Prenatal Therapy with Magnesium Sulfate and Its Correlation with Neonatal Serum Magnesium Concentration.

INTRODUCTION: Antenatal magnesium sulfate (MgSO4) administration has shown to be effective in minimizing cerebral palsy and severe motor dysfunction at the age of 2 years. The aim of this study is to determine the relationship between the magnesium dose delivered to the mother and the magnesium concentration in the neonates. MATERIALS AND METHODS: A prospective cohort study was conducted on neonates of less than 32 weeks' gestation admitted to the neonatal intensive care unit of University Hospital Complex of Vigo from December 2012 to July 2015. Comparative analysis of magnesium levels between the groups of neonates exposed to MgSO4 and the control group. RESULTS: A total of 118 neonates were included in the study. The mothers of 62 of them had received MgSO4 as a neuroprotective agent. There was a significant correlation between the full dose of MgSO4 received by the mother and the levels of magnesium in the neonate in the first 24 hours of life (r2 = 0.397; p < 0.001). CONCLUSION: The MgSO4 dose received by the mother has a linear relationship with the magnesium levels obtained in neonates.

Inicio, diagnóstico y seguimiento de un caso con deficiencia de acil-CoA deshidrogenasa de cadena muy larga / Debut, diagnosis and outcome of a case with very long chain acyl-CoA dehydrogenase deficiency

Los ácidos grasos representan el 80% de las necesidades energéticas en periodos de estrés metabólico. La betaoxidación de los ácidos grasos es catalizada por varias enzimas, como la acil-CoA deshidrogenasa-coenzima FAD, que posee 4 formas específicas según la longitud de la cadena de acil-CoA. La acil-CoA-deshidrogenasa de cadena muy larga es una de ellas. Su déficit cursa con la acumulación intramitocondrial de ésteres de acil-CoA de cadena larga, y afecta al corazón, el músculo esquelético y el hígado. Presentamos un caso iniciado a los 22 meses de edad con un síndrome Reye-like. Confirmamos un déficit de la betaoxidación de los ácidos grasos de cadena muy larga, con las mutaciones p.A232T (c.694G>A) y p.Y201C (c.602A>G) en los alelos del gen VLCAD. Describimos su evolución durante 17 años recibiendo una dieta pobre en ácidos grasos de cadena larga y suplementos con aceite MCT (AU)

Fatty acids represent 80% of energy needs during periods of stress. Beta-oxidation of fatty acids is catalyzed by some enzymes including acyl-CoA-dehydrogenase-coenzyme FAD, wich has four different ways according to the chain length of acyl-CoA. The very-long-chain-acyl-CoA-dehydrogenase is one of them. A deficiency of this enzyme produces an accumulation of long-chain-acyl-CoA-esters in mitochondrias, affecting heart, skeletal muscle and liver. We report the case of a 22-month aged child whose first symptom was a Reye-like syndrome. We confirmed that he was affected by a deficiency in the beta-oxidation of fatty acids of very long chain. He showed some mutations in the VLCAD gene alleles: p.A232T (c.694G>A) and p.Y201C (c.602A>G). We explain the evolution in the next 17 years, following a diet with very little long chain fatty acids and MCT oil supplements (AU)

Inter-observer variance with the diagnosis of myelodysplastic syndromes (MDS) following the 2008 WHO classification.

Morphology is the basis of the diagnosis of myelodysplastic syndromes (MDS). The WHO classification offers prognostic information and helps with the treatment decisions. However, morphological changes are subject to potential inter-observer variance. The aim of our study was to explore the reliability of the 2008 WHO classification of MDS, reviewing 100 samples previously diagnosed with MDS using the 2001 WHO criteria. Specimens were collected from 10 hospitals and were evaluated by 10 morphologists, working in five pairs. Each observer evaluated 20 samples, and each sample was analyzed independently by two morphologists. The second observer was blinded to the clinical and laboratory data, except for the peripheral blood (PB) counts. Nineteen cases were considered as unclassified MDS (MDS-U) by the 2001 WHO classification, but only three remained as MDS-U by the 2008 WHO proposal. Discordance was observed in 26 of the 95 samples considered suitable (27 %). Although there were a high number of observers taking part, the rate of discordance was quite similar among the five pairs. The inter-observer concordance was very good regarding refractory anemia with excess blasts type 1 (RAEB-1) (10 of 12 cases, 84 %), RAEB-2 (nine of 10 cases, 90 %), and also good regarding refractory cytopenia with multilineage dysplasia (37 of 50 cases, 74 %). However, the categories with unilineage dysplasia were not reproducible in most of the cases. The rate of concordance with refractory cytopenia with unilineage dysplasia was 40 % (two of five cases) and 25 % with RA with ring sideroblasts (two of eight). Our results show that the 2008 WHO classification gives a more accurate stratification of MDS but also illustrates the difficulty in diagnosing MDS with unilineage dysplasia.

Agentes anti-TNF en el tratamiento de la enfermedad de Crohn / Anti-TNF agents for the treatment of Crohn’s disease

Introducción: Los agentes anti-TNF constituyen hoy en día un arma terapéutica más en el tratamiento de la enfermedad de Crohn (EC) del adulto. A pesar de que la experiencia en niños es aún limitada, parecen ser fármacos eficaces y seguros. Objetivo: Evaluar la eficacia y la seguridad de los agentes anti-TNF infliximab y adalimumab en la inducción de la remisión de la EC a través de nuestra experiencia, y llevar a cabo una revisión de la evidencia científica respecto a su uso. Pacientes y métodos: Se llevó a cabo un estudio retrospectivo de los 7 pacientes con EC que recibieron infliximab o adalimumab en la unidad de gastroenterología infantil. Para evaluarla eficacia se utilizó el Pediatric Crohn’s Disease Activity Index, el valor de la proteína C reactiva (PCR) y la valoración clínica de la enfermedad perianal en las semanas 1, 4 y 8.Resultados: Siete pacientes (4 niños y 3 niñas), con una edad media de 13 años. En la semana 8 no hubo ningún paciente no respondedor, y en 5 de ellos (71,4%) se logró la remisión clínica. Se obtuvo un descenso medio de 21, 27 y 31 puntos en las semanas 1, 4 y 8, respectivamente, así como una reducción media de la PCR de 2,47 mg/dL. En 4 de los 5 pacientes con enfermedad perianal se observó una remisión completa a las 8 semanas. No se observaron reacciones infusionales. Discusión: Nuestra propia experiencia y la revisión de la evidencia al respecto nos hacen concluir que el tratamiento con agentes anti-TNF en la EC pediátrica parece ser seguro y efectivo, y hoy en día constituye un nuevo y esperanzador escalón en el tratamiento de la EC (AU)

Introduction: Anti-TNF agents have recently been found to be a useful weapon in the treatment of Crohn´s disease (CD) in adults. Although experience in children is still limited, they seem to be effective and safe. Objective: To assess the effectiveness and safety of the anti-TNF agents infliximab and adalimumab in induction of clinical remission in pediatric CD, combining our experience and the existing scientific evidence regarding their use. Patients and methods: We carried out a retrospective study of 7 patients with CD that received infliximab or adalimumab in the Pediatric Gastroenterology Department. To assess the effectiveness, we used the Pediatric Crohn’s Disease Activity Index (PCDAI), CRP levels and clinical evaluation of perianal involvement at weeks 1, 4 and 8. Results: 7 patients (4 boys and 3 girls), with a mean age of13 years. All patients had achieved some clinical response by week 8, and a clinical remission was observed in 5 out of 71.4 at the time. We observed a mean decrease of PCDAI of 21, 27and 31 points in weeks 1, 4 and 8 respectively. Mean levels of CRP were reduced from 2.47 mg/dL. In 4 of 5 patients with perianal involvement complete remission was observed at week 8. No infusion reactions were observed. Discussion: Our own experience and the existing evidence in this topic suggest that treatment with anti-TNF agents in pediatric CD is safe and effective. They are a new and encouraging step in the treatment of CD (AU)

[Flexural psoriasis induced by infliximab and adalimumab in a patient with Crohn's disease]. / Psoriasis secundaria al tratamiento con infliximab y adalimumab en la enfermedad de Crohn.

Anti-TNF drugs are used increasingly in several diseases with immune-mediated inflammation, not only in rheumatological conditions, but also in inflammatory bowel disease and psoriasis. Different side effects have been described over the last few years, including the development of psoriasis or psoriasiform exanthemas. These drugs began to be used in paediatrics during the 90's, therefore paediatricians need to be aware of the adverse effects that may occur. We describe here a flexural psoriasis induced by both infliximab and adalimumab in a paediatric patient with Crohn's Disease. To the best of our knowledge, this is the first reported paediatric case of psoriasis triggered by an anti-TNF drug, as well as the first case of psoriasis induced by adalimumab in patients with inflammatory bowel disease.

Efectividad de las Pruebas Psicométricas en el Diagnóstico y Seguimiento de Deterioro, Depresión y Ansiedad en las Personas Mayores / Effectiveness of Tests for the Diagnosis and Follow up of Deterioration, Anxiety and Depression in Elderly People

El presente estudio indaga acerca de la posible correlación existente entre depresión, ansiedad y deterioro en personas mayores. Se examina el valor predictivo de los cuestionarios utilizados en Atención Primaria puesto que los resultados estadísticos no siempre coinciden con la experiencia clínica. La conclusión final apunta a que existen dos variables que podrían justificar este hecho: La dificultad para evaluar síntomas afectivos frente a síntomas cognitivos en atención primaria. El desconocimiento del entorno en que envejecen las personas, que opera como variable contaminante en los resultados de la evaluación personal. Por último, se sugiere que se tengan en cuanta las diferencias entre Atención Primaria y práctica psiquiátrica a la hora de establecer un modelo para la identificación y tratamiento de la Depresión, utilizándose un instrumento de medida para el diagnóstico diferente del empleado para observar la evolución (AU)

This paper analyzes the correlation between depression, anxiety and deterioration in elderly people. Since statistical results not always match up clinical experience, the predictive value of primary health care was checked. As a conclusion it appears to be two reasons accounting for this fact: the difficulty to assess affective vs cognitive symptoms in primary health care and a lack of knowledge of the environment where people age –a fact that contaminates personal assessment results. Finally, a suggestion is made to consider the differences between primary care and psychiatric care with regard to establishing a model for depression identification and treatment –the tool for diagnosis should be different from the one used to check symptom evolution (AU)

Psoriasis secundaria al tratamiento con infliximab y adalimumab en la enfermedad de Crohn / Flexural psoriasis induced by infliximab and adalimumab in a patient with Crohn & apos; s disease

Los fármacos inhibidores del factor de necrosis tumoral alfa se usan cada vez más frecuentemente en la práctica clínica diaria. Han mostrado su efectividad en el tratamiento de trastornos de base inflamatoria mediada por el sistema inmunitario, principalmente enfermedades reumáticas, pero también en la enfermedad inflamatoria intestinal y en la psoriasis. En los últimos años se han descrito diversos efectos secundarios, entre los cuales se encuentra el desarrollo, que resulta paradójico, de psoriasis o exantemas psoriasiformes. Desde finales de los noventa, la extensión de estos fármacos a la edad pediátrica es un hecho, y es necesario que los pediatras conozcamos los fenómenos adversos que pueden producir. Describimos aquí un caso de psoriasis invertida secundaria al tratamiento con infliximab y adalimumab en un paciente de 13 años con enfermedad de Crohn. Hasta donde llegamos a conocer, se trata del primer caso comunicado en edad pediátrica, así como el primer caso desencadenado por adalimumab en la enfermedad inflamatoria intestinal (AU)

Anti-TNF drugs are used increasingly in several diseases with immune-mediated inflammation, not only in rheumatological conditions, but also in inflammatory bowel disease and psoriasis. Different side effects have been described over the last few years, including the development of psoriasis or psoriasiform exanthemas. These drugs began to be used in paediatrics during the 90’s, therefore paediatricians need to be aware of the adverse effects that may occur.We describe here a flexural psoriasis induced by both infliximab and adalimumab in a paediatric patient with Crohn’s Disease. To the best of our knowledge, this is the first reported paediatric case of psoriasis triggered by an anti-TNF drug, as well as the first case of psoriasis induced by adalimumab in patients with inflammatory bowel disease (AU)

Asociación de enfermedad celiaca y pancolitis ulcerosa: a propósito de un caso y revisión de la bibliografía / Association between celiac disease and ulcerative pancolitis: a case report and review of the literature

Presentamos el caso de una niña de 7 años y 6 meses de edad, diagnosticada de una enfermedad celiaca por presentar clínica, analítica y biopsia yeyunal compatibles, que mejoró tras instaurar una dieta exenta de gluten. Un año después presentó un cuadro de deposiciones con sangre, con analítica y estudio de colonoscopia sugestivo de pancolitis ulcerosa. Dado que la asociación de celiaquía y enfermedad inflamatoria intestinalapenas ha sido descrita en niños, nos parece interesante presentar el caso y llevar a cabo una revisión de la bibliografía disponible (AU)

We report the case of a 7 and a half-year-old girl who was diagnosed as having celiac disease on the basis of compatible clinical features, serological tests and jejunal biopsy. The course was favourable after a gluten-free diet. One year later, she presented bloody stools, with laboratory tests and colonoscopic findings that suggested ulcerative pancolitis. As the association between celiac disease and inflammatory bowel disease has rarely been reported in children, we consider it to be of great interest to present our case and review the available literature (AU)

Macroscopy and light microscopy of the discomallear ligament passing through the petrotympanic fissure in human fetuses

In light of the controversy reported in previousstudies, we conducted this study with theobjective of using macroscopy and lightmicroscopy to elucidate the morphology of thediscomallear ligament and detail its topographicrelationship with other fibrous structuresof the temporomandibular joint (TMJ). Two human fetuses with 36 and 37 weeks of intrauterine life were used. Bundles of longitudinal fibers crossed the petrotympanic fissure forming a single ligament. Microscopicanalysis of laminae from the discomallear andanterior malleolar ligament region showed that their insertion into the malleus is a region common to both ligaments. Therefore, these findings suggest that the discomallear and anterior malleolar ligaments could be distinct portions (anterior and superior) of the sameligament. Additionally, we propose the inclusion of these ligaments in future editions of the international anatomic nomenclature (AU)

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[Effectiveness of weight loss in the treatment of non-alcoholic steatohepatitis in an obese adolescent]. / Eficacia de la reducción de peso en la curación de la esteatohepatitis no alcohólica en un adolescente obeso.

Childhood obesity is the most frequent nutritional disorder in developed countries and has been described as a global epidemic by the World Health Organization. In children, as in adults, obesity is the most significant risk factor for the development of non-alcoholic fatty liver disease. Therefore, it may become the most frequent chronic liver disease in children. However, pediatric publications on this disorder, which can progress to severe liver disease with risk of mortality, are scarce, with small series and few histological studies. The present article describes an obese adolescent who presented severe steatosis and steatohepatitis, which responded to weight loss with clinical and histological normalization. The risk of obesity comorbidity is increasing significantly in the pediatric population.

Eficacia de la reducción de peso en la curación de la esteatohepatitis no alcohólica en un adolescente obeso / Effectiveness of weight loss in the treatment of non-alcoholic steatohepatitis in an obese adolescent

La obesidad infantil es el trastorno nutricional más frecuente en los países desarrollados, habiendo sido declarada por la Organización Mundial de la Salud como una epidemia global. En los niños, al igual que ocurre en los adultos, la obesidad es el factor de riesgo más importante para el desarrollo de la enfermedad hepática grasa no alcohólica, por lo que es probable que se convierta en la enfermedad hepática crónica infantil más frecuente. Sin embargo las publicaciones pediátricas sobre este trastorno, que puede llegar a ocasionar una grave enfermedad hepática con riesgo para la vida, son relativamente poco numerosas, con series pequeñas y con escasos estudios histológicos. El artículo describe a un adolescente obeso en el que se demostró esteatosis grave y esteatohepatitis que respondieron con normalización analítica e histológica a la reducción de peso. Se alerta sobre el incremento de esta comorbilidad de la obesidad en la población pediátrica

Childhood obesity is the most frequent nutritional disorder in developed countries and has been described as a global epidemic by the World Health Organization. In children, as in adults, obesity is the most significant risk factor for the development of non-alcoholic fatty liver disease. Therefore, it may become the most frequent chronic liver disease in children. However, pediatric publications on this disorder, which can progress to severe liver disease with risk of mortality, are scarce, with small series and few histological studies. The present article describes an obese adolescent who presented severe steatosis and steatohepatitis, which responded to weight loss with clinical and histological normalization. The risk of obesity comorbidity is increasing significantly in the pediatric population

Neural tube closure defects: a discussion of current models and clinicalpresentation of a skull from the Museumof Anatomy of a Brazilian University

Currently, neural tube defects (NTD) have anincidence rate of 1/1000 of those born alive.Their occurrence relates to the primary neurulationperiod. In this context, there are twomain embryogenesis models that attempt toexplain neural tube closure: the continuousclosure model and the multisite closuremodel. In this work, we studied a skull withNTD from the collection of the Federal Universityof São Paulo, Paulist School of Medicine,where the cephalic perimeter and indexwere measured and the dental arcade was usedto estimate chronological age. From thisanalysis we conclude that this was a microbrachycephalicskull, with anterior fontanelledisjunction and a neural tube closure defect atsite 2, according to the multisite classificationmodel. In general, NTDs present a highdegree of clinical and etiologic heterogeneity.The causes for this broad diversity of defectsare the intrauterine involvement of teratogenicfactors, among them maternal alcoholism,use of carbamazepine duringpregnancy, and folic acid deficiency, amongothers. There are many genes potentiallyinvolved in this class of defects configuring asmultifactorial. Thus, the multisite closuremodel allows one to explain many of thesedefects by suggesting the possibility of a differentgenetic control for each closure site,together with different sensitivities to environmentalfactors, both interacting with eachother as a probable NTD etiology (AU)

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Effect of pregnancy on pre-existing liver disease physiological changes during pregnancy.

The pregnant woman experiences physiological changes to support fetal growth and development. Particularly the physiological changes of the liver are the results of the increment of estrogens and progesterone during the pregnancy, and also the hemodynamics changes. (hemodilution). Telangiectasia may appear in up to 60% of normal pregnancies. Liver function test (LFT) abnormalities occurs in 3% of the pregnancies, and the Preeclampsia is the most frequent cause. Most of the articles agree that in normal pregnancy the LFT are either normal or slightly increase o decrease but within normal range. Thus, an increase in serum ALT, AST and GGT activities and serum bilirubin and total bile acid concentration during pregnancy may be pathologic and should prompt further evaluation. In the same way the serum albumin levels is significantly low and the serum alkaline phosphatase concentrations are considerably higher and are a normal component of the pregnancy , and if they are within normal range, do not usually indicate the presence of liver disease. The prothrombine time and the partial prothrombine time remain unchanged during pregnancy and serum fibrinogen increase in late pregnancy. Most of the articles related to plasma lipids in pregnancy agree that cholesterol. Triglyceride and lipoprotein increase during pregnancy. Use of gestational age of the pregnancy are the best guide to the differential diagnosis of liver disease in the pregnancy.

Ultrastructural evidence of vascularization of the central zone of the temporomandibular joint disc in human fetus

The present study examined the ultrastructuralfeatures of the articular discs of the temporomandibularjoint (TMJ) of nine humanfetuses aging from 21 to 28 weeks. The specimenof the fetal articular discs was sectionedfrontally and sagitally and examined under thescanning electron-microscope. The ultrastructuralsurvey of the architecture of the articulardisc revealed three bands composed of fibrocartilaginoustissues in the articular disc:namely, 1) anteromedial longitudinal fibers,the dominant component in the superior andinferior portions; 2) anteroposterior transversalfibers, 3) central diagonal fibers. The centralportion of the articular disc showedscattered blood vessels containing erythrocytes.To our knowledge, this is the firstdescription of the presence of blood vessels inthe central articular of the human TMJ articulardisc. This evidence is also lacking inclassic textbooks of Anatomy and Developmental Biology (AU)

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Evaluation of mandibular dynamics and bite force in myofascial pain follow-up

The purpose of this study was to assess clinicallyand through electronic axiography thechanges in mandibular dynamics in the symptomaticand asymptomatic phases occurringin patients with a diagnosis of myofascialpain. From October 2003 through December2004, a sample of 10 cases (all female aged,20-50 years old) clinically diagnosed ofmyofascial pain were followed up to identifychanges in mandibular movements. Thepatients were interviewed, and anamnesis anda clinical examination were performed.Patients with a diagnosis of myofascial painwere recorded with an electronic axiograph(Kavo, model Arcus digma™) and their biteforce was measured (Kratos™ digitaldynamometer). The patients were theninstructed about treatment and follow-up wascarried out. After the remission of symptoms,a new axiography and determination of biteforce was performed. Axiograph analysisshowed significant changes in the mandibulardynamic pattern between the symptomaticand asymptomatic phases and a statisticallysignificant (p<0.001) increase in bite force in100% of the patients after pain remission wasverified. The changes in mandibular dynamicswere: an increase in maximum jaw openingwithout pain in 100% of the sample and adecreased mandibular deviation in openingand closing jaw movements in 70% of thepatients. The present study suggests that axiographicstudy of mandibular movements andthe determination of bite force can contributeto a better understanding of temporomandibulardisorders, and an improvement indiagnostic criteria and the follow-up of therapeuticprocedures (AU)

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Pica y anemia ferropénica como manifestación inicial de enfermedad celiaca / No disponible

Comunicamos el caso de un niño que ingiere de manera habitual, desde hace un año, sustancias no nutritivas. En la exploración destaca la palidez cutánea y el examen hematológico es compatible con anemia ferropénica. La terapia con hierro oral no mejora sustancialmente los índice analíticos por lo que se amplía la búsqueda diagnóstica. La positividad de los anticuerpos IgA antitransglutaminas nos pone sobre la pista de un proceso malabsortivo, estableciendo la biopsia intestinal el diagnóstico de enfermedad celiáca (AU)

We communicate the case of a child whom ingest of habitual way, for a year, non nutritious substances. In the exploration it emphasizes the cutaneous pallor and the hematologic examination is compatible with ferropénica anemia. The therapy with oral iron does not improve substantially the analytical indexes reason why it is amplify the diagnostic search. The positive of the IgA anti – transglutaminase antibodies puts us on the track of a malabsortive process, establishing the intestinal biopsy the diagnosis of celiac disease (AU)

[Management of choledochal cyst: laparotomy or endoscopic]. / Tratamiento del quiste de colédoco: cirugía abierta o endoscópica?

The most generally accepted therapy of choledochal cyst is cystectomy and biliar derivation by laparotomy. Last years, endoscopic papilotomy by ERCP has been a valuable therapeutic alternative, no only a diagnostic method. In this study, we reviewed five pediatric patients operated in our Deparment in last five years for choledochal cyst. The initial therapy was laparotomy (n=4) and endoscopic papilotomy by ERCP (n=1) This one was made in other Hospital. Follow-up has been between one and five years. All patients are living. Four patients who were operated by laparotomy are asyntomatic. Patient who was treated by ERCP needed a new ERCP in first posoperative month. Five years ago, she had a seriuos acute pancreatitis and we decided laparotomy and biliar derivation. Since laparotomy, she had two new episodes of acute pancreatitis and she has needed a new endoscopic dilatation with ballon by ERCP. She has been asyntomatic for four months. In conclusion, we think laparotomy with biliar derivation is safer than ERCP in management of children with choledochal cyst. ERCP must be reserved to emergency situations before laparotomy or after postoperative complications, never as exclusive therapy.

Tratamiento del quiste de colédoco: ¿cirugía abierta o endoscópica? / Management of choledochal cyst: laparotomy or endoscopic

El tratamiento de elección en los quistes de colédoco ha sido su exéresis por laparotomía unida a derivación biliar, aunque en los últimos años se ha preconizado la papilotomía endoscópica no sólo como método diagnóstico, sino como posibilidad terapéutica. En este trabajo realizamos un estudio retrospectivo de cinco pacientes pediátricos intervenidos por quiste de colédoco en los últimos cinco años en nuestro Servicio. Los quistes se clasificaron en tipo I (n=4), uno de ellos asociados a malunión pancreatobiliar, y en tipo IV (n=1). El tratamiento inicial de los quistes consistió en resección del quiste (n=4) y en papilotomía endoscópica (n=1) en la paciente con malunión pancreatobiliar, técnica que fue realizada en otro Centro. Con un tiempo de seguimiento medio de tres años, todos los pacientes sobreviven. Los cuatro pacientes intervenidos inicialmente mediante cirugía abierta se encuentran asintomáticos desde la intervención. La paciente tratada mediante CPRE requirió al mes una nueva papilotomía y extracción de cálculos. A los cinco años presentó episodio severo de colangiopancreatitis aguda indicándose cirugía abierta exerética del quiste con derivación bilioentérica. Desde entonces ha presentado dos nuevos episodios de pancreatitis leve y ha requerido una nueva dilatación endoscópica con balón. Tras cuatro meses desde dicha dilatación, ha permanecido asintomática. En conclusión, la cirugía exerética con derivación biliar nos parece la opción más segura para el tratamiento de los niños con quiste de colédoco. Desde el punto de vista terapéutico, en quistes de colédoco y canal común biliopancreático, la CPRE debería ser utilizada con mucha cautela, y quizás reservarse para situaciones de emergencia previas a la cirugía o como tratamiento de rescate para complicaciones posquirúrgicas (AU)

The most generally accepted therapy of choledochal cyst is cystectomy and biliar derivation by laparotomy. Last years, endoscopic papilotomy by ERCP has been a valuable therapeutic alternative, no only a diagnostic method. In this study, we reviewed five pediatric patients operated in our Deparment in last five years for choledochal cyst. The initial therapy was laparotomy (n=4) and endoscopic papilotomy by ERCP (n=1) This one was made in other Hospital. Follow-up has been between one and five years. All patients are living. Four patients who were operated by laparotomy are asyntomatic. Patient who was treated by ERCP needed a new ERCP in first posoperative month. Five years ago, she had a seriuos acute pancreatitis and we decided laparotomy and biliar derivation. Since laparotomy, she had two new episodes of acute pancreatitis and she has needed a new endoscopic dilatation with ballon by ERCP. She has been asyntomatic for four months. In conclusion, we think laparotomy with biliar derivation is safier than ERCP in management of children with choledochal cyst. ERCP must be reserved to emergency situations before laparotomy or after posoperative complications, never as exclusive therapy (AU)

[Experimental model of auxiliary heterotopic liver-intestinal transplantation]. / Modelo experimental de trasplante hepato-intestinal auxiliar heterotópico.

In pigs, orthotopic liver-intestine transplantation (LITX) has high per operative morbidity and mortality. It is due to hemodynamic, coagulation and metabolism disorders during native liver hepatectomy (total hepatic vascular exclusion) and the postoperative diarrhea secondary to initial dysfunction of the graft and enterectomy of native intestine. To avoid those disturbances and to increase the survival, we have developed a porcine model of auxiliary heterotopic LITX. The allograft was harvested in-bloc, containing the liver, duodenum, pancreas, and jejunum. In the recipient, the liver and intestine were left intact. The allograft was implanted heterotopically, caudal to the native liver. Venous drainage was achieved with anastomosis of donor (D) to recipient (R) infrahepatic cava; and arterialization with anastomosis of D aortic conduit containing the celiac axis and SMA to infra-renal R aorta. The D jejunum was hooked-up to R jejunum. The experiment was performed in 16 animals without intraoperative deaths, hemodynamic stability and no blood requirements. Four animals were left alive 7 days with functioning grafts, suggesting the model viability.

[Economical impact of preterm delivery management based on fetal fibronectin results]. / Impacto económico del manejo del parto pretérmino con base en el resultado de fibronectina fetal.

BACKGROUND: Preterm labor continues to be the first cause (after congenital malformations) of morbidity and mortality during the perinatal period. One of the markers showing the highest sensitivity to predict preterm labor seems to be fetal fibronectin (fFN) determined in the cervicovaginal secretion. OBJECTIVES: To identify patients at risk of preterm labor based on the presence of fFN in cervicovaginal secretions and to analyze the cost-benefit of medical attention and hospital stay depending on the fFN results. MATERIAL AND METHODS: Four hundred and sixty two patients were admitted in a 6 month period to the Maternal-Fetal Medicine Department. All of them had symptoms of preterm labor. Their gestational ages were between 24 and 34 weeks, the fFN analyses were taken from cervical vaginal secretion. One hundred and fifty eight were fFN positive and 304 were negative. Patients with positive fFN were hospitalized and received specific treatment for preterm labor. The patients with negative fFN were sent home with no medical treatment. In order to calculate the economic impact of the hospital's medical attention we considered the total cost in pesos which included patient's hospital care when admitted with preterm labor symptoms, hospital stay, and neonatal attention. The total costs were compared and analyzed in the two groups. RESULTS: The average cost generated for fFN positive and negative patients was 23,059 and 7,859 pesos, respectively. Approximately 15,200 pesos were saved per patient in this group. Multiplying this amount among patients with negative fFN (n=304), we would have saved 4,620,000 pesos in a 6 month period. Our established medical management did not affect negatively maternal-fetal well being. For statistical purposes of variables the Mann Whitney U, chi square and McNemar's tests were calculated. CONCLUSION: By determining fFN for the diagnosis of preterm labor, we obtained savings of 4,620,000 pesos in a 6 month period avoiding unnecessary treatments and hospital stay in patients with negative fFN. Determination of fFN in cervical vaginal secretion in patients with symptoms of preterm labor showed to have high sensitivity and specificity in predicting preterm labor between 24-34 weeks of gestation, permitting a more rational use of medical management and resources and avoiding unnecessary treatments. The treatment instituted on the basis of an opportune diagnosis in patients with positive fFN showed to prolong weeks of gestation. Although a persistence of morbidity and mortality of prematurity has been reported, these have diminished in comparison with studies previously done in the institution.