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Precis Vascular diseases have been linked to alterations in optic nerve head perfusion. Purpose The main objective was to investigate the changes in peripapillary vessel density (VD) in post coronavirus disease (COVID-19) patients. Methods In this prospective pilot exploratory study, patients with COVID-19 that were attended in the Emergency Department of Hospital Clinico San Carlos (Madrid) were included. All patients underwent optic nerve head optical coherence tomography angiography using the Cirrus HD-OCT 500 with AngioPlex OCTA (Zeiss, Dublin, CA) 4 and 12 weeks after diagnosis by positive reverse transcriptase-polymerase chain reaction test from nasopharyngeal swab at the Emergency Department. Sociodemographic data, medical history, disease severity, and laboratory work-up were collected. Results One hundred and eighty eyes of 90 patients with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection were included. None of the patients reported visual changes. Severe patients were older, more frequently hispanic, dyslipidemic, and presented lower lymphocytes counts, as well as increased ferritin, D-dimer, fibrinogen, and international normalized ratio levels. No changes in optic nerve head vascularization were observed when both visits were compared. No correlation was found between VD and clinical parameters, disease severity and laboratory work-up. Conclusions Changes to peripapillary VD were not observed in patients with COVID-19 in the early months following diagnosis.

Key summary points Aim According to age, there are differences in the clinical profile, presentation, management, and short-term outcomes of patients with COVID-19 admitted to the Emergency Department. Findings A statistically significant association was found between demographic data, comorbidities, clinical, radiographic, analytical, and therapeutic variables and short-term results according to age-dependent categories. Age was a prognostic factor for hospital admission and in-hospital and 30-day mortality, and was associated with not being admitted to intensive care. Message Clinical presentation, management, and short-term outcomes differ according to age among patients with COVID-19 admitted to the Emergency Department. Electronic supplementary material The online version of this article (10.1007/s41999-020-00359-2) contains supplementary material, which is available to authorized users., Purpose To determine the differences by age-dependent categories in the clinical profile, presentation, management, and short-term outcomes of patients with laboratory-confirmed COVID-19 admitted to a Spanish Emergency Department (ED). Methods Secondary analysis of COVID-19_URG-HCSC registry. We included all consecutive patients with laboratory-confirmed COVID-19 admitted to the ED of the University Hospital Clinico San Carlos (Madrid, Spain). The population was divided into six age groups. Demographic, baseline and acute clinical data, and in-hospital and 30-day outcomes were collected. Results 1379 confirmed COVID-19 cases (mean age 62 (SD 18) years old; 53.5% male) were included (18.1%

Background Mucosal involvement is frequently seen in cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE). There is no consensus regarding the prevalence, and a wide range of lesions has been reported. Its prognostic significance is currently unknown and a matter of controversy. Objective To classify oral lesions in lupus, evaluate their prevalence and assess their possible association with disease activity. Methods We conducted a descriptive study between 2016 and 2017. A total of 150 lupus patients were matched by sex, age and smoking status with 151 healthy individuals. All subjects underwent a careful evaluation of oral mucosa. On the same day of the clinical assessment, each patient underwent a peripheral venous blood and urine analysis. All patients underwent a full medical history, physical examination and a careful examination of the oral cavity. For each one, we obtained photographs of ten areas of the oral cavity. Two dermatologists of our group blindly recorded the presence and morphology of oral lesions. The disease activity of CLE patients was scored using the Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index, and in SLE patients, activity was measured using the Systemic Lupus Erythematosus Disease Activity Index. Results In CLE patients, there was a statistically significant correlation between higher cutaneous disease activity and the following oral findings: discoid plaques, cobblestone and red/brown-pigmented macules. In patients with CLE, red macules on jugal mucosa were statistically associated with anaemia and positive antinuclear antibodies titres; additionally, the presence of gingivitis was related to systemic inflammation. In SLE patients, gingival telangiectases were statistically significantly associated with leucopenia, hypocomplementemia and systemic inflammation. Limitations Biopsies on mucosal lesions were not performed. Conclusion Some specific oral lesions correlate with disease activity in CLE and SLE.

Background and objectives To study the frequency of genetic mutations related to genetic heart disease among young patients admitted for syncope during sport practice. Patients and methods A case series study that included patients ≤45 years admitted for syncope during sport practice during 2010–2011. We collected demographic and clinical variables, genetic tests mutations and final clinical diagnosis. Results A genetic test was performed in 46 (76.7%) of 60 patients evaluated. The genetic test was positive in 12 (26%; 95% CI 15.6–40.3) patients; 10 (21.7%) had PKP2 mutation related to arrhythmogenic right ventricular dysplasia mutation, one (2.2%) KCNQ1 mutation and one (2.2%) SCN5A mutation related to channelopathies. The genetic test was positive in 11 (35.5%) cases of undetermined syncope and one (50%) case of cardiac syncope, being negative in all cases with neuromediated syncopes (p = .037). Conclusions Gene mutations are common in young patients suffering from syncope during sports, especially in those with cardiac or undetermined aetiology.

This study aims to test the reliability of ultrasound to graduate synovitis in static and video images, evaluating separately grayscale and power Doppler (PD), and combined. Thirteen trained rheumatologist ultrasonographers participated in two separate rounds reading 42 images, 15 static and 27 videos, of the 7-joint count [wrist, 2nd and 3rd metacarpophalangeal (MCP), 2nd and 3rd interphalangeal (IPP), 2nd and 5th metatarsophalangeal (MTP) joints]. The images were from six patients with rheumatoid arthritis, performed by one ultrasonographer. Synovitis definition was according to OMERACT. Scoring system in grayscale, PD separately, and combined (GLOESS-Global OMERACT-EULAR Score System) were reviewed before exercise. Reliability intra- and inter-reading was calculated with Cohen's kappa weighted, according to Landis and Koch. Kappa values for inter-reading were good to excellent. The minor kappa was for GLOESS in static images, and the highest was for the same scoring in videos (k 0.59 and 0.85, respectively). Excellent values were obtained for static PD in 5th MTP joint and for PD video in 2nd MTP joint. Results for GLOESS in general were good to moderate. Poor agreement was observed in 3rd MCP and 3rd IPP in all kinds of images. Intra-reading agreement were greater in grayscale and GLOESS in static images than in videos (k 0.86 vs. 0.77 and k 0.86 vs. 0.71, respectively), but PD was greater in videos than in static images (k 1.0 vs. 0.79). The reliability of the synovitis scoring through static images and videos is in general good to moderate when using grayscale and PD separately or combined.

The column in this issue is supplied by Juan Jose Olivero, MD, who recently retired as a nephrologist at Houston Methodist Hospital and member of the hospital's Nephrology Training Program. Dr. Olivero obtained his medical degree from the University of San Carlos School of Medicine in Guatemala, Central America, and completed his residency and nephrology fellowship at Baylor College of Medicine in Houston, Texas.

La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la colaboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia y la valoración de los beneficios y riesgos de las opciones asistenciales alternativas. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1ª. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2ª. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisiones a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Background/Objectives Maculo-papular drug exanthema (MPE) is the most common type of cutaneous adverse drug reaction (CAR). Exanthematous macules and papules may also be the initial presentation of severe CAR (SCAR). We aimed to identify characteristics associated with the diagnosis of SCAR in CAR-hospitalised patients. Methods This cross-sectional study was performed in a tertiary hospital in Chile. All CAR patients who were initially evaluated for exanthematous macules and papules were assessed for clinical, laboratory and pathological variables and these were contrasted with MPE or SCAR diagnosis at discharge. Results We enrolled 86 patients, of whom 25 (29%) had an at-discharge diagnosis of SCAR. SCAR patients were younger and the latency (time from starting drug to development of first skin lesions) was longer than in MPE patients: 43.6 ± 18.7 years versus 54.0 ± 21.8 years (P = 0.039) and 14 days; range 1 to 35, versus 7 days; range 1 to 45 (P = 0.001). The presence of cutaneous pain (OR 7.4 95% CI 1.3–41), mucosal involvement (OR 9.5 CI 95% 2.6– 34.5) and anticonvulsant use (OR 6.11 95% CI 1.91–19.53) were significantly associated with SCAR at discharge. Antibiotics use was significantly associated with MPE diagnosis (OR 2.8 95% CI 1.1–7.6). These six variables together explain 45% of the risk of having SCAR (R2 = 0.449). None of the early laboratory or pathological variables was associated with SCAR. Conclusions In hospitalised patients assessed for exanthematous macules and papules, the evaluation of these clinical features may aid in the early identification of SCAR cases.

A 54 year-old woman with a 3-year history of rheumatoid arthritis (RA) consulted us because of weight loss, fever and skin eruption. On physical examination, erythematous plaques with a pseudo-vesicular appearance were seen on the back of both shoulders. Histological examination was consistent with rheumatoid neutrophilic dermatosis (RND). After 3 days of prednisone treatment, the skin eruption resolved. RND is a rare cutaneous manifestation of seropositive RA, characterized by asymptomatic, symmetrical erythematous plaques with a pseudo-vesicular appearance. Histology characteristically reveals a dense, neutrophilic infiltrate with leucocitoclasis but without other signs of vasculitis. Lesions may resolve spontaneously or with RA treatment. This case illustrates an uncommon skin manifestation of active rheumatoid arthritis.

Key Clinical Message Sodium‐glucose cotransporter 2 (SGLT2) inhibitors are able to provoke diabetic ketoacidosis (DKA) with absence or low levels of ketone bodies in urine and slightly elevated blood glucose levels, which could delay the diagnosis; however, the presence of high urine output, due to the excretion of glucose, can help to identify the true cause.

We have read the letter sent to Emergency Medicine Journal by Dr Orso entitled ‘who is afraid of Emergency Medicine Physicians’1 and we would like to give our modest opinion. The need for a primary specialty in emergency medicine is evident, as the author points out, perhaps we would add the recent recommendations collected at the WHO general assembly on this particular issue.2 There is no doubt in any modern healthcare system.3 Emergency medicine has grown exponentially as a specialty in the last 20 years, with practically all the countries of Europe4 provide specific training in this area and with >100 countries in the world that have recognised this field …

We report the case of a 42-year-old female with a 5-year history of rheumatoid arthritis treated with Rituximab and Azathioprine. Three months after the initiation of Azathioprine, the patient started with dry cough and noted the rapid development of multiple subcutaneous nodules on her right leg. CT scan of the chest demonstrates pulmonary nodulosis. Skin biopsy was compatible with rheumatoid nodule. A diagnosis of "accelerated cutaneous and pulmonary nodulosis" was considered. Azathioprine was discontinued and Rituximab was restarted. Two months later, most of the subcutaneous nodules had disappeared. This is the second case report of accelerated rheumatoid nodulosis in association with Azathioprine treatment.

Acute generalized exanthematous pustulosis is an uncommon skin eruption, characterized by fever and the rapid onset of disseminated, non-follicular, sterile pustules, over an erythematous skin background. It is usually classified as a severe cutaneous adverse drug reaction, whose most relevant triggers are antibiotics and anticonvulsants. However, viral and bacterial infections have also rarely been associated with this dermatosis. We report the case of a patient, who developed lesions of acute generalized exanthematous pustulosis as an extrapulmonary manifestation of Mycoplasma pneumoniae infection.

SummaryBackground An algorithm based on measurement of a serum tumour necrosis factor antagonists (anti-TNF) and antidrug antibodies (ADA) has been proposed previously to guide dose escalation or therapy switching in the early (i.e. the first months of) treatment of psoriasis by anti-TNF. In long-term treatment of responding patients with psoriasis, it is usual to empirically reduce standard doses of anti-TNF to reduce exposure while maintaining clinical response. The relationship between serum anti-TNF, ADA levels and clinical efficacy in long-term treated patients with psoriasis has not yet been determined, so the potential role of these parameters in guiding dose escalation in this scenario is unknown. Aims To evaluate the relationship between drug/ADA levels and clinical efficacy in a group of patients with psoriasis undergoing long-term treatment with adalimumab or etanercept. Methods This was a single-centre, prospective, cohort study of patients with psoriasis receiving adalimumab or etanercept for a minimum of 48 weeks. All patients were started on the standard dose, but some adalimumab users had a reduced frequency of administration. Clinical efficacy was measured using the Psoriasis Area and Severity Index. Serum concentrations were measured by ELISA. Clinical assessment and blood sample collection were carried out simultaneously within 24 h before the next drug administration. Results In total, 21 patients were enrolled (67 simultaneous clinical and serum determinations: 38 receiving adalimumab, 29 receiving etanercept). We did not find any association between serum anti-TNF levels and clinical response. None of the patients developed ADA. Conclusions ADA and anti-TNF levels are not related to clinical effectiveness in patients with psoriasis undergoing long-term treatment with adalimumab or etanercept.

Patients with acute heart failure (AHF) are frequently evaluated in the Emergency Departments (ED) and discharged from their observation units (OU) without hospital admission. We examined direct discharge rates from the ED OU, risk factors for returning to the ED, and returning and mortality rates.This prospective, longitudinal, noninterventional, population-based cohort study included all the patients with AHF consecutively attended in seven Spanish EDs who were directly discharged without hospital admission. Reattendance (dependent variable) was accepted if occurred during the next 30 days after discharge. Twenty-nine independent variables were recorded, covering epidemiological, clinical, and functional data.Two hundred and fifty-nine of 740 patients (35%) diagnosed with AHF were entirely managed in the ED OU and discharged home (mean stay: 18.8 h); 26.7% of them were reattended. Only three variables were independently associated with the chance of reattendance: functional impairment predicted adverse outcomes [odds ratio (OR): 4.0, 95% confidence interval (95% CI): 1.7-9.1], while past history of hypertension and a systolic blood pressure greater than 160 mmHg at ED arrival decreased the risk of ED return (OR: 0.4, 95% CI: 0.2-0.9; and OR: 0.3; 95% CI: 0.1-0.9; respectively). An overall mortality of 4.7% was recorded during the next 30 days.One-third of the patients consulting at the ED for an episode of AHF can be directly discharged from the OU of ED, with relatively low rates of reattendance (26.7%) and mortality (4.7%). Emergency physicians should be especially cautious discharging patients with functional dependence because they are at increased risk of returning.

The risk of developing CVD is high among CKD patients and, as a result, cardiovascular-related complications account for high morbidity and mortality. Multiple factors contribute to CVD in CKD patients, including hypertension, anemia, inflammation, hyperlipidemia, calcium-phosphorus-parathyroid hormone imbalance, and hyperuricemia. Each one of these complications needs to be identified and treated in an attempt to improve survival. Early markers of CVD such as microalbuminuria and uric acid levels need to be added to the routine annual evaluation, particularly among high-risk individuals such as diabetics, hypertensives, smokers, and the elderly. Likewise, the use of eGFR is highly recommended as a screening tool in those individuals.

UNLABELLED: To investigate if serial clinical and ultrasound evaluations differ between early rheumatoid arthritis patients who do or do not develop erosive disease and to identify predictors of erosions. METHODS: Patients with at least 7 consecutive 2-monthly clinical and 3 consecutive 6-monthly ultrasound evaluations were included. Ultrasound (gray scale and power Doppler) assessed synovitis, power Doppler-positive synovitis (PD+) and power Doppler-negative synovitis (PD-) in each of 14 joints of the dominant hand. After 1 and 2 years, erosive disease was defined according to digitized radiography. Areas under the curve (AUCs) for serial assessments were calculated. Multivariate logistic regression analysis was performed. RESULTS: Seventy-one and 38 patients completed 1- and 2-year consecutive assessments. After 2 years (21.5 +/- 6.2 months), 13 patients developed erosions. At baseline, nonerosive patients had shorter duration of symptoms to RA diagnosis, lower number of the American College of Rheumatology (ACR) classification criteria, lesser synovitis and PD+ synovitis than erosive patients. At follow-up, erosive and nonerosive patients showed similar AUC for clinical, serological, and treatment parameters; erosive patients had higher AUCs for synovitis and PD+ synovitis than nonerosive patients. In the multivariate model, the amount of PD+ synovitis (odds ratio, 1.3; 95% confidence interval, 1.11-1.51; P = 0.001) and more ACR classification criteria (odds ratio, 2.3; 95% confidence interval, 1.05-5.02; P = 0.04), both at baseline, predicted erosive disease. CONCLUSIONS: Serial Power Doppler ultrasonography-assessed synovitis was greater in patients who developed erosions than in those who did not. More power Doppler positive (hypervascular) synovitis and more ACR classification criteria, both at baseline, were the only predictors of erosions.

Olmesartan medoxomil is a new angiotensin II receptor blockers (ARB) which exhibits pleiotropic effects that are not fully understood. Our aims were: i) to determine the effect of Olmesartan medoxomil on blood pressure, lipid profile and renal functionality in moderately hypertensive patients with non-controlled blood pressure, ii) to determine if Olmesartan medoxomil may exert anti-inflammatory effects and modify the expression profile of platelet proteins. Thirteen moderate hypertensive patients with non-controlled systolic blood pressure (SBP) and renal function classified as Kidney Disease Outcome Quality Initiative stage 2-3 were included. Patients were treated with Olmesartan medoxomil (20 mg/day) for 6 months. SBP, proteinuria and the plasma levels of cholesterol and low density lipoprotein (LDL)-cholesterol were reduced after the treatment. Olmesartan medoxomil did not modify the circulating plasma levels of a number of proteins associated with inflammation, but reduced the expression level of different platelet proteins including tropomyosin-β chain isotypes 3 and 4, serotransferrin isotypes 1 to 5, the leukocyte elastase inhibitor and the chloride intracellular channel-protein isotype 1. The expression of the gelsolin precursor isotype 4 was increased in the platelets after the treatment. In summary, Olmesartan medoxomil reduced SBP, total and LDL-cholesterol plasma levels and urinary protein excretion and induced changes in the expression of platelet proteins which may be related to some action of the drug at the megakaryocyte level.

The importance of vitamin Din mineral metabolism has been known for a long time. Deficiency of this compound can cause rickets in children and both osteomalacia and osteoporosis in adults, leading to increased risk of fracture.1 A significant number of pediatric and adult patients have vitamin D deficiency due to decreased sun exposure, reduced dietary intake, malabsorption, drug intake (anticonvulsants), and renal and hepatic disease.2 Recently, better understanding of the physiology of vitamin D and the discovery of new receptor sites in many organs/tissues have underscored vitamin D's multiple beneficial effects, including improved cardiovascular health.3 Moreover, studies have reported that correction of vitamin D deficiency has resulted in decreased risk of cancer and diabetes,4-6 improvement in the immune system,7 and improved muscle function.8 We summarize herein some of these observational studies.

Chronic kidney disease is frequently associated with cardiovascular disease, particularly among elderly patients, and this combination complicates the management of severe congestive heart failure (CHF).1•2 Even with adequate renal function, end-stage cardiomyopathy of any etiology can at times result in severe hemodynamic alterations leading to volume overload that is unresponsive to conventional diuretic therapy.7 Moreover, aggressive diuretic programs inevitably lead to acid/base and electrolyte-metabolic imbalance that further compounds the clinical scenario. Simultaneous correction of intractable fluid overload and metabolic disarray in these patients can be achieved by using different ultrafiltration modalities, including continuous venovenous hemofiltration/dialysis, sustained low-efficiency dialysis, sustained continuous ultrafiltration and continuous cyclic peritoneal dialysis. While the duration of these therapies varies, patients who do not have a favorable response within 30 days usually have a poor prognosis.3

We describe an interesting case of a patient who recovered function of a previously failed kidney allograft after immunosuppressive medications were discontinued for 4 months, requiring maintenance hemodialysis. He had a split-thickness skin graft to his abdomen because of previous surgical complications. His postoperative course was complicated by sepsis and refractory hypotension. The patient was diagnosed with adrenal insufficiency and was started on hydrocortisone. At the same time, hemodialysis was stopped for possible catheter-related infection. The patient recovered function of the previously failed allograft and has not required hemodialysis.

Acute kidney injury is a complication of open-heart surgery that carries a poor prognosis. Studies have shown that postoperative renal function deterioration in cardiovascular surgery patients increases in-hospital mortality and adversely affects long-term survival. Identifying individuals at risk for developing AKI and aggressive early intervention is extremely important to optimize outcomes. This paper provides an overview of the etiology, prognostic markers, risk factors, and prevention of AKI and treatments that may favorably affect outcomes.

Van der Wulp et al have shown a low frequency of pain assessment conducted at triage using the Manchester triage system (MTS) in Dutch emergency departments (EDs). The main reason was the thought of triage nurses …

Introduction Vascular calcification in chronic kidney disease (CKD) is extremely common and contributes to significant morbidity and mortality among these patients. The pathogenesis is complex and involves multiple factors, including elevated calcium x phosphorus product as well as deficiencies in circulating or locally produced inhibitors of calcification, parathyroid hormone, hyperlipidemia and inflammation. Similarly, valvular heart calcifications as well as myocardial and pulmonary calcifications of fatal consequences can also occur, presumably related to the same pathogenetic factors (Figures 1, 2). Other forms of extraskeletal tissue calcification of nonfatal consequences but leading to incapacity can also develop in CKD patients (Figure 3). These complications may be prevented by awareness and early intervention directed towards correcting some of the aforementioned participating mechanisms.

RATIONALE: Severe community-acquired pneumonia (sCAP) is a leading cause of death worldwide. Adjunctive therapies for sCAP are needed to further improve outcome. A systemic inhibitor of coagulation, tifacogin (recombinant human tissue factor pathway inhibitor) seemed to provide mortality benefit in the sCAP subgroup of a previous sepsis trial. OBJECTIVES: Evaluate the impact of adjunctive tifacogin on mortality in patients with sCAP. METHODS: A multicenter, randomized, placebo-controlled, double-blind, three-arm study was conducted from July 2005 to June 2008 at 188 centers in North and South America, Europe, South Africa, Asia, Australia, and New Zealand. Adults with sCAP were randomized to receive a continuous intravenous infusion of tifacogin 0.025 mg/kg/h, tifacogin 0.075 mg/kg/h, or matching placebo over 96 hours. MEASUREMENTS AND MAIN RESULTS: Severity-adjusted 28-day all-cause mortality. Of 2,138 randomized patients, 946, 238, and 918 received tifacogin 0.025 mg/kg/h, tifacogin 0.075 mg/kg/h, and placebo, respectively. Tifacogin 0.075 mg/kg/h was discontinued after the first interim analysis according to prespecified futility criterion. The 28-day all-cause mortality rates were similar between the 0.025 mg/kg/h (18%) and placebo groups (17.9%) (P = 0.56). Greater reduction in prothrombin fragment 1+2 and thrombin antithrombin complexes levels relative to baseline throughout the first 96 hours was found with tifacogin 0.025 mg/kg/h than with placebo. The incidence of adverse events and serious adverse events were comparable between the tifacogin 0.025 mg/kg/h and placebo groups. CONCLUSIONS: Tifacogin showed no mortality benefit in patients with sCAP despite evidence of biologic activity.

A 39-year-old woman presented with a 6-week history of anulcerated and indurated lesion in the upper lip (Fig. 1). Thehistological study showed an ulcer with dense lymphoplas-macytic infiltrate and the immunohistochemistry (IHC) waspositive for spirochetes. Both, the rapid plasma reagin test(RPR) andthemicrohemaglutinationofthe

To determine the level of knowledge about possible disease outcomes and living wills among patients with heart failure (HF) treated in an emergency department and to evaluate their willingness to draw up a living will.This cross-sectional, multicenter, noninterventional, prospective study included a consecutive series of patients. Patients' demographic and clinical characteristics were recorded. Once their symptoms were under control, patients were interviewed about their knowledge of and opinions about HF. The dependent variables were a good objective understanding of the disease and a willingness to draw up a living will, and factors associated with these variables were investigated.The study included 309 patients: 79% considered themselves well-informed, 51.5% really were well-informed, 39.8% wanted more information, and 54.7% wanted to participate more in decision-making. In addition, 13.3% knew what living wills involved, 4.9% had received information about them from their doctor, and 28.8% agreed to draw one up. There was an independent association between being objectively well-informed and willingness to draw up a living will. Moreover, the former was associated with admission to intensive care, feeling well-informed, and having participated sufficiently in decision-making; the latter with age75 years, wanting more information, understanding what a living will involved, and the referral center.The knowledge possessed by HF patients about the natural history of their disease was suboptimal, as was their knowledge about living wills and their willingness to draw one up. Providing better information about these issues is an essential part of the doctor-patient relationship.

Acute coronary syndromes (ACS) are associated with platelet activation. The aim of the present study was to study the protein expression level associated with glycolysis, oxidative stress, cytoskeleton and cell survival in platelets obtained during an ACS. Platelets from 42 coronary ischemic patients, divided into patients admitted within 24 h after the onset of chest pain (ACS group; n=16) and patients with stable coronary ischemic disease (CAD, n=26), were analyzed using proteomics. The expression levels of proteins involved in cellular cytoskeleton (F-actin capping, β-tubulin, α-tubulin isotypes 1 and 2, vinculin, vimentin and two Ras-related protein Rab-7b isotypes), glycolysis pathway (glyceraldehyde-3-phosphate dehydrogenase, lactate dehydrogenase and two pyruvate kinase isotypes) and cellular-related antioxidant system (manganese superoxide dismutase) and even the expression and activity of glutathione-S-transferase were significantly reduced in platelets from ACS patients compared to CAD patients. Moreover, reduction in the expression of proteins associated with cell survival such as proteasome subunit β type 1 was also observed in ACS platelets compared with CAD platelets. Principal component and logistic regression analysis suggested the existence of factors (proteins) expressed in the platelets inversely associated with acute coronary ischemia. In summary, these results suggest the existence of circulating antioxidant, cytoskeleton and glycolytic-"bewildered" platelets during the acute phase of a coronary event.

BACKGROUND Diabetic nephropathy represents the most common etiology for stage 5 chronic kidney disease in the United States, resulting in the need for dialysis and transplantation. It is estimated that about one-third of U.S. patients who need renal replacement therapy are diabetics. Chronic kidney disease (CKD) of any etiology is associated with cardiovascular disease and is more predictable in patients with diabetic nephropathy.1 Such individuals have an increased incidence of coronary artery disease and hypertension but also can have diabetic cardiomyopathy due to microvascular complications of diabetes.2 Optimal blood pressure, blood sugar, and blood lipid control as well as cessation of smoking are of utmost importance in preventing progression of cardiovascular, renal, and end-organ damage. Similarly, early recognition and treatment of microalbuminuria (a manifestation of systemic endothelial dysfunction) is extremely important in improving cardiovascular and renal outcomes.3

To investigate factors associated with short-term mortality in elderly patients seen in emergency departments for an episode of acute heart failure.A prospective, non-interventional, multicenter, cohort study was carried out in patients aged 65 years and older who were treated in the emergency department of one of eight tertiary hospitals in Spain. Twenty-eight independent variables that could influence mortality at 30 days were assessed. They covered epidemiological and clinical factors and daily functioning. Data were obtained by reviewing medical records or by interviewing the patient or a relative. Multivariate logistic regression analysis was performed.The study included 623 patients, 42 of whom (6.7%) died within 30 days of visiting the emergency department. Four variables were significantly associated with higher mortality: functional dependence at baseline (i.e., Barthel index=60; odds ratio [OR]=2.9; 95% confidence interval [CI], 1.2-6.5), New York Heart Association class III-IV (OR=3; 95% CI, 1.3-7), systolic blood pressure100 mmHg (OR=4.8; 95% CI, 1.6-14.5) and blood sodium135 mEq/l (OR=4.2; 95% CI, 1.8-9.6).Several factors evaluated on initial assessment in the emergency department, including the level of functional dependence, were found to determine a poor short-term prognosis in elderly patients who present with an episode of acute heart failure.

INTRODUÇÃO: Aproximadamente 50% dos pacientes com síndrome de Noonan (SN) apresentam mutações em heterozigose no gene PTPN11. OBJETIVO: Avaliar a freqüência de mutações no PTPN11 em pacientes com SN e analisar a correlação fenótipo-genótipo. PACIENTES: 33 pacientes com SN. MÉTODO: Extração de DNA de leucócitos periféricos e seqüenciamento dos 15 exons do PTPN11. RESULTADOS: Nove diferentes mutações missense no PTPN11, incluindo a mutação P491H, ainda não descrita, foram encontradas em 16 dos 33 pacientes. As características clínicas mais freqüentes dos pacientes com SN foram: pavilhão auricular com rotação incompleta e espessamento da helix (85%), baixa estatura (79%), prega cervical (77%) e criptorquidismo nos meninos (60%). O Z da altura foi de -2,7 ± 1,2 e o do IMC foi de -1 ± 1,4. Os pacientes com mutação no PTPN11 apresentaram maior freqüência de estenose pulmonar do que os pacientes sem mutação (38% vs. 6%, p< 0,05). Pacientes com ou sem mutação no PTPN11 não diferiram em relação à média do Z da altura, Z do IMC, freqüência de alterações torácicas, características faciais, criptorquidia, retardo mental, dificuldade de aprendizado, pico de GH ao teste de estímulo e Z de IGF-1 ou IGFBP-3. CONCLUSÃO: Identificamos mutações no PTPN11 em 48,5% dos pacientes com SN, os quais apresentaram maior freqüência de estenose pulmonar.

Objective: To compare the safety and clinical outcomes of enteral and parenteral nutrition in patients with acute pancreatitis. Data sources: Medline, Embase, Cochrane controlled trials register, and citation review of relevant primary and review articles. Study selection: Randomized controlled studies that compared enteral nutrition with parenteral nutrition in patients with acute pancreatitis. From 117 articles screened, six were identified as randomized controlled trials and were included for data extraction. Data extraction: Six studies with 263 participants were analyzed. Descriptive and outcome data were extracted. Main outcome measures were infections, complications other than infections, operative interventions, length of hospital stay, and mortality. The metaanalysis was performed with the random effects model. Data synthesis: Enteral nutrition was associated with a significantly lower incidence of infections (relative risk 0.45; 95% confidence interval 0.26 to 0.78, P= 0.004), reduced surgical interventions to control pancreatitis (0.48, 0.22 to 1.0, P= 0.05), and a reduced length of hospital stay (mean reduction 2.9 days, 1.6 days to 4.3 days, P

In this randomized controlled multicenter trial, we compared endoscopic variceal banding ligation (VBL) with propranolol (PPL) for primary prophylaxis of variceal bleeding. One hundred fifty-two cirrhotic patients with 2 or more esophageal varices (diameter >5 mm) without prior bleeding were randomized to VBL (n=75) or PPL (n=77). The groups were well matched with respect to baseline characteristics (age 56±10 years, alcoholic etiology 51%, Child-Pugh score 7.2±1.8). The mean follow-up was 34±19 months. Data were analyzed on an intention-to-treat basis. Neither bleeding incidence nor mortality differed significantly between the 2 groups. Variceal bleeding occurred in 25% of the VBL group and in 29% of the PPL group. The actuarial risks of bleeding after 2 years were 20% (VBL) and 18% (PPL). Fatal bleeding was observed in 12% (VBL) and 10% (PPL). It was associated with the ligation procedure in 2 patients (2.6%). Overall mortality was 45% (VBL) and 43% (PPL) with the 2-year actuarial risks being 28% (VBL) and 22% (PPL). 25% of patients withdrew from PPL treatment, 16% due to side effects. In conclusion, VBL and PPL were similarly effective for primary prophylaxis of variceal bleeding. VBL should be offered to patients who are not candidates for long-term PPL treatment

El trastorno antisocial de la personalidad (TAP) consiste en una incapacidad para adaptarse a las normas sociales que habitualmente rigen numerosos aspectos de la conducta de las personas en la adolescencia y la edad adulta. Los pacientes con TAP característicamente tienen problemas de irritabilidad y sentimientos agresivos hacia los demás, los cuales se expresan en el contexto de la amenaza o la intimidación. El TAP es menos común en la clínica comparándolo con la población general en la que se reporta una prevalencia media del 1.1. Se ha registrado una agregación familiar para el TAP en la que el 40-50% de la varianza puede ser explicada por influencias genéticas. La mayoría de los estudios de genética molecular en el TAP se han realizado utilizando la hipótesis basada en los estudios de asociación con genes candidatos, enfocándose en los genes relacionados a vías de neurotransmisión, siendo uno de los más relevantes, hasta el momento, el gen para la monoamino oxidasa (MAOA). Aquellos genes que promueven que cierta conducta exista entre los individuos debieron haberse elegido a través del proceso de la selección natural. De manera similar a otros comportamientos que tienen orígenes evolutivos, los comportamientos agresivos también deben ser codificados en los genes, que a la postre serán transmitidos a la descendencia.

Two different egg based media, with and without the incorporation of sodium pyruvate, were used to isolate M. paratuberculosis from sheep, goat and cattle samples obtained at our laboratory for two years. Both media were adequate for bovine material, with a slightly improved isolation rate for Herrold's egg yolk medium incorporating sodium pyruvate; however, most of the small ruminant strains grew only on Lowenstein-Jensen medium without sodium pyruvate. Those results point out the need to use different media when working with small ruminant samples and provide further evidence for the existence of different varieties of M. paratuberculosis causing paratuberculosis in cattle and in small ruminants.

We used microimmunofluorescence to survey the prevalence of antibodies to Chlamydia pneumoniae in 403 serum samples from asymptomatic subjects aged 6 months to 89 y in Santiago, Chile. The results suggest that Chlamydia pneumoniae infection is endemic in Chile, with a seroprevalence of 60% which does not differ by gender.

Hyperuricemia (serum uric acid levels >8mg/dl) has been associated with hypertension for a long time.1 At some point it was felt that elevated uric acid levels were the result of decreased kidney function, but recent clinical and experimental data have shown a direct correlation between high uric acid levels and progression of vascular injury, leading to increased cardiovascular morbidity and mortality, hypertension, and accelerated loss of kidney function. 2 The mechanism of action appears to be mediated by the profound effects of uric acid in human vascular cells, which include endothelial dysfunction, vascular proliferation, and nitric oxide release from vascular cells.3•5 Moreover, as a consequence of afferent arteriolar injury by hyperuricemia, chronic tubulointerstitial changes leading to progressive loss of kidney function and worsening hypertension can occur.6 Strategies to treat asymptomatic hyperuricemia should be considered in high-risk individuals to prevent progression of cardiovascular disease and chronic kidney disease.

The case of a recipient of a kidney transplant who developed pancreatitis, complicated by pancreatic pseudocyst subsequently infected by Candidi from an infected parenteral alimentation line, is reported. The case was further complicated by rupture of the cyst leading to Candida peritonitis and development of multiple fistulous tracts between the stomach, ileum, and colon. Despite the 50% mortality of acute pancreatitis in patients with transplants and the 50% mortality reported in Candida peritonitis, the patient was successfully treated by cystogastrostomy, peritoneal lavage, and amphotericin B in association with administration of mannitol and reduction of immunosuppression to a minimal level. After eight weeks of total parenteral alimentation, the fistulous tracts spontaneously closed and the patient was discharged with normal renal function.