An example of adaptation: experience of virtual clinical skills circuits of internal medicine students at the Faculty of Medicine, University of Granada (Spain) during the COVID-19 pandemic.

BACKGROUND: The state of alarm declared in Spain in response to the Coronavirus pandemic (COVID-19) has had far-reaching consequences in all areas of life. At the University of Granada's (UGR) Faculty of Medicine, online teaching was implemented immediately without any preexisting plan. Second-year undergraduates in medicine, particularly those enrolled in the subject 'Bases of Internal Medicine,' would normally undergo clinical skills circuits in face-to-face group settings. OBJECTIVE: To facilitate undergraduates' acquisition of specific transversal skills by means of an integrated online working system. DESIGN: Before the pandemic, teaching/learning methods consisted of 1) face-to-face group work; 2) teletutoring; 3) written work uploaded to the PRADO online platform for marking by the teletutor; and 4) presentation of written work to the group. As a result of the lockdown, presentations in class were suspended and replaced by online presentations. The means adopted by students in online presentations were freely chosen using various communication techniques: linear projection systems (6); acting/simulation (4); dramatization (1); and role-playing (1). RESULTS: The number of online clinical skills circuits developed was 12, one for each of the clinical skills circuits established for imparting this subject. A total of 12 presentations were made by the 10 groups, each lasting 15 minutes followed by a 5-minute discussion to settle any questions raised. The presentations were marked jointly by the teaching staff, coordinator, and students. CONCLUSIONS: The transference of classroom learning to the online environment proved an essential resource for teaching/learning clinical/practical skills during the lockdown, which have never before been imparted at distance.

Falsas creencias sobre el consumo de tabaco. Mentiras peligrosas / False beliefs on use of tobacco. Dangerous lies

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Biopsia líquida no tumoral: aplicación en neumología / The Use of Non-Tumor-Related Liquid Biopsy in Respiratory Medicine

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Liquid biopsy beyond of cancer: Circulating pulmonary cells as biomarkers of COPD aggressivity.

BACKGROUND: Pulmonary parenchymal destruction is consequence of Chronic Obstructive Pulmonary Disease (COPD), which results in degradation of the extracellular matrix and the appearance of peripheral pulmonary cells. The aim of this study is to demonstrate the feasibility of the detection and isolation of Circulating Pulmonary Cells (CPCs) in peripheral blood of patients with COPD. METHODS: 17 COPD patients were enrolled in this prospective study to isolate CPCs. Peripheral blood samples for CPC analysis were processed using positive immunomagnetic methods combined with a double immunocytochemistry. Two antibodies, anti-cytokeratin and anti-CD44v6 were used to confirm the epithelial nature of the isolated cells and their lung origin respectively. RESULTS: CK/CD44v6 positive CPCs were identified in 6 of 17 COPD patients (35.2% of the total) (range: 1-2 cells). No CPCs were detected in any of the 10 healthy volunteers. The COPD CPCs + patients showed a trend towards greater severity of the disease. CONCLUSIONS: This study suggest the feasibility to detect CPCs in peripheral blood of patients with COPD and its potential use as prognostic marker.

Half the deaths after surgery for lung cancer occur after discharge.

INTRODUCTION: Mortality following surgery for lung cancer increases at 90 days. The objective of this study was to determine the rate, factors, time to death, hospital stay until discharge, time to death after discharge and causes of mortality at 90 days following surgery for lung cancer. METHODS: A prospective follow-up study was performed in a cohort of 378 patients who underwent surgery for lung cancer between January 2012 and December 2016. Data on preoperative status, postoperative complications, and mortality were collected. RESULTS: Rates of mortality were 1.6% vs. 3.2% at 30 and 90 days, respectively. Half of deaths occurred between 31 and 90 postoperative days following discharge. The variables found to be related to mortality at 90 days were a Charlson Index >3 (p < 0.001), a history of stroke (p = 0.036), postoperative pneumonia (p = 0.001), postoperative pulmonary or lobar collapse (p = 0.001), reintubation (p < 0.001) and postoperative arrhythmia (p = 0.0029). The risk of mortality was also observed to be associated with the type of surgical technique -being higher for thoracotomy as compared to video-assisted thoracoscopy (VATS) (p = 0.011) -, and hospital readmission after discharge (p < 0.001). Adjusted odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Multivariate analysis revealed that a Charlson Index >3 (p = 0.001) OR 2.0 (1.55,2.78), a history of stroke (p = 0.018) OR 5.1 (1.81, 32.96) and postoperative pulmonary or lobar collapse (p = 0.001) OR 8.5 (2.41,30.22) were independent prognostic factors of mortality. The most common causes of death were related to respiratory (58.3%) and cardiovascular (33.2%) complications. CONCLUSIONS: Mortality at 90 days following surgery for lung cancer doubles 30-day mortality, which is a relevant finding of which both, patients and healthcare should be aware. Half the deaths within 90 days after surgery for lung cancer occur after discharge. Specific outpatient follow-up programs should be designed for patients at a higher risk of 90-day mortality.

Óxido nítrico alveolar y bronquial en la enfermedad pulmonar obstructiva crónica y el solapamiento de asma y EPOC (ACO) / Alveolar and Bronchial Nitric Oxide in Chronic Obstructive Pulmonary Disease and Asthma-COPD Overlap

Introducción: La medición del óxido nítrico en el aire exhalado diferencia fenotipos de pacientes con EPOC del solapamiento de asma y EPOC (ACO). Hasta el momento no se ha estudiado si existen diferencias entre los componentes alveolar y bronquial del FENO en este grupo de pacientes. Métodos: Estudio observacional transversal realizado en consultas externas de Neumología, incluyendo a pacientes con diagnóstico de EPOC a los que se les realizó una determinación del óxido nítrico en aire exhalado - FENO - diferenciando en esta medida el componente alveolar -CANO- y el de vía aérea central -JawNO-, y realizando las mediciones a distintos flujos. Se compararon los valores de CANO y JawNO entre los pacientes con eosinofilia (definidos como aquellos pacientes con ≥ 300 eosinófilos/ μL en sangre periférica, o bien ≥ 2% eosinófilos o ≥ 3% eosinófilos) y se realizó un análisis de regresión lineal para estudiar las variables clínicas y biológicas que se asociaban a estas mediciones. Resultados: Participaron en el estudio 73 pacientes con EPOC. Los criterios de eosinofilia utilizados se asociaban a incrementos de los valores de CANO y de JawNO (en este último caso solo los criterios ≥ 300 eosinófilos y ≥ 3% eosinófilos). CANO se asoció al recuento de eosinófilos y PCR, y JawNO se asoció a tabaquismo y recuento de eosinófilos. Conclusiones: Los pacientes diagnosticados de EPOC y que tienen características de ACO muestran mayor inflamación a nivel bronquial y de vía aérea pequeña. CANO y JawNO se relacionan con variables clínicas y biológicas

Introduction: Exhaled nitric oxide (FENO) measurements differentiate COPD phenotypes from asthma-COPD overlap (ACO). To date, no study has been conducted to determine whether alveolar and bronchial components differ in this group of patients. Methods: This was an observational cross-sectional study recruiting ambulatory COPD patients. FENO was measured, differentiating alveolar (CANO) from bronchial (JawNO) components using a multiple-flow technique. CANO and JawNO values were compared between eosinophilic COPD patients (defined as ≥ 300 eosinophils/μL in peripheral blood test, or ≥ 2% eosinophils or ≥ 3% eosinophils), and a linear regression analysis was performed to determine clinical and biological variables related to these measurements. Results: 73 COPD patients were included in the study. Eosinophil counts were associated with increased values of CANO and JawNO (for the latter only the association with ≥ 300 or ≥ 3% eosinophils was significant). CANO was also associated with CRP, and JawNO with smoking. Conclusions: Patients with COPD and ACO characteristics show increased inflammation in the large and small airways. CANO and JawNO are associated with clinical and biological variables

Alveolar and Bronchial Nitric Oxide in Chronic Obstructive Pulmonary Disease and Asthma-COPD Overlap. / Óxido nítrico alveolar y bronquial en la enfermedad pulmonar obstructiva crónica y el solapamiento de asma y EPOC (ACO).

INTRODUCTION: Exhaled nitric oxide (FENO) measurements differentiate COPD phenotypes from asthma-COPD overlap (ACO). To date, no study has been conducted to determine whether alveolar and bronchial components differ in this group of patients. METHODS: This was an observational cross-sectional study recruiting ambulatory COPD patients. FENO was measured, differentiating alveolar (CANO) from bronchial (JawNO) components using a multiple-flow technique. CANO and JawNO values were compared between eosinophilic COPD patients (defined as ≥ 300 eosinophils/µL in peripheral blood test, or ≥ 2% eosinophils or ≥ 3% eosinophils), and a linear regression analysis was performed to determine clinical and biological variables related to these measurements. RESULTS: 73 COPD patients were included in the study. Eosinophil counts were associated with increased values of CANO and JawNO (for the latter only the association with ≥ 300 or ≥ 3% eosinophils was significant). CANO was also associated with CRP, and JawNO with smoking. CONCLUSIONS: Patients with COPD and ACO characteristics show increased inflammation in the large and small airways. CANO and JawNO are associated with clinical and biological variables.

Guías clínicas en asma y enfermedad pulmonar obstructiva crónica: ¿cuál es su utilidad en la práctica clínica? / Clinical Guidelines in Asthma and Chronic Obstructive Pulmonary Disease: How Useful Are They in Clinical Practice?

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Futuro de la triple terapia en la enfermedad pulmonar obstructiva crónica / The Future of Triple Therapy in chronic obstructive pulmonary disease

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Predictors for 30-day readmission after pulmonary resection for lung cancer.

BACKGROUND: The purpose of this study was to assess the rate, cause, and factors associated with readmissions following pulmonary resection for lung cancer and their relationship with 90-day mortality. METHODS: A prospective cohort study was conducted of 379 patients who underwent surgery for lung cancer at the university hospitals Granada, Spain between 2012 and 2016. RESULTS: The rate of readmissions within 30 postoperative days was 6.2%. The most common reason for readmission was subcutaneous emphysema (21.7%), pneumonia (13%), and pleural empyema (8.5%). A higher probability of requiring urgent readmission was associated with a higher Charlson index (OR 2.0,95% confidence interval 1.50-2.67, P = 0.001); peripheral arterial vasculopathy (OR 4.8, 95%CI 1.27-18.85, P = 0.021); a history of stroke (OR 8.2, 95%CI 1.08-62.37, P = 0.04); postoperative atelectasis (OR 4.7, 95%CI 1.21-18.64, P = 0.026); and air leaks (OR 12.6, 95%CI 4.10-38.91, P = 0.001).The prediction multivariable model for readmission represents an area under the curve (ROC) of 0.90. Mortality at 90 postoperative days in the group of readmitted patients was 13% versus 1.5 for the group of patients who did not require readmission (P < 0.001). CONCLUSIONS: The factors predictive for readmission can help design individualized outpatient follow-up plans and programs for the reduction of readmissions.

Aprendizaje práctico de la medicina en entornos clínicos para alumnos de tercer curso. Consecución de objetivos de conocimiento / Practical learning in clinical medicine for students in the third course of medicine degree. Achievement of cognitive objectives

Objetivo. Presentar los principales resultados obtenidos en la consecución de los objetivos de conocimiento en el proyecto denominado 'Iniciación clínica básica centrada en la práctica médica', una innovación docente desarrollada en la asignatura 'Patología general' de la licenciatura de medicina durante el curso académico 2009-2010. Sujetos y métodos. Se seleccionaron 50 alumnos de tercero de medicina para el desarrollo del proyecto, cuya finalidad era contribuir a dotarles de los conocimientos y habilidades básicas para iniciarse en la atención sanitaria mediante la realización de prácticas clínicas orientadas y supervisadas en contextos asistenciales reales, con unos objetivos concretos y bajo la supervisión de médicos expertos. Resultados. Los resultados obtenidos fueron excelentes, mostrando la adquisición de todos los objetivos propuestos. La gran mayoría de los alumnos consideraron muy positiva, a la par que enriquecedora, la experiencia.Conclusión. La metodología propuesta, basada en las prácticas clínicas orientadas a la consecución de objetivos concretos, mejora el aprendizaje. La satisfacción tanto de los alumnos como de los profesores ha sido muy alta con los resultados obtenidos tras la implantación del proyecto (AU)

Aim. To present the main results obtained in the cognitive objectives in the project called 'Basic Clinical Initiation Centered Medical Practice', a teaching innovation developed in the introduction to Internal Medicine subject of medical degree during the academic year 2009-2010. Subjects and methods. 50 students were selected in the third course of medicine degree for the development of the project, which aimed to equip them with basic knowledge and skills to start on health care by conducting guided and supervised clinical practice in real clinical settings, with specific targets and under the supervision of medical experts. Results. The results were excellent, showing the purchase of all proposed objectives. Most students felt that it was a very positive and enriching experience. Conclusion. The proposed methodology, based on the achievement of specific goals, contributes to improve learning. The satisfaction of both students and teachers has been very high with the results obtained after implementation of the project (AU)