Severe, life-threatening phenotype of primary Sjögren's syndrome: clinical characterisation and outcomes in 1580 patients (GEAS-SS Registry).

OBJECTIVES: To analyse the clinical features and outcomes of patients presenting with life-threatening systemic disease in a large cohort of Spanish patients with primary Sjögren's syndrome (SS). METHODS: The GEAS-SS multicentre registry was formed in 2005 with the aim of collecting a large series of Spanish patients with primary SS, and included more than 20 Spanish reference centres with substantial experience in the management of SS patients. By January 2018, the database included 1580 consecutive patients fulfilling the 2002 classification criteria for primary SS. Severe, life-threatening systemic disease was defined as an activity level scored as "high" in at least one ESSDAI domain. RESULTS: Among 1580 patients, 208 (13%) were classified as presenting a severe, potentially life-threatening systemic disease: 193 presented one ESSDAI domain classified as high, 14 presented two high scored domains and only one presented three high activity domains. The ESSDAI domains involved consisted of lymphadenopathy in 78 (37%) cases, CNS in 28 (13%), PNS in 25 (12%), pulmonary in 25 (12%), renal in 21 (10%), cutaneous in 19 (9%), articular in 18 (9%), haematological in 7 (3%) and muscular in 4 (2%). Patients with severe systemic disease were more frequently men (p=0.001) and had a higher frequency of anaemia (p<0.001), lymphopenia (p<0.001), rheumatoid factor (p=0.021), low C3 levels (p=0.015), low C4 levels (p<0.001) and cryoglobulins (p<0.001). From a therapeutic point of view, systemic patients received more frequently glucocorticoids (p<0.001), immunosuppressants (p<0.001), intravenous immunoglobulins (p=0.008) and rituximab (p<0.001). We found an overall mortality rate of 20% in severe systemic patients, a rate that reached to 33% in patients presenting two or more high systemic involvements; these patients had a higher frequency of low C4 levels (p=0.012) and cryoglobulins (p=0.001) in comparison with those with a single severe organ involved. CONCLUSIONS: 13% of patients with primary SS develop a potentially life-threatening systemic disease (mainly lymphoma, but also severe internal organ involvements including nervous system, the lungs and the kidneys). This subset of patients requires intensive therapeutic management with a mortality rate of nearly 20% of cases.

A Machine Learning Model for Evaluating Imported Disease Screening Strategies in Immigrant Populations.

Given the high prevalence of imported diseases in immigrant populations, it has postulated the need to establish screening programs that allow their early diagnosis and treatment. We present a mathematical model based on machine learning methodologies to contribute to the design of screening programs in this population. We conducted a retrospective cross-sectional screening program of imported diseases in all immigrant patients who attended the Tropical Medicine Unit between January 2009 and December 2016. We designed a mathematical model based on machine learning methodologies to establish the set of most discriminatory prognostic variables to predict the onset of the: HIV infection, malaria, chronic hepatitis B and C, schistosomiasis, and Chagas in immigrant population. We analyzed 759 patients. HIV was predicted with an accuracy of 84.9% and the number of screenings to detect the first HIV-infected person was 26, as in the case of Chagas disease (with a predictive accuracy of 92.9%). For the other diseases the averages were 12 screenings to detect the first case of chronic hepatitis B (85.4%), or schistosomiasis (86.9%), 23 for hepatitis C (85.6%) or malaria (93.3%), and eight for syphilis (79.4%) and strongyloidiasis (88.4%). The use of machine learning methodologies allowed the prediction of the expected disease burden and made it possible to pinpoint with greater precision those immigrants who are likely to benefit from screening programs, thus contributing effectively to their development and design.

Screening Program for Imported Diseases in Immigrant Women: Analysis and Implications from a Gender-Oriented Perspective.

The female immigrant population is especially vulnerable to imported diseases. We describe the results of a prospective screening program for imported diseases performed in immigrant female patients. The protocol included tests for HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), Treponema pallidum, Trypanosoma cruzi, Strongyloides stercoralis and Schistosoma spp., intestinal parasites, malaria, and the detection of microfilaremia, according to the patient's origin. Six hundred eleven patients were studied. The most frequent imported diseases were intestinal parasitosis (39.4%), followed by syphilis (14.6%), HIV infection (9%), chronic HCV (5%), and HBV (3.3%). Most of the cases of HIV (78%) and HBV (85%) were diagnosed in patients aged between 16 and 45 years. Hepatitis C virus appeared mostly in patients in the 46- to 65-year range (P = 0.001; odds ratio [OD]: 3.667 [1.741-7.724]) or older than 65 years (P = 0.0001; OR: 26.350 [7.509-92.463]). Syphilis was diagnosed more frequently in patients older than 46 years (P = 0.0001; OR: 4.273 [2.649-6.893]). Multivariate analysis confirmed a greater presence of HCV infection (P = 0.049) and syphilis (P = 0.0001) in patients aged between 46 and 65 years. In 15.4% of patients, screening did not find any pathology. These data show a high prevalence of imported diseases in the female immigrant population, which may have serious consequences in terms of morbimortality and vertical transmission. Our results encourage the establishment of policies of active screening both in women of childbearing age and within the specific pregnancy screening programs.

Use of serology in a systematic screening programme for strongyloidiasis in an immigrant population.

OBJECTIVES: The aim of this cross-sectional study was to describe the results of a systematic serological screening programme for strongyloidiasis. METHODS: A prospective serological screening programme for strongyloidiasis was performed between 2009 and 2014 for all immigrant patients attending the Tropical Medicine Unit. Three formalin-ether concentrated stool samples and an ELISA for anti-Strongyloides stercoralis antibodies were used as screening tools. RESULTS: Of 659 patients screened, 79 (12%) were positive for S. stercoralis regardless of the diagnostic method used. The prevalence of infection was 42.9% in East African patients, 16.3% in Central African patients, 10.9% in those from South America, and 10% in the case of West Africa. Univariate analysis showed that infection by S. stercoralis was significantly more frequent in patients from Central Africa (p=0.026; OR 1.72, 95% CI 1.03-2.85) and East Africa (p<0.001; OR 5.88, 95% CI 1.75-19.32). Taking West Africa as the reference (as the area of lowest prevalence among the positive prevalence areas), the statistical analysis showed that the risk of infection was higher in East Africa (p=0.001; OR 6.750, 95% CI 2.127-21.423) and Central Africa (p=0.065; OR 1.747, 95% CI 0.965-3.163). CONCLUSIONS: Due to the potential complications of strongyloidiasis infection, we recommend that immigrant patients from developing countries be routinely screened for S. stercoralis, especially those from East Africa. A serological test is a highly appropriate screening tool.

Materiales docentes para el estudio independiente de la Farmacología durante la COVID-19 / Teaching materials for the independent study of Pharmacology during COVID-19

Fundamento: los materiales docentes para el estudio independiente en la enseñanza de la Farmacología Clínica son recursos que facilitan el aprendizaje a distancia en función de una enseñanza integral durante la pandemia de COVID-19. Objetivo: elaborar materiales docentes para el estudio independiente de los contenidos de la Farmacología Clínica durante la COVID-19. Métodos: se realizó una investigación de desarrollo en el campo de la educación médica, entre abril a junio de 2020 en la Facultad de Medicina de Villa Clara. Se utilizaron métodos teóricos para la fundamentación de la investigación y actualización mediante la revisión bibliográfica. Como método empírico, se utilizó la revisión documental de los documentos necesarios para el producto diseñado. Resultados: se elaboraron tres guías didácticas y tres materiales de apoyo a la docencia que permitieron una mejor apropiación de los contenidos y mejores resultados docentes en los estudiantes. Conclusiones: los materiales docentes para la enseñanza de la Farmacología Clínica en tiempos de pandemia fueron valorados como pertinentes y metodológicamente adecuados por el grupo de especialistas seleccionados.

Background: the teaching materials for independent study in the teaching of Clinical Pharmacology are resources that facilitate distance learning based on comprehensive teaching during the COVID-19 pandemic. Objective: to prepare teaching materials for the independent study of the contents of Clinical Pharmacology during COVID-19. Methods: a development research was carried out in the field of medical education, from April to June 2020 at Villa Clara School of Medicine. Theoretical methods were used for the foundation of the research and updating through the bibliographic review. As an empirical method, the documentary review of the documents necessary for the designed product was used. Results: three didactic guides and three teaching support materials were prepared that allowed a better appropriation of the contents and better teaching results in the students. Conclusions: the teaching materials for the teaching of Clinical Pharmacology in times of pandemic were valued as pertinent and methodologically adequate by the group of selected specialists.

La N-acetilcisteína reduce el progreso de daño cardíaco en modelos experimentales / N-acetylcysteine reduces myocardial injury progression in experimental models

RESUMEN La N-acetilcisteína es conocida en varias especialidades médicas. Su empleo en cardiología se ha incrementado desde hace décadas, por su potencial para disminuir el impacto del daño por reperfusión en el infarto miocárdico agudo. Pero el espectro de sus efectos es aún mayor, tiene acciones sobre los radicales de oxígeno, con un papel protector, por la vía de los grupos sulfhidrilos de regiones importantes de la membrana celular, los cuales interfieren y tienen efecto en la función endotelial y en los procesos complejos de adhesión como efectos secundarios; así como otros fenómenos del compartimento extravascular. Estos procesos están estrechamente relacionados con el aparato cardiovascular.

ABSTRACT N-acetylcysteine is known in a number of medical specialties and its ability to decrease the impact of reperfusion injury in acute myocardial infarction has boosted its use in cardiology over the past decades. N-acetylcysteine has a far-reaching range of effects since it functions as a protective agent against oxygen radicals through sulfhydryl groups in important regions of the cell membrane that interfere and affect endothelial functioning and complex adhesion processes as side effects; as well as other phenomena of the extravascular compartment. These processes are closely related to the cardiovascular system.

Consideraciones sobre el efecto cardiovascular de algunos antidiabéticos orales / Considerations on the cardiovascular effect of some oral antidiabetics

RESUMEN La diabetes mellitus tipo 2 se asocia a un elevado riesgo cardiovascular, dadas las proporciones epidémicas a las que está llegando; las guías de tratamiento ponen de relieve la necesidad de prevenir y reducir las complicaciones cardiovasculares y mejorar el control glucémico, especialmente en las etapas precoces de la enfermedad. Los fármacos que disminuyen o regulan la glucosa se han incrementado en los últimos años y, a consecuencia de ello, el tratamiento de la diabetes mellitus tipo 2 se ha vuelto cada vez más complejo y cambiante; por tanto, es importante conocer los diferentes medicamentos que existen hoy para el tratamiento de la diabetes mellitus y sus efectos, tanto positivos como negativos, a nivel cardiovascular. Las actuales recomendaciones hacen hincapié en la individualización de los objetivos glucémicos.

ABSTRACT Type 2 diabetes mellitus is associated to high cardiovascular risk. Given the epidemic proportions it is reaching, treatment guidelines emphasize the need of preventing and reducing major adverse cardiovascular events as well as improving glycemic control, especially in the early stages of the disease. The drugs that decrease or regulate glucose have increased in recent years and, as a result, the treatment of type 2 diabetes mellitus has become increasingly changing and complex; therefore, it is important to know the different drugs that exist nowadays for the treatment of diabetes mellitus and their effects, both positive and negative, at a cardiovascular level. The current recommendations emphasize the individualization of glycemic targets.

Orientaciones metodológicas para la impartición del tema Farmacocinética en tercer año de Medicina / Methodological guidelines for the teaching of the subject Pharmacokinetics in the third year of Medicine

RESUMEN Fundamento: la Farmacocinética es un tema que en Farmacología genera dificultades en los estudiantes debido a su complejidad, por lo que su impartición debe ser tratada en el colectivo de asignatura a través del trabajo metodológico. Objetivo: elaborar orientaciones metodológicas para el perfeccionamiento de la impartición del tema Farmacocinética en Farmacología I. Metodos: se realizó una investigación descriptiva transversal en la Universidad de Ciencias Médicas de Villa Clara de enero a junio de 2016. Fueron empleados como métodos teóricos: analítico-sintético, inducción-deducción y sistémico estructural-funcional; empíricos: análisis documental, la encuesta a estudiantes, entrevista a informantes clave y la tormenta de ideas como técnica participativa; y matemático-estadísticos. La investigación se desarrolló en tres etapas: diagnóstico, elaboración de las orientaciones metodológicas y la valoración por especialistas. Resultados: se constató que el insuficiente aprovechamiento del espacio de la consulta docente y la motivación de los alumnos por el estudio del tema fueron los factores que más influyeron en los deficientes resultados obtenidos, por lo que se fortaleció el trabajo metodológico del colectivo a través de la elaboración de orientaciones metodológicas que incluyeron una guía didáctica para favorecer el trabajo independiente. Conclusiones: las orientaciones metodológicas garantizaron un mejor desarrollo en la impartición del tema lo cual redundó en mejor apropiación de los conocimientos. Fueron avaladas por criterios de especialistas, quienes consideraron el producto como pertinente, útil, factible y con valor científico-pedagógico.

ABSTRACT Background: Pharmacokinetics is a subject that in Pharmacology generates difficulties in students due to its complexity, so that its teaching must be treated in the subject teaching staff meeting through methodological work. Objective: to develop methodological guidelines for the improvement of the teaching of the Pharmacokinetics subject in Pharmacology I. Methods: a cross-sectional descriptive research was carried out at Villa Clara University of Medical Sciences from January to June 2016. Theoretical methods were used: analytical-synthetic, induction-deduction and structural-functional systemic; empirical ones: documentary analysis, the student survey, interviews with key informants and brain-storming as a participative technique; and mathematical-statistics. The research was developed in three stages: diagnosis, preparation of methodological guidelines and assessment by specialists. Results: it was found that the insufficient use of the space of the teaching consultation class and the motivation of the students for the study of the subject were the factors that most influenced the poor results obtained, so the methodological work of the subject teaching staff meeting was strengthened through the elaboration of methodological guidelines that included a didactic guide to favor the independent work. Conclusions: the methodological guidelines ensured a better development in the teaching of the topic, which resulted in better appropriation of knowledge. They were endorsed by specialists, who considered the product as pertinent, useful, feasible and with scientific-pedagogical value.

Manual instructivo para la atención integral en Ginecología Infantojuvenil / Instructive manual for the comprehensive attention in Infant-youngsters Gynecology

Fundamento: la Ginecología Infantojuvenil es una rama muy sensible de la Ginecología, por las edades de sus pacientes y los temas que estudia. Objetivo: elaborar un manual instructivo sobre Ginecología Infantojuvenil para la docencia dirigido a los médicos generales y los especialistas en Ginecología y Obstetricia que laboran en la Atención Primaria de Salud (APS). Método: se realizó un estudio descriptivo transversal en el Hospital Universitario Gineco-Obstétrico "Mariana Grajales", de enero a diciembre de 2014. La muestra estuvo constituída por 12 docentes con experiencias en la Ginecología Infantojuvenil. Se utilizaron métodos teóricos: analítico-sintético e inductivo-deductivo para la fundamentación teórica, la elaboración del informe investigativo y explicar conceptos relacionados con el tema; empíricos: análisis documental del programa de estudio y los cursos de postgrado para valorar el grado de actualización en dichos contenidos, y la encuesta a docentes para determinar los núcleos de contenido que debían ser abordados en el material instructivo. Resultados: se evidencia la necesidad de actualizar los contenidos relacionados con el manejo y protocolos de actuación en relación con las afecciones infantojuveniles, por lo que se elaboró un manual instructivo con los temas demandados por los docentes consultados: trastornos menstruales posmenarquia, infecciones y malformaciones congénitas. Conclusiones: el manual instructivo para la atención integral en Ginecología Infantojuvenil fue evaluado como pertinente, de calidad y utilidad práctica por criterio de especialistas, porque contribuye a perfeccionar la preparación de los médicos involucrados en la atención de excelencia que demanda la prestación del referido servicio.

Background: the Infant-youngsters Gynecology is a very sensitive branch of Gynecology, for the ages of its patients and the topics that it studies. Objective: to elaborate an instructive manual on Infant-youngsters Gynecology for teaching, for general practitioners and Gynecology and Obstetrics specialists who work in the Primary Health cares (PHC). Method: it was carried out a cross-sectional descriptive study in "Mariana Grajales" Gynecological-obstetric University Hospital, from January to December 2014. The sample comprised 12 experienced professors in Infant-youngsters Gynecology. Theoretical methods were used: analytic-synthetic and inductive-deductive for the theoretical background, the elaboration of the research report and to explain concepts related with the topic; empiric ones: documental analysis of the study program and the post-graduate courses to value the updating level in its contents, and the survey to the professors to determine the content cores that should be approached in the instructive material. Results: it is evidenced the necessity of updating the contents related with the management and performance protocols in connection with Infant-youngstersaffections, that ´s why an instructive manual was elaborated with the topics that the consulted professors suggested: menstrual disorders, post-menarche, infections and congenital malformations. Conclusions: the instructive manual for the comprehensive attention in Infant-youngsters Gynecology was evaluated as pertinent, with quality and practical usefulness by specialists' criteria, because it contributes to perfect the preparation of the doctors involved in the excellence attention that demands the referred service.

Emphysematous pyelonephritis in dialysis patient after embolization of failed allograft.

Emphysematous pyelonephritis is an uncommon acute infection characterized by the presence of gas in the renal parenchyma. Diabetics account for most cases, and the mortality rate is high. We report a case of emphysematous pyelonephritis after therapeutic embolization of a nonfunctioning renal graft in a nondiabetic dialysis patient. Given the increasing popularity of therapeutic embolization to control graft intolerance syndrome associated with rejected kidneys, physicians should be aware of this potentially severe complication. We discuss the differential diagnosis from entities requiring different management strategies, such as postembolization syndrome, persistence of graft intolerance, and the presence of sterile intrarenal.