Big is not better: Comparing two alpha-Gal-bearing glycotopes in neoglycoproteins as biomarkers for Leishmania (Viannia) braziliensis infection.

The protozoan parasite Leishmania (Viannia) braziliensis is among Latin America's most widespread Leishmania species and is responsible for tegumentary leishmaniasis (TL). This disease has multiple clinical presentations, with cutaneous leishmaniasis (CL) being the most frequent. It manifests as one or a few localized skin ulcers, which can spread to other body areas. Hence, early diagnosis and treatment, typically with pentavalent antimonials, is critical. Traditional diagnostic methods, like parasite culture, microscopy, or the polymerase chain reaction (PCR) for detection of the parasite DNA, have limitations due to the uneven distribution of parasites in biopsy samples. Nonetheless, studies have revealed high levels of parasite-specific anti-α-Gal antibodies in L. (V.) braziliensis-infected patients. Previously, we demonstrated that the neoglycoprotein NGP28b, consisting of the L. (Leishmania) major type-2 glycoinositolphospholipid (GIPL)-3-derived trisaccharide Galpα1,6Galpα1,3Galfß conjugated to bovine serum albumin (BSA) via a linker, acts as a reliable serological biomarker (BMK) for L. (V.) braziliensis infection in Brazil. This indicates the presence of GIPL-3 or a similar structure in this parasite, and its terminal trisaccharide either functions as or is part of an immunodominant glycotope. Here, we explored whether extending the trisaccharide with a mannose unit would enhance its efficacy as a biomarker for the serological detection of L. (V.) braziliensis. We synthesized the tetrasaccharide Galpα1,6Galpα1,3Galfß1,3Manpα(CH2)3SH (G31SH) and conjugated it to maleimide-functionalized BSA to afford NGP31b. When we assessed the efficacy of NGP28b and NGP31b by chemiluminescent enzyme-linked immunosorbent assay on a cohort of CL patients with L. (V.) braziliensis infection from Bolivia and Argentina against a healthy control group, both NGPs exhibited similar or identical sensitivity, specificity, and accuracy. This finding implies that the mannose moiety at the reducing end is not part of the glycotope recognized by the parasite-specific anti-α-Gal antibodies in patients' sera, nor does it exert a relevant influence on the terminal trisaccharide's conformation. Moreover, the mannose does not seem to inhibit glycan-antibody interactions. Therefore, NGP31b is a viable and dependable BMK for the serodiagnosis of CL caused by L. (V.) braziliensis.

Parasitological and molecular search for Leishmania natural infection in phlebotomine sand flies in peri-urban and rural sites of an Argentinean area endemic for tegumentary leishmaniasis.

Leishmaniases are neglected tropical diseases caused by Leishmania spp. parasites transmitted by the bite of phlebotomine sand flies. In Argentina, the most endemic area of American tegumentary leishmaniasis (ATL) has been Orán department, Province of Salta, where Leishmania (Viannia) braziliensis prevails and Nyssomyia neivai is considered as its vector, although there is no accurate and sufficient information in this regard. The aim of this work was to search for natural infection by Leishmania spp. in sand flies from peri-urban and rural sites with ATL background in Orán department. For this, sand flies were caught at five sites; female sand flies captured with Shannon trap were dissected to microscopically examine their gut contents, while females captured with CDC traps were molecularly analyzed by duplex PCR with two primer pairs to simultaneously amplify kinetoplast DNA (kDNA) and mammalian actin. A total of 1921 females were captured, with Ny. neivai being the most abundant species (89%), followed by Migonemyia migonei (6%) and cortelezzii complex (3%). No natural infection was found in any of them neither by dissection nor by PCR, although the detection limit of kDNA PCR was up to 25 promastigotes. The absence of infected females in peri-urban sites suggest that the transmission did not take place in those environments during the study period. Future searches for natural infection should focus on rural settings to deepen knowledge and elucidate the role of the circulating sand fly species as all have been linked to ATL transmission at other sites.

Development of a Fluorescent Assay to Search New Drugs Using Stable tdTomato-Leishmania, and the Selection of Galangin as a Candidate With Anti-Leishmanial Activity.

Antimonials continue to be considered the first-line treatment for leishmaniases, but its use entails a wide range of side effects and serious reactions. The search of new drugs requires the development of methods more sensitive and faster than the conventional ones. We developed and validated a fluorescence assay based in the expression of tdTomato protein by Leishmania, and we applied this method to evaluate the activity in vitro of flavonoids and reference drugs. The pIR1SAT/tdTomato was constructed and integrated into the genome of Leishmania (Leishmania) amazonensis. Parasites were selected with nourseothricin (NTC). The relation of L. amaz/tc3 fluorescence and the number of parasites was determined; then the growth in vitro and infectivity in BALB/c mice was characterized. To validate the fluorescence assay, the efficacy of miltefosine and meglumine antimoniate was compared with the conventional methods. After that, the method was used to assess in vitro the activity of flavonoids; and the mechanism of action of the most active compound was evaluated by transmission electron microscopy and ELISA. A linear correlation was observed between the emission of fluorescence of L. amaz/tc3 and the number of parasites (r2 = 0.98), and the fluorescence was stable in the absence of NTC. No differences were observed in terms of infectivity between L. amaz/tc3 and wild strain. The efficacy of miltefosine and meglumine antimoniate determined by the fluorescence assay and the microscopic test showed no differences, however, in vivo the fluorescence assay was more sensitive than limiting dilution assay. Screening assay revealed that the flavonoid galangin (GAL) was the most active compound with IC50 values of 53.09 µM and 20.59 µM in promastigotes and intracellular amastigotes, respectively. Furthermore, GAL induced mitochondrial swelling, lipid inclusion bodies and vacuolization in promastigotes; and up-modulated the production of IL-12 p70 in infected macrophages. The fluorescence assay is a useful tool to assess the anti-leishmanial activity of new compounds. However, the assay has some limitations in the macrophage-amastigote model that might be related with an interfere of flavanol aglycones with the fluorescence readout of tdTomato. Finally, GAL is a promising candidate for the development of new treatment against the leishmaniasis.

Adrenal schwannoma in a female patient; A rare benign neoplasm: Case report and literature review.

INTRODUCTION: Schwannomas are rare, slow-growing, usually benign tumors that originate from myelin-producing Schwann cells. Adrenal schwannomas are an exceptionally rare subset of these tumors, with few cases reported in the literature. PRESENTATION OF CASE: We present the case of a 44-year old female patient being evaluated for chronic abdominal pain at the outpatient clinic. Clinical and laboratory workup was unremarkable. An abdominal CT scan was performed, revealing a left suprarenal solid mass (5 × 6 cm). Surgical resection of the adrenal gland was performed, given the patient's symptoms, the size of the tumor, and its malignant potential. The patient completed the postoperative period satisfactorily, and her symptoms improved. Histopathological findings were compatible with a benign adrenal schwannoma. DISCUSSION: Schwannomas generally appear in the head, neck and extremities, with the vestibulocochlear nerve being the most frequently involved site. Retroperitoneal schwannomas account for 1-5% of retroperitoneal masses and comprise only 1-3% of all schwannomas. Their incidence increases with age, from 4% in the general population, reaching 7% in patients over 70 years of age. CONCLUSION: Adrenal incidentalomas represent a diagnostic challenge. Because of the malignant potential of large (> 4 cm) adrenal masses and the lack of characteristic findings using conventional imaging techniques and laboratory diagnostic tools, surgical excision with histopathology and immunohistochemistry analysis are required for definitive diagnosis and optimal management.

Sand fly typing: a simple and morphologically-supported method based on polymorphism of 18S rRNA gene in a Leishmaniasis endemic area of Argentina.

Leishmaniases are vector-borne diseases that in the Americas are distributed from southern United States to northern Argentina. The vectors for this disease are small dipterans known as sand flies that are usually identified morphologically by observing structures with taxonomic value; but it is time-consuming, laborious, and requires entomological expertise. Then, this work was aimed at identifying sand flies with molecular techniques, using the morphological identification as a reference technique, in an endemic area of American Tegumentary Leishmaniasis (ATL) located in northern Argentina. For this, sand flies were caught at two patches of vegetation adjacent to rural areas in Orán department, Salta Province. Females were dissected with sterile needles; the head and last abdominal segments were analyzed for morphological identification. The remaining thorax and abdominal segments were used to extract DNA, which was amplified by PCR of the small subunit (SSU), 18S rRNA gene. PCR products were digested with CviQI and DdeI enzymes to identify sand fly species by Restriction Fragment Length Polymorphism (RFLP) analysis. Thus, the restriction pattern of each caught species was defined according to morphological identification. A total of 1501 females, belonging to four sand fly species, were captured. Nyssomyia neivai (1347/1501) was the most abundant species, followed by Migonemyia migonei (90/1501). From the total, 801 females were morphologically and molecularly identified, while 700 females were characterized only molecularly. For those females analyzed by both methods, there was total coincidence in the achieved result. Besides, the 5% (38/801) of females that could not be determined morphologically due to inadequate mounting were molecularly identified. All the females characterized just by PCR-RFLP, were successfully identified. Our results indicate that the explored method is capable of identifying the sand fly species that circulate in an ATL endemic area. Since this method is based on the analysis of markedly different patterns, the identification process might be more easily reproduced, as the bias introduced by the technician's lack of experience is removed.

Gallbladder osteoma in a 66-year-old female; Case report and review of literature.

INTRODUCTION: Gallbladder mesenchymal tumours are rare. The more common include fibroma, lipoma or haemangioma. A gallbladder osteoma is very rare indeed there is only one other case reported in medical literature). We report a new case. PRESENTATION OF CASE: A 66-year-old female presented to the emergency department complaining of colicky epigastric pain and generalised abdominal discomfort for 1 month. The pain was scored 5/10 but there were no associated symptoms of fever, nausea or vomiting. Vital signs were normal as were all laboratory parameters. An abdominal ultrasound revealed a thin walled gallbladder with a solitary 3 mm polyp. Motility studies confirmed gallbladder dyskinesia. Laboratory studies were ordered reporting normal findings. Abdominal ultrasound was ordered reporting an image suggesting a gallbladder polyp and gallbladder dyskinesia. Cholecystectomy was done without any incidents and the gallbladder was sent to pathology. Pathology reported mature bone tissue in the stromal gallbladder tissue. Due to the rareness of the presence of mature bone tissue in the gallbladder we decided to report the case for the medical community. DISCUSSION: Osteomas are mesenchymal cell tumors derived from the mesoderm; the gallbladder may be the primary site of numerous types of mesenchymal tumors, although these tumors are common the location is not. CONCLUSIONS: We report only the second case of gallbladder osteoma. These mesenchymal tumours are common but this location is not. This case report will serve to remind readers of both benign osteomas and unusual conditions causing gallbladder disease.

Estudio de la relación de los terceros molares superiores retenidos y el seno maxilar en radiografías panorámicas y tomografía (CBCT) / Study of the relationship of retained upper third molars and maxillary sinus in panoramic radiographs and tomography (CBCT)

Objetivo: Evaluar la eficacia de la radiografía panorámica para establecer la relación de los terceros molares superiores y la cortical inferior del seno maxilar, en comparación con la tomografía computarizada de haz cónico (CBCT). Material y métodos: El trabajo incluyó 72 pacientes, se estudiaron 34 terceros molares superiores retenidos izquierdos y 38 derechos. Se realizaron mediciones con el programa para establecer la distancia entre la cortical inferior del seno maxilar y el ápice del tercer molar superior a partir de la imagen de la radiografía panorámica en lo que se estableció como parámetros: «a distancia, en contacto y dentro del piso de seno maxilar¼. Luego, con los cortes oblicuos o paraaxiales de la tomografía computarizada (CBCT) se observó la verdadera ubicación en el plano bucopalatino. Resultados: Del total de los terceros molares superiores 34 fueron izquierdas (47.22%) y 38 derechas (52.78%). En la Rx. Panorámica, 18 casos (25%) se encontraron a distancia al seno maxilar, 12 en contacto (16.7%) y 42 por dentro (58.3%) del seno maxilar. En la tomografía se observaron 20 casos (27.8%) a distancia del conducto, 16 (22.2%) en contacto y 36 (50%) por dentro del seno maxilar. Se observaron diferencias estadísticamente significativas (p < 0.05) entre la Rx. panorámica y la tomografía (CBCT) de los terceros molares que se hallan por dentro del seno maxilar. Conclusión: A partir de los resultados obtenidos, podemos establecer que la radiografía panorámica no permite conocer la verdadera relación entre la cortical inferior del seno maxilar y los terceros molares superiores (AU)

Objective: To evaluate the effectiveness of panoramic radiography to establish the relationship of the upper third molars and the inferior cortical of the maxillary sinus, in comparison with the Cone Beam Computed Tomography (CBCT). Material and methods: The work included 72 patients, 34 upper left maxillary molars and 38 rights were studied. Measurements were made with the program to establish the distance between the lower cortex of the maxillary sinus and the apex of the upper third molar from the image of the panoramic radiograph in what was established as parameters: «at a distance, in contact and inside the floor of maxillary sinus¼. Then with the oblique or paraaxial slices of the computed tomography (CBCT) the true location in the bucco-palatal plane was observed. Results: Of the total upper third molars, 34 were left (47.22%) and 38 right (52.78%). In the panoramic X-ray 18 cases (25%) were found at distance to the maxillary sinus, 12 in contact (16.7%) and 42 inside (58.3%) of the maxillary sinus. The tomography showed 20 cases (27.8%) at a distance from the canal, 16 (22.2%) in contact and 36 (50%) inside the maxillary sinus. Statistically significant differences were observed (p < 0.05) between the Rx. panoramic and tomography (CBCT) of the third molars that are inside the maxillary sinus. Conclusion: From the results obtained, we can establish that the panoramic radiograph does not allow knowing the true relationship between the inferior cortical of the maxillary sinus and the upper third molars (AU)

Development of a Multilocus sequence typing (MLST) scheme for Pan-Leishmania.

Since the description of the Leishmania genus, its identification and organization have been a challenge. A high number of molecular markers have been developed to resolve phylogenetic differences at the species level and for addressing key epidemiological and population genetics questions. Based on Multilocus enzyme electrophoresis (MLEE), Multilocus sequence typing (MLST) schemes have been developed using different gene candidates. From 38 original gene targets proposed by other authors, 27 of them were chosen. In silico selection was made by analyzing free access genomic sequence data of 33 Leishmania species, one Paraleishmania representative, and one outgroup, in order to select the best 15 loci. De novo amplifications and primers redesign of these 15 genes were analyzed over a panel of 20 reference strains and isolates. Phylogenetic analysis was made at every step. Two MLST schemes were selected. The first one was based on the analysis of three-gene fragments, and it is suitable for species assignment as well as basic phylogenetic studies. By the addition of seven-genes, an approach based on the analysis of ten-gene fragments was also proposed. This is the first work that two optimized MLST schemes have been suggested, validated against a phylogenetically diverse panel of Leishmania isolates. MLST is potentially a powerful phylogenetic approach, and most probably the new gold standard for Leishmania spp. characterization.

Leishmaniasis mucocutánea con manifestacion oral: reporte de un caso / Mucocutaneous leishmaniasis with oral manifestation: case report

La Leishmaniasis es un grupo de enfermedades transmitidas por vectores y causada por la Leishmania, un parásito intracelular, que se presenta de preferencia en regiones tropicales y subtropicales. Se manifiesta mediante un amplio rango de formas clínicas como la cutánea, mucocutánea, y visceral, dependiendo de la especie y respuesta inmunológica del paciente. Se presenta el caso de un hombre de 35 años que acudió derivado a Unidad de Estomatología del Hospital Señor del Milagro, Salta, Argentina, presentando en la cavidad oral lesión, granulomatosa, ulcerada, dolorosa a la palpación, única, en paladar blando, de tres meses de evolución. Se realizaron estudios serológicos, parasitológicos y PCR. Los ELISAs lisados, PCRs y cultivos de materiales de lesiones fueron positivos, confirmando diagnóstico de leishmaniasis mucocutánea. El paciente fue derivado al Servicio de Dermatología donde recibió tratamiento con Antimoniato de Meglumina, con repuesta clínica favorable. El conocimiento de las manifestaciones orales puede llevar al diagnóstico clínico de leishmaniasis mucocutánea por parte del odontólogo, pudiendo entregar un tratamiento oportuno y a la vez ayudar al paciente, evitando complicaciones de esta enfermedad.

Leishmaniasis is a group of vector-borne diseases caused by Leishmania, an intracellular parasite, which occurs preferentially in tropical and subtropical regions. It manifests itself through a wide range of clinical forms such as cutaneous, mucocutaneous, and visceral, depending on the species and the patient's immune response. We present a case of a 35-year-old man who was referred to the Stomatology Unit of the Señor del Milagro Hospital, Salta, Argentina, presenting in the oral cavity lesion, granulomatous, ulcerated, painful on palpation, unique, soft palate with three months of evolution. Serological, parasitological and PCR studies were performed. Lysed ELISAs, PCRs and cultures of lesion materials were positive, confirming diagnosis of mucocutaneous leishmaniasis. The patient was referred to the Dermatology Service where he received treatment with Meglumine Antimony, with favorable clinical response. The knowledge of the oral manifestations can lead to the clinical diagnosis of mucocutaneous leishmaniasis by the dentist, being able to provide timely treatment and at the same time help the patient, avoiding complications of this disease.

Estudio de las variantes anatómicas en el conducto incisivo en pacientes desdentados utilizando la tomografía de haz cónico / Study of the anatomical variants in the incisive canal in edentulous patients using cone beam tomography

Introducción: La región anterior de la mandíbula, ubicada entre los agujeros mentonianos contiene conductos intraóseos con elementos vasculares y ramas nerviosas terminales provenientes del nervio alveolar inferior. El objetivo del trabajo es determinar las variantes anatómicas producidas en el conducto incisivo y las corticales superior, inferior, externa e interna en pacientes edéntulos con respecto a pacientes dentados en tomografía computarizada de haz cónico. Material y métodos: Se realizó un estudio comparativo, retrospectivo y observacional. Se estudiaron 50 tomografías en pacientes edéntulos y 50 en pacientes dentados de ambos sexos desde los 38 hasta los 81 años. En cada corte se realizó una medición en lo alto y ancho del conducto. También se determinó la posición del conducto incisivo mediante la realización de cuatro mediciones. Resultados: Se observaron diferencias significativas en lo que respecta al alto y ancho del conducto incisivo y también entre las distancias hacia la cortical vestibular, lingual, alveolar y basal entre pacientes dentados y desdentados. Conclusión: Se pudo comprobar una mayor resorción ósea en los pacientes desdentados, hallado entre el conducto incisivo y las corticales superior y vestibular y un menor calibre del conducto incisivo con respecto a los pacientes dentados (AU)

Introduction: The previous region of the mandible, located between the mental foramen, contains intraosseous ducts with vascular elements and terminal nervous branches from the inferior alveolar nerve. The objective of the work is to determine the anatomical variants produced in the incisive canal and the superior, inferior, external and internal cortices in edentulous patients with respect to dentate patients in cone beam computed tomography. Material and methods: A retrospective observation al comparative study was carried out. Fifty tomographies were studied in edentulous patients and 50 in dentate patients of both sex es from 38 to 81 years. In each cut a measure men twasmade in height and width of the conduit. The position of the incisive cannel was also determined by performing four measurements. Results: Significant differences were observed regarding the height and width of the incisal canal and also between the distances to the vestibular, lingual, alveolar and basal cortical area between dentate and edentulous patients. Conclusion: A greater bone reabsorption in thee dentulous patients found between the incisive canal and the superior and vestibular cortices and a smaller caliber of the incisive canal with respect to the dentate patient should be verified (AU)

Targeting the Immune System With Mesenchymal Stromal Cell-Derived Extracellular Vesicles: What Is the Cargo's Mechanism of Action?

The potent immunomodulatory activities displayed by mesenchymal stromal cells (MSCs) have motivated their application in hundreds of clinical trials to date. In some countries, they have subsequently been approved for the treatment of immune disorders such as Crohn's disease and graft-versus-host disease. Increasing evidence suggests that their main mechanism of action in vivo relies on paracrine signaling and extracellular vesicles. Mesenchymal stromal cell-derived extracellular vesicles (MSC-EVs) play a prominent role in intercellular communication by allowing the horizontal transfer of microRNAs, mRNAs, proteins, lipids and other bioactive molecules between MSCs and their targets. However, despite the considerable momentum gained by MSC-EV research, the precise mechanism by which MSC-EVs interact with the immune system is still debated. Available evidence is highly context-dependent and fragmentary, with a limited number of reports trying to link their efficacy to specific active components shuttled within them. In this concise review, currently available evidence on the molecular mechanisms underlying the effects of MSC-EV cargo on the immune system is analyzed. Studies that pinpoint specific MSC-EV-borne mediators of immunomodulation are highlighted, with a focus on the signaling events triggered by MSC-EVs in target immune cells. Reports that study the effects of preconditioning or "licensing" in MSC-EV-mediated immunomodulation are also presented. The need for further studies that dissect the mechanisms of MSC-EV cargo in the adaptive immune system is emphasized. Finally, the major challenges that need to be addressed to harness the full potential of these signaling vehicles are discussed, with the ultimate goal of effectively translating MSC-EV treatments into the clinic.

Molecular Identification of Leishmania spp. DNA from Archived Giemsa-Stained Slides of Patients from Salta, Argentina.

Cutaneous leishmaniasis is endemic in Salta province, which belongs to the northwest of Argentina. Leishmania spp. DNA from Giemsa-stained slides of up to 12 years in storage of patients from Salta was characterized through polymerase chain reaction (PCR) restriction fragment length polymorphism (RFLP). One hundred smears positive for microscopy, classified in a semiquantitative scale for amastigote density, were analyzed. Also, Leishmanin skin test (LST) results were included. DNA extraction was carried out applying lysis buffer with proteinase K, and then DNA was amplified with ribosomal internal transcribed spacer 1 primers. PCR products were digested with HaeIII enzyme. All PCR-positive smears (74/100) belonged to Viannia subgenus. A statistically significant, directly proportional relationship between semiquantitative microscopy and PCR results was detected. All patients had LST-positive results (induration ≥ 5 mm), and the smears of those with smaller induration (LST < 19 mm) gave a higher proportion of positive PCR results. This study determined that smear age did not affect PCR positivity, which allows retrospective analyzes and suggests smears might be useful for molecular complementary diagnosis. Because Leishmania (Viannia) braziliensis is the main circulating species in the study area, determining Viannia subgenus in all analyzed samples confirms previous findings. PCR positivity showed statistically significant differences according to semiquantitative microscopy, highlighting the importance of parasite burden in the diagnostic sensitivity of the method. Considering that smears of patients with smaller LST induration were more positive in PCR, a negative smear from patients with positive LST response, but < 19 mm, could actually represent a false-negative result.

Quantifying Dynamic Deformity After Dual Plane Breast Augmentation.

BACKGROUND: Dynamic breast deformity (DBD) is characterized by visible distortion and deformity of the breast due to contraction of the pectoralis major muscle after submuscular breast augmentation; fortunately, in most cases, this is not a clinically significant complaint from patients. The purpose of this study is to present a simple method for objectively measuring DBD in patients submitted to dual plane breast augmentation (DPBA). METHODS: We studied 32 women, between 18 and 50 years old, who underwent primary DPBA with at least 1 year of follow-up. Anthropometric landmarks of the breast were marked, creating linear segments. Standardized photographs were obtained both during no pectoralis contraction (NPC) and during maximum pectoralis muscle contraction (MPC); measurements of the linear segments were taken through ImageJ imaging software, and both groups were compared. RESULTS: We found statistically significant differences in all analyzed segments when comparing measurements of the breasts during NPC and MPC (p < 0.001). CONCLUSION: Our study proposes a novel, standardized method for measuring DBD after DPBA. This technique is reproducible, allowing for objective quantification of the deformity in any patient, which can be valuable for both patients and surgeons, as it allows for a more thorough discussion on DBD, both pre- and postoperatively, and may help both patients and surgeons to make more informed decisions regarding potential animation deformities after breast augmentation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

La reanimación cardiopulmonar pediátrica y la capacitación para la asistencia en emergencias / Pediatric cardiopulmonary resuscitation and basic skills training for emergency assistance

Se destacan las novedades en reanimación cardiopulmonar (RCP) pediátrica de la AHA 2015 y se repasa esquemáticamente el soporte vital básico y avanzado en los casos de paro cardiorrespiratorio en niños. Se resumen los aspectos claves y principales cambios realizados respecto de la actualización anterior (2010). Se sugiere incorporar en los hospitales un equipo de emergencias pediátrico y un equipo de rápida respuesta que brinden una atención inmediata y efectiva. Se describe un sistema de puntuación (puntaje PEWS) que permitiría identificar y predecir pacientes con riesgo de descompensación por diferentes etiologías. Se indica tratamiento inicial de la sepsis grave y shock séptico con un bolo de fluidos de 20 ml/kg en lactantes y niños con líquidos cristaloides o coloides. Se mantiene la secuencia C-A-B de las guías 2010 como orden de elección para la RCP pediátrica (aunque las recomendaciones ILCOR 2015 equiparan las secuencias A-B-C y C-A-B). La profundidad de las compresiones debe deprimir por lo menos un tercio del diámetro anteroposterior o aproximadamente 4 cm en lactantes. En los niños las compresiones se realizarán como en los adultos, por lo menos 5 a 6 cm de profundidad como límite superior; con una frecuencia de 100 a 120 CPM. En caso de reanimadores legos que no deseen o no puedan proporcionar ventilaciones, se utilizaran sólo compresiones torácicas. En los casos de FV y TV sin pulso, se realizará una descarga con desfibrilador monofásico o bifásico de energía inicial (2 a 4 J/kg) seguida de compresiones torácicas; dosis siguientes mayores o iguales a 4 J/kg son seguras y efectivas.

The new developments in pediatric cardiopulmonary resuscitation (CPR) (AHA 2015) and basic and advanced life support are reviewed schematically in cases of cardiopulmonary arrest in children. In this article we summarize the key aspects and major changes made to the previous update (2010). It is suggested that a Pediatric Emergency Team and a Rapid Response Team to provide fast and effective care should be incorporated in hospitals. A scoring system (PEWS) is described that will allow for the identification and prediction of patients at risk of decompensation due to different etiologies. Initial treatment of severe sepsis and septic shock with a fluid bolus of 20 ml/kg in infants and children with crystalloid or colloid fluids is indicated. The C-A-B sequence from the 2010 guides for pediatric CPR is maintained (although the recommendations of ILCOR 2015 attach the same importance to both "A-B-C" and "C-A-B" sequences). The depth of chest compression should be at least one third of the anteroposterior diameter, or approximately 4 cm in infants. In children and adults compressions are equivalent to depressing no more than 5 to 6 cm, with a compression frequency of 100 to 120 CPM. If lay rescuers do not want, or cannot, provide sufficient ventilation, we recommend that chest compressions should be performed. For treatment of non-pulsed VF and VT, an initial shock (2 to 4 J/kg) with mono or biphasic defibrillator should be applied, followed by chest compressions; subsequent doses of ≥ 4 J/kg are safe and effective.

Bilateral carotid body tumor resection in a female patient.

INTRODUCTION: Carotid body tumors also called carotid paragangliomas are rare neuroendocrine neoplasms derived from neural crest cells, approximately 3% of all paragangliomas occur in the head and neck area (Xiao and She, 2015); although they represent 65% of the head and neck paragangliomas (Georgiadis et al., 2008). PRESENTATION OF CASE: We present the therapeutic management of a 65-year-old woman with bilateral carotid body tumors. The patient presented to medical clinic for unrelated signs and symptoms of weight loss, dyspepsia, and epigastric pain. Physical examination showed bilateral non-tender neck masses for which imaging studies were ordered resulting in the diagnosis of bilateral carotid tumor. Surgical resection was staged with one week of distance between each tumor resection. DISCUSSION: Carotid Body Tumors can arise from the paraganglia located within the adventitia of the medial aspect of the carotid bifurcation.Resection is the only curative treatment. Carotid body tumors resection represents a special challenge due to potential neurovascular complications. CONCLUSIONS: Surgical resection of carotid body tumors represents a special challenge to the surgeon because of the complex anatomical location of the tumor, including close relationship with the cranial nerves, involvement of the carotid vessels and large vascularization of the tumor. With the advance of diagnosis and improvement in surgical techniques as well as the understanding of biological behavior of tumors, surgical treatment has become a safer alternative for treating these tumors.

Tumores da mão parte III: tumores de pele da mão / Tumors of the hand, Part III: Skin tumors of the hand

O tumor de pele da mão corresponde ao câncer primário mais comum dessa região. Apesar de proporcionalmente cobrir uma pequena superfície do corpo, corresponde a uma parte considerável de todos os tumores de pele. O objetivo principal deste trabalho é mostrar de forma simples e clara as lesões mais prevalentes e encontradas no ambulatório médico, de uma forma que este pode ser usado para consulta e orientação do profi ssional médico das mais diversas especialidades, objetivando um diagnóstico rápido e assertivo, que interferirá positivamente no desfecho da doença. Nesta terceira parte do trabalho são abordados fundamentos, conceitos, classifi cações e abordagens para o melhor prognóstico do paciente.

Skin tumor of the hand is the most common primary cancer of this region. Although covering a proportionally small surface of the body, it accounts for a substantial part of all skin tumors. The main aim of this work is to show simply and clearly the most prevalent injuries found in the outpatient clinic, so that it can be used by healthcare providers from various specialties as a consultation and guidance resource, aiming at a quick and assertive diagnosis that will interfere positively with disease outcome. This third part of the work covers the fundamentals, concepts, classifi cations and approaches for a better prognosis.

Tumores da mão parte II: Tumores ósseos da mão / Hand tumors – Part II: bone tumors of the hand

Tumores ósseos da mão podem ser divididos em benignos, malignos ou metastáticos. Os benignos são os mais comuns, sendo que destes os encondromas são os mais prevalentes (1). A incidência de tumores na mão é relativamente baixa; entretanto, caso esses tumores sejam malignos, podem ser localmente invasivos e comprometer a função da mão. Geralmente para tumores benignos é realizada ressecção intralesional do tumor; porém, para tumores malignos pode ser necessária ampla excisão ou até eventualmente amputação para que não ocorra recidiva tumoral. Este trabalho foi desenvolvido no Serviço de Cirurgia da Mão e Microcirurgia Reconstrutiva do Hospital São Lucas da PUCRS. Nosso objetivo é relatar os principais tipos de tumores da mão, dividindo-os em benignos e malignos, e orientar os médicos que realizarão seu primeiro atendimento em relação à clínica, exames necessários e opção de tratamentos.

Bone tumors of the hand can be divided into benign, malignant or metastatic. Benign tumors are the most common, and of these enchondromas are the most prevalent (1). The incidence of tumors in the hand is relatively low. If these are malignant tumors, however, they may be locally invasive and compromise the function of the hand. Generally for benign tumors intralesional tumor resection is performed, but malignant tumors can require wide excision or possibly even amputation so as to avoid tumor recurrence. This work was developed in the Service of Hand Surgery and Reconstructive Microsurgery at Hospital São Lucas of PUCRS. Our aim here is to describe the main types of hand tumors, dividing them into benign and malignant, and guide physicians seeing their fi rst patient with regard to clinical practice, necessary examinations and treatments choices.

Tumores da mão parte I: tumores de partes moles da mão / Hand tumors – Part I: Soft tissue tumors

Os tumores de partes moles da mão, principalmente os benignos como os cistos sinoviais, são queixas comuns, principalmente em consultas a cirurgiões da mão. Este trabalho tem por objetivo revisar os principais tipos de tumores de partes moles da mão, desde a sua apresentação clínica até uma revisão objetiva sobre seus diagnósticos e melhores opções terapêuticas. Visa auxiliar, também, na decisão de referência do paciente com uma lesão nodular ou cística da mão a um médico especialista após uma consulta ao médico generalista. As particularidades anatômicas e funcionais da mão tornam o estudo e o conhecimento das suas patologias fundamentais para um adequado manejo dos pacientes.

The soft tissue tumors of the hand, especially the benign ones such as synovial cysts, are common complaints, particularly in hand surgeons consultations. This work aims to review the main types of soft tissue tumors of the hand, from their clinical presentation to an objective review of their diagnoses and the best therapeutic options. It also aims to help in the decision to refer the patient with a nodular or cystic lesion of the hand to a medical specialist after consultation with the general practitioner. The anatomical and functional particularities of the hand make the study and knowledge of its conditions crucial for proper management of patients.

Proponen nuevas recomendaciones para la reanimación cardiopulmonar pediátrica / New developments in pediatric cardiopulmonary resuscitation

Se destacan las novedades en reanimación cardiopulmonar (RCP) pediátrica del ILCOR 2010. Se sugiere una nueva secuencia universal, sencilla, aplicable al paro cardiorrespiratorio en adultos, niños y lactantes, con un nuevo orden: C-A-B. Se resta importancia a la determinación de la presencia del pulso en lactantes o niños, si no se logra dentro de los 10 segundos. Los reanimadores legos dispuestos a realizar RCP básica que no pueden o no quieren proporcionar ventilación deberían realizar compresiones solamente. La efectividad de la compresión torácica se logra con una profundidad de compresión de al menos un tercio del diámetro anteroposterior del tórax o 4 cm en lactantes y 5 cm en niños. Se insiste en el uso temprano de la vía intraósea en caso de presentar dificultades para acceder a la vía intravenosa. Los datos refuerzan la eficacia y seguridad de los tubos endotraqueales con manguito en lactantes y niños pequeños. Se actualiza la fórmula del tamaño adecuado del tubo con manguito. Se relativiza la seguridad y utilidad de la maniobra de Sellik durante la intubación de emergencia. En los casos de shock por taquicardia ventricular sin pulso o fibrilación ventricular se indica desfibrilación con una dosis de energía inicial de 2 a 4 J/kg. Se sugiere la incorporación de un equipo de emergencias médicas especializado en el manejo de RCP. Se propone realizar autopsia a los jóvenes que fallecieron por muerte súbita para detectar posibles causas genéticas que indiquen la necesidad de estudiar a sus familiares.