Perforation of a decubitus gastric ulcer during intragastric balloon retrieval after surreptitious withdrawal of omeprazole.

Male, 24 yo, obesity class 1. We place him a 6 month intragastric balloon. He keeps asymptomatic while taking PPIs, having lost 13 kg in 4 months. He starts on month 5 with epigastric pain, just after abandoning omeprazole on his own. The pain worsens in spite of restarting PPIs and we schedule an urgent retrieval of the balloon. Gastric ulcer perforation occurs during balloon removal and the patient is operated.

Pelt Biting as a Practical Indicator of Social and Environment Stress in Farmed Red Deer.

Agonistic behavioural interactions play a decisive role in the competition for food, space, mating opportunities, and establishing social rank. We used pelt biting (number of bites on an animal's body) as a proxy for assessing the intensity of agonistic animal interactions and how it responded to social, population, and heat stress factors. We modelled a 14-year time series of pelt biting records and observational data of agonistic interactions on a population of captive Iberian red deer (Cervus elaphus). We found that (i) the higher the social rank of deer, the lower the number of pelt bites received; (ii) increasing heat stress conditions caused deer to suffer more pelt bites; (iii) males received more bites than females; (iv) the heavier the deer, the lower the number of bites on their bodies; (v) the bigger the group, the more bites exhibited on its members; (vi) deer 5-6 years old suffered greater rate of pelt biting than younger or older deer; and (vii) hinds that gave birth earlier in the parturition period suffered less pelt biting than those that gave birth around the peak of the parturition season (p < 0.01 for all effects). Pelt biting is useful to predict management situations in which deer welfare could be at stake.

Physicochemical, Microbiological and Technological Properties of Red Deer (Cervus elaphus) Milk during Lactation.

This study describes chemical, physical, microbiological and technological characteristics of red deer milk and the effect of lactation on these parameters in order to know their potential aptitude to elaborate dairy products. During 18 weeks, milk from five hinds was monitored for composition, bacteriology, somatic cell count (SCC), physical properties and rennet coagulation. Mean values (g/100 g) for fat, protein, lactose and dry matter were 10.4, 7.1, 4.3 and 24.2, respectively, and for urea, 265 mg/100 mL. Except for lactose, a significant increase in these components was observed (p < 0.01) as lactation progressed. The average values for bacteriology and SCC were 5.3 log cfu/mL and 4.7 log cells/mL, respectively. Regarding physical properties, conductivity (mean: 2.8 ms/cm), viscosity (3.1 Cp), coordinates L* (89.9) and a* (-3.1) and milk fat globule diameter (D4,3: 6.1 µm) increased along with lactation while density (1.038 g/mL) decreased (p < 0.01). The pH (6.7), acidity (22.9° Dornic), coordinate b* (8.4) and ethanol stability (66.6% v/v) were stable during the study period. The stage of lactation also has a significant impact on milk coagulation properties and mean curd yield was 3.29 g/10 mL. These results suggest that red deer milk could be a potential innovative source of milk for the dairy industry.

Principales medidas de profilaxis en endoscopia bariátrica. Guía Española de Recomendación de Expertos / No disponible

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Main prophylactic measures in bariatric endoscopy. Spanish Expert Recommendations Guideline.

Bariatric endoscopy (BE) encompasses a number of techniques -some consolidated, some under development- aiming to contribute to the management of obese patients and their associated metabolic diseases as a complement to dietary and lifestyle changes. To date different intragastric balloon models, suture systems, aspiration methods, substance injections and both gastric and duodenal malabsorptive devices have been developed, as well as endoscopic procedures for the revision of bariatric surgery. Their ongoing evolution conditions a gradual increase in the quantity and quality of scientific evidence about their effectiveness and safety. Despite this, scientific evidence remains inadequate to establish strong grades of recommendation allowing a unified perspective on prophylaxis in BE. This dearth of data conditions leads, in daily practice, to frequently extrapolate the measures that are used in bariatric surgery (BS) and/or in general therapeutic endoscopy. In this respect, this special article is intended to reach a consensus on the most common prophylactic measures we should apply in BE. The methodological design of this document was developed while attempting to comply with the following 5 phases: Phase 1: delimitation and scope of objectives, according to the GRADE Clinical Guidelines. Phase 2: setup of the Clinical Guide-developing Group: national experts, members of the Grupo Español de Endoscopia Bariátrica (GETTEMO, SEED), SEPD, and SECO, selecting 2 authors for each section. Phase 3: clinical question form (PICO): patients, intervention, comparison, outcomes. Phase 4: literature assessment and synthesis. Search for evidence and elaboration of recommendations. Based on the Oxford Centre for Evidence-Based Medicine classification, most evidence in this article will correspond to level 5 (expert opinions without explicit critical appraisal) and grade of recommendation C (favorable yet inconclusive recommendation) or D (inconclusive or inconsistent studies). Phase 5: External review by experts. We hope that these basic preventive measures will be of interest for daily practice, and may help prevent medical and/or legal conflicts for the benefit of patients, physicians, and BE in general.

Disección submucosa endoscópica en lesiones gástricas epiteliales: resultados a largo plazo en una cohorte española / No disponible

INTRODUCCIÓN: la disección submucosa endoscópica sobre lesiones gástricas (DSE-G) es una técnica que permite la resección de tumores gástricos precoces en bloque, con una tasa de curación similar a la cirugía y una morbimortalidad menor. OBJETIVO: analizar la supervivencia total, la supervivencia libre de enfermedad y la tasa de recidiva en pacientes sometidos a DSE-G en una cohorte española a lo largo de su evolución clínica. MATERIAL Y MÉTODOS: estudio observacional prospectivo. Inclusión de pacientes sometidos a DSE-G de 2008 a 2015, con seguimiento entre seis y 60 meses. Se analizó la recurrencia a cinco años mediante curvas de Kaplan-Meier y los resultados fueron comparados entre diferentes factores (en bloque vs. resección fragmentada, resecciones curativas R0 vs. margen lateral afecto ML+) usando test log-rank. RESULTADOS: se analizaron 35 pacientes sometidos a DSE-G, con una mediana de seguimiento de 33,62 meses. Se identificaron cuatro recidivas en este periodo (11,4%), tres de ellas tratadas mediante nueva DSE-G. La presencia de ML+ en la pieza histológica se relacionó con mayor tasa de recidiva local durante el seguimiento (p = 0,06). Las resecciones fragmentadas presentaron un mayor riesgo de recidiva pero sin detectarse diferencias estadísticamente significativas (p = 0,49). No se registraron fallecimientos por neoplasia gástrica ni gastrectomía por persistencia de enfermedad en este periodo. La tasa de supervivencia global en nuestra serie fue de 94,3%. CONCLUSIONES: la DSE-G realizada en nuestro medio permite una tasa elevada de curación a largo plazo evitando la cirugía. Estos resultados se asemejan a las series europeas publicadas y aún se encuentran lejos de las tasas de curación y recidiva de las cohortes asiáticas. Los casos de recidiva local pueden ser controlados mediante endoscopia

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Endoscopic submucosal dissection for gastric epithelial lesions: long-term results in a Spanish cohort.

INTRODUCTION: endoscopic submucosal dissection for gastric lesions (ESD-G) is a technique that allows en-bloc resection of early gastric tumors, with a cure rate similar to that of surgery but lower morbidity and mortality rates. OBJECTIVE: to assess total survival, disease-free survival and relapse rate during the course of disease in a Spanish cohort of patients undergoing ESD-G. MATERIAL AND METHODS: this was a prospective observational study of patients undergoing ESD-G from 2008 to 2015, with a follow-up ranging from six to 60 months. Recurrence at five years was analyzed using Kaplan-Meier curves and the results were compared according to several factors using the log-rank test. These included en-bloc versus piecemeal resection and R0 curative resection versus resection with affected lateral margins (LM+). RESULTS: a total of 35 patients undergoing ESD-G were assessed, with a median follow-up of 33.62 months. Four relapses were identified (11.4%) during this period, of which three were managed with repeat ESD-G. A histological specimen with LM+ was associated with a higher local relapse rate during follow-up (p = 0.06). Piecemeal resections had a higher relapse risk, although no statistically significant differences were identified (p = 0.49). No deaths from gastric cancer occurred and no gastrectomies due to persistent disease were performed during this period. The overall survival rate in our series was 94.3%. CONCLUSIONS: ESD-G in our setting provides high long-term cure rates, while avoiding surgery. These results are similar to those reported by the European series and remain far removed from the cure and relapse rates obtained in Asian cohorts. Local relapse cases may be monitored with endoscopy.

Long-term follow-up after endoscopic submucosal dissection of colorectal lesions in a Spanish cohort.

INTRODUCTION: ESD in the colon is an increasingly important technique in Western countries. There are few studies that include long term follow-up. AIM: to analyze the long term recurrence free survival rate after ESD and to compare recurrence rates according to different variables. METHODS: this was a prospective observational study of patients with a planned ESD from September 2008 to December 2015. When it was not possible to achieve an ESD, hybrid ESD was performed, either en bloc or piecemeal. Kaplan-Meier survival curves were used to assess the five year local recurrence free survival rate and the recurrence rate. The results were compared according to different factors. RESULTS: of the 89 patients scheduled for ESD who were initially enrolled in the study, 69 were finally included for follow-up. ESD was performed in 31 (45%) patients, KAR in eleven (16%) and pKAR in 27 (39%). The median follow-up was 27 months (range 6-60). The five year disease free survival rate was 81%. The average number of endoscopies needed to eliminate recurrence was two (range 2-7) and no patient required surgery for this reason. The recurrence rate was significantly higher in piecemeal resections vs en bloc resections (27% vs 15%, p = 0.036) and R1 resections vs R0 resections (26% vs 0%, p = 0.034). The presence of affected or unknown lateral margins in en bloc resections without other poor prognosis factors had higher recurrence rates but the difference was not statistically significant (28% vs 0%, p = 0.09). CONCLUSIONS: in our study, the five year disease free survival rate was 81% and no patient required surgery during follow-up. Piecemeal and R1 resections had significantly higher recurrence rates, as well as LM involvement, although this was not statistically significant.

Parenteral Cu Supplementation of Late-Gestating and Lactating Iberian Red Deer Hinds Fed a Balanced Diet Reduces Somatic Cell Count and Modifies Mineral Profile of Milk.

: This study describes the effects that Cu supplementation of late-gestating and lactating females (hinds) of Iberian red deer fed a balanced diet have on milk production, composition, and somatic cell count (SCC). Experimental hinds (n = 9) were subcutaneously injected every 42 days with Cu (0.83 mg Cu/kg body weight) from day 202 of gestation until the end of lactation (week 18). Control hinds (n = 8) were injected with a physiological saline solution with the same volume and at the same frequency as the experimental group. Copper supplementation decreased the SCC from 1.64 to 1.36 log 10/mL (p = 0.003) and modified the milk mineral profile. In particular, milk from hinds supplemented with Cu had more Ca (p = 0.02), Mg (p = 0.06), and K (p = 0.03) than milk from control hinds. However, Cu supplementation did not influence the Cu content of milk. Therefore, it can be concluded that Cu supplementation of hinds fed a balanced diet from late-gestation to the end of lactation could be a good strategy to reduce SCC and modify the mineral profile of milk increasing its Ca content.

Complete resolution of dysphagia after sequential Polyflex(TM) stenting in a case of recurrent anastomotic stenosis in an adult with congenital esophageal atresia

We present a case of intractable dysphagia in a 23-year-old female with type 1 esophageal atresia (EA) and subsequent postsurgical refractory esophageal strictures. The patient was referred due to increasing symptomatology and a slight response to balloon dilations. A biodegradable polydioxanone stent (ELLA) was placed, but this did not relieve the dysphagia. After the sequential placement of two siliconated polypropylene stents (Polyflex(TM), Boston Scientifics), the dysphagia was definitively relieved. To our knowledge, this is the first published case with a full resolution of dysphagia using this strategy in an adult patient

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Complete resolution of dysphagia after sequential Polyflex™ stenting in a case of recurrent anastomotic stenosis in an adult with congenital esophageal atresia.

We present a case of intractable dysphagia in a 23-year-old female with type 1 esophageal atresia (EA) and subsequent postsurgical refractory esophageal strictures. The patient was referred due to increasing symptomatology and a slight response to balloon dilations. A biodegradable polydioxanone stent (ELLA) was placed, but this did not relieve the dysphagia. After the sequential placement of two siliconated polypropylene stents (Polyflex™, Boston Scientifics), the dysphagia was definitively relieved. To our knowledge, this is the first published case with a full resolution of dysphagia using this strategy in an adult patient.

Alternative hypothesis for the origin of osteoporosis: the role of Mn.

Antlers represent an ideal experimental model for bone biology studies, because of their easy accessibility, and their rapid growth. Findings from our previous studies revealed that Mn plays an essential role in incorporating the circulating bone Ca to the growing antlers. Based on these findings, we hypothesize that Mn, an essential mineral for Ca fixation (or incorporation) into bones, might be released from bone, during its remodeling, to be available for prioritized function, most likely, brain function; Consequently, Ca incorporation will be dramatically affected, leading to osteoporosis, particularly in elderly people. Therefore, osteoporosis would precede brain malfunctioning diseases such as Alzheimer's or Parkinson's, and clinical data are available to support some of the predictions derived from this hypothesis.

Seasonal variations in red deer (Cervus elaphus) hematology related to antler growth and biometrics measurements.

The aim of the study was to relate seasonal hematology changes with the rest of physiological variations suffered by red deer, such as antler and biometrics cycle, and to assess the relationship between hematology and the effort performed in antler development. Blood samples were taken from 21 male red deer every 4 weeks during 18 months. Samples were analyzed for the main hematological parameters. Simultaneously, biometrics measurements were taken, such as antler length, body weight, body condition score, testicular diameter (TD), and thoracic and neck girth. All the blood cell types (erythrocytes, leukocytes, and platelets) showed seasonal variations, increasing as antler cleaning approached, as did hematocrit and hemoglobin. The final size of antlers was negatively related to leukocyte count, nonlymphoid leukocyte count, red cell distribution width, mean corpuscular hemoglobin, mean platelet volume, and TD, whereas it was positively related to body condition during antler growth. Huge seasonal variations in some hematological values have been found to be related to changes in antler and biometrics measurements. Since these variations are even greater than the caused by deer handling, they should be taken into account when evaluating hematology in deer populations.

Development of body condition in hinds of Iberian red deer during gestation and its effects on calf birth weight and milk production.

Reproductive effort affects body reserves and subsequent ability to reproduce. In fact, the energy costs of gestation and lactation in hinds of red deer have a marked effect on maternal condition. The objectives of this study were to examine the development of hind monthly body condition during gestation in relation to reproductive rest, age and age class, just as its effects on total milk yield and calf birth weight. Eighty hinds of Iberian red deer were used as subjects during 2 years of study. They had ad libitum access to food and water. Animals were weighed weekly, and body condition was individually assessed. Milking was carried out under anesthesia with a milking machine followed by hand milking to collect the remaining milk. Age and reproductive rest influenced body condition, improving with age (coefficient: 0.10+/-0.01; P<0.001) and reproductive rest (mean+/-SEM, 3.75+/-0.05 vs. 3.25+/-0.02, with and without rest respectively; P<0.001). Hind age correlated positively with her body condition (R=0.62, P<0.001), however, when age class was included in the model, age was not significant. The greater the age class (up to age class 4) the greater the body condition; however, hinds of age class 5 had a lower body condition, but no significant differences were observed. Development of the body condition during gestation was different to age class 1 with respect to the others, just as between hinds that rested the preceding year and those that did not.

Tuberculosis peritoneal en una paciente con ascitis y masa anexial. Reporte de caso / Peritoneal tuberculosis in a patient with ascites and an anexal mass. A case report

Objetivo: presentar el cuadro clínico y de laboratorio de una paciente con tuberculosis peritoneal. La tuberculosis puede afectar diferentes órganos con presentaciones clínicas que simulan otras patologías. Presentamos el caso de una paciente con ascitis y masa anexial diagnosticada por tomografía y con CA 125 elevado. Se realizó laparotomía exploradora con la impresión diagnóstica de tumor de ovario, encontrando adherencias y siembras peritoneales. La patología informó inflamación granulomatosa crónica compatible con tuberculosis.

Effect of advancing births on testosterone until 2.5 years of age and puberty in Iberian red deer (Cervus elaphus hispanicus).

This study aimed to determine the age of attainment of puberty, as well as the pattern of reproductive seasonality in males of Iberian red deer and the relationship of these factors with antler development. A second aim was to examine the effect of the advance of births on the variables mentioned. Fourteen males of Iberian deer were used, five of them born 2.5 months before the others (early group). Male deer were blood sampled from birth until 2.5 years of age to assess the time course of plasma testosterone. The study also included measurements of testicular and neck circumference. As in most cervids, concentration of plasma testosterone was associated to the phases of antler development. Early development affected testosterone titres, since the most precocious males in antler growth also showed higher levels of testosterone during the first and second year of age. In the same way, results suggested that the advance of calving may result in puberty attainment in the first autumn of its life. However, this would require an advance of calving greater than the one we induced since puberty in the Iberian deer is usually attained during second autumn of life at 15-16 months of age. Finally, calving advance also affected antler development. Thus, two of the five males whose birth was advanced, showed two antler cycles in their first year of life.

Compensatory extension of gestation length with advance of conception in red deer (Cervus elaphus).

Calving date in many mammals is matched to the time of greatest food availability. Out of season calving results in heavy penalties in terms of own and offspring survival or body condition. This study examined whether gestation length is affected by advancing fertilisation. Thirty-six red deer hinds (of the Iberian and Scottish subspecies) were subjected to a synchronisation treatment of oestrus, ovulation, and artificial insemination on three dates, with remaining non-pregnant females mated with an intact male in a last group. Gestation was longer the more the fertilisation was advanced; gestation lasted 241.5+/-1.3 days (d) in the first group, 237.4+/-1.2 d in the second, 235.1+/-1.3 d in the third, and 231.2+/-1.6 d in the last. Mean gestation lasted 234.2+/-0.7 d. Hinds gained less weight during gestation the more the fertilisation was advanced. The difference was due at least in part to net body weight of the hind after calving compared to that at mating, and calves did not differ in birth weight. As early born calves suffer greater mortality in the field, this enlargening of gestation might be a compensatory response of the hinds to match calving with food availability. Under natural conditions, similar small modifications of gestation length may help hinds to overcome short-term adverse conditions for calving. Because calf mortality is correlated with birth weight, hinds may have kept calf birth weight constant at the expense of greater body weight loss.

Progesterone determination in Iberian red deer by time-resolved fluorometry: an alternative method to RIA.

The validation for Iberian red deer of a commercially available Time-resolved fluoroimmunoassay (TR-FIA) designed for analysis of progesterone in human beings was carried out. Intra-assay coefficients of variation ranged from 3.6% to 7.4%, while inter-assay coefficients of variation varied from 5.2% to 15.5%. Accuracy, evaluated by comparing results yielded by TR-FIA with those obtained from a validated radioimmunoassay (RIA) in the measurement of 14 samples, provided a high regression coefficient (R(2)= 0.93). Different progesterone concentrations added to pool plasma showed percentages of recovery that ranged between 102.6% and 82.48%. The limit of detection was 0.102 nmol/L. The results obtained indicate that the present method is suitable for the measurement of progesterone in female Iberian red deer.

Characteristics of the oestrous cycle of Iberian red deer (Cervus elaphus hispanicus) assessed by progesterone profiles.

This study examines the length of the oestrous cycle in 16 Iberian red deer females assessed by means of changes in progesterone concentrations, along with the changes in the profile of this hormone. Samples were collected three occasions per week from the week after calving (15 May to 15 June) up to May of the following year. The oestrous cycle lasted 19.57+/-0.29 days (range 10-27 d) calculated in 130 oestrous cycles examined. Progesterone titres did not rise above 0.5 ng/ml in the follicular phase, except in four samples. The maximum peak in progesterone concentration during the luteal phase remained above 1 ng/ml in most cases. Twenty-five percent of the individuals studied (4 out of 16) showed an oestrous cycle lasting shorter than the mean (15.2+/-0.30 days) before the start of the reproductive season, followed by a period of sexual inactivity. The standard progesterone profile in natural oestrous cycles rose from basal levels to those above 0.5 ng/ml four days after onset of oestrus, reached a peak of 1.71+/-0.07 ng/ml and then declined to less than 0.2 ng/ml after day 20. Following the rapid decline of progesterone after day 14, the concentration remained around the baseline level of 0.1 to 0.2 ng/ml during the immediate pre- and post-ovulatory phase of the cycle.