Background:Critically ill patients are at risk of nosocomial infections, acquisition of multidrug-resistant pathogens, and substantial antimicrobial consumption. We assessed whether bathing with chlorhexidine reduces these outcomes compared to standard practices. Methods:We conducted an open-label, cluster-randomised crossover trial in 22 Brazilian intensive care units comparing daily chlorhexidine bathing versus soap and water bathing (control). Centres were randomised to 3- or 6-months chlorhexidine or control periods, separated by a 1-month washout. Primary outcome was nosocomial infection rate (central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia) during ICU stay. Secondary outcomes included specific nosocomial infections incidence, multi-drug resistant cultures, antibiotic use, length of stay, and mortality. This completed trial is registered at ClinicalTrials.gov, NCT05485051. Findings:From August 1st, 2022 to December 31, 2023, we included 15,935 patients (8247 chlorhexidine and 7688 control group). Mean age was 64·4 years (SD 17·3) in the chlorhexidine group [4315 (52·3%) male] and 64·2 years (SD 17·4) in the control group [4035 (52·5%) male]. A total of 201 nosocomial infections occurred in the chlorhexidine group, compared to 165 in the control group. There was no statistically significant difference in the overall nosocomial infections rate between groups [3·99 per 1000 patient-days in the chlorhexidine group and 3·45 per 1000 patient-days in the control group (rate-ratio, 1·09; 95% CI 0·95-1·25; p = 0·22)]. Patients in the chlorhexidine group had lower rates of multi-drug resistant cultures compared to the control group (14·42 vs. 20·13 per 1000 patient-days, rate-ratio, 0·73; 95% CI 0·59-0·91; p = 0·0092). Although overall antimicrobial consumption defined by WHO's DDD did not differ between groups (rate-ratio, 0·91; 95% CI 0·80-1·03; p = 0·14), there was a statistically significant difference in the consumption of antimicrobials in the Reserve group of WHO's AWaRe classification (rate-ratio, 0·73; 95% CI 0·59-0·90; p = 0·0071) in the chlorhexidine group. This reduction was not associated with higher mortality. Interpretation:Chlorhexidine bathing did not reduce the incidence of nosocomial infections in a general ICU population, but contributed to lower rates of multi-drug resistant pathogen isolation, and lower use of Reserve antimicrobials, potentially leading to a qualitative modification of antimicrobial use. Funding:This study was funded by the Brazilian Health Ministry through the Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS).
Background: Extensive debridement for Fournier gangrene may leave the testes exposed and produce complex scrotal and perineal defects. Local and locoregional pedicled flaps can provide durable vascularized coverage, but technique selection and the interpretation of functional and aesthetic results remain inconsistent. Objective: To evaluate indications, functional and aesthetic outcomes, and complications of scrotal reconstruction with local flaps after Fournier gangrene, and to propose a clinically useful method of selecting reconstructive techniques. Methods: A structured narrative review was performed using PubMed/MEDLINE and backward citation tracking through September 2026. Systematic reviews, reconstructive algorithms, comparative or observational cohorts, case series, and studies reporting patient-reported outcomes were prioritized. Evidence was synthesized by defect characteristics, flap type, function, appearance, and complications. No meta-analysis was attempted because of major heterogeneity in case selection, definitions, and follow-up. Results: Residual scrotal advancement is generally appropriate for defects that can be closed without tension, often involving less than approximately half of the scrotal surface. Pudendal and internal pudendal artery perforator flaps offer thin, potentially sensate tissue for larger defects, whereas superomedial or medial thigh flaps provide robust coverage for subtotal loss and perineal extension. Gracilis muscle-based reconstruction is most useful when dead space, contamination, or deeper perineal involvement requires vascularized bulk. Across the flap literature, complete flap loss is uncommon; a 2026 systematic review reported 1.6% overall loss. However, wound-edge necrosis, partial loss, seroma, dehiscence, infection, bulkiness, contour asymmetry, and donor-site morbidity remain relevant. Functional and aesthetic claims are limited by small retrospective series and infrequent use of validated patient-reported measures. Conclusion: Local flap reconstruction is reliable when the wound is controlled and the technique is matched to defect size, location, dead space, patient risk, and reconstructive goals. Native scrotal tissue should be preserved whenever tension-free closure is possible; larger or composite defects require a tailored pedicled flap. Current evidence supports low rates of total flap loss but does not establish the superiority of one flap or prove preservation of fertility or thermoregulation. Standardized long-term assessment is needed.
The distal tibiofibular syndesmosis is a critical fibrous joint essential for ankle stability. Injuries to this complex, if misdiagnosed or improperly treated, can lead to chronic pain, instability, and premature osteoarthritis. This review covers the essential aspects of syndesmotic injuries, including anatomy, biomechanics, diagnosis, and current treatment strategies. The syndesmosis is stabilized by the anterior and posterior inferior tibiofibular ligaments and the interosseous ligament. These structures permit controlled motion during ankle movement. The typical injury mechanism involves excessive external rotation and dorsiflexion, leading to a sequential ligamentous rupture. Clinical diagnosis relies on the mechanism of injury and physical tests such as the squeeze and external rotation tests, although their reliability is debated. Imaging is crucial for confirmation. Weight-bearing radiographs are the first-line study, but computed tomography (CT), especially weight-bearing CT, offers greater accuracy for diagnosing instability. Magnetic resonance imaging (MRI) is excellent for assessing soft-tissue damage and associated injuries. Treatment is determined by joint stability. Stable, partial injuries are managed conservatively with immobilization and structured rehabilitation. Unstable injuries require surgical intervention to ensure anatomic reduction and restore stability. While rigid screw fixation was historically the standard, it impairs physiological motion and often necessitates a second surgery for hardware removal. Flexible fixation with suture-button devices has emerged as the modern standard of care. This technique provides dynamic stabilization, allows for natural joint micro-motion, and is associated with improved clinical outcomes and a lower rate of reoperation. Arthroscopy is a valuable tool for diagnosing and treating these injuries, enabling direct visualization and debridement to ensure accurate reduction. Proper management of syndesmotic injuries is paramount for optimizing patient recovery and preserving long-term ankle function. Level of evidence IV.
This study aimed to explore the relationship between atopic dermatitis (AD) disease severity and impact on patients and to describe AD treatment patterns and barriers to treatment in Brazil and Colombia. Data were drawn from the Adelphi AD Disease Specific Programme™, a cross-sectional survey of physicians and their patients with AD, conducted in Brazil and Colombia between May 2022 and July 2023. Physicians provided data on demographics, clinical characteristics, treatments, and reasons for not prescribing targeted therapy (TT). Patients completed various patient-reported outcome (PRO) questionnaires: Patient-Oriented Eczema Measure, Dermatology Life Quality Index, EuroQol five-dimensional, and Work Productivity and Activity Impairment. Data were analysed descriptively. Comparisons between current severity were made using analysis of variance (ANOVA) or Kruskal–Wallis tests. Overall, 100 physicians provided data for 624 adult patients with AD from Brazil (n = 328) and Colombia (n = 296): 47
INTRODUCTION:Neuromyelitis optica spectrum disorders (NMOSD) is an autoimmune disorder primarily affecting the central nervous system, with cognitive impairments often overlooked in clinical studies. This systematic review and meta-analysis aimed to evaluate cognitive function in individuals with NMOSD, addressing gaps in the literature and informing clinical practice. METHODS:A comprehensive literature search identified 28 eligible studies involving 1365 patients. Cognitive performance was assessed using validated neuropsychological tools, including the Controlled Oral Word Association Test (COWAT), California Verbal Learning Test (CVLT), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Paced Auditory Serial Addition Test (PASAT), and Symbol Digit Modalities Test (SDMT). RESULTS:The analysis revealed significant cognitive deficits across multiple domains. Verbal fluency (COWAT: mean score 24.68, 95 % CI: 23.70-25.70) and memory recall (CVLT: mean score 43.01, 95 % CI: 42.26-43.78) were notably impaired. Global cognitive function was mildly affected, with mean scores of 27.34 (95 % CI: 26.97-27.72) on the MMSE and 26.54 (95 % CI: 26.51-26.57) on the MoCA. High variability (I² > 80 %) in cognitive performance was attributed to differences in study methodologies and patient characteristics. CONCLUSION:These findings underscore the prevalence of cognitive impairments in NMOSD and highlight the need for targeted neuropsychological assessments in this population. Incorporating cognitive evaluations into routine clinical practice could enhance patient management and improve quality of life.
