Assessment of quality indicators in pediatric major outpatient surgery. Influence of the COVID-19 pandemic. / Evaluación de los indicadores de calidad en cirugía mayor ambulatoria pediátrica. Influencia de la pandemia por COVID-19.

INTRODUCTION: Major Outpatient Surgery (MOS) is an organizational and management model for surgical care that allows selected patients to be treated efficiently and safely. Our objective was to evaluate the quality of the different activities through standardized quality indicators, analyzing whether they have been modified during the COVID-19 pandemic. MATERIALS AND METHODS: An observational and comparative descriptive study of the quality indicators (QI) of MOS in our Pediatric Surgery Department from 2019 to 2020 was carried out. In accordance with the International Association for Ambulatory Surgery (IAAS) and the recommendations of the Spanish Ministry of Health and Consumer Affairs, we assessed the basic quality and the degree of family satisfaction of patients undergoing MOS. RESULTS: A total of 848 and 652 interventions were performed in 2019 and 2020, respectively, with a mean age of 6 and 7 years. 539 (ambulatory rate (AR) 63.6%) and 465 (AR 71.3%) MOS surgeries were conducted in 2019 and 2020. In 2019, the overall substitution rate (SR) was 96.8%, hospitalization rate (HR) was 1.67%, suspension rate was 5.94%, and readmission rate was 1.48%. In 2020, the overall IS was 98.3%, HR was 0.86%, suspension rate was 4.73%, and readmission rate was 1.72%. No differences were found in terms of satisfaction between 2020 and 2019. CONCLUSIONS: QI allow us to know and analyze the performance and results of the different management units. In our department, the COVID-19 pandemic has not reduced the quality of CMA care.

INTRODUCCION: La cirugía mayor ambulatoria (CMA) es un modelo de gestión de asistencia quirúrgica que permite tratar de forma eficiente y segura a pacientes seleccionados. Nuestro objetivo es evaluar la calidad de esta actividad a través de indicadores de calidad estandarizados, analizando si se han visto modificados durante la pandemia por COVID-19. MATERIAL Y METODOS: Estudio descriptivo observacional y comparativo entre 2019 y 2020 de los indicadores de calidad (IC) de CMA de nuestra unidad de Cirugía Pediátrica. De acuerdo con la International Association for Ambulatory Surgery (IAAS) y las recomendaciones del Ministerio de Sanidad y Consumo, valoramos los indicadores de calidad básicos para CMA, así como el grado de satisfacción de las familias de pacientes intervenidos en este régimen. RESULTADOS: En total 848 y 652 intervenciones realizadas en 2019 y 2020, respectivamente, con edad media de 6 y 7 años. 539 (índice de ambulatorización (IA) 63,6%) y 465 (IA 71,3%) cirugías en régimen de CMA en 2019 y 2020. En 2019, índice de sustitución (IS) global 96,8%, índice de hospitalización (IH) 1,67%, índice de suspensión 5,94% e índice de reingreso 1,48%. En el año 2020, IS global 98,3%, IH 0,86%, índice de suspensión 4,73% e índice de reingreso 1,72%. No hemos encontrado diferencias en el grado de satisfacción entre ambos años. CONCLUSIONES: Los IC permiten conocer y analizar el funcionamiento y los resultados de las distintas unidades de gestión. En nuestra Unidad, la pandemia por COVID-19 no ha reducido la calidad de la asistencia en régimen de CMA.

Evaluación de los indicadores de calidad en cirugía mayor ambulatoria pediátrica. Influencia de la pandemia por COVID-19 / Assessment of quality indicators in pediatric major outpatient surgery. Influence of the COVID-19 pandemic

Introducción. La cirugía mayor ambulatoria (CMA) es un modelo de gestión de asistencia quirúrgica que permite tratar de forma eficiente y segura a pacientes seleccionados. Nuestro objetivo es evaluar la calidad de esta actividad a través de indicadores de calidad estandarizados, analizando si se han visto modificados durante la pandemia por COVID-19. Material y métodos. Estudio descriptivo observacional y comparativo entre 2019 y 2020 de los indicadores de calidad (IC) de CMA de nuestra unidad de Cirugía Pediátrica. De acuerdo con la International Association for Ambulatory Surgery (IAAS) y las recomendaciones del Ministerio de Sanidad y Consumo, valoramos los indicadores de calidad básicos para CMA, así como el grado de satisfacción de las familias depacientes intervenidos en este régimen. Resultados. En total 848 y 652 intervenciones realizadas en 2019 y 2020, respectivamente, con edad media de 6 y 7 años. 539 (índice de ambulatorización (IA) 63,6%) y 465 (IA 71,3%) cirugías en régimen de CMA en 2019 y 2020. En 2019, índice de sustitución (IS) global 96,8%, índice de hospitalización (IH) 1,67%, índice de suspensión 5,94% e índice de reingreso 1,48%. En el año 2020, IS global 98,3%, IH 0,86%, índice de suspensión 4,73% e índice de reingreso 1,72%. No hemos encontrado diferencias en el grado de satisfacción entre ambos años. Conclusiones. Los IC permiten conocer y analizar el funcionamiento y los resultados de las distintas unidades de gestión. En nuestra Unidad, la pandemia por COVID-19 no ha reducido la calidad de la asistencia en régimen de CMA.(AU)

Introduction: ajor Outpatient Surgery (MOS) is an organizational and management model for surgical care that allows selected patients to be treated efficiently and safely. Our objective was to evaluate the quality of the different activities through standardized quality indicators, analyzing whether they have been modified during the COVID-19 pandemic. Materials and methods: An observational and comparative descriptive study of the quality indicators (QI) of MOS in our Pediatric Surgery Department from 2019 to 2020 was carried out. In accordance with the International Association for Ambulatory Surgery (IAAS) and the recommendations of the Spanish Ministry of Health and Consumer Affairs, we assessed the basic quality and the degree of family satisfaction of patients undergoing MOS. Results: A total of 848 and 652 interventions were performed in 2019 and 2020, respectively, with a mean age of 6 and 7 years. 539 (ambulatory rate (AR) 63.6%) and 465 (AR 71.3%) MOS surgeries were conducted in 2019 and 2020. In 2019, the overall substitution rate (SR) was 96.8%, hospitalization rate (HR) was 1.67%, suspension rate was 5.94%, and readmission rate was 1.48%. In 2020, the overall IS was 98.3%, HR was 0.86%, suspension rate was 4.73%, and readmission rate was 1.72%. No differences were found in terms of satisfaction between 2020 and 2019. Conclusions: QI allow us to know and analyze the performance and results of the different management units. In our department, the COVID-19 pandemic has not reduced the quality of CMA care.(AU)

Clavien-Dindo classification: a tool to assess complications following surgical treatment in children with acute appendicitis. / Clasificación de Clavien-Dindo. Herramienta para evaluar las complicaciones tras el tratamiento quirúrgico en niños con apendicitis aguda.

INTRODUCTION: In pediatrics, there are few standard criteria to classify and consolidate postoperative complications, particularly in appendectomy, where according to the literature, complications range from 5% to 30%. METHODS: A cross-sectional, observational, retrospective study of patients undergoing surgery as a result of suspected acute appendicitis (AA) from December 2018 to January 2020 was carried out. Complications were grouped and consolidated according to the Clavien-Dindo (CD) classification. Postoperative complications and factors involved were analyzed by conducting a bivariate and multivariate statistical study using SPSS statistical software, version 25. RESULTS: A total of 124 patients were studied. Mean age was 9 years (3-14 years). 62% were boys, and 38% were girls. All patients underwent appendectomy - 80.6% through laparotomy, and 19.4% through laparoscopy. 20% of patients had postoperative complications, which were grouped according to the CD classification (p = 0.002). Most complications were included in the CD I group (64%). Collections treated with antibiotic therapy were included in the CD II group (28%). Intra-abdominal collections requiring re-intervention for drainage purposes were included in the CD IIIb group (8%). The main factors driving complications were complicated AA (81% gangrenous and perforated) (p < 0.001) and progression time (80% > 24 h of progression) (p = 0.036), which increased mean hospital stay by 7 ± 4 days (p = 0.016). 137 ± 37 CRP levels were associated with plastron identification (p < 0.001), whereas 109 ± 19 CRP levels were associated with peritonitis (p < 0.001). CONCLUSIONS: The Clavien-Dindo classification allows post-appendectomy complications in pediatric surgery to be classified using a common language, by associating complication grade with treatment complexity.

INTRODUCCION: En pediatría hay pocos criterios estándares para clasificar y unificar las complicaciones postquirúrgicas y en particular en la apendicectomía, donde, según la literatura, las complicaciones varían de un 5-30%. METODOS: Realizamos un estudio retrospectivo, observacional tipo transversal de los pacientes intervenidos por sospecha de apendicitis aguda (AA) durante diciembre 2018 a enero 2020. Las complicaciones fueron agrupadas y unificadas según la clasificación de Clavien-Dindo (CD). Se analizan las complicaciones postoperatorias y factores implicados, aplicando estudio estadístico bivariante y multivariante según el programa estadístico SPSS versión 25. RESULTADOS: Un total de 124 pacientes incluidos. Edad media 9 años (3-14 años). 62% niños, 38% niñas. A todos se les realizó apendicectomía, el 80,6% apendicectomía abierta, 19,4% por laparoscopia. El 20% presentó algún tipo de complicación en el postoperatorio y fueron agrupadas según la clasificación de CD (p = 0,002). En CD I (64%) se incluyen la mayoría de las complicaciones, En el grupo CD II (28%) colecciones tratadas con antibioticoterapia. En el grupo CD IIIb (8%), colección intraabdominal que requirió reintervención para su drenaje. Los principales factores implicados en la aparición de complicaciones fueron: AA complicadas (81% gangrenosas y perforadas) (p < 0,001), tiempo de evolución (80% > 24 h de evolución) (p = 0,036) que incrementó la estancia media 7 ± 4 días (p = 0,016). El valor de proteína C reactiva (PCR) (137 ± 37) se relacionó con la identificación de plastrón (p < 0,001), y el valor de PCR (109 ± 19) con peritonitis (p < 0,001). CONCLUSIONES: La clasificación de Clavien-Dindo permite utilizar un lenguaje común para clasificar las complicaciones postapendicectomía en cirugía pediátrica, expresando el grado de estas según complejidad del tratamiento utilizado para su resolución.

Clasificación de Clavien-Dindo. Herramienta para evaluar las complicaciones tras el tratamiento quirúrgico en niños con apendicitis aguda / Clavien-Dindo classification: a tool to assess complications following surgical treatment in children with acute appendicitis

Introducción: En pediatría hay pocos criterios estándares para clasificar y unificar las complicaciones postquirúrgicas y en particular en la apendicectomía, donde, según la literatura, las complicaciones varían de un 5-30%.Métodos: Realizamos un estudio retrospectivo, observacional tipo transversal de los pacientes intervenidos por sospecha de apendicitis aguda (AA) durante diciembre de 2018 a enero de 2020. Las complicaciones fueron agrupadas y unificadas según la clasificación de Clavien-Dindo (CD). Se analizan las complicaciones postoperatorias y factores impli- cados, aplicando estudio estadístico bivariante y multivariante según el programa estadístico SPSS versión 25.Resultados: Un total de 124 pacientes incluidos. Edad media, 9 años (3-14 años). 62% niños, 38% niñas. A todos se les realizó apendicectomía, el 80,6% apendicectomía abierta, 19,4% por laparoscopia. El 20% presentó algún tipo de complicación en el postoperatorio y fueron agrupadas según la clasificación de CD (p = 0,002). En CD I (64%) se incluyen la mayoría de las complicaciones. En el grupo CD II (28%) colecciones tratadas con antibioticoterapia. En el grupo CD IIIb (8%), colección intraabdominal que requirió reintervención para su drenaje.Los principales factores implicados en la aparición de complicaciones fueron: AA complicadas (81% gangrenosas y perforadas) (p < 0,001), tiempo de evolución (80% >24 h de evolución) (p = 0,036) que incrementó la estancia media 7 ± 4 días (p = 0,016). El valor de proteína C reactiva (PCR) (137 ± 37) se relacionó con la identificación de plastrón (p < 0,001), y el valor de PCR (109 ± 19) con peritonitis (p < 0,001). Conclusiones: La clasificación de Clavien-Dindo permite utilizar un lenguaje común para clasificar las complicaciones postapendicectomía en cirugía pediátrica, expresando el grado de estas según complejidad del tratamiento utilizado para su resolución.

Introduction: In pediatrics, there are few standard criteria to classify and consolidate postoperative complications, particularly in appendectomy, where according to the literature, complications range from 5% to 30%. Methods. A cross-sectional, observational, retrospective study of patients undergoing surgery as a result of suspected acute appendicitis (AA) from December 2018 to January 2020 was carried out. Complications were grouped and consolidated according to the Clavien-Dindo (CD) classification. Postoperative complications and factors involved were analyzed by conducting a bivariate and multivariate statistical study using SPSS statistical software, version 25.Results: A total of 124 patients were studied. Mean age was 9 years (3-14 years). 62% were boys, and 38% were girls. All patients underwent appendectomy – 80.6% through laparotomy, and 19.4% through laparoscopy. 20% of patients had postoperative complications, which were grouped according to the CD classification (p = 0.002). Most complications were included in the CD I group (64%). Collections treated with antibiotic therapy were included in the CD II group (28%). Intraabdominal collections requiring reintervention for drainage purposes were included in the CD IIIb group (8%). The main factors driving complications were complicated AA (81% gangrenous and perforated) (p < 0.001) and progression time (80% >24 h of progression) (p = 0.036), which increased mean hospital stay by 7 ± 4 days (p = 0.016). 137 ±37 CRP levels were associated with plastron identification (p < 0.001), whereas 109 ± 19 CRP levels were associated with peritonitis (p < 0.001).Conclusions: The Clavien-Dindo classification allows post-appendec tomy complications in pediatric surgery to be classified using a common language, by associating complication grade with treatment complexity.

SARS-CoV-2 contact tracing among disadvantaged populations during epidemic intervals should be a priority strategy: results from a pilot experiment in Barcelona.

OBJECTIVES: The aim of this study was to trace contacts of coronavirus disease 2019 (COVID-19) hospitalised patients and determine the risk factors of infection in urban areas. STUDY DESIGN: Longitudinal analysis of contacts identified from index cases. METHODS: A contact tracing study was carried out in the Northern Metropolitan area of Barcelona, Spain, during the inter-epidemic lapse of May to July 2020, a period of low SARS-CoV-2 incidence. Index cases were notified from the referral hospital. Contacts were traced and followed up for 14 days. Reverse transcription polymerase chain reaction was performed on day 0 and day 14 for contacts. RESULTS: In total, 368 contacts were identified from 81 index cases (median of seven contacts per index case), from which 308 were traced successfully. The median age of contacts was 28 years, 62% (223 of 368) were men. During the follow-up period, 100 contacts tested positive for COVID-19 (32.5% [95% confidence interval {CI} = 27.3-38.0]), with a secondary infection rate of 48.3% (95% CI = 40.8-55.9) among housemates. Clusters of index and respective contacts tended to aggregate within disadvantaged neighbourhoods (P < 0.001), and non-national index cases (N = 28, 34.1%) resulted in higher secondary infection rates compared with nationals (51.0% [95% CI = 41.0-60.9] vs 22.3% [95% CI = 16.8-28.8]; P < 0.001). CONCLUSIONS: Disadvantaged communities experience a disproportionate burden of COVID-19 and may act as infection reservoirs. Contact tracing with a cross-cutting approach among these communities is required, especially during inter-epidemic periods.

Current aspects in sepsis approach. Turning things around.

The incidence and prevalence of sepsis depend on the definitions and records that we use and we may be underestimating their impact. Up to 60% of the cases come from the community and in 30-60% we obtain microbiological information. Sometimes its presentation is ambiguous and there may be a delay in its detection, especially in the fragile population. Procalcitonin is the most validated biomarker for bacterial sepsis and the one that best discriminates the non-infectious cause. Presepsin and pro-adrenomedullin are useful for early diagnosis, risk stratification and prognosis in septic patients. The combination of biomarkers is even more useful to clarify an infectious cause than any isolated biomarker. Resuscitation with artificial colloids has worse results than crystalloids, especially in patients with renal insufficiency. The combination of saline solution and balanced crystalloids is associated with a better prognosis. Albumin is only recommended in patients who require a large volume of fluids. The modern molecular methods on the direct sample or the identification by MALDI-TOF on positive blood culture have helped to shorten the response times in diagnosis, to optimize the antibiotic treatment and to facilitate stewardship programs. The hemodynamic response in neonates and children is different from that in adults. In neonatal sepsis, persistent pulmonary hypertension leads to an increase in right ventricular afterload and heart failure with hepatomegaly. Hypotension, poor cardiac output with elevated systemic vascular resistance (cold shock) is often a terminal sign in septic shock. Developing ultra-fast Point-of-Care tests (less than 30 minutes), implementing technologies based on omics, big data or massive sequencing or restoring "healthy" microbiomes in critical patients after treatment are the main focuses of research in sepsis. The main benefits of establishing a sepsis code are to decrease the time to achieve diagnosis and treatment, improve organization, unify criteria, promote teamwork to achieve common goals, increase participation, motivation and satisfaction among team members, and reduce costs.

Costs of outpatient parenteral antimicrobial therapy (OPAT) administered by Hospital at Home units in Spain.

The aim of this study was to assess the direct healthcare costs of outpatient parenteral antimicrobial therapy (OPAT) administered by Hospital at Home (HaH) units in Spain. An observational, multicentre, economic evaluation of retrospective cohorts was conducted. Patients were treated at home by the HaH units of three Spanish hospitals between January 2012 and December 2013. From the cost accounting of HaH OPAT (staff, pharmacy, transportation, diagnostic tests and structural), the cost of each outpatient course was obtained following a top-down strategy based on the use of resources. Costs associated with inpatient stay, if any, were estimated based on length of stay and ICD-9-CM diagnosis. There were 1324 HaH episodes in 1190 patients (median age 70 years). The median (interquartile range) stay at home was 10 days (7-15 days). Of the OPAT episodes, 91.5% resulted in cure or improvement on completion of intravenous therapy. The mean total cost of each infectious episode was €6707 [95% confidence interval (CI) €6189-7406]. The mean cost per OPAT episode was €1356 (95% CI €1247-1560), mainly distributed between healthcare staff costs (46%) and pharmacy costs (39%). The mean cost of inpatient hospitalisation of an infectious episode was €4357 (95% CI €3947-4977). The cost per day of inpatient hospitalisation was €519, whilst the cost per day of OPAT was €98, meaning a saving of 81%. This study shows that OPAT administered by HaH units resulted in lower costs compared with inpatient care in Spain.

Sentinel lymph node biopsy as a prognostic factor in non-metastatic colon cancer: a prospective study

Purpose. Around a third of node-negative patients with colon cancer experience a recurrence after surgery, suggesting poor staging. Sentinel lymph node techniques combined with immunochemistry could improve colon cancer staging. We prospectively assessed the effect of Sentinel node mapping on staging and survival in patients with non-metastatic colon cancer. Methods. An observational and prospective study was designed. 105 patients with colon cancer were selected. Patients were classified according to node involvement as: N1, with node invasion detected by the conventional techniques; up-staged, with node invasion detected only by sentinel node mapping; and N0, with negative lymph node involvement by both techniques. Five-year survival and disease-free survival rates were analysed. Multivariate regression analyses were performed to identify prognostic factors for disease-free and overall survival. Results. Sentinel node mapping was successfully applied in 78 patients: 33 % were N1; 24.5 % were up-staged (18 patients with isolated tumour cells and 1 patient with micrometastases); and 42.5 % were N0. N1 patients had the poorest overall 5-year survival (65.4 %) and 5-year disease-free survival (69.2 %) rates compared with the other two groups. No significant 5-year survival differences were observed between N0 patients (87.9 %) and up-staged patients (84.2 %). Conclusions. Patients up-staged after sentinel node mapping do not have a poorer prognosis than patients without node involvement. Detection of isolated cancer cells was not a poor prognosis factor in these patients (AU)

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Sentinel lymph node biopsy as a prognostic factor in non-metastatic colon cancer: a prospective study.

PURPOSE: Around a third of node-negative patients with colon cancer experience a recurrence after surgery, suggesting poor staging. Sentinel lymph node techniques combined with immunochemistry could improve colon cancer staging. We prospectively assessed the effect of Sentinel node mapping on staging and survival in patients with non-metastatic colon cancer. METHODS: An observational and prospective study was designed. 105 patients with colon cancer were selected. Patients were classified according to node involvement as: N1, with node invasion detected by the conventional techniques; up-staged, with node invasion detected only by sentinel node mapping; and N0, with negative lymph node involvement by both techniques. Five-year survival and disease-free survival rates were analysed. Multivariate regression analyses were performed to identify prognostic factors for disease-free and overall survival. RESULTS: Sentinel node mapping was successfully applied in 78 patients: 33 % were N1; 24.5 % were up-staged (18 patients with isolated tumour cells and 1 patient with micrometastases); and 42.5 % were N0. N1 patients had the poorest overall 5-year survival (65.4 %) and 5-year disease-free survival (69.2 %) rates compared with the other two groups. No significant 5-year survival differences were observed between N0 patients (87.9 %) and up-staged patients (84.2 %). CONCLUSIONS: Patients up-staged after sentinel node mapping do not have a poorer prognosis than patients without node involvement. Detection of isolated cancer cells was not a poor prognosis factor in these patients.

Peritoneal mast cell degranulation and gastrointestinal recovery in patients undergoing colorectal surgery.

BACKGROUND: Degranulation of peritoneal mast cells (MCs) induced by intestinal manipulation has been proposed as a pathophysiological factor in postoperative ileus (POI). We aimed to explore the relationship between peritoneal and colonic MC degranulation and gastrointestinal (GI) recovery following colectomy. METHODS: Patients undergoing elective laparoscopic cholecystectomy (using a laparoscope and small abdominal incisions, n = 14), and elective laparoscopic (n = 32) or open partial colectomy (through a large abdominal incision, n = 10) were studied. MC protease tryptase and chymase were studied in peritoneal fluid at the beginning, middle, and end of each surgical intervention. Density of MCs in colectomy samples were examined and oro-caecal transit time by breath test, GI function recovery by clinical composite endpoint GI-2 and association between MC proteases and clinical recovery. KEY RESULTS: Open and laparoscopic colectomy caused greater peritoneal release of tryptase and chymase (323.0 ng/mL [IQR: 53.05-381.4] and 118.6 ng/mL [IQR: 53.60-240.3]), than cholecystectomy (41.64 ng/mL [IQR: 11.17-90.93]) at the end of the surgical intervention. However, there were no differences between laparoscopic and open colectomy. Increased peritoneal protease release during surgery was observed in patients who developed POI after colectomy. CONCLUSIONS & INFERENCES: Colorectal surgery causes protease release from peritoneal MCs. Protease release does not differ between both types of colectomy (laparoscopy vs laparotomy). However, MC activation is increased in colectomy patients developing POI. Therefore, degranulation of peritoneal MCs as a factor contributing to human POI after colectomy might be considered in future studies as a target to avoid POI.

Comparación del perfil psicofisiológico de ansiedad entre deportes de equipo (baloncesto) y deportes individuales / No disponible

Diversas investigaciones mencionan que los cambios en la temperatura de la piel permiten inferir acerca de estados emocionales, por ejemplo que ansiedad enfría las manos y un estado de relajación les genera calor (Labbé, 2006; Estrada y Pérez, 2008). En las intervenciones con Biofeedback, se emplea el Perfil Psicofisiológico del sujeto, consistente en el registro de su actividad fisiológica bajo diferentes estados o condiciones (Pérez, 1997; Estrada, 2002) (AU)

Rectal diversion without colostomy in Fournier's gangrene.

Fournier's gangrene is a potentially fatal necrotizing fasciitis affecting the perineum and genital area. The usual treatment includes prompt surgical debridement and, in many cases, a diverting colostomy. We present two cases of Fournier's gangrene that were treated with extensive local debridement and rectal diversion with a new device for faecal matter management, avoiding the need for a colostomy.

Endothelial progenitor cells are reduced in refractory hypertension.

Circulating endothelial progenitor cells (EPCs) play a key role in the maintenance of endothelial homoeostasis and promote vascular repair. They may also be of predictive value for cardiovascular events. Reduced EPC number and functional activity have been associated with several cardiovascular risk factors, but their relationship with hypertension remains unclear. The objective of this study was to investigate if number and function of circulating EPCs are reduced in patients with refractory hypertension (RHT). Circulating EPCs (CD34+ CD133+/CD45+) were isolated from peripheral blood by flow cytometry in 39 RHT and 30 normotensive controls. EPC number was also determined in vitro after 7 days in culture. After age adjustment, EPC concentration was significantly reduced in RHT as compared with controls (mean (95% CI), 33.8 (18.1-49.6) vs 69.1 (50.7-87.5) EPCs per 10(5) peripheral mononuclear cells (MNCs), respectively; P=0.014). After in vitro culture, EPCs were also reduced in patients as compared with controls (mean (95% CI), 142.3 (49.5-235.0) vs 611.0 (480.2-741.8) EPCs per field, respectively, P<0.001). In multiple linear regression analysis, circulating EPCs were significantly reduced by 56.3% in RHT as compared with control (P=0.006), independently of all other known risk factors. Moreover, RHT had a high independent predictive value for lower EPC proliferation. The number of EPCs per field was reduced by 76.7% in RHT with respect to controls (P<0.001). In summary, the number of circulating EPCs after culture is reduced in patients with RHT, which may be related to the increased rate of endothelial dysfunction, atherosclerotic disease and cardiovascular events observed in this population.

Mechanisms controlling function in the clasp and sling regions of porcine lower oesophageal sphincter.

BACKGROUND: Characterization of functional differences between lower oesophageal sphincter (LOS) clasp and sling muscles might aid the development of more specific pharmacological and surgical approaches for the treatment of motility disorders. METHODS: Circular LOS strips from 25 adult pigs were studied in organ baths to compare the physiology of clasp and sling fibres. RESULTS: Sling strips developed greater tone than clasp fibres (mean(s.e.m.) 7.59(0.89) versus 4.72(0.67) g; P = 0.017). LOS tone was more dependent on extracellular calcium in clasp strips and on the activity of cholinergic enteric motor neurones (EMNs) in sling strips. The amplitude of maximal relaxation caused by electrical field stimulation (EFS, 3Hz) of EMNs was greater in clasp strips (mean(s.e.m.) 74.5(2.3) versus 58.1(2.2) per cent of tone; P < 0.001). EFS-induced relaxation was reduced in clasp fibres and fully blocked in sling fibres by nitrergic blockade with 10 micromol/l 1H-[1,2,4]oxadiazole-[4,3-alpha]quinoxalin-1-one (ODQ). The amplitude of EFS cholinergic responses was significantly greater in sling fibres. In the clasp region, relaxation caused by stimulation of EMNs with 100 micromol/l nicotine was reduced by ODQ. In sling fibres, nicotine induced relaxation at rest and cholinergic contraction following ODQ. CONCLUSION: Clasp and sling fibres of the porcine LOS show marked intrinsic functional differences. This should be considered when developing more specific approaches to human LOS motility disorders.

Cambios ontogénicos en la reactividad cardiovascular inducidos por los esteroides androgénicos / Changes otogenics in the reactivity cardiovascular induced by those androgenic steroids

La mayor incidencia epidemiológica de eventos cardiovasculares fatales en el hombre, comparado con la mujer ha sido objeto de numerosas investigaciones para determinar el grado de influencia de la testosterona, en este efecto. Es conocido el papel protector cardiovascular de los estrógenos. La protección cardiovascular por administración de estrógenos exógenos a la mujer postmenopáusica es de un 30-40 por ciento, al compararla con las que no los reciben. Sin embargo el papel de los andrógenos es menos conocido ha... sido menos estudiado. En algunos estudios con dosis muy altas, se han encontrado que los andrógenos producen un pérfil lipídico aterogénico, aumentan la LDL y reducen la HDL, sin embargo otros estudios han demostrado un efecto antiaterogénico. Por otra parte, la testosterona aumenta la adhesividad de los monocitos a las células endoteliales humanas y estas expresan con mayor intensidad la molécula de adhesión VCAM-1. Los macrófagos humanos ex vivo a la dihidrotestosterona captan más avidamente los lípidos, efecto que no es observado al ser expuestos a estrógenos. Se ha encontrado que la testosterona aumenta la respuesta vasodilatadora dependiente e independiente del endotelio, efecto que desaparece por efecto del humo del cigarrillo o por hipercolesterolemia experimental. Sin embargo, los resultados en relación a la vasodilatación son contradictorios, ya que la privación de andrógenos (quirúrgica o farmacológicamente) en pacientes con cáncer de próstata. Se desconocen los mecanismos moleculares por lo que las andrógenos causarían vasodilatación. Un mecanismo probable por la cual la testosterona produce vasodilatación es la apertura de canales de potasio porque el efecto es antagonizado por el cloruro de bario, un bloqueante de dichos canales. Adicionalmente, se ha reportado que la vasodilatación experimental producida por esteroides andrógenicos dependiente del endotelio, en ratas es bloqueada por L-NAME; lo que sugiere que esta respuesta es mediada por el óxido nítrico. El desarrollo ontogénico de la vasodilatación dependiente del endotelio en la rata revela que esta es similar en machos y en hembras al nacer y aumenta progresivamente hasta llegar a la maduración sexual en etapa adulta; sin embargo la vasodilatación independiente del endotelio se atenúa con el desarrollo de la hembra y en el macho dicha respuesta se incrementa hasta un máximo que coincide con el desarrollo sexual determinado por la testosterona

Biological screening of plants of the Venezuelan Amazons.

A total of 21 extracts derived from 17 different plant species collected in Venezuelan Amazons have been tested for the following biological activities: cardiovascular activity, brine shrimp lethality, and inhibitory effects on the hydrolysis of glucose-6-phosphate in intact and disrupted microsomes. Eight extracts diminished rat blood pressure with or without changes in heart rate. The fruit extract of Swartzia leptopetala and the leaf and twig extract of Connarus lambertii resulted in death of experimental animals. The majority of extracts (17 extracts) showed significant toxicity against Artemia salina. Concerning the hydrolysis of glucose-6-phosphate, better inhibitory effects were observed in intact microsomes than in disrupted ones for all the extracts, suggesting that these extracts intervene with variable potency in glucose-6-phosphate transport through the microsomal membrane.

Association of junctional adhesion molecule with calcium/calmodulin-dependent serine protein kinase (CASK/LIN-2) in human epithelial caco-2 cells.

We report here that junctional adhesion molecule (JAM) interacts with calcium/calmodulin-dependent serine protein kinase (CASK), a protein related to membrane-associated guanylate kinases. In Caco-2 cells, JAM and CASK were coprecipitated and found to colocalize at intercellular contacts along the lateral surface of the plasma membrane. Association of JAM with CASK requires the PSD95/dlg/ZO-1 (PDZ) domain of CASK and the putative PDZ-binding motif Phe-Leu-Val(COOH) in the cytoplasmic tail of JAM. Temporal dissociation in the junctional localization of the two proteins suggests that the association with CASK is not required for recruiting JAM to intercellular junctions. Compared with mature intercellular contacts, junction assembly was characterized by both enhanced solubility of CASK in Triton X-100 and reduced amounts of Triton-insoluble JAM-CASK complexes. We propose that JAM association with CASK is modulated during junction assembly, when CASK is partially released from its cytoskeletal associations.

The molecular organization of endothelial junctions and their functional role in vascular morphogenesis and permeability.

We review here our work on the molecular and functional organization of endothelial cell-to-cell junctions. The first part of the review is dedicated to VE-cadherin, characterized by our group few years ago. This protein is a member of the large family of transmembrane adhesion proteins called cadherins. It is endothelial cell specific and plays a major role in the organization of adherens junctions. Inactivation of VE-cadherin gene or in vivo truncation of its cytoplasmic tail leads to a lethal phenotype due to the lack of correct organization of the vasculature in the embryo. We found that the defect was due to apoptosis of endothelial cells, which became unresponsive to the survival signal induced by vascular endothelial cell growth factor. Our data indicate that VE-cadherin may act as a scaffolding protein able to associate vascular endothelial cell growth factor receptor and to promote its signaling. In the second part of the review we consider another protein more recently discovered by us and called junctional adhesion molecule (JAM). This protein is a small immunoglobulin which is located at tight junctions in the endothelium and in epithelial cells. Evidence is discussed indicating that JAM takes part in the organization of tight junctions and modulates leukocyte extravasation through endothelial intercellular junctions in vitro and in vivo. The general role of tight junctions in endothelial cells is also discussed.

[Analysis of internal notices to the emergency team of the medical area at a general hospital]. / Análisis de los avisos internos al equipo de guardia del área médica en un hospital general.

OBJECTIVE: To study the frequency and characteristics of the hospitalized patients medical emergencies. PATIENTS AND METHODS: We have collected daily the notice to the emergency room from patients hospitalized and we have analyzed the clinical and epidemiological characteristics. RESULTS: Three hundred forty-one notices were recorded. The daily mean was higher on holidays. There were mostly medical problems (78%). Complementary explorations were performed in the 44% of the patients, and in the 77% the treatment was changed. CONCLUSIONS: The in-patient emergencies account for an important charge of work for the emergency team and involve important diagnosis and therapeutic decisions.

Homophilic interaction of junctional adhesion molecule.

Junctional adhesion molecule (JAM) is an integral membrane protein that belongs to the immunoglobulin superfamily, localizes at tight junctions, and regulates both paracellular permeability and leukocyte transmigration. To investigate molecular determinants of JAM function, the extracellular domain of murine JAM was produced as a recombinant soluble protein (rsJAM) in insect cells. rsJAM consisted in large part of noncovalent homodimers, as assessed by analytical ultracentrifugation. JAM dimers were also detected at the surface of Chinese hamster ovary cells transfected with murine JAM, as evaluated by cross-linking and immunoprecipitation. Furthermore, fluid-phase rsJAM bound dose-dependently solid-phase rsJAM, and such homophilic binding was inhibited by anti-JAM Fab BV11, but not by Fab BV12. Interestingly, Fab BV11 exclusively bound rsJAM dimers (but not monomers) in solution, whereas Fab BV12 bound both dimers and monomers. Finally, we mapped the BV11 and BV12 epitopes to a largely overlapping sequence in proximity of the extracellular amino terminus of JAM. We hypothesize that rsJAM dimerization induces a BV11-positive conformation which in turn is critical for rsJAM homophilic interactions. Dimerization and homophilic binding may contribute to both adhesive function and junctional organization of JAM.