Presence of Anti-T. cruzi Antibodies in Inhabitants and Dogs of Two Rural Settlements in the Sierra de Los Tuxtlas, Veracruz, Mexico.

PURPOSE: The aim of this study was to identify the risk factors associated with house infestation by Triatoma dimidiata as well as with Trypanosoma cruzi infection in humans and owned dogs in two rural communities from the municipality of Catemaco, Veracruz, Mexico. METHODS: One hundred and 16 human blood samples and 34 dog blood samples were collected. The presence of anti-T. cruzi antibodies was determined using four different ELISA assays. Moreover, reactive ELISA sera from humans and dogs were processed by indirect immunofluorescence (IFI) to confirm the presence of anti-T. cruzi antibodies. RESULTS: Serologic tests for T. cruzi infection showed a prevalence of 5.1% (6/116) in humans and of 50% (17/34) in owned dogs. CONCLUSION: The presence of animals (dogs, chickens and wild animals), as well as some characteristics of house construction were identified as risk factors for infestation and infection. Complementary studies must be carried out to allow a better understanding of the transmission dynamics in the state of Veracruz, Mexico, and the implementation of adequate control programs.

Public health impact of the COVID-19 pandemic on the emergency healthcare system.

BACKGROUND: The Lombardy region has been the Italian region most affected by the coronavirus disease 2019 (COVID-19) pandemic in 2020. The emergency healthcare system was under deep stress throughout the past year due to the admission of COVID-19 patients to the emergency department (ED) and had to be thoroughly reorganized. METHODS: We performed a retrospective descriptive analysis of patients admitted into the ED recorded in the Lombardy online regional portal called EUOL (Emergenza e Urgenza OnLine). We compared the data registered in the EUOL with the patients admitted to the EDs from 1 January 2019 to 31 December 2019 and from 1 January 2020 to 31 December 2020. RESULTS: The number of admissions to the ED decreased by 32.5% in 2020 compared with 2019, reaching the lowest number in March and April. However, the percentage of patients hospitalized after ED significantly increased in 2020 compared with 2019 (P < 0.0001), reflecting the management of patients with a more severe clinical condition. More patients arrived at the ED by ambulance in 2020 (21.7% in 2020 versus 15.1% in 2019; P < 0.0001), particularly during March and April. CONCLUSIONS: This analysis showed the importance of monitoring the pandemic's evolution in order to treat more critically ill patients, despite a lower number of patients.

Systematic review of clinical evidence on postoperative delirium: literature search of original studies based on validated diagnostic scales.

BACKGROUND: Postoperative delirium is a serious complication that can occur within the 5th postoperative day. In 2017, the European Society of Anesthesiologists delivered dedicated guidelines that reported the need for routine monitoring using validated scales. OBJECTIVE: Aim of this systematic review is to identify clinical studies related to postoperative delirium that included postoperative monitoring with validated scales. DESIGN: Systematic review METHODS: Searched keywords included the following terms: postoperative, postsurgical, post anesthesia, anesthesia recovery, delirium, and confusion. Two researchers independently screened retrieved studies using a data extraction form. RESULTS: Literature search led to retrieve 6475 hits; of these, 260 studies (5.6% of the retrieved), published between 1987 and 2021, included in their methods a diagnostic workup with the use of a postoperative delirium validated scale and monitored patients for more than 24 h, therefore are qualified to be included in the present systematic review. CONCLUSION: In conclusion, available clinical literature on postoperative delirium relies on a limited number of studies, that included a validated diagnostic workup based on validated scales, extracted from a large series of studies that used inconsistent diagnostic criteria. In order to extract indications based on reliable evidence-based criteria, these are the studies that should be selectively considered. The analysis of these studies can also serve to design future projects and to test clinical hypothesis with a more standardized methodological approach.

Caspofungin PK in critically ill patients after the first and fourth doses: suggestions for therapeutic drug monitoring?

We describe caspofungin pharmacokinetics (PK) after the first and fourth doses in 20 critically ill septic patients. Monte Carlo simulation was used to analyze the probability of target attainment (PTA) (AUC/MIC > 865) for Candida spp. Caspofungin concentrations were analyzed by HPLC in plasma and urine. A great variability in PK parameters was observed after both doses. Patients were divided in two groups according to their AUC values (AUC ≤ 75 mg h/L cut-off). In the low-AUC group Cmax, Cmin and AUC were lower, while Vd and Cl were higher than in the high-AUC group (p < 0.05, both at day 1 and 4). The mean 24-h urinary recovery of the drug was 8 ± 6.3% (day1) and 9.8 ± 6.3 (day4). Monte Carlo simulation analysis (0.03-1 mg/L MIC-range) showed that PTA was guaranteed only for MICs ≤ 0.03 mg/L in the low-AUC group, and for MICs ≤ 0.06 mg/L in the high-AUC group. No group had a PTA ≥ 90% for 0.125 mg/L MIC (the epidemiological cut-off). Mortality was higher in low-AUC group (p < 0.01). In our 'real-world' population, no clinical data can predict which patient will have lower, suboptimal caspofungin exposure, therefore we suggest TDM to optimize caspofungin therapy and reduce the risk of selecting resistances (CEAVC, 32366/2015; OSS.15.114, NCT03798600).

Procedural Recommendations for Lymphoscintigraphy in the Diagnosis of Peripheral Lymphedema: the Genoa Protocol.

INTRODUCTION: Lymphoscintigraphy is the gold standard for imaging in the diagnosis of peripheral lymphedema. However, there are no clear guidelines to standardize usage across centers, and as such, large variability exists. The aim of this perspectives paper is to draw upon the knowledge and extensive experience of lymphoscintigraphy here in Genoa, Italy, from our center of excellence in the assessment and treatment of lymphatic disorders for over 30 years to provide general guidelines for nuclear medicine specialists. METHOD: The authors describe the technical characteristics of lymphoscintigraphy in patients with limb swelling. Radioactive tracers, dosage, administration sites, and the rationale for a two-compartment protocol with the inclusion of subfascial lymphatic vessels are all given in detail. RESULTS: Examples of lymphoscintigraphic investigations with various subgroups of patients are discussed. The concept of a transport index (TI) for semi-quantitative analysis of normal/pathological lymphatic flow is introduced. Different concepts of injection techniques are outlined. DISCUSSION: It is past time that lymphoscintigraphy in the diagnosis of lymphatic disorders becomes standardized. This represents our first attempt to outline a clear protocol and delineate the relevant points for lymphoscintigraphy in this patient population.

Decreasing and preventing lymphatic-injury-related complications in patients undergoing venous surgery: A new diagnostic and therapeutic protocol.

Lymphatic complications following great and small saphenous vein surgery show a varying and non-negligible incidence in the literature. We undertook this study to investigate a new protocol to reduce lymphatic injuries in patients undergoing venous surgery. Eighty-six patients with lower limb venous insufficiency and varices were treated. Lymphoscintigraphy was performed preoperatively in 65 of them and postoperatively in 19. Blue dye was used in all patients and blue lymph nodes and lymphatics were identified intra-operatively and preserved or used to perform multiple lymphatic-venous anastomoses (MLVA). Patients were followed up fora period varying from 3 months to 6 years. Sixty-six patients were treated by greater saphenectomy and varicectomy, 12 patients had crossectomy and varicectomy, 4 patients underwent greater saphenectomy and varicectomy associated with MLVA, and 4 patients were treated by small saphenous vein stripping and varicectomy. No lymphatic complications occurred in any of the patients. A decrease of over 75% of excess volume was observed in 4 patients treated by MLVA. Lymphoscintigraphy showed normalization in the Transport Index in 4 patients treated with MLVA. Our results demonstrate that accurate diagnostic investigation and proper surgical technique is of paramount importance in the effort to avoid lymphatic complications during venous surgery.

Renal health after long-term exposure to tenofovir disoproxil fumarate (TDF) in HIV/HBV positive adults in Ghana.

OBJECTIVES: The study assessed markers of renal health in HIV/HBV co-infected patients receiving TDF-containing antiretroviral therapy in Ghana. METHODS: Urinary protein-to-creatinine ratio (uPCR) and albumin-to-protein ratio (uAPR) were measured cross-sectionally after a median of four years of TDF. At this time, alongside extensive laboratory testing, patients underwent evaluation of liver stiffness and blood pressure. The estimated glomerular filtration rate (eGFR) was measured longitudinally before and during TDF therapy. RESULTS: Among 101 participants (66% women, median age 44 years, median CD4 count 572 cells/mm3) 21% and 17% had detectable HIV-1 RNA and HBV DNA, respectively. Overall 35% showed hypertension, 6% diabetes, 7% liver stiffness indicative of cirrhosis, and 18% urinary excretion of Schistosoma antigen. Tubular proteinuria occurred in 16% of patients and was independently predicted by female gender and hypertension. The eGFR declined by median 1.8 ml/min/year during TDF exposure (IQR -4.4, -0.0); more pronounced declines (≥ 5 ml/min/year) occurred in 22% of patients and were associated with receiving ritonavir-boosted lopinavir rather than efavirenz. HBV DNA, HBeAg, transaminases, and liver stiffness were not predictive of renal function abnormalities. CONCLUSIONS: The findings mandate improved diagnosis and management of hypertension and suggest targeted laboratory monitoring of patients receiving TDF alongside a booster in sub-Saharan Africa.

Chemical acetylation of nixtamalized maize flour and structural, rheological and physicochemical properties of flour, dough and tortillas.

Nixtamalized maize tortilla is a basic food for the Mexican population. It has high energy due to high starch, which may be modified to decrease its bioavailability and to produce changes in the characteristics of flours. For this research, nixtamalized maize flour was prepared and subjected to an acetylation chemical process, with and without prior hydrolysis. Raw maize flour, traditionally nixtamalized maize flour, acetylated-nixtamalized maize flour (AF) and acetylated-hydrolyzed nixtamalized maize flour (AHF) were prepared and evaluated. These flours were used for dough and tortilla preparation and analyzed for degree of substitution (DS), physicochemical properties, structure, thermal, rheological, morphological and texture properties. FTIR spectra and DS showed the presence of acetyl groups. AHF showed the highest value for water absorption index. The resistant starch increased 0.27 and 0.42% for AF and AHF samples. The gelatinization enthalpy (∆Hg) for AF was greater than other flours. AF tortillas showed better characteristics than the traditional ones and their consumption was recommended since showed better RS.

Is the largest aqueous gold cluster a superatom complex? Electronic structure & optical response of the structurally determined Au146(p-MBA)57.

The new water-soluble gold cluster Au146(p-MBA)57, the structure of which has been recently determined at sub-atomic resolution by Vergara et al., is the largest aqueous gold cluster ever structurally determined and likewise the smallest cluster with a stacking fault. The core presents a twinned truncated octahedron, while additional peripheral gold atoms follow a C2 rotational symmetry. According to the usual counting rules of the superatom complex (SAC) model, the compound attains a number of 92 SAC electrons if the overall net charge is 3- (three additional electrons). As this is the number of electrons required for a major shell closing, the question arises of whether Au146(p-MBA)57 should be regarded as a superatom complex. Starting from the experimental coordinates we have analyzed the structure using density-functional theory. The optimized (relaxed) structure retains all the connectivity of the experimental coordinates, while removing much of its irregularities in interatomic distances, thereby enhancing the C2-symmetry feature. On analyzing the angular-momentum-projected states, we show that, despite a small gap, the electronic structure does not exhibit SAC model character. In addition, optical absorption spectra are found to be relatively smooth compared to the example of the Au144(SR)60 cluster. The Au146(SR)57 does not derive its stability from SAC character; it cannot be considered as a superatom complex.

Randomised study showed that recorded maternal voices reduced pain in preterm infants undergoing heel lance procedures in a neonatal intensive care unit.

AIM: Alleviating pain in neonates should be the goal of all caregivers. We evaluated whether recorded maternal voices were safe and effective in limiting pain in preterm infants undergoing heel lance procedures in the neonatal intensive care unit of an Italian children's hospital. METHODS: This prospective, controlled study took place from December 2013 to December 2015. We enrolled 40 preterm infants, born at a 26-34 weeks of gestation, at a corrected gestational age 29-36 weeks and randomised them to listen or not listen to a recording of their mother's voice during a painful, routine heel lance for blood collection. Changes in the infants' Premature Infant Pain Profile, heart rate, oxygen saturation and blood pressure during the procedure were compared by analysis of variance. Possible side effects, of apnoea, bradycardia, seizures and vomiting, were also recorded. RESULTS: Both groups showed a marked increase in PIPP scores and decrease in oxygen saturation during the procedure, but infants in the treatment group had significantly lower PIPP scores (p = 0.00002) and lower decreases in oxygen saturation (p = 0.0283). No significant side effects were observed. CONCLUSION: Using recorded maternal voices to limit pain in preterm infants undergoing heel lance procedures appeared safe and effective.

Blood pressure-lowering effects of nifedipine/candesartan combinations in high-risk individuals: subgroup analysis of the DISTINCT randomised trial.

The DISTINCT study (reDefining Intervention with Studies Testing Innovative Nifedipine GITS-Candesartan Therapy) investigated the efficacy and safety of nifedipine GITS/candesartan cilexetil combinations vs respective monotherapies and placebo in patients with hypertension. This descriptive sub-analysis examined blood pressure (BP)-lowering effects in high-risk participants, including those with renal impairment (estimated glomerular filtration rate<90 ml min-1, n=422), type 2 diabetes mellitus (n=202), hypercholesterolaemia (n=206) and cardiovascular (CV) risk factors (n=971), as well as the impact of gender, age and body mass index (BMI). Participants with grade I/II hypertension were randomised to treatment with nifedipine GITS (N) 20, 30, 60 mg and/or candesartan cilexetil (C) 4, 8, 16, 32 mg or placebo for 8 weeks. Mean systolic BP and diastolic BP reductions after treatment in high-risk participants were greater, overall, with N/C combinations vs respective monotherapies or placebo, with indicators of a dose-response effect. Highest rates of BP control (ESH/ESC 2013 guideline criteria) were also achieved with highest doses of N/C combinations in each high-risk subgroup. The benefits of combination therapy vs monotherapy were additionally observed in patient subgroups categorised by gender, age or BMI. All high-risk participants reported fewer vasodilatory adverse events in the pooled N/C combination therapy than the N monotherapy group. In conclusion, consistent with the DISTINCT main study outcomes, high-risk participants showed greater reductions in BP and higher control rates with N/C combinations compared with respective monotherapies and lesser vasodilatory side-effects compared with N monotherapy.

Role of Technology for the Management of AKI in Critically Ill Patients: From Adoptive Technology to Precision Continuous Renal Replacement Therapy.

This paper reports on the continuous renal replacement therapy (CRRT) technology group recommendations and research proposals developed during the 17th Acute Dialysis Quality Initiative Meeting in Asiago, Italy. The group was tasked to address questions related to the impact of technology on acute kidney injury management. We discuss technological aspects of the decision to initiate CRRT and the components of the treatment prescription and delivery, the integration of information technology (IT) on overall patient management, the incorporation of CRRT into other 'non-renal' extracorporeal technologies such as ECMO and ECCO2R and the use of sorbents in sepsis and propose new areas for future research. Instead of reviewing current knowledge, the group focused on developing a renovated research agenda that reflects current and future technological advances, centered on innovations in new equipment, membranes and IT that will permit the integration of patient care and decision-making processes for years to come.

Sentinel node mapping with radiotracer alone in vulvar cancer: a five year single-centre experience and literature review.

PURPOSE OF INVESTIGATION: The pathologic status of lymph node represents the most important prognostic factor in vulvar cancer patients, but a complete groin dissection is associated with high post-operative morbidity. Sentinel lymph node (SLN) could be representative of the totality of regional lymph nodes and consequently its biopsy might have a significant impact on clinical management in vulvar cancer patients. MATERIALS AND METHODS: From January 2006 to December 2010 45 patients with vulvar carcinoma are evaluated. Preoperative lymphatic mapping with technetium-99m-labeled nanocolloid was performed in all patients, followed by radioguided intraoperative detection. The detection rate is 100% of patients. All the SLNs were dissected separately for histopathological evaluation and a routine inguinofemoral lymphadenectomy was performed. RESULTS: Nine patients had positive SLNs. In the remaining 36 patients with negative SLNs, one of them showed positive non-SLNs at histological examination. It was the only false negative case in the present series. CONCLUSIONS: Based on literature review, lymphoscintigraphy and sentinel node biopsy under gamma-detecting probe guidance offer a reliable and careful method to identify sentinel node in early vulvar cancer. Taking certain guidelines, SLN biopsy seems to be a safe alternative to inguinofemoral node dissection in order to reduce morbidity of surgical treatment.

Implementation and preliminary validation of a new score that predicts post-operative complications.

BACKGROUND: An accurate pre-operative risk assessment could reduce morbidity and mortality for high-risk surgical patients. The aim of the study was to implement and preliminary validate a new score that could predict the occurrence of post-operative complications (PoCs): the Anesthesiological and Surgical Postoperative Risk Assessment (ASPRA) score. METHODS: The ASPRA score was created through a literature's review; a score of 1-3 was given to each identified risk factor, according to its statistical correlation with PoC. ASPRA was retrospectively applied to a derivation set of 176 surgical patients. A receiver operating characteristic (ROC) analysis evaluated the discriminating ability of the score and cutoff value in predicting the occurrence of PoCs, according to the Clavien-Dindo classification of surgical complications. The statistical validation of the score and related cutoff values was prospectively ran within a validation set of 1928 surgical patients. RESULTS: Through ROC analysis, an ASPRA score of 7 was chosen as the cutoff value in the derivation set. In the validation set, 65.3% of patients presented a PoC (Clavien ≥ 1). In this group, ROC analysis showed an area under the curve (AUC) of 0.72, and although potentially related to the high rate of complications a high positive predictive value of 87.0% has been observed. No significant differences were found in ROC-AUC, sensitivity, specificity, or positive or negative predictive value between the derivation and validation sets (P > 0.05). CONCLUSION: The new ASPRA score has a high positive predictive value to predict the occurrence of PoCs. Further prospective studies are required to confirm these results.

Higher levels of physical fitness are associated with a reduced risk of suffering sarcopenic obesity and better perceived health among the elderly: the EXERNET multi-center study.

OBJECTIVE: To evaluate the associations between physical fitness levels, health related quality of life (HRQoL) and sarcopenic obesity (SO) and to analyze the usefulness of several physical fitness tests as a screening tool for detecting elderly people with an increased risk of suffering SO. DESIGN: Cross-sectional analysis of a population-based sample. SETTING: Non-institutionalized Spanish elderly participating in the EXERNET multi-centre study. PARTICIPANTS: 2747 elderly subjects aged 65 and older. MEASUREMENTS: Body weight, height and body mass index were evaluated in each subject. Body composition was measured by bioelectrical impedance. Four SO groups were created based on percentage of body fat and relative muscle mass; 1) normal group, 2) sarcopenic group, 3) obesity group and 4) SO group. Physical fitness was evaluated using 8 tests (balance, lower and upper body strength, lower and upper body flexibility, agility, walking speed and aerobic capacity). Three tertiles were created for each test based on the calculated scores. HRQoL was assessed using the EuroQol visual analogue scale. RESULTS: Participants with SO showed lower physical fitness levels compared with normal subjects. Better balance, agility, and aerobic capacity were associated to a lower risk of suffering SO in the fittest men (odds ratio < 0.30). In women, better balance, walking speed, and aerobic capacity were associated to a lower risk of suffering SO in the fittest women (odds ratio < 0.21) Superior perceived health was associated with better physical fitness performance. CONCLUSIONS: Higher levels of physical fitness were associated with a reduced risk of suffering SO and better perceived health among elderly. SO elderly people have lower physical functional levels than healthy counterparts.

Antiretroviral blood levels in HIV/HCV-coinfected patients with cirrhosis after liver transplant: a report of three cases.

Since the introduction of combined antiretroviral therapy, human immunodeficiency virus (HIV) infection is no longer a contraindication for solid organ transplantation. In HIV/hepatitis C virus (HCV)-coinfected patients undergoing liver transplantation, HCV-related cirrhosis, drug-drug interactions, and calcineurin inhibitors-related toxicity affect clinical outcomes. Therapeutic drug monitoring can be useful to assess antiretroviral over- or underexposure in this cohort. We report the clinical characteristics along with antiretroviral trough levels of maraviroc, darunavir, and etravirine in 3 HIV/HCV-coinfected liver transplant recipients who developed post-transplant liver cirrhosis.

Development of END-of-Life ScorING-System to identify critically ill patients after initial critical care who are highly likely to die: a pilot study.

BACKGROUND: High quality palliative care should be provided for the dying patients in the intensive care unit (ICU). The aim of this pilot study is to develop a scoring system, the "END-of-Life ScorING-System" (ENDING-S), that may help to identify ICU patients at very high risk of dying after initial response to the intensive treatments and which could be used to facilitate palliative care. METHODS: The characteristics of longer-term ICU patients (>4 days) who are at very high risk of dying were identified through an analysis of the literature and developed in a retrospective cohort of patients. ENDING-S Score was developed through a multivariate analysis. Model accuracy was tested through ROC and Hosmer-Lemeshow analysis for model discrimination and calibration respectively. Cross validation was used to provide internal model validation. RESULTS: Potential predictors of death were identified and applied to 80 ICU patients. Significant variables in the multivariate analysis were the ratio of the ICU days in which the patient needs mechanical ventilation or vasoactive drugs divided by the total ICU days, the total ICU length of stay, and current sepsis. Analysis of accuracy showed a ROC-AUC equals to 0.98 (95% CI, 0.97 to 1), and agreement between the predicted probability and the observed frequency of death in the ICU was observed (P>0.05 at Hosmer-Lemeshow test). The internal validation confirms these results. CONCLUSION: In these preliminary results, ENDING-s shows acceptable calibration and discrimination properties. ENDING-S may raise awareness among ICU physicians about the importance of integrating palliative care into ICU daily practice.

Cost-effectiveness analysis of pazopanib in second-line treatment of advanced soft tissue sarcoma in Spain

Purpose. To assess the efficiency of pazopanib compared with trabectedin in the treatment of adult patients with selective subtypes of advanced soft-tissue sarcoma (STS) after chemotherapy failure. Methods. The progression of STS was modeled using a partitioned survival analysis model. Survival curves for pazopanib and trabectedin were modeled using data from PALETTE phase III clinical trial and based on unadjusted indirect comparison. Effectiveness was measured in quality-adjusted life years (QALY). The Spanish National Health System perspective was considered over a 10-year time horizon, including direct health care costs (Euros, 2014). A discount rate of 3 % was applied to both costs and outcomes. The robustness of the results was evaluated using univariate and probabilistic sensitivity analyses (PSA). Results. Pazopanib was associated with better health outcomes than trabectedin (0.705 versus 0.686 QALY). Pazopanib also showed lower direct health care costs (€21,861 versus €45,338), mainly due to lower cost of pharmacological treatment (€13,762 versus €33,392), administration (€57 versus €2,955) and AE management (€658 versus €1,695) costs. PSA confirmed that pazopanib was a dominant option in 71 % of the simulations performed. Conclusions. In this analysis, and from a health economics perspective, pazopanib was the option of choice versus trabectedin in the treatment of adult patients with advanced soft-tissue sarcoma after chemotherapy failure (AU)

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Cost-effectiveness analysis of pazopanib in second-line treatment of advanced soft tissue sarcoma in Spain.

PURPOSE: To assess the efficiency of pazopanib compared with trabectedin in the treatment of adult patients with selective subtypes of advanced soft-tissue sarcoma (STS) after chemotherapy failure. METHODS: The progression of STS was modeled using a partitioned survival analysis model. Survival curves for pazopanib and trabectedin were modeled using data from PALETTE phase III clinical trial and based on unadjusted indirect comparison. Effectiveness was measured in quality-adjusted life years (QALY). The Spanish National Health System perspective was considered over a 10-year time horizon, including direct health care costs (, 2014). A discount rate of 3% was applied to both costs and outcomes. The robustness of the results was evaluated using univariate and probabilistic sensitivity analyses (PSA). RESULTS: Pazopanib was associated with better health outcomes than trabectedin (0.705 versus 0.686 QALY). Pazopanib also showed lower direct health care costs (21,861 versus 45,338), mainly due to lower cost of pharmacological treatment (13,762 versus 33,392), administration (57 versus 2,955) and AE management (658 versus 1,695) costs. PSA confirmed that pazopanib was a dominant option in 71% of the simulations performed. CONCLUSIONS: In this analysis, and from a health economics perspective, pazopanib was the option of choice versus trabectedin in the treatment of adult patients with advanced soft-tissue sarcoma after chemotherapy failure.