[Biliary microbiote in cholecystectomized patients: Review of empirical antibiotherapy]. / Microbiota biliar en pacientes colecistectomizados: Revisión de la antibioterapia empírica.

OBJECTIVE: Cholecystitis is an important cause of hospital admission. In moderate or severe cholecystitis, the delay in treatment can lead to serious complications. Our objective is to analyze the microorganisms isolated in bile from cholecystectomized patients and their sensitivity pattern, to evaluate the empirical treatment in those cases in which the surgical removal of the gallbladder should be delayed. METHODS: Prospective descriptive study of biliary cultures of patients undergoing cholecystectomy from May 2013 to February 2015, in the Surgery Department of the Hospital General Universitari de Castelló. RESULTS: We studied 196 patients, 83 women (42.3%) and 113 men (57.7%), with an average age of 61.5 years. The most used antibiotics as empiric treatment were piperacillin/tazobactam (77.8%) and amoxicillin/clavulanic (14.8%). In 46.4% of patients (91/196) bile cultures were positive. 165 microorganisms were isolated. The majority were Gram-negative bacilli (60.5%), mainly of the Enterobacterales order (91/54.5%), with Escherichia coli being the most frequent microorganism (24%) followed by Klebsiella spp. (12.5%). 3 E. coli with extended-spectrum beta-lactamase (ESBL) and 1 K. pneumoniae with ESBL were isolated. Microorganisms producing carbapenemase and methicillin-resistant Staphylococcus aureus were not isolated. CONCLUSIONS: The bile microbiota, with a predominance of Enterobacterales is similar to that found in european studies..

mRNA profiling identifies low levels of phosphatases dual­specific phosphatase­7 (DUSP7) and cell division cycle­25B (CDC25B) in patients with early arthritis.

Phosphotyrosine phosphatases (PTPs) control phosphorylation levels and, consequently, regulate the output of intracellular signalling networks in health and disease. Despite the high number of PTPs expressed in CD4 T cells and their involvement in autoimmunity, information about the expression profile of PTPs in these cells has not been obtained in patients diagnosed with autoimmune diseases. Here, we compare the expression profile of PTPs in CD4 T cells of healthy volunteers and patients submitted to an early arthritis clinic, due to suspicion of rheumatoid arthritis, an autoimmune disease mediated by CD4 T cells. We found lower transcript levels of the mitogen-activated protein kinase (MAPK) phosphatase dual-specific phosphatase-7 (DUSP7) and the cell division cycle-25B (CDC25B) in T cells of patients. While the low expression level of DUSP7 was restricted to patients with positive rheumatoid factor and anti-citrullinated protein antibodies, the altered expression of CDC25B correlated with the activity of the disease. Low levels of CDC25B might contribute to the progression of the autoimmune arthritis and/or might be consequence of the inflammatory environment in the active disease. The possible role of DUSP7 and CDC25B as biomarkers of the disease in clinical protocols is discussed.

Percentage of hypochromic erythrocytes and reticulocyte hemoglobin equivalent predictors of response to intravenous iron in hemodialysis patients.

INTRODUCTION: Reticulocyte hemoglobin content and percentage of hypochromic red cells are incorporated into the European best practice guidelines on anemia management in chronic kidney disease. Sysmex XN analyzer (Sysmex Corporation, Kobe, Japan) reports reticulocyte hemoglobin equivalent (Ret-He) and the hypochromic fraction of erythrocytes (%Hypo-He). Our aim was to assess the value of these parameters, in terms of the sensitivity and specificity for detecting functional iron deficiency, in hemodialysis (HD) patients. METHODS: Forty HD patients in the maintenance phase of erythropoietin therapy were included. Intravenous iron supplementation was interrupted at least 3 weeks before recruitment. Two samples were analyzed for each patient: the baseline after the iron-free period and the second sample after 4 weeks of IV iron administration. Hemogram and biochemical parameters of the iron status were measured. Patients were classified as responders or nonresponders to an iron load; responders had an increase in Hb of at least 10 g/L after iron administration, compared to the baseline. To identify the efficiency of the test for predicting the response to iron administration, receiver operating characteristic analysis (ROC) was performed. RESULTS: According to the established criteria, 21 patients were responders and 19 nonresponders. ROC analysis results: Ret-He area under curve (AUC) was 0.84 (95% CI 0.64-0.93), at cutoff 30.8 pg, sensitivity 78.7%, and specificity 87.2%. % Hypo-He AUC was 0.78 (95% CI 0.64-0.91), at cutoff 2.4%, sensitivity 72.2%, and specificity 88.1%. CONCLUSIONS: % Hypo-He and Ret-He are reliable parameters for the study of erythropoiesis status in HD patients.

Bioactivation of Phytoestrogens: Intestinal Bacteria and Health.

Phytoestrogens are polyphenols similar to human estrogens found in plants or derived from plant precursors. Phytoestrogens are found in high concentration in soya, flaxseed and other seeds, fruits, vegetables, cereals, tea, chocolate, etc. They comprise several classes of chemical compounds (stilbenes, coumestans, isoflavones, ellagitannins, and lignans) which are structurally similar to endogenous estrogens but which can have both estrogenic and antiestrogenic effects. Although epidemiological and experimental evidence indicates that intake of phytoestrogens in foods may be protective against certain chronic diseases, discrepancies have been observed between in vivo and in vitro experiments. The microbial transformations have not been reported so far in stilbenes and coumestans. However, isoflavones, ellagitanins, and lignans are metabolized by intestinal bacteria to produce equol, urolithins, and enterolignans, respectively. Equol, urolithin, and enterolignans are more bioavailable, and have more estrogenic/antiestrogenic and antioxidant activity than their precursors. Moreover, equol, urolithins and enterolignans have anti-inflammatory effects and induce antiproliferative and apoptosis-inducing activities. The transformation of isoflavones, ellagitanins, and lignans by intestinal microbiota is essential to be protective against certain chronic diseases, as cancer, cardiovascular disease, osteoporosis, and menopausal symptoms. Bioavailability, bioactivity, and health effects of dietary phytoestrogens are strongly determined by the intestinal bacteria of each individual.

Metformin and cancer: Between the bioenergetic disturbances and the antifolate activity.

For decades, metformin has been the first-line drug for the treatment of type II diabetes mellitus, and it thus is the most widely prescribed antihyperglycemic drug. Retrospective studies associate the use of metformin with a reduction in cancer incidence and cancer-related death. However, despite extensive research about the molecular effects of metformin in cancer cells, its mode of action remains controversial. In this review, we summarize the current molecular evidence in an effort to elucidate metformin's mode of action against cancer cells. Some authors describe that metformin acts directly on mitochondria, inhibiting complex I and restricting the cell's ability to cope with energetic stress. Furthermore, as the drug interrupts the tricarboxylic acid cycle, metformin-induced alteration of mitochondrial function leads to a compensatory increase in lactate and glycolytic ATP. It has also been reported that cell cycle arrest, autophagy, apoptosis and cell death induction is mediated by the activation of AMPK and Redd1 proteins, thus inhibiting the mTOR pathway. Additionally, unbiased metabolomics studies have provided strong evidence to support that metformin alters the methionine and folate cycles, with a concomitant decrease in nucleotide synthesis. Indeed, purines such as thymidine or hypoxanthine restore the proliferation of tumor cells treated with metformin in vitro. Consequently, some authors prefer to refer to metformin as an "antimetabolite drug" rather than a "mitochondrial toxin". Finally, we also review the current controversy concerning the relationship between the experimental conditions of in vitro-reported effects and the plasma concentrations achieved by chronic treatment with metformin.

A membrane bioreactor for the simultaneous treatment of acetone, toluene, limonene and hexane at trace level concentrations.

The performance of a flat-membrane biofilm reactor (MBR) for the removal of acetone, toluene, limonene and hexane at concentrations ranging from 1.3 to 3.2 mg m(-3) was investigated at different gas residence times (GRT): 60, 30, 15 and 7 s. A preliminary abiotic test was conducted to assess the mass transport of the selected volatile organic compounds (VOCs) through the membrane. A reduced transport of limonene and hexane was observed with water present over the dense side of the membrane. The presence of a biofilm attached on the dense side of the membrane following bioreactor inoculation significantly increased VOC transport. High acetone and toluene removals (>93%) were recorded in the MBR regardless of the GRT. To remediate the low hexane removal performance (RE < 24%) recorded at the initial stages of the process, a re-inoculation of the membrane with a hexane-degrading consortium embedded in silicon oil was performed. Although hexane removal did not exceed 27%, this re-inoculation increased limonene removals up to 90% at a GRT of 7 s. The absence of inhibition of hexane biodegradation by substrate competition confirmed that hexane removal in the MBR was indeed limited by the mass transfer through the membrane. Despite the low carbon source spectrum and load, the microbiological analysis of the communities present in the MBR showed high species richness (Shannon-Wiener indices of 3.2-3.5) and a high pair-wise similarity (84-97%) between the suspended and the attached biomass.

Dehydroepiandrosterone effect on Plasmodium falciparum and its interaction with antimalarial drugs.

Dehydroepiandrosterone (DHEA) inhibits glucose 6-phosphate dehydrogenase (G6PDH) of different species and may potentially decrease intracellular glutathione. Therefore, it can have and enhance anti-parasitic action against Plasmodium spp. We evaluated the antiplasmodial activity and the interaction of DHEA with several antimalarial drugs. The inhibitory effect of DHEA on erythrocytic and G6PDH activity and changes in the content of total and reduced gluthatione Plasmodium falciparum content were also evaluated. DHEA showed antiplasmodial activity in vitro, but the potency was low (IC(50) 118.5 µM). DHEA inhibits G6PDH from healthy erythrocyte and decreases GSH content in both erythrocytes and P. falciparum. DHEA did not synergize or antagonize the antiplasmodial effect of several antimalarial drugs. The most important actions of DHEA were the inhibition of G6PDH activity, and the decrease in both P. falciparum and erythrocyte GSH. Since most of the GSH in Plasmodium spp. infected erythrocytes comes from the parasite itself, it is possible that DHEA analogs could act with higher selectivity, better potency, and might interact synergistically with antimalarials drugs.

A comparison of direct and pattern recognition control for a two degree-of-freedom above elbow virtual prosthesis.

Individuals with a transhumeral amputation have a large functional deficit and require basic functions out of their prosthesis. Myoelectric prostheses have used amplitude control techniques for decades to restore one or two degrees of freedom to these patients. Pattern recognition control has also been investigated for transhumeral amputees, but in recent years, has been more focused on transradial amputees or high-level patients who have received targeted muscle reinnervation. This study seeks to use the most recent advances in pattern recognition control and investigate techniques that could be applied to the majority of the transhumeral amputee population that has not had the reinnervation surgery to determine if pattern recognition systems may provide them with improved control. In this study, able-bodied control subjects demonstrated that highly accurate two degree-of-freedom pattern recognition systems may be trained using four EMG channels. Such systems may be used to better control a prosthesis in real-time when compared to conventional amplitude control with mode switching.

Vascular endothelial growth factor gene polymorphisms in patients with colorectal cancer.

BACKGROUND: Angiogenesis plays an important role in tumor progression. The vascular endothelial growth factor (VEGF) is an important regulator of angiogenesis. In the present study we evaluated single nucleotide polymorphisms (SNPs) -2578C > A, -1154G > A, and +936C > T in the VEGF gene, and their prognostic value for patients operated on for colorectal cancer (CRC). PATIENTS AND METHOD: VEGF polymorphisms have been analyzed in 177 patients who had undergone surgical resection at Hospital Clínico San Carlos. The analysis of these polymorphisms was performed with specific probes for each nucleotide in a multiplex reaction using real-time PCR. RESULTS: We only found a statistically significant relationship for one of these three polymorphisms, +936C > T, with gender and tumor location; 10.7% of patients heterozygotes for this SNP had tumors located in proximal colon, 35.2% in distal segment and 54.1% in rectum (p = 0.03). Patients with the +936T/T genotype had 100% overall survival (OS). CONCLUSION: Patients with a +936T/T genotype showed increased survival, therefore the +936C > T SNP could be a useful marker in the follow-up and clinical management of patients with colorectal cancer.

Effect of feed characteristics on the organic matter, nitrogen and phosphorus removal in an activated sludge system treating piggery slurry.

Piggery wastewater is characterized by its high content in nitrogen and phosphorus, as well as by a low C/N ratio. This type of wastewater is traditionally spread to croplands (with its subsequent leaching to groundwater) or rarely discharged into natural water bodies, which ultimately cause severe episodes of eutrophication in aquatic ecosystems. In this context, activated sludge systems constitute a robust and efficient treatment option. The performance of an activated sludge process using a pre-denitrification configuration treating both sieved and flocculated swine slurry at a hydraulic retention time (HRT) of 7.7 days was evaluated. In order to avoid bacterial wash-out, sludge from the settler was recirculated to the anoxic tank to accomplish denitrification. Once the biomass was acclimatized, the reactor was fed with swine slurry containing 19, 2.6, and 0.27 g/L of total chemical oxygen demand (COD), total Kjeldhal nitrogen (TKN), and soluble P, respectively. Nitrogen removal showed a clear dependency on the influent composition. When the influent TKN/total COD and soluble COD/total COD ratios were respectively 0.12-0.15 and 0.7, the reactor exhibited good removal efficiencies (up to 99 and 91 for N-NH(4)(+), TKN, respectively) while PO(4)(3-) was removed up to 65%. However, when the influent TKN/total COD ratio rose to 0.26 and soluble COD/total COD decreased to 0.3, the denitrification process was severely hindered concomitant with and accumulation of nitrite. Nevertheless, organic matter degradation was not affected by influent composition. At the last stage of the experiment, removals of dissolved phosphorus fell to 40% when the redox potential (ORP) profile showed a constant value of -400 mV, likely due to phosphate released from bacterial sludge.

Efficient nutrient removal from swine manure in a tubular biofilm photo-bioreactor using algae-bacteria consortia.

Concentrated animals feeding operations (CAFOs) often pose a negative environmental impact due to the uncontrolled spreading of manure into soils that ends up in the release of organic matter and nutrients into water bodies. Conventional aerobic methods treating CAFOs wastewater require intensive oxygenation, which significantly increases the operational costs. The alternative proposed in this research is the application of micro-algae based systems by taking advantage of the cost-effective in situ oxygenation via photosynthesis. A 4.9 L enclosed tubular biofilm photo-bioreactor was inoculated with an algal-bacterial consortium formed by the micro-algae Chlorella sorokiniana and a mixed bacterial culture from an activated sludge process. C. sorokiniana delivers the O(2) necessary to accomplish both organic matter and ammonium oxidation. The reactor was fed with diluted swine wastewater containing 180, 15 and 2,000 mg/L of NH(4) (+)-N, soluble P and total COD, respectively. The photo-bioreactor exhibited good and sustained nutrient removal efficiencies (up to 99% and 86% for NH(4) (+) and PO(4) (3-), respectively) while total COD was removed up to 75% when the biofilm was properly established. Liquid superficial velocities up to 0.4 m/s (achieved by culture broth recirculation) hindered the formation of a stable biofilm, while operation at velocities lower than 0.1 m/s supported stable process performance. The high shear stress imposed by the centrifugal recirculation pump disintegrated the large aggregates detached from the biofilm, which resulted in a poor settling performance and therefore poor COD removal efficiencies. Enclosed biofilm photo-bioreactors therefore offer a potentially more economical alternative to conventional tertiary treatments process.

The ovulation rate in anoestrous female goats managed under grazing conditions and exposed to the male effect is increased by nutritional supplementation.

This experiment was conducted to determine if feed supplementation before exposure of anoestrous does to males increases ovulation rate. Does (n=50) grazing natural vegetation were divided into two groups (n=25). One group received no feed supplementation, while the other was supplemented daily, with a mixture of 950 g of alfalfa hay, 290 g of rolled corn and 140 g of soy bean per animal for 7 days before exposure to bucks. On April 7, all females were exposed to four adult sexually active bucks (two per group) for 15 days. The ovulation rate at the ovulation detected within 5 days of exposure to males, assessed by transrectal ultrasonography, was greater (P<0.05) in supplemented (1.6+/-0.2) than in non-supplemented females (1.0+/-0.2). In contrast, ovulation rate at the subsequent ovulation, detected between days 6 and 15 of contact with males, was not different (P>0.05) between supplemented (1.3+/-0.1) and non-supplemented females (1.3+/-0.2). Feed supplementation 7 days before exposure to sexually active bucks of females managed under grazing conditions increased their ovulation rate at the first male-induced ovulation but the stimulatory effect of supplementation did not persist and was not observed at the subsequent ovulation.

El ictus en el siglo XXI. Tratamiento de urgencia / Stroke in the XXI Century. Emergency care

La enfermedad vascular, una verdadera epidemia, es la primera causa de muerte en los países desarrollados, responsable de más de una cuarta parte de las muertes documentadas a nivel mundial y la primera causa de discapacidad grave en el adulto. Las tres cuartas partes de los ictus afectan a pacientes mayores de 65 años, y debido a las previsiones de población en las que España será en el 2050 de las poblaciones más envejecidas del mundo, se prevé un incremento de la incidencia de esta patología en los próximos años. Numerosos estudios describen el escaso conocimiento de la población, sobre los signos y síntomas de presentación del ictus. Se recomienda elaborar campañas informativas orientadas a la población general para aumentar su conocimiento sobre los factores de riesgo, facilitar la identificación de los signos y síntomas de alarma y fomentar entre los pacientes el concepto del ictus como urgencia neurológica. El Código Ictus permite un rápido proceso de identificación, notificación y traslado de los pacientes a los servicios de urgencia hospitalarios. Los avances tecnológicos en el diagnóstico y la aparición de medidas terapéuticas eficaces, trombolíticos, hacen necesaria la organización coordinada y multidisciplinar. La Unidad de Ictus es la aproximación más eficaz y eficiente en el manejo de la fase aguda del ictus isquémico o hemorrágico. Los progresos en la investigación permitirán disponer de nuevas y mejores oportunidades para el tratamiento agudo del ictus (AU)

Cerebrovascular diseases have reached epidemic proportions worldwide. They are the major cause of mortality in developed countries, accounting for over one-quarter of worldwide documented deaths, and the leading cause of severe disability in adults. Given that Spain will become one of the countries most affected by population ageing, an increase in the incidence of these diseases is expected in coming years. Several studies have reported that public levels of awareness of stroke warning signs, symptoms and risk factors are relatively low. Information campaigns aimed at increasing these levels of awareness and considering stroke as a neurological emergency are needed. The stroke code is a system which allows rapid identification, notification, and transfer of stroke patients to the emergency units. Technological advances in stroke diagnosis, and the development of effective therapeutic measures, such as thrombolytics, require a coordinated multidisciplinary approach. Treating patients in Stroke Units is the most effective and efficient approach in acute ischemic or hemorrhagic stroke management. In coming years research advances will provide new and better strategies in acute stroke treatment (AU)

Predicting the accumulation of harmful metabolic byproducts during the treatment of VOC emissions in suspended growth bioreactors.

A predicting model is proposed to evaluate metabolic byproducts accumulation and process performance in suspended growth reactors treating air emissions contaminated with volatile organic compounds (VOCs). The model presented integrates a multistep kinetic model and a general mechanistic model describing bioreactor operation. This integrated model is based on general equations modeling, both mass transport and the mechanisms underlying pollutant biotransformation and byproducts accumulation, and can be applied to a wide range of operating conditions (VOC substrate, O2, and nutrients limitation). The model was tested for predicting benzyl alcohol (BA) accumulation in a chemostat reactor treating toluene. BA accumulates in Pseudomonas putida F1 cultures degrading toluene as a result of methyl monooxygenation reaction parallel to the main TOD degradation pathway. The operational conditions leading to BA accumulation are evaluated through simulations assays. Simulation results indicate that BA accumulation occurs when other substrates rather than toluene are limiting. Therefore, operation under toluene limitation is highly recommended to ensure not only the detoxification goals but also to avoid potential mutagenic effects of BA over the microbial culture.

Tomografía de 64 cortes: una nueva aproximación al diagnóstico de enfermedad coronaria / Sixty four slice computed tomography: a new approach to the diagnosis of coronary artery disease

Originalmente las arterias coronarias podían ser visualizadas directamente al abrir el tórax, luego mediante la cinecoronariografía e indirectamente con las pruebas no invasivas, que se desarrollaron para inferir el grado de obstrucción coronaria de acuerdo a la isquemia miocárdica inducida por el aumento de los requerimientos miocárdicos de oxígeno. La tomografía de las arterias coronarias permite su observación directa de una manera no invasiva, con las limitaciones propias de la irradiación y del contraste iodado. Sus indicaciones se están estableciendo en forma acelerada y su valor predictivo negativo es cercano al 100 por ciento, lo cual hace a esta nueva técnica una excelente herramienta para el diagnóstico de la enfermedad coronaria, a la vez de poder observar la función ventricular izquierda y órganos adyacentes al corazón.

Originally the coronary arteries could only be visualized when a thoracotomy was performed and thereafter with coronary arteriography. With the purpose of inferring the degree of coronary artery narrowing the so called non invasive test were developed to induce myocardial ischemia by an increase of myocardial oxygen demands. Multislice compared tomography offers the possibility of "seeing" the coronary arteries for the first time non-invasively, with the proper limitations of radiation and iodine contrast administration. Its indications are rapidly changing with a negative predictive value close to 100%, which makes this diagnostic tool unique for a better assessment not only of the coronary arteries but also of the left ventricular function and anatomy of its surrounding structures.

La adherencia al tratamiento nutricional y composición corporal: un estudio transversal en pacientes con obesidad o sobrepeso / Adherence to the nutritional treatment and body composition: a crooss-sectional study in patients with obesity or overweight

To assess nutritional adherence to treatment among obese or overweight patients and to examine the relationship between anthropometrical variables, 94 subjects between 20-50 years old randomly selected were recruited at two nutritional health centers in Medellin-Colombia. Nutritional adherence to treatment was evaluated using a questionnaire, with a total score above 24 considered as adherent to the treatment. In addition, socio-demographic information was obtained and anthropometrical variables were measured. We used descriptive statistical, Kolmogorov-Smirnov test, Chi-square for proportions comparison, and Student T test or U Mann Whitney for means comparison. A 68% of the patients were classified as no adherent to the nutritional treatment, with significant differences found according to physical activity (p= 0,013). Mean weight (p= 0,014), BMI (p= 0,026), waist circumference (p= 0,005) and waist-hip ratio (p= 0,022) differed according to adherence, being significantly higher in non adherent patients. Percent body fat did not change by degree of adherence. However when controls were separated by gender the results were significant for both men and women. Nutritional adherence to treatment in patients on a diet for weight reduction produces significant changes in body composition.

Se determinó la adherencia al tratamiento nutricional en pacientes con obesidad o sobrepeso y se examinó la relación entre ésta y variables antropométricas, mediante un estudio transversal en 94 sujetos entre 20 y 50 años seleccionados de forma aleatoria en dos centros de atención nutricional de Medellín. La adherencia al tratamiento nutricional se evaluó aplicando un cuestionario, donde puntajes mayores o iguales a 24 se consideraron como adherentes. Además, se obtuvo información socio-demográfica y antropométrica, previa estandarización de los evaluadores. Se utilizaron medidas descriptivas, prueba de Kolmogorov-Smirnov, Chi-cuadrado para comparación de proporciones, T de Student o U Mann Whitney para comparación de promedios. El 68% de los pacientes fueron clasificados como no adherentes al tratamiento nutricional, encontrando diferencias según actividad física (p=0,013). El peso promedio (p=0,014), Indice de Masa Corporal (p=0,026), perímetro de cintura (p=0,005) y relación cintura cadera (p=0,022), difirieron de acuerdo a la clasificación de adherencia, siendo significativamente más altos en los no adherentes. No hubo diferencias en el porcentaje de masa grasa según adherencia (p=0,690), pero se hallaron al controlar por sexo, p=0,009 mujeres y p=0,026 hombres. La adherencia al tratamiento nutricional en pacientes en dieta para reducir de peso, produce cambios significativos en la composición corporal.

Tratamiento de las infecciones urinarias adquiridas en la comunidad: perspectivas actuales y enfoque clínico del paciente / Treatment of community-acquired urinary infections: Current perspectives and patient clinical approach

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¿Se debe limitar el esfuerzo terapéutico en nutrición artificial? / Should the therapeutic effort in artificial nutrition be limited?

Fundamento. Existe acuerdo general entre los expertos en Bioética en no mantener un tratamiento si éste es considerado fútil. Sin embargo, no existe unanimidad sobre si la sueroterapia, la nutrición enteral (NE) y la parenteral (NP) son medidas terapéuticas o forman parte del concepto de cuidado paliativo. Objetivo. Conocer la opinión de usuarios y trabajadores sanitarios del Sistema Nacional de Salud (SNS) en estas cuestiones. Diseño. Estudio descriptivo transversal. Ámbito. Atención Primaria y especializada. Métodos. Se distribuyó una encuesta a 219 individuos (84 usuarios del SNS, 135 trabajadores sanitarios), que incluía variables sociodemográficas, la opinión sobre diferentes aspectos de ética y soporte nutricional y qué medidas se consideran como cuidado paliativo. Resultados. La mayoría de los encuestados opinan que la NE (70,8 por ciento; IC 95 por ciento: 64,2-76,8) y NP (54,8 por ciento; IC 95 por ciento: 47,9-61,6) forman parte de los cuidados básicos, con diferencias entre el personal sanitario y los usuarios del SNS. El 50,2 por ciento considera que no existen diferencias entre instaurar o retirar soporte nutricional. El 71,3 por ciento de los profesionales sanitarios responden que esta decisión depende del médico y el 60,5 por ciento de los usuarios del SNS opinan que depende del propio enfermo y/o familiares. Todas las medidas interrogadas se consideran como cuidados básicos, independientemente de las características del encuestado. Conclusiones. La nutrición artificial se entiende como un cuidado básico, independientemente de la situación y calidad de vida del paciente. Mientras los profesionales sanitarios opinan que la decisión de iniciar/retirarlas depende del médico, los usuarios del SNS consideran que depende del enfermo/familia en caso de incapacidad de éste (AU)

[Should the therapeutic effort in artificial nutrition be limited?]. / Se debe limitar el esfuerzo terapéutico en nutrición artificial?

BASIS: There exists general agreement among the experts in Bioethics in order not to maintain a treatment if it is considered that it is useless. However, there is no unanimity about if serotherapy, enteral nutrition (EN), and parenteral nutrition (PN) are really therapeutic measures or else they are measures that they are part of the concept of palliative care. OBJECTIVE: Know the opinion of users and health workers of National Health System (NHS) in these issues. DESIGN: Cross-sectional descriptive study. AREA: Primary and specialized care. METHODS: A survey was distributed to 219 individuals (84 users of the NHS, 135 health workers), that it included sociodemographic parameters, the opinion on different aspects of ethics and nutritional support, and the measures regarded as palliative care. RESULTS: The majority of the respondents think that the EN (70.8%; 95% IC: 64.2-76.8) and PN (54.8%; 95% IC: 47.9-61.6) are part of the basic care, with differences between the health personnel and the users of the NHS. 50.2% considers that there are no differences between applying or removing nutritional support. 71.3% of the health professionals answer that this decision depends on the medical, 60.5% of the users of the NHS thinks that it depends on the patient himself and/or its family members. All the evaluated measures are regarded as basic care, regardless of the characteristics of the respondent. CONCLUSIONS: Artificial nutrition is understood as a basic care, regardless of the situation and quality of life of the patient. While the health professionals think that the decision to initiate/to retire artificial nutrition depends on the physician, the users of the NHS consider that it depends on the patient/family in case of disability of this.

[Role of diet in the management of osteodystrophy during progressive renal insufficiency]. / Papel de la dieta en el manejo de la osteodistrofia en la insuficiencia renal progresiva.

Secondary hyperparathyrodism (SH) is an early manifestation of chronic renal failure (CRF), which has serious complications. Moreover, treating SH is not a risk-free process. Once in its advanced state, it is extremely difficult to reverse and therefore it is critical an early intervention and prevention. An excess of phosphorus and a deficit of calcium and calcitriol are key factors in the evolution of SH. Despite the fact that plasma phosphorus levels remain normal until an extremely advanced stage of CRF, and even apparent hyperphosphatemia in mild CRF, it has been shown that restricting dietary levels of protein and phosphorus impedes the progression of SH. A decrease of protein in the diet also decreases the amount of calcium, thus the calcium levels must be supplemented in order to prevent their deficit. In addition to that slightly diminished levels of calcitriol can be observed in the early stages of CRF, thus it is logical to provide this hormone. However, administering calcitriol may induce hypercalcemia and hyperphosphatemia, which in turn risks the onset of cardiovascular calcifications and complications. Therefore, the calcitriol dosage should be small and then adjusted according to the degree of SH. Neither the PTH levels nor alterations in the phospho-calcium metabolism follow a linear increase appropriate to the decrease in renal function, therefore we propose a treatment strategy which adapts to the different degrees of renal failure.