Impact of an integrated classifier using biomarkers, clinical and imaging factors on clinical decisions making for lung nodules.

Background: An integrated classifier that utilizes plasma proteomic biomarker along with five clinical and imaging factors was previously shown to be potentially useful in lung nodule evaluation. This study evaluated the impact of the integrated proteomic classifier on management decisions in patients with a pretest probability of cancer (pCA) ≤50% in "real-world" clinical setting. Methods: Retrospective study examining patients with lung nodules who were evaluated using the integrated classifier as compared to standard clinical care during the same period, with at least 1-year follow-up. Results: A total of 995 patients were evaluated for lung nodules over 1 year following the implementation of the integrated classifier with 17.3% prevalence of lung cancer. 231 patients met the study eligibility criteria; 102 (44.2%) were tested with the integrated classifier, while 129 (55.8%) did not. The median number of chest imaging studies was 2 [interquartile range (IQR), 1-2] in the integrated classifier arm and 2 [IQR, 1-3] in the non-integrated classifier arm (P=0.09). The median outpatient clinic visit was 2.00 (IQR, 1.00-3.00) in the integrated classifier arm and 2.00 (IQR, 2.00-3.00) in the non-integrated classifier (P=0.004). Fewer invasive procedures were pursued in the integrated classifier arm as compared to non-integrated classifier respectively (26.5% vs. 79.1%, P<0.001). All patients in the integrated classifier arm with post-pCA (likely benign n=39) had designated benign diagnosis at 1-year follow-up. Conclusions: In patients with lung nodules with a pCA ≤50%, use of the integrated classifier was associated with fewer invasive procedures and clinic visits without misclassifying patients with likely benign lung nodules results at 1-year follow-up.

Utility of Intracardiac Echocardiography for Infective Endocarditis and Cardiovascular Device-Related Endocarditis: A Contemporary Systematic Review.

The diagnosis of infective endocarditis (IE) can pose a significant challenge, particularly in cases of prosthetic valve endocarditis (PVE) or cardiac device-related endocarditis (CDIE) (1). While echocardiography remains a crucial diagnostic tool for identifying IE, including PVE and CDIE, there are certain circumstances where transesophageal echocardiography (TEE) may not be conclusive or practically feasible (2). Recently, intracardiac echocardiography (ICE) has emerged as a promising alternative for diagnosing IE and evaluating intracardiac infections, especially in cases where transthoracic echocardiography (TTE) has not been revealing, and TEE has been contraindicated. Furthermore, ICE has been found to be useful in guiding transvenous lead extractions in infected implantable cardiac devices (3). This systematic review aims to comprehensively explore the various applications of ICE in the diagnosis of IE and assess its efficacy in comparison to traditional diagnostic methods.

Gender-affirming vaginoplasty: Technical considerations in patients with genital skin deficiency.

INTRODUCTION: Gender dysphoria affects over 1 million American adults. Vaginoplasty is a critical step in gender affirmation, and many patients have insufficient genital skin for full-depth penile inversion vaginoplasty (PIV). We reviewed the literature for technical considerations addressing this and present our data supporting the use of peritoneal flaps (Davydov technique). MATERIALS AND METHODS: A comprehensive review of modern literature was conducted. Second, we present a retrospective case review of our experience with PIV, including data from procedures utilizing peritoneal flaps. RESULTS: We identified 20 original articles, including retrospective and prospective case and cohort studies. Approaches included the application of local soft tissue grafts and flaps, peritoneal flaps, and intestinal segments. Between June 2018 and February 2021, 47 patients at our institution, underwent PIV for the treatment of gender dysphoria. Nineteen of those patients underwent robotic-assisted peritoneal flap procedure in addition to PIV. In this cohort, the mean follow-up was 200.6 ± 124.8 days. Mean neovaginal depth was 13.1 ± 3.0 cm intra-operatively and 11.0 cm at the last follow-up. Twenty-six percent of complications were Clavien Grade 1 or 2; others included wound dehiscence (30.4%), perianal and urethral fistula (13.0%), and neovaginal stenosis (8.7%). The majority of patients reported satisfactory results in terms of sexual function with intact tactile and erogenous sensation. Almost half were able to have penetrative vaginal intercourse at the last follow-up. We did not aim to perform statistical calculations to compare the outcomes of PIV with and without robotic-assisted peritoneal flap augmentation, as the groups were not constructed in that manner. However, it is evident that anatomical and functional results as well as the distribution of postoperative complications seem similar. CONCLUSION: Vaginoplasty is indicated in a growing population of patients with a wide range of medical histories and anatomic variations. Genitourinary reconstructive surgeons must have several methods to achieve full-depth vaginoplasty in cases of inadequate genital skin. Peritoneal flaps serve as a versatile, safe, and functionally advantageous solution.

Outcomes of penile inversion vaginoplasty and robotic-assisted peritoneal flap vaginoplasty in obese and nonobese patients.

AIM: To explore the impact of body mass index (BMI) on the outcomes of gender-affirming vaginoplasty. METHODS: A cohort consisting of all gender-affirming vaginoplasties in our practice between September 27th, 2018, and September 1st, 2022 were identified, and data were retrospectively collected. Patients were classified as obese if their BMI was ≥30 kg/m2 at the time of surgery and nonobese if their BMI was <30 kg/m2 . Complications were assigned a Clavien-Dindo grade and grouped as Grade ≥2 versus Grade ≤1. Patient-reported functional outcomes of intact erogenous sensation, tactile sensation, ability to achieve penetrative vaginal intercourse, and cosmetic satisfaction were assessed. RESULTS: A total of 58 patients with a mean follow-up time of 6.9 months were included. Seventeen patients (mean BMI = 36.8 kg/m2 ) were classified as obese and 41 patients (mean BMI = 25.1 kg/m2 ) were classified as nonobese. No significant differences in outcomes were identified in the obese versus nonobese groups in terms of the incidence of complications. Patient-reported functional outcomes did not differ significantly between the two groups. CONCLUSIONS: Similar results can be achieved with gender-affirming vaginoplasty in obese patients when compared to their nonobese counterparts. Eligibility for this procedure should not be restricted based on BMI alone.

Use of phosphodiesterase-5 inhibitors and the incidence of melanoma.

INTRODUCTION: Recent evidence of a causal link between Phosphodiesterase-5-inhibitor (PDE-5i) use and melanoma has caused concern in PDE-5i use and was even addressed in the 2018 American Urological Association guideline on erectile dysfunction (ED). Given that several studies have affirmed this low probability but statistically significant association, one might expect a shift in melanoma diagnoses since PDE-5is were introduced in 1998. We sought to determine if the introduction of PDE-5i drugs for ED treatment increased incidence of melanoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to compare the incidence of melanoma diagnosis in American men between 1973 and 2015, providing over a decade of data before and after PDE-5i introduction in 1998. Interrupted time-series and logistic regression were used to assess this relationship. RESULTS: Over 43 years, the SEER database has reported 292,166 cases of Melanoma, with males accounting for 53.7% of cases (Standard deviation [SD] 3%, Range 47.5-58.3%). After the introduction of PDE-5i, there was no proportional increase in melanoma diagnoses, in fact demonstrating a 2% lower incidence from prediction models (p < 0.05). CONCLUSION: Our analysis of the SEER database demonstrates that the trend in incidence of melanoma has fallen in the era of PDE-5i use for ED. These findings may be of value in counseling patients anxious about the potential association between PDE-5i use and skin cancer; however, continued research analyzing individual-level risk are needed.

Lactato como marcador temprano de hipoxia cerebral en pacientes neurológicos bajo anestesia general: una revisión sistemática / Lactate as an early marker of cerebral hypoxia in neurological patients under general anesthesia: a systematic review

Resumen: Las complicaciones neurológicas perioperatorias secundarias a hipoxia durante procedimientos de sedación y anestesia general son frecuentes en cirugía cardiovascular y en pacientes con comorbilidades. Sin embargo, hasta el momento no existe un consenso para el diagnóstico de estas posibles complicaciones. En pacientes con trauma encefálico severo y/o hemorragia subaracnoidea el lactato cerebral no fue útil para predicción de hipoxia cerebral; pese a ello, la relación de lactato/piruvato podría ser una herramienta para diagnóstico intraoperatorio de hipoxia cerebral aguda. Los estudios sugieren que éste debe asociarse a otros marcadores y/o a monitoreo multimodal. Es necesario realizar estudios que evalúen su valor predictivo para hipoxia cerebral.

Abstract: Perioperative neurological complications secondary to hypoxia during sedation and general anesthesia procedures are frequent in cardiovascular surgery, and in patients with comorbidities. However, so far there is no consensus for the diagnosis of these possible complications. In patients with head trauma severe and/or subarachnoid hemorrhage cerebral lactate was not useful for predicting cerebral hypoxia, however the lactate/pyruvate ratio could be a tool for intraoperative diagnosis of acute cerebral hypoxia. Studies suggest that it must be associated with other markers or multimodal monitoring. Further studies are needed to evaluate lactate predictive value for the diagnosis of cerebral hypoxia.

Efectos cardiovasculares en usuarios de cocaína / Cardiovascular effects in cocaine users

Resumen La cocaína es una sustancia psicoactiva ampliamente utilizada de forma recreativa. El uso indiscriminado de esta sustancia genera múltiples consultas a los servicios de emergencias, principalmente debido a sus efectos cardiovasculares. Los mecanismos fisiopatológicos actúan principalmente en sistema nervioso simpático, cardiomiocito, plaquetas, canales de sodio y potasio, entre otros. El objetivo principal de esta revisión es demostrar los efectos cardiovasculares asociados al uso de la cocaína.

Abstract Cocaine is a psychoactive substance widely used recreationally. The indiscriminate use of this substance generates multiple consultations to the emergency services, mainly due to its cardiovascular effects. The physio pathological mechanisms act mainly in sympathetic nervous system, cardiomyocyte, platelets, sodium and potassium channels, among others. The main objective of this review is to demonstrate the cardiovascular effects associated with the use of cocaine.

Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis.

INTRODUCTION: Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. AIM: To investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections. METHODS: This retrospective institutional review board-exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device. MAIN OUTCOME MEASURES: Intraoperative culture data from infected IPPs. RESULTS: Two hundred twenty-seven intraoperative cultures (2002-2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation. CONCLUSION: This study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success. Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. J Sex Med 2017;14:455-463.

Epidemiología del virus pandémico Influenza A H1N1 en la provincia Granma (2009–2011) / Epidemiology of the pandemic virus A H1N1 Influenza in Granma province (2009- 2011)

Introducción: En un mundo cada vez mas globalizado, con una población superior a los seis mil millones de personas, marcado por grandes inequidades sociales y con cambios climáticas evidentes los virus de la influenza serán un riesgo permanente para la seguridad de la humanidad. Objetivo: Caracterizar la epidemia del nuevo virus Influenza A H1N1 en su circulación por la provincia Granma. Mayo–2009 a Abril–2011. Método: Se realizó un estudio descriptivo y retrospectivo de la epidemiología del nuevo virus Influenza A H1N1 en su circulación por la provincia Granma, en el período Mayo–2009 a Abril–2011. En el período analizado se tomaron 1178 muestras de exudados faríngeos y nasales para estudios virológicos, el 8.32 por ciento fueron positivas al virus Influenza A H1N1. Resultados: Los adolescentes de 12 a 18 años fue el grupo de edad más afectado por el virus pandémico y dentro de ellos los de 15 años. El sexo femenino fue el de más casos. El municipio Bayamo aportó más del 50 por ciento de los casos. Los síntomas y signos más frecuentes fueron: fiebre, tos, rinorrea, expectoración, malestar general, cefalea, estornudos. El factor predisponerte más importante fue la edad: niños y adultos jóvenes. Conclusiones: En el período que abarcó la investigación se estudiaron 39 Brotes de IRA; el 32.94 por ciento de las muestras fueron positivas al virus causante de la epidemia, en total hubo 7 fallecidos, 6 del sexo femenino, ninguna embarazada o puérpera(AU)

Introduction: In a globalized world, with a population over the six thousand million people, marked by great social inequities and with evident climatic changes; the influenza viruses will be a permanent risk for the human security. Objective: To characterize the epidemic of the new virus AH1N1 Influenza in its circulation in Granma province during. May 2009 to April 2011. Method: it was performed a descriptive and retrospective study of the epidemiology of the new virus AH1N1 Influenza in its circulation in Granma province during the period May 2009 to April 2011. In the analyzed period there were taken 1178 samples of pharyngeal and nasal exudates for virologic studies, 8.32 percent were positive to the virus. Results: The teenagers of 12 to 18 years were the most affected by the pandemic virus, especially the 15 year- old- teenagers. The feminine sex prevailed. Bayamo municipality contributed with more than 50 percent of the cases. The most frequent symptoms and signs were: fever, cough, rhinorrhea, expectoration, general discomfort, headaches and sneezes. The most important predisposing factor was the age in children and young adults. Conclusions: In the period that covered the investigation there were studied 39 outbreaks of IRA; 32.94 percent of the samples were positive to the virus that caused the epidemic, there were 7 deceased patients, 6 females, and no pregnants(EU)

Prueba de la oxidasa con papel del filtro / Oxidasa test with filter paper

Se hizo un ensayo de laboratorio con el cual se lograron tirillas reactivas para la prueba de la oxidasa, óptimas para usar en 7-9 meses, teniendo como antioxidante el  naftol al 0,5 por ciento el cual no interfirió en los resultados de la prueba con este ensayo se demostró que se puede utilizar 0,5 gramos del reactivo cada 7-9 meses(AU)

A laboratory trial was done which there were obtained reagent samples for the oxidasa test eminently good to be used in 7-9 months having as antioxidizing, the naphtol to 0,5 per cent which did not interfered in the test, it was proved that it can be used 0,5 grams of reagent each 7-9 months(AU)

Eficiencia de los Laboratorios de Microbiología de la provincia Granma en el diagnóstico de la tuberculosis en el año 2004 / Efficiency of Microbiological Laboratoris of Granma province in the pulmonary tuberculosis diagnostic in 2004

Se hizo un estudio descriptivo para valorar la eficiencia de los laboratorios de Microbiología de la provincia Granma en el diagnóstico de la tuberculosis pulmonar en el año 2004. El municipio Bayamo fue el que más pacientes estudió y el que más caso aportó. La sensibilidad de los laboratorios en el diagnóstico de la tuberculosis fue el 82,7 por ciento y la especificidad de 100 por ciento. Consideramos buena la eficiencia de los laboratorios de Microbiología de la provincia Granma en el diagnóstico de la tuberculosis pulmonar durante el año 2004(AU)

A descriptive study was carried out to valve the efficiency of mocrobiological laboratories of Granma, Province in the pulmonary tuberculosis diagnostic in 2004. Bayamo was the municipality that studied more patients and cases. The laboratories sensibility in the tuberculosis diagnosis was of 82,7 per cent and the epecific test of 100 per cent. The efficiency of microbiological laboratories in Granma was considered useful in the pulmonary tuberculosis diagnostic during 2004(EU)

Comportamiento de los aislamientos de coprocultivos del Laboratorio de Microbiología en el año 2002 / Behaviour of the isolation of coprocultive in Microbiology Laboratory in 2002 year

Las Enfermedades Diarréicas Agudas (EDA) constituyen una causa importante de morbilidad e ingresos en instituciones hospitalarias de niños menores de 5 años. Estas son una manifestación de infección por muy diversos patógenos bacterianos, viricos y parásitos intestinales. Muchos de estos cuadros los producen gérmenes bien definidos y se les llaman enfermedades diarréicas específicas, entre los que podemos mencionar, cólera, Shigelosis, salmonelosis, infección por Escherichia colí, yersiniosis, giardiasis, campilobacteriosis, criptosporidiasis y gastroenteropatía víricas. Aproximadamente, 70,0-80,0 por ciento del gran número de episodios esporádicos de diarrea en personas que acuden a los establecimientos de salud en los países menos desarrollados se podrían diagnosticar etiologicamente si se dispusiera y se hiciera uso de la batería completa de los nuevos métodos de laboratorio(AU)

Papel del Médico de la Familia en el programa de prevención y control de la leptospirosis / Family doctor ´s role in the prevention and control program of leptospirosis

Se realizó un estudio descriptivo en el que se tuvo en cuenta dos periodos de trabajo de enero a mayo del 2002 y del año 2003, con el objetivo de demostrar la efectividad del Programa de Prevención y Control de la Leptospirosis por el médico de la familia, en el mismo comparamos al frecuencia de obtención de los sueros pares tanto en el Hospital Provincial Carlos M de Céspedes, Hospital Infantil General Milanés y los obtenidos en la áreas de salud. En los dos periodos estudiados se observaron diferencias en el pareamiento de los sueros entre el Hospital Provincial Carlos M de Céspedes 52 por ciento en el año 2002, mientras que en igual periodo las áreas de salud ocupan un lugar privilegiado con un 89 por ciento de pareamiento. A pesar de no haber variación en el procedimiento serológico utilizado, se observó un aumento en el número de reactores. El Policlínico Tipo III marcha a la vanguardia en el Programa de Prevención y Control de la Leptospirosis en el municipio Bayamo(AU)

A descriptive study was carried out during Lanuary to May from 2002 to 2003. Inthis work we compare the obtainment frequency of pair serums to show the effectiveness of prevention and control program of leptospirosis for family doctor. So much in Carlos Manuel de Céspedes Hospital and General Milanés infantile hospital and the ones obtainedin health areas. In the two periods etudied the differences in the coupling of serums were observedin Carlos Manuel de Céspedes hospital (52 per cent) in 2002, while in the same period the health areas have aprivileged place with a 89 percent of coupling. Despite of the absence of variation in the serologic procedure used, an increasing of reactor numbers was observed the tipo III policlinical goes to the first place in the prevention and control program of leptospirosis in Bayamo, municipality(EU)

Repercusión inmunoprofiláctica de la identificación de los serogrupos de leptospira interragans circulantes en la zona del Cauto de enero/2005 a junio/2006 / Inmunoprophylactic repercussion of serugroups identification of leptospira interrogans circulating in Cauto Zone since January 2005 to 2006

Se hizo un estudio descriptivo de los serogrupos circulantes de Leptospira en los pacientes sospechosos y vacunados con la antileptospirósica trivalente Vax–Spiral en la región del Cauto en el período de enero de 2005 a Junio de 2006. Las pruebas diagnosticadas utilizadas fueron: HA pasiva y Microaglutinación. Se encontró un porciento bajo de pacientes con sueros reactores a la HA en este estudio. El municipio Bayazo fue el que mayor número de reactores tuvo a la HA. Predominaron los serogrupos Icterohaemorrageae, Australis en la prueba de la Microaglutinación. Casi la mitad de los casos diagnosticados fueron serogrupos que no están incluidos en la vacuna(AU)

A descriptive study was carried out in circulating serogroups of leptospira in suspicious patients and previously vaccinated with antileptospira trivalent Vax-Spiral in Cauto region from January 2005 to June 2006, the diagnostic test used were: Indirect hemagglutination and microgglutination, it was found a low percent of patients with reactors serum to indirect hemogglutination. Bayamo had the greater numbers of studied cases and it also had the greater reactors to the indirect hemogglutination. Icterohaemorrageae australis, serogroups were predominated in icrogglutination test. Almost a half of the diagnosed cases were to serogroups that are not included in the vaccine(AU)

Evaluación de la vigilancia de dengue en la provincia Granma en el año 2001 / Evaluation of dengue vigilance in Granma province 2001

Se realizó un estudio descriptivo, transversal evaluando la vigilancia de dengue en la Provincia Granma a través de la nuestras de monosuero que llegan provenientes de las diferentes áreas para el análisis de los municipios por edad, sexo, comparando la presencia de foco de Aedes aegypti con la indicación y positividad, así como caracterizando las definiciones encontradas en la vigilancia, arrojando resultados de gran valor y estadísticamente con gran significación entre las variables utilizadas que nos sirven para incrementar y/0 mejorar la vigilancia de dengue en nuestra provincia.(AU)

A descriptive and transversal study was carried out avaluating the vigilante of dengue in Granma Province through the simples of monoserum that comes from the different areas, for the municipalities analysis by age, sex, comparing the presence of aedes- aegypty pocos with the indication and positivity, and characterizing the definitions found in the vigilante, showing results of great values that are statistically of paramount importance among the variables used to increase and to emprove the vigilance of dengue in our province

Comportamiento de los sueros pares para leptospira, 2001-2003 / Pair serun behaviour for leptospirosis 2001-2003

Se realizó un estudio descriptivo en el que se tuvo en cuenta los años 2001 al 2003, con el objetivo de demostrar el comportamiento de los sueros pareados en los casos con sospecha clínica epidemiológica procedente de los municipios de la zona del Cauto, en el mismo en la estratificación de los resultados en tiempo y espacio se logró más del 99 por ciento de pareamiento predominando los títulos de anticuerpo a la técnica de la HA 1:20 y 1:80 donde el médico de asistencia juega un papel protagónico en el cumplimiento de esta actividad(AU)

A descriptive study was carried out since 2001 to 2003 to show the paired serum behaviour in the suspecious cases of epidemiological clinic; proceeding from Cauto Zone and in the stratification of the results according to time and space, more than 99 per cent of clouping was obtained prevailing antibody tittles of the HH 1:20 and 1:80 techniques, where the assistant doctor plays a protagonic role in the accompliment of this activity(EU)

Gasto por uso de medios de cultivos en la realización de exudados vaginales. Laboratorio de Microbiología 2009 / Expenses for the use culture means in the performance of vaginal exudates. Microbiology Laboratory. 2009

Se realizó un trabajo descriptivo para evaluar los gastos por las indicaciones excesivas de exudados vaginales con cultivos, donde se incluyeron los 4023 pacientes que se realizaron exudados en el laboratorio de Microbiología durante el año 2004. Los exudados con cultivos que se realizan en nuestro laboratorio procedente fundamentalmente de las áreas de salud del municipio Bayamo, arrojando resultados con baja positividad (38,4 por ciento), los resultados positivos en el 59,0 por ciento pueden resultar de exudados simples. Las edades extremas menos de 10 años y 50 y + tienen mejor nivel de positividad a los gérmenes por exudados con cultivos que el resto de los grupos de edades. Existe un exceso de gasto por las indicaciones de exudados vaginales con cultivos, alrededor de 754,098 pesos en MLC(AU)

It was performed a descriptive research to evaluate the exparses due to the excessive indications of vaginal culture exudates, including the 4023 patients with exudates in the Microbiology laboratory during 2004. The culture exudates that are performed in our laboratory, mainly from the health areas of Bayamo, showing results with low positivity (38.4 percent), the positive results in the 59.0 percent may come from simple exudates. The extreme ages under 10 years and over 50 have better level of positivity to the germs by culture exudates than the rest of the group of ages. There is an excess of exparses for the indications of vaginal culture exudates, about 754.098 pesos in MLC.