Real-world antidiabetic drug use and fracture risk in 12,277 patients with type 2 diabetes mellitus: a nested case-control study.

We conducted a nested case-control study to study the association between antidiabetic treatments (alone or in combination) use and fracture risk among incident type 2 Diabetes mellitus patients. We found an increased risk of bone fracture with insulin therapy compared to metformin monotherapy. INTRODUCTION: Patients with type 2 diabetes mellitus (T2DM) have an increased risk of fragility fractures, to which antidiabetic therapies may contribute. We aimed to characterize the risk of fracture associated with different antidiabetic treatments as usually prescribed to T2DM patients in actual practice conditions. METHODS: A case-control study was nested within a cohort of incident T2DM patients registered in 2006-2012 in the Information System for Research Development in Primary Care (Catalan acronym, SIDIAP), a database which includes records for > 5.5 million patients in Catalonia (Spain). Each case (incident major osteoporotic fracture) was risk-set matched with up to five same-sex controls by calendar year of T2DM diagnosis and year of birth (± 10 years). Study exposure included previous use of all antidiabetic medications (alone or in combination), as dispensed in the 6 months before the index date, with metformin (MTF) monotherapy, the most commonly used drug, as a reference group (active comparator). RESULTS: Data on 12,277 T2DM patients (2049 cases and 10,228 controls) were analyzed. Insulin use was associated with increased fracture risk (adjusted OR 1.63 (95% CI 1.30-2.04)), as was the combination of MTF and sulfonylurea (SU) (adjusted OR 1.29 (1.07-1.56)), compared with MTF monotherapy. Sensitivity analyses suggest possible causality for insulin therapy but not for the MTF + SU combination association. No significant association was found with any other antidiabetic medications. CONCLUSIONS: Insulin monotherapy was associated with an increased fracture risk compared to MTF monotherapy in T2DM patients. Fracture risk should be taken into account when starting a glucose-lowering drug as part of T2DM treatment.

Programa de comunicación a distancia. Elaboración de indicadores cuali-cuantitativos para su evaluación / Outreach education program. Development of qualitative and quantitative assessment markers.

La Oficina de Comunicación a distancia (OCD) es una estructura creada en 1997 en el Hospital de Pediatría Juan P. Garrahan, con el objetivo de responder consultas a distancia y facilitar el seguimiento de pacientes, con la intención de evitar los traslados innecesarios. Ha dado respuesta a más de 25000 consultas. Actualmente, en el marco del Programa de Comunicación a Distancia (PCD), funcionan 88 OCD distribuidas en 12 de las 23 provincias argentinas. Se presentan resultados sobre una muestra de 148 consultas realizadas al Hospital Garrahan desde 6 provincias, que participaron de un estudio de tipo descriptivo, retrospectivo, cuali-cuantitativo. Éste permitió formular nuevas formas de registro de la tarea y elaborar indicadores cualicuantitativos para evaluar el PCD: consultas, motivo de consulta, tipo de paciente consultado, necesidad de la consulta, duración de la enfermedad al momento de la consulta, derivación sugerida, tiempo de respuesta. Se analizó el número de consultas y las sugerencias de derivación, mostrando las primeras un progresivo y significativo incremento desde la implementación del PCD. Con relación a los motivos de consulta, 84% correspondió a definición de diagnóstico y tratamiento, 16% a motivos de seguimiento e intercurrencias. 62% presentaba patologías crónicas. 95% de los pacientes fueron definidos como complejos. 79% correspondió a consultas definidas como imprescindibles. La derivación fue sugerida en el 54% de las consultas. La mediana del tiempo de respuesta fue de 48 horas. El bajo porcentaje atribuido a "motivos de seguimiento" evidencia la necesidad de profundizar estrategias para promoverlo. El PCD oficializó una modalidad de comunicación que canaliza prácticas anteriormente realizadas a través de vías informales, resignificando la gestión como acto asistencial. Contribuyó a la implementación de metodologías de evaluación conjunta de los indicadores considerados, que contemplan el contexto de la población con la que se trabaja (AU)

In 1997, the Outreach Communication Office (OCO) was created at the Pediatric Hospital Juan P. Garrahan with the aim of responding to consultations from remote places and facilitating follow-up of patients while avoiding unnecessary patient transportations. More than 25,000 consultations have been responded. Currently, within the framework of the Program of Outreach Communication (POC), 88 OCO's are operating distributed over 12 of the 23 Argentine provinces. Here we present the results of a sample of 148 consultations made at the Garrahan Hospital from six provinces that participated in a descriptive, retrospective, qualitative and quantitative study. The study allowed formulation of new methods of task registration and the development of qualitative and quantitative indicators to evaluate the POC: consultations, reason for consultation, type of patient, urgency of the consultation, disease duration until the moment of consultation, suggested referral, and time to response. The number of consultations and suggestions for referral were analyzed showing a progressive and significant increase of the former since the implementation of the POC. Of the reasons for consultation, 84% was related to definition of diagnosis and treatment, 16% to follow-up and intercurrencies. Of all patients, 62% had chronic diseases and 95% were considered complex patients. Of the consultations, 79% were defined as essential and 54% of the patients were referred to specialists. Mean time to response was 48 hours. The low percentage of consultations for "reasons of follow-up" reveals the need to develop strategies to encourage this modality. The POC has officialized a means of communication channeling practices that previously were informal giving a new meaning to the concept management in health care. The POC has contributed to the implementation of methodologies for the assessment of global markers taking into account the context of the population in question (AU)

Response to pegylated interferon plus ribavirin in HIV-infected patients with chronic hepatitis C due to genotype 4.

SUMMARY: Hepatitis C virus (HCV) genotypes 1 and 4 respond less well to pegylated interferon (pegIFN) plus ribavirin (RBV) therapy. For this reason most studies merge these two genotypes when assessing virological response. However, in most trials the HCV genotype 4 population is rather small, and conclusions are mainly derived from what occurs in HCV-1 patients. All HCV-4 patients coinfected with HIV who received pegIFN plus RBV in two different multicentre studies, PRESCO and ROMANCE, conducted respectively in Spain and Italy, were retrospectively analyzed. Baseline plasma HCV-RNA, proportion of patients with HCV-RNA <10 IU / mL at week 4 (rapid virological response), and HCV-RNA declines >2 logs at week 12 (early virological response, EVR) were all assessed as predictors of sustained virological response (SVR). Overall, 75 patients (60 men) were evaluated. Median age was 40 years and median CD4 count 598 cells / mm(3); 49% had plasma HIV-RNA <50 copies / mL; 71% had elevated liver enzymes and 31% had advanced liver fibrosis (Metavir F3-F4). Median serum HCV-RNA was 5.7 log IU / mL. Rapid virological response was attained by 10 (20%) patients and EVR by 26 (42%). Using intention-to-treat and on-treatment (OT) analyses, SVR was achieved by 21 / 75 (28%) and 21 / 62 (34%) of HCV-4 patients, respectively. In the multivariate analysis (OT), baseline HCV-RNA (OR 0.09 for every log increment; 95% CI: 0.01-0.7) and EVR (OR: 7.08; 95% CI: 1.8-27.2) were significantly and independently associated with SVR. This is the largest series of HIV-infected patients with chronic hepatitis C due to HCV-4 treated with pegIFN plus RBV examined so far and the results show that HCV-4 behaves similarly to HCV-1. Therefore, these patients should be considered as difficult to treat population. Baseline serum HCV-RNA and EVR are the best predictors of SVR in HCV-4 / HIV-coinfected patients.

Posición inusual de cables de marcapasos a través de vena cava superior izquierda / Unusual position of a pacemaker cable

No disponible

[Absence of benefit with triple antiaggregation in acute non persistent ST segment elevation myocardial infarction in patients not subjected to early interventionism]. / Ausencia de beneficio con triple antiagregación en el síndrome coronario agudo sin elevación persistente del segmento ST, en pacientes no sometidos a intervencionismo precoz.

OBJECTIVE: To assess the efficacy and safety of a treatment with clopidogrel when associated or not to the treatment with tirofiban and aspirin for high-risk non-ST segment elevation myocardial infarction (non-STEMI), without early angioplasty. SETTING: Intensive Care and Coronary Unit (ICCU), in a center with no Hemodynamic Laboratory. DESIGN: Non randomized clinical trial. PARTICIPANTS: One hundred and twenty-three patients admitted with the diagnosis of high-risk non-STEMI, defined as patients with chest pain and one of the following: ST segment depression or transient elevation or an elevation in cardiac troponin I (TropIc). INTERVENTIONS: We included patients admitted in a 24-month period. During the first 12-month period, the patients received tirofiban and clopidogrel (group A). In the second one, clopidogrel was not administered (group B). Urgent cardiac catheterism was requested if recurrent ischemic chest pain with ST segment changes, left ventricular failure or hemodynamic instability were present. PRIMARY VARIABLES: A composite of recurrent ischemic chest pain with ST segment changes or death during ICCU admission was evaluated as an efficacy variable. A variable of safety was defined as the occurrence of intracranial or gastrointestinal bleeding, or any hemorrhagic event accompanied by a drop of at least 3 g/dl of hemoglobin. The rate of urgent cardiac catheterisms was recorded. RESULTS: Neither the rate of the efficacy variable (19.6 % in group A and 19.4% in group B; p = 0.97), nor the rate of the safety variable (3.5% and 2.9% of patients in groups A and B, p = 1) showed statistically significant difference. There was no statistically significant difference in the rate of urgent cardiac catheterism (19.6% in group A and 13.4% in group B; p = 0.35). CONCLUSIONS: In the early course of high-risk non-STEMI with a conservative management strategy, the addition of clopidogrel to tirofiban does not change the rate of ischemic events, death, need of urgent catheterism or hemorrhagic events.

Critical role of ribavirin for the achievement of early virological response to HCV therapy in HCV/HIV-coinfected patients.

The response to hepatitis C virus (HCV) therapy seems to be lower in HCV/HIV-coinfected patients than in HCV-monoinfected individuals. Given that most pivotal trials conducted in coinfected patients have used the combination of pegylated interferon (pegIFN) along with fixed low doses (800 mg/day) of ribavirin (RBV), it is unclear whether HIV itself and/or suboptimal RBV exposure could explain this poorer outcome. Two well-defined end points of early virological response were evaluated in Peginterferon Ribavirina España Coinfección (PRESCO), a multicentre trial in which the combination of pegIFN plus RBV (1000 mg if body weight <75 kg and 1200 mg if >75 kg) was prescribed to coinfected patients. For comparisons, we used unpublished data from early kinetics in two other large trials, one performed in HIV-negative patients [Pegasys International Study Group (PISG)] in which RBV 1000-1200 mg/day was used and another [AIDS Pegasys Ribavirin Coinfection Trial (APRICOT)] in which HIV-positive patients received fixed low RBV doses (800 mg/day). A total of 348 HCV/HIV-coinfected patients from the PRESCO trial were analysed as well as all patients treated with pegIFN plus RBV, who completed 12 weeks of therapy in the comparative studies (435 in PISG and 268 in APRICOT). Negative serum HCV-RNA at week 4 (which has the highest positive predictive value of sustained virological response, SVR) was attained in 33.3%, 31.2% and 13% of treated patients with HCV genotype 1, respectively, in PRESCO, PISG and APRICOT. For HCV genotypes 2/3, responses were 83.7%, 84.2% and 37%, respectively. A decline lower than 2 log(10) at week 12 (which has the highest negative predictive value of SVR) was seen in 25.5%, 19.5% and 37% of HCV genotype-1-infected patients, and in 2.1%, 2.9% and 12% of genotypes-2/3-infected patients, respectively. Prescription of high RBV doses enhances the early virological response to HCV therapy in HCV/HIV-coinfected patients, with results approaching those seen in HCV-monoinfected patients.

Ausencia de beneficio con triple antiagregación en el síndrome coronario agudo sin elevación persistente del segmento ST, en pacientes no sometidos a intervencionismo precoz / Absence of benefit with tripleantiaggregation in acute non persistent ST segment elevation myocardial infarction in patients not subjected to early interventionism

Objetivo. Valorar la eficacia y seguridad del tratamiento con clopidogrel cuando se asocia o no al tratamiento con tirofibán más ácido acetilsalicílico (AAS) en el síndrome coronario agudo sin elevación persistente del segmento ST (SCASEST) de alto riesgo, sin intervencionismo precoz. Ámbito. Unidad de Cuidados Intensivos (UCI), en centro sin laboratorio de hemodinámica. Diseño. Ensayo clínico sin asignación aleatoria. Pacientes. Ciento veintitrés pacientes con SCASEST de alto riesgo, definido como dolor torácico y uno de los siguientes: descenso del segmento ST o ascenso transitorio o aumento de troponina I cardíaca (TropIc). Intervenciones. Estudio desarrollado durante veinticuatro meses. Los primeros doce meses el tratamiento incluía tirofibán y clopidogrel (grupo A); en los siguientes doce meses, el clopidogrel no se administraba (grupo B). El cateterismo cardíaco urgente se solicitó si aparecía dolor torácico recurrente con cambios en el segmento ST, fallo ventricular izquierdo o inestabilidad hemodinámica. Variables principales. Se evaluó una variable de eficacia, formada por la combinación de la aparición de dolor torácico con cambios en el segmento ST o muerte durante la estancia en la UCI, y una variable de seguridad, definida por la existencia de hemorragias intracraneales, digestivas o aquellas asociadas a una disminución de hemoglobina de al menos 3 g/dl. Se registró la frecuencia de realización de cateterismo urgente. Resultados. No hubo diferencias estadísticas significativas en la frecuencia de la variable de eficacia (19,6% en el grupo A y 19,4% en el grupo B; p = 0,97), ni en la de seguridad (3,5 y 2,9% en los grupos A y B respectivamente; p = 1). Tampoco existió diferencia estadística significativa en la realización de cateterismo urgente (19,6% en el grupo A y 13,4% en el grupo B; p = 0,35). Conclusiones. En el curso inicial del SCASEST de alto riesgo con una estrategia de tratamiento conservadora, la adición de clopidogrel al tirofibán no modifica la aparición de eventos isquémicos, muerte o necesidad de cateterismo urgente, ni se asocia a un incremento de complicaciones hemorrágicas

Objective. To assess the efficacy and safety of a treatment with clopidogrel when associated or not to the treatment with tirofiban and aspirin for high-risk non-ST segment elevation myocardial infarction (non-STEMI), without early angioplasty. Setting. Intensive Care and Coronary Unit (ICCU), in a center with no Hemodynamic Laboratory. Design. Non randomized clinical trial. Participants. One hundred and twenty-three patients admitted with the diagnosis of high-risk non-STEMI, defined as patients with chest pain and one of the following: ST segment depression or transient elevation or an elevation in cardiac troponin I (TropIc). Interventions. We included patients admitted in a 24-month period. During the first 12-month period, the patients received tirofiban and clopidogrel (group A). In the second one, clopidogrel was not administered (group B). Urgent cardiac catheterism was requested if recurrent ischemic chest pain with ST segment changes, left ventricular failure or hemodynamic instability were present. Primary variables. A composite of recurrent ischemic chest pain with ST segment changes or death during ICCU admission was evaluated as an efficacy variable. A variable of safety was defined as the occurrence of intracranial or gastrointestinal bleeding, or any hemorrhagic event accompanied by a drop of at least 3 g/dl of hemoglobin. The rate of urgent cardiac catheterisms was recorded. Results. Neither the rate of the efficacy variable (19.6 % in group A and 19.4% in group B; p = 0.97), nor the rate of the safety variable (3.5% and 2.9% of patients in groups A and B, p = 1) showed statistically significant difference. There was no statistically significant difference in the rate of urgent cardiac catheterism (19.6% in group A and 13.4% in group B; p = 0.35). Conclusions. In the early course of high-risk non-STEMI with a conservative management strategy, the addition of clopidogrel to tirofiban does not change the rate of ischemic events, death, need of urgent catheterism or hemorrhagic events

[Sedoanalgesia with remifentanil in definitive pacemaker implant]. / Sedoanalgesia con remifentanilo en el implante de marcapasos definitivo.

OBJECTIVE: Describe the use of remifentanil in definitive pacemaker implant. DESIGN: Prospective, observational study. SCOPE: Intensive Care Unit of two general hospitals. PATIENTS: Ninety-four patients subjected to DPM implant under sedation with remifentanil. INTERVENTIONS: The protocol for DPM implant was conducted: premedication with metoclopramide, remifentanil perfusion (20 micro g/ml), local infiltration with mepivacaine 2%, administration of magnesium metamizole at the end of the implant and posterior discontinuation of remifentanil. Remifentanil perfusion was initiated at 2 micro g/minute, increasing it until reaching a sedation grade 2-3 on the Ramsay scale, with a maximum of 6 micro g/minute. MAIN ENDPOINTS: Time needed to reach the desired sedation grade and duration of sedation, maximum dose of remifentanil necessary, frequency that another sedation was needed and of adverse events were recorded. Continuous quantitative endpoints were expressed as mean +/- SD. RESULTS: A sedation grade 2-3 was achieved with a perfusion rhythm of 3.6 +/- 1.4 micro g/min, in 20 +/- 22 minutes. In 89 patients (94.6%), the implant was performed only with remifentanil. Frequency of adverse events were nauseas/vomiting 21.3%, hypotension 5.3% and respiratory depression 1%. Remifentanil perfusion was discontinued in 3 patients (3.2%) due to appearance of adverse events. Another sedoanalgesic was used in 2 patients (2.1%). CONCLUSIONS: Remifentanil is useful in the implant of DPM as a sedoanalgesia method. Serious undesired effects are rare. Future studies are necessary to completely establish its effectiveness and safety in these types of procedures.

Sedoanalgesia con remifentanilo en el implante de marcapasos definitivo / Sedoanalgesia with remifentanilin definitive pacemaker implant

Objetivo. Describir el empleo de remifentanilo en el implante de marcapasos definitivo. Diseño. Estudio prospectivo observacional. Ámbito. Unidad de Cuidados Intensivos de dos hospitales generales. Pacientes. Noventa y cuatro pacientes sometidos a implante de marcapasos definitivo (MPD) bajo sedación con remifentanilo. Intervenciones. Se llevó a cabo el protocolo para implantación de MPD: premedicación con metoclopramida, perfusión de remifentanilo (20 µg/ml), infiltración local con mepivacaína 2%, administración de metamizol magnésico al terminar el implante y suspensión posterior de remifentanilo. La perfusión de remifentanilo se inició con 2 µg/minuto, incrementándola hasta alcanzar un grado de sedación 2-3 en la escala de Ramsay, con un máximo de 6 µg/minuto. Variables principales. Se registraron los tiempos transcurridos en alcanzar el grado de sedación deseado y de permanencia de la sedación, la dosis máxima necesaria de remifentanilo, la frecuencia con la que se necesitó otra sedación y la de efectos adversos. Las variables cuantitativas continuas se expresaron como media ± desviación estándar (DE). Resultados. Un grado de sedación 2-3 se consiguió con un ritmo de perfusión de 3,6 ± 1,4 µg/minuto, en 20 ± 22 minutos. En 89 pacientes (94,6%) el implante se llevó a cabo con remifentanilo exclusivamente. La frecuencia de efectos adversos fueron náuseas/vómitos 21,3%, hipotensión 5,3% y depresión respiratoria 1%. La perfusión de remifentanilo fue suspendida en 3 pacientes (3,2%) por la aparición de efectos adversos. Se empleó otra sedoanalgesia en 2 pacientes (2,1%). Conclusiones. El remifentanilo es útil en el implante de MPD como método de sedoanalgesia. Los efectos indeseables graves son poco frecuentes. Son necesarios futuros estudios para establecer completamente su efectividad y seguridad en este tipo de procedimientos

Objective. Describe the use of remifentanil in definitive pacemaker implant. Design. Prospective, observational study. Scope. Intensive Care Unit of two general hospitals. Patients. Ninety-four patients subjected to DPM implant under sedation with remifentanil. Interventions. The protocol for DPM implant was conducted: premedication with metoclopramide, remifentanil perfusion (20 µg/ml), local infiltration with mepivacaine 2%, administration of magnesium metamizole at the end of the implant and posterior discontinuation of remifentanil. Remifentanil perfusion was initiated at 2 µg/minute, increasing it until reaching a sedation grade 2-3 on the Ramsay scale, with a maximum of 6 µg/minute. Main endpoints. Time needed to reach the desired sedation grade and duration of sedation, maximum dose of remifentanil necessary, frequency that another sedation was needed and of adverse events were recorded. Continuous quantitative endpoints were expressed as mean ± SD. Results. A sedation grade 2-3 was achieved with a perfusion rhythm of 3.6 ± 1.4 µg/min, in 20 ± 22 minutes. In 89 patients (94.6%), the implant was performed only with remifentanil. Frequency of adverse events were nauseas/vomiting 21.3%, hypotension 5.3% and respiratory depression 1%. Remifentanil perfusion was discontinued in 3 patients (3.2%) due to appearance of adverse events. Another sedoanalgesic was used in 2 patients (2.1%). Conclusions. Remifentanil is useful in the implant of DPM as a sedoanalgesia method. Serious undesired effects are rare. Future studies are necessary to completely establish its effectiveness and safety in these types of procedures

Empleo conjunto de tirofibán y clopidogrel en el síndrome coronario agudo sin elevación del segmento ST de alto riesgo / Combined use of tirofiban and clopidogrel in the high risk acute coronary syndrome without ST segment elevation

Objetivo. Descripción del empleo simultáneo de tirofibán y clopidogrel en el síndrome coronario agudo sin elevación persistente del segmento ST (SCASEST) de alto riesgo. Diseño. Estudio de cohorte de comienzo, prospectivo, incluyendo pacientes durante 12 meses, con seguimiento desde el ingreso en Unidad de Cuidados Intensivos (UCI) hasta el alta hospitalaria. Ámbito. UCI de un hospital sin laboratorio de hemodinámica. Pacientes. Muestra consecutiva de 56 pacientes con SCASEST que presentaban ascenso transitorio del segmento ST, descenso del mismo o elevación de la troponina Ic. Se excluyeron posteriormente 4 pacientes por no cumplir los criterios de inclusión. Todos completaron el período de seguimiento. Intervenciones. Los pacientes fueron tratados con ácido acetilsalicílico, clopidogrel, tirofibán, heparina sódica y medicación antiisquémica, según las indicaciones de las guías de consenso en vigor. Se solicitó cateterismo cardíaco cuando apareció angina refractaria, fallo ventricular o inestabilidad hemodinámica. Variables principales. Se registraron los eventos isquémicos durante el período de seguimiento, la realización de cateterismo cardíaco y las complicaciones hemorrágicas.Resultados. Durante el ingreso en la UCI 21 pacientes (40,3%) presentaron ángor de repetición y/o fallo ventricular izquierdo y dos pacientes (3,8%) fallecieron. En la planta de hospitalización 6 pacientes (12%) sufrieron ángor de repetición y/o fallo ventricular izquierdo. Se realizó cateterismo en 11 pacientes (21,1%) desde la UCI y en 20 (40%) desde la planta de hospitalización. Se registraron 2 hemorragias graves (3,8%) y una trombocitopenia (1,9%). Conclusiones. La aparición de complicaciones en el SCASEST de alto riesgo es frecuente, incluso cuando se emplean simultáneamente tirofibán y clopidogrel. Para conocer si esta estrategia terapéutica puede contribuir a la estabilización clínica de los pacientes con SCASEST se requieren estudios con tirofibán sólo. El riesgo hemorrágico del empleo de tirofibán con clopidogrel es aceptable

Objective. Description of simultaneous use of tirofiban and clopidogrel in the high risk acute coronary syndrome without persistent ST segment elevation (SCASEST). Design. Prospective, onset cohort study, including patients for 12 months, with follow-up from admission to ICU until hospital discharge. Scope. Intensive Care Unit (ICU) of a hospital without hemodynamic laboratory. Patients. Consecutive sample of 56 patients with SCASEST who had transitory increase of ST segment, decrease of it or elevation of troponin Ic. Four patients were excluded later as they did not comply with the inclusion criteria. All completed the follow-up period. Interventions. The patients were treated with aspirin, clopidogrel, tirofiban, heparin sodium and anti-ischemic medication according to the consensus guidelines in force. Cardiac catheterism was requested when refractory angina, ventricular failure or hemodynamic instability appeared. Primary endpoints. The ischemic events were recorded during the follow-up period, the performance of the cardiac catheterism and the bleeding complications. Results. During the admission in the ICU, 21 patients (40.3%) had recurrent angina and/or left ventricular failure. Two patients (3.8%) died. Six patients (12%) in the hospitalization ward had recurrent angina and/or left ventricular failure. Catheterism was done in 11 patients (21.1%) from the ICU and in 20 (40%) from the hospitalization ward. Two serious bleedings (3.8%) and one thrombocytopenia (1.9%) were recorded. Conclusions. The appearance of complications in high risk SCASEST is frequent, even when tirofiban and clopidogrel are used simultaneously. To know if this therapeutic strategy may contribute to clinical stabilization of SCASEST patients, studies versus tirofiban alone are required. Bleeding risk due to the use of tirofiban with clopidogrel is acceptable

[Effect of the availability of a medicalized mobile ICU (MMICU) on the hospital admissions after an out-of-hospital cardiorespiratory arrest (OH-CRA)]. / Efecto de la disponibilidad de una UVI móvil medicalizada en los ingresos hospitalarios tras una parada cardiorrespiratoria extrahospitalaria.

Patients admitted in an ICU after OH-CRA before and after the implementation of a MMICU were evaluated. During a period of 11 years, divided into a pre-MMICU period (1988-1993) and a post-MMICU period (1994-1998), 39 patients were admitted in the pre period and 64 patients in the post period. The basal characteristics, the etiologies of OH-CRA and of death in ICU they were similar. The incidence of severe anoxic encephalopathy (SAE) it doubled in the post period. There were not significant differences both to the discharge from ICU and to the hospital discharge. We conclude that after implementing a MMICU more patients are admitted in ICU resuscitated after OH-CRA. The survival does not vary, but the incidence of SAE increases.

Efecto de la disponibilidad de una UVI móvil medicalizada en los ingresos hospitalarios tras una parada cardiorrespiratoria extrahospitalaria / Effect of the availability of a medicalized mobile ICU

Se analizaron pacientes (px) ingresados en UCI tras una parada cardiorrespiratoria extrahospitalaria (PCR-E) antes y después de implantar una UVI móvil medicalizada (UVIMM). Durante 11 años, divididos en período pre-UVIMM (1988-1993) y post-UVIMM (1994-1998), ingresaron 39 px en el período pre y 64 px en el post-UVIMM. Las características basales, las etiologías de PCR-E y de fallecimiento en UCI fueron similares. La incidencia de encefalopatía anóxica severa (EAS) se duplicó en el período post. No hubo diferencias significativas tanto al alta de UCI como al alta hospitalaria. Concluimos que tras implantar una UVIMM ingresan en UCI más px reanimados tras una PCR-E. La supervivencia no varía, pero aumenta la incidencia de EAS (AU)

Estudio de tolerancia a cefpodoxima proxetil en pacientes con hipersensibilidad a betalactámicos / Study of tolerance to cefpodoxime proxetil in patients allergic to beta-lactam antibiotics

Objetivos: Se seleccionó de forma aleatoria a un grupo de 30 pacientes (< 65 años) diagnosticados de hipersensibilidad a betalactámicos mediante pruebas cutáneas o provocación controlada para estudiar su tolerancia a cefpodoxima proxetil, una cefalosporina de tercera generación que se administra por vía oral. Material y metodos: Se realizaron pruebas cutáneas con penicilina G, amoxicilina, ampicilina, cefpodoxima proxetil, cefalexina, ceftazidima y cefotaxima; simultáneamente se extrajo sangre para la realización de una prueba de liberación de histamina con penicilina G, amoxicilina, ampicilina y cefpodoxima. Se realizó una prueba de tolerancia oral con dosis terapéuticas (200 mg) de cefpodoxima proxetil (Otreon) a simple ciego a 26 pacientes.Se volvió a administrar el fármaco 15 días después. Se solicitó consentimiento informado por escrito a todos los pacientes. Se utilizaron como controles 36 pacientes que habían tolerado betalactámicos en los 6 meses previos. Resultados: Todos los pacientes toleraron con normalidad la administración de dosis terapéuticas de cefpodoxima proxetil. En el estudio se analizan los resultados de las distintas pruebas realizadas tanto in vivo como in vitro. Conclusiones: La tolerancia a cefpodoxima proxetil, una cefalosporina de tercera generación que se administra por vía oral, ha sido buena en pacientes con hipersensibilidad a betalactámicos. Con nuestro estudio apoyamos los datos existentes en la actualidad de que la reactividad cruzada clínica con cefalosporinas en pacientes con hipersensibilidad constatada a betalactámicos es muy escasa. Antes de recomendar su uso es necesario realizar más estudios (AU)

Postirradiation multiple minute digitate porokeratosis.

BACKGROUND: Development of multiple minute digitate hyperkeratoses (MMDH) after irradiation has been reported previously. The keratotic lesions in these cases were confined within the irradiation field, and histopathological examination disclosed a focal column of parakeratosis (cornoid lamella) arising from an epidermis devoid of granular layer. OBJECTIVE: We describe a 78-year-old woman who developed multiple, discrete, tiny, filiform, keratotic papules on the anterior aspect of the right chest wall, 13 months after postmastectomy cobalt irradiation therapy for mammary infiltrating ductal carcinoma. CONCLUSION: Postirradiation MMDH represents a peculiar radiation-induced disorder that we believe should be distinguished from other cases of MMDH and included within the spectrum of porokeratosis.

Hypertrichosis lanuginosa acquisita preceding extraskeletal Ewing's sarcoma.

A 62-year-old woman with acquired hypertrichosis lanuginosa as a paraneoplastic presenting sign of an extraskeletal Ewing's sarcoma is described. Despite initial comprehensive screening to rule out an associated malignancy, a definitive diagnosis of sarcoma was established only 1 year after the onset of the cutaneous symptoms. To the best of our knowledge, this is the first report of hypertrichosis lanuginosa acquisita associated with a soft tissue sarcoma. Our observation expands the spectrum of malignancies associated with this uncommon paraneoplastic disorder.

Anaphylaxis to calcitonin.

BACKGROUND: The calcitonin is an hormone produced by the thyroid gland C cells. The salmon calcitonin is used in some osteomuscular diseases. There are few references of allergic reaction to this hormone. We introduce a case of a sixty years old woman with several previous episodes of rhinitis, conjunctivitis and perspiration immediately after the administration of salmon calcitonin with nasal spray or intramuscular administration (Calsynar). There were some temporal periods of good tolerance between these episodes. METHODS: Skin prick test (SPT), nasal and intramuscular challenge test with commercial salmon calcitonin (Miacalcic) were performed. Leukocyte histamine release test with salmon calcitonin and serum tryptase levels at baseline and after intramuscular challenge test were performed. RESULTS: The patient skin prick test with commercial calcitonin (Miacalcic. 50 UI/ml) was positive and negative in controls. The nasal challenge test with a calcitonin nasal spray, up to 150 UI, was negative. The intramuscular challenge test with 25 UI of Miacalcic was positive with an immediate anaphylactic reaction. Whole blood histamine release studies were negative. Serum tryptase levels after intramuscular challenge did not increase significantly with regard to the basal levels. CONCLUSION: We have introduced a case of anaphylaxis by calcitonin that suggest an IgE mediated hypersensitivity reaction.

Irritant-induced asthma: clinical and functional aspects.

We report on three patients who experienced persistent asthma symptoms after repetitive irritant exposure which took place over a period from several days to months. Airway inflammation was assessed by induction of sputum and functional follow-up information was obtained from serial lung function tests. All patients had bronchial hyperresponsiveness to methacholine at the time of diagnosis. However, induced sputum samples did not show increased differential count of eosinophils. Treatment with inhaled corticosteroids was started in all of the patients and two of them were removed from work. In the two patients who left the workplace, methacholine inhalation test became negative when symptoms disappeared, whereas the patient who continued working had persistent asthma symptoms and a deterioration of bronchial hyperresponsiveness.