Cohorte descriptiva de pacientes adultos con hipertensión portal en una institución de tercer nivel en Colombia / Descriptive cohort of adult patients with portal hypertension at a tertiary care institution in Colombia

Introducción. La hipertensión portal (HTP) se define como una elevación anormal de la presión venosa en el sistema portal que lleva al desarrollo de vías colaterales para desviar el flujo sanguíneo de la zona. Dentro de su etiología están las relacionadas con la cirrosis hepática y otras causas denominadas no cirróticas. El objetivo de este estudio fue evaluar los principales hallazgos demográficos, clínicos y paraclínicos en un grupo de pacientes con HTP, y determinar el uso de ayudas invasivas y no invasivas, y su disponibilidad para el diagnóstico y seguimiento de los pacientes en los centros que no cuentan con laboratorio de hemodinamia hepática, reflejando la dinámica de múltiples escenarios en Colombia. Metodología. Se realizó un estudio descriptivo de corte transversal, retrospectivo, en pacientes atendidos en una institución de tercer nivel del sur de Colombia, entre enero del año 2015 y diciembre del año 2020. Resultados. Se obtuvo una muestra de 61 pacientes en donde la mayoría de casos correspondían a hombres en la séptima década de la vida, procedentes del área urbana. La principal causa de consulta fue el sangrado digestivo (39,3 %), asociado a la presencia de telangiectasias (arañas vasculares) en el 37,2 %, seguido de circulación colateral (31,3 %) e ictericia (19,7 %). En la ecografía abdominal (realizada en el 57,4 % de los pacientes) predominaron la cirrosis (68 %) y la presencia de esplenomegalia (14,2 %), y en lospacientes con Doppler portal (realizado en el 16,4 %) se encontró hígado cirrótico (80 %) y dilatación portal (40 %). Con respecto a los hallazgos en la esofagogastroduodenoscopia predominó la presencia de várices esofágicas y gastritis crónica. Conclusión. El principal motivo de consulta fue el sangrado digestivo, en tanto que la cirrosis fue el antecedente y el hallazgo imagenológico más frecuente, seguido de las várices esofágicas. Se encontró que el uso de paraclínicos, ecografía abdominal, ecografía con Doppler portal y esofagogastroduodenoscopia fueron los más utilizados en el contexto clínico de los pacientes con el diagnóstico de HTP.

Introduction. Portal hypertension (PHT) is defined as an abnormal elevation of venous pressure in the portal system that leads to the development of collateral pathways to divert blood flow from the area. Within its etiology are those related to liver cirrhosis and other so-called non cirrhotic causes. The aim of this study was to evaluate the main demographic, clinical and paraclinical findings in a group of patients with PHT, and to determine the use of invasive and non-invasive aids, and their availability for the diagnosis and follow-up of patients in centers that do not have a hepatic hemodynamics laboratory, reflecting the dynamics of multiple scenarios in Colombia. Methodology. A descriptive, retrospective, cross-sectional, retrospective study was conducted in patients attended in a third level institution in Southern Colombia, between January 2015 and December 2020. Results. A sample of 61 patients was obtained where the majority of cases corresponded to men in the seventh decade of life, from the urban area. The main cause of consultation was digestive bleeding (39.3%), associated with the presence of telangiectasias (spider veins) in 37.2%, followed by collateral circulation (31.3%) and jaundice (19.7%). In abdominal ultrasound (performed in 57.4% of the patients), cirrhosis (68%) and the presence of splenomegaly (14.2%) predominated, and in patients with portal Doppler (performed in 16.4%), cirrhotic liver (80%) and portal dilatation (40%) were found. With respect to the findings in the esophagogastroduodenoscopy, esophageal varices and chronic gastritis were predominant. Conclusion. The main reason for consultation was gastrointestinal bleeding, while cirrhosis was the most frequent history and imaging finding, followed by esophageal varices. It was found that the use of paraclinics, abdominal ultrasound, ultrasound with portal Doppler and esophagogastroduodenoscopy were the most used in the clinical context of patients diagnosed with PHT.

Umbral crítico de administración en pacientes con trauma severo y reanimación endovascular: ¿Un concepto útil? / Critical Administration Threshold in severe trauma patients and endovascular resuscitation: A useful concept?

Introducción. Se describe la utilidad del umbral crítico de administración (CAT por su denominación en inglés) como herramienta para la reanimación hemostática en pacientes con trauma severo y oclusión endovascular aórtica. Métodos. Revisión retrospectiva de pacientes adultos con hemorragia por trauma, con o sin oclusión endovascular aórtica (REBOA), atendidos entre enero de 2015 y junio de 2020, en un centro de trauma nivel I en Cali, Colombia. Se registraron variables demográficas, severidad del trauma, estado clínico, requerimiento transfusional, tiempo hasta CAT+ y CAT alcanzado (1, 2 ó 3). Resultados. Se incluyeron 93 pacientes, se utilizó REBOA en 36 y manejo tradicional en 57. El grupo REBOA presentó mayor volumen de sangrado (mediana de 3000 ml, RIC: 1950-3625 ml) frente al grupo control (mediana de1500 ml, RIC: 700-2975ml) (p<0,001) y mayor cantidad de glóbulos rojos transfundidos en las primeras 6 horas (mediana de 5, RIC:4-9); p=0,015 y en las primeras 24 horas (mediana de 6, RIC: 4-11); p=0,005. No hubo diferencias estadísticamente significativas en número de pacientes CAT+ entre grupos o tiempo hasta alcanzarlo. Sin embargo, el estado CAT+ durante los primeros 30 minutos de la cirugía fue mayor en grupo REBOA (24/36, 66,7 %) frente al grupo control (17/57, 29,8 %; p=0,001), teniendo este mayor tasa de mortalidad intrahospitalaria frente a los pacientes CAT-. Conclusión. El umbral crítico de administración es una herramienta útil en la reanimación hemostática de pacientes con trauma y REBOA, que podría predecir mortalidad precoz.

Introduction. The objective is to describe the utility of the Critical Administration Threshold (CAT) as a tool in hemostatic resuscitation in patients with severe trauma and REBOA. Methods. Retrospective review between January 2015 and June 2020 of adult patients with hemorrhage secondary to trauma with or without REBOA in a level I trauma center in Cali, Colombia. Demographic variables, trauma severity, clinical status, transfusion needs, time to CAT+ and number of CAT achieved (1, 2 or 3) were recorded. Results. Ninety-three patients were included, in which REBOA was used in 36 and traditional management in 57. The REBOA group had a higher bleeding volume (3000 ml), IQR: 1950-3625 ml vs the control group (1500 ml, IQR: 700-2975 ml) (p<0.001) and a higher rate of PRBC units transfused in the first 6 hours (median 5, IQR: 4-9); p=0.015 and in the first 24 hours (median 6, IQR: 4-11); p=0.005. There were no statistically significant differences in the number of CAT+ patients between groups or time to CAT+. However, CAT+ status during the first 30 minutes of surgery was higher in the REBOA Group (24/36, 66.7%) vs. the control group (17/57, 29.8%; p=0.001), having this group a higher in-hospital mortality rate vs. CAT- patients. Conclusion. CAT is a useful tool in the hemostatic resuscitation of patients with trauma and REBOA that could predict early mortality.

Bundle para quantificação de perda sanguínea pós-parto vaginal / Bundle para la cuantificación de pérdida sanguínea posparto vaginal / Bundle for quantifying vaginal blood loss after childbirth

Resumo Objetivo Construir e validar o conteúdo de um bundle para quantificação da perda sanguínea pós-parto vaginal. Métodos Estudo metodológico desenvolvido de fevereiro a agosto de 2022, em três etapas: levantamento bibliográfico, construção do instrumento e validação de conteúdo por 14 experts. O instrumento para validação foi composto por 11 itens selecionados a partir de revisão sistemática. Para cada item do bundle aplicou-se escala Likert e para verificar a concordância entre experts, calculou-se o Índice de Concordância. Consideraram-se válidos os itens com concordância acima de 80%. A validação de conteúdo foi realizada em uma única rodada de avaliação. Resultados A versão final do bundle foi composta por nove itens. Os cuidados propostos estão relacionados à quantificação direta do sangramento pós-parto e seu registro, observação da puérpera, a utilização de protocolos institucionais em casos de hemorragia pós-parto, assim como a capacitação da equipe. Conclusão O estudo permitiu construir e validar bundle para quantificação da perda sanguínea pós-parto vaginal, com vistas à melhora do diagnóstico de hemorragia pós-parto.

Resumen Objetivo Elaborar y validar el contenido de un bundle para la cuantificación de pérdida sanguínea posparto vaginal. Métodos Estudio metodológico, llevado a cabo de febrero a agosto de 2022, en tres etapas: análisis bibliográfico, construcción del instrumento y validación de contenido por 14 expertos. El instrumento para validación consistió en 11 ítems seleccionados a partir de revisión sistemática. Se aplicó la escala Likert para cada ítem del bundle; y para verificar la concordancia entre expertos, se calculó el Índice de Concordancia. Se consideraron válidos los ítems con concordancia superior a 80 %. La validación de contenido se realizó en una única ronda de evaluación. Resultados La versión final del bundle consistió en nueve ítems. Los cuidados propuestos están relacionados con la cuantificación directa del sangrado posparto y su registro, la observación de la puérpera, la utilización de protocolos institucionales en casos de hemorragia posparto, así como también la capacitación del equipo. Conclusión El estudio permitió elaborar y validar un bundle para la cuantificación de pérdida sanguínea posparto vaginal, con el fin de mejorar el diagnóstico de hemorragia posparto.

Abstract Objective To construct and validate the content of a bundle to quantify vaginal blood loss after childbirth. Methods This is a methodological study developed from February to August 2022, divided into bibliographic survey, instrument construction and content validity, by 14 experts. The instrument for validity consisted of 11 items selected from a systematic review. For each item in the bundle, a Likert scale was applied, and to check agreement among experts, the Concordance Index was calculated. Items with agreement above 80% were considered valid. Content validity was carried out in a single round of assessment. Results The final version of the bundle consisted of nine items. The proposed care is related to direct quantification of postpartum bleeding and its recording, observation of postpartum women, use of institutional protocols in cases of postpartum hemorrhage as well as team training. Conclusion The study allowed constructing and validating a bundle for quantifying vaginal blood loss after childbirth, with a view to improving postpartum hemorrhage diagnosis.

Avaliação do colírio de brimonidina 0,2% em comparação à nafazolina 0,025% + feniramina 0,3% nas cirurgias de estrabismo / Evaluation of 0.2% brimonidine eye drops compared to 0.025% naphazoline + 0.3% pheniramine in strabismus surgery

RESUMO Objetivo: Avaliar o efeito do colírio de brimonidina 0,2% na redução da hiperemia e do sangramento ocular durante as cirurgias de estrabismo, em comparação com o colírio de nafazolina 0,025% + feniramina 0,3%. Métodos: Foram avaliados 14 pacientes com estrabismo e indicação de correção cirúrgica bilateral. Foi instilado antes do procedimento, de forma aleatória, um colírio em cada olho dos pacientes avaliados. A análise subjetiva da hiperemia conjuntival e do sangramento perioperatório foi realizada de forma duplo-cega, por dois cirurgiões. A avaliação objetiva do nível de hiperemia conjuntival foi realizada por análise das imagens obtidas por meio do software ImageJ®. Resultados: A análise de modelos multivariados de efeito misto indicou diferenças estatisticamente significantes entre os grupos em relação à hiperemia (avaliador 2) e ao sangramento intraoperatório (avaliadores 1 e 2), com maiores escores nos casos tratados com colírio de nafazolina + feniramina. Entretanto, não houve diferença estatística na análise objetiva realizada por meio da saturação de cores obtidas pelo programa ImageJ®. Conclusão: O colírio de brimonidina pode ser superior ao colírio de nafazolina + feniramina na redução do sangramento, levando-se em conta apenas a análise subjetiva.

ABSTRACT Objective: To evaluate the effect of 0.2% brimonidine eye drops in reducing hyperemia and ocular bleeding during strabismus surgeries, in comparison with 0.025% naphazoline + 0.3% pheniramine eye drops. Methods: Fourteen patients with strabismus and indication for bilateral surgical correction were evaluated. Before the procedure, the eye drops were instilled randomly in each eye of the evaluated patients. The subjective analysis of conjunctival hyperemia and perioperative bleeding was performed in a double-blind manner, by 02 surgeons. The objective assessment of the level of conjunctival hyperemia was performed by analyzing the images obtained using the ImageJ® software. Results: The analysis of multivariate mixed effect models indicated statistically significant differences between the groups in relation to hyperemia (rater 2) and intraoperative bleeding (raters 1 and 2) with higher scores in cases treated with naphazoline + pheniramine eye drops. However, there were no statistically significant differences in the objective analysis of color saturation obtained by the ImageJ® program. Conclusion: Brimonidine eye drops may be superior to naphazoline + pheniramine eye drops in reducing bleeding, taking into account the subjective analysis only.

Ocular manifestation of vertical transmission of dengue: case report / Manifestação ocular de transmissão vertical de dengue: relato de caso

ABSTRACT A 7-week-old male delivered by cesarean section presented with a positive serology for dengue along with preretinal and retinal hemorrhages, vitreous opacities and cotton wool spots. The patient and his mother had positive serologies for Non Structural Protein 1 (NS1) by ELISA. Retinal and vitreous findings improved over a sixteen-week period. Spectral domain optical coherence tomography (OCT) showed preserved macular architecture. In this case report, we suggest that retinal and vitreous changes may be the ocular presenting features of vertically transmitted dengue in newborns, and that those findings may resolve with no major structural sequelae.

RESUMO Neonato de 7 semanas, do sexo masculino, nascido de parto cesárea, apresentou sorologia positiva para dengue com hemorragias retinianas e pré-retinianas, opacidades vítreas e manchas algodonosas. O paciente e sua mãe haviam apresentado sorologias positivas para Non Structural Protein 1 através de ELISA. Achados na retina e no vítreo melhoraram em um período de dezesseis semanas. O exame de tomografia de coerência óptica de domínio espectral demonstrou arquitetura macular preservada. Neste relato de caso, sugerimos que alterações na retina e no vítreo podem ser os achados oculares aparentes em neonatos com infecção vertical por dengue, e que estes podem se resolver sem maiores sequelas estruturais.

Findings of ocular examinations in healthy full-term newborns / Achados de exame ocular realizado em recém-nascidos a termo saudáveis

ABSTRACT Purpose: To assess the anterior and posterior segments of full-term neonates over a 1.5-year period. Methods: The findings of full-term neonates who underwent ophthalmological examinations between June 2019 and December 2020 were analyzed, and the results were retrospectively recorded. Results: The study comprised 2972 neonates with a mean birth week of 38.7 ± 1.2 weeks and a mean birth weight of 3235 ± 464 g. The neonates were examined on an average of 49.3 ± 18.9 postnatal days. Of the examined neonates, 185 (6.2%) showed abnormal ophthalmological findings, the most prevalent of which were retinal hemorrhage in 2.3% (n=68) and white changes in the peripheral retina in 1.9% (n=55) of the neonates. Cases of optic disc pathologies (n=20), choroidal nevus (n=10), iris-choroidal coloboma (n=5), subconjunctival hemorrhage (n=6), non-specific retinal pigmentary change (n=4), congenital cataract (n=3), posterior synechia (n=3), iris nevus (n=3), corneal opacity (n=1), choroidal coloboma (n=1), iris coloboma (n=1), buphthalmos (n=1), anophthalmos (n=1), microphthalmia (n=1), lid hemangioma (n=1), and vitreous hemorrhage (n=1) collectively accounted for approximately 2% of all neonates. Pathologies that could potentially impair vision, which were detected by ophthalmological examination, accounted for 1.2% of all neonates (n=37). Conclusion: The most prevalent finding of the ophthalmological examinations of neonates in the present study was retinal hemorrhage. Ophthalmological examinations of neonates can help in identifying diseases that may affect their vision and are curable or may lead to amblyopia in the long term.

RESUMO Objetivo: Avaliar os segmentos anterior e posterior em recém-nascidos a termo durante um período de 1,5 anos. Métodos: Foram analisados recém-nascidos a termo que tiveram os olhos examinados entre junho de 2019 e dezembro de 2020, e os resultados foram registrados retrospectivamente. Resultados: O estudo foi composto por 2.972 recém-nascidos com média de uma semana de nascimento de 38,7 ± 1,2 semanas e um peso médio ao nascer de 3235 ± 464 g. Os recém-nascidos foram examinados em média pós-natal de 49,3 ± 18,9 dias. Dos recém-nascidos, 185 (6,2%) apresentaram resultados oculares anormais. Os achados oculares anormais mais prevalentes foram hemorragia da retina em 2,3% (n=68) e alterações brancas na retina periférica em 1,9% (n=55) dos recém-nascidos. Casos de patologias de disco óptico (n=20), nevo de coroide (n=10), coloboma iris-coroide (n=5), hemorragia subconjuntival (n=6), alteração pigmentar da retina não específica (n=4), catarata congênita (n=3), Sinequia posterior (n=3), nevo da íris (n=3), opacidade da córnea (n=1), coloboma de coroide (n=1), coloboma de íris (n=1), buftalmos (n=1), anoftalmia (n=1), microftalmia (n=1), hemangioma de pálpebra (n=1) e hemorragia vítrea (n=1) contabilizaram coletivamente cerca de 2% dos recém-nascidos. As patologias que potencialmente prejudicam a visão, detectadas por exame ocular, representaram 1,2% dos recém-nascidos (n=37). Conclusão: O achado mais prevalente de exames oculares de recém-nascidos neste estudo foi hemorragia da retina. Exames oftalmológicos em recém-nascidos podem ser úteis na identificação de doenças que podem impactar a visão deles, podendo ser curáveis ou levar à ambliopia no longo prazo.

Homocysteine serum levels in patients with ruptured and unruptured intracranial aneurysms: a case-control study / Homocisteína sérica em pacientes com aneurismas rotos e não rotos: um estudo caso-controle

Abstract Background There is very few data regarding homocysteine's influence on the formation and rupture of intracranial aneurysms. Objective To compare homocysteine levels between patients with ruptured and unruptured intracranial aneurysms, and to evaluate possible influences of this molecule on vasospasm and functional outcomes. Methods This is a retrospective, case-control study. We evaluated homocysteinemia differences between patients with ruptured and unruptured aneurysms; and the association of homocysteine levels with vasospasm and functional outcomes. Logistic regressions were performed. Results A total of 348 participants were included: 114 (32.8%) with previous aneurysm rupture and 234 (67.2%) with unruptured aneurysms. Median homocysteine was 10.75μmol/L (IQR = 4.59) in patients with ruptured aneurysms and 11.5μmol/L (IQR = 5.84) in patients with unruptured aneurysms. No significant association was detected between homocysteine levels and rupture status (OR = 0.99, 95% CI = 0.96-1.04). Neither mild (>15μmol/L; OR = 1.25, 95% CI 0.32-4.12) nor moderate (>30μmol/L; OR = 1.0, 95% CI = 0.54-1.81) hyperhomocysteinemia demonstrated significant correlations with ruptured aneurysms. Neither univariate (OR = 0.86; 95% CI 0.71-1.0) nor multivariable age-adjusted (OR = 0.91; 95% CI = 0.75-1.05) models evidenced an association between homocysteine levels and vasospasm. Homocysteinemia did not influence excellent functional outcomes at 6 months (mRS≤1) (OR = 1.04; 95% CI = 0.94-1.16). Conclusion There were no differences regarding homocysteinemia between patients with ruptured and unruptured intracranial aneurysms. In patients with ruptured aneurysms, homocysteinemia was not associated with vasospasm or functional outcomes.

RESUMO Antecedentes Existem poucos dados sobre a influência da homocisteína na formação e rotura de aneurismas intracranianos (AI). Objetivo Comparar os níveis de homocisteína entre pacientes com AI rotos e não rotos e influências no vasoespasmo e resultados funcionais. Métodos Estudo caso-controle, que avaliou as diferenças de homocisteinemia entre pacientes com aneurismas rotos e não rotos, além da associação entre níveis de homocisteína, vasoespasmo e estado funcional. Regressões logísticas foram realizadas. Resultados Um total de 348 participantes foram incluídos: 114 (32,8%) com aneurismas rotos e 234 (67,2%) não rotos. A homocisteína mediana foi de 10,75μmol/L (IQR = 4,59) nos rotos e 11,5μmol/L (IQR = 5,84) nos não rotos. Não houve associação significativa entre os níveis de homocisteína e o status de ruptura (OR = 0,99, 95% CI = 0,96-1,04). Nem a hiperhomocisteinemia leve (>15μmol/L; OR = 1,25, 95% CI = 0,32-4,12) nem a moderada (>30μmol/L; OR = 1,0, 95% CI = 0,54-1,81) mostraram correlações significativas com aneurismas rotos. Modelos univariados (OR = 0,86; 95% CI = 0,71-1,0) e multivariados ajustados por idade (OR = 0,91; 95% CI = 0,75-1,05) não evidenciaram associação entre homocisteína e vasoespasmo. A homocisteinemia não influenciou resultados funcionais excelentes em seis meses (mRS ≤ 1) (OR = 1,04; 95% CI = 0,94-1,16). Conclusão Não houve diferenças em relação à homocisteinemia entre pacientes com aneurismas intracranianos rotos e não rotos. Em pacientes com aneurismas rotos, a homocisteinemia não foi associada ao vasoespasmo ou resultados funcionais.

Early-onset neonatal sepsis as a risk factor for peri-intraventricular hemorrhage in premature infants / Sepse precoce como fator de risco para hemorragia peri-intraventricular em prematuros

ABSTRACT Objective: To assess early-onset sepsis as a risk factor of peri-intraventricular hemorrhage in premature infants born at less than or equal to 34 weeks' gestation and admitted to a neonatal intensive care unit (NICU). Methods: This retrospective cohort study included premature patients born at less than or equal to 34 weeks' gestation who were admitted to the NICU of a tertiary hospital in southern Brazil, and born from January 2017 to July 2021. Data were collected from patients' medical records. Early-onset sepsis was measured according to the presence or absence of diagnosis within the first 72 hours of life, whereas the outcome, peri-intraventricular hemorrhage, was described as the presence or absence of hemorrhage, regardless of its grade. Results: Hazard ratios were calculated using Cox regression models. A total of 487 patients were included in the study, of which 169 (34.7%) had some degree of peri-intraventricular hemorrhage. Early-onset sepsis was present in 41.6% of the cases of peri-intraventricular hemorrhage, which revealed a significant association between these variables, with increased risk of the outcome in the presence of sepsis. In the final multivariate model, the hazard ratio for early-onset sepsis was 1.52 (95% confidence interval 1.01-2.27). Conclusion: Early-onset sepsis and the use of surfactants showed to increase the occurrence of the outcome in premature children born at less than or equal to 34 weeks' gestation. Meanwhile, factors such as antenatal corticosteroids and gestational age closer to 34 weeks' gestations were found to reduce the risk of peri-intraventricular hemorrhage.

RESUMO Objetivo: O objetivo do presente trabalho foi avaliar a sepse precoce como fator de risco para hemorragia peri-intraventricular (HPIV) em prematuros com 34 semanas ou menos, admitidos em Unidade de Terapia Intensiva (UTI) Neonatal. Métodos: Este estudo de coorte retrospectivo incluiu pacientes prematuros com 34 semanas ou menos, que receberam alta da UTI Neonatal de hospital terciário, no sul do Brasil, nascidos no período de janeiro de 2017 a julho de 2021. Os dados foram coletados por meio dos prontuários desses pacientes. A sepse precoce foi mensurada conforme a presença ou a ausência do diagnóstico nas primeiras 72 horas de vida. Já o desfecho, hemorragia peri-intraventricular, foi descrito conforme a presença ou ausência da hemorragia, independentemente do grau. Resultados: Hazard ratios (HR) foram calculados por meio de modelos de regressão de Cox. Foram incluídos no estudo 487 pacientes. Destes, 169 (34,7%) apresentaram algum grau de hemorragia peri-intraventricular. A sepse precoce esteve presente em 41,6% dos casos de hemorragia peri-intraventricular e apresentou associação significativa, elevando o risco do desfecho quando presente. No modelo multivariável final, o HR para a sepse precoce foi de 1,52 (intervalo de confiança de 95% — IC95% 1,01-2,27). Conclusão: Sepse precoce e uso de surfactante demonstraram aumentar a ocorrência do desfecho em crianças prematuras até 34 semanas, enquanto fatores como corticoide antenatal e idades gestacionais mais próximas a 34 semanas mostraram reduzir o risco de ocorrência hemorragia peri-intraventricular.

Primary Anorectal Melanoma: Case Report and Review of a Rare Neoplasm

Primary anorectal melanoma is a rare malignant melanocytic neoplasm; its principal manifestation is rectal bleeding. It has an ominous prognosis with a five-year survival rate of 10%. The case of a 56-year-old woman with rectal bleeding and the sensation of a rectal mass is presented. A polypoid lesion, resected transanally, was documented in the distal rectum during the colonoscopy. The histological study confirmed a primary anorectal melanoma.

El melanoma anorrectal primario es una neoplasia melanocítica maligna poco frecuente, su principal manifestación es el sangrado rectal. Tiene un pronóstico ominoso con una tasa de sobrevida del 10% a 5 años. Se presenta el caso de una mujer de 56 años con rectorragia y sensación de masa rectal. Durante la colonoscopia se documentó una lesión polipoide en el recto distal, que se resecó por vía transanal. El estudio histológico confirmó la presencia de un melanoma anorrectal primario.

Complicaciones del tratamiento endovascular y quirúrgico en las hemorragias subaracnoideas aneurismáticas en Uruguay: análisis prospectivo de una serie de 211 casos

Introducción: si bien varios estudios han abordado la comparación entre el tratamiento endovascular y el clipado quirúrgico de aneurismas rotos, no existe aún evidencia firme respecto a la utilización de una u otra técnica en términos de seguridad y mejor pronóstico. El objetivo de este trabajo es analizar las distintas modalidades de tratamiento de la hemorragia subaracnoidea (HSA) implementadas en Uruguay y su impacto sobre la curación del aneurisma y el pronóstico de los pacientes. Material y método: estudio prospectivo y multicéntrico que incluyó a todos los pacientes mayores de 18 años que fueron asistidos por HSA espontánea aneurismática en Uruguay entre el 1 de noviembre de 2019 y el 31 de octubre de 2020. Fueron relevadas las características clínico-epidemiológicas y comorbilidades al momento del diagnóstico, el tipo de tratamiento recibido y variables de evolución clínica durante los siguientes seis meses. Los datos fueron procesados a través del software estadístico Statistical Package for Social Sciences (SPSS) y el nivel de significación utilizado en los test fue de 5%. Debido al carácter multicéntrico y nacional del estudio, debió ser sometido a evaluación por todos los comités de ética de las instituciones de salud participantes. Resultados: se observó un total de 211 casos en el período evaluado. La media de edad fue de 57 años con predominancia del sexo femenino (75%). En el 74% de los casos fue indicado algún tipo de tratamiento específico (43% cirugía abierta y 31% terapia endovascular), mientras al resto de los pacientes no se les pudo tratar el aneurisma por su grave situación neurológica; 52 pacientes tuvieron complicaciones vinculadas al tratamiento recibido, observándose una mayor proporción de estas en el caso de la cirugía abierta respecto a la terapia endovascular (42% vs 21,5%; p=0,008). Conclusiones: se observó una mayor tasa de complicaciones en el tratamiento quirúrgico, sin impacto en la morbimortalidad. De los factores predictores independientes de mala evolución clínica encontrados, el único vinculado al tipo de tratamiento fue la presencia de isquemia extensa.

Introduction: While several studies have addressed the comparison between endovascular treatment and surgical clipping of ruptured aneurysms, there is still no definitive evidence regarding the use of one or the other in terms of safety and improved prognosis. The objective of this study is to analyze the various modalities of subarachnoid hemorrhage (SAH) treatment implemented in Uruguay and their impact on aneurysm resolution and patient prognosis. Method: This is a prospective, multicenter study that includes all patients over 18 years of age who were treated for spontaneous aneurysmal subarachnoid hemorrhage in Uruguay between November 1, 2019, and October 31, 2020. We collected and examined clinical-epidemiological characteristics and comorbidities at the time of diagnosis, the type of treatment received, and clinical outcome variables over the following 6 months. The data were analysed using the Statistical Package for Social Sciences (SPSS) software, and a significance level of 5% was applied in the tests. Due to the multicenter and national nature of the study, it had to be submitted for evaluation to all the Ethics Committees of the participating healthcare institutions. Results: A total of 211 cases were observed during the evaluated period. The mean age was 57 years with a predominance of females (75%). In 74% of the cases, some form of specific treatment was recommended (43% open surgery and 31% endovascular therapy), while the remaining patients could not undergo aneurysm treatment due to their severe neurological condition. 52 patients experienced complications related to the treatment received, with a higher proportion of these in the case of open surgery compared to endovascular therapy (42% vs. 21,5%; p=0,008). Conclusions: A higher rate of complications was observed in the surgical treatment, with no impact on morbidity and mortality. Among the independent predictors of poor clinical outcomes identified, the only one related to the type of treatment was the presence of extensive ischemia.

As campanhas de prevenção e promoção da saúde, bem como os avanços na medidas terapêuticas voltadas para pacientes neurocríticos conseguiram reduzir a incidência de pacientes com lesão cerebral aguda que evoluem para morte encefálica (ME). No entanto, na maioria dos países latino-americanos, os órgãos que podem ser perfundidos adequados para transplante (TX) vêm de doadores falecidos em ME. A doação em assistolia e em particular a doação em assistolia controlada (DAC), é uma opção aceita e válida para a obtenção de órgãos, o que contribuiria para a redução das listas de espera para transplantes. Durante o processo DAC, são aplicados conceitos com forte cunho bioético, que são fundamentais na o momento da tomada de decisão. Este artigo tem como objetivo analisar esses conceitos, com o objetivo de oferecer ferramentas válidas à equipe de saúde, para os processos em que há deliberação moral como ocorre na doação de órgãos em assistolia controlada considerada parte integrante dos cuidados de fim de vida.

Neumonía por Pneumocystis jirovecii asociada a hemorragia alveolar difusa en un paciente con trasplante renal

La neumonía por Pneumocystis jirovecii es una enfermedad fúngica oportunista descrita principalmente en pacientes con VIH, sin embargo, tras la introducción de la TARV, ha incrementado su incidencia en pacientes con inmunosupresión no asociada a VIH, como neoplasias hematológicas y trasplantes de órganos sólidos. Presentamos el caso de un varón de 17 años, receptor de un trasplante renal, con inmunosupresión prolongada con corticoesteroides, con cuadro clínico de tos, disnea y fiebre. La TC mostró micronódulos pulmonares centrolobulillares y vidrio esmerilado. El LBA fue compatible con hemorragia alveolar difusa (HAD), con RPC positiva para P. jirovecii. Se descartaron otras infecciones y enfermedades autoinmunes. Recibió tratamiento con cotrimoxazol con buena evolución clínica y mejoría radiológica. Si bien las causas más frecuentes de HAD son etiologías autoinmunes como enfermedades reumatológicas o vasculitis, es prioritario descartar causas infecciosas, incluyendo P. jirovecii, ya que el tratamiento dirigido puede tener un impacto significativo en la mortalidad en este grupo de pacientes.

Pneumocystis jirovecii pneumonia is an opportunistic fungal infection, described mainly in HIV patients, however, after the introduction of ART, its presentation has increased in patients with non-HIV immunosuppression, such as hematological cancers, solid or hematopoietic stem cell transplantation. We report the case of a 17-year-old male, kidney transplant patient, with prolonged immunosuppression with corticoesteroids, with history of cough, dyspnea, and fever. Chest CT evidences centrilobular pulmonary micronodules with ground glass. BAL was performed compatible with diffuse alveolar hemorrhage, with positive PCR for P. jirovecii. Other infections and autoimmune disease were ruled out. He received treatment with cotrimoxazole with clinical improvement of the patient, and follow up chest CT at the end of treatment showed decrease of pulmonary infiltrates. Although the most frequent causes of DAH are autoimmune etiologies such as rheumatic diseases or vasculitis, it is a priority to rule out infectious causes, including P. jirovecii, since targeted treatment could have a significant impact on mortality outcomes in this group of patients.

Ligadura de la arteria lingual: estrategia para hemorragias por lesión de la arteria en la base de la lengua: informe de dos casos / Lingual Artery Ligation: Strategy for Bleeding from Artery Injury at the Base of the Tongue: Report of Two Cases

La hemorragia producida por lesión de la arteria lingual en la base de la lengua por cirugías o por tumores es infrecuente. La mayor frecuencia en la indicación de abordajes transorales para tratar diferentes patologías que afectan la orofaringe requiere que el equipo quirúrgico tenga experiencia en el manejo de esta complicación. La ligadura de la arteria lingual en el cuello es una técnica quirúrgica muy eficaz para solucionar la hemorragia, pero es importante conocer las posibles variantes anatómicas que puede tener la arteria en su trayecto cervical. Debido a su baja incidencia se propone como objetivo describir dos casos clínicos de pacientes que tuvieron hemorragias graves por lesión de la arteria lingual en la base de la lengua, producidas por daño quirúrgico y por erosión por tumor. [AU]

The bleeding caused by injury to the lingual artery at the base of the tongue due to surgery or tumors is infrequent. The increased frequency in the indication of transoral approaches to treat different pathologies affecting the oropharynx requires the surgical team to have experience in managing this complication. Ligation of the lingual artery in the neck is a very effective surgical technique to solve the bleeding; however, it is essential to be aware of the possible anatomical variants the artery may have in its cervical trajectory. Due to its low incidence, we propose to describe two clinical cases of patients who had severe bleeding due to a lesion of the lingual artery at the base of the tongue, produced by surgical damage and erosion due to a tumor. [AU]

Hemorragia digestiva alta

Introducción: La hemorragia digestiva alta tiene una elevada morbimortalidad. La endoscopía digestiva alta es el estudio de elección para su diagnóstico y tratamiento. Objetivo: Describir la conducta ante la hemorragia digestiva alta. Métodos: Para la revisión bibliográfica se consultaron artículos científicos indexados en idioma español e inglés, relacionados con la hemorragia digestiva, publicados en las bases de datos PubMed, SciELO, Medline y Cochrane, pertenecientes a autores dedicados al estudio de este tema. Desarrollo: La hemorragia digestiva alta se clasifica, según la etiología de origen, en variceal y no variceal. La mayoría de los pacientes con hemorragia digestiva alta el sangrado se autolimita. La causa más habitual es la úlcera péptica, pero en caso de sangrado masivo la etiología más frecuente es la variceal. El empleo precoz de la terlipresina en los pacientes con hemorragia digestiva alta variceal mejora el control del sangrado y disminuye la mortalidad. Se debe hacer uso de escalas validadas de estratificación del riesgo: escala de riesgo de Rockall (tiene como propósito principal predecir la mortalidad y riesgo de resangrado del paciente) y la escala de Glasgow-Blatchford). Conclusiones: Sospechar la presencia de hemorragia digestiva alta, estratificar su riesgo e instaurar el manejo inicial y apropiado constituye una prioridad para el médico de urgencia.

Introduction: Upper gastrointestinal bleeding presents high morbidity and mortality. Upper gastrointestinal endoscopy is the study of choice for its diagnosis and treatment. Objective: To describe the management of upper gastrointestinal bleeding. Methods: For the bibliographic review, the consultation was carried out of scientific articles indexed in Spanish and English, related to gastrointestinal bleeding, published in the databases PubMed, SciELO, Medline and Cochrane, belonging to authors dedicated to the study of this subject. Development: Upper gastrointestinal bleeding is classified, according to the etiology of origin, into variceal and nonvariceal. In most patients with upper gastrointestinal bleeding the bleeding as such is self-limiting. The most common cause is peptic ulcer; however, in the case of massive bleeding, the most frequent etiology is variceal. Early use of terlipressin in patients with variceal upper gastrointestinal bleeding improves bleeding control and decreases mortality. Validated risk stratification scales should be used: Rockall risk scale (its main purpose is to predict patient mortality and risk of bleeding recurrence) and the Glasgow-Blatchford scale. Conclusions: Suspecting the presence of upper gastrointestinal bleeding, stratifying its risk, as well as instituting initial and appropriate management, are a priority for the emergency physician.

Manejo odontológico del paciente en tratamiento de anticoagulante oral sometido a cirugía oral: una revisión narrativa / Stomatological management of anticoagulated patients undergoing oral surgery: a narrative review

Resumen Los pacientes que se encuentran bajo tratamiento de anticoagulantes orales, presentan alteraciones en distintas etapas de la hemostasia, lo que conlleva a tener implicancias y consideraciones médico/quirúrgicas durante su atención. En la actualidad, no existe un consenso en relación con el manejo odontológico de estos pacientes que serán sometidos a procedimientos quirúrgicos, llevando a protocolos clínicos que siguen diversas posturas, como la de disminuir la ingesta farmacológica del anticoagulante, sustituir con heparina y la de mantener el tratamiento bajo control. Objetivo Establecer el manejo estomatológico del paciente que se encuentra en tratamiento de anticoagulante oral mediante una revisión profunda de la literatura Materiales y método Se realizó una búsqueda de revisión bibliográfica manualmente de artículos indexados a las bases de datos de PUBMED y EBSCO que correspondiesen a las palabras "cirugía bucal", "anticoagulantes", "atención dental" y "hemorragia oral". En cuanto a los criterios de inclusión, se consideraron revisiones bibliográficas, estudios observacionales, ensayos clínicos, guías, revisiones sistemáticas y metaanálisis publicados entre noviembre de 2005 y 2022, en idiomas inglés o español. Conclusiones Existen múltiples protocolos para la atención del paciente anticoagulado que será sometido bajo procedimiento de cirugía oral menor. Es importante considerar el anticoagulante utilizado, motivo, control de este, el procedimiento a realizar en el paciente y medidas hemostáticas tanto intra como postoperatorias por realizar, tras analizar lo anterior, se advierte que disminuir la ingesta del fármaco para realizar el procedimiento, puede ser más perjudicial al paciente como al clínico, por lo tanto se sugiere mantener el tratamiento antitrombótico y realizar un correcto manejo médico/quirúrgico.

Abstract Patients undertaking oral anticoagulant treatment may experience alterations in different stages of hemostasis, which lead to medical/surgical implications and considerations during their care. Currently, there is no consensus regarding the dental management of these patients, as they go through surgical procedures. This leads to clinical protocols that follow numerous approaches, such as reducing the pharmacological intake of the anticoagulant, replacing it with heparin, and maintaining the controlled treatment. Objective: To establish the stomatological management of the patient undergoing oral anticoagulant treatment through an in depth review of the literature. Materials and Method: A manual bibliographic review search of articles indexed to the PUBMED and EBSCO databases corresponding to the words "oral surgery", "oral bleeding", "anticoagulants" and "dental management" was performed. Regarding the inclusion criteria: bibliographic reviews, observational studies, clinical trials, guidelines, systematic reviews, and meta-analyses published between November 2005 and 2022, in English or Spanish, were considered. Conclusion: There are multiple protocols for the care of the anticoagulated patient who will undergo a minor oral surgery procedure. It is important to reflect on the anticoagulant used, the reason for it, its supervision, the surgical procedure that will be undertaken by the patient, and both intraoperative and postoperative hemostatic measures to be implemented. After analyzing the above, it is noted that reducing the intake of the drug to perform the surgical procedure may be harmful to the patient and to the clinician, therefore it is suggested to maintain the antithrombotic treatment and carry out a correct medical/surgical management.

Intracranial hemorrhages in patients with COVID-19: a systematic review of the literature, regarding six cases in an Amazonian population / Hemorragias intracranianas em pacientes com COVID-19: uma revisão sistemática da literatura, a propósito de seis casos na população amazônica

Abstract Background Coronavirus disease 2019 (COVID-19) has emerged as a public health emergency worldwide, predominantly affecting the respiratory tract. However, evidence supports the involvement of extrapulmonary sites, including reports of intracranial hemorrhages. Objective To describe six original cases and review the literature on intracranial hemorrhages in patients diagnosed with COVID-19 by molecular methods. Methods A systematic literature review was performed on MEDLINE, PubMed, and NCBI electronic databases to identify eligible studies. Of the total 1,624 articles retrieved, only 53 articles met the inclusion criteria. Results The overall incidence of intracranial hemorrhage in patients hospitalized for COVID-19 was 0.26%. In this patient group, the mean age was 60 years, and the majority were male (68%) with initial respiratory symptoms (73%) and some comorbidity. Before the diagnosis of hemorrhage, 43% of patients were using anticoagulants, 47.3% at therapeutic doses. The intraparenchymal (50%) was the most affected compartment, followed by the subarachnoid (34%), intraventricular (11%), and subdural (7%). There was a predominance of lobar over non-lobar topographies. Multifocal or multicompartmental hemorrhages were described in 25% of cases. Overall mortality in the cohort studies was 44%, while around 55% of patients were discharged from hospital. Conclusion Despite the unusual association, the combination of these two diseases is associated with high rates of mortality and morbidity, as well as more severe clinicoradiological presentations. Further studies are needed to provide robust evidence on the exact pathophysiology behind the occurrence of intracranial hemorrhages after COVID-19 infection.

Resumo Antecedentes A COVID-19 emergiu como uma emergência de saúde pública em todo o mundo, proporcionando lesão principalmente do trato respiratório. No entanto, várias evidências apontam para acometimento de sítios extrapulmonares, incluindo relatos de hemorragias intracranianas. Objetivo Descrever seis casos originais e revisar a literatura sobre hemorragias intracranianas em pacientes com diagnostico de COVID-19 por métodos moleculares. Métodos A revisão sistemática da literatura foi feita nas bases de dados eletrônicas da MEDLINE, PubMed e NCBI para identificar os estudos elegíveis. Do total de 1.624 artigos recuperados, apenas 53 artigos preencheram os critérios de inclusão. Resultados A incidência geral de hemorragia intracraniana nos pacientes internados por COVID-19 foi de 0,26%. A média de idade foi de 60 anos, e a maioria dos pacientes era do sexo masculino (68%) com sintomas respiratórios iniciais (73%) e alguma comorbidade. Antes do diagnóstico de hemorragia, 43% estavam em uso de anticoagulantes, 47,3% destes em doses terapêuticas. O compartimento mais acometido foi o intraparenquimatoso (50%), seguido do subaracnoideo (34%), intraventricular (11%) e subdural (7%). Houve predomínio de topografias lobares sobre as não-lobares. Hemorragias multifocais ou multicompartimentais foram descritas em 25% dos casos. A mortalidade geral nos estudos de coorte foi de 44%, enquanto houve alta hospitalar em cerca de 55% dos pacientes. Conclusão Apesar da associação incomum, a combinação dessas doenças está relacionada com altas taxas de mortalidade e morbidade, bem como apresentações clínico-radiológicas mais graves. Mais estudos são necessários para oferecer evidências robustas sobre a fisiopatologia exata por trás da ocorrência de hemorragias intracranianas após infecção por COVID-19.

Hemorragia digestiva como forma de presentación poco usual de amiloidosis intestinal primaria: reporte de caso

La amiloidosis intestinal es una enfermedad sistémica rara y subdiagnosticada, la cual se caracteriza por el depósito extracelular de proteínas que se agrupan en fibras amiloides. Esta entidad es infrecuente y suele ser una forma de presentación en el contexto de una amiloidosis sistémica, cuyo diagnóstico se basa en la presencia a amiloide en la histología. La clínica suele ser inespecífica; diarrea crónica, pérdida de peso, dolor y distensión abdominal; siendo la hemorragia digestiva una manifestación muy poco frecuente. Se presenta el caso de una mujer de 61 años con clínica de baja de peso, distención abdominal, náuseas, vómitos y melena. En la tomografía se evidenció un engrosamiento mural de asas yeyunales con captación de contraste, hallazgo que se corroboró con enteroscopia anterógrada a doble balón en el cual se evidenciaron múltiples úlceras en yeyuno, signos de atrofia, friabilidad y dilatación de luz yeyunal. En la anatomía patológica se aprecia arquitectura vellositaria distorsionada y ulcerada con histoquímica positiva a Rojo Congo e inmunohistoquímica lambda (+++). Además, se realizó aspirado de médula ósea y biopsia de hueso compatible con infiltración de mieloma múltiple monoclonal a cadena Lambda. Durante la estancia hospitalaria la paciente cursó con complicaciones como la desnutrición crónica, infección recurrente y varios episodios de suboclusión intestinal; caracterizada por neumatosis intestinal; debido a múltiples episodios de estas complicaciones la paciente fallece. Dentro de la práctica clínica en gastroenterología la amiloidosis intestinal como parte del diagnóstico diferencial de la hemorragia digestiva alta es infrecuente, por lo que los antecedentes de diagnóstico de mieloma múltiple u otras gammapatías monoclonales asociadas a cadenas ligeras es crucial para un diagnóstico precoz y tratamiento adecuado.

Intestinal amyloidosis is a rare and underdiagnosed systemic disease, which is characterized by the extracellular deposition of proteins that are grouped into amyloid fibers. This entity is rare and is usually a form of presentation in the context of systemic amyloidosis, the diagnosis of which is based on the presence of amyloid in histology. The clinic is usually non-specific; chronic diarrhea, weight loss, abdominal pain and bloating; Gastrointestinal bleeding is a very rare manifestation. The case of a 61-year-old woman with symptoms of weight loss, abdominal distension, nausea, vomiting and long hair is presented. Tomographically, a wall thickening of jejunal loops with contrast uptake was evidenced, a finding that was corroborated by a double-balloon anterograde stereoscopy in which multiple were evidenced. The pathology shows distorted and ulcerated villous architecture with positive histochemistry for Congo Red and LAMBDA (+++) immunohistochemistry. In addition, bone marrow aspirate and bone biopsy compatible with infiltration of Lambda chain monoclonal multiple myeloma were performed. During the hospital stay, the patient developed complications such as chronic malnutrition, recurrent infection and several episodes of intestinal subocclusion; characterized by intestinal pneumatosis; due to multiple episodes of these complications, the patient died. Within clinical practice in gastroenterology, intestinal amyloidosis as part of the differential diagnosis of upper gastrointestinal bleeding is infrequent, so a history of diagnosis of multiple myeloma or other monoclonal gammopathy associated with light chains is crucial for early diagnosis and adequate treatment.

Necrosis esofágica aguda (esófago negro) asociado a neoplasias digestivas / Acute esophageal necrosis (black esophagus) associated with digestive neoplasms

INTRODUCCIÓN. La necrosis esofágica aguda es un síndrome raro que se caracteriza endoscópicamente por una apariencia negra circunferencial irregular o difusa de la mucosa esofágica intratorácica, la afectación es generalmente del esófago distal y la transición abrupta de mucosa normal en la unión gastroesofágica, con extensión proximal variable. CASOS. Se presentan dos casos con diferentes comorbiliades, presentación de signos y síntomas, antecedentes y tratamiento, teniendo en común el diagnóstico a través de endoscopía digestiva alta. RESULTADOS. Caso clínico 1: tratamiento clínico basado en hidratación, suspensión de vía oral, omeprazol intravenoso y sucralfato; mala evolución clínica caracterizada por: disfagia, intolerancia oral y recurrencia del sangrado digestivo alto, se realiza colocación de gastrostomía endoscópica. Caso clínico 2: esófago con mucosa con fibrina y parches de necrosis extensa, se realiza compensación tanto de foco infeccioso pulmonar como hidratación y nutrición, en estudios complementarios se observa masa colónica, con estudio histopatológico confirmatorio de adenocarcinoma de colon en estado avanzado. DISCUSIÓN. La esofagitis necrotizante aguda es una entidad inusual, de baja prevalencia e incidencia, asociada con estados de hipoperfusión sistémica y múltiples comorbilidades que favorezcan un sustrato isquémico. Al revisar los reportes de casos que hay en la literatura médica, los casos que reportamos se correlaciona con las características clínicas, epidemiológicas, endoscópicas y factores de riesgo causales de la enfermedad. La presentación clínica más frecuente es el sangrado digestivo alto, que se debe correlacionar con el hallazgo endoscópico clásico. Nuestro primer caso reportado termina con la colocación de una gastrostomía para poder alimentarse. CONCLUSIÓN. El pronóstico de la necrosis esofágica aguda es malo y se requiere un alto índice de sospecha clínica y conocimiento de esta infrecuente patología para un diagnóstico temprano y un manejo oportuno. Se requiere una evaluación por endoscopia digestiva alta. Es una causa de sangrado gastrointestinal que conlleva tasas altas de mortalidad, principalmente en adultos mayores frágiles. El reconocimiento temprano y la reanimación agresiva son los principios fundamentales para un mejor resultado de la enfermedad.

INTRODUCTION. Acute esophageal necrosis is a rare syndrome that is characterized endoscopically by an irregular or diffuse circumferential black appearance of the intrathoracic esophageal mucosa, the involvement is generally of the distal esophagus and the abrupt transition of normal mucosa at the gastroesophageal junction, with variable proximal extension. CASES. Two cases are presented with different comorbidities, presentation of signs and symptoms, history and treatment, having in common the diagnosis through upper gastrointestinal endoscopy. RESULTS. Clinical case 1: clinical treatment based on hydration, oral suspension, intravenous omeprazole and sucralfate; poor clinical evolution characterized by: dysphagia, oral intolerance and recurrence of upper digestive bleeding, endoscopic gastrostomy placement was performed. Clinical case 2: esophagus with mucosa with fibrin and patches of extensive necrosis, compensation of both the pulmonary infectious focus and hydration and nutrition is performed, in complementary studies a colonic mass is observed, with a confirmatory histopathological study of colon adenocarcinoma in an advanced state. DISCUSSION. Acute necrotizing esophagitis is an unusual entity, with low prevalence and incidence, associated with states of systemic hypoperfusion and multiple comorbidities that favor an ischemic substrate. When reviewing the case reports in the medical literature, the cases we report correlate with the clinical, epidemiological, endoscopic characteristics and causal risk factors of the disease. The most common clinical presentation is upper gastrointestinal bleeding, which must be correlated with the classic endoscopic finding. Our first reported case ends with the placement of a gastrostomy to be able to feed. CONCLUSION. The prognosis of acute esophageal necrosis is poor and a high index of clinical suspicion and knowledge of this rare pathology is required for early diagnosis and timely management. Evaluation by upper gastrointestinal endoscopy is required. It is a cause of gastrointestinal bleeding that carries high mortality rates, mainly in frail older adults. Early recognition and aggressive resuscitation are the fundamental principles for a better outcome of the disease.

Complicaciones neurológicas de la prematuridad / Neurological consequences of prematurity

Resumen Los nacimientos prematuros representan un in dicador importante de salud de un país. Estos niños tienen un mayor riesgo de mortalidad y morbilidad. Las principales lesiones encefálicas en los prematuros incluyen lesiones de la sustancia blanca, hemorragias intracraneanas y lesiones cerebelosas, que pueden ser detectadas mediante ecografía encefálica y resonancia magnética, siendo esta última la técnica más sensible. Estas lesiones pueden tener repercusión a largo plazo en el neurodesarrollo de los prematuros, con un mayor riesgo de parálisis cerebral, trastornos cognitivos, con ductuales, sensoriales y del aprendizaje, entre otros. Es fundamental aplicar estrategias de prevención y aten ción temprana para reducir las consecuencias negativas de las lesiones encefálicas asociadas a la prematuridad.

Abstract Premature births are an important health indicator for a country. These children have a higher risk of mor tality and morbidity. The main brain injuries in preterm infants include white matter injuries, intracranial hem orrhages, and cerebellar injuries. These injuries can be detected through brain ultrasound and magnetic reso nance imaging (MRI), with MRI being the most sensitive technique. Perinatal brain injuries may have long-term consequences on the neurodevelopment of preterm infants, with an increased risk of cerebral palsy, cogni tive, behavioral, sensory, and learning disorders, among others. It is key to implement prevention strategies and early intervention to reduce the negative consequences of brain injuries associated with prematurity.

Manejo perioperatorio de medicación anticoagulante y antiagregante antiplaquetaria en radiología intervencionista / Perioperative management of anticoagulants and antiplatelets agents in interventional radiology

Resumen El número de personas en tratamiento con fármacos anticoagulantes o antiplaquetarios está en crecimiento constante debido al aumento de la supervivencia de los pacientes con fibrilación auricular, válvulas cardiacas mecánicas o que han sufrido un evento isquémico o trombótico agudo. Cuando estos pacientes necesitan un procedimiento radiológico intervencionista que acarrea riesgo de sangrado, es necesario analizar el riesgo trombótico del paciente al interrumpir la medicación frente al riesgo hemorrágico del procedimiento para tomar la decisión más adecuada en cada caso. Por tanto, es una decisión individualizada y supone un desafío para los/as radiólogos/as que realicen estas técnicas. Nuestro objetivo en esta revisión es mostrar las recomendaciones actuales sobre el manejo perioperatorio de la medicación anticoagulante y antiplaquetaria, adaptada al intervencionismo radiológico.

Abstract The number of people treated with anticoagulant or antiplatelet agents is constantly growing due to the increased survival of patients with atrial fibrillation, mechanical cardiac valves or who have suffered an acute thrombotic or ischemic event. When these patients need an interventional radiological procedure that carries a risk of bleeding, it is necessary to analyze the thrombotic risk of the patient when interrupting the medication against the hemorrhagic risk of the procedure, to make the most appropriate decision in each case. Therefore, it is an individualized decision, and it is a challenge for radiologists who perform these techniques. Our goal in this review is to update the current recommendations on the perioperative management of anticoagulant and antiplatelet agents, adapted to the radiological interventionism.

Manejo das irregularidades menstruais secundárias ao uso de contraceptivos ­ análise das recomendações atuais / Management of menstrual irregularities secondary to contraceptive use ­ analysis of current recommendations

As irregularidades menstruais representam uma série de desordens na quantida- de, duração, frequência ou regularidade do sangramento uterino. Entre suas cau- sas destaca-se o sangramento secundário ao uso de anticoncepcionais, uma razão frequente de descontinuidade dos contraceptivos, podendo aumentar as taxas de gestações não planejadas. Boa parte dos contraceptivos pode levar a mudanças no padrão de sangramento uterino, e a abordagem inicial do sangramentos irregula- res inclui a avaliação de outras possíveis causas, o reforço do uso correto da medi- cação, a tranquilização da paciente quanto à benignidade do quadro e à tendência a melhora com a continuidade do uso. Os anti-inflamatórios podem ser usados como estratégia inicial, e, não havendo resposta satisfatória, há alternativas espe- cíficas para cada método. Este trabalho visa identificar as recomendações atuais sobre o manejo do sangramento anormal decorrente de contraceptivos, por meio de revisão narrativa de estudos publicados sobre o tema nos últimos vinte anos.

Abnormal uterine bleeding represents a series of disorders in the amount, du- ration, frequency and or regularity of uterine bleeding. Among its causes, uterine bleeding secondary to the use of contraceptives stands out as a frequent reason for contraceptive discontinuity, which could lead to unplanned pregnancies. Most contraceptives can cause changes in the pattern of uterine bleeding, and the ini- tial approach of the abnormal bleeding includes assessing other possible cau- ses, reinforcing the correct use of medication, and reassuring the patient about the benignity of the condition and the tendency to improve with the continuity of the treatment. Anti-inflammatory drugs can be used as an initial strategy, and, if there is no satisfactory answer, there are specific alternatives for each contracep- tive method. This work aims to identify them current recommendations on the management of abnormal bleeding resulting from contraceptives use, through a narrative review of studies published on the subject in the last twenty years.