Colesteatoma del conducto auditivo externo: Experiencia de 5 años Hospital del Salvador / External ear canal cholesteatoma: 5-year experience Hospital del Salvador

Introducción: El colesteatoma del conducto auditivo externo (CCAE) es una estructura quística revestida por epitelio escamoso estratificado queratinizado que tiene la capacidad de invadir y erosionar localmente al hueso temporal. Su incidencia es de 0,19 a 0,3/100.000 habitantes siendo 60 veces menos frecuente que el de oído medio. Objetivo: Describir las características epidemiológicas, clínicas, imagenológicas y tratamiento de los pacientes diagnosticados con CCAE en el Servicio de Otorrinolaringología Hospital del Salvador. Material y Método: Se presenta una serie de ocho casos clínicos recopilados durante el período 2017 y 2021. Se realizó revisión de fichas clínicas, biopsias y tomografías computadas de oídos (TC oídos). Se describen los hallazgos y tratamiento efectuado. Resultados: El promedio de edad fue de 65,6 años, correspondiente a 5 mujeres y 3 hombres con presencia de tabaquismo y diabetes en la mitad de los casos. Los síntomas y signos más frecuentes fueron otalgia e hipoacusia seguido de otorrea. 7 pacientes se presentaron con tímpano íntegro y el compromiso de la pared inferior del conducto se evidenció en 6 de 8 pacientes. La TC oídos mostró erosión ósea del conducto, con o sin compromiso de estructuras adyacentes, en todos los casos y el diagnóstico histológico fue efectuado en el 100% de los pacientes. Se privilegió el tratamiento conservador mediante curaciones óticas periódicas asociado a ácido salicílico al 3% y/o antibióticos tópicos en 6/8 pacientes. Conclusiones: El CCAE es una entidad poco frecuente sin signos ni síntomas patognomónicos por lo que el diagnóstico histológico junto con el estudio imagenológico es perentorio. El tratamiento conservador es una alternativa terapéutica válida que ofrece buenos resultados en pacientes con adecuada adherencia al tratamiento y posibilidad de seguimiento estricto.

Introduction: External ear canal cholesteatoma (EECC) is a cystic structure lined by keratinized stratified squamous epithelium that has the ability to locally invade and erode the temporal bone. Its incidence is 0.19 to 0.3 / 100,000 habitants, being 60 times less frequent than that of the middle ear. Aim: To describe the epidemiological, clinical, imaging and treatment characteristics of patients diagnosed with EECC in the Hospital del Salvador ENT department. Material and Methods: A series of eight clinical cases collected during the period 2017 and 2021 is presented. A review of clinical records, biopsies and computed tomography of the ear (ear CT) was carried out. The findings and treatment carried out are described. Results: The average age was 65.6 years corresponding to 5 women and 3 men with the presence of smoking and diabetes in half of the cases. The most frequent symptoms and signs were earache and hearing loss followed by otorrhea. 7 patients presented with an intact eardrum and compromise of the inferior wall of the canal was evidenced in 6 of 8 patients. Ears CT showed bone erosion of the canal with or without compromise of adjacent structures in all cases and the histological diagnosis was made in 100% of the patients. Conservative treatment with periodic ear dressings associated with 3% salicylic acid and / or topical antibiotics was favored in 6/8 patients. Conclusion: EECC is a rare entity without pathognomonic signs or symptoms, therefore the histological diagnosis together with the imaging study is peremptory. Conservative treatment is a valid therapeutic alternative that offers good results in patients with adequate adherence to treatment and the possibility of strict follow-up.

Type II hiatal hernias: do they exist or are they actually parahiatal hernias?

BACKGROUND: Type II hiatal hernias (HH) are characterized by a portion of the gastric fundus located above the esophageal hiatus adjacent to the esophagus while the gastroesophageal junction (GEJ) remains fixed below the esophageal hiatus. This type of HH has been called the "true" paraesophageal hernia (PEH) because the fundus appears to the side of the esophagus. In our experience, Type II HHs are occasionally identified on radiographic testing, however they are rarely, if ever, confirmed intraoperatively. This led to our question: Does Type II HH exist? METHODS: We searched for evidence of type II HH in three locations: 1. Retrospective review of all first-time PEH repairs (excluding Type I HHs and re-operative cases) performed at the University of Washington Medical Center from 1994 to 2021; 2. Operative videos available on YouTube and WebSurg websites; and 3. Abstracts from the SAGES annual meetings from 2005 to 2021. RESULTS: We found no evidence of Type II HH in any of our three searches. We performed 846 PEH repairs: 760 Type III, 75 Type IV, and 11 parahiatal. Upon website video review, we found only one possible type II hernia, though it too was likely a para-hiatal hernia. No video or case presentations of a type II HH were identified within SAGES annual meeting abstracts. CONCLUSION: Type II HHs do not exist as they are currently defined. Although uncommon, parahiatal hernia can easily be misinterpreted as Type II HH. We should consider changing the hiatal hernia classification system to prevent ongoing clinical confusion.

Nerve gaps repaired with acellular nerve allografts recellularized with Schwann-like cells: Preclinical trial.

BACKGROUND: Acellular nerve allografts (ANA) recellularized with mesenchymal stem cells (MSC) or Schwann cells (SC) are, at present, a therapeutic option for peripheral nerve injuries (PNI). This study aimed to evaluate the regenerative and functional capacity of a recellularized allograft (RA) compared with autograft nerve reconstruction in PNI. METHODS: Fourteen ovines were randomly included in two groups (n=7). A peroneal nerve gap 30 mm in length was excised, and nerve repair was performed by the transplantation of either an autograft or a recellularized allograft with SC-like cells. Evaluations included a histomorphological analysis of the ANA, MSC pre differentiated into SC-like cells, at one year follow-up functional limb recovery (support and gait), and nerve regeneration using neurophysiological tests and histomorphometric analysis. All evaluations were compared with the contralateral hindlimb as the control. RESULTS: The nerve allograft was successfully decellularized and more than 70% of MSC were pre differentiated into SC-like cells. Functional assessment in both treated groups improved similarly over time (p <0.05). Neurophysiological results (latency, amplitude, and conduction velocity) also improved in both treated groups at twelve months. Histological results demonstrated a less organized arrangement of nerve fibers (p <0.05) with an active remyelination process (p <0.05) in both treated groups compared with controls at twelve months. CONCLUSIONS: ANA recellularized with SC-like cells proved to be a successful treatment for nerve gaps. Motor recovery and nerve regeneration were satisfactorily achieved in both graft groups compared with their contralateral nontreated nerves. This approach could be useful for the clinical therapy of PNI.

Ophthalmological findings in patients with leukaemia in a Colombian population. / Hallazgos oftalmológicos en pacientes con leucemia en una población colombiana.

OBJECTIVE: To report the ocular manifestations in patients with leukaemia. METHODS: This is a retrospective, descriptive and observational study in patients with ocular manifestations of leukaemia. RESULTS: A total of 14 eyes were evaluated corresponding to 8 patients (5 women and 3 men) with ocular manifestations of leukaemia. The mean age at diagnosis was 43 years (31-76 years). Six eyes corresponded to patients with acute myeloid leukaemia (AML), four eyes to acute lymphoid leukaemia (ALL), two eyes to chronic myeloid leukaemia (CML), and the remaining two belonged to patients with hairy cell leukaemia (HCL). The primary ocular findings were choroidal invasion in 12 eyes (85.7%), retinal infiltration in 4 eyes (28.6%), and neuro-ophthalmic disorders in 4 eyes (28.6%). The mean visual acuity improved from 0.689 to 0.449 (logMAR) (P=.012) after the systemic and intrathecal chemotherapy. Of the eight patients, four died from systemic complications of the underlying disease. CONCLUSIONS: This is the first report of multiple ocular manifestations secondary to leukaemia in a Colombian population. It is important to keep in mind that this disease is included within the masquerade syndromes and that the ophthalmological findings that, while subtle, can also be devastating and be signs of a life-threatening disease.

[Bearing surfaces in primary hip arthroplasty. Is there any difference?] / Pares articulares en prótesis primaria de cadera. ¿Existe alguna diferencia?

INTRODUCTION: In primary hip replacement, different materials are used for bearing surfaces. In our medium metal or ceramic heads with highly crossed-linked polyethylene (PA) are the most used. These combinations have good results, but it is not clear which is clinically superior. The objective of this study is to determine whether there is any clinically significant difference based on a systematic review of the literature and national registries of arthroplasty. MATERIAL AND METHODS: We conduct a systematic review of the literature and national registries of arthroplasty and we were looking for studies comparing bearing surfaces: ceramic-highly cross-linked polyethylene (CP) and metal-highly cross-linked polyethylene (MP); describing the revision rate according to the surface type with a minimum 10-year follow-up. The outcome evaluated was: review rate for any cause depending on surface type. RESULTS: Two out of fifteen national registries were included. The Australian registry shows a difference in the 15-year revision rate: CP: 6.3 (IC 5.8, 6.7) vs MP: 5.1 (IC 4.6, 5.7). The New Zealand registry shows no differences in revision rate/100 components/year: CP 0.54 (0.48-0.61) vs MP 0.61 (0.57-0.66). We do not find clinical studies with inclusion criteria that answer the research question. CONCLUSION: The results of this review show a high survival rate with the use of highly cross-linked polyethylene, the results are similar when using ceramic or metal heads.

INTRODUCCIÓN: En un reemplazo total de cadera primario (RTC), diferentes materiales son los que se usan para las superficies de apoyo. En nuestro medio, las cabezas de metal o cerámica con polietileno altamente entrecruzado (PA) son los más utilizados. Estas combinaciones tienen buenos resultados, pero no es claro cuál es superior clínicamente. Basados en una revisión sistemática de la literatura y de los registros nacionales de artroplastía, el objetivo de este estudio es determinar si existe alguna diferencia significativa desde el punto de vista clínico. MATERIAL Y MÉTODOS: Realizamos una revisión sistemática de la literatura y de los registros nacionales de artroplastía. Buscamos estudios en los que se compararan los tipos de superficie de contacto: cerámica-polietileno altamente entrecruzado (CP) y metal-polietileno altamente entrecruzado (MP), además de los registros nacionales de artroplastía que describieran, con un seguimiento mínimo de 10 años, la tasa de revisión según el tipo de superficie. El desenlace evaluado fue: tasa de revisión por cualquier causa según el tipo de superficie. RESULTADOS: Dos de quince registros nacionales fueron incluidos: el registro australiano muestra una diferencia en la tasa de revisión a 15 años, comparando CP: 6.3 (IC 5.8, 6.7) contra MP: 5.1 (IC 4.6, 5.7). El registro de Nueva Zelanda no muestra diferencias en la tasa de revisión/100 componentes/año: CP de 0.54 (0.48-0.61) en comparación con MP de 0.61 (0.57-0.66). No encontramos estudios clínicos con los criterios de inclusión que respondan la pregunta de investigación. CONCLUSIÓN: Los resultados de esta revisión muestran una alta supervivencia cuando se usa polietileno altamente entrecruzado; asimismo, los resultados son similares cuando se utilizan cabezas de cerámica o metálicas.

Experiencia en estapedostomías en Hospital del Salvador entre 2012 y 2018 / Stapedotomy experience at Hospital del Salvador between 2012 and 2018

INTRODUCCIÓN: La otoesclerosis es una enfermedad de presumible origen metabólico que determina la fijación de la cadena osicular. La estapedostomía con instalación de prótesis es la cirugía de elección en la actualidad para esta patología. OBJETIVO: Describir experiencia y resultados del tratamiento quirúrgico de pacientes con otoesclerosis en el Hospital del Salvador entre los años 2012 y 2018. Material y método: Estudio descriptivo retrospectivo mediante revisión de fichas clínicas de pacientes intervenidos quirúrgicamente en nuestro servicio desde enero de 2012 hasta septiembre de 2018 con sospecha de otoesclerosis. RESULTADOS: Se realizaron en total 52 cirugías a 45 pacientes, 40 vía microscópica, 10 vía endoscópica y 2 mixtas, se utilizaron dos modelos de prótesis, Schuknecht - type piston and wire y Stapes-Prothesen. El promedio tonal puro (PTP) por vía aérea prequirúrgico fue de 65 dB, con una diferencia ósea-aérea (gap) promedio de 36 dB. El PTP promedio posquirúrgico fue de 35 dB con gap promedio de 9 dB, logrando en promedio una mejoría de 31 dB en la vía aérea y 27 dB de cierre de gap. El 92% de los pacientes intervenidos lograron mejoría con respecto al gap posoperatorio. CONCLUSIÓN: La estapedostomía es una intervención que si bien no está exenta de complicaciones, ha demostrado ser segura y tener buenos resultados auditivos en la mayoría de los pacientes.

INTRODUCTION: Otosclerosis is a presumable metabolic disease that determines ossicular chain fixation. Stapedotomy with prosthesis installation is the surgery of choice for this pathology at present. AIM: To describe the experience and results of the surgical treatment of patients with otosclerosis in the Hospital del Salvador between 2012 and 2018. MATERIAL AND METHODS: Clinical records were reviewed of patients treated surgically in our department from January 2012 to September 2018 with suspicion of otosclerosis. RESULTS: A total of 52 surgeries were performed in 45 patients, 42 via microscopy and 10 via endoscopy, two models of prostheses were used Schuknecht - type piston and wire y Stapes-Prothesen. The pure tonal average (PTP) by pre-surgical air was 65 dB, with an average air gap (gap) of 36 dB. The average post-surgical PTP was 35 dB with an average gap of 9 db, achieving on average an improvement of 31 dB in the airway and 27 dB of gap closure. 92% of the patients who underwent surgery improved with respect to the postoperative gap. CONCLUSION: The stapedotomy is an intervention that although not free of complications, has been shown to be safe and have good hearing results in most patients.

Historia del manejo de rinitis atrófica / The history of the treatment of atrophic rhinitis

La rinitis atrófica es una enfermedad crónica progresiva caracterizada por dilatación anormal de las cavidades nasales con atrofia de la mucosa, submucosa y cornetes nasales subyacentes. Los factores etiopatogénicos aún son desconocidos. Su presentación clínica consiste en congestión nasal paradójica asociado a secreciones viscosas, con presencia de costras secas de mal olor. La higiene nasal con irrigación de alto volumen y baja presión es el estándar de tratamiento médico. El tratamiento quirúrgico busca reducir el tamaño de las cavidades nasales y promover la regeneración de la mucosa nasal así como también su vascularización y lubricación. A lo largo de la historia se han descrito múltiples procedimientos quirúrgicos que han buscado estrechar la cavidad nasal para permitir el paso de aire de forma más fisiológica. Por otra parte, se han propuesto intervenciones radicales como el cierre de las fosas nasales para disminuir los síntomas y mejorar la calidad de vida. En este artículo se resumen los principales manejos y procedimientos propuestos junto con sus resultados y conclusiones. Si bien la mayoría de las técnicas descritas ya no se utilizan en la actualidad, es importante conocerlas ya que aún existen pacientes que fueron sometidos a ellas pudiendo presentar complicaciones y/o efectos adversos.

Atrophic rhinitis is a chronic progressive disease characterized by abnormal dilatation of the nasal cavities with atrophy of the mucosa, nasal submucosa and underlying nasal turbinates. The etiopathogenic factors are still unknown. Its clinical presentation consists of paradoxical nasal congestion associated with viscous secretions, usually with the presence of dry, bad-smelling crusts. Nasal hygiene with high pressure irrigation remains the standard of medical treatment. Surgical treatment seeks to reduce the size of nasal cavities and promote regeneration of nasal mucosa as well as its vascularization and lubrication. Throughout history, multiple surgical procedures have been described that have sought the narrowing of the nasal cavity to allow the passage of air more physiologically. On the other hand, radical interventions have been proposed such as the closure of the nostrils to reduce symptoms and improve quality. This article summarizes the main proposed procedures along with their results and conclusions. Although most of the techniques described are no longer used today, it is important to know them since there are still patients who were subjected to them and may present complications and / or adverse effects.

Pares articulares en prótesis primaria de cadera. ¿Existe alguna diferencia? / Bearing surfaces in primary hip arthroplasty. Is there any difference?

Resumen: Introducción: En un reemplazo total de cadera primario (RTC), diferentes materiales son los que se usan para las superficies de apoyo. En nuestro medio, las cabezas de metal o cerámica con polietileno altamente entrecruzado (PA) son los más utilizados. Estas combinaciones tienen buenos resultados, pero no es claro cuál es superior clínicamente. Basados en una revisión sistemática de la literatura y de los registros nacionales de artroplastía, el objetivo de este estudio es determinar si existe alguna diferencia significativa desde el punto de vista clínico. Material y métodos: Realizamos una revisión sistemática de la literatura y de los registros nacionales de artroplastía. Buscamos estudios en los que se compararan los tipos de superficie de contacto: cerámica-polietileno altamente entrecruzado (CP) y metal-polietileno altamente entrecruzado (MP), además de los registros nacionales de artroplastía que describieran, con un seguimiento mínimo de 10 años, la tasa de revisión según el tipo de superficie. El desenlace evaluado fue: tasa de revisión por cualquier causa según el tipo de superficie. Resultados: Dos de quince registros nacionales fueron incluidos: el registro australiano muestra una diferencia en la tasa de revisión a 15 años, comparando CP: 6.3 (IC 5.8, 6.7) contra MP: 5.1 (IC 4.6, 5.7). El registro de Nueva Zelanda no muestra diferencias en la tasa de revisión/100 componentes/año: CP de 0.54 (0.48-0.61) en comparación con MP de 0.61 (0.57-0.66). No encontramos estudios clínicos con los criterios de inclusión que respondan la pregunta de investigación. Conclusión: Los resultados de esta revisión muestran una alta supervivencia cuando se usa polietileno altamente entrecruzado; asimismo, los resultados son similares cuando se utilizan cabezas de cerámica o metálicas.

Abstract: Introduction: In primary hip replacement, different materials are used for bearing surfaces. In our medium metal or ceramic heads with highly crossed-linked polyethylene (PA) are the most used. These combinations have good results, but it is not clear which is clinically superior. The objective of this study is to determine whether there is any clinically significant difference based on a systematic review of the literature and national registries of arthroplasty. Material and methods: We conduct a systematic review of the literature and national registries of arthroplasty and we were looking for studies comparing bearing surfaces: ceramic-highly cross-linked polyethylene (CP) and metal-highly cross-linked polyethylene (MP); describing the revision rate according to the surface type with a minimum 10-year follow-up. The outcome evaluated was: review rate for any cause depending on surface type. Results: Two out of fifteen national registries were included. The Australian registry shows a difference in the 15-year revision rate: CP: 6.3 (IC 5.8, 6.7) vs MP: 5.1 (IC 4.6, 5.7). The New Zealand registry shows no differences in revision rate/100 components/year: CP 0.54 (0.48-0.61) vs MP 0.61 (0.57-0.66). We do not find clinical studies with inclusion criteria that answer the research question. Conclusion: The results of this review show a high survival rate with the use of highly cross-linked polyethylene, the results are similar when using ceramic or metal heads.

Laryngeal sequelae secondary to surgical treatment for recurrent respiratory papillomatosis in children.

OBJECTIVE: to describe the frequency and predictive factors associated with laryngeal scarring caused by surgical treatment of recurrent respiratory papillomatosis (RRP) in children. INTRODUCTION: RRP is an important cause of hoarseness and respiratory obstruction in children. The current standard of care for RRP is the systematic and repetitive surgical interventions. The repetitive surgeries may increase the risk of sequelae. A larger number of surgeries, the surgical technique used, and disease severity are related to an increased risk of scarring. MATERIAL AND METHODS: A retrospective, descriptive review of the medical charts of patients with RRP younger than 18 years was conducted. Between 2014 and 2017, 79 patients were identified; five patients were excluded. Demographic and clinical data were recorded and analyzed. The patients were divided into two groups, one with and the other without surgical sequelae, for comparison to identify sequela-associated factors. RESULTS: 75 patients, 40 (53.3%) male, were analyzed. Age at symptom onset ranged from 2 months to 13 years. Median age at the time of diagnosis was 42 months. Overall, 44% presented with disseminated disease. A median of nine (range, 1 to 86) surgeries were performed in each patient with a median of two (range, 0.6 to 10) of the average number of surgeries per year per patient. 29 patients (38.7%) had laryngeal sequelae. When comparing the patients with and without sequelae, statistically significant differences were found in the variables of dissemination during the course of the disease, overall number of surgeries and mean number of surgeries per year, history and number of previous surgeries at an outside institution, urgent surgeries, and CO2 laser use. Patients who underwent more than 10 surgeries or who had a history of previous surgeries at an outside institution had a higher frequency of laryngeal scarring in multivariate analysis. CONCLUSION: Scarring secondary to surgical treatment for RRP is common. Surgery-related variables seem to be predisposing factors. A greater number of surgeries and surgeries performed at less specialized centers are strongly related to this complication. Future studies with a larger sample size are necessary to determine whether other factors are involved.

Bilateral enucleation due to multi-bacterial fulminant endogenous panophthalmitis. / Enucleación bilateral por panoftalmitis endógena polimicrobiana fulminante.

The case is presented of a 62 year-old woman with a rapid, progressive bilateral decrease in visual acuity and panuveitis with orbital cellulitis. She was also in poor general condition, with emesis and fever. Septicaemia due to Klebsiella pneumoniae and bilateral endogenous panophthalmitis were diagnosed. The ocular infection quickly progressed to sclerokeratitis and bilateral perforation despite broad spectrum systemic antibiotic management, and eventually the patient required bilateral enucleation. Microbiological cultures of the surgical pieces identified Klebsiella pneumoniae and Candida magnoliae. To our knowledge, this is the third published case that required bilateral enucleation or evisceration due to endogenous panophthalmitis, and the first case of endogenous ocular infection caused by Candida magnoliae.

High incidence of anti-cytokine autoantibodies in dogs with immune diseases suggests important immuno-regulatory functions.

Autoantibodies against cytokines have been associated with immunodeficiency, susceptibility to infectious diseases, autoimmunity and inflammation in humans, but have not yet been investigated in the Veterinary field so far. The aim of the current study was to determine the presence of anti-cytokine autoantibodies in canines suffering from various conditions including recurrent infections, autoimmune diseases and cancer in comparison to healthy controls. This is the first report of the presence of autoantibodies against cytokines in dogs. A total of 101 serum samples (51 patients and 50 clinically healthy dogs) from the state of Mexico and surroundings were analysed using a multiplex bead-based flow cytometry assay. Results show significant levels of various anti-cytokine autoantibodies in diseased dogs but not in healthy controls. In addition we show distinct associations of various disease types to the specificity of anti-cytokine autoantibodies and to response complexities. Apart from the direct functional/causal implication of anti-cytokine auto-antibodies on disease processes, this findings point to the possibility to use anti-cytokine response patterns as diagnostic tools.

Estimulación Magnética Trascraneal "Theta-Burst Intermitente" en un paciente con Trastorno del Espectro Autista: Reporte de un caso / Intermittent Theta-Burst Transcranial Magnetic Stimulation in a Patient with Autism Spectrum Disorder: A Case Report

Resumen Introducción: La estimulación magnética transcraneal (EMT) es una opción potencial de tratamiento para la sintomatología de trastorno del espectro autista. Objetivos: Determinar la eficacia de la EMT en modalidad theta-burst intermitente (ETBi) sobre la corteza pre frontal dorso lateral izquierda (CDLPF) en el manejo de comportamientos patológicos asociados con TEA. Pacientes y Métodos: Paciente masculino de 10 años de edad diagnosticado con TEA con (ADOS) Autistic Diagnostic Observation Schedule, presenta una historia familiar de una hermana menor con TEA. Tanto el estudio de Resonancia Magnética encéfalo (IRM) y IRM funcional (IRMf) con paradigma emocionales se efectuaron antes del tratamiento de ETBi, inmediatamente después de tratamiento ETBi, y después de 6 meses de tratamiento con ETBi. Resultados: La prueba de ATEC reporto mejoría en las escalas de comunicación, cognición, social y comportamiento, 83%,81%,72% y 52% respectivamente. La puntuación total mejoro un 66% inmediatamente después de tratamiento y 55% en un periodo de 6 meses. La IRMf revelo la activación de la corteza frontal, parietal y occipital antes del tratamiento con ETBi y persistiendo la mejoría por 6 meses. Conclusión: ETBi una técnica de neuromodulación no invasiva bien tolerado que requiere un tiempo de administración menor que el tratamiento estándar.

Abstract Background: Transcranial magnetic stimulation (TMS) is a potential treatment option for autism spectrum disorder (ASD) symptomatology. Objectives: To determine the efficacy of the TMS intermittent theta-burst stimulation (iTBS) protocol over the left dorsolateral prefrontal cortex (DLPFC) in the management of pathological behaviors associated with ASD. Patient/Methods: A 10-year-old male diagnosed with ASD by the Autism Diagnostic Observation Schedule (ADOS) presented with a family history of ASD with a younger sister diagnosed with the same disorder. Both magnetic resonance imaging (MRI) and functional MRI (fMRI) scans for emotional paradigms were performed before the iTBS treatment, immediately after the iTBS treatment, and after 6 months of iTBS treatment. Results: The ATEC reports revealed improvement in communication, cognition, sociability, and behavior scales by 83%, 81%, 72%, and 52%, respectively. The overall score improved by 66% immediately after the treatment and by 55% lasting over a 6-month period. The fMRI revealed the activation of the frontal, parietal, and occipital cortex before iTBS treatment, and a better integration and activation of the frontal, temporal, and occipital cortex after iTBS treatment and persisted after 6 months. Conclusions: iTBS is a well-tolerated, non-invasive neuromodulation technique that requires relatively less administration than the standard treatment.

Laryngeal reconstruction in children with recurrent respiratory papillomatosis.

OBJETIVES: To describe our experience in reconstructive laryngeal surgery in patients with recurrent respiratory papillomatosis (RRP). INTRODUCTION: RRP is a rare laryngeal disease requiring multiple surgical endoscopic interventions during its course. These interventions may cause secondary lesions that may compromise airway patency. Open larynx reconstructive surgery, as tracheostomy, is a procedure considered to potentially favor extralaryngeal papilloma dissemination. In patients with RRP, the use of endoscopic posterior cricoid split and rib grafting has not been previously described. METHODS: The clinical charts of 230 patients with RRP seen between 1996 and 2017 were reviewed. All patients who underwent airway expansion procedures either by open or endoscopic approach were included in the study. RESULTS: Four patients with RRP underwent laryngeal surgery for laryngeal stenosis were included. A double-stage open approach was used in two patients and a single-stage endoscopic approach in the remaining two. The two tracheostomized patients were decannulated while tracheostomy was avoided in the two patients who underwent a single-stage endoscopic procedure. Two patients had active papillomatous lesions limited to the larynx at the time of surgery; no dissemination was observed during follow-up (cases 1 and 3). One patient had extralaryngeal disseminated papilomatosis; surgery did not lead to an increased lesion load compared to presurgical lesions (case 4). The patient who did not have active lesions did not have recurrence (case 2). CONCLUSIONS: Reconstructive laryngeal surgery is a safe and effective option in the management of stenotic sequelae resulting from the surgical treatment of RRP, allowing for decannulation or avoiding tracheostomy.

Síndrome de Susac: caso clínico y revisión / Susac syndrome: clinical case and literature review

RESUMEN El síndrome de Susac (SS) es una enfermedad autoinmune microangiopática poco frecuente, caracterizada por la tríada clínica: encefalopatía, alteraciones visuales e hipoacusia. Es una entidad de prevalencia desconocida dado su difícil diagnóstico debido a que la mayoría de las veces no se presenta con la tríada clínica clásica, y, dado que presenta múltiples diagnósticos diferenciales. Se reporta un caso de SS presentado en el Hospital del Salvador, con descripción de sus manifestaciones clínicas, estudio y manejo inicial. Además de una revisión en la literatura sobre la variabilidad de los hallazgos clínicos y el manejo de esta patología.

ABSTRACT Susac syndrome (SS) is a rare autoimmune micronagiopathic disease, characterized by the clinical triad of, encephalopathy, visual impairment and hearing loss. It is a difficult entity to diagnose since most of the time it does not present itself with the classical clinical triad, and it may be confused with other differential diagnoses. One clinical case of a patient with SS is described, its clinical manifestations, diagnosis and initial treatment. In addition, a literature review about the multiple clinical findings and management of these disease.

SAGES Foregut Surgery Masters Program: a surgeon's social media resource for collaboration, education, and professional development.

BACKGROUND: Facebook is a popular online social networking platform increasingly used for professional collaboration. Literature regarding use of Facebook for surgeon professional development and education is limited. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has established a Facebook group dedicated to discussion of surgery of the esophagus, stomach, and small intestine-the "SAGES Foregut Surgery Masters Program." The aim of this study is to examine how this forum is used for professional development, education, and quality improvement. METHODS: Member and post statistics were obtained from https://grytics.com , a Facebook group analytics service. All posts added to the Foregut forum since its creation in April 2015 through December 2016 were reviewed and categorized for content and topic. Posts were reviewed for potential identifiable protected health information. RESULTS: As of December 2016, there were 649 total members in the group. There have been a total of 411 posts and 4116 comments with a median of 10.1 comments/post (range 0-72). Posts were categorized as operative technique (64%), patient management (52%), continuing education (10%), networking (10%), or other (6%). Video and/or photos were included in 53% of posts with 4% of posts depicting radiologic studies and 13% with intraoperative photos or videos. An additional 40 posts included links to other pages, such as YouTube, journal articles, or the SAGES website. One post (0.2%) contained identifiable protected health information and was deleted once recognized by the moderators of the group. CONCLUSION: Social media is a unique, real-time platform where surgeons can learn, discuss, and collaborate towards the goal of optimal treatment of surgical disease. Active online surgical communities such as the SAGES Foregut Surgery Masters Program have the potential to enhance communication between surgeons and are a potential innovative adjunct to traditional methods of continuing surgical education. Surgical societies should adopt and promote professional and responsible use of social media.

Timpanoplastía endoscópica: experiencia en el Hospital del Salvador / Endoscopic tympanoplasty: experience in Hospital del Salvador

RESUMEN Introducción: La técnica endoscópica para la cirugía de oído ha presentado un gran avance en los últimos años, debido al avance de las ópticas de alta resolución e instrumental quirúrgico. El uso de endoscopio en timpanoplastías facilita la visualización de zonas de difícil acceso, como es el caso de pacientes con pared anterior del conducto auditivo externo prominente y perforaciones timpánicas anteriores, además permite la revisión de la caja timpánica y de las vías de ventilación del oído medio. Objetivo: Mostrar la timpanoplastía endoscópica (TE) como alternativa en pacientes con otitis media crónica y analizar el éxito anatómico y funcional. Material y método: Revisión de fichas clínicas de pacientes sometidos a TE en el Hospital del Salvador. Resultados: Catorce pacientes fueron operados entre octubre de 2015 y agosto de 2016. La edad promedio fue de 45 años. Todos fueron sometidos a TE unilateral. Once de 14 perforaciones comprometía alguno de los cuadrantes anteriores. De éstas, en el 82% el borde anterior de la perforación no era visible con otomicroscopía. Se realizó otoendoscopía y audiometría 2 meses poscirugía, logrando un éxito anatómico de 92,8%, y mejoría en el PTP posoperatorio en todos los pacientes. Conclusión: Los resultados obtenidos son similares a los descritos utilizando microscopio. La TE permite mejor visualización convirtiendo esta técnica en una alternativa quirúrgica y de docencia atractiva. Es necesario realizar seguimiento a estos pacientes y aumentar el número de pacientes en el futuro.

ABSTRACT Introduction: The endoscopic ear surgery technique has been a great advance in the last years due to the developments in high resolution optics and surgical instruments. The use of an endoscope provides the visualization of difficult access zones in the middle ear, such as patients with prominent anterior wall of the external auditory canal and anterior tympanic perforations. Aim: To describe the endoscopic tympanoplasty (ET) as an alternative treatment for patients who suffer from chronic otitis media, and to analyze the functional and anatomic outcome. Material and method: Clinical record review of patients submitted to a ET in Hospital del Salvador. Results: 14 patients were operated during October 2015 and August 2016. The average age was 45 years. All of them where submitted to a unilateral ET. 11 of 14 perforations compromised some of the anterior quadrants. In 82% of the latter the anterior edge of the perforation was not visible with otomicroscopy. An otomicroscopy and audiometry were performed 2 months after surgery, anatomic outcome success was of 92,8%, and PTA improved after surgery in all patients. Conclusion: The obtained results are similar to those described using microscope. ET allows improved visualization making this technique an attractive surgery and teaching choice. It is necessary to evaluate these results with a higher number of patients.

Cirugía endoscópica de oído para el manejo del colesteatoma atical / Endoscopic ear surgery approach for attic cholesteatoma treatment

RESUMEN El colesteatoma es la presencia de epitelio plano queratinizado en zonas neumatizadas del hueso temporal, cuya ubicación más frecuente es el ático. En la década de los noventa, se inicia el desarrollo de la cirugía endoscópica de oído, ofreciendo una nueva perspectiva en el tratamiento del colesteatoma. Se presentan dos casos clínicos de pacientes con colesteatoma atical. Se realiza abordaje endoscópico transcanal con resección macroscópica completa del colesteatoma. Audiometría posoperatoria evidencia mejoría de hipoacusia de conducción.

ABSTRACT The cholesteatoma is the presence of keratinized squamous epithelium in pneumatized areas of the temporal bone, its most frequent location is the attic. In the 1990s the development of the ear endoscopic surgery begins, offering a new perspective for cholesteatoma treatment. Two clinical cases of patients who present attic cholestatoma are described. A transcanal endoscopic approach with complete macroscopic resection was accomplished. Post-surgical audiometry shows improvement of the conductive hearing loss.

Viewer discretion advised: is YouTube a friend or foe in surgical education?

BACKGROUND: In the current era, trainees frequently use unvetted online resources for their own education, including viewing surgical videos on YouTube. While operative videos are an important resource in surgical education, YouTube content is not selected or organized by quality but instead is ranked by popularity and other factors. This creates a potential for videos that feature poor technique or critical safety violations to become the most viewed for a given procedure. METHODS: A YouTube search for "Laparoscopic cholecystectomy" was performed. Search results were screened to exclude animations and lectures; the top ten operative videos were evaluated. Three reviewers independently analyzed each of the 10 videos. Technical skill was rated using the GOALS score. Establishment of a critical view of safety (CVS) was scored according to CVS "doublet view" score, where a score of ≥5 points (out of 6) is considered satisfactory. Videos were also screened for safety concerns not listed by the previous tools. RESULTS: Median competence score was 8 (±1.76) and difficulty was 2 (±1.8). GOALS score median was 18 (±3.4). Only one video achieved adequate critical view of safety; median CVS score was 2 (range 0-6). Five videos were noted to have other potentially dangerous safety violations, including placing hot ultrasonic shears on the duodenum, non-clipping of the cystic artery, blind dissection in the hepatocystic triangle, and damage to the liver capsule. CONCLUSIONS: Top ranked laparoscopic cholecystectomy videos on YouTube show suboptimal technique with half of videos demonstrating concerning maneuvers and only one in ten having an adequate critical view of safety. While observing operative videos can be an important learning tool, surgical educators should be aware of the low quality of popular videos on YouTube. Dissemination of high-quality content on video sharing platforms should be a priority for surgical societies.

Impaired ovarian response to exogenous gonadotropins in female rat offspring born to mothers perinatally exposed to Bisphenol A.

The ovary is sensitive to disruption by the environmental estrogen Bisphenol A (BPA). Our aim was to investigate whether perinatal exposure to BPA (50µg/kgday), orally administered, affects ovarian response to exogenous gonadotrophins (PMSG or PMSG+hCG) in prepubertal female offspring. An altered response to gonadotrophins was observed in BPA-exposed rats. Increased proportion of antral follicles, altered levels of ovarian steroidogenic enzymes, gonadotropin receptors, AR and ERß were observed in PMSG group. Besides that, in response to PMSG+hCG, a persistent high Fshr mRNA expression and a decreased number of follicles with high expression of PR before ovulation were observed. After ovulation, there was an increase in antral atretic follicles, reduced Lhcgr mRNA expression and high serum levels of E2. Therefore, an early exposure to a low dose of BPA during perinatal period induces ovarian changes leading to an altered response to exogenous gonadotropin treatment later in life.