Choledococele as a cause of recurrent abdominal pain and biliary sepsis.

We report the case of a 91-year-old female with acute cholangitis and long-standing symptoms of recurrent colic- related abdominal pain after cholecystectomy. She was diagnosed by abdominal CT of saccular dilation of the intramural bile duct in the duodenum suggesting choledococele. ERCP was performed in which the presumptive diagnosis was confirmed, and choledochotomy and choledochoplasty were done with excellent subsequent progress. Choledococele is the least common type of biliary cyst. It consists of a cystic dilation of the intramural portion of the common bile duct that protrudes into the duodenal lumen and causes symptoms of recurrent abdominal pain and biliary events. ERCP is a key test in both diagnosis and treatment except when they cannot be approached by this technique or malignancy is suspected.

The unstudied effects of wording and answer formats in the analysis of impartiality in public service provision.

Impartiality in public services provision is an important dimension that explains the quality of government (QoG). The analysis of impartiality has boomed in recent years at different territorial levels, like countries or regions. The impartiality measures depend on several attributes that are aggregated using different methods. However, little attention has been given to the effects of negative wording attributes and the number of format answers, despite the efforts made by previous studies to build robust composite impartiality indices. This study corrects this existing gap partly using one of the most extensive surveys (the European Quality of Government Index 2021) that include attributes related to impartiality (six attributes and 129,991 citizens). The method will be based on a fuzzy clustering approach, the extended Apostle model and an ordinary binary probit model. The results show that the type of wording and the number of answer options affect impartiality. The analysis of the main differences observed is affected by some insightful covariates such as country, gender, being native, town size, occupation, and the perception of the economic situation.

Lessons from the Criticality of the Spanish High Capacity Road Network on Direct, Representative Democracies and Technocracies.

This paper aims to shed some light on an issue that has not been analyzed enough in previous studies on complex transportation networks. The financial crisis and disrupting events like the COVID-19 pandemic episode are affecting how governments make crucial decisions regarding policymaking paying more attention to experts' opinions. The impacts of disruptive events that could affect each road section will be analyzed using the criticality of the high capacity road network in Spain under different policymaking scenarios, such as direct democracy based on pure provincial decentralization (federal or cantonal vision), representative democracy in which decisions are taken by the National Parliament, and the governance based on technocracy stimulated by 'what matters is what works' (Southern Local Economy, 16(4), 264-271, 2001) using an Evidence-Based Policy Making (EBPM) case study based on a Data Envelopment Analysis applied to four accessibility indicators. We will complement our analysis with the different results obtained by the different national parties that were represented in the past election (November, 2019): PSOE, PP, VOX, Unidas Podemos, Ezquerra Republicana de Catalunya, Ciudadanos, Junts per Catalunya, Partido Nacionalista Vasco and Euskal Herria Bildu, exploring in-depth the obtained differences between the technocrat solution and the direct and representative democracy results. Important insights and lessons for the future will be obtained from the different party visions observed among the regionalist (nationalist) and the state-wide parties. The spillover effects created by the networks are so important that the room for federalist solutions might be very limited. Supplementary Information: The online version contains supplementary material available at 10.1007/s12061-022-09451-5.

Analysis of the main determinants of away-from-home consumption of fishery and aquaculture products in the EU28.

The European Union (EU) is the largest market in nominal terms for fishery and aquaculture products (FAPs), partly due to the away-from-home consumption of these products in restaurants and food outlets. In view of this, it is necessary to identify the main determinants of the away-from-home consumption patterns in order to propose strategies that could increase the consumption of FAPs. Following this, ordered probit models were estimated alongside their marginal effects to identify the most relevant factors determining the frequency of away-from-home consumption of FAPs in the EU28, using a representative sample of 27732 EU residents. We found that those in the highest classes of society are most likely to consume FAPs away-from-home more frequently. Also, the most important reasons for consuming FAPs away-from-home more frequently are that they are less expensive than other foods, taste good, and are healthy and easy to digest. In addition, among the different nationalities, British consumers are more likely to consume FAPs away-from-home. We also found that there is a higher frequency of away-from-home consumption of FAPs for consumers between the ages of 25 and 54, who do not live in rural areas, who prefer wild-caught and local and marine products, and that are very satisfied with their lives. The study contributes to the literature with the analysis of FAPs away-from-home consumption by using a large representative sample of EU28 consumers. The study is also relevant with respect to the extensive list of determinants that include factors related to the attitudes of respondents to FAPs and socio-demographic characteristics.

Value of PD-L1, PD-1, and CTLA-4 Expression in the Clinical Practice as Predictors of Response to Nivolumab and Ipilimumab in Monotherapy in Patients With Advanced Stage Melanoma.

BACKGROUND: The introduction of immune checkpoint inhibitors (ICI) has improved the survival outcomes of patients with advanced melanoma. To date, only a few studies have evaluated the immunohistochemical (IHC) expression of PD-1 and CTLA-4 in tumor-infiltrating lymphocytes (TILs) as predictive markers of response to ICI, most of them in the context of clinical trials. Moreover, the predictive value of PD-L1 in melanoma cells in the response to immunotherapy is unclear. The aim of our study was to assess the IHC expression of PD-L1, PD-1, and CTLA-4 in samples of patients with advanced melanoma and to establish their prognostic value as predictors of ICI response in a university hospital. METHODS: The expression of PD-L1, PD-1, and CTLA-4 was evaluated in pretreatment tumor samples in a series of 35 patients, 21 patients treated with nivolumab and 14 patients with ipilimumab in monotherapy. RESULTS: In the nivolumab group, 4 tumors (19%) were positive for PD-L1 and all of them showed a partial response to the treatment. However, 4 patients whose tumors did not express PD-L1 also responded to nivolumab. PD-1 expression was not associated with better progression-free survival (PFS). In the ipilimumab group, 5 patients (35.7%) showed expression of CTLA-4. Positive cases showed a better PFS; however, one negative case responded to ipilimumab. CONCLUSIONS: Nivolumab produces a better response compared with ipilimumab in patients with melanoma. The IHC expression of PD-L1 and CTLA-4 are associated with a higher response rate to nivolumab and ipilimumab, respectively, and better PFS, but the existence of responder patients with negative expression suggests that they are not adequate biomarkers to select candidate patients for ICI in the clinical practice.

A Best-Worst Measure of Attitudes toward Buying Seabream and Seabass Products: An Application to the Island of Gran Canaria.

Attitudes are important key drivers that affect consumers' seafood consumption. The present investigation used a best-worst scaling approach to measure the level of importance and satisfaction of consumers' attitudes towards the purchase of seabream and seabass in Gran Canaria (Spain). The investigation also compared the results of the best-worst scaling (BWS) approach with those of the traditional Likert-scale method and offers a different perspective of the results using an Importance-Satisfaction Analysis (ISA). The results indicate that the most important attributes concerned the hygiene and safety of the product, the health benefits, the freshness, the taste and the nutrients. At the same time, these attributes were ranked as those which satisfied consumers the most. However, some of the results obtained from the methodologies differed. The results suggest that, in the Likert-scale task, respondents might be overstating the importance and satisfaction of the attributes; while in the BWS, consumers were forced to evaluate a trade-off in the selection of the best and worst attributes in each scenario, so the task impeded, in principle, to define every attribute as very important and providing a high satisfaction. As a result, we consider that BWS offers more reliable and clearer results than traditional Likert-scale experiments.

Association of APOA5 and APOC3 Genetic Polymorphisms With Severity of Hypertriglyceridemia in Patients With Cutaneous T-Cell Lymphoma Treated With Bexarotene.

Importance: Hypertriglyceridemia is the most frequent and limiting adverse effect of bexarotene therapy in cutaneous T-cell lymphoma (CTCL). Despite standard prophylactic measures, there is a wide variability in the severity of this complication, which could be associated with both genetic and environmental factors. Objectives: To analyze the association between genetic polymorphisms of apolipoprotein genes APOA5, APOC3, and APOE and the severity of hypertriglyceridemia during bexarotene therapy and to optimize patient selection for bexarotene therapy based on adverse effect profile. Design, Setting, and Participants: This case series study was conducted in 12 university referral hospitals in Spain from September 17, 2014, to February 6, 2015. One hundred twenty-five patients with a confirmed diagnosis of CTCL who had received bexarotene therapy for at least 3 months were enrolled. Nine patients were excluded owing to missing analytic triglyceride level data, leaving a study group of 116 patients. Data on demographic and cardiovascular risk factor were collected, and a complete blood analysis, including lipid profile and genetic analysis from a saliva sample, was performed. Main Outcomes and Measures: Primary outcomes were the maximal triglyceride levels reported in association with the minor alleles of the polymorphisms studied. Results: Among 116 patients, the mean (SD) age was 61.2 (14.7) years, 69 (59.5%) were men, and 85 (73.2%) had mycosis fungoides, the most prevalent form of CTCL. During bexarotene therapy, 96 patients (82.7%) experienced hypertriglyceridemia, which was severe or extreme in 8 of these patients (8.3%). Patients who carried minor alleles of the polymorphisms did not show significant differences in baseline triglyceride concentrations. After bexarotene treatment, carriers of at least 1 of the 2 minor alleles of APOA5 c.-1131T>C and APOC3 c.*40C>G showed lower levels of triglycerides than noncarriers (mean [SD], 241.59 [169.91] vs 330.97 [169.03] mg/dL, respectively; P = .02). Conclusions and Relevance: These results indicate that the screening of APOA5 and APOC3 genotypes may be useful to estimate changes in triglyceride concentrations during bexarotene treatment in patients with CTCL and also to identify the best candidates for bexarotene therapy based on the expected adverse effect profile.

Xanthomatous Cells in Cutaneous Graft-Versus-Host Disease Biopsies: A Clue for the Diagnosis of Hepatic Graft-Versus-Host Disease.

Graft-versus-host disease (GVHD) is one of the most common and serious complications of hematopoietic stem-cell transplantation that mainly affects the skin, gastrointestinal tract, and liver. Hepatic GVHD is associated with high morbidity and mortality, and its diagnosis can be especially challenging because of nonspecific clinical signs and symptoms. It must be suspected in patients with elevated liver enzymes and cholestasis, especially in those with a history of preceding skin rash and diarrhea. We describe 3 patients with cutaneous and hepatic GVHD that presented with severe hypercholesterolemia and hypertriglyceridemia, and no xanthomatous macular lesions, in which cutaneous biopsies revealed the presence of xanthomatous dermal histiocytes. We propose that the presence of these xanthomatous cells in skin biopsies from patients with cutaneous GVHD could be a dermatopathological clue for the diagnosis of hepatic GVHD.

A body of knowledge representation model of ecotourism products in southeastern Ecuador.

The corpus of knowledge or Bodies of Knowledge (BOK) term it used to describe a set of structures than codify all concept, terms, techniques, and sustainable activities that constitute the domain of the exercise of a profession or specific area of knowledge in our case in Ecotourism context. Ecotourism combines passion for travel with the interest in the preservation of nature and it is related to concepts of sustainability, conservation and participation of the local community, this term has been used to promote tourism activities in the natural environment and attract tourists interested in nature and culture of places to visit. In the Amazon rainforest ecotourism is an activity that contributes both to the awareness of travelers and the communities, in addition to income generated by this activity helps to preserve this heritage. The aim of this article is to contribute to the estimation of discrete choice models in order to analyze individual preferences, by analyzing the demand for ecotourism products in Ecuador's southeastern region, province of Zamora Chinchipe, using data obtained from surveys conducted during 2018, which provide information about the preferences of visitors to the area, through discrete choice experiments, and supported on BOK model. This experiment consisted in the creation of twelve choice scenarios defined by two hypothetical ecotourism products each. Thus, the alternatives were defined in terms of the following attributes: price, hiking, participation in rituals, tasting local cuisine, visit to crafts center and experience of community life (codes of BOK).

Cutaneous Indeterminate Cell Histiocytosis of Donor Origin After Allogeneic Hematopoietic Stem-Cell Transplantation.

Allogeneic hematopoietic stem-cell transplantation and solid-organ transplantation are associated with an increased risk of secondary neoplasms. Indeterminate cell histiocytosis (ICH) is a rare disease composed of so-called indeterminate cells, an alleged cutaneous dendritic cell subset displaying histological and some ultrastructural and immunophenotypic features of Langerhans cells but lacking Birbeck granules. We report a case of cutaneous ICH occurring after allogeneic hematopoietic stem-cell transplantation for a myelodysplastic syndrome in a 56-year-old man. Microsatellite analysis demonstrated that the neoplastic cells were derived from the donor's hematopoietic system. This case broadens the spectrum of complications after stem-cell transplantation and demonstrates that cutaneous ICH in the setting of myelodysplastic syndromes may have a nonrelated origin to dysplastic myeloid cells.

Incapacidad temporal por contingencia común en las matronas del Hospital Universitario «Virgen de la Arrixaca» durante 2009-2010 / Temporary incapacity due to common diseases in midwives of Hospital Universitario "Virgen de la Arrixaca" during 2009-2010

Objetivo: Describir las características y la evolución de la incapacidad temporal (IT) por contingencia común en las matronas del Hospital Universitario «Virgen de la Arrixaca», y su relación con determinadas variables sociodemográficas y laborales. Personas/material y método: Se realizó un estudio observacional, descriptivo, retrospectivo y transversal de las IT de 85 matronas en los años 2009-2010. Se analizó la relación de edad, sexo, estabilidad laboraly turno con el número de episodios, duración de la IT y número de horas de trabajo perdidas. Se obtuvieron los índices recomendados de la Organización Internacional del Trabajo (OIT).Resultados: Se produjeron un total de 120 episodios de IT, con una duración de 1.561 días y 7.222 horas reales de trabajo perdidas. La duración media de los episodios fue de 13 días. Se observó una relación entre la edad y estabilidad laboral con el número de IT y horas perdidas; también entre la estabilidad y la duración en días de la IT. Se obtuvo un índice de frecuencia superior en 2009 (74,11) y un índice de duración media superior en 2010 (15,71), lo que indica un mayor índice de gravedad (10,54 días/48,25 horas) y tasa de absentismo (2,9) en 2010. Conclusiones: El perfil de la matrona asociado a los procesos de IT es el de una mujer con estabilidad laboral (fija, interina y otras condiciones) y de mayor edad. El patrón tipo de IT es de corta duración, pero con gran pérdida de horas reales y mayor presencia en los meses fríos. Se observa un incremento en los índices de duración y de gravedad y en la tasa de absentismo en 2010 con respecto a 2009, aunque los resultados se acercan a la media aceptada por la OIT (AU)

Objective: To describe the characteristics and evolution of temporary incapacity (TI) due to common diseases in midwives working at "Virgende la Arrixaca" University Hospital ant its relation to certain social, demographic and occupational indicators. Staff/material and methodology: An observational, descriptive, retrospective, cross-sectorial study was carried out in 85 cases of TI in midwives in 2009-2010. Age, sex, job stability and day/night shifts were analyzed related to the number of TI episodes, the TI length (number ofdays) and the number of lost working hours. Rates according to the International Labour Organization recommendations were obtained. Results: There were 120 episodes of TI with a length of 1,561 days and a total amount of 7,222 lost working hours. Each episode took 13 days on average. The study showed that age and job-stability variables were related to the number of TI episodes and to the total amount of lost working hours. Job stability and episodes length were also observed to be related. The frequency index was higher in 2009 (74.11), as the length index was higher in 2010 (15.71). This means a higher severity index (10.54 days/48.25 hours) and a higher absenteeism rate (2.9) in 2010. Conclusions: The midwife profile in a situation of temporary incapacity is linked to elder women with job stability (permanent contract, interim and other). TI episodes are short in length, but they mean an important amount of lost working hours. Episodes are more likely to happen in wintertime. An increase in length index, severity index and absenteeism rate is observed in 2010 over 2009. Despite all, results agree with the International Labour Organization recommended data (AU)

The combination of bortezomib and dexamethasone is an efficient therapy for relapsed/refractory scleromyxedema: a rare disease with new clinical insights.

Scleromyxedema (SM) is a rare primary cutaneous inflammatory mucinosis characterised by papular mucinosis, monoclonal gammopathy and extracutaneous involvement. Most therapeutic options have failed in SM but high-dose therapy followed by autologous peripheral blood stem cell transplantation (APBSCT) appears to be highly effective, although SM normally relapses. We report the case of a 29-yr-old patient with severe SM who achieved stringent complete response with Bortezomib plus Dexamethasone after an early relapse subsequent to a high-dose melphalan regimen followed APBSCT. It is of particular note that dermatological lesions responded to both therapies before M-component modifications, suggesting that SM is independent of M-component characteristics. However, treatment should be directed towards the underlying plasma cell malignancy with typical anti-myeloma agents.

Atrofodermia idiopática de Pasini y Pierini. Estudio de cuatro casos / Idiopathic atrophoderma of Pasini and Pierini. Study of 4 cases

La atrofodermia idiopática de Pasini y Pierini (AIPP) es una forma infrecuente de atrofia cutánea de etiología desconocida. Describimos el cuadro clínico e histológico de 4 mujeres con AIPP. Tres tenían las lesiones en la espalda, la cuarta en la región glútea. El estudio histológico de 2 pacientes reveló un grado variable de alteración del colágeno (esclerosis e hialinización). En las otras pacientes la dermis era aparentemente normal. Se discute si la AIPP es una entidad individualizada o relacionada con la morfea. Ambos cuadros, aunque separados, podrían formar parte de un mismo espectro dentro de las denominadas dermatitis fibrosantes. Nosotros no hemos encontrado serología positiva a Borrelia burgdorferi en nuestros pacientes

Idiopathic atrophoderma of Pasini and Pierini (IAPP) is an infrequent form of cutaneous atrophy, of unknown etiology. We describe the clinical and histological symptoms of four women with IAPP. Three of them had lesions on the back, while the fourth had them on the buttocks. The histological study of two patients revealed a variable degree of collagen alteration (sclerosis and hyalinization). In the other patients, the dermis was apparently normal. There is discussion about whether IAPP is a distinct entity or is related to morphea. Both sets of symptoms, although separate, could form part of the same spectrum within the fibrosing type of dermatoses. We found no positive serology for B. burgdorferi in our patients

[Idiopathic atrophoderma of Pasini and Pierini. Study of 4 cases]. / Atrofodermia idiopática de Pasini y Pierini. Estudio de cuatro casos.

Idiopathic atrophoderma of Pasini and Pierini (IAPP) is an infrequent form of cutaneous atrophy, of unknown etiology. We describe the clinical and histological symptoms of four women with IAPP. Three of them had lesions on the back, while the fourth had them on the buttocks. The histological study of two patients revealed a variable degree of collagen alteration (sclerosis and hyalinization). In the other patients, the dermis was apparently normal. There is discussion about whether IAPP is a distinct entity or is related to morphea. Both sets of symptoms, although separate, could form part of the same spectrum within the fibrosing type of dermatoses. We found no positive serology for B. burgdorferi in our patients.

Nodulosis acelerada por metotrexato en un paciente con artritisreumatoide y síndrome de Sjögren / Methotrexate-induced accelerated nodulosis in a patient with rheumatoid arthritis and Sjögren´s syndrome

La nodulosis acelerada por metotrexato se describió inicialmente en pacientes con artritis reumatoide que recibían tratamiento con este fármaco. Se caracteriza por la aparición brusca de nódulos reumatoides y/o aumento de los preexistentes, coexistiendo con un buen control analítico y clínico de la enfermedad articular. La retirada del fármaco induce la regresión total o parcial de los nódulos y su reintroducción a nuevas recidivas. Presentamos a un varón de 70 años con artritis reumatoide erosiva de más de 25 años de evolución, con factor reumatoide positivo, autoanticuerpos y síndrome de Sjögren secundario. Desde hacía unos años presentaba dos nódulos subcutáneos en la superficie cubital de ambos antebrazos. Por una intensa reagudización de la sintomatología articular se instauró tratamiento con metotrexato (7,5 mg/semanales), con una excelente respuesta clinicoanalítica. Cuatro años después, todavía en tratamiento con metotrexato, presentó nuevos nódulos en ambas manos y un aumento llamativo de los preexistentes, que no se acompañaban de un empeoramiento de la artritis ni de alteraciones analíticas. Ante la sospecha de una nodulosis acelerada por metotrexato éste se suspendió, con lo que remitieron totalmente los nódulos de más reciente aparición y disminuyeron de tamaño los preexistentes. Nueve meses más tarde, por reagudización de la artritis, se reintrodujo el metotrexato lo que motivó un nuevo episodio de nodulosis, que mejoró al suspender definitivamente la administración del fármaco. (AU)

[Comparison of the efficacy of 1% flutrimazole cream twice a day with 1% flutrimazole cream once a day for the treatment of superficial dermatophytoses]. / Comparación de la eficacia de flutrimazol crema 1% dos veces al día frente a flutrimazol crema 1% una vez al día en el tratamiento de las dermatofitosis superficiales.

Different clinical studies have demonstrated flutrimazole's efficacy in the treatment of superficial dermatomycoses when administered either twice daily or once daily for four weeks. The aim of the present study was to compare both dosing schedules for the treatment of superficial dermatomycoses. In this randomized, controlled, double blind study, we included 84 patients suffering superficial dermatophytosis (confirmed by microscopic examination (KOH) and culture) susceptible for topical monotherapy. Forty-one patients received flutrimazole 1% twice daily (TD) and forty-three once daily (OD) for four weeks. The efficacy of treatment was evaluated by clinical and mycological criteria at the end of treatment (D28) and after four weeks without treatment (D58). Clinical and mycological cure rates on D28 were 50% with TD and 65% with OD treatment. Only considering clinical evaluation, clinical cure rates on D28 were 63% (TD) and 70% (OD). Also, clinical and mycological cure rates on D56 were 65% with TD and 72% with OD treatment. Only considering clinical evaluation, clinical cure rates on D56 were of 68% (TD) and 72% (OD). The overall tolerability was similar in both treatment groups. The efficacy assessment at the end of treatment (D28) and four weeks after treatment discontinuation (D56) showed that the OD treatment is not inferior to the TD treatment, with similar clinical and mycological cure rates and clinical cure rates in both cases. The OD administration of flutrimazole cream 1% is the most appropriate dosing schedule as it provides the same efficacy, it improves patient's compliance and the cost per day of treatment.