Lung ultrasound and procalcitonin, improving antibiotic management and avoiding radiation exposure in pediatric critical patients with bacterial pneumonia: a randomized clinical trial.

BACKGROUND: Pneumonia is a major public health problem with an impact on morbidity and mortality. Its management still represents a challenge. The aim was to determine whether a new diagnostic algorithm combining lung ultrasound (LUS) and procalcitonin (PCT) improved pneumonia management regarding antibiotic use, radiation exposure, and associated costs, in critically ill pediatric patients with suspected bacterial pneumonia (BP). METHODS: Randomized, blinded, comparative effectiveness clinical trial. Children < 18y with suspected BP admitted to the PICU from September 2017 to December 2019, were included. PCT was determined at admission. Patients were randomized into the experimental group (EG) and control group (CG) if LUS or chest X-ray (CXR) were done as the first image test, respectively. Patients were classified: 1.LUS/CXR not suggestive of BP and PCT < 1 ng/mL, no antibiotics were recommended; 2.LUS/CXR suggestive of BP, regardless of the PCT value, antibiotics were recommended; 3.LUS/CXR not suggestive of BP and PCT > 1 ng/mL, antibiotics were recommended. RESULTS: 194 children were enrolled, 113 (58.2%) females, median age of 134 (IQR 39-554) days. 96 randomized into EG and 98 into CG. 1. In 75/194 patients the image test was not suggestive of BP with PCT < 1 ng/ml; 29/52 in the EG and 11/23 in the CG did not receive antibiotics. 2. In 101 patients, the image was suggestive of BP; 34/34 in the EG and 57/67 in the CG received antibiotics. Statistically significant differences between groups were observed when PCT resulted < 1 ng/ml (p = 0.01). 3. In 18 patients the image test was not suggestive of BP but PCT resulted > 1 ng/ml, all of them received antibiotics. A total of 0.035 mSv radiation/patient was eluded. A reduction of 77% CXR/patient was observed. LUS did not significantly increase costs. CONCLUSIONS: Combination of LUS and PCT showed no risk of mistreating BP, avoided radiation and did not increase costs. The algorithm could be a reliable tool for improving pneumonia management. CLINICAL TRIAL REGISTRATION: NCT04217980.

Inflammatory profiles in women with eating disorder: Linking inflammatory biomarkers to clinical phenotypes.

INTRODUCTION: Eating disorders (ED) represent a group of very complex and serious diagnoses characterized by emotional dysregulation and impulsivity. New approaches are necessary to achieve effective diagnosis and treatments. Shifting biomarker research away from the constraints of diagnostic categories may effectively contribute to a dimensional differentiation across disorders according to neurobiology (e.g., inflammatory biomarkers). Thus, the aim of our study was to identify inflammatory profiles in patients with ED. METHODS: A sample of 100 women with an ED (23.4 ± 8.55 years) and 59 healthy controls (HC) (20.22 ± 4.18 years) was used. K-means cluster analysis was followed to identify inflammatory clusters considering seven blood biomarkers (iNOS, TNFα, COX2, p38, ERK, TBARS and PPARγ). Moreover, a wide assessment of clinical features was conducted. RESULTS: Two distinct clusters were identified. Cluster 1 patients were characterized by higher inflammatory levels of TNF-α, COX2, p38, and ERK, and had more restrictive anorexia diagnosis than cluster 2. Cluster 2 participants showed higher inflammatory levels of iNOS and were older than cluster 1 and controls and had lower BMI than HC. In addition, they had higher levels of bulimic symptoms than those from the cluster 1 and HC, and higher impulsivity than HC. All ED patients (regardless of cluster) showed higher ED symptoms and more trauma than HC. CONCLUSIONS: Our study revealed that inflammatory dysfunction may be linked with clinical endophenotypes in ED, one more restrictive (cluster 1) with an inflammation/oxidative endophenotype more cytokine and MAPK/ERK mediated, and the other more impulsive, with more bulimic symptoms (cluster 2) with NO free radical high output source iNOS. Trauma seems to be a vulnerability factor for both endophenotypes.

Comparison of Direct Oral Anticoagulants vs Vitamin K Antagonists After Transcatheter Mitral Valve Replacement.

BACKGROUND: There is currently no established recommendation for antithrombotic treatment following transcatheter mitral valve replacement (TMVR). However, based on the analogy with surgical mitral bioprosthesis, vitamin K antagonists (VKAs) are predominantly used. OBJECTIVES: The purpose of this study was to compare bleeding and thrombotic events associated with direct oral anticoagulants (DOACs) or VKAs in a prospective cohort of TMVR patients. METHODS: We enrolled consecutive patients who underwent transseptal TMVR using a SAPIEN family prosthesis at our center between 2011 and 2023. The primary outcome was the occurrence of bleeding. VKAs were administered to patients until October 2019, after which DOACs were prescribed. The median follow-up was 4.7 months (Q1-Q3: 2.6-6.7 months). RESULTS: A total of 156 patients were included. The mean age was 65 ± 18.5 years, and 103 patients (66%) were women. The median EuroSCORE II was 7.48% (Q1-Q3: 3.80%-12.97%). Of the participants, 20.5% received DOACs and 79.5% were treated with VKAs. The primary outcome was observed in 50 (40%) patients in the VKA group and 3 (9%) patients in the DOAC group (adjusted HR: 0.21; 95% CI: 0.06-0.74; P = 0.02). Treatment with DOAC was associated with a shorter length of hospital stay. No significant differences were found in terms of thrombotic events, major vascular complications, stroke, or death. CONCLUSIONS: The use of DOACs after TMVR, compared with VKAs, appears to reduce the risk of bleeding complications and decrease the length of hospital stay for patients, without a significant increase in the risk of thrombotic events.

Neurocognitive profile associated with borderline personality disorder: building specific indices of executive function.

The objective of this work is the creation of specific indices of the different executive functions (EF).

Perfil neurocognitivo asociado al trastorno límite de personalidad: creación de índices específicos de función ejecutiva / Neurocognitive profile associated with borderline personality disorder: building specific indices of executive function

Introducción. El objetivo de este trabajo es la creación de índices específicos de las distintas funciones ejecutivas (FE), que permitan comprender de forma más completa y no mediante pruebas aisladas el rendimiento ejecutivo asociado al trastorno límite de la personalidad (TLP). Metodología. 118 pacientes con TLP y 81 controles fueron evaluados con una batería neuropsicológica. Se crearon tres índices de atención, memoria y FE. Las pruebas que forman el índice ejecutivo se agruparon en cuatro índices ejecutivos diferentes: flexibilidad cognitiva, planificación, memoria de trabajo e inhibición de respuesta. Las puntuaciones para cada dominio se obtuvieron a través de las puntuaciones estandarizadas de las pruebas que los componían. Resultados. Los resultados mostraron diferencias significativas en los índices de memoria, atención y FE, así como en los diferentes índices ejecutivos de flexibilidad cognitiva, planificación, memoria de trabajo e inhibición de respuesta, entre los pacientes con TLP y los controles. Conclusiones. Este estudio ha permitido la creación de cuatro índices ejecutivos, siendo el primero hasta la fecha en hacerlo. Estos resultados establecen un perfil neurocognitivo del TLP caracterizado por un deterioro ejecutivo específico de la flexibilidad cognitiva, la planificación, la memoria de trabajo y la inhibición de la respuesta. Estos hallazgos avalan que los pacientes con TLP podrían beneficiarse de la aplicación de programas neuropsicológicos, especialmente enfocados en mejorar determinadas FE, y sientan las bases para la investigación de la relación entre estos déficits ejecutivos específicos y ciertas características clínicas del TLP, como diferentes tipos de comportamiento impulsivo y diferentes errores de mentalización. (AU)

Introduction. The objective of this work is the creation of specific indices of the different executive functions (EF), which allow a more complete understanding of the executive performance associated with borderline personality disorder (BPD) and not through isolated tests. Methodology. 118 patients with BPD and 81 controls were evaluated with a neuropsychological battery. Three indices of attention, memory and FE were created. The tests that make up the executive domain were grouped into four different executive indices: cognitive flexibility, planning, working memory, and response inhibition. The batteries for each domain were compared through the standardized batteries of the tests that comprised them. Results. The results showed differences in the memory, attention, and EF indices, as well as in the different executive indices of cognitive flexibility, planning, working memory, and response inhibition, between BPD patients and controls. Conclusions. This study has allowed the creation of four executive indexes, being the first to do so. These results established a neurocognitive profile of BPD characterized by executive-specific impairment of cognitive flexibility, planning, working memory, and response inhibition. These findings support that patients with BPD will benefit from the application of neuropsychological programs, especially focused on improving a certain EF, and lay the foundations for the investigation of the relationship between these specific executive deficits and certain clinical characteristics of BPD, such as different types of Impulsive behavior and different mentalization errors. (AU)

Oxidative stress and inflammatory pathways in female eating disorders and borderline personality disorders with emotional dysregulation as linking factors with impulsivity and trauma.

BACKGROUND: Borderline personality disorder (BPD) and eating disorders (ED) are both disorders with emotional dysregulation that may share some similar biological underpinnings, leading to oxidative/inflammatory alterations. Unfortunately, to date, no studies have assessed the relationship between clinical features, inflammatory alterations and childhood trauma across these disorders. Our aim was to identify the potential common and disorder-specific inflammatory pathways and examine possible associations between these dysregulated pathways and the clinical features. METHODS: We studied a sample of 108 women (m = 27.17 years; sd = 7.64), divided into four groups: 23 patients with a restrictive ED (ED-R), 23 patients with a bingeeating/ purging ED (ED-P) and 26 patients with BPD; whereas the control group included 23 healthy subjects. Several inflammatory/oxidative parameters: tumor necrosis factor alpha (TNFα), Thiobarbituric Acid Reactive Substances (TBARS), inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX2), p38 mitogenactivated protein kinases, ERK mitogen-activated protein kinases and c-Jun NH2- terminal kinase (JNK), and some antiinflammatory antioxidant elements: glutathione peroxidase (GPx), superoxide dismutase (SOD), catalase (CAT), Kelch-like ECHassociated protein (Keap1) were determined in plasma or peripheral blood mononuclear cells. Furthermore, clinical, impulsivity, trauma and eating behavior questionnaires were administered. RESULTS: Three main inflammatory/oxidative components were extracted using principal component analysis (59.19 % of biomarker variance explained). Disorder-specific dysfunction in the inflammatory and oxidative pathways in patients with BPD and ED were revealed by means of relationships with specific principal components (p < .01). BPD patients showed higher levels of a component featured by elevated levels of JNK and lower of GPx and SOD. ED-R and impulsivity were associated with a component featured by the activation of ERK and negative influence of Keap1. The component featured by the suppression of catalase and COX2 was associated with both ED subtypes and trauma exposure. CONCLUSION: Several risk factors such as trauma, impulsivity and eating disorder symptoms were transdiagnostically associated with some inflammatory alterations regardless of diagnosis. These findings suggest that the clinical profile comprising trauma exposure and an emotional dysregulation disorder might constitute a specific endophenotype highly linked with inflammatory alterations.

Telocytes/CD34+ Stromal Cells in the Normal, Hyperplastic, and Adenomatous Human Parathyroid Glands.

Telocytes/CD34+ stromal cells (TCs/CD34+ SCs) have been studied in numerous organs and tissues, but their presence and characteristics in the parathyroid glands have not been explored. Using immunological and ultrastructural procedures, we assess the location, arrangement, and behavior of TCs/CD34+ SCs in normal human parathyroids, during their development and in their most frequent pathologic conditions. In normal parathyroids, TCs/CD34+ SCs show a small somatic body and long thin processes with a moniliform aspect, form labyrinthine systems, connect other neighboring TCs/CD34+ SCs, vessels, adipocytes, and parenchymal cells directly or by extracellular vesicles, and associate with collagen I. TCs/CD34+ SCs and collagen I are absent around vessels and adipocytes within parenchymal clusters. In developing parathyroids, TCs/CD34+ SC surround small parenchymal nests and adipocytes. In hyperplastic parathyroids, TCs/CD34+ SCs are prominent in some thickened internodular septa and surround small extraglandular parenchymal cell nests. TCs/CD34+ SCs are present in delimiting regions with compressed parathyroids and their capsule in adenomas but absent in most adenomatous tissue. In conclusion, TCs/CD34+ SCs are an important cellular component in the human parathyroid stroma, except around vessels within parenchymal nests. They show typical characteristics, including those of connecting cells, are present in developing parathyroids, and participate in the most frequent parathyroid pathology, including hyperplastic and adenomatous parathyroids.

Delimiting CD34+ Stromal Cells/Telocytes Are Resident Mesenchymal Cells That Participate in Neovessel Formation in Skin Kaposi Sarcoma.

Kaposi sarcoma (KS) is an angioproliferative lesion in which two main KS cell sources are currently sustained: endothelial cells (ECs) and mesenchymal/stromal cells. Our objective is to establish the tissue location, characteristics and transdifferentiation steps to the KS cells of the latter. For this purpose, we studied specimens of 49 cases of cutaneous KS using immunochemistry and confocal and electron microscopy. The results showed that delimiting CD34+ stromal cells/Telocytes (CD34+SCs/TCs) in the external layer of the pre-existing blood vessels and around skin appendages form small convergent lumens, express markers for ECs of blood and lymphatic vessels, share ultrastructural characteristics with ECs and participate in the origin of two main types of neovessels, the evolution of which gives rise to lymphangiomatous or spindle-cell patterns-the substrate of the main KS histopathological variants. Intraluminal folds and pillars (papillae) are formed in the neovessels, which suggests they increase by vessel splitting (intussusceptive angiogenesis and intussusceptive lymphangiogenesis). In conclusion, delimiting CD34+SCs/TCs are mesenchymal/stromal cells that can transdifferentiate into KS ECs, participating in the formation of two types of neovessels. The subsequent growth of the latter involves intussusceptive mechanisms, originating several KS variants. These findings are of histogenic, clinical and therapeutic interest.

Intussusceptive angiogenesis facilitated by microthrombosis has an important example in angiolipoma. An ultrastructural and immunohistochemical study.

The microvasculature of angiolipoma frequently presents thrombi. Our objectives are to assess whether intussusceptive angiogenesis (IA) participates in vasculature formation in non-infiltrating angiolipoma and, if so, to explore how thrombi are involved in the IA process. For this purpose, we studied angiolipoma specimens (n: 52), using immunohistochemistry, and confocal and electron microscopy. The results showed the presence of folds and pillars, hallmarks of IA, dividing the vessel lumen. Folds showed a cover formed by reoriented endothelial cells from the vessel wall, or from newly formed folds, and a core initially formed by thrombus fragments (clot components as transitional core), which was replaced by extracellular matrix and invaginating pericytes establishing numerous peg-and-socket junctions with endothelial cells (mature core). A condensed plasmatic electron-dense material surrounded and connected folds and pillars with each other and with the vascular wall, which suggests a clot role in fold/pillar arrangement. In conclusion, we contribute to IA participation in capillary network formation in angiolipoma and the immunohistochemical and ultrastructural events by which microthrombosis facilitates IA. Therefore, in addition to the histogenesis of angiolipoma, we provide an easily obtainable substrate for future studies on clot component action in IA, of clinical and therapeutic interest.

Executive dysfunction in eating disorders: Relationship with clinical features.

Eating disorders (ED) are severe mental disorders that may result in significant functional impairment and disability. Neuropsychological studies have consistently found impaired executive function (EF) among ED patients. EF is particularly involved in fundamental skills of daily living and in behavioral and emotional regulation. In this study, impairment of executive functioning is investigated in patients with eating disorders and the associations with clinical features and clinical subtypes are analyzed. METHOD: 75 female patients (m = 22.01 years, sd = 9.15) with eating disorder (43 restrictive anorexia, 30 binge-eating anorexia and 13 bulimia nervosa) and 37 healthy controls (m = 18.54 years, sd = 4.21) were included in the study. An extensive assessment of executive function domains (verbal fluency, set shifting, attention span, selective attention, working memory, inhibitory control and processing speed) was carried out in both groups. Clinical scales for food intake restriction, binge-eating/purging, depression, anxiety and impulsivity were also administered and correlated with scores on executive function tests. RESULTS: Patients with an ED had significantly lower scores than healthy controls in performance of several executive function tests, particularly in set shifting, interference control and processing speed (p < .01, in all three domains). Executive function impairment was related to anxious, depressive and eating disorder symptoms (p < .05), regardless of clinical subtype. CONCLUSIONS: Executive function impairment in eating disorders is associated with greater ED symptomatic severity and might involve a negative treatment outcome. Therefore, cognitive remediation techniques should probably be considered in a number of severe patients with ED.

Predictive value of the feeling of emptiness in suicidal behaviour of emotionally unstable disorders.

PURPOSE: This study investigates the feeling of emptiness in patients with borderline personality disorder (BPD) and patients with eating disorder (ED) and its relationship with suicidal behaviour and childhood traumatic events. METHODOLOGY: One hundred three BPD patients and 107 ED patients were assessed with the Feeling of Emptiness Scale (FES) and the Traumatic Experiences Questionnaire (TQ). Suicidal behaviour was assessed with a specific interview for frequency and intensity of suicidal behaviour. RESULTS: Significant differences were found between the different factors of the FES between BPD patients and ED patients. A significant relationship was observed between Factors 1 and 4 of the FES and suicidal behaviour scores in both groups. Traumatic experiences were more strongly related to Factors 1, 2 and 4 in BPD patients. CONCLUSIONS: BPD patients and ED patients show similar scores in the global construct of feeling of emptiness. However, results suggest some qualitatively difference between the nature of feeling of emptiness in BPD and in ED. As expected, suicidal behaviour is most frequently in BPD patients, and is significantly associated with Factors 1 and 4 of the FES in both groups. Therefore, feeling of emptiness could be a predictor of suicidal behaviours in patients with emotional and behavioural instability.

Comparison of the Behavior of Perivascular Cells (Pericytes and CD34+ Stromal Cell/Telocytes) in Sprouting and Intussusceptive Angiogenesis.

Perivascular cells in the pericytic microvasculature, pericytes and CD34+ stromal cells/telocytes (CD34+SCs/TCs), have an important role in angiogenesis. We compare the behavior of these cells depending on whether the growth of endothelial cells (ECs) from the pre-existing microvasculature is toward the interstitium with vascular bud and neovessel formation (sprouting angiogenesis) or toward the vascular lumen with intravascular pillar development and vessel division (intussusceptive angiogenesis). Detachment from the vascular wall, mobilization, proliferation, recruitment, and differentiation of pericytes and CD34+SCs/TCs, as well as associated changes in vessel permeability and functionality, and modifications of the extracellular matrix are more intense, longer lasting over time, and with a greater energy cost in sprouting angiogenesis than in intussusceptive angiogenesis, in which some of the aforementioned events do not occur or are compensated for by others (e.g., sparse EC and pericyte proliferation by cell elongation and thinning). The governing mechanisms involve cell-cell contacts (e.g., peg-and-socket junctions between pericytes and ECs), multiple autocrine and paracrine signaling molecules and pathways (e.g., vascular endothelial growth factor, platelet-derived growth factor, angiopoietins, transforming growth factor B, ephrins, semaphorins, and metalloproteinases), and other factors (e.g., hypoxia, vascular patency, and blood flow). Pericytes participate in vessel development, stabilization, maturation and regression in sprouting angiogenesis, and in interstitial tissue structure formation of the pillar core in intussusceptive angiogenesis. In sprouting angiogenesis, proliferating perivascular CD34+SCs/TCs are an important source of stromal cells during repair through granulation tissue formation and of cancer-associated fibroblasts (CAFs) in tumors. Conversely, CD34+SCs/TCs have less participation as precursor cells in intussusceptive angiogenesis. The dysfunction of these mechanisms is involved in several diseases, including neoplasms, with therapeutic implications.

Documento internacional de consenso sobre apnea obstructiva del sueño / International Consensus Document on Obstructive Sleep Apnea

El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura más actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedades científicas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedades internacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoamericano. El documento consta de un manuscrito principal, con las novedades más relevantes, y una serie de manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los apartados del documento internacional de consenso. Este documento no cubre la edad pediátrica ni el manejo del paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos de consenso aparte). Palabras clave: Apnea obstructiva del sueño Diagnóstico Tratamiento

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents). Keywords: Obstructive sleep apnea Diagnosis Treatment

International Consensus Document on Obstructive Sleep Apnea. / Documento internacional de consenso sobre apnea obstructiva del sueño.

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).

Ultrastructural Study of Platelet Behavior and Interrelationship in Sprouting and Intussusceptive Angiogenesis during Arterial Intimal Thickening Formation.

Platelets in atherosclerosis, bypass stenosis, and restenosis have been extensively assessed. However, a sequential ultrastructural study of platelets in angiogenesis during the early phases of these lesions has received less attention. Our objective was the study of platelets in angiogenesis and vessel regression during intimal thickening (IT) formation, a precursor process of these occlusive vascular diseases. For this purpose, we used an experimental model of rat occluded arteries and procedures for ultrastructural observation. The results show (a) the absence of platelet adhesion in the de-endothelialized occluded arterial segment isolated from the circulation, (b) that intraarterial myriad platelets contributed from neovessels originated by sprouting angiogenesis from the periarterial microvasculature, (c) the association of platelets with blood components (fibrin, neutrophils, macrophages, and eosinophils) and non-polarized endothelial cells (ECs) forming aggregates (spheroids) in the arterial lumen, (d) the establishment of peg-and-socket junctions between platelets and polarized Ecs during intussusceptive angiogenesis originated from the EC aggregates, with the initial formation of IT, and (e) the aggregation of platelets in regressing neovessels ('transitory paracrine organoid') and IT increases. In conclusion, in sprouting and intussusceptive angiogenesis and vessel regression during IT formation, we contribute sequential ultrastructural findings on platelet behavior and relationships, which can be the basis for further studies using other procedures.

Dificultades para la participación en actividades académicas de la Escuela Nacional de Salud Pública - Perú, 2018 - 2020

Introducción. Las tasas de abandono de cursos obstaculizan el logro de metas de capacitación del personal afectando el servicio que brindan a la población. Objetivo. Identificar las principales dificultades y obstáculos que los trabajadores de salud reportan para participar en las actividades académicas de ENSAP, 2018-2020, con fines de mejorar el alcance de su oferta académica. Métodos. Investigación transversal descriptiva de nivel nacional aplicando un cuestionario virtual anónimo tipo Likert de 44 preguntas, validado (α de Cronbach de 0,888). Resultados. Recibimos 3299 respuestas de personal con características generales similares y representativas del público objetivo y beneficiario de ENSAP. Las respuestas fueron de una muestra mayoritariamente femenina, con formación enfermería y/o técnico en enfermería, entre los 30 y 49 años de edad. 41% tuvo un trabajo adicional; dedica a la capacitación un máximo 5 horas/semana después de las 18:00 hs. La carga laboral (82%), carga familiar (51%), mala conexión a red (57%), la falta de reconocimiento o compensación por capacitación de los jefes (49%), olvidar haberse inscrito (47%) y olvidar la contraseña de acceso (41%) fueron los obstáculos más mencionados. Conclusiones. La formación continua a distancia ofrece una oportunidad para llegar al personal de salud nivel nacional. El alto número de inscritos en las actividades de ENSAP refleja una gran demanda e interés por capacitarse a distancia, pero es necesario plantear alternativas frente a los obstáculos que enfrentan para culminar la capacitación sin reforzar las desigualdades existentes.

Introduction. Dropout rates hinder the achievement of staff training goals, affecting the service they provide to the population. Objective. Identify the main difficulties and obstacles to participate in the academic activities of ENSAP, 2018-2020, that health workers report in order to improve the scope of its academic offer. Methods. Descriptive cross-sectional research at the national level applying an anonymous online Likert-type questionnaire with 44 questions, validated (Cronbach's α of 0.888). Results. We received 3299 responses from personnel with similar general characteristics and representative of the target audience and beneficiary of ENSAP. The answers come from a mostly female sample, with nursing and / or nursing technical training, between 30 and 49 years of age. 41% have an additional job; dedicates a maximum of 5 hours / week to training and after 6:00 p.m. Excessive workload (82%), family burden (51%), poor network connection (57%), lack of recognition or compensation for training hours (49%), forgetting registration (47%) and forgetting platform´s password (41%) were the most mentioned obstacles. Conclusions. Continuous training through online modalities offers a great opportunity to reach more people at the national level. The high number of people enrolled in ENSAP activities reflects a great demand and interest in distance training, but it is necessary to propose alternatives to the obstacles they face to complete training without reinforcing existing inequalities.

Impact of Mitral Annular Calcium and Mitral Stenosis on Outcomes After Transcatheter Aortic Valve Implantation.

Mitral annular calcium (MAC) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI) and may be associated with mitral stenosis (MAC-MS). Their impact on post-TAVI outcomes remains controversial. We sought to assess the impact of MAC and MAC-MS on clinical outcomes following TAVI. We included 1,177 patients who consecutively underwent TAVI in our institution between January 2008 and May 2018. MAC diagnosis reposed on echocardiogram and computed tomography. The combination of MAC and a mean transmitral gradient ≥ 5 mmHg defined MAC-MS. The study included 1,177 patients, of whom 504 (42.8%) had MAC and 85 (7.2%) had MAC-MS. Patients with and without MAC had similar outcomes except for a higher rate of pacemaker implantation in MAC patients (adjusted HR: 1.32, 95% CI: 1.03-1.69, p = 0.03). The subgroup of patients with severe MAC had similar outcomes. However, MAC-MS was an independent predictor of all-cause mortality at 30 days (adjusted HR: 2.30, 95% CI: 1.08-4.86, p = 0.03) and 1 year (adjusted HR: 1.73, 95% CI: 1.04-2.89, p = 0.04). In conclusion, MAC is present in nearly half of the patients treated with TAVI but MAC-MS is far less frequent. In itself, even severe, MAC does not influence outcomes while MAC-MS is an independent predictor of all-cause 1-year mortality. Measurement of mean transmitral gradient identifies patients with MAC at high risk after TAVI.

Causes and predictors of mortality after transcatheter mitral valve implantation in patients with severe mitral annulus calcification.

OBJECTIVES: To evaluate the causes and predictors of mortality after valve-in-mitral annulus calcification (MAC) transcatheter mitral valve implantation (TMVI). BACKGROUND: Conventional surgical mitral valve replacement is associated with a high risk in patients with mitral valve disease associated with severe MAC. In this population, TMVI may be an attractive alternative option. However, its prognostic factors are poorly understood. METHODS: All patients undergoing valve-in-MAC TMVI from 2013 to 2018 in our center were included. Indication for TMVI relied on the judgment of the local heart team. Patients were followed at 30 days and 1 year. RESULTS: A total of 34 patients underwent valve-in-MAC TMVI. The mean age was 79 ± 11 years and 73% of patients were women. Their mean EuroSCORE 2 was 8 ± 7%. The transseptal approach was used in 79% of patients and a hybrid transatrial in 29%. Balloon expandable transcatheter heart valves were used in all the patients. Technical success was achieved in 76% of the patients. Thirty-day and 1-year all-cause mortality rates were 14.7% and 32.4%, respectively. The main two causes of 1-year mortality were congestive heart failure (8.8%) and infective endocarditis (5.9%). In multivariate analysis, the only predictor of 1-year mortality was the presence of periprothetic mitral regurgitation grade 2 (HR, 5.69; 95%CI, 1.59-27.88, p = 0.032). CONCLUSION: Early and mid-term mortality remains high after valve-in-MAC TMVI and seems to be associated with the presence of paravalvular mitral regurgitation. However, whether the latter is a prognostic factor or marker remains to be determined to improve clinical outcomes in this high-risk population.

Cd34+ Stromal Cells/Telocytes in Normal and Pathological Skin.

We studied CD34+ stromal cells/telocytes (CD34+SCs/TCs) in pathologic skin, after briefly examining them in normal conditions. We confirm previous studies by other authors in the normal dermis regarding CD34+SC/TC characteristics and distribution around vessels, nerves and cutaneous annexes, highlighting their practical absence in the papillary dermis and presence in the bulge region of perifollicular groups of very small CD34+ stromal cells. In non-tumoral skin pathology, we studied examples of the principal histologic patterns in which CD34+SCs/TCs have (1) a fundamental pathophysiological role, including (a) fibrosing/sclerosing diseases, such as systemic sclerosis, with loss of CD34+SCs/TCs and presence of stromal cells co-expressing CD34 and αSMA, and (b) metabolic degenerative processes, including basophilic degeneration of collagen, with stromal cells/telocytes in close association with degenerative fibrils, and cutaneous myxoid cysts with spindle-shaped, stellate and bulky vacuolated CD34+ stromal cells, and (2) a secondary reactive role, encompassing dermatitis-e.g., interface (erythema multiforme), acantholytic (pemphigus, Hailey-Hailey disease), lichenoid (lichen planus), subepidermal vesicular (bullous pemphigoid), psoriasiform (psoriasis), granulomatous (granuloma annulare)-vasculitis (leukocytoclastic and lymphocytic vasculitis), folliculitis, perifolliculitis and inflammation of the sweat and sebaceous glands (perifolliculitis and rosacea) and infectious dermatitis (verruca vulgaris). In skin tumor and tumor-like conditions, we studied examples of those in which CD34+ stromal cells are (1) the neoplastic component (dermatofibrosarcoma protuberans, sclerotic fibroma and solitary fibrous tumor), (2) a neoplastic component with varying presentation (fibroepithelial polyp and superficial myxofibrosarcoma) and (3) a reactive component in other tumor/tumor-like cell lines, such as those deriving from vessel periendothelial cells (myopericytoma), epithelial cells (trichoepithelioma, nevus sebaceous of Jadassohn and seborrheic keratosis), Merkel cells (Merkel cell carcinoma), melanocytes (dermal melanocytic nevi) and Schwann cells (neurofibroma and granular cell tumor).