Cognitive biases and knowledge deficits leading to delayed recognition of cryptococcal meningitis.

Cryptococcal meningitis is a potentially devastating infectious complication of immunosuppression best characterized in individuals with HIV. Early recognition of and appropriate antifungal therapy for cryptococcal meningitis has a profound effect on outcomes, but with more varied presentations in well-resourced countries recognition may be delayed. We present four cases of cryptococcal meningitis in immunosuppressed patients, each with significant delays in diagnosis. Pulling from recollections of providers and the documented chart assessments, we discuss and tabulate the cognitive biases and diagnostic errors that contributed to delay. We further explore the knowledge deficits regarding cryptococcal meningitis that appeared in these cases. Once meningitis was considered, each of these cases of cryptococcal meningitis was rapidly diagnosed. Diagnostic delay was driven by knowledge deficits, followed by common biases such as availability heuristics and premature closing. These delays could be countered by maintaining broad differential diagnoses, re-evaluating the patient presentation after recognition of immunosuppression, and early consultation of specialists. Delay in diagnosis of cryptococcal meningitis is associated with high morbidity and mortality. By exploring the various case presentations and errors made, we hope to provide a counter to some of the knowledge deficits associated with cryptococcal meningitis, and to provide actionable advice for early consultation to infectious disease specialists in order to improve outcomes.

[Persistent chylothorax in patient with lymphangioleiomyomatosis]. / Quilotórax persistente en paciente con linfangioleiomiomatosis.

Lymphangioleiomyomatosis (LAM) is a rare disease that affects women in fertile age and presents a systemic progressive evolution, being the lung and the mediastinic lymph nodes the most affected organs. The pulmonary disease is characterized by dyspnea, pleural effusion, hemoptysis and spontaneous pneumothorax, being the chylothorax a frequent complication in the course of this disease, appearing in up to 30% of cases. The treatment of chylothorax is not standardized and it is necessary a multidisciplinary approach: nutritional, pharmacological, respiratory and even surgery. These patients present high risk of malnutrition due to the constant loss of chyle, therefore a suitable nutritional management is essential to avoid more complications.

Quilotórax persistente en paciente con linfangioleiomiomatosis / Persistent chylothorax in patient with lymphangioleiomyomatosis

La linfangioleiomiomatosis (LAM) es una enfermedad poco frecuente que afecta a mujeres en edad fértil y presenta una evolución sistémica progresiva, siendo el pulmón y los ganglios mediastínicos los órganos más afectados. La afectación pulmonar se caracteriza por disnea, derrame pleural, hemoptisis y neumotórax espontáneo, siendo el quilotórax una complicación frecuente en el curso evolutivo de esta enfermedad, produciéndose hasta en el 30% de casos. El tratamiento del quilotórax no está estandarizado y precisa de un manejo multidisciplinar nutricional, farmacológico, respiratorio y en ocasiones quirúrgico. Estos pacientes presentan un alto riesgo de malnutrición debido a la pérdida continua de quilo, por lo que es fundamental un adecuado tratamiento (AU)

Lymphangioleiomyomatosis (LAM) is a rare disease that affects women in fertile age and presents a systemic progressive evolution, being the lung and the mediastinic lymph nodes the most affected organs. The pulmonary disease is characterized by dyspnea, pleural effusion, hemoptysis and spontaneous pneumothorax, being the chylothorax a frequent complication in the course of this disease, appearing in up to 30% of cases. The treatment of chylothorax is not standardized and it is necessary a multidisciplinary approach: nutritional, pharmacological, respiratory and even surgery. These patients present high risk of malnutrition due to the constant loss of chyle, therefore a suitable nutritional management is essential to avoid more complications (AU)

Organic Thermochemistry at High ab Initio Levels. 3. A G3 Study of Cyclic Saturated and Unsaturated Hydrocarbons (Including Aromatics).

With the purpose of exploring the reliability of the enthalpies of formation calculated using the G3 method, we have examined a series of saturated and unsaturated alicyclic hydrocarbons varying the size and the number of formal double bonds in the molecule. Heats of formation have been calculated at the G3 level through both atomization reactions and bond separation isodesmic reactions, and comparisons with experimental values and with values previously calculated at the G2(MP2) and G2 levels have been made. The quality of the G3-calculated enthalpies of formation using atomization reactions is comparable to that obtained at the G2 level using bond separation reactions, whereas G3 calculations are two to three times faster than G2 calculations.

Changing patterns of gastric cancer mortality in Spain.

Time trends and the geographical variation of mortality from gastric cancer in Spain are analysed. The national (1961-1980) and the provincial (1975-1980) crude death rates as well as the age adjusted death rates were calculated using the population census (years 1960 and 1970) and the figures for national and provincial mortality. Mortality increased until 1963-1965 and then decreased significantly (P less than 0.01). Analysis of the geographic distribution reveals that the mortality rate is significantly higher in the interior than in the coastal provinces of the country, and higher in the provinces over 600 m above sea level.

[Should the diagnosis of cancer be communicated to patients? Evaluation of a sample opinion survey of the Spanish population]. / Faut-il communiquer le diagnostic de cancer aux malades? Evaluation d'un sondage d'opinion dans la population espagnole.

The aim of this paper is to determine the opinion of healthy individuals among whom might be future cancer patients, about communicating the diagnosis of this disease to the patients. An inquiry was performed on a representative sample of the spanish population. It covered 2493 persons over the age of 18. Two questions were asked: 1) "If you suffered from cancer would you prefer your physician to tell you or not?" 2) "If the cancer patient were a very near relative of yours (parent, etc.), would you wish the physician to inform the patient or not?" 69% gave a positive reply to the first question and 23% answered in the negative. The number of affirmative answers was significantly higher among the following groups: men (76%); young persons (82%); individuals with a high cultural level (79%; the unemployed (80%); and non-believers (86%). 42% answered "yes" to the second question and 44% answered "no". The number of affirmative answers was significantly higher among the following: men (48%); young people (54%); non-believers (65%); it was significantly lower among housewives (33%). The conclusion is that the diagnosis of cancer should not be communicated indiscriminately to the patient in all cases. The future problem lies in determining which persons should be informed of the diagnosis.

Hepatic acetylator polymorphism in breast cancer patients.

Hepatic acetylator phenotype has been determined, using sulfamethazine, in 81 white Spanish women with histologically proven breast cancer and in 75 adequate female controls. No differences were detected in the distribution of acetylator phenotype between the two groups of slow acetylators, 49 patients (60.5%) and 45 controls (60%). The percentage of acetylated sulfamethazine in plasma for each phenotype was not different either. Our results suggest that there is no relationship between the hepatic acetylator polymorphism and the risk of developing breast cancer in women.

[Evolution of breast cancer mortality in Spain]. / Evolution de la mortalité par cancer du sein en Espagne.

A study is presented about the evolution of the breast cancer mortality in Spain between 1961 and 1980. This has been increasing strongly of several factors: 1) In actual increase of this disease, rising its adjusted death rates by age from 8/100,000 (1961) to 13/100,000 (1980) (increase = 62%); the truncated standardized rates between 35 and 64 years raised from 18/100,000 (1961) to 28/100,000 (1980): there is high correlation between both types of rates. 2) An increase of the female population at breast cancer risk (over 45 yr). A selective and significative rise of mortality from this cancer for the age groups under menopause, especially for the group 30-34 years (160%). The increase of female breast cancer mortality is statistically significant. It is necessary researching the causes of such increase.