[Clinical development of anti-FXII therapeutics as a target in thrombo-inflammation]. / Développement clinique des thérapeutiques anti-facteur XII ciblant la thrombo-inflammation.

The history of anticoagulation has evolved considerably, from non-specific drugs to molecules that directly target specific coagulation factors, such as direct oral anticoagulants (DOACs). Since last decade, DOACs are widely used in clinical practice because of their ease to use with favorable pharmacological profile and not requiring monitoring. New therapeutics targeting the contact phase of coagulation are currently under development, and could make it possible to prevent thrombotic risk without altering hemostasis, thereby reducing the risk of bleeding. Factor XII, being at the crossroads between hemostasis and inflammation, appears to be an interesting target that could limit thrombo-inflammation without increasing bleeding risk. The aim of this article is to summarize the main information concerning FXII inhibitors and to review the results of various clinical trials available to date, focusing on applications beyond hemostasis, such as in the management of hereditary angioedema.

Prostate health index (PHI) as an accurate prostate cancer predictor.

PURPOSE: This study aims to compare the ability of the PHI versus tPSA test to predict the presence of PCa in our population. METHODS: A prospective observational study was performed. We included patients with tPSA ≥ 2.5 ng/ml, biopsy naïve or previous negative biopsy, undergoing a blood test, which includes tPSA, fPSA, and p2PSA, and a prostate biopsy between March 2019 and March 2022. Patients with PCa found in the biopsy-Group A-were compared with patients with a negative biopsy result-Group B. Diagnostic accuracy of tPSA and PHI was assessed by receiver operating characteristic [ROC] curves and logistic regression. RESULTS: 140 men were included. Fifty-seven (40.7%) had a positive prostate biopsy result (Group A), and 83 (59.3%) had a negative biopsy result (Group B). The mean age was similar in both groups (mean ± standard deviation), 66.86 ± 6.61 years. No difference was found in the tPSA value between the groups (Group A PSA: 6.11 ng/ml (3.56-17.01); Group B: 6.42 ng/ml (2.46-19.45), p = 0.41). The mean value of PHI was statistically different between groups (Group A 65.50 (29-146) vs. Group B 48 (16-233), p = 0.0001). The area under the curve 0.44 for tPSA and 0.77 for PHI. The multivariate logistic regression model applied to PHI showed a significant increase in its predictive accuracy: 72.14% in the model without PHI, 76.09% with PHI. CONCLUSION: The PHI test improves PCa detection compared to tPSA in our population.

Orbital ophthalmomiasis due to Dermatobia hominis in an immunosuppressed patient from the ecuadorian andean area.

An 83-year-old Ecuadorian male, indigent with a history of malnutrition and chronic alcoholism, presented with a clinical feature characterized by progressive growth of larvae at the left eye level (LE), associated with areas of ocular tissue putrefaction. Upon admission, his vision in the right eye (RE) was of hand movement and no light perception in LE, the anterior segment of the RE showed a brunescent cataract, with no other alteration, while the LE presented edema, bipalpebral erythema and an abundant number of mobile larvae distributed throughout the orbit, associated with areas of necrosis, putrefaction and distortion of the anatomy of the ocular tissues. Orbital tomography showed a significant compromise of the orbit, indicating surgical management by left orbital exenteration with taxonomic identification of the larvae as Dermatobia hominis associated with it, antibiotic treatment was implemented and a frontal fasciocutaneous flap was performed by the plastic surgery department.

Making thirsty cities sustainable: A nexus approach for water provisioning in Quito, Ecuador.

In view of accelerated climate change and urban demographics, balancing human and ecosystem needs for water resources is a critical environmental challenge of global significance. Since water, agriculture, health, and energy are inextricably linked, sustainable development goals (SDGs) actions in one policy area commonly have impacts on the others, as well as on the ecosystems that natural resources and human activities ultimately depend upon. Managing urban water supply systems therefore requires a nexus approach that integrates goals across sectors, reduces the risk that SDG actions will undermine one another, and ensures sustainable resource use. We developed a transdisciplinary methodological framework based on a Pareto frontier analysis to define the sustainable solutions of a multi-objective optimization among four competing criteria, water provision, water quality, energy cost, and biodiversity conservation. The study was applied to three mountainous headwater basins in the Ecuadorian Andes, which provide around 30% of Quito's total water supply. We found that an optimized management of water intake structures would meet current consumption needs while reducing the probability of emergence of water pathogens and limiting the impact on aquatic biodiversity by 30% and 9% respectively, without any increase in energy costs for pumping water from other sources. Nonetheless, under future scenarios of climate change and water demand, higher energy consumption, and therefore an increase in operating costs, would be needed to meet urban demand and preserve environmental conditions. Overall, the range of Pareto optimal water supply strategies across the water-health-energy-biodiversity nexus provides valuable information for decision makers and offers support for achieving sustainable management of water resources.

Exposure to the COVID-19 pandemic environment and generosity.

We report data from an online experiment which allows us to study how generosity changed over a 6-day period during the initial explosive growth of the COVID-19 pandemic in Andalusia, Spain, while the country was under a strict lockdown. Participants (n = 969) could donate a fraction of a €100 prize to an unknown charity. Our data are particularly rich in the age distribution and we complement them with daily public information about COVID-19-related deaths, infections and hospital admissions. We find correlational evidence that donations decreased in the period under study, particularly among older individuals. Our analysis of the mechanisms behind the detected decrease in generosity suggests that expectations about others' behaviour, perceived mortality risk and (alarming) information play a key-but independent-role for behavioural adaptation. These results indicate that social behaviour is quickly adjusted in response to the pandemic environment, possibly reflecting some form of selective prosociality.

[Opicapone for the treatment of Parkinson's disease: real-life data in Spain]. / Opicapona para el tratamiento de la enfermedad de Parkinson: datos de vida real en España.

Opicapone is a catechol-O-methyl-transferase (iCOMT) inhibitor authorized in Europe in 2016 and indicated as adjunctive therapy to preparations of levodopa/ DOPA decarboxylase inhibitors in adult patients with Parkinson's disease and end-of-dose motor fluctuations who cannot be stabilised on those combinations. The efficacy of opicapone in these patients has been demonstrated in two pivotal randomized clinical trials, BIPARK I and BIPARK II, in which it has demonstrated its superiority versus placebo and non-inferiority versus entacapone. Although they constitute the gold standard for the evaluation of interventions, randomized clinical trials present limitations of external validity due to the use of strict eligibility criteria. Therefore, it is considered necessary to have a more comprehensive evaluation of the efficacy of the drug, complementing the information obtained from randomized clinical trials with that of "real world or real clinical practice" studies. The objective of this review has been to collect and put into perspective the information available on opicapone coming from real clinical practice studies in Spain. The data from Spain with opicapone in 18 series with more than 1,000 patients in total, confirm the safety and efficacy previously reported with this iCOMT. Furthermore, they show that opicapone is especially useful in patients with a less advanced stage of the disease and mild motor fluctuations, which would suggest that the earlier its introduction in the therapeutic scheme for the management of motor fluctuations, the better is the benefit-risk ratio for the drug.

TITLE: Opicapona para el tratamiento de la enfermedad de Parkinson: datos de vida real en España.Resumen. La opicapona es un inhibidor de la catecol-O-metiltransferasa (iCOMT) autorizado en Europa en 2016 como terapia adyuvante a las preparaciones de levodopa/inhibidores de la dopa descarboxilasa en pacientes adultos con enfermedad de Parkinson y fluctuaciones motoras de final de dosis que no puedan ser estabilizados con esas combinaciones. La eficacia de la opicapona en estos pacientes ha sido demostrada en dos ensayos clínicos pivotales, BIPARK I y BIPARK II, en los que se ha demostrado la superioridad frente al placebo y la no inferioridad frente a la entacapona. A pesar de que constituyen el estándar para la evaluación de intervenciones, los ensayos clínicos aleatorizados presentan limitaciones de validez externa debidas a la utilización de criterios estrictos de elegibilidad. Por tanto, se considera necesario disponer de una evaluación más amplia de la eficacia general del fármaco, complementando la información de los ensayos clínicos aleatorizados con estudios de 'vida real o práctica clínica real'. El objetivo de esta revisión ha sido recopilar y poner en perspectiva la información disponible sobre los resultados de la opicapona en estudios de práctica clínica real en España. Los datos acumulados en España con opicapona en 18 series con más de 1.000 pacientes confirman la seguridad y la eficacia de este iCOMT comunicadas previamente. Además, muestran que la opicapona es especialmente útil en pacientes en un estadio de la enfermedad menos avanzado y fluctuaciones motores leves, lo que sugeriría una mejor relación beneficio-riesgo cuanto más temprana sea su introducción en el esquema terapéutico para el tratamiento de las fluctuaciones motoras.

Bacillus spp. characterization and his intervention as a possible non-traditional etiology of chronic renal insufficiency in Tierra Blanca, Veracruz, Mexico.

Environmental, socioeconomic, educational, custom, occupation, and native pathogen microbiota factors have been identified as unique etiological factors by region for chronic renal insufficiency (CRI). In the region of Tierra Blanca, Veracruz, there is a significant incidence of CRI. The objective of this research was to identify the presence of the genus Bacillus spp. and its kinetic characterization for recognition as a possible non-traditional etiology of CRI in the region. The methodology included the isolation and morphological, biochemical, molecular and kinetic characterization of strains of the genus Bacillus spp. and an analysis of factors that indicate that their presence could affect the occupational health of the population, prompting cases of CRI. The presence of Bacillus cereus (pathogenic strain for humans) was established (biochemical identification, similarity 99%, by 16S rRNA gene) in sugarcane crops, mainly in the MEX-69-290 variety, with the higher growth rate and lower lag phase, compared to the other isolates. The strains are reported as a potential danger of direct infection and a risk factor for the indirect development of CRI, in the non-traditional cause modality, in the sugarcane fields. It is recommended that committed actions be undertaken to protect and promote the health of the population.

Prolonged intravenous immunoglobulin treatment in very low birth weight infants with late onset sepsis.

BACKGROUND: Neonatal infections are a leading cause of morbi-mortality despite advances in antimicrobials and neonatal care. Preterm infants have greater susceptibility to sepsis due to an immature immune system and lower immunoglobulin levels. Intravenous immunoglobulins (IVIG) have been used in several studies as an adjuvant treatment to improve this physiological immune deficiency, with different outcomes. METHODS: Very low birth weight (VLBW) infants who developed sepsis in the neonatal ICU were studied. They were randomly divided in 2 groups: one group was treated with antibiotics (Group I), and the other received antibiotics plus a 500 mg/kg/day of IVIG during 7 days (Group II). Serum IgG concentration was determined at initiation, during and after treatment Group I, and daily during the 7 days of therapy in Group II. RESULTS: The baseline IgG concentration in group II was 486 g/dL, and increased to 852 mg/dL after the first dose of IVIG (p < 0.01). After the seventh day of infusion a mean IgG level of 1898 mg/dL was achieved. A direct correlation (r = 0.94) between IgG concentration and days of treatment was observed. Blood cultures were positive in 70% of the infants in group I and 75.5% in group II. Staphylococcus epidermidis was the most frequent isolated bacteria in blood cultures. The lethality rate was 25.0% in group I and 5.0% in Group II (p < 0.03). We did not observe collateral effects with the administration of IVIG. CONCLUSIONS: Prolonged therapy with IVIG seems to be safe and effective as an adjuvant treatment in VLBW infants with sepsis.

Tumor fibroso solitario de la glándula tiroides con extensión intratorácica / Solitary fibrous tumor of the thyroid gland with intrathoracic extension

El tumor fibroso solitario (TFS) es una neoplasia mesenquimal de células fusiformes infrecuente descrita inicialmente en la pleura pero con localización reconocida en otros sitios. El TFS de la glándula tiroides (TFST) es aun más raro. Se describe el caso de una mujer de 65 años de edad, con masa cervical de crecimiento progresivo, a tal punto que ya la masa se hacía notable en parte inferior de su cuello, siendo este el único síntoma narrado. La paciente presentaba una gran masa tiroidea en el lóbulo derecho con extensión intratorácica. Se practicó hemitiroidectomia derecha (paciente tenia historia previa de resección del lóbulo tiroideo izquierdo por lesión benigna) Total, además de toracotomía endoscópica por la extensión de la masa la cual en la tomografía contrastada, se originaba en el lóbulo tiroideo derecho y descendía paralelo a la columna dorsal desplazando a la tráquea y el esófago. La patología reportó un tumor de 15 centímetros, con células fusiformes y patrón de crecimiento hemangiopericítico sin pleomorfismo, atipia, mitosis o necrosis. Luego de practicar diferentes estudios y marcadores tumorales, de todos estudios fueron positivos CD34, Bcl2, CD99 y vimentina. Se diagnosticó tumor fibroso solitario de glándula tiroides. El nervio vago derecho fue lesionado en la cirugía, actualmente está en terapia de voz. Al momento actual casi seis meses luego de su cirugía, no se documenta recidiva tumoral.

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm initially described as spindle cells in the pleura but recognized location elsewhere. The TFS thyroid gland (TFST) even infrequent. A case of a 65 years old woman with progressive growth of a right cervical mass without associated symptoms described other than cosmesis is described . The patient had a thyroid mass in the right lobe with intrathoracic extension. A right Hemi thyroidectomy and thoracotomy for the extent of the mass was performed. Pathology reported a 15 cm tumor with spindle cell and growth pattern hemangiopericitic without pleomorphism, atypia, mitosis or necrosis. Immunohistochemistry was positive for CD34, Bcl-2, CD99 and vimentin, making the diagnosis of solitary fibrous tumor of thyroid gland. The patient's right Vagus nerve was injured intraoperatively and she is currently under voice therapy. Currently now, almost six months after her surgery she is free of disease.

Impact of harmful use of alcohol on the sedation of critical patients on mechanical ventilation: A multicentre prospective, observational study in 8 Spanish intensive care units / Impacto del consumo de riesgo de alcohol en la sedación de pacientes críticos en ventilación mecánica: Estudio observacional prospectivo, multicéntrico en 8 unidades de cuidados intensivos (UCI) Españolas

PURPOSE: To evaluate the impact of a history of harmful use of alcohol (HUA) on sedoanalgesia practices and outcomes in patients on mechanical ventilation (MV). METHODS: A prospective, observational multicentre study was made of all adults consecutively admitted during 30 days to 8 Spanish ICUs. Patients on MV > 24 h were followed-up on until discharge from the ICU or death. Data on HUA, smoking, the use of illegal (IP) and medically prescribed psychotropics (MPP), sedoanalgesia practices and their related complications (sedative failure [SF] and sedative withdrawal [SW]), as well as outcome, were prospectively recorded. RESULTS: A total of 23.4% (119/509) of the admitted patients received MV >24h; 68.9% were males; age 57.0 (17.9) years; APACHE II score 18.8 (7.2); with a medical cause of admission in 53.9%. Half of them consumed at least one psychotropic agent (smoking 27.7%, HUA 25.2%; MPP 9.2%; and IP 7.6%). HUA patients more frequently required PS (86.7% vs. 64%; p < 0.02) and the use of >2 sedatives (56.7% vs. 28.1%; p < 0.02). HUA was associated to an eightfold (p < 0.001) and fourfold (p < 0.02) increase in SF and SW, respectively. In turn, the duration of MV and the stay in the ICU was increased by 151h (p < 0.02) and 4.4 days (p < 0.02), respectively, when compared with the non-HUA group. No differences were found in terms of mortality. CONCLUSIONS: HUA may be associated to a higher risk of SF and WS, and can prolong MV and the duration of stay in the ICU in critical patients. Early identification could allow the implementation of specific sedation strategies aimed at preventing these complications

OBJETIVO: Evaluar el impacto del consumo enólico de riesgo (HUA) en las prácticas de sedoanalgesia y la evolución de pacientes en ventilación mecánica (MV). MÉTODOS: Estudio prospectivo observacional multicéntrico de todos los adultos ingresados consecutivamente durante 30 días en 8 UCIs españolas. Los pacientes en MV > 24h fueron evaluados hasta el alta de UCI o exitus. Se registró el HUA, consumo de tabaco, psicótropos ilegales (IP) o bajo prescripción médica (MPP) las prácticas de sedoanalgesia y sus complicaciones asociadas (Fracaso de Sedación/SF y Síndrome de Privación/SW) así como datos sobre la evolución clínica. Resultados: El 23.4% (119/509) de los ingresados, requirieron VM ≥ 24 h: Varones 68.9%; Edad 57.0 (17.9) años; APACHEII 18.8 (7.2); Ingreso por causa medica 53.9%. La mitad consumían al menos un psicotrópico (tabaco: 27.7%; HUA: 25.2%; PPM: 9.2%; PI: 7.6%). Los pacientes con HUA requirieron más frecuentemente PS (86.7% vs. 64%; p < 0.02) y doble sedación (56.7% vs. 28.1%; p < 0.02). El HUA se asoció a incidencias 8 (p < 0.001) y 4 (p < 0.02) veces superiores de SF y SW y prolongó en 151 (p < 0.02) horas y 4.4 (p < 0.02) días, el tiempo de VM y estancia media en UCI respectivamente respecto al grupo no-HUA. No se encontraron diferencias en la mortalidad. Conclusiones: El HUA podría asociarse a un mayor riesgo de SF y WS y prolongar los tiempos de MV y LOS en los pacientes críticos. Su identificación precoz permitiría implementar estrategias específicas de sedación orientadas a prevenir estas complicaciones

Retinal development in the gilthead seabream Sparus aurata.

The retinal development of the gilthead seabream Sparus aurata has been analysed from late embryonic development to juvenile stages using classical histological and immunohistological methods. Five significant phases were established. Phases 1 and 2 comprise the late embryonic and hatching stages, respectively. The results indicate that during these early stages the retina is composed of a single neuroblastic layer that consists of undifferentiated retinal progenitor cells. Phase 3 (late prolarval stage) is characterized by the emergence of the retinal layers and the appearance of neurochemical profiles in differentiating photoreceptors, amacrine and ganglion cells. Phases 4 and 5 comprise the late larval and juvenile stages. In these stages, all the retinal cell types can be detected immunohistochemically. All the maturational events described are first detected in the central retina and, as development progresses, spread to the rest of the retina following a central-to-peripheral gradient. The results of this study suggest that S. aurata is an altricial teleost species that hatches with a morphologically undifferentiated retina. The most relevant processes involved in retinogenesis occur during the late prolarval stage (phase 3).

Impact of harmful use of alcohol on the sedation of critical patients on mechanical ventilation: A multicentre prospective, observational study in 8 Spanish intensive care units.

PURPOSE: To evaluate the impact of a history of harmful use of alcohol (HUA) on sedoanalgesia practices and outcomes in patients on mechanical ventilation (MV). METHODS: A prospective, observational multicentre study was made of all adults consecutively admitted during 30 days to 8 Spanish ICUs. Patients on MV >24h were followed-up on until discharge from the ICU or death. Data on HUA, smoking, the use of illegal (IP) and medically prescribed psychotropics (MPP), sedoanalgesia practices and their related complications (sedative failure [SF] and sedative withdrawal [SW]), as well as outcome, were prospectively recorded. RESULTS: A total of 23.4% (119/509) of the admitted patients received MV >24h; 68.9% were males; age 57.0 (17.9) years; APACHE II score 18.8 (7.2); with a medical cause of admission in 53.9%. Half of them consumed at least one psychotropic agent (smoking 27.7%, HUA 25.2%; MPP 9.2%; and IP 7.6%). HUA patients more frequently required PS (86.7% vs. 64%; p<0.02) and the use of >2 sedatives (56.7% vs. 28.1%; p<0.02). HUA was associated to an eightfold (p<0.001) and fourfold (p<0.02) increase in SF and SW, respectively. In turn, the duration of MV and the stay in the ICU was increased by 151h (p<0.02) and 4.4 days (p<0.02), respectively, when compared with the non-HUA group. No differences were found in terms of mortality. CONCLUSIONS: HUA may be associated to a higher risk of SF and WS, and can prolong MV and the duration of stay in the ICU in critical patients. Early identification could allow the implementation of specific sedation strategies aimed at preventing these complications.

Granulomatosis de Wegener con anticuerpos anticitoplasma de neutrófilo frente a catepsina G / Wegener's granulomatosis with anti-neutrophil cytoplasmic antibodies against anti-cathepsin G antigen

La granulomatosis de Wegener pertenece al grupo de vasculitis de vaso pequeño asociadas a anticuerpos anticitoplasma de neutrófilo. Se caracteriza por inflamación granulomatosa y vasculitis necrosante que puede afectar a diversos órganos, principalmente cursa con afectación renal y de las vías respiratorias. Es una enfermedad rara en la infancia y el diagnóstico precoz es fundamental para el pronóstico a largo plazo de la enfermedad. La presencia de anticuerpos anticitoplasma de neutrófilo con patrón citoplasmático o de títulos elevados de anticuerpos antiproteinasa-3 ha sido actualmente incluida en los criterios diagnósticos de vasculitis en niños. En este artículo se presenta un caso de granulomatosis de Wegener en la infancia, con presencia de anticuerpos anticitoplasma de neutrófilo con patrón citoplasmático con ausencia de anticuerpos antiproteinasa-3 y presencia de niveles elevados de anticuerpos anticatepsina G, raramente asociados a granulomatosis de Wegener (AU)

Wegener’s granulomatosis belongs to the group of small vessel vasculitis associated with anti-neutrophil cytoplasmic antibodies characterized by granulomatous inflammation andnecrotising vasculitis in various organs with particular involvement of the upper and lower respiratory tracts and kidneys. Wegener’s granulomatosis is a rare disorder in childhood and early diagnosis of this disease is critical to the long-term prognosis of the disease. The presence of positive cytoplasmic antineutrophil cytoplasmic antibody staining or a high titre of proteinase 3 antibodies were added as new criteria of vasculitis in childhood. This article presents a case of Wegener’s granulomatosis, with the presence of anti-neutrophil cytoplasm antibodies with cytoplasmic pattern with absence of anti-proteinase 3 antibodies and presence of high levels of anti-cathepsin G antibodies, rarely described in Wegener’s granulomatosis (AU)

[Wegener's granulomatosis with anti-neutrophil cytoplasmic antibodies against anti-cathepsin G antigen]. / Granulomatosis de Wegener con anticuerpos anticitoplasma de neutrófilo frente a catepsina G.

Wegener's granulomatosis belongs to the group of small vessel vasculitis associated with anti-neutrophil cytoplasmic antibodies characterized by granulomatous inflammation and necrotising vasculitis in various organs with particular involvement of the upper and lower respiratory tracts and kidneys. Wegener's granulomatosis is a rare disorder in childhood and early diagnosis of this disease is critical to the long-term prognosis of the disease. The presence of positive cytoplasmic antineutrophil cytoplasmic antibody staining or a high titre of proteinase 3 antibodies were added as new criteria of vasculitis in childhood. This article presents a case of Wegener's granulomatosis, with the presence of anti-neutrophil cytoplasm antibodies with cytoplasmic pattern with absence of anti-proteinase 3 antibodies and presence of high levels of anti-cathepsin G antibodies, rarely described in Wegener's granulomatosis.

Hígado graso agudo del embarazo y síndrome HELLP: aspectos diagnósticos y terapéuticos / Acute fatty liver of pregnancy and HELLP syndrome: diagnostic and therapeutic aspects

HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) and acute fatty liver of pregnancy (AFLP), cause liver dysfunction in the third trimester of pregnancy and determine risk of maternal and fetal mortality. Many maternal complications can occur, including acute renal failure and coagulopathy. Early diagnosis, prompt delivery and adequate supportive care are the key to a good outcome in most of the patients. In some cases, despite an appropriate conventional management, the disease may progress to multiple organ dysfunction, progressive liver insufficiency or severe hepatic complications (subcapsular hematoma, liver rupture), requiring adjunctive medical therapy, such as plasma exchange, surgery or liver transplantation.

El síndrome HELLP (hemolysis, elevated liver enzymes, and low platelet count) y el hígado graso agudo del embarazo (acute fatty liver of pregnancy -AFLP), son causa de disfunción hepática en el tercer trimestre del embarazo y condicionan riesgo de mortalidad materna fetal. Se pueden presentar diversas complicaciones como insuficiencia renal aguda y coagulopatía, entre otras. El diagnóstico oportuno, la interrupción del embarazo y un manejo de sostén adecuado permiten sacar adelante a la mayoría de las pacientes. En algunos casos, a pesar de un manejo convencional adecuado, la enfermedad puede evolucionar con disfunción multiorgánica, insuficiencia hepática progresiva o complicaciones hepáticas graves (hematoma subcapsular, rotura hepática), requiriendo de terapia médica adyuvante, como la plasmaféresis, cirugía o incluso trasplante hepático.

Síndrome metabólico y trasplante hepático / Metabolic syndrome and liver transplantation

The metabolic syndrome is a common disorder in liver transplant recipients and a major risk factor for cardiovascular disease, one of the leading causes of death in the late post transplant period. The components of metabolic syndrome are often exacerbated by transplant specific factors, such as immunosuppression. In addition to cardiovascular disease, nonalcoholic fatty liver disease recurrent or de novo, and accelerated fibrosis in hepatitis C can also be considered as complications of metabolic syndrome post liver transplantation. Early recognition and aggressive management of metabolic syndrome can improve the survival of liver transplant recipients.

El síndrome metabólico es una entidad frecuente en los pacientes receptores de trasplante hepático y un importante factor de riesgo para las enfermedades cardiovasculares, una de las principales causas de muerte en el período post trasplante tardío. Los componentes del síndrome metabólico se encuentran frecuentemente exacerbados por factores propios del trasplante, como la terapia inmunosupresora. Además de la patología cardiovascular, la hepatopatía grasa no alcohólica recurrente o de novo, y la fibrosis acelerada en hepatitis por virus C se pueden considerar también complicaciones post trasplante hepático del síndrome metabólico. Un reconocimiento precoz y un manejo agresivo del síndrome metabólico pueden mejorar la sobrevida de los pacientes trasplantados hepáticos.

Serum concentrations of osteocalcin, procollagen type 1 N-terminal propeptide and beta-CrossLaps in obese subjects with varying degrees of glucose tolerance.

AIMS: To evaluate serum levels of osteocalcin (OC), procollagen type 1 N-terminal propeptide (P1PN) and beta-CrossLaps (beta-CTx) in obese subjects and their relationship with glucose metabolism parameters. SUBJECTS: Sixty-four obese patients classified according to their glucose tolerance. DESIGN: Case-control study. MEASUREMENTS: A 75-g oral glucose tolerance test was performed with determinations of glucose and insulin between 0 and 120 min. Serum concentrations of OC, P1PN and beta-CTx were quantified in baseline samples. RESULTS: Patients with type 2 diabetes (T2D, n = 24) exhibited OC serum levels (2·6 ± 1·0 nm) significantly lower than those found in subjects with normal glucose tolerance (NGT, n = 20, 3·9 ± 1·5 nm, P < 0·01). We found no significant differences in P1NP and beta-CTX levels among patients with NGT, prediabetes and T2D. Multiple regression analysis showed that serum OC concentration, but not P1NP or beta-CTx levels, was independently related to 2-h plasma glucose. CONCLUSION: Obese patients with T2D showed significantly reduced levels of OC in comparison with patients with lower degrees of glucose tolerance derangement. Our results also suggest that OC was the only bone marker independently related to the degree of glucose metabolism derangement in these patients.

Infecciones bacterianas en el paciente cirrótico / Bacterial infections in patients with cirrhosis

Las infecciones bacterianas constituyen una complicación frecuente y severa en pacientes cirróticos debido a la existencia de alteraciones inmunológicas diversas, traslocación bacteriana y una mayor respuesta inflamatoria. La producción aumentada de citoquinas proinflamatorias, óxido nítrico y otros mediadores favorece el desarrollo de otras complicaciones, tales como deterioro hemodinámico, insuficiencia renal y encefalopatía hepática. Los efectos hemodinámicos de los mediadores inflamatorios son capaces de acentuar las alteraciones de la circulación sistémica y renal propias de la cirrosis. La insuficiencia renal en pacientes con sepsis no relacionada a peritonitis bacteriana espontánea tiene mal pronóstico incluso en casos reversibles y el índice MELD pareciera ser un buen predictor en este sentido. Estudio recientes sobre encefalopatía hepática sugieren que la respuesta inflamatoria y sus mediadores pueden ser importantes en la modulación de los efectos del amonio sobre el cerebro en los pacientes con cirrosis. El diagnóstico y tratamiento oportuno de la infección permiten mejorar el pronóstico en estos pacientes. La relación entre infección y hemorragia digestiva es estrecha, fundamentando el uso de antibióticos profilácticos. El uso de albúmina en cirróticos con infecciones diferentes a peritonitis bacteriana espontánea no ha demostrado reducir la incidencia de insuficiencia renal ni la mortalidad.

Bacterial infections are a frequent and severe complication in cirrhotic patients due to the existence of multiple immune alterations, bacterial translocation and increased inflammatory response. Increased production of proinflammatory cytokines, nitric oxide and other mediators promotes the development of other complications such as hemodynamic deterioration, renal failure and hepatic encephalopathy. Hemodynamic effects of inflammatory mediators are able to increase changes of systemic and renal circulation, typical of cirrhosis. Renal failure in patients with sepsis unrelated to spontaneous bacterial peritonitis has a poor prognosis, even in reversible cases; MELD score might be a good predictor in this regard. Recent studies about hepatic encephalophaty suggest that inflammatory response and its mediators may be important in modulating the effect of ammonia on the brain of the cirrhotic patient. Early diagnosis and treatment of the infection can improve the prognosis in these patients. The relationship between infection and gastrointestinal bleeding is narrow, justifying the use of prophylactic antibiotics. The administration of albumin to patients with cirrhosis and infections other than spontaneous bacterial peritonitis has not shown to reduce the incidence of renal failure or mortality.

[Monitoring of pain. Recommendations of the Analgesia and Sedation Work Group of SEMICYUC]. / Monitorización del dolor. Recomendaciones del grupo de trabajo de analgesia y sedación de la SEMICYUC.

In critically ill patients, pain is frequently underestimated and so insufficiently managed. Psychological, haemodynamic and neuroendocrine responses, secondary to untreated pain, could produce morbidity and even increases in patient mortality. All members of the intensive care team must have abilities to assess and to manage pain. The evaluation of pain in the critically ill patient is very difficult but extremely important. Self-reported pain is the starting point for treatment. The pain scores recommended are, VAS (visual analogue scale) and NRS (numeric rating scale) in communicative patients and Campbell scale in uncommunicative patients. Adequate and regular patient assessment leads to improved pain control. Scores higher than 3 points should not be permitted. A pain-free Intensive Care Unit should be a quality standard healthcare aim.