Minor, Nonterpenoid Volatile Compounds Drive the Aroma Differences of Exotic Cannabis.

Cannabis sativa L. produces a wide variety of volatile secondary metabolites that contribute to its unique aroma. The major volatile constituents include monoterpenes, sesquiterpenes, and their oxygenated derivates. In particular, the compounds ß-myrcene, D-(+)-limonene, ß-caryophyllene, and terpinolene are often found in greatest amounts, which has led to their use in chemotaxonomic classification schemes and legal Cannabis sativa L. product labeling. While these compounds contribute to the characteristic aroma of Cannabis sativa L. and may help differentiate varieties on a broad level, their importance in producing specific aromas is not well understood. Here, we show that across Cannabis sativa L. varieties with divergent aromas, terpene expression remains remarkably similar, indicating their benign contribution to these unique, specific scents. Instead, we found that many minor, nonterpenoid compounds correlate strongly with nonprototypical sweet or savory aromas produced by Cannabis sativa L. Coupling sensory studies to our chemical analysis, we derive correlations between groups of compounds, or in some cases, individual compounds, that produce many of these diverse scents. In particular, we identified a new class of volatile sulfur compounds (VSCs) containing the 3-mercaptohexyl functional group responsible for the distinct citrus aromas in certain varieties and skatole (3-methylindole) as the key source of the chemical aroma in others. Our results provide not only a rich understanding of the chemistry of Cannabis sativa L. but also highlight how the importance of terpenes in the context of the aroma of Cannabis sativa L. has been overemphasized.

Pharmacokinetics of cefiderocol during extracorporeal membrane oxygenation: A case report.

Patients with extracorporeal membrane oxygenation (ECMO) support do frequently receive broad-spectrum antibiotics, due to the high frequency of infection by multidrug resistant microorganisms. The extracorporeal circuit can alter the pharmacokinetics (PK) of administered drugs, and in the case of antibiotics this may lead to treatment failure. Cefiderocol is a new cephalosporin that exhibits excellent in vitro activity against many multidrug-resistant (MDR) microorganisms, but there is no published data about the modifications of its PK in patients with ECMO support. Herein we report the results of a pharmacokinetic investigation of cefiderocol in a critically ill patient receiving extracorporeal respiratory support.

Impacto de la Pandemia de COVID-19 en un Hospital de agudos de segundo nivel. Factores asociados / Impact of the COVID-19 Pandemics in a Secondary Level Acute Care Hospital. Associated Factors

Objetivo: Describir el impacto, repercusiones y características de la transmisión del SARS-CoV-2 en un hospital de segundo nivel, con el fin de implantar estrategias de intervención que permitan disminuir la morbimortalidad asociada a la misma. Método: Se incluyó una muestra de 1.694 usuarios COVID-19 ingresados en un centro de segundo nivel con SARS-CoV-2 y 367 profesionales casos confirmados. El diseño del estudio fue observacional, mediante recogida de los resultados microbiológicos positivos de marzo de 2020 a junio de 2021. Principales resultados: El 1,7% del total de la muestra (1.694 casos ingresado) se consideró de origen nosocomial. Y el 1,4% de los 367 profesionales COVID-19. Conclusiones: La adquisición nosocomial del virus se tradujo en una mayor gravedad del cuadro y en el incremento de los días de estancia hospitalaria. El estricto cumplimiento de las medidas de control y vigilancia epidemiológica de los casos de COVID-19 ha permitido mejorar los resultados.(AU)

Aim: To describe the impact, implications, and characteristics of the transmission of SARS-CoV-2 in a second-level hospital, in order to implement intervention strategies that reduce the morbidity and mortality associated with it. Methods: A sample of 1,694 COVID-19 patients admitted to a second-level center with SARS-CoV-2 and 367 professional confirmed cases was included. The study design was observational, by collecting positive microbiological results from March 2020 to June 2021. Main Results: 1.7% of the total sample (1 694 admitted cases) were considered of nosocomial origin. And 1.4% of the 367 COVID-19 professionals. Conclusions: The nosocomial acquisition of the virus translated into a greater severity of the condition and an increase in the days of hospital stay. Strict compliance with the epidemiological surveillance and control measures for COVID-19 cases has improved results.(AU)

Clinical value of procalcitonin in critically ill patients infected by SARS-CoV-2.

Background Blood procalcitonin (PCT) levels usually increase during infectious diseases and might be helpful to differentiate bacterial from non-bacterial origin. COVID-19 patients could present co-infections at initial presentation in the Emergency Department and nosocomial infections during stay in the ICU. However, the published literature has not established whether PCT changes could aid in the diagnosis of infectious complication during the COVID-19 pandemic. Methods Retrospective, single-center, cohort study, including COVID-19 patients admitted between March and May 2020. The data were prospectively collected for department purposes; laboratory results were collected automatically at admission and during the whole patient admission. Results 56 patients were analyzed (female 32%, male 68%), 35 were admitted to ICU, and 21 received general ward care. 21 ICU patients underwent mechanical ventilation (88%), and 9 died during admission (26%). Non-survivors had higher initial blood PCT levels than survivors at ICU admission (p.

Vasopressin antagonist efficacy and safety in volume-overloaded critically ill patients: a new therapeutic alternative.

Objectives: To assess tolvaptan's efficacy and safety in critical care patients with volume overload. Methods: Prospective observational study. Twenty-eight patients in the recovery phase from multiple organ failure and with volume overload refractory to conventional therapy treated with tolvaptan were included. Results: Patients received an initial daily dose of 3.75 (n=1), 7.5 (n=8) and 15 (n=19) mg of tolvaptan. Median treatment duration was 2 days (range: 1 to 12). All patients presented an increase in 24 hours diuresis after the first dose (median increase from baseline (IQR)=1114 (285-1943) mL), with a median net daily fluid loss of 1007 mL (456-2380) mL after 24 hours. High diuretic efficacy (daily fluid loss higher than 0.5 L with tolvaptan first dose) was detected in 18 patients (64.3%). Initial hyponatraemia was present in 16 (57.1%) patients, while overly rapid correction with tolvaptan treatment occurred in two patients without clinical consequences. Two patients presented hypophosphataemia after treatment. Conclusion: Tolvaptan is an effective therapeutic option in critically ill patients with volume overload refractory to conventional diuretics. Further studies are required to evaluate its safety profile and its effect on short-term outcomes and mortality.

Mejora de los conocimientos sobre higiene de manos del personal sanitario tras un curso de formación del Hospital Universitario La Paz y sus percepciones sobre la higiene de manos / No disponible

OBJETIVOS: analizar el grado de conocimientos y las percepciones en higiene de manos de las personas involucradas en la asistencia sanitaria del Hospital Universitario La Paz. MATERIAL Y MÉTODOS: estudio cuasiexperimental. Durante el período 2016-2017 se empleó una encuesta de conocimientos y de percepciones en una muestra de 2614 sujetos, seguida de formación, tras la que se repitió la encuesta de conocimientos. Se realizaron las pruebas: ji-cuadrado y Test-T sobre los resultados de las encuestas de conocimientos, pre y post curso. Además, se realizó una regresión logística multivariante donde la variable dependiente era las puntuaciones excelentes (14-15 puntos) y las independientes el sexo, la edad y las categorías profesionales de mayor participación en la muestra. RESULTADOS: la puntuación media de la encuesta de conocimientos pre y post formación fue de 11,9 y 12,7 (p < 0,001), respectivamente. Ser mujer, tener entre 10 y 18 años de experiencia profesional y pertenecer a la categoría profesional de enfermería, se asoció a una mayor probabilidad de obtener una puntuación excelente (OR = 1,8 95%; IC = 1,3-2,4). Predominaron las percepciones favorables y la falta de tiempo se identificó como la principal causa de incumplimiento. «Descripción de un brote polimicrobiano en una unidad de cuidados intensivos durante la ola pandémica de COVID-19 de marzo 2020». CONCLUSIONES: el nivel de conocimientos en higiene de manos fue alto y mejoró mediante una actividad formativa en todo el personal. La sobrecarga laboral es un escollo importante para un buen cumplimiento de la higiene de manos

OBJECTIVES: to analyze the degree of knowledge and perceptions in hand hygiene of the people involved in health care at Hospital Universitario La Paz. MATERIAL AND METHODS: quasi-experimental study. During the period 2016-2017 a survey of knowledge and perceptions was carried out in a sample of 2,614 subjects. This was followed by training, after which the knowledge survey was repeated. The tests were performed: chi-square and Test-T on the results of the survey of knowledge, before and after the course. In addition, a multivariate logistic regression was performed and the dependent variable was excellent scores (14-15 points) and the independent variables were sex, age and the professional categories with the highest participation in the sample. RESULTS: the mean score of the pre and post training knowledge survey was 11.9 and 12.7 (p < 0.001), respectively. Being a woman, having between 10 and 18 years of professional experience and belonging to the professional category of nursing, was associated with a greater probability of obtaining an excellent score (OR = 1.8, 95%; IC 1,3-2,4). Favorable perceptions predominated and lack of time was identified as the main cause of noncompliance. CONCLUSIONS: the level of knowledge in hand hygiene was high and improved through a training activity for all staff. Work overload is a major stumbling block for good hand hygiene compliance

Hábito tabáquico entre los alumnos del IES Estuaria (Huelva) / Smoking habit among IES Estuaria (Huelva) students

OBJETIVO: Describir el hábito tabáquico entre los alumnos del Instituto de Educación Secundaria (IES) Estuaria de Huelva, con el fin de implantar estrategias de intervención que permitan la deshabituación voluntaria de los fumadores interesados y la concienciación de los no consumidores para evitar nuevas incorporaciones al consumo. PACIENTES Y MÉTODOS: La población objeto fueron los alumnos de ESO en el IES Estuaria del curso 2018-2019. La recogida de la información fue realizada mediante cuestionario en cada una de las clases, por personal sanitario entrenado para tal fin, en horario escolar. RESULTADOS: Del total de 211 alumnos de ESO con que cuenta el IES, han cumplimentado el cuestionario 195 (92,42%). La edad media del primer consumo, entre los 80 alumnos que manifiestan haberlo probado es de 12,13 años (DT 1,9). No existen diferencias significativas ente sexos a la hora de implantación del consumo (χ2: 0,231 ρ: 0,631), pero sí en cuanto a las perspectivas futuras de instauración del hábito, ya que el 59,6% de los hombres no prevén fumar en un futuro frente a 40,4% de las mujeres, mientras que de las personas que si prevén fumar el 58,5% son mujeres y el 41,5% hombres, con unas diferencias significativamente estadísticas (χ2: 5,01 ρ: 0,025) y un RR de 2,074 (IC 95% 1,091-3,944). Existe una asociación estadísticamente significativa entre los alumnos que conviven con fumadores habituales y las perspectivas futuras que tienen de convertirse a su vez en adictos (χ2: 7,71 ρ: 0,005), con un RR de 2,9 (IC 95% 1,35-6,3). Al valorar la asociación entre los fumadores habituales y el hecho de convivir o no con fumadores, los resultados nos muestran una asociación estadísticamente significativa (χ2: 5,48 ρ: 0,019) con un RR de 3,39 (IC 95% 1,07-10,68), ambas variables tienen 3,39 veces más posibilidades de presentarse unidas que separadas. CONCLUSIONES: En el ámbito educativo está plenamente justificada la necesidad de intervención, ya que es el espacio más adecuado para hacer prevención y promoción de la salud por ser el lugar donde mayor tiempo pasan y tienen constante interrelación con el grupo de iguales. Existen factores que no han sido reflejados como la instauración del hábito entre el grupo de iguales. Para posteriores estudios similares en otros centros educativos sería aconsejable tener en cuenta el consumo en "la pandilla" o de "los mejores amigos", como factores influyentes en los primeros contactos con el consumo de tabaco

OBJECTIVE: Describe the smoking habit among students of Secondary School (IES) Estuaria, in order to establish intervention strategies that make it possible for those smokers who want to undergo voluntary smoking cessation to do so and to raise awareness of those who do not smoke in order to avoid new incorporations to smoking. PATIENTS AND METHODS: The study population included students from Secondary School of the 2018-2019 course in the IES Estuaria. Information collection was made using a questionnaire in each one of the classes, administered by health care personnel who were trained for such purpose, independent of the Education Center during School hours. RESULTS: Out of a total of 211 students of secondary educations in the IES, 195 (92.42%) filled out the questionnaire. The mean age of the first consumption among the 80 students who stated they had tried it is 12.13 years (SD 1.9). There are no significant differences between genders in regards to initiation of smoking (χ2: 0.231 ρ: 0.631), however there is a difference in regards to the future perspectives of beginning the habit since 59.6% of the men do not foreseen that they will smoke in the future versus 40.4% of women while of those do, 58.5% are women versus 41.5% men, with statistically significant differences (χ2: 5.01 ρ: 0.025), with a RR of 2.074 (95% CI 1.091-3.944). There is a statistically significant association among students who live with usual smokers and the future perspectives that they have of becoming addicts (χ2: 7.71 ρ: 0.005), with a RR of 2.9 (95% CI 1.35-6.3). On evaluating the association between usual smokers and whether they live with smokers or not, the results show a statistically significant association (χ2: 5.48 ρ: 0.019), with a RR of 3.39 (95% CI 1.07-10.68). Both variables have 3.39 times more likelihood of occurring simultaneously than separately. CONCLUSIONS: In the educational setting, the need for intervention is fully justified since it is the best place to use prevention and promotion of health because it is where they spend the most time and where there is also a constant interrelationship with the peer group. Life together factor is a clearly differentiating element in regards to usual established smokers and in regards to the perspectives of the students as future smokers. The same does not occur in regards to the first consumers. There is discrepancy between dependence level and motivation level that may explain why the time period as smokers in these ages is still short and why they have still not shown health problems that could lead to motivational elements to quit

Galería de imágenes en el sitio web de Ciencias Médicas de Sancti Spíritus / Gallery of images in the web site of Medical Sciences University of Sancti Spíritus

Fundamento: La mayoría de los sitios web utilizan galerías de imágenes para mostrar sus productos y servicios, la página web del Centro Provincial de Información de Ciencias Médicas de Sancti Spíritus no tenía una galería de imágenes médicas donde los profesionales de la salud pudieran compartir, organizar y preservar el patrimonio fotográfico de las Ciencias Médicas del territorio. Objetivo: Proponer una Galería de imágenes en el sitio web del Centro Provincial de Información de Ciencias Médicas de la de Sancti Spíritus. Desarrollo: Para el diseño de esta Galería se utilizó el sistema de gestión de contenidos Drupal porque es totalmente gratuito, personalizable, muy potente y flexible, incorpora las funcionalidades más comunes, es prácticamente un estándar "de facto", facilita la internacionalización, facilita la escalabilidad, el sistema implementado constituye un medio idóneo para lograr el acceso abierto a las imágenes médicas. Conclusiones: La Galería de imágenes médicas del sitio web es una fuente de consulta para los profesionales de la salud, esta contribuye a la actividad docente, asistencial e investigadora de los profesionales.

Background: Most of the web sites use galleries of images to show their products and services, the web site of the Provincial Center of Information of the Medical Sciences University of Sancti Spíritus didn't have a gallery of medical images where the professionals of the health could share, organize and preserve the photographic patrimony of the Medical Sciences in the territor. Objective: To propose a Gallery of images in the web site of the Provincial Center of Information of Medical Sciences University of Sancti Spíritus. Development: For the design of this Gallery the system of administration of contained Drupal was used because it is completely free, customizable, very potent and flexible, it incorporates the most common functionalities, it is practically a standard "of facto", it facilitates the internationalization, it facilitates the scalability, the implemented system constitutes a suitable mean to achieve the open access to the medical images Conclusions: The Gallery of medical images of the web site is a consultation source for the professionals of the health, it contributes to educational, assistance activity and investigative of professionals.

Galería de imágenes en el sitio web de Ciencias Médicas de Sancti Spíritus / Gallery of images in the web site of Medical Sciences University of Sancti Spíritus

La mayoría de los sitios web utilizan galerías de imágenes para mostrar sus productos y servicios, la página web del Centro Provincial de Información de Ciencias Médicas de Sancti Spíritus no tenía una galería de imágenes médicas donde los profesionales de la salud pudieran compartir, organizar y preservar el patrimonio fotográfico de las Ciencias Médicas del territorio. Objetivo: Proponer una Galería de imágenes en el sitio web del Centro Provincial de Información de Ciencias Médicas de la de Sancti Spíritus. Desarrollo: Para el diseño de esta Galería se utilizó el sistema de gestión de contenidos Drupal porque es totalmente gratuito, personalizable, muy potente y flexible, incorpora las funcionalidades más comunes, es prácticamente un estándar “de facto”, facilita la internacionalización, facilita la escalabilidad, el sistema implementado constituye un medio idóneo para lograr el acceso abierto a las imágenes médicas. Conclusiones: La Galería de imágenes médicas del sitio web es una fuente de consulta para los profesionales de la salud, esta contribuye a la actividad docente, asistencial e investigadora de los profesionales(AU)

Most of the web sites use galleries of images to show their products and services, the web site of the Provincial Center of Information of the Medical Sciences University of Sancti Spíritus didn't have a gallery of medical images where the professionals of the health could share, organize and preserve the photographic patrimony of the Medical Sciences in the territory. Objective: To propose a Gallery of images in the web site of the Provincial Center of Information of Medical Sciences University of Sancti Spíritus. Development: For the design of this Gallery the system of administration of contained Drupal was used because it is completely free, customizable, very potent and flexible, it incorporates the most common functionalities, it is practically a standard "of facto", it facilitates the internationalization, it facilitates the scalability, the implemented system constitutes a suitable mean to achieve the open access to the medical images. Conclusions: The Gallery of medical images of the web site is a consultation source for the professionals of the health, it contributes to educational, assistance activity and investigative of professionals(AU)

Circulating sclerostin and estradiol levels are associated with inadequate response to bisphosphonates in postmenopausal women with osteoporosis.

INTRODUCTION: The biological mechanisms associated with an inadequate response to treatment with bisphosphonates are not well known. This study investigates the association between circulating levels of sclerostin and estradiol with an inadequate clinical outcome to bisphosphonate therapy in women with postmenopausal osteoporosis. METHODS: This case-control study is based on 120 Spanish women with postmenopausal osteoporosis being treated with oral bisphosphonates. Patients were classified as adequate responders (ARs, n=66, mean age 68.2±8 years) without incident fractures during 5 years of treatment, or inadequate responders (IRs, n=54, mean age 67±9 years), with incident fractures between 1 and 5 years of treatment. Bone mineral density (DXA), structural analysis of the proximal femur and structural/fractal analysis of the distal radius were assessed. Sclerostin concentrations were measured by ELISA and 17ß-estradiol levels by radioimmunoassay based on ultrasensitive methods. RESULTS: In the ARs group, sclerostin serum levels were significantly lower (p=0.02) and estradiol concentrations significantly higher (p=0.023) than in the IRs group. A logistic regression analysis was performed, including as independent variables in the original model femoral fracture load, 25 hydroxyvitamin D, previus history of fragility fracture, sclerostin and estradiol. Only previous history of fragility fracture (OR 14.04, 95% CI 2.38-82.79, p=0.004) and sclerostin levels (OR 1.11, 95% CI 1.02-1.20, p=0.011), both adjusted by estradiol levels remained associated with IRs. Also, sclerostin concentrations were associated with the index of resistance to compression (IRC) in the fractal analysis of the distal radius, a parameter on bone microstructure. CONCLUSIONS: Sclerostin and estradiol levels are associated with the response to bisphosphonate therapy in women with postmenopausal osteoporosis.

High prevalence of undiagnosed vertebral fractures in patients suffering from hip fracture at their hospital admission: weak concordance among observers.

BACKGROUND: Vertebral fracture is often underdiagnosed. Patients with hip fracture may suffer from vertebral fracture without knowing it. The diagnosis of vertebral fracture is sometimes difficult because there is no consensus regarding the definition of osteoporotic vertebral fracture, and several indexes may be used to diagnose it and the concordance between several observers may not be optimal. OBJECTIVE: To study the concordance in the diagnosis of vertebral fracture done by three different doctors: an orthopedic surgeon, a radiologist, and a bone mineral metabolism expert. METHODS: A lateral thoracic-lumbar spine X-Ray was performed in 177 patients suffering from hip fracture to assess the presence or absence of vertebral fractures. Three different observers applied Genant's criteria for it. Concordance between observers was measured using Cohen's kappa coefficient. RESULTS: Patients suffering from hip fractures have undiagnosed vertebral fractures in a range that varies from 41.8 to 47.5% depending on the observer. The concordance in the diagnosis of vertebral fractures is quite low, ranging a Cohen's kappa coefficient from 0.43 to 0.55 and a percentage of concordance varying from 64 to 72%. The best concordance was found between observers 1 and 3. DISCUSSION: Depending on the observer who made the diagnosis, the prevalence of previously undiagnosed vertebral fractures in patients with HF varied widely. We selected three different observers to assess the possible differences in the diagnosis of vertebral fractures among these patients and using the same method (Genant's semi-quantitative assessment), surprisingly, there was little concordance among the three of them. CONCLUSION: Patients with hip fracture have high prevalence of undiagnosed vertebral fractures. The diagnosis of these fractures varies widely depending on the observers and the Cohen's kappa coefficient and percentage of concordance is rather low.

Spanish consensus on premature menopause.

INTRODUCTION: While we recognise that the term premature menopause is more accepted by most non-specialist health care providers and by the general population, 'primary ovarian insufficiency' (POI) is currently considered the most apposite term to explain the loss of ovarian function, because it better explains the variability of the clinical picture, does not specify definitive failure, and highlights the specific ovarian source. Its pathogenesis involves a congenital reduction in the number of primordial follicles, poor follicle recruitment, or accelerated follicular apoptosis. However, its cause is unknown in most cases. AIM: This guide analyses the factors associated with the diagnosis and treatment of POI and provides recommendations on the most appropriate diagnostic and therapeutic measures for women under 40 years of age who experience POI. METHODOLOGY: A panel of experts from various Spanish scientific societies related to POI (Spanish Menopause Society, Spanish Fertility Society, and Spanish Contraception Society) met to reach a consensus on these issues. RESULTS: Hormonal therapy (HT) is considered the treatment of choice to alleviate the symptoms of hypoestrogenism and to prevent long-term consequences. We suggest that HT should be continued until at least age 51, the average age at natural menopause. The best treatment to achieve pregnancy is oocyte/embryo donation. If a patient is to undergo treatment that will reduce her fertility, she should be informed of this issue and the available techniques to preserve ovarian function, mainly vitrification of oocytes.

Osteoporosis and metabolic syndrome according to socio-economic status, contribution of PTH, vitamin D and body weight: The Canarian Osteoporosis Poverty Study (COPS).

BACKGROUND: Poverty is associated with a great number of diseases, but the prevalence of vitamin D deficiency, secondary hyperparathyroidism and the potential association of osteoporosis, osteoporotic fractures and metabolic syndrome in this situation are less well known. OBJECTIVE: To evaluate the associations between poverty, bone density, fragility fractures and metabolic syndrome in a population of southern European postmenopausal women. Also, to assess the potential role of vitamin D and parathyroid hormone (PTH) levels in these associations. METHOD: Cross-sectional study was carried out in 1 250 postmenopausal Caucasian Spanish women. The socio-economic status of the participants was determined after a personal interview, according to the criteria of the Spanish Institute of Statistics. Participants were divided into two socio-economic levels: low (poverty) and medium or high socioeconomic level. The study protocol included a health questionnaire, a complete physical examination, lateral radiograph of the dorsal and lumbar spine and measurement of bone mineral density (BMD) at the lumbar spine (L2-L4) and proximal femur. Fasting blood was obtained to measure 25-hydroxy-vitamin D (25-OHD), intact PTH and selected biochemical variables. RESULTS: Low socio-economic status was associated with 25-OHD insufficiency, higher values of PTH, higher body weight and body mass index (BMI), lower values of BMD at the lumbar spine and a higher prevalence of fragility fractures, both vertebral and nonvertebral. Poverty was also associated with higher prevalence of metabolic syndrome, but this association was driven mainly by the higher BMI and not by poverty itself. Both vitamin D insufficiency and elevated PTH were consistently related to poverty and osteoporotic fractures. CONCLUSIONS: Poor postmenopausal women in southern Europe have a high prevalence of metabolic syndrome and osteoporotic fractures. Poverty was associated with higher BMI and metabolic syndrome on the one hand and, on the other, with 25OHD insufficiency, higher PTH levels and osteoporosis. 25OHD insufficiency and/or secondary hyperparathyroidism do not have a significant influence on the presence of metabolic syndrome in this population.

Discriminative ability of heel quantitative ultrasound in postmenopausal women with prevalent vertebral fractures: application of optimal threshold cutoff values using classification and regression tree models.

Quantitative ultrasound (QUS) of the heel has been proposed as a screening tool to evaluate the bone status and risk of osteoporotic fragility fractures. The aim of this study was to define threshold values that would maximize the predictive ability of QUS to discriminate subjects with vertebral fractures using the classification and regression trees (CART) models. A cross-sectional analysis was made of a cohort of 1,132 postmenopausal women with a mean age of 58 years. A total of 205 women (18.1 %) presented with a history of vertebral fracture. For all patients, a questionnaire of osteoporosis risk factors was given and measurements of the heel QUS and bone mineral density at the lumbar spine and the proximal femur, obtained by dual-energy X-ray absorptiometry (DXA), were made. Spinal radiographs were assessed for vertebral fractures. Sensitivity, specificity, predictive values, likelihood ratios, and receiver operator characteristics (ROC) curve QUS values were calculated using the optimal threshold identified in the CART models. Cutoff values calculated from best CART model (i.e., a QUS index >90.5 %) yielded a sensitivity of 80.3 % (95 % CI 69.2-88.1), a negative predictive value of 94 % (95 % CI 90.1-96.5), and a specificity of 68.8 % (95 % CI 63.3-73.8). This cutoff value would obviate the need to perform DXA in 32.8 % of the women of our population at risk for vertebral fractures. The area under the ROC curve of the best model was 0.8071. QUS was shown to discriminate between women with and without a history of vertebral fracture and constitutes a useful tool for assessing vertebral fracture risk. The application of decision trees (CART analyses) was helpful to define the optimal threshold QUS values.

Risk factors for prediction of inadequate response to antiresorptives.

Some patients sustain fractures while on antiresorptives. Whether this represents an inadequate response (IR) to treatment or a chance event has not been elucidated. We performed a study to identify which patients are more likely to fracture while on treatment. This is a multicentric, cross-sectional study of postmenopausal women on antiresorptives for osteoporosis in 12 Spanish hospitals, classified as adequate responders (ARs) if on treatment with antiresorptives for 5 years with no incident fractures or inadequate responders (IRs) if an incident fracture occurred between 1 and 5 years on treatment. Poor compliance, secondary osteoporosis, and previous anti-osteoporosis treatment other than the assessed were exclusion criteria. Clinical, demographic, analytical, dual-energy X-ray absorptiometry (DXA) variables, and proximal femur structure analysis (ImaTx™) and structural/fractal analyses of distal radius were performed. A total of 179 women (76 IRs; mean (SD): age 68.2 (9.0) years; 103 ARs, age 68.5 (7.9) years) were included. History of prior fracture (p = 0.005), two or more falls in the previous year (p = 0.032), low lumbar spine bone mineral density (BMD) (p = 0.02), 25 hydroxyvitamin D (p = 0.017), and hip ImaTx fracture load index (p = 0.004) were associated with IR. In the logistic regression models a fracture before treatment (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.47-8.82; p = 0.005) and levels of 25 hydroxyvitamin D below 20 ng/mL (OR, 3.89; 95% CI, 1.55-9.77; p = 0.004) significantly increased risk for IR, while increased ImaTx fracture load (OR, 0.96; 95% CI, 0.93-0.99; p = 0.006; per every 100 units) was protective, although the latter became not significant when all three variables were fitted into the model. Therefore, we can infer that severity of the disease, with microarchitectural and structure deterioration, as shown by previous fracture and hip analysis, and low levels of 25 hydroxy vitamin D carry higher risk of inadequate response to antiresorptives. More potent regimes should be developed and adequate supplementation implemented to solve this problem.

Discriminative ability of heel quantitative ultrasound in postmenopausal women with prevalent low-trauma fractures: application of optimal threshold cutoff values using CART models.

Quantitative ultrasound (QUS) of the heel has been proposed as a screening tool to evaluate the bone status and risk of osteoporotic fragility fractures. The aim of this study was to define threshold values of QUS that would maximize the predictive ability of this technique to discriminate subjects with fragility fractures. A cross-sectional analysis was made of a cohort of 1132 postmenopausal women with a mean age of 58 yr. A total of 361 women (31.9%) presented with a history of osteoporotic fracture. Most fractures (74.1%) were nonvertebral. For all patients, a questionnaire of osteoporosis risk factors and measurements of the heel QUS and bone mineral density at the lumbar spine and the proximal femur obtained by dual-energy X-ray absorptiometry (DXA) were assessed. Spinal radiographs were assessed for fractures and historical nonvertebral fragility fractures. Sensitivity, specificity, predictive values, likelihood ratios, and receiver operator characteristic (ROC) curve QUS values were calculated using the optimal threshold identified in the classification and regression trees (CART) models. Cutoff values calculated from the best CART model (i.e., a quantitative ultrasound index (QUI) greater than 88.5% in women aged 58 yr or older) yielded 88.8% (95% confidence interval [CI]: 81.4-93.5) for sensitivity, a negative predictive value of 93.8 (95% CI: 89.4-96.4), and 70.4% (95% CI: 64.6-75.7) for specificity. This cutoff value would obviate the need to perform DXA in 43.1% of the population. The area under the ROC curve of the best model was 0.8363 (95% CI: 0.8249-0.8477). In conclusion, QUS was shown to discriminate between women with and without a history of fragility fracture and constitutes a useful tool for assessing fracture risk. The application of decision trees (CART analyses) was helpful to define the optimal threshold QUS values.

Current evidence for recommendation of surgery, medical treatment and vitamin D repletion in mild primary hyperparathyroidism.

Management of patients with mild primary hyperparathyroidism (PHPT) has been widely discussed because most patients today do not have specific symptoms. While surgery is always an option, the recommendations for treatment have shifted, which mostly reflects changes in clinical practice. In this study, we aimed to evaluate evidence for the current recommendations concerning operation vs observation, repletion with vitamin D (VitD) and alternative medical management. Surgery is followed by normalisation of calcium and parathyroid hormone (PTH) and a decrease in bone turnover followed by an increase in bone mass. It is not known what the consequences would be for the frequency of fractures. Randomised studies have indicated beneficial effects of operation on quality of life (QoL), but the effects have been minor and inconsistent. Operation seems not to be superior to observation for cardiovascular risk factors. Although PHPT patients in average have slightly decreased plasma 25OH VitD, severe symptomatic VitD deficiency seems not to be a characteristic of PHPT patients in Europe. However, if present, we recommend VitD substitution before final decision on surgical treatment. It is unknown whether routine VitD supplementation should be offered preoperatively to all patients with mild PHPT or as part of long-term medical treatment. Targeted medical management could be an option for patients with contraindications to surgery. Antiresorptive therapy might be appropriate for patients with a low bone mass to prevent further bone loss. Calcimimetics could be tried to control serum calcium levels although there is no evidence of an effect on the hypercalcaemic symptoms or the QoL. Combined therapy with calcimimetics and alendronate could be considered for patients with hypercalcaemia and overt bone disease.