Multifactorial approach and adherence to prescribed oral medications in patients with type 2 diabetes

The aims of this study were to assess adherence to oral hypoglycaemic/cardiovascular drugs and determine non-adherence predictors in type 2 diabetes patients. It was designed as a population-based cross-sectional study in which 90 patients from a primary care setting were studied. Pill count and self-report methods were used to measure adherence. Logistic regression analysis was performed to predict factors related to non-adherence. Adequate adherence to all drugs was found in 29 patients (35.4%; 95% confidence interval (CI) 25.0-45.7). Variables associated with non-adherence were HbA1c odds ratio (OR) 2.32 (95% CI: 1.09-4.95), systolic blood pressure OR 1.68 (95% CI: 1.08-2.62), total cholesterol OR 1.34 (95% CI: 1.08-1.66), number of pills OR 1.80 (95% CI: 1.26-2.55) and duration of disease OR 0.44 (CI 95%: 0.24-0.83). In conclusion, one in three patients had adequate adherence. Factors associated with non-adherence were duration of disease, complexity of drug regimen and inadequate control of cardiovascular risk factors.

Pure testicular carcinoid associated with intratubular germ cell neoplasia

This case report describes for the first time a case of pure testicular carcinoid pre-aortic lymph node metastases in a 25 year old patient with carcinoid syndrome. The simultaneous occurrence of intratubular germ cell neoplasia in the surrounding testicular tissue was identified by OCT4 and placental-like alkaline phosphatase positivity. This confirmed that the tumour had a germ cell origin in the testis, rather than being a metastasis from an extragenital carcinoid.

The vascular surgeon facing clinical ethical dilemmas (the VASCUETHICS Study): 'V'-shaped association between compassionate attitudes and professional seniority

OBJECTIVE

To evaluate the association between compassionate attitudes and seniority in vascular surgeons facing clinical ethical dilemmas (CED).

SUBJECTS AND METHODS

(1) DESIGN: Cross-sectional. (2) SUBJECTS: Vascular surgeons (residents included) from the 28 vascular teaching departments of one European country. (3) MEASUREMENTS: Multidisciplinary team-designed, structured and self-administered questionnaire consisting of five clinical ethical dilemmas, of which four had conflict between compassion towards a 'small' or 'very costly' beneficial action vs. a reasonable but more 'pragmatic' allocation of health resources. Participants stated their degree of agreement with eight answers representing the two attitudes on a continuous scale. (4) STATISTICS: Cluster analysis and logistic regression model adjusted by confounding factors.

RESULTS

Two hundred and fifty three vascular surgeons (median age 37 years, 74% male) from the 26 participating teaching vascular departments (public hospitals) completed the questionnaire (88% surgeons/department). Cluster analysis identified two groups of surgeons according to their pattern of answers: Group I (n=63) were mainly compassionate whereas Group II (n=180) were mainly pragmatic. The multivariate analysis disclosed, after adjusting for additional private practice, on call services and career status, a significant V-shaped relationship between the compassionate behaviour and seniority. Surgeons with 8-15 years experience were the least compassionate.

CONCLUSIONS

The youngest and the most senior vascular surgeons were more prone to favour compassionate attitudes when facing clinical ethical dilemmas. Although both compassionate and pragmatic attitudes may be legitimate ethically, physicians not favouring compassion may be at risk of leaving the patient without an advocate within the health care system.

[Chronic spontaneous lumbar epidural hematoma]

We report an exceptional case of cauda equina syndrome, caused by a chronic epidural hematoma of the lumbar spine, (L2-L3). A 53 year old man without history of trauma, lumbar punctures or antiagregant medication, suffered from progressive back pain and minor motor deficit in the legs. The etiology, MRI, intraoperative findings and microscopical study are presented and discussed. After surgery there was a complete resolution of the clinical picture.

Possible azithromycin-associated hiccups

OBJECTIVE

To report a case of persistent hiccups associated by azithromycin therapy.

CASE SUMMARY

A 76-year-old man presented with persistent hiccups after beginning azithromycin for the treatment of pharyngitis. Hiccups were persistent and exhausting. Discontinuation of azithromycin and therapy with baclofen finally resolved hiccups. No organic cause of hiccups was identified despite extensive investigation.

DISCUSSION

Pharmacotherapeutic agents have been uncommonly associated with hiccups. Corticosteroids (dexamethasone and methylprednisolone), benzodiazepines (midazolam) and general anaesthesia have been the specific agents mentioned most frequently in the literature as being associated with the development of hiccups. Few cases of drug-induced hiccups have been reported related to macrolide antimicrobials. Using the Naranjo adverse effect reaction probability scale this event could be classified as possible (score 5 points), mostly because of the close temporal sequence, previous reports on this reaction with other macrolides and the absence of any alternative explanation for hiccups. Our hypothesis is that a vagal mechanism mediated by azithromycin could be the pathogenesis of hiccups in our patient.

CONCLUSIONS

Diagnosis of drug-induced hiccups is difficult and often achieved only by a process of elimination. However, macrolide antimicrobials have been reported to be associated with hiccups and vagal mechanism could explain the development of this side-effect.

The effect of written information on adherence to antibiotic treatment in acute sore throat

A randomised clinical trial was conducted to establish whether written instructions, in addition to verbal ones, significantly improve adherence to antibiotic treatment for acute sore throat in comparison with verbal instructions only. Patients were selected by consecutive sampling at seven primary healthcare surgeries. The pill count average was 87.4+/-25.2% and it was higher in the intervention group (93.7+/-24.5%) than in the control group (81.1+/-24.5%) (P < 0.05). Absolute risk reduction was 14% (95% confidence interval (CI), -3.77 to 26.56); relative risk reduction was 24.9% (95% CI, -11.04 to 58.28); the number needed to treat was 8.77. Written instructions, in addition to verbal ones, significantly improve compliance with antibiotic treatment in tonsillitis of acute sore throat in comparison with verbal instructions only.

Lipopolysaccharide needs soluble CD14 to interact with TLR4 in human monocytes depleted of membrane CD14

Toll-like receptors recognize specific patterns of microbial components and regulate the activation of both innate and adaptive immunity. TLR4 recognizes lipopolysaccharide (LPS) in monocytes/macrophages with the help of other molecules like CD14 and MD-2, which indicates that the functional LPS receptor forms a large complex. The functional relationship between the components has been the subject of debate, as have the modifications induced by the ligand in the expression of some of these components. Moreover, as for other members of this family of receptors, the possible direct interaction of receptors and their ligands is a matter of discussion. In this paper we address the question of whether the expression of some of the components influences the expression of the rest. Human monocytes in which CD14 has been downregulated through interference in the turnover of the molecule at the Golgi level, show normal membrane TLR4 expression, when compared with control cells. On the other hand, LPS alters membrane TLR4 expression by monocytes devoid of membrane CD14 only in the presence of human serum. The effect of serum is blocked by anti-CD14 monoclonal antibodies, which strongly suggests a functional role for soluble CD14/LPS complexes in the interaction with TLR4. Our data add information on the relationship between the components of the LPS receptor and the characteristics of the interaction of LPS and TLR4 in cells devoid of membrane CD14.

Hydrochlorothiazide-induced acute non-cardiogenic pulmonary edema

We report the case of a 64 year-old male with non cardiogenic pulmonary edema episodes after oral administration of 12.5 mg of hydrochlorothiazide. In vitro immunologic study with basophil activation test and late cellular activation study (CD69 and production of interferon gamma) with chlorothiazide were performed, and no activation was observed. As a consequence, like in previous cases published, the pathogenic mechanism remains unknown, and it probably is an idiosyncratic reaction.

Role of surface States in scanning tunneling spectroscopy of (111) metal surfaces with Kondo adsorbates

A nearly free-electron model to describe scanning tunneling spectroscopy of (111) metal surfaces with Kondo impurities is presented. Surface states are found to play an important role giving a larger contribution to the conductance of Cu(111) and Au(111) than Ag(111) surfaces. The different line shapes observed when Co is adsorbed on the different substrates are mainly determined by the position of the surface band onset relative to the Fermi energy and the decay length of the surface state into the substrate. The lateral dependence of the line shape amplitude is found to be bulklike for R|| < or approximately 3-5 A and surfacelike at larger distances, in agreement with experimental data.

Anti-Inflammatory Cytokines Induce Lipopolysaccharide Tolerance in Human Monocytes Without Modifying Toll-Like Receptor 4 Membrane Expression

Toll-like receptor 4 (TLR4) participates in innate immunity by detecting lipopolysaccharides (LPS) of Gram-negative bacterial cell walls. TLR4 macrophage expression in mice is modulated by LPS. This fact constitutes, at least partially, the molecular basis for LPS tolerance. Very recently, the effect of interferon-gamma (IFN-gamma), a pro-inflammatory cytokine, has been described on TLR4 membrane expression of human monocytes. IFN-gamma up-regulates TLR4 expression and antagonizes the LPS-induced TLR4 down-regulation. These data prompted us to study the expression of membrane TLR4 in human mono- cytes in which LPS tolerance was induced by LPS and by anti-inflammatory cytokines [interleukin-10 (IL-10) and transforming growth factor beta1 (TGFbeta1)]. Data concerning this latter model, and more specifically, the effect of anti-inflammatory cytokines over TLR4 expression, are not available at present. We show here that membrane TLR4 expression in human monocytes falls after LPS exposure. The effect was prolonged for 12 h, but then expression returned to normal levels. The incubation of human monocytes with IL-10, TGFbeta1 or a mixture of both induces no alterations in membrane TLR4 expression. However, these cytokines are able to substitute the tolerizing LPS exposure in order to induce LPS tolerance. Our data help to achieve a better understanding of the way cytokines control the cellular expression of TLR.

Proximity of the layered organic conductors alpha-(BEDT-TTF)2MHg(SCN)4 (M = K, NH4) to a charge-ordering transition

While the optical properties of the superconducting salt alpha-(BEDT-TTF)(2)-NH4Hg(SCN)(4) remain metallic down to 2 K, in the nonsuperconducting K analog a pseudogap develops at frequencies of about 200 cm(-1) for temperatures T<200 K. We show that the optical conductivity calculated with exact-diagonalization techniques on an extended Hubbard model at quarter filling is consistent with the observed low-frequency feature. We argue that the different optical responses observed are a consequence of the proximity of these compounds to a charge-ordering transition driven by the intermolecular Coulomb repulsion.

Clinical study of an outbreak of Legionnaire's disease in Alcoy, Southeastern Spain

The aim of this study was to identify the clinical features of Legionnaires' disease, sudden outbreaks of which demand a quick and flexible clinical approach, particularly with regard to diagnosis and therapy. A prospective and comparative study based on a clinical protocol was performed during an outbreak of Legionnaires' disease in Alcoy, Spain. The outbreak was environmental in origin, linked to cooling towers. Data about epidemiological and clinical features, blood chemistry values, radiological and microbiological findings, and characteristics related to the clinical course of Legionnaires' disease were obtained for 357 patients admitted to hospital with community-acquired pneumonia (177 with Legionella pneumonia). Patients with Legionnaires' disease were younger (mean age, 65.3+/-16.5 years) and more likely to be smokers compared with patients with other types of pneumonia (28.8% vs. 11.1%; P<0.01). Moreover, they had not been admitted to any hospital because of pneumonia in the previous year. Patients with Legionnaires' disease had higher fever, more severe headache, and less expectoration as well as lower sodium blood levels (mean, 132.6+/-4.8 mmol/l vs. 135.7 mmol/l; P<0.01). Radiological studies also showed that fewer patients with Legionnaires' disease had pleural effusion (9% vs. 19.4% of those with non- Legionella pneumonia). The presence of headache, high fever, hyponatremia, scanty or null expectoration, and current cigarette smoking provides physicians with important clues for a high suspicion of Legionella pneumonia before the results of confirmatory laboratory tests are available.

Superconductivity mediated by charge fluctuations in layered molecular crystals

We consider the competition between superconducting, charge ordered, and metallic phases in layered molecular crystals with the theta and beta(") structures. Applying slave-boson theory to the relevant extended Hubbard model, we show that the superconductivity is mediated by charge fluctuations and the Cooper pairs have d(xy) symmetry. This is in contrast to the kappa-(BEDT-TTF)(2)X family, for which theoretical calculations give superconductivity mediated by spin fluctuations and with d(x(2)-y(2)) symmetry. We predict several materials that should become superconducting under pressure.