Exposure to UV Radiation in Lifeguards on Barcelona's Beaches: An Underestimated Occupational Risk. / [Artículo traducido] Exposición a radiación ultravioleta en socorristas de las playas de Barcelona: un riesgo laboral infravalorado.

BACKGROUND: The development of skin cancer is closely related to high exposure to UV radiation. Lifeguards are at an increased risk of excessive sun exposure. OBJECTIVES: The main objective of this study was to measure the exposure of Barcelona's beach lifeguards to UV radiation. METHODS: Measurements in the work chair were taken every 30min on a typical working day from 10:45 am to 19:15 pm. These measurements were carried out on four different days. These data were used to calculate the erythematous doses received during working hours, as well as those potentially received throughout the summer season. Vitamin D production was also estimated for the four days that the radiation received was measured, and the amount generated was calculated for the entire summer season. RESULTS: Exposure to UV radiation among Barcelona lifeguards far exceeds safety limits. In some locations, the exposure to UVB radiation is more than 16 times the minimum erythematous dose for phototype II skin. LIMITATIONS: This study assessed the radiation received during only four days. However, is a much higher number than most of the published papers. CONCLUSION: Although the health risks of excessive exposure to UV radiation are known, Barcelona's beach lifeguards are insufficiently protected.

Exposure to UV Radiation in Lifeguards on Barcelona's Beaches: An Underestimated Occupational Risk.

BACKGROUND: The development of skin cancer is closely related to high exposure to UV radiation. Lifeguards are at an increased risk of excessive sun exposure. OBJECTIVES: The main objective of this study was to measure the exposure of Barcelona's beach lifeguards to UV radiation. METHODS: Measurements in the work chair were taken every 30min on a typical working day from 10:45 am to 19:15 pm. These measurements were carried out on four different days. These data were used to calculate the erythematous doses received during working hours, as well as those potentially received throughout the summer season. Vitamin D production was also estimated for the four days that the radiation received was measured, and the amount generated was calculated for the entire summer season. RESULTS: Exposure to UV radiation among Barcelona lifeguards far exceeds safety limits. In some locations, the exposure to UVB radiation is more than 16 times the minimum erythematous dose for phototype II skin. LIMITATIONS: This study assessed the radiation received during only four days. However, is a much higher number than most of the published papers. CONCLUSION: Although the health risks of excessive exposure to UV radiation are known, Barcelona's beach lifeguards are insufficiently protected.

Synchronous primary cutaneous melanomas: a descriptive study of their clinical features, histology, genetic background of the patients and clinical outcomes.

BACKGROUND: Around 0.5% of cutaneous melanoma (CM) patients will present with synchronous melanomas when first seen. Moreover, 26-40% of patients with multiple primary melanomas present with synchronous lesions. OBJECTIVES: To assess the prevalence, clinical and histopathological characteristics, germline mutations and outcome in patients with synchronous melanoma. METHODS: Clinical and histopathological data from 4703 melanoma patients were included. Clinical, histological and genetic mutational status information was analysed. Kaplan-Meier curves were used to investigate survival outcomes. RESULTS: A total of 144 patients (3.06%) presented simultaneously with two or more primary melanomas. During follow-up, 25.7% of patients with synchronous melanoma developed a new primary melanoma compared to 8.6% of patients diagnosed with single melanoma (P < 0.001). Germinal CDKN2A mutations were identified in 10.7% of patients with synchronous melanomas and genetic variants in MC1R in 72%. No significant differences in all survival outcomes between patients with synchronous melanomas and single melanomas were found. CONCLUSION: Synchronous melanomas are more frequent than previously reported and are more frequent in older patients compared to single melanomas. Moreover, these patients have a higher risk of developing a new primary melanoma during follow-up and have higher rates of germline susceptibility variants. Nevertheless, these findings were not associated with worse outcomes.

Cattle welfare assessment at the slaughterhouse level: Integrated risk profiles based on the animal's origin, pre-slaughter logistics, and iceberg indicators.

Detection of on farm and transport animal welfare problems at slaughterhouse level is a key issue for the meat industry; however, usually, the assessments do not include basic aspects of animal health. For that reason, it is necessary to develop an assessment method that has an integrative scope and identifies the risk profiles in animals. Therefore, the aim of the present study was to detect cattle welfare indicators that can be implemented at the slaughterhouse level and to develop integrated risk profiles based on the animal's origin, pre-slaughter logistics, and animal-based indicators. We recorded the origin, commercial category, transportation details, and horn size of 1040 cattle upon arrival at the slaughterhouse. Cattle welfare was measured based on individual scores for vocalizations, stunning shots, carcass bruises, meat pH, severe hoof injuries, and organ condemnations. To characterize operational and logistic practices from the farm to the slaughterhouse, a two-step cluster analysis was applied to the aforementioned variables (production system, cattle type, horn size, journey distance, vehicle type), which identified four clusters: small feedlot and free-range profile (C1, n = 216, 20.8 %), feedlot profile (C2, n = 193, 18.6 %), culled dairy cows profile (C3, n = 262, 25.2 %), and free-range profile (C4, n = 369, 35.5 %). The animal's diet and environmental conditions might have influenced the development of hoof disorders in C1 animals (P = 0.023), the proportion of animals that were re-shot was highest in C2 animals (P = 0.033), and C3 and C4 animals were most likely to suffer injuries such as severe bruising (P = 0.001). In addition, the number of stunning shots, meat pH, carcass bruises, severe hoof injuries, and liver condemnations, explained a significant variation in the incidence of various health and welfare consequences based on an animal's origin, which confirmed their importance as 'welfare iceberg' indicators. The study provided detailed data that can be included into assessment methods for the welfare of slaughter cattle, which can be tailored to specific production systems.

Claw disorders as iceberg indicators of cattle welfare: Evidence-based on production system, severity, and associations with final muscle pH.

This study presents a novel approach to use claw disorders in cattle as a retrospective welfare indicator characterized at the abattoir. A total of 1040 cattle (2080 front and back left claws) were analyzed from 143 batches, originating from feedlots, free-range, and dairy systems. Our results indicate that abnormal claw shapes (>55%) and fissures of the claw wall (>25%) had the highest prevalence, regardless of the system of origin. For the seven types of lesions monitored, numerous associations were found between lesions in the front and rear limbs typical of each production system. Ultimate meat pH was higher in animals with white line disease and skin wounds in feedlot and free-range cattle. We conclude that claw disorders can be used as an iceberg indicator to provide valuable information about animal fitness, and the ability to cope with the husbandry and pre-slaughter environment. These indicators can be used to improve the level of welfare of the animals.

La fisioterapia española en tiempos de pandemia de la COVID-19 / Spanish physiotherapy in times of the COVID-19 pandemic

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Incidencia de enfermedad pulmonar obstructiva crónica en pacientes con el virus de la inmunodeficiencia humana. Análisis post-hoc del estudio viva / Incidence of chronic obstructive pulmonary disease in patients with human immunodeficiency virus. Post-hoc analysis of the viva study

Introducción: desde la aparición de la terapia antiretroviral la supervivencia de los pacientes infectados por el virus de la inmunodeficiencia humana (VIH) ha aumentado considerablemente tomando importancia la aparición de otras patologías crónicas en estos pacientes como puede ser la enfermedad pulmonar obstructiva crónica (EPOC). Nuestro objetivo fue conocer la incidencia de EPOC en una cohorte de pacientes VIH derivados en un programa de detección de hipertensión pulmonar (HTP). Material y Métodos: análisis post-hoc, de un prospectivo, pseudo-experimental de pacientes con infección del VIH a los que se les preguntaba por disnea y en caso afirmativo eran derivados a consultas de neumología para despistaje de HTP. Resultado: desde 2014 hasta 2016, reclutamos un total de 32 pacientes, con un predominio de varones (75%). La disnea según la mMRC (Medical Reserach Council) fue grado 1, 2 y 3 en el 37,5%, 43,8% y 18,8%, respectivamente. La prevalencia de tabaquismo fue del 87,1% (intervalo de confianza [IC] 95%: 71- 96,4%), y 18 pacientes fueron catalogados de EPOC (62%; IC95%: 42,2 - 79,3%). Conclusión: la incidencia de EPOC en nuestra serie fue muy superior a la de la población general. Es necesario plantear estrategias de búsqueda activa de EPOC en estos pacientes para un diagnóstico y tratamiento precoz

Introduction: Since the advent of antiretroviral therapy, the survival of patients infected with the human immunodeficiency virus (HIV) has considerably increased, with the occurrence of other chronic diseases such as chronic obstructive pulmonary disease (COPD) gaining importance in these patients. Our objective was to find out the incidence of COPD in a cohort of HIV patients that were referred to a program to detect pulmonary hypertension (PH). Materials and Methods: Post hoc analysis of a prospective, quasi-experimental study on HIV-infected patients who were asked whether they had dyspnea. If this was the case, they were referred to a pulmonologist for PH screening. Results: From 2014 to 2016, we recruited a total of 32 patients, with a predominance of male recruits (75%). According to the mMRC (Modified Medical Research Council) Dyspnea Scale, 37.5%, 43.8% and 18.8% were classified as Grade 1, 2 and 3, respectively. The prevalence of smoking was 87.1% (95% confidence interval [CI]: 71 - 96.4%), and 18 patients were classified with COPD (62%; 95% CI: 42.2 - 79.3%). Conclusion: The incidence of COPD in our sample was much higher than that of the general population. It is necessary to plan active search strategies for COPD in these patients for early diagnosis and treatment

Parenteral drug use as the main barrier to hepatitis C treatment uptake in HIV-infected patients.

OBJECTIVES: Our objective was to identify patient factors associated with being untreated for hepatitis C virus (HCV) infection in HIV-coinfected patients. METHODS: A prospective longitudinal study was carried out. HIV-infected patients with active chronic HCV infection included in the HERACLES cohort (NCT02511496) constituted the study population. The main study outcome was receipt of HCV direct-acting antiviral (DAA) treatment from 1 May 2015 to 1 May 2017. The population was divided into patients who were receiving HCV treatment during follow-up and those who were not. RESULTS: Of the 15 556 HIV-infected patients in care, 3075 (19.7%) presented with chronic HCV infection and constituted the study population. At the end of the follow-up, 1957 patients initiated HCV therapy (63.6%). Age < 50 years, absence of or minimal liver fibrosis, being treatment-naïve, HCV genotype 3 infection, being in the category of people who inject drugs using opioid substitutive therapy (OST-PWID), and being in the category of recent PWID were identified as significant independent risk factors associated with low odds of DAA implementation. When a multivariate analysis was performed including only the PWID population, both OST-PWID [odds ratio (OR) 0.552; 95% confidence interval (CI) 0.409-0.746) and recent PWID (OR 0.019; 95% CI 0.004-0.087) were identified as independent factors associated with low odds of treatment implementation. CONCLUSIONS: We identified factors, which did not include prioritization of a DAA uptake strategy, that limited access to HCV therapy. The low treatment uptake in several populations seriously jeopardizes the elimination of HCV infection in the coming years.

Induction of transcription factors, miRNAs and cytokines involved in T lymphocyte differentiation in BCG-vaccinated subjects.

The BCG vaccine induces a Th1 phenotype, which is essential for protection against Mycobacterium tuberculosis. However, the effects of BCG vaccination over time on the T helper subpopulation and the microRNAs involved in adulthood have not been studied. In the present study, we explored the involvement of microRNAs, transcription factors and multifunctional cytokines in BCG vaccination by examining their levels both before and after vaccination of healthy adults. Peripheral blood mononuclear cells were obtained at 0, 2 and 6 months after vaccination. Cells were cultured in the presence or absence of ESAT-6 and CFP-10 or M. tuberculosis filtrate. The expression levels of miRNAs and transcription factors were evaluated using qRT-PCR. Cytokine production in supernatants and serum samples was evaluated using ELISA. Multifunctional CD4+ T cells were analyzed using multiparametric flow cytometry. We observed a decrease in the expression levels of T-BET, GATA3 and FOXP3 at 2 months and miR-146a, miR-326 and miR-155 at 6 months after receiving the vaccine. In the supernatant, the production of IL-17 was increased after 6 months, with both stimuli. In contrast, IL-10, TNF-α and IFN-γ increased at 2 months. In the serum, high levels of IL-10 were found after 2 months compared to time 0 and 6 months. The production of multifunctional cells that expressed the cytokine profiles CD4+TNF-α+IFN-γ-IL-10-, CD4+TNF-α+IL-1IFN-γ-, CD4+IL-10+IFN-γ-TNF-α- and CD4+IL-17+IFN-γ- predominantly increased after 2 months with and without the stimulus. Correlation analysis revealed a negative association between FOXP3 and miR-155 (r=-0.5120, p=0.0176) and between IL-17 and miR-326 (r=-0.5832, p=0.0364). This study is the first to demonstrate roles for microRNAs, transcription factors and cytokines in the T helper differentiation lineage and to describe the possible mechanism by which their expression is modulated by the presence of the BCG vaccine in adulthood. In conclusion, our results suggest that the BCG vaccine induces a modulation in transcription factors and miRNAs with high production of multifunctional cells CD4+TNF-α+IL-10+IFN-γ-.

[Internal circular arc osteosynthesis of tibiotalocalcaneal arthrodesis]. / Die innere Kreisbogen-Osteosynthese der tibio-talo-calcanealen Arthrodese.

Tibiotalocalcaneal arthrodesis has recently become more popular as a form of reconstructive surgery. The precise anatomical orientation and the functional extrinsic musculature of the hindfoot are essential for a satisfactory result. Fixation of the arthrodesis is a mechanical problem. Straight and angulated nails are not anatomically or mechanically ideal. A circular arc nail can fix the tibia, the talus and the calcaneus in anatomical alignment. This is a pure "bone nail", in contrast to the "intramedullary nail," which is driven through an existing opening in long bones. The nail is driven through a circular arc-shaped opening in the bone, which results in optimal form-fit between nail and bone. A corresponding aiming device permits the precise shaping of the bone tunnel, which follows the orientation of the bone trabeculae. The instrumentation was applied in 11 cases, with the following indications: post-traumatic conditions, congenital deformities, chronic polyarthritis and diabetic Charcot arthropathy. The desired alignment of the hindfoot is not affected while the nail is being introduced. The fixation achieves primary stability thus allowing for early functional treatment.

Cerebral Hemodynamics Patterns by Transcranial Doppler in Patients With Acute Liver Failure.

INTRODUCTION: About half of patients with acute liver failure (ALF) show clinical signs of cerebral edema and intracranial hypertension. Neuroimaging diagnostics and electroencephalography have poor correlation with intracranial pressure measurement. OBJECTIVE: The objective of this study was to characterize the cerebral hemodynamics patterns with transcranial Doppler (TCD) sonography in patients with ALF. METHOD: We studied 21 patients diagnosed with ALF, admitted to the intensive care unit (ICU) at the Centro de Investigaciones Médico Quirúrgicas of Cuba. All of these patients had a TCD performed on arrival at ICU, evaluating the following: systolic (SV), diastolic (DV), and medium (MV) flows velocities and pulsatility index (PI) in right middle cerebral artery (RMCA) via temporal windows. RESULTS: The sonographic patterns of cerebral hemodynamics were as follows: low-flow, 12 patients (57.1%); high resistance, 5 patients (23.8%); and hyperemic, 4 patients (19%). Patients who died while waiting had lower MV RMCA (56.1 vs 58.1 cm/s) and higher PI (1.71 vs 1.41) than patients who could undergo transplantation (P = .800 and P = .787, respectively). CONCLUSIONS: In patients diagnosed with ALF admitted to the ICU the predominating cerebral hemodynamic pattern was low-flow with resistance increase. The TCD was shown to be a useful tool in the initial evaluation for prognosis and treatment.

Peroneal tendon dislocation.

INTRODUCTION: Peroneal tendon instability goes often mis- or undiagnosed in the acute setting of evaluation of ankle sprains. The current article provides a concise overview regarding peroneal tendon instability. METHODS: A proper history, clinical assessment and imaging help to establish the correct diagnosis. Conventional radiography, ultrasound, magnetic resonance imaging and sometimes computed tomography may help to elucidate the pattern of injury. RESULTS: Nonoperative treatment can be considered in the acute setting. However, high failure rates up to 50 % have been reported in the literature. This is even better reflected in the chronic stage of peroneal instability, in which most of the patients need surgical treatment. In contrast, surgical treatment attempts to restore structural stabilization of the peroneal tendon and retinacular complex. The simple reconstruction and repair of the damaged retinacular structures and tendons achieve excellent results. In patients with structural abnormalities of the retromalleolar groove, groove-deepening procedures may be considered. Most of chronic personal tendon instabilities need to be addressed by surgery due to the frustrating results obtained by nonoperative measures. However, reconstruction of the tendinous and retinacular structures can yield good-to-excellent outcomes.

Clinical Pharmacokinetics of Rifampin in Patients with Tuberculosis and Type 2 Diabetes Mellitus: Association with Biochemical and Immunological Parameters.

Tuberculosis (TB) remains a major public health issue due to the increasing incidence of type 2 diabetes mellitus (T2DM), which exacerbates the clinical course of TB and increases the risk of poor long-term outcomes. The aim of this study was to characterize the pharmacokinetics of rifampin (RIF) and its relationship with biochemical and immunological parameters in patients with TB and T2DM. The biochemical and immunological parameters were assessed on the same day that the pharmacokinetic evaluation of RIF was performed. Factors related to the metabolic syndrome that is characteristic of T2DM patients were not detected in the TB-T2DM group (where predominant malnutrition was present) or in the TB group. Percentages of CD8(+) T lymphocytes and NK cells were diminished in the TB and TB-T2DM patients, who had high tumor necrosis factor alpha (TNF-α) and low interleukin-17 (IL-17) levels compared to healthy volunteers. Delayed RIF absorption was observed in the TB and TB-T2DM patients; absorption was poor and slower in the latter group due to poor glycemic control. RIF clearance was also slower in the diabetic patients, thereby prolonging the mean residence time of RIF. There was a significant association between glycemic control, increased TNF-α serum concentrations, and RIF pharmacokinetics in the TB-T2DM patients. These altered metabolic and immune conditions may be factors to be considered in anti-TB therapy management when TB and T2DM are concurrently present.

Central fatigue induced by short-lasting finger tapping and isometric tasks: A study of silent periods evoked at spinal and supraspinal levels.

The neural substrates of fatigue induced by muscular activity have been addressed in depth in relation to isometric tasks. For these activities, when fatigue develops, it has been noted that the duration of the silent periods (SPs) increases in response to both transcranial magnetic stimulation (TMS) of primary motor cortex or electric cervicomedullary stimulation (CMS). However, fatigue is known to be task-dependent and the mechanisms giving rise to a decrease in motor performance during brief, fast repetitive tasks have been less studied. We hypothesized that fatigue induced by repetitive fast finger tapping may have physiological mechanisms different from those accounting for fatigue during an isometric contraction, even in cases of matched effort durations. In these tasks, we examined the contribution of spinal and supraspinal motor circuits to the production of fatigue. The tapping rate and maximal voluntary contractions (MVC), and TMS- and CMS-evoked SPs were obtained at the time of fatigue, and while subjects maintained maximal muscle activation after fast finger-tapping (or isometric activity) of different durations (10 or 30s). Results showed different mechanisms of fatigue triggered by isometric contraction and repetitive movements, even of short duration. Short-lasting repetitive movements induce fatigue within intracortical inhibitory circuits. They increased TMS-SPs, but not CMS-SPs. On the other hand, isometric contraction had a clear impact on spinal circuits. The consideration of these differences might help to optimize the study of fatigue in physiological conditions and neurological disorders.

Caso 6. Aneurisma gigante de arteria hipogástrica en paciente con bifurcado / Case 6. Giant hypogastric artery aneurysm in a patient with a bifurcated gift

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Solución del caso 6. Aneurisma gigante de arteria hipogástrica en paciente con bifurcado / Solution to case 6. Giant hypogastric artery aneurysm in a patient with bifurcation

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Spectroscopic measurement of cortical nitric oxide release induced by ascending activation.

The transition from sleep to the awake state is regulated by the activation of subcortical nuclei of the brainstem (BS) and basal forebrain (BF), releasing acetylcholine and glutamate throughout the cortex and inducing a tonic state of neural activity. It has been suggested that such activation is also mediated by the massive and diffuse cortical release of nitric oxide (NO). In this work we have combined the spectroscopic measurement of NO levels in the somatosensory cortex of the cat through its marker methemoglobin, as well as two other hemodynamic markers (oxyhemoglobin--oxyHb--and deoxyhemoglobin--deoxyHb), together with the electrical stimulation of BS and BF--to induce an experimental transition from a sleep-like state to an awake-like mode. The results show an increase of NO levels either after BS or BF activation. The response induced by BS stimulation was biphasic in the three studied markers, and lasted for up to 30s. The changes induced by BF were monophasic lasting for up to 20s. The systemic blockade of NO production abolished the observed responses to BS whereas responses to BF stimulation were much less affected. These results indicate a crucial role for NO in the neuronal activation induced by the ascending systems.

[Complex reconstruction in Charcot arthropathy using the Ilizarov ring fixator]. / Komplexe Rekonstruktionen bei Charcot-Arthropathie mittels Ilizarov-Ringfixateur.

BACKGROUND: From the foot surgeon's point of view, the surgical treatment of Charcot neuro-osteopathy is considered challenging. Conservative treatment using plaster and orthoses is used to treat Charcot arthropathy, especially in the acute stage of a treatment strategy. Surgical treatment using the Ilizarov ring fixator is established for the correction of residual misalignments and also in the acute stage. Advantages of the ring fixator are great stability of the apparatus, low loading of the soft tissues caused by foreign material, and possible long-term treatment. OBJECTIVES: The aim of this work is to explain the indication, planning of correction, assembly of Ilizarov ring fixator, and the postoperative treatment with respect to the literature and the authors' experience. The aim of treatment with the Ilizarov ring fixator is a plantigrade, resilient, ulcer-free foot. Treatment is lengthy for both the affected patients and the attending orthopedic surgeon, and great attention is required to achieve the desired corrections and a good result for the patient. DISCUSSION: According to the literature and the authors' experience, the results indicate that the Ilizarov ring fixator represents a viable method for the preservation of the affected limb in patients with Charcot neuro-osteopathy. The assembly of the apparatus must follow the principles of Ilizarov in order to avoid failure. Corrective osseous and soft tissue interventions require a detailed preoperative analysis.

Abacavir/lamivudine plus darunavir/ritonavir in routine clinical practice: a multicentre experience in antiretroviral therapy-naive and -experienced patients.

OBJECTIVES: To present clinical experience with a regimen including abacavir/lamivudine + darunavir/ritonavir in a cohort of HIV-1-infected patients. METHODS: A retrospective, multicentre cohort study, including all consecutive adult HIV-1-infected patients who started abacavir/lamivudine + darunavir/ritonavir from April 2008 to December 2010 and had at least one follow-up visit. The primary endpoint was HIV-1 viral load (VL) <40 copies/mL at week 48. RESULTS: One hundred and eighty-three patients (42 naive and 141 experienced) from 19 hospitals in Spain were studied. The median follow-up was 26.7 (0.5-58.6) months, 79.8% were men, the median age was 47.1 (21.4-80.5) years, 26.2% had AIDS and 38.8% were positive for hepatitis C virus. At baseline, the median CD4 count was 246 cells/mm(3) in naive patients and 393 cells/mm(3) in experienced patients and the median VL was 4.80 and <1.59 log copies/mL, respectively. At week 48, 81.8% of naive patients and 84.2% of experienced patients receiving the regimen reached a VL <40 copies/mL, whereas at 96 weeks this occurred in 90.5% and 92.8%, respectively. CD4 cell count increases at 48 and 96 weeks were +176.5 and +283.5 cells/mm(3) in naive patients and +74.9 and +93 cells/mm(3) in experienced patients, respectively. Overall, 86 (47%) patients discontinued the study regimen, in many cases possibly related to non-medical reasons, such as drug switches to reduce cost or changes in address due to economic constraints. Three patients died of causes unrelated to therapy and 19 (10.4%) discontinued the regimen due to adverse events. CONCLUSIONS: In our cohort, abacavir/lamivudine + darunavir/ritonavir was safe, well tolerated and achieved high rates of virological suppression. In a proportion of patients, discontinuation of this effective regimen was possibly due to non-medical reasons.