El lentigo maligno: actualización y claves en el diagnóstico y el tratamiento / Update on Lentigo Maligna: Diagnostic Signs and Treatment

El lentigo maligno es un melanoma cutáneo in situ que asienta en zonas con daño solar acumulado. Su presentación más habitual es como una mancha irregularmente pigmentada de crecimiento lento y progresivo localizada en la cara de un paciente añoso. Aunque el porcentaje real de casos de lentigo maligno que evoluciona a formas invasoras es desconocido, se calcula que supone entre un 2 y un 5% de los casos. Tanto el diagnóstico clínico como histopatológico del lentigo maligno puede suponer un reto, especialmente en casos precoces o atípicos. Su tratamiento también puede suponer un desafío por su localización en áreas muy visibles y por su tamaño frecuentemente considerable, lo que tiene implicaciones estéticas y ocasionalmente también funcionales derivadas de la cirugía. En este trabajo revisamos las claves clínicas e histopatológicas para facilitar el diagnóstico del lentigo maligno. También revisamos las opciones de tratamiento con especial atención a la cirugía (AU)

Lentigo maligna is an in situ cutaneous melanoma that arises in sun-damaged skin. Its most common presentation is a progressive, slow-growing, irregularly pigmented spot on the face of older patients. Although the exact percentage of Lentigo maligna that progresses to invasive tumors is unknown, it is thought to lie between 2% and 5%. Both the clinical and histologic diagnosis of Lentigo maligna can be challenging, especially in patients with early-stage or atypical disease. Treatment also holds challenges, because lesions are located in highly visible areas and are often large. Surgery can thus compromise cosmetic and sometimes functional outcomes. We review clinical and histopathological findings that can facilitate the diagnosis of Lentigo maligna. We also examine treatment options, with a focus on surgery (AU)

[Translated article] Update on Lentigo Maligna: Diagnostic Signs and Treatment / El lentigo maligno: actualización y claves en el diagnóstico y el tratamiento

Lentigo maligna is an in situ cutaneous melanoma that arises in sun-damaged skin. Its most common presentation is a progressive, slow-growing, irregularly pigmented spot on the face of older patients. Although the exact percentage of Lentigo maligna that progresses to invasive tumors is unknown, it is thought to lie between 2% and 5%. Both the clinical and histologic diagnosis of Lentigo maligna can be challenging, especially in patients with early-stage or atypical disease. Treatment also holds challenges, because lesions are located in highly visible areas and are often large. Surgery can thus compromise cosmetic and sometimes functional outcomes. We review clinical and histopathological findings that can facilitate the diagnosis of Lentigo maligna. We also examine treatment options, with a focus on surgery (AU)

El lentigo maligno es un melanoma cutáneo in situ que asienta en zonas con daño solar acumulado. Su presentación más habitual es como una mancha irregularmente pigmentada de crecimiento lento y progresivo localizada en la cara de un paciente añoso. Aunque el porcentaje real de casos de lentigo maligno que evoluciona a formas invasoras es desconocido, se calcula que supone entre un 2 y un 5% de los casos. Tanto el diagnóstico clínico como histopatológico del lentigo maligno puede suponer un reto, especialmente en casos precoces o atípicos. Su tratamiento también puede suponer un desafío por su localización en áreas muy visibles y por su tamaño frecuentemente considerable, lo que tiene implicaciones estéticas y ocasionalmente también funcionales derivadas de la cirugía. En este trabajo revisamos las claves clínicas e histopatológicas para facilitar el diagnóstico del lentigo maligno. También revisamos las opciones de tratamiento con especial atención a la cirugía (AU)

Update on Lentigo Maligna: Diagnostic Signs and Treatment. / El lentigo maligno: actualización y claves en el diagnóstico y el tratamiento.

Lentigo maligna is an in situ cutaneous melanoma that arises in sun-damaged skin. Its most common presentation is a progressive, slow-growing, irregularly pigmented spot on the face of older patients. Although the exact percentage of Lentigo maligna that progresses to invasive tumors is unknown, it is thought to lie between 2% and 5%. Both the clinical and histologic diagnosis of Lentigo maligna can be challenging, especially in patients with early-stage or atypical disease. Treatment also holds challenges, because lesions are located in highly visible areas and are often large. Surgery can thus compromise cosmetic and sometimes functional outcomes. We review clinical and histopathological findings that can facilitate the diagnosis of Lentigo maligna. We also examine treatment options, with a focus on surgery.

Renunciations in forefoot surgery. Critical analysis of surgical waiting lists. / Renuncias en cirugía del antepié. Análisis crítico de las listas de espera.

INTRODUCTION: The high prevalence of forefoot pathology generates long surgical waiting lists (SWL). We have detected a considerable number of patients who withdraw surgery, which creates an important distortion in our activity and high expenditure of resources. Our objective is to study the factors related to these resignations, as well as, compare them with other pathologies of high prevalence and ambulatory surgical treatment: carpal tunnel syndrome (CTS) and internal meniscopathy (IM). MATERIAL AND METHODS: Retrospective study of the surgical cancellations on 2,399 patients included in the SWL of the Foot and Ankle Unit of our center for forefoot surgery, between January/2014 and March/2018, both included. RESULTS: We have found 389 renunciations, which represent 16.22% of the inclusions in SWL, with 84.83% of women. The pathologies with the highest rate of resignation have been Morton metatarsalgia (24%) and hallux rigidus (20.16%). The most frequent pathology, hallux valgus, records 15.96% of resignations that occur mostly between 6 and 9 months. In the CTS and IM, the resignation rate has been 17.42 and 8.92%, respectively, with higher resignation rates in the first 3 months. CONCLUSIONS: The withdrawal of a scheduled intervention on the forefoot registers a high frequency in our environment, which can be related to factors such as the type of pathology, its natural history, response to orthopedic interventions, time in LEQ, and other non-specific ones on which we must investigate, to rationalize and establish duties in our SWL.

La percepción de la depresión y de su tratamiento / How depression and its treatment are perceived

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Retronychia: an underdiagnosed disease.

Retronychia is a recently described cause of ingrowth of the nail plate on the ventral surface of the proximal nail fold. Clinical features are repeated episodes of proximal paronychia, nail plate thickening, and occasionally granulation tissue emergence. The usual treatments for paronychia such as antibiotics and antifungals are ineffective in these cases. Avulsion of the nail plate is the treatment of choice for these patients, but effective treatment is usually delayed owing to inadequate diagnosis. Herein, we describe a 28-year-old woman with a case of retronychia. She was treated for two months with oral and topical antifungal and antibiotics by her general practitioner. After proper diagnosis and avulsion of the nail she presented a normal and non-painful growth of the affected nail.

Treatment of relapse after allogeneic stem cell transplantation in children and adolescents with ALL: the Frankfurt experience.

Therapy for post-transplant relapse of paediatric ALL is limited. Standardised curative approaches are not available. We hereby describe our local procedure in this life-threatening situation. A total of 101 ALL patients received their first allogeneic stem cell transplantation (SCT) in our institution. After relapse, our primary therapeutic goal was to cure the patient with high-dose chemotherapy or specific immunotherapy (HDCHT/SIT) followed by a second SCT from a haploidentical donor (transplant approach). If this was not feasible, low-dose chemotherapy and donor lymphocyte infusions (LDCHT+DLI) were offered (non-transplant approach). A total of 23 patients suffered a post-transplant relapse. Eight patients received HDCHT/SIT, followed by haploidentical SCT in 7/8. Ten received LDCHT+DLI. The eight patients treated with a second transplant and the ten treated with the non-transplant approach had a 4-year overall survival of 56% and 40%, respectively (P=0.232). Prerequisites for successful treatment of post-transplant relapse by either a second transplant or experimental non-transplant approaches are good clinical condition and the capacity to achieve haematological remission by the induction treatment element.

La imagen en el sarcoma sinovial pleuropulmonar primario / Imaging in primary pleuropulmonary synovial sarcoma

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Analysis of the performance of 100% rapid review using an average time of 1 and 2 minutes according to the quality of cervical cytology specimens.

OBJECTIVES: To compare the performance of the 100% rapid review method carried out in a mean time of either 1 or 2 minutes according to cytological final result, and to assess whether the presence of obscuring factors in cervical smear samples affects the frequency of false-negative results. METHODS: A total of 5,235 smears classified as negative (93.0%) or unsatisfactory (2.1%) at routine screening were submitted to 100% rapid review using mean times of 1 and 2 minutes. RESULTS: Of the 5,235 smears submitted to 1-minute rapid review, 88 were considered suspect and of these, 45 were confirmed as abnormal in the cytological final result. When the time used was 2 minutes, 67 smears were considered suspect, 44 of which were confirmed as abnormal. Sensitivity and specificity were similar in the 1- and 2-minute reviews. In smears in which samples were satisfactory and had no obscuring factors, sensitivity and specificity were 64.2% and 98.9% and 61.5% and 99.5% for the 1- and 2-minute reviews, respectively. In comparison, in smears in which the sample was satisfactory for analysis but partially obscured (50-75%), sensitivity and specificity were 64.7% and 99.9% and 70.6% and 99.8% for the 1- and 2-minute reviews, respectively. CONCLUSIONS: The method of rapid review of 100% showed no difference in the detection of false-negative results using the time of 1 or 2 minutes. The quality of the sample did not influence the detection of false-negatives.

Multivariate analyses of immune reconstitution in children after allo-SCT: risk-estimation based on age-matched leukocyte sub-populations.

The speed of immune recovery after allo-SCT is of central importance to overcome infectious complications and relapse. To evaluate the immune reconstitution of pediatric patients concerning overall survival, we developed a three-component multivariate model and generated a reference domain of ellipsoidal shape on the basis of normal leukocyte subtype values of 100 healthy children and adolescents. The leukocyte subtypes include absolute nos. of leukocytes, CD14(+) monocytes, lymphocytes, CD3(+) T cells, CD3(+)CD4(+) helper T cells, CD3(+)CD8(+) cytotoxic T cells, CD3(-)CD56(+) natural killer-cells and CD19(+) B cells, all of which are correlated, thus, requiring the application of multivariate as opposed to multiple univariate modeling. According to their immune reconstitution, 32 pediatric patients post allo-SCT were classified into low-risk and high-risk groups on the basis of our new model. Therefore, we evaluated if the patients reached the ellipsoid of normal leukocyte sub-population values post SCT. We detected a significantly higher number of long-time survivors among the low-risk group compared with the high-risk group at days 200 (P=0.001) and 300 (P<0.0001). This is superior to our previously published univariate analysis. Combined with the clinical observation, a classification into risk groups based on an extended patient cohort may represent a predictor for complications.

[Statement about diagnosis assessment ano non pharmacological treatment of obesity]. / Diagnóstico, evaluación y tratamiento no farmacológico del paciente con sobrepeso u obesidad.

The risk of complications of obesity is proportional to body mass index and is higher in severe or morbid obesities and when abdominal or visceral fat is predominant. In Chile the prevalence of obesity is increasing. According to the World Health Organization, obese subjects must reduce at least a 5% of their weight to reduce the risk of complications. Although this amount of reduction is seldom achieved with non pharmacological treatments, better results are obtained with multidisciplinary/ approaches that include a medical, psychosocial and laboratory assessment, to determine obesity level and different factors involved and the associated complications. In a second stage, goals of treatment are set and a personalized treatment is designed including dietary changes and physical activity. The aim is to obtain perdurable lifestyles modifications.

Variation in sclerophylly among Iberian populations of Quercus coccifera L. is associated with genetic differentiation across contrasting environments.

Evergreen oaks are an emblematic element of the Mediterranean vegetation and have a leaf phenotype that seems to have remained unchanged since the Miocene. We hypothesise that variation of the sclerophyll phenotype among Iberian populations of Quercus coccifera is partly due to an ulterior process of ecotypic differentiation. We analysed the genetic structure of nine Iberian populations using ISSR fingerprints, and their leaf phenotypes using mean and intracanopy plasticity values of eight morphological (leaf angle, area, spinescence, lobation and specific area) and biochemical traits (VAZ pool, chlorophyll and beta-carotene content). Climate and soil were also characterised at the population sites. Significant genetic and phenotypic differences were found among populations and between NE Iberia and the rest of the populations of the peninsula. Mean phenotypes showed a strong and independent correlation with both genetic and geographic distances. Northeastern plants were smaller, less plastic, with smaller, spinier and thicker leaves, a phenotype consistent with the stressful conditions that prevailed in the steppe environments of the refugia within this geographic area during glaciations. These genetic, phenotypic, geographic and environmental patterns are consistent with previously reported palaeoecological and common evidence. Such consistency leads us to conclude that there has been a Quaternary divergence within the sclerophyllous syndrome that was at least partially driven by ecological factors.

¿Cuántas víctimas se necesitan para definir un desastre? / How many victims are needed to define a disaster?

Objetivo. Describir una situación de atención de víctimas múltiples. Analizar las características particulares del síndrome de inhalación de humo (SIH). Material y Métodos. Se evaluaron 5 pacientes (pts), ingresados al Servicio de Emergencias del HRRG en Noviembre del 2006, de los cuales tres ingresaron al Servicio de Terapia Intensiva (STI), único en la zona norte de la Provincia de Tierra del Fuego. La capacidad instalada del Hospital es de 5 camas de Terapia Intensiva con 5 respiradores microprocesador y con un ingreso anual de 300 pts con un índice de ocupación de camas de 5.4 pts/día. Los motivos de ingreso al STI fueron: Síndrome de Inhalación de Humo (SIH) e Insuficiencia Respiratoria Aguda. Se dividió a las Lesiones de la Inhalación de Humo (LIH) en: Lesión Térmica de la Vía Aérea (LTVA), Asfixia (A) y Lesiones por Gases Irritantes (LGI)*. Se evaluaron: Índice Trauma Pediátrico (ITP), APACHE II, características demográficas, estadía en TI (ETI), déficit de base en las 48 hs (DB/48) y mortalidad (M). Resultados. De los 5 pts (2 mujeres y 3 hombres), la edad promedio fue 8,6 años (rango 3-16), el APACHE II (promedio): 24.6 puntos (rango 2230), la ETI (promedio): 11,6 días (rango 1-18), ITP (promedio): 0 (-4 a +4) y el DB 48 (promedio) 11.4 mEq (rango -6 a -19). La mortalidad global fue del 40%. Tres pacientes presentaron LTVA, A y LGI, mientras que los dos restantes presentaron LTVA y A. Conclusión. La recepción de los 5 pts superó, en forma inmediata, los recursos en el sistema local hospitalario, cumpliendo con la definición de desastre. La acidosis metabólica durante las primeras 48 hs en el contexto del SIH se acompañó de mayor morbimortalidad.(AU)

How many victims are necessary to define a disaster? Objective. Describe a situation of care of multiple victims. Analyse the particular characteristics of smoke inhalation syndrome (SIH). Material and methods. 5 patients (pt) admitted to the Emergency Service of HRRG in November 2006 were evaluated. Three patients were admitted to the Intensive Care Unit, the only Service in the northern province of Tierra del Fuego. The Intensive Care Unit has 5 beds and 5 critical care ventilators to assit patients with respiratory failure. We admitted roughly 300 patients each year. The reasons for the admision were: Smoke inhalation Syndrome (SIH) and acute respiratory failure Injuries because inhaling smoke (LIH) were classified in: Thermal Injury of the Air (LTVA), Asphyxia (A) and Gas Injures Irritants (LGI). We consigned Pediatric Trauma Index (ITP), Apache II score, demographics, length of stay in STI, the basic deficit within 48 hours (DB/48) and mortality (M). Results. Of the 5 pt (2 women and 3 men), age was 8.6 years (range 3-16), the Apache II: 24.6 (range 22-30), length of stay 11.6 days (range 1-18), ITP: 0 (-4 to +4) and DB 48 (average) - 11.4 mEq (-6 to -19 range). The mortality rate was 40%. Three patients had LTVA, A and LGI, while the remaining two, both presented LTVA and A Conclusion. The admission of the 5 pt exceeded, immediately, resources in the local hospital system, fulfilling with the definition of disaster. The metabolic acidosis during the first 48 hours in the context of SIH was associated with increased morbidity and mortality(AU)

Rapid pre-screening of cervical smears as a method of internal quality control in a cervical screening programme.

OBJECTIVE: To evaluate the performance of rapid pre-screening (RPS) as a method of internal quality control in the cytopathological examination of cervical smears for cervical cancer screening. METHODS: The sample consisted of 6135 cervical smears submitted to RPS and routine screening (RS) methods. The smears classified as negative in RPS and RS were considered final diagnoses, and were not, therefore, submitted to any additional review. The smears identified as suspect or unsatisfactory according to RPS were analysed separately by two different cytologists irrespective of the diagnosis reached in RS. Smears considered abnormal or unsatisfactory at RS were also reviewed. When both cytologists issued concordant diagnoses, this was considered the final diagnosis. Discordant results were analysed by a third cytologist and a consensus meeting was held to define the final diagnosis. RESULTS: Taking abnormalities detected by RS as the denominator, RPS had a sensitivity of 63.0% for the detection of all abnormal smears and 96.7% for high grade squamous intraepithelial lesion (HSIL). When compared with the final diagnosis, sensitivity of RPS for all abnormal smears was 74.9% and for HSIL 95.0%. Of the 529 abnormal smears confirmed in the final diagnosis, 2.15% were detected only by the RPS. CONCLUSION: RPS is an effective alternative method of internal quality control with high sensitivity for the detection of more severe lesions. It also permits monitoring of the laboratory rate of false-negative results, and allows constant evaluation of the performance both of the pre-screening and RS cytologists.

Diversity of rhizobial bacteria isolated from nodules of the Gypsophyte Ononis tridentata L. growing in Spanish soils.

The aim of this work is to describe the diversity and phylogeny of rhizobial bacteria associated to nodules of Ononis tridentata L. in different geographical regions of Spain. Twenty-two bacterial isolates were characterized using several molecular techniques (16S amplified ribosomal deoxyribonucleic acid restriction analysis, fingerprinting, and sequencing) and phylogenies were inferred from their 16S and nodC gene sequences. Phylogenetically, the isolates grouped with the genera Rhizobium, Mesorhizobium, Phylobacterium, and Bosea. The nodC gene, essential for nodulation, was detected for the first time in isolates close to the genera Bosea and Phyllobacterium. The bacteria isolated showed a high diversity at the genus, species, and strain level regardless of the geographical origin of the host plant. This is the first report describing bacteria associated to nodules of O. tridentata. This shrub legume is highly prized for the revegetation of gypsum soils in semiarid Mediterranean areas. Our molecular description of bacteria associated to this legume improves the current understanding of the ecology of this plant species. Our findings have implications for formulating suitable bacterial inocula to recover gypsum ecosystems.

Evaluation of 100% rapid rescreening of negative cervical smears as a quality assurance measure.

OBJECTIVE: The objective of this study was to compare the performance of 100% rapid rescreening, 10% random rescreening and the review of smears selected on the basis of clinical criteria, as a method of internal quality control of cervical smears classified as negative during routine screening. METHODS: A total of 3149 smears were analysed, 173 of which were classified as positive and 2887 as negative, while 89 smears were considered unsatisfactory. The smears classified as negative were submitted to 100% rapid rescreening, 10% random rescreening, and rescreening based on clinical criteria. The rescreening stages were blinded and results were classified according to the Bethesda 2001 terminology. Six cytologists participated in this study, two of whom were responsible for routine screening while the other four alternated in carrying out rescreening so that no individual reviewed the same slide more than once. RESULTS: The 100% rapid rescreening method identified 92 suspect smears, of which 42 were considered positive at final diagnosis. Of the 289 smears submitted to the 10% rescreening method, four were considered abnormal but only one was confirmed positive in the final diagnosis. Of the 690 smears rescreened on the basis of clinical criteria, 10 were considered abnormal and eight received a positive final diagnosis. CONCLUSIONS: The 100% rapid rescreening method is more efficient at detecting false-negative results than 10% random rescreening or rescreening on the basis of clinical criteria, and is recommended as an internal quality control method.

Winter photoinhibition in the field involves different processes in four co-occurring Mediterranean tree species.

Photoinhibition was examined in four co-occurring Mediterranean evergreen tree species during two consecutive winters. In response to low temperatures and saturating light, Juniperus phoenicea L., Pinus halepensis Mill., Quercus coccifera L. and Q. ilex ssp. ballota (Desf.) Samp. exhibited marked chronic photoinhibition, indicated by low predawn maximal photochemical efficiency of photosystem II (PSII) (Fv/Fm). Low Fv/Fm values were correlated with high concentrations of xanthophyll cycle components (VAZ) and with the maintenance of high concentrations of zeaxanthin overnight (DPSpd). In all species, however, chronic photoinhibition was enhanced as the winter progressed in the absence of changes in DPSpd, suggesting cumulative damage toward the end of winter. Photoinhibition differed among species: P. halepensis always displayed significantly higher Fv/Fm values; and Q. coccifera had the lowest Fv/Fm values, showing a high sensitivity to the combination of high light and low temperatures. Differences among species were not fully explained by differences in the xanthophyll pool or its de-epoxidation state. Chronic photoinhibition overlapped with a dynamic photoinhibition as shown by the low values of photochemical efficiency of the open reaction centers of PSII at midday. Winter photoprotective strategies differed among species and may involve photoprotective mechanisms in addition to those associated with xanthophylls. The observed species-specific differences matched results obtained for the same species in summer; however, comparison of the two seasons suggests that the higher VAZ concentration observed in winter has an additional structural photoprotective role.

Pichia anomala outbreak in a nursery: exogenous source?

BACKGROUND: Pichia anomala is a rare cause of fungemia. From February to April, 1998, eight cases of fungemia occurred in the intensive care and high risk units of the Nursery. There were four infants with P. anomala infection, one of whom also had Candida parapsilosis infection, two cases with C. parapsilosis infection and two with Candida albicans infection. OBJECTIVE: To determine factors associated with fungemia in the intensive care and high risk units of the Nursery, especially P. anomala. METHODS: A cohort study with 59 newborns. RESULTS: Factors associated with fungemia were: central venous catheter (CVC) (P = 0.0006); total parenteral nutrition (TPN) (P = 0.0005); lipid emulsion (P = 0.002); previous antimicrobial use (P = 0.002); and other invasive procedures (P = 0.002). Factors associated with P. anomala fungemia were: CVC (P = 0.004); TPN (P = 0.018); previous antibiotic use (P = 0.037); and other invasive procedures (P = 0.037). Evaluation of the units demonstrated that there were several technical problems involving administration of TPN that was manipulated in the Nursery without precautions. Changes in TPN formulation and education as to adequate technique were implemented. During follow-up (1998 to 1999) only two fungemias occurred that were caused by C. albicans. Cultures of hands of personnel were negative for P. anomala. Electrophoretic karyotyping of P. anomala showed three profiles. CONCLUSIONS: Factors associated with fungemia were catheter use, invasive procedures and total parenteral nutrition, suggesting that the acquisition of P. anomala was exogenous.