El método AMFE (Análisis Modal de Fallos y Efectos) aplicado a la anticoagulación de pacientes con fibrilación auricular no valvular / Failure Mode and Effects Analysis (FMEA) method applied to anticoagulation of patients with non-valvular atrial fibrillation

OBJETIVOS: El propósito de este trabajo es contribuir a mejorar el proceso de la anticoagulación en pacientes con fibrilación auricular no valvular (FANV) mediante acciones de sensibilización y formación al colectivo de atención primaria. MATERIALES Y MÉTODOS: Se realizaron 38 grupos focales secuenciados según una adaptación del método de Análisis Modal de Fallos y Efectos. Cada reunión fue dinamizada mediante una metodología de «tormenta de ideas» (brainstorming). Participaron 482 médicos (444 de atención primaria y 38 cardiólogos) de ámbito nacional con representación geográfica homogénea. El trabajo de campo se extendió entre el 28 de marzo y el 20 de junio de 2017. RESULTADOS: Las principales acciones inseguras que pueden comportar un evento hemorrágico o trombótico son la anticoagulación incorrecta o la falta de seguimiento del paciente, debidos sobre todo a carencias formativas en el manejo de la FANV y no tener en cuenta posibles interacciones que pueden darse con fármacos antagonistas de la vitamina K. Las principales recomendaciones para paliar estos fallos se centraron en un buen seguimiento de los pacientes con FANV, en realizar o actualizar los protocolos o guías de práctica clínica y en potenciar la formación continuada de los médicos que habitualmente manejan a pacientes con FANV tratados con anticoagulantes orales. CONCLUSIONES: Un porcentaje significativo de pacientes con FANV no están correctamente anticoagulados, y para paliar este problema se requieren acciones específicas, entre las que destaca la formación sobre anticoagulación en general, y sobre uso de los anticoagulantes orales de acción directa en particular

OBJECTIVES: To contribute to the improvement of the process of anticoagulation in patients with nonvalvular atrial fibrillation (NVAF) through awareness and training activities for Primary Care Physicians. MATERIALS AND METHODS: A total of 38 focus groups, sequenced according to an adaptation of the Failure Mode and Effects Analysis (FMEA) method. Each meeting was driven by "brainstorming" methodology. The geographical representation was homogeneous, with a total of 482 national. physicians (444 Primary Care Physicians, and 38 cardiologists). The meetings were held between March 28 and June 20, 2017. RESULTS: The main unsafe actions that can lead to a haemorrhagic or thrombotic event are incorrect anticoagulation or lack of patient follow-up. These events are mainly caused by training deficiencies in the management of NVAF, or by not taking into account possible interactions with vitamin K antagonist drugs. The main recommendations to alleviate these failures were focused on a good follow-up of patients with NVAF, on creating or updating the protocols or clinical practice guidelines, and on promoting the continuous training of physicians who usually manage patients with non-valvular AF treated with oral anticoagulants. CONCLUSIONS: A significant percentage of patients with NVAF are not correctly anticoagulated. Specific actions are required to alleviate this problem. Among them, the importance of a general anticoagulation training was emphasised, and particularly, the use of direct oral anticoagulants

[Failure Mode and Effects Analysis (FMEA) method applied to anticoagulation of patients with non-valvular atrial fibrillation]. / El método AMFE (Análisis Modal de Fallos y Efectos) aplicado a la anticoagulación de pacientes con fibrilación auricular no valvular.

OBJECTIVES: To contribute to the improvement of the process of anticoagulation in patients with nonvalvular atrial fibrillation (NVAF) through awareness and training activities for Primary Care Physicians. MATERIALS AND METHODS: A total of 38 focus groups, sequenced according to an adaptation of the Failure Mode and Effects Analysis (FMEA) method. Each meeting was driven by «brainstorming¼ methodology. The geographical representation was homogeneous, with a total of 482 national. physicians (444 Primary Care Physicians, and 38 cardiologists). The meetings were held between March 28 and June 20, 2017. RESULTS: The main unsafe actions that can lead to a haemorrhagic or thrombotic event are incorrect anticoagulation or lack of patient follow-up. These events are mainly caused by training deficiencies in the management of NVAF, or by not taking into account possible interactions with vitamin K antagonist drugs. The main recommendations to alleviate these failures were focused on a good follow-up of patients with NVAF, on creating or updating the protocols or clinical practice guidelines, and on promoting the continuous training of physicians who usually manage patients with non-valvular AF treated with oral anticoagulants. CONCLUSIONS: A significant percentage of patients with NVAF are not correctly anticoagulated. Specific actions are required to alleviate this problem. Among them, the importance of a general anticoagulation training was emphasised, and particularly, the use of direct oral anticoagulants.

Natural Infection of Canavalia ensiformis with Tobacco mosaic virus in Venezuela.

Jack bean (Canavalia ensiformis) is a valuable green manure and cover-crop species. In late summer of 2002, jack bean plants showing severe stunting, leaf mosaic, mottling, distortion, and general yellowing were observed in fields located in Maracay, Aragua State, Venezuela. Sap from symptomatic leaves was used to mechanically inoculate healthy jack bean, and field symptoms were successfully reproduced. Similar inoculations on Nicotiana tabacum var. Sansum resulted in mosaic symptoms and leaf distortion. Electron microscopic examination of leafdip preparations showed filamentous rods resembling those of a tobamovirus. Tobacco mosaic virus (TMV) was specifically identified with TMV-specific polyclonal antibody (PVAS-958, ATTC) in enzyme-linked immunosorbent assay. Sequence analysis of a coat protein gene (CP) fragment amplified using reverse transcription-polymerase chain reaction (RT-PCR) with primers TMV-CP-F and TMV-CP-R (1) from total RNA confirmed the diagnosis. Nucleotide and deduced amino acid sequences of a 450-bp region of the RT-PCR product were 96 to 99% and 98 to 100% identical, respectively, to the TMV CP gene in GenBank Accession Nos. J02415 and X68110. On the basis of foliar symptoms, incidence of TMV in jack bean was more than 50% in this experimental field. The source of infection is not known. Because TMV is reported to be seedborne in many other plant species, testing jack bean seed stocks for TMV infection could have important implications on the future control of the virus. To our knowledge, this is the first report of natural infection of jack bean by a tobamovirus. Reference: (1) N. J. Spence et al. Eur. J. Plant Pathol. 107:633, 2001.

Optimización de esquemas de punción en biopsia ecodirigida para la detección del cáncer de próstata / Optimization of puncture schedule in transrectal ultrasound guided prostate biopsy in prostatic cancer

El esquema clásico de biopsias por sextantes ha demostrado ser insuficiente en el diagnóstico del cáncer de próstata. Sin embargo, aún no existe consenso en cuanto a número y zonas a biopsiar durante este procedimiento, existiendo numerosas propuestas al respecto en la literatura. Los estudios han descrito un mayor rendimiento con biopsias dirigidas hacia la zona lateral. Efectuamos un estudio prospectivo comparando la sensibilidad de los distintos focos en forma individual, evaluándose diversas combinaciones de éstos con el fin de generar una estrategia óptima en términos de detección y número de muestras. Se incluyeron 110 pacientes consecutivos sometidos a biopsia de próstata. Se registró edad, APE, volumen prostático, Gleason, tacto rectal y morbilidad derivada del procedimiento. Además de la biopsia rutinaria por sextantes en ubicación parasagital, se agregaron dos muestras laterales a cada lado, en la base y en la zona media. En próstatas > 50 cc se agregaron dos muestras de la zona de transición. Se calculó el rendimiento de cada foco de biopsia en forma separada, analizándose varios esquemas derivados de distintas combinaciones, comparándose con pruebas no paramétricas. Treinta y nueve (35,5 por ciento) de los pacientes presentó cáncer en la biopsia. Estos pacientes eran de mayor edad (p=0,056), tenían próstatas más pequeñas (p=0,028) y APE más elevados (p=0,0003). El esquema clásico por sextantes detectó sólo el 69,2 por ciento de los cánceres en comparación con el esquema de 10 muestras (p=0,001), este rendimiento se mantuvo al eliminar la muestra de la base de la zona lobular media, obteniéndose de esta manera una combinación óptima compuesta por 8 muestras. Esta tendencia se mantuvo al analizar según APE, volumen prostático y tacto rectal, siendo significativa en próstatas < 50 cc (p=0,008), en pacientes con TR negativo (p=0,003) y con APE < 10 ng/ml (p=0,004). Se constató una morbilidad baja, no diferenciándose significativamente de la publicada en series con 6 muestras. La biopsia ecodirigida debiera incluir al menos 8 muestras, incluyéndose la zona lateral basal y media, el ápex y la media de la zona lobular media. El mayor número de muestras no implica una mayor morbilidad.

Síndrome de Dressler y pericarditis constrictiva transitoria / Transient constrictive pericarditis after Dressler's syndrome

Tras un infarto de miocardio inferior complicado con síndrome de Dressler, se presentaron datos de insuficiencia cardíaca derecha persistente en una mujer de 52 años. El estudio hemodinámico mostró datos de constricción y la coronariografía una oclusión de la arteria coronaria derecha. La paciente fue tratada con colchicina con alivio de su hepatomegalia y sus edemas periféricos. Ocho meses más tarde la paciente reingresó para evaluación de una disnea de reciente comienzo. La coronariografía reveló su evolución hacia una enfermedad trivaso severa y el estudio hemodinámico objetivó la desaparición de la fisiología constrictiva. El paciente fue sometido a cirugía de revascularización coronaria. Durante el acto quirúrgico el pericardio no estaba engrosado ni calcificado. La biopsia del mismo mostró un ligero edema con mínima fibrosis (AU)

[Morphological characterization of annatto fruits 9bixa orellana L.) and its correspondence with protein and isoenzym patterns]. / Caracterización morfológica de frutos de onoto (Bixa orellana L.) y su correspondencia con patrones de proteínas e isoenzimas.

A group of 32 annatto genotypes collected in five Venezuelan regions (Oriente, Centro, Llanos, Andes and Amazonas) and in Brazil were used for morphological studies. The fruit variables with the greatest discriminatory power in the formation of groups were capsule size, spinosity and seed size. On the other hand, an association group among the variables spinosity, spine length, dehiscence and apex shape were formed, also a proportional association between capsule and seed size, and between dehiscent capsule and brown coloured seeds. Additionally, in order to discriminate morphological variables behaviour in respond to electrophoretic variables, a group of protein and isozyme bands associated with fruit characteristics were established. Therefore, a classification system of this species was possible using morphological studies of the capsules, even though a determined association relating morphological and molecular patterns was not found.

[Identification and genetic variability of annatto genotypes (Bixa orellana L.) by means of hydrosoluble proteins and isoenzymes]. / Identificación y variabilidad genética de genotipos de onoto (Bixa orellana L.) mediante el uso de proteínas hidrosolubles e isoenzimas.

In order to identify and to determine the genetic variability of 36 annatto genotypes (Bixa orellana L.) collected in five Venezuelan regions (Oriente, Centro, Llanos, Andes and Amazonas) and in Brazil, hydrosoluble protein patterns as well as specific isozyme patterns (alpha-esterase, beta-esterase and peroxidase) were studied using extracts of germinated annatto seeds with radicles of 10 to 15 mm long. Each electrophoretic system allowed genotype discrimination by means of unique banding patterns: both the hydrosoluble protein and the electrophoretic system of beta-esterase with nine banding patterns each; whilst alpha-esterase and peroxidase discriminated eight and three genotypes, respectively. On the other hand, a combination of all the systems permitted a greater discrimination since 34 out of 36 genotypes could be distinguished. Eight mayor groups were formed that showed high levels of genetic diversity (40 to 60%) with no association between geographic and genetic distances, probably because of human influence in the aleatory distribution of this crop. Results obtained indicated that using electrophoretic banding patterns, a classification system could be established for identification and genetic variability purposes in this species.

Deglycosylation is necessary but not sufficient for activation of proconcanavalin A.

Concanavalin A (ConA), one of the most studied plant lectins, is formed in jack bean (Canavalia ensiformis) seeds. ConA is synthesized as an inactive glycoprotein precursor proConA. Different processing events such as endoproteolytic cleavages, ligation of peptides and deglycosylation of the precursor are required to generate the different polypeptides constitutive of mature ConA. Among these events, deglycosylation of the prolectin appears as a key step in the lectin activation. The detection of deglycosylated proConA in immature jack bean seeds indicates that endoproteolytic cleavages are not prerequisite for its deglycosylation. Both the structure of the lectin precursor N-glycans Man8-9GlcNAc2 and the capacity of Endo H to cleave these oligosaccharide from native proConA in vitro favoured Endo H-type glycosidases as candidates for proConA deglycosylation in planta. Evidence for pH-dependent changes in the prolectin folding were obtained from analysis of the N-glycan accessibility and activation of the deglycosylated lectin precursor in acidic conditions. These data are consistent with the observation that both deglycosylation and acidification of the pH are the minimum requirements to convert the inactive precursor into an active lectin.

[Perioperative monitoring using transesophageal echocardiography in a case of endocarditis-related tricuspid valve disease]. / Monitorización perioperatoria con ecocardiografía transesofágica en un caso de valvulopatía tricuspídea por endocarditis.

The risk of infectious endocarditis is higher for intravenous drug users than for patients with either rheumatic disease or valve prostheses. We report the case of a 33-year-old woman who self-administered opioid drugs parenterally and who developed a clinical picture of infectious endocarditis. Serious involvement of the tricuspid valve developed in the form of vegetation requiring surgical repair, during which transesophageal echocardiography was used for perioperative monitoring.

Monitorización perioperatoria con ecocardiografía transesofágica en un caso de valvulopatía tricuspídea por endocarditis / Perioperative monitoring with transesophageal echocardiography in a case of tricuspid valve disease due to endocarditis

El riesgo de endocarditis infecciosa entre los consumidores de drogas por vía intravenosa es superior al que pudieran presentar los pacientes afectados de enfermedad reumática o prótesis valvulares. Presentamos el caso de una mujer de 33 años de edad, consumidora de opiáceos por vía parenteral, que presentó cuadro de endocarditis infecciosa con importante afección de la válvula tricúspide en forma de gran vegetación que requirió tratamiento quirúrgico reparador, durante el cual se realizó monitorización perioperatoria mediante ecocardiografía transesofágica (AU)

No disponible

Preparing physicians for careers in primary care internal medicine: 17 years of residency experience.

The objective of this survey was to demonstrate whether a primary care track internal medicine residency program emphasizing community-based health care of the urban sick poor trains physicians who will continue to practice in general internal medicine or similar fields. Thirty-five primary care residents (100% of graduates) who trained from 1976 through 1993 in the Adult Primary Care Track of the Internal Medicine Residency Program at St. Vincent's Hospital, New York were used as participants.

Histaminergic drugs in the rat caudate nucleus: effects on learned helplessness.

The effect of pharmacological manipulation of histaminergic receptors in the caudate nucleus (CN) has been examined in rats previously submitted to inescapable electric shock to produce learned helplessness (LH). Histamine H1 agonist 2-tiazolylethyl amine (TEA) microinjection produced protective effects, preventing the activity and cognitive loss typical in LH. Injection of the H1 antagonist astemizole (AZ) produced effects symmetrical to those produced by TEA, further reducing activity and impairing cognitive functions. The histamine H2 agonist 4-methyl-histamine (4MH) produced a shift on the side preference for rotation that interfered in the learning tests and obscured the effects of this drug on LH. Injection of the H2 antagonist cymetidine (CYM) caused LH-like effects in control animals. Thus, brain histamine seems to play a relevant role in the control of motor and cognitive functions of the CN.

[Pulsed Doppler of the hepatic veins: a new test in the assessment of aortic insufficiency]. / Doppler pulsado de las venas hepáticas: un nuevo test en la valoración de la insuficiencia aórtica.

In order to determine the value of the analysis of the hepatic vein flow pattern in the gradation of aortic regurgitation, two-dimensional and Doppler studies were carried out in 13 healthy individuals (control group) and 36 patients with aortic regurgitation (study group), in a prospective fashion. By 2-D and Doppler Echocardiography, aortic regurgitation was graded as mild in 5 patients, moderate in 13 and severe in the remaining. In 25 patients of the study group, hemodynamic and angiographic studies were available. Moderate or severe pulmonary hypertension was detected in 11 patients. Peak and integral velocities of the systolic, diastolic and "A" waves were measured on pulsed Doppler hepatic veins flow tracings. Both peak and integral hepatic vein diastolic flow velocities in postexpiratory apnea were significant lower in patients with severe aortic regurgitation with respect to the remaining study group patients and control group patients. Sensitivity and specificity for the detection of severe aortic regurgitation were 100 and 67% respectively. An postexpiratory increase in the retrograde "A" wave was observed in 11 patients with severe and 6 with moderate aortic regurgitation. Sensitivity and specificity for the detection of severe aortic regurgitation were 58 and 67% respectively. In this study, characteristic pulsed Doppler hepatic vein flow patterns are defined for patients with aortic regurgitation. Sensitivity and specificity of the findings allows the identification of severe AR. This results could have diagnostic and therapeutic implications.

[Changes in the flow patterns of the hepatic veins obtained by pulsed Doppler during the postoperative follow-up of a patient with acute aortic insufficiency]. / Modificación de los patrones de flujo de las venas hepáticas obtenidos por Doppler pulsado durante el seguimiento postoperatorio de un paciente con insuficiencia aórtica aguda.

Blood flow pattern recording of hepatic veins using pulsed Doppler technique is a valid method for the assessment of hemodynamic changes in right atrium. We describe a patient with severe aortic regurgitation secondary to acute infective endocarditis who underwent surgical repair. Before surgery and during the postoperative period, several evolutive studies (including conventional echo and hepatic veins pulsed Doppler recordings) were performed. The different central blood flow patterns were correlated with changing hemodynamic conditions during follow-up of the patient. These central flow velocities reflect changes in right atrial pressure contours, and are easily obtained non-invasively with pulsed wave Doppler ultrasound of the hepatic veins. They could be an useful method for assessing right heart filling dynamics, reporting characteristic patterns in other cardiac disease states.

[The importance of the echocardiographic diagnosis of a mycotic aneurysm of the mitral septal leaflet in infectious endocarditis of the aortic valve: the surgical implications]. / Importancia del diagnóstico ecocardiográfico del aneurisma micótico del velo septal mitral en la endocarditis infecciosa de la válvula aórtica: implicaciones quirúrgicas.

Mycotic aneurysm of the septal leaflet of the mitral valve is an infrequent complication associated with aortic infective endocarditis. The most probable mechanisms implicated on its formation are two: the lesion induced by regurgitant jet striking on septal mitral leaflet and the direct spreading of infection through the fibrosa inter-valvular. We describe the preoperative diagnosis of mycotic aneurysms of the septal mitral leaflet by two-dimensional echocardiography and color flow mapping in 2 patients. Surgical management will depend on the anatomic characteristics of the aneurysm and its hemodynamic repercussion. Careful echocardiographic search for mycotic mitral aneurysms should be performed in cases of aortic valve endocarditis, in view of its important prognostic implications.

[Active infective endocarditis complicated by paravalvular abscess. Review of 40 cases]. / Endocarditis infecciosa activa complicada con absceso paravalvular. Revisión de 40 casos.

We have performed a retrospective analysis of the clinical, echocardiographic, surgical and necropsy data in 40 patients affected by infective endocarditis complicated by paravalvular abscess. The abscess developed on prosthetic valve in 13 cases, and on native valve in 27. Aortic valve was the most affected (85%). The clinical course was considered to be acute in 52% of the patients. Fever persisted despite of adequate antibiotic therapy in 57%. In 90%, overt heart failure were present. Staphylococcus were the most frequent causative microorganism (S. aureus, 22.5%; S. epidermidis, 20%). Bundle branch or atrioventricular block were detected in 18 patients (sensibility, 45%; specificity, 88%). Bidimensional echocardiography, along with Doppler techniques when necessary, detected an abscess in 81% of patients (sensibility, 80%; specificity, 84%). Thirty patients were operated. Eight of them (26%) died, two intraoperatively. Ten patients were not operated and nine died (90%). The difference was significant (p less than 0.001). Only age and surgical treatment were related to early survival. Over the follow-up of the operated patients, five presented prosthetic dehiscence, but only two required a new operation 3 months after the first intervention, and none died. In conclusion, the detection of a paravalvular abscess complicating an infective endocarditis is an indication for surgical treatment. Both surgical mortality and postoperative prosthetic dehiscence are acceptable. Bidimensional echocardiography is the most reliable tool for the diagnosis of this complication.

A new precise microcomputer based rotometer.

The rotometer described here consists of a data acquisition system made of several reed relays which are activated by a small moving magnet when the animal performs rotations. The apparatus has an angular discrimination which is dependent on the number of reed relays used. A simple interface is used to normalize the pulses produced when the reed relay contacts are closed. This normalized output closes key contacts in the keyboard of a microcomputer resulting in ASCII strings. A simple BASIC program is used for computation of various turn fractions. The program also calculates the total number of movements over time, allowing the assessment of activity vs. time.

Characterization of bone PG II cDNA and its relationship to PG II mRNA from other connective tissues.

Two cDNA clones encoding the small proteoglycan II (PG II) of bone were isolated from a lambda gt11 expression library. These clones expressed recombinant protein which was cross-reactive with polyclonal and monoclonal antisera to PG II molecules from several connective tissues. The longest clone, lambda Pg 20 was studied in detail. The clone was shown to encode PG II by hybrid selected translation and immunoprecipitation. Northern analysis showed two species of the PG II message of approximately 1.4 and 1.8 kb. Substantial amounts of PG II message were found in bone, tendon, articular cartilage, skin, smooth muscle and cornea. Trace amounts of message were also detected in liver and brain. Radiolabeled bovine PG II cDNA hybridized to RNA from several other species including the human, rat and chicken. The level of PG II mRNA in chick embryonic fibroblasts was sensitive to transformation by Rous sarcoma virus.

Osteonectin mRNA: distribution in normal and transformed cells.

Overlapping cDNA clones encoding bovine osteonectin were isolated from a lambda gt11 expression library constructed from bovine bone cell mRNA. The longest clone, lambda On 17 (insert size 2.0 kb) was studied in detail. The clone was shown to encode osteonectin by hybrid select translation experiments and by DNA sequence analysis. Northern analysis of bone cell RNA showed the length of the osteonectin mRNA to be 2.0 kb. Osteonectin message was found in bone but not in soft tissue (liver and brain) preparations consistent with the distribution of the protein in these tissues. On the other hand, osteonectin message was observed in tendon, a tissue in which little or no osteonectin protein is found in vivo. Hybridization of osteonectin cDNA was detected in cells from a number of species including human, rat, mouse and chick. The level of osteonectin mRNA was drastically decreased in chick embryo fibroblasts transformed by Rous sarcoma virus.