The Eastern European experience on occupational skin diseases. Make underreporting an issue?

BACKGROUND: While legislation in most of the Eastern European countries is nowadays widely harmonized with the legal safety and health provisions of Western countries, there is still a sustained resistance to the notification of occupational skin diseases (OSD). OBJECTIVE: The aim of the study was to identify the main barriers in notification and recognition of OSD in 22 Eastern European countries. METHODS: An online survey was administered to key persons in the field of occupational safety and health in 22 Eastern European countries. Multiple variables of the notification system were studied, including clinical, organizational and educational issues. RESULTS: The main causes of underreporting OSD are ineffective enforcement of occupational safety and health legislation, contractual relationship employer-employee, long duration of the notifying process, restrictions of the notification systems in terms of who is entitled to notify an OSD, ineffective regulations in regards to the pre-employment and periodical medical examination, ineffective compensation schemes, restraints and hesitations, mainly from the doctors, inappropriate mentalities - fear of losing the jobs, fining of the employers by the authorities, stigmatization of the workers with OSD, additional costs for employers, stakeholders' lack of interest in notifying, lack of guidelines and protocols and lack of preventive programmes. CONCLUSIONS: The most valuable method for a proper recognition of OSD is to increase the awareness of physicians involved in the management of OSD (occupational physicians, GPs, dermatologists), as well as employers and workers. There is an urgent need to improve national legislation, to develop and promote adequate preventive programmes, emphasizing ethical, legal, economical and psychological aspects in order to achieve an increased recognition and a real reporting of OSD, and to enforce an international action plan for Eastern Europe in order to improve the notification of OSD.

Third-line rescue therapy with bismuth-containing quadruple regimen after failure of two treatments (with clarithromycin and levofloxacin) for H. pylori infection.

BACKGROUND: Helicobacter pylori eradication therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin fails in >20 % of cases. A rescue therapy with PPI-amoxicillin-levofloxacin still fails in >20 % of patients. AIM: To evaluate the efficacy and tolerability of a bismuth-containing quadruple regimen in patients with two consecutive eradication failures. METHODS: Prospective multicenter study of patients in whom 1st treatment with PPI-clarithromycin-amoxicillin and 2nd with PPI-amoxicillin-levofloxacin had failed. A 3rd eradication regimen with a 7- to 14-day PPI (standard dose b.i.d.), bismuth subcitrate (120 mg q.i.d. or 240 mg b.i.d.), tetracycline (from 250 mg t.i.d. to 500 mg q.i.d.) and metronidazole (from 250 mg t.i.d. to 500 mg q.i.d.). Eradication was confirmed by (13)C-urea-breath-test 4-8 weeks after therapy. Compliance was determined through questioning and recovery of empty medication envelopes. Adverse effects were evaluated by means of a questionnaire. RESULTS: Two hundred patients (mean age 50 years, 55 % females, 20 % peptic ulcer/80 % uninvestigated-functional dyspepsia) were initially included, and two were lost to follow-up. In all, 97 % of patients complied with the protocol. Per-protocol and intention-to-treat eradication rates were 67 % (95 % CI 60-74 %) and 65 % (58-72 %). Adverse effects were reported in 22 % of patients, the most common being nausea (12 %), abdominal pain (11 %), metallic taste (8.5 %), and diarrhea (8 %), none of them severe. CONCLUSION: A bismuth-containing quadruple regimen is an acceptable third-line strategy and a safe alternative after two previous H. pylori eradication failures with standard clarithromycin- and levofloxacin-containing triple therapies.

Mortality and cardiovascular risk in vasculitis ANCA. Importance of hypertension and renal function. Experience from southern Spain.

BACKGROUND: Cardiovascular disease (CVD) is one of the principal causes of death in antineutrophil cytoplasmic antibody-(ANCA)-associated vasculitis (AAV). OBJECTIVES: To evaluate the mortality and it's causes and CVD and its vascular risk factors (VRFs) in AAV patients in Andalusia. METHODS: A multicenter cohort of 220 AAV patients followed-up from 1979 until June 2020 was studied in Andalussia, south of Spain. The information, including socio-demographic and clinical data was recorded retrospectively through chart review. Data was analysed using Chi2, ANOVA and Cox proportional hazards regresion as uni and multivariate test with a 95% confidence interval (CI). RESULTS: During a mean ± standard deviation follow-up of 96.79 ± 75.83 months, 51 patients died and 30 presented at least one CVE. Independent prognostic factors of mortality were age (HR 1.083, p=0.001) and baseline creatinine (HR 4.41, p=0.01). Independent prognostic factors of CVE were age [hazard ratio (HR) 1.042, p=0.005] and the presence of hypertension (HTN) six months after diagnosis (HR 4.641, p=0.01). HTN, diabetes and renal failure, all of these important VRFs, are more prevalent in AAV patients than it is described in matched general population. CONCLUSIONS: Age and baseline renal function, but not CVEs, are predictors of mortality and age and early HTN are independent predictors for having a CVE. CVD screening in AAV patients is demanded.

Diagnostic imaging in neuro-ophthalmology. / Diagnóstico por la imagen en neuroftalmología.

Neuro-ophthalmology is a field combining neurology and ophthalmology that studies diseases that affect the visual system and the mechanisms that control eye movement and pupil function. Imaging tests make it possible to thoroughly assess the relevant anatomy and disease of the structures that make up the visual pathway, the nerves that control eye and pupil movement, and the orbital structures themselves. This article is divided into three sections (review of the anatomy, appropriate imaging techniques, and evaluation of disease according to clinical symptoms), with the aim of providing useful tools that will enable radiologists to choose the best imaging technique for the differential diagnosis of patients' problems to reach the correct diagnosis of their disease.

Human intestinal pro-inflammatory CD11chighCCR2+CX3CR1+ macrophages, but not their tolerogenic CD11c-CCR2-CX3CR1- counterparts, are expanded in inflammatory bowel disease.

Although macrophages (Mϕ) maintain intestinal immune homoeostasis, there is not much available information about their subset composition, phenotype and function in the human setting. Human intestinal Mϕ (CD45+HLA-DR+CD14+CD64+) can be divided into subsets based on the expression of CD11c, CCR2 and CX3CR1. Monocyte-like cells can be identified as CD11chighCCR2+CX3CR1+ cells, a phenotype also shared by circulating CD14+ monocytes. On the contrary, their Mϕ-like tissue-resident counterparts display a CD11c-CCR2-CX3CR1- phenotype. CD11chigh monocyte-like cells produced IL-1ß, both in resting conditions and after LPS stimulation, while CD11c- Mϕ-like cells produced IL-10. CD11chigh pro-inflammatory monocyte-like cells, but not the others, were increased in the inflamed colon from patients with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Tolerogenic IL-10-producing CD11c- Mϕ-like cells were generated from monocytes following mucosal conditioning. Finally, the colonic mucosa recruited circulating CD14+ monocytes in a CCR2-dependent manner, being such capacity expanded in IBD. Mϕ subsets represent, therefore, transition stages from newly arrived pro-inflammatory monocyte-like cells (CD11chighCCR2+CX3CR1+) into tolerogenic tissue-resident (CD11c-CCR2-CX3CR1-) Mϕ-like cells as reflected by the mucosal capacity to recruit circulating monocytes and induce CD11c- Mϕ. The process is nevertheless dysregulated in IBD, where there is an increased migration and accumulation of pro-inflammatory CD11chigh monocyte-like cells.

Systematic review: factors associated with relapse of inflammatory bowel disease after discontinuation of anti-TNF therapy.

BACKGROUND: The discontinuation of anti-tumour necrosis factor (anti-TNF) treatment in inflammatory bowel disease (IBD) patients in remission could be considered. AIM: To evaluate the factors associated with relapse of IBD after discontinuation of anti-TNF therapy. METHODS: Electronic (PubMed/Embase) and manual search up to January 2015. RESULTS: The overall risk of relapse after discontinuation of anti-TNFs (27 studies) was 44% for Crohn's disease (CD; follow-up range: 6-125 months) and 38% for ulcerative colitis (follow-up range: 6-24 months). Several factors were investigated to identify patients who are more likely to achieve long-lasting remission after anti-TNF discontinuation. The factors associated with a higher risk of relapse are younger age, smoking, longer disease duration, and fistulising perianal CD. Laboratory markers such as low haemoglobin levels, high C-reactive protein levels and high faecal calprotectin seem to increase the risk of relapse. On the other hand, low serum anti-TNF levels seem to be associated with a lower risk of flare-up. Mucosal healing seems to decrease the risk of relapse after anti-TNF discontinuation (overall, this risk is 26% at 1 year with mucosal healing and 42% without), although this observation has not been confirmed by some authors. In patients receiving escalated anti-TNF doses or receiving anti-TNFs for the prevention of post-operative CD recurrence, the risk of relapse after discontinuation is high (>75%). Re-administration of the drug in those who relapsed after stopping treatment is effective and safe. CONCLUSIONS: A high proportion of patients with IBD relapse after discontinuation of anti-TNF treatment. As available data are insufficient to make strong recommendations on when anti-TNF therapy could be stopped, decisions should be taken on an individual basis.

Systematic review with meta-analysis: the efficacy of a second anti-TNF in patients with inflammatory bowel disease whose previous anti-TNF treatment has failed.

BACKGROUND: One-third of patients with Crohn's disease (CD) or ulcerative colitis (UC) receiving anti-TNFs do not respond to treatment, and a relevant proportion experience loss of response or intolerance. AIM: To investigate the efficacy and safety of a second anti-TNF agent after primary/secondary failure or intolerance to a first drug. INCLUSION CRITERIA: studies evaluating the efficacy of infliximab (IFX), adalimumab (ADA) and certolizumab-pegol (CZP) as the second anti-TNF in CD or UC. SEARCH STRATEGY: Bibliographical searches (PubMed/Embase). DATA SYNTHESIS: percentage of response/remission; the meta-analysis was performed using the inverse variance method. RESULTS: We included 46 studies (37 CD, 8 UC, 1 pouchitis). The CD studies comprised 32 switching IFX→ADA, 4 IFX→CZP and 1 ADA→IFX. Overall, the second anti-TNF after the failure of IFX in CD induced remission in 43% and response in 63% of patients. The remission rate was higher when the reason to withdraw the first anti-TNF was intolerance (61%) than after secondary (45%) or primary failure (30%); response rates were, respectively, 72%, 62% and 53%. All UC studies switched IFX→ADA, six of them reporting remission rates ranging from 0% to 50%. Adverse events rate ranged from 0% to 81% in CD, most of them mild (serious adverse event 0-21%, discontinuation rate <20%). CONCLUSIONS: The efficacy of a second anti-TNF in CD patients largely depends on the cause for switching. The remission rate is higher when the reason to withdraw the first anti-TNF is intolerance (61%), compared with secondary (45%) or primary failure (30%). Further studies of switch ADA→IFX are needed to evaluate this strategy. PROSPERO-registry-number: CRD42014012943.

Helicobacter pylori second-line rescue therapy with levofloxacin- and bismuth-containing quadruple therapy, after failure of standard triple or non-bismuth quadruple treatments.

BACKGROUND: The most commonly used second-line Helicobacter pylori eradication regimens are bismuth-containing quadruple therapy and levofloxacin-containing triple therapy, both offering suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens. AIMS: To evaluate the efficacy and tolerability of a second-line quadruple regimen containing levofloxacin and bismuth in patients whose previous H. pylori eradication treatment failed. METHODS: This was a prospective multicenter study including patients in whom a standard triple therapy (PPI-clarithromycin-amoxicillin) or a non-bismuth quadruple therapy (PPI-clarithromycin-amoxicillin-metronidazole, either sequential or concomitant) had failed. Esomeprazole (40 mg b.d.), amoxicillin (1 g b.d.), levofloxacin (500 mg o.d.) and bismuth (240 mg b.d.) was prescribed for 14 days. Eradication was confirmed by (13) C-urea breath test. Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by questionnaires. RESULTS: 200 patients were included consecutively (mean age 47 years, 67% women, 13% ulcer). Previous failed therapy included: standard clarithromycin triple therapy (131 patients), sequential (32) and concomitant (37). A total of 96% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 91.1% (95%CI = 87-95%) and 90% (95%CI = 86-94%). Cure rates were similar regardless of previous (failed) treatment or country of origin. Adverse effects were reported in 46% of patients, most commonly nausea (17%) and diarrhoea (16%); 3% were intense but none was serious. CONCLUSIONS: Fourteen-day bismuth- and levofloxacin-containing quadruple therapy is an effective (≥90% cure rate), simple and safe second-line strategy in patients whose previous standard triple or non-bismuth quadruple (sequential or concomitant) therapies have failed.

Laser treatment of condylomata acuminata in pregnancy.

A young patient in the third trimester of pregnancy had massive condylomata acuminata, successfully treated with the carbon dioxide laser. Lack of postoperative pain and of vulvar edema, minimal blood loss and easy vaginal delivery at term were significant factors in this case.

[Real clinical medicine and evidence-based medicine: evaluative clinical research]. / Medicina clínica real y medicina basada en la evidencia: una investigación clínica evaluativa.

BACKGROUND: The clinical view is essential in the application of a new paradigm on "evidence based medicine". Also, we hardly haven't studies that had been made with patients in real time and place. We analyzed the rate of evidence that found our clinical praxis. METHODS: A randomized observational epidemiological study was made over 689 clinical decisions in relation with 167 pathological processes, considered in 36 patients. Age (65.9, SD 2.1), sex (23 F, 13 M), comorbidity (4.6, SD 2.1), poly-pharmacy (8.8, SD 3.3). Case-mix of GRDs (infections--even HIV-, chronic respiratory affections, neurologic, cardiovascular diseases, diabetes and its complications ..., in decreased order. We used the D.L. Sackett's criterium (evidence level one "experimental", level two "no experimental but convincing-rational", level three "without any scientific base". A progressive internal control was used in order to adjust the "arbitrariness in the assignation". RESULTS: 60% of the decisions provided elevated care evidence level; 24.5% in level number two, and 15.5% without any foundation. The proceedings reasonably founded were 84.5%. The pharmacological treatment had more evidence. The diagnosticum was more empiric. The primary illness and its treatment concentrated more evidence that the enclosed conditions (65% level one and 50% respectively). The prediction is still unknown (null evidence). CONCLUSIONS: More than a half of the patients were benefited of a clinical praxis, tested in effectiveness and safety. 15.5% of the decisions had an uncertain effect (favourable, newer or damaging). Nowadays, the complex clinical praxis, despite of exceeding the paradigm of "evidence based medicine", should tend toward scientific foundation as much as possible.

Insuficiencia social: concepto y método para su valoración clínica / Social insufficiency: concept and method for its clinical evaluation

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Frequencia da discrepancia de membros inferiores apos artroplastia total de quadril / Frequency of leg-length discrepancy following total hip arthroplasty

Verificar a frequencia da ocorrencia de discrepancia de membros inferiores apos a artroplastia total de quadril, por meio de analise radiografica. Sao apresentados o conceito de discrepancia de membros inferiores, os metodos de avaliacao existentes para obtencao da discrepancia de membros inferiores e sua importancia clinica. Material e metodos: foram analisados examesde 120 pacientes portadores de osteoartrose primaria ou secundaria unilateral, sendo 72 do sexo masculino e 48 dp feminino, com idades variando entre a segunda e setima decada de vida. Os participantes dessa pesquisa foram pacientes operados pelo Grupo do Quadril, do departamento de Ortopedia e Traumatologia do Hospital Sao Paulo. Com radiografias simples em plano anteroposterior utilizando osoftware Corel Draw, versao 10, foram realizadas tres linhas para medida e pela diferenca entre essas linhas de medida foi obtida a diferenca entre os membros inferiores. O teste de hipotese foi verificado pela aplicacao de teste parametrico da diferenca das medias. A apresentacao estatistica inclui o calculo de medidas de tendencia central e de dispersao. Resultados? foi observado que entre os 120 pacientes submetidos a artroplastia total de quadril avaliados neste estudo, 100 apresentaram discrepancia de membros inferiores, sendo (35 por cento) alongamentos (discrepancias positivas) e (65 por cento) encurtamentos (discrepancias negativas). Essas diferencas foram maiores que 1 cm, seja negativos ou positivos, em (36 por cento) dos pacientes avaliados. Conclusao: houve discrepancias entre os membros inferiores apos artroplastia total de quadril, sendo maiores de 1 cm em 36 por cento dos pacientes

Sobre la llamada «Medicina basada en la evidencia» y la práctica de la Medicina Interna en Andalucía / On so-called «Evidence-based medicine» and Internal Medicine clinical practice in Andalusia

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