Vaccination Ameliorates Cellular Inflammatory Responses in SARS-CoV-2 Breakthrough Infections.

BACKGROUND: Data on cellular immune responses in persons with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection following vaccination are limited. The evaluation of these patients with SARS-CoV-2 breakthrough infections may provide insight into how vaccinations limit the escalation of deleterious host inflammatory responses. METHODS: We conducted a prospective study of peripheral blood cellular immune responses to SARS-CoV-2 infection in 21 vaccinated patients, all with mild disease, and 97 unvaccinated patients stratified based on disease severity. RESULTS: We enrolled 118 persons (aged 50 years [SD 14.5 years], 52 women) with SARS-CoV-2 infection. Compared to unvaccinated patients, vaccinated patients with breakthrough infections had a higher percentage of antigen-presenting monocytes (HLA-DR+), mature monocytes (CD83+), functionally competent T cells (CD127+), and mature neutrophils (CD10+); and lower percentages of activated T cells (CD38+), activated neutrophils (CD64+), and immature B cells (CD127+CD19+). These differences widened with increased disease severity in unvaccinated patients. Longitudinal analysis showed that cellular activation decreased over time but persisted in unvaccinated patients with mild disease at 8-month follow-up. CONCLUSIONS: Patients with SARS-CoV-2 breakthrough infections exhibit cellular immune responses that limit the progression of inflammatory responses and suggest mechanisms by which vaccination limits disease severity. These data may have implications for developing more effective vaccines and therapies. Clinical Trials Registration. NCT04401449.

Long-term evaluation of pulmonary function and survival of patients with interstitial pneumonia with autoimmune features.

OBJECTIVES: Interstitial pneumonia with autoimmune features (IPAF) includes patients with interstitial lung disease with autoimmune features who do not meet criteria for a connective tissue disease (CTD). Previous studies showed a wide variation in the radiologic pattern, pulmonary function and prognosis but there is still limited data on longitudinal outcomes. We aim to describe the long-term pulmonary function, radiological patterns, and survival of IPAF patients and explore a classification based on CTD-like subgroups by using clinical/serologic data. METHODS: Retrospective analysis of IPAF patients who were sub-classified into six CTD-(like) subgroups: systemic lupus erythematosus-like, rheumatoid arthritis-like, Sjögren's syndrome-like, scleroderma, myositis-like, and unclassifiable. Linear mixed-effect models were used to compare the change in percent-predicted forced vital capacity (FVC%), percent-predicted diffusion capacity (DLCO%), and six-minute walk distance (SMWD) over time; and survival in the entire cohort and according to CTD-like subgroups and radiological patterns. RESULTS: Fifty-nine patients fulfilled IPAF criteria. FVC%, DLCO%, and SMWD remained stable over time. There was no difference between usual interstitial pneumonia (UIP) versus non-UIP radiologic patterns. Thirty-five patients were sub-classified into CTD-like subgroups. Survival decreased from 79% at 60 months to 53% at 120 months in the entire cohort but was similar among CTD-like subgroups and radiological patterns. CONCLUSIONS: Long-term pulmonary function and six-minute walk test remained stable over 36 months in our IPAF cohort. Prognosis and pulmonary function in UIP had similar outcomes compared to non-UIP. Although 40% of IPAF patients could not be sub-classified, our exploratory subclassification stratified 60% of patients into a CTD-like subgroup.

Efficacy and adverse effects of methotrexate compared with azathioprine in the antisynthetase syndrome.

OBJECTIVES: To study the efficacy in terms of muscle strength, and corticosteroid tapering as well as the prevalence of adverse effects in patients with the antisynthetase syndrome (ASyS) treated with azathioprine (AZA) compared to those treated with methotrexate (MTX). METHODS: We compared the clinical outcomes in ASyS patients treated with AZA versus MTX including change in corticosteroid dose, strength, and creatine kinase (CK) as well as the prevalence of adverse effects. RESULTS: Among 169 patients with ASyS, 102 were treated at some point exclusively with either AZA or MTX (± corticosteroids). There were no significant differences in the rate of muscle strength recovery, CK decrease or corticosteroid tapering between those ASyS patients treated with MTX versus AZA. The prevalence of adverse events in patients treated with AZA and MTX was similar (29% vs. 25%, p>0.05); elevated liver enzymes (17% AZA vs. 12% MTX) and gastrointestinal involvement (10% AZA vs. 8% MTX) were the most common adverse events. While no patients treated with AZA developed lung complications, two of the patients treated with MTX experienced reversible pneumonitis with MTX cessation. CONCLUSIONS: AZA and MTX showed similar efficacy and adverse events in patients with ASyS. Pneumonitis is a rare but important event in patients receiving MTX.

A longitudinal cohort study of the anti-synthetase syndrome: increased severity of interstitial lung disease in black patients and patients with anti-PL7 and anti-PL12 autoantibodies.

Objective: The aim was to study the prevalence, rate of appearance and severity of clinical features in patients with different anti-synthetase syndrome (ASyS) autoantibodies. Methods: All Johns Hopkins Myositis Longitudinal Cohort subjects positive for any ASyS autoantibodies were included. Clinical information, including symptoms, signs, strength, creatine kinase concentrations and pulmonary function tests, were prospectively collected. The standardized mortality and cancer rates and the rate of appearance and intensity of the different organ manifestations were assessed using univariate and multivariate analysis and compared between ASyS autoantibodies. Results: One hundred and twenty-four (73.4%) patients were positive for anti-Jo1, 23 (13.6%) for anti-PL12, 16 for anti-PL7 (9.5%) and 3 (1.8%) for anti-EJ or anti-OJ, respectively. The mean length of follow-up was 4.1 years. Anti-PL12 was more frequent in black subjects. Anti-PL12 and anti-PL7 were associated with more prevalent and severe lung involvement, often without muscle involvement. Anti-Jo1 displayed more severe muscle involvement compared with anti-PL12 patients. Concurrent anti-Ro52 was more prevalent in anti-Jo1 patients and was associated with earlier development of mechanic's hands, DM-specific skin findings and arthritis. Independent of ASyS antibody status, black patients demonstrated more severe lung involvement than white patients. There was no significant increase in mortality or cancer risk in ASyS patients compared with the general US population. Conclusion: Different ASyS autoantibodies are associated with phenotypically distinct subgroups within the ASyS spectrum. Anti-PL7 and anti-PL12 are characterized by more severe lung involvement, whereas anti-Jo1 is associated with more severe muscle involvement. Black race is a major prognostic factor associated with lung disease severity.

Alterations in the plasma proteome persist ten months after recovery from mild to moderate SARS-CoV-2 infection.

Background: Limited data are available describing the effects of SARS-CoV-2 breakthrough infections on the plasma proteome. Methods: PCR-positive SARS-CoV-2 patients, enrolled in a natural history study, underwent analysis of the plasma proteome. A prospective cohort of 66 unvaccinated and 24 vaccinated persons with different degrees of infection severity were evaluated acutely (within 40 days of symptom onset), and at three and ten months. Comparisons based on vaccination status alone and unsupervised hierarchical clustering were performed. A second cohort of vaccinated Omicron patients were evaluated acutely and at ten months. Results: Acutely, unvaccinated patients manifested overexpression of proteins involved in immune and inflammatory responses, while vaccinated patients exhibited adaptive immune responses without significant inflammation. At three and ten months, only unvaccinated patients had diminished but sustained inflammatory (C3b, CCL15, IL17RE) and immune responses (DEFA5,TREM1). Both groups had underexpression of pathways essential for cellular function, signaling, and angiogenesis (AKT1, MAPK14, HSPB1) across phases. Unsupervised clustering, based on protein expression, identified four groups of patients with variable vaccination rates demonstrating that additional clinical factors influence the plasma proteome. The proteome of vaccinated Omicron patients did not differ from vaccinated pre-Omicron patients. Conclusions: Vaccination attenuates the inflammatory response to SARS-CoV-2 infection across phases. However, at ten months after symptom onset, changes in the plasma proteome persist in both vaccinated and unvaccinated individuals, which may be relevant to post-acute sequelae of SARS-CoV-2 and other viral infections associated with post-acute infection syndromes.

Longitudinal analysis of the lung proteome reveals persistent repair months after mild to moderate COVID-19.

In order to assess homeostatic mechanisms in the lung after COVID-19, changes in the protein signature of bronchoalveolar lavage from 45 patients with mild to moderate disease at three phases (acute, recovery, and convalescent) are evaluated over a year. During the acute phase, inflamed and uninflamed phenotypes are characterized by the expression of tissue repair and host defense response molecules. With recovery, inflammatory and fibrogenic mediators decline and clinical symptoms abate. However, at 9 months, quantified radiographic abnormalities resolve in the majority of patients, and yet compared to healthy persons, all showed ongoing activation of cellular repair processes and depression of the renin-kallikrein-kinin, coagulation, and complement systems. This dissociation of prolonged reparative processes from symptom and radiographic resolution suggests that occult ongoing disruption of the lung proteome is underrecognized and may be relevant to recovery from other serious viral pneumonias.

Quantitative CT Metrics Associated with Variability in the Diffusion Capacity of the Lung of Post-COVID-19 Patients with Minimal Residual Lung Lesions.

(1) Background: A reduction in the diffusion capacity of the lung for carbon monoxide is a prevalent longer-term consequence of COVID-19 infection. In patients who have zero or minimal residual radiological abnormalities in the lungs, it has been debated whether the cause was mainly due to a reduced alveolar volume or involved diffuse interstitial or vascular abnormalities. (2) Methods: We performed a cross-sectional study of 45 patients with either zero or minimal residual lesions in the lungs (total volume < 7 cc) at two months to one year post COVID-19 infection. There was considerable variability in the diffusion capacity of the lung for carbon monoxide, with 27% of the patients at less than 80% of the predicted reference. We investigated a set of independent variables that may affect the diffusion capacity of the lung, including demographic, pulmonary physiology and CT (computed tomography)-derived variables of vascular volume, parenchymal density and residual lesion volume. (3) Results: The leading three variables that contributed to the variability in the diffusion capacity of the lung for carbon monoxide were the alveolar volume, determined via pulmonary function tests, the blood vessel volume fraction, determined via CT, and the parenchymal radiodensity, also determined via CT. These factors explained 49% of the variance of the diffusion capacity, with p values of 0.031, 0.005 and 0.018, respectively, after adjusting for confounders. A multiple-regression model combining these three variables fit the measured values of the diffusion capacity, with R = 0.70 and p < 0.001. (4) Conclusions: The results are consistent with the notion that in some post-COVID-19 patients, after their pulmonary lesions resolve, diffuse changes in the vascular and parenchymal structures, in addition to a low alveolar volume, could be contributors to a lingering low diffusion capacity.

Long-Term Treatment With Azathioprine and Mycophenolate Mofetil for Myositis-Related Interstitial Lung Disease.

BACKGROUND: The efficacy of azathioprine (AZA) and mycophenolate mofetil (MMF) for interstitial lung disease (ILD) has been described, but mainly in connective tissue disease-associated ILD. The objective of this study was to evaluate the effect of AZA and MMF on lung function and prednisone dose in myositis-related ILD (M-ILD). METHODS: In this retrospective study, patients with M-ILD seen at Johns Hopkins and treated with AZA or MMF and no other steroid-sparing agents were included. Linear mixed-effects models adjusted for sex, age, antisynthetase antibody, and smoking status were used to compare the change in FVC % predicted, diffusing capacity of the lungs for carbon monoxide (Dlco) % predicted, and prednisone dose. RESULTS: Sixty-six patients with M-ILD were treated with AZA and 44 with MMF. At treatment initiation, mean FVC % predicted and Dlco % predicted were significantly lower in the AZA group than in the MMF group. In both groups, FVC % predicted improved and the prednisone dose was reduced over 2 to 5 years; however, for Dlco % predicted, only the AZA group improved. The adjusted model showed no significant difference in posttreatment FVC % predicted or Dlco % predicted between groups (mean difference of 1.9 and -8.2, respectively), but a 6.6-mg lower dose of prednisone at 36 months in the AZA group. Adverse events were more frequent with AZA than MMF (33.3% vs 13.6%; P = .04). CONCLUSIONS: In M-ILD, AZA treatment was associated with improved FVC % predicted and Dlco % predicted, and lower prednisone dose. Patients treated with MMF had improved FVC % predicted and lower prednisone dose. After 36 months, patients treated with AZA received a lower prednisone dose than those treated with MMF.

More prominent muscle involvement in patients with dermatomyositis with anti-Mi2 autoantibodies.

OBJECTIVE: To define the clinical phenotype of dermatomyositis (DM) with anti-Mi2 autoantibodies. METHODS: In this longitudinal cohort study, the prevalence and severity of clinical features at disease onset and during follow-up in patients with anti-Mi2-positive DM were compared to patients with anti-Mi2-negative DM, antisynthetase syndrome (AS), and immune-mediated necrotizing myopathy (IMNM). Longitudinal anti-Mi2 autoantibody titers were assessed. RESULTS: A total of 58 patients with anti-Mi2-positive DM, 143 patients with anti-Mi2-negative DM, 162 patients with AS, and 170 patients with IMNM were included. Among patients with anti-Mi2-positive DM, muscle weakness was present in 60% at disease onset and occurred in 98% during longitudinal follow-up; fewer patients with anti-Mi2-negative DM developed weakness (85%; p = 0.008). Patients with anti-Mi2-positive DM were weaker and had higher creatine kinase (CK) levels than patients with anti-Mi2-negative DM or patients with AS. Muscle biopsies from patients with anti-Mi2-positive DM had prominent necrosis. Anti-Mi2 autoantibody levels correlated with CK levels and strength (p < 0.001). With treatment, most patients with anti-Mi2-positive DM had improved strength and CK levels; among 10 with multiple serum samples collected over 4 or more years, anti-Mi2 autoantibody titers declined in all and normalized in 3, 2 of whom stopped immunosuppressant treatment and never relapsed. Patients with anti-Mi2-positive DM had less calcinosis (9% vs 28%; p = 0.003), interstitial lung disease (5% vs 16%; p = 0.04), and fever (7% vs 21%; p = 0.02) than did patients with anti-Mi2-negative DM. CONCLUSIONS: Patients with anti-Mi2-positive DM have more severe muscle disease than patients with anti-Mi2-negative DM or patients with AS. Anti-Mi2 autoantibody levels correlate with disease severity and may normalize in patients who enter remission.

Risk factors for mortality and mortality rates in interstitial lung disease patients in the intensive care unit.

Data on interstitial lung disease (ILD) outcomes in the intensive care unit (ICU) is of limited value due to population heterogeneity. The aim of this study was to examine risk factors for mortality and ILD mortality rates in the ICU.We performed a systematic review using five databases. 50 studies were identified and 34 were included: 17 studies on various aetiologies of ILD (mixed-ILD) and 17 on idiopathic pulmonary fibrosis (IPF). In mixed-ILD, elevated APACHE score, hypoxaemia and mechanical ventilation are risk factors for mortality. No increased mortality was found with steroid use. Evidence is inconclusive on advanced age. In IPF, evidence is inconclusive for all factors except mechanical ventilation and hypoxaemia. The overall in-hospital mortality was available in 15 studies on mixed-ILD (62% in 2001-2009 and 48% in 2010-2017) and 15 studies on IPF (79% in 1993-2004 and 65% in 2005-2017). Follow-up mortality rate at 1 year ranged between 53% and 100%.Irrespective of ILD aetiology, mechanical ventilation is associated with increased mortality. For mixed-ILD, hypoxaemia and APACHE scores are also associated with increased mortality. IPF has the highest mortality rate among ILDs, but since 1993 the rate appears to be declining. Despite improving in-hospital survival, overall mortality remains high.

Role of Procrastination as a Mediator of Self-Efficacy and Emotional State in Academic Situations / Papel da Procrastinação como Mediador da Auto-Eficácia e do Estado Emocional em Situações Acadêmicas / Rol de la Procrastinación como Mediador de la Autoeficacia y el Estado Emocional en Situaciones Académicas

Abstract The need to analyze the relationship between procrastination, self-efficacy and emotional state lies on its impact on productivity, academic performance, and mental health. This research examined the role of academic procrastination as a mediator between self-efficacy and emotional state. A total of 531 university students (59.1% female) participated, with an average age of 21.69 years. The results identified that self-efficacy has a negative influence on procrastination. Likewise, the model was able to corroborate that self-efficacy decreases procrastination and produces a positive affective state. At the same time, a person with high self-efficacy can decrease their negative feelings; however, when procrastinating their negative feelings increase. Furthermore, this model did not vary between gender and academic semester groups, which shows that the results can be interpreted equivalently between these groups.

Resumo A necessidade de analisar a relação entre a procrastinação, a autoeficácia e o estado emocional está no seu impacto sobre a produtividade, o desempenho acadêmico e a saúde mental. Esta pesquisa teve como objetivo examinar o papel da procrastinação acadêmica como mediadora entre a autoeficácia e o estado emocional. Participaram 531 estudantes universitários (59,1% do sexo feminino), com idade média de 21,69 anos. Os resultados identificaram que a autoeficácia tem uma influência negativa sobre a procrastinação. Da mesma forma, o modelo foi capaz de corroborar que a autoeficácia diminui o comportamento procrastinador e produz um estado afetivo positivo. Ao mesmo tempo, uma pessoa com alta autoeficácia pode diminuir seu estado emocional negativo, porém, ao procrastinar, seu estado emocional negativo aumenta. Além disso, esse modelo foi invariável entre os grupos de gênero e semestre acadêmico, o que mostra que os resultados podem ser interpretados de forma equivalente entre esses grupos.

Resumen La necesidad de analizar la relación entre procrastinación, autoeficacia y estado emocional radica en su impacto en la productividad, rendimiento académico y salud mental. Esta investigación examinó el rol de la procrastinación académica como elemento mediador entre la autoeficacia y el estado emocional. Participaron 531 estudiantes universitarios (59.1% mujeres), con edad promedio de 21.69 años. En los resultados se identificó que la autoeficacia influye negativamente en la procrastinación. Asimismo, el modelo pudo corroborar que la autoeficacia disminuye la conducta procrastinadora y produce un estado afectivo positivo. Al mismo tiempo, una persona con alta autoeficacia puede disminuir su emocionalidad negativa, no obstante, cuando procrastina su estado emocional negativo incrementa. Además, este modelo fue invariante entre grupos de sexo y semestres académicos, lo que demuestra que se puede interpretar los resultados de forma equivalente entre estos grupos.

[Knowledge, practices and attitudes toward volunteer work in an influenza pandemic: cross-sectional study with Peruvian medical students]. / Conocimientos, prácticas y actitudes hacia el voluntariado ante una influenza pandémica: estudio transversal con estudiantes de medicina en Perú.

INTRODUCTION: Reductions in health personnel during disasters or epidemics such as an influenza pandemic may need to include volunteer students. OBJECTIVE: The aim of this article is to determine knowledge and practices about pandemic influenza and the attitudes towards volunteer work in Peruvian medical students. METHODS: We performed a cross-sectional analytic study by simple sampling using a survey regarding “"knowledge and practices"” about pandemic influenza and the attitudes to volunteer work. RESULTS: From the group of 865 students who were surveyed, 848 accepted to participate in the investigation (54% were male and their mean age was 22.1 ± 3.0). Ninety-seven percent correctly identified the spread routes of influenza and 81% knew its treatment. Regarding preventive measures, covering the mouth when coughing/sneezing and hand-washing were the most commonly recognized options (95% y 92%, respectively), and vaccination was the less recognized one (54%). The most common practice, readily acknowledged as preventive, was covering when coughing/sneezing (86%). Regarding volunteer works, students answered that it is a moral/ethical/professional obligation (77%); that a contingency university service needs to be established (88%), that it does not have to substitute for the lack of workers (49%), and that its role should be related to hospital work (83%). Coming from a public university was more associated to the concept that volunteer work was a moral obligation and that the student should be punished if he/she refuses to be a volunteer, whereas being from a private university was more related to a history of been involved in volunteering programs. CONCLUSIONS: In general, medical students have good knowledge and practices toward influenza. There is a good disposition to volunteer their work and skills, recognizing it as a moral/ethical/professional obligation.

INTRODUCCIÓN : La reducción crítica en el personal de salud ante situaciones de desastre o epidemia como una pandemia de influenza podría requerir la necesidad de incluir estudiantes voluntarios. OBJETIVO: El objetivo del artículo es determinar los conocimientos y prácticas sobre influenza pandémica y la actitud hacia el voluntariado en estudiantes de medicina peruanos. MÉTODOS: Estudio transversal analítico por muestreo simple utilizando una encuesta. RESULTADOS: De los 865 estudiantes, 848 aceptaron participar en el estudio (54% varones, edad promedio 22,1 ± 3,03). El 97% identificó de manera correcta las vías de propagación de la influenza y el 81% conocía su tratamiento. Sobre medidas preventivas correctas, cubrirse al toser o estornudar y lavado de manos fueron las respuestas mejores reconocidas (95% y 92%, respectivamente) y la vacunación fue la menor (54%). La práctica más frecuentemente realizada fue cubrirse al toser o estornudar (86%). Al respecto del voluntariado los participantes respondieron que es un deber moral/ético/profesional (77%), que se debe instituir un servicio universitario de contingencia (88%), que no debe suplir la falencia de trabajadores (49%) y que debe radicar en atención médica hospitalaria (83%). El pertenecer a universidades estatales estuvo más asociado a pensar que el voluntariado es una obligación moral y que el estudiante debe ser castigado en caso se niegue a ser voluntario, mientras que el pertenecer a universidades particulares estuvo más asociado con el antecedente de haber participado en un programa de voluntariado. CONCLUSIONES: En general, los estudiantes poseen un buen nivel de conocimientos y prácticas sobre influenza. Hay una buena disposición hacia el voluntariado reconociéndolo como una obligación moral/ética/profesional.

Anatomic variations of the branches of the aortic arch in a Peruvian population.

PURPOSE: Previous publications from two countries in South America found one anatomical variation not previously reported in the rest of the world, which in turn give some clues with regard to a racial difference. The objective of the present study is to describe variations in the anatomical distribution of the branches of the aortic arch in a Peruvian population. OBJECTIVE: To describe variations in the anatomical distribution of the branches of the aortic arch in a Peruvian population. METHODS: A descriptive study of patients who underwent a tomography angiography of the aorta was performed. We analyzed the reports that showed the description of the variations of the branches of the aortic arch based on the eight types currently described in the literature. RESULTS: From 361 analyzed reports, 282 patients (78.12%) had a normal aortic arch configuration (type I; aortic arch gives rise to the brachiocephalic trunk, left common carotid and left subclavian arteries); followed by type II (left common carotid artery as a branch of the aorta) with 41 patients (11.36%); and type IX (common ostium for the brachiocephalic trunk and the left common carotid artery) with 25 patients (6.93%). The latter and two other types are new variations. CONCLUSION: Aortic Arch Type I, Type II and Type IX were the most frequent variations in this Peruvian study. Additionally, we also found two more new types that have not been previously described in the literature. Further investigation regarding these variations is needed in order to assess a racial factor in South America and possible relationships with clinical or surgical events.

INTRODUCCIÓN : Reportes previos en dos países de América del Sur encontraron una variante anatómica que no había sido reportada en el resto del mundo, lo que podría dar indicios acerca de una diferencia racial. OBJETIVO: Describir las variaciones en la distribución anatómica de las ramas del arco aórtico en una población peruana. MÉTODOS: Estudio retrospectivo de una serie de casos de personas en quienes se realizó una angiografía por tomografía de la aorta torácica. Se analizaron los informes que registraron la descripción de las variaciones de las ramas del arco aórtico, basados en los ocho tipos descritos por la literatura científica. RESULTADOS: Se analizaron 361 informes. Se encontró que 282 pacientes (78,12%) tuvieron la configuración clásica (tipo I, arco aórtico que da origen al tronco braquiocefálico, a la carótida común izquierda y a la subclavia izquierda), seguido por el tipo II (arteria carótida común izquierda como rama del tronco braquiocefálico) con 41 pacientes (11,36%), y el tipo IX (un ostium común para el tronco braquiocefálico y la carótida común izquierda) con 25 pacientes (6,93%). Este último y otros dos tipos resultaron ser nuevas variantes del arco aórtico. CONCLUSIÓN: En esta serie de casos peruana, los tipos de arco aórtico I, II y IX fueron los más frecuentes. Adicionalmente, se encontraron otros dos tipos nuevos que no habían sido descritos en la literatura previamente. Es necesario profundizar la investigación sobre estas variantes para evaluar el factor racial en Sudamérica y una posible relación con eventos clínicos o quirúrgicos.

[Effect of intravenous infusion of KCl on the electrocardiogram and serum potassium in dogs with normal renal function]. / Efecto de la infusión endovenosa de KCl en el electrocardiograma y potasio sérico en perros con función renal normal.

Variations in serum potassium (K+) and electrocardiographic changes at different infusion speeds of intravenous K+ were studied in dogs. Solutions of 20, 40, 60 and 80 mEq of K+ were infused in one hour to dogs with normal renal function and normal serum K+. Nine dogs were studied: three without prior hydration and six with previous hydration. Infusing 20 mEq/hour of K+ produced an increase in heart rate without changes in the electrocardiogram. With 40 mEq/hour there were changes in the "t" and "p" waves, and with 60 and 80 mEq/hour, alterations consistent with cardiac ischemia and ventricular tachycardia. Dogs without hydration had more obvious and fatal electrocardiographic changes. Doses of 20 mEq/hour of K + caused no morbidity or mortality in the animals studied. Higher doses showed various complications which depended on the hydration status of the animal, its urinary flow and potassium level.

Acute Respiratory Distress Syndrome Secondary to Histoplasmosis-induced Hemophagocytic Lymphohistiocytosis / Síndrome de distrés respiratorio agudo secundario a linfohistiocitosis hemofagocítica inducida por histoplasmosis

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Sodium chloride 0.9% versus Lactated Ringer in the management of severely dehydrated patients with choleriform diarrhoea.

INTRODUCTION: Although experience within Peru suggests clinical and physiological benefits of treating dehydration caused by diarrhoea with Lactated Ringer's solution (LR) over sodium chloride 0.9%, (NaCl) there is little documented scientific evidence supporting this view. It is important to clarify this issue and determine the best solution for use during epidemics. METHODOLOGY: Forty patients suffering from dehydration due to choleriform diarrhoea were enrolled in the study. Twenty patients were treated using NaCl (Group A) and the other twenty with LR (Group B). After diuresis recovery was achieved, the patients were continued on a course of oral rehydration salts. Serum electrolytes, arterial pH, HCO3-, and pCO2 were measured at three stages: at admission, after diuresis recovery, and after 12 hours. RESULTS: Acidosis was corrected more quickly with LR that NaCl. The hyperosmolality and hypernatremic states were corrected with both solutions. CONCLUSION: LR use resulted in a better clinical response than NaCl, illustrated by more rapid physiological correction, showing that mixed metabolic acidosis was corrected more quickly and more appropriately with this treatment.

[A decade of no effective inpatient medical discharges, experience from a hospital in Lima, Peru]. / Una década de altas médicas no efectivizadas en un hospital de Lima, Perú

Our aim is to describe the financial implications of no effective in patient discharges from 2001-2010 from a general hospital in lima city. For this purpose we analyzed the total amounts, cancellations and exonarations from the patient accounts with a non effective medical discharge because of hospital "debts". We found that the number of patients with a non effective medical discharge decreased 70% from 2001 to 2010, the number of days between the medical discharge until the day the patient left the hospital decreased 80%. The total amounts, cancellations and exonarations decreased 63%, 53% and 68%, respectively. The average amount of exoneration was 61,7%. In conclusion, the non effective medical discharges increase patient debts, which are partially exonerated and assumed by the hospital. Even though it has decreased in the last decade, this could be explained by the implementation of the new health insurance policies.

Validation of the Spanish Center for Epidemiological Studies Depression and Zung Self-Rating Depression Scales: a comparative validation study.

BACKGROUND: Depressive disorders are leading contributors to burden of disease in developing countries. Research aiming to improve their diagnosis and treatment is fundamental in these settings, and psychometric tools are widely used instruments to support mental health research. Our aim is to validate and compare the psychometric properties of the Spanish versions of the Center for Epidemiological Studies Depression Scale (CES-D) and the Zung Self-Rating Depression Scale (ZSDS). METHODOLOGY/PRINCIPAL FINDINGS: A Spanish version of the CES-D was revised by 5 native Spanish speaking psychiatrists using as reference the English version. A locally standardized Spanish version of the ZSDS was used. These Spanish versions were administered to 70 patients with a clinical diagnosis of DSM-IV Major Depressive Episode (MDE), 63 without major depression but with clinical diagnosis of other psychiatric disorders (OPD), and 61 with no evidence of psychiatric disorders (NEP). For both scales, Cronbach's alpha (C-α) and Hierarchical McDonald Omega for polychoric variables (MD-Ω) were estimated; and receiver operating characteristics (ROC) analysis performed. For the CES-D and ZSDS scales, C-α was 0.93 and 0.89 respectively, while MD-Ω was 0.90 and 0.75 respectively. The area under the ROC curve in MDE+OPD was 0.83 for CES-D and 0.84 for ZSDS; and in MDE+NEP was 0.98 for CES-D and 0.96 for ZSDS. Cut-off scores (co) for the highest proportions of correctly classified (cc) individuals among MDE+OPD were ≥29 for CES-D (sensitivity (ss) = 77.1/specificity (sp) = 79.4%/(cc) = 78.2%) and ≥47 for ZSDS (ss = 85.7%/sp = 71.4%/cc = 78.9%). In the MDE+NEP, co were ≥24 for the CES-D (ss = 91.4%/sp = 96.7%/cc = 93.9%) and ≥45 for the ZSDS (ss = 91.4%/sp = 91.8%/cc = 91.6%). CONCLUSION: Spanish versions of the CES-D and ZSDS are valid instruments to detect depression in clinical settings and could be useful for both epidemiological research and primary clinical settings in settings similar as those of public hospitals in Lima, Peru.