Comportamiento clínico de infección de vías urinarias en embarazadas atendidas en el Hospital Amistad Japón Nicaragua, Granada, 2018-2020

Las infecciones del tracto urinario permanecen entre las complicaciones médicas más comunes durante el embarazo. En Nicaragua la infección urinaria suele presentarse en el 17-20% de las embarazadas según datos del ministerio de salud. El objetivo de la presente investigación es describir el comportamiento clínico de la infección de vías urinarias en embarazadas hospitalizadas, sala de alto riesgo obstétrico, Hospital Amistad Japón Nicaragua, Granada, enero 2018- diciembre 2020. El tipo de estudio fue descriptivo, retrospectivo, de corte transversal, con un total de 186 embarazadas; muestreo no probabilístico. Entre los principales resultados encontrados se destacan: 61.8% de las embarazadas tenía la edad de 20 a 34 años, 84.9% cursaron educación primaria, 50.5% tenían unión estable y un 66.1% procedía de zona urbana. La edad gestacional más frecuente fue de 35 a 40 semanas de gestación con 33.3%, el síntoma más encontrado fue la disuria (79.0%) y el signo más común fiebre (51.6%). El tipo de infección de vías urinarias más diagnosticado fue la infección de vías urinarias con sintomatología severa (64%) utilizando mayormente esquema con antibiótico por vía intravenosa. Se recomienda la educación continua en este tema para poder realizar un diagnóstico precoz y tratamiento oportuno y trabajar por la prevención y seguimiento. Palabras clave: Comportamiento clínico, infección de vías urinarias, sintomatologí

The effect of corticosteroid versus platelet-rich plasma injection therapies for the management of lateral epicondylitis : a systematic review

Introduction: Lateral epicondylitis is a common musculoskeletal disorder of the upper limb. Corticosteroid injection has been widely used as a major mode of treatment. However, better understanding of the pathophysiology of the disease led to a major change in treating the disease, with new options including platelet-rich plasma (PRP) are currently used. Objectives/research aim: To systematically evaluate the effect of corticosteroid versus PRP injections for the treatment of LE. Hypothesis: PRP injections provide longer-term therapeutic effect and less rate of complications compared to corticosteroid injection. Level of evidence: Level 2 evidence (4 included studies are of level 1 evidence, 1 study of level 2 evidence). Design: Systematic Review (according to PRISMA guidelines). Methods: Eleven databases used to search for relevant primary studies comparing the effects of corticosteroid and PRP injections for the treatment of LE. Quality appraisal of studies performed using Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0, CASP Randomised Controlled Trial Checklist, and SIGN Methodology Checklist 2. Results: 732 papers were identified. Five randomised controlled trials (250 Patients) met the inclusion criteria. Clinical findings: Corticosteroid injections provided rapid symptomatic improvement with maximum effect at 6/8/8 weeks before symptoms recurrence, whereas PRP showed slower ongoing improvements up to 24/52/104 weeks(3 studies). Corticosteroid showed more rapid symptomatic improvement of symptoms compared to PRP up to the study end-point of 3 months (1 study). Comparable therapeutic effects of corticosteroid and PRP were observed at 6 weeks (1 study). Ultrasonographic Findings: (1) Doppler activity decreased more significantly in patients who received corticosteroid compared to PRP. (2) Reduced tendon thickness and more patients with cortical erosion noted in corticosteroid group whereas increased tendon thickness and less number of patients with common extensor tendon tears noted in PRP group. (3) Fewer patients reported Probe-induced tenderness and oedema in the common extensor tendon in both corticosteroid and PRP groups (2 studies). Conclusion: Corticosteroid injections provide rapid therapeutic effect in the short-term with recurrence of symptoms afterwards, compared to the relatively slower but longer-term effect of platelet-rich plasma

Rare predicted loss-of-function variants of type I IFN immunity genes are associated with life-threatening COVID-19

Background: We previously reported that impaired type I IFN activity, due to inborn errors of TLR3- and TLR7-dependent type I interferon (IFN) immunity or to autoantibodies against type I IFN, account for 15–20% of cases of life-threatening COVID-19 in unvaccinated patients. Therefore, the determinants of life-threatening COVID-19 remain to be identified in ~ 80% of cases. Methods: We report here a genome-wide rare variant burden association analysis in 3269 unvaccinated patients with life-threatening COVID-19, and 1373 unvaccinated SARS-CoV-2-infected individuals without pneumonia. Among the 928 patients tested for autoantibodies against type I IFN, a quarter (234) were positive and were excluded. Results: No gene reached genome-wide significance. Under a recessive model, the most significant gene with at-risk variants was TLR7, with an OR of 27.68 (95%CI 1.5–528.7, P = 1.1 × 10−4) for biochemically loss-of-function (bLOF) variants. We replicated the enrichment in rare predicted LOF (pLOF) variants at 13 influenza susceptibility loci involved in TLR3-dependent type I IFN immunity (OR = 3.70[95%CI 1.3–8.2], P = 2.1 × 10−4). This enrichment was further strengthened by (1) adding the recently reported TYK2 and TLR7 COVID-19 loci, particularly under a recessive model (OR = 19.65[95%CI 2.1–2635.4], P = 3.4 × 10−3), and (2) considering as pLOF branchpoint variants with potentially strong impacts on splicing among the 15 loci (OR = 4.40[9%CI 2.3–8.4], P = 7.7 × 10−8). Finally, the patients with pLOF/bLOF variants at these 15 loci were significantly younger (mean age [SD] = 43.3 [20.3] years) than the other patients (56.0 [17.3] years; P = 1.68 × 10−5). Conclusions: Rare variants of TLR3- and TLR7-dependent type I IFN immunity genes can underlie life-threatening COVID-19, particularly with recessive inheritance, in patients under 60 years old

Margin Positivity and Survival Outcomes: A Review of 14,471 Patients with 1-cm to 4-cm Papillary Thyroid Carcinoma

Papillary thyroid carcinoma (PTC) comprises the majority of thyroid malignancy, but it is associated with excellent long-term survival. Highly prevalent, with increasing incidence, the optimal operative management for patients with 1- to 4-cm PTC remains unclear. This study determined factors that affect clinical outcomes, including survival, in this patient population. Patients with 1- to 4-cm PTC, who underwent thyroidectomy between 2004 and 2016, were identified in the National Cancer Database (NCDB). Factors affecting survival, including margin status, extent of resection, operative volume, and institution type, were studied. Outcomes were estimated by Kaplan-Meier and log rank tests. Cox proportional hazard and binary logistic regression analyses identified factors affecting survival as well as margin positivity. Of 14,471 patients with 1- to 4-cm PTC, 2,269 (15.7%) exhibited lymphovascular invasion, 6,925 (47.9%) had multifocality, 14,235 (98.3%) underwent total thyroidectomy, and 2,212 (15.3%) had microscopic margin positivity, which conferred lower survival (hazard ratio [HR] 1.464, p < 0.05), with 30-day and 90-day mortality of 0.1% and 0.2%, respectively. Operative volume (odds ratio [OR] 0.979, p < 0.01) and thyroid surgery at an academic center (OR 0.623, p < 0.001) were associated with lower odds of margin positivity. In patients with 1- to 4-cm PTC, margin positivity confers lower survival. Factors associated with lower rate of margin positivity are higher operative volume and referral for treatment at academic center. Because margin positivity is a modifiable risk factor, referral of patients with aggressive features of PTC to high volume academic centers may improve survival

Intraoperative parathormone monitoring to predict operative success in patients with normohormonal hyperparathyroidism

Background: It is unclear whether parathyroidectomy guided by intraoperative parathormone (PTH) monitoring is predictive of operative success in patients with normohormonal hyperparathyroidism (nhHPT), a variant of primary hyperparathyroidism (pHPT) in which patients develop clinical manifestations similar to those of pHPT. This study examined intraoperative Pill monitoring in patients undergoing parathyroidectomy for nhHPT. Methods: We performed a retrospective review of prospectively collected data from adult (age > 18 yr) patients who underwent parathyroidectomy for pHPT at 1 of 2 North American medical centres (in Calgary, Alberta, Canada, or Miami, Florida, United States) between 2007 and 2015. In patients with nhHPT, we used the criterion of an intraoperative decrease of more than 50% in PTH after abnormal gland excision. We defined operative success as continuous eucalcemia more than 6 months after parathyroidectomy. Results: Of 333 patients, 38 (11.4%) had nhHPT, with mean preoperative calcium and PTH levels of 2.7 mmol/L and 53 pg/dL, respectively. An intraoperative decrease of more than 50% in PTH level was seen in 27 patients (71.0%) with nhHPT and 265 patients (89.8%) with classic pHPT at 5 minutes (p < 0.001); the corresponding values at 20 minutes were 35 (92.1%) and 286 (96.9%). Although 5 patients (13.2%) with nhIIPT did not reach this criterion until 20 minutes, the rate of operative success was still 97.0% at long-term follow-up (mean 13 mo, range 6-67 mo). Of the 38 patients, 3 (7.9%) did not have an intraoperative decrease of more than 50% in PTH level by 20 minutes. Two of the 3 achieved operative success and remained normocalemic, and 1 developed recurrent disease at 12 months. Conclusion: Parathyroidectomy guided by intraoperative PTH monitoring accurately predicted operative success in patients with nhEIPT. Intraoperative PTIi monitoring may also help identify multiglandular disease in patients with nhHPT, using criteria similar to those in classic pHPT, with comparable operative success

Sex Differences in Papillary Thyroid Cancer

Papillary thyroid cancer (PTC) is three times more common in women than men. However, PTC in men appears to be associated with poorer outcomes than in women. This study compares the clinical presentation and pathologic features of men and women with PTC. A retrospective review of prospectively collected data for patients with PTC who underwent fine needle aspiration (FNA) of a solitary thyroid nodule and thyroidectomy at a single institution was performed. Factors including age, ultrasound features, FNA results, extent of surgical operation and final histopathology were compared between male and female patients. Descriptive statistics using chi-square and t-test statistics compared outcomes by sex. Of the 851 patients with PTC, 158 (19%) were men and 693 (81%) were women. Mean age and standard deviation (SD) of patients was 48 (± 14) years, and most were of Hispanic origin (69%). Men had a significantly higher rate of radiation exposure relative to women, respectively (8% vs. 2%, P<0.01). There were no ultrasonographic or FNA cytologic differences among sexes. Men had more aggressive pathologic features including lymphovascular invasion (LVI) (47% vs. 34%, P<0.01) and positive lymph nodes (LN) (36% vs. 27%, P<0.05) compared to women. Thyroid lobectomy with isthmusectomy was more commonly performed among men compared to women (24% vs. 13%, P<0.01). Men with PTC have higher rates of radiation exposure associated with more aggressive disease with LVI and LN involvement on final histopathology compared to women. Total thyroidectomy with possible central neck dissection should further be considered when counseling men with PTC

Risk Factors for Capsular Contracture in Alloplastic Reconstructive and Augmentation Mammaplasty: Analysis of the National Surgical Quality Improvement Program (NSQIP) Database

BACKGROUNDCapsular contracture is the most common complication of breast augmentation and reconstruction. It occurs in up to 45% of patients and is theorized to occur secondary to an immune reaction. It can lead to pain, dissatisfaction with aesthetic outcomes, and reoperation. The gold standard for management is capsulectomy. Prior similar studies are limited by narrow inclusion criteria, single-surgeon analysis, small sample size, or univariate analysis. The goal of the following study is to prospectively identify possible risk factors for capsular contracture using a national database. METHODSA retrospective review was conducted utilizing the National Surgical Quality Improvement Program (NSQIP) Database of prospectively collected data of patients undergoing periprosthetic and/or total capsulectomy for capsular contracture from 2013 to 2016. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for variables using a multivariable binary logistic regression model. RESULTSA total of 6547 patients underwent reconstructive or augmentation mammaplasty with a prosthetic implant, out of which 2543 (39%) underwent capsulectomy. Capsular contracture was more likely in older (OR: 1.10, 95% CI: 1.09-1.10, p<.001), overweight (OR: 1.12, 95% CI: 1.10-1.13, p<.001), and cancer patients (OR: 7.71, 95% CI: 2.22-28.8, p=0.001). Wound infection was associated with capsulectomy (OR: 6.69, 95% CI: 1.74-25.8, p<.001). CONCLUSIONThese identified risk factors should be comprehensively addressed with patients during the informed consent process before breast augmentation or reconstruction with implants. LEVEL OF EVIDENCE IIIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

Margin Positivity and Survival in Papillary Thyroid Microcarcinoma: A National Cancer Database Analysis

The rising incidence of thyroid cancer has been attributed to increased detection of papillary thyroid microcarcinoma (PTMC). Although some PTMCs are thought to harbor aggressive pathologic features, the clinical significance of these features remains unclear. This study examines factors associated with survival in this patient population. Adults with PTMC, defined as papillary thyroid carcinoma ≤ 1.0 cm, who underwent thyroidectomy between 2004 and 2016, were identified in the National Cancer Database. Demographic and clinical variables were analyzed. The primary aim was to identify factors associated with survival. The secondary aim was to assess the association of microscopic margins on survival and to identify factors associated with margin positivity. Overall survival was estimated using Kaplan-Meier methods and compared using log rank tests. Cox proportional hazards and binary logistic regression models identified factors associated with survival and margin positivity, respectively. Of 77,817 patients with PTMC, 13,507 met inclusion criteria; 2,649 (20%) of these patients presented with advanced features: extrathyroidal extension (n = 916, 7%), lymphovascular invasion (n = 398, 3%), lymph node involvement (n = 2,003, 15%), and distant metastasis (n = 39, <1%). Microscopic margin positivity was present in 906 patients and associated with increased risk of death (hazard ratio 1.58, 95% CI 1.04–2.41). Academic facilities (odds ratio [OR] 0.75, 95% CI 0.59–0.95) and operative volume (OR 0.98, 95% CI 0.97–0.98) were associated with decreased margin positivity. Positive margin status was significantly associated with increased risk of death for PTMC. Higher operative volume and treatment at academic centers were associated with lower rates of margin positivity and may help improve survival outcomes in PTMC patients with aggressive features. [Display omitted

Extent of regional lymph node surgery and impact on outcomes in patients with early-stage breast cancer and limited axillary disease undergoing mastectomy

Management of the axilla in patients with early-stage breast cancer (ESBC) has evolved. Recent trials support less extensive axillary surgery in patients undergoing mastectomy. We examine factors affecting regional lymph node (RLN) surgery and outcomes in patients with ESBC undergoing mastectomy. Women with clinical T1/2 N0 M0 invasive BC who underwent mastectomy with 1-2 positive nodes were selected from the National Cancer Database (2004-2015). Axillary surgery was defined by number of RLNs examined: 1-5 sentinel LN dissection (SLND), and ≥ 10 axillary LND (ALND). Binary logistic regression and survival analyses were performed to assess the association between axillary surgery and clinical characteristics, and overall survival (OS), respectively. 34,243 patients were included: 13,821 SLND (40%) and 20,422 ALND (60%). SLND significantly increased from 21% (2004) to 45% (2015) (p < .001). Independent factors associated with SLND were treatment year, non-Academic centers, geographic region, tumor histology, and postmastectomy radiotherapy (PMRT). Multivariable survival analysis showed that ALND was associated with better OS (HR 0.78, 95% CI 0.72-0.83, p < .001) relative to SLND; however, there was no difference in patients with LN micrometastases treated without RT (HR 0.87, 95% CI 0.73-1.05, p = .153) or patients receiving PMRT (HR 0.92, 95% CI 0.76-1.13, p = .433). SLND has significantly increased in patients undergoing mastectomy with limited axillary disease and is influenced by patient, tumor, and treatment factors. Survival outcomes did not differ by axillary treatment for patients with LN micrometastases treated without RT or patients who received PMRT. SLND may be considered in select patients with ESBC and limited axillary disease undergoing mastectomy

Lymph Node Sampling and Survival in Child and Adolescent Extremity Soft-Tissue Sarcoma

The significance of lymph node sampling (LNS) on disease-specific survival (DSS) of extremity soft tissue sarcomas (STS) is unknown. We investigated the effect of LNS on DSS in child and adolescent extremity STS. The Surveillance, Epidemiology, and End Results registry was queried for patients aged <20 y with extremity STS who underwent surgery. Patient demographics were collected and analyzed. A total of 1550 patients were included, with findings of 10-y DSS of 74% for all extremity STS and 49% for rhabdoymyosarcoma (RMS) (P < 0.005). LNS was associated with worse DSS in patients with extremity nonrhabdomyosacrcoma soft tissue sarcomas (79% versus 84%, P = 0.036). Conversely, LNS was associated with an improved DSS in patients with extremity RMS (64% versus 49%, P = 0.005). LNS is positively associated with an improved DSS in child and adolescent extremity RMS. Multivariate analysis found no correlation between DSS and LNS in child and adolescent extremity nonrhabdomyosarcoma soft tissue sarcomas