The small and inconspicuous majority: Revealing the megadiversity and historical biogeography of the Pristimantis unistrigatus species group (Anura, Strabomantidae).

With more than 600 recognized species, the genus Pristimantis is already the most diverse among vertebrates, but described species only represent a fraction of the actual diversity in this clade. This genus is widely distributed throughout the Neotropics and represents an interesting model for biogeographic studies because Pristimantis spp. are direct developing and generally have narrow ecological niches and low dispersal abilities. The P. unistrigatus species group is one of the most important components in the genus (ca. 200 recognized species) and has been supported by morphological but not by molecular evidence. We assessed the species boundaries and distribution in the P. unistrigatus species group and infer spatiotemporal patterns of diversification related to historical landscape changes in the Neotropics. We gathered three mitochondrial, and two nuclear DNA loci from 416 specimens throughout the range of the group, and including 68 nominal species. We redefine the group based on the obtained phylogeny and found 151 candidate species that composes it, with 83 of these remaining undescribed. We recovered 11 major clades within the group that diverged before 13 Ma. The diversification of the group started during the early Miocene most likely in northwestern South America, currently corresponding to western Amazonia and northern Andes. The other neotropical areas subsequently acted as sinks, receiving lineages mostly during the last 10 Ma, after the demise of the Pebas System and the setup of the modern Amazonian hydrographic system.

Total-evidence phylogeny and evolutionary morphology of New World pitvipers (Serpentes: Viperidae: Crotalinae).

Crotalines (pitvipers) in the Americas are distributed from southern Canada to southern Argentina, and are represented by 13 genera and 163 species that constitute a monophyletic group. Their phylogenetic relationships have been assessed mostly based on DNA sequences, while morphological data have scarcely been used for phylogenetic inquiry. We present a total-evidence phylogeny of New World pitvipers, the most taxon/character comprehensive phylogeny to date. Our analysis includes all genera, morphological data from external morphology, cranial osteology and hemipenial morphology, and DNA sequences from mitochondrial and nuclear genes. We performed analyses with parsimony as an optimality criterion, using different schemes for character weighting. We evaluated the contribution of the different sources of characters to the phylogeny through analyses of reduced datasets and calculation of weighted homoplasy and retention indexes. We performed a morphological character analysis to identify synapomorphies for the main clades. In terms of biogeography, our results support a single colonization event of the Americas by pitvipers, and a cladogenetic event into a Neotropical clade and a North American/Neotropical clade. The results also shed light on the previously unstable position of some taxa, although they could not sufficiently resolve the position of Bothrops lojanus, which may lead to the paraphyly of either Bothrops or Bothrocophias. The morphological character analyses demonstrated that an important phylogenetic signal is contained in characters related to head scalation, the jaws and the dorsum of the skull, and allowed us to detect morphological convergences in external morphology associated with arboreality.

First record of Tmesiphantes Simon, 1892 (Araneae, Theraphosidae) in Peru: a new species and its phylogenetic placement.

The tarantula genus Tmesiphantes Simon, 1892 includes 20 valid species distributed in Argentina and Brazil. These spiders are distinguished from other Theraphosinae genera by the presence of an incrassate femur III, more evident in males, urticating hair types III and IV on the abdominal dorsum, few cuspules on the labium (0 to 30), maxillae with a maximum of 200 cuspules and sternum rounded. From recent examination of material from Peru, we discovered specimens that share all the morphological characters of Tmesiphantes, but did not fit with any known species. In the present study T. intiyaykuy sp. nov. is diagnosed, described, and illustrated. This new species resembles T. caymmii in the circular patch with stiff setae on midventral abdomen but can be distinguished by the shape of the palpal bulb and spermathecae. Also, we performed a phylogenetic analysis using morphological characters to infer the taxonomic placement of the new species. The analysis included 26 terminal species and 36 characters. Representatives of Tmesiphantes formed a monophyletic group and T. intiyaykuy sp. nov. is close related with T. caymmii. A dichotomous identification key and a geographic distribution map were constructed for recognized species of Tmesiphantes.

Phylogenetic relationships of the Boana pulchella Group (Anura: Hylidae).

In this paper we present a phylogenetic analysis of the treefrogs of the Boana pulchella Group with the goals of (1) providing a rigorous test of its monophyly; (2) providing a test of relationships supported in previous studies; and (3) exploring the relationships of the several species not included in previous analyses. The analyses included>300 specimens of 37 of the 38 species currently included in the group, plus 36 outgroups, exemplars of the diversity of Boana and the other genera of the hylid tribe Cophomantini. The dataset included eight mitochondrial genes (12S, 16S, CytB, COI, ND1, tRNAIle, tRNALeu, and tRNAVal) and five nuclear genes (RHO, TYR, RAG-1, CXCR4, SIAH1). The phylogenetic analyses recover the monophyly of the B. pulchella Group with lower support than previous studies, as a result of the inclusion of the B. claresignata Group, which is recovered as its sister taxon. Within the B. pulchella Group, the inclusion of almost all species of the group had little impact on previous notions of its phylogeny, except for the rejection of the hypothesized B. polytaenia Clade (B. goiana and B. phaeopleura are nested in the clade here called the B. prasina Clade), which is redefined. Phylogenetic support is strong for five major clades, which collectively include all but three of the species sampled: the B. balzani Clade (B. aguilari, B. balzani, B. gladiator, B. melanopleura, B. palaestes), the redefined B. polytaenia Clade (B. botumirim, B. buriti, B. cipoensis, B. jaguariaivensis, B. leptolineata, B. polytaenia, B. stenocephala, and two undescribed species), the B. prasina Clade (B. bischoffi, B. caingua, B. cordobae, B. goiana, B. guentheri, B. marginata, B. phaeopleura, B. prasina, B. pulchella, and one undescribed species), the B. riojana Clade (B. callipleura, B. marianitae, B. riojana), and the B. semiguttata Clade (B. caipora, B. curupi, B. joaquini, B. poaju, B. semiguttata, B. stellae, and two undescribed species). The monophyly of the B. prasina + B. riojana Clades, and that of the B. polytaenia + B. semiguttata Clades are well-supported. The relationships among these two clades, the B. balzani Clade, B. ericae + B. freicanecae, and B. cambui (representing the deepest phylogenetic splits within the B. pulchella Group) are recovered with weak support. We discuss the phenotypic evidence supporting the monophyly of the B. pulchella Group, and the taxonomy of several species, identifying three new synonyms of Boana polytaenia, one new synonym of Boana goiana, and one new synonym of B. riojana.

Vastly underestimated species richness of Amazonian salamanders (Plethodontidae: Bolitoglossa) and implications about plethodontid diversification.

We present data showing that the number of salamander species in Amazonia is vastly underestimated. We used DNA sequences of up to five genes (3 mitochondrial and 2 nuclear) of 366 specimens, 189 corresponding to 89 non-Amazonian nominal species and 177 Amazonian specimens, including types or topotypes, of eight of the nine recognized species in the region. By including representatives of all known species of Amazonian Bolitoglossa, except for one, and 73% of the currently 132 recognized species of the genus, our dataset represents the broadest sample of Bolitoglossa species, specimens, and geographic localities studied to date. We performed phylogenetic analyses using parsimony with tree-alignment and maximum likelihood (ML) with similarity alignment, with indels as binary characters. Our optimal topologies were used to delimit lineages that we assigned to nominal species and candidate new species following criteria that maximize the consilience of the current species taxonomy, monophyly, gaps in branch lengths, genetic distances, and geographic distribution. We contrasted the results of our species-delimitation protocol with those of Automated Barcode Gap Discovery (ABGD) and multi-rate Poisson Tree Processes (mPTP). Finally, we inferred the historical biogeography of South American salamanders by dating the trees and using dispersal-vicariance analysis (DIVA). Our results revealed a clade including almost all Amazonian salamanders, with a topology incompatible with just the currently recognized nine species. Following our species-delimitation criteria, we identified 44 putative species in Amazonia. Both ABGD and mPTP inferred more species than currently recognized, but their numbers (23-49) and limits vary. Our biogeographic analysis suggested a stepping-stone colonization of the Amazonian lowlands from Central America through the Chocó and the Andes, with several late dispersals from Amazonia back into the Andes. These biogeographic events are temporally concordant with an early land bridge between Central and South America (~10-15 MYA) and major landscape changes in Amazonia during the late Miocene and Pliocene, such as the drainage of the Pebas system, the establishment of the Amazon River, and the major orogeny of the northern Andes.

Earless toads sense low frequencies but miss the high notes.

Sensory losses or reductions are frequently attributed to relaxed selection. However, anuran species have lost tympanic middle ears many times, despite anurans' use of acoustic communication and the benefit of middle ears for hearing airborne sound. Here we determine whether pre-existing alternative sensory pathways enable anurans lacking tympanic middle ears (termed earless anurans) to hear airborne sound as well as eared species or to better sense vibrations in the environment. We used auditory brainstem recordings to compare hearing and vibrational sensitivity among 10 species (six eared, four earless) within the Neotropical true toad family (Bufonidae). We found that species lacking middle ears are less sensitive to high-frequency sounds, however, low-frequency hearing and vibrational sensitivity are equivalent between eared and earless species. Furthermore, extratympanic hearing sensitivity varies among earless species, highlighting potential species differences in extratympanic hearing mechanisms. We argue that ancestral bufonids may have sufficient extratympanic hearing and vibrational sensitivity such that earless lineages tolerated the loss of high frequency hearing sensitivity by adopting species-specific behavioural strategies to detect conspecifics, predators and prey.

Linear IgA bullous dermatosis in a latin adolescent treated with cyclosporine and prednisone.

INTRODUCTION: Linear IgA bullous dermatosis (LABD) is a rare autoimmune disease. Although dapsone is the initial treatment, other immunomodulators are used in resistant cases or when dapsone is unavailable. CASE REPORT: A 12-year-old Mexican child, with no relevant medical history, developed in May 2023 a disseminated dermatosis affecting all body segments, including mucous membranes, characterized by erythematous patches and plaques evolving into the formation of serous and serosanguinous blisters and vesicles, distributed in a "string of pearls" pattern. LABD was suspected and confirmed by skin biopsy, which showed a subepidermal blister with neutrophilic infiltration and linear Immunoglobulin A deposits at the dermo-epidermal junction by direct immunofluorescence. Treatment with prednisone (2 mg/kg/day) and cyclosporine (5 mg/kg/day) resulted in improvement and lesion remission within 2 weeks. Both drugs needed to be discontinued for 3 months due to intermittent blistering. Cyclosporine was continued as maintenance therapy at a dose of 4 mg/kg/day for 8 months. CONCLUSIONS: The report highlights the use of cyclosporine as an alternative immunomodulator for DAAL, an immunosuppressive agent used in autoimmune disorders. Few cases, including this one, have described complete remission and control of the dermatosis with cyclosporine, accompanied by prednisone at the start of treatment.

INTRODUCCIÓN: La dermatosis ampollosa por IgA lineal es una enfermedad autoinmunitaria rara. Aunque la dapsona es el tratamiento inicial, se usan otros inmunomoduladores en casos resistentes o cuando la dapsona no está disponible. CASO CLÍNICO: Un niño mexicano de 12 años, sin antecedentes relevantes, desarrolló en mayo de 2023 una dermatosis diseminada a todos los segmentos corporales, incluyendo las mucosas, caracterizada por manchas y placas eritematosas que evolucionaron hacia la formación de ampollas y vesículas serosas y serohemáticas, distribuidas en forma de «cadena de perlas¼. Se sospechó dermatosis ampollosa por IgA lineal y se confirmó mediante biopsia cutánea, que mostró una ampolla subepidérmica con infiltrado neutrófilo y depósitos lineales de IgA en la unión dermoepidérmica mediante inmunofluorescencia directa. El tratamiento con prednisona (2 mg/kg al día) y ciclosporina (5 mg/kg al día) resultó en mejoría y la remisión de las lesiones a las 2 semanas. Fue necesario dejar ambos fármacos durante 3 meses debido a la aparición intermitente de ampollas. Se dejó ciclosporina como terapia de mantenimiento a dosis de 4 mg/kg al día por 8 meses. CONCLUSIONES: El reporte destaca el uso de ciclosporina como inmunomodulador alternativo para la dermatosis ampollosa por IgA lineal, un agente inmunosupresor utilizado en trastornos autoinmunitarios. Pocos casos, incluido este, han descrito la remisión completa y el control de la dermatosis con ciclosporina, acompañada de prednisona al inicio del tratamiento.

Clinical and epidemiological characteristics of pilomatricomas in a Mexican pediatric population.

BACKGROUND: Pilomatricoma is a common benign adnexal neoplasm in children. There are few epidemiological studies on this subject, with most relying solely on descriptive statistics. METHODS: A cross-sectional study conducted in two tertiary hospitals in Mexico City from January 2017 to December 2023. Clinical and electronic records of patients with histopathological diagnosis of pilomatricoma, both sexes, under 18 years old, with any type of present comorbidity were selected. Records of patients with diagnosis not confirmed by histopathology or incomplete records were not included in the study. RESULTS: Fifty-two cases with pilomatrixoma were included in the study, showing a total of 74 lesions. About 23.1% of the cases had multiple pilomatrixomas. 40.4% of the cases experienced pain; this symptom was associated with lesions > 15 mm in diameter and with multiple pilomatrixomas. Risk factors for lesions > 15 mm included age under 8 years, positive tent sign, tumor evolution longer than a year, and a non-classical clinical variety. The head and neck were the most commonly affected areas. The left upper extremity presented larger pilomatrixomas (median 18.5 mm) and occurred more frequently in adolescent patients (mean age 12.1 years) compared to other body areas. CONCLUSIONS: Pilomatrixoma in children shows clinical diversity, with specific findings based on size, number, and anatomical location.

INTRODUCCIÓN: El pilomatricoma es una neoplasia anexial benigna frecuente en la infancia. Hay muy pocos estudios epidemiológicos al respecto y la mayoría solo han utilizado estadística descriptiva. MÉTODOS: Estudio transversal realizado en dos hospitales de concentración de la Ciudad de México de enero de 2017 a diciembre de 2023. Se seleccionaron expedientes clínicos y electrónicos de pacientes con diagnóstico histopatológico de pilomatricoma, ambos sexos, menores de 18 años, con cualquier tipo de comorbilidad presente. No se incluyeron los expedientes de pacientes con diagnóstico no confirmado por histopatología o expediente incompleto. RESULTADOS: Se incluyeron 52 casos con diagnóstico de pilomatricoma que mostraron un total de 74 lesiones. El 23.1% de los pacientes tuvieron pilomatricomas múltiples. El 40.4% experimentaron dolor; este signo se asoció con lesiones de diámetro superior a 15 mm y pilomatricomas múltiples. La edad menor de 8 años, el signo de la tienda de campaña positivo, un tiempo de evolución mayor de 1 año y una variedad clínica no clásica son factores de riesgo asociados con las lesiones mayores de 15 mm. La cabeza y el cuello fueron las áreas más comúnmente afectadas por estos tumores. La extremidad superior izquierda presento pilomatricomas de mayor tamaño (mediana 18.5 mm), y ocurrieron más en pacientes adolescentes (media 12.1 años), en comparación con otras áreas del cuerpo. CONCLUSIONES: El pilomatricoma en niños muestra diversidad clínica. Presenta hallazgos y asociaciones específicas según el tamaño, el número y la ubicación anatómica.

Multisystem Inflammatory Syndrome in Children and Cardiac Involvement: A Quaternary Center Experience.

We prospectively analyzed clinical and laboratory characteristics associated with cardiac involvement and severe presentation in multisystem inflammatory syndrome in children. Of 146 patients, 66 (45.2%) had cardiac dysfunction and 26 (17.8%) had coronary artery abnormalities. Lower serum albumin levels, absolute lymphocyte and platelet counts, and elevated ferritin, fibrinogen, d-dimer and interleukin-6 levels were associated with cardiac dysfunction. Possible treatment complications were identified.

Better Guidelines and Policies: AAP's Partnership for Policy Implementation.

OBJECTIVES: In 2005, the American Academy of Pediatrics founded the Partnership for Policy Implementation (PPI). The PPI has collaborated with authors to improve the quality of clinical guidelines, technical reports, and policies that standardize care delivery, improve care quality and patient outcomes, and reduce variation and costs. METHODS: In this article, we describe how the PPI trained informaticians apply a variety of tools and techniques to these guidance documents, eliminating ambiguity in clinical recommendations and allowing guideline recommendations to be implemented by practicing clinicians and electronic health record (EHR) developers more easily. RESULTS: Since its inception, the PPI has participated in the development of 45 published and 27 in-progress clinical practice guidelines, policy statements, technical and clinical reports, and other projects endorsed by the American Academy of Pediatrics. The partnership has trained informaticians to apply a variety of tools and techniques to eliminate ambiguity or lack of decidability and can be implemented by practicing clinicians and EHR developers. CONCLUSIONS: With the increasing use of EHRs in pediatrics, the need for medical societies to improve the clarity, decidability, and actionability of their guidelines has become more important than ever.

Dermatoscopic Patterns in Childhood Vitiligo and Their Association With Reflectance Confocal Microscopy Findings.

INTRODUCTION: The diagnosis of vitiligo is mainly based on clinical findings. However, dermoscopy or reflectance confocal microscopy (RCM) could be useful for assessing its progression (stability, pigmen-tation, or depigmentation). OBJECTIVES: To evaluate the correlation of dermatological findings by dermoscopy and RCM in pediatric vitiligo. METHODS: We conducted a cross-sectional, descriptive, and analytical clinical study. Pediatric patients with vitiligo of both sexes, aged > 1 year and < 18 years, with all spectrums of the disease were includ-ed. Vitiligo lesions were evaluated clinically, by dermoscopy, and microscopy. RESULTS: A total of 40 patients with vitiligo were included. Eight dermoscopic patterns were found: reduced/absent pigment network, perifollicular pigmentation, trichromic, tapioca sago, perifollicular depigmentation, starburst, leukotrichia, and erythema. Skin with a normal pigment network showed complete dermal papillary rings and half-rings. Skin with reduced/absent pigment network also had an absence of papillary rings or only showed half-rings and was more common in unstable vitiligo. The trichrome pattern only showed half-rings. The Tapioca sago pattern showed complete papillary rings and appeared in younger patients. Perifollicular pigmentation showed half-rings and complete rings and did not show associations. The diffuse borders did not present complete papillary structures. It was found that vitiligo duration time of fewer than 24 months (Odds Ratio 4.56, CI 1.09-18.99) and absent papillary rings (OR 2.75, CI 1.01-7.51) are associated with unstable prognosis. CONCLUSIONS: Certain dermatoscopic and microscopic findings, such as the reduction/absence of the pigment network, tapioca sago pattern, and absence of papillary rings, can be used to assess the stabil-ity of the disease and provide insight into the clinical behaviour of vitiligo.

Dermatoscopic Patterns in Vitiligo.

Vitiligo is a chronic, acquired autoimmune pigmentary skin disease, most times it can be diagnosed clinically. Dermoscopy can confirm vitiligo in a non-invasive way. It is a diagnostic technique that visualizes sub-macroscopic morphological structures which correspond with specific histological structures. It detects subtle changes in the pigment pattern, evaluates vitiligo activity, attempts of re-pigmentation, leucotrichia, and differentiates it from other hypo pigmentary disorders. Most dermatoscopic clues used to assess vitiligo activity are found at the perifollicular level in the center and edge of the lesion. Perifollicular pigmentation is present in both active lesions and treated pigmented lesions with treatment. However, perifollicular depigmentation represents poor response, in treated lesions, and poor prognosis in untreated ones. The center of the lesion has reduced and/or absent pigment network, in active and stable lesions. If on dermoscopy the center of the lesion shows islands of pigment, erythema, or telangiectasias, re-pigmentation is suggested. At the periphery of the lesion, unstable vitiligo usually shows up as a diffuse border, trichrome pattern, micro-Koebner/comet tail phenomenon, satellite lesions, or a tapioca sago pattern. In stable lesions it is more frequent to find well defined or trichromic border. Pigmented lesions commonly present sharp borders and marginal or perilesional hyperpigmentation.

Pigmented neurofibroma with hypertrichosis.

BACKGROUND: Pigmented (or melanocytic) neurofibroma (PN) constitutes only 1% of cases and is considered a rare variant of neurofibroma containing melanin-producing cells. In addition, the association of PN with hypertrichosis is infrequent. CASE REPORT: We describe the case of an 8-year-old male with a neurofibromatosis type 1 (NF1) diagnosis, who presented a light brown hyperpigmented plaque, smooth and well-demarcated, and hypertrichosis on the left thigh. The skin biopsy showed characteristics of neurofibroma; however, in the deep portion of the lesion, melanin deposits positive for S100, Melan-A, and HMB45 were observed, thus establishing the diagnosis of pigmented neurofibroma. CONCLUSIONS: Although PN is a rare subtype of neurofibroma, it is considered a chronically progressive benign tumor containing melanin-producing cells. These lesions can appear alone or in association with neurofibromatosis. Since this is a tumor that can be confused with other skin lesions, biopsy analysis is essential to differentiate it from other pigmented skin tumors, such as melanocytic schwannoma, dermatofibrosarcoma protuberans, neurocristic hamartoma, or neuronevus. Surveillance is part of the treatment, and surgical resection is sometimes performed.

INTRODUCCIÓN: El neurofibroma pigmentado (NP) o melanocítico constituye solamente el 1% de los casos y se considera como una variante rara del neurofibroma que contiene células productoras de melanina. Además, la asociación de NP con hipertricosis es muy rara. CASO CLÍNICO: Se describe el caso de un paciente de sexo masculino de 8 años 2 meses de edad con diagnóstico de neurofibromatosis tipo 1 (NF1), quien presentaba en la cara anterior del muslo izquierdo una placa hiperpigmentada de color café claro, bien delimitada y de consistencia suave, e hipertricosis. La biopsia de piel presentó cambios característicos de neurofibroma; sin embargo, en la porción profunda de la lesión se observaron depósitos de melanina positivos para S100, Melan-A y HMB45, con lo que se estableció el diagnóstico de neurofibroma pigmentado. CONCLUSIONES: Aunque el NP es un subtipo raro del neurofibroma, se considera que es un tumor benigno de evolución crónica de células productoras de melanina. Estas lesiones aparecen en solitario o asociadas con neurofibromatosis. Dado que es un tumor que puede confundirse con otras lesiones cutáneas, es fundamental el análisis de la biopsia para diferenciarlo de otros tumores cutáneos pigmentados, como el schwanoma melanocítico, dermatofibrosarcoma protuberans, hamartoma neurocrístico o neuronevus. La vigilancia es parte del tratamiento y, en ocasiones, se lleva a cabo la resección quirúrgica.

Molecular phylogenetics, species diversity, and biogeography of the Andean lizards of the genus Proctoporus (Squamata: Gymnophthalmidae).

The family Gymnophthalmidae comprises ca. 220 described species of Neotropical lizards distributed from southern Mexico to Argentina. It includes 36 genera, among them Proctoporus, which contains six currently recognized species occurring across the yungas forests and wet montane grasslands of the Amazonian versant of the Andes from central Peru to central Bolivia. Here, we investigate the phylogenetic relationships and species limits of Proctoporus and closely related taxa by analyzing 2121 base pairs of mitochondrial (12S, 16S, and ND4) and nuclear (c-mos) genes. Our taxon sampling of 92 terminals includes all currently recognized species of Proctoporus and 15 additional species representing the most closely related groups to the genus. Maximum parsimony, maximum likelihood and Bayesian phylogenetic analyses recovered a congruent, fully resolved, and strongly supported hypothesis of relationships that challenges previous phylogenetic hypotheses and classifications, and biogeographic scenarios. Our main results are: (i) discovery of a strongly supported clade that includes all species of Proctoporus and within which are nested the monotypic Opipeuter xestus (a genus that we consider a junior synonym of Proctoporus), and two species of Euspondylus, that are therefore transferred to Proctoporus; (ii) the paraphyly of Proctoporus bolivianus with respect to P. subsolanus, which is proposed as a junior synonym of P. bolivianus; (iii) the detection of seven divergent and reciprocally monophyletic lineages (five of them previously assigned to P. bolivianus) that are considered confirmed candidate species, which implies that more candidate species are awaiting formal description and naming than currently recognized species in the genus; (iv) rejection of the hypothesis that Proctoporus diversified following a south to north pattern parallel to the elevation of the Andes; (v) species diversity in Proctoporus is the result of in situ diversification through vicariance in the grasslands of the high Andes, with at least five dispersals contributing to montane forest species.

Clinical Decision Support Stewardship: Best Practices and Techniques to Monitor and Improve Interruptive Alerts.

Interruptive clinical decision support systems, both within and outside of electronic health records, are a resource that should be used sparingly and monitored closely. Excessive use of interruptive alerting can quickly lead to alert fatigue and decreased effectiveness and ignoring of alerts. In this review, we discuss the evidence for effective alert stewardship as well as practices and methods we have found useful to assess interruptive alert burden, reduce excessive firings, optimize alert effectiveness, and establish quality governance at our institutions. We also discuss the importance of a holistic view of the alerting ecosystem beyond the electronic health record.

Burnout in clinicians.

Burnout is a response to sustained job stressors manifesting as a classic triad of emotional exhaustion, depersonalization, and a sense of reduced accomplishment. With 42% of physicians demonstrating some symptoms of burnout, this has already reached epidemic proportions. The COVID-19 pandemic has only worsened this phenomenon.

[Acne in the newborn.] / Acné en el recién nacido

Neonatal acne (NA) is a transitory dermatosis that occurs between the second and fourth weeks of life in 20% of children. This condition is more frequent in males, with a male-female ratio of 4.5:1. Present primary skin lesions are open and closed comedones which can evolve into papules, erythematous pustules and, in rare cases, nodules and cysts. NA topography includes the forehead, cheeks, chin, and eyelids, but occasionally it spreads to the scalp, neck, and trunk. NA occurs due to an elevated production of placental and neonatal androgens (of adrenal origin in both sexes and of testicular origin in males) which cause enlargement of the sebaceous glands and increases the production of sebum. Most cases are mild and transient, but if NA is severe and long-lasting, clinical and paraclinical examination will be necessary to find congenital adrenal hyperplasia or a virilizing tumor of adrenal or gonadal origin. The diagnosis of NA is clinical; its main differential -diagnoses are neonatal cephalic pustulosis, other neonatal vesiculopustular dermatoses, infectious diseases, and acneiform reactions. The resolution of NA is spontaneous. In most cases, the use of a mild dermal cleanser and water will be sufficient. For comedogenic lesions (open and closed comedones), topical retinoids or 20% azelaic acid may be used, as well as some topical antibiotics for inflammatory lesions.

El acné neonatal es una dermatosis transitoria que ocurre entre la segunda y la cuarta semanas de vida en uno de cada cinco niños. Es más frecuente en los varones, con una relación de sexo masculino-femenino de 4.5:1. Las manifestaciones clínicas incluyen comedones abiertos y cerrados que pueden progresar a lesiones inflamatorias como pápulas, pústulas eritematosas y, en casos raros, nódulos y quistes. Las zonas afectadas incluyen la frente, las mejillas, el mentón y los párpados, y en algunas ocasiones puede extenderse a la piel cabelluda, el cuello y el tronco. Ocurre por la mayor producción de andrógenos placentarios y neonatales (de origen suprarrenal en ambos sexos y de origen testicular en los varones), que provoca hipertrofia de las glándulas sebáceas y mayor producción de sebo. La mayoría de los casos son leves y autolimitados. Cuando el acné neonatal es grave y prolongado, se debe considerar la posibilidad de hiperandrogenismo, cuyas causas más frecuentes en esta edad son la hiperplasia suprarrenal congénita y los tumores, adrenales o gonadales, productores de andrógenos. El diagnóstico del acné neonatal es clínico: se debe distinguir de la pustulosis cefálica neonatal, otras dermatosis neonatales vesiculopustulares, enfermedades infecciosas y reacciones acneiformes. Habitualmente, un dermolimpiador suave y agua resultan suficientes para su manejo. Las lesiones obstructivas (comedones abiertos y cerrados) pueden requerir retinoides tópicos o ácido azelaico al 20%, y las lesiones inflamatorias, algunos antibióticos tópicos.

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

BACKGROUND: Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden. OBJECTIVE: (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics. MATERIALS AND METHODS: We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric. RESULTS: Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden. CONCLUSION: Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used.

Leukemia cutis and other dermatological findings in pediatric patients with acute myeloid leukemia.

Background: Leukemia cutis (LC) is the infiltration of neoplastic leukocytes into the skin, causing skin lesions. In children, it appears more frequently in patients with acute myeloblastic leukemia (AML), particularly in subtypes with a monocytic component. Methods: We studied a retrospective cohort including all AML cases from the Hospital Infantil de México Federico Gómez between January 2009 to December 2019 and described the clinical characteristics of those who presented LC and other mucocutaneous manifestations. The information was collected from clinical records and analyzed using SPSS software (version 17). Results: We identified 54 AML cases: 53.7% were males, and 75.9% of the patients presented at least one dermatosis in the course of the disease. LC was clinically present in 14.8% of patients and was histologically confirmed in 9.2% of them; two congenital leukemia cases were identified. Among these patients, LC was more frequent in males. LC patients were younger than those without LC, the most frequent AML subtype was M2 (37.5%), and the most frequent clinical manifestations were plaques, chloromas, and gingival hyperplasia. None of the patients presented LC before AML diagnosis. Conclusions: Currently, only a few studies about LC on pediatric populations have been reported, and the existing ones have small sample sizes. We found clinical and epidemiological similarities with other populations in the studied sample.

Introducción: La leucemia cutis (LC) es la infiltración de leucocitos neoplásicos a la piel que provoca lesiones cutáneas. En la población infantil aparece con más frecuencia en pacientes con leucemia mieloblástica aguda (LMA), principalmente en los subtipos con componente monocítico. Métodos: Se estudió una cohorte retrospectiva en el Hospital Infantil de México Federico Gómez entre enero de 2009 y diciembre de 2019 para conocer las características clínicas de los pacientes con LMA que cursaron con LC y otras manifestaciones mucocutáneas. La información se recabó de los expedientes clínicos y se analizó con el programa estadístico SPSS versión 17. Resultados: Se identificaron 54 casos de LMA: el 53.7% en el sexo masculino y el 46.3% en el sexo femenino. El 75.9% de los pacientes presentaron alguna dermatosis durante el curso de su enfermedad. La LC se presentó clínicamente en el 14.8% de los pacientes y se confirmó histológicamente en el 9.2% de ellos; dos casos correspondieron a leucemia congénita. De estos pacientes, la LC fue más frecuente en el sexo masculino, los pacientes fueron más jóvenes que el grupo sin LC, el subtipo de LMA más frecuente fue el M2 (37.5%) y las principales manifestaciones clínicas fueron placas infiltradas, cloromas e hiperplasia gingival. Ninguno de los pacientes presentó LC antes del diagnóstico de LMA. Conclusiones: Hasta ahora existen pocos estudios de LC en las diferentes variedades de leucemia en la población infantil, y los existentes cuentan con un tamaño de muestra pequeño. En este estudio se reportan estadísticas descriptivas y se encuentran similitudes clínico-epidemiológicas con otras poblaciones.

An Endemic and Endangered New Species of the Lizard Liolaemus montanus Group from Southwestern Peru (Iguania: Liolaemidae), with a Key for the Species of the L. reichei Clade.

The southwestern Andes of Peru harbor a hidden taxonomic diversity of reptiles. We describe a new species of Liolaemus Wiegmann (Iguania: Liolaemidae) from xerophytic environments of the southwestern slopes of the Andes of Peru, 2,400-2,900 m asl. The new species, previously considered to be a population of L. insolitus Cei, exhibits unique diagnostic characters of morphology, scalation and color pattern, and molecular evidence that suggest that it belongs in the Liolaemus montanus species group and the L. reichei clade. Moreover, the species is endemic to the eastern slopes of La Caldera batholith in the Department of Arequipa, southern Peru. We also provide information on the conservation status of the species and suggest it be included in the IUCN red list of the threatened species as endangered (EN). A key for the species of the L. reichei clade is provided.