Exacerbations Among Patients With Asthma Are Largely Dependent on the Presence of Multimorbidity.

BACKGROUND AND OBJECTIVE: Comorbidities can influence asthma control and promote asthma exacerbations (AEs). However, the impact of multimorbidity in AEs, assessed based on long-term follow-up of patients with asthma of different degrees of severity, has received little attention in real-life conditions. To describe the epidemiological and clinical characteristics and predictors of AEs in patients who had presented at least 1 AE in the previous year in the MEchanism of Genesis and Evolution of Asthma (MEGA) cohort. METHODS: The work-up included a detailed clinical examination, pulmonary function testing, fractional exhaled nitric oxide (FeNO), blood counts, induced sputum, skin prick-tests, asthma questionnaires, and assessment of multimorbidity. The number of moderate-severe AEs in the preceding year was registered for each patient. RESULTS: The study population comprised 486 patients with asthma (23.7% mild, 35% moderate, 41.3% severe). Disease remained uncontrolled in 41.9%, and 47.3% presented ≥1 moderate-severe AE, with a mean (SD) annual exacerbation rate of 0.47 (0.91) vs 2.11 (2.82) in mild and severe asthma, respectively. Comorbidity was detected in 56.4% (66.6% among those with severe asthma). Bronchiectasis, chronic rhinosinusitis with nasal polyps, atopy, psychiatric illnesses, hyperlipidemia, and hypertension were significantly associated with AEs. No associations were found for FeNO, blood eosinophils, or total serum IgE. Sputum eosinophilia and a high-T2 inflammatory pattern were significantly associated with AEs. Multivariable regression analysis showed a significant association with asthma severity, uncontrolled disease, and low prebronchodilator FEV1/FVC. CONCLUSION: Our study revealed a high frequency of AE in the MEGA cohort. This was strongly associated with multimorbidity, asthma severity, poor asthma control, airflow obstruction, higher sputum eosinophils, and a very high-T2 inflammatory pattern.

Evaluation of an Online Educational Program for Parents and Caregivers of Children With Food Allergies.

BACKGROUND AND OBJECTIVE: The increasing prevalence of food allergy affects both patients and their families. Objective: The aim of this study was to evaluate the impact of an online educational program designed for parents and caregivers of children with food allergies. The program was developed by a multidisciplinary group comprising health care professionals, researchers, and expert patients under the participatory medicine model. MATERIAL AND METHODS: Participants took a 2-week online educational program covering major topics in food allergy management. General knowledge about the disease, symptoms, treatment, and topics relevant to families' daily lives were evaluated. The contents included educational videos, online forums, and live video chats. A pretest/posttest questionnaire survey was used to evaluate the impact of the program. RESULTS: A total of 207 participants enrolled in the educational program, which was completed by 130 (62.8%). Knowledge acquisition improved significantly following participation in the program in 15 out of 30 items (50%), reaching P<.001 for 8 items (26.7%). Of the 207 participants who started the program, 139 (67.1%) visited online forums, and 27.5% attended video chats. Average overall satisfaction with the educational program was 8.78 (on a scale of 0 to 10). CONCLUSIONS: The results obtained show that parents improved their knowledge in all areas of food allergy. The high level of satisfaction among participants suggests that digital learning tools are effective and motivational, enabling patients to acquire appropriate knowledge and thus increasing their quality of life.

A new classification system for the restoration of root filled teeth.

The aim of this report is to (i) review the current literature on the status of root filled teeth, (ii) analyse the most important factors in decision-making, (iii) discuss the current restorative concepts, and (iv) classify both the evidence and clinical practice in a way that seeks to be clear, understandable and helpful for clinicians. Restoration of root filled teeth represents a challenge for the clinician and remains a controversial subject. The guidelines describe a new classification that is drawn from evidence presented in the literature and also from clinical expertise-based reviews. It describes five categories of teeth.

Knowledge of asthma and anaphylaxis among teachers in Spanish schools.

INTRODUCTION: Allergic diseases affect 15-20% of the paediatric population in the industrialised world. Most educational centres in Spain do not have health professionals among their staff, and the teachers are in charge of child care in school. The advisability of specific training of the teaching staff should be considered, with the introduction of concrete intervention plans in the event of life-threatening emergencies in schools. MATERIAL AND METHODS: Evaluation of the training needs constitutes the first step in planning an educational project. In this regard, the Health Education Group of the Spanish Society of Clinical Immunology, Allergology and Paediatric Asthma (Grupo de Educación Sanitaria de la Sociedad Española de Inmunología Clínica, Alergología y Asma Pediátrica [SEICAAP]) assessed the knowledge of teachers in five Spanish Autonomous Communities, using a self-administered questionnaire specifically developed for this study. The data obtained were analysed using the SPSS statistical package. RESULTS: A total of 2479 teachers completed the questionnaire. Most of them claimed to know what asthma is, and almost one half considered that they would know how to act in the event of an asthma attack. This proportion was higher among physical education teachers. Most would not know how to act in the case of anaphylaxis or be able to administer the required medication. In general, the teachers expressed interest in receiving training and in having an interventional protocol applicable to situations of this kind. DISCUSSION: It is important to know what the training requirements are in order to develop plans for intervention in the event of an emergency in school. Teachers admit a lack of knowledge on how to deal with these disorders, but express a wish to receive training.

Evaluation of an educational programme with workshops for families of children with food allergies.

BACKGROUND: When a child is diagnosed with a food allergy, prevention and patient education are the key interventions for maintaining the child's health and quality of life and that of his or her whole family. However, health education activities for the families of children with food allergies are very limited, and most of these activities have not been evaluated. Therefore, the objectives of the present study were to develop an educational programme, to empower its participants through workshops, and to evaluate its results. METHODS: Several types of educational materials were created specifically for the programme, called "Proyecto CESA" ("STOP-FAR Project: Stop Food-Induced Allergic Reactions"). The programme was carried out in seven Spanish cities and was attended by parents and caregivers. The workshops were led by physicians specialising in allergies and by expert patients. Afterwards, participant learning and satisfaction were evaluated based on questionnaires that were completed both before and after the workshops. RESULTS: A significant improvement was observed in 29 items out of 40 (McNemar's test). Participant satisfaction with the programme was also very high: 90% rated the course between 8 and 10 points out of a possible 10 (41% rated it as a 10). CONCLUSION: The face-to-face workshops, which included utilisation of educational materials, had positive results in terms of learning as well as in levels of satisfaction in participating families.

Repeated evolution of exaggerated dewlaps and other throat morphology in lizards.

The existence of elaborate ornamental structures in males is often assumed to reflect the outcome of female mate choice for showy males. However, female mate choice appears weak in many iguanian lizards, but males still exhibit an array of ornament-like structures around the throat. We performed a phylogenetic comparative study to assess whether these structures have originated in response to male-male competition or the need for improved signal efficiency in visually difficult environments. We found little evidence for the influence of male-male competition. Instead, forest species were more likely to exhibit colourful throat appendages than species living in open habitats, suggesting selection for signal efficiency. On at least three independent occasions, throat ornamentation has become further elaborated into a large, conspicuously coloured moving dewlap. Although the function of the dewlap is convergent, the underlying hyoid apparatus has evolved very differently, revealing the same adaptive outcome has been achieved through multiple evolutionary trajectories. More generally, our findings highlight that extravagant, ornament-like morphology can evolve in males without the direct influence of female mate choice and that failure to consider alternative hypotheses for the evolution of these structures can obscure the true origins of signal diversity among closely related taxa.

Key innovations and island colonization as engines of evolutionary diversification: a comparative test with the Australasian diplodactyloid geckos.

The acquisition of key innovations and the invasion of new areas constitute two major processes that facilitate ecological opportunity and subsequent evolutionary diversification. Using a major lizard radiation as a model, the Australasian diplodactyloid geckos, we explored the effects of two key innovations (adhesive toepads and a snake-like phenotype) and the invasion of new environments (island colonization) in promoting the evolution of phenotypic and species diversity. We found no evidence that toepads had significantly increased evolutionary diversification, which challenges the common assumption that the evolution of toepads has been responsible for the extensive radiation of geckos. In contrast, a snakelike phenotype was associated with increased rates of body size evolution and, to a lesser extent, species diversification. However, the clearest impact on evolutionary diversification has been the colonization of New Zealand and New Caledonia, which were associated with increased rates of both body size evolution and species diversification. This highlights that colonizing new environments can drive adaptive diversification in conjunction or independently of the evolution of a key innovation. Studies wishing to confirm the putative link between a key innovation and subsequent evolutionary diversification must therefore show that it has been the acquisition of an innovation specifically, not the colonization of new areas more generally, that has prompted diversification.

Telemedicine in the management of patients with headache: current situation and recommendations of the Spanish Society of Neurology's Headache Study Group.

INTRODUCTION: The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations. METHOD: The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain. RESULTS: COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools. CONCLUSIONS: The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.

Rigid-CLL: avoiding constant-distance computations in cell linked-lists algorithms.

Many of the existing molecular simulation tools require the efficient identification of the set of nonbonded interacting atoms. This is necessary, for instance, to compute the energy values or the steric contacts between atoms. Cell linked-lists can be used to determine the pairs of atoms closer than a given cutoff distance in asymptotically optimal time. Despite this long-term optimality, many spurious distances are anyway computed with this method. Therefore, several improvements have been proposed, most of them aiming to refine the volume of influence for each atom. Here, we suggest a different improvement strategy based on avoiding to fill cells with those atoms that are always at a constant distance of a given atom. This technique is particularly effective when large groups of the particles in the simulation behave as rigid bodies as it is the case in simplified models considering only few of the degrees of freedom of the molecule. In these cases, the proposed technique can reduce the number of distance computations by more than one order of magnitude, as compared with the standard cell linked-list technique. The benefits of this technique are obtained without incurring in additional computation costs, because it carries out the same operations as the standard cell linked-list algorithm, although in a different order. Since the focus of the technique is the order of the operations, it might be combined with existing improvements based on bounding the volume of influence for each atom.

Molecular phylogenetics and historical biogeography of the west-palearctic common toads (Bufo bufo species complex).

In most pan-Eurasiatic species complexes, two phenomena have been traditionally considered key processes of their cladogenesis and biogeography. First, it is hypothesized that the origin and development of the Central Asian Deserts generated a biogeographic barrier that fragmented past continuous distributions in Eastern and Western domains. Second, Pleistocene glaciations have been proposed as the main process driving the regional diversification within each of these domains. The European common toad and its closest relatives provide an interesting opportunity to examine the relative contributions of these paleogeographic and paleoclimatic events to the phylogeny and biogeography of a widespread Eurasiatic group. We investigate this issue by applying a multiproxy approach combining information from molecular phylogenies, a multiple correspondence analysis of allozyme data and species distribution models. Our study includes 304 specimens from 164 populations, covering most of the distributional range of the Bufo bufo species complex in the Western Palearctic. The phylogenies (ML and Bayesian analyses) were based on a total of 1988 bp of mitochondrial DNA encompassing three genes (tRNAval, 16S and ND1). A dataset with 173 species of the family Bufonidae was assembled to estimate the separation of the two pan-Eurasiatic species complexes of Bufo and to date the main biogeographic events within the Bufo bufo species complex. The allozyme study included sixteen protein systems, corresponding to 21 presumptive loci. Finally, the distribution models were based on maximum entropy. Our distribution models show that Eastern and Western species complexes are greatly isolated by the Central Asian Deserts, and our dating estimates place this divergence during the Middle Miocene, a moment in which different sources of evidence document a major upturn of the aridification rate of Central Asia. This climate-driven process likely separated the Eastern and Western species. At the level of the Western Palearctic, our dating estimates place most of the deepest phylogenetic structure before the Pleistocene, indicating that Pleistocene glaciations did not have a major role in splitting the major lineages. At a shallow level, the glacial dynamics contributed unevenly to the genetic structuring of populations, with a strong influence in the European-Caucasian populations, and a more relaxed effect in the Iberian populations.

[Extracorporeal membrane oxygenation after cardiac surgery in 12 patients with cardiogenic shock]. / Oxigenador de membrana extracorpóreo en 12 casos de shock cardiogénico tras cirugía cardiaca.

OBJECTIVES: Mortality is high when cardiogenic shock develops after cardiotomy, making it impossible to discontinue extracorporeal circulation and/or leading to low postoperative cardiac output that is refractory to treatment with vasoactive drugs or implantation of an intra-aortic balloon pump. Extracorporeal membrane oxygenation (ECMO) provides temporary assisted circulation, lending hemodynamic and respiratory support to the patient with cardiogenic shock in order to prevent multiple organ failure and death. MATERIAL AND METHODS: For this retrospective study of cases in which ECMO was applied in our hospital's assisted circulation unit, we analyzed demographic data, indication, score on the European system for cardiac operative risk evaluation (Euroscore), duration of assistance, complications, and survival. RESULTS: In the first 3 years after the assisted circulation unit was established, during which 1375 cardiac interventions took place, ECMO was used postoperatively in 12 patients (0.87%). In 8 of the patients, assistance was provided during cardiac surgery following cardiotomy and in 4 transplant patients it was used following primary graft failure. The mean (SD) patient age was 56.8 (9.1) years. The Euroscore predicted 37.3% (16.7%) of the deaths. ECMO was used for a mean of 5.4 (2.5) days. The most frequent complications were bleeding in the surgical area, cardiac tamponade, and acute renal insufficiency. Overall in-hospital mortality was 50%, lower than rates reported in the literature. CONCLUSIONS: ECMO provided viable temporary support, maintaining adequate cardiac output while the patient's condition could be observed and heart function evaluated. Mortality was reduced.

SEDAR/SECCE ECMO management consensus document.

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.

Telemedicine in the management of patients with headache: current situation and recommendations of the Spanish Society of Neurology's Headache Study Group. / Aplicación de la telemedicina en la asistencia a pacientes con cefaleas: situación actual y recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología.

INTRODUCTION: The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations. METHOD: The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain. RESULTS: COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools. CONCLUSIONS: The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis]. / Análisis descriptivo de mortalidad en cirugía cardiaca en los hospitales públicos de la Comunidad Valenciana en el año 2007.

OBJECTIVE: To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. METHODS: Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. RESULTS: The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. CONCLUSIONS: The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

Discoid meniscus in children and adolescents: Correlation between morphology and meniscal tears. / Menisco discoide en niños y adolescentes: correlación entre la morfología y la presencia de lesiones.

BACKGROUND: Some authors have suggested that the diminished vascular blood supply, peripheral stability and thickness of the discoid meniscus (DM) would make it more prone to tears. The aims of this study are two-fold: 1) To analyse morphological characteristics by magnetic resonance (MRI), and 2) To correlate the size of the meniscus with the presence of meniscal tears. METHODS: The MRI of patients ≤18 years-old over a period of 5 years were reviewed, and patients with DM were identified. We analysed demographic data, location (medial or lateral), morphology (Watanabe), meniscal tears (Crues classification), pattern, displacement, and other associated findings. Meniscal height and thickness per width (TxW) were also calculated. The correlation between variables: morphology, height and TxW with the presence of meniscal tears were statistically analysed. RESULTS: Six hundred and eighty-five MRI (675 patients) were analysed. Forty-three knees (38 patients, 20 males) were found to have a DM (6.3%). The average age was 12.2±3.8 years (range: 4-18 years). Sixty-three percent had some type of meniscal injury. Patients with complete MD had a higher incidence of injuries (77.3 vs. 47.6%; P=.001). Longitudinal (bucket handle) and complex tears (n ??=11) only occurred in patients with complete DM. DM with tears presented a nonsignificant tendency to have higher meniscal height and higher TxW (6.29±1.26 vs 5.75±.66mm; P=.20 and 107.5±36.02 vs. 91.54±16.5mm2; P=.162). CONCLUSION: The results of this series support the theory that a larger meniscal size would be one of the main predisposing factors for the DM to be injured. STUDY DESIGN: Cross-sectional study (Level of evidence: III).

Differences in early postoperative complications in elective and emergency heart transplantation.

INTRODUCTION AND OBJECTIVES: The immediate postoperative period is a critical phase in heart transplantation. Severe complications occur that may influence short-term and medium-term morbidity and mortality in these patients. The aim of this study was to analyze the incidence of severe complications in emergency and nonemergency transplantations. MATERIALS AND METHODS: We studied 152 patients who underwent heart transplantation between 2001 and 2007. Combined transplantations and retransplantations were excluded. Two groups were considered: emergency transplantations (36 patients, 24%) and elective transplantations. We compared survival and occurrence of infection, primary graft failure (PGF), renal and hepatic failure, respiratory complications, cardiac tamponade, arrhythmias, reoperation, and intensive care unit (ICU) stay. RESULTS: The emergency transplantation group had a greater number of ischemic patients, with a more prolonged cardiopulmonary bypass time, and a larger proportion of donors were women. Overall mortality in the intensive care unit was 2.6%, with no differences between groups. However, emergency procedures were significantly associated with a higher incidence of PGF, need for intraaortic balloon pump, and a more prolonged mechanical ventilation time, as well as a greater number of bacterial infections and a significantly longer ICU stay. CONCLUSIONS: In our series, emergency transplantation showed no greater perioperative mortality. We observed a greater number of severe complications, such as PGF, bacterial infection, and more prolonged mechanical ventilation time.

[Hypokalemic rhabdomyolysis and tetany as a presentation of celiac disease in an adult]. / Rabdomiolisis hipopotasémica y tetania como forma de presentación de enfermedad celiaca en un adulto.

We describe the case of a 38-year-old man with an hypokalaemic rhabdomyolysis and tetany as a presentation of celiac disease. We discuss the several electrolytic disturbances found in this patient with chronic diarrhoea and malabsorption syndrome and also the treatment which conduced to complete clinical resolution. We conclude that celiac disease should be considered a cause of hypokalaemic rhabdomyolysis.

Severe renal failure and thrombotic microangiopathy induced by malignant hypertension successfully treated with spironolactone.

Malignant hypertension can cause thrombotic microangiopathy (TMA) characterized by hemolytic anemia and thrombocytopenia. On the other hand, severe hypertension is sometimes associated with hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP). Distinguishing these entities is important because of therapeutic implications. Plasmapheresis should be initiated as soon as possible if we are dealing with TTP. We describe the case of a 30-year-old man referred to our hospital with malignant hypertension, severe renal failure and TMA: haemoglobin=9g/dL, total bilirubin=0.4mg/dL, haptoglobin≤10mg/dL, platelet count=59,000/µL and schistocytes on peripheral smear. He required initiation of hemodialysis. Additionally, we considered that the possible cause of TMA was malignant hypertension according to the presence of hypertensive retinopathy and thrombocytopenia which remitted only with blood pressure control, hence, plasmapheresis was not given. Renal function did not improve and the patient remained chronic hemodialysis. Intensive therapy for hypertension with a combination of antihypertensive drugs including spironolactone successfully lowered his blood pressure without developing hyperkalemia.