[Experience of patients with immune-mediated inflammatory diseases seen in a multidisciplinary integrated care unit]. / Experiencia de los pacientes con enfermedades inflamatorias inmunomediadas atendidos en una unidad de atención integral multidisciplinar.

OBJECTIVE: To describe the aspects with the greatest impact on the satisfaction of patients treated in a multidisciplinary unit specialising in immune-mediated inflammatory diseases (IMIDs) and to identify areas for improvement in the care model. METHODS: Cross-sectional descriptive study using a satisfaction survey structured in three blocks: sociodemographic variables, functional aspects of the unit and satisfaction with the professionals. Immediate satisfaction was measured on aspects related to the care received, the physical structure and the likelihood of recommending the unit. RESULTS: A total of 168 patients completed the surveys, the mean score of overall satisfaction with the unit was 4.75 (SD:0.4). The regression model showed the relationship between overall satisfaction and unit signage (OR:3.558, p=0.045, 95% CI: 1.027-12.33), coordination between professionals (OR:9.043, p=0.000, 95% CI: 2.79-29.28) and participation in decision making (OR: 44.836, p=0.000, 95% CI: 5.49-365.97). In terms of immediate satisfaction, the overall Net Promoter Score (NPS) was 87 (excellent). The mean score for coordination with Primary Care was 4.54 (SD:0.8) and they scored waiting time to be seen with 4.49 (SD:0.8), so they have been considered an area for improvement The mean score for coordination with Primary Care was 4.54 (SD:0.8) and they scored waiting time to be seen with 4.49 (SD:0.8), so both were considered areas for improvement. CONCLUSIONS: Coordination between intra-centre professionals and patient participation in decision-making explain the excellent level of patient satisfaction. The monitoring of satisfaction has made it possible to implement immediate improvement actions.

Efficacy of bortezomib to intensify the conditioning regimen and the graft-versus-host disease prophylaxis for high-risk myeloma patients undergoing transplantation.

This multicenter phase I trial was designed to evaluate the safety and efficacy of bortezomib (Bz) as part of both the conditioning regimen and the graft-versus-host disease (GvHD) prophylaxis. Patients received fludarabine, melphalan and Bz (days -9 and -2). GVHD prophylaxis consisted of Bz (days +1, +4, and +7), sirolimus (Siro) from day -5 and tacrolimus (Tk) from -3 (except the first five patients that did not receive Tk). Twenty-five patients with poor prognostic multiple myeloma were included. Eleven out of the 19 patients had high-risk features. Out of the 21 patients evaluable at day +100, 14 were in CR (67%) and 7 (33%) in PR. Cumulative incidence (CI) of nonrelapse mortality at 1 year was 24%. CI of grades 2-4 and 3-4 acute GvHD was 35% and 10%, respectively; CI of chronic GvHD was 35% and 55% at 1 and 2 years, respectively. Overall and event free survival at 2 years were 64% and 31%, respectively. Bz as part of the conditioning regimen and in the combination with Siro/tacrolimus for GvHD prophylaxis is safe and effective allowing an optimal disease control early after transplant and reducing the risk of GvHD.

Follow-up of infants born to mothers with autoinmune thyroid disease. What should not be screened? / Seguimiento del hijo de madre con patología tiroidea autoinmune. ¿Qué no debemos cribar?

INTRODUCTION: Thyroid dysfunction is a common problem in pregnant women. It is usually of an autoimmune origin, with Hashimotós thyroiditis and Graves disease being the most common conditions. Although hormonal changes and transplacental antibody transfer may occur, specific neonatal screening has not been shown to be useful. PATIENTS AND METHOD: A prospective study of newborns of women with autoimmune thyroid disease born at a level III university hospital (November 2013-December 2016). Neonates were selected during their stay at the maternity. Babies with perinatal asphyxia were excluded. Data were collected from the clinical histories of mothers and newborns. RESULTS: A total of 191 neonates were included. Ninety percent of mothers had been diagnosed with autoimmune hypothyroidism. Only 5.8% of newborns had some laboratory disorder, consisting of slightly increased thyroid-stimulating hormone levels, which returned to normal at the age of one month and did not correlate to thyroid peroxidase antibody levels. Transient hyperthyrotropinemia was diagnosed in one newborn and required thyroxin treatment during the first year of life. Among newborns from mothers with Graves disease, 36.8% had some abnormal laboratory value during the first 7 days of life, but there were no cases of hyperthyroidism and only one of transient hyperthyrotropinemia. CONCLUSIONS: Experience at our hospital in screening of newborns from hypothyroid mothers reveals a high number of laboratory controls with a poor diagnostic yield. No relationship was found between thyroid peroxidase antibody levels and thyroid dysfunction. We support the recommendations to continue testing serum thyroid-stimulating hormone and FT4 levels at 48h of life in newborns of mothers with autoimmune hypothyroidism.

Multifocal Tumorous Pseudoangiomatous Stromal Hyperplasia Presenting as Asymmetric Bilateral Breast Enlargement.

PASH is a benign proliferation of stromal myofibroblasts that affects mostly premenopausal women and typically shows estrogen and progesterone receptor expression, allowing speculation regarding a hormonal cause. It usually presents as an incidental finding on a mammogram or as a palpable mass. We present a case of diffuse asymmetrical massive breast enlargement in a premenopausal woman with history of previous multiple PASH excisions for recurrent lesions, caused by multifocal tumorous PASH virtually replacing the breast parenchyma. Immunohistochemistry examination showed no hormone receptor expression. Despite its benign nature, such presentation of PASH is managed with bilateral mastectomy and immediate reconstruction with expanders for cosmetic and comfort reasons, while tumor excision or expectant management is deemed to lead to recurrence and progression. Although a hormonal origin is speculated based on hormone expression studies and typical patient profile, this case showed 0 % estrogen/progesterone expression in the final histology specimen.

[Reconstruction of a traumatic lateral trochlear defect with a radial head autograft]. / Reconstrucción de defecto troclear lateral traumático con autoinjerto de cabeza radial.

OBJECTIVE: To report the result of a severe articular defect secondary to a complex open fracture of the distal humerus, using the ipsilateral radial head as a bone autograft for the trochclear region as an alternative to total arthroplasty. CASE REPORT: We describe a patient who suffered an open fracture of the elbow with bone loss in the distal humeral region and, after the initial stabilisation surgery, needed a reconstruction with an ipsilateral radial head autograft. DISCUSSION: Open fractures of elbow are rare. When there is a severe trochlear defect, surgical options are total elbow arthroplasty, where the short and medium term results appear to be insufficient, or elbow arthrodesis. We believe that reconstruction of the defect using an ipsilateral radial head autograft is a more functional alternative than the other procedures described. CONCLUSION: Radial head reconstruction with ipsilateral lateral trochlear defects is a technique that, unlike fusion, preserves functionality without the problems of total elbow arthroplasty.

Susceptibilidad in vitro de candida spp: aisladas de la cavidad oral de pacientes VIH/Sida a itraconazol, clotrimazol y ketoconazol / In vitro susceptibility of candida ssp: isolated fromthe oral cavity of HIV/AIDS patientes to itraconazole, clotrimazole and ketoconazole

La candidiasis orofaríngea (COF) permanece como una de las principales infecciones oportunistas en pacientes infectados con el virus de la inmunodeficiencia humana (VIH) y con el síndrome de inmunodeficiencia adquirida (sida), y aunque su incidencia ha disminuido con la introducción de la terapia antirretroviral de alta eficacia, continúa siendo una afección característica en estos pacientes. En el presente trabajo se realizó un estudio de susceptibilidad in vitro mediante la metodología del CLSI, frente a itraconazol, ketoconazol y clotrimazol de 144 aislamientos clínicos de Candida, aisladas de la cavidad oral de pacientes infectados con el VIH/sida con cuadros clínicos de COF. La identificación de los aislamientos demostró que más del 90% pertenecían a Candida albicans. Al determinar el patrón general de susceptibilidad frente a los azoles estudiados mediante el método de microdilución en caldo del documento M27-A2 del Clinical and Laboratory Standard Institute, C. albicans exhibió valores de concentración mínima inhibitoria (CMI) en un rango de 0,01 a 8µg/mL para el itraconazol y el ketoconazol y de 0,01 a 2 g/mL para el clotrimazol. Sólo el 2,1 % de los aislamientos mostró franca resistencia frente al itraconazol, en tanto que el 3,5 % quedó clasificado dentro de la categoría “susceptible dosis-dependiente” para este triazol. La mayoría de los aislamientos de C. albicans mostraron valores de CMI frente al ketoconazol y al clotrimazol menores a 0.06 g/mL, siendo de un 96,9% (129 aislamientos) y de un 97,7% (129 aislamientos), respectivamente. El clotrimazol tuvo una mejor actividadin vitro comparado con los restantes azoles frente a los aislamientos estudiados. Candida spp. Mostró una elevada sensibilidad in vitro a los azoles estudiados. Se hace necesario continuar realizando estudios epidemiológicos para determinar los patrones de susceptibilidad y tasas de resistencias frente a los agentes...

The oropharyngeal candidiasis (OFC) remains as one of the principal opportunistic infections in patients infected with the human immunodeficiency virus (HIV) and with the acquired immunodeficiency syndrome (aids), and although his incidence has declined with the introduction of the highly active anti-retroviral therapy (HAART), remains as a typical complaint in these patients. A study of antifungal in vitro susceptibility testing, following the CLSI methodology, was realized against itraconazole, ketoconazole and clotrimazole of 144 clinical isolations of Candida, isolated from the oral cavity of patients infected with HIV/aids, with clinical pictures of OFC. The isolation’s identification, demonstrated that more than 90% belonged to Candida albicans. The determination of the general pattern of susceptibility, following the document M27-A2 of the Clinical and Laboratory Standard Institute, against to the studied azoles by means of the method of microdilution in liquid medium, show that the majority of C. albicans isolates showed values of MIC against ketoconazole and clotrimazole lower than 0.06 g/mL, representing a 96,9% (129 isolations) and a 97,7% (129 isolations), respectively. C. albicans exhibited the widest range of minimal inhibitory concentration (MIC). Only 2.1% of the isolations showed resistance against to itraconazole, while 3.5 % remained classified in the category “sensible dose - dependent” for this triazole. The majority of the strains showed values of MIC against ketoconazole and clotrimazole below 0.06 g/mL. The clotrimazole had a better in vitro activity compared with the remaining azoles opposite to the isolations. Candida spp. showed a high in vitro sensibility to the azoles studied. It becomes necessary the maintenance of epidemiologic studies for the determination of susceptibility patterns and of resistances rates against to the antifungal agents

Diagnóstico micológico en pacientes infectados por el virus de la inmunodeficiencia humana / Mycological diagnosis in patients infected with human immunodeficiency virus

Con el descubrimiento del virus de la inmunodeficiencia humana (VIH) en 1981, la frecuencia de las infecciones oportunistas en pacientes inmunodeprimidos, especialmente los infectados por el VIH, ha experimentado un notable incremento. Dentro de éstas se encuentran las de etiología fúngica, las cuales presentan un alto grado de mortalidad si no son diagnosticadas y tratadas a tiempo. En nuestro país con la instauración de la terapia antirretroviral altamente efectiva a partir del año 2001, se ha notado una reducción significativa en la morbilidad y la mortalidad por infecciones oportunistas, en particular por las micosis, muy comunes en este tipo de pacientes. En el presente estudio se realizó el diagnóstico micológico procedente de pacientes infectados por el VIH/sida, durante el período comprendido entre enero 2005 y diciembre de 2009. De un total de 1173 muestras biológicas procesadas, solamente resultaron positivas 324 para un 27,6% de positividad. La candidiasis orofaríngea y la meningoencefalitis criptococóccica fueron las infecciones diagnosticadas con una mayor incidencia. En las muestras analizadas la concordancia en la positividad entre el examen directo y el examen por cultivo micológico fue de un 56,2%, lo que confirma la importancia del empleo del examen directo en la visualización de estructuras fúngicas a partir de muestras clínicas

With the discovery of the human immunodeficiency virus (HIV) in 1981, the frequency of the opportunistic infections in the immunosuppressed patients, especially the infected ones by the HIV, it has experienced a notable increase. Inside these there are those of micotic aetiology, which present a high grade of mortality, if they are not diagnosed and treated on time. In our country with the instauration of the highly effective antirretroviral therapy since the year 2001, a significant reduction has been seen in the morbidity and the mortality of the opportunistic infections, specialle those caused by fungus, in this type of patients. In the present study the positividad was analyzed in the mycological diagnosis realized by conventional methods of the different clinical samples received in the National Laboratory of Reference of Mycology, from patients infected with HIV/aids during the period between January 2005 and December 2009. Of a whole of 1173 biological samples processed only 324 turned out positive, for 27, 6 % of positivity, being the oropharingeal candidiasis and the cryptococcal meningoencefalitis, those of major incidence observed. In the clinical samples analyzed, a concordance of 56,2 % was obtained in the positividad of the samples studied by means of direct examination and mycologycal cultures, which confirms the importance of direct preparations of clinical samples for the visualization of fungal elements from clinical samples

Colonization with vancomycin-resistant enterococci (VRE) in intensive care unit patients in Cordoba City, Argentina.

The purpose of this study was to determine the prevalence of colonization with vancomycin-resistant enterococci (VRE) among intensive care unit (ICU) patients in a hospital in Córdoba, Argentina. We collected 235 rectal swab specimens from 147 ICU patients. Resistance to vancomycin was screened with the disk diffusion method, and MICs were determined with the E-test method. Vancomycin-resistant genotypes were determined by PCR. The VRE strains were isolated from 18/147 patients (12.2%). The isolates were identified as Enterococcus faecium (94.4%), and Enterococcus gallinarum (5.6%). PCR showed that the E. faecium strains carried the vanA gene, and the E. gallinarum strain carried the vanC1 gene. Our study indicated that at least 12.2% of ICU patients were VRE carriers.

Bilateral and subcutaneous palmar nodules in a 2-year-old child suggesting deep granuloma annulare.

Granuloma annulare is a benign, relatively common dermatosis in childhood. The subcutaneous form is rare, and lesions typically occur on the legs, buttocks and scalp. We report a case of a deep granuloma annulare confined to the palms of the hands in a 2-year-old child.

Maximal respiratory pressures in myasthenia gravis. Relation to single fiber electromyography.

OBJECTIVES: The respiratory muscle weakness was evaluated in mild forms of myasthenia gravis (MG) and was compared with single fiber electromyography results (SFEMG) in the extensor digitorum communis muscle. MATERIAL AND METHODS: We assessed 61 treated MG patients without clinical respiratory involvement (13 ocular forms, 28 form IIa and 20 form IIb patients) by maximal respiratory pressure (MRP) to ascertain whether they were consistent with SFEMG results. RESULTS: Maximal expiratory pressure (MEP) and maximal inspiratory pressure (MIP) were reduced below the lower limit for healthy subjects in 85% and 77% of ocular patients; in 93% and 89% of form IIa, respectively; and in 95% of form IIb. The highest percentage of MEP and MIP reduction showed a positive correlation with increased jitter (r=0.45, P<0.001; r=0.27; P<0.05 respectively) and impulse blocking (r=0.35, P<0.01; r=0.28, P<0.05 respectively). CONCLUSION: We consider MRP measure useful for assessing respiratory muscle weakness in MG patients with subclinical respiratory involvement.

Enzyme-linked immunosorbent assay for detection and quantification of Cryptococcus neoformans antigen.

An enzyme-linked immunosorbent assay was standardized for the detection of cryptococcal antigen in serum and cerebrospinal fluid. The system was evaluated in clinical samples from patients infected by human immunodeficiency virus with and without previous cryptococcosis diagnosis. The evaluated system is highly sensitive and specific, and when it was compared with latex agglutination there were not significant differences. A standard curve with purified Cryptococcus neoformans antigen was settled down for the antigen quantification in positive samples.

Oxaliplatin or paclitaxel in patients with platinum-pretreated advanced ovarian cancer: A randomized phase II study of the European Organization for Research and Treatment of Cancer Gynecology Group.

PURPOSE: This was a multicentric, open, randomized, phase II study of single-agent paclitaxel and oxaliplatin to evaluate the efficacy of oxaliplatin in a relapsing progressive ovarian cancer patient population and to analyze the safety profile and impact of both agents on quality of life, time to progression, and survival. PATIENTS AND METHODS: Eighty-six patients with platinum-pretreated advanced ovarian cancer were randomly assigned to two arms: 41 received paclitaxel at 175 mg/m(2) over 3 hours every 3 weeks, and 45 received oxaliplatin at 130 mg/m(2) over 2 hours every 3 weeks. For inclusion, patients had to have a performance status of 0 to 2 and to have received at least one and no more than two prior cisplatin- and/or carboplatin-containing chemotherapy regimens within the last 12 months. RESULTS: Seven confirmed responses were observed in each arm, for an overall response rate in the total treated population of 17% (95% confidence interval [CI], 7% to 32%) in the paclitaxel arm and 16% (95% CI, 7% to 29%) in the oxaliplatin arm. Median time to progression was 14 weeks and 12 weeks, and overall survival was 37 weeks and 42 weeks in the paclitaxel and oxaliplatin arms, respectively. Among 63 patients with a 0- to 6-month progression-free, platinum-free interval, there were five objective responses with paclitaxel in 31 patients and two objective responses with oxaliplatin in 32 patients. Nine patients (22%) in the paclitaxel arm had grade 3 or 4 neutropenia (National Cancer Institute of Canada [NCIC] Common Toxicity Criteria). Two patients (4%) experienced grade 3 thrombocytopenia in the oxaliplatin arm. Maximum grade (grade 3) NCIC neurosensory toxicity was experienced by three patients (7%) in the paclitaxel arm and by four patients (9%) in the oxaliplatin arm. CONCLUSION: Single-agent oxaliplatin at 130 mg/m(2) every 3 weeks is active with moderate toxicity in patients with cisplatin-/carboplatin-pretreated advanced ovarian cancer.

Clinical significance of abdominal scintigraphy using 99mTc-HMPAO-labelled leucocytes in patients with seronegative spondyloarthropathies.

Abdominal scintigraphy shows silent gut inflammation in patients with spondyloarthropathies (Sp) without clinical evidence of gut inflammation. Abdominal scintigraphy images are different than those obtained in patients with ulcerative colitis or Crohn's disease and are not related to the anti-inflammatory drugs administered. The aim of this study was to examine the clinical associations of findings on abdominal scintigraphy in patients with Sp. A total of 204 Sp patients (European Spondylarthropathy Study Group 1991 criteria) and 54 non-Sp controls receiving non-steroidal anti-inflammatory drugs were studied. Abdominal scintigraphy images were obtained at 30 and 120 min after injection of technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO)-labelled leucocytes. 99mTc-HMPAO-labelled leucocyte scans were positive in 104 Sp patients (50.9%) and in six non-Sp controls (2.9%) (P<0.001; OR=8.32; 95% CI=3.23-22.67). Silent gut inflammation was not associated with any of the following: age of onset, duration of evolution, sex, family history of Sp or psoriasis, articular manifestations, extra-articular manifestations, radiological findings or HLA-B27 positivity. Positive abdominal scintigraphy was associated with active disease (P < 0.0001; OR=52.7; 95% CI=19-145.6) and an increase in the C-reactive protein (P < 0.005; OR = 3.4; 95% CI = 1.5-7.4). It is concluded that (a) abdominal scintigraphy using 99mTc-HMPAO-labelled leucocytes is of value in detecting the silent gut inflammation in Sp patients, and (b) silent gut inflammation is related to the clinical activity, but is not associated with any particular type of illness or with HLA-B27.

Clinical significance of abdominal scintigraphy using (99m)Tc-HMPAO-labelled leucocytes in patients with seronegative spondyloarthropathies.

Abdominal scintigraphy shows silent gut inflammation in patients with spondyloarthropathies (Sp) without clinical evidence of gut inflammation. Abdominal scintigraphy images are different than those obtained in patients with ulcerative colitis or Crohn's disease and are not related to the anti-inflammatory drugs administered. The aim of this study was to examine the clinical associations of findings on abdominal scintigraphy in patients with Sp. A total of 204 Sp patients (European Spondylarthropathy Study Group 1991 criteria) and 54 non-Sp controls receiving non-steroidal anti-inflammatory drugs were studied. Abdominal scintigraphy images were obtained at 30 and 120 min after injection of technetium-99m hexamethylpropylene amine oxime ((99m)Tc-HMPAO)-labelled leucocytes. (99m)Tc-HMPAO-labelled leucocyte scans were positive in 104 Sp patients (50.9%) and in six non-Sp controls (2.9%) (P<0.001; OR=8.32; 95% CI=3.23-22.67). Silent gut inflammation was not associated with any of the following: age of onset, duration of evolution, sex, family history of Sp or psoriasis, articular manifestations, extra-articular manifestations, radiological findings or HLA-B27 positivity. Positive abdominal scintigraphy was associated with active disease (P<0.0001; OR=52.7; 95% CI=19-145.6) and an increase in the C-reactive protein (P<0.005; OR=3.4; 95% CI=1.5-7.4). It is concluded that (a) abdominal scintigraphy using (99m)Tc-HMPAO-labelled leucocytes is of value in detecting the silent gut inflammation in Sp patients, and (b) silent gut inflammation is related to the clinical activity, but is not associated with any particular type of illness or with HLA-B27.