Severe Food Protein-Induced Enterocolitis Syndrome After Hematopoietic Stem Cell Transplantation: Pediatric Case Report.

BACKGROUND: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy. In the last few years, after the publication of the consensus guidelines, with refined diagnostic criteria and improved awareness, FPIES is diagnosed with increased frequency. However, despite having a background of immune dysregulation, this complication has just been described once in the posttransplant setting, in an adult patient. To the best of our knowledge, there are no reports of pediatric patients developing FPIES after a hematopoietic stem cell transplant (HCT). METHODS: Retrospective review of a pediatric patient who developed severe FPIEs after a HCT. RESULTS: In this case report, the clinical presentation and diagnosis challenges of a pediatric patient who developed severe FPIES after HCT are described. The patient developed severe vomiting, diarrhea, lethargy, and shock and required admission to the pediatric intensive care unit in three occasions before the diagnosis was made. CONCLUSIONS: To the best of our knowledge, this is the first report of severe FPIES post-HCT in a pediatric patient. Physicians who are looking after pediatric patients in the post-HCT setting need to be aware of this possibility and include this entity in the differential diagnosis in order to reduce its associated morbidity.

Electric currents of 448 kHz upregulate anti-senescence pathways in human dermal fibroblasts.

BACKGROUND: Currently, finding new therapeutic strategies that reduce skin aging is a challenge for dermatologists and aesthetic doctors. In recent years, physical therapies have been included in the options for antiaging treatments; however, the biological bases of such treatments have scarcely been studied. One of these physical therapies is capacitive-resistive electric transfer (CRET) therapy. Previous studies have shown that subthermal treatment with CRET promotes the proliferation and migration of various cell types involved in skin regeneration, such as human ADSC (stem cells), fibroblasts, or keratinocytes. OBJECTIVE: This study investigates the effects of in vitro treatment with CRET-Std (standard, non-modulated signal) or CRET-Mod (modulated signal) on cell proliferation and migration, markers of aging, and extracellular matrix production. METHODS: Three types of human dermal fibroblasts were used: neonatal fibroblasts (HFn), replicative senescent fibroblasts (HFs), and adult fibroblasts (HFa). The effects of electric stimulation on cell proliferation and migration were studied through XTT and wound closure assays, respectively. The expression of the aging marker ß-galactosidase was assessed using a colorimetric assay, whereas immunoblot, immunofluorescence, and ELISAs were carried out to analyze the expression levels of migration, aging, and extracellular matrix proteins. RESULTS: The treatment with CRET-Std increased HFn and HFa proliferation, as well as migration in the three types of fibroblasts studied compared to those of the controls. Conversely, CRET-Mod did not modify either of these two processes with respect to the controls. Additionally, CRET-Std also reduced the cellular senescence markers ß-gal, vimentin, p53, and p21 in all three types of human skin fibroblasts. In addition, the application of CRET-Std also induced fibronectin production in HFn and was able to stimulate ECM neocollagenesis. CONCLUSION: CRET treatment improves a number of functions related to migration and proliferation, and it reduces age-related cellular changes in human dermal fibroblasts. Therefore, the use of this CRET therapy to reduce the signs of dermal aging and to promote tissue regeneration could be of interest.

Anti-Fibrotic Effects of RF Electric Currents.

Hypertrophic scars and keloids are two different manifestations of excessive dermal fibrosis and are caused by an alteration in the normal wound-healing process. Treatment with radiofrequency (RF)-based therapies has proven to be useful in reducing hypertrophic scars. In this study, the effect of one of these radiofrequency therapies, Capacitive Resistive Electrical Transfer Therapy (CRET) on biomarkers of skin fibrosis was investigated. For this, in cultures of human myofibroblasts treated with CRET therapy or sham-treated, proliferation (XTT Assay), apoptosis (TUNEL Assay), and cell migration (Wound Closure Assay) were analyzed. Furthermore, in these cultures the expression and/or localization of extracellular matrix proteins such as α-SMA, Col I, Col III (immunofluorescence), metalloproteinases MMP1 and MMP9, MAP kinase ERK1/2, and the transcription factor NFκB were also investigated (immunoblot). The results have revealed that CRET decreases the expression of extracellular matrix proteins, modifies the expression of the metalloproteinase MMP9, and reduces the activation of NFκB with respect to controls, suggesting that this therapy could be useful for the treatment of fibrotic pathologies.

Outcomes of peroral endoscopic myotomy in patients with spastic esophageal motility disorders that do not fulfill Chicago Classification criteria.

INTRODUCTION: per-oral endoscopic myotomy (POEM) has become a mainstream treatment for achalasia and is a promising therapy in spastic disorders. METHODS: this is a retrospective study of prospectively collected data (case series). We present the first results of the use of POEM in patients with atypical spastic esophageal motor disorders that do not satisfy current Chicago Classification criteria. Seven consecutive patients with troublesome and persistent symptoms (12-180 months) related to atypical spastic esophageal motor dysfunction were systematically assessed before and after POEM, the extent of which was tailored by manometric findings. In five of the patients, other endoscopic or surgical procedures had failed. RESULTS: high-resolution manometry (HRM) showed a spastic esophageal body contractile segment in varying positions and lengths along the esophageal body which did not meet Chicago Classification criteria. After POEM, dysphagia and/or chest pain had either resolved or was greatly reduced. HRM 3-6 months after myotomy showed that the regions of spastic contraction targeted by myotomy had been ablated. There were no major complications. The clinical responses were fully maintained up to the most recent assessments after POEM (range 7-44 months). CONCLUSION: in our seven patients, POEM was a highly effective treatment for patients with troublesome symptoms related to atypical spastic esophageal motility disorders.

Does capsule endoscopy impact clinical management in established Crohn's disease?

BACKGROUND: Capsule endoscopy (SBCE) has developed a relevant role in patients with established Crohn's Disease (CD). However, evaluation of the impact in clinical management has been scarce. AIMS: To evaluate therapeutic impact of SBCE in an 11-year real-life cohort of known CD patients. METHODS: Retrospective single center study including all patients with established CD submitted to SBCE procedure from 01/01/2008 to 31/12/2019. Patency capsule was used in selected patients. Small bowel mucosal inflammation was quantified using Lewis score. Therapeutic impact was defined as a change in CD-related treatment recommended based on SBCE results. Patients were assigned to four groups regarding SBCE indication: staging, flare, post-op and remission. RESULTS: From the 432 SBCE performed 87.5% were conclusive. Active disease was present in 63.7 of patients; 41.6% mild inflammation and 21.9% moderate-to-severe activity. A change of management was guided by SBCE in 51.3% of procedures: 199 (46.1%) escalation and 23 (5.3%) de-escalation, with significant changes in all groups. Escalation increased with disease activity: 57.8% in mild and 89.5% in moderate-to-severe disease. De-escalation was conducted in 13.9% procedures with mucosal healing and 1.1% with mild disease. CONCLUSION: SBCE is a useful tool for guiding therapeutic management in CD patients both for treatment escalation and de-escalation.

Can we predict an incomplete capsule endoscopy? Results of a multivariate analysis using a logistic regression model.

BACKGROUND AND AIMS: small bowel capsule endoscopy (SBCE) does not reach the cecum within the battery lifetime in approximately 15-35 % of patients. Incomplete examinations result in diagnostic delays and increase the economic burden. To date, risk factors for incomplete examinations have been described with contradictory results. The aims of this study were to analyze the rate and identify risk factors for incomplete examinations, excluding capsule retentions, in a large cohort of patients. METHODS: data from 1,894 consecutive SBCE examinations performed from January 2009 to December 2015 were analyzed. Variables recorded included demographics, past medical and surgical history, biochemical parameters and procedure characteristics. The rate of incomplete examinations, excluding capsule retentions, was calculated and a multivariate analysis using a logistic regression model was performed in order to evaluate predictive factors. RESULTS: the incidence of incomplete examinations, excluding capsule retentions, was 10.1 % (187 incomplete procedures). The multivariate analysis showed that age > 65 years, gastric transit time > 41 minutes and SB transit time > 286 minutes are predictive factors for incomplete examinations, increasing the probability of this event by 199 % (OR: 1.99; 95 % CI: 1.34-2.95), 260 % (OR: 2.60; 95 % CI: 1.72-3.93) and 352 % (OR: 3.52; 95 % CI: 2.26-5.48), respectively. CONCLUSIONS: age > 65 years, gastric transit time > 41 minutes and SB transit time > 286 minutes are predictive factors for incomplete examinations excluding capsule retentions. Both age and gastric transit time events are known before the procedure ends. Therefore, pharmacologic or endoscopic measures may be taken into account to avoid incomplete examinations.

Response of human cancer cells to simultaneous treatment with sorafenib and radiofrequency current.

Due to their alleged analgesic, anti-inflammatory and tissue regenerative effects, capacitive-resistive electrothermal therapy (CRET), which is based on non-invasive exposure to radiofrequency (RF) currents, is often applied to chemotherapeutically treated patients with cancer. Our previous studies have demonstrated that subthermal CRET currents can elicit a number of cell responses, including anti-proliferative effects, in the human liver cancer cell line HepG2. Such effects involve significant changes in the regulation of proteins involved in MAPK signaling pathways, which are also implicated in the cancer cell response to standard anticancer drugs such as sorafenib. This overlap in response pathways may lead to competitive, neutralizing or blocking interactions between the electrical and chemical treatments, thus raising questions on the advisability of CRET treatment for their analgesic, anti-inflammatory or other purposes in patients undergoing chemotherapy. The present study analyzed the effects of simultaneous treatment with sorafenib and 448-kHz, subthermal CRET current on the proliferation and viability of HepG2 cell cultures. Cell viability was assessed through Trypan blue or XTT assays, while flow cytometry was applied for cell cycle and apoptosis analysis. The expression of proteins involved in cell proliferation were assessed by immunoblotting and immunofluorescence. The results revealed no evidence to suggest that the electrical treatment counteracted or neutralized the cellular response to sorafenib at the different conditions evaluated. Furthermore, at the standard pharmacological sorafenib concentration, 5 µM, the combined treatment elicited an anti-proliferative response significantly stronger than that induced by each of the treatments when applied separately in HepG2 cells. These data do not support the hypothesis that CRET exposure may inhibit or diminish the effects of a chemotherapeutic drug used in cancer treatment, and highlights the requirement for further investigation into the cell response to the combined action of electrical and chemical treatments.

In vitro stimulation with radiofrequency currents promotes proliferation and migration in human keratinocytes and fibroblasts.

Capacitive-resistive electric transfer (CRET) therapies have been proposed as strategies for regeneration of cutaneous tissue lesions. Previous studies by our group have shown that intermittent stimulation with 448 kHz CRET currents at subthermal densities promotes in vitro proliferation of human stem cells involved in tissue regeneration. The present study investigates the effects of the in vitro exposure to these radiofrequency (RF) currents on the proliferation and migration of keratinocytes and fibroblasts, the main cell types involved in skin regeneration. The effects of the electric stimulation on cell proliferation and migration were studied through XTT and wound closure assays, respectively. The CRET effects on the expression and location of proteins involved in proliferation and migration were assessed by immunoblot and immunofluorescence. The obtained results reveal that electrostimulation promotes proliferation and/or migration in keratinocytes and fibroblasts. These effects would be mediated by changes observed in the expression and location of intercellular adhesion proteins such as ß-catenin and E-cadherin, of proteins involved in cell-to-substrate adhesion such as vinculin, p-FAK and the metalloproteinase MMP-9, and of other proteins that control both processes: MAP kinases p-p38, p-JUNK and p-ERK1/2. These responses could represent a mechanism underlying the promotion of normotrophic wound regeneration induced by CRET. Indeed, electric stimulation would favor completion of granulation tissue formation prior to the closure of the outer tissue layers, thus preventing abnormal wound cicatrization or chronification.

Anti-NXP2-Positive Paraneoplastic Dermatomyositis With Histopathologic Changes Confined to the Acrosyringia.

BACKGROUND: Paraneoplastic syndromes consist of a group of disorders that are not related to the extension of the primary tumor or its metastases and that might be the first manifestation of a hidden neoplasm. It is a well-known association between dermatomyositis (DM) and cancer, especially gynecological tumors in women and lung cancer in men. METHODS: We describe the case of a 67-year-old male who developed muscular weakness and pruritic skin lesions. Skin biopsies were performed and histologic findings were consistent with DM. RESULTS: Skin biopsy showed interface dermatitis with vacuolar degeneration of the basal layer, dermal mucin deposits, and necrotic keratinocytes in the acrosyringia, a finding that has been previously reported in lupus erythematous but not in DM. Autoimmunity tests showed positivity for antinuclear antibodies and anti-NXP2, a recently described antibody associated with juvenile DM and, more rarely, with paraneoplastic DM. CONCLUSION: We present the first case in the literature with histopathologic changes of DM affecting the acrosyringia. Besides, our patient autoimmunity results support the utility of the new myositis-specific autoantibodies and its relation with a clinical phenotype.

Metformin-Induced Generalized Fixed Drug Eruption With Cutaneous Hemophagocytosis.

Fixed drug eruption (FDE) consists of recurrent dusky-red to brownish macules or patches at the same sites after the readministration of the causative drug. It usually presents as a solitary lesion, but generalized eruptions have been described. The most frequently implied drugs are antibiotics, anticonvulsants, and analgesics. Only 2 cases due to metformin have been reported. Histopathologic features of FDE include vacuolar degeneration of the basal layer, necrotic keratinocytes, and superficial and deep perivascular lymphocytic infiltrate. Cutaneous hemophagocytosis in the context of a FDE has not been previously reported. We describe the case of an 86-year-old man who developed a pruritic generalized macular eruption of reddish to violaceous patches. Skin biopsy was performed and the dermal infiltrate was immunohistochemically studied. Histopathology showed interface dermatitis with vacuolar degeneration of the basal layer, necrotic keratinocytes, and superficial and deep perivascular lymphohistiocytic infiltrate. In deep dermis, histiocytes with engulfed cells inside their cytoplasm were seen. Lymphoid enhancer binding factor 1 immunostain demonstrated that most of these cells were lymphocytes. We present the first case with cutaneous hemophagocytosis in the context of a metformin-induced generalized FDE. In this particular case, hemophagocytosis was just a histopathologic finding with no systemic consequences for the patient.

Primary dermal pleomorphic liposarcoma: utility of adipophilin and MDM2/CDK4 immunostainings.

Liposarcoma, usually arises in deep soft tissues and pleomorphic liposarcoma (PL), is the rarest histopathologic variant. However, 15 cases of entirely dermal PL have been reported. We describe a case of a 79-year-old man who developed a rapidly growing nodule on his thorax. Excisional biopsy was performed and immunohistochemical studies were carried. The lesion was a well-circumscribed dermal nodule composed of multivacuolated pleomorphic lipoblasts and atypical mitotic figures. Neoplastic cells expressed CD10 and resulted negative S100 protein, Melan-A, MITF-1, AE1/AE3, CD4, CD68 (PGM1), retinoblastoma gene family protein, pericentrine and lysozyme. Adipophilin stain showed the lipid contents in the cytoplasm of the neoplastic cells. MDM2 and CDK4 resulted both negative. A diagnosis of primary dermal PL was made. This case shows the utility of adipophilin immunostaining to prove the lipid contents in neoplastic cells, which has the advantage of using formalin-fixed paraffin-embedded tissue and making needless frozen sections and ultrastructural studies to show these findings. Negative MDM2/CDK4 staining in our case argues against the possibility of dedifferentiated liposarcoma and further supports the diagnosis of true PL.

Algunas consideraciones sobre la transferencia mitocondrial: ¿un nuevo problema para la bioética? / Some thoughts on the mitochondrial transfer: a new issue for bioethics? / Algumas considerações sobre a transferência mitocondrial: um novo problema para a bioética?

En febrero de 2015 el Reino Unido dio el primer paso para la aprobación de la transferencia mitocondrial como técnica terapéutica. Teóricamente, gracias a eso será posible para muchas mujeres engendrar descendencia libre de patologías asociadas a defectos mitocondriales. Sin embargo, esta práctica enfrenta severas dudas desde un punto de vista ético. Entre las objeciones destacan: su estrecha vinculación con la clonación humana; la alteración de los genes de la línea germinal; la modificación de la identidad del ser humano al que dará lugar; la destrucción de embriones humanos que envuelve, o el elevado riesgo que encierra para la salud del ser humano resultante. En este texto se analiza la solvencia de todas estas objeciones de forma crítica, resaltando las fortalezas de algunas de ellas. En particular, se aboga por una restricción cuidadosa del uso de esta técnica, que promueva el empleo de alternativas más respetuosas con la salud del futuro ser humano.

In February 2015 the United Kingdom took the first step towards the adoption of mitochondrial transfer as a therapeutic technique. Theoretically, it will make it possible for many women to get rid of pathologies associated with mitochondrial defects. However, this practice has been subjected to severe doubts from an ethical standpoint. Among these objections, we could highlight the following: its close association with human cloning; the alteration of the germline genes; the modification in the identity of the human being involved; the destruction of human embryos; or the high risk to the health of the human being. In this text we will analyze these objections critically, highlighting the strength of all of them. As a result, we will call for a careful restriction of the use of this technique, and the promotion of the use of alternative options much more respectful of the human future.

Em fevereiro de 2015 o Reino Unido deu o primeiro passo para a aprovação da transferência mitocondrial como técnica terapêutica. Teoricamente, graças a isso será possível a muitas mulheres engendrar descendência livre de patologias associadas a defeitos mitocondriais. No entanto, esta prática enfrenta severas dúvidas a partir de um ponto de vista ético. Entre as objeções destacam: sua estreita vinculação com a clonagem humana; a alteração dos genes da linha germinal; a modificação da identidade do ser humano ao qual dará lugar; a destruição de embriões humanos que envolve, ou o elevado risco que encerra para a saúde do ser humano resultante. Neste texto se analisa a solvência de todas estas objeções de forma crítica, ressaltando as fortalezas de algumas delas. Em particular, se advoga por uma restrição cuidadosa do uso desta técnica, que se promova o emprego de alternativas mais respeitosas com a saúde do futuro ser humano.

Aspectos bioético-jurídicos de las instrucciones previas o testamento vital en el contexto normativo español / Bioethical and legal issues of advance directives or living wills in the context of Spain / Aspectos bioético-jurídicos das instruções prévias ou testamento vital no contexto normativo espanhol

La discrepancia que genera la institución de las instrucciones previas se aprecia en distintos niveles -ético, jurídico social-, y alcanza incluso al ámbito terminológico, esto es, los términos empleados para referirse a esta institución no son en absoluto pacíficos o unívocos: desde testamentos vitales, voluntades o directivas anticipadas, deseos expresados anteriormente, etc., lo que lleva a cierta confusión sobre si se trata o no de la misma figura y a cierta inseguridad jurídica, ámbito por cierto sumamente prolijo en este sentido. No obstante la abundante legislación y doctrina sobre el particular, existe poca información acerca de la forma de registrar el documento, la posibilidad de consultarlo o los límites para su cumplimiento. Este artículo trata de ofrecer mayor luz al respecto, en el seno de la normativa española.

The discrepancy generated by advanced directives is observed in several levels -ethical, legal and social-, and reaches even the terminological field, that is, the terms employed to refer to the issue are not distinct or indifferent at all: from living will to advanced directives to wishes previously expressed, etc., which confers some confusion about whether it refers to the same issue or to some legal insecurity, field otherwise very complex in this sense. In spite of the abundant legislation and doctrine about the issue, there is little information about the way to register the document, the possibility to consult it and the limits about its fulfillment. This article tries to offer more understanding of the issue considering the norms of Spain.

A discrepância que gera a instituição das instruções prévias é apreciada em distintos níveis -ético, jurídico social-, e alcança inclusive o âmbito terminológico, isto é, os termos empregados para se referir a esta instituição não são em absoluto pacíficos ou unívocos: desde testamentos vitais, vontades ou diretivas antecipadas, desejos expressados anteriormente, etc., o que leva a certa confusão sobre se se trata ou não da mesma figura e a certa insegurança jurídica, âmbito por certo sumamente prolixo neste sentido. Não obstante a abundante legislação e doutrina sobre o particular, existe pouca informação acerca da forma de registrar o documento, a possibilidade de consultá-lo ou os limites para seu cumprimento. Este artigo trata de oferecer maior luz a respeito, no seio da normativa espanhola.

The European Union Integrated Political Crisis Response Arrangements: Improving the European Union's Major Crisis Response Coordination Capacities.

In recent years, the European Union (EU) has progressively assumed more and more of a primary role in crisis response coordination. The EU Integrated Political Crisis Response arrangements (IPCR) were recently approved to facilitate this task. These new agreements, which substitute for the Crisis Coordination Agreements, will add more flexibility to crisis response mechanisms in the EU. They will also strengthen cooperation between the different relevant agents in a major crisis situation and create new useful tools, such as the Integrated Situational Awareness and Analysis. Their real performance still needs to be fully tested, but some weakness can already be foreseen. This article provides a deep analysis of this new legislation.

[Transsexuality: law and health-related aspects in the Spanish legal system]. / La transexualidad: aspectos jurídico-sanitarios en el ordenamiento español.

The social weight of transsexual groups has been and continues to be crucial in many aspects regarding transsexuality, from the progressive elimination of discrimination to influence in the legislative branch. This paper especially discusses a classic demand of these groups, comprehensive medical treatment of transsexual people within the National Health System. Thus, progress in the development of an adequate healthcare system for these groups, their treatment in the legal systems of Spain in general and of some of its autonomous communities with more noteworthy laws (especially in Andalusia, an autonomous community that has been pioneering in this regard, as well as the Basque Country and Navarre) and remaining challenges will be observed in this work. The article will also take particular note of the substantial developments that the publication of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders has established in this area.

La transexualidad: aspectos jurídico-sanitarios en el ordenamiento español / Transsexuality: law and health-related aspects in the Spanish legal system

El fenómeno de la transexualidad es un asunto en el que el peso social, en concreto de los colectivos transexuales, ha sido y sigue siendo crucial en muchos aspectos, desde la progresiva eliminación de la discriminación hasta la influencia para que el poder legislativo se pronuncie. En este artículo de investigación se tratará especialmente una de las reivindicaciones clásicas del colectivo, esto es, el tratamiento sanitario integral de la persona transexual dentro del Sistema Nacional de Salud. En este sentido, se observarán los avances en el desarrollo de un sistema sanitario adecuado para este colectivo, su tratamiento por parte de los distintos ordenamientos jurídicos en España, en general, y en alguna de sus comunidades autónomas con legislaciones más destacables (en especial Andalucía como comunidad autónoma pionera, el País Vasco y la Comunidad Foral de Navarra) y los retos pendientes, haciendo una especial investigación en torno a las sustanciales novedades que ha implantado en este ámbito la publicación de la quinta edición del Manual diagnóstico y estadístico de los trastornos mentales.

The social weight of transsexual groups has been and continues to be crucial in many aspects regarding transsexuality, from the progressive elimination of discrimination to influence in the legislative branch. This paper especially discusses a classic demand of these groups, comprehensive medical treatment of transsexual people within the National Health System. Thus, progress in the development of an adequate healthcare system for these groups, their treatment in the legal systems of Spain in general and of some of its autonomous communities with more noteworthy laws (especially in Andalusia, an autonomous community that has been pioneering in this regard, as well as the Basque Country and Navarre) and remaining challenges will be observed in this work. The article will also take particular note of the substantial developments that the publication of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders has established in this area.