[Antimicrobial stewardship program in urinary tract infections due to multiresistant strains in the emergency department]. / Programa de optimización de antibioterapia en infección urinaria por cepas multirresistentes en el servicio de urgencias.

OBJECTIVE: Urinary tract infections (UTI) are a frequent reason for attendance at emergency department (ED). The present study evaluates the impact of a multidisciplinary program for the optimization of antibiotic therapy in patients with UTI caused by multi-drug resistant bacteria treated from the hospital ED. METHODS: Descriptive study of the implementation of a program in which emergency, microbiology and pharmacy departments participated. Antibiotic treatment of the patients who consulted the ED with positive urine cultures caused by multidrug-resistant bacteria was reviewed upon discharge. In those patients with inappropriate treatment, doctors and/or pharmacists of the next level of healthcare or patients in the case of home discharge were contacted. The impact of the program was evaluated based on new visits to the ED at 30 days after discharge, compared with the results obtained from the usual practice three months prior the intervention. RESULTS: During the first year, 2,474 urine cultures of patients with UTI were reviewed, 533 (21.7%) were caused by multidrug-resistant bacteria. Empirical treatment was inappropriate in 287 (53.4%), making treatment modifications in 243 of them. 73 (19.3%) patients returned to the ED 30 days after discharge, being lower than the results obtained in the three months prior intervention (27.9%; p=0.031), without significant differences in new visits associated with UTI. CONCLUSIONS: The implementation of a multidisciplinary program focused on multidrug resistant UTI at discharge form ED correct antibiotic therapy in a large number of patients, being a potentially tool to reduce the number of new ED visits.

[Analysis of the incidence and epidemiology of non-tuberculous mycobacterial infections in the health area III of Aragón]. / Análisis de la incidencia y epidemiología de las infecciones por micobacterias no tuberculosas en el área de salud III de la comunidad autónoma de Aragón.

OBJECTIVE: The main objective of our investigation was to know the incidence and epidemiology of non-tuberculous mycobacteria (NTM) in our area and the prevalence of comorbidities in patients with MNT infection. As secondary objectives, we studied the distribution by species of MNT, the forms of disease and the type of sample used for its diagnosis. METHODS: A retrospective study was carried out in which all the isolates of mycobacteria carried out by the microbiology laboratory of the Hospital Clínico Universitario Lozano Blesa of Zaragoza during the period between January 1, 2011 and December 31, 2018 were included. RESULTS: A total of 533 mycobacteria were isolated, of which 295 (55.35%) were tuberculosis (MTB) and 238 (44.65%) were MNT. Of the whole MNT isolates, only 15.54% were considered clinically significant. Twenty-one species were identified being the most frequent: M. gordonae (26.89%), M. fortuitum (19.75%) and M. avium (16.39%). 32.72% of the MNT isolates were found in people over 70 years of age. CONCLUSIONS: We can confirm that the reported number of MNT isolates in our area is higher than in previous periods. MNT infection is more common in men and those older than 70 years. The epidemiology, especially the risk factors, of MNT disease is changing.

High sensitivity thermal lens microscopy: Cr-VI trace detection in water.

In this work, a low detection limit for hexavalent chromium in water of parts per trillions (21ng/L) was achieved using a micro-spatial thermal lens spectroscopy setup with coaxial counter-propagating pump and probe laser beams and an integrated passive optical Fabry-Perot resonator, aided with a well-established diphenyl carbazide colorimetric method. Cr-VI concentrations in the range of µg/L, i.e. well-below the toxicity thresholds in humans and animals (26 and 190mg/L respectively) and below those delimited by international regulations for drink water (~0.05-0.5mg/L), have been obtained by measurements in bottled and tap water samples. The developed thermal lens microscope is also capable to detect Cr-VI directly in potassium dichromate solutions using pump beam wavelengths within the very low optical absorption region in the visible part of the spectrum, i.e., without the use of any colorimetric method.

Use of second generation supra-glottic airway devices during laparoscopic cholecystectomy: a prospective, randomized comparison of LMA Proseal™, LMA SupremeTM and igel™.

INTRODUCTION: Supra-glottic airway devices (SADs) with an inbuilt drain channel, such as the LMA Proseal™ (LMA-P), LMA SupremeTM (LMA-S) and i-gel™ (i-gel), have been used for laparoscopic cholecystectomy. We compared safety, efficacy, and ease of use, as well as the incidence of adverse events between these devices. METHODS: One hundred and eighty adult, ASA 1-3 patients scheduled to undergo elective cholecystectomy under general anesthesia were randomly allocated to one of three groups: LMA-P, LMA-S or i-gel. The primary outcome was to evaluate oropharyngeal leak pressure (OLP). Secondary outcomes were to evaluated speed of insertion, ease of insertion of the device and the drain tube, as well as the incidence of intraoperative adverse events and postoperative oropharyngeal discomfort (POPD). RESULTS: Mean OLP was significantly higher for LMA-P (LMA-P 30.87; i-gel 29.28; LMA-S 29.02 cm H20, P = 0.007). OLP was correlated with a higher maximum tidal achieved volume (P = 0.025). Insertion times were shorter for the i-gel, which was 1.7 s faster to insert than LMA-P (P = 0.04). The success rate on first attempt was higher for the LMA-S (P = 0.004). The drain tube was easily inserted in the LMA-S group (p < 0.001). I-gel showed higher sore throat scoring 2 hours postoperatively (P = 0.008) and reported slower POPD decrease during that time (P < 0.001). CONCLUSIONS: Among SAD's, LMA-S is the easiest to insert (including the drain tube), LMA-P achieved the best leak pressure, and i-gel fastest to insert, although associated with the worst POPD scoring.

Evaluación morfo-metabólica del adenocarcinoma mucinoso de uraco mediante tomografía por emisión de positrones - tomografía computarizada (PET-TC) / Morphological-metabolic evaluation of the urachal mucinous adenocarcinoma by positron emission tomography-computed tomography (PET-CT)

El adenocarcinoma mucinoso de uraco es una neoplasia maligna rara, localizada entre la vejiga y el ombligo, y que generalmente se encuentra en estadio avanzado al momento del diagnóstico. Analizamos un caso clínico en el que la PET-TC proporcionó información morfológica y metabólica valiosa para determinar el diagnóstico y la estadificación(AU)

The urachal mucinous adenocarcinoma is a rare malignant neoplasm located between the bladder and the umbilicus. It is usually found in an advanced stage at the moment of diagnosis. We have analyzed a clinical case in which the PET-CT study provided valuable morphological and metabolic information for diagnosis and staging(AU)

CCR9+ T cells contribute to the resolution of the inflammatory response in a mouse model of intestinal amoebiasis.

Analysis of the mechanisms underlying the inflammatory response in amoebiasis is important to understand the immunopathology of the disease. Mucosal associated effector and regulatory T cells may play a role in regulating the inflammatory immune response associated to Entamoeba histolytica infection in the colon. A subpopulation of regulatory T cells has recently been identified and is characterized by the expression of the chemokine receptor CCR9. In this report, we used CCR9 deficient (CCR9(-/-)) mice to investigate the role of the CCR9(+) T cells in a murine model of E. histolytica intestinal infection. Intracecal infection of CCR9(+/+), CCR9(+/-) and CCR9(-/-) mice with E. histolytica trophozoites, revealed striking differences in the development and nature of the intestinal inflammatory response observed between these strains. While CCR9(+/+) and CCR9(+/-) mice were resistant to the infection and resolved the pathogen-induced inflammatory response, CCR9(-/-) mice developed a chronic inflammatory response, which was associated with over-expression of the cytokines IFN-γ, TNF-α, IL-4, IL-6 and IL-17, while IL-10 was not present. In addition, increased levels of CCL11, CCL20 and CCL28 chemokines were detected by qRT-PCR in CCR9(-/-) mice. E. histolytica trophozoites were identified in the lumen of the cecum of CCR9(-/-) mice at seven days post infection (pi), whereas in CCR9(+/+) mice trophozoites disappeared by day 1 pi. Interestingly, the inflammation observed in CCR9(-/-) mice, was associated with a delayed recruitment of CD4(+)CD25(+)FoxP3(+) T cells to the cecal epithelium and lamina propria, suggesting that this population may play a role in the early regulation of the inflammatory response against E. histolytica, likely through IL-10 production. In support of these data, CCR9(+) T cells were also identified in colon tissue sections obtained from patients with amoebic colitis. Our data suggest that a population of CCR9(+)CD4(+)CD25(+)FoxP3(+) T cells may participate in the control and resolution of the inflammatory immune response to E. histolytica infection.

Morphological-metabolic evaluation of the urachal mucinous adenocarcinoma by positron emission tomography-computed tomography (PET-CT).

The urachal mucinous adenocarcinoma is a rare malignant neoplasm located between the bladder and the umbilicus. It is usually found in an advanced stage at the moment of diagnosis. We have analyzed a clinical case in which the PET-CT study provided valuable morphological and metabolic information for diagnosis and staging.

Management of ischemic hemorrhagic cystitis with hyperbaric oxygen therapy.

We report a case of a T8 paraplegic woman who experienced necrosis of the bladder due to inadvertent chronic over distention. After bladder repair, the patient suffered from severe ischemic hemorrhagic cystitis. Despite many attempts to control the bleeding with standard treatments, the hematuria continued. Although hyperbaric oxygen (HBO2) therapy has not been proven to be helpful in patients with hemorrhagic cystitis not related to radiation or chemotherapy, the physiopathologic mechanisms of the cysttis, involving ischemia, led us to believe that outpatient would benefit from HBO2 therapy in analogy to the approved use of HBO2 therapy in radiation cystitis. Since the use of HBO2 therapy has not been previously reported in this situation, we met with some hesitation from the HBO2 therapy department After reviewing the literature and discussing the case, a medical panel reached a consensus to allow us to commence the treatment The patient had a remarkable response, and remains without hematuria 6 mo. after treatment.

The Fab fragment of anti-digoxin antibody (digibind) binds digitoxin-like immunoreactive components of Chinese medicine Chan Su: monitoring the effect by measuring free digitoxin.

Chan Su, a Chinese medicine prepared from the skin glands of Chinese toads, is used in the treatment of cardiovascular diseases. Severe toxicity and even death has been reported from overdose with Chan Su. The cardiotonic effect of Chan Su is attributed to bufadienolides, which also have apparent digitoxin activity. We demonstrated that these components of Chan Su could be neutralized by digibind, both in vitro and in vivo. For in vitro experiments, we supplemented drug-free serum pools with aqueous extract of Chan Su. Then, to aliquots of serum pool containing Chan Su, various amounts of digibind (10, 25 or 50 microg/ml of serum) were added. After incubation, total and free digitoxin concentrations (in the protein-free ultrafiltrate) were measured using the fluorescence polarization immunoassay (FPIA) and a FLX/TDx analyzer. For in vivo experiments, mice were fed with Chan Su by gavage. After 45 min, 200 microg of digibind was administered by injection. Fifteen minutes after injection, blood was collected for analysis of total and free apparent digitoxin activities. We observed complete removal of apparent digitoxin activity from protein-free ultrafiltrate both in vitro and in vivo by digibind, indicating that digibind successfully binds Chan Su. We conclude that digibind neutralizes Chan Su, and measuring the free digitoxin concentrations can monitor such an effect.

Evaluación de estrategias de afrontamiento, nivel de funcionamiento y edad en personas con dolor oncológico y benigno / Evaluation of confronting strategies, functioning level and age in persons with benign and oncologic pain

Antecedentes: Desde la disciplina psicológica se viene prestando atención particular al tema del dolor crónico desde finales de los 70. Actualmente, y desde esta perspectiva, el dolor crónico se entiende como una experiencia que coloca a las personas bajo estrés, en tanto que atenta directamente contra su bienestar. Ante tal experiencia, los individuos ponen en marcha diferentes mecanismos de actuación o estrategias de afrontamiento para intentar reducir el malestar provocado por dicha situación. La conclusión genérica de los diversos estudios que se han venido efectuando a este respecto, apuntan hacia que el tipo de estrategias de afro ntamiento utilizadas por los pacientes con dolor crónico incide en el grado de ajuste que éstos presentan ante su enfermedad. Es por ello que el análisis de dichas estrategias se constituye en un factor relevante a la hora de diseñar intervenciones multidisciplinare s .Objetivos: El trabajo que se presenta ha tenido un triple objetivo. De un lado, delimitar el efecto que las estrategias de afrontamiento utilizadas por los pacientes tienen tanto sobre el grado de dolor experimentado, como sobre el nivel de funcionamiento cotidiano. De otro, indagar la existencia de posibles diferencias en los modos de afrontamiento que pueden caracterizar a los pacientes con dolor crónico benigno o de origen maligno, lo que tendría importantes rep e rcusiones en el establecimiento de la terapéutica conveniente en cada caso. Asimismo, ha sido analizada la influencia que otras variables, como la edad de los sujetos, tiene en la explicación de la modulación de la experiencia de dolor.Métodos: La muestra está compuesta de 197 pacientes con dolor crónico, de los cuales 105 presentan dolor de carácter benigno y 92 dolor de tipo oncológico. En el proceso de evaluación se han utilizado los siguientes cuestionarios: el Cuestionario de evaluación del dolor de McGill , el Inventario de Control del Dolor de Vanderbilt y el Inventario Multidimensional del Dolor de Haven-Yale (WHYMPI). Con el objetivo de analizar las relaciones causales entre las variables indicadas, se ha utilizado como metodología de análisis los Modelos de Ecuaciones Estructurales y, puesto que se cumplía el supuesto de normalidad multivariada, se ha empleado el método de estimación de "máxima probabilidad". Puesto que se deseaba establecer simultáneamente el ajuste del modelo en los grupos de pacientes con dolor benigno y oncológico, se ha aplicado un contraste multimuestra sobre las matrices de covarianza de ambos grupos.Resultados: Con respecto a la variable dolor los resultados indican que las estrategias pasivas influyen significativamente sobre el dolor, tanto oncológico como benigno, siendo dicha relación positiva, mientras que se observa que las estrategias activas sólo influyen en el dolor benigno (aunque no significativamente), y en este caso, la relación es negativa. En cuanto a la variable funcionamiento, se ha encontrado que el dolor, la edad y el uso de estrategias pasivas influyen en el funcionamiento de los pacientes con dolor benigno siendo dichas relaciones negativas, pero ninguna de las variables estudiadas influye sobre el funcionamiento de los pacientes con dolor oncológico.Conclusiones: Posiblemente la conclusión más evidente derivada de los anteriores resultados sea la existencia de una marcada diferencia entre los sujetos con dolor crónico oncológico y aquéllos que sufren un dolor crónico benigno, en lo referente al uso de estrategias de afrontamiento utilizadas por ambos grupos de pacientes. Consiguientemente, ha de concluirse que es primordial considerar estas diferencias cuando se diseñen intervenciones psicológicas dirigidas a los diversos grupos de pacientes que padecen dolor crónico (AU)

[Volvulus of the gallbladder. Description of a case]. / Vólvulo de vesícula biliar. A propósito de un caso.

Volvulus of the gallbladder is infrequent and is predominantly observed in elderly women, being related to anatomical abnormalities of the gallbladder which, associated with other factors, favor twisting. This is commonly diagnosed as acute cholecystitis, causing severe, acute abdominal pain with a rapid evolution which may lead to the death of the patient if emergency surgery is not performed. A case of gallbladder volvulus diagnosed as acute appendicitis is presented as is a review of the literature.

[Gastric anisakiasis diagnosed by endoscopy]. / Anisakiasis gástrica diagnosticada por endoscopia.

Anisakiasis is a parasitic infestation of increasing incidence in Spain. The case of a 75-years-old male diagnosed with gastric anisakiasis by endoscopy is presented. This case presents some peculiarities such as the previous ingestion of undercooked microwaved fish and the posterior serologic study (determination of IgE specific for Anisakis simplex) which confirmed the diagnosis. The importance of the endoscopic techniques in the diagnosis and treatment of gastric anisakiasis is emphasized.

Patterns of anxiety and personality disorder comorbidity.

The purpose of this study was to examine patterns of comorbidity of DSM-III-R anxiety disorders and personality disorders (PD). Two-hundred subjects were independently interviewed with the Structured Clinical Interview for DSM-III-R (SCID) and the Personality Disorder Examination (PDE) face-to-face by two experienced clinicians. One-hundred and forty-six also completed the Personality Diagnositc Questionnaire-Revised (PDQ-R). Rates of personality disorder among patients with and without anxiety disorders were determined by each of the three instruments. Comorbidity between panic disorder social phobia, obsessive-compulsive disorder and simple phobia and a conservative estimate of individual Axis II disorders was examined. Results indicate that panic disorder, either current or lifetime, is associated with borderline, avoidant, and dependent personality disorders: social phobia is associated with avoidant personality disorder, and obsessive-compulsive disorder is associated with obsessive-compulsive and avoidant personality disorders. Anxiety disorders with personality disorders are characterized by chronicity and lower levels of functioning compared with anxiety disorders without personality disorders.

Results of radical cystectomy for transitional cell carcinoma of the bladder and the effect of chemotherapy.

BACKGROUND: Radical cystectomy continues to be one of the primary modalities of treatment for locally advanced bladder cancer. However, long-term survival after cystectomy has improved only marginally in the last decade, and still, nearly half of the patients die from the disease within 5 years. Adjuvant treatments such as radiation therapy and chemotherapy have been used, but a clear advantage has not been demonstrated. METHODS: The authors reviewed 130 patients who underwent radical cystectomy by the same surgeon as treatment for transitional cell carcinoma of the bladder. Morbidity, postoperative mortality, overall survival time, and accuracy of clinical staging as well as the effect of perioperative chemotherapy were evaluated. RESULTS: The overall actuarial survival rate at 2, 5, and 10 years was 80%, 53%, and 45%, respectively. The survival rate based on T-classification at 5 years was 82%, 65%, and 28% for less than pT2, pT2, and greater than pT2, respectively. Regional lymph node status had a significant effect on survival. The 5-year survival rate for all patients with negative nodes was 65%, whereas patients with positive nodes had a 18% 5-year survival rate. The overall clinical staging error was 61.5%, with 41.5% of the cancers understaged. Of the patients with cTis, 60% were found to be of greater extent than pT1 tumors. No apparent survival advantage was noted for those patients who received perioperative chemotherapy when compared with patients who were followed conservatively or received chemotherapy upon relapse. These results, however, are not conclusive because this was an observation study and the number of patients was limited. CONCLUSIONS: Only a modest improvement in survival time after radical cystectomy has been observed in the last decade, despite the use of adjuvant treatments such as radiation and chemotherapy. The pathologic (pT) classification is the most accurate prognostic indicator. Clinical errors in classification are common and impair the evaluation of neoadjuvant treatments. A high incidence of invasive tumors of greater extent than pT1 was found among patients with clinical cTis; this supports an aggressive approach when these patients do not respond promptly to intravesical chemotherapy. Prospective randomized studies are needed to evaluate objectively the benefit of perioperative adjuvant treatment in locally advanced transitional cell carcinoma of the bladder.

Lymphoma of urethra in patient with acquired immune deficiency syndrome.

Primary involvement of the urethra by lymphoma is rare. We report the first case of a primary urethral B-cell lymphoma as the initial manifestation of the acquired immune deficiency syndrome (AIDS). A fifty-seven-year-old black man was evaluated for obstructive voiding symptoms and bloody urethral discharge. Workup revealed a urethral mass which, on pathologic examination, was a large B-cell lymphoma.

Transurethral polytetrafluoroethylene injection in female patients with urinary continence.

We present our results with the use of transurethral injection of polytetrafluoroethylene (Teflon) in 128 female patients with moderate to severe urinary incontinence from 1964 to 1991. Of the patients 60% had undergone previous surgical treatment for the incontinence. The etiologies included stress incontinence, neurogenic bladder, congenital anomalies, trauma and others. More than 73% of the patients improved (54.3% were totally dry). The failure rate was 27%. Complications were minimal. Urinary tract infection and temporary urinary retention occurred in 7 and 6 patients, respectively. Mean followup was 31 months. This study demonstrates that transurethral polytetrafluoroethylene injection is a useful treatment of moderate to severe urinary incontinence in female patients. Polytetrafluoroethylene is particularly useful for patients with failed previous incontinence procedures and poor surgical candidates. Failures are more likely in patients with periurethral fibrosis secondary to a previous urethral operation.

Prolonged antinociceptive activity of pseudodipeptide analogues of Lys-Trp(Nps) and Trp(Nps)-Lys.

Peptide bond substitution in the molecules of Lys-Trp(Nps) (LTN) and Trp(Nps)-Lys (TNL) by an aminomethylene and ketomethylene bond, respectively, afforded pseudodipeptides with analgesic activity. The new compounds Lys psi(CH2NH)-Trp(Nps)-OMe (LTNAM) and Trp(Nps)psi(COCH2)(R,S)-Lys (TNLKM) induced a dose-dependent and naloxone-reversible analgesia following intracerebroventricular (ICV) administration to mice. The antinociceptive effects were longer lasting compared to those induced by the parent compounds. The pseudodipeptides protected Met-enkephalin degradation by rat striatal slices and, combined with an ineffective dose of the opioid peptide, induced analgesia. LTNAM and TNLKM were as potent as LTN to inhibit brain aminopeptidase in vitro and ex vivo. An increased resistance to proteolysis of the pseudodipeptides may explain their prolonged analgesic activity.