Effectiveness of using a chatbot to promote adherence to home physiotherapy after total knee replacement, rationale and design of a randomized clinical trial.

BACKGROUND: Rehabilitation is essential to optimize outcomes after surgical procedures in musculoskeletal disorders. However, adherence to rehabilitation continues to be an important barrier, since compliance with the programs is not always as desired, which may have a negative impact on clinical results. METHODS: Randomized controlled trial aimed at to determining the effectiveness of using a virtual assistant (i.e., chatbot) to promote adherence to home rehabilitation. Overall, seventy patients under 75, undergoing total knee replacement, who have a personal smartphone and are familiar with its use, will be assigned into the control (standard care) or the experimental (standard care plus virtual assistant) group. Adherence (primary outcome) will be assessed three months after surgery. The WOMAC questionnaire, knee pain and system usability scale will be also outcomes of interest at three months and one year. Overall, an analysis of variance will look for possible time, group and time*group interactions. DISCUSSION: The expected result is to determine whether the use of a chatbot that interacts with the patient can increase adherence to post-surgical home physiotherapy, and result in better clinical results (functional and pain) than standard care. TRIAL REGISTRATION: clinicaltrials.gov id. NCT05363137.

Fall classification, incidence and circumstances in patients undergoing total knee replacement.

To propose a fall-classification framework for patients undergoing total knee replacement (TKR). In addition, we reinforced the available evidence on fall incidence and circumstances and compared the characteristics of fallers versus. nonfallers. Retrospective and prospective data were collected from 253 subjects with severe knee osteoarthritis who were waiting for primary TKR. Falls were classified considering the location of the destabilizing force, source of destabilization and fall precipitating factor. Fall incidence and circumstances were described; the characteristics of fallers and nonfallers in terms of functional and balance performance were compared with F-tests (95% CI). The fall incidence before surgery was 40.3% (95% CI 34.2% to 46.6%). This figure decreased to 13.1% (95% CI 9.2% to 18.0%) and to 23.4% (95% CI 17.8% to 29.6%) at 6 and 12 months after surgery, respectively. Most falls were caused by destabilizations in the base of support (n = 102, 72%) and were due to extrinsic factors (n = 78, 76%) and trip patterns. Significant differences between fallers and nonfallers were found in knee extensor strength and monopodal stability in the surgical limb (p < 0.05). Falls are prevalent in patients with severe knee osteoarthritis. Symptoms and functional performance improve after surgery, and fall incidence is reduced. Most fall events originate from disruptions in the base of support and are precipitated by extrinsic factors, generally trips during walking activities.

[Renal transplant recipient evaluation.] / Estudio urológico del candidato a trasplante renal.

Urological evaluation is essential to guarantee the success of the kidney transplant. Urologists working within a multidisciplinary team have a crucial role to detect and manage certain recipient urological conditions that could jeopardize the function and survival of the graft.The critical aspects that Urologists should consider in thepre-transplant evaluation would be:- Is renal transplantation surgical technique feasible with assumable risks based on the recipient's baseline characteristics? age, life expectancy, performance status,physical examination...- Is bladder function adequate to properly ensure the urine storage and voiding?- Is there a potentially treatable urinary flow obstruction?- Are there urological pathologies in the recipient that could lead to post-transplant complications that compromise graft survival: functional, infectious, oncological comorbidities…?- Based on the patient's cardiovascular risk factors, arteriosclerosis in the aorto-iliac territory colud put at risk thearterial anastomosis? In this chapter, we will try to explain how the pre-transplant urological evaluation should be guided according to the specific recipient characteristics. We will also explain which pre-transplant surgeries are required to avoid some risky that may compromise the recipient and graft survival after renal transplantation, as well as those should be postponed after transplantation.

La evaluación urológica en el estudio pre-trasplante es una pieza clave para garantizar eléxito del mismo. El papel del urólogo dentro de un equipo multidisciplinar que lleva a cabo esta evaluación es fundamental para detectar y manejar ciertas patologías urológicas del receptor que podrían poner en riesgo la función y supervivencia del injerto. Los puntos clave que el urólogo debe tratar en la consulta pretrasplante serían:- ¿La técnica quirúrgica del trasplante renal es viable con riesgos asumibles en base a las características basales del receptor? Edad biológica, esperanza de vida ,estado basal, exploración física…- ¿La función vesical es adecuada para asegurar un correcto almacenaje de la orina y una adecuada excreción de la misma?- ¿Existe una obstrucción al flujo urinario potencialmente tratable?- ¿Existen en el receptor patologías urológicas que puedan conllevar complicaciones en el post-trasplante que comprometan la función y supervivencia del injerto?:funcionales, infecciosas, oncológicas…- ¿En base a los factores de riesgo cardiovascular del paciente, podría existir una arteriosclerosis en el territorioaorto-iliaco que impida una anastomosis arterial congarantías? En este capítulo, trataremos de exponer cómo debemos orientar la consulta pre-trasplante desde el punto de vista urológico, comenzando por el estudio básico hasta el estudio más específico en base a características concretas del receptor. Además, expondremos cuáles son las cirugías pre-trasplante requeridas para eliminar condiciones de riesgo presentes en el potencial receptor que puedan comprometer la supervivencia del mismo y del injerto tras el trasplante renal así como, aquellos procedimientos programados indicados tras el trasplante.

Sensorimotor training prior total knee arthroplasty and effects on functional outcome: A systematic review and meta-analysis.

BACKGROUND: Altered muscle activation patterns and proprioception, loss of strength, and weight bearing asymmetries are common limitations after total knee arthroplasty, which can also affect balance. Therefore, preoperative sensorimotor training has been proposed to enhance surgical outcome. RESEARCH QUESTION: Is preoperative sensorimotor training effective in improving functional outcome in patients undergoing total knee arthroplasty? Does preoperative sensorimotor training affect secondary outcomes such as balance, pain, and quality of life? METHODS: A systematic review and meta-analysis were conducted by searching PEDro, MEDLINE, Embase, Cochrane Library, and Scopus databases from inception to May 2020. Studies were eligible if participants underwent total knee arthroplasty after two or more weeks of preoperative sensorimotor training. A meta-analysis compared the effects of such interventions with standard care before and after surgery using standardized mean differences (SMD) with 95 % confidence interval (CI). Functional outcome was the primary measure. Balance, pain, and quality of life were also outcomes of interest. RESULTS: Of the 384 items identified, 7 met the inclusion criteria, and 332 participants were assessed. There was limited evidence suggesting that preoperative sensorimotor training enhanced self-reported function (SMD, 0.89; 95 % CI, 0.16-1.62), functional performance (SMD, 0.56; 95 % CI, 0.19 to 0.93), or knee function (SMD = 0.22-1.05) compared with conventional care. Moderate quality evidence suggested that benefits were only maintained in terms of functional performance up to 3 months after surgery (SMD = 0.37; 95 % CI, 0.13 to 0.62). The outcome was similar after one year. SIGNIFICANCE: Compared with conventional care, preoperative sensorimotor training may enhance early postoperative functional recovery, with no additional benefits on balance, knee function, or pain. The outcome is the same one year after surgery, regardless of whether such training is implemented. Further investigation is needed to determine whether sensorimotor training may be a feasible conservative treatment for severe knee osteoarthritis.

A randomized controlled trial assessing the effects of preoperative strengthening plus balance training on balance and functional outcome up to 1 year following total knee replacement.

PURPOSE: To investigate the effects of including balance training in a preoperative strengthening intervention on balance and functional outcomes in patients undergoing total knee replacement (TKR) and compare these effects to those induced by preoperative strengthening and no intervention. METHODS: Eighty-two subjects scheduled for TKR were randomly allocated into the strengthening (ST, n = 28) group: a preoperative lower limb strengthening intervention; the strengthening + balance (ST + B, n = 28) group: same intervention augmented with balance training; and the control group (n = 26). The Berg Balance Scale (BBS) and the function in daily living subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-ADL) were the primary outcomes. The secondary measures included balance and mobility, self-reported status, and knee function. The outcomes were assessed at baseline, 1 week before surgery, and 2, (primary endpoint), 6 and 52 weeks after surgery. RESULTS: Compared with the controls, the participants in the ST and ST + B groups presented significant improvements from baseline to the end of the preoperative intervention in BBS (p = 0.005) and KOOS-ADL (p < 0.001). At 6 weeks post-surgery, the knee extensor strength values were similar in the two treatment groups and significantly higher than that in the controls. Overall, the participant outcomes in all groups stabilized at 1 year after surgery. CONCLUSION: A preoperative strengthening intervention, regardless of whether it is complemented with balance training, enhances strength but not balance or functional outcomes at 6 weeks after surgery. Patients are expected to present similar performance at 1 year postoperatively, but adequately statistically powered trials are needed to confirm the findings. LEVEL OF EVIDENCE: II. TRIAL REGISTRATION: NCT02995668.

Climacturia after robot-assisted laparoscopic radical prostatectomy.

INTRODUCTION: Adverse effects in the sexual sphere are common in patients who have undergone radical prostatectomy (RP). Climacturia, involuntary loss of urine during orgasm, occurs in 20-40% of cases after PR. We analyse its prevalence and associated risk factors after Robotic-assisted laparoscopic radical prostatectomy (RALRP). OBJECTIVES: We analyse the climacturia prevalence after robotic-assisted laparoscopic radical prostatectomy (RALRP) and the association with other related factors. MATERIALS AND METHODS: Retrospective study of 100 patients underwent PRLAR from May 2011 to July 2014. After excluding patients who received radiotherapy after surgery (17), those who did not have sexual activity (7) and those with whom it could not be possible contacted (14), a structured telephone interview was conducted in 62 patients, investigating: presence and intensity of climacturia, orgasmic quality, incontinence and erectile dysfunction (ED). Other factors analysed included neurovascular preservation and rehabilitative treatment for ED. The statistical analysis consisted of Chi2test and logistic regression to evaluate associated factors. RESULTS: The mean age was 56 vs 59 years and the mean follow-up time was 26.6 vs 20.3 months, in the group with climacturia and without climacturia, respectively. The prevalence of climacturia was 17.9% (slight leaks-82% and severe leaks-18%). In 37% of these patients occurred in all orgasms. The quality of orgasm after surgery was worse in 47%, better in 13% and equal in 40%. The quality of the orgasm worsened more frequently in the climacturia group (63% vs 37%). The urinary incontinence rate was 41%, always effort incontinence. It was more frequent in patients with climacturia (62% vs 38%). In all patients with climacturia, bilateral neurovascular bundles preservation was performed. 32% of the patients had undergone post-surgical erectile rehabilitation with oral drugs. No statistically significant differences were found between patients with or without climacturia respect to the parameters analysed. CONCLUSIONS: Climacturia rate after PRLAR in our series was 17.9%. Patients with climacturia presented worse quality orgasms and a higher incontinence rate (p> 0.05). None of the analysed parameters could be defined as predictors of climacturia.

The effects of preoperative balance training on balance and functional outcome after total knee replacement: a randomized controlled trial.

OBJECTIVE: To assess the effects of preoperative balance training on the early postoperative balance and functional outcomes after total knee replacement surgery and to test whether an outpatient intervention may be as effective as a domiciliary intervention. DESIGN: This is a three-arm randomized controlled trial. SETTING: University hospital. SUBJECTS: Eighty-six individuals were recruited. Seventy-seven were analysed, aged 72.1 (SD 7.6) years, of which 68% were women. OUTCOME MEASURES: Overall state of balance, as measured with the Berg Balance Scale, and patient-perceived functionality, as measured with the Knee Injury and Osteoarthritis Outcome Score Function in Activities in Daily Living (KOOS-ADL) questionnaire, were the primary outcomes. Secondary assessments targeted knee function, balance and mobility, quality of life, and self-reported outcomes. The primary end-point was six weeks after surgery. INTERVENTION: The hospital group implemented a four-week preoperative outpatient balance-oriented intervention. The home group implemented similar training, but this was domiciliary. The control group was instructed to keep performing their normal activities. RESULTS: Home and hospital groups presented a moderate effect against the control group (dhospital-control = 0.54; dhome-control = 0.63), both being similarly effective in improving the overall state of balance at six weeks after surgery (P = 0.013). KOOS-ADL scores showed no between-group differences and a small effect size (d < 0.5; P = 0.937). Secondary assessments suggested non-significant between-group differences. CONCLUSION: Preoperative balance training, conducted either as domiciliary or as an outpatient, is an effective approach to enhance early postoperative balance outcome but not the perceived functionality of individuals undergoing total knee replacement.

In-home versus hospital preoperative balance and proprioceptive training in patients undergoing TKR; rationale, design, and method of a randomized controlled trial.

BACKGROUND: Severe knee osteoarthritis, as well as the surgical procedure of total knee replacement that aims to reduce its symptoms, cause great deterioration on the proprioceptive system. Taking this fact into account, and considering that balance abilities positively influence the capacity to perform basic functional tasks, this trial aims to find the short and mid-term effects of a preoperative balance and proprioceptive training when conducted by patients undergoing total knee replacement. Along with the effects, it is intended to determine whether in-home based training can be as effective as hospital training. The results will help to conclude whether the possible benefits may outweigh the health costs. METHODS: Seventy-five participants will take part. The trial will include in-home and supervised hospital experimental training compared to a non-active control group in order to estimate the actual effect of the proposal against the benefits due exclusively to the surgical procedure. Interventions last 4 weeks prior to surgery, and the follow-up will be at 2w, 6w, and 1y following the operation. The primary outcomes are in agreement with the goals: self-reported functionality in terms of KOOS and overall balance in terms of the Berg Balance Scale. The secondary outcomes will include the measurements of static and dynamic balance abilities, pain, function, and quality of life. DISCUSSION: It is expected for the results of this trial to provide relevant information in order to decide if a specific intervention is cost-effective to be implemented in clinical practice. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT03100890 . Registered in April 4, 2017.

The usefulness of densitometry in predicting the composition and fragility of urolithiasis.

INTRODUCTION: The choice of ideal treatment for a given lithiasis is a crucial factor for its success, minimizing the number of interventions and complications. Previous determination of stone composition and its fragility is desirable, to predict its behavior during extracorporeal shock wave lithotripsy and for evaluation of its appropriateness, or to set the indication for other techniques. OBJETIVES: To determine the role of densitometry in the prediction of composition and fragility of urinary lithiasis undergoing SWL. METHODS: Experimental prospective, blinded, in vitro study using 193 urinary calculi of known composition : monohydrated calcium oxalate, mixed calcium oxalate, uric acid, and calcium carbonate, obtained from spontaneous passage or surgery. Densitometry and SWL were performed on them. We compare the mineral composition of the stone and mineral density of each composition group to check if they are characteristic of each type and correlate these parameters with the energy dose required to fragment them down to a given fragment size. RESULTS: Only 53 out of 193 stones showed valuable data. Calcium carbonate was the composition showing grater mineral content and density (1,24 gr and 0,47 gr/cm2), followed by mixed oxalate (0,51/0,26) and uric acid (0,52/ 0,15), finishing with the monohydrate calcium oxalate group (0,32/0,05).Only the comparison between calcium carbonate and monohydrated calcium oxalate showed statistically significant results (p<0,05). Correlation coefficients between mineral content (0,347) and density (0,424) and the energy used for stone fragmentation to a given fragment size were statistically significant (p<0,05) CONCLUSIONS: In our study, the use of densitometry to determine stone composition and lithiasic fragility did not show conclusive results due to the limited number of calculi tested. Nevertheless, there are signs that, with a different study design , more practically useful results could be achieved.

Pathogenic brucellae replicate in human trophoblasts.

Brucellae replicate in a vacuole derived from the endoplasmic reticulum (ER) in epithelial cells, macrophages, and dendritic cells. In animals, trophoblasts are also key cellular targets where brucellae efficiently replicate in association with the ER. Therefore, we investigated the ability of Brucella spp. to infect human trophoblasts using both immortalized and primary trophoblasts. Brucella extensively proliferated within different subpopulations of trophoblasts, suggesting that they constitute an important niche in cases where the fetal-maternal barrier is breached. In extravillous trophoblasts (EVTs), B. abortus and B. suis replicated within single-membrane acidic lysosomal membrane-associated protein 1-positive inclusions, whereas B. melitensis replicated in the ER-derived compartment. Furthermore, B. melitensis but not B. abortus nor B. suis interfered with the invasive capacity of EVT-like cells in vitro. Because EVTs are essential for implantation during early stages of pregnancy, the nature of the replication niche may have a central role during Brucella-associated abortion in infected women.

Thrombocytosis and hematocrit as prognostic factors in renal carcinoma.

OBJECTIVE: To examine the connection between preoperative thrombocytosis and hematocrit and survival in a group of patients operated for renal cell carcinoma. METHODS: Retrospective study with descriptive and statistical analysis of 139 patients with renal cell carcinoma treated surgically over the last 4 years in our Urology clinical unit. 116 (83,45%)were diagnosed at a localized clinical stage, whereas 23 (16,54%) presented as locally advanced or metastatic disease. We collected data about survival and time on surveillance, imaging and histological characteristics of the tumor and analytical parameters. Data were analyzed by the SPSS statistical software. RESULTS: The average platelet count and hematocrit before surgery were 260,930 cells/mm3 and 41.10%, respectively. We found a statistical correlation between platelet count at the time of diagnosis and survival. Patients with platelet counts higher than 350,000 cells/mm3 had a poor survival (OR: 2.94; CI 95% 1.04- 8.27). We also found that patients with high hematocrit at diagnosis presented a lower risk of death (OR: 0.92; CI 95% 0.85- 0.99). The global survival at the end of the study was 88.4%. Multivariate analysis did not show any significant result because of the low number of deaths. CONCLUSION: The presence of high platelet count or low hematocrit correlate with poor survival in a group of surgically treated renal cell carcinoma patients. Nevertheless more studies with longer surveillance and higher number of patients are needed.

Brucellosis vaccines: assessment of Brucella melitensis lipopolysaccharide rough mutants defective in core and O-polysaccharide synthesis and export.

BACKGROUND: The brucellae are facultative intracellular bacteria that cause brucellosis, one of the major neglected zoonoses. In endemic areas, vaccination is the only effective way to control this disease. Brucella melitensis Rev 1 is a vaccine effective against the brucellosis of sheep and goat caused by B. melitensis, the commonest source of human infection. However, Rev 1 carries a smooth lipopolysaccharide with an O-polysaccharide that elicits antibodies interfering in serodiagnosis, a major problem in eradication campaigns. Because of this, rough Brucella mutants lacking the O-polysaccharide have been proposed as vaccines. METHODOLOGY/PRINCIPAL FINDINGS: To examine the possibilities of rough vaccines, we screened B. melitensis for lipopolysaccharide genes and obtained mutants representing all main rough phenotypes with regard to core oligosaccharide and O-polysaccharide synthesis and export. Using the mouse model, mutants were classified into four attenuation patterns according to their multiplication and persistence in spleens at different doses. In macrophages, mutants belonging to three of these attenuation patterns reached the Brucella characteristic intracellular niche and multiplied intracellularly, suggesting that they could be suitable vaccine candidates. Virulence patterns, intracellular behavior and lipopolysaccharide defects roughly correlated with the degree of protection afforded by the mutants upon intraperitoneal vaccination of mice. However, when vaccination was applied by the subcutaneous route, only two mutants matched the protection obtained with Rev 1 albeit at doses one thousand fold higher than this reference vaccine. These mutants, which were blocked in O-polysaccharide export and accumulated internal O-polysaccharides, stimulated weak anti-smooth lipopolysaccharide antibodies. CONCLUSIONS/SIGNIFICANCE: The results demonstrate that no rough mutant is equal to Rev 1 in laboratory models and question the notion that rough vaccines are suitable for the control of brucellosis in endemic areas.

Immunopathological responses and kinetics of Brucella melitensis Rev 1 infection after subcutaneous or conjunctival vaccination in rams.

The innocuousness of the Brucella melitensis Rev 1 live attenuated vaccine strain has never been fully assessed in rams. The immunopathological responses and the kinetics and distribution of the infection induced by this strain were determined after subcutaneous or conjunctival vaccination in both young (3-4 months old) and adult (12 months old) rams. At regular intervals after vaccination the animals were bled for serological studies, and slaughtered for both pathological and bacteriological examinations. The serological response after conjunctival inoculation was of lower intensity and duration than that induced subcutaneously, being the differences more evident in young rams. No genital lesions were produced and genital organs and accessory sexual glands were never found infected, being Rev 1 infection restricted to lymph nodes and spleen. Immunostained Rev 1 bacteria were located intracellularly in plasmablasts, dendritic follicular cells and macrophages in the target lymph nodes, in which cellular hyperplasia was the dominant pathological response. Subcutaneous vaccination induced a generalized infection by 2 weeks after vaccination, being then restricted to the prescapular target lymph node. Infection after conjunctival vaccination was less generalized, being restricted essentially to the cranial lymph nodes. Rev 1 infection was fully cleared by 3 months after vaccination in all animals. These results confirm the innocuousness of B. melitensis Rev 1 vaccine in rams.

[Metastatic Crohn's disease involving the penile foreskin]. / Afectación prepucial de la enfermedad de Crohn metastásica.

OBJECTIVE: To describe the case of the patient with history of Crohn's disease presenting metastatic extension to the penile foreskin. METHODS: Circumcision was carried out and the skin was sent to the pathology department. RESULTS: Pathologic study of the specimen showed an ulcerated granuloma without caseum, typically associated with metastatic Crohn's disease. After one year of follow-up there is no evidence of recurrence. CONCLUSIONS: Crohn's disease is a disease of unknown origin, the main characteristic of which is the development of non necrotizing granulomas that may involved not only the gastrointestinal tract. When the extraintestinal involvement is not produced by continuity we call it metastatic disease. Such metastases may be found in the genitourinary tract, and other sites. This involvement may include lithiasis, amyloidosis, ... and the presence of lesions in the genital skin, as in our case.

Residual virulence and immunogenicity of CGV26 and CGV2631 B. melitensis Rev. 1 deletion mutant strains in sheep after subcutaneous or conjunctival vaccination.

The CGV26 and CGV2631 strains are novel engineered Brucella melitensis Rev.1 mutant strains deleted for the bp26 gene or for both bp26 and omp31 genes, respectively, coding for proteins of diagnostic significance. The residual virulence and immunogenicity of both mutants were compared to the parental Rev.1 strain in sheep after subcutaneous or conjunctival vaccination. The deletion of the bp26 gene or both bp26 and omp31 genes had no significant effect on the intracellular survival of the Rev.1 strain in ovine macrophage cultures. The kinetics of infection induced by both mutants in sheep was similar to the Rev.1 strain, and inoculation by the subcutaneous route produced wider and more generalized infections than the conjunctival route. All strains were cleared from lymph nodes and organs within 3 months after inoculation. The CGV26 and CGV2631 mutants induced both specific systemic antibody response and lymphoproliferation in sheep. The kinetics of the responses induced by the mutants was quite similar to that of the parental Rev.1 strain, except for the intensity of the lymphoproliferative response, which was attenuated for the CGV2631 mutant. In conclusion, the residual virulence of both CGV26 and CGV2631 mutants in sheep was similar to that of the parental Rev.1 vaccine strain. These mutants induced also significant specific antibody and cell-mediated immunity in sheep and are suitable to be evaluated as potential vaccine candidates against B. melitensis and B. ovis infections in sheep.