[Consensus statement on the use of acetaminophen/tramadol in patients with moderate-severe pain]. / Documento de consenso sobre el uso de la combinación paracetamol/tramadol en pacientes con dolor moderado-intenso.

OBJECTIVES: To present recommendations on the use of the paracetamol/tramadol (P/T) combination in patients with moderate-intense pain based on best evidence and experience. METHODS: The method of nominal groups and Delphi was followed, and supported by a systematic literature review (SLR). A multidisciplinary panel of 12 experts in pain management was selected. In the first nominal group meeting, the aim, scope, users, and sections of the consensus document, were defined, along with the preliminary general recommendations. For the SLR, the inclusion and exclusion criteria, as well as the search strategies, were defined. Two reviewers selected and analysed the articles. This evidence was discussed in a second nominal group meeting, and definitive recommendations were developed. For each recommendation, the evidence levels and grade of recommendation grades were classified according to the Oxford model, and the grade according to the Delphi technique. It was defined as an agreement if at least 70% of the participants scored ≥7 for each recommendation (1=total disagreement to 10=total agreement). RESULTS: A total of 20 recommendations were produced, which covered general aspects, such as the assessment of pain, and those specific to P/T management. These latter included the indications of the P/T combination (patient profile, dosing, prescription, formulations), risk management (contraindications, precautions, interactions, concomitant use with other medications, follow-up, special situations), and patient education. CONCLUSIONS: These recommendations attempt to resolve any of the routine clinical questions, and help in the making of decisions on the use of the P/T combination in patients with moderate-intense pain.

Factors associated with ATXN2 CAG/CAA repeat intergenerational instability in Spinocerebellar ataxia type 2.

Spinocerebellar ataxia type 2 (SCA2) is a neurodegenerative disorder caused by the unstable expansion of a cytosine-adenine-guanine (CAG)/cytosine-adenine-adenine (CAA) repeat in the ATXN2 gene, which normally encodes 22 glutamines (Q22). A large study was conducted to characterize the CAG/CAA repeat intergenerational instability in SCA2 families. Large normal alleles (Q24-31) were significantly more unstable upon maternal transmissions. In contrast, expanded alleles (Q32-750) were significantly more unstable during paternal transmissions, in correlation with repeat length. Significant correlations were found between the instability and the age at conception in paternal transmissions. In conclusion, intergenerational instability at ATXN2 locus is influenced by the sex, repeat length and age at conception of the transmitting parent. These results have profound implications for genetic counseling services.

Use of a temporary inferior vena cava filter during pregnancy in patients with thromboembolic events.

There are circumstances in the management of thromboembolic events during pregnancy when anticoagulant therapy is either contraindicated or not advisable, such as when pulmonary embolism (PE) or deep venous thrombosis is diagnosed close to term, given the risk of bleeding during delivery. In these cases, the thromboembolic risk can be controlled using temporary inferior vena cava filters (T-IVCFs). We present the case of a pregnant woman with thrombophilia who remained at rest for eight weeks due to an amniotic prolapse and for whom the placement of a T-IVCF was decided at 32 weeks' gestation after anticoagulant therapy had failed. An emergency caesarean section was performed at 33 weeks' gestation due to placental abruption following the spontaneous onset of preterm labour. The risk of bleeding during delivery when high doses of heparin are used, and the risk of PE when the heparin dose is decreased, needs to be evaluated versus the risks related to T-IVCF placement procedure and, as such, a review of the published experience in this field is warranted. We have concluded that T-IVCFs can be a safe alternative treatment for pregnant women in whom anticoagulation therapy is either contraindicated or not advisable.

Role of glutathione S-transferases in the spinocerebellar ataxia type 2 clinical phenotype.

Spinocerebellar ataxia type 2 (SCA2) is a neurodegenerative and incurable hereditary disorder caused by a CAG repeat expansion mutation on ATXN2 gene. The identification of reliable biochemical markers of disease severity is of paramount significance for the development and assessment of clinical trials. In order to evaluate the potential use of glutathione-S-transferase (GST) activity as a biomarker for SCA2, a case-control study in 38 affected, presymptomatic individuals or healthy controls was conducted. An enlarged sample of 121 affected individuals was set to assess the impact of GST activity on SCA2 clinical expression. There was a significant increase in GST activity in affected individuals relative to controls, although sensibility and specificity were not high. GST activity was not significantly influenced by sex, age, disease duration or CAG repeat size and did not significantly influence disease severity markers. These findings show a disruption of in vivo GST activity in SCA2, suggesting a role for oxidative stress in the neurodegenerative process.

The Cuban program for predictive testing of SCA2: 11 years and 768 individuals to learn from.

Having reported the world's highest prevalence of spinocerebellar ataxia type 2 (SCA2), health professionals in Cuba developed a program for the predictive testing of this condition. Between February 2001 and December 2011, a total of 1050 individuals requested their inclusion in the presymptomatic testing (PST) program. Their medical records were retrospectively analyzed in the present descriptive study. A total of 768 participants completed the protocol, 204 withdrew and 78 were excluded. The PST uptake was 24.91%. Females predominated and 70.96% had negative test results. Their main motivations were risk assessment in their descendants, physical and psychological preparation to cope with the disease and planning for the future. The profile of Cuban participants in the predictive testing program is similar to the one reported for other programs all over the world, nevertheless the genetic counseling practice at the community level is a distinctive aspect, which is valuable in providing at-risk individuals with wide and proper knowledge before their testing inclusion request. The SCA2 predictive testing program has high uptake rates and is renowned in our population. Future research is needed to assess the long-term psychological impact in the participants, their partners and relatives.

La docencia del área de Toxicología de la Universidad de La Laguna / The teaching of Toxicology at the University of La Laguna

La docencia de Toxicología en la Universidad de La Laguna (ULL) se integra en diversas Licenciaturas y Grados tales como Farmacia, Ciencia y Tecnología de los Alimentos (CTA), Medicina, Náutica y Transporte Marítimo y el Máster Oficial de Seguridad y Calidad de los Alimentos. En la Licenciatura de Farmacia en la ULL, el Área de Toxicología imparte la asignatura troncal Toxicología de 7 créditos y dos asignaturas optativas, Drogodependencias y Toxicología Clínica y Laboral, de 4,5 créditos cada una. En el Grado en Farmacia, se imparte la asignatura obligatoria de Toxicología (9 ECTS) y la asignatura optativa de Drogodependencias (6 ECTS). Asimismo, se imparte un total de 11 créditos en la Licenciatura de CTA quedando ésta extinguida en el curso académico 2013/2014. En la Licenciatura de Medicina, se imparte docencia de Toxicología en las asignaturas de Medicina Legal y Toxicología (asignado 1 crédito) y Toxicología clínica (4,5 créditos) mientras que en el Grado de Medicina se integra en las asignaturas Farmacología, anestesia y tratamiento del dolor (9 ECTS) y Aspectos éticos, aspectos legales y aspectos humanísticos de la Medicina (6 ECTS). En ellas, la Toxicología tiene asignado 1 y 0,5 ECTS, respectivamente. La Licenciatura de Náutica y Transporte Marítimo, la docencia de Toxicología se engloba en una asignatura obligatoria mientras que en el Grado en Ingeniería Radioelectrónica se incluye en una asignatura optativa (3 ECTS). En la docencia de Postgrado, la Toxicología se imparte en el Máster Oficial en Seguridad y Calidad de los Alimentos desde dos módulos con 6 ECTS cada uno de ellos (AU)

The Toxicology Department at the University of La Laguna (ULL) offers courses included in the curricula of several degrees such as Pharmacy, Food Science and Technology, Medicine, Marine and Maritime Transport, and Food Safety and Quality Master program. In the Bachelor of Pharmacy at ULL that will end in 2014/2015, the Toxicology Department offers the mandatory subject "Toxicology", with 7 credits, as well as two optional subjects ("Clinical and Professional Toxicology", and "Drug Addiction"), with 4.5 credits each. In the Degree in Pharmacy, the "Toxicology" course is a compulsory subject worth 9 credits in the European Credit Transfer System (ECTS) and the optional "Drug Addiction" subject remains, and will be worth 6 ECTS. The Toxicology Department also gives a total of 11 credits in the Food Science and Technology Bachelor that will end in the academic course 2013/2014. In the Bachelor of Medicine, Toxicology is taught in two courses: "Pharmacology, anesthesia and pain management" (9 ECTS, of which 1 ECTS is for toxicology) and "Ethical, legal and humanistic aspects of medicine" (6 ECTS, of which 0.5 ECTS is for toxicology). In the Bachelor of Nautical and Maritime Transport, Toxicology is included in a mandatory subject while in the Bachelor of Radio Electronics Engineering, Toxicology is an optional subject (3 ECTS). As for postgraduate teaching, Toxicology is taught in the Master program in Food Safety and Quality, in two modules of 6 ECTS each (AU)

Ensayo clinico aleatorizado para evaluar la efectividad de dos vias de administracion de hierro, oral e intravenosa, en el tratamiento de la anemia ferropenica posparto / No disponible

Objetivo: Comparar el efecto del tratamiento con hierro oral e intravenoso en la anemia ferropenica posparto. Material y método Trece mujeres con hemoglobina 7-10g/dl y ferritina < 15µg/l a las 24h posparto fueron aleatorizadas en 2 grupos, uno recibió hierro intravenoso (2 dosis de 200mg de hierro sacarosa) los días 2 y 4 tras el parto, y el otro el tratamiento estandar, 200mg de sulfato ferroso oral 2 veces/dia durante 6 semanas. Resultados En el grupo del hierro intravenoso los valores de ferritina el día 7 fueron superiores (p=0,002) (..) (AU)

Objective: To compare the effect of treatment with oral and intravenous iron in postpartumiron deficiency anemia. Material and method: Thirteen women with hemoglobin values of 7-10 g/dl and ferritin values of < 15 microgram/l at 24 h postdelivery were randomized in two groups: one group received intravenous iron (two doses of 200 mg ferrous sucrose) on days 2 and 4 after labor and the other group received standard treatment with oral ferrous sulphate 200 mg twice daily for 6 weeks. Results: By day 7, ferritin levels were significantly higher (p = 0.002) in the group treated with intravenous iron (298.3 ± 159,1 g/l) than in that treated with oral iron (21.3 ± 9.4 g/l). Byday 14, differences between these two groups were also detected (123.7 ± 65.1 g/l in the intravenous iron group and 24.6 ± 9.3 g/l in the oral iron group, p = 0.004). Hemoglobin and hematocrit levels increased in both groups on days 7, 14 and 42 with no statistically significant differences. Adverse effects were detected in the oral iron group only (29%, n = 2), although allwere mild. Conclusions: Intravenous iron could be an alternative in the treatment of postpartum iron deficiency anemia, especially in patients who are unable to tolerate or who reject oral formulations (AU)

Tunneling of a leech into a free flap breast reconstruction.

Leeches are well known to migrate over the surface of the treated tissues. At times, they can be located in remote locations once they become engorged and detach. We report the first case of a leech tunneling through a dermal bite wound on a breast free flap.

Saccade velocity is reduced in presymptomatic spinocerebellar ataxia type 2.

OBJECTIVE: A characteristic feature of spinocerebellar ataxia type 2 (SCA2) is saccadic slowing at early disease stages. We sought to determine whether this sign is detectable before clinical manifestation and quantifies the disease progression throughout life in linear fashion. METHODS: In a specialized ataxia clinic, 54 presymptomatic carriers of SCA2 polyglutamine expansions and 56 relatives without mutation were documented with regard to their maximal saccade velocity (MSV). RESULTS: Among the control individuals, a significant effect of aging on MSV was observed. After elimination of this age influence through a matched-pair approach, a presymptomatic decrease of MSV could be shown. The MSV reduction was stronger in carriers of large expansions. In the years before calculated disease manifestation, the MSV impairment advanced insidiously. CONCLUSION: Saccade velocity is a sensitive SCA2 endophenotype that reflects early pontine degeneration and may be a useful diagnostic parameter before the onset of ataxia. SIGNIFICANCE: Future neuroprotective therapies of polyglutamine neurodegeneration may be assessed by MSV from earliest to prefinal disease stages.

Saccade velocity is reduced in presymptomatic spinocerebellar ataxia type 2

A characteristic feature of spinocerebellar ataxia type 2 (SCA2) is saccadic slowing at early disease stages. We sought to determine whether this sign is detectable before clinical manifestation and quantifies the disease progression throughout life in linear fashion. In a specialized ataxia clinic, 54 presymptomatic carriers of SCA2 polyglutamine expansions and 56 relatives without mutation were documented with regard to their maximal saccade velocit Spinocerebellar ataxia type 2 Among the control individuals, a significant effect of aging on MSV was observed. After elimination of this age influence through a matched-pair approach, a presymptomatic decrease of MSV could be shown. The MSV reduction was stronger in carriers of large expansions. In the years before calculated disease manifestation, the MSV impairment advanced insidiously.Saccade velocity is a sensitive SCA2 endophenotype that reflects early pontine degenerationPolyglutamine expansion and may be a useful diagnostic parameter before the onset of ataxia. Significance: Future neuroprotective therapies of polyglutamine neurodegeneration may be assessed by MSV from earliest to prefinal disease stages...(AU)

[Implementation and evaluation of critical hazards and check points analysis (CHCPA) in gofio-producing industries from Tenerife]. / Implantación y evaluación del análisis de peligros y puntos de control críticos (APPCC) en las industrias tinerfeñas productoras de Gofio.

OBJECTIVE: To satisfactorily implement the critical hazards and check points analysis. SETTING: Tenerife Island Subjects: 15 industries INTERVENTION: visits to gofio-manufacturing industries were done with the aim of giving advice to employers and workers, and thereafter, the intervention was assessed verifying the hygiene and sanitary conditions of the industry and the correct application of the established auto-control system. RESULTS: After the advising intervention, we observed that certain parameters taken into account from the hygiene and sanitary perspective have been corrected, such as modifying the facilities to adapt them to in force regulations, or asking the suppliers to certify raw materials. With regards to food production process, the intervention was effective in such a way that more than have of the industries reduced the time of those phases with higher contamination susceptibility and to carry out the control registries that were established. CONCLUSIONS: All industries implemented the auto-control system by means of registration charts of each one of the elaboration phases. 86% of the industries have introduced more hygienic materials. 60% implemented a reduction in intermediate times of production phases. 26% perfmored some obsolete machinery replacement modernaizing the facilities.

Nitrate intake from drinking water on Tenerife island (Spain).

Although meat and vegetable products contain higher concentrations of nitrate, drinking water is the fastest and most direct form of nitrate consumption by the population. It becomes contaminated with nitrates when sea water infiltrates fresh water aquifers and when rain and irrigation water wash through soils that have been excessively treated with nitrated fertilizers. Nitrates are of great toxicological interest as they are involved in the origin of nitrites and nitrosamines and the development of metahaemoglobinaemia in infants. The objective of this study was to determine the quantities of NO(3)(-) in the water supply of each of the Island's municipalities and in the leading brands of bottled waters consumed by the population of Tenerife. This parameter is necessary for the determination of Acceptable Daily Intake (A.D.I.) of nitrates from drinking water. With one unremarkable exception, the nitrate levels found in the water analyzed were optimum for human consumption and amply complied with current European Legislation.

Sinus venosus syndrome: atrial septal defect or anomalous venous connection? A multiplane transoesophageal approach.

OBJECTIVE: To discuss the anatomical features of sinus venosus atrial defect on the basis of a comprehensive transoesophageal echocardiography (TOE) examination and its relation to surgical data. METHODS: 24 patients (13 men, 11 women, mean (SD) age 37 (17) years, range 17-73 years) with a posterior interatrial communication closely related to the entrance of the superior (SVC) or inferior vena cava (IVC) who underwent TOE before surgical repair. Records of these patients were retrospectively reviewed and compared with surgical assessments. RESULTS: In 13 patients, TOE showed a deficiency in the extraseptal wall that normally separates the left atrium and right upper pulmonary vein from the SVC and right atrium. This deficiency unroofed the right upper pulmonary vein, compelling it to drain into the SVC, which overrode the intact atrial septum. In three patients, TOE examination showed a defect in the wall of the IVC, which continued directly into the posterior border of the left atrium. Thus, the intact muscular border of the atrial septum was overridden by the mouth of the IVC, which presented a biatrial connection. In the remaining eight patients, the defect was located in the muscular posterior border of the fossa ovalis. A residuum of atrial septum was visualised in the superior margin of the defect. Neither caval vein overriding nor anomalous pulmonary vein drainage was present. CONCLUSIONS: Sinus venosus syndrome should be regarded as an anomalous venous connection with an interatrial communication outside the confines of the atrial septum, in the unfolding wall that normally separates the left atrium from either caval vein. It results in overriding of the caval veins across the intact atrial septum and partial pulmonary vein anomalous drainage. It should be differentiated from posterior atrial septal defect without overriding or anomalous venous connections.

Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition.

Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. We discuss a series of 11 patients with pathologically confirmed left atrial dissection who had been diagnosed previously by transesophageal echocardiography. Predisposing factors and surgical or pathologic findings were reviewed to identify the pathogenic mechanism and to explain the clinical course, hemodynamic disorder, and echocardiographic features. Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, and blunt chest trauma also could be related to its development. Transesophageal echocardiography identified a mobile intimal flap of the atrial wall that was creating a false chamber and allowed accurate diagnosis of prosthetic mitral valve function, endocarditis complications, and a left ventricular pseudoaneurysm after acute myocardial infarction. Color flow Doppler was particularly useful in identifying complications: communication between the false chamber and true left atria, permitting mitral regurgitation through the periannular route; development of atrial shunts; and severe tricuspid regurgitation caused by disruption of the anterior papillary muscle.

Discrete subaortic stenosis in adults: increased prevalence and slow rate of progression of the obstruction and aortic regurgitation.

OBJECTIVES: We sought to determine the prevalence and rate of progression of left ventricular outflow tract obstruction (LVOTO) and aortic regurgitation (AR) in adults with discrete subaortic stenosis (DSS). BACKGROUND: Discrete subaortic stenosis is an uncommon form of LVOTO, with rapid hemodynamic progression in children, but the prevalence and rate of progression in adults have not been studied so far. METHODS: The prevalence of DSS was determined in 2,057 consecutive adults diagnosed with congenital heart disease (CHD). The relationship between LVOTO on Doppler echocardiography and patient age was analyzed. Sequential changes in LVOTO and AR were determined for patients with two or more Doppler echocardiograms obtained with at least a two-year interval. RESULTS: A total of 134 adults (mean age 31 +/- 17 years) were diagnosed with DSS. The prevalence was 6.5% for all adults with CHD. Sixty patients (44%) had other associated CHD. The mean age of 29 patients who had undergone an operation for DSS during their adult life (56 +/- 15 years) was significantly higher than that of 64 patients (27 +/- 13 years) who had not required a surgical intervention (p < 0.0001). A significant relationship between LVOTO and patient age (r = 0.61, p < 0.0001) was found: 21 +/- 16 mm Hg in patients <25 years old, 51 +/- 47 mm Hg for those between 25 and 50 years old, and 78 +/- 36 mm Hg for those >50 years old. The LVOTO increased from 39.2 +/- 28 to 46.8 +/- 34 mm Hg (p = 0.01) during a mean follow-up of 4.8 +/- 1.8 years in 25 patients. The slope of the change in LVOTO was 2.25 +/- 4.7 mm Hg per year of follow-up. Aortic regurgitation was detected by color Doppler imaging in 109 patients (81%), but it was hemodynamically significant in <20%. An increase in the mean degree of AR over time was not significant (baseline: 1.3 +/- 0.8; follow-up: 1.5 +/- 0.9; p = 0.096). CONCLUSIONS: The prevalence of DSS is increasing in adults due to the greater number of repaired CHDs that develop into evolutive DSS. In contrast to infants and children, adults with DSS show a slow rate of LVOTO progression. Aortic regurgitation is a common but usually mild and nonprogressive consequence. The current indications for surgical intervention should be revised.

[Pulmonary artery primary sarcoma: diagnosis with transthoracic and transesophageal echocardiogram]. / Sarcoma primario de arteria pulmonar: diagnóstico mediante ecocardiograma transtorácico y transesofágico.

Pulmonary artery sarcoma is a rare malignant disease and diagnosis before surgery or autopsy is difficult. We present a case of a pulmonary artery sarcoma diagnosed with transtoracic and transesophagic echocardiogram which was treated surgically.

[Multiple progressive occlusions of intracranial arteries]. / Oclusiones progresivas múltiples de arterias intracraneales.

OBJECTIVES: We present a case of multiple progressive occlusions of intracranial arteries, a variety of Taveras' syndrome, without smoke spirals, which may be confused with other multifocal disorders. PATIENT: A 30 year old woman was admitted to hospital with a clinical picture of fluctuating paresia of her left limbs, blurred vision and urgency of micturition which partially recovered. On examination there was paresia of the left arm, generalized increased reflexes and facial asymmetry. RESULTS: On MRI there were areas of marked hyperintensity at T2. Some of these took up gadolinium at T1 and had a serpiginous pattern, compatible with vasculopathy. On angiography, stenosis and filling defect were seen in the left carotid artery. The anterior cerebral and left Sylvian arteries were filled by the vertebrobasilar system via the posterior communicating artery and an anomalous trigeminal artery. CONCLUSIONS: The clinical picture of multiple progressive occlusions of intracranial arteries is a variety of moya-moya disease, without the typical smoke spirals, which may lead to confusion with clinical pictures of arteritis and demyelinating disorders if angiography is not done, since this is essential for diagnosis.