Epidemiología molecular de la tuberculosis

The application of genotyping tools allowed us to discriminate between the Mycobacterium tuberculosis isolates obtained in the laboratory. The differentiation between single strains opened the door to molecular epidemiology studies, which had helped us to progress in our knowledge of how this pathogen is transmitted in the progressively more complex socio-epidemiological scenario. The genetic stability of this microorganism led to develop specific methodologies, which are thoroughly revised in this chapter. In addition to their application in epidemiology, we review, how they can offer a response to different diagnostic and clinical challenges. Finally, we focus on describing the novel genomic revolution we are experiencing in the analysis of tuberculosis, the methodology in which it is based and the novel possibilities it offers, including new routes of integrating both the molecular and genomic languages in innovative post-genomic proposals, better suited to our real-life context.     

Aplicaciones de la dinámica de fluidos computacional a la neumología

Computational Fluid Dynamics (CFD) is a computer-based tool for simulating fluid movement. The main advantages of CFD over other fluid mechanics studies include: substantial savings in time and cost, the analysis of systems or conditions that are very difficult to simulate experimentally (as is the case of the airways), and a practically unlimited level of detail. We used the Ansys-Fluent CFD program to develop a conducting airway model to simulate different inspiratory flow rates and the deposition of inhaled particles of varying diameters, obtaining results consistent with those reported in the literature using other procedures. We hope this approach will enable clinicians to further individualize the treatment of different respiratory diseases.     

Seguridad en el uso de la ecografía en reumatología durante la pandemia COVID-19. Documento de posicionamiento de la Sociedad Española de Reumatología

Ultrasound is a widely implemented imaging modality in rheumatology practice that implies a great interaction between patient and professional. The COVID-19 pandemic requires a change in our clinical practice, through the adoption of new strategies that allow comprehensive care for our patients, guaranteeing the safety of both patients and healthcare professionals.ObjetiveOur objective was to develop practical recommendations, agreed among a panel of experts, on the use and safety of rheumatological ultrasound during the COVID-19 pandemic.MethodsWe performed a narrative review of the available literature. Based on the literature review, we produced preliminary recommendations that were subsequently agreed among a panel of experts using the Delphi methodology with a 1-5 Likert scale. Agreement for each recommendation was considered if 75% of the panel members scored the item ≥4 on the Likert scale.Results5 overarching principles and 28 recommendations were issued and agreed among the panel. Group consensus was achieved in 100% of items.ConclusionsThe document provides useful information about preventive measures in the practice of ultrasound in rheumatology in times of a COVID-19 pandemic based on the experience and literature available to date.     

Documento de consenso para la formación en ecografía en la especialidad de Nefrología

Ultrasound is an essential tool in the management of the nephrological patient allowing the diagnosis, monitoring and performance of kidney intervention. However, the usefulness of ultrasound in the hands of the nephrologist is not limited exclusively to the ultrasound study of the kidney. By ultrasound, the nephrologist can also optimize the management of arteriovenous fistula for hemodialysis, measure cardiovascular risk (mean intimate thickness), implant central catheters for ultrasound-guided HD, as well as the patient's volemia using basic cardiac ultrasound, ultrasound of the cava inferior vein and lungs.From the Working Group on Interventional Nephrology (GNDI) of the Spanish Society of Nephrology (SEN) we have prepared this consensus document that summarizes the main applications of ultrasound to Nephrology, including the necessary basic technical requirements, the framework normative and the level of training of nephrologists in this area. The objective of this work is to promote the inclusion of ultrasound, both diagnostic and interventional, in the usual clinical practice of the nephrologist and in the Nephrology Services portfolio with the final objective of offering diligent, efficient and comprehensive management to the nephrological patient.     

Influencia de la pandemia COVID-19 sobre la epidemiología de la bronquiolitis aguda

IntroductionThe COVID-19 pandemic has changed the circulation of some viruses associated with acute bronchiolitis. We analyzed the epidemiology of bronchiolitis admissions during the COVID-19 pandemic compared with 8 previous epidemic seasons.MethodsAn observational and ambispective study was performed, including infants admitted with bronchiolitis in a tertiary hospital during 2 periods: COVID-19 pandemic (15th March 2020 to 3 rd August 2021) and pre-pandemic (1st September 2012 to 14th March 2020). Demographic, clinical data and etiologies were collected.ResultsFive hundred ten patients were hospitalized with bronchiolitis: 486 in the pre-pandemic period with an average of 61 admissions per season vs. 24 during the pandemic, observing a 60.7% reduction in bronchiolitis admissions. During the pandemic, bronchiolitis outbreak was delayed until spring–summer 2021. Respiratory syncytial virus was the most frequent etiological agent in both periods.ConclusionWe observed a change in the seasonality of bronchiolitis during the pandemic COVID-19, possibly influenced by control measures against SARS-CoV-2.     

Situación de la ecografía en la reumatología española 2012

ObjectiveTo know the situation of ultrasound in Spanish rheumatology.MethodsA National survey addressed to all rheumatology units in hospitals with at least 200 beds. The questionnaire studied: a) the availability and the model of the ultrasound equipment, b) the degree of training, c) the purpose and areas of ultrasound examination, d) the usefulness, and e) the relevance of ultrasound in the training of residents.Results169 units of the 234 surveyed physicians answered the questionnaire. The availability of ultrasound equipment was high (90%), 38.7% of rheumatologists use ultrasound, although half of the units had a rheumatologist especially dedicated to performing them. Training plans have enabled the incorporation of ultrasound, but there are areas that could be improved. The utility in routine clinical practice was scored at 7.8 (0-10), and ultrasound was integrated in the diagnostic and therapeutic decisions. There is a broad consensus on the need to include ultrasound in the training of residents. Administration is adding ultrasound to the portfolio of specialty services.ConclusionsIn just 15 years, ultrasound has become available in 90% of rheumatology units from being previously inexistent. Its use is extensive, integrated into clinical practice and linked to the decision making processes. Training plans have been effective, but areas for improvement were identified, and there is a broad consensus on the need to integrate ultrasound in residents’ training.     

Objetivos y metodología de la fase iii de BIOBADASER

ObjectiveDescribe the objectives, methods and results of the first year of the new version of the Spanish registry of adverse events involving biological therapies and synthetic drugs with an identifiable target in rheumatic diseases (BIOBADASER III).MethodologyMulticenter prospective registry of patients with rheumatic inflammatory diseases being treated with biological drugs or synthetic drugs with an identifiable target in rheumatology departments in Spain. The main objective of BIOBADASER Phase III is the registry and analysis of adverse events; moreover, a secondary objective was added consisting of assessing the effectiveness by means of the registry of activity indexes. Patients in the registry are evaluated at least once every year and whenever they experience an adverse event or a change in treatment. The collection of data for phase iii began on 17 December 2015.ResultsDuring the first year, 35 centers participated. The number of patients included in this new phase in December 2016 was 2,664. The mean age was 53.7 years and the median duration of treatment was 8.1 years. In all, 40.4% of the patients were diagnosed with rheumatoid arthritis. The most frequent adverse events were infections and infestations.ConclusionsBIOBADASER Phase III has been launched to adapt to a changing pharmacological environment, with the introduction of biosimilars and small molecules in the treatment of rheumatic diseases. This new stage is adapted to the changes in the reporting of adverse events and now includes information related to activity scores.     

FGF23: de la nefrología de salón a la cabecera del paciente

Twenty years have passed since the identification of klotho and the fibroblast growth factor 23 (FGF23), the regulatory binomial of phosphate homeostasis. Being kidney the main source of klotho as well as a target organ in the phosphate regulation, most studies involving klotho and FGF23 had a «nephrocentric» focus. Considering that circulating FGF23 can reach exaggerated levels at the end stage of chronic kidney disease (CKD), the bias of this approach allowed to recognize the harmful «off target» klotho-independent effect of FGF23. All of these findings have caused a revolution on our previous knowledge about mineral homeostasis and currently, we are facing a new scenario in the clinical management of CKD, where FGF23 emerges simultaneously as an early biomarker of phosphate retention but also as a therapeutic target. In this review, we describe the disturbances of FGF23 in the CKD and we focus on how the maintenance of circulating FGF23 into a supraphysiological adaptive range from the initial stages of CKD and the control of «unlimited hyperphosphatonism» generated by the resistance to FGF23 action at end stages should emerge as new treatment paradigms in chronic kidney disease - mineral and bone disorders (CKD-MBD). The recent development of an automated FGF23 assay, already validated for clinical use, should be the starting point to individualize all our knowledge from epidemiological studies and will allow us to use it properly for the patient's personalized care. Then, now we are in the momentum to assess the discriminating thresholds to distinguish the physiological adaptive FGF23 elevation related to each CKD stage from the exaggerated increase that would be interpreted as a poor regulatory compensation that will requires the adoption of therapeutic intervention.     

Eficacia de la rifaximina en los diferentes escenarios clínicos de la encefalopatía hepática

Hepatic encephalopathy is a frequent complication in patients with cirrhosis of the liver and is associated with a high mortality rate. Costs attributed to the management of patients with cirrhosis are especially high due to complications, such as hepatic encephalopathy, given that they increase the number of days of hospital stay. Different drugs are currently used to treat hepatic encephalopathy, and the main ones are lactulose, L-ornithine L-aspartate (LOLA), and certain antibiotics, especially rifaximin-α (RFX). Even though many of them have been shown to be effective to greater or lesser degrees, it is important to understand the differences between them, so that every patient receives individualized treatment and the best option is chosen, in accordance with the different clinical scenarios. Thus, the aim of the present study was to analyze the evidence on the advantages and disadvantages of the individual or combined use of the 3 main treatments for hepatic encephalopathy, specifically taking into consideration their different degrees of efficacy, their impact on quality of life, prophylaxis, and cost reduction.     

Recomendaciones para la reapertura y reinicio de actividades de las Unidades de Neurogastroenterología ante la pandemia por COVID-19. Posicionamiento de la Sociedad Latinoamericana de Neurogastroenterología

The COVID-19 pandemic has forced the establishment of preventive measures against contagion during the performance of diagnostic and therapeutic tests in gastroenterology. Digestive tract motility tests involve an intermediate and elevated risk for the transmission of COVID-19 infection. Given their elective or non-urgent indication in the majority of cases, we recommend postponing those tests until significant control of the infection rate in each Latin American country has been achieved during the pandemic. When the health authorities allow the return to normality, and in the absence of an effective treatment for or preventive vaccine against COVID-19 infection, we recommend a strict protocol for classifying patients according to their infectious-contagious status through the appropriate use of tests for the detection of the virus and the immune response to it, and the following of protective measures by the healthcare personnel to prevent contagion during the performance of a gastrointestinal motility test.     

La docencia de la nefrología en el grado de medicina

The teaching of nephrology as part of a degree in medicine is potentially one of the most decisive factors when choosing a speciality. Until now, however, we have not had an overview of the teaching of nephrology in Spain. We have integrated information available in public databases with a survey and personal interviews with those responsible for teaching in Spanish medical faculties. In 2019, there were 44 universities offering a medicine degree in Spain, in 16 Autonomous Communities (34 of which were public and 10 private). For learning purposes, students have a number of hospital beds ranging from 0.2 to 4.7, and there are Autonomous Communities that have a higher proportion of students per inhabitant or per physician, such as Madrid or the Community of Navarra. In 16 universities there are tenured teaching staff (professors and lecturers), in 8 contracted medical lecturers, and in 2 assistant lecturers. In 21 medical faculties, theoretical and practical nephrology is taught by associate lecturers. The subject is taught between the third and fifth years of the degree, the median being the fourth year. It is usually integrated with another subject and only in the University of Navarra is it an independent subject, with 3 credits. The total number of hours devoted to theoretical teaching (both theoretical classes and seminars) is highly variable and ranges from 11 to 35, with a median of 17.5. Variability is observed in both the number of theoretical subjects (range 11 to 31) and seminars (range 0 to 9). Among the faculties that teach seminars, the ratio of theoretical topics to seminars ranges from 1.6 to 18. Most faculties evaluate clinical practices with various modalities and percentage of assessment. Knowledge is mostly assessed by a multiple choice exam.In conclusion, there is a high level of variability in the curriculum for the teaching of nephrology as part of a degree in medicine in Spain. Teaching staff who are tenured or who have a stable affiliation with universities make up just 23% of the total and, in many faculties, teaching depends exclusively on associate professors.     

Actualización de la Guía Mexicana para el Tratamiento Farmacológico de la Artritis Reumatoide del Colegio Mexicano de Reumatología

BackgroundThe pharmacologic management of rheumatoid arthritis has progressed substantially over the past years. It is therefore desirable that existing information be periodically updated. There are several published international guidelines for the treatment of rheumatoid arthritis that hardly adapt to the Mexican health system because of its limited healthcare resources. Hence, it is imperative to unify the existing recommendations and to incorporate them to a set of clinical, updated recommendations; the Mexican College of Rheumatology developed these recommendations in order to offer an integral management approach of rheumatoid arthritis according to the resources of the Mexican health system.ObjectiveTo review, update and improve the available evidence within clinical practice guidelines on the pharmacological management of rheumatoid arthritis and produce a set of recommendations adapted to the Mexican health system, according to evidence available through December 2012.MethodsThe working group was composed of 30 trained and experienced rheumatologists with a high quality of clinical knowledge and judgment. Recommendations were based on the highest quality evidence from the previously established treatment guidelines, meta-analysis and controlled clinical trials for the adult population with rheumatoid arthritis.ResultsDuring the conformation of this document, each working group settled the existing evidence from the different topics according to their experience. Finally, all the evidence and decisions were unified into a single document, treatment algorithm and drug standardization tables.ConclusionsThis update of the Mexican Guidelines for the Pharmacologic Treatment of Rheumatoid Arthritis provides the highest quality information available at the time the working group undertook this review and contextualizes its use for the complex Mexican health system.     

Cambios en la epidemiología de la hepatitis A: repercusiones clínicas y preventivas

Introduction and objectivesHepatitis A Virus Infection (HAI) has been related to the hygienic-sanitary situation of an area, the changes in the epidemiology of HAI in the province of Guadalajara between 1991 and 2017 are analyzed.Materials and methodsCases of HAI declared between 1991 and 2017 in Guadalajara were included. The variables analyzed were age, sex, environment, risk factors for HAI and need for hospitalization. The incidence was compared in three periods: 1991–1999, 2000–2008 and 2009–2017.ResultsTwo hundred and thirty-three cases of HAI were declared, the average incidence rate was 4.27 cases/100,000 inhabitants, highest between 1991 and 1999 (6.93) and lowest between 2009 and 2017 (1.92), with an increment in 2017 (5.5). The median age was 16 years (IR: 8.5-28.5 years), 58.4% were male, and the highest incidence occurred between 5 and 14 years in both sexes. The most frequent risk factors were family and non-family contact and trips to endemic areas (18.6%, 17.3% and 18.2%, respectively). The last risk factor increased after 2000 (P=.001), as did the incidence in urban areas. The MSM group showed an increase in the last period (P<.001). Hospital admissions increased progressively from the first to the third period studied (P=.001).ConclusionsHAI has a low incidence in our area. More cases related to travel or sexual practices are observed. This should be considered when establishing prevention policies, including vaccination of the most exposed people.     

La tasa de filtrado glomerular estimada es un biomarcador precoz de la insuficiencia renal aguda asociada a la cirugía cardíaca

Background

and objective Acute kidney injury (AKI) diagnosis is still based on serum creatinine and diuresis. However, increases in creatinine are typically delayed 48 h or longer after injury. Our aim was to determine the utility of routine postoperative renal function blood tests, to predict AKI one or 2 days in advance in a cohort of cardiac surgery patients.

Impacto de la ecografía pulmonar Durante la pandemia por SARS-CoV-2: distinción entre la neumonía viral y la bacteriana

IntroductionLung ultrasound is an accessible, low-cost technique that has demonstrated its usefulness in the prognostic stratification of COVID-19 patients. In addition, according to previous studies, it can guide us towards the potential aetiology, especially in epidemic situations such as the current one.Patients and methods40 patients were prospectively recruited, 30 with confirmed SARS-CoV-2 pneumonia and 10 with community-acquired pneumonia. The patients included underwent both a chest X-ray and ultrasound.ResultsThere were no differences in the 2 groups in terms of clinical and laboratory characteristics. The main ultrasound findings in the SARS-CoV-2 group were the presence of confluent B lines and subpleural consolidations and hepatinization in the community-acquired pneumonia group. Pleural effusion was more frequent in the community-acquired pneumonia group. There were no normal lung ultrasound exams. Analysis of the area under the curve curves showed an area under the curve for lung ultrasound of 89.2% (95% CI: 75.0-100%, p < .001) in the identification of SARS-CoV-2 pneumonia. The cut-off value for the lung score of 10 had a sensitivity of 93.3% and a specificity of 80.0% (p < .001).DiscussionThe combination of the findings of the lung ultrasound, with a lung score greater than 10, added to the rest of the additional tests, can be an excellent tool to predict the aetiology of the pneumonia.