Fetal Anemia: Determinants and Perinatal Outcomes according to the Method of Intrauterine Blood Transfusion.

INTRODUCTION: Fetal anemia from hemolytic disease treated by intrauterine transfusion (IUT) can be performed by intraperitoneal, intracardiac, and intravascular transfusion (IVT). Objective of our study was to compare different transfusion techniques. METHODS: Retrospective review of IUT secondary to red cell alloimmunization was conducted at eight international centers from 2012 to 2020. Severe anemia suspected if middle cerebral artery peaks systolic velocity ≥1.5 multiples of the median. Demographic, delivery, and postnatal variables were analyzed. RESULTS: Total of 344 procedures, 325 IVT and 19 other techniques (non-IVT) included. No difference in demographics, history of stillbirth (20.5 vs. 15.8%, p = 0.7), prior pregnancy IUT (25.6 vs. 31.6%, p = 0.5) or neonatal transfusion (36.1 vs. 43.8%, p = 0.5). At first IUT, non-IVT had higher hydrops (42.1% vs. 20.4%, p = 0.03), lower starting hematocrit (13.3% [±6] vs. 17.7% [±8.2], p = 0.04), and trend toward lower gestational age (24.6 [20.1-27] vs. 26.4 [23.2-29.6] weeks, p = 0.08). No difference in birthweight, neonatal phototherapy, exchange, or simple transfusion was observed. CONCLUSION: This is one of the largest studies comparing techniques to treat fetal anemia. IVT was most performed, other techniques were more likely performed in hydrops, and lower starting hematocrit was seen. Neither technique affected outcomes. This study may suggest that physician's experience may be the strongest contributor of outcomes.

Philadelphia-negative chronic myeloproliferative neoplasm follow-up: when the phone rings. Changes during the COVID-19 pandemic and patient satisfaction. Experience in 30 health centers in Spain.

The SARS-CoV-2 pandemic has favored the expansion of telemedicine. Philadelphia-negative chronic myeloproliferative neoplasms (Ph-MPN) might be good candidates for virtual follow-up. In this study, we aimed to analyze the follow-up of patients with Ph-MPN in Spain during COVID-19, its effectiveness, and acceptance among patients. We present a multicenter retrospective study from 30 centers. Five hundred forty-one patients were included with a median age of 67 years (yr). With a median follow-up of 19 months, 4410 appointments were recorded. The median of visits per patient was 7 and median periodicity was 2.7 months; significantly more visits and a higher frequency of them were registered in myelofibrosis (MF) patients. 60.1% of visits were in-person, 39.5% were by telephone, and 0.3% were videocall visits, with a predominance of telephone visits for essential thrombocythemia (ET) and polycythemia vera (PV) patients over MF, as well as for younger patients (< 50 yr). The proportion of phone visits significantly decreased after the first semester of the pandemic. Pharmacological modifications were performed only in 25.7% of the visits, and, considering overall management, ET patients needed fewer global treatment changes. Telephone contact effectiveness reached 90% and only 5.4% required a complementary in-person appointment. Although 56.2% of the cohort preferred in-person visits, 90.5% of our patients claimed to be satisfied with follow-up during the pandemic, with an 83% of positive comments. In view of our results, telemedicine has proven effective and efficient, and might continue to play a complementary role in Ph-MPN patients' follow-up.

Design and validation of a predictive model for determining the risk of developing fibromyalgia.

OBJECTIVES: Fibromyalgia is a prevalent disease of unknown aetiology and is difficult to diagnose. Despite the availability of the American College of Rheumatology criteria for diagnosis, it continues to be a challenge in the field of primary health care in terms of identifying individuals with susceptibility to developing the disease. The aim of this study is to design and validate a predictive model of fibromyalgia in subjects with a history of chronic pain. METHODS: This multicentre observational retrospective cohort study was performed on patients aged >18 years, who visited four primary health centres between 2017 and 2020, with a diagnosis of fibromyalgia or arthritis. The Bootstrapping resampling method was used for the validation of the model. RESULTS: A total of 198 subjects with fibromyalgia (93 with osteoarthritis, 20 with other types of arthritis, 4 with rheumatoid arthritis) and 120 without fibromyalgia (116 with osteoarthritis, 23 with other types of arthritis, 7 with rheumatoid arthritis) participated in the study. The predictive factors of the final model were self-reported age at onset of symptoms, first-line family history of neurological diseases, exposure to levels of stress, history of post-traumatic acute emotional stress, and personal history of chronic widespread pain prior to diagnosis, comorbidity, and pharmacological prescription during the year of diagnostic confirmation. The predictive capacity adjusted by Bootstrapping was 0.972 (95% CI: 0.955-0.986). CONCLUSIONS: The proposed model showed an excellent predictive capacity. The risk calculator designed from the predictive model allows health professionals to have a useful tool to identify subjects at risk of developing fibromyalgia.

Social determinants of health for moderate and severe periodontal disease in rural and urban populations.

OBJECTIVE: We assessed the prevalence of moderate and severe periodontitis and its association with social determinants of health in rural and urban population from the State of Chiapas, in Southern Mexico. MATERIAL AND METHODS: A cross-sectional population-based study was conducted in 2013 comprising people 20 years and older. The determinants were categorized as proximal (age, sex, indigenous origin, diabetes, smoking, diet), intermediate (level of schooling, occupation, medical and dental care), and structural (type of institution of health care provision, residence area). Periodontal status was assessed using the Periodontal Screening and Recording (PSR) Index. RESULTS: In total, 467 persons (72.4% women; mean age 43.0 years [s.d 14.7]) participated. Of them, 76.5% lived in rural areas and 56.7% were of indigenous origin. Participants with moderate and severe periodontitis had a significantly lower toothbrushing frequency (44.1% and 44.8%, respectively), and poorer oral hygiene (90% and 90.3%, respectively) compared with people without periodontitis (29.4% for toothbrushing frequency and 74.5% for oral hygiene). Moderate periodontitis was associated with poor oral hygiene (OR=2.63) and no schooling (OR=1.86). Severe periodontitis was associated with age (OR=1.05), poor oral hygiene (OR=3.99), no schooling (OR=2.08), and the interaction term of rural area and indigenous origin (RM=5.23). CONCLUSIONS: Social determinants of health play an important role in the development of periodontitis. Preventive oral health programs should thus focus on the specific social, economic, and geographical context of the population.

The effect of spinal anesthesia that is performed in sitting or right lateral position on post-spinal headache and intraocular pressure during elective cesarean section.

Background: Although spinal anesthesia can be applied in different patient positions, the most frequently used positions are sitting and lateral positions. It is known that different patient positions during spinal anesthesia have effects on hemodynamic parameters, postdural puncture headache, and intraocular pressure. Aim: The study aimed to determine the effect of spinal anesthesia performed in either sitting or right lateral position on postspinal headache and intraocular pressure during elective cesarean section. Patients and Methods: The study was a randomized controlled study of 104 eligible pregnant women scheduled to undergo elective cesarean section. The women were randomized into two groups. Spinal anesthesia was performed either in the sitting (Group S, n = 53) or the right lateral position (Group L, n = 51). Heart rate and blood pressure were recorded throughout the operation. The participants were informed and monitored for postspinal headaches. Intraocular pressure before and after the operation was measured with Icare PRO. The obtained data were statistically compared between the two groups. Results: There was no difference between the groups in terms of demographic data. Postdural puncture headache was observed in five patients in Group S and one patient in Group L (P =0.04). There was no difference between the groups in terms of intraocular pressure (P >.05). Heart rate was not significantly different between the groups; however, there was a significant difference in average blood pressure in 1, 5, 30, and 40 minutes (P <.05). The number of trials administered to patients for spinal anesthesia was significantly higher in Group L (P =0.01). Conclusion: Spinal anesthesia performed in the sitting position for cesarean section caused a higher postspinal headache than in the right lateral position, but the position did not affect intraocular pressure.

M1 and M2 mAChRs activate PDK1 and regulate PKC ßI and ε and the exocytotic apparatus at the NMJ.

Neuromuscular junctions (NMJ) regulate cholinergic exocytosis through the M1 and M2 muscarinic acetylcholine autoreceptors (mAChR), involving the crosstalk between receptors and downstream pathways. Protein kinase C (PKC) regulates neurotransmission but how it associates with the mAChRs remains unknown. Here, we investigate whether mAChRs recruit the classical PKCßI and the novel PKCε isoforms and modulate their priming by PDK1, translocation and activity on neurosecretion targets. We show that each M1 and M2 mAChR activates the master kinase PDK1 and promotes a particular priming of the presynaptic PKCßI and ε isoforms. M1 recruits both primed-PKCs to the membrane and promotes Munc18-1, SNAP-25, and MARCKS phosphorylation. In contrast, M2 downregulates PKCε through a PKA-dependent pathway, which inhibits Munc18-1 synthesis and PKC phosphorylation. In summary, our results discover a co-dependent balance between muscarinic autoreceptors which orchestrates the presynaptic PKC and their action on ACh release SNARE-SM mechanism. Altogether, this molecular signaling explains previous functional studies at the NMJ and guide toward potential therapeutic targets.

Violacein and its antifungal activity: comments and potentialities.

Violacein is an important natural antimicrobial pigment that is mainly produced by Chromobacterium violaceum and Janthinobacterium lividum. It presents a significant range of effects against phytopathogenic and human fungi, besides being featured as having low toxicity, and by its important ecological role in protecting amphibian species and applications in dyed medical fabric. The hypothesis about violacein's action mechanisms against mucormycosis (Rhizopus arrhizus) and candidiasis (Candida auris) is herein discussed based on data available in the scientific literature.

Biologically synthesized silver nanoparticles as potent antibacterial effective against multidrug-resistant Pseudomonas aeruginosa.

Pseudomonas aeruginosa is one of the most worrisome infectious bacteria due to its intrinsic and acquired resistance against several antibiotics and the recalcitrance of its infections; hence, the development of novel antimicrobials effective against multidrug-resistant P. aeruginosa is mandatory. In this work, silver nanoparticles obtained by green synthesis using a leaf extract and fungi were tested against a battery of clinical strains from cystic fibrosis, pneumonia and burnt patients, some of them with multidrug resistance. Both nanoparticles showed a potent antibacterial effect, causing severe damage to the cell wall, membrane and DNA, and inducing the production of reactive oxygen species. Moreover, the nanoparticles derived from fungi showed synergistic antibacterial effects with the antibiotics meropenem and levofloxacin for some clinical strains and both kinds of nanoparticles were nontoxic for larvae of the moth Galleria mellonella, encouraging further research for their implementation in the treatment of P. aeruginosa infections.

Analysis of Patients with Major Fractures with and without COVID-19 Infection.

PURPOSE OF THE STUDY As in orthopedic trauma patients, a hyperinflammatory response due to cytokine release occurs in patients with moderate and severe COVID-19 infection. In these patients, untimely surgical intervention can create more destructive situations in the postoperative period. Our aim in this study was to investigate the effect of COVID-19, trauma and surgical intervention on acute phase reactants' levels in patients with and without COVID-19 infection. MATERIAL AND METHODS Twenty-four patients diagnosed with COVID-19 infection and major fractures requiring surgical treatment were evaluated retrospectively (Group 1). Twenty-four COVID-19 negative patients with similar trauma were included in the study as a control group (Group 2). These two groups were compared in terms of demographic data, time to surgery, total hospitalization time, and preoperative and postoperative acute phase reactants' [C-reactive protein (CRP), D-dimer, ferritin, fibrinogen and white blood cell (WBC)] values. RESULTS Time to surgery was 8.3 ± 0.7 days and the total hospital stay was 15.2 ± 0.8 days, in Group 1. These values were determined as 3.3 ± 0.4 and 6.5 ± 0.6 days, respectively for the patients in Group 2 (p < 0.001 and p < 0.001, respectively). When the acute phase reactant values studied during admission were examined, a significant difference was found between the two groups in terms of CRP, D-dimer, ferritin and WBC (p = 0009, p = 0.002, p < 0.001 and p < 0.001, respectively). In the preoperative period, a significant difference was observed between the groups in terms of CRP and ferritin (p = 0.011, p < 0.001, respectively). A significant difference was found only in terms of ferritin from the laboratory values studied in the postoperative period (p < 0.001). DISCUSSION To our knowledge, the present study is the first study which compares and investigates the effects of COVID-19 infection, major fracture and surgical intervention on acute phase reactants' values. Surgical treatment is generally recommended as soon as possible in daily orthopedic practice. However, in patients with asymptomatic or mildly symptomatic COVID-19 infection, it remains unclear how long surgical intervention will be delayed after admission and clinical stabilization of patients with a fracture that requires surgical fixation. In a meta-analysis, patients with COVID-19 infection accompanying hip fracture had a mortality rate of 32.6% in the early postoperative period, and the mortality risk of these patients was found to be 5.66 times higher compared to patients without COVID-19 infection. In our study, one patient (4.2%) with COVID-19 infection who underwent partial hip arthroplasty due to femoral neck fracture. CONCLUSIONS The follow-up and treatment of patients with COVID-19 infection with accompanying a major fracture requiring orthopedic surgery is a complex situation. We recommend that acute phase reactants such as CRP, D-dimer, erythrocyte sedimentation rate (ESR), and ferritin should be closely monitored in these patients during the period from admission to surgery, and surgical intervention should be performed while these values are in remission or decline. Key words: COVID-19, fracture, trauma, acute phase reactants, surgical timing.

The Relationship of CRP/Albumin ratio level and prognosis in pregnant COVID-19 patients.

Background: The C-reactive protein (CRP)/albumin ratio (CAR) is one of the new tools to assess the severity of inflammation. It is used to determine clinical severity and prognosis in many diseases. Aim: The present study aimed to investigate the relationship between C-reactive protein (CRP)/albumin ratio (CAR) and prognosis in pregnant patients with more severe COVID-19 infection. Retrospective study. Patients and Methods: The study was conducted in a retrospective manner by scanning the files of pregnant patients who had a positive polymerase chain reaction test result and were hospitalized in Adiyaman Training and Research Hospital. The patients were divided into two groups: patients who were admitted to the intensive care unit and patients who were not admitted. CRP/albumin ratio (CAR) levels were compared between these two groups. The cut-off value was determined in the prediction of intensive-care admission and poor prognosis. Results: 117 patient files were reviewed. 13 patients were followed up with intensive care, whereas 104 patients completed their treatment in the service. The CAR levels of the patients admitted to intensive care were significantly higher (P < 0.01). In the estimation of intensive-care admission, the CAR level was determined to be 0.970 in the area under the curve with 100% sensitivity and 86.5% specificity in the receiver operating characteristic (ROC) curve. The cut-off CAR level was calculated as 1.8. Conclusion: CAR is a valuable biomarker for predicting prognosis, as well as follow-ups of pregnant COVID-19 patients.

Comparison of propofol-fentanyl and propofol-ketamine for sedoanalgesia in percutaneous endoscopic gastrostomy procedures.

Background: Percutaneous endoscopic gastrostomy (PEG) procedures are performed under sedation in critically ill patients who cannot be fed orally. Aim: We compared the efficacy and safety of propofol-fentanyl and propofol-ketamine for deep sedation in patients undergoing PEG. Retrospective Study. Materials and Methods: The study was conducted from 1 January 2013 to 31 December 2018 in Adiyaman University. The patients given propofol-fentanyl (0.5-1.2 mg/kg and 0.2-1 µg/kg, respectively) for sedo-analgesia were designated Group F, and those who received propofol-ketamine (0.2-0.6 mg/kg and 0.5-1 mg/kg, respectively) were placed in Group K. The demographic and hemodynamic characteristics, recovery times, perioperative complications, and need for additional doses were recorded. Results: Seventy-one patients who underwent PEG were analyzed. The age, sex, American Society of Anesthesiologists (ASA) score, comorbidities, duration of anesthesia, and duration of the PEG procedure were similar in the two groups. Recovery time was longer in Group K. The total propofol dose was 64 mg in Group F and 35 mg in Group K. Additional doses of propofol were administered to 12 patients in Group F, compared to none in Group K. The mean blood pressure values were higher in Group K at all-time points. The perioperative complication rate was higher in Group F. Desaturation was observed in 9 (22.5%) patients in Group F and in 3 (9.6%) patients in Group K. Hypotension was observed in 4 (10%) patients in Group F. Conclusion: Propofol-ketamine should be preferred for sedoanalgesia during PEG procedures because of the lower dose of propofol, more stable blood pressure, and greater peripheral oxygen saturation. In addition, we believe ketamine-propofol is safer based on its low complication rate.

The impact of digital game addiction on musculoskeletal system of secondary school children.

BACKGROUND: The widespread use of digital devices causes adolescents to spend long periods of time in front of the screen. AIMS: This study aimed to analyze the impacts of digital game addiction on the musculoskeletal system of secondary school children in Kayseri. PATIENTS AND METHODS: A total of 1000 healthy children have been included. A questionnaire, which has been prepared by the researchers and questions children's socio-demographic knowledge, sport habits, durations of study, types of digital tools they use to play games, using positions and durations of use, has been applied to the children. A visual analog scale was used to assess pain intensity. Game addiction has been evaluated through Computer Game Addiction Scale for Children. RESULTS: Between computer and phone use and neck pain, a significant correlation has been found (P < 0.05). Between game addiction and wrist, back and low back pain, a significant correlation has been detected. While males use more computer, tablet and are more addicted to games, the scores of head, wrist and back pain in females have been found out to be significantly high. CONCLUSIONS: As they cause musculoskeletal problems, the higher the time children consume in front of digital devices and the more they use it in wrong posture; the more the complaints about pain are.

Diagnostic accuracy of first-trimester combined screening for early-onset and preterm pre-eclampsia at 8-10 compared with 11-13 weeks' gestation.

OBJECTIVES: To compare the ability of first-trimester combined screening for pre-eclampsia (PE) to predict early-onset and preterm PE when pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) were assessed before vs after 11 weeks' gestation. METHODS: This was a secondary analysis of a prospective cohort study of singleton pregnancies undergoing routine first-trimester screening conducted at Vall d'Hebron University Hospital, Barcelona, Spain, between October 2015 and September 2017. Demographic characteristics, obstetric history, maternal history and biophysical markers (mean uterine artery pulsatility index and mean arterial blood pressure (MAP)) were recorded at the first-trimester scan (at 11 + 0 to 13 + 6 weeks' gestation). Maternal serum concentrations of PAPP-A and PlGF were assessed from the routine first-trimester blood test (at 8 + 0 to 13 + 6 weeks). Women were classified into two groups depending on whether serum biomarkers were assessed at 8 + 0 to 10 + 6 weeks or at 11 + 0 to 13 + 6 weeks. Probability scores for early-onset and preterm PE were calculated by using two different algorithms: the multivariate Gaussian-distribution model and The Fetal Medicine Foundation (FMF) competing-risks model. Receiver-operating-characteristics (ROC) curves were produced and detection rates at fixed 5% and 10% false-positive rates were computed to compare the performance of these algorithms when PAPP-A and PlGF were assessed before vs after 11 weeks. RESULTS: Of the 2641 women included, serum biomarkers were assessed before 11 weeks in 1675 (63.4%) and at or after 11 weeks in 966 (36.6%). Of these, 90 (3.4%) women developed PE, including 11 (0.4%) cases of early-onset PE and 30 (1.1%) of preterm PE. Five (45.5%) cases of early-onset and 16 (53.3%) of preterm PE were identified in the group in which serum biomarkers were assessed at 8 + 0 to 10 + 6 weeks and six (54.5%) cases of early-onset and 14 (46.7%) of preterm PE in the group in which serum biomarkers were assessed at 11 + 0 to 13 + 6 weeks. In the prediction of early-onset and preterm PE using the Gaussian algorithm, no differences were observed between the areas under the ROC curves (AUCs) when PAPP-A and PlGF were measured before or after 11 weeks. In the prediction of early-onset and preterm PE using the FMF algorithm, no differences were observed between AUCs for any of the combinations used for risk calculation when the serum biomarkers were obtained before vs after 11 weeks, except for the combination of PAPP-A and MAP, which showed a greater AUC for the prediction of early-onset PE when PAPP-A was measured at or after 11 weeks. CONCLUSIONS: The prediction of early-onset and preterm PE is similar when serum biomarkers are measured before or after 11 weeks. This allows the use of a two-step approach for PE risk assessment that permits immediate risk calculation at the time of the first-trimester scan. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Antibacterial properties of phenothiazine derivatives against multidrug-resistant Acinetobacter baumannii strains.

AIM: As options to treat recalcitrant bacterial infections which are increasingly limited due to multidrug-resistant strains, searching for new, effective antibacterial compounds is necessary. One strategy is to generate treatment alternatives by drug repurposing. METHODS AND RESULTS: In this work, phenotypic microarrays were used for the screening of miscellaneous compounds against the growth and biofilm formation of Acinetobacter baumannii, an important emergent multidrug-resistant opportunistic pathogen. The results showed that the phenothiazine derivatives, such as promethazine, trifluoperazine, thioridazine, and chlorpromazine, inhibited the growth of antibiotic-sensitive and multidrug-resistant strains (showing minimal inhibitory concentrations ranging from 0·05 to 0·6 g l-1 and minimal bactericidal concentrations ranging from 0·1 to 2·5 g l-1 ). All phenothiazine derivatives were active against biofilm cells (with minimal biofilm eradication concentrations ranging from 0·5 to >3 g l-1 ). Chlorpromazine promoted reactive oxigen species (ROS) production, and cell membrane and DNA damage. Chlorpromazine showed synergy with antibiotics such as ceftazidime, meropenem, and colistin and was an effective treatment for experimentally infected Galleria mellonella when combined with ceftazidime. CONCLUSIONS: It was demonstrated that phenothiazine derivatives, especially chlorpromazine, are drugs with attractive antibacterial properties against nosocomial MDR strains of A. baumannii, by generating ROS and cell membrane and DNA damage. SIGNIFICANCE AND IMPACT OF THE STUDY: The present study indicates that repurposing phenothiazine derivatives for treating recalcitrant infections by A. baumannii could be promising.

Consensus on definition and severity grading of lymphatic complications after kidney transplantation.

BACKGROUND: The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy. METHODS: Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres. RESULTS: Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention. CONCLUSION: A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.

ANTECEDENTES: La incidencia de complicaciones linfáticas tras el trasplante renal (post-kidney-transplantation lymphatic, PKTL) varía considerablemente en la literatura. Esto se debe en parte a que no se ha establecido una definición universalmente aceptada. Este estudio tuvo como objetivo proponer una definición aceptable para las complicaciones PKTL y un sistema de clasificación de la gravedad basado en la estrategia de tratamiento. MÉTODOS: Se realizó una búsqueda sistemática de la literatura relevante en MEDLINE y Web of Science. Se logró un consenso para la definición y la clasificación de gravedad de las PKTL entre veinte centros de trasplante de alto volumen. RESULTADOS: En 32 de los 87 estudios incluidos se definía la linforrea/linfocele. Sesenta y tres artículos describían como se trataban las PKTL, pero ninguno calificó la gravedad de las mismas. La definición propuesta para la linforrea fue la de un débito diario superior a 50 ml de líquido (no orina, sangre o pus) a través del drenaje o del orificio cutáneo tras su retirada, más allá del 7º día postoperatorio del trasplante renal. La definición propuesta para linfocele fue la de una colección de líquido de tamaño variable adyacente al riñón trasplantado, tras haber descartado un urinoma, hematoma o absceso. Las PKTL de grado A fueron aquellas con escaso impacto o que no requirieron tratamiento invasivo; las PKTL de grado B fueron aquellas que precisaron intervención no quirúrgica y las PKTL de grado C aquellas en que fue necesaria la reintervención quirúrgica. CONCLUSIÓN: Se propone una definición clara y una clasificación de gravedad basada en la estrategia de tratamiento de las PKTLs. La definición propuesta y el sistema de calificación en 3 grados son razonables, sencillos y fáciles de comprender, y servirán para estandarizar los resultados de las PKTL y facilitar las comparaciones entre los diferentes estudios.

The Effect of Proprioceptive Exercises on Balance and Physical Function in Institutionalized Older Adults: A Randomized Controlled Trial.

OBJECTIVES: To evaluate the efficacy of a proprioceptive exercise program on functional mobility, musculoskeletal endurance, dynamic and static balance, gait, and risk of falls in institutionalized older adults. DESIGN: Randomized, single-blind, controlled trial. SETTING: A Spanish nursing home in the autonomous community of Extremadura, Spain. PARTICIPANTS: An initial sample was created by recruiting 148 older adult volunteers. The final sample (N=42) was randomly divided into 2 groups. INTERVENTIONS: Both the control and experimental group received physical therapy treatment based on a combination of adapted exercises and other physical therapy techniques (physical therapy intervention program) for a period of 12 weeks. This program consisted of 45 minutes (group intervention) plus 100 minutes (individual intervention) a week, for a total of 36 sessions (29 hours). The experimental group received a proprioceptive training program during the same intervention period, which was conducted twice weekly (24 sessions), with each session lasting 55 minutes. MAIN OUTCOME MEASURES: Timed Up and Go (TUG), Cooper, Tinetti, 1-leg stance, and the Morse Fall Scale (MFS). RESULTS: Analysis of variance showed a time × group interaction in TUG score (F=10.41, P=.002), Cooper test (F=5.94, P=.019), Tinetti score (F=6.41, P=.015), and MFS scores (F=5.24, P=.028). Differences between groups were achieved for TUG scores (d=0.76), Tinetti scores (d=1.12), 1-leg stance test scores (d=0.77), and MFS scale scores (d=0.85). In the experimental group, within-group analyses showed pre- to post-treatment differences for TUG scores (d=0.72), Cooper test scores in meters (d=0.18), Tinetti scores (d=0.60), 1-leg stance scores (d=0.55), and MFS scores (d=0.42). CONCLUSIONS: A proprioceptive exercise program demonstrated significant improvements compared with the control group in areas such as functional mobility, musculoskeletal endurance, balance, gait, and risk of falls in institutionalized older adults. This study may help to enhance our understanding of the impact of a specific protocol for a proprioceptive rehabilitation program.

Proper pertussis vaccination will probably not increase vaccination coverage: a case-control study.

Vaccination coverage (VC) against pertussis can increase when management practices and policies at primary care centres (PCCs) are reinforced. From 2011 to 2015, we performed a case-control study to evaluate VC among pertussis patients treated at PCCs in Barcelona, Spain. We recorded pertussis in patients from 8- to 16-year-olds at 52 PCCs. Pertussis cases had laboratory diagnostic and controls were healthy outpatients visiting the same facility for reasons other than cough. DTaP/dTap VC was recorded as either proper vaccination status (five doses recorded) or improper vaccination status (<5 doses recorded). We used a logistic regression model to estimate OR and 95% CI. We included 229 cases and 576 controls. VC was higher in cases (mean 5.01, s.e.: 0.57) than in controls (4.89, s.e.: 0.73). Around 69% of the cases had received DTaP primary immunisation after 2-5 years and 31.4% of cases had the dTap booster immunisation after 7-10 years. The 87% of children 5-9 years were properly vaccinated. We found no protection from becoming ill among properly vaccinated children (OR 1.87; 95% CI 1.22-2.85). The highest VC was observed in patients with confirmed pertussis, which was likely due to a more exhaustive follow-up of the VC in these patients. Being properly vaccinated against pertussis will probably not increase VC.

Muscle function deterioration in patients with haemophilia: Prospective experience from Costa Rica.

INTRODUCTION: In haemophilia, recurrent joint bleeds are responsible for the development of chronic joint damage, because blood induces biochemical changes in joint structures. Joint degeneration is a long process, and structural damage is often preceded by joint dysfunction, which is represented by quantitative and qualitative changes in the contraction pattern of muscles around the joints. Muscle function in patients with haemophilia is still poorly investigated. AIM: The aim of this 2-year prospective study was to assess the changes in muscle function of lower limbs in a group of patients affected with haemophilia in San José, Costa Rica. METHODS: Muscle function of lower limbs was assessed by means of surface electromyography (sEMG) accomplished at study enrolment and after 2 years of follow-up. Gluteus medius, vastus medialis, biceps femoris, gastrocnemius and tibialis anterior were examined. All patients underwent concurrent clinical examination using Haemophilia Joint Health Score (HJHS). RESULTS: Sixty patients aged 2-43 years with severe haemophilia underwent clinical and sEMG evaluation. Thirty-two patients (53%) had target joints. sEMG parameters were altered in all patients and were not correlated to the presence of target joints and/or an abnormal HJHS. Muscle function deterioration was observed after 2 years of follow-up despite an unmodified HJHS. CONCLUSIONS: Muscle function of lower limbs as detected by means of sEMG was impaired in patients with haemophilia irrespective of the presence of overt joint damage. sEMG is a simple and sensitive assessment tool able to detect muscle dysfunction and so favouring the implementation of early rehabilitation therapy.

Frequency and prognostic value of resistance/intolerance to hydroxycarbamide in 890 patients with polycythaemia vera.

The clinical significance of resistance/intolerance to hydroxycarbamide (HC) was assessed in a series of 890 patients with polycythaemia vera (PV). Resistance/intolerance to HC was recorded in 137 patients (15·4%), consisting of: need for phlebotomies (3·3%), uncontrolled myeloproliferation (1·6%), failure to reduce massive splenomegaly (0·8%), development of cytopenia at the lowest dose of HC to achieve a response (1·7%) and extra-haematological toxicity (9%). With a median follow-up of 4·6 years, 99 patients died, resulting in a median survival of 19 years. Fulfilling any of the resistance/intolerance criteria had no impact on survival but when the different criteria were individually assessed, an increased risk of death was observed in patients developing cytopenia [Hazard ratio (HR): 3·5, 95% confidence interval (CI): 1·5-8·3, P = 0·003]. Resistance/intolerance had no impact in the rate of thrombosis or bleeding. Risk of myelofibrotic transformation was significantly higher in those patients developing cytopenia (HR: 5·1, 95% CI: 1·9-13·7, P = 0·001) and massive splenomegaly (HR: 9·1, 95% CI: 2·3-35·9, P = 0·002). Cytopenia at the lowest dose required to achieve a response was also an independent risk factor for transformation to acute leukaemia (HR: 20·3, 95% CI: 5·4-76·5, P < 0·001). In conclusion, the unified definition of resistance/intolerance to HC delineates a heterogeneous group of PV patients, with those developing cytopenia being associated with an adverse outcome.

Quality of care in patients with diabetic kidney disease in Asia: The Joint Asia Diabetes Evaluation (JADE) Registry.

AIMS: Diabetic kidney disease independently predicts cardiovascular disease and premature death. We examined the burden of chronic kidney disease (CKD, defined as an estimated GFR < 60 ml/min/1.73 m(2) ) and quality of care in a cross-sectional survey of adults (age ≥ 18 years) with Type 2 diabetes across Asia. METHODS: The Joint Asia Diabetes Evaluation programme is a disease-management programme implemented using an electronic portal that systematically captures clinical characteristics of all patients enrolled. Between July 2007 and December 2012, data on 28 110 consecutively enrolled patients (China: 3415, Hong Kong: 15 196, India: 3714, Korea: 1651, Philippines: 3364, Vietnam: 692, Taiwan: 78) were analysed. RESULTS: In this survey, 15.9% of patients had CKD, 25.0% had microalbuminuria and 12.5% had macroalbuminuria. Patients with CKD were less likely to achieve HbA1c < 53 mmol/mol (7.0%) (36.0% vs. 42.3%) and blood pressure < 130/80 mmHg (20.8% vs. 35.3%), and were more likely to have retinopathy (26.2% vs. 8.7%), sensory neuropathy (29.0% vs. 7.7%), cardiovascular disease (26.6% vs. 8.7%) and self-reported hypoglycaemia (18.9% vs. 8.2%). Despite high frequencies of albuminuria (74.8%) and dyslipidaemia (93.0%) among CKD patients, only 49.0% were using renin-angiotensin system inhibitors and 53.6% were on statins. On logistic regression, old age, male gender, tobacco use, long disease duration, high HbA1c , blood pressure and BMI, and low LDL cholesterol were independently associated with CKD (all P < 0.05). CONCLUSIONS: The poor control of risk factors, suboptimal use of organ-protective drugs and high frequencies of hypoglycaemia highlight major treatment gaps in patients with diabetic kidney disease in Asia.