[Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]. / Evaluación de la colaboración entre atención primaria y hospitalaria para mejorar la polimedicación inapropiada.

INTRODUCTION AND OBJECTIVES: To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy. MATERIALS AND METHODS: Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated. RESULTS: A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services. CONCLUSIONS: PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

Phenotype and natural history of elderly onset inflammatory bowel disease: a multicentre, case-control study.

BACKGROUND: Onset during old age has been reported in upto 10% of total cases of inflammatory bowel disease (IBD). AIM: To evaluate phenotypic characteristics and the use of therapeutic resources in patients with elderly onset IBD. METHODS: Case-control study including all those patients diagnosed with IBD over the age of 60 years since 2000 who were followed-up for >12 months, identified from the IBD databases. Elderly onset cases were compared with IBD patients aged 18 to 40 years at diagnosis, matched by year of diagnosis, gender and type of IBD (adult-onset). RESULTS: One thousand three hundred and seventy-four elderly onset and 1374 adult-onset cases were included (62% ulcerative colitis (UC), 38% Crohn's disease (CD)). Among UC patients, elderly onset cases had a lower proportion of extensive disease (33% vs 39%; P < 0.0001). In CD, elderly onset cases showed an increased rate of stenosing pattern (24% vs 13%; P < 0.0001) and exclusive colonic location (28% vs 16%; P < 0.0001), whereas penetrating pattern (12% vs 19%; P < 0.0001) was significantly less frequent. Regarding the use of therapeutic resources, there was a significantly lower use of corticosteroids (P < 0.0001), immunosuppressants (P < 0.0001) and anti-TNFs agents (P < 0.0001) in elderly onset cases. Regarding surgery, we found a significantly higher surgery rate among elderly onset UC cases (8.3% vs 5.1%; P < 0.009). Finally, elderly onset cases were characterised by a higher rate of hospitalisations (66% vs 49%; P < 0.0001) and neoplasms (14% vs 0.5%; P < 0.0001). CONCLUSIONS: Elderly onset IBD shows specific characteristics and they are managed differently, with a lower use of immunosuppressants and a higher rate of surgery in UC.

An ex vivo experiment to reproduce a forward fall leading to fractured and non-fractured radii.

Forward falls represent a risk of injury for the elderly. The risk is increased in elderly persons with bone diseases, such as osteoporosis. However, half of the patients with fracture were not considered at risk based on bone density measurement (current clinical technique). We assume that loading conditions are of high importance and should be considered. Real loading conditions in a fall can reach a loading speed of 2m/s on average. The current study aimed to apply more realistic loading conditions that simulate a forward fall on the radius ex vivo. Thirty radii from elderly donors (79y.o.±12y.o., 15 males, 15 females) were loaded at 2m/s using a servo-hydraulic testing machine to mimic impact that corresponds to a fall. Among the 30 radii, 14 had a fracture after the impact, leading to two groups (fractured and non-fractured). Surfacic strain fields were measured using stereovision and allow for visualization of fracture patterns. The average maximum load was 2963±1274N. These experimental data will be useful for assessing the predictive capability of fracture risk prediction methods such as finite element models.

[Prolonged response with paclitaxel after immunotherapy by pembrolizumab in lung cancer]. / Réponse prolongée sous paclitaxel après immunothérapie par pembrolizumab dans le cancer bronchique.

INTRODUCTION: Pembrolizumab, a humanized monoclonal antibody IgG4 anti-PD-1, having offered promising results in patients suffering from non-small cell lung cancer metastatic and heavily pretreated. OBSERVATION: We report here the case of an unexpected good response after pembrolizumab failure obtained with paclitaxel in a 68-year-old patient with stage IV lung adenocarcinoma. Moreover, the response duration with paclitaxel was more than fourteen months. CONCLUSION: Our case suggests a mutual potentiation of chemotherapy and immunotherapy, and raises the issue of the treatment sequence to favor.

Antioxidant and toxicological evaluation of a Tamarindus indica L. leaf fluid extract.

In the scientific community, there is a growing interest in Tamarindus indica L. leaves, both as a valuable nutrient and as a functional food. This paper focuses on exploring its safety and antioxidant properties. A tamarind leaf fluid extract (TFE) wholly characterised was evaluated for its anti-DPPH activity (IC50 = 44.36 µg/mL) and its reducing power activity (IC50 = 60.87 µg/mL). TFE also exhibited a high ferrous ion-chelating capacity, with an estimated binding constant of 1.085 mol L(-1) while its influence over nitric oxide production in human leucocytes was irregular. At low concentrations, TFE stimulated NO output, but it significantly inhibited it when there was an increase in concentration. TFE was also classified as a non-toxic substance in two toxicity tests: the acute oral toxicity test and the oral mucous irritability test. Further toxicological assays are needed, although results so far suggest that TFE might become a functional dietary supplement.

Onsager's irreversible thermodynamics of the dynamics of transient pores in spherical lipid vesicles.

Onsager's irreversible thermodynamics is used to perform a systematic deduction of the kinetic equations governing the opening and collapse of transient pores in spherical vesicles. We show that the edge tension has to be determined from the initial stage of the pore relaxation and that in the final state the vesicle membrane is not completely relaxed, since the surface tension and the pressure difference are about 25% of its initial value. We also show that the pore life-time is controlled by the solution viscosity and its opening is driven by the solution leak-out and the surface tension drop. The final collapse is due to a non-linear interplay between the edge and the surface tensions together with the pressure difference. We also discuss the connection with previous models.

Appraisal of the difference between the mesiodistal diameters of deciduous incisors and molars and permanent teeth.

AIM: Difference in tooth size between deciduous and permanent teeth can resolve space problems during development of the dentition. AIM: To determine the difference in size between deciduous and permanent teeth in the anterior and posterior areas of the mouth in a group of school-age children from Medellin, Colombia. DESIGN: this longitudinal prospective, descriptive investigation was carried out in 139 skeletal Class I dental stone casts from school-age children from Medellin. Patients were followed annually from 6 to 12 years of age. The final sample consisted of 53 children (35 girls and 18 boys). Leeway space and the incisor liability were determined. RESULTS: A higher positive leeway space was found in the mandible than in the maxilla (3.622 mm and 1.556 mm, respectively). Incisor liability was negatively higher in the maxilla than in the mandible (-7.884mm and -5.386mm, respectively). Six patients showed a negative leeway space between -1.582 mm and -3.184 mm for the mandible and the maxilla, respectively. No statistical significant differences were found by gender; girls showed higher leeway space and incisor liability than boys. CONCLUSION: Normal values for one ethnic group should not be considered normal for another and each group must be treated according to its own characteristics.

The structural modeling of the interaction between levofloxacin and the Mycobacterium tuberculosis gyrase catalytic site sheds light on the mechanisms of fluoroquinolones resistant tuberculosis in Colombian clinical isolates.

We compared the prevalence of levofloxacin (LVX) resistance with that of ofloxacin (OFX) and moxifloxacin (MFX) among multidrug resistant (MDR) MTB clinical isolates collected in Medellin, Colombia, between 2004 and 2009 and aimed at unraveling the underlying molecular mechanisms that explain the correlation between QRDR-A mutations and LVX resistance phenotype. We tested 104 MDR isolates for their susceptibility to OFX, MFX, and LVX. Resistance to OFX was encountered in 10 (9.6%) of the isolates among which 8 (7.7%) were also resistant to LVX and 6 (5.7%) to MFX. Four isolates resistant to the 3 FQ were harboring the Asp94Gly substitution, whilst 2 other isolates resistant to OFX and LVX presented the Ala90Val mutation. No mutations were found in the QRDR-B region. The molecular modeling of the interaction between LVX and the DNA-DNA gyrase complex indicates that the loss of an acetyl group in the Asp94Gly mutation removes the acid base interaction with LVX necessary for the quinolone activity. The Ala90Val mutation that substitutes a methyl for an isopropyl group induces a steric modification that blocks the LVX access to the gyrase catalytic site.

Tomato and tomato byproducts. Human health benefits of lycopene and its application to meat products: a review.

During recent decades, the food industry, consumers, and regulatory authorities have developed a significant interest in functional foods because of their potential benefits for human health over and above their basic nutritional value. Tomato is the second most important vegetable crop in the world. The amount of the related wastes is estimated at up to 50,000 tons per year, representing a serious disposal problem with a consequent negative impact on the environment. Tomato byproducts contain a great variety of biologically active substances, principally lycopene, which have been demonstrated by in vitro and in vivo studies to possess antioxidant, hypolipidemic, and anticarcinogenic activities. The aim of this review is to present an overview of the functional and physiological properties of the principal bioactive compound present in tomato and tomato byproducts, lycopene, its addition to meat, and meat products.

Effect of tiger nut fibre addition on the quality and safety of a dry-cured pork sausage ("Chorizo") during the dry-curing process.

There is a growing interest in the revalorization of co-products from the food industry. Co-products from tiger nuts (Cyperus esculentus) milk production are a suitable fibre source. "Chorizo" is the most popular dry-cured meat product in Spain. The aim of this work was to study the effect of the tiger nut fibre addition (0, 5, and 7.5%) on the quality (composition, physicochemical, and sensorial properties) and safety (oxidation and microbial quality) of a Spanish dry-cured sausage, during the 28days of its dry-curing process. Tiger nut fibre (TNF) addition decreased fat and increased moisture content. The addition of TNF significantly increased (p<0.05) the total dietary fibre content of "Chorizo". Lightness (L*), yellowness (b*) and redness index (a*/b*) were significantly (p<0.05) affected by the fibre content. The addition of 5% and 7.5% TNF to chorizo provided rich fibre and a healthier product. Although there were slight changes in the physicochemical properties, its quality (traditional characteristics) and its safety remained.

Effect of the molecular weight and concentration of chitosan in pork model burgers.

Chitosan of high and low molecular weights was added at 0%, 0.25%, 0.5% and 1% concentrations to a burger model system. Burgers were evaluated by physicochemical analysis, cooking characteristic and storage stability. The antioxidant activity of chitosan was studied in vitro. The addition of chitosan influenced pH and color properties, in molecular weight and concentration dependent ways. Cooking properties were significantly affected by the chitosan. High molecular weight chitosan improved all cooking characteristics compared with control samples. Low molecular weight chitosan increased the shelf life of burgers, enhanced the red color and reduced total viable counts, compared with control and high molecular weight chitosan samples. The antioxidant activity of chitosan was dependent on molecular weight and concentration. The results indicate that high molecular weight chitosan (HMWC) improves all cooking characteristics and antioxidant activity while low molecular weight chitosan extends the red color and reduces total viable counts.

Eficacia de los programas de cribado de hepatocarcinoma: ¿mejoran las opciones terapéuticas de estos pacientes? / Are hepatocellular carcinoma surveillance programs effective at improving the therapeutic options?

Objetivo: determinar si la utilización en nuestro medio delprograma de cribado de HCC establecido –alfa-fetoproteína (AFP)y ecografia semestral– en pacientes con hepatopatía crónica permitedetectar pacientes en estadios precoces de la enfermedad.Material y métodos: Diseño experimental: estudio retrospectivo.Criterios diagnósticos de HCC: 2 o más técnicas de imagencon lesión hipervascular mayor de 2 cm o 1 técnica de imagencon lesión hipervascular mayor de 2 cm asociado a AFPmayor de 400 ng/ml. Pacientes: 85 pacientes diagnosticados deHCC en el Hospital Donostia entre los años 2003 y 2005. Datosanalizados: información demográfica (sexo, edad), factores deriesgo (alcohol, virus de hepatitis, hemocromatosis, otras enfermedadesasociadas), e información clínica (etiología de la hepatopatía,estadio de Child-Pugh, determinación de AFP, hallazgos radiológicos,criterios de resecabilidad, tratamiento recibido,evolución). Se divide la muestra en dos grupos según hubieran seguidoo no un programa de cribado.Resultados: el 70% de los pacientes del grupo de cribado sediagnostican en estadio precoz frente al 26,7% del grupo de nocribado (p < 0,05). Trece pacientes no pueden recibir tratamientocurativo a pesar del diagnóstico en fase precoz (9 en el grupo decribado y 4 en el de no cribado). La sensibilidad global del cribadoen nuestra serie es del 95%.Conclusiones: en nuestro medio, el programa de cribado dehepatocarcinoma es eficaz en términos de aplicación de tratamientoscurativos(AU9

Aim: to evaluate whether the current surveillance programs(ultrasonography and alpha-fetoprotein testing every six months)are successful in detecting patients in the early stages.Material and methods: the health records of all patientsdiagnosed with hepatocellular carcinoma in Donostia Hospitalbetween 2003 and 2005 were reviewed retrospectively. Eightyfivepatients (11 women and 74 men) were included in the studyand demographic data, risk factors and clinical data were obtained.Patients were split into two groups according to whether ornot they had been included in a surveillance program.Results: seventy per cent of patients of the surveillance groupis diagnosed in early stage opposite to 26.7% of patients in nosurveillance group (p < 0.05). Thirteen patients cannot receivecurative treatment in spite of the diagnosis in early stage (9 in thesurveillance group and 4 in the no surveillance group. The globalsensibility of the surveillance program in our series is 95%.Conclusions: current hepatocellular carcinoma surveillanceprograms, which comprise six-monthly ultrasonography and alpha-fetoprotein tests, are highly sensitive and effective. These programsresult in the detection of hepatocellular carcinoma in itsearly-stages, when potentially curative treatment may be offered(AU)

Are hepatocellular carcinoma surveillance programs effective at improving the therapeutic options.

AIM: to evaluate whether the current surveillance programs (ultrasonography and alpha-fetoprotein testing every six months) are successful in detecting patients in the early stages. MATERIAL AND METHODS: the health records of all patients diagnosed with hepatocellular carcinoma in Donostia Hospital between 2003 and 2005 were reviewed retrospectively. Eighty-five patients (11 women and 74 men) were included in the study and demographic data, risk factors and clinical data were obtained. Patients were split into two groups according to whether or not they had been included in a surveillance program. RESULTS: seventy per cent of patients of the surveillance group is diagnosed in early stage opposite to 26.7% of patients in no surveillance group (p < 0.05). Thirteen patients cannot receive curative treatment in spite of the diagnosis in early stage (9 in the surveillance group and 4 in the no surveillance group. The global sensibility of the surveillance program in our series is 95%. CONCLUSIONS: current hepatocellular carcinoma surveillance programs, which comprise six-monthly ultrasonography and alpha-fetoprotein tests, are highly sensitive and effective. These programs result in the detection of hepatocellular carcinoma in its early-stages, when potentially curative treatment may be offered.

[Massive intravascular hemolysis secondary to sepsis due to Clostridium perfringens]. / Hemólisis masiva intravascular secundaria a sepsis por Clostridium perfringens.

Massive hemolysis secondary to sepsis caused by Clostridium perfringens is a rare entity but appears fairly often in the literature. In nearly all published reports, the clinical course is rapid and fatal. We describe the case of a 75-year-old woman with diabetes who was admitted with symptoms consistent with acute cholecystitis. Deteriorating hemodynamics and laboratory findings were consistent with intravascular hemolysis, coagulation disorder, and renal failure. Gram-positive bacilli of the Clostridium species were detected in blood along with worsening indicators of hemolysis. In spite of antibiotic and surgical treatment, hemodynamic support and infusion of blood products, the patient continued to decline and died in the postoperative recovery unit 14 hours after admission. Mortality ranges from 70% to 100% in sepsis due to Clostridium perfringens, and risk of death is greater if massive hemolysis is present, as in the case we report. Only a high degree of clinical suspicion leading to early diagnosis and treatment can improve the prognosis. This bacterium should therefore be considered whenever severe sepsis and hemolysis coincide.

Hemólisis masiva intravascular secundaria a sepsis por Clostridium perfringens / Massive intravascular hemolysis secondary to sepsis due to Clostridium perfringens

La hemólisis masiva asociada a la sepsis por Clostridiumperfringens, aunque infrecuente, ha sido descritaen un número significativo de casos clínicos. En casitodos ellos la evolución del cuadro ha sido rápidamentefatal. Presentamos el caso de una mujer de 75 años diabéticaingresada por un cuadro compatible con colecistitisaguda que sufrió un deterioro hemodinámico y datosanalíticos compatibles con hemólisis intravascular, coagulopatíae insuficiencia renal. Se detectaron bacilosgram positivo tipo clostridio en sangre y un marcadoempeoramiento de los datos de hemólisis. A pesar deltratamiento antibiótico y quirúrgico y del soporte hemodinámicoy hemoterápico, la paciente evolucionó negativamente,falleciendo a las 14 horas de su ingreso en reanimación.La mortalidad de la sepsis por Clostridiumperfringens llega a ser del 70-100%, sobre todo si se asociaa una hemólisis masiva como ocurrió en nuestrocaso. Sólo un alto grado de sospecha clínica que determineun diagnóstico y tratamiento precoz puede evitar elpronóstico tan infausto. Por ello deberíamos pensar enesta bacteria ante toda sepsis grave asociada a hemólisis(AU)

Massive hemolysis secondary to sepsis caused by Clostridium perfringens is a rare entity but appears fairlyoften in the literature. In nearly all published reports, theclinical course is rapid and fatal. We describe the case of a75-year-old woman with diabetes who was admitted withsymptoms consistent with acute cholecystitis. Deterioratinghemodynamics and laboratory findings were consistentwith intravascular hemolysis, coagulation disorder, andrenal failure. Gram-positive bacilli of the Clostridiumspecies were detected in blood along with worseningindicators of hemolysis. In spite of antibiotic and surgicaltreatment, hemodynamic support and infusion of bloodproducts, the patient continued to decline and died in thepostoperative recovery unit 14 hours after admission.Mortality ranges from 70% to 100% in sepsis due toClostridium perfringens, and risk of death is greater ifmassive hemolysis is present, as in the case we report. Onlya high degree of clinical suspicion leading to early diagnosisand treatment can improve the prognosis. This bacteriumshould therefore be considered whenever severe sepsis andhemolysis coincide(AU)

Effect of tiger nut fibre on quality characteristics of pork burger.

Horchata is a refreshing beverage obtained from tiger nut tubers that yields high amount of by-products. These by-products have a high content of fibre that allows its application in the development of dietary fibre rich foods. The utilization of increasing levels (0%-control, 5%, 10% and 15%) of tiger nut fibre (TNF), in the formulation of pork burgers was evaluated. This evaluation was based on: chemical composition, physicochemical, cooking characteristics and sensory properties of burgers. Pork burgers elaborated with TNF had higher nutritional value (higher fibre content) and better cooking characteristics (higher cooking yield, fat retention and moisture retention) than control burgers. Some of the negative changes in colour (a* decrease and b* increase) and texture (chewiness and springiness increase) parameters due to TNF addition observed in raw burgers were masked by the stronger modifications due to the cooking process. Burgers with TNF were perceived as less greasy, less juicy, more grainy and with less meaty flavour than controls; although this perception did not reduce the overall acceptability of burgers. Overall acceptability scores were slightly lower in burgers with 15% TNF, although no significant differences were detected with the scores of control, 5% and 10% TNF burgers. TNF addition to burgers is a promising and convenient application as dietary fibre of burgers was significantly increased without changes in sensory acceptance.