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Study design: This is a prospective, multicenter, and observational study with the aim of describing physiological characteristics, respiratory management, and outcomes of children with acute hypoxemic respiratory failure (AHRF) from different etiologies receiving invasive mechanical ventilation (IMV) compared with those affected by SARS-CoV-2. Methods and Main Results: Twenty-eight patients met the inclusion criteria: 9 patients with coronavirus disease 2019 (COVID-19) and 19 patients without COVID-19. Non-COVID-19 patients had more pre-existing comorbidities (78.9% vs. 44.4%) than COVID-19 patients. At AHRF onset, non-COVID-19 patients had worse oxygenation (PaO2/FiO2 = 95 mmHg (65.5–133) vs. 150 mmHg (105–220), p = 0.04), oxygenation index = 15.9 (11–28.4) vs. 9.3 (6.7–10.6), p = 0.01), and higher PaCO2 (48 mmHg (46.5–63) vs. 41 mmHg (40–45), p = 0.07, that remained higher at 48 h: 54 mmHg (43–58.7) vs. 41 (38.5–45.5), p = 0.03). In 12 patients (5 COVID-19 and 7 non-COVID-19), AHRF evolved to pediatric acute respiratory distress syndrome (PARDS). All non-COVID-19 patients had severe PARDS, while 3 out of 5 patients in the COVID-19 group had mild or moderate PARDS. Overall Pediatric Intensive Care Medicine (PICU) mortality was 14.3%. Conclusions: Children with AHRF due to SARS-CoV2 infection had fewer comorbidities and better oxygenation than patients with non-COVID-19 AHRF. In this study, progression to severe PARDS was rarely observed in children with COVID-19.

BACKGROUND We aimed to study the associations of adipocytokines, endothelial damage markers, and high-sensitivity C-reactive protein (hs-CRP) with metabolic syndrome (MetS) components. METHODS This cross-sectional study included 202 subjects categorized into MetS and No-MetS according to Harmonizing Adult Treatment Panel III. RESULTS Subjects with MetS showed higher levels of proinflammatory molecules but significantly lower adiponectin levels than subjects with No-MetS. Among the studied adipocytokines, plasminogen activator inhibitor-1 (PAI-1) and adiponectin showed the strongest associations with most MetS components. PAI-1 was associated with MetS (odds ratio (OR) 1.107 (1.065–1.151), P < 0.0001), whereas adiponectin was inversely associated with MetS (OR 0.710 (0.610–0.825), P < 0.0001). Following adjustment by sex, age, body mass index, and 24-hour urinary sodium excretion in a multivariate analysis, the association of PAI-1 (OR 1.090 (1.044–1.137), P < 0.0001) and adiponectin (OR 0.634 (0.519–0.775), P < 0.0001) with MetS remained significant. Multivariate analyses supported a model in which systolic blood pressure (BP) could be predicted by PAI-1, hs-CRP, and matrix metalloproteinase 2 (R2 = 0.125; P = 0.04); diastolic BP (R2 = 0.218; P = 0.0001) and glucose (R2 = 0.074; P = 0.0001) could be predicted by PAI-1; waist circumference could be predicted by PAI-1 and hs-CRP (R2 = 0.28; P = 0.016). Receiver operating characteristic curve analysis showed that a PAI-1 concentration had the best sensitivity and specificity for discriminating subjects with MetS. CONCLUSION PAI-1 and adiponectin rendered the most robust associations with MetS components in a general population, indicating that unfavorable adipose tissue performance is a key contributor to these metabolic anomalies. Further prospective analyses should allow establishing whether these adipocytokines can anticipate the progress of MetS and cardiovascular risk.

Intussusceptive angiogenesis (IA) is currently considered an important alternative and complementary form of sprouting angiogenesis (SA). Conversely, intussusceptive lymphangiogenesis (IL) is in an initial phase of study. We compare their morphofunctional characteristics, since many can be shared by both processes. To that end, the following aspects are considered: A) The concept of IA and IL as the mechanism by which blood and lymphatic vessels split, expand and remodel through transluminal pillar formations (hallmarks of intussusception). B) Terminology and historical background, with particular reference to the group of Burri, including Djonov and Patan, who initiated and developed the vessel intussusceptive concept in blood vessels. C) Incidence in normal (e.g. in the sinuses of developing lymph nodes) and pathologic conditions, above all in vessel diseases, such as dilated veins in hemorrhoidal disease, intravascular papillary endothelial hyperplasia (IPEH), sinusoidal hemangioma, lobular capillary hemangioma, lymphangiomas/lymphatic malformations and vascular transformation of lymph nodes. D) Differences and complementarity between vessel sprouting and intussusception. E) Characteristics of the cover (endothelial cells) and core (connective tissue components) of pillars and requirements for pillar identification. F) Structures involved in pillar formation, including endothelial contacts of opposite vessel walls, interendothelial bridges, merged adjacent capillaries, vessel loops and spilt pillars. G) Structures resulting from pillars with intussusceptive microvascular growth, arborization, remodeling and segmentation (compartmentalization). H) Influence of intussusception in the morphogenesis of vessel tumors/ pseudotumors; and I) Hemodynamic and molecular control of vessel intussusception, including VEGF, PDGF BB, Hypoxia, Notch, Endoglobin and Nitric oxide.

Sinusoidal hemangioma, characterized by interconnecting thin-walled vascular spaces, may present papillae/pseudo-papillae and zones that resemble intravascular papillary endothelial hyperplasia (IPEH). Our objectives are to explore the existence of zones in IPEH with sinusoidal hemangioma characteristics, the mechanism of papillary and septa formation in sinusoidal hemangioma and the comparison of this mechanism with that in IPEH. For these purposes, specimens of 4 cases of each entity were selected and studied by serial histologic sections and by immunochemistry and immunofluorescence procedures. The results showed a) zones with characteristics of sinusoidal hemangioma in IPEH cases, b) presence in both entities of papillae with a cover formed by a monolayer of CD34+ and CD31+ endothelial cells (ECs) and a core formed by either type I collagen and αSMA+ cells (presenting a pericyte/smooth muscle cell aspect) or thrombotic components, and c) a similar piecemeal angiogenic mechanism in papillary formation, including sprouting of intimal ECs toward the vessel wall itself or intravascular thrombi, formation of vascular loops that encircle and separate vessel wall or thrombus components, and parietal or thrombotic papillae development. The major differences between both entities were the number, arrangement and substrate of papillae: myriad, densely grouped, parietal and thrombotic papillae in IPEH, and a linear arrangement of predominant parietal papillae in sinusoidal hemangioma, originating septa (segmentation). In conclusion, sinusoidal hemangioma and IPEH are interrelated processes, which share morphologic findings and a piecemeal angiogenic mechanism, combining sprouting and intussusceptive angiogenesis, and leading to papillary formation and vessel segmentation.

Objectives:To characterize cardiac preload responsiveness in pediatric patients with cardiovascular dysfunction and dilated cardiomyopathy using global end-diastolic volume index, stroke volume index, cardiac index, and extravascular lung water index.Design:Prospective multicenter observational stud

Testicular Leydig cells (LC) regulate the proper development of male individuals, both during fetal life (fetal LC) and puberty (adult LC). In the ovaries of adult women, there are cells that are very similar to Leydig cells, the ovarian hilus cells (OHC), which also produce testosterone. The origin of these cells, in both sexes, remains unknown and is still a matter of debate. We have studied the location, characteristics and relationships of the OHC in 90 patients. The indications for oophorectomy were: metrorrhagia (n=9), prolapse (n=8), endometrial hyperplasia (n=14), cancer (endometrial, myometrial, or cervical) (n=35), uterine leiomyomata (n=14), and various ovarian tumors (cysts and benign tumors, borderline and malignant) (n=10). In addition to the hilus, occasionally the nodules, nests and clusters of OHC were located in the mesovarium, the mesosalpinx, and in the medullar and cortical regions of the ovaries. The morphological (including crystalloids of Reinke) and immunohistochemical (positivity for calretinin and alpha-inhibin) findings were similar to those described for testicular LC. Therefore, OHC can be considered ovarian Leydig cells (OLC). LC are usually found in small numbers in the ovaries, but if one looks for them intentionally, one always finds them. Close relationships were observed between the OLC with nerves and vessels. Moreover, an intraneural location of the OLC was demonstrated in all cases, and these intraneural cells showed similar characteristics to extraneural OLC, suggesting that they derive from endoneural cells which are present in the vegetative nerves of the ovaries.

In this chapter, we outline the role of human CD34+ stromal cells/telocytes (CD34+ SC/TCs) as progenitor cells during repair. The in vivo activation phenomena of CD34+ SC/TCs in this process include increased size; separation from the neighbouring structures (mainly of the vascular walls); association with inflammatory cells, predominantly macrophages; development of the organelles of synthesis (rough endoplasmic reticulum and Golgi apparatus); cell proliferation with presence of mitosis and high proliferative index (transit-amplifying cells); and fibroblastic and myofibroblastic differentiation. A procedure to study these tissue-resident cells, comparison of their behaviour in vivo and in vitro and different behaviour depending on location, time, type of injury (including tumour stroma) and greater or lesser proximity to the injury are also considered.

To determine the accuracy and usefulness of noninvasive continuous hemoglobin (Hb) monitoring in critically ill patients at risk of bleeding.An observational prospective study was made, comparing core laboratory Hb measurement (LabHb) as the gold standard versus transcutaneous hemoglobin monitoring (SpHb).Pediatric Intensive Care Unit of a tertiary University Hospital.Patients weighing3kg at risk of bleeding.SpHb was measured using the Radical7 pulse co-oximeter (Masimo Corp., Irvine, CA, USA) each time a blood sample was drawn for core laboratory analysis (Siemens ADVIA 2120i).Sociodemographic characteristics, perfusion index (PI), pleth variability index, heart rate, SaOA total of 284 measurements were made (80 patients). Mean LabHb was 11.7±2.05g/dl. Mean SpHb was 12.32±2g/dl (Pearson 0.72, RSpHb shows a good overall correlation to LabHb, though with wide limits of agreement. Its main advantage is continuous monitoring of patients at risk of bleeding. The reliability of the method is limited in cases with poor peripheral perfusion.

In this chapter, we outline the role of human CD34+ stromal cells/telocytes (CD34+ SC/TCs) as progenitor cells during repair. The in vivo activation phenomena of CD34+ SC/TCs in this process include increased size; separation from the neighbouring structures (mainly of the vascular walls); association with inflammatory cells, predominantly macrophages; development of the organelles of synthesis (rough endoplasmic reticulum and Golgi apparatus); cell proliferation with presence of mitosis and high proliferative index (transit-amplifying cells); and fibroblastic and myofibroblastic differentiation. A procedure to study these tissue-resident cells, comparison of their behaviour in vivo and in vitro and different behaviour depending on location, time, type of injury (including tumour stroma) and greater or lesser proximity to the injury are also considered.

We investigated the development of two-dimensional space concepts within a mathematics unit on grids, coordinates, and rectangles, part of a large-scale curriculum development project funded by the NSF Data from case studies, interviews, paper-and-pencil tests, and whole-class observations were collected during field tests with 4 fourth-grade classrooms. Students had to overcome substantial hurdles in learning to spatially structure two-dimensional grids, including interpreting the grid's components as line segments rather than regions; appreciating the precision of location the lines required, rather than treating them as fuzzy boundaries or indicators of intervals; and learning to trace vertical or horizontal lines that were not axes. We found no evidence for a relationship between students' strategies for naming and locating coordinates and their other knowledge of grid and coordinate systems; instead, such knowledge was related to students' levels of competence in three aspects of more complex coordinate situations: number sense, spatial-geometric relationships, and the ability to discriminate and integrate the two

The mineralocorticoid receptor (MR) is a ligand dependent transcription factor. MR has been traditionally associated with the control of water and electrolyte homeostasis in order to keep blood pressure through aldosterone activation. However, there is growing evidence indicating that MR expression is not restricted to vascular and renal tissues, as it can be also expressed by cells of the immune system, where it responds to stimulation or antagonism, controlling immune cell function. On the other hand, aldosterone also has been associated with proinflammatory immune effects, such as the release of proinflammatory cytokines, generating oxidative stress and inducing fibrosis. The inflammatory participation of MR and aldosterone in the cardiovascular disease suggests an association with alterations in the immune system. Hypertensive patients show higher levels of proinflammatory mediators that can be modulated by MR antagonism. Although these proinflammatory properties have been observed in other autoimmune and chronic inflammatory diseases, the cellular and molecular mechanisms that mediate these effects remain unknown. Here we review and discuss the scientific work aimed at determining the immunological role of MR and aldosterone in humans, as well as animal models.

© 2017 The Authors., With the aim of studying delta‐like protein 1 (DLK1) with respect to the relationship between adipocyte leptin and adenohypophyseal hormones, we carried out an immunohistochemical study analysing the presence of receptors for these hormones in the pituitary and adipose cells of male wild‐type (WT) mice (Dlk1+/+) compared to knockout (KO) mice (Dlk1−/−). The mRNA expression of these molecules was also determined using the reverse transcriptase‐polymerase chain reaction. The results obtained showed that, in WT adipose cells, all of the adenohypophyseal hormone receptors were present, with a higher mRNA expression for growth hormone (GH) receptor and thyroid‐stimulating hormone (TSH) receptor. Of the total cells in the anterior pituitary lobe, 17.09±0.9% were leptin receptor (LEPR) immunoreactive (‐IR), mainly in GH‐IR and prolactin (PRL)‐IR cells (41.5±3.8%; 13.5±1.7%, respectively). In Dlk1−/− mice, adipocyte cells showed a significant increase in the TSH receptor mRNA expression level. Moreover, the percentage of LEPR‐IR GH cells showed a statistically significant increase compared to controls, from 41.5±3.8% to 53.1±4.0%. By contrast, only 3.0±0.6% of LEP‐IR anterior pituitary cells were detected in Dlk1 KO mice, as opposed to 6.8±1.1% observed in WT mice. The results suggest that relationships exist between adipocytes and pituitary GH, PRL and TSH cells, in addition to an influence with respect to the synthesis and release of pituitary leptin, particularly in PRL cells., Support was provided by the Consejería de Ciencia y Tecnología JCCM (grants PAI06‐0066‐6930 and PII1I09‐0065‐8194 to C. Díaz).

OBJECTIVE: To find an equation that can calculate quality reference standards on the sum expected per doctor, adjusted for the size of his/her list, his/her characteristics and patients included in chronically ill services. This objective is posed within a strategy of individualising information and evaluation as a tool to promote improvement. DESIGN: Crossover, descriptive study. SETTING: Autonomous community of the Canary Islands. Tenerife Health Area, primary care management. PARTICIPANTS: The study was performed with 51 doctors belonging to 10 primary care teams, for whom there was quality information available due to their having used the CRONOS computer programme for a sufficient period of time. The period analysed ran from January to November 1997. MEASUREMENTS AND MAIN RESULTS: Multiple regression analysis through automatic algorithm of step-by-step selection of variables. There was a close relationship between the variability of the pharmacy sum per doctor (adjusted r2: 0.81; F, 66.05; p < 0.000) and the size of the list; also between the former and the characteristics of the users on the list. The most relevant variables were the percentage of women over 55 and the mean drug consumption per consultation with patients during the study period. It was seen, in relation to this last variable, that the percentage of pensioners and the number of hypertense patients included were important. CONCLUSION: Given the high variability explained, we propose broadening the study to all the doctors, so as to give the results greater consistency and offer quality reference information, in line with the above-mentioned improvement plan.

The economic situation has made it necessary to optimize resources by adjusting the pharmaceutical expenditure. Citicoline was (2011) the 10th drug by rank of billed amount. Its approved indications are stroke (acute and sub-acute) and head injury, but not cognitive decline associated with age, the presumed indication for most of its use.To assess the conditions of use of citicoline in the Health Area of Tenerife, in order to detect deviations from the indications of use as stipulated in the prescribing information sheet and the pattern of prescription, with emphasis on the analysis of its use in dementia where currently it has no indication or evidence to support it.Cross-sectional study of prescription-indication. A 680 patient sample, segmented by reference hospital (error±5%; CI: 0.95%; P=0.5) was taken from the 4036 patients with a prescription of citicoline billed during august-october 2011 (obtained from the prescription database program, Farmacanarias).We found that 123 patients (18.1%) had an appropriate indication. By including the prescription regimen, 28 patients (4.1%) had adequate indication and dose levels, and in only 2 patients (0.2%) an appropriate indication, dosage and duration were found."The correct prescription-indication" of citicoline is inappropiate in almost all patients studied. Impact actions are needed in order to optimize prescription, improve patient safety by reducing potential interactions, and the occurrence of adverse effects, and improve efficiency by promoting savings.

Spondylodiscitis is an uncommon disease in children. It is often misdiagnosed or the diagnosis is made late in the course of illness.To review the clinical, analytical and radiological characteristics of children with spondylodiscitis in the Materno-Infantil Hospital of Malaga.Retrospective cohort study on children diagnosed with spondylodiscitis, during a period of 11 years.Eighteen patients were included in the study. Spondylodiscitis was more frequent in patients younger than 3 years old and older than 12 years old. The average time of delay in diagnosis was 26.9 days. In 8 cases the diagnosis was missed initially. Three clinical patterns appeared: in children under 3 years of age, refusing to walk and sit (100%) and irritability (42%); between 3 and 12 years of age, limb (100%) and abdominal pain (100%); in adolescents, back pain (75%). Fever was present in 38% of the cases, and low-grade fever in 8 (44%). A total of 50% of the patients had a moderate leucocytosis, and a slight increase in ESR; the most frequent location was L3-L4. X-ray diagnosis was pathological in 88% of the cases. The initial MRI diagnosed 100% of the cases. In addition, nerve roots damage (5 cases), inflammatory masses/paravertebral abscesses (5), epidural abscess (1) and psoas abscesses (2) were detected. A total of 94% of the children received antibiotics and 100% of the children underwent immobilization. All patients recovered early after the beginning of treatment, with the exception of those affected by psoas abscesses. The radiological follow-up was done in 17 patients (12 by MRI). After a mean of 14 months (rank 1-48), persistent diminution of disc space was seen in 100% of the children, and improvement of soft-tissue inflammation. Clinically (follow-up only in 11 patients) all patients regained normal mobility and only 27% had moderate pain.Spondylodiscitis, whose delay in the diagnosis is frequent, is a serious illness. Complications include abscesses and nerve root damage. MRI is the study of choice to determine the extension to neighbouring tissues.

Patient safety constitutes one of the main objectives in health care. Among other recommendations, such as the creation of training centres and the development of patient safety programmes, of great importance is the creation of training programmes for work teams using medical simulation. Medical simulation is defined as "a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation or to understand systems or human actions". In this way, abilities can be acquired in serious and uncommon situations with no risk of harm to the patient. This study revises the origins of medical simulation and the different types of simulation are classified. The main simulators currently used in Pediatrics are presented, and the design of a simulation course applied to the training of pediatric emergencies is described, detailing all its different phases. In the first non face-to-face stage, a new concept in medical training known as e-learning is applied. In the second phase, clinical cases are carried out using robotic simulation; this is followed by a debriefing session, which is a key element for acquiring abilities and skills. Lastly, the follow-up phase allows the student to connect with the teachers to consolidate the concepts acquired during the in-person phase. In this model, the aim is to improve scientific-technical abilities in addition to a series of related abilities such as controlling crisis situations, correct leadership of work teams, distribution of tasks, communication among the team members, etc., all of these within the present concept of excellence in care and medical professionalism.

Crohn's disease (CD) is an intestinal inflammatory disease of unknown origin that is sometimes associated with cutaneous manifestations. These skin lesions are usually nonspecific (erythema nodosum, erythema multiforme and pyoderma gangrenosum) and should be differentiated from the cutaneous lesions corresponding to the typical histological pattern of CD; most of these extend directly from the involved bowel. Noncaseating granulomatous infiltration in skin anatomically distant from areas of gastrointestinal CD and separated by normal skin is extremely rare. This entity, known as metastatic Crohn's disease, can be the first symptom of CD or even more unusually can appear during the course of the disease.We report the case of a 9-year-old boy, previously diagnosed with ileocolic and perianal CD, who had been receiving treatment with mesalazine, prednisone and 6-mercaptopurine for 3 years. He presented with swelling of the penis and scrotum of 2 weeks' evolution, without any other symptoms. Testicular ultrasound showed thickening of the scrotal wall and increased flux at this site. Skin biopsy showed noncaseating granulomas. Results of special staining techniques were negative for the presence of microorganisms. The prednisone dose was increased and metronidazole was added, with noticeable improvement in the lesions. Due to reappearance of cutaneous lesions when the prednisone dose was reduced, the patient currently receives maintenance treatment.