José Antonio Mirón-Canelo

Factores de riesgo de fracaso de la corrección quirúrgica de la incontinencia urinaria de esfuerzo mediante cinta suburetral transobturatriz

OBJECTIVE To identify risk factors leading to treatment failure in a sample of 302 women with stress urinary incontinence (SUI) treated by transobturator vaginal tape (TOT) with a medium follow-up of 4 years (range 1-6). MATERIAL AND METHODS A population based cohort study with prospectively data from 302 women, aged 41-81 years underwent TOT between April 2003-November 2010. Data were collected by validated questionnaire on urinary incontinence, the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), and clinical data-records. Continence was achieved in 262 (Group A) and 40 continued with incontinence (Group B). We investigated the relationship between age, SUI evolution time, type and number of childbirths (eutocic, dystocic, nulliparous, multiparous status) and medical and/or surgical backgrounds. The ICIQ-SF questionnaire was used to describe whether the surgery outcomes were successful or not. RESULTS Group A were younger (p=0.0001), had less SUI evolution time (p=0.017); more eutocic childbirths (p=0.000018). Group B had more dystocic childbirth (p=0.022), previous tension free vaginal tape (TVT) or TOT (p=0.03.), antidepressant-anxiolytic drugs (p=0.003), antihypertensive drugs (p=0.0005), type 1 diabetes (p=0.02), arterial hypertension (p=0.0007), respiratory diseases (p=0.025). Differences were not found with regard to nulliparous (p=0.701), multiparous status (p=0.42), obesity (p=0.18), intestinal disorders (p=0.59), oophorectomy (p=0.19), caesarean (p=0.17), prolapse surgery (p=0.29), hysterectomy (p=0.57), allergies (p=0.48), arthritis (p=0.22), arthrosis (p=0.44), depression (p=0.74), type 2 diabetes (p=0.44), smoking patterns (p=0.28), fibromyalgia (p=0.47). CONCLUSIONS Elderly women, with long evolution SUI, dystocic delivery, previous TVT or TOT appear as independent risk factors associated to TOT failure. These factors may make the indication of another surgical approach recommendable.

Association between Occupational Exposure to Wood Dust and Cancer: A Systematic Review and Meta-Analysis.

Objective To perform a systematic review to analyze the association between occupational exposure to wood dust and cancer. Methods A systematic literature search of entries made in the MEDLINE-PubMed database between 1957 and 2013 was conducted to identify studies that had assessed the relationship between occupational exposure to wood dust and different types of cancer. A meta-analysis of selected case-control and cohort studies was subsequently performed. Results A total of 114 studies were identified and 70 were selected for review. Of these, 42 studies focused on the relationship between wood dust and nasal cancer (n = 22), lung cancer (n = 11), and other types of cancer (n = 9). Low-to-moderate quality evidence that wood dust acts as a carcinogen was obtained, and a stronger association between wood dust and nasal adenocarcinoma was observed. A lesser association between wood dust exposure and lung cancer was also observed. Several studies suggested that there is a relationship between wood dust and the onset of other cancers, although there was no evidence to establish an association. A meta-analysis that included four case-controls studies showed that workers exposed to wood dust exhibited higher rates of nasal adenocarcinoma than other workers (odds ratio = 10.28; 95% confidence interval: 5.92 and 17.85; P<0,0001), although a large degree of heterogeneity was found. Conclusions Low-to-moderate quality evidence supports a causal association between cancer and occupational exposure to wood dust, and this association was stronger for nasal adenocarcinoma than for lung cancer. There was no evidence of an association between wood dust exposure and the other cancers examined.

Comparison of sublingual therapeutic vaccine with antibiotics for the prophylaxis of recurrent urinary tract infections.

Objective: To compare the clinical impact of a prophylactic treatment with sublingual immunostimulation in the prevention of recurrent urinary tract infections (rUTIs) with the use of antibiotics. Material and Methods: Retrospective cohort study evaluating the medical records of 669 women with rUTIs; 339 had a 6-month prophylaxis with antibiotics and 360 a 3-month prophylaxis with a sublingual bacterial preparation (MV 140-Uromune®). The time frame after the prophylaxis-period until the appearance of a new infection (assessed by uroculture) was scored and followed during 1 year. The absolute risk reduction (ARR) and number needed to treat (NNT) were also calculated. Results: All patients treated with antibiotics experienced a new UTI during the scoring period of 12 months, being 19 days the median number of days free of UTIs (range 5–300). In the group treated with the bacterial preparation, 35 (9.7%) patients experienced an UTI in the same period. Kaplan-Meier curves comparing the accumulated survival (disease-free time) between both groups were significant different (P < 0.0001). The absolute risk reduction (ARR) was 90.28% (87.18–93.38) and the number needed to treat (NNT) 1.1 (1.1–1.1). Conclusions: These results suggest that the treatment with this bacterial preparation significantly reduces the incidence of rUTIs, arising as an effective strategy to reduce the frequency of rUTIs. It reduces antibiotic consumption, matching the current recommendations due to the raise of antimicrobial resistance. Randomized, double-blind and placebo-controlled, clinical trials are needed to establish, more accurately, the clinical impact of this bacterial preparation in patients with rUTIs.

Valoración de los estudiantes sobre su formación en la Facultad de Medicina

Objetivo: Conocer y analizar la valoracion y las opiniones que tienen los alumnos de sexto curso de medicina sobre el proceso de ensenanza-aprendizaje en su facultad. Sujetos y metodos: Se realiza un estudio transversal a partir de los datos primarios aportados por una encuesta que se aplica a 225 alumnos de sexto de medicina. Resultados: Del total de encuestados, 208 alumnos (95%; IC 95% = 95 ± 3) no se consideran formados para ejercer la medicina y 214 (96%; IC 95% = 96 ± 3) no se encuentran capacitados para ejercerla. La calidad global de la formacion recibida en el pregrado es valorada por el 55% (IC 95% = 55 ± 7) de los alumnos con una puntuacion media de 3 en una escala de 1 a 5. Se valora positivamente la formacion teorica y negativamente las habilidades clinicas, sociales y de comunicacion, las actitudes y los aspectos relacionados con la gestion. Para 169 alumnos, un 75% (IC 95% = 75 ± 6), la prueba MIR ha condicionado la formacion, tanto en contenidos (70%; IC 95% = 70 ± 3) como en metodologia (58%; IC 95% = 58 ± 6). Conclusiones: Globalmente, existe una evolucion positiva entre 1999 y 2008-2010. Los resultados de este trabajo ponen de manifiesto la necesidad de introducir cambios en el proceso de ensenanza-aprendizaje de la medicina que mejoren la formacion efectiva y la satisfaccion.

B-learning training in the certification of causes of death

INTRODUCTION An adequate certification of causes of death is essential for Public Health. The objective of this work is to improve the professional competence of medicine students and family doctors with regard to the certification of causes of death according to the international regulations of the WHO. METHODS Intervention-formation, before and after design, addressed to students of Medicine in their last year (6th year), and Family Doctors and Interns. The blended learning or b-learning program consisted in an on-site seminar-workshop, plus basic information/documentation stored in an on-line platform, together with the preparation of Certificates of Causes of Death based on Clinical Histories of real cases. RESULTS 308 students participated in the program. We observed an individual improvement in the professional competence in all certifications of death, which was significant in 3 out of 5 cases (it was not significant in a medical-legal case of violent death and the case of a pluripathological chronic patient). The intermediate causes improved in all cases. Most formal aspects of the certification improved with significant changes. In the group of 62 Family Doctors and interns who took part in the program there were improvements in the basic or underlying causes in 4 of the 5 cases and improvements in the formal quality of the assessment, although less significantly than in students, because they started with better basal indexes in their certificates in the Before stage of the study. CONCLUSIONS Blended learning training has shown to be effective in improving the professional competence, both in students of the Degree of Medicine and in practicing Family Doctors and Interns.

PDE-5 inhibitors in monotherapy versus combination therapy in a sample of 1200 patients with erectile dysfunction

OBJECTIVES To compare the effectiveness in the treatment of erectile dysfunction when using PDE-5 inhibitors (PDE5i), alprostadil (PG-E1) and testosterone (TES) in monotherapy or combination therapy. MATERIAL AND METHODS Observational multicentre retrospective study of men diagnosed and treated for ED between January 2008 and January 2014. Age, social and employment situation, pathological medical history, risk factors, usual treatments, IIEF-5 at the first consultation and at first and each 6 months follow-ups, physical examination, calculated total and free testosterone and received treatment were analysed. Descriptive statistics, one-way ANOVA analysis, Chi2 for qualitative data, t-test, Fishers exact test and Pearsons correlation coefficient were used; p < 0.05 is considered significant. RESULTS Average age was 58.61 years, SD5.02, average follow- up time 48.21 months, SD 6.21, range 6-174 months. Out of the patients 76.12% were married, 9.81% divorced/separated, 10.04% single, 4.03% widowed; 85.14% of the total in stable partnership but 66.16% were not accompanied by their partners. In total 844 patients received monotherapy (597 PDE5i; 62 PG-E1; 36 TES; 27 penile prosthesis; 121 psychotherapy/alternative therapies) and 357 combination therapy (167 PDE5i+TES; 124 PDE5i+PGE1; 66 PG-E1+TES). There was a homogeneous distribution between risk factors and medical history groups. Satisfactory response according to IIEF-5 was achieved for 72.33% of patients on PDE5i monotherapy, 46.65% of patients on PDE5i+PG-E1 combination therapy and 83.41% of patients on PDE5i+TES. CONCLUSIONS The best therapeutic success for ED in this series was achieved through a combination of testosterone+PDE-5 inhibitors without increasing morbidity and maintaining the response over time. Larger studies with longer follow-up will corroborate these findings.

Results of the surgical correction of urinary stress incontinence according to the type of transobturator tape utilized

OBJECTIVES To analyze the short and long term results of tapes of different materials used to treat stress urinary incontinence (SUI). A secondary objective was to evaluate the ability to adjust the tape after implantation. MATERIALS AND METHODS Retrospective chart review of 355 patients with SUI operated between March 2003 and October 2011. Eight different types of transobturator tapes were used: Gynecare TVT-O®, Monarc®, SAFYRE®, Contasure KIM®, I-Stop®, DynaMesh®, Aris® Bandellete and Swing-band®. Results and complications were recorded. RESULTS The mean age at operation was 61 years. Correction of SUI was achieved in 87.88% of cases. The best results were obtained with Contasure KIM® (98.26 % continence). The tape was well tolerated and was elastic enough to be able to be adjusted 48-72 hours after implantation without deformation. Slings with macropores and over lock stitches on the superior and inferior borders presented the lower rates of postoperative urinary retention, pain, perior postoperative bleeding and urinary tract infections. CONCLUSIONS Transobturator tension free tapes require a short operation time and have a low complication rate. The possibility of adjustment in the early postoperative period increases the success rate and reduces complications. Knotless meshes with macropores and over lock stitches appear to be better balanced, are quite resistant to stretching and deformation when readjusted after implantation and present a low infection rate.

Medication adherence and barriers among low-income, uninsured patients with multiple chronic conditions

BACKGROUND Poor adherence to long-term therapies is a public health concern that affects all populations. Little is known about the context of adherence in chronic diseases for the uninsured population in the United States. OBJECTIVE To evaluate medication adherence and barriers among low-income, uninsured adults recently initiating new therapy for a chronic disease. METHODS A cross-sectional study in two Community Health Centers located in Chatham County, Georgia, was performed between September and December 2015. Patients, randomly selected for inclusion in the study, were eligible if they had been prescribed medication for 2 or more chronic conditions and had recently started a new medication regimen. The Morisky-Green-Levine questionnaire was used to assess adherence. Potential barriers were analyzed using the Multidimensional Model proposed by the World Health Organization-social and economic, healthcare team and system-related, condition-related, therapy-related, and patient-related factors. Multivariate logistic regression models were used to analyze factors associated with non-adherence. RESULTS A total of 150 participants were interviewed at 6 months after treatment initiation. Non-adherence was reported by 52% of the participants. Higher adjusted odds of non-adherence were observed in participants who did not receive information about their medications (adjusted odds ratio [AOR] = 2.40, 95% confidence interval [CI] = 1.01-5.74), did not regularly visit a primary health-care provider (AOR = 2.74, 95% CI = 1.09-6.88), and had changes in their treatment (AOR = 3.75, 95% CI = 1.62-8.70). Alternatively, adjusted odds of non-adherence were lower for patients who reported using pillboxes (AOR = 0.31, 95% CI = 0.10-0.95), having help from a caregiver (AOR = 0.15, 95% CI = 0.04-0.60), and integrating medication dosing into daily routines (AOR = 0.18, 95% CI = 0.06-0.59). CONCLUSIONS Medication non-adherence was common among low-income, uninsured patients initiating therapy for chronic conditions. Several modifiable barriers highlight opportunities to address medication non-adherence through multidisciplinary interventions.

Association between allelic variants of the human glucocorticoid receptor gene and autoimmune diseases: A systematic review and meta-analysis

INTRODUCTION The human glucocorticoid receptor gene (NR3C1) is considered to play a role in the differences and sensitivities of the glucocorticoid response in individuals with autoimmune diseases. The objective of this study was to examine by means of a systematic review previous findings regarding allelic variants of NR3C1 in relation to the risk of developing systemic autoimmune diseases. METHODS Studies that analysed the genotype distribution of NR3C1 allelic variants among patients with systemic autoimmune diseases were retrieved. A meta-analysis was conducted with a random effects model. Odds ratios (ORs) and their confidence intervals (CIs) were calculated. In addition, sub-analysis by ethnicity, sensitivity analysis and tests for heterogeneity of the results were performed. RESULTS Eleven studies met the inclusion criteria for meta-analysis. We found no evidence that the analysed NR3C1 polymorphisms, rs6198, rs56149945, and rs6189/rs6190, modulate the risk of developing a systemic autoimmune disease. Nonetheless, a protective role for the minor allele of rs41423247 was found among Caucasians (OR=0.78; 95% CI: 0.65, 0.92; P=0.004). A subgroup analysis according to underlying diseases revealed no significant association either for Behçets disease or rheumatoid arthritis, while correlations between NR3C1 polymorphisms and disease activity or response to glucocorticoids could not be evaluated due to insufficient data. CONCLUSIONS There is no clear evidence that the analysed NR3C1 allelic variants confer a risk for developing systemic autoimmune diseases although the minor G allele of rs41423247 may be protective among Caucasians.