An experimental apparatus for the study of high-temperature degradation and solid-deposit formation of lubricants.

When exposed to high surface temperatures, engine lubricating oils degrade and may form solid deposits, which cause operational issues and increase shutdown time and maintenance costs. Despite its being a common issue in engine operation, the information available on the mechanics of this phenomenon is still lacking, and the experimental data and conditions must be updated to match the improvements in both lubricant stability and engine efficiency. To this end, an experimental apparatus has been developed to study the mechanisms that lead to the degradation and deposit formation of lubricants at high temperatures. The apparatus is designed to operate at pressures up to 69 bar, surface temperatures up to 650 °C, oil bulk temperatures up to 550 °C, and flow rates of <14 mL/min. In this apparatus, the oil is cycled through a heated test section, and deposits accumulate on the heated surface. The time required for deposits to start accumulating under the test conditions is determined based on the recorded temperature traces, and collected oil and deposit samples may be analyzed to determine changes in composition over time due to high-temperature exposure. The removable test section can be modified to accommodate different geometries, surface materials, and flow paths to adapt the instrument to a range of potential research directions. This paper presents the technical details of the new apparatus and the steps taken to characterize the experimental conditions. In addition, sample data are provided to show the unique capabilities of the new instrument, and an Arrhenius plot for Castrol Perfecto X 32 in the surface temperature range of 445-475 °C is presented as a demonstration of its use for quantifying the coking delay time. The new instrument detailed herein is the first such device to demonstrate a reliable, lab-scale technique for studying lube oil coke formation and deposition at temperatures and pressures of interest to power generation gas turbines.

Assessment of ITER radiation environment during the remote-handling operation of In-Vessel components with D1SUNED.

During ITER operational life, a remote-handled cask will be used to transfer In-Vessel components to the Hot Cell for maintenance, storage and decommissioning purposes. Due to the distribution of penetrations for system allocation in the facility, the radiation field of each transfer operation presents a high spatial variability; all operations must be studied independently for workers and electronics protection. In this paper, we present a fully representative approach to describe the radiation environment during the complete remote-handling scenario of In-Vessel components in the ITER facility. The impact of all relevant radiation sources during different stages of the operation is addressed. As-built structures and 2020 baseline designs are considered to produce the most detailed neutronics model of the Tokamak Complex, the 400,000-tonne civil structure hosting the tokamak, up to date. Novel capabilities of the D1SUNED code have allowed to compute the integral dose, the dose rate and the photon-induced neutron flux of both moving and static radiation sources. Time bins are included in the simulations to compute the dose rate caused by In-Vessel components at all positions along the transfer. The time evolution of the dose rate is built in video format with a 1-m resolution, especially valuable for hot-spots identification.

Assessment of the Relationship Between Inflammation and Glomerular Filtration Rate.

Background: Chronic kidney disease (CKD) is a global health problem. As it progresses to end stages, renal replacement therapy is required but ultimately, the best treatment is transplantation. Decreased renal function has been associated with an inflammatory state associated to primary CKD and in kidney transplant recipients (KTRs). Objective: To establish how the serum concentrations of some cytokines, such as interleukin (IL)-2, IL-8, IL-22, IL-17α, interferon-gamma, IL-4, and transforming growth factor-ß, correlate with various CKD stages. Methods: One hundred and forty-one KTRs between the ages of 18 and 75 years were included in the study. We also included 112 live kidney donors, 37 CKD PGCKD+3, and 76 GPhealthy. Participants were grouped according to their glomerular filtration rate (GFR) and their circulating cytokine levels, previously quantified by ELISA. Results: By linear regression analysis, we established the relation of each cytokine with the GFR. Transforming growth factor-ß correlated positively with the GFR in the study population, except in healthy individuals. A negative correlation of IL-8 and IL-17α and GFR was found in all cases. Conclusions: Whether these cytokines (IL-8 and IL-17α) could be used as inflammatory biomarkers indicating CKD progression, regardless of the type of population, remains to be prospectively determined.

Contexte: L'insuffisance rénale chronique (IRC) est un problème de santé mondial. Une thérapie de remplacement rénal est nécessaire au fur et à mesure que la maladie évolue vers les stades terminaux. Mais, en définitive, le meilleur traitement reste la transplantation. La réduction de la fonction rénale a été associée à un état inflammatoire associé à l'IRC primaire; une association observée aussi chez les receveurs d'une greffe de rein. Objectif: Déterminer la façon dont les concentrations sériques de certaines cytokines, notamment IL-2, IL-8, IL-22, IL-17a, IFN-γ, IL-4 et TGF-ß, corrèlent avec divers stades de l'IRC. Méthodologie: Ont été inclus dans l'étude 141 receveurs d'une greffe rénale âgés de 18 à 75 ans, 112 donneurs vivants de rein, 37 personnes atteintes d'IRC (PGIRC+3) et 76 personnes en bonne santé (PGen santé). Les sujets ont été regroupés en fonction de leur débit de filtration glomérulaire (DFGe) et de leur taux de cytokines en circulation, quantifiés préalablement par ELISA. Résultats: Une analyse de régression linéaire a servi à établir la relation entre chaque cytokine et le DFGe. Dans la population étudiée, une corrélation positive a été observée entre TGF-ß et le DFGe, sauf chez les individus sains. Dans tous les cas, la corrélation s'est avérée négative entre le DFGe et les taux d'IL-8 et d'IL-17a. Conclusion: Il reste à déterminer prospectivement si ces cytokines (IL-8 et IL-17a) pourraient être utilisées comme biomarqueurs inflammatoires pour indiquer la progression de l'IRC, quelle que soit la population.

Retrospective study of the incidence of sarcoidosis-like reaction in patients treated with immunotherapy.

AIM: To assess the frequency of radiographically evident drug-induced sarcoidosis-like reaction (DISR) in patients treated with anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) therapy, anti-programmed cell death protein 1 (PD-1) therapy, or a combination of both in a single centre. MATERIALS AND METHODS: The images and medical records of 457 patients with metastatic melanoma or head and neck cancer treated with either anti-CTLA-4 therapy, anti-PD-1 therapy, or a combination of both at University of California medical centre were reviewed retrospectively and the incidence of radiological manifestations of DISR was assessed among these treatment groups. RESULTS: Radiological manifestations of DISR were found in 19/457 patients (4.1%). The mean interval from the initiation of immunotherapy to development of DISR was 5.5 months (range 2.3-13.5 months). Mean interval from radiological detection of DISR to imaging evidence of resolution was 5.8 months (range 1.6-18.3 months). Three patients out of 81 (3.7%), 11/297 (3.7%), and 5/79 (6.3%) developed sarcoidosis-like reaction after treatment with anti-CTLA-4 antibody, anti-PD-1 antibody, and a combination of both, respectively. Most patients with DISR were asymptomatic and did not require systemic therapy. Most patients did not demonstrate concomitant increased maximum standardised uptake value (SUVmax) in other organs on their integrated 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT). CONCLUSIONS: In the present retrospective study of patients treated with immune checkpoint inhibitors (ICIs), DISR occurred in approximately 3.7% of patients treated with either anti-CTLA-4 or anti-PD-1 antibody and 6.3% of patients treated with a combination of both.

Microbialites show a distinct cyanobacterial phylogenetic structure and functional redundancy in Bacalar lagoon and Cenote Azul sinkhole, Yucatan Peninsula, Mexico.

Cyanobacterial components of microbialites from two geographically close systems, the Bacalar lagoon (BL) and the Cenote Azul sinkhole (CA) in Quintana Roo, Mexico, were characterized. BL and CA systems were studied along a longitudinal gradient (north to south) and a depth gradient (5-30 m), respectively. Microscopic observations, 16S rRNA amplicon sequencing, and shotgun metagenomics were used to characterize Cyanobacteria. Both systems showed similar metabolic/functional profiles but harbored completely different cyanobacterial taxa. BL was dominated by Nostocales, including a population of previously undescribed Chakia sp., while CA was dominated by an unknown taxon of Chroococcales, comprising 70% of relative abundance through all depths. Interestingly, cyanobacterial assemblages in microbialites exhibited phylogenetic overdispersion in most of the BL sites, while CA sites exhibited phylogenetic clustering, these differences were attributed to depth/light conditions and possibly different times of geological formation for BL and CA systems.

A multi-center retrospective cohort study defines the spectrum of kidney pathology in Coronavirus 2019 Disease (COVID-19).

Kidney failure is common in patients with Coronavirus Disease-19 (COVID-19), resulting in increased morbidity and mortality. In an international collaboration, 284 kidney biopsies were evaluated to improve understanding of kidney disease in COVID-19. Diagnoses were compared to five years of 63,575 native biopsies prior to the pandemic and 13,955 allograft biopsies to identify diseases that have increased in patients with COVID-19. Genotyping for APOL1 G1 and G2 alleles was performed in 107 African American and Hispanic patients. Immunohistochemistry for SARS-CoV-2 was utilized to assess direct viral infection in 273 cases along with clinical information at the time of biopsy. The leading indication for native biopsy was acute kidney injury (45.4%), followed by proteinuria with or without concurrent acute kidney injury (42.6%). There were more African American patients (44.6%) than patients of other ethnicities. The most common diagnosis in native biopsies was collapsing glomerulopathy (25.8%), which was associated with high-risk APOL1 genotypes in 91.7% of cases. Compared to the five-year biopsy database, the frequency of myoglobin cast nephropathy and proliferative glomerulonephritis with monoclonal IgG deposits was also increased in patients with COVID-19 (3.3% and 1.7%, respectively), while there was a reduced frequency of chronic conditions (including diabetes mellitus, IgA nephropathy, and arterionephrosclerosis) as the primary diagnosis. In transplants, the leading indication was acute kidney injury (86.4%), for which rejection was the predominant diagnosis (61.4%). Direct SARS-CoV-2 viral infection was not identified. Thus, our multi-center large case series identified kidney diseases that disproportionately affect patients with COVID-19 and demonstrated a high frequency of APOL1 high-risk genotypes within this group, with no evidence of direct viral infection within the kidney.

Early Posttransplant Blood Transfusion and Risk for Worse Graft Outcomes.

INTRODUCTION: Blood transfusion is a risk factor for allosensitization. Nevertheless, blood transfusion posttransplant remains a common practice. We evaluated the effect of posttransplant blood transfusion on graft outcomes. METHODS: We included nonsensitized, first-time, kidney-alone recipients transplanted between 1 July 2015 and 31 December 2017. Patients were grouped based on receiving blood transfusion in the first 30 days posttransplant. The primary end point was a composite outcome of biopsy-proven acute rejection, death of any cause, or graft failure in the first year posttransplant. Secondary outcomes included the individual components of the primary outcome and the cumulative incidence of de novo donor-specific antibodies (DSAs). RESULTS: Two hundred seventy-three patients were included. One hundred twenty-seven (47%) received blood transfusion. Patients in the transfusion group were more likely to be older, have had a deceased donor, and have received induction with basiliximab. There was no difference between groups in the composite primary outcome (adjusted hazard ratio = [HR] 1.34; 95% confidence interval [CI], 0.83-2.17; P = 0.23). The cumulative incidence of de novo DSAs during the first year posttransplant was similar between groups (12.8% transfusion vs. 10.9% no transfusion, P = 0.48). CONCLUSION: Early transfusion of blood products in kidney transplant recipients receiving induction with lymphocyte depletion was not associated with an increased hazard of experiencing acute rejection, death from any cause, or graft loss.

Fístula cutánea odontogénica: a propósito de un caso / Odontogeniccutaneous fistula: a case report

Resumen Las fístulas cutáneas de origen odontogénico son canales anómalos originados a partir de procesos infecciosos dentarios crónicos,que desembocan en la superficie de la mucosa de la cavidad oral o cutánea. El diagnóstico es clínico y se confirma con radiografía panorámica. Los diagnósticos diferenciales son principalmente actinomicosis, tuberculosis cutánea crónica, histoplasmosis y neoplasias. El tratamiento consiste en la extracción quirúrgica de la causa y del trayectofistuloso.

Summary Skin fistulas of odontogenic origin are abnormal channels originating from chronic dental infectious processes, which flow into the mucosal surface of the oral or skin cavity. The diagnosis is clinical and confirmed with panoramic radiography. Differential diagnoses are mainly actinomycosis, chronic cutaneous tuberculosis, histoplasmosis, and neoplasms. Treatment consists of surgical removal of the cause and the fistulous tract.

Influence of operational conditions and wastewater properties on the removal of organic micropollutants through ozonation.

The objective of this study was to evaluate the influence of operational conditions and wastewater properties on the removal of pharmaceuticals, contrast media and antibiotics through ozonation, in order to facilitate the optimization of treatment and its implementation on a full scale. Pilot-scale ozone oxidation trials were performed on treated wastewater, before and after post-precipitation, over a seven-month period, including summer and winter months. Hydraulic retention times as short as 7 min were found to be sufficient for organic micropollutant removal. A short hydraulic retention time reduces both investment costs and land use. Neither the choice of ozone dispersion method, a static mixer or a Venturi injector, nor the wastewater temperature had any significant effect on the removal efficiency of organic micropollutants, however, higher removal was achieved after on-site post-precipitation with aluminum chloride.

APOL1 Risk Variants and Acute Kidney Injury in Black Americans with COVID-19.

BACKGROUND AND OBJECTIVES: Black Americans have a higher incidence of kidney disease compared with populations that do not have recent African ancestry. Two risk variants in the APOL1 are responsible for a portion of this higher risk. We sought to assess the odds of AKI conferred by APOL1 risk alleles in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Black Americans who tested positive for coronavirus disease 2019 (COVID-19) were genotyped to determine APOL1 risk allele status. We assessed the incidence of AKI, persistent AKI, and AKI requiring KRT within 21 days of the PCR-based diagnosis. Outcomes were adjusted for age, sex, body mass index, hypertension, eGFR, and use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. RESULTS: In total, 126 cases of SARS-CoV-2 infection were included within a 5-month period, with 16 (13%) and 110 (87%) cases with two and zero/one APOL1 high-risk alleles, respectively. AKI occurred in 11 (69%) patients with two APOL1 high-risk alleles and 39 (35%) patients with zero/one high-risk alleles (adjusted odds ratio, 4.41; 95% confidence interval, 1.11 to 17.52; P=0.04). Persistent AKI occurred in eight (50%) patients with two APOL1 high-risk alleles and 21 (19%) of those with zero/one high-risk alleles (adjusted odds ratio, 3.53; 95% confidence interval, 1.8 to 11.57; P=0.04). AKI KRT occurred in four (25%) of those with two APOL1 high-risk alleles and eight (7%) of those with zero/one high-risk alleles (adjusted odds ratio, 4.99; 95% confidence interval, 1.02 to 24.4, P=0.05). CONCLUSIONS: APOL1 high-risk alleles are associated with greater odds of AKI in Black American patients with COVID-19.

Programmed cell death-1 (PD-1) and programmed death-ligand 1 (PD-L1) expression in PD-1 inhibitor-associated colitis and its mimics.

AIMS: Immune checkpoint inhibitors (ICIs) have revolutionised the treatment of advanced malignancies by boosting immune-mediated destruction of neoplastic cells, but are associated with side effects stemming from generalised immune system activation against normal tissues. Checkpoint ligand expression in non-tumoral cells of tissues affected by immune-related adverse effects has been described in ICI-associated hypophysitis, myocarditis, and acute interstitial nephritis. We aimed to investigate the tissue expression of the immune checkpoint receptor programmed cell death-1 (PD-1) and its ligand, programmed death-ligand 1 (PD-L1), in PD-1 inhibitor-associated colitis (PD1i colitis). METHODS AND RESULTS: PD-1 and PD-L1 immunohistochemical expression levels were analysed in 15 cases of PD1i colitis and potential mimics-infectious colitis and inflammatory bowel disease (IBD). Increased epithelial expression of PD-L1 was observed in PD1i colitis as compared with normal colon and infectious colitis, but the expression level was lower than that in IBD. Conversely, PD-1 expression in inflammatory cells was higher in infectious colitis, intermediate in IBD, and minimal or absent in normal colon and in patients receiving PD-1 inhibitors. CONCLUSIONS: Although our results do not justify the use of PD-L1 as a discriminatory marker of PD1i colitis against other entities within the differential diagnosis, they support the concept that PD1i colitis and IBD have similar pathogenetic mechanisms. They also highlight the fact that PD-L1 epithelial overexpression is a commonly used mechanism of the gastrointestinal tract mucosa to protect itself from inflammatory-mediated damage resulting from different aetiologies, which probably underpins the high incidence of gastrointestinal immune-related adverse effects in patients receiving ICI therapies, in whom this mechanism is disrupted.

Lost in Transportation: Calcium Oxalate Crystals in Kidney Biopsy Specimens Fixed in Michel Medium May Disappear.

CONTEXT.­: Calcium oxalate (CaOx) deposits in a kidney biopsy specimen can be seen in acute or chronic kidney injury and in oxalate nephropathy. Although no established cutoff criteria to diagnose oxalate nephropathy versus incidental CaOx deposition in the kidney exist, these conditions require different treatment. We noticed a significant decrease in the number of CaOx deposits in the kidney biopsy cores that were fixed in Michel transport medium (MTM) as compared to their counterparts fixed in formalin. OBJECTIVE.­: To investigate the impact of different fixatives on the number of CaOx deposits in kidney biopsy specimens. DESIGN.­: Retrospective search for kidney biopsies with diagnosis of CaOx deposition was performed in our Renal Pathology Database between January 1, 2015 and October 15, 2018. RESULTS.­: Seventy-six biopsies with an increased number of CaOx deposits were identified. CaOx deposits were counted on slides from the frozen tissue (MTM fixed or fresh frozen) and from the formalin-fixed cores. The density of CaOx deposits was significantly higher in formalin-fixed cores (13.6 ± 10.0/cm) than in MTM-fixed cores (3.2 ± 5.1/cm; P < .001). CaOx density in the kidney biopsy specimens decreased progressively with increased fixation time in MTM. No significant differences in the CaOx density between formalin-fixed and fresh frozen tissue were observed. CONCLUSIONS.­: Our data demonstrate that fixation in MTM may result in a significant reduction in the number of CaOx deposits in a kidney biopsy specimen. This may make the diagnosis difficult, especially in small biopsy specimens with limited tissue in the formalin-fixed paraffin block.

Trends in the Use of Cardiac Imaging for Patients With Heart Failure in Canada.

Importance: Cardiac imaging is a component of the provision of medical care for patients with heart failure that has experienced a broad expansion in past decades. However, there is a paucity of studies examining the patterns of use of cardiac imaging modalities in real-world clinical practice. Objectives: To investigate temporal trends in the use and costs of cardiac imaging for the examination of patients with heart failure in Canada and to examine the association between the institution of an accreditation program and the use of echocardiography. Design, Setting, and Participants: A repeated cross-sectional study based on population-based administrative databases in Ontario, Canada, of individuals with heart failure identified using a validated algorithm based on hospital admissions and ambulatory physician claims was conducted between April 1, 2002, and March 31, 2017. Main Outcomes and Measures: The incidence and prevalence of heart failure and the age- and sex-adjusted rate of use and costs of cardiac imaging, including resting and stress echocardiography, myocardial perfusion scintigraphy, invasive coronary angiography, computed tomography, magnetic resonance imaging, and positron emission tomography. Results: A total of 882 355 adults (50.1% women; median age, 76 years [interquartile range, 66-83 years]) with prevalent heart failure were identified. The age- and sex-standardized prevalence of heart failure remained stable during the study (2.4% [95% CI, 2.4%-2.4%] in 2002 and 2.0% [95% CI, 2.0%-2.0%] in 2016). There was an increase in the rate of use of resting echocardiography, from 386 tests (95% CI, 373-398) per 1000 patients with heart failure in 2002 to 533 (95% CI, 519-547) per 1000 patients in 2011. Coinciding with the initiation of an accreditation program for echocardiography in 2012, there was an immediate reduction in the rate of use (-59.5 tests per 1000 patients with heart failure; P < .001), which was followed by a plateau in subsequent years. At the same time, there was a 10.8% relative reduction in the use of myocardial perfusion scintigraphy and an 11.2% relative reduction in the use of invasive coronary angiography from 2011 to 2016 and the incorporation of newer modalities after they became publicly insured health services. Conclusions and Relevance: These findings suggest that resting echocardiography remains the most used imaging technique for patients with heart failure, exceeding the use of and the cost spent on other modalities. Stabilization in the use of traditional imaging modalities coincided temporally with the emergence of advanced techniques and provincewide quality improvement policy initiatives.

Importance of Nonobstructive Coronary Artery Disease in the Prognosis of Patients With Heart Failure.

OBJECTIVES: This study sought to examine the prognostic significance of nonobstructive coronary artery disease (CAD) in patients with heart failure (HF), as a distinct category apart from those with normal coronary arteries. BACKGROUND: Individuals with HF are often dichotomized into ischemic versus nonischemic categories according to the underlying etiology. This binary classification creates a heterogeneous group, combining individuals with nonobstructive CAD with those with normal coronary arteries under the nonischemic label. METHODS: A cohort of individuals with HF and reduced ejection fraction undergoing invasive coronary angiography was examined and linked to administrative databases for outcomes evaluation. Patients were divided into those with normal coronary arteries, nonobstructive disease, and obstructive disease. The primary outcome was the composite of cardiovascular death, nonfatal acute myocardial infarction, nonfatal stroke, or HF hospitalization. RESULTS: Of 12,814 individuals, 2,656 (20.7%) had normal coronary arteries, 2,254 (17.6%) had nonobstructive CAD, and 7,904 (61.7%) had obstructive CAD. The risk of the primary outcome was increased in the nonobstructive group (hazard ratio [HR]: 1.17; 95% confidence interval [CI]: 1.04 to 1.32; p = 0.01) relative to those with normal coronary arteries. Nonobstructive CAD was associated with an increased hazard of cardiovascular death (HR: 1.82; 95% CI: 1.27 to 2.62; p = 0.001) and death of any cause (HR: 1.18; 95% CI: 1.05 to 1.33; p = 0.005). There were no significant differences in the rate of acute myocardial infarction, stroke, or HF hospitalization. CONCLUSIONS: Among HF patients with reduced ejection fraction, the presence of nonobstructive CAD was independently associated with an increased hazard of the primary composite outcome and death of any cause.

Analysis of the effectiveness of training school personnel in the management of food allergy and anaphylaxis

Background: Food allergy is a very frequent and increasingly common disease in children and adolescents. It affects quality of life and can even be life-threatening. Given that 10-18% of allergic/anaphylactic food reactions take place in schools, it is essential to provide school personnel with training on the management of reactions. Methods: The Allergy Unit of Hospital Universitario de Fuenlabrada, Spain, organized a conference entitled "Management of Food Allergy in Children and Adolescents in School Centers" during which teachers, cooks, cafeteria monitors, and summer-camp leaders underwent a training course. Attendees filled out a questionnaire with eight questions before and after the course to assess their self-efficacy in management of food allergy and anaphylaxis. The results were compared. Results: A total of 191 people participated (51% dining-room monitors, 24% teachers, 13% cooks, and 12% other professions). The areas in which the attendees presented the lowest confidence before receiving the course were recognition of symptoms and treatment of the reactions/anaphylaxis. The mean score for each of the eight concepts evaluated improved after the training course. This improvement was significant in the management of anaphylaxis. Conclusions: Our study demonstrates the usefulness of a self-efficacy scale in school personnel as a tool to assess the ability to manage food allergy and anaphylaxis. It can help to identify problem areas in which more specific training programs can be implemented

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Analysis of the effectiveness of training school personnel in the management of food allergy and anaphylaxis.

BACKGROUND: Food allergy is a very frequent and increasingly common disease in children and adolescents. It affects quality of life and can even be life-threatening. Given that 10-18% of allergic/anaphylactic food reactions take place in schools, it is essential to provide school personnel with training on the management of reactions. METHODS: The Allergy Unit of Hospital Universitario de Fuenlabrada, Spain, organized a conference entitled "Management of Food Allergy in Children and Adolescents in School Centers" during which teachers, cooks, cafeteria monitors, and summer-camp leaders underwent a training course. Attendees filled out a questionnaire with eight questions before and after the course to assess their self-efficacy in management of food allergy and anaphylaxis. The results were compared. RESULTS: A total of 191 people participated (51% dining-room monitors, 24% teachers, 13% cooks, and 12% other professions). The areas in which the attendees presented the lowest confidence before receiving the course were recognition of symptoms and treatment of the reactions/anaphylaxis. The mean score for each of the eight concepts evaluated improved after the training course. This improvement was significant in the management of anaphylaxis. CONCLUSIONS: Our study demonstrates the usefulness of a self-efficacy scale in school personnel as a tool to assess the ability to manage food allergy and anaphylaxis. It can help to identify problem areas in which more specific training programs can be implemented.

Acute renal failure in a patient with PR3-ANCA and monoclonal immunoglobulin deposition disease: Case report.

RATIONALE: Acute renal failure developing over a short period of time with evidence of glomerular disease by urine sediment microscopy characterizes the clinical syndrome of rapidly progressive glomerulonephritis (RPGN), of which the most common causes are ANCA-associated glomerulonephritis (GN), immune-complex mediated GN and anti-GBM disease. PATIENT CONCERNS: This was a middle-aged gentleman who presented with acute renal failure and a positive PR3-ANCA. DIAGNOSIS: Renal biopsy showed an unusual combination of PR3-ANCA GN with focal crescents, monoclonal immunoglobulin deposition disease (MIDD) and mesangial IgA deposition on renal biopsy. INTERVENTIONS: Serum and urine protein electrophoresis (UPEP) and immunofixation showed no detectable monoclonal paraprotein; bone marrow biopsy was negative for plasma cell neoplasia. He received high dose steroids and rituximab. OUTCOMES: The patient did not respond to treatment and progressed to end-stage renal failure within 2 months after presentation. LESSONS: To our knowledge, the simultaneous occurrence of MIDD, PR3-ANCA and mesangial IgA has not been reported. This case highlights not only the diagnostic but also the therapeutic challenges that such a complex case presentation poses to clinicians, where the culprit may not always be what would seem most obvious (such as ANCA in a patient with RPGN) but may, in fact, be an underlying and unsuspected disease, or possibly a combination of both.

Percepciones de los profesionales sobre la atención prestada, obstáculos y dilemas éticos relacionados con el final de la vida en hospitales, centros de Atención Primaria y residencias de ancianos / Perceptions of health care professionals about end-of-life care, obstacles and ethical dilemmas in hospitals, primary care and nursing homes

Fundamento: Este estudio compara la percepción de la práctica profesional, los obstáculos percibidos y los dilemas éticos de profesionales de medicina y enfermería en la atención al final de la vida en atención primaria (AP), atención hospitalaria (AH) y residencias de ancianos (RA). Material y Métodos: Estudio descriptivo, transversal y multicéntrico. Se realizó un muestreo intencional de profesionales de medicina y enfermería con más de cuatro meses de antigüedad de cuatro hospitales, cinco centros de AP y veintinueve RA de Granada. Se recogieron mediante un cuestionario ad hoc: la percepción de la práctica profesional en ocho dimensiones (estructura y procesos, aspectos físicos, psicológicos, sociales, espirituales, culturales, éticos y cuidados del moribundo), la frecuencia percibida de dilemas éticos, y los obstáculos para el cuidado. Se compararon las puntuaciones de los distintos contextos con la prueba ANOVA y análisis post hoc. Resultados: Participaron 378 profesionales, 215 (56,9%) de AH, 97 (25,7%) de AP y 66 (17,5%) de RA. En comparación a los profesionales de AP y AH, los de RA fueron significativamente (p <0,01) más jóvenes y con mayor experiencia profesional, y puntuaron significativamente mejor (p <0,01) tanto su propia práctica profesional como la de la institución en relación a las dimensiones de estructura y procesos de atención, aspectos físicos, psicológicos, sociales, espirituales, culturales y atención al moribundo. Los aspectos psicológicos y éticos fueron los peor valorados en todos los contextos, no encontrándose diferencias respecto a estos últimos. En comparación a los otros ámbitos estudiados, los profesionales de AP identificaron menos dilemas y los de RA percibieron mayores obstáculos. Conclusiones: Profesionales de AP y AH presentan resultados similares en la percepción de la atención al final de la vida, e inferiores a los de RA, pese a que en las RA se presentan más dilemas y obstáculos

Background: This study compares the perceptions of physicians and nurses regarding professional practice, perceived obstacles and ethical dilemmas in end-of-life care in primary care (PC), hospitals and nursing homes (NH). Methods: Descriptive, cross-sectional and multicentre study. Intentional sampling of physicians and nurses with more than four months professional practice from four hospitals, five PC centres and twenty-nine NH in Granada was carried out. An ad hoc questionnaire was developed to assess perception of professional practice in eight dimensions (structure and processes of care, physical, psychological, social, spiritual, cultural, ethical aspects and care for the dying), frequency of ethical dilemmas, and obstacles to optimum care. Scores of different settings were compared using the ANOVA test and post hoc analysis. Results: A total of 378 professionals participated, 215 (56.9%) from hospitals, 97 (25.7%) from PC and 66 (17.5%) from NH. NH professionals were older and had more professional experience than those from PC and hospitals, and they also rated both the institution and their own professional practice significantly better (p<0.01) than other professionals with respect to the dimensions of structure and processes of care, physical, psychological, social, spiritual, cultural aspects and care for the dying. Psychological and ethical aspects were the worst valued in all settings, with no differences regarding ethical aspects. Fewer ethical dilemmas were identified by PC professionals, while NH professionals perceived greater obstacles to end-of-life care in relation to other settings. Conclusion: Primary care and hospitalization presented similar results on the perception of end-of-life care, and lower results than those of nursing homes, although in these centres more ethical dilemmas and more obstacles were identified