The STARMEN trial indicates that alternating treatment with corticosteroids and cyclophosphamide is superior to sequential treatment with tacrolimus and rituximab in primary membranous nephropathy.

A cyclical corticosteroid-cyclophosphamide regimen is recommended for patients with primary membranous nephropathy at high risk of progression. We hypothesized that sequential therapy with tacrolimus and rituximab is superior to cyclical alternating treatment with corticosteroids and cyclophosphamide in inducing persistent remission in these patients. This was tested in a randomized, open-label controlled trial of 86 patients with primary membranous nephropathy and persistent nephrotic syndrome after six-months observation and assigned 43 each to receive six-month cyclical treatment with corticosteroid and cyclophosphamide or sequential treatment with tacrolimus (full-dose for six months and tapering for another three months) and rituximab (one gram at month six). The primary outcome was complete or partial remission of nephrotic syndrome at 24 months. This composite outcome occurred in 36 patients (83.7%) in the corticosteroid-cyclophosphamide group and in 25 patients (58.1%) in the tacrolimus-rituximab group (relative risk 1.44; 95% confidence interval 1.08 to 1.92). Complete remission at 24 months occurred in 26 patients (60%) in the corticosteroid-cyclophosphamide group and in 11 patients (26%) in the tacrolimus-rituximab group (2.36; 1.34 to 4.16). Anti-PLA2R titers showed a significant decrease in both groups but the proportion of anti-PLA2R-positive patients who achieved immunological response (depletion of anti-PLA2R antibodies) was significantly higher at three and six months in the corticosteroid-cyclophosphamide group (77% and 92%, respectively), as compared to the tacrolimus-rituximab group (45% and 70%, respectively). Relapses occurred in one patient in the corticosteroid-cyclophosphamide group, and three patients in the tacrolimus-rituximab group. Serious adverse events were similar in both groups. Thus, treatment with corticosteroid-cyclophosphamide induced remission in a significantly greater number of patients with primary membranous nephropathy than tacrolimus-rituximab.

Programas de optimización del uso de antimicrobianos en los servicios de urgencias españoles: Estudio PROA-URG / Antibiotic stewardship programs in the Spanish emergency services: PROA-URG Study

Introducción: Los programas de optimización de antimicrobianos (PROA) son herramientas clave en la adecuación de estos fármacos. La información disponible sobre la aplicación e indicadores para monitorizar estos programas en urgencias es limitada. El objetivo del estudio es conocer el grado de implantación de programas PROA en los servicios de urgencias, así como el uso de antimicrobianos en estas unidades. Material y métodos. Estudio multicéntrico retrospectivo. Se envió una invitación a todos los participantes del grupo de trabajo de farmacéuticos de urgencias REDFASTER-SEFH. Se utilizó un cuestionario de 21 ítems, contestado por un equipo formado por especialistas en los servicios de farmacia hospitalaria, urgencias, enfermedades infecciosas y microbiología. Resultados. 18 hospitales completaron la encuesta. Catorce (77,8%) disponían de un responsable PROA en la unidad. El valor de DDD por 1000 ingresos osciló entre 36,5 y 400,5 (mediana 100,4 [RIQ:57,2-157,3]). El grupo de carbapenémicos y macrólidos presentó una amplia variabilidad. Únicamente seis (33,3%) hospitales disponían de informe anual de resistencias específico para urocultivos y hemocultivos en urgencias. El porcentaje de multirresistentes en urocultivos fue del 12,5% y en hemocultivos del 12,2%. El porcentaje de adecuación en bacteremia de acuerdo con el resultado del hemocultivo fue del 81,0% (RIQ:74,6-85,0%), y en infección urinaria del 78,0% (RIQ:71,5-88,0%). Conclusiones. Pese a la existencia de responsables PROA, actividades formativas y guías de tratamiento en urgencias, la información sobre el uso de antimicrobianos y el perfil de resistencias en estas unidades es limitado. Futuras actividades han de ir encaminadas a mejorar la información sobre los resultados PROA propios para estas unidades. (AU)

Introduction: Antimicrobial stewardship programs (ASP) have become a key tool in the adaptation of these drugs to the health system. The information available on the application and indicators used in these programs in emergency departments is scarce. The objective of this study is to know theextent of ASP implementation in the emergency departments, as well as the use of antimicrobials in these units. Material and methods. Multicenter retrospective study. An invitation was sent to all participants of the REDFASTER-SEFH emergency pharmacist working group. A questionnaire was used consisting of 21 items, answered by a team made up of a pharmacist, emergency room specialist, infectious disease specialist and microbiologist. Results. Eighteen hospitals completed the survey. Fourteen (77.8%) had an ASP manager. The DDD value per 1000 admissions ranged between 36.5 and 400.5 (median: 100.4 [IQR:57.2-157.3]). Both carbapenem and macrolide group presented wide variability in use. Six (33.3%) hospitals had an annual report on the specific resistance profile for urine and blood cultures. The percentage of multi-drug resistant strains in urine cultures was 12.5% and in blood cultures 12.2%. The percentage of adequacy in the bacteremia treatment was 81.0% (IQR:74.6-85.0%), while in urinary tract infections was 78.0% (IQR:71.5-88.0). Conclusions: Despite the existence of ASP members in emergency services, as well as the training activity and local guidelines is common. knowledge of the use of antimicrobials and resistances is limited. Future activities must be aimed at improving information about the ASP results in these units. (AU)

[Efficacy of interventions aimed at the main carers of dependent individuals aged more than 65 years old. A systematic review]. / Eficacia de las intervenciones dirigidas a cuidadores principales de personas dependientes mayores de 65 años. Una revisión sistemática.

BACKGROUND: In our environment, care of the dependent elderly is usually provided by family members, thereby ensuring autonomy and avoiding institutionalization of the dependent adult. Thirty-three percent of Spanish caregivers have acknowledged the importance of acquiring the knowledge and skills necessary for daily care. Consequently, several interventions have been developed by health professionals from distinct disciplines. OBJECTIVE: The purpose of this study was to systematically review and evaluate the efficacy of published interventions for the caregivers of dependent elderly individuals. MATERIAL AND METHODS: We conducted a systematic review of the literature on interventions in the caregivers of the dependent elderly (older than 65 years old) published between 1996 and 2006. The inclusion criteria included controlled clinical trials with outcome measures related to effectiveness in reducing caregiver burden, anxiety and depression. Our search yielded 15 reports. RESULTS: The interventions produced statistically significant reductions in burden (40%), anxiety (50%) and depression (90%). Interventions requiring active participation by caregivers and those based on cognitive-behavioral therapy were more effective than those focused on knowledge acquisition. CONCLUSION: Due to the heterogeneity of caregiving interventions, evaluation of both the clinical and statistical significance of these interventions is essential. Reducing the chronic stress experienced by caregivers is difficult to achieve. Consequently, future experimental designs should take into account the needs reported by caregivers as well as promote active participation.

Eficacia de las intervenciones dirigidas a cuidadores principales de personas dependientes mayores de 65 años. Una revisión sistemática / Efficacy of interventions aimed at the main carers of dependent individuals aged more than 65 years old. A systematic review

Introducción: el cuidado de un anciano dependiente en nuestroentorno social es asumido por los miembros de su familia o cuidadoresprincipales (CP); ellos son los responsables de mantenerla autonomía del anciano y de su permanencia en el entorno familiar.El 33% de los CP españoles manifiestan la importancia deadquirir conocimientos y habilidades para el cuidado, por lo queprofesionales de la salud de distintas disciplinas han diseñadodiferentes programas de intervención.Objetivo: el propósito de este estudio fue realizar una revisiónsistemática sobre la eficacia de las intervenciones dirigidas a CPde ancianos dependientes.Material y métodos: se realizó una revisión sistemática de la literaturacientífica publicada sobre intervenciones dirigidas a CPde personas mayores de 65 años dependientes, realizadas de1996 a 2006. Los criterios de inclusión fueron: artículos primarioscon selección aleatoria grupo experimental/grupo control y queanalizaran la eficacia de la intervención sobre la sobrecarga, laansiedad o la depresión. La muestra final la compusieron 15 estudiosque cumplían los criterios de inclusión.Resultados: las intervenciones mostraron resultados estadísticamentesignificativos sobre la sobrecarga (40%), la ansiedad(50%) y la depresión (90%).Las intervenciones con participación activa de los CP y basadasen terapia cognitivo conductual fueron más eficaces que aquellascuyo contenido se centró exclusivamente en la adquisiciónde conocimientos.Conclusiones: la heterogeneidad de las intervenciones hacenimprescindible, en esta área de estudio, valorar la relevancia clínicade los resultados además de la significación estadística. Dadoque los efectos del cuidado son estresores crónicos difícilmentemodificables, en futuros estudios se debería planteardiseños experimentales, sin olvidar las necesidades expresadaspor los propios CP y promoviendo su participación activa(AU)

Background: in our environment, care of the dependent elderlyis usually provided by family members, thereby ensuring autonomyand avoiding institutionalization of the dependent adult.Thirty-three percent of Spanish caregivers have acknowledgedthe importance of acquiring the knowledge and skills necessaryfor daily care. Consequently, several interventions have been developedby health professionals from distinct disciplines.Objective: the purpose of this study was to systematically reviewand evaluate the efficacy of published interventions for the caregiversof dependent elderly individuals.Material and methods: we conducted a systematic review of theliterature on interventions in the caregivers of the dependent elderly(older than 65 years old) published between 1996 and 2006.The inclusion criteria included controlled clinical trials with outcomemeasures related to effectiveness in reducing caregiverburden, anxiety and depression. Our search yielded 15 reports.Results: the interventions produced statistically significant reductionsin burden (40%), anxiety (50%) and depression (90%).Interventions requiring active participation by caregivers andthose based on cognitive-behavioral therapy were more effectivethan those focused on knowledge acquisition. Conclusion: due to the heterogeneity of caregiving interventions,evaluation of both the clinical and statistical significance of theseinterventions is essential. Reducing the chronic stress experiencedby caregivers is difficult to achieve. Consequently, future experimentaldesigns should take into account the needs reportedby caregivers as well as promote active participation(AU)