Streptococcus Species Abundance in the Gut Is Linked to Subclinical Coronary Atherosclerosis in 8973 Participants From the SCAPIS Cohort

BACKGROUND

Gut microbiota have been implicated in atherosclerotic disease, but their relation with subclinical coronary atherosclerosis is unclear. This study aimed to identify associations between the gut microbiome and computed tomography-based measures of coronary atherosclerosis and to explore relevant clinical correlates.

METHODS

We conducted a cross-sectional study of 8973 participants (50 to 65 years of age) without overt atherosclerotic disease from the population-based SCAPIS (Swedish Cardiopulmonary Bioimage Study). Coronary atherosclerosis was measured using coronary artery calcium score and coronary computed tomography angiography. Gut microbiota species abundance and functional potential were assessed with shotgun metagenomics sequencing of fecal samples, and associations with coronary atherosclerosis were evaluated with multivariable regression models adjusted for cardiovascular risk factors. Associated species were evaluated for association with inflammatory markers, metabolites, and corresponding species in saliva.

RESULTS

The mean age of the study sample was 57.4 years, and 53.7% were female. Coronary artery calcification was detected in 40.3%, and 5.4% had at least 1 stenosis with >50% occlusion. Sixty-four species were associated with coronary artery calcium score independent of cardiovascular risk factors, with the strongest associations observed for Streptococcus anginosus and Streptococcus oralis subsp oralis (P<1×10-5). Associations were largely similar across coronary computed tomography angiography-based measurements. Out of the 64 species, 19 species, including streptococci and other species commonly found in the oral cavity, were associated with high-sensitivity C-reactive protein plasma concentrations, and 16 with neutrophil counts. Gut microbial species that are commonly found in the oral cavity were negatively associated with plasma indole propionate and positively associated with plasma secondary bile acids and imidazole propionate. Five species, including 3 streptococci, correlated with the same species in saliva and were associated with worse dental health in the Malmö Offspring Dental Study. Microbial functional potential of dissimilatory nitrate reduction, anaerobic fatty acid β-oxidation, and amino acid degradation were associated with coronary artery calcium score.

CONCLUSIONS

This study provides evidence of an association of a gut microbiota composition characterized by increased abundance of Streptococcus spp and other species commonly found in the oral cavity with coronary atherosclerosis and systemic inflammation markers. Further longitudinal and experimental studies are warranted to explore the potential implications of a bacterial component in atherogenesis.

Accurate detection of benign and malignant renal tumor subtypes with MethylBoostER: An epigenetic marker-driven learning framework

Current gold standard diagnostic strategies are unable to accurately differentiate malignant from benign small renal masses preoperatively; consequently, 20% of patients undergo unnecessary surgery. Devising a more confident presurgical diagnosis is key to improving treatment decision-making. We therefore developed MethylBoostER, a machine learning model leveraging DNA methylation data from 1228 tissue samples, to classify pathological subtypes of renal tumors (benign oncocytoma, clear cell, papillary, and chromophobe RCC) and normal kidney. The prediction accuracy in the testing set was 0.960, with class-wise ROC AUCs >0.988 for all classes. External validation was performed on >500 samples from four independent datasets, achieving AUCs >0.89 for all classes and average accuracies of 0.824, 0.703, 0.875, and 0.894 for the four datasets. Furthermore, consistent classification of multiregion samples (N = 185) from the same patient demonstrates that methylation heterogeneity does not limit model applicability. Following further clinical studies, MethylBoostER could facilitate a more confident presurgical diagnosis to guide treatment decision-making in the future.

Time-resolved hadronic particle acceleration in the recurrent nova RS Ophiuchi

Recurrent novae are repeating thermonuclear explosions in the outer layers of white dwarfs, due to the accretion of fresh material from a binary companion. The shock generated when ejected material slams into the companion star's wind can accelerate particles. We report very-high-energy (VHE, [Formula: see text]) gamma rays from the recurrent nova RS Ophiuchi, up to a month after its 2021 outburst, observed using the High Energy Stereoscopic System. The VHE emission has a similar temporal profile to lower-energy GeV emission, indicating a common origin, with a two-day delay in peak flux. These observations constrain models of time-dependent particle energization, favoring a hadronic emission scenario over the leptonic alternative. Shocks in dense winds provide favorable environments for efficient acceleration of cosmic-rays to very high energies.

High chromosomal mobility of rDNA clusters in holocentric chromosomes of Triatominae, vectors of Chagas disease (Hemiptera-Reduviidae)

The subfamily Triatominae (Hemiptera-Reduviidae) includes more than 150 blood-sucking species, potential vectors of the protozoan Trypanosoma cruzi, causative agent of Chagas disease. A distinctive cytogenetic characteristic of this group is the presence of extremely stable chromosome numbers. Unexpectedly, the analyses of the chromosomal location of ribosomal gene clusters and other repetitive sequences place Triatominae as a significantly diverse hemipteran subfamily. Here, we advance the understanding of Triatominae chromosomal evolution through the analysis of the 45S rDNA cluster chromosomal location in 92 Triatominae species. We found the 45S rDNA clusters in one to four loci per haploid genome with different chromosomal patterns: On one or two autosomes, on one, two or three sex chromosomes, on the X chromosome plus one to three autosomes. The movement of 45S rDNA clusters is discussed in an evolutionary context. Our results illustrate that rDNA mobility has been relatively common in the past and in recent evolutionary history of the group. The high frequency of rDNA patterns involving autosomes and sex chromosomes among closely related species could affect genetic recombination and the viability of hybrid populations, which suggests that the mobility of rDNA clusters could be a driver of species diversification.

Revealing x-ray and gamma ray temporal and spectral similarities in the GRB 190829A afterglow

Gamma-ray bursts (GRBs), which are bright flashes of gamma rays from extragalactic sources followed by fading afterglow emission, are associated with stellar core collapse events. We report the detection of very-high-energy (VHE) gamma rays from the afterglow of GRB 190829A, between 4 and 56 hours after the trigger, using the High Energy Stereoscopic System (H.E.S.S.). The low luminosity and redshift of GRB 190829A reduce both internal and external absorption, allowing determination of its intrinsic energy spectrum. Between energies of 0.18 and 3.3 tera-electron volts, this spectrum is described by a power law with photon index of 2.07 ± 0.09, similar to the x-ray spectrum. The x-ray and VHE gamma-ray light curves also show similar decay profiles. These similar characteristics in the x-ray and gamma-ray bands challenge GRB afterglow emission scenarios.

Multimessenger observations of a flaring blazar coincident with high-energy neutrino IceCube-170922A

Previous detections of individual astrophysical sources of neutrinos are limited to the Sun and the supernova 1987A, whereas the origins of the diffuse flux of high-energy cosmic neutrinos remain unidentified. On 22 September 2017, we detected a high-energy neutrino, IceCube-170922A, with an energy of ~290 tera–electron volts. Its arrival direction was consistent with the location of a known γ-ray blazar, TXS 0506+056, observed to be in a flaring state. An extensive multiwavelength campaign followed, ranging from radio frequencies to γ-rays. These observations characterize the variability and energetics of the blazar and include the detection of TXS 0506+056 in very-high-energy γ-rays. This observation of a neutrino in spatial coincidence with a γ-ray–emitting blazar during an active phase suggests that blazars may be a source of high-energy neutrinos.

Search for γ-Ray Line Signals from Dark Matter Annihilations in the Inner Galactic Halo from 10 Years of Observations with H.E.S.S

Spectral lines are among the most powerful signatures for dark matter (DM) annihilation searches in very-high-energy γ rays. The central region of the Milky Way halo is one of the most promising targets given its large amount of DM and proximity to Earth. We report on a search for a monoenergetic spectral line from self-annihilations of DM particles in the energy range from 300 GeV to 70 TeV using a two-dimensional maximum likelihood method taking advantage of both the spectral and spatial features of the signal versus background. The analysis makes use of Galactic center observations accumulated over ten years (2004-2014) with the H.E.S.S. array of ground-based Cherenkov telescopes. No significant γ-ray excess above the background is found. We derive upper limits on the annihilation cross section ⟨σv⟩ for monoenergetic DM lines at the level of 4×10^{-28}  cm^{3} s^{-1} at 1 TeV, assuming an Einasto DM profile for the Milky Way halo. For a DM mass of 1 TeV, they improve over the previous ones by a factor of 6. The present constraints are the strongest obtained so far for DM particles in the mass range 300 GeV-70 TeV. Ground-based γ-ray observations have reached sufficient sensitivity to explore relevant velocity-averaged cross sections for DM annihilation into two γ-ray photons at the level expected from the thermal relic density for TeV DM particles.

H.E.S.S. Limits on Linelike Dark Matter Signatures in the 100 GeV to 2 TeV Energy Range Close to the Galactic Center

A search for dark matter linelike signals iss performed in the vicinity of the Galactic Center by the H.E.S.S. experiment on observational data taken in 2014. An unbinned likelihood analysis iss developed to improve the sensitivity to linelike signals. The upgraded analysis along with newer data extend the energy coverage of the previous measurement down to 100 GeV. The 18 h of data collected with the H.E.S.S. array allow one to rule out at 95% C.L. the presence of a 130 GeV line (at l=-1.5°, b=0° and for a dark matter profile centered at this location) previously reported in Fermi-LAT data. This new analysis overlaps significantly in energy with previous Fermi-LAT and H.E.S.S.

RESULTS

No significant excess associated with dark matter annihilations was found in the energy range of 100 GeV to 2 TeV and upper limits on the gamma-ray flux and the velocity weighted annihilation cross section are derived adopting an Einasto dark matter halo profile. Expected limits for present and future large statistics H.E.S.S. observations are also given.

The use of ertapenem for the treatment of community-acquired pneumonia in routine hospital practice: a matched cohort study

OBJECTIVE

The clinical response to ertapenem in community-acquired pneumonia (CAP) at the setting of routine hospital practice has been scarcely evaluated.

METHODS

We retrospectively compared CAP cases treated with ertapenem or with other standard antimicrobials (controls) at a tertiary 1,434-bed center from 2005 to 2014.

RESULTS

Out of 6,145 patients hospitalized with CAP, 64 (1%) ertapenem-treated and 128 controls were studied (PSI IV-V 72%, mean age 73 years.). A significant higher proportion of bedridden patients (41% vs. 21%), residence in nursing homes (19% vs. 7%), previous use of antibiotics (39% vs. 29%) and necrotizing (13% vs. 1%) or complicated (36% vs. 19%) pneumonia, was observed in the ertapenem vs. non-ertapenem patients. Initial treatment with ertapenem was independently associated with an earlier resolution of signs of infection. In patients aged 65 or older the independent risks factors for mortality were: PSI score (7.0, 95%CI 1.8-27.7), bedridden status (4.6, 95%CI 1.1-20.9) and Health Care Associated Pneumonia (HCAP) (4.6, 95%CI 1.3-16.5). First-line treatment with ertapenem was an independent protector factor in this subgroup of patients (0.1, 95%CI 0.1-0.7).

CONCLUSIONS

Ertapenem showed a superior clinical response in frail elderly patients with complicated community-acquired pneumonia, and it may be considered as a first-line therapeutic regimen in this setting.

Search for Dark Matter Annihilations towards the Inner Galactic Halo from 10 Years of Observations with H.E.S.S

The inner region of the Milky Way halo harbors a large amount of dark matter (DM). Given its proximity, it is one of the most promising targets to look for DM. We report on a search for the annihilations of DM particles using γ-ray observations towards the inner 300 pc of the Milky Way, with the H.E.S.S. array of ground-based Cherenkov telescopes. The analysis is based on a 2D maximum likelihood method using Galactic Center (GC) data accumulated by H.E.S.S. over the last 10 years (2004-2014), and does not show any significant γ-ray signal above background. Assuming Einasto and Navarro-Frenk-White DM density profiles at the GC, we derive upper limits on the annihilation cross section ⟨σv⟩. These constraints are the strongest obtained so far in the TeV DM mass range and improve upon previous limits by a factor 5. For the Einasto profile, the constraints reach ⟨σv⟩ values of 6×10^{-26}  cm^{3} s^{-1} in the W^{+}W^{-} channel for a DM particle mass of 1.5 TeV, and 2×10^{-26}  cm^{3} s^{-1} in the τ^{+}τ^{-} channel for a 1 TeV mass. For the first time, ground-based γ-ray observations have reached sufficient sensitivity to probe ⟨σv⟩ values expected from the thermal relic density for TeV DM particles.

Constraints on an annihilation signal from a core of constant dark matter density around the milky way center with H.E.S.S

An annihilation signal of dark matter is searched for from the central region of the Milky Way. Data acquired in dedicated on-off observations of the Galactic center region with H.E.S.S. are analyzed for this purpose. No significant signal is found in a total of ∼9  h of on-off observations. Upper limits on the velocity averaged cross section, ⟨σv⟩, for the annihilation of dark matter particles with masses in the range of ∼300  GeV to ∼10  TeV are derived. In contrast to previous constraints derived from observations of the Galactic center region, the constraints that are derived here apply also under the assumption of a central core of constant dark matter density around the center of the Galaxy. Values of ⟨σv⟩ that are larger than 3×10^{-24}  cm^{3}/s are excluded for dark matter particles with masses between ∼1 and ∼4  TeV at 95% C.L. if the radius of the central dark matter density core does not exceed 500 pc. This is the strongest constraint that is derived on ⟨σv⟩ for annihilating TeV mass dark matter without the assumption of a centrally cusped dark matter density distribution in the search region.

Search for photon-linelike signatures from dark matter annihilations with H.E.S.S

Gamma-ray line signatures can be expected in the very-high-energy (E(γ)>100 GeV) domain due to self-annihilation or decay of dark matter (DM) particles in space. Such a signal would be readily distinguishable from astrophysical γ-ray sources that in most cases produce continuous spectra that span over several orders of magnitude in energy. Using data collected with the H.E.S.S. γ-ray instrument, upper limits on linelike emission are obtained in the energy range between ∼ 500 GeV and ∼ 25 TeV for the central part of the Milky Way halo and for extragalactic observations, complementing recent limits obtained with the Fermi-LAT instrument at lower energies. No statistically significant signal could be found. For monochromatic γ-ray line emission, flux limits of (2 × 10(-7) -2 × 10(-5)) m(-2) s(-1) sr(-1) and (1 × 10(-8) -2 × 10(-6)) m(-2) s(-1)sr(-1) are obtained for the central part of the Milky Way halo and extragalactic observations, respectively. For a DM particle mass of 1 TeV, limits on the velocity-averaged DM annihilation cross section ⟨σv⟩(χχ → γγ) reach ∼ 10(-27) cm(3)s(-1), based on the Einasto parametrization of the Galactic DM halo density profile.

[Assessment of basic activities of daily living and cognitive impairment in centenarians: correlation between the scales used]

OBJECTIVE

To analyse the concordance between different scales used to assess basic activities of daily living and cognitive impairment in centenarians.

METHOD

A domiciliary interview was carried out with all centenarians in our area. Three scales of basic activities of daily living (Katz index [KI], Barthel index [BI], Red Cross physical impairment index [RCPI]), and two of cognitive impairment assessment(Mini cognoscitive test [MCT], Red Cross psychic impairment index [RCPI]) were completed.

RESULTS

A total of 80 centenarians were interviewed, 26 men and 64 women, mean age 100.8±1.3. More than half of centenarians had functional independence or slight dependence. Men were more frequently independent than women (BI 70±34.4 vs. 50.4±36.3; P=.005). The results of cognitive impairment tests were discordant, although men had less cognitive impairment than women (MCT 16.5±9.1 vs. 11.6±8.1; P=.008). The three scales of basic activities of daily living uniformly classified the centenarians, with a high level of concordance between them: KI and BI similarly classified up to 95% of the centenarians (Kappa 0.899), BI and RCPI to 97.5% (kappa 0.95), KI and RCPI to 97.5% (Kappa 0.95). Nevertheless, the concordance between the cognitive impairment measured by RCPI and MCT was low; only 58.8% of centenarians were equally classified (Kappa 0.295).

CONCLUSIONS

Any of three scales analysed for assessment of basic activities of daily living is useful in centenarians. Nevertheless, the best way to assess cognitive impairment in these patients needs to be defined.

Search for a dark matter annihilation signal from the galactic center halo with H.E.S.S

A search for a very-high-energy (VHE; ≥100  GeV) γ-ray signal from self-annihilating particle dark matter (DM) is performed towards a region of projected distance r∼45-150  pc from the Galactic center. The background-subtracted γ-ray spectrum measured with the High Energy Stereoscopic System (H.E.S.S.) γ-ray instrument in the energy range between 300 GeV and 30 TeV shows no hint of a residual γ-ray flux. Assuming conventional Navarro-Frenk-White and Einasto density profiles, limits are derived on the velocity-weighted annihilation cross section (σv) as a function of the DM particle mass. These are among the best reported so far for this energy range and in particular differ only little between the chosen density profile parametrizations. In particular, for the DM particle mass of ∼1  TeV, values for (σv) above 3×10(-25)  cm(3) s(-1) are excluded for the Einasto density profile.

Energy spectrum of cosmic-ray electrons at TeV energies

The very large collection area of ground-based gamma-ray telescopes gives them a substantial advantage over balloon or satellite based instruments in the detection of very-high-energy (>600 GeV) cosmic-ray electrons. Here we present the electron spectrum derived from data taken with the High Energy Stereoscopic System (H.E.S.S.) of imaging atmospheric Cherenkov telescopes. In this measurement, the first of this type, we are able to extend the measurement of the electron spectrum beyond the range accessible to direct measurements. We find evidence for a substantial steepening in the energy spectrum above 600 GeV compared to lower energies.

Limits on an energy dependence of the speed of light from a flare of the active galaxy PKS 2155-304

In the past few decades, several models have predicted an energy dependence of the speed of light in the context of quantum gravity. For cosmological sources such as active galaxies, this minuscule effect can add up to measurable photon-energy dependent time lags. In this Letter a search for such time lags during the High Energy Stereoscopic System observations of the exceptional very high energy flare of the active galaxy PKS 2155-304 on 28 July 2006 is presented. Since no significant time lag is found, lower limits on the energy scale of speed of light modifications are derived.

[25 years experience in cerebrospinal shunt. Are new systems better?]

INTRODUCTION

Since the introduction of the first ventricular shunt in 1949, the cerebrospinal shunts are the most used choice for the management of hydrocephalus in children. With the technological advance, systems have been developing increasingly sophisticated. Our aim is to study the incidence of complications after the implantation of these shunts and the variables associated to it.

MATERIAL AND METHODS

We perform a retrospective study between 1981 and 2006, gathering the patients between 0 and 15 years treated at our Hospital for the placement of a cerebrospinal shunt or as consequence of a problem of the device. We analyze the tipe of shunt (Hakim, Pudentz, Delta, Orbis-Sigma, Strata, Codman), etiology of hydrocephalus, age, immediate and late complications, permanence of the system, changes of the system and cerebrospinal fluid. The qualitative data were analyze by c2 test. We also estimate survival of shunts with Kaplan-Meier stimator and make a multivariant Cox regression analysis.

RESULTS

A total of 75 patients. The main etiology for hydrocephalous was myelomeningocele, followed by congenital and posthemorrhagic. Most of the patients presented complications of the system in the follow-up. They were adjusted for age, sex, etiology, shunt and surgeon. The variable that had an independent effect for predicting the presence of a complication was the type of shunt, being the most ancient systems those with major survival. The most frequent complication in the immediate period (< 3 month) was the obstruction and infection of the proximal catheter or shunt. Distal catheter disconnection or break prevailed in the late one. We got few functional complications, these were not related with the type of shunt.

CONCLUSIONS

In our experience, the shunts with the less short-term probability of complication (< 3 months) have been old simple systems like Hakim and Pudentz. The functional complications, that are those which presumably should be reduced by the new programmable systems, don,t seem do it, neither mean longer survival of the system.

Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes in primary care. The gap between guidelines and reality in Spain

To evaluate the level and factors affecting control of diabetes and cardiovascular risk factors in type 2 diabetes (TYPE 2 DM) patients. Multicentre cross-sectional study: a sample of 430 primary care practices across Spain selected 1907 type 2 diabetic patients. The first five consecutive ambulatory patients with TYPE 2 DM were eligible for the inclusion into the survey. Patients were free of known cardiovascular disease (CVD). Control criteria were defined based on 2002 American Diabetes Association (ADA) clinical practice recommendations. A total of 1907 patients (51% women) aged 63 +/- 9 years. Smoking prevalence was 22.6%, 50.6% had levels of A1c < 7%. Mean blood pressure (BP) was 148 +/- 17/86 +/- 10 mmHg. Only 7.8% have achieved the target of BP < 130/80 mmHg. Among the 1180 patients (65%) treated for hypertension, this target was attained in only 4.4% of patients. A measurement for low-density lipoprotein (LDL) cholesterol was available in 1669 patients (88%). Only 5.9% of patients achieved the target of LDL < 100 mg/dl. Among the 638 patients (41.6%) on drug treatment for dyslipidaemia, this target was attained in only 5.6% of patients. Among type 2 diabetic patients in Spain the prevalence of cardiovascular risk factors is high. Control of glycaemia, smoking, BP and LDL are far from optimal despite the widespread use of guidelines for the management of diabetes and CVD. The application of published recommendations needs to be reinforced.

Fast Variability of Tera–Electron Volt γ Rays from the Radio Galaxy M87

The detection of fast variations of the tera-electron volt (TeV) (10(12) eV) gamma-ray flux, on time scales of days, from the nearby radio galaxy M87 is reported. These variations are about 10 times as fast as those observed in any other wave band and imply a very compact emission region with a dimension similar to the Schwarzschild radius of the central black hole. We thus can exclude several other sites and processes of the gamma-ray production. The observations confirm that TeV gamma rays are emitted by extragalactic sources other than blazars, where jets are not relativistically beamed toward the observer.

HESS observations of the galactic center region and their possible dark matter interpretation

The detection of gamma rays from the source HESS J1745-290 in the Galactic Center (GC) region with the High Energy Spectroscopic System (HESS) array of Cherenkov telescopes in 2004 is presented. After subtraction of the diffuse gamma-ray emission from the GC ridge, the source is compatible with a point source with spatial extent less than 1.2;{'}(stat) (95% C.L.). The measured energy spectrum above 160 GeV is compatible with a power law with photon index of 2.25+/-0.04(stat)+/-0.10(syst) and no significant flux variation is detected. It is finally found that the bulk of the very high energy emission must have non-dark-matter origin.

A low level of extragalactic background light as revealed by γ-rays from blazars

The diffuse extragalactic background light consists of the sum of the starlight emitted by galaxies through the history of the Universe, and it could also have an important contribution from the 'first stars', which may have formed before galaxy formation began. Direct measurements are difficult and not yet conclusive, owing to the large uncertainties caused by the bright foreground emission associated with zodiacal light. An alternative approach is to study the absorption features imprinted on the gamma-ray spectra of distant extragalactic objects by interactions of those photons with the background light photons. Here we report the discovery of gamma-ray emission from the blazars H 2356 - 309 and 1ES 1101 - 232, at redshifts z = 0.165 and z = 0.186, respectively. Their unexpectedly hard spectra provide an upper limit on the background light at optical/near-infrared wavelengths that appears to be very close to the lower limit given by the integrated light of resolved galaxies. The background flux at these wavelengths accordingly seems to be strongly dominated by the direct starlight from galaxies, thus excluding a large contribution from other sources-in particular from the first stars formed. This result also indicates that intergalactic space is more transparent to gamma-rays than previously thought.

Discovery of very-high-energy γ-rays from the Galactic Centre ridge

The source of Galactic cosmic rays (with energies up to 10(15) eV) remains unclear, although it is widely believed that they originate in the shock waves of expanding supernova remnants. At present the best way to investigate their acceleration and propagation is by observing the gamma-rays produced when cosmic rays interact with interstellar gas. Here we report observations of an extended region of very-high-energy (> 10(11) eV) gamma-ray emission correlated spatially with a complex of giant molecular clouds in the central 200 parsecs of the Milky Way. The hardness of the gamma-ray spectrum and the conditions in those molecular clouds indicate that the cosmic rays giving rise to the gamma-rays are likely to be protons and nuclei rather than electrons. The energy associated with the cosmic rays could have come from a single supernova explosion around 10(4) years ago.

[Renal transplantation in the northwest of Spain: analysis of the activity in the region of Galicia]

BACKGROUND

Spain is the world leader in organ transplant rates, and the national average is maintained in the northwestern Spanish region of Galicia. However, there is no official registry recording transplantation results in this region. In this paper we report a study of patient and graft survival and risk factors among kidney transplant patients in Galicia between January 1996 and December 2000.

METHODS

Patients receiving kidney transplants in Galicia in the above period were monitored up to the end of 2001, deaths and graft losses were recorded and analysed by actuarial and Kaplan-Meier methods, and possible risk factors for death and graft loss were evaluated using Cox's proportional hazards model.

RESULTS

In the study period, 672 kidneys were transplanted, all from deceased donors. Graft and patient survival rates were respectively 80% and 94% after 1 year, and 67% and 83%, after 5 years. Two-thirds of graft losses occurred within the first year and the most common cause was vascular thrombosis (44%). Independent risk factors for graft loss were donor asystole (relative risk [RR] = 3.41, 95% confidence interval [CI]: 1.73-6.73), donor age (RR = 1.54, CI: 1.05-2.27 for 40-60-year-olds, RR = 2.59, CI: 1.66-4.07 for over-60s, relative to under-40s), donation from outside the institution in which implant was performed (RR = 1.43, CI: 1.02-2.02), acute rejection (RR = 2.32, CI: 1.63-3.22), and retransplantation (RR = 1.56, CI: 1.03-2.37). The main causes of death were infections (38%), followed by cardiovascular pathologies (30%) and tumours (11%).

CONCLUSIONS

The kidney transplant rate varies excessively within Galicia; the global rate is 50 per million inhabitants per year. Patient survival is similar to those recorded in national registers, but graft survival is deficient, apparently due to a high incidence of vascular thrombosis.

Discovery of Very High Energy Gamma Rays Associated with an X-ray Binary

X-ray binaries are composed of a normal star in orbit around a neutron star or stellar-mass black hole. Radio and x-ray observations have led to the presumption that some x-ray binaries called microquasars behave as scaled-down active galactic nuclei. Microquasars have resolved radio emission that is thought to arise from a relativistic outflow akin to active galactic nuclei jets, in which particles can be accelerated to large energies. Very high energy gamma-rays produced by the interactions of these particles have been observed from several active galactic nuclei. Using the High Energy Stereoscopic System, we find evidence for gamma-ray emission of >100 gigaelectron volts from a candidate microquasar, LS 5039, showing that particles are also accelerated to very high energies in these systems.

A new population of very high energy gamma-ray sources in the Milky Way

Very high energy gamma-rays probe the long-standing mystery of the origin of cosmic rays. Produced in the interactions of accelerated particles in astrophysical objects, they can be used to image cosmic particle accelerators. A first sensitive survey of the inner part of the Milky Way with the High Energy Stereoscopic System (HESS) reveals a population of eight previously unknown firmly detected sources of very high energy gamma-rays. At least two have no known radio or x-ray counterpart and may be representative of a new class of "dark" nucleonic cosmic ray sources.

High-energy particle acceleration in the shell of a supernova remnant

A significant fraction of the energy density of the interstellar medium is in the form of high-energy charged particles (cosmic rays). The origin of these particles remains uncertain. Although it is generally accepted that the only sources capable of supplying the energy required to accelerate the bulk of Galactic cosmic rays are supernova explosions, and even though the mechanism of particle acceleration in expanding supernova remnant (SNR) shocks is thought to be well understood theoretically, unequivocal evidence for the production of high-energy particles in supernova shells has proven remarkably hard to find. Here we report on observations of the SNR RX J1713.7 - 3946 (G347.3 - 0.5), which was discovered by ROSAT in the X-ray spectrum and later claimed as a source of high-energy gamma-rays of TeV energies (1 TeV = 10(12) eV). We present a TeV gamma-ray image of the SNR: the spatially resolved remnant has a shell morphology similar to that seen in X-rays, which demonstrates that very-high-energy particles are accelerated there. The energy spectrum indicates efficient acceleration of charged particles to energies beyond 100 TeV, consistent with current ideas of particle acceleration in young SNR shocks.

[Prognostic markers determining the start of dialysis]

BACKGROUND

It is widely known that renal disease progresses towards the terminal stage regardless of the cause. The aim of this study is to identify prognostic factors in the progression that determine the start of dialysis.

METHODS

From january 1998 until december 1999, 76 patients diagnosed with renal failure were monitored, 52 of whom started dialysis treatments. Clinical and analytical variables were studied. An actuarial analysis was carried out following the methodology of Kaplan-Meier to determine the likelihood of the need for dialysis and the Cox proportional risk analysis was also used.

RESULTS

The patients enrolled in this study were between 20 and 78 years of age. 49 (64.5%) of the subjects were men and 27 (35.5%) were women. The most prevalent pathology was nephroangiosclerosis (26.3%), followed by diabetes (25.0%). During the monitoring program, 68.4% of the patients began dialysis treatments (table I). Systolic blood pressure, haemoglobin and the total proteins were univariately identified as prognostic variables. 89.47% and 71.58% of the patients with a systolic blood pressure reading of under 140 mmHg had not begun dialysis after 12 and 24 months respectively. 87.02% and 53.63% of the patients with a systolic blood pressure reading of over 140 mmHg had not begun dialysis after 12 and 24 months respectively (p = 0.025) (fig. 1). With a haemoglobin level higher than 10 gr/dl after 12 months 92.7% had not started dialysis, dropping to 72.33% after 24 months. With a haemoglobin level of under 10 g/dl 78.6% and 37.59% had not started dialysis after 12 and 24 months respectively (p = 0.0008) (fig. 2). Taking into account the mean values of different variables in the two year period prior to starting or not starting dialysis, it was found that haemoglobin significantly affected the risk of the need to start dialysis treatments [RR = 0.729; 95% CI = (0.554;0.959)], while systolic blood pressure was on the borderline of statistical significance (table IV).

CONCLUSIONS

Haemoglobin levels significantly affect the risk of the need to start dialysis treatments, while other variables were identified as possible prognostic factors.

[Lung cancer in the health care area of A Coruña (Spain): incidence, clinical approach and survival]

OBJECTIVE

To determine the incidence, clinical approach, diagnostic delay and survival for bronchogenic carcinoma (BC) in the public health area of A Coruña (Spain).

PATIENTS AND METHOD

This was a retrospective study of patients with a diagnosis of BC made in 1995 and 1996 in a health care area with 509,000 inhabitants. For analysis we gathered demographic, clinical and cyto-histologic data and analyzed diagnostic delay, extension of disease and time of death. Crude, age-specific and age-standardized incidences were calculated.

RESULTS

BC was diagnosed in 378 patients (95% men and 5% women). The crude incidence was 37 per 100,000 inhabitants (73.7 per 100,000 men and 3 per 100,000 women) and the age-standardized incidence was 21.7 per 100,000. Diagnosis was by cyto-histology in 87% of the cases, and the most frequent biopsy finding was epidermoid carcinoma. Diagnosis was by clinical or radiologic findings for 13.7%, and patients in that group were older and had greater comorbidity. No symptoms were present in 13% and in those patients diagnosis was earlier, with non-small BC predominating and 60% treated surgically. The diagnostic delay (time from the first symptom to histologic confirmation) was 2.5 months (median, 2.1), and length of delay did not affect survival. Surgery was performed in 23% of the patients with non-small BC. The median survival was 7.1 months (5.2 months for patients who were not treated surgically, and 37.6 for those who were).

CONCLUSIONS

The incidence of BC in men in our study is consistent with that reported for other Spanish regions, although the incidence we observed for women is much lower. Diagnostic delay did not affect survival. The percentage of patients with surgical-stage disease is very low and survival is very short. These findings support the need for early diagnosis.

Factors leading to the removal of the intrauterine implant Gynefix

OBJECTIVE

The objective of this study was to determine the incidence of expulsion of the Gynefix intrauterine implant, to analyze the variables associated with the above and to examine the efficacy of this intrauterine contraceptive model in users at the Municipal Family Planning Center-SERGAS in A Coruña, Spain.

METHODS

A prospective observational study was performed on all women (n = 358) who had a Gynefix implant inserted from March 1998 to September 2000.

RESULTS

The accumulated incidence of implant expulsion was 6.7% (95% confidence interval (CI) 4.4-9.9) with a pregnancy rate of 0.6% (95% CI 0.09-2.2). The probability of implant removal decreases with the rise in the number of implants that have been inserted by the professional. A multivariate analysis adjusted for age, number of implants and uterine position showed that the position of the uterus was the variable that independently determined the probability of removal.

CONCLUSIONS

It is concluded that retroflexion of the uterus increases the probability of removal.

Factors predicting a hospital stay of over 3 days in patients with acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

To investigate the factors predicting a hospital stay of over 3 days in patients who required hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD).

DESIGN AND SETTING

A cross-sectional study was done at a tertiary hospital serving an area of 500 000 inhabitants.

SUBJECTS

A total of 273 patients (alpha=0.05; accuracy=5.94%) who had been admitted consecutively to the Short Stay Medical Unit at the Juan Canalejo Hospital in A Coruña, from February 1998 to March 1999, with a diagnosis focusing on exacerbation of COPD. Methods. Demographic variables, past medical history, symptoms, arterial blood gases, functional tests, treatment and the cause of exacerbation were studied in each patient. The hospital stay was dichotomized into <or=3 vs. >3 days. The prognostic factors of a hospital stay were determined by log regression. Results. The mean stay was 4.6 +/- 5.1 days (range: 1-64). After monitoring the associated covariables, the following were found to have an independent effect on the prediction of a hospital stay of over 3 days: weekend admissions (OR=4.17; 95% CI: 2.42-7.18), the presence of cor pulmonale (OR=2.19; 95% CI: 1.27-3.78), and the respiratory rate on admission (OR=1.09; 95% CI: 1.03-1.14). Arterial blood gases and functional tests showed no independent effect. Conclusions. The factors having an independent prognostic value in determining the length of hospital stays in patients with COPD are weekend admission, cor pulmonale and respiratory rate. Additional studies are required to validate these findings.

The importance of the removal of the intrauterine device in genital colonization by actinomyces

OBJECTIVE

To determine whether, in addition to treatment with antibiotics, it is necessary to remove the intrauterine device (IUD) to eliminate genital colonization by Actinomyces.

METHODS

A randomized clinical trial was carried out. Patients were divided into two groups. The intervention group did not have their IUDs removed, while the control group did. Both groups were treated with trimethoprim and sulfamethoxazole. A total of 43 patients were included.

RESULTS

The patients from the intervention group and the control group proved to be comparable. The post-intervention cytology smear tested negative for Actinomyces in 100% of the patients whose IUD had been removed and in 66.7% of those whose IUD had not been removed (p = 0.005). The probability that colonization by Actinomyces will continue if the IUD is not removed is greater the longer the patient has been exposed to the IUD. After 24 months, relative risk (RR) = 2, after 36 months RR = 2.16 and after 48 months RR = 2.66.

CONCLUSIONS

The removal of the IUD has been effective in genital colonization by Actinomyces. The protective effect exerted by the removal of the IUD was found to be greater in proportion to the length of time the patient had used it.

Operative results and death predictors for nonruptured abdominal aortic aneurysms in the elderly

Elective repair of abdominal aortic aneurysms (AAA) in the elderly has conventionally been associated with higher mortality rates than in younger patients, although some authors do not agree with this view. The aim of this study is to look into current results of surgical treatment in elderly patients with nonruptured AAA and to define those factors associated with an increased mortality. Over a period of 2 years (1995-1996), 183 patients aged 75 or older were operated on for nonruptured AAA in 21 hospitals. Their medical records were reviewed and those factors that could be related to death were analyzed. Those variables with statistical significance through univariate analysis were entered into a multivariate logistic regression model to predict mortality. The results showed that surgery for nonruptured AAA in the elderly has a greater mortality rate than that in younger patients, but it is not so great as to deny surgical correction to prevent rupture in selected cases, especially if they are unsuitable for endovascular repair. These patients must first undergo thorough cardiac and renal function evaluation. Selective screening must be considered, so earlier detection and treatment in younger patients can be performed.

Surgical treatment of ruptured abdominal aortic aneurysms in the elderly

The aims of this study were to investigate current results of surgical treatment for elderly patients with ruptured abdominal aortic aneurysms (AAA) and to define factors associated with mortality. The study included 112 patients aged 75 years or older who were operated on for a ruptured AAA. The surgeries took place from January 1995 to December 1996 in 21 hospitals in Spain. Variables that could be related to death were retrospectively analyzed by entering data into SPSS statistical software. These variables included sex, age, diabetes, hypertension, cardiopathy, pulmonary obstructive disease, renal dysfunction, symptomatic cerebrovascular disease, peripheral occlusive disease, peripheral aneurysms, hematocrit on admission, preoperative hypotension, loss of consciousness, cardiac arrest, AAA location, aneurysm size, type of rupture, place of aortic cross-clamping, type of graft, use of cell saver, technical complications, intraoperative blood loss, and transfusion requirements. Postoperative complications were also considered, including renal failure, sepsis, coagulopathy, cardiac complications, pulmonary complications, colon ischemia, prosthetic graft complications, and need for reoperation. For univariate statistical analysis, the Student's t-test, Mann-Whitney test, and chi-square test were used. Those variables showing statistical significance were entered into a multivariate logistic regression model. The results of these analyses indicate that in elderly patients undergoing surgery for ruptured AAA have a high operative mortality. Comorbid factors, however, were not identified as independent predictors of death. Surgery should not be denied these patients and selective screening should be contemplated.

Eight years with the same IUD

The purpose of this study was to determine the efficacy of the TCu380A (GYNET 380 IUD) in long-term users for periods of > 5 years and to obtain the incidence of Actinomyces as related to length of use and reasons for removal. The report is a retrospective descriptive study of all the clinical cases (n = 370 patients) at the Municipal Family Planning Centre-SERGAS A Coruña, Spain, of women who had a TCu380A IUD inserted during the period 1988-1989 with a September 1997 cutoff date for data analysis. A total of 271 (73.5%) patients had been using the TCu380A IUD for > 5 years with 100% efficacy. The accumulated incidence of Actinomyces was 5.9% (CI 95%: 3.8-8.9). The highest incidence was found between the second and third year of use. There was no increase in the incidence of Actinomyces after 5 years of use. The most common reason for removal of the IUD was the duration of use of 8 years with the same device (32.3%).

Achalasia: the usefulness of manometry for evaluation of treatment

Although manometry is used with increasing frequency to evaluate the effectiveness of different treatments for achalasia, the criteria for a successful manometric response have not been well defined. Manometric responses were collected before and after 43 treatments in 35 patients with achalasia in order to determine manometric changes after different clinical outcomes: 15 unsuccessful outcomes and 28 successful outcomes were reported. In the latter, resting pressure of the lower esophageal sphincter decreased to 12.8 mm Hg, whereas in unsuccessful outcomes this was significantly higher (28.2 mm Hg). A decrease of lower esophageal sphincter pressure below 17 mm Hg or more than 40% of the pretreatment level was associated with successful outcomes. Our data suggest that manometry is a good indicator of therapeutic effectiveness and we propose that it be used systematically for objective evaluation of achalasia treatment.

[Community acquired pneumonia requiring admission to hospital. Etiology and follow-up of 366 cases]

An eighteen-month prospective study designed to determine the incidence, etiology and prognosis of community acquired pneumonia (CAP) in adults requiring admission to hospital.

METHODS

We studied 366 patients admitted to hospital after being diagnosed of CAP at the Emergency Room of a General Hospital. Standard laboratory methods were used for culture from blood and sputum, and serology tests for Legionella pneumophila. Mycoplasma pneumoniae, Chlamydia psittaci and Coxiella burnetti. Patients were evaluated until complete recovery, paying special attention to prognostic factors predictive of death.

RESULTS

An etiological diagnosis was established in 99 patients (27.6%). Legionella pneumophila was the most common pathogen accounting for 30 cases (8.2%), followed by Streptococcus pneumoniae with 26 cases. 26 patients died (mortality rate of 7%); factors predictive of death included pre-existing disease, tachypnea and elevated blood urea nitrogen level.

CONCLUSIONS

CAP represented 4.4% of admissions. Legionella pneumophila was the most frequently identified pathogen. If tachypnea and/or uremia are noted on admission, there is an increase in the risk of death.

Long term effects of ritodrine on blood pressure and heart rate of adolescents exposed during the prenatal stage

OBJECTIVE

To determine the long term cardiovascular effects in adolescents exposed to ritodrine during prenatal stage.

STUDY DESIGN

Twenty-seven ritodrine-exposed subjects and 19 controls, of both sexes, clinically healthy, and born at normal term, were evaluated for systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) each during 48 hours, with a Colin Ambulatory monitor. Data analysis were performed by individual Cosinor method, and non-parametric Mann Whitney's test and Lamotte procedures.

RESULTS

Adolescents who were exposed to ritodrine showed losses in the HR rhythm and rising middle pulse values. Although SBP and DBP rhythm remains constant, the increase of maximum and minimum values for SBP as well as a rise of maximal rates of DBP suggest a possible hypertensive effect mediated by beta mimetic exposure.

CONCLUSION

This study suggests a hypertensive effect mediated by beta mimetic exposure.