Latin American formal consensus on the indications for the surgical treatment of massive and irreparable rotator cuff tears.

OBJECTIVES: To implement the Formal Consensus Method among a group of experts in shoulder surgery in Latin America, in order to establish appropriate indications for the surgical treatment of massive and irreparable rotator cuff injuries. METHODS: The Formal Consensus Method was used to develop surgical treatment recommendations for massive and irreparable rotator cuff tears (MIRCT). Three independent groups of experts in shoulder surgery were confirmed. The steering group conducted a systematic literature review and constructed a voting matrix consisting of 348 clinical scenarios. The rating group, composed of 15 members, rated each scenario on two occasions: first anonymously and then during an in-person discussion meeting. The median and voting ranges were used to classify each scenario as inappropriate, uncertain, or appropriate for each surgical technique. Finally, the reading group, consisting of 10 surgeons, reviewed, evaluated and rated the recommendations derived from the detailed analysis of the voting grids. RESULTS: The main finding of the study reveals a high percentage (70%) of clinical scenarios in which consensus was achieved regarding the appropriateness or inappropriateness of different surgical alternatives for the treatment of massive and irreparable rotator cuff injuries. Through a detailed analysis of the voting grids, a total of 20 recommendations were elaborated concerning the appropriateness of various surgical techniques in addressing irreparable rotator cuff tears. CONCLUSIONS: The indications for the operative treatment of MIRCT were determined based on expert consensus and the best available evidence, they seek to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios. LEVEL OF EVIDENCE: V.

Diseño y Validación de una Aplicación Móvil, para el Diagnóstico de Anemia en Pre-Escolares. Estudio de Precisión Diagnóstica / Design and Validation of a Mobile Application for the Diagnosis of Anemia in Preschoolers. Diagnostic Accuracy Study

La anemia afecta a miles de niños. Para el diagnóstico se cuantifica la hemoglobina (Hb); técnica que no se encuentra al alcance de toda la población. Contar con un instrumento validado de fácil aplicación, puede ayudar al diagnóstico. El objetivo de este estudio fue validar una aplicación móvil (APP) para diagnosticar anemia en niños de 2 a 5 años, aplicable por padres o tutores. Estudio de validación de escalas. Mediante búsqueda bibliografía se recopilaron ítems y dominios relacionados con anemia en niños. Una vez reducidos, se construyó un cuestionario para pilotaje, con tres hematólogos pediatras. El resultado de este fue posteriormente validado por 22 expertos mediante aplicación de escalas tipo Likert. Los ítems validados, se contrastaron con la Hb de niños de 267 niños de 2 a 5 años de los andes ecuatorianos (2.560 msnm). Se determinó asociación de los ítems con Hb y con los resultados obtenidos y se construyó la APP. 14 ítems fueron analizados. Todos ellos puntuaron sobre la mediana de la distribución (35,5 puntos) y fueron valorados por, al menos el 50 % de los expertos. Se seleccionaron palidez palmar, astenia y sueño en horas no habituales. Todos mostraron asociación significativa con anemia (p<0,05), y fueron aplicados como preguntas a padres o tutores y contrastados con el valor de Hb. Sensibilidad y especificidad para palidez fue: 85,1 % y 85,0 %; astenia: 72,3 % y 87,7 %; sueño en horas no habituales: 68,1 % y 87,7 %; palidez más astenia o sueño: 95,7 % y 74,6 %; y debilidad más sueño: 92,5 % y 76,8 %. Se desarrolló y validó una APP para diagnóstico de anemia en niños de 2 a 5 años aplicable por padres o tutores.

SUMMARY: Anemia affects thousands of children, and to reach a diagnosis, hemoglobin (Hb) is quantified. This technique however, is not always accessible to the general population. Therefore, the availability of a validated instrument can be useful in the diagnosis. The aim of this study was to validate a mobile application (APP), to diagnose anemia in children from 2 to 5 years old, applicable by parents or guardians. Scale validation study. Through a bibliographic search, items and domains related to anemia in children were collected. Once reduced, a pilot questionnaire was constructed with three pediatric hematologists. The result was later validated by 22 experts through the application of the Likert-type scales. The validated items were contrasted with the Hb of children of 267 children from 2 to 5 years of age from the Ecuadorian Andes (2,560 meters above sea level). The association of the items with Hb and with the results obtained was determined, and the APP was constructed. 14 items were analyzed. All of them scored above the median of the distribution (35.5 points) and were valued by at least 50 % of the experts. Palmar pallor, asthenia, and sleep at unusual hours were selected. All showed a significant association with anemia (p<0.05) and were applied as questions to parents or guardians and contrasted with the Hb value. Sensitivity and specificity for pallor was: 85.1 % and 85.0 %; asthenia: 72.3 % and 87.7 %; sleep at unusual hours: 68.1 % and 87.7 %; paleness plus fatigue or sleepiness: 95.7 % and 74.6 %; and weakness plus sleep: 92.5 % and 76.8 %. An APP for the diagnosis of anemia in children from 2 to 5 years old applicable by parents or guardians was developed and validated.

Shoulder Injury Related to Vaccine Administration Following Misplaced SARS-CoV-2 Vaccination: A Case Report and Review of Literature.

Introduction: To confront the SARS-CoV-2 pandemic, a large share of the population must be immunized. Intramuscular vaccination of the shoulder is the preferred technique as it is easily exposed and guarantees a good immune reaction. Local side effects, such as pain and swelling, are common after deltoid inoculation. They usually resolve within 3 days. Shoulder injury related to vaccine administration (SIRVA) should be considered if the symptoms persist. The aim of this presentation is to describe a typical case of SIRVA after SARS-CoV-2 vaccination and provide information to the general orthopedic surgeon to properly diagnose, report, and treat these cases. Case Report: A 69-year-old female health-care professional without history of shoulder pain consulted the senior author for persistent severe left shoulder pain 3 months following the second dose of Sputnik V COVID-19 vaccination. She claimed an improper application technique that caused immediate pain and loss of active range of motion (ROM). She underwent medical treatment with several doctors during 3 months with poor results. A magnetic resonance imaging (MRI) of the left shoulder done 5 days after vaccination showed mild subacromial-subdeltoid bursitis. A follow-up MRI at 2 months after application revealed synovial hypertrophy and distention of the subacromial-subdeltoid bursa. We prescribed a dose of depot betamethasone and home-based program of gentle exercises. Although initial response was quick, the patient required shoulder arthroscopy the following months, due to persistence in pain and functional limitations. Conclusion: SIRVA cases may occur and should be suspected in all individuals without a history of shoulder symptoms or dysfunction who experience sudden pain and reduced ROM following deltoid muscle vaccination. Treatment must be initiated early with corticosteroids and rehabilitation. The low probability of this complication does not outweigh the advantages of vaccination.

Guía de práctica clínica para el tratamiento de infecciones odontogénicas en el Seguro Social de Salud del Perú (EsSalud) / Clinical practice guidelines for the treatment of odontogenic infection of the Peruvian Health Social Security (EsSalud)

Introducción. El presente artículo resume las recomendaciones basadas en evidencias de la guía de práctica clínica (GPC) para el tratamiento de los pacientes con infecciones odontogénicas (absceso dentoalveolar, celulitis facial y absceso cervicofacial) en el Seguro Social de Salud del Perú (EsSalud). Objetivo. Brindar recomendaciones clínicas basadas en evidencia para el tratamiento de pacientes con infecciones odontogénicas en EsSalud. Métodos. Se conformó un grupo elaborador de la guía (GEG) que incluyó cirujanos dentistas, especialistas y metodólogos. El GEG formuló cuatro preguntas clínicas a ser respondidas en la presente GPC. Se realizó búsquedas sistemáticas de revisiones sistemáticas y cuando fue considerado pertinente­ estudios primarios en PubMed y CENTRAL durante el año 2019. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buena práctica clínica y el flujo- grama de tratamiento. Finalmente, la GPC fue aprobada con Resolución N° 067­IET- SI-ESSALUD-2020. Resultados. La presente GPC abordó cuatro preguntas clínicas, divididas en dos temas: manejo farmacológico y manejo quirúrgico de las infecciones odontogénicas. En base a dichas preguntas se formularon seis recomendaciones fuertes, dos recomendaciones condicionales, 11 puntos de buena práctica clínica, y un flujograma. Conclusión. El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para tratamiento de las infecciones odontogénicas (absceso dentoalveolar, celulitis facial y absceso cervicofacial) en EsSalud.

Introduction. This article summarizes the evidence-based recommendations of the clinical practice guide (CPG) for the treatment of patients with odontogenic infections (dentoalveolar abscess, facial cellulitis and cervicofacial abscess) in the Social Security of Health of Peru (EsSalud). Objective. To provide evidence-based clinical recommendations for the treatment of patients with odontogenic infections in EsSalud. Methods. A guideline development group (GEG) was formed that included dental surgeons, specialists, and methodologists. The GEG formulated four clinical questions to be answered in this CPG. We conducted systematic searches for systematic reviews and when deemed relevant - primary studies in PubMed and CENTRAL during 2019. The evidence was selected to answer each of the clinical questions posed. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and the treatment flow chart. Finally, the CPG was approved with Resolution No. 067 ­ IETSI-ESSALUD-2020. Results. This CPG addressed four clinical questions, divided into two topics: pharmacological management and surgical management of odontogenic infections. Based on these questions, six strong recommen- dations were formulated, two conditional recommendations, 11 points of good clinical practice, and a flow chart. Conclusion. This article summarizes the methodology and evidence-based conclusions of the CPG for the treatment of odontogenic infections (dentoalveolar abscess, facial cellulitis and cervicofacial abscess) in EsSalud.

Un inusual caso de granuloma piogeno oral multiple, ¿asociado a tratamiento con levotiroxina? / An unusual case of multiple oral pyogenic granuloma, ¿associated with treatment with levothyroxin?

RESUMEN El Granuloma piógeno (GP) es una lesión tumoral, no neoplásica, vascular, generalmente solitaria, que se presenta en la cavidad oral o piel, la etiología aún no está muy clara, se considera que es una lesión reactiva a varios estímulos de bajo grado, entre los cuales podemos contar traumas repetidos, agresiones, factores hormonales y ciertos fármacos. El GP múltiple, es un fenómeno raro, generalmente asociado al uso de drogas, como la carbamacepina, ciclosporina, retinoides, levotiroxina, etc. Se presenta el caso de una paciente de 50 años, referida por presentar aumento de volumen en reborde alveolar del primer, tercer y cuarto cuadrantes; con antecedentes de psoriasis eritrodermica e hipotiroidismo, en tratamiento con levotiroxina aproximadamente seis meses antes que se presenten las lesiones; se realiza exeresis quirúrgica y curetaje subperiostico, se enviaron las muestras a anatomía patológica, confirmándose el diagnóstico definitivo de GP; por los antecedentes, y la aparición casi simultánea de las lesiones en múltiples cuadrantes, se sospecha que estas, están asociadas al consumo terapéutico de levotiroxina para el hipotiroidismo.

SUMMARY Pyogenic Granuloma (GP) is a tumorous, non-neoplastic, vascular, generally solitary lesion that presents itself in the oral cavity or skin, the etiology is still not very clear, it is considered to be a reactive lesion to several low grade stimuli, among which we can count repeated trauma, aggressions, hormonal factors and certain drugs. The multiple GP, is a rare phenomenon, generally associated with the use of drugs, such as carbamacepine, cyclosporine, retinoids, levothyroxine, etc. It presents the case of a patient of 50 years, referred for presenting increased volume in alveolar ridge of the first, third and fourth quadrants, with a history of erythrodermic psoriasis and hypothyroidism, in treatment with levothyroxine approximately six months before the lesions occur; Surgical exeresis and subperiosteal curettage is performed, samples were sent to pathological anatomy, confirming the definitive diagnosis of GP; because of the history, and the almost simultaneous appearance of the lesions in multiple quadrants, it is suspected that these are associated with the therapeutic consumption of levothyroxine for hypothyroidism.

Queratoquiste odontogenico recurrente en paciente con sindrome de Gorlin-Goltz / Recurrent odontogenic keratocyst in patient with Gorlin-Goltz Syndrome

RESUMEN El Síndrome de Gorlin-Goltz (SGG) es un desorden autosómico dominante, se caracteriza por presentar anomalías esqueléticas, Queratoquistes Odontogénicos (QQOs) múltiples y carcinoma de células basales. Se han realizado estudios comparativos de los QQOs asociados y no asociados al SGG, y se encontró la presencia de mayor número de quistes satélites, proliferaciones sólidas del epitelio, inflamaciones, calcificaciones, más intensa ac-tividad mitótica de las células epiteliales, y mayor recurrencia de los QQOs asociados al SGG. El propósito de este reporte de caso es proporcionar una base objetiva para el manejo terapéutico de los QQOs en pacientes con SGG y una revisión de la literatura científica. Se presenta el caso de una paciente de 63 años, con antecedentes de SGG, sometida a múltiples intervenciones quirúrgicas, incluida exéresis de QQOs en ambos maxilares, que acudió a la consulta nueve años después de su última intervención para un control por la especialidad, donde se evidenció recurrencia de la lesión en maxilar superior derecho, realizándose enucleación, ostectomia periférica y aplicación de solución de Carnoy.

SUMMARY Gorlin-Goltz syndrome (GGS) is an autosomal dominant disorder characterized by skeletal abnormalities, multi-ple Keratocysts Odontogenic (KCOs) and basal cell carcinoma. Comparative studies of the associated KCOs and those not associated with the GGS have been performed, and the presence of a greater number of satellite cysts, solid proliferations of the epithelium, inflammations, calcifications, more intense mitotic activity of the epithelial cells, and greater recurrence of the KCOs associated with the GGS. The purpose of this case report is to provide an objective basis for the therapeutic management of KCOs in patients with GGS and a review of the scientifi c literature. We present the case of a 63-year-old patient, with a history of GGS, who underwent multiple surgical interventions, including exeresis of KCOs in both jaws, who came to the consultation, nine years after her last intervention, for an Odontostomatological check-up, finding KCO recurrent in upper right maxilla, performing enucleation, peripheral ostectomy and application of carnoy solution.

A retrospective comparison of the incidence of bacterial infection following anterior cruciate ligament reconstruction with autograft versus allograft.

PURPOSE: To compare the incidence of bacterial infection in anterior cruciate ligament (ACL) reconstruction with autograft versus allograft. METHODS: We completed a retrospective medical record review of ACL reconstructions performed at our institutions between 2001 and 2005. These included 170 autograft, 628 allograft, and 3 combined autograft/allograft reconstructions. Data collection included patient demographics, comorbidities, preoperative antibiotics, fixation type, and the occurrence of deep postoperative infection. RESULTS: Of the 801 patients who underwent ACL reconstruction, 6 (0.75%) developed a confirmed deep infection. There were 2 confirmed deep infections in 170 autograft reconstructions (1.2%) compared with 4 confirmed deep infections in 628 allograft reconstructions (0.6%). Multivariate analysis revealed that ACL reconstruction using autograft had a nearly twice the risk of infection compared to allograft reconstructions (adjusted odds ratio, 1.83; 95% confidence interval, 0.16 to 12.94). CONCLUSIONS: This study failed to find a higher rate of deep bacterial infection in ACL reconstructions when allograft tissue was used. We therefore feel that surgeons should consider allograft tissue as an alternative to autograft when there is a concern about donor-site morbidity, or for revision reconstructions. LEVEL OF EVIDENCE: Level III, therapeutic retrospective comparative study.

Engaging needles: a simple technique for arthroscopic side-to-side rotator cuff repair.

We present a simplified technique for the side-to-side arthroscopic rotator cuff repair. The instruments required for this technique are a 45 degrees Suture Lasso (SL; Arthrex, Naples, FL) and a 17F spinal needle (SN). With the arthroscope in the lateral portal, the SL is inserted through the posterior cannulas to grab healthy tissue at the posterior margin of the cuff. Through the anterior cannulas or through a skin puncture, the SN is inserted to catch healthy tissue at the anterior margin. Once both instruments are through the tissues, we manipulate them to make their tips converge. Because the SN diameter is small, it is very easy to engage its tip into the SL tip. Once engaged, a No. 1 PDS monofilament suture is easily passed through both instruments. When the suture comes out of the SL handle, both instruments can be pulled out, leaving the suture in place. Using a suture retriever clamp, the sutures are retrieved through a cannula for knot tying. This technique can be repeated as many times as necessary to place enough sutures in a side-to-side fashion to achieve the repair.

Engaging needles: a simple technique for arthroscopic side-to-side rotator cuff repair.

We propose that the tibial remnant of the anterior cruciate ligament (ACL) is able to enhance the revascularization and cellular proliferation of the graft, to preserve proprioceptive function, and to acquire anatomic placement of the graft without roof impingement. Therefore, it seems reasonable to assume that preserving the tibial remnant as much as possible as a source of reinnervation, if technically possible without causing impingement, would be of potential benefit to the patient. Our surgical technique was developed to maximize the preservation of the tibial remnant. The distally attached semitendinosus and gracilis tendons are harvested using a tendon stripper. Once satisfactory placement of 2 guide pins convergently is done, create a closed-end socket in the lateral femoral condyle with an adequate sized curved curette. For anatomic placement of the graft, the tibial tunnel should be positioned within the boundaries of the normal ACL tibial remnant. The reamer must be advanced very carefully to minimize injury to the residual remnant at the intra-articular margin of the tibial tunnel. Penetration should stop at the base of the stump. The folded grafts are then pulled intra-articularly through the tibial tunnel, the tibial remnant, and the femoral socket by pulling sutures under arthroscopic visualization. The ACL tibial remnant is compacted by the tendon passage. The graft is secured proximally by tying sutures in the lateral femoral condyle and distally at the tibia with double staples using a belt-buckle method. The advantages of our technique include maximal preservation of the tibial remnant, no roof impingement from intrasynovial anatomic placement of the graft, the simplicity of the procedure, the minimal need for hardware or special instruments, the economic benefit, and the potential prevention of tibial tunnel enlargement by preventing synovial fluid leakage.

New reference levels for CA125 in pre- and postmenopausal women.

Objective: CA125 is a glycoprotein commonly produced by the endometrium. Serum CA125 is widely useful as a marker for ovarian cancer screening, with 35 U/mL the generally accepted upper limit of normal. Since CA125 is known to fluctuate with vaginal bleeding and menopausal status, the purpose of this study was to develop different reference ranges for normal women of differing physiologic states.Methods: We retrospectively analyzed 1,407 patients with serum CA125 levels taken at Cleveland Clinic Florida between 1992 and 1997. Patients with obvious elevation of CA125 from gynecologic cancers were excluded. Student t test was used to determine statistical significance.Results: Among 1,407 patients studied, 256 were premenopausal, 46 perimenopausal, 957 postmenopausal, and 148 excluded due to known gynecologic cancers. There was a significant difference between the mean CA125 values of premenopausal (19.3 +/- 15.6) and postmenopausal women (11.7 +/- 9.2) with P.7 x 10(-6). Among premenopausal women, there was a statistically significant difference between CA125 levels during menses (21.4 +/- 19.3) and luteal phase (14.0 +/- 9.1) with P =.03. Among the subgroup of postmenopausal women with known bleeding history, the mean CA125 values for women with vaginal bleeding was 12.49 +/- 11.5 compared to those without bleeding, 9.62 +/- 4.6 (P =.017).Conclusions: For normal premenopausal women, the overall upper limit of CA125 should be 50 U/mL. However, if menstrual status is known, the upper normals should be: 62 during menses, 51 for proliferative phase, and 32 for luteal phase. For postmenopausal women, the CA125 levels should be no more than 35 for those with vaginal bleeding and 20 for those without bleeding. The stratified CA125 values may help provide more specific ovarian cancer screening.