Niña de 8 años de edad con una masa genital poco frecuente / 8 years old girl with unusual genital mass

Introducción: Las tumoraciones interlabiales en las niñas son una patología poco frecuente. Abarcan un amplio espectro de posibles lesiones que pueden generar confusión en su diagnóstico y manejo. Caso clínico: Niña de 8 años de edad que acude al servicio de urgencias por presentar flujo vaginal sanguinolento y prurito de 5 días de evolución. Inicialmente se orientó como himenitis, pero ante la persistencia de la clínica, se realizó una vaginoscopia y una cistoscopia, en las que se observó un prolapso de la mucosa uretral de grado II-III. Se trató la afección de manera conservadora con estrógenos tópicos y baños de asiento, y la paciente no ha precisado cirugía hasta el momento. Las masas interlabiales en las niñas generan confusión en su diagnóstico, manejo y pronóstico. Discusión: Conocer las características clínicas propias de cada entidad permitirá hacer un buen diagnóstico, sin precisar pruebas invasivas y más costosas, y asimismo, evitará un retraso en el diagnóstico. Conclusiones: Presentamos un caso clínico de tumoración interlabial en una niña en edad prepuberal como forma de presentación del prolapso uretral, una patología poco frecuente en la infancia

Introduction: Interlabial tumors in children are a rare finding. They cover a broad spectrum of possible causes that can lead to confusion in diagnosis and management. Case report: A 8-year-old
girl who was referred to the emergency room for 5 days of bloody vaginal discharge and itching. Initially a hymenitis was suspected but due to the persistence of the symptoms a cystoscopy was performed, showing prolapsed urethral mucosa grade II-III. She was treated conservatively with topical estrogens and sitz baths without needing surgery so far. Discussion: Genital masses in girls generate confusion in diagnosis, management and prognosis. Knowing the clinical features of each entity may allow us a good diagnosis without requiring more invasive and expensive tests and thus also avoid a delay in the diagnosis. Conclusion: We present a case of interlabial mass as a form of presentation of urethral prolapse, a rare pathology in childhood

Assessing Community Cancer care after insurance ExpanSionS (ACCESS) study protocol.

BACKGROUND: Cancer is the second most common cause of mortality in the United States. Cancer screening and prevention services have contributed to improved overall cancer survival rates in the past 40 years. Vulnerable populations (i.e., uninsured, low-income, and racial/ethnic minorities) are disproportionately affected by cancer, receive significantly fewer cancer prevention services, poorer healthcare, and subsequently lower survival rates than insured, white, non-Hispanic populations. The Affordable Care Act (ACA) aims to provide health insurance to all low-income citizens and legal residents, including an expansion of Medicaid eligibility for those earning ≤138% of federal poverty level. As of 2012, Medicaid was expanded in 32 states and the District of Columbia, while 18 states did not expand, creating a 'natural experiment' to assess the impact of Medicaid expansion on cancer prevention and care. METHODS: We will use electronic health record data from up to 990 community health centers available up to 24-months before and at least one year after Medicaid expansion. Primary outcomes include health insurance and coverage status, and type of insurance. Additional outcomes include healthcare delivery, number and types of encounters, and receipt of cancer prevention and screening for all patients and preventive care and screening services for cancer survivors. DISCUSSION: Cancer morbidity and mortality is greatly reduced through screening and prevention, but uninsured patients are much less likely than insured patients to receive these services as recommended. This natural policy experiment will provide valuable information about cancer-related healthcare services as the US tackles the distribution of healthcare resources and future health reform. TRIAL REGISTRATION: Clinicaltrails.gov identifier NCT02936609.

Evaluating community health centers' adoption of a new global capitation payment (eCHANGE) study protocol.

Primary care patient-centered medical homes (PCMHs) are an effective healthcare delivery model. Evidence regarding the most effective payment models for increased coordination efforts is sparse. This protocol paper describes the evaluation of an Alternative Payment Methodology (APM) implemented in a subset of Oregon community health centers (CHCs), using a prospective matched observational design. The APM is a primary care payment reform intervention that changed Oregon's Medicaid payment for several CHCs from fee-for-service reimbursement to a per-member-per-month capitated payment. We will implement a difference-in-difference analytic approach to evaluate pre-post APM changes between intervention and control groups, including: 1) clinic-level outcomes, 2) patient-level clinical outcomes, and 3) patient-level econometric outcomes. Findings from the project will be of national significance, as there is a need for evidence regarding how novel payment methods might enhance PCMH capabilities and support their capacity to produce better quality and outcomes. If this capitated payment method is proven effective, study findings will inform dissemination of similar APMs nationwide.

Economic contraction, alcohol intoxication and suicide: analysis of the National Violent Death Reporting System.

OBJECTIVES: Although there is a large and growing body of evidence concerning the impact of contracting economies on suicide mortality risk, far less is known about the role alcohol consumption plays in the complex relationship between economic conditions and suicide. The aims were to compare the postmortem alcohol intoxication rates among male and female suicide decedents before (2005-2007), during (2008-2009) and after (2010-2011) the economic contraction in the USA. METHODS: Data from the restricted National Violent Death Reporting System (2005-2011) for male and female suicide decedents aged 20 years and older were analysed by Poisson regression analysis to test whether there was significant change in the fractions of suicide decedents who were acutely intoxicated at the time of death (defined as blood alcohol content ≥0.08 g/dL) prior, during and after the downturn. RESULTS: The fraction of all suicide decedents with alcohol intoxication increased by 7% after the onset of the recession from 22.2% in 2005-2007 to 23.9% in 2008-2011. Compared with the years prior to the recession, male suicide decedents showed a 1.09-fold increased risk of alcohol intoxication within the first 2 years of the recession. Surprisingly, there was evidence of a lag effect among female suicide decedents, who had a 1.14-fold (95% CI 1.02 to 1.27) increased risk of intoxication in 2010-2011 compared with 2005-2007. CONCLUSIONS: These findings suggest that acute alcohol intoxication in suicide interacts with economic conditions, becoming more prevalent during contractions.

Characteristics of adult male and female firearm suicide decedents: findings from the National Violent Death Reporting System.

OBJECTIVE: To examine the risk factors and precipitating circumstances associated with firearm suicide. METHODS: Data from the restricted National Violent Death Reporting System (2003-6) for 25 491 male and female suicide decedents aged 18 and older were analysed by multiple logistic regression to estimate the relative odds of firearm use with 95% CIs. RESULTS: Firearms were often used in male (58.1%) and female (31.2%) suicides. Among male decedents, older age, veteran status, residing in areas with higher rates of firearm availability, raised blood alcohol concentration, acute crisis and relationship problems were all associated with firearm use. Conversely, men with a diagnosis of a mental health problem, a history of suicide attempts or alcohol problems had lower odds of firearm use. Among female decedents, factors with a significant effect on firearm use included: being older, married, white and a veteran; residing in areas with higher rates of firearm availability; having an acute crisis; having experienced the death of a relative or friend; being depressed; and having relationship problems. Of note, women who had a treated DSM-IV-diagnosed problem, previous suicide attempts and physical health problems were less likely to use firearms. CONCLUSIONS: These findings challenge the conventional view that those who are severely depressed and suicidal are prone to highly lethal methods, such as firearms. Rather, firearms users may be reacting to acute situations.

Monitoring metals near a hazardous waste incinerator. Temporal trend in soils and herbage.

In recent years, incineration has been demonstrated to be a commercially available technology for hazardous waste (HW) disposal (Richter and Johnke, 2004). However, because of the potential adverse effects of toxic emissions, waste incinerators are still an important cause for concern for the public. In spite of that, compliance with current EU emissions has vastly reduced the probability of adverse health effects (Glorennec et al., 2005). With respect to metals, a number of studies have shown that these elements are emitted by industrial, medical and municipal waste incinerators (Schumacher et al., 1997; Rimmer et al., 2006). Filter ash is an especially problematic residue because it contains high metal concentrations (Lisk et al., 1989). After combustion in modern HW incinerators (HWIs), metals contained in HW are mainly collected in bottom and fly ash, with only small quantity of metals being discharged from the stack as particulate matter or vapor (Jung et al., 2004). However, the atmospheric emission of these elements is a matter of concern.

Role of SAM-dependent thiol methylation in the renal toxicity of several solvents in mice.

The role of S-adenosylmethionine (SAM)-dependent thiol methylation in the nephrotoxicity of seven industrial solvents was studied in mice. The seven following solvents were utilized: bromobenzene (BB), styrene (STY), tetrachloroethylene (TTCE), trichloroethylene (TCE), 1,1-dichloroethylene (DCE), 1,2-dichloroethane (DCA) and hexachlorobutadiene (HCB). The experimental model comprised mice pretreated with periodate oxidized adenosine (ADOX) (100 micromol kg(-1) i.p.) 30 min before injection of solvents. In the first 4 h after ADOX treatment, the SAM levels were about fourfold higher than controls for the liver and kidney. The S-adenosylhomocysteine (SAH) levels were increased by factors of 11 and 14 and the SAM/SAH ratios were decreased by factors of 3 and 10 for the liver and kidney, respectively. These results show that ADOX treatment probably induces an inhibition of methyltransferase SAM-dependent in the liver and kidney and thus decreases the methylation capabilities. A single oral administration of BB (500 or 800 mg kg(-1)), TTCE (3500 or 4000 mg kg(-1)), TCE (3000 or 3500 mg kg(-1)) or STY (400 or 600 mg kg(-1)) did not induce renal toxicity, evaluated by the percentage of damaged tubules compared to controls. On the other hand, the three solvents DCE, HCB and DCA were nephrotoxic and the percentage of damaged tubules observed for each solvent was significantly different from the value of <1.8% for controls: 19% and 40% for DCE (130 and 200 mg kg(-1)), 50% and 46% for HCB (80 and 100 mg kg(-1)) and 5.1% and 7.6% for DCA (1000 and 1500 mg kg(-1)). The ADOX treatment in the mice did not modify the renal toxicity of the seven solvents. Thus, their renal toxicity, when it existed, was probably independent of the SAM-dependent thiolmethyltransferase activity in the mice. The results of this study are discussed from two viewpoints. The first concerns the general considerations on inhibition of thiol methyltransferase activities in mice and the second is related to the different solvents that are evoked individually.

Nephrotoxicity mechanism of 1,1-dichloroethylene in mice.

Male Swiss OF1 mice were administered orally with a single dose (200 mg/kg) of 1,1-dichloroethylene (DCE). Examination of cryostat kidney sections stained for alkaline phosphatase (APP) revealed damage to about 50% of the proximal tubules at 8 h following DCE administration. Pretreatment with the anionic transport inhibitor probenecid by i.p., (0.75 mmol/kg, 30 min prior to and 10 min and 5 h following DCE administration) and with the gamma-glutamyltranspeptidase (GGT) inactivator acivicin by gavage and i.p. (50 mg/kg, 1 h and 30 min prior to DCE administration) failed to prevent DCE-induced renal toxicity. Pretreatment with the beta-lyase inactivator amino-oxyacetic acid (AOAA) by gavage (100 mg/kg, 30 min prior to and 10 min and 5 h following DCE administration), and with the renal cysteine conjugate S-oxidase inhibitor methimazole by i.p. (40 mg/kg, 30 min prior to DCE administration) reduced the number of damaged tubules by approximately 50 and 60%, respectively in mice treated with DCE. The results suggest that the DCE undergoes biotransformation by NADPH-cytochrome P450 to several reactive species which conjugate with glutathione (GSH). After arriving in the kidneys, the resulting conjugates reach the renal cells by a mechanism which depends on neither GGT, nor on an anionic transport system which is sensitive to probenecid. Once in the cells, the presumed GSH conjugates and/or their derivatives undergo secondary modification by beta-lyase and cysteine conjugate S-oxidase to reactive metabolite(s).

Nephrotoxicity mechanism of cis-platinum (II) diamine dichloride in mice.

Male Swiss OF1 mice were injected subcutaneously with 20 mg/kg of cis-platinum (II) diamine dichloride (cis-platin). Examination of cryostat kidney sections stained for alkaline phosphatase (APP) revealed damage to about 10, 20, 40 and 50% of the proximal tubules after 7, 24, 48 and 72 h, respectively. Pretreatment with the glutathione synthesis inhibitor, buthionine sulfoximine (BSO), (i.p. 3 mmol/kg) potentiated the tubule damage of cis-platin. In contrast, pretreatment with organic anion transport inhibitor probenecid (i.p. 3 x 0.75 mmol/kg) reduced the number of damaged tubules by approximately 80% at 72 h after cis-platin injection. Pretreatment with the gamma-glutamyltranspeptidase (gamma-GT) inactivator acivicin (AT-125, 50 mg/kg p.o., plus 50 mg/kg i.p.) failed to prevent cis-platin induced renal toxicity. Pretreatment with the beta-lyase inactivator aminooxyacetic acid (AOAA, 2 x 100 mg/kg p.o.) and with the renal cysteine conjugate S-oxidase inhibitor methimazole (40 mg/kg i.p.) reduced the number of damaged tubules by approximately 40% and 75%, respectively in mice treated with cis-platin. The results suggest that the platinum-sulfhydryl group complexes formed are taken up by the kidney cells through an organic anion transport mechanism which is probenecid-sensitive. In the cells these complexes are stable for several hours, depending on the intracellular glutathione (GSH) level, and gradually undergo transformation to reactive metabolite(s) by renal intracellular beta-lyase and S-oxidase.