Disease phenotypes in adult patients with suspected undifferentiated autoinflammatory diseases and PFAPA syndrome: Clinical and therapeutic implications.

BACKGROUND: Undifferentiated autoinflammatory diseases are characterized by recurrent or persistent fever, usually combined with other inflammatory manifestations, and negative or inconclusive genetic studies for monogenic autoinflammatory disorders. AIMS: To define and characterize disease phenotypes in adult patients diagnosed in an adult reference center with undifferentiated autoinflammatory diseases, and to analyze the efficacy of the drugs used in order to provide practical diagnostic and therapeutic recommendations. METHODS: Retrospective study (2015-2022) of patients with undifferentiated autoinflammatory diseases among all patients visited in our reference center. Demographic, clinical, laboratory features and detailed therapeutic information was collected. RESULTS: Of the 334 patients with a suspected autoinflammatory disease, 134 (40%) patients (61% women) were initially diagnosed with undifferentiated autoinflammatory diseases. Mean age at disease onset and at diagnosis was 28.7 and 37.7 years, respectively. In 90 (67.2%) patients, symptoms started during adulthood. Forty-four (32.8%) patients met diagnostic/classification criteria for adult PFAPA syndrome. In the remaining patients, four additional phenotypes were differentiated according to the predominant manifestations: a) Predominantly fever phenotype (n = 18; 13.4%); b) Predominantly abdominal/pleuritic pain phenotype (n = 9; 6.7%); c) Predominantly pericarditis phenotype (n = 18; 13.4%), and d) Complex syndrome phenotype (n = 45; 33.6%). Prednisone (mainly on demand), colchicine and anakinra were the drugs commonly used. Overall, complete responses were achieved with prednisone in 41.3%, colchicine in 40.2%, and anakinra in 58.3% of patients in whom they were used. By phenotypes, prednisone on demand was more effective in adult PFAPA syndrome and colchicine in patients with the abdominal/pleuritic pain pattern and PFAPA syndrome. Patients with complex syndrome achieved complete responses with prednisone (21.9%), colchicine (25.7%) and anakinra (44.4%), and were the group more often requiring additional immunosuppressive drugs. CONCLUSIONS: The analysis of the largest single-center series of adult patients with undifferentiated autoinflammatory diseases identified and characterized different disease phenotypes and their therapeutic approaches. This study is expected to contribute to increase the awareness of physicians for an early identification of these conditions, and to provide the best known therapeutic options.

Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry.

INTRODUCTION: Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS: This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS: We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION: EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.

Equitable Partnerships between Community-Based and Traditional Public Health Organizations: Recommendations from the Field.

The purpose of this brief report was to qualitatively explore barriers to fostering equitable partnerships between community-based organizations (CBOs) and traditional public health (TPH) groups, and to provide interviewee-driven recommendations. We conducted semi-structured interviews from February to June 2019 with representatives from CBOs (n = 9), TPH groups (n = 12), and the Praxis Project (n = 2). We used thematic analysis with a priori categories (e.g., barriers) and themes being allowed to emerge within the categories. Interviewees discussed group tensions arising from power dynamics, initial distrust, and inherent differences. Also, the TPH-dominated funding landscape reportedly caused issues for CBOs, such as mission distortion, inequitable funding distribution, and lack of long-term funding. Interviewees suggested several potential solutions such as personal relationship building, addressing power dynamics, and inclusive funding agenda-setting processes. Those working in public health can follow the practical guidance presented in this study and others to foster equitable partnerships with communities and the CBOs that represent them.

Resource utilization and outcomes in emergency general surgery during the COVID19 pandemic: An observational cost analysis.

BACKGROUND: Over the course of the COVID19 pandemic, global healthcare delivery has declined. Surgery is one of the most resource-intensive area of medicine; loss of surgical care has had untold health and economic consequences. Herein, we evaluate resource utilization, outcomes, and healthcare costs associated with unplanned surgery admissions during the height of the pandemic in 2020 versus the same period in 2019. METHODS: Retrospective analysis on patients ≥18 years admitted from the emergency department to General & Digestive and Gastrointestinal Surgery Services between February and May 2019 and 2020 at our center; clinical outcomes and unadjusted and adjusted per-person healthcare costs were analyzed. RESULTS: Consults and admissions to surgery declined between February and May 2020 by 37% and 19%, respectively, relative to the same period in 2019, with even greater relative decline during late March and early April. Time between onset of symptoms to diagnosis increased from 2±3 days 2019 to 5±22 days 2020 (P = 0.01). Overall hospital stay was two days less in 2020 (P = 0.19). Complications (Comprehensive Complication Index 10.3±23.7 2019 vs. 13.9±25.5 2020, P = 0.10) and mortality rates (3% vs. 4%, respectively, P = 0.58) did not vary. Mean unadjusted per-person costs for patients in the 2019 and 2020 cohorts were 5,886.72€±12,576.33€ and 5,287.62±7,220.16€, respectively (P = 0.43). Following multivariate analysis, costs remained similar (4,656.89€±390.53€ 2019 vs. 4,938.54±406.55€ 2020, P = 0.28). CONCLUSIONS: Healthcare delivery and spending for unplanned general surgery admissions declined considerably due to COVID19. These results provide a small yet relevant illustration of clinical and economic ramifications of this healthcare crisis.

Evaluation of African Maize Cultivars for Resistance to Fall Armyworm Spodoptera frugiperda (J. E. Smith) (Lepidoptera: Noctuidae) Larvae.

The fall armyworm (FAW) has recently invaded and become an important pest of maize in Africa causing yield losses reaching up to a third of maize annual production. The present study evaluated different aspects of resistance of six maize cultivars, cropped by farmers in Kenya, to FAW larvae feeding under laboratory and field conditions. We assessed the arrestment and feeding of FAW neonate larvae in no-choice and choice experiments, development of larvae-pupae, food assimilation under laboratory conditions and plant damage in a field experiment. We did not find complete resistance to FAW feeding in the evaluated maize cultivars, but we detected differences in acceptance and preference when FAW larvae were given a choice between certain cultivars. Moreover, the smallest pupal weight and the lowest growth index were found on 'SC Duma 43' leaves, which suggests an effect of antibiosis of this maize hybrid against FAW larvae. In contrast, the highest growth index was recorded on 'Rachar' and the greatest pupal weight was found on 'Nyamula' and 'Rachar'. The density of trichomes on the leaves of these maize cultivars seems not to be directly related to the preference of neonates for feeding. Plant damage scores were not statistically different between cultivars in the field neither under natural nor artificial infestation. However, plant damage scores in 'Nyamula' and 'Jowi' tended to be lower in the two last samplings of the season compared to the two initial samplings under artificial infestation. Our study provides insight into FAW larval preferences and performance on some African maize cultivars, showing that there are differences between cultivars in these variables; but high levels of resistance to larvae feeding were not found.

Potential roles of selected forage grasses in management of fall armyworm (Spodoptera frugiperda) through companion cropping.

Production of maize, Zea mays L. (Poaceae), in sub-Saharan Africa is threatened by a new invasive pest, fall armyworm (FAW), Spodoptera frugiperda (JE Smith) (Lepidoptera: Noctuidae). To mitigate this threat, push-pull companion cropping, a system originally developed for management of lepidopteran stemborers, may be used to control FAW. The original system involved trap crops that functioned as a 'pull' component to attract moths away from the main crop. How grass species can be used as trap crops in a push-pull system to control FAW is a question that remains to be answered, because maize is already a highly preferred host plant. Therefore, we tested oviposition preference of FAW female moths in no-choice and two-choice experiments and larval performance on six selected grasses (Poaceae) to assess their roles as trap crop 'pull' plants in the system. In no-choice tests, numbers of eggs deposited on Brachiaria brizantha (Hochst. ex A. Rich.) R. Webster cv. 'Piata', cv. 'Mulato II', and cv. 'Xaraes', and Napier grass (Pennisetum purpureum K. Schumach) cv. 'South Africa' were not statistically different from those deposited on maize. In two-choice tests between grasses and maize, there were no significant differences in number of eggs laid when the plants were of the same size. However, in two-choice tests with maize plants half of the size of the grasses, significantly more eggs were laid on B. brizantha cv. Xaraes and P. purpureum cv. South Africa than on maize, suggesting that crop phenology could make a difference. Numbers of larvae arrested on grass leaf cuts were considerably lower than those on maize leaf cuts after 48 h. In two-choice tests with maize, molasses grass (Melinis minutiflora P. Beauv.) was the only grass that was significantly preferred to maize for larval settlement after 24 h. After 48 h in the two-choice test, it was the only grass that retained larvae, although the larval count was significantly lower than on maize. Our data show that none of the grasses tested were strongly preferred to maize, but the results indicate plants attractive to FAW adults and larvae that could be utilized in a multiple trap crop approach to target various stages of the pest. Furthermore, results indicate the importance of planting these companion plants earlier than maize.

Acute Care Surgery during the COVID-19 pandemic in Spain: Changes in volume, causes and complications. A multicentre retrospective cohort study.

BACKGROUND: during the COVID-19 pandemic, the number of Acute Care Surgery procedures performed in Spanish hospitals decreased significantly. The aim of this study was to compare Acute Care Surgery activity during the COVID-19 pandemic and during a control period. MATERIAL AND METHODS: a multicenter retrospective cohort study was performed including patients who underwent Acute Care Surgery in three tertiary care hospitals in Spain during a control (11th March 2019 to 21st April 2019) and a pandemic (16th March 2020 to 26th April 2020) period. Type of surgical procedures, patients' features and postoperative complications were compared. RESULTS: two hundred and eighty-five and 117 patients were included in each group. Mean number of patients who underwent Acute Care Surgery during the control and pandemic periods was 2.3 and 0.9 patients per day and hospital (p < 0.001), representing a 58.9% decrease in Acute Care Surgery activity. Time from symptoms onset to patient arrival at the Emergency Department was longer during the pandemic (44.6 vs. 71.0 h, p < 0.001). Surgeries due to acute cholecystitis and complications from previous elective procedures decreased (26.7% vs. 9.4%) during the pandemic, while bowel obstructions and abdominal wall hernia surgeries increased (12.3% vs. 22.2%) (p = 0.001). Morbidity was higher during pandemic period (34.7% vs. 47.1%, p = 0.022), although this difference was not statistically significant in the multivariate analysis. Reoperation rate (17.9% vs. 12.8%, p = 0.212) and mortality (6.7% vs. 4.3%, p = 0.358) were similar in both groups. CONCLUSION: during the COVID-19 pandemic, a significant reduction in the performance of Acute Care Surgery procedures was observed. Moreso, a longer time from symptoms onset to patient arrival at the Emergency Department was noted. Higher morbidity was observed in patients undergoing Acute Care Surgery during the pandemic period, although there was not any difference in mortality or reoperation rate.

Spinal metastases: From conventional fractionated radiotherapy to single-dose SBRT.

AIM: To review the recent evolution of spine SBRT with emphasis on single dose treatments. BACKGROUND: Radiation treatment of spine metastases represents a challenging problem in clinical oncology, because of the high risk of inflicting damage to the spinal cord. While conventional fractionated radiation therapy still constitutes the most commonly used modality for palliative treatment, notwithstanding its efficacy in terms of palliation of pain, local tumor control has been approximately 60%. This limited effectiveness is due to previous lack of technology to precisely target the tumor while avoiding the radiosensitive spinal cord, which constitutes a dose-limiting barrier to tumor cure. MATERIALS AND METHODS: A thorough review of the available literature on spine SBRT has been carried out and critically assessed. RESULTS: Stereotactic body radiotherapy (SBRT) emerges as an alternative, non-invasive high-precision approach, which allows escalation of tumor dose, while effectively sparing adjacent uninvolved organs at risk. Engaging technological advances, such as on-line Cone Beam Computed Tomography (CBCT), coupled with Dynamic Multi-Leaf Collimation (DMLC) and rapid intensity-modulated (IMRT) beam delivery, have promoted an interactive image-guided (IGRT) approach that precisely conforms treatment onto a defined target volume with a rapid dose fall-off to collateral non-target tissues, such as the spinal cord. Recent technological developments allow the use of the high-dose per fraction mode of hypofractionated SBRT for spinal oligometastatic cancer, even if only a few millimeters away from the tumor. CONCLUSION: Single-dose spine SBRT, now increasingly implemented, yields unprecedented outcomes of local tumor ablation and safety, provided that advanced technology is employed.