A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

Objective: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. Design: A secondary analysis derived from multicenter, observational study. Setting: Critical Care Units. Patients: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. Interventions: Corticosteroids vs. no corticosteroids. Main variables of interest: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. Results: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR = 0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. Conclusion: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

Objetivo: Evaluar si el uso de corticoesteroides (CC) se asocia con la mortalidad en la unidad de cuidados intensivos (UCI) en la población global y dentro de los fenotipos clínicos predeterminados. Diseño: Análisis secundario de estudio multicéntrico observacional. Ámbito: UCI. Pacientes: Pacientes adultos con COVID-19 confirmado ingresados en 63 UCI de España. Intervención: Corticoides vs. no corticoides. Variables de interés principales: A partir del análisis no supervisado de grupos, 3 fenotipos clínicos fueron derivados y clasificados como: A grave, B crítico y C potencialmente mortal. Se efectuó un análisis multivariado después de un propensity optimal full matching (PS) y una regresión ponderada de Cox (HR) y análisis de Fine-Gray (sHR) para evaluar el impacto del tratamiento con CC sobre la mortalidad en la población general y en cada fenotipo clínico. Resultados: Un total de 2.017 pacientes fueron analizados, 1.171 (58%) con CC. Después del PS, el uso de CC no se relacionó significativamente con la mortalidad en UCI (OR: 1,0; IC 95%: 0,98-1,15). Los CC fueron administrados en 298/537 (55,5%) pacientes del fenotipo A y no se observó asociación significativa con la mortalidad (HR = 0,85; 0,55-1,33). Un total de 338/623 (54,2%) pacientes del fenotipo B recibieron CC sin efecto significativo sobre la mortalidad (HR = 0,72; 0,49-1,05). Por último, 535/857 (62,4%) pacientes del fenotipo C recibieron CC. En este fenotipo, se evidenció un efecto protector de los CC sobre la mortalidad HR (0,75; 0,58-0,98). Conclusión: Nuestros hallazgos alertan sobre el uso indiscriminado de CC a dosis moderadas en todos los pacientes críticos con COVID-19. Solamente pacientes con elevado estado de inflamación podrían beneficiarse con el tratamiento con CC.

Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry.

OBJECTIVES: To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients. BACKGROUND: ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce. METHODS: This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI). RESULTS: In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1-0.36), p < 0.001). CONCLUSIONS: Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.

Software Suite Training Tool for MSK Exploration and Botulinum Toxin Infiltration Based on Ultrasound Imaging for the Spasticity Treatment.

Nowadays, one of the choice techniques for the spasticity treatment is the ultrasound-guided infiltration of Botulinum Toxin, because it is safe and effective. In order to medical professionals can carry out this technique, they need training and education. One of the safest and most time-free ways to facilitate the acquisition of practical medical skills is through simulators. In this paper we present an innovative technological environment, which includes an ultrasound simulator for training in muscle exploration and infiltration. The simulation platform will guide health professionals, with great realism and high degree of interactivity, in the autonomous training of all the tasks involved in the spasticity treatment procedure by infiltration of Botulinum Toxin, without the need for a real patient or costly phantoms.

HUSP: A Smart Haptic Probe for Reliable Training in Musculoskeletal Evaluation Using Motion Sensors.

As a consequence of the huge development of IMU (Inertial Measurement Unit) sensors based on MEMS (Micro-Electromechanical Systems), innovative applications related to the analysis of human motion are now possible. In this paper, we present one of these applications: a portable platform for training in Ultrasound Imaging-based musculoskeletal (MSK) exploration in rehabilitation settings. Ultrasound Imaging (USI) in the diagnostic and treatment of MSK pathologies offers various advantages, but it is a strongly operator-dependent technique, so training and experience become of fundamental relevance for rehabilitation specialists. The key element of our platform is a replica of a real transducer (HUSP-Haptic US Probe), equipped with MEMS based IMU sensors, an embedded computing board to calculate its 3D orientation and a mouse board to obtain its relative position in the 2D plane. The sensor fusion algorithm used to resolve in real-time the 3D orientation (roll, pitch and yaw angles) of the probe from accelerometer, gyroscope and magnetometer data will be presented. Thanks to the results obtained, the integration of the probe into the learning platform allows a haptic sensation to be recreated in the rehabilitation trainee, with an attractive performance/cost ratio.

Evaluation of the fetal cerebellum by magnetic resonance imaging. / Valoración del cerebelo fetal mediante resonancia magnética.

Obstetric protocols dictate that the fetal cerebellum should always be assessed during sonograms during pregnancy. For various reasons, including technical limitations or inconclusive sonographic findings, suspicion of cerebellar abnormalities is one of the most common indications for prenatal magnetic resonance imaging (MRI). Although sonography is the imaging technique of choice to assess the cerebellum, MRI shows the anatomy of the posterior fossa and abnormalities in the development of the fetal cerebellum in greater detail and thus enables a more accurate prenatal diagnosis. We describe and illustrate the normal anatomy of the fetal cerebellum on MRI as well as the different diseases that can affect its development. Moreover, we review the most appropriate terminology to define developmental abnormalities, their differential diagnoses, and the role of MRI in the prenatal evaluation of the posterior fossa.

Vitamin D status and incidence of tuberculosis infection conversion in contacts of pulmonary tuberculosis patients: a prospective cohort study.

The objective of this study was to estimate the relationship between serum vitamin D (VitD) status and tuberculosis (TB) infection conversion (TBIC), measured by the tuberculin skin test (TST) and an interferon-gamma release assay, the QuantiFERON-TB Gold In-Tube (QFT-GIT) test, in the contacts of pulmonary TB patients in Castellon (Spain) in a prospective cohort study from 2010 to 2012. Initially, the participants were negative to latent TB infection after a screening that included TST and QFT-GIT tests, and other examinations. A baseline determination of 25-hydroxyvitamin D [25(OH)D] was obtained by chemiluminescence immunoassay. After 8-10 weeks, participants were screened for a second time to determine TB infection conversion (TBIC). Poisson regression models were used in the statistical analysis. Of the 247 participants in the cohort, 198 (80·2%) were screened twice and 18 (9·1%) were TBIC cases. The means of VitD concentration in the TBIC cases and the non-cases were 20·7±11·9 and 27·2±11·4 ng/ml (P = 0·028), respectively. Adjusted for high exposure and TB sputum acid-fast bacilli (AFB)-positive index case, higher serum VitD concentration was associated with low incidence of TBIC (P trend = 0·005), and an increase of 1 ng/ml VitD concentration decreased the incidence of TBIC by 6% (relative risk 0·94, 95% confidence interval 0·90-0·99, P = 0·015). The results suggest that sufficient VitD level could be a protective factor of TBIC.

[Vascular rings, our experience with 18 cases]. / Anillos vasculares, nuestra experiencia en 18 casos.

AIM: Vascular rings are a rare cause of compression of the trachea and/or the esophagus, causing stridor and/or severe dysphagia. We present our experience in the diagnosis and management of vascular rings. METHODS: Retrospective study in which we analyzed clinical history, diagnosis and management of 18 patients diagnosed with vascular ring between January 1985 and December 2013. We evaluate endoscopy as a diagnostic method. RESULTS: A total of 18 patients were included, with a median age of 2 years. 83.3% (15/18) had some type of symptom: 46.7% (7/15) had respiratory symptoms such as respiratory distress, stridor, recurrent respiratory infections, bronchospasm with wheezing or asthma in older children; 20% (3/15) had digestive symptoms such as dysphagia, vomiting and regurgitation; and 33.3% (5/15) combined respiratory and digestive symptoms. The remaining patients, 16.7% (3/18) were asymptomatic and the diagnosis was casual. The most common types of vascular rings were double aortic arch (27.8%) and aberrant subclavian right artery (27.8%). In 3 cases (16.7%) a Kommerell diverticulum was associated. 44.4% (n = 8) was operated on, the remaining did not present symp- toms which justify the intervention (n = 10). 37.5% of patients had postoperative complications (iatrogenic recurrent paralysis and persistent tracheomalacia). There was no mortality in our series. The median follow-up was 6.4 years. At the moment, 88.9% of patients are asymptomatic, and 33.3% have been definitely discharged. CONCLUSIONS: Vascular rings are rare, and usually presented with common symptoms in childhood. Therefore, in front of a longstanding and recurrent respiratory symptoms, or dysphagia, we should think of a vascular ring. Not all subjects are candidates for surgical correction; therefore a multidisciplinary evaluation is essential.

Real needle for minimal invasive procedures training using motion sensors and optical flow.

Minimally invasive percutaneous insertion procedures are widely used techniques in medicine. Their success is highly dependent on the skills of the practitioner. This paper presents a haptic simulator for training in these procedures, whose key component is a real percutaneous insertion needle with a sensory system incorporated to track its 3D location at every instant. By means of the proposed embedded vision system, the attitude (spatial orientation) and depth of insertion of a real needle are estimated. The proposal is founded on a novel depth estimation procedure based on optical flow techniques, complemented by sensory fusion techniques with the attitude calculated with data from an Inertial Measurement Unit (IMU) sensor. This procedure allows estimating the needle attitude with an accuracy of tenths of a degree and the displacement with an accuracy of millimeters. The computational algorithm runs on an embedded computer with real-time constraints for tracking the movement of a real needle. This haptic needle location data is used to reproduce the movement of a virtual needle within a simulation app. As a fundamental result, an ergonomic and realistic training simulator has been successfully constructed for healthcare professionals to acquire the mental model and motor skills necessary to practice percutaneous procedures successfully.

Estimation of dietary folic acid intake in three generations of females in Southern Spain.

An adequate folic acid intake has been related to female fertility. The recommended intake of this vitamin was recently increased to 400µg/day, with an additional 200µg/day during pregnancy. The Mediterranean Diet includes sources of folate such as pulses, green-leaf vegetables, fruit, cereals, and dried fruits; other foods of interest are liver and blue fish. The objectives were to determine the foods that contribute most to folate intake and analyze the factors that influence their consumption by three generations in a female population (n=898; age, 10-75yrs) from Southern Spain: 230 adolescents (10-16yrs), 296 healthy pregnant women (19-45yrs), and 372 menopausal women (>45yrs). Participants completed a previously validated semi-quantitative food frequency questionnaire. Over 90% of their folate intake was supplied by cereals, fruit, natural juice, pulses, and cooked and raw vegetables. The mean (SD) daily intake of folate was 288.27(63.64) µg. A higher Mediterranean Diet Score (MDS) was significantly related to a greater folate intake. The daily folate intake was not significantly influenced by educational level, number of children, or place of residence (rural vs. urban). In logistic regression analysis, the factors related to an adequate folate intake (>2/3 of recommendations) were higher age, higher MDS, and lower BMI.

Several benthic species can be used interchangeably in integrated sediment quality assessment.

The selection of the best management option for contaminated sediments requires the biological assessment of sediment quality using bioindicator organisms. There have been comparisons of the performance of different test species when exposed to naturally occurring sediments. However, more research is needed to determine their suitability to be used interchangeably. The sensitivity of two amphipod species (Ampelisca brevicornis and Corophium volutator) to sediments collected from four different commercial ports in Spain was tested. For comparison the lugworm, Arenicola marina, which is typically used for bioaccumulation testing, was also tested. Chemical analyses of the sediments were also conducted. All species responded consistently to the chemical exposure tests, although the amphipods, as expected, were more sensitive than the lugworm. It was found that C. volutator showed higher vulnerability than A.brevicornis. It was concluded that the three species can be used interchangeably in the battery of tests for integrated sediment quality assessment.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy.

INTRODUCTION: Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC. MATERIALS AND METHODS: Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed. RESULTS: Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization. CONCLUSION: In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Host phylogeny and environment shape the diversity of salamander skin bacterial communities.

The composition and diversity of animal-associated microbial communities are shaped by multiple ecological and evolutionary processes acting at different spatial and temporal scales. Skin microbiomes are thought to be strongly influenced by the environment due to the direct interaction of the host's skin with the external media. As expected, the diversity of amphibian skin microbiomes is shaped by climate and host sampling habitats, whereas phylogenetic effects appear to be weak. However, the relative strength of phylogenetic and environmental effects on salamander skin microbiomes remains poorly understood. Here, we analysed sequence data from 1164 adult salamanders of 44 species to characterise and compare the diversity and composition of skin bacteria. We assessed the relative contribution of climate, host sampling habitat, and host phylogeny to the observed patterns of bacterial diversity. We found that bacterial alpha diversity was mainly associated with host sampling habitat and climate, but that bacterial beta diversity was more strongly associated with host taxonomy and phylogeny. This phylogenetic effect predominantly occurred at intermediate levels of host divergence (0-50 Mya). Our results support the importance of environmental factors shaping the diversity of salamander skin microbiota, but also support host phylogenetic history as a major factor shaping these bacterial communities.

A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

OBJECTIVE: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. DESIGN: A secondary analysis derived from multicenter, observational study. SETTING: Critical Care Units. PATIENTS: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. INTERVENTIONS: Corticosteroids vs. no corticosteroids. MAIN VARIABLES OF INTEREST: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. RESULTS: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. CONCLUSION: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

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.

Large cell neuroendocrine carcinoma on the floor of the mouth: a rare entity in an unusual location.

Neuroendocrine carcinomas (NEC) are a group of malignant neoplasms usually located in the lungs or gastrointestinal tract. Fewer cases are located in the head and neck, and in these rare presentations, the lingual tonsil, larynx, and major salivary glands are the most frequently affected sites. NECs exhibit similar characteristics regardless of where they arise. However, because these neoplasms are rare, a clear understanding of their aetiopathogenesis has yet to be described, and options for treatment have varied and are not unified. A rare NEC of the floor of the mouth is reported here; it appears that this location has not been reported previously. The diagnosis was established through histopathological analysis, and the patient underwent systemic treatment. He had a partial response to treatment in the first 3 months, but died 6 months after the initial diagnosis. This highly uncommon tumour can pose a significant diagnostic challenge for clinicians and pathologists alike and can result in diagnostic delay.

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.

Mathematical model optimized for prediction and health care planning for COVID-19.

OBJECTIVE: The COVID-19 pandemic has threatened to collapse hospital and ICU services, and it has affected the care programs for non-COVID patients. The objective was to develop a mathematical model designed to optimize predictions related to the need for hospitalization and ICU admission by COVID-19 patients. DESIGN: Prospective study. SETTING: Province of Granada (Spain). POPULATION: COVID-19 patients hospitalized, admitted to ICU, recovered and died from March 15 to September 22, 2020. STUDY VARIABLES: The number of patients infected with SARS-CoV-2 and hospitalized or admitted to ICU for COVID-19. RESULTS: The data reported by hospitals was used to develop a mathematical model that reflects the flow of the population among the different interest groups in relation to COVID-19. This tool allows to analyse different scenarios based on socio-health restriction measures, and to forecast the number of people infected, hospitalized and admitted to the ICU. CONCLUSIONS: The mathematical model is capable of providing predictions on the evolution of the COVID-19 sufficiently in advance as to anticipate the peaks of prevalence and hospital and ICU care demands, and also the appearance of periods in which the care for non-COVID patients could be intensified.

Genomic characterization of antifungal Acinetobacter bacteria isolated from the skin of the frogs Agalychnis callidryas and Craugastor fitzingeri.

Chytridiomycosis, a lethal fungal disease caused by Batrachochytrium dendrobatidis (Bd), is responsible for population declines and extinctions of amphibians worldwide. However, not all amphibian species are equally susceptible to the disease; some species persist in Bd enzootic regions with no population reductions. Recently, it has been shown that the amphibian skin microbiome plays a crucial role in the defense against Bd. Numerous bacterial isolates with the capacity to inhibit the growth of Batrachochytrium fungi have been isolated from the skin of amphibians. Here, we characterized eight Acinetobacter bacteria isolated from the frogs Agalychnis callidryas and Craugastor fitzingeri at the genomic level. A total of five isolates belonged to Acinetobacter pittii,Acinetobacter radioresistens, or Acinetobactermodestus, and three were not identified as any of the known species, suggesting they are members of new species. We showed that seven isolates inhibited the growth of Bd and that all eight isolates inhibited the growth of the phytopathogen fungus Botrytis cinerea. Finally, we identified the biosynthetic gene clusters that could be involved in the antifungal activity of these isolates. Our results suggest that the frog skin microbiome includes Acinetobacter isolates that are new to science and have broad antifungal functions, perhaps driven by distinct genetic mechanisms.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy.

INTRODUCTION: Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC. MATERIALS AND METHODS: Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed. RESULTS: Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization. CONCLUSION: In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Current status and needs for changes in critical care training: the voice of the young cardiologists.

AIMS: The implementation of the 2013 European Society of Cardiology (ESC) Core Curriculum guidelines for acute cardiovascular care (acc) training among European countries is unknown. We aimed to evaluate the current status of acc training among cardiology trainees and young cardiologists (<40 years) from ESC countries. METHODS AND RESULTS: The survey (March-July 2019) asked about details of cardiology training, self-confidence in acc technical and non-technical skills, access to training opportunities, and needs for further training in the field. Overall 614 young doctors, 31 (26-43) years old, 55% males were surveyed. Place and duration of acc training differed between countries and between centres in the same country. Although the majority of the respondents (91%) had completed their acc training, the average self-confidence to perform invasive procedures and to manage acc clinical scenarios was low-44% (27.3-70.4). The opportunities for simulation-based learning were scarce-18% (5.8-51.3), as it was previous leadership training (32%) and knowledge about key teamwork principles was poor (48%). The need for further acc training was high-81% (61.9-94.3). Male gender, higher level of training centres, professional qualifications of respondents, longer duration of acc/intensive care training, debriefings, and previous leadership training as well as knowledge about teamwork were related to higher self-confidence in all investigated aspects. CONCLUSIONS: The current cardiology training program is burdened by deficits in acc technical/non-technical skills, substantial variability in programs across ESC countries, and a clear gender-related disparity in outcomes. The forthcoming ESC Core Curriculum for General Cardiology is expected to address these deficiencies.