[Respiratory and physical recovery in cervical spinal cord injury. Seventeen years' experience in a weaning and rehabilitation center: An observational study]

INTRODUCTION AND OBJECTIVES

Spinal cord injury (SCI) is a devastating entity that generates substantial disability. The outcome of respiratory and motor features has an impact in human and social well-being. We analyzed demographic characteristics, motor and respiratory outcomes, and determined equipment needs at discharge in a weaning and rehabilitation center.

MATERIAL AND METHOD

Observational, descriptive and retrospective study of medical records between January 2002 and December 2018. Tracheostomised cervical SCI patients with invasive mechanical ventilation were included. Forced vital capacity (upright and supine), maximal inspiratory and expiratory pressures, ASIA and Spinal Cord Independence MeasureIII (SCIMIII) were obtained.

RESULTS

Of 1603 patients, 3.5% had SCI, and 28 met the inclusion criteria. The most frequent level of injury was C4-C5 (17/28), 21/28 had ASIAA classification, and 19 showed no change in either the ASIA or the SCIM score. In all, 22/28 patients were weaned, while 15/28 were decannulated. Twenty four patients were discharged to home. The most relevant change in SCIMIII was in the 5th component of respiration and sphincter subscale, related to weaning and tracheostomy. At discharge, 23/24 patients needed both respiratory and motor aids.

CONCLUSIONS

The admission rate of SCI patients was low in our weaning and rehabilitation center, with almost all being admitted for traumatic causes. Severity remained unchanged in most ASIAA patients. Respiratory recovery was more clinically significant than recovery of motor function. Upon discharge, most of our patients had to be equipped with both respiratory and motor aids.

Spanish-dementia knowledge assessment scale (DKAS-S): psychometric properties and validation

BACKGROUND

Alzheimer's disease (AD) is the most frequent cause of cognitive impairment. Community knowledge of the disease has proven to be a very important aspect of the development of interventions and the evaluation of their effectiveness. However, it is necessary to have standardized and recognized tools in different languages. The aim of the current study was to develop a cross-cultural adaptation of the Spanish Dementia Knowledge Assessment Scale (DKAS-S) and to assess their psychometric properties with cohorts of health students and professional and non-professional caregivers of AD patients from several regions of Spain.

METHODS

We developed and translated the DKAS into Spanish following the forward-back-forward translation procedure. Then, we performed a cross-sectional study to assess the validity, reliability and feasibility of the DKAS-S. We also performed an analysis to obtain test-retest reliability measures. The study was performed in four medical centres across three regions in Spain. From May to September 2019, we administered the scale to students, professional and non-professional caregivers; including a subgroup of non-professional caregivers of patients with early-onset AD (< 65 years).

RESULTS

Eight hundred forty-six volunteer participants completed the DKAS-S: 233 students (mean age 26.3 ± 9.2 years), 270 professional caregivers (mean age 42.5 ± 11.7 years) and 343 non-professional caregivers of AD patients. (mean age was 56.4 ± 13.16). The DKAS-S showed good internal consistency (Cronbach's α = 0.819) and good test-retest reliability (time 1: 28.1 ± 8.09 vs time 2: 28.8 ± 7.96; t = - 1.379; p = 0.173). Sensitivity to change was also significant in a subgroup of 31 students who received education related to AD and dementias between each administration (time 1: 25.6 ± 6.03) to (time 2: 32.5 ± 7.12; t = - 5.252, p = 0.000). The validity of the construct was verified by confirmatory factor analysis, although there were challenges in the inclusion of some items in the original 4 factors.

CONCLUSIONS

The 25-item DKAS-S showed good psychometric properties for validity and reliability and the factorial analysis when it was administered to a population of students and professional and non-professional caregivers. It was a useful instrument for measuring levels of knowledge about dementia in Spanish population.

Recommendations on multidisciplinary management of elective surgery in people with haemophilia

Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.

Respiratory muscle strength and state of consciousness values measured prior to the decannulation in different levels of complexity. A longitudinal prospective case series study

OBJECTIVE

To describe the variables related to effective cough capacity and the state of consciousness measured prior to decannulation and compare their measured values between the different areas of care such as the Intensive Care Unit (ICU), General ward and Mechanical Ventilation Weaning and Rehabilitation Centers (MVWRC). Secondarily analyze the evolution of patients once decannulated.

DESIGN

Case series, longitudinal and prospective.

SCOPE

Multicentric 31 ICUs (polyvalent) and 5 MVWRC.

PATIENTS

Tracheostomized adults prior to decannulation.

MEASUREMENTS

Maximum expiratory pressure, peak expiratory flow coughed (PEFC), Glasgow Coma Scale (GCS).

RESULTS

Two hundred and seven decannulated patients, 124 (60%) in ICU, 59 (28%) General ward and 24 (12%) in MVWRC. The PEFC presented differences between the patients (ICU 110 - 190 l/min versus MVWRC 167.5 - 232.5 l/min, p <.01). The GCS was different between General ward (9 -15) versus ICU (10-15) and MVWRC (12-15); p <.01 and p <.01, respectively. There were differences in the days of hospitalization (p <.01), days with tracheostomy (<0.01) and the number of patients referred at home (p =.02) between the different scenarios.

CONCLUSION

There are differences in the values of PEFC and GCS observed when decannulating between different areas. A considerable number of patients are decannulated with values of PEFC and maximum expiratory pressure below the suggested cut-off points as predictors of failure in the literature. No patient in our series was decanulated with an GCS <8, this reflects the importance that the treating team gives to the state of consciousness prior to decannulation.

Fluctuations of the anthropometric indices and mortality of patients with incident heart failure: a prospective study in the community

BACKGROUND

The relationship between the fluctuations of the anthropometric indices (AIs) and the prognosis of patients with incident heart failure (HF) in a population-based cohort is unknown.

AIMS

To assess the relationship between the fluctuations of the AIs, body mass index (BMI), waist hip ratio (WHR), and weight height ratio (WHeR) and the prognosis of patients with incident HF.

METHODS

Anthropometric indices were prospectively measured in a 10-year population-based study of 6492 patients with incident HF (GAMIC cohort). 4530 patients (66.7%) died, during a mean follow-up of 72.7 ± 14.2 months. A time-updated analysis of the changes of the AIs was performed to assess their association with mortality and morbidity (hospitalisations and visits).

RESULTS

Patients with incident HF presenting ≥ 5% decrease or ≥ 7% increase of the AIs have an increased mortality [HR ≥ 1.65 (1.52-2.34) or HR ≥ 1.71 (1.58-1.85), respectively, p < 0.001]. Mortality risk increased ≥ 1.43-fold (p = -0.0003) for each 10% change in the AIs. There was an accelerated pattern of reduction in the AIs in the 6 months prior to death, and an accelerated increase in the AIs in the 3 months prior to hospitalisation. These observations were independent of the aetiology (ischaemic vs. non-ischaemic), the type of HF (systolic vs. non-systolic), and other predictors of mortality.

CONCLUSIONS

Time-updated changes (increase or decrease) of the AIs, BMI, WHR and weight height ratio are independently associated with the mortality of patients with incident HF.

[Decrease in hospitalizations due to polyvalent medical day hospital]

INTRODUCTION

The day hospital is an alternative to hospitalization. This alternative improves accessibility and comfort of the patients, and avoids hospitalizations. Nevertheless, the efficacy of the polyvalent medical day hospital in avoiding hospitalizations has not been evaluated.

OBJECTIVE

To analyze hospital stays avoided by the polyvalent medical day hospital of a university hospital of the Andalusian Health Service.

METHODS

An observational prospective study of the patients studied and/or treated in the polyvalent medical day hospital of the Hospital Universitario Puerto Real over a one year period.

RESULTS

A total of 9640 patients were attended to, with 1413 procedures and 4921 i.v. treatments. There were 3182 visits to the priority consultation of the polyvalent medical day hospital. The most frequent consultation complaints were constitutional symptoms (15.9%) and anemia (14.5%). After the first visit, 21.5% of the patients were discharged and fewer than 3% were hospitalized. Hospitalization was avoided in 16.8% of the patients, there being a 6.0% decrease in the need for hospital beds (5.0% reduction in the internal medicine unit). Inadequate hospitalizations and 30-day readmissions decreased 93.3% and 4.2%, respectively. The most frequent diagnosis was neoplasm (26.0%), and most of the beds freed up were generated by patients diagnosed of neoplasm (26.7%).

CONCLUSION

With this type of polyvalent medical day hospital, we have observed improved efficiency of health care, freeing up hospital beds by reducing hospitalizations, inadequate hospitalizations and re-admissions in the medical units involved.

Mortality and morbidity of heart failure treated with digoxin. A propensity-matched study

BACKGROUND

The role of digoxin in the prognosis of patients with heart failure (HF) remains unclear.

AIMS

To evaluate the relationship of commencing treatment with digoxin (CTDig) with the mortality and the morbidity of patients with HF.

METHODS

Prospective study over 8 years on 4467 patients with HF. Main outcomes were all-cause and cardiovascular mortality, hospitalisations and visits. We analyse the independent relationship of CTDig, with the mortality and the morbidity, stratifying patients for cardiovascular comorbidity, after propensity score-matching for potential confounders (1421 patients who CTDig vs. another 1421 patients non-exposed to digoxin).

RESULTS

During a median follow up of 46.1 months, 1872 patients (65.9%) died, and 2203 (77.5%) were hospitalised. CTDig was associated with a lower all-cause mortality (HR = 0.90 [95% CI, 0.84-0.97]), and cardiovascular mortality (HR = 0.87 [0.81-0.96]), hospitalisation (HR = 0.91 [0.86-0.97]), 30-day readmission for HF (HR = 0.88 [0.79-0.95]), and visits (HR = 0.94 [0.90-0.98]) (p < 0.001 in all cases), after adjustment for the propensity to take digoxin, other medications, and other potential confounders. These effects of digoxin were independent of gender, or type of HF (systolic or non-systolic).

CONCLUSION

The data suggest that therapy with digoxin is associated with an improved mortality and morbidity of HF, including women and patients with non-systolic HF.

Utilization patterns and associated costs of factor assistance programmes among persons with haemophilia: a single institution review

Although individuals with haemophilia have benefited from advances and the availability of safe, effective factor replacement products, high treatment costs and insurance coverage limits remains a significant concern among persons with this disease. Many uninsured haemophiliacs turn to emergency rooms for treatment and/or patient assistance programmes for treatment of a bleed or injury. However, neither of these options is a sustainable solution for managing the care of patients with this costly disease. This study was conducted to examine the use of factor assistance programmes and estimate annual amounts of factor dispensed by each programme along with their associated costs. Retrospective review of pharmacy and medical record of all patients who attended the Gulf States Hemophilia and Thrombophilia Center, and who were enrolled in any factor assistance programme(s) between January 2007 and December 2010 was performed. During the 4-year observation period, approximately 19% of the centre's haemophilia patient population was enrolled and received free factor products from at least one patient assistance programme. In addition, approximately 9.1 million dollars (US) worth of factor replacement therapy was donated to our patients during the study time. Although assistance programmes have helped many uninsured individuals with haemophilia to receive free factor products, they are not an enduring answer to the insurance problems many of our patients face. More effort needs to be focused on how to effectively manage uninsured persons with haemophilia to ensure that their health care and treatment needs are adequately met.

Management of difficult-to-treat inhibitor patients

The workshop looked at seven scenarios based on fictional and real-life cases of difficult-to-treat patients with haemophilia A or haemophilia B and inhibitors with the aim of sharing clinical opinion and experience from around the world. Delegate opinions on the best treatment option for each scenario are described together with actual treatment given in real-life cases and its outcome.

In non-severe hemophilia A the risk of inhibitor after intensive factor treatment is greater in older patients: a case-control study

BACKGROUND

 Twenty-five percent of new anti-factor VIII (FVIII) antibodies (inhibitors) that complicate hemophilia A occur in those with mild and moderate disease. Although intensive FVIII treatment has long been considered a risk factor for inhibitor development in those with non-severe disease, its strength of association and the influence of other factors have remained undefined.

OBJECTIVE

 To evaluate risk factors for inhibitor development in patients with non-severe hemophilia A.

METHODS

 Information on clinical and demographic variables and FVIII genotype was collected on 36 subjects with mild or moderate hemophilia A and an inhibitor and 62 controls also with mild or moderate hemophilia A but without an inhibitor.

RESULTS

 Treatment with FVIII for six or more consecutive days during the prior year was more strongly associated with inhibitor development in those ≥30years of age compared with those <30years of age [adjusted odds ratio (OR) 12.62; 95% confidence interval (CI), 2.76-57.81 vs. OR 2.54; 95% CI, 0.61-10.68]. Having previously received <50days of FVIII was also not statistically associated with inhibitor development on univariate or multivariate analysis.

CONCLUSIONS

 These findings suggest that inhibitor development in mild and moderate hemophilia A varies with age, but does not vary significantly with lifetime FVIII exposure days: two features distinct from severe hemophilia A.

Thrombin generation and fibrinolysis in anti-factor IX treated blood and plasma spiked with factor VIII inhibitor bypassing activity or recombinant factor VIIa

Activated prothrombin complex concentrates (aPCC) and recombinant activated factor VIIa (rFVIIa) are two important therapies in haemophilia patients with inhibitors and improve clot stability. We hypothesized that potential differences in procoagulant and fibrinolytic actions of aPCC and rFVIIa may lie in the clot stability against fibrinolytic activation. We used thrombin generation, fluorescence detection and thromboelastometry in anti-factor IXa (FIXa) aptamer-treated whole blood (WB) and plasma to evaluate: (i) generation of thrombin and activated factor X (FXa) and (ii) viscoelastic properties of blood clots in the presence of tissue plasminogen activator (tPA) after addition of aPCC (0.4 U mL(-1)) or rFVIIa (60 nm). Peak thrombin generation increased from 85 +/- 19 nm in aptamer-treated plasma to 276 +/- 83 nm and 119 +/- 22 nm after addition of aPCC and rFVIIa respectively (P < 0.001). FXa activity increased within 20 min by 87 +/- 6% and by 660 +/- 97% after addition of aPCC and rFVIIa respectively (P < 0.001). TPA-induced lysis time increased from 458 +/- 378 s in aptamer-treated WB to 1597 +/- 366 s (P = 0.001) and 1132 +/- 214 s (P = 0.075), after addition of aPCC and rFVIIa respectively. In this haemophilia model using the anti-FIXa aptamer, the larger amount of thrombin was generated with aPCC compared with rFVIIa, while FXa generation was more rapidly increased in the presence of rFVIIa. Furthermore, clot formation in anti-FIXa aptamer-treated WB was less susceptible to tPA-induced fibrinolysis after adding aPCC compared with rFVIIa.

Treatment on demand--in vivo dose finding studies

Since the discovery of replacement therapy the goal of treatment for haemophilia patients has always been the prevention of haemorrhagic episodes. However, the "ideal"" plasma level needed to prevent hemathrosis or treat haemorrhages is still unknown. It seems that the doses of treatment have been arrived at by trial and error based in the pharmacokinetics of the factors and the characteristics of the replacement product. This review provides some guidelines for the treatment of haemophilia, however the doses are not based in randomized trials.

Characterization of oncogene-silenced transgenic plants: implications for Agrobacterium biology and post-transcriptional gene silencing

SUMMARY Agrobacterium tumefaciens tumorigenesis is initiated by the horizontal transfer of a suite of oncogenes that alter hormone synthesis and sensitivity in infected plant cells. Transgenic plants silenced for the iaaM and ipt oncogenes are highly recalcitrant to tumorigenesis, and present a unique resource to elucidate fundamental questions related to Agrobacterium biology and post-transcriptional gene silencing (PTGS). The oncogene-silenced transgenic tomato line 01/6 was used to characterize A. tumefaciens growth in planta and to screen for iaaM and ipt sequence variants. Even in the absence of macroscopic and microscopic indications of tumorigenesis, A. tumefaciens is capable of long-term survival in the hypocotyl tissues of the 01/6 line. A. tumefaciens growth, however, is significantly reduced in the 01/6 line, with populations decreased by 96% relative to wild-type at 52 days post-inoculation. In addition, the 01/6 line displayed suppression of tumorigenesis against all 35 tested strains of A. tumefaciens. High target homology is an absolute requirement of PTGS, therefore this result suggests that regions of the iaaM and ipt oncogenes are very highly conserved across most A. tumefaciens strains. Finally, graft transmissibility of oncogene silencing was assessed by grafting various non-silenced tomato genotypes on to the 01/6 line. Phenotypic and molecular evidence (tumorigenesis and absence of small interfering RNAs, respectively) suggest that oncogene silencing is not graft-transmissible, at least to wild-type and antisense iaaM-over-expressing genotypes.

RNAi-mediated oncogene silencing confers resistance to crown gall tumorigenesis

Crown gall disease, caused by the soil bacterium Agrobacterium tumefaciens, results in significant economic losses in perennial crops worldwide. A. tumefaciens is one of the few organisms with a well characterized horizontal gene transfer system, possessing a suite of oncogenes that, when integrated into the plant genome, orchestrate de novo auxin and cytokinin biosynthesis to generate tumors. Specifically, the iaaM and ipt oncogenes, which show approximately 90% DNA sequence identity across studied A. tumefaciens strains, are required for tumor formation. By expressing two self-complementary RNA constructions designed to initiate RNA interference (RNAi) of iaaM and ipt, we generated transgenic Arabidopsis thaliana and Lycopersicon esculentum plants that are highly resistant to crown gall disease development. In in vitro root inoculation bioassays with two biovar I strains of A. tumefaciens, transgenic Arabidopsis lines averaged 0.0-1.5% tumorigenesis, whereas wild-type controls averaged 97.5% tumorigenesis. Similarly, several transformed tomato lines that were challenged by stem inoculation with three biovar I strains, one biovar II strain, and one biovar III strain of A. tumefaciens displayed between 0.0% and 24.2% tumorigenesis, whereas controls averaged 100% tumorigenesis. This mechanism of resistance, which is based on mRNA sequence homology rather than the highly specific receptor-ligand binding interactions characteristic of traditional plant resistance genes, should be highly durable. If successful and durable under field conditions, RNAi-mediated oncogene silencing may find broad applicability in the improvement of tree crop and ornamental rootstocks.

[The debate on the organization, functions and efficiency of nursing in primary care: apropos of a qualitative study]

OBJECTIVE

To show the opinions that doctors and nurses express on the organisation and competences of primary care nursing, and on inter-professional relations.

DESIGN

Qualitative research study based on the group discussion technique known as Philips 66.

SETTING AND PARTICIPANTS

Three discussion groups, one of nurses, one of doctors and a third mixed, with 6 components each, half from Cáceres and the rest from other provinces, and all involved in primary care health delivery.

MEASUREMENTS AND MAIN RESULTS

In the discussions, the three groups coincided in the importance given to nursing clinics and home visits, in the organisational advantages that the attachment as a norm of the population to a nursing clinic would bring, in the ability of nurses to perform the techniques they have habitually used, and in defence of one sole clinical record per patient. They blamed each other mutually for making few home visits. Doctors attributed to nurses under-use of records and nurses alleged doctors took no notice of their notes. On the question of their relations, doctors thought that nurses did not take on joint responsibility for the work-loads in health centres; and nurses thought that doctors did not wish to share tasks, but rather delegate or order them.

CONCLUSIONS

The attachment of the population to nursing clinics would favour the extension of care, the commitment to the population and the real delivery of services, as well as professional autonomy and recognition.

Renal cell carcinoma

Renal cell carcinoma (RCC) continues to be a frustrating tumor for clinicians to manage and treat. Progress has been made in the identification of risk factors, particularly dietary risk factors. An increased risk has been seen with frequent consumption of fried meat and poultry. Citrus fruits, vitamin C, beta-carotene, and alpha-tocopherol have demonstrated a protective effect against RCC. Other factors that have been associated with the risk of RCC are smoking (which doubles the risk), obesity, hypertension, and exposure to asbestos and petroleum products. Response rates for systemic treatment of RCC continue to hover at about 20%; however, some nonchemotherapy treatments may provide palliation with few side effects. In addition, lower dose combinations of interleukin-2 and interferon alfa may be as beneficial as higher dose regimens, but with less toxicity. Molecular prognostic factors, including proliferation markers, karyometric analyses, oncogenes, and cell adhesion molecules and proteases are areas of intense investigation and may provide mechanisms for identifying patients who require more (or less) aggressive treatment.

Third-trimester maternal serum beta-HCG level and umbilical blood flow in fetal growth retardation

OBJECTIVE

To determine the relationship between maternal serum beta-HCG level and umbilical artery systolic/diastolic ratio in fetal growth retardation.

METHODS

Maternal serum beta-HCG was measured in 57 pregnant women in the third trimester, 31 with a fetal growth retardation and 26 with a normal growth. The systolic/diastolic ratio was measured in a midsection of the umbilical cord the same day of the biochemical determination.

RESULTS

The serum beta-HCG level was statistically significant higher in pregnant women with a fetal growth retardation associated with a high systolic/diastolic ratio (n = 9) (P < 0.001). There were no differences between the fetuses with a normal growth (n = 26) and those with an intrauterine growth retardation and a normal systolic/diastolic ratio (n = 22). There was a significant positive correlation between maternal serum beta-HCG level and umbilical artery systolic/diastolic ratio (P < 0.01).

CONCLUSION

Fetal growth retardation due to Doppler-defined vascular placental insufficiency is associated with a higher maternal serum beta-HCG level.

Haemoculture of Leishmania (Viannia) braziliensis from two cases of mucosal leishmaniasis: re-examination of haematogenous dissemination

Leishmania parasites were isolated from peripheral blood leucocytes of 2 patients with mucosal disease among a total of 23 parasitologically confirmed cases of leishmaniasis. One had had mucosal leishmaniasis for 4 years and active pulmonary tuberculosis was also diagnosed. The other patient presented a cutaneous lesion on his right leg of 3 months duration and asymptomatic mucosal involvement. He had received intravenous antimonials before isolation of parasites. Both patients had positive indirect fluorescent antibody and Montenegro skin tests. L. (Viannia) braziliensis was isolated from both patients. This culture of parasites from leucocytes provided direct evidence for metastatic spread of Leishmania via the blood.