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Background: Mohs micrographic surgery (MMS) is used for the treatment of high-risk cutaneous squamous cell carcinoma (cSCC). MMS examines the surgical margins in real time and does not commonly examine the central component of the tumor. Objective: To determine if debulk specimens provide additional details relevant to tumor staging not gained from routine MMS. Methods: A retrospective chart review of debulk specimens taken during MMS for cSCC was performed. Dermatopathology reports were analyzed and tumors were staged using Brigham and Women’s Hospital and American Joint Committee on Cancer’s 8th edition staging systems. Results: Permanent section evaluation of debulk specimens did not result in clinically meaningful information for staging that could not be gained from MMS layers or initial biopsy analysis. Limitations: A single institution, and a small sample size of 39 tumors. Conclusions: Evaluation of debulk specimens during MMS may not always be an effective use of time or health care resources.

Purpose: Definitive intent radiation therapy (RT) for early-stage mucosa-associated lymphoid tissue (MALT) lymphoma typically includes a dose of 24 to 30 Gy. While modest, these doses may have associated toxicity. For patients with indolent B-cell lymphoma, there is increasing support for the use of ultra–low-dose RT (ULDRT) using 4 Gy in 2 fractions as part of a response-adapted approach, as high rates of complete response have been documented. This paradigm has been prospectively evaluated in the management of orbital and gastric indolent B-cell lymphomas; however, there is limited data guiding the use of ULDRT for lung MALT. Methods: We conducted a retrospective review of 20 patients at our institution with lung MALT treated with ULDRT as part of a response-adapted approach. Clinical variables including prior systemic therapy and symptoms were abstracted from the electronic health record. Responses were assessed using the revised Lugano criteria. Results: At a median follow up of 17 months following 4 Gy (IQR, 8-37 months), we observed 100% local control. Nineteen patients (95%) experienced a complete response. No patients with stage IE disease at RT (17/20; 85%) experienced distant progression. Nine patients (45%) were symptomatic prior to RT, with improvement or resolution of symptoms in 7 (7/9; 78%). One patient developed grade 2 pleuritic pain following RT, which resolved with a brief course of steroids. No other toxicities were noted. Conclusions: ULDRT, given in a response-adapted approach, is effective and well tolerated by patients with lung MALT.

Objective:. Our aim was to assess whether complications after pancreatoduodenectomy (PD) impact long-term quality of life (QoL) and functional outcomes. Background:. There is an increasing number of long-term post-PD survivors, but few studies have evaluated long-term QoL outcomes. Methods:. The EORTC QLQ-C30 and QLQ-PAN26 questionnaires were administered to patients who survived >5 years post-PD. Clinical relevance (CR) was scored as small (5–10), moderate (10–20), or large (>20). Patients were stratified based on whether they experienced a complication during the index hospitalization. Results:. Of 305 patients >5 years post-PD survivors, with valid contact information, 248 completed the questionnaires, and 231 had complication data available. Twenty-nine percent of patients experienced a complication, of which 17 (7.4%) were grade 1, 27 (11.7%) were grade 2, and 25 (10.8%) were grade 3. Global health status and functional domain scores were similar between both groups. Patients experiencing complications reported lower fatigue (21.4 vs 28.1, P < 0.05, CR small) and diarrhea (15.9 vs 23.1, P < 0.05, CR small) symptom scores when compared to patients without complications. Patients experiencing complications also reported lower pancreatic pain (38.2 vs 43.4, P < 0.05, CR small) and altered bowel habits (30.1 vs 40.7, P < 0.01, CR moderate) symptom scores. There was a lower prevalence of worrying (36.2% vs 60.5%, P < 0.05) and bloating (42.0% vs 56.2%, P < 0.05) among PD survivors with complications. Conclusions:. Post-PD complication rates were not associated with long-term global QoL or functionality, and may be associated with less severe pancreas-specific symptoms.

Background:. During the 2022 to 2023 orthopaedic surgery residency application cycle, “signaling” was added, allowing applicants to communicate strong interest to 30 programs of their choosing. This study's purpose was to evaluate signaling's impact on the 2022 to 2023 application cycle. Methods:. A cross-sectional survey was distributed to applicants who applied to a single residency program. We evaluated how many interviews the average applicant received, what proportion of interviews came from programs they had signaled, and what percentage of applicants matched at a program they had signaled. We stratified data by American Orthopaedic Association status, United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, research items, sex, and race. Results:. This survey was distributed to 611 applicants, with 124 (20.3%) responding to the survey. Ninety-five respondents (76.6%) matched. The percentage of applicant interviews that came from signaled programs was 78.7%. Ninety-one percent of matched applicants matched at a program they signaled. Sixty-three percent of matched applicants performed an away rotation at their matched programs. Forty-five percent of applicants felt that signaling incentivized reducing the programs they applied to, and applicants gave signaling a high favorability rating of 4/5. Applicants with Alpha Omega Alpha status received more interviews per application (0.18 ± 0.11 vs. 0.10 ± 0.10, p < 0.001) and more interviews from programs they did not signal (74% of interviews from signaled programs vs. 90% of interviews from signaled programs, p < 0.001). Higher Step 1 and Step 2 scores were associated with more interviews per application (Step 1: 0.16 ± 0.12 vs. 0.12 ± 0.08, p = 0.032) (Step 2: 0.16 ± 0.11 vs. 0.12 ± 0.09, p = 0.032). Conclusion:. Orthopaedic residency applicants received most of their interviews from programs that they signaled, with an overwhelming majority matching at signaled program. Alpha Omega Alpha status and high USMLE scores were associated with more interviews granted per application, regardless of signaling status. Signaling seems to be a favorable option for orthopaedic applicants. Data from future application cycles will help further evaluate signaling's impact on the orthopaedic match.

Background: Increasing evidence supports the united airway disease concept for the management of upper and lower respiratory tract diseases, particularly in patients with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). However, evidence for a combined approach in asthma and CRSwNP is scarce. Objective: In this systematic review, we focused on the role of biologics in the lung function and quality of life in patients with severe asthma and CRSwNP. Methods: We conducted a systematic search of 3 electronic databases using 2 search strategies to identify studies published from January 2010 to March 2022. Quality assessment was performed with the Critical Appraisal Skills Programme. Results: Of 1030 studies identified, 48 original studies reporting data of benralizumab (12), dupilumab (14), mepolizumab (10), omalizumab (13), and reslizumab (2) were analyzed. Primary diagnosis was mostly asthma or CRSwNP, with only 15 studies, mainly observational, performed in populations with united airway disease. In total, 18 studies reported data on quality of life (mostly 22-item Sino-Nasal Outcome Test score), 8 on lung function (mostly FEV1), and 22 on both outcomes. Significant FEV1 and 22-item Sino-Nasal Outcome Test score improvements were consistently observed after 24-week treatment, and thereafter, mostly in real-world studies that included variable proportions of patients with asthma/CRSwNP. Conclusions: The use of biologics in patients with severe asthma and CRSwNP was overall associated with significant improvements in lung function and quality of life. However, we observed a high heterogeneity of populations and outcome measurements across studies. Notwithstanding the need of larger studies, our results reinforce the joint management of asthma and CRSwNP as united airway disease in clinical practice.

We present a female patient with heart failure with reduced ejection fraction who underwent left bundle branch cardiac resynchronization therapy. Left bundle branch lead implantation was complicated with septal branch perforation causing an iatrogenic coronary fistula complicated by septal hematoma formation and development of shock. Occlusion by covered stents was successfully achieved. (Level of Difficulty: Advanced.)

Background: Respiratory multimorbidities are linked to asthma, such as allergic rhinitis (AR) with early allergic asthma and chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) with late nonallergic asthma. Objective: Our aim was to investigate the association of asthma severity and control with specific upper airway phenotypes. Method: Patients with asthma were prospectively recruited from 23 pulmonology and ear, nose, and throat clinics. Asthma severity and control, as well as upper airway comorbidities (AR and non-AR [NAR], CRSwNP, and CRS without nasal polyps [CRSsNP]) were assessed according to international consensus guidelines definitions. Results: A total of 492 asthmatic patients were included. Half of the asthmatic patients (49.6%) had associated rhinitis (37.0% had AR and 12.6% had NAR) and 36.2% had CRS (16.7% had CRSsNP and 19.5% had CRSwNP), whereas 14.2% had no sinonasal symptoms. Most cases of AR (78%) and NAR (84%) were present in patients with mild-to-moderate asthma, whereas CRSwNP was more frequent in patients with severe asthma (35% [P < .001]), mainly nonatopic asthma (44% [P < .001]). Patients with severe asthma with CRSwNP had worse asthma control, which was correlated (r = 0.249 [P = .034]) with sinus occupancy. Multiple logistic regression analysis showed that late-onset asthma, intolerance of aspirin and/or nonsteroidal anti-inflammatory drugs, and CRSwNP were independently associated with severe asthma. Conclusion: Severe asthma is associated with CRSwNP, with sinus occupancy affecting asthma control. This study has identified 2 main different upper airway treatable traits, AR and CRSwNP, which need further evaluation to improve management and control of patients with asthma.

Purpose: Purpose: Radiation therapy (RT) and the antibody-drug conjugate brentuximab vedotin (BV) are standard-of-care treatment options for patients with certain B and T-cell lymphomas; however, there are limited data exploring the safety of concurrent BV and RT (BVRT). Methods and Materials: We performed a single institutional retrospective review of 44 patients who received BVRT. Results: Twenty percent of patients (9/44) developed new grade 2 or higher (G2+) hematologic toxicity (HT) after BVRT, which was associated with radiation dose (median dose of 35 Gy in those with new G2+ HT compared with 15 Gy in those without; P < .001). Acute G2+ elevation in aspartate transaminase or alanine transaminase level was associated with administration of concurrent chemotherapy with BVRT (57% vs 21%; P = .047) but was not associated with any RT factors. Local control (LC) was achieved in 24 of 42 patients (57%) with available follow-up. Ten patients (23%) proceeded to stem cell transplant or cellular therapy after BVRT at a median of 48 days (interquartile range, 27-188 days). At last follow-up, 10 patients (23%) remained without evidence of disease. Conclusions: Our analysis demonstrates that the combination of BV and RT is well tolerated, though care should be taken during RT planning to reduce the risk of HT. This combination can be considered for patients in need of both local and systemic disease control.

Multiple sclerosis is a frequent condition where the diagnosis relies on clinical presentation, neurologic examination, cerebro spinal fluid markers, and diagnostic imaging tests; however, atypical variants of the disease can lead to misdiagnosis in some scenarios. Herein, we describe a case of a 24-year-old patient with multiple sclerosis with megacystic plaques, in which appropriate interpretation of the imaging findings lead to a proper diagnosis and treatment.

Pharmacomechanical therapy and catheter-directed thrombolysis have been shown to be very effective in the treatment of venous thromboembolism; however, there is much less data regarding inferior vena cava thrombi. Tumor thrombi pose an even greater clinical challenge as anti-coagulation and thrombolysis are not effective. We present the case of a 61-year-old male who presented with an inferior vena cava thrombus emanating from an accessory right hepatic vein, treated with aspiration thrombectomy.

Aberrant coagulation in sickle cell disease (SCD) is linked to extracellular vesicle (EV) exposure. However, there is no consensus on the contributions of small EVs (SEVs) and large EVs (LEVs) toward underlying coagulopathy or on their molecular cargo. The present observational study compared the thrombin potential of SEVs and LEVs isolated from the plasma of stable pediatric and adult SCD patients. Further, EV lipid and protein contents were analyzed to define markers consistent with activation of thrombin and markers of underlying coagulopathy. Results suggested that LEVs—but not SEVs—from pediatrics and adults similarly enhanced phosphatidylserine (PS)-dependent thrombin generation, and cell membrane procoagulant PS (18:0;20:4 and 18:0;18:1) were the most abundant lipids found in LEVs. Further, LEVs showed activated coagulation in protein pathway analyses, while SEVs demonstrated high levels of cholesterol esters and a protein pathway analysis that identified complement factors and inflammation. We suggest that thrombin potential of EVs from both stable pediatric and adult SCD patients is similarly dependent on size and show lipid and protein contents that identify underlying markers of coagulation and inflammation.

Background: Dupilumab is a treatment approved for uncontrolled moderate-to-severe atopic dermatitis (AD). Tropical and developing countries such as Colombia have characteristics that may impact the natural history of AD and access to medical treatments. In that sense, we aimed to describe the effectiveness and safety of dupilumab in adults with moderate to severe AD in a Colombian multicenter cohort. Methods: Multicenter descriptive study that included patients who started treatment between March 2018 and May 2020 in 6 centers. Disease severity was assessed using the following: Scoring Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI), Patient Oriented Eczema Measure (POEM), and Dermatology Life Quality Index (DLQI). These measurements were collected according to availability at baseline, 3–5 months, 6–12 months, and more than 12 months. Days of sick leave, hospitalizations, and AD flares before and after dupilumab treatment were reported. Adverse events (AEs) were recorded during follow-up. Results: Ninety-three patients were included, with a median age of 32 years (IQR: 24.0; 40.0) and a disease evolution time of 21 years (IQR: 16.0; 29.5). 88.2% had at least 1 allergic disease other than AD. An improvement greater than or equal to 75% EASI was observed in 41.7% of patients at 3–5 months, in 73.7% of patients at 6–12 months, and in 75.0% of patients after 12 months. For those reporting SCORAD and POEM, the median percent change ([IQR], n) from baseline in SCORAD was −67.1 ([−79.2; −54.2], n = 16), −70.5 ([−85.8; −47.9], n = 36) and −66.7 ([−77.3; −51.0], n = 13); and POEM, −58.6 ([−66.4; −55.5], n = 4), −73.0 ([−86.5; −66.7], n = 16) and −87.3 ([−93.4; −69.6], n = 8), respectively. Before initiation of dupilumab treatment, 82 (88.2%) patients reported at least 1 flare of AD in the past 12 months. During the follow-up period, 30 (32.3%) patients reported at least 1 exacerbation or flare. Twelve patients (12.9%) presented an AE and 3 (3.2%) patients discontinued dupilumab for this cause. Conclusions: Dupilumab was effective and safe for the treatment of moderate to severe AD in point-of-care settings, with results similar to randomized controlled and other real-life studies. These positive results are still maintained even though a high number of patients had short interruptions in the use of dupilumab due to administrative problems.

Immune checkpoint inhibitors (ICIs) are increasingly used in the treatment of cancer. Immune checkpoint inhibitors may cause a wide-range of autoimmune toxicities referred to as immune-related adverse events (irAEs). There is a paucity of data regarding the presentations and outcomes of patients receiving ICIs who seek care in an emergency department (ED). We performed a retrospective review of patients receiving an ICI who presented to a tertiary care ED between May 1, 2017, and April 30, 2018. Data including ED chief complaint, diagnosis, treatment, and disposition were collected along with baseline characteristics and diagnosis at the time of outpatient oncology follow-up. We report descriptive statistics summarizing the characteristics of the cohort. There were 98 ED visits identified among 67 unique patients. Immune-related adverse events were diagnosed in 16 (16.3%) cases. The most common chief complaints within the irAE group were gastrointestinal symptoms 10 (62.5%). Among the 16 confirmed irAE cases, the most common irAE diagnosed was colitis 9 (56.3%). Two (12.5%) patients with irAEs received corticosteroids during their stay in the ED, and 10 (62.5%) patients with irAEs required hospital admission. Emergency medicine providers documented consideration of an irAE in the differential diagnosis in 14.3% of all ED visits and in 43.8% of visits in which an irAE was ultimately diagnosed. Emergency providers should be familiar with ICIs given their expanding use and potential adverse effects to improve early recognition and patient outcomes in ED settings.

Background: As female genital cosmetic surgeries have significantly increased, appropriate tools to evaluate self-esteem about women's own genitalia are necessary. Aim: to translate, culturally adapt to Spanish women and to evaluate the psychometric properties of the Female Genital Self-Image Scale (FGSIS). Methods: FGSIS was forward and backward translated, culturally adapted into Spanish and its content evaluated through Delphi consensus. One item from the original scale was discarded after expert panel evaluation, developing the final Spanish scale (FGSIS-S) consisting of 6 items. Its psychometric properties were evaluated among 202 women attending gynecological consults through an online survey. The survey included socio-demographic data and FGSIS-S. Main Outcome Measure: Socio-demographic items, psychometric characteristics of the FGSIS-S (construct evaluation, internal consistency and test-retest reliability) were assessed. Results: FGSIS-S proved to relate appropriately with the proposed construct (sum-content validity index 0.9, and significant inverse correlation with women concerned about their genital appearance or considering cosmetic surgery) with a 1-factor solution on exploratory factor analysis. The test proved good internal consistency (McDonald's omega 0.86) and test-retest reliability (intraclass correlation 0.86, P < .001). In 41.1% of cases, women referred concern about their genital's self-image and in 12.4% had considered undergoing cosmetic surgery. Clinical Translation: The validated version of FGSIS-S can help both professionals and patients, and its implementation can be easily made in gynecological consults. Strengths and Limitations: The main limitation is a self-selection bias in women attending gynecological consults, who may be more worried about their gynecological/sexual health. The sample is also a relatively homogeneous Caucasian population, with medium-high educational level, coming from gynecological consults. Strengths include the large sample size and the demographic survey that permitted evaluating the performance of FGSIS-S in the context of concern about genitals or consideration of cosmetic surgery. Conclusion: FGSIS-S is an adequate scale to measure women's genital image self-perception in Spanish-speaking population of Spain.Bartolomé A, Villalaín C, Bermejo R, et al. Spanish Translation, Transcultural Adaptation, Validation and Clinical Applicability of Female Genital-Self Image Scale (FGSIS). Sex Med 2022;10:100558.

Background: A low proportion of patients with ST-elevation myocardial infarction (STEMI) in low- to middle-income countries receive reperfusion therapy. Although primary percutaneous coronary intervention (PCI) is the method of choice, a pharmacoinvasive strategy (PIs) is reasonable when primary PCI cannot be delivered on a timely basis. The aim of our study was to assess the efficacy and safety of a PIs compared with primary PCI in a real-world setting. Methods: This was a prospective registry that included patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary composite end point was the occurrence of cardiovascular death, cardiogenic shock, recurrent myocardial infarction, or congestive heart failure at 30 days according to the reperfusion strategy used. The key safety end point was major bleeding (Bleeding Academic Research Consortium [BARC] score 3-5) at 30 days. Results: We included 579 patients with STEMI, 49.7% underwent primary PCI and 50.2% received PIs. Those who received a PIs approach were more likely to present with Killip class > 1 and to have a history of diabetes but were less likely to have a previous cardiovascular disease diagnosis. No statistically significant difference was shown in the primary composite end point according to reperfusion strategy (hazard ratio for PIs, 0.76; 95% confidence interval, 0.48-1.21; P = 0.24). Major bleeding was not different among groups (hazard ratio for PIs, 0.92; 95% confidence interval, 0.45-1.86; P = 0.81). Two patients in the PIs group (0.6%) and no patients in the PCI group had intracranial bleeding (P = 0.15). Conclusions: In this prospective real-world registry, major cardiovascular outcomes and bleeding were not different among patients who underwent a PIs or primary PCI. The study suggests that a PIs is an effective and safe option for patients with STEMI when access to primary PCI is limited. Résumé: Contexte: Une faible proportion des patients qui subissent un infarctus du myocarde avec élévation du segment ST (STEMI) dans les pays à revenus faibles/intermédiaires reçoivent un traitement de reperfusion. Même si l’intervention coronarienne percutanée (ICP) primaire constitue la méthode de prédilection, une stratégie pharmaco-invasive représente une option raisonnable lorsque l’ICP primaire ne peut être réalisée dans un délai acceptable. Cette étude visait à évaluer l’efficacité et l’innocuité d’une stratégie pharmaco-invasive comparativement à une ICP primaire dans la pratique courante. Méthodologie: Cette étude consistait en une étude de registre prospective et regroupait des patients présentant un STEMI et ayant subi une reperfusion pendant les 12 heures suivant l’apparition des symptômes. Le principal critère d’évaluation regroupé correspondait à l’occurrence du décès cardiovasculaire, du choc cardiogénique, d’une récidive de l’infarctus du myocarde ou d’une insuffisance cardiaque congestive dans les 30 jours suivants, selon la stratégie de reperfusion utilisée. Le principal critère d’évaluation de l’innocuité était les hémorragies majeures (score de 3 à 5 selon le Bleeding Academic Research Consortium [BARC]) à 30 jours. Résultats: L’étude regroupait 579 patients présentant un STEMI, dont 49,7 % avaient subi une ICP primaire et 50,2 % avaient reçu une stratégie pharmaco-invasive. Les patients ayant reçu une stratégie pharmaco-invasive étaient plus susceptibles de présenter une classe de Killip > 1 et des antécédents de diabète, mais étaient moins susceptibles d’avoir déjà reçu un diagnostic de maladie cardiovasculaire. Aucune différence significative sur le plan statistique n’a été observée pour ce qui est du principal critère d’évaluation regroupé selon la stratégie de reperfusion (rapport des risques instantanés [RRI] de la stratégie pharmaco-invasive : 0,76; intervalle de confiance [IC] à 95 % : 0,48-1,21; p = 0,24). Aucune différence n’a été observée entre les groupes quant aux hémorragies majeures (RRI de la stratégie pharmaco-invasive : 0,92; IC à 95 % : 0,45-1,86; p = 0,81). Deux patients du groupe ayant reçu une stratégie pharmaco-invasive (0,6 %) ont présenté une hémorragie intracrânienne, comparativement à aucun patient du groupe ayant subi une ICP (p = 0,15). Conclusions: Selon cette étude de registre prospective en pratique courante, les résultats concernant les hémorragies et les événements cardiovasculaires majeurs n’ont pas été différents entre les patients ayant subi une ICP primaire et ceux ayant reçu une stratégie pharmaco-invasive. L’étude suggère que la stratégie pharmaco-invasive constitue une option sûre et efficace pour les patients qui présentent un STEMI, lorsque l’accès à une ICP primaire est limité.

Mitral annular calcification tends to be significant in patients of advanced age or with underlying processes such as increased mechanical stress. When severe, it can significantly affect perioperative outcomes, especially if mitral decalcification is required for success. This report describes a versatile heart-team approach to a very complex condition. (Level of Difficulty: Advanced.)

Summary: Background: The city of Manaus, Brazil, has seen two collapses of the health system due to the COVID-19 pandemic. We report anti-SARS-CoV-2 nucleocapsid IgG antibody seroconversion rates and associated risk factors in Manaus residents before the second wave of the epidemic in Brazil. Methods: A convenience sample of adult (aged ≥18 years) residents of Manaus was recruited through online and university website advertising into the DETECTCoV-19 study cohort. The current analysis of seroconversion included a subgroup of DETECTCoV-19 participants who had at least two serum sample collections separated by at least 4 weeks between Aug 19 and Oct 2, 2020 (visit 1), and Oct 19 and Nov 27, 2020 (visit 2). Those who reported (or had no data on) having a COVID-19 diagnosis before visit 1, and who were positive for anti-SARS-CoV-2 nucleocapsid IgG antibodies at visit 1 were excluded. Using an in-house ELISA, the reactivity index (RI; calculated as the optical density ratio of the sample to the negative control) for serum anti-SARS-CoV-2 nucleocapsid IgG antibodies was measured at both visits. We calculated the incidence of seroconversion (defined as RI values ≤1·5 at visit 1 and ≥1·5 at visit 2, and a ratio >2 between the visit 2 and visit 1 RI values) during the study period, as well as incidence rate ratios (IRRs) through cluster-corrected and adjusted Poisson regression models to analyse associations between seroconversion and variables related to sociodemographic characteristics, health access, comorbidities, COVID-19 exposure, protective behaviours, and symptoms. Findings: 2496 DETECTCoV-19 cohort participants returned for a follow-up visit between Oct 19 and Nov 27, 2020, of whom 204 reported having COVID-19 before the first visit and 24 had no data regarding previous disease status. 559 participants were seropositive for anti-SARS-CoV-2 nucleocapsid IgG antibodies at baseline. Of the remaining 1709 participants who were seronegative at baseline, 71 did not meet the criteria for seroconversion and were excluded from the analyses. Among the remaining 1638 participants who were seronegative at baseline, 214 showed seroconversion at visit 2. The seroconversion incidence was 13·06% (95% CI 11·52–14·79) overall and 6·78% (5·61–8·10) for symptomatic seroconversion, over a median follow-up period of 57 days (IQR 54–61). 48·1% of seroconversion events were estimated to be asymptomatic. The sample had higher proportions of affluent and higher-educated people than those reported for the Manaus city population. In the fully adjusted and corrected model, risk factors for seroconversion before visit 2 were having a COVID-19 case in the household (IRR 1·49 [95% CI 1·21–1·83]), not wearing a mask during contact with a person with COVID-19 (1·25 [1·09–1·45]), relaxation of physical distancing (1·31 [1·05–1·64]), and having flu-like symptoms (1·79 [1·23–2·59]) or a COVID-19 diagnosis (3·57 [2·27–5·63]) between the first and second visits, whereas working remotely was associated with lower incidence (0·74 [0·56–0·97]). Interpretation: An intense infection transmission period preceded the second wave of COVID-19 in Manaus. Several modifiable behaviours increased the risk of seroconversion, including non-compliance with non-pharmaceutical interventions measures such as not wearing a mask during contact, relaxation of protective measures, and non-remote working. Increased testing in high-transmission areas is needed to provide timely information about ongoing transmission and aid appropriate implementation of transmission mitigation measures. Funding: Ministry of Education, Brazil; Fundação de Amparo à Pesquisa do Estado do Amazonas; Pan American Health Organization (PAHO)/WHO.

Giant aortic aneurysms are rare entities with a high mortality, and only a few cases have been described. Spinal cord ischemia secondary to an aortic aneurysm occurs even more rarely. We present the case of a giant aneurysm of the infrarenal abdominal aorta that was initially manifested through bilateral lower limb weakness.

Adenylosuccinate lyase deficiency is a rare genetic disorder with few reported cases in the United States. Magnetic resonance imaging findings in the brain include hypomyelination and low generalized parenchymal volume. Presented here is a case in a 3-month-old male who presented with hypotonia and seizures and was subsequently diagnosed with adenylosuccinate lyase deficiency. Given the rarity of this diagnosis, findings demonstrated in this case may prompt ordering physicians to broaden their approach to genetic testing in the setting of hypomyelination. Comparison is also made to more common hypomyelinating leukodystrophies. Keywords: Adenylosuccinate lyase deficiency, Hypomyelination

This study aimed to determine if the current health-related quality of life (HRQoL) tools created for survivors of testicular cancer are collecting the highest quality of data via a two-step methodological critique of both the seminal studies that produced a survivor of testicular cancer HRQoL tool (Phase 1) and the actual tool itself (Phase 2). It is the goal of this current article to present and discuss Phase 1. A systematic review aimed to assess the methodological quality of studies conducted to create instruments used to measure survivors of testicular cancer HRQoL. Five reviewers independently assessed each study with the 20-item Appraisal Tool for Cross-Sectional Studies (AXIS). Inter-rater agreement and Fleiss’ kappa was also assessed to ensure consistency in reported scores. Assessments for the EORTC QLQ-TC 26 and CAYA-T studies were low (AXIS 52.5%; IRA 95%; κ = 0.779) and fair (AXIS 65%; IRA 80%; κ = 0.599), respectively. Critical appraisal of the scales included issues within the three core AXIS domains. Primary concerns related to sampling methodology and the lack of a qualitative component of their core conceptual development phase. Both reviewed seminal studies have significant methodological concerns that question the tools’ quality. Next steps include extensive appraisal of the psychometric properties of the EORTC QLQ TC-26 and the CAYA-T to complete the comprehensive review. Accurate and reliable data are necessary to understand survivor of testicular cancer HRQoL and assist in building the bridge of communication between health care professionals and survivors to help to improve patient outcomes.

Social inequity can have broad health impacts. The purpose of this study was to examine the effects of low income and nonadherence to health supervision visits on emergency room (ER) utilization in Eastern Brooklyn, New York. This study surveyed parents/guardians of children who received routine medical care at Brookdale ambulatory clinics from June 2017 to February 2018. Participants were asked to fill out a questionnaire on social demographics, food insecurity, and relocation. Electronic medical records (EMRs) were reviewed to retrieve numbers of missing health supervision and ER visit in past 12 months. Comorbidity was identified through EMR by International Classification of Diseases. Logistic regression analyses were used to examine the effects of nonadherence to health supervision visits on ER utilization when controlling for demographics, food insecurity, recent moving, and comorbidity. Among 268 participants, 56.0% reported their household income was less than $20,000 annually, 39.6% missed at least 1 health supervision visit, and 31.7% had at least 1 ER visit within the past 12 months. Younger age (adjusted odds ratio [aOR] = 0.92, 95% confidence interval [CI] = 0.86-0.97, P < .01), household income less than $20,000 (aOR = 1.86, 95% CI = 1.02-3.39), preexisting comorbidity (aOR = 2.36, 95% CI = 1.26-4.42), and nonadherence to health supervision visits (aOR = 5.83, 95% CI = 3.21-10.56) were associated with increased ER utilization. Nonadherence to health supervision visits is an independent risk factor and potentially modifiable. Evaluation and remediation should be pursued as a means of improving health outcomes of children in vulnerable circumstances.

Introduction: This study aimed to investigate the prevalence of acute kidney injury (AKI) following hip fracture surgery in geriatric patients and to identify predictors for development of AKI with a focus on possible preventable risk factors. Methods: In this retrospective cohort study, we reviewed electronic medical records of all patients above 65 years of age who underwent hip fracture surgery at Copenhagen University Hospital, Bispebjerg, Denmark, in 2018. Acute kidney injury was assessed according to the Kidney Disease Improving Global Outcomes guidelines. Multivariate logistic regression analyses were used to identify independent risk factors for AKI. Results: Postoperative AKI developed in 28.4% of the included patients (85/299). Acute kidney injury was associated with increased length of admission (11.3 vs 8.7 days, P < .001) and 30-day mortality (18/85 vs 16/214, P = .001). In multivariable analysis, higher age (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.08, P = .004), heart disease (OR: 1.78, 95% CI: 1.01-3.11, P = .045), and postoperative blood transfusion (OR: 1.84, 95% CI: 1.01-3.36, P = .048) were associated with AKI. Moreover, a higher postoperative C-reactive protein (199.0 ± 99.9 in patients with AKI, 161.3 ± 75.2 in patients without AKI) and lower postoperative diastolic blood pressure were observed in patients developing AKI. Discussion and Conclusion: Acute kidney injury was common following hip fracture surgery and associated with longer admissions and increased mortality. Patients developing AKI were older and showed several postoperative similarities, including higher C-reactive protein, lower postoperative diastolic pressure, and the need for blood transfusion.

Renal cell carcinoma (RCC) and prostatic adenocarcinoma (PCa), occurring as a double primary is uncommon, but well documented. However, metastatic PCa in a RCC is quite rare. We report a case of an 81-year old male chemical engineer with history of hematuria and prostatomegaly suspicious for carcinoma, who underwent left radical nephrectomy for a renal mass. Histopathology revealed RCC that harbored an undiagnosed PCa. Periureteral tumor deposit likewise showed combined metastasis of RCC and PCa. Keywords: Tumor-to-tumor metastasis, Collision tumor, Periureteral implants, Prostate adenocarcinoma, Renal cell carcinoma

Background:. Acne keloidalis nuchae is a debilitating condition mainly affecting the occipital region or nape of the neck. Surgical approaches are limited in aesthetic outcomes. Three innovative surgical approaches based on selection criteria are presented for enhanced and more predictable wound healing and posterior hairline cosmesis. Methods:. “Bat excision” and secondary intention healing are shown for 2 of 37 representative patients and confined to the area between the occipital protuberance superiorly and posterior hairline inferiorly. Lesions with ≤3 cm vertical width were required to be in the lower one-half portion of this zone. The same procedure was aided by the use of tension sutures for lesions with >3 cm vertical width area within the defined zone. It was also suitable for breaches of the 2 horizontal lines defined above but generally located in the nuchal area. Debridement of premature epithelizing granulation tissue is shown in 2 additional patients. Results:. Use of these procedures with debridement in selected patients allowed fine control over the hairline shape and resulted in narrower scars. The mean maximum sagittal width of excised lesions was 5.4 cm. Excised lesion width ≥6.5 cm was highly predictive of >2.5 cm wide scar (P = 0.001). Conclusion:. Innovative procedures based on selection criteria can extend the approach of acne keloidalis nuchae excision with secondary intention healing to better control the final hairline shape and minimize scarring.

La diabetes mellitus tipo 2 (DM2) es una enfermedad altamente prevalente, la cual ha mostrado un incremento acelerado en las últimas décadas, pues se ha duplicado el número de personas con esta enfermedad. Diversos estudios epidemiológicos revelan que el 70% de las muertes por diabetes son causadas por eventos cardiovasculares (enfermedad coronaria y accidente cerebrovascular). Recientemente se ha observado una expansión en el descubrimiento de medicamentos para el manejo de la DM2, los mismos que, para su introducción en el mercado, deben mostrar beneficios adicionales para el sistema cardiovascular. Este artículo tiene como propósito determinar el papel de los nuevos medicamentos hipoglicemiantes que actúan en el sistema de las incretinas y sus efectos en la prevención primaria de eventos cardiovasculares.

Se expone el caso de un adolescente de 14 años de edad, con síndrome de Marfan y antecedente de tres cirugías cardiovasculares previas: valvuloplastia aórtica y mitral a los cinco años y valvuloplastia aórtica y reconstrucción de la aorta torácica con tubo de pericardio bovino a sus diez años. En primer tiempo quirúrgico se realizó reemplazo valvular aórtico por válvula mecánica y valvuloplastia mitral y tricuspidea, y en segundo tiempo quirúrgico, durante la misma hospitalización, exclusión endovascular de aneurisma de aorta descendente asintomático sin complicaciones. Antes del egreso se diagnosticó una endofuga tipo II que se manejó con observación clínica. Luego de un año del procedimiento, los controles clínico y tomográfico son satisfactorios.