Factors Associated with Anti-Tuberculosis Medication Adverse Effects: A Case-Control Study in Lima, Peru

BACKGROUND: Long-term exposure to anti-tuberculosis medication increases risk of adverse drug reactions and toxicity. The objective of this investigation was to determine factors associated with anti-tuberculosis adverse drug reactions in Lima, Peru, with special emphasis on MDR-TB medication, HIV infection, diabetes, age and tobacco use. METHODOLOGY AND RESULTS: A case-control study was performed using information from Peruvian TB Programme. A case was defined as having reported an anti-TB adverse drug reaction during 2005-2010 with appropriate notification on clinical records. Controls were defined as not having reported a side effect, receiving anti-TB therapy during the same time that the case had appeared. Crude, and age- and sex-adjusted models were calculated using odds ratios (OR) and 95% confidence intervals (95%CI). A multivariable model was created to look for independent factors associated with side effect from anti-TB therapy. A total of 720 patients (144 cases and 576 controls) were analyzed. In our multivariable model, age, especially those over 40 years (OR = 3.93; 95%CI: 1.65-9.35), overweight/obesity (OR = 2.13; 95%CI: 1.17-3.89), anemia (OR = 2.10; IC95%: 1.13-3.92), MDR-TB medication (OR = 11.1; 95%CI: 6.29-19.6), and smoking (OR = 2.00; 95%CI: 1.03-3.87) were independently associated with adverse drug reactions. CONCLUSIONS: Old age, anemia, MDR-TB medication, overweight/obesity status, and smoking history are independent risk factors associated with anti-tuberculosis adverse drug reactions. Patients with these risk factors should be monitored during the anti-TB therapy. A comprehensive clinical history and additional medical exams, including hematocrit and HIV-ELISA, might be useful to identify these patients

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Modelling human choices: MADeM and decision‑making

Research supported by FAPESP 2015/50122-0 and DFG-GRTK 1740/2. RP and AR are also part of the Research, Innovation and Dissemination Center for Neuromathematics FAPESP grant (2013/07699-0). RP is supported by a FAPESP scholarship (2013/25667-8). ACR is partially supported by a CNPq fellowship (grant 306251/2014-0)

Comparative anatomical study of the gluteal thigh flap and the inferior gluteal artery perforator flap

A despeito da evolução nos cuidados aos pacientes acamados, as úlceras de pressão encontram-se dentre os problemas que acometem estes indivíduos com grande impacto social e econômico. A reparação através de retalhos se estabeleceu como a terapêutica de escolha nos casos de úlceras em estágios avançados. As freqüentes recidivas devem ser consideradas pelo cirurgião durante todos os momentos do tratamento, de modo a não comprometer alternativas futuras durante a sua correção. O advento dos retalhos fasciocutâneos e vascularizados por artérias perfurantes permitiu o tratamento das úlceras de pressão preservando-se a musculatura, com isto reduzindo a morbidade e a perda sanguínea. O retalho glúteo femoral se estabeleceu como opção de escolha no tratamento das úlceras da região isquiática por seu padrão vascular constante, sua reprodutibilidade e a proximidade com a região acometida. Em um período de cinco anos as recidivas destes casos induziram à realização de outras opções cirúrgicas nos pacientes acometidos. O retalho vascularizado por vasos perfurantes da artéria glútea inferior foi utilizado com sucesso nestes pacientes, levando à dúvida sobre qual deveria ser a primeira opção no tratamento da afecção. Apesar de tratarem-se de retalhos já descritos e estudados são discordantes os dados acerca das características anatômicas dos dois retalhos. Ademais, não existem estudos comparando as características da anatomia dos retalhos citados os quais permitam o estabelecimento de um algoritmo de escolha do retalho mais indicado para determinado tipo de defeito. O presente estudo avaliou as características anatômicas do retalho glúteo femoral, através de dissecções anatômicas, comparando-as com as do retalho vascularizado por vaso perfurante da artéria glútea inferior. Foram dissecadas 37 regiões glúteas e posteriores de coxa em 21 cadáveres frescos, não formolizados, com menos de 24 horas do óbito. Todos os retalhos foram avaliados segundo os seguintes parâmetros: dimensões máximas da porção cutânea do retalho que permitissem a síntese primária da área doadora, comprimento do pedículo vascular e espessura do retalho. Além disso avaliou-se o número de pedículos perfurantes presentes no retalho vascularizado por vasos perfurantes da artéria glútea inferior. A análise comparativa demonstrou que o retalho vascularizado pelo vaso perfurante da artéria glútea é mais largo porém mais curto do que o retalho glúteo femoral (p<0,001; p=0,002). O retalho glúteo femoral é menos espesso tanto em sua porção proximal quanto na distal quando comparado ao retalho vascularizado pelo vaso perfurante da artéria glútea inferior (p<0,001; p=0,029). O comprimento do pedículo vascular do retalho glúteo femoral é maior do que o do retalho vascularizado pelo vaso perfurante da artéria glútea inferior (p<0,001) bem como seu arco de rotação. As informações colhidas permitem concluir que o retalho vascularizado pelo ramo perfurante da artéria glútea inferior é mais largo e mais espesso do que o retalho glúteo femoral. As vantagens do retalho glúteo femoral são o maior comprimento do pedículo e seu maior arco de rotação. Por apresentar características mais próximas às da área a ser tratada e menor arco de rotação, sugere-se que o retalho vascularizado pelo vaso perfurante da artéria glútea inferior deve ser encarado como primeira opção no tratamento das úlceras de pressão na região isquiática. O retalho glúteo femoral deve ser reservado nos casos de recidiva ou lesões localizadas em regiões mais mediais da região perinealDespite the evolution in the care of bedridden patients, pressure ulcers remain a clinical problem that has a great social and economic impact. Flap coverage was established as the treatment of choice for ulcers in advanced stages of development. The surgeon should consider the occurrence of recurrences during all stages of treatment, thereby ensuring that future alternatives for the correction of this condition are available.The introduction of flaps not containing muscle (fasciocutaneous and perforator flaps) has allowed the preservation of muscle during the treatment of pressure ulcers, reducing morbidity and blood loss. At our hospital, the gluteal thigh flap was established as the first choice in the treatment of ulcers of the ischial region, owing to its constant vascularization, reproducibility, and proximity to the affected region. In a 5-year period, recurrence required additional surgeries in the affected patients. The inferior gluteal artery perforator flap (IGAP) was successfully used in these patients, raising doubt about the appropriate first option in the treatment of these ulcers. Although both the gluteal thigh flap and the inferior gluteal artery perforator flap are established in daily clinical practice and are widely studied, there is conflicting information about their anatomical characteristics. Furthermore, there are no studies comparing the anatomical characteristics of the 2 flaps, which would enable the establishment of an algorithm for choosing the most suitable flap for a particular type of defect. The present study evaluated the anatomical characteristics of the gluteal thigh flap, through anatomical dissections, in comparison with those of the inferior gluteal artery perforator flap. Thirty-seven gluteal and posterior femoral regions of the thigh were dissected in 21 fresh cadavers, within less than 24 hours of death. The following parameters were evaluated in all flaps: maximum dimensions of the skin island to allow primary synthesis of the donor area, length of the vascular pedicle and flap thickness. In addition, the number of perforating pedicles present in the inferior gluteal artery perforator flap was evaluated. The comparative analysis showed that the IGAP flap is wider but shorter than the gluteal femoral flap (p < 0.001, p = 0.002). The gluteal thigh flap is thinner in both the proximal and the distal portion compared with the IGAP flap (p < 0.001, p = 0.029). The vascular pedicle of the gluteal thigh flap is longer (p < 0.001) and its arc of rotation is wider than that of the inferior gluteal artery perforator flap. The information collected suggested that the inferior gluteal artery perforator flap is wider and thicker than the gluteal femoral flap. The advantages of the gluteal femoral flap are its longer pedicle and its wider arc of rotation. However, because it is closer to the area being treated, the inferior gluteal artery perforator flap should be considered the first option in the treatment of ulcers of the ischial region. The gluteal thigh flap should be reserved for cases of recurrence or lesions located in more medial regions of the perineu

Immediate conservative breast surgery reconstruction with perforator flaps: New challenges in the era of partial mastectomy reconstruction?

Introduction: Although the use of local flaps in conservative breast surgery (CBS) reconstruction is a reliable technique, little information has been available regarding outcome following the use of perforator flaps. The purpose of this study is to analyze the feasibility, surgical planning and outcome following CBS reconstruction with intercostal artery perforator (ICAP) flap. Patients/methods: Thirteen patients underwent CBS reconstructions with an ICAP flap. These flaps were raised from adjacent tissue located on the lateral and thoracic region and based on perforators originating from the costal and muscular segment of the intercostal vessels. The technique was indicated in patients with small/moderate volume breasts. Results: Mean time of follow-up was 32 months. Flap complications were evaluated and information on patient satisfaction were collected. 61.5 percent had tumors located in the lower-outer quadrants and 69.2 percent had tumors measuring 2 cm or less (T1). Complications occurred in 3 patients (23%), including wound dehiscence in 2 patients and fat necrosis in one. All cases were treated by conservative approach with a good result. No flap loss or wound infection were reported. 90 percent were either satisfied or very satisfied with their result. Conclusion: The ICAP flap is a reliable technique for immediate CBS reconstruction. The technique is advantageous because it does not require the use of muscle transfer, with minimum donor site morbidity. Success depends on patient selection, coordinated planning with the oncological surgeon and careful intra-operative management. (C) 2011 Elsevier Ltd. All rights reserved

Reconstruções pelveperineais com uso de retalhos cutâneos baseados em vasos perfurantes: experiência clínica com 22 casos Reconstruction of pelviperineal injuries with perforator flaps: clinical experience with 22 cases

INTRODUÇÃO: As lesões pelveperineais representam grande parcela das interconsultas para o cirurgião plástico em hospitais gerais. O objetivo do presente trabalho é apresentar a experiência obtida no tratamento de pacientes com lesões perineais, sacrais e de quadril com o uso de retalhos com vasos perfurantes. MÉTODO: Foram estudados, retrospectivamente, os pacientes submetidos a avaliação pela equipe da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, nos meses de fevereiro a maio de 2009, que apresentavam feridas em região pelveperineal e no quadril. No total, 22 pacientes foram submetidos a reconstrução com retalhos cutâneos e fasciocutâneos baseados em vasos perfurantes, de acordo com os critérios de inclusão. O período de seguimento médio foi de 6 meses. RESULTADOS: A lesão pelveperineal foi úlcera por pressão em 20 (91%) casos, infecção profunda em 1 (4,5%), e hidradenite perineal em 1 (4,5%). A opção dos retalhos foi previamente estabelecida, dependendo do local da ferida: úlceras sacrais, retalho baseado nas perfurantes da artéria glútea superior em 15 (68,2%) casos; úlceras isquiáticas, retalho baseado nos vasos perfurantes da artéria glútea inferior em 3 (13,6%) casos; e úlceras trocantéricas, retalho tensor da fascia lata perfurante em 2 (9,1%) casos. Retalho fasciocutâneo inervado gluteofemoral foi a opção para a reconstrução pós-síndrome de Fournier em um paciente e após ressecção de hidradenite perineal em outro. Houve necessidade de nova sutura para fechamento primário tardio em deiscência 3% da superfície do retalho. Os resultados foram mantidos no período de seguimento avaliado. CONCLUSÕES: Os resultados obtidos no presente estudo foram satisfatórios e ficou demonstrada a utilidade de retalhos cirúrgicos sem incorporação de músculo para reconstruções pelveperineais. Essa alternativa para tratamento é menos mórbida para as áreas doadoras e preserva o tecido muscular para possível intervenção futura.INTRODUCTION: Plastic surgery consultation is commonly sought for the treatment of pelviperineal injuries in general hospitals. The objective of this study was to present the experience acquired in the treatment of perineal, sacral, and hip injuries with the use of perforator flaps. METHODS: Patients referred to the Plastic Surgery Division of the Clinical Hospital of Medicine College of Universidade de São Paulo for evaluation of pelviperineal and hip wounds from February to May 2009 were retrospectively evaluated. A total of 22 patients underwent reconstruction with skin and fasciocutaneous flaps based on the perforator vessels, according to the inclusion criteria. The average follow-up period was 6 months. RESULTS: Pelviperineal injuries consisted of pressure ulcers in 20 cases (91%), deep infection in 1 case (45%), and perineal hidradenitis in 1 case (4.5%). The choice of flap for reconstruction was dependent on the local wound: 15 cases (68.2%) of sacral ulcers were repaired with a superior gluteal artery perforator flap; 3 cases (13.6%) of ischial ulcers were repaired with an inferior gluteal artery perforator flap; and 2 cases (9.1%) of trochanteric ulcers were repaired using a tensor fascia lata perforator flap. A fasciocutaneous gluteofemoral flap was selected for reconstruction of post Fournier' syndrome in 1 patient and was used after resection of perineal hidradenitis in 1 patient. A new suture for late primary closure was necessary in 3 (13.6%) cases in which the suture line dehiscence was 3% necrosis of the flap surface. These results were maintained during the follow-up evaluation period. CONCLUSIONS: The results of the study were satisfactory, and the utility of surgical flaps without the incorporation of muscle for pelviperineal reconstruction was demonstrated. This treatment alternative decreases donor site morbidity and preserves the muscular tissue for future interventions