[Systemic and extrapulmonary manifestations of COVID-19]. / Manifestaciones sistémicas y extrapulmonares en la COVID-19.

Although fever and respiratory symptoms are the main clinical expression of COVID-19 disease, important extrapulmonary complications that affect the majority of the organs and systems may occur. Multisystemic involvement can mainly be attributed to the generalized location of ACE2 receptors throughout the body, which act as the main point of entry for the virus. Systemic manifestations may occasionally appear before the typical symptoms, although they generally occur later or are sequelae of the disease. Thromboembolic complications are concerning due to their frequency and severity; they are the result of a hypercoagulable state with multiple possible clinical manifestations. Cardiac, neurological, gastrointestinal, renal, endocrine-metabolic, skin, and ocular complications may occur. The manifestations and specific therapeutic aspects of COVID-19 disease in pregnant women as well as implications of the disease on children are discussed. The corresponding tests must be performed in all patients with a clinical suspicion of COVID-19 in order to confirm the diagnosis of the infection. The specific diagnostic tests that are indicative of involvement of different organs are guided based on clinical suspicion. These tests are conducted on an individual basis taking into account the isolation measures required and the severity of each case. Likewise, the corresponding treatment is administered according to criteria that generally similar to those for the general population.

Mining for natural product antileishmanials in a fungal extract library.

Leishmaniasis is a Neglected Tropical Disease caused by the insect-vector borne protozoan parasite, Leishmania species. Infection affects millions of the World's poorest, however vaccines are absent and drug therapy limited. Recently, public-private partnerships have developed to identify new modes of controlling leishmaniasis. Most of these collaborative efforts have relied upon the small molecule synthetic compound libraries held by industry, but the number of New Chemical Entities (NCE) identified and entering development as antileishmanials has been very low. In light of this, here we describe a public-private effort to identify natural products with activity against Leishmania mexicana, a causative agent of cutaneous leishmanaisis (CL). Utilising Hypha Discovery's fungal extract library which is rich in small molecule (<500 molecular weight) secondary metabolites, we undertook an iterative phenotypic screening and fractionation approach to identify potent and selective antileishmanial hits. This led to the identification of a novel oxidised bisabolane sesquiterpene which demonstrated activity in an infected cell model and was shown to disrupt multiple processes using a metabolomic approach. In addition, and importantly, this study also sets a precedent for new approaches for CL drug discovery.

The antifungal Aureobasidin A and an analogue are active against the protozoan parasite Toxoplasma gondii but do not inhibit sphingolipid biosynthesis.

Toxoplasma gondii is an obligate intracellular protozoan parasite of the phylum Apicomplexa, and toxoplasmosis is an important disease of both humans and economically important animals. With a limited array of drugs available there is a need to identify new therapeutic compounds. Aureobasidin A (AbA) is an antifungal that targets the essential inositol phosphorylceramide (IPC, sphingolipid) synthase in pathogenic fungi. This natural cyclic depsipeptide also inhibits Toxoplasma proliforation, with the protozoan IPC synthase orthologue proposed as the target. The data presented here show that neither AbA nor an analogue (Compound 20), target the protozoan IPC synthase orthologue or total parasite sphingolipid synthesis. However, further analyses confirm that AbA exhibits significant activity against the proliferative tachyzoite form of Toxoplasma, and Compound 20, whilst effective, has reduced efficacy. This difference was more evident on analyses of the direct effect of these compounds against isolated Toxoplasma, indicating that AbA is rapidly microbicidal. Importantly, the possibility of targeting the encysted, bradyzoite, form of the parasite with AbA and Compound 20 was demonstrated, indicating that this class of compounds may provide the basis for the first effective treatment for chronic toxoplasmosis.

High HCV subtype heterogeneity in a chronically infected general population revealed by high-resolution hepatitis C virus subtyping.

OBJECTIVES: This study aimed to characterize the chronically infected general hepatitis C virus (HCV) population in Barcelona using a highly sensitive subtyping method that can identify the 67 recognized HCV subtypes and diagnose mixed infection by various genotypes/subtypes in a single individual. The resulting information has implications for selecting optimal direct-acting antiviral (DAA) treatment for each patient and establishing public healthcare policies in our setting. METHODS: Consecutive HCV patients (treatment-naïve or interferon-based failures) attending Vall d'Hebron Hospital outpatient clinics from February 2015 to May 2016 (N=1473) were included in the study. Patient samples were characterized using HCV subtyping by next-generation ultra-deep pyrosequencing. RESULTS: The following genotypes (G) were found: G1 (1126/1473 (76.4%)), G4 (145/1473 (9.8%)), G3 (135/1473 (9.2%)), G2 (51/1473 (3.5%)), and G5 (1/1473 (0.1%)). Twenty-two subtypes were seen: 1b (790/1473 (53.6%)), 1a (332/1473 (22.5%)), 3a (133/1473 (9.0%)), 4d (105/1473 (7.1%)), 4a (29/1473 (2.0%)), and 2c (25/1473 (1.7%)), with 16 low-prevalence subtypes accounting for the remaining 3.0% (44/1473). There was a worrisome 1.0% (15/1473) of mixed infections. G2 (51/1473 (3.5%)) showed a high level of heterogeneity. Analyses by age groups showed a predominance of G1b over G1a (428/506 (84.6%) vs. 24/506 (4.7%)) in patients born before 1950 (N=506/1473), and similar percentages of these subtypes in those born between 1951 and 1975 (N=834/1473) (315/834, 37.8% vs. 266/834, 31.9%) and after 1976 (N=133/1473) (47/133, 35.3% vs. 42/133, 31.6%). CONCLUSIONS: Subtype distribution showed a higher level of heterogeneity than was expected, particularly for G2. Prevalence of mixed infections was around 1%. HCV subtype distribution related to patient age group suggested that patients born from 1936 to 1975 in our setting should undergo screening for the infection. Next-generation sequencing enabled better classification of candidates for DAA-based treatment.

Phosphorylation Regulates Functions of ZEB1 Transcription Factor.

ZEB1 transcription factor is important in both development and disease, including many TGFß-induced responses, and the epithelial-to-mesenchymal transition (EMT) by which many tumors undergo metastasis. ZEB1 is differentially phosphorylated in different cell types; however the role of phosphorylation in ZEB1 activity is unknown. Luciferase reporter studies and electrophoresis mobility shift assays (EMSA) show that a decrease in phosphorylation of ZEB1 increases both DNA-binding and transcriptional repression of ZEB1 target genes. Functional analysis of ZEB1 phosphorylation site mutants near the second zinc finger domain (termed ZD2) show that increased phosphorylation (due to either PMA plus ionomycin, or IGF-1) can inhibit transcriptional repression by either a ZEB1-ZD2 domain clone, or full-length ZEB1. This approach identifies phosphosites that have a substantial effect regulating the transcriptional and DNA-binding activity of ZEB1. Immunoprecipitation with anti-ZEB1 antibodies followed by western analysis with a phospho-Threonine-Proline-specific antibody indicates that the ERK consensus site at Thr-867 is phosphorylated in ZEB1. In addition to disrupting in vitro DNA-binding measured by EMSA, IGF-1-induced MEK/ERK phosphorylation is sufficient to disrupt nuclear localization of GFP-ZEB1 fusion clones. These data suggest that phosphorylation of ZEB1 integrates TGFß signaling with other signaling pathways such as IGF-1. J. Cell. Physiol. 231: 2205-2217, 2016. © 2016 Wiley Periodicals, Inc.

Removal of cadmium from aqueous solutions by adsorption onto orange waste.

The use of orange wastes, generated in the orange juice industry, for removing cadmium from aqueous solutions has been investigated. The material was characterized by Fourier transform infrared spectroscopy and batch experiments were conducted to determine the adsorption capacity of the biomass. A strong dependence of the adsorption capacity on pH was observed, the capacity increasing as pH value rose. Kinetics and adsorption equilibrium were studied at different pH values (4-6). The adsorption process was quick and the equilibrium was attained within 3h. The maximum adsorption capacity of orange waste was found to be 0.40, 0.41 and 0.43 mmol/g at pH 4-6, respectively. The kinetic data were analysed using various kinetic models - pseudo-first order equation, pseudo-second order equation, Elovich equation and intraparticle diffusion equation - and the equilibrium data were tested using four isotherm models - Langmuir, Freundlich, Sips and Redlich-Peterson. The data were fitted by non-linear regression and five error analysis methods were used to evaluate the goodness of the fit. The Elovich equation provides the greatest accuracy for the kinetic data and the Sips model the closest fit for the equilibrium data.

Combination of qualitative and quantitative methods for developing a new Health Related Quality of Life measure for patients with anogenital warts.

BACKGROUND: Anogenital warts are the most easily recognized sign of genital Human Papilloma Virus infection. The objective was to develop a short, valid and reliable questionnaire to measure Health Related Quality of Life (HRQL) in patients with anogenital warts. METHODS: First a literature review was performed to identify relevant papers describing the impact of anogenital warts in HRQL; second the main domains were identified by some experts in a focus group, and third in-depth-semi-structured interviews were conducted in patients with anogenital warts to identify the initial set of items. A qualitative reduction of the initial set of items was performed based on the mean scoring of the experts for the three scales: clarity, frequency and importance. The initial questionnaire was pilot tested in 135 patients. Rasch analysis was performed with the results of the questionnaire in order to refine the instrument. Spearman's correlation was calculated between the initial questionnaire and the reduced version. Additionally the measurement properties (validity and reliability) of the resulting final questionnaire were tested and compared using standard procedures (Cronbach's Alpha and item-total correlation). RESULTS: the main domains identified as affected in patient's life were: sexual, colleagues and partner relationships. After a proper qualitative reduction the initial set of 134 items was reduced to 22. The questionnaire was pilot tested in 135 patients and two dimensions were identified after the multifactorial analysis: emotional dimension and sexual activity dimension. As a result of the Rasch analysis the questionnaire was reduced to 10 items. High correlation was found between the initial and the reduced version for the two dimensions. Cronbach's alpha values were acceptable (0.86). CONCLUSION: The initial 22 items questionnaire was reduced by Rasch analysis to a version of 10 items, with two dimensions: emotional and sexual. The results suggest the adequacy of the 10 items to evaluate HRQL of patients with anogenital warts in a valid and reliable way.

Improvement of coagulation-flocculation process using anionic polyacrylamide as coagulant aid.

A physicochemical treatment (coagulation-flocculation) was applied to a slaughterhouse wastewater, using anionic polyacrylamide as coagulant aid to improve the settling velocity of the flocs formed with the coagulants used: ferric sulphate, aluminium sulphate and polyaluminium chloride. The optimum speed and stirring time for the flocculation stage were ascertained along with the optimum pH and coagulant and coagulant aid doses. The speed and coagulation time were initially set according to recommendations in the literature concerning the treatment of this type of water. Chemical oxygen demand (COD), biochemical oxygen demand at 5 days (BOD5) and total suspended solids (TSS) were recorded at the beginning and end of each experiment in order to monitor the process. Once the optimal conditions had been established, several parameters were measured in order to assess the coagulation-flocculation process: particle number and size, sludge volume, nutrients (ammonia nitrogen, total Kjeldahl nitrogen, albuminoid nitrogen, orthophosphate, total phosphorus) and the residual concentration of iron and aluminium in clarified water. Anionic polyacrylamide, when added with ferric sulphate or polyaluminium chloride led to a significant increase in the settling speed.

Efficacy and tolerability of ebastine 10 mg plus pseudoephedrine 120 mg in the symptomatic relief of the common cold.

Background: The objective of this multicenter, parallel, double-blind, placebo-controlled clinical trial was to determine the efficacy and tolerability of the combination of ebastine 10 mg plus pseudoephedrine 120 mg once daily after 3 days of treatment in the symptomatic relief of patients with a common cold. Methods: The principal variable studied was the evaluation of overall efficacy and secondary variables were improvement of the patient, evolution of symptoms, disposition of the patient to take the medication again, and variation in nasal peak flow. Results: The percentage of subjects showing a good or excellent treatment efficacy was significantly higher in the group treated with ebastine plus pseudoephedrine (75.8%) than in the group treated with placebo (57.6%; p<0.001). Statistically significant differences were also found in favor of ebastine plus pseudoephedrine when comparing the changes in the sum of scores for nasal and ocular symptoms (p<0.006) or total symptoms (p<0.0016). The tolerability of the active treatment studied was good; that is, no significant differences were found between ebastine 10 mg plus pseudoephedrine 120 mg and placebo. Most adverse events described were slight or moderate in intensity, and no serious adverse events were reported. Conclusions: The combination of ebastine 10 mg immediate release and pseudoephedrine 120 mg sustained release was found effective in the symptomatic treatment of patients suffering from a common cold and as safe as placebo.

Microscopic observation of particle reduction in slaughterhouse wastewater by coagulation-flocculation using ferric sulphate as coagulant and different coagulant aids.

A coagulation-flocculation treatment has been applied to a slaughterhouse liquid effluent, using ferric sulphate as coagulant and activated silica, powdered activated carbon, cationic polyacrylamide, polyvinyl alcohol, polyacrylic acid and anionic polyacrylamide as coagulant aids in order to improve the settling time. Once the optimal conditions had been established (speed and time of stirring during flocculation step, pH, coagulant and coagulant aid doses), the efficiency of the coagulation-flocculation process was studied by comparing the particle size distribution before and after the addition of the coagulant. When ferric sulphate was used without the coagulant aids, particle removal efficiency varied with size, although overall efficiency was quite substantial (87%). The use of coagulant aids improved the removal efficiency, except in the case of activated silica, when it fell to 78%. In all other cases removal efficiency values between 93% (for polyvinyl alcohol) and 99% (for anionic polyacrylamide) were reached.

Estudio multicéntrico de la eficacia del tratamiento intraarticular con ácido hialurónico (Adant) en artrosis de rodilla / Multicenter clinical trial on the efficacy of intra-articular hyaluronic acid (Adant®) in osteoarthritis of the knee

Fundamento: El objetivo de este ensayo fue evaluar la eficacia y la seguridad del tratamiento con ácido hialurónico en pacientes con artrosis de rodilla, siguiendo un diseño prospectivo, multicéntrico y no controlado con un seguimiento de 6 meses. Material y métodos: Los 10 centros participantes incluyeron un total de 112 pacientes evaluables con diagnóstico de artrosis de rodilla tanto clínico (criterios ARA) como radiológico: leve (grados 1-2 de Kellgren and Lawrence [KL]); moderado (grado 3 de KL), y grave (grado 4 de KL). La eficacia del tratamiento con cinco inyecciones intraarticulares de ácido hialurónico (Adant, Tedec-Meiji Farma, S.A.) se evaluó comparando la puntuación basal, de los signos y síntomas clínicos (dolor, movilidad y función basado en la escala propuesta por The Knee Society) con los obtenidos en las visitas postratamiento. La seguridad se valoró mediante registro sistemático de acontecimientos adversos durante todo el estudio. Resultados: Todos los parámetros de eficacia estudiados (dolor, movilidad, deambulación y subida/bajada de escaleras) pusieron de manifiesto una mejoría significativa (p = 0,0001) en todas las visitas de seguimiento con respecto a los valores basales. El 64 por ciento de los pacientes presentó una respuesta muy buena (incremento > 20 por ciento respecto a la puntuación basal) durante al menos 6 meses tras la última administración de ácido hialurónico. El porcentaje de acontecimientos adversos por inyección, con independencia de su relación con el tratamiento, fue del 3,6 por ciento y el de acontecimientos adversos posible/probablemente relacionados fue del 1,3 por ciento: vértigo (n = 2), dolor de rodilla (n = 2), edema (n = 1), prurito (n = 1) e hipersensibilidad (n = 1). Únicamente este último supuso abandono del tratamiento. Conclusión: La administración de ácido hialurónico intraarticular parece que es una alternativa segura y bien tolerada para el tratamiento de la artrosis de rodilla tanto leve como grave, con una duración de los efectos de, al menos, 6 meses (AU)

The efficacy of orgotein in the treatment of acute toxicity due to radiotherapy on head and neck tumors.

AIMS AND BACKGROUND: To assess the efficacy of orgotein in the treatment of acute secondary effects of radiotherapy on head and neck tumors. MATERIAL AND METHODS: Data were collected on 41 patients who received radiotherapy for tumors of the head and neck. Radiotherapy was the exclusive treatment in 19.5% of cases, with surgery in 24.4%, chemotherapy in 48.8%, and with both in 7.3%. The toxicity requiring use of orgotein was: oropharynx mucositis (26.8%), dysphagia (34.2%), or both (39%), in grade 2 or more according to the RTOG scale. Orgotein (8 mg i.m.) was administered every 48 hrs until radiotherapy was finished. RESULTS: The overall response rate was 92.5%; a complete response was obtained in 12 patients (30%) and partial in 25 (62.5%). The reduction in toxicity at the end of radiotherapy was one grade in 18 patients (45%), 2 grades in 16 (40%), 3 in 2 patients (5%), and 4 grades in the only patient with grade 4 acute toxicity. A statistically significant influence was shown in obtaining complete response: laryngeal tumor location (P = 0.037), duration of radiotherapy of more than 53 days (P = 0.002), discontinuation for non-toxic reasons (P = 0.008). CONCLUSIONS: We consider that orgotein is highly effective in dealing with acute secondary effects of radiotherapy on the head and neck area.

Nutrient removal and sludge production in the coagulation-flocculation process.

Nutrient removal and sludge production in the coagulation-flocculation process, applied to a slaughterhouse effluent, have been studied. Fe2(SO4)3, Al2(SO4)3 and polyaluminium chloride were used as coagulants. Inorganic products were used as coagulant aids: activated silica, powdered activated carbon and precipitated calcium carbonate and synthetic polyelectrolytes: cationic polyacrylamide, polyacrilic acid, anionic polyacrylamide and polyvinyl alcohol. Performances were measured under optimum conditions for the products used. They were found after studying the different variables which influence the process. Phosphorus removal is very high (approximately 100% for the orthophosphate and between 98.93% and 99.90% for the total phosphorus). Ammonia nitrogen removal is very low although appreciable performances are observed for albuminoid nitrogen (73.9-88.77%). The use of coagulant aids reduces the volume of the sludge produced up to 41.6%.

Deriving a compound quality of life measure from the EORTC-QLQ-C30/LC13 instrument for use in economic evaluations of lung cancer clinical trials.

Many clinical trials involve parallel collection of quality of life (QoL) and economic data, requiring patients to complete similar questionnaires at regular intervals. This additional burden often leads to disappointing response rates and inconclusive results. Data obtained in the LU-16 trial with the European Organization for Research and Treatment of Cancer Quality of Life (EORTC-QLQ-C30)/LC-13 QoL instrument for lung cancer were re-analysed, using multivariate techniques. The analysis demonstrated the inherent non-linearity of QoL data, with resulting interpretational problems. A new integrated linear QoL measure was developed which maximises the use of the information collected and can serve as a proxy utility measure for economic evaluation. It was successfully validated with data from another lung cancer trial with encouraging results. For individual patients, trends in QoL are revealed more clearly with narrower confidence intervals. This approach yields relative weightings and rankings for the main issues affecting QoL ratings in lung cancer patients, most importantly fatigue, breathlessness, poor concentration and disruption to family and social life.

Evaluation of CT findings for diagnosis of pleural effusions.

Computed tomography studies are usually used to assess patients with pleural effusions, and radiologists should be aware of the significance of different CT findings for the diagnosis of the effusion. The purpose of this study was to evaluate CT findings for etiological diagnosis of pleural effusions. Contrast-enhanced CT of the chest of 211 patients with pleural effusion of definite diagnosis were evaluated. The CT images were evaluated for the presence and extent of pleural effusion, thickening or nodules, extrapleural fat and other changes in the mediastinum or lung. The CT scans were read by two independent observers and correlation between them was evaluated. Comparison of CT findings between benign and malignant effusions, between exudates and transudates, and between empyemas and the other parapneumonic effusions were carried out. Kappa values for most CT findings were > 0.85. Loculation, pleural thickening, pleural nodules, and extrapleural fat of increased density were only present in exudative effusions. Multiple pleural nodules and nodular pleural thickening were the only pleural findings limited to malignant pleural effusions. The signs were also more frequently seen in empyemas than in other parapneumonic effusions. Computed tomography findings can help to distinguish between transudates and exudates. Although there is some overlap between benign and malignant pleural effusions, pleural nodules and nodular pleural thickening were present almost exclusively in the latter. Although differences between CT findings of empyemas and the other parapneumonic effusions exist, there is no finding which can definitely differentiate between them.

Evaluation of the relative cost-effectiveness of treatments for infertility in the UK.

This paper aims to complement existing clinical guidelines by providing evidence of the relative cost-effectiveness of treatments for infertility in the UK. A series of decision-analytical models have been developed to reflect current diagnostic and treatment pathways for the five main causes of infertility. Data to populate the models are derived from a systematic review and routine National Health Service activity data, and are augmented with expert opinion. Costs are derived from an analysis of extra-contractual referral tariffs and private sector data. Sensitivity analysis has been carried out to take account of the uncertainty of model parameters and to allow results to be interpreted in the light of local circumstances. Results of the modelling exercise suggest in-vitro fertilization is the most cost-effective treatment option for severe tubal factors and endometriosis, with surgery the most cost-effective in the case of mild or moderate disease. Ovulatory factors should be treated medically with the addition of laparoscopic ovarian diathermy in the presence of polycystic ovarian syndrome. For other causes, stimulated intrauterine insemination (unexplained and moderate male factor) and stimulated donor intrauterine insemination (severe male) are cost-effective.