Exacerbaciones de asma en el servicio de urgencias del hospital universitario La Paz

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina. Fecha de lectura: 07-02-2020El objetivo principal de esta tesis es estudiar las características clínicas y demográficas de los pacientes asmáticos de 14 años en adelante, atendidos en el Servicio de Urgencias del Hospital Universitario La Paz, por una exacerbación asmática de cualquier nivel de gravedad, a lo largo del periodo natural del año 2014. Como objetivo secundario se postula, entre otros, la determinación de la prevalencia de bronquiectasias en pacientes con asma moderada-grave, que sufren frecuentes exacerbaciones, con el fin de caracterizarlos mejor tanto epidemiológica como clínicamente. En primer lugar, se llevó a cabo un estudio epidemiológico, abierto, observacional retrospectivo (no intervencionista) en el que se incluyeron todos los pacientes mayores de 14 años, que desde el 1 de enero de 2014 al 31 de diciembre de 2014, fueron atendidos en el Servicio de Urgencias del Hospital Universitario La Paz, con clínica sugerente de exacerbación asmática. En el primer trabajo la población de estudio comprendió 831 pacientes (888 eventos de exacerbación). Los factores de riesgo de hospitalización fueron: edad avanzada, la ausencia de un diagnóstico previo de asma, el asma mal controlada, la infección respiratoria y la exacerbación grave con mayor necesidad de tratamiento. La tasa de hospitalización fue significativamente menor en pacientes con ≥400 eosinófilos/mm3. En el segundo trabajo se analizaron 52 pacientes (de los 831 previos), que sufrieron una recaída después de haber sido atendidos en el Servicio de Urgencias, haciendo un total de 66 episodios. La probabilidad promedio de recaída fue de 6 ± 0,8%. Los factores relacionados con una mayor probabilidad de recaída fueron: haber tenido visitas múltiples al Servicio de Urgencias en un año, asma no controlada, sibilancias en la auscultación pulmonar, eosinofilia periférica ≥400/mm3 y haber sido dado de alta en la primera visita al Servicio de Urgencias. En segundo lugar, se realizó un estudio epidemiológico también abierto, observacional retrospectivo sobre el que versa el tercer capítulo de esta tesis. En él se analizaron las historias clínicas de 264 pacientes derivados a la Consulta de Asma Grave del Hospital La Paz, entre los años 2010 y 2013, con sospecha de asma grave o de control difícil. Se identificaron bronquiectasias en 86 pacientes. Estos pacientes tenían hipersensibilidad a antiinflamatorios no esteroideos y enfermedad por reflujo gastroesofágico con mayor frecuencia que los sujetos sin bronquiectasias, pero menor frecuencia de dermatitis atópica. Los sujetos con bronquiectasias tuvieron una tasa mayor de hospitalización por exacerbaciones de asma y niveles más altos de eosinófilos en sangre que los sujetos sin bronquiectasias

Geomorphology of the Avilés Canyon System, Cantabrian Sea (BayofBiscay)

The Avilés Canyon System (ACS) is a complex, structurally-controlled canyon and valley system constituted by three main canyons of different morphostructural character. They are, from east to west: La Gaviera Canyon, El Corbiro Canyon and Avilés Canyon. In addition to this ACS, a new canyon has been surveyed: Navia Canyon. We present for the first time a high resolution multibeam map showing with great detail the morphological and structural complexity of this segment of the Cantabrian margin. ACS presents a tectonic imprint marked by NW-SE, NNE-SSW and E-W structures. The morphology of their reaches as well as their single mouth, in addition to some rock dredges in their major valleys, demonstrates active down-slope flushing. The continental shelf shows a flat, uniform slope with local and well defined rock outcrops south of Aviles Canyon head. Sedimentary zones are limited, showing thin unconsolidated sedimentary cover. Strong continental margin water dynamics avoid thicker sediment deposition, being littoral sedimentary dynamics responsible for transport to the canyons heads and conduit to the Biscay Abyssal plain. Biscay Abyssal Plain shows evidence of a strong westward current affecting the surveyed strip of this more than 10 km wide plain. Presence of two parallel deep sea channels, erosive scarps, and erosion of gully divides on the lower slope, may indicate that this is part of the distal fan at the termination of the large turbiditic system fed by Cap Ferret, Capbreton and other large canyons (Santander, Torrelavega, Lastres and Llanes) to the west of ACS.Instituto Español de OceanografíaVersión del edito

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Overexpression of the pumpkin (<i>Cucurbita maxima</i>) 16 kDa phloem protein CmPP16 increases tolerance to water deficit

<div><p>The phloem plays an important role in the delivery of nutrients and signals between photosynthetic to heterotrophic tissues. Proteins and RNAs in the phloem translocation stream may have an important role in maintaining the integrity of the sieve tube system, as well as in long-distance signaling. CmPP16 is a pumpkin phloem protein, which has been shown to bind RNA in a non-sequence specific manner, and move it cell-to-cell and conceivably, long-distance. The protein and RNA are found in both companion cell (CC) and sieve elements (SE). However, a more precise function for this protein is not known. In this work we report the overexpression of CmPP16 fused to GFP via transformation of pumpkin (<i>Cucurbita maxima</i> cv. Big Max) plants in the cotyledonary stage by direct inoculation of <i>Agrobacterium tumefaciens</i> and <i>Agrobacterium rhizogenes</i>. Plants overexpressing <i>CmPP16</i> did not show an obvious phenotype. However, these plants displayed higher photosynthetic capacity during drought than wild-type (WT) pumpkin or transformed with another construct. These results suggest that CmPP16 may be involved in the response to stress through long-distance signaling.</p></div