Quality of cancer care in Spain: recommendations of a patients' jury.

The aim of the study was to evaluate quality of cancer care in Spain through patient's views, experiences and perceptions; with the purpose of making recommendations to improve cancer care. A modified citizen's jury was organised with the participation of 30 members and four experts as witnesses. For 1 day jurors representing 13 of 17 Spanish Autonomous Communities were met to make recommendations for improving the quality of cancer care in Spain. Concerns were identified regarding care fragmentation, test delays, duplications and poor social and emotional support. Some recommendations highlighted the need to improve the access to psycho-oncology care as well as support in social care and counselling, addressing patients to specific care. Some strategies proposed by the jury included a 24-h call centre, continuity in palliative care and appropriate follow-up and support after the end of therapy. In conclusion, the experience of cancer should include access to multiple specialists, effective coordination of care, accurate information about the disease and treatment options, and timely attention to symptoms and psychosocial needs.

Impact of a multidisciplinary medication reconciliation program on clinical outcomes: A pre-post intervention study in surgical patients.

BACKGROUND: Previous studies have evaluated the effects of medication reconciliation (MR) and suggest that it is effective in decreasing medication discrepancies. Nevertheless, a recent overview of systematic reviews concluded that there is no clear evidence in favor of MR in patient-related outcomes and healthcare utilization, and further research about it is needed. OBJECTIVE: To evaluate the impact of a multidisciplinary MR program on clinical outcomes in patients with colorectal cancer presenting other chronic diseases, undergoing elective colorectal surgery. METHODS: We performed a pre-post study. Adult patients scheduled for elective colorectal cancer surgery were included if they presented at least one "high-risk" criteria. The MR program was developed by internists, pharmacists and surgeons, and ended with the obtention of the patient's pre-admission medication list and follow-up care until discharge. The primary outcome was the length of stay (LOS). Secondly, we evaluated mortality, preventable surgery cancellations and risk factors for complications. RESULTS: Three hundred and eight patients were enrolled. Only one patient in the pre-intervention group suffered a preventable surgery cancellation (p = 0.317). The mean LOS was 13 ± 12 vs. 11 ± 5 days in the pre-intervention and the intervention cohort, respectively (p = 0.435). A difference in favor of the intervention group in patients with cardiovascular disease (p = 0.038) and those >75 years old (p = 0.043) was observed. No difference was detected in the mortality rate (p = 0.999) neither most of the indicators of risk factors for complications. However, the management of preoperative systolic blood pressure of hypertensive patients (p = 0.004) and insulin reconciliation in patients with treated diabetes (p = 0.003) were statistically better in the intervention group. CONCLUSIONS: No statistically significant change was observed in the mean global LOS. A statistically significant positive effect on LOS was observed in vulnerable populations: patients >75 years old and those with cardiovascular disease, who presented a 5-day reduction in the mean LOS.

Impact of medication reconciliation on health outcomes: An overview of systematic reviews.

BACKGROUND: Recent systematic reviews and meta-analyses suggest that medication reconciliation (MR) is effective in decreasing the risk of medication discrepancies. Nevertheless, the association between MR and subsequent improved healthcare outcomes is not well established. OBJECTIVES: This systematic review of reviews set out to identify published systematic reviews on the impact of MR programs on health outcomes and to describe key components of the intervention, the health outcomes assessed and any associations between MR and health outcomes. METHODS: PubMed, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and SCOPUS were searched from inception to May 2019. Systematic reviews of all study designs, populations, intervention providers and settings that measured patient-related outcomes or healthcare utilization were considered. Methodological quality was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). Two investigators performed study selection, quality assessment and data collection independently. RESULTS: Five systematic reviews met the inclusion criteria: 2 were rated as low quality and 3 as critically low quality. Reviews included primary studies in different settings (hospitals, the community and residential aged care facilities) that reported the impact of MR on mortality, length of stay, Emergency Department (ED) visits, readmissions, physician visits and healthcare utilization. Only one review reported results on mortality. However, healthcare utilization, which usually included ED visits and readmissions, was communicated in all reviews. Meta-analyses were conducted in all reviews except one. Medication reconciliation was not consistently found to be associated with improvements in health outcomes. CONCLUSIONS: Few systematic reviews support the value of MR in achieving good patient-related outcomes and healthcare utilization improvements. The quality of the systematic reviews was low and the primary studies included commonly involved additional activities related to MR. There was no clear evidence in favor of intervention in mortality, length of stay, ED visits, unplanned readmissions, physician visits and healthcare utilization.

[Pharmacogenetic analysis of the absorption kinetics of cyclosporine in a population of Spanish cardiac transplant patients]. / Análisis farmacogenético de la cinética de absorción de ciclosporina en una población española de pacientes trasplantados cardíacos.

OBJECTIVE: To determine how single nucleotide polymorphisms located on genes MDR1, CYP3A4 and CYP3A5 affect the absorption kinetics of cyclosporine in cardiac transplant patients. METHOD: We selected a sample of 30 adult patients having previously undergone a primary cardiac transplant and who had received cyclosporine as an immunosuppressant. During the first month after the transplant, we performed a pharmacokinetic study of each patient to determine values in the cyclosporine concentration area under the 12-hour curve, steady-state cyclosporine concentration, maximum cyclosporine concentration, and time to reach that concentration. Single nucleotide polymorphisms were genotyped in all patients: MDR1 3435C > T, CYP3A4-390A > G and CYP3A5 6986A > G. RESULTS: Being a carrier of the T-allele for polymorphism MDR1 3435C > T is associated with higher values in the cyclosporine concentration area under the 12-hour curve (p = 0.01) and in steady-state cyclosporine concentration (p = 0.05), compared with those from patients who do not carry that allele. DISCUSSION: Our results show that genotype differences in MDR1 3435C > T can explain part of the variability in cyclosporine absorption among individuals in the population of Spanish cardiac transplant recipients.

[Work of a multidisciplinary team in the control of the prescription of ertapenem]. / Actuación de un equipo multidisplinario en el control de la prescripción de ertapenem.

OBJECTIVE: To determine the effectiveness of the intervention of a multidiscipline antimicrobial control group in the correct prescription of Ertapenem. METHOD: A four-month long, prospective study into prescriptions for Ertapenem was carried out in a third-level hospital. Assessment into the degree of suitability of each prescription according to the infections commission usage criteria. In the situation where prescriptions were not suitable, recommendations were given and acceptance of this was recorded. The effectiveness of the antimicrobial treatment used was assessed and treatment was considered effective when there was remission of the signs and symptoms of the infection when the treatment was completed. The treatment was considered to have failed when the signs and symptoms of infection persisted or progressed, requiring the addition of another antimicrobial agent, changing antibiotics or the prolongation of the treatment for longer than 2 weeks. Lastly, the differences in the average length of stay and the duration of the antibiotic treatment between groups were analysed. RESULTS: Forty-eight prescriptions were assessed. The usage criterion was adequate in 48 % of cases, with 78 % effectiveness in this group. In the cases where the prescription was not adequate, but a change in prescription was accepted, the effectiveness was 92 %, with 55.5 % of those cases not accepting recommendation for change. The average stay was higher in this last group (p = 0.07). The duration of the antibiotic treatment in the patients who accepted the change in prescription was significantly less than in those who did not accept it (2 vs 7.4 days, p < 0.0001). CONCLUSIONS: The control of Ertapenem prescriptions by a multidisciplinary team was effective.

[Patients' competences and health literacy assessment questionnaire]. / Valoración de las competencias en salud de los pacientes: Instrumento VACS.

OBJECTIVE: To design a questionnaire to identify patients with difficulties to obtain, understand and use health information. MATERIAL AND METHOD: Qualitative study through semi-structured interviews and a consensus technique. A review of the literature on health literacy was carried out. Five semi-structured interviews were conducted with experts in the field. A 12-item instrument was designed. Content validity was determined using the Health Consensus technique. Participants were health professionals and patient representatives (5 semi-structured interviews and 60 Health Consensus). An instrument to measure the level of skills and literacy in patients' health was developed. The measures were 7categories on the health competencies and literacy construct: Ability to search for information, ability to understand the information, ability to communicate with health professionals, capacity for operational understanding, competence in decision making, ability to move and navigate through the health system, and competencies in self-care. RESULTS: A 12-item questionnaire was designed. The median scores obtained in the Health Consensus ranged between 6.08 (1.43) and 7.22 (1.52), with an agreement level of between 73.87% to 84.19%. Finally, a 5-item instrument was obtained to assess the patients' health competencies. CONCLUSIONS: The questionnaire is a useful tool to detect those at risk of having difficulties in obtaining, understanding and using health information. This would allow professionals to focus their attention on the type of information patients need and better adapt it to their needs.

[Assessment of safety practices for medication-use systems in Spanish hospitals (2007)]. / Evaluación de las prácticas de seguridad de los sistemas de utilización de medicamentos en los hospitales españoles (2007).

BACKGROUND AND OBJECTIVE: To examine the current status of safety practices for medication-use systems in Spanish hospitals and to identify major areas of risk. MATERIAL AND METHOD: Those hospitals that completed the "Medication use-system safety self-assessment for hospitals" between June 1 and July 15, 2007, were included in the study. The survey contained 232 items for evaluation grouped into 20 core characteristics. RESULTS: A total of 105 hospitals from the 17 autonomous communities in Spain participated in the study. The average aggregate score for the survey of all the participating hospitals was 612.7 (39.7% of the maximum possible score) and there were no differences found with regard to number of beds, training activity or type of hospital. When core characteristics were analyzed, there were 3 criteria with the lowest values (< 25%), associated with professional training, skills, and the establishment of a system for reporting errors. Another 9 criteria, with percentages between 25% and 50%, reflected practices related to: access to information regarding patients and medications; communication of medication orders; prevention of errors due to naming, labeling, and packaging problems; standardization of medication delivery devices; restriction of medications in patient care units; and safety culture and double-checking procedures. CONCLUSIONS: Many opportunities for improvement have been identified, particularly in areas related to training, risk management, incorporating new technologies and patient participation. The information obtained may prove useful for prioritizing practices when establishing patient safety strategies, and as a baseline for successfully monitoring the effectiveness of the initiatives and programs consequently set into motion.

[Effects of hypotherapy on the motor function of persons with Down's syndrome: a systematic review]. / Efectos de la hipoterapia sobre la funcion motora en personas con sindrome de Down: revision sistematica.

INTRODUCTION: Down's syndrome is the main cause of intellectual disability and the most common human genetic alteration. Motor impairments are among the most important alterations presented by Down's syndrome subjects. Hippotherapy is a treatment on and with a horse, and it is currently being used as a therapy to correct those dysfunctions. AIM: To review published research literature on the effect exerted by hippotherapy on the gross motor function of people with Down's syndrome. SUBJECTS AND METHODS: The bibliography in the following databases has been widely searched: CINAHL, Medline, The Cochrane Library, PEDro, Scopus, and Web of Science. The journals Fisioterapia and Cuestiones de Fisioterapia have also been consulted. The electronic literature search strategy was addressed in two thematic fields: Down's syndrome and hippotherapy. Studies selection was carried out following inclusion and exclusion criteria and rejecting duplicate papers. That search included articles published between 2000 and 2016. RESULTS: For this work, 23 articles were found, 15 of which were discarded for different reasons, leaving 8 valid ones. CONCLUSIONS: There is no strong evidence on the improvement of gross motor function in people with Down's syndrome after treatment with hippotherapy. More studies with higher methodological quality, are needed to verify the effectiveness of hippotherapy in the treatment of gross motor function in subjects with Down's syndrome.

TITLE: Efectos de la hipoterapia sobre la funcion motora en personas con sindrome de Down: revision sistematica.Introduccion. El sindrome de Down es la principal causa de discapacidad intelectual y la alteracion genetica humana mas comun. Entre las alteraciones mas importantes que se presentan se encuentran las deficiencias motoras. La hipoterapia es un tratamiento sobre el caballo y con el caballo, y se usa en la actualidad como terapia en la correccion de dichas disfunciones. Objetivo. Analizar las evidencias cientificas existentes sobre el efecto que la hipoterapia ejerce en la funcion motora de personas con sindrome de Down. Sujetos y metodos. Se efectuo una amplia busqueda de la bibliografia en las siguientes bases de datos: CINAHL, Medline, The Cochrane Library, PEDro, Scopus y Web of Science. Ademas, se consultaron las revistas Fisioterapia y Cuestiones de Fisioterapia. Las busquedas se realizaron incluyendo los articulos publicados entre los años 2000 y 2016. La estrategia de busqueda electronica se planteo en dos bloques tematicos: sindrome de Down e hipoterapia. La seleccion de articulos se llevo a cabo siguiendo unos criterios de inclusion y exclusion, y se eliminaron los articulos duplicados. Resultados. En la busqueda realizada para esta investigacion se encontraron 23 articulos, y quedaron como validos ocho despues de excluir el resto por diferentes motivos. Conclusiones. No existen evidencias solidas sobre la mejora o no de la funcion motora en personas con sindrome de Down tras el tratamiento con hipoterapia. Son necesarios mas estudios, y de mayor calidad metodologica, para poder constatar la efectividad de la hipoterapia en el tratamiento de la funcion motora gruesa en sujetos con sindrome de Down.

[Failure mode effect analysis applied to preparation of intravenous cytostatics]. / Análisis modal de fallos y efectos aplicado a la elaboración de citostáticos intravenosos.

OBJECTIVE: To proactively identify risks in the preparation of intravenous cytostatic drugs, and to prioritise and establish measures to improve safety procedures. MATERIAL AND METHODS: Failure Mode Effect Analysis methodology was used. A multidisciplinary team identified potential failure modes of the procedure through a brainstorming session. The impact associated with each failure mode was assessed with the Risk Priority Number (RPN), which involves three variables: occurrence, severity, and detectability. Improvement measures were established for all identified failure modes, with those with RPN>100 considered critical. The final RPN (theoretical) that would result from the proposed measures was also calculated and the process was redesigned. RESULTS: A total of 34 failure modes were identified. The initial accumulated RPN was 3022 (range: 3-252), and after recommended actions the final RPN was 1292 (range: 3-189). RPN scores >100 were obtained in 13 failure modes; only the dispensing sub-process was free of critical points (RPN>100). A final reduction of RPN>50% was achieved in 9 failure modes. CONCLUSIONS: This prospective risk analysis methodology allows the weaknesses of the procedure to be prioritised, optimize use of resources, and a substantial improvement in the safety of the preparation of cytostatic drugs through the introduction of double checking and intermediate product labelling.

Nonspecific immune response of peripheral blood neutrophils in two horse breeds (Anglo-Arabian and Spanish-Arabian): response to exercise.

The aim of the present paper was: (1) to find out if there were any differences in the nonspecific immunological pattern of peripheral blood neutrophil between two breeds of horses (AA and SA); (2) to evaluate the effects of an exercise in the aerobic-anaerobic threshold. This has been observed in a group of 11 untrained horses (6 SA and 5 AA) of 2.5 years old. No statistically significant differences were found in the different stages of immune response between the rest and immediately after physical exercise to two breeds. However, the chemotaxis was significant higher at rest in the AA than SA breed. A positive correlation was found at rest between the phagocytic and oxidative metabolism activity for AA breed and a negative correlation too between the adherence and chemotaxis with phagocytic capacity, immediately after exercise test, for the same breed.

Effects of training on phagocytic and oxidative metabolism of peripheral neutrophils in horses exercised in the aerobic-anaerobic transition area.

Using simple techniques, the neutrophil function, in its phagocytosis and oxidative metabolism stages, was evaluated in horses. This was done before and after moderate exercise at the aerobic-anaerobic threshold (standardized heart rate 150 beats/min and lactate level of 3.07 +/- 0.21 mmol/L). The objective was to determine whether regular training and moderate exercise improved the neutrophil function. A group of 19 horses was used; 11 of these were untrained and the remainder trained for national jumping events. The exercise test consisted of a 5 min trot followed by a 3 min gallop on a long lunge. Blood samples were taken for analysis before, immediately after and 15 min after exercise. The results showed that (a) there is a difference in the internalization of particles (PI, PP and PE) by neutrophils from trained and untrained horses at a single time point during active recovery, and PP is higher in trained horses immediately after exercise; and (b) oxidative metabolism is significantly lower in untrained animals before and 1 min after exercise. The moderate exercise at the aerobic-anaerobic threshold did not have any influence on the peripheral blood neutrophil function of the phagocytosis and oxidative metabolism of particles.

[Stability and in vitro activity of voriconazole eyedrops at a concentration of 3 microg/mL]. / La estabilidad y actividad in vitro de voriconazol en colirio a una concentración de 3 microg/mL.

OBJECTIVE: To assess the stability and activity of voriconazole 3 microg/mL eyedrops as prepared for use against amphotericin B- and fluconazole-resistant fungal endophthalmitis. METHOD: Stability (concentration using UV-spectrophotometry; pH, osmolarity, and particle formation) and sterility were analyzed under various preservation conditions--room temperature (22-24 degrees C) or refrigerated (2-8 degrees C). The preparation's in vitro efficacy was analyzed using the standard National Committee for Clinical Laboratory Standards method for 30 days. RESULTS: Voriconazole concentrations were found to be within limits allowed by the United Stated Pharmacopeia (90-115%). pH (room temperature: 6.96-7.60; refrigerated: 6.84-7.21) and osmolarity (room temperature: 265-284 mOsm/l; refrigerated: 270-285 mOsm/l) remained within eye physiological ranges throughout the study under the analyzed conditions. The preparation s antifungal activity remained stable during the first three weeks. CONCLUSIONS: The voriconazole 3 microg/mL eyewash preparation remained stable, sterile and with full antifungal activity for 21 days when stored both at room temperature and under refrigeration conditions.

[Tacrolimus blood levels and incidence of graft rejection in heart transplantation]. / Relación entre los niveles de tacrolimus en sangre y la incidencia de rechazo en enfermos trasplantados de corazón.

OBJECTIVE: To determine the relationship between pharmacokinetic parameters and clinical outcomes after heart transplantation and to determine the range of tacrolimus blood levels which provides the most effective protection against graft rejection. To study other factors that predict graft rejection. METHOD: We retrospectively analyzed the clinical outcomes of all adult patients who received a heart transplant between January 2000 and October 2003 and had routine monitoring of tacrolimus trough levels at the time of scheduled endomyocardial biopsy. Rejection was defined as Grade = 3, based on the International Society for Heart and Lung Transplantation (ISHLT) criteria. The follow-up period was 1 year. All patients were on a triple therapy regimen of Tacrolimus (TAC), Corticosteroids and Azatioprine/Micophenolate Mofetil. Data were analyzed by Student s t-test, univariate logistic regression and ROC curve. RESULTS: Tacrolimus blood levels measured at day +5 postransplant were the strongest predictor of acute graft rejection over a 1-year follow-up period (rejection 5.76 +/- 3.4 ng/ml vs no rejection 9.66 +/- 2.73 ng/ml, p = 0.016). A decrease of one unit in TAC trough level values at day +5 postransplant implied a 1.58 greater risk of rejection (p = 0.05). Overall incidence of treated acute rejection was lower for patients with trough levels higher than 8 ng/ml on day +5 postransplant (33 vs 80%, p = 0.055, Fisher s exact test). CONCLUSIONS: Data suggest that in heart transplant patients it may be crucial to achieve tacrolimus levels of at least 8 ng/ml during the first days postsurgery to avoid rejection.

[Prevalence and factors associated with peripheral artery disease in patients with type 2 diabetes mellitus in Primary Care]. / Prevalencia y factores asociados a la enfermedad arterial periférica en pacientes con diabetes mellitus tipo 2 en Atención Primaria.

INTRODUCTION: Peripheral artery disease in the lower limbs (PAD) is a prevalent condition that entails high morbidity in diabetic patients; this study assesses PAD in these patients and its socio-demographic and clinic associated variables. MATERIAL AND METHODS: Descriptive study in a systematic sample of diabetic patients (DM2) aged 50-80 years, in Primary Care settings. The dependent variable was the presence of PAD diagnosed by ankle-brachial index (ABI) ≤ 0.9; independent variables: socio-demographic, clinical and laboratory. STATISTICS: bivariate and multiple logistic regression analyses were performed to determine the variables associated with low ABI. RESULTS: A sample of 251 patients, 52.6% women; mean age: 68.5 ±8.5. A low ABI was detected in 18.3% (95% Confidence Interval (95% CI):13.3-23.3%), with 6 subjets (2.4%) previously diagnosed as suffering PAD. Age (OR=1.07; 95% CI: 1.02-1.12) and retinopathy (OR=2.69; 95% CI: 1.06-6.81) were associated (multiple logistic regression analysis) with ABI. CONCLUSIONS: The percentage of patients diagnosed with PAD is very low, although PAD prevalence is high among DM2 patients attending Primary Care clinics, especially in older patients and those with retinopathy. We emphasize the recommendation of performing the ABI test in this population at risk.

Diplogonoporiasis presumably introduced into Spain: first confirmed case of human infection acquired outside the Far East.

A 58-year-old man who was very fond of eating raw fish and had not left Zaragoza Province in Spain in the last 20 years excreted a short chain of gravid proglottids. Treatment with 50 mg/kg of paromomycin sulfate was divided into three doses, all given within the same day, followed by administration of a laxative at night. On days 1 and 2 post-treatment, several chains of degenerated proglottids were evacuated. Only eggs were expelled on days 3 and 4. A long complete strobila including the scolex, and immature, mature, and gravid segments was spontaneously discharged on day 25 after treatment. It was identified as Diplogonoporus balaenopterae, and was the first confirmed case of diplogonoporiasis outside the Far East (all previous cases were reported from Japan, except for one recent case reported from Korea). The origin of this case, outside of its normal geographic location, may be associated with the importation of fish into Spain. The viability of the infective larval stage is evidence of its resistance to export/import conditions. Treatment with paromomycin sulfate did not result in the whole worm being discharged but several short strobilar chains showed drug-induced degeneration.

Socioeconomic status and preventive health-care use by children in Spain.

National health systems are intended to provide equal access to health-care services to whole populations. However, they do not seem to address successfully the problem of social class differentials in access to health care, in particular access to preventive care. This study examines the relationship between the socioeconomic status (SES) of families and the use of preventive health care by children under a national health system in Spain. The study is based on weighted multivariate ordinal logistic regression analyses of data from the 1987 Spanish National Health Survey for a sample of 5,622 children, one to 10 years of age. A positive relationship was found between preventive health-care use by children and the SES of their families. Adult respondents' level of education and total family income were the most influential variables in this relationship. As these increased, children were more likely to receive visual, hearing, and dental exams. In addition, there was a gradient effect between family income and rate at which children received these preventive health-care services. Universal access to care, like that available in Spain, does not guarantee that social inequalities in children's receipt of preventive health care will not persist. In order to succeed, health-care reform must deal with social issues beyond financial access to care.

Clinical pharmacokinetics of tacrolimus in heart transplantation: new strategies of monitoring.

The aim of this study was to investigate the absorption profile of tacrolimus (TAC) in heart transplant patients in order to find the best sampling time to predict the total exposure and to explore the target range for optimal clinical immunosuppression. Twenty-five full pharmacokinetic studies were performed in 22 heart transplant patients (11 men and 7 women) at less than 1 year posttransplant. The immunosuppressive treatment was steroids plus azathioprine or mycophenolate mofetil and TAC. The mean age was 55 years (36-64 years) and the mean weight 70.49 kg (50-111 kg). After three days of receiving the same dose, eight blood samples were collected at 0.5, 1, 2, 4, 6, 8, and 12 hours postmorning dose. TAC concentrations were measured by microparticle enzyme immunoassay (IMx). Area under the concentration-time curve(AUC(0-12)) was calculated by the trapezoidal rule. Using 0-4 hours TAC blood concentrations, a projected 12 hours AUC (extrapolated AUC(0-4)) was calculated assuming C0 and C12 were comparable. A high interpatient TAC pharmacokinetics variability that was greater during the absorption phase was observed. A Cmax (30.5+/-13.8 ng/mL) was reached at 2.3+/-1.5 h. When target trough levels were achieved (10-20 ng/mL), the mean tacrolimus exposure was 230.6+/-59.2 ng h/mL (120.14-327.7) (n=19). Correlation between AUC(0-12) and C0 was relatively good (r2=0.74). Between individual time points, C4 showed the best correlation (r2=0.88). In any case the best strategy to monitor is to obtain the extrapolated AUC(0-4) (r2=0.98), as a good approach to patients with a poor response to treatment.

New strategies of cyclosporine monitoring in heart transplantation: initial results.

The aim of this study was to evaluate cyclosporine (CyA) absorption profiles in heart transplantation to establish the most adequate monitoring strategy and determine the optimal therapeutic range for AUC(0-4) or C2 levels. A total of 22 full pharmacokinetic studies were performed at steady-state in 22 adult heart transplant recipients (18 men, 4 women). Twelve studies were performed during the first month posttransplant (group I), and 10 studies were done after 1 month (group II). In 9 outpatients we performed an abbreviated AUC(0-4). The mean age of the patients was 49+/-15 years (range, 15-72 years), and the mean weight was 70.4+/-10.8 kg (mean, 54-98 kg). The CyA dosage had been adjusted to maintain trough levels (C0) in the putative target ranges of 200 to 400 ng/mL in group I and between 100 to 300 ng/mL in group II. Blood samples were drawn prior to and at 0.5, 1, 2, 4, 6, 8, and 12 hours after the morning dose. The CyA blood levels were measured by the AxSYM cyclosporine assay. The AUC was calculated by the trapezoidal rule. Multiple linear regression was done to evaluate the predictive ability of various limited sampling strategies. The C0 correlated poorly, either with the full AUC (r2=0.64) or the AUC(0-4) (r2=0.43), while C2 seemed to be the most accurate single predictor of drug exposure (r2=0.92 for AUC(0-12); r2=0.74 for AUC(0-4)). For both AUC(0-4) and AUC(0-12), all 2- or 3-point strategies had r2 values approaching that of the C2 value. In conclusion, C2 is a simple, fast, and accurate value to predict AUC(0-4) in routine clinical practice. Its implementation must focus on ensuring the commitment of all unit staff, thus ensuring that patients are sampled on time and minimizing the impact on workload.

Locomotor, cardiocirculatory and metabolic adaptations to training in Andalusian and Anglo-Arabian horses.

The effects of two training programmes in 20 Andalusian and 12 Anglo-Arabian horses were evaluated by an increasing intensity work test at velocities of 4, 5, 6, 7 and 8 m sec(-1). Heart rate was monitored and blood samples were drawn at rest and after each velocity to analyse packed cell volume, haemoglobin concentration, plasma lactate and potassium levels. Furthermore, the programmes were video-taped and stride length, duration and frequency, stance (restraint and propulsion), swing phase durations and stride vertical component were measured. The training protocol of the Andalusian horses produced significant decreases in the cardiovascular, haematological and metabolic responses to exercise. Locomotory training adaptation consisted of an increased stride frequency and a reduced stride length and vertical stride component. The last variable was the limiting factor of stride length both before and after training in the Andalusian horses. A different training protocol for show-jumping competition in Anglo-Arabian horses failed to show significant differences in the studied parameters to the work test, although an increase in stride length at velocities of over 6 m sec(-1) was observed. Stride vertical component did not have an effect on the physiological response to exercise, either before or after training.

Hematological changes observed in Andalusian horses with laminitis.

Clinical blood chemistry was studied on 13 Andalusian horses with laminitis. Ten healthy horses were used as controls. Blood samples were taken within the first 24 hr after the onset of the disease in Obel grade 3 before any type of treatment was given. No significant differences were observed in the number of red blood cells and white blood cells between Andalusian horses affected by laminitis and healthy animals. Significant decrease in the number of neutrophils and increased number of lymphocytes were noted. A significant increase in the enzymatic activity of CPK, LDH and AST in these animals strongly suggested the presence of muscular and hepatic disorders. The K ion increased, meeting with a slight acidosis. There was also an increase of glucose and total proteins. This fact may be a result of an excessive intake of carbohydrates (which could cause hyperglycaemia) and a diminution of the plasma volume, as a consequence of fluid movement as well as the sweating process (which could cause protein haemoconcentration).