Treatment of Symptomatic Carotid Webs.

BACKGROUND: The present study aims to describe the clinical characteristics and treatment outcomes of patients with symptomatic carotid web treated at a single institution in South America. METHODS: Retrospective study of a single-center experience of patients with carotid webs surgically treated from September 2019 to September 2023. RESULTS: Ten patients had carotid webs, 6 (60%) were females. Median age was 54.5 years (range: 35-77 years). All patients were symptomatic. Diagnosis was made in 90% (n = 9) of the patients with either computed tomography angiography or magnetic resonance alone. One (10%) patient underwent angiography for definite diagnosis. The median interval from the first neurological event to intervention was 90 months (range: 3 days-108 months). Four (40%) patients underwent surgical treatment within 1 month from symptom onset and carotid web diagnosis, with a median of 3.5 days (range: 3-9 days). Six (60%) patients underwent delayed surgical treatment since the cause of the neurological event was uncertain, with a median of 54 months (range: 6-108 months). These 6 patients had recurrent neurological events. Three (30%) patients underwent carotid endarterectomies with polyurethane patch and 3 (30%) by eversion technique. Three (30%) patients underwent segmental resection and reanastomosis of the internal carotid artery. One underwent internal carotid artery plasty with saphenous vein. At a median follow-up of 30 months (range: 6-46 months), 1 patient persists with mild aphasia, another patient has severe aphasia and right hemiparesis, both as sequelae of their initial strokes, and another patient has suffered 3 nonischemic episodes of brief transient right hemiparesis attributed to epileptic seizures. The other 7 patients remain without new neurological events. CONCLUSIONS: Neurological events of carotid distribution deserve accurate imaging work up, keeping in mind the diagnosis of carotid web. Surgical treatment for carotid web seems effective for preventing recurrences; nevertheless, further studies are warranted to define the best management for these patients.

Active Versus Passive Drainage Systems for Subdural Hematomas: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Chronic subdural hematoma (CSDH) management involves various surgical techniques, with drainage systems playing a pivotal role. While passive drainage (PD) and active drainage (AD) are both used, their efficacy remains contentious. Some studies favor PD for lower recurrence rates, while others suggest AD superiority. A systematic review and meta-analysis were conducted to address this controversy, aiming to provide clarity on optimal drainage modalities post-CSDH evacuation. METHODS: This systematic review and meta-analysis followed preferred reporting items for systematic reviews guidelines, searching PubMed, Embase, and Web of Science until February 2024. Inclusion criteria focused on studies comparing active vs PD for subdural hematomas. Data extraction involved independent researchers, and statistical analysis was conducted using R software. The assessment of risk of bias was performed using the Risk of Bias in Non-Randomized Studies of Interventions framework and the Risk Of Bias 2 tool. RESULTS: In this meta-analysis, involving 1949 patients with AD and 1346 with PD, no significant differences were observed in recurrence rates between the active (13.6%) and passive (16.4%) drainage groups (risk ratio [RR] = 0.87; 95% CI: 0.58-1.31). Similarly, for complications, infection, hemorrhage, and mortality, no significant disparities were found between the 2 drainage modalities. Complication rates were 7.5% for active and 12.6% for PD (RR = 0.74; 95% CI: 0.36-1.52). Infection rates were available for 635 patients of the active group, counting for 2% and 2.6%, respectively (RR = 0.98; 95% CI: 0.24-4.01). Hemorrhage rates were also available for 635 patients of the active group, counting for 1.1% and 2.2%, respectively (RR = 0.44; 95% CI: 0.11-1.81). Mortality rates were 2.7% and 2.5%, respectively (RR = 0.94; 95% CI: 0.61-1.46). CONCLUSION: Our study found no significant difference between passive and AD for managing complications, recurrence, infection, hemorrhage, or mortality in CSDH cases. Further large-scale randomized trials are needed for clarity.

Impact of Elevated Serum Triglycerides on Children with Acute Recurrent or Chronic Pancreatitis from INSPPIRE-2.

OBJECTIVE: To determine if mild-moderate hypertriglyceridemia (HTG) is associated with increased development of chronic pancreatitis (CP) or pancreatitis-associated complications in children with acute recurrent or CP. STUDY DESIGN: Longitudinal data from the INternational Study group of Pediatric Pancreatitis: In search for a cuRE-2 (INSPPIRE-2) cohort of children with acute recurrent or CP (n = 559) were analyzed. Subjects were divided into normal triglycerides (<150 mg/dL; 1.7 mmol/L), any HTG (≥150 mg/dL; ≥1.7 mmol/L), mild-moderate HTG (150-499 mg/dL; 1.7-5.6 mmol/L), moderate HTG (500-999 mg/dL; 5.6-11.3 mmol/L), and severe HTG groups (≥1000 mg/dL; ≥11.3 mmol/L), based on highest serum triglyceride value. Laboratory, imaging, pancreatitis and hospital events, complications, and quality of life data were analyzed. RESULTS: In children with acute recurrent or CP and HTG, there was no increase in the number of pancreatitis attacks per person-years, nor an increase in CP prevalence. However, HTG severity was associated with increased pancreatic inflammation, pancreatic cysts, pain, hospital days, number of hospitalizations, intensive care, and missed school days. CONCLUSIONS: Mild-moderate HTG in children with acute recurrent or CP was not associated with increased pancreatitis frequency, nor increased development of CP, but was associated with increased pancreatitis complications and disease burden. As a treatable condition, treatment of mild-moderate HTG may be considered to reduce pancreatitis-associated complications and medical burden in children with acute recurrent or CP.

Ablation of Atrioventricular Nodal Reentrant Tachycardia with Focal Cryoablation, Compared with Radiofrequency Ablation: Single-Center Experience. / Ablação de Taquicardia Reentrante Nodal Atrioventricular com Crioablação Focal, Comparada com Ablação por Radiofrequência: Experiência em Centro Único.

BACKGROUND: The ablation of atrioventricular nodal reentrant tachycardia (AVNRT) with cryoablation is an alternative to radiofrequency (RF) ablation in patients due to the low risk of total atrioventricular block. An increase in early-late recurrences after cryoablation is reported as an important disadvantage. OBJECTIVES: In this study, we aimed to compare the acute procedural success and the long-term recurrence rates of patients, with AVNRT who underwent methods. METHODS: 73 patients with AVNRT were included in the study: 32 with cryoablation and 41 with RF ablation. There was no statistically significant difference between acute procedural success in methods. The ablation procedure was performed by an operator experienced in arrhythmology. The choice of RF or cryoablation was made in the electrophysiology laboratory based on the material already available during the procedure. After the procedure, the patients were evaluated every 3 months for 2 years in polyclinic control. The significance level adopted in the statistical analysis was 5%. RESULTS: The 2 groups of patients were homogeneous. The fluoroscopy time (p<0.001) was shorter, but atrium-his (p=0.004) and his-ventricular (p=0.015) times were longer in the cryoablation group. There was no significant difference, in terms of acute procedural success, post-procedure jump without a single echo, and presence of echo and jump. CONCLUSIONS: Cryoablation requires less fluoroscopy time and is a safe non-inferior alternative to RF ablation in patients with AVNRT. The risk of AV block is a significant problem with the use of RF energy, making it less suitable for use in young and physically active patients.

FUNDAMENTO: A ablação da taquicardia por reentrada nodal atrioventricular (TRNAV) com crioablação é uma alternativa à ablação por radiofrequência (RF) em pacientes devido ao baixo risco de bloqueio atrioventricular total. Um aumento nas recorrências precoces e tardias após a crioablação é relatado como uma desvantagem importante. OBJETIVOS: Neste estudo, objetivamos comparar o sucesso do procedimento agudo e as taxas de recorrência em longo prazo de pacientes com TRNAV submetidos a métodos. MÉTODOS: Foram incluídos no estudo 73 pacientes com TRNAV: 32 com crioablação e 41 com ablação por RF. Não houve diferença estatisticamente significativa entre o sucesso agudo do procedimento nos métodos. O procedimento de ablação foi realizado por operador com experiência em arritmologia. A escolha entre RF ou crioablação foi feita no laboratório de eletrofisiologia com base no material já disponível durante o procedimento. Após o procedimento, os pacientes foram avaliados a cada 3 meses durante 2 anos em controle policlínico. O nível de significância adotado na análise estatística foi de 5%. RESULTADOS: Os dois grupos de pacientes foram homogêneos. O tempo de fluoroscopia (p<0,001) foi menor, mas os tempos his-átrio (p=0,004) e his-ventricular (p=0,015) foram maiores no grupo crioablação. Não houve diferença significativa em termos de sucesso agudo do procedimento, salto pós-procedimento sem eco único e presença de eco e salto. CONCLUSÕES: A crioablação requer menos tempo de fluoroscopia e é uma alternativa segura e não inferior à ablação por RF em pacientes com TRNAV. O risco de bloqueio AV é um problema significativo com o uso de energia de RF, tornando-o menos adequado para uso em pacientes jovens e fisicamente ativos.

[Recurrence of post-kidney transplant glomerulonephritis: clinicopathological characteristics]. / Recurrencia de glomerulonefritis postrasplante renal: características clínico-patológicas.

INTRODUCTION: Glomerulonephritis (GN) is one of the main causes of end-stage renal disease worldwide and therefore a frequent cause of kidney transplantation, with the possibility of recurrence of GN (Recurrent Glomerulonephritis [GNR]) in the transplanted kidney. The purpose of this study was to identify the clinic and pathological characteristics of GNR in a population of transplant patients. MATERIALS AND METHODS: A descriptive, retrospective study was carried out in 109 patients in whom GNR was documented in the transplanted kidney demonstrated by biopsy during the period between 1998-2021. RESULTS: Of 109 patients, the most frequent GNR was GNIgA, in 38.5% (42), followed by FSGS with 31.2% (34); These same entities were the ones that presented the greatest graft dysfunction, with 50% (21) and 26.2% (11) respectively. The ranges of proteinuria indicated by the biopsy were 31.2% (34) with a range of 500 to 3500mg/24h and 34.9% (38) with proteinuria >3500mg/24h. In relation to the time elapsed between the transplant and the diagnosis of GNR, 33% (36) of the cases were >5 years, followed by 1 to 5 years in 26.6% (29). Recurrence in patients with GNIgA occurred mostly after 5 years post-transplant with 45.2% (19) and for FSGS it was between 1 and 6 months. CONCLUSION: We found a general frequency of GNR presentation similar to those reported by other centers where biopsies are performed for clinical indication, finding that the GN that recurred most frequently are GNIgA and FSGS.

Fecal microbiota transplantation through colonoscopy in the treatment of recurrent Clostridioides difficile: Experience at a university center.

INTRODUCTION: The majority of cases of Clostridioides difficile infection (CDI) respond to antibiotic treatment. Fecal microbiota transplantation (FMT) has been accepted as an effective treatment in cases of recurrent CDI. AIM: Our aim was to describe the clinical results of FMT performed for the treatment of recurrent CDI. MATERIAL AND METHODS: The study was conducted on patients with recurrent CDI treated with FMT through colonoscopy, within the time frame of January 2021 and December 2023. Demographic and clinical data were collected, including pre-FMT treatment data, the FMT success rate, and clinical progression during follow-up. Telephone surveys were carried out to evaluate satisfaction. RESULTS: Thirteen patients with a mean age of 55 years underwent FMT (including 7 patients above 65 years of age and one pregnant woman). Patients presented with a median of 3 previous episodes of CDI (range 2-4). The median time interval from first episode of CDI to FMT was 4 months (range 3-10). The effectiveness of a single FMT session was 100%. During post-FMT follow-up (median of 11 months, range 3-32), 3 patients have presented with a new CDI episode, and a successful second FMT was performed on 2 of them. No adverse events were registered, and all patients had a positive perception of FMT. CONCLUSIONS: In the present study, despite its small size, FMT through colonoscopy was shown to be a safe, effective, and lasting therapy in cases of recurrent CDI, concurring with results from larger studies.

Analysis of reported cases of repeated violence in Espírito Santo.

OBJECTIVES: Identify the frequency of recurrent violence in cases reported in Espírito Santo and the associated factors. METHODS: Cross-sectional study. Which included data on violence in Espírito Santo from 2011 to 2018, from the Notifiable Diseases Information System, and, Statistical analyzes were performed using the chi-square test and Poisson regression. RESULTS: 54.2% (N:14.966) of reported cases of violence are repeated, and higher prevalences were associated with female sex (PR:1.54), child (PR: 1.29) or elderly victims (PR: 1.25), the presence of disabilities/disorders (PR:1.42) and occurrence in urban/peri-urban areas (PR: 1.10). Furthermore, there is a greater frequency of injuries caused by a single aggressor (PR: 1.20), man (PR: 1.28), aged 25 or over (PR: 1.09), known to the victim (PR: 2.81) and at home (PR: 1.69). CONCLUSION: The reported cases of violence showed a high frequency of recurrence, and were associated with the studied characteristics of the victim, the aggressor and the event.

Effectiveness of congenital myelodysplastic clubfoot treatment by the Ponseti method-Systematic review.

In myelomeningocele children, the incidence of equinocavovarus feet, considering all foot deformities, is 25-36%. Treatment options consist of extensive surgeries resulting in rigid feet with better alignment. Ponseti method expanded its indications since the early 2000s, including myelodysplastic feet. However, the literature on success, recurrence, and complication rates remains sparse. Therefore, a systematic review was performed in Pubmed, Scopus, Embase, Lilacs, and Web of Science databases on October 28, 2020 and July 11, 2023. Normality and sample proportion analysis with 95% confidence intervals were estimated. Risks of bias and the quality of studies were also evaluated. Success, recurrence, and complication rates were evaluated and analyzed. Eight case series were identified with 101 patients (176 feet). According to this model, the initial success rate was 93% (95% CI = 0.88-0.96) with I2 = 0%, and the final success was 63% (at 4.9 years of follow-up). Recurrence rate was 62% (95% CI = 50-72), and complication rate was 29% (95% CI = 22-38). Ponseti method for myelodysplastic clubfoot is effective (93% of initial correction). However, there are high complication and recurrence rates, and longer follow-up is needed to identify recurrences and urge for early intervention. Foot abduction brace should be used to avoid recurrences.

Blinatumomab en pacientes pediátricos con leucemia linfoblástica aguda de precursores de células B recidivante o refractaria / Blinatumomab in pediatric patients with relapsed or refractory B-cell precursor acute lymphoblastic leukemia

INTRODUCCIÓN: Cuadro clínico: La leucemia linfoblástica aguda (LLA) de precursores de células B recidivante o refractaria en pacientes pediátricos se manifiesta con síntomas como fatiga, fiebre persistente, pérdida de peso, infecciones recurrentes, dolor óseo, ganglios linfáticos inflamados y sangrado fácil. Los análisis de sangre pueden revelar recuentos anormales de glóbulos blancos y blastos inmaduros en la sangre periférica. La biopsia de médula ósea confirma el diagnóstico, mostrando infiltración de células leucémicas. El tratamiento implica quimioterapia intensiva, terapia dirigida y posiblemente trasplante de médula ósea. Tecnología sanitária: Blinatumomab es un anticuerpo monoclonal biespecífico que actúa como puente entre células T y células cancerosas, específicamente en la LLA. Une las células T a las células B cancerosas, activando las células T para que destruyan selectivamente a las células B malignas que expresan el antígeno CD19. Este mecanismo estimula la respuesta inmunitaria antitumoral y promueve la lisis de las células cancerosas. Blinatumomab está aprobada por la Dirección General de Medicamentos, Insumos y Drogas (DIGEMID) del Perú para el tratamiento de la LLA de precursores de células B (LLA-B) recidivante o refractaria en adultos y niños. Justificación de la evaluación: Este informe de evaluación de tecnología sanitaria con evaluación multicriterio (ETS-EMC) se realizó a solicitud del Comité Farmacoterapéutico (CFT) del Hospital Nacional Guillermo Almenara Irigoyen (HNGAI) ­ Red Prestacional Almenara de EsSalud, en el marco de la Décimo Quinta disposición complementaria final del reglamento de la Ley N° 31336, Ley Nacional de Cáncer aprobado mediante Decreto Supremo N.º 004-2022-SA. OBJETIVOS: Identificar, evaluar y sintetizar la mejor evidencia disponible para informar los criterios de carga de enfermedad, necesidad clínica, efectos deseables, efectos indeseables, certeza de la evidencia, balance de efectos, nivel de innovación, equidad, recursos necesarios y costo-efectividad para la evaluación multicriterio de blinatumomab en pacientes pediátricos con leucemia linfoblástica aguda de precursores de células B recidivante o refractaria. Reportar la valoración de los criterios y la recomendación efectuada por el Grupo de Trabajo de la ETS-EMC respecto al uso de blinatumomab en pacientes pediátricos con leucemia linfoblástica aguda de precursores de células B recidivante o refractaria. METODOLOGÍA: A partir de una pregunta clínica, se realizó una ETS-EMC sobre blinatumomab considerando diez criterios: Carga de enfermedad, Necesidad clínica, Efectos deseables, Efectos indeseables, Balance de efectos, Certeza de evidencia, Nivel de innovación, Equidad, Recursos necesarios, y Costo-efectividad. Para ello se siguió la metodología desarrollada por el grupo de trabajo Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) en base al marco de la Evidencia para la Decisión (EtD). RESULTADOS: Pregunta clínica y graduación de desenlaces: La pregunta PICO validada fue la siguiente: P: Pacientes pediátricos con LLA-B recidivante o refractaria; I: Blinatumomab; C: Quimioterapia de rescate; O: Sobrevida global, Remisión completa, Sobrevida libre de recaída, Porcentaje de pacientes que recibieron un trasplante alogénico de células madre hematopoyéticas (TACH), Calidad de vida, Eventos adversos (EA) serios, Discontinuación debido a EA. La graduación de desenlaces fue la siguiente: Desenlaces críticos: Sobrevida global, Calidad de vida, EA serios; Desenlaces importantes: Porcentaje de pacientes que recibieron un TACH, Remisión completa, Sobrevida libre de recaída, Discontinuación debido a EA. Carga de enfermedad: En el Perú, la tasa de incidencia de la LLA es de 1.46 por cada 100,000 individuos por año, con aproximadamente 498 casos nuevos y 344 muertes estimadas en 2019. Asimismo, se registraron 59.96 años de vida ajustados por discapacidad (AVAD) por cada 100,000 personas. La mayoría de los casos afectan a adultos jóvenes, adolescentes y niños. En el grupo de edad menor de 20 años, la tasa de incidencia de la LLA es de 2.23 por cada 100,000 individuos por año, con alrededor de 268 casos nuevos y 170 muertes estimadas en 2019. Además, en este grupo específico, se observaron 112.60 AVAD por cada 100,000 personas. Necesidad clínica: Se identificó una GPC elaborada por la NCCN para el tratamiento de pacientes pediátricos con LLA, incluyendo la LLA-B, publicada en 2024. En la guía se recomienda que los pacientes pediátricos con múltiples recaídas (segunda o posteriores) o refractarios reciban opciones de tratamiento como quimioterapia. Los médicos especialistas señalaron que la población objetivo presenta resistencia a tratamientos previos y ha sido sometida a múltiples líneas de quimioterapia a dosis elevadas. En este sentido, han agotado todas las opciones terapéuticas convencionales. Después de una votación, todos los miembros del Grupo de Trabajo acordaron que no existe una alternativa de tratamiento disponible y, por lo tanto, existe una necesidad clínica. CONCLUSIONES: El objetivo de esta ETS-EMC fue evaluar la TS blinatumomab en pacientes pediátricos con LLA-B recidivante o refractaria, bajo 10 criterios: carga de enfermedad, necesidad clínica, efectos deseables, efectos indeseables, certeza de la evidencia, balance de efectos, nivel de innovación, equidad, recursos necesarios y costo-efectividad. La LLA afecta principalmente a adultos jóvenes, adolescentes y niños. En el Perú, en el grupo de edad menor de 20 años, la tasa de incidencia de la LLA es de 2.23 por cada 100,000 individuos por año, con alrededor de 268 casos nuevos y 170 muertes estimadas en 2019. Además, en este grupo específico, se observaron 112.60 AVAD por cada 100,000 personas. Se identificó una GPC elaborada por la NCCN para el tratamiento de pacientes pediátricos con LLA, publicada en 2024. En la guía se recomienda que los pacientes pediátricos con múltiples recaídas o refractarios reciban opciones de tratamiento como la quimioterapia. Los médicos especialistas señalaron que la población objetivo presenta resistencia a tratamientos previos y ha sido sometida a múltiples líneas de quimioterapia a dosis elevadas. En este sentido, han agotado todas las opciones terapéuticas convencionales. Esta ETS-EMC evaluó blinatumomab frente a quimioterapia de rescate en niños con LLA-B recurrente o refractaria, utilizando datos del ECA de fase 3, Estudio 20120215. Sin embargo, este estudio no investigó el régimen aprobado por la DIGEMID para esta población ni incluyó muestras representativas, al excluir casos de recaídas múltiples o resistencia al tratamiento. El estudio pivotal para la población de interés, MT103-205, de un solo brazo, por su propio diseño no permitió establecer una relación causal entre el tratamiento y los resultados observados. Al comparar los resultados de ambos estudios para blinatumomab, se observó una tasa de mortalidad y eventos adversos más baja en el Estudio 20120215, posiblemente debido al mejor pronóstico de pacientes con primera recaída. Por lo tanto, la aplicabilidad del Estudio 20120215 al contexto clínico objetivo es cuestionable, y la evidencia disponible no respalda plenamente el uso de blinatumomab en esta población. Después de la votación, la mayoría de los integrantes del Grupo de Trabajo expresaron incertidumbre respecto a la magnitud de los efectos deseables e indeseables. En cuanto al balance entre riesgos y beneficios, la mayoría consideró que era también incierto. La certeza global de la evidencia evaluada se consideró muy baja, ya que este nivel de certeza se asignó a todos los desenlaces críticos evaluados, es decir, mortalidad y EA serios. La TS fue clasificada como no innovadora porque no generaba una mejora sustancial en los desenlaces relevantes para la salud de los pacientes, basado en evidencia con certeza al menos moderada. No se identificaron estudios sobre inequidades asociadas al uso de blinatumomab en la población objetivo de esta ETS-EMC. Tras la votación, el Grupo de Trabajo mayoritariamente no pudo determinar si la terapia aumentaría o reduciría la equidad en salud. El análisis de costos, centrado exclusivamente en el precio del medicamento, muestra que el costo por paciente tratado con blinatumomab varía en un rango de 2,310,000.00 soles (para un tratamiento completo de 5 ciclos) a 924,000.00 soles (para un tratamiento esperado de 2 ciclos). Así, se consideró que el uso de blinatumomab se asociaba con costos extensos. Hasta la fecha de esta evaluación, no se ha realizado ningún estudio de costo-efectividad de blinatumomab en el tratamiento de niños con LLA-B recidivante o refractaria en nuestra región. Teniendo en cuenta lo previamente expuesto, no se recomienda el uso de blinatumomab en pacientes pediátricos con LLA-B recidivante o refractaria (recomendación en contra de la intervención basada en una certeza de evidencia muy baja).

Revascularização completa versus parcial para idosos com síndrome coronariana aguda: uma metanálise e revisão sistemática de dados randomizados e ajustados multivariáveis / Complete versus partial revascularization for elderly people with acute coronary syndrome: a meta-analysis and systematic review of randomized, multivariable-adjusted data

Introdução: Evidências de estudos randomizados apoiam a revascularização completa em vez do culpado apenas para pacientes com síndrome arterial coronariana aguda (SCA) e doenças coronarianas multiarteriais. Se estes resultados se estendem a pacientes idosos, no entanto, não foi completamente explorado. Métodos: Realizamos uma revisão sistemática e meta-análise comparando os resultados clínicos de idosos (definidos como idade >;75 anos) com SCA e DMV submetidos à intervenção coronária percutânea (ICP) completa vs. parcial. Foram pesquisados ​​PubMed, Embase e Cochrane. Calculamos razões de risco agrupadas com intervalos de confiança (IC) de 95% para preservar os dados de tempo até o evento. Resultados: Incluímos 7 estudos, dos quais 2 eram RCT e 5 eram coortes ajustadas multivariáveis, compreendendo um total de 10 147, dos quais 43,8% foram submetidos à revascularização completa. Em comparação com PCI apenas parcial, a revascularização completa foi associada a uma menor mortalidade por todas as causas (razão de risco 0,71; IC 95% 0,60-0,85; P < 0,01), mortalidade cardiovascular (razão de risco 0,64; IC 95% 0,52-0,79; P < 0,01) e infarto do miocárdio recorrente (razão de risco 0,65; IC 95% 0,50-0,85; P < 0,01). Não houve diferença significativa entre os grupos em relação ao risco de revascularizações (razão de risco 0,80; IC 95% 0,53-1,20; P = 0,28). Conclusão: Entre pacientes idosos com SCA e DAC multiarterial, a revascularização completa está associada a um menor risco de mortalidade por todas as causas, mortalidade cardiovascular e infarto do miocárdio recorrente.

Efficacy of sacubitril-valsartan vs. angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in preventing atrial fibrillation recurrence after catheter ablation: a systematic review and meta-analysis

BACKGROUND: Patients who have undergone catheter ablation for atrial fibrillation (AF) may experience recurrence of this condition. The efficacy of sacubitril-valsartan (S/V) in preventing AF recurrence compared with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) is not established. This meta-analysis aimed to establish the best therapeutic choice for preventing AF recurrence after catheter ablation. METHOD: A systematic search of the PubMed, Embase, and Cochrane databases was conducted for randomized controlled trials (RCTs) and observational studies comparing the use of S/V with ACEI/ARB in patients who underwent catheter ablation. Results are presented as mean difference (MD) with 95% confidence interval (CI). Heterogeneity was assessed with the I2 statistic, and outcomes are expressed as relative risk (RR). R software version 4.2.3 was used for the analysis. RESULTS: Three RCTs and one cohort study, comprising 642 patients with 319 patients in the S/V group and 323 in the control group, were included. Follow-up ranged from 6 to 36 months, with mean ages ranging from 58.9 to 65.8 years. A significant reduction in persistent AF occurrence was demonstrated favoring the S/V group (RR: 0.54; 95% CI: [0.41, 0.70]; p = 0.000004; I2: 80%) over the ACEI/ARB group. There was no significant difference in left ventricular ejection fraction with S/V use (MD: 1.23; 95% CI: [-0.12, 2.60]; p = 0.076; I2: 0%) compared with ACEI/ARB. The analysis also showed a significant reduction in left atrial volume index (MD: -5.33; 95% CI: [-8.76, -1.90]; p = 0.002; I2: 57%) in the S/V group compared with the ACEI/ARB group. CONCLUSION: This meta-analysis demonstrated the efficacy of S/V in reducing the incidence of AF in patients undergoing catheter ablation compared with the use of ACEI/ARB. However, more RCTs are needed for a comprehensive evaluation of its efficacy in reducing AF recurrence after catheter ablation in clinical practice.

Impact of patient's sex on groin hernia repair: A systematic review and meta-analysis.

BACKGROUND: Groin hernia repair (GHR) is a performed procedure worldwide, with approximately 20 million surgeries carried out each year. Despite being less common in females, there is a lack of research on how sex influences the outcomes of GHR. This systematic review and meta-analysis aim to assess how patient sex impacts results in GHR. METHODS: We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. We searched for studies up to October 2023 in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. The studies included focused on sex outcomes for both robotic and open GHR procedures. Data extraction and quality assessment were conducted using the Risk of Bias in Non-Randomized Studies - Of Interventions tool. Our statistical analysis was performed using the metafor package in RStudio. RESULTS: After screening a total of 3917 articles, we identified 29 studies that met our criteria, comprising a total of 1,236,694 patients. Among them, 98,641 (7.98%) patients were females. Our findings showed that females had higher rates of hernia recurrence (RR 1.28), chronic pain (RR 1.52), and surgical site infections (SSIs) (RR 1.46) compared to males. Females showed a lower tendency to undergo minimally invasive surgery (MIS) with a relative risk of 0.82 (95% CI 0.69-0.97; p = 0.02). CONCLUSION: Females tend to face higher rates of complications after GHR such as an elevated risk of chronic pain, recurrence, and surgical site infections (SSI). Moreover, they undergo fewer MIS options compared to males. These results underscore the importance of research to enhance outcomes for women undergoing GHR.

Resultados quirúrgicos de la herniorrafia inguinal en los pacientes mayores de 80 años: Revisión sistemática y metaanálisis / Surgical outcomes of inguinal herniorrhaphy in patients over 80 yearsof age: Systematic review and meta-analysis

Introducción. Los pacientes octogenarios y nonagenarios conforman un grupo etario en progresivo crecimiento. La hernia inguinal es una patología que aumenta progresivamente con la edad. Este trabajo tuvo como objetivo conocer los resultados quirúrgicos de los pacientes mayores de 80 años a quienes se les realizó herniorrafía inguinal. Métodos. De acuerdo con las guías PRISMA, se realizó una revisión sistemática de PubMed, Embase y Google Scholar. Se incluyeron estudios que reportaron la incidencia de complicaciones y mortalidad después de una herniorrafía inguinal en los pacientes octogenarios y nonagenarios. Se calculó la proporción de pacientes con complicaciones después de una herniorrafía inguinal según los datos presentados, con su respectivo intervalo de confianza del 95 %. Resultados. Catorce estudios reportaron un total de 19.290 pacientes, entre quienes se encontró una incidencia acumulada de infección del sitio operatorio de 0,5 % (IC95% 0,460 - 0,678), seroma de 8,7 % (IC95% 6,212 - 11,842), hematoma de 2,6 % (IC95% 2,397 - 2,893), dolor crónico de 2,1 % (IC95% 0,778 - 4,090) y recidiva de 1,2 % (IC95%0,425 - 2,284), para una morbilidad de 14,7 % (IC95% 9,525 - 20,833). Conclusión. Las complicaciones de la herida quirúrgica, el dolor crónico y la recidiva en los pacientes mayores de 80 años a quienes se les realiza herniorrafia inguinal son comparables con las de la población general.

Introduction. Octogenarian and nonagenarian patients constitute a progressively growing age group. Inguinal hernia is a pathology that increases with age. This study aims to understand the surgical outcomes of inguinal herniorrhaphy in patients over 80 years of age. Methods. A systematic review of PubMed, Embase, and Google Scholar was conducted following PRISMA guidelines. Studies reporting the incidence of complications and mortality after inguinal herniorrhaphy in octogenarian and nonagenarian patients were included. The proportion of patients with complications after inguinal herniorrhaphy was calculated based on the data presented, with its respective 95% confidence interval. Results. Fourteen studies reported a total of 19,290 patients, among whom a cumulative incidence of surgical site infection of 0.5 (95% CI 0.460 ­ 0.678), seroma of 8.7% (95% CI 6.212 ­ 11.842), hematoma of 2.6% (95% CI 2.397 ­ 2.893), chronic pain 2.1% (95% CI 0.778 ­ 4.090), recurrence 1.2% (95% CI 0.425 ­ 2.284), and morbidity 14.7% (95% CI 9.525 ­ 20.833) were found. Conclusion. Surgical wound complications, chronic pain, and recurrence in patients over 80 years of age undergoing inguinal herniorrhaphy are comparable to those in the general population.

[Open surgical management of recurrent pigmented villonodular synovitis: case report and literature review]. / Manejo quirúrgico abierto de la sinovitis villonodular pigmentada recurrente: reporte de caso y revisión de literatura.

INTRODUCTION: pigmented villonodular synovitis (PVNS) is a benign condition that affects the knee, leading to abnormal proliferation of the synovial membrane and the accumulation of hemosiderin in the joint cavity. Although it can be surgically treated, PVNS tends to have a high recurrence rate, potentially resulting in chronic joint damage. CASE REPORT: we present the case of a young woman who experienced localized pain in her right knee due to a recurrence of PVNS. Magnetic resonance imaging revealed multiple multilobulated cystic lesions affecting the entire joint, including the ligaments. The patient underwent open surgical resection with a favorable clinical outcome. Histopathological examinations confirmed the absence of malignancy. CONCLUSION: while arthroscopy is typically the preferred treatment for PVNS, this case highlights the tendency for recurrence associated with this approach. Open surgical resection, supported by benign histopathological findings in this case, suggests a favorable long-term prognosis.

INTRODUCCIÓN: la sinovitis villonodular pigmentada (SVNP) es una enfermedad benigna que afecta la articulación de la rodilla, que causa una proliferación anormal de la membrana sinovial y la acumulación de hemosiderina en la cavidad articular. A pesar de que es posible tratarla mediante cirugía, la SVNP tiende a tener una alta tasa de recurrencia, lo que puede resultar en daño articular crónico. REPORTE DEL CASO: se presenta el caso de una mujer joven que experimentó dolor localizado en la rodilla derecha debido a una recurrencia de SVNP. La resonancia magnética reveló múltiples lesiones quísticas multilobuladas que afectaban a toda la articulación, incluyendo los ligamentos. La paciente fue sometida a una resección quirúrgica abierta, con una evolución clínica favorable. Los exámenes histopatológicos confirmaron la ausencia de malignidad. CONCLUSIÓN: aunque la artroscopía se considera el tratamiento de elección para la SVNP, este caso ilustra la tendencia a la recurrencia asociada con este enfoque. La resección quirúrgica abierta, respaldada por los hallazgos histopatológicos benignos en este caso, sugiere un pronóstico favorable a largo plazo.

Shouldice versus Lichtenstein inguinal hernia repair: A meta-analysis of randomized controlled trials.

BACKGROUND: The Lichtenstein technique is the standard treatment for adult open inguinal hernia repair. Among the non-mesh repair techniques, Shouldice has shown the best results and is comparable to mesh repairs in selected cases. Due to the risk of chronic groin pain associated with the Lichtenstein technique, Shouldice has increased in popularity, and some surgeons have adopted it as a viable first-line option. METHODS: MEDLINE, Cochrane, Central Register of Clinical Trials, and EMBASE for randomized controlled trials (RCT) published until February 2024. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed using the Cochran Q test and I2 statistics with p-values <0.10 and I2 > 25% considered significant. Statistical analysis was performed using R Software, version 4.1.2. RESULTS: Fourteen RCTs comprising 2784 patients were included, of whom 1379 (47.5%) were submitted to the Shouldice hernia repair and 1513 (52.5%) to the Lichtenstein technique. Shouldice was associated with a significant increase in the recurrence rate (4.2% vs. 0.9%; RR 3.68; 95% CI 2.05-6.60; p < 0.001; I2 = 0%) compared with Lichtenstein. The number needed to treat (NNT) to prevent one Shouldice recurrence was 30.3. There were no significant differences between groups in chronic pain, urinary retention, bladder injury, testicular atrophy, wound infection, hematoma-seroma, or hypesthesia. CONCLUSION: The Lichtenstein technique was associated with reduced recurrence rates compared with Shouldice in patients undergoing inguinal hernia repair. However, the overall recurrence rate with the Shouldice technique was still low (4.2%), suggesting that it may be a viable option in selected patients.

Desarda versus Lichtenstein inguinal hernia repair: A meta-analysis of randomized controlled trials.

BACKGROUND: The Lichtenstein technique is the gold standard for adult open inguinal hernia repair with mesh. The Desarda technique emerged in 2001 as a novel, promising non-mesh technique that has demonstrated low recurrence and postoperative complications. METHODS: We searched MEDLINE, the Cochrane Central Register of Clinical Trials, and Embase for randomized controlled trials (RCT) published until April 2024. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed using Cochran's Q test and I2 statistics, with p-values <0.10 and I2>25% considered significant. Statistical analysis was performed using the R software, version 4.1.2. RESULTS: Eighteen RCTs comprising 1756 patients were included, of whom 861 (49%) were submitted to Desarda and 895 (51%) were submitted to Lichtenstein. Desarda was associated with lower seroma rates (OR 0.55; 95% CI 0.35-0.89; and p = 0.014), less operative time (MD -8.6 min; 95% CI -14.5 to -2.8; and p < 0.01), lower postoperative pain on day one (MD -1.3 VAS score; 95% CI -2.3 to -0.3; p < 0.01) or chronic pain (OR 0.32; 95% CI 0.12-0.88; and p = 0.028), and faster return-to-work activities (MD -2.1 days; 95% CI -3.7 to -0.6; and p < 0.01). The recurrence rate was 1.4% for Desarda versus 2.1% for Lichtenstein, with no statistical difference between techniques. CONCLUSION: In this meta-analysis, Desarda significantly decreases seroma operative time, postoperative pain on day 1, chronic pain, and return-to-work activities.

The duration of antibiotic therapy for fracture related infection does not affect recurrence but leads to increased adverse effects: a comparison among 6, 12 and 24 weeks of treatment.

PURPOSE: The optimal duration of antibiotic therapy for fracture-related infection (FRI) has not been well defined. Our aim was to assess the recurrence rate of infection in patients who underwent six, 12, or 24 weeks of antibiotic therapy following surgical treatment for FRI one year after antibiotic discontinuation. Additionally, complications were monitored. METHODS: Patients with FRI underwent surgical treatment, and antibiotic therapy was initiated. The patients were divided into groups at the 6th and 12th weeks of antibiotic therapy. The primary endpoint was the recurrence of deep or superficial infection at 90 days and one year after the end of antimicrobial therapy. RESULTS: There was no difference in the recurrence of infection 90 days or one year after stopping antibiotic therapy among patients treated for six, 12, or 24 weeks (p = 0.98 and p = 0.19, respectively). The overall recurrence rate of infection 90 days after stopping antibiotic therapy was 4.9% (8/163), and one year after discontinuation of antibiotic therapy was 9.8% (16/163). There was a statistically significant difference in the incidence of adverse effects among the three groups (chi-square; p = 0.01). Adverse effects were more common in the group treated for 24 weeks than in the groups treated for 6 weeks (z score, p = 0.017) or 12 weeks (z score, p = 0.005). CONCLUSION: Antibiotic therapy longer than 6 weeks did not reduce the recurrence of FRI after one year of follow-up. Additionally, antibiotic treatment for 24 weeks increases adverse events such as skin reactions and acute renal failure.

Clinical efficacy of radiofrequency ablation guided by high-density mapping on persistent atrial fibrillation.

Objective: The study aimed to explore the clinical efficacy of radiofrequency ablation (RFA) guided by high-density mapping on persistent atrial fibrillation (PsAF). Method: A total of 190 patients with PsAF undergoing RFA were divided into a routine group (n = 105) and a high-density mapping group (n = 85). The indicators of therapeutic efficacy were collected and compared. Results: A statistically significant difference was found in the overall rate of post-operative recurrence between the two groups (11.58% vs. 23.81%, χ2 = 5.055, p = 0.025). The effects of different treatment methods on SF-36 score varied (FSF-36 treatment = 43.142, p < 0.05), and SF-36 scores at 3, 6, and 12 months of both groups were in the same order: the high-density mapping group > the routine group. While surgery guided by high-density substrate mapping (odds ratio = 0.453, 95% confidence interval: [0.232-0.784], p < 0.001) was a protective factor for recurrence. Conclusion: For patients with PsAF, more accurate mapping is conducted on the atrial substrate using a PentaRay electrode, which further verifies that the success rate of individualized ablation strategy is like mainstream procedures, and it significantly improves the subsequent health status of patients and reduces their incidence of adverse reactions.

Objetivo: Explorar la eficacia clínica de la ablación por radiofrecuencia guiada por mapeo de alta densidad en el tratamiento de la fibrilación auricular persistente. Método: Ciento noventa pacientes con fibrilación auricular persistente que recibieron ablación por radiofrecuencia se dividieron en dos grupos: convencional (n = 105) y mapeo de alta densidad (n = 85). Se recopilaron y compararon los indicadores de eficacia. Resultados: La diferencia en la tasa total de recurrencia posoperatoria entre los dos grupos fue estadísticamente significativa (11,58% vs. 23,81%; χ2 = 5055; p = 0.025). Los efectos de los diferentes métodos de tratamiento en el puntaje SF-36 variaron (FSF-36 tratamiento = 43.142, p < 0.05), y los puntajes SF-36 a los 3, 6 y 12 meses de ambos grupos siguieron el mismo orden: grupo de mapeo de alta densidad > grupo convencional. Por su parte, la cirugía guiada por mapeo de matriz de alta densidad (OR: 0.453; IC95%: 0.232-0.784; p < 0.001) es un factor protector contra la recurrencia. Conclusión: Para los pacientes con fibrilación auricular persistente, el uso de electrodos Pentaray para mapear con mayor precisión en la matriz auricular verificó aún más que la tasa de éxito de la estrategia de ablación individualizada es similar a la de la cirugía convencional, mejorando significativamente el estado de salud posterior del paciente y reduciendo la incidencia de reacciones adversas.

Effect of urinary tract infection on the outcome of the allograft in patients with kidney transplantation.

BACKGROUND: Urinary tract infections (UTIs) are the second most common cause of graft dysfunction, accounting for significant morbidity, and are associated with poor graft and patient survival. This study aimed to assess the association between post-renal transplant UTI and graft outcomes. METHODS: We examined the effect of UTIs on graft outcomes in patients who underwent renal transplantation surgery between January 2010 and December 2022. The study population included 349 renal transplantations, of which 74 experienced 140 UTI events. Based on the number of UTI episodes, patients were categorized into three groups. RESULTS: Of the 349 recipients, 275 (74.4%) had no UTI, 47 (18.8%) had non-recurrent UTIs (NR-UTIs), and 27 (6.8%) had recurrent UTIs (R-UTIs). Kaplan-Meier survival analysis showed that post-KT UTI status was a significant factor in graft survival, death-censored graft survival, and patient survival after a follow up of 5 years (log rank, P < 0.001). R-UTIs were associated with very poor graft survival and patient survival when compared with no UTI after a follow up of 5 years (hazard ratio [HR], 1.506; 95% confidence interval [CI], 1.233-1.840; P < 0.001 & HR, 1.529; 95% CI, 1.227-1.905; P = 0.001). R-UTIs were more likely to be associated with multi-drug resistant Gram-negative organisms (Klebsiella pneumonia or Escherichia coli) with resistance to nitrofurantoin (RR, 2.753; 95% CI, 1.257-6.032; P = 0.01) and carbapenem (RR, 2.064; 95% CI, 0.988-4.314; P = 0.05). CONCLUSION: Compared to no UTI, R-UTIs were associated to worse graft and patient outcomes after a follow-up of 5 years, whereas NR-UTIs were associated with poor graft and patient outcomes in the long term.