An optimisation approach for planning preventive drought management measures.

While drought impacts are widespread across the globe, climate change projections indicate more frequent and severe droughts. This underscores the pressing need to increase resistance and resilience to drought. The strategic application of Preventive Drought Management Measures (PDMMs) is a suitable avenue to reduce the likelihood of drought and ameliorate associated damages. In this study, we use an optimisation approach with a multicriteria decision-making method to allocate PDMMs for reducing the severity of agricultural and hydrological droughts. The results indicate that implementing PDMMs can reduce the severity of agricultural and hydrological droughts, and the obtained management scenarios (solutions) highlight the utility of multi-objective optimisation for PDMMs planning. However, examined management scenarios also illustrate the trade-off between managing agricultural and hydrological droughts. PDMMs can alleviate the severity of agricultural droughts while producing opposite effects for hydrological droughts (or vice versa). Furthermore, the impact of PDMMs displays temporal and spatial variabilities. For instance, PDMMs implementation within a specific subbasin may mitigate the severity of one type of drought in a given month yet exacerbate drought conditions in preceding or subsequent months. In the case of hydrological droughts, the PDMMs may intensify streamflow deficits in the intervened subbasins while alleviating the hydrological drought severity downstream (or vice versa). These complexities emphasise a customised implementation of PDMMs, considering the basin characteristics (e.g., rainfall distribution over the year, soil properties, land use, and topography) and the quantification of PDMMs' effect on the severity of each type of drought.

Early rehabilitation vs. conventional immobilization in nonoperative treatment of proximal humeral fracture: a systematic review.

OBJECTIVE: Fractures of the proximal humerus (PHF) are commonly treated conservatively. Evidence suggests that a period of immobilization of one week or less may lead to some advantages compared to a traditional 3-4 weeks of immobilization. The purpose of this systematic review was to assess the clinical and radiological results in the case of early rehabilitation vs. delayed rehabilitation after PHF. MATERIALS AND METHODS: In July 2023, a literature search was carried out on the PubMed, MEDLINE, and Embase databases to identify all the randomized trials comparing early rehabilitation vs. delayed rehabilitation after PHF. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, and overall clinical and radiological findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 5 studies, including 378 patients and dealing with early vs. delayed rehabilitation in case of conservative treatment of PHF, were included in this study. Early rehabilitation was started within 1 week and consisted mainly of pendulum exercise and progressive passive mobilization. Early rehabilitation was associated with better pain and functional scores within the first 3 months in 3 studies. No difference in pain or function was reported at 6 months or longer follow-up, and no differences in complications rate were observed between early vs. delayed rehabilitation groups. CONCLUSIONS: This systematic review suggests that early mobilization within one week in case of conservative treatment of PHF leads to improved function recovery and reduced pain, especially in the first months of rehabilitation, without differences at longer follow-up and without increasing complications rate. Reducing immobilization time could accelerate function recovery and regaining independence in daily life activities.

The TEOGIC study project: a comprehensive characterization of early onset gastrointestinal cancer in the Northern area of Spain.

BACKGROUND: Gastrointestinal cancers represent one of the most prevalent diseases worldwide. Strikingly, the incidence of Early Onset Gastrointestinal Cancer (EOGIC) has been rising during the last decades and changes in lifestyle and environmental exposure seem to play a role. EOGIC has been defined as a different entity compared to on-average gastrointestinal cancer, with distinct clinical and molecular characteristics. Inherent to the particularities of younger age, there is an unmet need for a tailored approach for the management of these patients. The TEOGIC proposes a comprehensive study to characterize EOGIC patients in the northern of Spain. METHODS: Patients with histologically confirmed new diagnosis of colorectal, gastroesophageal and pancreatic adenocarcinoma will be considered for two cohorts: EOGIC (≤ 50 years old) and non-EOGIC (60-75 years old), with a ratio of 1:2. Two hundred and forty patients will be recruited in 4 Public Hospitals from northern Spain. After receiving unified informed consent, demographic and clinical data of the patients will be collected in a REDCap database. Lifestyle related data will be obtained in questionnaires assessing diet, physical activity and the general quality of life of the patients before diagnosis. Biological samples prior to any onco-specific treatment will be obtained for the analyses of circulating inflammatory proteins, gut microbiota, and the proteome of the tumor microenvironment. Histologic characteristics and routine biomarkers will be also collected. Thereafter, data will be integrated and analyzed to assess tumor specific, pan-tumor and sex-associated differential characteristics of EOGIC. DISCUSSION: The underlying risk factors and differential characteristics of EOGIC remain poorly studied, particularly in our geographical area. Although limited by the exploratory nature and the small sample size estimated to be recruited, TEOGIC represents the first attempt to comprehensively characterize these young patients, and thus attend to their special needs. Findings derived from this study could contribute to raise awareness and preventive behaviors in the population. In parallel, molecular studies could lead to the identification of potential novel non-invasive biomarkers and therapeutic targets that would help in the development of the tailored clinical management of these patients, focusing on screening programs for early diagnosis and precision medicine.

Neonatal innate immunity response in invasive candidiasis.

Infections caused by Candida spp. are frequent in critically hospitalized patients, especially among premature neonates, representing one of the most common healthcare-related infections. Although there is considerable production of current knowledge about the mechanisms of immune response, aspects involved in the newborn's innate defense are not fully understood. The aim of this study was to describe the innate immune mechanisms involved in the defense of neonates against invasive candidiasis. This is an integrative literature review from the Scopus, Scifinder, Medline, Web of Science databases and the electronic libraries ScienceDirect and Scielo, in the period between 2002 and 2020, with rescue based on primary descriptor Immunity Innate plus secondary descriptors Candidiasis Invasive AND Infant Newborn. We have observed the involvement of various mechanisms in the neonatal response against invasive candidiasis, including the recognition, signaling, recruitment, and initiation of an effective immune response. These mechanisms encompass the presence of antimicrobial peptides, phagocytosis, synthesis of reactive oxygen species, inflammatory mediators, and complex cell signaling systems mediated by Pattern Recognition Receptors (PRRs). With this study, it is expected to contribute to the expansion of knowledge about the immunological mechanisms involved in the innate immune response of the newborn against disseminated infections caused by Candida species, and in the same sense, highlight the importance of this knowledge as a reflex in the decrease in mortality in the neonatal period.

Modulation of Phospholipase A2 Membrane Activity by Anti-inflammatory Drugs.

The phospholipase A2 (PLA2) superfamily consists of lipolytic enzymes that hydrolyze specific cell membrane phospholipids and have long been considered a central hub of biosynthetic pathways, where their lipid metabolites exert a variety of physiological roles. A misregulated PLA2 activity is associated with mainly inflammatory-derived pathologies and thus has shown relevant therapeutic potential. Many natural and synthetic anti-inflammatory drugs (AIDs) have been proposed as direct modulators of PLA2 activity. However, despite the specific chemical properties that these drugs share in common, little is known about the indirect modulation able to finely tune membrane structural changes at the precise lipid-binding site. Here, we use a novel experimental strategy based on differential scanning calorimetry to systematically study the structural properties of lipid membrane systems during PLA2 cleavage and under the influence of several AIDs. For a better understanding of the AIDs-membrane interaction, we present a comprehensive and comparative set of molecular dynamics (MD) simulations. Our thermodynamic results clearly demonstrate that PLA2 cleavage is hindered by those AIDs that significantly reduce the lipid membrane cooperativity, while the rest of the AIDs oppositely tend to catalyze PLA2 activity to different extents. On the other hand, our MD simulations support experimental results by providing atomistic details on the binding, insertion, and dynamics of each AID on a pure lipid system; the drug efficacy to impact membrane cooperativity is related to the lipid order perturbation. This work suggests a membrane-based mechanism of action for diverse AIDs against PLA2 activity and provides relevant clues that must be considered in its modulation.

Heterogeneity of sensitization profiles and clinical phenotypes among patients with seasonal allergic rhinitis in Southern European countries-The @IT.2020 multicenter study.

BACKGROUND: Pollen allergy poses a significant health and economic burden in Europe. Disease patterns are relatively homogeneous within Central and Northern European countries. However, no study broadly assessed the features of seasonal allergic rhinitis (SAR) across different Southern European countries with a standardized approach. OBJECTIVE: To describe sensitization profiles and clinical phenotypes of pollen allergic patients in nine Southern European cities with a uniform methodological approach. METHODS: Within the @IT.2020 multicenter observational study, pediatric and adult patients suffering from SAR were recruited in nine urban study centers located in seven countries. Clinical questionnaires, skin prick tests (SPT) and specific IgE (sIgE) tests with a customized multiplex assay (Euroimmun Labordiagnostika, Lübeck, Germany) were performed. RESULTS: Three hundred forty-eight children (mean age 13.1 years, SD: 2.4 years) and 467 adults (mean age 35.7 years SD: 10.0 years) with a predominantly moderate to severe, persistent phenotype of SAR were recruited. Grass pollen major allergenic molecules (Phl p 1 and/or Phl p 5) ranged among the top three sensitizers in all study centers. Sensitization profiles were very heterogeneous, considering that patients in Rome were highly poly-sensitized (sIgE to 3.8 major allergenic molecules per patient), while mono-sensitization was prominent and heterogeneous in other cities, such as Marseille (sIgE to Cup a 1: n = 55/80, 68.8%) and Messina (sIgE to Par j 2: n = 47/82, 57.3%). Co-sensitization to perennial allergens, as well as allergic comorbidities also broadly varied between study centers. CONCLUSIONS: In Southern European countries, pollen allergy is heterogeneous in terms of sensitization profiles and clinical manifestations. Despite the complexity, a unique molecular, multiplex, and customized in-vitro IgE test detected relevant sensitization in all study centers. Nevertheless, this geographical diversity in pollen allergic patients imposes localized clinical guidelines and study protocols for clinical trials of SAR in this climatically complex region.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I.

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II.

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Congenital ectropion in Noonan syndrome.

Ten-year-old female patient, with facial dysmorphia, scoliosis, short stature, muscular hypotonia, patent foramen ovale and maturational delay, presented for correction of bilateral congenital ectropion. Ophthalmological examination revealed bilateral lower eyelid ectropion, euryblepharon and lagophthalmos, with a positive Bell's phenomenon. She was treated with full-thickness autologous skin grafts on the lower eyelids with bilateral lateral canthoplasty, resolving the ectropion and improving eyelid occlusion. Subsequently, a genetic study was performed that revealed a mutation in the PTPN11 gene and allowed, together with the clinical picture, to make the diagnosis of Noonan syndrome. Noonan syndrome is a multisystem genetic disorder with a wide variety of phenotypes, which usually presents with ocular and periocular disorders. Eyelid ectropion, a distinctive feature of this patient, is a rare ophthalmological manifestation of this syndrome that can be corrected with full-thickness skin graft and lateral canthoplasty.

[Translated article] Requirements for Accessing New Dermatology Drugs in Spain: Results of the EQUIDAD Study.

BACKGROUND: Although the Spanish Ministry of Health prepares national therapeutic positioning reports (TPRs) and drug reimbursement policies, each of the country's 17 autonomous communities (ACs) is responsible for health care services and prescription requirements in its territory. The aim of the EQUIDAD study was to describe and explore potential differences in prescription requirements for new dermatology drugs across the autonomous communities. MATERIAL AND METHODS: Cross-sectional study conducted in April and May, 2023. Two dermatologists with management responsibilities from each autonomous community reported on territorial and more local prescription requirements for drugs covered by national TPRs issued between 2016 and 2022. RESULTS: Thirty-three researchers from 17 autonomous communities participated. The data submitted revealed between-community inequities in access to new drugs. Overall, 64.7% of the regions imposed additional prescription requirements to those mentioned in the TPRs for psoriasis. This percentage was lower for atopic dermatitis (35.3%) and melanoma (11.8%). The most common requirement for accessing a new drug was a previous prescription for another drug. Differences and additional requirements were also detected at the local level (i.e., differences between hospitals within the same autonomous community). CONCLUSIONS: Spain's autonomous communities have multiple regional and local prescription requirements that are not aligned with national TPR recommendations. These differences result in inequitable access to new drugs for both patients and practitioners across Spain.

Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain. / Cierre de herida en cirugía protésica de rodilla y cadera (PTR y PTC): Resultados de una encuesta sobre la práctica clínica en España.

BACKGROUND AND OBJECTIVE: In orthopedic surgery, it is clear that an optimal standardized closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyze the clinical practice of surgical wound closure in orthopedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain. METHOD: an ad hoc group of specialists in orthopedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings. RESULTS: A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence). CONCLUSIONS: There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.

Requirements for Accessing New Dermatology Drugs in Spain: Results of the EQUIDAD Study. / Condicionantes de acceso a nuevos medicamentos dermatológicos en España: resultados del proyecto EQUIDAD.

BACKGROUND: Although the Spanish Ministry of Health prepares national therapeutic positioning reports (TPRs) and drug reimbursement policies, each of the country's 17 autonomous communities (ACs) is responsible for health care services and prescription requirements in its territory. The aim of the EQUIDAD study was to describe and explore potential differences in prescription requirements for new dermatology drugs across the autonomous communities. MATERIAL AND METHODS: Cross-sectional study conducted in April and May, 2023. Two dermatologists with management responsibilities from each autonomous community reported on territorial and more local prescription requirements for drugs covered by national TPRs issued between 2016 and 2022. RESULTS: Thirty-three researchers from 17 autonomous communities participated. The data submitted revealed between-community inequities in access to new drugs. Overall, 64.7% of the regions imposed additional prescription requirements to those mentioned in the TPRs for psoriasis. This percentage was lower for atopic dermatitis (35.3%) and melanoma (11.8%). The most common requirement for accessing a new drug was a previous prescription for another drug. Differences and additional requirements were also detected at the local level (i.e., differences between hospitals within the same autonomous community). CONCLUSIONS: Spain's autonomous communities have multiple regional and local prescription requirements that are not aligned with national TPR recommendations. These differences result in inequitable access to new drugs for both patients and practitioners across Spain.

[Translated article] Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain.

BACKGROUND AND OBJECTIVE: In orthopaedic surgery, it is clear that an optimal standardised closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyse the clinical practice of surgical wound closure in orthopaedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain. MATERIAL AND METHOD: An ad hoc group of specialists in orthopaedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings. RESULTS: A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence). CONCLUSIONS: There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.

Cerebral microbleeds. Utility of SWI sequences.

OBJECTIVES: Define the concept of cerebral microbleeds (CMBs) and describe the most useful MRI sequences for detecting this finding. Review the entities that most frequently present with CMBs and that may benefit from the use of susceptibility-weighted imaging (SWI) sequences. CONCLUSIONS: SWI is a useful MRI sequence for the detection and characterization of microhemorrhages, venous structures and other sources of susceptibility in imaging. SWI is particularly sensitive to local magnetic field inhomogeneities generated by certain substances and is superior to T2* GRE sequences for this assessment. CMBs may be seen in different neurologic conditions, in certain infrequent clinical contexts and have a key role as a biomarker status in gliomas (ITTS) and as a marker of inflammatory activity in multiple sclerosis.

MAPK11 (p38ß) is a major determinant of cellular radiosensitivity by controlling ionizing radiation-associated senescence: An in vitro study.

Background and purpose: MAPKs are among the most relevant signalling pathways involved in coordinating cell responses to different stimuli. This group includes p38MAPKs, constituted by 4 different proteins with a high sequence homology: MAPK14 (p38α), MAPK11 (p38ß), MAPK12 (p38γ) and MAPK13 (p38δ). Despite their high similarity, each member shows unique expression patterns and even exclusive functions. Thus, analysing protein-specific functions of MAPK members is necessary to unequivocally uncover the roles of this signalling pathway. Here, we investigate the possible role of MAPK11 in the cell response to ionizing radiation (IR). Materials and methods: We developed MAPK11/14 knockdown through shRNA and CRISPR interference gene perturbation approaches and analysed the downstream effects on cell responses to ionizing radiation in A549, HCT-116 and MCF-7 cancer cell lines. Specifically, we assessed IR toxicity by clonogenic assays; DNA damage response activity by immunocytochemistry; apoptosis and cell cycle by flow cytometry (Annexin V and propidium iodide, respectively); DNA repair by comet assay; and senescence induction by both X-Gal staining and gene expression of senescence-associated genes by RT-qPCR. Results: Our findings demonstrate a critical role of MAPK11 in the cellular response to IR by controlling the associated senescent phenotype, and without observable effects on DNA damage response, apoptosis, cell cycle or DNA damage repair. Conclusion: Our results highlight MAPK11 as a novel mediator of the cellular response to ionizing radiation through the control exerted onto IR-associated senescence.

[Patient with cervical spinal cord injury and benign paroxysmal positional vertigo treated with particle repositioning maneuvers]. / Paciente con lesión medular cervical y vértigo posicional paroxístico benigno tratado con maniobras de reposición de partículas.

Benign paroxysmal positional vertigo (BPPV) is characterized by short, sudden episodes of vertigo when the head moves in specific positions. The treatment is particle repositioning maneuvers. BPPV usually is underdiagnosed, unreported and therefore not adequately treated. We present the case of a patient with spinal cord injury and BPPV. A 72-year-old patient who suffered a C5 fracture with spinal cord injury C5 AIS C that required surgical fixation. In the spinal cord injury unit BPPV of the left lateral semicircular canal was documented and treated using specific repositioning maneuvers, the patient progressively improved and was able to complete the rehabilitation treatment. The spinal cord injury unit with access to vestibular rehabilitation units can carry out the diagnosis and specific treatment of BPPV, minimizing the risks for the patient.

Predictive factors of destination at discharge after spinal cord injury.

INTRODUCTION: One of the main goals of the rehabilitation of patients with spinal cord injury (SCI) is the reintegration of the individual to their family, social, and work setting. The objective of this study was to identify the factors that determine the discharge destination after a traumatic spinal cord injury. MATERIAL AND METHODS: We conducted a retrospective descriptive study of 305 patients with SCI who completed the rehabilitation treatment at the spinal injury unit of Hospital Insular de Gran Canaria between 2001 and 2018. RESULTS: During the study period, we observed an increase in the number of patients referred to long-term care centres, from 9.14% between 2001 and 2010 to 18.4% between 2011 and 2018 (P < .01). Of 20 variables that presented a significant association with destination at discharge in the univariate study, 7 presented a significant association in the multivariate study: age (OR: 1.05; 95% CI, 1.02-1.08), living with a partner (OR: 0.26; 95% CI, 0.09-0.76), residing on another island (OR: 3.57; 95% CI, 1.32-9.63), smoking (OR: 3.44; 95% CI, 1.26-9.44), diabetes (OR: 6.51; 95% CI, 1.46-29.02), history of psychiatric disorders (OR: 3.79; 95% CI, 1.31-10.93), and scores on the Spinal Cord Independence Measure-III (SCIM-III) (OR: 0.48; 95% CI, 0.33-0.69). CONCLUSIONS: Our findings identified advanced age, living on the island of Tenerife, not being married, smoking, type 2 diabetes mellitus, history of psychiatric disorders, and low SCIM-III scores as predictive factors of referral to a long-term care centre in patients with traumatic SCI in the Canary Islands.

Experiences that matter in bipolar disorder: a qualitative study using the capability, comfort and calm framework.

BACKGROUND: When assessing the value of an intervention in bipolar disorder, researchers and clinicians often focus on metrics that quantify improvements to core diagnostic symptoms (e.g., mania). Providers often overlook or misunderstand the impact of treatment on life quality and function. We wanted to better characterize the shared experiences and obstacles of bipolar disorder within the United States from the patient's perspective. METHODS: We recruited 24 individuals diagnosed with bipolar disorder and six caretakers supporting someone with the condition. Participants were involved in treatment or support services for bipolar disorder in central Texas. As part of this qualitative study, participants discussed their everyday successes and obstacles related to living with bipolar disorder during personalized, open-ended interviews. Audio files were transcribed, and Nvivo software processed an initial thematic analysis. We then categorized themes into bipolar disorder-related obstacles that limit the patient's capability (i.e., function), comfort (i.e., relief from suffering) and calm (i.e., life disruption) (Liu et al., FebClin Orthop 475:315-317, 2017; Teisberg et al., MayAcad Med 95:682-685, 2020). We then discuss themes and suggest practical strategies that might improve the value of care for patients and their families. RESULTS: Issues regarding capability included the struggle to maintain identity, disruptions to meaningful employment, relationship loss and the unpredictable nature of bipolar disorder. Comfort related themes included the personal perception of diagnosis, social stigma and medication issues. Calm themes included managing dismissive doctors, finding the right psychotherapist and navigating financial burdens. CONCLUSIONS: Qualitative data from patients with bipolar disorder helps identify gaps in care or practical limitations to treatment. When we listen to these individuals, it is clear that treatments must also address the unmet psychosocial impacts of the condition to improve patient care, capability and calm.

Massive hemorrhage after arterioesophageal fistula from an unknown aberrant subclavian artery.

The aberrant right subclavian artery has an incidence of 0.5%-1% in the population, generally with retroesophageal location. It can lead to the formation of an arterio-esophageal fistula in patients with predisposing risk factors due to devices placed in esophageal or tracheal position, as it is particularly susceptible to extrinsic compression and pressure necrosis. We present the case of a patient with a postsurgical tracheoesophageal fistula, who developed massive bleeding due to an arterioesophageal fistula secondary to an unknown aberrant right subclavian artery. For hemostatic management, alternative maneuvers were performed, such as the placement of a Foley-type urinary catheter at the point of bleeding and the subsequent placement of a Sengstaken-Blakemore balloon in cranial position. Given the severity of the condition and the possible diagnostic delay, it seems appropriate to consider performing a preoperative CT angiography in patients with risk factors who undergo these procedures.