Trastornos circadianos del sueño / Circadian Sleep Disorders

Resumen El sistema circadiano está sincronizado al ciclo luz-oscuridad que es generado por la rotación de la tierra, asegurando que la vigilia sea durante el día y que el sueño ocurra durante la noche. Sin embargo, el ritmo de sueño-vigilia puede estar desincronizado del ciclo luz-oscuridad o desincronizado de manera endógena, dando como resultado: insomnio, fatiga y bajo rendimiento en las actividades cotidianas. Mientras que los trastornos del sueño están clasificados por la Asociación Americana de Trastornos del Sueño como: disomnias intrínsecas, disomnias extrínsecas, parasomnias o trastornos del sueño médicos/psiquiátricos. Los trastornos circadianos del sueño se han categorizado por separado, en parte para reconocer que en la mayoría de los casos la etiología de los trastornos circadianos es una mezcla de factores internos y ambientales, o por un desajuste temporal entre ambos. Los síntomas generalmente son insomnio o hipersomnia, síntomas comunes en pacientes con trastornos circadianos del sueño, aunque hay otras causas a las que pueden atribuirse y que deben excluirse antes de realizar el diagnóstico de un trastorno circadiano del sueño. En el paciente sin otra patología del sueño, un registro diario de actividades, comidas, ejercicio, siestas y la hora de acostarse es una herramienta esencial para evaluar los trastornos circadianos del sueño. Estos registros deben mantenerse durante 2 semanas o más, ya que una perturbación debida a cambios de trabajo o viajes a través de zonas horarias puede tener efectos sobre el sueño y el estado de alerta durante el día, semanas después del evento.

Abstract The circadian system is synchronized to the light-dark cycle generated by the rotation of the earth, ensuring that wakefulness is during the day and sleep occurs at night. However, the sleep-wake rhythm may be out of sync with the light-dark cycle or endogenously out of sync, resulting in insomnia, fatigue, and poor performance in activities of daily living. Sleep disorders are classified by the American Sleep Disorders Association, as intrinsic dyssomnias, extrinsic dyssomnias, parasomnias, or medical/psychiatric sleep disorders. Circadian sleep disorders have been categorized separately to recognize that in most cases the etiology of circadian disturbances is a mix of internal and environmental factors or a temporary mismatch between the two. Symptoms are usually insomnia or hypersomnia, common symptoms in patients with circadian sleep disorders although other causes can be attributed and must be excluded before a diagnosis of a circadian sleep disorder is made. In the patient without other sleep pathology, a daily record of activities, meals, exercise, naps, and bedtime is an essential tool in assessing circadian sleep disorders. These records should be kept for 2 weeks or more, as a disturbance due to job changes or travel across time zones can have effects on sleep and daytime alertness weeks after the event.

Cutting Edge: Hyperinflammatory Monocytes Expressing CD56 Abound in Severe COVID-19 Patients.

Proinflammatory monocytes play a preponderant role in the development of a cytokine storm causing fatal consequences in coronavirus disease 2019 (COVID-19) patients, highlighting the importance of analyzing in more detail monocyte distribution in these patients. In this study, we identified an atypical monocyte subpopulation expressing CD56 molecules that showed a low level of HLA-DR and high level of l-selectin. They released higher amounts of TNF-α and IL-6 and expressed genes associated with an excessive inflammatory process. Remarkably, the frequency of CD56+ monocytes inversely correlated with that of CD16+ monocytes and a high CD56+/CD16+monocyte ratio was associated with both disease severity and mortality, as well as with serum concentration of type I IFN, a factor able to induce the appearance of CD56+ monocytes. In conclusion, severe COVID-19 is characterized by the abundance of hyperinflammatory CD56+ monocytes, which could represent a novel marker with prognostic significance and, possibly, a therapeutic target for controlling the inflammatory process occurring during COVID-19.

Ultrasound-guided placement of long peripheral cannula in children with cystic fibrosis.

BACKGROUND: The natural history of cystic fibrosis (CF) lung disease is a chronic deterioration of lung function with intermittent episodes of pulmonary infectious exacerbations (PExs). Reliable venous access is a milestone of effective management of such exacerbations, managed both in hospital and outpatient chronic therapy. The aim of our study was to analyze the feasibility of ultrasound-guided positioning of long peripheral catheters (LPC) as reliable midterm venous access in children affected by CF. METHODS: In this single-center prospective study, over a 60-month period, we included paediatric CF subjects admitted with PExs and undergoing intravenous antibiotic treatment. LPCs were inserted in all participants by paediatric anaesthesiologists with ultrasound guide technique. Prospective data were collected assessing catheter positioning procedure and complications. RESULTS: A total of 122 LPC insertions were performed in 55 CF children. Participants had a median age of 6.75 years (interquatile range: 3.7-13.5) at the time of catheter insertion. Implantation was successful on the first attempt in 86% of cases; 2 (1%) major insertion-related complications were reported. Eighty-eight percent of catheters were electively removed at the end of antibiotic therapy without any complication. Seven percent of the catheters were removed electively for occlusion and 2% for local dislodgment. CONCLUSIONS: The results of the present study suggest that ultrasound-guided positioning of LPCs are safe alternative means of peripheral venous access in children with chronic diseases such as CF.

Wunderlich Syndrome Associated With Angiomyolipomas.

Wünderlich syndrome (WS) is a spontaneous retroperitoneal hemorrhage confined to the subcapsular or perinephric space without a history of trauma. Since it is a rare condition with a significant mortality rate if not treated timely, it is essential to identify its risk factors and early clinical manifestations for a favorable outcome. Various conditions are associated, but the most common causes are benign and malignant renal neoplasms. We present a 26-year-old female with a history of tonic-clonic seizures who presented to the ED with intense abdominal pain located on the right flank with a palpable mass. Management included IV fluids and blood transfusion. She underwent a right total nephrectomy. She was later diagnosed with tuberous sclerosis. A 44-year-old female with a three-year history of right costovertebral pain and recurrent urinary tract infections that presented to the ED with acute right flank pain was diagnosed with WS secondary to an angiomyolipoma and underwent right total nephrectomy. WS is a very rare pathology that represents a diagnostic challenge for the physician. The treatment will depend on the hemodynamic condition of the patient. Active follow-up should be reserved for those who have small tumors, are asymptomatic, and have hemodynamic stability. Surgical or radiology intervention is reserved for those who are hemodynamically unstable or who have a suspicion of renal cell carcinoma.

Radiation Oncology Residency Training in Latin America: A Call to Attention.

Purpose: Despite the call to increase the number of radiation oncologists in Latin America, the quality, similarity, and number of residency training programs are unknown. We seek to describe the current state of residency programs in radiation oncology in Latin America. Methods and Materials: Latin American Residents in Radiation Oncology performed a cross-sectional analysis of universities and training centers for radiation oncologists in Latin America. Latin American Residents in Radiation Oncology members identified and contacted current residents and specialists at each center to obtain information and documents that described their training curricula. Results: As of 2020, 13 of 23 (56.5%) Latin American countries have radiation oncology training. Seventy-three training centers were identified (59 active and 14 inactive), associated with 28 universities. On average, each active center trains 2.6 new residents per year, and in total, 156 residents are trained annually. The average length of training programs is 3.6 years. Brazil and Mexico comprise 31 (52.5%) and 7 (11.9%) of active programs, respectively, and 64 (41.8%) and 50 (32.7%) residents, respectively. Training is available in 38 cities in 13 countries, and outside Brazil and Mexico, only 13 cities in 11 countries (9 capitals and 4 noncapital cities). Individualized curriculum documents were provided by 20 (83.3%) of 24 non-Brazilian programs, while 1 standardized guideline was provided for Brazilian training programs. These demonstrated variation between subjects taught, their devoted time, outside specialty rotations, and experiences in modern techniques. Seventy-five percent include volumetric modulated arc therapy, 70% stereotactic radiosurgery, and 55% stereotactic body radiation therapy training. One-hundred percent include gynecologic brachytherapy education and <50% brachytherapy education in other disease sites. Conclusions: Training is highly centralized in capital cities. The number of trainees is insufficient to close the current human resource divide but is limited by available job openings. Over 50% of training programs now include technological training in stereotactic radiosurgery, stereotactic body radiation therapy, or volumetric modulated arc therapy; however, substantial variation still exists. The development of radiation oncology specialists must be improved and modernized to address the escalating demand for cancer care.

Evaluación de la calidad de la atención en los servicios ambulatorios desde la perspectiva del paciente hipertenso / Evaluation of the Quality of Care in Outpatient Services in Hypertensive Patients

Introducción: El manejo de la hipertensión arterial es un desafío para el sistema de salud hondureño, existe insuficiente información para evaluar la calidad de la atención desde la percepción del paciente sobre los servicios de salud recibidos. Objetivo: Evaluar la calidad de la atención a pacientes hipertensos en los servicios ambulatorios de la Secretaría de Salud de Honduras, entre abril de 2017 y abril de 2018. Métodos: Estudio cuantitativo, descriptivo, transversal. La muestra fue de 6720 encuestados mayores de 20 años con hipertensión arterial, abordados de manera ambulatoria en unidades de la Secretaría de Salud de Honduras. Se obtuvo información sobre estructura física de unidades de salud, procesos en la atención y grado de satisfacción de usuarios sobre la atención recibida. Resultados: El 54,4 por ciento (3662) de los entrevistados provenían de área urbana y el 45,5 por ciento (3058) área rural, el 73,6 por ciento (4945) eran del sexo femenino, antecedentes de padecer sobrepeso el 17,3 por ciento (1,164), el 28,9 por ciento (1944) presentaban colesterol y triglicéridos altos. En los procesos de atención se les realizó la medición de niveles de tensión arterial al 94,9 por ciento (6379). Conclusiones: Los pacientes valoraron como buena la calidad de la atención recibida y consideraron que le dieron respuesta a su problema de salud. La estructura de servicios se valoró con insuficientes recursos humanos, materiales, medios diagnósticos y medicamentos con instalaciones físicas con deficiencias (reducidas, poca ventilación)(AU)

Introduction: The management of arterial hypertension is a challenge for the Honduran health system; there is insufficient information to evaluate the quality of care from the patient's perception of the health services received. Objective: To evaluate the quality of care in the outpatient services of the Ministry of Health, in Honduras, for hypertensive patients, from April 2017 to April 2018. Methods: This a quantitative, descriptive, cross-sectional study. The sample consisted of 6,720 respondents older than 20 years with arterial hypertension, who were treated on an outpatient basis in units of the Honduran Ministry of Health. The information was gathered from the physical structure of health units, care processes and the degree of user satisfaction of the care received. Results: 54.4percent (3,662) of the interviewees came from urban areas and 45.5percent (3,058) from rural areas. 73.6percent (4,945) were female, with overweight history in 17.3percent (1,164), 28.9percent (1944) had high cholesterol and triglycerides. Blood pressure levels were measured to 94.9percent (6379) in the care processes. Conclusions: The patients rated the quality of care received as good and considered that it responded to their health problem. The structure of services was assessed as having insufficient human resources, materials, diagnostic means and medicines and deprived physical facilities (small, poor ventilation)(AU)

Perfil neuropsicológico en pacientes con trauma craneoencefálico atendidos en un hospital de alta complejidad de Medellín, Colombia / Neuropsychological profile of patients with traumatic brain injury evaluated in a high complexity hospital in Medellin, Colombia

RESUMEN INTRODUCCIÓN: El trauma craneoencefálico (TCE) es una de las principales causas de daño cerebral y discapacidad en personas menores de 40 años. Según su severidad, se puede clasificar en leve, moderado o grave, en función de la escala de coma de Glasgow. Muchos pacientes quedan con secuelas neuropsicológicas y comportamentales que pueden afectar en mayor o menor grado su funcionalidad. El objetivo del estudio fue determinar las diferencias en el perfil neuropsicológico, las características clínicas y el compromiso funcional en pacientes con TCE según la clasificación de la severidad. METODOLOGÍA: Se realizó un estudio observacional, analítico, de corte transversal. Se revisaron las historias clínicas y los reportes neuropsicológicos de adultos con TCE evaluados por neuropsicología entre los años 2014 y 2019. Se compararon los resultados de pruebas neuropsicológicas, síndromes neuropsicológicos y funcionalidad según la severidad del TCE. RESULTADOS: Se estudiaron 48 pacientes, 38 de ellos hombres (73 %), con una mediana de edad de 35 años (RI: 25-51). En 14 casos el TCE fue leve, en 18 moderado y en 16 severo. El síndrome neuropsicológico más frente fue el amnésico (100 %), seguido del disejecutivo (79 %) y el compromiso en la atención (77 %). No se encontraron diferencias según severidad del TCE. Cuarenta y un pacientes (85 %) presentaron cambios comportamentales, 14 (29 %) experimentaron alteración en las actividades básicas de la vida diaria y 32 (68 %) en las actividades instrumentales. CONCLUSIONES: Las alteraciones neuropsicológicas, comportamentales y funcionales posteriores a un TCE son frecuentes, sin embargo, no se encontraron diferencias significativas según severidad del trauma.

ABSTRACT INTRODUCTION: Traumatic Brain Injury (TBI) is one of the main causes of brain damage and disability in people under 40 years of age. The severity of TBI can be classified as mild, moderate, or severe based on the Glasgow coma scale. Many patients are left with neuropsychological and behavioral sequelae that can affect functionality to a greater or lesser degree. The objective of the study was to determine the differences in the neuropsychological profile, clinical characteristics and functional impairment in patients with TBI according to severity. METHODOLOGY: An observational, analytical, cross-sectional study was carried out. The clinical records and neuropsychological reports of adults with TBI evaluated between 2014 and 2019 were reviewed. The results of neuropsychological tests, neuropsychological syndromes, and functionality according to severity of TBI were compared. RESULTS: 48 patients were studied, 35 were males (73 %), the median age was 35 years (IR: 25-51). In 14 TBI was mild, in 18 moderate and 16 severe. The most common neuropsychological syndrome was amnesic (100 %) followed by dysexecutive (79 %) and attentional commitment (77 %). No differences were found according to severity of TBI. 41 patients (85 %) presented behavioral changes, 14 (29 %) presented alteration in basic activities of daily life and 32 (68 %) in instrumental activities. CONCLUSIONS: Neuropsychological, behavioral and functional alterations are frequent after TBI; however, no significant differences were found according to the severity of the trauma.

Mandible bone density in adolescents with cerebral palsy using antiepileptic drugs / Densidade óssea da mandíbula em adolescentes com paralisia cerebral em uso de drogas antiepilépticas

Objective: The aim of this study was to assess the bone density of the mandible in adolescents with cerebral palsy (CP) treated with antiepileptic drugs using one beam computed tomography (CBCT). Methods: The study was carried out with 18 adolescents aged 12­18 years, undergoing routine dental treatment at the dental clinic of APCD-São Caetano do Sul. CBCT scans were of divided into two groups: G1 adolescents with CP using antiepileptic drugs and G2 normoactive adolescents. A single dentomaxillofacial radiologist assessed and evaluated the images using Dental Slice software and Image J. Fisher's exact tests as well as paired and unpaired Student's t-tests were performed. Results: Groups differed significantly with regard in the values of density (p < 0.001), with G1 presenting lower values compare to G2. G1 showed significantly lower density means on the right side, left side, and right/left sides of the mandible edge than G2 (p < 0.001). Conclusion: CP patients using antiepileptic drugs show evidence of bone mineral density loss of the mandible.(AU)

Objetivo: O objetivo deste estudo foi avaliar a densidade ótica óssea da mandíbula em adolescentes com paralisia cerebral (PC) tratados com drogas antiepilépticas por meio de tomográfica computadorizada de feixe cônico (TCFC). Métodos: O estudo foi realizado com 18 adolescentes de 12 a 18 anos, em tratamento odontológico de rotina na clínica odontológica da APCD-São Caetano do Sul. As TCFC foram divididas em dois grupos: G1 adolescentes com PC em uso de antiepilépticos e G2 adolescentes normoativos. Um único radiologista dentomaxilofacial assessou e avaliou as imagens usando usando os softwares Dental Slice e Image J. Os testes exatos de Fisher, bem como os testes t de Student pareados e não pareados foram realizados. Resultados: Os grupos diferiram significativamente quanto aos valores de densidade óptica (p <0,001), com o grupo G1 apresentando valores menores em relação ao G2. O grupo G1 apresentou médias de densidade óptica significativamente menores nos lados direito, esquerdo e direito / esquerdo da borda da mandíbula do que o G2 (p <0,001). Conclusão: Pacientes com PC em uso de drogas antiepilépticas apresentam evidências de perda de densidade óssea da mandíbula (AU)

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks.

ABSTRACT: Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results.

BACKGROUND: Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. METHOD: prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. RESULTS: Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. CONCLUSIONS: We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.

Human cornea conservation in coconut water solution / Conservação de córneas humanas em solução de água de coco

ABSTRACT Purpose: The aim of this study was to evaluate the physical and chemical characteristics of coconut water and to analyze the use of coconut water solution for the conservation of human corneas. Methods: This was an experimental and controlled study performed at the Eye Bank of the General Hospital of Fortaleza. The coconut water-based solution was prepared at the Goat Seed Technology Laboratory of the Department of Veterinary Medicine of the State University of Ceará. Discarded corneas from the Eye Bank were divided into two groups for sequential experiments: G1, coconut water-based solution (experimental group), and G2, conservative treatment with OPTISOL GS® (control group). The osmolality of corneas in G1 was analyzed sequentially at 275, 300, 325, 345, 365, and 400 mOsm/L. The viability of the corneas was determined by specular microscopy and biomicroscopy on the first, third, and seventh days. Results: Corneas preserved in a solution of 365 and 345 mOsm/L had a transparency of 8 mm until the third day and had diffuse edema in the periphery, central folds, and partial epithelium loss until the seventh day. The 365-mOsm/L solution was associated with the worst results during follow-up. Corneas placed in Optisol-GS retained their original aspects. Conclusions: Coconut water-based preservative partially maintained corneal transparency and epithelial integrity, especially during the first three days of follow-up. The coconut water-based solutions used were not effective for use as preservatives in a human eye bank.(AU)

RESUMO Objetivos: As características físico-químicas e o baixo custo da água de coco foram fundamentais para o este estudo. Analisar o uso de solução a base de água de coco como meio de conservação de córneas humanas em banco de olhos. Métodos: Estudo experimental e controlado realizado no Banco de Olhos do Hospital Geral de Fortaleza. Utilizou-se solução à base de água de coco preparada no laboratório de Tecnologia de Sêmen de Caprinos do Departamento de Medicina Veterinária da Universidade Estadual do Ceará. Foram usadas córneas de descartes divididas em dois grupos: G1 (Conservante com água de coco) - grupo experimental e G2 (grupo Conservante com OPTISOL GS®) grupo controle, em experimentos sequenciais. A osmolaridade do G1 foi analisada sequencialmente com 275, 300, 325, 345, 365 e 400 mOsm/L. A viabilidade das córneas foram realizadas por microscopia especular e biomicroscopia nos 1º, 3º e 7º dias. Resultados: As córneas em solução de 365 e 345 mOsm/L apresentavam transparência nos 8mm centrais até o 3º dia, com edema em toda periferia, dobras centrais e edema 2+, com perda parcial do epitélio até 7º dia, sendo o de maior osmolaridade com melhor transparência durante o seguimento. Grupo com 275, 300 e 400 mOsm/L, córnea opaca, edema difuso, perda total do epitélio no 3º dia. As córneas em Optisol mantiveram seus aspectos. Conclusões: O conservante à base de água de coco manteve em parte a transparência corneana e a integridade epitelial, especialmente nos primeiros 3 dias de seguimento. A solução conservante com água de coco nas formulações utilizadas não se mostrou eficaz para o uso em banco de olhos humanos.(AU)

A meta-analytic review for the patella sexual dimorphism assessment / Una revisión meta-analítica para la evaluación del dimorfismo sexual de la patela

Sexual dimorphism is one of the most important ways to identify bone remains in mass disasters. Many of them have been used for this purpose; mainly skull, pelvis and long bones. However, only a few studies using the patella have been done and, to our knowledge, there are no assessments of previous results in the literature. Meta-analysis provides a useful strong tool to test, in a systematic way, the most relevant information about a given research field. The aim of this study is to apply the meta-analytic technique to assess the major studies concerning sexual dimorphism in the patella by measuring classical metric traits: maximum height and maximum width, with different techniques, such as caliper, radiography, tomography and magnetic resonance. The 17 papers found, involving a total sample size higher than 2600 patellae, showed a very high heterogeneity- around 93 % of I2 value, for height and width measurements when all the studies were analyzed together. Homogeneity increased when each study was classified according to the techniques used. In this case, a statistical difference appeared, among the several subgroups of techniques for the two measurements, suggesting the importance of the methodology used. Maximum height and maximum width were all showed to be statistically relevant in distinguishing both sexes.

El dimorfismo sexual es una de las formas más importantes para identificar restos óseos en desastres masivos. Se han utilizado huesos como cráneo, pelvis y huesos largos para la diferenciación sexual. Sin embargo, solo se han realizado unos pocos estudios con la patela y, hasta donde sabemos, no hay evaluaciones de resultados anteriores en la literatura. El meta-análisis proporciona una herramienta sólida y útil para probar, de manera sistemática, la información más relevante sobre un cierto campo de investigación. El objetivo de este estudio consiste en aplicar la técnica metaanalítica para evaluar los principales estudios sobre dimorfismo sexual en la patela midiendo los rasgos métricos clásicos: altura máxima y anchura máxima, con diferentes técnicas: calibre, radiografía, tomografía y resonancia magnética. Los 17 de documentos encontrados, con un tamaño de muestra total superior a 2600 patelas, mostraron una heterogeneidad muy alta, alrededor del 93 % del valor de I2, para mediciones de altura y anchura cuando todos los estudios se analizaron juntos. La homogeneidad aumentó cuando cada estudio se clasificó de acuerdo con las técnicas utilizadas. En este caso, se observó diferencias estadísticas, entre los subgrupos de técnicas para las dos mediciones, lo que sugiere la importancia de la metodología utilizada. La altura máxima y la anchura máxima mostraron ser estadísticamente relevantes para distinguir ambos sexos.

Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results.

BACKGROUND: Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. METHOD: prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. RESULTS: Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. CONCLUSIONS: We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.

Factores de riesgo de complicaciones respiratorias en cirugía oncológica de mama con anestesia total intravenosa / Risk factors of respiratory complications in breast cancer surgery with total intravenous anesthesia

A prospective longitudinal cohort study was performed in patients with breast cancer operated surgically with the use of total intravenous anesthesia in the provincial hospital Carlos Manuel de Céspedes de Bayamo, from the Cauto region during the period from January 1 from 2014 to December 31, 2016, with the aim of identifying the risk factors hypothetically related to the appearance of respiratory complications. It was established that the exposed cohort was constituted by 79 patients who developed complications during the study period and met the inclusion criteria. The diagnosis of respiratory complications was made during the entire surgical procedure and finished. The magnitude of the associations was estimated by calculating the relative risks (RR) of complications. The age of the patient equal to or greater than 65 years, and smoking were the surgical risk factors depending on the patient related to the onset of respiratory complications in breast cancer surgery with total intravenous anesthesia, not alcoholism. Anemia, obesity, low weight and recent respiratory tract infection were surgical risk factors dependent on associated diseases related to the appearance of respiratory complications. The ASA III-IV classification and the surgical time of more than three hours were surgical risk factors related to surgery related to the appearance of respiratory complications.

Se realizó un estudio longitudinal prospectivo de cohorte en pacientes con cáncer de mama intervenidos quirúrgicamente con el empleo de anestesia total intravenosa en el hospital provincial "Carlos Manuel de Céspedes de Bayamo, procedentes de la región del Cauto durante el período comprendido desde el 1ro de enero de 2014 hasta 31 de diciembre de 2016, con el objetivo de identificar los factores de riesgo hipotéticamente relacionados con la aparición de complicaciones respiratorias. Se estableció que la cohorte expuesta estuvo constituida por 79 pacientes que desarrollaron complicaciones en el período de estudio y cumplieron con los criterios de inclusión. La evaluación del diagnóstico de complicaciones respiratorias se realizó durante todo el procedimiento quirúrgico y terminado éste. La magnitud de las asociaciones se estimó mediante el cálculo de los riesgos relativos (RR) de complicaciones. La edad de la paciente igual o superior a 65 años, y el tabaquismo fueron los factores de riesgo quirúrgico en función del enfermo relacionados con la aparición de complicaciones respiratorias en cirugía oncológica de mama con anestesia total intravenosa, no así el alcoholismo. La anemia, la obesidad, bajo peso y la infección reciente del tracto respiratorio fueron los factores de riesgo quirúrgico dependiente de enfermedades asociadas relacionados con la aparición de complicaciones respiratorias. La clasificación ASA III-IV y un tiempo quirúrgico superior a tres horas se constituyeron en los factores de riesgo quirúrgico en función de la cirugía relacionados con la aparición de complicaciones respiratorias.

Bio-behavioral survey of syphilis in homeless men in Central Brazil: a cross-sectional study / Um inquérito bio-comportamental sobre sífilis em homens sem-teto no Centro-oeste do Brasil: um estudo transversal / Cuestionario bioconductual sobre la sífilis en hombres sin techo en el Centro-oeste de Brasil: un estudio transversal

The objective of this study was to investigate the prevalence and factors associated with syphilis in homeless men in Central Brazil. It is a cross-sectional study conducted with 481 individuals attending four therapeutic communities between October and December 2015. A structured interview was conducted to collect sociodemographic data and risk factors for syphilis. Rapid/point-of-care and VDRL tests were performed to determine exposure to syphilis and the presence of active syphilis, respectively. Poisson regression analysis was used to verify the risk factors associated with the outcomes investigated. Of the study participants, 10.2% were reactive to the rapid test, and 5.4% had active syphilis. At the multiple regression analysis, schooling (adjusted prevalence ratio - APR: 0.89; p = 0.005), history of genital ulcer (APR: 2.59; p = 0.002), STI history (APR: 1.97; p = 0.042), and sexual intercourse under drug effects (APR: 1.60; p = 0.022) were independent factors associated with lifetime syphilis. Also, history of genital ulcer (APR: 2.19; p = 0.019), STI history (APR: 1.74; p = 0.033) and number of sexual partners in the last year (APR: 1.02; p = 0.044) were associated with active syphilis. The prevalence of syphilis among homeless men was rather high, confirming the vulnerability of this group to this infection. These results emphasize the need for educational intervention, improvement of risk reduction programs, availability of diagnostic tests, especially the rapid test, and treatment.

O estudo teve como objetivo investigar a prevalência da sífilis e fatores associados em homens sem-teto no Centro-oeste do Brasil. A amostra nesse estudo transversal incluiu 481 indivíduos que frequentavam comunidades terapêuticas entre outubro e dezembro de 2015. Uma entrevista estruturada foi usada para coletar dados sociodemográficos e fatores de risco para sífilis. Foram realizados testes rápidos e VDRL para determinar a exposição à sífilis e a presença de sífilis ativa, respectivamente. A análise de regressão de Poisson foi usada para verificar os fatores de risco associados aos desfechos investigados. Entre os participantes, 10,2% foram reativos ao teste rápido e 5,4% tinham sífilis ativa. Na análise de regressão múltipla, a escolaridade (razão de prevalência ajustada - RPA: 0,89; p = 0,005), história de úlcera genital (RPA: 2,59; p = 0,002), história de DST (RPA: 1,97; p = 0,042) e relações sexuais sob o efeito de drogas (RPA: 1,60; p = 0,022) apareceram como fatores independentes associados à história pregressa de sífilis. Além disso, a história de úlcera genital (RPA: 2,19; p = 0,019), história de DST (RPA: 1,74; p = 0,033) e número de parceiros sexuais no último ano (RPA: 1,02; p = 0,044) estiveram associados à sífilis ativa. A prevalência de sífilis em homens sem-teto era bastante elevada, confirmando a vulnerabilidade desse grupo à infecção. Os achados enfatizam a necessidade de intervenções educacionais, melhoria dos programas de redução de risco, disponibilidade de testes diagnósticos (sobretudo o teste rápido) e tratamento adequado.

El objetivo de este estudio fue investigar la prevalencia y los factores asociados con la sífilis en hombres sin techo en el Centro-oeste de Brasil. Se trata de un estudio transversal, llevado a cabo con 481 personas que asistían a cuatro comunidades terapéuticas entre octubre y diciembre de 2015. La entrevista estructurada se realizó con el fin de recabar datos sociodemográficos y factores de riesgo para la sífilis. Se realizaron pruebas de diagnóstico rápido y serológicas para la sífilis (VDRL por sus siglas en inglés) para determinar la exposición a la sífilis y la presencia de sífilis activa, respectivamente. Se usó el análisis por regresión de Poisson para verificar los factores de riesgo asociados con los resultados investigados. Entre los participantes en el estudio, un 10,2% fueron reactivos a las pruebas de diagnóstico rápido, y un 5,4% tenían sífilis activa. En el análisis de regresión múltiple, la escolarización (la razón de prevalencia ajustada - APR: 0,89; p = 0,005), un historial de úlcera genital (APR: 2,59; p = 0,002), un historial de ETS (APR: 1,97; p = 0,042), e intercambios sexuales bajo los efectos de las drogas (APR: 1,60; p = 0,022) fueron factores independientes asociados con la sífilis a lo largo de la vida. Asimismo, un historial de úlcera genital (APR: 2,19; p = 0,019), un historial de ETS (APR: 1,74; p = 0,033) y el número de parejas de índole sexual en el último año (APR: 1,02; p = 0,044) estuvieron asociados con sífilis activa. La prevalencia de sífilis entre los hombres sin techo fue bastante alta, confirmando la vulnerabilidad de este grupo a la infección. Estos resultados enfatizan la necesidad de intervenciones educativas, así como una mejora en los programas de reducción del riesgo, disponibilidad de pruebas de diagnóstico, especialmente pruebas rápidas, y tratamiento.

WITHDRAWN: Corrigendum to "Thiol-ene Michael-type formation of gelatin/poly(ethylene glycol) biomatrices for three-dimensional mesenchymal stromal/stem cell administration to cutaneous wounds" [Acta Biomater. 9(11) (2013) 8802-8814].

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.actbio.2017.06.005. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Initial clinical experience with a polytetrafluoroethylene vascular dialysis graft reinforced with nitinol at the venous end.

OBJECTIVE: The purpose of this study was to examine the outcomes of a vascular hybrid polytetrafluoroethylene (PTFE) graft, provided with a nitinol-reinforced section (NRS) on one end, in hemodialysis vascular access placement. METHODS: A retrospective study was conducted including all the consecutive patients who underwent Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) implantation for hemodialysis access placement between October 2013 and November 2015. A propensity-matched control group was obtained from consecutive patients who underwent standard PTFE arteriovenous graft implantation between January 2010 and July 2013. The selection criteria were inadequate venous material for autogenous arteriovenous fistula placement, patent deep venous circulation, and vein diameter of 4 to 8.5 mm. The implantation technique involves the insertion of the NRS some centimeters into the target vein. Fluoroscopic guidance helps deploy the device in the desired landing zone (ie, position of the proximal end of the NRS), based on anatomic landmarks. Survival, functional patency rates, and complications were compared with a propensity-matched historical control group. Vein diameter, previous vascular access placement, and diabetes were tested as predictors of reintervention with a logistic regression analysis. RESULTS: There were 32 patients (14 men; mean age, 69 ± 14 years) who received the GHVG graft. The historical control group included 43 patients. Technical success was 100%. The graft configuration was brachial-axillary (n = 22 [69%]), brachial-basilic loop (n = 5 [16%]), brachial-antecubital loop (n = 3 [9%]), axilloaxillary loop (n = 1 [3%]), and femoral-femoral loop (n = 1 [3%]). Mean NRS oversize was 20% ± 7% (range, 3%-34%; median, 19%). Perioperative complications requiring revision included acute limb ischemia treated with thrombectomy (n = 1 [3%]) and graft infection requiring explantation (n = 2 [6%]). Two patients (6%) died in the hospital of unrelated causes. The mean follow-up was 15 ± 11 months (range, 0-33 months; median, 15.5). The propensity-matched groups included 25 patients each. Survival estimates at 24 months for the GHVG and standard PTFE groups were 91% ± 6% and 82% ± 9% (P > .05), respectively. The 12-month patency estimates were as follows: functional primary patency, 66% ± 10% vs 51% ± 10% (P > .05); functional assisted primary patency, 75% ± 9% vs 51% ± 10% (P > .05); and functional secondary patency, 79% ± 9% vs 67% ± 10% (P > .05). Reduction in vein diameter was associated with reintervention. CONCLUSIONS: The GHVG is a safe and effective alternative to standard PTFE in hemodialysis access surgery. Careful planning for the landing zone is advisable, especially for small outflow veins. Larger studies and randomized trials are needed to define the role for this device. A study including a greater number of centers experienced with this device is currently under way.

Incisão vertical para remoção de osso autógeno da sínfise mentual: relato de dois casos clínicos / Vertical incision to autogenous bone removal from the mental symphysis: report of two clinical cases

O presente artigo apresenta o relato de dois casos clínicos onde através de uma técnica alternativa de incisão vertical foram removidos tecidos ósseos da região de sínfise mentual para aumento de volume ósseo em outra região para posterior reabilitação com implante osseo integrado. No primeiro relato em um paciente de 40 anos foi removido osso autógeno em bloco da sínfise mentual com a técnica da incisão vertical para aumento vertical na região da pré-maxila associado com biomaterial e posteriormente instalados dois implantes cilíndricos na região dos 12 e 22. O segundo relato, em paciente com 72 anos, removeu osso particulado da região de sínfise mentual e procedeu-se a enxertia do seio maxilar através da técnica da janela lateral e ambas as áreas utilizaram a técnica da incisão vertical.Constatou-se em ambos os casos minimização de edemas e sintomatologia dolorosa pós-operatórias e nenhum paciente relatou parestesia na região doadora, algo comum em casos com a remoção pela técnica tradicional.

This paper presents a report of two cases where using an alternative technique of vertical incision were removed bone tissue of the symphysis chin region to increase bone volume in another region for later rehabilitation with osseointegrated implant. The first report on a 40 year old patient was removed autogenous bone in the chin symphysis block with the vertical incision technique for vertical increase in pre maxilla associated with biomaterial and then installed two cylindrical implants in the region of 12 and 22. The second account in patients with 72 years removed particulate bone symphysis chin region and decided to graft the maxillarysinus through the lateral window technique and both areas have used the technique of vertical incision. It was found in both cases minimizing swelling and postoperative painful symptoms and no patients reported numbness in the donor area, something common in cases with removing the traditional technique.