[Translated article] Current situation of robotics in knee prosthetic surgery: A technology that has come to stay?

Robotic surgery is a surgical technique that is on the rise. The goal of robotic-assisted total knee arthroplasty (RA-TKA) is to provide the surgeon with a tool to accurately execute bone cuts according to previous surgical planning to restore knee kinematics and balance of soft tissue, being able to precisely apply the type of alignment that we choose. In addition, RA-TKA is a very useful tool for training. Within the limitations, there is the learning curve, the need for specific equipment, the high cost of the devices, the increase in radiation in some systems and that each robot is linked to a specific type of implant. Current studies show, with RA-TKA, variations in the alignment of the mechanical axis are reduced, postoperative pain is improved and earlier discharge is facilitated. On the other hand, there are no differences in terms of range of motion, alignment, gap balance, complications, surgical time or functional results.

Proposal for updating the Health Assessment Questionnaire

OBJECTIVE

To propose a consensus modification of the HAQ according to the predominant values, language, and culture of the society.

METHODS

First, a scoping review of the literature and a survey of HAQ users were conducted to identify the problems of this questionnaire. In a second phase, a meeting was held with expert professionals to discuss the results and design proposals for modification.

RESULTS

The scoping review allowed us to describe the main versions of the HAQ, as well as their psychometric properties. The HAQ users survey assessed the degree of comprehension, usefulness, timeliness, and universality of each of the items, and suggestions and opinions on its main limitations were accepted. During the discussion meeting, modifications to the items were proposed based on the results of the scoping review and the users survey. In addition, the difficulty of understanding the items, their difficulty in assessing intended movements, redundancy, obsolescence, and possible gender bias were taken into account.

CONCLUSIONS

An update of the Spanish version of the HAQ is proposed based on the literature review and expert opinion that highlights the paradigm shift in cultural values and aims to increase the content validity and discrimination capacity of this questionnaire.

[Translated article] Trichoscopy: An Update

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and frontal fibrosing alopecia.

[Result of the update of the clinical pathway for hip fracture in the elderly at a university hospital in Madrid]

BACKGROUND AND OBJECTIVES

Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge.

MATERIAL AND METHOD

A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year.

RESULTS

Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year.

CONCLUSIONS

Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.

[Autoimmune haemolytic anaemia]

Autoimmune haemolytic anaemias (AIHA) are acquired haematological disorders caused by increased peripheral erythrocyte destruction mediated by autoantibodies against erythrocyte antigens. They classified according to aetiology into primary and secondary, and according to the type of antibody and reaction temperature into AIHA due to warm antibodies (w-AIHA) and AIHA due to cold antibodies (c-AIHA). The mainstay of management in w-AIHA remains glucocorticoid therapy, and the early addition of rituximab has shown good results in recent studies. Primary c-AIHA is mainly treated with rituximab, alone or in combination with chemotherapy. New drugs such as Syk inhibitors, anti-FcRn Ig and complement inhibitors are in advanced development and will expand the therapeutic arsenal, especially in refractory or relapsed cases.

Trichoscopy: An Update

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and fibrosing frontal alopecia.

Main changes in the "COVID-19 in paediatrics" clinical practice guideline

We present a summary of the main modifications to the “COVID-19 in Paediatrics” clinical practice guideline made from its initial version, published in 2021, and the version published in 2022. The document was developed following the structured steps of evidence-based medicine and applying the GRADE system to synthesize the evidence, assess its quality and, when appropriate, issue graded recommendations (based on the quality of the evidence, values and preferences, the balance between benefits, risks and costs, equity and feasibility). This update also includes the modifications proposed by external reviewers.

We summarised the main modifications in the following sections: epidemiology, clinical features, diagnosis, prevention, treatment and vaccines. In relation to the body of knowledge achieved in the first year of the pandemic, the literature published in the second year contributed additional data, but without substantial modifications in many the areas. The main changes took place in the field of vaccine research. This update was completed in December 2021, coinciding with the emergence of infections by the omicron variant, so the document will need to be updated in the future.

[Update on gastric cancer. New molecular classifications]

Gastric cancer (GC) is an aggressive tumor, which is usually diagnosed at an advanced stage and shows high mortality rates. Several GC classifications have been published, based on features such as tumor location, endoscopic features or microscopic architecture. However, TNM stage remains the mainstay of GC management and treatment. In the last years, technical advances have allowed us to investigate the biological heterogeneity of GC and develop new molecular classifications. This knowledge may enhance current classifications, and has the potential to refine GC management and aid in the identification of new molecular targets. In this literature review we have summarized the main findings in epidemiology, screening, classification systems and treatment of GC, focusing on the molecular alterations and new molecular classifications published in the last years.

[Patent foramen ovale. An update for primary care]

Patent foramen ovale (FOP) is the most prevalent cause of cryptogenic strokes in people under 60 years old. Although it is usually asymptomatic, it has a high risk of producing paradoxical embolism and, therefore, stroke with indeterminate outcomes. The study should be started based on clinical suspicion, and includes a multidisciplinary assessment and a determination of the type of treatment to be performed. The therapeutic possibilities range from conservative treatment (indefinite antithrombotic treatment), to its percutaneous closure (currently the most widely used). The first objective is to decrease the number of stroke recurrences. Conservative treatment should be reserved for those cases of low embolic risk. The risk assessment must be individualised, fundamentally based on the anatomical characteristics of the FOP and the patient clinic picture. The use of the RoPE risk scale (The Risk of Paradoxical Embolism) should be a tool to consider.

Update of the Grupo Español de Leucemia Linfocítica Crónica clinical guidelines of the management of chronic lymphocytic leukemia

BACKGROUND AND OBJECTIVE

The broad therapeutic arsenal and the biological heterogeneity of patients with chronic lymphocytic leukemia (CLL) makes it difficult to standardize treatment for CLL patients with specific clinical settings in routine clinical practice. These considerations prompted us to elaborate the present consensus document, which constitutes an update of the previous version published in 2013, mainly focusing on novel treatment strategies that have been developed over last 5 years, namely B-cell receptor inhibitors (ibrutinib and idelalisib), anti-CD20 monoclonal antibodies (ofatumumab and obinutuzumab), and Bcl-2 inhibitors (venetoclax).

MATERIAL AND METHODS

A group of experts from the Spanish Chronic Lymphocytic Leukemia Group reviewed all published literature from January 2010 to January 2016, in order to provide recommendations based on clinical evidence. For those areas without strong scientific evidence, the panel of experts established consensus criteria based on their clinical experience.

RESULTS

The project has resulted in several practical recommendations that will facilitate the diagnosis, treatment, and follow-up of patients with CLL.

CONCLUSIONS

There are many controversial issues in the management of CLL with no appropriate studies for making consensus recommendations.

Pathological outcomes and agressiveness of low-risk prostate cancer in Northern African men

BACKGROUND

Northern African (NAf) men show a high incidence of advanced prostate cancer (PCa) at diagnosis. Several studies suggested the existence of ethnic differences in the PCa aggressiveness and this has led to some concerns related to the inclusion of some ethnic groups into active surveillance protocols.

OBJECTIVE

To evaluate pathological outcomes and aggressiveness of low risk PCa treated by radical prostatectomy in a NAf ethnic group.

SUBJECTS AND METHODS

Data of 147 NAfs, who underwent radical prostatectomy for low risk PCa diagnosed via a 12-core biopsy in 2 academic centers between 2011 and 2015, were reviewed retrospectively to assess rates of worse pathological outcomes defined as: Gleason score upgrade to at least 3+4, upstage to pT3a or higher or pN1, and positive surgical margins.

RESULTS

Overall significant upstage and/or upgrade occurred in 20.2% and positive surgical margins occured in18.3%. In multivariate logistic regression analysis, independent variables that predicted for upstage and/or upgrade or positive surgical margins in the entire cohort were: NCCN risk group (low risk>very low risk), advanced age>60 years, PSA>6ng/ml, PSA density≥0.15, more than 2 positive cores in biopsy, more than 50% cancer involvement in positive cores, clinical stage (T2a>T1c) and UCSF-CAPRA-S score>3.

CONCLUSIONS

Our study found that, at least pathologically, NAf men do not have more aggressive disease than Caucasians and African Americans in both low and very low risk PCa. Thus, we think that active surveillance is a suitable approach for selected patients since there is no definitive data that show a more aggressive natural history of PCa in NAf men.