Clinical ethics protocols in the clinical ethics committees of Madrid

INTRODUCTION

Currently, The nature and scope of Clinical Ethics Protocols (CEPs) in Madrid (Spain) are not well understood.

OBJECTIVES

The main objective is to describe the features of 'guideline/recommendation' type CEPs that have been or are being developed by existing Clinical Ethics Committees (CECs) in Madrid. Secondary objectives include characterisation of those CECs that have been the most prolific in reference to CEP creation and implementation and identification of any trends in future CEP development.

METHODS

We collected CEPs produced and in process by CECs accredited in the public hospitals in Madrid, Spain, from 1996 to 2008.

RESULTS

CECs developed 30 CEPs, with 10 more in process. The most common topic is refusal of treatment (seven CEPs developed; two in process). If CEPs addressing terminal illness, Do-Not-Resuscitate orders and advance directives are placed into a separate 'ethical problems at the end of life' category, this CEP subject emerges as the most common (eight developed; four in process). There is a relationship between the age of the CEC and the development of CEPs (the oldest CECs have developed more CEPs). CECs now seem to be more likely to engage in CEP development.

CONCLUSIONS

The CECs in Madrid, Spain, have developed a significant number of CEPs (30 in total and 10 in process) and there is a trend towards continued development. The most frequent topics are ethical problems at the end of life and refusal of treatment by the patient.

[Changes in knowledge and carrying out the advance directives of patients admitted to internal medicine]

BACKGROUNDS

Advance directives (ADs), are documents in which patients express in advance that their wishes are fulfilled when they are unable to communicate them. It is unknown whether patients admitted to internal medicine are more aware of and make ADs.

OBJECTIVE

To study the changes in the level of knowledge and implementation of AD among patients admitted to an internal medicine department of a hospital in Madrid since a specific regulation to implement them was introduced.

PATIENTS AND METHODS

A survey was conducted among patients admitted to internal medicine in two periods: 2008 and 2010.

RESULTS

A total of 206 surveys were analysed (84 in 2008 and 122 in 2010). The mean age of the patients was 76.8 years, and 51.5% were women. More than two-thirds (69.4%) had a co-morbidity. and 4.4% had a terminal illness, with no statistical differences between the periods. Only 5.3% knew what ADs are, 1 had implemented ADs, and 46.1%, once informed, would like to implement them. There were no differences between 2008 and 2010 as regards knowledge and implementation of AD. In 2010 there was a greater interest to implement them (would like to implement them: 52.5 vs 36.9%), although in 2010 less respondents believe that AD would change the attitude of the doctor (not change the attitude: 92.6 vs. 69%, P<.001).

CONCLUSIONS

Knowledge and implementation of AD did not change significantly in the years following the regulation (from 2008-2010). In both periods, their knowledge and implementation are scarce.

A simple prognostic score for risk assessment in patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common disease that poses potential serious problems. Its clinical course is often unpredictable. Identification of high risk patients enables early appropriate treatment.

METHODS

We conducted a prospective study to develop a new prognostic method that can objectively and easily grade the severity of AP within the first 72 h of admission. The prediction rule was based on clinical and analytical parameters in 308 patients admitted in a community-based hospital. We validated the score in 193 additional patients in the same hospital.

RESULTS

Independent prognostic factors related to poor prognosis were age >65 years, leucocytes >13,000/mm(3), albumin <2.5 mg/dL, calcium <8.5 mg/dL and reactive C protein >150 mg/dL. We assigned points to each of the independent factors for complicated AP in proportion to the regression coefficients. We defined three different risk groups according to the points obtained in the prediction rule. Low risk, 0 points (18% patients, 0% risk), moderate, 1-3 points (56% patients, 19% risk) and high, 4-6 points (26% patients, 73% risk). The sensitivity of this formula was 90% with specificity of 63%. The positive and negative predictive values were 50% and 94% respectively.

CONCLUSIONS

Our simple prediction rule is an additional tool that may help physicians stratifying the severity of AP. Patients with high risk for complicated AP should be kept under close surveillance whereas low risk patients would not need special monitoring.

Lymphoma microenvironment: culprit or innocent?

Studies are revealing that lymphoid neoplasms are characterized by well-defined chromosome translocations and by the accumulation of subsequent molecular alterations involving mainly the cell cycle and/or apoptotic pathways. However, survival of B and T tumor cells is also dependent on the interactions with the accompanying cells that comprise the lymphoma microenvironment. Although non-tumor cells can contribute both positive and negative signals to the lymphoma cells, in this review we present compelling evidence of the essential influence of the tumor microenvironment on the initiation and progression of specific lymphoma types, highlighting some new therapeutic approaches that target the lymphoma microenvironment.

Absence of cardiovascular autonomic dysfunction and vagal pancreatic impairment in idiopathic achalasia of the oesophagus

Extra-oesophageal autonomic dysfunction in idiopathic achalasia is not well documented, due to contradictory results reported. We aimed to study the cardiovascular and pancreatic autonomic function in patients with idiopathic achalasia. Thirty patients with idiopathic achalasia (16M/14F; 34.5 +/- 10.8 years) and 30 healthy volunteers (13M/17F; 34.8 +/- 10.7 years) were prospectively studied. Age >60 years and conditions affecting results of autonomic evaluation were excluded. Both groups underwent the sham feeding test and plasmatic levels of pancreatic polypeptide (PP) were determined by radioimmunoassay (basal, at 5, 10, 20 and 30 min). Cardiovascular parasympathetic (deep breathing, standing, Valsalva) and sympathetic function (postural decrease of systolic blood pressure, Handgrip test) were assessed. Statistical comparison of basal and increase levels of PP and parasympathetic/sympathetic cardiovascular parameters was performed between groups. Basal levels of PP were similar in controls and patients and maximum increase of PP during sham feeding test. A similar rate of abnormal cardiovascular tests was found between groups (P > 0.05). E/I ratio was the mostly impaired parameter (patients: 36.7% vs controls: 20%, P = 0.15, chi-squared test). Autonomic cardiovascular tests and pancreatic response to vagal stimulus are not impaired in patients with primary achalasia of the oesophagus.

Oesophageal motility disorders in type 1 diabetes mellitus and their relation to cardiovascular autonomic neuropathy

The relationship between cardiovascular autonomic neuropathy (CVAN) and oesophageal dysfunction in diabetes mellitus has not been well established because reports are contradictory. The aim of this study was to assess oesophageal function and its correlation with CVAN in type 1 diabetic patients without oesophageal symptoms. Forty-six type 1 diabetic patients without oesophageal symptoms (DG) and 34 healthy volunteers (CG) were studied. Both groups underwent CVAN tests and oesophageal manometry and pH-metry. Differences between groups regarding results of cardiovascular autonomic tests and oesophageal studies were statistically analysed. Compared with the CG, the DG group showed insufficient lower oesophageal sphincter (LOS) relaxation and a higher percentage of simultaneous waves (P < 0.01). Patients with CVAN (n = 22) showed a higher prevalence of pathological simultaneous contractions (>10%), and the prevalence of simultaneous waves related to the degree of autonomic neuropathy was: 9% of patients without CVAN, 7% of those suspected to have it and 50% of patients with CVAN (P < 0.001). Factors associated with the presence of pathological simultaneous waves (>10%) were the presence of CVAN and duration of diabetes (P < 0.05, logistic regression analysis). Increase in simultaneous waves and impaired relaxation of LOS are more frequent in diabetic patients with CVAN.

Prevalence of silent fecal and urinary incontinence in women from the town of Teruel

OBJECTIVES

To study the prevalence of fecal (FI) and urinary incontinence (UI) in women from Teruel (Spain), as well as the clinical conditions associated with these disorders.

METHODS

We studied prospectively women with an age range of 20-64 years who were randomly selected from the population seen in a primary care center because of medical disorders not related to incontinence. Patients with functional or cognitive impairment were excluded. Medical and obstetric antecedents, as well as the type and frequency of incontinence symptoms were collected in a questionnaire.

RESULTS

Out of 115 women, 103 completed the study (mean age: 41+/-12 years range 20-64). UI was present in 34.9% (stress 33%, urge 14%, mixed 47%), FI in 14 (13.6%) (flatus 57%, liquid stools 43%), and 10 (9.7%) displayed both disorders. Age > 42 years and body mass index more or equal of 25 were associated with FI and UI; pregnancy was only associated with UI, but the group of women with more or equal of 2 vaginal deliveries showed a higher frequency of FI (p < 0.05, Chi squared test). In the multivariate analysis, only the presence of UI was associated with FI (OR 6.0; CI 95% 1.7-21). Association of FI and UI was more frequent in women older than 42 years (OR 16.7, CI 95% 1.9-141). No statistical differences were found when smoking, exercise, and type of childbirth were compared between the presence/absence of FI or UI.

CONCLUSIONS

Urinary and fecal incontinence are frequent in women, and the coexistence of both disorders is not uncommon. Age, overweight and parity are associated with the presence of fecal and/or urinary incontinence.

Unstimulated salivary flow rate, pH and buffer capacity of saliva in healthy volunteers

OBJECTIVES

To assess the salivary flow rate, pH, and buffer capacity of healthy volunteers, and their relationships with age, gender, obesity, smoking, and alcohol consumption, and to establish the lower-end value of normal salivary flow (oligosialia).

METHODS

A prospective study was conducted in 159 healthy volunteers (age > 18 years, absence of medical conditions that could decrease salivary flow). Unstimulated whole saliva was collected during ten minutes, and salivary flow rate (ml/min), pH, and bicarbonate concentration (mmol/l) were measured using a Radiometer ABL 520. The 5 percentile of salivary flow rate and bicarbonate concentration was considered the lower limit of normality.

RESULTS

Median salivary flow rate was 0.48 ml/min (range: 0.1-2 ml/min). Age younger than 44 years was associated with higher flow rates (OR 2.10). Compared with women, men presented a higher flow rate (OR 3.19) and buffer capacity (OR 2.81). Bicarbonate concentration correlated with salivary flow rate. The lower-end values of normal flow rate and bicarbonate concentration were 0.15 ml/min and 1.800 mmol/l, respectively. The presence of obesity, smoking, and alcohol consumption did not influence salivary parameters.

CONCLUSIONS

In healthy volunteers, salivary flow rate depends on age and gender, and correlates with buffer capacity. Obesity, smoking, and alcohol use do not influence salivary secretion.

Dental and periodontal lesions in patients with gastro-oesophageal reflux disease

OBJECTIVE

Dental erosion has been considered an extraesophageal manifestation of gastro-oesophageal reflux disease, but few reports have studied the relationship between this disease and other periodontal or dental lesions. The aim of this study was to investigate the prevalence of dental and periodontal lesions in patients with gastro-oesophageal reflux disease.

PATIENTS AND METHODS

A total of 253 subjects were prospectively studied between April 1998 and May 2000. Two study groups were established: 181 patients with gastro-oesophageal reflux disease and 72 healthy volunteers. Clinical assessment, including body mass index and consumption of tobacco and alcohol, was performed in all subjects, as well as a dental and periodontal examination performed by a dentist physician, blind as to the diagnosis of subjects. Parameters evaluated were: (a) presence and number of dental erosion, location and severity, according to the Eccles and Jenkins index [Prosthet Dent 1979;42:649-53], modified by Hattab [Int J Prosthes 2000;13:101-71; (b) assessment of dental condition by means of the CAO index; and (c) periodontal status analysed by the plaque index, the haemorrhage index, and gingival recessions.

RESULTS

Clinical parameters were similar in both groups (p > 0.05). Age was statistically associated with the CAO index, presence of dental erosion, and gingival recession (p < 0.001, Student's t-test). Compared with the control group, the percentage of dental erosion was significantly higher in the gastro-oesophageal reflux disease group (12.5 vs. 47.5%, p < 0.001, chi2-test), as was the number and severity of dental erosions (p < 0.001, Student's t-test). Location of dental erosion was significantly different between groups. Age was not statistically related to either the amount or severity of dental erosion. CAO and periodontal indices were similarly distributed between groups.

CONCLUSIONS

Dental erosion may even be considered as an extraesophageal manifestation of gastro-oesophageal reflux disease. The fact that the prevalence of caries and periodontal lesions is similar in patients with gastro-oesophageal reflux disease and in healthy volunteers suggests a lack of relationship with gastro-oesophageal reflux disease.

[Prospective and comparative study of pacemaker implants carried out at the electrophysiology laboratory and the operating room]

INTRODUCTION AND OBJECTIVES

Permanent pacemaker implantation is done by different physicians with either a surgical or clinical training. Our objective was to evaluate if there were significant differences in the implantation parameters and in the complication rate among implantations performed by cardiologists in the electrophysiologic laboratory and cardiological surgeons in the operating room.

MATERIAL AND METHODS

We prospectively collected those patients' data who received a first pacemaker implantation by cardiovascular surgeons and electrophysiologists during the year 1998. Data collected included demographic information, indication for pacing, surgical time, complications during procedure, stimulation and sensing thresholds as well as type of pacing.

RESULTS

We first-implanted 216 pacemakers in a one year period, 101 by cardiovascular surgeons and 115 by electrophysiologists. 56% were male patients. Average age in the surgery group was 74.2 +/- 9 years and 72.09 +/- 12 in the electrophysiology group (p = NS). Main diagnoses were as follows: complete heart block in 32.9% patients, complete heart block 2. degrees 16.4%, sinus node dysfunction 12.2%, AV node ablation 12.2% and others. The complications rate for surgery group was 4% and 1.7% for electrophysiologists (p = NS). Electrophysiologists placed more bicameral devices. No clinically significant differences were found among other implant parameters.

CONCLUSIONS

Pacemaker implant by cardiologists in an electrophysiologists laboratory is a safe procedure that does not have more complications when compared to the same procedure done in the operating room by surgeons. This allows hospital resource optimization and reduction of hospital stay length.

Moment analysis as a systematic tool for NMR powder pattern analysis

The low order moments for chemical shift and second-order quadrupolar powder patterns have been calculated as functions of the anisotropy and asymmetry parameter of the governing interaction, and the expressions inverted to give these parameters as a function of the moments. Theoretical simulations and experimental experience show that moment analysis in most cases equals and in some cases exceeds the accuracy of direct inspection as a method of obtaining NMR parameters. We illustrate the efficacy of the method applied to 31P chemical shift spectra of nucleic acids, and 39K second-order patterns of series of potassium salts.

Radiofrequency ablation of a posteroseptal atrioventricular accessory pathway in a left-sided tricuspid ring with Ebsteinlike anomaly in a patient with congenitally corrected transposition of the great arteries

Radiofrequency ablation successfully eliminated a posteroseptal accessory pathway in a left-sided tricuspid ring with Ebsteinlike anomaly in a patient with a congenitally corrected transposition of the great arteries.

[Analysis of local electrograms and characteristics of the ablation procedure in left-sided accessory pathways that required five or more pulses of radiofrequency]

INTRODUCTION AND OBJECTIVES

Radiofrequency ablation of left sided accessory pathways requires multiple pulses in some patients due to different factors such as inadequate mapping, inappropriate tissue electrode contact and particular anatomic factors. However these characteristics have not been specifically analyzed.

METHODS

We have studied a prospective ablative series of 65 consecutive patients with left-sided pathways submitted to radiofrequency ablation by a simplified technique. In every application point, we analyzed the electrogram features, application point, impedance, potency and temperature.

RESULTS

52 patients (80%) required less than 5 radiofrequency pulses (group A) and 13 (20%) required > or = than 5 pulses (group B). The presence of a suggestive potential accessory pathway in local electrogram was similar in both groups and there were no differences in the local A-V or V-A intervals. However, in patients with pre-excitation the Delta-V interval was shorter in group A than in group B (8 ms vs 15 ms; p < 0.001). Furthermore, the impedance observed from the ablation point in group A was lower (108 +/- 12 vs 121 +/- 22 ohms; p < 0.001), and the maximum watts required to reach the predetermined temperature was higher in group A (42 +/- 16 vs 31 +/- 18 watts; p < 0.001). Final success of the procedure was 100%.

CONCLUSIONS

Patients requiring more than 5 radiofrequency pulses had electrograms and tissue contact equal or better than those requiring less than 5 pulses. This suggests that difficulties encountered in some procedures can be due to anatomical factors rather than inaccurate mapping or insufficient tissue contact.

[Prevalence of drinkers at risk and associated factors among men attending primary care clinics]

OBJECTIVES

To quantify the prevalence of risk drinkers among men seeking health care, establish consumption patterns and relate them to socio-demographic features and health habits.

DESIGN

Crossover study. First phase of an experimental study.

SETTING

Four primary care teams in Area 10, Madrid.

PATIENTS

Males between 18 and 65 who attended for on-demand medical care. A systematic sample was selected (n = 562).

MEASUREMENTS

A questionnaire collecting socio-demographic characteristics, health habits and alcohol consumption (frequency, consumption pattern, intake of Weekly Units of alcohol (WU) and alcohol-related problems). 94.2% replied. 38% were habitual drinkers (drink four or more days a week), while 18.9% were week-end drinkers. Prevalence of drinkers consuming over 21 WU was 24.8%; and over 35 WU, 16.2%. Whether the cut-off point was fixed at 21 or 35 WU. The alcohol taken was related to educational level, physical exercise, smoking and taking other drugs. On average, single people, smokers, other drug-consumers, ex-drinkers and habitual drinkers were those who displayed most problems connected with alcohol consumption.

CONCLUSIONS

There is a similar profile of health habits for the groups consuming over 21 WU and 35 WU, which should make preventive care pay attention to both groups of drinkers.

Vascular and hormonal responses to arginine: provision of substrate for nitric oxide or non-specific effect?

1. The vascular and hormonal effects of L- and D-arginine were compared in healthy subjects and in patients with insulin-dependent diabetes mellitus or untreated essential hypertension. 2. Infusion of L- or D-arginine (40 mumol/l) in the forearm vascular bed, sufficient to increase the local concentration approximately 20-fold, had no effect on blood flow or the vasodilator response to acetylcholine (30 and 100 nmol/min) in patients with insulin-dependent diabetes (n = 7) or essential hypertension (n = 7), or in age- and sex-matched control subjects (n = 7 in both groups). 3. Systemic infusion of 10 g of L-arginine (n = 5) or D-arginine (n = 3) increased plasma concentration of arginine approximately 20-fold without altering supine or erect haemodynamics. Increases in plasma insulin, prolactin and glucagon were seen with both enantiomers. The stereopurity of arginine was confirmed in a cell-culture assay system. 4. We conclude that, in healthy subjects and patients with essential hypertension or insulin-dependent diabetes, synthesis of nitric oxide within the vasculature is not limited by substrate availability. At high concentrations of arginine, non-stereospecific effects, including alterations in hormone concentration, occur. It remains to be determined whether these non-stereospecific hormonal changes might contribute to certain haemodynamic effects of arginine.

Participation of Na+ channels in the response of carotid body chemoreceptor cells to hypoxia

The role played by Na+ channels of carotid body (CB) chemoreceptor cells was investigated by studying the effects of tetrodotoxin (TTX) on the release of 3H-labeled catecholamines ([3H]CA) by adult rabbit CBs previously incubated with the precursor [3H]tyrosine. TTX inhibited partially the release of [3H]CA elicited by mild hypoxia (10 or 7% O2) or by depolarizing incubation medium containing 20 or 30 mM KCl, but the response to more intense hypoxia (5 or 2% O2) or to higher KCl concentration (40 or 50 mM) was not significantly affected. The release of [3H]CA elicited by acidic stimuli, either 20% CO2 (pH 6.6) or the protonophore dinitrophenol (100 microM), although comparable in magnitude to that elicited by mild hypoxia, was not modified by TTX. These results provide evidence for the first time that Na+ channels of chemoreceptor cells participate in the transduction of hypoxic stimuli into the neurotransmitter release response of these cells and suggest that Na+ current operates as an amplifying device that enhances the initial cell depolarization mediated by the closure of the O2-sensitive K+ channels. Sympathetic denervation of CBs was followed by a marked reduction in the release of [3H]CA elicited by veratridine or by 20 mM KCl, suggesting that the number of Na+ channels in chemoreceptor cells decreases after denervation.

5-Coordinate Si Compounds as Intermediates in the Synthesis of Silicates in Nonaqueous Media

Sodium silicoglycolate, an organosilicon compound in which silicon is in 5-coordination with respect to oxygen, is shown to be a reaction intermediate in the synthesis of a purely siliceous sodalite with ethylene glycol as solvent. The presence of silicon-29 nuclear magnetic resonances at -105.5 +/- 0.3 parts per million in solution and -102.7 parts per million in the solid state as well as x-ray powder diffraction patterns demonstrate that 5-coordinate silicon is intimately involved in the synthesis. Silicon compounds of the 5-coordinate type are highly reactive and are promising starting materials for the synthesis of novel silicone polymers, molecular sieves, glasses, semiconductors, and ceramics. We have used sodium silicoglycolate to prepare the molecular sieve silicalite as well as sodalites of different compositions.

Characterization of cultured chemoreceptor cells dissociated from adult rabbit carotid body

Short-term cell cultures were obtained from enzymatically dissociated carotid bodies from adult rabbits, and morphological and functional characterization of the cultured chemoreceptor cells were carried out. Under phase contrast, freshly isolated type I cells are round, bright, and 10-14 microns in diameter and exhibit strong fluorescence when stained with the glyoxylic acid technique. The content of endogenous dopamine in the cultures increased from 80 pmol/10(5) cells 2 h after plating the cells to 200 pmol/10(5) cells on the 3rd day, and the rate of synthesis and storage of [3H]dopamine from the precursor [3H]tyrosine increased from 1.7 pmol.10(5) cells-1.h-1 in 1-day cultures to 4 pmol.10(5) cells-1.h-1 on the 3rd day; the later values represent 80-85% of the expected values for the intact carotid body. After labeling with [3H]tyrosine, cultured chemoreceptor cells release [3H]dopamine when challenged by hypoxia, high external K+, or the protonophore dinitrophenol, the pattern of response being similar to that of the intact carotid body. When studied by whole cell clamp recording, individual chemoreceptor cells exhibit a marked variability in the properties of some ionic currents; the data, however, do not support the existence of distinct subpopulations of type I cells.