Fungal-associated pneumonia in patients with hematological malignancies.

PURPOSE: Patients with hematologic malignancies (HM) are at high risk of invasive lung fungal infections (ILFI). To describe the main characteristics, treatment, and outcomes for five years in adult patients with HM and fungal pneumonia. METHODS: We conducted a retrospective study at Instituto Nacional de Cancerología (INCan), a referral tertiary care oncology hospital with 135 beds in Mexico City, Mexico. We included all cases of fungal pneumonia in patients with HM from January 1, 2017, to December 31, 2022. Cases were classified as proven, probable, and possible according to EORTC/MSG criteria 2021. RESULTS: Two hundred ten patients were included; the mean age was 40 years. The most frequent HM was acute lymphoblastic leukemia (n=74) and acute myeloid leukemia (n=68). One hundred forty patients (66.7%) had severe neutropenia for a median of 16 days. All patients had a CT thorax scan; in 132 (62.9%), multiple nodules were documented. Serum galactomannan (GM) was positive in 21/192 (10.9%) and bronchoalveolar lavage in 9/36 (25%). Fifty-three patients (25.2%) died in the first month. In the multivariate analysis for mortality in the first 30 days, hypoalbuminemia, shock, possible ILFI, and inappropriate antifungal treatment were statistically associated. CONCLUSIONS: In high-risk HM patients, CT thorax scan and GM help diagnose ILFI. An appropriate antifungal improves mortality.

Minimal numerical ingredients describe chemical microswimmers' 3-D motion.

The underlying mechanisms and physics of catalytic Janus microswimmers is highly complex, requiring details of the associated phoretic fields and the physiochemical properties of catalyst, particle, boundaries, and the fuel used. Therefore, developing a minimal (and more general) model capable of capturing the overall dynamics of these autonomous particles is highly desirable. In the presented work, we demonstrate that a coarse-grained dissipative particle-hydrodynamics model is capable of describing the behaviour of various chemical microswimmer systems. Specifically, we show how a competing balance between hydrodynamic interactions experienced by a squirmer in the presence of a substrate, gravity, and mass and shape asymmetries can reproduce a range of dynamics seen in different experimental systems. We hope that our general model will inspire further synthetic work where various modes of swimmer motion can be encoded via shape and mass during fabrication, helping to realise the still outstanding goal of microswimmers capable of complex 3-D behaviour.

Is it in their eyes? Correlation between microorganisms isolated from bronchial aspirates and conjunctival swabs in a Pediatric Intensive Care Unit.

OBJECTIVE: Our observational, retrospective study aimed to determine the correlation between bacteria isolated from bronchial aspirates of pediatric ICU patients (PICU) with respiratory infections and those obtained from conjunctival swabs of the same patients exhibiting clinical conjunctivitis. METHODS: Throughout the period from 2015 to 2022, we reviewed all clinically significant bronchial aspirates (≥105 CFU/mL) and positive conjunctival swabs obtained from PICU patients. These records were retrieved from the microbiology database, cross-referencing the data to identify patients who tested positive for both during the same clinical episode. RESULTS: The median age of the patients was 5 months (interquartile range: 1-7). Among the cohort, twenty-one patients exhibited positivity in both bronchial aspirate and conjunctival swab samples, showcasing a microbial match in 85.71% of cases (18 out of 21). The most frequently isolated microorganisms were Haemophilus influenzae (55.6%), followed by Pseudomonas aeruginosa (14.3%), Klebsiella aerogenes (9.5%), and Escherichia coli, Stenotrophomonas maltophilia, and Enterobacter cloacae, each accounting for 4.8% of the isolates. CONCLUSIONS: Our study demonstrates a strong concordance between the isolated microorganisms from both samples in patients presenting clear symptoms of clinical conjunctivitis. These findings provide a basis for future prospective studies that may leverage conjunctival swabs as a predictive tool for identifying microorganisms involved in respiratory infections.

Detection of cytomegalovirus in bronchoalveolar lavage fluid from immunocompromised patients with pneumonitis by viral culture and DNA quantification.

PURPOSE: To compare the detection of human cytomegalovirus (HCMV) in bronchoalveolar lavage (BAL) fluid by viral culture and quantitative polymerase chain reaction (qPCR), and to establish a viral load threshold that can identify cases of HCMV replication indicative of pneumonitis. There is currently no universal viral load cut-off to differentiate between patients with and without pneumonitis, and the interpretation of qPCR results is challenging. METHODS: 176 consecutive BAL samples from immunosuppressed hosts with signs and/or symptoms of respiratory infection were prospectively studied by viral culture and qPCR. RESULTS: Concordant results were obtained in 81.25% of the BAL samples. The rest were discordant, as only 34% of the qPCR-positive BAL samples were positive by culture. The median HCMV load was significantly higher in culture-positive than in culture-negative BAL samples (5038 vs 178 IU/mL). Using a cut-off value of 1258 IU/mL of HCMV in BAL, pneumonia was diagnosed with a sensitivity of 76%, a specificity of 100%, a VPP of 100% and VPN of 98%, and HCMV was isolated in 100% of the BAL cultures. CONCLUSION: We found that a qPCR-negative was a quick and reliable way of ruling out HCMV pneumonitis, but a positive result did not always indicate clinically significant replication in the lung. However, an HCMV load in BAL fluid of ≥ 1258 IU/mL was always associated with disease, whereas < 200 IU/mL rarely so.

Recommendations on the use of azole antifungals in hematology-oncology patients.

The administration of antifungals for therapeutic and, especially, prophylactic purposes is virtually a constant in patients requiring hematology-oncology treatment. Any attempt to prevent or treat Aspergillus or Mucor infections requires the administration of some drugs in the azole group, which include voriconazole, posaconazole and isavuconazole, noted for their activity against these pathogens. One very relevant aspect is the potential risk of interaction when associated with one of the antineoplastic drugs used to treat hematologic tumors, with serious complications. In this regard, acalabrutinib, bortezomib, bosutinib, carfilzomib, cyclophosphamide, cyclosporine A, dasatinib, duvelisib, gilteritinib, glasdegib, ibrutinib, imatinib, nilotinib, ponatinib, prednisone, ruxolitinib, tacrolimus, all-transretinoic acid, arsenic trioxide, venetoclax, or any of the vinca alkaloids, are very clear examples of risk, in some cases because their clearance is reduced and in others because of increased risk of QTc prolongation, which is particularly evident when the drug of choice is voriconazole or posaconazole.

[Translated article] One-year mortality and associated factors in patients undergoing surgery for hip fracture.

INTRODUCTION: Hip fractures are very common injuries in elderly patients and are associated with increased mortality. OBJECTIVE: To identify the factors associated with mortality in patients after one year of being operated for hip fracture in an Orthogeriatric Program. METHODS: We design an observational analytical study in subjects older than 65 years admitted to the Hospital Universitario San Ignacio for hip fracture who were treated in the Orthogeriatrics Program. Telephone follow-up was performed one year after admission. Data were analyzed using a univariate logistic regression model and a multivariate logistic regression model was applied to control the effect of the other variables. RESULTS: Mortality was 17.82%, functional impairment was 50.91%, and institutionalization was 13.9%. The factors associated with mortality were moderate dependence (OR=3.56, 95% CI=1.17-10.84, p=0.025), malnutrition (OR=3.42, 95% CI=1.06-11.04, p=0.039), in-hospital complications (OR=2.80, 95% CI=1.11-7.04, p=0.028), and older age (OR=1.09, 95% CI=1.03-1.15, p=0.002). The factor associated with functional impairment was a greater dependence at admission (OR=2.05, 95% CI=1.02-4.10, p=0.041), and with institutionalization was a lower Barthel index score at admission (OR=0.96, 95% CI=0.94-0.98, p=0.001). CONCLUSIONS: Our results shows that the factors associated with mortality one year after hip fracture surgery were: moderate dependence, malnutrition, in-hospital complications and advanced age. Having previous functional dependence is directly related to greater functional loss and institutionalization.

Benefits in quality of life following an obstructive sleep apnea screening and treatment program in patients with acute ischemic stroke. / Beneficios en la calidad de vida de un programa de cribado y tratamiento de apnea obstructiva del sueño en pacientes con ictus isquémico agudo.

INTRODUCTION: Obstructive sleep apnea (OSA) has been proposed as a factor that worsens stroke prognosis. Our aim was to determine if an OSA intervention could improve quality of life (QOL, first objective) and modified Rankin score (mRS, second objective). PATIENTS AND METHODS: The intervention group of this quasi-experimental study included patients with acute ischemic stroke <72 hours who underwent polygraphy and Continuous Positive Airway Pressure (CPAP) and hygienic-dietary measures if required. The control group followed routine clinical practice. The Short Form 36 Health Survey (SF-36) and mRS were applied at the sixth month after stroke in both groups. RESULTS: Fifty-five vs. sixty-two patients were included in the intervention and control group respectively. In the intervention group, 64.71% of patients accepted the proposed CPAP (16 cases with a good adherence). An improvement in SF-36 items was detected in the intervention group: physical functioning (p = 0.008), role physical (p = 0.002), bodily pain (p = 0.008), general health (p <0.001), vitality (p = 0.001) and role emotional (p = 0.015). In a per-protocol analysis, all these improvements were verified in the group of patients treated with good CPAP adherence (p < 0.05 in all the same SF-36 items). The percentage of patients with physical component summatory = 50 was higher in the intervention group (p = 0.003). There were no differences in the median of mRS (p = 0.262). CONCLUSIONS: Although more evidence is needed, a significant improvement in QOL was suggested after our OSA intervention, particularly in patients with good CPAP adherence.

TITLE: Beneficios en la calidad de vida de un programa de cribado y tratamiento de apnea obstructiva del sueño en pacientes con ictus isquémico agudo.Introducción. La apnea obstructiva del sueño (AOS) se ha propuesto como un factor de mal pronóstico en el ictus. Pretendemos determinar si una intervención sobre la AOS puede mejorar las escalas de calidad de vida (primer objetivo) y de discapacidad (segundo objetivo). Pacientes y métodos. El grupo de intervención de este estudio cuasi experimental incluye a pacientes con ictus isquémico agudo menor de 72 horas de evolución a quienes se les realizó poligrafía, así como presión positiva continua en las vías aéreas (CPAP) y medidas higienicodietéticas si se requerían. En el grupo de control se siguió la práctica clínica habitual. Se aplicaron las escalas Short Form 36 Health Survey (SF-36) y modified Rankin Score (mRS) en el sexto mes del ictus en ambos grupos. Resultados. Se incluyó a 55 y a 62 pacientes en el grupo de intervención y en el de control, respectivamente. En el grupo de intervención, el 64,71% de los pacientes aceptó la CPAP indicada (16 casos con buena adhesión). Se detectó una mejoría en los ítems de la escala SF-36 en el grupo de intervención: funcionamiento físico (p = 0,008), rol físico (p = 0,002), dolor corporal (p = 0,008), salud general (p menor de 0,001), vitalidad (p = 0,001) y rol emocional (p = 0,015). En un análisis por protocolo, todas estas mejorías se comprobaron en el grupo de pacientes tratados con CPAP con buena adhesión (p menor de 0,05 en todos los ítems de la SF-36). El porcentaje de pacientes con el sumatorio del componente físico = 50 fue más alto en el grupo de intervención (p = 0,003). No había diferencias en la mediana de la mRS (p = 0,262). Conclusiones. Aunque se necesitan más evidencias, nuestro estudio sugiere una mejoría significativa de la calidad de vida tras nuestra intervención en la AOS, especialmente en pacientes con buena adhesión a la CPAP.

One-year mortality and associated factors in patients undergoing surgery for hip fracture. / Mortalidad al año y factores asociados en pacientes llevados a cirugía por fractura de cadera.

INTRODUCTION: Hip fractures are very common injuries in elderly patients and are associated with increased mortality. OBJECTIVE: To identify the factors associated with mortality in patients after one year of being operated for hip fracture in an Orthogeriatric Program. METHODS: We design an observational analytical study in subjects older than 65 years admitted to the Hospital Universitario San Ignacio for hip fracture who were treated in the Orthogeriatrics Program. Telephone follow-up was performed one year after admission. Data were analyzed using a univariate logistic regression model and a multivariate logistic regression model was applied to control the effect of the other variables. RESULTS: Mortality was 17.82%, functional impairment was 50.91%, and institutionalization was 13.9%. The factors associated with mortality were moderate dependence (OR=3.56, 95% CI=1.17-10.84, p=0.025), malnutrition (OR=3.42, 95% CI=1.06-11.04, p=0.039), in-hospital complications (OR=2.80, 95% CI=1.11-7.04, p=0.028), and older age (OR=1.09, 95% CI=1.03-1.15, p=0.002). The factor associated with functional impairment was a greater dependence at admission (OR=2.05, 95% CI=1.02-4.10, p=0.041), and with institutionalization was a lower Barthel index score at admission (OR=0.96, 95% CI=0.94-0.98, p=0.001). CONCLUSIONS: Our results shows that the factors associated with mortality one year after hip fracture surgery were: moderate dependence, malnutrition, in-hospital complications and advanced age. Having previous functional dependence is directly related to greater functional loss and institutionalization.

Antimicrobial resistance in Gram-negative bacilli in Spain: an experts' view.

BACKGROUND: Antibiotic resistance in Gram-negative bacilli poses a serious problem for public health. In hospitals, in addition to high mortality rates, the emergence and spread of resistance to practically all antibiotics restricts therapeutic options against serious and frequent infections. OBJECTIVE: The aim of this work is to present the views of a group of experts on the following aspects regarding resistance to antimicrobial agents in Gram-negative bacilli: 1) the current epidemiology in Spain, 2) how it is related to local clinical practice and 3) new therapies in this area, based on currently available evidence. METHODS: After reviewing the most noteworthy evidence, the most relevant data on these three aspects were presented at a national meeting to 99 experts in infectious diseases, clinical microbiology, internal medicine, intensive care medicine, anaesthesiology and hospital pharmacy. RESULTS AND CONCLUSIONS: Subsequent local debates among these experts led to conclusions in this matter, including the opinion that the approval of new antibiotics makes it necessary to train the specialists involved in order to optimise how they use them and improve health outcomes; microbiology laboratories in hospitals must be available throughout a continuous timetable; all antibiotics must be available when needed and it is necessary to learn to use them correctly; and the Antimicrobial Stewardship Programs (ASP) play a key role in quickly allocating the new antibiotics within the guidelines and ensure appropriate use of them.

Relación entre alteraciones de la tomografía computarizada de tórax en pacientes hospitalizados por neumonia COVID-19 y la recuperacion funcional respiratoria a los 3 meses del alta / Relationship between alterations of CT tomography of the thorax in patients hospitalized for pneumonía COVID-19 and respiratory functional recovery 3 months after discharge

Introducción: La neumonía por coronavirus SARS-CoV-2 es una enfermedad nueva, por lo que las secuelas a largo plazo siguen siendo poco claras y los reportes del tema son aún escasos. El presente estudio buscó describir los hallazgos tomográficos al ingreso hospitalario y luego de 3 meses de neumonía asociada a COVID-19 y correlacionarlos con la alteración de las pruebas de función pulmonar a los 3 meses de la hospitalización. Pacientes y Métodos: Estudio de cohorte prospectivo que evaluó las secuelas funcionales pulmonares y la evolución del compromiso imagenológico a los tres meses de hospitalización por neumonía asociada a COVID-19. Todos los exámenes fueron revisados por un radiólogo experto. Se identificó el patrón tomográfico predominante y se estableció la extensión de las alteraciones mediante un puntaje, previamente validado. En las TC de seguimiento, se evaluó la extensión del compromiso imagenológico, el porcentaje de reducción del compromiso del espacio aéreo y presencia de otras alteraciones. Estos hallazgos se relacionaron con las pruebas de función pulmonar (PFP) a los 3 meses (espirometría, DLCO y test de caminata de 6 min: TC6M). Para estos análisis los pacientes se agruparon según la oxigenoterapia utilizada en la hospitalización: oxigenación estándar (O2), cánula nasal de alto flujo (CNAF) o ventilación mecánica invasiva (VMI). Resultados: Se evaluaron un total de 116 pacientes, de los cuales 75 eran hombres, edad promedio fue 60,6 ± 14,5 años. Los pacientes fueron seguidos en promedio 100 días. 70 pacientes pertenecieron al grupo O2 estándar, 25 CNAF y 21 VMI. La TC control a los 3 meses mostró que 78 pacientes presentaron recuperación tomográfica mayor a 50%. El promedio del puntaje de extensión del compromiso tomográfico fue significativamente mayor en el grupo con PFP alterada, comparado con el grupo con PFP normal (espirometría 6,8 vs. 4,6, p = 0,03; DLCO 5,7 vs. 4,1, p = 0,04, TC6M 7,0 vs. 4,2, p = 0,002). Conclusiones: En el seguimiento de los pacientes adultos hospitalizados por neumonía asociada a COVID-19, los pacientes con mayor extensión del compromiso imagenológico pulmonar fueron los que presentaron alteraciones funcionales pulmonares significativas.

Introduction: SARS-CoV-2 pneumonia is an emergent disease, then long term sequelae are still on investigation. This study evaluated the imaging features at the admission to the hospital and then 3 months after discharge of patients hospitalized with COVID-19 pneumonia and compared findings with functional respiratory recovery. Patients and Methods: Prospective cohort study of patients hospitalized with SARS-CoV-2 pneumonia in "Hospital Naval Almirante Nef", Viña del Mar Chile. Imaging evolution and respiratory function were analyzed after 3 months discharge. All the imagens were reviewed by an expert radiologist, who identified a predominant pattern and defined an extension score previously validated. These findings were compared with 3 months CT and respiratory function evaluated with spirometry, DLCO and 6 minutes walking test (6MWT). Also, patients were categorized in 3 different group, depending on oxygen support: conventional oxygen, high-flow nasal cannula (HFNC) and mechanical ventilation. Results: 116 patients were evaluated, 75 men with a mean age of 60.6 ± 14.5 years-old. The median follow-up was 100 days. 70 patients were on conventional oxygen group, 25 in high-flow nasal cannula and 21 in mechanical ventilation. 3-month CT control showed tomographic recovery > 50% in 78 patients. The mean score of extension was significant higher in the group with altered respiratory functional test, compared with the group with normal results (spirometry 6.8 vs. 4.6, p = 0.03; DLCO 5.7 vs. 4.1, p = 0.04; 6MWT 7.0 vs. 4.2, p = 0.002). Conclusion: 3 months after discharge of COVID-19 pneumonia, patients with higher tomographic score present significant abnormalities in respiratory functional test.

Ubiquitous defect-induced density wave instability in monolayer graphene.

Quantum materials are notoriously sensitive to their environments, where small perturbations can tip a system toward one of several competing ground states. Graphene hosts a rich assortment of such competing phases, including a bond density wave instability ("Kekulé distortion") that couples electrons at the K/K' valleys and breaks the lattice symmetry. Here, we report observations of a ubiquitous Kekulé distortion across multiple graphene systems. We show that extremely dilute concentrations of surface atoms (less than three adsorbed atoms every 1000 graphene unit cells) can self-assemble and trigger the onset of a global Kekulé density wave phase. Combining complementary momentum-sensitive angle-resolved photoemission spectroscopy (ARPES) and low-energy electron diffraction (LEED) measurements, we confirm the presence of this density wave phase and observe the opening of an energy gap. Our results reveal an unexpected sensitivity of the graphene lattice to dilute surface disorder and show that adsorbed atoms offer an attractive route toward designing novel phases in two-dimensional materials.

Recuperación laboral clínica y funcional a 3 meses del alta en pacientes hospitalizados por neumonía por SARS-CoV-2: relación con la terapia recibida / Clinical and functional recovery and return to work 3 months after discharge in patients hospitalized for SARS-CoV-2 pneumonia: relationship with the therapy received

Resumen Introducción: La presentación clínica de neumonía por COVID-19 ha sido bien documentada; sin embargo, sus repercusiones a largo plazo son aún motivo de investigación. Objetivo: Evaluar la recuperación laboral, clínica y funcional respiratoria, a 3 meses del egreso de pacientes hospitalizados por neumonía por SARS-CoV-2, en relación con la terapia ventilatoria recibida. Pacientes y Métodos: Se analizó una cohorte prospectiva de 116 pacientes con neumonía por COVID-19 del Hospital Naval Almirante Nef de Viña del Mar, con seguimiento clínico y funcional respiratorio 3 meses después de su alta. Resultados: Mediana del seguimiento: 100 días. Constitución de la cohorte: 75 hombres, mediana de edad 60 años, 50% obesos, 34,5% fumadores y 13,8% con comorbilidad respiratoria. 16% recibió rehabilitación. Se reportó disnea en 48,3% y fatigabilidad en 33,6%. Solo 54,8% retornó al trabajo. El 65,2% que utilizó oxigenoterapia (O2) volvió a trabajar comparado con 44% que utilizó cánula nasal de alto flujo (CNAF) y 33,3% con ventilación mecánica invasiva (VMI). Mayoritariamente el grupo de O2 volvió a la vida normal en comparación con CNAF y VMI (71,4 versus 17,5% y 11,1% respectivamente). La función pulmonar fue normal en 39 pacientes (33,6%). La serie que volvió a vida normal tuvo mayor porcentaje de DLCO y test de caminata de 6 minutos normales. En comparación con la serie O2, la serie CNAF tuvo mayor frecuencia de alteración de DLCO (OR = 5) seguido por la serie VMI (OR = 3,6). Conclusión: A 3 meses de seguimiento, se evidenció ausentismo laboral, persistencia de síntomas y alteración funcional respiratoria (DLCO), especialmente en quienes recibieron soporte ventilatorio adicional a oxigenoterapia.

Introduction: The clinical presentation of COVID-19 pneumonia has been well documented; however, its long-term repercussions are still a matter of investigation. Objective: to evaluate the occupational, clinical and functional respiratory recovery, 3 months after the discharge of patients hospitalized for SARS-CoV-2 pneumonia, in relation to the ventilatory therapy received. Patients and Methods: A prospective cohort of 116 patients with COVID-19 pneumonia from Hospital Naval Almirante Nef (Viña del Mar, Chile) was analyzed, with clinical and functional respiratory follow-up at 3 months after being discharged. Results: Median follow-up: 100 days. Composition of the cohort: 75 men, median age 60 years-old, 50% obese, 34.5% smokers and 13.8% with respiratory comorbidity. 16% received rehabilitation. Dyspnea was reported in 48.3% and fatigue in 33.6%. Only 54.8% returned to work. 65.2% who used oxygen therapy (O2) returned to work compared to 44% who used high-flow nasal cannula (HFNC) and 33.3% with invasive mechanical ventilation (IMV). Mostly the O2 group returned to normal life compared to HFNC and VMI (71.4 versus 17.5% and 11.1% respectively). Lung function was normal in 39 patients (33.6%). The series that returned to normal life had higher percentage of normal DLCO and six-minute walk test. Compared to the O2 series, the CNAF series had a higher frequency of DLCO alteration (OR = 5) followed by the VMI series (OR = 3.6). Conclusion: At 3 months of follow-up, absenteeism from work, persistence of symptoms and respiratory functional alteration (DLCO) were evident, especially in those who received ventilatory support in addition to oxygen therapy.

[Diagnostic protocol for chronic manifestations of COVID-19]. / Protocolo diagnóstico de las manifestaciones crónicas de la COVID-19.

Many people who have had COVID-19 continue to have symptoms weeks and months after recovering from the acute disease. They present with a highly heterogeneous set of manifestations whose pathophysiology is unknown. There is no uniform nomenclature or agreed-upon diagnostic criteria. One of the main risk factors for its onset is having required intensive care unit admission. The most common manifestations are fatigue and respiratory symptoms, of note among which is dyspnea. The diagnostic approach is focused on ruling out other possible causes that could be responsible for said manifestations. Therefore, a comprehensive evaluation of the patient is conducted followed by a later approach aimed at the nonspecific symptoms.

A persistent ultraviolet outflow from an accreting neutron star binary transient.

All disc-accreting astrophysical objects produce powerful disc winds. In compact binaries containing neutron stars or black holes, accretion often takes place during violent outbursts. The main disc wind signatures during these eruptions are blue-shifted X-ray absorption lines, which are preferentially seen in disc-dominated 'soft states'1,2. By contrast, optical wind-formed lines have recently been detected in 'hard states', when a hot corona dominates the luminosity3. The relationship between these signatures is unknown, and no erupting system has as yet revealed wind-formed lines between the X-ray and optical bands, despite the many strong resonance transitions in this ultraviolet (UV) region4. Here we report that the transient neutron star binary Swift J1858.6-0814 exhibits wind-formed, blue-shifted absorption lines associated with C IV, N V and He II in time-resolved UV spectroscopy during a luminous hard state, which we interpret as a warm, moderately ionized outflow component in this state. Simultaneously observed optical lines also display transient blue-shifted absorption. Decomposing the UV data into constant and variable components, the blue-shifted absorption is associated with the former. This implies that the outflow is not associated with the luminous flares in the data. The joint presence of UV and optical wind features reveals a multi-phase and/or spatially stratified evaporative outflow from the outer disc5. This type of persistent mass loss across all accretion states has been predicted by radiation-hydrodynamic simulations6 and helps to explain the shorter-than-expected duration of outbursts7.

Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study.

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

Quistes subglóticos adquiridos: Reporte de tres casos y revisión de la literatura / Acquired subglottic cysts: Report of three cases and review of the literature

Los quistes subglóticos adquiridos son una causa rara de estridor en la infancia, cuyo reporte ha ido en aumento en las últimas décadas. Su aparición se relaciona con la prematurez y la intubación en el periodo neonatal. Histológicamente, se observa una obstrucción de las glándulas mucosas de la subglotis debido una metaplasia escamosa del epitelio respiratorio. Esta es una condición que usualmente requiere de un alto índice de sospecha para llegar al diagnóstico, ya que pueden confundirse con otras patologías como laringitis aguda (croup), laringomalacia o asma. La nasofibroscopía permite sospechar su presencia, pero el gold standard diagnóstico lo constituye la laringo-tra-queo-broncoscopía directa en pabellón. Existen diversas técnicas para su manejo, siendo las más frecuentemente utilizadas la marsupialización con instrumental frío y láser. La recurrencia es frecuente, por lo que algunos autores han utilizado mitomicina C y la terapia antirreflujo para intentar disminuirla. Sin embargo, hasta la fecha falta evidencia de calidad que permita llegar a un consenso respecto al manejo ideal de esta patología. En este trabajo, presentamos tres casos clínico de pacientes con antecedentes de prematurez que fueron diagnosticados con quistes subglóticos adquiridos y manejados en un hospital pediátrico de alta complejidad.

Acquired subglottic cysts are an infrequent cause of stridor in infants, which has been increasingly reported in the last decades. Its appearance is related to prematurity and intubation in the neonatal period. Histologically, findings are characterized by an obstruction of the mucosal glands, due to squamous metaplasia of the respiratory epithelium. This condition usually requires a high index of suspicion to be diagnosed, as it can be misdiagnosed as croup, laryngomalacia or asthma. Flexible nasendoscopy allows an initial exploration of the larynx, but direct laryngo-tracheo-bronchoscopy in the operating room is the diagnostic gold standard. There are several techniques for its management, but the most frequently used are cold-steel marsupialization and laser. Recurrence is common, and some authors have used mitomycin C and antireflux therapy to try to decrease it. However, up to date, there is a lack of high-quality evidence, regarding the ideal management of this pathology, which prevents reaching a consensus. In this article, we present three clinical cases of premature patients who were diagnosed with subglottic cysts, treated in a tertiary pediatric hospital.

Collective motion of run-and-tumble repulsive and attractive particles in one-dimensional systems.

Active matter deals with systems whose particles consume energy at the individual level in order to move. To unravel features such as the emergence of collective structures, several models have been suggested, such as the on-lattice model of run-and-tumble particles implemented via the persistent exclusion process (PEP). In our work, we study a one-dimensional system of run-and-tumble repulsive or attractive particles, both on-lattice and off-lattice. Additionally, we implement cluster motility dynamics in the on-lattice case (since in the off-lattice case, cluster motility arises from the individual particle dynamics). While we observe important differences between discrete and continuous dynamics, few common features are of particular importance. Increasing particle density drives aggregation across all different systems explored. For non-attractive particles, the effects of particle activity on aggregation are largely independent of the details of the dynamics. In contrast, once attractive interactions are introduced, the steady-state, which is completely determined by the interplay between these and the particles' activity, becomes highly dependent on the details of the dynamics.

Management of congenital and acquired airway pathologies in newborns by a cross-disciplinary committee at a third level hospital. / Manejo de la patología congénita y adquirida de la vía aérea en el neonato por parte de un comité multidisciplinar en un centro terciario.

INTRODUCTION: Neonatal airway examination through flexible/rigid bronchoscopy has proved to be useful in the presence of persistent stridor and extubation failure, as well as to assess complications following cardiac surgery. At our institution, these examinations are carried out by a pulmonologist, a neonatologist, an otorhinolaryngologist, and a pediatric surgeon from the pediatric airway committee, established in 2014. OBJECTIVE: To analyze the airway examinations performed in neonates during their stay at the neonatology/neonatal intensive care unit since the airway committee was established. MATERIAL AND METHODS: A retrospective study of the airway examinations conducted in neonates from 2015 to 2019 was carried out. Clinical and demographic data, number of examinations, indications, findings, and complications were collected. Results are presented as mean and standard deviation. Statistical significance was established at p < 0.05. RESULTS: 92 airway examinations were analyzed in 51 patients (54.9% of whom were female). 51% of the patients were premature. Extubation failure and persistent respiratory symptoms following successful extubation were the most frequent indications for airway examination (35.3%). Stratification by gestational age or weight at birth was not associated with an increased risk of pathological findings at examination (p > 0.05). The most frequent finding was vocal cord paralysis (n = 14; 27.5%). In 10 patients (19.6%), no pathological findings were observed. CONCLUSION: Airway examination is useful in patients with stridor to identify vocal cord paralysis following extubation failure. It also allows congenital airway pathologies to be diagnosed and treated. The number of examinations with no pathological findings was similar to that reported in international series.

INTRODUCCION: La exploración de vía aérea mediante broncoscopia flexible/rígida en el neonato ha demostrado utilidad en el estridor persistente, extubaciones fallidas o para valorar complicaciones tras cirugía cardiaca. En nuestro hospital estas exploraciones son practicadas por un neumólogo, neonatólogo, otorrinolaringólogo y cirujano pediátrico del Comité de Vía Aérea Pediátrica, formado en 2014. OBJETIVO: Analizar las exploraciones de vía aérea practicadas a neonatos durante su estancia en Neonatología/Unidad de Cuidados Intensivos Neonatales desde la constitución del Comité de Vía Aérea. MATERIAL Y METODOS: Estudio retrospectivo de exploraciones de vía aérea practicadas a neonatos de 2015-2019. Se recogen datos clínicos y demográficos, número de exploraciones, indicación, hallazgos y complicaciones. Se presentan las medias con su desviación estándar. Se consideró un resultado estadísticamente significativo cuando p < 0,05. RESULTADOS: Se analizaron 92 exploraciones de vía aérea en 51 pacientes (género femenino: 54,9%). El 51% de los pacientes fueron prematuros. La extubación fallida y la persistencia de sintomatología respiratoria tras una extubación satisfactoria fueron las indicaciones más frecuentes (35,3%). La estratificación por edad gestacional o por peso al nacimiento no se asociaba a un mayor riesgo de presentar hallazgos patológicos en la exploración. El hallazgo más frecuente fue la parálisis de cuerda vocal (n = 14; 27,5%). En 10 pacientes (19,6%) no se encontraron hallazgos patológicos. CONCLUSION: La exploración de la vía aérea es útil en pacientes con estridor postextubación y para identificar parálisis de cuerda vocal tras extubación fallida. Además, permite el diagnóstico y tratamiento de patologías congénitas de la vía aérea.