Consumption of H1 antihistamines during the first trimester of pregnancy in Spain, and estimation of the overall risk for congenital defects in the newborn

Teratología ClínicaH1 antihistamines (H1A) are drugs that have been used for many years for treatment of allergic diseases, as for the control of nausea and morning sickness in pregnant women. Here it is analyzed the evolution of their global use during gestation and by the different groups of H1A, along the last 31 years in the ECEMC data. In addition, their potential risk on the embryo development regarding congenital defects is analysed. The data belongs to the Spanish Collaborative Study of Congenital Malformations (ECEMC), for the period 1977-2008. The ECEMC is a hospital-based, case-control study and surveillance system, aimed at performing clinical and epidemiological studies on congenital defects, the methodology of which includes the collection of about 310 items on each newborn infant registered, whether case or control, on their pregnancy and family history, and many types of prenatal exposures. During the study period the ECEMC surveyed and examined a total of 2,607,822 consecutive newborns, and a total of 39,561 out of them had congenital defects identifiable during the first three days of life. After having excluded those cases diagnosed centrally at ECEMC as presenting with syndromes, the studied samples were 33,056 cases and 32,258 controls. The total data of the different tables may not be the same because they include only the cases and controls with each data specified. The analysis of the evolution of H1A consumption by pregnant women in Spain along the years showed a statistically significant increasing trend, from 12.66% and 11.51% for cases and controls, respectively, in 1977 to 13.90% and 15.86%, respectively, in 2008. This increase has occurred at the expense of doxilamine (combined with vitamin B6) used as an antiemetic, and of three subgroups of H1A used in the control of allergic processes (Alquilamines, Piperazines, and Piperidines). None of the subgroups of H1A has shown an increased risk for birth defects (after its use during the first trimester of pregnancy), except the group of Piperidines (OR=6.83; p=0.003). However, due to the small samples of exposed infants, it is not possible to perform any type of multivariate analysis to control for possible confounders. Hence, we cannot rule out that the observed risk could be due to uncontrolled factors. If a pregnant woman had allergic problems and needs to be treated, she has to be treated because the risks for her and for the embryo overwhelm the ones derived from the treatment if any. For such treatment, if the allergic process only can be controlled with a piperidine, this product could be used, although not as the first option. On the other hand, the combination of doxilamine and pyridoxine (vitamin B 6) is a safe option for the control of nausea and vomiting during pregnancy.N

Chondroid Tumors: Review of Salient Imaging Features and Update on the WHO Classification

Chondrogenic tumors are typically well recognized on radiographs, but differentiation between benign and malignant cartilaginous lesions can be difficult both for the radiologist and for the pathologist. Diagnosis is based on a combination of clinical, radiological and histological findings. While treatment of benign lesions does not require surgery, the only curative treatment for chondrosarcoma is resection. This article (1) emphasizes the update of the WHO classification and its diagnostic and clinical effects; (2) describes the imaging features of the various types of cartilaginous tumors, highlighting findings that can help differentiate benign from malignant lesions; (3) presents differential diagnoses; and (4) provides pathologic correlation. We attempt to offer valuable clues in the approach to this vast entit

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project):A clinical trial by clusters

This study was funded by the Fondo de Investigaciones Sanitarias FIS Grant Number PI11/0477 ISCIII.-REDISSEC Proyecto RD12/0001/0012 AND FEDER Funding.Background: Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs. Methods/design: We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment. The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6months post-intervention, using 95% confidence intervals. A linear multilevel regression will be used to adjust the model. Discussion: The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance. Trial registration: ClinicalTrials.gov: NCT02210442.Publisher PDFPeer reviewe

Marco activo de recursos de innovación docente: Madrid

Una guía de espacios e instituciones para actividades educativas complementarias en enseñanza secundaria y Formación Profesional

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p &lt; 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics

Typification and nomenclatural updating in Dioscorea (Dioscoreaceae) descritas o relacionadas con las colecciones de Martín de Sessé y José Mariano Mociño

15 páginas, 4 figuras.[ES] Se han estudiado las colecciones de la familia Dioscoreaceae depositadas en los herbarios del Real Jardín Botánico de Madrid (MA), Conservatorio y Jardín Botánico de Ginebra (G) y del Instituto Botánico de Barcelona (BC), realizadas por Martín de Sessé y Lacasta (1751-1808) y José Mariano Mociño Losada (1757- 1820) durante la Real Expedición Botánica a Nueva España (1787-1803) , así como algunos tipos relacionados con ellas exis - tentes en otros herbarios (BR, K, P y MEXU). Sin olvidar la importancia histórica que tienen estos especímenes, se han lectotipificado cinco especies y, en consecuencia, aclarado algunos problemas nomenclaturales pendientes desde hace años en varias especies mexicanas del género Dioscorea (Dioscoreaceae), así como resuelto dudas sobre su localización[EN] The collections of the family Dioscoreaceae filed in the Herbaria of the Royal Botanic Garden of Madrid (MA), Conservatory and Botanic Garden of Geneva (G) and from the Botanic Institute of Barcelona (BC), made by Martín de Sessé y Lacasta (1751-1808) and José Mariano Mociño y Losada (1757-1820) during the Royal Botanic Expedition to Nueva España (1787-1803) were studied; as well as, some type specimens related with them filed in other herbaria (BR, K, P and MEXU). Results show that independently from the historical importance of the collections themselves, five species have been lectotypified and in consequence, have allowed initially, to apply to them the current accepted names, as well as, to solve important doubts due to the ignorance where herbaria they were filed in, and more important to solve nomenclatural issues pending for many years in several Mexican species of the genus Dioscorea (Dioscoreaceae).A la Facultad de Estudios Superiores Iztacala UNAM y a la Comisión Nacional para el Estudio y uso de la Biodiversidad (CONABIO-proyecto DS001).Peer reviewe

Tipificación y actualización nomenclatural en Disocorea (Dioscoreaceae) descritas o relacionadas con las colecciones de Martín de Sessé y José Mariano Mociño

Téllez Valdés, O., Blanco Fernández de Caleya, P. y Rico Arce, L. 2010. Tipificación y actualizaciones nomenclaturales en Dioscorea (Dioscoreaceae) descritas o relacionadas con las colecciones de Martín de Sessé y José Mariano Miciño. Anales Jard. Bot. Madrid 67 (1): 49-63. Se han estudiado las colecciones de la familia Dioscoreaceae de positadas en los hervarios del Real Jardín Botánico de Madrid (MA). Conservatorio y Jardín Botánico de Ginebra (G) y del Instituto Botánico de Barcelona (BC), realizadas por Martín de Sessé y Lacasta (1751-1808) y Jose Mariano Mociño Losada (1757-1820) durante la Real Expedición Botánica a Nueva España (1787-1803), así como algunos tipos relacionados con ellas existentes en otros herbarios (BR, K, P y MEXU). Sin olvidar la importancia histórica que tienen estos especímenes, se han lectotipificado cinco especies mexicanas del género Dioscorea (Dioscoreaceae), así como resuelto dudas sobre su localización

Consumo de Antihistamínicos-H1 durante el primer trimestre del embarazo en España, y estimación del riesgo global para defectos congénitos en el recién nacido / Consumption of H1 antihistamines during the first trimester of pregnancy in Spain, and estimation of the overall risk for congenital defects in the newborn

H1 antihistamines (H1A) are drugs that have been used for many years for treatment of allergic diseases, as for the control of nausea and morning sickness in pregnant women. Here it is analyzed the evolution of their global use during gestation and by the different groups of H1A, along the last 31 years in the ECEMC data. In addition, their potential risk on the embryo development regarding congenital defects is analysed. The data belongs to the Spanish Collaborative Study of Congenital Malformations (ECEMC), for the period 1977-2008. The ECEMC is a hospital-based, case-control study and surveillance system, aimed at performing clinical and epidemiological studies on congenital defects, the methodology of which includes the collection of about 310 items on each newborn infant registered, whether case or control, on their pregnancy and family history, and many types of prenatal exposures. During the study period the ECEMC surveyed and examined a total of 2,607,822 consecutive newborns, and a total of 39,561 out of them had congenital defects identifiable during the first three days of life. After having excluded those cases diagnosed centrally at ECEMC as presenting with syndromes, the studied samples were 33,056 cases and 32,258 controls. The total data of the different tables may not be the same because they include only the cases and controls with each data specified. The analysis of the evolution of H1A consumption by pregnant women in Spain along the years showed a statistically significant increasing trend, from 12.66% and 11.51% for cases and controls, respectively, in 1977 to 13.90% and 15.86%, respectively, in 2008. This increase has occurred at the expense of doxilamine (combined with vitamin B6) used as an antiemetic, and of three subgroups of H1A used in the control of allergic processes (Alquilamines, Piperazines, and Piperidines). None of the subgroups of H1A has shown an increased risk for birth defects (after its use during the first trimester of pregnancy), except the group of Piperidines (OR=6.83; p=0.003). However, due to the small samples of exposed infants, it is not possible to perform any type of multivariate analysis to control for possible confounders. Hence, we cannot rule out that the observed risk could be due to uncontrolled factors. If a pregnant woman had allergic problems and needs to be treated, she has to be treated because the risks for her and for the embryo overwhelm the ones derived from the treatment if any. For such treatment, if the allergic process only can be controlled with a piperidine, this product could be used, although not as the first option. On the other hand, the combination of doxilamine and pyridoxine (vitamin B6) is a safe option for the control of nausea and vomiting during pregnancy