Brooke-Spiegler Syndrome with Parotid Gland Involvement.

A 60-year-old black man, working in construction sector, was referred to dermatology clinic for having multiple hardened and asymptomatic tumors on the scalp, face, and trunk for more than 40 years. There was a progressive increase in the number and size of lesions, causing significant aesthetic and functional impairment. In his family history, a son had numerous normochromic papules on the centrofacial region with a diagnosis of multiple trichoepithelioma. The deceased mother of our patient presented lesions similar to those of her grandson but without a confirmatory diagnosis. (SKINmed. 2023;21:47-50).

Technical Aspects of Using a Second Magnetic Grasper to Improve the Surgical Field in Single Port Revisional Bariatric Surgery.

BACKGROUND: The future of minimally invasive surgery in revisional surgery is experiencing changes with new equipment such as the magnetic assistance that can be used with single port devices in order to perform an incisionless surgery (Luengas R, Galindo J, Castro M, et al. Surg Obes Relat Dis. 2021;17(1):147-152). Magnetic assistance through an auxiliary grasper with two internal magnets serves beyond liver retraction in different steps of the surgery improving the surgical field by obtaining a better visualization and triangulation. PURPOSE: Expose the feasibility of using two internal magnetic graspers by single port performing a conversion surgery of sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB). METHODS: A 36-year-old female patient underwent a SG in 2015 and consults in 2021 because of severe GERD with a 33-point GERD-HRQL score. She has preoperative evaluation for a conversion surgery from SG to RYGB. Using a single port device through the umbilicus, an additional 5 mm trocar was placed in the left side of the abdomen. Two internal magnets were introduced through the umbilicus, and they were controlled by two external magnets placed over the abdomen with an articulated arm. The first magnet was used for liver retraction and the second one to perform both anastomoses, close the intermesenteric and Petersen defect, acting as an auxiliary grasper. The ethical committee approval was obtained through an informed consent from the participant included in the study.

Keloids and Hypertrophic Scars.

Keloids and hypertrophic scars are abnormal responses to wound-healing. While hypertrophic scars remain limited to the areas of trauma, keloids most often develop over several years, growing out from the limits of the initial wound area. Both lesions may cause itching, burning, and pain, and they may lead to significant impairment of self-esteem, socialization, and quality of life. Although they might be observed in all races, they are far more common in Africans and African descendants than in Caucasians.We extensively reviewed their treatment, including compression with pressure garments, occlusion with siliconized and non-siliconized gel sheets, gels, corticosteroid and antineoplastic injections, and the use of lasers and intense pulsed light (IPL) therapy. We also reviewed new therapies, including botulinum toxin injection, and addressed outcomes of various studies. (SKINmed. 2022;20:432-443).

Intergenerational transmission of parental smoking: when are offspring most vulnerable?

BACKGROUND: Previous literature has showed that the likelihood of smoking is higher among offspring with smoking parents. The aim of this cohort study is to investigate during which smoking initiation stages and at what ages adolescents are more likely to be influenced by parental smoking. METHODS: This study used the EPITeen Cohort, which recruited 13-year-old adolescents born in 1990, enrolled at schools in Porto, Portugal. Participants (n = 996) were followed across four waves at 13, 17, 21 and 24 years old. We computed the odds ratio (OR) and 95% confidence intervals for the prevalence of the different smoking states (never smoking, experimenter, less than daily smoker, daily smoker and former smoker), and incidence transitions between these states (to smoking experimenter; to less than daily smoker, to daily smoker; to former smoker) as function of age, parental smoking status and their interaction. RESULTS: Compared with other participants, those with two smoking parents had an increased prevalence of experimentation at 13 years (OR for the interaction at 13 years compared with 24 years = 2.13 [1.50-3.01]) and daily smoking at all ages (OR for parental smoking =1.91 [1.52-2.40]). The latter increase is related to a significantly increased risk to transit from early smoking stages to daily smoking at all ages (OR for parental smoking = 1.83 [1.43-2.34]). CONCLUSIONS: Parental smoking influences offspring's daily smoking prevalence especially by increasing the risk to transit to daily smoking up to early adulthood. Prevention should focus on parents and parental influences especially among offspring who may transition to daily smokers.

Evaluation of cardiovascular risk in patients with psoriatic disease in a multiracial population: a cross-sectional study.

BACKGROUND: Psoriatic disease (PD) is a chronic inflammatory disorder often associated with cardiovascular risk (CVR) factors such as obesity, hypertension, diabetes, dyslipidaemia and smoking. It is estimated that 2%-4% of the population worldwide has PD. Cutaneous lesions of psoriasis (PsO) may be associated with psoriatic arthritis (PsA) in up to 40% of patients. Studies have been carried out around the world with the aim of evaluating CVR in such patients. AIM: To determine CVR in a multiracial population with PsA or PsO from southeastern Brazil, which has a predominantly tropical climate, compared with controls. METHODS: A cross-sectional study was carried out in outpatients with PsO or PsA followed up at a quaternary referral hospital in Rio de Janeiro. The Framingham Risk Score (FRS) was used to predict cardiovascular events (CVEs) over 10 years in patients with PsO and PsA compared with controls. RESULTS: FRS was significantly higher at 10 years in patients with PsO (mean ± SD 16.3 ± 14) and PsA (18.0 ± 15) compared with controls (10.6 ± 9.5) (P = 0.01) and also increased with age. The chance of having a high FRS in the PsO and PsA groups increased by 0.30 and 0.23 times per year, respectively, compared with controls (PsO vs. controls 95% CI 0.090-1.00; PsA vs. controls 95% CI 0.08-0.75). CONCLUSION: In this multiethnic Brazilian population, both PsO and PsA were associated with higher CVR compared with controls. The frequency of high FRS was highest in the sixth decade of life for all three groups of participants. Annual assessment of patients with PD is necessary in order to prevent CVEs.

Radiological Structured Report Integrated with Quantitative Imaging Biomarkers and Qualitative Scoring Systems.

The benefits of structured reporting (SR) in radiology are well-known and have been widely described. However, there are limitations that must be overcome. Radiologists may be reluctant to change the conventional way of reporting. Error rates could potentially increase if SR is used improperly. Interruption of the visual search pattern by keeping the eyes focused on the report rather than the images may increase reporting time. Templates that include unnecessary or irrelevant information may undermine the consistency of the report. Last, the lack of support for multiple languages may hamper the adaptation of the report to the target audience. This work aims to mitigate these limitations with a web-based structured reporting system based on templates. By including field validators and logical rules, the system avoids reporting mistakes and allows to automatically calculate values and radiological qualitative scores. The system can manage quantitative information from imaging biomarkers, combining this with qualitative radiological information usually present in the structured report. It manages SR templates as plugins (IHE MRRT compliant and compatible with RSNA's Radreport templates), ensures a seamless integration with PACS/RIS systems, and adapts the report to the target audience by means of natural language extracts generated in multiple languages. We describe a use case of SR template for prostate cancer including PI-RADS 2.1 scoring system and imaging biomarkers. For the time being, the system comprises 24 SR templates and provides service in 37 hospitals and healthcare institutions, endorsing the success of this contribution to mitigate some of the limitations of the SR.

[Multidisciplinary approach in the lymphedema patient: From rehabilitation to microsurgery]. / Abordaje multidisciplinar en el paciente con linfedema: de la rehabilitación a la microcirugía.

Lymphedema is a chronic disease with a high incidence in our society. In this paper, we present a review with the latest advances in imaging techniques and surgical reconstructive treatment of lymphedema (lymphovenous anastomosis, vascularized lymph node transfer, and prophylactic lymphedema surgery). In addition, a protocol is established based on a multidisciplinary team (composed of physiatrists, plastic surgeons, radiologists and nuclear medicine radiologists) to optimize the treatment of these patients.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters.

INTRODUCTION AND AIMS: The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes. MATERIALS AND METHODS: A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion. RESULTS: The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%. CONCLUSIONS: Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

Tuberous Sclerosis.

Tuberous sclerosis is a rare autosomal dominant genetic disorder. It is characterized by the appearance of benign tumors, known as hamartomas, which can affect multiple organs, including the skin. Cutaneous manifestations are present in almost all patients; therefore, the dermatologist has a fundamental role in the history and evolution of the disease in spite of being a multisystemic disorder. Two tumor suppressor genes, CET1 and CET2, involved in tissue growth and cell proliferation, show mutation in this disease, which leads to the appearance of various benign tumors, hamartomas. Clinical characteristics are more than three hypomelanotic macules, more than three angiofibromas or face or scalp cephalic fibrotic plaque, more than two ungual fibromas, shagreen plaque, multiple retinal hamartomas, etc. Treatment is basically symptomatic, and genetic counseling is very important. This is an autosomal dominant disorder, although there is spontaneous mutation and no familial history in 65% of patients. When one of the parents is affected, genetic study is useful for prenatal diagnosis.

Paraneoplastic Dermatoses in Breast Cancer: Malignant Acanthosis Nigricans with Tripe Palm.

Our patient was a 43-year-old, single black woman, born and living in Paracambi, State of Rio de Janeiro, who worked as a surgical instrumentalist. She was sent to our sector of dermatology due to hypochromia and diffuse skin roughness that had first appeared 8 years previously. She had been diagnosed 6 months before admission with ductal infiltrating metastatic carcinoma in the right breast, with therapeutic failure of chemotherapy and radiotherapy. Her menarche had occurred at age 13 years, she reported normal menstrual cycles from there on, and she had never been pregnant. She denied neoplasias and other comorbidities in her family history.

Cutaneous Horn of the Glans.

Cutaneous horn is a protuberance constituted by compact keratinous material, with a hard consistence similar to a horn, which occurs more frequently in photoexposed areas. The authors describe a case of cutaneous horn on the glans considered a rare location. Verrucous carcinoma was the histopathological diagnosis of the base of the horn and lichen sclerosis, the precursor lesion.

Oversewing staple line of the gastric remnant in gastric bypass reduces postoperative bleeding.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is a surgery with low rate complications. However, it is not exempt from them, and 1-6% suffer complications such as postoperative bleeding. Many intraoperative techniques have been evaluated to reduce postoperative bleeding, like the oversewing or reinforcement of the staple line. This study aims to evaluate the rate of postoperative bleeding in the oversewing of the staple line of the gastric remnant group versus the stapling only group. METHODS: This is a 2-center, case-control study. We randomly selected two groups who underwent RYGB or OAGB: group A (n = 225) with oversewing from 2019 to 2020 and group B (n = 225) with stapling only between the period of 2017-2018; both groups with similar demographic characteristics. RESULTS: The overall mean age was 37.39 ± 9.6 years and mean BMI was 41.59 ± 8.6 kg/m2; the postoperative bleeding rate was significantly lower (p < 0,05) in patients with oversewing of the staple line of the gastric remnant. Operative time was shorter for the stapling only group and the difference between the mean operative time was 10.6 min. CONCLUSIONS: Oversewing the staple line of the gastric remnant significantly reduces the incidence of postoperative bleeding regardless of BMI. Being a cost-effective technique compared to others available despite the increase in operating time.

"Coisa de menina": implicações e atribuições do feminino no atendimento de uma adolescente / "Girly things": implications and attributions of feminine aspects on an adolescent's psychological care / "Cosa de niña": implicaciones y atribuciones del femenino en el cuidado de una adolescente / « Chose de fille ¼: implications et attributions du féminin pendant une séance avec une adolescente

O presente artigo tem como objetivo discutir aspectos e atribuições do feminino na constituição da mente e expressão da sexualidade de uma adolescente de 13 anos de idade. Para tal, são utilizados excertos de sessões realizadas ao longo de um ano e meio de trabalho psicanalítico. O discurso apresentado pelos pais significa a feminilidade com uma compreensão apoiada na fantasia da falta originária, na qual as características da menina se afirmam pelo que ela não tem e não pode ser, limitando possibilidades mais genuínas de reconhecimento. Quanto à paciente, a recusa da feminilidade é discutida, não como uma expressão ontológica, mas defensiva, de modo a encontrar meios de existência própria em oposição às expectativas dos pais. O artigo discute aspectos de "vir a ser", próprios da adolescência, precedentes à definição da sexualidade propriamente dita, compreendendo o feminino como construção individual que virá a qualificar possibilidades de expressão do eu em continência e criatividade.

The present article's main objective was to discuss implications and attributions of feminine aspects in the constitution of the mind and the expression of sexuality of a thirteen-year-old girl. For such, fragments of sessions held over one and a half years of psychoanalytical care were used. Parent's discourse comprehends femininity based on the concept of original absence, in which girl's characteristics are affirmed by what she lacks and cannot be, limiting more genuine possibilities of recognition. As for the patient, the refusal of femininity is discussed not as an ontological expression, but as a defensive one, in a way to find means of self existence in opposition to the parent's expectations. The article approaches aspects of "coming to be", particular to adolescence, that precedes the final definition of sexuality, interpreting the feminine as an individual construction that will come to qualify possibilities of expression of the self in continence and creativity.

Este artículo tiene como objetivo discutir aspectos y atribuciones del femenino en la constitución de la mente y expresión de la sexualidad de una adolescente de trece años. Para eso, son utilizados fragmentos de sesiones realizadas durante un año y medio de trabajo psicoanalítico. El discurso presentado por los padres significa la feminidad por una comprensión basada en la fantasía de la carencia original, en la que las características de la niña son afirmadas por lo que no tiene y no puede ser, limitando posibilidades de reconocimiento más genuinas. En cuanto a la paciente, se discute el rechazo de la feminidad no como una expresión ontológica, sino como una expresión defensiva, para encontrar formas de existencia propia en oposición a las expectativas de los padres. El artículo discute aspectos del "venir a ser" propios de la adolescencia, precedidos a la definición de sexualidad, entendiendo lo femenino como una construcción individual que calificará las posibilidades de expresión del yo en la continencia y la creatividad.

Cet article, il a comme but de discuter les aspects et les attributions du féminin dans la constitution mentale et l'expression de la sexualité d'une jeune fille de treize ans. Pour cela, ce sont utilisés des extraits de séances de travaux psychanalytiques réalisées pendant un an et demi. Le discours présenté par les parents signifie la féminilité avec une compréhension appuyée sur la fantaisie du manque originaire, dans laquelle les caractéristiques de la fille se soutiennent par ce qu'elle n'en a pas et ne peut pas être, limitant ainsi les possibilités les plus originales de reconnaissance. Quant à le patient, le refus de la féminilité est discuté pas comme une expression ontologique mais défensive, donc de trouver des moyens d'existence propre en opposition aux expectatives des parents. L'article questionne des aspects de « devenir ¼ propres de l'adolescence qui précède à la définition de la sexualité, proprement dite, comprenant le féminin comme construction individuelle qui pourra qualifier des possibilités d'expression du moi en continence et en créativité.

Establishment of a production process for a novel vaccine candidate against Lawsonia intracellularis

BACKGROUND: Lawsonia intracellularis remains a problem for the swine industry worldwide. Previously, we designed and obtained a vaccine candidate against this pathogen based on the chimeric proteins: OMP1c, OMP2c, and INVASc. These proteins formed inclusion bodies when expressed in E. coli, which induced humoral and cellular immune responses in vaccinated pigs. Also, protection was demonstrated after the challenge. In this study, we established a production process to increase the yields of the three antigens as a vaccine candidate. RESULTS: Batch and fed-batch fermentations were evaluated in different culture conditions using a 2 L bioreactor. A fed-batch culture with a modified Terrific broth medium containing glucose instead of glycerol, and induced with 0.75 mM IPTG at 8 h of culture (11 g/L of biomass) raised the volumetric yield to 627.1 mg/L. Under these culture conditions, plasmid-bearing cells increased by 10% at the induction time. High efficiency in cell disruption was obtained at passage six using a high-pressure homogenizer and a bead mill. The total antigen recovery was 64% (400 mg/L), with a purity degree of 70%. The antigens retained their immunogenicity in pigs, inducing high antibody titers. CONCLUSIONS: Considering that the antigen production process allowed an increment of more than 70-fold, this methodology constitutes a crucial step in the production of this vaccine candidate against L. intracellularis.

Applicability and results of liver transplant combined with neoadjuvant chemo-radiotherapy in the treatment of unresectable hilar cholangiocarcinoma. / Aplicabilidad y resultados del trasplante hepático combinado con quimiorradioterapia neoadyuvante en el tratamiento del colangiocarcinoma perihiliar irresecable.

BACKGROUND: In 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA). AIM: To analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat. METHODS: Observational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found. RESULTS: Between 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5-192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years. CONCLUSION: The suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.

Pancreatic ductal adenocarcinoma: Eleven years of experience at a tertiary care hospital center. / Adenocarcinoma ductal de páncreas. Experiencia de 11 años en un centro de tercer nivel.

INTRODUCTION AND AIM: Pancreatic cancer is considered one of the most aggressive solid tumors. In Mexico, it is the twelfth cause of cancer, with 4,489 cases diagnosed annually, and accounts for 4.9% of oncologic deaths. The aim of our study was to describe the clinical and epidemiologic characteristics of the patients diagnosed with pancreatic cancer spanning an 11-year period at the Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". METHODS: A retrospective, cross-sectional study was conducted that included 479 patients diagnosed with pancreatic cancer, within the time frame of 2003-2013. The documented findings were summarized through descriptive statistics. RESULTS: Of the patients with pancreatic ductal adenocarcinoma, 50.9% were women, and the mean patient age at diagnosis was 61.5 years. A total of 48.4% of the cases were diagnosed at clinical stage IV, 12.9% presented with clinical stage III, and 25.0% had localized disease. Surgery was performed on 37.5% of the patients, the most frequent of which was pancreatoduodenectomy. The surgical mortality rate was 5.5%. CONCLUSION: The clinical characteristics in our study group were similar to those described in the literature. However, the number of candidates for surgical treatment was higher than that reported in other hospitals and the percentage of borderline tumors was lower. Those differences, respectively, are possibly associated with the nature of our referral center and the prolonged intervals between diagnosis and treatment that result in the loss of potential surgical patients.