Epilepsy and education: A case-control analysis of the impact of an intensive epilepsy training program on undergraduate medical students.

AIMS: To evaluate the knowledge, attitudes, and practical skills of students submitted to a 6-week intensive training in epilepsy compared to students without any training but mandatory neurology classes. METHODS: It is a case-control study. After completing a 6-week intensive Academic, Clinical, and Research Program in epilepsy, TUMSs answered a validated Knowledge Attitudes and Practices (KAP) questionnaire. The control group, composed of undergraduate students who shared the same age, academic year, and compulsory hours for learning about epilepsy as TUMSs, was also assessed through the KAP instrument. Answers from both groups were submitted to Fisher exact and the χ2 test to observe differences among groups. Descriptive statistics were also performed. RESULTS: TUMSs displayed better results in theoretical knowledge such as the definition and causes of epilepsy, and the application of paraclinical studies essential for diagnosing epilepsy. From their perspective, people with epilepsy encounter restricted opportunities for preserving their social life and employment and they are more prone to workplace accidents. They are convinced that facing epilepsy presents a notable risk due to the difficulties linked with diagnosis, considering epilepsy a challenging disease for general practitioners to identify and follow up. Likewise, they exhibited improvement in treatment adjustment and treatment monitoring of patients with epilepsy, mainly in pregnancy cases. Finally, they had greater knowledge about what to do when they witness a person experiencing a seizure. CONCLUSION: Our study showed that a 6-week intensive education program in epilepsy increased the knowledge and practical skills and changed the attitude toward patients with epilepsy of undergraduate students.

Critically Ill Patients with Renal Hyperfiltration: Optimizing Antibiotic Dose.

Renal hyperfiltration (RHF) is a prevalent phenomenon in critically ill patients characterized by augmented renal clearance (ARC) and increased of elimination of renally eliminated medications. Multiple risk factors had been described and potential mechanisms may contribute to the occurrence of this condition. RHF and ARC are associated with the risk of suboptimal exposure to antibiotics increasing the risk of treatment failure and unfavorable patient outcomes. The current review discusses the available evidence related to the RHF phenomenon, including definition, epidemiology, risk factors, pathophysiology, pharmacokinetic variability, and considerations for optimizing the dosage of antibiotics in critically ill patients.

Disseminated multidrug-resistant tuberculosis and SARS-CoV-2 co-infection in a child with IL-12Rß1 deficiency.

Mendelian Susceptibility to Mycobacterial Disease describes a spectrum of inherited defects, of which complete deficiency of the interleukin-12 receptor ß subunit 1 (IL-12Rß1) is the most common cause. This condition results in a predisposition to severe disease caused by mycobacteria. We report a case of disseminated multidrug-resistant tuberculosis with extensive central nervous system affection with SARS-CoV-2 co-infection, in a 4-year-old child with IL-12Rß1 complete deficiency.

Early clinical outcomes after transaxillary versus transfemoral TAVI. Data from the Spanish TAVI registry.

INTRODUCTION AND OBJECTIVES: Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access. METHODS: We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics. RESULTS: A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n=113 TXA group and n=3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P=.95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P=.001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P=.003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P=.03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P=.039 and OR, 2.3; 95%CI, 1.2-4.5; P=.01, respectively). CONCLUSIONS: Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA.

Outcomes of Sepsis and Septic Shock in Cancer Patients: Focus on Lactate.

The number of oncological patients (OP) admitted to intensive care units (ICU) for sepsis/septic shock has dramatically increased in recent years. The definition of septic shock has been modified, adding hyperlactatemia as a severity biomarker for mortality. However, it remains poorly reported in septic OP. We performed a retrospective analysis from a prospective database of sepsis/septic shock patients admitted to our ICU between September 2017 and September 2019 and followed until day 90. We identified 251 patients and 31.9% had active oncological comorbidity, mainly solid tumor (81.3%). Septic shock criteria were met for 112 (44.6%). Hyperlactatemia was observed in 136 (54.2%) patients and this was associated with a lower survival rate. Overall 90-day mortality was 15.1%. In OP vs. non-OP, hyperlactatemia was more frequent (65% vs. 49.1%, p = 0.013) and associated with lower survival (65.4% vs. 85.7%, p = 0.046). In OP, poor performance status was also associated with lower survival (HR 7.029 [1.998-24.731], p = 0.002) In an adjusted analysis, cancer was associated with lower 90-day survival (HR 2.690 [1.402-5.160], p = 0.003). In conclusion, septic OP remains a high mortality risk group in whom lactate levels and performance status could help with better risk stratification.

Targeted high volume hemofiltration could avoid extracorporeal membrane oxygenation in some patients with severe Hantavirus cardiopulmonary syndrome.

BACKGROUND: Hantavirus cardiopulmonary syndrome (HCPS) has a high lethality. Severe cases may be rescued by venoarterial extracorporeal membrane oxygenation (VA ECMO), alongside substantial complications. High volume hemofiltration (HVHF) is a depurative technique that provides homeostatic balance allowing hemodynamic stabilization in some critically ill patients. METHODS: We implemented HVHF before VA ECMO consideration in the last five severe HCPS patients requiring mechanical ventilation and vasoactive drugs admitted to our intensive care unit. Patients were considered HVHF-responders if VA ECMO was avoided and HVHF-nonresponders if VA ECMO support was needed despite HVHF. A targeted-HVHF strategy compounded by aggressive hyperoncotic albumin, sodium bicarbonate, and calcium supplementation plus ultrafiltration to avoid fluid overload was implemented on three patients. RESULTS: Patients had maximum serum lactate of 8.8 (8.7-12.8) mmol/L and a lowest cardiac index of 1.8 (1.8-1.9) L/min/m2 . The first two required VA ECMO. They were connected later to HVHF, displayed progressive tachycardia and declining stroke volume. The opposite was true for HVHF-responders who received targeted-HVHF. All patients survived, but one of the VA ECMO patients suffered a vascular complication. CONCLUSION: HVHF may contribute to support severe HCPS patients avoiding the need for VA ECMO in some. Early connection and targeted-HVHF may increase the chance of success.

Hemodynamic and Pulmonary Permeability Characterization of Hantavirus Cardiopulmonary Syndrome by Transpulmonary Thermodilution.

Hantavirus cardiopulmonary syndrome (HCPS) is characterized by capillary leak, pulmonary edema (PE), and shock, which leads to death in up to 40% of patients. Treatment is supportive, including mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO). Hemodynamic monitoring is critical to titrate therapy and to decide ECMO support. Transpulmonary thermodilution (TPTD) provides hemodynamic and PE data that have not been systematically used to understand HCPS pathophysiology. We identified 11 HCPS patients monitored with TPTD: eight on MV, three required ECMO. We analyzed 133 measurements to describe the hemodynamic pattern and its association with PE. The main findings were reduced stroke volume, global ejection fraction (GEF), and preload parameters associated with increased extravascular lung water and pulmonary vascular permeability compatible with hypovolemia, myocardial dysfunction, and increased permeability PE. Lung water correlated positively with heart rate (HR, r = 0.20) and negatively with mean arterial pressure (r = -0.27) and GEF (r = -0.36), suggesting that PE is linked to hemodynamic impairment. Pulmonary vascular permeability correlated positively with HR (r = 0.31) and negatively with cardiac index (r = -0.49), end-diastolic volume (r = -0.48), and GEF (r = -0.40), suggesting that capillary leak contributes to hypovolemia and systolic dysfunction. In conclusion, TPTD data suggest that in HCPS patients, increased permeability leads to PE, hypovolemia, and circulatory impairment.

Survival of Critically Ill Oncologic Patients Requiring Invasive Ventilatory Support: A Prospective Comparative Cohort Study With Nononcologic Patients.

PURPOSE: Cancer is in the process of changing to become a chronic disease; therefore, an increasing number of oncologic patients (OPs) are being admitted to intensive care units (ICUs) for supportive care of disease or therapy-related complications. We compare the short- and long-term outcomes of critically ill mechanically ventilated OPs with those of their nononcologic counterparts. PATIENTS AND METHODS: We performed a prospective study of patients admitted to our ICU between October 2017 and February 2019. Demographic, physiologic, laboratory, clinical, and treatment data were obtained. The primary outcome was survival at 28 days and at the end of the follow-up period. Secondary outcomes were survival according to acute severity scoring (Acute Physiology and Chronic Health Evaluation II score), Eastern Cooperative Oncology Group (ECOG) performance status, and Charlson comorbidity index. RESULTS: A total of 1,490 patients were admitted during the study period; 358 patients (24%) were OPs, and 100 of these OPs were supported with mechanical ventilation. Seventy-three percent of OPs had an ECOG performances status of 0 or 1, and 90% had solid tumors. Reason for admission to the ICU was postoperative admission in 44 patients and neutropenic infection in 10 patients. The follow-up period was 148 days (range, 42 to 363 days). Survival at 28 days was similar between OPs and nononcologic patients and associated with the Acute Physiology and Chronic Health Evaluation II score. However, long-term survival was lower in OPs compared with nononcologic patients (52% v 76%, respectively; P < .001) and associated with poor ECOG performance status. CONCLUSION: Short-term survival of critically ill, mechanically ventilated OPs is similar to that of their nononcologic counterparts and is determined by the severity of the critical illness.

A composite measure of habitat loss for entire assemblages of species.

Habitat destruction is among the greatest threats facing biodiversity, and it affects common and threatened species alike. However, metrics for communicating its impacts typically overlook the nonthreatened component of assemblages. This risks the loss of habitat going unreported for species that comprise the majority of assemblages. We adapted a widely used measure for summarizing researcher output (the h index) to provide a metric that describes natural habitat loss for entire assemblages, inclusive of threatened and nonthreatened species. For each of 447 Australian native terrestrial bird species, we combined information on their association with broad vegetation groups with distributional range maps to identify the difference between the estimated pre-European and current extents of potential habitat, defined as vegetation groups most closely associated with each species. From this, we calculated the loss index (LI), which revealed that 30% of native birds have each lost at least 30% of their potential natural habitat (LI = 30). At the subcontinental scale, LIs ranged from 15 in arid Australia to 61 in the highly transformed southeastern part of the country. Different subcomponents of the assemblage had different LI values. For example, Australia's parrots (n = 52 species) had an LI of 38, whereas raptors (n = 32 species) had an LI of 25. The LI is simple to calculate and can be determined using readily available spatial information on species distributions, native vegetation associations, and human impacts on natural land cover. This metric, including the curves used to deduce it, could complement other biodiversity indices if it is used for regional and global biodiversity assessments that compare the status of natural habitat extent for assemblages within and among nations, monitor changes through time, and forecast future changes to guide strategic land-use planning. The LI is an intuitive tool that can be used to summarize and communicate how human actions affect whole assemblages, not just threatened species.

Una Medida Compuesta de la Pérdida del Hábitat para Ensamblajes Enteros de Especies Resumen La destrucción del hábitat está entre las principales amenazas para la biodiversidad, además de que afecta tanto a especies comunes como a las especies amenazadas. Sin embargo, las medidas para comunicar los impactos de esta destrucción generalmente ignoran al componente no amenazado de los ensamblajes de especies. Esto genera el riesgo de que la pérdida del hábitat pase desapercibida en el caso de las especies que conforman a la mayoría de los ensamblajes. Adaptamos una medida de uso amplio para resumir las contribuciones de los investigadores (el índice h) y así proporcionar una medida que describa la pérdida del hábitat para ensamblajes enteros, incluyendo a las especies amenazadas y a las no amenazadas. Para cada una de las 447 especies de aves terrestres nativas a Australia, combinamos la información sobre su asociación con grupos generales de vegetación con mapas de extensión de su distribución para identificar la diferencia entre la extensión estimada previa a la llegada de los europeos y la extensión actual de los hábitats potenciales, definidos como los grupos de vegetación asociados más cercanamente con cada especie. A partir de esto, calculamos el índice de pérdida (LI, en inglés), el cual reveló que el 30% de cada una de las aves nativas ha perdido al menos el 30% de su hábitat natural potencial (LI = 30). A escala subcontinental, los LI variaron desde 15 para las partes áridas de Australia, hasta 61 en la altamente transformada parte sureste del país. Los diferentes subcomponentes del ensamblaje tuvieron diferentes valores de LI. Por ejemplo, los loros australianos (n = 52 especies) tuvieron un LI de 38, mientras que las aves rapaces (n = 32 especies) tuvieron un LI de 25. El LI es fácil de calcular y puede determinarse usando información espacial que ya se encuentra disponible, las asociaciones con la vegetación nativa y los impactos humanos sobre la cobertura natural del suelo. Esta medida, incluyendo las curvas que se usan para deducirla, podrían complementar otros índices de biodiversidad si se usa para evaluaciones de la biodiversidad regional y global, las cuales comparan el estado de la extensión del hábitat natural para ensamblajes dentro y entre las naciones, monitorean cambios a través del tiempo y pronostican cambios futuros que guíen la planeación del uso de suelo estratégico. El LI es una herramienta intuitiva que puede usarse para resumir y comunicar cómo las acciones humanas afectan a ensamblajes enteros, no sólo a las especies amenazadas.

The exceptional value of intact forest ecosystems.

As the terrestrial human footprint continues to expand, the amount of native forest that is free from significant damaging human activities is in precipitous decline. There is emerging evidence that the remaining intact forest supports an exceptional confluence of globally significant environmental values relative to degraded forests, including imperilled biodiversity, carbon sequestration and storage, water provision, indigenous culture and the maintenance of human health. Here we argue that maintaining and, where possible, restoring the integrity of dwindling intact forests is an urgent priority for current global efforts to halt the ongoing biodiversity crisis, slow rapid climate change and achieve sustainability goals. Retaining the integrity of intact forest ecosystems should be a central component of proactive global and national environmental strategies, alongside current efforts aimed at halting deforestation and promoting reforestation.

Rasmussen aneurysm: A rare but not gone complication of tuberculosis.

This report describes the case of a 30-year-old homeless man from Pereira, Colombia with tuberculosis, who presented with massive hemoptysis and associated aneurysm of the left upper lobe (Rasmussen aneurysm). Computed tomography angiography with three-dimensional reconstruction confirmed the aneurysm, and embolization was performed successfully.

El verdadero rostro de Eugenio Espejo / The true face of Eugenio Espejo

Se realizó una investigación histórica, con enfoque cualitativo, cuya población de estudio estuvo constituida por los documentos de interés salvaguardados en el Archivo de Indias, así como aquellos de las fuentes periodísticas de época que versaron alrededor de la figura de Eugenio Espejo. El estudio tuvo el propósito de establecer la fidelidad histórica de la iconografía de ese precursor de la nacionalidad ecuatoriana.

A historical research was carried out with a qualitative approach. The study population was cons-tituted by the documents of interest filed in Archivo de Indias, as well as those of the sources from press that revolved around the figure of Eugenio Espejo. The purpose of the study was to establish the historical fidelity of the iconography of that forerunner of Ecuadorian nationality.Keywords: history; famous persons; Anthropology, physical.

La evaluación integral de la adherencia al tratamiento en mujeres con VIH/sida: validación de un cuestionario / Integral assessment of adherence to treatment in women with HIV/AIDS: validation of a questionnaire

Objetivo: El estudio tuvo como objetivo construir y establecer las propiedades psicométricas del Cuestionario de adherencia al tratamiento para mujeres con VIH/sida (CAT-M VIH), con el fin de contribuir a lo que actualmente es una necesidad y una prioridad a nivel mundial, tanto para el control de la infección como para el mejoramiento de la calidad de vida de las enfermas. Las medidas de evaluación actuales son limitadas y deficientes, siendo importante el desarrollo de nuevos instrumentos que consideren las diferencias según el género. Método: El estudio fue de tipo instrumental (psicométrico). La muestra se seleccionó intencionalmente y estuvo compuesta por 121 mujeres con VIH/sida, atendidas en 8 instituciones de salud de la ciudad de Cali y que recibían tratamiento antirretroviral. Las propiedades psicométricas analizadas fueron la validez de contenido, la capacidad de discriminación de los ítems, la estructura factorial como indicador de validez de constructo y la fiabilidad del CAT-M VIH. Resultados: El cuestionario quedó conformado por 17 ítems que se refieren a comportamientos de adherencia a aspectos farmacológicos, a aspectos no farmacológicos y de autocuidado, a medidas para prevenir las infecciones de transmisión sexual (ITS) y a disminuir el consumo de drogas. Cuenta con unas propiedades psicométricas preliminares aceptables, entre ellas, una adecuada fiabilidad (a=0.634) y una buena estructura interna. Los ítems que lo componen presentan adecuados índices de discriminación y pertinencia a nivel clínico. Conclusiones: El CAT-M VIH constituye una propuesta de mejoría de las limitaciones teóricas y metodológicas en la evaluación de la adherencia al tratamiento en mujeres; responde a una concepción integral que trasciende la toma de medicamentos antirretrovirales y con una gran utilidad a nivel clínico e investigativo que se discute en este artículo.

Purpose: The purpose of the study was to construct and establish the psychometric properties of the questionnaire of adherence to treatment for HIV-infected women (CAT-M VIH), contributing to the current global need of controlling HIV infection and improving the quality of life for HIV patients. The existing assessment measures are limited and deficient; hence, the development of new tools considering gender differences is important. Method: The study was instrumental (psychometric). The sample was composed of 121 women with HIV/aids attending 8 health-service facilities in the city of Cali and taking antiretroviral medication. The psychometric properties assessed were the content validity, the items discrimination ability, the factorial structure as an index to construct validity, and the reliability of the CAT-M VIH. Results: The questionnaire was finally composed of 17 items, which reflect adherence behavior to pharmacological treatment, to nonpharmacological and self-care aspects, to the prevention of sexually transmitted diseases advice, and to drug use restrictions. The preliminary psychometric properties are acceptable, having good reliability (a=0.634) and good internal structure. The items have adequate discrimination indexes and clinical relevance. Conclusions: The CAT-M VIH could aid in improving the theoretical and methodological limitations in assessing adherence to treatment of women, responding to an integral concept of such that includes more than the antiretroviral medication taken and having substantial clinical and research utility, which is discussed in this article.

Surgical treatment of multiple mycotic aneurysms: in the ascending aorta, aortic arch, and descending aorta.

We report a clinical case of multiple mycotic aneurysms, in the ascending aorta, aortic arch, and descending aorta. The patient underwent surgery to replace the ascending aorta and aortic arch by means of a highly modified "elephant trunk" technique and with the aid of arterial cannulation from the right subclavian artery, which provided antegrade cerebral perfusion. Samples of purulent material taken from the aneurysmal wall yielded cultures positive for Staphylococcus aureus. The patient was treated with antibiotics for 6 weeks and then underwent a 2nd procedure for the aneurysmal resection of the descending thoracic aorta and the abdominal aorta, through a thoracic laparo-phrenicectomy. We comment on the clinical and surgical aspects of the case.

Multiple Local Recurrent Myxoma.

Cardiac myxomas, usually considered benign tumors, occasionally pursue an aggressive clinical course. The recurrence of sporadic myxomas is much less frequent than that of complex or familial myxomas (1-3% vs. 22% vs. 12%, respectively). We report a case of sporadic myxoma with multiple local recurrence in the left atrium diagnosed by transesophageal two-dimensional echocardiography 4 years after the first excision.