Tourniquet application in time-critical aquatic emergencies on a moving rescue water craft (RWC): Can speed and precision coexist?

Lifeguards are the first responders to any type of aquatic incident, including rapid rescue situations such as boating and sporting accidents, animal bites/attacks, and cases involving massive bleeding. In their line of work, rescue boats such as Rescue Water Craft (RWC) are commonly utilized the aim of this study is to evaluate the time and technique of placing a tourniquet on the sled of an RWC navigating at full speed. METHODS: A randomized crossover study design was used with a sample of 44 lifeguards. The inclusion criteria required that participants be certified lifeguards with experience in RWC operations and possess knowledge of responding to massive bleeding. Two CAT tourniquet placement tests were performed. In the 1) Beach-Tourniquet (B-TQ) test: it was performed on land and in the 2) Rescue Water Craft-tourniquet (RWC-TQ) test, sailing at a cruising speed of 20 knots. The evaluation was recorded in a checklist on the steps and timing of the correct application TQ by direct observation by an expert instructor. RESULTS: The tourniquet placement on RWC was an average of 11 s slower than when placed on the beach (BT-TQ 35.7 ± 8.0 vs. 46.1 ± 10.9 s, p > 0.001). In the percentage analysis of the results on correct execution of the skills, higher values are obtained for the B-TQ test than in RWC-TQ in Distance to the wound (into 5-7 cm), band adjustment, checking the radial pulse and reporting the time of tourniquet placement (p > 0.005). CONCLUSION: The placement of a tourniquet on a RWC navigating at 20 knots is feasible, relatively quick, and technically well executed.

Phosphocalcic metabolism after biliopancreatic diversion.

BACKGROUND: Malabsorptive techniques to treat morbid obesity have been followed by alterations in phosphocalcic metabolism. Knowledge of the preoperative situation is important to assess the influence of these techniques on phosphocalcic metabolism and to consider treatments for these alterations. METHODS: 61 consecutive morbidly obese patients (50 women, 11 men, age 19 to 63 years) having had biliopancreatic diversion (BPD) were studied in a prospective manner. Preoperative and postoperative levels of calcium, phosphorus, 25-hydroxyvitamin D, tartrate resistant acid phosphate, plasma parathormone (PTH), tubular absorption of phosphate, and urinary calcium and pyridinolines were analyzed, as well as the potential risk factors for their alterations. Follow-up of all patients was a minimum of 4 years. RESULTS: Before BPD, 42.3% of patients presented an increase in PTH and 54% a decrease in the 25-OH vitamin D, but the values of calcium and plasma phosphorus maintained at normal level. 81.8% of the patients with an increase in the PTH maintained high levels after BPD, while 60% of those with a normal preoperative PTH also presented hyperparathyroidism 4 years after the intervention. A correlation between the levels of plasma PTH and body mass index was not found. CONCLUSION: Morbid obesity is accompanied by a high percentage of hyperparathyroidism. BPD produces malabsorption of vitamin D during the first years, favoring the persistence or appearance of hyperparathyroidism. It is important to recognize and treat the secondary hyperparathyroidism. The postoperative period could necessitate more energetic interventions to get more efficient control of the phosphocalcic metabolism.

[Differences in the synthesis pattern of vasoactive factors in gestational hypertension and preeclampsia]. / Diferencias en el patrón de síntesis de factores vasoactivos en la hipertensión gestacional y en la preeclampsia.

BACKGROUND AND OBJECTIVE: The gestational hypertension -HG- and preeclampsia -P- are hypertensive diseases whose pathogenic mechanism has not been determined yet. The aim of this work is to define some patterns of vasoactive factors release that allow to explain the origin of the differences between both entities. DESIGN: Prospective case-control study. MATERIAL AND METHODS: Two groups of target patients were consecutively selected, GH (n=21) and P patients (n=21). Every patient was matched with a pregnant of similar age and week of pregnancy. Two control groups were obtained, one respect to the GH and another one respect to the P group. A biochemistry, blood cell count, coagulation and quantification of vasoactive factors endothelin, nitrites and GMPc were performed in every woman. Results of GH and P groups were compared with their respective control group with the paired Student's t Test. RESULTS: Both systolic and diastolic arterial pressures were higher in hypertensive pregnants (GH and P) than in their respective controls. Moreover, blood endothelin and GMPc were higher in GH and P. GH pregnants showed decreased norepinephrine and increased epinephrine urinary excretion , as well as an increased plasma nitrites concentration than control group. P patients did not show statistically significant differences in catecholamines urinary excretion nor in plasma nitrites concentration respect their control group. CONCLUSION: There are relevant differences in the synthesis patterns of vasoactive factors between gestational hypertension and preeclampsia. These differences could account for a decreased tissue perfusion in preeclampsia and could also contribute to the genesis of the renal dysfunction of this entity.

[Management of a first depressive episode in the primary care setting. Use of antidepressants and referrals]. / Manejo en atención primaria de un primer episodio depresivo. Uso de antidepresivos y derivaciones.

INTRODUCTION: The majority of patients who have a first depressive episode are treated by Primary Care physicians. The aim of this study was to evaluate the use of antidepressants and referrals to mental health and the treatment modifications made by psychiatrists. MATERIAL AND METHODS: A descriptive, retrospective study was conducted on patients from 64 Primary Care clinics, distributed in five Spanish provinces. The clinical history data, regarding use of antidepressants, criteria for referral, and response of psychiatric services were evaluated from June 2008 to June 2011. RESULTS: The study included 324 patients. The most commonly prescribed medication was escitalopram, with selective serotonin reuptake inhibitors (SSRI) making up 73.5% of the total. More than two-thirds (69.7%) of the patients were on treatment for at least 6 months, with no reason recorded for the 40.4% drop-outs. A large majority of professionals (76.9%) wait at least 3 weeks before modifying the medication, especially changing antidepressant. The Primary Care physicians referred 39.2% of patients to psychiatry, although much of these referrals (43.9%) had no justification. There was a lower referral rate to psychology (23.1%). An antidepressant was given to a large number of patients on multiple medications, without taking into account the risk of interactions in a high percentage. CONCLUSIONS: The Primary Care physician appropriately uses the antidepressants of the first choice, but does not pay attention to the risks in complex patients. There must be an appropriate duration of treatment and an improvement of the criteria for referral to mental health services.

Abordaje laparoscópico mediante puerto único versus técnica convencional en el tratamiento quirúrgico del cáncer de endometrio / Single port laparoscopic approach versus conventional technique in the surgical treatment of endometrial cancer

Objetivo: El objetivo de este estudio es comparar el abordaje laparoscópico convencional con el acceso por puerto único en el tratamiento quirúrgico del cáncer de endometrio. Materiales y métodos: Estudio retrospectivo sobre 36 pacientes, 18 operadas con técnica convencional y 18 con acceso por puerto único mediante una única incisión en la piel y 3 en la fascia, para la inserción de un trócar de 10mm y 2 de 5mm. Resultados: Se obtiene menor dolor postoperatorio (22,3% vs. 83,3%, p<0,001) y un mejor resultado estético (10 vs. 8, p=0,001) en el grupo de pacientes intervenidas por puerto único. El tiempo quirúrgico fue mayor en el grupo con técnica convencional (120 vs. 180min; p=0,027). En cuanto a estancia hospitalaria (2,5 vs. 2,5 días, p=0,69), pérdida sanguínea (1,15 vs. 1,25g/dl, p=1), número de ganglios extirpados (16,5 vs. 18; p=0,78) y complicaciones intra (0% vs. 5%, p=0,19) y posquirúrgicas (16,6% vs. 11,1%, p=0,63) no hubo diferencias significativas. Conclusión: El abordaje por puerto único es una técnica factible, segura y efectiva en el tratamiento del cáncer ginecológico, presentando una menor tasa de dolor postoperatorio y un mejor resultado estético.(AU)

Objective: The objective of this study is to compare conventional laparoscopy with transumbilical single-port access for the surgical treatment of endometrial cancer. Materials and methods: A retrospective study was performed with 36 patients, of whom 18 were operated using conventional laparoscopy, and 18 using a transumbilical single-port access (laparoendoscopic single-site surgery, or LESS) by making a single incision in the umbilical skin of 2-3cm, and 3 incisions in the fascia. One 10-mm trocar and two 5-mm trocars were inserted next to each other to access the abdominal cavity. Results: There were no statistical differences between groups in postoperative changes in haemoglobin concentration (1.15 vs. 1.25g/dL, P=1), hospital stay (2.5 vs. 2.5 days, P=.69), intraoperative complication rate (0% vs. 5%, P=.19), postoperative complications (16.6% vs. 11.1%, P=.63), number of pelvic lymph nodes (16.5 vs. 18, P=.78), and number of para-aortic lymph nodes (9 vs. 10, P=.64). Patients in the LESS group experienced less postoperative pain (22.3% vs. 83.3%, P<.001), and had a higher rate of satisfaction with the cosmetic results (10 vs. 8, P=.001). The median operating time was lower in the LESS group (120-180min, P=.027). Conclusion: Laparoendoscopic single-site surgery is a feasible, safety and effective technique for the treatment of endometrial cancer, with less postoperative pain and better cosmetic results.(AU)

Evolución de la competencia en el agua de los socorristas acuáticos / Evolution of the Competence in Water of the Aquatic Lifeguards

En el año 2006 entró en vigor la normativa que actualmente regula la formación de socorristas en la Comunidad Autónoma de Madrid (España). El objetivo de este estudio es conocer la influencia de la aplicación de esta normativa sobre el porcentaje de aspirantes que obtiene el diploma de socorrista acuático y sobre su nivel de competencia en el agua. Para ello, se han analizado las marcas de tiempo acreditadas por 6.105 aspirantes a socorrista (4.288 hombres y 1.817 mujeres) que se formaron entre los años 1993 y 2016. Los resultados demuestran que, desde la entrada en vigor de dicha normativa, se ha incrementado el porcentaje de aspirantes que obtiene el diploma de socorrista acuático, pero se ha disminuido su nivel de competencia en el agua. Se recomienda que las instituciones competentes establezcan objetivos y criterios de evaluación que promuevan la mejora del nivel de competencia en el agua de estos profesionales

In 2006, the normative that currently regulates the training of lifeguards in the Autonomous Community of Madrid (Spain) came into force. The objective of this study is to know the influence of the application of this regulation on the percentage of applicants who obtain the aquatic lifeguard diploma and on their level of competence in the water. For this purpose, the time marks, accredited by 6,105 applicants to lifeguards (4,288 men and 1,817 women) who received this training between 1993 and 2016, have been analysed. The results show that, since the regulation came into force, the percentage of applicants who obtain the lifeguard diploma has increased, but their level of competence in the water has decreased. Therefore, it is recommended that objectives and assessment criteria that are established by the institutions, encourage the improvement of the level of competence in the water of these professionals

Cyclosporine increases local glomerular synthesis of reactive oxygen species in rats: effect of vitamin E on cyclosporine nephrotoxicity.

BACKGROUND: We report an investigation of the effects of cyclosporine (CsA) on kidney function, the glomerular synthesis of reactive oxygen species, the peroxidation of lipids, and the levels of thromboxane B2 (TXB2). The effect of the simultaneous administration of the antioxidant vitamin E (Vit E) and CsA in rats was also evaluated. METHODS: Adult male Wistar rats were treated for 30 days with CsA (30 mg/kg/day), with Vit E (0.05 mg/ml), with CsA plus Vit E, or with the vehicle used for administration of CsA, namely 12.6% ethanol. RESULTS: CsA induced kidney failure and increased the glomerular synthesis of superoxide anion, H2O2, malonyldialdehyde, and TXB2. Vit E minimized the adverse effects of CsA on kidney function and the glomerular synthesis of these compounds. CONCLUSIONS: Our results suggest that the acute decrease in glomerular filtration rate induced by CsA might be mediated by the synthesis of reactive oxygen species and subsequent peroxidation of lipids, which increases the levels of TXB2. Treatment with Vit E prevented these effects, suggesting a possible role for antioxidants in the prevention of CsA nephrotoxicity.

Retinoids as a potential treatment for experimental puromycin-induced nephrosis.

1 Puromycin aminonucleoside (PAN)-induced nephrosis is a model of human minimal change disease. In rats, PAN induces nephrotic-range proteinuria, renal epithelial cell (podocyte) damage, infiltration of mononuclear leukocytes, and apoptosis of several renal cell types. 2 Retinoic acid (RA) modulates a wide range of biological processes, such as inflammation and apoptosis. Since renal damage by PAN is characterized by inflammatory infiltration and epithelial cell death, the effect of treatment with all-trans RA (tRA) was examined in the PAN nephrosis model and in the cultured differentiated podocyte. 3 Treatment with tRA 4 days after PAN injection did not inhibit the proteinuria peak but reversed it significantly. However, treatment with tRA both before and 2 days after the injection of PAN protected the glomerular epithelial cells, diminishing the cellular edema and diffuseness of the foot process effacement. Preservation of the podocyte architecture correlated with the inhibition of proteinuria. The anti-inflammatory effect of tRA was evidenced by the inhibition of PAN-induced interstitial mononuclear cell infiltration and the decreased renal expression of two molecules involved in monocyte infiltration: fibronectin and monocyte chemoattractant protein-1. TUNEL assays showed that tRA inhibited the PAN-induced apoptosis of cultured differentiated mouse podocytes. 4 We conclude that tRA treatment may prevent proteinuria by protecting the podocytes from injury and diminishing the interstitial mononuclear infiltrate in the model of PAN nephrosis. Retinoids are a potential new treatment for kidney diseases characterized by proteinuria and mononuclear cell infiltration.

Total and regional bone mass values and biochemical markers of bone remodeling in endometriosis.

OBJECTIVE: TO measure peripheral, axial, and total bone mass and to assess markers of bone remodeling in women with endometriosis, with the aim of addressing previous reports of diminished peripheral bone mass in these patients. METHODS: Whole body bone densitometry, estradiol (E2) levels, and biochemical bone markers (calcium, phosphorus, total alkaline phosphatase, tartrate-resistant acid phosphatase, and total proteins) were determined in 28 patients with endometriosis and compared with findings in 33 controls. RESULTS: There were no significant differences between the groups in bone mass at different sites or in biochemical bone markers. We observed a significant negative correlation between tartrate-resistant acid phosphatase and E2 levels (P < .001) and with total (P < .001), head (P < .01), and axial (trunk) (P < .001) bone mass. Total alkaline phosphatase did not correlate with any of the indices studied. CONCLUSIONS: Bone mass was not lower in any of the areas studied in women with endometriosis. There was a significant negative correlation of tartrate-resistant acid phosphatase with E2 and with total, head, and trunk bone mass.

Direct interactions between platelets and cultured rat mesangial cells.

Platelets seem to be involved in the pathogenesis of some kidney diseases, but the exact relationships between platelets and the changes in renal function are incompletely known. Mesangial cells (MC) were incubated with platelet-supernatants (PS) and cellular surface area (CSA) and myosin light-chain phosphorylation (MLCP) were measured. CSA of PS-incubated MC (PS-MC) significantly diminished, as compared to control MC (70 +/- 6% vs. 100 +/- 5%). PS induced a significant increase in MLCP with respect to control cells (150 +/- 23% vs. 100 +/- 18%). When platelets were pretreated with indomethacin, the PS-dependent contraction was abolished. Pretreatment with sulotroban (SU) or BN-52021 (BN), a thromboxane A2 (TXA2) and a platelet-activating factor (PAF) receptor blocker respectively, also completely blocked the PS effects. In other experiments, platelets were activated with thrombin (T), adding the so obtained PS to MC. Moreover, cells were also preincubated with T and then added PS. No changes in CSA were observed in either case. It may be concluded that PS contracted cultured MC, and these changes could be related to the decreased glomerular filtration rate (GFR) observed in some diseases in which platelets seem to be involved. TXA2 and PAF may be responsible for this effect. In contrast, T incubation inhibited the effect of PS, perhaps through a direct relaxing effect of T in MC.

Thromboxane A2 and platelet-activating factor decrease in the platelet-mesangial cell interactions.

To analyze the metabolisms of platelet-activating factor (PAF) and Thromboxane A2 (TxA2) when platelets and mesangial cells (MC) interact, immunoreactive thromboxane B2 (TxB2) and PAF were measured after incubation of cultured rat MC with platelets (P) and with platelet supernatants (PS). In both cases, TxB2 significantly decreased with respect to the P synthesis and to the PS content, suggesting an increased degradation of this metabolite or even the existence of a specific effect of MC upon platelet TxB2. When immunoreactive PAF was measured, results were comparable to those observed for TxB2. Moreover, when intrinsic mesangial cell synthesis of PAF was assessed by analyzing the [3H]-acetate incorporation by prelabeled MC in the HPLC fraction coeluting with cold PAF standards, it was possible to demonstrate that P or PS did not modify PAF synthesis in these cells. In summary, present results support the existence of a specific effect of mesangial cells upon platelet TxA2 and PAF.

Cyclosporin A-induced hydrogen peroxide synthesis by cultured human mesangial cells is blocked by exogenous antioxidants.

Cyclosporin A (CsA) is the immunosupressor most widely used in transplanted patients for preventing organ rejection, but it has some toxic side effects in vascular beds and kidney. The purpose of this work was to study if H2O2, a reactive oxygen species, is involved in the CsA-induced toxic effects on kidney in vitro. Human mesangial cells (HMC) in culture were incubated in presence of CsA (10[-5]-10[-8]M) and H2O2 was measured by flow cytometry. The specificity of the probe used in this method was demonstrated as fluorescence was not detected when superoxide anion generated through a Xanthine-Xanthine oxidase system was present, but fluorescence was noted when H2O2 was present in the incubation medium, both directly and after addition of superoxide dismutase to the medium thus promoting H2O2 synthesis. CsA induced a significant dose and time-response increased H2O2 synthesis by cultured HMC. This increase appeared 5 min after CsA addition, being maximal between 15-45 min at CsA concentration of 10(-7)M. When HMC were preincubated with antioxidants as vitamin E or selenium, the CsA-induced H2O2 production was partially blocked. In addition, selenium also induced an increased activity of glutathion peroxidase in HMC after 24 hours of incubation, suggesting that it exerted its H2O2 scavenging action through the modulation of the activity of this enzyme.

Etidronate versus clodronate in the prevention of postovariectomy bone loss. An experimental study in rats.

OBJECTIVE: We compared the diphosphonates etidronate and clodronate to find out which was more effective in inhibiting the loss of bone mass after ovariectomy in rats. METHODS: Five lots of female Sprague Dawley rats, each containing 15 rats (14 wks old; mean weight 290 g), were kept under identical living conditions (12 hrs of light and 12 hrs of darkness), habitat, and diet following the current norms of the European Economic Community. One lot was kept as a control; one lot underwent sham ovariectomy (Sham-OVX); and the remaining 3 lots were anesthesized and underwent double ovariectomy (OVX). One lot of ovariectomized rats was given etidronate by esophageal tube, 5 mg/kg/day (OVX-E); one lot was treated with intraperitoneal clodronate, 5 mg/kg/3 days (OVX-Cl). The remaining lot was not manipulated (OVX). The animals' right femurs were then dissected for measurements of the bone mineral content. RESULTS AND CONCLUSION: Bone densitometry revealed that loss of bone mass 2 months after ovariectomy in the OVX-Cl group was 2.3%, not differing from that of the control group; bone loss in the OVX-E group was 11.7%, significantly different from the control group and from the OVX-Cl group (p < 0.001). These results show that clodronate is superior to etidronate in inhibiting osteopenia after ovariectomy in rats.

Changes in body composition in women treated with gonadotropin-releasing hormone agonists.

OBJECTIVE: The changes that agonists of gonadotropin-releasing hormone (GnRH) produce in mineral bone mass are known, but, as far as we know, those produced by these agents in other body compartments are unknown. METHODS: We studied these changes using dual-energy X-ray absorptiometry in 50 eugonadal women treated with decapeptyl (Triptoreline), 3.75 mg injected intramuscularly, at 28-day intervals for 6 months. RESULTS: There were significant increases in fat content (9.5%, P < 0.0005) and weight (1.3%, P < 0.01), and significant decreases in fat-free mass (-1.9%, P < 0.0001) and water content (-1.8%, P < 0.0002). Bone mass was lost in the axial skeleton (-3.6%, P < 0.0001) but not in the peripheral skeleton. CONCLUSIONS: The changes induced in body composition by the GnRH agonists are similar to those of natural menopause.

Biochemical markers of nutrition in type-I and type-II osteoporosis.

We studied nutritional deficits, using as markers the levels of transferrin, retinol-binding protein, and prealbumin, in 20 women with osteoporotic hip fractures (type II), 40 women with vertebral fractures (type I), and two groups of age-matched control subjects. The concentrations of all three nutritional markers were lower in the two groups of patients than in their matched controls, and in type-I as compared with type-II osteoporosis. In the osteoporotic patients, simple linear regression showed a significant correlation between the variables which we studied (r2 ranged from 0.5 to 0.7; p < 0.001), the best correlation being between prealbumin and retinol-binding protein in type-II osteoporosis. Our results suggest that there is a more marked nutritional deficit in type-II than in type-I osteoporosis.

[Usefulness of the percentage of free prostatic specific antigen in the differential diagnosis between benign prostatic hyperplasia and prostate cancer]. / Utilidad de la fracción libre del antígeno prostático específico en el diagnóstico diferencial entre hiperplasia prostática benigna y cáncer de próstata.

BACKGROUND: PSA (prostatic specific antigen) is the most used tumor marker to monitor prostate cancer (PC). It is an acceptably sensitive test. Molecular forms of PSA give a chance to improve its specificity. We have evaluated the usefulness of the ratio free PSA/total PSA (f-PSA/t-PSA%) to diagnose prostate cancer, in the range between 4 and 20 ng/ml; i.e. the interval in which values overlap for patients with PC and benign prostatic hyperplasia (BPH) in our environment. PATIENTS AND METHODS: Prospective study on 269 patients, 73 with PC and 196 with BPH. Both t-PSA and f-PSA were determined using microparticles enzyme immune assay (MEIA) with AXSYM (Abbott) analyzer. RESULTS: Statistically significant differences were evidenced in f-PSA/t-PSA% for patients with PC vs. BPH; but that did not happen for t-PSA values. Sensitivity and specificity values were established for different cut-off points. ROC curve analysis proved diagnostic efficacy was better for f-PSA/t-PSA% than for t-PSA. CONCLUSIONS: f-PSA/t-PSA percentage is a useful tool for the differential diagnosis between PC and BPH. A ratio lower than 12% selects a population with high risk of cancer. A percentage over 18% is useful to avoid or delay the indication of biopsy.

Influencia de la longitud del vaso sobre las pruebas de socorrismo acuático profesional / The effect of pool length on the results of professional lifeguard saving tests

En este estudio se ha seleccionado a 2.528 aspirantes a la certificación de socorrista acuático (1.798 hombres y 730 mujeres). Todos ellos han realizado las cuatro pruebas físicas de agua cronometradas que se exigen para trabajar de socorrista en piscinas, instalaciones acuáticas y medio natural en la Comunidad Autónoma de Madrid (España). Del total de los participantes, 1.887 aspirantes realizaron dichas pruebas en vaso de 25 metros y 641 lo hicieron en vaso de 50 metros. El objetivo de este estudio es conocer la influencia de la longitud del vaso en el que se desarrollan estas pruebas físicas, sobre el porcentaje de aprobados y sobre las marcas de tiempo que emplean los participantes para realizarlas. Los resultados de esta investigación demuestran que la longitud del vaso en el que se evalúa a los aspirantes a socorrista, influye significativamente sobre las marcas de tiempo que obtienen y también sobre el número de aprobados

In this study 2.528 aspirants for aquatic lifeguard certification (1.798 men and 730 women) were selected. All the participants of the study have performed the four physical tests of chronometric water required in order to work as a lifeguard for swimming pools, aquatic and open water in the Comunidad Autónoma de Madrid (Spain). Of the whole participants, 1.887 aspirants were tested in a 25-meter pool and 641 were done so in a 50-meter pool. The aim of this study is to know the influence of the length of the pool in which these physical tests are developed, on the pass rate and on the time needed by the sample to carry them out. The results of this research show that the length of the pool in which the aspirants are evaluated, influences on the time marks obtained by them and also on the number of approved ones

Outcome of acute renal injury in diabetic mice with experimental endotoxemia: role of hypoxia-inducible factor-1 α.

The role of diabetic nephropathy in the outcome of acute renal injury (AKI) is not well defined. Herein we evaluate the outcome of lipopolysaccharide- (LPS-) induced AKI in streptozotocin-induced diabetes, as well as the potential role of Hypoxia Inducible Factor (HIF-1 α ) in this condition. Although 6 h after LPS injection all mice developed a decrease in renal function, proteinuric diabetic mice showed a better recovery of this parameter throughout the study (72 h). Both HIF-1 α and vascular endothelium growth factor (VEGF) were found to be upregulated in diabetic mice. After LPS injection, all animals showed an upregulation of these factors, although it was higher in the diabetic group. Glycated albumin (GA) was found to upregulate HIF-1 α in HK-2 cells, which resulted in increased production of VEGF. Interestingly, LPS cooperated with GA to induce HIF-1 α upregulation. In conclusion, diabetic mice display a better recovery of AKI after experimental endotoxemia. Moreover, these animals showed an increased expression of both HIF-1 α and VEGF that was reproduced by incubating renal cells with GA. Since VEGF is considered a survival factor for tubular cells, our findings suggest that diabetes displays HIF-1 α upregulation that might function as a "precondition state" offering protection from endotoxic AKI.

Effectiveness of a diagnostic algorithm combining clinical probability, D-dimer testing, and computed tomography in patients with suspected pulmonary embolism in an emergency department.

OBJECTIVE: The aim of our study was to assess the clinical effectiveness of a simplified algorithm using the Wells clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism (PE) in an Emergency Department (ED). METHODS: Patients with clinically suspected PE from the Emergency Department were included from May 2007 through December 2008. Clinical probability was assessed using the Wells clinical decision rule and a VIDAS D-dimer assay was used to measure D-dimer concentration. Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using the dichotomized version of the Wells clinical decision rule. Pulmonary embolism was considered excluded in patients with unlikely probability and normal D-dimer test (< 500 ng/ml). All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months. RESULTS: 241 patients were included in the study. The prevalence of PE in the entire population was 23.6%. The combination of unlikely probability using the dichotomized Wells clinical decision rule and a normal D-dimer level occurred in 23.6%, thus making CT unnecessary. During the followup period, no thromboembolic events were recorded and there were no deaths related to venous thromboembolic disease (3-month thromboembolic risk 0% [95% CI, 0%-8%]). CONCLUSIONS: In this study we have confirmed the effectiveness of a diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT in the evaluation and management of patients with clinically suspected pulmonary embolism.