Determining the Need for Additional Testing With Quantiferon TB Gold in Patients With Positive Tuberculin Skin Tests and a History of BCG Vaccination.

OBJECTIVE:  To determine if the QuantiFERON-TB Gold (QFT) testing can be obviated for the diagnosis of latent tuberculosis infection (LTBI) in patients with a positive tuberculin skin test (TST) and a history of Bacillus Calmette-Guerin (BCG) vaccination by identifying high-risk features in patients with positive TST and a history of BCG vaccination who are associated with positive QFT. METHODS:  Retrospective chart review was done for 76 adult patients by dividing them into two groups. Group 1 consisted of true positive TST patients who had BCG vaccination and were positive for QFT. Group 2 consisted of false positive TST patients who had BCG vaccination but were negative for QFT. The two groups were compared to determine if the high-risk features of TST induration diameter of 15mm and more, TST induration of 20mm and more, recent immigration to the US, the advanced age of more than 65 years, country of origin with high TB burden, known exposure to active TB, and smoking history were more prevalent in Group 1 compared to Group 2. RESULTS:  Group 1 had 23 patients and Group 2 had 53 patients. Group 1 had a higher prevalence of patients with PPD induration of more than 10mm than Group 2, which was statistically significant with a P value of 0.03. Other risk factors of advanced age, exposure to active TB and smoking did not show statistically significant differences between Groups 1 and 2.  Conclusion: This study also confirms that if the TST induration is more than 10mm in patients with a history of BCG vaccination, the TST induration is likely because of LTBI and is less likely because of cross-reaction with BCG vaccination.

Cost-Effectiveness of Dexamethasone Intravitreal Implant in Naïve and Previously Treated Patients with Diabetic Macular Edema.

PURPOSE: To compare the direct costs associated with the dexamethasone intravitreal implant (DEX-i) in treatment-naïve and previously treated eyes with diabetic macular edema (DME) in a real clinical setting. METHODS: Retrospective and single-center study conducted in a real clinical scenario. Consecutive DME patients, either naïve or previously treated with vascular endothelial growth factor inhibitors (anti-VEGF), who received treatment with one or more DEX-i between May 2015 and December 2020, and who were followed-up for a minimum of 12 months, were included in the study. The cost analysis was performed from the perspective of the Andalusian Regional Healthcare Service. The primary effectiveness endpoint was the probability of achieving an improvement in best-corrected visual acuity (BCVA) ≥ 15 ETDRS letters after 1 year of treatment. The incremental cost-effectiveness ratio (ICER) of different improvements in BCVA was calculated. RESULTS: Forty-nine eyes, twenty-eight (57.1%) eyes from the treatment-naïve group and twenty-one (42.9%) from the previously treated group, were included in the analysis. The total cost of one year of treatment was significantly lower in the treatment-naïve eyes than in the previously treated eyes [Hodges-Lehmann median difference: EUR 819.1; 95% confidence interval (CI): EUR 786.9 to EUR 1572.8; p < 0.0001]. The probability of achieving a BCVA improvement of ≥15 letters at month 12 was significantly greater in the treatment-naïve group than in the previously treated group (rate difference: 0.321; 95% CI: 0.066 to 0.709; p = 0.0272). The Cochran-Mantel-Haenszel Odds Ratio of achieving a BCVA improvement of ≥15 letters at month 12 was 3.55 (95% CI: 1.09 to 11.58; p = 0.0309). In terms of ICER, the treatment-naïve group showed cost savings of EUR 7704.2 and EUR 5994.2 for achieving an improvement in BCVA ≥ 15 letters at month 12 and at any of the measured time points, respectively. CONCLUSIONS: DEX-i was found to be more cost-effective in treatment-naïve eyes than in those previously treated with anti-VEGF. Further studies are needed to determine the most cost-effective treatment based on patient profile.

Clozapine-Induced Pericardial Effusion Presenting with Persistent Tachycardia.

Clozapine is an atypical antipsychotic used in refractory schizophrenia and depression. Its use is often complicated by its vast side-effect profile including cardiovascular reactions, agranulocytosis, and seizures. Specifically, the cardiac complications of clozapine have been shown to predominantly cause myocarditis and pericarditis. In this case report, the case of a 58-year-old male being treated for treatment-resistant depression and schizophrenia who suffers from tachycardia is presented. He is treated empirically for orthostatic hypotension with IV fluids without much success. Further imaging and echocardiography demonstrated a pericardial effusion, a rare reaction (≤1 : 10000) that has only been documented in a handful of case reports. This anecdotal evidence highlights the significance of polyserositis/pericardial effusion in the context of clozapine-induced orthostatic hypotension resistant to rehydration. When starting a patient on clozapine, it is important to consider further workup and monitoring with laboratory baseline biomarkers and cardiac evaluation with symptomatic individuals. Upon immediate cessation of clozapine, the pericardial effusion should spontaneously resolve without complication and should not be rechallenged.

McConnell's Sign Still Holds Its Value: A Lesson Learned from Two Cases.

Acute pulmonary embolism (PE) can be potentially fatal if not diagnosed and treated early. Mortality in untreated cases can be as high as 30%. Atypical presentation and submassive PE can be missed due to subtle clinical features. Computerized tomography pulmonary angiogram is expensive, exposes to radiation and carries the risk of contrast nephropathy or anaphylactic reactions. On the contrary, McConnell's sign, which is a highly specific sign of PE, can be demonstrated at the bedside with a transthoracic echocardiogram (TTE). Here we discuss two cases where bedside TTE demonstrating McConnell's sign helped in the diagnosis and treatment of PE.

Challenges and perspectives of child labor.

Child labor is one of the oldest problems in our society and still an ongoing issue. During the time, child labor evolved from working in agriculture or small handicraft workshops to being forced into work in factories in the urban setting as a result of the industrial revolution. Children were very profitable assets since their pay was very low, were less likely to strike, and were easy to be manipulated. Socioeconomic disparities and lack of access to education are among others contributing to the child labor. Religious and cultural beliefs can be misguiding and concealing in delineating the limits of child labor. Child labor prevents physical, intellectual, and emotional development of children. To date, there is no international agreement to fully enforced child labor. This public health issue demands a multidisciplinary approach from the education of children and their families to development of comprehensive child labor laws and regulations.

Spectroscopic analysis of corrosion products in a bronze cauldron from the Late Iberian Iron Age.

Selected bronze fragments unearthed at Cerro de la Cruz (Almedinilla, southern Spain) were analyzed to determine the chemical composition of the corrosion products formed on their surface. The fragments came from a large bronze cauldron used in an Iberian village that was devastated in the mid II century BCE - possibly around 141 BCE. The fragments were analyzed by using various instrumental techniques including electron scanning microscopy coupled to energy dispersive X-ray spectroscopy (SEM-EDS), X-ray fluorescence (XRF) spectroscopy, and also by X-ray diffraction (XRD) and micro-Raman spectroscopy. Based on the results, being buried for a long time caused the main elements in the alloy to mineralize and form stratified layers consisting of various mineral phases including cuprite (Cu2O), malachite [Cu2CO3(OH)2] and cassiterite (Sn2O). The fragments also contained chloride and trihydroxychloride compounds such as nantokite (CuCl) and atacamite [Cu2Cl(OH)3], respectively, which make conservation of archaeological objects troublesome. These results testify to a strong interaction of the alloy elements with soil components. Also, the results obtained suggest a Type I of corrosion structure. Using the SEM-EDS, XRD and XRF and micro-Raman spectroscopies allowed corrosion products in the fragments to be successfully characterized in microchemical and structural.

Divertículos duodenales periampulares y el fallo técnico-terapéutico durante colangiopancreatografía retrógrada endoscópica (CPRE) / Periampullary duodenal diverticula and technical-therapeutic failure during endoscopic retrograde cholangiopancreatography (ERCP)

Resumen Introducción y objetivos: los divertículos duodenales periampulares (DDP) son infrecuentes y su hallazgo es incidental. Además, se clasifican en tres tipos según Boix por la cercanía a la ampolla mayor. El objetivo de este estudio fue realizar una descripción de nuestra experiencia con esta anomalía anatómica y demostrar la forma en que esto afecta la tasa de éxito técnica y terapéutica del procedimiento. Material y métodos: se realizó un estudio de corte transversal, con recolección de datos de forma retrospectiva en un período de 5 años de pacientes con divertículos periampulares duodenales. Se evaluó el fracaso terapéutico, complicaciones y dificultad de canulación de la vía biliar. Resultados: se evaluó un total de 214 pacientes, con una relación mujer-hombre de 2,15:1. La distribución de los sujetos por tipo de DDP fue: tipo 1 (29,9 %), tipo 2 (51,9 %) y tipo 3 (18,2 %). La indicación más frecuente de CPRE fue los cálculos del conducto biliar común en un 53,3 %. El DDP tipo 1 presentó mayor dificultad de canulación (11,6 %) y falla terapéutica (28,12 %). Conclusión: la presencia de DDP durante la CPRE se asocia con una mayor falla técnica (falla en la canulación) y falla terapéutica (persistencia de la obstrucción biliar). Además, estas fallas aumentan considerablemente cuando se trata de una papila intradiverticular tipo 1 de la clasificación según Boix. Por lo anterior, se sugiere que los procedimientos endoscópicos biliares en estas condiciones sean realizados por endoscopistas con gran experiencia con el fin de minimizar la probabilidad de falla técnica y terapéutica, y las complicaciones asociadas.

Abstract Introduction and objectives: Periampullary duodenal diverticula are infrequent, and their finding is incidental. They are classified into three types according to Boix due to their proximity to the larger blister. This study aims to describe the experience with this anatomical abnormality and to demonstrate how this affects the technical and therapeutic success rate of the procedure. Materials y Methods: A cross-sectional study was conducted, with retrospective data collection over a 5-year period of patients with periampullary duodenal diverticula. Therapeutic failure, complications, and difficulty of cannulation of the bile duct were evaluated. Results: A total of 214 patients were evaluated, with a female-male ratio of 2.15: 1. The distribution of the subjects by type of PDD was: type 1 (29.9%), type 2 (51.9%), and type 3 (18.2%). The most frequent indication for ERCP was common bile duct stones in 53.3%. Type 1 PDD presented greater difficulty in cannulation (11.6%) and therapeutic failure (28.12%). Conclusion: The presence of PDD during ERCP is associated with greater technical failure (failure in cannulation) and therapeutic failure (persistence of biliary obstruction). In addition, this failures increases considerably when it is a type 1 intradiverticular papilla of the Boix classification. Therefore, it is suggested that biliary endoscopic procedures in these conditions are performed by highly experienced endoscopists to minimize the probability of technical and therapeutic failure and associated complications.

Revision of the Neotropical species of the caddisfly genus Wormaldia McLachlan (Trichoptera: Philopotamidae).

Wormaldia McLachlan 1865 is the 2nd largest genus in the family Philopotamidae (Trichoptera) after Chimarra Stephens 1829 and is diverse and widely distributed, with ca. 175 extant species in all biogeographic regions except the Australasian. In this monograph, 14 previously described species are recognized for the Neotropical region: W. alicia Bueno-Soria, Santiago-Fragoso, & Barba-Alvarez 2005 [Mexico]; W. arizonensis (Ling 1938) [Mexico, USA]; W. cornuta Bueno-Soria & Holzenthal1986 [Mexico]; W. dampfi Ross & King 1956 [Mexico, Nicaragua]; W. dorsata Ross & King 1956 [Mexico]; W. endonima Ross & King 1956 [Mexico]; W. esperonis Ross & King 1956 [Mexico]; W. insignis (Martynov 1912) [Peru]; W. luma Bueno-Soria & Holzenthal 1986 [Mexico]; W. matagalpa Flint 1995 [Costa Rica, Guatemala, Nicaragua]; W. palma Flint 1991 [Colombia]; W. planae Ross & King 1956 [southwestern USA, Mexico, Caribbean, Central America, and northern South America]; W. prolixa Flint 1991[Colombia]; and W. tarasca Bueno-Soria & Holzenthal 1986 [Mexico]. Also, 36 additional Neotropical species are newly diagnosed, described, and illustrated: W. andrea [Ecuador]; W. anhelitus [Central America]; W. araujoi [Ecuador]; W. aymara [Bolivia]; W. barbai [Mexico]; W. bolivari [Venezuela]; W. boteroi [Colombia]; W. buenorum [Mexico]; W. calderonae [Mexico]; W. chrismark [Panama]; W. contrerasi [Panama]; W. dachiardiorum [Colombia]; W. eberhardi [Panama]; W. flinti [Bolivia, Panama]; W. francovilla [Panama]; W. fredycarol [Costa Rica, Panama]; W. gallardoi [Costa Rica, Panama]; W. gonzalezae [Venezuela]; W. hedamafera [Costa Rica, Nicaragua]; W. imberti [Costa Rica]; W. inca [Peru]; W. isela [Mexico]; W. juarox [Costa Rica]; W. lauglo [Panama]; W. machadorum [Costa Rica, Panama]; W. maesi [Nicaragua]; W. menchuae [Guatemala]; W. monsonorum [Costa Rica]; W. navarroae [Mexico]; W. paprockevi [Costa Rica]; W. saboriorum [Panama]; W. tocajoma [Costa Rica]; W. trondi [Costa Rica, Panama]; W. tupacamara [Bolivia]; W. zunigae [Colombia]; and W. zunigarceorum [Costa Rica, Panama]. In addition, the species W. arcopa Denning 1966 from Panama is considered a junior subjective synonym of W. planae. Furthermore, new distribution records for the Neotropical region for several species are given. Diagnoses, redescriptions, and illustrations of the male genitalia of the other 14 described Neotropical species in the genus are also presented. Illustrations of the forewing and hind wing of 19 species are also given. A structural terminology for male tergum X is proposed. Finally, a key for identification of males of all Neotropical species is provided.

Manejo actual de la enfermedad por reflujo gastroesofágico: punto de vista del cirujano / Updating management of the gastroesophageal reflux disease: surgeon's point of view

El reflujo gastroesofágico patológico (RGEP), es una de las condiciones clínicas más prevalentes del tracto digestivo; por su evolución crónica, requiere manejo médico a largo plazo y a pesar de que vivimos en la era de la más potente supresión de ácido, aún tenemos indicaciones quirúrgicas precisas. Existe un grupo de pacientes portadores de enfermedad persistente y progresiva, poseen un esfínter esofágico inferior incompetente, con pérdida de la capacidad de limpieza en el tercio distal del esófago, muchos de ellos con reflujo mixto y cuya sintomatología persiste, empeora ó desarrollan complicaciones propias de la enfermedad incluso mientras reciben tratamiento médico. Presentamos entonces los elementos clínicos que ayudan al reconocimiento de esta variante de la enfermedad, lo cual facilitaría distinguir que pacientes deben continuar con manejo médico y cuales deben ser derivados al cirujano, con el objeto de prevenir complicaciones tales como esófao de Barrett y cáncer