[Pilot Drug Utilization Study of systemic antifungal agents in the Hospital Clínico San Carlos. Proposal of a study method]

INTRODUCTION

The study aims to define a method for the evaluation of the usage of systemic antifungal agents, and test it, in order to be able to develop larger studies.

METHOD

Drug Use Study, pilot, observational, prescription- indication. We proposed a definition of antifungal type of treatment using as host factors the EORTC (European Organization for Research and Treatment of Cancer) criteria, the patient's clinical data as well as any evidence of fungal infection. Adequate use was evaluated by three standards of comparison: summary of product characteristics, hospital recommendations and an experts' committee.

RESULTS

60 antifungal prescriptions were recovered: fluconazole: 39; itraconazole: 6; liposomal amphotericin B: 5; caspofungin: 5; voriconazole: 5. Treatment was started as follows (N;%): microbiological (28;46.7), empirical (22;36.7) and prophylactic use (7;11.7). The indication for antifungal treatment was considered adequate in more than 90% of the cases for the three standards of comparison, whereas selection in 75-83% of the cases.

CONCLUSIONS

The method is considered satisfactory for the evaluation of antifungal treatments and is proposed for being used in larger studies. For all the antifungal agents evaluated, a high degree of appropriateness of use was found, though some conditions are considered improvable.

Identification of missing persons: the Spanish "Phoenix" program

In 1999, Spain was the first country to officially start a National Program to try to identify cadavers and human remains which could not be identified by the use of traditional forensic approaches. This attempt is called "Phoenix Program". Two independent mitochondrial DNA (mtDNA) databases were generated, which can automatically compare and match identical or similar sequences. One is the Reference Database, with mtDNA sequences from maternal relatives of missing persons, who provide the samples (buccal swabs) voluntarily; the other is the Questioned Database, comprised of mtDNA data of unknown remains and cadavers. Although the first phase of the program (typing of all unidentified human remains) will probably not be completed until December 2003, positive identifications are being made in the interim. To date, more than 1,200 families have contacted Phoenix, and at least 280 reference samples and 48 questioned evidences have been analyzed. When mtDNA matches are found, another independent analysis is performed as a part of the quality control mechanism. Once a match is confirmed (so far in 6 cases), an attempt is made to analyze short tandem repeat (STR) loci. We call for international collaboration to make this effort valuable worldwide.

Psychological characterization of testicular feminization syndrome

Ten cases with testicular feminization syndrome (TFS) diagnosed at the National Institute of Endocrinology and Metabolism, were studied. The patients were interviewed and subjected to the following psychological tests: Raven's Progressive Matrices, the MMPI, the 16PF, and the TAT. Laboratory determinations included: nuclear chromatin, karyotype, FHS, LH, estradiol, testosterone and nitrogen retention test. Intellectual achievement was found normal, and as far as psychological stability is concerned (MMPI) there was no common profile typical of the group. Psychosexual attitudes showed alterations related to acceptance of body image, fears to be unable to maintain the stability of the couple, and lack of a strong maternal drive. Personality profile manifested two outstanding traits in the group: Dominance (E+) and Shrewdness (N+), the former being remarkably high for a female population. A hypothesis is advanced in regard to the psychological alterations of the possible role of partial androgenization of the central nervous system in these patients.

A preliminary pharmacological trial of the monthly injectable contraceptive cycloprovera

A comparative pharmacological pilot study of the monthly injectable contraceptive CycloProvera was carried out in 11 women in four centres. There were no significant differences in the results between the centres except that the injection-bleeding interval appeared to be shorter in Swedish women than in those in Havana and Mexico. Medroxyprogesterone acetate was detectable in blood for 28 to 62 days after injection of CycloProvera and although follicular activity returned in less than 28 days after injection in many of the women, corpus luteum function was suppressed for at least seven weeks in all women. Most of the women retained a regular menstrual pattern; six of 33 cycles were amenorrhoeic. There was no significant change in any of the biochemical and haematological analyses.

Sterility caused by functional absence of ejaculatory ducts

Five patients with functional absence of genital excretory ducts are presented, with emphasis on the scarcity of physical and complementary data obtained. The low impairment of spermatogenesis is pointed out. Seminal characteristics are analysed and the diagnostic importance of spermogram data stressed. The importance of the qualitative determination of fructose for the diagnosis of this syndrome is noted, as well as the incidence of this syndrome as the cause of azoospermia and sterility. The existence of a unilateral congenital absence of ejaculatory ducts is demonstrated. Cases of this sort cannot be detected unless a contralateral acquired lesion occurs.

Spermatogenesis in Klinefelter's syndrome

The results of a study of seminal fluid, chromosomal formula and testicular tissue performed on 32 patients with Klinefelter's syndrome are presented. The significance of the microscopic study of seminal fluid in this syndrome is well emphasized. The possible relationship of the histological pattern to spermatogenic function and chromosomal constitution is discussed. Our conclusions are that most patients were azoospermic and the the volume of the ejaculate was low or absent. The decreased density of seminal fluid was the result of the absence of spermatozoa. The seminal pH remained normal during the study. Finally, we consider that cases showing areas of spermatogenesis with spermatozoa might correspond to a gondal mosaicism we have failed to diagnose.

Familial Cushing's syndrome

Cushing's syndrome has been demonstrated in four of seven siblings with clinical manifestations appearing around puberty in three of the four siblings. The only other associated findings in these cases were short stature and disturbed carbohydrate metabolism. Adenomatous hyperplasia of the adrenal glands was demonstrated in 3 of the patients, and a virilizing adrenal carcinoma in the fourth sibling. The pathogenesis of the adrenocortical disorders in these siblings is discussed.