The importance of association of comorbidities on COVID-19 outcomes: a machine learning approach.

BACKGROUND: The individual influence of a variety of comorbidities on COVID-19 patient outcomes has already been analyzed in previous works in an isolated way. We aim to determine if different associations of diseases influence the outcomes of inpatients with COVID-19. METHODS: Retrospective cohort multicenter study based on clinical practice. Data were taken from the SEMI-COVID-19 Registry, which includes most consecutive patients with confirmed COVID-19 hospitalized and discharged in Spain. Two machine learning algorithms were applied in order to classify comorbidities and patients (Random Forest -RF algorithm, and Gaussian mixed model by clustering -GMM-). The primary endpoint was a composite of either, all-cause death or intensive care unit admission during the period of hospitalization. The sample was randomly divided into training and test sets to determine the most important comorbidities related to the primary endpoint, grow several clusters with these comorbidities based on discriminant analysis and GMM, and compare these clusters. RESULTS: A total of 16,455 inpatients (57.4% women and 42.6% men) were analyzed. According to the RF algorithm, the most important comorbidities were heart failure/atrial fibrillation (HF/AF), vascular diseases, and neurodegenerative diseases. There were six clusters: three included patients who met the primary endpoint (clusters 4, 5, and 6) and three included patients who did not (clusters 1, 2, and 3). Patients with HF/AF, vascular diseases, and neurodegenerative diseases were distributed among clusters 3, 4 and 5. Patients in cluster 5 also had kidney, liver, and acid peptic diseases as well as a chronic obstructive pulmonary disease; it was the cluster with the worst prognosis. CONCLUSION: The interplay of several comorbidities may affect the outcome and complications of inpatients with COVID-19.

The Use of Corticosteroids or Tocilizumab in COVID-19 Based on Inflammatory Markers.

BACKGROUND: The inflammatory cascade is the main cause of death in COVID-19 patients. Corticosteroids (CS) and tocilizumab (TCZ) are available to treat this escalation but which patients to administer it remains undefined. OBJECTIVE: We aimed to evaluate the efficacy of immunosuppressive/anti-inflammatory therapy in COVID-19, based on the degree of inflammation. DESIGN: A retrospective cohort study with data on patients collected and followed up from March 1st, 2020, to May 1st, 2021, from the nationwide Spanish SEMI-COVID-19 Registry. Patients under treatment with CS vs. those under CS plus TCZ were compared. Effectiveness was explored in 3 risk categories (low, intermediate, high) based on lymphocyte count, C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, and D-dimer values. PATIENTS: A total of 21,962 patients were included in the Registry by May 2021. Of these, 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). MAIN MEASURES: The primary outcome of the study was in-hospital mortality. Secondary outcomes were the composite variable of in-hospital mortality, requirement for high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV), or intensive care unit (ICU) admission. KEY RESULTS: A total of 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). No significant differences were observed in either the low/intermediate-risk category (1.5% vs. 7.4%, p=0.175) or the high-risk category (23.1% vs. 20%, p=0.223) after propensity score matching. A statistically significant lower mortality was observed in the very high-risk category (31.9% vs. 23.9%, p=0.049). CONCLUSIONS: The prescription of CS alone or in combination with TCZ should be based on the degrees of inflammation and reserve the CS plus TCZ combination for patients at high and especially very high risk.

Differential Diagnosis of Hepatic Mass with Central Scar: Focal Nodular Hyperplasia Mimicking Fibrolamellar Hepatocellular Carcinoma.

Fibrolamellar hepatocellular carcinoma is a primary hepatic tumor that usually appears in young adults. Radical surgery is considered curative for this kind of tumor, so early diagnosis becomes essential for the prognosis of the patients. The main characteristic of this entity is the central scar, which is the center of differential diagnosis. We report the case of a 30-year-old man who was diagnosed with fibrolamellar hepatocellular carcinoma by ultrasonography. Contrast-enhanced CT confirmed this diagnosis, and the patient underwent a [18F] fluorocholine PET/CT. Hypermetabolism and the morphology in the nuclear medicine exploration suggest neoplastic nature of the lesion. Radical surgery was performed, and histopathologic analysis was performed, which resulted in focal nodular hyperplasia. Hepatic masses with central scar could have a difficult differential diagnosis, and focal nodular hyperplasia could mimic fibrolamellar hepatocellular carcinoma imaging patterns. These morphofunctional characteristics have not been described in [18F] Fluorocholine PET/CT, so there is a need to find out the potential role PET/CT in the differential diagnosis of hepatic mass with central scar.

Acute Coronary Syndromes, Gastrointestinal Protection, and Recommendations Regarding Concomitant Administration of Proton-Pump Inhibitors (Omeprazol/Esomeprazole) and Clopidogrel.

The Food and Drug Administration and the European Medicines Agency sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. The purpose is to know the gastroprotective approach in patients with acute coronary syndrome (ACS) and the level of follow-up of the alert. In 17 hospitals with catheterization laboratory in Spain, 1 per region, we studied 25 consecutive patients per hospital whose diagnosis of discharge since October 1, 2013, had been any type of ACS. We analyzed their baseline clinical profile, the gatroprotective agents at admission and discharge and the antiplatelet therapy at discharge. The number of patients included was 425: age 67.2 ± 12.5 years, women 29.8%, diabetes 36.5%. The patients presented unstable angina in 21.6%, non-ST-elevation myocardial infarction in 35.3% and ST-elevation myocardial infarction in 43.1%. Conservative approach was chosen in 17.9%, bare-metal stents 32.2%, ≥ 1 drug-eluting stent 48.5%, and surgery 1.4%. Aspirin was indicated in 1.9%, aspirin + clopidogrel 73.6%, aspirin + prasugrel 17.6%, and aspririn + ticagrelor 6.8%. Gastroprotective agents were present in 40.2% patients at admission and this percentage increased to 93.7% at discharge. Of the 313 (73.6%) on clopidogrel in 96 (30.6%) was combined with omeprazole and 3 (0.95%) with esomeprazole, whereas the most commonly used was pantoprazole with 190 patients (44.7%). In conclusion, almost the totality of the patients with an ACS receive gastroprotective agents at the moment of discharge, most of them with proton-pump inhibitors. In one every 3 cases of the patients who are on clopidogrel, the recommendation of the Food and Drug Administration and the European Medicines Agency is not followed.

Limitaciones al uso de los nuevos antiagregantes en los síndromes coronarios agudos relacionadas con las características de los pacientes / Use of the New Antiplatelet Agents in Acute Coronary Syndromes: Limitations Related to Patient Characteristics

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Leiomioma intraorbitario. Caso clínico y revisión de la literatura / Orbital leiomyoma. Case report and review of the literature

Los leiomiomas son lesiones de lento crecimiento originarias del músculo liso. La localización orbitaria solo ha sido descrita en 25 casos. Sus características histológicas y la ausencia de recurrencia tras la resección total apoyan su comportamiento benigno. Presentamos un caso de hemangioleiomioma intraconal en una mujer de 55 años tratado quirúrgicamente mediante craneotomía fronto-orbitaria con resección total y sin recurrencia de la lesión tras 15 meses de seguimiento. Se discuten los hallazgos histológicos y radiológicos, enfatizando en el papel pronóstico de la cirugía

Leiomyoma are slowly growing lesions arising from smooth muscle. Orbital location hasbeen reported in 25 cases. Histological findings and no recurrence after total resectionsupport their benign behaviour. We report an intraconal orbital haemangioleiomyoma ina 55-year-old female treated by total resection through fronto-orbital craniotomy, with norecurrence after 15 months of follow-up. Radiological and pathological features are discussed, emphasising the prognostic role of the surgery

[Orbital leiomyoma. Case report and review of the literature]. / Leiomioma intraorbitario. Caso clínico y revisión de la literatura.

Leiomyoma are slowly growing lesions arising from smooth muscle. Orbital location has been reported in 25 cases. Histological findings and no recurrence after total resection support their benign behaviour. We report an intraconal orbital haemangioleiomyoma in a 55-year-old female treated by total resection through fronto-orbital craniotomy, with no recurrence after 15 months of follow-up. Radiological and pathological features are discussed, emphasising the prognostic role of the surgery.

La inervación del disco intervertebral / Innervation of the intervertebral disc

Hasta hace poco la inervación del disco intervertebral fue objeto de debate. La introducción de técnicas de inmunohistoquímica asociadas a anticuerpos específicos y los estudios con trazadores nerviosos retrógrados han permitido conocer mejor la inervación del disco en condiciones normales y patológicas así como las características de las terminaciones y sus patrones de distribución en ambas situaciones. Las controversias que existen acerca de las bases estructurales del dolor discogénico han despertado el interés por conocer la influencia de la inervación en el dolor lumbar de origen discal y sus características. Actualmente sabemos que la neoinervación patológica de las fisuras radiales es un factor importante en la génesis del dolor discogénico dentro de un complejo mecanismo en que están implicados factores neurobioquímicos, inflamatorios y biomecánicos (AU)

Until very recently, intervertebral disc innervation was a subject of considerable debate. Nowadays, the introduction of inmunohistochemical techniques associated to specific antibodies and studies with retrograde tracers in nerves have allowed greater understanding of disc innervation in physiological and pathological conditions and also endings characteristics and their patterns of distribution in both situations. The existing controversies regarding structural basis of discogenic pain, have raised the interest of knowing the influence of innervation in back pain from discal origin and its characteristics. Today, we know that pathologic neoinnervation accompanying radial fissures is an important factor in the genesis of discogenic pain; within a complex mechanism in which other neurobiomechemical, inflammatory and biomechanical factors are involved

[Innervation of the intervertebral disc]. / La inervación del disco intervertebral.

Until very recently, intervertebral disc innervation was a subject of considerable debate. Nowadays, the introduction of inmunohistochemical techniques associated to specific antibodies and studies with retrograde tracers in nerves have allowed greater understanding of disc innervation in physiological and pathological conditions and also endings characteristics and their patterns of distribution in both situations. The existing controversies regarding structural basis of discogenic pain, have raised the interest of knowing the influence of innervation in back pain from discal origin and its characteristics. Today, we know that pathologic neoinnervation accompanying radial fissures is an important factor in the genesis of discogenic pain; within a complex mechanism in which other neurobiomechemical, inflammatory and biomechanical factors are involved.

Síndrome febril y debilidad muscular en un paciente de 50 años / Fever and muscle weakness in a 50-year-old patient

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Infección de herida operatoria y peritonítis apendicular en el Hospital Regional Honorio Delgado Arequipa, periodo 1989 a 1994

Fueron revisadas las historias clínicas de 291 pacientes egresados con el diagnóstico de apendicitis aguda complicada con peritonitis durante el periodo 1989 a 1994 en el Hospital Regional Honorio Delgado Arequipa. Se encontró una incidencia de 48.80 por ciento de infección de la herida operatoria. Esta incidencia fue mayor en pacientes menores de 5 años y mayores de 40 años. El sexo del paciente no tuvo relación alguna con la frecuencia de la herida infectada, al igual que el tipo de peritonitis. En cuanto a la técnica quirúrgica, la incisión más utilizada fue la de Mac Burney seguida por la paramedia derecha; se realizó lavado y drenáje en gran porcentaje de pacientes 81.79 por ciento y 95.85 por ciento respectivamente; sin embargo, ninguno de estos procedimientos se asoció con una mayor o menor frecuencia de herida infectada. La exteriorización del drenaje por la incisión, no se asoció a mayor frecuencia de herida infectada con relación al drenaje por cobertura. En caso de cierre diferido, se encontró una reducción significativa de la herida infectada, no así el cierre primario que fue utilizado en el mayor porcentaje de pacientes(8.83 por ciento), se presentó mayor indice de ésta complicación al igual que el drenaje del celular subcutaneo. Asimismo el tiempo operatorio mayor a 3 horas, se asoció a una frecuencia de 75 por ciento de herida infectada, en cambio, en actos operatorios de menor duración, la incidencia de herida infectada también fue menor. Cuando el hallazgo operatorio fue apéndice digerida y apendicitis gangrenosa y perforada, la incidencia de herida infectada alcanzó mayores porcentajes, 56.04 por ciento y 69.23 por ciento respectivamente. Asimismo, el contenido purulento con mal olor tuvo mayor incidencia de herida infectada y el contenido purulento si mal olor se asoció a menor incidencia. El tratamiento en base a uno o dos antibióticos no mejoró el pronóstico de las heridas con respecto al grupo que no recibió antibióticos. En cambio, la terapia con tres drogas presentó una reducción significativa en la frecuencia de herida infectada, Gentamicina asociada a Cloranfenicol fue el esquema de tratamiento más utilizado. La secresión purulenta fue la manifestación más frecuente de infección de herida. Complicaciones tales como la celulitis y fascitis necrotizante tuvieron incidencia de 3.52 por ciento y 2.11 por ciento. En los cultivos de herida infectada se encontró predominio de las enterobacterias, en especial Escherichia Coli. El tiempo promedio de hospitalización de pacientes con infección de herida fue de 19.3 y el 12.67 por ciento de pacientes estuvieron hospitalizados por más de 30 días. El promedio de los que no cursaron con herida infectada fue de 7.7 días