El bloqueo interatrial avanzado predice recurrencia de infarto cerebral embólico de origen no determinado / Advanced interatrial block predicts recurrence of embolic stroke of undetermined source

Antecedentes: El bloqueo interatrial avanzado (BIA-a) es considerado un factor de riesgo independiente para infarto cerebral (IC). Nuestro objetivo fue analizar si el BIA-a predice recurrencia de IC en pacientes con infarto cerebral embólico de origen no determinado (ESUS).MétodosCiento cuatro pacientes con diagnóstico confirmado de ESUS fueron seguidos durante una mediana de 15 meses (RIQ 10-48). Los datos clínicos, las características de la onda P y presencia de BIA en electrocardiograma realizado durante el evento índice, fueron registrados. La interpretación de los electrocardiogramas se realizó de forma centralizada y ciega en (XXXX2). La recurrencia de ESUS fue el desenlace primario.ResultadosLa mediana de edad de los casos fue de 47 años (rango 19-85); 50% fueron mujeres. Se encontró BIA en 36 casos (34,6%); parcial (BIA-p) en 29 (27,9%) y BIA-a en 7(6,7%). Dieciséis pacientes (15,4%) presentaron IC recurrente; de los cuales 5 tenían BIA-p y 4 BIA-a (p=0,01;OR 9,44:IC 95% 1,88-47,46). La mediana de duración de la onda P fue mayor en pacientes con recurrencia (p=0,009). En el análisis multivariado de regresión logística, los factores de riesgo independientes para recurrencia de IC fueron: el BIA-a (p<0,001; OR 10,86:IC 95% 3,07-38,46), género masculino (p=0,028; OR 4,6:IC 95% 1,18-17,96) y la edad mayor a 50 años (p=0,039; OR 3,84:IC 95% 1,06-13,88); en riesgos proporcionales de Cox fueron: edad mayor a 50 años (p=0,002; HR 7,04:IC 95% 2,06–23,8) y duración de la onda P (por ms) p=0,007 (HR 1,02:IC 95% 1,01-1,04).ConclusionesEl BIA-a y edad mayor a 50 años predicen recurrencia de ESUS. (AU)

Background: Advanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS).Methods104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram. Electrocardiogram findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable.ResultsMedian age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04).ConclusionsAdvanced IAB and age older than 50 years predict ESUS recurrence. (AU)

Advanced interatrial block predicts recurrence of embolic stroke of undetermined source. / El bloqueo interatrial avanzado predice recurrencia de infarto cerebral embólico de origen no determinado.

BACKGROUND: Advanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS). METHODS: 104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram. Electrocardiogram findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable. RESULTS: Median age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04). CONCLUSIONS: Advanced IAB and age older than 50 years predict ESUS recurrence.

Advanced interatrial block predicts recurrence of embolic stroke of undetermined source.

BACKGROUND: Advanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS). METHODS: 104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram (ECG). ECG findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable. RESULTS: Median age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04). CONCLUSIONS: Advanced IAB and age older than 50 years predict ESUS recurrence.

Bronquio traqueal o bronquio porcino. Imagen a propósitode un caso clínico / Tracheal bronchio or porcine bronchio. Image for the purpose of a clinical case

El bronquio traqueal o bronquio porcino es una rara anomalía congénita que se define como la salida del bronquio del lóbulo superior derecho directamente a la tráquea, próximo a la carina principal. En principio se considera una variante anatómica de la normalidad, pero hay que tener especial cuidado en ciertas situaciones como la intubación orotraqueal (AU)

The tracheal bronchus or porcine bronchus is a rare congenital anomaly that is defined as the exit of the bronchus from the right upper lobe directly to the trachea, close to the main carina. In principle, it is considered an anatomical variant of normality, but special care must be taken in certain situations such as orotracheal intubation (AU)

Cuerpo extraño intrabronquial. La importancia de una buenasistemática en la fbrobroncoscopia / Cuerpo extraño intrabronquial. La importancia de una buena sistemática en la fbrobroncoscopia

Una correcta sistemática en el estudio fibrobroncoscópico de masas tumorales periféricas es necesaria para describir todo el árbol bronquial, tales como la presencia de cuerpos extraños como en nuestro paciente. Nuestro caso condujo al diagnóstico de infección por Aspergillus spp, patología en la que dependiendo de su gravedad varía el tratamiento que se administra (AU)

A correct systematic in the fibrobronchoscopic study of peripheral tumor masses is necessary to describe the entire bronchial tree, such as the presence of foreign bodies as in our case. Our case led to the diagnosis of infection by Aspergillus spp, a pathology that, depending on its severity, varies the treatment administered (AU)

Chronic adolescent stress causes sustained impairment of cognitive flexibility and hippocampal synaptic strength in female rats.

Females that experience chronic stress during development, particularly adolescence, are the most vulnerable group to stress-induced disease. While considerable attention has been devoted to stress-induced manifestation of anxiety, depression, and PTSD, evidence indicates that a history of chronic stress is also a risk factor for cognitive decline and dementia - with females again in a higher risk group. This interplay between sex and stress history indicates specific mechanisms drive neural dysfunction across the lifespan. The presence of sex and stress steroid receptors in the hippocampus provides a point of influence for these variables to drive changes in cognitive function. Here, we used a rodent model of chronic adolescent stress (CAS) to determine the extent to which CAS modifies glutamatergic signaling resulting in cognitive dysfunction. Male and female Wistar rats born in-house remained non-stressed (NS), unmanipulated aside from standard cage cleaning, or were exposed to either physical restraint (60 min) or social defeat (CAS) each day (6 trials each), along with social isolation, throughout the adolescent period (PND 35-47). Cognition was assessed in adult (PND 80-130) male and female rats (n = 10-12) using the Barnes Maze task and the Attention Set-Shift task. Whole hippocampi were extracted from a second cohort of male and female rats (NS and CAS; n = 9-10) and processed for RNA sequencing. Brain tissue from the first cohort (n = 6) was processed for density of glutamatergic synaptic markers (GluA1, NMDA1a, and synaptophysin) or whole-cell patch clamping (n = 4) to determine glutamatergic activity in the hippocampus. Females with a history of chronic stress had shorter latencies to locate the goal box than NS controls during acquisition learning but showed an increased latency to locate the new goal box during reversal learning. This reversal deficit persisted across domains as females with a history of stress required more trials to reach criterion during the reversal phases of the Attention Set-Shift task compared to controls. Ovariectomy resulted in greater performance variability overall during reversal learning with CAS females showing worse performance. Males showed no effects of CAS history on learning or memory performance. Bioinformatic prediction using gene ontology categorization indicated that in females, postsynaptic membrane gene clusters, specifically genes related to glutamatergic synapse remodeling, were enriched with a history of stress. Structural analysis indicated that CAS did not alter glutamate receptor density in females. However, functionally, CAS females had a decreased AMPA/NMDA-dependent current ratio compared to controls indicating a weakening in synaptic strength in the hippocampus. Males showed only a slight change in density of NMDA1a labeling in the CA3 region with a history of stress. The data observed here suggest that females are at risk for impaired cognitive flexibility following a history of adolescent stress, possibly driven by changes in glutamatergic signaling.

Persistencia a largo plazo de agentes biológicos en el tratamiento de pacientes con Artritis Reumatoidea: una revisión sistemática de la literatura / Long-term persistence of biological agents in the treatment of patients with Rheumatoid Arthritis: a systematic literature review

La persistencia en el tratamiento es un marcador subrogante de éxito de tratamiento a largo plazo. Objetivo: Evaluar la persistencia de los agentes biológicos utilizados para el tratamiento de pacientes con artritis reumatoidea (AR) a un tiempo de 5 años y determinar las principales causas asociadas a persistencia o discontinuación. Material y métodos: Se realizó una revisión sistemática de la literatura (RSL), según las recomendaciones PRISMA, en las bases de datos Pubmed, Cochrane y Lilacs, y estudios presentados en los congresos ACR, EULAR, PANLAR (2018/2019) hasta Enero 2020. Dos revisoras independientes, evaluaron todas las publicaciones identificadas, por título y abstract y por full text, de acuerdo a la metodología PICO. Los criterios de elegibilidad fueron estudios de pacientes ≥ 18 años con diagnóstico de AR, en tratamiento con agentes biológicos, que midieran persistencia/discontinuación en un período de tiempo igual o superior a 5 años y que estuvieran en idioma inglés o español. En el caso de falta de acuerdo entre las dos revisoras, un tercer revisor fue consultado. La información extraída fue analizada mediante estadística descriptiva, se calculó el porcentaje promedio de persistencia de cada agente biológico a los 5 años. Resultados: Se seleccionaron 56 artículos luego de la remoción de los duplicados y de la exclusión por título/abstract, y por full text. De ellos 13, eran fase de extensión a largo plazo de estudios randomizados controlados, 15 cohortes retrospectivas, 18 cohortes prospectivas y 10 cohortes retro-prospectivas y correspondían a un total de 72177 (rango: 79-10396) pacientes con AR, con una edad media 53.8 años ± 12.1, 78.2% de sexo femenino y un tiempo promedio de evolución de la AR de 9.7 años ± 8.4. En 33.9% de los estudios, la terapia biológica estaba combinada con drogas modificadoras de la AR convencionales (DMARs-c), en 3.6% en monoterapia, 48.2% ambas modalidades y en 14.3% no informaba. Un estudio fue realizado en 1° línea (metotrexato näive), 29 estudios en 2° línea (respuesta inadecuada a MTX y/o DMARs-c), 5 en 3° línea (respuesta inadecuada a DMARs biológicas-b-), 12 en ≥2° línea terapéutica y en 9 no especificaban. En 30 estudios que evaluaron 2° línea terapéutica, la mayor persistencia correspondió a tocilizumab (TCZ) 66.41% (IC95% 57.8-79.94), abatacept (ABA) 57.91% (IC95% 50.96-64.87) y golimumab (GOL) 54.38% (IC95% 48.58-60.19). Y 10 estudios, en los cuales el DMAR-b había sido analizado en 3° línea terapéutica, las mayores tasas de retención correspondieron a rituximab (RTX) 61.19% (IC95% 57.53-66.22) y TCZ 61.1% (IC95% 58.81-63.32). Entre los estudios que evaluaron predictores, los más frecuentemente asociados a mayor sobrevida fueron: tratamiento combinado con DMAR-c, etanercept versus infliximab y adalimumab y 2° línea de tratamiento vs 3° o 4° línea y los asociados a menor sobrevida fueron: mayor uso de esteroides, mayor actividad basal de la enfermedad y sexo femenino. Conclusiones: En esta RSL, la persistencia de los DMAR-b a 5 años en pacientes con respuesta inadecuada a DMARs-c y DMARs-b fue numéricamente mayor para los agentes no TNFi. Y entre los TNFi, GOL presentó mayor retención en 2° línea terapéutica.

Treatment persistence is a surrogate marker for long-term treatment success. Objective: To assess the persistence of the biological agents used for treatment of patients with rheumatoid arthritis (RA) over 5 years period and to determine the main causes associated with persistence or discontinuation. Material and methods: A systematic literature review (SLR) was carried out, according to PRISMA recommendations, including Pubmed, Cochrane and Lilacs databases, and studies presented at the ACR, EULAR, PANLAR congresses (2018/2019) until January 2020. Two independent reviewers evaluated the identified publications, by title and abstract and full text, according to PICO methodology. Eligibility criteria were: studies including RA patients ≥ 18 years, treated with biological agents, which measured persistence/ discontinuation for a period of time equal to or greater than 5 years and who were in English or Spanish language. In the case of lack of agreement between the two reviewers, a third reviewer was consulted. The extracted information was analyzed using descriptive statistics, an average percentage of persistence for each biological agent at 5 years was calculated. Results: 56 articles were selected after removal of duplicates and exclusion by title/abstract, and by full text. Long-term extension phase of randomized controlled studies were 13, another 15 retrospective cohorts, 18 prospective cohorts and 10 retro-prospective cohorts and corresponded to a total of 72177 (range: 79-10396) patients with RA, with a mean age of 53.8 years ± 12.1, 78.2% female and an average RA disease duration of 9.7 years ± 8.4. In 33.9% of the studies, biological therapy was combined with conventional disease modifying anti-rheumatic drugs (c-DMARDs), in 3.6% monotherapy, 48.2% both modalities, and in 14.3% not reported. One study was in the 1st line (methotrexate näive), 29 studies in 2nd line (inadequate response to MTX and/or c-DMARDs), 5 in 3rd line (inadequate response to biological b-DMARDs), 12 in ≥2nd therapeutic line and in 9 studies did not specify this condition. In 30 studies which evaluated the 2nd therapeutic line, the highest persistence corresponded to tocilizumab (TCZ) 66.41% (95% CI 57.8-79.94), abatacept (ABA) 57.91% (95% CI 50.96-64.87) and golimumab (GOL) 54.38% (95% CI 48.58-60.19). In 10 studies, in which b-DMARD had been analyzed in 3rd therapeutic line, highest retention rates corresponded to rituximab (RTX) 61.19% (95% CI 57.53-66.22) and TCZ 61.1% (95% CI 58.81-63.32). Among studies that evaluated predictors, the most frequently associated with higher survival were: combined treatment with c-DMARD, etanercept versus infliximab and adalimumab and 2nd line of treatment vs. 3rd or 4th line whereas those associated with lower survival rates were: greater use of steroids, higher baseline disease activity, and female gender. Conclusions: In this SLR, the 5-year persistence of b-DMARD in patients with inadequate response to DMARs-c and DMARs-b was numerically greater for non-TNFi agents. And among TNFi, GOL presented a higher retention in 2nd therapeutic line.

Effectiveness of the use of an algorithm in the diagnostic approach of joint pain patients by primary care physicians.

There is a high percentage of error in the approach of patients with joint pain by primary care physicians. An algorithm can help improve this misdiagnosis problem. Our study seeks to determine the effectiveness of an algorithm when used by primary care physicians for the diagnosis of cases of joint pain patients. A randomized clinical experiment was carried out. Primary care physicians from five cities in Colombia developed a series of clinical cases, which were presented to them through a website on their personal cell phones. Half of the doctors developed the cases using the diagnostic algorithm, and the other half developed the cases without the use of the algorithm. Main measures were proportion of correct diagnosis, number, type of laboratory and diagnostic images requested for the diagnostic approach of clinical cases. Two hundred and twenty-four primary care physicians participated. The overall proportion of cases correctly diagnosed was 37.3% higher in the intervention group; we found a greater difference in cases of spondyloarthritis (60.8%), followed by systemic lupus erythematosus with joint involvement (32.2%), rheumatoid arthritis (30.3%) and osteoarthritis (25.9%). The average number of tests requested to develop clinical cases was lower in the intervention group than in the control group, both globally and for each of the four diseases, with statistically significant differences for each of the comparisons. The diagnostic algorithm proved to be an effective tool when used by primary care physicians; the proportion of correct diagnoses increased, and the number of tests requested in the development of the cases decreased.

Hidden Costs in the Physiology of Argia anceps (Zigoptera: Coenagrionidae) due to Pollution.

Before a population becomes extinct, there are hidden costs in the physiology at the individual level that provide valuable insights into their condition. Here, we study two dams with one species in common (Argia anceps Garrison, 1996) to evaluate whether their physiological condition differed (total protein quantity, prophenoloxidase (proPO) and phenoloxidase (PO) activity, and protein carbonylation) during two consecutive years. The first dam, "El Gallinero" (contaminated, C), contains organic input from mines and agricultural activity, whereas the second, "Paso de Vaqueros" (non-contaminated, NC), is part of a biosphere reserve. Although at a phenological level, some physiological differences were observed (2012 vs 2013), individuals from the contaminated population had less total protein (2012, median = 1.815 µg/µL; 2013, 0.081 µg/µL) and more carbonylations in their proteins (2012, median = 19.00 nmol/mg; 2013, median = 121.69 nmol/mg) compared with the non-contaminated population (protein quantity in 2012, median = 3.716 µg/µL; 2013, median = 0.054 µg/µL; protein carbonylations in 2012, median = 0.00 nmol/mg; 2013, median = 99.44 nmol/mg). However, no significant differences were found in prophenoloxidase (C, median = 0.002 Vmax; NC, median = 0.002 Vmax) and phenoloxidase activity (C, median = 0.002 Vmax; NC, median = 0.001 Vmax). In addition, the biological oxygen demand (BOD) and Zn were more elevated in the C than NC population (C, BOD = 11.7, Zn = 0.17; NC, BOD = 8, Zn = 0.14). The results show that the impact of human activity can be observed not only through the extinction of species, but also at the physiological level of the individuals composing the populations through the evaluation of biomolecular damage, which can be observed at a much shorter scale compared with species extinction.

Cheiloscopy in individuals with Down syndrome and their nonsyndromic biological siblings.

The study aimed to carry out a comparative analysis between the lip print patterns in individuals with Down Syndrome and their nonsyndromic biological siblings. This was a cross-sectional blind study using an inductive approach and extensive direct observation procedures. A total of 68 cheiloscopic charts, named cheilograms, were divided into two groups (n=34), as follows: G1, including Down Syndrome individuals; and G2, including their nonsyndromic siblinggs. The convenience sample was selected in the city of João Pessoa, PB, Brazil. The following features were evaluated in eight labial regions called sub-quadrants: oral commissures (downturned, horizontal and upturned); lip thickness (thin, medium, thick and mixed); and labial grooves (I - complete vertical; I '- incomplete vertical; II - bifurcated; III - criss-cross; IV - reticular; or V - undefined). The data were analyzed by paired Student's t test and McNemar's Chi-square, with a 5% significance level. Most Down Syndrome individuals were found to have downturned oral commissures in 73.5% of cases, while their siblings showed a predominance of horizontal commissures in 73.5% of cases (p=0.009). There was no statistically significant difference for lip thickness between groups. In the analysis of labial groove patterns, Down Syndrome individuals (G1) showed a significant prevalence of the type I pattern (52.2%) as compared to their nonsyndromic siblings (30.1%) (p =< 0.001). Due to the tendency of having vertical labial groove patterns and downturned commissures, Down Syndrome individuals present cheiloscopic differences in relation to their nonsyndromic biological siblings, which suggests that syndromic genetics influences the development of these features. However, this may imply in a reduced potential of cheiloscopic identification due to the low divergence of labial phenotypes among Down Syndrome individuals.

Infección quirúrgica profunda en cirugía instrumentada de raquis toracolumbar. Diez años de experiencia / Deep surgical site infection following thoracolumbar instrumented spinal surgery. Ten years of experience

Objetivo: Describir las características y la evolución de la infección profunda en cirugía instrumentada de raquis toracolumbar (IPCITL) en nuestro centro en un periodo de 10años. Material y método: Estudio descriptivo retrospectivo. Se analizan datos del paciente (epidemiológicos/salud), datos operatorios, presentación de la infección, gérmenes cultivados, limpiezas quirúrgicas requeridas, extracción de los implantes y complicaciones significativas derivadas de la infección. Resultados: Se revisan 110 pacientes (80mujeres). El seguimiento medio tras el diagnóstico de infección fue de 3,6años. Etiologías más frecuentes: escoliosis idiopática del adolescente, deformidad del adulto y estenosis lumbar degenerativa. El 62% de pacientes presentaban algún dato clínico que les hacía proclives a la infección. La aparición de la infección fue precoz (0-3meses de la cirugía primaria) en el 60,4% de los casos, retardada (3-24meses) en el 11,7% y tardía (más de 24meses) en el 27%. Todos los pacientes fueron tratados mediante limpieza quirúrgica. El 25% necesitaron más de una limpieza. Se extrajeron los implantes en el 46% de los pacientes (en el 71% de ellos en la primera limpieza). Los gérmenes aislados con mayor frecuencia fueron Staphylococcus coagulasa-negativo, Propionibacterium acnes y Enterococcus. Hubo complicaciones significativas derivadas de la IPCITL en el 15% de casos. El 88% de ellas precisaron cirugías complejas para su tratamiento. Conclusiones: Las IPCITL tardías son más frecuentes de lo esperado según la literatura. En IPCITL globalmente predominan gérmenes cutáneos. Las IPCITL provocan una alta tasa de complicaciones, que habitualmente requieren tratamiento mediante cirugías complejas

Objective: To describe thee characteristics and evolution of deep surgical site infection following thoracolumbar instrumented spinal surgery (DSITIS) in our centre over a period of ten years. Material and method: Descriptive retrospective study. Patient data (epidemiological/health status), surgical data, infection characteristics/presentation, isolated microorganisms, required surgical debridements, implant removal and major complications linked to infection were evaluated. Results: We included 110 patients (80 females). Median follow-up after infection diagnosis was 3.6years. Adolescent idiopathic scoliosis, adult deformity and degenerative lumbar stenosis were the most frequent aetiologies. Sixty-two percent of the patients had at least one clinical feature that made them prone to infection. Infection presentation was early (0-3months from first surgery) in 60.4% of the cases, delayed (3-24months) in 11.7%, and late (more than 24months) in 27%. All patients were treated by surgical debridement. Twenty-five percent needed more than one surgical debridement. Implants were removed in 46% of the patients (71% in the first surgical debridement). The most frequent isolated microorganisms were coagulasa-negative Staphylococcus, Propionibacterium acnes and Enterococcus. Major complications appeared in 15% of the patients, and 88% of them required major surgeries. Conclusions: Late DSITIS is more frequent than previously reported. Skin microorganisms predominate among the DSITIS culprits. DSIITS produce a high rate of major complications that usually require major surgery for treatment

Management of non-renal non-neurologic persistent lupus activity in real world patients from Argentina.

Management of systemic lupus erythematosus patients is challenging because of disease heterogeneity. Although treatment of renal nephritis is more standardized, treating non-renal lupus activity remains controversial. Our objective was to identify non-renal, non-neurologic persistent active systemic lupus erythematosus patients in our cohort and described therapeutic behaviors in them. All systemic lupus erythematosus patients (American College of Rheumatology and/or Systemic Lupus Erythematosus International Collaborating Clinics criteria) seen at a university hospital between 2000 and 2017 were included and electronic medical records manually reviewed. Persistent lupus activity was defined as a patient with a Systemic Lupus Erythematosus Disease Activity Index score ≥ 6 (without renal and central nervous system manifestations) despite being on a stable treatment regimen for ≥ 30 days. Stable treatment could include prednisone alone (7.5-40 mg/d) or combined with antimalarial drugs and immunosuppressant therapies. A total of 257 lupus patients were included, 230 females (89.5%, 95% confidence interval 85.1-92.7), mean age at diagnosis 29.9 years (SD 16.4). After a median cohort follow-up of 5.7 years (interquartile range 2.4-10.2), 14 patients (5.4%, 95% confidence interval 3.2-9.0) showed persistent non-renal non neurologic lupus activity, with a median disease duration of 11.3 years (interquartile range 3.6-19.4). At that time, 12/14 (85.7 %, 95% confidence interval 52.6-97.0%) had low complement and 11/14 (78.6 %, 95% confidence interval 46.5-93.9%) had positive antiDNA antibodies. The main reasons for being refractory were mucocutaneous disease (50%, 95% confidence interval 23.5-76.5) and arthritis (42.9%, 95% confidence interval 18.5-71.2). Therapeutic choices after being refractory were: only increasing corticosteroid dose in one patient, starting rituximab in four, belimumab in eight, and in one mycophenolate and rituximab; with good response in all of them. In conclusion, 5.4% of systemic lupus erythematosus patients in our cohort were considered to have non-renal non neurologic persistent lupus activity, with mucocutaneous and arthritis the main manifestations. In total, 92.8% of these patients started a biologic treatment at this point (rituximab or belimumab).

Correction to: PANLAR consensus statement on biosimilars.

The two co-authors of the mentioned above article were incorrect. The correct are authors should have been "P. A. Beltrán" instead of "P. A. B. Roa" and "J. F. Diaz-Coto" instead of "L. Diaz Soto".

Causes of fetal third-degree atrioventricular block and use of hydroxychloroquine in pregnant women with Ro/La antibodies.

INTRODUCTION/OBJECTIVES: Complete congenital atrioventricular block (AVB) may be due to cardiac malformations or the presence of maternal antibodies (autoimmune AVB). Our objective was to estimate the prevalence of autoimmune AVB among all AVB in newborns treated at our hospital. Secondly, we estimated the prevalence of AVB among mothers with anti-Ro/La antibodies and examined the relationship of those fetal AVB with mother's use of hydroxychloroquine during pregnancy. METHODS: Retrospective cohort in which we reviewed electronic medical records from years 2000 to 2014 of (a) all mothers with children born with third degree AVB and (b) all pregnant women with anti-Ro/La-positive antibodies. RESULTS: Twenty-three AVBs were diagnosed. Ten (43.5%, 95% CI 23.2-65.5) were associated with maternal rheumatologic disease. The remaining 13 were associated with cardiac malformations. Sixty-two pregnancies in 47 mothers with Ro/La antibodies were identified; eight (12.9%, 95% CI 5.7-23.8) suffered AVB. Fourteen mothers consumed hydroxychloroquine during full pregnancy (one newborn (7.1%) suffered AVB) and 48 did not (7 newborns with AVB (14.6%); p = 0.5). CONCLUSIONS: All congenital AVB diagnosed at our hospital without cardiac malformations were associated with a maternal rheumatologic disease/antibodies. Therefore, if a AVB is diagnosed in a newborn without structural heart disease, the mother should be studied for an autoimmune disease. We found a high prevalence of AVB among mothers with anti-Ro/La antibodies. Although not statistically significant, AVBs in mothers with Ro/La antibodies were numerically more frequent in those not using hydroxychloroquine.Key Points• Although structural heart malformations were the predominant cause of third-degree AVB, autoimmune AVB was still a significant cause.• The distinction between structural or non-structural cause of AVB constitutes an essential issue since it determines the prognostic of these fetuses in terms of complications.• Although not statistically significant, AVBs in mothers with Ro/La antibodies were more frequent in those not using hydroxychloroquine.• If an AVB is diagnosed in a newborn without structural heart disease, the mother should be studied for an autoimmune disease.

PANLAR consensus statement on biosimilars.

INTRODUCTION: Biologics have improved the treatment of rheumatic diseases, resulting in better outcomes. However, their high cost limits access for many patients in both North America and Latin America. Following patent expiration for biologicals, the availability of biosimilars, which typically are less expensive due to lower development costs, provides additional treatment options for patients with rheumatic diseases. The availability of biosimilars in North American and Latin American countries is evolving, with differing regulations and clinical indications. OBJECTIVE: The objective of the study was to present the consensus statement on biosimilars in rheumatology developed by Pan American League of Associations for Rheumatology (PANLAR). METHODS: Using a modified Delphi process approach, the following topics were addressed: regulation, efficacy and safety, extrapolation of indications, interchangeability, automatic substitution, pharmacovigilance, risk management, naming, traceability, registries, economic aspects, and biomimics. Consensus was achieved when there was agreement among 80% or more of the panel members. Three Delphi rounds were conducted to reach consensus. Questionnaires were sent electronically to panel members and comments about each question were solicited. RESULTS: Eight recommendations were formulated regarding regulation, pharmacovigilance, risk management, naming, traceability, registries, economic aspects, and biomimics. CONCLUSION: The recommendations highlighted that, after receiving regulatory approval, pharmacovigilance is a fundamental strategy to ensure safety of all medications. Registries should be employed to monitor use of biosimilars and to identify potential adverse effects. The price of biosimilars should be significantly lower than that of reference products to enhance patient access. Biomimics are not biosimilars and, if they are to be marketed, they must first be evaluated and approved according to established regulatory pathways for novel biopharmaceuticals. KEY POINTS: • Biologics have improved the treatment of rheumatic diseases. • Their high cost limits access for many patients in both North America and Latin America. • Biosimilars typically are less expensive, providing additional treatment options for patients with rheumatic diseases. • PANLAR presents its consensus on biosimilars in rheumatology.

Sexto reporte de eventos adversos con tratamientos biológicos en Argentina: Informe del registro BIOBADASAR / Sixth report of adverse events with biological treatments in Argentina: Report of the BIOBADASAR registry

Objetivo: Actualizar los resultados del registro BIOBADASAR sobre seguridad, duración y causas de interrupción del tratamiento luego de 8 años de seguimiento. Métodos: BIOBADASAR es un registro de seguridad de terapias biológicas establecido por la Sociedad Argentina de Reumatología. Se presenta la descripción de BIOBADASAR 3.0, una cohorte compuesta por 53 centros de Argentina seguidos prospectivamente desde agosto de 2010 hasta enero de 2018. Resultados: Se registraron 4656 pacientes, 6234 tratamientos [3765 casos (terapia con biológicos) y 2469 controles (terapia no biológicos)]. Se interrumpió el tratamiento en el 44,6% en los casos vs. 27,9% en los controles. Causa principal de discontinuación fue por ineficacia (40% casos vs. 32% controles). Se presentaron 3154 eventos adversos (2230 en casos vs. 924 en controles), de los cuales el 13,6% fueron graves (9,8% en casos y 3,7% en controles). El evento adverso (EA) más frecuente en ambos grupos fueron las infecciones (43,56% en casos vs. 34,31% en los controles, RR: 3,42; IC 95%: 3,02-3,88), y de ellas las de vías aéreas superiores (14,5%). Las neoplasias se presentaron en 78 casos vs. 45 en controles (RR: 1,98; IC 95%: 1,37-2,86). Conclusiones: En este sexto reporte no se observan tendencias diferentes sobre seguridad, duración y causas de interrupción del tratamiento respecto a informes previos. Las infecciones fueron el principal EA y la ineficacia, seguido por EA y la pérdida de pacientes las principales causas de suspensión del tratamiento. El advenimiento de nuevos agentes biológicos y la necesidad de control en seguridad a largo plazo, fortalece el uso de este tipo de registro.

Objective: Update the results of the BIOBADASAR registry on safety, duration and causes of treatment interruption after 8 years of follow-up. Methods: BIOBADASAR is a safety record of biological therapies established by the Argentine Society of Rheumatology. The description of BIOBADASAR 3.0 is presented, a cohort of 53 centers in Argentina followed prospectively from August 2010 to January 2018. Results: 4656 patients were registered, 6234 treatments [3765 cases (therapy with biologicals) and 2469 controls (non-biological therapy)]. Treatment was interrupted in 44.6% in cases vs. 27.9% in controls. Main cause of discontinuation was due to inefficiency (40% cases vs. 32% controls). There were 3154 adverse events (2230 in cases vs. 924 in controls), of which 13.6% were tombs (9.8% in cases and 3.7% in controls). The most frequent adverse event (AE) in both groups were infections (43.56% in cases vs. 34.31% in controls, RR: 3.42, 95% CI: 3.02-3.88), and the upper airway pathways (14.5%). Neoplasms were published in 78 cases versus 45 controls (RR: 1.98, 95% CI: 1.37-2.86). Conclusions: In this article, there are no different trends regarding safety, duration and causes of interruption of treatment compared to previous reports. Infections were the main causes of treatment discontinuation. The advent of new biological agents and the need for control over long-term security, strengthens the use of this type of registration.

Deep surgical site infection following thoracolumbar instrumented spinal surgery. Ten years of experience. / Infección quirúrgica profunda en cirugía instrumentada de raquis toracolumbar. Diez años de experiencia.

OBJECTIVE: To describe the characteristics and evolution of deep surgical site infection following thoracolumbar instrumented spinal surgery (DSITIS) in our centre over a period of ten years. MATERIAL AND METHOD: Descriptive retrospective study. Patient data (epidemiological/health status), surgical data, infection characteristics/presentation, isolated microorganisms, required surgical debridements, implant removal and major complications linked to infection were evaluated. RESULTS: We included 110 patients (80 females). Median follow-up after infection diagnosis was 3.6years. Adolescent idiopathic scoliosis, adult deformity and degenerative lumbar stenosis were the most frequent aetiologies. Sixty-two percent of the patients had at least one clinical feature that made them prone to infection. Infection presentation was early (0-3months from first surgery) in 60.4% of the cases, delayed (3-24months) in 11.7%, and late (more than 24months) in 27%. All patients were treated by surgical debridement. Twenty-five percent needed more than one surgical debridement. Implants were removed in 46% of the patients (71% in the first surgical debridement). The most frequent isolated microorganisms were coagulasa-negative Staphylococcus, Propionibacterium acnes and Enterococcus. Major complications appeared in 15% of the patients, and 88% of them required major surgeries. CONCLUSIONS: Late DSITIS is more frequent than previously reported. Skin microorganisms predominate among the DSITIS culprits. DSIITS produce a high rate of major complications that usually require major surgery for treatment.

Towards standardized patient reported physical function outcome reporting: linking ten commonly used questionnaires to a common metric.

OBJECTIVES: Outcomes obtained using different physical function patient reported outcome measures (PROMs) are difficult to compare. To facilitate standardization of physical function outcome measurement and reporting we developed an item response theory (IRT) based standardized physical function score metric for ten commonly used physical function PROMs. METHODS: Data of a total of 16,386 respondents from representative cohorts of patients with rheumatic diseases as well as the Dutch general population were used to map the items of ten commonly used physical function PROMs on a continuous latent physical function variable. The resulting IRT based common metric was cross-validated in an independent dataset of 243 patients with gout, osteoarthritis or polymyalgia in which four of the linked PROMs were administered. RESULTS: Our analyses supported that all 97 items of the ten included PROMs relate to a single underlying physical function variable and that responses to each item could be described by the generalized partial credit IRT model. In the cross-validation analyses we found congruent mean scores for four different PROMs when the IRT based scoring procedures were used. CONCLUSIONS: We showed that the standardized physical function score metric developed in this study can be used to facilitate standardized reporting of physical function outcomes for ten commonly used make physical function PROMs.

The Brazilian identified human osteological collections.

This short communication aims to inform the scientific community of the existence of seven identified osteological collections in Brazil, most of which are housed in universities: 21st Century Collection of the Center for Studies in Forensic Anthropology, Recife; Identified Skeletal Collection of Sergipanos of the University Tiradentes, Aracaju; Identified Skull Collection of the State of Bahia, Aracaju; Osteological and Tomographic Collection - Prof. Dr. Eduardo Daruge, Piracicaba; Osteological Collection of the Institute of Teaching and Research in Forensic Sciences, Guarulhos; Identified Skull Collection of the Anatomy Museum Alfonso Bovero, São Paulo; and the Identified Skull Collection, São Paulo. Three of these collections are from a northeast population, whereas the others are from individuals from the southeast region. Altogether, there are 925 skeletons and more than 998 skulls (three of the referenced collections have only skulls). Data on the number of individuals, sex, age, origin, and dates of inhumation and exhumation are available. This large quantity of identified skeletal remains is a fundamental source of research material that can be used to characterize the Brazilian population and facilitate the development of forensic anthropology. When contextualized within the reference series from South and Central America, it is clear that the Brazilian skeletal reference series hold a position of prominence.

Species Richness and Abundance of Cerambycidae (Coleoptera) in Huatulco, Oaxaca, Mexico; Relationships with Phenological Changes in the Tropical Dry Forest.

Cerambycidae have an important ecological role in initiating the degradation process of dead wood, but few studies have evaluated Cerambycidae community attributes in relation to ecosystem phenology. We surveyed the cerambicid fauna of the tropical dry forest in Huatulco, Oaxaca, Mexico, and explored the relationship of Cerambycidae species richness and abundance with phenological changes in vegetation. We applied three collecting methods of light traps, direct collection, and Malaise traps to survey Cerambycidae throughout 2005. To determine seasonal variations, we collected samples in the dry season month of February in the rainy season of May-July and August-September, and in the transition months of October and November through. We collected and identified 145 species, 88 genera, 37 tribes, and four subfamilies. The subfamily with the highest number of species was Cerambycinae (100 species), and the tribe with the highest number of genera and species was Elaphidiini with 13 genera and 33 species. The ICE non-parametric estimator determined an overall expected richness of 373 species, while the overall Shannon Diversity Index was 4.1. Both species richness and abundance varied seasonally, with the highest values recorded in the rainy season and the lowest in the dry season. Overall species abundance was not significantly correlated to monthly rainfall or EVI neither, only for "direct collecting" the EVI vs Richness and EVI vs Shannon Diversity Index were significantly correlated. We propose that the seemingly contradictory relationships between seasonal richness patterns of Cerambycidae and the greening/senescence of vegetation (EVI) may be explained by the seasonal availability of dead organic matter, flowers, or leafy vegetation that may be synchronized with the behavior of different cerambycid species.