Online team-based electrocardiogram training in Haiti: evidence from the field.

BACKGROUND: The electrocardiogram (ECG) is the most relied upon tool for cardiovascular diagnosis, especially in low-resource settings because of its low cost and straightforward usability. It is imperative that internal medicine (IM) and emergency medicine (EM) specialists are competent in ECG interpretation. Our study was designed to improve proficiency in ECG interpretation through a competition among IM and EM residents at a teaching hospital in rural central Haiti in which over 40% of all admissions are due to CVD. METHODOLOGY: The 33 participants included 17 EM residents and 16 IM residents from each residency year at the Hôpital Universitaire de Mirebalais (HUM). Residents were divided into 11 groups of 3 participants with a representative from each residency year and were given team-based online ECG quizzes to complete weekly. The format included 56 ECG cases distributed over 11 weeks, and each case had a pre-specified number of points based on abnormal findings and complexity. All ECG cases represented cardiovascular pathology in Haiti adapted from the Association of Program Directors in Internal Medicine evaluation list. The main intervention was sharing group performance and ECG solutions to all participants each week to promote competition and self-study without specific feedback or discussion by experts. To assess impact, pre- and post-intervention assessments measuring content knowledge and comfort for each participant were performed. RESULTS: Overall group participation was heterogeneous with groups participating a median of 54.5% of the weeks (range 0-100%). 22 residents completed the pre- and post-test assessments. The mean pre- and post-intervention assessment knowledge scores improved from 27.3% to 41.7% (p = 0.004). 70% of participants improved their test scores. The proportion of participants who reported comfort with ECG interpretation increased from 57.6% to 66.7% (p = 0.015). CONCLUSION: This study demonstrates improvement in ECG interpretation through a team-based, asynchronous ECG competition approach. This method is easily scalable and could help to fill gaps in ECG learning. This approach can be delivered to other hospitals both in and outside Haiti. Further adaptations are needed to improve weekly group participation.

Does distance from a clinic and poverty impact visit adherence for noncommunicable diseases? A retrospective cohort study using electronic medical records in rural Haiti.

BACKGROUND: Adherence to regular outpatient visits is vital to managing noncommunicable diseases (NCDs), a growing burden in low and middle-income countries. We characterized visit adherence among patients with NCDs in rural Haiti, hypothesizing higher poverty and distance from the clinic were associated with lower adherence. METHODS: We analyzed electronic medical records from a cohort of adults in an NCD clinic in Mirebalais, Haiti (April 2013 to June 2016). Visit adherence was: 1) visit constancy (≥1 visit every 3 months), 2) no gaps in care (> 60 days between visits), 3) ≥1 visit in the last quarter, and 4) ≥6 visits per year. We incorporated an adapted measure of intensity of multidimensional poverty. We calculated distance from clinic as Euclidean distance or self-reported transit time. We used multivariable logistic regressions to assess the association between poverty, distance, and visit adherence. RESULTS: We included 463 adult patients, mean age 57.8 years (SE 2.2), and 72.4% women. Over half of patients had at least one visit per quarter (58.1%), but a minority (19.6%) had no gaps between visits. Seventy percent of patients had a visit in the last quarter, and 73.9% made at least 6 visits per year. Only 9.9% of patients met all adherence criteria. In regression models, poverty was not associated with any adherence measures, and distance was only associated with visit in the last quarter (OR 0.87, 95% CI [0.78 to 0.98], p = 0.03) after adjusting for age, sex, and hardship financing. CONCLUSIONS: Visit adherence was low in this sample of adult patients presenting to a NCD Clinic in Haiti. Multidimensional poverty and distance from clinic were not associated with visit adherence measures among patients seen in the clinic, except for visit in the last quarter. Future research should focus on identifying and addressing barriers to visit adherence.

Overexpression of the immediate-early genes Egr1, Egr2, and Egr3 in two strains of rodents susceptible to audiogenic seizures.

Genetic animal models of epilepsy are an important tool for further understanding the basic cellular mechanisms underlying epileptogenesis and for developing novel antiepileptic drugs. We conducted a comparative study of gene expression in the inferior colliculus, a nucleus that triggers audiogenic seizures, using two animal models, the Wistar audiogenic rat (WAR) and the genetic audiogenic seizure hamster (GASH:Sal). For this purpose, both models were exposed to high intensity auditory stimulation, and 60min later, the inferior colliculi were collected. As controls, intact Wistar rats and Syrian hamsters were subjected to stimulation and tissue preparation protocols identical to those performed on the experimental animals. Ribonucleic acid was isolated, and microarray analysis comparing the stimulated Wistar and WAR rats showed that the genomic profile of these animals displayed significant (fold change, |FC|≥2.0 and p<0.05) upregulation of 38 genes and downregulation of 47 genes. Comparison of gene expression profiles between stimulated control hamsters and stimulated GASH:Sal revealed the upregulation of 10 genes and the downregulation of 5 genes. Among the common genes that were altered in both models, we identified the zinc finger immediate-early growth response gene Egr3. The Egr3 protein is a transcription factor that is induced by distinct stress-elicited factors. Based on immunohistochemistry, this protein was expressed in the cochlear nucleus complex, the inferior colliculus, and the hippocampus of both animal models as well as in lymphoma tumors of the GASH:Sal. Our results support that the overexpression of the Egr3 gene in both models might contribute to neuronal viability and development of lymphoma in response to stress associated with audiogenic seizures. This article is part of a Special Issue entitled "Genetic and Reflex Epilepsies, Audiogenic Seizures and Strains: From Experimental Models to the Clinic".

Total and mutated EGFR quantification in cell-free DNA from non-small cell lung cancer patients detects tumor heterogeneity and presents prognostic value.

Mutation analysis of epidermal growth factor receptor (EGFR) gene is essential for treatment selection in non-small cell lung cancer (NSCLC). Analysis is usually performed in tumor samples. We evaluated the clinical utility of EGFR analysis in plasma cell-free DNA (cfDNA) from patients under treatment with EGFR inhibitors. We selected 36 patients with NSCLC and EGFR-activating mutations. Blood samples were collected at baseline and during treatment with EGFR inhibitors. Wild-type EGFR, L858R, delE746-A750, and T790M mutations were quantified in cfDNA by droplet digital PCR. Stage IV patients had higher total circulating EGFR copy levels than stage I (3523 vs. 1003 copies/mL; p < 0.01). There was high agreement for activating mutations between baseline cfDNA and tumor samples, especially for L858R mutation (kappa index = 0.679; p = 0.001). In 34 % of advanced NSCLC patients, we detected mutations in cfDNA not previously detected in tumor samples and double mutations in 17 %. Patients with baseline total EGFR copy levels above the median presented decreased overall survival (OS) (341 vs. 870 days, p < 0.05) and progression-free survival (PFS) (238 vs. 783 days; p < 0.05) compared with those with total EGFR copy levels below the median. Patients with baseline concentrations of activating mutations above the median (94 copies/mL) had lower OS (317 vs. 805 days; p < 0.05) and PFS (195 vs. 724 days; p < 0.05). During follow-up, T790M resistance mutation was detected in 53 % of patients. Total and mutated EGFR analysis in cfDNA seems a relevant tool to characterize the molecular profile and prognosis of NSCLC patients harboring EGFR mutations.

Molecular characterization and clonal diversity of methicillin-susceptible Staphylococcus aureus in milk of cows with mastitis in Brazil.

Mastitis is an important disease for the dairy industry worldwide, causing economic losses and reducing milk quality and production. Staphylococcus aureus is a worldwide agent of this intramammary infection, which also causes foodborne diseases. The objective of this study was to determine the frequency of methicillin-susceptible Staphylococcus aureus (MSSA) isolates in milk of mastitis cows in Brazil and to analyze the genetic lineages and the content of antimicrobial resistance genes and virulence factors among these isolates. Fifty-six MSSA isolates were recovered from 1,484 milk samples (positive for the California mastitis test) of 518 cows from 11 different farms in Brazil (representing 51% of total Staph. aureus obtained), and they were further characterized. Methicillin-susceptible Staphylococcus aureus were isolated from 3.7% of California mastitis test-positive tested milk samples and from 6.2% of tested mastitic cows. Methicillin-susceptible Staphylococcus aureus isolates were characterized by spa typing, agr typing, and multilocus sequence typing, and resistance and virulence traits were investigated by PCR. Seven spa types were identified among MSSA (% of isolates): t127 (44.6), t605 (37.5), t002, t1784, t2066 (1.8), and 2 new ones: t10856 (10.7) and t10852 (1.8). Five distinct sequence types (ST) were detected (% of isolates): ST1 (46.4), ST126 (37.5), ST133 (10.7), ST5 (3.6), and a novel ST registered as ST2493 (1.8). Resistances were detected for streptomycin, chloramphenicol, and tetracycline. One strain contained the chloramphenicol resistance gene (fexA; included within transposon Tn558) and 3 strains contained the tetracycline resistance gene [tet(K)]. Methicillin-susceptible Staphylococcus aureus strains were susceptible to most of the antibiotics studied and lacked the virulence genes of Panton-Valentine leukocidin (lukF/S-PV), toxic shock syndrome toxin 1 (tst), exfoliative toxin A (eta), and exfoliative toxin B (etb), as well as the genes of the immune evasion cluster. Methicillin-susceptible Staphylococcus aureus isolates were detected in a relatively low proportion of cows with mastitis (6.2%) and recovered isolates presented high diversity of genetic lineages, with CC1 and CC126 the predominant clonal complexes, and CC133 also being detected. Larger epidemiological studies with molecular characterization of isolates are required to deepen the knowledge on the circulating genetic lineages among the cow population with mastitis.

Functional phenotypic plasticity mediated by water stress and [CO2] explains differences in drought tolerance of two phylogenetically close conifers.

Forests are threatened globally by increased recurrence and intensity of hot droughts. Functionally close coexisting species may exhibit differences in drought vulnerability large enough to cause niche differentiation and affect forest dynamics. The effect of rising atmospheric [CO2], which could partly alleviate the negative effects of drought, may also differ between species. We analysed functional plasticity in seedlings of two taxonomically close pine species (Pinus pinaster Ait., Pinus pinea L.) under different [CO2] and water stress levels. The multidimensional functional trait variability was more influenced by water stress (preferentially xylem traits) and [CO2] (mostly leaf traits) than by differences between species. However, we observed differences between species in the strategies followed to coordinate their hydraulic and structural traits under stress. Leaf 13C discrimination decreased with water stress and increased under elevated [CO2]. Under water stress both species increased their sapwood area to leaf area ratios, tracheid density and xylem cavitation, whereas they reduced tracheid lumen area and xylem conductivity. Pinus pinea was more anisohydric than P. pinaster. Pinus pinaster produced larger conduits under well-watered conditions than P. pinea. Pinus pinea was more tolerant to water stress and more resistant to xylem cavitation under low water potentials. The higher xylem plasticity in P. pinea, particularly in tracheid lumen area, expressed a higher capacity of acclimation to water stress than P. pinaster. In contrast, P. pinaster coped with water stress comparatively more by increasing plasticity of leaf hydraulic traits. Despite the small differences observed in the functional response to water stress and drought tolerance between species, these interspecific differences agreed with ongoing substitution of P. pinaster by P. pinea in forests where both species co-occur. Increased [CO2] had little effect on the species-specific relative performance. Thus, a competitive advantage under moderate water stress of P. pinea compared with P. pinaster is expected to continue in the future.

Antigiardial Activity of Foeniculum vulgare Hexane Extract and Some of Its Constituents.

Foeniculum vulgare is used for the treatment of diarrhea in Mexican traditional medicine. Hexane extract showed 94 % inhibition of Giardia duodenalis trophozoites at 300 µg/mL. Therefore, 20 constituents of hexane extract were evaluated to determine their antigiardial activity. Interestingly, six compounds showed good activity toward the parasite. These compounds were (1R,4S) (+)-Camphene (61%), (R)(-)-Carvone (66%), estragole (49%), p-anisaldehyde (67%), 1,3-benzenediol (56%), and trans, trans-2,4-undecadienal (97%). The aldehyde trans, trans-2,4-undecadienal was the most active compound with an IC50 value of 72.11 µg/mL against G. duodenalis trophozoites. This aldehyde was less toxic (IC50 588.8 µg/mL) than positive control metronidazole (IC50 83.5 µg/mL) against Vero cells. The above results could support the use of F. vulgare in Mexican traditional medicine.

Evaluating resident involvement and the 'July effect' in parotidectomy.

OBJECTIVE: This study aimed to evaluate the effect of resident involvement and the 'July effect' on peri-operative complications after parotidectomy. METHOD: The American College of Surgeons National Surgical Quality Improvement Program database was queried for parotidectomy procedures with resident involvement between 2005 and 2014. RESULTS: There were 11 733 cases were identified, of which 932 involved resident participation (7.9 per cent). Resident involvement resulted in a significantly lower reoperation rate (adjusted odds ratio, 0.18; 95 per cent confidence interval, 0.05-0.73; p = 0.02) and readmission rate (adjusted odds ratios 0.30; 95 per cent confidence interval, 0.11-0.80; p = 0.02). However, resident involvement was associated with a mean 24 minutes longer adjusted operative time and 23.5 per cent longer adjusted total hospital length of stay (respective p < 0.01). No significant difference in surgical or medical complication rates or mortality was found when comparing cases among academic quarters. CONCLUSION: Resident participation is associated with significantly decreased reoperation and readmission rates as well as longer mean operative times and total length of stay. Resident transitions during July are not associated with increased risk of adverse peri-operative outcomes after parotidectomy.

Successful treatment of three cases of primary extramammary Paget's disease of the vulva with Imiquimod--proposal of a therapeutic schedule.

BACKGROUND/AIM: Extramammary Paget's disease (EMPD) is an intraepidermal adenocarcinoma of apocrine gland-bearing skin. Although surgery remains the mainstay of treatment, loss of tissue function and high recurrence rates have been reported. Recently, topical Imiquimod has been shown as a safe and effective treatment option for extramammary Paget's disease. METHODS: Three patients diagnosed of EMPD of the vulva were treated with a daily application of 5% Imiquimod cream for three weeks, followed by an every other day application for an additional three weeks. RESULTS: Complete clinical and histological remission of the disease was achieved in the three patients. Mild irritation and tenderness were observed as the only side effects. CONCLUSION: Based on our results, we consider that Imiquimod cream is a safe and effective therapeutic option for the treatment of vulvar EMPD. These promising results warrant further studies to determine the real efficacy and safety of Imiquimod 5% cream for the treatment of this uncommon disease.

High Poverty and Hardship Financing Among Patients with Noncommunicable Diseases in Rural Haiti.

Background: Poverty is a major barrier to healthcare access in low-income countries. The degree of equitable access for noncommunicable disease (NCD) patients is not known in rural Haiti. Objectives: We evaluated the poverty distribution among patients receiving care in an NCD clinic in rural Haiti compared with the community and assessed associations of poverty with sex and distance from the health facility. Methods: We performed a cross-sectional study of patients with NCDs attending a public-sector health center in rural Haiti 2013-2016, and compared poverty among patients with poverty among a weighted community sample from the Haiti 2012 Demographic and Health Survey. We adapted the multidimensional poverty index: people deprived ≥44% of indicators are among the poorest billion people worldwide. We assessed hardship financing: borrowing money or selling belongings to pay for healthcare. We examined the association between facility distance and poverty adjusted for age and sex using linear regression. Results: Of 379 adults, 72% were women and the mean age was 52.5 years. 17.7% had hypertension, 19.3% had diabetes, 3.1% had heart failure, and 33.8% had multiple conditions. Among patients with available data, 197/296 (66.6%) experienced hardship financing. The proportions of people who are among the poorest billion people for women and men were similar (23.3% vs. 20.3%, p > 0.05). Fewer of the clinic patients were among the poorest billion people compared with the community (22.4% vs. 63.1%, p < 0.001). Patients who were most poor were more likely to live closer to the clinic (p = 0.002). Conclusion: Among patients with NCD conditions in rural Haiti, poverty and hardship financing are highly prevalent. However, clinic patients were less poor compared with the community population. These data suggest barriers to care access particularly affect the poorest. Socioeconomic data must be collected at health facilities and during community-level surveillance studies to monitor equitable healthcare access. Highlights: Poverty and hardship financing are highly prevalent among NCD patients in rural Haiti.Patients attending clinic are less poor than expected from the community.People travelling farther to clinic are less poor.Socioeconomic data should be collected to monitor healthcare access equity.

[Sensibility of Entamoeba histolytica trophozoites to ivermectin]. / Sensibilidad de trofozoítos de Entamoeba histolytica a ivermectina.

Amebiasis caused by Entamoeba histolytica is a problem of public world health. The most frequent clinical presentation are the dysentery and the amebic liver abscess. Fifty millions of cases and more than 100.000 deaths for this disease are reported annually worldwide. The life cycle of E. histolytica has two phases: trophozoite and cyst. Trophozoites are the causal agent of disease. The effective treatment for the amebiasis includes drugs with serious collateral effects. Ivermectin is a macrolid with activity against endoparasites and ectoparasites causing strongiloidosis, filariasis, oncocercosis, scabiasis and pediculosis. The use of ivermectin has been extended almost worldwide; it is recognized as a safe drug. The main objective of this study was to determine in vitro sensibility of trophozoites of E. histolytica was to the treatment with ivermectin. To determine the sensibility of the parasites to the drug, E. histolytica was cultivated in PEHPS medium. During its logarithmic growth phase the trophozoites were exposed to different concentrations of ivermectin. As controls other antiparasitic drugs were used. For each drug, serial dilutions were prepared, and mixed in culture tubes with parasites (2 x 104 cells/ml). They were incubated for 72 h and then the percentage of growth inhibition was calculated by Probit analysis. Ivermectin showed activity against trophozoites of E. histolytica. The 50% of growth inhibition of ivermectin was 6.40 mg/ml. This dose was higher than for other anti parasitic drugs. Its activity in vivo in animal models remains to be demonstrated.

[Spanish translation and validation of the Neuromuscular Module of the Pediatric Quality of Life Inventory (PedsQL): evaluation of the quality of life perceived by 5-7 years old children with neuromuscular disorders and by their parents]. / Traducción y validación al español del módulo neuromuscular de la escala Pediatric Quality of Life Inventory (PedsQL): evaluación de la calidad de vida autopercibida por niños de 5-7 años con enfermedades neuromusculares y sus padres.

INTRODUCTION: The recent advances in the therapies for some neuromuscular disorders imply a better prognosis. As a consequence, health-related quality of life has emerged as a core outcome. It is particularly important to know both the self-perceived health-related quality of life by children, as soon as possible, as well as the parental perception. Therefore, it is essential to have valid and specific scales for proper assessment. AIM: To assess the validity and reliability of the Spanish version of Pediatric Quality of Life Inventory (PedsQL) Neuromuscular Module for self-perceived and parent perceived quality of life of children aged 5-7 with neuromuscular disorders. SUBJECTS AND METHODS: Cross-cultural validity of the Spanish version was carried out with the permission of the Mapi-Research-Trust. Subsequently, a test-retest was administered to 27 children aged 5-7 and 37 parents in order to evaluate internal consistency, intra-observer reliability and construct validity. RESULTS: The Cronbach alpha coefficient showed good internal consistency for children and was rated as excellent by parents. Furthermore, the intra-observer correlation indicated an excellent reliability for both. Construct validity analysis suggested that a new scale structure with more dimensions might be more adequate. Moreover, said structure will also explain a greater percentage of variability. CONCLUSION: The Spanish version of PedsQL Neuromuscular Module for the self-perceived and parent-perceived quality of life of children aged 5-7 showed good internal consistency and reliability.

TITLE: Traducción y validación al español del módulo neuromuscular de la escala Pediatric Quality of Life Inventory (PedsQL): evaluación de la calidad de vida autopercibida por niños de 5-7 años con enfermedades neuromusculares y sus padres.Introducción. Los recientes avances en el abordaje terapéutico de las enfermedades neuromusculares pediátricas han permitido un mejor pronóstico y, en consecuencia, surge la necesidad de medir la calidad de vida relacionada con la salud como parte de un abordaje integral. Es importante disponer de instrumentos válidos y específicos para su correcta valoración que contemplen la calidad de vida relacionada con la salud tanto autopercibida por los niños como por los padres. Objetivo. Evaluar la validez y la fiabilidad de la versión española del módulo neuromuscular de la Pediatric Quality of Life Inventory (PedsQL) para la medición de la calidad de vida autopercibida por niños de 5 a 7 años con enfermedades neuromusculares y la de sus padres. Sujetos y métodos. Con autorización de Mapi-Research-Trust, se procedió a la adaptación transcultural de la versión española de la escala. Posteriormente, se realizó un test-retest a 27 niños de 5 a 7 años y a 37 padres para evaluar la consistencia interna, la fiabilidad y la validez de constructo. Resultados. El coeficiente alfa de Cronbach mostró una consistencia interna buena para los niños y excelente para los padres. La correlación intraobservador indicó una excelente fiabilidad para ambos. La validez de constructo sugirió que una estructura de más dimensiones podría ser más adecuada y explicaría un mayor porcentaje de variabilidad. Conclusiones. La versión española del módulo neuromuscular de la PedsQL para evaluar calidad de vida de niños de 5 a 7 años con enfermedades neuromusculares y de sus padres tiene buena consistencia interna y fiabilidad.

Salbutamol tolerability and efficacy in patients with spinal muscular atrophy type II.

Spinal muscular atrophy (SMA) is an autosomal recessive disease caused by homozygous deletions or loss-of-function mutations in SMN1, which result in a degeneration of motor neurons in the spinal cord and brain stem. Even without a randomized placebo-controlled trial, salbutamol has been offered to patients with SMA in the neuromuscular clinics of most of hospitals for many years. We describe the response to salbutamol in 48 patients with SMA type II who were not taking any other medication. We investigate the changes over an eighteen-month period in motor functional scales and we analyze side effects and subjective response to treatment. Our results suggest that oral administration of salbutamol might be helpful in the maintenance of motor function in patients with SMA type II. An apparent beneficial effect was observed in functional scales of children under the age of 6, especially during the first 6 months of therapy. The majority of patients of all ages referred some kind of subjective positive effect associated with therapy intake. Salbutamol seemed safe and was well tolerated without serious side effects.

Constructing 3D crystal templates for photonic band gap materials using holographic optical tweezers.

A simple and robust method is presented for the construction of 3-dimensional crystals from silica and polystyrene microspheres. The crystals are suitable for use as templates in the production of three-dimensional photonic band gap (PBG) materials. Manipulation of the microspheres was achieved using a dynamic holographic assembler (DHA) consisting of computer controlled holographic optical tweezers. Attachment of the microspheres was achieved by adjusting their colloidal interactions during assembly. The method is demonstrated by constructing a variety of 3-dimensional crystals using spheres ranging in size from 3 microm down to 800 nm. A major advantage of the technique is that it may be used to build structures that cannot be made using self-assembly. This is illustrated through the construction of crystals in which line defects have been deliberately included, and by building simple cubic structures.

High throughput method to characterize acid-base properties of insoluble drug candidates in water.

In drug design experimental characterization of acidic groups in candidate molecules is one of the more important steps prior to the in-vivo studies. Potentiometry combined with Yasuda-Shedlovsky extrapolation is one of the more important strategy to study drug candidates with low solubility in water, although, it requires a large number of sequences to determine pKa values at different solvent-mixture compositions to, finally, obtain the pKa in water (pwwKa) by extrapolation. We have recently proposed a method which requires only two sequences of additions to study the effect of organic solvent content in liquid chromatography mobile phases on the acidity of the buffer compounds usually dissolved in it along wide ranges of compositions. In this work we propose to apply this method to study thermodynamic pwwKa of drug candidates with low solubilities in pure water. Using methanol/water solvent mixtures we study six pharmaceutical drugs at 25 °C. Four of them: ibuprofen, salicylic acid, atenolol and labetalol, were chosen as members of carboxylic, amine and phenol families, respectively. Since these compounds have known pwwKa values, they were used to validate the procedure, the accuracy of Yasuda-Shedlovsky and other empirical models to fit the behaviors, and to obtain pwwKa by extrapolation. Finally, the method is applied to determine unknown thermodynamic pwwKa values of two pharmaceutical drugs: atorvastatin calcium and the two dissociation constants of ethambutol. The procedure proved to be simple, very fast and accurate in all of the studied cases.

[Knowledge and attitudes of health care professionals in advance healthcare directives]. / Conocimientos y actitudes sobre voluntades anticipadas en profesionales sanitarios.

BACKGROUND AND OBJECTIVE: The advanced healthcare directive is a new style of health care relationship, based on the respect of the patients autonomous decisions: as well as a valuable tool that enables a proper management of the decisions made at the end of life. The objective of this study was to explore the knowledge and attitudes of the health care professionals regarding the advance directives, as well as the resources for advanced care planning in a municipality of Madrid during 2016-2017. MATERIAL AND METHODS: A cross-sectional descriptive study was carried out on a population of Health care professionals of Primary and Specialised Care. The knowledge and attitudes questionnaire about the advance directives was used. Sociodemographic and knowledge variables related to resources for the advanced care planning. Statistical-descriptive analysis was performed. RESULTS: A total of 431 professionals were included, with a mean age of 44.55 years (SD: 11.1). As regards knowledge about advance directives, the mean score was 5.08 (SD 2.4), with statistically significant differences being found between professional groups. A small percentage (4.6%) of the professionals had their document of Advance directives ready, and 42% of professionals did not know if they were regulated by the Community of Madrid. Less than half (41.5%) of the professionals knew the palliative resources of their institution. CONCLUSIONS: The health care professional's knowledge about advance directives, as well as the resources for the advanced care planning, show deficiencies at training and information level. Almost half of the professionals did not know if these are regulated in the Community of Madrid. They also believe that it would be useful to plan, and very useful to have the Advance directives document ready.

[Environmental tobacco smoke and pneumonia in children living in Monterrey, México]. / Humo de Tabaco Ambiental y Neumonías en Niños de Monterrey, México.

OBJECTIVE: Acute respiratory diseases occupy the first 5 places in infantile morbidity and mortality around the world, two million children directly dying from such cause annually. Environmental tobacco smoke (ETS) contains toxic and irritating compounds having an injurious effect on health, producing increased risk of morbidity and mortality in non-smoking adults and children. Our main objective was determining the association between ETS and pneumonia in children. MATERIAL AND METHODS: This was an unmatched case and controls hospital-based study. Odds ratio (OR) and 95% confidence interval (CI) were calculated. RESULTS: A total of 285 patients (142 cases and 143 controls) were studied; 47,4 % of the patients were female and average age was 4,5,+2,7. OR for patients being exposed to ETS developing pneumonia was 3,44 (CI: 2,11-5,6). DISCUSSION: Children being exposed to ETS increases the risk of developing pneumonia by more than threefold.

[Bilateral testicular tumours]. / Tumores bilaterales de testículo.

OBJECTIVES: To study the incidence and characteristic of the bilateral tumours of testicle. MATERIAL AND METHODS: It was carried out a retrospective study on a database of testiculars tumours 98 tried in our service among the years 1979 and 2004. RESULTS: We registered 4 cases of bilateral tumours (4,1%) in the series. The interval of appearance of the second tumor oscillated between 14 months and 4 and a half years (being the medium of 47 months). In three cases the initial tumour was an embryonic Carcinoma and in one a tumour of Lydia. In two cases the second tumour was of the same type histological (embryonic Ca and tumour of Leydig), while in the other two cases of embryonic Ca, the second tumour was a seminoma and a teratocarcinoma. Regarding the histology of the first tumour, it was observed that only 3 of the 27 embryonic Ca (11%) of our series, they experienced a second neoplasia in front of 1 of the 2 tumours of Leydig (50%). CONCLUSIONS: The incidence of bilateral tumours in our series was of 4,1%. In our series the risk of the second tumour seems to be higher in patients with Leyding tumours, therefore the lesser number of tumours do not allow us to know significantly conclusions.

[Current status of congenital myasthenic syndromes]. / Estado actual de los sindromes miastenicos congenitos.

Since Engel reported the first case of congenital myasthenia in 1977 and the first pathogenic gene was found in 1995, knowledge about congenital myasthenic syndromes has continued to grow. Over the years, the pathogenic basis, its clinical features, the phenotype-genotype correlations that have been established and its therapeutic management have all been described. In this group of diseases the safety margin of neuromuscular transmission is altered by different mechanisms: in the synthesis or storage of acetylcholine quanta in the synaptic vesicles, in the calcium-mediated release of acetylcholine in the nerve terminal or in the efficiency of the quantum released to generate a post-synaptic depolarisation. Increased knowledge about them has enabled a number of different therapeutic strategies to be established. In this review the main updates on these syndromes are reported, including: the genes described as classifying 50% of cases, their current classification based on the localisation of the proteins that alter neuromuscular transmission, including a new group of congenital myasthenias, glycosylation disorders, the main key diagnoses and the therapeutic management of this group of under-diagnosed patients.

TITLE: Estado actual de los sindromes miastenicos congenitos.Desde la descripcion de Engel del primer caso de miastenia congenita en 1977 y el hallazgo en 1995 del primer gen patogeno, el conocimiento de los sindromes miastenicos congenitos se ha ido desarrollando, y se han descrito la base patogena, sus caracteristicas clinicas, las correlaciones fenotipo-genotipo establecidas y su abordaje terapeutico. En este grupo de enfermedades se altera el margen de seguridad de la transmision neuromuscular por distintos mecanismos: en la sintesis o almacenamiento de los quantum de acetilcolina en las vesiculas sinapticas, en la liberacion de acetilcolina en el nervio terminal mediada por calcio o en la eficiencia de la cuanta liberada para generar una despolarizacion postsinaptica. Su conocimiento ha permitido establecer distintas estrategias terapeuticas. En esta revision se describen las principales actualizaciones de estos sindromes: los genes descritos que clasifican un 50% de los casos, su clasificacion actual basandose en la localizacion de las proteinas que alteran la transmision neuromuscular, incluyendo un nuevo grupo de miastenias congenitas, los trastornos de la glicosilacion, las principales claves diagnosticas y el abordaje terapeutico de este grupo de pacientes infradiagnosticados.

Cuantificación de gluten en las raciones de combate españolas / Quantification of gluten in Spanish combat rations

Las personas con enfermedad celiaca pueden ingresar en los centros docentes militares de formación y su alimentacióndurante los ejercicios de instrucción se puede realizar mediante raciones de combate, individuales o colectivas. Objetivo: Cuantificar elgluten en las raciones de combate con etiquetado precautorio de alérgenos (EPA) o sin gluten en su composición. Material y Métodos:Se analizaron 39 muestras de raciones individuales de combate (23 con EPA y 16 sin cereales con gluten en su composición) y 6 racionescolectivas (sin cereales con gluten en su composición), mediante un kit comercial de inmunoabsorción ligada a enzimas (ELISA). Resultados: Los resultados de todas las muestras se encontraron por debajo del límite de cuantificación (< 5mg/kg de gluten). Conclusiones:Los resultados del contenido en gluten obtenidos sobre las muestras y los lotes analizados muestran un riesgo bajo de exposición. (AU)

People with celiac disease can join the military training centers and and their diet during training exercises can be donethrough combat rations, individual or collective rations. Objective: To quantify the gluten in the combat rations with precautionarylabeling of allergens (PAL) or gluten-free in its composition. Material and Methods: 39 individual operational rations samples (23with PAL and 16 without cereals with gluten in their composition) and 6 collective rations (without cereals with gluten in their composition) were analyzed using a commercial enzyme-linked immunosorbent assay (ELISA) kit. Results: All samples were below thelimit of quantification (< 5mg/kg of gluten) and the results met the quality criteria. Conclusions: The gluten results obtained on thesamples and batches analyzed show a low risk of exposure. (AU)