Uterine Arteriovenous Malformation: Diagnostic and Therapeutic Challenges.

Uterine arteriovenous malformations are a rare cause of puerperal haemorrhage, but their incidence is increasing due to both improved diagnosis and the more frequent use of uterine surgery in recent years. The use of ultrasound, both B-mode and Doppler, is recommended for diagnosis and follow-up, as it has been shown to be the simplest and most cost-effective method. Endometrial thickening associated with an anechoic and vascular intramiometrial structure is very useful for diagnosis and can help to exclude other causes of dysfunctional bleeding. Pulsed Doppler shows low-resistance vessels and high pulsatility indices with a high peak systolic velocity (PSV). In a healthy myometrium, the vessels have a peak systolic velocity of 9-40 cm/s and a resistance index between 0.6 and 0.8, whereas in the case of AVMs, the systolic and diastolic velocities are 4-6 times higher (PSV 25-110 cm/s with a mean of 60 cm/s and a resistance index of 0.27-0.75 with a mean of 0.41). For treatment, we must individualise each case, taking into account haemodynamic stability, the patient's reproductive wishes, and the severity of the AVM as assessed by its size and PSV.

Coxiella burnetii seroprevalence in sheep herd from Paraguay: First evidence of bacterial circulation in the country.

Coxiella burnetii is the agent of Q fever, a disease that poses risks to public health and damages livestock. We discovered the circulation of C. burnetii for the first time in Paraguay, based on the seropositivity of a flock of >300 sheep. The animals were tested by IFA for anti-C. burnetii antibodies and by SAM for anti-Leptospira spp. antibodies, an important differential diagnosis for reproductive disorders in sheep in Paraguay. C. burnetii seropositivity was determined in 45%, in contrast to Leptospira spp. which had no reactive samples. Cases of miscarriage and fetal resorption were associated with high seropositivity titers. This study suggests the circulation of a unique genotype in the country and an imminent risk to public health, since in addition to being highly transmissible and infectious to humans, Q fever is still not a cause for concern on the part of government and health agencies in the country.

Clinical Characteristics, Frailty, and Mortality of Residents With COVID-19 in Nursing Homes of a Region of Madrid.

OBJECTIVES: To describe the clinical characteristics, 30-day mortality, and associated factors of patients living in nursing homes (NH) with COVID-19, from March 20 to June 1, 2020. DESIGN: This is a retrospective study. A geriatric hospital-based team acted as a consultant and coordinated the care of older people living in NHs from the hospital. SETTING AND PARTICIPANTS: A total of 630 patients aged 70 and older with Coronavirus Disease 2019 COVID-19 living in 55 NHs. METHODS: A logistic regression was performed to analyze the factors associated with mortality. In addition, Kaplan-Meier curves were applied according to mortality and its associated factors using the log-rank Mantel-Cox test. RESULTS: The diagnosis of COVID-19 was mainly made by clinical compatibility (N = 430). Median age was 87 years, 64.6% were women and 45.9% were transferred to be cared for at the hospital. A total of 282 patients died (44.7%) within the 30 days of first attention by the team. A severe form of COVID-19 occurred in 473 patients, and the most frequent symptoms were dyspnea (n = 332) and altered level of consciousness (n = 301). According to multiple logistic regression, male sex (P = .019), the Clinical Frailty Score (CFS) ≥6 (P = .004), dementia (P = .012), dyspnea (P < .001), and having a severe form of COVID-19 (P = .001), were associated with mortality, whereas age and care setting were not. CONCLUSIONS AND IMPLICATIONS: Mortality of the residents living in NHs with COVID-19 was almost 45%. The altered level of consciousness as an atypical presentation of COVID-19 should be considered in this population. A severe form of the disease, present in more than three-quarters of patients, was associated with mortality, apart from the male sex, CFS ≥6, dementia, and dyspnea, whereas age and care setting were not. These findings may also help to recognize patients in which the Advance Care Planning process is especially urgent to assist in the decisions about their care.

Effect of intravenous iron on functional outcomes in hip fracture: a randomised controlled trial.

OBJECTIVES: to determine the safety and effect of intravenous iron sucrose on functional outcomes, delirium, nosocomial infections and transfusion requirements in older patients with hip fracture. DESIGN: single-centre randomised, double-blind, placebo-controlled clinical trial. SETTING AND PARTICIPANTS: orthogeriatric share care service at an academic tertiary care hospital. A total of 253 patients were recruited: 126 patients were assigned to intravenous iron and 127 to placebo. METHODS: on days 1, 3 and 5 after admission, the iron group received 200 mg Venofer® (iron sucrose) in 100 ml saline and the placebo group 100 ml saline. The primary outcome was absolute functional gain, considered as Barthel index (BI) at discharge minus BI on admission. Secondary outcomes included incidence of postoperative delirium according to the confusion assessment method, proportion of patients recovering prior functional status at 3 months, postoperative transfusion requirements, haemoglobin at 3 months, incidence of nosocomial infections and safety. RESULTS: the median participant age was 87 (interquartile range, 82.5-91.5) years. Most patients were female (72.7%), and the median previous BI was 81(59-95). No significant effect of intravenous iron was observed for the primary outcome: the median AFG score was 17.1 points (4.8-23.3) in the intravenous iron group and 16 points (6-26) in the placebo group (P = 0.369). No significant treatment effects were observed for other functional outcomes or secondary end points. CONCLUSION: while we found no impact of intravenous iron sucrose on functional recovery, incidence of postoperative delirium, transfusion requirements, haemoglobin at 3 months, mortality and nosocomial infections rates in older patients with hip fracture, we did find that the intervention was safe.

Gestación gemelar en paciente con epidermolisis bullosa distrófica recesiva severa: revisión de la bibliografía en base a un caso clínico / Twin pregnancy in woman affected by severe recessive dystrophic epidermolysis bullosa: a case report and a literature review

La epidermolisis bullosa distrófica es un grupo de trastornos hereditarios de muy baja prevalencia que se caracterizan por una extrema fragilidad cutánea como consecuencia de una alteración de la cohesión de la unión epidermodérmica. Sin embargo, las manifestaciones clínicas van más allá de las lesiones cutáneas, habiéndose descrito afectación de la mayoría de aparatos y sistemas y siendo frecuente también cierto grado de desnutrición y anemia de origen multifactorial. Presentamos el caso de una paciente de 34 años, secundigesta, con epidermólisis bullosa distrófica recesiva severa, gestante gemelar bicorial y biamniótica, que seguimos durante todo el embarazo y su finalización. La baja prevalencia de la enfermedad hace que el manejo de la gestación suponga un reto para el ginecobstetra. A pesar de que los casos publicados hacen creer que la gestación no modifica el curso natural de la enfermedad, lo cierto es que se recomienda que el embarazo sea seguido por un equipo multidisciplinar. Existen publicados casos en los que se finaliza la gestación por vía vaginal, sin embargo, no existe evidencia suficiente para considerar ésta como la vía de elección.

Dystrophic epidermolysis bullosa is a group of hereditary disorders that has very low prevalence. It is characterized by an extreme cutaneous fragility as a consequence of a cohesion alteration of the epidermis and dermis junction. However, the clinical manifestations also affect other systems and organs, being able to cause malnutrition and anemia. We present the case of a 34-year-old woman affected by severe recessive dystrophic epidermolysis bullosa, with a bichorial and biamniotic twin pregnancy, whom we have followed throughout the pregnancy. The low prevalence of this disease makes the management of the pregnancy a challenge for the obstetrician. Although the published cases suggest that gestation does not modify the natural course of the disease, it is recommended that these pregnancies are monitored by a multidisciplinary team. Some published cases describe vaginal delivery. Nevertheless, it is not clear that this should be the first choice.

Gestación gemelar en paciente con epidermólisis bullosa distrófica / Twin pregnancy in a patient with distrophic bullyus epidermolisis

La epidermólisis bullosa distrófica es un grupo de trastornos hereditarios de muy baja prevalencia que se caracterizan por una extrema fragilidad cutánea como consecuencia de una alteración de la cohesión de la unión epidermodérmica. Sin embargo, las manifestaciones clínicas van más allá de las lesiones cutáneas, habiéndose descrito afectación de la mayoría de aparatos y sistemas y siendo frecuente también cierto grado de desnutrición y anemia de origen multifactorial. Presentamos el caso de una paciente de 34 años, secundigesta, con epidermólisis bullosa distrófica, gestante gemelar bicorial y biamniótica, que seguimos durante todo el embarazo y su finalización. La baja prevalencia de la enfermedad hace que el manejo de la gestación suponga un reto para el tocólogo. A pesar de que los casos publicados hacen creer que la gestación no modifica el curso natural de la enfermedad, lo cierto es que se recomienda realizar un seguimiento del embarazo por un equipo multidisciplinar. Existen publicados casos en los que se finaliza la gestación por vía vaginal, sin embargo, no está claro que sea esta la vía de elección

Dystrophic epidermolysis bullosa is a group of hereditary disorders that has very low prevalence. It is characterized by an extreme cutaneous fragility as a consequence of a cohesion alteration of the epidermis and dermis junction. However, the clinical manifestations also affect other systems and organs, being able to cause malnutrition and anemia. We present the case of a 34-year-old woman affected by dystrophic epidermolysis, with a bichorial and biamniotic twin pregnancy, whom we have followed throughout the pregnancy. The low prevalence of this disease makes the management of the pregnancy a challenge for the obstetrician. Although the published cases suggest that gestation does not modify the natural course of the disease, the truth is that it is recommended to monitor pregnancy by a multidisciplinary team. Some published cases describe vaginal delivery, even though it is not clear that this should be the first choice

Can we predict levator ani muscle avulsion in instrumental deliveries through intrapartum transperineal ultrasound?

Introduction: To determine whether intrapartum translabial ultrasound (ITU) is useful for the prediction of levator ani muscle (LAM) avulsions in instrumental deliveries (vacuum and forceps). Materials and methods: Prospective, observational study, including (1/2016 - 5/2016) 77 nulliparous women, with singleton pregnancies of ≥37 weeks of gestation and with cephalic presentation, who required vacuum or forceps instrumentation to complete the delivery. The ITU parameters evaluated were Angle of Progression (AoP), Progression Distance (PD), Head Direction (HD), and Midline Angle (MLA), both at rest and with maternal push. Evaluation of LAM avulsion was performed at 6 months postpartum with 3-4D transperineal ultrasound. Complete avulsion was defined as an abnormal insertion of LAM in the lower pubic branch identified in all three central slices. Results: Data from 48 nulliparous women were finally included in the study (34 vacuum and 14 forceps). We observed no difference in obstetric parameters between the two study groups (group with avulsion of LAM -14 cases, 29.2% - and group without avulsion of LAM -34 cases, 70.8%). The "LAM avulsion group" had an AoP and a PD of 136.7 ± 22.4 and 43.5 ± 15.6, respectively, versus 141.6 ± 21.3 and 47.2 ± 16.8 recorded in the group without avulsion (NS), respectively. We obtained a ROC curve for AoP and PD with a push of 0.66 (95% CI, 0.28-1.00) and 0.57 (95% CI, 0.39-0.75), respectively. Conclusions: ITU is not a useful technique to predict the occurrence of LAM avulsion in instrumental deliveries with vacuum or forceps.

Diagnostic and prognostic value of electrophysiologic study in patients with nondocumented palpitations.

The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitations. However, in the setting of nondocumented palpitations the value of the electrophysiologic study (EPS) needs additional investigation. We investigated the utility of the EPS in patients with nondocumented palpitations. A total of 172 patients with normal electrocardiographic findings and nondocumented palpitations underwent an EPS. The clinical and electrophysiologic characteristics were assessed. The symptoms were long-lasting (>5 minutes) in 56%. Sudden onset was present in 99%, and termination was rapid in 65%. Neck palpitations were reported in 36%. The EPS findings were normal in 86 patients (50%); atrioventricular nodal reentrant tachycardia was induced in 43, orthodromic reentrant tachycardia in 9, and nonsustained atrial tachycardia/fibrillation (AT/AF) in 34. Long-lasting episodes, sudden termination, and neck palpitations predicted positive EPS findings and were associated with reentrant supraventricular tachycardia (p<0.001). The induction of AT/AF was associated with age >50 years and structural heart disease (p<0.001). After 53 ± 36 months of follow-up, 92% of patients with negative EPS findings were symptom free. Only 32% of patients with induced AT/AF remained free of symptoms (p<0.001). The recurrence of palpitations was more prevalent among patients with structural heart disease and aged >50 years (p<0.001). In conclusion, 50% of patients with nondocumented palpitations had positive EPS findings. A long duration, sudden termination, and neck palpitations, together with structural heart disease and age >50 years, predicted tachycardia inducibility and recurrence and could help in selecting patients suitable for EPS and ablation.