[Approach to refractory gastroesophageal reflux disease]. / Abordaje de la enfermedad por reflujo gastroesofágico refractaria.

An adequate approach to refractory gastroesophageal reflux disease (rGERD) is essential for achieving therapeutic success. From the precise definition of rGERD to the detailed characterization of its phenotypes, it will pave the way for the customization of optimal therapy for each patient. In this narrative literature review, the aim is to provide an updated synthesis of the utility of various diagnostic tools and explore the wide range of therapeutic options, both medical and invasive, available for this condition.

Conocimiento de las enfermedades genéticas raras en la práctica clínica diaria

En este número, nos complace presentar 4 trabajos multidisciplinarios que incluyen disciplinas como la Genética Pediátrica, la Hematología, y Nefrología.  Estos trabajos de gran calidad representan el esfuerzo de meses de los colegas especialistas en el área de la genética clínica multidisciplinaria. Cada contribución representa una herramienta para la educación y la docencia a múltiples niveles del aprendizaje médico. (provisto por Infomedic International)

In this issue, we are pleased to present 4 multidisciplinary papers that include disciplines such as Pediatric Genetics, Hematology, and Nephrology. These high quality papers represent the efforts of months of specialist colleagues in the area of multidisciplinary clinical genetics. Each contribution represents a tool for education and teaching at multiple levels of medical learning. (provided by Infomedic International)

Radiation therapy for optic nerve sheath meningiomas: Local control and treatment related visual changes.

Objective: Our primary objective is to evaluate the local control of optic nerve sheath meningiomas (ONSMs) treated with ionizing radiation and related visual changes after treatment. Our secondary objective is to describe the clinical characteristics and perform an analysis of the treatment impact on the functional status of this group of patients. Methods: We present our series of 19 patients treated with ionizing radiation therapy at our radio-neurosurgery unit between 2016 and 2022. The setting, ophthalmological follow-up, morbidity, and survival are analyzed and discussed. Results: Patients were followed up, and the impact of treatment on local disease control, visual alterations of the affected eye, and functional status of the patient were analyzed. The progression-free survival (PFS) median was 60 months (95% CI 50.3-69.6 months). The estimated PFS rates at 48 and 66 months were 100% and 66%, respectively. At diagnosis, nine (47.3%) eyes were in amaurosis and ten (52.6%) with vision. Of the ten patients without amaurosis at the time of diagnosis, three (30%) maintained unchanged visual acuity, and seven (70%) had decreased visual acuity; three of them developed amaurosis during the first year after treatment (p = 0.018). Conclusions: Using ionizing radiation therapy is a successful treatment for the local control of ONSMs. This therapeutic modality can compromise the visual acuity of the affected eye and improve dyschromatopsia and campimetry defects. The life prognosis is good for these patients, with a zero mortality rate, but their vision prognosis is poor.

The operational and financial impact of adding anaerobic screening of platelets.

BACKGROUND AND OBJECTIVES: We evaluated the operational and safety impact of implementing anaerobic culture screening of apheresis and pooled platelets at the American Red Cross on the already established use of the aerobic culture screening of each donation performed no sooner than 24 h following collection. MATERIALS AND METHODS: Platelets were screened for bacterial contamination with the BACT/ALERT 3D® (bioMérieux, Durham, NC) microbial detection testing system. The addition of anaerobic culture to the already existing aerobic culture resulted in sampling an additional 8-10 mL from each donation. RESULTS: Implementation of anaerobic testing resulted in an approximate 3.5-fold increased rate of False Positive BACT/ALERT alarms. There was a modest increase in the rate of True Positive alarms of 1.4-fold with increased detection of Klebsiella and Propionibacterium species, including Cutibacterium acnes. In addition, there was an approximate 3.5-fold increase rate of False Positives and a 13.5-fold increase rate of Indeterminates, the majority (~57%) were due to Cutibacterium acnes. The combined costs and lost revenue associated with adding anaerobic screening increased by ~$1,000,000/year due to testing cost and product discards. CONCLUSION: The addition of anaerobic culture to aerobic culture to the original donation (without the introduction of sampling delay) resulted in a significant increase in the rate of alerts. The 40% increased rate of True Positive alarms may have modestly improved platelet safety. However, there was a disproportionate increase in the rate of False Positive and Indeterminate bacterial culture alarms, which added substantial cost and overall loss of platelet products.

How do we use the National Healthcare Safety Network for Hemovigilance in Massachusetts?

BACKGROUND: Use of the National Healthcare Safety Network (NHSN) has been essential to the success of the Massachusetts Hemovigilance Program and has allowed for the timely identification of signals and trends over a defined population that correlate with national and international hemovigilance (HV) data. Here, we outline how the NHSN system is used for monitoring HV data in Massachusetts and encourage adoption of NHSN for nationwide HV surveillance. STUDY DESIGN AND METHODS: A collaboration that grew over time between local HV stakeholders and the Massachusetts Department of Public Health (MDPH) resulted in the change from a paper-based method of reporting adverse reactions and monthly transfusion activity for compliance with state requirements to replacement with statewide adoption of reporting via NHSN. RESULTS: Over 1.5 million blood products were transfused in Massachusetts between 2017 and 2021, with 3000 adverse reactions among 10 defined types reported. Using NHSN, MDPH has been able to produce numerous reports, publications, and presentations that have made previously non-obtainable HV and blood utilization data available. DISCUSSION: Although limitations to these self-reported data exist, such as lack of external validation, successful statewide implementation of NHSN for hospital blood bank reporting is possible and has benefits beyond those for regulatory oversight. It results in standardized, actionable data at both the hospital and state level, enabling inter-facility comparisons, benchmarking, and opportunities for practice improvement.

Características epidemiológicas y microbiológicas de los episodios de Neutropenia Febril (NF) en niños con cáncer en el Hospital del Niño - Dr. José Renán Esquivel (HNJRE)

Introducción: La neutropenia febril (NF) constituye una complicación frecuente, considerada una urgencia infectológica en los pacientes con cáncer que reciben tratamiento mielosupresor. Metodología: Se realizó un estudio retrospectivo descriptivo a través de la revisión de los expedientes de todos los episodios de NF secundarios a quimioterapia ingresados en el Hospital del Niño - Dr. José Renán Esquivel durante el periodo de enero a diciembre de 2017. Resultados: El estudio consistió en la evaluación de características epidemiológicas e identificación de agentes infecciosos en 49 casos de NF, y 104 eventos febriles. Se observó que el 51% de los casos eran varones, con una edad promedio de 7 años, y recuperación de NF en los primeros 7 días del 68%. La mayoría de las hospitalizaciones (53,8%) duraron de 1 a 7 días, con una relación directa con los días de fiebre y la presencia de neutropenia. La letalidad registrada fue de 6.1%. Los agentes etiológicos más frecuentes fueron la Pseudomonas aeruginosa, los Estafilococos coagulasa negativos y Staphylococcus aureus meticilino sensible. Conclusión: Los hallazgos permiten conocer la epidemiología actual de los pacientes con NF que se admiten al hospital, con el fin de optimizar el tratamiento para reducir la tasa de letalidad. (provisto por Infomedic International)

Introduction: Febrile neutropenia (NF) constitutes a frequent complication, considered an infectious emergency in cancer patients receiving myelosuppressive treatment. Methodology: A descriptive retrospective study was conducted by reviewing the records of all episodes of NF secondary to chemotherapy admitted to the Hospital del Niño - Dr. José Renán Esquivel during the period from January to December 2017. Results: The study consisted of the evaluation of epidemiological characteristics and identification of infectious agents in 49 cases of NF, and 104 febrile events. It was observed that 51% of the cases were male, with a mean age of 7 years, and recovery from NF in the first 7 days of 68%. Most hospitalizations (53.8%) lasted from 1 to 7 days, with a direct relationship with the number of days of fever and the presence of neutropenia. The case fatality rate was 6.1%. The most frequent etiological agents were Pseudomonas aeruginosa, coagulase-negative Staphylococci and methicillin-sensitive Staphylococcus aureus. Conclusion: The findings provide insight into the current epidemiology of patients with NF admitted to the hospital, in order to optimize treatment to reduce the case-fatality rate. (provided by Infomedic International)

Retinal Detachment Associated With Giant Retinal Tears: Surgical Management and Outcomes in the Past 2 Decades.

Purpose: To describe the surgical outcomes of rhegmatogenous retinal detachments (RRDs) associated with giant retinal tears (GRTs) and define factors associated with primary anatomic failure. Methods: This retrospective consecutive study comprised primary GRT-RRD surgeries between 1999 and 2021 at a single institution. Exclusion criteria were a follow-up of less than 3 months and incomplete surgical data. Results: The series included 69 eyes (64 patients). Single-surgery anatomic success (SSAS) was achieved in 75% and final anatomic success (FAS) in 90%. The mean logMAR visual acuity improved from 1.5 ± 1.1 to 0.6 ± 0.9. Preoperative factors significantly associated with redetachment were proliferative vitreoretinopathy (PVR) (odds ratio [OR], 6.2; P < .01), hypotony (OR, 13.6; P < .01), and a 180-degree or larger GRT (OR, 3.3; P = .04). All cases were treated with pars plana vitrectomy (PPV) and perfluoro-N-octane (PFCL). Perfluoropropane (C3F8) was used in 59% and silicone oil in 41%; the redetachment rate was significantly lower in gas cases (15% vs 39%) (P = .02). An encircling band, placed in 84% eyes, had a tendency to reduce redetachment (22% vs 36%) (P = .32). Lensectomy was performed in 61% of phakic eyes, with no effect on redetachment (20% vs 21%) (P = .92). On multivariate analysis, PVR and hypotony were significantly associated with redetachment. Conclusions: PPV with PFCL achieved high SSAS and FAS rates. PVR and hypotony were the main preoperative factors associated with anatomic failure. In cases without PVR, C3F8 tamponade significantly increased SSAS. Encircling scleral buckling showed a nonsignificant tendency toward an increase in SSAS. Lensectomy had no effect on SSAS.

Solution-Processed Polymer Dielectric Interlayer for Low-Voltage, Unipolar n-Type Organic Field-Effect Transistors.

The integration of organic electronic circuits into real-life applications compels the fulfillment of a range of requirements, among which the ideal operation at a low voltage with reduced power consumption is paramount. Moreover, these performance factors should be achieved via solution-based fabrication schemes in order to comply with the promise of cost- and energy-efficient manufacturing offered by an organic, printed electronic technology. Here, we propose a solution-based route for the fabrication of low-voltage organic transistors, encompassing ideal device operation at voltages below 5 V and exhibiting n-type unipolarization. This process is widely applicable to a variety of semiconducting and dielectric materials. We achieved this through the use of a photo-cross-linked, low-k dielectric interlayer, which is used to fabricate multilayer dielectric stacks with areal capacitances of up to 40 nF/cm2 and leakage currents below 1 nA/cm2. Because of the chosen azide-based cross-linker, the dielectric promotes n-type unipolarization of the transistors and demonstrated to be compatible with different classes of semiconductors, from conjugated polymers to carbon nanotubes and low-temperature metal oxides. Our results demonstrate a general applicability of our unipolarizing dielectric, facilitating the implementation of complementary circuitry of emerging technologies with reduced power consumption.

Frequency of functional esophageal disorders in patients with refractory reflux symptoms in Lima, Peru.

Gastroesophageal reflux disease (GERD) is a clinical condition in which gastric reflux causes symptoms or damage to the esophageal mucosa. It is managed with proton pump inhibitors, however, up to 45% of patients with suspected GERD are refractory to treatment. It is necessary to establish a true GERD diagnosis by means of a digestive endoscopy, which does not show lesions in approximately 70% of patients. In this scenario, it is necessary to perform an esophageal pH-impedance measurement, a procedure that allows to determine whether exposure to gastric acid is pathological. Of this group, patients with pathological acid exposure are diagnosed as true non-erosive reflux disease (NERD). If, in addition to not presenting esophageal lesions, they have a physiological exposure to gastric acid, they suffer from esophageal hypersensitivity or functional heartburn, which are functional disorders. These require a different approach from that of GERD or NERD, as the symptoms are not due to pathological exposure to gastric acid. The aim was to calculate the frequency of esophageal hypersensitivity and functional heartburn in patients with suspected NERD. This was a cross-sectional study. Data was collected by reviewing pH-impedance and manometry reports, 166 patients were selected. The frequency for functional disorders was 86.15%, being 46.9% for functional heartburn and 39.2% for esophageal hypersensitivity. The frequency of functional disorders was higher than that reported in previous studies. In conclusion, age, psychological conditions, dietary, cultural, ethnic or lifestyle factors inherent to our environment might play important roles in the development of functional disorders.

[Generation of a predictive test for the diagnosis of the etiology of variceal upper gastrointestinal bleeding]. / Generación de un test predictivo para el diagnóstico de la etiología de la hemorragia digestiva alta variceal.

Our objective was to develop a diagnostic test to predict the etiology of Variceal Upper Gastrointestinal Bleeding (VUGIB). We conducted a retrospective cohort study. Medical records of patients over 18 years of age with Upper Gastrointestinal Bleeding (UGIB) who attended the emergency service of Hospital Cayetano Heredia (HCH) in Lima-Peru between 2019 and 2022 were reviewed; demographic, laboratory and clinical data were collected. Subsequently, predictive variables of variceal upper gastrointestinal bleeding (VUGIB) were identified using multiple logistic regression. Each variable with predictive capacity was assigned a score with a cut-off point and served to build a predictive scale for VUGIB. 197 medical records of patients with UGIB were included, of which 127 (64%) had non-variceal bleeding, and 70 (36%), variceal. Four independent predictors were identified: hematemesis (red vomit) (OR: 4,192, 95% CI: 1.586-11.082), platelet count (OR: 3.786, 95% CI: 1.324-10.826), history of UGIB (OR: 2.634, 95% CI: 1.017-6.820), signs of chronic liver disease (OR: 11.244, 95% CI: 3.067-35.047), with which a predictive scale was constructed, with a cut-off point >7 and ≤7; which showed a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative of 58.6%, 90.6%, 77.4%, 79.9%, 6.20, and 0.46 respectively. In conclusion, the predictive scale with a cut-off point >7 is useful for predicting the presence of VUGIB in patients who attend the emergency room for UGIB.

How do I manage a blood product shortage?

BACKGROUND: The demand for blood products sometimes exceeds the available inventory. Blood product inventories are dependent upon the availability of donors, supplies and reagents, and collection staff. During prolonged extreme shortages, blood centers and transfusion services must alter practices to meet the needs of patients. STUDY DESIGN AND METHODS: The Association for the Advancement of Blood and Biotherapies Donor and Blood Component Management Subsection compiled some strategies from its blood center and hospital transfusion service members that could be implemented during blood product shortages. RESULTS: Some strategies that blood centers could use to increase their available inventories include increasing donor recruitment efforts, using alternate types of collection kits, manufacturing low-yield apheresis-derived platelets and/or whole blood-derived platelets, using cold-stored platelets, transferring inventory internally among centers of the same enterprise, using frozen inventory, decreasing standing order quantities, prioritizing allocation to certain patient populations, filling partial orders, and educating customers and blood center staff. Transfusion service strategies that could be implemented to maximize the use of the limited available inventory include increasing patient blood management efforts, using split units, finding alternate blood suppliers, trading blood products with other hospital transfusion services, developing a patient priority list, assembling a hospital committee to decide on triaging priorities, using expired products in extreme situations, and accepting nonconforming products after performing safety checks. DISCUSSION: Blood centers and transfusion services must choose the appropriate strategies to implement based on their needs.

Advantages of Intraoperative Neuromonitoring Over Direct Visualization of the Recurrent Laryngeal Nerve During Thyroidectomy.

BACKGROUND: The well-recognized risk of injury to the recurrent laryngeal nerve (RLN) during thyroidectomy has instigated various preventive measures. One such measure involves directly visualizing the RLN, but this is not always feasible in practice. A more recent approach involves using intraoperative neuromonitoring to identify and preserve the RLN. This study aims to evaluate the effectiveness of intraoperative neuromonitoring compared to single visualization of the RLN in averting nerve injury. METHODS: We conducted a retrospective, observational, and descriptive study on a cohort of 218 patients. A Chi-square test was employed to determine the influence of intraoperative neuromonitoring on the incidence of nerve injury, with P < 0.05 considered statistically significant. We used Jamovi software version 2.3.18 to analyze the data. RESULTS: Of the 218 patients, intraoperative neuromonitoring was used in 150 (68.8%) cases; none of which resulted in nerve injury. Conversely, 68 (31.2%) patients underwent surgery without the use of neuromonitoring, with two (2.9%) patients in this group experiencing nerve injury (p=0.037). In comparison, the risk of nerve injury was 0% in the group monitored intraoperatively and 2.94% in the group that did not undergo intraoperatively neuromonitoring. Further, the relative risk of complications was 0.66% in patients operated with neuromonitoring, while it was 5.88% in the group operated without neuromonitoring, thus demonstrating a clinically significant protective against vasculonervous complications. CONCLUSION: The results advocate for the use of intraoperative neuromonitoring, whenever available, as it is a safe method for significantly decreasing the incidence of RLN injury during thyroidectomy compared with only visualization.

Effects and Assessment of the Optic Pathway After Management with Stereotactic Radiosurgery for Intracranial Tumors: A Comprehensive Literature Review.

Intracranial tumors are treated through a minimally invasive procedure called stereotactic radiosurgery (SRS), which uses precisely targeted radiation beams. When SRS is used to treat tumors in or near the optic pathway, which is responsible for transmitting visual information from the eyes to the brain, it is essential to assess the effects of treatment on visual function. The optic pathway is considered relatively radiation-sensitive, and high doses of radiation can lead to visual impairment or loss. Various methods can be used to assess the effects of SRS on the optic pathway, including visual acuity testing, visual field testing, and imaging studies. These assessments can be performed before and after treatment to track changes in visual function and detect potential complications or side effects. Assessing the optic pathway after management with SRS for intracranial tumors is essential to the treatment process to ensure that patients receive the best possible outcomes while minimizing the risk of complications. Close collaboration between the multidisciplinary team is often necessary to optimize treatment planning and monitoring of treatment response. In this review, we conducted an extensive analysis of the effects of radiation in patients with intracranial tumors after receiving radiotherapy.

Generación de un test predictivo para el diagnóstico de laetiología de la hemorragia digestiva alta variceal

Nuestro objetivo fue desarrollar un test diagnóstico para predecir la etiología de la Hemorragia Digestiva Alta Variceal (HDAV). Realizamos un estudio de cohorte retrospectivo. Se revisaron historias clínicas de pacientes mayores de 18 años con Hemorragia Digestiva Alta (HDA) que acudieron al servicio de emergencia del Hospital Cayetano Heredia (HCH) de Lima-Perú entre el 2019 a 2022, se recolectaron datos demográficos, de laboratorio y clínicos; posteriormente, se identificaron variables predictivas de HDAV mediante una regresión logística múltiple. A cada variable con capacidad predictiva se les asignó un puntaje con un punto de corte y sirvió para construir una escala predictiva de HDAV. Se incluyeron 197 historias clínicas de pacientes con HDA, de los cuales 127 (64%) tuvieron sangrado de causa no variceal, y, 70 (36%), variceal. Se identificaron 4 factores predictivos independientes: hematemesis (vómito rojo) (OR: 4,192, IC 95%: 1,586-11,082), recuento de plaquetas (OR: 3,786, IC 95%: 1,324-10,826), antecedente de HDA (OR: 2,634, IC 95%: 1,017-6,820), signos de enfermedad hepática crónica (OR: 11,244, IC 95%: 3,067-35,047), con los que se construyó una escala predictiva, con un punto de corte >7 y ≤7; que mostró una sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo, cociente de probabilidad positivo, y, negativo de 58,6%, 90,6%, 77,4%, 79,9%, 6,20, y 0,46 respectivamente. En conclusión, la escala predictiva con un punto de corte >7 es útil para predecir la presencia de la HDAV en pacientes que acuden a la emergencia por HDA.

Our objective was to develop a diagnostic test to predict the etiology of Variceal Upper Gastrointestinal Bleeding (VUGIB). We conducted a retrospective cohort study. Medical records of patients over 18 years of age with Upper Gastrointestinal Bleeding (UGIB) who attended the emergency service of Hospital Cayetano Heredia (HCH) in Lima-Peru between 2019 and 2022 were reviewed; demographic, laboratory and clinical data were collected. Subsequently, predictive variables of variceal upper gastrointestinal bleeding (VUGIB) were identified using multiple logistic regression. Each variable with predictive capacity was assigned a score with a cut-off point and served to build a predictive scale for VUGIB. 197 medical records of patients with UGIB were included, of which 127 (64%) had non-variceal bleeding, and 70 (36%), variceal. Four independent predictors were identified: hematemesis (red vomit) (OR: 4,192, 95% CI: 1.586-11.082), platelet count (OR: 3.786, 95% CI: 1.324-10.826), history of UGIB (OR: 2.634, 95% CI: 1.017-6.820), signs of chronic liver disease (OR: 11.244, 95% CI: 3.067-35.047), with which a predictive scale was constructed, with a cut-off point >7 and ≤7; which showed a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative of 58.6%, 90.6%, 77.4%, 79.9%, 6.20, and 0.46 respectively. In conclusion, the predictive scale with a cut-off point >7 is useful for predicting the presence of VUGIB in patients who attend the emergency room for UGIB.

Frequency of functional esophageal disorders in patients with refractory reflux symptoms in Lima, Peru

Gastroesophageal reflux disease (GERD) is a clinical condition in which gastric reflux causes symptoms or damage to the esophageal mucosa. It is managed with proton pump inhibitors, however, up to 45% of patients with suspected GERD are refractory to treatment. It is necessary to establish a true GERD diagnosis by means of a digestive endoscopy, which does not show lesions in approximately 70% of patients. In this scenario, it is necessary to perform an esophageal pH-impedance measurement, a procedure that allows to determine whether exposure to gastric acid is pathological. Of this group, patients with pathological acid exposure are diagnosed as true non-erosive reflux disease (NERD). If, in addition to not presenting esophageal lesions, they have a physiological exposure to gastric acid, they suffer from esophageal hypersensitivity or functional heartburn, which are functional disorders. These require a different approach from that of GERD or NERD, as the symptoms are not due to pathological exposure to gastric acid. The aim was to calculate the frequency of esophageal hypersensitivity and functional heartburn in patients with suspected NERD. This was a cross-sectional study. Data was collected by reviewing pH-impedance and manometry reports, 166 patients were selected. The frequency for functional disorders was 86.15%, being 46.9% for functional heartburn and 39.2% for esophageal hypersensitivity. The frequency of functional disorders was higher than that reported in previous studies. In conclusion, age, psychological conditions, dietary, cultural, ethnic or lifestyle factors inherent to our environment might play important roles in the development of functional disorders.

La enfermedad por reflujo gastroesofágico (ERGE) es una condición clínica en la que el reflujo gástrico provoca síntomas o daños en la mucosa esofágica. Se maneja con inhibidores de la bomba de protones; sin embargo, hasta el 45% de los pacientes con sospecha de ERGE son refractarios al tratamiento. Por lo cual, es necesario establecer un verdadero diagnóstico de ERGE mediante una endoscopia digestiva, que no muestra lesiones en aproximadamente el 70% de los pacientes. En este escenario, es necesario realizar una medición de pH-impedancia esofágica, procedimiento que permite determinar si la exposición al ácido gástrico es patológica. De este grupo, los pacientes con exposición patológica al ácido son diagnosticados como verdadera enfermedad por reflujo no erosiva (ERNE). Si además de no presentar lesiones esofágicas, tienen una exposición fisiológica al ácido gástrico, padecen hipersensibilidad esofágica o pirosis funcional, que son trastornos funcionales. Estos requieren un enfoque diferente al ERGE o ERNE, ya que los síntomas no se deben a una exposición patológica al ácido gástrico. El objetivo fue calcular la frecuencia de hipersensibilidad esofágica y pirosis funcional en pacientes con sospecha de ERNE. Este fue un estudio transversal. Los datos se recopilaron mediante la revisión de informes de pH-impedancia y manometría, se seleccionaron 166 pacientes. La frecuencia de trastornos funcionales fue de 86,15%, siendo 46,9% de pirosis funcional y 39,2% de hipersensibilidad esofágica. La frecuencia de trastornos funcionales fue superior a la reportada en estudios previos. En conclusión, la edad, las condiciones psicológicas, los factores dietéticos, culturales, étnicos o de estilo de vida inherentes a nuestro entorno podrían jugar un papel importante en el desarrollo de trastornos funcionales.

Nelson's Syndrome: A Narrative Review.

Nelson's syndrome (NS) is an uncommon disease occurring as a complication of bilateral adrenalectomy (BLA) in patients with persistent Cushing's disease (CD) due to an adrenocorticotropin-producing pituitary tumor. The first reports of this syndrome were done in the 50s, although its pathophysiology is still not understood. Every year, between 1.8 and 2.6 cases are thought to occur per million people. It is characterized by hyperpigmentation, elevated adrenocorticotropic hormone (ACTH) plasma levels, and typical signs and symptoms related to pituitary adenomas, such as visual deficits due to optic pathway compression or decreased hormone production from the adenohypophysis. NS represents a challenge due to the lack of accepted diagnostic criteria and the complexity of its treatment. Moreover, the development of stereotactic radiosurgery (SRS) in the last few years has become an essential but controversial strategy for this syndrome. This review presents a comprehensive overview of NS.

The Role of an Exoskeleton Simulation of Senescence in Health Sciences Education.

Background: Education in the formation of human capital in health constantly presents challenges. New tools in the emerging contexts may strengthen empathic attitudes. We developed an educational intervention that included a senescence simulator and assessed its impact on perception and attitudes in healthcare students. Methods: A cross-sectional comparative study was conducted that assessed acquired knowledge and self-perception using a semistructured survey administered before and after the demonstration and intervention using the simulator and reported the experience through the role of the patient and caregiver. The data were analyzed statistically to identify the demographic characteristics and differences between the groups of students. The data were analyzed statistically to identify the demographic characteristics and differences between the groups of students in the responses pre-post intervention, using statistical software (IBM SPSS Statistics 26.0). Results: Of the 256 participants surveyed before the intervention, 93.8% described cognitive deterioration as a significant disability and 53.1% considered the health system to be inadequate in meeting the needs of older individuals. Only 59.8% stated that the current academic training meets the educational requirements for the care of the elderly. In total, 98.9% of the participants reported that the simulator changed their perception by increasing their empathy. In total, 76.2% showed greater sensitivity to older adults and 79.3% reported that the experiential learning consolidated their professionalizing perspective. Among the younger participants (aged 18-20 years), sensitivity and reorientation toward pursuing an associated graduate degree were higher after the intervention (p=0.01). Conclusions: Educational strategies, such as the senescence simulator, offer an experiential intervention that strengthens the knowledge and attitudes toward older individuals. During the pandemic emergency, it proved to be a useful educational strategy in consolidating caring behavior as a hybrid educational tactic. The senescence simulation enabled the participants to widen their educational and professional schemes to encompass the care of the older population.

A new surgical technique for sutureless partial nephrectomy: renal sutureless device.

BACKGROUND: Several factors impact the preservation of renal function after partial nephrectomy. Warm ischemia time is the main modifiable surgical factor. Renorrhaphy represents the key of hemostasia, but it is associated with increase of warm ischemia time and complications. The aim of this study was to describe our initial surgical experience with a new surgical technique for sutureless partial nephrectomy, based on the application of our own developed renal-sutureless-device-RSD. METHODS: Between 2020-2021, 10 patients diagnosed with renal cell carcinoma stage cT1a-b cN0M0 with an exophytic component were operated using renal-sutureless-device-RSD. Surgical technique of sutureless partial nephrectomy with renal-sutureless-device-RSD is described in a step-by-step fashion. Clinical data was collected in a dedicated database. Presurgical, intraoperative, postoperative variables, pathology and functional results were evaluated. Medians and ranges of values for selected variables were reported as descriptive statistics. RESULTS: Partial nephrectomy was carried out with the use of renal-sutureless-device-RSD without renorrhaphy in all cases (70%cT1a-30%cT1b). Median tumor size was 3.15 cm (IQR: 2.5-4.5). R.E.N.A.L Score had a range between 4a-10. Median surgical time was 97.5 minutes (IQR 75-105). Renal artery clamping was only required in 4 cases, with a median warm ischemia time of 12.5 minutes (IQR 10-15). No blood transfusion, intraoperative and postoperative complications were noted. Free-of-disease margin rate achieved was 90%. Median length of stay was 2 days (IQR 2-2). Laboratory data on hemoglobin and hematocrit levels, as well as renal function tests, remained stable after partial nephrectomy. CONCLUSIONS: Our initial experience suggests that a sutureless PN using the RSD device is feasible and safe. Further investigation is needed to determine the clinical benefit of this technique.

Pigmentation abnormalities in Coffin-Siris syndrome.

Pigmentary abnormalities in Coffin-Siris Syndrome should be considered as part of the wide phenotypical spectrum of this patients.

Does Time and Size Matter in Retrograde Intrarenal Surgery? Results Analysis Using a Low-Pressure Technique.

PURPOSE: Kidney stone disease affects 5% of the population and is associated with non-negligible morbidity. Retrograde intrarenal surgery and percutaneous nephrolithotomy are the treatments of choice. We analyzed the results from our patients who underwent retrograde intrarenal surgery at controlled pressure. MATERIALS AND METHODS: We conducted an observational, descriptive, retrospective study of 403 patients who underwent retrograde intrarenal surgery at the Hospital Clínico Universitario Lozano Blesa (Zaragoza, Spain) between January 2013 and December 2019. RESULTS: The mean surgical time was 111.1 minutes, with a mean stone volume of 3.5 cm3 (maximum volume, 38.3 cm3). A total of 70 patients (17.3%) developed postoperative Clavien-Dindo complications-64 minor (91.4%) and 6 major (8.6%). In addition, 28 patients (6.9%) presented with an early complication (<3 months), with urinary tract infection and pyelonephritis being the most common. The stone-free rate was 69.0%, with a retreatment rate of 4.7%. CONCLUSIONS: Sex was statistically significantly related to the onset of minor Clavien postoperative complications (p = 0.001). Similarly, corticosteroid use was associated with the onset of major Clavien complications (p = 0.030). Neither surgical time nor stone volume was found to be statistically significantly related to the onset of Clavien postoperative complications or early complications.