A Smartphone App for Real-Time Assessment of Malaria Prophylaxis Adverse Events.

Background: Growth of international travel to malarial areas over the last decades has contributed to more travelers taking malaria prophylaxis. Travel-related symptoms may be wrongly attributed to malaria prophylaxis and hinder compliance. Here, we aimed to assess the frequency of real-time reporting of symptoms by travelers following malaria prophylaxis using a smartphone app. Method: Adult international travelers included in this single-center study (Barcelona, Spain) used the smartphone Trip Doctor® app developed by our group for real-time tracking of symptoms and adherence to prophylaxis. Results: Six hundred four (n = 604) international travelers were included in the study; 74.3% (449) used the app daily, and for one-quarter of travelers, malaria prophylaxis was prescribed. Participants from the prophylaxis group traveled more to Africa (86.7% vs. 4.3%; p < 0.01) and to high travel medical risk countries (60.8% vs. 18%; p < 0.01) and reported more immunosuppression (30.8% vs. 23.1% p < 0.01). Regarding symptoms, no significant intergroup differences were observed, and no relationship was found between the total number of malarial pills taken and reported symptoms. Conclusions: In our cohort, the number of symptoms due to malaria prophylaxis was not significantly higher than in participants for whom prophylaxis was not prescribed, and the overall proportion of symptoms is higher compared with other studies.

Intraoperative adenosine for pheochromocytoma with myocardial infarction and SARS-CoV-2. Case report / Adenosina intraoperatoria para feocromocitoma con infarto miocárdico y SARS-CoV-2. Reporte de caso

Abstract Pheochromocytomas are neuroendocrine tumors capable of synthetizing, storing and releasing catecholaminergic hormones that may lead to lifethreatening hemodynamic instability. The COVID-19 pandemic has increased the risks and perioperative complexity of the patients undergoing pheochromocytoma-associated adrenalectomy. This article discusses the use of adenosine for the management of hypertensive crisis during this intervention, as well as the need to individualize the suitable timing for surgery after recent COVID-19 infection. This article discusses the case of a patient with a finding of right adrenal incidentaloma; further studies determined a metanephrines secreting pheochromocytoma. Following hospital admission for preoperative optimization, the eve of the procedure the patient developed an acute myocardial infarction and subsequently SARS-CoV-2 symptomatic infection. Intraoperatively, hypertensive peaks were managed with continuous adenosine perfusion. The patient was discharged after 48 hours. Preoperative optimization positively influences the intraoperative management of patients with pheochromocytoma. The intraoperative use of adenosine allows for adequate and safe control of hypertensive crises. Each situation must be individualized in patients pending surgery, with a recent COVID-19 infection.

Resumen Los feocromocitomas son tumores neuroendocrinos capaces de sintetizar, almacenar y liberar hormonas catecolaminérgicas que pueden provocar inestabilidad hemodinámica con compromiso vital. La pandemia por COVID-19 ha aumentado los riesgos y la complejidad perioperatoria de los pacientes sometidos a adrenalectomía por feocromocitoma. Describimos el uso de adenosina para manejar las crisis hipertensivas durante esta intervención, así como establecer la necesidad de individualizar el momento quirúrgico idóneo tras infección reciente por COVID-19. Presentamos el caso de un paciente con hallazgo de incidentaloma suprarrenal derecho cuya ampliación de estudio se orientó como feocromocitoma secretor de metanefrinas. Tras ingreso hospitalario para optimización preoperatoria, el día previo al procedimiento presentó un infarto agudo de miocardio y posteriormente una infección sintomática por SARS-CoV-2. Intraoperatoriamente se manejaron los picos hipertensivos con perfusión continua de adenosina. Tras 48 horas recibió el alta hospitalaria. La optimización preoperatoria influye positivamente en el manejo intraoperatorio de los pacientes con feocromocitoma. El uso intraoperatorio de adenosina permite un adecuado y seguro control de las crisis hipertensivas. En pacientes pendientes de cirugía con infección reciente por COVID-19 se requiere individualizar cada situación.

Predictive power of the grace score in population with diabetes.

INTRODUCTION: Current clinical practice guidelines recommend risk stratification in patients with acute coronary syndrome (ACS) upon admission to hospital. Diabetes mellitus (DM) is widely recognized as an independent predictor of mortality in these patients, although it is not included in the GRACE risk score. OBJECTIVES: The objective of this study is to validate the GRACE risk score in a contemporary population and particularly in the subgroup of patients with diabetes, and to test the effects of including the DM variable in the model. MATERIAL AND METHODS: Retrospective cohort study in patients included in the ARIAM-SEMICYUC registry, with a diagnosis of ACS and with available in-hospital mortality data. We tested the predictive power of the GRACE score, calculating the area under the ROC curve. We assessed the calibration of the score and the predictive ability based on type of ACS and the presence of DM. Finally, we evaluated the effect of including the DM variable in the model by calculating the net reclassification improvement. RESULTS: The GRACE score shows good predictive power for hospital mortality in the study population, with a moderate degree of calibration and no significant differences based on ACS type or the presence of DM. Including DM as a variable did not add any predictive value to the GRACE model. CONCLUSIONS: The GRACE score has an appropriate predictive power, with good calibration and clinical applicability in the subgroup of diabetic patients.

GRACE Score Validation in Predicting Hospital Mortality: Analysis of the Role of Sex.

Background: The GRACE (Global Registry of Acute Coronary Events) risk score is recommended for risk stratification in acute coronary syndrome (ACS). It does not include sex, a variable strongly associated with ACS prognosis. The aim of this study was to examine if sex adds prognostic information to the GRACE score in a contemporary population. Materials and Methods: Analysis of discrimination and calibration of GRACE score in the validation population, derived from the ARIAM-SEMICYUC registry (2012-2015). Outcome was hospital mortality. The uniformity of fit of the score was tested in predefined subpopulations: with and without ST-segment elevation myocardial infarction (STEMI and NSTEMI). Results: A total of 9781 patients were included: 4598 with NSTEMI (28% women) and 5183 with STEMI (23% women). Discriminative capacity of the GRACE score was significantly lower in women with STEMI compared to men (area under the receiver operating characteristic curve [AUC] 0.82, 95% CI 0.78-0.86 vs. AUC 0.90, 95% CI 0.88-0.92, p = 0.0006). In multivariate analysis, female sex predicted hospital mortality independently of GRACE in STEMI (p = 0.019) but not in NSTEMI (p = 0.356) (interaction p = 0.0308). However, neither the AUC nor the net reclassification index (NRI) improved by including female sex in the STEMI subpopulation (NRI 0.0011, 95% CI -0.023 to 0.025; p = 0.928). Conclusions: Although female sex was an independent predictor of hospital mortality in the STEMI subpopulation, it does not substantially improve the discriminative ability of GRACE score.

Accessibility to Reperfusion Therapy Among Women with Acute Myocardial Infarction: Impact on Hospital Mortality.

BACKGROUND: The available evidence about the effect of gender and/or sex on mortality differences is contradictory. Our aim is to assess the impact of gender on the access to reperfusion therapy in patients with acute coronary syndrome with ST-segment elevation (STEMI), and secondly, to analyze the effect of delay on the differences with regard to hospital mortality. METHODS: A retrospective cohort study was conducted among consecutive patients with STEMI included in the ARIAM-SEMICYUC registry (2010-2013). RESULTS: A total of 4816 patients were included (22.09% women). Women were older, presented with longer patient delay (90 vs. 75 minutes, p=0.0066), higher risk profile (GRACE>140: 75.1% vs. 56.05%, p<0.0001), and received less reperfusion therapy (68.8% vs. 74.7%, p<0.0001) with longer total reperfusion time (307 vs. 240 minutes, p<0.0001). Women received less thrombolysis (24.53% vs. 29.98%, p<0.0001) and longer door-to-needle time (85 vs. 70 minutes, p 0.0023). We found no differences regarding primary percutaneous coronary intervention or door-to-balloon time. Women also had higher hospital mortality (crude odds ratio 2.54, 95% confidence interval 1.99-3.26, p<0.0001), which persisted after controlling the effect of patient delay, age, risk (GRACE), and reperfusion (adjusted odds ratio 1.43, 95% confidence interval 1.0-2.06, p=0.0492). Using TIMI or Killip risk scores as risk estimates yielded nonsignificant results. CONCLUSIONS: Compared with men, women with STEMI have worse access to reperfusion and higher hospital mortality. The impact of the differences in accessibility on mortality gap remains uncertain.

Uso de estrategia invasiva precoz en pacientes diabéticos con síndrome coronario agudo sin elevación del ST / Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndromes

Fundamento y objetivos: La estrategia invasiva reduce la mortalidad de los pacientes con síndrome coronario agudo sin elevación del ST (SCASEST) de alto riesgo, entre los que se incluyen los pacientes diabéticos. Sin embargo, diversas publicaciones han puesto de manifiesto una infrautilización de esta estrategia invasiva en estos pacientes. El objetivo de este estudio es conocer las características de los pacientes diabéticos que se tratan de forma conservadora, e identificar determinantes del uso de una u otra estrategia. Paciente y métodos: Estudio de cohortes retrospectivo, realizado en diabéticos con SCASEST incluidos en los cortes anuales de 2010 y 2011 en el registro ARIAM-SEMICYUC. Se realizó un análisis bruto y ajustado mediante regresión logística no condicional. Resultados: Se han analizado 531 pacientes diabéticos, de los cuales 264 (49,7%) recibieron estrategia invasiva. Los pacientes diabéticos que se tratan de forma conservadora son un subgrupo caracterizado por su mayor edad y comorbilidad cardiovascular, mayor riesgo hemorrágico y ausencia de electrocardiograma (ECG) de alto riesgo. Se identifican como variables predictoras independientes asociadas al tratamiento conservador, el ECG de bajo riesgo, el Killip al ingreso superior a 1, alto riesgo hemorrágico y el tratamiento previo con clopidogrel. Conclusiones: El temor a las complicaciones hemorrágicas o la presencia de lesiones coronarias avanzadas podrían ser la causa de la infrautilización de la estrategia invasiva en los pacientes diabéticos con SCASEST (AU)

Background and objectives In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy. Patients and Methods Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n = 531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression. Results We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class > 1, high risk of bleeding and pretreatment with clopidogrel. Conclusions The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS (AU)

[Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndromes]. / Uso de estrategia invasiva precoz en pacientes diabéticos con síndrome coronario agudo sin elevación del ST.

BACKGROUND AND OBJECTIVES: In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy. PATIENTS AND METHODS: Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n=531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression. RESULTS: We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class>1, high risk of bleeding and pretreatment with clopidogrel. CONCLUSIONS: The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS.

Building diversity in a complex academic health center.

For 30 years, the many diversity-related health sciences programs targeting the University of Pittsburgh undergraduate campus, school of medicine, schools of the health sciences, clinical practice plan, and medical center were run independently and remained separate within the academic health center (AHC). This lack of coordination hampered their overall effectiveness in promoting diversity and inclusion. In 2007, a group of faculty and administrators from the university and the medical center recognized the need to improve institutional diversity and to better address local health disparities. In this article, the authors describe the process of linking the efforts of these institutions in a way that would be successful locally and applicable to other academic environments. First, they engaged an independent consultant to conduct a study of the AHC's diversity climate, interviewing current and former faculty and trainees to define the problem and identify areas for improvement. Next, they created the Physician Inclusion Council to address the findings of this study and to coordinate future efforts with institutional leaders. Finally, they formed four working committees to address (1) communications and outreach, (2) cultural competency, (3) recruitment, and (4) mentoring and retention. These committees oversaw the strategic development and implementation of all diversity and inclusion efforts. Together these steps led to structural changes within the AHC and the improved allocation of resources that have positioned the University of Pittsburgh to achieve not only diversity but also inclusion and to continue to address the health disparities in the Pittsburgh community.

Prinzmetal's angina in a patient with angiosarcoma of the right cardiac chambers.

Variant (Prinzmetal's) angina pectoris is a clinical syndrome characterized by the presence of angina at rest, coinciding with a transient ST-segment elevation. This syndrome is often caused by vasospasm, either on a normal coronary artery or at the site of a coronary atherosclerotic stenosis. We describe a classic case of variant angina associated with an angiosarcoma of the right heart chambers.

Similitudes y discrepancias en las características clinicopatológicas de feocromocitomas y paragangliomas / Clinical and pathological similarities and differences between pheochromocytomas and paragangliomas

Objetivo: Comparar características clínicas, principalmente adrenérgicas, de los feocromocitomas (FC), paragangliomas simpáticos (PGLS) y parasimpáticos (PGLPS).Pacientes y método: Se incluyó en el estudio a 34 pacientes diagnosticados y tratados consecutivamente de FC (20), PGLS (9) y PGLPS (5), con una edad media de 44 (rango, 17-74) años. Se comparó formas de presentación, manifestaciones clínicas, producción hormonal, características patológicas y resultados tras el tratamiento. Resultados: Los pacientes fueron atendidos por múltiples servicios. Los FC se diagnosticaron predominantemente por clínica adrenérgica (65%); los PGLS, por clínica adrenérgica (44%) y por efecto compresivo (45%), y los PGLPS, por efecto masa (100%). Sin embargo, cuando se evaluó de forma dirigida la clínica adrenérgica, el 80% de los FC, el 66,7% de los PGLS y el 40% de los PGLPS la habían manifestado. Presentaron secreción hormonal el 82,4% de los FC y el 100% de los PGLS. No se realizó estudio bioquímico en 3 FC, 5 PGLS y en ningún PGLPS. El tamaño tumoral (en mm) de los FC fue significativamente mayor que los PGLS y PGLPS (59 ± 28, 39 ±16 y 34 ± 26). Tras la extirpación del tumor, 17pacientes con FC, 7 con PGS y 4 con PGLPS quedaron libres de enfermedad, en 1 con PGLPS, éste persiste parcialmente, 1 PGLS recidivó y 5 pacientes murieron (3 con FC y 2 con PGLS).Conclusiones: En nuestro estudio observamos que se diagnostica por clínica adrenérgica los FC (65%) y los PGLS (44%), y además los PGLPS también presentaron clínica compatible con producción de catecolaminasen el interrogatorio dirigido en un 40%. Queremos reseñar el alto porcentaje de manifestaciones adrenérgicas en el grupo de tumores extra adrenales, que no se suele estudiarlos en este sentido, por tanto creemos que deben ser manejados como una misma entidad nosológica por una unidad de referencia (AU)

Objective: To compare the clinical features, mainly adrenergic manifestations, in patients with pheochromocytoma (PCT), sympathetic paraganglioma (SPGL) and parasympathetic paraganglioma (PSPGL).Patients and method: Thirty-four patients consecutively diagnosed and treated for PCT (n = 20), SPGL (n = 9) and PSPGL (n = 5) were included in the present study. The mean age was 44 years (range, 17-74). The forms of presentation, clinical manifestations, results of diagnostic tests, pathological characteristics, and postsurgery outcomes were analyzed. Results: The patients were treated in different medical units in our hospital. Diagnosis of PCT was mainly based on adrenergic symptoms (65%), SPGL on adrenergic symptoms (44%) and compressive symptoms (65%) and PSPGL on the basis of the tumor mass effect (100%). However, exhaustive analysis of adrenergic manifestations revealed that 80%, 66.7% and 40% of patients with PCT,SPGL and PSPGL respectively had adrenergic manifestations. Eighty-two percent of patients with PCT and 100% of those with SPGL showed increased urinaryexcretion of catecholamines and their metabolites. Biochemical studies were not performed in three patients with PCT and five with SPGL and were performed in all patients with PSPGL. The mean tumoral size (in mm) was significantly higher in PCT than in SPGL and PSPGL (59 ± 28, 39 ± 16 and 34 ± 26). After surgery, 17 patients with PCT, seven with PGS and four with PSPGL were considered cured, one patient showed partially persistent PSPGL, one patient with SPGL relapsed, and five patients died (three with PCT and two with SPGL).Conclusions: In the present study, 65% of PCT and 44% of SPGL were diagnosed on the basis of adrenergic symptoms, while 40% of PSPGL also showed symptoms compatible with catecholamine production. We highlight the high percentage of adrenergic manifestations in the group of extra-adrenal tumors, which are not usually investigated in this context. Therefore, we believe that PCT, SPGL and PSPGL should be considered as the same nosological entity in different locations and should be managed in referral units (AU)

Tratamiento quirúrgico del bocio endotorácico que produce síndrome compresivo en ancianos con múltiples enfermedades concomitantes / Surgical treatment of endothoracic goiter producing compressive syndromes in elderly patients with multiple comorbidities

El bocio endotorácico produce una potencial morbimortalidad derivada tanto de la compresión de estructuras que atraviesan el estrecho cervicotorácico como de su posible malignización. El tratamiento quirúrgico en el anciano, con enfermedad asociada en la mayoría de los casos, se cuestiona por el alto riesgo anestésico y quirúrgico que conlleva. Se presentan 3 casos intervenidos de bocio endotorácico que producía síndrome compresivo en el mediastino, todos con enfermedades importantes asociadas. Tras la exéresis quirúrgica, realizada sin complicaciones, los pacientes mostraron remisión total de la clínica compresiva y mejoría de su calidad de vida. El desarrollo de las técnicas anestésicas y la habilidad y la experiencia de algunos cirujanos hace que la edad no figure como factor limitante en la indicación de tratamiento quirúrgico de estos pacientes ancianos

Endothoracic goiter produces potential morbidity and mortality due to possible compression of surrounding structures and its potential for malignant transformation. Surgical treatment of this entity in the elderly, who usually have associated diseases, has been questioned due to the high surgical and anesthetic risk it carries. We present three cases of endothoracic goiter that produced mediastinal compression syndrome in patients with significant associated diseases. Surgical excision was performed without complications and the patients showed complete remission of compressive symptoms and improved quality of life. Because of the development of anesthetic techniques and the skill and experience of some surgeons, age is not a limiting factor in the indication for surgical treatment in these elderly patients

Participação do óxido nítrico no efeito sedativo e antinociceptivo dos agonistas alfa 2 - adrenérgicos / nvolvement of nitric oxide in the sedative and antinociceptive alpha 2 agonist - adrenergic

O mecanismo do efeito sedativo da clonidina (CLO), um agonista alfa2 adrenérgico não é claro. Como a ativação dps receptores alfa2 adrenérgico induz a liberação de óxido nítrico (NO) das células endoteliais, restamos a hipótese de que o efeito sedativo e antinociceptivo da CLO sistêmica dependeria de mecanismos relacionados a via NOGMPc. P 7NI reduziu significativamente o tempo de sono induzido pela clonidina...A CLO (3-120 mg/kg) and RIL induziram efeito antinociceptivo dose-dependente no teste das contorções abdominais e TFL. O efeito antinociceptivo da CLO foi significativamente reduzido pela inibição da NO syntase and guanylyl ciclase. O efeito da RIL também foi reduzido pelo 7-NI. O efeito antinociceptivo da morfina foi inibido pela naloxona, que não inibiu o efeito da CLO. Nossos resultados sugerem que o efeito da CLO sistêmica não envolve receptor opióide e é modulado por uma via NO-GMPc.