Clinical and economic burden of acute exacerbations of idiopathic pulmonary fibrosis: a prospective observational study in Spain (OASIS study).

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a fatal progressive lung disease entailing significant impairment in health-related quality of life (HRQoL) and high socioeconomic burden. The course of IPF includes episodes of acute exacerbations (AE-IPF) leading to poor outcomes. This study aimed to compare management, costs and HRQoL of patients with AE-IPF to patients without AE-IPF during one year in Spain. MATERIALS AND METHODS: In a 12-month, prospective, observational, multicenter study of IPF patients, healthcare resource use was recorded and costs related to AE-IPF were estimated and compared between patients with and without AE-IPF. HRQoL was measured with the St. George's Respiratory Questionnaire (SGRQ), EuroQoL 5 dimensions 5 levels questionnaire (EQ-5D-5L), EQ-5D visual analogue scale (EQ-VAS) and the Barthel Index. RESULTS: 204 IPF patients were included: 22 (10.8%) experienced ≥ 1 acute exacerbation, and 182 (89.2%) did not. Patients with exacerbations required more primary care visits, nursing home visits, emergency visits, hospital admissions, pharmacological treatments and transport use (p < 0.05 for all comparisons). Likewise, patients with exacerbations showed higher annual direct health AE-IPF-related costs. In particular, specialized visits, emergency visits, days of hospitalization, tests, palliative care, transport in ambulance and economic aid (p < 0.05 for all comparisons). Exploratory results showed that patients with AE-IPF reported a non-significant but substantial decline of HRQoL compared with patients without AE-IPF, although causality can be inferred. CONCLUSION: We observed significantly higher resource use and cost consumption and lower HRQoL among patients suffering exacerbations during the study. Thus, preventing or avoiding AE-IPF is key in IPF management.

Unravelling groundwater and surface water sources in the Esteros del Iberá Wetland Area: An isotopic approach.

In the Esteros del Iberá Wetland Area (EIWA, NE Argentina), the southern sector of the transboundary Guarani Aquifer System (SAG) is overlain by the Ramsar listed Iberá Wetlands and several rivers, that combined extend across 37,930 km2 and represent one of the largest freshwater systems on the South American continent. Previous hydrogeological studies encompassing the entire SAG proposed preferential discharge of groundwater of various origins and ages to the EIWA. In this study, a multi-tracer study using major ionic species, δ18O, δ2H and 222Rn was conducted in lagoons, rivers, wells, and boreholes in the EIWA to confirm if discharge from the transboundary SAG is contributing to the surface water system. End-member Mixing Analysis (EMMA) determined the existence of four main end-members: groundwater from the SAG, more saline groundwater from the deeper Pre-SAG, and two poorly mineralised end-members from shallow, Post-SAG. EMMA calculations clearly illustrated complex binary and ternary mixing patterns involving the four end-members and highlighted the role of geological structures, specifically regional steep faults, in controlling the mixing patterns. 222Rn activities allowed in-situ identification of preferential deep groundwater discharge into both surface waters and shallow groundwaters. These findings provide strong evidence for the widespread existence of upward flows along major faults in this sector of the SAG, inducing complex mixing flow patterns and explaining the presence of old groundwater in shallow aquifers. Mapping the sources of water and the hydrological interactions are relevant for improving water balance estimates and develop management policies towards the preservation of these wetlands.

Identifying and quantifying geochemical and mixing processes in the Matanza-Riachuelo Aquifer System, Argentina.

The Matanza-Riachuelo River Basin, in the Northeast of the Buenos Aires Province, is one of the most industrialized and populated region in Argentina and it is worldwide known for its alarming environmental degradation. In order to prevent further damages, the aquifer system, which consists of two overlaid aquifers, is being monitored from 2008 by the river basin authority, Autoridad de la Cuenca Matanza-Riachuelo. The groundwater chemical baseline has been established in a previous paper (Zabala et al., 2016), and this one is devoted to the identification of the main physical and hydrogeochemical processes that control groundwater chemistry and its areal distribution. Thirty five representative groundwater samples from the Upper Aquifer and thirty four from the deep Puelche Aquifer have been studied with a multi-tool approach to understand the origin of their chemical and isotopic values. The resulting conceptual model has been validated though hydrogeochemical modeling. Most of the aquifer system has fresh groundwater, but some areas have brackish and salt groundwater. Water recharging the Upper Aquifer is of the Ca-HCO3 type as a result of soil CO2 and carbonate dissolution. Evapotranspiration plays a great role concentrating recharge water. After recharge, groundwater becomes Na-HCO3, mostly due to cation exchange with Na release and Ca uptake, which induces calcite dissolution. Saline groundwaters exist in the lower and upper sectors of the basin as a result of Na-HCO3 water mixing with marine water of different origins. In the upper reaches, besides mixing with connate sea water other sources of SO4 exist, most probably gypsum and/or sulfides. This work highlights the relevance of performing detailed studies to understand the processes controlling groundwater chemistry at regional scale. Moreover, it is a step forward in the knowledge of the aquifer system, and provides a sound scientific basis to design effective management programs and recovery plans.

Uso de la alitretinoína oral para el tratamiento del eczema crónico de manos grave y refractario al tratamiento en el sistema sanitario público español: descripción y análisis de la práctica clínica actual / Oral Alitretinoin in the Treatment of Severe Refractory Chronic Hand Eczema in the Spanish National Health System: Description and Analysis of Current Clinical Practice

INTRODUCCIÓN: El eczema de manos (ECM) afecta a cerca del 10% de la población, presentándose entre el 5 y el 7% de los casos como una enfermedad crónica grave y siendo refractario al tratamiento con corticoides tópicos entre el 2 y el 4% de las veces. El propósito del artículo es describir el uso de la alitretinoína oral en pacientes con ECM refractario a corticoides tópicos potentes en el ámbito sanitario público español. MATERIAL Y MÉTODOS: Estudio observacional descriptivo, exploratorio, transversal, basado en la revisión retrospectiva de historias clínicas de pacientes con ECM en tratamiento con alitretinoína en el ámbito sanitario público español. RESULTADOS: Se revisaron 62 historias clínicas de pacientes de 13 centros distribuidos en 5 comunidades autónomas del territorio español. Alitretinoína se utilizó predominantemente a dosis de 30mg/día, principalmente en un único ciclo, tras el cual la mayoría de pacientes lograron una respuesta clínica satisfactoria según el juicio médico. Los eventos adversos fueron todos previsibles y en línea con los tratamientos sistémicos con retinoides. Los dermatólogos estuvieron de acuerdo en que los beneficios clínicos logrados con alitretinoína favorecían la adherencia al tratamiento y una reincorporación más rápida de los pacientes al trabajo. CONCLUSIÓN: Los resultados muestran un uso de alitretinoína oral en línea con las recomendaciones establecidas así como la buena respuesta al tratamiento asociado y los pocos efectos adversos. Los dermatólogos coinciden que los beneficios alcanzados favorecen la adherencia al tratamiento y mejoran la calidad de vida relacionada con la salud de los pacientes

BACKGROUND AND OBJECTIVE: Hand eczema affects nearly 10% of the population. The condition becomes severe and chronic in 5% to 7% of cases and is refractory to topical corticosteroids in 2% to 4%. This study aimed to describe the current use of oral alitretinoin in treating Spanish national health system patients with hand eczema that is refractory to potent topical corticosteroids. MATERIALS AND METHODS: Observational, descriptive, exploratory, cross-sectional study based on the retrospective analysis of records for patients with hand eczema treated with alitretinoin in the Spanish national health system. RESULTS: We reviewed the records for 62 patients in 13 hospitals in 5 different administrative areas (autonomous communities) of Spain. Alitretinoin was usually used at a dosage of 30mg/d. In most cases the physician judged the clinical response to be satisfactory after a single cycle. The recorded adverse effects were foreseeable and of the type reported for systemic retinoids. The dermatologists agreed that the clinical benefits achieved with alitretinoin favored adherence to treatment and an early return to work. CONCLUSIONS: The results show that oral alitretinoin is being used according to established recommendations and that response is good, with few adverse effects. The dermatologists agreed that the benefits favored adherence and improved the patients' health related quality of life

Oral Alitretinoin in the Treatment of Severe Refractory Chronic Hand Eczema in the Spanish National Health System: Description and Analysis of Current Clinical Practice.

BACKGROUND AND OBJECTIVE: Hand eczema affects nearly 10% of the population. The condition becomes severe and chronic in 5% to 7% of cases and is refractory to topical corticosteroids in 2% to 4%. This study aimed to describe the current use of oral alitretinoin in treating Spanish national health system patients with hand eczema that is refractory to potent topical corticosteroids. MATERIALS AND METHODS: Observational, descriptive, exploratory, cross-sectional study based on the retrospective analysis of records for patients with hand eczema treated with alitretinoin in the Spanish national health system. RESULTS: We reviewed the records for 62 patients in 13 hospitals in 5 different administrative areas (autonomous communities) of Spain. Alitretinoin was usually used at a dosage of 30mg/d. In most cases the physician judged the clinical response to be satisfactory after a single cycle. The recorded adverse effects were foreseeable and of the type reported for systemic retinoids. The dermatologists agreed that the clinical benefits achieved with alitretinoin favored adherence to treatment and an early return to work. CONCLUSIONS: The results show that oral alitretinoin is being used according to established recommendations and that response is good, with few adverse effects. The dermatologists agreed that the benefits favored adherence and improved the patients' health related quality of life.

Stressful life events severity in patients with first and recurrent depressive episodes.

BACKGROUND: Stressful life events are associated with depression and their role in first onset and recurrences is a promising but controversial perspective of research. The objective is to analyze the role of number of previous episodes and life events exposure in a large sample of primary care depressive patients taking into account life events severity. METHOD: 10,257 patients with DSM-IV criteria for a current single or recurrent major depressive episode were recruited by 2,056 general practitioners in a cross-sectional epidemiological study. Patients answered the Montgomery-Asberg Depression Rating Scale, the Patient Health Questionnaire and the Social Readjustment Rating Scale (SRRS). Stressful life events were categorized into three levels of severity (severe, moderate and mild). All relevant confounding variables were analyzed: age, gender, depression severity, somatic symptoms severity and length of episode. RESULTS: We found a significant positive correlation with number of episodes and depression severity. There was no significant correlation of SRRS scores with age, gender and length of episode. ANOVA exploring life events severity with regard to number of episodes showed statistically differences in SRRS total score, moderate life events and mild life events (F = 15.14, p < 0.001) but not for severe life events. CONCLUSIONS: Prevention and treatment strategies for recurrent depression need to manage life stressful events during mild and long-term periods and not just in the initial recurrences of the disease.

Medical comorbidity in recurrent versus first-episode depressive patients.

OBJECTIVE: This study compares the comorbidity of affective disorders and medical diseases in primary care patients with either a first or recurrent depressive episode. METHOD: A cross-sectional epidemiological study in primary care centres in Spain was designed. A total of 10,257 primary care patients suffering a DSM-IV major depressive episode (MDD) were analysed. Depression was assessed using the Montgomery-Asberg Depression Rating Scale (MADRS), and World Health Organization (WHO) medical diagnoses were provided by the patient's general practitioner according to medical records revised on the basis of radiology or laboratory test data. RESULTS: A total of 88.6% of recurrent patients and 71.1% of first-episode depressive patients reported a medical condition (aOR = 2.61, CI = 2.31-2.93). All medical conditions were more prevalent in the recurrent group than in first-episode group, and with the exception of myocardial infarction, psoriasis and migraine, all other crude ORs showed statistically significant differences between first- and recurrent episodes patients after adjusting for gender, age, education, socioeconomic status and body mass index (BMI). CONCLUSION: Recurrent depression is associated with a decrement in health that is significantly greater than in first-episode depression. Special attention needs to be paid to the physical health in the middle- and long-term management of patients with affective disorders.

Análisis del nivel de satisfacción profesional y de la visión de futuro de la medicina intensiva como especialidad / Analysis of levels of professional satisfaction and view of the future of critical care medicine as a speciality

Fundamento. Dos objetivos fundamentan este estudio: conocer el nivel de satisfacción profesional de los médicos adscritos a los servicios de medicina intensiva y averiguar cuál es la visión de futuro de la medicina intensiva como especialidad. Métodos. Mediante una encuesta realizada a 245 médicos intensivistas de un mismo ámbito territorial y contestada por 46, se describen y analizan las respuestas obtenidas en cuanto al nivel de satisfacción laboral, la organización del servicio de medicina intensiva, los valores de los profesionales y el posicionamiento estratégico de la especialidad. Se analizan las características consideradas más positivas y más negativas por sus profesionales. Resultados. El análisis del nivel de satisfacción profesional es en general positivo. Mayoritariamente existe un acuerdo con el modelo actual de organización del staff en los servicios de medicina intensiva. Aunque la actividad asistencial es considerada prioritaria, se valora de forma positiva la docencia e investigación. El modelo actual de la medicina intensiva no parece ser el más adecuado, y la mayoría está de acuerdo en aceptar planteamientos de cambio. Las características positivas de la medicina intensiva hacen referencia al propio enfermo crítico y a su atención global y continuada; así como al know-how de sus profesionales. Las características negativas se relacionan principalmente con el síndrome de burnout. Conclusiones. Factores internos característicos de la medicina intensiva condicionan el nivel de satisfacción profesional, pero éste se ve influido también por factores externos. Existe un deseo de adaptar la organización de la medicina intensiva al futuro de la especialidad, pero sin perder una serie de "privilegios" inherentes a la organización clásica de atención del enfermo crítico (AU)

Myocarditis: a rare complication during Legionella infection.

Legionella often causes systemic manifestations. The clinical spectrum now includes cardiac legionellosis. The first case of myocarditis was reported by Gross in 1981. To date few additional cases have been described. Myocardial involvement might be more frequent than supposed in legionnaires' disease.

ICU pneumonias: a multi-institutional study.

We conducted a prospective multi-institutional study of nosocomial and community-acquired pneumonias in 1378 patients admitted to the ICUs of six hospitals. We also investigated 1005 of these patients who were intubated and mechanically ventilated for a reason other than pneumonia, the risk of developing pneumonia, and the relationship between the incidence of pneumonia and the length of time during which the patients were mechanically ventilated. A bacteriologic diagnosis was made in 38% of the nosocomial and 21% of the community-acquired pneumonias. The total mortality rate was 40%; 47% of the patients with nosocomial and 17% of the patients with community-acquired pneumonias died. Because it was difficult to make an etiologic diagnosis in two-thirds of the cases, the treatment had to be based on an assumed causative organism.

Massive thyroxine intoxication: evaluation of plasma extraction.

Six patients were admitted after erroneous massive intake of levothyroxine (70-1200 mg over an interval of 2-12 days). All patients developed classical symptoms of thyrotoxicosis within 3 days of the first dose; five patients presented grade II-III coma and one became stuporous (days 7-10). Two patients developed left ventricular failure and three had arrhythmias (days 8-11). Total thyroid hormone levels in serum on admission ranged 935-7728 nmol/l for T4 (TT4) and 23-399 nmol/l for T3 (TT3). All patients received treatment with hydrocortisone and Propranolol. Propylthiouracil was also given in 3 cases. Extractive techniques (charcoal haemoperfusion and/or plasmapheresis) were initiated 8-14 days after the first dose of L-T4. The plasma disappearance rate (K) of TT4 with plasmapheresis was 30 times higher, on average, than under standard medical treatment (M). Also, K of TT4 under haemoperfusion was about five times higher than K under M. K changes for TT3 were higher under haemoperfusion than under plasmapheresis. Furthermore, extractive procedures shortened the average half life of TT4, (from 106.5 +/- 44.6 to 59.7 +/- 20.2 h, p less than 0.05).