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Faizal B, Nair L, Pavithran J, Moni M, Sheejamol VS. Role of surgery along with antimicrobials in refractory skull base osteomyelitis-A prospective observational study. Clin Otolaryngol 2024. [PMID: 38829037 DOI: 10.1111/coa.14188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/21/2024] [Accepted: 05/18/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION Study aimed to ole of surgery along with antimicrobials to improve clinical outcomes in treating refractory cases of skull base osteomyelitis (SBO). METHODS A prospective observational study in a tertiary care centre with 70 SBO patients meeting eligibility criteria. The study population comprised 35 patients refractory to systemic antimicrobials of at least 4 weeks duration who later underwent surgery in addition to medication (surgical group). They were compared with a medical group that responded to medications alone. The outcome variables studied were the resolution of clinical features (pain, discharge, radiology, and inflammatory markers), culture yield, and total duration of treatment. RESULTS According to our study, relief of pain was faster in the surgical group (1.66 against 4.57 months) with statistical significance (p < 0.001). Relief of symptoms (p < 0.001), radiological improvement (p = 0.001), and normalising of inflammatory markers (p < 0.001) were better in the surgical group than in the medical group. The duration of treatment was an average of 9.2 months in the surgical group compared to 11.3 months in the medical group (p = 0.019). Microbial culture from deep tissue sampling was positive in 24 surgical patients (68.57%). CONCLUSIONS The treatment response in selected patients of refractory SBO who underwent surgery along with antimicrobials was better than the group who responded to antimicrobials alone. Surgery provided higher microbial yield resulting in culture-specific antimicrobials. The surgical group observed faster relief of symptoms, reduced hospital stay, and total treatment duration.
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Affiliation(s)
- Bini Faizal
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Lakshmi Nair
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Jayanthy Pavithran
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Merlin Moni
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - V S Sheejamol
- Department of Biostatistics, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
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Gomes PM, Cabral DC, Costa JB, Fernandes T, Camacho Ó, Penêda JF, Duarte D, Viana M. Hyperbaric oxygen therapy in malignant otitis externa: a retrospective analysis. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08734-6. [PMID: 38767696 DOI: 10.1007/s00405-024-08734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE Malignant otitis externa (MOE) is a rare form of invasive osteomyelitis of the external ear canal. It is typically caused by Pseudomonas aeruginosa in immunocompromised patients. The diagnosis is clinical, and the initial treatment involves systemic antibiotics or antifungal therapy. Surgery is usually only considered when medical treatment has failed. Although hyperbaric oxygen therapy (HBOT) is recommended for refractory osteomyelitis, there are no specific guidelines for MOE. METHODS This is a retrospective study that evaluates clinical data, treatment, and results obtained in patients diagnosed with MOE treated with HBOT at the Pedro Hispano Hospital between 2007 and 2022. RESULTS During the study period, fifteen patients diagnosed with MOE were admitted for treatment with HBOT. All patients received antibiotic and/or antifungal therapy, and three required surgical intervention before starting HBOT. The pathology was successfully managed on all patients. CONCLUSIONS HBOT may be an effective adjuvant treatment option in patients with MOE but it lacks robust scientific evidence. However, its therapeutic value should not be underestimated due to the good results and few adverse effects reported in recent retrospective studies and case reports.
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Affiliation(s)
- Pedro Marques Gomes
- Department of Otorhinolaryngology, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Rua de Santo António, Lote 14, São Pedro do Sul, Porto, Portugal.
| | - Diogo Cunha Cabral
- Department of Otorhinolaryngology, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Rua de Santo António, Lote 14, São Pedro do Sul, Porto, Portugal
| | - Joana Borges Costa
- Department of Otorhinolaryngology, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Rua de Santo António, Lote 14, São Pedro do Sul, Porto, Portugal
| | - Tiago Fernandes
- Department of Hyperbaric Medicine, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Porto, Portugal
| | - Óscar Camacho
- Department of Hyperbaric Medicine, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Porto, Portugal
| | - José Ferreira Penêda
- Department of Otorhinolaryngology, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Rua de Santo António, Lote 14, São Pedro do Sul, Porto, Portugal
| | - Delfim Duarte
- Department of Otorhinolaryngology, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Rua de Santo António, Lote 14, São Pedro do Sul, Porto, Portugal
| | - Miguel Viana
- Department of Otorhinolaryngology, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Rua de Santo António, Lote 14, São Pedro do Sul, Porto, Portugal
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Azeez TA, Adeagbo AK. The Association Between Malignant Otitis Externa and Diabetes Mellitus in Africa: A Systematic Review. Indian J Otolaryngol Head Neck Surg 2023; 75:3277-3287. [PMID: 37974885 PMCID: PMC10645783 DOI: 10.1007/s12070-023-03939-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/06/2023] [Indexed: 11/19/2023] Open
Abstract
Diabetes mellitus is one of the risk factors for malignant otitis externa. There are very few studies on the disease in Africa and there is a need to pool the prior studies to highlight the characteristics of the disease. The study type is a systematic review and the PRISMA guidelines were followed. Using the appropriate terms, relevant medical databases were systematically searched. Thirty-two studies met the eligibility criteria with a total sample size of 848, who were mainly elderly. Diabetes mellitus was present in 94% of the participants. Average duration of diabetes diagnosis in the participants was 12.4 years. The pooled HbA1c was 9.8%. The most common symptoms were otalgia (96.1%), otorrhoea (75.8%) and hearing loss (56.1%). Pseudomonas was the most common isolate (72%). Fluoroquinolones and the 3rd-generation cephalosporins were the preferred antibiotics. The pooled cure rate from antimicrobial usage was 76.2%. In addition to medications, 24.6% of the affected individuals required debridement. About 1.6% of the participants died from malignant otitis externa. Malignant otitis externa is associated with poorly controlled diabetes. Pseudomonas is the most common cause and a significant proportion gets cured with prolonged antibiotherapy.
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Affiliation(s)
- Taoreed Adegoke Azeez
- Department of Medicine, Reddington Multi-Specialist Hospital, 12, Idowu Martins Street, Victoria Island, Lagos, Nigeria
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Fenberg RB, Sylvester MJ, Davidson S, McKean EL, VanKoevering KK. Central Skull Base Osteomyelitis: A Case Series from a Tertiary Care Center Over 5 Years. Ann Otol Rhinol Laryngol 2023; 132:1300-1305. [PMID: 36648119 DOI: 10.1177/00034894221147806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Skull base osteomyelitis may rarely present in the sphenoid bone or clivus without an otologic source. This is referred to as central skull base osteomyelitis (CSBO). Knowledge regarding CSBO is limited to case reports and small case series. Here we present a case series to further describe typical patient characteristics, clinical presentation, and clinical course associated with this rare infection. METHODS All patients treated at a single academic tertiary care institution for CSBO from 2016 through 2020 were identified. Inclusion criteria included culture proven CSBO without an otologic or iatrogenic source. Data were extracted via patient chart review and qualitatively analyzed. RESULTS Seven patients were identified with CSBO, 5 male and 2 female. Age ranged from 63 to 87 (average 76). Risk factors included advanced age, diabetes, and history of radiation. The most common presenting symptom was headache (6), followed by otalgia (4). Two patients presented with cranial neuropathies. Diagnosis was facilitated by history and exam (including flexible laryngoscope exam), imaging (MRI), and labs (ESR). All patients received endoscopic biopsy and culture (most commonly polymicrobial, with diverse species). Treatment involved IV antibiotics, with a limited role for surgery. All patients survived and achieved resolution of infection. CONCLUSIONS CSBO remains a diagnostic challenge due to its rarity and vague presenting symptoms that overlap with presentation of sinonasal malignancies. A high index of suspicion is required by the evaluating provider to ensure a timely diagnosis with early treatment in order to limit the significant morbidity which can be associated with this infection. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Rachel B Fenberg
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael J Sylvester
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan - Michigan Medicine, Ann Arbor, MI, USA
| | - Steven Davidson
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Erin L McKean
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan - Michigan Medicine, Ann Arbor, MI, USA
| | - Kyle K VanKoevering
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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胡 丽, 高 雪, 王 曦, 徐 金, 王 晓. [Research progress of necrotizing otitis externa]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2023; 37:843-847;852. [PMID: 37828893 PMCID: PMC10803230 DOI: 10.13201/j.issn.2096-7993.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Indexed: 10/14/2023]
Abstract
Necrotizing otitis externa is a progressive infectious disease involving the external auditory canal and even the skull base, which can lead to serious complications and even death if not treated in time. In this paper, the latest advances in etiology, pathogenesis, clinical manifestations, diagnosis and treatment were reviewed based on previous literature, providing reference for clinical diagnosis, treatment and future research.
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Affiliation(s)
- 丽敏 胡
- 火箭军特色医学中心耳鼻咽喉科(北京,100088)Department of Otorhinolaryngolgoy, PLA Rocket Force Characteristic Medical Center, Beijing, 100088, China
| | - 雪 高
- 火箭军特色医学中心耳鼻咽喉科(北京,100088)Department of Otorhinolaryngolgoy, PLA Rocket Force Characteristic Medical Center, Beijing, 100088, China
| | - 曦 王
- 火箭军特色医学中心耳鼻咽喉科(北京,100088)Department of Otorhinolaryngolgoy, PLA Rocket Force Characteristic Medical Center, Beijing, 100088, China
| | - 金操 徐
- 火箭军特色医学中心耳鼻咽喉科(北京,100088)Department of Otorhinolaryngolgoy, PLA Rocket Force Characteristic Medical Center, Beijing, 100088, China
| | - 晓东 王
- 火箭军特色医学中心研究部Department of Research, PLA Rocket Force Characteristic Medical Center
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Tsilivigkos C, Avramidis K, Ferekidis E, Doupis J. Malignant External Otitis: What the Diabetes Specialist Should Know-A Narrative Review. Diabetes Ther 2023; 14:629-638. [PMID: 36897495 PMCID: PMC10064349 DOI: 10.1007/s13300-023-01390-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
AIMS Malignant external otitis (MEO) is a special type of external otitis associated with extensive inflammation and osteomyelitis. It is believed to originate from the external auditory meatus and advance regionally to the soft tissues and the bone, eventually involving the skull base. Pseudomonas aeruginosa and diabetes mellitus are factors commonly involved in the pathogenesis of MEO. Although its treatment has changed considerably during the last decades, morbidity and mortality of the disease remain high. Our aim was to review basic aspects of MEO, a disease unknown until 1968, which attracts great interest among Ears, Nose and Throat (ENT), diabetes and infectious diseases specialists. METHODS AND RESULTS In this narrative review we mainly include relevant papers written in English or with an English abstract. We searched PubMed and Google Scholar, using the keywords malignant external otitis, malignant otitis externa, necrotizing external otitis, skull base osteomyelitis, diabetes mellitus and surgery up to July 2022. Some of the most recent articles, with specific references to earlier articles and a book reference regarding the pathophysiology, diagnosis and treatment of MEO and its relationship to diabetes mellitus, were included. CONCLUSION MEO is not an uncommon disease and is principally treated by ENT surgeons. Nevertheless, diabetes specialists should be aware of the disease presentation and management, since they will often encounter patients with undiagnosed MEO or will need to manage glucose levels in patients hospitalized with the disease.
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Affiliation(s)
- Christos Tsilivigkos
- First Department of Otolaryngology, Hippokration General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece.
| | - Konstantinos Avramidis
- Second Department of Internal Medicine, Hippokration General Hospital, 15772, Athens, Greece
| | - Eleftherios Ferekidis
- First Department of Otolaryngology, Hippokration General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece
| | - John Doupis
- Department of Internal Medicine and Diabetes, Salamis Naval and Veterans Hospital, Salamis Naval Base, 18900, Salamis Island, Greece
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Relapsing Aspergillus otomycosis despite prolonged systemic antifungal therapy and resolution after topical voriconazole administration: A case report. Med Mycol Case Rep 2022; 39:23-25. [PMID: 36632528 PMCID: PMC9826810 DOI: 10.1016/j.mmcr.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022] Open
Abstract
We report a case of intractable Aspergillus otomycosis with multiple relapses despite conventional topical and systemic antifungal treatment, and adjunctive usage of hyperbaric oxygen therapy. Of note, otomycosis relapsed even after six months of continuous systemic antifungal treatment with therapeutic drug levels and without treatment interruption; and only resolved after application of topical voriconazole. (max. 75 words).
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Fischer HG, Gey A, Fischer M, Plontke SK. [Hyperbaric oxygen therapy : Selected indications in the discipline of otorhinolaryngology]. HNO 2022; 70:848-860. [PMID: 36173420 DOI: 10.1007/s00106-022-01227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/29/2022]
Abstract
Hyperbaric oxygenation (HBO) represents the controlled exposure to positive pressure with simultaneous inhalation of pure oxygen. It is considered to be an effective treatment option for diseases with restricted blood flow as oxygen not only binds chemically to hemoglobin but also physically dissolves in blood plasma. With the help of a hyperbaric chamber the ambient pressure of a patient can be modified and the physiological characteristics in positive pressure can be medically used. The indications relevant to otorhinolaryngology are necrotizing otitis externa and skull base osteomyelitis, other forms of osteomyelitis, gangrene, wound healing disorders and sudden loss of hearing. When choosing a treatment, not only the availability and costs of HBO treatment play a role but also the patient's tolerance of overpressure. The risks of treatment, e.g., due to oxygen toxicity or barotrauma of the middle ear or the paranasal sinuses, must be weighed up against the potential benefits.
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Affiliation(s)
- Hans-Georg Fischer
- Praxis für Hals-Nasen-Ohrenheilkunde, Schlehenweg 30, 04329, Leipzig, Deutschland. .,Abteilung für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Bundeswehrkrankenhaus Hamburg, Hamburg, Deutschland. .,Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsmedizin Halle, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland.
| | - Alexandra Gey
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsmedizin Halle, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Martin Fischer
- Klinik für Allgemein‑, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg, Leipzig, Deutschland
| | - Stefan K Plontke
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsmedizin Halle, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
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Novel magnetic iron-nickel/poly(ethersulfone) mixed matrix membranes for oxygen separation potential without applying an external magnetic field. Sci Rep 2022; 12:13675. [PMID: 35953625 PMCID: PMC9372052 DOI: 10.1038/s41598-022-16979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022] Open
Abstract
This work presents novel magnetic mixed matrix poly(ethersulfone) (PES) membranes that combine the advantages of low-cost common PES polymer and low-cost iron–nickel magnetic alloys. Moreover, the presented magnetic mixed matrix PES membranes were fabricated and used without applying an external magnetic field during either the membrane casting or the separating process. The fabricated magnetic membranes were prepared using the phase inversion technique and N-methylpyrrolidone and N,N‐Dimethylformamide solvents mixture with volumetric ratio 1:9 and Lithium chloride as an additive. The used iron–nickel magnetic alloys were prepared by a simple chemical reduction method with unique morphologies (Fe10Ni90; starfish-like and Fe20Ni80; necklace-like). The fabricated membranes were characterized using Scanning Electron Microscope (SEM) and Scanning-Transmission Electron Microscope (STEM) imaging, energy dispersive X-ray (EDX), Thermogravimetric (TGA), and X-ray diffraction (XRD). Also, static water contact angle, membrane thickness, surface roughness, membrane porosity, membrane tensile strength as well as Vibrating Sample Magnetometer (VSM) analysis and oxygen transition rate (OTR) were determined. Moreover, the effect of alloy concentration and using Lithium chloride as an additive on the properties of the fabricated blank PES and magnetic mixed matrix PES membranes were studied. The presented novel magnetic mixed matrix PES membranes have high coercivity up to 106 (emu/g) with 3.61 × 10–5 cm3/cm2·s OTR compared to non-oxygen permeable blank PES membranes. The presented novel magnetic mixed matrix PES membranes have good potential in (oxygen) gas separation.
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Ortega MA, Fraile-Martinez O, García-Montero C, Callejón-Peláez E, Sáez MA, Álvarez-Mon MA, García-Honduvilla N, Monserrat J, Álvarez-Mon M, Bujan J, Canals ML. A General Overview on the Hyperbaric Oxygen Therapy: Applications, Mechanisms and Translational Opportunities. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:864. [PMID: 34577787 PMCID: PMC8465921 DOI: 10.3390/medicina57090864] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 12/17/2022]
Abstract
Hyperbaric oxygen therapy (HBOT) consists of using of pure oxygen at increased pressure (in general, 2-3 atmospheres) leading to augmented oxygen levels in the blood (Hyperoxemia) and tissue (Hyperoxia). The increased pressure and oxygen bioavailability might be related to a plethora of applications, particularly in hypoxic regions, also exerting antimicrobial, immunomodulatory and angiogenic properties, among others. In this review, we will discuss in detail the physiological relevance of oxygen and the therapeutical basis of HBOT, collecting current indications and underlying mechanisms. Furthermore, potential areas of research will also be examined, including inflammatory and systemic maladies, COVID-19 and cancer. Finally, the adverse effects and contraindications associated with this therapy and future directions of research will be considered. Overall, we encourage further research in this field to extend the possible uses of this procedure. The inclusion of HBOT in future clinical research could be an additional support in the clinical management of multiple pathologies.
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Affiliation(s)
- Miguel A. Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Cancer Registry and Pathology Department, Hospital Universitario Principe de Asturias, 28806 Alcala de Henares, Spain
| | - Oscar Fraile-Martinez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Enrique Callejón-Peláez
- Underwater and Hyperbaric Medicine Service, Central University Hospital of Defence—UAH Madrid, 28801 Alcala de Henares, Spain;
| | - Miguel A. Sáez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Pathological Anatomy Service, Central University Hospital of Defence—UAH Madrid, 28801 Alcala de Henares, Spain
| | - Miguel A. Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Jorge Monserrat
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Immune System Diseases—Rheumatology, Oncology Service an Internal Medicine, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcala de Henares, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - María Luisa Canals
- ISM, IMHA Research Chair, Former of IMHA (International Maritime Health Association), 43001 Tarragona, Spain;
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