Development of a Consensus-Derived Synoptic Operative Report for Rectal Prolapse: A Report From the Pelvic Floor Disorders Consortium.

BACKGROUND: Narrative operative reports may omit or obscure data from an operation. OBJECTIVE: To develop a synoptic operative report for rectal prolapse that includes core descriptors as developed by an international consensus of expert pelvic floor surgeons. DESIGN: Descriptors for patients undergoing rectal prolapse surgery were generated through review. Members of the Pelvic Floor Disorders Consortium were recruited to participate in a 3-round Delphi process using a 9-point Likert scale. Descriptors that achieved 70% agreement were kept from the first round, and descriptors scoring 40% to 70% agreement were recirculated in subsequent rounds. A final list of operative descriptors was determined at a consensus meeting, with a final consensus meeting more than 70% agreement. SETTINGS: This survey was administered to members of the Pelvic Floor Disorders Consortium. PATIENTS: No patient data are included in this study. MAIN OUTCOME MEASURES: Descriptors meeting greater than 70% agreement were selected. RESULTS: One hundred seventy-six surgeons representing colorectal surgeons, urogynecologists, and urologists distributed throughout North America (56%), Latin America (4%), Western Europe (29%), Asia (4%), and Africa (1%) participated in the first round of Delphi voting. After 2 additional rounds and a final consensus meeting, 16 of 30 descriptors met 70% consensus. Descriptors that met consensus were surgery type, posterior dissection, ventral dissection, mesh used, type of mesh used, mesh location, sutures used, suture type, pouch of Douglas and peritoneum reclosed, length of rectum imbricated, length of bowel resected, levatoroplasty, simultaneous vaginal procedure, simultaneous gynecologic procedure, simultaneous enterocele repair, and simultaneous urinary incontinence procedure. LIMITATIONS: The survey represents the views of members of the Delphi panel and may not represent the viewpoints of all surgeons. CONCLUSIONS: This Delphi survey establishes international consensus descriptors for intraoperative variables that have been used to produce a synoptic operative report. This will help establish defined operative reporting to improve clinical communication, quality measures, and clinical research. See Video Abstract . DESARROLLO DE UN PROTOCOLO OPERATORIO SINPTICO DERIVADO DE CONSENSO PARA EL PROLAPSO RECTAL UN INFORME DEL CONSORCIO DE TRASTORNOS DEL PISO PLVICO: ANTECEDENTES:Los protocolos operativos narrativos frecuentemente pueden omitir u oscurecer datos de un procedimiento.OBJETIVO:Nuestro objetivo es desarrollar un protocolo operatorio sinóptico para el prolapso rectal que incluya descriptores básicos desarrollados por un consenso internacional de cirujanos expertos en piso pélvico.DISEÑO:Los descriptores para pacientes sometidos a cirugía de prolapso rectal se generaron mediante revisión. Se reclutó a miembros del Consorcio de Trastornos del Piso Pélvico para participar en un proceso Delphi de 3 rondas utilizando una escala Likert de 9 puntos. Los descriptores que lograron un 70% de acuerdo se mantuvieron en la primera ronda, los descriptores que obtuvieron un 40-70% de acuerdo se recircularon en rondas posteriores. Se determinó una lista final de descriptores operativos en una reunión de consenso, con una reunión de consenso final de más del 70% de acuerdo.ESCENARIO:Esta fue una encuesta administrada a miembros del Consorcio de Trastornos del Piso Pélvico.PRINCIPALES MEDIDAS DE RESULTADO:Se seleccionaron los descriptores que cumplieron más del 70% de acuerdo.RESULTADOS:Ciento setenta y seis cirujanos en representación de cirujanos colorrectales, uroginecólogos y urólogos distribuidos en América del Norte (56%), América Latina (4%), Europa Occidental (29%), Asia (4%) y África (1%) participaron en la primera ronda de votación Delphi. Después de dos rondas adicionales y una reunión de consenso final, 16 de 30 descriptores alcanzaron un 70% de consenso. Los descriptores que alcanzaron consenso fueron: tipo de cirugía, disección posterior, disección ventral, malla utilizada, tipo de malla utilizada, ubicación de la malla, suturas utilizadas, tipo de sutura, cierre del fondo de saco de Douglas y peritoneo, longitud del recto superpuesto, longitud del intestino resecado, plastía de los elevadores , procedimiento vaginal simultáneo, procedimiento ginecológico simultáneo, reparación simultánea de enterocele y procedimiento simultáneo de incontinencia urinaria.LIMITACIONES:La encuesta representa las opiniones de los miembros del panel Delphi y puede no representar los puntos de vista de todos los cirujanos.CONCLUSIONES/DISCUSIÓN:Esta encuesta Delphi establece descriptores de consenso internacional para las variables intraoperatorias que se han utilizado para producir un protocolo operatorio sinóptico. Esto ayudará a establecer protocolos operativos definidos para mejorar la comunicación clínica, las medidas de calidad y la investigación clínica. (Traducción-Dr. Felipe Bellolio ).

Durable Approaches to Recurrent Rectal Prolapse Repair May Require Avoidance of Index Procedure.

BACKGROUND: Surgical treatment of recurrent rectal prolapse is associated with unique technical challenges, partially determined by the surgical approach used for the index operation. Success rates are variable, and data to determine the best approach in patients with recurring prolapse are lacking. OBJECTIVE: The study aimed to assess current surgical approaches to patients with prior rectal prolapse repairs and to compare short-term outcomes of de novo and redo procedures, including recurrence of rectal prolapse. DESIGN: Retrospective analysis of a prospective database. SETTINGS: The Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement database. De-identified surgeons at more than 25 sites (81% high volume) self-reported patient demographics, prior repairs, symptoms of incontinence and obstructed defecation, and operative details, including history of concomitant repairs and prior prolapse repairs. PATIENTS: Patients who were offered surgery for full thickness rectal prolapse. INTERVENTIONS: Incidence and type of repair used for prior rectal prolapse surgery were recorded. Primary and secondary outcomes of index and redo operations were calculated. Patients undergoing rectal prolapse re-repair (redo) were compared with patients undergoing first (de novo) rectal prolapse repair. The incidence of rectal prolapse recurrence in de novo and redo operations was quantified. OUTCOMES: The primary outcome of rectal prolapse recurrence in de novo and redo settings. RESULTS: Eighty-nine (19.3%) of 461 patients underwent redo rectal prolapse repair. On short-term follow-up, redo patients had prolapse recurrence rates similar to those undergoing de novo repair. However, patients undergoing redo procedures rarely had the same operation as their index procedure. LIMITATIONS: Self-reported, de-identified data. CONCLUSION: Our results suggest that recurrent rectal prolapse surgery is feasible and can offer adequate rates of rectal prolapse durability in the short term but may argue for a change in surgical approach for redo procedures when clinically feasible. See Video Abstract . LOS ENFOQUES DURADEROS PARA LA REPARACIN DEL PROLAPSO RECTAL RECURRENTE PUEDEN REQUERIR EVITAR EL PROCEDIMIENTO NDICE: ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal recurrente se asocia con desafíos técnicos únicos, determinados en parte por el abordaje quirúrgico utilizado para la operación inicial. Las tasas de éxito son variables y faltan datos para determinar el mejor abordaje en pacientes con prolapso recurrente.OBJETIVO:Evaluar los enfoques quirúrgicos actuales para pacientes con reparaciones previas de prolapso rectal y comparar los resultados a corto plazo de los procedimientos de novo y rehacer, incluida la recurrencia del prolapso rectal.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.AJUSTE:Base de datos de mejora prospectiva de la calidad del Consorcio multicéntrico de trastornos del suelo pélvico. Cirujanos no identificados en más de 25 sitios (81% de alto volumen) informaron datos demográficos de los pacientes, reparaciones previas, síntomas de incontinencia y defecación obstruida y detalles operativos, incluido el historial de reparaciones concomitantes y reparaciones previas de prolapso.INTERVENCIONES:Se registro la incidencia y el tipo de reparación utilizada para la cirugía de prolapso rectal previa. Se calcularon los resultados primarios y secundarios de las operaciones de índice y reoperacion. Se compararon los pacientes sometidos a una nueva reparación (reoperacion) de prolapso rectal con pacientes sometidos a una primera reparación (de novo) de prolapso rectal. Se cuantificó la incidencia de recurrencia del prolapso rectal en operaciones de novo y rehacer.RESULTADOS:El resultado primario de recurrencia del prolapso rectal en entornos de novo y redo. Ochenta y nueve (19,3%) de 461 pacientes se sometieron a una nueva reparación del prolapso rectal. En el seguimiento a corto plazo, los pacientes reoperados tuvieron tasas de recurrencia de prolapso similares a los de los sometidos a reparación de novo. Sin embargo, los pacientes sometidos a procedimientos de rehacer rara vez tuvieron la misma operación que su procedimiento índice.LIMITACIONES:Datos no identificados y autoinformados.CONCLUSIONES/DISCUSIÓN:Nuestros resultados sugieren que la cirugía de prolapso rectal recurrente es factible y puede ofrecer tasas adecuadas de durabilidad del prolapso rectal en el corto plazo, pero puede abogar por un cambio en el enfoque quirúrgico para rehacer los procedimientos cuando sea clínicamente factible. (Traducción-Dr. Mauricio Santamaria ).

Systematic documentation of the introduction of COVID-19 vaccines in Latin America and the Caribbean / Documentación sistemática de la introducción de vacunas contra la COVID-19 en América Latina y el Caribe / Documentação sistemática da introdução das vacinas contra a COVID-19 na América Latina e no Caribe

ABSTRACT Objective. To document the process of introducing COVID-19 vaccines in a selection of Latin American and Caribbean countries, including the lessons learned and the strengths and weaknesses, and similarities and differences among programs. Methods. This descriptive study is based on a systematic evaluation of the process of introducing COVID-19 vaccines in Argentina, Belize, Brazil, Costa Rica, Panama and Peru. Data were collected through a questionnaire distributed to key stakeholders. Six informants from each of the included countries participated in this study. The period of the study was from December 2021 through September 2022. Results. The main strengths reported by countries were health workers' commitment to delivering vaccinations, evidence-based decision-making, the development of plans for vaccine introduction, the participation of national immunization technical advisory groups, the availability of economic resources and positive actions from the respective Ministry of Health. The main challenges were the actions of antivaccination groups, problems with electronic immunization registries, a lack of vaccines, delays in the delivery of vaccines and the scarcity of health personnel at the local level. Conclusions. Commitment, the participation of multiple sectors, the availability of resources and preparedness planning were some of the many strengths shown by countries introducing COVID-19 vaccines. Weaknesses included third parties' interests, the lack of information systems and difficulty in accessing vaccines and vaccine services. There is a window of opportunity for countries to maintain the good practices that allowed for the processes' strengths and to assess the identified weaknesses to invigorate immunization programs and prepare for future health crises.

RESUMEN Objetivo. Documentar el proceso de introducción de las vacunas contra la COVID-19 en un algunos países de América Latina y el Caribe, incluidas las enseñanzas extraídas y sus puntos fuertes y débiles, así como las similitudes y diferencias entre los distintos programas. Métodos. Este estudio descriptivo se basa en una evaluación sistemática del proceso de introducción de las vacunas contra la COVID-19 en Argentina, Belice, Brasil, Costa Rica, Panamá y Perú. Los datos se recopilaron mediante un cuestionario distribuido a las principales partes interesadas. El estudio contó con la participación de un informante de cada uno de los seis países incluidos. El período de estudio fue de diciembre del 2021 a septiembre del 2022. Resultados. Los países indicaron como puntos fuertes principales el compromiso del personal de atención de salud con la vacunación, la toma de decisiones basada en la evidencia, la formulación de planes para la introducción de las vacunas, la participación de grupos técnicos asesores nacionales sobre inmunización, la disponibilidad de recursos económicos y las medidas favorables adoptadas por respectivos los Ministerios de Salud. Los retos más importantes fueron las acciones de los grupos contrarios a las vacunas, los problemas con los registros electrónicos de vacunación, la falta de vacunas, los retrasos en la entrega de vacunas y la escasez de personal de atención de salud a nivel local. Conclusiones. Se observó que el compromiso, la participación de múltiples sectores, la disponibilidad de recursos y la planificación de la preparación eran algunos de los puntos fuertes de los países que introdujeron las vacunas contra la COVID-19. Los puntos débiles fueron los intereses de terceros, la falta de sistemas de información y las dificultades para acceder a las vacunas y a los servicios de vacunación. Los países disponen ahora de una oportunidad para mantener las buenas prácticas que propiciaron los puntos fuertes de los procesos y evaluar los puntos débiles identificados a fin de fortalecer los programas de inmunización y prepararse para futuras crisis de salud.

RESUMO Objetivo. Documentar o processo de introdução da vacina contra a COVID-19 em alguns países da América Latina e do Caribe, incluindo as lições aprendidas e os pontos fortes e fracos, bem como semelhanças e diferenças entre os programas. Métodos. Este estudo descritivo baseia-se em uma avaliação sistemática do processo de introdução das vacinas contra a COVID-19 na Argentina, em Belize, no Brasil, na Costa Rica, no Panamá e no Peru. Os dados foram coletados por meio de um questionário distribuído às principais partes interessadas. Seis informantes de cada um dos países incluídos participaram do estudo, que foi realizado entre dezembro de 2021 e setembro de 2022. Resultados. Os principais pontos fortes relatados pelos países foram o comprometimento dos profissionais de saúde com a vacinação, a tomada de decisões baseadas em evidências, o desenvolvimento de planos para a introdução de vacinas, a participação de grupos técnicos assessores nacionais sobre imunização, a disponibilidade de recursos econômicos e ações positivas dos respectivos ministérios da Saúde. Os principais desafios foram as ações de grupos antivacina, problemas com os registros eletrônicos de imunização, a falta de vacinas, atrasos na entrega das vacinas e a escassez de pessoal de saúde em nível local. Conclusões. O comprometimento, a participação de vários setores, a disponibilidade de recursos e o planejamento de preparação foram alguns dos muitos pontos fortes demonstrados pelos países ao introduzirem as vacinas contra a COVID-19. Entre os pontos fracos estavam os interesses de terceiros, a falta de sistemas de informação e a dificuldade de acesso às vacinas e aos serviços de vacinação. Há uma janela de oportunidade para que os países mantenham as boas práticas que viabilizaram os pontos fortes dos processos e avaliem os pontos fracos identificados a fim de revigorar os programas de imunização e preparar-se para futuras crises sanitárias.

Antegrade Intramedullary Screws in Metacarpal Fractures of Pediatric Patients.

Metacarpal fractures are common injuries in pediatric patients. In adults, cannulated intramedullary screws are an excellent stabilization option for metacarpal fractures and are widely used, but in pediatric patients with open physes, their use is a relative contraindication. The risk of injury to the physis in classic retrograde screw placement makes this type of osteosynthesis not an option. We present the case of an 8-year-old patient with fractures of two adjacent metacarpals with rotational malalignment and scissoring, in which closed reduction was performed, and stabilization with cannulated intramedullary screws using antegrade placement to avoid injury to the physis.

Diverticular Inflammation and Complication Assessment classification, CODA score and fecal calprotectin in clinical assessment of patients with diverticular disease: A decision curve analysis.

BACKGROUND AND AIMS: The Diverticular Inflammation and Complication Assessment (DICA) classification and the Combined Overview on Diverticular Assessment (CODA) were found to be effective in predicting the outcomes of Diverticular Disease (DD). We ascertain whether fecal calprotectin (FC) can further aid in improving risk stratification. METHODS: A three-year international, multicentre, prospective cohort study was conducted involving 43 Gastroenterology and Endoscopy centres. Survival methods for censored observations were used to estimate the risk of acute diverticulitis (AD) in newly diagnosed DD patients according to basal FC, DICA, and CODA. The net benefit of management strategies based on DICA, CODA and FC in addition to CODA was assessed with decision curve analysis, which incorporates the harms and benefits of using a prognostic model for clinical decisions. RESULTS: At the first diagnosis of diverticulosis/DD, 871 participants underwent FC measurement. FC was associated with the risk of AD at 3 years (HR per each base 10 logarithm increase: 3.29; 95% confidence interval, 2.13-5.10) and showed moderate discrimination (c-statistic: 0.685; 0.614-0.756). DICA and CODA were more accurate predictors of AD than FC. However, FC showed high discrimination capacity to predict AD at 3 months, which was not maintained at longer follow-up times. The decision curve analysis comparing the combination of FC and CODA with CODA alone did not clearly indicate a larger net benefit of one strategy over the other. CONCLUSIONS: FC measurement could be used as a complementary tool to assess the immediate risk of AD. In all other cases, treatment strategies based on the CODA score alone should be recommended.

Increasing opportunities for international surgeons.

Social media has completely transformed communication among surgeons. Although we have learned a lot, we still have many challenges to resolve with these tools. Nevertheless, social media has opened many novel opportunities for the surgical community worldwide. Many of these opportunities would never be realized without social media tools, especially in low and middle-income countries. We will discuss the main tools and their applications for increasing opportunities for international surgeons.

Elimination of cervical cancer in Latin America (Project ECHO-ELA): lessons from phase one of implementation.

We describe the outcomes of The Extension for Community Healthcare Outcomes-Elimination of Cervical Cancer in The Americas (ECHO-ELA) program, which was developed as a tri-lateral cooperation between Pan American Health Organization (PAHO), the U.S. National Cancer Institute (NCI) and The University of Texas MD Anderson Cancer Center (MD Anderson). The program's purpose is to disseminate strategies for cervical cancer prevention and is structured around the three pillars of the World Health Organization's (WHO) Cervical Cancer Elimination Strategy and the associated 90-70-90 target goals. The target audience includes health authorities from Latin American and Caribbean countries, as well as PAHO's non-communicable disease Focal Points in country offices as well as clinical and public health collaborators. The virtual sessions are held in Spanish for 1.5 hours every month using the ECHO® format. From May 2020 to June 2021, 14 ECHO sessions were held with an average of 74 participants per session (range: 46 - 142). We conducted two anonymous surveys (baseline and follow up) and two focus groups. Respondents stated that the topics they learned the most about included the state of HPV vaccination in the region and strategies for implementing HPV vaccination. Identified needs included support between ECHO sessions and country-specific technical assistance. The ECHO-ELA program provides a forum for increased collaboration between countries in Latin America/Caribbean and the dissemination of best-practice strategies to reach the WHO Cervical Cancer Elimination target goals.

Se describen los resultados del programa ECHO® (Extension for Community Healthcare Outcomes) para la eliminación del cáncer cervicouterino en las Américas (ECHO-ELA), que se concibió como una cooperación trilateral entre la Organización Panamericana de la Salud (OPS), el Instituto Nacional del Cáncer de los Estados Unidos (NCI) y el centro contra el cáncer MD Anderson (MD Anderson) de la Universidad de Texas. La finalidad del programa es difundir las estrategias para la prevención del cáncer cervicouterino, y está estructurado en torno a los tres pilares de la estrategia para la eliminación del cáncer cervicouterino de la Organización Mundial de la Salud (OMS) y los objetivos 90-70-90 conexos. El público destinatario comprende autoridades de salud de países de América Latina y el Caribe, así como los puntos focales de la OPS para las enfermedades no transmisibles en las Representaciones en los países, además de colaboradores en el ámbito clínico y de la salud pública. Las sesiones virtuales se llevan a cabo en español, durante 1,5 horas cada mes, utilizando el formato ECHO®. De mayo del 2020 a junio del 2021 se celebraron 14 sesiones de ECHO, con un promedio de 74 participantes por sesión (límites: 46-142). Se realizaron dos encuestas anónimas (al inicio y de seguimiento) y dos grupos de opinión. Los encuestados declararon que los temas sobre los que más aprendieron fueron la situación de la vacunación contra el VPH en la región y las estrategias para poner en marcha la vacunación contra el VPH. Entre las necesidades mencionadas figuraban el apoyo entre las sesiones de ECHO y la asistencia técnica específica para cada país. El programa ECHO-ELA brinda un foro para una mayor colaboración entre los países de América Latina y el Caribe y para difundir las estrategias sobre las mejores prácticas, a fin de alcanzar los objetivos de la OMS de eliminación del cáncer cervicouterino.

Este trabalho descreve os resultados do programa Extension for Community Healthcare Outcomes para eliminação do câncer do colo do útero nas Américas (ECHO ELA), desenvolvido na forma de cooperação trilateral entre a Organização Pan-Americana da Saúde (OPAS), o Instituto Nacional do Câncer dos Estados Unidos (NCI) e o MD Anderson Cancer Center da Universidade do Texas (MD Anderson). O programa visa a disseminar estratégias para a prevenção do câncer do colo do útero e está estruturado em torno dos três pilares da estratégia de eliminação do câncer do colo do útero da Organização Mundial da Saúde (OMS) e das Metas 90-70-90 associadas. O público-alvo inclui autoridades sanitárias de países da América Latina e do Caribe, bem como os pontos focais de doenças não transmissíveis nas representações da OPAS nos países, além de colaboradores clínicos e de saúde pública. Todos os meses, são realizadas sessões virtuais de uma hora e meia em espanhol usando o formato ECHO®. No período de maio de 2020 a junho de 2021, foram realizadas 14 sessões do ECHO, com uma média de 74 participantes por sessão (variação: 46 a 142). Foram realizadas duas enquetes anônimas (linha de base e acompanhamento) e dois grupos focais. Os entrevistados afirmaram que os tópicos sobre os quais mais aprenderam foram a situação da vacinação contra o HPV na região e as estratégias para implementar a vacinação contra o HPV. As necessidades identificadas incluíam apoio entre as sessões do ECHO e assistência técnica específica para o país. O programa ECHO ELA oferece um fórum para aumentar a colaboração entre os países da América Latina e do Caribe e difundir melhores práticas para atingir as metas de eliminação do câncer do colo do útero da OMS.

Elimination of cervical cancer in Latin America (Project ECHO-ELA): lessons from phase one of implementation / Eliminación del cáncer cervicouterino en América Latina (Proyecto ECHO-ELA): aprendizajes de la primera fase de implementación / Eliminação do câncer do colo do útero na América Latina (Projeto ECHO-ELA): lições da primeira fase de implementação

ABSTRACT We describe the outcomes of The Extension for Community Healthcare Outcomes-Elimination of Cervical Cancer in The Americas (ECHO-ELA) program, which was developed as a tri-lateral cooperation between Pan American Health Organization (PAHO), the U.S. National Cancer Institute (NCI) and The University of Texas MD Anderson Cancer Center (MD Anderson). The program's purpose is to disseminate strategies for cervical cancer prevention and is structured around the three pillars of the World Health Organization's (WHO) Cervical Cancer Elimination Strategy and the associated 90-70-90 target goals. The target audience includes health authorities from Latin American and Caribbean countries, as well as PAHO's non-communicable disease Focal Points in country offices as well as clinical and public health collaborators. The virtual sessions are held in Spanish for 1.5 hours every month using the ECHO® format. From May 2020 to June 2021, 14 ECHO sessions were held with an average of 74 participants per session (range: 46 - 142). We conducted two anonymous surveys (baseline and follow up) and two focus groups. Respondents stated that the topics they learned the most about included the state of HPV vaccination in the region and strategies for implementing HPV vaccination. Identified needs included support between ECHO sessions and country-specific technical assistance. The ECHO-ELA program provides a forum for increased collaboration between countries in Latin America/Caribbean and the dissemination of best-practice strategies to reach the WHO Cervical Cancer Elimination target goals.

RESUMEN Se describen los resultados del programa ECHO® (Extension for Community Healthcare Outcomes) para la eliminación del cáncer cervicouterino en las Américas (ECHO-ELA), que se concibió como una cooperación trilateral entre la Organización Panamericana de la Salud (OPS), el Instituto Nacional del Cáncer de los Estados Unidos (NCI) y el centro contra el cáncer MD Anderson (MD Anderson) de la Universidad de Texas. La finalidad del programa es difundir las estrategias para la prevención del cáncer cervicouterino, y está estructurado en torno a los tres pilares de la estrategia para la eliminación del cáncer cervicouterino de la Organización Mundial de la Salud (OMS) y los objetivos 90-70-90 conexos. El público destinatario comprende autoridades de salud de países de América Latina y el Caribe, así como los puntos focales de la OPS para las enfermedades no transmisibles en las Representaciones en los países, además de colaboradores en el ámbito clínico y de la salud pública. Las sesiones virtuales se llevan a cabo en español, durante 1,5 horas cada mes, utilizando el formato ECHO®. De mayo del 2020 a junio del 2021 se celebraron 14 sesiones de ECHO, con un promedio de 74 participantes por sesión (límites: 46-142). Se realizaron dos encuestas anónimas (al inicio y de seguimiento) y dos grupos de opinión. Los encuestados declararon que los temas sobre los que más aprendieron fueron la situación de la vacunación contra el VPH en la región y las estrategias para poner en marcha la vacunación contra el VPH. Entre las necesidades mencionadas figuraban el apoyo entre las sesiones de ECHO y la asistencia técnica específica para cada país. El programa ECHO-ELA brinda un foro para una mayor colaboración entre los países de América Latina y el Caribe y para difundir las estrategias sobre las mejores prácticas, a fin de alcanzar los objetivos de la OMS de eliminación del cáncer cervicouterino.

RESUMO Este trabalho descreve os resultados do programa Extension for Community Healthcare Outcomes para eliminação do câncer do colo do útero nas Américas (ECHO ELA), desenvolvido na forma de cooperação trilateral entre a Organização Pan-Americana da Saúde (OPAS), o Instituto Nacional do Câncer dos Estados Unidos (NCI) e o MD Anderson Cancer Center da Universidade do Texas (MD Anderson). O programa visa a disseminar estratégias para a prevenção do câncer do colo do útero e está estruturado em torno dos três pilares da estratégia de eliminação do câncer do colo do útero da Organização Mundial da Saúde (OMS) e das Metas 90-70-90 associadas. O público-alvo inclui autoridades sanitárias de países da América Latina e do Caribe, bem como os pontos focais de doenças não transmissíveis nas representações da OPAS nos países, além de colaboradores clínicos e de saúde pública. Todos os meses, são realizadas sessões virtuais de uma hora e meia em espanhol usando o formato ECHO®. No período de maio de 2020 a junho de 2021, foram realizadas 14 sessões do ECHO, com uma média de 74 participantes por sessão (variação: 46 a 142). Foram realizadas duas enquetes anônimas (linha de base e acompanhamento) e dois grupos focais. Os entrevistados afirmaram que os tópicos sobre os quais mais aprenderam foram a situação da vacinação contra o HPV na região e as estratégias para implementar a vacinação contra o HPV. As necessidades identificadas incluíam apoio entre as sessões do ECHO e assistência técnica específica para o país. O programa ECHO ELA oferece um fórum para aumentar a colaboração entre os países da América Latina e do Caribe e difundir melhores práticas para atingir as metas de eliminação do câncer do colo do útero da OMS.

Molecular detection of Leptospira spp. in small wild rodents from rural areas of São Paulo State, Brazil

ABSTRACT Background: Leptospirosis represents a One Health issue, affecting humans and animals. This study investigated pathogenic leptospires in small wild rodents in São Paulo, Brazil. Methods: Kidney samples from 164 rodents underwent qPCR testing, targeting pathogenic Leptospira spp. Results: Thirty-five animals (21.34%) tested positive, including five rodent species: Akodon montensis (2/21; 9.5%), Necromys lasiurus (1/4; 25%), Oligoryzomys nigripes (24/92; 26.1%), Oligoryzomys flavescens (5/26; 19.2%), and Sooretamys angouya (3/14; 21.4%). Botucatu municipality exhibited the highest prevalence, with 42.5% (20/47) of the animals testing positive. Conclusions: The presence of Leptospira spp. in wild rodents suggests they may be chronic carriers, contaminating the environment.

Angiomixoma agresivo pélvico: reporte de caso y revisión / Aggressive pelvic angiomyxoma: case report and revision / Angiomixoma agressivo: relato de caso e revisão

El angiomixoma agresivo pélvico es un tumor de partes blandas extremadamente raro, del cual se han reportado alrededor de 350 casos hasta la fecha. A continuación se reporta el caso clínico de una paciente que presentó dicho tumor y se describe el proceso diagnóstico y su tratamiento quirúrgico. Por otro lado, se realiza una breve revisión de la literatura disponible hasta el momento sobre el tema.

Aggressive pelvic angiomyxoma is an extremely rare soft tissue tumor, of which around 350 cases have been reported to date. This article aims at reporting the case of a patient presenting said tumor, as well as describing its diagnostic approach and its surgical treatment. On the other hand, it aims at briefly reviewing the available literature on the subject.

O angiomixoma pélvico agressivo é um tumor extremamente raro dos tecidos moles, tendo sido descritos até à data cerca de 350 casos. Relatamos o caso de uma doente que apresentava este tumor e descrevemos o processo de diagnóstico e tratamento cirúrgico. É também feita uma breve revisão da literatura disponível até à data sobre o assunto.

Competência profissional do enfermeiro na unidade de trauma / Professional competence of nurses in the trauma unit

Objetivo: Analizar la competencia profesional del personal de enfermería en la unidad de trauma. Metodología: Investigación cuantitativa, descriptiva y transversal, que fue desarrollada con 47 profesionales de enfermería. Este grupo se desempeñaba en cuatro sectores de riesgo de la unidad de trauma de un hospital público en el noreste de Brasil. Se aplicó un cuestionario validado sobre la competencia profesional del personal de enfermería en emergencias, compuesto por módulos y dominios, entre ellos variables sociodemográficas, formación profesional, caso ficticio y autoevaluación de las acciones diarias correspondientes a la realidad laboral. La recolección de datos se realizó de julio a septiembre de 2019. Para el análisis de datos, se utilizó estadística descriptiva, el software SPSS y la prueba de chi-cuadrado. Para verificar la significancia, se adoptó un valor de p<0.05. Resultados: Se observó que la mayoría de personas participantes eran del sexo femenino, especialistas y tenían más de una relación laboral. En cuanto a los dominios ''relaciones de trabajo'' y ''práctica profesional'', las personas participantes se autoevaluaron como ''muy competentes'' o ''extremadamente competentes'' en todas las acciones que retratan la realidad de trabajo en que están insertas. En el dominio ''excelencia profesional'', la acción ''participa periódicamente en simulación realista en emergencias'' fue la única evaluada como ''poco competente''. En el caso ficticio, en las tres declaraciones, más de la mitad de las personas participantes calificó el comportamiento de la persona profesional en enfermería como ''extremadamente competente'', ''muy competente'' o ''competente''. Conclusión: La mayoría de profesionales en enfermería no juzgaron correctamente las acciones realizadas por la persona enfermera en el caso ficticio, aunque se autoevaluaron como competentes en las acciones que realizan diariamente. Por lo tanto, el estudio plantea la necesidad de que el servicio invierta en educación permanente vinculada al compromiso profesional para garantizar una atención de alta calidad.

Objetivo: Analisar a competência profissional do enfermeiro na unidade de trauma. Metodologia: Pesquisa quantitativa, descritiva e transversal, desenvolvida com 47 enfermeiros que atuavam em quatro setores da unidade de trauma do hospital público no nordeste brasileiro. Aplicou-se questionário validado sobre a competência profissional do enfermeiro em emergências composto por variáveis sociodemográficas, de formação profissional, um caso fictício e autoavaliação das ações diárias correspondente à realidade do trabalho. A coleta de dados foi realizada nos meses de julho a setembro de 2019. Para análise dos dados, utilizou estatísticas descritivas, o software SPSS e teste do qui-quadrado, para verificar significância adotou-se valor de p<0,05. Resultados: Observou-se que a maioria dos enfermeiros eram do sexo feminino, especialistas e possuíam mais de um vínculo empregatício. Referente aos domínios ''Relações de Trabalho'' e ''Prática Profissional'', os enfermeiros se autoavaliaram como ''muito competente'' ou ''extremamente competente'' em todas as ações que retratam a realidade de trabalho na qual estavam inseridos. No domínio ''Excelência profissional'' a ação ''Participa de simulação realística em emergências periodicamente'' foi a única avaliada como ''pouco competente''. No caso fictício, nas três afirmativas, mais da metade dos enfermeiros julgaram como ''extremamente competente'', ''muito competente'' ou ''competente'' a conduta do enfermeiro no caso. Conclusão: A maioria dos enfermeiros não julgaram corretamente as ações realizadas pelo enfermeiro no caso fictício, mesmo se autoavaliando como competentes nas ações que desempenham diariamente. Sendo assim, o estudo levanta a necessidade do serviço de investir em educação permanente atrelado ao empenho profissional para garantir cuidados de alta qualidade.

Aim: To analyze the professional competence of nurses in trauma units. Methods: This was a quantitative, descriptive and cross-sectional study developed with 47 nurses who work in four areas of the trauma unit of a public hospital in the Northeast of Brazil. A validated Likert Scale questionnaire was applied to evaluate the professional competence of nurses during emergencies; this scale included sociodemographic variables, professional training, a fictitious case, and a self-assessment of daily activities related to the reality of work. The data collection was carried out from July to September 2019. To analyze the data, the researchers employed descriptive statistics or the SPSS software and a qui-square test to verify the significance using a p value of <0.05. Results: It was observed that the majority of the nurses were female specialists who had more than one employment relationship. Regarding the domains ''Work Relations'' and ''Professional Practice'', the nurses assessed themselves as ''highly competent'' or ''extremely competent'' in all the actions that portray the reality of work in which they are immersed. In the ''Professional Excellence'' domain, the action ''periodically participates in realistic simulation in emergencies'' was the only one evaluated as ''little competent''. In the fictitious case, across all three statements, more than half of the nurses rated the nurse's behavior in the case as ''extremely competent'', ''very competent'', or ''competent''. Conclusion: Most of the nurses do not correctly judge the actions performed by the nurse in a fictitious case, even when they self-assess themselves as competent in the actions they perform daily. The study also raises the need for the service to invest in permanent professional training endeavor to guarantee competent labor and high-quality care.

Benign Anorectal Disorder Management in Low-Resource Settings.

There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.

Does Concomitant Pelvic Organ Prolapse Repair at the Time of Rectopexy Impact Rectal Prolapse Recurrence Rates? A Retrospective Review of the Prospectively Collected Pelvic Floor Disorders Consortium Quality Improvement Database Pilot.

BACKGROUND: Pelvic organ prolapse is reported in 30% of women presenting with rectal prolapse. Combined repair is a viable option to avoid the need for future pelvic floor interventions. However, the added impact of adding a modicum of middle compartment suspension by closing the pouch of Douglas during a rectal prolapse repair has not been studied. OBJECTIVE: The study aimed to assess the impact of middle compartment suspension on the durability of rectal prolapse repair. We also aimed to determine whether adding some form of pouch of Douglas closure to achieve middle compartment suspension leads to any improvements in the rates or severity of postoperative constipation or in the rates or severity of postoperative fecal incontinence. DESIGN: This study was a retrospective analysis of a multicenter prospective database. SETTING: Data were analyzed from the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery database. Deidentified surgeons at more than 20 sites (75% academic, 81% high volume) self-reported patient demographics, previous repairs, symptoms of fecal incontinence and obstructed defecation, and operative details, including addition of concomitant gynecologic repairs, use of mesh, posterior or ventral dissection, and sigmoidectomy. PATIENTS: Patients were included who underwent abdominal repair for rectal prolapse. INTERVENTIONS: Abdominal rectopexy procedures with and without middle compartment suspension were compared. Middle compartment suspension was defined as excision and closure of the pouch of Douglas with some degree of colpopexy or culdoplasty. MAIN OUTCOME MEASURES: The primary outcome of prolapse recurrence and secondary outcomes of incontinence and constipation were calculated via univariate and multivariable regression by comparing those who underwent rectopexy with and without middle compartment suspension. RESULTS: Of the 198 patients (98% female, age 60.2 ± 15.6 years) who underwent abdominal repairs (59% robotic), 138 patients (70%) underwent some concomitant middle compartment suspension. Patients who had an added middle compartment suspension seemed to have lower early rectal prolapse recurrences. On multivariable regression to control for age, previous repairs, and the use of mesh, addition of some form of pouch of Douglas repair was associated with a decrease in short-term recurrences. LIMITATIONS: Our data need to be interpreted cautiously. Future studies are critically needed to further explore this observation, with an a priori, prospective definition of middle compartment suspension, validated measurement of concomitant pathology, and longer follow-up. CONCLUSION: Our results suggest that some middle compartment suspension at the time of rectal prolapse repair may improve short-term durability of rectal prolapse repair. See Video Abstract at http://links.lww.com/DCR/C30 . LA REPARACIN CONCOMITANTE DEL PROLAPSO DE RGANOS PLVICOS EN EL MOMENTO DE LA RECTOPEXIA AFECTA LAS TASAS DE RECURRENCIA DEL PROLAPSO RECTAL UNA REVISIN RETROSPECTIVA DE UNA BASE DE DATOS RECOPILADA PROSPECTIVAMENTE DEL CONSORCIO SOBRE LA MEJORA DE LA CALIDAD DE TRASTORNOS DEL PISO PLVICO: ANTECEDENTES:El prolapso de órganos pélvicos se informa en el 30 % de las mujeres que presentan prolapso rectal y la reparación combinada es una opción viable para evitar la necesidad de futuras intervenciones del suelo pélvico. Sin embargo, no se ha estudiado el impacto adicional de agregar un mínimo de suspensión del compartimento medio cerrando el fonde de saco de Douglas durante una reparación de prolapso rectal.OBJETIVO:Nuestro objetivo fue evaluar el impacto de la suspensión del compartimento medio con respecto a la durabilidad de la reparación del prolapso rectal. Quisimos de igual manera determinar si el agregado de algún tipo de cierre del fondo de saco de Douglas para lograr la suspensión del compartimento medio conduce a alguna mejora en las tasas o la gravedad del estreñimiento posoperatorio así como en las tasas o la gravedad de la incontinencia fecal posoperatoria.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.ESCENARIO:Base de datos Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement. Cirujanos no identificados en >20 sitios (75% académicos, 81% de alto volumen) datos demográficos de pacientes auto informados, reparaciones previas, síntomas de incontinencia fecal y defecación obstruida, y detalles quirúrgicos, incluida la suma de reparaciones ginecológicas concomitantes, uso de malla, disección anterior o posterior y sigmoidectomía.INTERVENCIONES:Se compararon los procedimientos de rectopexia abdominal con y sin suspensión del compartimento medio). La suspensión del compartimento medio se definió como la escisión y cierre del fondo de saco de Douglas con algún grado de colpopexia o culdoplastia.RESULTADOS:El resultado principal de la recurrencia del prolapso y los resultados secundarios de incontinencia y estreñimiento se calcularon mediante regresión uni y multivariable al comparar los que fueron sometidos a rectopexia con y sin suspensión del compartimento medio.PACIENTES:Pacientes sometidos a reparación abdominal por prolapso rectal.RESULTADOS:De los 198 pacientes (98% mujeres, edad 60,2 ± 15,6 años) sometidas a reparaciones abdominales (59% robótica), 138 (70%) fueron sometidas igualmente y de manera concomitante a alguna suspensión del compartimento medio. Los pacientes a los que se les añadió una suspensión del compartimento medio parecían tener menores recurrencias tempranas del prolapso rectal y, en la regresión multivariable para controlar la edad, las reparaciones previas y el uso de malla, la adición de alguna forma de reparación del fondo de saco de Douglas se asoció con una disminución de las recurrencias a corto plazo.LIMITACIONES:Nuestros datos deben interpretarse con cautela. Se necesitan de manera critica, estudios futuros para explorar más a fondo esta observación, con una definición prospectiva a priori de la suspensión del compartimento medio, una medición validada de la patología concomitante y un seguimiento más prolongado.CONCLUSIONES:Nuestros resultados sugieren que alguna suspensión del compartimento medio en el momento de la reparación del prolapso rectal puede mejorar la durabilidad a corto plazo de la reparación del prolapso rectal. Consulte Video Resumen en http://links.lww.com/DCR/C30 . (Traducción-Dr. Osvaldo Gauto ).

HPV vaccine introduction in the Americas: a decade of progress and lessons learned.

INTRODUCTION: Human papillomavirus (HPV) is an important public health concern due to its causative role in many cancers, especially cervical cancer, and other conditions that lead to serious health consequences in both men and women. In Latin America and the Caribbean, nearly 60,000 new cases of cervical cancer and another 7,000 HPV-associated cancers are diagnosed annually. AREAS COVERED: HPV vaccination combined with comprehensive cervical cancer control programmingis paving the way for eliminating cervical cancer as a major public health problem and drastically reducing other HPV-associated diseases. To date, 44 countries and territories in the Americas have introduced HPV vaccines as part of their national immunization programs and cervical cancer control strategies. Early lessons from HPV vaccine introduction suggest that transparent and credible evidence-based decision-making, information, education and communication about HPV and cervical cancer, coordination with existing cervical cancer control initiatives, and precise planning for ensuring effective uptake of the vaccine in target groups are all critical elements of success. EXPERT OPINION: There is an urgent need for strategies to increase HPV vaccine coverage, and as the integrated control programs evolve and other HPV-associated disease becomes important for public health, there will be a need for continued program and policy evaluation.

Aetiology and incidence of diarrhoea requiring hospitalisation in children under 5 years of age in 28 low-income and middle-income countries: findings from the Global Pediatric Diarrhea Surveillance network.

INTRODUCTION: Diarrhoea remains a leading cause of child morbidity and mortality. Systematically collected and analysed data on the aetiology of hospitalised diarrhoea in low-income and middle-income countries are needed to prioritise interventions. METHODS: We established the Global Pediatric Diarrhea Surveillance network, in which children under 5 years hospitalised with diarrhoea were enrolled at 33 sentinel surveillance hospitals in 28 low-income and middle-income countries. Randomly selected stool specimens were tested by quantitative PCR for 16 causes of diarrhoea. We estimated pathogen-specific attributable burdens of diarrhoeal hospitalisations and deaths. We incorporated country-level incidence to estimate the number of pathogen-specific deaths on a global scale. RESULTS: During 2017-2018, 29 502 diarrhoea hospitalisations were enrolled, of which 5465 were randomly selected and tested. Rotavirus was the leading cause of diarrhoea requiring hospitalisation (attributable fraction (AF) 33.3%; 95% CI 27.7 to 40.3), followed by Shigella (9.7%; 95% CI 7.7 to 11.6), norovirus (6.5%; 95% CI 5.4 to 7.6) and adenovirus 40/41 (5.5%; 95% CI 4.4 to 6.7). Rotavirus was the leading cause of hospitalised diarrhoea in all regions except the Americas, where the leading aetiologies were Shigella (19.2%; 95% CI 11.4 to 28.1) and norovirus (22.2%; 95% CI 17.5 to 27.9) in Central and South America, respectively. The proportion of hospitalisations attributable to rotavirus was approximately 50% lower in sites that had introduced rotavirus vaccine (AF 20.8%; 95% CI 18.0 to 24.1) compared with sites that had not (42.1%; 95% CI 33.2 to 53.4). Globally, we estimated 208 009 annual rotavirus-attributable deaths (95% CI 169 561 to 259 216), 62 853 Shigella-attributable deaths (95% CI 48 656 to 78 805), 36 922 adenovirus 40/41-attributable deaths (95% CI 28 469 to 46 672) and 35 914 norovirus-attributable deaths (95% CI 27 258 to 46 516). CONCLUSIONS: Despite the substantial impact of rotavirus vaccine introduction, rotavirus remained the leading cause of paediatric diarrhoea hospitalisations. Improving the efficacy and coverage of rotavirus vaccination and prioritising interventions against Shigella, norovirus and adenovirus could further reduce diarrhoea morbidity and mortality.

Prognostic performance of the 'DICA' endoscopic classification and the 'CODA' score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study.

OBJECTIVE: To investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA). DESIGN: A multicentre, prospective, international cohort study. SETTING: 43 gastroenterology and endoscopy centres located in Europe and South America. PARTICIPANTS: 2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications. INTERVENTIONS: A 3-year follow-up was performed. MAIN OUTCOME MEASURES: To predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score). RESULTS: The 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p<0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p<0.001), respectively. The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10% and <2.5% in CODA B; >10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981). CONCLUSIONS: DICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score. TRIAL REGISTRATION NUMBER: NCT02758860.