A two-stage predictive model to simultaneous control of trihalomethanes in water treatment plants and distribution systems: adaptability to treatment processes.

The trihalomethanes (TTHMs) and others disinfection by-products (DBPs) are formed in drinking water by the reaction of chlorine with organic precursors contained in the source water, in two consecutive and linked stages, that starts at the treatment plant and continues in second stage along the distribution system (DS) by reaction of residual chlorine with organic precursors not removed. Following this approach, this study aimed at developing a two-stage empirical model for predicting the formation of TTHMs in the water treatment plant and subsequently their evolution along the water distribution system (WDS). The aim of the two-stage model was to improve the predictive capability for a wide range of scenarios of water treatments and distribution systems. The two-stage model was developed using multiple regression analysis from a database (January 2007 to July 2012) using three different treatment processes (conventional and advanced) in the water supply system of Aljaraque area (southwest of Spain). Then, the new model was validated using a recent database from the same water supply system (January 2011 to May 2015). The validation results indicated no significant difference in the predictive and observed values of TTHM (R 2 0.874, analytical variance <17%). The new model was applied to three different supply systems with different treatment processes and different characteristics. Acceptable predictions were obtained in the three distribution systems studied, proving the adaptability of the new model to the boundary conditions. Finally the predictive capability of the new model was compared with 17 other models selected from the literature, showing satisfactory results prediction and excellent adaptability to treatment processes.

Optic neuritis in a traveler returning from Dominican Republic to Spain with dengue virus infection.

A search of medical literature will show that dengue infection is rarely linked to optic neuritis. Here we report the development of loss of vision in a female traveler who returned to Spain from the Caribbean after acquiring a dengue infection.

An unusual case of pancytopenia in a nonagenarian: visceral leishmaniasis.

Older patients referred for further investigation of pancytopenia is common in internal medicine and geriatric clinics and it is important to consider a wide range of underlying diagnoses. We present an unusual case of febrile pancytopenia in a nonagenarian who was diagnosed with visceral leishmaniasis. This is a rare and unusual diagnosis in nonagenarians, although the leishmaniasis is endemic on the Mediterranean coast of Spain. It is important to identify it because it is treatable and curable.

Characteristics and outcome in nonagenarians admitted in general internal medicine and other specialties.

UNLABELLED: To describe the characteristics of nonagenarians admitted to the surgical and medical divisions at a tertiary hospital and compare them with nonagenarians admitted to other hospital care services. METHODS: A retrospective study of all hospital discharge episodes via the registry of the Basic Minimum Data Set at the Hospital General Universitario de Alicante from January 2007 until December 2011. RESULTS: Of the 165,870 hospitalizations, 2461 (1.5%) were nonagenarians. The highest number of admitted nonagenarians was in the Division of General Internal Medicine (DGIM) (n=751), followed by the short stay unit (SSU) (n=633). The rate of nonagenarians per 100 admissions to the DGIM was 10.2, significantly higher than that of those admitted to the SSU (6.2) (p<0.001), the service of orthopedic and trauma surgery (2.2) (p<0.001), and other specialties. Females comprised 64.8% of the nonagenarians. Mortality was 17% for the nonagenarians admitted, while for those admitted to the DGIM it was 27.7%. Those hospitalized in the SSU had a lower risk of death during hospitalization (8.1%) (odds ratio [OR] 0.23, 95% confidence interval [CI] 0.16-0.32) and a greater risk of being admitted for diseases and disorders of the circulatory system (OR: 1.58, 95% CI: 1.22-2.05), particularly for heart failure and shock (OR: 1.82, 95% CI: 1.30-2.53), and being discharged with home hospitalization (OR: 8.05, 95% CI: 5.5-11.8). CONCLUSIONS: Nonagenarian patients represent a tenth of those admitted to the DGIM. The profile of nonagenarians admitted to the DGIM is different from other hospital services. Hospital mortality for nonagenarians admitted to the DGIM is high and superior to other hospital services.

Multicenter epidemiological and clinical study on imported Chagas diseases in Alicante, Spain.

Recently, there has been an increase in the number of patients with Chagas disease outside of areas that are generally considered endemic. The aim of this investigation is to describe the clinical profile of a series of patients with Chagas disease in Alicante, Spain, which is a province located on the coast of the Mediterranean Sea. This study was performed at four general hospitals in Alicante between January 2002 and May 2011. A total of 128 patients from seven countries were diagnosed with Trypanosoma cruzi. The main country of origin of these patients was Bolivia (n5101; 78.9%), and the median of age of these patients was 35 years (range: 0­72 years). Four (3.3%) patients were children under 14 years of age, and 81 (63.3%) were female. Polymerase chain reaction (PCR) was used to analyze 106 patients, 66.0% of whom demonstrated positive PCR results. Visceral involvement was diagnosed in 26.8%: 24.1% demonstrated cardiac involvement, 0.9% demonstrated gastrointestinal involvement, 0.9% demonstrated cardiac and gastrointestinal involvement, and 0.9% demonstrated involvement of the central nervous system. Syncope was found to be associated with cardiomyopathy (28.0% versus 5.2%) (odds ratio: 6.5; 95% confidence interval: 1.5­27.1). Seventy-six patients received treatment with benznidazole, of whom 57 (75.0%) completed the treatment course without significant adverse events and 17.1% discontinued benznidazole due to adverse events. In total, 50% of patients experienced documented adverse reactions. Among patients with positive PCR results before treatment, all demonstrated negative PCR results following treatment. In conclusion, majority of our patients were female Bolivians immigrants, one of four of our patients demonstrated cardiac involvement, and treatment tolerance was poor. It is important to improve the clinical and epidemiological knowledge of Chagas disease in nonendemic with additional multicenter studies in order to determine the magnitude of this problem and provide improved public health and health resource planning.

Primary percutaneous coronary intervention for ST-segment elevation acute myocardial infarction in nonagenarian patients: results from a Spanish multicentre registry.

AIMS: Data on primary percutaneous coronary intervention for ST-segment elevation in nonagenarian patients are very limited. Our aim was to evaluate the results of primary percutaneous coronary intervention in patients ≥ 90 years old with ST-segment elevation acute myocardial infarction. METHODS AND RESULTS: We conducted a multicentre registry focused on nonagenarians treated with percutaneous coronary interventions, gathering data from five tertiary centres in Spain. We included 38 patients with ST-segment elevation acute myocardial infarction who presented within 12 hours after symptoms onset and who were treated with primary percutaneous intervention. Mean age was 91.5 (90-98). Angiographic success was achieved in 90%, and TIMI 3 flow in 76% of cases. In-hospital mortality was 34.2%, concentrated in patients with major bleeding (100% vs. 31.4%), final TIMI flow grade <3 (71.4% vs. 22.7%), and Killip class > I at admission (53.3% vs. 21.7%). CONCLUSIONS: Primary percutaneous coronary intervention in nonagenarians with ST-segment elevation acute myocardial infarction is associated with high rate of successful recanalisation of the infarct-related artery. Mortality is concentrated in patients with severe bleeding during hospitalisation, heart failure at admission, and final TIMI flow <3.

Two-year follow-up of sirolimus-eluting stents for the treatment of proximal left anterior descending coronary artery stenosis.

INTRODUCTION: Sirolimus-eluting stents (SES) have demonstrated low target vessel revascularizations and low incidence of angiographic restenosis in several clinical scenarios. The aim of the present study was to assess the efficacy and safety of SES for the treatment of proximal left anterior descending coronary artery (pLAD) lesions. METHODS: Ninety-six patients with severe pLAD stenosis were enrolled. Angiographic and clinical follow-up were performed at 6 and 24 months, respectively. Death, myocardial infarction (MI), new target lesion revascularization (TLR), and target vessel failure (TVF) were registered. Clinical, angiographic, and procedural variables were analyzed to identify predictors of restenosis. RESULTS: Mean clinical follow-up was 858+/-158 days (26.5+/-8.3 months). Angiographic procedural success was 100%. Angiographic follow-up showed 8.4% of binary restenosis without edge-restenosis phenomenon. Late loss was 0.15+/-0.65 mm; 15.6% of patients had an adverse cardiac event, with 1% of death, 5.2% of MI, 6.3% of TLR, and 9.4% of TVF. At 2 years, the probabilities of cumulative TVF- and TLR-free survival were 90.6% and 93.7%, respectively. Interestingly, no adverse cardiac events were registered between the first and second years. Female gender (OR 10.7 CI 95%[1.7-66.7]) and in-stent restenosis (OR 8.2, CI 95%[1.2-56.4]) were found as independent predictors of binary restenosis. Advanced chronic renal failure showed a strong trend toward worse outcome in terms of binary restenosis (P=0.063). CONCLUSIONS: SES for the treatment of pLAD stenosis proved safe and effective in a long-term follow-up with low incidence of adverse cardiac events and restenosis. Female gender and in-stent restenosis were predictors of binary restenosis.

Arteritis de Takayasu en una paciente con enfermedad de Crohn / Takayasu arteritis in a patient with Crohn’s disease

No disponible

[Effect of maximum dose of atorvastatin on inflammation, thrombogenesis and fibrinolysis in high-risk patients with ischemic heart disease]. / Efecto de dosis máximas de atorvastatina en la inflamación, la trombogénesis y la función fibrinolítica en pacientes con cardiopatía isquémica de alto riesgo.

INTRODUCTION AND OBJECTIVES: It has been suggested that high doses of statins can be more effective in reducing the incidence of new cardiovascular events than conventional doses. The present study analyzed the effect of increasing the atorvastatin dose to 80 mg/day on indices of inflammation (C-reactive protein or CRP), thrombogenesis (prothrombin fragment [F1+2]) and fibrinolysis (tissue-type plasminogen activator antigen, t-PA, and its inhibitor PAI-1) in high-risk patients with ischemic heart disease. PATIENTS AND METHOD: We studied 27 patients with high-risk coronary heart disease who had lipid levels above those recommended despite treatment with atorvastatin at 40 mg/day. At baseline, patients were compared with 21 normocholesterolemic subjects without arteriosclerotic disease. Twenty-four patients were reevaluated 3 months after the atorvastatin dose was increased to 80 mg/day. RESULTS: The CRP, F1+2, t-PA and PAI-1 levels were significantly higher in patients than control subjects (all P<.05). After the atorvastatin dose was increased, significant reductions in CRP, F1+2, and PAI-1 levels were observed (P<.05). There was a significant positive correlation between the reduction in cholesterol level and that in F1+2 (r=0.43; P=.023). No other significant correlations were found. CONCLUSIONS: In a group of patient with high-risk heart disease and elevated lipid levels, increasing the atorvastatin dose led to significant improvements in inflammatory, thrombogenic, and hypofibrinolytic states.

Efecto de dosis máximas de atorvastatina en la inflamación, la trombogénesis y la función fibrinolítica en pacientes con cardiopatía isquémica de alto riesgo / Effect of maximum dose of atorvastatin on inflammation, thrombogenesis and fibrinolysisin high-risk patients with ischemic heart disease

Introducción y objetivos. Se ha indicado que la utilización de dosis altas de estatinas podría reducir la aparición de nuevos eventos cardiovasculares en comparación con las dosis convencionales. Nuestro objetivo fue estudiar el efecto del incremento de la dosis de atorvastatina (80 mg/día) en diferentes marcadores del sistema inflamatorio (proteína C reactiva [PCR]), hemostático (fragmento F 1+2 de la protrombina [F1+2]) y fibrinolítico(activador tisular del plasminógeno antigénico [t-PA] y suinhibidor [PAI-1]). Pacientes y método. Se estudió a 27 pacientes concardiopatía isquémica de alto riesgo que presentaban cifras lipídicas superiores a las recomendadas a pesar del tratamiento con 40 mg/día de atorvastatina. Se compararon con 21 sujetos normocolesterolémicos sin enfermedad arteriosclerótica conocida. Se revaluó a 24 pacientesa los 3 meses del incremento de la dosis. Resultados. Los pacientes presentaron cifras elevadas de PCR, F1+2, t-PA, y PAI-1 en comparación con el grupo control (en todos, las variables tuvieron un valor de p <0,05). Tras incrementar la dosis de atorvastatina se ob-servó una reducción de las cifras de PCR, F1+2 y PAI-1 (p< 0,05). Se observó una correlación positiva entre losporcentajes de reducción de colesterol y del F1+2 (r =0,46; p = 0,023), sin que se hallara otra correlación significativa entre los demás parámetros. Conclusiones. Al incrementar las dosis de atorvastatina a 80 mg/día se consigue una reducción de los estadosinflamatorios, trombógenicos e hipofibrinolíticos en un grupo de pacientes con cardiopatía isquémica de altoriesgo y cifras elevadas de lípidos a pesar del tratamientocon dosis de 40 mg/día de atorvastatina

Introduction and objectives. It has been suggestedthat high doses of statins can be more effective in reducing the incidence of new cardiovascular events than con-ventional doses. The present study analyzed the effect ofincreasing the atorvastatin dose to 80 mg/day on indicesof inflammation (C-reactive protein or CRP), thrombogenesis (prothrombin fragment [F1+2]) and fibrinolysis (tissue-type plasminogen activator antigen, t-PA, and its inhibitor PAI-1) in high-risk patients with ischemic heart disease. Patients and method. We studied 27 patients withhigh-risk coronary heart disease who had lipid levels above those recommended despite treatment with atorvastatin at 40 mg/day. At baseline, patients were compared with 21 normocholesterolemic subjects without arteriosclerotic disease. Twenty-four patients were reevaluated 3months after the atorvastatin dose was increased to 80 mg/day. Results.The CRP, F1+2, t-PA and PAI-1 levels weresignificantly higher in patients than control subjects (all P<.05). After the atorvastatin dose was increased, significant reductions in CRP, F1+2, and PAI-1 levels were ob-served (P<.05). There was a significant positive correla-tion between the reduction in cholesterol level and that in F1+2 (r=0.43; P=.023). No other significant correlationswere found. Conclusions. In a group of patient with high-risk heartdisease and elevated lipid levels, increasing the atorvastatin dose led to significant improvements in inflammatory, thrombogenic, and hypofibrinolytic states

[Acute myocardial failure in a young man: Q-fever myocarditis]. / Insuficiencia cardíaca aguda en varón joven: miocarditis por fiebre Q.

Coxiella burnetii myocarditis is a rare but severe clinical form of acute Q fever. We report the case of a 40-year-old man hospitalized for acute febrile syndrome. Forty-eight hours later, he presented dyspnea, orthopnea, and paroxysmal nocturnal dyspnea; cardiac auscultation revealed a third sound and echocardiography showed a diffusely hypokinetic and dilated left ventricle (30% ejection fraction). Serological studies showed antibodies against phase-II C. burnetii antigens (IgG titer 1:320 and IgM 1:50). The patient was treated with losartan, furosemide, and clarithromycin, resulting in rapid improvement. Six months after admission, the echocardiographic changes had completely disappeared.

Insuficiencia cardíaca aguda en varón joven: miocarditis por fiebre Q / Acute myocardial failure in a young man: Q-fever myocarditis

La miocarditis por Coxiella burnetii constituye una forma infrecuente pero grave de presentación de fiebre Q aguda.Presentamos un caso de miocarditis por fiebre Q en un varón de 40 años que ingresó con síndrome febril y a las 48 h comenzó con disnea, ortopnea y disnea paroxística nocturna, se detectó un tercer ruido cardíaco y la ecocardiografía reveló un ventrículo izquierdo dilatado con hipocinesia difusa y fracción de eyección del 30 por ciento. El estudio serológico puso de manifiesto anticuerpos frente antígenos en fase II de C. burnetii a título de IgG 1:320 e IgM 1:50. La evolución con tratamiento con losartán, furosemida y claritromicina fue favorable, y la ecocardiografía al cabo de 6 meses puso de manifiesto la resolución completa de las alteraciones (AU)

Dermatomiositis ampollosa asociada a enfermedad de Crohn / Bullous dermatomyositis associated with Crohn'disease

Presentamos una mujer de 46 años ingresada por disfagia, pérdida de fuerza, y erupción cutánea papuloeritematosa con formación de vesículas y ampollas. La determinación de enzimas musculares y el electromiograma confirmaron el diagnóstico de dermatomiositis. Ninguna de las exploraciones complementarias realizadas logró evidenciar la asociación de una neoplasia interna. Dos meses más tarde la paciente presenta un cuadro de rectorragia, dolor abdominal y fiebre. Se practicó colonoscopia y biopsia colóníca que fueron compatibles con una enfermedad de Crohn. Se presenta el caso y se revisa la formación de lesiones vesiculares en el curso de una dermatomiositis así como su asociación a enfermedad inflamatoria intestinal (AU)

Guías de práctica clínica de la Sociedad Española de Cardiología en valvulopatías / Guidelines of the Spanish Society of Cardiology on valve heart disease

Las enfermedades de las válvulas cardíacas, que siguen siendo una causa importante de morbimortalidad en todo el mundo, han sufrido cambios radicales desde hace 40 años, en que se implantaron las primeras prótesis. Estos cambios han sido propiciados por los avances científico-tecnológicos, pero también por la mejoría en las condiciones de vida de los países desarrollados. La disponibilidad de la penicilina para tratar las faringoamigdalitis estreptocócicas y un menor hacinamiento que el existente antaño han hecho de la fiebre reumática una rara entidad en los países desarrollados. Como contrapartida, han aparecido a lo largo de los años otras formas de afectación valvular. La etiología de algunas de estas valvulopatías (p. ej., la válvula mitral mixomatosa) sigue siendo desconocida; otras, como la estenosis valvular aórtica calcificada de tipo senil, parecen ser el tributo a pagar por el alargamiento en la expectativa de vida. Por lo que respecta al diagnóstico, la ecocardiografía se ha erigido en una poderosísima herramienta para visualizar los cambios anatómicos de las válvulas, interpretar los complejos trastornos hemodinámicos y valorar la repercusión sobre el ventrículo izquierdo. Además, la iteración de estas exploraciones incruentas ha permitido conocer mucho mejor la historia natural de las valvulopatías leves o moderadas y precisar más adecuadamente el momento idóneo de la intervención quirúrgica, sin esperar, en muchos casos, la aparición de sintomatología avanzada. Esto ha sido posible también por los grandes avances de la cirugía, que se pueden resumir en: a) la mejora de las técnicas de circulación extracorpórea y de la protección miocárdica; b) el perfeccionamiento de los sustitutos valvulares, tanto mecánicos como biológicos; c) la introducción de técnicas imaginativas para reparar las lesiones de la válvula mitral, y d) la utilización del eco transesofágico para valorar intraoperatoriamente la calidad de la reparación valvular. Paralelamente, la dilatación con catéter-balón de la válvula mitral estenótica ha surgido como alternativa a la comisurotomía mitral quirúrgica. Todos estos cambios, y otros muchos que no es posible referir en este resumen, hacen oportuno que revisemos el manejo actual del paciente portador de una valvulopatía (AU)