Carfentanilo: una doble amenaza para la salud pública / Carfentanil: a double threat to public health

El carfentanilo es un opioide sintético con una potencia 10.000 veces superior a la de la morfina. Esta y otras características posicionan al carfentanilo como una sustancia de interés dual, pues ha sido empleada como agente incapacitante y como droga de abuso. Entre las características toxicocinéticas del carfentanilo destacan su elevada liposolubilidad y la posibilidad de que siga una cinética de eliminación no lineal. En 2002 este compuesto fue empleado por las Fuerzas de Seguridad Rusas para intentar resolver la crisis de rehenes del teatro Dubrovka de Moscú, causando la muerte de al menos 123 rehenes. Por otro lado, el carfentanilo, se ha empleado como droga de abuso y como adulterante en otras drogas. En caso de intoxicación por carfentanilo puede ser necesaria la administración de dosis repetidas de antídoto. Los antecedentes expuestos en este trabajo justifican la necesidad de desarrollar y validar un método analítico para la detección del carfentanilo y su metabolito norcarfentanilo en muestras biológicas. (AU)

Carfentanil is a synthetic opioid with a potency 10,000 times greater than that of morphine. For this and other reasons carfentanil is a substance with dual interest, since it has been used as an incapacitating agent and as an abuse drug. Among the toxicokinetic characteristics of carfentanil, its high lipid solubility stands out. In addition, there is the possibility that carfentanil follows a non-linear elimination kinetics. In 2002 this compound was used by the Russian Security Forces to try to resolve the hostage crisis at the Dubrovka theater in Moscow, causing the death of at least 123 hostages. On the other hand, carfentanil has been used as a drug of abuse and as an adulterant in other drugs. In case of carfentanil overdose, the administration of repeated doses of antidote may be necessary. The content of this review justifies the need to develop and validate an analytical method for the detection of carfentanil and its metabolite norcarfentanil in biological samples. (AU)

SEOM clinical guidelines for anaemia treatment in cancer patients (2020).

Anaemia is defined by the presence of haemoglobin (Hb) levels < 13 g/dL in men and 12 g/dL in women. Up to 39% of cancer patients present it at the time of diagnosis and up to 40% have iron deficiency. Anaemia causes fatigue, functional deterioration and a reduction in the quality of life; it has also been associated with a poorer response to anti-tumour treatment and lower survival. Basic diagnostic tests for anaemia are simple and should be a routine part of clinical practice. These guidelines review the available evidence on the use of different therapies for treating anaemia: erythropoiesis-stimulating agents, iron supplements, and transfusion of blood products.

Factors associated with the onset of major depressive disorder in adults with type 2 diabetes living in 12 different countries: results from the INTERPRET-DD prospective study.

AIMS: To examine the factors that are associated with changes in depression in people with type 2 diabetes living in 12 different countries. METHODS: People with type 2 diabetes treated in out-patient settings aged 18-65 years underwent a psychiatric assessment to diagnose major depressive disorder (MDD) at baseline and follow-up. At both time points, participants completed the Patient Health Questionnaire (PHQ-9), the WHO five-item Well-being scale (WHO-5) and the Problem Areas in Diabetes (PAID) scale which measures diabetes-related distress. A composite stress score (CSS) (the occurrence of stressful life events and their reported degree of 'upset') between baseline and follow-up was calculated. Demographic data and medical record information were collected. Separate regression analyses were conducted with MDD and PHQ-9 scores as the dependent variables. RESULTS: In total, there were 7.4% (120) incident cases of MDD with 81.5% (1317) continuing to remain free of a diagnosis of MDD. Univariate analyses demonstrated that those with MDD were more likely to be female, less likely to be physically active, more likely to have diabetes complications at baseline and have higher CSS. Mean scores for the WHO-5, PAID and PHQ-9 were poorer in those with incident MDD compared with those who had never had a diagnosis of MDD. Regression analyses demonstrated that higher PHQ-9, lower WHO-5 scores and greater CSS were significant predictors of incident MDD. Significant predictors of PHQ-9 were baseline PHQ-9 score, WHO-5, PAID and CSS. CONCLUSION: This study demonstrates the importance of psychosocial factors in addition to physiological variables in the development of depressive symptoms and incident MDD in people with type 2 diabetes. Stressful life events, depressive symptoms and diabetes-related distress all play a significant role which has implications for practice. A more holistic approach to care, which recognises the interplay of these psychosocial factors, may help to mitigate their impact on diabetes self-management as well as MDD, thus early screening and treatment for symptoms is recommended.

Comparative genomics reveals signature regions used to develop a robust and sensitive multiplex TaqMan real-time qPCR assay to detect the genus Dickeya and Dickeya dianthicola.

AIMS: Dickeya species are high consequence plant pathogenic bacteria; associated with potato disease outbreaks and subsequent economic losses worldwide. Early, accurate and reliable detection of Dickeya spp. is needed to prevent establishment and further dissemination of this pathogen. Therefore, a multiplex TaqMan qPCR was developed for sensitive detection of Dickeya spp. and specifically, Dickeya dianthicola. METHODS AND RESULTS: A signature genomic region for the genus Dickeya (mglA/mglC) and unique genomic region for D. dianthicola (alcohol dehydrogenase) were identified using a whole genome-based comparative genomics approach. The developed multiplex TaqMan qPCR was validated using extensive inclusivity and exclusivity panels, and naturally/artificially infected samples to confirm broad range detection capability and specificity. Both sensitivity and spiked assays showed a detection limit of 10 fg DNA. CONCLUSION: The developed multiplex assay is sensitive and reliable to detect Dickeya spp. and D. dianthicola with no false positives or false negatives. It was able to detect mixed infection from naturally and artificially infected plant materials. SIGNIFICANCE AND IMPACT OF THE STUDY: The developed assay will serve as a practical tool for screening of propagative material, monitoring the presence and distribution, and quantification of target pathogens in a breeding programme. The assay also has applications in routine diagnostics, biosecurity and microbial forensics.

RAS Mutation Decreases Overall Survival After Optimal Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy of Colorectal Peritoneal Metastasis: A Modification Proposal of the Peritoneal Surface Disease Severity Score.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are currently the most accepted treatment for peritoneal metastases from colorectal cancer. Restrictive selection criteria are essential to obtain the best survival benefits for this complex procedure. The most widespread score for patient selection, the peritoneal surface disease severity score (PSDSS), does not include current biological factors that are known to influence on prognosis. We investigated the impact of including RAS mutational status in the selection criteria for these patients. METHODS: We studied the risk factors for survival by multivariate analysis using a prospective database of consecutive patients with carcinomatosis from colorectal origin treated by CRS and HIPEC in our unit from 2009 to 2017. The risk factors obtained were validated in a multicentre, international cohort, including a total of 520 patients from 15 different reference units. RESULTS: A total of 77 patients were selected for local análisis. Only RAS mutational status (HR: 2.024; p = 0.045) and PSDSS stage (HR: 2.90; p = 0.009) were shown to be independent factors for overall survival. Early PSDSS stages I and II associated to RAS mutations impaired their overall survival with no significant differences with PSDSS stage III overall survival (p > 0.05). These results were supported by the international multicentre validation. CONCLUSIONS: By including RAS mutational status, we propose an updated RAS-PSDSS score that outperforms PSDSS alone providing a quick and feasible preoperative assessment of the expected overall survival for patients with carcinomatosis from colorectal origin undergone to CRS + HIPEC.

A randomized control trial of the impact of LCPUFA-ω3 supplementation on body weight and insulin resistance in pubertal children with obesity.

BACKGROUND: Paediatric obesity and insulin resistance (IR) are potentially reversible inflammatory conditions. Long chain polyunsaturated fatty acids omega-3 (LCPUFA-ω3) show anti-inflammatory and metabolic properties, but their clinical efficacy is unclear. OBJECTIVE: The objective of this study is to evaluate whether supplementation with LCPUFA-ω3 for 3 months reduces insulin resistance and weight to adolescents with obesity. METHODS: Double-blind trial of 366 adolescents with obesity randomly assigned to 1.2-g LCPUFA-ω3 (DO3) or 1-g sunflower oil (DP) daily for 3 months; both groups received an energy-restricted diet. Children attended monthly for anthropometric, dietary, and clinical measurements. Basal and final blood samples were obtained to measure metabolic markers and erythrocytes fatty acids. Regression models were used for analysis. RESULTS: A total of 119 DO3 and 126 DP children completed follow-up. At baseline, 92% of children presented IR, 66% hypertriglyceridemia, 37% low-grade inflammation, and 32% metabolic syndrome. Despite erythrocytes LCPUFA-ω3 increased more in DO3 (Median differences = 0.984 w/w%; 95 IC = 0.47, 1.53, P < 0.001), body weight, insulin, and HOMA changed similarly in both groups at the end of intervention. Adjusting for basal values, changes in weight, insulin, and HOMA was not related with supplementation. CONCLUSIONS: Supplementation with LCPUFA-ω3 does not affect body weight or insulin in adolescents with obesity.

Efectos de entrenamiento físico específico y técnicas de relajación sobre los parámetros dolorosos de la cefalea tensional en estudiantes universitarios: un ensayo clínico controlado y aleatorizado / Effects of physical therapy and relaxation techniques on the parameters of pain in university students with tension-type headache: A randomised controlled clinical trial

INTRODUCCIÓN: Los tratamientos no farmacológicos consiguen controlar la cefalea tensional, sin embargo, la evidencia es todavía limitada. Esta investigación estudia la eficacia de una intervención fisioterápica, basada en cinesiterapia cervical y pautas de higiene postural, que pretende mejorar los resultados obtenidos únicamente con técnicas de relajación (Entrenamiento Autógeno de Schultz [EA]). MÉTODOS: Se seleccionó a 152 estudiantes universitarios (sector poblacional entre quienes esta patología es muy frecuente), 84 mujeres (55,3%) y 68 hombres (44,7%), con edad media de 20,42 años (DT = 2,36), diagnosticados de cefalea tensional, según criterios de la International Headache Society. Se diseñó un ensayo clínico, no farmacológico, controlado y aleatorizado, con evaluación ciega de las variables respuesta. Se compararon los resultados de 2 muestras paralelas e independientes, aplicando a una el EA y a la otra la combinación de este con un programa de cinesiterapia cervical y educación postural. Se cuantificaron la mejoría en los parámetros dolorosos (frecuencia, intensidad y duración) y la reducción del consumo de fármacos, en diarios de cefaleas, antes de los tratamientos y después, a las 4 semanas y a los 3 meses. RESULTADOS: Los 2 grupos de intervención evolucionaron positivamente, consiguiéndose una reducción más significativa en la frecuencia e intensidad de las cefaleas con el tratamiento combinado (p < 0,01) (d = 0,4). CONCLUSIONES: Las terapias activas, no invasivas, como el EA y la cinesiterapia cervical, y especialmente la combinación de ambos, consiguen reducir la cefalea tensional, al prevenir y controlar las posibles causas psicofísicas de este trastorno. Como futuras líneas de investigación, sería interesante evaluar el mantenimiento de los beneficios a largo plazo

INTRODUCTION: Despite the impact of cerebrovascular disease (CVD) on global health, its morbidity and time trends in Spain are not precisely known. :Objective The purpose of our study was to characterise the epidemiology and trends pertaining to stroke in Aragon over the period 1998-2010. METHODS: We conducted a retrospective, descriptive study using the data of the Spanish health system's Minimum Data Set and included all stroke patients admitted to acute care hospitals in Aragon between 1 January 1998 and 31 December 2010. We present data globally and broken down by stroke subtype, sex, and age group. RESULTS: The number of cases increased by 13% whereas age- and sex-adjusted hospitalisation rates showed a significant decrease for all types of stroke (mean annual decrease of 1.6%). Men and women in younger age groups showed opposite trends in hospitalisation rates for ischaemic stroke. Case fatality rate at 28 days (17.9%) was higher in patients with intracerebral haemorrhage (35.8%) than in those with subarachnoid haemorrhage (26.2%) or ischaemic stroke (13%). CVD case fatality showed a mean annual decline of 2.8%, at the expense of the fatality rate of ischaemic stroke, and it was more pronounced in men than in women. DISCUSSION: Understanding stroke epidemiology and trends at the regional level will help establish an efficient monitoring system and design appropriate strategies for health planning

Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy (HIPEC) by Minimally Invasive Approach, an Initial Experience.

BACKGROUND: The cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard treatment in patients with carcinomatosis peritoneal from different origins. The use of a minimally invasive approach for this high complex procedure might be an alternative that provides them less morbidity and faster recovery with similar oncologic outcomes. METHODS: We describe the initial experience of CRS and HIPEC done via the laparoscopic route in patients with minimal peritoneal metastases in our Unit from March 2016 to January 2018. RESULTS: A total of eight patients were operated by this minimally invasive approach. The different diagnoses were low-grade pseudomyxoma peritonei (2), benign multicystic mesothelioma (2), primary epithelial ovarian carcinomatosis (2) and locally advanced colon carcinoma T4 (2). The median age was 54 (20-62) years, the median PCI was 3 (2-4), the median operative time was 287 min (240-360), complete cytoreduction CC0 was achieved in all the patients, and no major morbidity was observed. The median length of stay was 4.75 days (4-5). After a median follow-up of 9.5 months, no relapse has been observed. CONCLUSION: The results suggest that this minimally invasive approach for CRS and HIPEC is feasible and safe in a highly selected group of patients with peritoneal surface malignancies.

Effects of physical therapy and relaxation techniques on the parameters of pain in university students with tension-type headache: A randomised controlled clinical trial. / Efectos de entrenamiento físico específico y técnicas de relajación sobre los parámetros dolorosos de la cefalea tensional en estudiantes universitarios: un ensayo clínico controlado y aleatorizado.

INTRODUCTION: Non-pharmacological treatments help control tension-type headache; however, evidence about their effectiveness is still limited. This study evaluates the effectiveness of physical therapy based on cervical spine kinesiotherapy and posture correction exercises compared to a programme of relaxation techniques only (Schultz's Autogenic Training, AT). METHODS: Tension-type headache is very common among university students. We randomly selected 152 university students with a diagnosis of tension-type headache according to the criteria of the International Headache Society. Eighty-four were women (55.3%) and 68 were men (44.7%). Mean age was 20.42±2.36 years. The study design is a randomised controlled trial of a non-pharmacological intervention with a blinded evaluation of response variables. We compared the results of two independent samples: AT was used in one of the groups while the other group received AT plus cervical spine kinesiotherapy and posture correction training. Patients recorded any changes in the parameters of pain (frequency, intensity, and duration) and drug consumption in a headache diary before treatment, at 4 weeks, and at 3 months. RESULTS: Both interventions achieved a decrease in all the parameters of pain; however, decreases in frequency and intensity were more significant in the combined treatment group (P<0.01) (d=0.4). CONCLUSIONS: Such active, non-invasive therapies as AT and cervical spine kinesiotherapy, and especially the combination of both, effectively reduce tension-type headache by preventing and managing the potential psychophysical causes of this disorder. Future research should aim to assess the long-term effects of these interventions.

Evaluación de la penetración de cementos obturadores de canales mediante microscopía electrónica de barrido / Evaluation of the penetration of root canal filling cements through scanning electron microscopy

Antecedentes: la literatura odontológica demuestra que los tratamientos endodónticos fallidos, comúnmente son debidos a la persistencia de los microorganismos. Una característica importante de los cementos obturadores de canales es su habilidad para penetrar en los túbulos dentinarios, logrando así un sellado impermeable entre las paredes dentinarias y el material de obturación central, reduciendo las filtraciones potenciales y aumentando la resistencia a la fractura. Objetivo: Evaluar mediante microscopía electrónica de barrido (MEB) la penetración de MTA Fillapex, cemento de Grossman (CG) y top seal a lo largo del conducto radicular. Materiales y métodos: Estudio experimental in vitro, en 36 dientes premolares humanos divididos aleatoriamente en 3 grupos, (n= 12), los cuales fueron preparados con técnica endodóntica Step Back. Cada grupo se dividió en 2 subgrupos utilizando como irrigante NaOCl al 2,5%, al igual que NaOCl al 2,5% + EDTA al 17%. Los canales fueron obturados con técnica de condensación lateral, seccionados longitudinalmente para observar mediante microscopia electrónica de barrido a nivel de los tercios cervical, medio y apical, la penetración del cemento al interior de los túbulos dentinarios. Se realizó análisis estadístico con SPSS v 22 IBM con p< 0,05 y las pruebas Kruskal-Wallis y Mann-Whitney. Resultados: Mediante la prueba Kruskal-Wallis, los cementos de Grossman y top seal al utilizar NaOCl + EDTA presentaron valores de p= 0,025 y p= 0,002 en los tercios medio y apical respectivamente. La prueba de Mann Whitney mostró un valor p= 0,031 en el tercio apical para el cemento MTA Fillapex al utilizar NaOCl. Los valores de la mediana fueron MTA Fillapex tercio medio= 2,0000, tercio apical= 1,0000; top seal tercios medio y apical= 4,0000; cemento de Grossman tercios medio y apical= 4,0000. Al ser igual el valor de la mediana entre los cementos top seal y Grossman se utilizaron los valores de la varianza con un resultado estadísticamente significativo para el cemento de Grossman= 0,276 en el tercio medio y top seal= 0,176 en el tercio apical. La prueba de Mann Whitney arrojó un valor p= 0,031 en el tercio apical para el cemento MTA Fillapex. Con un valor de mediana de NaOCl= 3,0000, NaOCl + EDTA= 1,0000. Conclusiones: Al comparar los cementos obturadores MTA Fillapex, top seal y cemento de Grossman utilizando como irrigante NaOCl + EDTA se observó mayor penetración del cemento de Grossman. A nivel del tercio apical se observó mayor penetración con el cemento top seal. El cemento obturador MTA Fillapex presentó mayor penetración a nivel del tercio apical al utilizar como irrigante NaOC (AU)

Background: the literature has shown that failed endodontic treatments are commonly due to the persistence of microorganisms. One important characteristic of root canal filling cements is their ability to penetrate the dentinal tubules, achieving an impermeable sealing between the dentinal walls and the central filling material, reducing potential filtrations and increasing the resistance to fracture. Objective: To evaluate through scanning electron microscopy (SEM) the penetration of MTA Fillapex, Grossman sealer and top seal all along the root canal. Methods: In vitro experimental study, in 36 human teeth randomly divided into 3 groups, (n= 12), which were prepared with the Step Back endodontic technique. Each group was divided into 2 subgroups using NaOCl 2.5%, and NaOCl 2.5% + EDTA 17% as irrigating solutions. The root canals were sealed using the lateral condensation technique, longitudinally sectioned to observe through scanning electron microscopy the cervical, medium and apical thirds, the penetration of the cement inside the dentinal tubules. The statistical analysis was performed with SPSS v22 IBM with p < 0.05 and the Kruskal-Wallis and Mann-Whitney tests. Results: through the Kruskal- Wallis test the Grossman sealer and top seal when using NaOCl + EDTA showed values of p= 0.025 and p= 0.002 in the medium and apical thirds respectively. The Mann-Whitney test showed a value of p= 0.031 in the apical third for the MTA Fillapex when using NaOCl. The median values were MTA Fillapex medium third= 2.000, apical third= 1.000; top seal medium and apical thirds= 4.000. Since the median values between the top seal and Grossman sealer were the same, the values from the variance were used, with a statistically significant result for the Grossman sealer= 0.276 in the medium third and top seal = 0.176 in the apical third. The Mann-Whitney test showed a value p= 0.031 in the apical third for the MTA Fillapex. With a median value of NaOCl= 3.000, NaOCl + EDTA= 1.000. Conclusions: When comparing the filling cements MTA Fillapex, top seal and Grossman sealer using NaOCl + EDTA as an irrigating solution, more penetration from the Grossman sealer was observed in medium third. At the apical third, more penetration from the top seal sealer was observed. The MTA Fillapex cement showed the greatest penetration at the apical third when using NaOCl as an irrigating solution (AU)

Cucurbita ficifolia (Cucurbitaceae) modulates inflammatory cytokines and IFN-γ in obese mice.

This study investigated the effect of aqueous extract of Cucurbita ficifolia Bouché on systemic chronic inflammation in an obesity model induced by monosodium glutamate (MSG) via modulating the expression of adipokines (TNF-α, IL-6, resistin, and adiponectin) and immune-regulatory cytokines (IFN-γ and IL-10). Cucurbita ficifolia extract was administered daily by gavage to lean and MSG-obese mice for 30 days. At the end of treatment, cytokine mRNA expression in adipose tissue was determined by real-time polymerase chain reaction (PCR), and the protein levels of these cytokines were also quantified by enzyme-linked immunosorbent assay (ELISA). Cucurbita ficifolia extract decreased body mass and inflammation in MSG-obese mice by reducing the expression of TNF-α and IL-6; these decreases were parallel to significant reductions in protein levels. The extract also increased protein levels of IL-10 in lean mice and IFN-γ in both lean and MSG-obese mice. In conclusion, C. ficifolia extract modulates systemic chronic inflammation in MSG-obese mice and could have a beneficial effect on the adaptive immune system in obesity.

Programa de largo seguimiento de supervivientes de cáncer pediátrico en la Región de Murcia: preferencias y actitudes de los profesionales de Atención Primaria / Long-term follow up of childhood cancer survivors in the Murcia Region: preferences and attitudes of Primary Care professionals

OBJETIVO: Evaluar actitudes, creencias y conocimientos de los profesionales médicos de Atención Primaria acerca del seguimiento de los supervivientes de cáncer pediátrico (SCP) y divulgar el Programa de Largo Seguimiento de Supervivientes de Cáncer Pediátrico en la Región de Murcia (PLASESCAP-MUR). MATERIAL Y MÉTODOS: Estudio transversal descriptivo mediante cuestionario estructurado y autocumplimentado. Se enviaron cuestionarios a todos los profesionales médicos de Atención Primaria del Área de Salud 1 del Servicio Murciano de Salud. RESULTADOS: Tasa de respuesta del 58% (100/172). El 71 y el 22% eran médicos de familia y pediatras, respectivamente. El 49% atendió algún SCP en los últimos 5 años. El 84% refiere que nunca o pocas veces recibió un informe detallado de evaluación global del superviviente. Más del 75% encuentran bastante o muy útiles el acceso a información detallada de largo seguimiento. El 95% prefiere atender a los supervivientes conjuntamente con consulta de largo seguimiento. Un 80% considera que mejorando la calidad ambiental del entorno podría disminuir la morbimortalidad de los supervivientes. Se encontró una relación estadísticamente significativa entre años practicando medicina y percepción de importancia de algunos factores medioambientales. CONCLUSIONES: Para el largo seguimiento de los SCP parece importante aumentar la capacitación de los profesionales sanitarios de Atención Primaria y la información detallada a través de un plan personalizado de largo seguimiento de cada superviviente. PLASESCAP-MUR proporciona un seguimiento integrativo a los supervivientes de cáncer pediátrico en un modelo de atención compartida entre la Unidad de Largo Seguimiento y Atención Primaria

OBJECTIVE: To assess attitudes, beliefs and knowledge of primary medical care professionals as regards the follow-up of Childhood Cancer Survivors (CCS) and the introduction of a Long-Term Follow-Up Program for Childhood Cancer Survivors in the Region of Murcia (PLASESCAP-MUR). MATERIAL AND METHODS: Descriptive cross-sectional study using a structured, self-administered questionnaire. These questionnaires were sent to all primary medical care professionals in Murcia Health District 1. RESULTS: Response rate of 58% (100/172), with 71% and 22% being family physicians and pediatricians, respectively, of whom 49% provided medical care to a CCS in the last 5 years, with 84% reporting that they never or rarely received a detailed report of overall assessment of the survivor. More than 75% found that access to detailed follow-up information was quite or very useful; 95% prefer to consult experts when providing medical care to survivors, and 80% believe that improving the quality of the environment may decrease the morbidity and mortality of the survivors. A statistically significant relationship was found between the length of practicing medicine and the perception of the importance of environmental factors. CONCLUSIONS: It seems to be important to increase the training of primary care professionals for the long-term follow-up of CCS, as well as having the detailed information through a personalized long-term follow-up of each survivor. PLASESCAP-MUR offers an integrated follow-up to CCS in a model of shared care between Long Term Monitoring Units and Primary Care Units

Inicio, diagnóstico y seguimiento de un caso con deficiencia de acil-CoA deshidrogenasa de cadena muy larga / Debut, diagnosis and outcome of a case with very long chain acyl-CoA dehydrogenase deficiency

Los ácidos grasos representan el 80% de las necesidades energéticas en periodos de estrés metabólico. La betaoxidación de los ácidos grasos es catalizada por varias enzimas, como la acil-CoA deshidrogenasa-coenzima FAD, que posee 4 formas específicas según la longitud de la cadena de acil-CoA. La acil-CoA-deshidrogenasa de cadena muy larga es una de ellas. Su déficit cursa con la acumulación intramitocondrial de ésteres de acil-CoA de cadena larga, y afecta al corazón, el músculo esquelético y el hígado. Presentamos un caso iniciado a los 22 meses de edad con un síndrome Reye-like. Confirmamos un déficit de la betaoxidación de los ácidos grasos de cadena muy larga, con las mutaciones p.A232T (c.694G>A) y p.Y201C (c.602A>G) en los alelos del gen VLCAD. Describimos su evolución durante 17 años recibiendo una dieta pobre en ácidos grasos de cadena larga y suplementos con aceite MCT (AU)

Fatty acids represent 80% of energy needs during periods of stress. Beta-oxidation of fatty acids is catalyzed by some enzymes including acyl-CoA-dehydrogenase-coenzyme FAD, wich has four different ways according to the chain length of acyl-CoA. The very-long-chain-acyl-CoA-dehydrogenase is one of them. A deficiency of this enzyme produces an accumulation of long-chain-acyl-CoA-esters in mitochondrias, affecting heart, skeletal muscle and liver. We report the case of a 22-month aged child whose first symptom was a Reye-like syndrome. We confirmed that he was affected by a deficiency in the beta-oxidation of fatty acids of very long chain. He showed some mutations in the VLCAD gene alleles: p.A232T (c.694G>A) and p.Y201C (c.602A>G). We explain the evolution in the next 17 years, following a diet with very little long chain fatty acids and MCT oil supplements (AU)

El Hospital de Día-Centro Educativo Terapéutico Pradera de San Isidro. Un dispositivo para el tratamiento intensivo de trastornos mentales graves en niños y adolescentes / The Mental Health Day Care Hospital-Educational Therapeutic Centre Pradera de San Isidro. An institution for the acute treatment of severe mental disorders in children and adolescents

Los problemas de salud mental en niños y adolescentes son motivos de consulta frecuentes en Atención Primaria (AP). En la mayor parte de los casos, un tratamiento ambulatorio desde AP o desde su Centro de Salud Mental (CSM) es suficiente para una mejora significativa. Sin embargo, en ocasiones la sintomatología puede ser la manifestación de una estructuración psíquica seriamente dañada. En esos casos, donde existe un trastorno mental grave (TMG), es posible que dichos tratamientos ambulatorios no sean suficientes. En el presente artículo se presenta el Hospital de Día-Centro Educativo Terapéutico (HD-CET) Pradera de San Isidro. Un dispositivo de hospitalización parcial que forma parte de la red de Salud Mental de la Comunidad de Madrid, en el que se atiende a menores con TMG mediante un tratamiento ambulatorio intensivo. EL HD-CET consta de dos unidades: la de infantil (de 6 a 11 años) y la de adolescentes (de 12 a 17 años). Ambas cuentan con un equipo multidisciplinar de profesionales de Salud Mental, así como con un equipo docente encargado del aspecto académico de los pacientes. Se trabaja desde el modelo de comunidad terapéutica, procurando proporcionar al paciente experiencias emocionales correctoras que logren una mejora significativa y profunda del TMG (AU)

Child and adolescence mental health conditions are common in Primary Care (PC). In most cases, Mental Health Services (MHS) will achieve a good response in an outpatient basis. However, certain symptoms may indicate seriously damaged psychic structures, as found in Severe Mental Disorders (SMD), whose ambulatory care in PC and MHS may not be sufficient. Pradera de San Isidro Mental Health Day Care Hospital-Educational Therapeutic Centre (DCH-ETC) is part of Madrid Regional Mental Health Care Services, attending children and adolescents with SMD in a outpatient intensive program. DCH-ETC comprises a Children Unit attending patients of 6 to 11 years and an Adolescents Unit for patients from 12 to 17 years. A team of teachers is responsible for the continuing academic education of patients. With a Therapeutic Community model, the program aims to provide corrective emotional experiences leading to a deep and significant improvement in SMD (AU)

Experiencia y tratamiento anestésico en el implante transcatéter de la prótesis valvular aórtica autoexpandible CoreValve ® / Anesthetic management and experience in the transcatheter implantation of the CoreValve ® self-expanding aortic valve

Objetivo. Analizar la experiencia y el tratamiento anestésico perioperatorio en la implantación transcatéter de la válvula aórtica autoexpandible CoreValve® en un hospital universitario terciario. Material y métodos. Estudio observacional analítico con revisión de datos incorporados a una base mantenida de forma prospectiva de 142 pacientes diagnosticados de estenosis aórtica severa, a los que se implantó una válvula aórtica autoexpandible CoreValve® entre diciembre de 2007 y diciembre de 2012. Resultados. La media de edad de los pacientes fue de 82,5 ± 6,1 años y el EuroSCORE logístico de 14,9 ± 11,2. En 107 pacientes (75,3%) se utilizó anestesia general, y en 35 (24,6%), anestesia local con sedación. La anestesia local con sedación se asoció con un menor requerimiento de fármacos vasoactivos (p = 0,003) durante el implante. No encontramos diferencias estadísticamente significativas entre ambas técnicas anestésicas en el tiempo de duración del procedimiento, en la estancia hospitalaria ni en la morbimortalidad. La tasa de éxito fue del 97,1%. La complicación más frecuente fueron los trastornos de la conducción, que precisaron la implantación de marcapasos definitivo en 46 pacientes (32,3%). No hubo ningún exitus intraoperatorio, la mortalidad por cualquier causa a los 30 días fue del 6,3% y la supervivencia al año estimada por el método de Kaplan-Meier fue de 83,1%. Conclusiones. Este estudio confirma que en pacientes con estenosis aórtica severa y alto riesgo quirúrgico la sustitución valvular aórtica transcatéter es una alternativa efectiva y segura. Tanto la anestesia general como la local con sedación son opciones válidas, dependiendo de la experiencia del equipo (AU)

[Adalimumab versus etanercept in the treatment of active rheumatoid arthritis: cost-effectiveness analysis]. / Adalimumab versus etanercept en el tratamiento de la artritis reumatoide: análisis coste-efectividad.

PURPOSE: To assess the effectiveness and efficiency of the two alternatives mainly used in our area, etanercept (ETN) and adalimumab (ADA), for the treatment of rheumatoid arthritis (RA) patients under real clinical practice. MATERIAL AND METHODS: We performed a retrospective observational study, where the time horizon was 12 months referred to the year 2012. We analyzed the characteristics of patients, and the effectiveness and efficiency of ETN and ADA in our study population. INCLUSION CRITERIA: patients over 18 years, diagnosed with RA treated at the outpatient clinic of the Rheumatology Health Sector of Teruel. We determined the mean decrease in DAS28 value (DAS28r) of each drug and we defined as a unit of effectiveness in pharmacoeconomic study, a DAS28 value at baseline (DAS28a) less than 3.2 points and DAS28r greater than 1.2 points. As parameter to determine the cost-effectiveness of both alternatives we used net health benefits (NHB). RESULTS: The average value of DAS28a was 2,25 and 2,72 points for ETN and ADA respectively, with a value of DAS28r 1,01 points higher for ETN, although not statistically significant (p> 0.05). NHB obtained a value of -0.121, 95% CI (-0.951 to 0.709). CONCLUSIONS: Both alternatives are effective in the treatment of RA, although it seems to be a trend in favor of ETN in cost-effectiveness degree.

Objetivo: Valorar el grado de efectividad y eficiencia de las dos alternativas principalmente utilizadas en nuestro ámbito, etanercept (ETN) y adalimumab (ADA), para el tratamiento de pacientes diagnosticados de artritis reumatoide (AR) en condiciones reales de la práctica clínica diaria. Material y método: Se realizó un estudio observacional retrospectivo, cuyo horizonte temporal fue de 12 meses referidos al año 2012, en el que se analizaron las características de los pacientes, así como la efectividad y eficiencia de ETN y ADA en la población de estudio. Se estudiaron todos los pacientes de ambos sexos mayores de 18 años, diagnosticados de AR, atendidos en las consultas externas del Servicio de Reumatología del Sector Sanitario de Teruel. Se determinó el descenso medio del valor de DAS28 (DAS28r) de cada fármaco y se definió como unidad de efectividad en el estudio farmacoeconómico un valor DAS28 al inicio (DAS28a) inferior a 3,2 puntos y DAS28r mayor a 1,2 puntos. Como parámetro del estudio para determinar el coste-efectividad de ambas alternativas se utilizó el beneficio neto sanitario (BNS). Resultados: El valor medio de DAS28a fue 2,25 y 2,72 puntos para ETN y ADA respectivamente, con un valor DAS28r de 1,01 puntos superior para ETN, aunque sin ser estadísticamente significativo (p > 0,05). El cálculo del parámetro BNS obtuvo un valor igual a -0,121; IC95% (-0,951 a 0,709), sin embargo la inclusión del valor 0 en el intervalo de confianza hizo que no se observaran diferencias de coste-efectividad. Conclusiones: Ambas alternativas son efectivas en el tratamiento de la AR, aunque parece existir una tendencia a favor de ETN en el grado coste-efectividad sin ser significativa.

Adalimumab versus etanercept en el tratamiento de la artritis reumatoide: análisis coste-efectividad / Adalimumab versus etanercept in the treatment of active rheumatoid arthritis: cost-effectiveness analysis

Objetivo: Valorar el grado de efectividad y eficiencia de las dos alternativas principalmente utilizadas en nuestro ámbito, etanercept (ETN) y adalimumab (ADA), para el tratamiento de pacientes diagnosticados de artritis reumatoide (AR) en condiciones reales de la práctica clínica diaria. Material y método: Se realizó un estudio observacional retrospectivo, cuyo horizonte temporal fue de 12 meses referidos al año 2012, en el que se analizaron las características de los pacientes, así como la efectividad y eficiencia de ETN y ADA en la población de estudio. Se estudiaron todos los pacientes de ambos sexos mayores de 18 años, diagnosticados de AR, atendidos en las consultas externas del Servicio de Reumatología del Sector Sanitario de Teruel. Se determinó el descenso medio del valor de DAS28 (DAS28r) de cada fármaco y se definió como unidad de efectividad en el estudio farmacoeconómico un valor DAS28 al inicio (DAS28a) inferior a 3,2 puntos y DAS28r mayor a 1,2 puntos. Como parámetro del estudio para determinar el coste-efectividad de ambas alternativas se utilizó el beneficio neto sanitario (BNS). Resultados: El valor medio de DAS28a fue 2,25 y 2,72 puntos para ETN y ADA respectivamente, con un valor DAS28r de 1,01 puntos superior para ETN, aunque sin ser estadísticamente significativo (p > 0,05). El cálculo del parámetro BNS obtuvo un valor igual a -0,121; IC95% (-0,951 a 0,709), sin embargo la inclusión del valor 0 en el intervalo de confianza hizo que no se observaran diferencias de coste-efectividad. Conclusiones: Ambas alternativas son efectivas en el tratamiento de la AR, aunque parece existir una tendencia a favor de ETN en el grado coste-efectividad sin ser significativa (AU)

Purpose: To assess the effectiveness and efficiency of the two alternatives mainly used in our area, etanercept (ETN) and adalimumab (ADA), for the treatment of rheumatoid arthritis (RA) patients under real clinical practice. Material and methods: We performed a retrospective observational study, where the time horizon was 12 months referred to the year 2012. We analyzed the characteristics of patients, and the effectiveness and efficiency of ETN and ADA in our study population. Inclusion criteria: patients over 18 years, diagnosed with RA treated at the outpatient clinic of the Rheumatology Health Sector of Teruel. We determined the mean decrease in DAS28 value (DAS28r) of each drug and we defined as a unit of effectiveness in pharmacoeconomic study, a DAS28 value at baseline (DAS28a) less than 3.2 points and DAS28r greater than 1.2 points. As parameter to determine the cost-effectiveness of both alternatives we used net health benefits (NHB). Results: The average value of DAS28a was 2,25 and 2,72 points for ETN and ADA respectively, with a value of DAS28r 1,01 points higher for ETN, although not statistically significant (p> 0.05). NHB obtained a value of -0.121, 95% CI (-0.951 to 0.709). Conclusions: Both alternatives are effective in the treatment of RA, although it seems to be a trend in favor of ETN in cost-effectiveness degree (AU)

[Anesthetic management and experience in the transcatheter implantation of the CoreValve(®) self-expanding aortic valve]. / Experiencia y tratamiento anestésico en el implante transcatéter de la prótesis valvular aórtica autoexpandible CoreValve(®)

OBJECTIVE: To analyze the experience and anesthetic management in the transcatheter implantation of the CoreValve(®) self-expanding aortic valve, in a university tertiary hospital. MATERIAL AND METHODS: Observational analytical review of data incorporated into a prospectively maintained database of 142 patients diagnosed with severe aortic stenosis who underwent implantation of a CoreValve(®) aortic self-expanding aortic valve between December 2007 and December 2012. RESULTS: The mean age of patients was 82.5±6.1 years and the logistic EuroSCORE was 14.9±11.2. General anesthesia was used in 107 patients (75.3%), with local anesthesia with sedation in 35 (24.6%). Local anesthesia and sedation was associated with a lower requirement of vasoactive drugs (P=.003) during implantation. No statistically significant differences were found between the 2 anesthetic techniques in the duration of the procedure, hospital stay, or morbimortality. The success rate was 97.1%. The most common complication was conduction disorders that required implantation of a permanent pacemaker in 46 patients (32.3%). There was no intraoperative mortality, and all-cause mortality at 30 days was 6.3%, with a one-year survival estimated by the Kaplan-Meier of 83.1%. CONCLUSIONS: This study confirms that in patients with severe aortic stenosis and high surgical risk, transcatheter implantation of aortic valve is a safe and effective alternative. Both, general anesthesia and local anesthesia with sedation are valid options, depending on the experience of the team.

[Analisis of the budget impact of adalimumab and etanercept in rheumatoid arthritis and spondyloarthropathies]. / Análisis del impacto presupuestario de adalimumab y etanercept en artritis reumatoide y espondiloartropatías.

PURPOSE: To assess the economic impact derived from the widening of the administration intervals of adalimumab (ADA) and etanercept (ETN) for the treatment of rheumatoid arthritis (RA) and spondyloarthropathies (SAP) at our working environment. MATERIAL AND METHODS: A budget impact model (BIM) was developed to estimate the economic impact that would have widening the usual administration intervals of ADA, 40 mg every 2 weeks and ETN, 50 mg weekly (scenario A), to ADA, 40 mg every 3 weeks, and ETN, 50 mg every 2 weeks (scenario B) according to the guidelines and recommendations applied to these studies, specifying the target population, the study perspective, the temporal horizon, and analysing the study robustness by a threshold univariate sensitivity analysis. RESULTS: 71 patients were included in the study. The application of the BIM showed yearly savings for ADA and ETN of 19.784 ??and 38.271 ?, respectively. The net cost, that is to say the saving that this would imply within the temporal horizon considered (2 years), was 116.110 ?. The sensitivity analysis showed that the estimated BIM for the study period was very robust since the net result in the different scenarios varied very little, being negative in the new scenarios. CONCLUSIONS: widening the administration intervals of ADA and ETN to every 3 weeks and 2 weeks respectively, would be a strategy that would allow generating savings in the hospital budget close to 116.110 ??for the temporal horizon considered, achieving this way optimization of the treatment with these two drugs.

Objetivo: Evaluar el impacto económico derivado de la ampliación de los intervalos de administración de adalimumab (ADA) y etanercept (ETN), en el tratamiento de la artritis reumatoide (AR) y espondiloartropatias (EAP) en nuestro ámbito de trabajo. Material y método: Se desarrolló un modelo de impacto presupuestario (MIP) para estimar la repercusión económica que tendría la ampliación en los intervalos habituales de administración de ADA 40 mg cada dos semanas y ETN 50 mg semanal (escenario A), por ADA 40 mg cada tres semanas y ETN 50 mg cada dos semanas (escenario B) de acuerdo a las guías y recomendaciones que se aplican a estos estudios, especificando la población diana, la perspectiva del estudio, el horizonte temporal y analizando la robustez del estudio a través de un análisis de sensibilidad univariante de tipo umbral. Resultados: Se incluyeron un total de 71 pacientes en el estudio. La aplicación del MIP mostró unos ahorros anuales para ADA y ETN de 19.784??y 38.271 ??respectivamente. El coste neto, es decir, el ahorro que esto supuso en el horizonte temporal considerado (dos años) ascendió a 116.110 ?. El análisis de sensibilidad realizado mostró que el MIP estimado para el periodo de estudio fue muy robusto ya que el resultado neto en diferentes escenarios apenas variaba, manteniéndose negativo en los nuevos escenarios. Conclusiones: La ampliación de los intervalos de administración de ADA y ETN cada tres semanas y dos semanas respectivamente, sería una estrategia que permitiría generar ahorros en el presupuesto hospitalario cercanos a los 116.110 ??en el horizonte temporal considerado, consiguiendo así una optimización del tratamiento con estos fármacos.