Validation of the RIM Score-COVID in the Spanish SEMI-COVID-19 Registry

The significant impact of COVID-19 worldwide has made it necessary to develop tools to identify patients at high risk of severe disease and death. This work aims to validate the RIM Score-COVID in the SEMI-COVID-19 Registry. The RIM Score-COVID is a simple nomogram with high predictive capacity for in-hospital death due to COVID-19 designed using clinical and analytical parameters of patients diagnosed in the first wave of the pandemic. The nomogram uses five variables measured on arrival to the emergency department (ED): age, sex, oxygen saturation, C-reactive protein level, and neutrophil-to-platelet ratio. Validation was performed in the Spanish SEMI-COVID-19 Registry, which included consecutive patients hospitalized with confirmed COVID-19 in Spain. The cohort was divided into three time periods: T1 from February 1 to June 10, 2020 (first wave), T2 from June 11 to December 31, 2020 (second wave, pre-vaccination period), and T3 from January 1 to December 5, 2021 (vaccination period). The model's accuracy in predicting in-hospital COVID-19 mortality was assessed using the area under the receiver operating characteristics curve (AUROC). Clinical and laboratory data from 22,566 patients were analyzed: 15,976 (70.7%) from T1, 4,233 (18.7%) from T2, and 2,357 from T3 (10.4%). AUROC of the RIM Score-COVID in the entire SEMI-COVID-19 Registry was 0.823 (95%CI 0.819-0.827) and was 0.834 (95%CI 0.830-0.839) in T1, 0.792 (95%CI 0.781-0.803) in T2, and 0.799 (95%CI 0.785-0.813) in T3. The RIM Score-COVID is a simple, easy-to-use method for predicting in-hospital COVID-19 mortality that uses parameters measured in most EDs. This tool showed good predictive ability in successive disease waves.

A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients

OBJECTIVE

To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes.

DESIGN

A secondary analysis derived from multicenter, observational study.

SETTING

Critical Care Units.

PATIENTS

Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain.

INTERVENTIONS

Corticosteroids vs. no corticosteroids.

MAIN VARIABLES OF INTEREST

Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes.

RESULTS

A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality.

CONCLUSION

Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

First-in-human phase 2 trial with mite allergoids coupled to mannan in subcutaneous and sublingual immunotherapy

BACKGROUND

Polymerized allergens conjugated to non-oxidized mannan (PM-allergoids) are novel vaccines targeting dendritic cells (DCs). Previous experimental data indicate that PM-allergoids are readily taken up by DCs and induce Treg cells. This first-in-human study was aimed to evaluate safety and to find the optimal dose of house dust mite PM-allergoid (PM-HDM) administered subcutaneously (SC) or sublingually (SL).

METHODS

In a randomized, double-blind, double-dummy, placebo-controlled trial, 196 subjects received placebo or PM-HDM at 500, 1000, 3000, or 5000 mannan-conjugated therapeutic units (mTU)/mL in 9-arm groups for 4 months. All subjects received 5 SC doses (0.5 ml each) every 30 days plus 0.2 ml SL daily. The primary efficacy outcome was the improvement of titrated nasal provocation tests (NPT) with D. pteronyssinus at baseline and at the end of the study. All adverse events and reactions were recorded and assessed. Secondary outcomes were the combination of symptom and medication scores (CSMS) and serological markers.

RESULTS

No moderate or severe adverse reactions were reported. Subjects improving the NPT after treatment ranged from 45% to 62% in active SC, 44% to 61% in active SL and 16% in placebo groups. Statistical differences between placebo and active groups were all significant above 500 mTU, being the highest with 3000 mTU SL (p = 0.004) and 5000 mTU SC (p = 0.011). CSMS improvement over placebo reached 70% (p < 0.001) in active 3000 mTU SC and 40% (p = 0.015) in 5000 mTU SL groups.

CONCLUSIONS

PM-HDM immunotherapy was safe and successful in achieving primary and secondary clinical outcomes in SC and SL at either 3000 or 5000 mTU/ml.

Prior influenza vaccine is not a risk factor for bacterial coinfection in patients admitted to the ICU due to severe influenza

OBJECTIVE

To determine whether the prior usage of the flu vaccine is a risk factor for bacterial co-infection in patients with severe influenza.

DESIGN

This was a retrospective observational cohort study of subjects admitted to the ICU. A propensity score matching, and logistic regression adjusted for potential confounders were carried out to evaluate the association between prior influenza vaccination and bacterial co-infection.

SETTINGS

184 ICUs in Spain due to severe influenza.

PATIENTS

Patients included in the Spanish prospective flu registry.

INTERVENTIONS

Flu vaccine prior to the hospital admission.

RESULTS

A total of 4175 subjects were included in the study. 489 (11.7%) received the flu vaccine prior to develop influenza infection. Prior vaccinated patients were older 71 [61-78], and predominantly male 65.4%, with at least one comorbid condition 88.5%. Prior vaccination was not associated with bacterial co-infection in the logistic regression model (OR: 1.017; 95%CI 0.803-1.288; p=0.885). After matching, the average treatment effect of prior influenza vaccine on bacterial co-infection was not statistically significant when assessed by propensity score matching (p=0.87), nearest neighbor matching (p=0.59) and inverse probability weighting (p=0.99).

CONCLUSIONS

No association was identified between prior influenza vaccine and bacterial coinfection in patients admitted to the ICU due to severe influenza. Post influenza vaccination studies are necessary to continue evaluating the possible benefits.

Is there any effect of flu vaccine on the SARS-CoV-2 infected patients?

Objectives

On 11 March, WHO declared a global pandemic caused by a new virus of the family Coronaviridae that has since been called SARS-CoV-2. COVID-19 does not have specific antiviral drug treatment currently. There are currently more than one hundred research projects into vaccines against SARS-CoV-2 worldwide, and 17 of them are already being tested on humans, according to the WHO. Until we have an effective vaccine, the possible preventive effect of flu vaccine for SARS-CoV-2 infection based on cross-reactivity has been postulated.

Our objective was to analyse the effect of vaccination against flu virus in the season prior to the COVID-19 pandemic in our hospitalized SARS-CoV-2 infected patients.

Methods

We performed a retrospective observational cohort study of patients admitted to hospital with SARS-CoV2 infection. We analysed the differences between patients who had received or had not the flu vaccination for the 2019–2020 season.

Results

We found no significant differences (p = 0.09) in patients who died (43 in total), of whom 23 (21.5%) were vaccinated against the flu and 20 (13.5%) were not. In mortality, we obtained an adjusted OR = 0.873 (95% CI: 0.294–2.083), and about the success of health care the adjusted OR was 1.447 (95% CI: 0.610–3.430).

Conclusions

Flu vaccination in patients admitted for SARS-CoV-2 infection had neither a beneficial nor a harmful effect on the clinical courses or outcomes of patients admitted to an European hospital.

High incidence of pulmonary thromboembolism in hospitalized SARS-CoV-2 infected patients despite thrombo-prophylaxis

Background

Objectives

Methods

Results

Conclusion

Bacterial Mucosal Immunotherapy with MV130 Prevents Recurrent Wheezing in Children: A Randomized, Double-Blind, Placebo-controlled Clinical Trial

Rationale: Recurrent wheezing in children represents a severe public health concern. Wheezing attacks (WA), mainly associated with viral infections, lack effective preventive therapies. Objectives: To evaluate the efficacy and safety of mucosal sublingual immunotherapy based on whole inactivated bacteria (MV130) in preventing WA in children. Methods: A Phase 3 randomized, double-blind, placebo-controlled, parallel-group trial including a cohort of 120 children <3 years old with ⩾3 WA during the previous year was conducted. Children with a positive skin test to common aeroallergens in the area where the clinical trial was performed were excluded from the trial. Subjects received MV130 or placebo daily for 6 months. The primary endpoint was the number of WA within 1 year after the first dose comparing MV130 and placebo. Measurements and Main Results: There was a significant lower number of WA in MV130 versus the placebo group, 3.0 (interquartile range [IQR], 2.0-4.0) versus 5.0 (IQR, 3.0-7.0) (P < 0.001). As secondary outcomes, a decrease in the duration of WA and a reduction in symptoms and medication scores in the MV130 versus placebo group were found. No adverse events were reported related to the active treatment. Conclusions: Mucosal bacterial immunotherapy with MV130 shows safety and clinical efficacy against recurrent WA in children.Clinical trial registered with www.clinicaltrials.gov (NCT01734811).

Prior influenza vaccine is not a risk factor for bacterial coinfection in patients admitted to the ICU due to severe influenza

OBJECTIVE

To determine whether the prior usage of the flu vaccine is a risk factor for bacterial co-infection in patients with severe influenza.

DESIGN

This was a retrospective observational cohort study of subjects admitted to the ICU. A propensity score matching, and logistic regression adjusted for potential confounders were carried out to evaluate the association between prior influenza vaccination and bacterial co-infection.

SETTINGS

184 ICUs in Spain due to severe influenza.

PATIENTS

Patients included in the Spanish prospective flu registry.

INTERVENTIONS

Flu vaccine prior to the hospital admission.

RESULTS

A total of 4175 subjects were included in the study. 489 (11.7%) received the flu vaccine prior to develop influenza infection. Prior vaccinated patients were older 71 [61-78], and predominantly male 65.4%, with at least one comorbid condition 88.5%. Prior vaccination was not associated with bacterial co-infection in the logistic regression model (OR: 1.017; 95%CI 0.803-1.288; p=0.885). After matching, the average treatment effect of prior influenza vaccine on bacterial co-infection was not statistically significant when assessed by propensity score matching (p=0.87), nearest neighbor matching (p=0.59) and inverse probability weighting (p=0.99).

CONCLUSIONS

No association was identified between prior influenza vaccine and bacterial coinfection in patients admitted to the ICU due to severe influenza. Post influenza vaccination studies are necessary to continue evaluating the possible benefits.

Genetic and activity dependent-mechanisms wiring the cortex: Two sides of the same coin

The cerebral cortex is responsible for the higher-order functions of the brain such as planning, cognition, or social behaviour. It provides us with the capacity to interact with and transform our world. The substrates of cortical functions are complex neural circuits that arise during development from the dynamic remodelling and progressive specialization of immature undefined networks. Here, we review the genetic and activity-dependent mechanisms of cortical wiring focussing on the importance of their interaction. Cortical circuits emerge from an initial set of neuronal types that engage in sequential forms of embryonic and postnatal activity. Such activities further complement the cells' genetic programs, increasing neuronal diversity and modifying the electrical properties while promoting selective connectivity. After a temporal window of enhanced plasticity, the main features of mature circuits are established. Failures in these processes can lead to neurodevelopmental disorders whose treatment remains elusive. However, a deeper dissection of cortical wiring will pave the way for innovative therapies.

Evaluation of the immunogenicity and protective efficacy of a recombinant CS6-based ETEC vaccine in an Aotus nancymaae CS6 + ETEC challenge model

Colonization factors or Coli surface antigens (CFs or CS) are important virulence factors of Enterotoxigenic E. coli (ETEC) that mediate intestinal colonization and accordingly are targets of vaccine development efforts. CS6 is a highly prevalent CF associated with symptomatic ETEC infection both in endemic populations and amongst travelers. In this study, we used an Aotus nancymaae non-human primate ETEC challenge model with a CS6 + ETEC strain, B7A, to test the immunogenicity and protective efficacy (PE) of a recombinant CS6-based subunit vaccine. Specifically, we determined the ability of dscCssBA, the donor strand complemented recombinant stabilized fusion of the two subunits of the CS6 fimbriae, CssA and CssB, to elicit protection against CS6 + ETEC mediated diarrhea when given intradermally (ID) with the genetically attenuated double mutant heat-labile enterotoxin LT(R192G/L211A) (dmLT). ID vaccination with dscCssBA + dmLT induced strong serum antibody responses against CS6 and LT. Importantly, vaccination with dscCssBA + dmLT resulted in no observed diarrheal disease (PE = 100%, p = 0.03) following B7A challenge as compared to PBS immunized animals, with an attack rate of 62.5%. These data demonstrate the potential role that CS6 may play in ETEC infection and that recombinant dscCssBA antigen can provide protection against challenge with the homologous CS6 + ETEC strain, B7A, in the Aotus nancymaae diarrheal challenge model. Combined, these data indicate that CS6, and more specifically, a recombinant engineered derivative should be considered for further clinical development.

The clinical evidence of second-generation H1-antihistamines in the treatment of allergic rhinitis and urticaria in children over 2 years with a special focus on rupatadine

INTRODUCTION

Many obstacles limit the development of pharmacologic studies in children, in particular ethical and practical issues. Therefore, although second-generation H1-antihistamines (sgAH) are recommended by international guidelines as first-line therapy in childhood allergies, most data on the efficacy of antihistamines in children has been extrapolated from studies in adult patients.

AREAS COVERED

The current review focuses on rupatadine, a well-studied modern sgAH that has dual affinity for histamine H1-receptors and PAF receptors. In recent years, clinical efficacy and safety controlled-clinical trials on rupatadine were conducted in children and were based on latest current guidelines using validated tools of allergic rhinitis and urticaria.

EXPERT OPINION

Children are not little adults since they present specific physiologic, metabolic, and developmental differences that should be evaluated in specific trials. The clinical evidence with rupatadine in children is the most recent and validated in accordance with current recommendations, with extensive direct data on efficacy and safety in pediatric populations over 2 years old.

Transient callosal projections of L4 neurons are eliminated for the acquisition of local connectivity

Interhemispheric axons of the corpus callosum (CC) facilitate the higher order functions of the cerebral cortex. According to current views, callosal and non-callosal fates are determined early after a neuron’s birth, and certain populations, such as cortical layer (L) 4 excitatory neurons of the primary somatosensory (S1) barrel, project only ipsilaterally. Using a novel axonal-retrotracing strategy and GFP-targeted visualization of Rorb⁺ neurons, we instead demonstrate that L4 neurons develop transient interhemispheric axons. Locally restricted L4 connectivity emerges when exuberant contralateral axons are refined in an area- and layer-specific manner during postnatal development. Surgical and genetic interventions of sensory circuits demonstrate that refinement rates depend on distinct inputs from sensory-specific thalamic nuclei. Reductions in input-dependent refinement result in mature functional interhemispheric hyperconnectivity, demonstrating the plasticity and bona fide callosal potential of L4 neurons. Thus, L4 neurons discard alternative interhemispheric circuits as instructed by thalamic input. This may ensure optimal wiring.

It is traditionally believed that callosal and non-callosal fates are determined early after a neuron’s birth, and that cortical layer (L) 4 excitatory neurons of the primary somatosensory (S1) barrel cortex project only ipsilaterally. However, here authors demonstrate, using a novel axonal retrotracing strategy, that L4 neurons develop transient interhemispheric axons that are refined in an area- and layer-specific manner during postnatal development.

Validation of a Spanish version of the EuroPrevall Food Allergy Quality of Life Questionnaire-Parental Form

BACKGROUND

Food allergy can have a major impact on quality of life of children and their parents. Questionnaires have been developed to measure the impact of this disorder. We aimed to validate the EuroPrevall questionnaire on Food Allergy-Quality of Life Questionnaire, Parent Form (FAQLQ-PF) and the Food Allergy Independent Measure (FAIM), translated into Spanish.

METHODS

The internal consistency of the FAQLQ-PF and the FAIM, translated into Spanish (Spain) and completed by the parents of 74 children with IgE-mediated food allergy, were evaluated with Cronbach's alpha. To test construct validity of the FAQLQ-PF, its correlation with the FAIM was also calculated. To assess their discriminant validity, we compared the values of both depending on the number of offending foods and for children with and without anaphylaxis.

RESULTS

The values of Cronbach's alpha for the three domains in the FAQLQ-PF were over 0.9. The value of alpha for FAIM questions was below 0.6, which was attributed to the wording of one question. When this question was removed, alpha increased to over 0.70. There was a significant correlation between the FAQLQ-PF score and the FAIM. There were significantly poorer FAQLQ-PF scores in children with more food allergies and worse FAIM in those who had had anaphylaxis.

CONCLUSIONS

The Spanish version of the FAQLQ-PF had a good internal consistency, good construct validity and validity to discriminate patients with more food allergies and anaphylaxis. It can be used as a tool to evaluate and monitor the quality of life in families with food allergic children.

[Surgical treatment of tracheal stenosis. A 11-year report in a pediatric hospital]

OBJECTIVES

To report our experience in the surgical treatment of patients having acquired and congenital tracheal stenosis.

MATERIAL AND METHODS

Fifty eight patients with tracheal stenosis were surgically treated between July 2005 and May 2016, 29 were females and 29 were males. Thirty patients had acquired stenosis and 28 had congenital stenosis.

RESULTS

Five to 12 rings were resected (median 5) in 26 patients, in 2 cartilage was grafted in the anterior wall, in another carinostomy was performed, and in the remaining, the trachea was replaced using an aortic cryopreserved graft. In those with congenital stenosis, 14 patients underwent slide technique; in eleven, 3 to 6 rings were resected (median 5); in 3 a patch was grafted in the anterior tracheal wall. Seven patients died: 2 with acquired stenosis and 5 with congenital stenosis. Global survival was 88% (28 of 30 patients with acquired stenosis and 23 of 28 with congenital). From 28 living patients operated on due to acquired stenosis, 26 are asymptomatic, one presents graft stenosis, and one has a stoma in the aortic graft. From 23 living patients operated on due to congenital stenosis, 20 remain asymptomatic and 3 have tracheal stents placed on.

CONCLUSIONS

Surgical treatment of acquired stenosis is easier and presents less severe complications. Congenital stenosis often requires more than one procedure to control the disease, and presents a higher mortality rate.

[Patients treated with micafungin during their stay in intensive care unit]

OBJECTIVES

To determine the reasons of prescription, the characteristics of patients and factors that affected the outcome of critically ill patients treated with micafungin (MCF) during their stay in Spanish ICUs.

MATERIAL AND METHODS

Observational, retrospective and multicenter study. Patients admitted to the ICU between March 2011 and October 2012 (20-month period) treated with MCF for any reason were included in the study. Severity of patients at the beginning of treatment was measured with the APACHE II, SOFA, Child-Pugh and MELD scores. Reasons for the use of MCF were classified as prophylaxis, preemptive treatment, empirical treatment and directed treatment. Continuous variables are expressed as mean and standard deviation or median, and categorical variables as percentages. A multivariate analysis was performed to identify variables related to intra-ICU mortality.

RESULTS

The study population included 139 patients admitted to 19 Spanish ICUs, with a mean age of 57.3 (17.1) years, 89 (64%) men, with surgical (53.2%) and/or medical (44.6%) conditions, APACHE II score of 20.6 (7.7) and SOFA score of 8.4 (4.3), with 84.2% of patients requiring mechanical ventilation, 59% parenteral nutrition, 37.4% extrarenal depuration procedures and 37.4% treatment with steroids. MCF was indicated as empirical treatment of a proven infection in 51 (36.7%) cases, pre-emptive treatment in 50 (36%) especially as a result of the application of the Candida score (32 cases), directed treatment of fungal infection in 23 (16.5%) and as prophylactic treatment in 15 (10.8%) cases. In 108 (77%) cases, a daily dose of 100mg was administered, with a loading dose in only 9 cases (6.5%). The mean duration of treatment was 13.1 (13) days. A total of 59 (42.4%) patients died during their stay in the ICU and 16 after ICU discharge (hospital mortality 53.9%). Independent risk factors for intra-ICU mortality were the Child-Pugh score (OR 1.45, 95% CI 1.162-1.813; P=.001) and the MELD score (OR 1.05, 95% CI 1.011-1.099; P=.014).

CONCLUSIONS

MCF is usually administered at a dose of 100mg/day, without loading dose and in 72.7% of cases as pre-emptive or empirical treatment. Factors that better predicted mortality were indicators of liver insufficiency at the time of starting treatment.

[Progresses in the diagnosis of allergy]

The traditional diagnosis of allergy by Prick tests and/or RAST offers very limited information about the real nature of allergic problems and of their clinical, therapeutic and prognostic implications. The diagnosis by allergic components (natural or recombinant) suppose a great qualitative step leading a great improving in the diagnosis and treatment of allergic patients, because its use with clinical history and other diagnostic in vivo or in vitro methods improve importantly the diagnostic accuracy.

Progresos en el diagnóstico de la alergia

El diagnóstico tradicional de la alergia mediante pruebas por punción, RAST, o ambas, ofrece información muy limitada respecto a la auténtica naturaleza de los problemas alérgicos y de sus implicaciones clínicas, terapéuticas y de pronóstico. El diagnóstico por componentes alergénicos (naturales o recombinantes) supone un gran salto cualitativo que está permitiendo gran mejoría en el diagnóstico y tratamiento de los pacientes alérgicos, porque su uso concomitante con la historia clínica y otros métodos diagnósticos in vivo e in vitro mejora de manera relevante la precisión diagnóstica.

[Recommendations of the Infectious Diseases Work Group (GTEI) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Infections in Critically Ill Patients Study Group (GEIPC) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) for the diagnosis and treatment of influenza A/H1N1 in seriously ill adults admitted to the Intensive Care Unit]

The diagnosis of influenza A/H1N1 is mainly clinical, particularly during peak or seasonal flu outbreaks. A diagnostic test should be performed in all patients with fever and flu symptoms that require hospitalization. The respiratory sample (nasal or pharyngeal exudate or deeper sample in intubated patients) should be obtained as soon as possible, with the immediate start of empirical antiviral treatment. Molecular methods based on nucleic acid amplification techniques (RT-PCR) are the gold standard for the diagnosis of influenza A/H1N1. Immunochromatographic methods have low sensitivity; a negative result therefore does not rule out active infection. Classical culture is slow and has low sensitivity. Direct immunofluorescence offers a sensitivity of 90%, but requires a sample of high quality. Indirect methods for detecting antibodies are only of epidemiological interest. Patients with A/H1N1 flu may have relative leukopenia and elevated serum levels of LDH, CPK and CRP, but none of these variables are independently associated to the prognosis. However, plasma LDH> 1500 IU/L, and the presence of thrombocytopenia <150 x 10(9)/L, could define a patient population at risk of suffering serious complications. Antiviral administration (oseltamivir) should start early (<48 h from the onset of symptoms), with a dose of 75 mg every 12h, and with a duration of at least 7 days or until clinical improvement is observed. Early antiviral administration is associated to improved survival in critically ill patients. New antiviral drugs, especially those formulated for intravenous administration, may be the best choice in future epidemics. Patients with a high suspicion of influenza A/H1N1 infection must continue with antiviral treatment, regardless of the negative results of initial tests, unless an alternative diagnosis can be established or clinical criteria suggest a low probability of influenza. In patients with influenza A/H1N1 pneumonia, empirical antibiotic therapy should be provided due to the possibility of bacterial coinfection. A beta-lactam plus a macrolide should be administered as soon as possible. The microbiological findings and clinical or laboratory test variables may decide withdrawal or not of antibiotic treatment. Pneumococcal vaccination is recommended as a preventive measure in the population at risk of suffering severe complications. Although the use of moderate- or low-dose corticosteroids has been proposed for the treatment of influenza A/H1N1 pneumonia, the existing scientific evidence is not sufficient to recommend the use of corticosteroids in these patients. The treatment of acute respiratory distress syndrome in patients with influenza A/H1N1 must be based on the use of a protective ventilatory strategy (tidal volume <10 ml / kg and plateau pressure <35 mmHg) and positive end-expiratory pressure set to high patient lung mechanics, combined with the use of prone ventilation, muscle relaxation and recruitment maneuvers. Noninvasive mechanical ventilation cannot be considered a technique of choice in patients with acute respiratory distress syndrome, though it may be useful in experienced centers and in cases of respiratory failure associated with chronic obstructive pulmonary disease exacerbation or heart failure. Extracorporeal membrane oxygenation is a rescue technique in refractory acute respiratory distress syndrome due to influenza A/H1N1 infection. The scientific evidence is weak, however, and extracorporeal membrane oxygenation is not the technique of choice. Extracorporeal membrane oxygenation will be advisable if all other options have failed to improve oxygenation. The centralization of extracorporeal membrane oxygenation in referral hospitals is recommended. Clinical findings show 50-60% survival rates in patients treated with this technique. Cardiovascular complications of influenza A/H1N1 are common. Such problems may appear due to the deterioration of pre-existing cardiomyopathy, myocarditis, ischemic heart disease and right ventricular dysfunction. Early diagnosis and adequate monitoring allow the start of effective treatment, and in severe cases help decide the use of circulatory support systems. Influenza vaccination is recommended for all patients at risk. This indication in turn could be extended to all subjects over 6 months of age, unless contraindicated. Children should receive two doses (one per month). Immunocompromised patients and the population at risk should receive one dose and another dose annually. The frequency of adverse effects of the vaccine against A/H1N1 flu is similar to that of seasonal flu. Chemoprophylaxis must always be considered a supplement to vaccination, and is indicated in people at high risk of complications, as well in healthcare personnel who have been exposed.

WIP is a negative regulator of neuronal maturation and synaptic activity

Wiskott-Aldrich syndrome protein (WASP) -interacting protein (WIP) is an actin-binding protein involved in the regulation of actin polymerization in cells, such as fibroblasts and lymphocytes. Despite its recognized function in non-neuronal cells, the role of WIP in the central nervous system has not been examined previously. We used WIP-deficient mice to examine WIP function both in vivo and in vitro. We report here that WIP(-)(/-) hippocampal neurons exhibit enlargement of somas as well as overgrowth of neuritic and dendritic branches that are more evident in early developmental stages. Dendritic arborization and synaptogenesis, which includes generation of postsynaptic dendritic spines, are actin-dependent processes that occur in parallel at later stages. WIP deficiency also increases the amplitude and frequency of miniature excitatory postsynaptic currents, suggesting that WIP(-)(/-) neurons have more mature synapses than wild-type neurons. These findings reveal WIP as a previously unreported regulator of neuronal maturation and synaptic activity.

The trypanocidal activity of the alkaloid oliverine involves inhibition of DNA synthesis

The Trypanosoma cruzi parasite is an etiologic agent of the American trypanosomiasis called Chagas disease. This pathology affects more than 24 million persons and represents one of the most important public health problems in Latin America. Taking into account this, it is necessary the search of new antitrypanosomal agents that show a major level of efficacy and minor indexes of toxicity in affected patients. Vast source of them are the natural products from plants with enormous structural diversity. A particular type of these compounds is represented by aporphinoid alkaloids. In our experiments, anonaine (2), oliverine (3) and guatterine (5) displayed antitrypanosomal activity. The compound 3 showed the most important activity with an IC50 = 12.00 ± 0.36 &#956;M. Its mechanism of action may include inhibition of DNA synthesis.

Variation among endoscopy units in the achievement of the standards of colonoscopic performance indicators

BACKGROUND/AIMS

To assess the achievement of quality standards of colonoscopy at six endoscopy units.

METHODOLOGY

Three indicators were used to assess the quality of 1056 colonoscopies performed at six hospitals: cecal intubation; adequate colon cleansing; and removal and recovery of all detected polyps. Analyses were performed on the total number of colonoscopies and on colonoscopies in which polyps were actually detected. The accomplishment of each indicator and a global compound index of all three indicators, named the Problem Rate, were analyzed. Results from each endoscopy unit were compared to previously established standards.

RESULTS

Adequate colon cleansing was the most frequent problem for quality in all centers; adequate colon preparation was 67% (range 50 to 84%). The cecum was reached in 84% of all colonoscopies (range 76 to 90%). 75% of all patients (range 28. 79%) had all polyps excised and recovered. All centers had rates below standard for one or several indicators (p<0.01, all cases). Two of the participant hospitals had an overall problem rate above the estimated standard (p<0.01).

CONCLUSIONS

There is a significant variation in the achievement of quality standards of colonoscopy between endoscopy units. Colon cleansing is the most frequent quality problem for colonoscopy.

IMPACT: a facility to study the interaction of low-energy intense particle beams with dynamic heterogeneous surfaces

The Interaction of Materials with Particles and Components Testing (IMPACT) experimental facility is furnished with multiple ion sources and in situ diagnostics to study the modification of surfaces undergoing physical, chemical, and electronic changes during exposure to energetic particle beams. Ion beams with energies in the range between 20 and 5000 eV can bombard samples at flux levels in the range of 10(10)-10(15) cm(-2) s(-1); parameters such as ion angle of incidence and exposed area are also controllable during the experiment. IMPACT has diagnostics that allow full characterization of the beam, including a Faraday cup, a beam imaging system, and a retarding field energy analyzer. IMPACT is equipped with multiple diagnostics, such as electron (Auger, photoelectron) and ion scattering spectroscopies that allow different probing depths of the sample to monitor compositional changes in multicomponent and/or layered targets. A unique real-time erosion diagnostic based on a dual quartz crystal microbalance measures deposition from an eroding surface with rates smaller than 0.01 nm/s, which can be converted to a sputter yield measurement. The monitoring crystal can be rotated and placed in the target position so that the deposited material on the quartz crystal oscillator surface can be characterized without transfer outside of the vacuum chamber.

Developing core sets for persons with bipolar disorder based on the International Classification of Functioning, Disability and Health

INTRODUCTION

Functioning is increasingly being taken into account when assessing the impact of bipolar disorder (BD) on the individual, as well as the effectiveness of treatments. With the International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally agreed-upon framework and system for classifying the typical spectrum of problems in functioning, given the environmental context in which subjects live. ICF Core Sets are subgroups of ICF items selected to capture those aspects of functioning that are most likely to be affected by specific disorders. Within a given disorder, both Brief and Comprehensive Core Sets can be established to serve specific purposes.

OBJECTIVE

The aim of this paper is to outline the development process of the ICF Core Sets for BD.

METHODS

The final definition of ICF Core Sets for BD will be determined at an ICF Core-Sets Consensus Conference, which will integrate evidence from preliminary studies, namely (a) semi-structured interviews with people with BD in different countries, (b) a Delphi exercise with international experts participating and (c) a cross-sectional study.

CONCLUSION

ICF Core Sets are being designed with the goal of providing useful standards for research, clinical practice and teaching. We believe that these ICF Core Sets for BD will stimulate research leading to improved understanding of functioning, disability and health in BD. Such research, we hope, will lead to interventions and accommodations to improve restoration and maintenance of functioning and minimise disability among people with BD throughout the world.

Normal cellular senescence and cancer susceptibility in mice genetically deficient in Ras-induced senescence-1 (Ris1)

Oncogenic Ras triggers a permanent cell-cycle arrest known as oncogene-induced senescence (OIS) that constitutes a relevant tumor suppressor mechanism. Ris1 (Ras-induced senescence-1) is a novel gene that was identified in a screen as specifically upregulated during Ras-induced senescence, and that is located at a chromosomal region, 3p21.3, frequently lost in human cancer. Moreover, Ris1 is highly conserved in vertebrates, does not present paralogs, and its sequence does not reveal similarities with other proteins or domains. To analyse the physiological function of Ris1 and test its putative role as a tumor suppressor gene, we have generated mutant mice deficient for this gene. Ris1-null mice are viable, fertile, develop normally and do not display any obvious abnormalities. Of relevance, Ris1-deficient mice had a normal lifespan and did not exhibit predisposition to spontaneous tumors or to tumors induced by chemical carcinogens. Finally, Ris1-deficient embryonic fibroblasts were indistinguishable from wild-type cells regarding their proliferation properties, immortalization, senescence and oncogenic transformation. These findings do not support a role of Ris1 in tumor suppression or in OIS.

Androgen-dependent regulation of Her-2/neu in prostate cancer cells

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Background: The mechanisms underlying the progression of prostate cancer to androgen independence remain poorly understood. Overexpression of Her-2/neu (c-ErbB2) activates the androgen receptor pathway and confers a survival and growth advantage to prostate cancer cells in an androgen-deficient milieu. Methods: Androgen-sensitive prostate cancer cell line LNCaP was used as a model system in vitro and in vivo. Experiments in mice were undertaken by injecting cells orthotopically into the ventral lobe of the mice prostate. Results: Here, we report that androgen receptor (AR) and Her-2/neu reciprocally regulate each other in LNCaP human prostate cancer cells. Absence of androgens, AR blockade with Casodex (bicalutamide) or suppression of AR with RNAi induced Her-2/neu protein expression and phosphorylation in vitro and in vivo. Similarly, suppression of Her-2-neu expression resulted in AR upregulation. In contrast, upon re-administration of androgens, Her-2/neu mRNA, protein and phosphorylation levels decreased linearly with increasing concentrations of androgens as LNCaP cells re-entered the cell cycle. Conclusions: Thus, induction and activation of Her-2/neu occurs in an androgen-depleted environment or as a result of AR inactivation, promoting androgen-independent survival of prostate cancer cells.

No significant financial relationships to disclose.

A novel icetexane diterpene, 5-epi-icetexone from Salvia gilliessi is active against Trypanosoma cruzi

In this work the effect of a novel compound, 5-epi-icetexone (ICTX) obtained from Salvia gilliessi Benth. (Labiatae), is studied on cultured epimastigotes of Trypanosoma cruzi (Tulahuen). It was found that the compound exerts an antiproliferative effect on the parasites at concentrations between 2.8 and 4.2 microM, and similar sensitivity in other strains (Dm28c, CL-Brener and Y-strain). The compound was deleterious at concentrations higher than 4.2 microM, with an estimated IC50 of 6.5+/-0.75 microM, but with low cytotoxicity to mammalian cells. These effects were irreversible, even at short times of exposure to the drug. In solution, ICTX showed to be stable for at least 96 h at 29 degrees C. With cytostatic dose a little percentage of parasites was resistant to the action of ICTX, and they continued growing although with different kinetic. By electron transmission microscopy, at dose of 4.2 microM an external vesiculization was observed on the first day of exposure to the compound, but the parasite cytoplasm became plenty of vacuoles and exhibited nuclear disorganization from the second day of exposure. It was concluded that ICTX is active against T. cruzi and may act by multiple mechanisms. In future, this novel icetexane diterpene may be a good candidate for therapeutic use against Chagas' disease.

Abnormal Sp1 transcription factor expression in Alzheimer disease and tauopathies

Sp1 transcription factor expression was examined by immunohistochemistry, immunofluorescence and confocal microscopy in Alzheimer disease (AD), Pick disease (PiD), progressive supranuclear palsy (PSP), Parkinson disease (PD) and Dementia with Lewy bodies (DLB). Sp1 partly co-localizes with hyper-phosphorylated tau deposits in neurofibrillary tangles, dystrophic neurites of senile plaques and neuropil threads in AD, and in neurons, astrocytes and oligodendrocytes bearing hyper-phosphorylated tau in PiD and PSP. Sp1 is not found in alpha-synuclein inclusions in PD and DLB. These modifications are not associated with changes in the total expression levels of Sp1, as revealed with gel electrophoresis and Western blotting of brain homogenates. Furthermore, no co-immunoprecipitation of Sp1 and phospho-tau was observed in AD and PiD cases. Since Sp1 binding sites are present in the promoters of several genes involved in amyloid and tau, and Sp1 is regulated by oxidative stress, the present findings suggest that Sp1 deposition in hyper-phosphorylated tau deposits may have functional consequences in the pathology of AD and other tauopathies.

Applicability of the Rockall score in patients undergoing endoscopic therapy for upper gastrointestinal bleeding

BACKGROUND

The Rockall score is used to assess the prognosis of patients with upper gastrointestinal bleeding.

AIM

To assess the applicability of the Rockall score in patients undergoing endoscopic therapy for upper gastrointestinal bleeding.

METHODS

Retrospective evaluation of the Rockall score in the period 1995-2001. To evaluate the applicability of the Rockall system, two groups were created: group I (Rockall<or=5 points) and group II (Rockall>or=6 points).

RESULTS

Two hundred and twenty-two patients were included. The median age of patients was 65 +/ -17 years. Hypotension and associated diseases were present in 20 and 50% of patients, respectively. Re-bleeding occurred in 50 patients (23%) whose median score was 7, whereas the median score of patients without re-bleeding was 6 (p=0.14). There were 20 deaths (9%) with a median score of 8, whilst the median score of surviving patients was 6 (p<0.001). Sixteen patients in group I (18.4%) and 34 in group II (25.2%) re-bled (p=0.25). All the patients who died belong to group II with a Rockall score>or=6 (15% versus 0% in groups II and I, respectively, p<0.001).

CONCLUSION

The Rockall score can be used in patients who undergo therapeutic endoscopy for upper gastrointestinal bleeding to identify those with high risk for mortality.

Accelerated amyloid deposition, neurofibrillary degeneration and neuronal loss in double mutant APP/tau transgenic mice

Even though the idea that amyloid beta peptide accumulation is the primary event in the pathogenesis of Alzheimer's disease has become the leading hypothesis, the causal link between aberrant amyloid precursor protein processing and tau alterations in this type of dementia remains controversial. We further investigated the role of beta-amyloid production/deposition in tau pathology and neuronal cell death in the mouse brain by crossing Tg2576 and VLW lines expressing human mutant amyloid precursor protein and human mutant tau, respectively. The resulting double transgenic mice showed enhanced amyloid deposition accompanied by neurofibrillary degeneration and overt neuronal loss in selectively vulnerable brain limbic areas. These findings challenge the idea that tau pathology in Alzheimer's disease is merely a downstream effect of amyloid production/deposition and suggest that reciprocal interactions between beta-amyloid and tau alterations may take place in vivo.

Increased sensitivity to MPTP in human alpha-synuclein A30P transgenic mice

In addition to genetic factors, environmental factors have long been suspected to contribute to the pathogenesis of Parkinson's disease (PD). We investigated the possible interaction between genetic factors and neurotoxins by testing whether alpha-synuclein A30P Tg5093 transgenic mice show increased sensitivity to secondary toxic insults like 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) or rotenone. While sensitivity to chronic treatment with rotenone was not enhanced in the Tg5093 line, chronic treatment with 80 or 150 mg/kg MPTP resulted in increased deterioration of the nigrostriatal dopaminergic system as assessed by quantitation of nigral tyrosine hydroxylase (TH) positive neurons and striatal dopamine (DA) levels in Tg5093 mice when compared to non-transgenic littermate controls. Thus, the results of this study demonstrate a role for the overexpression of mutant human alpha-synuclein A30P in increased vulnerability of DA neurons to MPTP.

A randomised open-label study of tiagabine given two or three times daily in refractory epilepsy

Efficacy and tolerability of tiagabine was evaluated in patients with non-controlled partial seizures in a multicentre, open-label, parallel group study. Tiagabine was administered either two (b.i.d.) or three times daily (t.i.d.) as adjunctive therapy and titrated stepwise to a target of 40 mg/day during a 12-week, fixed-schedule titration period; this was followed by a 12-week flexible continuation period. The primary efficacy endpoint was the proportion of patients completing the fixed-schedule titration period. A total of 243 patients were randomised and received treatment, 123 to b.i.d. and 120 to t.i.d. dosing. Fewer patients in the b.i.d. (76 and 62%) than in the t.i.d. (87 and 72%) group completed the fixed-schedule titration period (OR: 0.562; 95% CI: 0.309-1.008; P=0.0532). The median percentage decrease in all types of seizure (excluding status epilepticus) during the fixed schedule titration period was 33.4% for the b.i.d. and 23.8% for the t.i.d. groups (P=0.9634; Van Elteren's test). The proportion of responders was similar for the b.i.d. and t.i.d. groups. There were no significant differences between dosage regimens in the change in median seizure rates from baseline. Adverse events were more frequent during the titration than the continuation period. Most events were mild and related to the central nervous system. Although their incidence was similar between treatment groups, severity was more frequent in the b.i.d. group. Our results suggest that during titration tiagabine is better tolerated with t.i.d. dosing, but during long-term maintenance, a t.i.d. schedule is as effective and well tolerated as b.i.d.