[Teaching experience of the anesthesiology training unit at Hospital Universitario Nuestra Señora de Candelaria]. / Experiencia de la unidad docente de Anestesiología y Reanimación del Hospital Universitario Nuestra Señora de Candelaria.

BACKGROUND: Health care in Spain has improved progressively and professionals are now required to meet competency levels that safeguard the citizen's right to health protection. To achieve this, instructors in residency training programs and resident physicians themselves are calling for a common framework for training to ensure quality and consistency. Given the scarcity of articles related to training in our journal and following the First Meeting of Residency Program Instructors of the Sociedad Española de Anestesiologia y Reanimación (SEDAR), there has arisen a need to explain how SEDAR's training unit is organized. METHODS: In order to facilitate the sharing of experiences of those involved in training anesthesiology medical residents, we undertook a descriptive analysis of our hospital's curriculum. RESULTS: The structure and operation of the department are described in this report. The results of anonymous surveys completed annually show the satisfaction of residents (9.4 out of 10) and physicians (8.7 out of 10). An audit by the Ministry of Health showed that the curriculum met 100% of the required criteria.

Spatial assessment of wolf-dog hybridization in a single breeding period.

Understanding the dynamics of wolf-dog hybridization and delineating evidence-based conservation strategies requires information on the spatial extent of wolf-dog hybridization in real-time, which remains largely unknown. We collected 332 wolf-like scats over ca. 5,000km2 in the NW Iberian Peninsula to evaluate wolf-dog hybridization at population level in a single breeding/pup-rearing season. Mitochondrial DNA (MtDNA) and 18 ancestry informative markers were used for species and individual identification, and to detect wolf-dog hybrids. Genetic relatedness was assessed between hybrids and wolves. We identified 130 genotypes, including 67 wolves and 7 hybrids. Three of the hybrids were backcrosses to dog whereas the others were backcrosses to wolf, the latter accounting for a 5.6% rate of introgression into the wolf population. Our results show a previously undocumented scenario of multiple and widespread wolf-dog hybridization events at the population level. However, there is a clear maintenance of wolf genetic identity, as evidenced by the sharp genetic identification of pure individuals, suggesting the resilience of wolf populations to a small amount of hybridization. We consider that real-time population level assessments of hybridization provide a new perspective into the debate on wolf conservation, with particular focus on current management guidelines applied in wolf-dog hybridization events.

Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis.

A systematic review and meta-analyses were conducted to evaluate the effects of interventions to reduce sugar-sweetened beverages (SSB) or increase water intakes and to examine the impact of behaviour change techniques (BCTs) in consumption patterns. Randomized and nonrandomized controlled trials published after January 1990 and until December 2016 reporting daily changes in intakes of SSB or water in volumetric measurements (mL d-1 ) were included. References were retrieved through searches of electronic databases and quality appraisal followed Cochrane principles. We calculated mean differences (MD) and synthesized data with random-effects models. Forty studies with 16 505 participants were meta-analysed. Interventions significantly decreased consumption of SSB in children by 76 mL d-1 (95% confidence interval [CI] -105 to -46; 23 studies, P < 0.01), and in adolescents (-66 mL d-1 , 95% CI -130 to -2; 5 studies, P = 0.04) but not in adults (-13 mL d-1 , 95% CI -44 to 18; 12 studies, P = 0.16). Pooled estimates of water intakes were only possible for interventions in children, and results were indicative of increases in water intake (MD +67 mL d-1 , 95% CI 6 to 128; 7 studies, P = 0.04). For children, there was evidence to suggest that modelling/demonstrating the behaviour helped to reduce SSB intake and that interventions within the home environment had greater effects than school-based interventions. In conclusion, public health interventions - mainly via nutritional education/counselling - are moderately successful at reducing intakes of SSB and increasing water intakes in children. However, on average, only small reductions in SSBs have been achieved by interventions targeting adolescents and adults. Complementary measures may be needed to achieve greater improvements in both dietary behaviours across all age groups.

An epidemic of pulmonary hypertension after toxic rapeseed oil ingestion in Spain.

The cardiac profile of 38 patients readmitted to the hospital with the clinical and radiologic findings of pulmonary artery hypertension and right ventricular failure 2 months after ingestion of toxic rapeseed oil was determined with M-mode and two-dimensional echocardiography, pulsed Doppler flow studies and right and left heart catheterization and ventriculography. The echocardiogram and pulsed Doppler recordings revealed right ventricular enlargement in 84% of the patients, indirect evidence of pulmonary artery hypertension in 76% and tricuspid insufficiency in 13%. At cardiac catheterization (n = 11) the mean (+/- standard deviation) pulmonary artery pressure was 40 +/- 9 mm Hg, mean pulmonary systemic vascular resistance ratio was 0.45 +/- 0.12 and mean right ventricular end-diastolic pressure was 13 +/- 4 mm Hg. Pulmonary artery hypertension was sustained after the acute administration of 100% oxygen and persisted in six patients who were restudied within 6 months. Cardiac index and left heart pressures were normal in all but one patient. The contrast ventriculographic studies revealed right ventricular dilation in all patients, tricuspid regurgitation in three patients and a normal left ventricular contraction pattern in all but one patient. The data confirm that symptomatic pulmonary artery hypertension and associated right ventricular dysfunction can complicate toxic rapeseed oil ingestion and that these findings persist for at least 6 months.

Influence of collateral circulation on in-hospital death from anterior acute myocardial infarction.

OBJECTIVES: Our purpose was to study whether the in-hospital prognosis of anterior acute myocardial infarction (AMI) is influenced by preexistent collateral circulation to the infarct-related artery. BACKGROUND: Collateral circulation exerts beneficial influences on the clinical course after AMI, but demonstration of improved survival is lacking. METHODS: We studied 238 consecutive patients with anterior AMI treated by primary angioplasty within the first 6 h of the onset of symptoms. Fifty-eight patients with basal Thrombolysis in Myocardial Infarction (TIMI) flow >1 in the infarct-related artery or with inadequate documentation of collateral circulation were excluded. Collateral channels to the infarct-related artery before angioplasty were angiographically assessed, establishing two groups: 115 patients (64%) without collateral vessels (group A) and 65 patients (36%) with collateral vessels (group B). RESULTS: There were no differences in baseline characteristics between groups A and B, except for the greater prevalence of previous angina in group B (15% vs. 34%, p = 0.003). During the hospital stay, 26 patients (23%) in group A and 5 (8%) in group B died (p = 0.01). Cardiogenic shock accounted for 74% of deaths. Cardiogenic shock developed in 30 patients (26%) in group A and in 4 (6%) in group B (p = 0.001). The absence of collateral circulation appeared to be an independent predictor of in-hospital death (odds ratio 3.4, 95% confidence interval 1.2 to 9.6, p = 0.02) and cardiogenic shock (odds ratio 5.6, 95% confidence interval 1.9 to 17, p = 0.002). CONCLUSIONS: Preexistent collateral circulation decreases in-hospital death from anterior AMI by reducing the incidence of cardiogenic shock.

Low molecular weight heparin (reviparin) in percutaneous transluminal coronary angioplasty. Results of a randomized, double-blind, unfractionated heparin and placebo-controlled, multicenter trial (REDUCE trial). Reduction of Restenosis After PTCA, Early Administration of Reviparin in a Double-Blind Unfractionated Heparin and Placebo-Controlled Evaluation.

OBJECTIVES: The specific objective of the REDUCE trial was to evaluate the effect of low molecular weight heparin on the incidence and occurrence of restenosis in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Unfractionated heparin and its low molecular weight fragments possess antiproliferative effects and have been shown to reduce neointimal smooth muscle cell migration and proliferation in response to vascular injury in experimental studies. METHODS: The REDUCE trial is an international prospective, randomized, double-blind, multicenter study. Twenty-six centers in Europe and Canada enrolled 625 patients with single-lesion coronary artery obstructions suitable for PTCA. Three hundred six patients received reviparin as a 7,000-U bolus before PTCA, followed by 10,500 U as an infusion over 24 h and then twice-daily 3,500-U subcutaneous application for 28 days. The 306 patients in the control group received a bolus of 10,000 U of unfractionated heparin followed by an infusion of 24,000 U over 24 h. These patients then underwent 28 days of subcutaneous placebo injections. The primary end points were efficacy (defined as a reduction in the incidence of major adverse events [i.e., death, myocardial infarction, need for reintervention or bypass surgery]), absolute loss of minimal lumen diameter and incidence of restenosis during the observation period of 30 weeks after PTCA. RESULTS: Using the intention to treat analysis for all patients, 102 (33.3%) in the reviparin group and 98 (32%) in the control group have reached a primary clinical end point (relative risk [RR] 1.04, 95% confidence interval [CI] 0.83 to 1.31, p = 0.707). Likewise, no difference in late loss of minimal lumen diameter was evident for both groups. Acute events within 24 h occurred in 12 patients (3.9%) in the reviparin group and 25 (8.2%) in the control group (RR 0.49, 95% CI 0.26 to 0.92, p = 0.027) during or immediately after the initial procedure. In the control group, eight major bleeding complications occurred, and in the reviparin group, seven were observed within 35 days after PTCA. CONCLUSIONS: Reviparin use during and after coronary angioplasty did not reduce the occurrence of major clinical events or the incidence of angiographic restenosis over 30 weeks.

Concomitance and interactions of pathogens in the Iberian wolf (Canis lupus).

With the aim of improving our understanding of their epidemiological features, exposure to or presence of Canine Parvovirus (CPV), Canine Distemper Virus (CDV), Leishmania infantum and Sarcoptes scabiei were studied in 88 wild wolves from Asturias (Northern Spain) by means of long-term (2004-2010) serological and molecular data. Individual and population factors and the possible interactions between them were also statistically analyzed for better understanding the contact/presence of studied pathogens. The overall seroprevalence values were 19%, 61%, 20% and 0% for CDV, CPV, S. scabiei and Leishmania, respectively, while a 46% of studied wolves showed Leishmania genetic material presence. Sarcoptic mange, CDV and CPV showed higher seroprevalence values in the areas with higher wolf densities, and a positive association between CDV and S. scabiei antibody responses was detected. Reported data highlight the need of considering concomitant pathogens and their possible interactions for a better understanding of diseases and their management in wildlife.

Echocardiographic assessment of the adequacy of pulmonary arterial banding.

Thirty-one echocardiograms of 21 patients who had pumonary arterial banding were analyzed to assess the aequacy of surgery. In 5 patients the echocardiograms were obtained before and after banding and in 16 patients only after surgery. Right and left ventricular systolic time intervals were measured echographically. The ratios of the right ventricular preejection period to right ventricular ejection time (RPEP/RVET) were correlated with both diastolic (r = 0.94) and systolic (r = 0.86) pulmonary arterial pressures distal to the band. The analysis of right ventriclar systolic time intervals, especially the RPEP/RVET ratio, clearly differentiated patients with an adequate band (distal pulmonary arterial diastolic pressure less than 15 mm Hg) from patients with an inadequate band (distal pulmonary arterial diastolic pressure equal to or greater than 30 mm Hg). The results indicate that echocardiography is a useful noninvasive tool in evaluating the adequacy of the pulmonary arterial band and facilitates the follow-up of patients after banding.

Determining whether acute myocardial infarction in patients with previous coronary bypass grafting is the result of narrowing of a bypass conduit or of a native coronary artery.

The relation between electrocardiographic changes and the infarct-related coronary artery was studied in 76 patients with acute myocardial infarction 77 +/- 49 months after coronary artery bypass surgery in a retrospective series. When the infarct-related coronary artery was a graft, the electrocardiogram showed ST elevation and new Q waves less often; although the infarction was smaller, these patients presented a worse in-hospital prognosis.

Clonidine infusions into the locus coeruleus attenuate behavioral and neurochemical changes associated with naloxone-precipitated withdrawal.

Clonidine, an alpha-2-adrenergic agonist, suppresses signs of opiate withdrawal in animals and in man. Electrical or chemical stimulation of the nucleus locus coeruleus (LC) increases noradrenergic activity and brain concentration of the noradrenergic metabolite MHPG, and produces many signs of opiate withdrawal. Thus, clonidine's ability to attenuate withdrawal might be due to the reduction of noradrenergic neuronal activity originating in the LC, but additional alpha-2-adrenergic receptors throughout the body and other mechanisms may also play a role. The present study explored the neuroanatomical and pharmacological selectivity of alpha-2-adrenergic receptors of the LC in the anti-withdrawal action of clonidine. Experiment 1 tested the hypothesis that behavioral and biochemical measures of naloxone-precipitated withdrawal from morphine would be blocked by infusions of clonidine (0.6 or 2.4 micrograms/microliters) into the LC. Significant reductions were observed in the occurrence of diarrhea, ptosis, weight loss and wet-dog shakes. Clonidine also reversed the naloxone-precipitated increase in hippocampus MHPG concentration. In experiment 2 subjects received an LC infusion or IP injection of a non-lipophilic alpha-2-agonist (ST-91), which does not penetrate the blood-brain barrier, or of clonidine into the dorsal parabrachial nucleus (DPB) to test the selectivity of the effects of clonidine infusions into the LC. ST-91 infusions into the LC reduced several of the observed withdrawal signs and increased others (e.g., jumping). Although peripheral injections of ST-91 attenuated some of the checked signs associated with naloxone-precipitated withdrawal, the frequency of wet-dog shakes was not reduced. ST-91 infusions into the LC, but not systemic ST-91 administration, prevented the withdrawal-induced increase in hippocampus MHPG concentration. Clonidine infused lateral to the LC into the DPB did not significantly attenuate withdrawal or reduce hippocampus MHPG levels. These results provide behavioral and biochemical evidence to support the suggestion that clonidine significantly attenuates naloxone-precipitated withdrawal through an interaction with noradrenergic neurons located in the vicinity of the LC.

Lateral neglect in a head movement task: more impairment with unilateral than bilateral lesions of the superior colliculus in the rat.

Unilateral lesions of the superior colliculus produce contralateral neglect. This study determined if bilateral lesions would impair head orientation in a way expected from the summation of two contralateral neglects. Rats were trained to make various head movements to get water at a 3 x 3 array of holes, each with a recessed water-baited dipper. On each of 20 trials in a session, a water-deprived subject approached and sampled the array by orienting its head and inserting its snout in the holes in a self-determined sequence. The measures recorded for each position and for each trial were: the order in which a baited position was sampled (selection order), the number of times it was not sampled (misses), and the number of times it was sampled when dry (perseverations). Radio-frequency lesions were made and testing was resumed after 3 days. Large unilateral lesions of the superior colliculus produced a neglect of contralateral positions and increased perseverations to ipsilateral positions. Center positions were also neglected but to a lesser extent. Bilateral lesions of the superior colliculus produced only a moderate increase in lateral misses and no increase in lateral perseverations. Bilateral lesions did produce a neglect of upper positions on both sides. The results indicate that a major contributor to contralateral neglect produced by a unilateral lesion is an antagonistic process that promotes orientation to the side ipsilateral to the lesion.

Mediterranean spotted fever in Salamanca, Spain. Epidemiological study in patients and serosurvey in animals and healthy human population.

Mediterranean spotted fever is a spotted fever group rickettsiosis caused by Rickettsia conorii. The fever has a recognized incidence in large geographic areas, and its presence in Salamanca Province (Spain) has been well documented since 1981. This work presents the results of the centralized prospective survey carried out in this area and was designed to study the epidemiological behavior of the disease and the prevalence of antibodies against R. conorii among animals and healthy human population. In 110 patients with confirmed diagnosis by an immunofluorescent antibody test we have observed a bimodal temporal curve of incidence of Mediterranean spotted fever in our zone and their predominant origin in villages under 2000 inhabitants. The serosurvey in a statistically representative sample of the human population of Salamanca shows a rate of 73.5% of reactive sera and percentages as high as 82% in samples from small villages. The seroepidemiological study of 300 animals reveals a widespread response to rickettsial antigens throughout the province. Immunofluorescent antibody titers of greater than or equal to 1:40 are present in 93% of dogs and high rates and titers are detected in other domestic mammals, suggesting their feasible epidemiological role in Mediterranean spotted fever.

Hepatocellular carcinoma and markers of apoptosis (bcl-2, bax, bcl-x): prognostic significance.

Patients with tumors expressing promoters of apoptosis (bax) versus inhibitors of apoptosis (bcl-2, bcl-x) may have increased survival. The purpose of this study was to determine the frequency of expression of apoptotic markers in hepatocellular carcinoma (HCC) and their relationship with prognosis. Seventy HCC were immunostained for bcl-2, bax, and bcl-x. Staining intensity in tumor cells was graded 0 to 3+. Follow-up data were available for mean survival (57 cases) and death rates (58 cases). These values and clinical parameters were related to prognosis. Staining frequency for bcl-2, bax, and bcl-x was 20%, 66%, and 60%, respectively. Immunostaining intensity of bax correlated with overall survival and death rates: of 57 patients, the 37% with 0 to 1+ intensity had a median survival of 6.6 months, the 63% with 2 to 3+ intensity had a median survival of 31.9 months (P = 0.05); 86% of 19 patients with 0 to 1+ intensity died, and 50% of 36 patients with 2 to 3+ intensity died (P < 0.05). Intensity of bcl-x staining tended to correlate with survival: of the 57 patients with 0 to 1+, 42% had a median survival of 32.7 months compared with 5.8 months in the 58% with 2 to 3+ intensity (P = 0.06). By multivariate analysis, this relationship held for bax (P = 0.011) and bcl-x (P = 0.048). There was no correlation between bcl-2 expression, stage, or gender and prognosis. Patients with bax-expressing HCC experience improved survival compared with those with no or low bax expression, in uni- and multivariate models. Patients with no or low bcl-x tended toward improved survival compared with patients with more bcl-x in their HCC. bcl-2 expression did not correlate with prognosis.

[Congenital cardiac diverticulum originating from both ventricles]. / Divertículo cardíaco congénito con origen en ambos ventrículos.

Congenital cardiac diverticuli are infrequent. More so, if one is specially restrictive with the criteria. Usually, they are not isolated but a part of a malformation syndrome that affects the medium thoraco-abdominal line and have an embryological explanation. We present a case of congenital cardiac diverticulum originating from both ventricles with a thoraco-abdominal malformation. We describe the clinical findings, the nuclear magnetic resonance, the echocardiography and cardiac catheterization. We comment the anatomy, the total diagnosis, therapy and complications.

[Experience with the Palmaz-Schatz stent in the treatment of postangioplasty coronary dissection]. / Experiencia con el stent de Palmaz-Schatz en el tratamiento de la disección coronaria postangioplastia. Resultados a corto y medio plazo.

Some authors have proposed the use of coronary stenting as a good therapeutic strategy for post angioplasty acute coronary dissection. We present our experience with the Palmaz-Schatz stent for the treatment of acute coronary dissection after percutaneous coronary angioplasty. Twenty five stents were deployed in nineteen patients with occlusion (7) or threatened occlusion (12). Eleven patients (58%) had multivessel disease, seven (37%) unestable angina and six (32%) previous myocardial infarction. The attempted lesion was type A in four patients (21%), type B in thirteen (68%) and type C in two (11%) according to the American College of Cardiology/American Heart Association classification. To cover the dissection was necessary to deploy three stents in two patients, and two stents in two more. The other fifteen patients received one stent each. In eighteen patients (95%) the stent deployment was accomplished with immediate angiographic success. Twelve stents were deployed in the right coronary artery, eight in the left anterior descending and five in the circumflex. In sixteen patients (84%) the stent successfully solved the occlusion or threatened occlusion reassuming a normal coronary flow. There were 10 complications in six patients: one death (5%), 3 cases of emergency coronary artery bypass graft (16%), 2 acute myocardial infarction (11%), 2 hemorrhagic complications (11%) and 2 cases of subacute thrombosis of the stent (11%). The Palmaz-Schatz stent seems to be a useful tool for the management of acute coronary dissection with a fair number of complications. The results obtained during hospitalization are maintained with a more than acceptable restenosis rate.

[Coronary endoprosthesis (stents) implanted without coumadin administration: one year's experience]. / Implantación de endoprótesis coronarias (stents) sin dicumarínicos: un año de experiencia.

BACKGROUND AND OBJECTIVES: Subacute occlusion and bleeding complications have been the major limitations of coronary stenting. Several authors have suggested the nonessential role of oral anticoagulation to prevent occlusions. METHODS: We treated 121 patients (125 stent procedures with initial angiographic success) with the following regimen: heparin 10-20,000 IU i.v. and ASA 325 mg i.v. during the procedure, followed by ASA 125-325 mg/day/6 months and ticlopidine 250-500 mg/day/3 months. 40 patients were also treated with enoxaparine (14,000 IU/day, median) for 10 days. RESULTS: 172 stents (119 Palmaz-Schatz, 35 Wiktor and 18 of other types) were implanted in 148 lesions (in 45 cases with non-occlusive dissection or suboptimal results and the rest electively). Most of the stents were deployed at high pressure (median 14 atm.). The procedure was ended when the stent expansion was considered as optimal by angiography and/or intravascular ultrasound. No patient developed signs of subacute occlusion at follow-up (30-441 days). 2 patients developed non-Q wave myocardial infarction (occlusion of side branches). The rates of bleeding and vascular complications were 0.8% and 1.6%, respectively. CONCLUSIONS: Coronary stenting with high pressure dilatation and without subsequent anticoagulation seems to be associated with low rates of subacute occlusion and bleeding or vascular complications.

[Primary coronary angioplasty in acute anterior myocardial infarction: immediate results]. / Angioplastia primaria en el infarto agudo de miocardio de localización anterior: resultados inmediatos.

BACKGROUND: Some reports have indicated that primary angioplasty not contaminated by previous intravenous infusion of thrombolytic agents represents an efficient approach to the treatment of acute myocardial infarction. PATIENTS AND METHODS: As a part of a more ambitious protocol aiming to compare primary angioplasty and intravenous recombinant tissue plasminogen activator, we performed direct coronary angioplasty in 33 patients (18 randomized to angioplasty and 15 because of contraindication to thrombolysis) that were admitted to our hospital with acute myocardial infarction with less than 5 hours elapsed from the onset of pain and with clear electrocardiographic criteria of anterior infarction. RESULTS: In 30 of the 33 patients (90.9%) the left anterior descending artery was recanalized and TIMI 2 flow in 17 and 3 in 13 was obtained. The average time elapsed from the onset of pain to the opening of the artery was 228 +/- 70 (120-390) minutes and from the time of admission to the coronary care unit to complete reperfusion 91 +/- 43 minutes (33-120). Thirty one patients (93.9%) were discharged from the hospital and two (6.1%) died. There was only one hemorrhagic complication without sequelae. CONCLUSIONS: Primary coronary angioplasty in acute anterior myocardial infarction is an efficient, safe and not so difficult therapeutic strategy. Even though it requires a complex around the clock on call set up it is specially useful in specific subsets of patients.

[Cytomegalovirus pneumonitis in immunocompetent adults: report of a case]. / Neumonitis por citomegalovirus en pacientes adultos inmunocompetentes: a propósito de un caso.

Cytomegalovirus produces congenital and acquired infections most of them asymptomatic. The percentage of clinical cases with visceral affection increases in patients suffering from a deficiency cellular immunity, showing the great importance of this defensive system in the control of the infection. This case presents an infection by Cytomegalovirus with visceral affection in an immunocompetent adult host. This is a mean duration of fever as the only symptom with lymphocytosis, biochemical hepatic changes and an interstitial pulmonary radiologic image. We think this case is a matter of considerable interest because it is a challenge in the study of the pathogenic mechanisms of this infection.

[Radiologic aspects of granulomatous colitis]. / Aspectos radiológicos de la colitis granulomatosa.

The granulomatous colitis represents the peculiar clinical and radiological manifestations of the Crohn disease, localized in the colon. Although it can be localized in any organ of the digestive apparatus, the affection of the colon follows in importance to the ileocecal, with identical pathologic characteristics. The radiology is a fundamental pillar of the diagnostic when there are established direct and indirect signs of the macroscopic alterations, of its development and complications. We present our experience in 53 cases of granulomatous colitis of which, there was in 25 of them, besides ileal afectation. Three patients in precocious phase, presented irregular contours and inflammatory polypus, standing out the importance of the mucous patron study. In no estenotic phase with evident signs of the granulomatous afectation, there were observed 42 cases with typical patron on cobblestone and 8 cases in no estenotic phase with looseness of mucous relief and haustras. The presence of fistulizations was little frequent, only in two cases.