Regulating Gambling Use through the Overton Window: From an Addictive Behavior to a Social and Epidemiological Problem.

During the last decade, gambling (online and offline) regulation has become a social and epidemiological problem all around Europe. The aftermaths of this addiction have increased since the so-called "responsible gambling law", in the second decade of the 21st century. The Overton window (OW) strategy is a political theory that describes how the perception of public opinion can be modified so that ideas that are inconceivable for society become accepted over time. The objective of this study is to identify whether an OW has been used to bias the adequacy of the gambling debate, as well as its scientific, legal, and political bases and the main consequences for both the general population and the major risk groups, especially the consequences in social and health contexts. The study was conducted by the application of the historical-logical method as the central axis of analysis and reflection, and the technique of qualitative research content analysis as a procedure in the process of execution of the scientific task, related to a historical trend study of the research object. The main consequences found were: the political acceptance of gambling for economical causes and taxes benefits, the use of popular characters to increase the acceptance of the pattern of behavior, the inclusion of the gambling operators as agents in the risks control, and the absence of intervention until the main consequences have been transformed into an epidemiological problem (with social aftermaths higher than the previously identified related to the gambling problems). Furthermore, the results suggest the need to implement prevention and health promotion strategies and the adoption of specific legal measures that regulate the access and the marketing of gambling operators' activities.

Factores clínicos y ecocardiográficos asociados al bajo gasto cardíaco posoperatorio en pacientes con tratamiento quirúrgico cardiovascular / Clinical and echocardiographic factors associated with the postoperative low cardiac output in patients with cardiovascular surgical treatment i: en

Introducción: Entre las diferentes complicaciones que surgen en el periodo posoperatorio inmediato, el bajo gasto cardíaco presenta mayor morbilidad y mortalidad asociadas, con una incidencia de hasta 45,0 %. Objetivo: Determinar los factores relacionados con la aparición posoperatoria del bajo gasto cardíaco en pacientes con tratamiento quirúrgico cardiovascular y circulación extracorpórea, según variables demográficas, clínicas y ecocardiográficas. Métodos: Se realizó una investigación analítica, de casos y controles, la cual incluyó a pacientes que recibieron tratamiento quirúrgico cardíaco en el Servicio de Cardiología y Cirugía Cardiovascular del Hospital Provincial Clinicoquirúrgico Docente Saturnino Lora de Santiago de Cuba, desde enero hasta diciembre de 2019. Cada grupo de estudio estuvo conformado por 43 integrantes, para lo cual se consideró la presencia del síndrome de bajo gasto cardíaco (casos) o no (controles). Resultados: En la serie predominaron los pacientes menores de 65 años de edad en ambos grupos de estudio (51,2 y 73,5 % para casos y controles, respectivamente), así como el sexo masculino (60,9 %); de igual modo, resultó más frecuente la intervención quirúrgica de emergencia (80,2 %). La fibrilación auricular y la función sistólica del ventrículo derecho presentaron alta significación estadística (p<0,05). Conclusiones: Algunos elementos clínicos y ecocardiográficos (edad, fibrilación auricular, función sistólica de los ventrículos izquierdo y derecho, así como intervención quirúrgica de emergencia) se asociaron de manera independiente a la aparición del bajo gasto cardíaco.

Introduction: Among the different complications that arise in the immediate postoperative period, the low cardiac output presents higher associated morbidity and mortality, with an incidence of up to 45.0 %. Objective: To determine the factors related to the postoperative emergence of the low cardiac output in patients with cardiovascular surgical treatment and extracorporeal circulation, according to demographic, clinical and echocardiographic variables. Methods: An analytic, cases and controls investigation was carried out, which included patients that received heart surgical treatment in the Cardiology and Cardiovascular Surgery Service of Saturnino Lora Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, from January to December, 2019. Each study group was conformed by 43 members, for which was considered the presence (cases) or not (controls) of the low cardiac output syndrome. Results: In the series there was a prevalence of the patients under 65 years in both study groups (51.2 and 73.5 % for cases and controls, respectively), as well as the male sex (60.9 %); in a same way, the emergency surgical intervention was the most frequent (80.2 %). The atrial fibrillation and the systolic function of the right ventricle presented high statistical significance (p <0.05). Conclusions: Some clinical and echocardiographic elements (age, atrial fibrillation, systolic function of the left and right ventricles, as well as emergency surgical intervention) were associated in an independent way with the emergence of the low cardiac output.

Disfunción ventricular derecha en paciente adulto con comunicación interventricular posinfarto / Right ventricular dysfunction in adult patient with post-infarction ventricular septal defect

RESUMEN Introducción: La disfunción ventricular derecha es la alteración aguda o crónica de la morfología y función de dicha estructura, de origen multifactorial. En los últimos años existe consenso acerca de su función como determinante del estado funcional y factor pronóstico en diversas enfermedades. Objetivo: Destacar la importancia del manejo multidisciplinario y algunas de las opciones terapéuticas que se les pueden brindar a estos pacientes. Presentación del caso: Paciente de 58 años de edad, con antecedentes de salud aparente, que acudió al Servicio de emergencias, donde se le diagnosticó un infarto agudo de miocardio de topografía inferior. Se trasladó a la unidad de cuidados intensivos quirúrgicos del Servicio de Cirugía Cardiovascular debido a una complicación mecánica por comunicación interventricular. Se recibió con elementos clínicos de insuficiencia cardíaca aguda clase funcional IV. Progresivamente presentó deterioro del estado hemodinámico por lo que requirió el uso de apoyo vasoactivo con norepinefrina; hipoxia, hipercapnia, presiones venosas centrales entre 15 y 18 cmH2O y elementos clínicos de disfunción de ventrículo derecho; se decidió instrumentar vía aérea, administrar sedación y relajación por asincronías a paciente ventilado. Sin otra opción que el tratamiento quirúrgico se llevó a discusión donde se decidió esperar a la mejoría del estado hemodinámico con tratamiento médico. Conclusiones: Las enfermedades cardiovasculares no dejan de aparecer en escenarios cada vez más complejos con elevada morbimortalidad. Se evidencia la importancia del consenso clínico-quirúrgico en el momento de la toma de decisiones.

ABSTRACT Introduction: Right ventricular dysfunction is the acute or chronic alteration of the morphology and function of this structure, of multifactorial origin. In recent years there is consensus about its role as a determinant of functional status and prognostic factor in various diseases. Objective: Highlight the importance of multidisciplinary management and some of the therapeutic options that can be provided to these patients. Case Presentation: A 58-year-old patient with an apparent health history went to the Emergency Service, where he was diagnosed with an acute myocardial infarction of lower topography. He was transferred to the surgical intensive care unit of the Cardiovascular Surgery Service due to a mechanical complication from ventricular septal defect. He was received presenting clinical elements of acute heart failure functional class IV. He progressively presented deterioration of the hemodynamic state, so it required the use of vasoactive support with norepinephrine; hypoxia, hypercapnia, central venous pressures between 15 and 18 cmH2O and clinical elements of right ventricular dysfunction; it was decided to implement airway, administer sedation and relaxation by asynchrony to ventilated patient. With no other option than surgical treatment, it was brought to discussion and it was decided to wait for the improvement of the hemodynamic state with medical treatment. Conclusions: Cardiovascular diseases do not cease to appear in increasingly complex scenarios with high morbidity and mortality. The importance of clinical-surgical consensus at the time of decision-making is evident.

Estimating hospital inpatient cost-savings with sucroferric oxyhydroxide in patients on chronic hemodialysis in five European countries: a cost analysis.

AIMS: Hyperphosphatemia is common among patients with advanced chronic kidney disease (CKD) undergoing dialysis. The iron-based phosphate binder (PB), sucroferric oxyhydroxide (SO), has a low daily pill burden and is indicated for the control of serum phosphorus in these patients. In a retrospective database study, hemodialysis patients switched to long-term SO therapy had fewer hospitalizations compared with patients switched to other PB therapies. This economic analysis aimed to quantify potential cost-savings of reduced hospitalizations associated with SO for healthcare systems in five European countries. MATERIALS AND METHODS: All-cause hospital admissions incidence data were sourced from a real-world retrospective database study comparing adult, in-center hemodialysis patients maintained on 2 years of SO therapy (mSO) versus patients who discontinued SO (dSO) within 90 days of their first prescription and switched to other PBs. A literature search was conducted to determine the cost per hospital admission for dialysis patients in the healthcare setting of each European country. A cost-model combined the incidence rate of all-cause hospital admissions and the cost per admission to estimate the country-specific inpatient costs for the mSO and dSO groups. RESULTS: Annual inpatient cost-savings per patient in the mSO group versus the dSO group were €1,201, €2,097, €2,059, €1,512, and €3,068 in France, Germany, Italy, Spain, and the UK, respectively. When annual PB drug costs per patient were considered, the net annual economic cost-savings per patient were €327, €1,585, €1,022, €1,100, and €2,204, respectively. LIMITATIONS: Hospital admissions data used in the analysis were observational in nature and derived from a US hemodialysis patient population; the effect of SO therapy on hospitalization rates for US and European hemodialysis patients may differ. The analysis did not consider indirect healthcare costs associated with hospitalizations. CONCLUSION: SO therapy may offer substantial inpatient cost-savings by reducing all-cause hospital admissions attributable to uncontrolled hyperphosphatemia.

Biomarcadores como predictores de mortalidad en pacientes graves con infecciones / Biomarkers as mortality predictors in severely-ill patients with infections

Introducción: Actualmente se buscan biomarcadores que se modifiquen paralelamente con la historia natural de la sepsis. Objetivo: Describir las variaciones de la proteína C reactiva, la eritrosedimentación y el conteo de eosinófilos en pacientes graves portadores de enfermedad infecciosa en diferentes etapas. Método: Se realizó una investigación aplicada y analítica de cohorte, según el estado de la temática, alcance y aplicabilidad de los resultados. Se realizó en pacientes graves con enfermedades infecciosas ingresados en la unidad cuidados intensivos del Hospital Saturnino Lora, durante marzo de 2018 hasta marzo de 2019. El universo estuvo constituido luego de aplicar los criterios de inclusión y exclusión por 41 pacientes, 21 fallecidos y 20 vivos. Las variables estudiadas fueron edad, sexo, origen, gravedad y seguimiento del proceso infeccioso, biomarcadores de respuesta inflamatoria e infección y estado al egreso. Para el procesamiento de la información estadística se emplearon valores promedios como medidas de resumen para variables cuantitativas y porcentajes para variables cualitativas. Para la asociación estadísticamente significativa entre los criterios de interés se aplicó el Test X2 de Independencia. Resultados: La sepsis resultó más frecuente en pacientes masculinos en edades intermedias de la vida, fundamentalmente de origen respiratorio y fue la eosinopenia el biomarcador que más se alteró en los diferentes momentos de la investigación Conclusión: El biomarcador asociado a la sepsis que más se alteró en los diferentes momentos del estudio fue la eosinopenia con mayor asociación como predictor de mortalidad en los diferentes momentos que se realizó el análisis(AU)

Introduction: Currently, biomarkers are being sought that become modified in parallel with the natural history of sepsis. Objective: To describe the variations in C-reactive protein, erythrocyte sedimentation and eosinophil count in severely-ill patients with infectious disease at different stages. Method: An applied and analytical cohort research was carried out, according to the state of the subject, scope and applicability of the outcomes. It was carried out in severely-ill patients with infectious diseases admitted to the intensive care unit of the Saturnino Lora Hospital, from March 2018 to March 2019. The study population was made up after applying the inclusion and exclusion criteria in 41 patients, 21 deceased and 20 alive. The variables studied were age, sex, origin, severity, and monitoring of the infectious process, biomarkers of inflammatory response and infection, and discharge status. For the processing of statistical information, mean values TX 2;were used as summary measures for quantitative variables and percentages for qualitative variables. For the statistically significant association between the criteria of interest, the chi-square Independence test was applied. Results: Sepsis was more frequent among male patients in intermediate ages of life, mainly of respiratory origin; while eosinopenia was the biomarker that was most altered at different moments of the investigation Conclusion: The biomarker associated with sepsis that was most altered at different times of the study was eosinopenia, with the greatest association as a predictor for mortality at the different times when the analysis was performed(AU)

Impacto del primer año de tratamiento sustitutivo renal en la hospitalización de una comunidad autónoma / Impact of first year renal replacement therapy on the hospital admissions of a regional public health system

INTRODUCCIÓN Y OBJETIVOS: La enfermedad renal crónica tiene una alta prevalencia y coste, así como un mayor riesgo de ingreso. Disponemos de registros públicos y obligatorios, pero no hay referencias recientes para estimar el impacto que el tratamiento sustitutivo renal (TSR) tiene en la actividad hospitalaria. MÉTODOS: Tras las autorizaciones pertinentes, hemos integrado las bases de datos REMER (2013-2014) y CMBDH (2013-2015) para analizar la actividad hospitalaria durante el primer año de TSR. RESULTADOS: Un total de 767 pacientes iniciaron TSR en los 7 hospitales de tercer nivel de la Comunidad de Madrid. Más de una tercera parte lo hicieron de forma no programada durante un ingreso. Este inicio es más frecuente en HD que en DP, pero existen diferencias clínicas relevantes en edad y en comorbilidad. Descartando este primer episodio, casi el 60% de pacientes ingresan durante el primer año. La tasa de ingreso es de 1,2 ingresos/paciente, más alta en HD que en TX y DP; la estancia media es de 8,6días. El coste agregado de los ingresos del primer año es de 12.006 €/paciente. Nuestro análisis asegura la inclusión exhaustiva de todos los episodios y la estimación precisa de costes. CONCLUSIONES: El impacto del TSR en la actividad hospitalaria ha sido infraestimado y es una parte importante del coste global del TSR. Los resultados de la literatura internacional no pueden extrapolarse a nuestro país por las diferencias en el modelo sanitario y perfil de paciente. La integración de bases de datos clínicas es técnicamente viable y podría abrir una vía inmensa de información que solo requiere apoyo institucional para su desarrollo

INTRODUCTION AND OBJECTIVES: Chronic kidney disease has a high prevalence and economic impact, and an increased risk of hospitalization. Although there are public regional and country registries, we have not found references to estimate the impact of renal replacement therapy (RRT) on hospital admissions. METHODS: We obtained authorization from the ethics committee and health authorities to integrate the REMER [Madrid Kidney Disease Registry] (2013-2014) and Minimum Basic Data Set (2013-2015) databases and to analyze the admissions during the first year of RRT. RESULTS: 767 patients started RRT in all the hospitals of our region across all RRT modalities. More than a third of the patients start dialysis during a hospital admission. This unplanned start, more common in HD than PD, shows relevant differences in patient profile or admission characteristics. Without considering this initial episode, almost 60% of patients were admitted during their first year. The hospitalization rate was 1.2 admissions/patient, higher in HD than in TX or PD; the mean length of stay was 8.6 days. The estimated cost of admissions during the first year is €12,006/patient. Our analysis ensures the exhaustive inclusion of all episodes and accurate estimation based on the discharge form. CONCLUSION: The impact of RRT on hospitals has been underestimated and is very relevant when calculating the total cost of RRT. Results from other countries cannot be extrapolated due to differences in the health system and patient profile. The integration of clinical databases could open up an opportunity that needs only institutional support for its development

Clinical profile of women diagnosed with Fabry disease non receiving enzyme replacement therapy / Perfil clínico de mujeres diagnosticadas de la enfermedad de Fabry no tratadas con sustitución enzimática

Introduction and objective: Fabry disease (FD) is an X-linked lysosomal storage disorder due to a deficiency of the alpha-galactosidase A enzyme. Although women were historically considered only carriers, many studies have contradicted this fact. The main aim of this work was to set the first Spanish study out of the on-going registries on health status and management of women diagnosed with FD who were not receiving enzyme replacement therapy (ERT). Material and methods: An epidemiological, cross-sectional, descriptive and multicentre study was assessed in women diagnosed for FD who were not receiving ERT. Assessments on symptomatology and severity were collected using several clinical questionnaires. Additionally, clinical information and lab tests were obtained from clinical records. Results: Thirty-three women with a mean age of 45.6±16.2 years were studied. Symptom onset was at a median age of 35.5 years old (range: 30.0-51.5), being diagnosed a median of 2 years later (range: 1.0-1.5). Missense mutations were the most prevalent mutation (n=22, 68.8%). Although 69% considered themselves as asymptomatic, 22 (66.7%) showed at least one FD-related clinical symptom. Using Mainz Severity Score index and Fabry International Prognosis Index neurological symptomatology obtained higher scores both for severity and prognostic. The EQ-5D questionnaire showed 42.2% patients referring to some anxiety or depression, and 30.3% thought that their life was somehow altered by the pain. 62.5% were not receiving any treatment and ERT was offered only to one patient (3.6%) who refused it. Conclusions: Although most of the heterozygous women for FD had not received ERT or either symptomatic treatment, they present symptoms of disease. Careful follow-up of female patients or some adjuvant treatment may be considered to delay progressive organ damage and improve patient quality of life

Introducción y objetivo: La enfermedad de Fabry (EF) es un trastorno de almacenamiento lisosómico hereditario, ligado al cromosoma X y derivado de una deficiencia de la enzima alpha-galactosidasa A. Aunque históricamente solo se ha considerado portadoras a las mujeres, esto ha sido contradicho por muchos estudios. El objetivo principal de este trabajo ha sido establecer un primer estudio español independiente de los registros actuales sobre la situación y seguimiento clínico de las mujeres diagnosticadas con EF que no recibían terapia de sustitución enzimática (TRE). Material y métodos: Se llevó a cabo un estudio epidemiológico, transversal, descriptivo y multicéntrico en mujeres diagnosticadas con EF que no recibían TRE. Las evaluaciones sobre la sintomatología y la gravedad fueron recopiladas mediante varios cuestionarios clínicos. Adicionalmente se obtuvo información clínica y resultados de pruebas de laboratorio de las historias clínicas. Resultados: Se estudiaron 33 mujeres con una edad media de 45,6±16,2 años. El inicio de los síntomas se produjo a una mediana de edad de 35,5 años (rango: 30,0-51,5), siendo diagnosticado en una mediana de 2 años después (rango: 1,0-1,5). Las mutaciones de sentido erróneo fueron las más frecuentes (n=22; 68,8%). Aunque el 69% se consideraron a sí mismas asintomáticas, 22 (66,7%) mostraron al menos un síntoma clínico relacionado con la EF. Utilizando el índice de severidad de Mainz y el índice pronóstico internacional de Fabry, la sintomatología neurológica obtuvo puntuaciones más altas tanto para la gravedad como para el pronóstico. El cuestionario de calidad de vida EQ-5D mostró que el 42,2% de las pacientes referían cierta ansiedad o depresión, y el 30,3% pensó que su vida estaba interferida de alguna manera por el dolor. El 62,5% no recibía ningún tratamiento y solo se ofreció TRE a una paciente (3,6%), que lo rechazó. Conclusiones: Aunque la mayoría de las mujeres heterocigotas para la EF no habían recibido TRE, ni tampoco ningún tratamiento sintomático, sí presentan síntomas de la enfermedad. Un seguimiento cuidadoso de las pacientes junto con alguna terapia adyuvante podría ser de interés para retrasar el daño progresivo de los órganos y mejorar la calidad de vida de las pacientes

Impact of first year renal replacement therapy on the hospital admissions of a regional public health system. / Impacto del primer año de tratamiento sustitutivo renal en la hospitalización de una comunidad autónoma.

INTRODUCTION AND OBJECTIVES: Chronic kidney disease has a high prevalence and economic impact, and an increased risk of hospitalization. Although there are public regional and country registries, we have not found references to estimate the impact of renal replacement therapy (RRT) on hospital admissions. METHODS: We obtained authorization from the ethics committee and health authorities to integrate the REMER [Madrid Kidney Disease Registry] (2013-2014) and Minimum Basic Data Set (2013-2015) databases and to analyze the admissions during the first year of RRT. RESULTS: 767 patients started RRT in all the hospitals of our region across all RRT modalities. More than a third of the patients start dialysis during a hospital admission. This unplanned start, more common in HD than PD, shows relevant differences in patient profile or admission characteristics. Without considering this initial episode, almost 60% of patients were admitted during their first year. The hospitalization rate was 1.2admissions/patient, higher in HD than in TX or PD; the mean length of stay was 8.6days. The estimated cost of admissions during the first year is €12,006/patient. Our analysis ensures the exhaustive inclusion of all episodes and accurate estimation based on the discharge form. CONCLUSION: The impact of RRT on hospitals has been underestimated and is very relevant when calculating the total cost of RRT. Results from other countries cannot be extrapolated due to differences in the health system and patient profile. The integration of clinical databases could open up an opportunity that needs only institutional support for its development.

Clinical profile of women diagnosed with Fabry disease non receiving enzyme replacement therapy.

INTRODUCTION AND OBJECTIVE: Fabry disease (FD) is an X-linked lysosomal storage disorder due to a deficiency of the α-galactosidase A enzyme. Although women were historically considered only carriers, many studies have contradicted this fact. The main aim of this work was to set the first Spanish study out of the on-going registries on health status and management of women diagnosed with FD who were not receiving enzyme replacement therapy (ERT). MATERIAL AND METHODS: An epidemiological, cross-sectional, descriptive and multicentre study was assessed in women diagnosed for FD who were not receiving ERT. Assessments on symptomatology and severity were collected using several clinical questionnaires. Additionally, clinical information and lab tests were obtained from clinical records. RESULTS: Thirty-three women with a mean age of 45.6±16.2 years were studied. Symptom onset was at a median age of 35.5 years old (range: 30.0-51.5), being diagnosed a median of 2 years later (range: 1.0-1.5). Missense mutations were the most prevalent mutation (n=22, 68.8%). Although 69% considered themselves as asymptomatic, 22 (66.7%) showed at least one FD-related clinical symptom. Using Mainz Severity Score index and Fabry International Prognosis Index neurological symptomatology obtained higher scores both for severity and prognostic. The EQ-5D questionnaire showed 42.2% patients referring to some anxiety or depression, and 30.3% thought that their life was somehow altered by the pain. 62.5% were not receiving any treatment and ERT was offered only to one patient (3.6%) who refused it. CONCLUSIONS: Although most of the heterozygous women for FD had not received ERT or either symptomatic treatment, they present symptoms of disease. Careful follow-up of female patients or some adjuvant treatment may be considered to delay progressive organ damage and improve patient quality of life.

Déficit de testosterona en los pacientes en diálisis: diferencias según la técnica de diálisis / Testosterone deficiency in dialysis patients: Difference between dialysis techniques

Los varones con enfermedad renal crónica cursan a menudo con deficiencia en testosterona. Se desconoce si el déficit de testosterona que acompaña a la pérdida de función renal se asocia con el tipo de tratamiento sustitutivo de la función renal. Métodos: El estudio de corte transversal incluyó 79 varones prevalentes en diálisis, 43 en hemodiálisis (HD) y 36 en diálisis peritoneal (DP). Con una edad media de 69 años, el 31,6% eran diabéticos. Se evaluaron los niveles de testosterona endógena (inmunoluminiscencia: N 3-10,5ng/ml), marcadores nutricionales/inflamatorios, marcadores de metabolismo óseo mineral, anemia, tipo de técnica y permanencia. La composición corporal fue estimada mediante bioimpedancia vectorial y espectroscópica. Se considera déficit de testosterona cuando los niveles son inferiores a 3ng/ml. Resultados: Los niveles de testosterona medios fueron 8,81±6,61ng/ml. El 39,5% de los pacientes en HD y el 5,6% de los de DP presentaban déficit de testosterona. Los niveles de testosterona se correlacionaron directamente con el tipo de técnica, HD (rho Spearman 0,366; p < 0,001) y el tiempo de permanencia (Rho −0,412; p=0,036) en el análisis univariante y solo con la técnica de HD en el multivariante. No se encontraron otras correlaciones significativas. Conclusiones: Los niveles circulantes de testosterona en hombres en diálisis se asocian de manera independiente con la técnica de HD. Se puede concluir que, en la reducción de testosterona que acompaña de manera natural a la pérdida de masa muscular e inflamación, se asocia un nuevo factor que es la técnica dialítica. Se necesitan estudios para elucidar si la técnica per se favorece la eliminación de testosterona (AU)

Testosterone deficiency is a prevalent condition in male patients with chronic kidney disease. However, it is not known whether the type of renal replacement therapy has an impact on testosterone deficiency that accompanies loss of renal function. Methods: The cross-sectional study enrolled 79 prevalent male patients on dialysis; 43 on haemodialysis (HD) and 36 on peritoneal dialysis (PD). The median age was 69 years and 31.6% were diabetics. Endogenous testosterone levels were measured by immunoluminescence assay (normal range 3-10.5ng/ml), while nutritional/inflammatory markers, bone and mineral metabolism markers, anaemia, type of dialysis technique and time on dialysis were also assessed. Body composition was evaluated by bioimpedance vector analysis and bioimpedance spectroscopy. Testosterone deficiency was defined as levels below 3ng/ml. Results: Mean testosterone levels were 8.81±6.61ng/ml. Testosterone deficiency affected 39.5% of HD patients and only 5.6% of PD patients. In the univariate analysis, testosterone levels were directly correlated with type of dialysis technique (HD) (Rho Spearman 0.366; P<.001) and time on dialysis (Rho −0.412; P=.036) and only with the HD technique in the multivariate analysis. No other significant correlations were found. Conclusions: Circulating testosterone levels in men on dialysis were independently associated with HD technique. It can be concluded that a new factor —namely the dialysis technique— may be associated with falling testosterone levels and the associated loss of muscle mass and inflammation. Further studies are needed to establish whether the dialysis technique itself triggers testosterone elimination (AU)

Testosterone deficiency in dialysis patients: Difference between dialysis techniques. / Déficit de testosterona en los pacientes en diálisis: diferencias según la técnica de diálisis.

Testosterone deficiency is a prevalent condition in male patients with chronic kidney disease. However, it is not known whether the type of renal replacement therapy has an impact on testosterone deficiency that accompanies loss of renal function. METHODS: The cross-sectional study enrolled 79 prevalent male patients on dialysis; 43 on haemodialysis (HD) and 36 on peritoneal dialysis (PD). The median age was 69 years and 31.6% were diabetics. Endogenous testosterone levels were measured by immunoluminescence assay (normal range 3-10.5ng/ml), while nutritional/inflammatory markers, bone and mineral metabolism markers, anaemia, type of dialysis technique and time on dialysis were also assessed. Body composition was evaluated by bioimpedance vector analysis and bioimpedance spectroscopy. Testosterone deficiency was defined as levels below 3ng/ml. RESULTS: Mean testosterone levels were 8.81±6.61ng/ml. Testosterone deficiency affected 39.5% of HD patients and only 5.6% of PD patients. In the univariate analysis, testosterone levels were directly correlated with type of dialysis technique (HD) (Rho Spearman 0.366; P<.001) and time on dialysis (Rho -0.412; P=.036) and only with the HD technique in the multivariate analysis. No other significant correlations were found. CONCLUSIONS: Circulating testosterone levels in men on dialysis were independently associated with HD technique. It can be concluded that a new factor -namely the dialysis technique- may be associated with falling testosterone levels and the associated loss of muscle mass and inflammation. Further studies are needed to establish whether the dialysis technique itself triggers testosterone elimination.

Cambios en la prescripción de antimicrobianos utilizados en un hospital infantil / Changes in the antimicrobials prescription used in a pediatric hospital

Se realizó un estudio descriptivo y transversal de 32 niños, tratados con antimicrobianos, quienes se encontraban ingresados en el Hospital Infantil Norte Docente "Dr. Juan de la Cruz Martínez Maceira" de Santiago de Cuba, desde julio hasta diciembre del 2013, con vistas a identificar los cambios en la prescripción de estos antimicrobianos. Se halló que la mayoría de estas prescripciones se realizaron en los pacientes de 4-5 años de edad que presentaron infecciones respiratorias, y el agente causal mayormente aislado fue el neumococo. Entre los antibacterianos que fueron cambiados primaron: penicilinas, cefalosporinas y macrólidos, los cuales se sustituyeron debido a la inadecuada evolución de los afectados, así como a los resultados del antibiograma. Otras variables, tales como edad, localización de la infección, así como tipo y duración del tratamiento no influyeron en la decisión del cambio.

A descriptive and cross-sectional study of 32 children, treated with antimicrobials who were admitted in "Dr. Juan de la Cruz Martínez Maceira" Northern Teaching Children Hospital in Santiago de Cuba, was carried out from July to December, 2013, aimed at identifying the changes in the prescription of these antimicrobials. It was found that most of these prescriptions were carried out in the 4-5 years patients that presented breathing infections, and the most isolated causal agent was the pneumococcus. Among the antibacterial drugs that were changed prevailed: penicillins, cephalosporins and macrolids, which were substituted due to the inadequate clinical course of those affected, as well as to the results of the antibiogram. Other variables, such as age, localization of the infection, as well as type and duration of the treatment didn't influence in the decision of the change.

Cambios en la prescripción de antimicrobianos utilizados en un hospital infantil / Changes in the antimicrobials prescription used in a pediatric hospital

Se realizó un estudio descriptivo y transversal de 32 niños, tratados con antimicrobianos, quienes se encontraban ingresados en el Hospital Infantil Norte Docente Dr Juan de la Cruz Martínez Maceira de Santiago de Cuba, desde julio hasta diciembre del 2013, con vistas a identificar los cambios en la prescripción de estos antimicrobianos. Se halló que la mayoría de estas prescripciones se realizaron en los pacientes de 4-5 años de edad que presentaron infecciones respiratorias, y el agente causal mayormente aislado fue el neumococo. Entre los antibacterianos que fueron cambiados primaron: penicilinas, cefalosporinas y macrólidos, los cuales se sustituyeron debido a la inadecuada evolución de los afectados, así como a los resultados del antibiograma. Otras variables, tales como edad, localización de la infección, así como tipo y duración del tratamiento no influyeron en la decisión del cambio(AU)

A descriptive and cross-sectional study of 32 children, treated with antimicrobials who were admitted in Dr. Juan de la Cruz Martínez Maceira Northern Teaching Children Hospital in Santiago de Cuba, was carried out from July to December, 2013, aimed at identifying the changes in the prescription of these antimicrobials. It was found that most of these prescriptions were carried out in the 4-5 years patients that presented breathing infections, and the most isolated causal agent was the pneumococcus. Among the antibacterial drugs that were changed prevailed: penicillins, cephalosporins and macrolids, which were substituted due to the inadequate clinical course of those affected, as well as to the results of the antibiogram. Other variables, such as age, localization of the infection, as well as type and duration of the treatment didn't influence in the decision of the change(AU)

The alpha-galactosidase A p.Arg118Cys variant does not cause a Fabry disease phenotype: data from individual patients and family studies.

Lysosomal α-galactosidase A (α-Gal) is the enzyme deficient in Fabry disease (FD), an X-linked glycosphingolipidosis caused by pathogenic mutations affecting the GLA gene. The early-onset, multi-systemic FD classical phenotype is associated with absent or severe enzyme deficiency, as measured by in vitro assays, but patients with higher levels of residual α-Gal activity may have later-onset, more organ-restricted clinical presentations. A change in the codon 118 of the wild-type α-Gal sequence, replacing basic arginine by a potentially sulfhydryl-binding cysteine residue - GLA p.(Arg118Cys) -, has been recurrently described in large FD screening studies of high-risk patients. Although the Cys118 allele is associated with high residual α-Gal activity in vitro, it has been classified as a pathogenic mutation, mainly on the basis of theoretical arguments about the chemistry of the cysteine residue. However its pathogenicity has never been convincingly demonstrated by pathology criteria. We reviewed the clinical, biochemical and histopathology data obtained from 22 individuals of Portuguese and Spanish ancestry carrying the Cys118 allele, including 3 homozygous females. Cases were identified either on the differential diagnosis of possible FD manifestations and on case-finding studies (n=11; 4 males), or on unbiased cascade screening of probands' close relatives (n=11; 3 males). Overall, those data strongly suggest that the GLA p.(Arg118Cys) variant does not segregate with FD clinical phenotypes in a Mendelian fashion, but might be a modulator of the multifactorial risk of cerebrovascular disease. The Cys118 allelic frequency in healthy Portuguese adults (n=696) has been estimated as 0.001, therefore not qualifying for "rare" condition.

Pacientes con Giardia lamblia diagnosticada por frotis duodenal / Patients with Giardia lamblia diagnosed through duodenal smear

Se efectuó un estudio descriptivo y transversal de 105 pacientes mayores de 15 años con infección por Giardia lamblia, diagnosticada por frotis duodenal mediante endoscopia en el Servicio de Gastroenterología del Policlínico de Especialidades del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, desde enero hasta diciembre del 2012, con vistas a caracterizarles. Entre las variables analizadas figuraron: edad, sexo, síntomas digestivos referidos, positividad del frotis e imagen endoscópica. Se utilizó el porcentaje como medida de resumen. Predominaron el sexo femenino (58,0 %), el grupo etario de 29-39 años (38,0 %), la epigastralgia como síntoma principal (66,6 %) y las imágenes endoscópicas grados I y II como las más frecuentes (68,4 y 41,3 %, respectivamente). El índice de positividad a la giardiasis fue relevante.

A descriptive and cross sectional study of 105 patients older than 15 years with infection by Giardia lamblia, diagnosed through duodenal smear by means of endoscopy was carried out in the Gastroenterology Service of the Specialties Polyclinic from "Saturnino Lora Torres" Teaching Provincial Clinical Surgical Hospital in Santiago de Cuba, from January to December, 2012, with the objective of characterizing them. Among the analyzed variables there were: age, sex, referred digestive symptoms, positivity of the smear and endoscopic image. The percentage was used as summary measure. Female sex (58.0%), the age group 29-39 years (38.0%), the epigastralgia as main symptom (66.6%) and the endoscopic images grades I and II prevailed as the most frequent (68.4 and 41.3%, respectively). The positivity index for giardiasis was relevant.

Pacientes con Giardia lamblia diagnosticada por frotis duodenal / Patients with Giardia lamblia diagnosed through duodenal smear

Se efectuó un estudio descriptivo y transversal de 105 pacientes mayores de 15 años con infección por Giardia lamblia, diagnosticada por frotis duodenal mediante endoscopia en el Servicio de Gastroenterología del Policlínico de Especialidades del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba, desde enero hasta diciembre del 2012, con vistas a caracterizarles. Entre las variables analizadas figuraron: edad, sexo, síntomas digestivos referidos, positividad del frotis e imagen endoscópica. Se utilizó el porcentaje como medida de resumen. Predominaron el sexo femenino (58,0 por ciento), el grupo etario de 29-39 años (38,0 por ciento), la epigastralgia como síntoma principal (66,6 por ciento) y las imágenes endoscópicas grados I y II como las más frecuentes (68,4 y 41,3 por ciento, respectivamente). El índice de positividad a la giardiasis fue relevante(AU)

A descriptive and cross sectional study of 105 patients older than 15 years with infection by Giardia lamblia, diagnosed through duodenal smear by means of endoscopy was carried out in the Gastroenterology Service of the Specialties Polyclinic from Saturnino Lora Torres Teaching Provincial Clinical Surgical Hospital in Santiago de Cuba, from January to December, 2012, with the objective of characterizing them. Among the analyzed variables there were: age, sex, referred digestive symptoms, positivity of the smear and endoscopic image. The percentage was used as summary measure. Female sex (58.0 percent), the age group 29-39 years (38.0 percent), the epigastralgia as main symptom (66.6 percent) and the endoscopic images grades I and II prevailed as the most frequent (68.4 and 41.3 percent, respectively). The positivity index for giardiasis was relevant.(AU)

Bisphenol a in chronic kidney disease.

Phenols are uremic toxins of intestinal origin formed by bacteria during protein metabolism. Of these molecules, p-cresol is the most studied and has been associated with renal function impairment and vascular damage. Bisphenol A (BPA) is a molecule with structural similarity with phenols found in plastic food and beverage containers as well as in some dialyzers. BPA is considered an environmental toxicant based on animal and cell culture studies. Japanese authorities recently banned BPA use in baby bottles based on observational association studies in newborns. BPA is excreted in urine and uremic patients present higher serum levels, but there is insufficient evidence to set cut-off levels or to link BPA to any harmful effect in CKD. However, the renal elimination and potential exposure during dialysis warrant the monitoring of BPA exposure and the design of observational studies in which the potential health risks of BPA for end-stage renal disease patients are evaluated.

[Bacteraemia at a second level hospital: epidemiological study, analysis of pronostic factors associated to mortality and economic cost estimation]. / Bacteriemias en un hospital de segundo nivel: estudio epidemiológico, análisis de factores pronósticos asociados a mortalidad y estimación de su coste económico.

INTRODUCTION: Bacteraemia (B) accounts for a considerable proportion (0.36%) of all hospital admissions due to infections diseases and it is associated to increased hospital costs. The aim of this study is to describe a cohort of patients with bacteraemia at a second level hospital, to analyze factors associated to mortality and its economical impact during hospital admission. PATIENTS AND METHODS: Observational study of a cohort of adult patients with bacteraemia admitted at a second level hospital during 2010. Data collection from clinical records has been done according to a standard protocol: epidemiological and clinical variables and factors associated to mortality were analysed. Total economical cost per patient was estimated. RESULTS: 148 patients were included: 80 community B (55.4%), 23 health care associated B (15.5%) and 45 nosocomial B (28.5%). The incidence was 9 cases 10.000 persons/year. Mean age was 69 years and the global mortality was 24%. In bivariate analysis smoking, diabetes mellitus, McCabe Jackson score type I-II, Pitt Index ≥ 3, APACHE ≥ 20, Glasgow ≤ 9, shock, respiratory distress, invasive procedures, nosocomial bacteraemia and inadequate empiric or definitive antibiotic treatment were associated to mortality (p<0.05). Factors associated to mortality in multivariate analysis included McCabe Jackson score type I-II (OR 4.95; 95% CI 1.095-22.38), haemodialysis during acute stage (OR 7.8; 95% CI 2.214-27.773) and inadequate empiric antibiotic treatment (OR 7.68; 95% CI 19.82-29.77). Admission economic cost per patient was 9,459 € for community acquired bacteriemia, 5,656 € for health care associated bacteraemia and 41,680€ for nosocomial bacteraemia. CONCLUSIONS: Comorbidity, inadequate empiric antibiotic treatment and haemodialysis during acute phase are statistically significantly in our cohort of patients with bacteraemia.

Análisis comparado del marco jurídico sobre Calidad de la Atención y Seguridad del Paciente (CASP) en América Latina, España y la Comunidad Europea

El 5 de octubre del 2007 durante la 27.ª Conferencia Sanitaria Panamericana, se emite la Resolución CSP27/10 sobre Política y Estrategia Regional para la Garantía de la Calidad de la Atención Sanitaria, incluyendo la Seguridad del Paciente (CASP). Esta Resolución se basa en el documento presentado el 17 de julio del mismo año (CSP27/16), que define la calidad de la atención, incluyendo la seguridad del paciente, como la cualidad de la atención sanitaria esencial para la consecución de los objetivos nacionales de salud, la mejora de la salud de la población y el futuro sostenible del sistema de atención en salud.

Bacteriemias en un hospital de segundo nivel: Estudio epidemiológico, análisis de factores pronósticos asociados a mortalidad y estimación de su coste económico / Bacteraemia at a second level hospital: epidemiological study, analysis of pronostic factors associated to mortality and economic cost estimation

Introducción. Las bacteriemias (B) representan el 0,36% de los ingresos por patología infecciosa y generan un gasto sanitario importante. El objetivo es analizar una cohorte de pacientes con bacteriemia ingresados en un hospital de segundo nivel: determinar las características epidemiológicas y los factores asociados a mortalidad y estimar su coste. Pacientes y Métodos. Estudio observacional retrospectivo de una cohorte de pacientes adultos ingresados con bacteriemia verdadera en un hospital de segundo nivel durante el año 2010. Se recopilaron los datos clínicos y epidemiológicos de los pacientes y se analizaron los factores asociados a mortalidad. Se estimó el coste económico del ingreso por paciente. Resultados. Se incluyeron 148 episodios: 80 B comunitarias (55,4%), 23 B asociadas a cuidados sanitarios (15,5%) y 45 B nosocomiales (28,5%). La incidencia fue de 9 casos 10.000 habitantes/ año. La edad media fue de 69 años y la mortalidad global del 24%. En el análisis bivariante se asociaron a mortalidad (p< 0,05): hábito tabaquico, diabetes mellitus, McCabe Jackson tipo I-II, índice de Pitt >= 3, APACHE >= 20, Glasgow <=9, shock, distress respiratorio, la necesidad de algún procedimiento invasivo, la bacteriemia nosocomial y el tratamiento antibiótico empírico o definitivo incorrecto. En el análisis multivariante se asociaron de forma estadísticamente significativa con la mortalidad: McCabe tipo I-II (OR 4,95; IC 95% 1,095-22,38), necesidad de hemodiálisis durante el proceso clínico (OR 7,8; IC 95% 2,214-27,773) y tratamiento empírico inadecuado (OR 7,68; IC 95% 19,82- 29,77). El coste estimado por paciente es de 9.459€ en el caso de las B comunitarias, 5.656€ para las B asociadas a los cuidados sanitarios y 41.680€ para las B nosocomiales. Conclusiones. La gravedad de la enfermedad de base, el tratamiento antibiótico empírico inadecuado y la necesidad de hemodiálisis durante el proceso clínico son los principales factores pronósticos de mortalidad en nuestra cohorte de pacientes con bacteriemia(AU)

Introduction. Bacteraemia (B) accounts for a considerable proportion (0.36%) of all hospital admissions due to infections diseases and it is associated to increased hospital costs. The aim of this study is to describe a cohort of patients with bacteraemia at a second level hospital, to analyze factors associated to mortality and its economical impact during hospital admission. Patients and Methods. Observational study of a cohort of adult patients with bacteraemia admitted at a second level hospital during 2010. Data collection from clinical records has been done according to a standard protocol: epidemiological and clinical variables and factors associated to mortality were analysed. Total economical cost per patient was estimated. Results. 148 patients were included: 80 community B (55.4%), 23 health care associated B (15.5%) and 45 nosocomial B (28.5%). The incidence was 9 cases 10.000 persons/year. Mean age was 69 years and the global mortality was 24%. In bivariate analysis smoking, diabetes mellitus, McCabe Jackson score type I-II, Pitt Index >=3, APACHE >= 20, Glasgow <=9, shock, respiratory distress, invasive procedures, nosocomial bacteraemia and inadequate empiric or definitive antibiotic treatment were associated to mortality (p<0.05). Factors associated to mortality in multivariate analysis included McCabe Jackson score type I-II (OR 4.95; 95% CI 1.095-22.38), haemodialysis during acute stage (OR 7.8; 95% CI 2.214-27.773) and inadequate empiric antibiotic treatment (OR 7.68; 95% CI 19.82- 29.77). Admission economic cost per patient was 9,459€ for community acquired bacteriemia, 5,656€ for health care associated bacteraemia and 41,680€ for nosocomial bacteraemia. Conclusions. Comorbidity, inadequate empiric antibiotic treatment and haemodialysis during acute phase are statistically significantly in our cohort of patients with bacteraemia(AU)