Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial.

BACKGROUND: Despite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT. METHODS: The Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic "add-on" trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes). RESULTS: The average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82). CONCLUSIONS: In patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function. TRIAL REGISTRATION: The trial is registered on ClinicalTrials.gov: NCT03353272 (27/11/2017).

The influence of a cognitive behavioural approach on changing patient expectations for conservative care in shoulder pain treatment: a protocol for a pragmatic randomized controlled trial.

BACKGROUND: Despite similar outcomes for surgery and conservative care, the number of surgeries to treat rotator cuff related shoulder pain has increased. Interventions designed to enhance treatment expectations for conservative care have been shown to improve patient expectations, but no studies have yet explored whether such interventions influence patient decisions to pursue surgery. The purpose of this randomized clinical trial is to examine the effect of an intervention designed to improve expectations of conservative care on the decision to have surgery. METHODS: We will test the effectiveness of the Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention which is intended to change expectations regarding conservative care. The PEERC intervention will be evaluated in a randomized, pragmatic "add-on" trial, to better understand the effect the intervention has on outcomes. Ninety-four (94) participants with rotator cuff related shoulder pain referred for physical therapy will be randomized to receive either impairment-based care or impairment-based care plus PEERC. Both groups will receive impairment-based conservative treatment created by compiling the evidence associated with established, effective interventions. Participants assigned to the impairment-based care plus PEERC condition will also receive the PEERC intervention. This intervention, informed by principles of cognitive behavioral therapy, involves three components: (1) strategies to enhance engagement, (2) education and (3) cognitive restructuring and behavioral activation. Outcomes will be assessed at multiple points between enrolment and six months after discharge. The primary outcome is patient reported decision to have surgery and the secondary outcomes are pain, function, expectations and satisfaction with conservative care. DISCUSSION: Rotator cuff related shoulder pain is highly prevalent, and because conservative and surgical treatments have similar outcomes, an intervention that changes expectations about conservative care could alter patient reports of their decision to have surgery and ultimately could lead to lower healthcare costs and decreased risk of surgical complications. TRIAL REGISTRATION: This study is registered as NCT03353272 at ClincialTrials.gov.

Top Ten Tips Palliative Care Clinicians Should Know About Diagnosing, Categorizing, and Addressing Fatigue.

Fatigue is a multifactorial symptom that is commonly faced by patients with cancer, chronic disease, and other serious illnesses. Fatigue causes suffering across biopsychosocial domains and affects patients and their loved ones. In this article, a consortium of professionals across cancer care, physical therapy, exercise, pharmacy, psychiatry, and palliative medicine offers tips and insights on evaluating, categorizing, and addressing fatigue in the setting of serious illness. The comprehensive approach to managing fatigue underscores the importance of collaborative efforts characteristic of interdisciplinary palliative care. Prioritizing screening, diagnosing, and treating fatigue is crucial for enhancing patients' and families' overall quality of life.

Do Climate and Environmental Characteristics Influence Concussion Incidence in Outdoor Contact Sports? A Systematic Review.

OBJECTIVE: To obtain a comprehensive understanding of the implications of environmental and climate factors on sport-related concussion incidence in outdoor contact sports. DATA SOURCES: MEDLINE (via Ovid), Embase (via Elsevier), CINAHL Complete (via EBSCOhost), SPORTDiscus (via EBSCOhost), and Scopus (via Elsevier). STUDY SELECTION: Studies that report incidence of sport-related concussion, assess data from athletes participating in outdoor contact sports, report on 1 or more climate or environmental factors, and report a diagnosis of concussion performed by a licensed medical professional were included. Reasons for exclusion included no report on extrinsic or environmental factors, no data on sport-related concussion incidence, and self-report of concussion diagnosis. DATA EXTRACTION: This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using 2 reviewers at each phase and a third reviewer for conflict resolution. DATA SYNTHESIS: A total of 7558 articles were reviewed, and 20 met the inclusion criteria. There was moderate to strong strength of evidence concluding no difference between surface type (grass versus artificial) on sport-related concussion risk. Moderate to strong strength of evidence was found supporting no difference in sport-related concussion incidence based on game location (home versus away). There was no consensus on the effects of altitude or temperature on sport-related concussion incidence. One high-quality study found a decreased risk of sport-related concussion when playing in wet versus dry conditions. Heterogenous populations and data collection methods prevented extraction and meta-analysis. CONCLUSIONS: Although a consensus on specific environmental and climate factors that influence sport-related concussion incidence was limited, the majority of studies were of high quality and gave insight into opportunities for future investigation. Administrators of large injury surveillance databases should consider including specific environmental and climate factors to provide investigators with robust data sets to better understand potential associations with sport-related concussion.

Early Initiation of Vestibular Therapy Following Sports-Related Concussions: A Retrospective Cohort Study.

BACKGROUND: Vestibular dysfunction is common following sports-related concussions (SRC). Within the current practice, it is theorized that patients with vestibular dysfunction as sequelae of sports-related concussion have a prolonged recovery time compared to those without vestibular dysfunction. STUDY METHOD:  A retrospective, cohort investigation of 282 subjects with sports-related concussions with vestibular dysfunction was conducted at The Sports Medicine Concussion Clinic, Duke University. The primary endpoint was the return-to-play (RTP) date. RESULTS: For every one-day increase in time from injury to initial vestibular therapy, the geometric mean time from injury to RTP increases by 1.02 days (exp{ß}=1.02 days; 95% CI: 1.01, 1.02 days; p<0.001). CONCLUSION:  Our data suggest an association between the timing of vestibular therapy in SRC and a direct relationship to earlier recovery and return to sport.

Effect of Concussion on Reaction Time and Neurocognitive Factors: Implications for Subsequent Lower Extremity Injury.

Background: Recent evidence has demonstrated that athletes are at greater risk for a lower extremity injury following a return-to-sport (RTS) after sport-related concussion (SRC). The reason for this is not completely clear, but it has been hypothesized that persistent deficits in neurocognitive factors may be a contributing factor. Hypothesis/Purpose: This study assessed simple reaction time, processing speed, attention, and concentration in a group of athletes, post-concussion upon clearance for RTS for potential deficits that may result in slower reaction time, processing speed, attention, and concentration. The researchers hypothesized that the concussion group would demonstrate worse scores on both assessments compared to a sex-, age-, and sport-matched cohort. Study Design: Case-controlled study. Methods: Twelve participants who had suffered a SRC and eight healthy individuals who were matched to the concussed group by age, sex, and sport were evaluated. Those with a concussion had been cleared for RTS by a licensed healthcare provider. Each participant underwent neurocognitive tests that included a simple reaction time test (SRT) and the King-Devick Test (K-D). Independent t-tests were performed to compare the groups with significance set a priori at p<0.05. Results: There was a significant difference (p =0.024) between groups for SRT with the concussed group demonstrating a better SRT than the control group. There were no significant differences (p =0.939) between the groups for the K-D. Conclusion: With no significant differences between groups in the K-D assessment and, surprisingly, the concussed group having a better SRT compared to the healthy group, our hypothesis was not supported. Clinical Relevance: These specific measures, compounded with extensive post-concussion time lapse until RTS clearance, may have limited capacity in revealing potential persistent deficits in relevant neurocognitive characteristics. Level of Evidence: Level of Evidence 3.

Linking health education, civic engagement, and research at a large Federally Qualified Health Center to address health disparities.

OBJECTIVE: To develop a framework for patient-centered research in a community health center. STUDY SETTING: Primary organizational case-study data were collected at a large Federally Qualified Health Center (FQHC) in Southern California from 2019 to 2021. STUDY DESIGN: Thirty stakeholders, including patients, community leaders, students, medical providers, and academic partners, participated in community-engagement capacity-building exercises and planning. These activities were guided by Community Based Participatory Principles and were part of an initiative to address health disparities by supporting patient and community-engaged research. DATA COLLECTION: The study included an iterative development process. Stakeholders participated in a total of 44 workgroup meetings and 7 full-group quarterly convenings. The minutes of the meetings from both workgroups and quarterly convenings were used to document the evolution of the initiative. PRINCIPLE FINDINGS: Stakeholders concluded that health equity research needs to be part of a larger engagement ecosystem and that, in some ways, engagement on research projects may be a later-stage form of engagement following patient/community and staff/researcher coeducation and cocapacity building efforts. CONCLUSIONS: Community health center stakeholders viewed successful engagement of community members in patient-centered health equity research as involving a web of longitudinal, evolving internal and external relationships rather than discrete, time-limited, and single-project-based dyadic connections.

Impact of a school-level intervention on leisure-time physical activity levels on school grounds in under-resourced school districts.

Even the best school physical education programs fall short of providing enough physical activity (PA) to meet students' PA guidelines thus increasing PA at other times throughout the school day could help students meet recommended PA levels. Unstructured leisure-time periods during the school day represent an opportunity to promote PA, particularly among students in underserved school districts. Between 2014 and 2018, we partnered with 14 elementary and 5 secondary schools in low-income Latino communities to increase students' leisure time moderate to vigorous physical activity (MVPA). Schools received consultation and technical assistance on their wellness policy, and some created wellness committees. Schools selected 1-2 PA/nutrition promotion activities for the academic year. Following the System for Observing Play and Leisure Activity in Youth protocol, we conducted a pre- vs. post- analysis of observations of school time student PA (levels of MVPA, energy expenditure, proportion of areas in which games and sports were prominent) in 4936 pre-intervention play areas and 4404 post-intervention areas before school, during lunch recess, and after school. We utilized linear and logistic regression analyses to test pre/post changes in these dependent variables using school area characteristics, period of observation, and temperature as covariates. Following our intervention, MVPA levels before school, during lunch recess, and after school increased significantly from 19.8% at baseline to 25.6% among elementary girls and from 25.4% to 33.2% among elementary boys. Decomposition of these effects suggested that the benefits were partially mediated by increased adult playground supervision. We did not observe any significant changes in PA levels among secondary school girls or boys. Our school-level intervention aimed at promoting PA was associated with modest but meaningful increases in leisure-time PA among elementary, but not secondary, school students. The effects were attributable in part to increased adult supervision on the playground.

Do older adults with shoulder disorders who meet the minimal clinically important difference also present low disability at discharge? An observational study.

BACKGROUND: The choice of outcome success thresholds may influence clinical management, pay-for-performance, and assessment of value-based care. OBJECTIVE: To evaluate outcomes success thresholds in older adults using two different methods: 1) Minimal clinically important differences (MCIDs) of the Quick-DASH and 2) Dichotomization of the Quick-DASH based on low disability rating at discharge DESIGN: An observational design (retrospective database study). SETTING: Dataset of 1109 patients with shoulder disorders. PARTICIPANTS: 297 older adults patients who were diagnosed with rotator cuff related shoulder disorders and were managed through physical therapy treatment. MAIN OUTCOME MEASURES: We categorized and calculated how many patients met 8.0 and 16.0 point changes on the Quick-DASH. To evaluate outcomes success thresholds using dichotomization, patients who discharge score of ≤20 on the Quick-DASH were considered positive responders with successful outcomes. RESULTS: The percentage of positive responders who met the MCID thresholds for the Quick-DASH were 63.3% using MCID of 8.0 points, 39.7% using the MCID of 16.0 points, and 46.12% who met discharge score of ≤ 20 on the Quick-DASH. 39.0% met both MCID of 8.0 points and discharge score of ≤ 20 on the Quick-DASH. Only 28% met both MCID of 16.0 points and discharge score of = 20 on the Quick-DASH. CONCLUSION: Three different success threshold derivations classified patients into three very different assessments of success. Quick-DASH scores of ≤ 20 represent low levels of self-report disability at discharge and can be a stable clinical option for a measure of success to capture whether a treatment results in meaningful improvement.

Program Evaluation of Environmental and Policy Approaches to Physical Activity Promotion in a Lower Income Latinx School District in Southeast Los Angeles.

There is alarming population wide prevalence of low adolescent physical activity as this represents a risk factor for later chronic disease development. There is evidence to suggest that schools with strong wellness policies have students that are more frequently active. We designed an intervention to enhance students' physical activity levels in five majority Latinx, underserved school districts. Evaluation consisted of assessment of written quality of school-district wellness policies; observation of student's physical activity during leisure times; and after-school program practices and policies. We examined one of these district's results more closely, the only participating district with a community coalition, and extracted lessons learned. On the physical activity section of the wellness policy, this district covered a moderate extent of recommended content areas using weak language. Compared to previous reports, we identified low vigorous activity levels for girls and boys at baseline (respectively, 12% and 18%). Finally, we identified that of four after school program sites assessed at baseline, no program reported the recommended 50% or more of program time dedicated to physical activity. Based on these evaluation findings, additional strategies are urgently needed to encourage all students and particularly more girls to be physically active throughout the school day.

Clinical examination factors that predict delayed recovery in individuals with concussion.

BACKGROUND: Risk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery (DR) in individuals with concussion diagnosis. A secondary aim explored the influence of early examination on individual prognosis. METHODS: The study was a retrospective, observational cohort design that included 163 individuals seen at a concussion clinic who were followed longitudinally until cleared for sports activity. Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at initial evaluation. DR was calculated by taking the median value associated with time to clearance for activity. Bivariate logistic regression analysis was calculated to determine odds ratios (and 95% confidence intervals) for the odds of DR with presence or absence of each clinical finding. Multivariate analyses were used to define the best predictors of DR. RESULTS: 80 of 163 individuals were considered delayed in their clearance to activity. Cognitive impairments (OR = 2.72; 95%CI = 1.40, 5.28), visual exam findings (OR = 2.98; 95%CI = 1.31, 6.80), and vestibular exam findings (OR = 4.28; 95%CI = 2.18, 8.43) all increased the odds of a DR. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examination after injury was a mediator for DR. CONCLUSIONS: The clinical examination provides value in identifying individuals who are likely to exhibit a delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a DR to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.

RE-AIM analysis of a community-partnered policy, systems, and environment approach to increasing consumption of healthy foods in schools serving low-income populations.

Prevalences of childhood overweight and obesity represent major public health concerns. School-based policy strategies represent one approach to increasing access to healthy foods; however, overall health impact of such initiatives is often overlooked. We undertook program evaluation of a school wellness policy focused approach in low-income, multiracial communities in southeast Los Angeles. We convened groups of key stakeholders including superintendents, principals, teachers, school staff, and parents to prioritize school-level implementation of wellness policy items to improve access to healthy foods, including healthier classroom celebrations. The purpose is to synthesize these findings within the RE-AIM framework (Reach, Efficacy, Adoption, Implementation, Maintenance) to describe cumulative impact of this health system-led community-partnered effort to promote healthy eating throughout the school day. We evaluated reach by comparing students reached by the intervention relative to the eligible population. We assessed effectiveness by examining changes in nutrition in wellness policy quality and after school program practices pre- and post-intervention interviews). We evaluated adoption by comparing sites that approved participation in the intervention and its evaluation versus completing evaluation assessments. We evaluated implementation as the number of schools convening a wellness council. Finally, we examined maintenance by evaluating changes in wellness policy and afterschool practices for those sites with pre- and post-test assessment. We reached 43.5% of the priority student population. We noted improvement in wellness policy quality and after school practices pre- to post-intervention (effectiveness). We found that 42.9% of after school programs completed the assessment while 40.0% of school districts triggered a post-intervention wellness policy evaluation (adoption). Eleven of 19 schools convened wellness councils (implementation) while in the subset of sites that completed pre- and post-test evaluation some improvements were noted (maintenance). We use this application of the REAIM framework to extract lessons learned from districts and after school programs that participated throughout the grant period. Through our partnership with schools we learned that our program evaluation filled an information gap for districts working to meet USDA's wellness policy requirement. Finally, while the wellness policy is an important lever in striving towards health equity in districts disproportionately impacted by obesity, additional policy, system, and environmental approaches are required to build a culture of health.

Factors Associated With Leisure Time Physical Activity Among Schoolchildren in a Predominantly Latino Community.

BACKGROUND: School initiatives aimed at increasing physical activity (PA) may improve the health of children in low-income communities. METHODS: Assessors completed 5909 observations of students' PA during leisure periods using a validated instrument in 19 schools in low-income Latino communities. We examined relationships between school environment factors (eg, presence of playground equipment) and levels of moderate-to-vigorous physical activity (MVPA). RESULTS: Overall, 16.4% of students were engaged in vigorous activity, lower than reported in prior analyses. Consistent with earlier reports, boys were more engaged in vigorous PA than girls (18.6% vs 13.2%). Playground equipment, such as balls and jump ropes, were present in 27.5% of activity areas. Supervision was present in 83.1% of observations; however, staff members were only observed leading organized activity in 1.7%. Playground equipment was associated with higher rates of MVPA, particularly among elementary boys (p < .0001). Staff supervision was not associated with MVPA, possibly because staff members rarely led organized activity. CONCLUSIONS: We found low rates of leisure time PA among students in this low-income Latino community. The presence of playground equipment was favorably associated with activity levels. Increasing the availability of playground equipment might promote activity among children in similar populations.

Interaction of gender and body composition on rectus femoris morphology as measured with musculoskeletal ultrasound imaging.

BACKGROUND: Quadriceps function is an important measure in patients recovering postoperatively. Traditionally, strength measures that require high levels of resistance are contraindicated during the early postoperative phase. Thus it may be helpful to evaluate the utilization of other tools, such as ultrasound imaging, that allow for assessment during a position of low resistance. HYPOTHESIS: The rectus femoris cross-sectional area (CSA) is affected by sex and body composition in healthy subjects. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: Thirty-two healthy subjects (16 women, 16 men), selected from a previously larger study, were chosen for analysis. All subjects underwent a maximal volitional isometric contraction protocol from 0° to 90° of knee motion controlled by an isokinetic dynamometer. In the contracted and resting positions, the rectus femoris CSA was measured at each angle using ultrasound imaging. The contractile index (contracted - resting CSA) was calculated at each position. Subjects were separated into 1 of 4 groups based on sex and fat percentage (low or high). These data were analyzed using mixed-factor analysis of variance (group × angle) for each variable, with a critical α level of 0.05. RESULTS: A significant interaction was noted for the CSA of the rectus femoris at rest (P < 0.03) and during contraction (P < 0.02). For both variables, all groups performed similarly, with the exception of women with high body fat percentage. No statistically significant interaction existed for the contractile index; however, a main effect for angle (P < 0.01) was observed. CONCLUSION: Rectus femoris CSA appears to depend on sex as well as the body composition of individuals. CLINICAL RELEVANCE: Traditional subjective assessment measures of quadriceps strength and function have low reliability and functional validity. With the improved feasibility of ultrasound imaging in the clinical setting, quadriceps size may be more accurately measured during the early postoperative stages.

Sex differences in rectus femoris morphology across different knee flexion positions.

UNLABELLED: PURPOSEBACKGROUND: Quadriceps function is an important outcome following lower extremity injury and surgery. Measurements of quadriceps function are particularly helpful initially post surgery, however traditional quadriceps strength measures like isokinetic testing are contraindicated during this time period. Inclusion of dynamic musculoskeletal ultrasound imaging in the clinical setting has been beneficial in understanding quadriceps activation specifically rectus femoris (RF) contraction; however, there is a paucity of literature in this area. The purpose of the current study was to describe the cross-sectional area (CSA) of the RF across varying knee flexion angles. METHODS: Forty-five adult recreational athletes were recruited for the study (21 males, 24 females). All subjects underwent tests of maximal volitional isometric contractions of the knee extensors at 0, 30, 60 and 90 degrees of knee flexion. During the trials, musculoskeletal ultrasound images of the RF at 15 cm from the superior pole of the patella were taken at rest and during contraction for each of the angular positions. Mixed model ANOVAs (angle x sex) were utilized to examine the differences between males and females for different angular positions. These analyses were conducted for the resting CSA, active CSA, and the contractile index (resting - active). RESULTS: RF cross-sectional area increased with increasing angles of knee flexion for both the resting and active conditions. The contractile index consistently decreased as knee flexion angle increased. No statistically significant interactions or main effects for sex were observed, although differences were observed in the trajectories of the data sets for males and females. CONCLUSIONS: RF CSA is dependent on knee flexion angle in both males and females. As a result, the assessment of RF CSA should be conducted in a standardized position if this variable is to be utilized as a meaningful measure of muscle size during rehabilitation. Additional research should seek out which factors are associated with clinically relevant factors that effect RF CSA across the range of knee flexion. LEVEL OF EVIDENCE: 3b.

Estudio clinico de 200 pacientes con sida en el Hospital Vargas / Clinical study of 200 patient with aids in the Vargas Hospital

En el presente trabajo se estudiaron 200 pacientes con SIDA provenientes del Hospital Vargas entre 1985-1994. Los hallazgos fueron agrupados principalmente de acuerdo a: 1) complicaciones del SNC, gastrointestinales, respiratorias metabólicas, hematológicas y renales; 2)cáncer y SIDA. Finalmente, se hizo una discusión de las diversas entidades clínicas haciendo énfasis en las más frecuentes.

Uso de BEP y BEPIM en cáncer de células germinales de testiculo: experiencia de diez años en el Instituto Oncológico Luis Razetti / Use of BEP and BEPIM in cancer of germ cell of testis: experience of ten years in the Oncologic Institute Luis Razetti

El cáncer de testículo es la neoplasia más común en los hombres entre 15 y 35 años de edad. Con el advenimiento de la quimioterapia basada en el cisplatino, este tumor se ha convertido en el prototipo de cáncer curable, aún en estadios avanzados. Se revisaron las historias clínicas de 28 pacientes del IOLR con diagnóstico de cáncer de células germinales de testículos que recibieron quimioterapia con los esquemas BEP o BEPIM desde 1986 a 1996. Seis pacientes tenían seminomas clásicos, y 22 tumores no seminomatosos. Nueve pacientes tenían enfermedad catalogada como avanzada, 13 tenían enfermedad moderada y 6 presentaron enfermedad mínima. Diecinueve pacientes recibieron el esquema BEP y 9 el esquema BEPIM. Quince pacientes tuvieron respuesta completa con BEP y 2 con BEPIM

Formas inusuales de presentación clínica de la histoplasmosis diseminada progresiva en pacientes con infección por el virus de inmunodeficiencia humana / Inusual forms of clinic presentation of progressive disseminated histoplasmosis with human inmunodeficiency virus infection

En el presente trabajo se describen 5 pacientes con infección por el virus de inmunodeficiencia humana e hitosplasmosis diseminada progresiva con formas clínicas inusuales. Tres de ellos tenían diseminación cutánea, uno diseminación gastrointestinal, y uno ambas presentaciones. Además se observó que el paciente sobrevivió 18 meses presentaba anticuerpos contra el Hitoplasma capsulatum.

Biopsias rectales en pacientes con infección por el virus de inmunodeficiencia humana / Rectal biopsies from HIV infected patients

Se realizó rectosigmoidoscopia y toma de biopsia rectal en treinta y seis pacientes con infección por el virus de la inmunodeficiencia humana, en el Hospital Vargas de Caracas. Treinta y tres pacientes eran del sexo masculino y tres del sexo femenino. La edad promedio fue de treinta y dos años. Setenta y tres por ciento de los pacientes eran homosexuales. El hábito sexual fue el principal factor de riesgo para la adquisición de la infección. Cuarenta y cuatro por ciento de los pacientes presentaron alteraciones en la rectosigmoidoscopia, siendo los hallazgos más frecuentes: mucosas hiperémicas y petequiales. Todas las biopsias rectales reportaron alteraciones: ocho casos asociados a oportunistas, dos casos con sarcoma de Kaposi y veintiseis casos con rectitis crónica inespecífica. Venticuatro por ciento de las biopsias presentaron hiperplasia linfoide

Tumor de células germinales de testículos: 2º primario en testículo contralateral: a propósito de un caso / Testicular germ cell tumors: 2º primary in contralateral testis: to proposite of a case

Se analiza el caso de un paciente de 29 años, con diagnóstico de teratoma maligno de testículo izquierdo, en 1988; quien, siete años después desarrolla un tumor mixto (a predominio de carcinoma embrionario) en el testículo contralateral, siendo tratado con quimioterapia y resección de masa abdominal, encontrando en tumor retroperitonal, teratoma con transformación maligna. Se revisa la literatura. Los tumores de células germinales de testículos, constituyen el 95 por ciento de los cánceres testiculares en pacientes entre 15 y 35 años. Estos pacientes constituyen una población de riesgo para el desarrollo de 2º neoplasias particularmente en el testículo contralateral