Computational Model Based on Optical Coherence Tomography (OCT) Skin Scanning to Identify and Quantify Acute Radiation Dermatitis (ARD): A Prospective Diagnostic Study.

BACKGROUND: acute radiation dermatitis (ARD) is the most widely reported radiotherapy-induced adverse event. Currently, there is no objective or reliable method to measure ARD. OBJECTIVE: our main objective was to identify and quantify the effects of radiotherapy with a computational model using optical coherence tomography (OCT) skin scanning. Secondary objectives included determining the ARD impact of different radiotherapeutic schemes and adjuvant topical therapies. METHODS: we conducted a prospective, single-center case series study in a tertiary referral center of patients with breast cancer who were eligible for whole breast radiotherapy (WBRT). RESULTS: a total of 39 women were included and distributed according to the radiotherapeutic schemes (15, 20, and 25 fractions). A computational model was designed to quantitatively analyze OCT findings. After radiotherapy, OCT scanning was more sensitive revealing vascularization changes in 84.6% of the patients (vs 69.2% of the patients with ARD by clinical examination). OCT quantified an increased vascularization at the end of WBRT (P < .05) and a decrease after 3 months (P = .032). Erythematous skin changes by OCT were more pronounced in the 25-fraction regime. CONCLUSION: an OCT computational model allowed for the identification and quantification of vascularization changes on irradiated skin, even in the absence of clinical ARD. This may allow the design of standardized protocols for ARD beyond the skin color of the patients involved.

Computational Model Based on Optical Coherence Tomography (OCT) Skin Scanning to Identify and Quantify Acute Radiation Dermatitis (ARD): A Prospective Diagnostic Study.

BACKGROUND: Acute radiation dermatitis (ARD) is the most widely reported radiotherapy-induced adverse event. Currently, there is no objective or reliable method to measure ARD. OBJECTIVE: Our main objective was to identify and quantify the effects of radiotherapy with a computational model using optical coherence tomography (OCT) skin scanning. Secondary objectives included determining the ARD impact of different radiotherapeutic schemes and adjuvant topical therapies. METHODS: We conducted a prospective, single-center case series study in a tertiary referral center of patients with breast cancer who were eligible for whole breast radiotherapy (WBRT). RESULTS: A total of 39 women were included and distributed according to the radiotherapeutic schemes (15, 20, and 25 fractions). A computational model was designed to quantitatively analyze OCT findings. After radiotherapy, OCT scanning was more sensitive revealing vascularization changes in 84.6% of the patients (vs 69.2% of the patients with ARD by clinical examination). OCT quantified an increased vascularization at the end of WBRT (P<.05) and a decrease after 3 months (P=.032). Erythematous skin changes by OCT were more pronounced in the 25-fraction regime. CONCLUSION: An OCT computational model allowed for the identification and quantification of vascularization changes on irradiated skin, even in the absence of clinical ARD. This may allow the design of standardized protocols for ARD beyond the skin color of the patients involved.

Development and validation of a minimally invasive and image-guided tape stripping method to sample atopic skin in children.

BACKGROUND: Molecular skin profiling techniques, typically performed on skin samples taken by punch biopsy, have enhanced the understanding of the pathophysiology of atopic dermatitis (AD), thereby enabling the development of novel targeted therapeutics. However, punch biopsies are not always feasible or desirable, and novel minimally invasive methods such as skin tape stripping have been developed. AIM: To develop, optimize and validate a novel tape stripping method guided by noninvasive in vivo skin imaging to sample atopic skin in children. METHODS: Skin tape stripping-based procedures were compared and optimized using data from 30 healthy controls (HCs: 5 adults, 25 children) and 39 atopic children. Evaluations were guided by high-resolution photography, reflectance confocal microscopy, optical coherence tomography and transepidermal water loss measurements. We assessed and compared adverse events (AEs), the time needed to perform the sampling and the cDNA levels obtained from the tapes. RESULTS: Tape stripping methods based on previously described protocols resulted in erosions in all participants and required a median time of 65 min to perform (range 60-70 min), but provided good cDNA yield. Shorter durations appeared less invasive but provided lower cDNA yield. The final optimized tape stripping protocol, using 11 tapes of 22 mm in diameter, each applied twice for 5 s with 90° rotation, did not produce significant AEs, was completed within a median time of 7 min (range 5-15 min) and provided good cDNA yield both in HCs and atopic children. CONCLUSION: Our minimally invasive method is safe and reliable, and provides reproducible acquisition of cDNA in atopic children. In addition, it enables rapid sample collection, a crucial factor in clinical practice.

Compartments of the crural fascia: clinically relevant ultrasound, anatomical and histological findings.

PURPOSE: Compartment syndrome is a surgical emergency that can occur in any part of the body and can cause cell necrosis when maintained over time. The resulting defects can affect the nerves, muscle cells, bone tissue, and other connective tissues inside the compartment, and fasciotomy has to be performed. The anatomical and histological characteristics of the leg make acute, chronic, and exertional compartment syndrome more likely in this limb. For these reasons, knowledge of the ultrasound, anatomical, and histological features of the crural fascia can help in the treatment of leg compartment syndrome. METHODS: Twenty-one cryopreserved lower limbs from adult cadavers and from one 29-week-old fetus were obtained from the dissection room. They were examined by ultrasound and a subsequent anatomical dissection and microscopy to study the crural fascia and its relationship with the different muscles. Anthropometric measurements were taken of the distances from the head of the fibula and lateral malleolus to the origin of the tibialis anterior muscle in the crural fascia, the exit of the superficial fibular nerve, and the fascia covering the deep posterior muscles of the leg. RESULTS: The crural fascia has very important clinical relationships, which can be identified by ultrasound, as the origin of the tibialis anterior muscle at 16.25 cm from the head of the fibula and the exit of the superficial fibular nerve that crosses this fascia at 21.25 cm from the head of the fibula. Furthermore, the presence of a septum that fixes the deep posterior muscles of the leg and the vessels and nerve can be seen by ultrasound and can explain the possible development of a posterior compartmental syndrome of the leg. Awareness of these features will help to keep these structures safe during the surgical treatment of compartment syndrome. CONCLUSION: The ultrasound study allows identification of anatomical structures in the leg and, thus, avoids damage to them during surgery for compartmental syndromes.

Non-invasive clinical and microscopic evaluation of the response to treatment with clobetasol cream vs. calcipotriol/betamethasone dipropionate foam in mild to moderate plaque psoriasis: an investigator-initiated, phase IV, unicentric, open, randomized clinical trial.

BACKGROUND: Treatment response for psoriasis is typically evaluated using clinical scores. However, patients can relapse after clinical clearance, suggesting persistent inflammation. Dermoscopy, reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) can non-invasively improve treatment response assessment. OBJECTIVES: To compare the clinical and non-invasive microscopic features in a psoriatic target lesion treated with clobetasol cream or calcipotriol/betamethasone dipropionate foam (Cal/BD foam). METHODS: Prospective, unicentric, open, randomized clinical trial comparing clinical data [total clinical score (TCS)] and microscopic data (dermoscopy, RCM and OCT) in psoriasis patients treated with clobetasol or Cal/BD foam. RESULTS: We included 36 adult patients (22 men). At week 4, more patients treated with Cal/BD foam achieved TCS ≤1 than with clobetasol (63.2% vs. 18.8%, P = 0.016). Treatment satisfaction was higher with Cal/BD foam (P < 0.03). Microscopically, Cal/BD foam induced more reduction in epidermal thickness at week 4 (P < 0.049). Dilated horizontal blood vessels were more common with clobetasol than with Cal/BD foam at week 8 (69.2% vs. 31.2%, P = 0.159). If epidermal hyperplasia was noted at baseline, the response was poorer with clobetasol (P = 0.029). LIMITATIONS: Small sample size, open study, imaging sampling bias. CONCLUSION: Cal/BD foam is more effective than clobetasol, has better patient satisfaction and induces greater reduction in the hyperkeratosis/acanthosis, regardless of baseline epidermal hyperplasia.

Pheochromocytoma: A three-decade clinical experience in a multicenter study. / Feocromocitoma: experiencia clínica de tres décadas en un estudio multicéntrico.

OBJECTIVE: To analyze the clinical and analytical features, diagnostic tests, therapies, and outcomes of pheochromocytoma (PCC). DESIGN AND METHODS: A multicenter retrospective study in surgically treated patients with PCC followed in 3 Spanish tertiary referral hospitals. RESULTS: A total of 106 patients (61 [57.5%] women, mean age 52.3 ± 14.8 years) were evaluated. At diagnosis, PCC was symptomatic in 62% and sporadic in 83%. Patients with familial PCC were significantly younger than those with sporadic disease (40.8 ± 14.2 years vs. 54.5 ± 13.9 years, p<.001). Familial PCCs were more frequently associated with MEN2A (n=8). Levels of 24-h urinary fractionated metanephrines were positively related to tumor size. The maximum tumor diameter was 4.3cm (3-6cm); 27.7% of the patients had tumors ≥6cm. Incidental PCCs were significantly smaller than symptomatic PCCs (3.4cm [2.4-5.0cm] vs. 5.6cm [4.0-7.0cm], p<.001). Scintigraphy by 123I-metaiodobenzylguanidine showed a high sensitivity (81.9%). Preoperative alpha blockade with phenoxybenzamine was used in 93.6% and doxazosin in the rest. Laparoscopic surgery was used in 2/3 of the patients, with a low conversion (1.9%) to open surgery. Perioperative complications appeared in approximately 20% of patients, mainly hypertensive crisis (9.4%). Recurrent disease appeared in 10%, and malignant PCC was uncommon (6.3%). CONCLUSIONS: PCCs surgically treated in Spain are usually large, symptomatic, and sporadic tumors diagnosed around the sixth decade of life. Hereditary PCC is usually associated with MEN2A. The main type of surgical technique used is laparoscopic surgery, and the prevalence of metastatic PCC is low.

Clinical features, diagnosis and therapy of pituicytoma: an update.

BACKGROUND: Pituicytomas (PTs) are extremely rare, low-grade glial tumors closely related to the neurohypophyseal axis. Definite conclusions concerning the optimal diagnostic and therapeutic approach to these neoplasms are lacking to date, as most of this information has been presented as case reports. METHODS: Retrospective review of case reports published in the scientific literature to date, including a new illustrative example treated in our department. RESULTS: 116 cases were collected. PTs had a higher prevalence in the fifth and sixth decades of life, with a slight male predominance. Main symptoms, which tended to be progressive, included visual field defects and pituitary-hypothalamic dysfunction. Radiologically, PTs were found anywhere along the hypothalamic-pituitary axis mimicking other, more frequent tumors growing in this anatomical region. Surgical treatment included both transcranial or transsphenoidal approaches, and resulted in gross total resection and morbidity rates of 46.8 and 59%, respectively; the latter essentially consisted in anterior and posterior pituitary dysfunction, with limited impact on daily quality of life. CONCLUSIONS: Due to both low frequency and the absence of pathognomonic clinical and/or radiological features, formulating a suspicion diagnosis of PT represents a considerable challenge even for experienced professionals. The indication for treatment should be made on an individual basis, but it is inescapable in the presence of a visual field defect. The surgical approach has to be tailored according to the topography of the tumor and preoperative symptoms; the greatest challenges in accomplishing a gross total removal are represented by the degree of adherence and vascularization of the PT.

[Experience in the conservative treatment of renal trauma]. / Experiencia en el tratamiento conservador del traumatismo renal.

OBJECTIVE: The management of renal trauma has been changing in recent years so that nowadays, even in high grades, an initial conservative treatment is advocated. The aim of this work is to review the presentation, initial attitude and evolution of the renal traumas treated in our institution. MATERIAL AND METHODS: Retrospective review of patients with renal trauma treated at our institution in the last 10 years. Epidemiological variables, production mechanism, pediatric trauma index (PTI), treatment and evolution were analyzed. RESULTS: We studied 26 patients, 18 men (69.3%). The most frequent mechanism was the direct hit in 11 patients (42.31%). The most frequently side affected was the right one in 14 patients (53.85%). The grade III traumatism according to American Association for the surgery of Trauma (AAST) was the most repeated, 11 patients (42.31%). Nine patients (44.55%) presented concomitant injuries in other solid organs. In 24 patients (92.30%) the initial treatment was conservative with supportive measures. One patient presented with hemodynamic instability and an urgent intervention was conducted, performing a supraselective embolization with immediate control of the active bleeding. In another patient, a double J catheter was placed due to disruption of the excretory tract. Of the patients treated conservatively initially, only one patient (4.1%) required secondary surgical maneuvers due to a complication. CONCLUSIONS: In patients with renal trauma, non-surgical treatment is safe and effective. In case of hemodynamic instability or complication, interventional radiological techniques have been demonstrated to be safe and effective in the pediatric population.

OBJETIVO: El manejo del traumatismo renal ha ido variando en los últimos años de modo que en la actualidad, incluso en los grados altos, se aboga por un tratamiento inicial conservador. El objetivo de este trabajo es revisar la presentación, actitud inicial y evolución de los traumatismos renales atendidos en nuestra institución. MATERIAL Y METODOS: Revisión retrospectiva de pacientes con traumatismo renal atendidos en los últimos 10 años. Se analizaron las variables epidemiológicas, mecanismo de producción, índice de trauma pediátrico (ITP), tratamiento y evolución. RESULTADOS: Se estudiaron 26 pacientes, 18 varones (69,23%). La causa más frecuente fue el golpe directo en 11 pacientes (42,31%). El lado más frecuentemente afectado fue el derecho en 14 pacientes (53,85%). El traumatismo grado III según la American Association for the Surgery of Trauma (AAST) fue el más común, 11 pacientes (42,31%). Nueve pacientes (44,55%) presentaron lesiones concomitantes en otros órganos sólidos. En 24 pacientes (92,30%) el tratamiento inicial fue conservador con medidas de soporte. Un paciente se presentó con inestabilidad hemodinámica y se intervino de forma urgente realizándose embolización supraselectiva con control inmediato del sangrado activo. En otro paciente se colocó un catéter doble J por disrupción de la vía excretora. De los pacientes tratados de manera conservadora inicialmente solo 1 paciente (4,1%) requirió maniobras quirúrgicas secundarias debido a una complicación. CONCLUSIONES: En pacientes con traumatismo renal el tratamiento no quirúrgico es seguro y eficaz. En caso de inestabilidad hemodinámica o complicación, las técnicas radiológicas intervencionistas han demostrado ser seguras y efectivas en la edad pediátrica.

Straight and tilted implants for supporting screw-retained full-arch dental prostheses in atrophic maxillae: A 2-year prospective study.

BACKGROUND: To evaluate, over a 2-year period, the treatment outcomes for maxillary full-arch fixed dental prostheses (FDPs) supported by a combination of both tilted and axially-placed implants and to compare the marginal bone loss (MBL) and implant survival rates (SR) between tilted and axial implants. MATERIAL AND METHODS: A retrospective study has been carried out. Thirty-two patients (16 males and 16 females) treated with maxillary full-arch FDPs were included in this retrospective study. A total of 187 implants were inserted to rehabilitate the fully edentulous maxillary arches: 36% of them were tilted (T group, n = 68) and the remaining 64% were axially placed (A group, n = 119). From the total, 28% of the implants (n=53) were immediately loaded with screw-retained provisional acrylic restorations, whereas 72% underwent conventional delayed prosthetic loading 6 months post-operatively. Definitive restorations were hybrid implant prostheses (metal framework covered with high-density acrylic resin) and metal-ceramic screw-retained implant prostheses, and were placed 6 months after surgery. Such definitive restorations were checked for proper function and aesthetics every three months for two years. Peri-implant marginal bone levels were assessed by digital radiographs immediately after surgery and MBL was assessed at definitive implant loading (baseline) and 2 years afterwards. RESULTS: The 2-year implant SR were 100% for axially placed implants and 98.5% for tilted implants. No significant differences were found amongst the A and T implant groups. Marginal bone loss measured at 2 years after definitive prosthetic loading was of -0.73 ± 0.72 mm (maximum MBL of 1.43 mm) for axially positioned implants vs. -0.51 ± 0.92 mm for tilted implants (maximum bone 1.45 mm). Differences in MBL were statistically significant when comparing immediately and delayed loaded implants. CONCLUSIONS: Based on the results of this retrospective clinical study, full-arch fixed prostheses supported by a combination of both tilted and axially placed implants may be considered a predictable and viable treatment modality for the prosthetic rehabilitation of the completely edentulous maxilla.

[Nephroblastoma. Long-term experience in the multidisciplinary approach]. / Nefroblastoma. Experiencia a largo plazo en el abordaje multidisciplinario.

OBJECTIVES: Main objective: to perform a descriptive study of patients with nephroblastoma, diagnostic tests, medical and surgical treatment. Secondary objective: to evaluate the rate of relapse and 5-year survival and risk factors for relapse and death. MATERIALS AND METHODS: Retrospective study of patients with nephroblastoma treated according to the protocol of the SIOP-2001. Demographic variables, comorbidities and associated syndromes were collected. Other data were tumor location, size, extent and stage. The relapse rate and the development of other secondary tumors as well as the long-term survival were also studied. RESULTS: We collected 33 patients with nephroblastoma. A biopsy was performed in 7 patients (21.2%). The Kaplan-Meir curve for event-free survival (tumor recurrence) was 84% with a 95% CI = [0.73-0.98] and the Kaplan-Meier overall survival curve was 0.93 95% CI [0.85-1]. Recurrence occurred in all patients before the first year. CONCLUSIONS: Nephroblastoma is a tumor with a favorable prognosis. The unfavorable histology as well as advanced stages are factors of a poor prognosis. The follow-up must be exhaustive during the first year after the diagnosis.

OBJETIVOS: Objetivo principal: realizar un estudio descriptivo de los pacientes con nefroblastoma, las pruebas diagnósticas, el tratamiento médico y la actitud quirúrgica. Objetivo secundario: valorar la tasa de recidiva y de supervivencia a 5 años y los factores de riesgo para la recidiva y el fallecimiento. MATERIAL Y METODOS: Estudio retrospectivo de pacientes con nefroblastoma tratados según el protocolo de la SIOP-2001. Se recogieron las variables demográficas, comorbilidades y síndromes asociados. Otros datos fueron la localización del tumor, el tamaño, la extensión y el estadio. Se estudió también la tasa de recidiva y/o el desarrollo de otros tumores secundarios así como la supervivencia a largo plazo. RESULTADOS: Se recogieron 33 pacientes con nefroblastoma. En 7 pacientes (21,2%) se realizó una biopsia. La curva de Kaplan-Meir para la supervivencia libre de evento (recidiva tumoral) fue del 84% con un IC 95%= [0,73-0,98] y la curva de Kaplan-Meier de supervivencia global fue de 0,93 IC 95% [0,85-1]. La recidiva se produjo en todos los pacientes antes del primer año. CONCLUSIONES: El nefroblastoma es un tumor con buen pronóstico. La histología desfavorable así como estadios avanzados son factores de mal pronóstico. El seguimiento debe ser exhaustivo durante el primer año tras el diagnóstico.

[Hazardous drinking in Parisian medical students]. / Alcoolisation à risque chez des étudiants en médecine parisiens.

OBJECTIVES: Binge drinking is widespread in medical students but is poorly studied in France. The aim was to evaluate the number of binge drinking episodes and to better characterize them among a sample of French medical students. METHODS: We carried out a cross-sectional study at Paris VII's Faculty of Medicine. Through a brief self-questionnaire we focused on the prevalence rate of binge drinking in the past two weeks and examined the associations between hazardous drinking and the number of drinks consumed, demographic data (gender, age, familial status and student fraternity membership), clinical aspects (context, intended effects and adverse consequences), tobacco or illegal substances use, and eventual relationship with alcohol or tobacco use disorders. RESULTS: Among 302 medical students, 74.8% of them experienced at least one binge-drinking episode in the last two weeks. There was no significant difference in demographic data. However, the association between binge drinking and to living alone was borderline significant (P=0.051). Students experienced on mean 2.4 (SD, 1.6) episodes in the last two weeks and their mean maximum number of drinks was equal to 10.3 (SD, 4.6). We observed a significant association between the number binge drinking episodes and the mean maximum consumption of alcohol drinks (P=0.004). The maximum quantity of alcohol drinks was significantly higher (P<0.001) in students who experienced two binge-drinking episodes (mean=11.23, SD=4.56), compared to those who experienced only one episode (mean=9.04, SD=3.96). Binge drinkers were more likely to consume alcohol at a party than at a friendly drink (P=0.029) and more frequently sought drunkenness (P<0.001) and to escape from daily concerns (P=0.004). They experienced more negative events like black-outs (P<0.001), aggressive behaviors (P=0.002), drunk driving (P=0.025), unsafe sexual relationships (P=0.010) and need of emergency responders (P=0.047). Binge drinkers were more likely to simultaneously consume tobacco (P<0.001) or illegal substances (P<0.001), and presented more alcohol use disorder (P<0.001) and tobacco-dependence (P=0.007). CONCLUSIONS: This first French study in 302 medical students has highlighted the extent of binge drinking in this specific population. The threshold of two binge-drinking episodes in two weeks may be useful to identify a distinctive pattern of consumption and set up adequate prevention actions. Finally binge drinking seemed to be close to an addictive process. Our findings support the need to develop targeted prevention programs in French medical students, which could be designed around several interventions in campuses and student parties. Cohort studies could be necessary to provide an epidemiological follow-up of the French medical student population, particularly about the risk of alcohol use disorder.

[Complications in the conservative managemennt of splenic rupture]. / Complicaciones en el tratamiento conservador del traumatismo esplénico.

INTRODUCTION: Management of splenic rupture in haemodynamically stable children is non-surgical treatment. However, complications can occur during follow-up. Objective: to study the frequency, evolution and treatment of complications of conservative treatment of splenic rupture. Secondary objective: to evaluate the results of the American Pediatric Surgical Association (APSA) clinical guideline in conservative treatment. MATERIAL AND METHODS: Retrospective study of patients with abdominal trauma between 2010-2016. We included children under 15 years of age with splenic injury after blunt abdominal trauma. Demographic variables, mechanism and degree of injury of American Association for the Surgery of Trauma were studied in the sample. The complications, the time of onset and their treatment were analyzed. The treatment was based on the recommendations of the APSA with the exception of ultrasound follow-up. In case of complications and according to the clinical and characteristics, embolization was indicated. RESULTS: Twenty-eight patients were attended, 21 males (75%). The median age was 8.35 years (6.28-11.35). Seven patients (25%) presented complications: two arteriovenous fistula (AVF), three pseudo-aneurysms and two hemorrhages. The median time to diagnosis of complications was 5.67 days (P25 4- P75 5.75). Embolization was performed in two patients with pseudo-aneurysm. Another patient underwent emergency splenectomy for rebleeding. The rest of the complications resolved spontaneously. CONCLUSIONS: In splenic rupture, unlike APSA, ultrasound monitoring is useful to rule out early complications.

INTRODUCCION: El manejo estándar de las lesiones esplénicas en pacientes hemodinámicamente estables es el tratamiento no quirúrgico. Sin embargo, durante el seguimiento pueden surgir complicaciones. Objetivo: estudiar la frecuencia, evolución y tratamiento de las complicaciones del tratamiento conservador del traumatismo esplénico. Objetivo secundario: evaluar los resultados de la guía clínica de la American Pediatric Surgical Association (APSA) en el tratamiento conservador. MATERIAL Y METODOS: Estudio retrospectivo de pacientes con traumatismo abdominal entre 2010-2016. Se incluyeron menores de 15 años con lesión esplénica tras un traumatismo abdominal cerrado. En la muestra se estudiaron variables demográficas, mecanismo y grado de lesión según la American Association for the Surgery of Trauma. Se analizaron las complicaciones, el tiempo de aparición y su tratamiento. El tratamiento se fundamentó en las recomendaciones de la APSA a excepción del seguimiento ecográfico. En caso de aparición de complicaciones y en función de la clínica y de las características se indicó tratamiento con embolización. RESULTADOS: Se atendieron 28 pacientes, 21 varones (75%). La mediana de edad fue 8,35 años (6,28-11,35). Siete pacientes (25%) presentaron complicaciones: dos fístulas arteriovenosas (FAV), tres pseudoaneurismas y dos hemorragias. La media de tiempo para el diagnóstico de las complicaciones fue de 5,67 días. En dos pacientes con pseudoaneurisma se realizó embolización. Un paciente fue sometido a esplenectomía de urgencia por resangrado. El resto de complicaciones se resolvieron espontáneamente. CONCLUSIONES: En el traumatismo esplénico, a diferencia de la APSA, el seguimiento ecográfico en pacientes con lesiones de alto grado es útil para descartar complicaciones de forma precoz.

[Should the laparoscopic approach be avoided in a Nissen fundoplication procedure?] / ¿Debe evitarse el abordaje laparoscópico en la cirugía antirreflujo?

OBJECTIVE: A recently published trial concludes that the recurrence of GER by laparoscopic fundoplication (LF) is higher than by open surgery (OF) modifying their informed consent and the surgery approach. Objective: To analyze our results to assess changing clinical practice where the laparoscopy is the approach of choice. MATERIAL AND METHODS: Retrospective study of patients undergoing laparoscopic fundoplication between 2010-2015. The same criteria of the reference clinical trial were applied in the collected data and recurrence criteria. RESULTS: 56 patients were operated. Our patients were comparable on sex and neurological injury to those of the study. Our average follow-up was 2.6 years (0.07-6.3). During the monitoring period there were five recurrences. The relative risk (RR) of failure in the LF group was 4 times higher than ours (RR 4.19; 95% CI, 1.66-10.5). Our survival was 90% per year. Multivariate analysis was performed (Cox regression controlling neurological injury, esophageal atresia and after gastrostomy). Neurological injury (p= 0.01) was the only risk factor for recurrence. CONCLUSION: A clinical trial is not enough to change clinical practice, but it motivates further studies. According to our review, the results suggest no increased risk of recurrence with laparoscopy but long-term monitoring is necessary.

OBJETIVO: Un ensayo publicado recientemente concluye que la recurrencia del reflujo gastroesofágico mediante funduplicatura laparoscópica (FL) es mayor que en cirugía abierta (FA) modificando así su consentimiento informado y la vía de abordaje. Objetivo: analizar nuestros resultados para valorar modificar la práctica clínica donde el abordaje de elección es la laparoscopia. MATERIAL Y METODOS: Estudio retrospectivo de pacientes intervenidos de enfermedad por reflujo gastroesofágico entre el 2010-2015. En la recogida de datos así como en los criterios de recidiva se aplicaron los mismos criterios que los del ensayo clínico de referencia. RESULTADOS: Se intervinieron 56 pacientes. Nuestros pacientes fueron comparables a los del estudio en cuanto al sexo y al daño neurológico. Nuestra media de seguimiento fue 2,6 años (0,07-6,3). Durante este periodo se produjeron cinco recidivas. El riesgo relativo (RR) de fracaso en su grupo de FL multiplica por 4 el nuestro (RR 4,19; IC 95%: 1,66-10,5). Nuestra supervivencia fue del 90% al año. Realizado un análisis multivariante (regresión de Cox controlando daño neurológico, atresia de esófago y gastrostomía previa) solo el daño neurológico (p= 0,01) fue factor de riesgo de recidiva. CONCLUSION: Puesto que un ensayo clínico no es suficiente para modificar la práctica clínica, es necesaria la realización de más estudios. De acuerdo a la revisión realizada, actualmente nuestros resultados no sugieren mayor riesgo de recidiva con laparoscopia pero es necesario un seguimiento a largo plazo.

[Prophylactic thyroidectomy in RET proto-oncogen mutation]. / Tiroidectomía profiláctica en mutación del protooncogén RET.

OBJECTIVE: Analysis of prophylactic thyroidectomy cases carried out in our Center in patients with RET gene mutations. MATERIAL AND METHODS: Retrospective study of 25 patients with RET proto-oncogene mutations subjected to prophylactic thyroidectomy between January 2000 and January 2016. Epidemiologic variables, surgical technique, histological results and follow-up were studied. RESULTS: Our sample consists of 25 patients, 15 males and 10 females. The range of age was from 7 months to 12 years old, with a median of 5 years old. We obtained 21 cases with NEM2A, from which 19 (76%) presented 634 mutation and 2 (8%) presented 611 mutation. Four cases were NEM2B, all with 918 mutation. Microscopical findings showed microcarcinoma, in situ carcinoma or medullary thyroid carcinoma in 16 patients (64%). Eight of them showed hyperplasia (32%) and 1 presented fibrosis (4%). The presence of elevated calcitonin was correlated with histologic alterations in 7 cases (43.7%), without significant differences (χ2 0.3; p 0.6). From 16 patients with carcinoma (13 NEM2A and 3 NEM2B), 10 were 5 years old or less at the moment of the surgery. A total thyroidectomy was performed in all patients. There were no intra or post-surgical complications. During the follow-up of the patients, levels of calcitonin, calcium, parathormone, catecholamines and metanephrines were normal, except from one case. CONCLUSIONS: The study of RET proto-oncogene allows the identification of patients susceptible of performing a prophylactic thyroidectomy, which have to be carried out early, in an experienced centers.

OBJETIVO: Analizar los casos de tiroidectomía profiláctica realizados en nuestro centro en pacientes con mutaciones del gen RET. MATERIAL Y METODOS: Estudio retrospectivo de 25 pacientes con mutación del protooncogén RET a los que se les realizó tiroidectomía profiláctica entre enero del 2000 y enero de 2016. Se estudiaron variables epidemiológicas, técnica quirúrgica, resultados anatomopatológicos y seguimiento. RESULTADOS: Nuestra serie consta de 25 pacientes, 15 varones y 10 mujeres. La mediana de la edad fue de 5 años con un rango de 7 meses a 12 años. Obtuvimos 21 casos con MEN2A de los que 19 (76%) presentaban la mutación 634 y 2 (8%) la mutación 611. Cuatro casos fueron MEN2B, todos con la mutación 918. Los hallazgos microscópicos revelaron microcarcimona, carcinoma in situ o carcinoma medular de tiroides en 16 casos (64%). 8 presentaron hiperplasia (32%) y 1 (4%) fibrosis. La presencia de calcitonina elevada se correlacionó con alteraciones anatomopatológicas en 7 casos (43,7%), pero no mostró diferencias significativas (χ² 0,3; p 0,6). De los 16 pacientes con carcinoma, (13 MEN2A, 3 MEN2B), 10 de ellos (62,5%) tenían 5 años o menos en el momento de la intervención. En todos los casos se realizó tiroidectomía total. No existieron complicaciones intra ni postoperatorias. Durante el seguimiento, los valores de calcitonina, calcio, paratohormona, catecolaminas y metanefrinas se han mantenido normales, excepto en 1 paciente. CONCLUSIONES: El estudio del protooncogén RET permite identificar pacientes susceptibles de realizar tiroidectomía profiláctica, la cual debe ser realizada de forma precoz, y en centros con experiencia.

Polymorphism G1359A of the cannabinoid receptor gene (CNR1): allelic frequencies and influence on cardiovascular risk factors in a multicentre study of Castilla-Leon.

BACKGROUND: A polymorphism (1359 G/A) of the CNR1 gene was reported as a common polymorphism in Caucasian populations and was related to cardiovascular risk factors. The present study aimed to investigate the allelic distribution of polymorphism (G1359A) of the CB1 receptor gene in a geographical area of Spain (Community of Castilla y Leon) and to evaluate the influence of this polymorphism on obesity anthropometric parameters and cardiovascular risk factors in the fasted state in obese patients. METHODS: A population of 341 obese subjects was analysed. Tetrapolar electrical bioimpedance measurement, blood pressure measurement, a serial assessment of nutritional intake with 3 days of written food records and a biochemical analysis were all performed. RESULTS: One hundred and seventy-seven patients (51.9%) had the genotype G1359G (wild-type group) and 164 (48.1%) patients were A carriers: G1359A (136 patients; 39.9%) or A1359A (28 patients; 8.2%) (mutant type group). The Health Area of Palencia had a lower frequency of wild-type genotype and G allelic frequency than all the other Health Areas. Segovia and Burgos Areas had a higher frequency of wild-type genotype and G allelic frequency than the other Health Areas. High-density lipoprotein (HDL) cholesterol was higher in the mutant type group and blood tryglicerides were lower in the same group. CONCLUSIONS: In conclusion, the novel finding of the present study is the association of the mutant type group G1359A and A1359A with a better lipid profile (triglycerides and HDL cholesterol) than the wild-type group. The frequencies of this polymorphism are different among Health Areas of Castilla y Leon (Spain).

[Laparoscopic adrenalectomy: advantages of the minimally invasive approach]. / Adrenalectomía por vía laparoscópica: ventajas del abordaje mínimamente invasivo.

AIM: To describe our experience as a tertiary center on the use of laparoscopic adrenal surgery in children. MATERIAL AND METHODS: A descriptive, retrospective study of patients with pathologic adrenal masses undergoing laparoscopic adrenal surgery, between 2012 and 2015. Epidemiological variables, surgical technique, complications and follow-up were studied. RESULTS: Nine patients were studied with a median age of 62 months (5-184). In 3 patients (33.33%) there was a prenatal diagnosis. Three patients had symptoms: hypertension and renal failure, precocious puberty, and an infected lymph node secondary to metastasis. In the rest, findings were incidental. In five patients the lesion was located on the right side and in four, on the left. The operation was performed laparoscopically. There was one conversion to open surgery because of poor visualization of the surgical field and no major intra- or postoperative complications were noted. The average hospital stay was 4 days (2-5). Postoperative pain was controlled during the first 24 hours with first step painkillers. Diagnoses were histologically confirmed: two ganglioneuroma, three neuroblastoma, bronchogenic cyst, pulmonary sequestration and adenoma. Mean follow-up was 22 months (1-53). CONCLUSIONS: In our series this surgical approach is associated with low morbidity and mortality, early recovery, shorter hospital stay and satisfactory results. We therefore propose laparoscopic adrenalectomy as a good alternative for approaching the pathologic adrenal masses in the pediatric population.

OBJETIVO: Describir nuestra experiencia como centro terciario en el uso de la laparoscopia para la exéresis de lesiones adrenales en la edad pediátrica. MATERIAL Y METODOS: Estudio descriptivo y retrospectivo de pacientes con lesiones en la glándula suprarrenal intervenidos de suprarrenalectomía laparoscópica entre los años 2012 y 2015. Se estudiaron variables epidemiológicas, técnica quirúrgica, complicaciones y seguimiento. RESULTADOS: Se estudiaron 9 pacientes con una mediana de 62 meses (5-184). Tres pacientes (33,33%) tenían un diagnóstico prenatal y tres pacientes debutaron con síntomas: hipertensión e insuficiencia renal, pubertad precoz y otro con un adenoflemón secundario a metástasis. En el resto, el hallazgo fue incidental. En cinco pacientes la lesión se situó en el lado derecho y en cuatro en el izquierdo. La intervención se realizó por vía laparoscópica. En un paciente se convirtió a cirugía abierta por mala visualización en el campo quirúrgico. No se produjeron complicaciones perioperatorias ni necesidad de trasfusión. La media de la estancia hospitalaria fue de 4 días (2-5). El dolor postoperatorio fue controlado durante las primeras 24 horas y con analgésicos de primer escalón. Los diagnósticos confirmados por histología fueron: seis neuroblastomas, dos ganglioneuromas y un adenoma. La media de seguimiento fue de 22 meses (1-53). CONCLUSIONES: En nuestra serie esta vía de abordaje está asociada a una baja morbimortalidad con una recuperación precoz, corta estancia hospitalaria y resultados satisfactorios. Por tanto, proponemos la adrenalectomía laparoscópica como una buena alternativa para el abordaje de las lesiones suprarrenales en la población pediátrica.

Sensitivity penalty induced by non-ideal dual polarization downconverter in digital coherent receivers.

The implementation agreement of the Optical Internet Forum for a dual polarization (DP) I/Q downconverter defines strict requirements for the phase diversity network, resulting in a negligible penalty, but does not specify the extinction ratio (ER) of the polarization beam splitters (PBS) on which the polarization diversity network is based. We propose a novel metric, based on the Frobenius norm of the Jones receiver matrix, to accurately estimate the sensitivity penalty from receiver non-idealities, stablishing a precise interface for hardware specification. Results will be numerically verified for the reception of 112 Gbps DP-QPSK signals in a realistic receiver scenario with subsequent state-of-art DSP algorithms. The proposed metric highlights the benefits of the polarization diversity scheme based on two PBS, compared to the common alternative based on a PBS and a BS, as it achieves an improvement in the receiver sensitivity of at least 3 dB for the same ER. Furthermore, this paper shows than the sensitivity penalty is negligible for an ER higher than 16 dB and that it less than 2 dB for an ER of 8 dB. These results can have an important impact in monolithically integrated DP downconverters in which practical integration of PBS with high ER is still challenging.

[Cricopharyngeal achalasia: diagnosis and therapeutic alternatives]. / Acalasia cricofaríngea: diagnóstico y alternativas terapéuticas.

INTRODUCTION: The cricopharyngeal achalasia is an esophageal motor disorder that entails a lack of relaxation of the upper esophageal sphincter. It is rare in children and its etiology is related to multiple factors. The symptoms are nonspecific and may be masked by other diseases. CLINICAL CASE: Report two infants with dysphagia and choking episodes. Upper gastrointestinal series confirmed cricopharyngeal achalasia. The first patient was treated with endoscopic dilatation, and did not require further therapies. In the second patient, despite numerous dilatations and myotomy, the symptoms persisted so he received botulinum toxin injections. COMMENTS: Diagnosis of achalasia is obtained by upper gastrointestinal series and thanks to a high index of clinical suspicion. The use of endoscopic dilatation is the first option because it is not an invasive technique, but it usually requires several sessions. The second-line therapy is surgery, a more aggressive technique. In addition, the injection of botulinum toxin represents a safe and effective alternative, although it is a less widespread method in pediatrics.

INTRODUCCION: La acalasia cricofaríngea es un trastorno motor que consiste en la falta de relajación del esfínter esofágico superior. Es poco frecuente en pediatría y de etiología multifactorial. Los síntomas son inespecíficos y pueden quedar enmascarados. CASO CLINICO: Se presentan dos lactantes con disfagia y episodios de atragantamiento. El tránsito intestinal confirmó el diagnóstico de acalasia. En el primero, se realizaron dilataciones endoscópicas, siendo suficientes. En el segundo, a pesar de numerosas dilataciones y una miotomía, la clínica persistía, por lo que se procedió a inyecciones de toxina botulínica. COMENTARIOS: El diagnóstico de acalasia se obtiene mediante un tránsito intestinal y gracias a un alto índice de sospecha. El uso de las dilataciones es la técnica de elección por su baja agresividad, pero se requieren varias sesiones, y, como segunda línea, la cirugía, técnica más invasiva. Además, contamos con la inyección de toxina botulínica, método menos extendido en pediatría, pero seguro y eficaz como alternativa.

[Thoracoscopic resection of lung metastases guided by hook wire]. / Metastasectomía pulmonar toracoscópica guiada con arpón.

OBJECTIVE: To describe our experience in the use of the guided hook wire placement to undergo thoracoscopic resection of pulmonary metastases in children. MATERIAL AND METHODS: We conducted a retrospective review, between January 2008 and December 2014 of the patients that were diagnosed with pulmonary metastases by image and who underwent a thoracoscopic metastasectomy. Patients in whom a CT- guided hook was done before the surgery were included. RESULTS: Eleven procedures were done in ten patients with a median age of 10 years (range 2-16 years). The cancer diagnoses were: 4 osteosarcoma, 1 nephroblastoma, 1 suprarrenal carcinoma, 1 liver sarcoma, 1 pseudopappilary tumor of pancreas 2 hepatoblastomas. All patients had subpleural metastases (size 2-11 mm) and only one hook was used in each procedure. 8 patients had metastases at the time of diagnosis, and the other 2 were diagnosed during the follow-up of the primary cancer. The median follow-up was 27 months (range 2-28 months). In this period, two patients had relapse of the primary tumor, with exitus. At present, the other children are free disease. The CT-guided hook wire fixation was successful and without major complications in all patients. The lesion indentified by image was resected. The result was 4 malignant lesions, and 7 benigns. CONCLUSION: The use of the CT- guided needle and hook wire placement for the resection of the metastases lesions is a safe and effective technique. We consider it the technique to choice in case of solitary and subpleural lesions.

OBJETIVO: Describir nuestra experiencia en el uso de marcaje guiado por arpón para la realización de metastasectomía torascocópica pulmonar en pacientes en edad pediátrica. MATERIAL Y METODOS: Estudio descriptivo, retrospectivo, de pacientes con diagnóstico radiológico de metástasis pulmonar en los que se realizó metastasectomía toracoscópica entre enero de 2008 y diciembre 2014. Se incluyeron aquellos pacientes en los que se utilizó, para la realización de la metastasectomía pulmonar, un marcaje de las lesiones mediante arpón guiado por tomografía axial computarizada. Aquellos en los que no se realizó esta técnica fueron excluidos de este análisis. RESULTADOS: Se realizaron 11 procedimientos en un total de 10 pacientes con una mediana de edad de 10 años (rango 2-16). Los tumores primarios fueron 4 osteosarcomas, 1 nefroblastoma, 1 carcinoma suprarrenal, 1 sarcoma hepático, 1 tumor pseudopapilar de páncreas, 2 hepatoblastomas. Todos los pacientes tenían metástasis subpleurales (tamaño 2-11 mm) y se utilizó un único arpón en cada procedimiento. 8 pacientes tenían metástasis al diagnóstico y 2 durante la evolución de su tumor primario. El marcaje fue exitoso y sin complicaciones mayores en todos los pacientes. En todos se resecó la lesión que previamente habíamos marcado radiológicamente. Se hallaron 4 metástasis de tumor primario y 7 lesiones no malignas. Tras una mediana de seguimiento de 27 meses (rango 2-84 meses) dos pacientes tuvieron recaída de tumor primario con exitus. El resto se encuentra libre de enfermedad. CONCLUSION: El marcaje con arpón guiado por tomografía computarizada (TC) para la resección de las lesiones metastásicas es una técnica segura y eficaz. Lo consideramos técnica de elección en caso de lesiones únicas y subpleurales.

Polarization-beam-splitter-less integrated dual-polarization coherent receiver.

Conventional dual-polarization coherent receivers require polarization beam splitters for either the signal or the local oscillator path. This severely hinders monolithic integration, since integrated polarization splitting devices often exhibit stringent fabrication tolerances. Here we propose a dual-polarization monolithically integrated coherent receiver architecture that completely avoids the use of polarization splitting elements. Polarization management is instead achieved by adequately engineering the birefringence of the interconnecting waveguides. The resultant receiver is highly tolerant to fabrication deviations and thus offers a completely new route for monolithic integration of dual-polarization receivers without any type of active tuning.