Molecular and cytogenetic evidence for sibling species in the Chagas disease vector Triatoma maculata.

Triatoma maculata (Hemiptera, Reduviidae, Triatominae) occurs across dry-to-semiarid ecoregions of northern South America, where it transmits Trypanosoma cruzi, causative agent of Chagas disease. Using 207 field-caught specimens from throughout the species' range, mitochondrial(mt) DNA sequence data, and cytogenetics, we investigated inter-population genetic diversity and the phylogenetic affinities of T. maculata. Mitochondrial DNA sequence analyses (cytb and nd4) disclosed a monophyletic T. maculata clade encompassing three distinct geographic groups: Roraima formation (Guiana shield), Orinoco basin, and Magdalena basin (trans-Andean). Between-group cytb distances (11.0-12.8%) were larger than the ~7.5% expected for sister Triatoma species; the most recent common ancestor of these T. maculata groups may date back to the late Miocene. C-heterochromatin distribution and the sex-chromosome location of 45S ribosomal DNA clusters both distinguished Roraima bugs from Orinoco and Magdalena specimens. Cytb genealogies reinforced that T. maculata is not sister to Triatoma pseudomaculata and probably represents an early (middle-late Miocene) offshoot of the 'South American Triatomini lineage'. In sum, we report extensive genetic diversity and deep phylogeographic structuring in T. maculata, suggesting that it may consist of a complex of at least three sibling taxa. These findings have implications for the systematics, population biology, and perhaps medical relevance of T. maculata sensu lato.

Multidisciplinary approach detects speciation within the kissing bug Panstrongylus rufotuberculatus populations (Hemiptera, Heteroptera, Reduviidae).

BACKGROUND: Panstrongylus rufotuberculatus (Hemiptera-Reduviidae) is a triatomine species with a wide geographic distribution and a broad phenotypic variability. In some countries, this species is found infesting and colonising domiciliary ecotopes representing an epidemiological risk factor as a vector of Trypanosoma cruzi, etiological agent of Chagas disease. In spite of this, little is known about P. rufotuberculatus genetic diversity. METHODS: Cytogenetic studies and DNA sequence analyses of one nuclear (ITS-2) and two mitochondrial DNA sequences (cyt b and coI) were carried out in P. rufotuberculatus individuals collected in Bolivia, Colombia, Ecuador and Mexico. Moreover, a geometric morphometrics study was applied to Bolivian, Colombian, Ecuadorian and French Guiana samples. OBJECTIVES: To explore the genetic and phenetic diversity of P. rufotuberculatus from different countries, combining chromosomal studies, DNA sequence analyses and geometric morphometric comparisons. FINDINGS: We found two chromosomal groups differentiated by the number of X chromosomes and the chromosomal position of the ribosomal DNA clusters. In concordance, two main morphometric profiles were detected, clearly separating the Bolivian sample from the other ones. Phylogenetic DNA analyses showed that both chromosomal groups were closely related to each other and clearly separated from the remaining Panstrongylus species. High nucleotide divergence of cyt b and coI fragments were observed among P. rufotuberculatus samples from Bolivia, Colombia, Ecuador and Mexico (Kimura 2-parameter distances higher than 9%). MAIN CONCLUSIONS: Chromosomal and molecular analyses supported that the two chromosomal groups could represent different closely related species. We propose that Bolivian individuals constitute a new Panstrongylus species, being necessary a detailed morphological study for its formal description. The clear morphometric discrimination based on the wing venation pattern suggests such morphological description might be conclusive.

Bacteriome depiction and the trophic status of the largest Northern highland lake from Andes system: Lago de Tota, Boyacá, Colombia.

Lago de Tota is the largest highland lake in Colombia and one of the most remarkable of Northern Andean Mountain range. This lake is under an anthropogenic-based eutrophication process as a consequence of non-sustainable agriculture practices developing nearby. Notable relationship between the trophic status and Bacteriome loop dynamics has been increasingly disclosed in lakes worldwide. We performed a 16S sequencing analysis to depict the bacterial community present and we inferred its potential gene function in Lago de Tota. Parameters for determining current trophic condition such as total nitrogen (TN), dissolved carbon (DOC), particulate organic matter (POM), and chlorophyll-a (chl-a) were measured. A total of 440 Operational Taxonomic Units (OTUs) arranged into 50 classes were identified based on V3-V4 regions of the 16S rRNA gene, harboring high-frequent likely found environmental classes such as Actinobacteria, Gammaproteobacteria, Bacteroidia, Acidimicrobia, and Verrucomicrobiae. A total of 26 bacterial classes configure most abundant predicted functional processes involved in organic matter decomposition (i.e., carbohydrate metabolism, amino acid metabolism, xenobiotic biodegradation, and energy metabolism). In general, Actinobacteria, Alphaproteobacteria, and Gammaproteobacteria show the highest potential gene functional contributors, although other low-frequent classes OTUs are also relevant in processes of carbohydrate metabolism, xenobiotic biodegradation, and energy metabolism. The Trophic State Index indicates an oligo-mesotrophic status, and additional variables measured (i.e., POM, DOC) suggest the increasing carbon accumulation. Results provide preliminary evidence for several bacteria groups related to eutrophication of Lago de Tota. Under this picture, we suggest that further studies for Bacteriome loop spatial-temporal description are essential to inform local water quality monitoring strategies.

Differences in inpatient and outpatient hepatitis C virus prevalence and linkage to care rates in a safety net hospital hepatitis C screening program.

BACKGROUND AND AIM: Routine screening for hepatitis C virus (HCV) infection is crucial in identifying the 50% of infected persons unaware of their infection. We added an inpatient screening initiative to our successful outpatient HCV screening program in an urban, safety-net hospital. METHODS: From March 2017 to December 2019, HCV screening was performed in inpatient and outpatient settings at Grady Health System. We compared care cascade outcomes, including anti-HCV testing, RNA testing, and linkage to care (LTC) between these settings. RESULTS: A total of 29 751 patients were tested for anti-HCV: 8883 inpatients and 20 868 outpatients. The anti-HCV population was predominantly Black (76.2%) and male (67.9%). The total anti-HCV prevalence was 8.9%, with 14% of inpatients and 6.7% of outpatients testing positive. RNA testing was performed on 86%. The prevalence of active HCV infection was 59.3% in those that were anti-HCV positive; inpatient prevalence was 66%, and outpatient was 53.8%. Of those with active infection, 67.5% were linked to care (57.3% of inpatients and 77.8% of outpatients). CONCLUSION: We found significant differences in prevalence of anti-HCV and LTC rates between inpatients and outpatients during an HCV screening program. Higher anti-HCV prevalence among inpatients may be due a higher prevalence of non-birth year HCV risk factors. LTC rates were lower in the inpatient setting despite a robust linkage strategy. The striking prevalence of HCV in both settings warrants continued screening, expansion to additional settings, and novel strategies to improve inpatient linkage rates, especially in the setting of new universal HCV screening guidelines.

Population structure and ancestry prediction of Aedes aegypti (Diptera: Culicidae) supports a single African origin of Colombian populations.

BACKGROUND: A previous phylogeographic study revealed two Aedes aegypti African-related mitochondrial lineages distributed in Colombian's cities with different eco-epidemiologic characteristics with regard to dengue virus (DENV). It has been proposed these lineages might indicate independent invasion sources. OBJECTIVES: Assessing to Colombian population structure and to support evidence of its probable source origin. METHODS: We analysed a total of 267 individuals from cities of Bello, Riohacha and Villavicencio, which 241 were related to the West and East African mitochondrial lineages (termed here as WAL and EAL, respectively). Eight polymorphic microsatellite loci were analysed aiming population structure. FINDINGS: Results indicate substantial gene flow among distant and low-connected cities composing a panmictic population with incipient local differentiation of Ae. aegypti is placed in Colombia. Likewise, genetic evidence indicates no significant differences among individuals related to WAL and EAL is placed. MAIN CONCLUSIONS: Minimal genetic differentiation in low-connected Ae. aegypti populations of Colombia, and lack concordance between mitochondrial and nuclear genealogies suggest that Colombian Ae. aegypti shared a common demographic history. Under this scenario, we suggest current Ae. aegypti population structure reflects a single origin instead of contemporary migration, which founding populations have a single source from a mitochondrial polymorphic African ancient.

High-throughput analysis of the Trypanosoma cruzi minicirculome (mcDNA) unveils structural variation and functional diversity.

Trypanosoma cruzi causes Chagas disease and has a unique extranuclear genome enclosed in a structure called the kinetoplast, which contains circular genomes known as maxi- and minicircles. While the structure and function of maxicircles are well-understood, many aspects of minicircles remain to be discovered. Here, we performed a high-throughput analysis of the minicirculome (mcDNA) in 50 clones isolated from Colombia's diverse T. cruzi I populations. Results indicate that mcDNA comprises four diverse subpopulations with different structures, lengths, and numbers of interspersed semi-conserved (previously termed ultra-conserved regions mHCV) and hypervariable (mHVPs) regions. Analysis of mcDNA ancestry and inter-clone differentiation indicates the interbreeding of minicircle sequence classes is placed along diverse strains and hosts. These results support evidence of the multiclonal dynamics and random bi-parental segregation. Finally, we disclosed the guide RNA repertoire encoded by mcDNA at a clonal scale, and several attributes of its abundance and function are discussed.

Robustness in population-structure and demographic-inference results derived from the Aedes aegypti genotyping chip and whole-genome sequencing data.

The mosquito Aedes aegypti is the primary vector of many human arboviruses such as dengue, yellow fever, chikungunya, and Zika, which affect millions of people worldwide. Population genetic studies on this mosquito have been important in understanding its invasion pathways and success as a vector of human disease. The Axiom aegypti1 SNP chip was developed from a sample of geographically diverse A. aegypti populations to facilitate genomic studies on this species. We evaluate the utility of the Axiom aegypti1 SNP chip for population genetics and compare it with a low-depth shotgun sequencing approach using mosquitoes from the native (Africa) and invasive ranges (outside Africa). These analyses indicate that results from the SNP chip are highly reproducible and have a higher sensitivity to capture alternative alleles than a low-coverage whole-genome sequencing approach. Although the SNP chip suffers from ascertainment bias, results from population structure, ancestry, demographic, and phylogenetic analyses using the SNP chip were congruent with those derived from low-coverage whole-genome sequencing, and consistent with previous reports on Africa and outside Africa populations using microsatellites. More importantly, we identified a subset of SNPs that can be reliably used to generate merged databases, opening the door to combined analyses. We conclude that the Axiom aegypti1 SNP chip is a convenient, more accurate, low-cost alternative to low-depth whole-genome sequencing for population genetic studies of A. aegypti that do not rely on full allelic frequency spectra. Whole-genome sequencing and SNP chip data can be easily merged, extending the usefulness of both approaches.

Chromosomal divergence and evolutionary inferences in Rhodniini based on the chromosomal location of ribosomal genes.

In this study, we used fluorescence in situ hybridisation to determine the chromosomal location of 45S rDNA clusters in 10 species of the tribe Rhodniini (Hemiptera: Reduviidae: Triatominae). The results showed striking inter and intraspecific variability, with the location of the rDNA clusters restricted to sex chromosomes with two patterns: either on one (X chromosome) or both sex chromosomes (X and Y chromosomes). This variation occurs within a genus that has an unchanging diploid chromosome number (2n = 22, including 20 autosomes and 2 sex chromosomes) and a similar chromosome size and genomic DNA content, reflecting a genome dynamic not revealed by these chromosome traits. The rDNA variation in closely related species and the intraspecific polymorphism in Rhodnius ecuadoriensis suggested that the chromosomal position of rDNA clusters might be a useful marker to identify recently diverged species or populations. We discuss the ancestral position of ribosomal genes in the tribe Rhodniini and the possible mechanisms involved in the variation of the rDNA clusters, including the loss of rDNA loci on the Y chromosome, transposition and ectopic pairing. The last two processes involve chromosomal exchanges between both sex chromosomes, in contrast to the widely accepted idea that the achiasmatic sex chromosomes of Heteroptera do not interchange sequences.

Benznidazole-resistance in Trypanosoma cruzi is a readily acquired trait that can arise independently in a single population.

Benznidazole is the frontline drug used against Trypanosoma cruzi, the causative agent of Chagas disease. However, treatment failures are often reported. Here, we demonstrate that independently acquired mutations in the gene encoding a mitochondrial nitroreductase (TcNTR) can give rise to distinct drug-resistant clones within a single population. Following selection of benznidazole-resistant parasites, all clones examined had lost one of the chromosomes containing the TcNTR gene. Sequence analysis of the remaining TcNTR allele revealed 3 distinct mutant genes in different resistant clones. Expression studies showed that these mutant proteins were unable to activate benznidazole. This correlated with loss of flavin mononucleotide binding. The drug-resistant phenotype could be reversed by transfection with wild-type TcNTR. These results identify TcNTR as a central player in acquired resistance to benznidazole. They also demonstrate that T. cruzi has a propensity to undergo genetic changes that can lead to drug resistance, a finding that has implications for future therapeutic strategies.

Electropneumatic system for the simulation of the pulmonary viscoelastic effect in a mechanical ventilation scenario.

The viscoelastic properties of the lung have important implications during respiratory mechanics in terms of lung movement or work of breathing, for example. However, this property has not been well characterized due to several reasons, such as the complex nature of the lung, difficulty accessing its tissues, and the lack of physical simulators that represent viscoelastic effects. This research proposes an electropneumatic system and a method to simulate the viscoelastic effect from temporary forces generated by the opposition of magnetic poles. The study was tested in a mechanical ventilation scenario with inspiratory pause, using a Hamilton-S1 mechanical ventilator (Hamilton Medical) and a simulator of the human respiratory system (SAMI-SII). The implemented system was able to simulate the stress relaxation response of a Standard Linear Solid model in the Maxwell form and showed the capacity to control elastic and viscous parameters independently. To the best of our knowledge, this is the first system incorporated into a physical lung simulator that represents the viscoelastic effect in a mechanical ventilation scenario.

Brachiocephalic Vein and Superior Vena Cava Reconstruction with a Superficial Femoral Vein Graft.

Superior vena cava syndrome (SVCS) is an entity that has become more frequent due to the increasing use of indwelling central venous catheters. Surgical management is considered in patients with extensive venous thrombosis and when endovascular therapy is not feasible. The use of superficial femoral vein is an excellent technique for reconstruction of the brachiocephalic vein and superior vena cava (SVC) in cases with benign and malignant etiologies. We describe two cases of SVCS that were managed surgically at our institution with replacement of the SVC and brachiocephalic veins with a superficial femoral vein graft technique.

Unveiling the causes of pericardial effusion in a contemporary case series of pericardiocentesis in Latin America.

Pericardial effusions requiring pericardiocentesis have multiple causes that vary among geographical regions and health contexts. This procedure can be performed for diagnostic or therapeutic indications. The purpose of this study was to identify the principal causes of pericardial effusions and indications for pericardiocentesis, exploring differences among groups. This was a retrospective case series of patients who underwent pericardiocentesis for pericardial effusion in a single center in Latin America. Demographic, clinical, echocardiographic, and procedural variables were recorded and analyzed. The primary outcome was to determine the causes of pericardial effusions in these patients and the indication (diagnostic, therapeutic, or both). The results are presented in two groups (inflammatory and noninflammatory) according to the cause of the pericardial effusion. One hundred sixteen patients with pericardial effusion underwent pericardiocentesis. The median age was 58 years (IQR 46.2-70.7), and 50% were male. In the noninflammatory pericardial effusion group, there were 61 cases (53%), among which neoplastic pericardial effusion was the most frequent cause (n = 25, 40.9%). In the inflammatory group, there were 55 cases (47%), and the main cause was postpericardiectomy syndrome after cardiac surgery (n = 31, 56.4%). In conclusion, the principal indication for pericardiocentesis was therapeutic (n = 66, 56.8%). Large pericardial effusion without hemodynamic effect of cardiac tamponade was significantly more frequent in the inflammatory group (p = 0.03). The principal cause of pericardial effusion in patients who underwent pericardiocentesis was postpericardiectomy syndrome after cardiac surgery, followed by neoplastic pericardial effusion. Pericardiocentesis is mainly a therapeutic procedure.

Repair with a pulmonary neovalve in tetralogy of Fallot: does this avoid ventricular dysfunction?

OBJECTIVES: Given the anatomical variations of tetralogy of Fallot (TOF), different surgical techniques can be used to achieve correction. Transannular patches (TAPs) are the most commonly used technique; they are associated with right ventricular dysfunction, the incidence of which can be reduced through pulmonary valve preservation. METHODS: Between January 2010 and July 2019, we performed 274 surgical corrections of tetralogy of Fallot at Fundación Cardioinfantil; 63 patients (23%) underwent repair with a TAP in addition to a pulmonary neovalve (Group I), 66 patients (24.1%) received a TAP without a pulmonary valve (Group II) and 145 patients (52.9%) had a repair with valve preservation (Group III). We analysed patient's characteristics before, during and after surgery at a 30-day follow-up. RESULTS: We found that patients in Group III were older (P = 0.04). Group II had the lowest level of O2 saturation before surgery (82%, P = 0.001). Cardiopulmonary bypass and aortic cross-clamp times were longer in Group I (P < 0.001). Right ventricular dysfunction was less frequent in Group III (15.9%, P = 0.011). Severe residual pulmonary regurgitation was more common in Group II (21.9%, P = 0.001). CONCLUSIONS: Preservation of the pulmonary valve is an important factor for immediate postoperative management of tetralogy of Fallot. Patients who were repaired with a TAP with or without a pulmonary neovalve had a higher incidence of right ventricular dysfunction than those with pulmonary valve preservation.

Local-scale virome depiction in Medellín, Colombia, supports significant differences between Aedes aegypti and Aedes albopictus.

Aedes spp. comprise the primary group of mosquitoes that transmit arboviruses such as dengue, Zika, and chikungunya viruses to humans, and thus these insects pose a significant burden on public health worldwide. Advancements in next-generation sequencing and metagenomics have expanded our knowledge on the richness of RNA viruses harbored by arthropods such as Ae. aegypti and Ae. albopictus. Increasing evidence suggests that vector competence can be modified by the microbiome (comprising both bacteriome and virome) of mosquitoes present in endemic zones. Using an RNA-seq-based metataxonomic approach, this study determined the virome structure, Wolbachia presence and mitochondrial diversity of field-caught Ae. aegypti and Ae. albopictus mosquitoes in Medellín, Colombia, a municipality with a high incidence of mosquito-transmitted arboviruses. The two species are sympatric, but their core viromes differed considerably in richness, diversity, and abundance; although the community of viral species identified was large and complex, the viromes were dominated by few virus species. BLAST searches of assembled contigs suggested that at least 17 virus species (16 of which are insect-specific viruses [ISVs]) infect the Ae. aegypti population. Dengue virus 3 was detected in one sample and it was the only pathogenic virus detected. In Ae. albopictus, up to 11 ISVs and one plant virus were detected. Therefore, the virome composition appears to be species-specific. The bacterial endosymbiont Wolbachia was identified in all Ae. albopictus samples and in some Ae. aegypti samples collected after 2017. The presence of Wolbachia sp. in Ae. aegypti was not related to significant changes in the richness, diversity, or abundance of this mosquito's virome, although it was related to an increase in the abundance of Aedes aegypti To virus 2 (Metaviridae). The mitochondrial diversity of these mosquitoes suggested that the Ae. aegypti population underwent a change that started in the second half of 2017, which coincides with the release of Wolbachia-infected mosquitoes in Medellín, indicating that the population of wMel-infected mosquitoes released has introduced new alleles into the wild Ae. aegypti population of Medellín. However, additional studies are required on the dispersal speed and intergenerational stability of wMel in Medellín and nearby areas as well as on the introgression of genetic variants in the native mosquito population.

The effectiveness of a comprehensive diabetes program for glycemic control and adherence, and the selection of candidates for sensor-augmented insulin pump therapy.

OBJECTIVE: This study aimed to estimate the effectiveness of a comprehensive diabetes program (CDP) in terms of glycemic control, adherence, and the selection of candidates for sensor-augmented insulin pump therapy (SAP). METHODS: We compared diabetes control before and 6 months after CDP. The program was based on disease management using a logical model dealing with the following: case management, education and coaching, nutritional assessment, and mental health. RESULTS: The CDP improved glycemic control, HbA1c decreased by 0.56% (p-value=0.004; 95% CI: 0.14-0.98) and 19.1% of the patients reached the HbA1c goal without hypoglycemia. The CDP reduced by 52.4% the indication for SAP due to better glycemic control (36.4%) or non-adherence issues (63.6%); the remaining 47.6% persisted with poor glycemic control despite good adherence and were scaled to SAP. Among the 30 suitable candidates for SAP therapy, 60% did not reach the HbA1c goal and 40% had either hypoglycemic episodes (severe or persistent) or dawn phenomenon. The overall non-adherence rate was 33.3%. CONCLUSIONS: CDP optimized the selection of suitable candidates for SAP by improving glycemic control and identifying adherence issues early. These results provide evidence of the impact of the implementation of patient selection and educational protocols in the real-life setting of a highly experienced clinic.

The effectiveness of a comprehensive diabetes program for glycemic control and adherence, and the selection of candidates for sensor-augmented insulin pump therapy.

OBJECTIVE: This study aimed to estimate the effectiveness of a comprehensive diabetes program (CDP) in terms of glycemic control, adherence, and the selection of candidates for sensor-augmented insulin pump therapy (SAP). METHODS: We compared diabetes control before and 6 months after CDP. The program was based on disease management using a logical model dealing with the following: case management, education and coaching, nutritional assessment, and mental health. RESULTS: The CDP improved glycemic control, HbA1c decreased by 0.56% (p-value=0.004; 95% CI: 0.14-0.98) and 19.1% of the patients reached the HbA1c goal without hypoglycemia. The CDP reduced by 52.4% the indication for SAP due to better glycemic control (36.4%) or non-adherence issues (63.6%); the remaining 47.6% persisted with poor glycemic control despite good adherence and were scaled to SAP. Among the 30 suitable candidates for SAP therapy, 60% did not reach the HbA1c goal and 40% had either hypoglycemic episodes (severe or persistent) or dawn phenomenon. The overall non-adherence rate was 33.3%. CONCLUSIONS: CDP optimized the selection of suitable candidates for SAP by improving glycemic control and identifying adherence issues early. These results provide evidence of the impact of the implementation of patient selection and educational protocols in the real-life setting of a highly experienced clinic.

Real-world effectiveness and safety of sensor-augmented insulin pump therapy in adults with type 1 diabetes: Long-term follow-up.

OBJECTIVE: To evaluate the effectiveness and safety of sensor-augmented insulin pump therapy (SAP) in addition to a comprehensive diabetes program on glycated hemoglobin (HbA1c), severe hypoglycemia, ketoacidosis, and the hospital admission rate in patients with type 1 diabetes under real-world settings during a 2-year follow-up. METHODS: This was a retrospective real-life study comparing diabetes control before and after SAP therapy initiation. Patients ≥18 years old with type 1 diabetes were included. They were followed for 2 years with clinical assessments at months 3, 6, 12, 18, and 24. Effectiveness was estimated by difference in medians of HbA1c from baseline and at each follow-up visit. Safety was assessed by comparing the annual rates of severe hypoglycemia, hyperglycemic crisis, and hospital admission related to diabetes. RESULTS: 162 patients were included, median age 32 years, women 73%). The main indication for SAP was poor metabolic control (51.2%). At 2 years HbA1c decreased from 8.4% to 7.5% (-0.9%, 95% CI: 0.5-1.2; p<0.0001), HbA1c ≤7% improved from 14.2% to 25.3% (11.1%, 95% CI: 19.7-2.5; p=0.006), and severe hypoglycemia decreased from 22.2% to 14.1% (-8.1%, 95% CI: -16.5 to 0.3; p=0.03). CONCLUSIONS: SAP therapy improved glycemic control after the third month of use and for up to 2 years of follow-up, with lower rates of hospital admission and severe hypoglycemia. More studies are needed to assess the add-on impact of education programs and technologies for diabetes care.

Reproducibility of minor salivary gland biopsy reports in Sjögren's syndrome and its correlation with disease biomarkers.

INTRODUCTION/OBJECTIVE: Sjögren's syndrome (SS) is a systemic autoimmune disease that is challenging to diagnose. Although minor salivary gland biopsy (MSGB) is a useful ancillary study, different factors make its interpretation difficult. Also, the significance of distinct histopathological findings is unknown. We aimed to determine the concordance between pathologists and rheumatologists in interpreting the MSGB results, as well as the correlation between MSGB findings, paraclinical features, and SS diagnosis. METHODS: This descriptive retrospective study reviewed medical charts from 998 individuals from a single center where MSGBs had been performed. Rheumatologists interpreted biopsy reports from pathologists, and interobserver variability was calculated. Logistic regression using immunological parameters and histological findings was performed. RESULTS: We included 998 patients with a median age of 55 years (45-64 years); the majority of patients were females (n = 934, 93.6%). Chisholm and Mason's scoring system was the most frequently used scale (55.1%). There was a good correlation between pathologists and rheumatologists for diagnosing SS using MSGB findings (Cohen's kappa 0.91). We observed a strong association between interstitial plasmocytes and SS (OR 24, 95% CI 9.09-64.94, p = 0). CONCLUSION: The MSGB is an essential tool for the diagnosis of SS. Although different factors may negatively affect its reproducibility, histological findings, such as interstitial plasmocytes, may predict the risk of developing SS. Key Points • We provide information based on 998 patients with suspected SS diagnosis. • Chisholm and Mason's scale is the most frequently used compared to Greenspan's and Tarpley's scales. • There is good correlation between pathologists and rheumatologists for the diagnosis of SS using MSGB.

Surgical management of a giant right coronary artery aneurysm with coronary arteriovenous fistula: case report.

BACKGROUND: Coronary artery aneurysms (CAAs) are uncommon, and giant aneurysms (>2 cm) are even more unusual. Coronary atherosclerosis and Kawasaki disease are the leading causes for this pathology. The treatment for this condition is controversial because the evidence is based on case report series. CASE SUMMARY: We describe the case of a 77-year-old female patient who presented with heart failure symptoms. She was diagnosed with a giant saccular aneurysm arising from the right coronary artery (RCA) ostium and a fistula between the RC and the left anterior descending artery (LAD) to the coronary sinus. And an atrial septal defect (ASD) and severe tricuspid regurgitation were also found. The patient underwent surgery through a medium sternotomy, the aneurysm was opened and resected under cardiopulmonary bypass. The RCA was ligated at the distal end of the aneurysm, and a saphenous vein graft bypass was performed. A coronary arteriovenous fistula from the distal portion of RC and LAD artery to a severely enlarged coronary sinus was found and corrected with an autologous pericardial patch. Closure of the ASD was performed with a pericardial patch and a tricuspid ring annuloplasty was done. Post-operative course was uneventful. DISCUSSION: There are few cases of giant coronary aneurysms associated with fistulas reported in the literature. Despite the endovascular percutaneous techniques available to treat these patients, we believe that surgical treatment was the best option for this particular case. We consider that surgical treatment is a very good option for giant CAAs associated with AV fistulas that are not susceptible for current endovascular available devices. The literature lacks evidence regarding the best approach for these cases, and we think that invasive treatment should be tailored according to the heart's anatomy and patient risk.

Real-world effectiveness and safety of sensor-augmented insulin pump therapy in adults with type 1 diabetes: Long-term follow-up.

OBJECTIVE: To evaluate the effectiveness and safety of sensor-augmented insulin pump therapy (SAP) in addition to a comprehensive diabetes program on glycated hemoglobin (HbA1c), severe hypoglycemia, ketoacidosis, and the hospital admission rate in patients with type 1 diabetes under real-world settings during a 2-year follow-up. METHODS: This was a retrospective real-life study comparing diabetes control before and after SAP therapy initiation. Patients ≥18 years old with type 1 diabetes were included. They were followed for 2 years with clinical assessments at months 3, 6, 12, 18, and 24. Effectiveness was estimated by difference in medians of HbA1c from baseline and at each follow-up visit. Safety was assessed by comparing the annual rates of severe hypoglycemia, hyperglycemic crisis, and hospital admission related to diabetes. RESULTS: 162 patients were included, median age 32 years, women 73%). The main indication for SAP was poor metabolic control (51.2%). At 2 years HbA1c decreased from 8.4% to 7.5% (-0.9%, 95% CI: 0.5-1.2; p<0.0001), HbA1c ≤7% improved from 14.2% to 25.3% (11.1%, 95% CI: 19.7-2.5; p=0.006), and severe hypoglycemia decreased from 22.2% to 14.1% (-8.1%, 95% CI: -16.5 to 0.3; p=0.03). CONCLUSIONS: SAP therapy improved glycemic control after the third month of use and for up to 2 years of follow-up, with lower rates of hospital admission and severe hypoglycemia. More studies are needed to assess the add-on impact of education programs and technologies for diabetes care.