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With the current drawdown of military operations and attrition of experienced personnel, Military-Civilian Partnerships (MCP) will be integral to preparing forward surgical teams to deploy. This review of the literature from 1980 through 2020 describes the characteristics of these complex relationships. Each identified MCP article was evaluated for measured MCP outcomes and classified using the Evidence Level of Individual Studies (ELIS) framework. From this review, a framework was developed for describing MCP and 5 distinct MCP types were identified including the clinical Just-In-Time Training, Skills Sustainment, and Integrated MCP as well as Mentorship and Strategic focused partnerships. While the overall ELIS level of MCP outcomes data is low, this review suggests that just-in-time MCP are under-utilized and not adequate to sustain and replenish combat casualty relevant skills. Clinical experiences in trauma at regular intervals (Skills Sustainment and Integrated ) are better partnership models to prepare surgical teams for deployment. Level of evidence Literature Review, Level V.

The immune checkpoints inhibitors targeting PD-1 or PD-L1 represent a new paradigm in the cancer treatment strategy. However, some populations of patients do not benefit from these agents. The identification of predictive biomarkers appears as an essential step for the treatment pathway, to guarantee the access to an evidence-based medicine accounting for the potential toxicity profile, the cost for the healthcare system and the clinical benefit eventually provided by these new drugs. In this review, we propose, based on scientific literature and industrial communications, an overview of the current landscape of predictive biomarkers related to PD-1 or PD-L1 inhibitors efficacy, validated or under development, their evidence level, and limits accounting for identified or potential confounding factors. Our paper shows that, despite the important amount of work performed in this field, there is not yet a validated and efficient solution for the prediction of the activity and/or the toxicity of anti-PD-1 and anti-PD-L1 antibodies.

Objetivo: realizar uma revisão integrativa da literatura, focada na identificação e avaliação de estudos primários objetivando o controle tópico do sangramento em feridas tumorais. Métodos: foi feita pesquisa bibliográfica no perí­odo de dezembro de 2020 a janeiro de 2021 nas bases de dados Scopus, Cinahl, PubMed e Web of Science e usados os descritores wounds and injuries, hemorrhage, neoplasms e nursing e as palavras chaves symptom management, bleeding e therapeutics. Resultados: A amostra final foi composta por 06 estudos. Os delineamentos mais frequentes foram série de casos/relato de caso, com cinco estudos (83,3%), e um estudo de coorte (16,7%). Portanto, cinco estudos (83,3%) apresentaram ní­vel de evidência 6 (fraca) e um (16,7%), ní­vel de evidência 4 (moderada). Conclusão: recomenda-se que estudos posteriores com melhor delineamento metodológico sejam conduzidos a fim de produzir evidências mais concretas.

Introduction: The use of substances to enhance sports performance among professional and amateur athletes is increasing. Such substances may either be included in the group of dietary supplements or fall into pharmacological classes. Every substance used for this purpose is called an ergogenic agent. The number of ergogenic options available increases every day, favoring overuse and use without proper guidance. Among the dietary supplements, we highlight the use of creatine, a substance widespread in sports. Among the pharmacological groups, many drugs are used. Recently the use of sildenafil citrate by professional athletes from various predominantly aerobic sports modalities was reported in the media. Objective: To compare and demonstrate the responses caused by physical training associated with the use of creatine and sildenafil citrate in mice. Methods: A swim training protocol was applied and then an electrophysiograph was used in order to obtain parameters related to contraction intensity, the area under the curve and the percentage drop. Results: The responses obtained demonstrated the ergogenic action of creatine because it altered the parameters used for measurement. The use of sildenafil citrate did not yield satisfactory results to frame the drug as an ergogenic agent. Conclusion: Creatine has an ergogenic effect, reducing the percentage drop after 10 seconds, while sildenafil demonstrated no ergogenic potential and, interestingly, resulted in weaker responses when compared to the exercise groups. Evidence level II; Comparative prospective study . RESUMEN Introducción: El uso de sustancias con el objetivo de aumentar el rendimiento deportivo entre atletas profesionales y amateurs es creciente. Tales sustancias pueden formar parte del grupo de suplementos alimentarios o integrar clases farmacológicas. Toda sustancia empleada para ese fin es denominada agente ergogénico. El número de opciones entre los agentes ergogénicos aumenta cada día, favoreciendo así su uso excesivo y sin la debida orientación. Entre los suplementos alimentarios, se destaca el uso de creatina, sustancia muy difundida en el medio deportivo. Ya entre los grupos farmacológicos, muchas sustancias son usadas. Recientemente, fue divulgado entre los medios de comunicación el uso de citrato de sildenafil por atletas profesionales, de varias modalidades deportivas, predominantemente las aeróbicas. Objetivos: Comparar y demostrar las respuestas ocasionadas por el entrenamiento físico, asociadas al uso de creatina y citrato de sildenafil en ratones. Métodos: Se aplicó un protocolo de entrenamiento de natación y, a continuación, se usó un electrofisiógrafo con el objetivo de obtener parámetros referentes a la intensidad de contracción, al área bajo la curva y a la caída porcentual. Resultados: Las respuestas obtenidas demuestran acción ergogénica de la creatina, visto que alteraron los parámetros empleados para la medición. Ya el uso de citrato de sildenafil no presentó resultados satisfactorios para encuadrar al fármaco como agente ergogénico. Conclusión: La creatina presenta efecto ergogénico porque reduce la caída porcentual después de 10 segundos, mientras que el sildenafil no presentó potencial ergogénico y, curiosamente, demostró respuestas inferiores cuando comparado a los grupos de ejercicio. Nivel de evidencia II; Estudio prospectivo comparativo . RESUMO Introdução: O uso de substâncias com o objetivo de aumentar o rendimento esportivo entre atletas profissionais e amadores é crescente. Tais substâncias podem fazer parte do grupo de suplementos alimentares ou integrar classes farmacológicas. Toda substância empregada para esse fim é denominada de agente ergogênico. O número de opções entre os agentes ergogênicos aumenta a cada dia, favorecendo assim o uso em demasia e sem a devida orientação. Entre os suplementos alimentares, salientamos a utilização de creatina, substância muito difundida no meio esportivo. Já entre os grupos farmacológicos, muitas substâncias são utilizadas. Recentemente, foi divulgado entre os meios de comunicação o uso de citrato de sildenafila por atletas profissionais de várias modalidades esportivas, predominantemente as aeróbicas. Objetivos: Comparar e demonstrar as repostas ocasionadas pelo treinamento físico, associadas ao uso de creatina e citrato de sildenafila em camundongos. Métodos: Aplicou-se um protocolo de treinamento de natação e, a seguir, empregou-se um eletrofisiógrafo com objetivo de obter parâmetros referentes à intensidade de contração, à área sob a curva e à queda percentual. Resultados: As respostas obtidas demonstram ação ergogênica da creatina, visto que alteraram os parâmetros empregados para a mensuração. Já a utilização de citrato de sildenafila não apresentou resultados satisfatórios para enquadrar o fármaco como agente ergogênico. Conclusão: A creatina apresenta efeito ergogênico porque reduz a queda percentual após 10 segundos, já a sildenafila não apresentou potencial ergogênico e, curiosamente, demonstrou respostas inferiores quando comparado aos grupos de exercício. Nível de evidência II; Estudo prospectivo comparativo .

Introduction The purpose of this scoping review was to systematically evaluate literature addressing menstrual suppression in the military population and to identify gaps in the literature. Materials and Methods A scoping review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines was completed. Quality appraisal was conducted using the Johns Hopkins Evidence-Based Practice (EBP) Evidence Level and Quality Guide. Results Thirteen research articles and nine non-research articles were included. The themes identified were methods for menstrual suppression, barriers to menstrual suppression, and educational recommendations. Conclusions Six gaps were identified: (1) readiness, (2) single branch of service, (3) options for suppression, (4) hesitance to suppress, (5) provider practices, and (6) stagnant research. Recommendations for future research, practice, and military health policy are provided. Expanding research on menstrual suppression in U.S. military service members will enhance the health of military service members, provider practices, and military health policy to promote military readiness.

Background Due to random motion of fetuses and maternal respirations, image quality of fetal brain MRIs varies considerably. To address this issue, visual inspection of the images is performed during acquisition phase and after 3D-reconstruction, and the images are re-acquired if they are deemed to be of insufficient quality. However, this process is time-consuming and subjective. Multi-instance (MI) deep learning methods (DLMs) may perform this task automatically. Purpose To propose an MI count-based DLM (MI-CB-DLM), an MI vote-based DLM (MI-VB-DLM), and an MI feature-embedding DLM (MI-FE-DLM) for automatic assessment of 3D fetal-brain MR image quality. To quantify influence of fetal gestational age (GA) on DLM performance. Study type Retrospective. Subjects Two hundred and seventy-one MR exams from 211 fetuses (mean GA ± SD = 30.9 ± 5.5 weeks). Field strength/sequence T2 -weighted single-shot fast spin-echo acquired at 1.5 T. Assessment The T2 -weighted images were reconstructed in 3D. Then, two fetal neuroradiologists, a clinical neuroscientist, and a fetal MRI technician independently labeled the reconstructed images as 1 or 0 based on image quality (1 = high; 0 = low). These labels were fused and served as ground truth. The proposed DLMs were trained and evaluated using three repeated 10-fold cross-validations (training and validation sets of 244 and 27 scans). To quantify GA influence, this variable was included as an input of the DLMs. Statistical tests DLM performance was evaluated using precision, recall, F-score, accuracy, and AUC values. Results Precision, recall, F-score, accuracy, and AUC averaged over the three cross validations were 0.85 ± 0.01, 0.85 ± 0.01, 0.85 ± 0.01, 0.85 ± 0.01, 0.93 ± 0.01, for MI-CB-DLM (without GA); 0.75 ± 0.03, 0.75 ± 0.03, 0.75 ± 0.03, 0.75 ± 0.03, 0.81 ± 0.03, for MI-VB-DLM (without GA); 0.81 ± 0.01, 0.81 ± 0.01, 0.81 ± 0.01, 0.81 ± 0.01, 0.89 ± 0.01, for MI-FE-DLM (without GA); and 0.86 ± 0.01, 0.86 ± 0.01, 0.86 ± 0.01, 0.86 ± 0.01, 0.93 ± 0.01, for MI-CB-DLM with GA. Data conclusion MI-CB-DLM performed better than other DLMs. Including GA as an input of MI-CB-DLM improved its performance. MI-CB-DLM may potentially be used to objectively and rapidly assess fetal MR image quality. Evidence level 4 TECHNICAL EFFICACY: Stage 3.

Megaprostheses were introduced in oncological orthopedic surgery for reconstruction after bone tumor resections with good results; more recently, megaprostheses have been receiving an increasing role even in non-neoplastic hip and knee conditions like periprosthetic and very comminuted osteoporotic fractures and in treatment for resistant non-union of femur fractures. Nevertheless, literature about the use of megaprosthesis, especially in non-oncological musculoskeletal conditions, is still lacking high evidence level studies showing long-term outcomes. The purpose of this paper is carry out a review of the current megaprosthesis literature and present a multicenter study on a new prosthetic implant (“SMS multicentric study”), collecting the data on the use of a single implant (Smart Modularity System/SMS) in 11 orthopedic centers in order to obtain clinical and radiographic results.

Introduction It has been suggested that visceral adipose tissue (VAT) is associated with several non-communicable chronic diseases, but measuring it is difficult. Thus, anthropometry could be used because is easily applied in clinical practice. Objectives The present study aimed to develop and validate VAT estimation equations (Eq) in military men. Methods The sample consisted of 409 (mean age, 36.5 ± 6.7 years) military men in the Brazilian Army (BA) divided into an equation group (EG) ( n = 270; mean age, 37.0 ± 6.3 years) and a validation group (VG) ( n =139; mean age, 36.0 ± 7.2 years). Anthropometric, hemodynamic and DXA body composition evaluations ( GE iLunar ) were performed. The Student’s t test, Pearson’s correlation, and stepwise general linear regression were applied. Bland-Altman graphics were used to assess the concordance between VAT by Eq and by DXA. The level of significance was 95% ( p < 0.05). Results Age, waist circumference (WC), hip circumference and body mass index presented the main significant positive correlations with the VAT-DXA. Four Eq were created Eq1 ( r 2 = 0.793), Eq2 ( r 2 = 0.810), Eq3 ( r 2 = 0.817), and Eq 4 ( r 2 = 0.823) ( p < 0.05). No differences were observed between VAT by DXA and VAT by Eq ( p = 0.982, p = 0.970, p = 0.495 and p = 0.698). Bland-Altman analysis also presented good concordance as the bias was close to zero and was not statistically significant. Conclusion Eq2 (age*13.0 + WC*60.0 - 4975,.5) was more suitable because it is easier to apply, has a higher predictive power (81.0%), less bias (1.86) and validation yielded average VAT values close to those found in DXA. It may still be considered a valuable tool for other extensive epidemiological studies in military men in the BA and can be used in adult men. Evidence Level I: Development of diagnostic criteria on consecutive patients (with universally applied reference ‘‘gold’’ standard). RESUMO Introdução A literatura científica tem sugerido que o tecido adiposo visceral (TAV) está associado a doenças crônicas não transmissíveis, mas é difícil fazer sua mensuração. Assim, a antropometria pode ser empregada por ser de fácil aplicação na prática clínica. Objetivos Este estudo teve como objetivo desenvolver e validar equações de estimativa (Eq) do TAV em militares. Métodos A amostra consistiu em 409 (média de idade 36,5 ± 6,7 anos) militares do Exército Brasileiro (EB) divididos em Grupo equação (GE) (n = 270; média de idade 37,0 ± 6,3 anos) e Grupo validação (GV) (n = 139; média de idade 36,0 ± 7,2 anos). Foram realizadas avaliações antropométricas, hemodinâmicas e de composição corporal por DXA (GE iLunar). O teste t de Student, a correlação de Pearson e a regressão linear geral Stepwise foram aplicados. Os gráficos de Bland-Altman foram usados para avaliar a concordância entre os resultados de TAV pela Eq e por DXA. O nível de significância adotado foi de 95% (p

The main of this research is to investigate self-care orientations related to the patient’s feeding, the presence of pets, the sun protection, and the vaccines use by immunosuppressive transplant patients, as the purpose of seeking information and qualifying them regarding the degree of evidence and level of recommendation. For this, a narrative review study was conducted on the topics: feeding, domestic animals, sun protection, and vaccines. We performed the review through the selection of descriptors and searches in databases such as PubMed, as well as guidelines related to the transplant or immunosuppressive patients. The studies present a few recommendation grades and evidence level, maybe due to the ethical situation. The degree of recommendation and level of evidence were adopted according to the Oxford Center for Evidence-Based Medicine. The patient’s feeding may be based on well-sourced, sanitized, well-cooked foods. This kind of patients might prefer fresh food. As for domestic animals such as cats, dogs, and birds they are allowed under hygienic and vaccination conditions. Exotic pets such as ducks, chickens, hamsters, and reptiles they are not recommended. The use of sunscreens is recommended to prevent the development of skin cancer. For the patients transplanted, only vaccines produced by the inactivated agent are indicated. The information identifi ed has a low level of recommendation and evidence, which may be related to ethical issues. The recommendations presented, despite the low evidence level and recommendation grade, are essential for preventing complications in transplant and immunosuppressive patients, and the classifi cation of evidence adopted is of a substantial diff erence in this research.

Summary CrossFit is a form of high-intensity interval training and comparable to other high-intensity exercises. CrossFit exercises increase VO2max, strength, endurance, and improves the body composition (e. g. lean body mass). The injury risk in CrossFit is similar to that of other, comparable sports such as Olympic weightlifting, powerlifting and gymnastics and lower than that of competitive contact sports such as rugby union and rugby league. Shoulder joint, shoulder girdle and spine injuries are predominating in CrossFit and require special attention from physicians and coaches. In particular, this includes expert instruction for CrossFit beginners as well as an initial orthopedic examination before starting CrossFit training. The involvement of well-educated coaches correlates with a decreased injury rate. For this reason, it is recommended that beginners complete a special program with slow load increase and instructions of the fundamental CrossFit techniques. In CrossFit, previous injuries also increase the risk of re-injury, which is consistent with the findings of other sport-related injury studies, and should also be taken into account. Evidence Level III

BACKGROUND: Determining the compositional response of articular cartilage to dynamic joint-loading using MRI may be a more sensitive assessment of cartilage status than conventional static imaging. However, distinguishing the effects of joint-loading vs. inherent measurement variability remains difficult, as the repeatability of these quantitative methods is often not assessed or reported. PURPOSE: To assess exercise-induced changes in femoral, tibial, and patellar articular cartilage composition and compare these against measurement repeatability. STUDY TYPE: Prospective observational study. POPULATION: Phantom and 19 healthy participants. FIELD STRENGTH/SEQUENCE: 3T; 3D fat-saturated spoiled gradient recalled-echo; T1ρ - and T2 -prepared pseudosteady-state 3D fast spin echo. ASSESSMENT: The intrasessional repeatability of T1ρ and T2 relaxation mapping, with and without knee repositioning between two successive measurements, was determined in 10 knees. T1ρ and T2 relaxation mapping of nine knees was performed before and at multiple timepoints after a 5-minute repeated, joint-loading stepping activity. 3D surface models were created from patellar, femoral, and tibial articular cartilage. STATISTICAL TESTS: Repeatability was assessed using root-mean-squared-CV (RMS-CV). Using Bland-Altman analysis, thresholds defined as the smallest detectable difference (SDD) were determined from the repeatability data with knee repositioning. RESULTS: Without knee repositioning, both surface-averaged T1ρ and T2 were very repeatable on all cartilage surfaces, with RMS-CV SDD) average exercise-induced in T1ρ and T2 of femoral (-8.0% and -5.3%), lateral tibial (-6.9% and -5.9%), medial tibial (+5.8% and +2.9%), and patellar (-7.9% and +2.8%) cartilage were observed. DATA CONCLUSION: Joint-loading with a stepping activity resulted in T1ρ and T2 changes above background measurement error. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY STAGE: 1 J. MAGN. RESON. IMAGING 2020;52:1753-1764.

While the world rushed to develop treatments for COVID-19, some turned hopefully to drug repurposing (drug repositioning). However, little study has addressed issues of drug repurposing in emergency situations from a broader perspective, taking into account the social and ethical ramifications. When drug repurposing is employed in emergency situations, the fairness of resource distribution becomes an issue that requires careful ethical consideration.This paper examines the drug repurposing in emergency situations focusing on the fairness using Japanese cases. Ethical issues under these circumstances addressed by the authors include: maintaining the evidence level, integrity of clinical research ethics, and voluntary consent by original indication patients. In order to address these issues, they argue that rapid accumulation of ethically and scientifically valid evidence is required, as is obtaining information on resource quantity.

Background Cardiac MR fingerprinting (cMRF) is a novel technique for simultaneous T1 and T2 mapping. Purpose To compare T1 /T2 measurements, repeatability, and map quality between cMRF and standard mapping techniques in healthy subjects. Study type Prospective. Population In all, 58 subjects (ages 18-60). FIELD STRENGTH/SEQUENCE: cMRF, modified Look-Locker inversion recovery (MOLLI), and T2 -prepared balanced steady-state free precession (bSSFP) at 1.5T. Assessment T1 /T2 values were measured in 16 myocardial segments at apical, medial, and basal slice positions. Test-retest and intrareader repeatability were assessed for the medial slice. cMRF and conventional mapping sequences were compared using ordinal and two alternative forced choice (2AFC) ratings. Statistical tests Paired t-tests, Bland-Altman analyses, intraclass correlation coefficient (ICC), linear regression, one-way analysis of variance (ANOVA), and binomial tests. Results Average T1 measurements were: basal 1007.4±96.5 msec (cMRF), 990.0±45.3 msec (MOLLI); medial 995.0±101.7 msec (cMRF), 995.6±59.7 msec (MOLLI); apical 1006.6±111.2 msec (cMRF); and 981.6±87.6 msec (MOLLI). Average T2 measurements were: basal 40.9±7.0 msec (cMRF), 46.1±3.5 msec (bSSFP); medial 41.0±6.4 msec (cMRF), 47.4±4.1 msec (bSSFP); apical 43.5±6.7 msec (cMRF), 48.0±4.0 msec (bSSFP). A statistically significant bias (cMRF T1 larger than MOLLI T1 ) was observed in basal (17.4 msec) and apical (25.0 msec) slices. For T2 , a statistically significant bias (cMRF lower than bSSFP) was observed for basal (-5.2 msec), medial (-6.3 msec), and apical (-4.5 msec) slices. Precision was lower for cMRF-the average of the standard deviation measured within each slice was 102 msec for cMRF vs. 61 msec for MOLLI T1 , and 6.4 msec for cMRF vs. 4.0 msec for bSSFP T2 . cMRF and conventional techniques had similar test-retest repeatability as quantified by ICC (0.87 cMRF vs. 0.84 MOLLI for T1 ; 0.85 cMRF vs. 0.85 bSSFP for T2 ). In the ordinal image quality comparison, cMRF maps scored higher than conventional sequences for both T1 (all five features) and T2 (four features). Data conclusion This work reports on myocardial T1 /T2 measurements in healthy subjects using cMRF and standard mapping sequences. cMRF had slightly lower precision, similar test-retest and intrareader repeatability, and higher scores for map quality. Evidence level 2 TECHNICAL EFFICACY: Stage 1 J. Magn. Reson. Imaging 2020;52:1044-1052.

Background Proximal Roux-en-Y gastric bypass is commonly used to manage obesity, performed using laparoscopic or robot-assisted minimally invasive surgery. As the prevalence of robotic bariatric surgery increases, further data is required to justify its use. Methods This was a large, retrospective analysis of prospectively recorded data for Roux-en-Y gastric bypass (RYGB) procedures performed using laparoscopic (LRYGB) or robotic (RRYGB; da Vinci Xi system, Intuitive Surgical Sàrl) surgery between January 2016 and March 2019. The surgical techniques did not differ apart from different trocar placements. Data collected included patient characteristics before and after RYGB, operative outcomes and complications. Results In total, 114 RRYGB and 108 LRYGB primary surgeries were performed. There were no significant differences between the groups, apart from a significantly shorter duration of surgery (116.9 vs. 128.9 min, respectively), lower C-reactive protein values at days 1 (31.1 vs. 44.1 mg/l) and 2 (50.3 vs. 77.8 mg/l) after the intervention, and overall complication rate (4.4 vs. 12.0%, Clavien-Dindo classification II-V) with RRYGB compared with LRYGB. There was a lower hemoglobin value in the postoperative course after RRYGB (12.1 vs. 12.6 g/dl, day 2). Conclusions In our experience, robotic RYGB has proven to be safe and efficient, with a shorter duration of surgery and lower rate of complications than laparoscopic RYGB. RRYGB is easier to learn and seems safer in less experienced centers. Increasing experience with the robotic system can reduce the duration of surgery over time. Further studies with higher evidence level are necessary to confirm our results.

Introduccion La cirugia endoscopica de columna ha demostrado ser una opcion en el tratamiento de hernias discal y estenosis foraminal El abordaje mas empleado es la via transforaminal, sin embargo, este abordaje es limitado en casos de hernias discales centrales extruidas y migradas El abordaje interlaminar completamente endoscopico ha permitido el tratamiento sintomatico de hernias discales centrales extruidas y migradas en el nivel L5 ­ S1, ademas es una novedosa alternativa para la resolucion de las dificultades tecnicas relacionadas con el abordaje posterolateral en este nivel El proposito del estudio es reportar los resultados obtenidos con el abordaje endoscopica interlaminar en el tratamiento de hernias discales centrales extruidas y migradas en dos anos de seguimiento Materiales y metodos Se realizo un estudio retrospectivo observacional descriptivo con las historias de pacientes que presentaron sintomatologia radicular secundaria a hernia discal central en el nivel L5 ­ S1 y que fueron tratados con cirugia por abordaje interlaminar completamente endoscopico Se evaluaron los indices de escala visual analoga (EVA) pre y posoperatorio, el criterio Oswestry ODI y el criterio MacNab Resultados Entre los anos 2008 y 2015 se realizaron un total de 99 procedimientos en el mismo numero de pacientes Todos fueron sometidos a una tecnica quirurgica estandar bajo anestesia local y sedacion La EVA tuvo una reduccion de 5,81 puntos El ODI bajo 45,63% Y el 88% de los pacientes tuvo una completa satisfaccion frente al tratamiento Discusion Los resultados obtenidos en esta muestra permiten considerar la fragmentectomia interlaminar endoscopica bajo anestesia local y sedacion como un procedimiento seguro, preciso y efectivo en la resolucion del dolor secundario a hernias discales centrales extruidas y migradas en el nivel L5 ­ S1 que cursan con radiculopatia El uso de anestesia local y sedacion como unica alternativa analgesica puede no ser la mejor opcion en este tipo de tecnicas Nivel de evidencia IV Background Endoscopic spine surgery has shown to be an option for disc hernias and foraminal stenosis Although the most used approach is transforaminal, this approach is limited in cases of extruded and migrated central hernias The full-endoscopic interlaminar approach has led to the treatment of the lumbar pain secondary to extruded and migrated central herniated discs at L5 - S1, and is an alternative for resolving technical difficulties related to the transforaminal approach at this level The aim of this article is to report the results obtained with a full-endoscopic interlaminar approach for the treatment of central extruded and migrated herniated discs, with a two-year follow-up Methods A descriptive observational retrospective study was conducted using the records of patients who had a radiculopathy secondary to a central herniated disc at level L5 - S1, and who were treated with a full-endoscopic interlaminar approach An evaluation was made of the pre-operative and post-operative visual analogue scale (VAS) scores, Oswestry ODI criteria, and MacNab criteria Results A total of 99 procedures were performed in the same number of patients between 2008 and 2015 All were treated with a standard surgical technique and under local anaesthesia and sedation The visual analogue score showed a reduction of 5 81 points The ODI was down 45 63%, and 88% of the patients were completely satisfied with the treatment Discussion The results lead us to consider that full-endoscopic interlaminar fragmentectomy under local anaesthesia and sedation is a safe, accurate, and effective procedure for the treatment of radiculopathy related to L5 - S1 extruded and migrated central hernia Use of local anaesthesia and sedation as the only analgesic alternative may not be the best option in this type of technique Evidence Level IV

Introduccion Tenemos como objetivo, cuantificar los cambios de la lordosis fisiologica en las distintas posiciones, de pie y en decubito ventral, sobre el Soporte de Cirugia Espinal (SCE) y evaluar indirectamente los cambios de diametro de los distintos foramenes, midiendo la distancia interpedicular Materiales y metodos 20 pacientes de 20 a 40 anos Se tomaron radiografias, en posicion de pie y sobre el SCE Se midio la lordosis lumbar en radiografias de pie, y sobre el SCE en dos posiciones (baja/alta) asi como la distancia interpedicular de los foramenes de cada segmento Resultados Se constata una perdida de la lordosis en la primera posicion de 21,65° (37,00%) y en la segunda posicion de 28,75° (49,14%) Encontramos un aumento de la distancia interpedicular en todos los niveles tanto en la posicion baja como alta del SCE Los foramenes que presentaron mayor apertura fueron los segmentos de L4-L5, seguidos por L5-S1 Conclusiones Se encontro una perdida promedio de la lordosis fisiologica del 37,00% y del 49,14% con la utilizacion del SCE en las dos posiciones utilizadas En todos los casos existio un aumento de la distancia interpedicular, que vario entre un 10 y un 15% Los foramenes que mayor apertura presentaron en las distintas posiciones fueron los segmentos L4-L5 seguido por L5-S1 La cifotizacion de los segmentos moviles permitirian una mejor liberacion sacorradicular al aumentar el diametro del canal y los foramenes Nivel de Evidencia: IV Background The aim of this study is to quantify the changes of the physiological lordosis in the different positions, standing and in ventral decubitus, on a Spinal Surgery Table (SST), and indirectly evaluate the changes in diameter of the different foramina, and measuring the interpedicular distance Methods The study included 20 patients from 20 to 40 years old X-rays were taken in standing position and on the SST Lumbar lordosis was measured using the X-rays in the standing position, and on the SST in two positions (low/high), as well as the interpedicular distance of the foramina of each segment Results A loss of lordosis was found in the first position of 22 65° (37 00%) and in the second position of 28 75° (49 14%) An increase was found in the interpedicular distance at all levels in both the low and high position of the SST The foramina with the greatest opening were the L4-L5 segments, followed by L5-S1 Discussion A mean loss of 37 00% and 49 14%, respectively, was found in the physiological lordosis with the use the SST in the two positions used In all cases there was an increase in the interpedicular distance, which varied between 10% and 15% The foramina with the greatest openness in the different positions were segments L4-L5 followed by L5-S1 The kyphotisation of the mobile segments would allow a better sacrum-radicular release when increasing the diameter of the channel and the foramina Evidence Level: IV

La Neuroartropatia de Charcot (NA), a pesar de ser documentada desde hace cerca 120 anos, es apenas en las dos ultimas decadas que su comprension viene en incremento, dado el entendimiento en la causalidad y la relacion proporcional con el incremento de la prevalencia de diabetes mellitus Ello genera retos importantes en su tratamiento enfocado actualmente en la preservacion a priori de la extremidad dada la relacion de la amputacion con incremento del gasto cardiaco, la perdida de calidad de vida, depresion, infeccion a niveles mas elevados de la extremidad, incremento de costos a largo plazo para el sistema sanitario, perdida de calidad de vida y la asociacion elevada con mortalidad a 5 anos incluso mayores a neoplasias tan prevalentes como de mama y colon Aunque el diagnostico es predominantemente clinico, el apoyo en quimica sanguinea, en imagenes convencionales y/o de resonancia magnetica, PET/TC ayudan a diferenciar el proceso per se y la posible relacion con infeccion subyacente El advenimiento de cirugias reconstructivas y la compresion tecnica de ellas vienen dando pistas para conseguir el objetivo de preservar la extremidad y rehabilitar a los pacientes diabetico Se hace una revision de la literatura mas reciente Nivel de evidencia: IV Charcot Neuroarthropathy (NA), despite being documented for close to 120 years, it is only in the last two decades that its comprehension has increased, given the understanding of causality and the proportional relationship with the increase in the prevalence of diabetes mellitus This generates important challenges in its treatment, currently focused on the a priori preservation of the limb, given the relationship of amputation with increased cardiac output, loss of quality of life, depression, infection at higher levels of the limb, increased long-term costs to the health system, loss of quality of life, and high association with 5-year mortality, which is even higher than the prevalence of cancers, such as breast and colon Although the diagnosis is predominantly clinical, the support in blood chemistry, in conventional imaging and / or magnetic resonance imaging, PET / CT, help to differentiate the process per se, as well as the possible relationship with underlying infection The advent of reconstructive surgeries and their technical compression are providing clues to achieve the aim of preserving the limb, and rehabilitate diabetic patients A review of the topic is presented herein Evidence Level: IV

Context Pygeum africanum is still being employed in urology practice for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostate hyperplasia (BPH). Evidence acquisition A non-exhaustive review has been carried out about Pygeum africanum, its mechanisms of action "in vitro" as well as "in vivo", clinical trials and routine clinical practice. Evidence synthesis The conclusions of the review and the reflections of the authors on the use of Pygeum africanum are described. Conclusions Although with an evidence level IV (based on expert opinion) the use of Pygeum africanum seems to be an option in the urological therapeutic arsenal.

Introduccion Las ulceras por presion (UPP) son una condicion frecuente en los pacientes con movilidad restringida, su sobreinfeccion implica un esfuerzo adicional en el tratamiento, ya que se asocia a complicaciones como osteomielitis cronica y sepsis El objetivo del estudio es describir las caracteristicas clinicas y sociodemograficas de los pacientes con UPP enfatizando en el perfil microbiologico de aquellos con sobreinfeccion Materiales y metodos Se realizo un estudio descriptivo retrospectivo que incluyo a 76 pacientes adultos con diagnostico de UPP sobreinfectadas sometidos a cirugia entre 2013 y 2015 Se obtuvo informacion demografica, clinica y microbiologica Se describieron los resultados segun la naturaleza de la variable Resultados De los 76 pacientes, 56 (73 7%) fueron hombres La mediana de edad fue de 45 anos La mediana de hospitalizacion fue de 22 5 dias, el principal motivo de inmovilidad fue la lesion medular (69,7%) Los patogenos mas comunes fueron Enterococcus faecalis (46%), Escherichia coli (43 4%), Streptococcus spp (35 5%) y Proteus spp (30 2%) En el 77,6% de los pacientes se aislaron dos o mas microorganismos en los cultivos Discusion La lesion medular en la condicion mas asociada a ulceras por presion en nuestro medio, principalmente en hombres jovenes La sobreinfeccion generalmente es polimicrobiana, lo que nos muestra la gran importancia de los cultivos para poder realizar un tratamiento especifico y efectivo Al conocer las caracteristicas clinicas y demograficas se pueden direccionar estrategias de prevencion y rehabilitacion que impacten de manera positiva en la calidad de vida de los pacientes y la sostenibilidad del sistema de salud Nivel de evidencia IV Background Pressure ulcers (PU) are a frequent condition in patients with restricted mobility Their infection requires an additional effort in the treatment, since it is associated with complications, such as chronic osteomyelitis and sepsis The aim of this study is to describe the clinical and sociodemographic characteristics of patients with PU, emphasising the microbiological profile of those with infection Materials and methods A retrospective descriptive study was carried out on 76 adult patients diagnosed with infected PU who underwent surgery between 2013 and 2015 Demographic, clinical, and microbiological information was obtained The results were described according to the nature of the variable Results Of the 76 patients, 56 (73 7%) were men The median age was 45 years The median number of days hospitalised was 22 5 days, and the main cause of immobility was spinal cord injury (69 7%) The most common pathogens were Enterococcus faecalis (46%), Escherichia coli (43 4%), Streptococcus spp (35 5%), and Proteus spp (30 2%) Two or more microorganisms were isolated in the cultures in 77 6% of the patients, Discussion Spinal cord injury is the condition most associated with pressure ulcers in this study, mainly in young men Infection is usually polymicrobial, which shows the great importance of the cultures, in order to be able to carry out a specific and effective treatment By knowing the clinical and demographic characteristics, prevention and rehabilitation strategies can be directed at having a positive impact on the quality of life of PU patients, and the sustainability of the health care system Evidence Level IV

Contrast-enhanced ultrasound is utilized in an increasing array of medical fields, including thoracic medicine. However, the technique is still relatively new and only sporadically mentioned in current guidelines and recommendations. The aim of this systematic review is to provide a literature overview and to critically appraise the current clinical applications of contrast-enhanced thoracic ultrasound (CETUS). A systematic literature search using major electronic databases and in accordance with PRISMA guidelines was performed. Studies with a primary focus on CETUS of thoracic disorders compared to a standard reference test were included. The QUADAS-2 tool was used for quality assessment of the studies. The search identified 43 articles: 1 randomized controlled study, 6 non-randomized controlled studies, 16 non-randomized non-controlled studies, 5 case series, 10 single case reports, and 5 animal studies. The overall risk of bias was judged to be high. Diagnostic accuracy measurements of noninvasive applications of CETUS were only reported in a few studies and they were too dissimilar for meta-analysis. Six studies compared CETUS-guided versus ultrasound-guided transthoracic needle biopsy of thoracic masses. They individually reported a significant increase in diagnostic accuracy in favor of CETUS guidance but were too heterogeneous for meta-analysis. The current literature on CETUS is overall heterogeneous with a few high evidence level studies, small study populations and a high risk of bias. CETUS-guided biopsy is the most frequent clinical application and increases diagnostic accuracy compared to ultrasound guidance by an average of 14.6 percentage points. Der kontrastverstärkte Ultraschall wird in immer mehr medizinischen Bereichen eingesetzt, darunter auch in der Thoraxmedizin. Diese Technik ist jedoch noch relativ neu und wird in aktuellen Richtlinien und Empfehlungen nur sporadisch erwähnt. Ziel dieser systematischen Übersichtsarbeit ist es, einen Literaturüberblick zu geben und die aktuellen klinischen Anwendungen des kontrastverstärkten Thorax-Ultraschalls (CETUS) kritisch zu bewerten. Es wurde eine systematische Literaturrecherche unter Verwendung der wichtigsten elektronischen Datenbanken in Übereinstimmung mit den PRISMA-Richtlinien durchgeführt. Eingeschlossen wurden Studien mit dem primären Schwerpunkt auf CETUS bei Erkrankungen des Thorax im Vergleich zum Standard-Referenztest. Das QUADAS-2-Tool wurde angewandt, um die Qualität der Studien zu beurteilen. Die Suche ergab 43 Artikel, davon 1 randomisierte kontrollierte Studie, 6 nichtrandomisierte kontrollierte Studien, 16 nichtrandomisierte nichtkontrollierte Studien, 5 Fallserien, 10 Einzelfallberichte und 5 Tierstudien. Das Bias-Risiko (Risiko für systematische Fehler) wurde insgesamt als hoch bewertet. Über Messungen der diagnostischen Genauigkeit von nichtinvasiven CETUS-Anwendungen wurde nur in wenigen Studien berichtet und diese waren für eine Metaanalyse zu unterschiedlich. In 6 Studien wurde die CETUS-geführte mit der ultraschallgeführten transthorakalen Nadelbiopsie bei Raumforderungen des Thorax verglichen. Jede von ihnen berichtete von einem signifikanten Anstieg der diagnostischen Genauigkeit zugunsten der CETUS-geführten Nadelbiopsie; die Studien waren jedoch für eine Metaanalyse zu heterogen. Die aktuelle Literatur zu CETUS ist insgesamt heterogen bei wenigen Studien mit hoher Evidenz, kleinen Studienpopulationen und einem hohen Bias-Risiko. Die CETUS-gesteuerte Biopsie ist die häufigste klinische Anwendung und erhöht die diagnostische Genauigkeit im Vergleich zur Ultraschallführung im Durchschnitt um 14,6 Prozentpunkte.

Objectives: to analyze scientific evidence on the implementation and performance of palliative care in Primary Health Care. Methods: an integrative literature review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, carried out in the PubMed, SciVerse Scopus and LILACS databases, in December 2020, without a time frame. Results: 22 original scientific articles were analyzed, 14 classified as evidence level VI. The objective was to understand the experiences and roles of professionals, patients and families on palliative care in Primary Health Care, articles focused on the theme of management and organization of health services and on the importance of educational interventions on the subject. Final Considerations: evidence found relating palliative care in Primary Health Care points to the possibility of this care; health teams work closely with the family and their home, but the need to expand this theme is still perceived. RESUMEN Objetivos: analizar la evidencia científica sobre la implementación y desempeño de los cuidados paliativos en la Atención Primaria de Salud. Métodos: revisión integradora de la literatura, de acuerdo con el Preferred Reporting Items for Systematic Reviews and Meta-Analyses, realizada en las bases de datos PubMed, SciVerse Scopus y LILACS, en diciembre de 2020, sin marco temporal. Resultados: se analizaron 22 artículos científicos originales, 14 clasificados como nivel de evidencia VI. El objetivo fue conocer las vivencias y roles de los profesionales, pacientes y familiares sobre los cuidados paliativos en Atención Primaria de Salud, artículos centrados en el tema de la gestión y organización de los servicios de salud y en la importancia de las intervenciones educativas sobre el tema. Consideraciones Finales: la evidencia encontrada que relaciona los cuidados paliativos en Atención Primaria de Salud apunta a la posibilidad de este cuidado; Los equipos de salud trabajan en estrecha colaboración con la familia y su hogar, pero aún se percibe la necesidad de ampliar este tema. RESUMO Objetivos: analisar evidências cientificas sobre a implementação e realização dos cuidados paliativos na Atenção Primária à Saúde. Métodos: revisão integrativa da literatura, segundo o Preferred Reporting Items for Systematic Reviews and Meta-Analyses, realizada nas bases de dados PubMed, SciVerse Scopus e LILACS, em dezembro de 2020, sem recorte temporal. Resultados: foram analisados 22 artigos científicos originais, 14 classificados com nível de evidência VI. Objetivou-se compreender as experiências e os papéis de profissionais, pacientes e familiares sobre cuidados paliativos na Atenção Primária à Saúde, artigos voltados para a temática de gestão e organização dos serviços de saúde e sobre a importância de intervenções educativas na temática. Considerações Finais: evidências encontradas relacionando cuidados paliativos na Atenção Primária à Saúde apontam para a possibilidade desse cuidado; equipes de saúde atuam de maneira próxima a família e seu domicílio, porém ainda se percebe a necessidade de ampliação deste tema.

Bronchial Thermoplasty (BT) is an epoch-making treatment that reduces bronchial smooth muscle by using a bronchoscope to reach the basket catheter to the bronchus and directing high-frequency current directly into the bronchi. In GINA Guidelines 2019, BT is considered to be additional treatment at Step V (the most severe), and the evidence level is B. The Japanese guidelines (JGL) also added BT as a treatment for Step 4, but it is reserved because there are still unclear points regarding long-term efficacy and safety. In Japan, as of April 1, 2019, 672 treatments were performed at 123 institutions nationwide. The average age of patients was 54.1 years, but 84 cases were over 70 years old. The average value of %FEV1 was 78.2%, but there were 94 cases less than 60%. There were 32 cases that underwent BT treatment at our institution. Of them, 12 cases with progress up to one year later could be observed. The average age was 56.1 years old, and each of 6 men and women had a %FEV1 of 70.5%. One year later, AQLQ and %FEV1 improved, and the number of exacerbations decreased, but exhaled NO values increased. %FEV1 improvement might be due to poorer lung function (70.5% vs. 77.8%) and more BT activation (average 1.28 times AIR2) compared to the AIR2 trial. In terms of improvement in %FEV1, patients with moderate obstructive disorder from 50 to 80% responded well after BT treatment. In the near future, various new antibody preparations such as IL-4 / 13 antibody and anti-TSLP antibody are expected to be promoted. Therefore, we first consider whether these antibody preparations can be applied to patients with refractory asthma. We consider that BT is indicated only when there is no indication or no expected effect of antibody preparations. In other words, BT treatment is the last resort of intractable asthma, and it is the duty of medical professionals involved in BT treatment to be able to advocate when it is best to give BT to such patients.

Background It is known that the success rates of phase III trials for solid cancers are low. The aim of this study was to investigate factors related to trial design and operation that were associated with the probability of the success of phase III trials for solid cancers based on the latest comprehensive data. Methods Relevant clinical trials, started between September 2007 and December 2017, were retrieved from ClinicalTrials.gov . Then, variables related to the selected trials such as types of primary endpoint and duration of trial enrollment were collected from the literature and ClinicalTrials.gov . Based on the collected data, a multivariate logistic regression analysis was conducted to find factors associated with the successful results. Results Four hundred phase III trials were found eligible for the study. Unsuccessful trials were 207 and successful trials were 193. As a result of multivariate logistic regression analysis, factors that presented a statistically significant relationship were primary endpoint (Odds ratio [OR]: 2.79 [95% CI: 1.59–4.89]), control arm (OR: 3.06 [95% CI: 1.39–6.73]), start year of trial (OR: 3.28 [95% CI: 1.87–5.77]), and duration of trial enrollment (OR: 0.77 [95% CI: 0.60–0.99]). Conclusion Type of primary endpoints (time-to-event endpoints other than overall survival), control arm (treatments with lower evidence level, placebo or best supportive care), and duration of trial enrollment (faster enrollment speed) were associated with phase III trial success.

Aim: This Danish national guideline describes the treatment of adult patients with Clostridioides (formerly Clostridium) difficile (CD) infection and the use of faecal microbiota transplantation (FMT). It suggests minimum standard for implementing an FMT service. Method: Four scientific societies appointed members for a working group which conducted a systematic literature review and agreed on the text and recommendations. All clinical recommendations were evalluated for evidence level and grade of recommendation. Results: In CD infection, the use of marketed and experimental antibiotics as well as microbiota-based therapies including FMT are described. An algorithm for evaluating treatment effect is suggested. The organisation of FMT, donor recruitment and screening, laboratory preparation, clinical application and follow-up are described. Conclusion: Updated evidence for the treatment of CD infection and the use of FMT is provided.