Clinical Characteristics and Electrophysiological Mechanisms Underlying Brugada ECG in Patients With Severe Hyperkalemia

[EN] Background-Several metabolic conditions can cause the Brugada ECG pattern, also called Brugada phenotype (BrPh). We aimed to define the clinical characteristics and outcome of BrPh patients and elucidate the mechanisms underlying BrPh attributed to hyperkalemia. Methods and Results-We prospectively identified patients hospitalized with severe hyperkalemia and ECG diagnosis of BrPh and compared their clinical characteristics and outcome with patients with hyperkalemia but no BrPh ECG. Computer simulations investigated the roles of extracellular potassium increase, fibrosis at the right ventricular outflow tract, and epicardial/endocardial gradients in transient outward current. Over a 6-year period, 15 patients presented severe hyperkalemia with BrPh ECG that was transient and disappeared after normalization of their serum potassium. Most patients were admitted because of various severe medical conditions causing hyperkalemia. Six (40%) patients presented malignant arrhythmias and 6 died during admission. Multiple logistic regression analysis revealed that higher serum potassium levels (odds ratio, 15.8; 95% CI, 3.1-79; P=0.001) and male sex (odds ratio, 17; 95% CI, 1.05-286; P=0.045) were risk factors for developing BrPh ECG in patients with severe hyperkalemia. In simulations, hyperkalemia yielded BrPh by promoting delayed and heterogeneous right ventricular outflow tract activation attributed to elevation of resting potential, reduced availability of inward sodium channel conductance, and increased right ventricular outflow tract fibrosis. An elevated transient outward current gradient contributed to, but was not essential for, the BrPh phenotype. Conclusions-In patients with severe hyperkalemia, a BrPh ECG is associated with malignant arrhythmias and all-cause mortality secondary to resting potential depolarization, reduced sodium current availability, and fibrosis at the right ventricular outflow tract.This work was funded in part by the CIBERCV (Centro de Investigacion Biomedica en Red Enfermedades Cardiovasculares), Instituto de Salud Carlos III (PI14/00857, DTS16/0160, PI17/1059, PI01106), Spanish Ministry of Ecomomy (TEC2013-46067-R) and the ERDF (European Regional Development Fund).Rivera-Juárez, A.; Hernández-Romero, I.; Puertas, C.; Zhang-Wang, S.; Sánchez-Álamo, B.; Martins, R.; Figuera, C.... (2019). Clinical Characteristics and Electrophysiological Mechanisms Underlying Brugada ECG in Patients With Severe Hyperkalemia. Journal of the American Heart Association. 8(3):1-15. https://doi.org/10.1161/JAHA.118.010115S11583Brugada, P., & Brugada, J. (1992). 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Modelado y digitalización de volúmenes por medio de escaneado 3D en grabado y dibujo

Memoria ID-0034. Ayudas de la Universidad de Salamanca para la innovación docente, curso 2017-2018

Apoyo y orientación a los estudiantes mediante la elaboración de asignaturas en el campo virtual, con sistemas tutoriales de interacción en línea y materiales docentes originales.

Memoria ID11-158. Ayudas de la Universidad de Salamanca para la innovación docente, curso 2011-2012

Creación de video-tutoriales de corta duración como nuevo método de aprendizaje en línea aplicado a las enseñanzas artísticas del EEES

Memoria ID12-0138. Ayudas de la Universidad de Salamanca para la innovación docente, curso 2012-2013

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project):A clinical trial by clusters

This study was funded by the Fondo de Investigaciones Sanitarias FIS Grant Number PI11/0477 ISCIII.-REDISSEC Proyecto RD12/0001/0012 AND FEDER Funding.Background: Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs. Methods/design: We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment. The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6months post-intervention, using 95% confidence intervals. A linear multilevel regression will be used to adjust the model. Discussion: The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance. Trial registration: ClinicalTrials.gov: NCT02210442.Publisher PDFPeer reviewe

II Edición la innovación docente en la Facultad de Ciencias Sociales: experiencias, retos y propuestas

Memoria ID-196. Ayudas de la Universidad de Salamanca para la innovación docente, curso 2018-2019

Elaboración de contenidos docentes sobre expresión artística para su difusión en abierto (OCW) y cerrado(Studium). Implementación de asignaturas para las nuevas metodologías de aprendizaje en el EEES

Memoria ID-0203. Ayudas de la Universidad de Salamanca para la innovación docente, curso 2009-2010.Los objetivos que se plantearon en la solicitud de este proyecto fueron la creación de contenidos generales y específicos para las diferentes asignaturas troncales y optativas que imparten los profesores del equipo solicitante, con el fin inmediato de promover su difusión en la plataforma STUDIUM, y posteriormente utilizar este medio como complemento en la enseñanza de las diferentes materias

Elaboración de contenidos docentes sobre expresión artística. Implementación de asignaturas en Studium para las nuevas tecnologías de aprendizaje en el EEES

Memoria ID-058. Ayudas de la Universidad de Salamanca para la innovación docente, curso 2010-2011.Este proyecto de innovación 2010-11 contó con una financiación de 525 euros que se invirtió en la adquisición de una cámara de fotos Canon de gran resolución. Esto ha facilitado que los miembros del equipo hayamos podido realizar un importante elenco de material gráfico digitalizado sobre los resultados de las imágenes de nuestros estudiantes (unas 200 imágenes), muchas de las cuales ya las hemos ido incorporado como material docente en distintos apartados de las asignaturas implementadas en abierto y cerrado. El resto de material gráfico estará disponible para seguir ilustrando otras asignaturas que se van a implementar el curso próximo: tanto la programación general, como los materiales de clase por temas y la ilustración gráfica de las prácticas

Recurrent acute interstitial nephritis: what lies beneath

Background: Acute interstitial nephritis (AIN) is an emerging cause of acute kidney disease. While this disease usually follows an acute course, it may occasionally recur, representing a major challenge for the clinician. Methods: We performed a retrospective, observational cohort study in 13 nephrology departments belonging to the Spanish Group for the Study of Glomerular Diseases. Patients with biopsy-proven AIN between 1996 and 2018 were included. Results: The study group consisted of 205 patients with AIN, 22 of which developed recurrent AIN (RAIN) after a median of 111 days from diagnosis. RAIN was due to a surreptitious reintroduction of a previously known implicated drug or toxic in six patients (27%), sarcoidosis in two (9%), Sjögren's syndrome in three (14%), light-chain-mediated AIN in two (9%) and tubulointerstitial nephritis and uveitis syndrome in two (9%), while in the rest of cases (32%), no precise cause could be identified. Microscopic haematuria was more frequent in patients with underlying systemic diseases. The first RAIN episode was treated with a repeated course of corticosteroids in 21 patients (95%). In six cases (27%), azathioprine and mycophenolate mofetil were added as corticosteroid-sparing agents. During a median follow-up of 30 months, 50 patients (27%) with no recurrences and 12 patients (55%) with RAIN reached Stages 4 and 5 chronic kidney disease (CKD). By multivariable logistic regression analysis, RAIN was independently associated with the risk of reaching Stages 4 and 5 CKD, even after adjusting for potential covariables. Conclusions: RAIN is infrequent but is associated with poor kidney survival. RAIN should prompt clinicians to search for an underlying aetiology other than drug induced. However, in a large percentage of cases, no precise cause can be identified

Impacto del COVID-19 sobre el bienestar de la infancia, adolescencia y familias en Canarias: oportunidades para reforzar el sistema de prevención y protección

La pandemia del covid-19 producida por el virus SARS-CoV-2 es una emergencia sanitaria que se extiende en el tiempo sin una clara fecha límite, lo cual aconseja no solo hacer un relato de su impacto en el pasado sino también extraer lecciones de lo vivido que nos preparen mejor para lo que pueda pasar. Este estudio centrado en el impacto del covid-19 sobre el bienestar de la infancia, adolescencia y familias, ofrece una mirada integradora, constructiva y proyectada al futuro, con un doble objetivo. En primer lugar, examinar cómo han funcionado varios ámbitos, además de la familia, en su función preventiva y protectora de la infancia y adolescencia en este tiempo de pandemia, recogiendo el punto de vista de informantes significativos en la Comunidad Autónoma de Canarias. Así, además de contar con las voces de niños, niñas, adolescentes y figuras parentales, se cuenta con la opinión de las y los profesionales en los ámbitos de familia, educación, sanidad, servicios sociales y de protección de menores, entidades sociales, justicia y medios de comunicación. En segundo lugar, derivar de todas las aportaciones un conjunto de mejoras y recomendaciones para el futuro. El estudio adopta un triple marco conceptual basado en una concepción ecológico-sistémica de la familia, en la prevención de riesgos y la promoción de fortalezas y capacidades resilientes, y en una visión actual del ejercicio de la parentalidad positiva en su diversidad. Siguiendo una metodología cualitativa, que utiliza grupos focales con discusión dirigida de opinión y entrevistas individuales, los resultados muestran las múltiples realidades vividas por las personas informantes que aportan sus puntos de vista sobre cuatro ejes temáticos: a) Las dificultades de funcionamiento en los diversos ámbitos resultantes del impacto negativo de la pandemia. b) Los ajustes que se han realizado para hacer frente a estas dificultades. c) Las fortalezas o capacidades resilientes con que se cuenta tanto a nivel personal como a nivel del sistema o ámbito. d) Las recomendaciones para una mejora de su funcionamiento, seguidas de un resumen con las conclusiones. De todo ello, se extraen lecciones aprendidas donde se observan coincidencias entre varios ámbitos. Señalemos, entre otros aspectos, la necesidad de adoptar de modo generalizado la perspectiva de derechos de la infancia; reconocer las muestras de resiliencia ante la adversidad; incorporar las nuevas prioridades en el sistema de valores sociales así como la revalorización del papel de la ciencia en la sociedad; robustecer el sistema público de prevención y mejorar los servicios educativos, sanitarios y judiciales de atención especializada para afrontar las consecuencias de la pandemia; superar la brecha digital para que todos se beneficien por igual de los avances tecnológicos; ajustar la imagen social de la infancia y de la adolescencia a la evidencia contrastada; y potenciar la gobernanza en la coordinación intersectorial. En suma, este estudio ofrece claves para una toma de decisiones informada que permita desarrollar respuestas más efectivas ante esta u otras posibles crisis sanitarias y así asegurar el cinturón que protege el bienestar de la infancia, adolescencia y las familias.The covid-19 pandemic caused by the SARS-CoV-2 virus is a sanitary emergency that extends over time without a dear deadline, which advises not only to make an account of its impact in the past but also to draw lessons from what we have experienced that will better prepare us for what will happen. This study focused on the impact of covid-19 in the well-being of children, adolescents and families, offering an integrative, constructive and future-oriented approach with a dual objective. First, to examine how several areas have functioned, in addition to the family, in their preventive and protective role for children and adolescents in this time of pandemic, from the point of view of significant informants in the Autonomous Community of the Canary lslands. Thus, in addition to having the voices of children, adolescents and parents, there is also the opinion of professionals in the fields of family, education, health, social and child protection services, social entities, justice, and the mass media. Second, to derive from all contributions a set of improvements and recommendations for the future. The study adopts a triple conceptual framework based on an ecological-systemic conception of the family, on the prevention of risks and the promotion of strengths and resilient capacities, and on a current vision of the exercise of positive parenting in its diversity. Following a qualitative methodology, which uses focus groups with oriented discussion of opinion and individual interviews, the results show the multiple realities experienced by respondents who contribute with their points of view on four thematic axes: a) The functional difficulties in the various areas resulting from the negative impact of the pandemic. b) The adjustments that have been made to address these difficulties. c) The strengths or resilient capacities available both at the personal level and at the system or field level. d) Recommendations for improving their functioning, followed by a summary with conclusions. From all of this, there are lessons learned where coincidences are observed between several fields. Let us point out, among other aspects, the necessity of adopting widespread the child rights perspective; to acknowledge signs of resilience against adversity; to incorporate new priorities in the social value system as well the revaluation of the role of science in society; to strengthen the public system of prevention and to improve educational, health and judicial services for specialized care to deal with the consequences of the pandemic; to bridge the digital divide so that all benefit equally from technological advances; adjust the social image of children and adolescents to the evidence; and strengthen governance in intersectoral coordination. In summary, this study offers keys to informed decision-making that would allow developing more effective responses to this or other possible sanitary crises and thus ensure the belt that protects the well-being of children, adolescents, and families