Íleo biliar como causa e obstrucción intestinal / Gallstone ileus as a cause of intestinal obstruction

Introducción. Comunicar un caso clínico poco habitual y revisar el manejo. Material y Métodos. Presentación de un caso clínicoResultados. El íleo biliar es una etiología poco habitual de obstrucción intestinal, aunque su incidencia aumenta con la edad. Sudiagnóstico requiere una alta sospecha clínica ya que menos del 50% de los pacientes tienen clínica biliar previa. La cirugía urgentees mandatoria para la resolución del cuadro obstructivo. Conclusiones. La resucitación del paciente y la extracción quirúrgicaurgente del cálculo biliar es el tratamiento de elección. Existe controversia sobre el manejo de la fístula colecistoduodenal. (AU)

Introduction. Report an unusual clinical case and review the management. Material and methods. Presentation of a clinical case.Results. Gallstone ileus is an unusual etiology of intestinal obstruction, although its incidence increases with age. Its diagnosisrequires a high clinical suspicion since less than 50% of patients have previous biliary symptoms. Urgent surgery is mandatory forthe resolution of the obstructive condition. Conclusions. Patient resuscitation and urgent surgical removal of the gallstone is thetreatment of choice. There is controversy about the management of cholecystoduodenal fistula. (AU)

Quantum state features of the FEL radiation from the occupation number statistics.

The coherence of free-electron laser (FEL) radiation has so far been accessed mainly through first and second order correlation functions. Instead, we propose to reconstruct the energy state occupation number distribution of FEL radiation, avoiding the photo-counting drawbacks with high intensities, by means of maximum likelihood techniques based on the statistics of no-click events. Though the ultimate goal regards the FEL radiation statistical features, the interest of the proposal also resides in its applicability to any process of harmonic generation from a coherent light pulse, ushering in the study of the preservation of quantum features in general non-linear optical processes.

Falla renal aguda en postoperatorio inmediato de cirugía correctiva de escoliosis / Case report of two cases: Acute renal failure adter scolisosis surgery

La cirugía correctiva de escoliosis es la alternativa terapéutica para los pacientes portadores de escoliosis severa con ángulos de Cobb > 40- 45º. La corrección ofrece solución a la deformidad estética, evita la progresión y/o corrige según sea el caso, el compromiso cardiopulmonar. Mejora además biomecánica de marcha y permite reintegración funcional de los pacientes. La artrodesis posterior con barras y tornillos es la técnica de elección, tiene un alto riesgo de hemorragia y de daño neurológico postoperatorio. En la actualidad, las estrategias de manejo anestésico ­ quirúrgico y la incorporación de neuromonitoreo continuo han disminuido la incidencia y el impacto clínico de estas complicaciones. Sin embargo, otras complicaciones como la falla renal aguda aún están presentes en pacientes de alto riesgo como portadores de patología neuromuscular. A continuación, se presenta un reporte y análisis de 2 casos clínicos de falla renal aguda en el postoperatorio inmediato en cirugía correctiva de escoliosis con artrodesis posterior, en pacientes portadores de escoliosis neuromuscular severa ocurridos durante el año 2015 en el hospital clínico San Borja Arriarán.

Corrective surgery is a therapeutic alternative for patients with scoliosis Cobb angle > 40-45ª. This surgery offers a solution to aesthetic deformities, prevents progression and in some cases can resolve the cardiopulmonary consequences. It also improves the ambulation biomechanics and allows the reintegration to total functionality. Posterior artrodesis with bars and pedicular screws is the technic of choice. It has a high risk of hemorrhagic complications and neurological damage. Presently, anaesthetic and surgical approaches, along with neurological somatosensitive monitoring, have decrease these complications. However, other complications, including acute renal failure are still present in high-risk cases such as patient with neuromuscular scoliosis. We present a case report including 2 patients with neuromuscular scoliosis that underwent posterior artrodesis in our hospital (Hospital Clinico San Borja Arriaran) during 2015. Both develop and acute renal failure in the early postoperative period.

Antithymidylate resistance enables transgene selection and cell survival for T cells in the presence of 5-fluorouracil and antifolates.

Antithymidylates (AThy) constitute a class of drugs used in the treatment of cancers such as lung, colon, breast and pancreas. These drugs inhibit DNA synthesis by targeting the enzymes dihydrofolate reductase (DHFR) and/or thymidylate synthase (TYMS). AThys effectively inhibit cancer cells, and also inhibit T cells, preventing anticancer immunity, which might otherwise develop from AThy-induced cancer destruction. We establish that T cells expressing mutant DHFR--DHFR L22F, F31S (DHFR(FS))--and/or mutant TYMS--TYMS T51S, G52S (TYMS(SS))-effectively survive in toxic concentrations of AThys methotrexate, pemetrexed and 5-fluorouracil. Furthermore, we show that DHFR(FS) permitted rapid selection of an inducible suicide transgene in T cells. These findings demonstrate that AThy resistances prevent AThy cytotoxicity to T cells while permitting selection of important transgenes. This technological development could enhance in vitro and in vivo survival and selection of T-cell therapeutics being designed for a broad range of cancers.

Anatomía radiológica del seno esfenoidal: análisis en 120 pacientes intervenidos / Radiologic anatomy of sphenoidal sinus, analysis of 120 surgically intervened patients

Introducción: La patología tumoral hipofisiaria es una consulta frecuente en Neurocirugía. La vía de abordaje a elegir preferentemente es transesfenoidal. Por esto, es de suma importancia conocer la anatomía de los senos paranasales cuando se planifica este abordaje. Materiales y Métodos: Se describe la anatomía radiológica de estudios por Tomografía Computada (TC) y Resonancia Magnética (RM) de 120 pacientes con diagnóstico de adenoma hipofisiario, que se sometieron a cirugía transesfenoidal de hipófisis, prestando especial interés en la morfología de las cavidades paranasales esfenoidales. Resultados: Tipo de neumatización: preselar 25 por ciento y postselar 75 por ciento; Septos: simples 45 por ciento y múltiples 55 por ciento; diámetros promedio: antero-posterior 2,3 cm, transverso: 3,3 cm y vertical: 2,25 cm. Los Senos esfenoidales con neumatización postselar tienen un diámetro anteroposterior significativamente mayor (P < 0,005) que los preselares. Los senos esfenoidales con septo simple tienen un diámetro transverso significativamente mayor (P < 0,007) que los con múltiples septos. El 50 por ciento de los septos siguen una trayectoria paramediana, y el 50 por ciento se desvía hacia una de las arterias carótidas. Conclusión: se confirma la gran variación anatómica del seno esfenoidal siendo independiente del sexo del paciente, además hemos constatado que la relación establecida por los septos intraselares con elementos vasculares intracraneales es muy variable, siendo este hallazgo de suma importancia en la planificación preoperatoria. Los hallazgos realizados por Tomografía computada (TC), pueden ser homologables a lo descrito por otros autores en disecciones cadavéricas.

Introduction: The pituitary tumor pathology is a common query in Neurosurgery. The choice of approach is transsphenoidal preferably, so it is extremely important to know the anatomy of the sinuses when planning this approach. Materials and Methods: We describe the radiological anatomy studies Computerized tomography (CT) and Magnetic Resonance (MR) of 120 patients with pituitary adenoma who underwent transsphenoidal pituitary surgery, with special attention to the morphology of the sphenoid sinuses. Results: Neumatization type: pre-sellar 25 percent and 75 percent post-sellar; Septa: Single 45 percent, multiple 55 percent, mean diameters: 2.3 cm anteroposterior, transverse: 3.3 cm and vertical: 2.25 cm. The sphenoid sinuses with postsellar neumatization have anteroposterior diameter significantly higher (P < 0.005) than the pre-sellar. The sphenoid sinuses are single septum transverse diameter significantly higher (P < 0.007) than those with multiple septa. The 50 percent of the septa paramedian follow a path, and 50 percent is diverted to one of the carotid arteries. Conclusion: Results support the large sphenoid sinus anatomical variation is independent of patient sex, and we found that the relationship established by the intrasellar septa with intracranial vascular elements is very variable, this finding being paramount in preoperative planning. The findings by computed tomography (CT) may be comparable to that described by other authors in cadaveric dissections.

Is "small for size syndrome" a relatively new complication after the ALPPS procedure?

Aim of this study is to assess the incidence and outcome of small for size syndrome after ALPPS procedure. This novel procedure is claimed to induce accelerated and increased growth of future liver remnant after major hepatectomies. We prospectively collected data on nine consecutive patients undergoing ALPPS procedure at our center. Main patients' characteristics, outcome and postoperative complications, including small for size syndrome were analyzed. Main interval between two stages of ALPPS was 15.1 days. Mean future liver remnant hypertrophy was 93.2%. Severe complications occurred in 44.4% of patients and mortality occurred in two cases (22.2%). Small for size syndrome occurred in two cases (22.2%). The first one was detected intraoperatively during first stage. It was successfully managed by spleno-renal venous shunt. Second case was not promptly detected and died on postoperative day 64. This case series provides evidence that SFFS can be an important complication after ALPPS procedure. If it is not promptly detected and properly managed it can be a cause of death as occurred in our case.

Revisión de técnica y utilidades de la tomosíntesis digital de tórax en la actualidad / A review of current techniques and usefulness of digital chest tomosynthesis

Digital tomosynthesis (DTS) of the chest is an imaging technique composed of similar components to digital radiography (DR). Its advantages over DR: more precise diagnosis of the thoracic structure alterations, useful for confirming or ruling out suspected nodules, detection of patients at high risk of lung cancer and the monitoring of known lesions. The DTS creates coronal thoracic reconstructions with resolution superior to CT; however it is limited by its depth resolution and sensitivity to movement, occasionally hiding lesions adjacent to the pleura, diaphragm and mediastinum. The radiation dose of DTS and the cost is much lower than CT. More specific applications as well as the pulmonary nodules are under investigation, such as mycobacterial infection, cystic fibrosis and others. A basic understanding of the usefulness of thoracic DTS and its technique may be useful for the radiologist.

La Tomosíntesis digital (TSD) de tórax es una técnica de imagen compuesta por piezas similares que la radiografía digital (RD). Sus ventajas de sobre RD: diagnóstico más preciso de las alteraciones estructuras torácicas, útil para confirmar o descartar la sospecha de nódulos, detección de los pacientes de alto riesgo de cáncer pulmonar y seguimiento de lesiones conocidas. La TSD crea reconstrucciones coronales torácicas con resolución superior a TC. Sin embargo, está limitada por su resolución de profundidad y susceptibilidad al movimiento, ocultando ocasionalmente lesiones adyacentes a pleura, diafragma y mediastino. La dosis de radiación de TSD y el costo son más bajos que la TC. Más aplicaciones específicas además de los nódulos pulmonares están bajo investigación, como la infección por micobacterias, fibrosis quística y otras. Una comprensión básica de la utilidad de TSD torácica y su técnica puede ser útil para el radiólogo.

An organizational model to improve the robotic system among general surgeons.

INTRODUCTION: Robotic surgery has gained wide acceptance in recent years. However its development is slower and the lack of high level experience with this technique is an important limitation. This manuscript discusses some of the reasons of it and aims to describe the organizational system we have progressively established in our center in order to improve the development of Robotic program in our surgical area. METHODS: Some points may be required to improve the robotic program development in a general surgical department, including: a broad availability of robotic system in a surgical area; an ideal setting area with mainly oncological and hepato-biliary-pancreatic disease; the need of a mainly young team; a broad application of the robotic system in more general surgical fields; a high motivation on robotic use; a departmental and institutional economical effort. We have tried to achieve these goals before starting the robotic program in our department at October 2010. RESULTS: From October 2010 until November 2013 a total of 170 procedures have been performed, 92% of them for malignant diseases. Conversion rate and overall morbidity was 5% and 19%, respectively. CONCLUSIONS: The organizational model defined in our center is facilitating the constant and progressive development of the robotic program. A broad and flexible availability of the robotic system, a progressive increase of young surgeons joining this technology as well as the institutional and departmental economical effort are the points with which the robotic system may increase its development in a surgical department.

Revealing interference by continuous variable discordant states.

In general, a pair of uncorrelated Gaussian states mixed in a beam splitter (BS) produces a correlated state at the output. However, when the inputs are identical Gaussian states the output state is equal to the input, and no correlations appear, as the interference had not taken place. On the other hand, since physical phenomena do have observable effects, and the BS is there, a question arises on how to reveal the interference between the two beams. We prove theoretically and demonstrate experimentally that this is possible if at least one of the two beams is prepared in a discordant, i.e., Gaussian correlated, state with a third beam. We also apply the same technique to reveal the erasure of polarization information. Our experiment involves thermal states and the results show that Gaussian discordant states, even when they show a positive Glauber P-function, may be useful to achieve specific tasks.

Quantum light in coupled interferometers for quantum gravity tests.

In recent years quantum correlations have received a lot of attention as a key ingredient in advanced quantum metrology protocols. In this Letter we show that they provide even larger advantages when considering multiple-interferometer setups. In particular, we demonstrate that the use of quantum correlated light beams in coupled interferometers leads to substantial advantages with respect to classical light, up to a noise-free scenario for the ideal lossless case. On the one hand, our results prompt the possibility of testing quantum gravity in experimental configurations affordable in current quantum optics laboratories and strongly improve the precision in "larger size experiments" such as the Fermilab holometer; on the other hand, they pave the way for future applications to high precision measurements and quantum metrology.

Experimental realization of quantum illumination.

We present the first experimental realization of the quantum illumination protocol proposed by Lloyd [Science 321, 1463 (2008)] and S. Tan et al. [Phys. Rev. Lett. 101, 253601 (2008)], achieved in a simple feasible experimental scheme based on photon-number correlations. A main achievement of our result is the demonstration of a strong robustness of the quantum protocol to noise and losses that challenges some widespread wisdom about quantum technologies.

The hyperactive Sleeping Beauty transposase SB100X improves the genetic modification of T cells to express a chimeric antigen receptor.

Sleeping Beauty (SB3) transposon and transposase constitute a DNA plasmid system used for therapeutic human cell genetic engineering. Here we report a comparison of SB100X, a newly developed hyperactive SB transposase, to a previous generation SB11 transposase to achieve stable expression of a CD19-specific chimeric antigen receptor (CAR3) in primary human T cells. The electro-transfer of SB100X expressed from a DNA plasmid or as an introduced mRNA species had superior transposase activity in T cells based on the measurement of excision circles released after transposition and emergence of CAR expression on T cells selectively propagated upon CD19+ artificial antigen-presenting cells. Given that T cells modified with SB100X and SB11 integrate on average one copy of the CAR transposon in each T-cell genome, the improved transposition mediated by SB100X apparently leads to an augmented founder effect of electroporated T cells with durable integration of CAR. In aggregate, SB100X improves SB transposition in primary human T cells and can be titrated with an SB transposon plasmid to improve the generation of CD19-specific CAR+ T cells.

[Effect of an oral hyperproteic nutritional supplement in malnourished elderly patients in nursing homes]. / Efecto de un suplemento nutricional oral hiperproteico en pacientes desnutridos ubicados en residencias geriátricas.

INTRODUCTION: Nutritional problems develop complications in geriatric patients and increase their morbidity and mortality. Hyperproteic nutritional supplements are one of the options to improve nutritional deficiencies. OBJECTIVES: To assess the beneficial effect and tolerance of one hyperproteic nutritional supplement (Ensure Plus High Protein, Abbott Laboratories, S.A.) in malnourished subjects over 65 years. METHODS: Observational, prospective, open, multicenter study. We included malnourished subjects over 65 years living in nursing homes located in Spain. Malnutrition was considered as GNRI score < 92 or BMI < 19. Before inclusion, we obtained signed informed consent of patients or their relatives. All participants received Ensure Plus High Protein for 8 weeks. The primary endpoints were changes observed in weight, BMI and GNRI. RESULTS: We analyzed 255 evaluable patients valid for intention-to-treat (ITT) analysis and 243 for the per-protocol (PP) analysis; 69% (n = 172) were female and 31% (n = 77) male. The average protein amount administered was 51 g/day. At the end of the study, statistically significant differences (p < 0.001) were found in weight, BMI and GNRI when compared to baseline, both in the ITT and the PP analysis. The average weight increase was (mean +/- SE) 2.86 +/- 0.13 kg for PP analysis; 80% of participants (n = 202) achieved a weight gain > 1 kg and 96 patients (39.5% PP analysis) had a weight gain > 7%. CONCLUSIONS: The addition of a hyperproteic oral nutritional supplement contributes positively in improving the nutritional status of our study malnourished geriatric patients in terms of significant increase in body weight, BMI and GNRI.

Efecto de un suplemento nutricional oral hiperproteico en pacientes desnutridos ubicados en residencias geriátricas / Effect of an oral hyperproteic nutritional supplement in malnourished elderly patients in nursing homes

Introducción: Los problemas nutricionales complican la evolución de los pacientes geriátricos y aumentan su morbilidad y mortalidad. Los suplementos nutricionales hiperproteicos constituyen una de las maneras de mejorar la ingesta nutricional. Objetivos: Determinar el efecto beneficioso y la tolerancia de un suplemento nutricional hiperprotéico (Ensure Plus High Protein®, Abbott Laboratories, S.A.) en sujetos mayores de 65 años diagnosticados de desnutrición. Métodos: Estudio observacional, prospectivo, abierto y multicéntrico. Se incluyeron sujetos > 65 años diagnosticados de desnutrición, ubicados en 59 residencias geriátricas en España. Se consideró desnutrición una puntuación GNRI < 92 ó IMC < 19. Antes de la inclusión, se obtuvo el consentimiento informado firmado de los pacientes o sus familiares. Todos los participantes tomaron Ensure Plus High Protein® durante 8 semanas. Las variables principales de valoración fueron peso, IMC y GNRI. Resultados: Se analizaron 255 pacientes válidos para el análisis ITT y 243 para el análisis PP, 69% (n = 172) mujeres y 31% (n = 77) hombres. La cantidad de proteína media administrada fue 51 gr./día. Al final del estudio, los tres parámetros principales -peso, IMC y GNRI- presentaron diferencias estadísticamente significativas (p < 0,001) con respecto a la visita basal, tanto en el análisis ITT como en el análisis por protocolo. El incremento de peso medio fue de (media ± EE) 2,86 ± 0,13 kg para el análisis PP. El 80% de los participantes (n = 202) consiguió un incremento de peso > 1 kg y 96 pacientes (39,5% análisis PP) obtuvieron una ganancia ponderal > 7%. Conclusiones: La adición de un suplemento nutricional oral hiperproteico contribuye favorablemente en la mejoría del estado nutricional de los pacientes geriátricos malnutridos en estudio en términos de incremento significativo del peso corporal, IMC y GNRI (AU)

Introduction: Nutritional problems develop complications in geriatric patients and increase their morbidity and mortality. Hyperproteic nutritional supplements are one of the options to improve nutritional deficiencies. Objectives: To assess the beneficial effect and tolerance of one hyperproteic nutritional supplement (Ensure Plus High Protein®, Abbott Laboratories, S.A.) in malnourished subjects over 65 years. Methods: Observational, prospective, open, multicenter study. We included malnourished subjects over 65 years living in nursing homes located in Spain. Malnutrition was considered as GNRI score < 92 or BMI < 19. Before inclusion, we obtained signed informed consent of patients or their relatives. All participants received Ensure Plus High Protein® for 8 weeks. The primary endpoints were changes observed in weight, BMI and GNRI. Results: We analyzed 255 evaluable patients valid for intention-to-treat (ITT) analysis and 243 for the per-protocol (PP) analysis; 69% (n = 172) were female and 31% (n = 77) male. The average protein amount administered was 51 g/day. At the end of the study, statistically significant differences (p < 0.001) were found in weight, BMI and GNRI when compared to baseline, both in the ITT and the PP analysis. The average weight increase was (mean ± SE) 2.86 ± 0.13 kg for PP analysis; 80% of participants (n = 202) achieved a weight gain > 1 kg and 96 patients (39.5% PP analysis) had a weight gain > 7%. Conclusions: The addition of a hyperproteic oral nutritional supplement contributes positively in improving the nutritional status of our study malnourished geriatric patients in terms of significant increase in body weight, BMI and GNRI (AU)

Full characterization of Gaussian bipartite entangled states by a single homodyne detector.

We present the full experimental reconstruction of Gaussian entangled states generated by a type-II optical parametric oscillator below threshold. Our scheme provides the entire covariance matrix using a single homodyne detector and allows for the complete characterization of bipartite Gaussian states, including the evaluation of purity, entanglement, and nonclassical photon correlations, without a priori assumptions on the state under investigation. Our results show that single homodyne schemes are convenient and robust setups for the full characterization of optical parametric oscillator signals and represent a tool for quantum technology based on continuous variable entanglement.

Estimate of mercury and methyl mercury intake associated with fish consumption from Sagua la Grande River, Cuba.

This paper provides an estimate of the weekly intake of total mercury (THg) and methyl mercury (MeHg) from consumption of fish from the Sagua la Grande River, Villa Clara, Cuba, by determining the THg levels in different fish species. The levels varied between 0.143 and 0.484 µ g g(-1) on a fresh weight basis. None of the analysed fish was found to have levels above the national and international regulatory levels, although THg levels over 0.2 µ g g(-1), the threshold concentration established by the World Health Organization (WHO) for the consumption by vulnerable population groups, were found in 75% of samples. The MeHg level was found to be 84% of the THg content. A Food Frequency Survey was given to 127 townspeople to estimate river fish consumption. The weekly intake of MeHg was found to be greater than the value established by the provisional tolerable weekly intake (PTWI) in 50% of children, in 80% of pregnant women, and in 75% of women in childbearing age. These weekly intakes can represent an important risk to the population's health, especially for vulnerable groups.

Starting a new program of split liver transplantation after a low learning curve: a reality in centers with large experience in liver surgery and whole liver transplantation.

BACKGROUND/AIMS: Split liver transplantation (SLT) is nowadays, considered an adequate surgical solution to expand the grafts from the existing pool of cadaveric donors. METHODOLOGY: A total of 897 liver transplantations were performed between 1986 and 2002; 20 were SLTs (2.3%). A 30% were children. RESULTS: Mean follow up of 15.15 months +/- 13.85. Median age was 42.27 +/- 25.65 yrs. Median recipient weight was 52.29 +/- 20.87 Kg. Mean donor weight was 76.1 +/- 13.11. The majority was "in situ" SLT (65%). There was no primary graft dysfunction. Two patients developed biliary complications (none in situ SLT). Early HAT occurred in 2 patients and delayed HAT in one. Four patients were retransplanted but none were performed because of primary graft dysfunction. Five patients died in the hospital. Fifteen patients (75%) survived the postoperative period and 3 patients died during follow-up. Mean patient survival time was 42 months (95% CI: 31-52). Actuarial patient survival was 93.3%, 84.4%, 84.4% at 6 months, 1 year and 3 years. Mean graft survival was 36 months (95% CI: 25-48). Actuarial graft survival was 87%, 72%, 72% at 6, 12, 36 months. Univariate analysis of risk factors for graft loss showed that the type of splitting technique (p=0.019), and the UNOS (1 and 2a) status of the recipient (p=0.001) were significantly associated with graft loss. CONCLUSIONS: In the context of large volume full cadaveric liver transplantation, split liver can provide adequate results (even after a short learning curve) mainly in elective cases and with the in situ technique.