ABSTRACT
Voriconazole, an antifungal agent, displays high intra- and inter-individual variability. The predictive pharmacokinetic (PK) index requires a minimum plasma concentration (Cmin) in patient serum of between 1-5.5 mg/L. It is common to encounter fungal infections in patients undergoing extracorporeal membrane oxygenation (ECMO) support, and data regarding voriconazole PK changes during ECMO are scarce. Our study compared voriconazole PKs in patients with and without ECMO support in a retrospective cohort of critically-ill patients. Fifteen patients with 26 voriconazole Cmin determinations in the non-ECMO group and nine patients with 27 voriconazole Cmin determinations in the ECMO group were recruited. The ECMO group had lower Cmin (0.38 ± 2.98 vs. 3.62 ± 3.88, p < 0.001) and higher infratherapeutic Cmin values (16 vs. 1, p < 0.001) than the non-ECMO group. Multivariate analysis identified ECMO support (-0.668, CI95 -0.978--0.358) and plasma albumin levels (-0.023, CI95 -0.046--0.001) as risk factors for low Cmin values. When comparing pre- and post-therapeutic drug optimisation samples from the ECMO group, the dose required to achieve therapeutic Cmin was 6.44 mg/kg twice a day. Therapeutic drug optimisation is essential to improve target attainment.
ABSTRACT
Spontaneous remissions (SRs) in acute myeloid leukemia (AML) are infrequent, poorly documented and transient. Similarly, morphological and cytogenetic complete remissions (CR) under azacitidine treatment are scarce. We report a 71-year-old man with a secondary AML arising from essential thrombocythemia (ET), who developed an SR after discontinuation of azacitidine following a respiratory infection (four courses were administered). The distinctive feature of our case is the depth of the achieved CR, documented by next-generation sequencing (NGS) techniques. We also detected persistence of molecular lesions that might already have been present in the previous ET clone. Our patient relapsed 5 months after achieving CR. We conclude that our patient showed a spontaneous remission of his AML rather than an exquisite response to azacitidine. We hypothesize that the concurrent respiratory infection, or any other unknown trigger, might have activated his immune system forcing the leukemic stem cell to enter a quiescent state through a yet unexplained mechanism.
Subject(s)
Leukemia, Myeloid, Acute , Thrombocythemia, Essential , Aged , Azacitidine/therapeutic use , Humans , Leukemia, Myeloid, Acute/complications , Leukemia, Myeloid, Acute/drug therapy , Male , Remission Induction , Remission, SpontaneousABSTRACT
Specialized paediatric and neonatal transport is a useful and essential resource in the interhospital transfer of these patients. It allows bringing the material and personal resources of an intensive care unit closer to the regional hospitals where the patient can be found. The benefits of these teams are very well demonstrated in the literature. These units should be part of the emergency systems, while it would be recommended that they be staff integrated in the tertiary hospitals, in order to maintain the necessary skills and competencies. The team, made up of physicians, nurses and emergency medical technicians, must master both the pathophysiology of transport and that of the critical patient in this age range. A high quality of both human and care is important, so continuous training and periodic recycling will be essential to be compliant with the quality indicators in transport. Likewise, it is essential to have specific vehicles adapted to this function, which allow carrying the wide variety of necessary material, as well as the electromedicine that is required. However, in Spain this paediatric and neonatal transport model is not standardized and therefore is not homogeneous: there are different models that do not always provide adequate quality, making it necessary to implement specialized units throughout the country to guarantee sanitary transport quality to any critical child or neonate.
Subject(s)
Transportation of Patients , Child , Child, Preschool , Humans , Infant , Infant, Newborn , SpainABSTRACT
El transporte pediátrico y neonatal especializado es un recurso útil y esencial en el traslado interhospitalario de estos pacientes. Permite acercar los recursos materiales y personales de una unidad de cuidados intensivos a los hospitales comarcales donde se pueda encontrar el paciente. Los beneficios de estos equipos están muy bien demostrados en la literatura. Estas unidades deberían formar parte de los sistemas de emergencias, al mismo tiempo que sería recomendable que estuvieran constituidas por personal integrado en los hospitales terciarios con el fin de mantener las habilidades y competencias necesarias. El equipo, compuesto por médicos, enfermeros y técnicos de emergencias sanitarias, tiene que dominar tanto la fisiopatología del transporte como la del paciente crítico en este rango de edad. Es importante una alta calidad tanto humana como asistencial, por lo que la formación continuada y el reciclaje periódico serán imprescindibles para poder cumplir correctamente con los indicadores de calidad en transporte. Así mismo, es fundamental contar con vehículos propios y adaptados a su función, que permitan llevar la gran variedad de material necesario, así como la electromedicina que se requiere. Sin embargo, en España este modelo de transporte pediátrico y neonatal no está estandarizado y por lo tanto no es homogéneo: existen diferentes modelos que no siempre aportan una adecuada calidad, siendo necesaria la implantación de unidades especializadas en todo el país para garantizar un transporte sanitario de calidad a cualquier niño o neonato crítico. (AU)
Specialized paediatric and neonatal transport is a useful and essential resource in the interhospital transfer of these patients. It allows bringing the material and personal resources of an intensive care unit closer to the regional hospitals where the patient can be found. The benefits of these teams are very well demonstrated in the literature. These units should be part of the emergency systems, while it would be recommended that they would be staff integrated in the tertiary hospitals, in order to maintain the necessary skills and competencies. The team, made up of physicians, nurses and emergency medical technicians, must master both the pathophysiology of transport and that of the critical patient in this age range. A high-quality of both human and care is important, so continuous training and periodic recycling will be essential to be compliant with the quality indicators in transport. Likewise, it is essential to have specific vehicles adapted to this function, which allow carrying the wide variety of necessary material, as well as the electromedicine that is required. However, in Spain this paediatric and neonatal transport model is not standardized and, therefore, is not homogeneous: there are different models that do not always provide adequate quality, making it necessary to implement specialized units throughout the country to guarantee sanitary transport quality to any critical child or neonate. (AU)
Subject(s)
Humans , Infant, Newborn , Transportation of Patients/classification , Transportation of Patients/trends , Intensive Care Units, Pediatric , SpainABSTRACT
Specialized paediatric and neonatal transport is a useful and essential resource in the interhospital transfer of these patients. It allows bringing the material and personal resources of an intensive care unit closer to the regional hospitals where the patient can be found. The benefits of these teams are very well demonstrated in the literature. These units should be part of the emergency systems, while it would be recommended that they would be staff integrated in the tertiary hospitals, in order to maintain the necessary skills and competencies. The team, made up of physicians, nurses and emergency medical technicians, must master both the pathophysiology of transport and that of the critical patient in this age range. A high-quality of both human and care is important, so continuous training and periodic recycling will be essential to be compliant with the quality indicators in transport. Likewise, it is essential to have specific vehicles adapted to this function, which allow carrying the wide variety of necessary material, as well as the electromedicine that is required. However, in Spain this paediatric and neonatal transport model is not standardized and, therefore, is not homogeneous: there are different models that do not always provide adequate quality, making it necessary to implement specialized units throughout the country to guarantee sanitary transport quality to any critical child or neonate.
ABSTRACT
This study explores the impacts of climate change on the hydrology of the headwater areas of the Duero River Basin, the largest basin of the Iberian Peninsula. To this end, an ensemble of 18 Euro-CORDEX model experiments was gathered for two periods, 1975-2005 and 2021-2100, under two Representative Concentration Pathways (RCP4.5 and RCP8.5), and were used as the meteorological forcings of the Variable Infiltration Capacity (VIC) during the hydrological modelling exercise. The projected hydrologic changes for the future period were analyzed at annual and seasonal scales using several evaluation metrics, such as the delta changes of the atmospheric and land variables, the runoff and evapotranspiration ratios of the overall water balance, the snowmelt contribution to the total streamflow and the centroid position for the daily hydrograph of the average hydrologic year. Annual streamflow reductions of up to 40% were attained in various parts of the basin for the period 2071-2100 under the RCP8.5 scenario, and resulted from the precipitation decreases in the southern subwatersheds and the combined effect of the precipitation decreases and evapotranspiration increases in the north. The runoff and the evapotranspiration ratios evinced a tendency towards an evaporative regime in the north part of the basin and a strengthening of the evaporative response in the south. Seasonal streamflow changes were mostly negative and dependent on the season considered, with greater detriments in spring and summer, and less intense ones in autumn and winter. The snowmelt contribution to the total streamflow was strongly diminished with decreases reaching -80% in autumn and spring, thus pointing to a change in the snow regime for the Duero mountains. Finally, the annual and seasonal changes of the centroid position accounted for the shape changes of the hydrograph, constituting a measure of seasonality and reflecting high correlations degrees with the streamflow delta changes.
ABSTRACT
High spatial resolution drought projections for the Iberian Peninsula (IP) have been examined in terms of duration, frequency, and severity of drought events. For this end, a set of regional climate simulations was completed using the Weather Research and Forecasting (WRF) model driven by two global climate models (GCMs), the CCSM4 and the MPI-ESM-LR, for a near (2021-2050) and a far (2071-2100) future, and under two representative concentration pathway (RCP) scenarios (RCP4.5 and RCP8.5). Projected changes for these simulations were analyzed using two drought indices, the Standardized Precipitation Evapotranspiration Index (SPEI) and the Standardized Precipitation Index (SPI), considering different time scales (3- and 12-months). The results showed that the IP is very likely to undergo longer and more severe drought events. Substantial changes in drought parameters (i.e., frequency, duration, and severity) were projected by both indices and at both time scales in most of the IP. These changes are particularly strong by the end of the century under RCP8.5. Meanwhile, the intensification of drought conditions is expected to be more moderate for the near future. However, the results also indicated key differences between indices. Projected drought conditions by using the SPEI showed more severe increases in drought events than those from SPI by the end of the century and, especially, for the high-emission scenario. The most extreme conditions were projected in terms of the duration of the events. Specifically, results from the 12-month SPEI analysis suggested a significant risk of megadrought events (drought events longer than 15 years) in many areas of IP by the end of the century under RCP8.5.
ABSTRACT
This work investigates climate-change projections over a transitional region between dry and wet climates, the Iberian Peninsula (IP). With this purpose, the Weather Research and Forecasting (WRF) model, driven by two global climate models (CCSM4 and MPI-ESM-LR) previously bias-corrected, was used to generate high-resolution climate information. Simulations were carried out for two periods, 1980-2014 and 2071-2100, and under two representative concentration pathways (RCP4.5 and RCP8.5). The analysis focused on changes in land-surface processes, their causes, and the potential impact on the climate system. To achieve this, seasonal projected changes of land-surface (soil moisture and surface evapotranspiration) and atmospheric variables involved in the hydrologic (i.e., precipitation and runoff) and energy balance (i.e., temperature and solar incoming radiation) were investigated. The results reveal that the IP is likely to experience a soil dryness by the end of the 21st century, particularly during summer and fall, more apparent in the southern IP, and stronger under the RCP8.5. However, such trends would have different implications throughout the year and directly affect the surface evapotranspiration. Moreover, soil-drying trends are mainly associated with reductions in the large-scale precipitation during spring, summer, and fall and by enhanced evapotranspiration particularly in spring over the northwestern IP. In addition, the results show notably changes in soil conditions at high altitude, particularly during winter, which may alter the land-atmosphere processes that currently occur in these regions. In this context, noteworthy changes in the climate system are expected, leading to adverse impacts on water resources and temperature. The results highlight the complex and nonlinear nature of land-atmosphere interactions in regions such as the IP, which is a tremendous challenge for adequately developing mitigation and adaptation strategies to anthropogenic climate change.
ABSTRACT
Introducción. La relación del nivel socioeconómico con las tasas de incidencia y de mortalidad por ictus está bien establecida. La evidencia de la relación con la supervivencia de los pacientes tras el ictus es menos concluyente. El nivel educativo es una medida de nivel socioeconómico muy utilizada en estudios con personas de edad avanzada. Objetivo. Estudiar la relación de la supervivencia en el primer año tras el ictus con el nivel de estudios. Pacientes y métodos. Se analizaron los datos de 544 pacientes con ictus isquémico agudo ingresados en los hospitales públicos de Bizkaia (España), seleccionados consecutivamente. Se obtuvieron datos por entrevista a pacientes o acompañantes y de historia clínica. Se estudiaron variables sobre situación funcional previa, gravedad del ictus, factores de riesgo cardiovascular y de atención al ictus. Se hizo un seguimiento de 12 meses para registrar, en su caso, la fecha de fallecimiento. Se realizó un análisis univariado y multivariado para identificar la relación del nivel de estudios con la supervivencia. Resultados. Tras 12 meses, sobrevivían 203 mujeres (86%) y 273 hombres (88,6%). En ambos sexos, las personas con menos estudios tuvieron peor situación funcional previa, mayor gravedad y fallecieron en mayor proporción. En el análisis multivariado, el nivel de estudios se mantuvo asociado con la supervivencia en el modelo ajustado para los hombres. Conclusiones. La diversidad de nivel educativo marca diferencias en la supervivencia de los pacientes con ictus isquémico en nuestro entorno. El impacto de este factor fue mayor en los hombres que en las mujeres
Aim. To assess the relationship between one-year survival after stroke and level of education. Patients and methods. We analysed data on 544 consecutively recruited patients admitted for acute ischaemic stroke in one the public hospitals of Bizkaia (Spain). Data were obtained through interviews with patients or accompanying persons and from medical records. We studied variables concerning previous functional status, stroke severity, cardiovascular risk factors and stroke care provided. Patients were followed up for 12 months and the dates of any deaths were recorded. Univariate and multivariate analyses were carried out to assess the relationship between level of education and survival. Results. A total of 203 (86%) women and 273 (88.6%) men were alive at 12 months. In both sexes, individuals with a lower level of education had poorer previous functional status, more severe strokes and higher mortality rates. In the multivariate analysis, the association between level of education and survival remained significant in the adjusted model in men. Conclusions. In our setting, there are differences in the survival of patients with ischaemic stroke as a function of level of education. The impact of this factor was greater in men than women
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Stroke/epidemiology , Survivorship , Risk Factors , Educational Status , Stroke/prevention & control , Cerebrovascular Disorders/epidemiology , Prospective Studies , Multivariate AnalysisABSTRACT
The exponentially decaying permeability model interprets the chronoamperometric currents arising from Tl+ reduction at a Hg electrode covered with a phospholipid monolayer (DOPC) containing gramicidin monomer by combining three processes: (i) the diffusion of an ion to a membrane surface with an array of channels, (ii) the conformational dynamics of the individual channels, and (iii) the passage of the ion through the channels. The introduction of a variable permeability allows us to uncouple the diffusion from the heterogeneous processes, given that the concentration of a species at the active surface can be obtained by semi-integration of the currents. Consideration of a reverse step for the dehydration process at the mouth of the channel allows the analysis of potential steps away from diffusion-limited conditions where a Nernstian-like behavior of the relevant parameter is observed. The model has been successfully applied to data with all trans retinol or benzo-alpha-pyrene as additive to the phospholipid monolayer and to monolayers without any additive at all.
Subject(s)
Ion Channels/chemistry , Benzo(a)pyrene/chemistry , Electrodes , Mercury/chemistry , Retinaldehyde/chemistryABSTRACT
Objetivo: Conocer la opinión de las matronas de los centros de atención primaria de la Comunidad de Madrid sobre la evolución de los programas de educación maternal que imparten. Personas y método: Estudio descriptivo y transversal. Se empleó como instrumento de medida un cuestionario de 15 preguntas cerradas. La población de estudio fueron la totalidad de las matronas de atención primaria de la Comunidad de Madrid (179). Resultados: Se recibieron 74 (41,3%) cuestionarios cumplimentados. El 76% de las matronas (56 del total de 74) llevaba trabajando más de 10 años. El 91% (67) afirmó que existe un cambio en la demanda de educación maternal relacionado con el cambio de las variables sociales; un 88% (64) manifestó haber realizado cambios en el programa; el 70% (52) indicó haber efectuado cambios en la metodología, y el 64% (47) había llevado a cabo cambios en los recursos didácticos. Conclusiones: Los resultados permiten observar cómo las matronas de la Comunidad de Madrid han adaptado sus programas de educación maternal en consonancia con las nuevas demandas sociales (AU)
Objective: To know the opinions of the midwives of the primary health care centers of the Community of Madrid concerning the evolution of maternal education programs in which they take part. Participants and method: A descriptive, cross-sectional study. The measurement tool employed was a questionnaire consisting of 15 closed questions. The study population included all the primary care midwives in the Community of Madrid (179). Results: Seventy-four questionnaires (41.3%) were completed and returned. Seventy-six percent of the midwives (56 of the 74) had been working for more than 10 years. In all, 91% (67) reported the existence of a change in the demand for maternal education related to the change in social variables; 88% (64) reported having made changes in the program; 70% (52) had made changes in the methodology and 64% (47) had made changes in the teaching resources. Conclusions: The results show how the midwives of the Community of Madrid have adapted their maternal education programs in accordance with the new social demands (AU)
