Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Association between COVID-19 and outstanding academic performance at a Spanish university

BACKGROUND

SARS-CoV-2 is the causative agent of COVID-19 identified in December 2019, an acute infectious respiratory disease that can cause persistent neurological and musculoskeletal symptoms such as headache, fatigue, myalgias difficulty concentrating, among others including acute cerebrovascular disease with a prevalence of 1-35%. The aim of this study is to evaluate the impact of COVID-19 in undergraduate students on their academic performance as an indicator of their intellectual ability and performance in a university that maintained 100% face-to-face teaching during the 2020-2021 academic year.

METHODS

A total of 7,039 undergraduate students were analyzed in a prospective cohort study at the University of Navarra. A questionnaire including sociodemographic and behavioral questions was sent. PCRs were performed throughout the academic year for the diagnosis of SARS-CoV-2 infection and students' academic results were provided by the academic center, adjusted descriptive and multivariate models were performed to assess the association.

RESULTS

A total of 658 (9.3%) participants were diagnosed with COVID-19, almost 4.0% of them achieved outstanding academic results, while uninfected students did so in 7.3%. SARS-CoV-2 infection was associated with a significant decrease in having outstanding academic results (OR = 0.57; 95% CI: 0.38-0.86).

CONCLUSION

Having COVID-19 disease, decreased academic performance in undergraduate students. Therefore, it is necessary to prevent infection even in the youngest sections of the population.

Current practice of rapid sequence induction in adults: A national survey among anesthesiologists in Spain

BACKGROUND

Rapid sequence induction (RSI) in adults has undergone changes in recent years due to pharmacological and technological advances. The objective of this survey was to evaluate current practice among Spanish anesthesiologists.

METHODS

A 31-item questionnaire regarding RSI practice was sent to anesthesiologists working in Spanish public hospitals. Differences in responses according to the type of hospital or experience of the respondent were compared for all data using the chi-square and Fisher's exact test.

RESULTS

Approximately 15.89% of Spanish anesthesiologists participated in the survey (1002 questionnaires). The results show considerable heterogeneity in most aspects of RSI. Less than 20% of respondents administer sodium citrate. Sixty-four percent place a nasogastric tube in patients with intestinal obstruction. Gastric residue is assessed by ultrasound in 6% of cases. Only 25% of respondents measure ETO₂ to check the effectiveness of preoxygenation, and 22% use nasal oxygen insufflation with nasal prongs or THRIVE. Sixty two percent of respondents apply cricoid pressure, but only 50% release the pressure when encountering intubation difficulty. Up to 40% of respondents reported cases of aspiration despite applying cricoid pressure. Propofol was the most commonly used hypnotic (97.6%), but there was no clear preference in the choice of neuromuscular relaxant (suxamethonium versus rocuronium ratio of approximately 1:1). Only 44% of respondents calculated the dose of sugammadex that would be required for emergency reversal of rocuronium.

CONCLUSIONS

The survey showed significant variation in RSI practice, similar to that of other countries. Quality prospective studies are needed to standardize clinical practice.

Evaluation and management of chemotherapy-induced cardiotoxicity in breast cancer: a Delphi study

Purpose

While much progress has been made in the treatment of breast cancer, cardiac complications resulting from therapy remain a significant concern. Both anthracyclines and novel targeted agents can inflict cardiac damage. The present study aimed to evaluate the difference between what it is currently done and what standards of care should be used to minimizing and managing cardiac toxicity in breast cancer survivors.

Methods

A two-round multicenter Delphi study was carried out. The panel consisted of 100 oncologists who were asked to define the elected therapies for breast cancer patients, the clinical definition and patterns of cancer drug-derived cardiac toxicity, and those protocols focused on early detection and monitoring of cardiovascular outcomes.

Results

Experts agreed a more recent definition of cardiotoxicity. Around 38 % of patients with early-stage disease, and 51.3 % cases with advanced metastatic breast cancer had preexisting risk factors for cardiotoxicity. Among risk factors, cumulative dose of anthracycline ≥450 mg/m² and its combination with other anticancer drugs, and a preexisting cardiovascular disease were considered the best predictors of cardiotoxicity. Echocardiography and radionuclide ventriculography have been the proposed methods for monitoring changes in cardiac structure and function. Breast cancer is generally treated with anthracyclines (80 %), so that the panel strongly stated about the need to plan a strategy to managing cardiotoxicity. A decline of left ventricular ejection fraction (LVEF) >10 %, to an LVEF value <53 % was suggested as a criterion for changing the dose schedule of anthracyclines, or suspending the treatment of chemotherapy plus trastuzumab until the normalization of the left ventricular function. The use of liposomal anthracyclines was strongly suggested as a treatment option for breast cancer patients.

Conclusions

The present report is the first to produce a set of statements on the prevention, evaluation and monitoring of chemotherapy-induced cardiac toxicity in breast cancer patients.

Paradoxical Expectation: Oscillatory Brain Activity Reveals Social Interaction Impairment in Schizophrenia

BACKGROUND

People with schizophrenia show social impairments that are related to functional outcomes. We tested the hypothesis that social interaction impairments in people with schizophrenia are related to alterations in the predictions of others' behavior and explored their underlying neurobiological mechanisms.

METHODS

Electroencephalography was performed in 20 patients with schizophrenia and 25 well-matched control subjects. Participants played as proposers in the repeated version of the Ultimatum Game believing that they were playing with another human or with a computer. The power of oscillatory brain activity was obtained by means of the wavelet transform. We performed a trial-by-trial correlation between the oscillatory activity and the risk of the offer.

RESULTS

Control subjects adapted their offers when playing with computers and tended to maintain their offers when playing with humans, as such revealing learning and bargaining strategies, respectively. People with schizophrenia presented the opposite pattern of behavior in both games. During the anticipation of others' responses, the power of alpha oscillations correlated with the risk of the offers made, in a different way in both games. Patients with schizophrenia presented a greater correlation in computer games than in human games; control subjects showed the opposite pattern. The alpha activity correlated with positive symptoms.

CONCLUSIONS

Our results reveal an alteration in social interaction in patients with schizophrenia that is related to oscillatory brain activity, suggesting maladjustment of expectation when patients face social and nonsocial agents. This alteration is related to psychotic symptoms and could guide further therapies for improving social functioning in patients with schizophrenia.

[Blind tracheal intubation through two supraglottic devices: i-gel versus Fastrach intubating laryngeal mask airway (ILMA)]

BACKGROUND AND OBJECTIVES

The use of supraglottic devices as a means of rescue in patients difficult to intubate or ventilate has increased in the field of anaesthetics and in emergency medicine. This study is designed to evaluate the success rate of blind intubations using two supraglottic devices, the Fastrach ILMA and the i-gel mask.

PATIENTS AND METHODS

A total of 80 patients (40 per group) were included. After positioning them a leak test was performed, the glottis view was checked with a fibrobronchoscope, and an attempt was made to introduce an endotracheal tube through the device, and the procedure was repeated. Adequate ventilation was evaluated, as well as the grade of fibrobronchoscope view, the success of the intubation, and the complications observed after their use.

RESULTS

There were no differences in the incidence of adequate ventilation with either device. The glottis view (Brimacombe scale) was better with i-gel (77.78% versus 68.42%) at the second attempt, but not on the first. A higher percentage of intubations were achieved with the Fastrach ILMA (70% versus 40%; P=.013). The incidence of throat pain was similar with both devices, but post-operative dysphonia was more frequent with i-gel (20% versus 0; P=.0053).

CONCLUSIONS

Both devices were equally effective in achieving adequate ventilation; however, the Fastrach ILMA enabled a higher number of intubations to be made than i-gel and with a lower incidence of post-operative dysphonia.

Someone has to give in: theta oscillations correlate with adaptive behavior in social bargaining

During social bargain, one has to both figure out the others' intentions and behave strategically in such a way that the others' behaviors will be consistent with one's expectations. To understand the neurobiological mechanisms underlying these behaviors, we used electroencephalography while subjects played as proposers in a repeated ultimatum game. We found that subjects adapted their offers to obtain more acceptances in the last round and that this adaptation correlated negatively with prefrontal theta oscillations. People with higher prefrontal theta activity related to a rejection did not adapt their offers along the game to maximize their earning. Moreover, between-subject variation in posterior theta oscillations correlated positively with how individual theta activity influenced the change of offer after a rejection, reflecting a process of behavioral adaptation to the others' demands. Interestingly, people adapted better their offers when they knew that they where playing against a computer, although the behavioral adaptation did not correlate with prefrontal theta oscillation. Behavioral changes between human and computer games correlated with prefrontal theta activity, suggesting that low adaptation in human games could be a strategy. Taken together, these results provide evidence for specific roles of prefrontal and posterior theta oscillations in social bargaining.

Stability of hepatoprotecting agent IFC-305 encapsulated into sol-gel titania nanoparticles and drug release evaluation: water and drug concentration effect

IFC-305 was encapsulated into nanostructured titania and functionalized with OH groups by the sol-gel process using titanium n-butoxide, to be used in a drug delivery system for the treatment of liver cancer. Synthesis was carried out at different molar hydrolysis ratios: 4, 8, 16 and 24 mol of water; and drug concentration of 10, 20 and 30%. Characterization of IFC-titania reservoirs was carried out by Fourier transformed infrared spectroscopy (FTIR), X-ray diffraction (XRD), thermal analysis (DTA-TGA), scanning electron microscopy (SEM), and N2 adsorption-desorption isotherms (BET), confirms that IFC-305 is entrapped and stabilized in the TiO2-OH matrix. Drug liberation in vitro was determined by UV spectrometry over a period of 1000 h. This study demonstrated that the higher water content and the higher amount of loaded IFC, favored hydrogen bonding between titania-OH surface and IFC-NH groups, increasing the rate of drug release.

On the antioxidant properties of kynurenic acid: free radical scavenging activity and inhibition of oxidative stress

Kynurenic acid (KYNA) is an endogenous metabolite of the kynurenine pathway for tryptophan degradation and an antagonist of both N-methyl-D-aspartate (NMDA) and alpha-7 nicotinic acetylcholine (α7nACh) receptors. KYNA has also been shown to scavenge hydroxyl radicals (OH) under controlled conditions of free radical production. In this work we evaluated the ability of KYNA to scavenge superoxide anion (O(2)(-)) and peroxynitrite (ONOO(-)). The scavenging ability of KYNA (expressed as IC(50) values) was as follows: OH=O(2)(-)>ONOO(-). In parallel, the antiperoxidative and scavenging capacities of KYNA (0-150 μM) were tested in cerebellum and forebrain homogenates exposed to 5 μM FeSO(4) and 2.5 mM 3-nitropropionic acid (3-NPA). Both FeSO(4) and 3-NPA increased lipid peroxidation (LP) and ROS formation in a significant manner in these preparations, whereas KYNA significantly reduced these markers. Reactive oxygen species (ROS) formation were determined in the presence of FeSO(4) and/or KYNA (0-100 μM), both at intra and extracellular levels. An increase in ROS formation was induced by FeSO(4) in forebrain and cerebellum in a time-dependent manner, and KYNA reduced this effect in a concentration-dependent manner. To further know whether the effect of KYNA on oxidative stress is independent of NMDA and nicotinic receptors, we also tested KYNA (0-100 μM) in a biological preparation free of these receptors - defolliculated Xenopus laevis oocytes - incubated with FeSO(4) for 1 h. A 3-fold increase in LP and a 2-fold increase in ROS formation were seen after exposure to FeSO(4), whereas KYNA attenuated these effects in a concentration-dependent manner. In addition, the in vivo formation of OH evoked by an acute infusion of FeSO(4) (100 μM) in the rat striatum was estimated by microdialysis and challenged by a topic infusion of KYNA (1 μM). FeSO(4) increased the striatal OH production, while KYNA mitigated this effect. Altogether, these data strongly suggest that KYNA, in addition to be a well-known antagonist acting on nicotinic and NMDA receptors, can be considered as a potential endogenous antioxidant.

Comparison of nanostructured titania matrices obtained by carbon template and sol-gel methods for controlled release of fluoxetine

Two types of titania matrix were investigated as a support for the prolonged drug delivery of the antidepressant fluoxetine. Sample MT was synthesized using carbon template and consisted of titania microtubes on which then fluoxetine was adsorbed. Sample SG was synthesized by the sol-gel method when the drug was added during the reaction. The morphology of the powder surfaces was found to be different: nanotubes versus almost spherical particles with much larger surface area of SG and smaller pores. The relative degrees of hydroxyl coverage of the surface were studied by FTIR-spectroscopy and were found to be much larger for the sol-gel complex. Theoretical modeling was applied to consider possible interactions between the drug and the matrices. The liberation of the drug was proved to be faster from complex MT and was attributed to weaker drug-matrix interactions in combination with larger pore size.

Influence of water/alkoxide ratio in the synthesis of nanosized sol-gel titania on the release of phenytoin

The sol-gel method was used to synthesize inorganic reservoirs with encapsulated antiepileptic drug phenytoin. The drug release profile was shown to depend on the morphology and surface properties of the matrix. A parameter of the synthesis such as water/alkoxide ratio r(w) was varied in order to investigate its influence on the matrix properties and as a result on the drug release profile. It was found that the specific surface area and crystallization degree decrease with an increase of r(w), whereas the hydroxyl group coverage increases with an increase of r(w). Drug release kinetics studies revealed that the initial release rate increases with an increase of water content in the reaction, whereas the long time release rate first slightly increases with an increase of water content from 4 to 8 and then decreases for r(w) = 16. The interplay of different parameters of the matrix is shown to be responsible for such a dependence and is discussed in the Article.

TiO2 Nanophases Formed Using the Sol-Gel Technique

We have prepared nanoparticles of titania using the sol-gel technique. The samples were characterized by FTIR, DTA, TGA, EPR and XRD. The properties observed with these techniques are correlated in the temperature region between 200 and 800°C. The Ti-OH bonds are basic to interpret this correlation.

Photocatalytic degradation of 2,4-dichlorophenoxyacetic acid over ZrO2, Cu/ZrO2 and Fe/ZrO2 photocatalysts synthesized by sol gel method

Photocatalytic oxidation of 2,4-dichlorophenoxyacetic acid was performed over ZrO2, Cu/ZrO2 and Fe/ZrO2 catalysts prepared by the sol-gel method. The samples were annealed at 400 degrees C. Textural and electronic characterization was carried out using BET and UV-Vis in order to establish the relationship between surface, pore volume and E(g) with the photoactivity of the materials. The degradation of the acid was followed by UV-Vis spectroscopy. The disappearance of the herbicide in solution follows approximately pseudo-first order kinetics. The apparent rate constants were calculated for the three catalysts. The results reveal that Fe/ZrO2 exhibits the best photoactivity for the degradation of 2,4-dichlorophenoxyacetic acid.

X-ray diffraction, and Raman scattering study of nanostructured ZrO2-TiO2 oxides prepared by sol-gel

In the present work, we study the phase composition of ZrO2-TiO2 system by means of XRD and Raman spectroscopy, using also TG-ATD, and N2 adsorption isotherms as complementary characterization techniques. TiO2-ZrO2 samples of selected compositions (0, 10, 90, 50 and 100% in weight of TiO2) were prepared by sol-gel method and annealed at three different temperatures (400, 600 and 800 degrees C). Structural characterization reveals that only the pure oxides are crystalline at 400 degrees C: TiO2 as anatasa with a minor brookite component, and ZrO2 as a mixture of tetragonal (majority) and monoclinic phases. Following the 600 degrees C calcination, the TiO2-ZrO2 50-50% sample forms the ZrTiO4 mixed oxide, although this materials remains partly amorphous. In contrast, samples with higher and lower TiO2 content form solid solutions with, respectively, anatasa and tetragonal ZrO2 structures. Zirconium incorporation into the TiO2 lattice leads to the expansion of the unit cell parameters, and it stabilizes the anatase phase, hindering its transformation into rutile. Similarly, dissolving titanium atoms into the ZrO2 structure delays the transformation from the tetragonal to the monoclinic polymorph.

Pt/TiO2 brain biocompatible nanoparticles: GBM treatment using the C6 model in Wistar rats

In the present work we synthesized inorganic oxide nanoparticle carriers of platinum compounds and tested their therapeutic effect on animal models in which C6 glioma cells have been inoculated. TiO(2)-containing Pt(NH(3))(4)Cl(2) complexes were synthesized using sol-gel methods. The platinum species are chemically bonded to the TiO(2) carrier, as shown by Fourier transform infrared spectroscopy of probe molecules. Treatment with TiO(2)-Pt nanoparticles reduces tumour growth rate by up to 56%, showing that a synergistic effect exists between the TiO(2) carrier and the platinum drug.

Hospitalised osteoporotic vertebral fractures in Spain: analysis of the national hospital discharge registry

This population-based study reveals clinical and epidemiologic characteristics of hospitalised osteoporosis-related vertebral fractures and indicates an association with a substantial hospital burden in Spain. These data provide a basis for assessing the impact of these fractures on the Spanish health-care system and to estimate future care requirements.

INTRODUCTION

Vertebral fractures (VF) are recognised as the most frequent complication of osteoporosis. Our objective was to determine the clinico-epidemiological characteristics and health-care burden of hospitalised VF in Spain.

METHOD

From the 2002 National Hospital Discharge Register, records for all osteoporosis-related VF in the Spanish population aged >or=30 years and over were retrieved. Diagnostic categories included the ICD-9-CM codes 805 and 733.xx. Population data were drawn from the National Statistics Institute.

RESULTS

In total, 7,100 records were eligible for analysis. According to Deyo-adapted Charlson index, 62% of cases had no associated comorbidity. VF were the cause of hospitalisation in 52% of cases. Overall in-hospital mortality was 3.5%. Men had higher adjusted mortality than women. Mean hospital stay was 11.4+/-0.2 days. Identified cases amounted to a hospitalisation rate of 2.76 cases per 10,000 population aged >or=30 years. Direct inpatient hospital costs exceeded 41 million euros and accounted for 0.078% of Spanish expenditure on hospitalisations and specialised care in 2002.

CONCLUSIONS

The national discharge database reveals epidemiological features of hospitalised osteoporosis-attributable VF and indicates an association with a substantial hospital burden in Spain. Our data provide a basis for assessing the impact of these fractures on the Spanish health-care system and to estimate future care requirements.

[Secondary amyloidosis (AA-type) due to localized cutaneous vasculitis]

We report a case of a 49 year old man, diagnosed soon after the outcome of casual proteinuria, of AA-type amyloidosis in relation to small and medium vessel cutaneous vasculitis without systemic involvement. This combination is a rare entity and only two cases of cutaneous hypersensibility vasculitis complicated with AA-type amyloidosis had been reported. We describe the results of the use of several immunosuppressive drugs during four years follow up with temporally total remission of the disease.

Growth of hydroxyapatite in a biocompatible mesoporous ordered silica

A novel biomaterial (HA-SBA-15) has been developed based on the growth of calcium phosphate hydroxyapatite (HA) nanoparticles within an organized silica structure (SBA-15). Characterization of the material was carried out using a combination of X-ray diffraction, X-ray fluorescence, transmission electron microscopy, N2 adsorption-desorption isotherms and nuclear magnetic resonance. Transmission electron microscopy observations and N2 porosimetry revealed the crystallization of hydroxyapatite nanoparticles inside the mesopore cavities of the silica structure. Specific surface areas of 760 m2 g(-1) and 260 m2 g(-1) were measured for the SBA-15 and the HA-SBA-15 material, respectively. The hydroxyl groups present in the silica nanostructure surface have brought about cationic defects in the silicium sites, mainly with those of tetrahedral symmetry, and promoted the formation of siloxanes. 29Si MAS-NMR analysis shows a significant reduction of the silanol groups concentration with HA growing within the base (SBA-15) material. Studies and brain tissue biocompatibility tests were carried out. Histopathological studies on the SBA-15 implant material showed no changes to the tissue nearby. The results confirmed the synthesis of a silica-based composite containing HA nanoparticles with the potential for biomedical applications.

[Helicobacter pylori does not contribute to iron deficiency in hemodialysis patients]

BACKGROUND

Many studies in the general population have shown a link between Helicobacter pylori infection and iron-deficiency, often resulting in iron-deficient anaemia. Despite the high prevalence of iron deficiency in hemodialysis patients, no studies have been performed in this population.

OBJECTIVE

To evaluate the role of Helicobacter pylori infection in the appearance of anemia and the iron requirements in our hemodialysis population.

MATERIAL AND METHODS

After excluding patients with severe pathology and short life expectancy and those with blood losses secondary to other causes, 79 patients were included.Iron requirements and anaemia were determined by iron serum, ferritin, and hematocrit values; and by transfusion, eritropoietin and iron requirements. The diagnosis of Helicobacter pylori status was established by the concordance of at least two of the three non invasive diagnostic methods performed (breath test, serology and fecal antigen of Helicobacter pylori).

RESULTS

Prevalence of Helicobacter pylori infection was 43%. No significant differences between patients infected or not by Helicobacter pylori were found in any of the variables analysed: hematocrit (33.5% versus 34.1%), serum iron (58.9 versus 63.7 pg/dl), ferritin(340.3 versus 264.2 ng/ml), transferrin saturation index (22.5% versus 25.2%), dose of eritropoietin administered (96.6 versus 93.5 U/kg/weekly), and parenteral iron (1,389 versus 1,538 mg/year). A noteworthy finding was that patients with Helicobacter pylori infection had been on hemodialysis for a shorter period than those without (37.4 versus 63.7 months,p = 0.04).

CONCLUSION

Helicobacter pylori infection has no effect on anaemia (hematocrit, Eritropoietin dose or iron needs) in our hemodialysis patients. Prevalence of Helicobacter pylori is lower in patients with longer time on dialysis. We consider that the diagnosis of Helicobacter pylori infection must be reserved for clinical peptic ulcer suspicion or patients on transplant waiting list.

[Standard precautions: are these known? Are they applied?]

A study carried out among postgraduate nurses detected a high degree of confusion regarding standard precautions. This led to the formation of a multidisciplinary group from various sections of the health system to investigate this topic in greater detail. Our study observed a high degree of conceptual confusion and a lack of knowledge about standard precautions and the new recommendations regarding decontamination and hand washing in diverse health collectives. It is worrisome to detect at risk habits in relation to self-protective measures among one-third of those surveyed. Knowledge of standard precautions should be integrated with greater efficiency in the medical study programs as well as in continuing professional development programs for health professionals.

Apolipoproteins E and C1 and brain morphology in memory impaired elders

Previous research has shown that polymorphisms of the apolipoproteins E ( APOE) and APOC1 represent genetic risk factors for dementia and for cognitive impairment in the elderly. The brain mechanisms by which these genetic variations affect behavior or clinical severity are poorly understood. We studied the effect of APOE and APOC1 genes on magnetic resonance imaging measures in a sample of 50 subjects with age-associated memory impairment. The APOE E4 allele was associated with reduced left hippocampal volumes and APOE*E3 status was associated with greater frontal lobe white matter volumes. However, no APOE effects were observed when analyses accounted for other potential confounding variables. The effects of APOC1 on hippocampal volumes appeared to be more robust than those of the APOE polymorphism. However, no modulatory effects on brain morphology outside the medial temporal lobe region were observed when demographic variables, clinical status, and other anatomical brain measurements were taken into consideration. Our results suggest that the role of the APOC1 polymorphism in brain morphology of the cognitively impaired elderly should be examined in further studies.

[Type II essential mixed cryoglobulinemia and renal disease. Hepatitis C virus association]

Recently a number of studies have implicated C virus as a major cause of mixed cryoglobulinemia. Several authors described that up to 95% of "essential" mixed cryoglobulinemia could be attributed to this viral infection. Nevertheless, its prevalence and clinical significance are not well known. We review our experience in relation with the clinical, biological and evolutive characteristics of patients diagnosed of type II mixed cryoglobulinemia.

METHODS

Descriptive and protocolized study of all cases found to have type II mixed cryoglobulinemia over a period of 8 years. Secondary cryoglobulinemic nephropathy was defined in a restrictive way: a plasma creatinine > 1.5 mg/dl and/or proteinuria > 500 mg/24 h and/or hematuria (> 15 red blood cells) need to be present in the absence of any other pathological conditions that could justify these alterations. Furthermore, the information obtained from available kidney biopsies was considered.

RESULTS

62 patients have been detected. C virus infection was demonstrated in 44 (72%). 52% had clinical symptoms related with cryoglobulinemia. 56% had alteration of renal tests, and 17 (27%) fulfil the conditions for the diagnosis of cryoglobulinemic nephropathy (nearly all with persistent microhematuria, median proteinuria 4.2 +/- 3.9 g/24 h; median plasma creatinine 2.8 +/- 1.8 mg/dl). Nine patients had been histologically examined, showing 6 cases a membranoproliferative glomerulonephritis pattern, one with associated extraglomerular vasculitis; two with mesangial proliferative pattern and one with membranous glomerulonephritis. The most striking differences between cryoglobulinemic nephropathy patients and the rest has been: higher amount of cryoglobulins (49 +/- 28 vs 20 +/- 22); more frequent hypocomplementemia, especially C4 (93% vs 59%) and recurrent purpura (75% vs 32%). No differences in the presence of C virus infection could be observed (75% vs 71%).

IN CONCLUSION

72% of patients with type II mixed cryoglobulinemia are infected by C virus (so 28% in our serie are "essential"); 52% have symptoms related with the presence of cryoglobulins, half of them with cryoglobulinemic nephropathy.

[Management of dyspepsia, gastroduodenal ulcer and Helicobacter pylori infection in primary care]

OBJECTIVE

To evaluate management of dyspepsia, gastroduodenal ulcer and Helicobacter pylori infection in the setting of family practice.

DESIGN

An observational transversal study was performed. An anonymous questionnaire was send by mail between January and October 2000.

SETTING

Primary care.

PARTICIPANTS

Physicians of 17 Primary Care centers.

RESULTS

Sixty-four per cent of the physicians returned the answered questionnaire (107/165). Primary care doctors reported they had indicated eradication therapy at least once during last year in 94.3%; 89.7% usually indicate H. pylori eradication for duodenal ulcer and 70.1% for gastric ulcer. The main method for the study of dyspepsia was endoscopy associated with antral histology or rapid urease test for determination of H. pylori status. Omeprazole, clarithromycin and amoxicillin twice daily for seven days was the preferred eradication therapy (77.6%). Forty-five percent of physicians systematically tested patients to confirm cure of the infection; 36.4% tested patients only if symptoms relapsed. Breath test (72.7%) was the preferred method to confirm eradication. Physicians with postgraduate specialty in Family Care and Community Medicine (MFyC) demand less often gastroenterologist evaluation, indicate less frequently upper tract radiology, use more often C13 urea breath test for diagnosis and indicate more often eradication treatment for erosive duodenitis than unspecialised family doctors.

CONCLUSIONS

Management of dyspepsia and H. pylori infection in Primary Care in our area is reasonably adapted to current consensus recommendations. Many differences in management were observed between MFyC and non-specialised primary care physicians.

Effect of pyrene on hepatic cytochrome P450 1A (CYP1A) expression in Nile Tilapia (Oreochromis niloticus)

The effect of pyrene on the regulation of the gene expression of cytochrome P4501A ( CYP1A) was studied in tilapia (Oreochromis niloticus), a tropical fish of great ecological and economical importance. To evaluate CYP1A mRNA, tilapia CYP1A cDNA was cloned, sequenced, and compared with those CYP1A reported sequences in the GeneBank DNA database. The top seven matches corresponded to CYP1A from other teleosts. Hepatic CYP1A mRNA levels showed a significant increase at day 1 after pyrene injection (20 mg kg(-1) body weight [BW]), and this CYP1A mRNA levels did not return to basal levels for up to 5 days. The immunoblot analysis of CYP1A protein levels using polyclonal rabbit-anti-trout antibodies in the liver of pyrene-treated (20 mg kg(-1) BW) tilapias showed a 1.9-fold increase at day 3 after injection. Ethoxyresorufin- O-deethylase (EROD) activity increased 18-fold with respect to control fish at day 3 after injection. CYP1A protein and EROD activity remained increased for 5 days after a single pyrene IP administration. Similarly, the highest concentration of 1-hydroxypyrene (1-OH pyrene) in bile was observed in fish sacrificed at day 3 after injection. EROD activity and 1-OH pyrene concentration showed a statistically significant correlation (r = 0.85) according to the Spearman test, suggesting the participation of this cytochrome in the biotransformation of pyrene.

[Systemic amyloidosis secondary to xanthogranulomatous pyelonephritis]

Secondary amyloidosis is a relatively common pathology in which chronic infectious diseases are common causes, especially infected bronchiectasis, osteomyelitis or chronic ulcers. The association of xanthogranulomatous pyelonephritis and systemic amyloidosis is extremely rare. To our knowledge, despite innumerable cases of xanthogranulomatous pyelonephritis reported in the literature, this association has been reported in only 8 previous cases. Patients usually complain of fever, back or flank pain and urinary tract symptoms. A long lasting evolution of the process is frequent. We report a 70 year old patient who developed amyloidosis secondary to xanthogranulomatous pyelonephritis. As well as the rarity of this association, this case is exceptional in its clinical presentation, without any urinary tract symptoms that could suggest the diagnosis.

[Assessment of long-term bone metabolism in patients with relative hypoparathyroidism after changing the calcium concentration of the dialyzate to 3mEq/L]

The existence of a low-bone turnover, non-aluminium related, has been more prevalent in recent years. Factors involved include the increasing number of older and diabetic patients initiating dialysis. Also higher intake of calcium salts and the widespread use of vitamin D derivates may play a role. Demonstration of low PTH secretion allows the recognition of the group of patients with special risk of adynamic bone disease. Little can be done to improve bone remodelling apart from correct management of risk factors previously mentioned. A decrease in dialysate calcium concentration can act in this way, but the long term effect of this procedure on bone mineral density has scarcely been established. The aim of this study was to evaluate the long term effect of lowering the dialysate calcium concentration from 3.5 to 3 mEq/L on bone mass and PTH activity in patients with hypoparathyroidism. We studied 19 patients with PTH < 120 pg/ml and calcemia between 8.5 and 10.5 mg/dl, without aluminium intoxication. Blood levels of Ca, P, alkaline phosphatase, aluminium, iPTH and dialysis doses were measured every 4 months during the two years of follow-up. Phosphate binders were closely monitored. Also calcium dietary feeding was measured by a 5-day dietetic registry at the beginning and 6 and 12 months later. Bone mineral density was assessed by quantitative computed tomography of the distal radius initially and after 18 months. PTH values had significantly increased from the first measurement (from 46 +/- 33 to 97 +/- 68 four months later). At the end of follow up, 8 patients (42%) had reached the objective of maintaining a PTHi above 120 pg/ml, while 11 had not reached it (3 were previously parathyroidectomized and two were diabetic). Only one patient has developed an exaggerated PTH response that has been controlled with oral vitamin D. No bone mineral loss was observed during the follow up. In conclusion, the use of a 3 mEq/l dialysate calcium may improve hypoparathyroidism in a substantial number of patients, avoiding the untoward effect that lower calcium concentration has on bone mineralization.

What is the optimal length of proton pump inhibitor-based triple therapies for H. pylori? A cost-effectiveness analysis

BACKGROUND

Triple therapy with a proton pump inhibitor, clarithromycin and amoxicillin is widely used for H. pylori infection. The appropriate length of treatment remains controversial.

AIM

To determine whether length of treatment has an impact on the cost-effectiveness of triple therapy.

METHODS

The study took the form of a cost-effectiveness analysis spanning 2 years. The perspective was societal and the setting, ambulatory care. Subjects were Helicobacter pylori-positive patients with a duodenal ulcer. The triple therapy trials spanned 7, 10 or 14 days and the main outcome measures were cost per patient and marginal cost for additional cured patient calculated for a low cost-of-care setting (Spain), for a high-cost setting (USA), and for two follow-up strategies: (i) systematic 13C-urea breath test after eradication; (ii) clinical follow-up, breath-test if symptoms recurred.

RESULTS

Base-case analysis showed that for both the 13C-UBT and the clinical follow-up branches, lowest costs were obtained with 7-day schedules both in Spain and the USA. Sensitivity analysis showed that in Spain, 10-day therapies would have to increase 7-day cure rates by 10-12% to become cost-effective. In contrast, in the USA only a 3-5% increase was needed. The corresponding figures for 14-day therapy were 25-35% and 8-11%, respectively.

CONCLUSIONS

Seven-day therapies seem the most cost-effective strategy. However, in high-cost areas the differences were less evident.