Micosis pulmonares en pacientes con diabetes mellitus. Características clínicas y factores de riesgo

BackgroundDiabetes mellitus is a public health problem in Mexico, and the trend of the disease is increasing. From 2000 to 2017, 7.32 million new cases were diagnosed, with pulmonary mycoses being one of the most serious complications.AimsTo describe the frequency and the clinical characteristics of patients diagnosed with pulmonary mycoses, and to identify the risk factors associated with this entity.MethodsCase–control study, paired by gender (1:1-3) and age (± 5 years), that analyzed patients with pulmonary mycosis (mucormycosis, histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis, cryptococcosis, paracoccidioidomycosis) and studied the risk factors present in each patient.ResultsFrom the 162 patients studied, 56 suffered pulmonary mycosis and 106 were controls. The median of the age was 51 and 50 years for the cases and for the controls, respectively. Multiple logistic regression analysis showed that patients with diabetes mellitus had an odds ratio of 8,3 (p < 0.001), and patients with a history of tuberculosis had an odds ratio of 8,8 (p < 0.001).ConclusionsOur results show that 52% of the patients with pulmonary mycoses had a history of diabetes mellitus. Diabetes mellitus is a relevant risk factor for pulmonary mycoses, which are usually diagnosed in advanced stages and have a high mortality.     

Association between Psoriasis and Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis

Psoriasis is considered a systemic inflammatory disorder. Previous studies have reported conflicting positive or negative correlations between psoriasis and chronic obstructive pulmonary disease. We performed a meta-analysis to determine whether there is an associated risk between psoriasis and chronic obstructive pulmonary disease. We performed a complete 30-year literature search of MEDLINE, Embase, and Cochrane Central Register databases on this topic. Four observational studies with a total of 13,418 subjects were identified. The odds ratios of chronic obstructive pulmonary disease in subjects with psoriasis/mild-to-moderate psoriasis were analyzed using the random-effects model, while the odds ratios of chronic obstructive pulmonary disease in subjects with severe psoriasis and current smoking in subjects with psoriasis were analyzed using the fixed-effect model. We found that psoriasis patients were at a greater risk of developing chronic obstructive pulmonary disease than the general population (odds ratio, 1.90; 95% confidence interval, 1.36–2.65) and that the association between of psoriasis and with chronic obstructive pulmonary disease was stronger among patients with severe psoriasis (odds ratio, 2.15; 95% confidence interval, 1.26–3.67). Psoriasis patients should be advised to cease smoking to reduce their risk of COPD. Moreover, identification of this potential risk may enable earlier implementation of preventive measures for reduction comorbidity and mortality rates.     

A rigorous yet simple quantitative risk assessment method for quarantine pests and non-native organisms

Internationally recognised guidelines for the assessment of risk posed by non‐native organisms generally suggest that the assessment is disaggregated into a series of components each being scored and then the scores added or averaged to give the final result. Assigning odds instead of scores allows a more rigorous probabilistic treatment of the data, which can offer more effective discrimination between organisms. For each component of the assessment, the odds express how likely is the evidence if the organism poses a risk as a quarantine pest. According to Bayesian theory, the odds for all components are multiplied together and the product divided by itself plus one to give the probability that the organism poses a risk as a quarantine pest given the evidence available (assuming that the prior probability is neutral). A general illustration of the different distributions of outcomes obtained from score averaging and probability is provided. The approach is then applied to a set of risk assessments for 256 potential quarantine pests compiled for Tanzania in 1997. The greater discrimination between cases may help improve communication between risk assessment scientists and regulatory decision makers.     

Derivation of Risk Management Criteria for Chemicals of Unknown Toxic Potency at Contaminated Sites

Environmental investigations of former industrial sites often detect the presence of chemicals for which no soil criteria exist and for which regulatory agencies have not derived estimates of toxic potency. This poses a considerable problem for making informed risk management decisions involving sites where such chemicals are present. As a result, a methodology has been developed for making risk-based decisions for chemicals of unknown toxic potency in soil at contaminated sites. The method is based on principles and procedures used by the US Food and Drug Administration (USFDA), the US Environmental Protection Agency (USEPA) and the Canadian Council of Ministers of the Environment (CCME). After analyzing the data on hundreds of carcinogenic and non-carcinogenic substances, the USFDA and other leading researchers have concluded that, if no toxicological data is available on a chemical, exposures less than 1.5?µg/person/day (i.e., 0.02?µg/kg body weight/day) are unlikely to result in appreciable health risks even if the substance was later found to be a carcinogen. To develop maximum soil concentrations that will be protective of human health (i.e., Risk Management Criteria or RMC), the above exposure limit of 0.02?µg/kg body weight/day has been assumed to be protective of risks from exposure to chemicals lacking toxicological data. Using a stochastic risk assessment model for estimating exposures to chemicals from contaminated sites, our analyses indicate that a soil concentration of 2?µg/g would be protective of human health for land uses that include residential, commercial, and industrial development provided no major indirect pathways exist at the site. If indirect pathways exists (e.g., vapor infiltration of soil gases, uptake of chemicals into garden produce, etc.), alternate RMC could be developed, that include such indirect pathways, using the methodology provided in this paper. Used by experienced risk assessors, the approach is a scientifically defensible screening method that will preclude many chemicals from unnecessary evaluation, while allowing risk assessors to focus efforts on chemicals of greater concern and make informed risk management decisions.     

Reconstructive breast surgery: referring physician knowledge and learning needs

Despite the positive impact that reconstructive breast surgery can have on a woman's quality of life, the percentage of eligible candidates that have this procedure remains surprisingly low. The authors hypothesized that this may be attributable to inadequate knowledge, inadequate information, and/or misinformation available to physicians caring for these patients. A needs assessment of primary care physicians, general surgeons, oncologists, and plastic surgeons was conducted to determine referring physicians' current level of knowledge of reconstructive breast surgery and to discover potential learning needs. This comprised a survey, focus groups, and individual interviews. Referring physicians rated their own knowledge of reconstructive breast surgery as low. Plastic surgeons rated their referring physicians' knowledge as even lower. Specific learning needs were identified, as large discrepancies between referring physicians' self-reported knowledge of individual breast reconstruction topics and their own opinion of their relevance were revealed. In addition, despite evidence to the contrary, more than one-third of referring physicians indicated a belief that a breast reconstruction delayed the detection of local cancer recurrence and adversely interfered with adjuvant oncologic therapy. This lack of knowledge and misinformation may be negatively affecting patient referrals to plastic surgeons, as more than one-third of referring physicians and 90 percent of plastic surgeons believed that eligible candidates were not being offered referrals because of inadequate referring physician knowledge of this topic. Furthermore, patients older than 49 years were not being referred despite the fact that plastic surgeons would consider these patients as potential surgical candidates. Referring physician gender affected both referral patterns and perceived importance of reconstructive breast surgery. Finally, personal beliefs and past experiences played a role both in physicians' decisions to refer patients and in patients' decisions to have breast reconstructions. These deficiencies in information, knowledge, and learning needs should be addressed by educational interventions during residency training and through continuing education endeavors.     

Perfusion Lung Scans Provide a Guide to Which Patients With Apparent Primary Pulmonary Hypertension Merit Angiography

There is hesitancy, based on the perceived risk, to do pulmonary angiography in patients believed to have primary pulmonary hypertension. Yet pulmonary hypertension due to major-vessel, chronic thromboembolism mimics primary pulmonary hypertension clinically and on standard laboratory tests. Because thromboembolic pulmonary hypertension is potentially remediable by thromboendarterectomy and primary pulmonary hypertension is not, differentiating between these disorders is essential. Angiography is required in patients with thromboembolic pulmonary hypertension to define the anatomic location of the thrombi. In evaluating perfusion lung scans of 110 patients with pulmonary hypertension to determine whether the scan might provide a guide to selecting those patients who merit angiography, no segmentalsize perfusion defects were noted on the scans of 64 patients with primary pulmonary hypertension, whereas all 46 patients with thromboembolic hypertension had one or more defects that were segmental in size or larger. These data indicate that a perfusion lung scan should be done in patients with pulmonary hypertension of uncertain cause and that those with one or more segmental or larger defects merit pulmonary angiography before being diagnosed as having primary pulmonary hypertension.     

A mapping technique to evaluate age‐0 salmon habitat response from restoration

To combat decades of anthropogenic degradation, restoration programs seek to improve ecological conditions through habitat enhancement. Rapid assessments of condition are needed to support adaptive management programs and improve the understanding of restoration effects at a range of spatial and temporal scales. Previous attempts to evaluate restoration practices on large river systems have been hampered by assessment tools that are irreproducible or metrics without clear connections to population responses. We modified a demonstration flow assessment approach to assess the realized changes in habitat quantity and quality attributable to restoration effects. We evaluated the technique's ability to predict anadromous salmonid habitat and survey reproducibility on the Trinity River in northern California. Fish preference clearly aligned with a priori designations of habitat quality: the odds of observing rearing Chinook or coho salmon within high‐quality habitats ranged between 10 and 16 times greater than low qualities, and in all cases the highest counts were associated with highest quality habitat. In addition, the technique proved to be reproducible with “substantial” to “almost perfect” agreement of results from independent crews, a considerable improvement over a previous demonstration flow assessment. These results support the use of the technique for assessing changes in habitat from restoration efforts and for informing adaptive management decisions.     

Anorexia Nervosa and Respecting a refusal of life-prolonging Therapy: A Limited Justification

People who suffer from eating disorders often have to be treated against their will, perhaps by being detained, perhaps by being forced to eat. In this paper it is argued that whilst forcing compliance is generally acceptable, there may be circumstances under which a sufferer's refusal of consent to treatment should be respected. This argument will hinge upon whether someone in the grip of an eating disorder can actually make competent decisions about their quality of life. If so, then the decision to refuse therapy may be on a par with other decisions to refuse life-prolonging therapy made by sufferers of debilitating chronic, or acute onset terminal illness. In such cases, palliation might justifiably replace aggressive therapy. The argument will also draw heavily on the distinction between competent refusal of therapy and passive euthanasia, and the distinction between incompetent and irrational decisions. Both distinctions will then be applied to decisions to refuse food. The extent to which sufferers from anorexia nervosa can be categorised as either incompetent or irrational will be examined. It is against this background that it will be argued that at least some of those who suffer from eating disorders should have their refusals respected, even if they may die as a result.     

Casting a wider net for countermeasure R&D funding decisions

Among potential bioweapons attacks, endemic infectious diseases (that is, those naturally occurring diseases that afflict us every year), and a potential influenza pandemic, how should we apportion funding and resources for basic research and countermeasure development? To address this question, I argue for a "combined risk assessment" that considers bioweapons attacks with natural pandemics and endemic infectious disease. At present, risk assessments for bioweapons attacks are carried out separately from the assessments long carried out for endemic infectious diseases to make public health and medical care decisions. One result of this separation is that funding decisions may be unduly influenced by an overblown fear of a big bioweapons attack and by political whim. The result of the simplified combined risk assessment presented here argues for more funding and resources for endemic infectious disease and for placing biodefense against anthrax and other bioweapons in a place lower in the risk hierarchy. Since the assessment here considers only fatalities to make the point that our priorities are skewed, the conclusions are only a "first word" on the subject, far from the last. Furthermore, the impact of other issues on priorities, such as national and international policy, is not considered. It is a call for a debate on the public stage of the policy and other rationale and the quantitative risk assessment arguments that now place bioweapons attacks at the top of our risk ranking.     

Time-based reward maximization

Humans and animals time intervals from seconds to minutes with high accuracy but limited precision. Consequently, time-based decisions are inevitably subjected to our endogenous timing uncertainty, and thus require temporal risk assessment. In this study, we tested temporal risk assessment ability of humans when participants had to withhold each subsequent response for a minimum duration to earn reward and each response reset the trial time. Premature responses were not penalized in Experiment 1 but were penalized in Experiment 2. Participants tried to maximize reward within a fixed session time (over eight sessions) by pressing a key. No instructions were provided regarding the task rules/parameters. We evaluated empirical performance within the framework of optimality that was based on the level of endogenous timing uncertainty and the payoff structure. Participants nearly tracked the optimal target inter-response times (IRTs) that changed as a function of the level of timing uncertainty and maximized the reward rate in both experiments. Acquisition of optimal target IRT was rapid and abrupt without any further improvement or worsening. These results constitute an example of optimal temporal risk assessment performance in a task that required finding the optimal trade-off between the ‘speed’ (timing) and ‘accuracy’ (reward probability) of timed responses for reward maximization.     

Comparative Study of District and Community Hospitals

Opinions conflict on whether there is a place in the Health Service for general practitioner (community) hospitals in which the patients'' treatment is mainly the responsibility of their family doctors. The authors therefore analysed a sample of the patients admitted in the course of a year to a group of two general district hospitals with a comparable sample of the patients admitted to a general practitioner hospital. The aim was to analyse the type of care provided in the general practitioner hospital, to assess whether it was appropriate for the type of cases treated, and to decide whether the patients would have been better off in the district general hospital (and vice versa). The main conclusions are that a district hospital is best for serious illnesses needing skilled decisions and assessments but that most of the work of these hospitals is not of this kind and a community hospital staffed by general practitioners offers many advantages to patients—provided the work being done is constantly under critical assessment. The authors plead for special refresher courses under the N.H.S. for general practitioners working in community hospitals.     

The effect of sea-level rise on coastal geomorphology

Sustainable management of coastal resources requires that future generations of people and wildlife enjoy an ongoing and equitable level of environmental quality ( Crooks & Turner 1999 ). The UK coast is, however, difficult to manage, being inhabited by a population with assets entrenched behind old flood defences and under threat from the combined risks of flooding and habitat change associated with rising sea-levels. Adopting a static policy approach towards sea-level rise conflicts with sustaining a dynamic coastal system that responds to perturbations via sediment movement and long-term evolution. At many locations maintaining a resilient coast demands the availability of space and sediments, but both are in short supply. Future management should incorporate adaptive measures, including strategic large-scale coastal floodplain reactivation, to support a resilient geomorphic response to sea-level rise. Management decisions will have major implications for coastal waterbirds.     

Association of Pulmonary Tuberculosis and Diabetes in Mexico: Analysis of the National Tuberculosis Registry 2000–2012

Background

Tuberculosis (TB) remains a public health problem in Mexico while the incidence of diabetes mellitus type 2 (DM) has increased rapidly in recent years.

Objective

To describe the trends of incidence rates of pulmonary TB associated with DM and not associated with DM and to compare the results of treatment outcomes in patients with and without DM.

Materials and Methods

We analysed the National Tuberculosis Registry from 2000 to 2012 including patients with pulmonary TB among individuals older than 20 years of age. The association between DM and treatment failure was analysed using logistic regression, accounting for clustering due to regional distribution.

Results

In Mexico from 2000 to 2012, the incidence rates of pulmonary TB associated to DM increased by 82.64%, (p <0.001) in contrast to rates of pulmonary TB rate without DM, which decreased by 26.77%, (p <0.001). Patients with a prior diagnosis of DM had a greater likelihood of failing treatment (adjusted odds ratio, 1.34 (1.11–1.61) p <0.002) compared with patients who did not have DM. There was statistical evidence of interaction between DM and sex. The odds of treatment failure were increased in both sexes.

Conclusion

Our data suggest that the growing DM epidemic has an impact on the rates of pulmonary TB. In addition, patients who suffer from both diseases have a greater probability of treatment failure.     

Screening for suicidal thoughts in primary care: the views of patients and general practitioners

Background It has been argued that primary care practitioners have an important part to play in the prevention of suicide. However, levels of assessment of risk of suicide among patients treated in this setting are generally low.Methods Cross-sectional survey of general practitioners (GPs) and people being treated in primary care who had signs of depression. The study combined open and closed questions on attitudes to screening or being screened for suicidal ideation.Results One hundred and one of 132 patients took part in the survey and 103 of 300 GPs completed a questionnaire. A majority of both GPs and patients stated that people should be screened for suicidal ideation. However, an important minority of patients and GPs stated that asking or being asked such questions made them feel uncomfortable. Less than half of GPs had received formal training on the assessment of suicide risk. GPs told the researchers that barriers to screening included time pressures, culture and language, and concerns about the impact that screening could have on people's mental health. One-quarter of GPs and one-fifth of patients supported the notion that screening for suicidal ideation could induce a person to have thoughts of self-harm.Conclusions GPs and family doctors should screen for suicidal risk among depressed patients and should receive training on how to do this as part of their general training in the assessment and management of mental disorders. Research should be conducted to examine what, if any, effect screening for suicidal ideation has on mental health.     

Risk assessment and cost-effectiveness/utility analysis

Decision-makers at all levels of public health and transfusion medicine have always assessed the risks and benefits of their decisions. Decisions are usually guided by immediately available information and a significant amount of experience and judgment. For decisions concerning familiar situations and common problems, judgment and experience may work quite well, but this type of decision process can lack clarity and accountability. Public health challenges are changing as emerging diseases and expensive technologies complicate the decision-makers' task, confronting the decision-maker with new problems that include multiple potential solutions. Decisions regarding polices and adoption of technologies are particularly complex in transfusion medicine due to the scope of the field, implications for public health, and legal, regulatory and public expectations regarding blood safety. To assist decision-makers, quantitative risk assessment and cost-effectiveness analysis are now being more widely applied. This set of articles will introduce risk assessment and cost-effectiveness methodologies and discuss recent applications of these methods in transfusion medicine.     

Risk Assessment in Navy Deployment Toxicology

The risk assessment process is a critical function for deployment toxicology research. It is essential to the decision making process related to establishing risk reduction procedures and for formulating appropriate exposure levels to protect naval personnel from potentially hazardous chemicals in the military that could result in a reduction in readiness operations. These decisions must be based on quality data from well-planned laboratory animal studies that guide the judgements, which result in effective risk characterization and risk management. The process of risk assessment in deployment toxicology essentially uses the same principles as civilian risk assessment, but adds activities essential to the military mission, including intended and unintended exposure to chemicals and chemical mixtures. Risk assessment and Navy deployment toxicology data are integrated into a systematic and well-planned approach to the organization of scientific information. The purpose of this paper is to outline the analytical framework used to develop strategies to protect the health of deployed Navy forces.     

Propuesta de desarrollo de una unidad de oncogeriatría. Tiempos de cambio: nuestra realidad

Age is one of the main risk factors for the development of cancer. It is expected that the progressive aging of the population will have an unprecedented impact on the incidence of various tumours. In fact, the management of elderly cancer patients is already a major public health problem in developed countries. However, elderly patients have systematically been excluded from cancer drug studies or protocol development. This has left health professionals in uncharted territory, without proper tools to address the multiple difficulties that arise in the treatment of these patients. A comprehensive geriatric assessment may serve as an ideal tool for the correct detection of hidden problems, facilitating treatment decisions in these complex patients, and integrating the care of patients with comorbidities.     

Parents' meetings in two neonatal units: a way of increasing support for parents.

For a combined total of three years meetings have been held regularly on two neonatal units for parents with infants requiring neonatal intensive care. These meetings give parents an opportunity to meet each other and members of staff in an informal atmosphere in the hope that mutual support will be gained. Initial assessment shows that the parents gain confidence in their ability to look after such small babies. The staff have gained a greater insight into the parents'' anxieties and problems and changes have been made in the procedures on these units. If new insight is to result in changes that benefit the parents their views must be made known and taken into account when policy decisions are made.     

Use and misuse of a digoxin assay service.

In a study of the use of a digoxin assay service and its influence on clinical management 285 assay requests were audited over 12 weeks. For 67 (24%) there was no clear clinical indication for the request and for 140 the period between the last dose of digoxin being given and the blood sample being taken was either unknown or inappropriate. Treatment in 64 patients (22%) was changed after the assay result was received [corrected]. 24 of these changes bore no relation to the original clinical indication for requesting the assay, suggesting that such changes were based on the assay result alone. Of samples collected within six hours after the last dose, 15 of 69 (22%) led to a reduction in treatment compared with 10 of 116 (9%) taken after six hours (p less than 0.025), thereby highlighting the danger that incorrectly timed samples may lead to inappropriate clinical decisions.