Individualized prediction of the effect of angiotensin receptor blockade on renal and cardiovascular outcomes in patients with diabetic nephropathy.

AIMS: To predict individualized treatment effects of angiotensin receptor blockers (ARBs) on cardiovascular and renal complications in order to help clinicians and patients assess the benefit of treatment (or adherence) and estimate remaining disease risk. MATERIALS AND METHODS: In patients with diabetic nephropathy, the 3-year treatment effect of ARBs was predicted in terms of absolute risk reduction (ARR) for end-stage renal disease (ESRD) and cardiovascular disease (CVD; i.e. myocardial infarction, stroke, hospitalization for heart failure) and all-cause mortality. Competing-risk-adjusted proportional hazard models were developed based on the Irbesartan Diabetic Nephropathy Trial (IDNT) and externally validated in the Reduction of Endpoints NIDDM with Angiotensin II Antagonist Losartan (RENAAL) trial. RESULTS: Predictors included in the model were age, sex, smoking sex, systolic blood pressure, urinary albumin/creatinine ratio, estimated glomerular filtration rate, albumin and phosphorus. The median predicted 3-year risk without treatment was 6.0% for ESRD and 28.0% for CVD and mortality. The median [interquartile range (IQR)] predicted 3-year ARR was 1.2 (0.4-3.1)% for ESRD and 2.2 (1.8-2.6)% for CVD and mortality, resulting in a combined ARR of 3.4 (2.4-5.5)%. The remaining disease risk was 4.7 (IQR 1.7-12.8)% for ESRD and 25.8% (IQR 20.3-31.9)% for CVD and mortality. CONCLUSIONS: The combined effects of ARBs on ESRD and CVD and mortality in patients with diabetic nephropathy vary considerably between patients. A substantial proportion of patients remain at high risk for both outcomes despite ARB treatment.

Differences in the antibiotic susceptibility of human Escherichia coli with poultry-associated and non-poultry-associated extended-spectrum beta-lactamases.

The concurrent presence of bla CTX-M-1 and bla TEM-52 genes on similar plasmids of Escherichia coli isolated from poultry, chicken meat and humans supports the occurrence of food-borne transmission of extended-spectrum beta-lactamase (ESBL) genes. ESBL-producing E. coli (ESBL-E. coli) are most frequently detected in hospitalised patients and are known to spread in healthcare settings. We hypothesised that poultry-associated (PA) ESBL genes are predominant in the community, where acquisition is fuelled by food contamination, whereas non-PA ESBL genes are predominant in hospitals, with acquisition fuelled by cross-transmission. Then, differences in antimicrobial selective pressure in hospitals and poultry would create differences in co-resistance between PA and non-PA ESBL-E. coli. We, therefore, determined the prevalence and co-resistance of PA and non-PA ESBL-E. coli in community-acquired and nosocomial urinary tract infections in humans and bla CTX-M-1 and bla TEM-52 isolates from poultry. A total of 134 human ESBL-E. coli urine isolates were included in this study. Isolates containing bla CTX-M-1 or bla TEM-52 were considered to be PA, with the remainder being non-PA. Also, 72 poultry ESBL-E. coli were included. Minimum inhibitory concentration (MIC) values were determined by broth microdilution. The prevalence of PA ESBL genes in isolates obtained in general practice and hospitals was 28 % versus 30 % (n.s.). Human PA ESBL-E. coli were more frequently susceptible to ciprofloxacin (51 % vs. 25 %; p = 0.0056), gentamicin (86 % vs. 63 %; p = .0.0082), tobramycin (91 % vs. 34 %; p = 0.0001) and amikacin (98 % vs. 67 %; p = 0.0001) compared to human non-PA ESBL-E. coli. PA ESBL-E. coli are not more prevalent in community acquired than nosocomial urine samples, but are more often susceptible to ciprofloxacin and aminoglycosides than non-PA ESBL-E. coli. This does not support the existence of different reservoirs of ESBL genes.

Multi-centre evaluation of a phenotypic extended spectrum ß-lactamase detection guideline in the routine setting.

This study aimed to evaluate the routine setting performance of a guideline for phenotypic detection of extended spectrum ß-lactamases (ESBLs) in Enterobacteriaceae, recommending ESBL confirmation with Etest or combination disc for isolates with a positive ESBL screen test (i.e. cefotaxime and/or ceftazidime MIC >1 mg/L or an automated system ESBL warning). Twenty laboratories submitted 443 Enterobacteriaceae with a positive ESBL screen test and their confirmation test result (74%Escherichia coli, 12%Enterobacter cloacae, 8%Klebsiella pneumoniae, 3%Proteus mirabilis, 2%Klebsiella oxytoca). Presence of ESBL genes was used as reference test. Accuracy of local phenotypic ESBL detection was 88%. The positive predictive value (PPV) of local screen tests was 70%, and differed per method (Vitek-2: 69%, Phoenix: 68%, disc diffusion: 92%), and species (95%K. pneumoniae-27%K. oxytoca). A low PPV (3%) was observed for isolates with automated system alarm but third-generation cephalosporin MICs <2 mg/L. Local ESBL confirmation had a PPV and negative predictive value (NPV) of 93% and 90%, respectively. Compared with centrally performed confirmation tests, 7% of local tests were misinterpreted. Combination disc was more specific than Etest (91% versus 61%). Confirmation tests were not reliable for P. mirabilis and K. oxytoca (PPV 33% and 38%, respectively, although NPVs were 100%). In conclusion, performance of Etests could be enhanced by education of technicians to improve their interpretation, by genotypic ESBL confirmation of P. mirabilis and K. oxytoca isolates with positive phenotypic ESBL confirmation, and by interpreting isolates with a positive ESBL alarm but an MIC <2 mg/L for cefotaxime and ceftazidime as ESBL-negative.

The changing epidemiology of bacteraemias in Europe: trends from the European Antimicrobial Resistance Surveillance System.

We investigated bacteraemia trends for five major bacterial pathogens, Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Enterococcus faecalis and Enterococcus faecium, and determined how expanding antimicrobial resistance influenced the total burden of bacteraemias in Europe. Aetiological fractions of species and antibiotic phenotypes were extracted from the European Antimicrobial Resistance Surveillance System (EARSS) database for laboratories, which consistently reported between 2002 and 2008. Trend analyses used generalized linear models. Robustness of results was assessed by iterative analysis for different geographic regions. From 2002 to 2008, the overall number of reports increased annually by 6.4% (95% confidence interval (CI) 6.2-6.5%), from 46 095 to 67 876. In the subset of laboratories providing denominator information, the overall incidence increased from 0.58/1000 patient-days to 0.90/1000 patient-days (7.2% per year; 95% CI 6.9-7.5%). The frequency of reported bacteraemia isolates of S. aureus and Streptococcus pneumoniae increased moderately, while increase in E. coli and Enterococcus faecium was more pronounced. Bacteraemias caused by methicillin-resistant S. aureus increased until 2005 (7.6% per year; 95% CI 6.1-9.1%), and then decreased (-4.8% per year; 95% CI -6.1 to -3.5%), whereas the number attributable to methicillin-sensitive S. aureus increased continuously (3.4% per year; 95% CI 3.0-3.7). Increasing rates of E. coli were mainly caused by antibiotic-resistant phenotypes. Our data suggest that the burden of bacterial bloodstream infection has been increasing for all species during EARSS surveillance. Trends were mainly driven by resistant strains and clearly dissociated between resistant and susceptible isolates. It appears that infections with resistant clones add to rather than replace infections caused by susceptible bacteria. As a consequence, expansion of antibiotic resistance creates an additional strain on healthcare systems.

Evaluation of a commercial microarray as a confirmation test for the presence of extended-spectrum ß-lactamases in isolates from the routine clinical setting.

Since the diagnostic characteristics of the Check-KPC ESBL microarray as a confirmation test on isolates obtained in a routine clinical setting have not been determined, we evaluated the microarray in a random selection of 346 clinical isolates with a positive ESBL screen test (MIC >1 mg/L for cefotaxime or ceftazidime or an ESBL alarm from the Phoenix or Vitek-2 expert system) collected from 31 clinical microbiology laboratories in the Netherlands in 2009. Using sequencing as the reference method the sensitivity of the microarray was 97% (237/245), the specificity 98% (97/99), the positive predictive value 99% (237/239) and the negative predictive value 92% (97/105).

Los antídotos en su lucha contra las intoxicaciones: a propósito de una intoxicación aguda por arsénico / No disponible

El arsénico es un metal que se encuentra ampliamente distribuido por la naturaleza. Actualmente la mayoría de las intoxicaciones, tanto agudas como crónicas, se ven en el medio laboral, pudiendo darse casos de intoxicación no industrial, a partir de la contaminación de productos domésticos o alimenticios por desechos industriales con arsénico o sus derivados. Sin embargo son excepcionales las intoxicaciones suicidas como el caso que nosotros describimos u homicidas por vía digestiva. En estos casos el tratamiento antídoto, basado en la reactividad química que poseen los agentes quelantes para formar complejos atóxicos e hidrosolubles que se eliminan por la orina, es vital para poder evitar las graves consecuencias incluso letales de dicha intoxicación aguda(AU)

Arsenic is a metal that is widely distributed in nature. Nowadays, most of the poisonings, both acute and chronic, can be seen in the work environment, with some cases of non-industrial contamination reported, caused by contamination of domestic or food products from industrial wastes containing arsenic or its derivatives. Even though, cases of self-poisoning via the digestive tract like the one we describe, or homicide, are exceptional. In these cases, antidotes based on the chemical reactivity owned by the chelating agents to form a non-toxic and water-soluble complex that can be eliminated in urine, are vital to avoid serious or even lethal consequences caused by acute poisoning(AU)

[Usefulness of Heliox in the management of a serious airway obstruction caused by a subglottic hemangioma]. / Utilidad del Heliox en el manejo de una obstrucción grave de la vía aérea por un hemangioma subglótico.

Heliox therapy, alone or combined with noninvasive ventilation, has successfully been used in the treatment of infants and children with respiratory disease such as airway obstruction. We describe the case of a 1-month-old infant with severe upper respiratory airway obstruction (approximately 80 %) secondary to multiple cervical hemangiomatosis effectively treated with either Heliox alone or combined with nasal continuous positive airway pressure. This treatment provided symptomatic relief and facilitated diagnosis and subsequent application of specific treatment; the patient was free of signs of respiratory distress and the use of aggressive treatments such as endotracheal intubation or tracheal cannulation was avoided. Heliox can constitute a multipurpose, safe and useful tool in the noninvasive management of infants and children with serious obstructive respiratory disease.

Utilidad del Heliox en el manejo de una obstrucción grave de la vía aérea por un hemangioma subglótico / Usefulness of heliox in the management of a serious airway obstruction caused by a subglottic hemangioma

El Heliox, administrado solo o en combinación con ventilación no invasiva, se ha empleado con éxito en el tratamiento de niños con patología respiratoria de carácter obstructivo. Presentamos el caso de una lactante de un mes de edad con hemangiomatosis cervical múltiple y una obstrucción severa (aproximadamente del 80 %) de la vía aérea, en la que la administración de Heliox, solo o en combinación con presión positiva en la vía aérea nasal, permitió su manejo y alivio sintomático, facilitó su evaluación diagnóstica y la instauración posterior de tratamiento electivo, manteniéndola en todo momento libre de signos de dificultad respiratoria y evitando la instauración de tratamientos inespecíficos más agresivos tales como la intubación o la canulación traqueal. El Heliox puede constituir una herramienta polivalente, segura y útil en el manejo conservador de niños con patología respiratoria obstructiva grave

Heliox therapy, alone or combined with noninvasive ventilation, has successfully been used in the treatment of infants and children with respiratory disease such as airway obstruction. We describe the case of a 1-month-old infant with severe upper respiratory airway obstruction (approximately 80 %) secondary to multiple cervical hemangiomatosis effectively treated with either Heliox alone or combined with nasal continuous positive airway pressure. This treatment provided symptomatic relief and facilitated diagnosis and subsequent application of specific treatment; the patient was free of signs of respiratory distress and the use of aggressive treatments such as endotracheal intubation or tracheal cannulation was avoided. Heliox can constitute a multipurpose, safe and useful tool in the noninvasive management of infants and children with serious obstructive respiratory disease

[Reversible posterior leukoencephalopathy syndrome: an infrequent complication in the course of haemolytic-uremic syndrome]. / Leucoencefalopatía posterior reversible: una complicación infrecuente en el curso del síndrome hemolítico urémico.

INTRODUCTION: Posterior reversible leukoencephalopathy syndrome (PRLS) is characterised by the sudden and usually transient onset of headaches, visual disorders, decreased awareness and convulsions associated with cerebral oedema in the posterior areas of the brain. Different reports have associated it with numerous processes and possibly with haemolytic-uremic syndrome (HUS). We describe a new case of PRLS within the context of HUS. CASE REPORT: We describe the case of a 4-year-old child with HUS who developed arterial hypertension that did not respond well to treatment and kidney failure that required renal replacement therapy. During the course of the disease the patient presented several transient episodes of headache, a lowered level of consciousness and seizures. Magnetic resonance imaging revealed multiple lesions in the white matter and the cortex that were hyperintense in T2 and hypointense in T1 situated in the bilateral occipital and right frontotemporoparietal regions. The patient made a full clinical recovery in a few days, although an magnetic resonance imaging scan performed at six weeks after the last episode showed partial remission of the lesions and a small cerebral infarction. CONCLUSIONS: The pathogenesis of PRLS is still not fully understood. Its multifactorial origin suggests that several different mechanisms may be involved. In the case reported here, it is possible that the arterial hypertension, retention of fluids and even the sessions of dialysis played a role in its development.

Leucoencefalopatía posterior reversible: una complicación infrecuente en el curso del síndrome hemolítico urémico / Reversible posterior leukoencephalopathy syndrome: an infrequent complication in the course of haemolytic syndrome

Introducción. El síndrome de leucoencefalopatía posterior reversible (SLPR) se caracteriza por la presentación aguda y habitualmente transitoria de cefalea, trastornos visuales, depresión del sensorio y convulsiones asociadas a un edema cerebral en las regiones posteriores del cerebro. Se ha descrito su asociación con múltiples procesos y eventualmente con el síndrome hemolítico urémico (SHU). Aportamos un nuevo caso de SLPR en el contexto de un SHU. Caso clínico. Niño de 4 años con un SHU, que desarrolló una hipertensión arterial de difícil control y una insuficiencia renal que precisó una terapia de reemplazo renal. Durante el curso de la enfermedad presentó varios episodios transitorios de cefalea, disminución del nivel de conciencia y crisis convulsivas. La resonancia magnética evidenció múltiples lesiones en la sustancia blanca y el córtex hiperintensas en T2 e hipointensas en T1 localizadas en la zona occipital bilateral y frontotemporoparietal derecha. La recuperación clínica fue completa en un período de días, si bien una resonancia magnética realizada a las seis semanas del último episodio mostró una remisión parcial de las lesiones y un pequeño infarto cerebral. Conclusiones. El SLPR es un trastorno cuya patogenia no se ha aclarado. Su origen multifactorial sugiere que diferentes mecanismos pueden estar implicados. En el caso presentado es posible que la hipertensión arterial, la retención de fluidos e incluso la diálisis hayan contribuido a su desarrollo

Introduction. Posterior reversible leukoencephalopathy syndrome (PRLS) is characterised by the sudden and usually transient onset of headaches, visual disorders, decreased awareness and convulsions associated with cerebral oedema in the posterior areas of the brain. Different reports have associated it with numerous processes and possibly with haemolyticuremic syndrome (HUS). We describe a new case of PRLS within the context of HUS. Case report. We describe the case of a 4-year-old child with HUS who developed arterial hypertension that did not respond well to treatment and kidney failure that required renal replacement therapy. During the course of the disease the patient presented several transient episodes of headache, a lowered level of consciousness and seizures. Magnetic resonance imaging revealed multiple lesions in the white matter and the cortex that were hyperintense in T2 and hypointense in T1 situated in the bilateral occipital and right frontotemporoparietal regions. The patient made a full clinical recovery in a few days, although an magnetic resonance imaging scan performed at six weeks after the last episode showed partial remission of the lesions and a small cerebral infarction. Conclusions. The pathogenesis of PRLS is still not fully understood. Its multifactorial origin suggests that several different mechanisms may be involved. In the case reported here, it is possible that the arterial hypertension, retention of fluids and even the sessions of dialysis played a role in its development

Aplicación precoz de la ventilación de alta frecuencia oscilatoria en un lactante con neumopatía química grave / Early application of high-frequency oscillatory ventilation in an infant with severe chemical neuropathy

No disponible

Trisomía parcial del cromosoma 5p / Partial trisomy of chromosome 5p

No disponible

[Addison's disease: the challenge of an early diagnosis]. / Enfermedad de Addison: el reto de un diagnóstico precoz.

Addison's disease is a set of symptoms which is produced due to the destruction of the suprarenal cortex, of a mainly autoimmune origin, on account of the presence of antibodies which attack it. This destruction takes place in a generally slow manner, causing symptoms to appear in an insidious way, added to the fact that these symptoms tend to be unspecific. Therefore it is easy to understand that its diagnosis at an early stage will be very difficult and is often interpreted as another disease. It is only when the deficit is important and adrenal crisis develop that we can reach the right diagnosis in a situation where the death risk is considerably high. We presented a clinical case as an example of what has been described previously. After several months of progressively deteriorating symptoms and several visits to different medical units, the patient is diagnosed as having an adrenal crisis and is immediately admitted to the intensive care unit.

Enfermedad de Addison: el reto de un diagnóstico precoz / Addison´s disease: the challenge of an early diagnosis

La enfermedad de Addison es un cuadro que se produce debido a la destrucción de la corteza suprarrenal, de origen principalmente auto inmune, por la presencia de anticuerpos contra la misma. Dicha destrucción tiene lugar de forma generalmente muy lenta por lo que la aparición de los síntomas es insidiosa, si añadimos el hecho de que estos síntomas suelen ser inespecíficos, es fácil entender que su diagnóstico en fases precoces sea muy difícil, con frecuencia interpretado como otra entidad clínica y sólo cuando el déficit es importante, dando lugar al desarrollo de las crisis adrenales, llegamos al diagnóstico correcto en una situación en la que el compromiso vital no es nada desdeñable. Presentamos un caso clínico ejemplo de lo anteriormente descrito, en el que tras varios meses de clínica progresiva y varias visitas a distintos servicios médicos, se diagnostica finalmente al presentar una crisis adisoniana que hace necesario su ingreso en una Unidad de Cuidados Intensivos

Addison 's disease is a set of symptoms which is produced due to the destruction of the suprarenal cortex, of a mainly autoimmune origin, on account of the presence of antibodies which attack it. This destruction takes place in a generally slow manner, causing symptoms to appear in an insidious way, added to the fact that these symptoms tend to be unspecific, Therefore it is easy to understand that its diagnosis at an early stage will be very difficult and is often interpreted as another disease, It is only when the deficit is important and adrenal crisis develop that we can reach the right diagnosis in a situation where the death risk is considerably high. We presented a clinical case as an example of what has been described previously, After several months of progressively deteriorating symptoms and several visits to different medical units, the patient is diagnosed as having an adrenal crisis and is immediately admitted to the intensive care unit