Synchronous Hartmann reversal and incisional hernia repair is associated with higher complication rate compared to a staged procedure.

Post operative ventral hernias are common following Hartmann's procedure. There is a debate whether hernia repair is safe when performed concomitantly with colostomy closure. In this study we aimed to evaluate the outcomes of synchronous Hartmann reversal (HR) with a hernia repair, compared to a staged procedure. A retrospective multi-center study was conducted, including all patients who underwent Hartmann's procedure from January 2004 to July 2017 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Two hundred and seventy-four patients underwent colostomy reversal following Hartmann's procedure. In 107 patients (39%) a concomitant ventral hernia was reported during the Hartmann's reversal. Out of this cohort, 62 patients (58%) underwent hernia repair during follow-up. Thirty two patients (52%) underwent a synchronous hernia repair and 30 patients (48%) underwent hernia repair as a separate procedure. Post operative complication rate was significantly higher in the colostomy reversal with synchronous hernia repair group when compared to HR alone group (53% vs. 20%; p < 0.01; OR 4.5). In addition, severe complication rate (Clavien-Dindo score ≥ 3) was higher in the synchronous hernia repair group (25% vs. 7%). A tendency for higher hernia recurrence rate was noted in the synchronous group (56% vs. 40%). Median follow up time was 2.53 years (range 1-13.3 years). Synchronous colostomy closure and ventral hernia repair following Hartmann's procedure carries a significant risk for post operative complications, indicating that a staged procedure might be preferable.

Dissipation in noisy chemical networks: The role of deficiency.

We study the effect of intrinsic noise on the thermodynamic balance of complex chemical networks subtending cellular metabolism and gene regulation. A topological network property called deficiency, known to determine the possibility of complex behavior such as multistability and oscillations, is shown to also characterize the entropic balance. In particular, when deficiency is zero the average stochastic dissipation rate equals that of the corresponding deterministic model, where correlations are disregarded. In fact, dissipation can be reduced by the effect of noise, as occurs in a toy model of metabolism that we employ to illustrate our findings. This phenomenon highlights that there is a close interplay between deficiency and the activation of new dissipative pathways at low molecule numbers.

Linfoma no hodgkin primario óseo en niños / Primary non-hodgkin lymphoma of bone in children

Objetivo: Conocer las características clínicas, radiológicas y el resultado del tratamiento de los casos de Linfoma No Hodgkin primario óseo que se presentaron en el Departamento de Pediatría Oncológica del Instituto Nacional de Enfermedades Neoplásicas (INEN). Métodos: Revisión retrospectiva de las historias clínicas de pacientes menores de 14 años encontradas en el archivo de estadística del INEN desde el 1ro de Enero de 1987 al 31 de Diciembre del 2008. La evaluación retrospectiva incluyó la recopilación de las estadísticas demográficas, clínicas, radiográficas, tratamiento y seguimiento de datos. Se usó la hoja de cálculo MS Excel para los análisis. Resultados: Se identificaron 509 casos de linfoma no Hodgkin de los cuales 5 casos fueron primario óseo. Los pacientes incluyeron 3 niños y 2 niñas con una edad media de 10.2 años. En la mayoría de los pacientes el hallazgo clínico principal fue dolor óseo. Tres niños tenían una lesión ósea solitaria y dos múltiples lesiones óseas. La tibia fue el hueso más frecuentemente afectado. Los cuatro pacientes que sobrevivieron fueron seguidos por un rango de 18 meses a 17 años. Un paciente falleció de shock séptico como complicación relacionada al tratamiento. El tiempo medio desde el diagnóstico hasta el fallecimiento fue de 1 año. Los cinco pacientes recibieron quimioterapia, un paciente recibió quimioterapia y luego cirugía. Conclusiones: La enfermedad localizada y la histología de células grandes se relacionan con un buen pronóstico. La imagen radiológica no permite un diagnóstico sin confirmación histológica. Utilizar criterios clínicos, radiológicos, de microscopía de rutina y un panel incompleto de marcadores de inmunohistoquímica, contribuye al diagnóstico erróneo de estas neoplasias. La inmunohistoquímica es definitiva para un diagnóstico y tratamiento adecuados. Un compromiso óseo clínico y radiológico similar puede presentarse en diferentes patologías tanto benignas como malignas en niños.

Objective: To determine the frequency of primary bone Non Hodgkin´s Lymphoma in children and to know the clinical features, radiological findings and treatment of cases in the Pediatric Oncology Department of the Instituto Nacional de Enfermedades Neoplasicas in Lima û Perú. Design: Review of all patients under age 14 diagnosed with primary bone Non Hodgkin´s Lymphoma between January 1, 1987 and December 31, 2008 at the Instituto Nacional de Enfermedades Neoplasicas in Lima û Peru. 509 cases of Non Hodgkin Lymphoma were identified during the study period, 5 cases were primary bone. We used the MS Excel spreadsheet for analysis. Results: The patients included three boys and two girls with a mean age of 10.2 years. In most patients the main clinical finding was bone pain. Three children had a solitary bone lesion and two multiple bone lesions. The tibia was most frequently involved. The four surviving patients were followed for a range of 18 months to 17 years. One patient died of septic shock as a complication related to treatment. The average time from diagnosis to death was 1 year. The five patients received chemotherapy, one patient received chemotherapy and then surgery. Conclusions: It appears that localized disease and large cell histology are associated with a good prognosis. The radiographic image does not allow a diagnosis without histological confirmation. Using clinical radiological, histological routine microscopy criteria and an unbalanced panel of immunohistochemical marker contribute to the misdiagnosis of these tumors. Immunohistochemistry is definitive for diagnosis and treatment. A clinical and radiological bone involvement can occur in various benign and malignant diseases in children.

Lesiones orales como única manifestación de histiocitosis de células de Langerhans / Oral lesions as a presenting sign of Langerhans cell histiocytosis

La histiocitosis de células de Langerhans es una entidad de etiología no bien establecida, antes conocida como Histiocitosis X. Engloba la triada de enfermedades: granuloma eosinófilo, la enfermedad de Hand-Schüller-Christian y la enfermedad de Letterer-Siwe. Su comportamiento clínico va desde una forma localizada hasta formas generalizadas afectando huesos, hígado, bazo, médula ósea y piel, entre otros. El presente reporte describe el caso de una niña de 3 años de edad que presenta nodulaciones en paladar duro, hiperplasia gingival en ambos maxilares, movilidad dentaria, gingivorragia y halitosis. A la cual le realizan examen de imágenes observando lesiones líticas, alteración de la densidad ósea, dientes flotantes, ausencia de gérmenes dentarios. No hubo evidencia de enfermedad en otros huesos, órganos o tejidos. La biopsia confirma el diagnóstico de Histiocitosis de células de Langerhans, iniciando tratamiento con quimioterapia y conjuntamente odontológico. Actualmente la niña ha completado su tratamiento oncológico con respuesta completa y es portadora de prótesis parcial removible en ambos maxilares.

Langerhans Cell Histiocytocis (LCH) is an entity of uncertain etiology, known previously as Histiocytosis X. It includes the following diseases: eosinophilic granuloma, Hand-Schuller-Christian disease and Letterer-Siwe disease. The clinical behavior goes from a localized lesion to a generalized involvement affecting bones, liver, spleen, bone narrow and skin. Ths report describes the case of a 3-year-old girl who presented with nodulesin the heart palate, gum hyperplasia of both maxilary bones, loose teeth, gum bleeding and halitosis. X-ray exams revealed lytic lesions, abnormal bone density, floating teeth, absence of dental germs. There was no evidence of disease in other bones, organs or tissues. A surgical biopsy was performed and confirmed the diagnosis of LCH. Chemotherapy treatment was begun as well as dental care. The patient has completed chemotherapy at this time with a complete response. She is wearing a partial removable prosthesis for both maxilary bones.

Germ cell tumors in children: gonadal and extragonadal.

Sixty-three pediatric patients with germ cell tumors are presented with details of symptoms, histological findings, staging, serological markers, treatment, and response to therapy. The primary sites were: ovarian 32, testicular 17, presacral 7, mediastinal 3, intraabdominal 2, vaginal 1, and right inguinal canal 1. These patients were treated with T2 (sequential use of dactinomycin, doxorubicin, vincristine, and cyclophosphamide, with or without radiation), T6 (combination chemotherapy with cyclophosphamide, bleomycin, dactinomycin, doxorubicin, methotrexate, vincristine), or VAB treatment protocols (velban, dactinomycin, bleomycin, cisplatin). The cure rate for stage I ovarian and testicular germ cell tumors was 100%; for stage III, all primary sites, 82% and for stage IV, all primary sites, 75%. Histology was prognostic in ovarian tumors of the immature malignant teratoma type; the neural type immature teratoma, grades II and III, had the worst prognosis. Initial debulking surgery in combination with chemotherapy and radiation plays an important role in germ cell tumors. Stages II, III, and IV germ cell tumors require aggressive treatment with surgery, radiation, and chemotherapy. For stage I patients, with primary ovarian malignant tumor, cure with surgery alone can be achieved in 50% of the cases and in testicular tumors in about 70% of the patients. For those with stage I and elevated serological markers, it is feasible to follow these markers and give no treatment until there is evidence of persistent elevation or a rise in titers after an initial fall. In those without elevated serological markers, one should take into consideration the size of the tumor and the histological type before taking the "wait and see" approach. These stage I tumors are highly curable when they first present but, if allowed to recur, chemotherapy may not offer the patient such a favorable response and cure rate.

The dimensional structure of medical students' perceptions of diseases.

First- and second-year medical students rated 35 diseases (e.g., cancer, heart attack, herpes, schizophrenia, alcoholism) on nine different rating scales (e.g., prognosis, ease of management). In order to uncover the underlying dimensional structure, mean ratings were subjected to multidimensional scaling analyses in which both diseases and rating scales were placed in the same configuration. The results indicated that a two-dimensional solution, accounting for 97% of the variance, was most appropriate. The first dimension distinguishes between diseases that appear to be more physiological in nature and those that have some psychological involvement as well. The second dimension seems most related to fear, seriousness, prognosis, patient desirability, and ease of management.

Cancer Opinionnaire. Medical students' attitudes toward psychosocial cancer care.

A questionnaire assessing attitudes toward psychosocial cancer care (the Cancer Opinionnaire) was constructed. Factor analysis revealed five factors: outcome expectations; candor; interest in treating cancer; psychosocial concerns: role of the physician; and psychosocial concerns: importance to the patient. Reliabilities ranged from 0.68 to 0.82. A multivariate analysis of variance indicated that second-year students, who had been exposed to a required first-year course stressing biopsychosocial concerns of medical care, expressed more positive attitudes than did entering first-year students. Additionally, female medical students expressed more positive attitudes than did male students. Addressing biopsychosocial concerns in the beginning of medical education may help establish a more open and fertile ground upon which later training will be received.

Canine transmissible venereal sarcoma: tumor cell and infiltrating leukocyte ultrastructure at different growth stages.

Electron microscopic study of the canine transmissible venereal sarcoma (N = 26) at different stages of growth showed that tumors in a progressive phase of growth (N = 12) were comprised mostly of large, round cells with prominent nuclei and nucleoli, a few spindle-shaped cells and collagen fibers, focal areas of necrosis, and lymphocyte infiltrates. Regressing tumors (N = 9) had the fewest viable round cells, greater numbers of infiltrating leukocytes, and were comprised almost entirely of connective tissue (collagen bundles) in the latest stages of regression. The infiltrating leukocytes consisted primarily of lymphocytes, some eosinophils, and neutrophils, but very few macrophages. Round-cell nuclei contained numerous perichromatin and interchromatin granules. Their cytoplasm often had annulate lamellae complexes and large deposits of glycogen. Loosely packed tumor cells had extensive proliferation and elongation of cytoplasmic extensions (filopodia). Evidence for cell-mediated tumor cell lysis was demonstrated by degenerative changes in tumor cells which were closely apposed to lymphocytes. Spindle-shaped cells in regressing tumors had intravacuolar collagen fragments, suggesting a possible degradative capacity by these cells.

Leukemic hypopyon.

A seven-year-old girl was successfully treated for acute lymphoblastic leukemia. Despite clinical remission she developed a monocular hypopyon which was treated successfully with topical and subtenons steroids. When the hypopyon reappeared, a diagnostic paracentesis revealed leukemic cells and a normal aqueous lactate dehydrogenase. Leukemic ocular infiltration may clinically mimic both neoplastic and inflammatory ocular conditions. The combination of paracentesis and lactate dehydrogenase assay greatly aid in the correct diagnosis.

Improved prognosis in children with intra-abdominal non-Hodgkin's lymphoma following LSA2L2 protocol chemotherapy.

Thirty-five consecutive, previously untreated patients with intra-abdominal non-Hodgkin's lymphoma (IANHL), seen between January 1971 and June 1978, were entered on the LSA2-L2 protocol. Six patients had Stage II disease, 23 Stage III and six Stage IV. The prevalent histologic types were diffuse lymphocytic poorly differentiated (13 patients) and diffuse undifferentiated (13 patients) followed by diffuse histiocytic (5 patients) and diffuse lymphoblastic (2 patients). All patients received LSA2-L2 protocol chemotherapy. Three of 4 patients with gross residual disease following initial surgery, who were seen prior to 1974, received radiation therapy during induction chemotherapy; there were no survivors among these 3 patients. Our treatment plan was revised in 1974 to include a "second-look" laparotomy during the third week of induction chemotherapy for all patients with gross residual intra-abdominal disease following their initial surgery. The disease-free actuarial survival for the total group of 35 patients is 72%. Fifteen of the 26 surviving patients are off therapy and have shown no evidence of recurrence or metastases (median observation time 26 + months). Fifteen of 26 patients seen after 1973 underwent the second laparotomy and only two were found to have residual disease. The LSA2-L2 protocol has significantly improved the disease-free survival rate of children with IANHL, even with widespread intra-abdominal and extra-abdominal disease at diagnosis. Further, the "second-look" laparotomy in patients with large unresectable disease at presentation has proved a useful method of unequivocal evaluation of response, thus eliminating unnecessary extensive abdominal irradiation in many of these children.

Evaluation of a psychiatric clerkship by videotape.

The authors used a videotape-based objective examination ingeneral psychiatry to assess the clinical competence of medical students who had completed their third-year clerkship. The test has been shown to be a reliable, valid measure of clinical competence. Subjective faculty grading related positively to test scores. Students on one ward had significantly lower overall test scores, with particularly low scores on clinical judgement questions. However, faculty grades for these students were not significantly different. This suggests that the faculty was unable to assess the relative efficacy of its own teaching. The test can provide objective assessment of student clinical competence and is a means of program evaluation.