Seagrass soils sequester up to half the metal emissions of one of the world's largest smelters.

One of the world's largest smelters has been operating in South Australia since 1889, affecting environment and human health. Here we quantified the magnitude of Pb, Zn and Cd emissions from the smelter sequestered in the soil of an adjacent 110 km2Posidonia australis seagrass meadows. Seagrass core records show that the smelter contaminated the entire area with decreasing sequestration with increasing distance from contamination points. The soil accumulated ~1300 t of Pb, ~3450 t of Zn, and ~ 90 t of Cd since 1889, and sequestered the equivalent of ~20 % of Pb, and ~50 % of Zn and Cd cumulative smelter emissions since 1999, showing that seagrass can be significant, long-term sinks of metal pollution in highly contaminated environments. Conservation efforts should prioritize these seagrass meadows to avoid the potential release of pollutants from their soils following habitat loss, which could turn seagrasses from a sink to a source of pollution.

Role of carbonate burial in Blue Carbon budgets.

Calcium carbonates (CaCO3) often accumulate in mangrove and seagrass sediments. As CaCO3 production emits CO2, there is concern that this may partially offset the role of Blue Carbon ecosystems as CO2 sinks through the burial of organic carbon (Corg). A global collection of data on inorganic carbon burial rates (Cinorg, 12% of CaCO3 mass) revealed global rates of 0.8 TgCinorg yr-1 and 15-62 TgCinorg yr-1 in mangrove and seagrass ecosystems, respectively. In seagrass, CaCO3 burial may correspond to an offset of 30% of the net CO2 sequestration. However, a mass balance assessment highlights that the Cinorg burial is mainly supported by inputs from adjacent ecosystems rather than by local calcification, and that Blue Carbon ecosystems are sites of net CaCO3 dissolution. Hence, CaCO3 burial in Blue Carbon ecosystems contribute to seabed elevation and therefore buffers sea-level rise, without undermining their role as CO2 sinks.

Seagrass soil archives reveal centennial-scale metal smelter contamination while acting as natural filters.

The upper Spencer Gulf in South Australia hosts the world's largest single stream Pb-Zn smelter, which has caused environmental and health issues related to elevated metal concentrations in the surrounding environment. The area also has extensive seagrass meadows, occupying >4000 km2. We reconstructed the fluxes of heavy metals over the last ~3000 years through a multi-parameter study of the soil archives formed by the seagrass Posidonia australis. Pb, Zn and Cd concentrations increased up to 9-fold following the onset of smelter operations in the 1880s, and the stable Pb isotopic signatures confirmed the smelter has been the main source of lead pollution in the seagrass soils until present. Preliminary estimates suggest that over the past 15 years seagrass meadows within 70 km2 of the smelter accumulated ~7-15% of the smelter emissions in their soils. Here we demonstrate that seagrass meadows act as pollution filters and sinks while their soils provide a record of environmental conditions, allowing baseline conditions to be identified and revealing the time-course of environmental change.

Preneoplastic Lesion in a Pancreas Allograft: Dilemma for the Pancreas Transplant Surgeon.

Although the relationship between immunosuppression and cancer risk is well-documented, the association between immunosuppression and the development of preneoplastic lesions (PNL) is less clear. PNLs pose a unique clinical conundrum in the transplanted pancreas because their prevalence in the general population is not infrequent. We present the case of a 58-year-old man with a history of diabetes mellitus type 1 who underwent successful pancreas transplantation with bladder drainage. His kidney function failed 13 years after his transplant and he developed recurrent painful hematuria with symptomatic anemia 2 years after initiating hemodialysis. Upon work-up, he was found to have a 4 cm intraductal papillary mucinous neoplasm in his pancreas allograft. At his enteric conversion, the intraductal papillary mucinous neoplasm was removed through a distal pancreatectomy due to concern for its malignant potential. He recovered well from surgery and continues to be insulin-free. With the rising incidence of PNLs from improved detection and the improved survival of pancreas allografts, the implications of PNLs may be more pronounced in the future. This case raises several important considerations for the pancreas transplant surgeon regarding adequate allograft surveillance protocols, treatment, and follow-up.

Tumor Biology as Predictor of Mortality in Liver Transplantation for Hepatocellular Carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most frequent primary malignant liver tumor, with the Milan criteria considered to be the gold standard for patient selection for liver transplantation (LT). MATERIALS AND METHODS: We performed a descriptive observational study, reviewing 20 years of experience of LT in patients with HCC in the Fundacion Valle del Lilí in Cali, Colombia. Subgroup analysis was undertaken for periods 1999 to 2007 and 2008 to 2015. RESULTS: Fifty-seven cases with a pretransplant HCC diagnosis were reviewed. In the first period patients within the Milan criteria had a recurrence-free survival at 5 years of 66.6%, and in those who exceeded the Milan criteria, recurrence-free survival was 75%. In the second period, patients within the Milan criteria, recurrence-free survival at 5 years was 93.5%, and in those who exceeded the Milan criteria, recurrence-free survival was 75.7%. No statistically significant difference was found in either period. For patients with mild and moderate tumor differentiation, the relapse survival rate at 5 years was 69.4% (95% confidence interval [CI] 35.8-87.8) and 74.7% (95% CI 44.5-90), respectively. All patients with poor tumor differentiation relapsed and died within 3 years. CONCLUSION: Global and recurrence-free survival among patients who met and patients who exceeded the Milan criteria was not significantly different, suggesting an expansion of the Milan criteria to include potential recipients who were previously excluded. Obtaining histologic differentiation and identifying vascular invasion will provide a more worthwhile contribution to LT decision making.

Liver Transplantation in Hepatitis C-Infected Patients: Experience From a South American Transplant Center.

BACKGROUND: Around 2.4% of the world's population is infected with hepatitis C virus (HCV), and it is the most common cause of liver transplantation (LT) in the world. Latin America (LA), with nearly 9% of the world population, has had a continuous increase in the number of LTs per year. Yet, due to the lack of mandatory data collection and a well-developed health-care system, access to transplantation is limited in most LA countries. We report the first LA experience of HCV-infected LT patients. METHODS: We performed a retrospective cohort study by reviewing the medical histories of all HCV-infected LT patients between 1996 and 2016 who acquired HCV before their LT, at the Fundación Valle del Lilí, Cali, Colombia. RESULTS: Between January 1996 and December 2015, a total of 770 LTs were performed, of which 75 had a cirrhotic liver due to HCV infection. With a median follow-up time of 24.4 months (interquartile range [IQR] 4.7-61.2 months), patient survival was 44.9% and 66.9% for the time periods 1996-2006 and 2007-2015, respectively. Hepatocellular carcinoma (HCC) was present in 30.6% of the patients, and overall postoperative complications had an incidence of 80%. CONCLUSIONS: This is the first report of LT in HCV-infected patients in Colombia and in LA. Our results are comparable to those of other transplant centers worldwide with regard to postoperative complications and patient survival. Patients with LT in the 1996-2006 time frame had higher morbidity and mortality. Studies including larger numbers of patients are needed to determine the reason for this finding.

Long-term Graft Survival After Kidney Allograft Torsion: Rapid Diagnosis and Surgical Management Key to Reversibility of Injury.

INTRODUCTION: Kidney allograft torsion (KAT) is a rare complication of kidney transplantation (KT) that occurs when the transplanted kidney rotates around its vascular pedicle, which may result in a catastrophic compromise of the graft's blood supply, deterioration of kidney function, and eventually premature graft death. CASE REPORT: We report the case of a patient who had an acute kidney injury (AKI) episode from KAT. Her diagnosis was ascertained expeditiously and she had prompt surgical management. Five years after the KAT event, her baseline creatinine (Cr) stabilized around 1.6 mg/dL and she has achieved >8-year graft survival. DISCUSSION: This case illustrates the reversibility of injury that can occur after a KAT event with a commensurate return to baseline kidney function when KAT is promptly diagnosed and treated. A high index of suspicion of this uncommon but catastrophic complication of KT must be maintained to achieve desirable long-term outcomes. A diagnosis of KAT must be considered when routine etiologies of an acute deterioration of kidney allograft function have been excluded. Finally, prophylactic nephropexy must be strongly considered with intraperitoneal placement of a kidney allograft to avoid KAT.

Carbon sequestration by Australian tidal marshes.

Australia's tidal marshes have suffered significant losses but their recently recognised importance in CO2 sequestration is creating opportunities for their protection and restoration. We compiled all available data on soil organic carbon (OC) storage in Australia's tidal marshes (323 cores). OC stocks in the surface 1 m averaged 165.41 (SE 6.96) Mg OC ha-1 (range 14-963 Mg OC ha-1). The mean OC accumulation rate was 0.55 ± 0.02 Mg OC ha-1 yr-1. Geomorphology was the most important predictor of OC stocks, with fluvial sites having twice the stock of OC as seaward sites. Australia's 1.4 million hectares of tidal marshes contain an estimated 212 million tonnes of OC in the surface 1 m, with a potential CO2-equivalent value of $USD7.19 billion. Annual sequestration is 0.75 Tg OC yr-1, with a CO2-equivalent value of $USD28.02 million per annum. This study provides the most comprehensive estimates of tidal marsh blue carbon in Australia, and illustrates their importance in climate change mitigation and adaptation, acting as CO2 sinks and buffering the impacts of rising sea level. We outline potential further development of carbon offset schemes to restore the sequestration capacity and other ecosystem services provided by Australia tidal marshes.

Sinistral Portal Hypertension After Live Segmental Pancreas Donation: A Long-Term Sequelae Presenting With Life-Threatening Upper Gastrointestinal Hemorrhage.

INTRODUCTION: Variceal hemorrhage from sinistral portal hypertension has never been reported as a complication of live pancreas donation. CASE REPORT: We present a 68-year-old patient who underwent a simultaneous live-donor laparoscopic segmental pancreatectomy and nephrectomy for the purposes of donating to her daughter. Her postoperative course was significant for an episode of acute pancreatitis with a pseudocyst formation. More than a decade later, she presented with variceal hemorrhage from sinistral portal hypertension, which after a diagnostic work-up, prompted a laparoscopic splenectomy. DISCUSSION: Sinistral portal hypertension is a long-term complication of live-donor pancreas donation.

Defining the Tipping Point in Surgical Performance for Laparoscopic Donor Nephrectomy Among Transplant Surgery Fellows: A Risk-Adjusted Cumulative Summation Learning Curve Analysis.

The United Network for Organ Sharing recommends that fellowship-trained surgeons participate in 15 laparoscopic donor nephrectomy (LDN) procedures to be considered proficient. The American Society of Transplant Surgeons (ASTS) mandates 12 LDNs during an abdominal transplant surgery fellowship. We performed a retrospective intraoperative case analysis to create a risk-adjusted cumulative summation (RACUSUM) model to assess the learning curve of novice transplant surgery fellows (TSFs). Between January 2000 and December 2014, 30 novice TSFs participated in the organ procurement rotation of our ASTS-approved abdominal transplant surgery fellowship. Measures of surgical performance included intraoperative time, estimated blood loss, and incidence of intraoperative complications. The performance of senior TSFs was used to benchmark novice TSF performance. Scores were tabulated in a learning curve model, adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events were significantly higher for novice TSFs than for senior TSFs. In univariable analysis, multiple renal arteries, high BMI, prior abdominal surgery, male donor, and nephrolithiasis were correlated with higher incidence of adverse surgical events. Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24-28 cases and proficiency by 35-38 cases.

Intrapancreatic Splenule in a Pancreas Allograft: Case Report.

A 16-year-old white man was involved in a motor vehicle collision and suffered head, chest, and abdominal trauma. Despite initial resuscitative efforts, he progressed to brain death and was designated to be an organ donor by his family. He had no earlier medical or surgical history and no high-risk behaviors. Blood work revealed normal creatinine, liver function tests, lipase, and amylase. Viral serologies were negative except for cytomegalovirus IgG and Epstein-Barr virus nucleic acid. Imaging revealed a right kidney contusion, a manubrial fracture, and fractures of right first rib and bilateral scapulae. No other abdominal trauma was identified, specifically to the pancreas, duodenum, or spleen. Our transplant center accepted the pancreas from this donor. During back-table inspection of the pancreas, a 1.5 × 1.5 cm dark purple rubbery mass was identified within the parenchyma of the pancreas in the tail. An incisional biopsy of the lesion was sent for frozen section, which yielded a mixed inflammatory infiltrate consisting of neutrophils and lymphocytes and an overlying fibrous capsule. The diagnosis of lymphoma or another neoplasm could not be definitely ruled out. Owing to uncertainty in diagnosis, the entire lesion was excised along with the distal pancreas with the use of a linear stapler. The staple line was oversewn with running 4-0 polypropylene suture, and the pancreas was transplanted. After surgery, the pancreas allograft functioned well with a small pancreatic leak, which had resolved by the first postoperative outpatient visit.

Impact of mooring activities on carbon stocks in seagrass meadows.

Boating activities are one of the causes that threaten seagrass meadows and the ecosystem services they provide. Mechanical destruction of seagrass habitats may also trigger the erosion of sedimentary organic carbon (Corg) stocks, which may contribute to increasing atmospheric CO2. This study presents the first estimates of loss of Corg stocks in seagrass meadows due to mooring activities in Rottnest Island, Western Australia. Sediment cores were sampled from seagrass meadows and from bare but previously vegetated sediments underneath moorings. The Corg stores have been compromised by the mooring deployment from 1930s onwards, which involved both the erosion of existing sedimentary Corg stores and the lack of further accumulation of Corg. On average, undisturbed meadows had accumulated ~6.4 Kg Corg m(-2) in the upper 50 cm-thick deposits at a rate of 34 g Corg m(-2) yr(-1). The comparison of Corg stores between meadows and mooring scars allows us to estimate a loss of 4.8 kg Corg m(-2) in the 50 cm-thick deposits accumulated over ca. 200 yr as a result of mooring deployments. These results provide key data for the implementation of Corg storage credit offset policies to avoid the conversion of seagrass ecosystems and contribute to their preservation.

El valor de la oxibutinina en parche transdérmico en el tratamiento de la vejiga hiperactiva / The value of oxybutynin in transdermal patches for treating overactive bladder

Contexto: Actualmente ya existe un amplio arsenal terapéutico de fármacos para el tratamiento del síndrome de vejiga hiperactiva (VH). Sin embargo, sigue siendo necesaria la aparición de nuevas moléculas o la evolución de fármacos conocidos para tratar de conseguir mejoras en cuanto a eficacia, adherencia y tolerabilidad. Objetivo: Describir la evidencia científica sobre la eficacia y seguridad de la oxibutinina transdérmica (OXI-TDS) en el tratamiento del síndrome de vejiga hiperactiva. Material y métodos: Se ha realizado una revisión sistemática sin restricciones temporales hasta mayo del 2015 en la base de datos bibliográfica MEDLINE/PubMed. Adicionalmente, se realizó una revisión manual de resúmenes publicados en congresos internacionales de Uroginecología. Resultados: Los estudios evaluados muestran que los pacientes tratados con OXI-TDS presentaron una reducción significativa en los episodios de incontinencia urinaria comparado con placebo y comparable con la observada en pacientes tratados con oxibutinina oral o con tolterodina. En todos los estudios se observó mejoría de los síntomas desde la segunda o la tercera semana de tratamiento y de forma mantenida hasta el final del tratamiento (6, 12 o 24 semanas). Asimismo, en el estudio de práctica clínica también se demostró mejora de la calidad de vida, obteniéndose beneficios en múltiples perfiles de pacientes, siendo la eficacia independiente de los tratamientos previos recibidos. La seguridad del fármaco se comprobó en los distintos perfiles de pacientes. Conclusiones: La OXI-TDS representa una alternativa eficaz en el tratamiento sintomático de los pacientes adultos con VH que, además, gracias a su perfil farmacocinético, mejor tolerabilidad, su diferente forma de administración y posología, podría suponer un valor añadido en el tratamiento de poblaciones especiales

Context: There is currently a broad therapeutic arsenal of drugs for treating overactive bladder syndrome (OAB). However, there is still a need for new compounds and for improving known drugs in terms of efficacy, compliance and tolerability. Objective: To report the scientific evidence on the safety and efficacy of transdermal oxybutynin (OXY-TDS) for treating OAB. Material and methods: A systematic review without time restrictions was conducted until May 2015 in the MEDLINE/PubMed database. We also performed a manual review of abstracts published in international urogynaecology congresses. Results: The evaluated studies show that patients treated with OXY-TDS experience a significant reduction in urinary incontinence episodes compared with placebo, which is comparable to that observed in patients treated with oral oxybutynin or with tolterodine. In all of the studies, we observed improvements in symptoms from the second or third week of treatment and in a sustained manner until the end of treatment (6, 12 or 24 weeks). The clinical practice study also showed improved quality of life, achieving benefits in numerous patient profiles, with an efficacy independent of previous treatments. The safety of the drug was demonstrated in the various patient profiles. Conclusions: OXY-TDS represents an effective alternative for the symptomatic treatment of adult patients with OAB, which, thanks to its pharmacokinetic profile, better tolerability, different administration method and dosage, could represent an added value in treating special populations

The value of oxybutynin in transdermal patches for treating overactive bladder.

CONTEXT: There is currently a broad therapeutic arsenal of drugs for treating overactive bladder syndrome (OAB). However, there is still a need for new compounds and for improving known drugs in terms of efficacy, compliance and tolerability. OBJECTIVE: To report the scientific evidence on the safety and efficacy of transdermal oxybutynin (OXY-TDS) for treating OAB. MATERIAL AND METHODS: A systematic review without time restrictions was conducted until May 2015 in the MEDLINE/PubMed database. We also performed a manual review of abstracts published in international urogynaecology congresses. RESULTS: The evaluated studies show that patients treated with OXY-TDS experience a significant reduction in urinary incontinence episodes compared with placebo, which is comparable to that observed in patients treated with oral oxybutynin or with tolterodine. In all of the studies, we observed improvements in symptoms from the second or third week of treatment and in a sustained manner until the end of treatment (6, 12 or 24 weeks). The clinical practice study also showed improved quality of life, achieving benefits in numerous patient profiles, with an efficacy independent of previous treatments. The safety of the drug was demonstrated in the various patient profiles. CONCLUSIONS: OXY-TDS represents an effective alternative for the symptomatic treatment of adult patients with OAB, which, thanks to its pharmacokinetic profile, better tolerability, different administration method and dosage, could represent an added value in treating special populations.

Bladder cancer in Spain 2011: population based study.

PURPOSE: We estimate the annual incidence of bladder cancer in Spain and describe the clinical profile of patients with bladder cancer enrolled in a population based study. MATERIALS AND METHODS: Using the structure of the Spanish National Health System as a basis, in 2011 the AEU (Spanish Association of Urology) conducted this study with a representative sample from 26 public hospitals and a reference population of 10,146,534 inhabitants, comprising 21.5% of the Spanish population. RESULTS: A total of 4,285 episodes of bladder cancer were diagnosed, of which 2,476 (57.8%) were new cases and 1,809 (42.2%) were cases of recurrence, representing an estimated 11,539 new diagnoses annually in Spain. The incidence of bladder cancer in Spain, age adjusted to the standard European population, was 20.08 cases per 100,000 inhabitants (95% CI 13.9, 26.3). Of patients diagnosed with a first episode of bladder cancer 84.3% were male, generally older than 59 years (81.7%) with a mean ± SD age of 70.5 ± 11.4 years. Of these patients 87.5% presented with some type of clinical symptom, with macroscopic hematuria (90.8%) being the most commonly detected. The majority of primary tumors were nonmuscle invasive (76.7%) but included a high proportion of high grade tumors (43.7%). According to the ISUP (International Society of Urologic Pathology)/WHO (2004) classification 51.1% was papillary high grade carcinoma. Carcinoma in situ was found in 2.2% of primary and 5.8% of recurrent cases. CONCLUSIONS: The incidence of bladder cancer in Spain, age adjusted to the standard European population, confirms that Spain has one of the highest incidences in Europe. Most primary nonmuscle invasive bladder cancer corresponded to high risk patients but with a low detected incidence of carcinoma in situ.

Evaluation of novel nystatin nanoemulsion for skin candidosis infections.

One of the most common fungal skin infections is candidosis. Topical application of drugs at the pathological sites offers potential advantage of direct drug delivery to the site of action. The main aim of this work was to evaluate an optimal nystatin nanoemulsion for topical application avoiding undesirable side effects as systemic absorption and toxicity. Surface morphology and droplet size distribution of nystatin nanoemulsion was determined by transmission electronic microscopy and dynamic light scattering. Vertical diffusion Franz-type cells and high-performance liquid chromatography were used to perform the in vitro release and ex vivo human skin permeation studies. Transdermal permeation parameters were estimated from the permeation values using different theoretical approaches. Microbiological studies were performed to evaluate the antifungal effect. Nanoemulsion exhibited a spherical shape with smooth surface and mean droplet size between 70 and 80 nm. The pharmacokinetic release showed the nanoemulsion is faster than commercial ointment Mycostatin(®) improving the potential therapeutic index. Permeation studies demonstrated nystatin was not absorbed into systemic circulation and the retained amount in the skin was sufficient to ensure an antifungal effect. This antifungal effect was higher for nystatin loaded nanoemulsion than nystatin itself. A therapeutic improvement of the nystatin nanoemulsion treatment compared with the classical ones was achieved.

The Posidonia oceanica marine sedimentary record: A Holocene archive of heavy metal pollution.

The study of a Posidonia oceanica mat (a peat-like marine sediment) core has provided a record of changes in heavy metal abundances (Fe, Mn, Ni, Cr, Cu, Pb, Cd, Zn, As and Al) since the Mid-Holocene (last 4470yr) in Portlligat Bay (NW Mediterranean). Metal contents were determined in P. oceanica. Both, the concentration records and the results of principal components analysis showed that metal pollution in the studied bay started ca. 2800yr BP and steadily increased until present. The increase in Fe, Cu, Pb, Cd, Zn and As concentrations since ca. 2800yr BP and in particular during Greek (ca. 2680-2465cal BP) and Roman (ca. 2150-1740cal BP) times shows an early anthropogenic pollution rise in the bay, which might be associated with large- and short-scale cultural and technological development. In the last ca. 1000yr the concentrations of heavy metals, mainly derived from anthropogenic activities, have significantly increased (e.g. from ~15 to 47µg g(-1) for Pb, ~23 to 95µg g(-1) for Zn and ~8 to 228µg g(-1) for As). Our study demonstrates for the first time the uniqueness of P. oceanica meadows as long-term archives of abundances, patterns, and trends of heavy metals during the Late Holocene in Mediterranean coastal ecosystems.

Efectividad y seguridad del uso de óxido nitroso para sedoanalgesia en urgencias / Safety and effectiveness of nitrous oxide for sedation-analgesia in emergency departments

Objetivos: Principales: evaluar la seguridad y la efectividad (mediante el análisis de la conducta del paciente) con el uso de óxido nitroso durante la realización de procedimientos dolorosos en los servicios de urgencias pediátricos (SUP); secundarios: evaluar su manejabilidad y su aceptación por el equipo médico y el paciente. Pacientes y métodos: Estudio post-autorización, prospectivo, observacional, multicéntrico, no aleatorizado y abierto (noviembre 2007-diciembre 2008), en el que participaron 7 SUP nacionales. Se incluyó a los pacientes de 2-18 años en los que se utilizó óxido nitroso para la realización de procedimientos dolorosos. Resultados: Se incluyó a 213 pacientes (27,2% < 5 años). La conducta del paciente fue considerada «buena/muy buena» en el 79,7%. El porcentaje de casos con conducta «mala/acepta con dificultad» fue mayor en < 5 años (33,3% vs. 15,1%; p=0,006), no detectándose diferencias significativas en función del procedimiento. Se registraron efectos adversos en 17 casos (7,9%), sin diferencias significativas en función de la edad, estar o no en ayunas ni la asociación de otros fármacos. Los más frecuentes fueron mareo y/o cefalea (10), seguido de vómitos (3). La administración fue considerada fácil por parte del equipo médico en el 96,6%. En el 92,7%, los padres aceptarían que volviera a ser utilizado en su hijo en una situación similar. Conclusiones: La administración de óxido nitroso logra una adecuada sedoanalgesia para la realización de procedimientos dolorosos, sobre todo en niños mayores de 5 años. Los efectos adversos registrados son escasos, leves y conocidos. La mayoría de los padres aceptaría nuevamente su uso en condiciones similares (AU)

Objectives: Primary objectives: to assess the safety and the effectiveness (analysing the behaviour of the patient) with the use of nitrous oxide during the performance of painful procedures in the Paediatric Emergency Departments (PED); secondary objectives: to evaluate the manageability of the method and its acceptance by both the medical team and the patient. Patients and methods: Post-marketing observational, prospective, multicentre, non-randomised and open (November 2007-December 2008) study, which involved seven national PED. We included patients between 2 and 18 years-old on whom a painful procedure was performed in the PED and nitrous oxide was used. Results: A total 213 patients were included (27,2% < 5years). Patient behaviour was considered «good/very good» in 79,7%, with no statistically significant difference in relation to the procedure performed. Patient behaviour was more often classified as «bad/accept with difficulty» among those < 5years (33.3% vs 15.1%, P=0.006). Adverse events occurred in 17 cases (7.9%), with no significant difference in the rate in relation to the age, fasting or not or in association with other drugs; the most frequent were dizziness and/or headache (10), followed by vomiting (3). The administration was considered easy by the medical team in the 96.6% of the cases. Parents would accept the use of nitrous oxide in their child in a similar situation in 92.7% of the cases. Conclusions: Administration of nitrous oxide achieves proper sedation and analgesia during painful procedures, especially in children older than 5years. Adverse events reported were few, mild and expected. Most parents would accept its use again in a similar situation (AU)

[Safety and effectiveness of nitrous oxide for sedation-analgesia in emergency departments]. / Efectividad y seguridad del uso de óxido nitroso para sedoanalgesia en urgencias.

PRIMARY OBJECTIVES: to assess the safety and the effectiveness (analysing the behaviour of the patient) with the use of nitrous oxide during the performance of painful procedures in the Paediatric Emergency Departments (PED); secondary objectives: to evaluate the manageability of the method and its acceptance by both the medical team and the patient. PATIENTS AND METHODS: Post-marketing observational, prospective, multicentre, non-randomised and open (November 2007-December 2008) study, which involved seven national PED. We included patients between 2 and 18 years-old on whom a painful procedure was performed in the PED and nitrous oxide was used. RESULTS: A total 213 patients were included (27,2% < 5 years). Patient behaviour was considered «good/very good¼ in 79,7%, with no statistically significant difference in relation to the procedure performed. Patient behaviour was more often classified as «bad/accept with difficulty¼ among those < 5 years (33.3% vs 15.1%, P=.006). Adverse events occurred in 17 cases (7.9%), with no significant difference in the rate in relation to the age, fasting or not or in association with other drugs; the most frequent were dizziness and/or headache (10), followed by vomiting (3). The administration was considered easy by the medical team in the 96.6% of the cases. Parents would accept the use of nitrous oxide in their child in a similar situation in 92.7% of the cases. CONCLUSIONS: Administration of nitrous oxide achieves proper sedation and analgesia during painful procedures, especially in children older than 5 years. Adverse events reported were few, mild and expected. Most parents would accept its use again in a similar situation.

Comparison of antiviral activity of regimens containing nucleos(t)ide (NUC) Pairs in HIV-Infected Patients Initiating REScue therapy (The NUCREST Study).

BACKGROUND: recycling nucleos(t)ides (NUCs) is useful in regions where new antiretrovirals are not available. This study compares the effectiveness of NUC-containing regimens as rescue therapy in routine care. METHODS: retrospective, multicentre cohort study (January 2001 to June 2006) of patients with ≥ 1 virological failure who started therapy with 2 NUCs and 1 non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI). The primary endpoint was the rate of treatment response at 6 months (intention-to-treat [ITT] analysis). RESULTS: we included 719 patients (average of 4 prior regimens over a median 6.1 years). The most frequent NUC pairs were tenofovir plus lamivudine (TDF+3TC; 25%), tenofovir plus stavudine (TDF+d4T; 23%), and stavudine plus didanosine (d4T+ddI; 15%). A boosted PI was used in 68% of total cases. Resistance to both NUCs was more frequent in zidovudine plus lamivudine (AZT+3TC; 22.0%), abacavir plus lamivudine (ABC+3TC; 35.5%), and stavudine plus lamivudine (d4T+3TC; 31.2%). No significant differences were observed in treatment response (overall 65%, P = .67); ddI+3TC (71%) and d4T+3TC (53%) had the highest and lowest response rates, respectively. Median time to failure was shorter with d4T+3TC, d4T+ddI, and ABC+3TC (48, 51, and 58 weeks, respectively; P = .0012). Lower response rates associated with an increasing number of thymidine analog mutations (TAMs) were observed for ABC+3TC (P = .027). CONCLUSION: the clinical utility of NUCs for rescue therapy is limited and selection should be individualized. Specific combinations (d4T+3TC and d4T+ddI) might be less efficacious.