La hernia umbilical en el paciente cirrótico: ¿tratamiento conservador o cirugía? / Umbilical hernia in cirrhotic patients: conservative treatment or surgery?

RESUMEN Antecedentes: la ascitis es una complicación de frecuente aparición en el paciente cirrótico que al producir un aumento de la presión intraabdominal puede originar una hernia de la pared abdominal; el defecto umbilical latente es su localización más habitual. Objetivo: presentar la incidencia y los beneficios que ofrece la resolución electiva de la patología um bilical en estos pacientes. Material y método: se presentan 15 pacientes, todos masculinos, que fueron intervenidos por hernia umbilical sintomática en forma electiva en el medio hospitalario. El período comprende desde enero del año 2015 a enero de 2019. El 100% de los enfermos cursa un cuadro de cirrosis hepática, con antecedentes de etilismo crónico. Se efectuó la reparación de la hernia con cierre del defecto y malla supraaponeurótica de polipropileno en la mayoría de los casos. Resultados: los pacientes fueron evaluados desde el punto de vista clínico con la escala (score) de Child en el preoperatorio. Se procedió a la evacuación de la ascitis en todos los casos y el control posoperatorio se efectuó cada 30 días los primeros 6 meses. Luego dos veces al año. No se evidenció recidiva. Dos pacientes no volvieron al control luego del año de la cirugía y 1 paciente falleció por la enfermedad de base a los 6 meses de la cirugía. Conclusiones: los enfermos con cirrosis hepática y hernia umbilical deben ser intervenidos quirúrgica mente en forma electiva. La observación y abstención quirúrgica conllevan el riesgo de rotura del saco herniario con alta morbimortalidad.

ABSTRACT Background: Background: Ascites is a common complication in patients with cirrhosis, and elevated intraabdominal pressure can lead to the development of abdominal wall hernias, particularly in patients with latent umbilical defects. Objectives: The aim of this study was to report the incidence and benefits of elective surgery for the management of umbilical hernias in cirrhotic patients with ascites. Material and methods: Between January 2015 and January 2019 15 patients with symptomatic umbi lical hernia underwent elective surgery in a public hospital; 100% were men with a history of alcoho lism and were hospitalized due to liver cirrhosis. The defect was closed, and a polypropylene mesh was placed in the supra-aponeurotic plane in most cases. Results: The preoperative risk was estimated using the Child-Pugh score. Ascites was evacuated in all the cases. Patients were followed-up every 30 days during the first 6 months and then twice a year. There were no hernia recurrences. Two patients were lost to follow-up 12 months after surgery and 1 patient died 9 months after the procedure due to progression of cirrhosis. Conclusions: Patients with liver cirrhosis and umbilical hernia should undergo elective surgery. Wat chful waiting is associated with higher risk of hernia rupture and high morbidity and mortality.

Dihydroartemisinin-piperaquine for the routine treatment of uncomplicated malaria in Northern Ghana

Background:Dihydroartemisinin-piperaquine is a first line treatment for uncomplicated malaria in Ghana. A facility-based study was undertaken to examine the effectiveness of thetreatment in the routine health care system.Methods:The study was undertaken at the Navrongodemographic surveillance area. Patients presenting with acute febrile illness were enrolled after informed consented and confirmation by microscopy. Patients were randomized into supervised group who received treatment under direct observation and unsupervised group which had only the first treatment given under supervision. Treatment was according to bodyweight and 42 days follow-up was undertaken.Results:A total of 194 patients were enrolled; 54.1% were females and 51% had supervised treatment. The median age and weight were 6.7 years and 20.0kg respectively. Mean baseline temperature, haemoglobin concentration and parasite density were, 37.6oC, 11.1 g/dl and 11,098 parasites per microliter of blood respectively. Study completion rate was 93.3%, day 42 polymerase chain reaction-unadjusted adequate clinical and parasitological responses rate (ACPR) was 93.4% by evaluable and 87.1 % by intention-to-treat (ITT). The day 42 ACPR by evaluable was 92.3% in the supervised arm compared to 94.4% in the unsupervised arm. The day 42 ACPR by ITT was 85.7% in the supervised and 88.5% in the unsupervised arms. The fever resolution and haemoglobin concentration changes for the two arms were similar.Conclusions: The results show that dihydroartemisinin-piperaquine iseffective and good first-line antimalarial in the routine health delivery system

Uso de adhesivos tisulares para el cierre de heridas en la práctica médica / Use of tissue adhesives for the wound closure in medical practice

Introducción: los adhesivos tisulares generan una película impermeable que una vez aplicados sobre la herida quirúrgica mantienen los bordes juntos hasta que se produce la cicatrización, lo que ayuda a disminuir el riesgo de infección de las heridas tratadas. Su empleo en la medicina permite simplificar procedimientos quirúrgicos complejos y brinda mayor comodidad al paciente. Objetivo: identificar los ámbitos de la práctica médica donde el cierre quirúrgico de heridas con el uso de adhesivos tisulares ofrece mejores resultados. Métodos: estudio descriptivo con un diseño de análisis de decisión, se confeccionó un árbol de decisión que comparó dos posibles alternativas: uso de adhesivos tisulares en adultos y en pediatría. La información se obtuvo de la literatura mediante la revisión de bases de datos médicas en el periodo de enero/2002 a diciembre/2012. Se identificaron 25 estudios (15,4 por ciento) que fueron válidos para estimar las probabilidades de complicaciones y éxito en el cierre de heridas. Resultados: el uso de adhesivos titulares en adultos mostró los mejores resultados con una alta probabilidad de éxito (0,99) para el cierre de heridas en piel y mucosas y especialmente en la cirugía de cabeza y cuello. En pediatría la probabilidad de éxito fue de 0,96 y su mejor uso se decidió en la cirugía de tórax y abdomen. Conclusiones: el uso de adhesivos titulares en adultos y niños ofrece una alta perspectiva de éxito para el cierre de heridas en piel y mucosas, si bien su uso en adultos es su mejor opción(AU)

Introduction: tissue adhesives generate, based on its characteristics, a water-proof film that once spread over the surgical wound, can keep wound edges together until cicatrization, all of which helps to decrease the infection risk. The use of tissue adhesives in medicine allows making complex surgical procedures simpler in addition to making the patient feel more comfortable. Objective: to identify the areas of medical practice where the surgical wound closure with adhesives exhibits better results. Methods: descriptive study with analysis decision design; a decision tree was created to compare two possible alternatives: use of tissue adhesives in adults and in pediatrics. Information was taken from literature through revision of medical database in the period of January 2002 to December 2012. Twenty five studies (15.4 percent), which were valid for estimating the odds of complications and successes of each wound closure option. Results: the use of tissue adhesives in adults showed the best results with high probabilities of being successful (0.99) in closing skin and mucosa wounds, mainly in the head and the neck. The probabilities for success in pediatrics were 0.96 and it is better used in thorax and abdomen surgery. Conclusions: use of tissue adhesives in adults and children provide high success probabilities for the closure of wounds in the skin and in the mucosa, although their use in adult people is the best choice(AU)

Localización del catéter de la arteria pulmonar de acuerdo con las zonas de West en radiografía portátil del tórax / Location of the pulmonary artery catheter according to West's zones in portable chest X-Ray

Objetivo: valorar la concordancia entre los observadores y entre las proyecciones anteroposterior y lateral de la ubicación del catéter. Metodología: en pacientes adultos con catéter de la arteria pulmonar les fueron tomadas radiografías de tórax portátil en proyecciones anteroposterior (AP) y translateral (LAT). Los estudios fueron interpretados en doble ciego por dos radiólogos independientes. Resultados: fueron incluidos 32 pacientes. Al evaluar la radiografía AP, 25porcentaje de los catéteres estaban ubicados en la zona 3 de West y 75porcentaje no lo estaban. En la radiografía translateral sólo 12 catéteres estaban en la zona 3. La concordancia interobservador en la placa AP fue 88porcentaje, en la lateral 73porcentaje y al evaluar la concordancia AP y LAT ésta fue de 57porcentaje.Conclusiones: la concordancia entre las proyecciones anteroposterior y translateral para definir la ubicación de la punta del catéter de la arteria pulmonar en zona 3 de West es baja y muy mala para la concordancia interobservador en la translateral. Evaluar el catéter de Swan-Ganz con una placa AP no es suficiente para otorgar credibilidad a los datos obtenidos de su medición.

CSF beta-1 Globulin--a potential marker in differentiating multiple sclerosis and acute disseminated encephalomyelitis: a preliminary study.

The exact diagnosis of demyelinating diseases is an enigma even in the best neurological centres. In the present study, the potential role of differential CSF proteins has been critically evaluated in differentiating multiple sclerosis (MS) and acute disseminated encephalomyelitis (ADEM). Cellulose acetate electrophoresis was carried out on CSF and serum samples of 14 MS patients, 23 ADEM patients and 30 controls. There was no statistically significant difference between serum electrophoresis of controls and MS patients. However, in case of CSF electrophoresis there was a statistically significant decrease in beta-1 fraction in 92.2% of MS patients (p=0.01). A comparison between serum electrophoresis of controls and ADEM patients indicated a statistically significant decrease in serum albumin in 87% patients and an increase of alpha-2 globulin in 73.9%. There was no statistically significant difference between CSF electrophoresis of controls and ADEM patients except for the prealbumin fraction which was raised in 60.9% of patients. No statistically significant difference was seen between the serum electrophoresis of ADEM and MS patients. However, on comparing CSF electrophoresis, it was seen that beta-1 fraction was significantly higher in ADEM patients (p<0.05). The predictive value of beta-1 fraction in differentiating MS and ADEM was then evaluated. The negative predictive value was 100% indicating that all samples with a beta-1 fraction of>6.5% cannot be diagnosed as MS. The significant decrease in beta-1 fraction in MS patients may prove to be an early indicator in differentiating between MS and ADEM patients.

Synthesis and secretion of lipoproteins by primary cultures of rat hepatocytes.

Synthesis and secretion of VLDL and LDL by primary cultures of rat hepatocytes maintained in serum free medium have been studied. A time-dependent increase found in the [3H]leucine labelled lipoproteins which floated at a density of 1.006 g/ml indicate the secretion of VLDL into the medium. That the hepatocytes also secrete. LDL is shown by floatation of [3H]leucine labelled lipoproteins by sequential centrifugation at a density range of 1.006-1.06 g/ml. Electrophoretic and immunoprecipitation analysis show that about 60% and 65% respectively of 3H-radioactivity is associated with apoB in the two fraction of lipoproteins. At about 12hr 70-75% lipoproteins in the culture medium is in the VLDL density range and 25-30% is in the LDL density range. Conversion of secreted VLDL to LDL has also been shown by incubating hepatocytes with pre-labelled lipoproteins when there is a decrease in the fraction of VLDL range with a corresponding increase in the fraction of the LDL density range. Addition of glycosaminoglycans such as hyaluronic acid, chondroitin sulphate, and heparin into the medium cause significant increase in the synthesis and secretion of [3H]apoB into the medium indicating a possible secretory control of apoB by local reuptake.

Synthesis and secretion of VLDL by rat hepatocytes--modulation by cholesterol and phospholipids.

The synthesis and secretion of apoB, the major protein component of very low density lipoprotein (VLDL) and low density lipoprotein (LDL), were studied using rat hepatocytes maintained in primary culture. Supplementation of hepatocytes with rat serum VLDL and LDL increased the production of apoB while delipidated lipoproteins had no significant effect, suggesting a role for lipids in the production of apoB. Addition of cholesterol to the culture medium also increased the production of apoB in a concentration-dependent manner. Pulse labelling followed by chase in presence of cholesterol indicated enhancement in apoB secretion. Mevinolin which inhibits cholesterol synthesis significantly reduced the secretion of apoB. The presence of phosphatidylcholine and phosphatidylethanolamine in the culture medium also increased the secretion of apoB into the medium. These data suggest that availability of lipids, particularly cholesterol, is an important determinant of apoB synthesis and secretion as VLDL.

Metabolism of very low density lipoproteins--effect of sardine oil.

The effect of feeding fish oil on the metabolism of lipoproteins was studied in rats. Rats were fed diet containing 10% sardine or groundnut oil for 6 weeks. There was a significant decrease in the total cholesterol, phospholipids and triglycerides as well as the amount of the lipids associated with VLDL and LDL in serum in fish oil-fed rats. The synthesis and secretion of lipoproteins particularly apoB containing lipoproteins by primary cultures of hepatocytes from these rats were studied by 14(C)-acetate or 3(H)-leucine labelling. Primary cultures of hepatocytes derived from sardine oil-fed rats showed reduced incorporation of 3(H)-leucine into apoB containing lipoproteins secreted into the medium when compared to those fed groundnut oil, indicating a decreased synthesis and secretion of apoB. This was further confirmed by significantly lower incorporation of 14(C)-radioactivity into total and individual lipids of VLDL secreted into the medium, as well as that associated with different lipids in cell layer. The activity of lipoprotein lipase in adipose tissue and aorta was significantly higher in rats fed sardine oil which may cause an increased clearance of triglyceride-rich lipoproteins from circulation. These results indicate that the fish oil exerts hypolipidemic effect particularly by decreasing the synthesis and secretion of VLDL by liver and possibly by an increased clearance of triglyceride-rich lipoproteins from circulation.