Accuracy in osteotomy drilling using a new universal and disposable drill-stop device for dental implant drills: an in vitro study using a bovine rib model.

BACKGROUND: This study aimed to evaluate the surgical accuracy of a new universal disposable stop system for implant drills (FCA Universal Drill Stop). MATERIAL AND METHODS: A total of 60 bovine ribs were included in this in vitro study. The ribs were randomized into three study groups (n=20 ribs per group). In each study group (Group1: drills without stop or control group, Group 2: prefabricated drills with stop or gold standard group, and Group 3: drills with FCA Universal Drill Stop) a total of 100 osteotomies were performed with implant drills in each group, following the drilling sequence for the placement of a dental implant of 10 mm length and 4 mm diameter. The accuracy of the depth of the osteotomies was quantified clinically (with periodontal probe) and radiologically, using ImageJ version 1.48v software. RESULTS: The order of highest to lowest accuracy (clinical and radiological) in the depth of osteotomies was: FCA Universal Drill Stop> prefabricated drills with a stop>drills without stop, with statistically significant differences being observed between both systems with stop with respect to the control group, although not between them. CONCLUSIONS: The new universal disposable stop system for implant drills, offers similar accuracy to prefabricated drills with stop, with both systems being much more accurate than implant drills without stop. Although this experimental evaluation showed favourable results, further clinical studies are necessary.

Stability of focusing regions and its vortex-solitonic properties.

Focusing regions, also known as caustic regions, are the singular solutions to the amplitude function of optical fields. Focusing regions are generated by the envelope curve of a set of critical points, which can be of attractor or repulsor type. The nature of the critical point depends on the refractive index. An important property of the critical points is that they present charge-like features. When a focusing region is generated in media with a random refractive index, current-like effects appear, and the evolution of the focusing regions follows a diffusion behavior. The morphology of the focusing regions may generate vortices or "eternal solutions" of solitonic type in a nonlinear medium. Herein, the condition under which these effects occur is analyzed and experimentally corroborated.

Erosion directionality and seasonality study using the anisotropy matrix. Application in a semiarid Mediterranean climate (SE Spain).

This paper is based on the fact that some climatic variables show a preferential directionality and grant a markedly anisotropic character to the weathering system acting on rocks. The aim of this work is to quantify the anisotropic degree of the weathering system and its effects on rock erosion. For this purpose, a new methodology based on the vector analysis of directional and time-dependent parameters is proposed to quantify the annual or seasonal anisotropy of the weathering system. Results show that, on the one hand, wind-driven rain and solar radiation are the most anisotropic variables, being north and east the most intense directions for wind-driven rain and southeast for solar radiation, in the case of the San José Tower, the reference monument of this study. On the other hand, the ranking from the most to the least eroded façades of the tower are: east (maximum recession depth of 26.77 mm) > south (15.53 mm) ≈ west (13.56 mm) > north (6.37 mm). Solar radiation and indirect processes arising therefrom are the most important weathering agents in the semiarid Mediterranean climate, whilst wind-driven rain is the main erosion factor especially due to its torrential character. According to our results, weathering and erosion agents are strongly anisotropic, which emphasizes the importance of integrating the anisotropic character of the weathering system in preventive strategies against surface deterioration of monuments. In this sense, this paper advances the United Nations' 2030 Agenda for Sustainable Development.

[Megalencephalic leukoencephalopathy with cysts -the clinical importance in the genetic era]. / Leucoencefalopatía megalencefálica con quistes: importancia de la descripción clínica en la era genética.

INTRODUCTION: Megalencephalic leukoencephalopathy with cysts is a leukodystrophy of genetic origin that produces an alteration in the water and ion homeostasis in the brain, generating vacuolar forms and chronic oedema in the white matter with progressive neurological deterioration. It should be suspected in infants who present progressive macrocephaly during the first year of life, motor retardation and characteristic findings in magnetic resonance brain scans. CASE REPORT: We report the case of a girl who was followed up from the age of 9 months due to progressive macrocephaly and delayed psychomotor development and brain MRI findings consistent with megalencephalic leukoencephalopathy with cysts, and the appearance of epilepsy during its development. The usual genetic studies (new generation sequencing and array) were negative, but as the diagnostic criteria were met, a complementary messenger RNA and DNA study was conducted, which confirmed the presence of two pathogenic variants in MLC1. CONCLUSIONS: Megalencephalic leukoencephalopathy with cysts is a rare condition. Progressive macrocephaly in the first year of life, the absence of deterioration or slow deterioration, and the possibility of developing epilepsy, spasticity and ataxia are characteristic signs in its course. It is important for these patients to undergo an imaging test that shows findings that characterise this condition, which, together with the clinical features, makes it possible to differentiate it from other leukodystrophies and to establish a confirmatory diagnosis. Genetic studies can confirm the associated mutation that makes it possible to predict the clinicoradiological phenotype.

TITLE: Leucoencefalopatía megalencefálica con quistes: importancia de la descripción clínica en la era genética.Introducción. La leucoencefalopatía megalencefálica con quistes es una leucodistrofia de origen genético que produce una alteración de la homeostasis del agua e iones en el cerebro, generando formas vacuolares y edema crónico en la sustancia blanca con deterioro neurológico progresivo. Debe sospecharse en los lactantes que presentan macrocefalia progresiva durante el primer año de vida, retraso motor y hallazgos característicos en la resonancia magnética cerebral. Caso clínico. Niña en seguimiento desde los 9 meses por macrocefalia progresiva y retraso del desarrollo psicomotor con presencia en la resonancia magnética cerebral de hallazgos compatibles con leucoencefalopatía megalencefálica con quistes, y aparición de epilepsia en su evolución. Los estudios genéticos habituales (secuenciación de nueva generación y array) fueron negativos, pero, al cumplir los criterios diagnósticos, se procedió al estudio del ARN mensajero y el ADN complementario, que confirmó la presencia de dos variantes patogénicas en MLC1. Conclusiones. La leucoencefalopatía megalencefálica con quistes es una entidad infrecuente. Es característica la macrocefalia progresiva en el primer año de vida, la ausencia de deterioro o deterioro lento, y la posibilidad de desarrollar epilepsia, espasticidad y ataxia en su evolución. Cobra importancia en dichos pacientes la realización de una prueba de imagen que muestre hallazgos propios de la entidad, lo que, junto con la clínica, permite diferenciarla de otras leucodistrofias y establecer un diagnóstico confirmatorio. Los estudios genéticos pueden constatar la mutación asociada que posibilita predecir el fenotipo clinicorradiológico.

[What is the diet of the immigrant population resident in Spain? Results based on a systematic review]. / ¿Cómo es la alimentación de la población inmigrante residente en España? Resultados a partir de una revisión sistemática.

Diet is a principal determinant of health and is interrelated with socioeconomic factors and the acculturation of immigrants. The aim of this study was to examine the existing evidence on food, nutrition, and diet amongst immigrant populations in Spain, its relationships with their countries of origin, and to evaluate the methodological quality of these studies. A systematic review was carried out that included seventeen cross-sectional studies, 71% of them were of average quality and only one was excellent; seven dealt with adolescents and ten dealt with adults, with a total of 9,871 participants. Insights on immigrant diet and nutrition were heterogeneous because the participant groups in these studies were from several different countries, each of which has distinct cultural and geographical characteristics. Adolescent diet was of lower quality, positively correlated to socioeconomic level; acculturation and length of residence were related to both positive (such as healthier dietary patterns, better adhesion to intake recommendations) and negative aspects (higher intake of meat or bakery products, lower intake of vegetables or fish, among others). Adults show a better intake of macronutrients, but a lower intake of micronutrients and non-observance of some intake recommendations; acculturation and length of residence were related to healthier dietary patterns, significantly related to type of employment. Immigrants from Mediterranean countries show a healthier diet than other immigrants, although the quality of their diet is worse than that of their peers in their countries of origin. Finally, the quality of the diet of non-Mediterranean immigrants improves when they become resident in Spain.

[The relationship between unemployment rates and lost work time due to sickness absence in an economic recession]. / Relación entre las tasas de desempleo y los indicadores de absentismo por incapacidad temporal durante periodos de crisis económica.

INTRODUCTION: Different countries have shown an inverse relationship between unemployment rates (UR) and indicators of sickness absence during periods of economic recession. OBJECTIVE: To evaluate the relationship between indicators of sickness absence and unemployment in Spain during 2009-2015. METHODS: We obtained incidence and absenteeism rates of non-work related sickness absence (NWSA) from Social Security data, and UR from the National Institute of Statistics. The relationship between indicators of NWSA and UR in the period 2009 to 2015 was graphically described using time trend plots. Scatter plots of NWSA indicators were also made against UR. Finally, we fitted linear regression models. RESULTS: Incidence (IR) and absenteeism rates (AR) of NWSA showed downward trends in 2009-2013 (IR 2009=28.07%, IR 2013=20.41%; AR 2009=2.53% and AR 2013=1.86%), changing to an upward trend up to 2015 (IR 2015=22.52%, AR 2015=2.12%). Unemployment rates trended upward in 2009-2013 (UR 2009=17.86%, UR 2013=26.10%), and then changed to a downward trend through 2015 (UR 2015=22.06%). There was an inverse relationship between UR and NWSA indicators. CONCLUSIONS: As in previous international studies, we found an inverse relationship between unemployment rates and indicators of sickness absence in Spain. More detailed studies are needed to evaluate explanatory hypotheses, such as those associated with the effects of discipline, selection and/or changes in the workforce.

INTRODUCCIÓN: Estudios realizados en varios países presentan una relación inversa entre las tasas de desempleo (TD) y los indicadores de absentismo por incapacidad temporal (IT) durante periodos de crisis económica. OBJETIVO: Evaluar la relación entre indicadores de absentismo y el desempleo en España (2009-2015). MÉTODOS: Se obtuvieron tasas de incidencia (TI) y absentismo (TA) por IT de origen común (ITcc) a partir de datos de la Seguridad Social, así como las TD según datos del Instituto Nacional de Estadística. Se describió gráficamente la evolución temporal de los indicadores de ITcc y el desempleo en el periodo 2009-2015. Para explorar dicha relación también se realizaron gráficos de dispersión de los indicadores frente a las TD. Posteriormente, se ajustaron modelos de regresión lineal simple. RESULTADOS: Las TI y TA descienden en 2009-2013 (TI 2009=28,07%, TI 2013=20,41%, TA 2009=2,53%, TA 2013=1,86%) momento en que cambia su tendencia, iniciando una fase ascendente hasta 2015 (TI 2015=22,52%, TA 2015=2,12%). La TD asciende en 2009-2013 (TD 2009=17,86%, TD 2013=26,10%), pasando a descender hasta 2015 (TD 2015=22,06%). Las TD y los indicadores de absentismo presentan una relación lineal inversa. CONCLUSIONES: Se observó una relación inversa entre el desempleo y los indicadores de absentismo en España. Son necesarios estudios específicos para poder evaluar hipótesis explicativas como las asociadas a los efectos de disciplina, selección y/o cambios en la fuerza de trabajo.

Evaluación de nivel de conocimientos sobre cuidado para pacientes neurocríticos en personal de enfermería / Evaluation of the level of knowledge about caring for neurocritical patients in nursing staff

Introducción: Los pacientes neurocríticos son aquellos con afectaciones en el sistema nervioso central y otros sistemas vitales, principalmente como consecuencia de traumatismos severos o complicaciones graves derivadas de enfermedades degenerativas. Su atención es fundamental durante el ingreso a las Unidades de Cuidados Intensivos (UCI), y su correcta realización por parte del personal de enfermería puede ser un factor decisivo para reducir efectos colaterales. Objetivo: Reconocer los niveles de conocimientos sobre el cuidado de pacientes neurocríticos del personal de enfermería de la UCI del Centro Médico Naval. Materiales y métodos: Se adaptó un instrumento para la evaluación de los cuidados en pacientes neurocríticos y se conformaron trece reactivos en forma de indicadores sobre tipo de conocimientos. Además, se aplicó una prueba no paramétrica de chi-cuadrada para variables cualitativas y una prueba exacta de Fisher. Resultados: El estudio arrojó una correlación entre un mayor nivel de conocimientos y los años de experiencia (p<0.005), el nivel de estudios (p<0.001) y la edad (p<0.002). No se encontraron asociaciones con el sexo o el turno de servicio. Conclusiones: En 22.5% de los casos se obtuvo un nivel regular de conocimientos, 2.5% tuvo un nivel deficiente y el 75% restante obtuvo un nivel de conocimientos por encima de lo esperado. La asociación entre el nivel de conocimientos sobre el cuidado de pacientes neurocríticos y el nivel de estudios, así como los años de experiencia en servicio, permiten mejorar las técnicas de atención a través de la capacitación continua del personal de enfermería.

Introduction: Neurocritical patients are those who suffer injuries in the central nervous system and other vital systems, mainly as a result of severe trauma or serious complications derived from degenerative diseases. The adequate care of these patients is essential during their admission to the Intensive Care Units (ICU); correct nursing staff performance is determinant to reduce collateral effects. Objective: To assess the level of neurocritical care expertise of the nursing staff of the ICU in the Centro Médico Naval. Materials and methods: An instrument for the evaluation of neurocritical care was adapted and 13 test items were used as indicators. In addition, a nonparametric chi-square test for qualitative variables and a Fisher exact test were applied. Results: The study showed a significant correlation between a higher level of knowledge and years of experience (p<0.005), level of education (p<0.001) and age (p<0.002). No associations were found between gender and nursing shift. Conclusions: 22.5% of the nursing staff had an average level of knowledge, 2.5% had a deficient level, and the remaining 75% had an unexpectedly high level of knowledge. The association between neurocritical care expertise and educational background, as well as the years of experience, generate an improvement in care skills through the continuous training of nursing staff.

Evidencia que tres ciclos de prono aumentan la PaO2/FiO2 en el enfermo de neumonía por COVID-19 / Evidence that three prone cycles increase PaO2/FiO2 in patients with COVID-19 pneumonia

Introducción: Es posible deducir la mejoría o empeoramiento del intercambio gaseoso en el paciente con COVID-19 en ventilación mecánica invasiva mediante el índice PaO2/FiO2 tras el uso de la posición prono. Objetivos: Identificar los cambios en el índice PaO2/FiO2 tras el uso de tres ciclos de prono, y detallar las características sociodemográficas de los pacientes. Material y métodos: En este estudio descriptivo y retrospectivo se analizaron los expedientes clínicos de 60 pacientes con COVID-19, se tomaron en cuenta valores de PaO2/FiO2, saturación de oxígeno y datos sociodemográficos. Resultados: Con el uso de tres ciclos de posición prono de 24 horas cada uno, en promedio la PaO2/FiO2 aumentó 26.38 mmHg (20%) y la saturación de oxígeno aumentó un 6.3%. 66.7% de la población eran hombres, y el promedio de edad fue de 67.10 años. Limitación: Hubo limitaciones de carácter retrospectivo debido al contexto de la pandemia de COVID-19 y la alta carga de trabajo que imposibilitó la adecuada recolección de información relevante, como los tipos de tratamiento farmacológico y de soporte vital empleados. Conclusiones: El uso de la posición prono en el paciente orointubado con COVID-19 constituye una estrategia de primera línea, pues ha demostrado un aumento en la PaO2/FiO2, que resulta en una mejoría en la oxigenación/perfusión.

Introduction: The improvement or worsening of gas exchange in patients with COVID-19 on invasive mechanical ventilation can be determined through the PaO2/FiO2 index after using the prone position. Objectives: To identify changes in the PaO2/FiO2 index after three prone cycles, and to describe the sociodemographic characteristics of the patients. Material and methods: In this descriptive and retrospective study, the clinical records of 60 patients with COVID-19 were analyzed, PaO2/FiO2 oxygen saturation values and sociodemographic data were considered. Results: With the use of three prone position cycles of 24 hours each, on average, the PaO2/FiO2increased by 26.38 mmHg (20.09%) and oxygen saturation increased by 6.3%. Male population represented 66.7%, and the average age was 67.10 years. Limitation: There was retrospective limitations due to the COVID-19 pandemic context and high workload, which made difficult to adequately record relevant information, including types of pharmacological and life support treatments used. Conclusions: The prone position used on orointubated patient with COVID-19 constitutes a first-line strategy; it has shown an increase in PaO2/FiO2 values, which leads to an improvement in oxygenation/perfusion.

Concordancia de valoraciones del dolor entre la Escala de Conductas Indicadoras del Dolor y Behavioral Pain Scale / Concordance of pain assessment between the Escala de Conductas Indicadoras de Dolor y Behavioral Pain Scale

Introducción: La valoración del dolor del paciente critico se basa en indicadores conductuales. Actualmente existen diversas escalas con diferencias en la forma de puntuar la presencia de dolor. Objetivo: Determinar la concordancia entre mediciones del dolor según la Escala de conductas indicadoras de dolor (ESCID) y la Behavioral Pain Scale (BPS). Métodos: Estudio observacional en pacientes con ventilación mecánica. Se aplicaron la BPS y la ESCID en reposo y durante aspiración de secreciones, a fin de determinar su concordancia mediante el coeficiente Kappa de Cohen y el nivel de dolor de la ESCID. Resultados: La concordancia estadística entre la BPS y la ESCID fue 0.23 según el coeficiente Kappa de Cohen, considerada "regular" de acuerdo con Landis y Koch. La BPS determinó presencia de dolor en 93.4% de pacientes durante la aspiración de secreciones, y la ESCID lo detectó en el 100%, clasificando 80% en nivel moderado­grave. Limitaciones de estudio: Muestra de 15 pacientes. El estudio se realizó en dos momentos. Originalidad: El resultado obtenido no tiene comparación con otro estudio, pues sólo se ha estudiado la concordancia entre observadores. Conclusiones: La concordancia entre las mediciones del dolor con ambas escalas se considera baja. La ESCID muestra mayor sensibilidad, aunque los niveles de puntuaciones bajas pueden ser causados por factores no relacionados con dolor. BPS muestra menor sensibilidad, pues considera la presencia de dolor con puntajes sin clasificaciones intermedias. Este estudio apoya el uso de ESCID como una escala confiable en las valoraciones del dolor.

Introduction: Pain assessment in critical patients is based on behavioral indicators. Currently, there are various scales that differ in their pain-scoring systems. Objective: To determine the concordance between pain measurements according the Behavioural Indicators of Pain Scale (ESCID, by its acronym in Spanish) and Behavioral Pain Scale (BPS). Methods: Observational study in patients subjected to mechanical ventilation. The BPS and the ESCID were applied at rest and during aspiration of secretions, in order to determine their concordance using Cohen's kappa coefficient and pain level according to ESCID. Results: The statistical concordance between the BPS and ESCID was 0.23 according to Cohen's kappa coefficient, considered "regular" as stated by Landis and Koch. BPS determined the presence of pain in 93.4% of patients during aspiration of secretions, and ESCID detected it in 100% of patients, with 80% in the moderate-severe level. Study limitations: Sample of 15 patients. The study was performed two times. Originality: The obtained results have no comparison with other studies, since they only analyze inter-observer concordance. Conclusions: The concordance between pain measurements with both scales is considered low. ESCID shows higher pain sensitivity, although low score levels may be caused by factors not related to pain. BPS shows lower sensitivity, since it considers the presence of pain with scores without intermediate classifications. This study supports the use of ESCID as a reliable scale for pain assessment

Candida albicans osteomyelitis of the zygomatic bone. A distinctive case with a possible peculiar mechanism of infection and therapeutic failure with fluconazole.

This report describes a distinctive case of zygomatic candidiasic osteomyelitis in a diabetic patient with oral candidiasis and malar ulceration secondary to topic 5-fluoroacil toxicity that eventually exposed part of the underlying bone. The mechanism of infection may have been self-inoculation of spores from muguet plaques on the oral mucosa to the exposed bone tissue by hand contact. Such a mechanism of bone infection probably should be considered in patients who frequently have oral candidiasis (diabetes, malignancies, and HIV infection) and open lesions of the skin and soft tissues. Treatment with fluconazole was ineffective, but amphotericin B was curative.

The prognostic value of right atrial pacing after acute myocardial infarction.

We performed right atrial pacing in 90 consecutive patients 10 to 30 days (mean 16.8 days) after acute myocardial infarction. Right atrial pacing was normal in 28 patients, depression of the ST segment occurred in 27 patients, systolic blood pressure fell below control values in 20 patients and, in 15 patients, right atrial pacing was non-diagnostic. Follow-up was from 12 to 28 months (mean = 17.3). Global mortality was 11.1%, with none of the patients with normal tests dying, 11% of those with ST depression, 30% of those with induced hypotension (P less than 0.01) and 7.1% of those in whom pacing was non-diagnostic. Patients with high clinical risk at discharge in Peel Class III-IV, showed 41.2% mortality during the period of follow-up. None of those had shown normal responses to pacing, but those dying included 50% of the patients with ST depression and 66.7% of those in whom right atrial pacing induced hypotension. Development of new angina during the period of follow-up was more frequent among the patients with ST depression (33.3%) (P less than 0.001). Thus, our results showed that right atrial pacing was useful in predicting mortality after acute myocardial infarction. In patients at high risk, we observed that a fall of systolic blood pressure was the best predictor of mortality.

Transient tachycardia- and bradycardia-dependent left anterior and left posterior hemiblocks. Effects of isoproterenol.

Tachycardia- and bradycardia-dependent, left anterior and left posterior hemiblocks as transient phenomena were registered in two patients spontaneously, and especially as a consequence of isoproterenol infusion. A chronic trifascicular type of A-V block was present in the first case, whereas in the second case a bradycardia-dependent left posterior hemiblock was registered during an acute myocardial infarction. In the first patient the isoproterenol effects were: (1) a shortening of the refractoriness and an increase of the conduction velocity in the injured fascicle, (2) an increase in the slope of phase-4 depolarization on the left posterior fascicle, and (3) a presumably shifting toward zero of threshold potential on the left anterior fascicle. Isoproterenol effects disappeared from 30 to 40 min after it was discontinued. In the second case the bradycardia-dependent left posterior hemiblock was registered during very fast heart rates (150 beats min). This finding supports the view that enhanced phase-4 depolarization is the main factor in the development of bradycardia-dependent intraventricular blocks in the course of acute myocardial ischemia.

[Acute pulmonary thromboembolism with severe hemodynamic compromise. The efficacy of systemic thrombolytic treatment in the coronary unit]. / Tromboembolismo pulmonar agudo con severo compromiso hemodinámico. Eficacia del tratamiento trombolitico por vía sistémica en la unidad coronaria.

A 79[correction of seventy]-year-old patient, who has been in bed a long time, suffered an episode of sudden dyspnea, tachycardia and tachypnea. An electrocardiogram registered at her admission in the coronary care unit showed a normal rhythm with right axis deviation and S1Q3T3 pattern and ST segment alterations. A ventilation-perfusion lung scanning demonstrated segmental perfusion defects with high probability of pulmonary embolism. She developed a low cardiac output syndrome, which neither responded to the volume expansion nor to the inotropic drugs. The bed-side hemodynamic measurements were a systolic pulmonary pressure of 60 mmHg, with a diastolic pressure of 18 mmHg and capillary wedge pressure of 13 mmHg with high pulmonary resistance. With this evidences, the diagnoses of massive pulmonary embolism was done, thrombolytic treatment was decided on. Two hundred and fifty thousands international units of streptokinase was administered, and then 100.000 UI/hour in 24 hours; after that with intravenous heparin. The low cardiac output syndrome disappeared. The patients recovered her systemic arterial pressure and her diuresis. The electrocardiographic signs vanished and both the pulmonary pressure and resistance decreased. We discussed the importance of intravenous thrombolytic treatment in massive pulmonary embolism. We concluded than this treatment is an useful strategy that not always needs a pulmonary arteriography, and could be used in low complexity centres, successfully in the massive pulmonary thromboembolism with severe hemodynamic damage.

[Use of intravenous esmolol in patient with severe heart failure and abnormal intraventricular gradient after aortic valve replacement]. / Uso de esmolol intravenoso en un paciente con insuficiencia cardíaca severa y gradiente intraventricular izquierdo anormal postsustitución valvular aórtica.

The presence of anomalous intraventricular flows of high velocity and dynamic ejective obstruction of the left ventricle post aortic valve replacement, generally by severe aortic stenosis, is a relatively infrequent, but severe complication. An early diagnosis is of crucial importance, since the usual treatments applied to postoperative heart failure are often inefficacious or even harmful. Even in cases of severe pump failure, when the clinical case is diagnosed adequately, endovenous short-action beta-blockers are useful.

[Dual-chamber pacemakers in obstructive hypertrophic cardiomyopathy: gradient variation with stress echocardiography]. / Marcapasos bicameral en la miocardiopatía hipertrófica obstructiva: variación del gradiente con ecocardiografía de estrés.

INTRODUCTION: Permanent cardiac pacing with a dual chamber pacemaker has become a valid alternative in treatment of patients with obstructive hypertrophic cardiomyopathy and refractory symptoms to pharmacological treatment, with a significant decrease of left ventricular outflow tract gradient. AIM: To assess any modification of the gradient with dobutamine stress echocardiography. PATIENTS AND METHODS: We study 10 patients with obstructive hypertrophic cardiomyopathy and angina and/or dyspnea refractory to customary pharmacological treatment. A dual chamber pacemaker had been implanted 3-6 months previously. A dobutamine stress echocardiography was performed, beginning with a 10 microgram/kg/min infusion, with increases of 10 micrograms each 3 minutes until a maximum of 40. Modification of subaortic gradient, severity of systolic anterior motion of mitral valve (SAM, degree 0-3/3) and severity of mitral regurgitation (degree 0-4/4) were assessed. RESULTS: Subaortic gradient decreased in all patients after pacemaker implantation (90 +/- 15 vs 20 +/- 10 mmHg; p < 0.001). With stress echocardiography the gradient increased in all patients (20 +/- 10 to 101 +/- 13 mmHg; p < 0.001). After implant there were only two patients with a +1 SAM, while during stress echocardiography SAM developed in all patients in +2 or +3 degree. Three patients had +1 mitral regurgitation after pacemaker implantation but during stress echocardiography 2-4/4 mitral regurgitation developed in all patients. CONCLUSIONS: Permanent dual chamber pacing decreased left ventricular outflow tract gradient in patients with obstructive hypertrophic cardiomyopathy, but during dobutamine stress echocardiography obstruction echocardiographic signs appeared.

[Improvement in fibrinolytic function following anticoagulant treatment in chronic rheumatic atrial fibrillation]. / Mejoría de la función fibrinolítica tras el tratamiento anticoagulante en la fibrilación auricular reumática crónica.

INTRODUCTION AND OBJECTIVES: Patients with rheumatic atrial fibrillation are considered at high risk of systemic embolism and require oral anticoagulation. Fibrinolytic function has been little studied. We evaluated fibrinolytic activation markers before starting anticoagulation, at 1 and 6 months following the introduction of oral anticoagulation therapy. We analyzed the relationship with left atrial diameter and mitral area. METHODS: Tissue plasminogen activator (tPA), its inhibitor (PAI-1), plasmin-antiplasmin complexes (PAP) and D-dimer were measured in 13 patients with rheumatic atrial fibrillation. Basal levels were compared with those found in plasma of 20 healthy subjects matched by sex and age. Transthoracic echocardiography was made. RESULTS: A significant increase for PAI-1 and D-dimer levels were detected in patients with atrial fibrillation group (p < 0.05), with no differences in tPA and PAP concentrations. Significant correlation between left atrial diameter and basal t-PA levels was found. Levels of t-PA, PAI-1 and D-dimer decreased significantly under anticoagulation therapy, whereas PAP levels were significantly increased. CONCLUSIONS: Patients with rheumatic atrial fibrillation show a relative hypofibrinolytic state due to elevated PAI-1 levels with no increase in PAP concentration. At six months of anticoagulation therapy, an improvement of fibrinolytic function markers was observed. This is consistent with the prophylactic effect of oral anticoagulants therapy against thromboembolic risk.

[The Influence of the growth hormone in the profile of blood pressure. Results in adult patients with deficiency in this hormone]. / Influencia de la hormona de crecimiento en el perfil de la presión arterial. Resultados en pacientes adultos con déficit de dicha hormona.

INTRODUCTION AND OBJECTIVES: There is an increasing interest in the relationship between the growth hormone (GH) and the heart since the GH has an important inotropic effect and its use has been tested in patients with severe systolic dysfunction. However, cardiovascular diseases are the main cause of increased morbimortality observed in patients with acromegaly. Growth hormone deficiency has been related to different clinical findings depending on the age of onset. Recent studies have demonstrated that GH deficiency in adults is associated with alterations in blood pressure. The aim of our study was to assess the influence of GH in blood pressure. PATIENTS AND METHODS: We studied 14 adult patients with GH deficiency and 15 healthy subjects, matched for sex and age. The diagnosis of GH deficiency was based on GH response to intravenous insulin tolerance test < 5 ng/ml and IGF-1 levels lower than the normal limit for each age group. In all the patients 24-hour Holter blood pressure monitorization was performed in addition to a treadmill test and echographic evaluation. RESULTS: All patients showed normal systolic and diastolic function in the echocardiographic study. Only one patient had an increased left ventricular mass. Blood pressure was lower in the patients than in the control subjects (p < 0.05). Moreover, the difference remained significant when analysis was based on the time of day. However, the patients showed normal blood pressure response to the effort test with a mean increase of 60%. The length of the exercise on the treadmill test was shorter in the subgroup of GH deficient patients. CONCLUSIONS: Lower systolic blood pressure was observed in GH deficiency patients. The patients studied did not show structural heart alterations. Blood pressure and chronotrophic response to the effort test were similar in both groups.

[Thrombogenic and endothelial damage markers in patients with ischemic systolic impairment]. / Marcadores de hipercoagulabilidad y daño endotelial en pacientes con disfunción sistólica de origen isquémico.

INTRODUCTION: Anticoagulation is rarely indicated in patients with left ventricular dysfunction who show an increased risk for thromboembolism. In theory, the three arms of the Virchow' triad may be present: abnormal blood flow, endothelial damage and prothrombotic markers. The aim of this study was to identify the last two arms. PATIENTS AND METHOD: We studied 82 consecutive patients with demonstrated ischaemic heart disease and sinus rhythm, and compared them with a control group comprised of 32 healthy subjects matched for age and sex. None or the patients had had an acute coronary event or hemodynamic decompensation within the 3 months prior to inclusion in the study. The plasma concentration or von Willebrand factor and fibrin d-dimer and fibrinogen were determined as endothelial damage and prothrombotic markers, respectively. A fractional shortening less than 29% by echography was defined as ventricular systolic dysfunction. RESULTS: The patients showed significantly higher levels of von Willebrand factor with respect to the control group (109.2 31.9 vs 85.5 32.6%, p < 0.01), with no differences in fibrinogen and fibrin d-dimer values. Twenty-six patients fulfilled criteria of left ventricular systolic dysfunction. Patients with left ventricular dysfunction showed higher fibrinogen (386 118 vs 322 102 mg/dl, p = 0.03) and fibrin d-dimer (0.36 0.22 vs 0.26 0.10 g/ml; p = 0.04) levels, with no differences in von Willebrand factor levels. CONCLUSIONS: After acute coronary events, patients with ischaemic heart disease show markers of endothelial damage. However, patients with left ventricular dysfunction show a hypercoagulable state.

[Bacteremic urinary infection in men: comparative study with bacteremic pyelonephritis in women]. / Infección urinaria bacteriémica en el varón. Estudio comparativo frente a la pielonefritis bacteriémica femenina.

OBJECTIVE: To compare the clinic and microbiologic characteristics of the extrahospitalary bacteremic urinary infections (EBUI) between men and women assisted in a 200 bed community hospital. PATIENTS AND METHODS: A prospective study of the EBUI diagnosed in our hospital from January 1991 to April 1994 was carried out. Quantitative variables were evaluated with t Student analysis, chi 2 was used for the comparation of proportions. The logistic regression step-by-step model was used in order to find out which variables influenced that the microorganism causing EBUI was Escherichia coli. RESULTS: 107 episodes of EBUI were recorded, 39 men and 68 women, with the same microorganism in blood and urine. Significative diferences in age (70 +/- 17 years in men, 58 +/- 24 years in women); the presence of urinary tract alterations (49% men vs 12% women) and in the presence of indwelling urinary catheter (26% men vs 3% female) were found. E. coli was responsible in a major proportion (p = 0.03) of the EBUI in women that in men, but only age > 65 was selected as explaining variable with the logistic regression model. CONCLUSIONS: The EBUI appears in old men with urinary tract alterations and/or manipulations, clearly different from the EBUI in women. Age greater than 65 years is the only predisponent factor of EBUI in men by bacteria other than E. coli.

[Association between ischemic heart disease and peptic ulcer. A case-control study]. / Asociación entre cardiopatía isquémica y ulcus péptico. Estudio de casos y controles.

AIM: To determine whether patients with ischemic heart disease (IHD) are at higher risk for peptic ulcer (PU). MATERIAL AND METHODS: We performed a case-control study. The patients were selected by simple random sampling of clinical histories. CASES: 310 patients with IHD (angina pectoris, myocardial infarct or both). CONTROLS: 310 patients without IHD, paired by age, sex and tobacco consumption. Data were obtained by review of the patients' clinical histories. Response variable: diagnosis of peptic ulcer by endoscopy, esophagogastroduodenal transit or surgery. The odds ratio (OR) was determined by logistic regression, adjusting for the effect of confounding variables and risk for PU. RESULTS: The mean age of the patients was 72.7 years (SD 8.6) and 70% were men. PU was found in 18.7% of the patients and in 12.3% of the controls with an adjusted OR of 1.77 (95% CI: 1.12-2.77; p = 0.01). This effect was produced at the expense of duodenal ulcer with an adjusted OR of 2.22 (95% CI: 1.29-3.74; p = 0.003). The adjusted OR of gastric ulcer was 1.13 (95% CI: 0.45-2.82; p = 0.8). CONCLUSIONS: After adjusting for the effect of confounding variables and risk factors for the development of PU, this disease was more frequent in the group of patients with IHD.