Emergency visits and mortality caused by ischemic heart disease attributable to fine particulate matter during the COVID-19 pandemic in Chile

POSITION DU PROBLèME: Le confinement mis en place au deuxième trimestre 2020 a entrainé une amélioration de la qualité de l'air de Santiago, capitale et plus grande ville du Chili, caractérisée par de fortes concentrations en particules fines PM_2,5 liées, en grande partie, au trafic routier. L'objectif était de mettre en évidence une potentielle réduction des visites aux urgences pour infarctus du myocarde aigu (IDM) et des décès dus à une cardiopathie ischémique (CPI) attribuable à l'émission de PM_2,5, en comparant les périodes équivalentes de 2019 et de 2020. MéTHODES: À Santiago, la surveillance de la qualité de l'air se fait grâce à neuf moniteurs situés dans neuf communes différentes : Cerro Navia, Cerrillos, El Bosque, Pudahuel, Independencia, La Florida, Quilicura, Santiago centre-ville et Las Condes (classées de la plus haute à la plus basse en matière de pauvreté multidimensionnelle). La concentration moyenne quotidienne de PM_2,5 a été décrite avec des séries temporelles, et les visites aux urgences pour IDM et les décès dus à une CPI ont été analysés de façon trimestrielle pour chaque année. Pour estimer l'impact de l'excès de PM_2,5, les fractions de risque attribuables (FRA) pour les visites aux urgences pour IDM et les décès pour CPI ont été calculées. RéSULTATS: La moyenne quotidienne des PM_2,5 a diminué dans huit des neuf communes de Santiago. Cependant, la réduction n'a été significative que dans trois communes. Les visites aux urgences pour IDM et les décès par CPI attribuables aux PM_2,5 ont diminué légèrement mais significativement dans ces trois communes. Les FRA dans les autres communes sont restées similaires à 2019. CONCLUSIONS: Une réduction significative de la FRA des PM_2,5 pour les décès par CPI et les visites aux urgences d'IDM n'a été observée que dans les communes avec une réduction significative de la concentration quotidienne moyenne de PM_2,5 pendant la pandémie de COVID-19.

Epigenetic regulation of TLR2-mediated periapical inflammation

AIM

To determine the methylation pattern of TLR2 gene promoter and its association with the transcriptional regulation of periapical inflammatory and angiogenic responses in symptomatic and asymptomatic forms of apical periodontitis.

METHODOLOGY

In this cross-sectional study, apical lesions were obtained from volunteers with asymptomatic apical periodontitis (AAP) (n = 17) and symptomatic apical periodontitis (SAP) (n = 17) scheduled for tooth extraction, and both total RNA and DNA were extracted. DNA was bisulfite-treated, a region of CpG island within the TLR2 gene was amplified by qPCR and the products were sequenced. Additionally, the mRNA expression of TLR2, TLR4, IL-6, IL-12, TNFalpha, IL-23, IL-10, TGFbeta, VEGFA and CDH5 was analysed by qPCR. The data were analysed with chi-square tests, Mann-Whitney or unpaired t-tests, and Spearman´s correlation; variable adjustments were performed using multiple linear regression (P < 0.05).

RESULTS

TLR2 depicted a hypomethylated DNA profile at the CpG island in SAP when compared with AAP, along with upregulated expression of TLR2, with pro-inflammatory cytokines IL-6 and IL-23, and the angiogenesis marker CDH5 (P < 0.05). TLR2 methylation percentage negatively correlated with mRNA levels of IL-23 and CDH5 in apical periodontitis. Lower methylation frequencies of single CpG dinucleotides -8 and -10 localized in close proximity to nuclear factor κB (NFκB) binding within the TLR2 promoter were identified in SAP versus AAP (P < 0.05). Finally, unmethylated -10 and -8 single sites demonstrated up-regulation of IL-23, IL-10 and CDH5 transcripts compared to their methylated counterparts (P < 0.05).

CONCLUSIONS

TLR2 gene promoter hypomethylation was linked to transcriptional activity of pro-inflammatory cytokines and angiogenic markers in exacerbated periapical inflammation. Moreover, unmethylated single sites in close proximity to NFκB binding were involved in active transcription of IL-23, IL-10 and CDH5.

Low-level arsenic exposure during pregnancy and its association with postpartum depression: A cohort study of women from Arica, Chile

BACKGROUND

While the relationship between inorganic arsenic exposure and psychological impairment has been studied previously, the association between low-level arsenic exposure during pregnancy and postpartum depression has not yet been examined. The objective is to estimate the association between low-level arsenic exposure during pregnancy and the Edinburgh score.

METHODS

A sample of 223 women was collected from five public health services in Arica, Chile. Participation was voluntary and written consent was mandatory. Sociodemographic data related to arsenic exposure and urine samples for total inorganic arsenic assessments were collected during the second trimester. Postpartum depression symptoms were estimated by the Edinburgh Postpartum Depression scale. We examined descriptive statistics and ran multiple linear regressions. The modifying effect of age and depression history was evaluated separately.

RESULTS

The median for total urinary inorganic arsenic was 14.6μg/L (range: 2-69.2μg/L), the median for postpartum depression score was 8 points (range: 0-27 points) and 20.6% of women were considered as postpartum depressed. For women older than 25years old without depression history, the adjusted coefficient for the total urinary natural logarithm of inorganic arsenic in multiple linear regressions was -2.51 (95% CI: -4.54, -0.48; P-value=0.02). For women older than 25years old with a depression history, this value was 2.09 (95% CI: -0.90, 5.08; P-value=0.16).

CONCLUSIONS

In this cohort, the number of children, physical perception, depression history, stressful maternity, and age were associated with postpartum depression score. The Edinburgh score was associated with inorganic arsenic in women older than 25years without depression history.

Do physicians correctly calculate thromboembolic risk scores? A comparison of concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores

BACKGROUND

Clinical risk scores, CHADS2 and CHA2 DS2 -VASc scores, are the established tools for assessing stroke risk in patients with atrial fibrillation (AF).

AIM

The aim of this study is to assess concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores, as well as to analyse the patient categories using CHADS2 and the potential improvement on stroke risk stratification with CHA2 DS2 -VASc score.

METHODS

We linked data from Atrial Fibrillation Spanish registry FANTASIIA. Between June 2013 and March 2014, 1318 consecutive outpatients were recruited. We explore the concordance between manual scoring and computer-based calculation. We compare the distribution of embolic risk of patients using both CHADS2 and CHA2 DS2 -VASc scores

RESULTS

The mean age was 73.8 ± 9.4 years, and 758 (57.5%) were male. For CHADS2 score, concordance between manual scoring and computer-based calculation was 92.5%, whereas for CHA2 DS2 -VASc score was 96.4%. In CHADS2 score, 6.37% of patients with AF changed indication on antithrombotic therapy (3.49% of patients with no treatment changed to need antithrombotic treatment and 2.88% of patients otherwise). Using CHA2 DS2 -VASc score, only 0.45% of patients with AF needed to change in the recommendation of antithrombotic therapy.

CONCLUSION

We have found a strong concordance between manual and computer-based score calculation of both CHADS2 and CHA2 DS2 -VASc risk scores with minimal changes in anticoagulation recommendations. The use of CHA2 DS2 -VASc score significantly improves classification of AF patients at low and intermediate risk of stroke into higher grade of thromboembolic score. Moreover, CHA2 DS2 -VASc score could identify 'truly low risk' patients compared with CHADS2 score.

Glucocorticoid Receptors, Brain-Derived Neurotrophic Factor, Serotonin and Dopamine Neurotransmission are Associated with Interferon-Induced Depression

BACKGROUND

The role of inflammation in mood disorders has received increased attention. There is substantial evidence that cytokine therapies, such as interferon alpha (IFN-alpha), can induce depressive symptoms. Indeed, proinflammatory cytokines change brain function in several ways, such as altering neurotransmitters, the glucocorticoid axis, and apoptotic mechanisms. This study aimed to evaluate the impact on mood of initiating IFN-alpha and ribavirin treatment in a cohort of patients with chronic hepatitis C. We investigated clinical, personality, and functional genetic variants associated with cytokine-induced depression.

METHODS

We recruited 344 Caucasian outpatients with chronic hepatitis C, initiating IFN-alpha and ribavirin therapy. All patients were euthymic at baseline according to DSM-IV-R criteria. Patients were assessed at baseline and 4, 12, 24, and 48 weeks after treatment initiation using the Patient Health Questionnaire (PHQ), the Hospital Anxiety and Depression Scale (HADS), and the Temperament and Character Inventory (TCI). We genotyped several functional polymorphisms of interleukin-28 (IL28B), indoleamine 2,3-dioxygenase (IDO-1), serotonin receptor-1A (HTR1A), catechol-O-methyl transferase (COMT), glucocorticoid receptors (GCR1 and GCR2), brain-derived neurotrophic factor (BDNF), and FK506 binding protein 5 (FKBP5) genes. A survival analysis was performed, and the Cox proportional hazards model was used for the multivariate analysis.

RESULTS

The cumulative incidence of depression was 0.35 at week 24 and 0.46 at week 48. The genotypic distributions were in Hardy-Weinberg equilibrium. Older age (p = 0.018, hazard ratio [HR] per 5 years = 1.21), presence of depression history (p = 0.0001, HR = 2.38), and subthreshold depressive symptoms at baseline (p = 0.005, HR = 1.13) increased the risk of IFN-induced depression. So too did TCI personality traits, with high scores on fatigability (p = 0.0037, HR = 1.17), impulsiveness (p = 0.0200 HR = 1.14), disorderliness (p = 0.0339, HR = 1.11), and low scores on extravagance (p = 0.0040, HR = 0.85). An interaction between HTR1A and COMT genes was found. Patients carrying the G allele of HTR1A plus the Met substitution of the COMT polymorphism had a greater risk for depression during antiviral treatment (HR = 3.83) than patients with the CC (HTR1A) and Met allele (COMT) genotypes. Patients carrying the HTR1A CC genotype and the COMT Val/Val genotype (HR = 3.25) had a higher risk of depression than patients with the G allele (HTR1A) and the Val/Val genotype. Moreover, functional variants of the GCR1 (GG genotype: p = 0.0436, HR = 1.88) and BDNF genes (Val/Val genotype: p = 0.0453, HR = 0.55) were associated with depression.

CONCLUSIONS

The results of the study support the theory that IFN-induced depression is associated with a complex pathophysiological background, including serotonergic and dopaminergic neurotransmission as well as glucocorticoid and neurotrophic factors. These findings may help to improve the management of patients on antiviral treatment and broaden our understanding of the pathogenesis of mood disorders.

Involvement of the -420C>G RETN polymorphism in myocardial fibrosis in patients with hypertrophic cardiomyopathy

AIMS

Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy and fibrosis. HCM is an autosomal-dominant disease caused by more than 400 mutations in sarcomeric genes. Changes in nonsarcomeric genes contribute to its phenotypic heterogeneity. Cardiac fibrosis can be studied using late gadolinium enhancement (LGE) cardiac magnetic resonance imaging. We evaluated the potential role of two polymorphisms in nonsarcomeric genes on interstitial fibrosis in HCM.

MATERIALS AND METHODS

Two polymorphisms in nonsarcomeric genes [ACE (deletion of 287 bp in the 16th intron) and RETN (-420C>G)] were analysed in 146 HCM patients. Cardiac fibrosis was assessed using LGE to determine the number of affected segments.

RESULTS

Allelic frequencies in ACE and RETN polymorphisms were consistent with the Hardy-Weinberg equilibrium (both P > 0.05). We found that the presence of the polymorphic allele in the -420C>G RETN polymorphism was independently associated with the number of affected segments of LGE (P = 0.038). Increased circulating resistin concentration, measured by enzyme-linked immunosorbent assay, was associated with a higher degree of cardiac fibrosis. Myocardial fibrosis, assessed by Masson's trichrome staining, was associated with the -420C>G RETN polymorphism in 46 tissue samples obtained by septal myectomy (P = 0.044).

CONCLUSIONS

The -420C>G RETN polymorphism was independently associated with the degree of cardiac fibrosis, assessed by LGE, in patients with HCM. In addition, there was an association between the polymorphism and the circulating resistin levels as well as with myocardial fibrosis in tissues obtained by myectomy. Investigating the physiological implication of the RETN polymorphism in HCM in combination with the use of imaging technologies might help to establish the severity of disease in patients with HCM.

Effect of UV radiation on habitat selection by Girella laevifrons and Graus nigra (Kyphosidae)

The effect of UV radiation on habitat use of two species of intertidal fishes that inhabit the same pools but exhibit different activity levels and diets was measured: the highly active omnivorous Girella laevifrons and the cryptic carnivorous Graus nigra. Individuals of each species were acclimated to a tank divided in three sections with different illumination; no light (NL), ultraviolet light (UV) and white light (WL), and the time spent and number of visits to each section were recorded. Although both species preferred the NL section, G. laevifrons spent more time in UV and less time in WL compared with G. nigra; G. laevifrons also displayed higher number of visits to UV, suggesting a different tendency in space use in response to UV exposure in intertidal fishes.

Estimation of the respiratory tract burden resulting from a prolonged inhalation exposure to aerosols of DU, based on the U in a 24-h urine sample taken years after exposure

A procedure is presented to estimate the respiratory tract burden from a prolonged inhalation exposure to particulate matter of depleted uranium, in cases where the rate of deposition is an unknown function. The precise range of possible values is identified. The calculations are based on the amount of depleted uranium measured in a single 24-h urine sample. In order to present an example, a simplified pharmacokinetical model is introduced. The results presented in this article are valid for any pharmacokinetical model represented by homogeneous linear differential equations with constant coefficients and non-zero initial values, and that clearly includes the International Commission on Radiological Protection model. In fact, they are applicable to any monitorable quantity measured over a short period of time, a monitorable quantity with a kinetic that can be described using a structurally similar system of differential equations to one describing these pharmacokinetical models.

Pro- and anti-inflammatory cytokine gene single-nucleotide polymorphisms in inflammatory bowel disease

Anti-inflammatory cytokines have an important role in disease, tumour and transplant processes. Alterations in the regulation of several cytokines have been implicated in a variety of inflammatory disorders, including IBD (inflammatory bowel disease) [Crohn's disease (CD) and ulcerative colitis (UC)]. Cytokine polymorphisms are also known to affect the level of gene expression. Thus, the aim of this study was to determine the relationship between cytokine polymorphisms and the IBD pathologies in a Spanish population. Polymorphisms analysis was performed using PCR-SSOP using a microbeads luminex assay. The following polymorphisms were determined: TNFα [-238G/A (rs361525) and -308G/A (rs1800629)], IFNγ [+874A/T (rs62559044)], TGFβ [+869C/T (rs1982073) and +915G/C (rs1800471)], IL10 [-1082A/A (rs1800896), -592A/C (rs1800872), -819C/T (rs1800871)], IL6 [-174C/G (rs1800795)], IL12p40 [3'UTR -1188A/C (rs3212227)], IL1α [-889C/T (rs1800587)], IL1β [-511C/T (rs1143634) and +3962C/T (rs1143633)], IL1R [Pst-1 1970C/T] and IL1RA [Mspa-1 11100C/T]. No statistical differences in TNFα, IFNγ, TGFβ, IL10, IL6, IL1α, IL1β, IL1R and IL1Ra genotypes and allele distributions between the IBD groups and healthy controls were found. However, we observed significant differences in the 3'UTR -1188A/C polymorphism of IL12p40. So -1188A allele was increased in patients with UC and the -1188C allele (high IL12p40 production) was increased in patients with CD with respect to controls. These data are in concordance with the fact that CD has been shown to be associated with a Th1 T-cell-mediated inflammation model and high IL12/IFNγ production at histological affected sites. These data suggest that cytokine polymorphisms in TNFα, IFNγ, TGFβ, IL10, IL6 and IL1α, IL1β, IL1R and IL1Ra cytokine gene do not seem to be relevant in IBD susceptibility and IL12p40 3'UTR -1188A/C polymorphism seems to be associated with a differential IBD development.

Prognostic value of two polymorphisms in non-sarcomeric genes for the development of atrial fibrillation in patients with hypertrophic cardiomyopathy

BACKGROUND

Several non-sarcomeric genes have been postulated to act as modifiers in the phenotypic manifestations of hypertrophic cardiomyopathy (HCM). The development of atrial fibrillation (AF) in HCM has adverse prognostic implications with increased thromboembolism and functional class impairment.

AIM

We tested the hypothesis that 2 non-sarcomeric genes [CYP11B2 (-344T>C) and COL1A1 (2046G>T)] are associated with the development of AF.

DESIGN

Prospective study.

METHODS

Two polymorphisms in non-sarcomeric genes [CYP11B2 (-344T>C) and COL1A1 (2046G>T)] were analysed in 159 HCM patients (49.3 ± 14.9 years, 70.6% male) and 136 controls. All subjects were clinically stable and in sinus rhythm at entry in the study, without ischemic heart disease or other significant co-morbidities that could mask the effect of the analysed polymorphisms (i.e. previous AF). Thirty-nine patients (24.4%) developed AF during a median follow-up of 49.5 months.

RESULTS

Patients with the -344T>C polymorphism in CYP11B2 gene had a higher risk for AF development [HR: 3.31 (95% CI 1.29-8.50); P = 0.008]. In a multivariate analysis, the presence of the C allele in CYP11B2 gene [HR: 3.02 (1.01-8.99); P = 0.047], previous AF [HR: 2.81 (1.09-7.23); P = 0.033] and a left atrial diameter of ≥42 mm [HR: 2.69 (1.01-7.18); P = 0.048] were independent predictors of AF development. The presence of the polymorphic allele was associated with higher aldosterone serum levels.

CONCLUSION

We have shown for the first time that the CYP11B2 polymorphism is an independent predictor for AF development in HCM patients. This highlights the importance of non-sarcomeric genes in the phenotypic heterogeneity of HCM. The association with higher aldosterone serum levels could relate to greater fibrosis and cardiac remodelling.

Action Sentences Activate Sensory Motor Regions in the Brain Independently of Their Status of Reality

Some studies have reported that understanding concrete action-related words and sentences elicits activations of motor areas in the brain. The present fMRI study goes one step further by testing whether this is also the case for comprehension of nonfactual statements. Three linguistic structures were used (factuals, counterfactuals, and negations), referring either to actions or, as a control condition, to visual events. The results showed that action sentences elicited stronger activations than visual sentences in the SMA, extending to the primary motor area, as well as in regions generally associated with the planning and understanding of actions (left superior temporal gyrus, left and right supramarginal gyri). Also, we found stronger activations for action sentences than for visual sentences in the extrastriate body area, a region involved in the visual processing of human body movements. These action-related effects occurred not only in factuals but also in negations and counterfactuals, suggesting that brain regions involved in action understanding and planning are activated by default even when the actions are described as hypothetical or as not happening. Moreover, some of these regions overlapped with those activated during the observation of action videos, indicating that the act of understanding action language and that of observing real actions share neural networks. These results support the claim that embodied representations of linguistic meaning are important even in abstract linguistic contexts.

Biomarkers in atrial fibrillation: an overview

Atrial fibrillation (AF) confers a raised risk of stroke and death, and this risk of adverse events is increased by the coexistence of other cardiovascular risk factors. The pathophysiology of AF is complex, involving the role of inflammation, structural remodelling with apoptosis, inflammation or fibrosis. These changes confer a prothrombotic or hypercoagulable state in this arrhythmia. Despite being easy to use for decision-making concerning oral anticoagulant therapy in AF, clinical risk scores used for stratification have shown modest capability in predicting thromboembolic events, and biomarkers may improve our identification of 'high risk' patients. Biomarkers, whether measured in the peripheral blood, urine or imaging-based may improve our knowledge of the pathophysiology of AF. Importantly these biomarkers could help in the assessment of AF prognosis. The aim of this review was to summarise the published data about biomarkers studied in AF, with focus on data from randomised prospective clinical trials and large community-based cohorts. We will also review the application of these biomarkers to prognosis on the main schemes used to help stratify risk in AF.

Interleukin-6 as a predictor of cardiovascular events in troponin-negative non-ST elevation acute coronary syndrome patients

AIM

Risk stratification in acute coronary syndrome without ST-segment elevation (NSTE-ACS) and troponin-negative remains a challenge. We evaluated the value of interleukin-6 (IL-6) and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prognosis assessment of low-moderate risk NSTE-ACS and troponin-negative, and whether these biomarkers could improve the predictive performance of the established thrombolysis in myocardial infarction (TIMI) risk score.

METHODS

A total of 212 low-moderate risk patients with NSTE-ACS and troponin-negative were prospectively studied. Clinical follow up at 6 months was performed for adverse endpoints.

RESULTS

A total of 28 patients (13.5%) presented adverse clinical events. Those with adverse clinical events were associated with higher levels of IL-6 [8.58 (5.13-20.95) ng/l vs. 6.12 (4.16-9.14) ng/l, p = 0.043] and NT-proBNP [275.3 (108.6-548.2) ng/l vs. 126.8 (55.97-430.20) ng/l, p = 0.046]. In moderate risk group, we observed a higher event rate in patients with troponin-negative but elevated levels of IL-6 (p = 0.024). Only elevated IL-6 (> 12.40 ng/l) was an independent predictor of adverse outcomes [hazard ratios: 3.62, 95% confidence interval (CI) 1.69-7.75, p = 0.001]. The addition of IL-6 and history of ischaemic heart disease (IHD) to TIMI risk score significantly improved both the discrimination (integrated discrimination improvement, p = 0.003) and reclassification (Clinical Net reclassification improvement, p = 0.010) of the model for adverse events.

CONCLUSIONS

Interleukin-6 is an independent predictor of adverse events in low-moderate risk patients with NSTE-ACS and troponin-negative. Its use identifies a higher risk population in moderate-risk patients. This provides together with history of IHD a better discrimination and reclassification beyond that achieved with clinical risk variables from TIMI risk score in these patients.

Unplanned pregnancy and discontinuation of SSRIs in pregnant women with previously treated affective disorder

OBJECTIVE

To identify the factors associated with discontinuation of selective serotonin reuptake inhibitors (SSRIs) in pregnant women and to determine the rates of SSRI reintroduction during pregnancy.

METHOD

A prospective study was conducted in the Perinatal Psychiatry Service of the Hospital Clínic in Barcelona. The total sample comprised 132 consecutive pregnant women with depressive or anxiety disorder (DSM-IV criteria), seen between January 2005 and December 2008 and who were receiving SSRIs at the time of conception. Clinical, psychometric and socio-demographic variables were collected at the first visit. All women were assessed during treatment with the Edinburgh Perinatal Depression Scale (EPDS) and the Spielberger State-Trait Anxiety Inventory (STAI). Dose and type of antidepressant were recorded at each visit during pregnancy.

RESULTS

Seventy women (53%) discontinued SSRI treatment upon confirmation of pregnancy. Socio-demographic, obstetric and psychiatric variables did not differ significantly between women who maintained and women who discontinued treatment. Only unplanned pregnancy was associated with a greater risk of discontinuation (OR=2.7, 95% CI=1.34-5.52). Women who discontinued treatment also had higher EPDS and STAI scores in the first visit and prenatal visit (34-36 weeks) (p<.05). Of the 70 women who discontinued treatment, 57.1% (N=40) reintroduced treatment, almost half of these in the first trimester of pregnancy.

CONCLUSIONS

Unplanned pregnancy was a risk factor for abrupt discontinuation of SSRIs upon confirmation of pregnancy in women with depressive or anxiety disorder. More than half the pregnant women who discontinued SSRIs reintroduced antidepressant therapy during pregnancy.

[Clinical factors and findings in knee arthroscopy of patients with knee arthrosis candidates for conversion to total replacement]

OBJECTIVES

To identify those clinical characteristic and arthroscopic findings in patients with knee arthrosis that are associated with worsening of the disease and subsequent total knee arthroplasty (TKA).

METHOD

A retrospective, descriptive study was conducted on 78 consecutive patients (88 knees) who underwent knee arthroscopy for arthrosis. The study included 44 women and 34 men, with a mean age of 58.9 years (range: 37-78 years). After a mean follow-up of 50.4 months (range: 12-96 months), those patients who progressed towards TKA were identified. A logistic regression model was applied to recognise the factors associated with deterioration of the arthrosis, with consequent progression towards a TKA.

RESULTS

Twenty-four out of the 88 knees progressed towards a TKA (27.3%) within a mean time of 13.5 months after arthroscopy (range: 13-29 months). The clinical characteristics that showed a significant association with poor progression of the arthrosis were: female gender (0.02) and Ahlbäck 2 (P=.04). Arthroscopic finding that proved significant correlation with worsening of the arthrosis towards TKA were: meniscal tears of the posterior horn (P=.02), meniscectomies above 60% (P=.03), and 2nd degree chondral lesions in loading areas of the medial femoral condyle (P=.02).

CONCLUSION

The variables associated with a greater chance of progressing towards a TKA after a knee arthroscopy due to arthrosis in this study were, female gender, grade 2 radiographic arthrosis, posterior horn meniscal lesions, meniscectomies over 60%, and chondral lesions in loading area of the medial femoral condyle.

Genetic polymorphisms of tumour necrosis factor alpha (TNF-α) promoter gene and response to TNF-α inhibitors in Spanish patients with inflammatory bowel disease

Tumour necrosis factor alpha (TNF-α) has an important role in inflammatory response. Alterations in the regulation of TNF-α have been implicated in a variety of inflammatory disorders, including Inflammatory bowel disease (IBD). Indeed, a common treatment for IBD is the use of TNF-α inhibitors. Polymorphisms in the TNF-α promoter region are known to affect the level of gene expression. Our aim was to investigate the influence of these single nucleotide polymorphisms (SNPs) in TNF-α promoter gene play in the risk of IBD in a Spanish population and their individual response to anti-TNF-α treatment. DNA samples from patients with IBD and controls were screened for TNF-α -238G/A (rs361525) and -308G/A (rs1800629) SNPs by PCR-SSOP using a microbeads luminex assay and compared with response to TNF-α inhibitors. There were not statistical differences in -238G/A and -308G/A allele and genotype frequencies between patients. However, we found an increased frequency of -308A allele and -308GA genotype in these nonresponders patients to TNF-α inhibitors with respect to responders patients (Pc < 0.05). This -308GA genotype has been classified as high producer of this cytokine. This fact could actually be interesting to explain the different response of patients with IBD with respect to TNF-α inhibitors. TNF-α promoter gene polymorphism does not seem to play a role in IBD susceptibility, but particular TNF-α genotypes may be involved in the different responses to TNF-α inhibitor treatment in Spanish patients with IBD.

A study of the SCN5A gene in a cohort of 76 patients with Brugada syndrome

We aim to study the SCN5A gene in a cohort of Brugada syndrome (BS) patients and evaluate the genotype-phenotype correlation. BS is caused by mutations in up to 10 different genes, SCN5A being the most frequently involved. Large genomic rearrangements in SCN5A have been associated with conduction disease, but its prevalence in BS is unknown. Seventy-six non-related patients with BS were studied. Clinical characteristics and family risk profile were recorded. Direct sequencing and multiplex ligation-dependent probe amplification (MLPA) of the SCN5A gene for identification of mutations and larger rearrangements were performed, respectively. Eight patients (10.5%) had point mutations (R27H, E901K, G1743R (detected in three families), V728I, N1443S and E1152X). Patients with mutations had a trend toward a higher proportion of spontaneous type I Brugada electrocardiogram (ECG) (87.5% vs 52.9%, p = 0.06) and had evidence of familial disease (62.5%, vs 23.5%, p = 0.03). The symptoms and risk profile of the carriers were not different from wild-type probands. There were non-significant differences in the prevalence of type I ECG, syncope and history of arrhythmia in carriers of selected polymorphisms. None of the patients had any deletion/duplication in the SCN5A gene. In conclusion, 10.5% of our patients had mutations in the SCN5A gene. Patients with mutations seemed to have more spontaneous type I ECG, but no differences in syncope or arrhythmic events compared with patients without mutations. Larger studies are needed to evaluate the role of polymorphisms in the SCN5A in the expression of the phenotype and prognosis. Large rearrangements were not identified in the SCN5A gene using the MLPA technique.

High sensitivity cardiac troponin T and interleukin-6 predict adverse cardiovascular events and mortality in anticoagulated patients with atrial fibrillation

There are limited data on the prognostic role of biomarkers in anticoagulated patients with atrial fibrillation (AF). We evaluated the prognostic value of high sensitivity TnT (hsTnT) and high-sensitivity interleukin-6 (hsIL6) in a large cohort of AF patients taking oral anticoagulant therapy (OAC) as both biomarkers have been associated with adverse cardiovascular events.

METHODS

We studied 930 patients (51% male; median age 76) with permanent/ paroxysmal AF who were stabilized (for at least 6 months) on OAC (INRs 2.0-3.0). Plasma hsTnT and hsIL6 levels were quantified by electrochemiluminescense immunoassay at baseline. Patients were followed-up for up to 2 years, and adverse events (thrombotic and vascular events, mortality and major bleeding) were recorded.

RESULTS

At follow-up, 96 patients (3.97%/year) died whilst 107 had an adverse cardiovascular event (3.14%/year). On multivariate analysis, high hsTnT and high hsIL6 remained significantly associated with prognosis even after adjusting for CHADS2 score: HR 2.21 (1.46-3.35, P<0.001) for high hsTnT and 1.97 (1.29-3.02, P=0.002) for high hsIL6, for adverse cardiovascular events. For all-cause mortality, the HRs were 1.79 (1.13-2.83, P=0.013) and 2.48 (1.60-3.85, P<0.001), respectively. The integrated discrimination index (IDI) values of clinical scores (CHADS2 and CHA2 DS2-VASc) were improved by the addition of hsTnT and/or hsIL6 (all P<0.05).

CONCLUSION

In a large 'real world' cohort of anticoagulated AF patients, both hsTnT and hsIL6 levels provided prognostic information that was complementary to clinical risk scores for prediction of long-term cardiovascular events and death, suggesting that these biomarkers may potentially be used to refine clinical risk stratification in AF.

New perspectives in antiplatelet therapy

Platelet activation is a complex mechanism of response to vascular injury and atherothrombotic disease, leading to thrombus formation. A wide variety of surface receptors -integrins, leucine-rich family receptors, G protein coupled receptors, tyrosine kinase receptors- and intraplatelet molecules support and regulate platelet activation. They are potential targets of antiplatelet therapy for the prevention and treatment of arterial thrombosis. Despite the overall clinical benefit of established antiplatelet drugs targeting cyclooxigenase-1 (COX-1), glycoprotein integrin αIIbβ3, and the purinergic P2Y(12) receptor of adenosine diphosphate, a significant proportion of treated patients continue to experience recurrent ischaemic events. This may be in partly attributed to insufficient inhibition of platelet activation. In addition, it should not be underestimated that these drugs are not immune from bleeding complications. The substantial progress in understating the regulation of platelet activation has played a key role in the development of novel antiplatelet agents. Current examples of drug under development and evaluation include: novel P2Y(12) receptor inhibitors (prasugrel, ticagrelor, cangrelor, and elinogrel), thrombin receptor PAR-1 antagonists (vorapaxar, atopaxar), new integrin glycoprotein IIb/IIIa inhibitors, and inhibitors targeting the thromboxane receptor (TP), phosphodiesterases, the collagen receptor glycoprotein VI, and intraplatelet signalling molecules. This review summarizes the mechanisms of action and current clinical evaluation of these novel antiplatelet agents.

Obstetrical and neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitors: the relevance of dose

OBJECTIVE

The purpose of this study was to evaluate the effects of prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) on obstetrical and neonatal outcomes.

METHOD

A case-control study was conducted to compare perinatal outcomes among pregnant women with affective disorder (DSM-IV criteria) and who received SSRIs during pregnancy with those of women without an active psychiatric disorder during pregnancy who were non-exposed to antidepressants during pregnancy. Each case was matched to two controls for maternal age (± 2 years) and parity.

RESULTS

A total of 252 women were enrolled in the study, 84 exposed and 168 non-exposed. Demographic and clinical characteristics did not differ significantly between the groups. The rates of prelabor rupture of membranes, induction of labor and cesarean delivery were slightly higher but not statistically significant in the exposed group. The mean gestational age at birth was 38.8 (± 1.86) weeks for the exposed group and 39.4 (± 1.52) weeks for the non-exposed group (p=.005). Rates for preterm birth were higher in the exposed group (OR=3.44, 95% CI=1.30-9.11). After stratification for dose, it was found that exposure to a high-dose was associated with lower gestational age (p=.009) and higher rates of prematurity (OR=5.07, 95% CI=1.34-19.23). The differences remained significant after controlling for maternal status and the length of exposure.

CONCLUSION

Women treated with SSRIs during pregnancy, mainly at high-dose, had an increased risk of preterm birth compared to healthy women of similar age and parity who were not exposed to SSRI during pregnancy.

Interactions between clopidogrel and proton pump inhibitors: a review of evidence

Clopidogrel is a thienopyridine, which inhibits the platelet P2Y adenosine diphosphate (ADP) receptor termed P2Y(12). It is taken as a prodrug that requires biotransformation to an active metabolite by cytochrome P450 (CYP) isoenzymes. In addition, esterases shunt the majority of clopidogrel to an inactive pathway, whilst the remaining prodrug requires two separate CYP-dependent oxidative steps. PPIs might diminish the antiplatelet effects and the clinical effectiveness of clopidogrel possibly through inhibition of CYP2C19 and CYP3A4 isoenzymes. Treatment with clopidogrel and aspirin decreases recurrent cardiovascular events after an acute coronary syndrome. However, an inherent increment of major bleeding is also associated with antiplatelet therapy, as well as dyspepsia with aspirin. Also, major bleeding has been associated with high risk for ischemic events and mortality. For this reason, a proton pump inhibitor (PPI) is often co-prescribed to reduce the risk of gastrointestinal tract bleeding, but its concomitant use might reduce the inhibitory effect of clopidogrel on platelet aggregation. Nevertheless, doubts exist about the possible interaction of concomitant PPI use that may reduce the inhibitory effect of clopidogrel on platelet aggregation. Indeed, there is some controversy with regard to the true risk of cardiovascular adverse events arising from a potential drug-drug interaction between clopidogrel and PPI. In this article, we will review the current status and controversies in relation to a possible interaction between clopidogrel and PPIs.

Clinical presentation and outcome of venous thromboembolism in COPD

Chronic obstructive pulmonary disease (COPD) is a moderate risk factor for venous thromboembolism (VTE), but neither the clinical presentation nor the outcome of VTE in COPD patients is well known. The clinical presentation of VTE, namely pulmonary embolism (PE) or deep venous thrombosis (DVT), and the outcome at 3 months (death, recurrent VTE or bleeding) were compared between 2,984 COPD patients and 25,936 non-COPD patients included in the RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry. This ongoing international, multi-centre registry includes patients with proven symptomatic PE or DVT. PE was the more frequent VTE presentation in COPD patients (n = 1,761, 59%). PE presentation was more significantly associated with COPD patients than non-COPD patients (OR 1.64, 95% CI 1.49-1.80). During the 3-month follow-up, mortality (10.8% versus 7.6%), minor bleeding (4.5% versus 2.3%) or first VTE recurrences as PE (1.5% versus 1.1%) were significantly higher in COPD patients than in non-COPD patients. PE was the most common cause of death. COPD patients presented more frequently with PE than DVT. It may explain the worse prognosis of COPD patients, with a higher risk of death, bleeding or VTE recurrences as PE compared with non-COPD patients. Further therapeutic options are needed.

Left atrial remodelling in hypertrophic cardiomyopathy: relation with exercise capacity and biochemical markers of tissue strain and remodelling

BACKGROUND

Left atrial remodelling, assessed as left atrial volume (LAV), has been proposed as a good marker of left ventricular diastolic dysfunction. The aim of this study was to analyse the influence of LAV on exercise performance in hypertrophic cardiomyopathy (HCM), and in a subset of subjects, assess the relation of LAV and exercise performance to four biomarkers of disease pathophysiology: matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) (as indices of tissue remodelling), N-terminal portion of pro B-type natriuretic peptide (NT-pro-BNP) (associated with ventricular dysfunction) and C-reactive protein (CRP, an index of inflammation).

METHODS

We studied 75 consecutive HCM patients (aged 46 +/- 14 years, 56 men) where LAV was calculated assuming the ellipsoid model with two orthogonal planes. LAV was indexed to body surface area. Exercise capacity was evaluated by treadmill exercise test (symptom limited) and assessed with metabolic equivalent units (MET). Basal NT-pro-BNP and CRP levels were measured in 70 patients, whereas MMP-2 and TIMP-1 in 43 patients.

RESULTS

Enlarged LAV was observed in those patients with previous atrial fibrillation (p = 0.016). Mean LAV was greater in patients with impaired functional New York Heart Association (NYHA) class (p < 0.001). LAV correlated with age (Spearman, r: 0.28), higher maximal left ventricular wall thickness (r: 0.32) and raised E/A ratio (r: 0.37) (all p < 0.01). LAV was significantly correlated with NT-pro-BNP values (r: 0.34; p = 0.04), MMP-2 (r: 0.32; p = 0.034), CRP (r: 0.33; p = 0.005) and correlated inversely with MET units (r: -0.39; p < 0.01). In multivariate analysis, MET units were only associated with NT-pro-BNP (p = 0.002) and LAV (p = 0.010).

CONCLUSIONS

Enlarged LAV is associated with impaired functional NYHA class and inversely with treadmill exercise capacity. Enlarged LAV is also associated with NT-pro-BNP, MMP-2 and CRP, perhaps as markers of disease severity and tissue remodelling. Age, LAV and NT-pro-BNP are independent predictors of exercise performance.

Predictors of mortality in patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia: the role of empiric antibiotic therapy

The objective of this study was to evaluate prognostic factors and the influence of different empiric antibiotic therapies on outcome and mortality in a cohort of 100 inpatients with bacteraemia (84 cases nosocomial) caused by methicillin-resistant Staphylococcus aureus (MRSA). Patients were investigated by means of a standard protocol at a 944-bed hospital in the years 2000-2004. Empiric antibiotic therapies included vancomycin (n = 49), teicoplanin (n = 20), linezolid (n = 17), other antibiotics active in vitro (n = 7), and inactive antibiotics (n = 7). Overall mortality was 40% (12% among linezolid-treated patients; 46.3% among glycopeptide-treated patients). In bivariate analyses, the following factors were statistically associated with higher mortality: rapidly fatal underlying disease, altered mental status, metabolic acidosis, and acute severe clinical condition at the onset of bacteraemia; development of complications (septic shock, renal failure, and disseminated intravascular coagulopathy); empiric monotherapy with glycopeptides (vs combination therapy with an aminoglycoside); and inadequate empiric treatment. Empiric therapy with linezolid was associated with lower mortality. In multivariate analysis, risk factors associated with higher mortality included acute severity of illness (OR 7.49; 95%CI 1.19-25.3) and altered mental status (OR 4.83; 95%CI 1.22-19.15) at onset, complications (OR 3.42; 95%CI 1.02-17.46), and inappropriate empiric treatment (OR 7.6; 95%CI 1.87-31.14). In multivariate analysis limited to patients who received empiric therapy with either linezolid (n = 17) or glycopeptides (n = 69), linezolid was associated with greater rates of survival (OR 7.7; 95%CI 1.1-53) and microbiological eradication (OR 11.76; 95%CI 1.46-90.9) but not with fewer complications (OR 0.71; 95%CI 0.16-3.25). In conclusion, the main prognostic factors associated with mortality in patients with MRSA bacteraemia are complications, acute severe clinical condition at onset, and inappropriate empiric treatment. Empiric therapy with linezolid was associated with greater survival and more successful microbiological eradication but did not reduce complications.

Bacteriemias por Staphylococcus aureus sensible a meticilina: epidemiología y factores pronósticos. Estudio prospectivo 2000-2003

BACKGROUND

Staphylococcus aureus bacteremia continues to be a major problem in hospitals due to its high prevalence, severity and treatment difficulties. This study aimed to evaluate epidemiological and clinical features, risk factors and influence of antibiotic choice in outcome and mortality in patients with methicillin susceptible S. aureus bacteremia (SAMSB).

PATIENTS AND METHODS

A prospective, observational study of inpatients with SAMSB (2000-3).

RESULTS

A total of 131 with SAMSB were included (mean age 56 years; 58% > or = 60 year-old); 56.5% were due to nosocomial bacteremia; 46% of all patients had an underlying condition (diabetes mellitus being the most frequent [28%]); a risk factor for bacteraemia was identified in 98% (intravenous catheter: 72%). Mortality rate was 16% (21/131). Comparative analysis according to nosocomial or community acquisition showed that the former was more frequent in Surgical Wards, patients with intravenous or urinary catheters, traumatic patients, dialysis and ICU patients. Initial severity and mortality were highest in community-acquired SAMSB. In multivariate analysis, risk factors associated with higher mortality were: presence of an ultimately or rapidly fatal underlying disease, acute severity of illness at onset and inadequate empirical treatment.

CONCLUSIONS

SAMSB is a clinically severe infection that occurs in patients with baseline disease, especially diabetics, that is almost always related to predisposing risk factors (mainly intravenous catheters). In the presence of a serious baseline disease, the initial critical clinical condition and inadequate empirical treatment are the main prognostic factors associated to greater mortality.

Association of the CT gene (CA) polymorphism with BMD in osteoporotic mexican women

Calcitonin (CT) plays a role in the pathogenesis of osteoporosis and genetic variations in or adjacent to the CT gene may be associated with loss of bone mineral density (BMD). The correlation between a dinucleotide (cytosine-adenine) repeat polymorphism at the CT locus and BMD was examined in 70 osteoporotic women, 70 non-osteoporotic women and 500 subjects from the Mexican population. The allele A and genotype AA frequencies were significantly higher in osteoporotic women than in non-osteoporotic women (60% vs 32%; p < 0.0001 and 41% vs 14%; p = 0.0007, respectively). Genotype AA was associated with the presence of osteoporosis [odds ratio 2.58; 95% confidence interval (CI); 1.62-4.12]. Likewise, the loss of lumbar BMD and T scores were related to the presence of allele A: subjects with a single A allele displayed lower values for lumbar BMD and T score (84.02% and -1.51, respectively) than those who do not present any A allele (89.61% and -0.88, respectively). Individuals with two alleles A showed the lowest lumbar BMD and T-score values (73.77% and -2.51, respectively). Analysis of potential confounder demonstrated that aging has a significant effect on osteoporosis development (odds ratio 1.1; 95% CI; 1.1052-1.152).

Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: findings from the RIETE registry

OBJECTIVES

To examine the clinical characteristics and outcomes of cancer patients with venous thromboembolism (VTE) in order to identify factors that place these patients at an increased risk for fatal pulmonary embolism (PE) or fatal bleeding.

PATIENTS AND METHODS

Registro Informatizado de la Enfermedad Trombo Embólica (RIETE) is a prospective registry of consecutive patients with symptomatic, objectively confirmed, acute VTE.

RESULTS

Up to January 2006, a total of 14 391 patients with symptomatic acute VTE were enrolled in RIETE, of whom 2945 (20%) had cancer. During the 3-month follow-up period the frequency of fatal PE in cancer patients was 2.6%, and that of fatal bleeding 1.0%. These frequencies were significantly higher than in VTE patients without cancer (1.4% and 0.3%, respectively). In patients with cancer, abnormal renal function, metastatic disease, recent major bleeding and recent immobility for >or= 4 days (42% of the 108 patients who died from PE or bleeding had recent immobility) were factors independently associated with an increased risk for both fatal PE and fatal bleeding. In addition, PE diagnosis on admission was an independent risk factor for fatal PE, while body weight < 60 kg was an independent risk factor for fatal bleeding.

CONCLUSIONS

Both fatal PE and fatal bleeding are more common in cancer patients with VTE than in those patients without cancer. In cancer patients, abnormal renal function, metastatic disease, recent major bleeding and recent immobility for >or= 4 days are associated with an increased risk for both fatal PE and fatal bleeding.

Instrument for Detection of Delirium in General Hospitals: Adaptation of the Confusion Assessment Method

Delirium is a common and severe disorder that is often misdiagnosed. The use of screening instruments is advisable for its early detection and treatment. In this study, the authors present an adaptation of the Confusion Assessment Method in order to improve its psychometric properties. One hundred fifty-three elderly inpatients were assessed in a four-phase procedure. Interrater reliability was high (kappa = 0.89). Sensitivity was 90%, and specificity was 100%; the value for negative predictive accuracy was 97%, and the value for positive predictive accuracy was 100%. The adaptation has convergent agreement with two other mental status tests, the Mini-Mental Status Examination and the Delirium Rating Scale. Our results suggest that the adaptation of the Confusion Assessment Method is sensitive, specific, reliable, and easy to use by clinicians.

[Clinical patterns of community acquired pneumonia microbiologically documented compared to the not documented.]Prospective and comparative study between 1991 and 1997]

INTRODUCTION

The diagnostic of the pneumonia is the problems more important for its adequate treatment and best evolution.

OBJECTIVES

To study in a prospective way the patron clinic de la NAC compared the documented with the not documented in a microbiological way. PATIENTS Y METHODS: We have studied patients with NAC hospitalized in the HUVA between January of 1991 and May of 1997. The diagnostical criterion of pneumonia and of the hospitable ingress were the classics accepted for this infections, was doing in all cases diagnostical studies not invasive. It was analyzed the clinical patron of the NAC microbiologically documented compare to with the not documented. In the same way, the documented was divided in typical and not typical according to the microorganisms aisled. Besides was realized an statistic study using tables of contingency and test Fisher.

RESULTS

It was studied 409 patients with NAC, from which 161 (39.6%) had microbiological documentation, it was found 119 micro organism typical and 42 atypical. On the one hand, the female sex, EPOC, fever, tos and purulence esputum and hyperglucaemia, were associated significantly with the documented NAC. The presence of cardiopaty, seriously initial clinical situation, gastrointestinal disorders and previous infections and use of antibiotics, were associated with not documented. The age more than 65 years, presence of comorbility, purulence sputum, pleural pain, toghether with VSG>50 and lobar infiltrate, were associated significantly to typical pneumonia, while tabaquical habit and extrapulmonary sintoms (artromialgias) were with the atypical.

CONCLUSIONS

The knowledge of the clinical patrons of the NAC are great impact in the diagnostic and treatment antibiotic adecuate.

Planimetric and histological study of the aortae in atherosclerotic chickens treated with nifedipine, verapamil and diltiazem

Calcium appears to be involved in many of the cellular events which are thought to be important in atherogenesis. Calcium channel blockers have been shown to reduce arterial lipid accumulation in animals without altering serum cholesterol. Avian models of atherosclerosis offer economic and technical advantages over mammalian models. In this study, we examine the effects of nifedipine, verapamil and diltiazem at clinical and higher doses, on the extent of atherosclerosis of egg-fed chickens. In order to assess the extent of atherosclerosis quantitatively, the aortic lesions of the thoracic and abdominal aorta, aortic arch and supraaortic regions were measured by planimetry. Atherosclerotic lesions were evaluated histologically. Statistically significant reductions in the lipid deposition of the aorta were found in all the treated groups. The extent and distribution of atherosclerotic lesions were decreased in a significant way by verapamil, nifedipine and diltiazem. The higher the dosage used, the higher the regression of the atherosclerotic lesions. At clinical dosage, nifedipine showed the highest decrease of the lesions. In addition, the chicken atherosclerosis model has proved itself useful and very suitable for in vivo drug intervention studies.

Effects of isolated obesity on systolic and diastolic left ventricular function

BACKGROUND

Obesity is associated with increased cardiovascular morbidity and mortality. A direct effect of isolated obesity on cardiac function is not well established.

OBJECTIVE

To determine the direct effect of different grades of isolated obesity on echocardiographic indices of systolic and diastolic left ventricular function.

METHODS

48 obese and 25 normal weight women were studied. They had no other pathological conditions. Obesity was classed as slight (n = 17; body mass index (BMI) 25-29.9 kg/m2), moderate (n = 20; BMI 30-34.9 kg/m2), or severe (n = 11; BMI > or = 35 kg/m2). Echocardiographic indices of systolic and diastolic function were obtained, and dysfunction was assumed when at least two values differed by > or = 2 SD from the normal weight group.

RESULTS

Ejection fraction (p < 0.05), fractional shortening (p < 0.05), and mean velocity of circumferential shortening (p < 0.05) were increased in slight and moderate obesity. Left ventricular dimensions were increased (p < 0.001) but relative wall thickness was unchanged. No obese patients met criteria for systolic dysfunction. In obese subjects, the mitral valve pressure half time (p < 0.01) and the left atrial diameter (p < 0.001) were increased and the deceleration slope was decreased (p < 0.01); all other diastolic variables were unchanged. No differences were found between obesity subgroups. Subclinical diastolic dysfunction was more prevalent among obese subjects (p = 0.002), being present in two with slight obesity (12%), seven with moderate obesity (35%), and five with severe obesity (45%). BMI correlated significantly with indices of left ventricular function.

CONCLUSIONS

Subclinical left ventricular diastolic dysfunction is present in all grades of isolated obesity, correlates with BMI, and is associated with increased systolic function in the early stages of obesity.

[Influence of consensual protocols on the use of antibiotics and bacterial resistance in a general hospital. A prospective study 1995-2000]

Reasoned and consensual protocols, by means of diversification of the use of antibiotics, significantly influence their consumption, preventing and reducing the development of bacterial resistance against the Gram-negative microorganisms most frequently isolated in general hospitals. The increase in the consumption of piperacillin-tazobactam was found to be significantly associated with an increased resistance of E. cloacae, but less so in K. pneumoniae and E. coli. Its activity against P. aeruginosa and against P. mirabilis was not affected throughout the study and it maintained a high sensivity to the end against P. aeruginosa and against P. mirabilis and partial recovery of activity against A. baumannii. No statistically significant differences were found between the stable consumption of cefotaxime, ciprofloxacin, ceftazidime and imipenem and bacterial resistance against E. coli, P. aeruginosa, P. mirabilis, K. pneumoniae, E. cloacae and A. baumannii. Imipenem presented greater activity against E. coli, K. pneumoniae, E. cloacae and A. baumannii. Piperacillin-tazobactam showed greater activity against P. aeruginosa, while ciprofloxacin showed the least activity against E. coli and P. mirabilis. Cefotaxime had the least activity against E. cloacae, P. aeruginosa and A. baumannii. Ceftazidime showed stable activity and was similar to piperacillin-tazobactam against E. coli, P. mirabilis, K. pneumoniae, E. cloacae and A. baumannii.

A new algorithm for rhythm discrimination in cardioverter defibrillators based on the initial voltage changes of the ventricular electrogram

AIMS

Ventricular activation onset is faster in supraventricular beats than in ventricular rhythms. The aim of this study was to evaluate a criterion to differentiate supraventricular (SVT) from ventricular tachycardia (VT) based on the analysis of the initial voltage changes in ICD-stored morphology electrograms.

METHODS

Far field ICD-stored EGMs were obtained from 68 VT and 38 SVT episodes in 16 patients. The first EGM peak was detected, three consecutive time epochs were defined within the preceding 80 ms window and the voltage changes with respect to a sinus template were analysed during each time period and combined into a single parameter for rhythm discrimination.

RESULTS

The algorithm was tested in an independent validation group of 442 VT and 97 SVT spontaneous episodes obtained from 22 patients with a dual chamber ICD. The area under the receiver-operator characteristics (ROC) curve indicated that the arrhythmia separability with this method was 0.95 (tolerance interval: 0.85-0.99) and 0.98 (0.87-0.99) for the control and validation groups respectively. A specificity of 0.91 was obtained at 95% sensitivity in the validation group.

CONCLUSION

The analysis of voltage changes during the initial ventricular activation process is feasible using the far field stored electrograms of an ICD system and yields a high sensitivity and specificity for arrhythmia discrimination.

[Pseudomonas aeruginosa bacteremia: clinical and epidemiological patterns and treatment]

Pseudomonas aeruginosa bacteremia has the highest mortality among Gram-negative infections. We studied its clinical and epidemiological patterns in order to achieve an early and accurate diagnosis and treatment. We prospectively studied 211 cases of P. aeruginosa bacteremia admitted to our hospital from 1991 to 1998. All patients had at least one positive blood culture for P. aeruginosa and clinical symptoms of bacteremia. The prognosis of the underlying disease, past illnesses, foci location, initial clinical status, type of bacteremia, complications, and the type of antibiotic treatment were analyzed. Clinical and microbiological controls were carried out at baseline, at the end of the treatment period, and 1 month later. Of the 211 cases, 73% were men with a mean age of 56.5 years. Overall, 45.5% were hospitalized in the ICU, 28% in the surgical ward, and 26% in the medical service, with a mean length of stay of 40.4 days. As risk factors we identified a length of stay more than 14 days (76.7%), previous manipulations (87.6%), and surgery (44.5%). A total of 43.1% had had an infection in the last 6 weeks, and 46.4% were treated with antibiotics, usually broad-spectrum antibiotics without activity against P. aeruginosa. The most frequent underlying diseases were neoplasia (25.5%), postsurgical cardiopathy (24.1%), nephrosis (22.7%), chronic obstructive pulmonary disease (17.5%) and diabetes (13.2%). The most frequent foci were pulmonary (29.3%), urinary (21.8%), and undetermined (38.3%). The mortality rate was 27.9% and was considered related to P. aeruginosa bacteremia in 76.2% of the cases. The antibiotic treatment was considered adequate in 89% of the cases. It was concluded that knowledge of the clinical and epidemiological factors of patients with P. aeruginosa bacteremia may help to optimize its management and to reduce its morbidity and mortality.

[Influence of the application of a rational, consensual protocol on the use of antibiotics in a general hospital]

A large increase in the use of wide-spectrum antibiotics has occurred in Spain. The objective of our study was to evaluate the influence of applying protocols for the use of such antibiotics. A prospective, observational study was carried out based on the information provided by the pharmacy service about prescriptions of ceftriaxone, cefotaxime, ceftazidime, imipenem and ciprofloxacin at the single-dosing department of the hospital. Two groups were included in the study: 1) control group (October-December 1995), which did not take into account the protocols for antibiotic treatment; and 2) the study group, during the same months in 1996, which took into account the consensual protocols. The criteria for the type of patient, infection and outcome, and type of antibiotic treatment were evaluated according to the rules of the international literature for this type of study. The baseline characteristics of both groups of patients were similar. Following the application of the protocol, a decrease in the use of antibiotics was observed (108 cases in group 2 vs. 207 cases in group 1); an increase in the appropriateness of treatment (50.72% in group vs. 77.57% in group 2); an increase in the cure rate (78.26% in group 1 vs. 91.67% in group 2); and a decrease of 5.01 days in the length of hospital stay (22.99 days in group 1 vs. 17.98 days in group 2), which was statistically significant, and thus led to a savings of 2073.74 Euros per cured patient. The application and adherence to a consensual protocol is a beneficial method of using antibiotics since it improves the quality of their use and makes it more cost-effective.

The somatics of psyche: structural neuromorphometry of bipolar disorder

Many neuroimaging investigations report structural differences in subjects with bipolar disorder; however, conflicting results are common in the limited number of available investigations. Thus, the structural correlates of bipolar disorders remain poorly understood. The authors reviewed the early investigations using computed tomography and examined gross structural differences, such as cerebral atrophy, ventricular enlargement, or cerebellar atrophy. Many of these investigations report significant differences in these features compared with controls, whereas others found no such differences. More recent magnetic resonance imaging (MRI) investigations have employed increasingly sophisticated imaging and research methodologies, allowing for the quantitative examination of specific brain regions. Because neuropsychological and functional studies suggest abnormalities in frontal, temporal and subcortical regions, many investigators have focused their MRI neuromorphometric studies on these temporal limbic structures. However, the number of investigations examining each of these regions remains small, and conflicting results continue to be reported. It seems clear that for many brain regions, the structural changes from normal may be subtle, and that the differences in the reported studies may be due to differences in research methodologies between studies and across centers.