[Update on celiac disease]. / Enfermedad celíaca.Revisión.

The prevalence of Celiac disease in the general population is approximately 1% and remains undiagnosed in a significant proportion of individuals. Its clinical presentation includes the classical malabsorption syndrome, unspecific and extra-intestinal manifestations, and silent celiac disease. The serologic diagnosis has an elevated sensitivity and specificity and, at least in adult population, it must be confirmed by biopsy in every case. Diagnosis in subjects already on gluten free diet includes HLA typing and gluten challenge with posterior serologic and histologic evaluation. The core of the treatment is the gluten free diet, which must be supervised by an expert nutritionist. Monitoring must be performed with serology beginning at 3-6 months, and with histology two years after the diagnosis, unless the clinical response is poor. Poor disease control is associated with complications such as lymphoma and small bowel adenocarcinoma. In the future, it is likely that new pharmacologic therapies will be available for the management of celiac disease.

Abundance and distribution of plant derived leaf waxes (long chain n-alkanes & fatty acids) from lake surface sediments along the west coast of southern South America: Implications for environmental and climate reconstructions.

Southern South America is the only large landmass that extends through the core of the Southern Westerly Winds (SWW), controlling hydrological and ecosystem variability in the region. In fact, the vegetation along the west coast changes from Temperate and Valdivian Rain Forest to the North Patagonian Evergreen Forest (ca. 42°S) due to the latitudinal influence of the SWW. Climate is an important driver of organic matter accumulation in lakes, hence changes in vegetation would be recorded in lacustrine sedimentary archives. This study evaluated leaf waxes contained in lake surface sediments as indicators of climate change along the west coast of southern South America, providing a biogeochemical dataset for ongoing and future (paleo)climate and environmental research. The fatty acid and n-alkane sediment leaf wax datasets are compared with latitudinal, orographic, and climatic (Mean Annual air Temperature [MAT] & Precipitation [MAP]) trends extracted from a monthly gridded reanalysis product of the Climate Forecast System Reanalysis. Fatty acids are more abundant than n-alkanes, with high abundances characterizing the transition between seasonal and year-round precipitation along the coast (ca. 42°S). The abundance of both leaf wax groups increases with MAP, suggesting precipitation as the main control on sedimentary leaf wax delivery to the lake sediments in the study area. The Carbon Preference Index (CPI) of the two groups show opposite trends, but both highlight the climate transition at ca. 42°S, and have a linear relationship with MAP. The opposite significant trends between n-alkane CPI and fatty acid CPI with MAP are interpreted as higher n-alkane production at much higher precipitation because leaf wax fatty acids are the precursors of n-alkanes. Hence, past periods during which these leaf waxes show opposite trends in CPI might be interpreted as a precipitation change, especially if additional information such as pollen, diatoms, chironomids and stable isotopes is available.

Low-dose radiotherapy to the lungs using an interventional radiology C-arm fluoroscope: Monte Carlo treatment planning and dose measurements in a postmortem subject.

Objective.The goal of this study was to use Monte Carlo (MC) simulations and measurements to investigate the dosimetric suitability of an interventional radiology (IR) c-arm fluoroscope to deliver low-dose radiotherapy to the lungs.Approach.A previously-validated MC model of an IR fluoroscope was used to calculate the dose distributions in a COVID-19-infected patient, 20 non-infected patients of varying sizes, and a postmortem subject. Dose distributions for PA, AP/PA, 3-field and 4-field treatments irradiating 95% of the lungs to a 0.5 Gy dose were calculated. An algorithm was created to calculate skin entrance dose as a function of patient thickness for treatment planning purposes. Treatments were experimentally validated in a postmortem subject by using implanted dosimeters to capture organ doses.Main results.Mean doses to the left/right lungs for the COVID-19 CT data were 1.2/1.3 Gy, 0.8/0.9 Gy, 0.8/0.8 Gy and 0.6/0.6 Gy for the PA, AP/PA, 3-field, and 4-field configurations, respectively. Skin dose toxicity was the highest probability for the PA and lowest for the 4-field configuration. Dose to the heart slightly exceeded the ICRP tolerance; all other organ doses were below published tolerances. The AP/PA configuration provided the best fit for entrance skin dose as a function of patient thickness (R2 = 0.8). The average dose difference between simulation and measurement in the postmortem subject was 5%.Significance.An IR fluoroscope should be capable of delivering low-dose radiotherapy to the lungs with tolerable collateral dose to nearby organs.

HLA in Jaidukama: an Amerindian secluded Colombian population with new haplotypes and Asian and Pacific-shared alleles.

America first inhabitants and peopling are still debated. In order to increase knowledge about these questions, we have aimed to detect HLA genes of an Amerindian secluded community: Jaidukama, who lives in North Colombia Equatorial forest. HLA genotyping and extended haplotype calculations were carried out in 39 healthy individuals belonging to 13 families. HLA frequencies were compared to other Amerindians and worldwide populations by calculating genetic distances, relatedness dendrograms and correspondence analyses. Only four DRB1 alleles were found (*0404, *0407, *1402 and *1602); however a total of 17 Amerindian different extended class I-class II HLA haplotypes were directly counted from the family studies, nine of them were specific of Jaidukamas. Some of the alleles or group of alleles within an extended haplotype (i.e. DQB1-DRB1) were also found in Asians and Pacific Islanders, further supporting existence of Asian and Pacific gene flow with Amerindians or a common founder effect. It is further supported that HLA extended haplotypes vary faster than alleles in populations. It is concluded that this unique model of Amerindian secluded families study suggests that rapid HLA haplotype variation may be more important than allele variation for survival (starting immune responses). This work may also be useful for future transplant programs in the area.

HLA genes in Uros from Titikaka Lake, Peru: origin and relationship with other Amerindians and worldwide populations.

Uros population from the Titikaka Lake live in about 42 floating reed ('totora') islands in front of Puno City (Peru) at a 4000 m high altiplano. They present both an mtDNA and a human leucocyte antigen (HLA) profile different from the surrounding populations: mtDNA A2 haplogroup is common to Uros and Amazon forest lowland Amerindians. HLA genetic distances between populations have been calculated and neighbour-joining dendrograms and correspondence analyses were carried out. Approximately 15 006 HLA chromosomes from worldwide populations have been used for comparisons. Only eight HLA-A alleles have been found, three of them accounting for most of the frequencies. The same phenomenon is seen for HLA-B, HLA-DRB1 and HLA-DQB1 alleles: a few alleles (3, 4 and 3, respectively) are present in most individuals. The presence of HLA-B*4801 and HLA-DRB1*0901 alleles in a relatively high frequency (although not the most frequent alleles found) is a characteristic shared with Asians and some populations from the Andean altiplano. Three specific Uros haplotypes have been found among the most frequent ones: HLA-A*680102-B*3505-DRB1*0403-DQB1*0302; HLA-A*2402-B*1504-DRB1*1402-DQB1*0301; and HLA-A*2402-B*4801-DRB1*0403-DQB1*0302. The present study suggests that Uros may have been one of the first populations from the shores of the Titikaka Lake coming from the Amazonian forest, which might have given rise to other later differentiated ethnic group (i.e. Aymaras). Uros HLA profile is also useful to study genetic epidemiology of diseases linked to HLA and to construct a future transplant waiting list by adding up regional lists in order to get a bigger pool for transplanting with better HLA matching.

The peopling of Madeira Archipelago (Portugal) according to HLA genes.

The Madeira-Porto Santo Archipelago was officially colonized in 1420 by Portuguese settlers. Its importance in Columbus' information for the American discovery and for slave traffic across the Atlantic is unquestionable. Thus, a complex peopling may have given rise to a present-day high admixture of ethnicities according to HLA genes. A sample of 173 healthy unrelated Madeirans was analysed and compared with 6986 HLA chromosomes from other worldwide populations. Genetic distances, neighbour-joining dendrograms and correspondence analyses were used for comparisons. Southern European, North African (including Canary Islands), Jewish and Mediterranean typical HLA alleles were found and genetic distances from Madeirans to these populations were the closest ones. In addition A*24-B*65-DRB1*0102-DQB1*0501 and A*68-B*08-DRB1*0301-DQB1*0201 haplotypes were newly found in Madeira and not found in any other population. Jewish-Armenian-Middle East haplotype (A*33-B*65-DRB1*0102-DQB1*0501) is one of the most common haplotypes; this haplotype is also present in Spaniards and North Africans. Quantitatively, Portuguese, North Africans (Algerians), Spaniards and Canary Islanders (in this order) are the most important parental populations to Madeirans. Results are discussed on the basis of the recorded historical peopling which does not show a noticeable African gene input in present-day Madeiran population according to our data; one of the closest related populations found is the Canary Islanders, suggesting that Guanche (Canary Islands first inhabitants) slaves gene flow is still noticed at present, both in Madeira and in Canary Islands populations.

[Latin-American Dialysis and Kidney Transplantation Registry: data on the treatment of end-stage renal disease in Latin America]. / Registro latino-americano di dialisi e trapianto: dati relativi al trattamento dell'insufficienza renale cronica terminale nell'America Latina.

Latin America, a region composed of a series of neighboring countries that share their history, Latin ancestry and language (Spanish or Portuguese), includes Mexico, Central America, the Spanish Caribbean islands, and South America. The Latin-American Dialysis and Kidney Transplantation Registry, which has been operative since 1991, collects data from 20 countries (Argentina, Brazil, Bolivia, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Dominican Republic, Venezuela and Uruguay), where 97% of Latin Americans live. The prevalence of renal replacement therapy (RRT) has increased from 119 patients per million (pmp) in 1991 to 478.2 in 2005 (147,158 patients [57%] on chronic hemodialysis, 58,251 [23%] on peritoneal dialysis and 52,565 [20%] living with a functioning kidney graft). The incidence rate also increased from 27.8 pmp in 1992 to 167 in 2005. The increment in prevalence and incidence occurred in all Latin- American countries. The transplantation rate increased from 3,7 pmp in 1987 to 15 pmp in 2005 (7,968 kidney transplants performed this year, the cumulative number being 98,415). Access to RRT was available for every patient diagnosed with end-stage renal disease only in Argentina, Brazil, Chile, Cuba, Puerto Rico, Venezuela and Uruguay. In Latin America, the incidence and prevalence of RRT increased year by year. Only in some countries is access to RRT available to 100% of diagnosed patients. Detection and prevention programs for chronic kidney disease are needed in the region. Meanwhile, access to RRT has to be improved for everybody who needs it.

Myocardial localization and isoforms of neural cell adhesion molecule (N-CAM) in the developing and transplanted human heart.

Neural cell adhesion molecule (N-CAM) has been implicated in cellular interactions involved in cardiac morphogenesis and innervation. Immunohistochemical techniques and Western blot analysis were used to determine the localization and isoforms of N-CAM in the developing and extrinsically denervated human heart. Myocardial and conducting cells in the fetal heart (7-24 wk gestation) exhibited sarcolemmal immunoreactivity, the major desialo N-CAM isoforms being 150, 145, 120, 115, and 110 kD. N-CAM expression appeared to be downregulated in the myocardium during adult life, with relatively little sarcolemmal immunoreactivity being detected in normal donor tissues. In contrast to the temporal changes observed in the myocardium, both the developing and mature cardiac innervation displayed N-CAM immunofluorescence staining, localized to neuronal cell bodies, nerve fascicles and fibres. Extrinsically denervated cardiac allografts, obtained 2 d to 91 mo after transplantation, showed extensive sarcolemmal and intercalated disc immunostaining and expression of 125-, 120-, and 115-kD isoforms. Tissues from explanted recipient hearts and atrial appendage samples obtained during coronary bypass graft operations were also examined and displayed varying amounts of N-CAM immunoreactivity. We conclude that the expression of N-CAM immunoreactivity and isoforms in the human heart is developmentally regulated and may be modulated by factors such as cardiac innervation and myocardial hypertrophy.

HLA Genes in Mayos Population from Northeast Mexico.

HLA class I and class II alleles have been studied in 60 unrelated people belonging to Mayos ethnic group, which lives in the Mexican Pacific Sinaloa State. Mayos HLA profile was compared to other Amerindians and worldwide populations' profile. A total of 14,896 chromosomes were used for comparisons. Genetic distances between populations, Neigbour-Joining dendrograms and correspondence analyses were performed to determine the genetic relationship among population. The new specific Mayo HLA haplotypes found are: HLA-A*02-B*35-DRB1*1406-DQB1*0301; HLA-A*02-B*48-DRB1*0404-DQB1*0302; HLA-A*24-B*51-DRB1*0407-DQB1*0302 and HLA-A*02-B*08-DRB1*0407-DQB1*0302. However, the typical Meso American HLADRB1*0407 represents a 40% of all DRB1 alleles. While common HLA characteristics are found in Amerindian distant ethnic groups, still new group specific HLA haplotypes are being found, suggesting that a common founder effect (i.e. high DRB1*0407) is noticed. Moreover, new HLA haplotypes are almost certainly appearing along time probably due to specific pathogen (?) selection for diversity. Mayo language is close to the Tarahumara one (another geographically close group); notwithstanding both groups are not genetically close according to our results, showing again the different evolution of genes and languages, which do not correlate. Finally, Sinaloa is one of the Mexican States in which more European genes are found. However, the results presented in this paper, where no European HLA genes are seen in Mayos, should have a bearing in establishing transplant programs and in HLA and disease studies.

HLA-G, -E and -F: allelism, function and evolution.

The major histocompatibility complex class I genes comprise a bunch of classical genes (A, B, C), non-classical genes (E, F and G), pseudogenes and truncated genes. MHC-E, -F and -G are now considered immune "tolerization" molecules, which not only interact with NK cells but with T lymphocyte subsets and other cells and have a role in fetus acceptation. A strong positive directional selection is acting for maintaining the observed low polymorphism on E, F and G loci in human and apes. Invariance must be important for this non-classical class I proteins function.

Hepatotoxicidad grave inducida por sertralina / Sertraline-induced severe hepatotoxicity

We report the case of a 19-year-old patient, with a history of traumatic liver damage, but with a normal liver profile at her first discharge; 1 month after the event, with post-traumatic stress disorder, treatment with 25 mg of sertraline was started every day; one month later, she develops severe hepatotoxicity without a specific etiology. According to the Naranjo algorithm, it is attributed as a probable case of sertraline hepatotoxicity. Management is carried out with support measures and suspension of the medication, and the patient recovers until she is asymptomatic, currently has normal liver tests

Reportamos el caso de una paciente de 19 años, con antecedentes de daño hepático traumático, pero con un perfil hepático normal en su primer alta; después de 1 mes del evento, con trastorno de estrés postraumático se inició tratamiento con 25 mg diarios de sertralina; un mes después, desarrolla una hepatotoxicidad severa sin etiología determinada. De acuerdo con el algoritmo de Naranjo, se atribuye como caso probable de hepatotoxicidad por sertralina. El manejo se realiza con medidas de apoyo y suspensión del medicamento, y la paciente se recupera hasta que se encuentra asintomática, actualmente tiene pruebas hepáticas normales

Guía de recomendación ACCHED-SCHGE para el funcionamiento de las unidades de endoscopia durante el brote de coronavirus (COVID-19) / Guideline recommendations ACHED-SCHGE for the endoscopy units during the Coronavirus outbreak (COVID-19)

The outbreak of COVID-19 disease has recently spread from its original place in Wuhan, Hubei province, China, to the entire world, and has been declared to be a pandemic by the World Health Organization in March 2020. All countries in America, in particular Chile, show an important increase in COVID-19 cases and deaths. The clinical manifestations of COVID-19 are a broad spectrum, from asymptomatic mild disease, to severe respiratory failure, shock, multiorgan dysfunction and death. Thus, high clinical suspicion and appropriate structure risk stratification are needed. Health care teams in endoscopy units, are at an increased risk of infection by COVID-19 from inhalation of droplets, mucosae contact, probably contamination due to contact with stools. Endoscopic aerosolized associated infections have also been reported. Different societies' recommendations, have recently placed digestive endoscopy (especially upper) among the high risk aerosol generating procedures (AGPs). In addition, live virus has been found in patient stools. On top of this, the infected health professionals may transmit the infection to their patients. Health care infection prevention and control (HCIPC), has been shown to be effective in assuring the safety of both health care personnel and patients. This is not limited to the correct use of personal protective equipment (PPE), but is based on a clear, detailed and well communicated HCIPC strategy, risk stratification, use of PPE, and careful interventions in patients with moderate and high risk of COVID-19. A conscientious approach regarding limited resources is important, as the simultaneous outbreak in all countries heavily affects the availability of health supplies. The Chilean Gastroenterology Society (SChGE) and Digestive Endoscopy Association of Chile (ACHED) are joining to provide continued updated guidance in order to assure the highest level of protection against COVID-19, for both patients and health care workers. This guideline will be updated online as needed.

El brote de la enfermedad denominada COVID-19, se ha extendido desde su origen en Wuhan, provincia de Hubei, China, a todo el mundo. La Organización Mundial de la Salud lo declaró pandemia en marzo de 2020. Todos los países de América, en especial Chile, presentan incremento de casos y fallecidos. Las manifestaciones clínicas de COVID-19 van desde una enfermedad leve, hasta insuficiencia respiratoria severa, shock, disfunción orgánica y muerte. Se necesita una alta sospecha clínica y una adecuada estratificación del riesgo. El equipo de salud en las unidades de endoscopia, tiene un mayor riesgo de COVID-19 que otras unidades clínicas y de apoyo diagnóstico, dada la mayor exposición a inhalación de gotas, contacto posible con mucosas y contaminación por contacto con deposiciones. Recomendaciones de diferentes sociedades colocan la endoscopia digestiva (especialmente la esofagogastroscopia o endoscopia digestiva alta, EDA) entre los procedimientos generadores de aerosoles (PGA) de alto riesgo. Además, se han encontrado virus viables en las deposiciones de los pacientes. Potencialmente, los profesionales de la salud infectados podrían contagiar a los pacientes. Se ha demostrado que la prevención y control de infecciones asociadas a la atención de salud (IAAS), son efectivos para garantizar la seguridad tanto del personal de salud, como de los pacientes. Esto no es solamente el correcto uso del equipo de protección personal (EPP), sino que se basa en una clara estrategia de IAAS, bien comunicada, con estratificación de riesgo, uso de EPP e intervenciones correctas en pacientes con riesgo moderado y alto. Es relevante un enfoque sobre los limitados recursos, dado la simultaneidad del brote en todos los países, que afecta la disponibilidad de insumos. La Sociedad Chilena de Gastroenterología (SChGE) y la Asociación Chilena de Endoscopia Digestiva (ACHED) publican esta guía actualizada para apoyar las buenas prácticas contra COVID-19, tanto para pacientes como para el equipo de salud. Esta guía podrá tener actualizaciones según avance la información disponible.

The origin of Palestinians and their genetic relatedness with other Mediterranean populations.

The genetic profile of Palestinians has, for the first time, been studied by using human leukocyte antigen (HLA) gene variability and haplotypes. The comparison with other Mediterranean populations by using neighbor-joining dendrograms and correspondence analyses reveal that Palestinians are genetically very close to Jews and other Middle East populations, including Turks (Anatolians), Lebanese, Egyptians, Armenians, and Iranians. Archaeologic and genetic data support that both Jews and Palestinians came from the ancient Canaanites, who extensively mixed with Egyptians, Mesopotamian, and Anatolian peoples in ancient times. Thus, Palestinian-Jewish rivalry is based in cultural and religious, but not in genetic, differences. The relatively close relatedness of both Jews and Palestinians to western Mediterranean populations reflects the continuous circum-Mediterranean cultural and gene flow that have occurred in prehistoric and historic times. This flow overtly contradicts the demic diffusion model of western Mediterranean populations substitution by agriculturalists coming from the Middle East in the Mesolithic-Neolithic transition.

Lack of MHC-G4 and soluble (G5, G6) isoforms in the higher primates, Pongidae.

HLA-G is a class Ib (nonclassical) major histocompatibility complex (MHC) protein expressed at the materno-fetal interface that may inhibit natural killer (NK) cell-mediated lysis in an allotype-independent manner. The human MHC-G transcript is differentially spliced, giving rise to at least six different forms. In order to study the evolutionary importance of this phenomenon, the presence of alternative splicing in MHC-G mRNA molecules from Pongidae (Chimpanzee, Gorilla, and Orangutan) has been investigated in the present work, and three alternative spliced isoforms (i.e.: G1, G2, and G3) have been found, but not the G4 and the soluble G5 and G6 ones. In addition, a novel MHC-G isoform is described in Gorilla, "G2 short." This molecule is similar to the G2 isoform, but it lacks 29 amino acids normally encoded by exon 4. Our findings suggest that soluble isoforms are not necessary for MHC-G function(s) in Pongidae or that MHC-G is not a functional protein, because G1 is not necessary for survival in humans and Cercopithecinae bear stop codons in MHC-G exon 3.

Perfusion fixation for placental morphologic investigation.

Fifty placentas were collected after vaginal delivery or cesarean section from normal and abnormal pregnancies and were fixed under different conditions of perfusion using a peristaltic roller pump. In each case a physiologic-heparin perfusate was used for less than 10 minutes, followed by a buffered solution of glutaraldehyde-formaldehyde. The best results were obtained with placentas from cesarean sections perfused immediately after delivery with a pressure maintained under 60 mm Hg. Placentas of this group were fixed within 30 minutes and electron microscopy demonstrated good preservation of cellular ultrastructure. Perfusion fixation could be performed up to 6 hours after delivery with satisfactory histologic results. In these cases, electron microscopy revealed ischemic changes 10 minutes after delivery and severe necrosis 1 hour after delivery. When the perfusion pressure was maintained over 60 mm Hg, diffuse damage of the villous morphology was observed. Histomorphometric analysis showed significant differences between terminal villi from nonperfused (immersed-fixed) placentas and perfused-fixed placentas. The mean barrier and trophoblastic thicknesses and the mean volume fraction of trophoblast were significantly (P less than .001) increased in the nonperfused group compared with the perfused group.

Studies of the Epitopes of Amoxicillin by Monoclonal Antibodies.

Four different mice monoclonal antibodies to amoxicillin (AX) were studied (AO 25.2, AO 6.2, AO 21.1, and AO 3.2). The specificity was determined by enzyme-linked immunosorbent assay inhibition using in the fluid phase free and conjugated monomers of AX, ampicillin, and benzylpenicillin with ε-aminocaproic acid. The monoclonal AO 25.2 (IgM isotype) recognized a chemical structure common to all penicillins used, presumably the thiazolidine ring. AO 6.2 (IgE) and AU 3.2 (IgG2a recognized mainly the side chain of AX and the clone AO 21.1 (IgG3) required for optimal inhibition of the conjugated monomer of AX, indicating that both the side chain and the new antigenic determinant were required for optimal inhibition. These results indicate that there are differences in the specificities of these antibodies and that the different parts of the AX molecule contribute to a different extent to the antigen-binding site.

A modified design of the buried radial forearm free flap for use in oral cavity and pharyngeal reconstruction.

OBJECTIVE: We present a new design for the radial forearm flap that includes a small monitor segment that is connected to the primary skin paddle by a fascial subcutaneous segment of tissue. This design modification permits buried flaps to be easily monitored and provides vascularized tissue coverage of the flap vessels as well as the great vessels in the neck. Immediate augmentation of the radical neck deformity can be achieved. SETTING: This study was conducted at a referral center. PATIENTS: Fifteen patients with squamous cell cancer of the pharynx and tongue base were included in this study. The defects in these patients were judged to be best reconstructed with a radial forearm free flap. RESULTS: All free flaps in this series survived. There was one case, described in detail, in which the fascial subcutaneous portion of the flap was exposed to salivary contamination. The flap vessels remained well protected and flap viability was unimpaired.

A systematic approach to functional reconstruction of the oral cavity following partial and total glossectomy.

Mobility, sensation, volume, and to a lesser extent, the shape of the tongue following partial glossectomy are critical elements to the successful rehabilitation of the patient with oral cancer. Our approach to tongue reconstruction is based on the extent and functional status of the residual tongue and whether there is an associated mandibulectomy. Despite the devastating effects of ablative surgery and radiation, the application of available reconstructive techniques can help to improve the quality of life of these patients. Herein, we present a revised classification scheme for tongue defects along with a discussion of the optimal method for reconstruction based on available techniques.

Perinatal management of unanticipated congenital laryngeal atresia.

Unless ventilation is achieved within minutes of delivery, patients with congenital laryngeal atresia will not survive. There are 2 settings in which survival is more likely: a tracheotomy may be immediately performed in the delivery room, or a communication may exist between the airway and the pharynx, allowing for air exchange. In the latter case, there are no characteristic findings on prenatal sonography to suggest the diagnosis and to ensure that preparations for immediate tracheotomy are made. We describe a neonate with unanticipated laryngeal atresia and a high tracheoesophageal fistula. Ventilation was maintained first by face mask and then by esophageal intubation until a tracheotomy could be performed. This report provides detailed photodocumentation of the anomaly, discusses the mechanism of air exchange, reviews the relevant embryological development, and outlines a protocol for perinatal management of unanticipated laryngeal atresia.

Rigid fixation of vascularized bone grafts in mandibular reconstruction.

OBJECTIVE: To evaluate the nature of complications and complication rates with the use of three different reconstruction plates for the rigid fixation of vascularized bone grafts in oromandibular reconstruction. DESIGN: We conducted a case series of 95 patients over a 6-year period, with a minimum follow-up of 6 months and a maximum follow-up of 66 months. SETTING: Academic tertiary referral medical center. PATIENTS: Forty-eight patients had vascularized bone grafts fixated to native mandible with AO stainless steel reconstruction plates; 25 patients, with AO titanium plates; and 22 patients, with titanium hollow screw reconstruction plates (THORPs). Types of vascularized flaps, mandibular defects to be reconstructed, and use of radiation therapy were similar among the three groups. INTERVENTION: The surgical approach involved oromandibular reconstruction with a vascularized bone graft rigidly fixated with a reconstruction plate. OUTCOME MEASURES: Clinically and radiographically noted complications and resultant treatment. RESULTS: In the grafts fixated with AO stainless steel reconstruction plates, three plate fractures, seven instances of loose screws, eight plate exposures, and two cases of nonunion occurred. No cases of plate fracture or nonunion occurred in the titanium or THORP groups. One titanium plate and two THORPs were exposed during the study period. One instance of loose screws occurred in the titanium group; none in the THORP group. Seventy-four percent of those complications occurred within 12.4 months (the mean follow-up time of the THORP group). The incidence of complications in the stainless steel group was significantly greater than that in the titanium or THORP groups. No statistically significant increase in the rate of complications was noted when radiation therapy was used as a component of treatment. CONCLUSIONS: To our knowledge, this is the first study to compare three different reconstruction plates for fixation in vascularized bone reconstruction of the mandible. AO THORPs are now used almost exclusively to rigidly fixate vascularized bone grafts because of their advanced design and their potential for osseointegration and because fewer screws are necessary to attain adequate fixation than with conventional AO reconstruction plates.