Methodological and reporting quality of systematic reviews on tuberculosis.

BACKGROUND: Systematic reviews are used to inform tuberculosis (TB) guidelines. However, there are no data on whether TB systematic reviews are conducted well and reported transparently. METHODS: We searched four databases for reviews published between 2005 and 2010. Methodological quality was evaluated using AMSTAR and quality of reporting was assessed using PRISMA. RESULTS: Of 152 articles, 137 (90%) met the inclusion criteria. Only 3 of 11 AMSTAR quality items were met in most reviews: appropriate methods to combine findings (67%), comprehensive literature search (72%) and presentation of characteristics of included studies (90%). The other eight items were met in 4-53% of the reviews. Only 4% of the reviews disclosed conflicts of interest. The majority of the PRISMA items were reported in more than 60-76% of the reviews. Only nine items were reported in less than 55% of the reviews, the lowest being the full-search strategy (30%), risk of bias across studies in the Methods (27%) and Results (21%) sections, and indication of a review protocol (15%). CONCLUSIONS: Systematic reviews in our survey were well reported but generally of moderate to low quality. Better training, use of reporting guidelines and registration of systematic reviews could improve the quality of TB reviews.

Enoxaparin as bridging anticoagulant treatment in cardiac surgery.

OBJECTIVE: To assess enoxaparin as bridging anticoagulant treatment in cardiac surgery. METHODS: Prospective registry of those patients who underwent cardiac surgery in our centre between December 2003 and June 2004 and required long-term anticoagulation. Subcutaneous enoxaparin was used as bridging anticoagulant treatment according to a pre-established protocol. The global thromboembolic risk was carefully assessed in all patients. All patients were followed up for 3 months. RESULTS: Of 140 patients who were included (mean (SD) age 66 (11); 49% female), 51 were already receiving long-term acenocumarol treatment before the index intervention. 50% of the patients were at high or very high risk for thromboembolic events in the postoperative period. The mean (SD) number of days between surgery and the first dose of anticoagulant was 2.01 (7) for acenocumarol and 1 (1.01) for enoxaparin. The mean (SD) daily dose of enoxaparin was 1.1 (0.27) mg/kg. Six thromboembolic events (4.3%; 95% CI 1.6 to 9.1) occurred, but only four of them were plausibly related to enoxaparin (2.9%; 95% CI 0.8 to 7.1). Six major haemorrhagic events (4.3%; 95% CI 1.6 to 9.1) occurred, but only three were plausibly related to enoxaparin (2.1%; 95% CI 0.4 to 6.1). CONCLUSIONS: These findings show a reasonable rate of adverse events using enoxaparin as bridging anticoagulant treatment in cardiac surgery. Randomised studies are necessary to evaluate the real efficacy and safety of enoxaparin as bridging anticoagulant treatment in cardiac surgery.

Experience with enoxaparin in patients with mechanical heart valves who must withhold acenocumarol.

OBJECTIVES: To evaluate the incidence of thromboembolic and haemorrhagic events in a cohort of patients with mechanical heart valves who had to withhold acenocumarol and were treated with enoxaparin. DESIGN: Observational prospective study. SETTING: In hospital; after discharge, and follow up by telephone call. PATIENTS AND METHODS: All consecutive patients with mechanical heart valves admitted to the authors' hospital between May 1999 and January 2002 who had to interrupt treatment with acenocumarol and were treated with enoxaparin as an alternative to other methods were enrolled. In each patient, the following characteristics were prospectively determined: the reason for interrupting acenocumarol, demographic data, estimated global risk for thromboembolic events, international normalised ratio before starting enoxaparin treatment, number of days taking enoxaparin, and mean level of anti-Xa activity during treatment. All patients were followed up through clinical history during the hospitalisation and by telephone after discharge to detect thromboembolic events. MAIN OUTCOME MEASURE: Presence of thromboembolic or haemorrhagic events. RESULTS: 82 patients were identified and followed up for a mean of 2.8 months (range 1.5-3.5 months) after discharge. 61 of them (74%) had one or more associated thromboembolic risk factors. Acenocumarol was interrupted (to perform an invasive procedure in 74 patients and because of haemorrhagic complication in 8) an average of 11.2 days (range 3-40 days). Most patients received the standard enoxaparin dose (1 mg/kg at 12 hour intervals). Mean (SD) anti-Xa activity was 0.58 (0.3) IU/ml (median 0.51). There were 8 minor and 1 major bleeding events during enoxaparin treatment. No thromboembolic complications were clinically detected during hospitalisation or during follow up (95% confidence interval 0% to 3.6%). CONCLUSIONS: Enoxaparin may be an effective and relatively safe substitute anticoagulant for patients with mechanical heart valves who must withhold acenocumarol.

Deterioro de la función renal con inhibidores de la enzima convertidora de la angiotensina / Renal function impairment with angiotensin converting enzyme inhibitors

Se trata de dos pacientes ancianos con historia de hipertensión arterial de varios años de evolución. El caso n.° 1, con patología arterioesclerótica severa del sector aortoilíaco, fue tratado con un inhibidor de la enzima convertidora de la angiotensina (IECA) y presentó deterioro reversible de la función renal. Este dato hizo pensar en patología vasculorrenal y se realizaron pruebas diagnósticas que no confirmaron dicha lesión. El diagnóstico definitivo fue nefroangioesclerosis. El caso n.° 2, mujer de 78 años, con antecedentes largos de hipertensión, fundamentalmente sistólica, fue tratada con un IECA y furosemida. La suspensión de ambos fármacos normalizó la función renal. Las exploraciones complementarias demostraron la existencia de placas de ateromas en ambas arterias renales y el diagnóstico final fue hipertensión vasculorrenal bilateral.El interés práctico de ambos casos radica en que a la hora de elegir un fármaco del tipo IECA/ARA II en pacientes ancianos se debe valorar la posible existencia de patología ateroesclerótica en las arterias renales y monitorizar la creatinina sérica durante unos días (AU)

Clinical and evolutive aspects in ventricular preexcitation syndromes in child.

Ventricular preexcitation syndromes (VPS) are very important between cardiac rhythm disturbances in childhood, because their presence can change the clinical and ECG picture and thus the treatment can be very difficult. The authors studied 58 cases of VPS in children (2 weeks-15 years old) admitted in a period of 3 years. The surface ECG showed VPS aspects: in 30% of cases we noticed WPW syndrome type B and the rest presented VPS with Mahaim pathways and Lown-Ganong-Levine syndrome. 4 cases were familial and 1 child a hidden WPW syndrome. In 65% of cases the cardiac symptoms put the diagnosis and 1/3 of cases were discovered by common ECG. The most important cardiac sign of the children with WPW syndrome was the paroxysmal supraventricular tachycardia, 4 cases presenting wide QRS complex. Others types of VPS were without clinical symptoms. The intravenous administration of digoxin + propranolol was the therapy of choice for paroxysmal supraventricular tachycardia in infants and children until 2-3 years old, and propranolol and chinidine after this age. The children older than 2-3 years and/or those with ineffective preventive for recurrent treatment received dysopiramide and specially amiodarone with satisfactory results; it was not necessary the surgical ablation of the aberrant pathway. Ventricular preexcitation syndromes and wrong treatment can induce severe ventricular arrhythmia, so all the tachyarrhythmias with unknown etiology and especially those with wide QRS complex must be investigated very carefully, using and Holter test and the endocavitary electrophysiology, for a correct medical and/or surgical treatment.

Homozygosity for R87H missense mutation and for a rare intron 7 DNA variant (7054G --> A) in the PROC genes of three siblings initially classified as heterozygotes for protein C deficiency.

We report the results of protein C gene (PROC) analysis in a Spanish family with hereditary PC deficiency characterized by the presence of three siblings with PC anticoagulant activity levels clearly below 50% of normal and PC antigen and amidolytic activities between 50 and 75% of normal. Their parents are first cousins and have PC levels between 50 and 80% of normal. Sequence analysis of the whole coding sequence of the PROC gene revealed that the three siblings are double homozygotes for a G to A transition at nucleotide 3203 that replaces arginine 87 by histidine (R87H) and for another G to A transition at nucleotide 7054, in intron 7 (7054G --> A). Both parents and one sister were found to be double heterozygotes for these two mutations. Screening for the intronic mutation in a control group and RT-PCR cDNA studies from ectopically transcribed mRNA indicated that 7054G --> A is most likely a rare but neutral DNA variant. These results and the fact that heterozygosity for the missense R87H mutation has also been found associated with a slightly decreased PC anticoagulant activity in another Spanish family, lead us to conclude that homozygosity for R87H is responsible for the PC deficient phenotype in these three siblings.

[Resistance to antivitamins K]. / Resistencia a los antivitamínicos K.

Resistance to oral anticoagulant is a rare phenomenon. We report the case of a 32-year-old woman who required anticoagulation due to a deep venous thrombosis. She gradually developed resistance to acenocumarol and warfarin. Although the HPLC (high performance liquid chromatography) method proved satisfactory acenocumarol levels in plasma, therapeutic anticoagulation was not achieved. The mechanisms of resistance are discussed.

[Uric acid calculi: infrequent cause of acute renal failure]. / Litiasis úrica: causa infrecuente de fracaso renal agudo.

We reviewed the clinical histories of 14 patients diagnosed of acute obstructive renal failure due to bilateral or unilateral uric calculi in patients with only one functioning kidney for a period of 14 years (1974-1987). Urine was alkalinized in all patients. The increase in urine pH was effective in resolving the obstruction in 12 patients. The alkalinizing methods which succeeded in permeabilizing the urinary tract, considering each functioning kidney independently were: intravenous in 5/21, upstream urethral catheterism in 9/21 and by nephrostomy catheter in 5/21. Surgery was performed in 2 patients. In the later the calculi were of double composition. The most frequent complications were: urinary infection in 7/14 patients, chronic renal failure in 4/14 patients, sepsis in 3/14 patients and bacteremia in 2/14 patients. None of the patients died.