The CORCOBIA study: Cut-off points of Alzheimer's disease CSF biomarkers in a clinical cohort.

INTRODUCTION: The analysis of the core biomarkers of Alzheimer's Disease (AD) in the cerebrospinal fluid (CSF) is recommended in the clinical units where it is available. Because of the absence of universal validated values, the determination of specific cut-off points for each center and its population is recommended. The main objective of the CORCOBIA study was to determine the cut-off points of core AD CSF biomarkers for several centers (Parc de Salut Mar, Barcelona and Hospital General de Granollers), which work with the same reference laboratory (Laboratori de Referència de Catalunya). METHODS: Prospective study including cognitively unimpaired individuals (CU, n = 42), subjects with amnestic mild cognitive impairment (aMCI, n = 35) and patients with dementia due to Alzheimer's Disease (AD, n = 48), in whom clinical and neuropsychological assessment, neuroimaging, APOE genotyping and lumbar puncture to analyse amyloid beta peptides (Aß42, Aß40), total tau (tTau) and phosphorylated Tau (pTau181) using the Lumipulse G600II (Fujirebio) was performed. The values of sensitivity (SE), specificity (SP), predictive values and area under the curve (AUC) were calculated, determining the cut-off point according to the Youden index by comparing the CU and AD groups. RESULTS: The resulting cut-offs and their AUC were the following: Aß42 750 pg/mL (AUC 0.809); Aß42/Aß40 0.062 (AUC 0.78); pTau181 69.85 pg/mL (AUC 0.81); tTau 522.0 pg/mL (AUC 0.79); Aß42/tTau 1.76 (AUC 0.86); Aß42/pTau181 10.25 (AUC 0.86). CONCLUSIONS: The determination of cut-off points of core AD CSF biomarkers for the participating centers allows a better diagnostic accuracy. The ratio CSF Aß42/pTau181 shows the highest AUC and better balance between sensitivity and specificity.

Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d'Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus. / Recomendaciones para la evaluación y manejo de la vía aérea difícil prevista y no prevista de la Societat Catalana d'Anestesiologia, Reanimació i Terapèutica del Dolor, basadas en la adaptación de guías de práctica clínica y consenso de expertos.

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.

Neuropsychological development in the child and adolescent offspring of patients diagnosed with schizophrenia or bipolar disorder: A two-year follow-up comparative study.

There has been growing scientific evidence in recent years that schizophrenia and bipolar disorder share clinical, cognitive, neuroimaging and genetic characteristics. This overlap might also be present in their offspring, who have an increased risk of developing both disorders. Comparing the characteristics of these samples may have important implications for understanding etiological processes. This study aimed to assess the development of cognitive functions over two years in a sample of child and adolescent offspring of patients diagnosed with schizophrenia (SZoff) or bipolar disorder (BDoff), comparing them with a community control group (CCoff). METHODS: 90 BDoff, 41 SZoff and 107 CCoff aged between 6 and 17 years were included at baseline. At the two-year follow-up, 84.9% of the sample was re-assessed (78 BDoff, 32 SZoff and 92 CCoff). All subjects were assessed with a comprehensive neuropsychological test battery at baseline and at the two-year follow-up to evaluate: intelligence quotient, working memory, processing speed, verbal memory and learning, visual memory, executive functions and sustained attention. RESULTS: Processing speed, verbal memory and executive functions showed different developmental patterns among the SZoff, BDoff and CCoff groups. The SZoff group maintained baseline performances in the three variables over time, while the BDoff group presented improved processing speed and executive functioning and the CCoff group showed improvements in verbal memory and executive functions at follow-up. CONCLUSIONS: These findings suggest that the development of some cognitive functions might differ between child and adolescent SZoff and BDoff, indicating different trajectories during neurodevelopment.

Gammadelta T cells as a predictor of surgical relapse of Crohn's disease.

BACKGROUND: We recently demonstrated a decrease in the overall lymphocyte population in the peripheral blood of patients with CD compared to healthy controls and this decrease is more evident in γδ T lymphocytes. The percentages of T cell subsets could reflect the risk of surgical relapse in CD patients. The aim of this study is to study the correlation between αß and γδ T cell subsets in the peripheral blood of patients with CD and the risk for surgery during follow up. METHODS: A prospective study of 102 patients with CD compared with 102 healthy subjects (control group) matched by age and sex was conducted. Lymphocytic populations of CD3+, CD4+, CD8+, CD56+, and αß and γδ T cell subsets were measured in the peripheral blood of all participants. RESULTS: We found evidence of a relationship between lower γδ T cell levels and risk of surgical relapse in CD. The lowest subsets observed in CD patients with surgical relapse were CD3+γδ, CD3+CD8+γδ and CD3+CD56+γδT cells. We observed a relationship between a decrease in γδ T cells and the most severe forms of the disease. The lowest levels of CD3+γδ and CD3+CD8+γδT cells were observed in the fistulizing phenotype. CONCLUSIONS: The deficit of γδ T cells was related with the severity and the risk for surgical relapse in CD patients. Patients with CD3+γδ deficit were more prone to surgery than patients without this deficit. These results suggest that γδ T cells could be used as markers of poor prognosis of CD following the diagnosis of the disease.

Analysis of the strengths and weaknesses of the programs, policies and practices of infant feeding in ecuador

Adequate nutrition during the first two years is important and ensures an adequate development in the human being. The following research evaluates the Global Strategy for Infant and Young Child Feeding (IYCF) for children under 5 years old, hosted by Ecuador in 2002. The tool applied was established by the Asia Group of The International Baby Food Action Network (IBFAN), which was called the World Breastfeeding Trends Initiative (WBTi). WBTi establishes a framework for assessing the compliance that a country has made in implementing the Global Strategy, helps key stakeholders plan and make decisions at various levels of action, and identifies the strengths and weaknesses of their policies and programs. The tool was applied in 23 key stakeholders from the main cities of the country and from the governmental and private sectors who were working actively for the Nutrition of Ecuadorian children. They were selected on the basis of their position and experience in the program evaluated and their willingness to participate. According to WBTi, Ecuador's level of compliance is Low. Three of the ten indicators that evaluated policies and programs scored critically; likewise, two of the five indicators that evaluated practices were scored with a critical score. The deficiencies in complying with the National Policies, Programs, and Coordination showed an important impact on their overall compliance, which, together with a short duration of breastfeeding and the extensive use of bottle feeding, significantly affect the Infant and Young Child Feeding(AU)

Una correcta nutrición durante los dos primeros años de vida es importante y asegura un adecuado desarrollo en el ser humano. La siguiente investigación evalúo la situación del país y los avances alcanzados en implementar la Estrategia Mundial para la Alimentación de Lactantes y Niños Pequeños (ALNP) (menores de 5 años); acogida por Ecuador en el año 2002. La herramienta fue establecida por el grupo de Asia de la Red Internacional de Grupos Pro-Alimentación Infantil (IBFAN), quien la denominó WBTi -World Breastfeeding Trends Initiative- (por sus siglas en inglés). La WBTi, establece un marco referencial para evaluar el cumplimiento de un país en relación a la implementación de la Estrategia Mundial para la ALNP y ayuda a actores claves a planificar y tomar decisiones en varios niveles de acción, identificando las fortalezas y debilidades de sus políticas y programas orientados a la protección, promoción y apoyo de la Alimentación del Infante. La herramienta se aplicó en 23 actores claves del sector privado y gubernamental, de las principales ciudades del país y quienes trabajaban activamente por la Nutrición de los niños del Ecuador. Los informantes claves, se seleccionaron en base a su cargo y experiencia en el programa evaluado y su voluntad a participar. Acorde a la WBTi, Ecuador tiene un nivel de cumplimiento bajo. Tres de los diez indicadores que evaluaron las políticas y programas de la ALNP obtuvieron un puntaje crítico; por otro lado, dos de los cinco indicadores que evaluaron las prácticas de la ALNP se calificaron con un puntaje crítico. La falla en las Políticas, Programas y Coordinación Nacional mostraron un impacto importante en el cumplimiento global de la Estrategia, las que conjuntamente con una corta duración de la lactancia materna y el amplio uso de la alimentación con biberón afectan de forma importante la alimentación del infante en el Ecuador(AU)

Determination of Anti-Anisakis Simplex Antibodies and Relationship with αß and γδ Lymphocyte Subpopulations in Patients with Crohn's Disease.

BACKGROUND: The etiology of Crohn's disease (CD) is still unknown although new theories are based on defects in innate immunity. We have previously shown a decrease in γδ T cells in CD patients. Previous studies have shown a high prevalence of anti-A. simplex immunoglobulins in CD patients. The diminution of γδ T cells in the peripheral blood and intestinal mucosa of CD patients may create a state of immunosuppression that would facilitate A. simplex infection. AIMS: To study the antibody responses to Anisakis antigens in Crohn's disease patients and its relationship with αß and γδ T cell subsets. METHODS: We recruited 81 CD patients and 81 healthy controls. αß and γδ T cell subsets and anti-A. simplex antibodies were measured. RESULTS: Levels of anti-A. simplex IgG and IgM were significantly increased in CD patients. Almost 20% of CD patients were positive for IgG and IgM anti-A. simplex versus only 3.7 and 2.5%, respectively, in normal subjects. However, lower specific IgA levels were observed in the group of CD patients versus healthy subjects. We found an association between CD3 + CD8 + Î³Î´ subset and IgM anti-A. simplex levels. In ileal cases and stricturing behavior of CD, we observed the highest levels of specific antibodies with the exception of anti-A. simplex IgA. CONCLUSIONS: The relationship of specific antibodies with a γδ T cell deficiency makes these cell candidates to play a role in the immune response against Anisakis. In addition, anti-Anisakis antibodies could be considered as markers of risk of progression in CD.

Analysis and evaluation of the effectiveness of epidural analgesia and its relationship with eutocic or dystocic delivery. / Análisis y evaluación de la efectividad de la analgesia epidural y su relación con el parto eutócico o distócico.

OBJECTIVE: Numerous studies have demonstrated the difference in the verbal rating scale with regard to obstructed labour and induced labour, so that obstructed labour and foetal macrosomia have been related to a greater sensation of pain during labour, particularly in the first stage. Even the epidural analgesia is linked to the need for instrumented or caesarean section due to foetal obstruction. The goal of the study is to analyze and evaluate the effectiveness of epidural analgesia in normal versus obstructed labour. PATIENTS AND METHODS: One hundred and eighty pregnant women were included in an observational, analytical, longitudinal and prospective study, that was performed in the Obstetrics Department of the Hospital Universitario Dexeus. All the nulliparous or multiparous over 36 weeks of pregnancy, after 3cm of cervical dilatation in spontaneous or induced labor were included. All the patients were given epidural analgesia according to protocol. RESULTS: The basic descriptive methods were used for the univariate statistical analysis of the sample and the Mann-Whitney U test was used for the comparison of means between both groups. The correlations between variables were studied by means of the Spearman coefficient of correlation. The differences regarded as statistically significant are those whose P<.05. CONCLUSION: In our population there were no statistically significant differences in the effectiveness of epidural analgesia in normal versus obstructed labour. Patients who got epidural analgesia and had obstructed labors have the same degree of verbal rating scale as patients that do not had obstructed labors (P>.05).

Septal flash predicts cardiac resynchronization therapy response in patients with permanent atrial fibrillation.

AIMS: Patients with heart failure (HF) as well as atrial fibrillation (AF) have suboptimal response to cardiac resynchronization therapy (CRT). Identification of mechanical abnormalities, amenable to correction with CRT, might improve the selection of candidates and CRT efficiency. We evaluated whether abnormal septal motion, assessed by the presence of septal flash (SF) is related to CRT response in patients with AF. METHODS AND RESULTS: Ninety-four CRT patients with AF were included. Echocardiography was performed in all subjects at baseline and at 12-month follow-up. Abnormal septal motion was defined by the presence of SF (early septal inward/outward motion within the isovolumic contraction period/QRS duration). Response to CRT was defined as a reduction (>15%) of the end-systolic volume of the left ventricle (LV). Univariate and multivariate analyses were performed to identify the predictors of CRT response. The mean age was 69 ± 8 years, 79% were males, and 59% of patients responded to CRT. Cardiovascular death was 14.4% and all-cause mortality was 16.5% during follow-up. Patients with SF at baseline that was acutely corrected by CRT were significantly more likely to respond than patients without SF. Baseline SF was an independent predictor of CRT response (OR 5.24; 95% CI 1.95-14.11). CONCLUSION: Abnormal septal motion, assessed by the presence of SF, is a mechanism amenable to CRT correction. Its correction is associated with a higher likelihood of CRT response in HF patients with long-standing AF. This could improve the selection of candidates to CRT in a subgroup with particularly poor response and long-term prognosis.

Prevalence of Trypanosoma cruzi infection in pregnant Latin American women and congenital transmission rate in a non-endemic area: the experience of the Valencian Health Programme (Spain).

This study describes the results of the health programme implemented in the Valencian Community (Spain) to achieve an early diagnosis of Chagas disease in pregnant Latin American women and their newborns. During 2009 and 2010, 1975 women living in the health districts of three university hospitals were enrolled via midwives or at the time of delivery. Diagnosis of disease was performed using two serological tests with different antigens. Congenital infection was diagnosed by parasitological, molecular or serological methods from blood samples obtained at birth or in subsequent controls. The overall seroprevalence of Chagas infection in pregnant women from 16 different endemic countries was 11·4%. Infection was higher in those from countries in the Gran Chaco Region (Bolivia, 34·1%; Paraguay, 7·4%; Argentina, 5·3%). Eight newborn infants from Bolivian mothers had congenital Chagas which represents a vertical transmission rate of 3·7%. In conclusion, this work supports the benefits of offering an early diagnosis to pregnant women and newborns during routine prenatal healthcare.

[Horner syndrome and brachial plexus blockade after epidural anesthesia for obstetric labor and cesarean section]. / Síndrome de Horner y bloqueo del plexo braquial tras anestesia epidural para trabajo de parto y cesárea.

A 30-year-old woman (ASA II, obese) in her 40th week of a first pregnancy required epidural analgesia for labor. When the cervix had dilated to 5 cm, the epidural infusion was started with a 9-mL bolus of 0.2% ropivacaine and 50 pg of fentanyl, after a negative test dose. An infusion of 0.2% ropivacaine and 1 microg/mL of fentanyl was started at a rate of 8 mL/h. A cesarean section was required after insufficient progress was made during 8 hours of labor. Eight milliliters of 0.75% ropivacaine was administered to provide anesthesia to T4; cesarean delivery was completed without complications. Early during postoperative recovery, in addition to motor blockade of the legs, the patient experienced a right brachial plexus blockade and Horner syndrome on the same side. Both effects disappeared spontaneously (1 and 4 hours later, respectively).

Crohn's disease and Sweet's syndrome: an uncommon association.

Sweet's syndrome or acute febrile neutrophilic dermatosis (SS) is characterized by the sudden onset of painful erythematous lesions (papules, nodules, and plaques) together with fever and neutrophilia. The lesions are typically located on hands, arms, upper trunk, neck and face, showing an asymmetric distribution. Acute phase reactants are usually elevated and dermal infiltration of neutrophils without vasculitis is seen on skin biopsies. It is considered as a marker of systemic disease in over half of the cases, and is associated with infections, inflammatory bowel disease, autoimmune connective tissue disorders and various neoplasias. Its association with Crohn's disease (CD) is unusual and it appears mainly in association with colonic involvement. Fewer than 50 cases have been published in the medical literature since its first description in 1964, some concurrent with the first episode of CD. We present two patients with Crohn's disease and Sweet's syndrome diagnosed in our department at the time of CD diagnosis, as well as their response to treatment, subsequent course of the disease, and a review of the scientific literature.

[Anesthetic management in a pregnant woman suffering from idiopathic thrombocytopenic purpura]. / Manejo anestésico en gestante afecta de púrpura trombocitopénica idiopática.

Idiopathic thrombocytopenic purpura is an autoimmune disorder characterized by a low platelet count. Onset usually occurs during adolescence with episodes of cutaneous and mucosal bleeding. Thrombocytopenia during pregnancy is associated with many diseases, of which idiopathic thrombocytopenic purpura is the most common in the first trimester. The need for treatment will depend on the platelet count and whether there is bleeding. At the end of pregnancy, however, whether delivery is vaginal or by cesarean, more aggressive therapeutic measures are required. Anesthetic management in this type of patient will be determined by coagulation status and platelet count, and local or regional anesthesia may be contraindicated. We report the case of a pregnant woman with idiopathic thrombocytopenic purpura who was admitted to the emergency department of our hospital with suspected preeclampsia.

[Specialized training in anesthesiology: the opinions of supervising tutors]. / La formación especializada en Anestesiología desde la perspectiva de los tutores.

OBJECTIVE: To evaluate the common curriculum for teaching theoretical knowledge in anesthesiology in Catalonia, Spain; to assess differences between hospital teaching programs, evaluation systems, and the situation for tutors. MATERIAL AND METHODS: A 35-item questionnaire was sent to 49 accredited tutors during the 2005-2006 academic year. The questionnaire covered 1) the curriculum and training rotations, 2) teaching and research, and 3) assessment and tutorial interventions. An additional question asked the respondent's view on how to improve instruction. RESULTS: Eighty-five percent of the tutors responded. Seventy-eight percent of the residents (168/216) follow some form of external rotation, most often in pediatric anesthesia (79%). The common courses are considered useful by 96% of the tutors. Ninety-two percent are satisfied with the current annual examination and 79% would extend the residency training period to 5 years. Eighty-two percent of the teaching centers have weekly instructional sessions. Eighty-one percent of the tutors consider the resident's logbook, filled in by 77% of residents, to be useful for assessment. Eighty-five percent take teacher training courses, 65% feel that their work is being recognized, and 92% do not allot a specific period of time for teaching. CONCLUSIONS: The survey has helped shed light on the current training situation in Catalonia. The common courses are of great help. The number of external rotations is high, overloading certain areas. Improvements could be made by unifying external rotations, updating the curriculum and extending the training period to 5 years, recognizing the role of the tutor, and establishing a specific time for teaching activity.

High prevalence of Blastocystis sp. in pigs reared under intensive growing systems: frequency of ribotypes and associated risk factors.

Three hundred and ninety-five pig fecal samples were analyzed looking for Blastocystis sp. using optical microscopy and PCR. A global prevalence of 46.8% has been observed in this study, although relative values of prevalence differ notably according to the strata examined, ranging from 9.3% in sows to 75% in weaners. Statistic analysis of the data included several risk factors such as different management systems, date of sample collection, fecal consistency, age and sex of the animals. The presence of the parasite was statistically associated to the variables "age" and "date of sample collection", being more prevalent in weaners and grower pigs and warm season. Random fragment-length polymorphism (RFLP-PCR) analysis of positive PCR samples revealed a high homology in the digestion pattern, appearing as two ribotypes. The results were further confirmed by sequencing of ten randomly selected samples, showing that the samples obtained in this study were included in two genotypes: genotype I previously named by Noël et al. [Noël, C., Dufernez, F., Gerbod, D., Edgcomb, V.P., Delgado-Viscogliosi, P., Ho, L.-Ch., Singh, M., Wintjens, R., Sogin, M.L., Capron, M., Pierce, R., Zenner, L., Viscogliosi, E., 2005. Molecular phylogenies of Blastocystis isolates from different hosts: implications for genetic diversity, identification of species, and zoonosis. J. Clin. Microbiol. 43, 348-355], in which Blastocystis sp. sequences from humans, pigs and cattle were included, and genotype II, which only included Blastocystis hominis sequences obtained from human and other primates. This is the first report including Blastocystis sequences from swine origin in genotype II.

A randomized comparison of levobupivacaine, bupivacaine and ropivacaine with fentanyl, for labor analgesia.

BACKGROUND: To compare the analgesic efficacy of epidural infusions of levobupivacaine, bupivacaine and ropivacaine in labor. METHODS: 102 nulliparous parturients in early labor were enrolled in this randomized, double-blind clinical trial. They were randomly assigned to receive one of three continuous epidural infusion regimens: levobupivacaine 0.125%, bupivacaine 0.125% or ropivacaine 0.2%, all with fentanyl 1 microg/mL at 8 mL/h. Supplementary analgesia was provided with an 8-mL epidural bolus of the study solution if visual analogue scale (VAS) score for pain was 40 (0-100 mm). Pain and motor and sensory block were measured at 0, 15 and 30 min, 1, 2, 3 and 4h and full cervical dilatation. RESULTS: Analgesia was satisfactory in all three groups, with VAS score <40 mm at all measurements. VAS scores were greater in those receiving levobupivacaine (P<0.005). Motor block was greater with bupivacaine than levobupivacaine (P<0.01). There were no differences in motor block between levobupivacaine and ropivacaine. There were no other differences between groups. CONCLUSION: All three regimens were effective during first stage of labor although pain scores were higher in those receiving levobupivacaine. Motor block was greater with bupivacaine than with levobupivacaine.

[Anesthetic management for elective cesarean section for a woman with beriberi]. / Manejo anestésico en cesárea electiva de una gestante con enfermedad de beriberi.

Beriberi is a disease caused by thiamine (vitamin B1) deficiency. Peripheral and central nerve involvement causes psychosis and memory loss as well as cardiocirculatory effects. We report the case of a 35-year-old woman 8 weeks pregnant who came to the emergency department after bouts of nausea and vomiting over a period of 6 days, with intolerance of both solids and liquids. The initial diagnosis of gastroenteritis was later changed to hyperemesis gravidarum. Episodes of vomiting and nausea continued 48 hours after admission, accompanied by vertical nystagmus, ataxia, and diminished osteotendinous reflexes. Evaluation of the clinical picture confirmed vitamin B1 deficiency, leading to a diagnosis of Wernicke-Korsakoff syndrome. Symptoms improved with thiamine therapy but did not entirely disappear. The patient was admitted for elective cesarean section at 37 weeks' gestation. Examination revealed neurological involvement (horizontal and vertical nystagmus) and general anesthesia was therefore chosen to assure adequate hemodynamic control given the possibility of cardiocirculatory alteration.

[Airway management in a man with ankylosing spondylitis]. / Manejo de la vía aérea en un paciente con espondilitis anquilosante.

We report a case of difficult airway management in a 41-year-old man with ankylosing spondylitis who was scheduled for total left hip replacement surgery. After several failed attempts to achieve regional anesthesia, we converted to general anesthesia with orotracheal intubation using a fiberoptic bronchoscope. Ankylosing spondylitis leads to fibrosis, ossification, and ankylosis along the spinal column and sacroiliac articulations. Cervical column and atlantooccipital articulation mobility are reduced and in severe cases the cervical vertebrae become fixed in a flexed position. This portion of the spine is also the most susceptible to fracture, particularly in hyperextension, an event that could lead to damage to the cervical spinal cord during maneuvers to manage the airway. Patients with this condition may also have temporomandibular joint involvement, further complicating airway management. We report the case of a patient with ankylosing spondylitis with fixation along the entire spine. The airway was managed by intubation with a fiberoptic bronchoscope. Spontaneous ventilation was maintained during the maneuver, and sedation was achieved with perfusion of remifentanil as the only anesthetic agent following failure of intradural anesthesia.