Detection of anti-HCV antibodies and risk factors in a population with access to public healthcare in Mexico.

INTRODUCTION AND AIM: Timely detection and diagnosis of hepatitis C virus (HCV) involves identifying the population that is predisposed to treatment and prevention, thus limiting complications and preventing infection. The aim of this study was to analyze and describe risk factors associated with anti-HCV antibody detection in a population with access to public healthcare that participated in a national screening program. MATERIAL AND METHODS: An analytic cross-sectional study was conducted that utilized data related to rapid tests carried out between September 2021 and October 2022 in 26 of the 32 states of Mexico. Anti-HCV reactive tests were selected, according to age and sex, for analyzing and comparing possible risk factors through descriptive and inferential statistics. The geographic distribution and density of the screening program at the state and municipal levels was analyzed. RESULTS: There were 75,185 anti-HCV antibody detections, 2,052 reactive tests, and mean participant age was 44.3 years (±15.1). Occupation: 32.3% were employees, 19% were housewives, and 18.2% were healthcare workers. Five out of every 10 cases had no indication of risk factors, but there was a 1.4 and 5-times greater likelihood of anti-HCV detection in men with a history of sharps injury or intravenous psychoactive substance use, compared with women. Regarding place of residence, 80% of the reactive tests were concentrated in the State of Mexico, Mexico City, and Guanajuato. CONCLUSIONS: The evidence herein helps determine the population and risk factors that should be focused on in carrying out the HCV microelimination strategy of continuous screening, diagnosis, medical treatment access, and epidemiologic surveillance.

Indicators sandflies and environment associated to spatial landscaping change in Chocó Biosphere Reserve UNESCO.

BACKGROUND OBJECTIVES: Sandflies are vector insects associated with terrestrial forest ecosystems; in the Ecuadorian Andes, they participate in the transmission of human cutaneous leishmaniasis. This geographical area represents an opportunity to evaluate the role of sandflies as bioindicators of the degree of intervention of tropical humid forest ecosystems (THF) associated with changes in the ecology of the local landscape. METHODS: CDC-light traps were used for collecting adult sandflies in February 2020 in a humid tropical forest within the Chocó Biosphere Reserve. All species were identified using morphological keys. Analysis data about abundance, richness, species accumulation, diversity index, species composition communities, species sex proportion, spatial sandflies environmental, Renyi's Diversity Profile were performed to compare six spatial habitats in Mashpi locality, Ecuador. RESULTS: Sandflies were collected (n-1435); the main species are represented by Trichophoromyia reburra, Nyssomyia trapidoi, Psathyromyia aclydifera, Psychodopygus panamensis and Lutzomyia hartmanni. Only Th. reburra is associated with not intervened forest, while the other three species are associated with intervened forest within Mashpi in the Choco Biosphere Reserve. The secondary forest has major sandflies' richness, while the primary forest exhibits major abundance. INTERPRETATION CONCLUSION: Th. reburra is a sandfly restricted to the Andean Forest and is a bioindicator of the high environmental health quality of the forest, while Ny. trapidoi and Pa. aclydifera are bioindicators of environmental disturbances in the forest. Additionally, Ps. panamensis, Lu. hartmanni and Ny. trapidoi are bioindicators of human impact and the risk of leishmaniasis.

Persistent pulmonary abnormalities after 18 months of SARS-CoV-2 pneumonia.

OBJECTIVE: To describe persistent pulmonary abnormalities detected on HRCT after 18 months of SARS-CoV-2 pneumonia, and to determine their extension and correlation with pulmonary function. PATIENTS AND METHODS: A prospective cross-sectional study with an initial cohort of 90 patients in follow-up due to persisting lung abnormalities on imaging, functional respiratory impairment and/or respiratory symptoms. Of these, 31 (34%) were selected for analysis due to the persistence of their lung abnormalities on HRCT at 18 months after infection. A double reading was performed for each HRCT (62 observations). RESULTS: Of the 31 patients included: 20 (65%) were men; mean age was 67 years; 17 (55%) were smokers/ex-smokers. The mean hospitalisation time was 38 days. Eighteen (58%) patients were admitted to intensive care units. Five patients (16%) suffered an acute pulmonary thromboembolism and three (9.7%) had a pneumothorax. The mean time between the onset of pneumonia and the follow-up HRCT was 20.34 months. Nineteen percent of patients suffered from total lung function abnormalities; and ground-glass opacities and reticulation were present in 12% and 4.5% respectively. The findings of the 62 readings were: ground-glass opacities (100%), reticulation (83%), subpleural curvilinear lines (62%), parenchymal bands (34%), traction bronchiectasis (69%), displacement of vessels/fissures (46%) and honeycombing (4.9%). Pulmonary function 18 months after the acute episode revealed a mean FVC of 92% of predicted value, with an FVC < 80% of predicted value in 11 patients (35.4%). Mean DLCO was 71% of predicted value, with a DLCO < 80% in 22 patients (70%). We observed a statistically significant relationship between total lung function abnormalities on HRCT and FVC (P < 0.05), and a trend towards statistical significance with DLCO (P = 0.051); there was a statistically significant relationship between the presence of ground-glass opacities and FEV1/FVC (P < 0.01). The relationships between reticulation and FVC, FVC%, FEV1, FEV1% and DLCO% were also considered statistically significant (P < 0.05). CONCLUSION: Persistent interstitial lung abnormalities are seen on HRCT for a subset of patients infected with SARS-CoV-2 pneumonia. Seventy percent of these patients suffered a slight decrease in DLCO.

Bacterial community assessment of drinking water and downstream distribution systems in highland localities of Ecuador.

Bacterial communities in drinking water provide a gauge to measure quality and confer insights into public health. In contrast to urban systems, water treatment in rural areas is not adequately monitored and could become a health risk. We performed 16S rRNA amplicon sequencing to analyze the microbiome present in the water treatment plants at two rural communities, one city, and the downstream water for human consumption in schools and reservoirs in the Andean highlands of Ecuador. We tested the effect of water treatment on the diversity and composition of bacterial communities. A set of physicochemical variables in the sampled water was evaluated and correlated with the structure of the observed bacterial communities. Predominant bacteria in the analyzed communities belonged to Proteobacteria and Actinobacteria. The Sphingobium genus, a chlorine resistance group, was particularly abundant. Of health concern in drinking water reservoirs were Fusobacteriaceae, Lachnospiraceae, and Ruminococcaceae; these families are associated with human and poultry fecal contamination. We propose the latter families as relevant biomarkers for establishing local standards for the monitoring of potable water systems in highlands of Ecuador. Our assessment of bacterial community composition in water systems in the Ecuadorian highlands provides a technical background to inform management decisions.

Prevalence and Risk Factors of Eimeria spp. in Broiler Chickens from Pichincha and Santo Domingo de los Tsáchilas, Ecuador.

Coccidiosis in chickens is a parasitic disease of economic importance for the poultry industry. In Ecuador, there is limited information regarding the prevalence of Eimeria spp. on commercial broiler farms. Therefore, a total of 155 poultry farms in the provinces of Pichincha and Santo Domingo de los Tsáchilas were surveyed. The analysis of fresh fecal samples was conducted to determine the parasitic load of six of the seven chicken Eimeria species (excluding E. mitis) through multiplex PCR. Additionally, an epidemiological survey was performed to assess the risk factors associated with the infection using a multivariable logistic regression model. All samples tested positive for the presence of Eimeria spp., despite the farmers having implemented prophylactic measures, and no clinical coccidiosis cases were recorded. The parasitic load varied between 25 and 69,900 oocyst per gram. The species prevalence was as follows: Eimeria spp. 100%, E. maxima 80.4%, E. acervulina 70.6%, E. praecox 55.4%, E. tenella 53.6%, E. necatrix 52.2%, and E. brunetti 30.8%. The main species combination was E. cervuline, E. maxima, E. necatrix, and E. praecox (23.90%), followed by E. tenella, as a unique species (10.69%), and then E. acervulina, E. maxima, and E. praecox (8.81%). It was observed that farms operated by independent producers had a higher amount of Eimeria spp. and higher probability of the presence of E. brunetti, E. necatrix, E. praecox, and E. tenella. Poultry houses located below 1300 m above sea level were associated with a higher parasitic load and the presence of E. brunetti. Birds younger than 35 days of age and from open-sided poultry houses (with rudimentary environmental control) had a higher probability of presenting E. maxima. Drinking water from wells increased the risk of E. praecox presence. Research aimed at designing control strategies to improve health management on poultry farms in the region would help minimize the impact of coccidiosis.

Indicators sand flies and environment associated to spatial landscaping change in Choco Biosphere Reserve UNESCO.

BACKGROUND OBJECTIVES: Sand flies are insects vector associated with terrestrial forest ecosystems; in the Ecuadorian Andes, they participate in the transmission of human cutaneous leishmaniasis. This geographical area is an opportunity to evaluate the role of sand flies as bioindicators od the degree of intervention of a tropical humid forest ecosystems (THF) associated with changes in the ecology of the local landscape. METHODS: CDC-light traps were used for collecting adults' sand flies in February 2020 in a humid tropical forest within Choco Biosphere Reserve. All species were identified using morphological keys. Analysis data about abundance, richness, species accumulation, diversity index, species composition communities, species sex proportion, spatial sand flies environmental, Renyi's Diversity Profile were performed to compare six spatial habitats in Mashpi locality, Ecuador. RESULTS: Sand flies were collected (n-1435); the main species are represented by Th. reburra Ny. trapidoi, Pa. aclydifera, Py. panamensis and Lu. hartmanni. Only Th. reburra is associated with not intervened forest, while the other 3 species are associated with intervened forest within Mashpi in the Choco Biosphere Reserve. The secondary forest has the major sandflies' richness, while the primary forest exhibits the major abundance. INTERPRETATION CONCLUSION: The results indicated that Th. reburra is a sandfly restricted to the Andean Forest and is a bioindicator of the high environmental health quality of the forest, while Ny. trapidoi and Pa. aclydifera are bioindicators of environmental disturbances in the forest. Additionally, Ps. panamensis, Lu. hartmanni and Ny. trapidoi are bioindicators of human impact and the risk of leishmaniasis.

The microbiome of the ice-capped Cayambe Volcanic Complex in Ecuador.

A major challenge in microbial ecology is to understand the principles and processes by which microbes associate and interact in community assemblages. Microbial communities in mountain glaciers are unique as first colonizers and nutrient enrichment drivers for downstream ecosystems. However, mountain glaciers have been distinctively sensitive to climate perturbations and have suffered a severe retreat over the past 40 years, compelling us to understand glacier ecosystems before their disappearance. This is the first study in an Andean glacier in Ecuador offering insights into the relationship of physicochemical variables and altitude on the diversity and structure of bacterial communities. Our study covered extreme Andean altitudes at the Cayambe Volcanic Complex, from 4,783 to 5,583 masl. Glacier soil and ice samples were used as the source for 16S rRNA gene amplicon libraries. We found (1) effects of altitude on diversity and community structure, (2) the presence of few significantly correlated nutrients to community structure, (3) sharp differences between glacier soil and glacier ice in diversity and community structure, where, as quantified by the Shannon γ-diversity distribution, the meta-community in glacier soil showed more diversity than in glacier ice; this pattern was related to the higher variability of the physicochemical distribution of variables in the former substrate, and (4) significantly abundant genera associated with either high or low altitudes that could serve as biomarkers for studies on climate change. Our results provide the first assessment of these unexplored communities, before their potential disappearance due to glacier retreat and climate change.

Management of acute stroke. Specific nursing care and treatments in the stroke unit.

OBJECTIVE: This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS: We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS: The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS: These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.

Beta-Lactam Antibiotic Resistance Genes in the Microbiome of the Public Transport System of Quito, Ecuador.

Multidrug-resistant bacteria present resistance mechanisms against ß-lactam antibiotics, such as Extended-Spectrum Beta-lactamases (ESBL) and Metallo-ß-lactamases enzymes (MBLs) which are operon encoded in Gram-negative species. Likewise, Gram-positive bacteria have evolved other mechanisms through mec genes, which encode modified penicillin-binding proteins (PBP2). This study aimed to determine the presence and spread of ß-lactam antibiotic resistance genes and the microbiome circulating in Quito's Public Transport (QTP). A total of 29 station turnstiles were swabbed to extract the surface environmental DNA. PCRs were performed to detect the presence of 13 antibiotic resistance genes and to identify and to amplify 16S rDNA for barcoding, followed by clone analysis, Sanger sequencing, and BLAST search. ESBL genes blaTEM-1 and blaCTX-M-1 and MBL genes blaOXA-181 and mecA were detected along QPT stations, blaTEM being the most widely spread. Two subvariants were found for blaTEM-1, blaCTX-M-1, and blaOXA-181. Almost half of the circulating bacteria found at QPT stations were common human microbiota species, including those classified by the WHO as pathogens of critical and high-priority surveillance. ß-lactam antibiotic resistance genes are prevalent throughout QPT. This is the first report of blaOXA-181 in environmental samples in Ecuador. Moreover, we detected a new putative variant of this gene. Some commensal coagulase-negative bacteria may have a role as mecA resistance reservoirs.

Multidisciplinary approach of the sequelae one month after hospital discharge in patients with severe bilateral COVID-19 pneumonia, are there differences depending on the respiratory therapy used during admission to intensive care?

OBJECTIVE: To describe the sequelae one month after hospital discharge in patients who required admission to Intensive Care for severe COVID 19 pneumonia and to analyze the differences between those who received therapy exclusively with high-flow oxygen therapy compared to those who required invasive mechanical ventilation. DESIGN: Cohort, prospective and observational study. SETTING: Post-intensive care multidisciplinary program. PATIENTS OR PARTICIPANTS: Patients who survived admission to the intensive care unit (ICU) for severe COVID 19 pneumonia from April 2020 to October 2021. INTERVENTIONS: Inclusion in the post-ICU multidisciplinary program. MAIN VARIABLES OF INTEREST: Motor, sensory, psychological/psychiatric, respiratory and nutritional sequelae after hospital admission. RESULTS: 104 patients were included. 48 patients received high-flow nasal oxygen therapy (ONAF) and 56 invasive mechanical ventilation (IMV). The main sequelae found were distal neuropathy (33.9% IMV vs 10.4% ONAF); brachial plexopathy (10.7% IMV vs 0% ONAF); decrease in grip strength: right hand 20.67kg (±8.27) in VMI vs 31.8kg (±11.59) in ONAF and left hand 19.39kg (±8.45) in VMI vs 30.26kg (±12.74) in ONAF; and limited muscle balance in the lower limbs (28.6% VMI vs 8.6% ONAF). The differences observed between both groups did not reach statistical significance in the multivariable study. CONCLUSIONS: The results obtained after the multivariate study suggest that there are no differences in the perceived physical sequelae one month after hospital discharge depending on the respiratory therapy used, whether it was high-flow nasal oxygen therapy or prolonged mechanical ventilation, although more studies are needed to be able to draw conclusions.

[Multidisciplinary approach of the sequelae one month after hospital discharge in patients with severe bilateral COVID-19 pneumonia, are there differences depending on the respiratory therapy used during admission to intensive care?] / Valoración multidisciplinar de las secuelas al mes del alta hospitalaria por neumonía grave COVID-19, ¿existen diferencias en función de la terapia respiratoria empleada durante su ingreso en Cuidados Intensivos?

Objective: To describe the sequelae one month after hospital discharge in patients who required admission to intensive care for severe COVID-19 pneumonia and to analyze the differences between those who received therapy exclusively with high-flow oxygen therapy compared to those who required invasive mechanical ventilation. Design: Cohort, prospective and observational study. Setting: Post-intensive care multidisciplinary program. Patients or participants: Patients who survived admission to the intensive care unit (ICU) for severe COVID-19 pneumonia from April 2020 to October 2021. Interventions: Inclusion in the post-ICU multidisciplinary program. Main variables of interest: Motor, sensory, psychological/psychiatric, respiratory and nutritional sequelae after hospital admission. Results: One hundred and four patients were included. 48 patients received high-flow nasal oxygen therapy (ONAF) and 56 invasive mechanical ventilation (IMV). The main sequelae found were distal neuropathy (33.9% IMV vs. 10.4% ONAF); brachial plexopathy (10.7% IMV vs. 0% ONAF); decrease in grip strength: right hand 20.67 kg (± 8.27) in VMI vs. 31.8 kg (± 11.59) in ONAF and left hand 19.39 kg (± 8.45) in VMI vs. 30.26 kg (± 12.74) in ONAF; and limited muscle balance in the lower limbs (28.6% VMI vs. 8.6% ONAF). The differences observed between both groups did not reach statistical significance in the multivariable study. Conclusions: The results obtained after the multivariate study suggest that there are no differences in the perceived physical sequelae one month after hospital discharge depending on the respiratory therapy used, whether it was high-flow nasal oxygen therapy or prolonged mechanical ventilation, although more studies are needed to be able to draw conclusions.

Immune response in breast cancer surgery. A comparative and prospective study of different anesthetic techniques.

INTRODUCTION: The main reason for high mortality in breast cancer is local recurrence and metastasis, despite surgery as the first therapeutic option. The anesthesia used in the operation room can determine the immune response. METHODS: A prospective, comparative and non- randomised study in patients undergoing breast cancer surgery was conducted in our hospital after obtaining approval from the Hospital's Institutional Review Board. Patients were divided in two groups: Group A received general anesthesia with propofol and opioids. Group B, in addition to general anesthesia, three interfascial blocks (Pec I, Pec II and BRILMA) were performed in all patients. Three blood samples were taken 1) previous anesthetic induction; 2) two hours after the end of the surgery and 3) 24-48 h after surgery. Leukocytes, CD3, CD4, CD8 and Natural Killer cells were determined at each time. RESULTS: 103 patients were included. 59 (group A) received general anesthesia and 54 (group B) general anesthesia and interfascial blocks. Regarding baseline characteristics, age was significantly higher in the group that received general anesthesia and mastectomy was more frequent in the group that received interfascial blocks. We observed after surgery an increase in leukocytes level that returns close to baseline levels. On the other hand, a reduction in the immune response was observed that also returns to the previous level 48 h after surgery. Group A and B get similar results and also subgroups of hormonal receptors (HER+, PR and/or ER+). CONCLUSIONS: Interfascial blocks in chest wall added to general anesthesia in breast cancer surgery has not shown a significant difference in the inflammatory response or immunological depression compared to general anesthesia as the only anesthetic technique. It seems to trend less immunological depression in the interfascial block group.

Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion.

INTRODUCTION: Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. MATERIAL AND METHODS: Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. RESULTS: The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60 min between G1-G3 (p = 0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (p = 0.6) or the number of lymph nodes removed (p = 0.061). The postoperative complication rate was 77% and did not change during the LC (p = 0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (p = 0.217). CONCLUSIONS: The inclusion of junior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.

[Evaluation of a general education course on sexuality for university students]. / Educación sexual en las carreras de la salud del Campus Eloísa Díaz de la Universidad de Chile.

BACKGROUND: Education on human sexuality was instituted in Eloisa Díaz Campus in 1946. From 2018 an online self-learning general education course on sexuality was started. AIM: To know the degree of knowledge about sexuality and the perception about the course of 586 students (42% women) who approved the course. MATERIAL AND METHODS: The Myths and False beliefs and Self-perception on sexuality tests were applied to students at the onset and the end of the course. They also anonymously evaluated the course. RESULTS: In the first assessment, the proportion of correct answers about sexuality and reproduction were 47 and 40% respectively. In the second assessment, 70% of respondents had open criteria about sexuality and 90% rejected traditional criteria. In the anonymous assessment, 95% estimated that the objectives of the course were accomplished. Its quality was considered good or excellent by 95% of respondents. CONCLUSIONS: This course was well accepted by students and corrects their knowledge gaps in sexuality. Despite the social unrest during 2019 and the pandemic during 2020, the course was successfully completed by most students.

A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment.

INTRODUCTION: Recent analyses emphasise that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays. MATERIAL AND METHODS: In 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced. RESULTS: The sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52min], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the "3-hour-effect" did not affect door-to-needle time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases. CONCLUSIONS: Hospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90min of symptom onset.

Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion. / Análisis del impacto de la curva de aprendizaje de la cistectomía radical asistida por robot con derivación urinaria intracorpórea sobre los resultados perioperatorios.

INTRODUCTION: Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. MATERIAL AND METHODS: Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. RESULTS: The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60minutes between G1-G3 (P=0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (P=0.6) or the number of lymph nodes removed (P=0.061). The postoperative complication rate was 77% and did not change during the LC (P=0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (P=0.217). CONCLUSIONS: The inclusion of júnior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.

[Optimizing the detection of subclinical atrial fibrillation after ESUS]. / Optimización de la detección de fibrilación auricular subclínica tras un ESUS.

INTRODUCTION: It has been estimated that approximately 20% of ischemic strokes have a cardioembolic origin and the cause is not detected or there are more than one in 9-25% of ischemic strokes. An adequate diagnostic approach of ESUS would allow an optimization of antithrombotic treatment. OBJECTIVE: Narrative update about the available evidence on the best diagnostic and therapeutic approach among patients with ESUS and how to optimize the detection of atrial fibrillation as a potential cause is reviewed. DEVELOPMENT: A search was conducted on PubMed (MEDLINE), using the MeSH terms [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Original data from clinical trials, prospective and retrospective studies and reviews were selected. CONCLUSIONS: The detection of atrial fibrillation after ESUS is mandatory to optimize the treatment. However, not all patients have the same risk of developing silent atrial fibrillation. There are some factors that increase this risk (left atrium enlargement, elderly, frequent premature supraventricular complexes). In these patients, a more prolonged monitorization could increase the possibility of detecting atrial fibrillation, and consequently, to benefit more from anticoagulant treatment.

TITLE: Optimización de la detección de fibrilación auricular subclínica tras un ESUS.Introducción. Se ha estimado que aproximadamente el 20% de los ictus isquémicos tiene un origen cardioembólico y que no se detecta la causa o que puede haber más de una en el 9-25% de ellos. Un proceso diagnóstico adecuado de ESUS permitiría optimizar el tratamiento antitrombótico. Objetivo. Revisión bibliográfica sobre la evidencia disponible acerca de la mejor aproximación diagnóstica y terapéutica de los pacientes con ESUS y cómo optimizar la detección de la posible fibrilación auricular como causa. Desarrollo. Se realizó una búsqueda a través de PubMed (MEDLINE), mediante los términos MeSH [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Se seleccionaron publicaciones originales de ensayos clínicos, y estudios prospectivos, retrospectivos y de revisión. Conclusiones. La detección de fibrilación auricular tras un ESUS es fundamental para optimizar el tratamiento. Sin embargo, no todos los pacientes tienen el mismo riesgo de presentar fibrilación auricular silente. Existen determinados factores que incrementan este riesgo (dilatación de la aurícula izquierda, edad avanzada, extrasistolia supraventricular frecuente). En estos pacientes, una monitorización más prolongada permitiría aumentar las posibilidades de diagnóstico de la fibrilación auricular y, por lo tanto, beneficiarse, en mayor medida, del tratamiento anticoagulante para evitar ictus recurrentes.

Causes of hypercalcemia in renal transplant recipients: persistent hyperparathyroidism and others.

Hypercalcemia is common in patients after kidney transplantation (KTx) and is associated with persistent hyperparathyroidism in the majority of cases. This retrospective, single-center study evaluated the prevalence of hypercalcemia after KTx. KTx recipients were evaluated for 7 years after receiving kidneys from living or deceased donors. A total of 301 patients were evaluated; 67 patients had hypercalcemia at some point during the follow-up period. The median follow-up time for all 67 patients was 62 months (44; 80). Overall, 45 cases of hypercalcemia were classified as related to persistent post-transplant hyperparathyroidism (group A), 16 were classified as "transient post-transplant hypercalcemia" (group B), and 3 had causes secondary to other diseases (1 related to tuberculosis, 1 related to histoplasmosis, and 1 related to lymphoma). The other 3 patients had hypercalcemia of unknown etiology, which is still under investigation. In group A, the onset of hypercalcemia after KTx was not significantly different from that of the other groups, but the median duration of hypercalcemia in group A was 25 months (12.5; 53), longer than in group B, where the median duration of hypercalcemia was only 12 months (10; 15) (P<0.002). The median parathyroid hormone blood levels around 12 months after KTx were 210 pg/mL (141; 352) in group A and 72.5 pg/mL (54; 95) in group B (P<0.0001). Hypercalcemia post-KTx is not infrequent and its prevalence in this center was 22.2%. Persistent hyperparathyroidism was the most frequent cause, but other important etiologies must not be forgotten, especially granulomatous diseases and malignancies.

Estrogen-secreting adrenocortical tumor in a postmenopausal woman: a challenging diagnosis.

SUMMARY: Adrenocortical carcinoma (ACC) is a malignant disorder with rapid evolution and severe prognosis in adults and most produce cortisol and androgen. Estrogen-secreting adrenocortical carcinomas are extremely rare, especially in women, tend to be larger and have worse prognosis compared with other types of ACCs. We report the case of a 58-year-old woman who presented with bilateral breast enlargement and postmenopausal genital bleeding. She presented high estradiol (818 pg/mL - 25 times above upper normal limit for postmenopausal women) and testosterone (158 ng/dL - 2 times above upper normal limit) levels and no suppression of cortisol after overnight 1 mg dexamethasone test (12.5 µg/dL; normal reference value: < 1.8 µg/dL). The patient had no clinical features of cortisol excess. MRI showed a 12 cm tumor in the right adrenal. Clinical findings of bilateral breast enlargement and postmenopausal genital bleeding with no signs of hypercortisolism associated with hormonal findings of elevated estradiol and testosterone levels would indicate either an ovarian etiology or an adrenal etiology; however, in the context of plasma cortisol levels non-suppressive after dexamethasone test and the confirmation of an adrenal tumor by MRI, the diagnosis of an adrenal tumor with mixed hormonal secretion was made. The patient underwent an open right adrenalectomy and pathological examination revealed an ACC with a Weiss' score of 6. Estradiol and testosterone levels decreased to normal range soon after surgery. She was put on mitotane treatment as adjuvant therapy, but due to side effects, we were unable to up-titrate the dose and she never achieved serum mitotane dosage above the desired 14 µg/mL. The patient remained in good health without any local recurrence or metastasis until 5 years after surgery, when increased levels of estradiol (81 pg/mL - 2.5 times above upper normal limit) and testosterone (170 ng/dL - 2.1 times above upper normal limit) were detected. MRI revealed a retroperitoneal nodule measuring 1.8 × 1.2 cm. The pathological finding confirmed the recurrence of the estrogen-secreting ACC with a Weiss' score of 6. After the second procedure, patient achieved normal estrogen and androgen serum levels and since then she has been followed for 3 years. The overall survival was 8 years after the diagnosis. In conclusion, although extremely rare, a diagnosis of an estrogen-secreting ACC should be considered as an etiology in postmenopausal women presenting with bilateral breast enlargement, genital bleeding and increased pure or prevailing estrogen secretion. LEARNING POINTS: Estrogen-secreting adrenocortical carcinomas are exceedingly rare in adults and account for 1-2% of adrenocortical carcinomas. Estrogen-secreting adrenal tumors can be present in females, but are even more rare, we found few cases described in the literature. In women, they present with precocious puberty or postmenopausal bleeding. Feminization in the context of an adrenal tumor is considered almost pathognomonic of malignancy. Feminizing ACCs tend to be larger and with worse prognosis compared with nonfeminizing ACCs.