Recurrent hydatid disease of the liver with intra-abdominal echinococcosis: Case in images

@#A 38-year-old female was admitted due to recurrent right upper quadrant (RUQ) abdominal pain. Three years prior to admission, the patient complained of a sudden onset of RUQ pain radiating to the right flank area. A month after the onset of pain, she consulted a physician, and she was advised to undergo endoscopy, but she did not comply. Three months after the consultation, an abdominal ultrasound was done, revealing a simple hepatic cyst. She then underwent aspiration of the cyst. However there was no resolution of the pain. A contrast-enhanced abdominal computed tomography (CT) scan revealed a recurrence of the hepatic cyst. Subsequently, she underwent laparoscopic fenestration of the cyst in liver segments VI, VII, and VIII. The biopsy results confirmed that the hepatic cyst was a hydatid cyst caused by Echinococcus granulosus. A month after the procedure, the abdominal pain recurred, and a repeat CT scan revealed another recurrence of the cyst. The patient was advised to undergo open surgery, but she did not consent. The patient denied taking anthelmintic drugs in the past. She did not experience any other symptoms—such as jaundice, nausea, vomiting, anorexia, or weight loss—along with the RUQ pain. She previously worked in Lebanon as a domestic helper for seven years and then moved to Taiwan, where she was employed for three years for the same work. She denied any direct exposure to dogs or sheep. On physical examination, she had a non-tender, firm, palpable mass in the RUQ area of the abdomen measuring 4x4 cm. The rest of the physical examination findings were unremarkable. A contrast-enhanced CT scan of the whole abdomen done two months prior to her admission showed multiple, well-defined, hypodense lesions in the right hepatic lobe. These lesions exhibited mildly enhancing walls and internal septations with rosette or honeycomb appearance. The two largest lesions seen in hepatic segments V and VII measured 8.6 x 6.1 x 5.2 cm and 9.5 x 8.5 x 7.4 cm, respectively (Figure 1). Similar hypodense lesions were seen in the right retroperitoneal space. At least two lesions were visible in the right perirenal space, measuring 8.8 x 6.1 x 6.5 cm and 6.1 x 5.9 x 3.8 cm, and at least two other lesions were visible in the right anterior pararenal space, within the region of the distal ascending colon, measuring 6.0 x 5.5 x 5.4 cm and 7.9 x 6.4 x 5.1 cm (Figure 2). At this point, we diagnosed the patient as having a recurrent hydatid cyst in the right hepatic lobe, with intraperitoneal extension in the right perirenal space and right anterior pararenal space, based on the CT scan findings. After securing medical clearance and administering mebendazole prophylactically at a dosage of 40 mg/kg/day, taken 3 times a day for 7 days prior to surgery, we aimed to sterilize the hydatid cysts and prevent surgical contamination.1 We did an exploratory laparotomy through a reverse L (Makuuchi) skin incision on the right upper abdominal quadrant (Figure 3). We subsequently performed a layered dissection down to the peritoneum. Intraoperatively, we noted adhesions at the posterior segments of the liver, right diaphragm and mid transverse colon. We then meticulously performed adhesiolysis. With extreme caution, we ensured to prevent any spillage of the cystic contents into adjacent structures and the abdominal cavity. Then, we covered the abdomen with abdominal packs soaked in 95% ethanol. Intraoperative liver ultrasonography revealed only one cystic lesion involving hepatic segments V, VI, and VII. The cyst was adherent to the right subdiaphragmatic area. We also noted multiple intraperitoneal cysts: one adherent to the right perirenal area measuring 8 x 6 cm, another adherent to the distal ascending colon and the mid transverse colon measuring 7 x 6 cm, and a third one non-adherent and floating in the anterior pararenal area measuring 4 x 4 cm. Before excising the intrahepatic mother cyst, we aspirated approximately 30-40 ml of cyst fluid and infused the cyst with an equivalent amount of 95% ethanol. After 15 minutes, we reaspirated the infused ethanol. We first carefully excised the intraperitoneal extensions of the cyst, (Figure 4) starting with the cyst in the distal ascending colon, then the cyst in the anterior pararenal area, and finally the right perirenal cyst, taking extreme caution to avoid rupturing the cyst. We then proceeded with the dissection of the hepatoduodenal ligament, where the portal triad is located, to provide access for our Pringle Maneuver. This step was followed by adhesiolysis at the right subdiaphragmatic area. Because of dense adhesions, there was a diaphragmatic injury, for which we performed phrenicorrhaphy. We then mobilized the right hepatic lobe through careful dissection of the triangular and coronary ligaments. The margins were marked under ultrasound guidance and the Pringle Maneuver was applied intermittently. We then carried out a parenchymal-sparing resection of segments V, VI, and VII. After securing hemostasis, we placed a Jackson Pratt drain in the subhepatic area. At the end of the surgery, we successfully resected hepatic segments V, VI, and VII, which contained an intrahepatic mother cyst with multiple spherical daughter cysts. Additionally, we excised three secondary cysts from the intraperitoneal area. Grossly, the excised specimen showed the right posterior segment of the liver with a surgically resected yellowish multiseptated cyst attached to it. This cyst has a fibrous rim and it contains several variable-sized daughter cysts (Figure 5). The excised intraperitoneal cyst from the distal ascending colon to mid transverse colon area (Figure 6), has a thick wall with a laminated external layer (Figure 7). The histopathological examination of the hydatid cyst showed E. granulosus protoscolices containing four acetabula and an armed rostellum with 30 to 36 hooks (Figure 8) . Sections of the liver showed liver parenchyma that was infiltrated by mononuclear cells. Adjacent to the liver parenchyma, the hydatid cyst wall contains an outer acellular laminated membrane, a germinal membrane, and remnants of the E. granulosus protoscolices, which resembled grains of sand (Figure 9 and 10). Postoperatively, the patient complained of dyspnea and tachypnea. On chest physical examination, we noted decreased breath sounds on the right. A chest x-ray done revealed a right-sided pneumothorax. Pneumothorax can occur during hepatectomy due to the escape of intraperitoneal carbon dioxide gas into the pleural cavity.2 We performed a chest tube thoracostomy insertion, and removed the tube after 5 days, once we observed full expansion of the patient’s right lung. We discharged the patient on the 9th postoperative day and prescribed oral antibiotics and pain relievers as home medications. Cystic echinococcosis (CE) or hydatid disease is a zoonotic parasitic disease caused by infection with the larval stage of the tapeworm E. granulosus. Dogs and other carnivores are definitive hosts, while sheep, cattle, and goats are intermediate hosts. Humans are accidental, intermediate hosts and become secondarily infected by ingesting food or water contaminated with eggs or gravid proglottids that are excreted in the definitive host’s feces. CE is endemic in North and East Africa, South America, China and Central Asia, and the Mediterranean countries.3 4 5 6 This disease has a low prevalence in Southeast Asia, particularly the Philippines.7 In our case, the patient probably acquired the infection when she worked in Lebanon, where echinococcosis is endemic. The liver and the lungs are the most common sites of the disease in humans. The concomitant occurrence of the cyst in the retroperitoneum or other intra-abdominal spaces is extremely rare,8 9 and it is associated with a high mortality and disability rate.10 Abdominal CT scan is a good imaging technique for visualizing wall calcifications in CE,11 and in our patient, enhancing walls and internal septations, which represent the walls of daughter cysts, were seen. Peritoneal seeding or cyst dissemination can occur due to a previous hepatic hydatid cyst surgery or after a spontaneous or traumatic rupture.12 These secondary cysts are formed from the liberated protoscolices caused by rupture of the daughter cysts.13 Although rare, when a cyst ruptures into the peritoneal cavity, it can lead to reactions ranging from mild hypersensitivity reaction to potentially fatal anaphylactic shock.14 A preoperative course of oral albendazole or mebendazole, as in the case of our patient’s medication, sterilizes the cysts and reduces their tension, thereby facilitating the surgery.15 16 It also kills most of the protoscolices within the hepatic hydatid cyst.17 Postoperatively, these drugs significantly reduce the risk of cyst recurrence.16 The prognosis of CE is generally good, and a complete cure is possible with total surgical excision without spillage.18 For hepatic echinococcosis, it is crucial to prioritize radical surgical resection in the initial surgery and preoperative anthelmintic therapy to minimize morbidity and recurrence often linked with conservative surgery.16 19

Experiencia con sacubitril/valsartán en una clínica de falla cardiaca / Experience with sacubitril/valsartan in a heart failure clinic

Resumen Objetivo: describir las características y el comportamiento clínico de pacientes tratados con sacubitril/valsartán en una clínica de falla cardiaca de un hospital de alta complejidad. Métodos: se analizaron en retrospectiva 56 pacientes en manejo con sacubitril/valsartán, entre enero de 2017 y mayo de 2018. A los tres meses de inicio del tratamiento, 87% de los pacientes fueron evaluados. Se determinaron cambios en clase funcional, fracción de eyección ventricular izquierda (FEVI) y presión arterial sistólica y diastólica. Se registraron reingresos hospitalarios por falla cardiaca, mortalidad cardiovascular y eventos adversos asociados a la medicación. Resultados: la edad promedio fue 71,3 años; 51,7% correspondían al sexo masculino, 73% tenía etiología isquémica, 35% clase funcional NYHA II y 60% NYHA III antes de iniciar el tratamiento con sacubitril/valsartán. Al finalizar el seguimiento, 57% mejoró su clase funcional y 81,7% se encontraba en clase funcional NYHA II (IC95%, -0,52 a-0,18; p=0,0002). Hubo mejoría significativa en los valores de FEVI respecto a los basales (IC95%, 4,27 a 11,86; p=0,0002). Se observó una disminución significativa de la presión arterial tanto sistólica como diastólica (p<0,01). Un paciente presentó muerte súbita (2%) y uno hospitalización por falla cardiaca (2%). Ningún paciente descontinuó la terapia por efectos adversos. Conclusión: sacubitril/valsartán es una terapia útil en pacientes con falla cardiaca sintomática y FEVI reducida. La población evaluada tenía un perfil demográfico y clínico semejante al del ensayo clínico PARADIGM-HF, lo cual sugiere que los desenlaces clínicos son similares en la población colombiana.

Abstract Objective: The aim of this study is to describe the characteristics and clinical behaviour of patients treated with sacubitril/valsartan in a heart failure clinic of a high complexity hospital. Methods: A retrospective analysis was performed on a total of 56 patients on treatment with sacubitril/valsartan, between January 2017 and May 2018. At three months from the start of the treatment, 87% of the patients were evaluated. Changes were observed in functional class, left ventricular ejection fraction (LVEF), and systolic and diastolic arterial pressure. A record was made of hospital re-admissions due to heart failure, cardiovascular mortality, and adverse events associated with the medication. Results: The mean age of the patients was 71.3 years, of which 51.7% were male. An ischaemic origin was found in 73%. NYHA II and NYHA III functional class was observed 35% and 60%, respectively, before starting the treatment with sacubitril/valsartan. At the end of follow-up, 57% improved their functional class, and 81.7% were found to be in NYHA II functional class (95% CI; -0.52 to -0.18:=0.0002). There was a significant improvement in the LVEF values compared to baseline (95% CI; 4.27 to 11.86; P=0.0002). A significant decrease was observed in both systolic and diastolic blood pressure (P<0.01). There was sudden death in one (2%) patient and one (2%) patient admitted due to heart failure. None of the patients stopped the therapy due to secondary effects. Conclusion: Sacubitril/valsartan is a useful therapy in patients with symptomatic heart failure and a decreased LVEF. The population evaluated had a demographic and similar clinical signs and symptoms to the PARADIGM-HF clinical trial, which suggests that the clinical outcomes are similar in the Colombian population.

Anesthetic use of eugenol and benzocaine in red tilapia (oreochromis sp.) / Uso anestésico de ugenol y benzocaína juveniles de tilapia roja (oreochromis sp.) / Eugenol e benzocaína como anestésicos em juvenis de tilápia vermelha (oreochromis sp.)

Abstract Background: routine practices such as biometrics, transportation and medical procedures are a source of stress to fish. The use of anesthetics is recommended to reduce undesirable effects of stress, such as decreased feed intake and even mortality -in critical cases. Objective: the aim of this study was to determine the anesthetic efficacy of eugenol and benzocaine in juveniles of red tilapia Oreochromis sp. Methods: juveniles of red tilapia (n=30), Oreochromis sp., were distributed in groups of 10 individuals as follows; G1: eugenol (50 mg/l), G2: eugenol (100 mg/l) and G3: benzocaine (100 mg/l). The fish were individually placed in the corresponding anesthetic solution. After immersion, times to achieve the different anesthetic stages were recorded. During anesthesia, the fish were measured, weighed and blood samples were collected for glucose and plasma cortisol analysis. Results: time to total loss of equilibrium was higher in G3 (p<0.05) compared to the other two groups. No significant differences were observed among groups regarding time to total loss of equilibrium or time to ventilation absence. Glucose levels were significantly higher in G1 (p=0.03) in comparison to G3. However, cortisol levels were higher in G3 as compared to the other groups (p<0.05). 10% mortality was observed in G1 fish. Conclusions: present findings indicate that 100 mg/l eugenol leads to induction of anesthesia in less than 3 minutes and recovery in less than 5 minutes, without mortality in juveniles of red tilapia.

Resumen Antecedentes: prácticas de rutina tales como biometría, transporte y procedimientos médicos representan una fuente de estrés para los peces. El uso de anestésicos está recomendado para contrarrestar los efectos nocivos del estrés, tales como disminución en el consumo de alimento y mortalidad en casos críticos. Objetivo: el presente trabajo buscó determinar la eficacia anestésica del eugenol y benzocaína en juveniles de tilapia roja Oreochromis sp. Métodos: en este estudio fueron utilizados 30 juveniles de tilapia roja (Oreochromis sp.) distribuidos en grupos de 10 individuos como sigue; G1: eugenol (50 mg/l), G2: eugenol (100 mg/l) y G3: benzocaína (100 mg/l). Los peces fueron ubicados individualmente en la solución anestésica correspondiente. Después de la inmersión fueron medidos los tiempos para alcanzar los diferentes planos anestésicos. En el tiempo de anestesia, los peces fueron medidos, pesados y colectadas muestras de sangre para análisis de glucosa y cortisol plasmático. Resultados: el tiempo de pérdida del eje de nado fue mayor en el G3 (p<0.05). No se encontraron diferencias significativas entre los grupos en el tiempo de recuperación del eje de nado y en el tiempo de ausencia de movimientos operculares. Los niveles de glucosa fueron significativamente mayores en los animales del G1 (p=0.03) respecto al G3. Sin embargo, los niveles de cortisol fueron mayores en el G3 respecto a los otros grupos (p<0.05). Se observó un porcentaje de mortalidad del 10% en los ejemplares del G1. Conclusiones: los resultados sugieren que el eugenol a una concentración de 100 mg/l lleva a una inducción anestésica menor a 3 minutos y recuperación menor a 5 minutos sin mortalidad en juveniles de tilapia roja.

Resumo Antecedentes: os procedimentos de rotina tais como a biometria, transporte e procedimentos clínicos são uma fonte de estresse para os peixes. O uso de anestésicos está recomendado para diminuir os efeitos nocivos do estresse, como por exemplo, a diminuição no consumo de alimento e em casos críticos mortalidade. Objetivo: o presente trabalho buscou determinar a eficácia anestésica do eugenol e da benzocaína em juvenis de tilápia vermelha Oreochromis sp. Métodos: neste estudo foram utilizados 30 juvenis de tilápia vermelha (Oreochromis sp.) distribuídos em grupos de 10 indivíduos de acordo ao anestésico utilizado; G1: eugenol (50 mg/l), G2: eugenol (100 mg/l) e G3: benzocaína (100 mg/l). Os animais foram passados pela solução anestésica correspondente, na qual se mediram tempos para atingir os diferentes estádios de anestesia. No tempo de anestesia, os peixes foram medidos, pesados e coletadas amostras do sangue para análise de glicose e cortisol plasmático. Resultados: o tempo de pérrdida do eixo de nado foi maior no G3 (p<0.05). Não se encontraram diferenças significativas entre os grupos no tempo de recuperação do eixo de nado e no tempo de ausência de movimentos operculares. Os níveis de glicose foram significativamente maiores nos animais do G1 (p=0.03) respeito ao G3. No entanto, os níveis de cortisol foram maiores no G3 em relação a os outros grupos (p<0.05). Observou-se um percentual de mortalidade de 10% nos exemplares do G1. Conclusão: os resultados sugerem que o eugenol a 100 mg/l provoca uma indução anestésica menor a 3 minutos e uma recuperação menor a 5 minutos sem mortalidade em juvenis de tilápia vermelha.

Stage-specific embryonic antigen: determining expression in canine glioblastoma, melanoma, and mammary cancer cells

The expression of stage-specific embryonic antigens (SSEAs) was determined in several types of canine cancer cells. Flow cytometry showed SSEA-1 expression in glioblastoma, melanoma, and mammary cancer cells, although none expressed SSEA-3 or SSEA-4. Expression of SSEA-1 was not detected in lymphoma, osteosarcoma, or hemangiosarcoma cell lines. Relatively stable SSEA-1 expression was observed between 24 and 72 h of culture. After 8 days in culture, sorted SSEA-1⁻ and SSEA-1⁺ cells re-established SSEA-1 expression to levels comparable to those observed in unsorted cells. Our results document, for the first time, the expression of SSEA-1 in several canine cancer cell lines.

Síndrome de Ehlers-Danlos Clásico o Ehlers-Danlos tipo I - II / The Classic Ehlers-Danlos or Ehlers-Danlos type I - II

El Síndrome de Ehlers-Danlos Clásico o Ehlers-Danlos tipo I - II, al igual que el Ehlers-Danlos Vascular son poco frecuentes, si se les compara con el tipo Hipermovible o tipo III, el que afecta al 39 por ciento de la población chilena. Es importante porque al tener marcada hiperlaxitud articular (contorsionistas) presenta subluxaciones importantes. Además, debido a la gran hiperextensibilidad de la piel, la que es muy frágil, tiene tendencia a heridas y a mala cicatrización. Al igual que los otros tipos de Síndrome de Ehlers-Danlos, el Clásico puede tener Hábito Marfanoide o/y Disautonomía. Se puede presentar también con Osteopenia u Osteoporosis, hernias, várices, hemorroides y prolapso. Tiene herencia autosómica dominante y la alteración genética es conocida (COL5A1 o COL5A2).

The Classic Ehlers-Danlos or Ehlers Danlos type I - II, as the Vascular Ehlers-Danlos are infrequent, as compared with the Hypermobile or type III, that affects 39 percent of the chilean population. It is important because due to the marked joint hypermobility (contosionists) presents important subluxations. Also due to the important skin laxity, which is fragile it has tendency to injuries and poor cicatrization. As the other Ehlers-Danlos types, the Classic Ehlers-Danlos can present with Marfanoid habitus and or Dysautonomia. It also can have Osteopenia or Osteoporosis, hernias, varicose veins, hemorrhoids and prolapse. It has dominant Autosomic inheritance and the genetic alteration is known (COL5A1 or COL5A2).

Síndrome de Ehlers-Danlos vascular: complicaciones vasculares graves en enfermos con hipermovilidad articular / Vascular Ehlers-Danlos syndrome: severe vascular complications in patients with articular hypermobility

El Síndrome de Ehlers-Danlos Vascular es una de las Alteraciones Hereditarias del Tejido Conectivo. Es poco frecuente, pero es de alta morbilidad y mortalidad. Se debe a una mutación del gen COL3A1, que da debilidad del tejido colágeno, por lo que se pueden producir complicaciones graves afectando a la piel, tubo digestivo, hígado, pulmón y sistema vascular. Se pueden producir rupturas intestinales, neumotórax espontáneo, dilatación o ruptura aortica y anuerismas, lo que puede llevar a la muerte súbita del paciente.

The Vascular Ehlers-Danlos is one of Hereditary Diseases of Connective Tissue. Has low prevalence, but high morbidity and mortality. It is due to a COL3A1 gene mutation, producing tissue fragility, which can produce serious complications in the skin, digestive tract, liver, lungs and in the vascular system. It is frequently associated to intestinal ruptures, spontaneous pneumothorax, dilation or rupture of the aorta anuerism, which can lead to sudden death.

Cuando sospechar el síndrome de Ehlers-Danlos tipo III, también llamadosindrome de Ehlers-Danlos hipermovible / When to suspect Ehlers-Danlos type III, also known as hypermobile Ehlers-Danlos syndrome

Ehlers-Danlos Syndrome type III is a very frequent disease, with dominant inheritance, that usually goes undiagnosed, due to lack of knowledge of the disease by physicians. In this article we discuss in detail clinical signs and symptoms that will enable doctors to suspect the diagnosis...

El síndrome de Ehlers-Danlos tipo III es una enfermedad hereditaria dominante, muy frecuente, que generalmente no es diagnosticada, debido a falta de conocimiento del tema por parte de los médicos. En este artículo se revisan, en detalle, los signos y síntomas clínicos de la enfermedad con el fin de ayudar al médico a sospechar el diagnóstico...

Bradicardia y convulsiones: una relación multicausal / Bradycardia and seizures: a multi-causal relationship

La disfunción del nodo sinusal consiste en una alteración en la generación del impulso en el nodo sinusal. Su principal causa es la degeneración fibrosa del tejido sinusal. Los casos asociados a convulsiones son multicausales y se deben a los efectos cardiodepresores de los anticonvulsivantes o de sus diluyentes; así mismo se pueden presentar casos de bradicardia y asistolia inducidos por las descargas epilépticas. Se expone el caso de una paciente con status epiléptico tratada con fenitoína endovenosa, quien recibía previamente carbamazepina y desarrolló disfunción del nodo sinusal considerada como un efecto secundario tóxico de su medicación anticonvulsivante.

Sinus node dysfunction is an alteration in the impulse generation in the sinus node. Its main cause is the fibrous degeneration of the sinus tissue. Cases associated with seizures have multiple causes and are due to the cardio-depressant effects of anticonvulsants or its diluents. Likewise, there may be cases of bradycardia and asystole induced by epileptic discharges. Here is presented the case of a female patient with status epilepticus who was treated with intravenous phenytoin and was previously receiving and developed sinus node dysfunction which was considered as a toxic side effect of her anticonvulsant medication.

Del rostro al texto: tras las huellas de la hiperlaxitud y la disautonomía en escritores / From the face to the text: after the fingerprints of the hyperlaxity and the dysautonomia in writers

At present there is a renew interest in delineating diagnostic criteria for the Ehlers-Danlos Syndrome type III (EDS-III), condition than even though is not serious, can produce poor quality of life, due to alteration of various organs and the presence of dysautonomia. The fragility of tissues, that causes the symptomatology, can frequently be reflected in some external signs. In this study, some authors have been selected that present facial signs that are characteristic of this syndrome and gives us the opportunity to look in their texts some tracts of this disease, by looking in their autobiographic texts or in their fiction works. This exercise of free association helps us to have a more complete view of their rich and complex personalities and helps us also to appreciate the importance in detecting and preventing the consequences of this disease, that with an adequate management can produce a notable improvement in the quality of life...

Hoy se está produciendo un renovado interés por afinar los criterios diagnósticos del síndrome de hipermovilidad articular (similar al SED-III), condición que, aunque no suele ser grave, puede traducirse en una mala calidad de vida, por trastornos en diversos órganos y la presencia de disautonomía. La debilidad de los tejidos conectivos, causante de la sintomatología, suele reflejarse también en algunos signos externos. En este estudio se seleccionan algunos escritores que presentan signos en el rostro característicos de este síndrome y que nos dan la oportunidad de buscar entre sus textos algunas pistas de esta enfermedad, ya sea en textos autobiográficos o en sus obras de ficción. Este ejercicio de libre asociación nos ayuda a tener una mirada más completa de sus ricas y complejas personalidades, y nos ayuda también a tomar conciencia de la importancia de detectar y prevenir las consecuencias de esta enfermedad, que con manejo adecuado puede traducirse en una mejoría notable de la calidad de vida...

Reconstrucción de un defecto vulvar crónico secundario al tratamiento de un carcinoma primario de la vagina: reporte de un caso y consideraciones de manejo / Reconstruction of a chronic secondary vulvar defect upon treatment of primary vaginal carcinoma: a case report and management considerations

El cáncer de vagina es una neoplasia rara, que constituye un 1% del cáncer genital femenino, aunque ha aumentado su incidencia en los últimos años. El manejo quirúrgico, adyuvante y reconstructivo resulta importante en el resultado oncológico y funcional de la enfermedad, pero puede comprometer la anatomía y función vaginal, y la de los órganos adyacentes. El avance en las terapias quirúrgicas y adyuvantes en pacientes más jóvenes ha conducido a una mayor supervivencia, implicando la necesidad de un mejor manejo del defecto anatómico de la lesión o de las secuelas de su tratamiento. Debe intentarse siempre que sea necesario un manejo multidisciplinario, desde la primera intervención, incluyendo la técnica reconstructiva correspondiente al defecto. Se presenta un caso de manejo conjunto oncológico y reconstructivo, mediante colgajo unilateral en flor de loto de un defecto vulvar crónico, originado tras el manejo de un cáncer vaginal primario previo.

Vaginal cancer is a rare neoplasm which makes up 1% of female genital cancer; however, its incidence has risen in the past few years. Adjuvant and reconstructive surgical management prove to be important in the oncologic and functional outcome of the disease, but may involve anatomy and function in the vagina, as well as in adjacent organs. Breakthroughs in surgical and adjuvant therapy have led to greater survival rates among younger patients, thus implying a greater need for improved management of the anatomical defect in the lesion or of treatment side effects. An effort should always be made towards interdisciplinary management, from the initial interven tion, including the corresponding reconstructive technique used on the defect. A case is presented on the combined oncologic and reconstructive management achieved by means of a lotus flower unilateral flap for a chronic vulvar defect brought about by previous primary vaginal cancer.

Dificultades en el diagnóstico y tratamiento de la disautonomía / Difficulties in the diagnosis and dysautonomia treatment

La disautonomía es una condición médica frecuente que, por lo general, cursa sin ser diagnosticada y es causa de fatiga crónica, mareos, desmayos y mala calidad de vida. estos enfermos muchas veces peregrinan de médico en médico, se les hacen múltiples exámenes, se plantean múltiples hipótesis, pero el diagnóstico preciso no se hace, ya que no se tiene en cuenta la disautonomía. Ésta frecuentemente se asocia al Síndrome de Hiperlaxitud Articular, que es una de las alteraciones hereditarias de la fibra colágena que es muy prevalente en Chile. El tratamiento, que es muy eficaz, suele fallar, ya que los enfermos temen tomar muchos líquidos y aumentar la sal y por miedo a los mineralocorticoides.

Dysautonomia is a frequent medical condition which goes undiagnosed and produces chronic fatigue, dizziness, syncope and poor quality of life. It is usually seen in association with the Joint Hypermobility Syndrome. Patients with Dysautonomia perambulate from physician to physician, get multiple tests, are given different medical hypothesis, but the precise diagnosis is not made. Even though there is a good treatment, the results are not as good as expected, because the patients are concerned about taking too much salt and water and are afraid of mineralocorticoids.

Prospective validation of protocol for occult penetrating cardiac injury

OBJECTIVE: Preliminary studies done at the Philippine General Hospital have documented the reliability of pericardial ultrasound in the diagnosis of occult penetrating cardiac injury. This study sought to validate a protocol formulated from these studies in a larger trauma patient population at a high-volume center. METHODS: Over a 2-year period, all hemodynamically stable patients with penetrating injury to the precordial area were managed according to the occult penetrating cardiac injury protocol. Patients with a negative result on pericardial ultrasound were admitted for 24-hour observation. Those with minimal fluid or equivocal findings underwent a subxiphoid pericardiotomy. Patients with moderate to large amounts of fluid on ultrasound, as well as those with positive results on subxiphoid pericardiotomy, underwent definitive surgery. Demographic data, wounding patterns, and clinical course were studied. RESULTS: Three hundred forty patients were analyzed. Majority (91%) had negative ultrasound results, and where either discharged after 24-hour observation, or were treated for other associated injuries. None developed signs or symptoms of cardiac tamponade on follow-up. Twenty-six patients (8%) had either minimal fluid or equivocal findings. These underwent subxiphoid pericardiotomy, of which 10 had positive cardiac injury while nine had serous fluid. Three had moderate amount of fluid on ultrasound and underwent immediate thoracotomy; all had significant cardiac injury. There were no late complications noted. CONCLUSION: Our data provides further validation that subxiphoid pericardial ultrasound is effective as an initial tool in ruling out cardiac injury. Because of a significant number of false positives in Filipino patients, those with minimal fluid should undergo subxiphoid pericardiotomy. The finding of moderate fluid is an indication for definitive surgery.

Síndrome de Ehlers-Danlos tipo III, llamado también síndrome de hiperlaxitud articular (SHA): epidemiología y manifestaciones clínicas / Ehlers-Danlos syndrome type III, also called joint hypermobility síndrome (JHS): epidemiology and clinical manifestations

El Síndrome de Ehlers-Danlos tipo III (SED-III), también llamado Síndrome de Hiperlaxitud Articular (SHA), es una enfermedad de los tejidos conectivos, muy frecuente y poco diagnosticada. Es debido a una alteración genética del colágeno que genera lesiones músculo-esqueléticas y extra-esqueléticas (hernias, várices, prolapso genital o rectal, miopía). Frecuentemente produce disautonomia en mujeres adolescentes, osteoporosis y osteoartritis precoz en ambos sexos. En este artículo hacemos un detallado análisis de los síntomas y signos que permiten sospechar el diagnóstico, recalcando la importancia de identificar la facies típica del SHA, lo que con experiencia es tan fácil como reconocer una persona con Síndrome de Down. Se destaca también la necesidad de usar el nombre de Ehlers-Danlos tipo III en vez de Síndrome de Hiperlaxitud Articular (SHA).

Ehlers-Danlos Syndrome (EDS-III), also called Joint Hypermobility Syndrome (JHS), is a connective tissue disease extremely frequent and usually undiagnosed. It is due to a genetic alteration of the collagen, generating musculoskeletal as well as extra-skeletal manifestations (hernias, varicose veins, genital and rectal prolapse, myopia). It causes dysautonomia, frequently in young adolescents girls, as well as osteoporosis and early osteoarthritis in both sexes. In this study, we make a detailed analysis of the manifestations and symptoms that permit a diagnostic suspicion, stressing the importance of being able to identify the typical JHS facies, which, with experience, is as easy to recognize as a person with Down Syndrome. We also stress the need to use the term Ehlers-Danlos type III (EDS-III), rather than Joint Hypermobility Syndrome (JHS).

Síndrome de Ehlers-Danlos con especial énfasis en el síndrome de hiperlaxitud articular: [revisión] / Ehlers-Danlos syndrome, with special emphasis in the joint hypermobility syndrome: [review]

There is an urgent need to increase the awareness on the Joint Hyper mobility Syndrome QHS). This is a congenital and prevalent emergent condition that is frequently undiagnosed and that causes significant health problems. Besides recurrent muscular-skeletal problems and signs and symptoms derived from tissue fragility, adolescents and young adults may develop osteoporosis, early osteoarthritis or dysautonomia, that are common in the disease, and deteriorate quality of life. Many JHS patients have signs and symptoms suggestive of fibromyalgia and are usually misdiagnosed. Physicians should be able to differentiate the less severe form of JHS from the Vascular Ehlers-Danlos Syndrome, to diagnose it before the appearance of serious complications and even death. The study of these diseases is a promising area for genomic and rheumatologic research.

MR Diagnosis of a Pulmonary Embolism: Comparison of P792 and Gd-DOTA for First-Pass Perfusion MRI and Contrast-Enhanced 3D MRA in a Rabbit Model

OBJECTIVE: To compare P792 (gadomelitol, a rapid clearance blood pool MR contrast agent) with gadolinium-tetraazacyclododecanetetraacetic acid (Gd-DOTA), a standard extracellular agent, for their suitability to diagnose a pulmonary embolism (PE) during a first-pass perfusion MRI and 3D contrast-enhanced (CE) MR angiography (MRA). MATERIALS AND METHODS: A perfusion MRI or CE-MRA was performed in a rabbit PE model following the intravenous injection of a single dose of contrast agent. The time course of the pulmonary vascular and parenchymal enhancement was assessed by measuring the signal in the aorta, pulmonary artery, and lung parenchyma as a function of time to determine whether there is a significant difference between the techniques. CE-MRA studies were evaluated by their ability to depict the pulmonary vasculature and following defects between 3 seconds and 15 minutes after a triple dose intravenous injection of the contrast agents. RESULTS: The P792 and Gd-DOTA were equivalent in their ability to demonstrate PE as perfusion defects on first pass imaging. The signal from P792 was significantly higher in vasculature than that from Gd-DOTA between the first and the tenth minutes after injection. The results suggest that a CE-MRA PE could be reliably diagnosed up to 15 minutes after injection. CONCLUSION: P792 is superior to Gd-DOTA for the MR diagnosis of PE.

Topography and axon arbor architecture in the visual callosal pathway: effects of deafferentation and blockade of TV-methyl-D-aspartate receptors

Visual callosal fibers link cortical loci in opposite hemispheres that represent the same visual field but whose locations are not mirror-symmetric with respect to the brain midline. Presence of the eyes from postnatal day 4 (P4) to P6 is required for this map to be specified. We tested the hypothesis that specification of the callosal map requires the activation of A'-methyl-D-aspartate receptors (NMDARs). Our results show that blockade of NMDARs with MK-801 during this critical period did not induce obvious abnormalities in callosal connectivity patterns, suggesting that retinal influences do not operate through NMDAR-mediated processes to specify normal callosal topography. In contrast, we found that interfering with NMDAR function either through MK801-induced blockade of NMDARs starting at P6 or neonatal enucleation significantly increases the length of axon branches and total length of arbors, without major effects on the number of branch tips. Our results further suggest that NMDARs act by altering the initial elaboration of arbors rather than by inhibiting a later-occurring remodeling process. Since the callosal map is present by P6, just as axonal branches of simple architecture grow into gray matter, we suggest that regulation of arbor development by NMDAR-mediated processes is important for maintaining the precision of this map.

Paraganglioma maligno retroperitoneal en el adulto / Malignant retroperitoneal paraganglioma in adults

Se reporta el caso de un paraganglioma retroperitoneal maligno de tipo no familiar, debido a su baja incidencia, y, en este caso en particular, por su comportamiento biológico agresivo con extenso compromiso abdominal y metastásico. Debido a que el diagnóstico histopatológico de malignidad es difícil, las características de infiltración local o las metástasis a distancia demostradas por imágenes —especialmente por CT y RM— son útiles para su diagnóstico. La gammagrafía con MIBG y el PET con nuevos radiotrazadores no sólo detectan correctamente la enfermedad metastásica, sino que, también, identifican candidatos para tratamiento con radiofármacos. Debe considerarse el diagnóstico de paraganglioma ante la presencia de una masa hipervascularizada ubicada en áreas anatómicas donde existe paraganglia, en un paciente con catecolaminas elevadas y glándulas adrenales normales.

Humo de Tabaco Ambiental y Neumonías en Niños de Monterrey, México / Environmental tobacco smoke and pneumonia in children living in Monterrey, México

Objetivo Las enfermedades respiratorias agudas ocupan en el mundo los primeros 5 lugares en morbilidad y mortalidad infantil, anualmente mueren más de dos millones de niños por esa causa. El humo del tabaco ambiental (HTA) contiene compuestos irritantes y tóxicos nocivos para la salud, que incrementan el riesgo de morbilidad y mortalidad en lactantes, niños y adultos no fumadores. Nuestro principal objetivo fue determinar la asociación entre HTA y la presencia de neumonías en niños. Material y métodos Se realizó un estudio de casos y controles no pareados. Se calcularon las razones de momios (RM) e intervalo de confianza 95 por ciento (IC) para cada variable. Resultados Se analizaron 285 pacientes, 142 casos y 143 controles, 47,4 por ciento femeninos, la edad promedio fue 4,5+2,7 años. La RM para expuestos al HTA fue 3,44, IC 2,1- 5,6. Discusión La exposición a HTA incrementa más de tres veces el riesgo de padecer neumonías en niños.

Objective Acute respiratory diseases occupy the first 5 places in infantile morbidity and mortality around the world, two million children directly dying from such cause annually. Environmental tobacco smoke (ETS) contains toxic and irritating compounds having an injurious effect on health, producing increased risk of morbidity and mortality in non-smoking adults and children. Our main objective was determining the association between ETS and pneumonia in children. Material and methods This was an unmatched case and controls hospital-based study. Odds ratio (OR) and 95 percent confidence interval (CI) were calculated. Results A total of 285 patients (142 cases and 143 controls) were studied; 47,4 percent of the patients were female and average age was 4,5,+2,7. OR for patients being exposed to ETS developing pneumonia was 3,44 (CI: 2,11-5,6). Discussion Children being exposed to ETS increases the risk of developing pneumonia by more than threefold.