Physical therapy in Down syndrome: systematic review and meta-analysis.

BACKGROUND: Down syndrome is the most common chromosomal abnormality, with a worldwide incidence of around 0.1% in live births. It is related to several conditions in which the physical therapy could take action-preventing co-morbidities. This study aims to evaluate the effectiveness of physical therapy in Down syndrome, to know and compare the effectiveness of different physical therapy interventions in this population. METHODS: A systematic review and a meta-analysis of randomised controlled trials were conducted. The search was performed during June 2018 in the following databases: PubMed, Web of Science, Physiotherapy Evidence Database and Scopus. The studies were selected using predefined inclusion and exclusion criteria. The Physiotherapy Evidence Database scale evaluated the quality of the methods used in the studies. Subsequently, the data were extracted, and statistical analysis was performed when possible. RESULTS: A total of 27 articles were included, of which nine contributed information to the meta-analysis. Statistical analysis showed favourable results for the strength of upper and lower limbs [standardised mean difference (SMD) = 1.46; 95% confidence interval (CI): (0.77-2.15); and SMD = 2.04; 95% CI: (1.07-3.01)] and mediolateral oscillations of balance [SMD = -3.30; 95% CI: (-5.34 to -1.26)]. CONCLUSIONS: The results show the potential benefit of certain types of physical therapy interventions, specifically in strength and balance, in people with Down syndrome. There are still many aspects to clarify and new lines of research.

Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus: do minimum inhibitory concentrations to vancomycin and daptomycin matter?

The use of vancomycin minimum inhibitory concentration (MIC) as an outcome predictor in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia has become an important topic for debate in the last few years. Given these previous results, we decided to investigate whether MICs to vancomycin or daptomycin had any effect on the evolution of patients with ventilator-associated pneumonia (VAP) due to MSSA. An observational, retrospective, multicenter study was conducted among patients with MSSA VAP. We analyzed the relationship between vancomycin and daptomycin MICs and early clinical response (72 h), 30-day mortality, intensive care unit (ICU) length of stay (LOS), and duration on mechanical ventilation. Univariate and multivariate analyses were performed. Sixty-six patients from 12 centers were included. Twenty-six patients (39%) had an infection due to MSSA strains with a vancomycin MIC ≥1.5 µg/mL. Daptomycin MIC was determined in 58 patients, of whom 17 (29%) had an MIC ≥1.0 µg/mL. Ten patients (15%) did not respond to first-line treatment. Only daptomycin MIC ≥1.0 µg/mL had a significant association [odds ratio (OR): 30.00; 95% confidence interval (CI): 2.91-60.41] with early treatment failure. The 30-day mortality was 12% (n = 8). Any variable was associated with mortality in the multivariate analysis. None of the variables studied were associated with ICU LOS or duration on mechanical ventilation. In patients with MSSA VAP, vancomycin MIC does not influence the response to antibiotic treatment or the 30-day mortality. Daptomycin MIC was directly related to early treatment failure.

Estimation of potential donors after cardiocirculatory death in Elche University General Hospital (Alicante, Spain). / Estimación de potenciales donantes en muerte cardiocirculatoria en el Hospital General Universitario de Elche.

OBJECTIVE: To evaluate the number and characteristics of potential organ donors among cardiocirculatory death cases. DESIGN AND SETTING: A retrospective observational study was made of individuals between 15-65 years of age who died in the period 2006-2014 in Elche University General Hospital (Alicante, Spain). INTERVENTION: A univariate analysis and binary logistic regression predictive model were performed to discriminate factors related to donation contraindication. VARIABLES OF INTEREST: Identification of patients with donation contraindication. RESULTS: Of the 1510 patients who died in the mentioned period, 1048 were excluded due to the application of exclusion criteria; 86 due to evolution towards brain death; and 20 due to losses. A total of 356 patients were analyzed, divided into two groups: 288 in non-heart beating donation II and 68 in non-heart beating donation III. Seventy patients were found to be potential non-heart beating donation II and 10 were found to be potential non-heart beating donation III, which could increase donation activity by 8-9 donors a year. The patients died in the ICU, Resuscitation, Emergency Care, Internal Medicine, Digestive Diseases and Neurology. The following protective factors against organ donation contraindication were identified: death in Emergency Care, cardiorespiratory arrest before or during admission, and heart, respiratory and neurological disease as the cause of admission. Death in Internal Medicine was associated to an increased risk of donation contraindication. CONCLUSIONS: Implementing a non-heart beating donation protocol in our hospital could increase the donation potential by 8-9 donors a year.

Independent positive association of plasma ß-carotene concentrations with adiponectin among non-diabetic obese subjects.

PURPOSE: Many epidemiological studies find an inverse correlation between carotenoids intake or carotenoids plasma concentrations and body mass index (BMI), insulin resistance or metabolic syndrome in the general population. However, it is not clear whether these relationships occur in obese population. METHODS: We conducted a cross-sectional study in 108 obese non-diabetic patients. RESULTS: There was an inverse correlation between plasma levels of pro-vitamin A carotenoids (α-carotene, ß-carotene and ß-cryptoxanthin) and both BMI and insulin resistance (estimated by the HOMA-IR). No correlation between plasma concentrations of lycopene or lutein/zeaxanthin and BMI or insulin resistance was found. The inverse association between the three pro-vitamin A carotenoids and HOMA-IR disappeared after adjustment for BMI and waist circumference. Interestingly, we identified a positive association between concentrations of ß-carotene and adiponectin in plasma that was independent of sex, age, smoking status, BMI and waist circumference. To our knowledge, such association has never been described in obese patients. CONCLUSION: These results suggest the existence of a favourable effect of ß-carotene on insulin sensitivity in obese individuals that could involve a positive regulation of adiponectin, either directly or via its pro-vitamin A activity. The demonstration of the potential benefits of ß-carotene towards insulin sensitivity would open the way to dietary strategies to prevent metabolic syndrome.

Correlation between body mass index and gut concentrations of Lactobacillus reuteri, Bifidobacterium animalis, Methanobrevibacter smithii and Escherichia coli.

BACKGROUND: Genus and species level analysis is the best way to characterize alterations in the human gut microbiota that are associated with obesity, because the clustering of obese and lean microbiotas increases with the taxonomic depth of the analysis. Bifidobacterium genus members have been associated with a lean status, whereas different Lactobacillus species are associated both with a lean and an obese status. OBJECTIVES AND METHODS: We analyzed the fecal concentrations of Bacteroidetes, Firmicutes, Methanobrevibacter smithii, the genus Lactobacillus, five other Lactobacillus species previously linked with lean or obese populations, Escherichia coli and Bifidobacterium animalis in 263 individuals, including 134 obese, 38 overweight, 76 lean and 15 anorexic subjects to test for the correlation between bacterial concentration and body mass index (BMI). Of these subjects, 137 were used in our previous study. FINDINGS: Firmicutes were found in >98.5%, Bacteroidetes in 67%, M. smithii in 64%, E. coli in 51%, Lactobacillus species between 17 and 25% and B. animalis in 11% of individuals. The fecal concentration of Lactobacillus reuteri was positively correlated with BMI (coefficient=0.85; 95% confidence interval (CI) 0.12-0.58; P=0.02) in agreement with what was reported for Lactobacillus sakei. As reported, B. animalis (coefficient=-0.84; 95% CI -1.61 to -0.07; P=0.03) and M. smithii (coefficient=-0.43, 95% CI -0.90 to 0.05; P=0.08) were negatively associated with the BMI. Unexpectedly, E. coli was found here for the first time to negatively correlate with the BMI (coefficient=-1.05; 95% CI -1.60 to -0.50; P<0.001). CONCLUSION: Our findings confirm the specificity of the obese microbiota and emphasize the correlation between the concentration of certain Lactobacillus species and obesity.

Assessment of cerebral blood flow velocities, brain midline shift and optic nerve sheath diameter by ultrasound in patients undergoing elective craniotomy: A prospective observational feasibility study.

BACKGROUND: Brain ultrasound allows measuring the cerebral flow velocity, brain midline shift and optic nerve sheath diameter. Literature is scarce in determining the feasibility to perioperatively perform these measurements altogether and the cerebrovascular behavior in patients scheduled for elective craniotomy. METHODS: We assessed bilateral cerebral flow velocities, composite index, brain midline shift and optic nerve sheath diameter by cerebral ultrasound in patients scheduled for elective craniotomy before anesthetic induction, at extubation, and at 6 and 24 h after. The aim was to assess the feasibility of brain ultrasound in patients for elective craniotomy and to describe the changes in cerebral flow velocities, brain midline shift and optic nerve sheath diameter from baseline values at different times in the postoperative period. RESULTS: Sixteen patients were included, of these two were excluded from analysis due to an inadequate sonographic window. There were no changes throughout the study regarding cerebral flow velocity, brain midline shift nor optic nerve sheath diameter assessments. All parameters were maintained in the physiological range without significant variations during the procedure. No perioperative complications were detected. CONCLUSIONS: The results of our study show the feasibility to perform a perioperative assessment of cerebral flow velocity, brain midline shift or optic nerve sheath diameter jointly and successfully to obtain additional information of baseline cerebral hemodynamics in patients scheduled for elective craniotomy and their postoperative changes during the first 24 h. Future studies with lager samples are needed to address the efficacy of cerebral ultrasound as a monitoring tool.

Organic law regulating euthanasia: knowledge and involvement of doctors in Spain one year after its implementation.

BACKGROUND AND AIMS: The Organic Law Regulating Euthanasia (LORE, for its initials in Spanish) came into force in June 2021. This study aims to examine knowledge of the LORE among physicians licensed in Spain as well as their involvement with and the impact of the law. METHODS: This work is a descriptive, cross-sectional study conducted by means of a survey. Information was gathered through a self-administered questionnaire. RESULTS: The survey was answered by 1446 physicians licensed in Spain. The samples' demographic characteristics were as follows: 54.7% were women, the mean age was 52 ±â€¯14 years, and 66.0% worked in a hospital. Catalonia was the autonomous community with the most participants (44.6%). Regarding specialties, anesthesiology and resuscitation had the highest number of participants (21.9%), followed by family and community medicine (18.5%). The LORE was known in detail by 24.3% of physicians, 58.0% had a positive opinion of it, and 31.1% had direct experience with the euthanasia procedure. Practitioners working in the hospital setting perceived the law more favorably compared to those in the primary care setting (62.3% vs. 47.3%, p < 0.01). CONCLUSIONS: Most doctors did not have in-depth knowledge of the LORE, although a majority supported its existence, particularly those in hospital medicine. Most physicians who viewed the LORE negatively were male, older, and worked in primary care. A minority of physicians considered registering as conscientious objectors.

Obesity-associated gut microbiota is enriched in Lactobacillus reuteri and depleted in Bifidobacterium animalis and Methanobrevibacter smithii.

BACKGROUND: Obesity is associated with increased health risk and has been associated with alterations in bacterial gut microbiota, with mainly a reduction in Bacteroidetes, but few data exist at the genus and species level. It has been reported that the Lactobacillus and Bifidobacterium genus representatives may have a critical role in weight regulation as an anti-obesity effect in experimental models and humans, or as a growth-promoter effect in agriculture depending on the strains. OBJECTIVES AND METHODS: To confirm reported gut alterations and test whether Lactobacillus or Bifidobacterium species found in the human gut are associated with obesity or lean status, we analyzed the stools of 68 obese and 47 controls targeting Firmicutes, Bacteroidetes, Methanobrevibacter smithii, Lactococcus lactis, Bifidobacterium animalis and seven species of Lactobacillus by quantitative PCR (qPCR) and culture on a Lactobacillus-selective medium. FINDINGS: In qPCR, B. animalis (odds ratio (OR)=0.63; 95% confidence interval (CI) 0.39-1.01; P=0.056) and M. smithii (OR=0.76; 95% CI 0.59-0.97; P=0.03) were associated with normal weight whereas Lactobacillus reuteri (OR=1.79; 95% CI 1.03-3.10; P=0.04) was associated with obesity. CONCLUSION: The gut microbiota associated with human obesity is depleted in M. smithii. Some Bifidobacterium or Lactobacillus species were associated with normal weight (B. animalis) while others (L. reuteri) were associated with obesity. Therefore, gut microbiota composition at the species level is related to body weight and obesity, which might be of relevance for further studies and the management of obesity. These results must be considered cautiously because it is the first study to date that links specific species of Lactobacillus with obesity in humans.

[Cerebrovascular accident with haemorrhagic transformation in a patient on antiplatelet treatment subjected to surgery of a hypophyseal macroadenoma]. / Accidente cerebrovascular con transformación hemorrágica en una paciente con tratamiento antiagregante intervenida de macroadenoma hipofisario.

The case is presented of a 51 year-old woman, proposed for endoscopic endonasal transsphenoidal resection of a hypophyseal macroadenoma diagnosed in the context of a stroke suffered 10 weeks before the date of the surgery. During this time, she had been treated with antiplatelet drugs, which were withdrawn 5 days before the surgery. The surgical procedure was performed without any incidents. On the second day after the surgery, the patient had an ischaemic infarction of the left cerebellar hemisphere, with signs of hydrocephaly and a posterior haemorrhagic transformation, with brain death 5 days after the operation. There are no definitive guidelines on the use of antiplatelet drugs in the perioperative period of neurosurgery. Also, there is no agreement as regards the waiting time between a cerebrovascular event and surgery, it appears that between 4 and 12 weeks would be the most advisable. The importance of an individual assessment of each patient before surgery is emphasised, as well as a review of the antiplatelet management of the patient with a risk of thrombosis in the context of neurosurgery, and their possible postoperative complications.

[Fibreoptic clinical training in anaesthesia. Course design and results based on a self-assessment survey]. / Entrenamiento clínico con fibrobroncoscopio en anestesia. Diseño y resultados del curso según encuesta de autoevaluación.

BACKGROUND AND OBJECTIVE: Fibreoptic intubation is the technique of choice for resolving complications related to a difficult airway. Our aim was to determine whether a clinical-practice-based, individualized course provides sufficient training and confidence to allow anaesthetists to routinely practice fibreoptic intubation. METHODS: Our hospital developed a clinical-practice-based, individualized course on fibreoptic intubation in general anaesthesia that provided practice in sedated spontaneously breathing patients and insertion through supraglottic devices. From 2005 to 2009, we e-mailed participants for response to an anonymous online self-assessment survey. We asked participants about the training outcomes and their overall degree of satisfaction. RESULTS: Seventy-seven participants were sent the questionnaire six months after the course and 61% responded. All respondents considered themselves skilled in handling the bronchoscope at the end of the course and 97% used it in their routine practice in patients with difficult airways. CONCLUSIONS: These results suggest a high success rate can be expected from individually tailored fibreoptic intubation courses that supplement theory and mannequin experience with clinical practice.

Anaesthetic management in neurosurgery in a patient with Eisenmenger syndrome and Down syndrome. A case report.

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.

[Efficacy of tele-rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review].

The COVID-19 pandemic has required the use of new technologies to carry out rehabilitation sessions for COP D remotely. The aim of this systematic review was to analyse the available evidence on the efficacy of telerehabilitation in COPD patients. PubMed, WOS, PEDro and Cochrane databases were consulted. The systematic review included nine clinical trials, 55.5% of which display good methodological quality. The most commonly used rehabilitation methods were applications or software for real-time video-calls, visualisation of exercises and recording progress. TR was as effective as outpatient pulmonary rehabilitation, with greater benefits in functional capacity, self-efficacy, mental health, exacerbations and emergency care visits, offering a cost-effective option with high patient satisfaction. The small number of studies and the variety of rehabilitation methods examined limit the value of the evidence obtained.

Mammalian target of rapamycin signal inhibitors could play a role in the treatment of BK polyomavirus nephritis in renal allograft recipients.

UNLABELLED: BK virus (BKV) nephropathy is a common viral infection in renal transplant patients, with a prevalence of 1-9% at approximately 12 months after surgery. While it is widely agreed that reduction of immunosuppression should be the first intervention after diagnosis of BKV infection, there is no consensus on whether calcineurin inhibitors or antiproliferative drugs should be reduced first. Furthermore, target levels of immunosuppressive drugs are poorly defined, as are criteria for replacing one immunosuppressive agent with another. RESULTS: We report our series of 15 renal transplant patients who underwent surgery between September 2004 and March 2010 and who developed BKV infection. The first 8 patients were treated with reduction of immunosuppression; 7 of these patients received cidofovir and 6 received intravenous immunoglobulin. The remaining 7 renal transplant recipients received mammalian target of rapamycin inhibitors (imTOR). In this group, we observed faster and more efficacious BKV clearance in plasma and urine and a steady improvement in allograft function, with no episodes of acute allograft rejection during follow-up. The polymerase chain reaction assay for BKV in urine became positive in 2 patients in whom imTOR were stopped due to severe side effects. CONCLUSIONS: The use of imTOR should be considered a first step in the treatment of renal transplant recipients with BKV infection. In our experience, this change in treatment was safe and resulted in viral clearance.

Comparison of the LMA Supreme™ with the LMA Proseal™ for airway management in patients anaesthetized in prone position.

BACKGROUND: The laryngeal mask airway (LMA) has been successfully used in patients in the prone position either for rescue or elective airway management. The reusable Proseal™ LMA (PLMA) and the single use Supreme™ LMA (SLMA) have been reported to be suitable for this purpose but few comparative data are available. In this study, we compared the clinical use of both devices in adult patients anaesthetized in the prone position. METHODS: One hundred and twenty patients undergoing surgery in the prone position were randomized to receive either the PLMA or the SLMA for airway management. Patients positioned themselves in the prone position and after pre-oxygenation, anaesthesia was induced using a target-controlled i.v. infusion of propofol and remifentanil. All PLMAs and SLMAs were inserted by experienced anaesthetists using a guided and a standard technique respectively. Ease of facemask ventilation, time and number of attempts needed for insertion, quality of ventilation, airway seal pressure, fibreoptic view, and complications were compared. RESULTS: There were no differences between groups in insertion time or first attempt success (100% vs. 98%). The PLMA required fewer manipulations (3% vs. 15%; P=0.02) to achieve effective ventilation and provided a higher seal pressure (mean [sd] 31 [4] vs. 27 [4] cm H2O; P<0.01). The fibrescopic view of the vocal cords was similar, although easier to achieve with the PLMA. The complication rate was low and similar between the groups. Blood was present on masks in 7% vs. 8% and sore throat in 3% vs. 5% of patients with the PLMA and SLMA, respectively. CONCLUSIONS: Airway management in patients anaesthetized in the prone position was efficient with both devices, although the PLMA required fewer manipulations and achieved a higher seal pressure.

[Experience with the proseal laryngeal mask in ventriculoperitoneal shunting]. / Experiencia con el uso de la mascarilla laríngea Proseal en pacientes sometidos a cirugía de derivación ventrículo peritoneal.

OBJECTIVE: To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitonea shunting. PATIENTS AND METHODS: We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded. RESULTS: Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateral-cervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases. CONCLUSIONS: The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand.

[Noninvasive mechanical ventilation in severe pneumonia due to H1N1 virus]. / Utilización de la ventilación mecánica no invasiva en neumonía grave por virus H1N1.

OBJECTIVE: The use of noninvasive mechanical ventilation was evaluated in our series of patients admitted to our ICU with pneumonia due to influenza A virus H1N1, assessing the need for intubation, arterial blood gases and clinical improvement, the development of complications and ICU and hospital stay. DESIGN: Retrospective and observational study. SETTING: ICU of Castellón University General Hospital (Castellón, Spain). POPULATION: Patients admitted to ICU with pneumonia due to influenza A virus H1N1 and acute hypoxemic respiratory failure. INTERVENTIONS: Boussignac CPAP, Helmet system and BiPAP Vision(®) were used. RESULTS: Five of 10 patients with pneumonia and hypoxemia were analyzed, showing 100% effectiveness of noninvasive mechanical ventilation in terms of clinical and arterial blood gas improvement, and avoiding intubation in all cases. There were no patient deaths in ICU or in hospital. The duration (median) of ventilation was 6 (4-11) days, with an ICU stay of 9 (7-11) days. The number of complications was low (except for urinary tract infection due to Pseudomonas aeruginosa), and only the noise produced by CPAP was underscored. There were no infections among the staff. CONCLUSIONS: Based on our results, increased use of noninvasive mechanical ventilation in future epidemics coujld be proposed.

Anaesthetic management in neurosurgery in a patient with Eisenmenger syndrome and Down syndrome. A case report. / Manejo anestésico en neurocirugía de paciente con síndrome de Eisenmenger y síndrome de Down. Reporte de un caso.

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger Syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.

Use of the Ambu(®) aScope™ in 10 patients with predicted difficult intubation.

Fibreoptic intubation is the gold standard for patients with predicted difficult intubation. The Ambu(®) aScope™ is a single-use device for fibreoptic tracheal intubation. We assessed its performance in 10 patients with predicted difficult tracheal intubation. The procedure was easy and successful in nine patients. However, the limited time of use did not permit intubation in one patient who required three attempts with different size tracheal tubes. The limited image resolution that can be expected of a single-use fibreoptic system and the absence of a suction channel are other potential limitations. On the other hand, being single-use this device has the advantage of avoiding the risk of infectious disease transmission and is always ready to use.

Insertion and use of the LMA Supreme in the prone position.

We investigated whether insertion of an LMA Supreme and its use for maintenance of anaesthesia is feasible in the prone position. Forty adult patients positioned themselves prone and were given propofol until the Bispectral Index was < 50. A size-4 LMA Supreme was inserted by experienced anaesthetists. Ease of insertion, ease of ventilation, efficacy of seal, ease of gastric tube insertion, blood staining, postoperative sore throat, and other complications were recorded. Insertion was successful at the first and second attempt in 37 (92.5%) and 3 (7.5%) patients, respectively. The mean (SD) insertion time was 21 (15) s. Oropharyngeal leak pressure was greater in females than males (29 (4) vs 25 (4) cmH(2)O, respectively, p = 0.01). Adequate ventilation was achieved in all patients. Gastric tube placement was successful in all patients. The frequency of blood staining and sore throat was 7.5% each. No other complications were noted. We conclude that use of the LMA Supreme in the prone position by experienced users is feasible.