Prevalence, risk factors and evolution of diabetes mellitus after treatment in primary aldosteronism. Results from the SPAIN-ALDO registry.

PURPOSE: To evaluate the prevalence, risk factors and evolution of diabetes mellitus (DM) after targeted treatment in patients with primary aldosteronism (PA). METHODS: A retrospective multicenter study of PA patients in follow-up at 27 Spanish tertiary hospitals (SPAIN-ALDO Register). RESULTS: Overall, 646 patients with PA were included. At diagnosis, 21.2% (n = 137) had DM and 67% of them had HbA1c levels < 7%. In multivariate analysis, family history of DM (OR 4.00 [1.68-9.53]), the coexistence of dyslipidemia (OR 3.57 [1.51-8.43]) and advanced age (OR 1.04 per year of increase [1.00-1.09]) were identified as independent predictive factors of DM. Diabetic patients were on beta blockers (46.7% (n = 64) vs. 27.5% (n = 140), P < 0.001) and diuretics (51.1% (n = 70) vs. 33.2% (n = 169), p < 0.001) more frequently than non-diabetics. After a median follow-up of 22 months [IQR 7.5-63.0], 6.9% of patients developed DM, with no difference between those undergoing adrenalectomy and those treated medically (HR 1.07 [0.49-2.36], p = 0.866). There was also no significant difference in the evolution of glycemic control between DM patients who underwent surgery and those medically treated (p > 0.05). CONCLUSION: DM affects about one quarter of patients with PA and the risk factors for its development are common to those of the general population. Medical and surgical treatment provides similar benefit in glycemic control in patients with PA and DM.

Reproducible measurement of vancomycin MICs within the susceptible range in Staphylococcus aureus by a broth microdilution method with a "quasi-continuum" gradient of antibiotic concentrations.

The availability of reproducible broth microdilution (BMD) methods including inter log2 antibiotic dilutions for measuring Staphylococcus aureus (SA) vancomycin minimum inhibitory concentrations (MICs) within the susceptible range is needed to elucidate the impact of vancomycin MICs on clinical outcomes of invasive SA infections. Here, we report on the development of a very precise BMD method that incorporates the following incremental antibiotic concentrations: 0.50, 0.62, 0.75, 0.87, 1.0, 1.25, 1.40, 1.50, 1.60, 1.75, and 2.0 µg/mL. The intra- and inter-assay coefficients of variation of this method were around 20%. The mean of the differences in MIC values for all isolates obtained across two independent runs performed at one center was 0.04 µg/mL [95% confidence interval (CI), 0.011-0.07 µg/mL] and that for ten isolates measured at two different centers was 0.04 µg/mL (95% CI, 0-13 µg/mL). Vancomycin MIC values differed by less than 0.1 µg/mL between runs for most isolates. Storage of isolates at -20 °C for up to 3 months had no impact on the vancomycin MIC values. The mean vancomycin MIC values obtained by the Etest using a standard inoculum (0.5 McFarland) were significantly higher (p ≤ 0.001) than those measured by BMD and the MIC values measured by the two methods correlated poorly (Rho, 0.319; p = 0.148). Nevertheless, the mean MIC values measured by the Etest using lower inocula (107 or 106 CFU/mL) and those measured by BMD were comparable and correlated significantly (p = 0.004 for 107 CFU/mL and p = 0.029 for 106 CFU/mL).

[Anesthetic approach in 2 patients with pulmonary lymphangiomyomatosis]. / Conducta anestésica en 2 pacientes afectadas de linfangiomiomatosis pulmonar.

Pulmonary lymphangiomyomatosis (PLM) is an idiopathic disease of females in fertile age. It results in respiratory failure characterized by obliteration of the small airways, emphysema, formation of bullae, hemoptysis, pneumothorax, pulmonary fibrosis, severe hypoxemia and reduced carbon monoxide diffusion capacity. The major lymphatic ducts are also involved, resulting in chylous pleural effusion and ascites. Pulmonary abnormalities improve objectively and subjectively after surgical therapy, which consists in bilateral oophorectomy. Its evolution results in death in no more than 10 years. We report the anesthetic approach to 2 patients with PLM. Patient 1 was a female who had already been diagnosed of PLM and had received medical and surgical therapy, requiring reoperation for the resection of cystic intestinal masses and abdominal eventration. Patient 2 had been scheduled for bilateral oophorectomy after a diagnosis of PLM. We discuss the clinical condition of both patients, the course of the disease, the previous treatments and the anesthetic technique in each case.

[Myasthenia gravis]. / Miastenia grave.

The present review updates myasthenia gravis. Immunopathogenesis of this condition, the clinical picture and degrees of involvement according to Osserman's classification, diagnostic procedures currently available, medical treatment and repercussion on the patient who is going yo be thymectomized are discussed. We review the works of several authors as far as concern to the use of muscle relaxants in myasthenic patients, peroperative monitoring of neuromuscular blockade, anesthetic techniques to be used, analgesia and intensive care required during postoperative period.

[Myasthenia gravis: thymectomy. Muscle relaxation with atracurium besilate]. / Miastenia grave: timectomía. Relajación muscular con besilato de atracurio.

We have carried out a prospective study on the use of the muscle relaxant, atracurium besilate, in 10 patients with myasthenia gravis, seven had type IIB and three had type IIA, who were scheduled for thymectomy, using ED95 0.20 mg/kg, and ten non myasthenic patients undergoing cholecystectomy using ED95 0.50 mg/kg. After monitoring neuromuscular transmission, the time for establishing maximum blockade (EMB), clinical efficacy time (CET), recovery index (RI) and total duration time (TDT) were measured and evaluated comparatively. Results showed that in myasthenics patients, EMB was faster, CET an TDT were more prolonged and RI was higher than in non myasthenic patients. We conclude that atracurium at doses of 0.20 mg/kg is currently the non depolarizing muscle relaxant of choice in myasthenic patients because of the excellent muscle relaxation allowing extubation in the operating room without reverting muscle blockade and not needing ventilatory support during postoperative period.

Contamination of barley seeds with Fusarium species and their toxins in Spain: an integrated approach.

Fusarium is a globally distributed fungal genus that includes different species pathogenic to cereals among others crops. Some of these Fusarium species can also produce toxic compounds towards animals and humans. In this work, the presence of the most important Fusarium toxins was determined in barley seeds from Spain, sampled according to European Union requirements. The results obtained were compared with the presence of mycotoxigenic species considered responsible for their synthesis by using species-specific polymerase chain reaction protocols. Fumonisins B(1) and B(2), zearalenone, trichothecenes type A (T-2 and HT-2) and trichothecenes type B (deoxynivalenol and nivalenol) were analysed by using high-performance liquid chromatography. Deoxynivalenol and zearalenone were detected in 72% and 38% of the barley samples, respectively, at levels below European Union limits in all cases. However, the co-occurrence of both toxins in 34% of the samples suggested that synergistic activity of these two mycotoxins should be evaluated. Nivalenol and HT-2/T-2 were detected at low levels in 17% and 10% of the samples, respectively. Fumonisins occurred in 34% of the samples at levels up to 300 µg/kg. This suggested that they might represent a risk in Spanish barley, and to our knowledge, this is the first report on the presence of fumonisins in barley in this country. The species-specific polymerase chain reaction assays to detect mycotoxin-producing Fusarium species showed a very consistent correlation between F. verticillioides detection and fumonisin contamination as well as F. graminearum presence and zearalenone, deoxynivalenol and nivalenol contamination in barley samples. The approach used in this study provided information of mycotoxin contamination of barley together with the identification of the fungal species responsible for their production. Detection of the species with the current polymerase chain reaction assay strategy may be considered predictive of the potential mycotoxin risk in this matrix.

Mycobiota and co-occurrence of mycotoxins in Capsicum powder.

This study aimed to: (1) determine the mycobiota of Capsicum powder samples, paying a special attention to the mycotoxigenic moulds; (2) evaluate the contamination levels of aflatoxins (AF), ochratoxin A (OTA), zearalenone (ZEA), deoxynivalenol (DON), T2 and HT2 toxins in those samples. Thirty-two samples were obtained through the methods of sampling established by the European Union legislation. Aspergillus and Eurotium were the most frequently found genera. Aspergillus section Nigri had the higher relative frequency in the samples, A. niger aggregate being the most representative group of this section. Other potentially mycotoxigenic Aspergillus, Fusarium and Penicillium species were found, but in a lower frequency. Co-occurrence of mycotoxins was confirmed in the 32 Capsicum powder samples. All samples were contaminated with AF and OTA, 27% with ZEA (36% of chilli and 18% of paprika samples), 9% with DON (18% of chilli and 6% of paprika samples), 6% with T2 (18% of chilli samples) and none of the samples contained HT2. Although in the present study the most common genera found (Aspergillus and Eurotium) belong to storage moulds, some field fungi such as Fusarium spp. were also found, and their toxins were sometimes detected. This fact supports the hypothesis that mycotoxin contamination of Capsicum products may occur both in the field and/or during storage.

Ochratoxin A levels in the plasma of healthy blood donors from Valencia and estimation of exposure degree: comparison with previous national Spanish data.

Blood plasma levels of ochratoxin A, a toxic secondary metabolite of several fungal species belonging to the genera Aspergillus and Penicillium, were determined in 168 blood donors from the population of Valencia (Spain) using LC-FLD. In conjunction with blood collection, detailed information on diet was obtained by using a questionnaire that encompassed a wide range of products potentially contaminated with the toxin. The investigation revealed a detection frequency of 100%. Mean level was 1.09 microg OTA/l of plasma and concentrations ranged between 0.15 and 5.71 microg OTA/l of plasma. Men's levels were slightly higher than levels observed in women. Results were analysed by Spearman rank correlation test and Gamma correlation statistic. There was no strong correlation between individual consumption of 26 food groups, described as possibly contaminated with OTA and plasma level of OTA. Multiple regression and factorial regression models were obtained explaining 14.9 and 64.4%, respectively, but they could not explain overall variability. Daily dietary intake of ochratoxin A was calculated on the basis of plasma toxin levels using the Breitholtz and Klassen formulae; for the overall population, mean values were 1.47 +/- 1.25 and 2.16 +/- 1.88 ng/kg bw/day, respectively. All results have been compared with other Spanish data.

Changes in ochratoxin A and type B trichothecenes contained in wheat flour during dough fermentation and bread-baking.

Ochratoxin A (OTA) and type B trichothecenes are mycotoxins that occur frequently in cereals and thus can be found in cereal by-products such as bread. The aim of this work was to study the variation of the levels of OTA, deoxynivalenol (DON), 3-acetyldeoxynivalenol (3-ADON) and nivalenol (NIV) during the bread-making process. This was done by using wheat flour spiked with different levels of toxins. Mycotoxin levels were controlled after fermentation of the dough with yeasts (Saccharomyces cerevisiae) and after further baking at different temperature-time combinations. Analysis of variance (ANOVA) of the results showed a significant reduction in OTA level (p < 0.05) during fermentation of the dough. The reduction ranged between 29.8% and 33.5%, depending on the initial concentration of toxin in the flour. During this period, the level of the other mycotoxins studied was not modified. By contrast, in the baking phase there were significant changes in the levels of the four mycotoxins, although the reduction was similar under all the baking conditions. Considering all the temperature-time conditions tested, it can be concluded that during the baking period the average reduction of OTA, NIV, 3-ADON, and DON was 32.9%, 76.9%, 65.6%, and 47.9%, respectively.

Use of the Univent System tube for difficult intubation and for achieving one-lung anaesthesia.

BACKGROUND: One-lung ventilation in major thoracic surgery is the most commonly accepted technique, not only for surgery on the lung but also in procedures involving the oesophagus, mediastinum and thoracic aorta. Conventional double-lumen tubes may sometimes be difficult to place correctly in patients in whom intubation is difficult. In such cases, the Univent System tube may be of help. It has a curved movable blocker of small calibre, and is designed to slide inside the bronchial tree and occlude all or part of the target lung. CASE REPORT: We describe a new application of the Univent System tube in three cases where intubation was presumed to be difficult, and in another with unexpected difficult intubation. The laryngeal approach was carried out with the distally displaced blocker, inserting it through the sub-epiglottis or the posterior commissure visible orifice. The tube was firmly held and slid through the length of the blocker, rotating slowly until fully introduced. The advantages and criteria for its use are discussed. CONCLUSION: Although the double-lumen tube is the first choice for one-lung ventilation, the Univent tube is a good option for selective bronchial intubation and in patients in whom difficult intubation is predicted.