The alpha-galactosidase A p.Arg118Cys variant does not cause a Fabry disease phenotype: data from individual patients and family studies.

Lysosomal α-galactosidase A (α-Gal) is the enzyme deficient in Fabry disease (FD), an X-linked glycosphingolipidosis caused by pathogenic mutations affecting the GLA gene. The early-onset, multi-systemic FD classical phenotype is associated with absent or severe enzyme deficiency, as measured by in vitro assays, but patients with higher levels of residual α-Gal activity may have later-onset, more organ-restricted clinical presentations. A change in the codon 118 of the wild-type α-Gal sequence, replacing basic arginine by a potentially sulfhydryl-binding cysteine residue - GLA p.(Arg118Cys) -, has been recurrently described in large FD screening studies of high-risk patients. Although the Cys118 allele is associated with high residual α-Gal activity in vitro, it has been classified as a pathogenic mutation, mainly on the basis of theoretical arguments about the chemistry of the cysteine residue. However its pathogenicity has never been convincingly demonstrated by pathology criteria. We reviewed the clinical, biochemical and histopathology data obtained from 22 individuals of Portuguese and Spanish ancestry carrying the Cys118 allele, including 3 homozygous females. Cases were identified either on the differential diagnosis of possible FD manifestations and on case-finding studies (n=11; 4 males), or on unbiased cascade screening of probands' close relatives (n=11; 3 males). Overall, those data strongly suggest that the GLA p.(Arg118Cys) variant does not segregate with FD clinical phenotypes in a Mendelian fashion, but might be a modulator of the multifactorial risk of cerebrovascular disease. The Cys118 allelic frequency in healthy Portuguese adults (n=696) has been estimated as 0.001, therefore not qualifying for "rare" condition.

Regulating Gambling Use through the Overton Window: From an Addictive Behavior to a Social and Epidemiological Problem.

During the last decade, gambling (online and offline) regulation has become a social and epidemiological problem all around Europe. The aftermaths of this addiction have increased since the so-called "responsible gambling law", in the second decade of the 21st century. The Overton window (OW) strategy is a political theory that describes how the perception of public opinion can be modified so that ideas that are inconceivable for society become accepted over time. The objective of this study is to identify whether an OW has been used to bias the adequacy of the gambling debate, as well as its scientific, legal, and political bases and the main consequences for both the general population and the major risk groups, especially the consequences in social and health contexts. The study was conducted by the application of the historical-logical method as the central axis of analysis and reflection, and the technique of qualitative research content analysis as a procedure in the process of execution of the scientific task, related to a historical trend study of the research object. The main consequences found were: the political acceptance of gambling for economical causes and taxes benefits, the use of popular characters to increase the acceptance of the pattern of behavior, the inclusion of the gambling operators as agents in the risks control, and the absence of intervention until the main consequences have been transformed into an epidemiological problem (with social aftermaths higher than the previously identified related to the gambling problems). Furthermore, the results suggest the need to implement prevention and health promotion strategies and the adoption of specific legal measures that regulate the access and the marketing of gambling operators' activities.

Changes in peritoneal membrane permeability and proteinuria in patients on peritoneal dialysis after treatment with paricalcitol − a preliminary study.

BACKGROUND: Patients on peritoneal dialysis (PD) have protein loss through peritoneal membrane (PM) and experience changes in permeability of the membrane. Paricalcitol is a selective vitamin D receptor activator with an effect upon systemic inflammation and an inhibitory effect upon the renin-angiotensin-aldosterone system (RAAS). METHODS: This study explores the possible effect of paricalcitol upon the PM in 23 patients on PD with high iPTH levels. Peritoneal kinetic studies were performed before and after paricalcitol, measuring also ultrafiltration/ day, peritoneal protein losses and proteinuria. Results were compared with a control group of 15 patients not receiving any form of vitamin D. RESULTS: With a mean dose of 1.3 µg/day, peritoneal protein loss decreased from 0.91 ± 0.35 to 0.76 ± 0.26 g/l (15.4%) (p = 0.007) and from 7.55 to 6.46 g/d (p < 0.033), and ultrafiltration increased from 844 to 1,002 ml/d (15.8%) (p = 0.037) and from 284 to 323 ml/4 h. (NS), with minimal change in the creatinine dialysate/plasma ratio 0.67 ± 0.12 vs. 0.65 ± 0.11. Proteinuria decreased from 1.65 to 1.25 g/l (21.9%) (p = 0.01) and iPTH decreased from 668 ± 303 to 291 ± 148 pg/ml (p < 0.001). In the control group, no changes in peritoneal membrane permeability and proteinuria were found. CONCLUSIONS: The results of the study indicate that paricalcitol is effective in treating hyperparathyroidism in patients on PD, and suggest an effect upon proteinuria and PM permeability (not previously reported), with diminished peritoneal protein loss and increased ultrafiltration. The antiinflammatory, antifibrotic and RAAS-modulating actions described for paricalcitol may be responsible for these findings, and could be important for preserving the peritoneum as a dialyzing membrane.

Estimating hospital inpatient cost-savings with sucroferric oxyhydroxide in patients on chronic hemodialysis in five European countries: a cost analysis.

AIMS: Hyperphosphatemia is common among patients with advanced chronic kidney disease (CKD) undergoing dialysis. The iron-based phosphate binder (PB), sucroferric oxyhydroxide (SO), has a low daily pill burden and is indicated for the control of serum phosphorus in these patients. In a retrospective database study, hemodialysis patients switched to long-term SO therapy had fewer hospitalizations compared with patients switched to other PB therapies. This economic analysis aimed to quantify potential cost-savings of reduced hospitalizations associated with SO for healthcare systems in five European countries. MATERIALS AND METHODS: All-cause hospital admissions incidence data were sourced from a real-world retrospective database study comparing adult, in-center hemodialysis patients maintained on 2 years of SO therapy (mSO) versus patients who discontinued SO (dSO) within 90 days of their first prescription and switched to other PBs. A literature search was conducted to determine the cost per hospital admission for dialysis patients in the healthcare setting of each European country. A cost-model combined the incidence rate of all-cause hospital admissions and the cost per admission to estimate the country-specific inpatient costs for the mSO and dSO groups. RESULTS: Annual inpatient cost-savings per patient in the mSO group versus the dSO group were €1,201, €2,097, €2,059, €1,512, and €3,068 in France, Germany, Italy, Spain, and the UK, respectively. When annual PB drug costs per patient were considered, the net annual economic cost-savings per patient were €327, €1,585, €1,022, €1,100, and €2,204, respectively. LIMITATIONS: Hospital admissions data used in the analysis were observational in nature and derived from a US hemodialysis patient population; the effect of SO therapy on hospitalization rates for US and European hemodialysis patients may differ. The analysis did not consider indirect healthcare costs associated with hospitalizations. CONCLUSION: SO therapy may offer substantial inpatient cost-savings by reducing all-cause hospital admissions attributable to uncontrolled hyperphosphatemia.

Nosocomial candidemia at a general hospital: prognostic factors and impact of early empiric treatment on outcome (2002-2005).

OBJECTIVES: To evaluate epidemiological and clinical prognosis factors related to mortality and impact of early empiric treatment on patients with nosocomial candidemia (NC). PATIENTS AND METHODS: Observational study of a cohort of 107 adult patients with NC admitted at a tertiary hospital (2002-5). RESULTS: In bivariate analysis, risk factors significantly associated with mortality rate (49.5%) were: age >65 years, previous steroid treatment, solid organ transplant, acute severity of illness, shock, renal failure and respiratory distress at onset, delayed or inadequate antifungal treatment, non-removal of central venous catheter and associated post-surgical bacterial sepsis or respiratory infection. In multivariate analysis, risk factor associated with mortality was acute severity of illness at onset (OR 76.9; CI 12.5-500) being early and adequate treatment (OR 11.8; CI 1.7-81.2) and early (<48h) removing of central venous catheter (OR 12.2; CI 1.9-74.9) factors associated with cure; there was no statistically significant difference between fungistatic (azoles) or fungicidal (amphotericin or caspofungin) treatment. CONCLUSIONS: Acute severity of illness at onset is associated with mortality in patients with NC whereas early and adequate treatment and early removing of central venous catheter are associated with cure.

Nosocomial candidemia at a general hospital: the change of epidemiological and clinical characteristics. A comparative study of 2 cohorts (1993-1998 versus 2002-2005).

BACKGROUND: Nosocomial candidemia (NC) is associated with high mortality, increased hospital stay and greater economical cost. AIMS: To evaluate epidemiological and clinical aspects of 2 different cohorts of non-paediatric patients with NC. METHODS: A retrospective observational and comparative study of patients with NC. Patients were identified by review of results of blood cultures from the hospital microbiology laboratory. We analysed epidemiological, clinical, microbiological and laboratory data and changes in the 2 cohorts: 1993-1998 (P1) and from 2002 to 2005 (P2). RESULTS: Eighty patients were studied during P1 and 107 during P2; incidence was 9/10,000 in P1 and 15.8/10,000 admitted patients in P2 (p<0.05). Mean age was 52 years in P1 and 61 years in P2 (p<0.05); 66% and 49% NC were due to Candida albicans in P1 and P2, respectively (p<0.05); diabetes was present in 12% in P1 and in 25% in P2 (p<0.05). All of the patients had previously received at least one course of broad-spectrum antibiotics. A statistically significant difference (p<0.05) in predisposing conditions was identified in central intravenous line rate (100% in P1 and 91% in P2) and previous surgery (43% in P1 and 78% in P2). Acute severity of illness at onset and complications were more frequent in P2 (p<0.05). Mortality rate was similar in P1 and P2 (51% and 49.5%, respectively). CONCLUSIONS: Frequency of NC has increased and non-albicans Candida is now more frequent than C. albicans. Although acute severity of illness at onset and complications are now more frequent, mortality remains the same.

Peritoneal protein losses in diabetic patients starting peritoneal dialysis: is there a relationship with diabetic vascular lesions?

During peritoneal dialysis (PD), a significant amount of protein is lost through the peritoneal membrane, and these losses could influence the patient's nutrition status. It has been reported that peritoneal protein loss (PPL) is greater in diabetic (D) patients than in nondiabetic (ND) patients, but the topic is still controversial, and the factors involved are not totally defined. We studied 23 patients on continuous ambulatory PD (12 with diabetes) who had experienced no episodes of infection during the preceding months. We measured peritoneal transport, PPL, proteinuria, and parameters of inflammation and nutrition. Our study was carried out during the first months of PD (2 - 4 months), which coincided with the first evaluation of peritoneal transport. The PPL was higher in D patients than in ND patients (8.4 +/- 2.2 g vs. 5.7 +/- 1.7 g daily, p < 0.001), as was proteinuria (3.7 +/- 2.7 g vs. 0.9 +/- 0.7 g daily, p = 0.003). In 83% of D patients and 54% of ND patients, peritoneal transport (p = 0.002) was high or high-average. Dialysate-to-plasma creatinine in D patients was 0.77 +/- 0.12 as compared with 0.66 +/- 0.09 in ND patients (p = 0.031). Parameters of nutrition and inflammation were normal in both groups of patients and showed no significant differences, except for serum total protein, which was significantly lower in D patients. Ultrafiltration, Kt/V, and weekly creatinine clearance were similar in both groups. The D patients with a higher PPL had the highest proteinuria values. We conclude that the higher PPL seen in D patients starting PD seems to be related to high membrane transport in these patients. The condition of high transport in D patients could be a result of diabetic microvascular lesions that cause a similar pattern of permeability in the peritoneal and glomerular membranes.

[Low mortality rate in an outbreak of Legionnaires' disease: correlation with the cytopathogenity study]. / Baja mortalidad en un brote de enfermedad del legionario: correlación con el estudio de citopatogenicidad.

BACKGROUND: In 2001 an outbreak of Legionnaires' diseases occurred in Murcia, Spain, with one of the lowest known rates of associated mortality. We describe the clinical data of a subgroup of patients, and present the results from molecular and virulence studies to correlate the lower mortality of the overall series with the strain virulence. PATIENTS AND METHODS: A subgroup of 86 patients from the outbreak of Legionnaires'disease was prospectively included. Demographic, risk factors and clinical evolution data were obtained. Moreover, we performed a pulsed field gel electrophoresis and cytopathogenicity assay of the Murcia outbreak that were compared with other unrelated Legionella isolates. RESULTS: Sixty-nine (77.9%) patients were males. The mean age of the patients was 58.2 years (range: 32-87). Smoking was the most frequent risk factor in 62 patients (71.7%) and 61 patients (70.2%) had underlying diseases. Clinical, laboratory and radiological manifestations were compatible with the atypical pneumonia syndrome. The mortality rate was 3.2%. All the clinical L. pneumophila isolates analyzed by PFGE showed the same subtype. When analyzing theses strains together with other Legionella strains, they were included in the group with lower virulence in the cytopathogenicity study. CONCLUSIONS: The most outstanding data in this subgroup of patients were: male-sex, smoking, atypical clinical manifestations and low mortality. The low virulence of this molecular genotype of L. pneumophila may be responsible, in part, for the low mortality observed in the outbreak in Murcia.

Clinical profile of women diagnosed with Fabry disease non receiving enzyme replacement therapy.

INTRODUCTION AND OBJECTIVE: Fabry disease (FD) is an X-linked lysosomal storage disorder due to a deficiency of the α-galactosidase A enzyme. Although women were historically considered only carriers, many studies have contradicted this fact. The main aim of this work was to set the first Spanish study out of the on-going registries on health status and management of women diagnosed with FD who were not receiving enzyme replacement therapy (ERT). MATERIAL AND METHODS: An epidemiological, cross-sectional, descriptive and multicentre study was assessed in women diagnosed for FD who were not receiving ERT. Assessments on symptomatology and severity were collected using several clinical questionnaires. Additionally, clinical information and lab tests were obtained from clinical records. RESULTS: Thirty-three women with a mean age of 45.6±16.2 years were studied. Symptom onset was at a median age of 35.5 years old (range: 30.0-51.5), being diagnosed a median of 2 years later (range: 1.0-1.5). Missense mutations were the most prevalent mutation (n=22, 68.8%). Although 69% considered themselves as asymptomatic, 22 (66.7%) showed at least one FD-related clinical symptom. Using Mainz Severity Score index and Fabry International Prognosis Index neurological symptomatology obtained higher scores both for severity and prognostic. The EQ-5D questionnaire showed 42.2% patients referring to some anxiety or depression, and 30.3% thought that their life was somehow altered by the pain. 62.5% were not receiving any treatment and ERT was offered only to one patient (3.6%) who refused it. CONCLUSIONS: Although most of the heterozygous women for FD had not received ERT or either symptomatic treatment, they present symptoms of disease. Careful follow-up of female patients or some adjuvant treatment may be considered to delay progressive organ damage and improve patient quality of life.

Impact of first year renal replacement therapy on the hospital admissions of a regional public health system. / Impacto del primer año de tratamiento sustitutivo renal en la hospitalización de una comunidad autónoma.

INTRODUCTION AND OBJECTIVES: Chronic kidney disease has a high prevalence and economic impact, and an increased risk of hospitalization. Although there are public regional and country registries, we have not found references to estimate the impact of renal replacement therapy (RRT) on hospital admissions. METHODS: We obtained authorization from the ethics committee and health authorities to integrate the REMER [Madrid Kidney Disease Registry] (2013-2014) and Minimum Basic Data Set (2013-2015) databases and to analyze the admissions during the first year of RRT. RESULTS: 767 patients started RRT in all the hospitals of our region across all RRT modalities. More than a third of the patients start dialysis during a hospital admission. This unplanned start, more common in HD than PD, shows relevant differences in patient profile or admission characteristics. Without considering this initial episode, almost 60% of patients were admitted during their first year. The hospitalization rate was 1.2admissions/patient, higher in HD than in TX or PD; the mean length of stay was 8.6days. The estimated cost of admissions during the first year is €12,006/patient. Our analysis ensures the exhaustive inclusion of all episodes and accurate estimation based on the discharge form. CONCLUSION: The impact of RRT on hospitals has been underestimated and is very relevant when calculating the total cost of RRT. Results from other countries cannot be extrapolated due to differences in the health system and patient profile. The integration of clinical databases could open up an opportunity that needs only institutional support for its development.

Simple criteria to assess mortality in patients with community-acquired pneumonia.

BACKGROUND AND OBJECTIVES: The Pneumonia Patient Outcomes Research Team (PORT) developed a prediction rule to identify patients with community-acquired pneumonia (CAP) who are at risk for death and other adverse outcomes. Simpler criteria are needed to evaluate risk of mortality in CAP. PATIENTS AND METHODS: Observational study of patients with CAP admitted to a tertiary care university hospital. Epidemiological, clinical, radiological and laboratory data associated with mortality were analysed. RESULTS: A cohort of 211 patients with CAP was studied. Severity distribution according to PORT score was 12.3%, 15.6%, 19%, 35.5% and 17.5% in groups I, II, III, IV and V, respectively; mean age was 63 years (range, 13 to 100 years); in 43.6% age was < 65 years; 61.5% patients had > or = 1 underlying disease (congestive heart failure in 33.6% and chronic lung disease in 29.9%). Mortality rate was 0% in groups I-II, 2.5% in group III, 5.3% in group IV and 27% in group V. All variables considered in PORT-score were included in a mortality predicting model; factors significantly associated with death were: altered mental status, respiratory rate > or = 30/min, pH < 7.35, glucose > or = 250 mg/dl and age > 65 years; 99% of patients who had none of these abnormalities survived. CONCLUSIONS: Simpler criteria to assess mortality in CAP were identified. Non-existence of altered mental status, respiratory rate > or = 30/min, pH < 7.35, glucose > or = 250 mg/dl and age > 65 years predicted a non-fatal outcome in 99% of patients. These clinical or laboratory findings should be considered as mortality predictors, can be used as severity adjustment measure and may help physicians make more rational decisions about hospitalization in CAP.

[Brain abscess. The experience of 30 years]. / Abscesos cerebrales. Experiencia de 30 años.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate epidemiological and clinical aspects of brain abscess (BA) and changes in clinical patterns during the last 30 years. PATIENTS AND METHOD: Observational study of a cohort of non-pediatric patients with BA admitted at a 944-bed hospital. Data collection from clinical records was done according to a standard protocol. We analysed epidemiological, clinical and microbiological data and localization as well as changes during a 30 year period divided in 2 equal length phases: 1976-1989 (P1), and 1990-2005 (P2). RESULTS: 108 patients with BA were included (mean age: 45 years; range: 12-86; > 40 years in 42.4% P1, and 71.4% in P2, p < 0.05); 66 patients were treated in P1 and 42 in P2 (annual incidence: 4-5 cases and 2-3 cases per 10(6) population in P1 and P2, respectively). A predisposing condition was identified in 86% cases with statistically significant differences (p < 0.05) in: otitis media (18.2% vs 2.4%); dental infection (3% vs 16.7%); penetrating cranial trauma (16.7% vs 0%); post-neurosurgery (15.1% vs 21.4%), in P1 and P2, respectively; microbiologic diagnosis was made in 76% (no statistical differences P1/P2). Clinical aspects statistically different in P1/P2: severely altered mental status (10.6% vs 0%); vomiting (37.9% vs 21.4%); focal neurological deficits (37.9% vs 71.4%). No statistically significant differences were found in other epidemiological, clinical, radiological, microbiological or outcome characteristics in P1/P2. CONCLUSIONS: In spite of a lower incidence in P2 and certain epidemiological and clinical differences in P1/P2, mortality and relapses rates have not significantly changed in a 30 year period.

[A comparative study of patients with methicillin susceptible versus methicillin resistant Staphylococcus aureus bacteremia: epidemiology and prognostic factors]. / Estudio comparativo de pacientes con bacteriemia por Staphylococcus aureus sensible a la meticilina frente a S. aureus resistente a la meticilina: epidemiología y factores pronósticos.

BACKGROUND AND OBJECTIVE: The influence of methicillin resistance in Staphylococcus aureus bacteremia (SAB) continues to be controversial. The aim of this study was to evaluate risk factors and mortality predictors in patients with SAB and the influence of methicillin resistance in mortality (SAMSB vs SAMRB). PATIENTS AND METHOD: Prospective study including 213 in-patients with SAB. RESULTS: Of 213 episodes of SAB, 131 (61.5%) were due to SAMS and 82 (38.5%) to SAMR. Risk factors associated with SAMRB were: nosocomial infection, presence of an ultimately or rapidly fatal underlying disease, diabetes mellitus, intravenous catheters, previous ICU hospitalization and therapy with broad-spectrum antibiotics. Severity and complications were more frequent in patients with SAMRB. Mortality was 42.6% in SAMRB cases vs 16% in SAMSB cases (p < 0.05). Multivariate analysis showed as independent predictors of mortality in patients with SAB: presence of an ultimately or rapidly fatal underlying disease, acute severity of illness at onset and inappropriate empirical therapy; methicillin resistance was not an independent predictor of mortality. CONCLUSIONS: Methicillin resistance was not an independent predictor of mortality in patients with SAB. Presence of a fatal underlying disease, acute severity of illness at onset and inappropriate therapy were the main prognosis factors in patients with SAB.

Disfunción ventricular derecha en paciente adulto con comunicación interventricular posinfarto / Right ventricular dysfunction in adult patient with post-infarction ventricular septal defect

RESUMEN Introducción: La disfunción ventricular derecha es la alteración aguda o crónica de la morfología y función de dicha estructura, de origen multifactorial. En los últimos años existe consenso acerca de su función como determinante del estado funcional y factor pronóstico en diversas enfermedades. Objetivo: Destacar la importancia del manejo multidisciplinario y algunas de las opciones terapéuticas que se les pueden brindar a estos pacientes. Presentación del caso: Paciente de 58 años de edad, con antecedentes de salud aparente, que acudió al Servicio de emergencias, donde se le diagnosticó un infarto agudo de miocardio de topografía inferior. Se trasladó a la unidad de cuidados intensivos quirúrgicos del Servicio de Cirugía Cardiovascular debido a una complicación mecánica por comunicación interventricular. Se recibió con elementos clínicos de insuficiencia cardíaca aguda clase funcional IV. Progresivamente presentó deterioro del estado hemodinámico por lo que requirió el uso de apoyo vasoactivo con norepinefrina; hipoxia, hipercapnia, presiones venosas centrales entre 15 y 18 cmH2O y elementos clínicos de disfunción de ventrículo derecho; se decidió instrumentar vía aérea, administrar sedación y relajación por asincronías a paciente ventilado. Sin otra opción que el tratamiento quirúrgico se llevó a discusión donde se decidió esperar a la mejoría del estado hemodinámico con tratamiento médico. Conclusiones: Las enfermedades cardiovasculares no dejan de aparecer en escenarios cada vez más complejos con elevada morbimortalidad. Se evidencia la importancia del consenso clínico-quirúrgico en el momento de la toma de decisiones.

ABSTRACT Introduction: Right ventricular dysfunction is the acute or chronic alteration of the morphology and function of this structure, of multifactorial origin. In recent years there is consensus about its role as a determinant of functional status and prognostic factor in various diseases. Objective: Highlight the importance of multidisciplinary management and some of the therapeutic options that can be provided to these patients. Case Presentation: A 58-year-old patient with an apparent health history went to the Emergency Service, where he was diagnosed with an acute myocardial infarction of lower topography. He was transferred to the surgical intensive care unit of the Cardiovascular Surgery Service due to a mechanical complication from ventricular septal defect. He was received presenting clinical elements of acute heart failure functional class IV. He progressively presented deterioration of the hemodynamic state, so it required the use of vasoactive support with norepinephrine; hypoxia, hypercapnia, central venous pressures between 15 and 18 cmH2O and clinical elements of right ventricular dysfunction; it was decided to implement airway, administer sedation and relaxation by asynchrony to ventilated patient. With no other option than surgical treatment, it was brought to discussion and it was decided to wait for the improvement of the hemodynamic state with medical treatment. Conclusions: Cardiovascular diseases do not cease to appear in increasingly complex scenarios with high morbidity and mortality. The importance of clinical-surgical consensus at the time of decision-making is evident.

Testosterone deficiency in dialysis patients: Difference between dialysis techniques. / Déficit de testosterona en los pacientes en diálisis: diferencias según la técnica de diálisis.

Testosterone deficiency is a prevalent condition in male patients with chronic kidney disease. However, it is not known whether the type of renal replacement therapy has an impact on testosterone deficiency that accompanies loss of renal function. METHODS: The cross-sectional study enrolled 79 prevalent male patients on dialysis; 43 on haemodialysis (HD) and 36 on peritoneal dialysis (PD). The median age was 69 years and 31.6% were diabetics. Endogenous testosterone levels were measured by immunoluminescence assay (normal range 3-10.5ng/ml), while nutritional/inflammatory markers, bone and mineral metabolism markers, anaemia, type of dialysis technique and time on dialysis were also assessed. Body composition was evaluated by bioimpedance vector analysis and bioimpedance spectroscopy. Testosterone deficiency was defined as levels below 3ng/ml. RESULTS: Mean testosterone levels were 8.81±6.61ng/ml. Testosterone deficiency affected 39.5% of HD patients and only 5.6% of PD patients. In the univariate analysis, testosterone levels were directly correlated with type of dialysis technique (HD) (Rho Spearman 0.366; P<.001) and time on dialysis (Rho -0.412; P=.036) and only with the HD technique in the multivariate analysis. No other significant correlations were found. CONCLUSIONS: Circulating testosterone levels in men on dialysis were independently associated with HD technique. It can be concluded that a new factor -namely the dialysis technique- may be associated with falling testosterone levels and the associated loss of muscle mass and inflammation. Further studies are needed to establish whether the dialysis technique itself triggers testosterone elimination.

Factores clínicos y ecocardiográficos asociados al bajo gasto cardíaco posoperatorio en pacientes con tratamiento quirúrgico cardiovascular / Clinical and echocardiographic factors associated with the postoperative low cardiac output in patients with cardiovascular surgical treatment i: en

Introducción: Entre las diferentes complicaciones que surgen en el periodo posoperatorio inmediato, el bajo gasto cardíaco presenta mayor morbilidad y mortalidad asociadas, con una incidencia de hasta 45,0 %. Objetivo: Determinar los factores relacionados con la aparición posoperatoria del bajo gasto cardíaco en pacientes con tratamiento quirúrgico cardiovascular y circulación extracorpórea, según variables demográficas, clínicas y ecocardiográficas. Métodos: Se realizó una investigación analítica, de casos y controles, la cual incluyó a pacientes que recibieron tratamiento quirúrgico cardíaco en el Servicio de Cardiología y Cirugía Cardiovascular del Hospital Provincial Clinicoquirúrgico Docente Saturnino Lora de Santiago de Cuba, desde enero hasta diciembre de 2019. Cada grupo de estudio estuvo conformado por 43 integrantes, para lo cual se consideró la presencia del síndrome de bajo gasto cardíaco (casos) o no (controles). Resultados: En la serie predominaron los pacientes menores de 65 años de edad en ambos grupos de estudio (51,2 y 73,5 % para casos y controles, respectivamente), así como el sexo masculino (60,9 %); de igual modo, resultó más frecuente la intervención quirúrgica de emergencia (80,2 %). La fibrilación auricular y la función sistólica del ventrículo derecho presentaron alta significación estadística (p<0,05). Conclusiones: Algunos elementos clínicos y ecocardiográficos (edad, fibrilación auricular, función sistólica de los ventrículos izquierdo y derecho, así como intervención quirúrgica de emergencia) se asociaron de manera independiente a la aparición del bajo gasto cardíaco.

Introduction: Among the different complications that arise in the immediate postoperative period, the low cardiac output presents higher associated morbidity and mortality, with an incidence of up to 45.0 %. Objective: To determine the factors related to the postoperative emergence of the low cardiac output in patients with cardiovascular surgical treatment and extracorporeal circulation, according to demographic, clinical and echocardiographic variables. Methods: An analytic, cases and controls investigation was carried out, which included patients that received heart surgical treatment in the Cardiology and Cardiovascular Surgery Service of Saturnino Lora Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, from January to December, 2019. Each study group was conformed by 43 members, for which was considered the presence (cases) or not (controls) of the low cardiac output syndrome. Results: In the series there was a prevalence of the patients under 65 years in both study groups (51.2 and 73.5 % for cases and controls, respectively), as well as the male sex (60.9 %); in a same way, the emergency surgical intervention was the most frequent (80.2 %). The atrial fibrillation and the systolic function of the right ventricle presented high statistical significance (p <0.05). Conclusions: Some clinical and echocardiographic elements (age, atrial fibrillation, systolic function of the left and right ventricles, as well as emergency surgical intervention) were associated in an independent way with the emergence of the low cardiac output.

Biomarcadores como predictores de mortalidad en pacientes graves con infecciones / Biomarkers as mortality predictors in severely-ill patients with infections

Introducción: Actualmente se buscan biomarcadores que se modifiquen paralelamente con la historia natural de la sepsis. Objetivo: Describir las variaciones de la proteína C reactiva, la eritrosedimentación y el conteo de eosinófilos en pacientes graves portadores de enfermedad infecciosa en diferentes etapas. Método: Se realizó una investigación aplicada y analítica de cohorte, según el estado de la temática, alcance y aplicabilidad de los resultados. Se realizó en pacientes graves con enfermedades infecciosas ingresados en la unidad cuidados intensivos del Hospital Saturnino Lora, durante marzo de 2018 hasta marzo de 2019. El universo estuvo constituido luego de aplicar los criterios de inclusión y exclusión por 41 pacientes, 21 fallecidos y 20 vivos. Las variables estudiadas fueron edad, sexo, origen, gravedad y seguimiento del proceso infeccioso, biomarcadores de respuesta inflamatoria e infección y estado al egreso. Para el procesamiento de la información estadística se emplearon valores promedios como medidas de resumen para variables cuantitativas y porcentajes para variables cualitativas. Para la asociación estadísticamente significativa entre los criterios de interés se aplicó el Test X2 de Independencia. Resultados: La sepsis resultó más frecuente en pacientes masculinos en edades intermedias de la vida, fundamentalmente de origen respiratorio y fue la eosinopenia el biomarcador que más se alteró en los diferentes momentos de la investigación Conclusión: El biomarcador asociado a la sepsis que más se alteró en los diferentes momentos del estudio fue la eosinopenia con mayor asociación como predictor de mortalidad en los diferentes momentos que se realizó el análisis(AU)

Introduction: Currently, biomarkers are being sought that become modified in parallel with the natural history of sepsis. Objective: To describe the variations in C-reactive protein, erythrocyte sedimentation and eosinophil count in severely-ill patients with infectious disease at different stages. Method: An applied and analytical cohort research was carried out, according to the state of the subject, scope and applicability of the outcomes. It was carried out in severely-ill patients with infectious diseases admitted to the intensive care unit of the Saturnino Lora Hospital, from March 2018 to March 2019. The study population was made up after applying the inclusion and exclusion criteria in 41 patients, 21 deceased and 20 alive. The variables studied were age, sex, origin, severity, and monitoring of the infectious process, biomarkers of inflammatory response and infection, and discharge status. For the processing of statistical information, mean values TX 2;were used as summary measures for quantitative variables and percentages for qualitative variables. For the statistically significant association between the criteria of interest, the chi-square Independence test was applied. Results: Sepsis was more frequent among male patients in intermediate ages of life, mainly of respiratory origin; while eosinopenia was the biomarker that was most altered at different moments of the investigation Conclusion: The biomarker associated with sepsis that was most altered at different times of the study was eosinopenia, with the greatest association as a predictor for mortality at the different times when the analysis was performed(AU)

Bisphenol a in chronic kidney disease.

Phenols are uremic toxins of intestinal origin formed by bacteria during protein metabolism. Of these molecules, p-cresol is the most studied and has been associated with renal function impairment and vascular damage. Bisphenol A (BPA) is a molecule with structural similarity with phenols found in plastic food and beverage containers as well as in some dialyzers. BPA is considered an environmental toxicant based on animal and cell culture studies. Japanese authorities recently banned BPA use in baby bottles based on observational association studies in newborns. BPA is excreted in urine and uremic patients present higher serum levels, but there is insufficient evidence to set cut-off levels or to link BPA to any harmful effect in CKD. However, the renal elimination and potential exposure during dialysis warrant the monitoring of BPA exposure and the design of observational studies in which the potential health risks of BPA for end-stage renal disease patients are evaluated.

[Bacteraemia at a second level hospital: epidemiological study, analysis of pronostic factors associated to mortality and economic cost estimation]. / Bacteriemias en un hospital de segundo nivel: estudio epidemiológico, análisis de factores pronósticos asociados a mortalidad y estimación de su coste económico.

INTRODUCTION: Bacteraemia (B) accounts for a considerable proportion (0.36%) of all hospital admissions due to infections diseases and it is associated to increased hospital costs. The aim of this study is to describe a cohort of patients with bacteraemia at a second level hospital, to analyze factors associated to mortality and its economical impact during hospital admission. PATIENTS AND METHODS: Observational study of a cohort of adult patients with bacteraemia admitted at a second level hospital during 2010. Data collection from clinical records has been done according to a standard protocol: epidemiological and clinical variables and factors associated to mortality were analysed. Total economical cost per patient was estimated. RESULTS: 148 patients were included: 80 community B (55.4%), 23 health care associated B (15.5%) and 45 nosocomial B (28.5%). The incidence was 9 cases 10.000 persons/year. Mean age was 69 years and the global mortality was 24%. In bivariate analysis smoking, diabetes mellitus, McCabe Jackson score type I-II, Pitt Index ≥ 3, APACHE ≥ 20, Glasgow ≤ 9, shock, respiratory distress, invasive procedures, nosocomial bacteraemia and inadequate empiric or definitive antibiotic treatment were associated to mortality (p<0.05). Factors associated to mortality in multivariate analysis included McCabe Jackson score type I-II (OR 4.95; 95% CI 1.095-22.38), haemodialysis during acute stage (OR 7.8; 95% CI 2.214-27.773) and inadequate empiric antibiotic treatment (OR 7.68; 95% CI 19.82-29.77). Admission economic cost per patient was 9,459 € for community acquired bacteriemia, 5,656 € for health care associated bacteraemia and 41,680€ for nosocomial bacteraemia. CONCLUSIONS: Comorbidity, inadequate empiric antibiotic treatment and haemodialysis during acute phase are statistically significantly in our cohort of patients with bacteraemia.

[Bacteraemia due to Escherichia coli producing extended-spectrum beta-lactamases (ESBL): clinical relevance and today's insights]. / Bacteriemias por Escherichia coli productor de betalactamasas de espectro extendido (BLEE): significación clínica y perspectivas actuales.

Antibiotic resistance is an old problem with new face as the rate of infections due to multidrug resistant bacteria is higher everyday and the number of new antibiotics to overwhelm the problem is becoming smaller. E. coli is the most frequent agent causing nosocomial or community-acquired bacteraemia being in our country 10% of them extended-spectrum beta-lactamases (ESBL) producing E. coli isolates. Nowadays the number of community- acquired or health-related infections caused by these ESBL producing E. coli is increasing. CTX-M has also become the most frequent ESBL compared to other enzymes. The role of these enzymes as a virulence factor increasing mortality in patients with bacteraemia due to E. coli is not well defined. The relevance of ESBL-E. coli seems to be related with the higher frequency of inadequate treatment and therefore the importance of identifying factors or features that might predict that the patient's infection is due to one of these isolates. In terms of prevention and control of infection measures, the role of patient's isolation is not clear but a proper prescription of antibiotics and antibiotic control policies are probably important to reduce the problem.