Case Report: Localized bullous pemphigoid induced by local triggers: a case series and a proposal for diagnostic criteria based on a literature review.

Introduction: Localized bullous pemphigoid (LBP) is an infrequent bullous pemphigoid (BP) variant restricted to a body region. According to the most compelling evidence, LBP occurs in patients with pre-existent serum antibodies against the basement membrane zone, which occasionally acquire the capacity to induce disease after the influence of different local factors acting as triggers. Methods: We hereby present a multicenter cohort of 7 patients with LBP developed after local triggers: radiotherapy, thermal burns, surgery, rosacea, edema and a paretic leg. In addition, we conducted a review of the literature, and we propose a set of diagnostic criteria for LBP, also based on our case series and the 2022 BP guidelines from the European Academy of Dermatology and Venereology. Results: During follow-up, three of the patients from our series evolved to a generalized BP, with only one requiring hospitalization. Our literature search retrieved 47 articles including a total of 108 patients with LBP, with a 63% with a potential local precipitating factor previous to their diagnosis. LBP mostly affected older females, and a subsequent generalized progression occurred in 16.7% of the cases. The most frequently involved areas were the lower limbs. Radiation therapy and surgery were responsible for the inducement of nearly 2 in 3 cases of LBP. We observed a significantly higher risk of generalization in cases where the trigger led to the developing of LBP earlier (p=0.016). Our statistical analysis did not detect any other prognosis factor for generalization when assessing direct immunofluorescence, histological and serological results, or other patient related factors. Conclusion: LBP should be suspected in patients with recurrent localized bullous eruptions. The presence of a trauma history in the same anatomic area is reported in most cases.

Vértigo en gestantes: presentación clínica, impacto en la calidad de vida y factores asociados / Vertigo in pregnancy: clinical presentation, impact on quality of life and associated factors

OBJETIVO: Evaluar las características clínicas, el impacto en la calidad de vida y los factores asociados con vértigo en gestantes hospitalizadas en una institución de alta complejidad. MÉTODO: Estudio transversal. Se realizó una encuesta dirigida a la presencia de vértigo y sus características clínicas en 2020-2021. La calidad de vida se evaluó con el cuestionario Dizziness Handicap Inventory (DHI). El análisis estadístico incluyó un modelo lineal generalizado. RESULTADOS: De 103 mujeres, el 19,4% indicaron vértigo principalmente en el segundo trimestre de gestación (60%), con una mediana de 3,5 (rango intercuartil: 1,5-7,5) episodios. Fueron referidos vértigos episódicos asociados con cambios posicionales (40%), acompañados de inestabilidad (60%), cefalea (60%), fotopsias (55%) y tinnitus (45%). Las mujeres con vértigo presentaron mayor frecuencia de discapacidad moderada a grave en las dimensiones del DHI emocional (30 vs. 2,4%; p = 0,001), funcional (40 vs. 2,4%; p < 0,001) y física (55 vs. 2,4%; p < 0,001) en comparación con las mujeres sin la patología. La hospitalización durante el embarazo Razón de proporción (RP): 4,02; intervalo de confianza del 95% [IC95%]: 1,64-9,85; p = 0,002) y la presencia de vértigo pregestacional (RP: 2,37; IC95%: 1,15-4,88; p = 0,019) se identificaron como factores asociados. CONCLUSIONES: La alta frecuencia de vértigo en las gestantes sugiere la importancia de estudiar esta condición durante el embarazo, para lograr un manejo integral y generar acciones de prevención y control efectivas.

OBJECTIVE: To evaluate clinical characteristics, impact on quality of life and factors associated with vertigo in pregnant women hospitalized in a highly complex institution. METHOD: A cross-sectional study was conducted in 2021-2022. One focused survey including Dizziness Handicap Inventory (DHI) was performed. The statistical analysis was performed using a generalized lineal regression. RESULTS: 103 patients were included, 19.4% indicated vertigo mostly during the second semester (60%). A median of 3.5 episodes was obtained (RIC: 1.5-7.5). Positional and episodic vertigos (40%) associated with unsteadiness (60%), headache (60%), photopsia (55%) and tinnitus (45%) were described. DHI in pregnant females with vertigo compared to those without vertigo, presented higher rates of moderate to severe disability in the emotional (30 vs. 2.4%: p = 0.001), functional (40 vs. 2.4%; p < 0.001) and physical (55 vs. 2.4%; p < 0.001) dimensions. Hospitalizations during the pregnancy (RP: 4.02; 95%CI: 1.64-9.85; p = 0.002) and previous episodes before pregnancy (RP: 2.37; 95%CI: 1.15-4.88; p = 0.019) were identified as associated factors with current vertigo episodes. CONCLUSIONS: The high frequency of vertigo in pregnant women suggests the importance of studying this condition during pregnancy, to achieve comprehensive management and generate effective prevention and control actions.

Implant connection and abutment selection as a predisposing and/or precipitating factor for peri-implant diseases: A review.

Peri-implant mucosal integration is becoming a critical aspect for long term implant health and can be triggered the selection of implant components. The aim of this review is therefore to investigate the evidence concerning implant connection and abutment characteristics (abutment materials, design, handling) as predisposing or precipitating factor for peri-implant mucositis and peri-implantitis. Although the evidence that these features can directly predispose/precipitate peri-implant diseases is limited, there are -few- studies showing a potential role of the implant connection, trans-mucosal configuration, and handling in the development of early bone loss and/or peri-implantitis. With bone level implants, conical internal connections (with inherent platform switching) might be preferred over internal flat-flat and external connections to decrease the risk of early bone loss and potentially the risk of peri-implant disease. Moreover, there is a trend suggesting moving the prosthetic interface coronally (to the juxta-mucosal level) as soon as possible to reduce the number of disconnections and to limit the risk of cements remnants. This can be achieved by choosing a tissue-level implant or to place a trans-mucosal abutment (one abutment-one time approach) to optimize the peri-implant soft tissue seal. In absence of evidence for the biocompatibility regarding several restorative materials, biocompatible materials such as titanium or zirconia should be preferred in the trans-mucosal portion. Finally, higher implants (≥2mm) with an emergence angle below 30° seem more favourable. It should however be noted that some of this information is solely based on indirect information (such as early bone loss) and more research is needed before making firm recommendations about abutment choice. [Correction added on 13 March 2023, after first online publication: 'longer implants (≥2mm)' was changed to 'higher implants (≥2mm)' in this version.].

Precipitating factors of catastrophic antiphospholipid syndrome: the role of anticoagulant treatment in a series of 112 patients.

BACKGROUND: The prevention of catastrophic antiphospholipid syndrome (CAPS), a rare complication of antiphospholipid syndrome (APS), is a major goal. OBJECTIVES: We analyzed its precipitating factors, focusing on anticoagulation immediately before CAPS episodes. METHODS: We retrospectively analyzed patients in the French multicenter APS/systemic lupus erythematosus database with at least 1 CAPS episode. Then we compared each patient with known APS before CAPS with 2 patients with non-CAPS APS matched for age, sex, center, and APS phenotype. RESULTS: We included 112 patients with CAPS (70% women; mean age, 43 ± 15 years). At least 1 standard precipitating factor of CAPS was observed for 67 patients (64%), which were mainly infections (n = 28, 27%), pregnancy (n = 23, 22%), and surgery (n = 16, 15%). Before the CAPS episode, 67 (60%) patients already had a diagnosis of APS. Of the 61 treated with anticoagulants, 32 (48%) received vitamin K antagonists (VKAs), 23 (34%) heparin, and 2 (3%) a direct oral anticoagulant. They were less likely than their matched patients with APS without CAPS to receive VKA (48% vs 66%, p = .001). Among those treated with VKA, 72% had a subtherapeutic international normalized ratio (ie, <2) versus 28% in patients with APS without CAPS (p < .001). Finally, excluding pregnant patients (n = 14) for whom we could not differentiate the effect of treatment from that of pregnancy, we were left with 47 cases, 32 (68%) of whom had recently begun a direct oral anticoagulant, planned bridging therapy, or had VKA treatment with international normalized ratio <2. CONCLUSION: These results strongly suggest that suboptimal anticoagulation management can trigger CAPS in patients with thrombotic APS.

Intraoperative hypovolemia as a possible precipitating factor for pituitary apoplexy: a case report.

BACKGROUND: Pituitary apoplexy is acute infarction with or without hemorrhage of the pituitary gland. It is a rare but potentially life-threatening emergency that most commonly occurs in the setting of pituitary adenoma. The mechanisms underlying pituitary apoplexy are not well understood, but are proposed to include factors of both hemodynamic supply and adenoma demand. In the case of patients with known pituitary macroadenomas undergoing major surgery for other indications, there is a theoretically increased risk of apoplexy in the setting of "surgical stress." However, risk stratification of patients with nonfunctioning pituitary adenomas prior to major surgery is challenging because the precipitating factors for pituitary apoplexy are not completely understood. Here we present a case in which intraoperative hypovolemia is a possible mechanistic precipitating factor for pituitary apoplexy. CASE PRESENTATION: A 76-year-old patient with a known hypofunctioning pituitary macroadenoma underwent nephrectomy for renal cell carcinoma, during which there was significant intraoperative blood loss. He became symptomatic with ophthalmoplegia on the second postoperative day, and was diagnosed with pituitary apoplexy. He was managed conservatively with cortisol replacement therapy, and underwent therapeutic anticoagulation 2 months after pituitary apoplexy for deep vein thrombosis. His ophthalmoplegia slowly resolved over months of follow-up. Pituitary apoplexy did not recur with therapeutic anticoagulation. CONCLUSIONS: When considering the risk of surgery in patients with a known pituitary macroadenoma, an operation with possible high-volume intraoperative blood loss may have increased risk of pituitary apoplexy because intraoperative hypovolemia may precipitate ischemia, infarction, and subsequent hemorrhage. This may be particularly relevant in the cases of elective surgery. Additionally, we found that we were able to therapeutically anticoagulate a patient 2 months after pituitary apoplexy for the management of deep vein thrombosis without recurrence of pituitary apoplexy.

Implant prosthodontic design as a predisposing or precipitating factor for peri-implant disease: A review.

Over the past decade, emerging evidence indicates a strong relationship between prosthetic design and peri-implant tissue health. The objective of this narrative review was to evaluate the evidence for the corresponding implant prosthodontic design factors on the risk to peri-implant tissue health. One of the most important factors to achieve an acceptable implant restorative design is the ideal implant position. Malpositioned implants often result in a restorative emergence profile at the implant-abutment junction that can restrict the access for patients to perform adequate oral hygiene. Inadequate cleansability and poor oral hygiene has been reported as a precipitating factors to induce the peri-implant mucositis and peri-implantitis and are influenced by restorative contours. The implant-abutment connection, restorative material selection and restoration design are also reported in the literature as having the potential to influence peri-implant sort tissue health.

Impact of local predisposing/precipitating factors and systemic drivers on peri-implant diseases.

BACKGROUND: Strong evidence suggests the infectious nature of peri-implant diseases occurring in susceptible hosts. Epidemiological reports, though, indicate that peri-implantitis is a site-specific entity. Hence, the significance of local factors that may predispose/precipitate plaque accumulation and the impact of systemic drivers that alter the immune response are relevant in the prevention and management of peri-implant disorders. PURPOSE: The purpose of the present review is to shed light on the significance of local and systemic factors on peri-implant diseases, making special emphasis on the associations with peri-implantitis. METHODS: The biologic plausibility and supporting evidence aiming at providing a concluding remark were explored in the recent scientific literature for local predisposing/precipitating factors and systemic drivers related to peri-implant diseases. RESULTS: Local predisposing factors such as soft tissue characteristics, implant position and prosthetic design proved being strongly associated with the occurrence of peri-implant diseases. Hard tissue characteristics, however, failed to demonstrate having a direct association with peri-implant diseases. Robust data points toward the strong link between residual sub-mucosal cement and peri-implant diseases, while limited data suggests the impact of residual sub-mucosal floss and peri-implantitis. Systemic drivers/habits such as hyperglycemia and smoking showed a strong negative impact on peri-implantitis. However, there is insufficient evidence to claim for any link between metabolic syndrome, atherosclerotic cardiovascular disease, and obesity and peri-implant diseases. CONCLUSION: Local predisposing/precipitating factors and systemic drivers may increase the risk of peri-implant diseases. Therefore, comprehensive anamnesis of the patients, educational/motivational programs and exhaustive prosthetically-driven treatment planning must be fostered aiming at reducing the rate of biological complications in implant dentistry.

Falla hepática aguda sobre crónica / Acute on chronic liver failure

La falla hepática aguda sobre crónica (ACLF) es un síndrome que se presenta en pacientes con cirrosis descompensada, y se caracteriza por una mortalidad elevada a 28 días, que se diagnostica con la combinación de falla hepática y extrahepática. Se han publicado numerosas definiciones, de las cuales se resalta la realizada por la Asociación Europea para el Estudio del Hígado (EASL), la cual tiene en cuenta 6 sistemas orgánicos (hígado, riñón, pulmón, cerebro, coagulación y circulación), y gradúa su gravedad basada en el número de sistemas comprometidos en el momento de la presentación. Entre los pilares en el abordaje del paciente con ACLF es imperiosa la búsqueda de los factores precipitantes, siendo los más frecuentes las infecciones bacterianas, el consumo excesivo de alcohol, la hemorragia de vías digestivas, la injuria hepática inducida por medicamentos y la cirugía hepática o cirugía mayor, teniendo en cuenta que aproximadamente en el 50 % de los casos no se logrará establecer la causa. Los pilares angulares del tratamiento constarán de la reversión o interrupción del factor precipitante, el soporte orgánico y, en aquellos pacientes que cumplan los criterios para trasplante, su realización oportuna.

Acute-on-chronic liver failure is a syndrome that occurs in patients with acute decompensated cirrhosis and is characterized by high 28-day mortality that is diagnosed with a combination of hepatic and extrahepatic organ failure. Numerous definitions have been published with great concern related to the etiology and cause of the decompensation, of which the one made by the European Association for the Study of the Liver (EASL) stands out, taking into account 6 organic systems (liver, kidney, lung, brain, coagulation, and circulation), and grades its severity based on the number of systems involved at the time of presentation. Among the pillars in the approach to the patient with ACLF, the search for precipitating factors is imperative, the most frequent being bacte-rial infections, excessive alcohol consumption, digestive tract bleeding, drug-induced liver injury, liver surgery or major surgery, keeping in mind that in approximately 50% of cases the cause will not be established. The cornerstones of treatment will consist of the reversal or interruption of the precipitating factor, organ support and, in those patients who meet the criteria for transplantation, its timely performance.

Bullying escolar: associação com possível bruxismo do sono e fatores desencadeantes / School bullying: association with possible sleep bruxism and triggering/precipitant factors

Bullying é um comportamento agressivo que gera consequências emocionais. Indivíduos vulneráveis estão sujeitos a sofrer esta agressão. Bruxismo do sono (BS) é uma atividade muscular mastigatória que está associado a fatores psicossociais. O objetivo do artigo 1 (n=431) foi analisar a associação de possível BS com bullying escolar. O objetivo do artigo 2 (n=425) foi identificar a associação entre fatores desencadeantes de bullying e indivíduos envolvidos em bullying como vítimas e vítimas-intimidadores. O objetivo do artigo 3 foi analisar a acurácia da resposta dada pelos responsáveis em um questionário acerca do BS comparado ao diário do sono. O estudo foi aprovado pelo Comitê de Ética e Pesquisa em Humanos da Universidade Federal de Minas Gerais (protocolo 82839718.4.0000.5149). Participaram da pesquisa escolares com idade entre 8 a 11 anos, matriculados em escolas públicas e privadas de Lavras, e seus responsáveis. Os responsáveis responderam a um questionário, desenvolvido para a pesquisa, com duas perguntas sobre a ocorrência do BS (ranger de dentes [RD]) nos escolares, dados sociodemográficos e um diário do sono de sete dias. Os escolares responderam um questionário, desenvolvido para a pesquisa, sobre dentes, cabelo, cor da pele, altura, peso, boca, nariz e outras características que podem interferir no relacionamento com os pares na escola; e preencheram a versão brasileira do Olweus Bully/Victim Questionnaire. A análise estatística do artigo 1, 2 e 3 incluiu análises descritivas. A regressão de Poisson (RR:Razão das Taxas) foi utilizada no artigo 1 e a regressão Logística Multinomial (OR) no artigo 2 (p≤0,05). No artigo 3 os resultados foram fornecidos com curva ROC e medição de acurácia (área sob a curva ­ AUC). Como resultado para o artigo 1 verificou-se que a frequência de RD entre os escolares vítimas-intimidadores foi 1,57 maior (RR=1,57; IC95%=1,04­2,36; p= 0,030). A frequência de RD entre os escolares que relataram acordar cansados pela manhã pelo menos uma vez por semana foi 1,33 vezes maior (RR=1,33; IC95%=1,00­1,78; p=0,050) e a frequência de RD entre escolares cuja renda familiar mensal é igual ou inferior a um salário mínimo apresentou 1,49 vezes maior (RR=1,49, IC95%=1,04-2,13, p=0,027). No artigo 2 observou-se que escolares vítimas-intimidadores eram mais propensos a serem de escola pública (OR=5,43, IC95%=1,14-25,91; p=0,034) e os escolares vítimas de bullying eram mais propensos a relatarem outras características individuais, como uso de óculos (OR=3,31; IC95%=1,14-9,57; p=0,027) e características dos dentes (OR=3,80; IC95%=1,38-10,41; p=0,010) como fatores que atrapalham seu convívio com os colegas. No artigo 3 verificou-se que a comparação do questionário com o diário do sono, para diagnóstico de BS, demonstrou uma AUC de 87,6% (IC95%=83,2% - 92,1%). Conclui-se que estar envolvido em comportamentos de bullying na escola, cansaço do escolar ao acordar e baixa renda familiar estão associados ao possível BS entre escolares. Os achados mostraram, também, que dentes e outras características individuais estão associados à ser vítima de bullying e estar envolvido em bullying como vítima-intimidador está associado com o tipo de escola. O questionário de diagnóstico de BS mostrou uma acurácia relevante quando comparado ao diário do sono de 7 dias.

Bullying is an aggressive behavior that generates emotional consequences. Vulnerable individuals are more likely to suffer this aggression. Sleep bruxism is a masticatory muscle activity that is associated with psychosocial factors. The objective of article 1 (n=431) was to analyze the association of possible sleep bruxism (SB) with school bullying. The objective of article 2 (n=425) was to identify the association between triggering factors of bullying and individuals involved in bullying as victims and bully-victims. The objective of article 3 was to analyze the accuracy of the response given by guardians in a questionnaire about sleep bruxism (SB) compared to the sleep diary. The study was approved by the Human Research Ethics Committee of the Federal University of Minas Gerais under protocol number CAAE 82839718.4.0000.5149. Schoolchildren aged between 8 and 11 years old, enrolled in public and private schools in Lavras, and their guardians participated in the research. Guardians answered a questionnaire, developed for research, about the occurrence of SB (gnashing teeth [GT]) in schoolchildren, sociodemographic data, and a seven- day sleep diary. The schoolchildren answered a questionnaire, developed for research, about teeth, hair, skin color, height, weight, mouth, nose, and other factors that can interfere with peer relationships at school. They completed the Brazilian version of the Olweus Bully/Victim Questionnaire. Statistical analysis of articles 1, 2 and 3 included descriptive analyses. Poisson regression (RR-Rate Ratio) was used in article 1 and Multinomial Logistic (OR) regression in article 2 (p≤0.05). In article 3 the results were provided with a ROC curve and accuracy measurement (area under the curve ­ AUC). As a result of article 1, it was found that the frequence of GT among schoolchildren were victims-bullies had 1.57 times higher (RR = 1.57; 95%CI=1.04­ 2.36; p= 0.030). The frequence of GT among schoolchildren who reported waking up tired in the morning at least once a week was 1.33 times higher (RR=1.33; 95%CI=1.00­1.78; p=0.050), frequence of GT among schoolchildren whose family monthly income is equal to a minimum wage or less presented 1.49 times higher (RR=1.49, 95% CI=1.04­2.13, p=0.027). In article 2, it was observed that bully-victim schoolchildren were more likely to be from public schools (OR=5.43, 95%CI=1.14- 25.91; p=0.034) and bullied schoolchildren were more likely to report other individual characteristics (example: use of glasses) (OR=3.31; 95%CI=1.14-9.57; p=0.027) and teeth characteristics (PR=3.80; 95%CI=1.38 -10.41; p=0.010) as factors that interfere with his interaction with colleagues. In article 3, it was found that the comparison of the questionnaire with the sleep diary, for the diagnosis of SB, showed an AUC of 87.6% (CI95%=83.2% - 92.1%) It was concluded that being involved in bullying behaviors at school, schoolchildren tiredness upon waking up, and low family income are associated with possible SB among students. The findings also showed that teeth and other individual characteristics are associated with bullying victims and being involved in bullying as a bully-victim is associated with the type of school. The SB diagnostic questionnaire showed relevant accuracy when compared to the 7-day sleep diary.

Dual-Drug Conjugated Glyco-Nanoassemblies for Tumor-Triggered Targeting and Synergistic Cancer Therapy.

Drug-conjugated nanoassemblies potentiate the efficiency of anticancer drugs through the advantages of high drug-loading capacity and passive/active targeting ability in cancer therapy. This study describes the synthesis of gemcitabine (Gem) and cisplatin (cisPt) dual-drug-functionalized glyco-nanoassemblies (GNs) for anticancer drug delivery systems. It also investigates the pH-triggered drug delivery of the conventional anticancer drug cisPt. A Gem-functionalized well-defined glycoblock copolymer backbone (P(iprFruMA-b-MAc)-Gem), which consists of fructose and methacrylic acid segments, was synthesized via a reversible addition-fragmentation chain transfer (RAFT) polymerization method. Following the hydrolysis of the protecting groups on the backbone copolymer, cisPt functionalization of P(FruMA-b-MAc)-Gem in aqueous media was carried out during the transformation of glycoblock polymers into self-assembled spherical glyco-nanoassemblies (GN3). Monodrug-functionalized glyco-nanoassemblies were also prepared either with Gem (GN1) or cisPt (GN2) to compare the synergetic effect of dual-drug conjugated glyco-nanoassemblies (GN3). The sizes of glyco-nanoassemblies GN1, GN2, and GN3 were found as 5.76 ± 0.64, 59.80 ± 0.13, and 53.80 ± 3.90 nm and dispersity (D) values as 0.476, 0.292, and 0.311 by dynamic light scattering (DLS) measurement, respectively. The in vitro studies revealed that the drug-free glyco-nanoassemblies are biocompatible at concentrations higher than 296 µg/mL. The drug-conjugated glyco-nanoassemblies (GN1 and GN2) exhibited in vitro cytotoxicity against human breast cancer cell lines of MDA-MB-231 comparable to free Gem and cisPt, illustrating an efficient drug release into the tumor environment. Additionally, GNs exhibited higher selectivity and preferential cellular internalization in MDA-MB-231 when compared to healthy cell lines of CCD-1079Sk. These dual-drug conjugated GNs can effectively enhance the killing of cancer cells and increase synergistic chemotherapy.

Medication-Related Osteonecrosis of the Jaw: 14 Years' Retrospective Study on Pathogenetic Trigger Events.

Although events such as tooth extraction and oral surgery were considered for a while the sole triggering factor for Medication-Related Osteonecrosis of the Jaw (MRONJ), it is still unclear if trigger events may be precipitating factors that accelerate the onset of the disease that would have possibly occurred anyway. Therefore, this research aimed to retrospectively analyze MRONJ cases diagnosed in our tertiary referral hospital during the last 14 years, focusing on the onset of the disease, potential trigger events, and countermeasures to update the knowledge on their pathogenesis. An audit of patients diagnosed with MRONJ attending our department from 2008 to 2021was performed. χ2 test and Fisher exact test were employed to assess the relationship between the medications used and trigger events; χ2 test was also used to assess any relationship between MRONJ localization and drug, drug class, trigger, or trigger type. Seventy-six patients' records were identified. Fifty-two records were selected for analysis. Trigger events for the onset of the disease were found in 35 cases (67.3%). χ2 test showed a correlation between the drug used and trigger event occurrence (P=0.045) confirmed by Fisher exact test (P=0.34). Visual histogram analysis showed positive correlation when Alendronate (12 cases, 85.7%), Zoledronate (12 cases, 75%), and Risedronate (2 cases, 100%) were administered. Subgroup analysis per underlying disease, showed a significant correlation between the drug used and trigger event occurrence in the osteoporosis group (χ2 test, P=0.021; Fisher exact test, P=0.009).

Fatores desencadeantes para limitações sociais e saúde mental em diabéticos / Triggering factors for social limitations and mental health in diabetics / Factores desencadenantes de limitaciones sociales y salud mental en diabéticos

Introdução:A Diabetes Mellitus é caracterizada como uma síndrome de múltiplas etiologias, que ocorre pela falta de insulina, ou resistência do organismo à mesma, estando relacionada à diversas complicações que demandam ao paciente adaptações no modo de viver e que podem ser geradores de sofrimento psicológico. Objetivo:Identificar os principais fatores desencadeantes para a ocorrência de limitações sociais e suas consequências na saúde mental de pacientes convivendo com diabetes. Metodologia:O estudo configura-se como revisão integrativa da literatura. Utilizou-se como critérios de inclusão: artigos completos, publicados de 2015 a 2020, nos idiomas inglês, português e espanhol. Foram excluídos: documentos de editoriais, revisões, resenhas, capítulos de livros e artigos que não atendessem ao objetivo proposto. A busca dos estudos se deu entre os meses de outubro a novembro de 2020 nas bases de dados: PubMed,CinahleEmbase. Foram utilizados descritores controlados identificados nos Descritores em CiênciasdaSaúde (DECs), Medical Subject Headings (MESH) e EMBASEEmtree, resultando em 2.063 estudos na identificação, passando por triagem e permanecendo 718, após a elegibilidade resultou em 12, dando origem a 9 estudos na amostra final. Resultados:A amostra final resultou na criação de eixos temáticos que trazem o aumento do sofrimento psicológico em pessoas com diabetes ocasionados pelas mudanças no estilo de vida, na falta de apoio familiar e social, na inatividade física, no impacto do gênero e da cultura, e no aumento dos sintomas de complicações e de comprometimento funcional, sendo desencadeantes para a ocorrência de limitações sociais. Conclusões:A diabetes e o seu tratamento geram limitações sociais na vida dos pacientes, pela necessidade de mudanças no estilo devida que demandam muita dedicação e tempo, tais fatores são considerados preditores para aumento dos riscos de sofrimento psicológico nesses pacientes (AU).

Introduction:Diabetes Mellitus is characterized by being a syndrome of multiple etiologies, which occurs due to the lack of insulin or the body's resistance to it, being related to various complications that require the patient to adapt their lifestyle and that can generate psychological suffering.Objective:Identify the main triggering factors for the occurrence of social limitations and their consequences on the mental health of patients living with diabetes.Method:This study is configured as an integrative review of the literature. The inclusion criteria were full articles, published from 2015 to 2020, in English, Portuguese and Spanish.Editorial documents, reviews, book chapters and articles that did not meet theproposed objective were excluded.The compilation of studies was carried out from October and November 2020 in the databases:PubMed, CinahlandEmbase. In addition, controlled descriptors identified in the Descriptors in Health Sciences (DECs), MESH and EMBASE Emtree were used, which resulted in 2,063 studies identified, submitted for selection, remaining 718, and 12 after the eligibility process, resulting in 9 studies in the final sample.Results:The final sample resulted in the creation of thematic axes that bring an increase in psychological suffering in people with diabetes caused by changes in their lifestyle, lack of family and social support, physical inactivity, impact of gender and culture, and the increase in symptoms of complications and functional impairment, triggering the occurrence of social limitations.Conclusion:Diabetes and its treatment generate social limitations in the lives of patients, due to the need for changes in their lifestyle that require a lot of dedication and time, such factors are considered predictors to increase the risks of psychological suffering in these patients (AU).

Introducción:La Diabetes Mellitus se caracteriza por ser un síndrome de múltiples etiologías, que se presenta por la falta de insulina o por la resistencia del organismo a esta, estando relacionada con diversas complicaciones que requieren del paciente adaptaciones ensumodo de vida y que pueden generar sufrimientopsicológico.Objetivo:Identificar los principales factores desencadenantes parala ocurrenciade limitaciones sociales y sus consecuencias enla salud mental de los pacientes que viven con diabetes.Metodología:Esteestudio se configura como una revisión integradora de la literatura. Se incluyeron: artículos completos, publicados de 2015 a 2020, en inglés, portugués y español.Se excluyeron: documentos editoriales, reseñas, capítulos de libros y artículos que no cumplieron con el objetivo propuesto.El compilado de estudiosse realizóde octubre y noviembre de 2020 en las bases de datos:Medline (PubMed®), CINAHL yEMBASE.Se utilizaron descriptores controlados identificados en los Descriptores enCiencias de la Salud (DECs), MESH y EMBASE Emtree, lo que resultó en 2.063 estudios identificados, sometidos a selección, quedando 718,y resultando, luego del procesode elegibilidad,en 12, dando lugar a 9 estudios en la muestrafinal. Resultados:La muestra final resultó en la creación de ejes temáticos que traen un aumento del sufrimiento psicológico en las personas con diabetes provocado por cambios en suestilo de vida, la falta de apoyo familiar y social, inactividad física, impacto del género y la cultura, y el aumento de los síntomas de complicaciones y deterioro funcional, desencadenando la ocurrencia de limitaciones sociales.Conclusiones:La diabetes y su tratamiento generan limitaciones sociales en la vida de los pacientes, debido a la necesidad de cambios en suestilo de vida que requieren mucha dedicación y tiempo, tales factores se consideran predictores para aumentar los riesgos de sufrimiento psicológico en estos pacientes (AU).

Algunos elementos de interés acerca del diagnóstico y tratamiento de la tormenta tirotóxica / Some elements of interest about the diagnosis and treatment of thyrotoxic storm

Introducción: La tormenta tirotóxica se produce por la liberación repentina y rápida de hormonas tiroideas al torrente sanguíneo. Constituye la complicación más peligrosa de la tirotoxicosis. Objetivo: Describir los principales elementos de interés acerca del diagnóstico y del tratamiento de la tormenta tirotóxica. Métodos: Se utilizaron como motores de búsqueda los correspondientes a las bases de datos Google Académico, Pubmed y SciELO. Las palabras clave utilizadas fueron: tormenta tirotóxica, tormenta tiroidea, tirotoxicosis, hipertiroidismo, diagnóstico y tratamiento. Se evaluaron y se incluyeron los trabajos de revisión, de investigación y las páginas web que tuvieran menos de 10 años de publicados y que por el título trataban el tema de estudio. Fueron excluidos los artículos que no estuvieran en idioma español, portugués o inglés. En total 34 artículos fueran referenciados. Conclusiones: El diagnóstico es eminentemente clínico y se realiza por la detección de factores desencadenantes. Se suma la exacerbación del cuadro clínico de tirotoxicosis previamente existente, el cual afecta a varios sistemas del organismo como consecuencia del aumento de las hormonas tiroideas circulantes. Lo ideal es prevenir la tormenta tirotóxica, aunque ya establecido el tratamiento no se debe retrasar la terapia de la causa desencadenante y de la causa específica. Deberá estar encaminada a reducir la síntesis y la secreción de las hormonas tiroideas y a minimizar las acciones periféricas de estas. Deberán emplearse diferentes fármacos y otras medidas terapéuticas para tratar las complicaciones sistémicas para complementar el tratamiento(AU)

Introduction: Thyrotoxic storm is caused by the sudden and rapid release of thyroid hormones into the bloodstream. It is the most dangerous complication of thyrotoxicosis. Objective: Describe some elements of interest about the diagnosis and treatment of thyrotoxic storm. Methods: Search engines corresponding to Google Scholar, Pubmed and SciELO databases were used. The keywords used were: thyrotoxic storm; thyroid storm; thyrotoxicosis; hyperthyroidism; diagnosis and treatment. The review papers, research papers and web pages, which in general, had less than 10 years of publication and that by the title dealt with the subject of study were evaluated and included. Articles that were not in Spanish, Portuguese or English were excluded. A total of 34 articles were referenced. Conclusions: The diagnosis is eminently clinical and is made by the detection of triggers, to which is added the exacerbation of the clinical picture of thyrotoxicosis previously existing, which affects several systems of the body as a result of the circulating thyroid hormones increase. The ideal is to prevent the thyrotoxic storm; although if the treatment is already established, the therapy of the triggering cause and the specific cause should not be delayed. It should be aimed at reducing the synthesis and secretion of thyroid hormones and minimizing their peripheral actions. Different drugs and other therapeutic measures should be used to treat systemic complications to complement treatment(AU)

Elementos básicos para el diagnóstico y manejo terapéutico del coma mixedematoso en el paciente adulto / Basic elements for the diagnosis and therapeutic management of myxedematous coma in adult patients

Introducción: A pesar de su baja incidencia, la gravedad del cuadro clínico y la alta mortalidad hacen del coma mixedematoso una complicación a tener en cuenta. Objetivo: Describir los elementos básicos para el diagnóstico y manejo terapéutico del coma mixedematoso en el paciente adulto. Métodos: Se realizó una búsqueda de literatura relevante sobre el tema. Se utilizaron buscadores de información científica como Pubmed y Google Académico. La estrategia de búsqueda incluyó los siguientes términos como palabras clave: hipotiroidismo primario, hipotiroidismo subclínico, diagnóstico y tratamiento. Fueron evaluados artículos de revisión, de investigación y páginas web que tuvieran menos de 10 años de publicados. Se consideraron los textos en idioma español e inglés y que hicieran referencia específicamente al tema de estudio a través del título. Fueron excluidos los artículos que no cumplieron con estas condiciones. Esto permitió el estudio de 64 artículos, de los cuales 40 fueron referenciados. Conclusiones: Para el diagnóstico del coma mixedematoso en el paciente adulto lo más importante es sospecharlo en aquellas personas que presenten factores precipitantes, acompañados de síntomas y signos de hipotiroidismo severo con diferentes grados de insuficiencia del sistema nervioso central, hipotermia, hipoventilación, insuficiencia circulatoria e hiponatremia. A esto se sumaría el escenario humoral característico y los posibles hallazgos dependientes de la enfermedad causante del hipotiroidismo. Se debe tratar con un reemplazo agresivo de levotiroxina sódica (vía endovenosa u oral, según posibilidades), unido a otras medidas de apoyo en el entorno hospitalario(AU)

Introduction: Despite its low incidence, the severity of the clinical picture and the high mortality make myxedematous coma a complication to be taken into account. Objective: Describe the basic elements for the diagnosis and therapeutic management of myxedematous coma in adult patients. Methods: A search of relevant literature on the subject was carried out. Pubmed and Google Scholar were used as search engines for scientific information. The search strategy included the following keyword terms: primary hypothyroidism, subclinical hypothyroidism, diagnosis and treatment. Review articles, research articles and Web pages that, in general, had less than 10 years of publication, in Spanish and English that specifically referred to the subject of study through the title were evaluated. Articles that did not meet these conditions were excluded. This allowed the study of 64 articles, of which 40 were referenced. Conclusions: For the diagnosis of myxedematous coma in the adult patient, the most important thing is to suspect it in those people who present precipitating factors, accompanied by symptoms and signs of severe hypothyroidism with different degrees of central nervous system insufficiency, hypothermia, hypoventilation, circulatory insufficiency and hyponatremia. To this would be added the characteristic humoral scenario and the possible findings dependent on the disease causing hypothyroidism. It should be treated with an aggressive replacement of levothyroxine sodium (intravenous or oral way, accodring to the possibilities), together with other supportive measures in the hospital setting(AU)

Not as simple as ABC: Tools to trigger massive transfusion in pediatric trauma.

BACKGROUND: Early and accurate identification of pediatric trauma patients who will receive massive transfusion (MT) is not well established. We developed the ABCD (defined as penetrating mechanism, positive focused assessment with sonography for trauma, shock index, pediatric age-adjusted [SIPA], lactate, and base deficit [BD]) and BIS scores (defined as a combination of BD, international normalized ratio [INR], and SIPA) and hypothesized that the BIS score would perform best in the ability to predict the need for MT in children. METHODS: Pediatric trauma patients (≤18 years old) admitted to our trauma center between 2008 and 2019 were identified. Using a receiver operator curve, we defined cutoff points for lactate (≥3.2), BD (≤-6.9), and INR (≥1.4). ABCD scores were calculated by combining penetrating mechanism; positive focused assessment with sonography for trauma examination; SIPA; lactate; and BD. BIS scores were calculated by combining BD, INR, and SIPA. The sensitivity, specificity, and accuracy of each score were calculated based on receiving MT. RESULTS: Seven hundred seventy-two patients were included, of which 59 (7.6%) underwent MT. The best predictor of receiving MT was achieved by a BIS score of ≥2 that was 98% sensitive and 23% specific with an area under the curve of 0.81. The ABCD score of ≥2 was 97% sensitive and 20% specific with an area under the curve of 0.77. CONCLUSION: The BIS score, which takes into account derangements in acidosis, coagulopathy, and SIPA, is accurate and easy to perform and can be incorporated into a simple bedside screening tool for triggering MT in pediatric trauma patients. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria, Level IV.

Autoestima y factores de bullying en estudiantes de bachillerato de la provincia de Chimborazo / Self-esteem and bullying factors in high school students in the province of Chimborazo

El objetivo principal de la presente investigación fue analizar la relación entre la autoestima, concebida como la percepción de las cualidades y características contenidas en el propio auto-concepto y los factores de victimización correspondientes al fenómeno del bullying. Para ello, se contó con una muestra de 341 estudiantes de unidades educativas de la provincia de Chimbo-razo, donde se analizaron los datos obtenidos de las baterías psicológicas aplicadas: Test de autoestima de Rosenberg y la Escala de victimización en la escuela. La media de nivel del nivel de autoestima es de =29,81, con una desviación estándar δ = 4,47. Por otro lado, al considerar los factores del bullying, el tipo de victimización más frecuente entre la muestra ha sido la relacional (= 15,48; DT= 4,90), seguido de la manifiesta verbal (= 8,14; DT= 2,32), y el menos habitual la manifiesta física (= 4,88; DT= 1,14). Se encontró que la mayor parte de los estudiantes presentan autoestima alta. Tanto en la victimización relacional, manifiesta física como en la manifiesta verbal existieron diferencias con respecto al género. Finalmente, se observó relaciones significativas positivas y negativas entre la autoestima y los diferentes factores de victimización.

The main objective of this research was to analyze the relationship between selfesteem, conceived as the perception of the qualities and characteristics contained in the selfconcept itself, and the victimization factors corresponding to the phenomenon of bullying. For this, a sample of 341 students from educational units in the province of Chimborazo was used. The data obtained from the applied psychological batteries were analyzed: the Rosenberg SelfEsteem Test and the School Victimization Scale. The mean level of the level of selfesteem is  = 29.81, with a stan-dard deviation δ = 4.47. On the other hand, when considering bullying factors, the most frequent type of victimization among the sample has been relational ( = 15.48; SD = 4.90), followed by verbal manifest ( = 8.14; DT = 2.32), and the least common is physical manifestation ( = 4.88; DT = 1.14). It was found that most of the students have high selfesteem. There were differences with respect to gender in relational victimization, physical and verbal manifest. Finally, signifi-cant positive and negative relationships were observed between self-esteem and the different victimization factors.

Dilema terapéutico: síndrome de abstinencia alcohólica y encefalopatía hepática concurrentes. A propósito de un caso / Therapeutic dilemma: alcohol withdrawal syndrome and concurrent hepatic encephalopathy. A case report

RESUMEN El trastorno por consumo de alcohol es una de las principales causas de morbimortalidad en el mundo. La enfermedad hepática alcohólica es una complicación común de este trastorno y la encefalopatía hepática es una seria comorbilidad de la cirrosis alcohólica. Los factores precipitantes pueden relacionarse con infección, sangrado gastrointestinal, deshidratación o efectos de psicofármacos (p. ej., benzodiacepinas e hipnóticos no benzodiacepínicos). Se expone un caso del manejo hospitalario de un paciente con un trastorno severo por consumo de alcohol, cirrosis y encefalopatía hepática, quien desarrolla síntomas de abstinencia alcohólica durante su hospitalización y la complejidad del manejo antagónico de un delirium gabaérgico propio de la encefalopatía hepática en el contexto de un delirium glutamatérgico-noradrenérgico por abstinencia alcohólica.

ABSTRACT Alcohol use disorder is one of the main causes of morbidity and mortality in the world. Alcoholic liver disease is a common complication of this disorder, and hepatic encephalopathy is a serious complication of alcoholic cirrhosis. Precipitating factors may be related to infection, gastrointestinal bleeding, dehydration or the effects of psychotropic drugs (e.g. benzodiazepines and non-benzodiazepine hypnotics). We present a case of the hospital management of a patient with a severe alcohol use disorder, cirrhosis and hepatic encephalopathy who developed alcohol withdrawal symptoms while in hospital, and discuss the complexity of the antagonistic management of a GABAergic delirium characteristic of hepatic encephalopathy in the context of a glutamatergic-noradrenergic delirium due to alcohol withdrawal.

The Elderly with Glucose-6-Phosphate Dehydrogenase Deficiency are More Susceptible to Cardiovascular Disease.

AIM: Recent studies suggest that glucose-6-phosphate dehydrogenase (G6PD) deficiency, a genetically inherited condition causing hemolytic anemia, may be a risk factor for cardiovascular disease (CVD). We aimed to perform a retrospective case-control study in Sardinia taking advantage from clinical records of patients undergoing upper digestive endoscopy and screened for H. pylori infection. METHODS: A total of 9,604 patients with a known G6PD status and a complete clinical history, encompassing CVD, and leading CVD risk factors, including H. pylori infection, undergoing upper endoscopy between 2002 and 2017 were enrolled in this study. RESULTS: Multivariate logistic regression analysis confirmed an increased CVD risk in subjects with G6PD deficiency [odd ratio (OR), 3.24; 95% confidence interval (CI) 2.44-4.30] after adjusting for potential confounders and effect modifiers, including H. pylori infection. Cardiovascular risk was similar in subjects with and without G6PD deficiency before age 60 (OR, 1.26; 95% CI 0.78-2.04, P=0.562), whereas it increased after age 60 in the former group (OR, 3.05; 95% CI 2.22-4.19, P＜0.0001) especially in males (OR 3.67; 95% CI 2.19-6.14) compared with females (OR, 2.96; 95% CI 1.89-4.64) by sex-specific logistic regression analysis. CONCLUSION: The risk of CVD was greater in G6PD-deficient subjects after age 60, both in males and females, than those with normal enzyme activity, after adjusting for conventional CVD risk factors and H. pylori infection. The reduction of important protective mechanisms against oxidative stress in the elderly might explain the study findings.

COVID-19 and the burning issue of drug interaction: never forget the ECG.

The coronavirus disease of 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has been rapidly escalating, becoming a relevant threat to global health. Being a recent virus outbreak, there are still no available therapeutic regimens that have been approved in large randomised trials and so patients are currently being treated with multiple drugs. This raises concerns regarding drug interaction and their implication in arrhythmic burden. In fact, two of the actually used drugs against SARS-CoV2, such as chloroquine and the combination lopinavir/ritonavir, might determine a QT (the time from the start of the Q wave to the end of the T wave) interval prolongation and they show several interactions with antiarrhythmic drugs and antipsychotic medications, making them prone to an increased risk of developing arrhythmias. This brief review focuses the attention on the most relevant drug interactions involving the currently used COVID-19 medications and their possible association with cardiac rhythm disorders, taking into account also pre-existing condition and precipitating factors that might additionally increase this risk. Furthermore, based on the available evidence and based on the knowledge of drug interaction, we propose a quick and simple algorithm that might help both cardiologists and non-cardiologists in the management of the arrhythmic risk before and during the treatment with the specific drugs used against SARS-CoV2.