The Management of Children and Adolescents with Overactive Bladder Refractory to Treatment with Parasacral Transcutaneous Electrical Nerve Stimulation.

BACKGROUND: Although parasacral TENS (pTENS) has been employed in various centers, there is a lack of studies on how children with overactive bladder (OAB) respond after failing to complete pTENS sessions. This study aimed to describe and assess treatments for OAB in children who did not respond to pTENS. MATERIAL AND METHODS: This retrospective case series examined patients aged 4-17 years. Patients were given subsequent treatment options, including: behavioral therapies; oxybutynin; imipramine; a combination of oxybutynin and imipramine; parasacral percutaneous electrical nerve stimulation (PENS); or a repeat course of pTENS. Outcomes were evaluated using the Dysfunctional Voiding Scoring System (DVSS) and the Visual Analogue Scale (VAS). RESULTS: Thirty children were included, with a median age of 7 years. Patients received one or more treatments. Of these, 70% underwent monotherapy. Among them, 57% experienced complete resolution of symptoms, 28% had partial resolution and were satisfied with the results, and 14% discontinued treatment. 30% out of the whole sample continued to experience bothersome symptoms. Complete response, according to initial subsequent, was achieved in: 54% with intensified behavioral therapies, 33% with oxybutynin, and 50% with imipramine alone. The median DVSS score decreased from 7.0 to 2.0 (p=0.025), while the median VAS score increased from 80 to 100 (p<0.001). CONCLUSION: Children with OAB refractory to pTENS who received structured subsequent treatments showed partial response in all cases, with complete symptom resolution in half of the patients. More intensive urotherapy, medications, or repeat pTENS in combination with oxybutinin can be effective for managing this challenging condition.

Predictors of ischemic stroke in Chagas disease: Insights into mechanisms beyond cardiomyopathy severity.

BACKGROUND: Chagas disease is a risk factor for ischemic stroke, which causes high mortality rates and significant disability. This study aims to determine the incidence and risk factors for ischemic strokes in a large cohort of Chagas cardiomyopathy patients, with a particular focus on the mechanisms involved in the pathophysiology of stroke in this condition. METHODS: The study enrolled 517 patients with Chagas cardiomyopathy who were referred to our institution from March 2000 to December 2021. All patients underwent systematic cardiological and neurological assessments. The primary outcome was the occurrence of ischemic stroke during the follow-up period, classified based on the SSS-TOAST and CCS criteria. Natural cubic splines functions were applied to examine the potential nonlinear association between continuous variables and stroke risk. RESULTS: The mean age of the cohort was 52 ± 13 years, and 299 (58 %) were men. During a mean follow-up period of 4.8 years (interquartile range-IQR 1.1 to 7.1 years), a total of 72 patients (14.8 %) had an ischemic stroke, being fatal in 10. The overall incidence rate of ischemic stroke was 3.0/100 patient-years (95 % confidence interval 2.4 to 3.8). The stroke subtypes were cardioembolic (n = 41), undetermined (n = 11), and other subtypes (n = 20). The predictors of stroke were age, left atrial volume, left ventricular ejection fraction (LVEF), LV thrombus and prior stroke with thrombus. There was a nonlinear relationship between stroke risk, LVEF, and left atrial volume. A bimodal distribution of stroke occurrences was observed according to the severity of LV dysfunction, with a threshold for LVEF of 45 %. The final model for stroke risk prediction showed good discrimination, with a C statistic of 0.775. CONCLUSIONS: In a contemporary cohort of Chagas disease patients with a broad spectrum of disease severity, stroke incidence remains high despite anticoagulation. Stroke risk shows a nonlinear association with ventricular dysfunction and left atrial size, highlighting a distinct bimodal pattern of stroke occurrence in Chagas disease.

Overall survival and cause-specific mortality in a hospital-based cohort of retinoblastoma patients in São Paulo, Brazil.

Studies are lacking on long-term effects among retinoblastoma patients in low- and middle-income countries. Therefore, we examined cause-specific mortality in a retrospective cohort of retinoblastoma patients treated at Antonio Candido de Camargo Cancer Center (ACCCC), São Paulo, Brazil from 1986 to 2003 and followed up through December 31, 2018. Vital status and cause of death were ascertained from medical records and multiple national databases. We estimated overall and cause-specific survival using the Kaplan-Meier survival method, and estimated standardized mortality ratios (SMRs) and absolute excess risk (AER) of death. This cohort study included 465 retinoblastoma patients (42% hereditary, 58% nonhereditary), with most (77%) patients diagnosed at advanced stages (IV or V). Over an 11-year average follow-up, 80 deaths occurred: 70% due to retinoblastoma, 22% due to subsequent malignant neoplasms (SMNs) and 5% to non-cancer causes. The overall 5-year survival rate was 88% consistent across hereditary and nonhereditary patients (p = .67). Hereditary retinoblastoma patients faced an 86-fold higher risk of SMN-related death compared to the general population (N = 16, SMR = 86.1, 95% CI 52.7-140.5), corresponding to 42.4 excess deaths per 10,000 person-years. This risk remained consistent for those treated with radiotherapy and chemotherapy (N = 10, SMR = 90.3, 95% CI 48.6-167.8) and chemotherapy alone (N = 6, SMR = 80.0, 95% CI 35.9-177.9). Nonhereditary patients had only two SMN-related deaths (SMR = 7.2, 95% CI 1.8-28.7). There was no excess risk of non-cancer-related deaths in either retinoblastoma form. Findings from this cohort with a high proportion of advanced-stage patients and extensive chemotherapy use may help guide policy and healthcare planning, emphasizing the need to enhance early diagnosis and treatment access in less developed countries.

Establishing an autogenous vascular access program in a Guatemalan comprehensive pediatric nephrology center.

BACKGROUND: The Guatemalan Foundation for Children with Kidney Diseases collaborated with Bridge of Life, a not-for-profit charitable organization, to establish a vascular access program. We reviewed our experience with graded surgical responsibility and structured didactic training, creating arteriovenous fistulas (AVF) for Guatemalan children. METHODS: Pediatric vascular access missions were completed from 2015 to 2023 and analyzed retrospectively. Follow-up was completed by the Guatemalan pediatric surgeons, nephrologists, and nursing staff. AVF patency and patient survival were evaluated by Kaplan-Meier life-table analysis with univariate and multivariable association between patient demographic variables by Cox proportional hazards models. RESULTS: Among a total of 153 vascular access operations, there were 139 new patient procedures, forming the study group for this review. The mean age was 13.6 years, 42.6% were female, and the mean BMI was 17.3. Radial or ulnar artery-based direct AVFs were established in 100 patients (71.9%) and ten of the 25 transposition procedures. Brachial artery inflow was required in 29 direct AVFs (20.9%). Two patients underwent femoral vein transpositions. Access-related distal ischemia was not encountered. Seven of the AVF patients later required access banding for arm edema; all had previous dialysis catheters (mean = 9, range 4-12). Primary and cumulative patency rates were 84% and 86% at 12 months and 64% and 81% at 24 months, respectively. The median follow-up was 12 months. Overall patient survival was 84% and 67% at 12 and 24 months, respectively. There were no deaths related to AVF access. CONCLUSIONS: Safe and functional AVFs were established in a teaching environment within a Guatemalan comprehensive pediatric nephrology center.

Dynamic evolution of kidney function in patients with STEC-hemolytic uremic syndrome followed for more than 15 years: unexpected changes.

BACKGROUND: Most studies regarding kidney outcomes in patients with Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome (STEC-HUS) focus on kidney status at last assessment. We aimed to describe patterns of changes in kidney function during follow-up and investigate associations between kidney function at 1st, 5th, and 10th year after onset and long-term kidney outcomes. METHODS: Data of patients with STEC-HUS followed for at least 15 years were analyzed. Kidney function patterns were constructed considering kidney status at 1st, 5th, 10th, and ≥ 15 years and defined as (1) progressive, if patients changed from complete recovery to any chronic kidney disease (CKD) stage or if CKD worsened; (2) improvement, if they shifted from any CKD stage to complete recovery or to a milder stage; and (3) stable, if remained unchanged. RESULTS: Of 152 patients included, after 1 year of follow-up, 47% had complete recovery, 22% CKD1, and 32% CKD2-5. At last assessment, 46% had complete recovery, 34% CKD1, and 19% CKD2-5. Despite percentages seeming similar, patients differed: 48% were stable, 27% improved, and 25% worsened. Further, 62% of patients with CKD2-4 in the 1st year normalized their glomerular filtration rate (GFR) thereafter. Comparison of kidney function between 1st, 5th, and 10th year to last assessment shows a stable pattern in 48, 59, and 69% respectively. CONCLUSIONS: Changes in kidney function showed a dynamic and complex behavior, with patients moving from one group to another. Consistently, kidney function neither at the 1st, 5th, or 10th year was representative of final outcome. Unexpectedly, two-thirds of patients with CKD2-4 after 1 year achieved normal eGFR later during follow-up.

Assessing the Relevance of Non-molecular Prognostic Systems for Myelodysplastic Syndrome in the Era of Next-Generation Sequencing.

Background: The Molecular International Prognostic Scoring System (IPSS-M) has improved the prediction of clinical outcomes for myelodysplastic syndromes (MDS). The Artificial Intelligence Prognostic Scoring System for MDS (AIPSS-MDS), based on classical clinical parameters, has outperformed the IPSS, revised version (IPSS-R). For the first time, we validated the IPSS-M and other molecular prognostic models and compared them with the established IPSS-R and AIPSS-MDS models using data from South American patients. Methods: Molecular and clinical data from 145 patients with MDS and 37 patients with MDS/myeloproliferative neoplasms were retrospectively analyzed. Results: Prognostic power evaluation revealed that the IPSS-M (Harrell's concordance [C]-index: 0.75, area under the receiver operating characteristic curve [AUC]: 0.68) predicted overall survival better than the European MDS (EuroMDS; C-index: 0.72, AUC: 0.68) and Munich Leukemia Laboratory (MLL) (C-index: 0.70, AUC: 0.64) models. The IPSS-M prognostic discrimination was similar to that of the AIPSS-MDS model (C-index: 0.74, AUC: 0.66) and outperformed the IPSS-R model (C-index: 0.70, AUC: 0.61). Considering simplified low- and high-risk groups for clinical management, after restratifying from IPSS-R (57% and 32%, respectively, hazard ratio [HR]: 2.8; P=0.002) to IPSS-M, 12.6% of patients were upstaged, and 5% were downstaged (HR: 2.9; P=0.001). The AIPSS-MDS recategorized 51% of the low-risk cohort as high-risk, with no patients being downstaged (HR: 5.6; P<0.001), consistent with most patients requiring disease-modifying therapy. Conclusions: The IPSS-M and AIPSS-MDS models provide more accurate survival prognoses than the IPSS-R, EuroMDS, and MLL models. The AIPSS-MDS model is a valid option for assessing risks for all patients with MDS, especially in resource-limited centers where molecular testing is not currently a standard clinical practice.

The burden of pre-operative anaemia and postoperative outcomes in 15 166 surgical patients from a public hospital in Brazil: A retrospective cohort study.

BACKGROUND: Preoperative anaemia is associated with poor postoperative outcomes; however, few studies have reported its prevalence in developing countries and its association with significant postoperative outcomes. OBJECTIVE: We aimed to identify the prevalence of anaemia and its association with postoperative outcomes in a major public hospital in Brazil. DESIGN: Retrospective cohort study. SETTING: Single-centre, 860-bed, quaternary university-affiliated teaching hospital in Southern Brazil. PATIENTS: We included adult patients who had undergone surgery between 2015 and 2019. Main outcome measures: The main outcome was the in-hospital 30-day postoperative mortality. According to the World Health Organisation, we defined anaemia and its sub-classification (mild, moderate, and severe). We developed Poisson regression models to examine the association between preoperative anaemia and outcomes. RESULTS: We included 15 166 patients, of whom 6387 (42.1%) were anaemic. After adjustment for confounding factors, patients with anaemia had an increased risk of in-hospital 30-day postoperative mortality (relative risk (RR) 1.69, 95% confidence interval (CI) 1.44 to 1.99, P  < 0.001). Mild [relative risk (RR) 1.38, 95% CI 1.12 to 1.71, P  = 0.003], moderate (RR 1.73, 95% CI 1.43 to 2.10, P  < 0.001), and severe anaemia (RR 2.43, 95% CI 1.92 to 3.07, P  < 0.001) were associated with the primary outcome. Anaemia increased the transfusion risk (RR 4.44, 95% CI 3.90 to 5.06, P  < 0.001) and postoperative intensive care unit (ICU) admission (RR 1.09, 95% CI 1.04 to 1.16, P  = 0.001). CONCLUSIONS: Four out of 10 patients had anaemia. These patients had an increased risk of adverse postoperative outcomes. Comprehension of the magnitude and impact of anaemia is essential to establish interventions in low-resource scenarios to optimise the patient's journey. STUDY REGISTRATION: Institutional Review Board Registration number 40522820000005327 (Brazilian CEP/CONEP System, available in https://plataformabrasil.saude.gov.br/ ).

Epidemiological characterization of clubfoot: a population-based study of a surveillance program in Colombia.

Clubfoot is a common musculoskeletal congenital abnormality, with a prevalence of 5-20 cases per 10 000 live births in low to middle-income countries. If left untreated, clubfoot causes severe consequences for the child: gait disturbances, reduced quality of life, and limited work opportunities. Our objective was to characterize clubfoot and determine its prevalence and associated risk factors in Bogotá and Cali, Colombia, from 2002 to 2020. A retrospective case-control study design was employed, analyzing data from birth defect reports provided by the Program for the Prevention and Follow-up of Congenital Defects and Orphan Diseases surveillance system. Cases included live births or stillbirths with clubfoot, while controls consisted of infants without congenital abnormalities, matched in terms of birth date and hospital. Prevalence was calculated considering a 95% confidence interval using Poisson distribution, and risk factors were assessed through adjusted odds ratios obtained by logistic regression model. Of 558 255 births, 861 cases of clubfoot were identified, 48.20% were postural clubfoot, and 15 cases were syndromic clubfoot. In Bogota, prevalence rate was 15.1 per 10 000 live births, whereas in Cali it was 17.29 per 10 000 live births. Family history of clubfoot within first-degree relatives was identified as a risk factor for clubfoot. Investigating risk factors for clubfoot holds significant importance in terms of preventing and reducing morbidity within this population. Helping to drive government and healthcare initiatives aimed at providing timely and effective treatment.

HIV prevalence among cervical (pre)cancer diagnoses in Suriname: a retrospective population study / Prevalencia del VIH en los casos diagnosticados de lesiones cervicouterinas (pre)cancerosas en Suriname: estudio poblacional retrospectivo / Prevalência de HIV em pacientes diagnosticadas com lesões cervicais (pré-) cancerosas no Suriname: estudo populacional retrospectivo

[ABSTRACT]. Objective. To determine the prevalence of HIV in women with (pre)cancerous cervical lesions in Suriname and their retention in care. Methods. A retrospective population study including all women diagnosed with (pre)invasive cervical intraepithelial neoplasia (CIN I to III or cervical cancer) in the only pathology department, during 2010–2020. The HIV test coverage and the HIV positivity ratio were determined through matching pathology data with the national HIV test database. The relation between retention in HIV care up to 2022 and different covariates was determined through Kaplan–Meier survival analysis and log-rank tests. Results. There were 2 901 (1 395 CIN I, 396 CIN II, 444 CIN III, and 666 cervical cancer) diagnoses of (pre) invasive cervical neoplasia. An overall HIV test coverage of 57.5% and a positivity ratio of 5.8% were found, with no difference among the (pre)cancer stages. The undiagnosed prevalence (women not previously known HIV-positive at cervical diagnosis) was 1.6% and 2.9% among precancer and cancer diagnoses, respectively. The median time in care of women with cervical cancer was 8 months for those not on antiretroviral therapy (ART) and 4 years for those starting ART. Among women with precancer stages this was 5 and 10 years, respectively (p < 0.05). Conclusions. HIV testing, followed by treatment initiation when found HIV-positive, should be prioritized in women diagnosed with cervical neoplasia. This will enhance the individual clinical outcomes and facilitate the control of the HIV epidemic in Suriname.

[RESUMEN]. Objetivo. Determinar la prevalencia del VIH en mujeres con lesiones cervicouterinas (pre)cancerosas en Suriname y su permanencia en la atención de salud. Métodos. Estudio poblacional retrospectivo en el que se incluyó a todas las mujeres a las que se diagnosticó una neoplasia intraepitelial cervicouterina (pre)invasiva (NIC I a III o cáncer cervicouterino) en el único departamento de anatomía patológica, entre el 2010 y el 2020. La cobertura de las pruebas del VIH y la tasa de positividad para el VIH se determinaron mediante el cotejo de los datos anatomopatológicos con la base de datos nacional de pruebas del VIH. La relación entre la permanencia en los servicios de atención a la infección por el VIH hasta el 2022 y las distintas covariables se determinó mediante un análisis de supervivencia de Kaplan-Meier y pruebas de orden logarítmico. Resultados. Hubo 2901 diagnósticos de neoplasia cervicouterina (pre)invasiva (1395 de NIC I, 396 de NIC II, 444 de NIC III y 666 de cáncer cervicouterino). Se observó una cobertura general de las pruebas del VIH del 57,5% y una tasa de positividad del 5,8%, sin diferencias entre los estadios de las lesiones precancerosas. La prevalencia no diagnosticada (mujeres sin positividad conocida previa para el VIH en el momento del diagnóstico del cáncer cervicouterino) fue del 1,6% y el 2,9% en las diagnosticadas de lesiones precancerosas y cáncer, respectivamente. La mediana del tiempo de permanencia en la atención de salud de las mujeres con cáncer cervicouterino fue de 8 meses en las que no recibían tratamiento antirretroviral y de 4 años en las que lo iniciaban. En el caso de las mujeres en estadio precancerosos fue de 5 y 10 años, respectivamente (p <0,05). Conclusiones. La realización de las pruebas del VIH, seguidas de un inicio del tratamiento al detectar un resultado positivo para el VIH, debe ser una prioridad en el caso de las mujeres a las que se diagnostica una neoplasia cervicouterina. Esto permitirá mejorar los resultados clínicos individuales y contribuirá al control de la epidemia de la infección por el VIH en Suriname.

[RESUMO]. Objetivo. Determinar a prevalência de infecção pelo HIV em mulheres com lesões cervicais (pré-)cancerosas no Suriname e a retenção dessas pacientes no cuidado. Métodos. Estudo populacional retrospectivo incluindo todas as mulheres diagnosticadas com neoplasia intraepitelial cervical (pré-)invasiva (NIC I a III ou câncer do colo do útero) em um único serviço de patologia no período de 2010 a 2020. Os dados de patologia foram cruzados com a base nacional de dados de testes de HIV para determinar a cobertura de testagem do HIV e o índice de positividade. A relação entre a retenção no cuidado do HIV até 2022 e diferentes covariáveis foi determinada por meio da análise de sobrevivência de Kaplan-Meier e testes de log-rank. Resultados. Houve 2901 diagnósticos de neoplasia cervical (pré-)invasiva (1395 NIC I, 396 NIC II, 444 NIC III e 666 casos de câncer do colo do útero). A cobertura geral do teste de HIV foi de 57,5%, com um índice de positividade de 5,8%, e não houve diferença entre os estágios da lesão cervical. A prevalência não diagnosticada (mulheres que não sabiam ser soropositivas para o HIV no momento do diagnóstico da lesão cervical) foi de 1,6% e 2,9% para os diagnósticos de lesões pré-cancerosas e cancerosas, respectivamente. O tempo mediano de tratamento de mulheres com câncer do colo do útero foi de 8 meses entre as que não receberam terapia antirretroviral (TARV) e de 4 anos entre as que iniciaram TARV. Entre as mulheres com lesões précancerosas, esses períodos foram de 5 e 10 anos, respectivamente (p < 0,05). Conclusões. A testagem de HIV, seguida de início do tratamento em caso de resultado positivo, deve ser priorizada em mulheres diagnosticadas com neoplasia cervical. Isso melhorará os resultados clínicos individuais e facilitará o controle da epidemia de HIV no Suriname.

Versatility in the use of cadaveric skin grafts for wound management.

BACKGROUND: Cadaveric skin grafts were initially used for the management of acute burn wounds. The biological coverage of the wound improves the quality of the wound bed, which prepares it to receive an autologous skin graft. The benefits of cadaveric skin graft in burn wounds have led to its use in the management of acute and chronic wounds of diverse etiologies. OBJECTIVE: To evaluate the use of cadaveric skin graft and subsequent autologous split-thickness skin graft (STSG) in the management of wounds of diverse etiologies at a single institution. MATERIALS AND METHODS: A retrospective analysis was performed of patients with wounds of different etiologies managed with cadaveric skin grafts followed by a second procedure in which autologous STSG was performed from May 2017 through May 2022 in the Plastic and Reconstructive Surgery Department of German Hospital, Buenos Aires, Argentina. RESULTS: A total of 25 patients with wounds of different etiologies were included. The mean affected body surface area (BSA) was 1.87%. The mean engraftment percentage of the cadaveric skin graft was 96.6%. The mean engraftment percentage of the STSG was 90.6%. All patients demonstrated improvement in local edema and inflammation, reduced secretions, and reduced pain after treatment. Two patients (8%) had complications, with 1 case of delayed healing of the donor site and 1 case of hypertrophic scarring. CONCLUSIONS: Cadaveric skin graft with subsequent STSG is a simple, safe, and effective alternative for the management of complex wounds of diverse etiologies. This technique is particularly useful in patients with multiple comorbidities who are at risk of recurrence and of developing multiple wounds during their lifetime.

Gram-Negative Bacilli Blood Stream Infection in Patients with Severe Burns: Microbiological and Clinical Evidence from a 9-Year Cohort.

Bloodstream infection is one of the most important and increasing complications in patients with severe burns. Most of the species affecting this population are Gram-negative bacilli that exhibit antimicrobial resistance. We conducted this study to determine the antimicrobial susceptibility profile and resistance mechanisms of these bacterial infections and their clinical associations on morbidity and mortality. We analyzed a retrospective cohort of burn patients. All patients included in this study had monobacterial blood stream infections during their hospital stay. We performed phenotypic and genotypic tests to determine the antimicrobial resistance mechanism and profile of each strain. Univariate and multivariate logistic regression analysis was performed between variables. We found 109 patients with monobacterial bacteremia. Pseudomonas spp. (50.7%), A. baumannii (46.4%), and Klebsiella spp. (13.8%) were the most common causative microorganisms. The Pseudomonas spp. isolates showed resistance to imipenem (81.5%), mainly by class A and class B carbapenemases. The A. baumannii isolates conferred resistance to imipenem (56.2%), mainly by class D carbapenemases. One quarter of Klebsiella spp. showed resistance to 3rd generation cephalosporins. We also observed that a total body surface area greater than 40% and three or more different types of invasive procedures might be related to increased mortality. Multidrug resistance is highly present. The extent of the burned area and a high number of different types of invasive procedures had an impact in decreasing survivorship in burn patients with bacteremia.

Tubal ectopic pregnancy: comparative management between pre and Covid-19 pandemic periods.

Objective: To evaluate whether there were differences in the presentation of patients with tubal ectopic pregnancy (EP) during the first year of the COVID-19 pandemic. Methods: We performed a retrospective cohort study of all cases of tubal EP between March 2019 and March 2020 (pre-pandemic) and between March 2020 and March 2021 (pandemic). We compared between these two groups the risk factors, clinical characteristics, laboratory data, sonographic aspects, treatment applied and complications. Results: We had 150 EP diagnoses during the two years studied, of which 135 were tubal EP. Of these, 65 were included in the pre-pandemic and 70 in the pandemic period. The prevalence of lower abdominal pain was significantly higher in the pandemic compared to the pre-pandemic period (91.4% vs. 78.1%, p=0.031). There was no significant difference in shock index, initial beta-hCG level, hemoglobin level at diagnosis, days of menstrual delay, aspect of the adnexal mass, amount of free fluid on ultrasound, and intact or ruptured presentation between the groups. Expectant management was significantly higher during the pandemic period (40.0% vs. 18.5%, p=0.008), surgical management was lower during the pandemic period (47.1% vs. 67.7%, p=0.023), and number of days hospitalized was lower in the pandemic period (1.3 vs. 2.0 days, p=0.003). Conclusion: We did not observe a significant difference in patient history, laboratory and ultrasound characteristics. Abdominal pain was more common during the pandemic period. Regarding treatment, we observed a significant increase in expectant and a decrease in surgical cases during the pandemic period.

The top hat procedure does not impact the management of women treated by LEEP in cervical cancer screening.

Objective: To describe Top-hat results and their association with margin status and disease relapse in a referral facility in Brazil. Methods: A retrospective study of 440 women submitted to LEEP to treat HSIL, in which 80 cases were complemented immediately by the top hat procedure (Top-hat Group - TH). TH Group was compared to women not submitted to Top-hat (NTH). The sample by convenience included all women that underwent LEEP from January 2017 to July 2020. The main outcome was the histological result. Other variables were margins, age, transformation zone (TZ), depth, and relapse. The analysis used the Chi-square test and logistic regression. Results: The TH Group was predominantly 40 and older (NTH 23.1% vs. TH 65.0%, p<0.001). No difference was found in having CIN2/CIN3 as the final diagnosis (NTH 17.0% vs. TH 21.3%, p=0.362), or in the prevalence of relapse (NTH 12.0% vs. TH 9.0%, p=0.482). Of the 80 patients submitted to top hat, the histological result was CIN2/CIN3 in eight. A negative top hat result was related to a negative endocervical margin of 83.3%. A CIN2/CIN3 Top-hat result was related to CIN2/CIN3 margin in 62.5% (p=0.009). The chance of obtaining a top hat negative result was 22.4 times higher (2.4-211.0) when the endocervical margin was negative and 14.5 times higher (1.5-140.7) when the ectocervical margin was negative. Conclusion: The top hat procedure did not alter the final diagnosis of LEEP. No impact on relapse was observed. The procedure should be avoided in women of reproductive age.

Biofilm formation and increased mortality among cancer patients with candidemia in a Peruvian reference center.

BACKGROUND: Candidemia is an invasive mycosis with an increasing global incidence and high mortality rates in cancer patients. The production of biofilms by some strains of Candida constitutes a mechanism that limits the action of antifungal agents; however, there is limited and conflicting evidence about its role in the risk of death. This study aimed to determine whether biofilm formation is associated with mortality in cancer patients with candidemia. METHODS: This retrospective cohort study included patients treated at Peru's oncologic reference center between June 2015 and October 2017. Data were collected by monitoring patients for 30 days from the diagnosis of candidemia until the date of death or hospital discharge. Statistical analyses evaluated the association between biofilm production determined by XTT reduction and mortality, adjusting for demographic, clinical, and microbiological factors assessed by the hospital routinary activities. Survival analysis and bivariate and multivariate Cox regression were used, estimating the hazard ratio (HR) as a measure of association with a significance level of p < 0.05. RESULTS: A total of 140 patients with candidemia were included in the study. The high mortality observed on the first day of post-diagnosis follow-up (81.0%) among 21 patients who were not treated with either antifungal or antimicrobial drugs led to stratification of the analyses according to whether they received treatment. In untreated patients, there was a mortality gradient in patients infected with non-biofilm-forming strains vs. low/medium and high-level biofilm-forming strains (25.0%, 66.7% and 82.3%, respectively, p = 0.049). In treated patients, a high level of biofilm formation was associated with increased mortality (HR, 3.92; 95% p = 0.022), and this association persisted after adjusting for age, comorbidities, and hospital emergency admission (HR, 6.59; CI: 1.87-23.24, p = 0.003). CONCLUSIONS: The association between candidemia with in vitro biofilm formation and an increased risk of death consistently observed both in patients with and without treatment, provides another level of evidence for a possible causal association. The presence of comorbidities and the origin of the hospital emergency, which reflect the fragile clinical condition of the patients, and increasing age above 15 years were associated with a higher risk of death.

[Exanthema after dengue vaccine (TAK003): first data of passive surveillance in a private vaccination center in Argentina]. / Exantema luego de la aplicación de la vacuna para dengue (TAK003): primeros datos de vigilancia pasiva en un centro de vacunación privado de Argentina.

INTRODUCTION: The tetravalent live virus vaccine developed by Takeda called Qdenga® is available in Argentina and approved for use from 4 years of age without age limit. The objective was to describe clinical characteristics and evolution of the initial reports of rash after the first dose. MATERIAL AND METHODS: The records of Events Supposedly Attributable to Vaccination or Immunization Reported in a Private Vaccination Center were reviewed between 15/11/2023 and 12/12/2023. Cases with skin rash that occurred outside the application site area were included. The main variables analyzed were age, sex, history of dengue, characteristics of the skin rash, accompanying symptoms, time elapsed from vaccination to the onset of the rash and evolution. The incidence of rash was calculated: cases/10,000 vaccinated. RESULTS: Out of 12 551 doses applied, 15 cases were included. Median age: 35 years, female sex: 8/15. Clinical forms of presentation: generalized micropapular (3/15), maculopapular (3/15), scarlatiniform (1/15), urticarian (1/15), multiform (1/15), erythematous in the face (1/15) and unspecified (5/15). Most common concomitant symptoms: pruritus (5/15), fever or low-grade fever (6/15), headache (3/15), retro-ocular pain (2/15), asthenia (2/15). Three cases reported a history of dengue. The median number of days of rash presentation was 8 days' postvaccination. All patients progressed favorably. The overall incidence was 1.2/1000 vaccinated. CONCLUSIONS: In passive surveillance, after more than 12 000 first doses administered, the presence of rash was observed in less than 0.12% of those vaccinated. Everyone evolved favorably.

Introducción: La vacuna tetravalente a virus vivos del laboratorio Takeda, denominada Qdenga®, está disponible en Argentina y aprobada para su uso a partir de los 4 años sin límite de edad. El objetivo fue describir las características clínicas y evolución de los primeros reportes de exantema post primera dosis. Material y métodos: Se revisaron los registros de los Eventos Supuestamente Atribuidos a la Vacunación e Inmunización reportados en los Centros Vacunar entre el 15/11/2023 al 12/12/2023. Se incluyeron los casos con exantema cutáneo que se presentaron fuera del área del sitio de aplicación. Las principales variables analizadas fueron edad, sexo, antecedente de dengue, características del exantema cutáneo, síntomas acompañantes, tiempo transcurrido desde la vacunación al inicio del exantema y evolución. Se calculó la incidencia del exantema: casos/1000 vacunados. Resultados: Sobre 12551 dosis aplicadas se incluyeron 15 casos. Mediana de edad: 35 años, sexo femenino: 8/15. Formas clínicas de presentación: generalizado micropapular (3/15), maculopapular (3/15), escarlatiniforme (1/15), urticariano (1/15), multiforme (1/15), eritematoso en cara (1/15) y sin especificar (5/15). Síntomas concomitantes más frecuentes: prurito (5/15), fiebre o febrícula (6/15), cefalea (3/15), dolor retro ocular (2/15), astenia (2/15). Tres casos refirieron antecedente de dengue. La mediana de días de presentación del exantema fue de 8 días post vacunación. Todos los pacientes evolucionaron favorablemente. La incidencia fue de 1.2/1000 vacunados. Conclusiones: En la vigilancia pasiva, luego de más de 12 000 primeras dosis administradas, se observó la presencia de exantema en menos del 0.12% de los vacunados. Todos evolucionaron favorablemente.

[Disorders in plasmatic levels of potassium, magnesium, and calcium in elderly adults associated with colistin: time series]. / Trastornos en niveles plasmáticos de potasio, magnesio y calcio en adultos mayores asociados a colistina: serie de tiempo.

INTRODUCTION: Water and electrolyte disturbances associated with colistin are understudied adverse effects in the medical literature. We aim to evaluate their incidence in hospitalized older adult patients. MATERIALS AND METHODS: A longitudinal retrospective study of the interrupted time series type was conducted on patients admitted to Dr. César Milstein Hospital. We included adults aged 65 and older who received colistin with normal serum potassium, magnesium, and calcium at the outset. Electrolyte values were collected before, during and after suspending the antibiotic. Values were compared using non-parametric tests, and a multivariate linear regression model with robust intervals was performed to assess sociodemographic and clinical characteristics associated with serum concentrations. RESULTS: A total of 89 patients were included. The rate of hypokalemia was 77.5% (n=69), and factors associated with potassium decline included older age, increased creatinine levels, and longer colistin treatment duration. Serum magnesium disturbances were reported in 66 (79.5%) of the 83 patients evaluated. The decrease in both electrolytes was statistically significant in the measured times and both values normalized after 72 hours of stopping antibiotic therapy. The incidence of acute kidney injury during colistin treatment in patients with normal baseline creatinine was 63.6% (n = 42/66), and in those with abnormal baseline creatinine, it was 47.8% (n = 11/23). CONCLUSION: We report high rates of electrolyte disturbances in patients treated with colistin, with hypokalemia being the most frequent, showing resolution following discontinuation of antibiotic therapy. Continuous monitoring of electrolyte levels and renal function during colistin treatment is crucial.

Introducción: Los trastornos hidroelectrolíticos asociados a la colistina son efectos adversos poco estudiados en la literatura médica. Nos propusimos evaluar su incidencia en pacientes adultos mayores hospitalizados. Materiales y métodos: Se realizó un estudio longitudinal retrospectivo, del tipo serie de tiempo interrumpida, en pacientes internados mayores de 65 años que recibieron colistina, con potasio, magnesio y calcio séricos normales al inicio. Se recabaron valores de dichos electrolitos previo, durante y luego de suspender el antibiótico. Se compararon los valores mediante test no paramétricos y se realizó un modelo multivariado de regresión lineal con intervalos robustos para evaluar las características sociodemográficas y clínicas asociadas a las concentraciones séricas. Resultados: Se incluyeron 89 pacientes. La tasa de hipocalemia fue del 77.5% (n = 69) y las variables asociadas al descenso del potasio fueron mayor edad, aumento de creatininemia, y duración de tratamiento con colistina. Se informaron trastornos del magnesio en 66 (79.5%) de los 83 pacientes evaluados. El descenso de ambos electrolitos fue estadísticamente significativo en los tiempos medidos, y ambos normalizaron valores tras 72 horas de suspendida la antibioticoterapia. La incidencia de insuficiencia renal aguda en pacientes con creatinina basal normal fue del 63.6%, (42/66) y con creatinina basal anormal de 47.8% (11/23). Conclusión: En pacientes tratados con colistina, el trastorno más frecuente fue la hipocalemia, mostrando resolución tras la suspensión del antibiótico. Es importante la monitorización constante de los niveles de electrolitos y la función renal durante el tratamiento con colistina.

[Incidence of metastasis and survival in patients with primary uveal melanoma]. / Incidencia de metástasis y sobrevida en pacientes con melanoma uveal primario.

INTRODUCTION: Primary uveal melanoma is the most common intraocular malignancy in adults. Almost 50% of patients die from metastatic disease despite successful local treatment. The objective was to estimate the incidence of metastasis and survival in patients with primary uveal melanoma. The second objective was to determine the independent predictors of metastasis. METHODS: A retrospective, observational, analytical study was carried out using an ambidirectional cohort design in patients from Buenos Aires City between January 2003 to January 2020. Patients with uveal melanoma and potential clinical predictors of metastasis were identified. The density of incidence of metastasis and mortality were determined, and survival curves were analyzed (Kaplan Meir) A univariate and multivariate analysis using Cox proportional hazard models was performed. RESULTS: 143 patients (mean age 57 SD 16) were included. The median thickness was 6.2 mm SD 3.4 mm, the mean tumor diameter was 12.6 mm (SD 3.8). 69.9% of the patients underwent conservative treatment with brachytherapy while 25.9% underwent enucleation. 19.6% presented metastasis, the median time to the event was 26.5 months. The specific mortality due to melanoma was 17.5%. Diameter greater than 12 mm and extension were predictor variables of metastasis in a multivariable model. CONCLUSION: Although the median time to the event (metastasis) is 26.5 moths, it could occur many years after local oncological effective treatment. An early diagnosis would allow finding smaller tumors and would improve the prognosis.

Introducción: El melanoma uveal primario es el tumor intraocular maligno más frecuente del adulto. Cerca del 50% de los pacientes fallecen de enfermedad metastásica, a pesar de un tratamiento local exitoso. El objetivo primario fue estimar la incidencia de metástasis y sobrevida en los pacientes con melanoma uveal primario. Como objetivo secundario se planteó determinar los predictores independientes de metástasis. Métodos: Se realizó un estudio analítico observacional, retrospectivo mediante un diseño de cohorte ambidireccional entre 2003 y 2020 en CABA, en pacientes con melanoma uveal primario y los potenciales factores clínicos predictores de metástasis. Se determinó la densidad de incidencia de metástasis, la mortalidad, y se analizaron las curvas de sobrevida (Kaplan-Meier). Se realizó un análisis uni y multivariado utilizando el modelo de riesgos proporcionales de Cox. Resultados: De los 143 pacientes (edad promedio 57, DS 16), la mediana del espesor fue de 6. 2 mm DS 3.4, la media del diámetro tumoral fue de 12.6 mm (DS 3.8). Un 69.9% realizó tratamiento conservador con braquiterapia, un 25.9% enucleación. Un 19.6% presentaron metástasis (mediana de tiempo al evento: 26.5 meses). La mortalidad específica por melanoma fue de 17.5%. El diámetro mayor a 12 mm y la extensión fueron variables predictoras de metástasis en el modelo multivariado. Conclusión: Si bien la mediana del tiempo al evento metástasis fue de 26.5 meses, puede presentarse muchos años después de un tratamiento local oncológicamente eficaz. Un diagnóstico precoz permitiría pesquisar tumores más pequeños y mejoraría el pronóstico.

Modified extensile calcaneal exposure is safe.

OBJECTIVE: The objective of this study was to evaluate the effect of open reduction and internal fixation for displaced intra-articular calcaneal fractures through a modified tarsal sinus incision. METHODS: A retrospective review over 3 years of the clinical data of patients with intra-articular calcaneal fractures treated with open reduction and internal fixation through lateral hook curvy incisions. The efficacy of the 25 lateral hook curvy incisions was analyzed. RESULTS: According to the AOFAS hindfoot function scoring criteria, there were 20 excellent (80%), 2 good (8%), 2 fair (8%), and 1 poor patient outcome. The average pre-operative Bohler's angle was 6.8 ± 8.9°, and the average angle at follow-up was 33.6 ± 5.7°. The average pre-operative Gissane angle was 89.2 ± 20.0°, and the average angle at follow-up was 115.5 ± 5.5°. CONCLUSIONS: A lateral hook curvy incision can expose the posterior articular surface of the calcaneus and the calcaneocuboid joint, reduce stripping and pulling of the soft tissue, and avoid calcaneus valgus caused by the pulling of the peroneus tendon.

OBJETIVO: Evaluar el efecto de la reducción abierta y la fijación interna de las fracturas de calcáneo intraarticulares desplazadas a través de una incisión del seno tarsiano modificada. MÉTODO: Revisión retrospectiva de 3 años de los datos clínicos de pacientes con fracturas intraarticulares de calcáneo tratadas con reducción abierta y fijación interna a través de incisiones laterales curvadas en gancho. Se analizó la eficacia de la incisión curvada con 25 ganchos laterales. RESULTADOS: Según los criterios de puntuación de la función del retropié de la AOFAS, hubo 20 resultados excelentes (80%), 2 buenos (8%), 2 regulares (8%) y 1 pobre. El ángulo de Bohler preoperatorio promedio fue de 6.8 ± 8.9° y el ángulo promedio en el seguimiento fue de 33.6 ± 5.7°. El ángulo de Gissane preoperatorio promedio fue de 89.2 ± 20.0° y el ángulo promedio en el seguimiento fue de 115.5 ± 5.5°. CONCLUSIONES: Una incisión curvada en gancho lateral puede exponer la superficie articular posterior del calcáneo y la articulación calcaneocuboidea, reducir el desprendimiento y la tracción del tejido blando, y evitar el calcáneo valgo causado por tracción del tendón peroneo.

Postoperative surgical margin results of the phyllodes tumors from a tertiary hospital.

OBJECTIVE: Phyllodes tumors in the breast are exceptionally uncommon fibroepithelial tumors. In the literature, they are typically categorized as benign phyllodes tumor, borderline phyllodes tumor, and malignant phyllodes tumor. This study aims to assess and present the clinical and surgical outcomes of patients diagnosed with phyllodes tumor. METHODS: The outcomes of patients aged 18 years and above diagnosed with phyllodes tumor between 2006 and 2023 were retrospectively reviewed. Patients were grouped as benign phyllodes tumor and borderline/malignant phyllodes tumor and compared by clinical and surgical results. RESULTS: Of all 57 patients with phyllodes tumor, 64.9% (n=37) were benign phyllodes tumor and 35.1% (n=20) were borderline/malignant phyllodes tumor [22.8% (n=13) borderline phyllodes tumor and 12.3% (n=7) malignant phyllodes tumor]. When the patients were divided into two groups as benign phyllodes tumor and borderline/malignant phyllodes tumor and compared, our cumulative (total) recurrence rate was 14.0%, with final surgical margin width between groups [(0

Time to death from cervical cancer and its predictors in hospitalized patients: a survival approach study in Mato Grosso, Brazil.

BACKGROUND: Cervical cancer (CC) is a serious public health concern, being the fourth most common cancer among women and a leading cause of cancer mortality. In Brazil, many women are diagnosed late, and in Mato Grosso, with its geographical diversity, there are specific challenges. This study analyzed hospital survival and its predictors using data from the Hospital Information System (SIH) of the Unified Health System (SUS) in Mato Grosso from 2011 to 2023. METHODS: Cox regression and Kaplan-Meier models were applied to determine survival time and identify mortality predictors. The adjusted Hazard Ratio (AHR) with a 95% Confidence Interval (CI) was used to measure the association between the factors analyzed. RESULTS: The hospital mortality rate was 9.88%. The median duration of hospitalization was 33 days (interquartile range [IQR]: 12-36), with a median survival of 43.7%. Patients were followed up for up to 70 days. In the multivariable Cox model, after adjusting for potential confounders, the risk of death during hospitalization was higher in patients aged 40-59 years (AHR = 1.39, p = 0.027) and 60-74 years (AHR = 1.54, p = 0.007), in the absence of surgical procedures (AHR = 4.48, p < 0.001), in patients with medium service complexity (AHR = 2.40, p = 0.037), and in the use of ICU (AHR = 4.97, p < 0.001). On the other hand, patients with hospital expenses above the median (152.971 USD) showed a reduced risk of death (AHR = 0.21, p < 0.001). CONCLUSION: This study highlights that hospitalized CC patients have reduced survival, underscoring the need for interventions to improve care, including strategies for early diagnosis and expanded access to adequately resourced health services.