Adaptation of antibiotic treatment to clinical practice guidelines in patients aged ⩾65 years hospitalised due to community-acquired pneumonia.

Early, conforming antibiotic treatment in elderly patients hospitalised for community-acquired pneumonia (CAP) is a key factor in the prognosis and mortality. The objective was to examine whether empirical antibiotic treatment was conforming according to the Spanish Society of Pulmonology and Thoracic Surgery guidelines in these patients. Multicentre study in patients aged ⩾65 years hospitalised due to CAP in the 2013-14 and 2014-15 influenza seasons. We collected socio-demographic information, comorbidities, influenza/pneumococcal vaccination history and antibiotics administered using a questionnaire and medical records. Bivariate analyses and multilevel logistic regression were made. In total, 1857 hospitalised patients were included, 82 of whom required intensive care unit (ICU) admission. Treatment was conforming in 51.4% (95% confidence interval (CI) 49.1-53.8%) of patients without ICU admission and was associated with absence of renal failure without haemodialysis (odds ratio (OR) 1.49, 95% CI 1.15-1.95) and no cognitive dysfunction (OR 1.71, 95% CI 1.25-2.35), when the effect of the autonomous community was controlled for. In patients with ICU admission, treatment was conforming in 45.1% (95% CI 34.1-56.1%) of patients and was associated with the hospital visits in the last year (<3 vs. ⩾3, OR 2.70, 95% CI 1.03-7.12) and there was some evidence that this was associated with season. Although the reference guidelines are national, wide variability between autonomous communities was found. In patients hospitalised due to CAP, health services should guarantee the administration of antibiotics in a consensual manner that is conforming according to clinical practice guidelines.

Prevalence of anti-rubella, anti-measles and anti-mumps IgG antibodies in neonates and pregnant women in Catalonia (Spain) in 2013: susceptibility to measles increased from 2003 to 2013.

Non-immune neonates and non-immune pregnant women are at risk of developing rubella, measles and mumps infections, including congenital rubella syndrome. We describe the seroepidemiology of measles, mumps and rubella (MMR) in neonates and pregnant women in Catalonia (Spain). Anti-rubella, anti-measles and anti-mumps serum IgG titres were assessed using enzyme-linked immunosorbent assay (ELISA) tests in 353 cord blood samples from neonates of a representative sample of pregnant women obtained in 2013. The prevalence of protective antibody titres in neonates was 96 % for rubella IgG (≥8 IU/ml), 90 % for measles IgG (>300 IU/ml) and 84 % for mumps IgG (>460 EU/ml). Slightly lower prevalences of protective IgG titres, as estimated from the cord blood titres, were found in pregnant women: 95 % for rubella IgG, 89 % for measles IgG and 81 % for mumps IgG. The anti-measles and anti-mumps IgG titres and the prevalences of protective IgG titres against measles and mumps increased significantly (p < 0.001) with maternal age. The prevalence of protective anti-measles IgG titres decreased by 7 % [odds ratio (OR) = 0.15, p < 0.001), the prevalence of protective anti-rubella IgG titres increased by 3 % (OR = 1.80, p < 0.05) and the MMR vaccination coverage (during childhood) in pregnant women increased by 54 % (OR = 2.09, p < 0.001) from 2003 to 2013. We recommend to develop an MMR prevention programme in women of childbearing age based on mass MMR vaccination or MMR screening and vaccination of susceptible women to increase immunity levels against MMR.

[Mortality and associated factors of patients with complex chronic diseases in rural and social transformation areas in Andalusia]. / Mortalidad y factores asociados de los pacientes con enfermedades crónicas complejas del ámbito rural y zonas de transformación social en Andalucía.

OBJECTIVE: To determine one-year mortality and associated factors in patients with complex chronic diseases (CCP) in rural health centres and social transformation needs areas (STNA) in Primary Health Care (PHC) in Andalusia. MATERIAL AND METHODS: Design: 1-Year longitudinal observational prospective open study. SETTING: 40 health centre. SUBJECTS: consenting subjects over 18yr according multiple health condition criteria. SAMPLE SIZE: 814 subjects (confidence interval 95%, alpha risk 0.03%, p=.2; 20% of sample increase due to possible losses). End-point: 1-year Mortality. INDEPENDENT VARIABLES: socio-demographic, socio-familial, clinical, functional (Barthel Index -BI-, Lawton-Brody Index), cognitive (Pfeiffer Test), prescribed drugs, social healthcare resources consumption, and quality of life (EQ-5D). DATA SOURCE: Interview and computerised clinical history Results: A total of 832 CCP were included (48.8% women). One-year mortality was 17.8% (n=148). Logistic regression model for mortality included: aged 85 and over, having a caregiver, haemoglobin level less 10g/L, hospital admission in last year, BI under 60 points, and active neoplasia. The calibration obtained from model was good (p=.85 in the Hosmer-Lemeshow goodness-of-fit test), and the discrimination power also good (AUC=0.772 [0.68-0.77] in ROC curve). CONCLUSIONS: 1-year mortality of CCP in rural centres and STNA in PHC was 17.8%. Knowledge of the factors related to the mortality of CCP helps to approach the needs and social-health resources management.

Outcomes of the PIRASOA programme, an antimicrobial stewardship programme implemented in hospitals of the Public Health System of Andalusia, Spain: an ecologic study of time-trend analysis.

OBJECTIVES: Inappropriate antimicrobial use favours the spread of resistance, and multidrug-resistant microorganisms (MDR) are currently of major concern. Antimicrobial stewardship programmes (ASPs) are essential for improving antibiotic use in hospitals. However, their impact on entire healthcare systems has not been thoroughly assessed. Our objective was to provide the results of an institutionally supported ASP involving 31 public hospitals in Andalusia, Spain. METHODS: We designed an ecologic time-series study from 1 January 2014 to 31 December 2017. Quarterly, data on indicators were collected prospectively, and feedback reports were provided. PIRASOA is an ongoing clinically based quality-improvement programme whose key intervention is the educational interview, regular peer-to-peer interventions between advisors and prescribers to reinforce the appropriate use of antibiotics. Seventy-two indicators were monitored to measure prescribing quality (inappropriate treatments), antimicrobial consumption (defined daily doses per 1000 occupied bed-days), incidence density of MDR per 1000 occupied bed-days and crude mortality rate associated with bloodstream infections. We used Joinpoint regression software to analyse the trends. RESULTS: The quality of antimicrobial prescribing improved markedly, and the inappropriate treatment rate was significantly lower, with quarterly percentage change (QPC) = -3.0%, p < 0.001. Total antimicrobial consumption decreased (QPC = -0.9%, p < 0.001), specifically carbapenems, amoxicillin/clavulanic acid, quinolones and antifungal agents, whereas antipseudomonal cephalosporin use increased. While the incidence of MDR showed a sustained decreasing trend (QPC = -1.8%; p 0.002), the mortality of patients with bloodstream infections remained stable (QPC = -0.2%, p 0.605). CONCLUSIONS: To date, the PIRASOA programme has succeeded in optimizing the use of antimicrobial agents and has had a positive ecologic result on bacterial resistance at level of an entire healthcare system.

[Prognostic factors for bronchiolitis complications in a pediatric intensive care unit]. / Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos.

OBJECTIVE: To analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU). PATIENTS AND METHOD: A retrospective study was performed on children with bronchiolitis admitted into a PICU between 2000 and 2006. Univariate and multivariate analysis were performed to study the prognostic factors of complications, mechanical ventilation requirements, mortality and PICU stays of more than 15 days. RESULTS: A total of 110 patients were studied, of whom 72 (65.5%) had high risk factors: prematurity (39.1%), cardiac disease (38.2%) and bronchopulmonary dysplasia (16.3%). A total of 82.7% of patients had complications; 26% need invasive mechanical ventilation and the mortality was 3.6%, and 16.4% stayed in PICU for more than 15 days. Factors associated with mechanical ventilation were the clinical Wood-Downes score and heart disease. A weight less than 5 kg was associated with complications; heart disease and invasive mechanical ventilation were associated with a longer PICU stay; prematurity and mechanical ventilation were associated with mortality. CONCLUSIONS: Children with bronchiolitis admitted into the PICU had a high frequency of complications, often needed mechanical ventilation and had long stays in the PICU, but the mortality is low. The best prognostic factors on admission into the PICU were the acute respiratory insufficiency score, the presence of heart disease and were premature at birth.

Insulin eye drops for refractory corneal epithelial defects. A case series / Colirio de insulina para defectos corneales epiteliales persistentes. Una serie de casos

Objetive: To report the clinical course of a case series of patients with persistent epithelial corneal defects (PECD) treated with insulin eye drops. Method: Retrospective review of five patients -four non-diabetic and one diabetic- in treatment with insulin eye drops 1 U/mL four times a day (QID). Results: Patients developed refractory epithelial ulcers due to different etiology (three infections, one trauma and one chemical injury). After treatment with topical insulin all defects were healed in about 30-60 days. Conclusion: Insulin formulated as 1 U/mL eye drops and administered QID can be an effective and safe option for PECD. (AU)

Objetivo: Comunicar la evolución clínica de una serie de casos de pacientes con defectos corneales epiteliales persistentes (PECD) tratados con colirio de insulina. Método: Revisión retrospectiva de cinco pacientes –cuatro no diabéticos y uno diabético– en tratamiento con colirio de insulina 1 U/mL cuatro veces al día (QID). Resultados: Los pacientes desarrollaron úlceras epiteliales refractarias de diferente etiología (tres infecciones, un traumatismo y una lesión química). Tras el tratamiento con insulina tópica todos las lesiones se curaron en unos 30-60 días. Conclusión: La insulina formulada en forma de colirio de 1 U/mL y administrada QID puede ser una opción eficaz y segura para la PECD. (AU)

Codon Usage Heterogeneity in the Multipartite Prokaryote Genome: Selection-Based Coding Bias Associated with Gene Location, Expression Level, and Ancestry.

Prokaryotes represent an ancestral lineage in the tree of life and constitute optimal resources for investigating the evolution of genomes in unicellular organisms. Many bacterial species possess multipartite genomes offering opportunities to study functional variations among replicons, how and where new genes integrate into a genome, and how genetic information within a lineage becomes encoded and evolves. To analyze these issues, we focused on the model soil bacterium Sinorhizobium meliloti, which harbors a chromosome, a chromid (pSymB), a megaplasmid (pSymA), and, in many strains, one or more accessory plasmids. The analysis of several genomes, together with 1.4 Mb of accessory plasmid DNA that we purified and sequenced, revealed clearly different functional profiles associated with each genomic entity. pSymA, in particular, exhibited remarkable interstrain variation and a high density of singletons (unique, exclusive genes) featuring functionalities and modal codon usages that were very similar to those of the plasmidome. All this evidence reinforces the idea of a close relationship between pSymA and the plasmidome. Correspondence analyses revealed that adaptation of codon usages to the translational machinery increased from plasmidome to pSymA to pSymB to chromosome, corresponding as such to the ancestry of each replicon in the lineage. We demonstrated that chromosomal core genes gradually adapted to the translational machinery, reminiscent of observations in several bacterial taxa for genes with high expression levels. Such findings indicate a previously undiscovered codon usage adaptation associated with the chromosomal core information that likely operates to improve bacterial fitness. We present a comprehensive model illustrating the central findings described here, discussed in the context of the changes occurring during the evolution of a multipartite prokaryote genome.IMPORTANCE Bacterial genomes usually include many thousands of genes which are expressed with diverse spatial-temporal patterns and intensities. A well-known evidence is that highly expressed genes, such as the ribosomal and other translation-related proteins (RTRPs), have accommodated their codon usage to optimize translation efficiency and accuracy. Using a bioinformatic approach, we identify core-genes sets with different ancestries, and demonstrate that selection processes that optimize codon usage are not restricted to RTRPs but extended at a genome-wide scale. Such findings highlight, for the first time, a previously undiscovered adaptation strategy associated with the chromosomal-core information. Contrasted with the translationally more adapted genes, singletons (i.e., exclusive genes, including those of the plasmidome) appear as the gene pool with the less-ameliorated codon usage in the lineage. A comprehensive summary describing the inter- and intra-replicon heterogeneity of codon usages in a complex prokaryote genome is presented.

[The effect of helium on ventilator parameters: in vitro study with a Servoi ventilator]. / Efecto del helio sobre los parámetros de los respiradores en ventilación mecánica: estudio in vitro con el respirador Servoi.

OBJECTIVE: To analyze the changes in respiratory parameters in a Servoi ventilator with heliox. MATERIAL AND METHODS: In vitro study with a Servoi (Maquet) ventilator in volume controlled (VC), pressure controlled (PC) and volume control regulated by pressure (VCPR) modes connected to an artificial lung. A heliox tank with a fixed concentration of helium 70 % and oxygen 30 % was connected to the air inlet of the ventilator. The ventilator was set in VC mode with tidal volumes of 30, 50, 100, 250 and 500 ml; in PC mode with pressure of 20 and 30 cmH(2)O and in VCPR mode with tidal volume of 150 ml. In each case FiO(2) of 21, 30, 40, 50, 60, 70, 80, 90 and 100 % was used. The FiO(2), inspired and expired tidal volume and inspiratory pressure measured by the ventilator and a pitot spirometer (Datex_S5) were compared. RESULTS: In VC and VCPR modes the increase in helium produced a progressive decrease in the pressure needed to administrate the set volume. Heliox also produced a decrease in the tidal volume measured by the spirometer and the tidal expired volume measured by the respirator. In PC mode, heliox produced a progressive increase in the inspired tidal volume, increasing the differences between inspired and expired tidal volumes. CONCLUSIONS: Heliox used with Servoi ventilator produces a decrease in inspiratory pressures in VC and VCPR modes, and an increase in inspiratory tidal volume in PC mode. In all modes heliox reduced the expired tidal volume measured by the ventilator and the spirometer. These changes should be borne in mind if heliox is used with this ventilator.

Application of a multivariate analysis method for non-target screening detection of persistent transformation products during the cork boiling wastewater treatment.

Cork boiling wastewater is a very complex mixture of naturally occurring compounds leached and partially oxidized during the boiling cycles. The effluent generated is recalcitrant and could cause a significant environmental impact. Moreover, if this untreated industrial wastewater enters a municipal wastewater treatment plant it could hamper or reduce the efficiency of most activated sludge degradation processes. Despite the efforts to treat the cork boiling wastewater for reusing purposes, is still not well-known how safe these compounds (original compounds and oxidation by-products) will be. The purpose of this work was to apply an HPLC-high resolution mass spectrometry method and subsequent non-target screening using a multivariate analysis method (PCA), to explore relationships between samples (treatments) and spectral features (masses or compounds) that could indicate changes in formation, degradation or polarity, during coagulation/flocculation (C/F) and photo-Fenton (PhF). Although, most of the signal intensities were reduced after the treatment line, 16 and 4 new peaks were detected to be formed after C/F and PhF processes respectively. The use of this non-target approach showed to be an effective strategy to explore, classify and detect transformation products during the treatment of an unknown complex mixture.

Identification and characterization of a nodH ortholog from the alfalfa-nodulating Or191-like rhizobia.

Nodulation of Medicago sativa (alfalfa) is known to be restricted to Sinorhizobium meliloti and a few other rhizobia that include the poorly characterized isolates related to Rhizobium sp. strain Or191. Distinctive features of the symbiosis between alfalfa and S. meliloti are the marked specificity from the plant to the bacteria and the strict requirement for the presence of sulfated lipochitooligosaccharides (Nod factors [NFs]) at its reducing end. Here, we present evidence of the presence of a functional nodH-encoded NF sulfotransferase in the Or191-like rhizobia. The nodH gene, present in single copy, maps to a high molecular weight megaplasmid. As in S. meliloti, a nodF homolog was identified immediately upstream of nodH that was transcribed in the opposite direction (local synteny). This novel nodH ortholog was cloned and shown to restore both NF sulfation and the Nif+Fix+ phenotypes when introduced into an S. meliloti nodH mutant. Unexpectedly, however, nodH disruption in the Or191-like bacteria did not abolish their ability to nodulate alfalfa, resulting instead in a severely delayed nodulation. In agreement with evidence from other authors, the nodH sequence analysis strongly supports the idea that the Or191-like rhizobia most likely represent a genetic mosaic resulting from the horizontal transfer of symbiotic genes from a sinorhizobial megaplasmid to a not yet clearly identified ancestor.

[Energy expenditure in critically ill children: correlation with clinical characteristics, caloric intake, and predictive equations]. / Consumo calórico en el niño crítico: relación con las características clínicas, el aporte calórico y las fórmulas teóricas de cálculo de las necesidades.

OBJECTIVE: To study energy expenditure (EE) in critically ill infants and children and its correlation with clinical characteristics, treatment, nutrition, caloric intake, and predicted energy expenditure calculated through theoretical formulas. PATIENTS AND METHODS: A prospective observational study was conducted in critically ill infants and children. Indirect calorimetry measurements were performed using the calorimetry module of the S5 Datex monitor. Data on mechanical ventilation, nutrition, and caloric intake were registered. Theoretical equations of energy requirement (WHO/FAO, Harris-Benedict, Caldwell-Kennedy, Maffeis, Fleisch, Kleiber and Hunter) were calculated. The statistical analysis was performed using the SPSS 12.0 package. RESULTS: Sixty-eight EE determinations were performed in 43 critically ill infants and children aged between 10 days and 15 years old. Measured EE was 58.4 (18.4) kcal/kg/day, with wide individual variability. EE was significantly lower in infants and children who had undergone cardiac surgery than in the remainder. No correlation was found between EE and mechanical ventilation parameters, vasoactive drugs, sedatives, or muscle relaxants. A correlation was found between caloric intake and EE. In a high percentage of patients, predictive equations did not accurately estimate EE. The respiratory quotient was not useful to diagnose overfeeding or underfeeding. CONCLUSIONS: Wide individual variability in EE was found in critically ill infants and children. Predictive equations did not accurately estimate EE. Indirect calorimetry measured by a specific module is a simple method that could allow generalized use of EE measurement in critically ill pediatric patients undergoing mechanical ventilation.

[Efficacy of heliox therapy in respiratory insufficiency in infants and children]. / Eficacia del tratamiento con heliox en niños con insuficiencia respiratoria.

OBJECTIVE: To analyze response to heliox therapy in critically ill infants and children with upper and/or lower airway respiratory insufficiency. PATIENTS AND METHODS: Sixty-five patients, aged between 12 days and 8 years old, treated with heliox through facial mask, nasal prongs or non-invasive ventilation were studied. Diagnoses were bronchiolitis (25), upper postextubation respiratory insufficiency (19), respiratory insufficiency after airway surgery (14), and croup-laryngotracheomalacia (7). Response to heliox treatment was measured by the change in clinical scores, respiratory rate, heart rate, pulse oximetry, blood gas analysis, and the need for non-invasive and invasive mechanical ventilation. RESULTS: Fifty-four patients (83.1 %) improved after heliox therapy, with statistically significant differences in clinical score (from 8.7 to 5.5), respiratory rate (from 51.4 to 38.8 rpm), and heart rate (from 161.6 to 145.6 bpm). No changes were observed in saturation or blood gas analysis. After heliox therapy, 29.8 % of patients required non-invasive ventilation and 26.5 % required intubation. Patients with bronchiolitis and those aged less than 1 year had a lesser response to heliox therapy and more frequently required non-invasive ventilation. No significant differences were found in intubation requirements. No adverse effects were observed. CONCLUSIONS: Heliox therapy improved clinical scores in infants and children with upper and lower airway respiratory insufficiency, but a significant percentage of patients needed non-invasive or invasive mechanical ventilation.

Cork boiling wastewater treatment and reuse through combination of advanced oxidation technologies.

Industrial preparation of cork consists of its immersion for approximately 1 hour in boiling water. The use of herbicides and pesticides in oak tree forests leads to absorption of these compounds by cork; thus, after boiling process, they are present in wastewater. Cork boiling wastewater shows low biodegradability and high acute toxicity involving partial inhibition of their biodegradation when conventional biological treatment is applied. In this work, a treatment line strategy based on the combination of advanced physicochemical technologies is proposed. The final objective is the reuse of wastewater in the cork boiling process; thus, reducing consumption of fresh water in the industrial process itself. Coagulation pre-treatment with 0.5 g/L of FeCl3 attained the highest turbidity elimination (86 %) and 29 % of DOC elimination. Similar DOC removal was attained when using 1 g/L of ECOTAN BIO (selected for ozonation tests), accompanied of 64 % of turbidity removal. Ozonation treatments showed less efficiency in the complete oxidation of cork boiling wastewater, compared to solar photo-Fenton process, under the studied conditions. Nanofiltration system was successfully employed as a final purification step with the aim of obtaining a high-quality reusable permeate stream. Monitoring of unknown compounds by LC-QTOF-MS allowed the qualitative evaluation of the whole process. Acute and chronic toxicity as well as biodegradability assays were performed throughout the whole proposed treatment line.

A consolidated analysis of the physiologic and molecular responses induced under acid stress in the legume-symbiont model-soil bacterium Sinorhizobium meliloti.

Abiotic stresses in general and extracellular acidity in particular disturb and limit nitrogen-fixing symbioses between rhizobia and their host legumes. Except for valuable molecular-biological studies on different rhizobia, no consolidated models have been formulated to describe the central physiologic changes that occur in acid-stressed bacteria. We present here an integrated analysis entailing the main cultural, metabolic, and molecular responses of the model bacterium Sinorhizobium meliloti growing under controlled acid stress in a chemostat. A stepwise extracellular acidification of the culture medium had indicated that S. meliloti stopped growing at ca. pH 6.0-6.1. Under such stress the rhizobia increased the O2 consumption per cell by more than 5-fold. This phenotype, together with an increase in the transcripts for several membrane cytochromes, entails a higher aerobic-respiration rate in the acid-stressed rhizobia. Multivariate analysis of global metabolome data served to unequivocally correlate specific-metabolite profiles with the extracellular pH, showing that at low pH the pentose-phosphate pathway exhibited increases in several transcripts, enzymes, and metabolites. Further analyses should be focused on the time course of the observed changes, its associated intracellular signaling, and on the comparison with the changes that operate during the sub lethal acid-adaptive response (ATR) in rhizobia.

Influence of continuous hemofiltration on the hemodynamics of trauma patients.

BACKGROUND: The aim of this prospective randomized controlled study was to investigate the effects of continuous venovenous hemofiltration on the hemodynamics and respiratory function of critically ill trauma patients with multiple organ dysfunction syndrome. METHODS: Thirty consecutive critically ill, mechanically ventilated, trauma patients with multiple organ dysfunction syndrome (without kidney failure) who had invasive hemodynamic monitoring for management of hypotension or hypoxemia were randomized to treatment with or without continuous venovenous hemofiltration. Hemodynamics profile was recorded immediately before and at 6, 12, 24, and 48 hours after the hemofiltration was started (mean of three set data each time). No changes in ventilatory parameters were performed during the study. RESULTS: Thirty patients were analyzed (15 with and 15 without hemofiltration). Both groups were similar in age (36 +/- 18 versus 36 +/- 14 years) and severity scores (Injury Severity Score, 32 +/- 16 versus 30 +/- 11; Acute Physiology and Chronic Health Evaluation II score, 22 +/- 7 versus 21 +/- 6; Goris score, 5.2 +/- 1.7 versus 5.2 +/- 1.8) and received similar inotropic support. We found a significant improvement in mean arterial pressure (80 +/- 9 to 94 +/- 8 (mm Hg), p = 0.01) and partial pressure of oxygen in arterial blood/inspiratory oxygen supply index (124 +/- 40 to 204 +/- 44, p = 0.03) in the intervention group during the study period. We did not find any other significant change in variables studied. CONCLUSIONS: Continuous venovenous hemofiltration is associated with a significant improvement in hemodynamic and respiratory variables in critically ill trauma patients with multiple organ dysfunction syndrome. This improvement can help in the management of these patients. Further work is necessary to define whether this technique can reduce the high mortality of this disease.

Sources of influence on medical practice.

OBJECTIVES: To explore the opinion of general practitioners on the importance and legitimacy of sources of influence on medical practice. METHODS: General practitioners (n=723) assigned to Primary Care Teams (PCTs) in two Spanish regions were randomly selected to participate in this study. A self administered questionnaire was sent by mail and collected by hand. The dependent variable collected the opinion on different sources that exert influence on medical practice. Importance was measured with a 9 item scale while legitimacy was evaluated with 16 items measured with a 1 to 7 point Likert scale. RESULTS: The most important and legitimate sources of influence according to general practitioners were: training courses and scientific articles, designing self developed protocols and discussing with colleagues. The worst evaluated were: financial incentives and the role played by the pharmaceutical industry. CONCLUSIONS: The development of medical practice is determined by many factors, grouped around three big areas: organisational setting, professional system and social setting. The medical professional system is the one considered as being the most important and legitimate by general practitioners. Other strategies of influence, considered to be very important by the predominant management culture (financial incentives), are not considered to be so by general practitioners. These results, however, are not completely reliable as regards the real network of influences existing in medical practice, which reflect instead different "value systems".

Antibiotic as ligand. Coordinating behavior of the cephalexin towards Zn(II) and Cd(II) ions.

The complex formation equilibria of Zn(II) and Cd(II) with cephalexin have been studied through potentiometric titrations. Experimental data were analyzed using the least squares computer program SUPERQUAD. The stability constants were 1g beta ZnCEX+ = 2.40, 1g beta Zn(CEX)(OH) = -4.54, 1g beta CdCEX+ = 2.18, and 1g beta Cd(CEX)(OH) = -5.18 (I = 0.1 M NaNO3), CEX complexes of formulae Zn(CEX)2(3)H2O and Cd(CEX)(OH)H2O have been synthesized and characterized by elemental analysis, IR spectra, conductivity measurements, and electronic and NMR spectra. The thermal behavior of the synthesized compounds were studied by TGA and DTA. We conclude that the metal ion interacts with the amido group of CEX.

[A reproducibility and validity study of a systematic review on ischemic cardiopathy. The Study Group of the Quality of Care (GRECA)]. / Estudio de la reproducibilidad y validez de una revisión sistemática sobre cardiopatía isquémica. Grupo de Estudio de la Calidad Asistencial (GRECA).

BACKGROUND: The systematic literature reviews have been proposed as a method of scientific evidence identification since they protect the final product from the subjectivity of each primary source reviewer. However, it is not known whether the different ways of evidence synthesis accomplish suitable criteria of objectivity, reliability and biases protection so as to be considered scientifically valid. An experiment of reliability and validity of a systematic literature review about coronary heart disease was carried out. MATERIAL AND METHODS: Study of blind concordance between two independent reviewers for the identification, selection, retrieval and quality evaluation of the articles by using the same protocol. The concordance was analysed by the kappa index for two observers in different categories. The validity was evaluated throughout the acceptability of the review users. RESULTS: The concordance for their identification capacity was poor although they used the same key words (869 versus 476). But the concordance improved when considering selection (26.6% versus 29.2%), retrieval (agreement = 76%) classification by kind of article (kappa = 0.60) and scoring by strength of the evidence (kappa = 0.87). The acceptability was high among review users. CONCLUSIONS: It would be assumed that, even under tight rules of performance, the systematic literature reviews are not completely protected against some biases which could damage their validity in a non easily controllable form. The implication of reviewers, experts in documentation and users of the literature, together with pilot studies performed previous to the review, seems to be the best way to yield better results.

[Do physicians' strikes influence the utilization profile of hospital emergency services?]. / Influyen las huelgas de médicos en el perfil de utilización de los servicios de urgencias hospitalarios?

BACKGROUND: To assess the differences in appropriateness of consultations and demographic outline of people attended in a hospital emergency facility (HEP) along the hospital physicians strike period in spring 1995. METHODS: Observational cross-sectional study in Health Area 1 in the province of Badajoz. 8964 patients assisted along the strike period were compared with 8024 attended in the same period of 1994 (no strike). RESULTS: The patients average was 169.13 (SD 27.35) a day in the strike period, during the control period this mean was 151.39 (SD 19.78) patients a day (p < 0.001). Demographic variables of patients were similar in both groups, with similar mean ages and gender proportion in all age and residence site groups. Most of patients went to the HEF self-promoted (70.1% and 65.8%) and without ambulance (92% and 90.8%) in both periods (strike and control). The outcome of medical care was home discharge in 85.35% during the strike period and 83.81% in the control period, with admission rates of 13.1% and 14.15% (p < 0.01). CONCLUSIONS: There are no significant differences in the HEF use features completely explained by the physicians strike.

Development of new positive-selection RIVET tools: detection of induced promoters by the excision-based transcriptional activation of an aacCI (GmR)-gfp fusion.

RIVET (Recombination Based in vivo Expression Technology) is a powerful genetic tool originally conceived for the identification of genes induced in complex biological niches where conventional transcriptomics is difficult to use. With a broader application, genetic recombination-based technologies have also been used, in combination with regulatory proteins and specific transcriptional regulators, for the development of highly sensitive biosensor systems. RIVET systems generally comprise two modules: a promoter-trap cassette generating genomic transcriptional fusions to the tnpR gene encoding the Tn-γδ TnpR resolvase, and a reporter cassette carrying res-flanked selection markers that are excised upon expression of tnpR to produce an irreversible, inheritable phenotypic change. We report here the construction and validation of a new set of positive-selection RIVET systems that, upon induction of the promoter-trap module, generate the transcriptional activation of an antibiotic-resistant and a green-fluorescent phenotype. Two classes of promoter-trap tools were constructed to generate transcriptional fusions to tnpR: one based on the use of a narrow-host-range plasmid (pRIVET-I), integrative in several Gram-negative bacteria, and the other based on the use of a broad-host-range plasmid (pRIVET-R). The system was evaluated in the model soil bacterium Sinorhizobium meliloti, where a clear-cut phenotypic transition from Nm(R)-Gm(S)-GFP(-) to Nm(S)-Gm(R)-GFP(+) occurred upon expression of tnpR. A S. meliloti integrative RIVET library was constructed in pRIVET-I and, as expected, changes in the extracellular conditions (e.g., salt stress) triggered a significant increase in the appearance of Gm(R)-GFP(+) (excised) clones. The sacB-independent positive-selection RIVET systems here described provide suitable basic tools both for the construction of new recombination-based biosensors and for the search of bacterial markers induced when microorganisms colonize and invade complex environments and eukaryotic hosts.