[Virtual consultations in Traumatology and Orthopaedic Surgery]. / Consultas virtuales en Traumatología y Cirugía Ortopédica.

OBJECTIVE: The objective of this study is to analyse the current system of virtual consultations between the levels of Primary and Specialised Care in the field of Traumatology and Orthopaedic Surgery (TOS) in our healthcare area. MATERIAL AND METHOD: A retrospective observational study was carried out on 90 consecutive patients who had a non-face-to-face consultation between 3 January 2017 and 10 February 2017 and subsequently a face-to-face consultation. All the patients belonged to the same healthcare area attached to the Nuestra Señora de Candelaria University Hospital. The data on the diagnostic orientation, medical history provided and complementary tests were evaluated by 2 observers, one with training in Family and Community Medicine and the other with specialised training in TOS, and compared with those obtained in the final face-to-face assessment. RESULTS: The results showed a low inter-judge agreement regarding the diagnostic orientation, anamnesis, exploration and complementary tests provided in the virtual consultation request. It was considered that only 59% for one observer (Family and Community Medicine) and 47.7% for the other (specialised care) had sufficient information for decision-making. Furthermore, 35.2% required more than one face-to-face assessment consultation until diagnosis and in 45.5% it was necessary to request new complementary tests. In 30.7%, there was no concordance in the suggested and final diagnosis. In 51.9%, no therapeutic action other than that carried out by Primary Care was carried out and 34.1% of the patients were referred to the Rehabilitation department. CONCLUSIONS: The current model of virtual consultations in TOS does not seem adequate to respond to this new healthcare model. The number of unnecessary referrals is very high despite the previous virtual assessment by a specialist in TOS. The Family and Community Medicine specialist should have more diagnostic resources and coordination between Primary and Specialised Care is necessary to determine, in the area of TOS, the type of consultations and conditions for which this system should be implemented to obtain adequate coordination and improve communication between both levels of care.

Liver growth factor induces testicular regeneration in EDS-treated rats and increases protein levels of class B scavenger receptors.

The aim of the present work was to determine the effects of liver growth factor (LGF) on the regeneration process of rat testes after chemical castration induced by ethane dimethanesulfonate (EDS) by analyzing some of the most relevant proteins involved in cholesterol metabolism, such as hormone sensitive lipase (HSL), 3ß-hydroxysteroid dehydrogenase (3ß-HSD), scavenger receptor SR-BI, and other components of the SR family that could contribute to the recovery of steroidogenesis and spermatogenesis in the testis. Sixty male rats were randomized to nontreated (controls) and LGF-treated, EDS-treated, and EDS + LGF-treated groups. Testes were obtained on days 10 (T1), 21 (T2), and 35 (T3) after EDS treatment, embedded in paraffin, and analyzed by immunohistochemistry and Western blot. LGF improved the recovery of the seminiferous epithelia, the appearance of the mature pattern of Leydig cell interstitial distribution, and the expression of mature SR-BI. Moreover, LGF treatment resulted in partial recovery of HSL expression in Leydig cells and spermatogonia. No changes in serum testosterone were observed in control or LGF-treated rats, but in EDS-castrated animals LGF treatment induced a progressive increase in serum testosterone levels and 3ß-HSD expression. Based on the pivotal role of SR-BI in the uptake of cholesteryl esters from HDL, it is suggested that the observed effects of LGF would facilitate the provision of cholesterol for sperm cell growth and Leydig cell recovery.

Hormone-sensitive lipase deficiency disturbs the fatty acid composition of mouse testis.

Hormone-sensitive lipase (HSL) is a key enzyme in the mobilization of fatty acids from intracellular stores. In mice, HSL deficiency results in male sterility caused by a major defect in spermatogenesis. The testes contain high concentrations of PUFA and specific PUFA are essential for spermatogenesis. We investigated the fatty acid composition and the mRNA levels of key enzymes involved in fatty acid metabolism in testis of HSL-knockout mice. HSL deficiency altered fatty acid composition in the testis but not in plasma. The most important changes were decreases in the essential n-6 PUFA LNA and the n-3 PUFA ALA, and an increase in the corresponding synthesis intermediates C22:4n-6 and C22:5n-3 without changes in DPAn-6 or DHA acids. Mead acid, which has been associated with an essential fatty acid deficit leading to male infertility, was increased in the testis from HSL-knockout mice. Moreover, the expression of SCD-1, FADS1, and FADS2 was increased while expression of ELOVL2, an essential enzyme for the formation of very-long PUFA in testis, was decreased. Given the indispensability of these fatty acids for spermatogenesis, the changes in fatty acid metabolism observed in testes from HSL-knockout male mice may underlie the infertility of these animals.

Circulating free testosterone in obese men after bariatric surgery increases in parallel with insulin sensitivity.

BACKGROUND AND AIM: Male hypogonadism has been linked to obesity and diabetes. We aimed to study the association of changes in insulin sensitivity and testosterone levels in severe obese patients submitted to bariatric surgery. SUBJECTS AND METHODS: Prospective intervention study with twenty consecutive patients who underwent bariatric surgery studied before and after significant weight loss. Serum testosterone, SHBG, fasting glucose, and insulin were measured among others. Free testosterone was calculated with the Vermeulen formula and insulin sensitivity with the homeostatic model assessment (HOMA). RESULTS: At baseline, thirteen patients had low total testosterone levels, whereas eight of these patients also had free testosterone levels below the reference range obtained from the control group. After bariatric surgery total testosterone, SHBG, and free testosterone significantly increased and achieved normal values in all evaluated patients. Insulin sensitivity improved in all of them. Multivariate linear regression showed that changes in fasting glucose (ß=-1.868, p=0.001), insulin (ß=-3.782, p=0.001), weight (ß=-0.622, p=0.002), and SHBG (ß=-0.635, p=0.022) were associated with changes in free testosterone (adjusted R2=0.936, F=26.613, p=0.001). When insulin resistance calculated by HOMA was in the model instead of insulin and glucose, it also was associated (ß=-3.488, p=0.008) with free testosterone (adjusted R2=0.821, F=11.111, p=0.005). CONCLUSIONS: Circulating tes tos terone in obese men increases after bariatric surgery in parallel with an improvement in insulin sensitivity.

Hipertensión e insuficiencia renal ligadas al complejo de esclerosis tuberosa / Hypertension and renal failure linked to tuberous sclerosis complex

La hipertensión arterial (HTA) y la insuficiencia renal (IR) están íntimamente ligadas al riesgo vascular. Presentamos el caso de una mujer hipertensa de 53 anos, diagnosticada de ˜cólico nefrítico un mes antes, remitida para estudio de HTA mal controlada e IR. Ante la exploración física y las pruebas complementarias se diagnostica de esclerosis tuberosa, enfermedad infrecuente, genética, de gran variabilidad clínica que es capaz de originar HTA e IR (AU)

Hypertension and renal failure are very closely related to vascular risk. We present the case of a hypertensive, 53-year-old woman, who had been diagnosed with nephritic spasm one month before being referred to our hospital for study of her ill-controlled hypertension and renal failure. After a physical examination and complementary tests, she was diagnosed with tuberous sclerosis complex, an uncommon genetic disease that is clinically very variable and that can be the cause of hypertension and renal failure (AU)

Haloperidol disrupts lipid rafts and impairs insulin signaling in SH-SY5Y cells.

Haloperidol exerts its therapeutic effects basically by acting on dopamine receptors. We previously reported that haloperidol inhibits cholesterol biosynthesis in cultured cells. In the present work we investigated its effects on lipid-raft composition and functionality. In both neuroblastoma SH-SY5Y and promyelocytic HL-60 human cell lines, haloperidol inhibited cholesterol biosynthesis resulting in a decrease of the cell cholesterol content and the accumulation of different sterol intermediates (7-dehydrocholesterol, zymostenol and cholesta-8,14-dien-3beta-ol) depending on the dose of the drug. As a consequence, the cholesterol content in lipid rafts was greatly reduced, and several pre-cholesterol sterols, particularly cholesta-8,14-dien-3beta-ol, were incorporated into the cell membrane. This was accompanied by the disruption of lipid rafts, with redistribution of flotillin-1 and Fyn and the impairment of insulin-Akt signaling. Supplementing the medium with free cholesterol abrogated the effects of haloperidol on lipid-raft composition and functionality. LDL (low-density lipoprotein), a physiological vehicle of cholesterol in plasma, was much less effective in preventing the effects of haloperidol, which is attributed to the drug's inhibition of intracellular vesicular trafficking. These effects on cellular cholesterol homeostasis that ultimately result in the alteration of lipid-raft-dependent insulin signaling action may underlie some of the metabolic effects of this widely used antipsychotic.

Clinical pathways as a healthcare tool: design, implementation and assessment of a clinical pathway for lower-extremity deep venous thrombosis.

OBJECTIVE: To design, implement and assess a clinical pathway for lower-extremity deep venous thrombosis, and to compare the length of hospital stay in two different periods. DESIGN: Development of the care pathway by a multidisciplinary team, followed by a controlled intervention study to compare two non-concomitant cohorts of patients corresponding to the years 2002 (before the implementation of the critical pathway) and 2004 (year of the implementation). SETTING: Academic tertiary care hospital. PARTICIPANTS: 90 patients, 42 corresponding to the year 2004 and 48 to 2002, admitted to hospital with a diagnosis of lower-extremity deep venous thrombosis (DVT). MAIN OUTCOME MEASURES: Length of hospital stay, hospitalisation costs and care indicators. RESULTS: The mean length of hospital stay was 6.78 days in 2002 and 4.72 days in 2004. This means a reduction of 2.06 days (p<0.012). The reduction in the length of hospital stay in 2004 situates the hospital 1.98 days below the mean stay of our community (6.7 days) for the same diagnosis and year. The impact of the clinical pathway was assessed using the following indicators: implementation indicator 92.2%, compliance indicator 65%, adverse events indicator 2.5% and satisfaction indicator 67%. In comparison with costs incurred in year 2002, implementation of the clinical pathway resulted in a saving of euro427.33 per patient and a total saving of euro17,093.20. CONCLUSIONS: The implementation of a lower-extremity DVT clinical pathway in our institution has help to reduce hospitalisation costs, due to a decreased length of hospital stay.

Multiple bone lesions resembling a metastatic origin. An unexpected diagnosis

Lytic and blastic lesions have been associated to malignant tumours, such as solid cancer (breast cancer, renal cancer, prostate cancer, malignant melanoma or thyroid tumours). Although a mixed pattern with lytic and blastic lesions is due to metastatic tumour, this is not the only possible origin. The following case shows a systematic. This case report shows the number of tests that were made in order to discover the origin of osteolytic and osteoblastic lesions and it is notable that there is not an occult neoplasia on every occasion (AU)

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Clinical characterisation of pneumonia caused by atypical pathogens combining classic and novel predictors.

The aim of this study was to characterise community-acquired pneumonia (CAP) caused by atypical pathogens by combining distinctive clinical and epidemiological features and novel biological markers. A population-based prospective study of consecutive patients with CAP included investigation of biomarkers of bacterial infection, e.g., procalcitonin, C-reactive protein and lipopolysaccharide-binding protein (LBP) levels. Clinical, radiological and laboratory data for patients with CAP caused by atypical pathogens were compared by univariate and multivariate analysis with data for patients with typical pathogens and patients from whom no organisms were identified. Two predictive scoring models were developed with the most discriminatory variables from multivariate analysis. Of 493 patients, 94 had CAP caused by atypical pathogens. According to multivariate analysis, patients with atypical pneumonia were more likely to have normal white blood cell counts, have repetitive air-conditioning exposure, be aged <65 years, have elevated aspartate aminotransferase levels, have been exposed to birds, and have lower serum levels of LBP. Two different scoring systems were developed that predicted atypical pathogens with sensitivities of 35.2% and 48.8%, and specificities of 93% and 91%, respectively. The combination of selected patient characteristics and laboratory data identified up to half of the cases of atypical pneumonia with high specificity, which should help clinicians to optimise initial empirical therapy for CAP.

Proyección europea de la Medicina Interna espasona en la base de datos Pub Med (réplica) / European projection of Spanish Internal Medicine in the PubMed database (reply)]

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[Salivary cortisol determination in the diagnosis of pediatric Cushing's disease]. / Determinación de cortisol salival en el diagnóstico de la enfermedad de Cushing pediátrico.

Endogenous Cushing's syndrome in children is a very rare entity. Diagnosis is complex due to the wide variety of tests available. Recently, the utility of salivary cortisol has been proposed for the diagnosis of this entity, although greater evidence is required, especially in pediatric patients. We report a 14-year-old girl with Cushing's disease due to a pituitary microadenoma in whom salivary cortisol determination was very useful for the diagnosis.

Determinación de cortisol salival en el diagnóstico de la enfermedad de Cushing pediátrico / Salivary cortisol determination in the diagnosis of pediatric Cushing’s disease

El síndrome de Cushing endógeno en niños es una entidad poco frecuente con un diagnóstico complejo debido a la multitud de pruebas existentes. Recientemente se ha propuesto la utilidad del cortisol salival para el diagnóstico del mismo, aunque su uso precisa todavía de más evidencias, especialmente en pacientes pediátricos. Se expone el caso de una niña de 14 años con enfermedad de Cushing por microadenoma hipofisario en el que la determinación de cortisol salival resultó de gran utilidad para el diagnóstico

Endogenous Cushing's syndrome in children is a very rare entity. Diagnosis is complex due to the wide variety of tests available. Recently, the utility of salivary cortisol has been proposed for the diagnosis of this entity, although greater evidence is required, especially in pediatric patients. We report a 14-year-old girl with Cushing's disease due to a pituitary microadenoma in whom salivary cortisol determination was very useful for the diagnosis

Utilidad de la tiroglobulina plasmática tras TSH humana recombinante en el cáncer diferenciado de tiroides libre de enfermedad / Utility of serum thyroglobulin determination after recombinant human thyrotropin administration in the follow-up patients with differentiated thyroid cancer without residual disease

Objetivos: Valorar la determinación de tiroglobulina (Tg) plasmática tras la administración de tirotropina (TSH) humana recombinante (TSHhr) en el seguimiento para valorar la persistencia de enfermedad o remisión del cáncer diferenciado de tiroides libre de enfermedad. Material y métodos: Estudio prospectivo en 38 pacientes con cáncer diferenciado de tiroides libres de enfermedad con concentraciones indetectables de Tg en tratamiento hormonal supresor. Se determinó la Tg, la TSH, tiroxina libre, la triyodotironina libre inicial y las 48 y las 72 h tras la administración de 0,9 mg por vía intramuscular de TSHhr, gammagrafías de extensión tumoral (GET) en situación de retirada del tratamiento hormonal supresor y ecografías cervicales. Resultados: La Tg tras TSHhr permaneció indetectable en 34 pacientes, y la ecografía y la GET resultaron negativas. En 3 pacientes se observó aumento de concentración de Tg tras TSHhr sin evidencia de enfermedad (ecografía y GET negativas) y en 1 paciente se observó un aumento de concentración de Tg tras la TSHhr, con presencia de enfermedad objetivada en la ecografía cervical y GET negativa. Conclusiones: La determinación de Tg tras TSHhr, unida a la realización de la ecografía cervical, es una prueba endocrinológica funcional útil en los pacientes con cáncer diferenciado de tiroides libre de enfermedad. Su realización evita la retirada del tratamiento hormonal supresor y la realización de GET que suponen un mayor coste económico e incapacidad para el paciente sin aportar más información relevante

Objectives: To evaluate serum thyroglobulin (Tg) determination after recombinant human thyrotropin (rhTSH) administration as screening in the follow-up of patients with differentiated thyroid cancer (DTC). Material and methods: A prospective study was performed in 38 patients with DTC without residual disease and undetectable Tg concentrations under thyroid hormone suppression therapy. Tg, thyroid-stimulating hormone, free T4, and free T3 were measured at baseline and 48 and 72 hours after administration of rhTSH (0.9 mg IM). In all patients, whole body scan (WBS) was performed after thyroid hormone withdrawal. Neck ultrasound was also performed. Results: After rhTSH administration Tg remained undetectable in 34 patients with negative neck ultrasound and WBS. Tg increased after rhTSH administration in 3 patients without evidence of active disease (negative WBS and neck ultrasound) and in 1 patient with evidence of active disease in neck ultrasound and negative WBS. Conclusions: Tg determination after rhTSH administration together with neck ultrasound is useful in the follow-up of patients with DTC and disease-free status. Tg determination avoids the need to withdraw thyroid hormone suppression and the use of other tests such as WBS, which lead to higher economic and social costs but do not provide further information in the follow-up of these patients

Community-acquired pneumonia of mixed etiology: prevalence, clinical characteristics, and outcome.

Community-acquired pneumonia (CAP) of mixed etiology has increasingly been appreciated in the literature, but its clinical significance remains unknown. The aim of this analysis was to describe the prevalence, clinical characteristics, and outcome of CAP of mixed etiology. Data were obtained from a 2-year prospective study of consecutive patients with CAP in whom an extensive microbiological workup was performed. Predefined strict criteria were used to establish the etiology. A total of 493 patients were included. A single pathogen was detected in 222 (45%) cases and two or more pathogens in 28 (5.7%) cases. Mixed infections were seen across all age groups and in patients treated both in hospital and as outpatients. The most frequent combinations of pathogens were those of a bacterium plus an "atypical" organism (28.6%) and of two bacterial organisms (28.6%). Compared with patients with monomicrobial pneumonia, patients with mixed pneumonia were more likely to have underlying conditions (64% vs. 45%, p=0.04) and dementia (25% vs. 10%, p=0.02). The incidence of a defined series of complications was higher in patients with mixed pneumonia (39.3% vs. 18.6%; OR=2.84; p=0.02). Community-acquired pneumonia of mixed etiology is uncommon. Patients with mixed pneumonia are more likely to have underlying medical conditions, and they may have a more severe course of disease.

Rosiglitazone up-regulates lipoprotein lipase, hormone-sensitive lipase and uncoupling protein-1, and down-regulates insulin-induced fatty acid synthase gene expression in brown adipocytes of Wistar rats.

AIMS/HYPOTHESIS: Although thiazolidinediones are now widely used to treat type 2 diabetes, their mechanism of action remains largely unknown. They are agonists for the transcription factor PPARgamma, and in addition to their insulin-sensitising effects, they can promote adipogenesis and control gene expression in adipose tissues. We have explored the effect of rosiglitazone on insulin-mediated induction of pivotal genes involved in lipid metabolism and thermogenesis in brown fat. The genes studied were: (1) lipoprotein lipase (lpl), which is involved in lipid uptake; (2) hormone-sensitive lipase (hsl), which mobilises fatty acids from stored triglycerides; (3) fatty acid synthase (fas), which regulates de novo lipogenesis; and (4) the uncoupling proteins (ucp) 1 and 3, which control thermogenesis. METHODS: We used fetal rat primary brown adipocytes cultured with insulin, rosiglitazone or both combined. Then, we studied gene expression by northern and western blotting, as well as 'run-on' and gel-shift assays to identify binding of potential transcription factors to the fas promoter. RESULTS: Exposure to rosiglitazone for 24 h induced ucp-1, lpl and hsl gene expression and when rosiglitazone was combined with insulin a synergistic effect on lpl and ucp-3 mRNA expression was produced. These effects were consistent with increased LPL and HSL activities as well as respiration rates, mainly in response to exogenous palmitate. In contrast, treatment with rosiglitazone did not alter FAS mRNA basal levels but prevented the induction elicited by insulin in a time- and dose-dependent manner. Correspondingly diminished FAS protein levels and activity, as well as cellular lipid content, were observed, indicating an antilipogenic action of rosiglitazone in brown adipocytes. Furthermore, rosiglitazone impaired insulin increase in the FAS transcription rate by antagonising insulin-induced binding of upstream stimulatory factors to the E-box consensus sequence in the FAS promoter and insulin-induced binding of activating protein-1. CONCLUSIONS/INTERPRETATION: Rosiglitazone prevents insulin-induced up-regulation of the main lipogenic enzyme but increases the expression of those enzymes involved in lipid uptake and mobilisation, favouring fatty acid utilisation through uncoupled respiration.

Epidemiological and clinical characteristics of occult bacteremia in an adult emergency department in Spain: influence of blood culture results on changes in initial diagnosis and empiric antibiotic treatment.

A prospective study was carried out to analyze the usefulness of blood culture results for adult patients who were discharged from the emergency department with bacteremia. Over a 29-month period, 110 patients with significant bacteremia who were seen in the emergency department and discharged home were studied. The mean age of the patients was 61.8 years. The most frequent initial major diagnosis was urinary tract infection (UTI) (n=63; 57.3%). Gram-negative organisms were isolated in 79 (71.8%) cases. A change in diagnosis (44.5% cases) was more common when the initial diagnosis was something other than UTI or when empiric antimicrobial therapy was ineffective or was not given (P<0.001). The significant predictors of modification of the initial empiric antibiotic therapy were ineffective empiric antimicrobial therapy and transfer of the patient from the emergency department to an infectious diseases outpatient clinic (P=0.01). Blood culture results may be useful for achieving the correct diagnosis in adult patients with bacteremia and for guiding treatment in the subsequent management of outpatients.

Publication of European Union research on infectious diseases (1991-2001): a bibliometric evaluation.

The study presented here analyzed the contents of 36 international infectious diseases journals from 1991 to 2001 to determine the number of reports prepared by authors in the European Union and to compare the per country scientific productivity. Articles included in the study were identified using the PubMed website. The number of publications in infectious disease journals produced by authors in the European Union experienced an exponential growth from 461 (19.2% of world production) in 1991 to 2,401 (35.9%) in 2001. The mean impact factor increased from 2.259 in 1991 to 3.001 in 2001. The leading countries in the total number of publications were the UK, France, and Germany. After taking population figures into account, Sweden, Denmark, and Finland headed the list, and after correcting for gross domestic product, the greatest producers were Sweden, Finland, and the UK. Overall, the scientific production and repercussion index of European Union research on infectious diseases experienced a notable rise during the last decade of the 20th century.

Hipotiroidismo en un paciente con hiperparatiroidismo primario: asociación o coincidencia / Hypothyroidism in a patient with primary hyperparathyroidism: association or coincidence

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