Efficacy and safety of administering oral misoprostol by titration compared to vaginal misoprostol and dinoprostone for cervical ripening and induction of labour: study protocol for a randomised clinical trial.

BACKGROUND: Among the various methods available, the administration of prostaglandins is the most effective for inducing labour in women with an unfavourable cervix. Recent studies have compared treatment with various titrated doses of oral misoprostol with vaginal misoprostol or dinoprostone, indicating that the use of an escalating dose of an oral misoprostol solution is associated with a lower rate of caesarean sections and a better safety profile. The objective of this study is to assess which of these three therapeutic options (oral or vaginal misoprostol or vaginal dinoprostone) achieves the highest rate of vaginal delivery within the first 24 h of drug administration. METHODS: An open-label randomised controlled trial will be conducted in Araba University Hospital (Spain). Women at ≥41 weeks of pregnancy requiring elective induction of labour who meet the selection criteria will be randomly allocated to one of three groups: 1) vaginal dinoprostone (delivered via a controlled-release vaginal insert containing 10 mg of dinoprostone, for up to 24 h); 2) vaginal misoprostol (25 µg of vaginal misoprostol every 4 h up to a maximum of 24 h); and 3) oral misoprostol (titrated doses of 20 to 60 µg of misoprostol following a 3 h on + 1 h off regimen up to a maximum of 24 h). Both intention-to-treat analysis and per-protocol analysis will be performed. DISCUSSION: The proposed study seeks to gather evidence on which of these three therapeutic options achieves the highest rate of vaginal delivery with the best safety profile, to enable obstetricians to use the most effective and safe option for their patients. TRIAL REGISTRATION: NCT02902653 Available at: https://clinicaltrials.gov/show/NCT02902653 (7th September 2016).

Predicted change in the number of permanent medical teachers from 2017 to 2026. The training of future physicians in critical condition. / Evolución previsible en el número de profesores permanentes de Medicina del 2017 al 2026. La formación de los futuros médicos en situación crítica.

The significant and progressive reduction in the number of permanent teachers in medical schools (professor, associate professor and assistant professor) is a reason for concern for the National Conference of Deans. This reduction will intensify in the coming decade (2017-2026). Forty-three percent of the permanent faculty will retire, as will 55% of the faculty linked to clinical areas, 34% of the faculty not linked to clinical areas and 32% of the faculty of basic areas. This deficit is significant now, and, in a few years, the situation will be unsustainable, especially in the clinical areas. This report reveals the pressing need to adopt urgent measures to alleviate the present situation and prevent a greater problem. The training of future physicians, immediately responsible for the health of our society, depends largely on the theoretical and practical training taught in medical schools, with the essential collaboration of healthcare institutions. Paradoxically, while the number of teachers decreases substantially, there is an exponential increase in the number of medical schools and students who are admitted every year without academic or healthcare justification.

Factores pronósticos en la neumonía adquirida en la comunidad / Prognostic factors in community-acquired pneumonia

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Noninvasive measurement of the maximum relaxation rate of inspiratory muscles in patients with neuromuscular disorders.

BACKGROUND: Slowing of inspiratory muscle relaxation has been used as an index for inspiratory muscle fatigue. However, maximum relaxation rate measured from oesophageal pressure traces after maximum sniff (P(oes) MRR) has limited clinical usefulness because it requires an oesophageal balloon catheter system. OBJECTIVES: It was the aim of this study to establish whether, in neuromuscular patients, maximum relaxation rate assessed from sniff nasal pressure (P(nasal) MRR) reflects oesophageal MRR and the tension-time index of the diaphragm (TT(di)). METHODS: Twenty patients with neuromuscular disease and 10 healthy subjects were studied. P(oes) and transdiaphragmatic pressure were measured while P(nasal) was recorded with a balloon advanced through the nose into the nasopharynx. Maximum P(oes), transdiaphragmatic pressure and P(nasal) were simultaneously measured while the patients performed maximal sniffs. The MRR (% pressure fall/10 ms) for each sniff, the TT(di) and the tension-time index of respiratory muscles were determined. RESULTS: Neuromuscular patients showed higher TT(di), lower P(oes) MRR and lower P(nasal) MRR than the control group. In patients with neuromuscular disease, the correlation coefficient of P(nasal) MRR and P(oes) MRR was 0.985 (p < 0.001). Regression analysis showed that P(oes) MRR = -1.101 + 1.113.P(nasal) MRR (r(2) = 0.929, standard error of the estimate = 0.208). Indeed, P(nasal) MRR was negatively correlated with TT(di) (r = -0.914, p < 0.001) and the tension-time index of respiratory muscles (r = -0.732, p < 0.001). In the neuromuscular group, the mean difference between P(nasal) MRR and P(oes) MRR was 0.286 +/- 0.217%/10 ms. CONCLUSIONS: P(nasal) MRR obtained from a maximal sniff accurately reflects P(oes) MRR and TT(di) in patients with neuromuscular disorders.

Prueba de la tuberculina y tratamiento de la infección tuberculosa latente (réplica) / Tuberculin test and latent tuberculous infection treatment

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[Effect of immunomodulator AM3 on the exacerbations in patients with chronic bronchitis: a systematic review of controlled trials]. / Efecto del inmunomodulador AM3 sobre las agudizaciones en enfermos con bronquitis crónica: una revisión sistemática de estudios controlados.

OBJECTIVE: Analyze the effect of AM3, an oral immunomodulator, on the exacerbations and on the use of antibiotics in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Systematic search of controlled clinical trials that used AM3 in some treatment group and that included data on the clinical effects of this drug on patients with COPD. SELECTED VARIABLES: Nine studies were detected in which the clinical effectiveness of AM3 was evaluated in relation to the number of infectious exacerbations, their length, and the length of the antibiotic treatment used. RESULTS: In comparison with placebo group, the average number of excaerbations suffered by the patients treated with AM3 declined significantly in 0.31 units (p < 0.001; 95% confidence interval: 0.20-0.42), without heterogeneity among the different studies (Q = 6.62; p > 0.43). With regard to the average length of the exacerbations and the average length of the antibiotic treatment used for the exacerbations, both variables declined significantly in the group treated with AM3 (3.10 days, p < 0.001, and 8.07 days, p < 0.001, respectively) but this positive effect could not be confirmed because trials were close to heterogeneity. CONCLUSIONS: The results of this systematic review show that AM3 has a clinical effect in the prevention of exacerbations of COPD patients because reduces significantly their number. This could be related to a slowing in the progression of the deterioration in the respiratory function with a potential impact on the quality of life of the patients. Furthermore, these data imply a positive therapeutic result and a possible decline in development of bacterial resistances secondary to the frequent and indiscriminate use of antibiotics in these patients.

Effect of exacerbations on quality of life in patients with chronic obstructive pulmonary disease: a 2 year follow up study.

BACKGROUND: A study was undertaken to evaluate exacerbations and their impact on the health related quality of life (HRQL) of patients with chronic obstructive pulmonary disease (COPD). METHODS: A 2 year follow up study was performed in 336 patients with COPD of mean (SD) age 66 (8.2) years and mean (SD) forced expiratory volume in 1 second (FEV(1)) 33 (8)% predicted. Spirometric tests, questions regarding exacerbations of COPD, and HRQL measurements (St George's Respiratory Questionnaire (SGRQ) and SF-12 Health Survey) were conducted at 6 month intervals. RESULTS: A total of 1015 exacerbations were recorded, and 103 (30.7%) patients required at least one hospital admission during the study. After adjustment for baseline characteristics and season of assessment, frequent exacerbations had a negative effect on HRQL in patients with moderate COPD (FEV(1) 35-50% predicted); the change in SGRQ total score of moderate patients with > or =3 exacerbations was almost two points per year greater (worse) than those with <3 exacerbations during the follow up (p = 0.042). For patients with severe COPD (FEV(1) <35% predicted) exacerbations had no effect on HRQL. The change in SGRQ total score of patients admitted to hospital was almost 2 points per year greater (worse) than patients not admitted, but this effect failed to show statistical significance in any severity group. There was a significant and independent seasonal effect on HRQL since SGRQ total scores were, on average, 3 points better in measurements performed in spring/summer than in those measured in the winter (p<0.001). CONCLUSIONS: Frequent exacerbations significantly impair HRQL of patients with moderate COPD. A significant and independent effect of seasonality was also observed.

Prueba de la tuberculina y tratamiento de la infección tuberculosa latente / Tuberculin testing and therapy of latent tuberculosis infection

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Pulmonary diffusing capacity in chronic dialysis patients.

Patients with end-stage renal disease treated by hemodialysis with bioincompatible membranes are exposed during the dialysis period to acute effects on lung microcirculation, which may result in pulmonary fibrosis and diffusion defects in long-standing dialysis. To investigate the occurrence of these possible chronic pulmonary alterations, we determined lung function in patients with chronic renal failure not undergoing hemodialysis and in patients who had been receiving regular hemodialysis both for short and long periods of time. Forty-three patients divided into three groups were studied: 17 patients before dialysis with a mean (SD) creatinine clearance of 14.1 (6.8) ml/min 11.73 m2, 10 patients receiving regular hemodialysis for a period of less than 12 months (mean 6.4 +/- 3.5 months), and 16 patients receiving regular hemodialysis for more than 5 years (mean 8.3 +/- 3.6 years). First-use bioincompatible cellulosic dialysis membranes were used in all the cases. The following parameters were recorded: forced vital capacity (FVC), forced expiratory volume in 1s (FEV1), total lung capacity (TLC), residual volume (RV), carbon monoxide transfer factor (TLCO), accessible lung volume (VA), carbon monoxide transfer factor/accessible lung volume (KCO- that is, TLCO/VA), and arterial blood gases. Patients receiving regular hemodialysis for more than 5 years showed significantly lower values of TLCO and KCO than patients before dialysis and patients receiving regular hemodialysis for less than 12 months. Seventy-five percent of patients on long-term hemodialysis had markedly reduced TLCO or KCO values (below 80% of the reference value) as compared with 17% of patients before dialysis and 10% of patients dialyzed for less than 12 months (P < 0.001). Differences among groups for the remaining parameters were not observed. In conclusion, patients undergoing long-term regular hemodialysis with a bioincompatible membrane showed a selective reduction in pulmonary diffusing capacity possibly due to chronic pulmonary fibrosis.

Neumólogos: ¿adónde vamos, de dónde venimos? / Pneumologists: Where are we going and where have we come from?

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Treatment and quality of life in patients with chronic obstructive pulmonary disease.

Treatments administered to patients with chronic obstructive pulmonary disease (COPD), especially when used in multiple combinations, are not free of interactions and side effects that can potentially impair health-related quality of life (HRQL). We studied HRQL and its relationship with treatment in a group of 441 patients with stage II or III COPD (age: 66.6 (SD: 8.3) years; FEV1: 32.4% (SD: 8.1%)) using the St George's Respiratory Questionnaire (SGRQ) and the 12-item short form (SF-12) Health Survey. The most prescribed drugs were ipratropium bromide (87.5%), inhaled corticosteroids (69.4%) and short-acting beta-2 agonists (64.9%). Patients with stage III of the disease were receiving more drugs, particularly short-acting beta-2 agonists (p = 0.002) and inhaled corticosteroids (p = 0.031). The use of theophyllines was associated with a worse total SGRQ score (beta = 4.49; p < 0.001), although this negative association decreased with advanced age. A trend towards worse SGRQ scores was observed with the use of high doses of long-acting beta-2 agonists (beta = 3.22; p = 0.072). Patients receiving three drugs or more presented worse total SGRQ scores than patients receiving fewer drugs (beta = 6.1, p < 0.001; and beta = 7.64, p < 0.001, respectively). These findings suggest that the use of multiple drugs in the treatment of patients with COPD is associated with worse total SGRQ scores. The effect of drugs, their dosages and associations with other drugs on HRQL merit further research.

[Analysis of the impact of Archivos de Bronconeumología through the Science Citation Index]. / Análisis de la repercusión de Archivos de Bronconeumología a través del Science Citation Index.

OBJECTIVE: To describe the impact factor of Archivos de Bronconeumología from 1997 until 2000 and to identify the patterns of citation of the journal and topics having the greatest impact. METHOD: SCISEARCH was used to locate citations of articles published by Archivos de Bronconeumología between 1995 and 1999. The following data were collected for each article: year of publication, authors, journal, country of publication, language, specialty or specialties, institution(s), residence of the first author and topic. The impact factor was calculated as the ratio of citations received in one year by articles published in Archivos de Bronconeumología during the two previous years and the total number of articles published by Archivos de Bronconeumología over the two years under study. RESULTS: The impact factor of Archivos de Bronconeumología was 0.107 in 1997, 0.089 in 1998, 0.105 in 1999 and 0.119 in 2000. Citations were found in a wide range of source journals, with respiratory system publications having little weight. Citations were made mainly by Spanish authors (75%) and self-citation was restrained (21.1%). Topics related to tuberculosis and respiratory infections (23.6% of the citations received) and chronic obstructive pulmonary disease (12.5%) made the greatest impact. CONCLUSION: The impact factor of Archivos de Bronconeumología is modest, although higher than those of some other publications included in Journal Citation Reports.