A new sponge from the Marjum Formation of Utah documents the Cambrian origin of the hexactinellid body plan.

Modern poriferans are classified into four classes-Calcarea, Demospongiae, Hexactinellida and Homoscleromorpha-the recognition of which in fossil specimens almost exclusively relies on spicule morphology and arrangement. Early fossil representatives of the phylum Porifera are morphologically diverse, and many of them problematically display characteristics that are incompatible with the classification scheme developed for modern taxa. Critically, hexactine spicules-a diagnostic feature of hexactinellids among modern taxa-are found in various Cambrian and Ordovician taxa that cannot be accommodated within the hexactinellid body plan. Here we describe a new poriferan from the Drumian Marjum Formation of Utah, Polygoniella turrelli gen. et sp. nov., which exhibits a unique combination of complex anatomical features for a Cambrian form, including a syconoid-like organization, a thick body wall, and a multi-layered hexactin-based skeleton. The hexactinellid-like body wall architecture of this new species supports a Cambrian origin of the hexactinellid body plan and provides valuable insights into character evolution in early glass sponges.

Toward Tailoring Just-in-Time Adaptive Intervention Systems for Workplace Stress Reduction: Exploratory Analysis of Intervention Implementation.

BACKGROUND: Integrating stress-reduction interventions into the workplace may improve the health and well-being of employees, and there is an opportunity to leverage ubiquitous everyday work technologies to understand dynamic work contexts and facilitate stress reduction wherever work happens. Sensing-powered just-in-time adaptive intervention (JITAI) systems have the potential to adapt and deliver tailored interventions, but such adaptation requires a comprehensive analysis of contextual and individual-level variables that may influence intervention outcomes and be leveraged to drive the system's decision-making. OBJECTIVE: This study aims to identify key tailoring variables that influence momentary engagement in digital stress reduction microinterventions to inform the design of similar JITAI systems. METHODS: To inform the design of such dynamic adaptation, we analyzed data from the implementation and deployment of a system that incorporates passively sensed data across everyday work devices to send just-in-time stress reduction microinterventions in the workplace to 43 participants during a 4-week deployment. We evaluated 27 trait-based factors (ie, individual characteristics), state-based factors (ie, workplace contextual and behavioral signals and momentary stress), and intervention-related factors (ie, location and function) across 1585 system-initiated interventions. We built logistical regression models to identify the factors contributing to momentary engagement, the choice of interventions, the engagement given an intervention choice, the user rating of interventions engaged, and the stress reduction from the engagement. RESULTS: We found that women (odds ratio [OR] 0.41, 95% CI 0.21-0.77; P=.03), those with higher neuroticism (OR 0.57, 95% CI 0.39-0.81; P=.01), those with higher cognitive reappraisal skills (OR 0.69, 95% CI 0.52-0.91; P=.04), and those that chose calm interventions (OR 0.43, 95% CI 0.23-0.78; P=.03) were significantly less likely to experience stress reduction, while those with higher agreeableness (OR 1.73, 95% CI 1.10-2.76; P=.06) and those that chose prompt-based (OR 6.65, 95% CI 1.53-36.45; P=.06) or video-based (OR 5.62, 95% CI 1.12-34.10; P=.12) interventions were substantially more likely to experience stress reduction. We also found that work-related contextual signals such as higher meeting counts (OR 0.62, 95% CI 0.49-0.78; P<.001) and higher engagement skewness (OR 0.64, 95% CI 0.51-0.79; P<.001) were associated with a lower likelihood of engagement, indicating that state-based contextual factors such as being in a meeting or the time of the day may matter more for engagement than efficacy. In addition, a just-in-time intervention that was explicitly rescheduled to a later time was more likely to be engaged with (OR 1.77, 95% CI 1.32-2.38; P<.001). CONCLUSIONS: JITAI systems have the potential to integrate timely support into the workplace. On the basis of our findings, we recommend that individual, contextual, and content-based factors be incorporated into the system for tailoring as well as for monitoring ineffective engagements across subgroups and contexts.

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years.

BACKGROUND: The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term. METHODS: This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes. RESULTS: A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an 11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries. CONCLUSIONS: Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term. LEVEL OF EVIDENCE: Level II, prospective comparative cohort study, before and after intervention.

Cretaceous amber inclusions illuminate the evolutionary origin of tardigrades.

Tardigrades are a diverse phylum of microscopic invertebrates widely known for their extreme survival capabilities. Molecular clocks suggest that tardigrades diverged from other panarthropods before the Cambrian, but their fossil record is extremely sparse. Only the fossil tardigrades Milnesium swolenskyi (Late Cretaceous) and Paradoryphoribius chronocaribbeus (Miocene) have resolved taxonomic positions, restricting the availability of calibration points for estimating for the origin of this phylum. Here, we revise two crown-group tardigrades from Canadian Cretaceous-aged amber using confocal fluorescence microscopy, revealing critical morphological characters that resolve their taxonomic positions. Formal morphological redescription of Beorn leggi reveals that it features Hypsibius-type claws. We also describe Aerobius dactylus gen. et sp. nov. based on its unique combination of claw characters. Phylogenetic analyses indicate that Beo. leggi and Aer. dactylus belong to the eutardigrade superfamily Hypsibioidea, adding a critical fossil calibration point to investigate tardigrade origins. Our molecular clock estimates suggest an early Paleozoic diversification of crown-group Tardigrada and highlight the importance of Beo. leggi as a calibration point that directly impacts estimates of shallow nodes. Our results suggest that independent terrestrialization of eutardigrades and heterotardigrades occurred around the end-Carboniferous and Lower Jurassic, respectively. These estimates also provide minimum ages for convergent acquisition of cryptobiosis.

Cost-effectiveness of robotic vs laparoscopic distal pancreatectomy. Results from the national prospective trial ROBOCOSTES.

INTRODUCTION: Although several studies report that the robotic approach is more costly than laparoscopy, the cost-effectiveness of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) is still an issue. This study evaluates the cost-effectiveness of the RDP and LDP approaches across several Spanish centres. METHODS: This study is an observational, multicenter, national prospective study (ROBOCOSTES). For one year from 2022, all consecutive patients undergoing minimally invasive distal pancreatectomy were included, and clinical, QALY, and cost data were prospectively collected. The primary aim was to analyze the cost-effectiveness between RDP and LDP. RESULTS: During the study period, 80 procedures from 14 Spanish centres were analyzed. LDP had a shorter operative time than the RDP approach (192.2 min vs 241.3 min, p = 0.004). RDP showed a lower conversion rate (19.5% vs 2.5%, p = 0.006) and a lower splenectomy rate (60% vs 26.5%, p = 0.004). A statistically significant difference was reported for the Comprehensive Complication Index between the two study groups, favouring the robotic approach (12.7 vs 6.1, p = 0.022). RDP was associated with increased operative costs of 1600 euros (p < 0.031), while overall cost expenses resulted in being 1070.92 Euros higher than the LDP but without a statistically significant difference (p = 0.064). The mean QALYs at 90 days after surgery for RDP (0.9534) were higher than those of LDP (0.8882) (p = 0.030). At a willingness-to-pay threshold of 20,000 and 30,000 euros, there was a 62.64% and 71.30% probability that RDP was more cost-effective than LDP, respectively. CONCLUSIONS: The RDP procedure in the Spanish healthcare system appears more cost-effective than the LDP.

Anal high-grade intraepithelial neoplasia and cancer in women living with HIV and HIV-negative women with other risk factors.

OBJECTIVE: To determine the prevalence and the risk factors for anal high-grade intraepithelial neoplasia and anal cancer (HSIL+) in women living with HIV (WLWHIV), and to compare them to HIV-negative women with other risk factors. DESIGN: Prospective cohort study. METHODS: WLWHIV and HIV-negative women with other risk factors were included. Screening for anal HSIL+ using anal cytology and HPV testing was performed. A high-resolution anoscopy with directed biopsy was also performed in patients with an abnormal cytology result or a positive HPV testing for high-risk (HR) genotypes, and in those with anal symptoms. RESULTS: The period prevalence of anal HR-HPV infection and histological HSIL was 57.9% and 10.9% among WLWHIV, and 60.8% and 9.2% among HIV-negative women. The prevalence of anal HPV 18 infection was higher in WLWHIV. The risk factors for anal HSIL+ in WLWHIV included anal HPV 16, other HR genotypes and low-risk genotypes infection, as well as a history of vulvar HSIL+. In HIV-negative women, the risk factors included anal HPV 16 infection, history of anogenital warts and of vulvar HSIL+, and immunosuppressive treatment. CONCLUSIONS: A high prevalence of anal HPV infection and HSIL was observed in WLWHIV and women with other risk factors. Both groups share anal HPV 16 infection and history of vulvar HSIL+ as risk factors for the development of anal HSIL+. Genotyping for anal HPV 16 may help identify women at higher risk of anal cancer.

Canine Distemper Virus: Origins, Mutations, Diagnosis, and Epidemiology in Mexico.

This review provides an overview of the canine distemper virus (CDV), a highly infectious pathogen causing severe disease in domestic dogs and wildlife. It shares genetic similarities with the human measles virus (HMV) in humans and the rinderpest virus (RPV) in cattle. The origin of CDV likely involves a mutation from human measles strains, possibly in the New World, with subsequent transmission to dogs. CDV has been globally observed, with an increasing incidence in various animal populations. Genomic mutations, especially in the H protein, contribute to its ability to infect different hosts. Diagnosis by molecular techniques like RT-qPCR offers rapid and sensitive detection when compared with serological tests. Genomic sequencing is vital for understanding CDV evolution and designing effective control strategies. Overall, CDV poses a significant threat, and genomic sequencing enhances our ability to manage and prevent its spread. Here, the epidemiology of CDV principally in Mexico is reviewed.

Quality of Life of the Primary Caregivers of Children with Cleft Lip and Palate in Guanajuato, Mexico: A Cross-Sectional Study.

Comprehensive treatment is crucial for patients with a cleft lip/palate. While studies have investigated its impact on children's quality of life, few have examined the effects on primary caregivers. The aim of the study was to compare the quality of life of caregivers of children with cleft lip/palate to a control group at the National School for Higher Studies, National Autonomous University of Mexico, Guanajuato. A cross-sectional study was conducted at a teaching dental clinic of the National School of Higher Studies, National Autonomous University of Mexico, Guanajuato, México, from May to December 2021 involving 140 caregivers (70 in each group). The WHOQoL Bref instrument assessed the quality of life. In addition to the descriptive analysis, a binary logistic regression analysis was carried out, taking dichotomized reported quality of life as the dependent variable. Among the caregivers, 88.6% were female (p > 0.05), and 45 (64.8%) from the study group reported poor quality of life (p < 0.05). A multivariate analysis indicated that caring for a child with cleft lip/palate raised the likelihood of poor quality of life (p < 0.05). The findings emphasize the need for comprehensive support for both patients and caregivers, as their well-being affects patient outcomes.

Modulation of the K/BxN arthritis mouse model and the effector functions of human fibroblast-like synoviocytes by liver X receptors.

The role of liver X receptors (LXR) in rheumatoid arthritis (RA) remains controversial. We studied the effect of LXR agonists on fibroblast-like synoviocytes (FLS) from RA patients and the K/BxN arthritis model in LXRα and ß double-deficient (Nr1h2/3-/-) mice. Two synthetic LXR agonists, GW3965 and T0901317, were used to activate LXRs and investigate their effects on cell growth, proliferation and matrix metalloproteinases, and chemokine production in cultured FLS from RA patients. The murine model K/BxN serum transfer of inflammatory arthritis in Nr1h2/3-/- animals was used to investigate the role of LXRs on joint inflammation in vivo. LXR agonists inhibited the FLS proliferative capacity in response to TNF, the chemokine-induced migration, the collagenase activity in FLS supernatant and FLS CXCL12 production. In the K/BxN mouse model, Nr1h2/3-/- animals showed aggravated arthritis, histological inflammation, and joint destruction, as well as an increase in synovial metalloproteases and expression of proinflammatory mediators such as IL-1ß and CCL2 in joints compared with wild type animals. Taken together, these data underscore the importance of LXRs in modulating the joint inflammatory response and highlight them as potential therapeutic targets in RA.

Swept-source optical coherence tomography early findings in patients with carotid artery disease.

PURPOSE: Ocular ischemic syndrome can be the first and only hint of life-threatening carotid artery disease. The early recognition of carotid stenosis-related retinal signs, as well as the comprehension of the pathophysiology behind retinal changes could become relevant for physicians to predict the risk of stroke. The aim of this study is to assess the carotid artery disease-induced early structural retinochoroidal changes by means of swept-source optical coherence tomography (SS-OCT). METHODS: A prospective observational study was conducted in 72 eyes with carotid stenosis. According to the degree of stenosis, the participants were divided into a normal group (34 eyes), a mild-moderate stenosis group (22 eyes), a severe stenosis group (16 eyes). SS-OCT and OCTA were performed to scan macular fovea. Central macular thickness (CMT), subfoveal choroidal thickness (SCT) and foveal avascular zona (FAZ) area were the major measurements for our study. RESULTS: CMT was significantly thicker in group 3 when compared to group 2 and 1. SCT was significantly thinner in group 3 vs group 1, being thicker in group 2 when compared to group 1. No significant differences were obtained when comparing FAZ in the superficial and middle capillary plexus although it was significant when comparing the FAZ in the deep capillary plexus between group 1 and 3. CONCLUSION: internal carotid artery stenosis greater than 70% leads to a significant increase in CMT and a decrease in SCT prior the development of clinical findings of ocular ischemia syndrome.

A long-headed Cambrian soft-bodied vertebrate from the American Great Basin region.

The fossil record suggests that chordates might have been minor components of marine ecosystems during the first major diversification of animal life in the Cambrian. Vertebrates are represented by a handful of rare soft-bodied stem-lineage taxa known from Konservat-Lagerstätten, including Myllokunmingia and Yunnanozoon from the Stage 3 of South China, and Emmonsaspis and Metaspriggina from Stage 4-Drumian deposits of northeast USA and British Columbia. Here, we describe the first soft-bodied vertebrate from the American Great Basin, a region home to a dozen Cambrian Konservat-Lagerstätten. Found in the Drumian Marjum Formation of Utah, Nuucichthys rhynchocephalus gen. et sp. nov. is characterized by a finless torpedo-shaped body that includes a snout-like anterior head bearing anterolateral eyes, approximately 25 thick myomeres, a large branchial chamber with a keel and approximately seven putative dorsal bars and a spiniform caudal process. Using Bayesian inference, our analysis recovers Nuucichthys within the vertebrate stem, closer to the crown than Pikaia, Yunnanozoon and Myllokunmingia, where it forms a polytomy with its Laurentian relatives, Emmonsaspis and Metaspriggina, and a scion consisting of conodonts and crown-group vertebrates. Based on the eye orientation and absence of fins, we tentatively reconstruct Nuucichthys as a pelagic organism with limited swimming abilities (planktonektic).

Conserved exopodite morphology in three-dimensionally preserved trilobites from the Walcott-Rust Quarry (Mohawkian, Ordovician) of New York, USA.

Trilobites were extremely abundant and diverse euarthropods from the Paleozoic Era, but our understanding of their non-biomineralized ventral morphology is restricted to localities with exceptional fossil preservation. The Ordovician-aged Walcott-Rust Quarry in New York State preserves exceptional trilobite fossils as calcite casts in three-dimensions with little to no deformation, providing a valuable view of their ventral morphology. Appendages of the two most abundant trilobites, Ceraurus pleurexanthemus and Flexicalymene senaria, have been known for over 150 years but the original preparation of the specimens as thin sections has led to significant disagreement about their anatomy. Ceraruus pleurexanthemus is more abundant in the thin section collections (157 specimens) and features nearly complete appendages including a subtriangular protopodite with stud-like gnathobases along the medial edge and long endites ventrally. The exopodite consists of a long proximal article bearing dumbbell-shaped lamellae (in cross section) and a shorter distal article, closely resembling that of the cheirurid Anacheirurus adserai from the Lower Ordovician Fezouata Shale biota of Morocco. The appendages of F. senaria (37 specimens) are less well preserved. The exopodite bears up to 40 dumbbell shaped lamellae (in cross section) and is proportionally longer relative to the endopodite of C. pleurexanthemus. The close morphological similarity observed between the exopodites of C. pleurexanthemus and A. adersai, despite originating from paleogeographically distant latitudes and temporally separated by over ca. 20 million years, shows that the proposed "Cambrian type" exopodite persisted through the majority of the Ordovician. The morphology of the endopodites between C. pleurexanthemus and A. adersai is more variable when compared to the organization of the exopodites, may reflect selective pressures from locomotion and feeding between these species.

Discovery of Novel Viruses in Culicoides Biting Midges in Chihuahua, Mexico.

Biting midges (Culicoides) are vectors of many pathogens of medical and veterinary importance, but their viromes are poorly characterized compared to certain other hematophagous arthropods, e.g., mosquitoes and ticks. The goal of this study was to use metagenomics to identify viruses in Culicoides from Mexico. A total of 457 adult midges were collected in Chihuahua, northern Mexico, in 2020 and 2021, and all were identified as female Culicoides reevesi. The midges were sorted into five pools and homogenized. An aliquot of each homogenate was subjected to polyethylene glycol precipitation to enrich for virions, then total RNA was extracted and analyzed by unbiased high-throughput sequencing. We identified six novel viruses that are characteristic of viruses from five families (Nodaviridae, Partitiviridae, Solemoviridae, Tombusviridae, and Totiviridae) and one novel virus that is too divergent from all classified viruses to be assigned to an established family. The newly discovered viruses are phylogenetically distinct from their closest known relatives, and their minimal infection rates in female C. reevesi range from 0.22 to 1.09. No previously known viruses were detected, presumably because viral metagenomics had never before been used to study Culicoides from the Western Hemisphere. To conclude, we discovered multiple novel viruses in C. reevesi from Mexico, expanding our knowledge of arthropod viral diversity and evolution.

Synovial Cyst of the extensor digitorum superficialis: A case report.

Background: A synovial cyst is a herniation of synovial tissue through a joint capsule, often mistaken for a ganglion cyst. The key distinctions are that synovial cysts have a synovial cell lining, while a ganglion cyst is delineated by dense fibrous connective tissue. Typically found near joints, synovial cysts are associated with conditions like osteoarthritis, prevalent in females aged 20 to 50. We present a rare case of a synovial cyst in the extensor digitorum superficialis of the right hand. Case summary: A 53-year-old Hispanic female visited our hand clinic due to a 3-year history of pain on the back of her right hand. At exploration, a 3 × 3 cm soft tumor was identified. Surgery revealed a clear-yellowish mass within the extensor digitorum superficialis tendon. Following the surgery, synovial cyst was confirmed by pathology and the patient was discharged without complications. Conclusion: This case highlights the rare presentation of an intratendinous synovial cyst and emphasizes the importance of a comprehensive understanding of synovial cysts in the differential diagnosis of hand tumors.

Exploring Variable Approaches in Complex Hernia Repair: A Comprehensive Literature Review.

Surgeons have long grappled with categorizing complex hernias, leading to varied interpretations and fluctuating incidence rates. Complex Abdominal Wall Reconstruction (CAWR) addresses repairs for large hernias, with defined factors including size, previous repairs, mesh placement, infections, and comorbidities. This review explores pivotal surgical techniques for complex hernia repair, starting with Preoperative Progressive Pneumoperitoneum (PPP) and progressing to innovative methods like Botulinum Toxin Type A. Mesh fixation, both open and laparoscopic, plays a crucial role, with synthetic and biological mesh options discussed. Hybrid techniques and the "sandwich" approach are proposed for intricate cases. Each technique presents advantages and limitations, emphasizing the ongoing quest for optimal outcomes.

Synthetic suture tape for medial patellofemoral ligament reconstruction is an effective treatment for complex paediatric patellofemoral instability.

PURPOSE: To assess the outcomes of medial patellofemoral ligament (MPFL) reconstruction using synthetic suture tape in paediatric patients with patellofemoral instability (PFI). METHODS: This ambispective comparative study, conducted from 2014 to 2022, included paediatric patients who underwent MPFL reconstruction with synthetic suture tape and had a minimum follow-up of 1 year. Pre- and postoperative clinical and functional outcomes, patient satisfaction and complications were assessed. RESULTS: The study comprised 22 patients (29 knees), with a median age at surgery of 14.4 years (interquartile range [IQR] 10.9-16.7) and a median follow-up of 46.5 months (24.7-66). Notably, 13 knees (44.8%) had open growth plates at the time of surgery. The cohort included patients with Down syndrome (3 patients), Ehlers-Danlos (2), arthrogryposis (1), generalized joint hypermobility (8) and previous unsuccessful PFI surgeries (8). Concomitant procedures were performed on 16 knees. Postoperatively, improvements were observed in all but one patient, who reported residual pain. There were two other complications: one suture-tape rupture and one surgical wound infection. Functional scores significantly improved: Kujala, +14 points (7-29) (p < 0.001); IKDC, +10.5 points (5.2-25.3) (p < 0.001); Tegner, +2 points (0-4) (p < 0.001); Lysholm, +15 points (0-37.5) (p < 0.001). Most patients achieved excellent outcomes by Crosby-Insall criteria (21 patients, 72.4%) and reported high satisfaction (23 patients, 79.3%). CONCLUSIONS: MPFL reconstruction using synthetic suture tape is a viable and effective treatment for paediatric patients with PFI, particularly for those with connective tissue disorders, generalized joint hypermobility or past surgical failures, significantly enhancing clinical and functional outcomes with an acceptable complication rate. LEVEL OF EVIDENCE: Level IV.

Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients.

INTRODUCTION: Identifying the complexity of palliative care needs is a key aspect of referral to specialized multidisciplinary early palliative care (EPC) teams. The PALCOM scale is an instrument consisting of five multidimensional assessment domains developed in 2018 and validated in 2023 to identify the level of complexity in patients with advanced cancer. (1) Objectives: The main objective of this study was to determine the degree of instability (likelihood of level change or death), health resource consumption and the survival of patients according to the level of palliative complexity assigned at the baseline visit during a 6-month follow-up. (2) Method: An observational, prospective, multicenter study was conducted using pooled data from the development and validation cohort of the PALCOM scale. The main outcome variables were as follows: (a) instability ratio (IR), defined as the probability of level change or death; (b) emergency department visits; (c) days of hospitalization; (d) hospital death; (e) survival. All the variables were analyzed monthly according to the level of complexity assigned at the baseline visit. (3) Results: A total of 607 patients with advanced cancer were enrolled. According to the PALCOM scale, 20% of patients were classified as low complexity, 50% as medium and 30% as high complexity. The overall IR was 45% in the low complexity group, 68% in the medium complexity group and 78% in the high complexity group (p < 0.001). No significant differences in mean monthly emergency department visits (0.2 visits/ patient/month) were observed between the different levels of complexity. The mean number of days spent in hospital per month was 1.5 in the low complexity group, 1.8 in the medium complexity group and 3.2 in the high complexity group (p < 0.001). The likelihood of in-hospital death was significantly higher in the high complexity group (29%) compared to the medium (16%) and low (8%) complexity groups (p < 0.001). Six-month survival was significantly lower in the high complexity group (24%) compared to the medium (37%) and low (57%) complexity groups (p < 0.001). CONCLUSION: According to the PALCOM scale, more complex cases are associated with greater instability and use of hospital resources and lower survival. The data also confirm that the PALCOM scale is a consistent and useful tool for describing complexity profiles, targeting referrals to the EPC and managing the intensity of shared care.

Clinical characterization and detection of subclinical atherosclerosis in subjects with extreme hyperalphalipoproteinemia. / Caracterización clínica y detección de arteriosclerosis subclínica en sujetos con hiperalfalipoproteinemia extrema.

INTRODUCTION AND OBJECTIVES: The association between HDL cholesterol (HDL-C) levels and death from cardiovascular disease follows a U-shaped pattern, increasing at the extremes. The objective of the study was to characterize a sample of subjects with extreme hyperalphalipoproteinemia (HAE). MATERIAL AND METHODS: 53 cases with HAE were recruited, 24 women (HDL-C>135mg/ dL) and 29 men (HDL-C>116mg/ dL). A detailed medical history was taken and questionnaires on adherence to the Mediterranean diet and physical activity were collected. Carotid ultrasounds were performed to detect the presence of suclinical atherosclerosis. RESULTS: The most prevalent cardiovascular risk factor (CVRF) was dyslipidemia (64%) with no significant differences between men and women, unlike hypertension (21% in women, versus 55% in men, p=0.01) and others CVRF, for example, diabetes. 7% of the series had previous cardiovascular disease, women had higher LDL cholesterol (p=0.002) and HDL-C than men (without significant differences). Plaque was detected in 53% of cases, being more prevalent in men. Patients with plaque were older, drank more alcohol and smoked more (p<0.05). CONCLUSIONS: Men had a higher prevalence of CVRF than women, except for dyslipidemia. Subclinical atherosclerosis occurred in more than half of the series. Age, alcohol consumption and smoking were independently associated with the presence of plaque, however, our data do not show a significant influence of HDL-C levels.