Optimizing Inpatient Care for Lung Cancer Patients with Immune Checkpoint Inhibitor- Related Pneumonitis Using a Clinical Care Pathway Algorithm.

Purpose: Immune checkpoint inhibitor-related pneumonitis (ICI-P) is a condition associated with high mortality, necessitating prompt recognition and treatment initiation. This study aimed to assess the impact of implementing a clinical care pathway algorithm on reducing the time to treatment for ICI-P. Methods: Patients with lung cancer and suspected ICI-P were enrolled, and a multi-modal intervention promoting algorithm use was implemented in two phases. Pre- and post-intervention analyses were conducted to evaluate the primary outcome of time from ICI-P diagnosis to treatment initiation. Results: Of the 82 patients admitted with suspected ICI-P, 73.17% were confirmed to have ICI-P, predominantly associated with non-small cell lung cancer (91.67%) and stage IV disease (95%). Pembrolizumab was the most commonly used immune checkpoint inhibitor (55%). The mean times to treatment were 2.37 days in the pre-intervention phase and, 3.07 days (p=0.46), and 1.27 days (p=0.40) in the post-intervention phases 1 and 2, respectively. Utilization of the immunotoxicity order set significantly increased from 0% to 27.27% (p = 0.04) after phase 2. While there were no significant changes in ICU admissions or inpatient mortality, outpatient pulmonology follow-ups increased statistically significantly, demonstrating enhanced continuity of care. The overall mortality for patients with ICI-P was 22%, underscoring the urgency of optimizing management strategies. Notably, all patients discharged on high-dose corticosteroids received appropriate gastrointestinal prophylaxis and prophylaxis against Pneumocystis jirovecii pneumonia infections at the end of phase 2. Conclusion: Implementing a clinical care pathway algorithm for ICI-P management standardizes care practices and enhances patient outcomes, underscoring the importance of structured approaches.

Quality improvement intervention to increase colorectal cancer screening at the primary care setting: a cluster-randomised controlled trial.

BACKGROUND: Approximately 81% of deaths in Argentina are from chronic non-communicable diseases and 21% caused by cancer. Colorectal cancer (CRC) is the second most frequent cancer in Argentina. Even though CRC screening has been recommended for adults from 50 to 75 years old by using a faecal immunochemical test (FIT) annually, screening rates remain below 20% in the country. METHODS: We conducted an 18-month, two-arm, pragmatic cluster-randomised controlled trial evaluating the effect of a quality improvement intervention, based on the Plan-Do-Study-Act cycles, considering barriers and catalysts to articulate theory and practice, to increase CRC screening rates using FITs at primary care level. The study involved ten public primary health centres in Mendoza province, Argentina. The primary outcome measure was the rate of effective CRC screening. Secondary outcomes were the rate of participants with a positive FIT, tests with invalid results and the rate of participants referred for colonoscopy. RESULTS: Screening was effective in 75% of the participants in the intervention arm vs 54.2% in the control arm, OR 2.5 (95% CI 1.4 to 4.4, p=0.001). These results remained unchanged after adjusting for individual demographic and socioeconomic characteristics. Regarding secondary outcomes, the overall prevalence of positive tests was 17.7% (21.1% in the control arm and 14.7% in the intervention arm, p=0.3648). The overall proportion of participants with inadequate test results was 5.2% (4.9% in the control arm vs 5.5% in the intervention arm, p=0.8516). All the participants with positive tests were referred for colonoscopy in both groups. CONCLUSIONS: An intervention based on quality improvement strategies proved to be highly successful in increasing effective CRC screening in Argentina's primary care setting within the public healthcare system. TRIAL REGISTRATION NUMBER: NCT04293315.

COVID-19 vaccination in patients with cancer receiving immune checkpoint inhibitors: a systematic review and meta-analysis.

BACKGROUND: Immune checkpoint inhibitors (ICI) can cause off-target inflammatory and immune-related adverse events (irAE). Conceivably, COVID-19 vaccination could trigger an inflammatory and immune response that could induce or aggravate irAE. METHODS: The objective of this systematic review is to appraise the efficacy and safety of COVID-19 vaccination in patients with cancer treated with ICI. The literature search was performed in PubMed and Embase in English from December 2019 to February 2022. The review included clinical trials, observational cohort studies, case series, and case reports reporting on the clinical efficacy and safety of COVID-19 vaccines on patients with cancer treated with ICI. Outcomes of interest included seroconversion, SARS-CoV-2 infection rate, severe COVID-19, COVID-19 mortality rate. Incidence of ICI irAEs was also ascertained as well as vaccine adverse events. A meta-analysis was conducted to estimate the pooled effect sizes of the outcomes when possible, using random effects models. RESULTS: Overall, 19 studies were included for the analysis (n=10 865 with 2477 receiving ICI). We analyzed 15 cohort studies, 1 cross-sectional study, and 3 case reports. There were no statistically significant differences in seroconversion rates after the second dose of the vaccine when comparing patients with cancer receiving ICI with patients without cancer (risk ratio, RR 0.97, 95% CI 0.92 to 1.03) or with patients with cancer without active treatment (RR 1.00, 95% CI 0.96 to 1.04). There was a higher probability of seroconversion in patients with cancer treated with ICI compared with patients with cancer treated with chemotherapy (RR 1.09, 95% CI 1.00 to 1.18). In a single study in patients receiving ICI, no differences were observed in risk of irAE between those receiving inactivated vaccine and those unvaccinated (pneumonitis RR 0.88, 95% CI 0.33 to 2.3; rash RR 1.03, 95% CI 0.66 to 1.62; arthralgia RR 0.94, 95% CI 0.51 to 1.75). There were no studies for other types of vaccines comparing vaccinated vs not vaccinated in patients treated with ICI. The most common vaccine-related adverse events were local pain or fatigue. Overall, the quality of evidence was rated as very low. CONCLUSION: COVID-19 vaccination appears to be effective and safe in patients with cancer receiving ICI.

Quality and content evaluation of websites with information about immune checkpoint inhibitors: An environmental scan.

BACKGROUND: Trustworthy educational information for patients is critical for increasing their knowledge base and preparing them for shared decision making with clinicians. As the internet has become an important source of health information for many patients, the purpose of this study was to assess the quality and content of websites with educational content about immune checkpoint inhibitors. METHODS: We performed an environmental scan of the currently available websites providing educational information for patients about immune checkpoint inhibitors. We used three search engines: Google, Bing, and Yahoo! (9/20/2021). Two independent investigators selected relevant uniform resource locators (URLs), appraised the quality of the websites, and collected their characteristics. We evaluated the accuracy, completeness, technical elements, design and aesthetics, readability, usability, and accessibility of the websites. The user experience was also evaluated. RESULTS: We identified 37 websites for analysis. In 10 websites (27%), it was not possible to know the source of the information provided. Thirty-three (89%) provided a definition with a simple explanation of cancer and treatment and 30 (81%) on complications of immune checkpoint inhibitors; only seven (19%) provided information about the balance between risks and benefits. Thirty-five (95%) provided a statement of purpose. Regarding the design, all 37 (100%) had appropriate visual aspects, typography, and grammar. Thirty-six (97%) were well organized. For most of the websites (n = 35, 95%) the content was easy to find. Only two websites had a readability score of 6, while the others had higher scores. Regarding the user experience, the overall quality of websites was rated as excellent in 16 (43%), good in 14 (38%), and fair in 7 (19%). CONCLUSIONS: Our findings reveal that websites with information about immune checkpoint inhibitors mostly have general information about cancer, the treatments, and adverse events. Few websites provide information about the balance between harms and benefits of treatment, costs, the source of the information, or the hierarchy of evidence. These findings identify the gap in the quality and content of websites for patients treated with immune checkpoint inhibitors and can help website creators and developers.

No es psoriasis todo lo que parece / Not all that seems is psoriasis

La pitiriasis rubra pilaris (PRP) es una enfermedad cutánea crónica caracterizada por pápulas foliculares, placas anaranjadas que dejan zonas de piel respetada e hiperqueratosis palmoplantar; su edad de presentación y su clínica son muy variables. Se trata de una enfermedad poco frecuente que puede ser mal diagnosticada de otras dermatosis con apariencia similar. Su tratamiento no está bien establecido y a veces puede resultar poco exitoso. Presentamos el caso de una niña de siete años con una clínica típica de PRP y realizamos una breve revisión de esta patología

Pityriasis rubra pilaris (PRP) is a chronic skin disease characterized by follicular papules, orange plaques that leave islands of non-affected skin, and palmoplantar hyperkeratosis, being its age and clinical presentation very variable. It is a rare disease that can be misdiagnosed with other dermatoses of similar appearance. Treatment is not well established and can be unsuccessful. We present the case of a 7-year-old girl with a typical PRP and expose a brief review of this pathology

Próxima escasez de enfermeras en España: el problema del que no se habla / The coming shortage of nurses in Spain: an unnoticed problema

OBJETIVO PRINCIPAL: Estimar la diferencia entre la oferta y la demanda de enfermeras en España en 2020, 2030, 2040 y 2050. METODOLOGÍA: Se han utilizado las proyecciones de población total, de población mayor de 65 años y de población entre 15 y 64 años para los años 2020, 2030, 2040 y 2050 facilitadas por Eurostat. Se ha estimado la oferta y la demanda de enfermeras extrapolando las ratios de 2016 a las cifras de población proyectadas para esos años. Resultados principales: se estima que en España la diferencia entre oferta y demanda de enfermeras podría ser de +21.024 (en 2020), +4.724 (en 2030), -23.155 (en 2040) y -39.510 (en 2050). Conclusión principal: Nuestras estimaciones sugieren que a partir de 2030 podría producirse escasez de profesionales de enfermería en España. Actualmente, pese a existir suficientes profesionales, dicha escasez se manifiesta de forma puntual en algunos puntos del país

OBJECTIVE: to estimate the gap between the supply and demand of nurses in Spain for 2020, 2030, 2040 and 2050. METHODS: we used the last population projections for total population and two age groups (ages 15 to 64, and older than 64) by Eurostat. Nurses supply and demand was estimated by extrapolating the 2016 nurses/population ratios for 2020, 2030, 2040 and 2050. RESULTS: we have estimated a gap of nurses of +21.024 (2020), +4.724 (2030), -23.155 (2040) and -39.510 (2050). CONCLUSIONS: These figures suggets that there may be a shortage of nurses in Spain from 2030. However, despite there are currently enough professionals, sometimes there is a shortage of nurses in certain areas in Spain

A prospective multicenter study assessing effectiveness and safety of secukinumab in a real-life setting in 158 patients.

BACKGROUND: Secukinumab is a first-in-class interleukin 17A monoclonal antibody that has demonstrated an excellent safety and efficacy profile in phase 3 studies. OBJECTIVE: To evaluate the effectiveness of secukinumab in daily clinical practice and to understand the clinical and epidemiologic characteristics of patients treated with secukinumab in clinical settings. METHODS: In this multicenter prospective observational study, we recruited adult patients with moderate-to-severe plaque psoriasis from 12 hospitals in Spain during January-December 2016. These patients were treated with secukinumab and prospectively followed at 12-week intervals for 52 weeks. RESULTS: In total, 158 patients were recruited to the study. A Psoriasis Area and Severity Index (PASI) score improvement ≥75% over baseline (PASI-75) was achieved by 57%, 83.5%, 89%, and 78.5% of patients at weeks 4, 12, 24, and 52, respectively. PASI-90 was achieved in 27.8%, 62%, 64.6%, and 63.2% of patients at weeks 4, 12, 24, and 52, respectively; PASI-75 and PASI-90 responders were significantly more common among patients with a body mass index <30 kg/cm2 and patients without previous biologic therapy failures. LIMITATIONS: Observational study. Time from onset of psoriasis was not evaluated. CONCLUSION: Secukinumab is a safe treatment with effectiveness rates similar to those found in its phase 3 studies. These rates endure up to a year from start of treatment.

Inequality as a Powerful Predictor of Infant and Maternal Mortality around the World.

BACKGROUND: Maternal and infant mortality are highly devastating, yet, in many cases, preventable events for a community. The human development of a country is a strong predictor of maternal and infant mortality, reflecting the importance of socioeconomic factors in determinants of health. Previous research has shown that the Human Development Index (HDI) predicts infant mortality rate (IMR) and the maternal mortality ratio (MMR). Inequality has also been shown to be associated with worse health in certain populations. The main purpose of the present study was to determine the correlation and predictive power of the Inequality Adjusted Human Development Index (IHDI) as a measure of inequality with the Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), Early Neonatal Mortality Rate (ENMR), Late Neonatal Mortality Rate (LNMR), and the Post Neonatal Mortality Rate (PNMR). METHODS AND FINDINGS: Data for the present study were downloaded from two sources: infant and maternal mortality data were downloaded from the Global Burden of Disease 2013 Cause of Death Database and the Human Development Index (HDI) and Inequality-Adjusted Human Development Index (IHDI) data were downloaded from the United Nations Development Program (UNDP). Pearson correlation coefficients were estimated, following logarithmic transformations to the data, to examine the relationship between HDI and IHDI with MMR, IMR, ENMR, LNMR, and PNMR. Steiger's Z test for the equality of two dependent correlations was utilized in order to determine whether the HDI or IHDI was more strongly associated with the outcome variables. Lastly, we constructed OLS regression models in order to determine the predictive power of the HDI and IHDI in terms of the MMR, IMR, ENMR, LNMR, and PNMR. Maternal and infant mortality were both strongly and negatively correlated with both HDI and IHDI; however, Steiger's Z test for the equality of two dependent correlations revealed that IHDI was more strongly correlated than HDI with MMR (Z = 4.897, p < 0.001), IMR (Z = 2.524, p = 0.012), ENMR (Z = 2.936, p = 0.003), LNMR (Z = 2.272, p = 0.023), and PNMR (Z = 2.277, p = 0.023). Furthermore, side-by-side OLS regression models revealed that, when IHDI was used as the predictor variable instead of HDI, the R2 value was 0.053 higher for MMR, 0.025 higher for IMR, 0.038 higher for ENMR, 0.029 higher for LNMR, and 0.026 higher for PNMR. CONCLUSIONS: Even when both the HDI and the IHDI correlate with the infant and maternal mortality rates, the IHDI is a better predictor for these two health indicators. Therefore, these results add more evidence that inequality is playing an important role in determining the health status of various populations in the world and more efforts should be put into programs to fight inequality.

Impact of a GRADE-based medical question answering system on physician behaviour: a randomised controlled trial.

Physicians are frequently faced with questions related to their patients' care that they cannot answer. A vast number of randomised trials have tested a wide variety of behaviour-changing strategies designed to improve practitioners' evidence utilisation, but systematic reviews have concluded that the effects are generally small and inconsistent. We conducted a randomised controlled trial to determine whether a question identification and solving system, using structured evidence summaries with recommendations, would change physician's behavior related to the care of their hospitalised patients. The trial was conducted at the secondary level, internal medicine ward. Relevant clinical questions were the units of randomisation; 14 clinicians participated in the study. The question identification and answering system was carried out using evidence summaries with recommendations based on the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach stressing influence on clinician behaviour (decision/recommendation concordance). During 131 morning reports, 553 questions were identified (4.2 questions per meeting). 398 were excluded because they were not about diagnostic or therapeutic interventions or because their answers could not have impact on clinician behaviour, and 31 were excluded because of lack of time to answer them, leaving 124 included questions. The proportion of clinical decisions concordant with the proposed recommendations was 79%in the intervention arm and 44% in the control arm: relative risk 1.8 (95% CI 1.3 to 2.4), number of evidence summaries needed to change a care decision for one question raised was 3 (95% CI 2 to 6). A question identification and answering system was feasible, effectively performed and significantly influenced clinician behaviour related to the care of hospitalised patients, which suggests that interventions facilitating accessibility and interpretability of the best available evidence at the point of care have the potential to significantly impact on the quality of healthcare.

[Ticagrelor in acute coronary syndrome. Explaining the inexplicable]. / Ticagrelor en el síndrome coronario agudo. Explicando lo inexplicable.

The PLATO study evaluated the efficacy of adding ticagrelor, instead of clopidogrel, to aspirin in patients with acute coronary syndrome, which showed surprisingly positive results making the drug acceptable to regulatory agencies and specialty societies worldwide. Notwithstanding the aforementioned success, contradictory information supplied by critical analysis was submitted by the sponsor. The controversial findings revealed several aspects that are difficult to explain, threatening the veracity of the study's conclusions. Mortality rate pattern, excessive benefit not comparable to prior studies, unexplained loss of follow-up development and inconsistency in findings in accordance with the country, the type of events arbitrator and monitoring committee are some of the most questionable issues. Dubious reaction to this trial is based on the fact that the information could not be found in published articles. This complex situation poses a challenge to the critical analysis of the text and raises questions as to how far the conflicts of financial interest influenced the development of the study, the communication of its results and probably, acceptance of the drug for commercial use.

Ticagrelor en el síndrome coronario agudo. Explicando lo inexplicable / [Ticagrelor in acute coronary syndrome. Explaining the inexplicable]

The PLATO study evaluated the efficacy of adding ticagrelor, instead of clopidogrel, to aspirin in patients with acute coronary syndrome, which showed surprisingly positive results making the drug acceptable to regulatory agencies and specialty societies worldwide. Notwithstanding the aforementioned success, contradictory information supplied by critical analysis was submitted by the sponsor. The controversial findings revealed several aspects that are difficult to explain, threatening the veracity of the study’s conclusions. Mortality rate pattern, excessive benefit not comparable to prior studies, unexplained loss of follow-up development and inconsistency in findings in accordance with the country, the type of events arbitrator and monitoring committee are some of the most questionable issues. Dubious reaction to this trial is based on the fact that the information could not be found in published articles. This complex situation poses a challenge to the critical analysis of the text and raises questions as to how far the conflicts of financial interest influenced the development of the study, the communication of its results and probably, acceptance of the drug for commercial use.

Ticagrelor en el síndrome coronario agudo. Explicando lo inexplicable. / [Ticagrelor in acute coronary syndrome. Explaining the inexplicable].

The PLATO study evaluated the efficacy of adding ticagrelor, instead of clopidogrel, to aspirin in patients with acute coronary syndrome, which showed surprisingly positive results making the drug acceptable to regulatory agencies and specialty societies worldwide. Notwithstanding the aforementioned success, contradictory information supplied by critical analysis was submitted by the sponsor. The controversial findings revealed several aspects that are difficult to explain, threatening the veracity of the studys conclusions. Mortality rate pattern, excessive benefit not comparable to prior studies, unexplained loss of follow-up development and inconsistency in findings in accordance with the country, the type of events arbitrator and monitoring committee are some of the most questionable issues. Dubious reaction to this trial is based on the fact that the information could not be found in published articles. This complex situation poses a challenge to the critical analysis of the text and raises questions as to how far the conflicts of financial interest influenced the development of the study, the communication of its results and probably, acceptance of the drug for commercial use.

Hiperqueratosis epidermolítica en forma de mosaico / Mosaic form of epidermolytic hyperkeratosis

Presentamos el caso de una niña de 6 años de edad con lesiones hiperqueratósicas distribuidas siguiendo las líneas de Blaschko en todo el hemicuerpo izquierdo. La biopsia cutánea demostró un patrón de hiperqueratosis epidermolítica. Se trató con acitretino a dosis de 0,5 mg/ kg/d con buena respuesta. Recordamos la importancia de este mosaicismo por la posibilidad de tener hijos afectados de eritrodermia ictiosiforme congénita ampollosa en la descendencia. (AU)

Acropigmentación reticulada de Dohi / Reticulate acropigmentation of Dohi

La acropigmentación reticulada de Dohi es un proceso discrómico consistente en la presencia de máculas hiper e hipopigmentadas con un patrón reticular, localizadas en el dorso de las manos y los pies, de aparición fundamentalmente en pacientes japoneses. Presentamos el caso de una joven de 20 años, de padre japonés y madre española, con lesiones cutáneas compatibles con una acropigmentación reticulada de Dohi. Este cuadro es de herencia autosómica dominante, aunque se han descrito casos de herencia recesiva y otros esporádicos como el nuestro. El diagnóstico diferencial debe hacerse con otros procesos con pigmentación reticulada como la acropigmentación reticulada de Kitamura y la enfermedad de Dowling-Degos (AU)

Enfermedad por arañazo de gato. Diagnóstico mediante reacción en cadena de la polimerasa (PCR) / Cat scratch disease. Molecular diagnosis by polimerase chain reaction (PCR)

La enfermedad por arañazo de gato es un proceso infeccioso provocado en la mayor parte de los casos por la bacteria Bartonella henselae. Se transmite mediante el arañazo de un animal, principalmente gatos jóvenes. El cuadro clínico que ocasiona con más frecuencia es una lesión de inoculación seguida de una adenitis reactiva de curso subagudo y autolimitado, por lo que no precisa tratamiento antibiótico. Tan sólo en un 1 por ciento de los casos la transmisión es indirecta mediante fomites (1) y sólo un 10 por ciento de los casos fistulizan en piel (2, 3). De forma clásica, el diagnóstico se ha realizado mediante la clínica y la histología; esta última, sin ser específica, es muy característica. Su cultivo es muy difícil, así como la tinción de Whartin-Starry, que también es muy específica, pero técnicamente difícil. Actualmente se dispone de serología y técnicas de reacción en cadena de la polimerasa (PCR) para su confirmación diagnóstica en los casos complicados. Describimos el caso de una mujer de 16 años que, sin antecedentes de contacto directo con ningún animal, desarrolló un cuadro de adenitis laterocervical y preesternal derecha de 9 meses de evolución con supuración y fistulización a la piel. Tras descartar otros procesos infecciosos, y a pesar de la negatividad de la serología para B. henselae, se llegó al diagnóstico de enfermedad por arañazo de gato tras la detección de la bacteria mediante PCR de la lesión cutánea (AU)

Eritema tóxico neonatal pustuloso / Pustular erythema toxicum neonatorum

Un neonato presentaba en el momento del nacimiento una erupción pustulosa generalizada que remitió espontáneamente en pocas horas. A lo largo de las 6 semanas siguientes presentó dos brotes similares que también remitieron espontáneamente. El cultivo aisló Staphylococcus hominis y un frotis de las pústulas mostró un predominio de eosinófilos, todo lo cual apoyó el diagnóstico de eritema tóxico neonatal (AU)