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Idiopathic pulmonary arterial hypertension is a serious condition that carries a poor prognosis. While exertional dyspnea is the most common symptom, angina like chest pain, most often due to right ventricle ischemia, may occur at advanced stages. We present a patient with pulmonary hypertension symptomatic for dyspnea and angina in whom computed coronary tomography angiography showed compression of the left main coronary artery by a large pulmonary artery aneurysm. Percutaneous coronary intervention and stenting was performed resulting in significant clinical improvement. This case emphasizes the role of different cardiovascular imaging modalities for the diagnosis of rare conditions.

Introduction: Surgical decision-making often relies on a surgeon's subjective assessment of a patient's frailty status to undergo surgery. Certain patient demographics can influence subjective judgment when compared to validated objective assessments. In this study, we explore the relationship between subjective and objective frailty assessments according to patient age, sex, and race. Methods: Patients were prospectively enrolled in urology, general surgery, and surgical oncology clinics. Using a visual analog scale (0−100), operating surgeons independently rated the patient's frailty status. Objective frailty was classified using the Fried Frailty Criteria ranging from 0 to 5. Multivariable proportional odds models were conducted to examine the potential association of factors with objective frailty, according to surgeon frailty rating. Subgroup analysis according to patient sex, race, and age was also performed. Results: Seven male surgeons assessed 203 patients preoperatively with a median age of 65. A majority of patients were male (61 %), white (67 %), and 60 % and 40 % underwent urologic and general surgery/surgical oncology procedures respectively. Increased subjective surgeon rating (OR 1.69; p 60, OR 1.75; p = 0.0001) patients, compared to male (OR 1.45; p = 0.0243), non-white (OR 1.48; p = 0.0109) and patients under 60 (OR 1.47; p = 0.0823). Conclusion: The surgeon's subjective assessment of frailty demonstrated tendencies to rate older, female, and non-white patients as frail; however, differences in patient sex, age, and race were not statistically significant.

The co-occurrence of Thrombocytopenia with Absent Radius (TAR) syndrome and Langerhans Cell Histiocytosis (LCH) is exceedingly rare, with scant documentation in existing medical literature. This case report aims to shed light on this unique intersection of conditions, emphasizing the diagnostic and therapeutic challenges it presents. A 27-year-old female with a history of TAR syndrome presented with microcytic anemia, hip pain, and gastrointestinal symptoms. Terminal ileum intubation during colonoscopy revealed superficial ulcerations, leading to a biopsy that confirmed LCH. Subsequent radiologic investigations, including CT and MRI, showed multiple osseous lesions in the pelvis, sacrum, and skull. A treatment plan involving IV Cytarabine was initiated due to concerns of CNS involvement, as indicated by mastoid air cell involvement and symptoms of dizziness and ear fullness. The case highlights the diagnostic value of terminal ileum intubation during colonoscopy, which was pivotal in diagnosing LCH in this patient. It also discusses the use of IV cytarabine, a chemotherapy drug that inhibits DNA synthesis, as a suitable treatment option given the suspected CNS involvement. The case adds to the limited literature on the natural history and management of adult patients with LCH, particularly in the context of TAR syndrome. This case report serves as a compelling addition to medical literature, highlighting the diagnostic complexities and treatment considerations in a patient with both TAR syndrome and LCH. It emphasizes the importance of comprehensive diagnostic approaches, including terminal ileum intubation during colonoscopy, and introduces IV cytarabine as a viable treatment option for cases with suspected CNS involvement.

BACKGROUND: In worldwide literature, it has been found that cesarean deliveries represent higher costs and are associated with maternal morbidity and other complications. OBJECTIVE: This study aimed to estimate the cost-effectiveness of elective cesarean delivery compared with spontaneous vaginal delivery in short-term maternal outcomes for low-risk obstetrical population in Colombia. STUDY DESIGN: A cost-effectiveness study using a healthcare-system perspective was performed in 2019 in Colombia. The reference population were women with full-term and low-risk pregnancy, either by spontaneous vaginal delivery or elective cesarean delivery under medical or nonmedical indications. An analytical decision model (decision tree) was designed for maternal outcomes. The time horizon was 42 days postpartum, and the health effects were measured by Quality Adjusted Life Years. A review of the literature and a validation process by a national expert committee were conducted to determine the maternal outcomes and estimate their probabilities. Costs were estimated with a top-down analysis, an incremental cost-effectiveness ratio was calculated, and finally, a sensitivity analysis was performed. RESULTS: Within a 42-day time horizon, it was found that spontaneous vaginal delivery is the less-expensive and more-effective mode of delivery, it showed a reduction in costs (324 USD) and a gain in Quality Adjusted Life Years (0.03) compared with elective cesarean delivery. Our analysis suggests that spontaneous vaginal delivery is the dominant alternative compared with elective cesarean delivery. CONCLUSION: Spontaneous vaginal delivery showed to be the cost-effective mode of delivery for low-risk obstetrical population in Columbia. These results are useful not only for obstetricians but for decision makers, who should encourage nationwide health policies in favor of spontaneous vaginal delivery.

Crouzon syndrome is a genetic condition characterized by a premature fusion of skull sutures resulting in head and facial deformities. Crouzon syndrome is usually suspected at birth through physical examination or in the antenatal period via ultrasonographic assessment. Once Crouzon syndrome is suspected, advanced imaging methods such as three-dimensional computed tomography must be requested, showing early signs of cranial sutures fusion. In this paper, we present a case of a six-year-old girl who was taken to a pediatrician control appointment due to abnormal facies. During the physical examination, a suspicion of Crouzon syndrome was raised. Therefore, a head computed tomography was requested, showing asymmetrical calvarium thickening, diffuse indentation of the inner table of the skull, and moderate hydrocephalus with a big cyst in the posterior fossa. Due to these findings, the patient was remitted to maxillofacial surgery for further evaluation; however, the medical appointment could not be achieved as a consequence of the poor medical insurance of the girl. This paper aims to describe and discuss the computed tomography findings of Crouzon syndrome.

Summary: Background: The use of rosuvastatin plus colchicine and emtricitabine/tenofovir in hospitalized patients with SARS-CoV-2 disease (COVID-19) has not been assessed. The objective of this study was to assess the effectiveness and safety of rosuvastatin plus colchicine, emtricitabine/tenofovir, and their combined use in these patients. Methods: This was a randomized, controlled, open-label, multicentre, parallel, pragmatic study conducted in six referral hospitals in Bogotá, Colombia. The study enrolled hospitalized patients over 18 years of age with a confirmed diagnosis of COVID-19 complicated with pneumonia, not on chronic treatment with the study medications, and with no contraindications for their use. Patients were assigned 1:1:1:1. 1) emtricitabine with tenofovir disoproxil fumarate (FTC/TDF, 200/300 mg given orally for 10 days); 2) colchicine plus rosuvastatin (COLCH+ROSU, 0.5 mg and 40 mg given orally for 14 days); 3) emtricitabine with tenofovir disoproxil plus colchicine and rosuvastatin at the same doses and for the same period of time (FTC/TDF+COLCH+ROSU); or 4) the Colombian consensus standard of care, including a corticosteroid (SOC). The primary endpoint was 28-day all-cause mortality. A modified intention-to-treat analysis was used together with a usefulness analysis to determine which could be the best treatment. The trial was registered at ClinicalTrials.gov: NCT04359095 Findings: Out of 994 candidates considered between August 2020 and March 2021, 649 (65.3%) patients agreed to participate and were enrolled in this study; among them, 633 (97.5%) were included in the analysis. The mean age was 55.4 years (SD ± 12.8 years), and 428 (68%) were men; 28-day mortality was significantly lower in the FTC/TDF+COLCH+ROSUV group than in the SOC group, 10.7% (17/159) vs. 17.4% (28/161) (hazard ratio [HR] 0.53; 95% CI 0.29 to 0.96). Mortality in the FTC/TDF group was 13.8% (22/160, HR 0.68, 95% CI 0.39 to 1.20) and 14.4% in the COLCH+ROSU group (22/153) (HR 0.78, 95% CI 0.44 to 1.36). A lower need for invasive mechanical ventilation was observed in the FTC/TDF+COLCH+ROSUV group than in the SOC group (risk difference [RD] - 0.08, 95% CI 0.11 to 0.04). Three patients presented severe adverse events, one severe diarrhoea in the COLCH+ROSU and one in the FTC/TDF+COLCH+ROSU group and one general exanthema in the FTC/TDF group. Interpretation: The combined use of FTC/TDF+COLCH+ROSU reduces the risk of 28-day mortality and the need for invasive mechanical ventilation in hospitalized patients with pulmonary compromise from COVID-19. More randomized controlled trials are needed to compare the effectiveness and cost of treatment with this combination versus other drugs that have been shown to reduce mortality from SARS-CoV-2 infection and its usefulness in patients with chronic statin use.

ABSTRACT: Background: COVID-19 initially caused less severe outbreaks in many low- and middle-income countries (LMIC) compared with many high-income countries, possibly because of differing demographics, socioeconomics, surveillance, and policy responses. Here, we investigate the role of multiple factors on COVID-19 dynamics in the Philippines, a LMIC that has had a relatively severe COVID-19 outbreak. Methods: We applied an age-structured compartmental model that incorporated time-varying mobility, testing, and personal protective behaviors (through a “Minimum Health Standards” policy, MHS) to represent the first wave of the Philippines COVID-19 epidemic nationally and for three highly affected regions (Calabarzon, Central Visayas, and the National Capital Region). We estimated effects of control measures, key epidemiological parameters, and interventions. Findings: Population age structure, contact rates, mobility, testing, and MHS were sufficient to explain the Philippines epidemic based on the good fit between modelled and reported cases, hospitalisations, and deaths. The model indicated that MHS reduced the probability of transmission per contact by 13-27%. The February 2021 case detection rate was estimated at ~8%, population recovered at ~9%, and scenario projections indicated high sensitivity to MHS adherence. Interpretation: COVID-19 dynamics in the Philippines are driven by age, contact structure, mobility, and MHS adherence. Continued compliance with low-cost MHS should help the Philippines control the epidemic until vaccines are widely distributed, but disease resurgence may be occurring due to a combination of low population immunity and detection rates and new variants of concern.

Background:. Electronic health records (EHRs) should help physicians stay organized, improve patient safety, and facilitate communication with both patients and fellow healthcare providers. However, few studies have directly evaluated physician satisfaction with EHR and its perceived impact on patient care. This study assessed trends and perceptions of EHR within the American plastic surgery community. Methods:. An Institutional Review Board–approved survey that assessed demographics, patterns of EHR use, and attitudes toward EHR was deployed by the American Society of Plastic Surgeons Member Survey Research Services. Statistical analyses were performed using Stata 14.2 and QDA Miner Lite software (Version 2.0; Provalis, Montreal, Canada). Significance level was P < 0.05. Results:. Among plastic surgeons who use EHR, EPIC Systems software (Epic, Verona, Wisc.) was the most common vendor, with users noting a net positive effect on the quality of care they provided to patients. Younger age and less years of experience were correlated with a more positive attitude toward EHR. Positive attitude was closely linked to shared responsibility among support staff over data entry, whereas negative attitude was tightly tied to the perceived time wasted because of EHR, followed by poor technical support and design. Conclusions:. EHR use among plastic surgeons was more common in academic-associated specialties and larger practice groups. Overall, age and practice type had weak associations with perceptions of EHR usage. On average, there were slightly more positive perceptions of EHR usage than negative. The most commonly perceived issues with EHR were wasted time and barriers to user-friendliness. These findings suggest the need for greater physician involvement in EHR optimization.

Summary:. Enhanced recovery after surgery pathways are well established in other surgical specialties but are relatively new in plastic surgery. These guidelines focus on improving patient care by incorporating evidence-based recommendations. Length of stay is shorter, and overall hospital costs are lower without compromising patient satisfaction. When care is standardized, ambiguity is removed and physician acceptance is improved. Yet, implementation can be challenging on an institutional level. The Johns Hopkins microsurgical breast reconstruction team identified areas of dogmatic dissonance during 3 focus groups to formalize an enhanced recovery pathway for microsurgical breast reconstruction. Six microsurgeons used nominal group technique to reach consensus. Four discussion points were identified: multidisciplinary buy-in, venous thromboembolism (VTE) chemophylaxis, early feeding, and dietary restrictions. Evidence-based recommendations and our enhanced recovery after surgery protocol are provided.

Objective: To measure and compare the accommodative amplitude of Filipino patients with different accommodative conditions using a wavefront aberrometer. Methods: A total of 120 eyes of 67 patients seen in a private eye center were included and divided into two groups (phakic and pseudophakic). After undergoing routine ophthalmologic examination that included manifest refraction and visual acuity testing, accommodative amplitude was measured using the iTrace™ wavefront aberrometer. Comparison of the measurements was made between the accommodative amplitude of phakic pre-presbyopes and presbyopes, and between eyes implanted with monofocal and accommodating intraocular lenses (IOLs). Results: The mean age of the pre-presbyopes was 27 years, presbyopes 50 years, monofocal IOL 69 years, and accommodating IOL 67 years. The mean accommodative amplitude of the pre-presbyopes was 1.64 ± 1.06D, presbyopes 0.99 ± 0.42D, monofocal IOL 0.36 ± 1.16D, and accommodating IOL 0.94 ± 0.89D. The pre-presbyopes had a higher accommodative amplitude than the presbyopes (p=0.008), while the accommodating IOL subgroup had a higher amplitude than the monofocal IOL subgroup (p=0.02). Increasing age was correlated with decreasing amplitude in the phakic group (r2 =0.926). There was no correlation between refractive error and amplitude of accommodation in the phakic and pseudophakic groups (r2 =0.02 for both groups). Conclusion: The wavefront aberrometer is a reliable tool in objectively measuring accommodative amplitude. Pre-presbyopes and accommodating IOLs were shown to have higher amplitudes of accommodation than presbyopes and monofocal IOLs.

Introdução: durante o exame de pediatria, genética, ecográ co ou de anatomia patológica de fetos de gestações gemelares, costumam aparecer interrogantes no diagnóstico diferencial, especialmente quando os casos se associam com maceração, com malformações ou com duplicação de estruturas. Objetivo: propor um algoritmo para o enfoque da autopsia perinatal em gestações múltiplas de difícil diagnóstico. Materiais e Métodos: estudo observacional descritivo do universo de gestações gemelares vistas no Departamento de Patologia do Hospital Universitário San Ignacio (husi) entre 2007 e 2013. De nimos como “gestação múltipla de difícil diagnóstico” aquela na que o exame do(s) feto(s) apresentou um dos diagnósticos diferenciais: feto macerado/evanescente, gêmeo siamês, fetus in fetu, feto acárdico ou teratoma congênito. Realizou-se o estudo anatomopatológico e junto com a literatura revisada, os gêmeos se analisaram e classificaram segundo o algoritmo proposto. Resultados: houve 59 casos de gestações gemelares nas que pelo menos um dos fetos requereu autopsia perinatal. As principais causas de morte foram as infeções ascendentes seguidas da síndrome de transfusão feto-fetal. Como gestações múltiplas de difícil diagnóstico observamos três fetos acárdicos e oito fetos macerados. Aplicouse o algoritmo proposto neste artigo. Conclusões: o diagnóstico nas gestações gemelares pode ser em ocasiões difícil. Identificamos os aspectos mais importantes a ter em conta da história clínica e da autopsia perinatal para chegar ao diagnóstico definitivo; desenvolvemos um algoritmo para ser aplicado nestas circunstâncias durante as autopsias perinatais.

Se describen dos casos de drenaje venoso pulmonar anómalo parcial del pulmón izquierdo a la vena vertical, la cual drena a su vez a la vena innominada, en dos niños de 6 y 8 años respectivamente. Se exponen el cuadro clínico, los hallazgos del cateterismo, la evolución clínica y el resultado postquirúrgico; adicionalmente, se hace una revisión de la literatura.

Establecer el impacto de la rehabilitación cardiaca en pacientes con falla cardiaca de origen isquémico con fracción de eyección menor del 40% en términos de síntomas, a través de la percepción subjetiva de la escala de Borg, VO2, MET y distancia en millas antes y al finalizar la terapia de rehabilitación cardiovascular. Diseño: Estudio de cohorte concurrente. Población: 224 pacientes que ingresaron al programa de rehabilitación cardiaca de La Fundación Clínica Abood Shaio en el periodo comprendido entre el 10 de diciembre de 2004 y el 2 de mayo de 2008. Mediciones: Se revisó la base de datos de rehabilitación cardiaca clasificando los parámetros de actividad física al ingreso y al egreso de la terapia. Resultados: En el impacto de la terapia de rehabilitación cardiaca al inicio, 63% de los pacientes se encontraba en las escalas uno y dos de Borg modificada, y al final 85% (p < 0,001) se ubicó en las escalas tres y cuatro; el VO2 al inicio fue de 7,79 y al final 19,04 (p < 0,001); los MET al inicio 2,22 y al final 5,44 (p < 0,001) y la distancia en millas por hora al inicio 1,33 y al final 2,58 (p < 0,001). Conclusiones: Se observó que la rehabilitación cardiaca tuvo un impacto significativo en los pacientes con falla cardiaca de origen isquémico con fracción de eyección del ventrículo izquierdo menor a 40% en términos de percepción de síntomas en forma subjetiva en la escala de Borg, VO2 indirecto, MET y distancia en millas por hora.

la evidencia disponible de stents liberadores de medicamento proviene de estudios controlados con estrictos criterios de inclusión, limitando sus conclusiones y haciendo difícil la aplicación de sus resultados en el mundo real. Objetivo: determinar la incidencia de trombosis de stents liberadores y no liberadores de medicamento en pacientes del «mundo real». Metodología: estudio de incidencia para determinar el número de casos de trombosis de stents implantados, mediante información obtenida a partir de historias clínicas, bases de datos y seguimiento clínico, y con base en características demográficas, factores de riesgo, consumo de clopidogrel y casos de trombosis del stent con un seguimiento de cero días a un año. Resultados: 640 stents implantados (69,2% no medicados, 30,8% medicados de los cuales 18,9% eran medicados con placlitaxel y 11,9% medicados con sirolimus). Se identificaron doce eventos de trombosis (siete stents medicados y cinco no medicados). La incidencia de trombosis con cualquier tipo de stent fue de 1,88% (IC 95% 0,97–3,28). La incidencia de trombosis con stent medicado fue 3,55% (IC 95% 1,43–7,32), y con stent no medicado 1,13% (IC 95% 0,37–2,64) p=0,000. El riesgo relativo de trombosis con stent medicado es de 3,14 (IC 95% 1,01–9,78) p=0,037. El riesgo relativo de presentar trombosis con stent medicado en infarto agudo del miocardio es 8,11 (IC 95% 2,32–28,31) p=0,001. Conclusiones: la incidencia de trombosis del stent aumenta en el mundo real, y existe mayor riesgo de trombosis de stents medicados especialmente cuando son implantados en el contexto de un infarto agudo del miocardio. Es necesario realizar estudios futuros que involucren una población de pacientes más amplia y con seguimiento a largo plazo.

Objective: To compare the pre- and postoperative changes in higher-order aberrations after standard LASIK (PlanoScan, Bausch & Lomb) and wavefront-guided LASIK (Zyoptix, Bausch & Lomb) and determine their effects on visual acuity, contrast sensitivity, and refractive outcomes at one year postoperatively. Methods: In a prospective, randomized clinical trial, 15 patients with low to moderate myopia had standard LASIK on one eye and wavefront-guided LASIK on the contralateral eye. A Hartmann-Shack aberrometer (Zywave, Bausch & Lomb) was used to measure the aberrations. Root-mean-square (RMS) values were determined. Uncorrected visual acquity (UCVA), best corrected visual acuity (BCVA), refractive errors, and contrast sensitivity were also measured. Results: Thirteen (87%) of the 15 eyes treated with Zyoptix and 12 (80%) of the 15 treated with PlanoScan had UCVA of 20/20 at one year postoperatively. The mean difference in the pre- and postoperative contrast sensitivity showed no significant changes in all spatial frequencies in both groups (p > 0.05). The difference in attempted versus achieved refraction was not significant between the two groups (p = 0.794). In all eyes, the total RMS increased postoperatively (p < 0.001), but the mean RMS difference from the preoperative values between the two groups was not statistically significant (p = 0.257). Conclusion: LASIK in low to moderate myopia increases overall high-order aberrations. Zyoptix LASIK offers no advantage over PlanoScan LASIK in decreasing highorder aberrations postoperatively and in achieving better visual and refractive outcomes.

Purpose: To compare pupil-size determination using a digital camera with the Rosenbaum-pupil-comparison and the millimeter-ruler methods. Methods: The pupil size of 30 eyes of 15 medical students with a mean age of 27 years was measured by two examiners using a digital camera, Rosenbaum pupil comparison, and direct millimeter rule. Both examiners determined the mean pupil sizes for bright, dim, and dark settings. Results: The mean pupil size as measured by both examiners at bright and dim light conditions was 5.6 mm (range 4.5 to 7.5) and 6.3 mm (range 4.5 to 8.0) respectively. The mean measurement for both examiners for dark is 7.0 (range 6.5 to 7.5). Only the digital camera was able to measure in dark setting with mean of 7.0 mm (range 6.5 to 7.5) for both examiners. Inter-examiner difference was lowest for the digital photography in all simulated settings. Conclusion: The use of digital camera in determining pupil size was comparable to Rosenbaum chart and direct millimeter rule with lower inter-examiner differences.

Objective: To determine whether there is an association between different capillaroscopic findings and pulmonary function tests in systemic sclerosis (SSc)., Methods: We did a retrospective observational study in a cohort of patients with SSc and early SSc. Patients with at least 1 nailfold videocapillaroscopy (NVC) magnified 120× were included. Pathological findings were giant capillaries, angiogenesis, and density loss. Findings were compared with lung function values: percent expected value of forced vital capacity (FVC), DLCO, and FVC/DLCO ratio. Other variables collected were sex and SSc type, and the presence of digital ulcers (DU), interstitial lung disease (ILD), scleroderma renal crisis, and/or pulmonary hypertension (PH)., Results: Of 136 patients with SSc, 85 had undergone an NVC. The frequency of ILD, DU, and PH was 24.1%, 28.7%, and 17.2%, respectively. Data analysis showed that patients with density loss had worse FVC% (86.91 ± 19.42 vs 101.13 ± 16.06, p < 0.01) and DLCO% (71.43 ± 21.19 vs 85.9 ± 19.81, p < 0.01) compared to those without., Conclusion: Patients with loss of density present worse FVC and DLCO values. Prospective studies are warranted to determine whether NVC is useful for studying pulmonary function in SSc.

A branched DNA (bDNA)-based quantitation of plasma human immunodeficiency virus type 1 (HIV-1) RNA was used to monitor the virologic status of 102 patients (29-906 CD4 cells/mm3) enrolled in clinical trials of antiretroviral and immune-based therapies. Virion-associated RNA was measurable in plasma of 74% of patients tested (10,000-10,000,000 RNA equivalents/mL). Virus levels measured by the bDNA assay exceeded titers obtained by quantitative plasma culture and were inversely correlated (r = -.378; P < .05) with total CD4 cell counts. The assay was used to demonstrate a significant decline (mean, 5-fold; range, 0- to 30-fold), relative to pretreatment, in virus load after beginning antiviral therapy and a transient increase (mean, 15-fold; range, 2- to 50-fold) after treatment with interleukin-2. The decrease in RNA was more dramatic than changes in serum p24 antigen. The bDNA assay yields reproducible results, is relatively easy, and should be useful in measuring HIV-1 RNA in patients in clinical trials.

Experimental conditions affecting the successful propagation of HIV-1 from the plasma of seropositive individuals were examined. It was determined that whole blood samples collected with lithium heparin as the anticoagulant, immediate plasma separation, and immediate culturing were best suited for obtaining viable virus from plasma. Virus was isolated by infecting fresh phytohemagglutinin-stimulated normal donor peripheral blood mononuclear cells (PBMCs) with plasma followed by weekly cocultivation with new target cells. The plasma virus isolation rate was the greatest and HIV-1 titers were the highest for those individuals with less than 200 CD4+ cells/mm3 and decreased as the level of CD4+ cells approached normal values. We were able to obtain positive cultures from 29.5% of those patients with CD4+ counts greater than 500/mm3. HIV-1 titers in plasma also correlated with high serum p24 antigen levels when serum was treated with glycine to dissociate antigen-antibody complexes.