Latrogenic Cushing’s syndrome by an interaction between cobicistat and fluticasone: a case report / Síndrome de Cushing yatrogénico asociado a la interacción entre cobicistat y fluticasona: caso clínico

We report a case of iatrogenic Cushing’s syndrome associated with an interaction between cobicistat and fluticasone in a seropositive woman treated with elvitegravir/cobicistat/emtricitabina/TAF (Genvoya®). This case highlights the importance to review interactions between antirretroviral therapy and other drugs, especially when antirretroviral scheme includes protease inhibitors enhanced with ritonavir or cobicistat. These enhancers interfere the cytochrome P-450 metabolic pathway. A large number of drugs are metabolized by cytochrome P-450 and may be altered by cobicistat or ritonavir. (AU)

Presentamos un caso de síndrome de Cushing asociado a la interacción entre cobicistat y fluticasona en una mujer seropositiva en tratamiento con elvitegravir/cobicistat/emtricitabina/TAF (Genvoya®). Este caso pone de manifiesto la importancia de la revisión de las interacciones entre el tratamiento antirretroviral y otros tratamientos concomitantes, especialmente cuando el esquema antirretroviral contiene inhibidores de proteasa potenciados con ritonavir o cobicistat. Esta potenciación afecta a la ruta metabólica mediada por el citocromo P450. Un elevado número de fármacos son metabolizados por el citocromo P450, y por tanto pueden verse afectados cuando se administran con ritonavir o cobicistat. (AU)

Experimental study showed that adding fortifier and extra-hydrolysed proteins to preterm infant mothers' milk increased osmolality.

AIM: Measuring milk osmolality after adjustable fortification is clinically relevant, as values exceeding recommended safety thresholds might result in gastrointestinal consequences. The aim of this study was to evaluate the effect of four fortification levels and storage time on the osmolality of human milk. METHODS: This was an experimental study using 71 spare samples of fresh breastmilk collected from 31 mothers of preterm infants. Osmolality was measured before and after adding commercial human milk fortifier containing dextrinomaltose and hydrolysed proteins at four different concentrations. Measurements were performed at various points during the 23 hours after fortification. RESULTS: The mean basal osmolality of the 71 human milk samples was 296 ± 14 milliosmoles (mOsm)/kg, and these remained stable over a period of 23 hours. Just after fortification, the four fortified formulas showed higher osmolalities than the nonfortified human milk, ranging between 384 ± 14 and 486 ± 15 mOsm/kg, respectively (p < 0.01). This osmolality increased significantly from 20 minutes to 23 hours after fortification (p < 0.05). CONCLUSION: Adding fortifier and extra-hydrolysed proteins to human preterm milk increased osmolality, and these osmolality levels also increased with time. We recommend evaluating the risk of hyperosmolality when a higher fortification level is needed, to avoid gastrointestinal problems.

Comparison of BNP and NT-proBNP assays in the approach to the emergency diagnosis of acute dyspnea.

N-terminal pro-brain natriuretic peptide (NT-proBNP) and BNP measurement could have a significant role in differentiating dyspnea between cardiac or pulmonary origin in the emergency room. The development of new and different commercial assays for these B-type natriuretic peptides offers the possibility of improving and simplifying their measurements but this could be defaulted due to the differences in methodology and the lack of assay standardization. We compared four available methods of measuring NT-proBNP and BNP and evaluated their usefulness in diagnosing the causes of breathlessness in the emergency room. The correlation of BNP with different assays was strong with r>0.98 (P<0.0001). Comparison studies between NT-proBNP and BNP procedures were in good agreement with r>0.87. The area under the receiver-operating characteristic curve (ROC) for BNP or NT-proBNP for detecting any cardiac dysfunction was higher than 0.96 (95% CI). A BNP value of 116 pg/mL measurement with the Access BNP assay (Beckman Coulter Inc., Fullerton, CA), a BNP value of 79 pg/mL with Advia Centaur BNP assay (Bayer Diagnostics, Tarrytown, NY), and an NT-proBNP level of 817 pg/mL in Elecsys NT-proBNP assay (Roche Diagnostic, Mannheim, Germany), showed both high sensitivity (>92%) and high specificity (>93%). We have found that NT-proBNP and BNP present similar diagnostic accuracies for the differential diagnosis of dyspnea.

[Comparison of high-resolution liquid chromatography versus microparticle enzyme immunoassay for the measurement of sirolimus levels in renal transplantation]. / Comparación de la cromatografía líquida de alta resolución frente al enzimoinmunoensayo de micropartículas para la determinación de sirolimus en trasplante renal.

OBJECTIVE: To compare sirolimus levels measured in whole blood using two analytical techniques: high-resolution liquid chromatography and microparticle enzyme immunoassay, and to evaluate whether hemoglobin, hematocrit, and time from kidney transplantation influence results obtained using the immune-enzymatic technique. METHOD: A retrospective, observational study in which all transplanted patients with at least one measurement of sirolimus levels using high-resolution liquid chromatography or microparticle enzyme immunoassay from October 2004 to May 2005 were consecutively included. For statistical comparisons simple linear regression, ANCOVA, intra-class correlation coefficient, and the method of agreement limits were all used. RESULTS: Ninety-one patients were assessed for a total of 307 measurements (median: 2, inter-quartile range: 1-4, range: 1-15) of sirolimus levels. The straight-line equation using the linear regression analysis was as follows: MEIA = 0.70 (95% CI: 0.39-1.01) + 1.14 (95% CI: 1.10-1.17) x HPLC/UV. The intra-class correlation coefficient between both measurements was 0.955 (95% CI 0.944-0.964). Mean overestimation using enzyme immunoassay was 24.8% +/- 19.4%. Difference in means between both measurements was 1.9 +/- 1.3 ng/mL. Agreement limits were established between -0.8 ng/mL (95% CI: -1.05; -0.55) and +4.6 ng/mL (95% CI: 4.35; 4.85). Factors such as post-transplant time, hemoglobin, and hematocrit did not influence overestimates obtained using enzyme immunoassays. These results were not influenced by non-independence in measurements. CONCLUSIONS: Despite enzyme immunoassay overestimates in establishing sirolimus levels in whole blood, its correlation with chromatography is acceptable. Added to its benefits versus chromatographic techniques, this renders enzyme immunoassay a good alternative for the measurement of sirolimus levels in whole blood.

Evaluación del tiempo de respuesta global de un laboratorio de urgencias con impresión remota / Evaluation of the global turnaround time in an emergency laboratory with remote printing

En el presente artículo se realiza una evaluación del tiempo de respuesta (TR) global de un laboratorio de urgencias, en el que el envío de resultados desde el laboratorio hasta el Servicio de Urgencias es mediante impresión remota, y se compara con los tiempos de respuesta obtenidos en el mismo laboratorio cuando el envío de resultados era mediante celadores. Se estudiaron 225 peticiones repartidas en los tres turnos laborales ( mañana, tarde y noche), en las que se analiza el tiempo transcurrido desde la solicitud del análisis hasta su recepción en el laboratorio y el tiempo intralaboratorio. Se considera importante realizar estudios periódicos del tiempo de respuesta y proponer medidas de mejora, así como reevaluar el resultado de la implantación de estas medidas. (AU)

Nuevo procedimiento colorimétrico para la determinación de adenosina desaminasa en líquidos biológicos / New colorimetric procedure of determining adenosine deaminase in body fluids

Se ha evaluado un nuevo reactivo para la determinación del enzima adenosina desaminasa (ADA) en los analizadores Cobas Mira S (Roche) y Synchron CX7 (Beckman), utilizando un método cinético colorimétrico basado en la cuantificación de inosina. La precisión expresada como coeficientes de variación fue menor del 3 por ciento (intradía) y menor del 2.7 por ciento (interdía) para valores de ADA entre 15.4 y 112 U/L. El método resultó lineal hasta valores de 395 U/L y presentó un límite de detección menor de 0.5 U/L. No se han observado interferencias debidas a bilirrubina (hasta 25 mg/dL), ni lípidos (Ivelip® hasta 2 por ciento), pero sí se observan aumentos significativos en la actividad de ADA debidos a hemolisis. Al comparar este método con un método comercial basado en la detección del amoniaco liberado, se obtuvieron coeficientes de correlación superiores a 0.97 en todos los casos. En conclusión, el nuevo procedimiento evaluado presenta una buena practicabilidad junto con una precisión y sensibilidad satisfactorias; por lo que resulta adecuado para las determinaciones urgentes y de rutina de adenosina desaminasa en fluídos biológicos (AU)

MRI and CT of ankylosing spondylitis with vertebral scalloping.

Three cases of cauda equina syndrome in long-standing ankylosing spondylitis are reported. In all, vertebral scalloping and dural ectasia were confirmed by magnetic resonance imaging and computed tomography. MRI showed widening of the dural sac with signal intensity corresponding to cerebrospinal fluid. CT demonstrated asymmetrical lesions of the posterior elements of the lumbar spine. Myelography was not felt necessary to confirm the findings.