Risk factors for gastroesophageal reflux after POEM for achalasia: a systematic review and meta-analysis.

INTRODUCTION: Peroral endoscopic myotomy (POEM) demonstrated similar efficacy to surgical myotomy in the management of achalasia. However, gastroesophageal reflux disease (GERD) is common after POEM. The aim of this study is to identify factors associated with GERD after POEM. METHOD: After searching electronic databases, randomized trials and observational studies including patients with achalasia or other spastic esophageal disorders, treated by POEM, and providing GERD data were selected. GERD was evaluated by 3 methods: pH monitoring, endoscopic findings, and symptoms. For each method, an analysis was performed comparing the outcomes related to the following independent variables: full-thickness (FT) vs circular myotomy, anterior vs posterior, long myotomy vs short myotomy, naive vs previous treatment failure, previous Heller myotomy (HM) vs non-previous-HM, Type I vs II, Type I vs III, and Type II vs III. RESULTS: 2869 publications were identified, and 25 studies met criteria for inclusion in the qualitative analysis. Of these, 18 were included in the meta-analysis. According to the endoscopic findings, circular and anterior myotomy demonstrated a lower trend of GERD with borderline significance (p = 0.06; p = 0.07, respectively). In the pH monitoring and symptom analyses, circular myotomy, anterior myotomy, treatment naive, and non-HM patients were associated with a lower occurrence of GERD; however, no statistically significant difference was found. When comparing achalasia subtypes, no statistical difference was found in all analyses. CONCLUSION: This systematic review and meta-analysis suggest that a circular anterior approach may limit post-POEM GERD and should be considered in appropriate patients.

Uterine compression sutures for postpartum hemorrhage: is routine postoperative cavity evaluation needed?

Postpartum hemorrhage due to uterine atony continues to be one of the major causes of maternal morbidity and mortality. Several uterine compression suture techniques have been described and are increasingly being used worldwide as a conservative approach. However, little is known about the long-term effects on the uterine cavity, as well as fertility and pregnancy outcomes. We reviewed the reported complications and uterine findings after the use of compression sutures, both in examinations to evaluate the cavity (hysteroscopy, hysterosalpingography or sonohysterography) and at cesarean section, in order to assess the possible usefulness of routine postoperative cavity evaluation. Overall, the use of uterine compression sutures is effective and safe; however, some severe and potentially life-threatening complications have been reported and could possibly have been prevented if uterine cavity evaluation had been performed. Routine follow-up, both by hysteroscopy and an imaging technique, seems worthwhile.

Multidrug-resistant bacteria as intestinal colonizers and evolution of intestinal colonization in healthy university students in Portugal.

Multidrug-resistant bacteria have been increasingly described in healthcare institutions, however community resistance also seems to be emerging. Escherichia coli an intestinal commensal bacteria, is also a pathogen and represents an important intestinal reservoir of resistance. Our aim was the study of the intestinal colonization and of the persistence of antibiotic resistant intestinal bacteria in healthy university students of Porto, in the north of Portugal. Samples from 30 university students were collected and analysed. Two E. coli isolates were randomly obtained from each student and Gram-negative bacilli resistant to antibiotics were studied. In addition, we evaluated changes in the Gram-negative intestinal colonization of ten university students in a short period of time. Molecular characterization showed a high presence of bla TEM in commensal E. coli . Gram-negative bacteria with intrinsic and extrinsic resistance were isolated, namely Pseudomonas spp., Enterobacter spp. and Pantoea spp. We isolated three ESBL-producing E. coli from two students. These isolates showed bla CTX-M group 1 (n=1), bla CTX-M group 9 (n=2), bla TEM (n=2), bla SHV (n=1) and tetA (n=2) genes. Additionally, they showed specific virulence factors and conjugational transfer of antibiotic resistance and virulence genes. One Pseudomonas spp. isolate resistant to carbapenems was detected colonizing one student. Our results confirm that healthy young adults may be colonized with commensals showing clinically relevant antibiotic resistance mechanisms, creating a risk of silent spread of these bacteria in the community.

Skin adhesive versus subcuticular suture for perineal skin repair after episiotomy--a randomized controlled trial.

OBJECTIVE: Surgical repair of perineal lesions after delivery is frequently associated with pain and discomfort, interfering with the normal activities of the puerperium. The aim of this study was to compare perineal skin repair after episiotomy with adhesive glue versus a subcuticular suture, regarding the incidence of pain and wound complications. STUDY DESIGN: Randomized clinical trial. SETTING: Tertiary care university hospital. MATERIAL AND METHODS: One hundred women having mediolateral episiotomy at vaginal delivery were enrolled. They were randomized to receive skin adhesive (n = 53) or subcuticular suture (n = 47) for closure of perineal skin. The main outcome measure was self-evaluated pain in the 30 days following delivery. Secondary outcome measures were technical difficulties reported with the procedure, duration of surgical repair, wound complications observed at 42-68 hours post-partum and re-initiation of sexual activity by 30 days post-partum. RESULTS: No significant differences were observed between the two groups in incidence of technical difficulties and failed procedures, pain during the procedure, wound complications at hospital discharge, self-evaluated measures of pain at 7 and 30 days or re-initiation of sexual activity by 30 days post-partum. The skin adhesive group had a significantly shorter mean duration of the procedure (four minutes less). CONCLUSION: Perineal skin closure using adhesive glue is faster than subcuticular suture, and associated with a similar incidence of complications and pain in the first 30 days.

A identificação segura como etapa do cuidado de qualidade: indicadores em uma maternidade nordestina / Safe identification as a stage of quality care: indicators in a northeastern maternity hospital / La identificación salvaguardia como una etapa de cuidado de calidad: indicadores en maternidad nortética

Estudo objetivou analisar a adesão ao protocolo de identificação segura, por meio do uso de pulseiras padronizadas, em uma maternidade-escola nordestina. Pesquisa retrospectiva, descritiva e transversal, de abordagem quantitativa, com dados relativos aos anos de 2018 a 2021. Foram realizadas 7115 verificações de presença de pulseira, sendo consideradas válidas apenas aquelas com dados do paciente corretos e legíveis. Observou- se que, em todo o período a proporção de pacientes com pulseiras padronizadas foi de 91,1%, sendo 2018 o ano com a maior taxa e 2019 a menor, com 94,1% e 88%, respectivamente. Verificou-se ainda que paciente neonatos tem taxa maior que pacientes adultas, sendo 93,1% e 89,1%, respectivamente em todos o período. Visto que ao longo dos anos essas taxas oscilam, a instituição deve sempre reforçar a adesão ao uso das pulseiras de identificação levando em consideração a checagem dos dados, legibilidade, localização e estado da pulseira antes de todo cuidado prestado ao paciente.

Study aimed to analyze adherence to the protocol of safe identification, through the use of standardized bracelets, in a northeastern maternity school. Retrospective, descriptive and cross-sectional research, with data for the years 2018 to 2021. 7115 bracelet presence checks were performed, and only those with correct and readable patient data were considered valid. It was observed that, throughout the period, the proportion of patients with standardized bracelets was 91.1%, with 2018 being the year with the highest rate and 2019 the lowest, with 94.1% and 88%, respectively. It was also found that neonatal patients have a higher rate than adult patients, being 93.1% and 89.1%, respectively, in all the period. Since over the years these rates oscillate, the institution must always reinforce adherence to the use of the identification bracelets taking into consideration the data check, readability, location and condition of the bracelet before all care given to the patient.

objetivo del estudio de analizar la adhesión al protocolo para la identificación segura, mediante el uso de brazaletes estandarizados, en una escuela de maternidad en el noreste. enfoque retrospectivo, descriptivo e intersectorial con datos para los años 2018 a 2021. Se realizaron 7115 controles de presencia de pulsera y sólo se consideraron válidos aquellos con datos correctos y legibles del paciente. Se observó que a lo largo del período la proporción de pacientes con pulsera estándar fue del 91,1%, siendo 2018 el año con mayor tasa y 2019 el más bajo, con 94,1% y 88% respectivamente. También se verificó que los pacientes neonatos tienen una tasa más alta que los adultos, de los cuales el 93,1% y el 89,1%, respectivamente, durante todo el período. Dado que estas tasas han fluctuado a lo largo de los años, la institución debe reforzar siempre su adhesión al uso de bandas de identificación, teniendo en cuenta el control de los datos, la legibilidad, la localización y el estado de la pulsera antes de toda la atención que se le preste.

Dual exposure to smoking and household air pollution is associated with an increased risk of severe asthma in adults in Brazil.

BACKGROUND: The relationship between smoking, household pollution, dual exposure and severity of asthma in adults has not been sufficiently studied. We examined and compared the effects of cigarette smoking, domestic wood burning pollution and dual exposure (tobacco and wood burning) upon asthma severity in adults. METHODS: This was a cross-sectional study performed with 452 individuals with mild to moderate asthma and 544 patients with severe asthma (previously untreated). Smoking and exposure to wood smoke were identified and quantified through questionnaires to evaluate current and/or previous exposure; objective determination of cigarette exposure was obtained through the measurement of urinary cotinine. Asthma control was evaluated through Asthma Control Questionnaire; and severity was classified according to the Global Initiative for Asthma criteria. Subjects were grouped according to exposure type into 4 groups: smokers, household pollution, dual-exposure and no-exposure. Chi square, Mann-Whitney, and Kruskal-Wallis tests were used for comparisons between groups. RESULTS: Out of 996 included individuals, 78 (7.8%) were exposed to cigarette smoking alone, 358 (35.9%) to household pollution alone, 155 (15.6%) to the two exposures combined and 405 (40.7%) were not exposed. Compared to unexposed individuals, exposure to household pollution resulted in poorer asthma control, higher proportion of severe asthma, and worse indicators of lung function. The double-exposed individuals were worse off in all the evaluated parameters, and they were significantly worse than subjects with single exposure to household air pollution in relation to asthma severity and lung function. These subjects were predominantly females, older, with longer residence time in rural areas, lower income and lower schooling levels. Multivariate analysis showed that exposure to household pollution and double exposure were predictive factors associated with lack of control and increased severity of asthma. CONCLUSIONS: Exposure to household pollution is associated with poorer control, greater severity, and poorer pulmonary function; double-exposed individuals have a greater risk of severe asthma and decreased lung function than those exposed only to household pollution.

Self-reported smoking status and urinary cotinine levels in patients with asthma.

OBJECTIVE: To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement. METHODS: This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test. RESULTS: Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma. CONCLUSIONS: Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.

Investigation and Management of Adnexal Masses in Pregnancy.

Adnexal masses can be found in 0.19 to 8.8% of all pregnancies. Most masses are functional and asymptomatic and up to 70% resolve spontaneously in the second trimester. The main predictors of persistence are the size (>5 cm) and the imagiological morphocomplexity. Those that persist carry a low risk of malignancy (0 to 10%). Most malignant masses are diagnosed at early stages and more than 50% are borderline epithelial neoplasms. Ultrasound is the preferred method to stratify the risk of complications and malignancy, allowing medical approach planning. Pregnancy and some gestational disorders may modify the levels of tumor markers, whereby their interpretation during pregnancy should be cautious. Large masses are at increased risk of torsion, rupture, and dystocia. When surgery is indicated, laparoscopy is a safe technique and should ideally be carried out in the second trimester of pregnancy.

Biofilm Formation on Different Materials Used in Oral Rehabilitation.

The aim of this study was to evaluate the density and the morphological aspects of biofilms adhered to different materials applied in oral rehabilitation supported by dental implants. Sixty samples were divided into four groups: feldspar-based porcelain, CoCr alloy, commercially pure titanium grade IV and yttria-stabilized zirconia. Human saliva was diluted into BHI supplemented with sucrose to grow biofilms for 24 or 48 h. After this period, biofilm was removed by 1% protease treatment and then analyzed by spectrophotometry (absorbance), colony forming unit method (CFU.cm-2) and field-emission guns scanning electron microscopy (FEG-SEM). The highest values of absorbance and CFU.cm-2 were recorded on biofilms grown on CoCr alloys when compared to the other test materials for 24 or 48 h. Also, FEG-SEM images showed a high biofilm density on CoCr. There were no significant differences in absorbance and CFU.cm-2 between biofilms grown on zirconia, porcelain and titanium (p<0.05). Microbiological assays associated with microscopic analyses detected a higher accumulation of oral biofilms on CoCr-based materials than that on titanium or zirconia that are used for prosthetic structures.

Bleomycin sclerotherapy for severe symptomatic and persistent pelvic lymphocele.

Background. Pelvic lymphoceles are frequently described as a complication of pelvic lymphadenectomy performed for surgical staging of gynaecologic malignancies. Case Report. A 72-year-old woman presented with severe symptomatic and refractory lymphocele associated with persistent lower limb lymphedema and recurrent erysipelas. After four CT fluoroscopy scan guided percutaneous catheter drainages, the lymphocele complicated with infection finally resolved with two sessions of bleomycin sclerotherapy. Conclusion. Symptomatic persistent lymphoceles require treatment and nowadays the first option is interventional radiologic procedures. Bleomycin is a safe and effective sclerosing agent and therefore should be regarded as a first-line treatment choice.

Self-reported smoking status and urinary cotinine levels in patients with asthma / Tabagismo entre asmáticos: avaliação por autorrelato e dosagem de cotinina urinária

ABSTRACT Objective: To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement. Methods: This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test. Results: Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma. Conclusions: Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.

RESUMO Objetivo: Descrever a frequência de tabagismo ativo entre pacientes com asma e indivíduos sem asma, usando questionários padronizados e dosagem da cotinina urinária. Métodos: Estudo transversal realizado em Salvador (BA), com 1.341 indivíduos, sendo 498 com asma grave, 417 com asma leve/moderada e 426 sem asma. O tabagismo foi identificado por meio de autorrelato utilizando questionários e por mensuração da cotinina urinária. Para a comparação das variáveis estudadas, utilizaram-se os testes do qui-quadrado e de Kruskal-Wallis. Resultados: Dos 55 participantes (4,1%) que se declararam tabagistas atuais, 5, 17 e 33 eram dos grupos asma grave, asma leve/moderada e sem asma, respectivamente. Desses 55, 32 (58,2%) eram tabagistas diários e 23 (41,8%) eram tabagistas ocasionais. Observaram-se níveis elevados de cotinina urinária entre não fumantes autodeclarados e tabagistas pregressos, especialmente no grupo asma grave, o que sugere omissão do hábito atual de fumar. A carga tabágica entre os fumantes e a proporção de ex-tabagistas foram maiores no grupo asma grave do que no grupo asma leve/moderada. Conclusões: O tabagismo pregresso esteve associado à asma grave. Tabagismo atual também foi observado em alguns pacientes com asma grave e detectou-se omissão em alguns casos. A investigação de tabagismo deve ser meticulosa em pacientes com asma grave e a entrevista desses deve ser complementada por uma avaliação objetiva.

Biofilm Formation on Different Materials Used in Oral Rehabilitation

Abstract The aim of this study was to evaluate the density and the morphological aspects of biofilms adhered to different materials applied in oral rehabilitation supported by dental implants. Sixty samples were divided into four groups: feldspar-based porcelain, CoCr alloy, commercially pure titanium grade IV and yttria-stabilized zirconia. Human saliva was diluted into BHI supplemented with sucrose to grow biofilms for 24 or 48 h. After this period, biofilm was removed by 1% protease treatment and then analyzed by spectrophotometry (absorbance), colony forming unit method (CFU.cm-2) and field-emission guns scanning electron microscopy (FEG-SEM). The highest values of absorbance and CFU.cm-2 were recorded on biofilms grown on CoCr alloys when compared to the other test materials for 24 or 48 h. Also, FEG-SEM images showed a high biofilm density on CoCr. There were no significant differences in absorbance and CFU.cm-2 between biofilms grown on zirconia, porcelain and titanium (p<0.05). Microbiological assays associated with microscopic analyses detected a higher accumulation of oral biofilms on CoCr-based materials than that on titanium or zirconia that are used for prosthetic structures.

Resumo O objetivo deste estudo foi avaliar a densidade e os aspectos morfológicos dos biofilmes aderidos a diferentes materiais aplicados em reabilitação oral sobre implantes dentários. Sessenta amostras foram divididas em quatro grupos: porcelana à base de feldspato, liga de CoCr, titânio grau IV comercialmente puro e zircônia estabilizada com ítrio. Saliva humana diluída em BHI foi suplementada com sacarose para possibilitar a formação de biofilme por 24 e 48 h. Após este período, o biofilme foi removido utilizando protease a 1% e, em seguida, analisada por espectrofotometria (absorbância), unidades formadoras de colônia (CFU.cm-2) e microscopia eletrônica de varredura (MEV). Os valores mais elevados de absorbância e CFU.cm-2 foram encontrados em ligas de CoCr quando comparado com os outros materiais testados. Os resultados obtidos foram semelhantes nos biofilmes formados sobre titânio e zircônia durante 24 e 48 h (p<0,05). As análises microbiológicas e microscópicas demostraram uma maior tendência ao acúmulo de biofilmes orais sobre estruturas protéticas baseadas em CoCr quando comparadas com porcelana feldspática, titânio ou zircônia.

Evolving indications for the EXIT procedure: the usefulness of combining ultrasound and fetal MRI.

The EXIT procedure (EX utero Intrapartum Treatment) encompasses a multidisciplinary approach to situations in which airway obstruction is anticipated. Uteroplacental circulation is maintained to avoid neonatal hypoxemia while intubation is attempted. Not only is it useful in congenital diaphragmatic hernia with intrauterine tracheal occlusion, but new indications have been proposed. We present two cases in which EXIT procedure was adopted (huge cervical mass with tracheal compression and a highly vascularized cephalocervical mass) for the same purpose on different grounds. Our two cases stress once more the importance of combining fetal ultrasound and magnetic resonance imaging in the characterization of cervical masses and its usefulness in programming the procedure with a multidisciplinary team.