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ABSTRACT The 35th Brazilian Congress of Surgery marked a turning point for surgical education in the country. For the first time, the Brazilian College of Surgeons included Global Surgery on the main congressional agenda, providing a unique opportunity to rethink how surgical skills are taught from a public health perspective. This discussion prompts us to consider why and how Global Surgery education should be expanded in Brazil. Although Brazilian researchers and institutions have contributed to the fields expansion since 2015, Global Surgery education initiatives are still incipient in our country. Relying on successful strategies can be a starting point to promote the area among national surgical practitioners. In this editorial, we discuss potential strategies to expand Global Surgery education opportunities and propose a series of recommendations at the national level.
RESUMO O 35º Congresso Brasileiro de Cirurgia foi marcado por discussões inovadoras para a educação cirúrgica no país. Pela primeira vez, o Colégio Brasileiro de Cirurgiões incluiu a Cirurgia Global na pauta principal do congresso, proporcionando uma oportunidade única de repensar como as habilidades cirúrgicas são ensinadas a partir de uma perspectiva de saúde pública. Essa discussão nos leva a considerar por que e como o ensino da Cirurgia Global deve ser expandido no Brasil. Embora pesquisadores e instituições brasileiras tenham contribuído para a expansão do campo desde 2015, as iniciativas de educação em Cirurgia Global ainda são incipientes em nosso país. Basear-se em estratégias bem-sucedidas pode ser um ponto de partida para promover a área entre os profissionais de cirurgia nacionais. Neste editorial, discutimos potenciais estratégias para expandir as oportunidades de educação em Cirurgia Global e propomos uma série de recomendações a nível nacional.
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Purpose@#The treatment approach for non-metastatic bladder cancer is guided by an invasion of the muscular layer of the bladder wall. Radical cystectomy is the recommended treatment for muscle-invasive disease. However, it has considerable morbidity and mortality and is not suited for many patients. Trimodality therapy consisting of chemoradiation after transurethral resection of bladder tumor offers a definitive approach with bladder-sparing potential. However, there is a lack of research defining the optimal combination of chemotherapy and radiation in this setting. @*Materials and Methods@#We extracted patient data from the National Cancer Database to compare survival outcomes and demographic factors in 2,227 non-metastatic bladder cancer patients who were treated with chemotherapy sequential to or concurrently with radiation. Sequential treatment was defined as chemotherapy beginning >14 days before radiation, and concurrent was defined as beginning within 14 days of the first radiation. @*Results@#The sequential treatment group patients were younger (mean age, 74 vs. 78 years; p < 0.001) with more advanced disease. We found no difference in overall survival between patients who received chemotherapy sequential to radiation and those who received concurrent chemoradiation only (p = 0.533). @*Conclusion@#Our data are concordant with a previous prospective study, and support that chemotherapy prior to radiation does not decrease survival outcomes relative to patients receiving only concurrent chemoradiation. Given that the sequential group had an overall higher stage but no difference in survival, downstaging chemotherapy prior to radiation may be helpful in these patients. Further studies including a larger, multi-institutional clinical trial are indicated to support clinical decision-making.
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@#Dorsal midbrain syndrome (DMS) is a supranuclear palsy of vertical gaze characterized by conjugate upgaze palsy, light-near dissociation, convergence-retraction nystagmus, lid retraction, and skew deviation. Majority of cases are due to primary midbrain lesions such as strokes or neoplasms, or due to pineal gland tumors compressing the said area. Presented here is the case of a 57-year-old male who came in with a chief complaint of diplopia and the typical signs of DMS. Cranial tomography scan revealed a parenchymal hemorrhage at the left thalamocapsuloganglionic region, a rarely reported site of a primary lesion causing DMS. In this case, the syndrome may have been a consequence of the mass effects and perilesional edema associated with the thalamocapsuloganglionic hemorrhage, or may have been due to disruption of supranuclear inputs to the dorsal mibdrain. This case provides further evidence that DMS may arise from lesions without obvious involvement of the said region. This case also highlights the importance of a thorough physical examination to elicit the findings associated with DMS, and the need to correlate these with a keen analysis of diagnostic test results.
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Ocular Motility Disorders , Ocular Motility Disorders , Ocular Motility Disorders , Ocular Motility DisordersABSTRACT
Background: Sexually transmitted diseases (STDs) management in sub-Saharan Africa is syndromic but molecular diagnostics provide quicker, sensitive diagnosis and treatment. Effective STD control hinges on identification and treatment of infected persons and sexual partner contact tracing. Objectives: This study assessed feasibility of using the Xpert CT/NG test to identify prevalent Chlamydia trachomatis (CT) and Neisseria gonorrhea (NG) infections among STD clinic attendees and their sexual partners and tested for antimicrobial resistance for N. gonorrhea. Methods: A cross-sectional study was conducted at 4 outpatient STD clinics in Kampala, Uganda from February 2019 to October 2019. Participants received a syndromic diagnosis, were tested for NG and CT, as well as their sexual partners. Urine (men) and high vaginal swabs (women) were collected, examined using Xpert CT/NG assay. A total of 79 participants were enrolled at baseline of whom 25 had CT/NG. 21 partners of infected baseline participants and 7 partners of the 21 primary partners were enrolled. Results: The mean age of the reported sexual partners was 26 (18-43) years. The prevalence of NG was 25% at baseline and 18 % for CT. Nine (11.4%) people were dually infected. Men were more likely to have NG (p<0.001) at multivariable level. Two participants tested HIV-1 positive. On microbiological culture, 8 samples (2.5%) grew NG, and all were resistant to penicillin, ciprofloxacin. For CT, we found a preponderance of the F-serovar in this population. Conclusion: The most prevalent organism was Neisseria gonorrhea. Generally, the prevalence of CT and NG was high. Infection proportions increased among primary partners, particularly women. Etiologic testing without partner tracing and treatment may underestimate burden of CT/NG in this population and contribute to re-infection
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Drug Resistance, Microbial , Sexual Partners , Gonorrhea , Sexually Transmitted Diseases , Chlamydia trachomatis , Prevalence , Sentinel Surveillance , Pathology, Molecular , Africa South of the Sahara , Information ServicesABSTRACT
Both acute and chronic kidney disease have a strong underlying inflammatory component. This review focuses primarily on T helper 17 (Th17) cells as mediators of inflammation and their potential to modulate acute and chronic kidney disease. We provide updated information on factors and signaling pathways that promote Th17 cell differentiation with specific reference to kidney disease. We highlight numerous clinical studies that have investigated Th17 cells in the setting of human kidney disease and provide updated summaries from various experimental animal models of kidney disease indicating an important role for Th17 cells in renal fibrosis and hypertension. We focus on the pleiotropic effects of Th17 cells in different renal cell types as potentially relevant to the pathogenesis of kidney disease. Finally, we highlight studies that present contrasting roles for Th17 cells in kidney disease progression.
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Both acute and chronic kidney disease have a strong underlying inflammatory component. This review focuses primarily on T helper 17 (Th17) cells as mediators of inflammation and their potential to modulate acute and chronic kidney disease. We provide updated information on factors and signaling pathways that promote Th17 cell differentiation with specific reference to kidney disease. We highlight numerous clinical studies that have investigated Th17 cells in the setting of human kidney disease and provide updated summaries from various experimental animal models of kidney disease indicating an important role for Th17 cells in renal fibrosis and hypertension. We focus on the pleiotropic effects of Th17 cells in different renal cell types as potentially relevant to the pathogenesis of kidney disease. Finally, we highlight studies that present contrasting roles for Th17 cells in kidney disease progression.
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PURPOSE: The aim of this study was to characterize the demographics, usage patterns and complication rates of clomiphene use in male patients.MATERIALS AND METHODS: We retrospectively analyzed male patients from ages 20 to 55 years old who were prescribed clomiphene citrate from 2001 to 2014 using the Truven Health MarketScan, a US claims database. We collected data regarding associated medical diagnoses, diagnostic testing, duration of use, and reported side effects including thrombotic events, vision problems, gynecomastia, mental disorders, liver disease, nausea, or skin problems.RESULTS: In total, 12,318 men took clomiphene and represented the primary study cohort, with a mean age of 37.8 years. The percentage of men prescribed clomiphene increased over the study period, as did the average age of clomiphene users. Associated diagnoses included male infertility (52.0%), testicular hypofunction (13.5%), erectile dysfunction (2.4%), and low libido (0.4%). Associated testing included semen analysis (43.7%), testosterone (23.5%), luteinizing hormone (19.3%), and follicle-stimulating hormone (21.1%) levels. The median time of clomiphene use was 3.6 months, with 63% of men stopping within 6 months. No increased risk of reported clomiphene side effects were apparent in men taking the medication.CONCLUSIONS: There is a rising prevalence of clomiphene usage without associated adverse side effects in the US. The variability in associated diagnoses, diagnostic testing, and duration of use suggest a need for greater awareness of the proper evaluation and treatment of the men who are prescribed clomiphene.
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The aim of this study was to evaluate and to compare the possible inflammatory changes by screening acute phase proteins concentrations in healthy bitches subjected to ovariohysterectomy. Minimally invasive and conventional (laparotomy) ovariohysterectomies were performed in 17 client-owned adult female mixed breed dogs. Nine animals were subjected to minimally invasive and eight animals to conventional ovariohysterectomy. Blood samples were taken before surgery, 24, 48 hours, and seven days postoperatively. Serum C-reactive concentration was determined by a commercial ELISA kit and serum haptoglobin concentration was measured via hemoglobin binding assay, both previously validated for use in dogs. As the data did not meet the normal distribution criteria, the nonparametric Kruskall-Wallis was performed to compare quantitative variables between groups. One-way ANOVA and the Friedman test were used for multiple comparisons between time points, with a P<0.05 considered significant. C-reactive protein concentration was significantly different (P<0.0001) at 24 hours postoperatively between groups. There was no significant difference in haptoglobin concentration between groups. C-reactive protein and haptoglobin concentrations were significantly different at 24 and 48 hours postoperatively for minimally invasive and conventional ovariohisterectomies. These findings provided an overview of the short-term inflammatory effects produced by minimally invasive and conventional ovariohysterectomies.(AU)
O objetivo deste trabalho foi avaliar e comparar o efeito inflamatório, por meio da determinação de proteínas de fase aguda, produzido por dois protocolos cirúrgicos distintos de ovariohisterectomia em cadelas. Para tanto, foram determinadas as concentrações de proteína C reativa (CRP) e haptoglobina (Hp) de 17 cadelas, sem raça definida, adultas, sendo nove animais submetidos à ovariohisterectomia pela técnica convencional por laparotomia e oito a ovariohisterectomia pela técnica minimamente invasiva. Para avaliar a resposta de fase aguda causada pelo trauma cirúrgico, amostras de sangue foram obtidas antes dos procedimentos cirúrgicos e em quatro momentos distintos após as cirurgias (24, 48 horas e sete dias) para as dosagens de CRP e Hp, com kit comercial ELISA e via ensaio de ligação com a hemoglobina, respectivamente, validados para o uso em cães. Como não houve distribuição normal dos dados, utilizou-se o teste de Kruskall-Wallis para comparação das variáveis quantitativas entre os dois grupos. Os testes de Friedman e One-way ANOVA foram usados para comparações múltiplas entre os momentos avaliados, sendo considerado P<0,05 como significante. Houve diferença significativa (P<0,0001) para as concentrações de CRP 24 horas após o procedimento cirúrgico entre os dois protocolos utilizados. Não houve diferença significativa para as concentrações de Hp entre os dois protocolos cirúrgicos. Foram evidenciadas alterações significativas para as concentrações de CRP e Hp 24 e 48 horas após as ovariohisterectomias, independentemente da técnica cirúrgica utilizada. As concentrações de CRP e Hp demonstraram o efeito inflamatório imediato induzido pela ovariohisterectomia convencional e minimamente invasiva.(AU)
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Animals , Female , Dogs , C-Reactive Protein/metabolism , Haptoglobins/metabolism , Ovariectomy/veterinary , Dogs/surgery , Hysterectomy/veterinary , C-Reactive Protein/analysis , Haptoglobins/analysis , Inflammation/metabolism , Inflammation/bloodABSTRACT
Background: In 2017, there will be 107,000 cases of gynecologic cancer diagnosed in the US with an overall survival of around 70%-most occurring in post-menopausal individuals. In this study, we have examined a younger (≤ 40 years of age) subpopulation of these women with high grade/ high stage gynecologic malignancies, attempting to identify unique genetic abnormalities or combinations thereof through tissue block specimens. This information was then analyzed in light of known target therapies to see if genetic analysis in this setting would yield significant therapeutic advantage. Methods: We retrospectively evaluated patients with high grade/high stage gynecologic cancers (≤ 40 years of age), examined the presence and status of 400 oncogenes and tumors suppressor genes from Formalin-fixed, Paraffin-embedded (FFPE) tissue and functionally classified mutations by SIFT and Polyphen. Results: Twenty women were identified and stratified into positive and negative outcomes. No demographic, clinicopathologic or treatment factors were significant between these groups. Of the 400 genes evaluated, twelve mutations were significant between the groups, six with targeted therapies. Mutations associated with negative outcomes within histologies/locations were evaluated: ERBB3 in epithelial (ovarian), ALK/GPR124/KMT2D in neuroendocrine (ovarian/endometrial), ROS1/EGFR, ROS1/ERBB3/KMT2D/NIRK1 and GPR124 in sarcoma. All negative outcomes were void of mutations in APC/ABL2. A predictive model for negative outcomes in our cohort was developed from these data: AKAP9-/MBD1-/APC-/ABL2- with a mutation load of > 20.5. Conclusions: Unique multi-gene and mutational outcome correlations were identified in our cohort. Resulting complex mutational profiles in distinctly aggressive gynecologic cancers suggested potential for novel therapeutic treatment. Future larger scale studies will be needed to correlate the genotypic and phenotypic features identified here (AU)
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Humans , Female , Adult , DNA Mutational Analysis , Retrospective Studies , Premenopause , Genital Neoplasms, Female , Genetic LinkageABSTRACT
La tos ocurre por la compleja acción del arco de la tos. En condiciones normales es esencial para proteger la vía aérea. Es un síntoma muy frecuente, con un gran número de etiologías posibles. El enfrentamiento diagnóstico de los pacientes con tos crónica, puede resultar un desafío diagnóstico. Deben considerarse las patologías más prevalentes, que incluyen el reflujo faringolaríngeo y la descarga posterior: ambas condiciones que son parte del área otorrinolaringológica. En el presente artículo de revisión se pretende entregar un enfoque actualizado de su enfrentamiento y manejo, con la finalidad de aportar información que resulte relevante para la práctica clínica diaria.
Cough occurs due to the complex action of the coughing arch. Under normal conditions it is essential to protect the airway. It is a very frequent symptom with a large of possible etiologies. The diagnosis process of patients with chronic cough can be a challenge. The most prevalent pathologies must be considered. Thus includes pharyngolaryngeal reflux and posterior discharge: both conditions that are part of the otorhinolaryngolocical area. In the present article review, we pretend to provide an updated approach and management to this condition, in order to asses relevant information to daily clinical practice.
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Humans , Cough/diagnosis , Cough/etiology , Otolaryngology , Chronic Disease , Cough/physiopathology , Cough/therapy , Laryngopharyngeal Reflux/complicationsABSTRACT
Background: The surgical and procedural specialties are continually evolving their methods to include more complex and technically difficult cases. These cases can be longer and incorporate multiple teams in a different model of operating room synergy. Patients are frequently older, with comorbidities adding to the complexity of these cases. Recording of this environment has become more feasible recently with advancement in video and audio capture systems often used in the simulation realm. Aims: We began using live capture to record a new procedure shortly after starting these cases in our institution. This has provided continued assessment and evaluation of live procedures. The goal of this was to improve human factors and situational challenges by review and debriefing. Setting and Design: B‑Line Medical’s LiveCapture video system was used to record successive transcatheter aortic valve replacement (TAVR) procedures in our cardiac catheterization/laboratory. An illustrative case is used to discuss analysis and debriefing of the case using this system. Results and Conclusions: An illustrative case is presented that resulted in long‑term changes to our approach of these cases. The video capture documented rare events during one of our TAVR procedures. Analysis and debriefing led to definitive changes in our practice. While there are hurdles to the use of this technology in every institution, the role for the ongoing use of video capture, analysis, and debriefing may play an important role in the future of patient safety and human factors analysis in the operating environment.
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Existe evidencia concluyente de la influencia del uso excesivo de pantallas con trastornos en el desarrollo biopsicosocial de niños y adolescentes. Objetivo: Analizar descriptivamente la influencia que ejerce el uso de medios de multimedia en el desarrollo de problemas de atención y del Trastorno de Déficit Atencional Hiperactivo (TDAH) en la población pediátrica. Método: Se efectuó una revisión de la literatura disponible en PudMed, Cochrane y EBSCO. Resultados: La exposición en la infancia y adolescencia a la televisión (TV) se relaciona con un riesgo elevado de desarrollar problemas de atención, dificultades escolares, comprensión lectora deficiente y otros trastornos cognitivos, existiendo una relación directa entre el número de horas de exposición con el fracaso académico; además, el TDAH sería un factor de riesgo de adicción a internet y juegos, existiendo evidencia sobre la asociación entre adicción a videojuegos y TDAH. Sólo un número de artículos desacreditan la asociación entre las pantallas y los problemas de atención o TDAH. Conclusiones: Existe una particular relación entre el uso excesivo de pantallas y los problemas de atención y TDAH, considerándose un factor de riesgo para su desarrollo. Palabras claves: atención, TDAH, problemas de aprendizaje, multimedia.
There is conclusive evidence of the relation between the excessive use of screens with developmental disorders in children and adolescents. Objective:Description of the relation between the use of multimedia and the development of attention difficulties and attention deficit and hyperactivity disorder (ADHD) in the pediatric population. Method: We reviewed the available literature on PudMed , Cochrane and EBSCO. Results:The exposure during childhood and adolescence to television (TV) is related with a high risk of developing attentional ad school difficulties, poor reading comprehension and other cognitive disorders. There is a direct relationship between the number of hours of exposure with academic failure; also, ADHD would be a risk factor of addiction to internet and videogames, there is evidence on the association between ADHD and addiction to video games. There is only a scant number of articles discrediting the association between screens and attention / ADHD issues. Findings: There is a relationship between excessive use of screens and ADHD, so that excessive screen use is considered a risk factor for devolping ADHD.Keywords: Attention, ADHD, Learning problems, multimedia, screen time.
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Objective: There are several physiologic advantages to early tracheal extubation and spontaneous ventilation following surgery for congenital heart disease [CHD]. In order for early tracheal extubation to be feasible, effective reversal of neuromuscular blockade is mandatory. Sugammadex reverses neuromuscular blockade with a mechanism that differs from acetylcholinesterase inhibitors. We aimed to study the effect of sugammadex on the fast track extubation
Methodology: We retrospectively reviewed our experience with the use of sugammadex to reverse neuromuscular blockade following cardiac surgery for CHD in infants and children, during a pediatric cardiac surgical trip of Heart Care International to Tuxtla, Mexico. Demographic data collected included age, weight, type of CHD, and the surgical procedure. Intraoperative data included sugammadex dose, outcome [successful tracheal extubation], and adverse effects, which could be attributed to sugammadex. Sugammadex was administered to 14 patients, who ranged in age from 1 to 16 years of age and in weight from 7.6 to 57.7 kilograms. Statistical analysis was done
Results: All 14 patients underwent successful tracheal extubation in the operating room within 15 min of completion of the surgical procedure. No patient required reintubation of the trachea during the postoperative course. No adverse effects related to sugammadex were noted
Conclusions: Our preliminary experience demonstrates that sugammadex effectively reverses neuromuscular blockade and allows for early tracheal extubation in pediatric patients following surgery for repair of CHD. Prompt and effective reversal of neuromuscular blockade allows for effective fasttracking with early tracheal extubation
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The UK urgently needs a public health strategy for NTD reduction, which could include the use of food supplements, food fortification or a combination of both. An updated nutritional benefit-risk analysis is needed to inform population-based and/or targeted public health policies for folic acid intake and reduction of risk of neural tube defects. Policymakers should be cautious about the long-term exposure of the population as a whole to additional folic acid, especially potential adverse effects on the nervous system and brain function in older people, and higher levels of intake during infancy and childhood. The European-wide authorised health claim for folic acid food supplements and reduced risk of NTDs could transform the communication of the health benefits for women of childbearing age. Vitamin B12 deficiency may be an independent risk factor for NTDs, in which case dietary interventions with folic acid combined with vitamin B12 need to be considered.
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Purpose: To evaluate the predictability of the refractive correction achieved with a positional accommodating intraocular lenses (IOL) and to develop a potential optimization of it by minimizing the error associated with the keratometric estimation of the corneal power and by developing a predictive formula for the effective lens position (ELP). Materials and Methods: Clinical data from 25 eyes of 14 patients (age range, 52–77 years) and undergoing cataract surgery with implantation of the accommodating IOL Crystalens HD (Bausch and Lomb) were retrospectively reviewed. In all cases, the calculation of an adjusted IOL power (PIOLadj) based on Gaussian optics considering the residual refractive error was done using a variable keratometric index value (nkadj) for corneal power estimation with and without using an estimation algorithm for ELP obtained by multiple regression analysis (ELPadj). PIOLadj was compared to the real IOL power implanted (PIOLReal, calculated with the SRK‑T formula) and also to the values estimated by the Haigis, HofferQ, and Holladay I formulas. Results: No statistically significant differences were found between PIOLReal and PIOLadj when ELPadj was used (P = 0.10), with a range of agreement between calculations of 1.23 D. In contrast, PIOLReal was significantly higher when compared to PIOLadj without using ELPadj and also compared to the values estimated by the other formulas. Conclusions: Predictable refractive outcomes can be obtained with the accommodating IOL Crystalens HD using a variable keratometric index for corneal power estimation and by estimating ELP with an algorithm dependent on anatomical factors and age.
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We report a case of a 60-year-old female who was known to have intralobar pulmonary sequestration and her only symptom was chronic cough. She had no history of infections and surgical resection led to complete resolution of her chronic cough.
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Glutaric aciduria type-1 [GA-1] is an autosomal recessive metabolic disorder due to the deficiency of the enzyme glutaryl-CoA dehydrogenase. The enzymatic defect leads to secondary damage to the central nervous system due to the accumulation of glutaric acid. Progressive neurologic effects with spasticity and orthopedic deformities necessitate frequent surgical and anesthetic care. We present a 13-year-old girl with glutaric academia type-1 who required anesthetic care for posterior spinal fusion. Previous reports of anesthetic care for these patients are reviewed, the end-organ involvement discussed, and options for anesthetic care presented