The role of cultural competency training to address health disparities in surgical settings.

BACKGROUND: Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities. SOURCES OF DATA: In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities. AREAS OF AGREEMENT: The unjustness of health care disparities is universally accepted. AREAS OF CONTROVERSY: Whether the outcome of CCT justifies the cost has not been effectively answered. GROWING POINTS: These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting. AREAS TIMELY FOR DEVELOPING RESEARCH: Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.

Barriers to early diagnosis and management of oral cancer in Latin America and the Caribbean.

OBJECTIVE: This study aimed to explore perceived barriers to early diagnosis and management of oral cancer, as well as potential pathways for improvement in Latin America and the Caribbean (LAC). METHODS: This cross-sectional study used a self-administered online questionnaire created via the Research Electronic Data Capture platform. The survey was distributed to health professionals trained in Oral Medicine, Oral Pathology, Oral and Maxillofacial Surgery, and Dentists with clinical and academic expertise in oral potentially malignant disorder (OPMD) and oral cancer. Data obtained were systematically organized and analyzed descriptively using Microsoft Excel. RESULTS: Twenty-three professionals from 21 LAC countries participated. Major barriers included the limited implementation of OPMD and oral cancer control plans (17.4%), low compulsory reporting for OPMD (8.7%) and oral cancer (34.8%), unclear referral pathways for OPMD (34.8%) and oral cancer (43.5%), and a shortage of trained professionals (8.7%). Participants endorsed the utility of online education (100%) and telemedicine (91.3%). CONCLUSION: The survey highlights major perceived barriers to early diagnosis and management of OPMD and oral cancer in LAC, as well as potential avenues for improvement.

Oral squamous cell carcinomas and oral potentially malignant disorders: A Latin American study.

OBJECTIVE: To determine the frequency of oral squamous cell carcinoma (OSCC) associated or not with oral potentially malignant disorders (OPMD), and the epidemiological profile and traditional risk factors in Latin America. METHODS: A retrospective observational study was conducted in 17 Latin American centres. There were included cases of OSCC, analysing age, gender, OSCC and their association with previous OPMD. Clinicopathological variables were retrieved. The condition of sequential-OSCC versus OSCC-de novo (OSCC-dn) was analysed concerning the aforementioned variables. Quantitative variables were analysed using Student's t-test, and qualitative variables with chi-square. RESULTS: In total, 2705 OSCC were included with a mean age of 62.8 years old. 55.8% were men. 53.75% of the patients were smokers and 38% were common drinkers. The lateral tongue border was the most affected site (24.65%). There were regional variations in OPMD, being leukoplakia the most frequent. Of the overall 2705 OSCC cases, 81.4% corresponded to OSCC-dn, while s-OSCC were 18.6%. Regarding lip vermillion SCC, 35.7% corresponded to de novo lip SCC and 64.3% were associated with previous OPMD. CONCLUSIONS: In Latin America, OSCC-dn seems to be more frequent with regional variations of some clinical and histopathological features. Further prospective studies are needed to analyse this phenomenon.

The prognosis of pre-frail chronic obstructive pulmonary disease patients for hospitalizations and mortality depends on their level of functional physical performance.

OBJECTIVE: To determine if pre-frail Chronic obstructive pulmonary disease (COPD) patients with poor and non-poor performance in the five-repetition sit-to-stand test (5-STS) had a worse prognosis for hospitalization and mortality at 2 years and for mortality at 5 years than non-frail patients. METHODS: We prospectively included patients with stable COPD, between 40 and 80 years, from a hospital in Spain. Patients were classified according their performance on the 5-STS test and level of frailty. Timing, number of hospitalizations, length of stay, and timing and rate of mortality were outcome measures. Patients were followed for 2 years for exacerbations and for 5 years for mortality. Kaplan-Meier curves and univariate and multivariate Cox proportional-hazard analyses, ANOVA tests and univariate and multivariate linear and logistic regression models were used. RESULTS: Of the 125 patients included, 25.6% were pre-frail with poor performance, 57% pre-frail with non-poor performance, and 17.4% non-frail with non-poor performance. Pre-frail patients with poor performance had a higher number of hospitalizations (adjusted beta: 0.49; 95% CI: 0.01-0.96), mortality rates (odds ratio: 11.33; 95% CI: 1.15-110.81), and risk at 5 years (adjusted hazard ratio: 8.77; 95% CI: 1.02-75.51) than non-frail patients. Pre-frail patients with poor performance also had worse prognoses than non-frail patients with respect to length of hospital stays (increased by 4.16 days) and timing to first hospitalization (HR: 6.01) in unadjusted models, but not when adjusted. CONCLUSION: The COPD prognosis of pre-frail patients with respect to the number of exacerbations with hospitalization and the timing and rate of mortality is dependent of functional performance.

Physical frailty characteristics have a differential impact on symptoms as measured by the CAT score: an observational study.

BACKGROUND: The physical frailty status affects the health status of patients with chronic obstructive pulmonary disease (COPD). The objective was to determine if the individual physical frailty characteristics have a differential impact on the CAT score. METHODS: This observational study included 137 patients with stable COPD. Physical frailty was measured with unintentional weight loss, low physical activity, exhaustion, slow walking speed and low grip strength and health status assessed with the COPD Assessment test (CAT). The following variables were evaluated as potential determinants of CAT: sex, age, body mass index, smoking, dyspnea, exacerbations, comorbidities, %FEV1, %FVC, anxiety and depression. RESULTS: The prevalence of characteristics for individual frailty was as follows: low grip strength, 60.6%; low physical activity, 27.0%; exhaustion, 19.7%; slow walking speed, 9.5%; and unintentional weight loss, 7.3%. A total of 17.5% of the patients were non-frail, 73.7% were pre-frail and only 8.7% were frail. One of the five frailty characteristics, exhaustion (adjusted ß coefficient 5.12 [standard error = 1.27], p = 0.001) was an independent determinant of CAT score in the final regression model which was adjusted by other independent determinants of CAT (dyspnea, exacerbations and anxiety). CONCLUSIONS: Due to the fact that exhaustion is a frequent and relevant psychological symptom on CAT score of patients with COPD, interventions should reduce that stress. Future research should explore how exhaustion persists or remits over time.

Patterns and predictors of exhaustion episodes in patients with stable COPD: A longitudinal study.

BACKGROUND AND OBJECTIVE: Exhaustion is the perception of low energy. Little is known about how exhaustion persists, remits or reappears over time in patients with chronic obstructive pulmonary disease (COPD) or how to predict these events. We determined the likelihood of transitions between states of exhaustion and no exhaustion among patients with stable COPD followed up for 2 years. We investigated combinations of potential factors for their abilities to predict new-onset exhaustion episodes. METHODS: We prospectively included 137 patients with stable COPD (mean age, 66.9 years ± 8.3). Exhaustion states were measured at baseline and 1 and 2 years later. Exhaustion was defined as an answer of "most of the time" or "a moderate amount of time" to 1 of 2 questions: "How often have you found it hard to get going?" and "How often does everything seem to require effort?" We evaluated demographic, non-respiratory and respiratory variables as potential predictors. The likelihoods of new episodes and recovery were calculated. Predictors were evaluated with generalised estimating equations. RESULTS: At baseline, 27 patients (19.7%) displayed exhaustion. Of the 110 patients without exhaustion at baseline, 17 (15.5%) displayed exhaustion at least once during the follow-up period. During the study period, a total of 204 annual transitions displaying no exhaustion at the beginning were identified. Of them, 10.3% transitioned to exhaustion in the next year. The likelihood of recovery after exhaustion was 50%. Independent predictors of new-onset exhaustion episodes within the following year were: the COPD assessment test score (odds ratio [OR] = 1.10; 95% confidence interval [CI] 1.01-1.21), depression (OR = 6.89; 95% CI: 1.00-47.41) and female gender (OR = 6.88; 95% CI: 1.83-25.73). CONCLUSIONS: Patients in stable COPD with high CAT scores and depression were most likely to experience new-onset exhaustion episodes Thus, exhaustion might be predicted by a combination of psychological factors and respiratory health status. Nevertheless, exhaustion is dynamic in COPD; half of patients recover from exhaustion.

Interobserver Reliability of Peripheral Muscle Strength Tests and Short Physical Performance Battery in Patients With Chronic Obstructive Pulmonary Disease: A Prospective Observational Study.

OBJECTIVE: To evaluate the interobserver reliability of the Short Physical Performance Battery (SPPB) and hand dynamometry when measuring isometric muscle strength in people with chronic obstructive pulmonary disease (COPD). DESIGN: Reliability study. Each patient was assessed by a pulmonology physician and a physical therapist in 2 separate sessions 7 to 14 days apart (mean, 9.8±0.8d). Each rater was blinded to the other's results. SETTING: Pneumology unit of a public hospital. PARTICIPANTS: Random sample of outpatients with stable COPD (N=30). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: SPPB and muscle strength (kg) using electronic handgrip and handheld dynamometers. Reliability was assessed with intraclass correlation coefficients (ICCs), standard error of measurement values, and Bland-Altman plots. ICCs were calculated for the SPPB summary score and for its 3 subscales. RESULTS: The ICCs for the overall reliability of the SPPB summary score and for grip and quadriceps strength were .82 (95% confidence interval [CI], .62-.91), .97 (95% CI, .93-.98), and .76 (95% CI, .49-.88), respectively. The standard error of measurement values were .55 points, 1.30kg, and 1.22kg, respectively. The mean differences between the rater's scores were near zero for grip strength and SPPB summary score measures. The ICCs for the SPPB subscales were .84 (95% CI, .66-.92) for the chair subscale, .75 (95% CI, .48-.88) for gait, and .33 (95% CI, -.42 to .68) for balance. CONCLUSIONS: Interobserver reliability was good for quadriceps and handgrip dynamometry and for the SPPB summary score and its chair stand and gait speed subscales. Both pulmonary physicians and physical therapists can obtain and exchange the scores. Because the reliability of the balance subscale was questionable, it is better to use the SPPB summary score.

Identifying COPD patients with poor health status and low exercise tolerance through the five-repetition sit-to-stand test and modified Medical Research Council Dyspnea Score.

BACKGROUND: The objective of this study was to determine whether the concomitant presence of poor health status (COPD Assessment Test, CAT ≥ 10 points) and low exercise tolerance (6-Minute Walking Test, 6MWT < 350 m) is associated with worse clinical characteristics in patients with COPD. In addition, we aimed to develop a readily applicable diagnostic model to discriminate COPD patients with these conditions. METHODS: A cross-sectional multicenter study involving 208 stable COPD patients (FEV1/FVC < 0.7, smoking history of at least 10 pack-years, and chronic respiratory symptoms) was carried out. The outcome measures were the 6MWT, CAT score, 5-repetition sit-to-stand test (5STS) and modified Medical Research Council Dyspnea Scale (mMRC). Patients were categorized into three groups: no condition (6MWT ≥ 350 m and CAT < 10 points), one condition (6MWT < 350 m or CAT ≥ 10 points), and both conditions (6MWT < 350 m and CAT ≥ 10 points). RESULTS: A total of 26 patients (12,5%) presented both conditions. These patients experienced a higher degree of dyspnea (p = 0.001), smoking pack-years (p = 0.011), severe obstruction (p = 0.006), and time on 5STS (p = 0.001). The probability of having both conditions directly increased with the time spent on the 5STS (ß=0.188; p = 0.010) and the degree of dyspnea (ß=1.920; p < 0.001) (R2=0.413). The scoring system, using the 5STS and dyspnea as surrogate measures, demonstrated adequate calibration between the predicted and observed risk (linear R2=0.852). CONCLUSIONS: COPD patients with concurrent conditions have worse clinical status. The diagnostic model developed to discriminate these patients shows good internal validation.

Diffuse pulmonary meningotheliomatosis diagnosed by transbronchial lung biopsy.

Minute pulmonary meningothelial-like nodules (MPMNs) are usually unique lesions in the lung parenchyma. Diffuse pulmonary meningotheliomatosis, which is presented as multiple MPMNs, has been less frequently described. MPMNs are mainly asymptomatic and are diagnosed after lung surgery or during autopsy. We report on a patient with multiple and bilateral pulmonary nodules, some of which were cavitated, diagnosed with diffuse pulmonary meningotheliomatosis by transbronchial lung biopsy. Diffuse pulmonary meningotheliomatosis should be included in the differential diagnosis of bilateral lung nodules.

Impact of COVID-19 pandemic on HbA1c management and results in pediatric and adult outpatients with diabetes.

Objectives: Diabetes mellitus intensify the risks and complications related to COVID-19 infection. A major effect of the pandemic has been a drastic reduction of in-person visits. The aim of this study was to evaluate the impact of the COVID-19 pandemic on HbA1c management and results among pediatric and adult outpatients with diabetes, considering the laboratory and point-of-care testing (POCT) HbA1c measurements. Methods: Observational retrospective study including patients from pediatric and adult diabetes units was conducted. HbA1c results obtained in the laboratory and POCT over 3 years (2019-2021) were collected from the laboratory information system. Results: After the lockdown, the number of HbA1c plummeted. Children returned soon to routine clinical practice. The number of HbA1c increased gradually in adults, especially in POCT. Globally, HbA1c results were lower in children compared with adults (p<0.001). HbA1c values in children (p<0.001) and adults (p=0.002) decreased between pre-pandemic and post-pandemic periods, though lower than the HbA1c reference change value. The percentage of HbA1c results above 8% remained stable during the study period. Conclusions: Continuous glucose monitoring and a telemedicine have been crucial, even allowing for improvements in HbA1c results. During the lockdown, patients with better metabolic control were managed in the laboratory whereas patients with poorer control or a severe clinical situation were attended in diabetes units by POCT. Adults returned to pre-pandemic management slowly because they were more susceptible to morbidity and mortality due to COVID-19. Coordination among all health professionals has been essential to offering the best management, especially in difficult scenarios such as the COVID-19 pandemic.

Development of the ESEx index: a tool for predicting risk of recurrent severe COPD exacerbations.

Background: In chronic obstructive pulmonary disease (COPD), multiple recurrent severe exacerbations that require hospitalization can occur. These events are strongly associated with death and other clinical complications. Objectives: We aimed to develop a prognostic model that could identify patients with COPD that are at risk of multiple recurrent severe exacerbations within 3 years. Design: Prospective cohort. Methods: The derivation cohort comprised patients with stable, moderate-to-severe COPD. Multivariable logistic regression analyses were performed to develop the final model. Based on regression coefficients, a simplified index (ESEx) was established. Both, model and index, were assessed for predictive performance by measuring discrimination and calibration. Results: Over 3 years, 16.4% of patients with COPD experienced at least three severe recurrent exacerbations. The prognostic model showed good discrimination of high-risk patients, based on three characteristics: the number of severe exacerbations in the previous year, performance in the five-repetition sit-to-stand test, and in the 6-minute-walk test. The ESEx index provided good level of discrimination [areas under the receiver operating characteristic curve (AUCs): 0.913]. Conclusions: The ESEx index showed good internal validation for the identification of patients at risk of three recurrent severe COPD exacerbations within 3 years. These tools could be used to identify patients who require early interventions and motivate patients to improve physical performance to prevent recurrent exacerbations.

Iodotyrosines Are Biomarkers for Preclinical Stages of Iodine-Deficient Hypothyroidism in Dehal1-Knockout Mice.

Background: Iodine is required for the synthesis of thyroid hormone (TH), but its natural availability is limited. Dehalogenase1 (Dehal1) recycles iodine from mono- and diiodotyrosines (MIT, DIT) to sustain TH synthesis when iodine supplies are scarce, but its role in the dynamics of storage and conservation of iodine is unknown. Methods: Dehal1-knockout (Dehal1KO) mice were generated by gene trapping. The timing of expression and distribution was investigated by X-Gal staining and immunofluorescence using recombinant Dehal1-beta-galactosidase protein produced in fetuses and adult mice. Adult Dehal1KO and wild-type (Wt) animals were fed normal and iodine-deficient diets for 1 month, and plasma, urine, and tissues were isolated for analyses. TH status was monitored, including thyroxine, triiodothyronine, MIT, DIT, and urinary iodine concentration (UIC) using a novel liquid chromatography with tandem mass spectrometry method and the Sandell-Kolthoff (S-K) technique throughout the experimental period. Results: Dehal1 is highly expressed in the thyroid and is also present in the kidneys, liver, and, unexpectedly, the choroid plexus. In vivo transcription of Dehal1 was induced by iodine deficiency only in the thyroid tissue. Under normal iodine intake, Dehal1KO mice were euthyroid, but they showed negative iodine balance due to a continuous loss of iodotyrosines in the urine. Counterintuitively, the UIC of Dehal1KO mice is twofold higher than that of Wt mice, indicating that S-K measures both inorganic and organic iodine. Under iodine restriction, Dehal1KO mice rapidly develop profound hypothyroidism, while Wt mice remain euthyroid, suggesting reduced retention of iodine in the thyroids of Dehal1KO mice. Urinary and plasma iodotyrosines were continually elevated throughout the life cycles of Dehal1KO mice, including the neonatal period, when pups were still euthyroid. Conclusions: Plasma and urine iodotyrosine elevation occurs in Dehal1-deficient mice throughout life. Therefore, measurement of iodotyrosines predicts an eventual iodine shortage and development of hypothyroidism in the preclinical phase. The prompt establishment of hypothyroidism upon the start of iodine restriction suggests that Dehal1KO mice have low iodine reserves in their thyroid glands, pointing to defective capacity for iodine storage.

Improving the Reliability Between the BODE Index and the BODS Index in Which the 6-Min Walk Test Was Replaced with the Five-Repetition Sit-to-Stand Test.

Purpose: The BODS index has been confirmed to have predictive properties similar to the original BODE index for mortality in COPD. We evaluated the agreement between the BODS index and the BODE and explored with an updated BODS how this agreement could be improved and its ability to correctly discriminate individual participants' mortality in a prospective cohort study. Patients and Methods: We included prospectively a consecutive sample of 137 patients with COPD, between 40 and 80 years, during 2014 and followed for 5 years (2014-2019) in the Pneumology section of a public university hospital in Spain. They participated in the baseline data collection, which included BODE- and BODS-related measurements and prognostic factors, and were followed up for 5-year mortality. We used Bland-Altman plots and the kappa coefficient to analyze the agreement between both the original and updated BODS and the BODE index, and we used the areas under ROC curves (AUC) to compare their discriminative abilities for 5-year all-cause mortality. Results: The original BODS index scores and quartiles had weak agreement with the BODE index, and our updated BODS strengthened these agreements (a small, statistically nonsignificant mean bias [<0.03] with LoAs<2 points, and a substantial Kappa coefficient [k =0.63; IC 95%: 0.53-0.73]). In addition, the updated BODS index scores had better summarized ability than the BODS index in discriminating participants' mortality during the following 5 years (AUC: 0.768 versus 0.736; p=0.04). Conclusion: The updated BODS index scores and quartiles may provide prognostic information similar to that provided by the BODE index in COPD. Future research should focus on index improvement through external validation, as well as the assessment of safety and effectiveness in clinical practice by means of impact studies.

Prognostic value of the five-repetition sit-to-stand test for mortality in people with chronic obstructive pulmonary disease.

BACKGROUND: Prognostic studies suggest that some musculoskeletal and functional capacity tests are independently associated with mortality in chronic obstructive pulmonary disease (COPD), but comparing their prognostic value is difficult because of differences in the selected covariates for regression modelling in those studies. OBJECTIVES: To assess the prognostic value of five musculoskeletal and functional capacity tests in predicting mortality risk in patients with COPD after adjusting for existing and confounding prognostic factors and to compare their ability to correctly discriminate the mortality of individual participants using the 6-min walk test (6MWT). We hypothesized that the examined tests have different prognostic value. METHODS: Prospective and longitudinal study. A total of 137 patients with stable COPD (mean [SD] age 67 [8.33] years; 87% male) were recruited from a hospital in Spain during 2014 and followed for 5 years (2014-2019). No one refused and only one was lost to follow-up. The outcome measure was 5 year all-cause mortality. RESULTS: A total of 37 patients died within 5 years. All musculoskeletal tests were associated with 5 year all-cause mortality in Cox proportional-hazards regression models. However, only the five-repetition sit-to-stand test (5-STS) score was an independent prognostic factor (hazard ratio 1.04 per sec, 95% confidence interval 1.01-1.08) after adjusting for history of heart disease, number of previous severe exacerbations, and dyspnoea. This model explained 50.7% of the variance in mortality. This test exhibited similar discriminative ability as the 6MWT for 5 year mortality (area under the receiver operating characteristic curve: 0.741vs 0.722; p = 0.92), and a highly prognostic cut-off for discriminating (15.98 s). This cut-off had higher likelihood ratios (LRs) than the 6MWT cut-off (∼350 m), especially for negative LRs (1/LR-: 7.69vs 2.00). CONCLUSIONS: The 5-STS is an objective measure for predicting mortality in patients with COPD and has good discriminative ability, with a cut-off for discriminating survival slight better than the 6MWT. The prognostic value of the other tests remains to be confirmed.

Validation of the Spanish Activity Questionnaire in COPD (SAQ-COPD) in Patients with Chronic Obstructive Pulmonary Disease.

Purpose: The Spanish Activity Questionnaire in COPD (SAQ-COPD) is a short, simple physical activity (PA) measurement instrument for patients with chronic obstructive pulmonary disease (COPD). In this study, we analyzed its validity and sensitivity to change. Methods: Prospective scale validation study. An accelerometer (DynaPort MoveMonitor®) and the Yale Physical Activity Survey (YPAS) were used as reference standards. The analyses examined the criterion validity (Spearman correlations), internal consistency (Cronbach's alpha), factorial structure, test-retest reliability (intraclass correlation coefficient, ICC), sensitivity to change and receiver operating characteristic (ROC) curve to classify patients with low PA. Results: A total of 300 patients diagnosed with COPD were analyzed (73% males, mean age 66 ± 8 years, 40.3% with severe airflow limitation). Cronbach's alpha was 0.60 and Spearman's correlations with accelerometer measurements of PA [number of steps, metabolic equivalents (MET), physical activity level (PAL)] and YPAS ranged from 0.37 to 0.53 (all p < 0.001). ICC was 0.69 (95% CI 0.61-0.74) and the area under the ROC curve to identify low PA was 0.65 (95% confidence interval: 0.58-0.73). Significant variations in SAQ-COPD scores were found between groups defined by YPAS for change. Conclusion: The SAQ-COPD questionnaire is a valid instrument for classifying PA in patients with COPD. Correlations with other instruments provide criterion validity and also demonstrate good sensitivity to change.

Effectiveness of individualized inhaler technique training on low adherence (LowAd) in ambulatory patients with COPD and asthma.

To analyze whether there is improvement in adherence to inhaled treatment in patients with COPD and asthma after an educational intervention based on the teach-to-goal method. This is a prospective, non-randomized, single-group study, with intervention and before-after evaluation. The study population included 120 patients (67 females and 53 males) diagnosed with asthma (70.8%) and COPD (29.1%). The level of adherence (low and optimal) and the noncompliance behavior pattern (erratic, deliberate and unwitting) were determined by the Test of the adherence to Inhalers (TAI). This questionnaire allows you to determine the level of adherence and the types of noncompliance. Low Adherence (LowAd) was defined as a score less than 49 points. All patients received individualized educational inhaler technique intervention (IEITI). Before the IEITI, 67.5% of the patients had LowAd. Following IEITI, on week 24, LowAd was 55% (p = 0.024). Each patient can present one or more types of noncompliance. The most frequent type was forgetting to use the inhaler (erratic), 65.8%. The other types were deliberate: 43.3%, and unwitting: 57.5%. All of them had decreased on the final visit: 51.7% (p = 0.009), 25.8% (p = 0.002), 39.2% (p = 0.002). There were no significant differences in adherence between asthma and COPD patients at the start of the study. The only predicting factor of LowAd was the female gender. An individualized educational intervention, in ambulatory patients with COPD and asthma, in real-world clinical practice conditions, improves adherence to the inhaled treatment.

Effectiveness of Non-Presential Individualized Exercise Training PrOgram(NIETO) in Lower Limb Physical Performance in Advanced COPD.

Muscle training, a component of pulmonary rehabilitation (PR), improves the physical performance of patients with chronic obstructive pulmonary disease (COPD). Despite the existing evidence, the traditional center-based PR model is applied to a small percentage of patients and presents numerous problems of accessibility, adherence, and costs. This study presents a home model of simple muscle training, non-presential, monitored by telephone and individualized, according to the severity of the COPD. In addition, to evaluate the results, simple tests associated with the physical performance of the lower limbs, previously validated in COPD, have been used, such as the four-meter walk, speed test (4MGS) and the five-repetition test sitting and standing (5STS). The objective was to evaluate whether the Individualized Non-Presential Exercise Training PrOgram (NIETO) induces improvements in the 4MGS, 5STS and quadriceps muscle strength (QMS) tests in outpatients with advanced COPD (FEV1 ≤ 50%). After one year, the QMS was significantly higher in the intervention group (IG) than in the control group (CG) (2.44 ± 4.07 vs. 0.05 ± 4.26 kg; p = 0.009). The 4MGS and 5STS tests were significantly shorter in IG than in CG (-0.39 ± 0.86 vs. 0.37 ± 0.96 s; p = 0.001) and (-1.55 ± 2.83 vs. 0.60 ± 2.06 s; p = 0.001), respectively. A home model of simple muscle training monitored by telephone such as NIETO, can improve 4MGS, 5STS, and quadriceps strength tests in outpatients with advanced COPD.

Pancreatic Metastasis from Malignant Melanoma: Not All That Glitters Is Gold.

Pancreatic adenocarcinoma is the most common malignancy of the pancreas; on rare occasions, metastatic tumors are present. Differentiating a primary neoplasm from a metastatic one is important for ensuring adequate treatment for the patient. We present a case of metastatic melanoma to the pancreas. A 60-year-old man presented with a history of weight loss, vague abdominal pain, jaundice, and pruritus. Laboratory tests showed increased total bilirubin, with a direct fraction predominance, as well as increased alkaline phosphatase and gamma glutamyl transferase. Imaging studies revealed a mass in the head of the pancreas. Endoscopic ultrasound (EUS)-guided fine needle biopsy was performed, and histologic examination confirmed the diagnosis of metastatic melanoma. This case report illustrates the invaluable use of EUS-guided tissue acquisition in the study of pancreatic solid lesions to obtain an accurate diagnosis. Melanomas should always be part of a differential diagnosis when evaluating patients with pancreatic masses.

The five-repetition sit-to-stand test is a predictive factor of severe exacerbations in COPD.

BACKGROUND: Although the six-minute-walk test (6MWT) has been used to predict chronic obstructive pulmonary disease (COPD) exacerbations, additional research is necessary to identify more rapid, simpler tests that are directly associated with exacerbations, such as the five-repetition sit-to-stand (5STS) test and 4-m gait speed (4MGS) test. AIMS: To determine the ability of the 5STS and 4MGS tests in predicting severe exacerbations in stable COPD over the following year, and to assess the ability of the best prognostic test to identify patients at high risk of hospital admission correctly. METHODS: This prospective study included 137 patients with stable COPD. Multiple logistic regression models were constructed to assess whether the 6MWT, 5STS, and 4MGS tests were associated with severe exacerbations in the year following the test. Receiver-operating characteristic curves and the area under the curve (AUC) were evaluated to determine the accuracy of each test for identifying patients with severe exacerbations. RESULTS: Scores of <350 m for the 6WMT and ⩽2 for the 5STS test were associated with severe exacerbations in the model adjusted for age and the number of exacerbations in the previous year. The 5STS test and the 6MWT had very similar predictive and discriminative abilities. Odds ratios were 3.20 (95% confidence interval [CI] 1.14-8.96) and 3.84 (95% CI 1.14-12.94) and AUCs were 0.793 (95% CI 0.704-0.882) and 0.783 (95% CI 0.686-0.879), respectively. CONCLUSIONS: The 5STS test predicted the risk of severe exacerbation within the following year among patients with COPD. The 5STS test could replace the 6MWT for identifying patients at high risk of hospital admission.

Urinothorax: presentation of a new case as pleural exudate.

Urinothorax or urothorax (UT) is a rare condition which often goes undiagnosed. In published cases of UT, the pleural fluid is usually transudative and is very rarely exudative. We present a case of UT after right nephroureterectomy for urothelial carcinoma, in which the pleural fluid presented characteristics of exudate. The diagnosis of UT was confirmed with the finding of a pleural/serum creatinine ratio above one and after demonstrating the presence of a postsurgical urinoma in the right renal fossa. UT should be included in the differential diagnosis of pleural effusion in patients with a recent urinary tract disorder, even when it is pleural exudate.