Assistência pré-natal às usuárias de substâncias psicoativas: dificuldades elencadas pelos profissionais da saúde / Prenatal care for users of psychoactive substances: difficulties listed by health professionals / Atención prenatal a consumidoras de sustancias psicoactivas: dificultades mencionadas por los profesionales de la salud

Objetivo: conhecer as dificuldades elencadas pelos profissionais de saúde na assistência pré-natal às usuárias de substâncias psicoativas. Método: estudo qualitativo, exploratório-descritivo, realizado nas mídias sociais, com profissionais da área da saúde que realizam atendimento pré-natal. A coleta de dados ocorreu de novembro de 2022 a janeiro de 2023 por meio de questionário eletrônico. Os dados foram analisados por meio da análise temática. Protocolo aprovado pelo Comitê de Ética em Pesquisa. Resultados: os profissionais destacam o déficit de conhecimento para abordar este público em específico. A abordagem superficial e condenatória do uso de substâncias pelas políticas públicas corrobora para que os profissionais se sintam preparados em parte para atender essas gestantes. Considerações finais: a capacitação dos profissionais é necessária para superar práticas condenatórias e retrógradas de cuidado que focam unicamente a abstinência; como também, o investimento na capacitação acerca da rede de atenção à saúde, buscando ampliar sua visibilidade e utilização.

Objective: understanding the difficulties listed by health professionals in prenatal care for users of psychoactive substances. Method: this is a qualitative, exploratory-descriptive study carried out on social media with health professionals who provide prenatal care. Data was collected from November 2022 to January 2023 using an electronic questionnaire. The data was analyzed using thematic analysis. Protocol approved by the Research Ethics Committee. Results: the professionals highlight the lack of knowledge to deal with this specific public. The superficial and condemnatory approach to substance use by public policies contributes to making professionals feel partly prepared to deal with these pregnant women. Final considerations: the training of professionals is necessary to overcome condemnatory and retrograde care practices that focus solely on abstinence; and investment in training about the health care network, seeking to increase its visibility and use.

Objetivo: conocer las dificultades mencionadas por los profesionales de la salud en la atención prenatal de las consumidoras de sustancias psicoactivas. Método: estudio cualitativo, exploratorio-descriptivo, realizado en redes sociales, con profesionales de la salud que brindan atención prenatal. La recolección de datos se llevó a cabo de noviembre de 2022 a enero de 2023 a través de un cuestionario electrónico. Los datos se analizaron mediante análisis temático. El protocolo fue aprobado por el Comité de Ética en Investigación. Resultados: los profesionales destacan que les falta el conocimiento para atender a este público específico. El abordaje superficial y condenatorio del consumo de sustancias por parte de las políticas públicas contribuye a que los profesionales se sientan parcialmente preparados para atender a esas gestantes. Consideraciones finales: es necesario capacitar a los profesionales para superar las prácticas asistenciales condenatorias y retrógradas que se centran únicamente en evitar el consumo; e invertir en capacitación sobre la red de atención de salud, para ampliar su visibilidad y uso.

Pre-hospital delay intention and its associated factors in the high-risk population of stroke: A latent profile analysis.

AIM: To explore the possible latent classifications of pre-hospital delayed intention at high risk of stroke and to analyze the characteristics of different profiles. METHODS AND RESULTS: A cross-sectional study was conducted in one community in Shanghai, China. 470 individuals at high risk of stroke were recruited, and self-reported questionnaires (including socio-demographic, stroke knowledge, health belief, and pre-hospital delay behavior intention scale) were distributed between April and June 2023. A latent profile analysis was employed to identify the delay intention clusters, and multinomial logistic regression was utilized to ascertain the factors influencing the latent classes of delay intention. 457 high-risk populations with a response rate of 97.23% were finally enrolled in this study. Four distinct classes were identified: High warning signs-Low delay intention (26.3%), Low warning signs-Low delay intention (17.7%), moderate level of delay intention (37.3%), and high level of delay intention (18.7%). The influencing factors included stroke knowledge, health belief, age, education background, the nearest distance to the medical institution, and household income. CONCLUSION: The pre-hospital delay intention among high-risk populations of stroke was classified into four distinct classes. It is crucial for individuals at high risk to remain vigilant towards stroke symptoms and to take prompt action. Health promotion education may be explored as a strategy to bridge the gap between the recognition of stroke symptoms and the low pre-hospital delay intention.

Molecular detection of high-risk papillomaviruses and vaccination status in normal cytology in Congo.

OBJECTIVE: The aim of this study was to identify the molecular prevalence of high-risk HPV infection and the distribution of genotypes present in normal cytology, as well as to determine the vaccination status of our study population. METHODS: 110 cervical samples were taken from individuals, and 1 ml of each sample was added to the Xpert HPV cartridge in the sample compartment before it was placed in the Cepheid GeneXpert system. Detection was performed simultaneously via amplification of the E6 and E7 genes in five fluorescent channels (HPV16, HPV18/45, HPV31/33/35/52/58, HPV51/59, and HPV39/56/66/68a). RESULTS: 36/110 (33%) of all samples tested were positive for HPV DNA. The predominant genotypes were HPV16 (12.7%) and other pooled HR-HPV types (8.2%). All women who received the Gardasil-9 vaccine (3.6%) had HPV, and infection was associated with travel outside Africa. 96.4% of the screened individuals had not received any HPV vaccine. CONCLUSION: Our research confirms a widespread HR-HPV infection in our population and extends the importance of studies on the molecular prevalence of HPV, particularly in women with normal cytology and apparent good health, in view of the cruel lack of public awareness of HPV infections.

Outcome of patient undergoing redo mitral valve surgery with incidence rate of mitral valve infective endocarditis.

BACKGROUND: The incidence of infective endocarditis (IE) in patients undergoing redo mitral valve (MV) surgery was evaluated. The outcomes of all the patients and the patients' specific characteristics were recorded. The patients were analyzed to further the research of IE in this population. METHOD: This was a retrospective review of patients admitted for redo MV surgery with a prospective follow-up of electronic medical records at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, from 2009 to 2019. Pre/intra/post-operative factors contributing to mortality, morbidity, and freedom of adverse events were analyzed. RESULT: A total of 211 patients underwent redo MV surgery, and 41 patients (19.4%) had IE; and 51% of this subset of patients, 21 individuals, developed IE after the initial MV surgery. MV stenosis was moderate/severe in 50 patients. Furthermore, MV regurgitation was present in 89 patients. Multivariate analysis of the data revealed multiple factors influencing mortality: age, peripheral vascular disease, concomitant procedures, peripheral vascular disease, red blood cell transfusions, preoperative mechanical valves, and active IE. In-hospital Mortality was 10.9%. The one-, five-, and ten-year survival was 88%, 79%, and 69% across all patients. CONCLUSION: Although redo MV surgery has acceptable outcomes; the presence of IE or concomitant procedures is a significant health detriment in these patients. Our study highlights the need for careful patient management and more in-depth research in this area to improve patient outcomes.

Events preceding death after high-risk surgery analyzed by Global Trigger Tool and reflective-thematic approach.

BACKGROUND: Postoperative mortality might be influenced by postoperative care, vigilance, and competence to rescue. This study aims to describe the course of events preceding death in a high-risk surgical cohort. METHODS: We analyzed hospital records of patients who died within 30 days after surgery in 4 high volume hospitals using (1) reflective narrative thematic approach to identify recurring themes reflecting issues with conduct of care and (2) Global Trigger Tool to describe incidence, timing, and types of adverse events (AEs) leading to harm. RESULTS: Preoperative predicted median risk of death in the studied group was 9%/13% according to SORT/P-POSSUM, respectively. Nine recurring themes were identified. Prominent themes were "consensus concerning aim and/or risk with planned surgery," "level of (intraoperative) competence and monitoring," and in the postoperative period "level of care and vigilance" on signs of deterioration. We found a total of 303 AEs, with only three patients (5%) having no adverse events. Most common severity category was "I," that is "contributed to patient's death" (n = 110, 36% of all AEs). Of these, 60% were classified as preventable or probably preventable. The peak incidence of AEs was seen on the day of index surgery. Most common types of AEs were "failure of vital functions" (n = 79, 26%), followed by infections (n = 45, 15%). CONCLUSIONS: A high predicted risk of death and a peak of adverse events on the day of index surgery were detected. Identified themes reflect lack of documented multi-professional consensus on how to handle prevalent perioperative risk, vigilance, and postoperative level of care.

The 2012 Briganti nomogram predicts disease progression after surgery in high-risk prostate cancer patients.

Objectives: We tested whether the 2012 Briganti nomogram for the risk of pelvic lymph node invasion (PLNI) may represent a predictor of disease progression after surgical management in high-risk (HR) prostate cancer (PCa) patients according to the European Association of Urology. Methods: Between January 2013 and December 2021, HR PCa patients treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND) were identified. The 2012 Briganti nomogram was evaluated as a continuous and categorical variable, which was dichotomized using the median. The risk of disease progression, defined as the event of biochemical recurrence and/or local recurrence/distant metastases was assessed by Cox regression models. Results: Overall, 204 patients were identified. The median 2012 Briganti nomogram score resulted 12.0% (IQR: 6.0-22.0%). PLNI was detected in 57 (27.9%) cases. Compared to patients who had preoperatively a 2012 Briganti nomogram score ≤12%, those with a score >12% were more likely to present with higher percentage of biopsy positive cores, palpable tumors at digital rectal examination, high-grade cancers at prostate biopsies, and unfavorable pathology in the surgical specimen. At multivariable Cox regression analyses, disease progression, which occurred in 85 (41.7%) patients, was predicted by the 2012 Briganti nomogram score (HR: 1.02; 95%CI: 1.00-1.03; p = 0.012), independently by tumors presenting as palpable (HR: 1.78; 95%CI: 1.10.2.88; p = 0.020) or the presence of PLNI in the surgical specimen (HR: 3.73; 95%CI: 2.10-5.13; p = 0.012). Conclusions: The 2012 Briganti nomogram represented an independent predictor of adverse prognosis in HR PCa patients treated with RARP and ePLND. As the score increased, so patients were more likely to experience disease progression, independently by the occurrence of PLNI. The association between the nomogram, unfavorable pathology and tumor behavior might turn out to be useful for selecting a subset of patients needing different treatment paradigms in HR disease.

High Risk Pregnancy and its Outcome in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: High-risk pregnancy is defined as one which is complicated by factors or factors that adversely affect the pregnancy outcome (maternal, perinatal or both). Early detection and effectivemanagement of high risk pregnancy helps in achieving favorable maternal and perinatal outcomes. This study aimed to find the prevalence of high risk pregnancy and its outcome among pregnant women admitted for delivery in the obstetrics and gynecology department of a tertiary care hospital Methods: A descriptive cross sectional study was conducted in a tertiary care hospital among high risk pregnant women admitted for delivery using structured proforma, from April 2023 to September 2023 after obtaining ethical approval from the Institutional Review Committee. Convenience sampling was used among pregnant women who met the inclusion criteria. Data was entered in excel and analysis was done using IBM SPSS Statistics. Point estimate was calculated at 95% Confidence Interval Results: Among 350 deliveries, high risk pregnancy was seen in 91 (26%) (16.15-32.00, 95% Confidence Interval). The high risk factors were previous history of cesarean section 25 (27.47 %) followed by hypothyroidism 19 (20.87%) and gestational diabetes mellitus 15 (16.48%). Out of 90 high risk pregnancy, 84 (92.30%) had term delivery. Lower segment cesarean section was done in 69 (75.82%) patients of which 26 (28.57%) underwent emergency cesarean section. The total number of births among high risk preganancies were 93 with two sets of twin births. A total of 13 (13.97%) of the babies had low-birth weight. CONCLUSIONS: The prevalence of high risk pregnancy was found to be similar as compared to studies done in similar settings.

Early and later remission from clinical high risk of psychosis. A latent class and predictor analysis.

BACKGROUND: In high-risk for psychosis (CHR-P) much focus has been on the transition to psychosis. However, the desired outcome remains symptomatic remission and improved functioning as early as possible. This study aims to investigate predictors of sub-groups of remission and functional outcomes. MATERIAL AND METHODS: A two-year prospective follow-up study of 104 CHR-P participants recruited in Norway using systematic early detection strategies. The Structural Interview for Prodromal Syndromes (SIPS) was used to assess CHR-P. Participants were classified as remitted or non-remitted based on their symptom scores. A latent class analysis was performed on the dichotomous data to identify latent classes regarding the timing of remission. t-tests and chi-squared tests were used to assess the association between class affiliations, predictors and outcomes. RESULTS: The latent class analysis showed moderate fit and divided the participants into three remission classes: "poor chance of remission" (16.7 %), "later remission" (34.3 %), and "early remission" (49.0 %). The "early remission" class had the highest probability of fast and stable remission, and had better premorbid academic, and baseline and 2-year global functioning than the "later remission" class. Baseline predictors such as age, SIPS symptoms, drug use, years in school and gender were not significantly associated with remission class. DISCUSSION: The study's main finding is the division of CHR-P remission into "early remission" and "later remission" and predictors of class affiliation. The monthly follow-up during the first six months allowed for the detection of this division. The findings suggest the importance of considering functioning in models of remission from CHR-P.

The epidemiology, treatments and outcomes of patients with hormone receptor positive, human epidermal growth factor receptor 2 negative, node-positive early breast cancer in Taiwan.

Aim: Estimate patient counts, treatment patterns and outcomes of a subset of patients with early breast cancer (EBC) presenting with hormone receptor positive, human epidermal growth factor receptor 2 negative, node positive features, who are at high-risk of recurrence, in Taiwan.Materials & methods: Data from Taiwan's National Health Insurance Research Database and Taiwan Cancer Registry from 1 January 2011 to 31 December 2020 were analyzed.Results: There were 4500 patients with high-risk EBC (10.4% of all patients with EBC) from 2012 to 2018, with an annual average incidence of 643 that increased over time. Five-year progression was 24.8% in patients with high-risk EBC and 8-year survival was low (69.6%).Conclusion: Patients with hormone receptor positive, human epidermal growth factor receptor 2 negative, node positive high-risk EBC clinical features are an increasing high-risk subset of all patients with EBC.

[Box: see text].

Multi-instance learning for identifying high-risk subregions associated with synchronous distant metastasis in clear cell renal cell carcinoma.

BACKGROUND: Clear cell renal cell carcinoma (ccRCC) is one of the most common histological subtypes of renal tumors. PURPOSE: To identify high-risk subregions associated with synchronous distant metastasis. METHODS: This study enrolled a total of 277 patients with ccRCC. Voxel intensity and local entropy values were compiled within the region of interest for all patients. Unsupervised k-means clustering yielded three subregions per tumor. Radiomic features were extracted, and random forest-based feature selection was conducted. The selected features were used in a multi-instance support vector machine (mi-SVM) model for training, and predictions were made on the validation cohort. Model performance was evaluated using five-fold cross-validation. The subregion with the highest score for patients with synchronous distant metastasis was identified across all cohorts. RESULTS: The mi-SVM model yielded an average area under the curve (AUC) of 0.812 in the training cohort and 0.805 in the validation cohort. In the entire cohort of patients with synchronous distant metastasis, subregion 2, characterized by tumor periphery and intratumoral transitional components, accounted for the highest proportion (48.57%, 30.6/63) among all subregions. It represents a high-risk subregion for synchronous distant metastasis of clear cell renal cell carcinoma. CONCLUSION: The peripheral and intratumoral transition zones of clear cell renal cell carcinoma are high-risk subregions associated with synchronous distant metastasis.

Diagnostic Accuracy of Cancer Antigen 15-3 as a Seromarker Among Recurrent Breast Carcinoma in Bangladesh.

BACKGROUND: The diagnosis of recurrent breast carcinoma is crucial for patient treatment. The present study aimed to assess the diagnostic accuracy of cancer antigen 15-3 (CA 15-3) as a sero-marker among recurrent breast carcinoma patients. METHODS: This prospective observational study evaluated the serum CA 15-3 among women (age ≥18 years) with recurrent breast carcinoma. The CA 15-3 was measured by the enzyme-linked immunosorbent assay (ELISA), and concentrations were stratified using a cut-off value of 30 U/mL. The receiver operating characteristic (ROC) curve observed that the sensitivity and specificity of the CA 15-3 cut-off value and the area under the AUROC curve demonstrate the goodness-of-fit of the prediction model. RESULTS: A total of 50 patients were recruited, with a mean age of 48.4 ±9.7years. The majority (n=28, 56.0%) of patients were 41 to 50 years old. Further, a total of 42 (84%) patients had high serum levels of CA 15-3, with a mean value of 72.7±9.5 U/mL. At the cut-off level of 30 U/mL, the ROC curve demonstrated sensitivity, specificity, positive predictive value, and negative predictive value of 95.7%, 69.4%, 84.1%, and 72.8%, respectively, to diagnose recurrent breast carcinoma. Nonetheless, the area under the ROC (AUROC) curve was 0.712, indicating a satisfactory fit for the prediction model. CONCLUSION: We found that CA 15-3 level ≥30 U/mL is highly sensitive and specific as a seromarker for detecting recurrent breast cancer among the Bangladeshi population. We recommend routinely monitoring breast cancer survivors using CA 15-3 biomarkers.

Assessing the Role of Fetal Doppler in High-Risk Obstetrics: Evidence From a Comprehensive Study.

Background Colour Doppler ultrasound is pivotal in modern obstetrics for evaluating maternal and fetal health, especially in high-risk pregnancies. It enhances fetal oxygenation and nutrient delivery assessment, aiding in the early detection of adverse outcomes. However, its effectiveness is influenced by operator skill and the potential for interpretative variability. Aim This study aims to assess the utility of Doppler ultrasound in evaluating fetal status in high-risk pregnancies at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, India. Materials and methods A hospital-based observational study was conducted from September 2022 to July 2024, including 145 high-risk pregnant women, of whom 120 delivered at the institute. The study included thorough maternal and fetal assessments, with regular Doppler studies starting at 28 weeks of gestation. The frequency of these studies was adjusted according to the changes and severity observed in the indices. Detailed documentation of both maternal and neonatal outcomes was meticulously maintained. Statistical analyses were performed using MS Excel (Microsoft® Corp., Redmond, WA, USA) and RStudio, Version 2023.08.0-daily+170 (RStudio, Inc., Boston, MA, USA), with a significance threshold of p < 0.05. Results The majority of participants were aged 21-30 years, with multigravida constituting 63.33%. Pregnancy-induced hypertension (PIH) and preeclampsia were the most common high-risk factors (28.33%). Abnormal umbilical artery (UA) flow patterns were observed in 58.33% of cases. Abnormal UA and middle cerebral artery (MCA) Doppler indices correlated significantly with adverse outcomes. Most deliveries were via caesarean section (82.5%), and 63.33% of neonates required Neonatal Intensive Care Unit (NICU) admission. Neonates with abnormal antenatal Doppler studies had significantly lower APGAR (appearance, pulse, grimace, activity, and respiration) scores and higher NICU admission rates. Discussion The study highlights the critical role of Doppler ultrasound in managing high-risk pregnancies, providing essential data for early interventions. Consistent with other studies, abnormal Doppler patterns were significantly associated with adverse neonatal outcomes, necessitating timely caesarean deliveries. Conclusion Fetal Doppler ultrasonography is essential for managing high-risk pregnancies, enabling timely therapeutic interventions and improving perinatal outcomes. Despite its limitations, Doppler technology remains invaluable in identifying at-risk foetuses and guiding clinical decisions for optimal pregnancy management.

Feasibility and Effectiveness of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra-Aortic Balloon Pump Assisted High-Risk Percutaneous Coronary Intervention in Complex Coronary Disease.

Background: Mechanical circulatory support may facilitate high-risk percutaneous coronary intervention (PCI). This study aimed to assess the feasibility, safety and effectiveness of high-risk PCI under the support of venoarterial extracorporeal membrane oxygenation (VA-ECMO) combined with intra-aortic balloon pump (IABP). Methods: We enrolled patients who received VA-ECMO plus IABP-assisted PCI procedures at our center from April 2012 to June 2018. Major adverse cardiac events (MACEs) included all-cause death, myocardial infarction, and target vessel revascularization. Results: A total of 10 patients were included, with a mean age of 71 years, EuroSCORE II of 19.9%, and SYNTAX score of 39.8. Procedural success was achieved in nine (90%) patients. The mean duration of ECMO support was 1.5 hours, and 2.6 stents were implanted per patient. Major complications included contrast-induced nephropathy needing hemodialysis in one (10%) patient, significant hemoglobin drop requiring blood transfusion in two (20%) patients, pulmonary infection in one (10%) patient, and local surgical incision infection in one (10%) patient. The accumulative mortality rates for the nine patients with procedural success were 0, 22.2%, and 44.4% at 1, 3, and 5 years follow-up, respectively. However, cardiac death occurred in only one (11.1%) patient. In addition, two patients received repeat PCI or coronary artery bypass grafting within two years following the index procedure. The overall incidence rates of MACEs were 11.1%, 44.4%, and 66.7% at 1, 3, and 5 years follow-up, respectively. Conclusions: VA-ECMO plus IABP-assisted high-risk PCI was feasible in patients with complex coronary disease, with a high procedural success rate and acceptable mid-term clinical outcomes.

Predictive model for left main coronary artery or triple vessel disease in patients with chronic coronary syndromes.

Background: Data about prediction of left main coronary artery disease (LMCAD)/three-vessel disease (TVD) in patients with chronic coronary syndromes (CCS) are lacking. Objectives: This study aimed to develop a model for predicting patients at risk of LMCAD/TVD. Methods: This study used retrospective data from patients with CCS scheduled for invasive coronary angiography (ICA) and who were retrospectively recruited between January 2018 and December 2020. Predictors were obtained and analyzed by using logistic regression analysis, and generated the prediction score. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The cut-off value and area under the curve (AUC) were analyzed by using the receiver operating characteristic (ROC) curve. Results: We recruited 162 patients with CCS. There were 75 patients in the non-LMCAD/TVD and 87 patients in the LMCAD/TVD groups. After the multivariate analysis, new onset of heart failure (HF) or left ventricular systolic dysfunction (LVSD) and suspected CAD, ST elevation (STE) in aVR, STE in V1 and lateral ST depression (STD) were associated with increased risk of LMCAD/TVD. Based on these 4 predictors, the prediction score was created. The cut-off value of the prediction score by using ROC curve analysis was 3.0. The sensitivity, specificity, PPV, and NPV were 71.26%, 86.67%, 86.11%, and 72.22%, respectively, with an AUC of 0.855. Conclusions: The CCS patients with new onset of HF or LVSD and suspected CAD, STE in aVR, and STE in V1 and lateral STD were associated with increased risk of LMCAD/TVD. The novel prediction score could predict LMCAD/TVD in those patients with acceptable sensitivity, specificity, PPV, and NPV.

Interaction of High- and Low-Risk Human Papillomavirus Genotypes is Associated with a Reduced Risk of Developing Cervical Cancer.

INTRODUCTION: Cervical cancer is among the most common types of cancer in women and is associated with human papillomavirus (HPV) infection. The association between cervical cancer and high-risk HPV infection has been well documented. However, the effect of simultaneous infection with high- and low-risk HPV or low-risk HPV alone on the risk of developing cervical malignancy remains unanswered in guidelines. METHOD: We investigated the association of high and low-risk HPVs (HR or LR) genotypes with cervical carcinoma risk and pathological and cytological information in cases recruited from a population-based cohort study of 790 patients. Correlation matrix and t-test were used for analysis. RESULTS: The percentage of HR+LR and HR-HPV16/18 were 9.30% and 11.20% in class II, 7.15% and 7.10% in class IV, and 7.15% and 5.80% in As-CUS smears. Interestingly, concurrent infection with HR-HPV and LR-HPV types led to a significant reduction in the risk of developing malignancy compared to the high-risk group (OR=0.3 (0.098-0.925), pvalue=0.04). The percentage of individuals with cervical malignancy was 10.2% and 28.2% within the co-infected and the HR-HPV participants. CONCLUSION: Our findings suggest that simultaneous infection with high- and low-risk HPV may reduce the risk of cervical malignancy.

Real-word outcomes for high-risk non-muscle-invasive bladder cancer: screened patients for the BRAVO trial.

OBJECTIVE: To report real-world outcomes for high-risk non-muscle-invasive bladder cancer (HRNMIBC), including bacillus Calmette-Guérin (BCG) and radical cystectomy (RC), as randomised comparisons of these have not been possible. METHODS: We detail consecutive participants screened for the BRAVO randomised controlled trial comparing RC with BCG (International Standard Randomised Controlled Trial Number [ISRCTN]12509361). Patients were prospectively registered and case-note review used for outcomes. The primary outcome was overall survival. Secondary outcomes included recurrence, progression, metastasis, and bladder cancer-specific survival. RESULTS AND LIMITATIONS: A total of 193 patients were screened, including 106 (54.9%) who received BCG, 43 (22.3%) primary RC, 37 (19.2%) 'other' treatment and seven (3.6%) hyperthermic intravesical mitomycin C. All-cause death occurred in 55 (28.5%) patients at median (interquartile range [IQR]) of 29.0 (19.5-42.0) months. In multivariable analysis, overall mortality was more common in older patients (hazard ratio [HR] 2.63, 95% confidence interval [CI] 1.35-5.13; Cox P = 0.004 for age >70 years), those recruited from district hospitals (HR 0.53, 95% CI 0.3-0.95; P = 0.032) and those who did not undergo RC as their first treatment (HR 2.16, 95% CI 1.17-3.99; P = 0.014). In all, 17 (8.8%) patients died from bladder cancer (BC) at median (IQR) of 22.5 (19-36.25) months. In multivariable analysis, BC-specific mortality was more common in older patients (HR 4.87, 95% CI 1.1-21.6; P = 0.037) and those with Tis/T1 disease (HR 2.26, 95% CI 1.23-4.16; P = 0.008) but did not vary with initial treatment. CONCLUSIONS: Patients with HRNMIBC are at high-risk of mortality. Those choosing RC as their initial treatment have lower risks of mortality than others, although this may reflect fitness and selection.

VCd versus VRd in Newly Diagnosed Multiple Myeloma: Matched Real-World Analysis from the Balkan Myeloma Study Group (BMSG).

BACKGROUND: Bortezomib, dexamethasone and cyclophosphamide (VCd) remains a popular regimen, due to its activity and low toxicity, while bortezomib, lenalidomide and dexamethasone (VRd) is widely used in US and Europe; both are combined with anti-CD38 monoclonal antibodies but VCd and VRd have not been compared directly in adequately powered prospective trials. AIM: We compared the outcomes of 1216 patients treated with VCd (N = 690) or VRd (N = 526) in a real-world setting. RESULTS: Patients treated with VCd had more often severe renal dysfunction, ISS-3 disease, hypercalcemia, elevated LDH, anemia, thrombocytopenia, poor performance while VRd-treated were older and received less often autologous transplant but more frequently maintenance but the duration of induction was similar. VRd was associated with substantially higher overall response and CR/VGPR rates to induction(P < .001) and improved PFS and OS in univariate analysis, especially among patients with standard risk disease, without renal dysfunction and in the elderly; however, in multivariate analysis there was no significant difference in either PFS or OS. In patients strictly matched 1:1 for major prognostic variables (188 in each group, total N = 376), the superiority of VRd in terms of responses rates and depth of response was confirmed, but without significant PFS or OS difference. CONCLUSION: VRd is a more active induction regimen than VCd, although use of maintenance with lenalidomide may dilute the PFS or OS benefit. VCd induction remains an option in special circumstances. With the implementation of monoclonal antibodies, VCd backbone can be considered for patients without access to or who do not tolerate VRd.

A Rare Case of Placenta Increta at Uterine Fundus.

Adherent placenta means a placenta that is not delivered spontaneously or even after manual removal within 30 minutes of baby birth. It is an uncommon and frequently unanticipated event with serious potential health circumstances and it should be managed by the medical team. This case study presents a rare instance of placenta increta in a 25-year-old woman, second gravida, at 36 weeks of gestation, with a history of cesarean section 16 months prior due to chorioamnionitis. The patient presented to the labor room in active labor, and antenatal ultrasound indicated placental implantation on the posterior surface of the upper uterine segment. Given the short inter-delivery interval, an emergency preterm lower segment cesarean section (LSCS) was performed, resulting in the birth of a healthy baby girl weighing 1.8 kg. During surgery, a morbidly adherent placenta was found over the fundus of the uterus. Following consultations with the patient and her relatives, an emergency obstetric total hysterectomy was performed. Intraoperatively, the patient received one unit of packed cell volume (PCV) and, postoperatively, two additional units of PCV and two units of fresh frozen plasma (FFP) were administered. On the third postoperative day, the patient developed right lung consolidation, necessitating a five-day stay in the Obstetric Intensive Care Unit (OBICU). The remaining postoperative period was uneventful, and the patient was discharged on the 10th postoperative day with the healthy infant. Placenta accreta, including its variants increta and percreta, represents abnormal placental implantation into the uterine wall, a condition whose incidence is rising due to increased cesarean sections and improved imaging detection.

Joint HIV and hepatitis C virus phylogenetic analyses signal network overlap among women engaged in sex work and men who purchase sex.

BACKGROUND: Transmission of HIV and hepatitis C virus (HCV) are heavily influenced by complex interactions within sexual or injecting networks where risk behaviors occur. In Ukraine, women engaged in sex work (WSW) and men who purchase sex (MWPS) are disproportionately affected by both viruses. The aim of our study was to the investigate the influence of underlying networks on transmission of HIV and HCV. METHODS: A cross-sectional integrated bio-behavioural survey was implemented among 560 WSW and 370 MWPS representative of sex work hotspots in Dnipro, Ukraine (December 2017 to March 2018). A portion of the HIV reverse transcriptase gene (n = 13; 62% WSW, 38% MWPS) and HCV NS5B gene (n = 46; 70% WSW, 30% MWPS) were sequenced from dried blood spot specimens. Tip-to-tip distances on phylogenetic trees were used to infer phylogenetic clusters for identifying potential transmission clusters. RESULTS: Phylogenetic analyses identified two HIV clusters containing four sequences (50% WSW; 50% MWPS) and 11 HCV clusters containing 31 sequences - the majority comprising infections in WSW (83.9%). Nearly half (45.4%) of HCV clusters contained at least one WSW with a history of injecting drugs. CONCLUSIONS: Joint analyses of HIV and HCV signal overlap in sex work and injecting networks in Ukraine, suggesting implications for the comprehensive coverage of prevention programs for WSW including harm reduction services. Conducting phylogenetic analyses with HCV may provide a more complete appraisal of underlying transmission networks than HIV alone, particularly in the context of high HIV treatment coverage yielding viral suppression.