An update of the Italian Stroke Organization-Stroke Prevention Awareness Diffusion Group guidelines on carotid endarterectomy and stenting: a personalized medicine approach

Although proof-based medicine has generated much valid evidence for the drawing up of guidelines and recommendations for best clinical practice in symptomatic and asymptomatic carotid stenosis, whether and when it is better to employ endarterectomy or stenting as the intervention of choice still remain matters of debate. Moreover, guidelines have been targeted up to now to the 'representative' patient, as resulting from the statistical analyses of the studies conducted on the safety and efficacy of both interventions as well as on medical therapy alone. The Italian Stroke Organization (ISO) and Stroke Prevention and Awareness Diffusion (SPREAD) group has thus decided to update its statements for an 8th edition. To this end, a multidisciplinary team of authors representing Italian scientific societies in the neurology, neuroradiology, vascular and endovascular surgery, interventional cardiology, and general medicine fields re-examined the literature available on stroke. Analyses and considerations on patient subgroups have allowed to model the risks/benefits of endarterectomy and stenting in the individual. Accordingly, the guideline's original methodology has been revised to follow the new SIGN (Scottish Intercollegiate Guideline Network) Grade-like approach, integrating it with new considerations on Precision, or Personalized Medicine. Therefore, this guideline offers recommendations on precision medicine for the single patient, and can be followed in addition to the more standard guidelines.

[Management of a first depressive episode in the primary care setting. Use of antidepressants and referrals]. / Manejo en atención primaria de un primer episodio depresivo. Uso de antidepresivos y derivaciones.

INTRODUCTION: The majority of patients who have a first depressive episode are treated by Primary Care physicians. The aim of this study was to evaluate the use of antidepressants and referrals to mental health and the treatment modifications made by psychiatrists. MATERIAL AND METHODS: A descriptive, retrospective study was conducted on patients from 64 Primary Care clinics, distributed in five Spanish provinces. The clinical history data, regarding use of antidepressants, criteria for referral, and response of psychiatric services were evaluated from June 2008 to June 2011. RESULTS: The study included 324 patients. The most commonly prescribed medication was escitalopram, with selective serotonin reuptake inhibitors (SSRI) making up 73.5% of the total. More than two-thirds (69.7%) of the patients were on treatment for at least 6 months, with no reason recorded for the 40.4% drop-outs. A large majority of professionals (76.9%) wait at least 3 weeks before modifying the medication, especially changing antidepressant. The Primary Care physicians referred 39.2% of patients to psychiatry, although much of these referrals (43.9%) had no justification. There was a lower referral rate to psychology (23.1%). An antidepressant was given to a large number of patients on multiple medications, without taking into account the risk of interactions in a high percentage. CONCLUSIONS: The Primary Care physician appropriately uses the antidepressants of the first choice, but does not pay attention to the risks in complex patients. There must be an appropriate duration of treatment and an improvement of the criteria for referral to mental health services.

Síndrome confusional agudo por adenoma paratiroideo: una enfermedad metabólica de tratamiento quirúrgico / Acute confusional state due to parathyroid adenoma: a metabolic disorder requiring surgical treatment

El diagnóstico diferencial del síndrome confusional agudo abarca un gran número de procesos entre los que hay que considerar firmemente las enfermedades metabólicas. El diagnóstico del hiperparatiroidismo como causa del mismo debe apoyarse en parámetros biológicos, y su tratamiento tiene un enfoque inicial destinado a corregir el trastorno neuropsiquiátrico y otro definitivo basado en la cirugía para revertir la desmineralización ósea y la mortalidad ulterior relacionada con la hipercalcemia. El abordaje quirúrgico debe efectuarse por cirujanos experimentados, cuyo objetivo principal conlleva la extirpación de la glándula enferma mediante técnicas lo menos agresivas posibles. Los estudios de imagen preoperatorios pueden contribuir a un abordaje selectivo que evite una exploración cervical bilateral. La determinación intraoperatoria de hormona paratiroidea intacta (PTHi), o el empleo de sonda isotópica, contribuyen a asegurar una solución quirúrgica efectiva

The differential diagnosis of acute confusional state encompasses a large number of processes including metabolic diseases. The diagnosis of hyperparathyroidism as a cause of acute confusional state should rest on biological parameters; treatment should initially be focused on correcting the neuropsychological disorder and then definitive surgical treatment should be undertaken to reverse bone demineralization and ulterior mortality related to hypercalcemia. The surgical approach should be carried out by experienced surgeons with the principal aim of extirpating the diseased gland using the least aggressive techniques possible. Preoperative imaging studies can help to ensure a selective approach that obviates bilateral cervical exploration. Intraoperative determination of intact parathyroid hormone (PTHi) levels or the use of a gamma probe help to ensure an effective surgical solution

Efecto de la edad y de la menopausia sobre la masa ósea / Effect of age and menopause on bone mass

Objetivos. Estudiar la variación en la pérdida de masa ósea que se produce en la columna lumbar y cadera durante los años previos a la aparición de la menopausia y durante la misma. Material y método. Análisis prospectivo de la masa ósea mediante densitometría ósea a mujeres sin medicación previa. Resultados. Estudio de 316 mujeres, el 81,6% con menopausia. Existe relación lineal negativa significativa entre la masa ósea y la menopausia en la columna lumbar y la cadera, con una fuerza de relación homogénea en la columna lumbar, siendo ésta más intensa en la cadera. Al nivel lumbar se aprecia una pérdida de hueso global del 17,6%, siendo más rápida en los 10 primeros años; en la cadera el porcentaje de pérdida es mayor. Discusión. Existe importante pérdida de masa ósea con la menopausia, mayor que la esperable sólo por la edad, más intensa en triángulo de Ward seguido del cuello, trocánter y columna lumbar; esto mismo aunque en menor intensidad ocurre en la época de la premenopausia

Objectives. To study the variation in bone loss in the lumbar spine and hip during pre- and postmenopausal periods. Material and method. Prospective analysis of the bone mass assessing the bone mineral density in women without previous medication. Results. Three hundred-sixteen women were studied, 81.6% of them were menopausal. We found a statistically significant negative linear correlation at lumbar spine and hip in all locations, with a homogenous force in lumbar spine, this being the most intense in the hip. On the lumbar level there was a decrease of 17.6% of the global bone mass, this loss being faster during the first ten years. The loss was greater in the hip. Conclusions. There is a clear loss of bone mass during the menopause, greater than that expected only due to age. The location with the most bone loss is the Ward's triangle, followed by the neck and the trocanter of the hip and the lumbar spine. The same, although on a smaller scale, was found during premenopause

The Charles River "hairless" rat mutation maps to chromosome 1: allelic with fuzzy and a likely orthologue of mouse frizzy.

Recent evidence has indicated that the recessive mutation affecting hypotrichosis in the Charles River (CR) "hairless" rat does not involve the hairless gene (hr) on rat chromosome 15. To determine if this mutation might be allelic (or orthologous) with any other previously mapped hypotrichosis-generating mutation in mammals, we have produced a panel of backcross rats segregating for the CR hairless rat mutation as well as numerous other markers from throughout the rat genome. Analysis of this panel has located the CR hairless rat's hypotrichosis-generating mutation on chromosome 1, near Myl2, where only the fuzzy mutation in rat (fz) and the frizzy mutation in mouse (fr) have been previously localized. Intercrossing fz/fz and CR hairless rats produced hybrid offspring with abnormal hair, showing that these two rat mutations are allelic. We suggest that the CR hairless rat mutation and fuzzy be renamed frizzy-Charles River (fr(CR)) and frizzy-Harlan (fr(H)), respectively, to reflect their likely orthology with the mouse fr mutation.

Hipertensión arterial por displasia fibromuscular en dos hermanas / Hypertension for fibromuscular dysplasia in two sisters

Presentamos a dos hermanas con hipertensión arterial descubierta cuando se encontraban embarazadas y producida en ambos casos por displasia fibromuscular de las arterias renales. Comentamos la infrecuente incidencia familiar de la misma y sus posibles causas y revisamos los procedimientos diagnósticos y terapéuticos utilizados (AU)

[Referral of patients with mental disorders from primary care to mental health units]. / Derivación de los pacientes con enfermedad mental desde Atención Primaria a Salud Mental.

INTRODUCTION: Most part of the patients suffering from mental disorders are treated by non-psychiatrist physicians, mainly by general practitioners (GPs). The aim of this study has been to analyse the factors influencing the referral of patients with mental illness to psychiatric services. METHODS: Using data of referrals from two Primary Care Centres (population: 28.039) to a Mental Health Unit in one year period, we analysed clinical records, information provided with the referral, and the opinion of GPs about mental illness. RESULTS: Out of the 486 referrals, the 153 patients without previous consultations were included in the analysis. Men, and those with higher educational status were referred more frequently. A 34% of the referrals included information about psychopathological symptoms, and 70% included clinical diagnosis. Primary care physicians specialised in family medicine included more data regarding psychopathological symptoms, and included a specific request more often than GPs without specialised training. Diagnostic accuracy (61%) were lower for adjustment and personality disorders, and in those patients with an urgent referral. Patients with an urgent referral did not present different clinical features, nor different severity than those with an ordinary referral. CONCLUSIONS: Management of patients with mental disorders in PHC should be improved with guidelines about treatment and referral. Different levels of care should be co-ordinated.

Remoçäo do folículo dominante por aspiraçäo transvaginal guiada por ultra-som e resposta superovulatória em vacas Nelore / Dominant follicle removal by ultrasound guided transvaginal aspiration and superovulatory response in Nellore cows

O presente estudo analisou o significado fisiológico do folículo dominante (FD) e sua remoçäo na resposta superovulatória de 42 vacas Nelore e testou a hipótese de que o número de folículos subordinados pequenos (3-8mm) poderia ser usado como critério único para a avaliaçäo da presença ou ausência de um FD nos ovários. Exames ultra-sonográficos foram realizados dois dias antes do início do tratamento superovulatório (D0) e as vacas foram divididas em três grupos: grupo sem FD (SFD), grupo com FD (FD) e grupo com um FD aspirado (FDA). A resposta superovulatória das doadoras näo diferiu entre os grupos, mas a taxa de viabilidade embrionária foi maior nos grupos SFD (69,40 por cento) e FDA (68,99 por cento) grupos, comparados ao FD (48,54 por cento). O número de estruturas näo fertilizadas näo diferiu entre os grupos SFD e FD nem entre SFD e FDA, mas foi maior no grupo FD comparados ao FDA. Pode-se concluir que, em vacas Nelore, a determinaçäo do número de folículos subordinados é um critério seguro para a avaliaçäo da presença ou ausência de um FD nos ovários, mas erros poderiam ser evitados se apenas folículos de 4-8mm fossem considerados, e que a presença de um FD no início da superovulaçäo reduz a taxa de viabilidade embrionária e sua remoçäo por aspiraçäo transvaginal guiada por ultra-som induziu taxas de viabilidade embrionárias semelhantes àquelas observadas na ausência de um FD

Plant litter feedback and population dynamics in an annual plant, Cardamine pensylvanica.

The presence of litter has the potential to alter the population dynamics of plants. In this paper, we explore the effects of litter on population dynamics using a simple experimental laboratory system with populations of the annual crucifer, Cardamine pensylvanica. Using a factorial experiment with four densities and three litter levels, we determined the effect of litter on biomass and plant fecundity, and the life stages responsible for these changes in yield. Although litter had significant effects on seed germination and on seedling survivorship, we show, using a population dynamics model, that these effects were not demographically significant. Rather, the potential effect of litter on population dynamics resulted almost entirely from its effect on biomass. Persistent litter suppressed plant biomass and apparently removed the direct density effect present in the absence of litter. Thus, litter changed the shape of the recruitment curve from slightly humped to asymptotic. In addition to changing the shape of the recruitment curve, litter reduced the carrying capacity of the populations. Thus, the population dynamics model indicated that not all statistically significant responses were dynamically significant. Given the potential complexity of litter effects, simple population models provide a powerful tool for understanding the potential consequences of short-term responses.

Ambulatory foot contact monitor to estimate metabolic cost of human locomotion.

The rate of metabolic energy expenditure during locomotion (Mloco) is proportional to body weight (Wb) divided by the time during each stride that a single foot contacts the ground (tc) (Nature Lond. 346: 265-267, 1990). Using this knowledge, we developed an electronic foot contact monitor. Our objective was to derive and cross-validate an equation for estimation Mloco from Wb/tc. Twelve males were tested [age = 19.4 +/- 1.4 (SD) yr, Wb = 78.4 +/- 8.0 kg] during horizontal treadmill walking (0.89, 1.34, and 1.79 m/s) and running (2.46, 2.91, and 3.35 m/s). Measured Mloco was defined as the total rate of energy expenditure, measured by indirect calorimetry, minus the estimated rate of resting energy expenditure. The equation to estimate Mloco was derived in six randomly selected subjects: Mloco = 3.702.(Wb/tc) - 149.6 (r2 = 0.93). Cross-validation in the remaining six subjects showed that estimated and measured Mloco were highly correlated (r2 = 0.97). The average individual error between estimated and measured Mloco was 0% (range -22 to 29%). In conclusion, Mloco can be accurately estimated from Wb and measurements of tc made by an ambulatory foot contact monitor.

Malignant head and neck germ cell tumours.

Malignant germ cell tumours of the head and neck are extremely rare. Their behaviour, despite aggressive surgical and adjuvant therapy, is relentless with most cases resulting in a fatal outcome. In this paper we present a case of a cervical embryonal carcinoma and review the presentation, clinical course and treatment of malignant germ cell tumours.

Comparative chemistry of elaiosomes of three species ofTrillium.

This study was designed to compare the chemistry of elaiosomes of three sympatric species ofTrillium to discover if there are correlations between chemistry and dispersal rates by ants. We quantified the amount of proteins and neutral lipids and qualitatively analyzed the fatty acids occurring in triglyceride, diglyceride, monoglyceride, and free fatty acid fractions.T. grandiflorum had the highest lipid concentration per milligram of protein and the highest total lipid per elaiosome, followed byT. erectum and then byT. undulatum. Oleic acid (18∶1) was abundant in all lipid fractions of each species. This fatty acid, which is responsible for corpse-carrying behavior in some ants, probably causes ants to pick up diaspores. Linoleic acid (18∶2) is relatively abundant inT. erectum andT. grandiflorum but not inT. undulatum and may cause ants that have picked up diaspores to move (carry) those diaspores back to the nest. Total elaiosome mass and fatty acid composition appear to explain whyT. erectum is dispersed most rapidly and why ants that have picked up elaiosomes move moreT. grandiflorum thanT. undulatum diaspores.