[Epidemiology, treatment and mortality in infection by carbapenemase-producing Enterobacteriaceae: retrospective study]. / Epidemiología, tratamiento y mortalidad en pacientes infectados por enterobacterias productoras de carbapenemasas: estudio retrospectivo.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) has become a significant problem in terms of public health and clinical outcome. OBJECTIVE: To assess the epidemiology, treatment and mortality in patients with infection due to CPE. MATERIAL AND METHODS: A retrospective analysis of 163 patients with CPE infection was carried out in a university hospital from July 2013 to October 2015. RESULTS: A total of 163 patients were included over the study period. Klebsiella pneumoniae was isolated in 95.1% of cases, and most of carbapenemases belonged to the OXA-48 group (93.0%). Acquisition was nosocomial in 124 cases (77.0%), healthcare-associated in 30 (18.6%), and 7 cases (4.3%) were community-acquired. The most frequent infections identified in this study were urinary tract (48.4%) and respiratory (19.5%) infections. Approximately half of the patients received antibiotic monotherapy. The 30-day mortality rate was 23.3%. Multivariate analysis revealed that the presence of septic shock at diagnosis (OR 4.2; IC 95% 1.5-11) was independently associated with an increase in death during the first month, unable to identify association with inappropriate antibiotic treatment. DISCUSSION: Further studies are needed to clarify whether antibiotic treatment of EPC infections should be combined or if monotherapy might be sufficient in mild infections.

Epidemiología, tratamiento y mortalidad en pacientes infectados por enterobacterias productoras de carbapenemasas: estudio retrospectivo / Epidemiology, treatment and mortality in infection by carbapenemase-producing Enterobacteriaceae: retrospective study

Resumen Introducción: Las enterobacterias productoras de carbapenemasas (EPC) suponen un reto para la salud pública y la práctica clínica. Objetivo: Analizar la epidemiología, el tratamiento y la mortalidad en pacientes infectados por EPC. Material y Métodos: Análisis retrospectivo de 163 pacientes infectados por EPC en un hospital universitario desde julio de 2013 a octubre de 2015. Resultados: Klebsiella pneumoniae fue aislada en 95,1% de los casos, y la mayoría de las carbapenemasas pertenecían al grupo OXA-48 (93%). La adquisición fue nosocomial en 124 casos (77%), asociada a cuidados sanitarios en 30 (18,6%), y 7 (4,3%) fueron de adquisición comunitaria. Las infecciones más frecuentes fueron las del tracto urinario (48,4%) y las respiratorias (19,5%). Aproximadamente, la mitad de los pacientes recibieron monoterapia antimicrobiana. La tasa de mortalidad a los 30 días fue de 23,3%. El análisis multivariante identificó que la presencia de shock séptico al diagnóstico (OR 4,2; IC 95% 1,5-11) estaba asociada de manera independiente con mayor mortalidad en el primer mes, sin lograr identificar asociación con el tratamiento antimicrobiano inapropiado. Discusión: Son necesarios más estudios para aclarar si el tratamiento antimicrobiano de las infecciones por EPC debe ser combinado o si podría ser suficiente la monoterapia en infecciones leves.

Abstract Background: Carbapenemase-producing Enterobacteriaceae (CPE) has become a significant problem in terms of public health and clinical outcome. Objective: To assess the epidemiology, treatment and mortality in patients with infection due to CPE. Material and Methods: A retrospective analysis of 163 patients with CPE infection was carried out in a university hospital from July 2013 to October 2015. Results: A total of 163 patients were included over the study period. Klebsiella pneumoniae was isolated in 95.1% of cases, and most of carbapenemases belonged to the OXA-48 group (93.0%). Acquisition was nosocomial in 124 cases (77.0%), healthcare-associated in 30 (18.6%), and 7 cases (4.3%) were community-acquired. The most frequent infections identified in this study were urinary tract (48.4%) and respiratory (19.5%) infections. Approximately half of the patients received antibiotic monotherapy. The 30-day mortality rate was 23.3%. Multivariate analysis revealed that the presence of septic shock at diagnosis (OR 4.2; IC 95% 1.5-11) was independently associated with an increase in death during the first month, unable to identify association with inappropriate antibiotic treatment. Discussion: Further studies are needed to clarify whether antibiotic treatment of EPC infections should be combined or if monotherapy might be sufficient in mild infections.

Historical epidemiology of hepatitis C virus in select countries-volume 4.

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

Strategies to manage hepatitis C virus infection disease burden-Volume 4.

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets-"WHO Targets" (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm: Volume 4.

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

Evaluation of oral microbiota in undernourished and eutrophic children using checkerboard DNA-DNA hybridization.

The aim of this study was to evaluate the relationship among nutritional status, gingival health and the composition of oral microbiota in children of a public school from a very poor area of San Miguel de Tucuman. Forty-five children ranging in age from 6 to 14 years old, 13 males and 32 females were studied. Twenty of these children were undernourished (Lejarraga-Morasso Table) and twenty-five were eutrophic. A clinical study that included DMF and dmf indexes, Löe Silness Plaque Index and bleeding on probing was performed. For microbiological study, saliva samples without stimulation were taken; aliquots of them were immediately placed in TAE buffer pH 7.6, adding NaOH (N and keeping at -70 °C until processed by checkerboard DNA-DNA hybridization method to check the presence of 40 oral microorganism species. Positive bleeding on probing was present in more than 80% of children, without significant differences between eutrophic and undernourished groups. Same result were obtain for the other clinical indexes (p > 0.05, Two Way ANOVA). Significant differences were found for some oral microorganism species, with a higher percentage of undernourished children harboring them. That was the case of S. gordonii (p < 0.05), Capnocitophaga gingivalis and C. ochraceae (p < 0.01 and p < 0.10, respectively), F. nucleatum ss nucleatum (p < 0.05), P. nigrescens (p < 0.10), Campylobacter gracilis (p < 0,05), and T. denticola (p < 0.10, multiple logistic regression). Significant differences were also found between children groups for E. saborreum (p < 0.001), P. acnes (p < 0.10), G. morbillorum (p < 0.05) and L. buccalis (p < 0.10). Gingivitis and bleeding on probing would not be related to nutritional status in the groups of children studied. There were significant differences for the presence of some of the main periodontal pathogen species between eutrophic and undernourished children. It would be important to study the meaning of significant differences found for the other microorganisms more deeply.

Cuidados al fin de la vida en geriatría / Care at the end of life in geriatrics

With aging, there are various geriatric syndromes that along with the most prevalent chronic diseases make harder the clinical management of the senior citizen patient. It is known that cancer as a disease is included in many palliative programs in the world, not so, another kind of chronic and degenerative diseases that gradually advance to cause the death of many patients. The intention of this document is to review the recommendations in order to give a better care at the end of the life of the geriatric patient. Always taking into account that people have the right to receive an adequate medical care with quality and that nowadays it is not possible that a sick person presents suffering by their uncontrolled symptoms. It is a work of the society and professionals to improve knowledge of palliative medicine and have a humane and compassionate attitude towards the terminal patient.

Estudio de la sensibilidad a los antimicrobianos de patógenos periodontales / Study of antimicrobial susceptibility of periodontal pathogens

Considerando que las diversas fallas en la implementación de la terapia antimicrobiana para el tratamiento de las periodontitis conducen a la aparición de cepas resistentes a los mismos, el objetivo de este trabajo fue realizar un estudio preliminar del patrón de resistencia a los antimicrobianos de uso común en la clínica de cepas de Porphyromonas gingivalis, Prevotella intermedia y Fusobacterium nucleatum. La prueba de sensibilidad a los antimicrobianos se realizó por el método de dilución en agar descrito por la NCCLS (National Committee for Clinical Laboratory Standards). Se probaron antimicrobianos seleccionados entre los más utilizados en la práctica clínica en nuestro medio: amoxicilina, clindamicina, doxiciclina, eritromicina, metronidazol y tetraciclina. Los resultados mostraron que el 100 por ciento de las cepas de P. gingivalisfueron resistentes a metronidazol y sensibles a tetraciclina, y un 33 por ciento sensibles a clindamicina. Las CIMs obtenidas para amoxicilina estuvieron entre 1 y 32 mg/ml, para doxiciclina entre 0,125 y 5 mg/ml y para eritromicina entre 8 y >32 mg/ml. En el caso de P. intermedia, se observó también un 100 por ciento de resistencia a metronidazol, un 67 por ciento de sensibilidad a tetraciclina y un 62,5 por ciento a clindamicina. Las CIMs para amoxicilina estuvieron entre 0,125 y 16 mg/ml, para doxicilina entre 0,125 y 4 mg/ml, y para eritromicina entre 8 y > 32 mg/ml. El 100 por ciento de las cepas de F. nucleatum resultaron sensibles a tetraciclina y resistentes a metronidazol, y el 25 por ciento fueron sensibles a clindamicina. En cuanto a amoxicilina, las CIMs estuvieron entre 0,125 y 16 mg/ml, para doxicilina entre 0,125 y 4 mg/ml, y eritromicina entre 16 y >32 mg/ml. Los patrones de resistencia obtenidos con estas cepas mostraron en general mayores porcentajes de resistencia que lo reportado por otros autores, lo que podría deberse a la falta de políticas de control en el uso de antimicrobianos en nuestro país...

Taking into account that several failures in antibiotic treatments used in periodontitis are driving to the appearance of resistant strains, the aim of this work was to realize a preliminary study of the resistance pattern to commonly used antimicrobials of regional Porphyromonas gingivalis, Prevotella intermedia and Fusobacterium nucleatum strains. Antibiotic susceptibility test was performed by NCCLS (National Committee for Clinical Laboratory Standards) agar dilution method. Proof antibiotics were selected among the most used in the clinical practice in our region: amoxicillin, clindamycin, doxycycline, erythromycin, metronidazole and tetracycline. The results showed that 100 percent of P.gingivalis strains were resistant to metronidazole and susceptible to tetracycline, and 33 percent susceptible to clindamycin. The MICs obtained for amoxicillin were between 1 and 32 mg/ml, for doxycycline between 0,125 and 5 mg/ml and for erythromycin between 8 and >32 mg/ml. In the case of P. intermedia, were also observed a 100 percent of resistance to metronidazole, 67 percent of susceptibility to tetracycline, and 62,5 percent of susceptibility to clindamycin.. The MICs for amoxicillin were between 0,125 y 16 mg/ml, for doxycycline between 0,125 and 4 mg/ml, and for erythromycin between 8 and >32 mg/ml. 100 percent of F. nucleatum strains were susceptible to tetracycline and resistant to metronidazole, and a 25 percent susceptible to clindamycin. MICs to amoxicillin were between 0,125 y 16 mg/ml, for doxycycline between 0,125 and 4 mg/ml, and to erythromycin between 16 and >32 mg/ml. Resistance patterns obtained with strains of our region showed higher percentages of resistance than those reported by other authors, which might owe to the lack of control politicise for the use of antimicrobials in our country. However, MICs values founded for the 50 and 90 percent of strains are similar to tose reported by NCCLS, except in the case of doxycycline, ...

Determinación de la variación de la contaminación ambiental en salas de clínica de la Facultad de Odontología UNT / Determination of the variation of environmental pollution in clinical facilities of the Faculty of Dentistry UNT

El control de infección es considerado uno de los principales intereses de la comunidad dental, ya que numerosos agentes infecciosos pueden transmitirse entre pacientes y el personal de la salud oral. Una de las potenciales vías de infección es el bioaerosol generado durante la práctica odontológica por los instrumentos de alta velocidad. Los aerosoles pueden ser inhalados, causando enfermedades infecciosas como gripe, tuberculosis y otras. El objetivo de este trabajo fue determinar la variación de la contaminación ambiental de las Salas Clínicas de la Facultad de Odontología de la UNT en distintas épocas del año. Para las siembras ambientales se utilizó el método de impactación por gravedad, exponiendo durante una hora cajas con agar sangre en diferentes zonas de las Salas Clínicas A, B y C. Fueron incubadas en aerobiosis a 37 C, durante 72 horas. Las exposiciones se realizaron en tres épocas del período lectivo: 1- El último día de práctica antes del receso invernal. 2- Durante el receso invernal. 3- El primer día de actividad luego del receso. Se usó el test de Anova de medidas repetidas para determinar: Un Efecto estadísticamente significativo entre los recuentos obtenidos de cada período con un P<0.0001.Un Efecto de interacción sala-período P=0.03. Un Efecto de sala P= 0.08 pero con una significancia del 10 por ciento. Estos resultados apoyan la necesidad de cumplir con las Normas de Bioseguridad, y establecer un Protocolo de limpieza y ventilación en la Salas de Clínicas de la Facultad

The infection control is considered one of the main interests of the dental community because there are lots of infectious agents that can be transmitted among patients and the personnel of oral health. One of the potential infection roads is the bioaerosol generated in the dentistry practice by the use of high-speed instruments. The infectious aerosols can be inhaled, causing infectious illnesses as flu, tuberculosis and others. The aim of this work was to determine how the contamination generated by aerosols in the clinical rooms of the FOUNT evolved in different times of the year. For this the impaction method by graveness was developed, using blood agar plates exposed during one hour in areas of the previously chosen rooms according to the biggest and smaller circulation of people and for the air produced by the movement of the doors. These plates were incubated at 37ø C in aerobiosis during 72 hours. The exhibitions were carried out in 3 times of the school period: 1 - before the winter recess with activity in the rooms. 2 - after the winter recess without activity in the rooms. 3 - after the winter recess with activity in the rooms. The results obtained from the average of CFU recount are: Room A, exposition 1: 327; exposition 2: 37; exposition 3: 180. Room B, exposition 1: 163; exposition 2: 6; exposition 3: 148. Room C, exposition 1: 286; exposition 2: 27; exposition 3: 136. There were carried out statistical studies that showed the significant difference between periods of recess and activity in clinical rooms. These results support the use of barriers of personal protection, the isolation with rubber dike during the dental treatment, and that a good ventilation is essential so that the causing microorganisms of illness of air transmission won’t remain in the air of the clinic rooms, in addition to the necessity of disinfections as a routine of all the surfaces. Supported by the Research Council of the National University of Tucumán

[Recovery of Veillonella from saliva]. / Recuperación de veillonellas a partir de saliva.

Veillonella spp. are anaerobic gram-negative cocci associated to oral health. Different types of cultures have been reported for the isolation of these microorganisms. Veillonella spp. colonies produce a red fluorescence, which is made visible through ultraviolet light and disappears in contact with oxygen. This feature would be very useful for rapid presumptive identification. The aims of this study were: 1. to compare the Rogosa selective medium for Veillonella with the cultures recommended by different authors in order to determine best saliva recovery, since this sample is generally used to determine the presence and predominance of this bacteria; 2. to detect red fluorescence production on these different culture media as a rapid method for identification. Selective medium for Veillonella, Schaedler agar for anaerobic bacteria with vitamin K, thioglycollate agar, brain heart infusion agar, Brucella agar, trypticase soy agar, and Columbia agar, all of them with and without the addition of vancomycin, and laked blood were used for this study. The tested sample was a saliva pool. Both, Veillonella colonies, and the total number of microorganisms were counted, and expressed as CFU/ml of saliva. The greatest Veillonella recovery in saliva was obtained with the selective medium for Veillonella with vancomycin and laked blood. The production of fluorescence was only observed in this medium.

Recuperación de veillonellas a partir de saliva / [Recovery of Veillonella from saliva]

Veillonella spp. are anaerobic gram-negative cocci associated to oral health. Different types of cultures have been reported for the isolation of these microorganisms. Veillonella spp. colonies produce a red fluorescence, which is made visible through ultraviolet light and disappears in contact with oxygen. This feature would be very useful for rapid presumptive identification. The aims of this study were: 1. to compare the Rogosa selective medium for Veillonella with the cultures recommended by different authors in order to determine best saliva recovery, since this sample is generally used to determine the presence and predominance of this bacteria; 2. to detect red fluorescence production on these different culture media as a rapid method for identification. Selective medium for Veillonella, Schaedler agar for anaerobic bacteria with vitamin K, thioglycollate agar, brain heart infusion agar, Brucella agar, trypticase soy agar, and Columbia agar, all of them with and without the addition of vancomycin, and laked blood were used for this study. The tested sample was a saliva pool. Both, Veillonella colonies, and the total number of microorganisms were counted, and expressed as CFU/ml of saliva. The greatest Veillonella recovery in saliva was obtained with the selective medium for Veillonella with vancomycin and laked blood. The production of fluorescence was only observed in this medium.

Recuperación de veillonellas a partir de saliva. / [Recovery of Veillonella from saliva]

Veillonella spp. are anaerobic gram-negative cocci associated to oral health. Different types of cultures have been reported for the isolation of these microorganisms. Veillonella spp. colonies produce a red fluorescence, which is made visible through ultraviolet light and disappears in contact with oxygen. This feature would be very useful for rapid presumptive identification. The aims of this study were: 1. to compare the Rogosa selective medium for Veillonella with the cultures recommended by different authors in order to determine best saliva recovery, since this sample is generally used to determine the presence and predominance of this bacteria; 2. to detect red fluorescence production on these different culture media as a rapid method for identification. Selective medium for Veillonella, Schaedler agar for anaerobic bacteria with vitamin K, thioglycollate agar, brain heart infusion agar, Brucella agar, trypticase soy agar, and Columbia agar, all of them with and without the addition of vancomycin, and laked blood were used for this study. The tested sample was a saliva pool. Both, Veillonella colonies, and the total number of microorganisms were counted, and expressed as CFU/ml of saliva. The greatest Veillonella recovery in saliva was obtained with the selective medium for Veillonella with vancomycin and laked blood. The production of fluorescence was only observed in this medium.

Ethinylestradiol/cyproterone acetate in polycystic ovary syndrome: lipid and carbohydrate changes.

OBJECTIVE: Ethinylestradiol (EE) combined with the antiandrogenic progestin cyproterone acetate (CPA) is a possible treatment in polycystic ovary syndrome (PCOS). We investigated the impact of EE/CPA on lipid and carbohydrate metabolism in women with PCOS,who were otherwise healthy. METHOD: The 31 women were separated into two groups paired by body mass index (BMI): Group A (control, n = 15) were cycled with 10 mg medroxyprogesterone acetate (MPA) x 10 days (Provera, Pharmacia & Upjohn) every month for 3 months; Group B (n = 16) were treated with 35 microg EE/2 mg CPA (Diane 35, Schering) for 3 months. Metabolic and hormonal conditions were similar in both groups. RESULTS: Group A showed no change in any hormone or metabolic parameter. Group B showed a significant decrease in free androgen index (-81%) and increase in sex hormone binding globulin (+ 639%), a decrease in low density lipoprotein cholesterol (-14%) and total cholesterol/high density lipoprotein (HDL) cholesterol index (-19%), and increases in HDL cholesterol (+ 23%) and triglycerides (+ 82%) (p < 0.001). Fasting insulin increased in 18%, the glucose/insulin index worsened in 8%, and the plasma glucose disappearance worsened in 12%, with no statistical significance (p= 0.092, p=0.308 and p= 0.237, respectively). CONCLUSION: Treatment of PCOS with EE/CPA induces important favorable changes regarding hormone parameters associated with hyperandrogenism, significant favorable changes in lipid profile except for triglyceride increase, and no significant change in carbohydrate metabolism (measured by fasting insulin, glucose/insulin index and plasma glucose disappearance). MPA cycling does not change any of these parameters.

Comparison of two major emergency department-based free-text chief-complaint coding systems.

INTRODUCTION: Emergency departments (EDs) using free-text chief-complaint data for syndromic surveillance face a unique challenge because a complaint might be described and coded in multiple ways. OBJECTIVE: Two major ED-based free-text chief-complaint coding systems were compared for agreement between free-text interpretation and syndrome coding. METHODS: Chief-complaint data from 21,736 patients at an urban ED were processed through both the New York City Department of Health and Mental Hygiene (DOHMH) syndrome coding system as modified by the Chicago Department of Public Health and the Real-Time Outbreak Detection System Complaint Coder (CoCo, version 2.1, University of Pittsburgh). To account for differences in each system's specified syndromes, relevant syndromes from the DOHMH system were collapsed into the corresponding CoCo categories so that a descriptive comparison could be made. DOHMH classifications were combined to match existing CoCo categories as follows: 1) vomit+diarrhea = Gastrointestinal; 2) cold+respiratory+asthma = Respiratory; 3) fevflu = Constitutional; 4) rash = Rash; 5) sepsis+other = Other, 6) unknown = Unknown. RESULTS: Overall agreement between DOHMH and CoCo syndrome coding was optimal (0.614 kappa). However, agreement between individual syndromes varied substantially. Rash and Respiratory had the highest agreement (0.711 and 0.594 kappa, respectively). Other and Constitutional had an intermediate level of agreement (0.453 and 0.419 kappa, respectively), but less than optimal agreement was identified for Gastrointestinal and Unknown (0.270 and 0.002 kappa, respectively). CONCLUSIONS: Although this analysis revealed optimal overall agreement between the two systems evaluated, substantial differences in classification schemes existed, highlighting the need for a consensus regarding chief-complaint classification.

Influence of temperature on flavour compound production from citrate by Lactobacillus rhamnosus ATCC 7469.

The citrate utilization by Lactobacillus rhamnosus ATCC 7469 was found to be temperature-dependent. The maximum citrate utilization and incorporation of [1,5-14C]citrate rate were observed at 37 degreesC. At this temperature, maximum citrate lyase activity and specific diacetyl and acetoin production (Y(DA%)) were observed. The high levels of alpha-acetolactate synthase and low levels of diacetyl reductase, acetoin reductase and L-lactate dehydrogenase found at 37 degreesC led to an accumulation of diacetyl and acetoin. Optimum lactic acid production was observed at 45 degreesC, according to the high lactate dehydrogenase activity. The NADH oxidase activity increased with increasing culture temperature from 22 degreesC to 37 degreesC. Thus there are greater quantities of pyruvate available for the production of alpha-acetolactate, diacetyl and aceotin, and less diacetyl and acetoin are reduced.

[Effect of low calcitonin doses on bone remodeling in postmenopausal women with high bone turnover rate]. / Efecto de dosis bajas de calcitonina sobre la remodelación ósea en mujeres postmenopáusicas con alto recambio.

BACKGROUND: Calcitonin is specially indicated for the treatment of osteoporosis in women that cannot receive estrogen replacement therapy or that have a high bone turnover rate. AIM: To study the effects of low intranasal calcitonin doses on bone remodeling in postmenopausal women with a high bone turnover. PATIENTS AND METHODS: Forty one healthy women aged 56 +/- 6 years old, with a mean lapse after menopause of 7.6 +/- 6.5 years and with a high bone turnover rate, evidenced by an urinary hydroxyproline (mg/dl)/creatinine (g/dl) ratio of 52.4 +/- 7.2, were studied. They were randomly assigned to receive 100 or 50 U/calcitonin thrice a week during 3 months or to a control group that received placebo. All received 500 mg/day calcium carbonate. Urinary hydroxyproline/creatinine ratio was measured a 0, 15, 30, 60 and 90 days. Plasma bone fraction of alkanine phosphatases was measured at 0, 30 and 90 days. RESULTS: Initial urinary hydroxyproline/creatinine ratio and plasma bone fraction of alkanine phosphatases were similar in all study groups and there was no change in these parameters during the study period. CONCLUSIONS: Intranasal calcitonin in doses of 100 U thrice a week or less, does not modify accelerated bone turnover in postmenopausal women.

A comparison of digital nonmydriatic fundus imaging with standard 35-millimeter slides for diabetic retinopathy.

PURPOSE: The purpose of this study was to compare nonmydriatic digital images with 35-mm slide images for the detection of diabetic retinal findings. STUDY DESIGN: Comparative, observational case series. PARTICIPANTS: Twenty-two patients with diabetes. METHODS: Diabetic patients underwent digital (nonmydriatic fundus camera attached to a digital back) and standard dilated 35-mm retinal photography of three areas: posterior pole, nasal retina, and temporal retina. The images were reviewed by a single masked grader for the presence or absence of specific retinal findings. PRIMARY OUTCOME MEASURES: Presence or absence of neovascularization of the disc (NVD), neovascularization elsewhere (NVE), venous beading (VB), nerve fiber layer (NFL) hemorrhage, dot-blot hemorrhage, microaneurysm (MA), clinically significant macular edema, cotton wool spot, intraretinal microvascular anomaly (IRMA), hard exudate (HE), and retinal pigment epithelial (RPE) pigmentary changes. RESULTS: Forty eyes of 22 patients underwent both imaging procedures. The agreement between image type was highest for IRMA (97.5%) and VB (95%) and lowest for RPE pigmentary changes (65%) and MA (62.5%). Sensitivity ranged from 25% (NVD) to 100% (VB). Specificity ranged from 90% (RPE pigmentary changes) to 100% (NVD, NVE, VB, NFL hemorrhage, HE). Positive predictive value ranged from 50% (IRMA) to 100% (NVD, NVE, HE, NFL, VB). Negative predictive value ranged from 48% (MA) to 100% (IRMA). CONCLUSIONS: Nonmydriatic digital fundus imaging for detection of diabetic retionopathy has a low sensitivity rate and a high specificity rate and is less clinically useful than standard dilated 35-mm fundus slide images.

[Cushing syndrome by ectopic ACTH secretion: analysis of the physiopathologic mechanism of hypokalemia. Report of two cases]. / Síndrome de Cushing por secreción ectópica de ACTH: análisis del mecanismo fisiopatológico de la hipokalemia. Comunicación de dos casos.

We report a 42 years old male and a 66 years old female with a Cushing syndrome caused by ectopic ACTH secretion secondary to a carcinoid tumor. These patients had both severe hypokalemia, resistant to medical treatment and that subsided with bilateral adrenalectomy and supplementation with dexametasone. Cushing syndrome caused by ectopic ACTH secretion is characterized by a severe and rapidly evolving hypercortisolism. Hypokalemia is present in 90% of cases and is probably caused by a defect in 11 beta hydroxysteroid dehydrogenase, that limits the binding of cortisol to aldosterone receptor, metabolizing it to cortisone. Therefore, this alteration will increase the mineralocorticoid action of cortisol.

Persistent hypokalemia after successful adrenalectomy in a patient with Cushing's syndrome due to ectopic ACTH secretion: possible role of 11beta-hydroxysteroid dehydrogenase inhibition.

Ectopic ACTH secretion is characterized by a high incidence of hypokalemia. The pathophysiology of hypokalemia has not been totally clarified, although it has been postulated that excessive amounts of adrenal steroids may play a role, as well as a possible role of the inhibition of the enzyme 11beta-hydroxysteroid dehydrogenase (11beta-OHSD). This enzyme normally converts cortisol to cortisone avoiding the mineralocorticoid action of cortisol. We present a patient with ectopic ACTH secretion due to a metastatic carcinoid tumor. The clinical picture was characterized by maintained hypokalemia (1.4 mmol/l) resistant to potassium, spironolactone and ketoconazole administration. A bilateral adrenalectomy was performed but the hypokalemia persisted while he was receiving a physiological dose of cortisol. Eight days after adrenalectomy cortisol was replaced by an equivalent dose of dexamethasone. This change was followed by a rapid and persistent normalization of hypokalemia suggesting a mineralocorticoid effect of cortisol. In conclusion, the origin of hypokalemia in our patient with ectopic ACTH secretion was secondary to cortisol. We postulate that this peculiar effect of cortisol could have happened if an inhibition of 11beta-OHSD occurred.