Hallazgos clínicos asociados con una descarga hemodinámica del ventrículo izquierdo incompleta en pacientes con asistencia ventricular izquierda / Clinical findings associated with incomplete hemodynamic left ventricular unloading in patients with a left ventricular assist device

Introducción y objetivos Los efectos hemodinámicos del dispositivo de asistencia ventricular izquierda de flujo continuo (DAVI-fc) en la descarga hemodinámica del ventrículo izquierdo (DHVI) y los factores clínicos que interfieren en su optimización no están bien definidos. Métodos Se estudió de manera retrospectiva la prevalencia de altas presiones capilares enclavadas (hPCWP) del ventrículo izquierdo en 104 pacientes cuyos parámetros del DAVI-fc se optimizaron siguiendo las actuales recomendaciones clínicas. Asimismo se analizó el valor de diferentes variables clínicas, hemodinámicas y ecocardiográficas para predecir el grado de DHVI en pacientes ambulatorios portadores de un DAVI-fc. Resultados El 28% de los pacientes presentaron hPCWP. La edad, la presión venosa central y la ausencia de tratamiento con inhibidores del sistema renina-angiotesiona-aldosterona y péptido natriurético cerebral se asociaron con mayor riesgo de hPCWP. Los pacientes con DHVI óptima presentaron una disminución del diámetro indexado del ventrículo izquierdo del 15,2±14,7% en comparación con el 8,9±11,8% del grupo con hPCWP (p=0,041). El péptido natriurético cerebral <300 pg/ml predijo la ausencia de hPCWP con un valor predictivo negativo del 86% (p <0,0001). Conclusiones Una DHVI óptima es posible hasta en el 72% de los pacientes portadores de DAVI-fc cuando se siguen las actuales recomendaciones para la optimización de los parámetros del DAVI-fc. La edad, la presión venosa central y el tratamiento con inhibidores del sistema renina-angiotesiona-aldosterona tienen un efecto importante a la hora de lograr este objetivo. La concentración de péptido natriurético cerebral y la magnitud del remodelado inverso del ventrículo izquierdo son métodos no invasivos útiles para evaluar la DHVI (AU)

Introduction and objectives The effect of a centrifugal continuous-flow left ventricular assist device (cfLVAD) on hemodynamic left ventricular unloading (HLVU) and the clinical conditions that interfere with hemodynamic optimization are not well defined. Methods We retrospectively evaluated the likelihood of incomplete HLVU, defined as high pulmonary capillary wedge pressure (hPCWP)> 15mmHg in 104 ambulatory cfLVAD patients when the current standard recommendations for cfLVAD rotor speed setting were applied. We also evaluated the ability of clinical, hemodynamic and echocardiographic variables to predict hPCWP in ambulatory cfLVAD patients. Results Twenty-eight percent of the patients showed hPCWP. The variables associated with a higher risk of hPCWP were age, central venous pressure, absence of treatment with renin-angiotensin-aldosterone system inhibitors, and brain natriuretic peptide levels. Patients with optimal HLVU had a 15.2±14.7% decrease in postoperative indexed left ventricular end-diastolic diameter compared with 8.9±11.8% in the group with hPCWP (P=.041). Independent predictors of hPCWP included brain natriuretic peptide and age. Brain natriuretic peptide <300 pg/mL predicted freedom from hPCWP with a negative predictive value of 86% (P <.0001). Conclusions An optimal HLVU can be achieved in up to 72% of the ambulatory cfLVAD patients when the current standard recommendations for rotor speed setting are applied. Age, central venous pressure and therapy with renin-angiotensin-aldosteron system inhibitors had a substantial effect on achieving this goal. Brain natriuretic peptide levels and the magnitude of reverse left ventricular remodeling seem to be useful noninvasive tools to evaluate HLVU in patients with functioning cfLVAD (AU)

Effectiveness of a primary care nurse delivered educational intervention for patients with type 2 diabetes mellitus in promoting metabolic control and compliance with long-term therapeutic targets: Randomised controlled trial.

BACKGROUND: Systematic reviews and meta-analyses have shown very different values for the effectiveness of education in type 2 diabetes mellitus. However, the achievement of therapeutic targets after educational programs has been poorly evaluated. OBJECTIVE: Evaluate the effectiveness of a structured and individualised education program for type 2 diabetes, provided by a primary care nurse, which featured educational reinforcements and family support to achieve metabolic control, and long-term therapeutic targets. METHODS: Randomised controlled clinical trial with two arms: Intervention and control group. The intervention consisted of six face-to-face sessions of 30 min and follow-ups after 12 and 24 months for 236 participants with type 2 diabetes mellitus in a primary care setting in Andalusia (Spain). The primary outcome variables were the values and achievement of the type 2 diabetes mellitus control targets established by the American Diabetes Association: Glycated haemoglobin, fasting blood glucose, total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, triglycerides, systolic and diastolic blood pressure. The secondary outcome variable was body mass index. RESULTS: From an overall total of 236 participants, 54.2% were male and the average age was 65.1 ±â€¯9.5. After 12 months, the glycated haemoglobin level and systolic blood pressure decreased in the intervention group. After 24 months, the following variables significantly improved among the intervention group participants: basal glycemia, glycated haemoglobin, total cholesterol low-density lipoprotein cholesterol, and diastolic blood pressure. The glycated haemoglobin target (<7%) was better achieved in the intervention group than in the control group (35.2% vs 24.7%, p < 0.003). The rest of the targets were not met. CONCLUSION: Continual diabetes education with reinforcement sessions provided by a nurse achieved reductions in glycated haemoglobin, basal glycaemia, total cholesterol, low-density lipoprotein-cholesterol and systolic blood pressure in both the medium and long term. It also increased the proportion of participants who achieved the therapeutic target of glycated haemoglobin.

Sex disparity persists in the prevention of cardiovascular disease in women on statin therapy compared to that in men.

BACKGROUND AND AIMS: The aim of this study was to assess whether women differ from men with regard to lowering lipid levels, achieving target of optimal lipid levels, and analyzing evidence-based dose and intensity of statin prescription in primary care patients. METHODS AND RESULTS: A multicenter cross-sectional survey was conducted among 1046 patients with dyslipidemia (554 women) who were receiving statin therapy from the Primary Health Care of Andalucía (Spain). A random sample was obtained using data from the electronic health record system. The primary outcomes were the prescription of statin therapy (intensity and dose), lowering lipid levels, and achieving target of optimal lipid levels. Women were less likely to be treated with a more potent statin than men (9.2% vs. 14.4%, p = 0.009), and they received lower doses (45 ± 59 mg/day vs. 56 ± 71 mg/day, p = 0.004) than men. Total cholesterol and LDL-C levels were higher in women than in men (5.7 ± 1.3 mmol/l vs. 5.2 ± 1.2 mmol/l, p < 0.0001 and 3.5 ± 1.2 mmol/l vs. 3.1 ± 1.0 mmol/l, p < 0.0001, respectively). Compliance with established goals for total cholesterol (47.7% vs. 31.3%, p < 0.0001) and LDL-C (39.7% vs. 25.4%, p < 0.0001) was superior in men than in women. In multivariate analysis, adjusted for age, the variables male gender and CVD were associated with a higher compliance with total cholesterol and LDL-C target levels, and the variable diabetes mellitus 2 was associated with a lower compliance with HDL-C and triglycerides target levels. CONCLUSIONS: Women were less likely to be prescribed high-intensity statin to achieve total cholesterol and LDL-C target levels, and mean doses of statin were lower in women than in men. Dyslipidemia is less closely controlled in women than in men.

Mycobacterium abscessus pulmonary infection complicated with vertebral osteomyelitis in a heart transplant recipient: case report and literature review.

Infections produced by Mycobacterium abscessus are emerging in immunosuppressed patients, such as solid organ transplant recipients. We report the first case, to our knowledge, of a vertebral osteomyelitis caused by M. abscessus in a heart transplant recipient, and review the risk factors, manifestations, and therapeutic approaches to this uncommon disease.

Development and Evaluation of an Automated, Home-Based, Electronic Questionnaire for Detecting COPD Exacerbations.

Collaboration between patients and their medical and technical experts enabled the development of an automated questionnaire for the early detection of COPD exacerbations (AQCE). The questionnaire consisted of fourteen questions and was implemented on a computer system for use by patients at home in an un-supervised environment. Psychometric evaluation was conducted after a 6-month field trial. Fifty-two patients were involved in the development of the questionnaire. Reproducibility was studied using 19 patients (ICC = 0.94). Sixteen out of the 19 subjects started the 6 month-field trial with the computer application. Cronbach's alpha of 0.81 was achieved. In the concurrent validity analysis, a correlation of 0.80 (p = 0.002) with the CCQ was reported. The results suggest that AQCE is a valid and reliable questionnaire, showing that an automated home-based electronic questionnaire may enable early detection of exacerbations of COPD.

Use of non-invasive positive pressure ventilation in emergency departments of hospitals in Spain.

A survey was undertaken of the use of non-invasive ventilation (NIV) in Spain. 45.7% of emergency departments use NIV. The average time it has been in use is 4 years. Public hospitals use NIV more frequently (89.5%) as well as teaching hospitals (78.1%). Emergency physicians are the professionals who most frequently use NIV (68.8%). High flux continuous positive airway pressure (58.4%) and facial masks (63.5%) are most commonly used. Only 18.9% of hospitals have quality registration in NIV and 35.6% have protocols for using NIV. The method is underused by technicians working in hospital emergency services and there is a lack of uniform protocols with other departments involved.

Epidemiology of appendectomy and appendicitis in the Valencian community (Spain), 1998-2007.

BACKGROUND/AIMS: Our purpose was to study the incidence of appendectomy and appendicitis in the Valencian community (Spain) during a period of 10 years (1998-2007). METHODS: Data on discharge diagnoses of appendectomy and appendicitis were downloaded from all public hospitals in the Valencian community. RESULTS: We identified 44,683 cases of appendectomies and 42,742 cases of appendicitis (95.7%) during the study period. The age-standardized incidence rates among men ranked between 132.1 cases per 100,000 population in 2003 and 117.46 cases per 100,000 population in 2000 without a clear trend through the study period. The appendiceal perforation rate was 12.1% and the negative appendectomy rate 4.3%. The global mortality was 0.38%. CONCLUSIONS: The incidence of appendectomy in our community presents a slight descending trend. This decline is more intense in females. The appendix perforation rate is lower than in other studies. The death rate is similar to other studies; however, it is very low in patients of younger age.

Detection and survival of prion agents in aquatic environments.

Environmental contamination is considered a potential mechanism of transmission of prion diseases. Sheep scrapie and cervid chronic wasting diseases (CWD) epizootics are thought to be maintained by natural horizontal transmission through the environment. Here, we describe a method for the detection of prion proteins (PrPres) in aquatic environments. The procedure is based on a glycine buffer-mediated extraction, sonication, and an ultracentrifugation step. The detection limit of the method was estimated to be over 5-10 microg of infected tissue. In order to determine the inactivation of these agents, we spiked infected brain tissue in urban sewage, seawater and a buffered solution (final concentrations of 0.1-0.2% brain in matrix), and studied the decay of BSE- and scrapie-associated PrPres over time (up to 265 days). Densitometric data from Western blots were plotted in logarithmic scale against time. Reduction of PrPres titer in sewage was quantified in one logarithm after 13.5 days for BSE, 27.9 days for mouse-passaged scrapie and 32.6 days for sheep scrapie. In the buffered solution, a logarithm of BSE-associated PrPres also disappeared earlier than that of scrapie (113.9 and 214.3 days, respectively). By means of the covariance analysis, these differences in the inactivation patterns were shown to be statistically significant. According to the data, prions may be stable for extended periods of time in buffered solutions like PBS, but would show limited survival in aquatic environmental matrices.

Response of the exocrine pancreas to the CCK on offspring rats of ethanol dams. Effects of folic acid.

AIMS: The aim of this study was to study the reverse effect of folic acid administered during gestation and lactation to ethanol-treated dams, on cholecystokinin Cholecystokinin (CCK) stimulus-secretion coupling in pancreatic exocrine secretion in offspring rats. METHODS: Animals were randomized into three groups: Control group (C) received water and basic diet during pregnancy and lactation period; ethanol-treated rats (E) received ethanol and basic diet; the ethanol+folic acid group (EF) received folic acid supplement concomitantly with ethanol administration. RESULTS: Body and pancreatic weight was lower in offsprings after ethanol treatment. Folic acid supplementation increased these parameters with respect to ethanol rats. After CCK stimulation, a significant decrease in amylase, lipase and chymotrypsin activities in the duodenal juice were detected in ethanol, this trend was partially corrected with folate supplementation. CONCLUSION: Ethanol exerts its action on exocrine pancreatic secretion by two pathways: 'per se' and diminishing the folic acid content, because a folic acid supplement in rats during pregnancy and lactation periods produces an advantageous effect on amylase, lipase and chymotrypsin secretion in their offspring. Although extrapolation from animal studies may be tenuous, the present findings may explain the use of folic acid in the prevention of ethanol-induced damage by increasing the enzyme levels to adequate physiological concentrations.

Transgenic mice expressing bovine PrP with a four extra repeat octapeptide insert mutation show a spontaneous, non-transmissible, neurodegenerative disease and an expedited course of BSE infection.

Transgenic (Tg) mice carrying four extra octapeptide repeats (OR) in the bovine PrP gene (10OR instead of 6) have been generated. In these mice, neuropathological changes were observed depending upon the level of transgene expression. These changes primarily involved a slowly advancing neurological disorder, characterized clinically by ataxia, and neuropathologically, by vacuolization in different brain areas, gliosis, and loss of cerebellar granule cells. Accumulation of insoluble bovine 10OR-PrP (bo10OR-PrP) was observed depending on the level of expression but no infectivity was found associated with this insoluble form. We also compared the behavior of bo6OR-PrP and bo10OR-PrP Tg mouse lines in response to BSE infection. BSE-inoculated bo10ORTg mice showed an altered course of BSE infection, reflected by reduced incubation times when compared to bo6ORTg mice expressing similar levels of the wild type 6OR-PrP. In BSE-inoculated mice, it was possible to detect PrP(res) in 100% of the animals. While insoluble bo10OR-PrP from non-inoculated bo10ORTg mice was non-infectious, brain homogenates from BSE-inoculated bo10ORTg mice were highly infectious in all the Tg mouse lines tested. This Tg mouse model constitutes a new way of understanding the pathobiology of bovine transmissible spongiform encephalopathy. Its potential applications include the assessment of new therapies against prion diseases.

Different behavior toward bovine spongiform encephalopathy infection of bovine prion protein transgenic mice with one extra repeat octapeptide insert mutation.

In humans, insert mutations within the repetitive octapeptide region of the prion protein gene (Prnp) are often associated with familial spongiform encephalopathies. In this study, transgenic mice expressing bovine PrP (boTg mice) bearing an additional octapeptide insertion to the wild type (seven octapeptide repeats instead of six) showed an altered course of bovine spongiform encephalopathy (BSE) infection, reflected as reduced incubation times when compared with boTg mice expressing similar levels of the wild-type six-octapeptide protein. In both boTg mouse lines (bo6ORTg and bo7ORTg), incubation times were affected drastically depending on transgene expression levels and the inoculum used. In accordance with the lack of an interspecies barrier to BSE infection, we detected the typical signs of CNS spongiform degeneration by histopathological analysis and the presence of the bovine prion PrP(res) by Western blot or immunohistochemical analyses. When 7OR-PrP(res) was propagated in bo7ORTg mice, a similar earlier onset of clinical signs was observed compared with bo6ORTg mice. Proteins PrP(C) and PrP(res) containing seven octapeptides (7OR-PrP(C) and 7OR-PrP(res)) showed similar protease sensitivity and insolubility in nondenaturing detergents to homologous 6OR-PrP(C) and 6OR-PrP(res). In addition, bo7ORTg mice showed a higher sensitivity than bo6ORTg mice for detecting prion infection in specimens previously diagnosed as negative by conventional biochemical techniques. In the absence of clinical signs of disease, 7OR-PrP(res) could be detected as early as 120 d after inoculation by immunohistochemical and Western blot analyses. These findings may help us improve the current mouse bioassays and understand the role of the octapeptide repeat region in susceptibility to disease.

[Variation in the pathology attended in out-patient Neurology Clinics: a demented future]. / Variación en la patología atendida en las consultas de Neurología: un futuro demencial.

INTRODUCTION: We analyze the changes observed between 1996 and 2001 in the distribution of the pathology attended and the follow up model used by the out-patient Neurology Clinic in the Marina Alta area, in order to confirm possible variations that may have repercussions for Human Resource needs in the provision of adequate neurological care. METHODS: We prospectively registered the attendance records for visits made to the Out-patient Neurology Clinic of Marina Alta in 1996. The variation coefficients between both series were calculated and compared. RESULTS: The average age of patients increased in 5 years. The number of patients attended increased 42.3%, new patients 40%, visits 13%, the "Review visit/First Visit" ratio reduced 29%. The attendance of patients with Cognitive Impairment (Cog. Imp.) doubled. There were no changes in the origins of the patients. Requests due to Cog. Imp. and parkinsonism increased significantly from Primary Care and Emergency Department. The delay to be attended increased 23%. Discharges increased 43.9%, highlighting an increase of 144% observed in the Cog. Imp. group. CONCLUSIONS: Changes have been observed in: the age of the population studied; the follow up of patients; the delay in attending them; and the pathology attended, with a significant increase in demand due to neurodegenerative pathology (especially Cog. Imp.). All this requires an increase in care needs that the Health Service has not been able to assume, creating an incongruous care model: we suggest a direct follow up model and offer a consultancy model.

Successful heart transplantation in patients with inherited myopathies associated with end-stage cardiomyopathy.

UNLABELLED: Inherited myopathies in patients with secondary end-stage cardiomyopathies have always been considered a relative contraindication for cardiac transplantation. High operative risk related to muscle impairment and potential graft involvement secondary to the underlying myopathy have been the two main reasons implicated in the poor prognosis. OBJECTIVE: The aim of this study was to evaluate the outcome in patients who underwent cardiac transplantation in our hospital due to end-stage cardiomyopathy secondary to inherited myopathies. METHODS: Among 311 patients who underwent heart transplantation in our hospital, five (2%) had end-stage cardiomyopathies related to inherited myopathies. Four patients had muscular dystrophy (three Becker's muscular dystrophy and one hips-dystrophy) and the fifth desminopathy. In one patient cardiomyopathy was the initial manifestation of the disease. Mean age at the time of transplantation was 38.6 years (range from 24 to 55). The mean follow-up after transplantation was 57.4 months (range from 13 to 128). The intraoperative and postoperative course of these individuals did not show higher complication rates than other patients. All recipients experienced successful rehabilitation; no evidence of graft dysfunction has been detected during follow-up. All of them are alive with a good performance status. CONCLUSIONS: In our experience, patients who underwent heart transplantation due to end-stage cardiomyopathy secondary to inherited myopathy with only a mild degree of muscle impairment did not display higher postoperative nor long-term complications compared to other recipients.

Determination of PAH in food samples by HPLC with fluorimetric detection following sonication extraction without sample clean-up.

A rapid method is proposed for the determination of 16 polycyclic aromatic hydrocarbons (PAH) in non-fatty food (mashed potato, potato and toasted bread samples) based on their extraction with ethyl ether-methylene chloride (1:1) by sonication, and subsequent separation by high-performance liquid chromatography (HPLC) with fluorimetric detection. A Hypersil Green PAH column was used with a gradient of acetonitrile-water as the mobile phase, together with a programme of ten excitation and emission wavelength pairs. At levels 1.60-2320 microg kg(-1), mean recoveries of PAH were in the range 70-86% for mashed potato, potato and toasted bread samples. The relative standard deviations were in the range 4.2-11% (n = 6). Total PAH found in mashed potato were in the range 9.35-17.1 microg kg(-1), in potato samples 8.47-17.2 microg kg(-1) and in toasted bread samples 7.38-18.0 microg kg(-1), with relative standard deviations in the range 0.8-12%. Only chrysene, determined in Ortiz toasted bread (7.38 microg kg(-1)), has carcinogenic properties.

Protective effect of folic acid against oxidative stress produced in 21-day postpartum rats by maternal-ethanol chronic consumption during pregnancy and lactation period.

In this paper we show the protective effect of folic acid on oxidative stress in offspring caused by chronic maternal ethanol consumption during pregnancy and the lactation period. Glutathione reductase (GR) specific activity was assayed in liver and pancreas of offspring and mothers. In the offspring, these tissues were also assayed for markers of oxidative damage to lipids and proteins. The results show that ethanol exposure during pregnancy and lactation increased the specific activity of GR in tissues of the mothers (32-34% increase) as well as in the liver of their progeny (24%). Thiobarbituric acid reactive substances (TBARS) were also increased in the liver and pancreas of 21-day-old rats (37- and 54%, respectively). Alcohol also increased the amount of carbonyl groups in proteins in both tissues. These measures of ethanol-mediated oxidative stress were mitigated when pregnant rats were treated with folic acid concomitantly to ethanol administration. The antioxidant capacity of folic acid seems to be involved in its protective effect. The results obtained in the present work suggest that folic acid may be useful in the prevention of damage and promotion of health of the progeny of ethanol-treated rats.

Nomenclatura de los anticuerpos monoclonales que se utilizan para marcar linfocitos, granulocitos y macrofagos / Monoclonal antibodies nomenclature that is used for marking, lynphocytes, monocytes and macrophages

El estudio histopatologico con hematoxilina y eosina se la principal fuente de informacion para el medico. Pero sumados al estudio morfologico, una serie de analisis inmunologicos, citogenicos y moleculares puede ayudar a un diagnostico certero. Las poblaciones celulares pueden identeificarse de acuerdo a las expresion de diferentes antigenos de superficie (marcadores). El empleo actual de AC monoclonales contra estos Ag colabora en la inmunotipificacion y por lo tanto con la individualizacion de las poblaciones celulares. El uso anarquico de diferentes nombres o acronimos pa Ac que estaban dirigidos contra el mismo Ag confundia la interpretacion de los resultados. Nuestra intencion fue elaborar un cuadro donde el medico encuentre la nomenclatura actualizada hasta el workshop de 1993-29, los sinonimos y las celulas o grupos de celulas que poseen el el Ag que puede detectar cada Ac. La deteccion de marcadores linfocitarios medieante un amplio panel de Ac complementa pero no sustituye la valoracion de la microscopia convencional. Si se emplea un grupo restringido de Ac puede confundirse el diagnostico. Se recomienda como minimo utilizar los siguientes Ac.Celulas T: CD1, CD2, CD3, CD4, CD5, CD7, CD8. Celulas B: CD19, CD20, CD21, CD22. ig superficie (A,G,M yD), cadena kappa y lambda. Serie mielomonocitica: CD!ú; CD! $; CDúú; CD&$; CD& (.Celulas progenitoras:CD38. Marcadores de proliferacion:CD38,CD71.(AU)

Nomenclatura de los anticuerpos monoclonales que se utilizan para marcar linfocitos, granulocitos y macrofagos / Monoclonal antibodies nomenclature that is used for marking, lynphocytes, monocytes and macrophages

El estudio histopatologico con hematoxilina y eosina se la principal fuente de informacion para el medico. Pero sumados al estudio morfologico, una serie de analisis inmunologicos, citogenicos y moleculares puede ayudar a un diagnostico certero. Las poblaciones celulares pueden identeificarse de acuerdo a las expresion de diferentes antigenos de superficie (marcadores). El empleo actual de AC monoclonales contra estos Ag colabora en la inmunotipificacion y por lo tanto con la individualizacion de las poblaciones celulares. El uso anarquico de diferentes nombres o acronimos pa Ac que estaban dirigidos contra el mismo Ag confundia la interpretacion de los resultados. Nuestra intencion fue elaborar un cuadro donde el medico encuentre la nomenclatura actualizada hasta el workshop de 1993-29, los sinonimos y las celulas o grupos de celulas que poseen el el Ag que puede detectar cada Ac. La deteccion de marcadores linfocitarios medieante un amplio panel de Ac complementa pero no sustituye la valoracion de la microscopia convencional. Si se emplea un grupo restringido de Ac puede confundirse el diagnostico. Se recomienda como minimo utilizar los siguientes Ac.Celulas T: CD1, CD2, CD3, CD4, CD5, CD7, CD8. Celulas B: CD19, CD20, CD21, CD22. ig superficie (A,G,M yD), cadena kappa y lambda. Serie mielomonocitica: CD!ú; CD! $; CDúú; CD&$; CD& (.Celulas progenitoras:CD38. Marcadores de proliferacion:CD38,CD71.