Kaposi's Varicelliform Eruption: A Potentially Life-Threatening Complication of Atopic Dermatitis.

Introduction: Kaposi's varicelliform eruption (KVE), also known as eczema herpeticum or eczema vaccinatum, is an acute dermatosis that affects patients with chronic dermatopathies. The diagnosis is primarily clinical and is characterised by the presence of a vesicular exanthema on physical examination. The exanthema subsequently evolves into crusted lesions with typical circular ulcerations in 'punched-out' areas on the skin affected by the underlying dermatopathy. Case description: We present the case of a 6-year-old patient who presented to the Paediatric Emergency department with skin lesions consistent with eczema herpeticum. The patient's management was initially outpatient; however, due to the slow progression of the condition, hospitalisation and intravenous antiviral treatment were initiated. Discussion: KVE affects patients with chronic dermatoses, especially atopic dermatitis. It is important to know the clinical presentation for an early suspicion. KVE is a medical emergency that requires prompt diagnosis and treatment. It can progress to secondary viraemia, which can be fatal in up to 10% of immunocompetent individuals and up to 50% of immunocompromised individuals. It is important to be aware of this condition and to start early treatment with antivirals, especially given the high prevalence of atopic dermatitis in our population. This condition is one of the most serious complications that can occur in these patients. LEARNING POINTS: To facilitate early suspicion and diagnosis, disseminate information about eczema vaccinatum.Emphasise the importance of initiating antiviral treatment early to prevent potential complications of eczema herpeticum.If left untreated, Kaposi's varicelliform eruption can result in up to a 10% mortality rate in immunocompetent individuals and a 50% mortality rate in those who are immunocompromised.

Early cortical atrophy in REM sleep behavior disorder. / Atrofia cortical precoz en el trastorno de conducta del sueño REM.

INTRODUCTION: The presence of cortical atrophy (focal or diffuse) prior to the development of symptoms of cognitive impairment could predict the earliest cases of neurodegenerative disease in patients with REM sleep behavior disorder (RSBD). We reviewed the usefulness of cranial CT and MRI as early markers of cortical atrophy in patients with RSBD at our center. PATIENTS AND METHODS: Retrospective observational descriptive analysis of patients diagnosed with RSBD from October 2012 to October 2022. All with cranial CT or MRI, evaluated by a neuroradiologist. RESULTS: 54 patients were included, 21 women (38.88%), 33 men (61.12%), mean age at diagnosis of RSBD: 69.04±12.625 years. Of the 54 patients, 44 (81.48%) had imaging tests consistent with their age, and 10 had atrophy greater than expected for their age. Of the 54 patients, 21 (38.88%) with a diagnosis of neurodegenerative disease, 33 (61.12%) persist as idiopathic, almost all with more than 5years of evolution (range of 1 to 10years of evolution without diagnosis). Of the 10 (18.52%) patients with greater atrophy, all were diagnosed with neurodegenerative disease (8 in 1year, 2 in 8years). CONCLUSIONS: Almost half of our series have developed a neurodegenerative disease in the first 10years of evolution. The majority of them presented global cortical atrophy measured by the GCA scale in the first year of diagnosis, without other neurological symptoms. Patients who did not show cortical atrophy at diagnosis have not yet developed the neurodegenerative disease in 10years of evolution. In our experience, the absence of cortical atrophy on cranial MRI or CT (measured by scales such as GCA) at the diagnosis of RSBD seems to predict slower progression cases. These data should be corroborated with larger series.

Adipose tissue IL-18 production is independent of caspase-1 and caspase-11.

BACKGROUND: Inflammation in adipose tissue, resulting from imbalanced caloric intake and energy expenditure, contributes to the metabolic dysregulation observed in obesity. The production of inflammatory cytokines, such as IL-1ß and IL-18, plays a key role in this process. While IL-1ß promotes insulin resistance and diabetes, IL-18 regulates energy expenditure and food intake. Previous studies have suggested that caspase-1, activated by the Nlrp3 inflammasome in response to lipid excess, mediates IL-1ß production, whereas activated by the Nlrp1b inflammasome in response to energy excess, mediates IL-18 production. However, this has not been formally tested. METHODS: Wild-type and caspase-1-deficient Balb/c mice, carrying the Nlrp1b1 allele, were fed with regular chow or a high-fat diet for twelve weeks. Food intake and mass gain were recorded weekly. At the end of the twelve weeks, glucose tolerance and insulin resistance were evaluated. Mature IL-18 protein levels and the inflammatory process in the adipose tissue were determined. Fasting lipid and cytokine levels were quantified in the sera of the different experimental groups. RESULTS: We found that IL-18 production in adipose tissue is independent of caspase-1 activity, regardless of the metabolic state, while Nlrp3-mediated IL-1ß production remains caspase-1 dependent. Additionally, caspase-1 null Balb/c mice did not develop metabolic abnormalities in response to energy excess from the high-fat diet. CONCLUSION: Our findings suggest that IL-18 production in the adipose tissue is independent of Nlrp3 inflammasome and caspase-1 activation, regardless of caloric food intake. In contrast, Nlrp3-mediated IL-1ß production is caspase-1 dependent. These results provide new insights into the mechanisms underlying cytokine production in the adipose tissue during both homeostatic conditions and metabolic stress, highlighting the distinct roles of caspase-1 and the Nlrp inflammasomes in regulating inflammatory responses.

Clinical practice guidelines for diagnostic and treatment of the chronic heart failure.

Chronic heart failure continues to be one of the main causes of impairment in the functioning and quality of life of people who suffer from it, as well as one of the main causes of mortality in our country and around the world. Mexico has a high prevalence of risk factors for developing heart failure, such as high blood pressure, diabetes, and obesity, which makes it essential to have an evidence-based document that provides recommendations to health professionals involved in the diagnosis and treatment of these patients. This document establishes the clinical practice guide (CPG) prepared at the initiative of the Mexican Society of Cardiology (SMC) in collaboration with the Iberic American Agency for the Development and Evaluation of Health Technologies, with the purpose of establishing recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. This document complies with international quality standards, such as those described by the US Institute of Medicine (IOM), the National Institute of Clinical Excellence (NICE), the Intercollegiate Network for Scottish Guideline Development (SIGN) and the Guidelines International Network (G-I-N). The Guideline Development Group was integrated in a multi-collaborative and interdisciplinary manner with the support of methodologists with experience in systematic literature reviews and the development of CPG. A modified Delphi panel methodology was developed and conducted to achieve an adequate level of consensus in each of the recommendations contained in this CPG. We hope that this document contributes to better clinical decision making and becomes a reference point for clinicians who manage patients with chronic heart failure in all their clinical stages and in this way, we improve the quality of clinical care, improve their quality of life and reducing its complications.

La insuficiencia cardiaca crónica sigue siendo unas de las principales causas de afectación en el funcionamiento y en la calidad de vida de las personas que la presentan, así como una de las primeras causas de mortalidad en nuestro país y en todo el mundo. México tiene una alta prevalencia de factores de riesgo para desarrollar insuficiencia cardiaca, tales como hipertensión arterial, diabetes y obesidad, lo que hace imprescindible contar con un documento basado en la evidencia que brinde recomendaciones a los profesionales de la salud involucrados en el diagnóstico y el tratamiento de estos pacientes. Este documento establece la guía de práctica clínica (GPC) elaborada por iniciativa de la Sociedad Mexicana de Cardiología (SMC) en colaboración con la Agencia Iberoamericana de Desarrollo y Evaluación de Tecnologías en Salud, con la finalidad de establecer recomendaciones basadas en la mejor evidencia disponible y consensuadas por un grupo interdisciplinario y multicolaborativo de expertos. Cumple con estándares internacionales de calidad, como los descritos por el Institute of Medicine de los Estados Unidos de América (IOM), el National Institute of Clinical Excellence (NICE) del Reino Unido, la Intercollegiate Network for Scottish Guideline Development (SIGN) de Escocia y la Guidelines International Network (G-I-N). El grupo de desarrollo de la guía se integró de manera interdisciplinaria con el apoyo de metodólogos con experiencia en revisiones sistemáticas de la literatura y en el desarrollo de GPC. Se llevó a cabo y se condujo metodología de panel Delphi modificado para lograr un nivel de consenso adecuado en cada una de las recomendaciones contenidas en esta GPC. Esperamos que este documento contribuya para la mejor toma de decisiones clínicas y se convierta en un punto de referencia para los clínicos que manejan pacientes con insuficiencia cardiaca crónica en todas sus etapas clínicas, y de esta manera logremos mejorar la calidad en la atención clínica, aumentar la calidad de vida de los pacientes y disminuir las complicaciones de la enfermedad.

[Construct validity of the TECS questionnaire for the quality of teamwork in surgery]. / Validez de constructo del cuestionario TECS para la calidad del trabajo en equipo en cirugía.

Objective: To assess the construct validity and reliability of the Trabajo en Equipo en Cirugía (TECS) questionnaire. Method: The questionnaire was administered to 401 undergraduate students who were doing surgery practices at three universities. An exploratory factor analysis was performed on the first 200 observations, and a confirmatory factor analysis on the remaining ones. The reliability of the instrument was established with Cronbach's alpha. Results: The average age of the study population was 22 years (± 1.4) and 65.5% were women. The factors "Student's disposition towards teamwork", "Structure of the work environment" and "Leadership and collaboration in the work team" showed excellent internal consistency with a Cronbach's alpha of 0.94. The results in the exploratory factor analysis showed adequate goodness of fit with the empirical data. Conclusions: The TECS is a valid (content and construct) and reliable instrument to assess the quality of teamwork in surgery in medical students.

Objetivo: Realizar la validación de constructo y el análisis de confiabilidad del cuestionario Trabajo en Equipo en Cirugía (TECS). Método: El cuestionario se aplicó a 401 estudiantes de pregrado que cursaban prácticas en cirugía en tres universidades. Sobre las primeras 200 observaciones se realizó un análisis factorial exploratorio, y sobre las restantes un análisis factorial confirmatorio. La confiabilidad del instrumento fue establecida con el alfa de Cronbach. Resultados: La edad promedio de la población en estudio fue de 22 años (± 1.4) y el 65.5% eran mujeres. Los factores «Disposición del estudiante hacia el trabajo en equipo¼, «Estructura del ambiente de trabajo¼ y «Liderazgo y colaboración en el equipo de trabajo¼ mostraron una excelente consistencia interna, con un alfa de Cronbach de 0.94. Los resultados en el análisis factorial exploratorio mostraron una adecuada bondad de ajuste con los datos empíricos. Conclusiones: El TECS es un instrumento válido (contenido y constructo) y confiable para evaluar la calidad del trabajo en equipo en cirugía en estudiantes de medicina.

The activity of psoriatic arthritis with axial involvement correlates with the PsAID12.

OBJECTIVE: To determine the impact of the disease in patients with PsA in daily clinical practice and to evaluate its relationship with its axial activity. METHODS: A cross-sectional study was conducted in consecutive patients attended from January 2021 to December 2021 who met the CASPAR criteria, with clinical of inflammatory back pain and positive axial imaging, with or without peripheral involvement. Demographic, clinical, analytical data, HAQ index, PsAID12 and activity index (BASDAI and ASDAS-PCR) were also collected. Patients were divided into two groups, those with high impact and those with low impact according to PsAID results. Continuous variables are shown as median (Q1-Q3) and categorical variables as percentages and frequencies. RESULTS: Of the 269 patients evaluated with PsA, 72 patients with axial involvement were included, 40 men (55.6%), with a median age of 54.1 years and disease duration of 7 years. 28.3% of the patients were obese and serum CRP level was 0.45 mg/dl (0.08-1.10). BASDAI was 4.2 (2.0-6.2) and ASDAS-PCR was 2.4 (1.5-3.2), which translates into 39.6% of patients in low activity or remission. The median PsAID total score was 3.9 (1.6-5.4), evaluated in 61 patients. The patients who achieved a PsAID12 ≤ 4 were 63%, mostly men and with lower CRP levels than PsAID ≥ 4 patients. In addition, low impact measured by the PsAID12 was associated with low results in BASDAI and ASDAS-PCR. CONCLUSIONS: Axial involvement reflected lower impact of the disease measured by PsAID12 and it is correlated with low activity measured by BASDAI and ASDAS-PCR.

EUS-guided tissue acquisition in patients with solid pseudopapillary neoplasms of the pancreas.

OBJECTIVES: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has been the most common method used for the preoperative cytopathological diagnosis of solid tumors of the pancreas. There are only a few reported cases about the role of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) in the pre-operative diagnosis of solid pseudopapillary neoplasms (SPN). This study aimed to evaluate the diagnostic yield of EUS-TA,including endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) andEUS-FNB, in patients with SPN. METHODS: We performed a retrospective analysis of patients with EUS-TA for SPN diagnosis in 2 referral centers. The primary outcome was the diagnostic yield of EUS-TA compared to the surgical specimen. RESULTS: Seventy-four patients with SPN of the pancreas were identified. Eighteen had a EUS-TA (10 EUS-FNB and 8 EUS-FNA). The median age of the patients was 31 years (IQR 21-38), and all patients were women. The most common presenting symptom was abdominal pain. Most of the tumors were in the head of the pancreas (9/18; 50%). The median tumor size by EUS was 4.5 cm (min-max 2-15 cm). The most common appearance on EUS was a solid lesion (n = 8/18, 44.4%). A definitive presurgical cytopathological diagnosis was obtained in 16/18 patients (88.8%) with EUS-TA. The sensitivity and positive predictive value of the EUS-TA were 94% each. One patient in the EUS-FNB group developed mild acute pancreatitis. CONCLUSION: The diagnostic yield of the EUS-TA in SPN is high. In most cases, the diagnosis was obtained with the first procedure. No differences in the diagnostic yield or AEs between EUS-FNA vs. EUS-FNB needles were seen.

La actividad de la artritis psoriásica con afectación axial se correlaciona con el PsAID12 / The activity of psoriatic arthritis with axial involvement correlates with the PsAID12

Objetivo: Determinar el impacto de la enfermedad en pacientes con artritis psoriásica (APs) en la práctica clínica diaria, y evaluar su relación con la actividad axial.Métodos: Se realizó un estudio transversal multicéntrico en pacientes consecutivos vistos desde enero 2021 hasta diciembre 2021 que cumplieron con los criterios CASPAR, con clínica dolor lumbar inflamatorio y prueba de imagen positiva, con o sin afectación periférica. También se recogieron datos demográficos, clínicos, analíticos, índice Health Assessment Questionnaire, PsAID12 e índices de actividad axial (BASDAI y ASDAS-PCR). Se dividió a los pacientes en 2 grupos según el alto o bajo impacto del cuestionario PsAID. Las variables continuas se mostraron como mediana (Q1-Q3) y las categóricas como porcentajes y frecuencias. Resultados: Se incluyeron 72 pacientes con afectación axial de los 269 evaluados con APs, 40 varones (55,6%), con una mediana de edad de 54,1 años y duración de la enfermedad de 7 años. El 28,3% de los pacientes eran obesos y el nivel sérico de PCR fue de 0,45mg/dl (0,08-1,10). El BASDAI fue de 4,2 (2,0-6,2) y el ASDAS-PCR de 2,4 (1,5-3,2), estando en baja actividad o remisión el 39,6%. La mediana de la puntuación total de PsAID fue de 3,9 (1,6-5,4), evaluado en 61 pacientes. Los pacientes que alcanzaron un PsAID12≤4 fueron el 63%, predominantemente varones, presentaron valores de PCR menores y se asoció a una menor puntuación de BASDAI y ASDAS-PCR. Conclusiones: Los pacientes con afectación axial reflejaban un bajo impacto de la enfermedad medido por PsAID12 y este se correlacionaba con baja actividad medido por BASDAI y el ASDAS-PCR.(AU)

Objective: To determine the impact of the disease in patients with PsA in daily clinical practice and to evaluate its relationship with its axial activity. Methods: A cross-sectional study was conducted in consecutive patients attended from January 2021 to December 2021 who met the CASPAR criteria, with clinical of inflammatory back pain and positive axial imaging, with or without peripheral involvement. Demographic, clinical, analytical data, HAQ index, PsAID12 and activity index (BASDAI and ASDAS-PCR) were also collected. Patients were divided into two groups, those with high impact and those with low impact according to PsAID results. Continuous variables are shown as median (Q1-Q3) and categorical variables as percentages and frequencies. Results: Of the 269 patients evaluated with PsA, 72 patients with axial involvement were included, 40 men (55.6%), with a median age of 54.1 years and disease duration of 7 years. 28.3% of the patients were obese and serum CRP level was 0.45mg/dl (0.08-1.10). BASDAI was 4.2 (2.0-6.2) and ASDAS-PCR was 2.4 (1.5-3.2), which translates into 39.6% of patients in low activity or remission. The median PsAID total score was 3.9 (1.6–5.4), evaluated in 61 patients. The patients who achieved a PsAID12≤4 were 63%, mostly men and with lower CRP levels than PsAID≥4 patients. In addition, low impact measured by the PsAID12 was associated with low results in BASDAI and ASDAS-PCR. Conclusions: Axial involvement reflected lower impact of the disease measured by PsAID12 and it is correlated with low activity measured by BASDAI and ASDAS-PCR.(AU)

Vulnerable period in heart failure: a window of opportunity for the optimization of treatment - a statement by Mexican experts.

Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.

Complications Secondary to the Use Of Sglt2 Inhibitors in Oncological Patients: A Series of 5 Cases.

Sodium-glucose cotransporter-2 (iSGLT2) inhibitors, which include dapagliflozin, canagliflozin and empagliflozin, are a class of drugs initially used in the oral treatment of diabetes, heart failure and renal failure. They target the reabsorption of glucose in the kidney. Although they bring benefit to patients with these conditions and in general produce few adverse effects, in some cases, iSGLT2 can cause serious adverse effects such as metabolic acidosis, and fungal or bacterial urinary infections. Oncology patients, who in general have a weak immune system and are usually treated with chemotherapy and/or immunotherapy, are more susceptible to this type of adverse events than other patients. For this reason, it is necessary to adequately select the patients eligible to receive this type of drug and evaluate the potential benefits for them. In this series of five cases, we present two cases of metabolic acidosis, two cases of bacterial urinary sepsis, and one case of fungal urinary sepsis that occurred in patients admitted to the Medical Oncology Department of the University Hospital of Salamanca in 2023. LEARNING POINTS: Adverse events associated with iSGLT2 can lead to serious complications in immunocompromised patients. There have been cases of prolonged admissions with high morbidity and mortality due to bacterial or fungal infections and metabolic acidosis, all of which are side effects derived from their use.In oncology patients, an adequate evaluation of the risk-benefit balance must be conducted before the introduction of new drugs.Studies should be conducted to assess the risk of serious adverse effects in oncology patients undergoing treatment with chemotherapy or immunotherapy.

Antiviral resistance in influenza viruses.

Influenza represents a major threat to public health worldwide, vaccination is the most effective strategy to reduce infections. However, achieving adequate vaccination rates is challenging and vaccination does not always guarantee complete protection. For this reason, antiviral drugs represent an important measure to reduce the risk of complications in high-risk patients. However, influenza viruses have a high mutation rate which causes genetic, biochemical, and pathogenic changes that represent a challenge both for the constant replacement of vaccines and reduce their susceptibility to antiviral action. This makes it necessary to determine the mechanisms of these processes, as well as their epidemiological surveillance and, of course, the development of new therapeutic options that may be available in the event of a widespread resistance phenomenon. In this article we review some of the relevant aspects of the replicative cycle of influenza viruses, the antivirals currently used, as well as their resistance mechanisms.

An Atypical Presentation of a Polyarticular Gout Flare: Case Report.

A 54-year-old man with a history of hypertension, atrial fibrillation, chronic kidney disease, nonischemic cardiomyopathy, osteoarthritis, and gout presented to the emergency department (ED) with dysuria, painful scrotal swelling, severe bilateral flank pain, back pain, atraumatic right arm (elbow and distally) pain and swelling, and bilateral knee pain. His physical exam was notable for fever, tachycardia, bilateral costovertebral angle (CVA) tenderness, exquisite pain, erythema, and swelling of bilateral knees and the right arm (elbow and distally). He met Systemic Inflammatory Response Syndrome (SIRS) criteria, was placed on Ceftriaxone for presumed septic pyelonephritis, and was admitted to the medicine team. With initially unremarkable imaging studies, the differential diagnosis was broadened, and subsequent infectious workups yielded grossly normal results. At the end of hospital day one, the patient remained febrile and without symptomatic improvement. Rheumatology was consulted and empirically treated; the patient with a dose of Anakinra due to concerns about a polyarticular flare of crystalline arthropathy. Subsequent arthrocentesis confirmed a final diagnosis of a polyarticular gout flare. This case highlights the diagnostic challenges a polyarticular gout flare poses and the importance of early involvement of specialists for prompt recognition, treatment, and avoidance of unnecessary interventions.

"Learning to learn" in the Extended Inverted Classroom: An evaluation of the effects of interactive teaching on knowledge and cognitive regulation in medical students.

INTRODUCTION: The evidence regarding the effects of the Inverted Classroom on students' metacognitive skills is limited. This study evaluates these effects on student perceptions about knowledge and cognitive regulation during a surgical course. METHODS: We measured student perceptions before and after a conventional Inverted Classroom in surgery using the Metacognitive Awareness Inventory. We evaluated the mean differences between the scores of the two measurements using Student's t-test (p < 0.05), and the size of the effect on knowledge and cognitive regulation using Cohen's d test (95%CI). RESULTS: A total of 158 students (pre-intervention) and 155 students (post-intervention) were included in the analysis. Significant differences were found (p < 0.05) in, as well as positive effects on, the students' abilities to know their own learning (declarative knowledge) (d = 0.24; 95%CI, 0.02-0.47), to use learning strategies (procedural knowledge) (d = 0.19; 95%CI, -0.02 to 0.41) and to understand when and why to use these strategies (conditional knowledge) (d = 0.20; 95%CI, -0.01 to 0.42), in addition to the abilities to plan (d = 0.31; 95%CI, 0.09-0.53) and to evaluate their learning (d = 0.31; 95%CI, 0.08-0.53). CONCLUSIONS: The Inverted Classroom has positive effects on metacognitive skills according to students' perceptions. Further studies are required that compare these effects with other methodologies for teaching in the classroom and the workplace.

Assessment of liver fibrosis in patients with rheumatoid arthritis treated with methotrexate: Utility of fibroscan and biochemical markers in routine clinical practice.

OBJECTIVES: To study the prevalence of liver fibrosis (LF) measured by FibroScan and APRI index in patients with rheumatoid arthritis (AR) undergoing treatment with methotrexate (MTX). METHODS: We included 59 patients with RA on MTX. Medical records, FibroScan measures and serological markers of liver damage were compared on the basis of cumulative methotrexate dose. RESULTS: Mean treatment duration was 82.4±65.1 months and mean cumulative dose was 5214.5±4031.9mg. Five patients met LF criteria by fibroscan, while only one patient had a suggestive APRI score. No statistically significant differences were found in terms of LF measured by both APRI and fibroScan between patients with cumulative doses above and below 4000mg. There was also no relationship between LF and treatment duration. CONCLUSIONS: The occurrence of LF in patients with RA on MTX is a multifactorial process that does not seem directly related to its cumulative dose. FibroScan may be a useful technique in clinical practice to screen for this complication.

Remote Patient Monitoring for Hypertension: Feasibility and Outcomes of a Clinic-Based Pilot in a Minority Population.

BACKGROUND: In the US 48% of adults have hypertension, with direct costs in excess of $130 billion per year. Remote patient monitoring (RPM) has been discussed as a useful tool in the treatment of hypertension, but few studies evaluate its cost effectiveness or efficacy in minority, lower socio-economic (SES) populations. Our study aims to evaluate the clinical and financial outcomes of RPM in hypertension management in a primarily minority, low-SES population. METHODS: In this prospective cohort pilot study, patients with uncontrolled primary hypertension (defined via Joint National Committee 8 guidelines) were randomly selected from a single academically affiliated primary care clinic. Patients were enrolled on a rolling basis for 90 days. Patients were given blood pressure cuffs and transmission hubs and asked to transmit daily blood pressure readings. Patients were called weekly by research assistants and concerns were escalated to the primary care physician. The control group was the remaining 299 uncontrolled hypertensive patients from the same clinic population analyzed via retrospective chart records at the conclusion of the interventional study period. The primary outcome was blood pressure control. Secondary outcomes were relative improvement in systolic pressure and direct costs. RESULTS: A total of 13 patients were enrolled into the RPM intervention; these patients were 54% female, 100% African American, and 77% Medicaid. When assessed via intention-to-treat analysis, patients in the intervention group had non-inferior blood pressure control at 90 days (46% experimental vs 31% control, P = .33) and average change in systolic blood pressure at 90 days (13.5 vs 3.7 mmHg, P = .174) while experiencing a significant reduction in office-based visits at 90 days (1.5 vs 5.9, P < .001) as compared to control. Results on per-protocol analysis also showed non-inferior BP control (63% vs 31%, P = .135). Financially, the program generated margins of $29 per patient at 90 days. CONCLUSIONS: Patients in our minority- and Medicaid-predominant cohort achieved noninferior blood pressure control as compared to retrospective control at 90 days and a significant reduction in all-cause clinic visits at 90 days. The program generated little revenue per patient, with main barriers to implementation including patient compliance and payor denial.

Late recurrence of lobular breast carcinoma presented as gastric metastasis.

A 81-year-old woman with a history of mild chronic heart failure and invasive lobular breast carcinoma pT2N0M0 diagnosed in 2009 and treated by mastectomy, chemotherapy, radiotherapy and adjuvant endocrine therapy with letrozole until 2016. Since then the patient has been disease-free. She presented to the Emergency Room in April 2023 due to severe postprandial epigastric pain and a 7 kg weight loss in the last 3 months. Abdominal computed tomography was performed showing thickening of the gastric antrum and proximal duodenum walls, peritoneal implants and ascites that suggested primary gastric tumor or lymphoma as the first possibility. An endoscopic ultrasound was schedule, performing a biopsy of the gastric lesion and placing a Hot-Axios® stent. The sample showed infiltration by lobular breast carcinoma CK7 (+), CK20 (-), CDX2 (-), GATA3 (+) GCDFP15 (+) RE (+) RP (-) HER2 (-). Treatment with capecitabine was started, with which it continues currently.

Assessment of liver fibrosis in patients with rheumatoid arthritis treated with methotrexate: Utility of fibroscan and biochemical markers in routine clinical practice / Evaluación de la fibrosis hepática en pacientes con artritis reumatoide en tratamiento con metotrexato: utilidad en la práctica clínica habitual del FibroScan y marcadores bioquímicos

Objectives: To study the prevalence of liver fibrosis (LF) measured by FibroScan and APRI index in patients with rheumatoid arthritis (AR) undergoing treatment with methotrexate (MTX). Methods: We included 59 patients with RA on MTX. Medical records, FibroScan measures and serological markers of liver damage were compared on the basis of cumulative methotrexate dose. Results: Mean treatment duration was 82.4±65.1 months and mean cumulative dose was 5214.5±4031.9mg. Five patients met LF criteria by fibroscan, while only one patient had a suggestive APRI score. No statistically significant differences were found in terms of LF measured by both APRI and fibroScan between patients with cumulative doses above and below 4000mg. There was also no relationship between LF and treatment duration. Conclusions: The occurrence of LF in patients with RA on MTX is a multifactorial process that does not seem directly related to its cumulative dose. FibroScan may be a useful technique in clinical practice to screen for this complication. (AU)

Objetivos: Estudiar la prevalencia de la fibrosis hepática (FH) medida por FibroScan e índice APRI en pacientes con artritis reumatoide (AR) en tratamiento con metotrexato (MTX). Métodos: Se incluyeron 59 pacientes con AR en tratamiento con MTX. Se compararon las historias clínicas, las mediciones de FibroScan y los marcadores serológicos de daño hepático en función de la dosis acumulada de MTX. Resultados: La duración media del tratamiento fue de 82,4±65,1 meses y la dosis media acumulada de 5214,5±4031,9mg. Cinco pacientes cumplían criterios de FH por FibroScan y un solo paciente por APRI. No se encontraron diferencias estadísticamente significativas en cuanto a FH tanto por APRI como por FibroScan en base a dosis acumuladas superiores o inferiores a 4000mg. Tampoco hubo relación entre FH y duración del tratamiento. Conclusiones: La FH en pacientes con AR tratados con MTX es un proceso multifactorial sin aparente relación directa con la dosis acumulada. El FibroScan puede ser una técnica útil en la práctica clínica para detectar esta complicación. (AU)

Cardiotoxicity Secondary to Immune Checkpoint Inhibitors in the Elderly: Safety in Real-World Data.

INTRODUCTION: Immunotherapy represents a key pillar of cancer treatments, with high response rates and long survival. Its use is increasing, mainly at the expense of the geriatric population due to the ageing of this population. However, despite its benefit, its safety in certain areas such as cardiotoxicity is largely unknown. The aim of this study is to assess the safety of immunotherapy in elderly patients using real-world data. METHODS: This is an ambispective study of patients ≥ 70 years old with solid tumours who were treated with immunotherapy at the University Hospital of Salamanca. Cardiotoxicity was assessed using the CTCAEv5.0 criteria. RESULTS: In total, 195 patients were included (76.9% male and 23.1% female), with a mean age of 75 years [70-93]. The percentage of patients with cardiotoxicity was 1.54%; 1.35% of patients with previous heart disease were diagnosed with cardiotoxicity, and 1.65% of those without previous heart disease were diagnosed with cardiotoxicity. The median time from the initiation of treatment until the cardiac event was 45 days [14-96]. The most frequent toxicity was myocarditis in 66.7% of patients, followed by arrhythmias in 33.3% of patients. CONCLUSIONS: Immunotherapy is shown to be a safe treatment in elderly cancer patients in terms of cardiotoxicity. The event rate shows no difference between patients with or without cardiac comorbidity.

Workplace bullying and sexual harassment among general surgery residents in Colombia / Acoso laboral y sexual en residentes de cirugía general en Colombia

INTRODUCTION: Workplace bullying and sexual harassment are concerns among general surgery residents in Colombia. OBJETIVE: To explore the prevalence and impact of workplace bullying and sexual harassment incidents among general surgery residents in Colombia. MATERIALS AND METHODS: This nationwide study was conducted in 2020. Residents selfrated their exposure to workplace bullying and to sexual harassment in the forms of gender harassment, unwanted sexual attention, and sexual coercion. We analyzed demographic variables, perpetrator's characteristics, and differences between victims and non-victims. RESULTS: The study included 302 residents. It found that 49% of general surgery residents in Colombia suffered from workplace bullying and 14.9% experienced sexual harassment. The main forms of sexual harassment were gender harassment (47%) and unwanted sexual attention (47%). Women reported significantly higher rates of being sexually harassed. Surgeons were the main perpetrators of sexual harassment. CONCLUSIONS: Workplace bullying and sexual harassment are frequent events in general surgery residency in Colombia. These findings suggest the need for interventions to improve the educational culture of surgical departments and decrease the prevalence of these behaviors.

Introducción: El acoso laboral y el acoso sexual son preocupaciones en la formación quirúrgica. Objetivo: Exploramos la magnitud de estos problemas entre los residentes de cirugía general en Colombia. Materiales y métodos: se realizó un estudio nacional en junio de 2020. Los residentes autoevaluaron su exposición a la intimidación y el acoso sexual en forma de acoso de género, atención sexual no deseada y coerción sexual. Se analizaron variables demográficas y perpetradores entre víctimas y no víctimas. Resultados: Se incluyeron un total de 302 residentes. Las tasas de acoso laboral y sexual fueron del 49% y 14,9%, respectivamente. Las principales formas de acoso sexual correspondieron al acoso de género (47%) y la atención sexual no deseada (47%). El acoso sexual fue significativamente mayor entre las mujeres. Los cirujanos fueron los principales perpetradores. Conclusiones: El acoso laboral y el acoso sexual son frecuentes en la formación quirúrgica en Colombia. Estos hallazgos conducen a intervenciones para mejorar la cultura educativa de los departamentos quirúrgicos para disminuir la prevalencia de estos comportamientos.

An enteroendocrine-microbial axis in the large intestine controls host metabolism.

Nutrient handling is an essential function of the gastrointestinal tract. Most nutrient absorption occurs in the small intestine and is coordinated by hormone-producing intestinal epithelial cells known as enteroendocrine cells (EECs)1. In contrast, the colon mostly reclaims water and electrolytes, and handles the influx of microbially-derived metabolites, including short chain fatty acids (SCFA)2-4. Hormonal responses of small intestinal EECs have been extensively studied but much less in known about the role of colonic EECs in metabolic regulation. To address this core question, we investigated a mouse model deficient in colonic EECs. We found that colonic EEC deficiency leads to hyperphagia and obesity. Surprisingly, colonic EEC deficiency results in altered microbiota composition and metabolism, which we found through antibiotic treatment and transfer to germ free recipients, to be both necessary and sufficient for the development of obesity. Moreover, studying stool and blood metabolomes, we found that differential glutamate production by intestinal microbiota corresponds to increase appetite due to EEC loss. Finally, we show that colonic glutamate administration can directly increase food intake and activate appetite centers in the central nervous system. These observations shed light on an unanticipated host-microbiota axis in the colon, part of a larger gut-brain axis, that regulates host metabolism and body weight.