Utilidad clínica de la micafungina en el niño y el adolescente

Micafungin is one of three echinocandins, a novel class of antifungal agents active against 1,3-β-D glucan in the fungal cell wall. It is a favorable safety profile have made it an attractive option in the treatment of invasive Candida and Aspergillus infections. Available studies have shown that younger children have lower C_max, shorter t½ and faster clearance than adults.     

Hacia el diagnóstico temprano de la candidiasis invasora en el paciente crítico

The management of invasive fungal infections in critically ill patients, from diagnosis to selection of the ther- apeutic protocol, is often a challenge. Early diagnosis and treatment are associated with a better prognosis, but apart from cases with positive cultures from blood or fluid/tissue biopsy, diagnosis is neither sensitive nor specific, and there is a need for specific markers in these diseases. Serodiagnostic assays such as mannan an-tigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, and mo-lecular techniques for the detection of fungal-specific DNA have been developed with promising results in critical care settings. One of the main features in diagnosis is the evaluation of risk factors for infection, which will identify patients in need of preemptive or empirical treatment. Clinical scores were built from those risk factors. The combination of prediction rules and non-culture microbiological tools could be currently be the key to improving the diagnosis and prognosis of invasive fungal infections in critically ill patients.     

Utilidad clínica de la micafungina en el tratamiento de las candidiasis invasoras en el paciente crítico

BackgroundOver the last 30 years a significant increase of Candida spp. invasive disease has been observed in non-neutropenic critical ill patients. Both fluconazole and amphotericin B have been considered first line treatment for invasive (proven and probable) Candida spp. disease, although the mortality rate is still high.ObjectivesTo review the current data on the use of micafungin for the treatment of Candida invasive disease in critical ill patients.MethodsThe pharmacologic, mycological and clinical properties of micafungin are reviewed based on current published data. The use and efficacy of micafungin for the treatment of Candida invasive disease in critical ill patients is discussed.Results and conclusionsTo reduce the rate of mortality more effective antifungals and pre-emptive treatment strategies are currently warranted. Candins achieve better results for the treatment of invasive Candida disease in non-neutropenic critical ill patients. Micafungin has a good safety profile (similar to fluconazole). Micafungin is a first line drug for the treatment of invasive Candida disease and may be used as a pre- emptive approach followed by a de-escalating strategy with azoles.     

Utilidad clínica de la micafungina en el tratamiento de las candidiasis invasoras en el paciente oncohematológico

BackgroundInvasive candidiasis is a severe infection among onco-hematological patients, with an attributable mortality around 40%. Micafungin has shown efficacy in antifungal prophylaxis among hematopoietic stem cell transplant recipients and in the treatment of esophageal candidiasis.AimsTo assess the role of micafungin in the treatment of invasive candidiasis among onco-hematological patients.MethodsLiterature review.ResultsIn a study on 126 patients with candidemia treated with micafungin, an overall response rate of 83% was reported. A double-blind study of 531 patients with invasive candidiasis comparing micafungin (100 mg/day) versus liposomal amphotericin B (3 mg/kg/day) reported success in 90% of patients in both arms, with a more favorable safety profile with micafungin. Other double blind randomized, phase III study compared two doses of micafungin (100 mg/day and 150 mg/day) with standard doses of caspofungin (70 mg loading dose, then 50 mg/day) in adults with invasive candidiasis. Overall success rate was 74% for micafungin 100 mg/day, 70% for micafungin 150 mg/day, and 71% for caspofungin. A double blind randomized study compared micafungin (2 mg/kg/day) to liposomal amphotericin B (3 mg/kg/day) in the treatment of invasive candidiasis in children with a predominance of infections with non-albicans Candida spp. Overall success rate was similar (73% for micafungin and 76% for liposomal amphotericin B).ConclusionsComparative phase III studies have demonstrated non-inferiority of micafungin compared to standard antifungal agents for invasive candidiasis. Micafungin is safe and effective in the treatment of children and adults with invasive candidiasis. Effectivity in invasive infections caused by non-albicans Candida spp is especially relevant in onco-hematological patients receiving fluconazole prophylaxis.     

Candidiasis invasora en el paciente crítico quemado

BackgroundThe advances in burn care therapy have extended considerably the survival of seriously burned patients, exposing them to infectious complications, notably fungal infections. Due to the difficulty in the diagnosis of invasive mycoses and their high associated mortality rates, approaches to prophylactic or pre-emptive antifungal therapy in high-risk burned patients have been proposed, although these guidelines remain controversial. On the other hand, the management of these conditions is a serious problem, especially in critically ill patients with multiorgan failure, including severely ill burn patients due to the shortage of available antifungal agents. However, in the last several years, the range of antifungal agents has been significantly extended, which have led to an improvement in the treatment of invasive fungal infection in this population.Clinical caseWe report a case of invasive candidiasis in a severelly ill burns patient successfully treated with an echinocandin. In this case report, current treatment options are discussed, and a review of the literature of previously published cases is made.ConclusionsThere are still significant gaps in our knowledge of the optimal diagnostic and management approach for invasive candidiasis in burn patients. Prospective studies are needed in this population to optimise management and improve outcomes in this state of high morbidity and mortality.     

Estimación del filtrado glomerular en el paciente anciano. Implicaciones clínicas en el uso de antibióticos

IntroductionIn elderly, impaired kidney function may lead to relevant clinical implications, especially in drug dosage. There is no consensus on the best formula to estimate glomerular filtration rate (GFR) in this context. While the Cockcroft–Gault (CG) equation is the most used one in drug development, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is the most employed by clinical laboratories. The objective of this study is to analyze the differences and implications of using one or another equation when adjusting the dose of antibiotics.Material and methodsCross-sectional study performed in patients older than 80 years admitted to an acute geriatric unit for infectious disease. Socio-demographic, functional, clinic, assistance and laboratory variables were gathered, calculating GFR according to CG and CKD-EPI. A concordance study between both equations, bivariate analysis and multiple linear regression were carried out.Results100 patients were recruited, with mean age 88.5 ± 4.2 years, and 54% women. A relative overestimation of 13.63 mL/min was observed in GFR according to CKD-EPI, with a low-moderate concordance between both formulas. Greater need for dose adjustment of antibiotics with GC than with CKD-EPI was detected (38% vs. 23%; P < .001), as well as dosage discrepancies, especially with levofloxacin.ConclusionsBoth equations are not interchangeable in the elderly. When used to adjust antibiotic dose, CKD-EPI may overestimate GFR and may cause an increase in adverse reactions. Further studies should be carried out with the aim of reaching a consensus on the most appropriate equation for the elderly patient.     

Guía clínica para el manejo del nódulo tiroideo y cáncer de tiroides durante el embarazo

Special considerations are warranted in management of thyroid nodule and thyroid cancer during pregnancy. The diagnostic and therapeutic approach of thyroid nodules follows the standard practice in non-pregnant women. On the other hand, differentiated thyroid cancer management during pregnancy poses a number of challenges for the mother and fetus. The available data show that pregnancy is not a risk factor for thyroid cancer development or recurrence, although flare-ups cannot be completely ruled out in women with active disease. If surgery is needed, it should be performed during the second term or, preferably, after delivery. A majority of pregnant patients with low-risk disease only need adjustment in levothyroxine therapy. However, women with increased serum thyroglobulin levels before pregnancy or structural disease require regular thyroglobulin measurements and neck ultrasound throughout pregnancy. Pregnancy is an absolute contraindication for radioactive iodine administration.     

Dinosaurios: rutas por el Jurásico de Asturias

Dinosaurios: rutas por el Jurásico de Asturias, José Carlos Martínez García Ramos, José Lires and Laura Piñuela, illustrated by Arturo de Miguel and Raúl Martín, 2002. Group Zeta in conjunction with La Voz de Asturias, Polígono de Puente Nora, 4, 33420 Lugones Asturias, Spain (www.elperiódico.com/asturias), 204 p., Deposito legal: AS-1.669/2002 (no ISBN number).     

Aspergilosis invasora en el paciente con enfermedad oncohematológica

Invasive aspergillosis is the most common invasive fungal infection in patients with acute hematological malignancies or treated with hematopoietic stem cell transplantation due to the marked alteration of the physiological mechanisms of antifungal immunity that takes place in these situations. For this reason, antifungal prophylaxis has a relevant role in these patients. The introduction of new antifungal agents has motivated the updating of recommendations for prophylaxis and treatment in different guidelines.The objectives of this chapter are a brief review of the mechanisms of immunity against fungi, the definition of risk for developing an invasive fungal infection and an update of the prophylaxis recommendations and treatment of invasive aspergillosis in the group of patients with hematological diseases.     

Relación entre el perfil oxidativo y el índice de diversidad de la dieta en adultos mayores de una zona urbano-marginal de Costa Rica

Background and objectiveThe older we get, the greater the production of reactive oxygen species and therefore the greater the oxidative stress, which is related to the deterioration of the health of older adults. This study analyzed the relationship between the oxidative profile and the dietary diversity index in an urban-marginal population of older adults in Costa Rica.MethodsEighty-eight older adults were studied and various markers of oxidative stress, serum glucose levels, lipid profile, and some micronutrients were determined. In addition, the body mass index (BMI) was calculated and the dietary diversity index (DDI) was determined.ResultsLipid peroxidation and DNA oxidation, a mean plasma antioxidant capacity percentage of 39.54 ± 10.67%, which decreased with age, were evidenced. 67% of the participants had alterations in glycemia, 73% had one or more alterations in blood lipid levels, 55% had insufficient vitamin D levels, and 68.6% were overweight. The average IDD was 4.91 points, indicating that the diet was not very diverse. No relationship was found between IDD and nutritional status, between nutritional status and oxidative stress, nor between biochemical variables and oxidative stress.ConclusionThe adults studied presented high oxidative stress, a high percentage of overweight, and a low IDD. A higher IDD was associated with a lower blood concentration of MDA and a higher % PAC.     

Tiña negra. Primera observación en el Uruguay

The first case in Uruguay of tinea nigra is described in a 44-year-old male patient with a maculous pigmented lesion on the right foot. It represents the most meridional case of the disease yet recorded in South America. Exophiala werneckii was isolated in cultures (strain 1905 IHM).     

Hiperparatiroidismo secundario en el cáncer de próstata avanzado

Background and ObjectiveHigh parathyroid hormone (PTH) concentrations are associated with increased bone resorption and bone matrix degradation. Some studies show elevated PTH concentrations and hypocalcemia in patients with advanced prostate carcinoma, although the pathophysiological significance of these findings is not well defined.Materials and methodsWe performed a retrospective study of 60 patients diagnosed with advanced prostate cancer (44 nonmetastatic and 16 metastatic) treated with androgen deprivation. In all patients, PTH, calcium, phosphorus, 25 (OH) vitamin D and prostate-specific antigen (PSA) were determined. Bone scintigraphy had previously been performed.ResultsIn patients with bone metastases, mean concentrations were as follows: calcium 9.19 mg/dl, phosphorus 3.47 mg/dl, 25 (OH) vitamin D 13.85 ng/ml, PTH 66.8 pg/ml and total PSA 101.27 ng/ml. For those without bone metastases, the results were calcium 9.39 mg/dl, phosphorus 3.38 mg/dl, 25 (OH) vitamin D 20.50 ng/ml, PTH 52.23 pg/ml and total PSA 2.52 ng/ml. PTH levels were significantly higher in patients with prostate cancer and bone metastases than in those without metastases (p=0.03). Vitamin D levels were also significantly lower in this group (p=0.03). There were no differences in other values.ConclusionsThe present study found increased PTH concentrations in patients with advanced prostate cancer. This finding could be useful to predict disease progression.     

Geriatría transversal. Un reto asistencial para el siglo xxi

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients’ risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term “Cross-speciality Geriatrics” is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.