[Conservative management of traumatic priapism in paediatric patients]. / Manejo conservador del priapismo traumático en la edad pediátrica.

INTRODUCTION: High-flow priapism is infrequent in pediatric patients. It is mostly secondary to perineal trauma resulting in laceration of a penile artery and the formation of an arterio-cavernous fistula. It does not constitute a medical emergency in itself, and allows conservative management awaiting spontaneous resolution. CLINICAL CASE: A six-year-old boy with painless persistent erection preceded by perineal trauma. Ultrasound imaging confirmed the clinical suspicion of high flow priapism secondary to arterio-cavernous fistula. After adopting a conservative approach, the patient presented progressive detumescence, as well as ultrasound resolution one month after the episode. COMMENTS: In high-flow priapism, venous drainage of the penis is preserved. The classical approach in adults is based on therapeutic angiography, which presents greater technical complexity and the risk of iatrogenic hypoxia in pediatric patients.

INTRODUCCION: El priapismo de alto flujo es una entidad infrecuente en la edad pediátrica. Es, en su mayoría, secundario a traumatismo perineal que provoca la laceración de una arteria peneana y formación de una fístula arterio-cavernosa. No constituye una emergencia médica, permitiendo un manejo conservador a la espera de su resolución espontánea. CASO CLINICO: Niño de seis años con erección persistente e indolora tras traumatismo perineal. El diagnóstico ecográfico confirma la sospecha de priapismo de alto flujo secundario a fístula arteria-cavernosa. Tras manejo conservador, presenta detumescencia progresiva y resolución ecográfica al mes del episodio. COMENTARIOS: En el priapismo de alto flujo el drenaje venoso del pene se encuentra conservado. El manejo clásico en adultos se fundamenta en la angiografía terapéutica, de mayor complejidad técnica y riesgo de hipoxia iatrogénica en el paciente pediátrico.

Conservative treatment of suprahepatic pseudoaneurysm in a pediatric patient. / Manejo conservador de un pseudoaneurisma suprahepático en un paciente pediátrico.

INTRODUCTION: Suprahepatic and inferior vena cava (IVC) pseudoaneurysms are rare in children. Most cases in adults are treated surgically due to the high risk of rupture. CASE REPORT: Seven-year-old girl referred for a thoracic-abdominal trauma of unknown origin. Hemodynamically stable, with a hemoglobin level of 9.1 g/dl. An emergency CT scan was performed, showing a pseudoaneurysm at the confluence of the IVC with the middle and left suprahepatic veins, with active bleeding contained by the hepatic capsule. Given the hemodynamic stability and surgical risk, conservative treatment was decided upon. CT-scan at 24 hours showed cessation of bleeding. A control CT-scan was performed one month, three months, one year, and one and a half years later, showing the lesion had disappeared. DISCUSSION: Conservative treatment of suprahepatic vein pseudoaneurysm/ICV is feasible in the case of hemodynamic stability provided that strict clinical and radiological surveillance is maintained.

INTRODUCCION: Los pseudoaneurismas suprahepáticos y de la vena cava inferior (VCI) son excepcionales en niños. La mayoría de casos en adultos se manejan quirúrgicamente debido al alto riesgo de rotura. CASO CLINICO: Niña de siete años remitida por traumatismo tóraco-abdominal no presenciado. Hemodinámicamente estable, con hemoglobina de 9,1 g/dL. Se realiza un TC urgente, objetivándose un pseudoaneurisma en la confluencia de la VCI con las suprahepáticas media e izquierda, con sangrado activo contenido por la cápsula hepática. Dada la estabilidad hemodinámica y el riesgo quirúrgico, se optó por un manejo conservador. En el TC a las veinticuatro horas se observó cese del sangrado. Se realizó un TC de control al mes, tres meses, un año y año y medio, con desaparición de la lesión. COMENTARIOS: El manejo conservador del pseudoaneurisma de las venas suprahepáticas/VCI es factible en caso de estabilidad hemodinámica siempre que se mantenga una vigilancia clínica y radiológica estrechas.

Analysis of a clinical guideline for treatment and early discharge in complicated acute appendicitis. / Análisis de una guía clínica para el tratamiento y alta precoz en apendicitis aguda complicada.

OBJECTIVE: The objective of this study was to assess the results of a clinical guideline for the treatment and early discharge of patients with complicated acute appendicitis in terms of infectious complications and hospital stay. MATERIALS AND METHODS: A guideline for appendicitis treatment according to severity was created. Complicated appendicitis cases were treated with ceftriaxone-metronidazole for 48h, with discharge being approved if certain clinical and blood test criteria were met. A retrospective analytical study comparing the incidence of postoperative intra-abdominal abscess (IAA) and surgical site infection (SSI) in patients under 14 years of age to whom the new guideline was applied (Group A) vs. the historical cohort (Group B, treated with gentamicin-metronidazole for 5 days) was carried out. A prospective cohort study to assess which antibiotic therapy (amoxicillin-clavulanic acid or cefuroxime-metronidazole) proved more effective in patients meeting early discharge criteria was also conducted. RESULTS: 205 patients under 14 years of age were included in Group A, whereas 109 patients were included in Group B. IAA was present in 14.3% of patients from Group A vs. 13.8% from Group B (p= 0.83), while SSI was present in 1.9% of patients from Group A vs. 8.25% from Group B (p= 0.008). Early discharge criteria were met by 62.7% of patients from Group A. Median hospital stay decreased from 6 to 3 days. At discharge, 57% of patients received amoxicillin-clavulanic acid, whereas 43% received cefuroxime-metronidazole, with no differences being found in terms of SSI (p= 0.24) or IAA (p= 0.12). CONCLUSIONS: Early discharge reduces hospital stay without increasing the risk of postoperative infectious complications. Amoxicillin-clavulanic acid is a safe option for at-home oral antibiotic therapy.

OBJETIVO: El objetivo de este estudio es evaluar los resultados en términos de complicaciones infecciosas y estancia hospitalaria de la instauración de una guía clínica para el tratamiento y alta precoz en pacientes con apendicitis aguda complicada. MATERIAL Y METODOS: Se elaboró una guía para el tratamiento de las apendicitis en función de su grado de severidad. Las complicadas se trataron con ceftriaxona-metronidazol durante 48 h, siendo alta si cumplen ciertos criterios clínicos y analíticos. Se realizó un estudio analítico retrospectivo comparando la incidencia de abscesos intraabdominales postquirúrgicos (AIA) e infección del sitio quirúrgico (ISQ) en pacientes menores de 14 años sometidos a la nueva guía (Grupo A), respecto a una cohorte histórica (Grupo B), en la que la pauta de tratamiento era gentamicina-metronidazol 5 días. Además, se realizó un estudio de cohortes prospectivas para evaluar qué antibioterapia (amocilina-clavulánico o cefuroxima-metronidazol) es más eficaz en los pacientes que cumplen criterios de alta precoz. RESULTADOS: Se incluyeron 205 pacientes menores de 14 años en el Grupo A y 109 en el Grupo B. Presentaron AIA un 14,3% en el grupo A, frente al 13,8% en el B (p=  0,83); e ISQ un 1,9% y un 8,25% respectivamente (p=  0,008). Cumplieron criterios de alta precoz el 62,7% de los pacientes del Grupo A. La mediana de estancia disminuyó a de 6 a 3 días. Al alta, el 57% recibieron amoxicilina-clavulánico y el 43% cefuroxima-metronidazol, sin hallarse diferencias en términos de ISQ (p=  0,24) ni de AIA (p=  0,12). CONCLUSIONES: El alta precoz disminuye la estancia hospitalaria sin aumentar el riesgo de complicaciones infecciosas postquirúrgicas. La amoxicilina-clavulánico es una opción segura para la antibioterapia oral domiciliaria.

Usefulness of intraoperative voiding cystourethrogram as an indicator of success in the endoscopic treatment of vesicoureteral reflux. / Utilidad de la cistouretrografía miccional intraoperatoria como indicador de éxito del tratamiento endoscópico del reflujo vesicoureteral.

OBJECTIVE: Up until now, serial voiding cystourethrogram (SVCU) has been regarded as the gold standard technique in the diagnosis of vesicoureteral reflux (VUR). The aim of intraoperative SVCU during endoscopic treatment is to detect those patients eligible to receive more biosynthetic material as a result of persistent VUR. The objective of this study was to assess the usefulness of SVCU as a predictor of treatment success. MATERIALS AND METHODS: An analytical, retrospective study of patient medical records was carried out. Patients included had undergone endoscopic VUR surgery from 2000 to 2019, and they were measured in ureteral units. VUR persistence at intraoperative SVCU following treatment was compared with SVCU results after 3 months. RESULTS: Of a total of 167 ureteral units undergoing surgery, persistent reflux immediately after surgery was observed in 17 cases (10% of the sample). Only 3 cases had other urological malformations. In the SVCU carried out after 3 months, reflux was found in 38% of the sample (64 cases). When comparing the results, intraoperative SVCU demonstrated a specificity of 92.6%, and a sensitivity of 15.6%. CONCLUSIONS: Given the low sensitivity (15.6%) of intraoperative SVCU to detect cases of persistent reflux in the mid-term, and considering the risks associated with radiation in the pediatric population - which is extremely sensitive to it -, intraoperative SVCU should be ruled out as a useful indicator of endoscopic treatment success.

OBJETIVO: La cistouretrografía miccional seriada (CUMS) ha sido hasta ahora el gold standard en el diagnóstico del reflujo vesicoureteral (RVU). La finalidad de la CUMS intraoperatoria durante el tratamiento endoscópico es detectar aquellos pacientes subsidiarios de inyectar más material biosintético por persistencia del RVU. En este estudio hemos querido evaluar la utilidad de esta prueba como predictor de éxito del tratamiento. MATERIAL Y METODOS: Estudio analítico retrospectivo mediante la revisión de historias clínicas de pacientes, medidos en unidades ureterales, intervenidos de RVU de forma endoscópica entre los años 2000 y 2019. Se comparó la persistencia de RVU en la CUMS intraoperatoria tras el tratamiento con el resultado de la CUMS a los 3 meses. RESULTADOS: De un total de 167 unidades ureterales intervenidas, se observó persistencia del reflujo inmediatamente tras la intervención en 17 casos (10% de la muestra). Solo 3 asociaban otras malformaciones urológicas. En la CUMS a los 3 meses se observó reflujo en el 38% de la muestra (64 casos). Al comparar los resultados, obtenemos para la CUMS intraoperatoria una especificidad del 92,6% y una sensibilidad del 15,6%. CONCLUSIONES: Dada la baja sensibilidad (15,6%) de la CUMS intraoperatoria para detectar los casos en los que persiste el reflujo a medio plazo y, teniendo en cuenta los riesgos asociados a la radiación que supone en una población especialmente sensible como es la pediátrica, se desestima su utilidad como indicador de éxito del tratamiento endoscópico.

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans.

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.