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Robot-assisted total knee arthroplasty (rTKA) involves a learning curve for orthopedic surgeons. The aim of the present study was to assess the surgical times of rTKA procedures performed by initial stage and proficiency stage surgeons in comparison with times of conventional total knee arthroplasty (cTKA). The results reveal that the learning curve for rTKA varies considerable between surgeons, suggesting that the skill and aptitude of the individual to adapt to the robotic system play key roles in the learning process. Proficiency stage surgeons were able to reduce rTKA surgical times to levels comparable with those of conventional surgeries after performing approximately 30 to 40 robotic procedures. Ongoing research has shown promising outcomes in terms of improved clinical results and reduced complications following the application of advanced robotic technology to total knee arthroplasty.

Introduction: Sickle cell disease (SCD) is an inherited and multisystem blood disorder characterized by hemolytic anemia, vaso-occlusive crises (VOCs), progressive multiorgan damage and increased mortality. In Brazil, it is one of the most common monogenic diseases afflicting 60,000 to 100,000 individuals, however, there are sparse epidemiological data, as well as information on the utilization of public healthcare resources. Method: This was a 5-year (2016 - 2020) retrospective study conducted at one Brazilian reference center on SCD - Santa Casa de Sao Paulo, in Sao Paulo, Brazil. Results: Among a total of 100 eligible adult patients, the median age was 31.0 years old, 84% of the patients were aged between 18 and 45 years old; 59% were women and 91% presented the genotype HbSS. The number of hematologist and non-hematologist visits at the outpatient unit were 2,198 and 1,436, respectively. The number of hospital ER visits was 758, of which 51% required 864 days of hospitalization. The main cause for seeking hospital medical care was the VOCs. The numbers and ratios of VOCs were: 1 to 10 VOCs, 64%; 11 to 20, 15%, and; 21 or more, 1%. There was a statistically significant difference between the number of VOCs and hospitalizations, as well as infection. Conclusion: Results indicate the burden of SCD on Brazilian patients’ daily lives, the impact of VOCs on public healthcare resources, the importance of having a national surveillance program to improve resource utilization and clinical outcomes of patients with SCD and the urgent need for the revitalizing of the current national comprehensive SCD care programs.

Abstract The present study reports a rare case of avulsion fracture of the tibial tuberosity in an adolescent. A 14-year-old male patient sprained his left knee during a soccer match. At the first emergency-room visit, he presented pain in his left knee, 2 +/4+ edema, and inability to walk and flex the affected knee, but no neurovascular changes or signs of compartment syndrome. Radiographs revealed a physeal fracture at the left proximal tibia, classified by Ogden, Tross and Murphy, and modified by Ryu and Debenham, as type IV, and complemented by Aerts et al. as type IV-B. Immobilization was performed with a plaster cast from the inguinal to malleolar regions, followed by analgesia. The patient was operated on the next day, when open reduction and internal fixation using 4.5-mm cannulated screws were performed. The patient was discharged one day after surgery, with plaster cast immobilization and load restraint for four weeks, and bone consolidation was radiologically confirmed three months after the procedure. The patient evolved with a range of motion similar to that of the contralateral limb, no length discrepancy in the lower limbs, and no complaints after one year of follow-up.

Abstract Objective To assess the risk factors involving longer hospital stays and early postoperative complications (first 30 days after surgery) in patients undergoing total knee arthroplasty (TKA). Materials and Methods Across-sectional study was conducted with collection of data of patients who underwent TKA in a private hospital between 2015 and 2019. The following data were collected: age, gender, body mass index, and clinical comorbid-ities. We also collected intraoperative data such as the grade on the classification of the American Society of Anesthesiologists (ASA), the duration of the surgery, the length of stay, the postoperative complications, and readmission within 30 days. Statistical models were used to investigate the possible risk factors associated with longer hospital stays and postoperative complications. Results There was evidence of an increase in the length of hospital stay in older patients, with higher grades on the ASA classification or who suffered postoperative complications. For each increase in 1 year of age, we expect the length of stay to be multiplied by 1.008 (95% confidence interval [95%CI]: 1.004 to 1.012; p < 0,001). In patients who were ASA grade III, the time is expected to be multiplied by 1.297 (95%CI: 1.083 to 1.554; p = 0,005) when compared with grade-I patients. In patients who suffered postoperative complications, the time is expected to be multiplied by 1.505 (95%CI: 1.332 to 1.700; p < 0.001) compared with patients without complications. Conclusion The present study demonstrated that, in patients who underwent primary TKA, preoperative characteristics such as older age and ASA grade > III, as well as the development of postoperative complications, independently predict the increase in the length of hospital stay.

Abstract Objective To compare the level of quality of life and satisfaction after two years of total knee arthroplasties between individuals above and below 65 years of age and to identify predictor factors of poor clinical outcome and low level of satisfaction in patients undergoing arthroplasty. Methods This is a retrospective cohort with data from patients diagnosed with knee osteoarthritis submitted to primary total knee arthroplasty from 2014 to 2018 (n= 190). Clinical outcomes were assessed using the following scores: visual analog scale (VAS) of pain, EQ-5D-3L and EUROQOL-VAS (quality of life scales), patient satisfaction level, and functional scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS), collected through a questionnaire applied preoperatively, as well as 1, 3, 12 and 24 months after surgery. Results Patients < 65 years old presented significantly lower values (clinical worsening) in KOOS-pain and KOOS-symptoms. There are no differences in the principal clinical scores that assess pain, function, and quality of life after the procedure, as well as in the rate of satisfaction with the procedure, among patients < 65 years old when compared with patients ≥ 65 years old. It was also observed that patients who were not satisfied with the procedure in the 24-month evaluation presented clinical results in some analyzed scores (KOOS-pain and EQ-VAS) similar to patients who declared themselves satisfied. Conclusion Scores that assess pain, function, quality of life, as well as satisfaction rate are similar between patients < 65 years old and those ≥ 65 years old.

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We report a case of a patient with necrotizing infection of the conjunctiva and Tenon’s capsule caused by Streptococcus pyogenes, a rare and atypical ophthalmologic condition. A 50-years-old male patient with acute red-eye, purulent discharge, and pain diagnosed with post-septal cellulitis presented with a yellowish and dense membrane covering the ocular surface with necrotic Tenon’s capsule. Patient was hospitalized, and intravenous antibiotics were initiated (ceftriaxone and clindamycin). Topical antibiotics and corticosteroids were also administered, and the infection was eradicated in 2 weeks. Ancillary exams excluded rheumatologic involvement. Conjunctival culture confirmed Streptococcus pyogenes growth. Tenon’s biopsy revealed unspecific acute inflammatory necrosis. This is an uncommon condition in daily ophthalmological clinic. Literature review reported 3 cases associated with previous ocular surgery.

Resumo As evidências de que ocorrerão mudanças climáticas globais em função do aumento da concentração de gases de efeito estufa têm se apresentado cada vez mais consistentemente e aceitas pela comunidade científica internacional. O objetivo deste trabalho foi avaliar estimativas de alterações climáticas na microrregião de Guarapuava no estado do Paraná, analisando os impactos sobre a cultura do trigo, utilizando modelagem para cenários futuros e comparando com um cenário base do passado. Foram ajustados modelos de adequação matemática utilizando Análise de Múltiplos Critérios (MCA) e Processo de Hierarquia Analítica (AHP), com a finalidade de avaliar os possíveis impactos das mudanças climáticas na cultura de trigo, utilizando os cenários climáticos RCP4.5 e RCP8.5 (IPCC) para o cálculo do índice de aptidão agrícola da cultura na microrregião de Guarapuava-PR. Os resultados indicam que o fator de maior impacto para a redução do índice de aptidão agrícola do trigo nos próximos 30 anos, é a projeção de aumento da temperatura média mensal em aproximadamente 1,5 a 2 °C durante o ciclo de desenvolvimento da cultura no campo.

Abstract Purpose: To report etiological diagnosis, predisposing risk factors, therapeutic strategies and visual outcome of patients treated at the Department of Ophthalmology of Federal University of São Paulo. Methods: This is a retrospective, descriptive, and observational study from medical and laboratory records of the Department of Ophthalmology of Federal University of São Paulo, including all patients with culture proven fungal keratitis in 5 years, from October 2012 through October 2017. Results: There were 2260 fungi microbiologic test requests. Of these, 140 samples had positive cultures for fungi and sixty-six patients were followed at our clinic. Forty-five patients (68.2%) were men, and the mean age was 48.06 (±17.39) years. Fusarium spp. was the most frequently isolated fungus (32 cases; 48.5%), followed by Candida parapsilosis (12 cases; 18.2%). Thirty-four patients (51.5%) underwent intracameral injection of amphotericin B (5 µg per 0.1 ml). In 11 patients (32.3%), infection was eradicated after intracameral amphotericin B associated to topical antifungal treatment and, in 23 patients (67.7%), therapeutic keratoplasty was needed. No complication related to intracameral amphotericin B injection was observed in this series. Forty-three patients (65.1%) ended up with therapeutic keratoplasty. Three patients (4.5%) evolved to evisceration or enucleation. At the last follow-up visit, 53 patients (80.3%) had visual acuity worse than 20/200. Conclusion: Despite current antifungals drugs and distinct administration strategies, fungal keratitis remains challenging. Delayed antifungal therapy may explain poor clinical outcomes. Intracameral amphotericin B associated to topical antfungal treatment seems to be a safe and helpful alternative for non-responsive fungal keratitis. But it is important to formulate other treatment strategies, hence to improve patients’ outcomes, since most patients ended-up with significant visual impairment even after current treatment.

The pancreas has two main functions: to produce and secrete digestive enzymes (exocrine function) and to produce hormones that regulate blood glucose and splanchnic secretion (endocrine function). The endocrine and exocrine portions of the pancreas are central regulators in digestion and metabolism, with continuous crosstalk between their deeply interconnected components, which plays a role in disease. Pancreatic neoplasms, inflammation, trauma, and surgery can lead to the development of type 3c diabetes when an insult simultaneously damages both acini and islets, leading to exocrine and endocrine dysfunction. In diabetes mellitus patients, pancreatic exocrine insufficiency is highly prevalent, yet little is known about the associations between diabetes mellitus and pancreatic exocrine function. This review aims to provide an overview of the physiology of the pancreas, summarize the pathophysiology and diagnostic work-up of pancreatic exocrine insufficiency, and explore the relationships between exocrine pancreatic insufficiency and diabetes mellitus. [ABSTRACT FROM AUTHOR]

Background: Endoscopic tattooing of colorectal lesions has been performed employing several markers. The indocyanine green (ICG) that uses near infrared fluorescence technology, has been recently adopted in laparoscopic colorectal cancer surgery. This study aims to systematically review the international literature to validate the ICG in laparoscopic colorectal surgery, in order to include the ICG in the therapeutic protocol. Methods: Following AMSTAR 2 criteria, we performed a systematic review to evaluate the use of green indocyanine as a marker for preoperative endoscopic tattooing and for lymph nodes mapping. The study selection was conducted using the PubMed database from January 1989 to July 2022. Results: We identified 25 eligible studies. 13 based on fluorescent tumor localization in laparoscopic colorectal surgery using ICG while 12 of them reported the lymphatic road mapping and sentinel node identification by ICG using a near-infrared camera system. One study analyzed both topics. Conclusions: In laparoscopic colorectal cancer surgery indocyanine green can be used to localize fluorescent tumors and mapping fluorescence lymph node. The use of ICG appears to be a valid and safe technique that helps the surgeon to achieve a better oncological radicality. However, the protocols need to be clarified by further studies. [ABSTRACT FROM AUTHOR]

Coronaviruses gained public attention during the severe acute respiratory syndrome (SARS) outbreak in East Asia in 2003 and spread of Middle Eastern respiratory syndrome (MERS) in 2012. Direct human-to-human contact and droplet are the main methods of transmission. Viral stability in aerosols on different surfaces supports evidence on indirect viral acquisition from fomites through the mucous membranes of the mouth, nose, and eyes. Given the pandemic circumstances, the level of evidence in COVID-19 and ophthalmology regarding eye infection, conjunctival transmission, and viral shedding through tears is insufficient. Presently, conjunctival transmission of coronaviruses has not been confirmed and remains controversial. Considering the physiology of the lacrimal system and ocular surface, the eyes are considered an immunoprotective site, with several antiviral molecules and anti-inflammatory proteins. Nevertheless, they represent an interface with the exterior world and face daily putative aggressors. Understanding the host’s ocular surface immunological and protective environment is crucial to clarify the potential of the conjunctiva as an entry route for SARS-CoV-2 and as part of this viral infection. We will discuss hypothetical ocular surface transmission mechanisms and related counterarguments addressed to both angiotensin-converting enzyme 2 receptors found on the conjunctival and corneal epithelia and lactoferrin, lysozyme, lipocalin and secretory IgA levels in the tear film. Hopefully, we will promote better understanding of this organ in COVID-19 infection and the potential transmission route that can be helpful in setting recommendations on best practices and protective guidelines to mitigate the disease spread.

PURPOSE:Clinical pathways in total knee arthroplasty (TKA) consist of general guidelines, including several topics as early rehabilitation and antibiotic systematization, which are used to improve patient's management, decrease complication rates and enhance clinical outcomes. The primary purpose of this study was to assess whether the use of a clinical pathway for TKA can contribute to reduce LOS and healthcare costs in a private hospital, without an increase in the hospital readmission rate. We also aimed to assess whether care providers adhered to the recommendations mainly antibiotic use and physical therapy. METHODS:Retrospective cohort study of 485 patients who underwent TKA at private hospital. Patients were analyzed in two groups: Group I (GI), composed by 220 TKA patients, prior to the clinical pathway implementation, and Group 2 (GII), with 265 TKA patients post-clinical pathway. Several outcomes were analyzed: length of hospital stay, time from use of prophylactic antibiotic therapy, readmission within 30 days, physical therapy and costs associated to procedures and hospitalization rates. RESULTS:The implementation of the clinical pathway was related with the reduction of the length of hospital stay from 6.3 days to 4.9 days (p = 0.021) without increase in readmissions. The physical therapy on the first postoperative day was most frequent in GII than GI (96.2% vs 78.1%, p < 0.001). Prophylactic ATB 60 minutes prior the surgery was significantly more used in GII than GI (99.2% vs 87.4%, p < 0.001). In addition, ATB suspension within 48 hours was significantly more frequent in GII than GI (84.7% vs. 51.6%, p < 0.001). The cost procedure of TKA showed a reduction of US$1,252.00 in GII when compared with GI (p

AIM: To compare the functional and anatomic results of femtosecond laser (FSL)-assisted deep anterior lamellar keratoplasty (DALK) associated with phototherapeutic keratectomy (PTK) and FSL-assisted DALK performed using the big-bubble technique in keratoconus. METHODS: During the first phase of the study, an electron microscopy histopathology pilot study was conducted that included four unsuitable donor corneas divided into two groups: in FSL group, FSL lamellar cuts were performed on two corneas and in FSL+PTK group, PTK was performed at the stromal beds of two corneas after FSL lamellar cuts were made. During the second phase of the study, a randomized clinical trial was conducted that included two treatment groups of patients with keratoconus: group 1 (n=14 eyes) underwent FSL-assisted DALK associated with PTK and group 2 (n=12 eyes) underwent FSL-assisted DALK associated with the big-bubble technique. The main outcome measures were the postoperative visual acuity (VA) and optical coherence tomography (OCT) measurements, confocal microscopic findings, and contrast sensitivity. RESULTS: In the pilot study, histopathology showed a more regular stromal bed in the FSL+PTK group. In the clinical trial, group 1 had significantly worse best spectacle-corrected VA and contrast sensitivity (P