Implementation of an Enhanced Recovery After Surgery (ERAS) protocol for acute complicated and uncomplicated appendicitis.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols are well-documented logistic programs in elective surgery but it is still uncertain whether ERAS can benefit emergency patients, because of significant challenges facing its application to emergency surgery. The aim of this study was to evaluate the implementation of an ERAS protocol for patients with acute appendicitis (AA), both complicated and uncomplicated. METHODS: A prospective observational study was performed at two university hospitals in Spain, between January 2012 and December 2019. Inclusion criteria were patients with diagnosis of AA, undergoing appendectomy following an ERAS protocol of perioperative care. The different items of the ERAS protocol were recorded and their implementation was separately evaluated. Analyzed variables also included postoperative complications, hospital stay and readmission rate. Levels of acute phase reactants were assessed as predictors of implementation for the ERAS protocol. RESULTS: Eight hundred fifty patients were included; 498 males (58.5%) and 302 females (41.5%), with a mean age of 34.95 ± 17 years. The implementation of all the items of the protocol was achieved in 770 patients (90.6%), 86.8% of patients with complicated AA and 93.1% of patients with uncomplicated AA (p = 0.02). Higher preoperative C-reactive protein (CRP) levels were significantly associated with the impossibility of implementing all the items of the ERAS protocol (p < 0.001), establishing a cut-off point at CRP = 13.5 mg/dl. CONCLUSIONS: The implementation of ERAS protocols is safe and feasible in patients with AA. Although the implementation rate of all the items is lower in patients with complicated AA, it can be completed in 86.8% of these patients. CRP levels over 13.5 mg/dl are predictors of difficulties in the implementation of all the items of ERAS protocols.

Concentrations of chlorinated pollutants in adipose tissue of yellow-legged gulls (Larus michahellis) from Spain: Role of gender and age.

Concentrations of 7 different polychlorinated biphenyl (PCB) congeners, and eleven organochlorine pesticides (OCPs) and metabolites, including DDTs (dichlorodiphenyltrichloroethane), HCHs (hexachlorocyclohexane isomers), Endosulfan, Endosulfan sulfate, Endrin, Dieldrin and HCB (hexachlorobenzene), were determined in adipose tissue of 57 yellow-legged gulls collected from NW and N Spain. Furthermore, the possible differences due to two endogenous factors, age and gender, were determined. All the analyzed PCBs were detected in over 66% of the samples, with levels of 291.9 (PCB 180), 34.5 (PCB 118), 0.7 (PCB 28), 432.6 (PCB 153), 225.5 (PCB 138), 1.3 (PCB 101) and 0.4 (PCB 52) µg/kg of adipose tissue. With respect to the OCPs and metabolites, only 4,4'-DDE and HCB were detected in more than 50% of the samples, with means of 360.6 and 2.5 µg/kg of adipose tissue, respectively. From all the considered contaminants, only 4,4'-DDE levels presented significant differences depending on the gender, with females showing higher values than males (p < 0.01). Significant differences (p < 0.001) were also found related to age for the levels of PCBs 180, 138, 101, 28 and 153, as well as 4,4'-DDE, with adult levels being higher than those in young birds. The results of the present study constitute a baseline to better assess the environmental impacts of PCB and OCP contamination at other coastal sites for future biomonitoring studies, with particular emphasis on gender- and age-related differences.

Does gender influence the levels of heavy metals in liver of wild boar?

The aim of this study was to determine heavy metal reference levels for risk assessment studies. For this purpose, the levels of lead, cadmium, copper and zinc were determined in liver tissues of wild boars sampled in NW Spain. The mean values were 0.383, 0.326, 23.50 and 56.86mg/kg dried weight, respectively. In general, the levels detected were similar to or lower than the levels reported in literature. This study not only provides a useful baseline for biomonitoring the levels of the analyzed contaminants in wildlife in NW Spain, it also helps to understand the effects of gender on the levels of these elements. Similar to studies performed in other geographical regions, no significant gender-related differences could be detected. Although differences were not significant, the levels of zinc, cadmium and lead were modestly higher in males (55.78, 0.346 and 0.424mg/kg, respectively) compared to females (45.25, 0.305 and 0.341mg/kg). Our results indicate that, although gender did not significantly affect heavy metal uptake and toxicokinetics of contaminants in wild boars, these effects could vary between species, populations, organs, and elements. It is therefore essential to investigate gender-related differences for each species.

Comparison of minilaparoscopy and single-incision intragastric surgery for gastric submucosal tumor resection in a porcine model.

BACKGROUND: The aim of this study was to develop an easy-to-induce and reproducible model of gastric submucosal tumor in swine to compare minilaparoscopy (ML) with single-incision (SI) intragastric surgery. METHODS: Twelve healthy female pigs (weight 30.94 ± 2.49 kg) underwent a transparietal injection of sterile alginate at the level of Z-line (n = 6) and at the pre-pyloric area (n = 6) creating a model of gastric submucosal pseudotumor. The operative procedures included intragastric resection with ML and SI approaches of cardiac and pre-pyloric lesions, with gastroscopic assistance. After resection, the gastric mucosal layer was closed using intracorporeal sutures. The operative time, complication rate and clinical evolution after 1 month were compared in the four groups that the pigs were arranged. RESULTS: The pseudotumors ranged in size from 3 to 6 cm in diameter. The access of the gastric cavity and resection of the experimental SMP and suturing of the mucosa were performed successfully in 12 animals using both approaches. Mean time to perform the exeresis of gastric cardia tumors was significantly higher in single-incision approach. No significant differences were observed in the surgical time during pyloric surgery. Minilaparoscopic approach reduced significantly the mucosa closure time in esophagogastric and pyloric pseudotumors. One month after, no alterations were shown in the abdominal cavity using exploratory laparotomy. CONCLUSIONS: The technical feasibility of performing safe and efficient intragastric approach of submucosal pseudotumors in swine model was verified in this study. Intragastric ML has advantages over SI, namely regarding the reduction in total surgical times and the fewer technical difficulties.

Concentrations of Metals, Metalloids, and Chlorinated Pollutants in Blood and Plasma of White Stork (Ciconia ciconia) Nestlings From Spain.

The aim of this study was to determine the levels of different inorganic elements (lead [Pb], mercury [Hg], and arsenic [As]) and persistent chlorinated pollutants (including polychlorinated biphenyls [PCBs] and organochlorine pesticides [OCPs]) in blood and plasma of White stork (Ciconia ciconia) nestlings from northwest (NW) Spain. The concentrations of PCBs were lower than the limit of detection in all samples. The OCPs γ-HCH, 4,4'-DDE, HCB, and endosulfan were detected most frequently in plasma from White stork nestlings. These OCPs were detected in 98, 54, 39, and 37 % of all samples, respectively. However, the concentrations of organic pollutants were lower than the risk thresholds for birds. The mean levels of the inorganic elements Pb, Hg, and As were found to be 36.92 ± 33.48, 16.48 ± 12.87, and 9.813 ± 13.84 µg/L, respectively. These levels were also lower than the risk thresholds for birds. This study not only provides a snapshot of the levels of both inorganic and organic contaminants in wild White storks in NW Spain, it also provides a useful baseline for biomonitoring levels of the measured contaminants in this area.

[Gallstone ileus, an uncommon cause of bowel obstruction]. / Íleo biliar, causa poco frecuente de obstrucción intestinal.

Gallstone ileus is a rare complication of cholelithiasis. It is characterized by bowel obstruction secondary to gallstone impaction at some point of the gastrointestinal tract due to the existence of a bilioenteric fistula. The aim of this analysis was to evaluate our experience through a retrospective study, covering a 12-year period. It included 14 cases (10 women and 4 men) with a median age of 81 years; 11 of the patients had comorbidities. The main analytic alteration was an increase in urea (median 79mg/dl). Diagnosis was confirmed through abdominal computed tomography in 10 cases and plain abdominal x-ray in 4. The stone was located in the jejunum in 6 cases, the ileum in 6, and the sigmoid colon in one; the mean stone size was 3cm. There were 11 cases of cholecystoduodenal fistula, one case of cholecystocolonic fistula, and one idiopathic fistula. Two patients died, including the patient that did not undergo surgery.

Treatment of periorbital hyperpigmentation using light devices.

The treatment of dark circles is one of the most common request from the patients attending to the esthetics clinic. A tired, sad or aged appearance is perceived by our patients. Moreover, it is a multifactorial problem and we could treat it with a wide range of treatments. With this systematic review, we want to check the best available evidence regarding the treatment of periorbital hyperpigmentation using light devices. We have reviewed 208 papers, including 14 of them for full consideration. Several light sources have demonstrated to be effective treating pigmented dark circles. The best results have been reported using intense pulsed light and rubi laser together with depigmenting substances. If we want to treat periocular hyperpigmentation, soft wrinkles, rhytides and skin density we should use carbo dioxide laser or Erbium:Yttrium Scandium Gallium Garnet. The Neodymium-Doped Yttrium Aluminium Garnet, alexandrite and diode lasers were the ones giving the worst outcome regarding pigmentation treatment. The concomitant use of depigmenting treatment may help getting better results and reducing the rate of post inflammatory hyperpigmentation. A better standardization and measuring of the obtained results is needed regarding pigmentation changes. We must keep on investigating on this topic with new clinical trials measuring objective results and combining different light devices for a multifactorial treatment of the dark circles.

Quality of life following transobturator sling surgery for female stress urinary incontinence.

OBJECTIVE: This descriptive study examines quality of life in women undergoing placement of a midurethral sling for stress urinary incontinence. MATERIALS AND METHODS: This was a retrospective cohort study based on data from 51 women consecutively undergoing this procedure at a tertiary hospital in the years 2014 and 2015. The main outcome variable was quality of life assessed through the Sandvick severity test and International Consultation on Incontinence Short Quality of Life Questionnaire (ICIQ-IU-SF) at the time points baseline or presurgery, and 6 months and 5 years postsurgery. Factors associated with treatment failure were determined through binary logistic regression. RESULTS: At 5-year follow up we obtained an absolute reduction of 8.78 points (95% CI 6.43-11.14; p < 0.001) in the ICIQ-IU-SF questionnaire and 4.54 (95% CI 3.25-5.83; p < 0.001) in the Sandvick severity test score, compared to baseline, in the 35 patients that completed follow-up. Out of the 51 patients that were followed, the rate of success in incontinence correction was 86.3% (44/50) with a failure rate of 12% (6/50). Multiparity and previous gynaecological surgery were identified as predisposing factors for treatment failure. Obesity was associated with a worse treatment outcome. CONCLUSION: Sling treatment for incontinence was successful in 86.3% (44/50) of participants and remained effective 5 years after surgery in terms of quality of life.

Non-destructive multibiomarker approach in European quail (Coturnix coturnix coturnix) exposed to the herbicide atrazine.

The effect of orally administered atrazine (25 or 100 mg/kg on days 0, 5, and 10 of the experiment) was studied in European quail (Coturnix coturnix coturnix) on four non-destructive biomarkers: fecal porphyrins, blood glutathione-S-transferase, glutathione reductase, reduced glutathione, and malondialdehyde (MDA). Uroporphyrin I (UPI) and coproporphyrins I and III (CPIII) were the main porphyrins detected in feces. The lowest dose of ATZ caused a significant (P < 0.05) increase in UPI and CPIII at day 5, and the highest dose of ATZ caused an induction of CPI and a significant (P < 0.05) decrease in MDA levels at day 30.

Effectiveness of retrobulbar hyaluronidase in the treatment of visual loss caused by periocular hyaluronic acid injection. A systematic review.

INTRODUCTION: Blindness after periocular cosmetic filler injection is a rare but devastating complication. Complication management protocols recommend injecting retrobulbar hyaluronidase if visual loss related to accidental intravascular injection of hyaluronic acid occurs. Given the dramatic increase in cosmetic filler injections and the variety of professionals that can deliver them, it is reasonable to assume that the incidence of complications will rise significantly. OBJECTIVE: To evaluate if there is evidence-based efficacy of retrobulbar hyaluronidase injection in visual loss secondary to periocular cosmetic filler injection. MATERIAL AND METHODS: The authors performed a search of English and Spanish language articles following the PRISMA statement published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series and experimental investigations. We identified a total of 13 patients in this review following defined inclusion and exclusion criteria. Finally, we included 15 articles in the study, 12 of them were cases / case series. The 2 remaining articles are experimental studies in animals with a control group, in which after causing selective occlusion of the ophthalmic artery, serial injections of retroocular hyaluronidase are administered with control of visual function. RESULTS: Of the 15 articles included in the study, we studied 17 patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness. Improvement was demonstrated in 3 cases. Animal studies demonstrate variable data are provided regarding the recovery of visual acuity. CONCLUSIONS: There is no confirmed evidence of retrobulbar hyaluronidase injection effectiveness in treating visual loss due to accidental intravascular injection of hyaluronic acid. More studies are needed to show the efficacy of hyaluronidase as a treatment for blindness caused by hyaluronic acid.

Kidney graft functionality 1 year after kidney transplantation.

OBJECTIVE: To determine the evolution, associated factors and the outcomes of transplanted people one year after the evolution of a cohort in Mexico. METHOD: Kidney transplant cohort from 2013 to 2017 in Mexico. 1118 patients were analyzed. Five outcomes were studied: overall survival, kidney graft, patient survival, delayed function, and acute dysfunction. Kaplan-Meier was used for kidney graft survival. For risk, bivariate and multivariate analyzes were performed with a significant value of p < 0.05. RESULTS: Of the 1118 kidney transplant patients, 57 (5.09%) had kidney graft loss, 52 (4.65%) died during the one-year follow-up; survival of the patient of 95.35% and of the graft 90.25%. CONCLUSIONS: The risk factors for the outcomes were transplantation from a deceased donor, recipient over 50 years of age and use of polyclonal agents. Infections and age are related to the death of the patient.

OBJETIVO: Determinar la funcionalidad del injerto renal a 1 año en una cohorte retrospectiva en México. MÉTODO: Cohorte de trasplante renal de 2013 a 2017 en México. Se analizaron 1118 pacientes. Se estudiaron cinco desenlaces: supervivencia global, supervivencia del injerto renal, supervivencia del paciente, función retardada y disfunción aguda. Para la supervivencia del injerto renal se usó Kaplan-Meier. Para el riesgo se realizó análisis bivariado y multivariado con valor significativo p < 0.05. RESULTADOS: De los 1118 pacientes con trasplante renal, 57 (5.09%) tuvieron pérdida del injerto, 52 (4.65 %) fallecieron durante el año de seguimiento; la supervivencia del paciente fue del 95.35% y la supervivencia del injerto fue del 90.25%. CONCLUSIONES: Los factores de riesgo para los desenlaces fueron trasplante de donante fallecido, receptor mayor de 50 años y uso de agentes policlonales. Las infecciones y la edad están relacionadas con la muerte del paciente.

[Treatment of acne in daily clinical practice: an opinion poll among Spanish dermatologists]. / Tratamiento del acné en la práctica clínica habitual: encuesta de opinión entre los dermatólogos españoles.

BACKGROUND AND OBJECTIVES: the aim of this study was to determine the approaches used to treat acne in clinical practice by Spanish dermatologists. A secondary objective of the study was to compare the practices of Spanish dermatologists with the Acne Global Alliance treatment algorithm and develop a Spanish treatment algorithm for acne. PATIENTS AND METHODS: a multicenter, cross-sectional survey was undertaken among 872 Spanish dermatologists. The study comprised 4 randomly distributed questionnaires. The first 3 contained the following case descriptions: severe acne associated with masculinization (case 1), mild comedonal acne (case 2), and moderate papulopustular acne (case 3). The fourth questionnaire contained 5 photographs of different types of acne and an algorithm containing various treatment options, from which dermatologists were asked to choose the most appropriate. RESULTS: for case 1, 55% of dermatologists chose oral antiandrogens/contraceptive drugs plus topical retinoids or topical benzoyl peroxide/antibiotics. In case 2, 62% chose topical retinoids and, in case 3, 68% chose systemic antibiotics plus benzoyl peroxide. Combination therapy was considered the treatment of choice in all types of acne, with topical retinoids as the initial treatment option for mild and moderate forms and the preferred option for maintenance therapy. CONCLUSIONS: in general, Spanish dermatologists treat acne in accordance with the Acne Global Alliance treatment algorithm. The varying opinions reported in response to open questions, however, confirm the need to unify criteria for the treatment of acne.

Exploratory analysis on the usage of Pi-score algorithm over endoscopic stone treatment step 1 protocol.

BACKGROUND: The Performance Improvement score (Pi-score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training. METHODS: The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during four courses in Barcelona and Milan. Collected data were independently analyzed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa statistics were used for comparison analysis. RESULTS: Sixteen hands-on training expert tutors and 47 3rd-year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task 1=0.30 ("fair"); Task 2=0.18 ("slight"); Task 3=0.10 ("slight"); Task 4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task 1=0.74 ("substantial"); Task 2=0.71 ("substantial"); Task 3=0.46 ("moderate"); Task 4=0.49 ("moderate"). CONCLUSIONS: Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.

Comparative study of esterase activities in different tissues of marine fish species Trachurus trachurus, Merluccius merluccius and Trisopterus luscus.

Pesticides are one of the most frequently anthropogenic xenobiotics detected in water. Among these, the organophosphorus pesticides (OPs) are very widely used in agriculture due to their broad spectrum of activity and their low price, but they also have high potent effects as neurotoxic compounds in non-target organisms. The aim of this study was to evaluate biomarkers acetylcholinesterase (AChE), butyrylcholinesterase (BChE), propionylcholinesterase (PChE) and carboxylesterase (CbE) in the representative Atlantic fish species Trachurus trachurus, Merluccius merluccius and Trisopterus luscus from "Rías Gallegas", a traditional Spanish fishing area. These esterase activities were evaluated in the brain, muscle and liver to determine the most adequate tissue to measure such enzymatic activities. The sensitivity of AChE and CbE activities from different tissues the widely used organophosphorus insecticide chlorpyrifos (CP), and its toxic metabolite (CP-oxon) was also tested. AChE activity was predominant in all tissues of the analysed species (particularly in brain constituting from 78.33%, 89.83% and 88.43% of total ChEs in Trachurus trachurus, Merluccius merluccius and Trisopterus luscus, respectively). Under in vitro exposure, esterases were shown to be highly sensitive to CP and especially to CP-oxon. Moreover, a similar effect observed on AChE and CbE activities could suggest that CbE activity might contribute efficiently against the toxic effects of CP, especially in muscle and the liver. The presence of BChE, PChE and upper CbE activities in muscle and the liver and their OP-sensibilities can be used to study their function in the pesticide biochemical detoxification pathways with a prominent role as a safeguarding mechanism against pesticide toxicity.

Effects of the application of vitamin E and silicone dressings vs conventional dressings on incisional surgical site infection in elective laparoscopic colorectal surgery: a prospective randomized clinical trial.

AIM: To compare the effect of conventional wound dressings (CD) with vitamin E and silicone (E-Sil) dressings on incisional surgical site infection (SSI) in patients undergoing elective colorectal laparoscopic surgery. PATIENTS AND METHODS: A prospective, randomized study was performed. Patients were assigned at random into two groups: an E-Sil group and a CD group. Incisional SSI, postoperative pain and acute phase reactants were investigated. RESULTS: In total, 120 patients were included in this study (60 in each group). The incisional SSI rate was 3.4% in the E-Sil group and 17.2% in the CD group (P = 0.013). Bacteroides fragilis alone grew in the cultures of infected wounds in the E-Sil group, while cultures for infected wounds in the CD group were polymicrobial. Mean postoperative pain 48 h after surgery was 27.1 [standard deviation (SD) 10.7] mm in the E-Sil group and 41.6 (SD 16.9) mm in the CD group (P < 0.001). White blood cell (WBC) count and C-reactive protein (CRP) level were lower in the E-Sil group, even after the exclusion of patients presenting with postoperative complications. CONCLUSION: Use of an E-sil dressing to cover the Pfannestiel wound after elective laparoscopic colorectal surgery leads to a reduction in the incisional SSI rate, lower postoperative pain, and a decrease in CRP level and WBC count.

Adult orbital xanthogranuloma as a cause of recurrent palpebral swelling. / Xantogranuloma orbitario del adulto como causa de inflamación palpebral recidivante.

Orbital adult-onset xanthogranuloma is a rare idiopathic inflammatory disorder included in the group of orbital xanthogranulomatous diseases with possible systemic associations. A 43 year-old woman presented with a deep fast-growing mass on the right upper eyelid. She had a past medical history of bilateral non-ulcerative nodules on the upper eyelid and two cosmetic upper lid blepharoplasties. An excisional biopsy was performed and the histopathology analysis confirmed the diagnosis of adult histiocytic xanthogranuloma. The systemic work up was negative and the patient is asymptomatic without treatment. Orbital xanthogranulomatous diseases are rare, but potentially life-threatening disorders. The ophthalmologist must be aware of this disease in order to make an early diagnosis using the anamnesis, clinical examination, and histology of the periocular lesions that may resemble palpebral xanthelasmas.

[Prostate adenocarcinoma and synchcronous multiple myeloma: a case report]. / Adenocarcinoma prostático y mieloma múltiple sincrónicos: a propósito de un caso.

PURPOSE: To report a case of synchronous prostatic cancer with multiple myeloma as inusual neoplasm presentation. To indicate the clinical data that they help to suspect the myeloma presence in the prostate bone metastatic disease. CASE REPORT: Patient 63 years old diagnosed of prostatic carcinoma with bone metastasis and BAC good responsive, who have clinical deterioration, hypercalcemia and renal insufficiency. RESULTS: The presacred mass biopsy and extension study to find one second tumour (myeloma). CONCLUSION: The presence of multiple myeloma must be to rule out when there are bone lytics injuries, well biochemical evolution with therapy and clinical deterioration, hypercalcemia and quickly progressive renal insufficiency.

Ki-67 is a prognostic marker for hormone receptor positive tumors.

PURPOSE: To evaluate the utility of Ki67 as a prognostic marker in Luminal B node-negative breast cancer patients. METHODS: We identified 888 patients with invasive breast carcinomas who underwent surgery between 1997 and 2004. Several classical factors were collected: age, tumor size, node involvement, tumor grade, estrogen and progesterone receptors, HER2 and Ki-67 expression. We analyzed if these parameters could be considered as a prognostic factor. In early Luminal B group, we investigated which of the following biological features provide information about bad prognosis: lack of progesterone receptor expression, HER2 overexpression/amplification or high Ki-67 value. RESULTS: The majority of patients were alive and without relapse of tumor at the moment of the analysis (70 %). The prognostic factors founded in multivariate analysis were: tumor size, node involvement, grade 3 and Ki-67 expression. When we stratified the sample by immunohistochemistry (IHC) in tumor subtypes, we assessed 680 patients and we observed 191 Luminal B tumors. The biological parameter related to the worst survival in absence of nodal involvement was Ki-67 value. CONCLUSIONS: Ki-67 represents an additional predictor of survival in Luminal B node negative breast cancer. Conversely, neither Progesterone-receptor nor HER2 status proved prognostic significance in this group in our study.

Specific Antigens by Federal Entity in Patients at the Transplant Unit of Specialities Hospital, National Medical Center Twenty-First Century, Mexico.

BACKGROUND: The study of the kidney transplant involves understanding the immunologic basis, such as histocompatibility and the genetic basis of a population. In Mexico, the study of the genetic basis has led to a genetic map by federal entities. METHODS: We performed an HLA study with 1,276 kidney transplant patients (recipients and donors) in the Hospital of the National Medical Center Twenty-First Century, determining HLA class I (A, B, and Cw) and class II (DRß1 and DQß1) antigens with the use of SSOP-PCR. A descriptive analysis was conducted with measures of central tendency (mean, SD). RESULTS: Of 1,276 HLA patients studied, we obtained 2,552 results for each class by the composition of the 2 haplotypes, and for HLA-Cw we processed 796 patients, for a total of 1,592 antigens for this class. We found antigens specific to each federal entity, and it was found that the Federal District had the highest number of specific antigens (10) followed by Morelos (7), Querétaro and Mexico State (3 each), and Tamaulipas, Aguascalientes, Michoacán, Guerrero, Puebla, and Oaxaca (1 each). CONCLUSIONS: The genetic map allows us to know proportions of antigens in every state in the center and south of Mexico owing to the diversity and area of influence of the National Medical Center XXIst Century, as well as the wide number of patients. Furthermore, there are still preserved proportionally distinct genetic roots in every entity.