Alejandro Jiménez Sosa

The GFR and GFR decline cannot be accurately estimated in type 2 diabetics

There are no adequate studies that have formally tested the performance of different estimating formulas in patients with type 2 diabetes both with and without overt nephropathy. Here we evaluated the agreement between baseline GFRs, GFR changes at month 6, and long-term GFR decline measured by iohexol plasma clearance or estimated by 15 creatinine-based formulas in 600 type 2 diabetics followed for a median of 4.0 years. Ninety patients were hyperfiltering. The number of those identified by estimation formulas ranged from 0 to 24:58 were not identified by any formula. Baseline GFR was significantly underestimated and a 6-month GFR reduction was missed in hyperfiltering patients. Long-term GFR decline was also underestimated by all formulas in the whole study group and in hyper-, normo-, and hypofiltering patients considered separately. Five formulas generated positive slopes in hyperfiltering patients. Baseline concordance correlation coefficients and total deviation indexes ranged from 32.1% to 92.6% and from 0.21 to 0.53, respectively. Concordance correlation coefficients between estimated and measured long-term GFR decline ranged from -0.21 to 0.35. The agreement between estimated and measured values was also poor within each subgroup considered separately. Thus, our study questions the use of any estimation formula to identify hyperfiltering patients and monitor renal disease progression and response to treatment in type 2 diabetics without overt nephropathy.

Undisclosed cocaine use and chest pain in emergency departments of Spain

AimsIllicit cocaine consumption in Spain is one of the highest in Europe. Our objective was to study the incidence of undisclosed cocaine consumption in patients attending in two Spanish Emergency Departments for chest pain.MethodsWe analysed urine samples from consenting consecutive patients attending ED for chest pain to determine the presence of cocaine, and other drugs, by semiquantative tests with fluorescence polarization immunoassay (FPIA).ResultsOf 140 cases, 15.7 presented positive test for drugs, and cocaine was present in 6.4%. All cocaine-positive patients were younger (p < 0.001); none was admitted to Hospital (p = 0.08). No significant differences in ED stay or need for hospitalization were found between cocaine-positive and negative patients.ConclusionThis finding in chest pain patients who consented to urine analysis suggests that the true incidence of cocaine use leading to such ED visits may be higher.

Incidence and impact of undisclosed cocaine use in emergency department chest pain and trauma patients.

BackgroundOne of the highest rates of illicit cocaine consumption in Europe is in Spain. Our objective was to study the incidence and impact of undisclosed cocaine consumption in patients attending the emergency department (ED) for trauma or chest pain.MethodsWe analysed urine samples from consecutive patients attending the ED for trauma or chest pain to determine the presence of cocaine, cannabis, amphetamine/metaamphetamine and opioids by semiquantative tests with fluorescence polarization immunoassay (FPIA).ResultsThirty percent of eligible patients participated. Of 75 cases, 61.3% had trauma and 38.7% chest pain; 25% presented a positive test for drugs. Cocaine was present in 13.3% and cannabis in the same proportion. No differences were found regarding positive cocaine test and chief complaint, ED or hospital stay, or additional tests. Cocaine-positive patients were significantly younger.

Nocturnal home pulse oximetry: variability and clinical implications in home mechanical ventilation.

Background: Nocturnal home pulse oximetry (NHPO) provides information by measuring a series of variables: time spent with SaO2 <90% expressed as percentage (T90) or in minutes (Tm90), mean SaO2 (MnS), and lowest SaO2 (LwS.) The presence of significant nocturnal desaturation has been proposed as a parameter in decision making with regard to initiating home mechanical ventilation (HMV) or monitoring HMV effectiveness. However, there is limited information on the possible variability of the test, and this could influence the interpretation of results. Objectives: To explore the variability between 2 consecutive measurements of NHPO and to determine clinical applications in HMV. Methods: The patients presented diseases susceptible to HMV treatment and were enrolled in stable condition without respiratory failure. NHPO was conducted on 2 consecutive nights. The variables analyzed were: T90, Tm90, Mns, and LwS. The coefficient of variation (CV), a concordance coefficient (CC), and the Bland-Altman method were used in order to explore the variability. Results: We studied 40 cases. Two were excluded, and the remaining 38 were aged 58 ± 16 years (19 males). Eighteen were receiving HMV. CV values exceeded 100% for T90 and Tm90 and were below 5% for MnS and LwS. The CC for T90, Tm90, and LwS showed confidence intervals with lower limits below 0.5, while for MnS the value was 0.88 (0.79–0.93). Conclusions: There is a wide variability in NHPO recordings for T90, Tm90, and LwS, so a single determination to detect nocturnal desaturation may not be valid for decision making; the parameter with the least interindividual variability and intraindividual variability was MnS.

Homocisteína y enfermedad arterial coronaria

Hemos leído con gran interés el artículo titulado «Concentraciones totales de homocisteína plasmática en pacientes puertorriqueños con cardiopatía isquémica» de Rodríguez et al1 publicado en el número de diciembre de la Revista. Si bien es indudable la enorme trascendencia del tema, nos parece oportuno comentar algunos aspectos. En primer lugar, en la introducción se comenta que en España los estudios de cardiopatía isquémica se han enfocado más hacia la teoría del aumento en colesterol, y no hay estudios sobre los valores de homocisteína en esta población. A este respecto, existe un estudio español2 que ha comunicado que en el 26% de los pacientes con enfermedad coronaria se comprueba hiperhomocisteinemia. En segundo lugar, los autores no determinan los valores de vitamina B6, B12 y ácido fólico donde su déficit puede ser una causa nutricional de hiperhomocisteinemia. Se ha sugerido que aproximadamente el 60% de la hiperhomocisteinemia se debe a niveles inadecuados de una o más de estas vitaminas en la sangre3. Asimismo, no se comenta el estado dietético de la población de estudio, ya que es probable que el responsable de la incapacidad de encontrar una asociación entre la enfermedad coronaria y la concentración de homocisteína sea un efecto de la variación dietética a corto y largo plazo4. En diversos estudios retrospectivos y prospectivos se ha indicado la posibilidad de que una prueba de carga no metionina mejoraría la capacidad de discriminar el riesgo de enfermedad coronaria con respecto a la medición de homocisteína en ayunas5. En tercer lugar, los resultados están expuestos sin la suficiente claridad. En la tabla 2 se expone la distribución de

EEG findings and outcomes of continuous video-EEG monitoring started prior to initiation of seizure treatment in the perinatal stroke

BACKGROUND To analyze the findings in the background EEG activity of infants who suffered perinatal stroke. METHODS Eleven neonates born 2009-2014 diagnosed of ischemic stroke by MRI (three of them with multistroke) underwent continuous video-EEG monitoring. Visual and spectral (power spectrum and coherence) analyses of the background EEG was performed in three moments: 1) Onset of EEG recording (prior to initiate seizure treatment), 2) Post-ictal epoch (1-2 h after the last seizure), and 3) one-two days after seizure control. All children aged 2-6 years underwent neurodevelopmental assessment. RESULTS Discontinuity, asymmetry, asynchrony, transients, and relative power spectrum in δ and θ frequency bands increased significantly (p < 0.05) in the post-ictal epoch with respect to onset of EEG recording. After seizure control, discontinuity, asynchrony, and θ power spectrum no longer had significant differences with those found at onset of EEG recording. Significant differences between the ischemic and unaffected hemispheres were found in transients and in β coherence (p = 0.002; p = 0.001, respectively) exclusively in the post-ictal epoch. Seizure burden and time-to-control ranged 5-38 min and 0.5-40 h respectively. Currently, only one child is affected by spastic monoparesis. The intelligence quotients ranged 96-123. CONCLUSIONS The background EEG can undergo significant changes in the post-ictal epoch due to the seizure activity triggered by the perinatal stroke. Most of these EEG changes involve all brain activity and not exclusively the ischemic hemisphere. Many of these modifications in the EEG background reverse following the seizure control. Video-EEG monitoring allows accurate/immediate diagnosis and rapid/intensive treatment of the stroke-associated seizures.