Neumonitis por hipersensibilidad: a propósito de un caso

La neumonitis por hipersensibilidad o alveolitis alérgica extrínseca se produce como consecuencia de la inhalación repetida de determinadas sustancias orgánicas o antígenos que, en individuos susceptibles, puede producir una inflamación de las paredes alveolares, bronquiolo e intersticio con alteración del intercambio gaseoso. Su presentación clínica puede ser muy diversa según la edad del paciente. Los niños de mayor edad suelen debutar con cuadros de disnea de esfuerzo que progresa hasta aparecer en reposo, hipoxemia y estertores crepitantes en la auscultación. No hay ninguna prueba definitiva que diagnostique por sí misma la enfermedad, pero los hallazgos analíticos, pruebas de imagen y función pulmonar apoyan la sospecha clínica. La medida más importante de tratamiento es evitar la exposición al antígeno responsable. En algunas ocasiones puede ser útil la utilización de corticoides orales. A continuación, presentamos el caso de un menor con datos clínicos de neumonitis por hipersensibilidad secundaria a la exposición a aves con hipertensión pulmonar secundaria. (provisto por Infomedic International)

Hypersensitivity pneumonitis or extrinsic allergic alveolitis occurs because of the repeated inhalation of certain organic substances or antigens which, in susceptible individuals, can cause inflammation of the alveolar, bronchiole and interstice with gas exchange disorder.  Its clinical presentation can be very diverse according to the age of the patient. Older children usually present as dyspnea with exercises that progress to appear at rest, hypoxemia, and rattles on auscultation. There is no definitive test that by itself diagnoses the disease, but laboratory findings, imaging tests, and pulmonary function support clinical suspicion. The most important measure of treatment is to avoid exposure to the responsibility antigen. Sometimes, the use of oral corticosteroids may be useful. Below, we present the case of a minor with clinical data of hypersensitivity pneumonitis secondary to exposure to birds with secondary pulmonary hypertension. (provided by Infomedic International)

Systems science methods in public health: what can they contribute to our understanding of and response to the cost-of-living crisis?

BACKGROUND: Many complex public health evidence gaps cannot be fully resolved using only conventional public health methods. We aim to familiarise public health researchers with selected systems science methods that may contribute to a better understanding of complex phenomena and lead to more impactful interventions. As a case study, we choose the current cost-of-living crisis, which affects disposable income as a key structural determinant of health. METHODS: We first outline the potential role of systems science methods for public health research more generally, then provide an overview of the complexity of the cost-of-living crisis as a specific case study. We propose how four systems science methods (soft systems, microsimulation, agent-based and system dynamics models) could be applied to provide more in-depth understanding. For each method, we illustrate its unique knowledge contributions, and set out one or more options for studies that could help inform policy and practice responses. RESULTS: Due to its fundamental impact on the determinants of health, while limiting resources for population-level interventions, the cost-of-living crisis presents a complex public health challenge. When confronted with complexity, non-linearity, feedback loops and adaptation processes, systems methods allow a deeper understanding and forecasting of the interactions and spill-over effects common with real-world interventions and policies. CONCLUSIONS: Systems science methods provide a rich methodological toolbox that complements our traditional public health methods. This toolbox may be particularly useful in early stages of the current cost-of-living crisis: for understanding the situation, developing solutions and sandboxing potential responses to improve population health.

Female sexuality before and after sacrocolpopexy or vaginal mesh: is vaginal length one of the key factors?

INTRODUCTION AND HYPOTHESIS: We aimed to demonstrate that laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx) versus anterior vaginal mesh (AVM) results in a longer vaginal length without impacting sexual activity or function. METHODS: We performed a secondary analysis of sexual outcomes of a previous randomized control trial comparing LSC-Cx and AVM in 120 women (60/group) with symptomatic POP stage ≥ 3. We evaluated sexually active (SA) and non-sexually active women (NSA) using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA-Revised (PISQ-IR) preoperatively and 1 year postoperatively. Multivariate logistic and linear regression models were built to assess the impact of different variables on sexual activity and function, respectively. RESULTS: Among 120 women included, no statistically significant differences were found between vaginal length and preoperative dyspareunia (20.7% AVM vs. 22,8% LSC-Cx) comparing SA to NSA women and LSC-Cx to AVM. Vaginal length was significantly longer after LSC-Cx versus AVM (p < 0.001). The postoperative dyspareunia rate was 17.2% AVM versus 10.5% LSC-Cx. Partnered women were significantly more likely to be SA than unpartnered women before (OR = 19.04; p = 0.006) and after surgery (OR = 36.28; p = 0.002). Only dyspareunia was independently associated with sexual function pre- (B = -0.431; p = 0.017) and postoperatively (B = -0.3 96; p = 0.007). CONCLUSIONS: Vaginal length was greater following LSC-Cx compared to AVM. While vaginal length has no impact on female sexuality pre- and postoperatively, the most important factors were "having a partner" for sexual activity and dyspareunia for sexual function. Persistence of dyspareunia was higher after AVM. LSC-Cx should be considered in women with POP undergoing mesh surgery with future sexual expectations.

Association of Kidney Disease, Potassium, and Cardiovascular Risk Factor Prevalence with Coronary Arteriosclerotic Burden, by Sex.

The present study aimed to determine the relationship between the prevalence of cardiovascular risk factors and the number and severity of coronary artery atherosclerotic lesions obtained by coronary angiography. We reviewed and analyzed 1642 records from consecutive patients at the Catheter Laboratory of Talca Regional Hospital in Chile between March 2018 and May 2019. Patients were stratified according to the presence and severity of atherosclerotic lesions: 632 (38.5%) had no lesions or <30% stenosis and 1010 (61.5%) had at least one coronary atherosclerotic lesion with ≥30% stenosis (CALS-30). CALS-30 was more frequent in males, smokers, and patients with diabetes and/or hypertension (all p-values < 0.02). Serum potassium, glycaemia, creatinine and glomerular filtration rates were also associated with CALS-30 (all p-values < 0.01) in males. The age and the proportion of males with CALS-30 increased with the number of risk factors (p-values for trends < 0.001). Our results showed a stronger association between the accumulation of risk factors and CALS-30 in women than in men. Serum potassium levels were inversely associated with CALS-30 in men but not in women.

Sexual activity and function in women with advanced stages of pelvic organ prolapse, before and after laparoscopic or vaginal mesh surgery.

INTRODUCTION AND HYPOTHESIS: The differential impact of specific pelvic organ prolapse (POP) surgery on sexual activity and function is unknown. Our primary aim was to analyse sexual inactivity and function in women with symptomatic advanced stages of POP and the changes incurred after laparoscopic or vaginal mesh surgery. METHODS: We performed a secondary analysis of sexual outcomes of a previously published randomised controlled trial comparing laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx) and anterior vaginal mesh (AVM) in 120 women (60/group) with symptomatic anterior POP stage ≥ 3 and apical ≥ 2. Sexual activity and function were assessed preoperatively and 1 and 2 years postoperatively using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA-Revised (PISQ-IR). RESULTS: Sexual activity was recovered in 42.9% of non-sexually active (NSA) women 1 year postoperatively, mainly in women with higher preoperative POP-related subscale scores of the PISQ-IR, which indicated a negative preoperative sexuality by POP. Recovery of sexual activity was greater after LSC-Cx, albeit not significantly (2 years: 35.5% AVM vs. 45% LSC-Cx). Among sexually active (SA) women preoperatively remaining SA postoperatively, the difference in the mean PISQ-IR summary score significantly improved [mean baseline difference - 2 years; all: 0.3 (95% CI 0.1 to 0.5) p = 0.001; AVM 0.19 (95% CI -0.1 to -0.5) p > 0.05; LSC-Cx 0.37 (95% CI 0.1 to 0.7) p = 0.003]. Preoperative dyspareunia was significantly reduced after LSC-Cx (baseline: 24.6%, 2 years: 9.8%, p = 0.0448), but not after AVM (baseline: 20.7%, 2 years: 18.2%, p = 0.7385). CONCLUSIONS: Most women reported improved sexual activity and function 2 years after LSC-Cx or AVM, mainly because of enhanced POP-related subscales in both NSA and SA women. Recovery of sexual activity and improved sexual function were greater after LSC-Cx compared to AVM, likely related to less postoperative dyspareunia.

Position of Ibero-American Society of Neurourology and UroGynecology (SINUG) on the use of vaginal meshes in pelvic organ prolapse.

AIMS: Pelvic organ prolapse (POP) is a very prevalent condition with a great impact on women's quality of life. At present, there is great controversy regarding the use of mesh in POP surgery. To understand the current moment, it is advisable to make a brief summary of the historical evolution of mesh use for pelvic floor pathology. The aim of this paper is to establish the position of the Ibero-American Society of Neurourology and UroGynecology (SINUG for its acronym in Spanish) regarding vaginal mesh reconstructive surgery. METHODS: A working committee from the SINUG's scientific board performed a literature search about the use of vaginal meshes for pelvic organ prolapse reconstructive surgery and about the position of different societies. We analyzed the evolution into three periods: before the Food and Drug Administration (FDA) statement, FDA statement, and after the statement. SINUG drew up a position statement regarding vaginal mesh reconstructive surgery, based on the available scientific evidence and the evolution of its use in different contexts. RESULTS: Before mesh appearance in the 1990s, native tissue repair was the surgical treatment of choice for POP. Vaginal mesh reconstructive surgery has been frequently accompanied by procedure underestimation by inexperienced surgeons, besides inadequate diagnoses and indications. This situation led to the presentation of serious complications including mesh extrusion, exposure, and contraction. CONCLUSIONS: Once reviewed the available evidence and the position of different societies, SINUG presents its vision in this communication, which is a summary of the document prepared by the society's scientific board.

Position of the Ibero-American Society of Neurourology and Urogynecology in relation to the use of synthetic suburethral meshes for the surgical treatment of female stress incontinence.

AIMS: The aim of this paper is to stablish de position of the Ibero-American Society of Neurourology and Urogynecology (SINUG) in relation to the use of suburethral meshes for the surgical treatment of female stress incontinence. METHODS: Tension-free mid-urethral slings (MUS) have become the most popular procedure for the treatment of stress urinary incontinence (SUI). In July 2018, the British government announced a pause in the use of meshes for both pelvic organ prolapse (POP) and urinary incontinence (UI) treatment without differentiating whether the meshes were used for treating UI or POP. The decision was taken to stop their use until the publication of the updated UI and POP guidelines of the British National Health Service, which is available from April 2019. SINUG has reviewed the evidence and official position of different societies in relation to the safety and efficacy of MUS in the surgical treatment of incontinence differentiating them from meshes used to repair POP. RESULTS: Data from synthetic mesh manufacturers indicate that in 2010, 300 000 women underwent surgical procedures to repair POP and approximately 260 000 were operated on for SUI. According to these estimates, approximately more than 80% of the surgical techniques for UI treatment were performed transvaginally with meshes. CONCLUSIONS: Once reviewed evidence and position of different societies, the SINUG presents its vision in this communication, which is a summary of the document analysing the state of topic prepared by the society.

Coital resumption after delivery among OASIS patients: differences between instrumental and spontaneous delivery.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) are associated with sexual dysfunction and a lower likelihood of sexual activity in the postpartum period. The aim of the present study was to compare coital resumption and the variables influencing this activity after delivery in women with and without a history of obstetric anal sphincter injury (OASIS) and according to the mode of delivery. METHODS: A prospective, observational, case-control study was performed at 6 months postpartum in 318 women: 140 with a history of primary repaired OASIS and 178 women without OASIS. Demographic and obstetric data, breastfeeding, and symptoms of urinary and anal incontinence were collected. Patients were asked about coital resumption and completed the validated specific Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). Continuous and non-continuous variables were compared using ANOVA and the Fisher exact tests, respectively. A multivariate logistic regression model and a multiple regression analysis were constructed to assess the impact of demographic and clinical variables on the percentage of coital resumption and on the PISQ-12 score, respectively. RESULTS: After a spontaneous delivery (SD), patients without OASIS showed a higher percentage of coital resumption than those with OASIS (98% vs. 77%; p = 0.003), and the PISQ-12 score was also higher (p < 0.001). PISQ-12 score was better in women with SD compared to those with operative vaginal delivery (OVD)(p < 0.001), independently of the history of OASIS. Current breastfeeding, a higher Wexner score and OVD negatively influenced the PISQ-12 score. CONCLUSIONS: After SD, women with OASIS resumed coital activity later than women without OASIS. Women with OVD resumed coital activity later, and had a lower PISQ-12 score than women with SD.

Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury.

PURPOSE: To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). METHODS: This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. RESULTS: 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, with an average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). CONCLUSIONS: The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.

Usefulness of pelvic floor ultrasound in stress urinary incontinence: evaluation before surgery and after placement of tension-free vaginal tape / Utilidad de la ecografía de suelo pélvico en la incontinencia urinaria de esfuerzo: valoración prequirúrgica y tras colocación de banda suburetral libre de tensión

Tension-free vaginal tape (TFVT) surgery is the approach of choice in women with moderate-severe stress urinary incontinence (SUI). Up to 15% of women are thought to experience complications after TFVT surgery. The sling fails in 5%, with persistence of SUI.Pelvic floor ultrasound could prove useful in the presurgical evaluation of women with SUI. Similarly, it enables us to study the location and function of the TFVT after surgery and is especially indicated in patients with symptoms suggestive of TFVT-associated complications. In fact, there is a correlation between some ultrasound parameters and the symptoms reported by the patient, such as position, distance to the urethral complex, symmetry, and Valsalva maneuver with respect to the urethra. Pelvic floor ultrasound enables us to make more detailed diag-noses and tailor decisions on therapy

La cirugía mediante banda suburetral libre de tensión es la técnica de elección en las mujeres con incontinencia urinaria de esfuerzo moderada-severa. Se estima que hasta un 15% de mujeres tendrán una complicación tras una cirugía mediante BSLT, y en un 5%, la banda fallará persistiendo la IUE. La ecografía de suelo pélvico (ESP) puede ser de utilidad para la evaluación prequirúrgica de las mujeres con IUE; a su vez, permite estudiar la localización y funcionalidad de las BSLT en el posoperatorio, especialmente indicada ante la presencia de sintomatología sugestiva de complicaciones asociadas a las BSLT. De hecho, existe una correlación entre algunos parámetros ecográficos y la clínica referida por la paciente, tales como la posición, distancia al complejo uretral, simetría, forma y movimiento en Valsalva respecto a la uretra. La ESP nos permite realizar diagnósticos más detallados y tomar decisiones terapéuticas cada vez más personalizadas

Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms.

INTRODUCTION AND HYPOTHESIS: The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS). METHODS: From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (Rs) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model. RESULTS: A total of 95 women were included in the study. Good correlation (κ= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, Rs =0.212) and Starck's (p < 0.001, Rs =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score. CONCLUSIONS: The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

Impacto de la longitud del introductor en procedimientos coronarios transradiales: estudio clínico randomizado analítico / Impact of introducer length in transradial coronary interventions: a clinical randomized study

Objetivos: El objetivo principal del estudio fue conocer el impacto de la longitud del introductor en la aparición de vasoespasmo radial en pacientes sometidos a cateterización coronaria. Los objetivos secundarios fueron conocer la relación entre la longitud y dolor al retirarlo, tiempo de procedimiento, radiación y analizar los factores de riesgo sugeridos para espasmo radial. Material y Métodos: Se realizó un estudio clínico randomizado analítico de 99 pacientes con indicación de cateterización coronaria. Se randomizaron a dos grupos y se les realizó el procedimiento con diferentes longitudes de introductor (25cm y 10cm), ambos con cubierta hidrofílica. Se registró el tiempo de procedimiento, dosis de radiación, radioscopia, dolor al retirar el introductor y vasoespasmo radial. Resultados: En el total de pacientes el procedimiento fue exitoso. Del total de pacientes, en 12 se observó espasmo radial, encontrándose una menor incidencia de vasoespasmo (18,75 por ciento vs 5,88 por ciento, p = 0,005) y menor dolor al retirar el introductor (43,75 por ciento vs 21,57 por ciento, p = 0,018) en pacientes con introductor corto. No se observaron diferencias entre ambos grupos en relación a los otros factores. Diabetes y género femenino se mostraron como predictores independientes de vasoespasmo radial en pacientes sometidos a procedimientos coronarios transradiales. Conclusiones: El uso de un introductor corto disminuye la incidencia de vasoespasmo radial y dolor al retirar el introductor durante procedimientos coronarios transradiales.

Aim: Radial artery spasm producing severe pain is the most common complication of trans-radial approach for coronary artery catheterization. It remains unclear whether the length of the introducer is related to this complication. The aim of this study was to assess the impact of introducer length on radial artery spasm and, also, to identify variables associated to this complication. Methods and results: 99 patients were randomized to receive either a long (25 cm) or a short (10 cm) introducer for coronary catheterization. Both types of introducer were hydrophilic coated. The procedure was successful in all subjects. Radial artery spasm developed in 12 patients, 18.8 percent of those receiving a long introducer vs 5.9 percent of those receiving the short one (p=0.005). Corresponding values for sheath retrieval pain were 21.6 per cent and 43.8 per cent, respectively (p=0.018). No between-group difference was observed in radiation dose, radioscopy time and total procedure time. Diabetes and female gender were predictors of radial artery spasm. Conclusion: Use of a shorter hydrophilic coated introducer resulted in a lesser incidence of radial artery spasm and associated pain, during coronary catheterization.

El síndrome de turner en la edad adulta / Turner syndrome in adulthood

El síndrome de Turner (ST) es la anomalía cromosómica más frecuente en mujeres, con una prevalencia de hasta 1/2500 nacidas vivas. El ST es el resultado de la pérdida o anormalidad del segundo cromosoma sexual en, al menos, una línea celular. Estas anomalías estructurales pueden presentarse en estado puro, entre las cuales la monosomía completa 45X0 es la más frecuente...

La obesidad incrementa el riesgo aterogénico en pacientes con síndrome de ovarios poliquísticos / Obesity increases the atherogenic risk in patients with polycystic ovary syndrome

Objetivo: establecer una relación entre las alteraciones de la glucosa, la insulina, el metabolismo de los lípidos, y los niveles hormonales en relación a la obesidad y la contextura corporal en mujeres con PCOS. Pacientes y métodos: estudio observacional tipo casos-controles, con 223 pacientes diagnosticadas de síndrome de ovarios poliquísticos (SOP) según los criterios de Rotterdam, y 25 controles sanas...