Predicting Short- and Long-Term Outcomes in Adult Heart Transplantation: Clinical Utility of MELD-XI Score.

BACKGROUND: Model for End-Stage Liver Disease scoring system excluding international normalized ratio (MELD-XI) has been related with worse outcomes after heart transplantation (HT). However, according to standards in prognostic models research, before implementing a risk score for daily clinical decision-making, its performance and impact on clinical practice/outcomes should be evaluated. The aim of this study was to evaluate the ability of the MELD-XI score to predict outcomes in daily clinical practice. MATERIAL AND METHODS: We retrospectively reviewed 190 consecutive adults undergoing HT between 2005-2015. Patients were stratified into low (MELD-XI <12) and high (MELD-XI ≥12) risk cohorts. Mortality rates at 30 days and 1 year were compared between MELD-XI groups. MELD-XI ability to predict 1-year mortality was assessed by the area under the receiver operating curve (AUC) and compared to that of bilirubin, creatinine, and pulmonary vascular resistance (PVR). RESULTS: Mortality rates at 30 days and 1 year were similar between groups (8% vs 13%; P = .28 and 21% vs 29%; P = .21, respectively). MELD-XI ability to predict 1-year mortality was poor and similar to that of bilirubin, creatinine, and PVR (0.51 vs 0.47 vs 0.50 vs 0.50, respectively). CONCLUSIONS: MELD-XI score utility in HT clinical decision-making is scarce since its discrimination ability is poor and similar to other simple prognostic variables.

Demanda de atención sanitaria en las unidades de identidad de género de Andalucía y Cataluña durante la década 2000 a 2009 / The demand for health care services in the gender identity units of Andalusia and Catalonia during the period of 2000 to 2009

Objetivo. Evaluar de forma comparada la demanda de atención sanitaria pública en dos unidades de trastornos de la identidad de género (Andalucía y Cataluña) durante la década 2000-2009. Método. Estudio descriptivo y comparativo de la demanda sanitaria, características de los solicitantes y cirugías realizadas. Resultados. Han solicitado asistencia sanitaria 828 pacientes en Andalucía y 549 en Cataluña. En ambas comunidades es similar el porcentaje de casos que cumplen criterios de transexualismo (88 vs. 89,8%), la frecuencia de casos excluidos del programa de reasignación sexual (16,7 vs. 15,3%), la razón de sexos hombre/mujer (1,6:1 vs. 2,1:1), y la edad media (28 vs. 29 años). Se han realizado 284 cirugías de reasignación sexual en Andalucía y 50 en Cataluña. Conclusiones. La demanda en Andalucía se ha mantenido estable y en Cataluña se ha incrementado en los últimos años. Las características demográficas y clínicas de los pacientes transexuales son similares y acordes con la mayoría de estudios realizados en otros países(AU)

Objective. To evaluate the demand for public health services in two gender identity disorder units (Andalusia and Catalonia) during the period of 2000-2009. Method. A descriptive and comparative study was made of the demand for health services, the demographic and clinical characteristics of the patients, and the sex reassignment surgeries performed. Results. A total of 828 subjects in Andalusia and 549 in Catalonia requested clinical assistance. In both communities, the percentages of cases diagnosed of transsexualism (88 vs 89.7%), the percentages excluded in the sex reassignment program (16.7 vs 15.3%), the male/female ratio (1.6:1 vs 2.1:1), and the mean age (28 vs 29years) were similar. A total of 284 sex-reassignment surgeries were performed in Andalusia and 50 in Catalonia. Conclusions. The demand has been maintained in Andalusia and has increased in Catalonia in recent years. The basic demographic (AU)

[The demand for health care services in the gender identity units of Andalusia and Catalonia during the period of 2000 to 2009]. / Demanda de atención sanitaria en las unidades de identidad de género de Andalucía y Cataluña durante la década 2000 a 2009.

OBJECTIVE: To evaluate the demand for public health services in two gender identity disorder units (Andalusia and Catalonia) during the period of 2000-2009. METHOD: A descriptive and comparative study was made of the demand for health services, the demographic and clinical characteristics of the patients, and the sex reassignment surgeries performed. RESULTS: A total of 828 subjects in Andalusia and 549 in Catalonia requested clinical assistance. In both communities, the percentages of cases diagnosed of transsexualism (88 vs 89.7%), the percentages excluded in the sex reassignment program (16.7 vs 15.3%), the male/female ratio (1.6:1 vs 2.1:1), and the mean age (28 vs 29 years) were similar. A total of 284 sex-reassignment surgeries were performed in Andalusia and 50 in Catalonia. CONCLUSIONS: The demand has been maintained in Andalusia and has increased in Catalonia in recent years. The basic demographic and clinical characteristics of transsexual patients were similar between both units and comparable to those of other countries.

La educación terapéutica de personas con diabetes. Experiencia del Servicio de Endocrinología y Nutrición del Hospital Universitario «Carlos Haya» de Málaga / Therapeutic education in people with diabetes. Experience from the Endocrinology and Nutrition Department of Carlos Haya University Hospital in Málaga, Spain

En la segunda mitad del siglo XX, la medicina ha cambiado más que en toda su historia anterior. Este cambio ha sido la consecuencia no sólo de los avances científicos y técnicos, sino también de los cambios del modelo social. Los pacientes han dejado de ser personas pasivas y han pasado a disfrutar de un creciente protagonismo en la toma de decisiones: es la manera de llevar a la práctica el principio de autonomía, que, junto con los principios de beneficencia y de justicia, constituyen los pilares básicos de la ética médica. Pero la autonomía no es real si el paciente no disfruta de los instrumentos para ejercerla realmente. La educación terapéutica es el mejor instrumento para transferir información desde el médico y el sistema sanitario hacia el paciente. La diabetes mellitus es el prototipo de enfermedad crónica susceptible de beneficiarse de la participación activa del paciente. Los programas de educación de pacientes diabéticos han pasado a formar parte de los espacios establecidos de atención clínica de la diabetes. Por lo general, hasta no hace mucho los servicios clínicos carecían de experiencia en la introducción de la educación como parte de la terapéutica clínica. No es sorprendente, pues, que la manera de organizar la educación de los pacientes haya sido muy diversa: dependía de la capacidad de cada servicio para dar respuesta a los nuevos retos, pero también, y sobre todo, de la sensibilidad y la cultura que se tuviera sobre la relación médico-enfermo. Así, aunque se ha hecho un esfuerzo por estandarizar la educación terapéutica, lo cierto es que ha habido tantos programas como espacios donde se ha puesto en marcha. En el presente artículo se reflexiona sobre la educación de pacientes desde la experiencia de más de 20 años en un servicio de endocrinología y nutrición

In the second half of the 20th century, the field of «Medicine» underwent more changes than throughout its entire previous history. This transformation has been the consequence not only of scientific and technical advances, but of changes in the social model as well. Patients have gone from being passive individuals to having an increasingly prominent role in the decision-making process. This is the manner of putting into practice the principle of autonomy, which, together with the principles of beneficence and justice, is a mainstay of medical ethics. However, this autonomy is not real if the patient is not provided with the tools he or she needs to actually exercise it. Therapeutic education is the best tool for transferring information from the physician and health care system to the patient. Diabetes mellitus represents the prototype of the chronic diseases that could benefit from the active participation of the patient. Education programs for diabetic patients have become a part of the conventional ambit of clinical care in diabetes. The staffs of clinical services generally lack experience in the introduction of education as a part of clinical therapeutics. Thus, it is not surprising that the approach to organizing patient education has varied widely. It has depended on the capacity of each service to respond to the new challenges, but, above all, on the existing sensitivity and culture with respect to the physician-patient relationship, as well. Although there has been an effort to standardize therapeutic education, the truth is that there have been as many programs as settings in which they have been introduced. In the present article, the authors reflect on patient education, following more than twenty years of experience in an endocrinology and nutrition department

Prevalence of obesity in south-east Spain and its relation with social and health factors.

Recent studies have confirmed important regional differences in the prevalence of obesity, as well as a tendency for this prevalence to increase. Determination of the social factors involved in obesity may be very useful to design intervention and prevention strategies. This transverse study was undertaken in Pizarra (Malaga, Spain) from a random sample of the population between 18 and 65 years of age (n = 1226). All participants were interviewed and given a physical examination. Standardized anthropometrical measurements were made, and a baseline blood sample was taken after an oral glucose tolerance test. The overall prevalence of obesity (BMI > 30 kg/m2) was 28.8%. This figure increased continuously from 10% in the group aged 18-25 years to above 50% in the groups aged over 55 years. This prevalence is higher than that reported in most other studies in Spain. The obese persons ate differently, at least from a qualitative viewpoint, probably more saturated fats and fewer unsaturated fats, and had a different behaviour concerning alcohol and smoking. Marital status was related with the rate of obesity, and the close relation between the level of education and the risk of obesity was confirmed (OR = 3.8 for being obese and having no education compared to having university studies). The most important consequence of the study was that all these factors are potentially modifiable and preventable. An increased level of general education in the population may well contribute decisively to a reduction in the prevalence of obesity.

[Treatment of Lesch-Nyhan syndrome]. / Tratamiento del síndrome de Lesch-Nyhan.

AIM: We have reviewed the treatments employed to alleviate the different manifestations of the Lesch Nyhan syndrome, the adverse reactions related to these treatments, and the prospectives of future therapeutic approaches now under active research. DEVELOPMENT: Lesch Nyhan syndrome is an X linked inherited disorder of purine metabolism caused by the deficiency of the enzyme hypoxanthine guanine phosphoribosyltransferase (HPRT). Clinical features include overproduction of uric acid and a neurologic syndrome related to the severity of the enzyme defect. CONCLUSIONS: Treatment with xanthine oxidase inhibitors is effective for the control of the elevated renal excretion of uric acid, but there is no specific treatment for the neurologic symptoms. Due to the low frequency of the syndrome and to the incomplete understanding of the pathophysiologic mechanisms underlying the neurologic manifestations, the treatments employed are merely symptomatic.

Increased levels of anti-oxidized low-density lipoprotein antibodies are associated with reduced levels of cholesterol in the general population.

Autoantibodies against epitopes of oxidized low-density lipoprotein (LDL), initially shown in human sera, were later related with the atherosclerotic process, although recent studies have questioned this association. Moreover, their association with total cholesterol and plasma LDL, or with the other lipoproteins, is not clear. We studied the relation between the levels of autoantibodies to oxidized LDL and lipoproteins in a population of 400 subjects from the lower Guadalhorce area in Malaga, Spain. Anti-oxidized LDL antibodies were measured by enzyme-linked immunosorbent assay (ELISA), and total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, and lipoprotein(a) [Lp(a)] were measured with commercial kits. Subjects who were positive for anti-oxidized LDL antibodies had significantly lower levels of total cholesterol (P <.01) and LDL cholesterol (P <.01). There was a negative correlation between titers of anti-oxidized LDL antibodies and levels of total cholesterol (P =.007) and LDL cholesterol (P =.024). This inverse relation between the levels of anti-oxidized LDL antibodies and the levels of total cholesterol and LDL cholesterol in a large population study, together with the discordances already published, suggests that the relation between anti-oxidized LDL antibodies, arteriosclerosis, and lipids is more complex than initially thought.

Unidad de trastornos de identidad de género de Andalucía. Experiencia del primer año de funcionamiento / Sexual identy unit of Andalucía

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Enfermería de familia frente a enfermería de pediatría / Family versus pediatric nursingobjectives

OBJETIVO: Conocer la opinión del pediatra de atención primaria con respecto a las dos formas de organización de la enfermería en los centros de salud (enfermería de familia y enfermería de pediatría): ventajas de una sobre otra, modelo preferido y sugerencias para implantarlo. MÉTODOS: Estudio Delphi, realizado desde octubre de 1999 hasta enero de 2000, con 58 pediatras de equipo de atención primaria del área 11 de Madrid. RESULTADOS: Las ventajas de la enfermería de pediatría fueron: mejor coordinación con el pediatra, mayor motivación y formación del profesional de enfermería, uniformidad de criterios, mejor conocimiento del paciente, preferencia de las familias, ampliación de actividades y separación de niños y adultos. El acuerdo sobre todas ellas fue mayor del 92 por ciento, con una importancia superior a 4 (en una escala de 0al 5). Las ventajas de la enfermería de familia fueron: ahorro, mejor conocimiento familiar y social, preferencia del colectivo de enfermería, posibilidad de cambio de profesional y continuidad en el seguimiento del adolescente. El acuerdo fue variable (del 29 al 61 por ciento), con una importancia inferior (del 2,8 al 3,6), según los enunciados. El 96 por ciento de los pediatras consideraron la enfermería de pediatría como la forma idónea de organización. Aunque el 75 por ciento no aportó ninguna sugerencia que pudiera favorecer la implantación del modelo preferido, el acuerdo sobre las iniciativas que aportaron el resto de participantes osciló entre el 68 y el 100 por ciento. CONCLUSIÓN: El pediatra de atención primaria opina que la enfermería de pediatría es más ventajosa que la enfermería de familia para su trabajo diario (AU)

In vivo modulation of G proteins and opioid receptor function by antisense oligodeoxynucleotides.

The work in our laboratory has been designed to characterize the transducer mechanisms coupled to neurotransmitter receptors in the plasma membrane. Particular attention has been paid to the physiological/pharmacological effects mediated by the opioid system. Antisense oligodeoxynucleotides have proved useful in correlating opioid receptor clones with those defined pharmacologically. The involvement of the cloned opioid receptors mu, delta, and kappa in analgesia has been determined by means of in vivo injection of ODNs directed to the receptor mRNAs. Using this strategy the classes of G-transducer proteins regulated by each type/subtype of opioid receptor in the promotion of antinociception have also been characterized. After displaying different patterns of binding to their receptors, opioids trigger a variety of intracellular signals. The physiological implications and therapeutic potential of these findings merit consideration.

Unsaturated fatty acids alter the insulin secretion response of the islets of Langerhans in vitro.

The aim of the present study is to examine the influence which different concentrations of free fatty acids (FFAs) have on the insulin secretion response of the islets of Langerhans when the culture is prolonged over a week. Animals were killed by decapitation and pancreatic islets of Langerhans isolated. The islets were incubated in enriched RPMI and oleic or linoleic acid was added at concentrations of 0.04, 0.1, 0.375, and 1 mmol/l. The medium without FFAs was used as a control. The culture time was 7 days. For insulin secretion studies, islets were selected after preincubation in batches of six islets in 1 ml of KRB (Krebs-Ringer buffer) containing one of the following: 5.5, 11.1, 16 or 26.7 mmol/l glucose, 10 mumol/l forskolin or 20 mmol/l arginine. The results showed a significant increase in insulin secretion observed after culture with 1 mmol/l oleic and linoleic acid compared to the other concentrations and the control culture for all the secretagogues used. However, at this same concentrations no increase was observed in insulin secretion as the glucose concentration rose, and this was noticeable with linoleic acid at concentrations of 0.375 mmol/l. In conclusion, culture of islets of Langerhans for a week with high concentrations of unsaturated fatty acids produces a hypersecretion of insulin which is not influenced by secretagogues such as glucose, arginine, or forskolin. The loss of gluco-sensitivity may become greater as the degree of unsaturation of the fatty acid used increases.

Adipose tissue fatty acids and size and number of fat cells from birth to 9 years of age--a cross-sectional study in 96 boys.

We studied interrelations between the size and number of fat cells and the composition of fatty acids in 96 boys from birth to 9 years of age. The size of fat cells increased during the first months of life and decreased over the second 6 months, in parallel with the tissue fat concentration and the skinfold thickness of subcutaneous fat. From the end of the first year of life, the size of the fat cell increased slowly. The number of fat cells did not begin to increase until the end of the first year of life, maintaining a continuous increase until 9 years of age. During the first years of life, important changes occurred in the concentration of adipose tissue fatty acids. Palmitic acid had the greatest concentration in adipose tissue at the moment of birth and then decreased, becoming stabilized from the age of 2 or 3 years. The concentrations of lauric, myristic, and myristoleic acids followed a course similar to that of adipocyte growth, probably reflecting changes in the accumulation of fat by the adipocyte. At the moment of birth, the concentrations of linoleic acid (C18:2), an essential fatty acid not synthesized by the organism, were low, increasing from the very first months of life. This increase correlated with the increase in fat cell size and number. These interrelations between the size and number of fat cells and the composition of adipose tissue fatty acids suggest the important role dietary fat can play in the childhood endowment of adipocytes.

[Surreptitious intake of diuretics as the cause of pseudo-Bartter's syndrome: apropos of a case and differential diagnosis]. / Ingesta subrepticia de diuréticos como causa de "Pseudo-Síndrome Bartter", a propósito de un caso y diagnóstico diferencial.

We describe a 39 years old patient with a history of chronic symptomatic hypokalemia. She denied taking any drugs. She satisfied the clinical criteria for Bartter's syndrome and more precisely for Gitelman's syndrome: hypokalemia in the presence of inappropriately high potassium excretion, metabolic alkalosis, hyperreninemic hyperaldosteronism, hypomagnesemia with inappropriately high magnesium excretion, normocalcemia, hypocalciuria and normal blood pressure. A HPLC analysis detected the presence of furosemide in urine and chlorthalidone in urine and plasma samples. After the self administration of diuretics was stopped, the above alterations came back to normality. Prior to the verification of a self administration of diuretics, the patient showed clinical and biochemical parameters that oriented to surreptitious diuretic ingestion (Pseudo-Bartter's syndrome) not to Bartter's syndrome or Gitelman's syndrome, particularly the plasma potassium readily restored to normal by the administration of potassium chloride supplements, the increased plasma uric acid with low uric acid fractional clearance, the widely different urine and plasma electrolyte levels and the presence psychiatric disorders. The literature is reviewed and differential diagnosis, among this three syndromes, is made.

[Diet and hypertriglyceridemia: influence of dietary modifications on plasma lipids, lipoproteins and apoproteins in patients with primary hypertriglyceridemia]. / Dieta e hipertrigliceridemia: influencia de las modificaciones dietéticas sobre los lípidos, lipoproteínas y apoproteínas plasmáticas en pacientes con hipertrigliceridemia primaria.

BACKGROUND: To investigate the influence of dietary changes on plasma lipoproteins and apoproteins in 10 patients with hypertriglyceridemia (plasma triglycerides greater than 1000 mg/dl). METHODS: A sequential study with three periods was designed: 1) Inclusion with uncontrolled free diet; 2) Two weeks of a diet with about 1000 calories/day, controlled with a daily survey; and 3) One week of "free" diet of about 2000 calories. At the end of the three periods the following were measured in each patient: weight, glycemia, plasma IRI and C-peptide, plasma, triglycerides, cholesterol, chylomicron, VLDL, LDL and HDL cholesterol. At the end of the second and third periods the caloric and immediate principles intake were individually considered. RESULTS: A reduction in plasma cholesterol and triglycerides was observed in all cases after the caloric reduction, and also a disappearance of chylomicrons. The reduction of triglycerides took place in all lipoproteins. By contrast, after the low-calorie diet only the VLDL-cholesterol was reduced, while LDL- and HDL-cholesterol increased. The apo C-III/apo C-II ratio was significantly reduced after the low-calorie diet. The plasma glycemia, IRI and C-peptide were negatively correlated with LDL-cholesterol and with the apo C-III/apo C-II ratio. The best model to explain the oscillations of plasma triglycerides depending on the diet was that including the three ingested immediate principles together with the total diet calories. CONCLUSIONS: During the caloric restriction there would be an increased catabolism of VLDL to LDL. This reduction would be mediated by C-III and C-II apoproteins, probably through the oscillations of plasma IRI.

[The response of the growth hormone to acute effort is a function of training]. / La respuesta de la hormona de crecimiento al esfuerzo agudo está en función del entrenamiento.

BACKGROUND: The increase of the growth hormone (GH) during exercise is known although the relationship of this response with other hormones, the type and intensity of the exercise, nutritional state and with the degree of training are reasons for discussion. The aim of this investigation was to study the response of the HG on a group of young adults with different degrees of training, according to the maximum consumption of oxygen (VO2 max) achieved over a short period of time. METHODS: Thirty-nine healthy subjects who underwent maximum effort on the treadmill were grouped according to VO2 max reached (less than 3,000 ml/min; 3,000-4,500 ml/min and greater than 4,500 ml/min). Systolic blood pressure (SBP) and diastolic blood pressure (DBP), respiratory quotient (RQ), O2 pulse, cardiac frequency (CF) respiratory equivalence (RE), glycemia, plasma insulin (PI), C peptide, lactic acid, venous pH, plasma renin activity (PRA), plasma aldosterone, thyrotropine (TSH), triodothyronine (T3), thyroxine (T4), adrenocorticotropine (ACTH), cortisol and GH were measured basally and following achievement of VO2 max. RESULTS: The GH was only increased in those subjects with a VO2 max higher than 3,000 ml/min with a significant positive correlation found between the GH and VO2 max and a significant negative correlation was found between the GH and lactic acid at the end of the test. The increase of glycemia at the end of the test correlated with the VO2 max. The PI and C peptide increased at the end of the test in the subjects with greater VO2 max capacity and correlated positively with the VO2 max and with the GH upon completion of the exercise. CONCLUSIONS: These results suggest that the response of the growth hormone to exercise is a function of maximum oxygen consumption although this only explains 24% of the variants of the growth hormone. Despite important hormonal and metabolic mobilization during exercise, no model of multiple regression has been found which substantially improves the association found between the growth hormone and maximum oxygen consumption.

[Computerized tomography of the pituitary gland in the diagnosis of prolactinoma: a concordance study]. / La tomografía computadorizada de hipófisis en el diagnóstico de los prolactinomas: estudio de concordancia.

BACKGROUND: The diagnostic capacity of computed tomography (CT) of the pituitary gland in the diagnosis of prolactinomas is difficult to define in terms of specificity and sensitivity since, up to the present, there is no definite diagnostic test for prolactin producing tumors. The aim of this study is to establish the consistency of CT of the hypophysis in the diagnosis of the prolactinomas based on a concordance design. METHODS: In the follow-up study of 48 patients diagnosed as affected of prolactinoma a concordance study was carried out on the blind lecture of 35 pituitary gland CT by two radiologists. RESULTS: The degree of concordance for all the diagnosis (kappa = 0.58) was greater than what might be expected by chance. The degree of concordance was also different for the different diagnosis given by the two radiologists: empty sella turcica, kappa = 0.84 (p less than 0.01); macroprolactinoma, kappa = 0.68 (p less than 0.01); microprolactinoma, kappa = 0.45 (p less than 0.01) and normal sella turcica, kappa = 0.28 (NS). CONCLUSIONS: CT of the hypophysis must be less sensitive (more false negatives) in cases of high prolactin due to microprolactinomas and less specific (more false positives) in cases of high prolactin due to a cause other than pituitary tumor, thereby making it a complementary diagnostic test to clinical evaluation and to prolactin determinations.