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Serna E.M.,Hospital Universitario Son Espases | Tapia F.C.,Servicio de Otorrinolaringologia
Facial Plastic Surgery | Year: 2014

Complex deviation of the nasal septum is one of the most challenging situations for the nasal surgeon. Standard septoplasty fails to obtain a good outcome when multiple planes of deviation are present. We describe three different techniques for extracorporeal nasal septum reconstruction suitable for any possible situation of the septal framework. Normal nasal patency and a good aesthetic result were achieved in every case. No important complications or sequelae appeared in any of the patients. Complete external reconstruction of the septal framework is the technique of choice in complex deviations of the nasal septum. © 2014 by Thieme Medical Publishers, Inc.


Burger M.,University of Würzburg | Grossman H.B.,University of Texas M. D. Anderson Cancer Center | Droller M.,Mount Sinai Medical Center | Schmidbauer J.,Medical University of Vienna | And 10 more authors.
European Urology | Year: 2013

Background Studies on hexaminolevulinate (HAL) cystoscopy report improved detection of bladder tumours. However, recent meta-analyses report conflicting effects on recurrence. Objective To assess available clinical data for blue light (BL) HAL cystoscopy on the detection of Ta/T1 and carcinoma in situ (CIS) tumours, and on tumour recurrence. Design, setting, and participants This meta-analysis reviewed raw data from prospective studies on 1345 patients with known or suspected non-muscle-invasive bladder cancer (NMIBC). Intervention A single application of HAL cystoscopy was used as an adjunct to white light (WL) cystoscopy. Outcome measurements and statistical analysis We studied the detection of NMIBC (intention to treat [ITT]: n = 831; six studies) and recurrence (per protocol: n = 634; three studies) up to 1 yr. DerSimonian and Laird's random-effects model was used to obtain pooled relative risks (RRs) and associated 95% confidence intervals (CIs) for outcomes for detection. Results and limitations BL cystoscopy detected significantly more Ta tumours (14.7%; p < 0.001; odds ratio [OR]: 4.898; 95% CI, 1.937-12.390) and CIS lesions (40.8%; p < 0.001; OR: 12.372; 95% CI, 6.343-24.133) than WL. There were 24.9% patients with at least one additional Ta/T1 tumour seen with BL (p < 0.001), significant also in patients with primary (20.7%; p < 0.001) and recurrent cancer (27.7%; p < 0.001), and in patients at high risk (27.0%; p < 0.001) and intermediate risk (35.7%; p = 0.004). In 26.7% of patients, CIS was detected only by BL (p < 0.001) and was also significant in patients with primary (28.0%; p < 0.001) and recurrent cancer (25.0%; p < 0.001). Recurrence rates up to 12 mo were significantly lower overall with BL, 34.5% versus 45.4% (p = 0.006; RR: 0.761 [0.627-0.924]), and lower in patients with T1 or CIS (p = 0.052; RR: 0.696 [0.482-1.003]), Ta (p = 0.040; RR: 0.804 [0.653-0.991]), and in high-risk (p = 0.050) and low-risk (p = 0.029) subgroups. Some subgroups had too few patients to allow statistically meaningful analysis. Heterogeneity was minimised by the statistical analysis method used. Conclusions This meta-analysis confirms that HAL BL cystoscopy significantly improves the detection of bladder tumours leading to a reduction of recurrence at 9-12 mo. The benefit is independent of the level of risk and is evident in patients with Ta, T1, CIS, primary, and recurrent cancer. © 2013 European Association of Urology.


News Article | December 7, 2016
Site: www.eurekalert.org

Suffering from sleep apnea can put patients at an increased risk for multiple emboli, according to a new study in the Dec. issue of CHEST GLENVIEW, IL, Dec. 7, 2016 - Pulmonary embolism (PE) is a major risk for patients suffering from venous thromboembolism (VTE) and can often be fatal. While advanced age, lack of exercise, and obesity all contribute to PE, it has been hypothesized that obstructive sleep apnea (OSA) may also promote the formation of blood clots. Because VTE is a chronic condition with reoccurring episodes of PE, researchers wanted to examine how OSA affected the rate of repeat PE occurrence. They found that after the first PE, OSA increases the risk for PE recurrence. Their results are published in the December issue of CHEST. Patients who have had one PE have a 30% chance of having another episode and recurring PE carries a 9% mortality rate. While anticoagulants are very effective at decreasing the possibility of PE, their use comes with an increased risk of bleeding. Identifying and understanding contributing risk factors that can be managed may help decrease the need for blood thinners. One such factor is OSA, which shares many of the same risk factors as PE, including advanced age, physical inactivity, and obesity. "There is growing evidence from cross-sectional and longitudinal studies that obstructive sleep apnea is a risk factor for pulmonary embolism," explained lead investigator Alberto Alonso-Fernández, MD, PhD, Hospital Universitario Son Espases, Palma de Mallorca, Spain. "This association represents a major public health burden, given the high prevalence of both disorders and the mortality rates of PE. However, to our knowledge, no longitudinal studies to date have explored the role of OSA as a risk factor for recurrent thromboembolic events." The study followed 120 patients for five to eight years after their first occurrence of PE. During the study, their sleep was monitored for signs of OSA. Investigators found that 19 of the patients had recurrent PE during the follow-up period and of those 19 patients, 16 of them suffered from OSA. "The main finding in this study is that after a first episode of PE, patients with OSA had a higher risk of recurrent PE than those without OSA," said Dr. Alonso-Fernández. "Moreover, AHI and nocturnal hypoxemia, assessed by the mean nocturnal oxygen saturation and percentage of total time the patient spent with their oxygen saturation below 90%, are independent risk factors for PE recurrence and for resuming anticoagulation because of a new thromboembolic event." Addressing why OSA may make people more susceptible to subsequent PE events, Dr. Alonso-Fernández stated, "PE is the result of Virchow's classic risk triad, namely vascular endothelial impairment, stasis of blood flow, and/or increased coagulability. OSA could hypothetically affect all three mechanistic pathways. Intermittent hypoxia increases oxidative stress, and inflammatory response that impairs endothelial function. OSA-related hemodynamic alterations and sedentarism may slow intravenous flow, and lastly, increased coagulability, platelet activity, and decreased fibrinolytic capacity in OSA may be improved after CPAP." While much attention has been paid to what causes the first PE, only a few known influencers have been identified as playing a role in recurrent PE, including cancer, continued estrogen use, vena cava filters, high post-anticoagulation D-dimer, male gender, and obesity. The current study found OSA is an independent risk factor for recurrent PE, even after adjusting for several factors including BMI. OSA is a common problem among obese people and investigators assert that the risk of recurrent PE that is attributed to obesity might be partially related to OSA. "Obesity is associated with sedentarism and venous stasis, and it has also been related to impaired fibrinolysis and high concentrations of clotting factors that might lead to a prothombotic state that can further increase because obesity is associated with high estrogen levels and chronic low-grate inflammation," proposed Dr. Alonso-Fernández. "It is tempting to speculate that OSA and obesity may additively or synergistically lead to up-regulation of procoagulant activity that may intensify the risk of PE recurrence." Knowing that OSA is an independent risk factor for recurrent PE is important information that can help physicians better understand treatment options. CPAP use is a proven intervention for OSA and patients with OSA may need to stay on anticoagulation therapy longer to reduce their risk for another PE. "Given the high prevalence of OSA in patients with PE, the procoagulability state induced by the intermittent hypoxia, and the risk for PE recurrence, the potential of CPAP and/or extend oral anticoagulation to reduce PE recurrence and mortality in patients with PE and OSA clearly warrants further study," concluded Dr. Alonso-Fernández.


Objective: Some studies suggest that open access articles are more often cited than non-open access articles. However, the relationship between open access and citations count in a discipline such as intensive care medicine has not been studied to date. The present article analyzes the effect of open access publishing of scientific articles in intensive care medicine journals in terms of citations count. Methods: We evaluated a total of 161 articles (76% being non-open access articles) published in Intensive Care Medicine in the year 2008. Citation data were compared between the two groups up until April 30, 2011. Potentially confounding variables for citation counts were adjusted for in a linear multiple regression model. Results: The median number (interquartile range) of citations of non-open access articles was 8 (4-12) versus 9 (6-18) in the case of open access articles (p=0.084). In the highest citation range (>8), the citation count was 13 (10-16) and 18 (13-21) (p=0.008), respectively. The mean follow-up was 37.5. ±. 3 months in both groups. In the 30-35 months after publication, the average number (mean. ±. standard deviation) of citations per article per month of non-open access articles was 0.28. ±. 0.6 versus 0.38. ±. 0.7 in the case of open access articles (p=0.043). Independent factors for citation advantage were the Hirsch index of the first signing author (β=0.207; p=0.015) and open access status (β=3.618; p=0.006). Conclusions: Open access publishing and the Hirsch index of the first signing author increase the impact of scientific articles. The open access advantage is greater for the more highly cited articles, and appears in the 30-35 months after publication. © 2012 Elsevier España, S.L. and SEMICYUC.


Oliver A.,Hospital Universitario Son Espases | Mulet X.,Hospital Universitario Son Espases | Lopez-Causape C.,Hospital Universitario Son Espases | Juan C.,Hospital Universitario Son Espases
Drug Resistance Updates | Year: 2015

The increasing prevalence of chronic and hospital-acquired infections produced by multidrug-resistant (MDR) or extensively drug-resistant (XDR) Pseudomonas aeruginosa strains is associated with significant morbidity and mortality. This growing threat results from the extraordinary capacity of this pathogen for developing resistance through chromosomal mutations and from the increasing prevalence of transferable resistance determinants, particularly those encoding carbapenemases or extended-spectrum β-lactamases (ESBLs). P. aeruginosa has a nonclonal epidemic population structure, composed of a limited number of widespread clones which are selected from a background of a large quantity of rare and unrelated genotypes that are recombining at high frequency. Indeed, recent concerning reports have provided evidence of the existence of MDR/XDR global clones, denominated high-risk clones, disseminated in hospitals worldwide; ST235, ST111, and ST175 are likely those more widespread. Noteworthy, the vast majority of infections by MDR, and specially XDR, strains are produced by these and few other clones worldwide. Moreover, the association of high-risk clones, particularly ST235, with transferable resistance is overwhelming; nearly 100 different horizontally-acquired resistance elements and up to 39 different acquired β-lactamases have been reported so far among ST235 isolates. Likewise, MDR internationally-disseminated epidemic strains, such as the Liverpool Epidemic Strain (LES, ST146), have been noted as well among cystic fibrosis patients. Here we review the population structure, epidemiology, antimicrobial resistance mechanisms and virulence of the P. aeruginosa high-risk clones. The phenotypic and genetic factors potentially driving the success of high-risk clones, the aspects related to their detection in the clinical microbiology laboratory and the implications for infection control and public health are also discussed. © 2015 Elsevier Ltd.


Macia M.D.,Hospital Universitario Son Espases | Rojo-Molinero E.,Hospital Universitario Son Espases | Oliver A.,Hospital Universitario Son Espases
Clinical Microbiology and Infection | Year: 2014

Biofilms are organized bacterial communities embedded in an extracellular polymeric matrix attached to living or abiotic surfaces. The development of biofilms is currently recognized as one of the most relevant drivers of persistent infections. Among them, chronic respiratory infection by Pseudomonas aeruginosa in cystic fibrosis patients is probably the most intensively studied. The lack of correlation between conventional susceptibility test results and therapeutic success in chronic infections is probably a consequence of the use of planktonically growing instead of biofilm-growing bacteria. Therefore, several in vitro models to evaluate antimicrobial activity on biofilms have been implemented over the last decade. Microtitre plate-based assays, the Calgary device, substratum suspending reactors and the flow cell system are some of the most used in vitro biofilm models for susceptibility studies. Likewise, new pharmacodynamic parameters, including minimal biofilm inhibitory concentration, minimal biofilm-eradication concentration, biofilm bactericidal concentration, and biofilm-prevention concentration, have been defined in recent years to quantify antibiotic activity in biofilms. Using these parameters, several studies have shown very significant quantitative and qualitative differences for the effects of most antibiotics when acting on planktonic or biofilm bacteria. Nevertheless, standardization of the procedures, parameters and breakpoints, by official agencies, is needed before they are implemented in clinical microbiology laboratories for routine susceptibility testing. Research efforts should also be directed to obtaining a deeper understanding of biofilm resistance mechanisms, the evaluation of optimal pharmacokinetic/pharmacodynamic models for biofilm growth, and correlation with clinical outcome. © 2014 European Society of Clinical Microbiology and Infectious Diseases.


In the last few years, glutamine has changed its status from a “non-essential” amino acid to “almost essential or indispensable” in the critical patient. This has occurred thanks to a series of studies and meta-analysis highlighting the beneficial effects on nosocomial infection, stay in ICU and hospital stay and mortality. After two multicentre studies (REDOXS and MetaPlus) which reviewed the effects of glutamine on critically ill patients, comments changed to: “we do strongly recommend that glutamine is not used in critically ill patients in shock or multiple organ failure” and: “there is an important questioning about the safety of this approach (combination of high-dose enteral and parenteral glutamine) which should not be ignored” and, therefore: “the committee decides to decrease the degree of recommendation for endovenous glutamine”; it currently states that glutamine “should be considered”. According to another multicentre study with severe trauma patients our group (a group which in theory was much benefitted from glutamine actions), and 143 patients, did not experience any observable benefit at the usual parenteral doses. We do agree with previous studies on the prognostic value of low levels of glutamine at admittance, which was confirmed if those levels were not back to normal after its administration, although there are no readily available analytic trials for this. This divergence about the usefulness of glutamine grows up as more and more multicentre studies in critical patients show there should be a change of attitude, and probably the clinical guidelines that welcomed its use should now be amended. © 2015, Grupo Aula Medica S.A. All rights reserved.


HYPOTHESIS: the endovenous administration of glutamine, independently of the type of nurtrition received, can reduce the ICU length of stay, the incidence of infections and the mortality in the traumatic patients admitted to the ICU. OBJECTIVES: The main objective is to assess the efficacy of glutamine suplementation, given intravenously, to reduce the incidence of infectious complications, mortality and ICU length of stay in the traumatic patients admitted to the ICU. Other objectives are: 1) to assess the efficacy of glutamine in different groups of patients according to the severity and the plasma levels of glutamine. 2) Record all the adverse events due to the intravenous administration of glutamine. METHODS: prospective, randomized, doble-blind and multicenter study with two parallel groups: placebo and treatment group. The patients who fulfill the inclusion criteria will receive either glutamine or placebo, independently of the type on nutrition. Glutamine will be administered as a pharmaconutrient at 0.5 g/kg/day during 5 days as a continous perfusion.


Lopez-Causape C.,Hospital Universitario Son Espases | Rojo-Molinero E.,Hospital Universitario Son Espases | MacIa M.D.,Hospital Universitario Son Espases | Oliver A.,Hospital Universitario Son Espases
Expert Review of Respiratory Medicine | Year: 2015

Chronic respiratory infection is the main cause of morbidity and mortality in cystic fibrosis (CF) patients. One of the hallmarks of these infections, led by the opportunistic pathogen Pseudomonas aeruginosa, is their long-term (lifelong) persistence despite intensive antimicrobial therapy. Antimicrobial resistance in CF is indeed a multifactorial problem, which includes physiological changes, represented by the transition from the planktonic to the biofilm mode of growth and the acquisition of multiple (antibiotic resistance) adaptive mutations catalyzed by frequent mutator phenotypes. Emerging multidrug-resistant CF pathogens, transmissible epidemic strains and transferable genetic elements (such as those encoding class B carbapenemases) also significantly contribute to this concerning scenario. Strategies directed to combat biofilm growth, prevent the emergence of mutational resistance, promote the development of novel antimicrobial agents against multidrug-resistant strains and implement strict infection control measures are thus needed. © 2015 Informa UK, Ltd.


Macia M.D.,Hospital Universitario Son Espases | Perez J.L.,Hospital Universitario Son Espases | Molin S.,Technical University of Denmark | Oliver A.,Hospital Universitario Son Espases
Antimicrobial Agents and Chemotherapy | Year: 2011

Biofilm growth, antibiotic resistance, and mutator phenotypes are key components of chronic respiratory infections by Pseudomonas aeruginosa in cystic fibrosis patients. We examined the dynamics of mutator and antibiotic-resistant populations in P. aeruginosa flow-cell biofilms, using fluorescently tagged PAO1 and PAOMS (mutator [mutS] derivative) strains. Two-day-old biofilms were treated with ciprofloxacin (CIP) for 4 days (t4) at 2 μg/ml, which correlated with the mutant prevention concentration (MPC) and provided an AUC/MIC ratio of 384 that should predict therapeutic success. Biofilms were monitored by confocal laser scanning microscopy (CLSM), and the numbers of viable cells and resistant mutants (4- and 16-fold MICs) were determined. Despite optimized pharmacokinetic/pharmacodynamic (PK/PD) parameters, CIP treatment did not suppress resistance development in P. aeruginosa biofilms. One-step resistant mutants (MexCD-OprJ or MexEF-OprN overexpression) were selected for both strains, while two-step resistant mutants (additional GyrA or GyrB mutation) were readily selected only from the mutator strain. CLSM analysis of competition experiments revealed that PAOMS, even when inoculated at a 0.01 proportion, took over the whole biofilm after only 2 days of CIP treatment outnumbering PAO1 by 3 log at t4. Our results show that mutational mechanisms play a major role in biofilm antibiotic resistance and that theoretically optimized PK/PD parameters fail to suppress resistance development, suggesting that the increased antibiotic tolerance driven by the special biofilm physiology and architecture may raise the effective MPC, favoring gradual mutational resistance development, especially in mutator strains. Moreover, the amplification of mutator populations under antibiotic treatment by coselection with resistance mutations is for the first time demonstrated in situ for P. aeruginosa biofilms. Copyright © 2011, American Society for Microbiology. All Rights Reserved.

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