Artificial intelligence in diagnosing upper limb musculoskeletal disorders: a systematic review and meta-analysis of diagnostic tests

Purpose

The integration of artificial intelligence (AI) in radiology has revolutionized diagnostics, optimizing precision and decision-making. Specifically in musculoskeletal imaging, AI tools can improve accuracy for upper extremity pathologies. This study aimed to assess the diagnostic performance of AI models in detecting musculoskeletal pathologies of the upper extremity using different imaging modalities.

Methods

A meta-analysis was conducted, involving searches on MEDLINE/PubMed, SCOPUS, Cochrane Library, Lilacs, and SciELO. The quality of the studies was assessed using the QUADAS-2 tool. Diagnostic accuracy measures including sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR, NLR), area under the curve (AUC), and summary receiver operating characteristic were pooled using a random-effects model. Heterogeneity and subgroup analyses were also included. All statistical analyses and plots were performed using the R software package.

Results

Thirteen models from ten articles were analyzed. The sensitivity and specificity of the AI models to detect musculoskeletal conditions in the upper extremity were 0.926 (95% CI: 0.900; 0.945) and 0.908 (95% CI: 0.810; 0.958). The PLR, NLR, lnDOR, and the AUC estimates were found to be 19.18 (95% CI: 8.90; 29.34), 0.11 (95% CI: 0.18; 0.46), 4.62 (95% CI: 4.02; 5.22) with a (P < 0.001), and 95%, respectively.

Conclusion

The AI models exhibited strong univariate and bivariate performance in detecting both positive and negative cases within the analyzed dataset of musculoskeletal pathologies in the upper extremity.

Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism

BACKGROUND

The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE.

METHODS

We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality.

RESULTS

Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE.

CONCLUSIONS

Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality.

Tumor ablation and vertebral augmentation in the treatment of vertebral metastases: A multicenter study

INTRODUCTION

Treatment of metastatic vertebral fractures without neural compression is performed with percutaneous cementation techniques. The increase in intratumoral pressure by these techniques can send tumor cells into the bloodstream. To prevent this dissemination and improve pain treatment, ablation techniques have been introduced that would allow the creation of a cavity in the tumor prior to cementation or directly necrosing the metastasis when its size is small.

MATERIAL

We present the experience with ablation of two hospitals and two different ablation techniques. The first group used radiofrequency ablation (A) in 14 patients (26 vertebrae), 4 of whom underwent vertebral arthrodesis. The second group used microwave ablation (B) in 93 patients (129 lesions) without associated vertebral instrumentation.

RESULTS

In group A pain improvement in VAS was 7.7-2.6 at 6 weeks. There were no complications derived from the ablation. In most cases cementation was associated. In the group B pain improvement in VAS went from 6.8-1.7 at 6 weeks. Cementation was associated in all cases. There were no complications derived from the ablation.

CONCLUSION

The association of ablation techniques with vertebral cementation is a safe technique that significantly improves the patient's pain and can help control the disease.

[Translated article] Tumor ablation and vertebral augmentation in the treatment of vertebral metastases: A multicenter study

INTRODUCTION

Treatment of metastatic vertebral fractures without neural compression is performed with percutaneous cementation techniques. The increase in intratumoral pressure by these techniques can send tumor cells into the bloodstream. To prevent this dissemination and improve pain treatment, ablation techniques have been introduced that would allow the creation of a cavity in the tumor prior to cementation or directly necrosing the metastasis when its size is small.

MATERIAL

We present the experience with ablation of two hospitals and two different ablation techniques. The first group used radiofrequency ablation (A) in 14 patients (26 vertebrae), 4 of whom underwent vertebral arthrodesis. The second group used microwave ablation (B) in 93 patients (129 lesions) without associated vertebral instrumentation.

RESULTS

In group A pain improvement in VAS was 7.7-2.6 at 6 weeks. There were no complications derived from the ablation. In most cases cementation was associated. In the group B pain improvement in VAS went from 6.8 to 1.7 at 6 weeks. Cementation was associated in all cases. There were no complications derived from the ablation.

CONCLUSION

The association of ablation techniques with vertebral cementation is a safe technique that significantly improves the patient's pain and can help control the disease.

Adaptation culturally and linguistically to the Chilean population and validation the Dry Eye Questionnaire 5

BACKGROUND AND OBJECTIVE

There are different methods for evaluating dry eye disease (DID), including questionnaires that analyze different aspects of its symptoms, which are important for its better understanding and therapeutic management. The Dry Eye Questionnaire 5 (DEQ-5), is unique in its kind, because in addition to its simplicity, it measures symptoms in 4 dimensions. the aim of this study is to adapt culturally and linguistically and validate this instrument to the Chilean population.

MATERIAL AND METHODS

for the adaptation, the translation and retro-translation of the original version was carried out, its linguistic analysis, the pilot test and the expert panel review (which included a linguistics specialist) were used. For the validation, a psychometric analysis of reliability and validity of the construct was incorporated. The sample in which it was validated was constituted by 205 people with dry eye disease.

RESULTS

141 (69%) of the respondents were women, the mean of age was 48 years ± 16,7, and the median of the total score DEQ-5 was 13 points (R.I 8 - 15 points). The adapted version resulted in a Cronbach alpha of 0.8085, scoring that classified it as good.

DISCUSSION

the questionnaire DEQ-5, which was adapted and validated, was a good instrument to be used in populations with similar characteristics of those in the study. More so, the factor analysis enriched comprehension of the way in which people with dry eye disease relate their symptoms and which questions relate more between them, representing in a better way the aspects evaluated of the symptomatology of this disease.

XAIRE: An ensemble-based methodology for determining the relative importance of variables in regression tasks. Application to a hospital emergency department

Nowadays it is increasingly important in many applications to understand how different factors influence a variable of interest in a predictive modeling process. This task becomes particularly important in the context of Explainable Artificial Intelligence. Knowing the relative impact of each variable on the output allows us to acquire more information about the problem and about the output provided by a model. This paper proposes a new methodology, XAIRE, that determines the relative importance of input variables in a prediction environment, considering multiple prediction models in order to increase generality and avoid bias inherent in a particular learning algorithm. Concretely, we present an ensemble-based methodology that promotes the aggregation of results from several prediction methods to obtain a relative importance ranking. Also, statistical tests are considered in the methodology in order to reveal significant differences between the relative importance of the predictor variables. As a case study, XAIRE is applied to the arrival of patients in a Hospital Emergency Department, which has resulted in one of the largest sets of different predictor variables in the literature. Results show the extracted knowledge related to the relative importance of the predictors involved in the case study.

AB0569 FRECUENCY, TYPE AND DETERMINANTS OF COGNITIVE DEFICIT IN A COLOMBIAN COHORT OF PATIENTS WITH SLE

Background

Cognitive deficit is part of the neuropsychiatric syndromes associated with systemic lupus erythematosus (SLE) (1). SLE patiens have 2.8 times more risk to develop cognitive deficit (2) and the prevalence is unknown among this population, with variable data from 5% to 80% (3). ACR (American Collegue of Rheumathology) recomends a specific neuropsychological battery (4), but many of the published studies uses variables diagnostic tests. Cardiovascular comorbidities and the use of certain immunosuppressive are involved in the development of cognitive deficit and may be confusors at the time of diagnosis (5). Cognitive deficit affects the quality of life and predisposes to the development of dementia (6). In our setting, the frequency of cognitive deficit as a manifestation of neuropsychiatric SLE is unknown. Determining conditions of it are unknown as well.

Objectives

1.To define the frequency and degree of cognitive deficit in a cohort of patients with SLE

2.To describe associated factors (including quality of life and depression).

Methods

This was a cross-sectional observational study with 94 patients with SLE. The presence of cognitive deficit was established through a screening test (MoCA test). The diagnosis was confirmed through a battery of specific neuropsychological tests that were performed to patients with abnormal MoCA test. Quality of life was assessed using the LupusCol questionnaire wich is a validated scale for for measuring quality of life in SLE Colombian population. To measure the presence of depression we use the Beck inventory, this scale is also validated in SLE population. An exploratory analysis of the variables was performed and differences were established. A multivariate analysis was performed to find the variables associated with the cognitive deficit.

Results

Of the 94 patients, 90 (95.7%) were women. Of the 94 patients, 43 (51.2%) presented some degree of depression. The median for the loss of quality of life was VIII 21.03% (IQ 10.2 - 40.3). 35 (37.2%) patients had abnormal screening test. Specific neuropsychological tests were applied to 31 (90%) and of those, 11 patients (12.2%) presented a cognitive deficit. An association between cognitive deficit with a greater deterioration in quality of life was found (OR 1.05, 95% CI 1.01,1.09).

Conclusion

The frequency of cognitive deficit is important. There is an association of cognitive deficit with worse scores in quality of life. In addition, it was found that half of the patients presented some degree of depression. The comprehensive assessment of patients with SLE should include the evaluation of cognitive deficit and depression, because of their impact in quality of life, among other clinical aspects.

References

[1]Liang MH, Corzillius M, Bae SC, Lew RA, Fortin PR, Gordon C, et al. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum. 1999;42(4):599–608

[2]Rayes H Al, Tani C, Kwan A, Marzouk S, Colosimo K, Medina-Rosas J, et al. What is the prevalence of cognitive impairment in lupus and which instruments are used to measure it? A systematic review and meta-analysis. Vol. 48, Seminars in Arthritis and Rheumatism. 2018. p. 240–55.

[3]Kello N, Anderson E, Diamond B. Cognitive Dysfunction in SLE : a case for initiating trials. Arthritis Rheumatol. 2019;71(9):1413–25

[4]Kozora E, Ellison MC, West S. Reliability and validity of the proposed American College of Rheumatology neuropsychological battery for systemic lupus erythematosus. Arthritis Care Res. 2004;51(5):810–8.

[5]Waterloo K, Omdal R, Mellgren SI, Husby G. Neuropsychological functions in systemic lupus erythematosus: A comparison with chronic whiplash patients. Eur J Neurol. 1997;4(2):171–7.

[6]Kanapathy A, Nik Jaafar NR, Shaharir SS, Chan LF, Rozita M, Ch’ng SS. Prevalence of cognitive impairment using the Montreal Cognitive Assessment questionnaire among patients with systemic lupus erythematosus: a cross-sectional 53 study at two tertiary centres in Malaysia. Lupus. 2019;28(7):854–61.

Disclosure of Interests

None declared

[Effectiveness, adherence and usability of a teleneurorehabilitation programme to ensure continuity of care for patients with acquired brain injury during the COVID-19 pandemic]

INTRODUCTION

The health pandemic brought about by SARS-CoV-2 (COVID-19) has limited access to neurorehabilitation programmes for many patients who have suffered stroke, traumatic brain injury or acquired brain damage due to some other cause. As telerehabilitation allows for the provision of care in situations of social distancing, it may mitigate the negative effects of confinement. The aim of this study was to determine the efficacy, adherence and usability of a teleneurorehabilitation intervention for patients with acquired brain injury.

PATIENTS AND METHODS

All patients included in a face-to-face neurorehabilitation programme at the time of the declaration of the state of alarm in Spain due to COVID-19 and who agreed to participate in the study were included in a teleneurorehabilitation programme. The effectiveness of the programme, understood as an improvement in independence, was quantified with the Barthel index. Adherence to the programme and usability of the tool were explored through questionnaires.

RESULTS

Altogether, 46 patients, accounting for 70.6% of the total, participated in the study. Participants significantly improved their independence and showed an improvement in the Barthel index between the start (77.3 ± 28.6) and the end of the programme (82.3 ± 26). Adherence to the intervention was very high (8.1 ± 2.2 out of 10) and the online sessions were the most highly rated content. The tool used showed a high usability (50.1 ± 9.9 out of 60) and could be used without assistance by more than half the participants.

CONCLUSION

The teleneurorehabilitation intervention was found to be effective in improving patients' independence, and promoted a high degree of adherence and usability.

Reverse transcriptase and protease inhibitors mutational viral load in HIV infected pregnant women with transmitted drug resistance in Argentina

Objective

Argentina has reported high levels of transmitted drug resistance (TDR), in HIV-infected pregnant women by population sequencing. We aimed to describe, in patients with TDR, the percentage of quasispecies harboring resistance mutations (RAMs) and mutational load (ML).

Patients and Methods

Retrospective study in a cohort of 40 naïve HIV-infected pregnant women, whose pretreatment samples had been genotyped by TRUGENE (period 2008-2014). Samples were re-sequenced with Ultra-deep Sequencing and ML was calculated considering baseline HIV-1 RNA load multiplied by the frequency of quasispecies harboring RAMs.

Results

TDR for NNRTIs, NRTIs and PIs was 17.5% (n=7 patients), 10% (n=4), 12.5% (n=5) respectively. Predominant NNRTI RAMs were K103N (n=4; 10%) and G190A/E/S (n=3; 7.5%). For NNRTIs, 78% of RAMs were present in >93.5% of viral population and ML was >1000 copies/mL (c/mL) for 89%, with a median (IQR) of 8330 c/ml (7738-29796). The following NRTI RAMs were described (per patient: % of quasispecies, ML): T215I (99.7%, 11014 c/ml); D67G (1.28%, 502 c/mL); M41L (79.8%, 88578 c/mL) and M184I (1.02%, 173 c/mL). Most frequent PI-RAMs were I85V, M46I, I50V and L90M (n=2, 5% each). For PIs, quasispecies with RAMs were <2.3% of viral population and ML was <350 c/mL for 77.8% of them.

Conclusion

NNRTI-RAMs are predominant within the viral population, usually exceeding the threshold of 1000 c/mL, indicating potential higher risk of perinatal transmission. Conversely, PI mutations appear mostly as minority variants, with potential lower risk of transmission. Among NRTI, quasispecies harboring RAMs and ML values were variable.

Interaction between three stress-related gene polymorphisms and food addiction increases the risk to develop obesity in a sample of Mexican people attending a nutrition clinic

Chronic stress exposure impacts negatively in individuals leading to food addiction, overweight or obesity. Stress-genes and their translation products are responsible for the responses of humans to adverse environments. Alterations in stress-genes expression or protein function may induce behaviors as compulsive eating of high-energy containing food, which decreases stress-induced negative feelings. However, chronic stress is not assessed in Mexican population. We analyzed here the association between polymorphisms of CRH, CRHR2 and glucocorticoids (GR, NR3C1) receptor genes with food addiction and obesity and overweight in Mexican patients of a Nutrition Clinic. We recruited 508 individuals of both genders, who accepted to participate in the study at their first visit to the clinic, obtaining their fat mass percentage and a blood sample for the genetic analysis. Participants answered the Yale's food addiction scale and were subjected to a Trier social test, as an acute stressful stimulus. Pre and post-test saliva samples were obtained to evaluate cortisol levels and adrenal axis' response to the acute stress. The 63% of participants classified as stressed (S); 6.5% of normal-weight individuals showed food-addiction, whereas 63% of participants with food-addiction were also stressed. The fat mass percentage was greater in stress-addiction than in stressed non-addiction participants. The best interaction model for obesity development risk comprehended the presence of polymorphisms of the three genes that in combination with food addiction increased the risk for developing obesity 2.8-4-fold. Thus, frequent stress exposure favors food-addiction, which along with genetic susceptibility seems to add up to Mexican obesity/overweight rates.

[Cancer immunotherapy: an update]

Cancer is one of the leading causes of death worldwide. The success rate of conventional anticancer therapeutic approaches such as chemotherapy is limited by the non-specific toxicity and low specificity towards specific tumors, which are highly dependent on the mutational burden present on each patient. Similarly, targeted therapies have proven to induce resistance in numerous malignancies. Therefore, immunotherapy has emerged as a better approach to discriminate between "the own" and "the non-own", which occurs through two types of mechanisms, innate and acquired immunity. Acquired immunity is one of the targets for new immunotherapeutic treatments, unleashing the power of antigen-specific T cells as a potential therapeutic weapon for cancer treatment. Thus, immunotherapy modifies the own immune system to increase the recognition and elimination of cancer cells by identifying these cancer antigens. One of the advantages of immunotherapy, when compared to conventional anticancer approaches, is the generation of long-term immunity (immunological memory). Currently, there are different potential types of immunotherapy in cancer to promote the modulation of the immune response. Among them, the use of cytokines, vaccines, viruses, monoclonal antibodies, and the generation of adaptive immune response cells have achieved successful results in some types of cancer.

Efficacy of Bifidobacterium breve CECT7263 for infantile colic treatment: an open-label, parallel, randomised, controlled trial

Infantile colic is a prevalent condition characterised by excessive crying with no effective treatment available. We aimed to evaluate the efficacy of Bifidobacterium breve CECT7263 and a combination of this and Lactobacillus fermentum CECT5716 versus simethicone in reducing the daily time spent crying in colicky infants. A multicentre randomised, open-label, parallel, controlled trial of 28 days was performed in 150 infants who were diagnosed with colic according to the Rome III criteria and who randomly received simethicone (80 mg/day; Simethicone group), B. breve CECT7263 (2×10⁸ cfu/day, Bb group), or a combination of L. fermentum CECT5716 and B. breve CECT7263 (1×10⁸ cfu/day per strain, Bb+Lf group). The main outcomes were minutes of crying per day and the percentage of reduction in daily crying from baseline. Data were analysed per intention to treat. All treatments significantly decreased the daily crying time at the end of the intervention (P-time <0.001). However, the infants in the Bb group had significantly decreased crying time from the first week of the study (P<0.05), whereas the Bb+Lf group and the simethicone group had significantly decreased crying time from the second week (P<0.05). The percentage of reduction in the minutes of crying from baseline in the Bb group was significantly higher than that in the Simethicone group every week of the intervention (-40.3 vs -27.6% at 1-week; -59.2 vs -43.2% at 2-weeks; -64.5 vs -53.5% at 3-week and -68.5 vs -59.5% at 4-weeks, P<0.05). Additionally, in the Bb group, infants had better night sleep, and parents reported a more positive mood at the end of the intervention. All the products used in the study were safe and well tolerated. In conclusion, the breastmilk-isolated probiotic strain B. breve CECT7263 is a safe and effective treatment for infantile colic, presenting an earlier and more robust effect than the reference prescribed drug, simethicone.

MICROBIOTA INSIGHTS IN CLOSTRIDIUM DIFFICILE INFECTION AND INFLAMMATORY BOWEL DISEASE

Inflammatory bowel disease (IBD) is characterized by chronic intestinal inflammation that includes Crohn´s disease (CD) and ulcerative colitis (UC). Although the etiology is still unknown, some specific factors have been directly related to IBD, including genetic factors, abnormal intestinal immunity, and/or gut microbiota modifications. Recent findings highlight the primary role of the gut microbiota closely associated with a persistent inappropriate inflammatory response. This gut environment of dysbiosis in a susceptible IBD host can increasingly worsen and lead to colonization and infection with some opportunistic pathogens, especially Clostridium difficile. C. difficile is an intestinal pathogen considered the main cause of antibiotic-associated diarrhea and colitis and an important complication of IBD, which can trigger or worsen an IBD flare. Recent findings have highlighted the loss of bacterial cooperation in the gut ecosystem, as well as the pronounced intestinal dysbiosis, in patients suffering from IBD and concomitant C. difficile infection (CDI). The results of intestinal microbiota studies are still limited and often difficult to compare because of the variety of disease conditions. However, these data provide important clues regarding the main modifications and interrelations in the complicated gut ecosystem to better understand both diseases and to take advantage of the development of new therapeutic strategies. In this review, we analyze in depth the gut microbiota changes associated with both forms of IBD and CDI and their similarity with the dysbiosis that occurs in CDI. We also discuss the metabolic pathways that favor the proliferation or decrease in several important taxa directly related to the disease.

Experimental studies of boron neutron capture therapy (BNCT) using histone deacetylase inhibitor (HDACI) sodium butyrate, as a complementary drug for the treatment of poorly differentiated thyroid cancer (PDTC)

PURPOSE

The present study analyzed different protocols of administration of boronophenylalanine (BPA) and sodium butyrate (NaB) to increase the BNCT efficacy for poorly differentiated thyroid cancer (PDTC).

MATERIALS AND METHODS

Nude mice implanted with human PDTC cells (WRO) were distributed into four protocols: 1) BPA; 2) BPA + ip NaB; 3) BPA + oral NaB; 4) Control. Biodistribution and histologic studies were performed. LAT (BPA transporter) isoforms gene expression was assessed by RT-PCR.

RESULTS

Tumor growth delay was observed in animals of the Protocol #3 (p < 0.05). NaB (Protocol #2) increased tumor boron uptake 2-h post BPA injection (p < 0.05). On the other hand, NaB upregulated the expression of all the isoforms of the LAT transporter in vitro. Histologic studies showed a significant decrease of mitotic activity and an increase of vacuoles in tumors of Protocol #3. Neutrons alone or combined with NaB caused some tumor growth delay (p < 0.05), while in the BNCT and BNCT + NaB groups, there was a halt in tumor growth in 70 and 80% of the animals, respectively.

CONCLUSIONS

Intraperitoneally administration of NaB increased boron uptake while oral administration for a longer period of time induced tumor growth delay previous to BPA administration. The use of NaB via ip would optimize the irradiation results.

Epigenetic regulation of TLR2-mediated periapical inflammation

AIM

To determine the methylation pattern of TLR2 gene promoter and its association with the transcriptional regulation of periapical inflammatory and angiogenic responses in symptomatic and asymptomatic forms of apical periodontitis.

METHODOLOGY

In this cross-sectional study, apical lesions were obtained from volunteers with asymptomatic apical periodontitis (AAP) (n = 17) and symptomatic apical periodontitis (SAP) (n = 17) scheduled for tooth extraction, and both total RNA and DNA were extracted. DNA was bisulfite-treated, a region of CpG island within the TLR2 gene was amplified by qPCR and the products were sequenced. Additionally, the mRNA expression of TLR2, TLR4, IL-6, IL-12, TNFalpha, IL-23, IL-10, TGFbeta, VEGFA and CDH5 was analysed by qPCR. The data were analysed with chi-square tests, Mann-Whitney or unpaired t-tests, and Spearman´s correlation; variable adjustments were performed using multiple linear regression (P < 0.05).

RESULTS

TLR2 depicted a hypomethylated DNA profile at the CpG island in SAP when compared with AAP, along with upregulated expression of TLR2, with pro-inflammatory cytokines IL-6 and IL-23, and the angiogenesis marker CDH5 (P < 0.05). TLR2 methylation percentage negatively correlated with mRNA levels of IL-23 and CDH5 in apical periodontitis. Lower methylation frequencies of single CpG dinucleotides -8 and -10 localized in close proximity to nuclear factor κB (NFκB) binding within the TLR2 promoter were identified in SAP versus AAP (P < 0.05). Finally, unmethylated -10 and -8 single sites demonstrated up-regulation of IL-23, IL-10 and CDH5 transcripts compared to their methylated counterparts (P < 0.05).

CONCLUSIONS

TLR2 gene promoter hypomethylation was linked to transcriptional activity of pro-inflammatory cytokines and angiogenic markers in exacerbated periapical inflammation. Moreover, unmethylated single sites in close proximity to NFκB binding were involved in active transcription of IL-23, IL-10 and CDH5.

Interleukin-17 mediated immunity during infections with Trypanosoma cruzi and other protozoans

Host resistance during infection with Trypanosoma cruzi, and other protozoans, is dependent on a balanced immune response. Robust immunity against these pathogens requires of the concerted action of many innate and adaptive cell populations including macrophages, neutrophils, dendritic cells, CD4+, and CD8+ T cells and B cells among others. Indeed, during most protozoan infections only a balanced production of inflammatory (TH1) and anti-inflammatory (TH2/regulatory) cytokines will allow the control of parasite spreading without compromising host tissue integrity. The description of TH17 cells, a novel effector helper T cell lineage that produced IL-17 as signature cytokine, prompted the revision of our knowledge about the mechanisms that mediate protection and immunopathology during protozoan infections. In this manuscript we discuss the general features of IL-17 mediated immune responses as well as the cellular sources, effector mechanisms and overall role of IL-17 in the immune response to T. cruzi and other protozoan infections.

Development of a 64 SNV panel for breed authentication in Iberian pigs and their derived meat products

Spanish legislation regulates the labelling of Iberian pig meat and dry-cured products, which are labelled as "Ibérico" or "100% Ibérico" when they come from Duroc x Iberian crossbred or Iberian purebred pigs. Although the analytical authentication of breed origin is not mandatory, a genetic diagnostic tool is demanded by producers and consumers. We have designed a 64 Single Nucleotide Variant genotyping panel displaying extreme allelic frequencies between Duroc and Iberian purebred samples. Average proportions of Iberian alleles of 0.99, 0.01, 0.77 and 0.48 were estimated by admixture clustering analysis of known origin samples, for Iberian and Duroc purebred, 75% Iberian and 50% Iberian classes, respectively. A supervised analysis with 1419 samples showed some overlapping between contiguous classes, but the calculated degrees of separability ranged from 0.800 to 0.996, exceeding the threshold value (0.70) for considering suitable for prediction. Therefore, this panel is a useful genetic tool to infer purebred or crossbred Iberian origin of live animals, meat and dry-cured products.

Hospital environment hygiene nurse: a key player to reduce healthcare associated infections by multi-resistant organisms

Background

Multi-Resistant Organisms (MRO) healthcare-associated infections (HAI) are closely associated with contamination of surfaces. Outsourced companies are usually in charge of both hospital hygiene and environmental hygiene personnel (EHP) supervision, which can result in bias.

Methods

A quasi-experimental study. The intervention was to add the "Hospital Environment Hygiene Nurse" (HEHN). MRO acquired infection rate and MRO acquired colonized rate were calculated, pre and post intervention. Confounding variables: MRO carriage rate upon admission and hospitalisation days median (HDM) were calculated.

Results

Median length of stay: 5 days (p=0.85, interquartile range=6 days). Carriage rate upon admission: 4.3% for pre-intervention vs 5.3% post-intervention, dif. (CI 95%): 1% (-1% to 2.9%) p=0.33. MRO acquired infection rate: 4.3% for pre-intervention vs. 2% post-intervention, Standardized Infection Ratio (SIR) (CI 95%): 0.47 (0.25 to 0.87). MRO acquired colonization rate:10.4% for pre-intervention vs. 7.9% post-intervention, SIR (CI 95%): 0.75 (0.53 to 1.07).

Conclusions

As a reinforcement to standard infection control (IC) measures in place, the incorporation of an exclusive, full-time HEHN was significantly useful to reduce MRO HAI.

Lower urinary tract symptoms and obstructive sleep apnea syndrome: Urodynamic evolution before and after one year of treatment with continuous positive airway pressure

OBJECTIVE

To report the clinical evolution and the urodynamic behaviour of several lower tract urinary symptoms in patients with obstructive sleep apnea syndrome before and after the treatment with continuous positive airway pressure (CPAP) devices.

METHODS

A prospective study was performed; patients with recent diagnosis of sleep apnea confirmed by nocturnal sleep polygraphy and absence of medical urological past history. In order to discard important lower urinary tract conditions, urological examinations were previously performed. Urinary symptoms were evaluated using the IPSS and OAB-V8 validated questionnaires, three-day Bladder Diary and invasive urodynamic examinations with a gap of one year before and one year after using the CPAP.

RESULTS

84 urodynamic studies were carried out in 43 patients. The IPSS score decreased by 3.58 points. The OAB-V8 score decreased by 2.87 points. Nocturia episodes decreased to one per night. The percentage of patients with nocturnal polyuria went down to 26%. The bladder compliance significantly increased (97.39 vs 200.40ml/cm H2O). The presence of detrusor overactivity decreased from 11 (before CPAP) to 5 patients (after CPAP).

CONCLUSION

The proper treatment with CPAP showed a statistical and clinical improvement of several LUTS with limited urodynamic modifications.

Effect of reproductive state on active dispersal in Triatoma infestans (Klug, 1834) (Hemiptera: Reduviidae: Triatominae) susceptible and resistant to deltamethrin

Triatoma infestans (Klug, 1834) is the main vector of the Chagas´ disease in Argentina. The presence of insects in the domestic environment after application of pyrethroid insecticides was reported. The colonization and the evolution of insecticide resistance are processes that can explain these control failures. In both processes, the active dispersal of insects is a determining factor. The aim of the present study was to determine whether the reproductive state modulate the dispersal capacity of females of T. infestans susceptible and resistant to deltamethrin. For this, different variables associated with active dispersal were measured in virgin and copulated females both susceptible and resistant to deltamethrin. The experimental arena was 10 m long and contained two shelters. Groups of 12 females of each experimental group were released in one of the shelters and were able to move during 3 days/nights. The results showed that the females mainly dispersed by walking regardless of the reproductive state and the toxicological phenotype. On the other hand, the copula affected the posterior dispersal capacity in females susceptible and resistant to deltamethrin. The copulated females dispersed more times, leaved more times from the shelters and showed a higher proportion of dispersed individuals than the virgin females. Finally, the insecticide resistance reduced the dispersal capacity of females. The resistant insects showed lower number of dispersal events, a lower proportion of dispersed individuals, and lower exit and entry events from/to shelter than susceptible insects. This is the first report of the effect of copula on the capacity of active dispersion in vectors of Chagas disease susceptible and resistant to insecticides.

Effect of nutritional state and dispersal on the reproductive efficiency in Triatoma infestans (Klug, 1834) (Hemiptera: Reduviidae: Triatominae) susceptible and resistant to deltamethrin

The dispersal of insects is determinant in the colonization of new areas and the propagation of insecticide resistance. Nutritional status and reproductive characteristics determine the colonization capacity after the dispersal event. Studies about of the effects of dispersal on reproduction in triatomines are few and none in resistant insects. The aim was to determine the effects of nutritional state and dispersal on the subsequent reproductive potential in Triatoma infestans (Klug, 1834) susceptible and resistant to deltamethrin. Three nutritional states were obtained with the number of feeds (NF) offered (0, 1 or 2). The resistant females were evaluated only with NF1. The experimental arena was 10 m long and contained two shelters. Groups of 30 virgin females of each NF were released in one of the shelters and were able to move during 3 days/nights. Females without possibility of dispersal were the controls. The reproductive parameters were determined on the couples between the experimental females and males from the breeding. The results showed that most of the females dispersed by walking. The dispersal had effects on the reproduction of the deltamethrin-susceptible females and this depended on the number of feeds. Fecundity, fertility and the proportion of females that oviposited were higher in females dispersed with two feeds but was lower in females dispersed with less feeds. In addition, the effect of the dispersal on the reproduction and the life time also depended of the toxicological phenotype. The resistant insect oviposited in higher proportion and showed greater fecundity and more weeks of life when they dispersed that when they did not do it, and was opposite to that observed in susceptible ones. Finally, the resistance to insecticide had an effect on the reproduction and the life span and this effect depended on whether the insects dispersed or not.

[Bacteremia caused by Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae. A retrospective study of 7 years]

OBJECTIVE

Bacteremia caused by Klebsiella pneumoniae carbapenemase-producing strains (Kp-KPC) is associated with high mortality. The hypothesis of our work is that there was an increase in the levels of resistance to different antimicrobials in Kp-KPC isolated from bacteremia.

METHODS

Retrospective and descriptive study in two periods: Period 1 (P1) 2010-2014 and period 2 (P2) 2015-2016. We included patients ≥18 years old with bacteremia caused by Kp-KPC in a General Hospital. We defined active drug (AD) if it was in vitro susceptible and in the case of meropenem if it had a MIC ≤ 8 mg/L in combination treatment.

RESULTS

Fifty episodes of bacteremia caused by Kp-KPC were analyzed in 45 patients. (P1: 21 and P2: 29). The following variables were similar in both periods: median age (53 vs. 52 years); male sex (45 vs. 62%); site of infection: primary bacteremia (52 vs.45%), bacteremia associated with catheter (24 vs.17%), and other (24 vs. 38%). During P2 there was a significant increase in colistin resistance (28 vs. 69%) (p <0.01), an increase in MIC to meropenem ≥ 16 mg/L (74 and 97%) (p = 0.02), and decrease in tigecycline resistance (29 vs. 4%) (p = 0.02). The overall mortality was 40 in P1 and 32% in P2 (p=0.7). There was not difference in mortality when the definitive treatment was with an active antimicrobial vs. two active antimicrobials, as well as between the different antimicrobials used.

CONCLUSIONS

There was a significant increase in bacteremia caused by Kp-KPC and the level of colistin resistance and MIC to meropenem. Overall mortality was high in both periods.

Evaluation of ultraviolet-C and spray-drying processes as two independent inactivation steps on enterotoxigenic Escherichia coli K88 and K99 strains inoculated in fresh unconcentrated porcine plasma

The objectives of this study were to assess the effectiveness of an ultraviolet (UV‐C, 254 nm) irradiation system and the spray‐drying method as two independent safety steps on inactivation of Escherichia coli K88 and K99 spiked in porcine plasma at 6·46 ± 0·04 log₁₀ ml⁻¹ and 6·78 ± 0·67 log₁₀ ml⁻¹ respectively for UV‐C method, and at 7·31 ± 0·39 log₁₀ ml⁻¹ and 7·66 ± 0·11 log₁₀ ml⁻¹, respectively for the spray‐drying method. The UV‐C method was performed at different UV light doses (from 750 to 9000 J l⁻¹) using a pilot plant UV‐C device working under turbulent flow. Spray‐drying treatment was done at inlet temperature 220 ± 1°C and two different outlet temperatures, 80 ± 1°C or 70 ± 1°C. Results indicated that UV‐C treatment induced a 4 log₁₀ viability reduction for both E. coli at 3000 J l⁻¹. Full inactivation of both E. coli strains was achieved in all spray‐dried samples dehydrated at both outlet temperatures. The special UV‐C system design for turbid liquid porcine plasma is a novel treatment that can provide an additional redundant biosafety feature that can be incorporated into the manufacturing process for spray‐dried animal plasma.

Significance and Impact of the Study

The safety of raw materials from animal origin such as spray‐dried porcine plasma (SDPP) may be a concern for the swine industry. Ultraviolet treatment at 254 nm (UV‐C) of liquid plasma has been proposed as an additional biosafety feature in the manufacturing process of SDPP. We found that UV‐C exposure in the liquid plasma at 3000 J l⁻¹ reduces about 4 log10 ml⁻¹ for E. coli K88 and K99. Full inactivation of both E. coli strains was achieved in all spray‐dried samples. The incorporation of UV‐C treatment to liquid plasma improves the robustness of the SDPP manufacturing process.

Combined effects of spray-drying conditions and postdrying storage time and temperature on Salmonella choleraesuis and Salmonella typhimurium survival when inoculated in liquid porcine plasma

The objective of this study was to determine the effectiveness of the spray-drying process on the inactivation of Salmonella choleraesuis and Salmonella typhimurium spiked in liquid porcine plasma and to test the additive effect of immediate postdrying storage. Commercial spray-dried porcine plasma was sterilized by irradiation and then reconstituted (1:9) with sterile water. Aliquots of reconstituted plasma were inoculated with either S. choleraesuis or S. typhimurium, subjected to spray-drying at an inlet temperature of 200°C and an outlet temperature of either 71 or 80°C, and each spray-drying temperature combinations were subjected to either 0, 30 or 60 s of residence time (RT) as a simulation of residence time typical of commercial dryers. Spray-dried samples were stored at either 4·0 ± 3·0°C or 23·0 ± 0·3°C for 15 days. Bacterial counts of each Salmonella spp., were completed for all samples. For both Salmonella spp., spray-drying at both outlet temperatures reduced bacterial counts about 3 logs at RT 0 s, while there was about a 5·5 log reduction at RT 60 s. Storage of all dried samples at either 4·0 ± 3·0°C or 23·0 ± 0·3°C for 15 days eliminate all detectable bacterial counts of both Salmonella spp.

SIGNIFICANCE AND IMPACT OF THE STUDY

Safety of raw materials from animal origin like spray-dried porcine plasma (SDPP) may be a concern for the swine industry. Spray-drying process and postdrying storage are good inactivation steps to reduce the bacterial load of Salmonella choleraesuis and Salmonella typhimurium. For both Salmonella spp., spray-drying at 71°C or 80°C outlet temperatures reduced bacterial counts about 3 log at residence time (RT) 0 s, while there was about a 5.5 log reduction at RT 60 s. Storage of all dried samples at either 4.0 ± 3.0°C or 23.0 ± 0.3°C for 15 days was effective for eliminating detectable bacterial counts of both Salmonella spp.

The optimal ethanol lock therapy regimen for treatment of biofilm-associated catheter infections: an in-vitro study

BACKGROUND

Ethanol-based lock therapy (LT) solutions are used as an alternative to antibiotics for the conservative management of catheter-related bloodstream infection. However, no clear consensus on regimen or dose has been reached.

AIM

To find the ethanol-based lock solution containing a sufficiently low concentration of ethanol for reduction of the metabolic activity of bacterial and fungal biofilms.

METHODS

Using an in-vitro model, three concentrations of ethanol (25%, 40%, 70%) were tested, with and without 60 IU of heparin, at six different time-points and against 24 h preformed biofilms of Staphylococcus aureus ATCC29213, Staphylococcus epidermidis (clinical isolate), Enterococcus faecalis ATCC33186, Candida albicans ATCC14058, and Escherichia coli ATCC25922. The reduction in the metabolic activity of the biofilm was measured using the tetrazolium salt assay and LT was considered to be successful when metabolic activity fell by >90%. Regrowth inhibition was then tested within 24 h and seven days after each LT regimen only at the ethanol concentration of the most successful LT regimen.

FINDINGS

The most successful LT was achieved with 40% ethanol + 60 IU of heparin only at 24, 72, and 24 h for seven-day regimens (P < 0.05). However, none of the regimens reached 45% RI within seven days of therapy.

CONCLUSION

According to our in-vitro data, an ethanol-based lock solution with 40% ethanol + 60 IU heparin administered daily for 72 h is sufficient to almost eradicate the metabolic activity of bacterial and fungal biofilms. Future studies are needed to study cell regrowth after LT.

Plasma ctDNA RAS mutation analysis for the diagnosis and treatment monitoring of metastatic colorectal cancer patients

Background

RAS assessment is mandatory for therapy decision in metastatic colorectal cancer (mCRC) patients. This determination is based on tumor tissue, however, genotyping of circulating tumor (ct)DNA offers clear advantages as a minimally invasive method that represents tumor heterogeneity. Our study aims to evaluate the use of ctDNA as an alternative for determining baseline RAS status and subsequent monitoring of RAS mutations during therapy as a component of routine clinical practice.

Patients and methods

RAS mutational status in plasma was evaluated in mCRC patients by OncoBEAM™ RAS CRC assay. Concordance of results in plasma and tissue was retrospectively evaluated. RAS mutations were also prospectively monitored in longitudinal plasma samples from selected patients.

Results

Analysis of RAS in tissue and plasma samples from 115 mCRC patients showed a 93% overall agreement. Plasma/tissue RAS discrepancies were mainly explained by spatial and temporal tumor heterogeneity. Analysis of clinico-pathological features showed that the site of metastasis (i.e. peritoneal, lung), the histology of the tumor (i.e. mucinous) and administration of treatment previous to blood collection negatively impacted the detection of RAS in ctDNA. In patients with baseline mutant RAS tumors treated with chemotherapy/antiangiogenic, longitudinal analysis of RAS ctDNA mirrored response to treatment, being an early predictor of response. In patients RAS wt, longitudinal monitoring of RAS ctDNA revealed that OncoBEAM was useful to detect emergence of RAS mutations during anti-EGFR treatment.

Conclusion

The high overall agreement in RAS mutational assessment between plasma and tissue supports blood-based testing with OncoBEAM™ as a viable alternative for genotyping RAS of mCRC patients in routine clinical practice. Our study describes practical clinico-pathological specifications to optimize RAS ctDNA determination. Moreover, OncoBEAM™ is useful to monitor RAS in patients undergoing systemic therapy to detect resistance and evaluate the efficacy of particular treatments.

Programa de selección genética enfocada en la calidad de cerdos Ibéricos puros de montanera

Los programas de selección genética son inusuales en el sector porcino Ibérico de extensivo. La empresa tradicional de productos de cerdo Ibérico, Sánchez Romero Carvajal (SRC), localizada en la Sierra de Huelva, junto con el Departamento de Mejora Genética Animal del INIA, se está esforzando en desarrollar un esquema de selección basado en evaluaciones BLUP-Modelo animal y enfocado a la mejora genética de cerdos Ibéricos puros de montanera. Los animales implicados en este programa pertenecen a una piara distribuida entre las fincas Montecastila y Tejarejo (La Granada de Riotinto). Para la selección de caracteres de crecimiento, composición de canal y calidad de carne y grasa, se dispone de registros de 1.205 animales de genealogía controlada. Los caracteres principales registrados son: ganancia media diaria en montanera, peso de canal y pesos de piezas nobles (jamones, paletas y lomos). Además, como caracteres de calidad se midieron: perfil de ácidos grasos en grasa subcutánea, porcentaje de grasa intramuscular, color, pérdidas de agua después de descongelado y cocinado, así como resistencia del lomo al corte. Las valoraciones genéticas para caracteres maternos (número de lechones nacidos vivos y peso de camada al destete) se han efectuado hasta la fecha usando datos de 5.134 camadas nacidas en 88 lotes de 1.456 cerdas y 22 verracos. Las reproductoras estaban localizadas en un sistema de parideras tradicionales. Esta información permite la obtención de estimas de heredabilidad y correlaciones genéticas, así como de un índice combinado construido con los valores mejorantes ponderados por los pesos económicos respectivos para cada carácter. Las actividades del programa permiten además la realización de diversos estudios de genética molecular. Estos estudios permitirán en el futuro aumentar la eficacia del programa de selección convencional.

Verificación racial de jamones y paletas Ibéricos comercializados en supermercados españoles

La Norma de Calidad española regula la comercialización tanto de producto fresco como curado procedente de raza Ibérica. La primera Norma, que fue aprobada en 2007 (Real Decreto 1469/2007), establecía que los productos etiquetados como “Ibérico” debían proceder de cerdos con al menos un 50% del genoma Ibérico y que el porcentaje restante debía proceder de Duroc. Esta Norma fue modificada en 2014 (Real Decreto 4/2014) añadiendo que el producto etiquetado como “100% Ibérico” debe proceder de cerdos Ibéricos puros y mantiene la misma regulación que en 2007 para el producto etiquetado como “Ibérico”. En el Grupo de Genética de Cerdos del INIA se ha desarrollado un chip de 64 SNPs para trazabilidad genética, que permite inferir la proporción del genoma de origen Ibérico y Duroc de animales y productos cárnicos. El objetivo de este trabajo consistió en comprobar si los productos curados (jamones y paletas) etiquetados como “Ibérico” por fabricantes y distribuidores representativos del sector y comercializados en los principales supermercados españoles cumplen este aspecto de la Norma de Calidad. 116 muestras problema procedentes de paquetes de loncheados de jamón y paleta comercializados como “Ibéricos” fueron genotipadas con este chip. Los genotipos fueron analizados usando el programa BAPS 5.3. En el 34.48% de las muestras analizadas la proporción estimada de genoma de origen Ibérico era inferior al 40% incumpliendo claramente la Norma. Cabe destacar que en cinco de las 116 muestras la proporción estimada de genes Duroc era del 100%. Estos resultados son indicativos de un insatisfactorio cumplimiento de la Norma de Calidad en diez de los doce distribuidores analizados. Un muestreo futuro mostrará si los controles más estrictos impuestos con la nueva Norma de 2014 han servido para mejorar el cumplimiento de la ley.

Ecological monitoring in a discrete-time prey-predator model

The paper is aimed at the methodological development of ecological monitoring in discrete-time dynamic models. In earlier papers, in the framework of continuous-time models, we have shown how a systems-theoretical methodology can be applied to the monitoring of the state process of a system of interacting populations, also estimating certain abiotic environmental changes such as pollution, climatic or seasonal changes. In practice, however, there may be good reasons to use discrete-time models. (For instance, there may be discrete cycles in the development of the populations, or observations can be made only at discrete time steps.) Therefore the present paper is devoted to the development of the monitoring methodology in the framework of discrete-time models of population ecology. By monitoring we mean that, observing only certain component(s) of the system, we reconstruct the whole state process. This may be necessary, e.g., when in a complex ecosystem the observation of the densities of certain species is impossible, or too expensive. For the first presentation of the offered methodology, we have chosen a discrete-time version of the classical Lotka-Volterra prey-predator model. This is a minimal but not trivial system where the methodology can still be presented. We also show how this methodology can be applied to estimate the effect of an abiotic environmental change, using a component of the population system as an environmental indicator. Although this approach is illustrated in a simplest possible case, it can be easily extended to larger ecosystems with several interacting populations and different types of abiotic environmental effects.

Porphyromonas Gingivalis and IgG1 and IgG2 Subclass Antibodies in Patients with Juvenile Idiopathic Arthritis

PURPOSE

The purpose of this study was to evaluate the periodontal status and the presence and concentration of Porphyromonas gingivalis (P. gingivalis) and immunoglobulin G (IgG) subclass against P. gingivalis in juvenile idiopathic arthritis (JIA) and its association with rheumatic clinical activity parameters.

METHODS

Rheumatologic conditions and periodontal status were clinically assessed in 51 patients with JIA. P. gingivalis, IgG1 and IgG2, high-sensitivity C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor (RF), anti-citrullinated protein antibodies (ACPAs), and human leukocyte antigen B27 were also evaluated.

RESULTS

Periodontitis was observed in 21.5 percent of the patients, 23.5 percent of whom were positive for P. gingivalis, which was associated with enthesitis-related arthritis (P<0.035). IgG1 against P gingivalis was associated with RF autoantibodies (P=0.05), and all patients positive for ACPAs had higher anti-P gingivalis IgG1 levels. A significant correlation was found between the presence of limited joint mobility and the plaque index in polyarticular JIA (r=0.55, P=0.028).

CONCLUSIONS

An association between IgG and rheumatic disease activity markers in JIA was evident. It is important to investigate the familiar periodontal status and clinical course in JIA, especially in enthesitis-related arthritis.

Outcome of Patients with Venous Thromboembolism and Factor V Leiden or Prothrombin 20210 Carrier Mutations During the Course of Anticoagulation

BACKGROUND

Individuals with factor V Leiden or prothrombin G20210A mutations are at a higher risk to develop venous thromboembolism. However, the influence of these polymorphisms on patient outcome during anticoagulant therapy has not been consistently explored.

METHODS

We used the Registro Informatizado de Enfermedad TromboEmbólica database to compare rates of venous thromboembolism recurrence and bleeding events occurring during the anticoagulation course in factor V Leiden carriers, prothrombin mutation carriers, and noncarriers.

RESULTS

Between March 2001 and December 2015, 10,139 patients underwent thrombophilia testing. Of these, 1384 were factor V Leiden carriers, 1115 were prothrombin mutation carriers, and 7640 were noncarriers. During the anticoagulation course, 160 patients developed recurrent deep vein thrombosis and 94 patients developed pulmonary embolism (16 died); 154 patients had major bleeding (10 died), and 291 patients had nonmajor bleeding. On multivariable analysis, factor V Leiden carriers had a similar rate of venous thromboembolism recurrence (adjusted hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.82-1.64), half the rate of major bleeding (adjusted HR, 0.50; 95% CI, 0.25-0.99) and a nonsignificantly lower rate of nonmajor bleeding (adjusted HR, 0.66; 95% CI, 0.43-1.01) than noncarriers. Prothrombin mutation carriers and noncarriers had a comparable rate of venous thromboembolism recurrence (adjusted HR, 1.00; 95% CI, 0.68-1.48), major bleeding (adjusted HR, 0.75; 95% CI, 0.42-1.34), and nonmajor bleeding events (adjusted HR, 1.10; 95% CI, 0.77-1.57).

CONCLUSIONS

During the anticoagulation course, factor V Leiden carriers had a similar risk for venous thromboembolism recurrence and half the risk for major bleeding compared with noncarriers. This finding may contribute to decision-making regarding anticoagulation duration in selected factor V Leiden carriers with venous thromboembolism.