Risk factors associated with death in Brazilian children with severe dengue: a case-control study

OBJECTIVE:

The purpose of this case-control study was to evaluate risk factors associated with death in children with severe dengue.

METHODS:

The clinical condition of hospitalized patients with severe dengue who died (cases, n = 18) was compared with that of hospitalized patients with severe dengue who survived (controls, n = 77). The inclusion criteria for this study were age under 13 years; hospital admission in São Luis, northeastern Brazil; and laboratory-confirmed diagnosis of dengue.

RESULTS:

Severe bleeding (hemoptysis), a defining criterion for dengue severity, was the factor most strongly associated with death in our study. We also found that epistaxis and persistent vomiting, both included as warning signs in the World Health Organization (WHO) classification of dengue, were strongly associated with death. No significant association was observed between any of the laboratory findings and death.

CONCLUSIONS:

The finding that epistaxis and persistent vomiting were also associated with death in children with severe dengue was unexpected and deserves to be explored in future studies. Because intensive care units are often limited in resource-poor settings, any information that can help to distinguish patients with severe dengue with a higher risk to progress to death may be crucial.     

Transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney morcellation: a proof of concept study

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Until now, the transvaginal approach has been the only method of removing larger specimens from the abdominal cavity using natural orifice transluminal endoscopic surgery. There has been no means of extracting larger specimens in men and the means are restricted even in women, particularly in young women. The present study shows that the difficulty of large specimen retrieval can be overcome, irrespective of the diameter of the chosen port, through natural orifices using morcellation.

OBJECTIVE

• ? To show, in a porcine model, the feasibility of a complete transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney extraction after morcellation through the same port.

MATERIALS AND METHODS

• ? Transvesical nephrectomy and morcellation were performed in six pigs at Minho University, Braga, Portugal after institutional review board approval.
• ? The transvesical port and the cystotomy were created under the guidance of a ureteroscope, while the remaining steps were done under the guidance of an operating telescope.
• ? Dissection of the renal vessels and kidney was performed using dissection grasping forceps and a vessel sealing system (LigaSure^?; Covidien, Mansfield, MA, USA) and morcellation was done using a Piranha^? morcellator (Richard Wolf, Knittlingen, Germany).

RESULTS

• ? There were no complications related to the creation of transvesical access.
• ? The image provided by the telescope was superior to that of the ureteroscope, especially underwater. Morcellation was quick and effective, with the support of a fixing needle through the abdominal wall, designed to fix the kidney, after laceration of a bowel loop occurred in the first experiment.
• ? It was found that technical improvements are needed to ensure safety of NOTES morcellation.

CONCLUSIONS

• ? Kidney morcellation after nephrectomy, using a natural orifice exclusively, is feasible.
• ? Despite technical limitations, this proof of concept study can be regarded as a potential step towards the application of NOTES in urology.