Position statement: asthma in Latin America. IS short-acting beta-2 agonist helping or compromising asthma management?

In Latin-America, with 603 million inhabitants, the average prevalence of asthma is estimated at 17%, but with wide fluctuations, ranging from 5% in some cities (Mexico) to 30% in Costa Rica. The risk of severe exacerbations seems to be higher in Latin America compared with other regions. A majority of patients uses daily quick-relief medication, with the belief that it is the most important treatment because of its rapid onset of action; without treating the underlying inflammation. Overuse of short-acting beta2 agonists (SABAs) is associated with increased risk of asthma deaths in a dose-response manner. Beta2 agonists increase the severity of asthma through enhanced bronchial hyperresponsiveness and reduced lung function. Also, it has been shown that overreliance on SABA delays recognition of a potentially life-threatening asthma attack. We believe that overreliance on SABA in asthma is also an important public health issue. The fact that SABA use in GINA is not supported by a randomized trial but by an anonymous paper; makes us guess that we use SABA just because we are used to do so. In 2019 GINA strategy introduces one of the most important changes in the management of Asthma in the past 30 years, highlighting anti-inflammatory reliever therapy. A combination of low dose ICS/fast action bronchodilator will not only treat symptoms, but more importantly the underlying inflammation, protecting patients from preventable asthma attacks. After 50 years of a SABA centric approach in asthma management, it is time to leave behind a treatment based just on the bronchodilation and tackle the inflammation.

Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study.

OBJECTIVES: To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later. METHODS: This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects. RESULTS: Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries. CONCLUSIONS: Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Anal sphincter trauma and anal incontinence in urogynecological patients.

OBJECTIVES: To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma. METHODS: This was a retrospective analysis of ultrasound volume datasets of 501 patients attending a tertiary urogynecological unit. All patients underwent a standardized interview including determination of St Mark's score for those presenting with AI. Tomographic ultrasound imaging (TUI) was used to evaluate the EAS and the internal anal sphincter (IAS). RESULTS: Among a total of 501 women, significant EAS and IAS defects were found in 88 and 59, respectively, and AI was reported by 69 (14%). Optimal prediction of AI was achieved using a model that included four abnormal slices of the EAS on TUI. IAS defects were found to be less likely to be associated with AI. In a multivariable model controlling for age and IAS trauma, the presence of at least four abnormal slices gave an 18-fold (95% CI, 9-36; P < 0.0001) increase in the likelihood of AI, compared with those with fewer than four abnormal slices. Using receiver-operating characteristics curve statistics, this model yielded an area under the curve of 0.86 (95% CI, 0.80-0.92). CONCLUSIONS: Both AI and significant EAS trauma are common in patients attending urogynecological units, and are strongly associated with each other. Abnormalities of the IAS seem to be less important in predicting AI. Our data support the practice of using, as a minimal criterion, defects present in four of the six slices on TUI for the diagnosis of significant EAS trauma.

Pelvic floor trauma: does the second baby matter?

OBJECTIVE: To ascertain the effect of a second delivery on pelvic floor anatomy. METHODS: This was a retrospective analysis of data obtained in two perinatal imaging studies. Women were invited for antenatal and two postnatal appointments. All had answered a standardized questionnaire and undergone a clinical examination and translabial four-dimensional ultrasound. Ultrasound volumes were acquired at rest, on Valsalva maneuver and on pelvic floor muscle contraction, and analyzed by postprocessing on a PC. Avulsion was diagnosed on tomographic ultrasound imaging. This study reports data obtained in those women who delivered a second child between the first and second postnatal assessments. RESULTS: Of 715 participants, 94 reported a second birth at their second postnatal appointment on average 2.7 years after their first birth; 65 had a vaginal delivery and 29 a Cesarean section. There were nine attempts at vaginal birth after Cesarean section (VBAC), of which six were successful. When we analyzed the ultrasound findings before and after a second delivery, there was no significant change observed in bladder-neck descent, cystocele descent and hiatal area on Valsalva. Delivery mode of the second birth seemed to have little effect on changes observed between follow-ups, although there was a trend towards increased bladder-neck descent in women after vaginal delivery. On reviewing patients diagnosed with avulsion at their 2-3-year visit and comparing them with findings at the first follow-up visit, we found identical (normal) findings in 87 cases. In five there was an unchanged avulsion. In one case, findings had improved from complete to partial avulsion. There was one new avulsion, in a patient who had delivered her first baby by emergency Cesarean section and her second by vacuum delivery. CONCLUSIONS: A second pregnancy and delivery do not seem to have a major effect on bladder support and/or levator function. However, we documented a case of major levator trauma after VBAC. The issue of pelvic floor trauma after VBAC may have to be investigated further.

Prevalence of anal sphincter injury in primiparous women.

OBJECTIVE: To determine the prevalence of obstetric anal sphincter injuries (OASIS) in a cohort of primiparous women and to evaluate their association with demographic, obstetric and ultrasound parameters. METHODS: This was a retrospective analysis of the ultrasound volume datasets of 320 primiparous women, acquired at 5 months postpartum. Tomographic ultrasound imaging (TUI) was used to evaluate the external anal sphincter (EAS). A significant EAS defect was diagnosed if a defect of > 30° was seen in four or more of six TUI slices bracketing the EAS. RESULTS: Significant EAS defects were found in 69 women (27.9% of those delivered vaginally). In nine of those a third-degree tear was diagnosed intrapartum and was sutured. In 60 women with significant defects there was no documentation of sphincter damage at birth, implying unidentified or occult defects (60/69, 87.0%). Among them, 29 had had a second-degree tear, two a first-degree tear and three an intact perineum. In 31 cases an episiotomy had been performed, with five extensions to a third-degree tear. On multivariate analysis only forceps delivery was significantly associated with OASIS. CONCLUSIONS: In this cohort of primiparous women we found OASIS in 27.9% of vaginally parous women, most of which had not been diagnosed in the delivery suite. There seems to be a need for better education of labor-ward staff in the recognition of OASIS. On the other hand, it is conceivable that some defects may be masked by intact tissue. The significance of such defects remains doubtful. Forceps delivery was the only identifiable risk factor.

Bone tumors of mixed origin: osteo-liposarcoma and osteo-rhabdomyosarcoma.

1. A complete perusal of the literature revealed twenty cases of primary liposarcoma of bone acceptable as such to the authors. These were tabulated as to location and age. 2. Eight cases of osteo-liposarcoma, primary in bone, were encountered in the literature and an additional case was reported by the authors. 3. The authors described for the first time in the literature a new primary tumor of bone of mixed origin: osteo-rhabdomyosarcoma. After careful perusal of the literature they added three additional cases: two cases, previously reported as primary rhabdomyosarcoma of bone, which on careful evaluation of the radiographs in said publications and the paucity of microphotographs they considered to be osteo-rhabdomyosarcomas, and the other case, previously reported as malignant mesenchymoma of the sternum following radiotherapy for breast cancer. 4. The authors prefer to classify these tumors (osteo-liposarcoma and osteo-rhabdomyosarcoma) as "Tumors of Mixed Origin" and not as "Malignant Mesenchymomas". 5. A complete review of the literature revealed 219 reported "dedifferentiated" chondrosarcomas, or chondrosarcomas "with additional mesenchymal component", among which only nine (9) contained a bona fide rhabdomyosarcomatous component. The rest exhibited other mesenchymal tumors as osteogenic sarcoma, fibrosarcoma, malignant fibrous histiocytoma, angiosarcoma, and undifferentiated sarcoma. The authors recommend to continue classifying these tumors as chondrosarcomas with additional mesenchymal component or even as "dedifferentiated" chondrosarcomas but not as malignant mesenchymomas.

Extraskeletal chondromas.

1. Extraskeletal chondromas occur in three variants: (a) as multiple nodules of synovial chondromatosis within a joint, (b) as a solitary lesion in association with articulations, within or adjacent to them, and (c) as an isolated cartilagenous lesion in the soft tissues, mostly of the hands and feet. 2. There are no histological characteristics which could differentiate articular, para-articular and soft tissue chondromas among themselves. 3. The latter two groups of extraskeletal chondromas are rare and frequently exhibit areas of immature cartilage with worrisome histologic features which could mislead the pathologist to an overdiagnosis of chondrosarcoma. 4. As a general rule, no matter how worrisome the histologic appearance of an extraskeletal, well delimited cartilagenous tumor may be, metastasis have not been recorded. Local recurrences are not infrequent after inadequate surgical removal; however, the tumor can always be controlled by adequate wide re-exision or resection. 5. Two cases of extraskeletal chondromas, one para-articular in the knee and the other in the soft tissue of the arm, have been presented with an exhaustive review of the literature on the subject. 6. It is of interest to note that our para-articular chondroma represents the first case reported in the literature where computerized tomography was utilized in the diagnosis. 7. The location of a soft tissue chondroma in the upper arm is extremely rare and only one previous case has been reported in said location.

Desmoplastic fibroma of bone: report of one case and review of the literature.

A case of a primary desmoplastic fibroma of bone has been presented with a complete review of the world's literature on the subject. Our case represents the one hundred and twenty seventh case (127th) reported. The usual aggressive local growth and the classical radiological and histological characteristics are very well depicted in the case. It represents the first case of this tumor of bone reported in Puerto Rico. No recurrence is evident twenty months after wide excision and intercallary bone graft.

Cholecystitis due to Schistosoma mansoni, fact or fancy.

A case of a 50-year-old female with schistosomiasis of the gallbladder is reported. The clinical and pathological findings are presented.

Distribución de fenotipos y genotipos del sistema ABO en la población de Costa Rica / ABO phenotype and genotype distribution in the Costa Rican population

Se analizaron 1177 muestras de sangre para investigar la distribución de los factores ABO en Costa Rica. La serie de datos obtenidos, sumados a los de investigaciones previas, permitió determinar la distribución de todos los fenotipos y genotipos del sistema: A1=27.45%, Aint=2.52%, A2=77%, A3=0.03%, B=l3.20%, A1B=2.67, AintB=0.12%, A2B=0.36%, A3B=0.001% y 0=52.87% en cuanto a los fenotipos y pi = 0.1670,p2=0.0154,p3=0.0047,p4=0.0001, q = 0.0857 y r = 0.7271 en cuanto a los genes. Se resalta el alto porcentaje de Aint en este país y el efecto depresivo que el gen B ejerce sobre el A en la población de grupo AB

Distribución de fenotipos y genotipos del sistema Rh-Hr en la población de Costa Rica / Rh-Hr phenotype and genotype distribution in the Costa Rican population

Se analizó 1155 muestras de sangre, procedentes de todas las provincias de Costa Rica, para investigar la distribución de los fenotipos y genotipos del sistema Rh-Hr. Se encontró que el fenotipo más común es el R1r, seguido, en orden descendente, por R1R2, R1R1, R2r, R2R2, R05, rr y R1Rz. Se discute la aparición de fenotipos raros mencionados en esta y otras investigaciones hechas en el país. Se encontró dos clases de fenotipos D**u con un porcentaje total de 0,6 por ciento, pero no encontramos la variable C**w (Rh8) en las muestras analizadas para tal efecto. Tomando en cuenta los resultados de este estudio y otros anteriores, se concluye que en Costa Rica la distribución de los fenotipos D**um Rh1 negativos y Rh1 positivos es de 0,5 por ciento 5;5 por ciento y 94 por ciento respectivamente

Primer informe de casos de depresión alelica en la población AB de Costa Rica / First report of cases of allelic depression in AB population of Costa Rica

Se investigaron dos familias en las que se demuestra la depresión alélica que el gen B ejerce sobre el gen A. En el primer caso la hija heredó un Aint de su madre y lo expresa como A2. En el segundo caso la madre expresa como A2 un gen Aint que se manifiesta como tal cuando es heredado por su hija, quien ya no tiene la influencia del gen B

Efecto depresivo del gen B sobre el gen A en la población costarricense de grupo AB / Depressive effect of gene B over gene A in AB group of population of Costa Rica

Se analizaron 500 muestras de sangre AB para investigar la distribución de los subgrupos de A en este tipo de sangre. Se encontró un descenso de Aint B y un aumento de A2B sobre lo estadísticamente esperado. Ambas diferencias son significativas y demuestran un efecto depresivo del gen B sobre el Aint aumentando falsamente el número de A2B. No se encontraron diferencias significativas en el porcentaje de A1B o A3B como si se han encontrado en otras poblaciones. Un 7 por ciento de las sangres A2B analizadas mostraron anticuerpos anti A1