Antifungal stewardship in a tertiary-care institution: a bedside intervention.

Antifungal stewardship (AFS) programmes are needed in tertiary-care hospitals. Our aim is to describe a bedside non-restrictive AFS programme, and to evaluate its economic impact. During the first year of the AFS a bundle of non-interventional measures were implemented. During the second year an infectious diseases specialist visited 453 patients receiving candins, liposomal amphotericin B, voriconazole or posaconazole. Monthly costs were studied with an interrupted time series (ITS) analysis. The main prescribing departments were haematology (35%), medical departments (23%), and intensive care units (20%). Reasons to start antifungal therapy were: targeted therapy (36%), prophylaxis (32%), empirical therapy (20%) and pre-emptive therapy (12%). At the initial visit, diagnostic advice was provided in 40% of cases. The most common therapeutic recommendations were to de-escalate the antifungal drug (17%) or to suspend it (7%). Annual total antifungal expenditure was reduced from US$3.8 million to US$2.9 million over the first 2 years, generating net savings of US$407,663 and US$824,458 per year after considering the cost of additional staff required. The ITS analyses showed a significant economic impact after the first 12 months of the intervention (p 0.042 at month 13), which was enhanced in the following 24 months (p 0.006 at month 35). The number of defined daily doses decreased from 66.4 to 54.8 per 1000 patient-days. Incidence of candidaemia was reduced from 1.49 to 1.14 (p 0.08) and related mortality was reduced from 28% to 16% (p 0.1). A collaborative and non-compulsory AFS program based on bedside intervention is an efficacious and cost-effective approach that optimizes the use of AF drugs.

Therapeutic inertia in hypercholesterolaemia is associated with ischaemic events in primary care patients. A case-control study.

BACKGROUND: The frequency of therapeutic inertia (TI) is very high in the management of vascular risk factors, although its impact on the incidence of ischaemic events is not well-established. Our aim was to investigate the relationship between TI in the treatment of hypercholesterolaemia and the appearance of ischaemic events. METHODS: An observational, multicentre, case-control study was conducted in 70 primary care centres in Spain. Case subjects (n = 235) were high-risk hypercholesterolaemic patients (both genders, ≥ 18 years) who had had a first event in the 12 months prior to recruitment. They were matched with 235 controls (by vascular risk, age and gender). The observation period was 18 months prior to the onset of a first event (cases) or to date of recruitment (control subjects). RESULTS: The TI in the basal visit (an average of 7.8 months before the event) was slightly higher in cases than in controls (39.7% vs. 34.8%, NS). However, the accumulated TI was similar in both groups (70.7% for cases and 73.95% for controls, NS). The multivariate analysis, taking ischaemic events as the dependent variable, showed that the TI at baseline visit was significantly associated with the development of the event [OR 2.18 (95% CI 1.04-4.51), p < 0.05]. Other variables also associated with the ischaemic event were a family history of premature vascular disease [OR 3.38 (95% CI 1.35-8.49), p < 0.05] and uncontrolled hypertension [OR 2.35 (95% CI 1.02-5.43), p < 0.05]. CONCLUSION: The TI in high-risk hypercholesterolaemic patients in primary prevention in Spanish primary care centres doubled the risk of an ischaemic event in the short term.

HER-2 Evaluation in a Specific Gastric Cancer Population with the Highest Rate of Mortality in Spain.

Gastric cancer (GC) still represents the second cause of cancer-related death worldwide. Radical resection is the mainstay of early stages treatment with little impact on overall survival (OS) in the advanced ones. HER-2 is the most relevant biological factor involved. Purpose. This study aims to show the relationship between HER-2 positivity and survival in patients with completely resected GC. Methods. Retrospective study of GC patients diagnosed in 2003-2005 at our institution. Surgical specimens underwent immunohistochemistry (IHC), and in cases +/++/+++ samples underwent also fluorescence in situ hybridisation (FISH) analyses of HER-2 and graduated according to experts' consensus. Results. 120 cases included. Overall expression detected in 7.5%. Correlation between HER-2 positive and female sex, advanced stages or histological grades, or intestinal type was detected. Early recurrences higher in HER-2 positive (66.6% versus 35.4%, P = 0.048). The median DFS for c-erbB-2 positive was 15 months (range 2-67 months), and OS was 25 months (range 10-67 months). In the case of patients with c-erbB-2, negative median DFS was 27 months (range 5-67 months) and OS for this sample is 47 months (range 29-67 months). Conclusions. These results emphasize the relevance of HER-2 positivity in GC as independent prognostic factor and support its current analyses in daily practice.

[The effect of helium on ventilator parameters: in vitro study with a Servoi ventilator]. / Efecto del helio sobre los parámetros de los respiradores en ventilación mecánica: estudio in vitro con el respirador Servoi.

OBJECTIVE: To analyze the changes in respiratory parameters in a Servoi ventilator with heliox. MATERIAL AND METHODS: In vitro study with a Servoi (Maquet) ventilator in volume controlled (VC), pressure controlled (PC) and volume control regulated by pressure (VCPR) modes connected to an artificial lung. A heliox tank with a fixed concentration of helium 70 % and oxygen 30 % was connected to the air inlet of the ventilator. The ventilator was set in VC mode with tidal volumes of 30, 50, 100, 250 and 500 ml; in PC mode with pressure of 20 and 30 cmH(2)O and in VCPR mode with tidal volume of 150 ml. In each case FiO(2) of 21, 30, 40, 50, 60, 70, 80, 90 and 100 % was used. The FiO(2), inspired and expired tidal volume and inspiratory pressure measured by the ventilator and a pitot spirometer (Datex_S5) were compared. RESULTS: In VC and VCPR modes the increase in helium produced a progressive decrease in the pressure needed to administrate the set volume. Heliox also produced a decrease in the tidal volume measured by the spirometer and the tidal expired volume measured by the respirator. In PC mode, heliox produced a progressive increase in the inspired tidal volume, increasing the differences between inspired and expired tidal volumes. CONCLUSIONS: Heliox used with Servoi ventilator produces a decrease in inspiratory pressures in VC and VCPR modes, and an increase in inspiratory tidal volume in PC mode. In all modes heliox reduced the expired tidal volume measured by the ventilator and the spirometer. These changes should be borne in mind if heliox is used with this ventilator.

Efecto del helio sobre los parámetros de los respiradores en ventilación mecánica: estudio in vitro con el respirador Servoi / The effect of helium on ventilator parameters: in vitro study with a Servoi ventilator

Objetivo: Analizar las modificaciones de los parámetros en el respirador Servoi con distintas concentraciones de héliox. Material y métodos: Estudio experimental en el que se utilizó un respirador Servoi (Maquet) en modalidades de volumen control (VC), presión control (PC) y volumen controlado regulado por presión (VCRP) conectado a un pulmón de artificial. El héliox se administró mediante una bombona con el 70 % de helio y el 30 % de oxígeno conectada a la entrada de aire del respirador. Se programó el respirador en VC con volúmenes corrientes de 30, 50, 100, 250 y 500 ml, en PC con presión de 20 y 30 cmH2O, y en VCRP con volumen corriente de 150 ml. En cada modalidad se programó una FiO2 de 21, 30, 40, 50, 60, 70, 80, 90 y 100 % y se comparó el volumen corriente inspirado, el espirado y la presión inspiratoria pico medidas por el respirador y por un espirómetro colocado entre la tubuladura y el pulmón de prueba y conectado a un monitor Datex_S5. Resultados: En modalidad de VC y VCRP el aumento de la concentración de helio produjo una disminución progresiva del pico de presión necesario para administrar el volumen programado y una disminución en el volumen corriente medido por el espirómetro y el volumen espirado medido por el respirador. En modalidad de PC el héliox produjo un aumento progresivo del volumen corriente inspirado con incremento en las diferencias entre el volumen corriente inspirado y el espirado. Conclusiones: La administración de héliox en el respirador Servoi produce una disminución de las presiones inspiratorias en las modalidades de VC y VCRP y un aumento del volumen corriente inspirado en la modalidad de PC. En todas las modalidades produce una falsa disminución en el volumen corriente espirado medido por el respirador y el espirómetro. Es necesario tener en cuenta estas alteraciones si se utiliza héliox con este respirador (AU)

Objective: To analyze the changes in respiratory parameters in a Servoi ventilator with heliox. Material and methods: In vitro study with a Servoi (Maquet) ventilator in volume controlled (VC), pressure controlled (PC) and volume control regulated by pressure (VCPR) modes connected to an artificial lung. A heliox tank with a fixed concentration of helium 70 % and oxygen 30 % was connected to the air inlet of the ventilator. The ventilator was set in VC mode with tidal volumes of 30, 50, 100, 250 and 500 ml; in PC mode with pressure of 20 and 30 cmH2O and in VCPR mode with tidal volume of 150 ml. In each case FiO2 of 21, 30, 40, 50, 60, 70, 80, 90 and 100 % was used. The FiO2, inspired and expired tidal volume and inspiratory pressure measured by the ventilator and a pitot spirometer (Datex_S5) were compared. Results: In VC and VCPR modes the increase in helium produced a progressive decrease in the pressure needed to administrate the set volume. Heliox also produced a decrease in the tidal volume measured by the spirometer and the tidal expired volume measured by the respirator. In PC mode, heliox produced a progressive increase in the inspired tidal volume, increasing the differences between inspired and expired tidal volumes. Conclusions: Heliox used with Servoi ventilator produces a decrease in inspiratory pressures in VC and VCPR modes, and an increase in inspiratory tidal volume in PC mode. In all modes heliox reduced the expired tidal volume measured by the ventilator and the spirometer. These changes should be borne in mind if heliox is used with this ventilator (AU)

Life cycle assessment of the removal of Diuron and Linuron herbicides from water using three environmentally friendly technologies.

Nowadays, every chemical treatment must be developed taking into account its global impact on the environment. With this objective a life cycle assessment (LCA) has been used as a tool for the assessment of the environmental impact of three environmentally friendly processes for the removal of Diuron and Linuron herbicides from water: artificial light assisted photo-Fenton, photo-Fenton coupled to biological treatment and solar assisted photo-Fenton. The inventoried data has been classified considering the potential environmental impacts categories included in the CML 2 baseline 2000 method. Among the three scenarios considered, photo-Fenton coupled to biological treatment proved to have the lowest environmental impact in all the studied categories due to the lower hydrogen peroxide and electricity consumptions. The environmental impacts associated with hydrogen peroxide and electricity production imply more than 72% in all the impact categories of the three scenarios, except for aquatic eutrophication potential category, where the main impacts are related to nitrogen emissions.

Crecimiento intrauterino retardado / Intrauterine growth retardation

No disponible

[Psychotherapy of personality disorders]. / Psicoterapia de los trastornos de la personalidad.

A review of classical psychodynamic concepts in the psychotherapy of personality disorders (PD) is carried out. New approaches, such as dialectic behavioral therapy or cognitive analytic therapy, are also studied. Whenever possible, evidence is given on the efficacy of these approaches. The article finishes with a PD by PD study of relevant psychotherapeutic issues.

Psicoterapia de los trastornos de la personalidad / Psychotherapy of personality disorders

Se proporciona una revisión de los conceptos psicodinámicos clásicos en la psicoterapia de los trastornos de la personalidad (TP). Se estudian asimismo nuevos abordajes, como la terapia dialéctica conductual o la terapia cognitivo analítica. Cuando es posible, la evidencia sobre la eficacia de estos métodos es señalada. El artículo acaba con un estudio de los aspectos psicoterapéuticos más importantes de cada TP (AU)

H2O2 formation from photocatalytic processes at the ZnO/water interface.

The paper focuses on the production of H2O2 by photocatalysis over ZnO in an aerated aqueous phase. The presence of different reductants that increase the H2O2 production in the aqueous phase is analysed; particular attention is paid to nitrite, which has been shown to be the reductant that produces the most significant increments in the H2O2 production. The photocatalytic anodic decomposition of ZnO in the presence of the different reductants is also investigated. From the results obtained, the relevance of the ZnO photocatalysis in the formation of environmental hydrogen peroxide is estimated.

La hipnosis en la terapia cognitivo-conductual: aplicaciones en el campo de las adicciones / Hypnosis in the cognitive-behavioral therapy: aplications in the field of addictions

En este artículo se pretende mostrar cómo la hipnosis puede incorporarse a las intervenciones cognitivo-conductuales, detallándose específicamente cuál es el modelo de trabajo propuesto en el ámbito de las adicciones. Se ha realizado un recorrido por las principales técnicas de intervención de este modelo en adicciones, demostrando cómo las técnicas de sugestión e hipnosis pueden utilizarse como coadyuvantes de las estrategias cognitivo-conductuales. Se concluye que el añadir hipnosis produce un efecto de sinergia en las terapias que se integra, por lo que la utilización de las técnicas sugestivas dentro del campo de las adicciones, puede aumentar la eficacia de estas intervenciones (AU)

Replacement of H2O2 by O2 in Fenton and photo-Fenton reactions.

The consumption of oxygen during the degradation of aniline by Fenton and photo-Fenton reactions is studied. The effect that parameters like aniline, Fe(II) and H2O2 initial concentration, pH, temperature and O2 flow rate have on the ratio O2 consumed/H2O2 consumed is examined. The determination of those combinations of experimental conditions for which an effective partial replacement of H2O2 by O2 as electron acceptor takes place is investigated. The results show that this replacement takes place in a variable extent, but the presence of H2O2 is necessary along the reaction, and the maximum consumption of O2 only takes place when the ratio amount of aniline mineralized vs. initial aniline concentration is minimal.

Oxidation of HSO3- in aqueous suspensions of alpha-Fe2O3, alpha-FeOOh, beta-FeOOH and gamma-FeOOH in the dark and under illumination.

The kinetics of oxidation of HSO3- ions in aqueous solutions in the presence of alpha-Fe2O3, alpha-FeOOH, beta-FeOOH and gamma-FeOOH is investigated. The oxidation of HSO3- follows a zero-order kinetics in suspensions of beta-FeOOH and gamma-FeOOH and a first-order kinetics for alpha-FeOOH and alpha-Fe2O3 systems. Some degradation of the iron(III) oxides takes place, evidenced by the presence of Fe(III) and Fe(II) in solution. Under illumination, the rate of HSO3- oxidation notably increases. In this case, the rate of oxidation of HSO3- by the four iron(III) oxides follows a kinetic equation of the type dx/dt=k(1-x)/x, where x is the fraction of HSO3- oxidized at time t. The rate constant of HSO3- photo-oxidation per unit of specific area for the different iron(III) oxides studied follows the order: alpha-Fe2O3>>gamma-FeOOH approximately beta-FeOOH>>alpha-FeOOH. Fe(II) and Fe(III) were also detected in solution after irradiation of the iron(III) oxide suspensions.

Immunophenotypic characterization of primary and secondary lymphoid follicles.

The need for an immunophenotypical referential framework relative to lymphoid follicle has led us to apply a panel of monoclonal and polyclonal antibodies, by means of a sensitive immunostaining method. Lymphoid follicle is an immunophenotypically complex structure made up of three lymphoid populations (B, being its bulk, and a few T and NK cells), dendritic reticulum cells (DRCs) and Flemming's macrophages. Follicular B population is To 15 +, B1+, OKB 7 +, HLA-DR + and C3bR +. In secondary follicles there are differential characteristic reactivities for each topographic compartment: Mantle zone is positive for OKB 2 and surface IgM (sIgM) and IgD (sIgD); germinal center (GC) clear zone (with centrocytic predominance) for OKT 9, sIgM and weakly for OKB 2; and GC dark zone (with centroblastic predominance) only for OKT 9. In sections, OKT 10 allows one to see immunoblasts and plasma cells, the latter being with lymphoplasmacytoid cells the only intracytoplasmic immunoglobulin holders. 10% of GC lymphocytes are T cells, almost exclusively T-helper (Leu 3a +). Another 10% to 15% of lymphoid cells are Leu 7 (HNK-1) +. In histological sections, DRCs are specifically marked with R4/23 and Flemming's macrophages with anti-alpha1-antitrypsin and anti-alpha1-antichymotrypsin antibodies, both populations being negative to OKM 1 and OKM 5.