The use of digital escape rooms in nursing education.

Negative attitudes and prejudices towards people with a mental disorder are common across cultures and societies. The stigma associated with mental illness leads to a lower quality of life, given the discrimination and social exclusion suffered by people with this type of disorder. In the field of health, research has shown that doctors and nurses also manifest these types of stigmatizing behaviors and attitudes. The present study aims to create and apply an educational escape room for the purpose of training nursing students in mental health, promoting positive attitudes towards people who have a mental disorder. To do so, a pre-post study was conducted with an experimental group and a control group to determine whether the escape room was effective for the modification of stigmatizing behaviors compared to transmissive lecture class, and a third measurement was made at 6 months only to the experimental group to evaluate whether the changes produced by the escape room were maintained in the long term. The results indicate that the students participating in the study obtained better scores in sensitization and these remain better over time. It is concluded that the escape room used is suitable for the training and sensitization of future nursing professionals in the field of mental health, facilitating the learning of knowledge and positive attitudes towards severe mental disorder.

Endocarditis caused by anaerobic bacteria.

BACKGROUND: Infective endocarditis (IE) caused by anaerobic bacteria is a rare and poorly characterized disease. Most data reported in the literature are from case reports [1-3]. Therefore, we assessed the situation of anaerobic IE (AIE) in Spain using the database of the Spanish Collaboration on Endocarditis (GAMES). METHODS: We performed a prospective study from 2008 to 2016 in 26 Spanish centers. We included 2491 consecutive cases of definite IE (Duke criteria). RESULTS: Anaerobic bacteria caused 22 cases (0.9%) of definite IE. Median age was 66 years (IQR, 56-73), and 19 (86.4%) patients were men. Most patients (14 [63.6%]) had prosthetic valve IE and all episodes were left-sided: aortic valves, 12 (54.5%); and mitral valves, 8 (36.4%). The most common pathogens were Propionibacterium acnes (14 [63.6%]), Lactobacillus spp (3 [13.63%]), and Clostridium spp. (2 [9.0%]), and the infection was mainly odontogenic. Fifteen of the 22 patients (68.2%) underwent cardiac surgery. Mortality was 18.2% during admission and 5.5% after 1 year of follow-up. When patients with AIE were compared with the rest of the cohort, we found that although those with AIE had a similar age and Charlson comorbidity index, they were more likely to have community-acquired IE (86.4% vs. 60.9%, p = 0.01), have undergone cardiac surgery (68.2% vs 48.7% p = 0.06), and have had lower mortality rates during admission (18.2% vs. 27.3%). CONCLUSION: IE due to anaerobic bacteria is an uncommon disease that affects mainly prosthetic valves and frequently requires surgery. Otherwise, there are no major differences between AIE and IE caused by other microorganisms.

The use of ertapenem for the treatment of community-acquired pneumonia in routine hospital practice: a matched cohort study.

OBJECTIVE: The clinical response to ertapenem in community-acquired pneumonia (CAP) at the setting of routine hospital practice has been scarcely evaluated. METHODS: We retrospectively compared CAP cases treated with ertapenem or with other standard antimicrobials (controls) at a tertiary 1,434-bed center from 2005 to 2014. RESULTS: Out of 6,145 patients hospitalized with CAP, 64 (1%) ertapenem-treated and 128 controls were studied (PSI IV-V 72%, mean age 73 years.). A significant higher proportion of bedridden patients (41% vs. 21%), residence in nursing homes (19% vs. 7%), previous use of antibiotics (39% vs. 29%) and necrotizing (13% vs. 1%) or complicated (36% vs. 19%) pneumonia, was observed in the ertapenem vs. non-ertapenem patients. Initial treatment with ertapenem was independently associated with an earlier resolution of signs of infection. In patients aged 65 or older the independent risks factors for mortality were: PSI score (7.0, 95%CI 1.8-27.7), bedridden status (4.6, 95%CI 1.1-20.9) and Health Care Associated Pneumonia (HCAP) (4.6, 95%CI 1.3-16.5). First-line treatment with ertapenem was an independent protector factor in this subgroup of patients (0.1, 95%CI 0.1-0.7). CONCLUSIONS: Ertapenem showed a superior clinical response in frail elderly patients with complicated community-acquired pneumonia, and it may be considered as a first-line therapeutic regimen in this setting.

Left-sided infective endocarditis in patients with liver cirrhosis.

OBJECTIVE: To evaluate the course of left-sided infective endocarditis (LsIE) in patients with liver cirrhosis (LC) analyzing its influence on mortality and the impact of surgery. METHODS: Prospective cohort study, conducted from 1984 to 2013 in 26 Spanish hospitals. RESULTS: A total of 3.136 patients with LsIE were enrolled and 308 had LC: 151 Child-Pugh A, 103 B, 34 C and 20 were excluded because of unknown stage. Mortality was significantly higher in the patients with LsIE and LC (42.5% vs. 28.4%; p < 0.01) and this condition was in general an independent worse factor for outcome (HR 1.51, 95% CI: 1.23-1.85; p < 0.001). However, patients in stage A had similar mortality to patients without cirrhosis (31.8% vs. 28.4% p = NS) and in this stage heart surgery had a protective effect (28% in operated patients vs. 60% in non-operated when it was indicated). Mortality was significantly higher in stages B (52.4%) and C (52.9%) and the prognosis was better for patients in stage B who underwent surgery immediately (mortality 50%) compared to those where surgery was delayed (58%) or not performed (74%). Only one patient in stage C underwent surgery. CONCLUSIONS: Patients with liver cirrhosis and infective endocarditis have a poorer prognosis only in stages B and C. Early surgery must be performed in stages A and although in selected patients in stage B when indicated.

Melatonin increases intracellular calcium in the liver, muscle, white adipose tissues and pancreas of diabetic obese rats.

Melatonin, a widespread substance with antioxidant and anti-inflammatory properties, has been found to act as an antidiabetic agent in animal models, regulating the release and action of insulin. However, the molecular bases of this antidiabetic action are unknown, limiting its application in humans. Several studies have recently shown that melatonin can modify calcium (Ca(2+)) in diabetic animals, and Ca(2+) has been reported to be involved in glucose homeostasis. The objective of the present study was to assess whether the antidiabetic effect of chronic melatonin at pharmacological doses is established via Ca(2+) regulation in different tissues in an animal model of obesity-related type 2 diabetes, using Zücker diabetic fatty (ZDF) rats and their lean littermates, Zücker lean (ZL) rats. After the treatments, flame atomic absorption spectrometry was used to determine Ca(2+) levels in the liver, muscle, main types of internal white adipose tissue, subcutaneous lumbar fat, pancreas, brain, and plasma. This study reports for the first time that chronic melatonin administration (10 mg per kg body weight per day for 6 weeks) increases Ca(2+) levels in muscle, liver, different adipose tissues, and pancreas in ZDF rats, although there were no significant changes in their brain or plasma Ca(2+) levels. We propose that this additional peripheral dual action mechanism underlies the improvement in insulin sensitivity and secretion previously documented in samples from the same animals. According to these results, indoleamine may be a potential candidate for the treatment of type 2 diabetes mellitus associated with obesity.

CD27+ B cells from a subgroup of common variable immunodeficiency patients are less sensitive to apoptosis rescue regardless of interleukin-21 signalling.

Common variable immunodeficiency (CVID) is a primary immunodeficiency characterized by hypogammaglobulinaemia and recurrent infections. Although the underlying cause is unknown, B cells from most CVID patients fail to differentiate to memory or plasma cells. We investigated if increased apoptosis could influence the fate of B cells. For this purpose we activated purified B lymphocytes of CVID patients with a surrogate T-dependent (anti-CD40) or T-independent [cytosine-phosphate-guanosine oligodeoxynucleotides (CpG-ODN) or anti-immunoglobulin (Ig)M)] stimulus with or without interleukin (IL)-21. We found that CD27(+) B cells were more sensitive than CD27(-) B cells to spontaneous apoptosis and less sensitive to rescue from apoptosis. The addition of IL-21 down-modulated the protective effect of all the stimuli on CD27(-) B cells and the protective effect of CpG-ODN and anti-IgM on CD27(+) B cells. In contrast, IL-21 rescued unstimulated CD27(-) B cells and improved the rescue of anti-CD40-stimulated CD27(+) B cells. When we compared patients and controls, mainly CD27(+) B cells from MB0 patients were less sensitive to rescue from apoptosis than those from MB1 patients and controls after activation, irrespective of the IL-21 effect. Increased apoptosis during an immune response could result in lower levels of immunoglobulin production in these patients.

IOFF generally extends fluorophore longevity in the presence of an optical trap.

The combination of optical tweezers force microscopy and single molecule fluorescence has previously been complicated by trap-induced photobleaching. Recent studies have suggested that this effect is caused by a sequential absorption of photons, leading to ionization of the fluorescent singlet state. In this work, we show the range of effects of optical trapping radiation on common fluorescent dyes. Using the interlaced optical force fluorescence (IOFF) laser modulation technique, we show that the removal of simultaneous near infrared radiation dramatically reduces photobleaching effects. However, these studies show that the sequential addition of near infrared radiation in some cases extends photobleaching longevity beyond the natural intrinsic decay. We suggest a refined photoelectronic mechanism that accounts for the possibility of reverse intersystem crossing from a reactive triplet state and explains the nature of trap-induced photobleaching.

[Effects of contrast, eccentricity and position in the detection of visual stimuli in humans]. / Efectos del contraste, excentricidad y posicion en la deteccion de estimulos visuales en humanos.

INTRODUCTION: Contrast, eccentricity and position of stimuli used on research of attention in human vision strongly vary among studies. AIM. To study how contrast, eccentricity and position affects detection of stimuli in humans. SUBJECTS AND METHODS: In adults with normal vision, we measured response times to stimuli (gray circles of 0.5 masculine of diameter) presented at random at eight polar coordinates, in three eccentricities with respect of fixation point (2.15, 3.83 and 5.53 masculine) and with three levels of contrast (6, 16 and 78%). RESULTS: Stimuli with eccentricity of 5.38 masculine and 6% of contrast showed the longest response times. In all eccentricities studied, longer response times were found with stimuli of 6% of contrast. Response times of stimuli of 16% and 78% of contrast showed similar response times in all eccentricities studied. Response times founded at eight polar coordinates were heterogeneous at eccentricities of 2.15 and 5.53 masculine, but not at 3.83 masculine. CONCLUSIONS: Contrast is the factor that most influence detection of visual stimuli used in this study, particularly at the biggest eccentricity employed. Response times among polar coordinates are also affected by eccentricities of 2.15 and 5.53 masculine, suggesting that distance of stimuli to fixation point is critical for visual detection of stimuli.

Efectos del contraste, excentricidad y posición en la detección de estímulos visuales en humanos / Effects of contrast, eccentricity and position in the detection of visual stimuli in humans

Introducción. Los estudios en humanos sobre percepción visual espacial tienen en común proyectar estímulos en laretina central, pero difieren notablemente en cuanto a su contraste, excentricidad y posición en el campo visual. Objetivo. Estudiar los efectos del contraste, excentricidad y posición en la detección de estímulos visuales presentados en la retina central humana. Sujetos y métodos. Se estudiaron los tiempos de respuesta, en personas con visión normal, a la presentación de estímulos (círculos grises de 0,5º de diámetro) presentados al azar en ocho coordenadas polares, con tres excentricidades (2,15,3,83 y 5,53º) y tres niveles de contraste (6, 16 y 78%). Resultados. Los estímulos presentados a 5,53º de excentricidad y contraste del 6% mostraron los tiempos de respuesta más elevados. Con este contraste, los tiempos de respuesta fueron mayores en todaslas excentricidades estudiadas. Por el contrario, con contrastes del 16 y 78%, los tiempos de respuesta fueron similares en las tres excentricidades. Para las ocho coordenadas polares, los tiempos de respuesta fueron homogéneos en la excentricidad de 3,83º y mostraron mayor variabilidad en las excentricidades de 2,15 y 5,53º. Conclusiones. De los tres factores analizados,el contraste es determinante en la detección de estímulos, especialmente en la excentricidad mayor. La posición también influye cuando los estímulos se presentan con excentricidades pequeñas o grandes, lo que sugiere que la distancia de los estímulos respecto al punto de fijación es crítica en la detección visual en este tipo de estudios

Introduction. Contrast, eccentricity and position of stimuli used on research of attention in human vision strongly vary among studies. Aim. To study how contrast, eccentricity and position affects detection of stimuli in humans. Subjects and methods. In adults with normal vision, we measured response times to stimuli (gray circles of 0.5º of diameter) presented at random at eight polar coordinates, in three eccentricities with respect of fixation point (2.15, 3.83 and 5.53º) and with three levels of contrast (6, 16 and 78%). Results. Stimuli with eccentricity of 5.38º and 6% of contrast showed the longest response times. In all eccentricities studied, longer response times were found with stimuli of 6% of contrast. Response times of stimuliof 16% and 78% of contrast showed similar response times in all eccentricities studied. Response times founded at eight polar coordinates were heterogeneous at eccentricities of 2.15 and 5.53º, but not at 3.83º. Conclusions. Contrast is the factor thatmost influence detection of visual stimuli used in this study, particularly at the biggest eccentricity employed. Response times among polar coordinates are also affected by eccentricities of 2.15 and 5.53º, suggesting that distance of stimuli to fixationpoint is critical for visual detection of stimuli

Effect of exercise on skeletal muscle proteolytic enzyme activity and meat quality characteristics in Iberian pigs.

The effects of physical activity on performance, carcass traits, Psoas major lysosomal and exoprotease acitivies and meat quality were studied in 24 castrated male Iberian pigs during the last fattening period (from 111.1±SD: 5.2kg). Pigs were randomly distributed in three groups. Two groups receiving the same diet were reared in confinement, one housed in individual pens of 8m(2) (sedentary group) and the other was housed outdoor with daily (up to 2km) forced walking (exercise group). And one group was reared under the traditional production system walking daily several km and fed mostly with acorn from Quercus ilex and Quercus rotundifolia and grass (free-range group). No differences were found in performance and carcass traits. In exercised pigs a lower activity of cathepsin B+L and total cathepsins (P<0.05) was observed. Exercise induced the inhibition of dipeptidyl peptidases II and III and arginyl aminopeptidase and the activation of dipeptidyl peptidases IV and leucyl aminopeptidase (P<0.05). Although no effects on total free amino acids in Psoas major muscle were observed the concentration of branched chain amino acids decreased in the free-range pig group probably related to an increase in physical activity. Exercise had no effects in Psoas major postmortem tenderness and water holding capacity.

Phenotypic characterisation of T-lymphocytes in COPD: abnormal CD4+CD25+ regulatory T-lymphocyte response to tobacco smoking.

Tobacco smoking induces an inflammatory response in the lungs of all smokers but, for reasons that are still poorly understood, only a proportion of them develop chronic obstructive pulmonary disease (COPD). Recent evidence indicates that this inflammatory response persists after smoking cessation, suggesting some type of auto-perpetuation mechanism similar to that described in autoimmune disorders. T-lymphocytes (CD4+ and CD8+) have been implicated in the pathogenesis of both COPD and several autoimmune processes. A subtype of regulatory CD4+ T-cells expressing CD25 (Tregs) plays a critical role in the maintenance of peripheral tolerance and the prevention of autoimmunity, but their potential role in COPD has not been explored. The present study sought to evaluate maturation (CD45RA/CD45R0) and activation markers (CD28) of T-lymphocytes and to explore potential Treg abnormalities in COPD. Flow cytometry was used to characterise T-lymphocytes obtained from blood and bronchoalveolar lavage fluid (BALF) in 23 patients with moderate COPD, 29 smokers with normal lung function and seven never-smokers. The main findings were that in BALF: patients with COPD showed higher CD8+CD45RA+ and lower CD8+CD45R0+ than smokers with normal lung function; and compared with never-smokers, smokers with preserved lung function showed a prominent upregulation of Tregs that was absent in patients with COPD. These observations indicate a final maturation-activation state of CD8+ T-lymphocytes in chronic obstructive pulmonary disease and, for the first time, identify a blunted regulatory T-cell response to tobacco smoking in these patients, further supporting a potential involvement of the acquired immune response in the pathogenesis of the disease.

Eco-Doppler venoso perioperatorio / Perioperative venous Doppler ultrasound

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Intracellular cytokine profile of T lymphocytes in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is characterized by an excessive inflammatory response to inhaled particles, mainly tobacco smoking. T lymphocytes are important regulatory cells that secrete several cytokines and participate actively in this inflammatory response. According to the pattern of cytokines secreted, the immune response is classified as cytotoxic or type 1 [interferon (IFN)-gamma-, interleukin (IL)-2-dependent] and humoral or type 2 (IL-4-, IL-5-, IL-10- and IL-13-dependent). This paper sought to compare the intracellular profile of cytokine expression determined by flow cytometry in T lymphocytes harvested from bronchoalveolar lavage (BAL) and peripheral blood in patients with COPD, smokers with normal lung function and never smokers. We found that BAL T lymphocytes from COPD patients had a higher percentage of positive stained cells for most of the cytokines analysed when compared to never smokers or smokers with normal lung function. Differences reached statistical significance for IL-4, IL-10 and IL-13, particularly in CD8(+) T cells. Furthermore, the expression of most of these cytokines was related inversely to the degree of airflow obstruction present suggesting local activation and/or selective homing of T lymphocytes to the lungs in COPD patients. These observations were not reproduced in circulating T lymphocytes. These results suggest that BAL T lymphocytes in patients with COPD produce more cytokines than in controls and tend to show a type 2 pattern of intracellular cytokine expression, particularly a Tc-2 profile. This is related inversely to the degree of airflow obstruction present.

Costimulatory molecules and cytokine production by T lymphocytes in common variable immunodeficiency disease.

Common variable immunodeficiency (CVID) is a heterogeneous syndrome characterized by hypogammaglobulinaemia and recurrent infections. Although early works pointed to a primary B-lymphocyte defect as a cause of the disease, a failure in T-lymphocyte cooperation has also been suggested. T cells exert their costimulatory function through either membrane costimulatory molecules or secreted cytokines, both having an influence in the development of the humoral response. The aim of our study was to evaluate whether an abnormal expression and induction of costimulatory molecules or alterations in the production of cytokines by T cells cause deficient T/B cooperation in CVID patients. We studied the expression and upregulation of costimulatory molecules (CD28, CD40L/CD154 and CTLA-4/CD152) and production of cytokines (IL-2, IL-4, IL-6, IL-10, IFN-gamma and TNF-alpha) in purified T lymphocytes from CVID patients stimulated with optimal doses of anti-CD3 or suboptimal doses of anti-CD3 and anti-CD28. Stimulated T cells from CVID patients expressed normal levels of CD28, CD40L/CD154 and CTLA-4/CD152 when compared with controls. Except for higher production of IL-4 after stimulation with anti-CD3, T cells of CVID patients produced similar amounts of cytokines compared with controls. An imbalance between costimulatory molecules expression (CD28, CD40L/CD154 and CTLA-4/CD152) and cytokine production by T cells does not explain a deficient cooperation between T and B cells in this group of CVID patients.

Blunted gamma delta T-lymphocyte response in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is characterised by an excessive inflammatory response to inhaled particles, mostly tobacco smoking. Although inflammation is present in all smokers, only a percentage of them develop COPD. T-lymphocytes are important effector and regulatory cells that participate actively in the inflammatory response of COPD. They comprise the T-cell receptor (TCR)-alpha beta (CD4+ and CD8+) and TCR-gamma delta T-lymphocytes. The latter represent a small percentage of the total T-cell population, but play a key role in tissue repair and mucosal homeostasis. To investigate TCR-alpha beta (CD4+ and CD8+) and TCR-gamma delta T-lymphocytes in COPD, the present authors determined, by flow cytometry, the distribution of both subpopulations in peripheral blood and bronchoalveolar lavage (BAL) samples obtained from patients with COPD, smokers with normal lung function and never-smokers. The present study found that: 1) the distribution of CD4+ and CD8+ lymphocytes in blood and BAL was similar in all three groups; 2) compared with nonsmokers, gamma delta T-lymphocytes were significantly increased in smokers with preserved lung function; and 3) this response was blunted in patients with COPD. These results highlight a novel, potentially relevant, pathogenic mechanism in chronic obstructive pulmonary disease.

Chronobiology of labour pain perception: an observational study.

BACKGROUND: Circadian variation may affect many biological and pharmacological phenomena. METHODS: To assess circadian variations in labour pain perception, 222 consecutive nulliparous women with uncomplicated pregnancy, spontaneous labour, cervical dilatation (3-5 cm), ruptured membranes and normal fetal heart rate tracings were studied. Visual analogue pain scores (VAPS) were analysed and divided into four periods: night (1:01 a.m. to 7:00 a.m.), morning (7:01 a.m. to 1:00 p.m.), afternoon (1:01 p.m. to 7:00 p.m.) and evening (7:01 p.m. to 1:00 a.m.). VAPS were also compared between daytime (morning+afternoon) and nocturnal (evening+night) periods. RESULTS: Daytime mean VAPS were lower than nocturnal scores [75.6 (15.1) vs 85.7 (14.1), P<0.0001]. VAPS were lower in the morning than in the afternoon, evening and night periods (anova, P<0.0001). CONCLUSION: Labour pain perception appears to be chronobiological, and this might be taken into account when enrolling parturients in studies designed to assess or treat labour pain.

Aplicación de la estrategia CHIVA. Estudio prospectivo a un año / Application of the chiva strategy. A prospective study at one year

Introducción. La cirugía tiende a ser cada vez menos invasiva. Podríamos englobar la estrategia CHIVA dentro del concepto de cirugía mínimamente invasiva. Objetivos. Evaluar de forma prospectiva los resultados clínicos a un año de la aplicación de la estrategia CHIVA en el tratamiento de las varices esenciales. Pacientes y métodos. Seguimiento durante un año de 225 pacientes (147 mujeres, 78 hombres). Clínicamente, 195 de ellos en estadio 2 (CEAP). Se les ha practicado un eco-Doppler previo a la cirugía. Posteriormente, al mes y al año se ha hecho una valoración clínica y clasificado el resultado en cuatro categorías. Además, al año se les ha hecho un nuevo eco-Doppler. El tipo de estrategia practicado ha sido en un sólo tiempo en el 97,8 por ciento de los casos. Resultados. Al año, la valoración clínica objetiva y subjetiva han sido buenas en el 87,6 y en el 90,7 por ciento de los casos, respectivamente. El diámetro medio de la safena interna ha pasado de 6,4 a 4,0 mm (t test; p = 0,001). Se han apreciado diferen cias significativas entre la valoración objetiva al mes y al año (p = 0,001), así como en la valoración subjetiva (p = 0,001), ya que un tercio de los pacientes con mala valoración al mes la tenían buena al año. Conclusión. La estrategia CHIVA en nuestra serie presenta unos buenos resultados a un año. La reducción significativa del diámetro de la safena indica que el componente hemodinámico en la fisiopatología de las varices es importante (AU)

Cirugía hemodinámica venosaen el tratamiento del síndrome varicoso / Venous haemodynamic surgery in the treatment of varicose syndrome

Objetivo. El presente trabajo de revisión pretende poner al día los diferentes aspectos del tema: justificación del método, terminología anatomicofuncional utilizada, principios estratégicos y modalidades de su aplicación. Finalmente, se analizan los resultados comunicados de las diferentes series disponibles. Desarrollo. La cura CHIVA (cura conservadora hemodinámica de la insuficiencia venosa ambulatoria) fue descrita por Franceschi en 1988. Tras una expansión inicial del procedimiento, su utilización disminuyó a causa de difundirse sin haberse testado adecuadamente. La estandarización posterior del método ha motivado que diferentes grupos adopten dicha estrategia con resultados satisfactorios. La terminología propuesta por la Asociación Europea de CHIVA en el año 2002 permite aplicar con precisión los distintos tipos de estrategias de este tratamiento. Se remarca que en el registro de actividad de la Sociedad Española de Angiología y Cirugía Vascular correspondiente al año 2002, una tercera parte de las varices intervenidas en unidades o servicios de Angiología y Cirugía Vascular en España se realizaron mediante cirugía hemodinámica venosa. Conclusiones. No existe una evidencia definitiva (se están desarrollando ensayos clínicos prospectivos aleatorizados) en favor de la cura CHIVA; sin embargo, los datos disponibles apoyan la alternativa de dicho procedimiento frente a la flebectomía en el tratamiento de las varices (AU)

Empiema por Pasteurella multocida en un postoperado de recambio valvular mitral por endocarditis / Pasteurella multocida empyema in a patient after mitral valve replacement secondary to endocarditis

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