A boy with fatigue and heart block: what's the mechanism?

When the atrioventricular node is damaged, accessory pathways can perform primary atrioventricular conduction but may spontaneously degrade during childhood. After surgical atrial septal defect repair during infancy, an adolescent male presented with fatigue due to iatrogenic complete atrioventricular node block with a degrading antegrade accessory pathway resulting in symptomatic bradyarrhythmia.

Mask use among health care workers and feelings of safety at work pre- and post- COVID-19 vaccine.

BACKGROUND: Correct mask use can prevent the spread of COVID-19 and hospitals require correct mask use. Despite this, there is variation in mask use among health care workers (HCW). Incorrect mask use may lead to increased infections and decreased feelings of safety. The purpose of this study was to determine variation in mask use among HCW as well as feelings of safety from exposure to COVID-19 when around colleagues before and after COVID-19 vaccine roll out. METHODS: This study used direct observation to assess mask use in patient-facing areas before and after COVID-19 vaccine. A staff survey was used to assess feelings of safety. RESULTS: Over 1,600 mask observations showed increased compliance from 94.6% to 97.5% (P = .001). Three hundred survey responses showed significantly increased feelings of safety (P < .001) after vaccine roll out, and 203 free-text responses with respondant reasoning were categorized into 6 themes. DISCUSSION: Understanding mask use behaviors and safety attitudes of HCW can help improve policies, workplace culture, and reduce HCW to HCW infections. CONCLUSIONS: Correct mask use was a highly adopted habit in patient-facing areas. The COVID-19 vaccine led to significantly increased feelings of safety among HCW, though the diverging narratives seen in the survey may be helpful to consider when crafting safety interventions.

Pheochromocytoma: 20 years of improving surgical care.

BACKGROUND: Laparoscopic adrenalectomy is now the standard for pheochromocytoma. We report two decades of institutional experience with pheochromocytoma adrenalectomy. METHODS: A retrospective review was undertaken of pheochromocytoma adrenalectomy patients between 1997 and 2017. Clinical variables and postoperative complications were recorded. Patients were divided into quartiles for analysis: group 1 from 1997 to 2001, group 2 from 2002 to 2006, group 3 from 2007 to 2011, and group 4 from 2012 to 2017. RESULTS: Eighty-two pheochromocytoma adrenalectomies were identified. The percentage of laparoscopic adrenalectomies increased over time: 60% in group 1-87.5% in group 4 (p = 0.03). The average tumor size decreased: 6.4 cm (2.8-14.3 cm) in group 1-4.6 cm (1.2-7.8 cm) in group 4 (p = 0.03). ICU utilization decreased from 80% to 40.6% (p = 0.03) and length of stay decreased from 7.2 days to 2.7 days (p = 0.005). Clavien-Dindo grade>3 complications did not differ between the quartiles (p = 0.08). CONCLUSION: Pheochromocytoma care has evolved from more open procedures with standard postoperative ICU stay to a laparoscopic resection with targeted ICU care and decreased length of stay. As experience with laparoscopic adrenalectomy increases, patient outcomes improve.

Laparoscopic vagal nerve blocking device explantation: case series and report of operative technique.

BACKGROUND: Vagal nerve blockade with the vBloc device (ReShape Lifesciences, St. Paul, MN) has been shown to provide durable 2-year weight loss in patients with moderate obesity. These devices may require removal. We present a series of patients and report our technique for laparoscopic removal of this device. METHODS: From December 2009 to December 2016, the medical records of patients who underwent laparoscopic explantation of a vagal blocking device at our institution were retrospectively reviewed. All patients initially underwent device placement as part of a multi-center, randomized, controlled trial. The device leads were removed with the application of firm traction in order to safely dissect them away from the stomach and esophagus as the body tended to form a fibrotic capsule surrounding the leads. Operative details, length of stay, 30-day post-operative complications, demographics and reasons for device removal were reported. RESULTS: Thirty patients were identified. Median age was 54 (37-65) years. Average operative time was 227.63 (± 100.21) min. Median time from implantation to removal was 41 (11-96) months. Removal reasons included device malfunction (7 patients, 23.3%), pain at the neuroregulator site (5 patients, 16.7%), retrosternal or epigastric pain (11 patients, 36.7%), weight regain or dissatisfaction with weight loss (15 patients, 50%), and severe nausea (2 patients, 6.7%). Two patients (6.7%) had Clavien-Dindo grade II complications following explantation. Thirteen patients (43.3%) had dense adhesions noted at the time of operation. Seroma formation at the neuroregulator site was the most common complication (7 patients, 23.3%). CONCLUSION: The vagal nerve blocking device can be safely removed laparoscopically with a low 30-day complication rate. Surgeons should be familiar with the details of the device appearance, the typical lead location, and should anticipate dense adhesions surrounding the leads. In addition, experience operating in the region of the gastroesophageal junction is imperative.

Discrete wavelength selection for the optical readout of a metamaterial biosensing system for glucose concentration estimation via a support vector regression model.

In this contribution, a method to select discrete wavelengths that allow an accurate estimation of the glucose concentration in a biosensing system based on metamaterials is presented. The sensing concept is adapted to the particular application of ophthalmic glucose sensing by covering the metamaterial with a glucose-sensitive hydrogel and the sensor readout is performed optically. Due to the fact that in a mobile context a spectrometer is not suitable, few discrete wavelengths must be selected to estimate the glucose concentration. The developed selection methods are based on nonlinear support vector regression (SVR) models. Two selection methods are compared and it is shown that wavelengths selected by a sequential forward feature selection algorithm achieves an estimation improvement. The presented method can be easily applied to different metamaterial layouts and hydrogel configurations.

Técnicas cognitivo-conductuales de fácil aplicación en asistencia primaria (parte 2) / Easily implemented cognitive behaviour techniques in primary care (part 2)

Las técnicas cognitivo-conductuales han demostrado ser de gran valor en el tratamiento de la mayoría de los cuadros mentales. En esta segunda parte del manuscrito seguimos presentando aquellas técnicas de inspiración cognitivo y conductual de fácil aplicación en las consultas de asistencia primaria (AU)

Cognitive behavioural therapy has shown to be very effective for treating the vast majority of mental health disorders. In this second part of the article, we continue commenting on those techniques that can be easily used in the Primary Care setting (AU)

[Easily implemented cognitive behaviour techniques in primary care (part 2)]. / Técnicas cognitivo-conductuales de fácil aplicación en asistencia primaria (parte 2).

Cognitive behavioural therapy has shown to be very effective for treating the vast majority of mental health disorders. In this second part of the article, we continue commenting on those techniques that can be easily used in the Primary Care setting.

Dynamic modeling of the hydrogel molecular filter in a metamaterial biosensing system for glucose concentration estimation.

We present a novel concept for ophthalmic glucose sensing using a biosensing system that consists of plasmonic dipole metamaterial covered by a layer of functionalized hydrogel. The metamaterial together with the hydrogel can be integrated into a contact lens. This optical sensor changes its properties such as reflectivity upon the ambient glucose concentration, which allows in situ measurements in the eye. The functionalization of the sensor with hydrogel allows for a glucose-specific detection, providing both selectivity and sensitivity. As a result of the presented work we derive a dynamic model of the hydrogel that can be used for further simulation studies.

[Easily implemented cognitive behaviour techniques in Primary Care (part 1)]. / Técnicas cognitivo-conductuales de fácil aplicación en atención primaria (I).

Cognitive behavioural therapy has shown to be very effective for treating the vast majority of mental health disorders. We comment on those techniques that can be easily used in the Primary Care setting.

Técnicas cognitivo-conductuales de fácil aplicación en atención primaria (I) / Easily implemented cognitive behaviour techniques in Primary Care (Part 1)

Las técnicas cognitivo-conductuales han demostrado ser de gran valor en el tratamiento de la mayoría de los cuadros mentales. Se presentan en este manuscrito aquellas técnicas de inspiración cognitivo y conductual de fácil aplicación en las consultas de atención primaria (AU)

Cognitive behavioural therapy has shown to be very effective for treating the vast majority of mental health disorders. We comment on those techniques that can be easily used in the Primary Care setting (AU)

Insulin dosage optimization based on prediction of postprandial glucose excursions under uncertain parameters and food intake.

Considering the difficulty in selecting correct insulin doses and the problem of hyper- and hypoglycemia episodes in type 1 diabetes, dosage-aid systems are very useful for these patients. A model-based approach to this problem must unavoidably consider uncertainty sources such as large intra-patient variability and food intake. In the present study, postprandial glucose is predicted considering this uncertain information using modal interval analysis. This approach calculates a safer prediction of possible hyper- and hypoglycemia episodes induced by insulin therapy for an individual patient's parameters and integrates this information into a dosage-aid system. Predictions of a patient's postprandial glucose at 5-h intervals are used to predict the risk for a given therapy. Then the insulin dose and injection-to-meal time with the lowest risk are calculated. The method has been validated for three different scenarios corresponding to preprandial glucose values of 100, 180 and 250mg/dl.

Prediction of glucose excursions under uncertain parameters and food intake in intensive insulin therapy for type 1 diabetes mellitus.

Considering the difficulty in the insulin dosage selection and the problem of hyper-and hypoglycaemia episodes in type 1 diabetes, dosage-aid systems appear as tremendously helpful for these patients. A model-based approach to this problem must unavoidably consider uncertainty sources such as the large intra-patient variability and food intake. This work addresses the prediction of glycaemia for a given insulin therapy face to parametric and input uncertainty, by means of modal interval analysis. As result, a band containing all possible glucose excursions suffered by the patient for the given uncertainty is obtained. From it, a safer prediction of possible hyper-and hypoglycaemia episodes can be calculated.

Terapéutica en Atención Primaria. Terapia cognitivo conductual y medicina de familia en el tratamiento integral de la depresión. Aproximación práctica / Therapy in Primary Health Care. Cognitive-behavioral therapy of thefamily in the integral treatment of depression. Practical approach

La terapia cognitivo conductual (TCC) ha demostrado ser de gran valor como parte del tratamiento integral o biopsicosocial de muchos cuadros mentales, y entre ellos la enfermedad depresiva. Su fundamento es doble y ecléctico; se basa en la psicología cognitiva de Beck y en los principios del aprendizaje clásico, operante y vicario. Es una psicoterapia del consciente donde sujeto y terapeuta interaccionan activamente. La TCC es de elección en el tratamiento de los cuadros depresivos considerados menores, y junto a los fármacos antidepresivos se ha demostrado eficaz en el tratamiento de los cuadros graves y en la prevención de recurrencias de la enfermedad. Debe ser considerada como parte del modelo terapéutico biopsicosocial de los cuadros mentales. El médico de familia puede, conociendo técnicas sencillas, aproximarse al esquema cognitivo de sus pacientes y poder junto a ellos elaborar esquemas de modificación de pensamientos erróneos, que generan conductas depresógenas

Cognitive behavioral therapy (CBT) has been shown to have great value as part of the integral or biopsychosocial treatment of many mental pictures, among them depressive disease. This has a double and eclectic basis. It is based on Beck's cognitive psychology and on the Classical, Operant and Vicarious principles. It is a psychotherapy of the consciousness where the subject and therapist actively interact. CBT is the choice in the treatment in minor depressive pictures and, together with antidepressants, has been shown to be effective in the treatment of serious pictures and in the prevention of disease recurrences. It should be considered as part of the biopsychosocial therapeutic model of mental pictures. The Family Doctor may approach the cognitive scheme of his/her patients through the knowledge of simple techniques and elaborate modification schemes of erroneous thoughts that generate depressogenic behaviors

Comprehensive pharmacokinetic model of insulin Glargine and other insulin formulations.

In this paper, a comprehensive pharmacokinetic model for different insulin formulations including insulin Glargine is developed based on the model proposed by Trajanoski et al. (1993). Current models show limitations for insulin Glargine due to the appearance of an uncharacteristic peak in the concentration-time evolution of plasma insulin that does not coincide with real experimental data. This important limitation has been solved in this paper by introducing a new virtual insulin state called the bound state, in addition to the dimeric and hexameric ones. Trying to describe the retarded action of insulin Glargine, the modeling idea behind this approach is that immediately after the subcutaneous injection all the insulin resides in the bound state, and only then small amounts of insulin in the hexameric form disengage from the bound state. For the model evaluation different simulation results are compared. Using experimental data published by Lepore et al. (2000), the developed model turned out to be capable of at least qualitatively predicting the concentration-time profile of plasma insulin. Both exogenous insulin flow simulations and spatial diffusion simulations show the plausibility and correct implementation of the derived model. Considering all these simulation results, the here presented new pharmacokinetic model demonstrates to be able to reproduce real patient behavior simulating even complete insulin regimes including long-acting, intermediate and short-acting insulin formulations.

Notificación de reacciones adversas a medicamentos.Conocimientos y actitudes entre médicos de Atención Primaria / Adverse drug reactions reporting: knowledge and attitude among primary health care practitioners

Objetivo: conocer los factores asociados a la infranotificación de sospechas de reacciones adversas a medicamentos (RAM) a los centros de farmacovigilancia mediante tarjeta amarilla y las diferencias entre los médicos notificadores y no notificadores. Diseño: estudio descriptivo transversal, mediante cuestionario autocumplimentado. Emplazamiento: diez equipos de Atención Primaria de la Comunidad Valenciana (España) seleccionados mediante muestreo a conveniencia. Participantes: la población de estudio estuvo constituida por los 143 médicos de familia y pediatras de los equipos seleccionados. Mediciones y resultados principales: se obtuvieron 109 cuestionarios (tasa de respuesta 76 porciento). El 77 porciento de los encuestados habían notificado alguna RAM. El sistema de notificación mediante tarjeta amarilla era conocido por el 94,5 porciento y sería el destino prioritario en caso de declarar una reacción adversa. La pereza, la difícil confirmación y la creencia de que la mayoría de las reacciones son ya conocidas fueron los motivos de no declaración más frecuentes. La mayor confianza en la seguridad de los medicamentos, menor conocimiento del mecanismo de declaración, menor acuerdo en la utilidad de declarar sospechas y en la posibilidad de identificar nuevas reacciones, la carencia de tarjetas amarillas, el desacuerdo con la necesidad de identificarse y con la ausencia de incentivo económico caracterizaron más frecuentemente a los no notificadores. Conclusiones: los médicos de Atención Primaria conocen mayoritariamente el sistema de farmacovigilancia. Los no notificadores no entienden la utilidad de un sistema basado en sospechas, confían excesivamente en la seguridad de los fármacos y no se sienten compensados por notificar reacciones (AU)