Optimizing Diabetes Care Through Listening to Multiple Voices.

This article is adapted from the address Dr. Caballero delivered as the recipient of the American Diabetes Association's Outstanding Educator in Diabetes Award for 2023. He delivered the address in June 2023 during the Association's 83rd Scientific Sessions in San Diego, CA. A webcast of this speech is available for viewing on the DiabetesPro website (https://events.diabetes.org/live/25/page/186).

Implicit or Unconscious Bias in Diabetes Care.

"Implicit bias," also called "unconscious bias," refers to associations outside of conscious awareness that adversely affect one's perception of a person or group. Awareness of implicit bias has been increasing in the realm of diabetes care. Here, the authors highlight several types of unconscious bias on the part of clinicians and patients, including biases based on race, ethnicity, and obesity. They discuss how these biases can negatively affect patient-centered clinical interactions and diabetes care delivery, and they recommend implementation of evidence-based interventions and other health system policy approaches to reduce the potential impact of such biases in health care settings.

Integral evaluation of effective conversion of sewage sludge from WWTP into highly porous activated carbon.

Urban sewage sludge (SL) is a major concern due to the number of environmental problems it causes. Its application for different purposes is strictly regulated, limiting the possibilities of recycling and reusing this material. Thus, in this work, a complete study of a simple method to convert SL into activated carbon (AC) was carried out. The comprehensive study involves an evaluation of the main process parameters, such as the activating agent (AA) content (25 %, 33 %, 50 %), using the lowest amount of AA as novelty, different pyrolysis temperatures (600 and 800 °C), and purification conditions (6 M HCl:AC ratio, v:w). Under controlled and optimised conditions and through a single combined activation and pyrolysis step followed by acid purification, ACs with well-developed porosity can be obtained. Surface area values of around 870 m2/g and over 60 % carbon content were achieved, demonstrating that the prepared ACs could have applications in a wide variety of fields as high-value products. As an innovative aspect in this research, the gases streams and liquid effluents generated during the global process were analysed, achieving elimination of over 63 % of the concentration of the chemical elements contained in the SL during the chemical purification stage. Finally, mass, energy, and economic balances were carried out to estimate the production cost of AC derived from SL (<€ 8/kg AC).

Miotomía endoscópica por vía oral (POEM) como tratamiento para la acalasia pediátrica: estudio multicéntrico y primeros resultados.

INTRODUCTION: Laparoscopic Heller miotomy of achalasia has been classically recognized as the gold standard management in children. There is increasing experience with the peroral endoscopic miotomy (POEM) approach in pediatrics, although the series published are scarce. The objective of this study was to present our experience in primary or secondary treatment of pediatric achalasia by POEM and its clinical success rate. METHODS: We performed a retrospective review of pediatric patients with achalasia who underwent POEM in some national centers from October 2016 to January 2023. We evaluated clinical efficacy (Eckardt score ≤3), demographic characteristics, intraoperative, preoperative and postoperative, complications, and follow-up. RESULTS: Fifteen POEM were performed in fourteen pediatric patients (aged 12 to 18 years) with achalasia. POEM was the first line treatment in 11 patients, but 4 (21.3%) had previous treatment: 1 (7,1%) pneumatic balloon dilation and 2 (14,2%) laparoscopic Heller myotomy and 1 (7,1%) previous POEM. The average age was 15 years (SD ± 1,9). The baseline Eckardt score was 7,5 (SD:± 1,8), with the baseline GERD score being 6 (SD:± 2,9). There was a Clavien Dindo grade 2 postoperative adverse event corresponding to mild pneumonia (7,1%). The postoperative Eckardt and GERD score after 12 months of follow-up were 0.7 (SD±1,2) and 0,5 (SD±0,7). The study has a success rate greater than 93%. CONCLUSIONS: POEM seems a safe and effective procedure, with a short postoperative period for treatment of pediatric achalasia.

Optimum timing for assessing phenotypic resistance against gastrointestinal nematodes in Pelibuey ewes.

The objective was to identify the optimal stage of production to evaluate the resistance of Pelibuey ewes against gastrointestinal nematodes (GIN). Faecal egg count (FEC) was used to classify the ewes as resistant, sensible or intermediate against GIN. Forty-seven ewes were mating during 30 d. The gestation was verified by ultrasonography, and the breeding date was used to calculate the productive stages. Faeces were taken weekly to determine the FEC. Blood samples were taken to determine the packed cell volume (PCV), the peripheral eosinophils count (PEC), plasma protein concentration (PP), and Immunoglobulin A (IgA) against Haemonchus contortus. The body condition score (BCS) was recorded at each visit. Six moments during the study (early, mid and late gestation; early, mid and late lactation) were considered. The ewes were classified according to FEC (mean FEC ± three standard errors). The higher FEC occurred during all lactation stages than during early and mid-gestation stages (P<0.05). PCV, PP, and BCS during early gestation stage were higher than shown during the lactation stages (P<0.01). The PEC and IgA were higher during all lactation stages than early and mid-gestation stages (P<0.05). Concerning the type of birth, double births showed higher FEC than single birth (P<0.01). The highest values of accuracy (100 %) and concordance (Youden's J = 1.0) were found during early lactation. Therefore, it is concluded that the optimal stage of production to evaluate phenotypic resistance against GIN infections in Pelibuey ewes was during the early lactation.

Parasite Community Analysis of The Gray Snapper Lutjanus Griseus (Perciformes,Lutjanidae) in a Tropical Region of The Southern Gulf of Mexico.

The gray snapper Lutjanus griseus is a commercially important fish species along its distribution range in the western Atlantic Ocean. However, despite its importance, there is still little knowledge about its parasitic fauna for the Mexican coasts of the Gulf of Mexico. The aims of this research were to generate a list of the parasitic fauna present in juvenile gray snapper L. griseus from a coastal lagoon located in southeastern Mexico, to evaluate the infection levels of parasites and to determine the relationship between the abundance of parasites and the fish size and condition factor. Samples of L. griseus (12 - 29.2 mm) were obtained in two periods of the year (dry and rainy seasons) to examine the intra-annual variability of its parasitic fauna. A total of 17 parasite species were recorded belonging to six taxonomic groups (Myxozoa, Monogenea, Digenea, Cestoda, Nematoda and Acanthocephala). The highest levels of infection (abundance, prevalence and intensity of infection) were found for the monogeneans Euryhaliotrema griseus and Euryhaliotrema fastigatum. There were no significant correlations between the total abundance of parasites and the fish condition and size (total length) in not any of the two seasons studied, suggesting that the body size and the biological condition index of the host did not directly influence the abundance of parasites in early life stages of L. griseus. Moreover, the species of parasites found that could be zoonotic for humans through the consumption of raw or inadequately cooked fish were the nematodes Contracaecum sp. type 1, Contracaecum sp. type 2, Cucullanus pargi and Pseudoterranova sp. The presence of the monogeneans E. griseus and E. fastigatum was also highlighted because these ectoparasite species are known to cause harm to fish under culture systems. All the parasite species found in this study, except nematodes, were new records of geographic distribution.

Identification of Somatic Proteins in Haemonchus Contortus Infective Larvae (L3) and Adults.

Haemonchus contortus is considered the most pathogenic nematode in sheep production systems based on grazing. Comparing infective larvae (L3) with adult parasites can lead to the identification of proteins that play an important role in parasite-host interactions. In this study, we report a list of H. contortus somatic proteins and made a comparative analysis of somatic proteins of L3 and adult worms. L3 and adult parasites were subjected to protein extraction and subsequently to peptide fractionation. Peptides were analysed by mass spectrometry and LC-MS/MS data analysis. Data analysis and search on SEQUEST and MASCOT against H. contortus from the WormBase ParaSite database resulted in the identification of 775 unique peptide sequences corresponding to 227 proteins at 1 % FDR. From these, 18 proteins were specific to L3 and 63 to adult parasites. The gene ontology (GO) enrichment analysis of the proteins specific to L3 and adult worms to gain insight into cellular components, molecular functions and biological processes that affect the parasite-host interaction showed some differences between the two parasite stages. The list of proteins found provides a database to identify target proteins that could be useful as biomarkers of the infection or in the generation of anthelmintic drugs that inhibit proteins essential for the establishment of the infection and the survival of adult parasites. They can also serve as new candidates for vaccine research.

Use of Diode Laser for Lip Repositioning, Evolution of the Conventional Technique. A Case Report.

INTRODUCTION: LipStaT® lip repositioning surgery using a diode laser for the management of gummy smiles offers promising and consistent long-term results. OBJECTIVE: To describe the technique through a clinical case, including its indications, preoperative evaluation, surgical approach, and recommendations after the intervention. CASE REPORT: A 29-year-old woman with excessive gingival display (EGD) of 4 mm when smiling; the LipStaT® technique was performed with a 940 nm diode laser to remove a strip of mucosa by ablating the epithelial tissue, and thus, achieve aesthetic, harmonic and functional results. The inflammation and postoperative pain were treated with the diode laser assisted lymphatic drainage technique. After follow-up, a satisfactory tissue response was observed, and no pain or inflammation was reported. CONCLUSION: The use of a 940 nm diode laser proved to be an effective treatment option for patients with a gummy smile, allowing control of intraoperative bleeding and improvement of the healing process obtaining predictable long-term results.

SAFETY AND EFFICACY OF THYMIC PEPTIDES IN THE TREATMENT OF HOSPITALIZED COVID-19 PATIENTS IN HONDURAS.

Coronavirus disease 2019 (Covid-19) active cases continue to demand the development of safe and effective treatments. This is the first clinical trial to evaluate the safety and efficacy of oral thymic peptides. ; We conducted a nonrandomized phase 2 trial with a historic control group to evaluate the safety and efficacy of a daily 250-mg oral dose of thymic peptides in the treatment of hospitalized Covid-19 patients. Comparisons based on standard care from registry data were performed after propensity score matching. The primary outcomes were survival, time to recovery, and number of participants with treatment-related adverse events or side effects by day 20. ; A total of 44 patients were analyzed in this study: 22 in the thymic peptide group and 22 in the standard care group. There were no deaths in the intervention group compared to 24% mortality in standard care by day 20 (log-rank P=0.02). Kaplan-Meier analysis showed a significantly shorter time to recovery by day 20 in the thymic peptide group than in the standard care group (median, 6 days vs. 12 days; hazard ratio for recovery, 2.75 [95% confidence interval, 1.34 to 5.62]; log-rank P=0.002). No side effects or adverse events were reported. ; In patients hospitalized with Covid-19, the use of thymic peptides resulted in no side effects, adverse events, or deaths by day 20. Compared with the registry data, a significantly shorter time to recovery and mortality reduction were measured.

Results of R-ESHAP as salvage therapy in refractory/relapsed follicular lymphoma: a real-world experience on behalf of GELCAB group.

There is no standard treatment for relapsed follicular lymphoma (FL). Although platinum-based combinations are one of the most used treatments, few data have been reported in this setting. Our aim was to analyse R-ESHAP efficacy in relapsed FL patients. We retrospectively analysed 80 FL patients treated with R-ESHAP in the first or successive relapses. Responding patients received a stem cell transplantation following R-ESHAP. Seventeen histologically transformed patients were included. Median age was 50 years. At R-ESHAP initiation, 85% of the patients were in an advanced stage, 28% had a bulky disease and 40% had increased LDH. There were no statistically significant differences between POD24 and non-POD24 patients in terms of response to R-ESHAP (ORR 72% vs. 93%, p = 0.109). When analyzing R-ESHAP efficacy according to the response to the immediately previous line, patients achieving CR or PR had better CR rates to R-ESHAP than those who did not respond (CR of 57% vs. 15%, respectively, p = 0.009), as well as differences in OS (7.2 vs. 1.4 years, p < 0.0001) and in PFS (2.1 vs. 0.3 years, p < 0.0001). R-ESHAP is an effective treatment in relapsed FL patients who respond to the previous line and has to be considered as an adequate alternative for some patients.

Diagnostic delay and outcome in immunocompetent patients with primary central nervous system lymphoma in Spain: a multicentric study.

INTRODUCTION: To assess the management of immunocompetent patients with primary central nervous system lymphomas (PCNSL) in Spain. METHODS: Retrospective analysis of 327 immunocompetent patients with histologically confirmed PCNSL diagnosed between 2005 and 2014 in 27 Spanish hospitals. RESULTS: Median age was 64 years (range: 19-84; 33% ≥ 70 years), 54% were men, and 59% had a performance status (PS) ≥ 2 at diagnosis. Median delay to diagnosis was 47 days (IQR 24-81). Diagnostic delay > 47 days was associated with PS ≥ 2 (OR 1.99; 95% CI 1.13-3.50; p = 0.016) and treatment with corticosteroids (OR 2.47; 95% CI 1.14-5.40; p = 0.023), and it did not improve over the years. Patients treated with corticosteroids (62%) had a higher risk of additional biopsies (11.7% vs 4.0%, p = 0.04) but corticosteroids withdrawal before surgery did not reduce this risk and increased the diagnostic delay (64 vs 40 days, p = 0.04). Median overall survival (OS) was 8.9 months [95% CI 5.9-11.7] for the whole series, including 52 (16%) patients that were not treated, and 14.1 months (95%CI 7.7-20.5) for the 240 (73.4%) patients that received high-dose methotrexate (HD-MTX)-based chemotherapy. Median OS was shorter in patients ≥ 70 years (4.1 vs. 13.4 months; p < 0.0001). Multivariate analysis identified age ≥ 65 years, PS ≥ 2, no treatment, and cognitive/psychiatric symptoms at diagnosis as independent predictors of short survival. CONCLUSIONS: Corticosteroids withdrawal before surgery does not decrease the risk of a negative biopsy but delays diagnosis. In this community-based study, only 73.4% of patients could receive HD-MTX-based chemotherapy and OS remains poor, particularly in elderly patients ≥ 70 years.

Impact of Monthly A1C Values Obtained at Home on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial.

The purpose of this randomized controlled clinical trial was to determine whether an A1C value obtained at home by participants followed by a phone discussion of the result with a clinician would lead to 1) a more rapid and significant decrease in A1C, 2) more effective advancement of diabetes treatment, and 3) improvement in diabetes self-care behaviors. The study included 307 participants with type 2 diabetes, most of whom were of Latino origin. All study participants experienced a statistically significant reduction in mean A1C (control subjects -0.3%, P = 0.04; intervention subjects -0.5%, P = 0.0002), but there was a statistically significant difference in the number of people who achieved a reduction of ≥0.5% by 6 months, favoring the intervention (33.6 vs. 46.7%, P = 0.05).

[A clinical management protocol for COVID-19 infection in pregnant women]. / Guía de actuación para el manejo de la infección por COVID-19 durante en el embarazo.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) has caused a large global outbreak and has had a major impact on health systems and societies worldwide. The generation of knowledge about the disease has occurred almost as fast as its global expansion. Very few studies have reported on the effects of the infection on maternal health, since its onset. The mother and foetus do not seem to be at particularly high risk. Nevertheless, obstetrics and maternal-foetal medicine practice have made profound changes in order to adapt to the pandemic. In addition, there are aspects specific to COVID-19 and gestation that should be known by specialists. In this review an evidenced-based protocol is presented for the management of COVID-19 in pregnancy.

Saving bones without risking brain-bisphosphonates and risk of stroke: matched case-control study.

We investigated the association between bisphosphonate treatment and the risk of stroke using a large routine clinical dataset. We found no association between bisphosphonate treatment and risk of stroke, after adjusting for large number of clinical and demographic confounders. INTRODUCTION: There is conflicting evidence on the link between bisphosphonates and stroke with studies variously showing increased, decreased or unchanged risk. We investigated the association between bisphosphonate treatment and the risk of stroke using a large routine clinical dataset. METHODS: We used a matched nested case-control study design analysing routinely collected electronic data from patients registered at primary care practices in England participating in the Royal College of General Practitioners Research and Surveillance Centre. Cases were patients aged 18 years or over, either living or dead, recorded as having had a stroke in the period 1 January 2005 to 31 March 2016. Each case was matched to one control according to age, sex, general practice attended and calendar time. Data were analysed using Stata, version 14.2. and RStudio, version 1.1.463. Conditional logistic regression was used to determine odds ratios for stroke according to bisphosphonate treatment and duration in cases compared with controls. We adjusted for disease risk groups, cardiovascular risk factors, treatments, smoking status, alcohol consumption, ethnicity, bisphosphonate types, fracture and socioeconomic status using IMD (Index of Multiple Deprivation). RESULTS: We included 31,414 cases of stroke with an equal number of matched controls. Overall, 83.2% of cases and controls were aged 65 years or older, and there were similar proportions of females (51.5%) and males (48.5%). Bisphosphonate treatment was not associated with stroke after adjusting for the wide range of confounders considered (OR 0.86, 95% CI 0.62-1.19). CONCLUSIONS: We found no association between bisphosphonate treatment and risk of stroke, after adjusting for other confounders.

A multinational observational study assessing insulin use: Understanding the determinants associated with progression of therapy.

AIMS: To describe global patterns of insulin treatment and to assess the impact of patient, provider, health system and economic influences on treatment decisions for patients with insulin-treated type 2 diabetes (T2D). METHODS: This prospective cohort study of insulin-treated patients with T2D was conducted across 18 countries categorized as high, upper-middle or lower-middle income regions. Information collected from patients included knowledge of diabetes, experiences and interactions with their healthcare provider. Physician information included specialty, practice size, availability of diabetes support services, volume of diabetes patients treated and time spent per patient. Physicians determined an individualized haemoglobin A1c (HbA1c) target for each patient by the start of the study. Changes in T2D therapies and HbA1c were recorded for 2 years. RESULTS: Complete treatment data were available for 2528 patients. Median age was 61 years and median duration of diabetes was 11.4 years. Changes to treatment regimen occurred in 90.0% of patients, but changes were less common in countries with a higher economic status (P < 0.001). Most treatment changes involved insulin, with changes in dose the most common. Overall predictors of change in insulin therapy included younger age, use of any insulin regimen other than basal only, higher mean baseline HbA1c and longer duration of T2D. HbA1c levels remained constant regardless of regional economic status. At baseline, 20.6% of patients were at their HbA1c target; at 2 years this was 26.8%. CONCLUSIONS: Among insulin-treated patients with T2D, treatment changes were common; however, only approximately one-fourth of individuals achieved their HbA1c target.

Direct antimicrobial susceptibility testing from the blood culture pellet obtained for MALDI-TOF identification of Enterobacterales and Pseudomonas aeruginosa.

To standardize the methodology for conducting direct antimicrobial susceptibility testing (AST) of Enterobacterales and Pseudomonas aeruginosa causing bacteremia from positive blood culture pellets. Two methods for processing positive blood cultures with Enterobacterales and P. aeruginosa were compared: a conventional method for identification and AST versus a direct method obtaining a pellet for both matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) identification and direct AST. A total of 157 (145 Enterobacterales, 12 P. aeruginosa) positive blood cultures were included. Microorganism identification showed 100% concordance between both methods at species and genus level. Definitive AST results were obtained 24 h earlier with the rapid method than the conventional one (p < 0.001). Of the 2814 MICs generated, there were discrepancies with respect to the conventional method in 47 (1.7%), 0.3% being very major (VME) and 1.3% major (ME) errors. Better results for AST were obtained when colony counts with the pellet were ≥ 105 cfu/ml. The essential agreement (EA) for antibiotics tested in Enterobacterales was at least 97%, except for ampicillin (95%). Regardless of colony count, the greatest discrepancies were observed for first/s-generation cephalosporins and aminoglycosides. In P. aeruginosa, EA was at least 92%, except for piperacillin-tazobactam (84%) and cefepime (76%). No VME occurred except for ceftazidime (8%). ME occurred in piperacillin/tazobactam (16%), ticarcillin, ceftazidime, tobramycin, amikacin, and colistin (8% each). Direct use of the blood culture pellet permits fast AST in bacteremia of Enterobacterales, enabling the clinicians to perform an early treatment adjustment. However, for Pseudomonas aeruginosa, the data needs expanding to improve the reliability of this technique.

Apple bagasse as a substrate for the propagation of Patagonian wine yeast biomass.

AIMS: A culture medium based on apple bagasse was designed and tested as a substrate for biomass production of conventional and unconventional native wine yeasts. METHODS AND RESULTS: The physicochemical characterization of the apple bagasse was carried out and its potential utility as a constituent of a complete culture medium for the production of yeast biomass was analysed using the experimental statistical designs. Growth parameters of conventional and nonconventional Patagonian wine yeasts were analysed with Placket-Burman designs and response surface methodology, comparing in each assay the apple bagasse substrate with the commonly used substrate for biomass development, cane molasses. Culture media composition was optimized and models were validated. CONCLUSIONS: This study demonstrates that, both from a nutritional and from an economic point of view, apple bagasse constitutes a more advantageous substrate than cane molasses for the propagation of native yeasts from Patagonia. SIGNIFICANCE AND IMPACT OF THE STUDY: We used an alternate carbon-rich material, generously available in our region, originally generated as fruit industrial waste, to transform it into a source of sustainable, economically profitable and environmentally friendly energy resource.

Descriptions of two new cases of Rocky Mountain spotted fever in Panama, and coincident infection with Rickettsia rickettsii in Rhipicephalus sanguineus s.l. in an urban locality of Panama City, Panama.

The clinical and pathologic characterisation of two fatal cases of tick-borne rickettsiosis in rural (El Valle) and urban (City of Panama) Panama are described. Clinical and autopsy findings were non-specific, but the molecular analysis was used to identify Rickettsia rickettsii in both cases. No ticks were collected in El Valle, while in the urban case, R. rickettsii was detected in Rhipicephalus sanguineus s.l., representing the first molecular finding in this tick in Panama and Central America.

Inbreeding load and purging: implications for the short-term survival and the conservation management of small populations.

Using computer simulations, we evaluate the effects of genetic purging of inbreeding load in small populations, assuming genetic models of deleterious mutations which account for the typical amount of load empirically observed. Our results show that genetic purging efficiently removes the inbreeding load of both lethal and non-lethal mutations, reducing the amount of inbreeding depression relative to that expected without selection. We find that the minimum effective population size to avoid severe inbreeding depression in the short term is of the order of Ne≈70 for a wide range of species' reproductive rates. We also carried out simulations of captive breeding populations where two contrasting management methods are performed, one avoiding inbreeding (equalisation of parental contributions (EC)) and the other forcing it (circular sib mating (CM)). We show that, for the inbreeding loads considered, CM leads to unacceptably high extinction risks and, as a result, to lower genetic diversity than EC. Thus we conclude that methods aimed at enhancing purging by intentional inbreeding should not be generally advised in captive breeding conservation programmes.

Comparing the phenotypic susceptibility of Pelibuey and Katahdin female lambs against natural gastrointestinal nematode infections under hot humid tropical conditions.

This study compared the phenotypic susceptibility of Pelibuey and Katahdin female lambs against gastrointestinal nematodes (GINs) under grazing conditions in the hot humid tropics of Mexico. The study was performed during the rainy season (August to October, 2014). It included 27 Pelibuey and 12 Katahdin female lambs from 6 months of age and live weight of 21.0 ± 3.7 and 23.3 ± 3.6 kg, respectively. Lambs were reared free of GIN infection before the study. The study lasted 91 days. Animals were weighed and sampled (blood and feces) on days 0 and 28 and every 7 days onwards. Fecal samples were obtained to determine fecal eggs of GIN per gram (EPG), and blood samples were used to determine the packed cell volume (PCV), the peripheral eosinophil counts (PECs), and optical densities (ODs) for IgA. The EPG counts were significantly lower for Pelibuey lambs compared to Katahdin throughout the study (P < 0.001). Similarly, Pelibuey lambs had higher mean PCV (P < 0.01) and PEC (P < 0.05) than Katahdin lambs during the study. The total weight gain and OD for IgA were similar between breeds (P > 0.05). Negative associations (P < 0.05) between EPG and PCV or PEC were moderate to strong for the lambs of both breeds. No association was found between EPG and IgA. In conclusion, Pelibuey lambs showed phenotypic evidence of higher resistance to natural GIN infections compared to Katahdin lambs sharing the same grazing conditions in the hot humid tropics. The most accurate phenotypic markers to identify a difference in susceptibility were EPG and PEC.