aimed to evaluate the approach of clinicians to candiduria in the oldest old, and its effect on clearance and mortality. MATERIAL AND METHODS: An observational study without intervention was carried out during 2012 and 2013 in three Spanish hospitals over patients with nosocomial candiduria aged 80 and over. Following a diagnostic algorithm, we assessed the appropriateness of antifungal therapy and analyzed the impact of the clinical approach (antifungal therapy, antibiotics discontinuation and catheter removal or replacement) on the outcome (mortality at 60 days and resolution, persistence or recurrence of candiduria). RESULTS: Hundred and forty eight patients were included. Symptomatology was attributable to candiduria in 31 instances and 19 asymptomatic patients were found at risk of developing candidemia. In response to culture-results, 77 (52%) of patients were treated with antifungals, mainly fluconazole (97.4%). The use of pharmacological therapy was appropriate (P<0.05) but subtherapeutical doses of fluconazole were widely used and follow-up samples were scarcely submitted. At 60 days of diagnosis the mortality was high (29.7%). The replacement or removal of the catheter resulted in a decrease in mortality and the use of antifungal treatment was associated with recurrence (P<0.05). CONCLUSIONS: In the absence of clinical practice guidelines with enough evidence, our study suggests that catheter removal should always be tried in the elderly with candiduria, since it reduces the mortality. The repetition of culture should help to better characterize the asymptomatic episodes, which are predominant, and to reduce the use of antifungals.

[Antifungal susceptibility of clinical isolates of Scopulariopsis species]. / Sensibilidad a antifúngicos de especies de Scopulariopsis de origen clínico.

INTRODUCTION: Scopulariopsis is a common soil saprophyte. In the last years the infections caused by Scopulariopsis species have increased, included superficial and invasive mycoses. This fungi has been reported resistant in vitro to some antifungal agents, although there is little information about this. The aim of the study was to establish in vitro antifungal susceptibility of clinical isolates of Scopulariopsis species against to broad-spectrum antifungal agents. METHODS: A total of 28 Scopulariopsis strains (10 S. brevicaulis, 7 S. koningii, 3 S. acremonium, 3 S. candida, 3 S. flava, 1 S. brumptii and 1 S. fusca) were tested using Sensititre Yeast One and broth microdilution methods to determine the minimum inhibitory concentrations (MICs) to amphotericin B, fluconazole, itraconazole, posaconazole, voriconazole and 5-fluorocytosine, and minimun effective concentration (MECs) to anidulafungin, caspofungin and micafungin. RESULTS: Our data confirm the high in vitro resistance of Scopulariopsis to antifungal agents. Anidulafungin, caspofungin, micafungin (MICs ≥ 8 mg/L), 5-fluorocytosine (MICs ≥ 64 mg/L), and fluconazole (MICs ≥ 128 mg/L) were inactive in vitro in all species. MICs of amphotericin B (range 2 to ≥ 8 mg/L) and itraconazole (0.5 to ≥ 16 mg/L) were high. The best antifungal activity was observed for posaconazole and voriconazole (0.5 to ≥ 8 mg/L). With Sensititre Yeast One method MICs obtained slightly lower. Scopulariopsis candida, S. flava and S. fusca were the most resistant species, while S. acremonium and S. brevicaulis showed the lowest MICs. CONCLUSIONS: MICs of all tested antifungal agents for Scopulariopsis were very high. Infections caused by Scopulariopsis species may not respond to antifungal treatment. Voriconazole is the drug of choice for treatment. We consider it appropriate to add amphotericin B in serious infections.

Molecular typing of Candida albicans isolates from patients and health care workers in a neonatal intensive care unit.

AIMS: The aim of this study was to investigate the genetic relatedness between Candida albicans isolates and to assess their nosocomial origin and the likeliness of cross-transmission between health care workers (HCWs) and hospitalized neonates in a neonatal intensive care unit (NICU). METHODS: We retrospectively analysed 82 isolates obtained from 40 neonates and seven isolates from onychomycosis of the fingers of five HCWs in a Tunisian NICU by using pulsed-field gel electrophoresis (PFGE) and randomly amplified polymorphic DNA (RAPD) analysis with CA1 and CA2 as primers. RESULTS: In RAPD analysis, the discriminatory power (DP) of CA1 and CA2 primers was 0·86 and 0·81, respectively. A higher DP was achieved by combining patterns generated by both primers (0·92), while PFGE karyotyping exhibited the lowest DP (0·62). The RAPD-CA1/CA2 analysis revealed that 65·8% of isolates obtained from neonates derived from a limited number (6) of groups of genetically identical strains, that five temporal clusterings occurred during the study period and that three HCWs' isolates and 11 isolates obtained from six neonates were identical. CONCLUSIONS: These findings argue for the nosocomial transmission of C. albicans in our NICU and for the transfer of strains from HCWs to patients. SIGNIFICANCE AND IMPACT OF THE STUDY: Identification of relatedness between Candida species obtained from neonates and health care workers by using molecular techniques with high discriminatory power is essential for setting up specific control measures in order to reduce the incidence of nosocomial candidiasis.

Structural and magnetic characterization of self-assembled iron oxide nanoparticle arrays.

We report about a combined structural and magnetometric characterization of self-assembled magnetic nanoparticle arrays. Monodisperse iron oxide nanoparticles with a diameter of 20 nm were synthesized by thermal decomposition. The nanoparticle suspension was spin-coated on Si substrates to achieve self-organized arrays of particles and subsequently annealed at various conditions. The samples were characterized by x-ray diffraction, and bright and dark field high resolution transmission electron microscopy. The structural analysis is compared to magnetization measurements obtained by superconducting quantum interference device magnetometry. We can identify either multi-phase Fe(x)O/γ-Fe(2)O(3) or multi-phase Fe(x)O/Fe(3)O(4) nanoparticles. The Fe(x)O/γ-Fe(2)O(3) system shows a pronounced exchange bias effect which explains the peculiar magnetization data found for this system.

[Dermatophytoses due to anthropophilic fungi in Cadiz, Spain, between 1997 and 2008]. / Dermatofitosis por hongos antropofílicos en Cádiz (1997-2008).

BACKGROUND AND OBJECTIVES: Cutaneous fungal infections are a major public health problem. The distribution of the dermatophytoses varies between countries and geographical areas. The aim of this study was to determine the incidence, epidemiology, etiology, and clinical course of the dermatophytoses caused by anthropophilic fungi in Cadiz, Spain, over the past 12 years. MATERIAL AND METHODS: The study, conducted between 1997 and 2008, included 2,235 samples from lesions of the skin, hair, and nails of 2,220 patients with a clinical suspicion of mycosis. Samples were examined by microscopy using potassium hydroxide and were cultured on mycological media. The dermatophytes were identified by their macroscopic and microscopic characteristics. RESULTS: Cultures were positive in 283 cases (12.7%). Anthropophilic dermatophytes (53.3%) were more common than zoophilic (41.3%) and geophilic (5.3%) dermatophytes. Trichophyton rubrum (38.2%) was the predominant pathogen isolated, followed by Microsporum canis (22.3%) and Trichophyton mentagrophytes (15.5%). Five other species of anthropophilic fungi were identified: Trichophyton tonsurans (5.6%), Trichophyton violaceum (4.9%), Epidermophyton floccosum (2.8%), Trichophyton soudanense (1.0%), and Trichophyton schoenleinii (0.7%). Infections caused by the anthropophilic fungi included tinea unguium (29.1%), tinea corporis (25.8%), tinea pedis (19.2%), tinea cruris (11.9%), tinea capitis (5.3%), and tinea faciei (3.3%). CONCLUSIONS: The principal fungus responsible for dermatomycosis in Cadiz was T. rubrum, and its incidence has been rising since 2000. The prevalence of other anthropophilic fungi, such as T. tonsurans and T. violaceum, has increased, though this is not directly related to immigration. E. floccosum, T. soudanense, and T. schoenleinii are isolated occasionally.

Identification of pathogenic yeast species by polymerase chain reaction amplification of the RPS0 gene intron fragment.

AIMS: This work focuses on the development of a method for the identification of pathogenic yeast. With this aim, we target the nucleotide sequence of the RPS0 gene of pathogenic yeast species with specific PCR primers. PCR analysis was performed with both the genomic DNA, whole cells of clinical isolates of Candida species and clinical samples. METHODS AND RESULTS: A single pairs of primers, deduced from the nucleotide sequence of the RPS0 gene from pathogenic yeast, were used in PCR analysis performed with both the genomic DNA and whole cells of clinical isolates of Candida species and clinical samples. The primers designed are highly specific for their respective species and produce amplicons of the expected sizes and fail to amplify any DNA fragment from the other species tested. The set of primers was tested successfully for the identification of yeast from colonies, blood cultures and clinical samples. These results indicate that genes containing intron sequences may be useful for designing species-specific primers for the identification of fungal strains by PCR. The sensitivity of the method with genomic DNA was evaluated with decreasing DNA concentrations (200 ng to 1 pg) and different cell amounts (10(7)-10(5) cells). CONCLUSION: The results obtained show that the amplification of RPS0 sequences may be suitable for the identification of pathogenic and other yeast species. SIGNIFICANCE AND IMPACT OF THE STUDY: Identification of Candida species using molecular approaches with high discriminatory power is important in determining adequate measures for the interruption of transmission of this yeast. The approach described in this work is based on standard technology, and it is specific, sensitive and does not involve complex and expensive equipment. Furthermore, the method developed in this work not only can be used in eight yeast species, but also provides the basis to design primers for other fungi species of clinical, industrial or environmental interest.

[Fungal peritonitis in ambulatory continuous peritoneal dialysis: description of 10 cases]. / Peritonitis fúngica en diálisis peritoneal continua ambulatoria: descripción de 10 casos.

BACKGROUND: Fungal peritonitis is a rare but serious complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS: During a ten-year period (1999-2008), from a total of 175 patients with chronic renal failure undergoing CAPD, we retrospectively studied 10 cases of fungal peritonitis analyzing the predisposing factors, clinical aspects, etiological agents and treatment. Diagnosis was based on elevated CAPD effluent count (>100/microl) and isolation of fungi on culture. RESULTS: Fungal peritonitis represented 3.6% of all peritonitis episodes. Nine patients had a history of previous bacterial peritonitis and all of them were under antibiotic therapy. Other common findings were: age higher than 70 years old (50%) and diabetes mellitus (40%). Direct microscopic examination of the peritoneal fluid was useful for the suspicion of fungal infection in six patients (60%). The responsible agents for peritonitis were: Candida parapsilosis (4), Candida albicans (2), Candida tropicales (1), Candida glabrata (1), Candida famata (1) and Fusarium oxysporum (1). Intraperitoneal and oral fluconazole, intravenous and oral voriconazole and intravenous amphotericin B were the antifungal agents used in the treatment. As a result of fungal infection, eight patients were transferred to hemodialysis. One patient died before the diagnosis and three other during the episode of peritonitis. CONCLUSIONS: Patients with previous bacterial peritonitis and antibiotic treatment were at greater risk of developing fungal peritonitis. Candida parapsilosis was the most common pathogen. For the successful management of fungal peritonitis besides the antifungal therapy, peritoneal catheter removal was necessary in 60% of patients.

[Susceptibility to antimicrobial agents of rapidly growing mycobacteria]. / Sensibilidad a los antimicrobianos de micobacterias de crecimiento rápido.

Rapidly growing mycobacteria are often associated with human diseases. We investigated the in vitro susceptibilities of 40 isolates to six antimicrobial agents: 17 Mycobacterium fortuitum, 11 M. chelonae and 12 M. abscessus isolated from several human sources: 29 respiratory secretions, 5 cutaneous abscesses, 4 corneal ulcers and 2 urine samples of patients treated at "Hospital Puerta del Mar" (Cádiz). Susceptibility studies were determined by the broth microdilution method for amikacin, clarithromycin, ciprofloxacin, levofloxacin, imipenem and cefoxitin. Results suggest that amikacin is the most effective antimicrobial agent for treating infections due to rapidly growing mycobacteria. Clarithromycin and imipenem show good activity against M. fortuitum and M. abscessus, but not against M. chelonae. Quinolones are only effective against M. fortuitum. It's important to identify, in rapidly growing mycobacteria infections, the etiologic agent to determine correct treatment.

[Antifungal susceptibility of Acremonium species using E-test and Sensititre]. / Sensibilidad a antifúngicos de especies de Acremonium mediante los metodos E-test y Sensititre.

Filamentous fungi have become a common cause of severe infections, especially in immunocompromised patients. In recent years, the number and diversity of the infections caused by Acremonium species have increased and numerous species have been implicated. As is the case for most emerging pathogens, the optimal therapeutic approach to Acremonium species remains to be determined. We used two methods to determine the in vitro susceptibility to amphotericin B, itraconazole and fluconazole for 15 clinical isolates of eight different species of Acremonium. The MICs were determined according to protocol M38-A of the National Committee for Clinical Laboratory Standards (NCCLS) document, using the Sensititre and E-test microdilution methods. Amphotericin B was effective in vitro for few species using the Sensititre method. However, high MICs were obtained with E-test. Fluconazole and itraconazole were ineffective according to both methods. Acremonium species are generally resistant to the most commonly used antifungal agents. Consequently, Acremonium susceptibility testing is recommended to assist in choosing adequate treatment of infections caused by this filamentous fungus.

[Smoking cessation and bupropion: anxiety and depression as predictors of therapeutic efficacy]. / Deshabituación tabáquica y bupropión: la ansiedad y la depresión como índices de eficacia terapéutica.

UNLABELLED: Smoking and depression are related. Bupropion, the first non-nicotinic drug that is an effective treatment in smoking cessation, is a tricyclic antidepressant that inhibits neuronal uptake of serotonin, dopamine and norepinephrine in the thalamic nuclei. OBJECTIVE: To assess if certain personality factors (anxiety or depression) might predict the efficacy of bupropion for smoking cessation. METHOD: The study was carried out in two smoking cessation clinics in Madrid and Barcelona. Fifty patients (21 men) declaring the desire to quit smoking were enrolled. Their mean age was 43.6 years (SD 8.75). The patients were treated with 300 mg of bupropion per day for one month and expired CO was monitored for 6 months. Personality factors were assessed on a hospital anxiety and depression scale (HADS). We evaluated whether there was a significant difference in HADS scores for patients who were still not smoking after 6 months and those who had not managed to quit. RESULTS: The 50 patients were smokers of a mean 39 packs per year (SD 17.82) and had mean scores of 7.4 (SD 4.15) for anxiety and 5.8 (SD 3.93) for depression. Four patients (8%) were unable to complete the study. After one month, 28% of the patients smoked, after 3 months 56% smoked and after 6 months 58% still smoked. The patients who smoked during the first month had higher depression scores than did the non-smokers (p = 0.03). After 3 and 6 months the patients who had managed to continue not smoking were those who had higher anxiety scores than did those who still smoked (p = 0.0052 at 3 months and p = 0.017 at 6 months). CONCLUSION: Patients who responded better to treatment with bupropion after 6 months of follow-up were those with higher anxiety scores on the HADS. Depression levels influenced outcome only during the first month.

Extracellular enzymatic activity in 11 Cryptococcus species.

The extracellular enzymatic activity of 36 strains of yeast belonging to 11 species of the genus Cryptococcus, has been investigated, using the API-ZYM (BioMérieux, France) commercial system, with the objective of determining the differences in the enzymatic profiles of the various species. The strains studied were: 9 of C. neoformans, 7 of C. albidus, 6 of C. laurentii, 5 of C. uniguttulatus, 3 of C. humicolus, and 1 each of C. ater, C. curvatus, C. dimennae, C. hungaricus, C. infirmo-miniatus and C. magnus. All the strains showed enzymatic activity with positivity to Phosphatase alkaline, Esterase lipase C8, Leucine arylamidase, Phosphatase acid and Naphthol-AS-BI-phosphohydrolase, and negativity to Lipase C14, Trypsin, Chemotrypsin, beta-galactosidase, beta-glucuronidase and alpha-manosidase. Variable enzymatic activity was shown to Esterase C4, Valine arylamidase, Cystine arylamidase, alpha-galactosidase, alpha-glucosidase, beta-glucosidase, N-acetyl-beta-glucosaminidase and alpha-fucosidase. This allowed 11 separate enzymatic patterns to be established. The species C. neoformans and C. laurentii each presented two distinct patterns; C. uniguttulatus, C. hungaricus and C. magnus shared the same pattern; C. albidus, C. ater, C. curvatus, C. dimennae, C. humicolus and C. infirmo-miniatus presented an individual enzymatic pattern. The results obtained suggest that the API-ZYM system could be useful for the identification of species of the genus Cryptococcus and for the differentiation of the enzymotypes for epidemiological purposes.