Análisis de las complicaciones del decúbito prono en el síndrome de distrés respiratorio agudo: estándar de calidad, incidencia y factores relacionados / Analysis of complications of prone position in acute respiratory distress syndrome: quality standard, incidence and related factors

Introducción: El sistema de monitorización mediante indicadores de calidad permite evaluar y mejorar la calidad asistencial. Atendiendo a los indicadores recomendados por la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias y dada la importancia del tratamiento postural en decúbito prono (DP) de pacientes con síndrome de distrés respiratorio agudo, resulta crucial el registro de las complicaciones que puedan producirse durante el procedimiento y su posterior análisis. Objetivos: Determinar el grado de cumplimiento del estándar de calidad recomendado por la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias en relación con el registro de complicaciones graves. Identificar la incidencia de complicaciones graves registradas y posibles factores relacionados. Método: Estudio descriptivo retrospectivo transversal, UCI polivalente (16 camas). Población: Pacientes con síndrome de distrés respiratorio agudo tratados con DP (enero 2012-diciembre 2013). Variables: Registros DP, extubaciones accidentales, retiradas de catéteres, úlceras por presión (UPP), obstrucción del tubo endotraqueal, urgencia procedimiento, horas DP, aporte nutricional, tipo de sonda alimentaria, regurgitación, retención alimentaria, uso de procinéticos y/o relajantes musculares. Resultados: La muestra del estudio fue de 38 casos habiéndose encontrado un registro adecuado de las complicaciones en un 92,1% de los casos. La única complicación grave registrada fueron las UPP con una incidencia del 25,7%. Posibles factores relacionados con UPP: horas en DP superior en pacientes que desarrollaron UPP (p=0,067); menor incidencia de UPP cuando el aporte nutricional ha sido adecuado (p=0,577). El 82,9% de los pacientes pronados no recibieron aporte nutricional adecuado. Conclusiones: El porcentaje de registros adecuadamente cumplimentados es muy elevado. Destaca la aparición de UPP (grado 1-2 mayoritariamente). No hay significación estadística, aunque sí tendencia, entre UPP y horas DP (AU)

Introduction: The monitoring system based on standards of quality allows clinicians to evaluate and improve the patient's care. According to the quality indicators recommended by Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias, and due to the importance of prone position (PP) as a treatment in patients with acute respiratory distress syndrome, it is fundamental to keep accurate record of serious adverse events occurring during the prone position procedure and its posterior analysis. Objectives: To establish fulfilment of the Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias standards of quality according to the register of serious complications. To identify the incidence of serious complications registered as well as to identify possible factors related to these complications. Method: Retrospective, cross-sectionsl descriptive study, polyvalent ICU (16 beds). Study population Patients with acute respiratory distress syndrome treated with PP (January 2012-December 2013). Study variables PP recording, accidental extubation, removal of catheters, decubitus ulcers (DU), ETT obstruction, urgency of the procedure, hours in PP, nutritional intake, type of feeding tube, food regurgitation/retention and use of prokinetics/muscle relaxant. Results: The study sample comprised 38 cases, with an adequate record of complications in 92.1% of the cases. DU were the only serious complication recorded, with a 25.7% incidence. Possible factors related to DU: more hours in PP in patients developing DU (p= .067). Less incidence of DU in well-nourished patients (p= .577). 82.9% of patients were not appropriately nourished. Conclusions: The percentage of records duly completed is very high. The presence of DU (grade 1-2 mostly) is to be noted. There is no stastistical significance, although a trend is obversed, between DU and hours in PP (AU)

Analysis of complications of prone position in acute respiratory distress syndrome: quality standard, incidence and related factors. / Análisis de las complicaciones del decúbito prono en el síndrome de distrés respiratorio agudo: estándar de calidad, incidencia y factores relacionados.

INTRODUCTION: The monitoring system based on standards of quality allows clinicians to evaluate and improve the patient's care. According to the quality indicators recommended by Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias, and due to the importance of prone position (PP) as a treatment in patients with acute respiratory distress syndrome, it is fundamental to keep accurate record of serious adverse events occurring during the prone position procedure and its posterior analysis. OBJECTIVES: To establish fulfilment of the Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias standards of quality according to the register of serious complications. To identify the incidence of serious complications registered as well as to identify possible factors related to these complications. METHOD: Retrospective, cross-sectionsl descriptive study, polyvalent ICU (16 beds). Study population Patients with acute respiratory distress syndrome treated with PP (January 2012-December 2013). Study variables PP recording, accidental extubation, removal of catheters, decubitus ulcers (DU), ETT obstruction, urgency of the procedure, hours in PP, nutritional intake, type of feeding tube, food regurgitation/retention and use of prokinetics/muscle relaxant. RESULTS: The study sample comprised 38 cases, with an adequate record of complications in 92.1% of the cases. DU were the only serious complication recorded, with a 25.7% incidence. Possible factors related to DU: more hours in PP in patients developing DU (p= .067). Less incidence of DU in well-nourished patients (p= .577). 82.9% of patients were not appropriately nourished. CONCLUSIONS: The percentage of records duly completed is very high. The presence of DU (grade 1-2 mostly) is to be noted. There is no stastistical significance, although a trend is obversed, between DU and hours in PP.

[Recommendations of the Latin-American network for the study and treatment of the neuropathic pain]. / Recomendaciones de la red latinoamericana para el estudio y tratamiento del dolor neuropático.

Neuropathic pain (NP) is a kind of pain which is distinct from the somatic or visceral pain that the GP is used to assessing; the clinical profile and the response to treatment of this kind of pain are different. Given its high incidence in the population, it is important that the non-specialized physician should be capable of identifying it early and start treatment. This work attempts to summarize the clinical, diagnostic, pathophysiological and therapeutic aspects of NP to guide the non-specialized physician in the identification and initial treatment of patients suffering from NP. At the same time, the therapeutic options which are only available at centers specialized in the treatment of pain in patients who do not progress satisfactorily are also summarized. This work includes the updates published on the latest guidelines and recommendations, which have had a major impact worldwide. As background to this report, highly-respected professionals from our field published in 2008 an important article in Spanish. This material sets out clinical, pathophysiological and diagnostic concepts which the authors of this work mostly agree with. On the other hand, we differ significantly in the therapeutic aspects.

Internet y el paciente dermatológico / Internet and the dermatologic patient

La difusión de Internet trasciende a todas las áreas de la sociedad humana. Su impacto en el enfermo cutáneo es objeto de análisis. Se considera la función educativa y preventiva de la Red, como facilitar las campañas de prevención o promover la consulta temprana. Se discuten sus riesgos potenciales en la salud pública: divulgación de información seudocientífica o posible de malinterpretarse, tendencia a la adicción y depresión. El empleo indebido de Internet puede ocasionar repercusiones ético-legales. El dermatólogo debe conocer los nuevos medios para afrontar los desafíos que le impone el paciente del siglo XXI (AU)

Interferon-kappa, a novel type I interferon expressed in human keratinocytes.

High throughput cDNA sequencing has led to the identification of interferon-kappa, a novel subclass of type I interferon that displays approximately 30% homology to other family members. Interferon-kappa consists of 207 amino acids, including a 27-amino acid signal peptide and a series of cysteines conserved in type I interferons. The gene encoding interferon-kappa is located on the short arm of chromosome 9 adjacent to the type I interferon gene cluster and is selectively expressed in epidermal keratinocytes. Expression of interferon-kappa is significantly enhanced in keratinocytes upon viral infection, upon exposure to double-stranded RNA, or upon treatment with either interferon-gamma or interferon-beta. Administration of interferon-kappa recombinant protein imparts cellular protection against viral infection in a species-specific manner. Interferon-kappa activates the interferon-stimulated response element signaling pathway and a panel of genes similar to those regulated by other type I interferons including anti-viral mediators and transcriptional regulators. An antibody that neutralizes the type I interferon receptor completely blocks interferon-kappa signaling, demonstrating that interferon-kappa utilizes the same receptor as other type I interferons. Interferon-kappa therefore defines a novel subclass of type I interferon that is expressed in keratinocytes and expands the repertoire of known proteins mediating host defense.

Cutaneous tuberculosis: efficient therapeutic response in a case with multiple lesions.

An unusual case of multiple lesions of tuberculosis verrucosa cutis and colliquative forms is reported. We emphasize a rapid response to conventional therapy.

Polymorphous crystallization and diffraction of threonine deaminase from Escherichia coli.

The biosynthetic threonine deaminase from Escherichia coli, an allosteric tetramer with key regulatory functions, has been crystallized in several crystal forms. Two distinct forms, both belonging to either space group P3121 or P3221, with different sized asymmetric units that both contain a tetramer, grow under identical conditions. Diffraction data sets to 2.8 A resolution (native) and 2. 9 A resolution (isomorphous uranyl derivative) have been collected from a third crystal form in space group I222.

Nucleoside diphosphate kinase from bovine retina: purification, subcellular localization, molecular cloning, and three-dimensional structure.

The biochemical and structural properties of bovine retinal nucleoside diphosphate kinase were investigated. The enzyme showed two polypeptides of approximately 17.5 and 18.5 kDa on SDS-PAGE, while isoelectric focusing revealed seven to eight proteins with a pI range of 7.4-8.2. Sedimentation equilibrium yielded a molecular mass of 96 +/- 2 kDa for the enzyme. Carbohydrate analysis revealed that both polypeptides contained Gal, Man, GlcNAc, Fuc, and GalNac saccharides. Like other nucleoside diphosphate kinases, the retinal enzyme showed substantial differences in the Km values for various di- and triphosphate nucleotides. Immunogold labeling of bovine retina revealed that the enzyme is localized on both the membranes and in the cytoplasm. Screening of a retinal cDNA library yielded full-length clones encoding two distinct isoforms (NBR-A and NBR-B). Both isoforms were overexpressed in Escherichia coli and their biochemical properties compared with retinal NDP-kinase. The structures of NBR-A and NBR-B were determined by X-ray crystallography in the presence of guanine nucleotide(s). Both isoforms are hexameric, and the fold of the monomer is similar to other nucleoside diphosphate kinase structures. The NBR-A active site contained both a cGMP and a GDP molecule each bound at half occupancy while the NBR-B active site contained only cGMP.

Amino acid substitutions in the C-terminal regulatory domain disrupt allosteric effector binding to biosynthetic threonine deaminase from Escherichia coli.

Shifts in the sigmoidal kinetics of allosteric threonine deaminase promoted by isoleucine and valine binding control branched chain amino acid biosynthesis in Escherichia coli. A highly conserved alpha-helix in the C-terminal regulatory domain of the tetrameric enzyme was previously implicated in effector binding and feedback inhibition. Double (447, 451) and triple (447, 451, 454) alanine replacements for the conserved amino acids leucine 447, leucine 451, and leucine 454 in this region yield enzyme variants that show increased sigmoidality in steady-state kinetics, and which are less sensitive to the allosteric modifiers isoleucine and valine. Equilibrium binding studies using fluorescence, enzyme kinetic, and calorimetric approaches indicate that the enzyme variants possess reduced affinity for isoleucine and valine, and suggest that heterotropic ligands can bind to the same site to promote their different effects. The increase in sigmoidal kinetics for the mutants relative to wild-type threonine deaminase may be attributable to the elimination of L-threonine binding to the effector sites, which activates the wild-type enzyme. Enzyme kinetic data and isotherms for active site ligand binding to the mutants can be analyzed in terms of a simple two-state model to yield values for allosteric parameters that are consistent with previous estimates based on an expanded two-state model for homotropic cooperativity for threonine deaminase.

Schwannoma maligno de localización pleuropulmonar en un caso de enfermedad de Von Recklinghausen / Malignant Schwannoma with pleuropulmonary localization in a case of Von Recklinghausen`s disease

Se presenta un caso de neurofibromatosis tipo I que desarrolló un schwannoma maligno pleuropulmonar. Se puntualiza el potencial maligno de la enfermedad, que suele ser diagnosticada por el dermatólogo, debido al compromiso cutáneo temprano(AU)

Schwannoma maligno de localización pleuropulmonar en un caso de enfermedad de Von Recklinghausen / Malignant Schwannoma with pleuropulmonary localization in a case of Von Recklinghausen`s disease

Se presenta un caso de neurofibromatosis tipo I que desarrolló un schwannoma maligno pleuropulmonar. Se puntualiza el potencial maligno de la enfermedad, que suele ser diagnosticada por el dermatólogo, debido al compromiso cutáneo temprano

Structure and control of pyridoxal phosphate dependent allosteric threonine deaminase.

BACKGROUND: Feedback inhibition of biosynthetic threonine deaminase (TD) from Escherichia coli provided one of the earliest examples of protein-based metabolic regulation. Isoleucine, the pathway end-product, and valine, the product of a parallel pathway, serve as allosteric inhibitor and activator, respectively. This enzyme is thus a useful model system for studying the structural basis of allosteric control mechanisms. RESULTS: We report the crystal structure of TD at 2.8 A resolution. The tetramer has 222 symmetry, with C-terminal regulatory domains projecting out from a core of catalytic PLP-containing N-terminal domains. The subunits, and especially the regulatory domains, associate extensively to form dimers, which associate less extensively to form the tetramer. Within the dimer, each monomer twists approximately 150 degrees around a thin neck between the domains to place its catalytic domain adjacent to the regulatory domain of the other subunit. CONCLUSIONS: The structure of TD and its comparison with related structures and other data lead to the tentative identification of the regulatory binding site and revealed several implications for the allosteric mechanism. This work prepares the way for detailed structure/function studies of the complex allosteric behaviour of this enzyme.

Porokeratosis of Mibelli and HIV-infection.

BACKGROUND: The exacerbation of porokeratosis of Mibelli associated with inmunosuppression has been well documented. MATERIALS AND METHODS: We describe the clinical and histologic data of three cases of HIV-infected patients, who developed porokeratosis following HIV-contact. RESULTS: The three reported patients were found to have the clinical and histologic features of porokeratosis of Mibelli. Either the exacerbation or development of the disease followed HIV infection. CONCLUSION: Although porokeratosis is not a disease indicative of AIDS, its flare-up or its presence in HIV-infected patients may serve as a marker of inmunodeficiency.

Reappraisal of Rasmussen's syndrome with special emphasis on treatment with high doses of steroids.

Eight patients with Rasmussen's syndrome and epilepsia partialis continua were treated with high doses of steroids, including pulses of methylprednisolone and prednisone in decreasing doses. Three patients exhibited clinical, radiological, or histological evidence of bilateral involvement. Epilepsy and focal deficit decreased within six months in seven patients. Only five patients, in whom steroid treatment had begun less than 15 months after the onset of epilepsia partialis continua, experienced a lasting effect although they had periodic episodes of transient relapse. Treatment with high doses of steroids seems advisable during the first year after onset of epilepsia partialis continua, before hemiplegia has developed and in cases with bilateral involvement.