Survival and Lung Function Changes in Hypersensitivity Pneumonitis According to Radiological Phenotypes Compared With Idiopathic Pulmonary Fibrosis.

INTRODUCTION: The main objective of this study was to estimate survival and changes in lung function in patients with chronic hypersensitivity pneumonitis (HP), both fibrotic (f-HP) and nonfibrotic (nf-HP), and to compare them with those in patients with idiopathic pulmonary fibrosis (IPF). METHODS: HP was diagnosed based on antigen exposure, HRCT (high-resolution CT scan), BAL (bronchoalveolar lavage), and histology. According to HRCT, HP was classified into fibrotic and non-fibrotic phenotypes. In most cases, IPF was diagnosed based on HRCT findings. RESULTS: We identified 84 patients: 46 with IPF, 18 with f-HP, and 20 with nf-HP. Five-year survival was 23.9% in IPF, 72% in f-HP, and 100% in nf-HP (p <0.0001). Honeycombing was associated with decreased survival in IPF (p <0.001) and in f-HP (p <0.0001). The mean loss of FVC (forced vital capacity) % pred. (percent predicted) was -18.3% in IPF (p =0.001), -4.8% in f-HP, and -6.0% in nf-HP. The mean change in DLCO (diffusion capacity for carbon monoxide) % pred. was -10.2% in IPF (p <0.002), -0.5% in f-HP, and +1.9% in nf-HP. The agreement between radiological phenotypes and histology in HP was 89.6%. CONCLUSIONS: We found shorter survival in IPF, followed by f-HP, and nf-HP. Over time, we did not find significant changes in FVC% pred. or DLCO% pred. in HP, while a significant decline in IPF was noted. In HP, we found strong agreement between radiological phenotypes and histology. Radiological signs suggestive of lung fibrosis in HP were reliable for the diagnosis of f-HP and seem to have intrinsic prognostic value.

Prevalence of Oropharyngeal Dysphagia and Its Value as a Prognostic Factor in Community-Acquired Pneumonia: A Prospective Case-Control Study.

BACKGROUND: Although oropharyngeal dysphagia (OD) is a common finding in patients with community-acquired pneumonia (CAP), specific recommendations are not provided in the current clinical guidelines. OBJECTIVES: To estimate the prevalence of OD and its associated factors among patients hospitalized for CAP and to assess one-year outcomes according to the presence or absence of OD. METHODS: We studied 226 patients hospitalized for CAP and 226 patients hospitalized for respiratory conditions other than CAP. We screened the risk of OD using the Eating Assessment Tool-10 (EAT-10), followed by the volume-viscosity swallow test (V-VST). RESULTS: A total of 122 (53.9%) patients with CAP had confirmed OD compared with 44 (19.4%) patients without CAP. Patients with CAP and OD were older (p < 0.001; 1.02-1.07) and had less familial/institutional support (p = 0.036; 0.12-0.91) compared to patients with CAP and no OD. OD was more prevalent as the CURB-65 score increased (p < 0.001). Patients with OD spent more time in the hospital (14.5 vs. 11.0 days; p = 0.038) and required more visits to the emergency room (ER). Twenty (16.4%) patients with CAP and OD died after discharge vs. one (0.8%) patient with CAP and no OD (p < 0.001; CI = 2.24-42.60). CONCLUSIONS: The prevalence of OD in hospitalized patients with CAP is higher than in patients hospitalized for other respiratory diagnoses. Advanced age, lower familial/institutional support, and increased CAP severity are associated with OD. Patients with CAP and OD are more frequent ER visitors after discharge and have a higher mortality. In patients with CAP and OD, aspiration pneumonia is likely underestimated.

[Human resources in the National Health System. Medical education. SESPAS Report 2024]. / Recursos humanos del Sistema Nacional de Salud. Formación. Informe SESPAS 2024.

The problems posed by medical education in Spain are diverse. This paper analyzes the system currently used to select candidates who will be admitted to a public faculty of medicine in Spain and some issues arising from the unprecedented increase in both public and private medical schools in our country. The importance of generic competencies in today's medicine and the need to return to a core design in specialist training are other aspects that are discussed. The degree of development of advanced accreditation diplomas and areas of specific competence is also subject to analysis. Finally, the authors emphasize the importance of continuous professional development and the idea of professional recertification as a system that guarantees patients the quality of the care they receive.

Humans with inherited MyD88 and IRAK-4 deficiencies are predisposed to hypoxemic COVID-19 pneumonia.

X-linked recessive deficiency of TLR7, a MyD88- and IRAK-4-dependent endosomal ssRNA sensor, impairs SARS-CoV-2 recognition and type I IFN production in plasmacytoid dendritic cells (pDCs), thereby underlying hypoxemic COVID-19 pneumonia with high penetrance. We report 22 unvaccinated patients with autosomal recessive MyD88 or IRAK-4 deficiency infected with SARS-CoV-2 (mean age: 10.9 yr; 2 mo to 24 yr), originating from 17 kindreds from eight countries on three continents. 16 patients were hospitalized: six with moderate, four with severe, and six with critical pneumonia, one of whom died. The risk of hypoxemic pneumonia increased with age. The risk of invasive mechanical ventilation was also much greater than in age-matched controls from the general population (OR: 74.7, 95% CI: 26.8-207.8, P < 0.001). The patients' susceptibility to SARS-CoV-2 can be attributed to impaired TLR7-dependent type I IFN production by pDCs, which do not sense SARS-CoV-2 correctly. Patients with inherited MyD88 or IRAK-4 deficiency were long thought to be selectively vulnerable to pyogenic bacteria, but also have a high risk of hypoxemic COVID-19 pneumonia.

Autoantibodies against type I IFNs in patients with critical influenza pneumonia.

Autoantibodies neutralizing type I interferons (IFNs) can underlie critical COVID-19 pneumonia and yellow fever vaccine disease. We report here on 13 patients harboring autoantibodies neutralizing IFN-α2 alone (five patients) or with IFN-ω (eight patients) from a cohort of 279 patients (4.7%) aged 6-73 yr with critical influenza pneumonia. Nine and four patients had antibodies neutralizing high and low concentrations, respectively, of IFN-α2, and six and two patients had antibodies neutralizing high and low concentrations, respectively, of IFN-ω. The patients' autoantibodies increased influenza A virus replication in both A549 cells and reconstituted human airway epithelia. The prevalence of these antibodies was significantly higher than that in the general population for patients <70 yr of age (5.7 vs. 1.1%, P = 2.2 × 10-5), but not >70 yr of age (3.1 vs. 4.4%, P = 0.68). The risk of critical influenza was highest in patients with antibodies neutralizing high concentrations of both IFN-α2 and IFN-ω (OR = 11.7, P = 1.3 × 10-5), especially those <70 yr old (OR = 139.9, P = 3.1 × 10-10). We also identified 10 patients in additional influenza patient cohorts. Autoantibodies neutralizing type I IFNs account for ∼5% of cases of life-threatening influenza pneumonia in patients <70 yr old.

Tuberculosis multirresistentediez años después / Multi-drug resistant tuberculosis, ten years later

La tuberculosis con resistencia a fármacos, sobre todo la que conlleva resistencia a rifampicina (TB-RR), se ha convertido en uno de los principales obstáculos para alcanzar el sueño de erradicar esta enfermedad. Y es que, para intentar curar la TB es necesario asociar tres o cuatro fármacos diferentes y, lamentablemente, son pocos los disponibles que se puedan considerar auténticamente eficaces. Pero, afortunadamente, el notable incremento que ha habido en los últimos años de la TB-RR en el mundo, ha motivado que se hayan invertido recursos en el desarrollo de nuevos fármacos para la TB, o que otros antimicrobianos investigados para otras enfermedades se hayan probado con éxito en la TB. Esto ha hecho que el manejo clínico de estos pacientes haya cambiado notablemente en los últimos tres a cuatro años, y resulte ahora más sencillo diseñar esquemas terapéuticos y conseguir mayores tasas de éxito. Todos estos cambios se actualizan en esta revisión. (AU)

Drug-resistant tuberculosis, especially those with resistance to rifampicin (RR-TB), has become one of the main obstacles to achieving the dream of eradicating tuberculosis. Furthermore, it is necessary to combine three or four different drugs in the attempt to cure TB, however, unfortunately, there are few available that can be considered genuinely effective. Fortunately, the notable worldwide increase in RR-TB in recent years has led to the investment of resources in the development of new drugs for TB, and other drugs investigated for other diseases have been successfully tested on TB. This has resulted in a clear change in the clinical management of these patients over the last 3-4 years, and it is now easier to design therapeutic regimens and achieve higher success rates. All these changes are updated in this review. (AU)

Multi-drug resistant tuberculosis, ten years later. / Tuberculosis multirresistentediez años después.

Drug-resistant tuberculosis, especially those with resistance to rifampicin (RR-TB), has become one of the main obstacles to achieving the dream of eradicating tuberculosis. Furthermore, it is necessary to combine three or four different drugs in the attempt to cure TB, however, unfortunately, there are few available that can be considered genuinely effective. Fortunately, the notable worldwide increase in RR-TB in recent years has led to the investment of resources in the development of new drugs for TB, and other drugs investigated for other diseases have been successfully tested on TB. This has resulted in a clear change in the clinical management of these patients over the last 3-4 years, and it is now easier to design therapeutic regimens and achieve higher success rates. All these changes are updated in this review.

Challenges in understanding host genetics and severity of community-acquired pneumonia.

This study found no association of the top two associated FER variants with severity of community-acquired pneumonia. Precise characterisation of phenotypes may be required in order to unravel the genetic mechanisms predisposing to poor outcome in sepsis. https://bit.ly/3jc9SmR.

Should MASP-2 Deficiency Be Considered a Primary Immunodeficiency? Relevance of the Lectin Pathway.

Mannose-binding lectin (MBL)-associated serine protease-2 (MASP-2) is an indispensable enzyme for the activation of the lectin pathway of complement. Its deficiency is classified as a primary immunodeficiency associated to pyogenic bacterial infections, inflammatory lung disease, and autoimmunity. In Europeans, MASP-2 deficiency, due to homozygosity for c.359A > G (p.D120G), occurs in 7 to 14/10,000 individuals. We analyzed the presence of the p.D120G mutation in adults (increasing the sample size of our previous studies) and children. Different groups of patients (1495 adults hospitalized with community-acquired pneumonia, 186 adults with systemic lupus erythematosus, 103 pediatric patients with invasive pneumococcal disease) and control individuals (1119 healthy adult volunteers, 520 adult patients without history of relevant infectious diseases, and a pediatric control group of 311 individuals) were studied. Besides our previously reported MASP-2-deficient healthy adults, we found a new p.D120G homozygous individual from the pediatric control group. We also reviewed p.D120G homozygous individuals reported so far: a total of eleven patients with a highly heterogeneous range of disorders and nine healthy controls (including our four MASP-2-deficient individuals) have been identified by chance in association studies. Individuals with complete deficiencies of several pattern recognition molecules of the lectin pathway (MBL, collectin-10 and collectin-11, and ficolin-3) as well as of MASP-1 and MASP-3 have also been reviewed. Cumulative evidence suggests that MASP-2, and even other components of the LP, are largely redundant in human defenses and that individuals with MASP-2 deficiency do not seem to be particularly prone to infectious or autoimmune diseases.

Aprendizaje autorregulado: una estrategia para 'enseñar a aprender' en ciencias de la salud / Self-regulated learning: a strategy to 'teach to learn' in health sciences

La formación de profesionales sanitarios conlleva unos objetivos de aprendizaje concretos que deben traducirse en unos resultados de aprendizaje observables y evaluables y, por lo tanto, que el conocimiento se alcance con un alto grado de pericia. Con el fin de mejorar el aprendizaje de habilidades clínicas se han desarrollado instrumentos para evaluar el aprendizaje autorregulado, un proceso activo en el que la persona selecciona las metas académicas que desea alcanzar y regula una serie de variables que intervienen en el aprendizaje con el objetivo de alcanzarlas. Un ejemplo de ello es la evaluación microanalítica del aprendizaje autorregulado, una entrevista estructurada que intenta captar los pensamientos, sentimientos y acciones dedicados a la ejecución de tareas específicas. La investigación actual en este campo ha demostrado que los estudiantes de alto rendimiento tienden en general a mostrar un pensamiento más estratégico y una mejor regulación al realizar las actividades o tareas. Se pretende establecer el microanálisis como estrategia para identificar el aprendizaje de los alumnos y como meta para poder generalizarse en la educación en ciencias de la salud

The training of healthcare professionals obeys to specific learning objectives that must result in observable and assessable learning achievements, and in mastered knowledge acquisition. In order to improve the learning process of clinical skills, several methods have been developed with the aim of assessing self-regulated learning. Self-regulated learning is an active process where individuals select the academic goals they wish to achieve and, for that purpose, they regulate a set of factors that influence their learning. Self-Regulated Learning Microanalytic Assessment and Training may be taken as an example. This method consists of a structured interview that tries to capture the thoughts, feelings and actions devoted to the execution of specific tasks. Current investigations in this field have shown that high-achievers tend to think more strategically and regulate themselves better when performing activities or tasks. Finally, the microanalysis may be implemented as the strategy used to identify how students learn, and to generalize in healthcare education

Lethal Influenza in Two Related Adults with Inherited GATA2 Deficiency.

The pathogenesis of life-threatening influenza A virus (IAV) disease remains elusive, as infection is benign in most individuals. We studied two relatives who died from influenza. We Sanger sequenced GATA2 and evaluated the mutation by gene transfer, measured serum cytokine levels, and analyzed circulating T- and B-cells. Both patients (father and son, P1 and P2) died in 2011 of H1N1pdm IAV infection at the ages of 54 and 31 years, respectively. They had not suffered from severe or moderately severe infections in the last 17 (P1) and 15 years (P2). A daughter of P1 had died at 20 years from infectious complications. Low B-cell, NK- cell, and monocyte numbers and myelodysplastic syndrome led to sequence GATA2. Patients were heterozygous for a novel, hypomorphic, R396L mutation leading to haplo-insufficiency. B- and T-cell rearrangement in peripheral blood from P1 during the influenza episode showed expansion of one major clone. No T-cell receptor excision circles were detected in P1 and P3 since they were 35 and 18 years, respectively. Both patients presented an exuberant, interferon (IFN)-γ-mediated hypercytokinemia during H1N1pdm infection. No data about patients with viremia was available. Two previously reported adult GATA2-deficient patients died from severe H1N1 IAV infection; GATA2 deficiency may predispose to life-threatening influenza in adulthood. However, a role of other genetic variants involved in immune responses cannot be ruled out. Patients with GATA2 deficiency can reach young adulthood without severe infections, including influenza, despite long-lasting complete B-cell and natural killer (NK) cell deficiency, as well as profoundly diminished T-cell thymic output.

El hospital universitario: criterios para su acreditación / The university hospital: Criteria for its accreditation

No disponible

Razonamiento clínico / Clinical reasoning

Todas las actuaciones médicas tienen una curva de aprendizaje, pero el razonamiento clínico se mantiene como un elemento clave en cualquiera de ellas. Los médicos experimentados manejan una gran cantidad de información en cualquier proceso clínico. Para conseguir la máxima eficiencia en la utilización de esta información, los clínicos emplean una serie de estrategias que les permiten combinar datos y sintetizarlos en un número reducido de hipótesis diagnósticas, evaluar los riesgos y los beneficios de realizar nuevos procedimientos diagnósticos y aplicar determinados tratamientos, y formular planes en el manejo del paciente. Uno de los objetivos principales de cualquier docente médico es promover el desarrollo de una forma de razonar experta en sus estudiantes. Sin embargo, enseñar estas habilidades cognitivas no es tarea sencilla porque no existe una teoría completa y ampliamente aceptada acerca de los procesos de razonamiento clínico, e incluso los médicos más experimentados a menudo no son conscientes de los métodos de razonamiento que utilizan para alcanzar un diagnóstico. Desde hace más de cuarenta años se ha investigado en este campo. En este artículo se revisan las bases científicas y las teorías propuestas a lo largo de este período acerca del modo de razonar de los clínicos. También se analiza la evolución de las estructuras del conocimiento y se examinan algunos errores frecuentes en razonamiento diagnóstico. Por último, se proponen algunas recomendaciones prácticas específicas para ayudar a los principiantes a fortalecer sus habilidades de razonamiento diagnóstico (AU)

There is a learning curve in almost everything doctors do, but judgment remains a key determinant of the value of any clinical intervention. Expert physicians manage huge amounts of information to ensure the quality of patient care by using a set of efficient reasoning strategies. These strategies allow them to combine and synthesize data into a few diagnostic hypotheses, assess benefits and risks of additional diagnostic procedures and treatments, and articulate plans for patient management. A major goal of the medical educators is to foster the development of expert clinical reasoning in apprentices. However, teaching these cognitive skills is a difficult task because there is no generally accepted inclusive theory of the clinical reasoning process and even the most seasoned clinicians are often unaware of the reasoning methods that lead them to achieve accurate diagnoses. Research in this field has been carried out for over 40 years. In this paper we review the scientific background and theories proposed throughout this time about how clinicians reason. We also analyze the evolution of knowledge structures and examine some common errors in diagnostic reasoning. Finally, we provide several practical and specific recommendations to help learners strengthen their diagnostic reasoning skills (AU)

Proyecto ULPGC-UniZambeze. Formación médica universitaria en países en desarrollo / ULPGC-UniZambeze project. Undergraduate medical education in developing countries

Todos los países, cualquiera que sea su grado de desarrollo, se esfuerzan por proporcionar unos cuidados sanitarios adecuados a sus ciudadanos. Gozar de buena salud es una condición básica para el desarrollo y la seguridad de las personas, a pesar de lo cual persisten enormes desigualdades en salud entre los países. Los educadores médicos tienen un papel clave en la reducción de estas desigualdades al abordar uno de los aspectos esenciales del problema: la acusada escasez de médicos que sufren algunas regiones, especialmente en el África subsahariana. Una de las mayores dificultades para afrontar esta cuestión es la falta de profesores cualificados, lo que podría solventarse mediante estancias cortas de graduados procedentes de países desarrollados que voluntariamente quisieran participar en este tipo de iniciativas. Pero el mundo de la educación médica tampoco es un terreno justo, equilibrado y equitativo, y trabajar en países pobres y alejados supone un reto importante. En este artículo, presentamos la experiencia en el diseño y desarrollo de un proyecto de formación de médicos en la Universidad de Zambeze, en Tete (Mozambique), llevada a cabo desde la Universidad de Las Palmas de Gran Canaria (AU)

Every nation-ich or poor and developed or developing-strives hard to deliver optimal healthcare to its citizens. Good health is the necessary condition for development and human security, but inequities in health persist. Medical educators have a key role to play in reducing inequities in global health by addressing the underlying doctor shortages that have reached crisis levels in some regions. The region in which these health inequities and doctor deficiencies are starkest is sub-Saharan Africa. In poor countries, a major constraint to approach this issue is the scarcity of qualified teachers. One of the options is the short-term placement of graduates from rich countries seeking opportunities to contribute in other countries that are severely deficient in faculty. But the world of medical education is not a level playing field and working in developing countries, and in remote areas in particular, can be challenging. In this article we show a recent experience carried out at the University of Las Palmas de Gran Canaria designing and supporting a project on undergraduate medical education at the University of Zambeze, in Tete, Mozambique (AU)

Saharan dust and the impact on adult and elderly allergic patients: the effect of threshold values in the northern sector of Gran Canaria, Spain.

Gran Canaria Island is frequently impacted by Saharan dust, a health hazard of particular concern to the island population and health agencies. Airborne mineral dust has the severest impact on the higher age groups of the population, and those with respiratory conditions; despite that, on average, the ambient particulate matter (PM) concentrations fall within international PM guidelines. During 2010 and 2011, an epidemiological survey, in parallel with an air quality study, was conducted at the Dr Negrín hospital in Gran Canaria. This included the quarterly monitoring of outpatients and recording of emergency patients with respiratory diseases, together with the measurement of aerosol, meteorological, and PM-related air quality levels. The finer more toxic particles were collected with PM2.5 (particulate matter with aerodynamic diameter less than 2.5 µm) aerosol samplers. The filter samples were gravimetrically and chemically analyzed for their elemental, water-soluble ions, carbon, and mineralogical contents. Individual particle morphology was measured by Scanning Electron Microscopy. Statistical analysis of the chemical and clinical data included the analysis of variance and calculation of Spearman correlation coefficients. No statistically significant relations were found between the allergic control group, the emergency room admissions, pulmonary conditions, medication, and elevated Saharan dust levels. However, changing environmental conditions, such as an increase in humidity or a reduction in ambient air temperature made a significant difference to the outcomes recorded on the health statements of the allergic and respiratory illness groups of the Gran Canary population.