Embryonic Cerebrospinal Fluid Increases Neurogenic Activity in the Brain Ventricular-Subventricular Zone of Adult Mice.

Neurogenesis is a very intensive process during early embryonic brain development, becoming dramatically restricted in the adult brain in terms of extension and intensity. We have previously demonstrated the key role of embryonic cerebrospinal fluid (CSF) in developing brain neurogenic activity. We also showed that cultured adult brain neural stem cells (NSCs) remain competent when responding to the neurogenic influence of embryonic CSF. However, adult CSF loses its neurogenic inductive properties. Here, by means of an organotypic culture of adult mouse brain sections, we show that local administration of embryonic CSF in the subventricular zone (SVZ) niche is able to trigger a neurogenic program in NSCs. This leads to a significant increase in the number of non-differentiated NSCs, and also in the number of new neurons which show normal migration, differentiation and maturation. These new data reveal that embryonic CSF activates adult brain NSCs, supporting the previous idea that it contains key instructive components which could be useful in adult brain neuroregenerative strategies.

Prognostic value of glomerular filtration rate 1 year after heart transplantation.

INTRODUCTION AND OBJECTIVES: The development of renal failure is one of the most important problems after heart transplantation (HT), but the wide range of definitions means that estimates of its prevalence vary considerably. Furthermore, its impact on mortality has not been adequately studied. The objective was to investigate the relationship between the glomerular filtration rate (GFR) 1 year after transplantation and mortality during follow-up. METHODS: The GFR was determined in 316 patients still living 1 year after transplantation using the abbreviated Modification of Diet in Renal Disease Study formula. Patients were divided into three groups according to GFR (i.e. <30, 30-59 and > or =60 mL/min per 1.73 m2) and pretransplant variables and rejection and infection rates within the first year were analyzed. The association between GFR at 1 year and mortality during follow-up was evaluated and reasons for the association were examined. RESULTS: There was no difference in the number of rejections or infections in the first year between the three groups. During a mean follow-up period of 6.3 years, 74% of patients with a GFR <30 mL/min per 1.73 m2 died, compared with 24% and 30% of those with a GFR > or =60 and 30-59 mL/min per 1.73 m2, respectively. Survival analysis (i.e. Cox regression analysis) demonstrated a significant difference between patients with a GFR <30 mL/min per 1.73 m2 and other patients (P< .001). A very low GFR at 1 year was the only independent predictor that remained statistically significant on multivariate analysis (hazard ratio =2.87; 95% confidence interval, 1.52-5.41). CONCLUSIONS: Severe renal dysfunction at 1 year was an independent predictor of long-term all-cause mortality in heart transplant patients.

Valor pronóstico de la tasa de filtración glomerular al año del trasplante cardiaco / Prognostic value of glomerular filtration rate 1 year after heart transplantation

Introducción y objetivos. Uno de los problemas más relevantes tras el trasplante cardiaco es el desarrollo de insuficiencia renal. La heterogeneidad en su definición hace que la estimación de su prevalencia sea variable. Por otro lado, su impacto en la mortalidad no ha sido suficientemente estudiado. El objetivo fue evaluar la relación entre la tasa de filtración glomerular al año (TFG) y la mortalidad en el seguimiento. Métodos. Se analizó la TFG de 316 pacientes vivos al año del trasplante mediante la fórmula abreviada Modification of Diet in Renal Disease Study. Se clasificaron en tres grupos según su TFG ( < 30, 30-59 y ≥ 60 ml/ min/1,73 m2, respectivamente) y se analizaron variables antes del trasplante, tasa de rechazo e infección durante el primer año. Se evaluó la relación entre la TFG al año y la mortalidad en el seguimiento y se revisaron sus causas. Resultados. No hubo diferencias en el número de rechazos ni infecciones durante el primer año en los tres grupos. En el seguimiento medio (6,3 años) falleció el 74% de los pacientes con TFG < 30, frente al 24% y al 30% de aquellos con TFG ≥ 60 y 30-59, respectivamente. El análisis de supervivencia (regresión de Cox) mostró diferencias estadísticamente significativas entre aquellos con TFG < 30 y el resto (p < 0,001). La TFG gravemente disminuida al año se mantuvo como el único predictor independiente en el análisis multivariable (hazard ratio = 2,87; intervalo de confianza del 95%, 1,52-5,41). Conclusiones. La disfunción grave de la función renal al año es un predictor independiente de mortalidad por todas las causas a largo plazo en el paciente con trasplante cardiaco (AU)

Introduction and objectives. The development of renal failure is one of the most important problems after heart transplantation (HT), but the wide range of definitions means that estimates of its prevalence vary considerably. Furthermore, its impact on mortality has not been adequately studied. The objective was to investigate the relationship between the glomerular filtration rate (GFR) 1 year after transplantation and mortality during follow-up. Methods. The GFR was determined in 316 patients still living 1 year after transplantation using the abbreviated Modification of Diet in Renal Disease Study formula. Patients were divided into three groups according to GFR (i.e. <30 30-59 and 8805 60 ml min per 1 73 m2 pretransplant variables rejection infection rates within the first year were analyzed association between gfr at mortality during follow-up was evaluated reasons for examined results there no difference in number of rejections or infections three groups a mean period 6 3 years 74 patients with <30 ml min per 1 73 m2 died compared with 24 and 30 of those a gfr 8805 60 30-59 respectively survival analysis i e cox regression demonstrated significant difference between patients <30 ml min per 1 73 m2 and other patients p <.001). A very low GFR at 1 year was the only independent predictor that remained statistically significant on multivariate analysis (hazard ratio =2.87; 95% confidence interval, 1.52-5.41). Conclusions. Severe renal dysfunction at 1 year was an independent predictor of long-term all-cause mortality in heart transplant patients (AU)

Hypertension and sleep apnea-hypopnea syndrome: changes in echocardiographic abnormalities depending on the presence of hypertension and treatment with CPAP.

INTRODUCTION: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with high prevalence. There is controversy as to whether cardiac abnormalities are due to the disease itself or to the arterial hypertension frequently associated with this disease. OBJECTIVES: To analyze echocardiographic abnormalities in a population of SAHS patients depending on the presence or absence of hypertension at the time of diagnosis and after six months of treatment with continuous positive airway pressure (CPAP). METHODS: We studied 85 consecutive patients diagnosed with SAHS who required treatment with CPAP (Hypertensive: 43, nonhypertensive: 42). We performed a baseline echocardiogram after six months of treatment. We analyzed morphological (wall thickness, diameters, ejection fraction) and functional (peak E- and A-wave velocities, deceleration time, Tei index) parameters of the left and right ventricles. RESULTS: Hypertensive patients were older and had higher blood pressure values, but there were no differences between groups in other clinical parameters. The hypertensive group had greater septal thickness (hypertensive: 12.1+/-2.3; nonhypertensive: 10.8+/-2.1mm; p=0.01). There were also differences in impairment of left (hypertensiveHT: 92.9%, nonhypertensive: 65%, p=0.002) and right (hypertensive: 74.4%, nonhypertensive: 42.1%, p=0.006) ventricular filling. After six months of treatment, an improvement of the myocardial performance index was noted in nonhypertensive patients (baseline Tei: 0.55+/-0.1 vs. 6-month Tei: 0.49+/-0.1; p=0.01), whereas no significant change was observed in hypertensive patients. CONCLUSIONS: Cardiac abnormalities in SAHS patients are increased in the presence of associated hypertension. Treatment with CPAP for six months improves cardiac abnormalities in nonhypertensive patients but not in hypertensive patients.

[Silent heart disease in patients with sleep apnea-hypopnea syndrome: usefulness of the myocardial performance index]. / Disfunción miocárdica silente en pacientes con síndrome de apneas-hipopneas durante el sueño. Valor del índice de rendimiento miocárdico.

OBJECTIVE: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with considerable cardiovascular impact. The myocardial performance index (MPI) is an echocardiographic parameter that is useful in the assessment of global myocardial function. The purpose of this study was to identify any differences in the MPI between patients with and without SAHS. PATIENTS AND METHODS: We studied 120 consecutive patients referred to our department for suspected SAHS. Following the overnight sleep study and after excluding all patients with hypertension, heart disease, or invalid recordings, 54 patients with SAHS and 13 patients without the disease matched for age and body mass were analyzed. A blinded cardiologist performed Doppler echocardiography, measuring parameters related to ventricular hypertrophy, systolic function, diastolic function, and the MPI. The data were compared by chi(2) and analysis of variance. RESULTS: Mean (SD) ventricular mass was greater in patients with SAHS (183.17 [40.5] g) than in those without that diagnosis (149 [26] g) (P=.005). No differences were observed in systolic function (78.5% [8.95%] vs 81.6% [7%]) (P=.2), although a higher percentage of patients with SAHS had abnormal diastolic function (71.2% vs 38.5%) (P=.049). The MPI was significantly higher in SAHS patients (0.54 [0.12] vs 0.46 [0.07]) (P=.028). CONCLUSIONS: On its own, SAHS leads to left ventricular hypertrophy. Diastolic involvement is common in these patients, although a large number of healthy individuals who are obese also present it. The MPI is higher in SAHS and could be a useful parameter to identify patients with silent heart disease before it progresses.

Inhibidores mTOR y edema unilateral / mTOR inhibitors and unilateral edema

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Disfunción miocárdica silente en pacientes con síndrome de apneas-hipopneas durante el sueño. Valor del índice de rendimiento miocárdico / Silent heart disease in patients with sleep apnea-hypopnea syndrome: usefulness of the myocardial performance index

OBJETIVO: El síndrome de apneas-hipopneas durante el sueño (SAHS) es una enfermedad emergente con importante repercusión cardiovascular. El índice de rendimiento miocárdico (IRM) es un parámetro ecocardiográfico útil en la valoración de la función miocárdica global. El objetivo del estudio ha sido analizar si hay diferencias en el IRM entre pacientes con SAHS y un grupo control. PACIENTES Y MÉTODOS: Hemos estudiado a 120 pacientes consecutivos remitidos por sospecha de SAHS a nuestra unidad. Una vez realizado el estudio nocturno y excluidos los hipertensos, cardiópatas o registros inadecuados, analizamos a 54 pacientes y 13 controles de similar edad e índice de masa corporal. Un cardiólogo que desconocía la asignación les realizó un ecocardiograma Doppler. Se midieron parámetros de hipertrofia ventricular, función sistólica, función diastólica y el IRM. Los datos se compararon mediante el test de la χ2 y ANOVA. RESULTADOS: Los pacientes con SAHS presentaron mayor masa ventricular que el grupo control (media ± desviación estándar: 183,17 ± 40,5 frente a 149 ± 26 g; p = 0,005). No se apreciaron diferencias entre ambos grupos en la función sistólica (un 78,5 ± 8,95 frente al 81,6 ± 7%; p = 0,2), pero un mayor porcentaje de pacientes con SAHS tenía alterada la función diastólica (un 71,2 frente al 38,5%; p = 0,049). El IRM fue significativamente mayor en el grupo con SAHS (0,54 ± 0,12 frente a 0,46 ± 0,07; p = 0,028). CONCLUSIONES: El SAHS por sí mismo produce hipertrofia ventricular izquierda. La afectación diastólica es importante en este grupo, pero también la presenta un número importante de personas sanas con obesidad. El IRM está incrementado en el SAHS y podría ser útil para identificar a los pacientes con disfunción miocárdica silente antes de su progresión

OBJECTIVE: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with considerable cardiovascular impact. The myocardial performance index (MPI) is an echocardiographic parameter that is useful in the assessment of global myocardial function. The purpose of this study was to identify any differences in the MPI between patients with and without SAHS. PATIENTS AND METHODS: We studied 120 consecutive patients referred to our department for suspected SAHS. Following the overnight sleep study and after excluding all patients with hypertension, heart disease, or invalid recordings, 54 patients with SAHS and 13 patients without the disease matched for age and body mass were analyzed. A blinded cardiologist performed Doppler echocardiography, measuring parameters related to ventricular hypertrophy, systolic function, diastolic function, and the MPI. The data were compared by c2 and analysis of variance. RESULTS: Mean (SD) ventricular mass was greater in patients with SAHS (183.17 [40.5] g) than in those without that diagnosis (149 [26] g) (P=.005). No differences were observed in systolic function (78.5% [8.95%] vs 81.6% [7%]) (P=.2), although a higher percentage of patients with SAHS had abnormal diastolic function (71.2% vs 38.5%) (P=.049). The MPI was significantly higher in SAHS patients (0.54 [0.12] vs 0.46 [0.07]) (P=.028). CONCLUSIONS: On its own, SAHS leads to left ventricular hypertrophy. Diastolic involvement is common in these patients, although a large number of healthy individuals who are obese also present it. The MPI is higher in SAHS and could be a useful parameter to identify patients with silent heart disease before it progresses

Heart transplantation in a patient with systemic mastocytosis.

Systemic mastocytosis is a hematologic disorder characterized by mast-cell proliferation and organ infiltration. A variety of stimuli and drugs can cause severe anaphylaxis in these patients. We report the case of a female patient diagnosed with systemic mastocytosis and advanced dilated cardiomyopathy in whom a heart transplant was successfully performed.

[Analysis of echocardiographic alterations observed in sleep apnea-hypopnea syndrome and how they are influenced by hypertension]. / Análisis de las alteraciones ecocardiográficas del síndrome de apneas e hipopneas del sueño y su modificación con la presencia de hipertensión arterial.

INTRODUCTION AND OBJECTIVES: Sleep apnea-hypopnea syndrome (SAHS) is associated with significant effects on the heart, which can be assessed using noninvasive methods such as transthoracic echocardiography. However, it is not clear whether these effects are due to the condition itself or are influenced by associated factors, such as high blood pressure (HBP). The objective of this study was to investigate the echocardiographic alterations observed in SAHS patients and how they are affected by the presence of concomitant HBP. METHODS: The study involved 103 consecutive patients (49 with HBP and 54 without) with SAHS and an indication for continuous positive airways pressure treatment and 24 controls matched for age and body mass index. Doppler echocardiography was performed in a blinded manner. Both morphology (i.e., wall thickness, and diameters) and function (i.e., ejection fraction, peak E and A wave velocities, mitral deceleration time, and Tei index) were assessed. Results were compared using ANOVA and Bonferroni's test. RESULTS: Hypertensive patients had larger morphological changes characteristic of left ventricular hypertrophy (i.e., increased septal and posterior wall thicknesses) than nonhypertensive patients, who in turn had larger changes than controls (septal thickness: HBP-SAHS, 12 [2] mm; non-HBP SAHS, 11 [2] mm, and controls, 9.5 [5] mm; 1 vs. 2, P=.038; 1 vs. 3, P=.0001, 2 vs. 3, P=.034) (posterior wall thickness: HBP-SAHS, 11 [2] mm; non-HBP SAHS, 10 [1] mm, and controls, 9 [1.5] mm; 1 vs. 2, P=.5; 1 vs. 3, P=.0001; 2 vs. 3, P=.001). In addition, there were also greater changes in ventricular filling patterns on the left (HBP-SAHS, 92%; non-HBP SAHS, 72%, controls, 29%; P=.0001) and on the right (HBP-SAHS, 72%; non-HBP SAHS, 58%; controls, 25%; P=.001). There was a trend towards a larger left ventricular Tei index (HBP-SAHS, 0.56 [0.2]; non-HBP SAHS, 0.54 [0.12]; controls, 0.5 [0.1]; 1 vs. 2, P=.8; 1 vs. 3, P=.09; 2 vs. 3, P=.7). CONCLUSIONS: From the time of diagnosis, SAHS was associated with left ventricular hypertrophy and impaired biventricular filling, even in the absence of concomitant HBP. The abnormalities observed were more severe when HBP was present.

Influence of immunosuppressive regimens on short-term morbidity and mortality in heart transplantation.

BACKGROUND: The goal of immunosuppressive therapy in heart transplantation is to maximize safety and efficacy while minimizing morbidity and mortality. We now have numerous drug combinations, but few have been compared with each other. AIM: To compare various immunosuppressive regimens assessing morbidity and mortality at one yr. METHODS: A total of 351 patients transplanted between 1989 and 2005 were included and grouped by immunosuppressive regimen into group 1 (n = 52): Muronomab (OKT3) 10 d, cyclosporine (CSA), azathioprine (AZA), steroids; group 2 (n = 193): OKT3 seven d, CSA, AZA, steroids; group 3 (n = 22): OKT3 seven d, CSA, mycophenolate mofetil (MMF), steroids; and group 4 (n = 84): interleukin-2 antagonists (IL-2), CSA, MMF, steroids. RESULTS: The incidence of acute graft failure and treated rejection was similar between groups (17% and 78% respectively). We found a statistically significant difference in the incidence of infections (p < 0.001), renal dysfunction (p = 0.011) and in diabetes mellitus (p = 0.023). There were no differences in survival at 30 d (97%), but differences were found at one yr (p = 0.011). The multivariate analysis showed a strong association between mortality and infection (p = 0.001) and between survival and the group 4 regimen (p < 0.001). CONCLUSION: There are differences in survival at one yr of heart transplant patients depending on the immunosuppressive regimen used. The best combination was induction with IL-2 antagonists, followed by CSA, MMF and steroids.

Análisis de las alteraciones ecocardiográficas del síndrome de apneas e hipopneas del sueño y su modificación con la presencia de hipertensión arterial / Analysis of echocardiographic alterations observed in sleep apnea-hypopnea syndrome and how they are influenced by hypertension

Introducción y objetivos. El síndrome de apneas e hipopneas del sueño (SAHS) conlleva importantes repercusiones cardiacas que se pueden evaluar mediante métodos no invasivos como la ecocardiografía transtorácica; sin embargo, está por dilucidar si se deben a la propia enfermedad o a la influencia de factores concomitantes como la hipertensión arterial (HTA). El objetivo de este estudio es analizar las alteraciones ecocardiográficas en pacientes con SAHS y si se modifican en caso de HTA concomitante. Métodos. Estudiamos a 103 pacientes consecutivos diagnosticados de SAHS e indicación de presión positiva continua en la vía aérea (HTA, 49 pacientes; sin HTA, 54) frente a 24 controles ajustados por edad e índice de masa corporal. Realizamos ecocardiograma-Doppler por un observador para el que la asignación estaba enmascarada. Analizamos variables morfológicas (grosor de paredes y diámetros) y funcionales (fracción de eyección, velocidad máxima de ondas E y A, tiempo de deceleración mitral e índice Tei). Se compararon los resultados mediante ANOVA y test de Bonferroni. Resultados. Los pacientes hipertensos tuvieron más alteraciones morfológicas tipo hipertrofia ventricular izquierda (mayor grosor de septo y pared posterior) que los no hipertensos, y éstos más que los controles. Grosor del septo: SAHS-HTA (1), 12 ± 2; SAHS sin HTA (2), 11 ± 2, y controles (3), 9,5 ± 5 mm (1 frente a 2, p = 0,038; 1 frente a 3, p = 0,0001, y 2 frente a 3, p = 0,034). Pared posterior: SAHS-HTA, 11 ± 2; SAHS sin HTA, 10 ± 1, y controles, 9 ± 1,5 mm (1 frente a 2, p = 0,5; 1 frente a 3, p = 0,0001, y 2 frente a 3, p = 0,001). También hubo más alteraciones en el patrón de llenado ventricular izquierdo (SAHS-HTA, 92%; SAHS sin HTA, 72%, y controles, 29%; p = 0,0001) y derecho (SAHS-HTA, 72%; SAHS sin HTA, 58%, y controles, 25%; p = 0,001). Los valores del índice Tei del VI tuvieron tendencia a incrementarse (SAHS-HTA, 0,56 ± 0,2; SAHS sin HTA, 0,54 ± 0,12, y controles, 0,5 ± 0,1; 1 frente a 2, p = 0,8; 1 frente a 3, p = 0,09; 2 frente a 3, p = 0,7). Conclusiones. El SAHS presenta signos de hipertrofia ventricular izquierda y alteración del llenado biventricular aun en ausencia de HTA concomitante, y desde el momento de su diagnóstico. Las alteraciones detectadas son mayores cuando se asocia HTA (AU)

Introduction and objectives. Sleep apnea-hypopnea syndrome (SAHS) is associated with significant effects on the heart, which can be assessed using noninvasive methods such as transthoracic echocardiography. However, it is not clear whether these effects are due to the condition itself or are influenced by associated factors, such as high blood pressure (HBP). The objective of this study was to investigate the echocardiographic alterations observed in SAHS patients and how they are affected by the presence of concomitant HBP. Methods. The study involved 103 consecutive patients (49 with HBP and 54 without) with SAHS and an indication for continuous positive airways pressure treatment and 24 controls matched for age and body mass index. Doppler echocardiography was performed in a blinded manner. Both morphology (i.e., wall thickness, and diameters) and function (i.e., ejection fraction, peak E and A wave velocities, mitral deceleration time, and Tei index) were assessed. Results were compared using ANOVA and Bonferroni's test. Results. Hypertensive patients had larger morphological changes characteristic of left ventricular hypertrophy (i.e., increased septal and posterior wall thicknesses) than nonhypertensive patients, who in turn had larger changes than controls (septal thickness: HBP-SAHS, 12 [2] mm; non-HBP SAHS, 11 [2] mm, and controls, 9.5 [5] mm; 1 vs. 2, P=.038; 1 vs. 3, P=.0001, 2 vs. 3, P=.034) (posterior wall thickness: HBP-SAHS, 11 [2] mm; non-HBP SAHS, 10 [1] mm, and controls, 9 [1.5] mm; 1 vs. 2, P=.5; 1 vs. 3, P=.0001; 2 vs. 3, P=.001). In addition, there were also greater changes in ventricular filling patterns on the left (HBP-SAHS, 92%; non-HBP SAHS, 72%, controls, 29%; P=.0001) and on the right (HBP-SAHS, 72%; non-HBP SAHS, 58%; controls, 25%; P=.001). There was a trend towards a larger left ventricular Tei index (HBP-SAHS, 0.56 [0.2]; non-HBP SAHS, 0.54 [0.12]; controls, 0.5 [0.1]; 1 vs. 2, P=.8; 1 vs. 3, P=.09; 2 vs. 3, P=.7). Conclusions. From the time of diagnosis, SAHS was associated with left ventricular hypertrophy and impaired biventricular filling, even in the absence of concomitant HBP. The abnormalities observed were more severe when HBP was present (AU)

[Clinical teams: planning and creating Institutes and Units in a Spanish National Health Service hospital]. / Areas clínicas: planificación y creación de institutos y unidades en un hospital del Sistema Nacional de Salud.

INTRODUCTION: Clinical Teams are framed within the New Organizational Models (1996) and Spanish national health system's Strategic Plan (1997). The objectives of the internal organization model are as follows: A) General: to implement health management systems in the health service. B) Specific: service, quality and financial improvement. MATERIAL AND METHOD: Methodology. 1. Jurisdiction. Self-managing despite having no separate legal status. 2. Creation: a) feasibility study and project viability. The drafting committee consisted of representatives of the Services' physicians, other health professionals and non-health employees (Representation and Participation Organizations), and explained the portfolio of specialty services and new diagnosis and treatment techniques to be implemented. Costs and a strategic analysis of the situation were evaluated. The project was approved by management and was sent to the Ministry of Health (formerly to the Territorial Health Agency (ratified) and to the Spanish national health system's General Directorate for Organization and Planning); b) homologation: institutional approval of health centers' self-management and the feasibility of the proposals. MATERIAL: 1. Resources. Resources of the assigned Services. 2. Structure. Horizontality, simplicity and operativity. 3. PURPOSE: a) clinical: role assigned to Specialized Care Services; b) management: responsibility for proper working order (actions), personnel performance (tasks), and custody and use of material resources (available resources), carried out with active and responsible participation of all departments. 4. Quality plan: patient-oriented care, evidence-based medicine (standards and protocols), evaluation of medical technologies (service corporation) and corporative quality guarantee. CONCLUSIONS: A voluntary, innovative, participative and decentralized management model.

Áreas clínicas: planificación y creación de institutos y unidades en un hospital del Sistema Nacional de Salud / Clinical teams: planning and creating Institutes and Units in a Spanish National Health Service hospital

Introducción. Las áreas clínicas se enmarcan en los Nuevos Modelos de Organización (1996) y en el Plan Estratégico del INSALUD (1997). Modelo organizativo interno cuyos objetivos son: a) generales: adoptar sistemas de gestión clínica e integral de la asistencia sanitaria, y b) específicos: mejora asistencial, de la calidad y económica. Material y método. Metodología. 1. Régimen jurídico: autonomía de gestión sin naturaleza jurídica propia. 2. Creación: a) estudio de factibilidad del proyecto. La comisión redactora la constituyen representantes de los facultativos de los servicios, del personal sanitario no facultativo y del personal no sanitario (órganos de representación y participación); explica la cartera de servicios y nuevas técnicas diagnósticas y de tratamiento a incorporar, evalúa costes y hace un análisis estratégico de la situación. El proyecto lo aprueba la gerencia y se envía a la Consejería de Sanidad (antaño, a la Dirección Territorial, que ratificaba, y a la Dirección General de Organización y Planificación del INSALUD), y b) homologación. Voluntad institucional de dotar a los centros sanitarios de autonomía de gestión y de factibilidad de las propuestas. Material. 1. Dotación: recursos de los servicios asignados. 2. Estructura: horizontalidad, simplicidad y operatividad. 3. Funciones: a) clínicas, las atribuidas a los servicios de atención especializada, y b) gestión, responsabilidad en el correcto funcionamiento (acciones), la actividad del personal (tareas) y la custodia y la utilización adecuadas de los recursos materiales (recursos disponibles), con la implicación activa y responsable de los profesionales. 4. Plan de calidad: atención centrada en el paciente, medicina basada en la evidencia científica (estándares y protocolos), evaluación de las tecnologías médicas (empresa de servicios) y garantía de calidad corporativa. Conclusiones. Modelo de gestión voluntario, innovador, participativo y descentralizado (AU)

Introduction. Clinical Teams are framed within the New Organizational Models (1996) and Spanish national health system's Strategic Plan (1997). The objectives of the internal organization model are as follows: A) General: to implement health management systems in the health service. B) Specific: service, quality and financial improvement. Material and method. Methodology. 1. Jurisdiction. Self-managing despite having no separate legal status. 2. Creation: a) feasibility study and project viability. The drafting committee consisted of representatives of the Services' physicians, other health professionals and non-health employees (Representation and Participation Organizations), and explained the portfolio of specialty services and new diagnosis and treatment techniques to be implemented. Costs and a strategic analysis of the situation were evaluated. The project was approved by management and was sent to the Ministry of Health (formerly to the Territorial Health Agency (ratified) and to the Spanish national health system's General Directorate for Organization and Planning); b) homologation: institutional approval of health centers' self-management and the feasibility of the proposals. Material. 1. Resources. Resources of the assigned Services. 2. Structure. Horizontality, simplicity and operativity. 3. Purpose: a) clinical: role assigned to Specialized Care Services; b) management: responsibility for proper working order (actions), personnel performance (tasks), and custody and use of material resources (available resources), carried out with active and responsible participation of all departments. 4. Quality plan: patient-oriented care, evidence-based medicine (standards and protocols), evaluation of medical technologies (service corporation) and corporative quality guarantee. Conclusions. A voluntary, innovative, participative and decentralized management model (AU)

Efecto rebote tras la inhalación de prostaciclina en hipertensión pulmonar / Rebound effect after prostacyclin inhalation in pulmonary hypertension

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[Relationship between echocardiographic abnormalities and sleep apnea-hypopnea syndrome severity]. / Alteraciones ecocardiográficas asociadas al síndrome de apnea-hipopnea del sueño en función de su gravedad.

INTRODUCTION AND OBJECTIVES: Sleep apnea-hypopnea syndrome (SAHS) is a prevalent condition that has well-known cardiovascular repercussions. However, few published echocardiographic studies have investigated the abnormalities present at SAHS diagnosis or their relationship with syndrome severity. Our objective was to evaluate myocardial structural, functional and performance parameters in these patients. METHODS: In total, 110 consecutive patients diagnosed with SAHS between June 2005 and 2006 who required treatment with continuous positive airway pressure were divided into two groups according to SAHS severity. Baseline echocardiography was carried out to evaluate structural and functional variables. Findings in the two groups were compared by univariate and multivariate analysis. RESULTS: The patients' mean age was 54 (13) years, their body mass index was 32 (6), 51% had comorbidities, and 74% were male. Patients with severe SAHS (i.e., apnea-hypopnea index [AHI] > or = 30) smoked and drank alcohol more and had larger neck circumferences. There was no significant difference in any structural parameter between the two groups. Functionally, patients with severe SAHS had shorter aortic (AHI<30 277 [4] ms vs AHIé30 263 [4] ms; P=.02) and pulmonary (AHI < 30 287 +/- 5 ms vs. AHI > or = 30 268 +/- 5 ms; P=.01) ejection times, and a higher Tei index (Left: AHI<30 0.51 [0.01] vs AHIé30 0.57 [0.02] [P=.04]; Right: AHI<30 0.38 [0.02] vs AHIé30 0.49 [0.03] [P=.02]). There were correlations between SAHS severity and the right Tei index, and aortic and pulmonary ejection times (P=.0001, P=.01, and P=.0001, respectively). The pulmonary ejection time was an independent predictor of SAHS severity (odds ratio: 0.98, 95% confidence interval, 0.97-0.99; P=.01). CONCLUSIONS: Myocardial performance is poorer in patients with SAHS. The Tei index and ejection times are all associated with SAHS severity. The pulmonary ejection time is an independent predictor of disease severity.

Alteraciones ecocardiográficas asociadas al síndrome de apnea-hipopnea del sueño en función de su gravedad / Relationship between echocardiographic abnormalities and sleep apnea-hypopnea syndrome severity

Introducción y objetivos. El síndrome de apnea-hipopnea del sueño (SAHS) es una enfermedad muy prevalente con repercusiones cardiovasculares conocidas. Sin embargo, son pocos los estudios ecocardiográficos publicados que evalúan estas alteraciones en el momento del diagnóstico y su relación con la gravedad del síndrome. Nuestro objetivo fue analizar parámetros morfológicos, funcionales y de rendimiento miocárdico en estos pacientes. Métodos. Analizamos a 110 pacientes consecutivos diagnosticados, entre junio de 2005 y 2006, de SAHS con indicación de presión positiva continua en la vía aérea (CPAP), divididos en 2 grupos según la gravedad. Realizamos una ecocardiografía basal y analizamos variables morfológicas y funcionales, comparando los resultados entre grupos mediante análisis univariable y multivariable. Resultados. La muestra presentaba una edad media de 54 ± 13 años, un índice de masa corporal de 32 ± 6, una comorbilidad del 51% y un porcentaje de varones del 74%. Los pacientes con SAHS grave (índice apnea-hipopnea [IAH] ≥ 30) presentaron mayor tabaquismo activo, consumo de alcohol y perímetro de cuello. No encontramos diferencias entre grupos al analizar los parámetros morfológicos. En los parámetros funcionales, los pacientes graves presentaron menor tiempo de eyección aórtico (IAH < 30 = 277 ± 4 ms; IAH ≥ 30 = 263 ± 4 ms; p = 0,02) y pulmonar (IAH < 30 = 287 ± 5 ms; IAH ≥ 30 = 268 ± 5 ms; p = 0,01), así como índices de Tei más elevados (izquierdo, IAH < 30 = 0,51 ± 0,01; IAH ≥ 30 = 0,57 ± 0,02; p = 0,04; derecho: IAH < 30 = 0,38 ± 0,02; IAH ≥ 30 = 0,49 ± 0,03; p = 0,02), observándose correlación entre la gravedad del SAHS y el índice de Tei derecho, el período aórtico y el pulmonar (p = 0,0001; p = 0,01; p = 0,0001, respectivamente). El período eyectivo pulmonar fue un predictor independiente de gravedad (odds ratio [OR] = 0,98; intervalo de confianza [IC] del 95%, 0,97-0,99; p = 0,01). Conclusiones. El rendimiento miocárdico esta disminuido en pacientes SAHS. Tanto el índice de Tei como los tiempos de eyección se asocian con gravedad. El tiempo de eyección pulmonar es una variable predictora independiente de gravedad de la enfermedad (AU)

Introducción y objetivos. En pacientes ambulatorios con insuficiencia cardiaca, la anemia es frecuente y se asocia con un aumento de la mortalidad. Estudiamos los determinantes del valor de hemoglobina y su valor pronóstico a medio plazo en una población amplia de pacientes hospitalizados con IC sistólica. Métodos. Se incluyó a 460 pacientes consecutivos (68,3 ± 12,3 años, 74% varones) hospitalizados con el diagnóstico de insuficiencia cardiaca y disfunción sistólica (fracción de eyección del ventrículo izquierdo [FEVI] < 45%). En el momento del alta hospitalaria se realizaron las determinaciones bioquímicas y hematológicas y se recogieron las variables clínicas y ecocardiográficas. Los pacientes fueron seguidos durante 16,8 ± 9,7 meses. Resultados. Un total de 189 (41,1%) pacientes presentaban anemia (según la definición de la Organización Mundial de la Salud). Los determinantes independientes del valor de hemoglobina fueron la edad (riesgo relativo [RR] = 1,035; intervalo de confianza [IC] del 95%, 1,011- 1,060; p = 0,004), el sexo femenino (RR = 1,843; IC del 95%, 1,083-3,135; p = 0,024), diabetes mellitus (RR = 1,413; IC del 95%, 1,087-1,838; p = 0,010), urea plasmática (RR = 1,013; IC del 95%, 1,005-1,022; p = 0,001) y diuréticos del asa (RR = 2,801; IC del 995%, 1,463-5,364; p = 0,002). Un menor valor de hemoglobina se asoció con un mayor riesgo de muerte evento (RR = 1,232; IC del 95%, 1,103-1,375; p < 0,001) y del evento combinado de muerte o reingreso por insuficiencia cardiaca (RR = 1,152; IC del 95%, 1,058-1,255; p < 0,001), pero no de reingreso por insuficiencia cardiaca no fatal (RR = 1,081; IC del 95%, 0,962-1,215; p = 0,265). La transfusión de hematíes durante el ingreso no modificó el incremento del riesgo de muerte (RR = 2,19; IC del 95%, 1,40-3,41, p = 0,001). Conclusiones. En pacientes hospitalizados con IC sistólica, el valor de hemoglobina en el momento del alta es un predictor independiente de mortalidad a medio plazo, pero no de reingresos por IC no fatal. Sus principales determinantes fueron la edad, el sexo, la función renal, la diabetes y la necesidad de diuréticos (AU)

Síndrome hemolítico-urémico en el trasplante cardiaco producido por sirolimus. Descripción de un caso / Hemolytic uremic syndrome due to sirolimus in a heart transplant recipient. Case report

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