Human intestinal microbiome: Role in health and disease.

The study of the microbiota and the microbiome, and specifically the intestinal one, has determined great interest due to the possible association of their alterations with numerous diseases. These include entities as diverse as Crohn's disease, autism, diabetes, cancer or situations as prevalent today as obesity. In view of this situation, different recommendations have been performed regarding the use of probiotics, prebiotics, and postbiotics as modulators of the microbiota and the microbiome, seeking both preventive and therapeutic effects, and faecal material transfer (FMT) is proposed as an alternative. The latter has emerged as the only proven beneficial intervention on the intestinal microbiome, specifically in the treatment of recurrent colitis associated with Clostridioides difficile (R-CDI). In the rest of the entities, the lowering of laboratory costs has favored the study of the microbiome, which is resolved by delivering reports with catalogs of microorganisms, metabolites or supposed biomarkers without consensus on their composition associated with healthy or diseased microbiota and the disease. There is still insufficient evidence in any disease for interventions on the microbiome beyond FMT and R-CDI. Multi- and multi-disciplinary work with extensive research and the application of artificial intelligence in this field may shed light on the questions raised currently. Ethical issues must also be resolved in light of possible interventions within the umbrella of personalized medicine.

Tuberculosis in Spain: An opinion paper.

This document is the result of the deliberations of the Committee on Emerging Pathogens and COVID-19 of the Illustrious Official College of Physicians of Madrid (ICOMEM) regarding the current situation of tuberculosis, particularly in Spain. We have reviewed aspects such as the evolution of its incidence, the populations currently most exposed and the health care circuits for the care of these patients in Spain. We have also discussed latent tuberculosis, the reality of extrapulmonary disease in the XXI century and the means available in daily practice for the diagnosis of both latent and active forms. The contribution of molecular biology, which has changed the perspective of this disease, was another topic of discussion. The paper tries to put into perspective both the classical drugs and their resistance figures and the availability and indications of the new ones. In addition, the reality of direct observation in the administration of antituberculosis drugs has been discussed. All this revolution is making it possible to shorten the treatment time for tuberculosis, a subject that has also been reviewed. If everything is done well, the risk of relapse of tuberculosis is small but it exists. On the other hand, many special situations have been discussed in this paper, such as tuberculosis in pediatric age and tuberculosis as a cause for concern in surgery and intensive care. The status of the BCG vaccine and its present indications as well as the future of new vaccines to achieve the old dream of eradicating this disease have been discussed. Finally, the ethical and medicolegal implications of this disease are not a minor issue and our situation in this regard has been reviewed.

Sexually transmitted infections in Spain: Current status.

Sexually Transmitted Infections (STI) are a major public health problem. The problems inherent to their diagnosis, treatment and prevention have to do not only with their nature, but also with organizational issues and overlapping competencies of the different health authorities in Spain. The real situation of STI in Spain, at present, is poorly known. For this reason, the Scientific Committee on COVID and Emerging Pathogens of the Illustrious Official College of Physicians of Madrid (ICOMEM) has formulated a series of questions on this subject which were distributed, not only among the members of the Committee, but also among experts outside it. The central health authorities provide very high and increasing figures for gonococcal infection, syphilis, Chlamydia trachomatis infection and lymphogranuloma venereum (LGV). Both HIV infection and Monkeypox are two important STI caused by viruses in our environment, to which it should be added, mainly, Herpes simplex virus (HSV) and Human papillomavirus (HPV) infections. Emerging microorganisms such as Mycoplasma genitalium pose not only pathogenic challenges but also therapeutic problems, as in the case of N. gonohrroeae. The pathways that patients with suspected STI follow until they are adequately diagnosed and treated are not well known in Spain. Experts understand that this problem is fundamentally managed in public health institutions, and that Primary Care and Hospital Emergency Services, together with some institutions that deal monographically with this problem, are the recipients of most of these patients. One of the most serious difficulties of STI lies in the availability of the microbiological tests necessary for their diagnosis, particularly in this era of outsourcing of microbiology services. Added to this is the increased cost of implementing the latest generation of molecular techniques and the difficulties of transporting samples. It is clear that STI are not diseases to which the entire population is equally exposed and it is necessary to have a better knowledge of the risk groups where to focus the necessary interventions adapted to their characteristics. It should not be forgotten that STI are also a problem in the pediatric age group and that their presence can be a marker of sexual abuse with all that this implies in terms of health care and medicolegal activity. Finally, STI are infections that are associated with a high cost of care for which we have very little information. The possibility of expanding the automatic performance of laboratory tests for STI surveillance through laboratory routines is encountering ethical and legal problems that are not always easy to solve. Spain has created a ministerial area of specific attention to STI and there are plans to improve the diagnosis, treatment and prevention of these problems, but we still lack the necessary evidence on their impact. We cannot forget that these are diseases that transcend the individual and constitute a Public Health problem.

Impact of the COVID-19 pandemic on the diagnosis and treatment of onco-hematologic patients: a discussion paper.

We do not know the precise figure for solid organ tumors diagnosed each year in Spain and it is therefore difficult to calculate whether there has been a decrease in cancer diagnoses as a consequence of the pandemic. Some indirect data suggest that the pandemic has worsened the stage at which some non-hematological neoplasms are diagnosed. Despite the lack of robust evidence, oncology patients seem more likely to have a poor outcome when they contract COVID-19. The antibody response to infection in cancer patients will be fundamentally conditioned by the type of neoplasia present, the treatment received and the time of its administration. In patients with hematological malignancies, the incidence of infection is probably similar or lower than in the general population, due to the better protective measures adopted by the patients and their environment. The severity and mortality of COVID-19 in patients with hematologic malignancies is clearly higher than the general population. Since the immune response to vaccination in hematologic patients is generally worse than in comparable populations, alternative methods of prevention must be established in these patients, as well as actions for earlier diagnosis and treatment. Campaigns for the early diagnosis of malignant neoplasms must be urgently resumed, post-COVID manifestations should be monitored, collaboration with patient associations is indisputable and it is urgent to draw the right conclusions to improve our preparedness to fight against possible future catastrophes.

Consensus Document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on Tracheotomy in Patients with COVID-19 Infection. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Perioperative management in thoracic surgery. / Manejo perioperatorio en cirugía torácica.

Thoracic surgery has undergone significant advances in recent years related to anesthetic and surgical techniques and the prevention and management of complications related to the procedure. This has allowed improvements in patient clinical outcomes in surgeries of this kind. Despite the above, thoracic surgery, especially related to pulmonary resection, is not without risk, and is associated to considerable morbidity and mortality. Fast track or enhanced recovery after anesthesia protocols, minimally invasive surgery, and intraoperative anesthetic management improve the prognosis and safety of thoracic surgery. Patients in the postoperative period of major thoracic surgery require intensive surveillance, especially the first 24-72hours after surgery. Admission to the ICU is especially recommended in those patients with comorbidities, a reduced cardiopulmonary reserve, extensive lung resections, and those requiring support due to life-threatening organ failure. During the postoperative period, intensive cardiorespiratory monitoring, proper management of thoracic drainage, aggressive pain control (multimodal analgesia and regional anesthetic techniques), nausea and multimodal rehabilitation are key elements for avoiding adverse events. Medical complications include respiratory failure, arrhythmias, respiratory infections, atelectasis and thromboembolic lung disease. The most frequent surgical complications are hemothorax, chylothorax, bronchopleural fistula and prolonged air leakage. The multidisciplinary management of these patients throughout the perioperative period is essential in order to ensure the best surgical outcomes.

Perioperative intensive care medicine. / Medicina intensiva perioperatoria.

Surgery represents one of the main therapeutic references in the world, affording greater survival and life expectancy for many patients. In general, the estimated postoperative mortality is low (around 1-4%). Thirteen percent of the surgical procedures have a high risk of complications, accounting for 80% of all postoperative deaths. Recently, there have been significant advances related to organizational aspects, new anesthetic and surgical techniques, prognostic scales, perioperative management and greater participation and involvement of the patient. This new series of Medicina Intensiva will address fundamental aspects of how Departments of Intensive Care Medicine can add value to the surgical process, in a coordinated manner with other services. Institutional policies are required to ensure the detection of patients at risk in hospitalization wards, with early admission to the ICU of those patients in whom admission is indicated, adapting the treatment in the ICU and optimizing the criteria for discharge. The detection and prevention of post-ICU syndrome in patients and relatives, and the follow-up of ICU discharge and hospitalization in a multidisciplinary manner can reduce the sequelae among critical surgical patients, improving the outcomes and quality of life, and restoring the patient to society. In future publications of this series directed to the surgical patient, updates will be provided on the perioperative management of some of the most complex surgeries.

Limitation of life-sustaining treatment in patients with prolonged admission to the ICU. Current situation in Spain as seen from the EPIPUSE Study.

OBJECTIVE: Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN: A prospective, observational cohort study was carried out. SETTING: Seventy-five Spanish ICUs. PATIENTS: A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. MAIN VARIABLES OF INTEREST: The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS: LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION: LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.

[Consensus conference on providing information of adverse events to patients and relatives]. / Conferencia de consenso sobre información de eventos adversos a pacientes y familiares.

OBJECTIVE: To develop recommendations regarding «Information about adverse events to patients and their families¼, through the implementation of a consensus conference. MATERIAL AND METHODS: A literature review was conducted to identify all relevant articles, the major policies and international guidelines, and the specific legislation developed in some countries on this process. The literature review was the basis for responding to a series of questions posed in a public session. A group of experts presented the best available evidence, interacting with stakeholders. At the end of the session, an interdisciplinary and multi-professional jury established the final recommendations of the consensus conference. RESULTS: The main recommendations advocate the need to develop policies and institutional guidelines in our field, favouring the patient adverse events disclosure process. The recommendations emphasize the need for the training of professionals in communication skills and patient safety, as well as the development of strategies for supporting professionals who are involved in an adverse event. The assessment of the interest and impact of specific legislation that would help the implementation of these policies was also considered. CONCLUSIONS: A cultural change is needed at all levels, nuanced and adapted to the specific social and cultural aspects of our social and health spheres, and involves all stakeholders in the system to create a framework of trust and credibility in which the processing of information about adverse events may become effective.

Granulibacter bethesdensis isolated in a child patient with chronic granulomatous disease.

Chronic granulomatous disease was diagnosed in a 10-year-old boy who, after some weeks' decline, developed acute respiratory distress leading to multiple organ failure and death. All microbiological analyses were negative, except two blood cultures from which the novel bacterium Granulibacter bethesdensis was isolated.

[Treatment recommendations at the end of the life of the critical patient]. / Recomendaciones de tratamiento al final de la vida del paciente crítico.

Admission of a patient in the Intensive Care Unit (ICU) is justified when the critical situation can be reverted or relieved. In spite of this, there is high mortality in the ICU in regard to other hospital departments. End-of-life treatment of critical patients and attention to the needs of their relatives is far from being adequate for several reasons: society denies or hides the death, it is very difficult to predict it accurately, treatment is frequently fragmented between different specialists and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts related to the decisions made regarding the critical patients who are in the end of their life, above all, with the limitation of life-sustaining treatments. Most are conflicts of values between the different parties involved: the patient, his relatives and/or representatives, health professionals, and the institution. The SEMICYUC Working Group of Bioethics elaborates these Recommendations of treatment at the end of the life of the critical patient in order to contribute to the improvement of our daily practice in such a difficult field. After analyzing the role of the agents involved in decision making (patient, familiar, professional, and health care institutions), of the ethical and legal foundations of withholding and withdrawal of treatments, guidelines regarding sedation in the end of the life and withdrawal of mechanical ventilation are recommended. The role of advance directives in intensive medicine is clarified and a written form that reflects the decisions made is proposed.

Red blood cell potassium and blood pressure in adolescents: a mixture analysis.

BACKGROUND AND AIM: Evidence from epidemiological and clinical studies has implicated potassium (K+) depletion in the pathogenesis and maintenance of essential hypertension. In adolescents prone to develop hypertension in the future, several studies have shown an inverse relationship between K+ intake and blood pressure (BP). The aim of this study was to determine whether the variation of red blood cell K+ content (RBCKi) in adolescents could be explained by a single distribution or by a mixture of two or more distributions. If more than one distribution could be identified, we studied whether they differed in BP, parental hypertension and other variables. METHOD AND RESULTS: Adolescents (n = 100) were recruited from a High School in the city of Valencia, Venezuela. BP, anthropometric measurements and parental history of hypertension were obtained from each subject. Venous blood and urine sample were obtained for RBC, plasma urine electrolyte measurements. Mixture analysis was used to analyze RBCKi distribution. The distribution of RBCKi levels fit significantly better in a bimodal (p < 0.01) than a unimodal or trimodal distribution. Diastolic blood pressure (75 +/- 1 vs 72 +/- 2 mmHg), systolic blood pressure (SBP) (119 +/- 1 vs 113 +/- 2 mmHg) and pulse pressure (PP) (44 +/- 1 vs 41 +/- 2 mmHg) were higher in the subgroup with low-RBCKi, but only SBP and PP values were statistically significant (p < 0.05). The low-RBCKi subgroup had 40% of the hypertensive parents vs 20% in the high-RBCKi subgroup. Adolescents with low RBCKi were three times more likely to have a hypertensive parent than adolescents with high RBCKi (chi 2 = 3, p = 0.04). CONCLUSION: K+ depletion in RBC, its bimodal distribution and its strong association with BP and parental hypertension suggest that low RBCKi in adolescents might represent an early sign of K+ depletion that could contribute to the development of future hypertension.

Identification of endothelial cell binding sites on the laminin gamma 1 chain.

The laminins belong to a family of trimeric basement membrane glycoproteins with multiple domains, structures, and functions. Endothelial cells bind laminin-1 and form capillary-like structures when plated on a laminin-1-rich basement membrane matrix, Matrigel. Laminin-1 is composed of 3 chains, alpha1, beta1, and gamma1. Because laminin-1 is known to contain multiple biologically active sites, we have screened 156 synthetic overlapping peptides spanning the entire laminin gamma1 chain for potential angiogenic sequences. Only 7 of these peptides, designated as C16, C25, C30, C38, C64, C75, and C102, disrupted the formation of capillary-like structures by human umbilical vein endothelial cells on Matrigel. Dose-response experiments in the presence of 50 to 200 microg/mL showed that tube formation was prevented by most peptides at 150 and 200 microg/mL, except for C16, which showed strong activity at all concentrations. Active peptides promoted vessel sprouting from aorta rings and angiogenesis in the chick chorioallantoic membrane assay. In addition, the active peptides also promoted endothelial cell adhesion to dishes coated with 0.1 microg of peptide and inhibited attachment to laminin-1 but not to plastic or fibronectin. Four of the active peptides, C25, C38, C75, and C102, may have cell-type specificity with endothelial cells, since they did not promote PC12 neurite outgrowth or adhesion of B16-F10 melanoma and human submandibular gland cells. These results suggest that specific laminin gamma1-chain peptides have angiogenic activity with potential therapeutic applications.

Propuesta de un plan de trabajo para período lectivo completo de jefe de trabajos prácticos de la Cátedra Clínica de Prótesis III-"B" (coronas y puentes)

Se propone un Plan de Trabajo para Jefe de Trabajos Prácticos, Ayudantes Monitores y Alumnos con énfasis en la optimización del empleo de Instalaciones, Material Humano, Metodología, Actividades y Evaluaciones con miras a lograr los Objetivos Generales y Específicos del área y mediante la adquisición por parte del alumno de Contenidos, orientados a generar no sólo destreza y conocimiento de material, instrumental y técnicas, sino también y con criterio científico y ético, habilidades y actitudes críticas frente a las enfermedades del Sistema Estomatognático que permitan Prevenir, Diagnosticar, Pronosticar y realizar el Plan de Tratamientos para rehabilitar el terreno dañado. Se valoriza en dicha misión la función del Jefe de Trabajos Prácticos como transmisor de la Experiencia Clínica fundamental a dichos fines.