Hallazgos incidentales en cirugía abdominal: masas y sarcomas retroperitoneales / Incidental findings in abdominal surgery: Retroperitoneal masses and sarcomas

Introducción. El retroperitoneo es una estructura que se extiende desde el diafragma hasta la pelvis, está delimitado adelante por el peritoneo parietal, atrás y a los lados por la fascia transversalis y se divide en 9 compartimientos. Se pueden encontrar lesiones primarias o secundarias, cuya evolución clínica varía desde un curso indolente hasta rápidamente progresivo, tanto local como a distancia. Su enfoque, desde el hallazgo hasta el tratamiento, es fundamental para el desenlace oncológico. Objetivo. Analizar la evaluación, el diagnóstico y el tratamiento de las masas retroperitoneales halladas incidentalmente y brindar un algoritmo de manejo. Métodos. Se hizo búsqueda en bases de datos como PubMed y MedicalKey de literatura referentes a tumores retroperitoneales, su diagnóstico y enfoque terapéutico, con el fin de presentar una revisión sobre el abordaje de las masas retroperitoneales y dar nuestras opiniones. Resultados. Se revisaron 43 referencias bibliográficas internacionales y nacionales, y se seleccionaron 20 de ellas, de donde se obtuvieron datos actualizados, recomendaciones de guías internacionales y experiencias nacionales, con lo cual se estructuró este manuscrito. Conclusiones. Las masas retroperitoneales abarcan un espectro de patologías que establecen un reto diagnóstico por su origen embriológico, localización y baja frecuencia. El diagnostico histológico es de vital importancia desde el inicio, para conocer la evolución natural de la enfermedad, y el manejo multidisciplinario en centros de referencia es fundamental para impactar en los desenlaces oncológicos. Existen variadas modalidades terapéuticas, como quimioterapia, radioterapia y resección quirúrgica con estándares oncológicos

Introduction. The retroperitoneum is an structure that extends from the diaphragm to the pelvis, bounded anteriorly by the parietal peritoneum, posteriorly and laterally by the transversalis fascia, and it is divided into 9 compartments. We can find primary or secondary lesions whose clinical evolution varies from an indolent course to a rapidly progressive one, both local and distant. Its approach from discovery to diagnosis and treatment is essential for the oncological outcomes. Objective. To analyze the evaluation, diagnosis and treatment of incidental retroperitoneal masses according to their origin and to provide a management algorithm. Methods. An updated literature search was carried out in databases such as PubMed and Medical Key on retroperitoneal tumors, therapeutic approach and diagnosis, obtaining national and international information to carry out a review article on the approach to retroperitoneal masses.Results. Forty-three international and national bibliographic references were reviewed, based on 20 updated data, recommendations from international guidelines and national experiences were obtained, with which a review and opinion manuscript was structured.Conclusions. Retroperitoneal masses cover a spectrum of pathologies that establish a diagnostic challenge due to their embryological origin, location and low frequency. Histological diagnosis is of vital importance from the beginning to know the natural evolution of the disease and multidisciplinary management in reference centers is essential to impact oncological outcomes. There are many therapeutic modalities from chemotherapy, radiotherapy and surgical resection with oncological standards

Neoplasias apendiculares incidentales / Incidental appendicular neoplasms

Las neoplasias apendiculares se presentan hasta en el 50 % de los casos como un episodio de apendicitis aguda. Existen características demográficas, clínicas y radiológicas que aumentan las posibilidades de un tumor apendicular subyacente, sin embargo, en la mayoría de los casos, son los hallazgos intraoperatorios los que alertan al cirujano. A pesar de que el tipo histológico determina la radicalidad del manejo quirúrgico de estos pacientes, algunas características macroscópicas pueden orientar a las patologías específicas y a una conducta adecuada. En general, los objetivos del manejo quirúrgico inicial se cumplen con una resección limitada al apéndice cecal, asociada a la citología de mucina y biopsia de los implantes peritoneales si están presentes, reservando las resecciones extendidas, como hemicolectomía derecha oncológica, para los pacientes con compromiso extenso de la base o del mesenterio apendicular ante la sospecha de neoplasias neuroendocrinas o adenocarcinoma del apéndice cecal.

Appendicular neoplasms present in up to 50% of cases as an episode of acute appendicitis. There are demographic, clinical and radiological characteristics that increase the chances of an underlying appendicular tumor; however, in most cases are the intraoperative findings that alert the surgeon. Although the histological type determines the radical nature of the surgical management of these patients, some macroscopic characteristics can guide specific pathologies and appropriate behavior. In general, the objectives of initial surgical management are met with a limited resection of the cecal appendix, associated with mucin cytology and biopsy of peritoneal implants if present, reserving extended resections such as oncological right hemicolectomy for patients with extensive compromise of the base or appendicular mesentery when neuroendocrine neoplasms or adenocarcinoma of the cecal appendix are suspected.

Tumores anexiales incidentales en cirugía abdominal / Incidental adnexal tumors in abdominal surgery

La posibilidad de encontrar una neoplasia benigna o maligna del ovario, de forma inesperada durante una intervención quirúrgica abdominal, es una realidad para todos los especialistas en cirugía. Si bien en muchos casos se tratará de una lesión benigna, el riesgo de cáncer no debe subestimarse, ya que, por ejemplo, la ruptura intraoperatoria de una lesión quística maligna puede reestadificar a una paciente con cáncer de ovario del estadio IA al IC, con todas las consecuencias que esto implica, como la necesidad de requerir quimioterapia adyuvante y tener un peor pronóstico. Por otro lado, en mujeres premenopáusicas debe discutirse con la familia o la paciente (idealmente) el riesgo e implicaciones de la ooforectomía uni o bilateral, incluso si esto amerita dejar el quirófano para obtener el consentimiento, o posponer el procedimiento definitivo para un segundo tiempo. La consulta intraoperatoria a un ginecólogo, siempre que sea posible, se debe llevar a cabo con el fin de respaldar la conducta adoptada. Conocer el manejo adecuado de las masas anexiales encontradas de forma incidental durante una cirugía abdominal, es una prioridad para todos los cirujanos generales.

The possibility of finding a benign or malignant neoplasm of the ovary unexpectedly during abdominal surgery is a reality for all specialists in surgery. Although in many cases it will be a benign lesion, the risk of cancer should not be underestimated, since, for example, the intraoperative rupture of a malignant cystic lesion may well re-stage a patient with ovarian cancer from stage IA to IC, with the consequences that this implies, such as the need for adjuvant chemotherapy and a worse prognosis. On the other hand, in premenopausal women, the risk and implications of unilateral or bilateral oophorectomy should be discussed with the family or the patient (ideally), even if this implies leaving the operating room to obtain consent, or postponing the definitive procedure for a second time. Intraoperative consultation with a gynecologist, whenever possible, should be carried out in order to support the adopted behavior. Knowing the proper management of adnexal masses found incidentally during abdominal surgery is a priority for all general surgeons.

Health Policy and Systems Research in Twelve Eastern Mediterranean Countries: a stocktaking of production and gaps (2000-2008).

BACKGROUND: The objectives of this study are to: (1) profile the production of Health Policy and Systems Research (HPSR) published between 2000 and 2008 in 12 countries in the Eastern Mediterranean Region (EMR): Bahrain, Egypt, Jordan, Lebanon, Libya, Morocco, Oman, Palestine, Sudan, Syria, Tunisia, and Yemen; (2) identify gaps; and (3) assess the extent to which existing HPSR produced in the region addresses regional priorities pertaining to Health Financing, Human Resources for Health and the Role of the Non-State Sector. This is the first stocktaking paper of HPSR production and gaps in the EMR. METHODS: Articles indexed on Medline between years 2000 and 2008 for the 12 study countries were selected. A MeSH term based search was conducted using country names. Articles were assessed using a coding sheet adapted for the region which included themes on: Governance Arrangements, Financial Arrangements, Delivery Arrangements, and Implementation Strategies. Identified articles were matched against regional research priorities to assess the extent to which research production aligns with priorities. RESULTS: A total of 1,487 articles (11.94%) fit the criteria in the coding sheet. Results showed an increase in HPSR production which peaked after 2005. Most identified articles focused on Delivery Arrangements (68.1%), and Implementation Strategies (24.4%). Most HPSR addressed priorities in Human Resources for Health (39%), and some articles focused on Health Financing (12%) and Role of the Non-State Sector (6.1%). CONCLUSIONS: Despite global calls for producing and translating HPSR into policy, there are still significant gaps in the EMR. More efforts are needed to produce HPSR and align production and translation with the demand for evidence by policymakers. Findings can help inform and direct future plans and activities for the Evidence Informed Policy Network- EMR, World Health Organization- EMR, and the Middle East and North Africa Health Policy Forum, in addition to being useful for countries that host or are planning to host KT platforms in the region.

Stakeholders' perspectives on the regulation and integration of complementary and alternative medicine products in Lebanon: a qualitative study.

BACKGROUND: The regulation of the markets for Complementary and Alternative Medicine (CAM) products presents a global challenge. There is a dearth of studies that have examined or evaluated the regulatory policies of CAM products in the Eastern Mediterranean Region (EMR). We investigate the regulatory frameworks and the barriers for the proper regulation and integration of CAM products in Lebanon, as an example of an EMR country with a weak public infrastructure. METHODS: We utilized a qualitative study design involving a series of semi-structured interviews with stakeholders of the CAM market in Lebanon. Snowball sampling was used to identify interviewees; interviews continued until the "saturation" point was reached. A total of 16 interviews were carried out with decision makers, representatives of professional associations, academic researchers, CAM product importers, policy makers and a media representative. Interviews were transcribed and thematic analysis of scripts was carried out. RESULTS: There was a consensus among all stakeholders that the regulation of the market for CAM products in Lebanon needs to be strengthened. Thematic analysis identified a number of impediments jeopardizing the safety of public consumption and hindering the integration of CAM therapies into mainstream medicine; including: weak infrastructure, poor regulation, ineffective policies and politics, weak CAM awareness and sub-optimal coordination and cooperation among stakeholders. With respect to policy instruments, voluntary instruments (self regulation) were deemed ineffective by stakeholders due to poor awareness of both users and providers on safe use of CAM products. Stakeholders' rather recommended the adoption of a combination of mixed (enhancing public awareness and integration of CAM into medical and nursing curricula) and compulsory (stricter governmental regulation) policy instruments for the regulation of the market for CAM products. CONCLUSIONS: The current status quo with respect to the regulation of CAM products in Lebanon is not conducive to public safety, nor does it support the integration of CAM products into the healthcare system. The Ministry of Health indeed plays a dominant role in the regulation of these products through a combination of mixed and compulsory policy instruments. Yet, the proper implementation of these regulations requires political resolve coupled with the cooperation of all CAM stakeholders.

Introducing female condoms to female sex workers in Central America.

CONTEXT: Female condoms have a potential role in reducing HIV infection among female sex workers in Central America. Research on how to introduce female condoms to this population is warranted. METHODS: Two rounds of focus groups with sex workers (115 in round one and 81 in round two) were conducted in El Salvador and Nicaragua in 2007-2008. In addition, we conducted structured interviews with 95 sex workers and direct observations of six health educators. RESULTS: Women reported that the design of the female condom made insertion and removal difficult to learn. About one-third of participants reported inserting it for the first time alone. Most women reported practicing 2-10 times before feeling skilled enough to use it with partners. Positive perceptions included lubrication, size, comfort and strength. Negative perceptions included the large package, initial physical discomfort and the possibility that the device would scare clients away. The participants preferred to learn to use female condoms from an instructional brochure plus instructor-led training in their workplace. They cited lack of exposure to female condoms among men and women as a barrier to female condom use and recommended education for both men and women; they also recommended distribution of female condoms at places where male condoms are available. CONCLUSIONS: If provisions are made for instructing women on female condom use in places where women will not feel stigmatized, and if supplies are easily and consistently available, uptake of the female condom among female sex workers in Central America seems likely. Health educators' use of promotional tools such as checklists and standardized messages is strongly recommended.

Central American sex workers' introduction of the female condom to different types of sexual partners.

Formative research was conducted in El Salvador and Nicaragua to inform promotion of female condoms to sex workers. Two rounds of focus groups with sex workers were conducted, with female condom training and supplies provided. Structured interviews with sex workers and direct observations of health educators were conducted. One third of sex acts were protected with female condoms in the previous 7 days. Women recommended nonpaying partners as "first try" partners but most frequently reported trying female condoms with clients. With clients, women preferred female condoms over male condoms but expressed no preference with nonpaying partners. Lack of exposure to female condoms among men and women was cited as a key barrier to female condom use. Strategies for persuading all partner types to try the female condom are suggested, and we provided promotional messages, based on results, to assist sex workers in introducing female condoms to different partners.

Growth inhibition of Staphylococcus aureus by chicken egg yolk antibodies.

INTRODUCTION: The aim was to evaluate the ability of egg yolk antibody (IgY) in blocking Staphylococcus aureus growth in vitro. MATERIALS AND METHODS: Specific IgY was produced by immunizing hens with formalin-killed S. aureus (ATCC 33593). Specific IgY against S. aureus was obtained from the yolks of their eggs with a carrageenan solution. IgY was identified by SDS-PAGE and Western blot and its activity against S. aureus was tested by ELISA. A growth inhibition assay and protein concentration determination were also conducted. RESULTS: ELISA indicated that the IgY was specific to the antigen; this activity was confirmed by Western blotting. The growth of S. aureus was inhibited by the specific IgY at concentrations of 1-5 microg/ml The bacteriostatic function of IgY appeared to result possibly from the interaction of IgY with surface components of S. aureus. In vitro experiments showed that the immunoglobulin from egg yolk interfered with the culture growth of the S. aureus. CONCLUSION: These findings indicate that eggs from hens immunized with appropriate antigens are a potentially useful source of passive immunity.

Characterization of an IgY polyclonal antibodies directed against the canine distemper virus

Canine distemper is a contagious, incurable, often fatal, multisystemic viral disease that affects the respiratory, gastrointestinal, and central nervous systems. Distemper is caused by the canine distemper virus (CDV). The development of antibodies to use in therapy and diagnosis is essential for the control of some diseases. Immunization of chickens with CDV results in the production of antibodies specific. However, there is relatively limited information available concerning immune response of CDV in this species. In the present study, immune responses were examined in serum and egg yolk from laying hens injected with CDV. The results demonstrated that the increase of antibody activity occurs first in the serum, and then in egg yolk with a lag in time of 1 to 3 week in the chickens. However, the time of elevated levels of antibody activity was much shorter in serum than the egg yolk.

Production and use of egg-yolk antibody for detection of canine parvovirus in feces

Canine parvovirus (CPV), cause an intestinal disease characterized by bloody diarrhea, is often fatal in puppies. The virus is transmitted by contact with infected dogs or their feces. The virus is very stable in the environment and may survive for several months in contaminated areas. The CPV attacks the rapidly diving cells of the bone marrow and the small intestine. Several laboratory tests have been developed and are available for specific viral diagnosis. Where facilities are available, rapid diagnosis can be made by electron microscopy (EM) of fecal material from cases with typical signs of disease. The virus also can be isolated in several feline and canine cell lines such as canine and feline kidney cells, but isolation is seldom used in practice since cell cultures are required and at least 1 week for results is required. Fecal hemagglutination-hemagglutination (HA-HI) tests have provided a simple and rapid method for detecting virus in fecal and tissue samples and are employed by several diagnostic laboratories, however the HA test is less sensitive than EM or enzyme-linked immunoassays (ELISA). In this work, the laying chickens are immunized with the canine parvovirus strain Cornell 780916-80 and the egg yolk antibody (IgY) isolated and characterized by indirect ELISA to detect canine parvovirus in feces.

Assessment of infrared spectroscopy and multivariate techniques for monitoring the service condition of diesel-engine lubricating oils.

This paper presents two methodologies for monitoring the service condition of diesel-engine lubricating oils on the basis of infrared spectra. In the first approach, oils samples are discriminated into three groups, each one associated to a given wear stage. An algorithm is proposed to select spectral variables with good discriminant power and small collinearity for the purpose of discriminant analysis classification. As a result, a classification accuracy of 93% was obtained both in the middle (MIR) and near-infrared (NIR) ranges. The second approach employs multivariate calibration methods to predict the viscosity of the lubricant. In this case, the use of absorbance measurements in the NIR spectral range was not successful, because of experimental difficulties associated to the presence of particulate matter. Such a problem was circumvented by the use of attenuated total reflectance (ATR) measurements in the MIR spectral range, in which an RMSEP of 3.8cSt and a relative average error of 3.2% were attained.