Recurrent obstruction of biliary stent-in-stent: a heated solution.

Intraductal radiofrequency ablation (RFA) has been used in the management of malignant biliary obstruction and ampullary neoplasms. Some small studies refer to its role in managing benign biliary strictures with some promising results. The complications are not neglectable, namely cholangitis, pancreatitis, bleeding, and perforation, although most of them can be managed conservatively. There are two catheters available. Only the ERLA (EndoLumunal Radiofrequency Ablation, Taewoong Medical) catheter can control temperature and impedance, allowing it to reduce the risk of complications.

The Value of Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer and Application of a Prognostic Score.

OBJECTIVES: Secondary cytoreductive surgery (SCS) is an option for treating patients with recurrent ovarian cancer. Three ongoing randomized trials are comparing SCS plus chemotherapy with chemotherapy alone, and few comparative studies have been published. MATERIALS AND METHODS: We performed a retrospective review of data on 209 patients with recurrent ovarian carcinoma who were treated at a single institution from 2000 to 2013. We analyzed prognostic factors in the recurrence setting to determine the value of SCS in a multivariate model, including propensity score, by prognostic group. RESULTS: In the univariate analysis, younger than 65 years, personal or family history of breast or ovarian cancer, stage I-II at diagnosis, residual disease 10 mm or less after primary debulking surgery, performance status 1 or less, CA125 less than 100, only 1 metastatic site of recurrence, platinum-free interval of more than 12 months, and SCS correlated with better overall survival. In the multivariate model, including propensity score, SCS remained associated with a 66% decrease in the risk of death (hazard ratio, 0.34; 95% CI, 0.15-0.76, P = 0.008). Secondary cytoreductive surgery was also linked to longer progression-free survival (hazard ratio, 0.50; 95% CI, 0.30-0.84, P = 0.008). There was no evidence of a benefit of SCS in patients with unfavorable prognosis (P for interaction = 0.654). CONCLUSIONS: Our results confirm the benefit of SCS in progression-free survival and overall survival in the recurrent setting and suggest that it exists not only for patients with a good prognosis.

Prenatal care and childbirth assistance in Amazonian women before and after the Pacific Highway Construction (2003-2011): a cross-sectional study.

BACKGROUND: Attention to prenatal care and child delivery is important for the health of women and children, but in the Amazon these indicators tend to be historically unfavorable, in part by geographical and political isolation. In 2003 both Brazilian and Peru governments have finished paving an international road connecting remotes areas in the Brazilian Amazon to the Pacific coast in Peru. METHODS: The situation of prenatal care and child delivery with mothers of children under 5 years old living in the urban area of Assis Brasil, Acre was assessed in two cross-sectional studies performed in 2003 and 2011, corresponding to the period before and after the Pacific highway construction. RESULTS: In 2003, most mothers were of black/Afro-American ethnicity, or "pardos" (the offspring of a Caucasian with a African descendant) (77.69 %), had more than 4 years of schooling (73.40 %) and had a mean age of 22.18 years. In 2011, the number of as a migration of indigenous women increased from 0 to 14.40 % of the respondents, because of migration from communities along the rivers to urban areas, with no other significant changes in maternal characteristics. No significant improvement in childbirth assistance was noticed between 1997 and 2011; only the percentage of in-hospital vaginal deliveries performed by doctors increased from 17.89 to 66.26 % (p <0.001) during this period. Access to prenatal care was associated with white ethnicity in 2003, and higher socioeconomic level and white ethnicity in 2011, while the higher number of prenatal visits was associated with higher maternal education and higher socioeconomic levels in 2011. Vaginal child delivery at a hospital facility was associated with maternal age in 2003, and year of birth, being of white ethnicity and higher level of education in 2011. CONCLUSIONS: The indicators of prenatal care and child delivery were below the national average, showing that geographical isolation still affects women's health care in the Amazon, despite the construction of the highway and governmental health protocols adopted during this period.

Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery and the Risk of Platinum Resistance in Epithelial Ovarian Cancer.

BACKGROUND: Interval debulking surgery (IDS) is an option for treating patients with advanced ovarian carcinoma. Two randomized trials have shown similar survival rates for primary debulking surgery (PDS) and IDS. One of the concerns with IDS is the potentially higher risk of inducing platinum resistance when treating patients with greater disease volume. METHODS: A retrospective review of data on 237 patients with stage IIIC and IV ovarian carcinoma who were treated at a single institution from 2000 to 2013. We analyzed the association of IDS with time to first platinum resistant relapse (TTPR); platinum-resistant disease at first relapse, defined as a platinum-free interval (PFI) after first-line chemotherapy of <6 months; and overall response rate (ORR) to chemotherapy at first platinum-sensitive relapse. RESULTS: The TTPR was 60 months, and the median TTPR was longer for the PDS (80.8 months) versus IDS group (39.3 months; p = 0.012) and for patients with residual disease (RD) ≤10 mm (80.8 months) compared with those with RD >10 mm (26.1 months; p < 0.001). In the multivariate analysis, IDS [hazard ratio (HR) 1.92; p = 0.009] and RD >10 mm (HR 1.65; p < 0.001) retained an increased risk of developing platinum-resistant disease. IDS was not associated with a greater risk of PFI <6 months at first relapse, and the ORR to platinum-based chemotherapy at first platinum-sensitive relapse was 87.2 % for patients who were treated with PDS compared with 68.0 % for those who underwent IDS (p = 0.051). CONCLUSIONS: IDS correlates with a higher risk of the development of platinum resistance.

Socioeconomic inequities and hepatitis A virus infection in Western Brazilian Amazonian children: spatial distribution and associated factors.

BACKGROUND: Hepatitis A is still a neglected health problem in the world. The most affected areas are the ones with disadvantaged socioeconomic conditions. In Brazil, seroprevalence studies showed that 64.7 % of the general population has antibodies against HAV (hepatitis A virus), and the Amazon region has the highest seroprevalence in the country. METHODS: In the present study the seroprevalence of total HAV antibodies in children between 1 and 5 years old residing in the urban area of Assis Brasil, Acre was measured and spatial distribution of several socioeconomic inequities was evaluated. RESULTS: In the year of 2011, seroprevalence rate was 16.66 %. Factors associated with having a positive serology identified by multivariate analysis were being of indigenous ethnicity [adjusted Odds Ratio (aOR) = 3.27, CI 1.45-7.28], usage of water from the public system (aOR = 8.18, CI 1.07-62.53), living in a house not located in a street (aOR = 3.48, CI 1.54-7.87), and child age over 4 years old (aOR = 2.43, CI 1.23-4.79). The distribution of seropositive children was clustered in the eastern part of the city, where several socioeconomic inequities (lack of flushed toilets, lack of piped water inside the household and susceptibility of the household to flooding during rain, low maternal education, having wood or ground floor at home, and not owning a house, lack of piped water at home, and type of drinking water) also clustered. CONCLUSIONS: The findings highlight that sanitation and water treatment still need improvement in the Brazilian Amazon, and that socioeconomic development is warranted in order to decrease this and other infectious diseases.

Low PTEN expression is associated with worse overall survival in head and neck squamous cell carcinoma patients treated with chemotherapy and cetuximab.

BACKGROUND: Platinum-based chemotherapy associated with cetuximab is the first-line treatment for inoperable recurrence or metastatic head and neck squamous cell carcinoma (HNSCC). There is no established biomarker for cetuximab efficacy in HNSCC. The PI3K pathway is one of the most frequently altered pathways in HNSCC. Loss of phosphatase and tensin homolog (PTEN) expression occurs in up to 30 % of cases. METHODS: This was a retrospective analysis of data from 61 patients with inoperable recurrence or metastatic HNSCC treated with cetuximab. PTEN, epidermal growth factor receptor and p16 expression were analyzed by immunohistochemistry and tested for association with clinical outcomes. RESULTS: Median overall survival was 11.4 months and progression-free survival was 6.9 months. Low PTEN expression was present in 26.2 % of patients and identified patients with worse prognosis. p16 was positive in only 8.5 % of tumors. CONCLUSIONS: Low PTEN expression in patients treated with cetuximab plus chemotherapy emerged as a prognostic biomarker and should be evaluated for its predictive role for cetuximab efficacy.

Drug-Drug Interaction between Oral Zamicastat and Continuous Epoprostenol Infusion at Steady-State Conditions in Healthy Subjects.

This study intended to evaluate the interactions between zamicastat and epoprostenol in healthy human subjects. This was a single-center, open-label, two-period study. In period 1, epoprostenol 8 ng/kg/min was administered alone. In period 2, epoprostenol 8 ng/kg/min was administered following an 8-day treatment with zamicastat. Since the initial dose of epoprostenol showed to be insufficiently tolerated, it was decreased to 6 ng/kg/min. Blood samples were collected to determine the metabolites of epoprostenol and concentrations of zamicastat and its metabolites. A total of 54 subjects were enrolled and data from 28 subjects were available for pharmacokinetic analysis. The epoprostenol plus zamicastat-to-epoprostenol geometric means ratio (GMR) and corresponding 90% confidence interval (CI) for Cav,ss and area under the plasma concentration-time curve from time 0 up to 16 h at steady state (AUC0-16,ss) of the metabolites of epoprostenol were within the acceptance bioequivalence range (80.00%-125.00%). The intrasubject coefficient of variation (ISCV) was below 10% for both parameters, on both metabolites. For zamicastat AUC0-τ,ss, the zamicastat plus epoprostenol-to-zamicastat GMR and corresponding 90% CI were within the bioequivalence acceptance range, while for zamicastat Cmax,ss, the lower limit of the 90% CI was slightly below the acceptance range. For zamicastat metabolites, Cmax,ss and AUC0-τ,ss and the zamicastat plus epoprostenol-to-zamicastat GMR were below the acceptance bioequivalence range. ISCV was between 30% and 41% for Cmax,ss and between 21% and 41% for AUC0-τ,ss, for zamicastat and both metabolites. This study showed that the administration of zamicastat did not significantly modify the cardiovascular effects of epoprostenol and that the interactions between zamicastat and epoprostenol are not expected to be clinically relevant.

Nutritional status of children under 5 years of age in the Brazilian Western Amazon before and after the Interoceanic highway paving: a population-based study.

BACKGROUND: The aim of this study was to analyse the prevalence of undernutrition, overweight and associated factors, before and after the implementation of the Interoceanic Highway. METHODS: A population-based cross-sectional study on children under 5 years of age was conducted in the municipality of Assis Brasil, AC, Brazil, in 2003 and 2010. Prevalence of undernutrition was observed by using height-for-age Z-scores (HAZ) and adopting a cut-off point equal to or lower than a -2 Z-score. Overweight prevalence was defined by a cut-off point equal to or greater than a +2 Z-score of the WHZ index. Z-scores were calculated relative to WHO 2006 reference data. Semi-structured questionnaires were applied to the children's guardians, investigating family socio-economic and demographic characteristics, morbidities, access to services and child care. Associated factors were identified by hierarchical multiple logistic regression analysis. RESULTS: The prevalence of low HAZ (undernutrition) was 7.0% in 2003 and 12.2% in 2010. The prevalence of high WHZ (overweight) was 1.0% and 6.6% for 2003 and 2010, respectively. It was not possible to adjust the multiple model for the year 2003. The factors associated with low HAZ in 2010 were: wealth index, the situation of living with biological parents, maternal height and presence of open sewage, whereas the factors associated with a high WHZ in the same year were: child's age, mother's time of residence in the location, mother's body mass index. CONCLUSIONS: Overweight increase within this undernutrition scenario reveals that the process of nutritional transition began in this Amazonian city only in the last decade, and therefore, it is delayed when compared to overweight in other parts of Brazil. Such nutritional transition in Assis Brasil may have been facilitated by the construction of the Interoceanic Highway.

Treatment of complex iatrogenic common hepatic duct injury following laparoscopic cholecystectomy.

We report the case of a woman in her 40s, with no significant medical history, submitted to a laparoscopic cholecystectomy in our institution for symptomatic gallbladder lithiasis. On postoperative day 4, she presented to our emergency room with severe abdominal pain and elevated inflammatory markers. Abdominal CT scan revealed a mass filled with liquid and air in the gallbladder fossa. Surgical exploration was performed revealing a major common hepatic duct iatrogenic injury, which was managed using suture over a T-tube. Three months after surgery, cholangiography showed a biliary stenosis, and a biodegradable stent was inserted through percutaneous transhepatic access. The difficulties in the management of this condition and its outcomes are discussed in this report.

Crohn's disease and intestinal tuberculosis: challenging from every angle.

A woman in her 20s with a recent diagnosis of Crohn's disease (CD) affecting the ileocaecal valve was started on adalimumab, after routine tuberculosis (TB) tests were negative. Her abdominal symptoms got worse and she started presenting respiratory distress and fever. Tomography revealed a left pleural effusion, pneumonia and peritonitis with pelvic abscess. The diagnosis of disseminated TB with digestive involvement was suggested and sputum cultures were positive for Mycobacterium tuberculosis Treatment for TB was started and immunosuppressants discontinued, leading to respiratory improvement. Abdominal imaging was repeated, showing worsening signs of multisegmental ileal wall thickening, ileocaecal valve obstruction and a persistent pelvic abscess. She was then submitted to a laparoscopic ileocaecal resection for suspicion of worsening CD. Histopathology showed chronic ileocolitis compatible with CD and ganglionic tuberculosis, revealing the diagnosis of intestinal tuberculosis superimposed in CD. Recovery was uneventful.

Safety of Endoscopy Units during the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic drastically changed the daily routine of all healthcare systems worldwide, and endoscopy units were no exception. Endoscopic exams were considered to have a high risk of transmission, and therefore, the safety of endoscopy units and the consequent need for pre-endoscopy SARS-CoV-2 screening were questioned early on. The aim of our study was to assess the safety of endoscopy units during the COVID-19 pandemic, as well as the effectiveness/necessity for SARS-CoV-2 screening prior to endoscopies. Material and Methods: This is a retrospective and single-center study carried out in a Portuguese tertiary hospital. All patients who underwent endoscopic procedures between September 1, 2020 and February 28, 2021 were included. The pre-endoscopy screening consisted of a specific questionnaire or a RT-PCR test for SARS-CoV-2 (nasal and oropharyngeal swab). Data were obtained through patient's clinical records and the Trace COVID platform. Results: A total of 2,166 patients were included. Patients had a mean age of 61.8 years and were predominantly male (56.2%, n = 1,218). Eighty-one (3.7%) patients had previous SARS-CoV-2 infection, with a median difference of 74 days (IQ 40.5:160.5) between infection and endoscopy. Most patients (70.2%, n = 1,521) underwent PCR screening for SARS-CoV-2 up to 72 h before the procedure, with the remaining patients (29.8%, n = 645) answering a questionnaire of symptoms and risk contacts up to 3 days before endoscopy. Of the patients who underwent RT-PCR screening for SARS-CoV-2, 21 (1.4%) tested positive, and all were asymptomatic at the time of the screening. The evaluation for SARS-CoV-2 infection up to 14 days after the endoscopic exams identified 9 positive patients (0.42%) for SARS-CoV-2. The median difference in days between endoscopy and the diagnosis of infection was 10 days. Discussion/Conclusion: Pre-endoscopy screening with RT-PCR test for SARS-CoV-2 identified a very small number of patients with COVID-19 infection as well as patients with COVID-19 infection in the following 14 days. Therefore, the risk of infection in endoscopy units is negligible if screening of symptoms and risk contacts is applied and individual protective equipment is used.

Introdução: A pandemia COVID-19 mudou drasticamente o dia-a-dia de todos os sistemas de saúde a nível mundial e as unidades de endoscopia não foram exceção. Os exames endoscópicos foram considerados exames com alto risco de transmissão pelo que desde cedo se questionou a segurança das unidades de endoscopia e a consequente necessidade de rastreio SARS-CoV-2 pré-endoscopia. O objetivo do estudo foi avaliar a segurança das unidades de endoscopia durante a pandemia por COVID-19 bem como a eficácia/necessidade de rastreio SARS-CoV-2 prévio aos exames endoscópicos. Material e métodos: Foi desenvolvido um estudo retrospetivo e unicêntrico, no qual todos os doentes submetidos a exames endoscópicos entre 1 de setembro de 2020 e 28 de fevereiro de 2021 foram incluídos. Como estratégia de rastreio pré endoscopia foram aplicados questionários específicos de sintomas e contactos de risco, ou teste PCR de SARS-CoV-2 (zaragatoa nasal e orofaríngea). Os dados clínicos foram obtidos através do processo clínico do doente e da plataforma Trace COVID-19. Resultados: Foram incluídos um total de 2,166 doentes submetidos a exames endoscópicos durante o período de estudo. Os doentes incluídos apresentaram uma média de idades de 61.8 anos e eram maioritariamente do sexo masculino (56.2%, n = 1,218). 3.7% (n = 81) dos doentes já tinha tido infeção por COVID-19 no passado, sendo a mediana da diferença de dias entre a infeção e a data do exame de 74 dias. A maioria dos doentes (70.2%, n = 1,521) foi submetido a rastreio por PCR de SARS-CoV-2 até 72 horas antes do procedimento, sendo os restantes doentes (29.8%, n = 645) submetidos a um questionário de sintomas e contactos de risco realizado até 3 dias antes do procedimento. Dos doentes que realizaram rastreio por PCR de SARS-CoV-2, 21 (1.4%) apresentaram teste positivo, estando todos assintomáticos à data do teste. Aquando da verificação de infeção por SARS-CoV-2 até 14 dias após a realização dos exames endoscópicos apurou-se que apenas 9 doentes (0.42%) testaram positivo para SARS-CoV-2, sendo a mediana da diferença de dias entre a data do exame e o diagnóstico de infeção de 10 dias. Discussão/Conclusão: O rastreio pré-endoscopia com teste PCR de SARS-CoV-2 identificou um número reduzido de doentes infetados com COVID-19 e o número de doentes com infeção por COVID-19, nos 14 dias seguintes aos exames endoscópicos, foi muito baixo. Assim, se aplicado o rastreio de sintomas e contactos de risco, usados os equipamentos de proteção individual adequados, o risco de infeção nas unidades de endoscopia torna-se negligenciável.

Transmural remission improves clinical outcomes up to 5 years in Crohn's disease.

INTRODUCTION: Evidence supporting transmural remission (TR) as a long-term treatment target in Crohn's disease (CD) is still unavailable. Less stringent but more reachable targets such as isolated endoscopic (IER) or radiologic remission (IRR) may also be acceptable options in the long-term. METHODS: Multicenter retrospective study including 404 CD patients evaluated by magnetic resonance enterography and colonoscopy. Five-year rates of hospitalization, surgery, use of steroids, and treatment escalation were compared between patients with TR, IER, IRR, and no remission (NR). RESULTS: 20.8% of CD patients presented TR, 23.3% IER, 13.6% IRR and 42.3% NR. TR was associated with lower risk of hospitalization (odds-ratio [OR] 0.244 [0.111-0.538], p < 0.001), surgery (OR 0.132 [0.030-0.585], p = 0.008), steroid use (OR 0.283 [0.159-0.505], p < 0.001), and treatment escalation (OR 0.088 [0.044-0.176], p < 0.001) compared to no NR. IRR resulted in lower risk of hospitalization (OR 0.333 [0.143-0.777], p = 0.011) and treatment escalation (OR 0.260 [0.125-0.540], p < 0.001), while IER reduced the risk of steroid use (OR 0.442 [0.262-0.745], p = 0.002) and treatment escalation (OR 0.490 [0.259-0.925], p = 0.028) compared to NR. CONCLUSIONS: TR improved clinical outcomes over 5 years of follow-up in CD patients. Distinct but significant benefits were seen with IER and IRR. This suggests that both endoscopic and radiologic remission should be part of the treatment targets of CD.

Hepatic resection due to a fish bone.

INTRODUCTION AND IMPORTANCE: Hepatic abscess due to foreign body is rare. Diagnosis is difficult and drainage may not be enough. Hepatic resection may be indicated. CASE PRESENTATION: A 76yo male patient resorted to the emergency room because of fever and abdominal pain. Abdominal CT diagnosed a hepatic abscess in the left lobe due to a fishbone. Percutaneous and surgical drainage failed. Laparotomic hepatic resection was necessary. The patient was discharged asymptomatic. CLINICAL DISCUSSION: Liver abscess due to foreign body usually occur in the left lobe. Drainage and removal of the foreign body are mandatory and can be achieved either by percutaneous or surgical drainage. Resection is rarely indicated but sometimes is the only way. The authors found only ten cases of hepatic resection due to pyogenic abscess because of a foreign body. CONCLUSIONS: Hepatic resection is rarely needed to treat a pyogenic abscess, but surgeons must be aware and able to proceed with it.

Parkinson's Disease and Fabry Disease: Clinical, Biochemical and Neuroimaging Analysis of Three Pedigrees.

BACKGROUND: Sporadic Parkinson's disease (PD) patients have lower α-galactosidase A (α-GAL A) enzymatic activity and Fabry disease (FD) patients potentially carry an increased risk of PD. OBJECTIVE: Determination of PD prevalence in FD and clinical, biochemical and vascular neuroimaging description of FD pedigrees with concomitant PD. METHODS: Clinical screening for PD in 229 FD patients belonging to 31 families, harbouring GLA gene mutation p.F113L, and subsequent pedigree analysis. Gender-stratified comparison of FD+/PD+ patients with their family members with FD but without PD (FD+/PD-) regarding Mainz scores, plasma & leukocytes α-GAL A enzymatic activity, urinary Gb3 and plasma Lyso-Gb3, vascular brain neuroimaging. RESULTS: Prevalence of PD in FD was 1.3% (3/229) (3% in patients aged ≥50 years). Three FD patients, one female (73 years old) (P1) and two males (60 and 65 years old) (P2 and P3), three different pedigrees, presented akinetic-rigid PD, with weak response to levodopa (16% - 36%), and dopaminergic deficiency on 18F-DOPA PET. No pathogenic mutations were found in a PD gene panel. FD+/PD+ patients had worse clinical severity of FD (above upper 75% IQR in Mainz scores), and cortico-subcortical white matter/small vessel lesions. P3 patient was under enzyme therapy, started 1 year before PD diagnosis. P2-P3 patients had higher leucocyte α-GAL A activity (2,2-3 vs.1,0 (median)(nmol/h/mg)). CONCLUSION: We have shown a high prevalence of PD in a late-onset phenotype of FD, presenting high cerebrovascular burden and weak response to levodopa. Further studies will untangle how much of this PD phenotype is due to Gb3 deposition versus cerebrovascular lesions in the nigro-striatal network.

Corporoplasty using bovine pericardium grafts in complex penile prosthesis implantation surgery.

PURPOSE: This paper is the first, to our knowledge, to propose the use of a bovine pericardium graft in corporoplasty for penile prosthesis implantation. The advantages of bovine pericardium graft have been demonstrated by its use in cardiac surgery, including low cost, biocompatibility, impermeability, resistance to dilatation, flexibility, low likelihood of retraction, absence of antigenic reaction and natural absorption of the tissue. In this paper, we propose the use of this heterologous material graft in corporoplasty for penile prosthesis implantation. MATERIALS AND METHODS: Five patients with a history of erosion, infection and fibrosis, mean time of follow-up 32 months (range 9-48 months). Bovine pericardium was used to cover large areas of implanted penile prostheses when use of the tunica albuginea was unfeasible. RESULTS: The surgical procedure resulted in no complications in all patients. CONCLUSIONS: Bovine pericardium may substitute synthetic and autologous material with the additional advantages of lower cost and greater availability.

Risk factors for pelvic and distant recurrence in locally advanced cervical cancer.

OBJECTIVE: Despite the benefits of concomitant radiotherapy and cisplatin for locally advanced cervical cancer, recurrence rates remain high. New treatment strategies such as consolidation chemotherapy and different concomitant chemotherapy combinations have been tested in recent years. Identification of the best candidates for each treatment strategy could optimize results. STUDY DESIGN: A retrospective review of data from 127 patients with locally advanced cervical cancer (International Federation of Gynecology and Obstetrics Stages IIB-IVA), treated at a single institution from 2005 to 2014. Risk factors for loco-regional and systemic recurrence, and prognostic factors for overall survival (OS) were analysed using Cox regression. Survival of patients treated with consolidation chemotherapy was compared with survival of patients not treated with consolidation chemotherapy in the role cohort and in a propensity-score-matched cohort. RESULTS: With a median follow-up time of 48.7 months, loco-regional-recurrence-free survival (LRFS), distant-metastasis-free survival (DMFS) and OS at 5 years were 76.6%, 54.0% and 63.0%, respectively. On multivariate analysis, tumour size ≥6 cm was associated with shorter LRFS [hazard ratio (HR) 5.18; 95% confidence interval (CI) 1.45-18.45; p = 0.011], and adenocarcinoma (HR 2.48; 95% CI 1.10-5.57; p = 0.028) and positive lymph nodes (HR 2.21; 95% CI 1.303-4.72; p = 0.041) were associated with shorter DMFS. Tumour size ≥6 cm was associated with shorter OS (HR 2.64; 95% CI 1.09-6.35; p = 0.031). Twenty-two patients were treated with consolidation chemotherapy; on univariate analysis, these patients had longer OS compared with patients who were not treated with consolidation chemotherapy (p = 0.043). In a propensity-score-matched cohort, patients treated with consolidation chemotherapy had longer DMFS and OS compared with patients who were not treated with consolidation chemotherapy, although the difference was not significant. CONCLUSIONS: Different risk factors are associated with loco-regional and distant metastases in patients with locally advanced cervical cancer, and could potentially lead to particular therapeutic strategies. Although the number of patients treated with consolidation chemotherapy in the study cohort was small, they seemed to live longer and to have better control of distant relapse then patients who were not treated with consolidation chemotherapy.

Acute paraparesis as presentation of an occult follicular thyroid carcinoma: A case report.

INTRODUCTION: Follicular thyroid carcinoma is the second most frequent type of well differentiated thyroid tumours. It is usually confined to the thyroid gland, however it can metastasize in a later stage of the disease. Signs and symptoms associated with bone metastasis are rare as first clinical manifestations. CASE REPORT: An 84-year-old female complained with acute paraparesis. Magnetic resonance imaging revealed an extensive intraosseous infiltrating lesion compatible with a bone metastasis from an occult tumour. Biopsy samples were compatible with bone metastasis from a follicular thyroid carcinoma. The patient was submitted to total thyroidectomy followed by iodine ablative therapy. DISCUSSION: Follicular thyroid carcinoma presentation with symptoms related to bone metastasis is rare. Patients with bone lesions, such as pathological fractures or compressive symptoms should be studied since they may have clinically unapparent lesions from an unknown tumour. Patients with FTC should be submitted to total thyroidectomy. Bone lesions may be addressed to improve quality of life however this decision depends on disease extent. CONCLUSION: Acute paraparesis is a rare form of presentation of thyroid carcinoma. These neoplasms must be taken into account when investigating metastasis to the bone from unknown neoplasms.

Protocol for a Steady-State FRET Assay in Cancer Chemoprevention.

Cancer chemoprevention is an important strategy to prevent, reverse, or suppress the development of cancer. One of the target pathways that has emerged in recent years is the Keap1-Nrf2-ARE system that regulates the protection of cells against various carcinogens and their metabolites. Increased concentrations of the redox transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) induces the activation of antioxidant and phase 2 detoxifying genes. Nrf2 is regulated by substrate adaptor protein Kelch-like ECH-associated protein 1 (Keap1) that can target Nrf2 for ubiquitination and degradation by the proteasome. The interaction between Nrf2 and Keap1 can be disrupted at the protein-protein interface in order to increase Nrf2 activity for potential therapeutic purposes. This chapter describes a protocol for a steady-state fluorescence or Förster resonance energy transfer (FRET) assay to examine the Keap1-Nrf2 protein-protein interaction (PPI), to investigate the effects of Nrf2 mutations on Keap1 binding and finally to identify potential inhibitors of this PPI. In the assay system Keap1 is conjugated to an YFP protein at the N-terminus whereas an Nrf2-derived 16-mer peptide containing a high-affinity "ETGE" motif is conjugated to a CFP protein at the N-terminus.

Stunting in children under five years old is still a health problem in the Western Brazilian Amazon: a population-based study in Assis Brasil, Acre, Brazil.

Despite the process of nutritional transition in Brazil, in some places, such as the Amazon region, stunting is still an important public health problem. We identified the prevalence and factors associated with stunting in children under five years old residing in the urban area of Assis Brasil. A survey was conducted in which a questionnaire on socioeconomic, maternal and children's conditions was applied, and height or length was measured. The children with height for age index below -2 Z-scores were considered stunted, according to the criteria by the World Health Organization. Four hundred and twenty-eight children were evaluated. Of these, 62 were stunted. Factors associated with stunting, according to adjusted models, were: the presence of open sewer, the wealth index for households, the receipt of governmental financial aid and the mother's height, age and education. Therefore, it was observed that family and the mother's characteristics as well as environmental and socioeconomic factors were closely related to the occurrence of stunting in the population studied, and such nutritional disturbance is still a health problem in the Brazilian Amazon.

Child Health in the Peruvian Amazon: Prevalence and Factors Associated with Referred Morbidity and Health Care Access in the City of Iñapari.

Introduction. Children under 5 years of age are more susceptible to developing morbidities such as diarrhea, respiratory infections, anemia, and malnutrition. The objective of the study is to evaluate the prevalence of reported morbidities in this age group in the city of Iñapari (Peru) and the access to health services in this municipality. Methods. Data collection using interviews that assessed socioeconomic and demographic conditions, child morbidity, and access to health services was performed in 2011. Statistical analysis was performed using SPSS 13.0. Results. Regarding morbidities that occurred during lifetime, 39.8% reported previous anemia and intestinal parasite infection. About 53.7% of the children reported any type of morbidities in the last 15 days before interview, being most frequent respiratory symptoms (38.9%), diarrhea (23,4%), and fever (23,1%). Only 63.1% of those reporting recent morbidities sought health care. These morbidities were associated with precarious sanitation and lack of infrastructure, the presence of other comorbidities, and poor access to health services. Conclusion. The main referred morbidities in Amazonian Peruvian children were diarrhea, respiratory symptoms, anemia, and vomiting. Incentives and improvements in the health and sanitation conditions would be important measures to improve the quality of life of the Amazonian child population.