Extreme self-monitoring, fear of hypoglycemia and obsessive-compulsive disorder in type 1 diabetes mellitus: when less is better

Background: Pre-existing psychological factors can strongly influence coping with type 1 diabetes mellitus and interfere with self-monitoring. Psychiatric disorders seem to be positively associated with poor metabolic control. We present a case of extreme compulsive blood testing due to obsessive fear of hypoglycemia in an adolescent with type 1 diabetes mellitus. Case report: Type 1 diabetes mellitus (anti GAD-antibodies 2624 U/l, norm < 9.5) was diagnosed in a boy aged 14.3 years [170 cm (+ 0.93 SDS), weight 50.5 kg (+ 0.05 SDS)]. Laboratory work-up showed no evidence for other autoimmune disease. Family and past medical history were unremarkable. Growth and developmental milestones were normal. Insulin-analog based basal-bolus regime was initiated, associated to standard diabetic education. Routine psychological evaluation performed at the onset of diabetes revealed intermittent anxiety and obsessivecompulsive traits. Accordingly, a close psychiatric follow-up was initiated for the patient and his family. An adequate metabolic control (HbA1c drop from >14 to 8%) was achieved within 3 months, attributed to residual -cell function. In the following 6 months, HbA1c rose unexpectedly despite seemingly adequate adaptations of insulin doses. Obsessive fear of hypoglycemia leading to a severe compulsive behavior developed progressively with as many as 68 glycemia measurements per day (mean over 1 week). The patient reported that he could not bear leaving home with glycemia < 15 mmol/l, ending up with school eviction and severe intra-familial conflict. Despite intensive psychiatric outpatient support, HbA1c rose rapidly to >14% with glycemia-testing reaching peaks of 120 tests/day. The situation could only be discontinued through psychiatric hospitalization with intensive behavioral training. As a result, adequate metabolic balance was restored (HbA1c value: 7.1 %) with acceptable 10-15 daily glycemia measurements. Discussion: The association of overt psychiatric disorders to type 1 diabetes mellitus is very rare in the pediatric age group. It can lead to a pathological behavior with uncontrolled diabetes. Such exceptional situations require long-term admissions with specialized psychiatric care. Slow acceptation of a "less is better" principle in glycemia testing and amelioration of metabolic control are difficult to achieve.

Endocardite infectieuse: mise au point [Infective endocarditis: update]

The pathogenesis of infective endocarditis (IE) is being dissected at the molecular level, which should help redefine new preventive and therapeutic strategies against IE. In spite of improving health care, the incidence of IE has not decreased over the last decades. While classical predisposing conditions such as rheumatic heart disease were being eradicated, new features of IE have emerged. These include IE in intravenous drug users, IE in elderly patients with sclerotic valve disease, prosthetic valve IE and nosocomial IE. The epidemiology, pathogenesis, diagnosis, prevention and treatment of IE are being reviewed in this article.

Salmeterol for the prevention of high-altitude pulmonary edema.

BACKGROUND: Pulmonary edema results from a persistent imbalance between forces that drive water into the air space and the physiologic mechanisms that remove it. Among the latter, the absorption of liquid driven by active alveolar transepithelial sodium transport has an important role; a defect of this mechanism may predispose patients to pulmonary edema. Beta-adrenergic agonists up-regulate the clearance of alveolar fluid and attenuate pulmonary edema in animal models. METHODS: In a double-blind, randomized, placebo-controlled study, we assessed the effects of prophylactic inhalation of the beta-adrenergic agonist salmeterol on the incidence of pulmonary edema during exposure to high altitudes (4559 m, reached in less than 22 hours) in 37 subjects who were susceptible to high-altitude pulmonary edema. We also measured the nasal transepithelial potential difference, a marker of the transepithelial sodium and water transport in the distal airways, in 33 mountaineers who were prone to high-altitude pulmonary edema and 33 mountaineers who were resistant to this condition. RESULTS: Prophylactic inhalation of salmeterol decreased the incidence of high-altitude pulmonary edema in susceptible subjects by more than 50 percent, from 74 percent with placebo to 33 percent (P=0.02). The nasal potential-difference value under low-altitude conditions was more than 30 percent lower in the subjects who were susceptible to high-altitude pulmonary edema than in those who were not susceptible (P<0.001). CONCLUSIONS: Prophylactic inhalation of a beta-adrenergic agonist reduces the risk of high-altitude pulmonary edema. Sodium-dependent absorption of liquid from the airways may be defective in patients who are susceptible to high-altitude pulmonary edema. These findings support the concept that sodium-driven clearance of alveolar fluid may have a pathogenic role in pulmonary edema in humans and therefore represent an appropriate target for therapy.

Análisis técnico-jurídico de la Ley de Emprendedores

Els temps canvien, i amb el temps, els negocis. L'entorn social, cultural i econòmic ha canviat durant els darrers anys i s’han desenvolupat grans oportunitats i difícils problemes. Molts dels països desenvolupats han sofert altes taxes d’atur i els individus han vist disminuïdes les seves qualitats de vida. Noves i a la vegada antigues opcions han sorgit per fer front a tots aquests canvis, una d’aquestes, l’autoocupació. Els emprenedors estan de moda, i qualsevol canvi social, implica un canvi legislatiu. El legislador espanyol ha trigat temps en desenvolupar mecanismes per protegir i promocionar als emprenedors. En primer lloc, aquesta investigació tracta d’entendre perquè Espanya és un dels països amb pitjors condicions per emprendre un negoci. En segon lloc, es pretén inspeccionar la Llei 14/2013 de recolzament als emprenedors i la seva internacionalització, aprovada els darrers mesos de l’any 2013, per veure si dóna solucions al problema anterior. En tercer lloc, per poder aconseguir aquesta difícil tasca, la investigació compara la legislació espanyola amb les necessitats reals dels emprenedors i amb les bones mesures implementades per altres països europeus. No hi ha dubte de que l’emprenedoria és una realitat, ara hem d’observar si les bones condicions per emprendre a Espanya també són una realitat.

Financiación autonómica y tributos cedidos: El impuesto de Sucesiones y Donaciones como instrumento de competencia fiscal

Aquest treball té com a objecte l'estudi del finançament de les CCAA posant l'accent en la figura del tribut cedit com a font de finançament de les mateixes. Més concretament es farà un estudi de la naturalesa de l'impost sobre successions i donacions com a tribut que tanca el marc de la imposició directa a Espanya i la seva repercussió en el sistema tributari actual. En primer lloc, s'estudia el sistema de finançament autonòmic. Posteriorment s'analitza l'impost de successions i donacions. Finalment, s'exposen algunes conclusions i reflexions sobre el sistema actual de finançament, així com la regulació del referit impost.

La nueva política criminal de la seguridad vial. Reflexiones a propósito de la LO 15/2007, de 30 de noviembre, y del Proyecto de Reforma del Código Penal

La reforma de los delitos contra la seguridad en el tráfico operada por LO 15/2007, de 30 de noviembre, constituye la expresión de un programa político-criminal de más amplio alcance, presente en el Proyecto de Reforma del Código Penal de 2007. En este trabajo se exponen las causas de la emergencia del nuevo derecho penal de la seguridad vial a la luz del paradi gma explicativo que ofrece el derecho penal postmoderno del riesgo -sometido aquí a necesarios ajustes- y se ofrece un análisis crítico de dos de los nuevos tipos: la conducción a velocidad por encima de determinados límites (art. 379.1) y la conducción con concentraciones de alcohol en aire espirado o en sangre superiores a determinadas tasas (0.6 mgr. o 1,2 gr. respectivamente) –art. 379.2-. Igualmente se analiza la propuesta del Proyecto de Reforma del Código de elevar a la categoría de delito las imprudencias leves con resultado de muerte. Tres piezas clave de un programa que trasluce una gran desconfianza hacia el estamento judicial y un optimismo infundado en las posibilidades del derecho penal para reducir eficazmente la siniestralidad vial.

Addition of nitrogen had no effect on yield and quality of apples in an high density orchard carrying a dwarf rootstock

The effect of N addition on apple yield and quality may vary according to the tree vigor. Apple trees developed over vigorous rootstocks had shown no response to N application in Brazil. In this study it was evaluated the effect of N addition to the soil on yield and quality of ´Royal Gala´ apples grafted on a dwarf rootstock (M.9). The orchard was planted in 1995 (2,857 trees ha-1) on an Oxisol containing 40 g kg-1 of organic matter and pH 6.0. The experiment was carried out from 1998 up to 2005. Treatments consisted of rates of N (0, 50, 100 and 150 kg ha-1 year-1 from 1998 to 2001, and respectively 0, 100, 200 and 300 kg ha-1 afterwards), all broadcasted within the tree row in two equal splits, at bud break and after harvest, as ammonium sulfate. Addition of N to the soil had no effect on fruit yield over the six years regardless of the applied rate. Averaged across treatments and years, fruit yield was 52.3 t ha-1. Nitrogen in the leaves (average of 24 g kg-1) or in the fruits (average of 346 mg kg-1) as well as some attributes related to fruit quality (color, firmness, acidity, soluble solids, physiological disorders) were unaffected by N addition. Some plant parameters related to tree vigor, however, grew higher with the increase on N rate. Thus, it is not necessary to apply N to deep Brazilian soils containing high organic matter in order to assure good fruit quality and yield on high-density orchards carrying dwarf rootstocks probably because the N required for tree growth and fruit production is supplied from soil organic matter decay.