Revisiting MOMS criteria for prenatal repair of spina bifida: upper gestational-age limit should be raised and assessment of prenatal motor function rather than anatomical level improves prediction of postnatal function.

OBJECTIVES: To determine if the lower-extremity neurological motor function level in fetuses with open spina bifida deteriorates within the 4-week interval between a first prenatal motor assessment at around 22 weeks of gestation and a second evaluation, prior to 'late' prenatal surgery, defined as surgery at 26-28 weeks and, in certain situations, up to 30 weeks, and to assess the association between prenatal presurgical motor-function level, anatomical level of the lesion and postnatal motor-function level. METHODS: This was a two-center cohort study of 94 singleton fetuses with open spina bifida which underwent percutaneous repair using the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique between December 2016 and January 2022. All women underwent two prenatal systematic ultrasound evaluations, approximately 4 weeks apart, with the second one being performed less than 1 week before surgery, and one postnatal evaluation via physical examination within 2 months of birth. Motor-function classification was from spinal level T12 to S1, according to key muscle function. Each leg was analyzed separately; in case of discrepancy between the two legs, the worst motor-function level was considered for analysis. Motor-function-level evaluations were compared with each other and with the anatomical level as observed on ultrasound. Independent predictors of a postnatal reduction in motor-function level were assessed using a logistic regression model. RESULTS: Prenatal motor-function level was assessed at a median gestational age of 22.5 (interquartile range (IQR), 20.7-24.3) and 26.7 (IQR, 25.4-27.3) weeks, with a median interval of 4.0 (IQR, 2.4-6.0) weeks. The median gestational age at surgery was 27.0 (IQR, 25.9-27.6) weeks and the postnatal examination was at median age of 0.8 (IQR, 0.3-5.4) months. There was no significant difference in motor-function level between the two prenatal evaluations (P = 0.861). We therefore decided to use the second prenatal evaluation for comparison with postnatal motor function and anatomical level. Overall, prenatal and postnatal motor function evaluations were significantly different from the anatomical level (preoperative assessment, P = 0.0015; postnatal assessment, P = 0.0333). Comparing prenatal with postnatal motor-function level, we found that 87.2% of babies had similar or improved motor function compared with that prior to prenatal surgery. On logistic regression analysis, lower anatomical level of defect and greater difference between anatomical level and prenatal motor-function level were identified as independent predictors of postnatal motor function (odds ratio, 0.237 (95% CI, 0.095-0.588) (P = 0.002) and 3.44 (95% CI, 1.738-6.813) (P < 0.001), respectively). CONCLUSIONS: During a 4-week interval between first ultrasound evaluation and late fetal surgical repair of open spina bifida, motor function does not change significantly, suggesting that late repair, ≥ 26 weeks, does not impact negatively on motor-function outcome. Compared with the anatomical level of the lesion, preoperative neurological motor-function assessment via ultrasound is more predictive of postnatal motor function, and should be included in preoperative counseling. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Biocellulose patch technique for fetoscopic repair of open spina bifida in twin pregnancy.

OBJECTIVES: Twin pregnancy is currently an exclusion criterion for prenatal repair of open spina bifida (OSB). The main objective of this study was to report on our experience of treating twin pregnancies with OSB using the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique. We also discuss reconsideration of the current exclusion criteria for fetal OSB repair. METHODS: Eight fetuses with OSB from seven twin pregnancies underwent successful prenatal repair. Six pregnancies were dichorionic diamniotic with only one twin affected, and one was monochorionic diamniotic with both twins affected. Percutaneous fetoscopy was performed under CO2 insufflation of the sac of the affected twin. Neurosurgical repair was performed using a biocellulose patch to protect the placode, with the skin sutured to hold the patch in place, with or without a myofascial flap. Neurodevelopment was assessed using the pediatric evaluation of disability inventory scale in babies older than 6 months of adjusted age, whereas the Alberta scale was used for babies younger than 6 months of adjusted age. RESULTS: All 14 fetuses were liveborn and none required additional repair. Gestational age at surgery ranged from 27.3 to 31.1 weeks, and gestational age at birth ranged from 31.6 to 36.0 weeks. Four out of eight affected twins developed sepsis, but had a good recovery. No sequela of prematurity was found in any of the unaffected twins. Short-term neurodevelopment was normal in all evaluated unaffected twins (5/5) and in all but one affected twins (7/8). In the affected group, only one baby required ventriculoperitoneal shunt placement. CONCLUSIONS: Prematurity is frequent after fetal surgery, and the risk is increased in twin pregnancy. Nevertheless, prenatal surgery using the SAFER technique is feasible, with low risk to both twins and their mother when performed by a highly experienced team. Long-term cognitive assessment of the unaffected twin is needed. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The 2022 Assisi Think Tank Meeting: White paper on optimising radiation therapy for breast cancer.

The present white paper, referring to the 4th Assisi Think Tank Meeting on breast cancer, reviews state-of-the-art data, on-going studies and research proposals. <70% agreement in an online questionnaire identified the following clinical challenges: 1: Nodal RT in patients who have a) 1-2 positive sentinel nodes without ALND (axillary lymph node dissection); b) cN1 disease transformed into ypN0 by primary systemic therapy and c) 1-3 positive nodes after mastectomy and ALND. 2. The optimal combination of RT and immunotherapy (IT), patient selection, IT-RT timing, and RT optimal dose, fractionation and target volume. Most experts agreed that RT- IT combination does not enhance toxicity. 3: Re-irradiation for local relapse converged on the use of partial breast irradiation after second breast conserving surgery. Hyperthermia aroused support but is not widely available. Further studies are required to finetune best practice, especially given the increasing use of re-irradiation.

Prevalence of supratentorial anomalies assessed by magnetic resonance imaging in fetuses with open spina bifida.

OBJECTIVES: To determine the prevalence of brain anomalies at the time of preoperative magnetic resonance imaging (MRI) assessment in fetuses eligible for prenatal open spina bifida (OSB) repair, and to explore the relationship between brain abnormalities and features of the spinal defect. METHODS: This was a retrospective cross-sectional study, conducted in three fetal medicine centers, of fetuses eligible for OSB fetal surgery repair between January 2009 and December 2019. MRI images obtained as part of the presurgical assessment were re-evaluated by two independent observers, blinded to perinatal results, to assess: (1) the type and area of the defect and its anatomical level; (2) the presence of any structural central nervous system (CNS) anomaly and abnormal ventricular wall; and (3) fetal head and brain biometry. Binary regression analyses were performed and data were adjusted for type of defect, upper level of the lesion (ULL), gestational age (GA) at MRI and fetal medicine center. Multiple logistic regression analysis was performed in order to identify lesion characteristics and brain anomalies associated with a higher risk of presence of abnormal corpus callosum (CC) and/or heterotopia. RESULTS: Of 115 fetuses included, 91 had myelomeningocele and 24 had myeloschisis. Anatomical level of the lesion was thoracic in seven fetuses, L1-L2 in 13, L3-L5 in 68 and sacral in 27. Median GA at MRI was 24.7 (interquartile range, 23.0-25.7) weeks. Overall, 52.7% of cases had at least one additional brain anomaly. Specifically, abnormal CC was observed in 50.4% of cases and abnormality of the ventricular wall in 19.1%, of which 4.3% had nodular heterotopia. Factors associated independently with higher risk of abnormal CC and/or heterotopia were non-sacral ULL (odds ratio (OR), 0.51 (95% CI, 0.26-0.97); P = 0.043), larger ventricular width (per mm) (OR, 1.23 (95% CI, 1.07-1.43); P = 0.005) and presence of abnormal cavum septi pellucidi (OR, 3.76 (95% CI, 1.13-12.48); P = 0.031). CONCLUSIONS: Half of the fetuses assessed for OSB repair had an abnormal CC and/or an abnormal ventricular wall prior to prenatal repair. The likelihood of brain abnormalities was increased in cases with a non-sacral lesion and wider lateral ventricles. These findings highlight the importance of a detailed preoperative CNS evaluation of fetuses with OSB. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization.

OBJECTIVE: A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome. METHODS: This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation. RESULTS: A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization. CONCLUSION: Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Stakeholder analysis in health innovation planning processes: A systematic scoping review.

Integrating health innovations into the health system is a complex endeavour that requires a well-designed planning process engaging key stakeholders. Stakeholder analyses lay the foundations to inform appropriate planning processes and undertake strategic actions. A systematic scoping review was performed to explore how stakeholder analyses are applied in health innovation planning processes and a guideline to report stakeholder analyses was developed. The literature search was conducted in PubMed, Scopus and DOAJ; grey literature was sought using Google. Articles reporting stakeholder analyses during the planning process of health policies, systems, products and technologies, and services and delivery methods were included. Fifty-one records were incorporated in the qualitative synthesis. Stakeholder analyses were conducted worldwide, used in all types of health innovations, applied in all phases of the planning process and conducted both prospectively and retrospectively. The steps followed to perform stakeholder analysis, the methods used, the stakeholder attributes analysed and how authors reported the analyses were heterogeneous. Forty-one studies reported the identification of stakeholders, 50 differentiated/categorised them and 25 analysed stakeholder relationships. Only some authors proposed future actions based on the results obtained in their stakeholder analysis. A list of Reporting Items for Stakeholder Analysis (i.e., the RISA tool) is proposed to contribute to the reporting guidelines to enhancing the quality and transparency of health research.

Collaborative health service planning: A stakeholder analysis with social network analysis to develop a community pharmacy service.

BACKGROUND: Stakeholder participation optimizes health planning, fostering the acceptability and integration of new health services. Collaborative approaches may help overcome existing challenges in the development, implementation and evaluation of community pharmacy services (CPSs). Stakeholder analyses lay the foundation for building collaboration in the integrated delivery of health care. OBJECTIVES: This stakeholder analysis was performed to organize a collaborative initiative to develop a CPS aimed at preventing cardiovascular diseases in Andalucía (Spain). It aimed to identify stakeholders, differentiate/categorize them, and analyze stakeholder relationships. METHOD: Stakeholders were identified using the snowballing technique. To differentiate/categorize stakeholders and analyze the relationships (i.e., collaboration) an online web-based questionnaire was sent to 186 stakeholders. Stakeholders were asked for: (1) their influence, interest and attitude toward the initiative; (2) stakes/interests; (3) capacity to contribute to the initiative; (4) desire for involvement; (5) concerns; (6) whom they considered a key stakeholder; and (7) the level of collaboration they had with other stakeholders. Data analysis combined descriptive qualitative content analysis, descriptive quantitative analysis and social network analysis. RESULTS: Of the 186 stakeholders approached, 96 (51.6%) participated. The identification process yielded 217 stakeholders (individuals, organizations or collectives), classified into 10 groups. Fifty-seven stakeholders were considered critical to the intended initiative. Most participant stakeholders supported the initiative and were willing to collaborate in the development of the CPS. Public health and science were the main driving interests. A collaboration network existed between the 96 stakeholders. CONCLUSION: This study revealed the magnitude of the social system surrounding the development of a CPS aimed at preventing cardiovascular disease. A large array of stakeholders was identified and analyzed, and a group of critical stakeholders selected. Stakeholder characteristics such as attitude toward the initiative, potential contribution, desire for involvement, and the existing collaboration network, provided complementary information that was helpful for planning the process and stakeholder engagement.

Reverse shoulder arthroplasty for acute proximal humeral fractures: Postoperative complications at 7 days, 90 days and 1 year.

BACKGROUND: In the last decade, the biomechanics of reverse shoulder arthroplasty (RSA) for proximal humeral fractures in the elderly have led to more functional outcomes and greater pain relief. However, its use has also introduced a significant rate of complications. The purpose of this study is to assess the complication rate of RSA in these cases as well as the relationship to ASA score and basic disease history. METHODS: We evaluate patients who underwent RSA due to acute proximal humeral fractures at three hospitals from 2010 to 2016. We analyze previous disease and anticoagulant treatment, American Society of Anesthesiologists (ASA) Physical Status Classification, and the transfusion rate to correlate these factors with major and minor postoperative complications at 7, 90, and 365 days. RESULTS: We include 103 patients (104 shoulders) over 65 years of age. Mean age is 77.31 years (62-91), 20 of which are male. The overall rate of complications is 25%, with 17.4% minor and 7.6% major complications. We observe a statistically significant relationship between a higher ASA score (3,4) and major complication at 90 days (p = 0.024) and a trend (p = 0.072) towards a higher ASA score with minor complication during the first week. Rheumatoid disease significantly increases major complications at 90 days (p = 0.037). The transfusion rate is 11.5%. CONCLUSIONS: The overall major complication rate of RSA for acute fractures is low in the elderly population. Although, the patient's history (e.g. previous rheumatoid pathology, neurological diseases, or anticoagulant treatment) as well as their ASA score should be considered before RSA surgery. The higher the ASA score and the presence of rheumatoid disease, leads to a higher rate of major complications during the first 90 days after surgery. LEVEL OF EVIDENCE: Level IV; Case series; Treatment study.

A stakeholder visioning exercise to enhance chronic care and the integration of community pharmacy services.

BACKGROUND: Collaboration between relevant stakeholders in health service planning enables service contextualization and facilitates its success and integration into practice. Although community pharmacy services (CPSs) aim to improve patients' health and quality of life, their integration in primary care is far from ideal. Key stakeholders for the development of a CPS intended at preventing cardiovascular disease were identified in a previous stakeholder analysis. Engaging these stakeholders to create a shared vision is the subsequent step to focus planning directions and lay sound foundations for future work. OBJECTIVES: This study aims to develop a stakeholder-shared vision of a cardiovascular care model which integrates community pharmacists and to identify initiatives to achieve this vision. METHODS: A participatory visioning exercise involving 13 stakeholders across the healthcare system was performed. A facilitated workshop, structured in three parts (i.e., introduction; developing the vision; defining the initiatives towards the vision), was designed. The Chronic Care Model inspired the questions that guided the development of the vision. Workshop transcripts, researchers' notes and materials produced by participants were analyzed using qualitative content analysis. RESULTS: Stakeholders broadened the objective of the vision to focus on the management of chronic diseases. Their vision yielded 7 principles for advanced chronic care: patient-centered care; multidisciplinary team approach; shared goals; long-term care relationships; evidence-based practice; ease of access to healthcare settings and services by patients; and good communication and coordination. Stakeholders also delineated six environmental factors that can influence their implementation. Twenty-four initiatives to achieve the developed vision were defined. CONCLUSIONS: The principles and factors identified as part of the stakeholder shared-vision were combined in a preliminary model for chronic care. This model and initiatives can guide policy makers as well as healthcare planners and researchers to develop and integrate chronic disease services, namely CPSs, in real-world settings.

Stakeholder analysis for the development of a community pharmacy service aimed at preventing cardiovascular disease.

BACKGROUND: Participatory approaches involving stakeholders across the health care system can help enhance the development, implementation and evaluation of health services. These approaches may be particularly useful in planning community pharmacy services and so overcome challenges in their implementation into practice. Conducting a stakeholder analysis is a key first step since it allows relevant stakeholders to be identified, as well as providing planners a better understanding of the complexity of the health care system. OBJECTIVES: The main aim of this study was to conduct a stakeholder analysis to identify those individuals and organizations that could be part of a leading planning group for the development of a community pharmacy service (CPS) to prevent cardiovascular disease (CVD) in Australia. METHODS: An experienced facilitator conducted a workshop with 8 key informants of the Australian health care system. Two structured activities were undertaken. The first explored current needs and gaps in cardiovascular care and the role of community pharmacists. The second was a stakeholder analysis, using both ex-ante and ad-hoc approaches. Identified stakeholders were then classified into three groups according to their relative influence on the development of the pharmacy service. The information gathered was analyzed using qualitative content analysis. RESULTS: The key informants identified 46 stakeholders, including (1) patient/consumers and their representative organizations, (2) health care providers and their professional organizations and (3) institutions and organizations that do not directly interact with patients but organize and manage the health care system, develop and implement health policies, pay for health care, influence funding for health service research or promote new health initiatives. From the 46 stakeholders, a core group of 12 stakeholders was defined. These were considered crucial to the service's development because they held positions that could drive or inhibit progress. Secondary results of the workshop included: a list of needs and gaps in cardiovascular care (n = 6), a list of roles for community pharmacists in cardiovascular prevention (n = 12) and a list of potential factors (n = 7) that can hinder the integration of community pharmacy services into practice. CONCLUSIONS: This stakeholder analysis provided a detailed picture of the wide range of stakeholders across the entire health care system that have a stake in the development of a community pharmacy service aimed at preventing CVD. Of these, a core group of key stakeholders, with complementary roles, can then be approached for further planning of the service. The results of this analysis highlight the relevance of establishing multilevel stakeholder groups for CPS planning.

Craneoplastia cnn costilla, procedimiento ideal: reporte de un caso / Split rib cranioplasty ideal procedure for Bolivia and the world: case report

aso de craneoplastia con costilla en un paciente con un síndrome de colgajo hundido, hacemos énfasis en la posibilidad de utilizar un injerto autológo, en este caso costilla en lugar de aloinjertos, siempre que sea posible. Las causas del problema fueron un defecto de la bóveda craneal secundaria a una craneotomía por edema cerebral pos-traumático y la colocación de una derivación ventrículo peritoneal. Los resultados obtenidos tanto desde el punto de vista neurofuncional como estético fueron excelentes.

A case of the syndrome of sinking skin flap and his treatment by performing slip rip autograph cranioplasty, the reasons for cranial reconstruction were calvaría defect from previous craniotomy a VP shunt. We emphasize on the convenience of the use of rib auto graft cranioplasty. Results were excellent.

Mielopatía necrotizante subaguda asociada a lupus eritematoso sistémico: reporte de un caso y revisión de la literatura / Subacute necrotizing myelopathy associated to SLE: case report and review of literature

Las mielopatías agudas representan un grupo heterogéneo de enfermedades, de distintas etiologías, hallazgos clínicos y radiológicos diferentes, y particular pronóstico. La Mielitis transversa (MT), es el prototipo del grupo, en el cual, un proceso inmunitario causa el daño neural en la médula espinal, resultando en varios grados de paresia, alteraciones sensitivas, y disfunción autonómica. La MT puede existir como parte de una enfermedad del Sistema nervioso Central multifocal (Esclerosis múltiple) enfermedad multisistémica (Lupus Eritematoso Sistémico), o aislada, como una entidad idiopática. En este artículo, presentamos un caso clínico, y revisamos recientes esquemas diagnósticos, que permiten sistematizar el diagnóstico y tratamiento de los pacientes con mielopatía aguda. Adicionalmente, resumimos el estado actual del conocimiento acerca de la epidemiología, historia natural de la enfermedad, inmunopatogénesis, y estrategias terapéuticas para pacientes con Mielitis transversa. El conocimiento actual sobre la clasificación, diagnóstico, patogénesis y tratamiento de la Mielitis Transversa, ha sufrido recientemente cambios y nuevos aportes, especialmente con el desarrollo de la neuroinmunopatología. Actualmente podemos iniciar tratamientos oportunos para muchos de éstos pacientes, y mejorar el pronóstico a largo plazo de ésta rara, pero discapacitante noxa.

Eosinophilic pleural effusion in cutaneous myiasis.

We have reported the case of a 54-year-old man with recurrent painful migratory subcutaneous nodules associated with marked blood eosinophilia and an eosinophilic pleural effusion. The entire syndrome was subsequently determined to be due to cutaneous myiasis caused by the larvae of Hypoderma lineatum, the cattle botfly. Infestation by this or other dipterous fly larvae should be among the parasitic diseases considered in the differential diagnosis of any patient with similar symptoms.