Impact of COVID-19 on surgical residency training programs in Mexico City: The third victim of the pandemic. A resident's perspective.

OBJECTIVE: The aim of this study is to assess the perceptions of the impact of health-care disruption due to COVID-19 on the academic training and skills of surgical trainees. MATERIAL AND METHODS: We developed a 32-question survey assessing the clinical and surgical impact of COVID-19 on surgical training programs and proposals to compensate for the decrease in surgical education. We got 453 responses of surgical trainees in Mexico City. RESULTS: Sixty-six percent of the respondents answered that their centers had converted to the exclusive attention of COVID-19 patients. Ninety-five percent reported a decrease in surgical skills learning and 91.8% reported a decrease to clinical exposure. On proposals, 75.6% reported that it is essential to take the necessary measures to recover the clinical and surgical milestones lost. In the binary logistic regression analysis, we found that the postgraduate year (≥ PG-Y3) was statistically significant factor (p ≤ 0.000) related to a favorable opinion to developing an academic contingency plan and postponing the end of the academic residency year. CONCLUSION: More than 90% of the survey respondents reported having been affected by COVID-19 mitigation strategies. Our data calls for urgent training adjustments by hospital and university program leaders to mitigate downstream educational repercussions.

OBJETIVO: Evaluar las percepciones del impacto de la interrupción de la atención médica por COVID-19 en la formación académica y las habilidades de los residentes quirúrgicos. MATERIAL Y MÉTODOS: Realizamos una encuesta de 32 preguntas, evaluando el impacto clínico y quirúrgico del COVID-19 en los programas de entrenamiento quirúrgico y propuestas para compensar la disminución de la educación quirúrgica. Obtuvimos 453 respuestas de residentes quirúrgicos en la Ciudad de México. RESULTADOS: El 66% respondió que sus centros se convirtieron en atención exclusiva de pacientes con COVID-19. El 95% presentó una disminución en el aprendizaje de habilidades quirúrgicas y el 91. 8% presentó una disminución de la exposición clínica. El 75.6% consideró fundamental tomar las medidas necesarias para recuperar las destrezas clínicas perdidas. En el análisis de regresión logística binaria, encontramos que el año de posgrado (> PG-Y3) fue un factor estadísticamente significativo (p <0,000) relacionado con una opinión favorable para desarrollar un plan de contingencia académica y posponer el final del año de residencia académica. CONCLUSIÓN: Más del 90% de los encuestados fueron afectados por las estrategias de mitigación de COVID-19. Nuestros datos exigen ajustes urgentes por parte de los líderes de programas de hospitales y universidades para mitigar las repercusiones educativas posteriores.

A Practical Score for Prediction of Outcome After Cerebral Venous Thrombosis.

Background: Most patients with cerebral venous thrombosis (CVT) have independent survival in the short term. However, identification of high-risk individuals with an unfavorable outcome is a challenging task. We aimed to develop a CVT grading scale (CVT-GS) to aid in the short-term clinical decision-making. Methods: We included 467 consecutive patients with CVT who were hospitalized from 1981 to 2015 in two third-level referral hospitals. Factors associated with 30-day mortality were selected with bivariate analyses to integrate a Cox proportional-hazards model to determine components of the final scoring. After the scale was configured, the prognostic performance was tested for prediction of short-term death or moderately impaired to death [modified Rankin scale (mRS) > 2]. CVT-GS was categorized as mild, moderate or severe for the prediction of 30-day fatality rate and a probability of mRS > 2. Results: The 30-day case fatality rate was 9.0%. The CVT-GS (0-13 points; more points predicting poorer outcomes) was composed of parenchymal lesion size > 6 cm (3 points), bilateral Babinski signs (3 points), male sex (2 points), parenchymal hemorrhage (2 points), and level of consciousness (coma: 3 points, stupor: 2, somnolence: 1, and alert: 0). CVT was categorized as mild (0-2 points, 0.4% fatality rate), moderate (3-7 points, 9.9% fatality rate), or severe (8-13 points, 61.4% fatality rate). The CVT-GS had an accuracy of 91.6% for the prediction of 30-day mortality and 85.3% for mRS > 2. Conclusions: CVT-GS is a practical clinical tool for prediction of outcome after CVT. This score may aid in clinical decision-making and could serve to stratify patients enrolled in clinical trials.

Acute Appendicitis After Kidney Transplantation: Experience at a Tertiary Care Hospital in Mexico City.

OBJECTIVES: Here, we describe the presentation, treatment, and outcomes of acute appendicitis in kidney transplant recipients at a tertiary care hospital in Mexico City. MATERIALS AND METHODS: We conducted a retrospective case series study at a tertiary care hospital in Mexico City from January 2000 to January 2015. RESULTS: During our study period, 1186 patients received a kidney transplant; among these patients, we identified 10 cases of acute appendicitis (0.008%). Four patients (40%) were diagnosed on day 5 of symptom onset. Nine patients (90%) showed abdominal pain, 2 patients (20%) presented with a typical migratory pattern, and 2 patients (20%) showed symptoms of small bowel intestinal obstruction. Thirty percent of patients (3/10) presented a rule-out Alvarado score (≤ 3 points). A computed tomography scan was performed in all but one patient; among these 9 patients, 1 (11.1%) had a false-negative result. Among all patients with acute appendicitis, 50% (5/10) presented with a periappendiceal abscess and 40% (4/10) showed localized peritonitis. An open and laparoscopic appendectomy was performed in 7 of 10 patients (70%) and 3 of 10 patients (30%), respectively. All patients received ceftriaxone plus metronidazole or ertapenem for 5 to 7 days. There were no reported treatment failures or recurrence of symptoms. CONCLUSIONS: The diagnosis of acute appendicitis in kidney transplant recipients requires a high index of suspicion. Kidney transplant recipients with acute appendicitis had good outcomes with a therapeutic approach similar to that used in the general population.

TGFBR2 mutation and MTHFR-C677T polymorphism in a Mexican mestizo population with cervico-cerebral artery dissection.

Spontaneous cervico-cerebral artery dissection (CCAD) is a common condition found among young patients with ischemic stroke. We examined the possible association between the polymorphism of methylenetetrahydrofolate reductase (MTHFR)-C677T and the gene mutation in transforming growth factor beta receptor II (TGFBR2) in a cohort of CCAD patients. One-hundred CCAD cases (65 males; mean age: 38.08 ± 10.68 years) and 100 matching controls were included. Ancestry informative markers (AIMs) were used to increase internal validity of the genetic analysis. Genotypes of the C677T polymorphism in the MTHFR gene were determined by polymerase chain reaction and restriction fragment length polymorphism; direct sequencing was used for a mutation analysis of the TGFBR2 gene. Associations were evaluated using a multivariate statistics, and Hardy-Weinberg equilibrium was analyzed. We also incorporated our data into a meta-analysis of the MTHFR-C677T. Sixty-three patients presented with vertebral and 37 with carotid artery dissection. Ancestry markers found a call rate on each over 95 %. All AIMs did not deviate from Hardy-Weinberg equilibrium (p > 0.05). The homozygous TT genotype was more frequent in cases (OR 2.04, CI 95 % 1.53-2.72, p = 0.005), whereas no significant difference was found on heterozygous CT genotype. TGFBR2 mutation was not present in our samples. In the meta-analysis of MTHFR/C677T variant, a total 613 cases and 1547 controls were analyzed; we found a moderate association for the recessive model genotype (OR 2.04, CI 95 % 1.53-2.72; p = 0.342; Z = 4.83; I (2) = 11.3). This study supports a positive association between the MTHFR-C677T polymorphism and genetically confirmed Mexican mestizo CCAD patients.

Time to recanalisation in patients with cerebral venous thrombosis under anticoagulation therapy.

BACKGROUND AND PURPOSE: Few studies have investigated the rates of recanalisation after cerebral venous thrombosis (CVT). Our objective was to investigate the recanalisation rate and to identify predictors of recanalisation in patients with CVT. METHODS: We included 102 patients with confirmed first-ever, non-septic CVT. All patients received anticoagulation for 12 months or until complete recanalisation. To assess recanalisation, patients underwent MR venography every 3 months until partial or complete recanalisation or for 12 months after diagnosis. We conducted two parallel analyses of complete recanalisation versus partial and no recanalisation versus any recanalisation. As a secondary objective we explored the influence of recanalisation on outcome and recurrent events. We calculated the probability of recanalisation using Kaplan-Meier analysis and conducted multivariate analysis using a Cox model. RESULTS: The mean age of patients was 33.5±11 years (80 (78.4%) women). Survival analysis indicated that 50% of the patients had any recanalisation (grades I, II and III) by 64 days and complete recanalisation (grade III) by 169 days. Adjusted Cox proportional model revealed that age <50 years (HR=11.5 95% CI=1.58 to 84.46, p=0.01) and isolated superior sagittal sinus thrombosis (HR=0.39, 95% CI=0.14 to 1.04, p=0.05) predict complete recanalisation, while age <50 years (HR=4.79; 95% CI=1.69 to 13.5, p=0.003) predicts any recanalisation. Patients with complete recanalisation had a greater chance of good functional outcome (HR=5.17; 95% CI=2.8 to 9.53, p<0.001). CONCLUSIONS: We found that recanalisation occurs over time, until month 11. Complete recanalisation may influence functional outcome.

Intracranial venous collaterals in cerebral venous thrombosis: clinical and imaging impact.

BACKGROUND AND PURPOSE: Few studies have examined collateral formation in patients with cerebral venous thrombosis (CVT). The aim of this study was to analyse the impact of baseline intracranial venous collaterals on the clinical outcome and imaging features of patients with acute CVT. MATERIAL AND METHODS: MRIs from consecutive patients with acute CVT were retrospectively analysed. The category system described by Qureshi was used to assess the pattern of venous collaterals. Clinical and imaging features and outcomes were analysed using bivariate and multivariate models to assess the association of collateral patterns with the type of parenchymal lesions and clinical outcome (modified Rankin Scale) at 30 and 90 days. RESULTS: One hundred patients were included (77 women; median age 32 years; and median of 18 months of follow-up). Venous collaterals were present in 88% of the patients; type I collaterals in 3 patients, type II collaterals in 27 patients, and type III collaterals in 58 patients. Twelve patients did not exhibit any collaterals. Cohen's κ coefficient between evaluators was 0.86. In the bivariate analysis, type III collaterals were associated with isolated intracranial hypertension and complete recovery, whereas type I collaterals were associated with encephalopathy. However, in the multivariate regression analysis, the collateral pattern was not associated with clinical presentation, type of brain lesion or outcome. CONCLUSIONS: Intracranial venous collaterals are frequently found in patients with CVT during the acute phase. However, they do not have an independent effect on the type of brain damage, clinical manifestations or prognosis.