Características clínicas y hallazgos endoscópicos en niños con hipertensión portal atendidos en un hospital pediátrico / Clinical characteristics and endoscopic findings in children with portal hypertension seen in a pediatric hospital

Antecedentes: El término hipertensión portal (HP) se define como el aumento patológico en el gradiente de presión porto-sistémico en cualquier segmento del sistema venoso portal. Objetivo: Determinar las características clínicas y hallazgos endoscópicos de pacientes con HP atendidos en el Hospital María, Especialidades Pediátricas (HMEP). Métodos: Se realizó un estudio observacional, descriptivo y retrospectivo. El universo fueron todos los pacientes de 18 años o menos con diagnóstico de HP que asistieron al servicio de gastroenterología pediátrica del HMEP entre 2015-2022. Fue tomado todo el universo para aná- lisis. Se realizó análisis de datos descriptivo univariado utilizando el programa STATA 15.1. Resultados: Se analizó un total de 38 pacientes, 55.3% (21/38) de edad preescolar. El 57.9% (22/38) fue masculino y el nivel de escolaridad más frecuente fue primaria incompleta en 55.3%. La procedencia en 79% (30/38) de la zona centro y oriente del país. El Sangrado Digestivo Alto (SDA) se en- contró en 42% de los pacientes (16/38) y la etiología pre-hepática fue la más frecuente en 65.8 % (25). Discusión: se encontró que el inicio de la enfermedad fue en pre-escolares con predominio del sexo masculino; las causas pre-hepáticas fueron la etiología más frecuente de SDA coincidiendo con lo publicado por otros autores. El SDA fue el síntoma inicial predominante, evidenciado en hallazgos endoscópicos como várices esofágicas y gástricas. Conclusión: La HP es poco frecuente en edad pediátrica tiene consecuencias severas en la calidad de vida y sobrevida del paciente...(AU)

Pararectus Approach in Acetabular Fractures in Patients Older Than 65 years. Is it Possible to Improve the Technique?

OBJECTIVES: Review clinical results of the treatment for acetabular fractures using the pararectus approach and analyze surgical variations of the traditional approach. DESIGN: Retrospective. SETTING: Tertiary referral hospital. PATIENTS: 46 patients over 65 years of age who sustained an acetabular fracture and underwent surgery using the pararectus approach. INTERVENTION: Fractures were treated using a pararectus approach. Three variations of the original technique were performed: (1) Ligature of the deep iliac circumflex artery and vein, (2) separation of the psoas and iliacus muscles, and (3) isolation of the spermatic cord in men and round ligament in women together with the iliac and epigastric vessels. MAIN OUTCOME MEASUREMENTS: Outcomes measures included surgical, demographic, and clinical data, and information related to follow-up. RESULTS: Duration of surgery, 125 minutes (95-210). Quality of reduction on postoperative computed tomography (CT) scan; anatomic in 22 patients (47.8%), incomplete in 16 (34.8%), and poor in 8 (17.4%). In patients in whom the hip was preserved (n = 41), functional status was excellent in 15 patients (36.5%), good in 17 (41.4%), fair in 6 (14.7%), and poor in 3 (7.4%), with mean functional score of 16 points (7-18). Seven patients (15.2%) developed posttraumatic osteoarthritis and 4 of these patients underwent total hip replacement. CONCLUSIONS: This study reports positive outcomes in fracture reduction and clinical outcomes with low complications in older patients who suffered acetabular fractures and were treated using a pararectus approach. Small variations in the technique, such as those proposed in this study, may help to widen access to the surgical site and simplify the technique. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Caroli's Syndrome: An Early Presentation.

Fibropolycystic liver disorders (FLD) arise from abnormal development of the ductal plate and are classified according to the size of the affected hepatobiliary duct. Congenital hepatic fibrosis (CHF) has small duct involvement characterized by a variable degree of periportal fibrosis and hyperplasia without affecting the liver's architecture. Caroli's disease (CD) is a rare autosomal recessive disorder with a prevalence of one case per 1,000,000 people and is characterized by cystic dilation of large intrahepatic ducts. When the disease presents with congenital hepatic fibrosis, it is referred to as Caroli's syndrome (CS). Patients are usually diagnosed around the age of 20 with episodes of cholangitis, portal hypertension or hepatomegaly. We present the case of a two-year-old male with a previous history of autosomal recessive polycystic kidney disease (ARPKD) who presented to the emergency room with variceal bleeding secondary to portal hypertension. The physical examination showed an acutely ill-looking boy, with evident paleness and distended abdomen. Past medical history was negative for previous gastrointestinal bleeding or episodes of cholangitis. An upper gastrointestinal endoscopy was performed, showing esophageal varices secondary to portal hypertension. Imaging studies revealed hepatosplenomegaly, alterations in liver echogenicity, and dilated saccular bile ducts affecting both liver lobes without observing any apparent obstruction, highly suggestive of CD. A liver biopsy revealed nodular liver tissue with marked fibrosis between nodules, which confirmed the presence of CHF. Both kidneys were increased in size, hyperechoic and with loss of corticomedullary differentiation. FLD commonly present with coexisting hepatobiliary and renal alterations. Therefore, starting at the time of initial diagnosis, all patients with ARPKD should be evaluated to detect liver abnormalities due to the high association. Despite the rarity of CS, especially in early childhood, the association between ARPKD and FLD is well documented. So if this clinical presentation arises, CS should be suspected.

Surgical Infection after Posterolateral Lumbar Spine Arthrodesis: CT Analysis of Spinal Fusion.

OBJECTIVE: To determine the incidence of infection after instrumented lumbar spine surgery, the demographic and surgical variables associated with acute infection, and the influence of infection and debridement on the consolidation of spinal fusion. METHODS: After obtaining approval from the hospital ethics committee, an observational study was made on a prospective cohort of consecutive patients surgically treated by posterolateral lumbar spine arthrodesis (n = 139, 2005-2011). In all cases, the minimum follow-up period was 18 months. The following bivariate analysis was conducted of demographic and surgical variables: non-infection group (n = 123); infection group (n = 16). Fusion rates were determined by multislice CT. Logistic regression analysis was performed. RESULTS: Incidence of deep infection requiring debridement: 11.51% (95% confidence interval, 5.85-17.18]). Bivariate analysis: differences were observed in hospital stay (7.0 days [range, 4-10] vs 14.50 days [range, 5.25-33.75]; P = 0.013), surgical time (3.15 h vs 4.09 h; P = 0.004), body mass index (25.11 kg/m2 [22.58-27.0] vs 26.02 kg/m2 [24.15 to 29.38]; P = 0.043), Charlson comorbidity index (median, 0 vs 1; P = 0.027), and rate of unsuccessful consolidation according to CT (18.4% vs 72.7%; P = 0.0001). In a model of multivariate logistic regression, taking as the dependent variable unsuccessful arthrodesis after 1 year, and adjusting for the other independent variables (infection, body mass index, Charlson comorbidity index, and surgical time), the only variable that was significantly associated with an outcome of unsuccessful spinal fusion after 1 year was infection, with OR = 12.44 (95% confidence interval, 2.50-61.76). CONCLUSION: Deep infection after instrumented lumbar spine arthrodesis is a common complication that compromises the radiographic outcome of surgery. Patients who develop a postoperative infection and require debridement surgery are 12 times less likely to achieve satisfactory radiological fusion.

Uncaria tomentosa (Willd. ex Schult.) DC (Rubiaceae) Sensitizes THP-1 Cells to Radiation-induced Cell Death.

BACKGROUND: Uncaria tomentosa (Willd. ex Schult.) DC (Rubiaceae), known as Cat's Claw or Uña de gato, is a traditionally used medicinal plant native to Peru. Some studies have shown that U. tomentosa can act as an antiapoptotic agent and enhance DNA repair in chemotherapy-treated cells although others have shown that U. tomentosa enhanced apoptosis. OBJECTIVE: To determine if treatment with U. tomentosa can significantly enhance cell death in THP-1 cells exposed to ionizing radiation. MATERIALS AND METHODS: THP-1 monocyte-like cells were treated with ethanolic extracts of U. tomentosa in the presence or absence of bacterial lipopolysaccharide and then exposed to ionizing radiation. Cell proliferation was assessed by MTT and clonogenic assays and the effects on cell cycle measured by flow cytometry and immunoblotting. Changes in cell signaling were determined by immunoblotting and cytokine ELISA and activation of apoptosis measured by caspase activation and DNA fragmentation analysis. RESULTS: Treatment of THP-1 cells with U. tomentosa had a small effect on cell proliferation. However, when the U. tomentosa-pretreated cells were also subjected to 5-9 Gy ionizing radiation, they showed a significant decrease in cell proliferation and increased cellular apoptosis as measured by DNA fragmentation and caspase activation. Treatment with U. tomentosa also decreased the expression of Cyclin E and Cyclin B, key regulators of normal cell cycle progression, and decreased the phosphorylation of various stress-activated, cell survival proteins including p38, ERK, and SAP/JNK kinase. CONCLUSIONS: These results suggest that U. tomentosa could be useful in enhancing cell death following anticancer therapies including ionizing radiation. SUMMARY: Treatment of THP-1 cells with Uncaria tomentosa increases their susceptibility to X-rays. The combination of Uncaria tomentosa and X-ray exposure strongly inhibits cell signaling and promotes apoptosis. Abbreviations Used: LPS: Lipopolysaccharide, TNF: Tumor necrosis factor: IL-1, Interleukin-1: SDS: Sodium dodecylsulphate, TBS: Tris-buffered saline.

PANCREOX: A Randomized Phase III Study of Fluorouracil/Leucovorin With or Without Oxaliplatin for Second-Line Advanced Pancreatic Cancer in Patients Who Have Received Gemcitabine-Based Chemotherapy.

Purpose The standard of care for second-line therapy in patients with advanced pancreatic cancer after gemcitabine-based therapy is not clearly defined. The CONKO-003 phase III study reported a survival benefit with second-line fluorouracil (FU) and oxaliplatin using the oxaliplatin, folinic acid, and FU (OFF) regimen. 1 PANCREOX was a phase III multicenter trial to evaluate the benefit of FU and oxaliplatin administered as modified FOLFOX6 (mFOLFOX6; infusional fluorouracil, leucovorin, and oxaliplatin) versus infusional FU/leucovorin (LV) in this setting. Patients and Methods Patients with confirmed advanced pancreatic cancer who were previously treated with gemcitabine therapy and with an Eastern Cooperative Oncology Group performance status of 0-2 were eligible. A total of 108 patients were randomly assigned to receive biweekly mFOLFOX6 or infusional FU/LV until progression. Progression-free survival (PFS) was the primary end point. Results Baseline patient characteristics were similar in both arms. No difference was observed in PFS (median, 3.1 months v 2.9 months; P = .99). Overall survival (OS) was inferior in patients assigned to mFOLFOX6 (median, 6.1 months v 9.9 months; P = .02). Increased toxicity was observed with the addition of oxaliplatin, with grade 3/4 adverse events occurring in 63% of patients who received mFOLFOX6 and 11% of those who received FU/LV. More patients in the mFOLFOX6 arm withdrew from study due to adverse events than in the FU/LV arm (20% v 2%), whereas the use of postprogression therapy was significantly higher in the FU/LV arm (25% v 7%; P = .015). No significant differences were observed in time to deterioration on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 global health scale. Conclusion No benefit was observed with the addition of oxaliplatin, administered as mFOLFOX6, versus infusional FU/LV in patients with advanced pancreatic cancer previously treated with first-line gemcitabine.

Arthroscopic treatment for internal contracture of the shoulder secondary to brachial plexus birth palsy: report of a case series and review of the literature.

OBJECTIVES: Internal rotation contracture of the shoulder is a common complication in children with brachial plexus birth palsy (BPBP), causing early functional limitation and glenohumeral dysplasia. Arthroscopic arthrolysis has recently been described as a treatment for the sequelae of this condition. METHODS: Review of five patients who underwent shoulder arthroscopy by anterior capsulotomy and partial tenotomy of the subscapularis. Both clinical and functional assessments were made (Mallet classification). Perioperative monitoring was conducted using MRI and ultrasound. RESULTS: The diagnosis was BPBP of the upper trunks (C5-C6) in all five patients (four girls and one boy, with a mean age of 2.8 years). The mean follow-up period was 19.9 months (range 12.8-39.9). The mean improvement obtained was 3.8 points according to the Mallet classification, 48° of external rotation and 54° of shoulder abduction. CONCLUSIONS: Arthroscopic arthrolysis of the shoulder in children with BPBP sequelae (internal rotation contractures) is a safe and effective procedure that produces clinical improvement in function and mobility.

Trapezio-metacarpal arthrodesis: procedure and results.

The high prevalence of trapezio-metacarpal joint (TMJ) osteoarthritis leads to develop techniques to improve surgical outcomes when conservative treatment has failed. We have evaluated 18 patients with Eaton III TMJ osteoarthritis, who underwent an arthrodesis. Using a dorsal-radial curved shaped skin incision the TMJ was exposed through the space between the abductor pollicis longus and the extensor pollicis brevis muscles. The articular capsule was divided and the TMJ was opened. Neat curettage was then performed in both joint surfaces by removing all the articular cartilage until some cancellous bone hints appeared underneath. The joint was then fixed in the optimal position by a 1.6 mm Kirschner wire and a 1.1 mm guide wire. A cannulated drill for the guide wire was used and matched to a cannulated lag screw. Then, a cylinder-shaped cancellous bone autograft harvested from the distal radius by a percutaneous approach was applied in the hole by drilling backwards in order to spread the bone about onto the hole walls. The joint was then definitively fixed by the cannulated lag screw. The K wires were removed by that time. DASH score changed from an average of 68 in the preoperative assessment to 39.4 at the end of the evolution time. The evolution of pain has decreased from 9.2 points preoperatively to 3.9 points in the postoperative using the visual analogue scale. In terms of mobility, it has decreased from 4 points preoperatively to 3.9 postoperatively, 14 patients got opposition of the thumb to the fifth finger, two of them to the head of the fifth metacarpal bone, one patient to the fourth finger, and one to the third. This slight decrease of mobility had no effect on performing activities of daily life, as expressed by the patients. The grip strength increased from 17 to 21.7 kg and the thumb opposition from 7.8 to 11.2 kg. All patients, except one, would have the operation again after knowing the final results. This patient said that results did not meet previous expectations. On the radiographic evaluation, consolidation has been achieved in 17 patients. When thumb carpo-metacarpal arthrodesis is indicated, the procedure provides a reliable and lasting treatment with satisfactory results. The development of new implants and the possibility of introducing autologous graft percutaneously as is described using this technique leads to improve the results.

Recurrent renal cell cancer: 10 years or more after nephrectomy.

Localized renal cell carcinoma (RCC) responds well to surgery. Patients often question how long they have to be on surveillance after their surgery. Several follow-up patterns have been described in the literature. Until 2009, no published established Canadian guidelines existed to assist Canadian health-care practitioners in the surveillance of these patients. We present 3 cases of RCC that recurred 10 years or longer after the initial nephrectomy. These cases emphasize the need for careful long-term follow-up, as recommended in the Canadian Urological Association guidelines. We also discuss the optimism of prolonged disease survival in the era of novel therapeutic agents that target angiogenesis.

A 4-aminoquinoline derivative that markedly sensitizes tumor cell killing by Akt inhibitors with a minimum cytotoxicity to non-cancer cells.

The purpose of this study was to evaluate the enhancement value of chloroquine analogs when used in combination with Akt inhibitors on the MDA-MB468, MDA-MB231 and MCF7 human breast cancer cell lines. The result showed that the combination of certain chloroquine analogs and Akt inhibitors are highly effective. In particular, the chloroquine analog N'-(7-fluoro-quinolin-4-yl)-N,N-dimethyl-ethane-1,2-diamine (compound 5) was highly effective in sensitizing cancer cell killing when combined with either Akt inhibitor 8 (1-{1-[4-(7-phenyl-1H-imidazo[4,5-g]quinoxalin-6-yl)-benzyl]-piperidin-4-yl}-1,3-dihydro-benzoimidazol-2-one) or 9 ([4-(2-chloro-4a,10a-dihydro-phenoxazin-10-yl)-butyl]-diethyl-amine hydrochloride). Importantly, the enhancement of chloroquine analogs 5 on cell killing by Akt inhibitors 8 and 9 was cancer-specific. Thus, this combinational approach is highly promising in controlling tumors with a minimum side effect. Structural analysis of effective and ineffective chloroquine analogs suggests that the 4-aminoquinoline scaffold and lateral side chain of dimethylamino functionality play an important role for the enhancement of cell killing by Akt inhibitors.

Uncaria tomentosa acts as a potent TNF-alpha inhibitor through NF-kappaB.

AIM OF THE STUDY: Uncaria tomentosa, commonly known as Cat's Claw or Uña de gato, is a medicinal plant that has been shown to have effective anti-inflammatory activities. We have previously shown that treatment of monocyte-like THP-1 cells with Uncaria tomentosa inhibits the production of the pro-inflammatory cytokine TNF-alpha while augmenting the production of IL-1beta. Since TNF-alpha and IL-1beta are usually regulated similarly and share a number of common promoter elements, including NF-kappaB and AP-1, the ability of Uncaria tomentosa to differentially regulate these inflammatory cytokines is of particular interest. MATERIALS AND METHODS: To determine the mechanism of action of Uncaria tomentosa, we investigated the effects of specific inhibitors of NF-kappaB on cellular responses including transcription factor activation using TransAM assays, the expression of cytokines as measured by ELISA, and cell survival as measured by changes in cell number following treatment. RESULTS: Treatment with Uncaria tomentosa inhibited the LPS-dependent activation of specific NF-kappaB and AP-1 components. In addition, treatment with Uncaria tomentosa enhanced cell death when NF-kappaB was inhibited. The ability of Uncaria tomentosa to inhibit TNF-alpha production was diminished when NF-kappaB activation was prevented by drugs that mask NF-kappaB subunit nuclear localization signals, while IL-1beta expression was unchanged. CONCLUSIONS: These results demonstrate that Uncaria tomentosa is able to elicit a response via an NF-kappaB-dependent mechanism. Further studies to characterize the mechanism by which Uncaria tomentosa can affect this pathway could provide a means to develop anti-TNF-alpha therapies.

Tendencia a la violencia e ideación suicida en adolescentes escolares en una ciudad de la Amazonía Peruana / Tendency to violence and suicidal ideation in school-aged

Tanto el suicidio como la violencia en adolescentes son fenómenos prevalentes en el mundo. Objetivos. Determinar la prevalencia de la ideación suicida y su asociación con tendencia a la violencia dirigida hacia otros, en adolescentes escolares. Materiales y métodos. Estudio transversal analítico, realizado en la ciudad amazónica de Pucallpa, Perú, en marzo-abril de 2008. Se aplicaron preguntas sobre tendencia a la violencia e ideación suicida del cuestionario de salud mental adaptado. La muestra fue seleccionada sistemáticamente, fueron 530 adolescentes de 12 a 19 años en los tres más grandes colegios de la ciudad. Resultados. El 31,3 por ciento de los encuestados presentó deseos pasivos demorir, 21,1 por ciento pensó en quitarse la vida y el 18,1 por ciento intentó suicidarse alguna vez, con mayoría en mujeres y en el grupo de 15 a 19 años. La tendencia a la violencia se expresó en pensamiento en 51,7 por ciento y en conducta violenta en 18,7 por cientode la muestra, predominantemente en varones (p menor que 0,001). Mediante el análisis multivariado, se encontró asociación ideación suicida y conducta violenta (OR=4,9 IC95 por ciento 1,4-17,5), pero no con pensamiento heteroagresivo (OR=2,1 IC95 por ciento 0,9-4,9). Conclusión. Existe alta prevalencia de ideación suicida y, haber pensado en quitarse la vida se asociócon haber presentado conducta violenta dirigida hacia otro. Rastrear y tratar a adolescentes violentos puede contribuira la disminución de la violencia y también del riesgo de suicidio.

Both suicide and violence among adolescents are prevalent phenomena in the world. Objectives. To determine theprevalence of suicidal ideation and its association with tendency to violence towards others, in school-aged youths.Material and methods. Analytical cross-sectional study conducted in the Peruvian Amazon city of Pucallpa, between March and April 2008. Questions about the tendency to violence and suicidal ideation were applied from adapted questionnaire of mental health. The sample was selected systematically, were 530 adolescents from 12 to 19 years-old in the three largest schools in the city. Results. 31.3 per cent of those polled presented passive wishes to die, 21.1 per cent thought to commit suicide and 18.1 per cent attempted suicide at least once in life, predominantly in females and in the group from 15 to 19 years-old. The trend of violence is expressed in thought (51.7 per cent) and violent behavior (18.7 per cent) predominantly in males(p minor that 0,001). By multivariate analysis, suicidal ideation was associated with violent behavior (OR = 4.9 IC95 per cent 1.4-17.5)and not with heteroaggressive thinking (OR = 2.1 IC95 per cent 0.9-4.9). Conclusions. There is high prevalence of suicidal ideation and have thought to commit suicide was associated with violent behavior. Track and treating violent adolescents can contribute to decrease violence and risk of suicide.

Treatment of THP-1 cells with Uncaria tomentosa extracts differentially regulates the expression if IL-1beta and TNF-alpha.

Uncaria tomentosa, commonly known as cat's claw, is a medicinal plant native to Peru, which has been used for decades in the treatment of various inflammatory disorders. Uncaria tomentosa can be used as an antioxidant, has anti-apoptotic properties, and can enhance DNA repair, however it is best know for its anti-inflammatory properties. Treatment with Uncaria tomentosa extracts inhibits the production of the pro-inflammatory cytokine, TNF-alpha, which is a critical mediator of the immune response. In this paper, we showed that treatment of THP-1 monocyte-like cells with Uncaria tomentosa extracts inhibited the MAP kinase signaling pathway and altered cytokine expression. Using ELISA assays, we showed that treatment with Uncaria tomentosa extracts augmented LPS-dependent expression of IL-1beta by 2.4-fold, while inhibiting the LPS-dependent expression of TNF-alpha by 5.5-fold. We also showed that treatment of LPS-stimulated THP-1 cells with Uncaria tomentosa extracts blocked ERK1/2 and MEK1/2 phosphorylation in a dose-dependent manner. These data demonstrate that treatment of THP-1 cells with Uncaria tomentosa extracts has opposite effects on IL-1beta and TNF-alpha secretion, and that these changes may involve effects on the MAP kinase pathway.

Phase II clinical trial results involving treatment with low-dose daily oral cyclophosphamide, weekly vinblastine, and rofecoxib in patients with advanced solid tumors.

PURPOSE: Preclinical studies indicate that conventional chemotherapeutic agents given continuously at low doses (metronomic chemotherapy) may provide an improved therapeutic index. Cyclophosphamide and vinblastine have been best studied in experimental models, where tumor growth inhibition is achieved, at least in part, through antiangiogenic mechanisms. EXPERIMENTAL DESIGN: Fifty patients with advanced solid tumors were enrolled in this phase II trial, 43 of whom had received at least one prior chemotherapy regimen. Patients were required to have Eastern Cooperative Oncology Group performance status of < or = 2, a life expectancy of >3 months, and at least one measurable lesion. All patients received oral cyclophosphamide (50 mg) and rofecoxib (25 mg) daily in addition to weekly injections of vinblastine (3 mg/m2). Half of the patients also received minocycline (100 mg) orally twice daily with the intent of further inhibiting tumor angiogenesis. The primary end point of the study was clinical benefit, defined as the percentage of patients experiencing an objective response or exhibiting stable disease for at least 6 months. RESULTS: For the 47 eligible patients, there were two (4%) complete responses and four (9%) partial responses, for an overall objective response rate of 13%. An additional eight patients achieved disease stabilization (stable disease > or = 6 months) (17%). The primary end point of clinical benefit was therefore 30%, (95% confidence interval, 16-44%). The median progression-free survival for all patients was 103 days and 289 days for patients experiencing clinical benefit. The incidence of patients experiencing grade 3/4 toxicities were as follows: neutropenia (10/2), anemia (2/0), and thrombocytopenia (1/0). No patients developed grade 3 or 4 nausea, vomiting, mucositis, or alopecia. CONCLUSIONS: This low-dose regimen consisting of daily oral cyclophosphamide and weekly vinblastine injections given concurrently with rofecoxib is associated with minimal toxicity and provides significant clinical benefit to patients with advanced solid tumors. These results are particularly encouraging given the nature of the study population and indicate that this approach merits further investigation in specific disease site studies.