Delayed iatrogenic atrial septal defect after implantation of a bicaval prosthesis device for the treatment of tricuspid regurgitation.

We present the case of a 71-year-old woman with rheumatic valvular disease who underwent mitro-aortic mechanical valve replacement and tricuspid annuloplasty in 2011. She required a dual-chamber pacemaker in 2012 and developed severe tricuspid regurgitation (TR), leading to percutaneous annuloplasty with Cardioband® system in 2021.

Statistical design for health monitoring in laboratory animal facilities using sentinel animals.

Regular health monitoring is crucial in laboratory animal facilities to determine the presence or absence of specific pathogens. One common approach to monitoring involves the use of sentinel animals, which are periodically exposed to biological material from the cages being monitored. At a certain point, some of these sentinel animals are tested for pathogens. This article discusses designing an effective sampling scheme to meet desired quality standards. It addresses questions such as the number of sentinel animals required, the frequency of sampling biological material, the selection of cages based on facility set-up, and the optimal frequency and quantity of sentinel animal tests. While existing design formulas are available for simple random sampling, no quantitative recommendation exists for using sentinel animals to the best of our knowledge. We propose a Monte Carlo simulation-based approach in this article to address this. Our algorithm has been implemented in a publicly accessible web page at http://nolan.cnb.csic.es/sentinelcagesmanager.

Immunogenicity of a Rotavirus VP8* Multivalent Subunit Vaccine in Mice.

Rotavirus remains a significant public health threat, especially in low-income countries, where it is the leading cause of severe acute childhood gastroenteritis, contributing to over 128,500 deaths annually. Although the introduction of the Rotarix and RotaTeq vaccines in 2006 marked a milestone in reducing mortality rates, approximately 83,158 preventable deaths persisted, showing ongoing challenges in vaccine accessibility and effectiveness. To address these issues, a novel subcutaneous vaccine formulation targeting multiple rotavirus genotypes has been developed. This vaccine consists of nine VP8* proteins from nine distinct rotavirus genotypes and sub-genotypes (P[4], P[6], P[8]LI, P[8]LIII, P[8]LIV, P[9], P[11], P[14], and P[25]) expressed in E. coli. Two groups of mice were immunized either with a single immunogen, the VP8* from the rotavirus Wa strain (P[8]LI), or with the nonavalent formulation. Preliminary results from mouse immunization studies showed promising outcomes, eliciting antibody responses against six of the nine immunogens. Notably, significantly higher antibody titers against VP8* P[8]LI were observed in the group immunized with the nonavalent vaccine compared to mice specifically immunized against this genotype alone. Overall, the development of parenteral vaccines targeting multiple rotavirus genotypes represents a promising strategy in mitigating the global burden of rotavirus-related morbidity and mortality, offering new avenues for disease prevention and control.

Prevalence of Computer Vision Syndrome and Its Risk Factors in a Spanish University Population.

OBJECTIVES: To determine the prevalence of digital eye strain or computer vision syndrome (CVS) and its risk factors in a university population (University of Valladolid, Spain). METHODS: An anonymous cross-sectional online survey was conducted in a university population [staff (lecturers and administrative employees) and students (undergraduate, master's, and PhD)], including two validated questionnaires (Ocular Surface Disease Index [OSDI] and the 17-item Computer-Vision Symptom Scale questionnaire [CVSS17]) and questions about sociodemographic data and visual display terminal use. The prevalence and risk factors for CVS (CVSS17≥29) (multivariate logistic regression model) were calculated. RESULTS: One thousand nine participants responded to the survey (35.2±15.2 years; 64.1% women). The mean OSDI and CVSS17 questionnaire scores were 18.9±15.6 and 31.5±6.4, respectively, and 35.4% of the respondents had dry eye symptoms (OSDI>22). The total prevalence of CVS was 65.4% (95% CI 62.1-68.3). Undergraduate students showed the highest CVS prevalence (72.6%; P <0.01), which was significant. In addition, women, participants younger than 36 years old, contact lens wearers, and subjects with dry eye symptoms reported a statistically higher CVSS17 score ( P ≤0.01). In the multivariate model, significant factors associated with the presence of CVS ( P ≤0.03) were female sex (OR=2.10; 95% CI 1.54-2.88), dry eye symptoms (OSDI>22) (OR=16.98; 95% CI 10.36-27.84), VTD use ≥6 hr daily (OR=1.96; 95% CI 1.09-3.52), and being an undergraduate student (OR=2.23; 95% CI 1.54-3.24). CONCLUSION: A high prevalence (65.4%) of CVS was found among the Spanish university population, with the undergraduate student group having the highest prevalence (72.6%). Female sex, more than 6 hr/day of visual display terminal use, being an undergraduate student, and dry eye symptoms significantly increased the risk of CVS in the university population.

Boosting Synergistic Antioxidant and Anti-Inflammatory Properties Blending Cereal-Based Nutraceuticals Produced Using Sprouting and Hydrolysis Tools.

Nutraceuticals obtained from sprouted wheat and oat grains and processing by-products (bran and hull, respectively) naturally containing antioxidant and anti-inflammatory compounds were evaluated. The objective of this study was the development of a cereal-based nutraceutical formula combining extracts from sprouts and by-products and the exploration for potential synergetic effects in their bioactive properties. The antioxidant and anti-inflammatory capacities, glycemic index, phytic acid, and ß-glucan of individual wheat bran hydrolysate (EH-WB), sprouted wheat (SW), oat hull hydrolysate (EH-OH), sprouted oat (SO), and combined ingredients (CI 1, CI 2, and CI3) were used to tailor an optimal nutraceutical formula. The three blend ingredients (CI 1, CI2, and CI3) were formulated at different ratios (EH-WB:SW:EH-OH:SO; 1:1:1:1, 2:1:2:1, and 1:2:1:2, w:w:w:w, respectively). The resulting mixtures showed total phenol (TPs) content ranging from 412.93 to 2556.66 µmol GAE 100 g-1 and antioxidant capacity values from 808.14 to 22,152.54 µmol TE 100 g-1 (ORAC) and 1914.05 to 7261.32 µmol TE 100 g-1 (ABTS•+), with Fe3+ reducing ability from 734. 02 to 8674.51 mmol reduced Fe 100 g-1 (FRAP) for the individual ingredients produced from EH-WB and EH-OH, where high antioxidant activity was observed. However, the anti-inflammatory results exhibited an interesting behavior, with a potentially synergistic effect of the individual ingredients. This effect was observed in CI2 and CI3, resulting in a higher ability to inhibit IL-6 and TNF-α than expected based on the anti-inflammatory values of their individual ingredients. Similar to the antioxidant properties, oat-based ingredients significantly contributed more to the anti-inflammatory properties of the overall mixture. This contribution is likely associated with the ß-glucans and avenanthramides present in oats. To ensure the bioaccessibility of these ingredients, further studies including simulated digestion protocols would be necessary. The ingredient formulated with a 2:1 hydrolysate-to-sprout ratio was the most effective combination, reaching higher biological characteristics.

Role of multimodality cardiac imaging for evaluation of intramyocardial dissection, from dissecting haematoma to false-pseudoaneurysm: a case series.

Background: Intramyocardial dissection (ID) is an extremely rare myocardial infarction mechanical complication. Although both clinical and imaging assessment of this rare condition remains a challenge, recent multimodality imaging techniques may help to confirm and to assess the progressive nature of the disease. Diagnosis may be reached in different stages, from as early as the intramyocardial dissecting haematoma to the severe false-pseudoaneurysm. Case summary: This series describes five cases of ID and provides insights into imaging findings and clinical course of this extremely uncommon condition. Our patients represented a wide range of clinical stages, from asymptomatic course to cardiogenic shock. The imaging diagnostic approach was very different from case to case and involved techniques such as echocardiography, cardiac CT, and cardiac magnetic resonance. Discussion: Intramyocardial dissection is a challenging condition in terms of diagnosis and clinical management associated with high morbidity and mortality. Furthermore, the different nomenclature found in the literature may be confusing. This case series supports the need of a terminology standardization and a multimodal imaging approach, which might be determinant for an accurate differential diagnosis and a suitable therapeutic management.

Successful treatment of diplopia using prism correction combined with vision therapy/orthoptics improves health-related quality of life.

Background: To track improvement in diplopia symptoms with strabismus-specific health-related quality of life (HRQOL) questionnaire across a treatment consisting of prism correction followed by vision therapy/orthoptics when prism treatment alone has not succeeded. Methods: Forty-eight participants with diplopia and a mean age of 62.45 were asked to complete an Adult Strabismus-20 (AS-20) questionnaire and a Diplopia Questionnaire (DQ) before and after prism correction. Inclusion criteria were diplopia reported on the DQ as "sometimes", "often" or "always" at reading or straight-ahead distance. The prism correction was classified as successful if the participant reported "never" or "rarely" on the DQ for reading and straight-ahead distance; and unsuccessful if the perceived diplopia worsened or remained the same. For all participants, mean initial AS-20 scores were compared with mean post-prism correction scores, taking into account AS-20 subscales (reading and general functions, and self-perception and interaction). Participants in the failed prism treatment subgroup subsequently underwent a programme of vision therapy wearing their prism correction, the results of which were again determined by participants' responses on the AS-20 questionnaire, completed before and after the vision therapy. Results: Five of the 48 participants dropped out of the study. Prism correction was classified as successful in 22 of 43 participants (51%), and unsuccessful in 21 (49%). Those participants for whom the prism correction was classified as a success showed a statistically significant improvement (p = 0.01) in both reading and general functions. In the failed treatment subgroup, no significant change in AS-20 score was recorded for any of the domains (p = 0.1). After treatment with vision therapy/orthoptics, however, 13 of the 20 participants in the unsuccessful prism correction subgroup (one of them dropped out the study) achieved binocular vision and statistically significant improvement in reading and general functions (p = 0.01). Conclusions: Although effective prism correction of diplopia is correlated with enhanced HRQOL, prism correction alone is frequently not sufficient to achieve this objective. In these cases, vision therapy/orthoptics treatment as a coadjutant to prism correction is shown to improve HRQOL.

The Repeatability and Agreement of Ocular Parameters Measured with the MYAH and Myopia Master Devices between Expert and Non-Expert Practitioners.

In myopia control, it is essential to measure the axial length (AL) and corneal parameters, and to monitor whether changes in these parameters have occurred over time. The aim of this study was to analyse the repeatability and agreement between expert and non-expert practitioners in ocular parameters measured by the MYAH and Myopia Master. Three repeated measurements (n = 42) were recorded with the MYAH and Myopia Master by two (an expert and a non-expert) observers in a randomized order. The AL, K1, K2, and white-to-white (WTW) distance were collected. The intraobserver repeatability was excellent in all parameters measured with both devices in both observers. The AL outcome presented the best repeatability with the MYAH and Myopia Master (intraclass correlation coefficient, ICC = 1.0; coefficient of variation, CV ≤ 0.06% for both observers), while the WTW presented poorer results (ICC ≤ 0.991; CV ≤ 0.52%). The Myopia Master provides a significantly (p ≤ 0.01) flatter K1 and K2 as well as a lower WTW (p ≤ 0.01) than the MYAH. No statistically significant difference in AL measurements was found with either device (p ≥ 0.10; ICC = 1.0). None of the parameters showed differences (p ≥ 0.12) between the expert and non-expert observer. The MYAH and Myopia Master provide consistent measurements in a healthy adult population regardless of the previous clinical experience of the observer. AL measurements should be used interchangeably but K1, K2, and WTW should be used interchangeably with caution.

Enhancing evidence-based practice into healthcare: Exploring the role of scientific skills in occupational therapists.

BACKGROUND: Research utilization and evidence-based practice (EBP) in occupational therapy rely on essential scientific skills. Despite prior research exploring factors influencing EBP, a gap remains in understanding the specific scientific competencies crucial for effective EBP application. OBJECTIVES: To (1) describe the level of scientific skills for EBP and research application, and (2) investigate the factors influencing higher scientific competence among 1159 Spanish-speaking occupational therapists. MATERIAL AND METHODS: We assessed the scientific skills using the HACTO-Screen online survey. Recruitment was conducted through a non-probability convenience sampling method between April to June 2020, using social networks and email dissemination to education and professional organizations in Spain and Spanish-speaking Latin American countries. RESULTS: Out of a total score of 115 points, participants showed a moderate level of scientific skills (mean: 62.7, SD: 21.6), with literature searching skills ranking the highest and scientific writing skills ranking the lowest. Associations were found between greater scientific competence and advanced degrees, ongoing research training, and on-the-job research. CONCLUSIONS: Continuous research training, higher academic degrees, and active research engagement are essential for enhancing scientific competence among occupational therapists. SIGNIFICANCE: Targeted training to enhance scientific skills and promote research utilization are crucial in advancing EBP in occupational therapy.

Effects of Tai-Chi on Quality of Life in People With Neurodegenerative Diseases. A systematic Review of Randomised Clinical Trials.

OBJECTIVE: This systematic review aimed to evaluate the effects of Tai Chi on the health-related quality of life (HRQoL) of people with neurodegenerative diseases. DATA SOURCE: This review followed the guidelines of the updated PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020. A systematic search in five electronic databases (Medline via PubMed, Web of Science, Scopus, PEDro, and OTseeker) was performed. STUDY INCLUSION AND EXCLUSION CRITERIA: Randomized control trials (RCTs) examining Tai Chi interventions to improve HRQoL in patients with neurodegenerative diseases published through March 2023 were included. DATA EXTRACTION: Data were extracted from each study by two independent researchers into a data extraction form based on the Cochrane recommendations. Methodological quality and risk of bias were assessed. DATA SYNTHESIS: A meta-analysis was performed using Review Manager 5.3 software. RESULTS: Of the 439 records that were screened, eight RCTs met the eligibility criteria. They assessed cognitive decline (n = 2) or Parkinson's disease (n = 6). RCT comparison groups included active interventions or usual care. The duration of Tai Chi therapy ranged from 8 to 24 weeks. A sensitivity analysis using a fixed effect model indicated that Tai Chi therapy significantly increased HRQoL [P < 001, SMD (95% CI) = .41 [.21, .60], I2 = 4%]. CONCLUSION: Tai Chi can effectively improve the HRQoL of people with neurodegenerative diseases, but the heterogeneity across intervention was relatively high. Further studies are needed as research into the benefits of Tai Chi in neurodegenerative disease rehabilitation is still limited.

Oncological outcomes in robot-assisted radical prostatectomy: the value of PSA density as a preoperative predictive factor.

Background: Pretreatment assessment of patients diagnosed with localized prostate cancer (PCa) is essential for therapeutic decision-making. Currently available staging systems based on prostate-specific antigen (PSA), Gleason score, and clinical stage allow for determining the prognostic characteristics of these patients. Several studies have evaluated the preoperative use of prostate-specific antigen density (PSAD) as a prognostic factor for further risk stratification. To date, the role of PSAD in this setting is still an object of debate. Objectives: The present analysis aimed to assess the predictive potential of PSAD for adverse oncological outcomes after robot-assisted radical prostatectomy (RARP) and to compare its accuracy to preoperative PSA (pPSA). Design and methods: We retrospectively reviewed 427 patients diagnosed with localized PCa who underwent RARP at a single institution between January 2015 and January 2020. Generating receiver operator characteristic (ROC) curves, calculating areas under the curves (AUCs), and using a linear regression model, we analyzed the association of PSAD and pPSA with postoperative positive surgical margins (PSM), Gleason score ⩾ 7, persistent PSA, and biochemical recurrence (BCR), with a median follow-up of 47 months. Results: PSAD showed a significant association with PSM (p < 0.0001), PSA persistence (p < 0.0001), and Gleason ⩾ 7 (p < 0.0001), without being statistically significant in predicting BCR (p = 0.098). The predictive value of PSAD was comparable to pPSA for outcomes of PSA persistence (AUC 0.727 versus 0.771) and Gleason ⩾ 7 (AUC 0.683 versus 0.649). Conclusion: PSAD is a predictive factor for postoperative oncological outcomes of PSM, Gleason score ⩾ 7, and persistence of PSA. Despite the need for further studies, PSAD could be useful as a prognostic parameter in conjunction with established staging systems.

Oncological outcomes in robot-assisted radical prostatectomy: the value of PSA density as a preoperative predictive factor Prostate-specific antigen density (PSAD) has an established role in the diagnostic process of prostate cancer (PCa). However, controversy remains on the assessment of its value as a pretreatment prognostic factor. The aim of our study was to evaluate the predictive ability of PSAD for oncological outcomes in PCa patients treated with robot-assisted radical prostatectomy (RARP) and to compare with the value of preoperative PSA (pPSA). The present analysis showed a significant association of PSAD with positive surgical margins (PSM), Gleason Score >=7 and prostate-specific antigen (PSA) persistence after RARP. Moreover, PSAD demonstrated to perform comparably to pPSA in predicting the outcomes of clinically significant PCa (csPCa) and post-RARP PSA persistence. Therefore, PSAD is considered a preoperative predictive factor potentially useful in conjunction with other previously established prognostic criteria and clinical features.

Smart Design of ZnFe and ZnFe@Fe Nanoparticles for MRI-Tracked Magnetic Hyperthermia Therapy: Challenging Classical Theories of Nanoparticles Growth and Nanomagnetism.

Iron Oxide Nanoparticles (IONPs) hold the potential to exert significant influence on fighting cancer through their theranostics capabilities as contrast agents (CAs) for magnetic resonance imaging (MRI) and as mediators for magnetic hyperthermia (MH). In addition, these capabilities can be improved by doping IONPs with other elements. In this work, the synthesis and characterization of single-core and alloy ZnFe novel magnetic nanoparticles (MNPs), with improved magnetic properties and more efficient magnetic-to-heat conversion, are reported. Remarkably, the results challenge classical nucleation and growth theories, which cannot fully predict the final size/shape of these nanoparticles and, consequently, their magnetic properties, implying the need for further studies to better understand the nanomagnetism phenomenon. On the other hand, leveraging the enhanced properties of these new NPs, successful tumor therapy by MH is achieved following their intravenous administration and tumor accumulation via the enhanced permeability and retention (EPR) effect. Notably, these results are obtained using a single low dose of MNPs and a single exposure to clinically suitable alternating magnetic fields (AMF). Therefore, as far as the authors are aware, for the first time, the successful application of intravenously administered MNPs for MRI-tracked MH tumor therapy in passively targeted tumor xenografts using clinically suitable conditions is demonstrated.

Association between telomere length and neuropsychological function at 4-5 years in children from the INMA project: a cross-sectional study.

Shortened telomere length (TL) has been associated with lower cognitive performance, different neurological diseases in adults, and certain neurodevelopmental disorders in children. However, the evidence about the association between TL and neuropsychological developmental outcomes in children from the general population is scarce. Therefore, this study aimed to explore the association between TL and neuropsychological function in children 4-5 years of age. We included 686 children from the INMA Project, a population-based birth cohort in Spain. Leucocyte TL was determined by quantitative PCR method, and neuropsychological outcomes were measured using the McCarthy Scales of Children's Abilities (MCSA). Multiple linear regression models were used to estimate associations adjusted for potential confounding variables. Main findings showed that a longer TL was associated with a higher mean working memory score (ß = 4.55; 95% CI = 0.39, 8.71). In addition, longer TL was associated with a higher mean global quantitative score (ß = 3.85; 95% CI = -0.19, 7.89), although the association was marginally significant. To our knowledge, this is the first study that shows a positive association between TL and better neuropsychological outcomes in children. Although further research is required to confirm these results, this study supports the hypothesis that TL is essential in protecting and maintaining a child's health, including cognitive functions such as working memory.

Cytomegalovirus-induced inactivation of TSC2 disrupts the coupling of fatty acid biosynthesis to glucose availability resulting in a vulnerability to glucose starvation.

IMPORTANCE: Viruses modulate host cell metabolism to support the mass production of viral progeny. For human cytomegalovirus, we find that the viral UL38 protein is critical for driving these pro-viral metabolic changes. However, our results indicate that these changes come at a cost, as UL38 induces an anabolic rigidity that leads to a metabolic vulnerability. We find that UL38 decouples the link between glucose availability and fatty acid biosynthetic activity. Normal cells respond to glucose limitation by down-regulating fatty acid biosynthesis. Expression of UL38 results in the inability to modulate fatty acid biosynthesis in response to glucose limitation, which results in cell death. We find this vulnerability in the context of viral infection, but this linkage between fatty acid biosynthesis, glucose availability, and cell death could have broader implications in other contexts or pathologies that rely on glycolytic remodeling, for example, oncogenesis.

Gastric variceal bleeding as a form of presentation of a pancreatic neuroendocrine tumor / Sangrado por varices gástricas como forma de presentación de un tumor neuroendocrino pancreático

NETs (neuroendocrine tumors) constitute a heterogeneous group of epithelial-type neoplasms with a predominantly neuroendocrine differentiation. Although the most common locations are the pancreas, digestive tract, and lung, this type of neoplasm can arise in virtually any organ in the body. They are rare tumors with a wide variety of clinical presentations. Symptomatic tumors are more frequent in younger patients and present at more advanced pathological stages. We present the case of a 42-year-old male with idiopathic splenomegaly and bicytopenia (anaemia and thrombocytopenia) under study by haematology department who was admitted due to an episode of melena and hemoglobin of 4.5 mg/dl. Isolated gastric varices (IGV1) with red spots were confirmed at gastroscopy and endoscopic variceal obturation using cyanoacrylate was performed in two sessions. An endoscopic ultrasonography was performed, showing thrombosis of the splenic vein extending towards the splenoportal confluence with anechoic serpiginous structures outside and inside the gastric wall suggestive of collateral circulation with gastric varices (GV). An increase in portal caliber was observed, with no signs of liver cirrhosis. Computed tomography confirms the findings. Two months/week/days later he was readmitted with rebleeding signs after starting anticoagulant treatment, so it was decided to perform a splenectomy due to failure of the endoscopic treatment. Histology revealed infiltration of the spleen by a well-differentiated neuroendocrine tumor (NET). Gallium PET/CT and Octreotid scan showed uptake in the body and tail of the pancreas with positivity for somatostatin receptors previously undetected by other means. Finally, treatment was completed with distal pancreatectomy and splenoportal axis trombectomy with vascular esplenic resection and the patient was discharged from hospital.(AU)

Suramin, a drug for the treatment of trypanosomiasis, reduces the prothrombotic and metastatic phenotypes of colorectal cancer cells by inhibiting hepsin.

Recently, our group identified serine-protease hepsin from primary tumor as a biomarker of metastasis and thrombosis in patients with localized colorectal cancer. We described hepsin promotes invasion and thrombin generation of colorectal cancer cells in vitro and in vivo and identified venetoclax as a hepsin inhibitor that suppresses these effects. Now, we aspire to identify additional hepsin inhibitors, aiming to broaden the therapeutic choices for targeted intervention in colorectal cancer. METHODS: We developed a virtual screening based on molecular docking between the hepsin active site and 2000 compounds from DrugBank. The most promising drug was validated in a hepsin activity assay. Subsequently, we measured the hepsin inhibitor effect on colorectal cancer cells with basal or overexpression of hepsin via wound-healing, gelatin matrix invasion, and plasma thrombin generation assays. Finally, a zebrafish model determined whether hepsin inhibition reduced the invasion of colorectal cancer cells overexpressing hepsin. RESULTS: Suramin was the most potent hepsin inhibitor (docking score: -11.9691 Kcal/mol), with an IC50 of 0.66 µM. In Caco-2 cells with basal or overexpression of hepsin, suramin decreased migration and significantly reduced invasion and thrombin generation. Suramin did not reduce the thrombotic phenotype in the hepsin-negative colorectal cancer cells HCT-116 and DLD-1. Finally, suramin significantly reduced the in vivo invasion of Caco-2 cells overexpressing hepsin. CONCLUSION: Suramin is a novel hepsin inhibitor that reduces its protumorigenic and prothrombotic effects in colorectal cancer cells. This suggests the possibility of repurposing suramin and its derivatives to augment the repertoire of molecular targeted therapies against colorectal cancer.

Successfully Managing Severe Anemia in a Trauma Patient Who Refused Blood Transfusion: A Case Report.

BACKGROUND Surgical management in patients who undergo traumatic blood loss but who refuse blood transfusion can be challenging, but physicians and surgeons must comply with the wishes and beliefs of their patients. This report describes the management of severe anemia, with hemoglobin level of 2.5 g/dL, in a 71-year-old male Korean trauma patient who declined blood transfusion. CASE REPORT A 71-year-old man was admitted to hospital with severe blood loss following trauma. He declined blood transfusion due to his religious belief as a Jehovah's Witness. On day 4, the patient's hemoglobin level dropped from 7.7 to 3.9 g/dL. Despite the need for blood transfusion, the patient refused. Hence, therapeutic strategies, including crystalloid fluid resuscitation, bleeding control, vasopressor support, erythropoietin administration, supplementation with iron, folic acid, and vitamin B12, coagulopathy correction, oxygen consumption reduction, and mechanical ventilation were implemented. Following 16 days of supportive management, the hemoglobin reached 7.4 g/dL. However, it suddenly decreased on day 41 (2.5 g/dL) due to episodes of melena secondary to an actively bleeding gastric ulcer, which was successfully managed with endoscopic hemostasis. Despite increased vasopressor dosage and addition of vasopressin and hydrocortisone, the patient became unresponsive with persistent hypotension. Methylene blue was used as the final therapeutic agent. The patient responded well and subsequently recovered without blood transfusion. CONCLUSIONS This report has presented the clinical challenges of managing the case of a patient who requires but declines blood transfusion and has highlighted the approach to clinical care while respecting the wishes of the patient.

Ventilatory, phonatory and swallowing impairments in advanced neuromuscular disease patients / Alteraciones ventilatorias, fonatorias y deglutorias en pacientes con enfermedad neuromuscular avanzada

Purpose: To analyze the ventilatory, phonatory and swallowing impairments and their relation with physical status in a group of advanced Neuromuscular Disease (NMD).Methods: A cross-sectional observational study was utilized 48 participants from the Association of NMD of Granada (Granada, España), university clinical research, University of Granada. A total of 24 advanced NMD patients and 24 healthy controls matched for age and sex were recruited. Advanced NMD patients were divided in two groups according to the level of their overall physical status (NMD higher physical status group or NMD lower physical status group). Hand grip strength, ventilatory, phonatory and swallowing features were analyzed.Results: There were significant differences (p<.05) among NMDs groups in ventilatory function. There were significant differences (p<.05) between NMDs groups in ventilatory, phonatory and swallowing function. Finally, there were significant differences (p<.05) among advanced NMDs groups in swallowing function and orofacial evaluation. Conclusion: Patients with lower physical status have higher risk of suffer ventilatory, phonatory and swallowing complications after diagnosis of NMD.(AU)

Propósito: Analizar las alteraciones ventilatorias, fonatorias y deglutorias y su relación con el estado físico en un grupo de Enfermos Neuromusculares (ENM) avanzados.Métodos: Se realizó un estudio observacional transversal con 48 participantes de la Asociación de ENM de Granada (Granada, España), y de la facultad de ciencias de la salud de la Universidad de Granada. Se reclutaron un total de 24 pacientes con ENM avanzada y 24 controles sanos emparejados por edad y sexo. Los pacientes con ENM avanzada se dividieron en dos grupos según el nivel de su estado físico general (grupo de ENM de mayor estado físico o grupo de ENM de menor estado físico). Se analizó la fuerza de agarre de las manos y las características ventilatorias, fonatorias y deglutorias.Resultados:Se encontraron diferencias significativas (p<0,05) entre los grupos de ENM en la función ventilatoria. También, se observaron diferencias significativas (p<0,05) entre los grupos de ENM en la función fonatoria y deglutoria. Por último, existieron diferencias significativas (p<0,05) entre los grupos de ENM avanzados respecto a la condición miofuncional orofacial.Conclusiones: Los pacientes con menor estado físico tienen mayor riesgo de sufrir complicaciones ventilatorias, fonatorias y deglutorias tras el diagnóstico de ENM.(AU)