Evaluation of Reproductive Histology Response of Adult Fasciola hepatica in Goats Vaccinated with Cathepsin L Phage-Exposed Mimotopes.

Fasciolosis, a globally re-emerging zoonotic disease, is mostly caused by the parasitic infection with Fasciola hepatica, often known as the liver fluke. This disease has a considerable impact on livestock productivity. This study aimed to evaluate the fluke burdens and faecal egg counts in goats that were administered phage clones of cathepsin L mimotopes and then infected with F. hepatica metacercariae. Additionally, the impact of vaccination on the histology of the reproductive system, specifically related to egg generation in adult parasites, was examined. A total of twenty-four goats, which were raised in sheds, were divided into four groups consisting of six animals each. These groups were randomly assigned. The goats were then subjected to two rounds of vaccination. Each vaccination involved the administration of 1 × 1013 phage particles containing specific mimotopes for cathepsin L2 (group 1: PPIRNGK), cathepsin L1 (group 2: DPWWLKQ), and cathepsin L1 (group 3: SGTFLFS). The immunisations were carried out on weeks 0 and 4, and the Quil A adjuvant was used in combination with the mimotopes. The control group was administered phosphate-buffered saline (PBS) (group 4). At week 6, all groups were orally infected with 200 metacercariae of F. hepatica. At week 22 following the initial immunisation, the subjects were euthanised, and adult F. hepatica specimens were retrieved from the bile ducts and liver tissue, and subsequently quantified. The specimens underwent whole-mount histology for the examination of the reproductive system, including the testis, ovary, vitellaria, Mehlis' gland, and uterus. The mean fluke burdens following the challenge were seen to decrease by 50.4%, 62.2%, and 75.3% (p < 0.05) in goats that received vaccinations containing cathepsin L2 PPIRNGK, cathepsin L1 DPWWLKQ, and cathepsin L1 SGTFLFS, respectively. Animals that received vaccination exhibited a significant reduction in the production of parasite eggs. The levels of IgG1 and IgG2 isotypes in vaccinated goats were significantly higher than in the control group, indicating that protection is associated with the induction of a mixed Th1/Th2 immune response. The administration of cathepsin L to goats exhibits a modest level of efficacy in inducing histological impairment in the reproductive organs of liver flukes, resulting in a reduction in egg output.

Insecticidal activity of two organic extracts from Libidibia coriaria (Jacq.) Schltdl. fruits against Spodoptera frugiperda J. E. Smith.

This study describes the chemical characterisation of two extracts (ethyl acetate, EtOAc-E and hexanic, Hx-E) from Libidibia coriaria fruits and their insecticidal properties on Spodoptera frugiperda. The HPLC analysis in EtOAct-E revealed the presence of ellagic acid and phenolic compounds. The CG-MS analysis in Hx-E revealed the presence of Hexadecanoic acid, 11-Methylheptacosane, Dodecanoic acid and Nonacosane as major compounds. The application of both extracts was performed on the dorsal part of each larva via aspersion. The larval mortality, relative growth and emergence percentage of adults were evaluated. The Hx-E caused a 93.33% mortality at 100 mg/mL at 24 h post-application. A minor relative growth with both EtOAc-E (12.64 mg) and Hx-E (7.90 mg) was observed compared with their respective negative controls (methanol = 25.05 mg and tween20 = 24.53 mg). The lowest emergence percentage of adults with the Hx-E (25%) at 50 mg/mL was observed. Libidibia coriaria fruits exhibit insecticidal properties against S. frugiperda.

Effects of Zilpaterol Hydrochloride with a Combination of Vitamin D3 on Feedlot Lambs: Growth Performance, Dietary Energetics, Carcass Traits, and Meat Quality.

This study evaluated the impact of supplementing ZH in combination with D3 on the growth performance, energy efficiency, carcass traits, and meat quality of feedlot lambs. Thirty-two Dorper × Katahdin cross lambs (37.3 ± 5.72 kg) were utilized in a 29 d experiment in a completely randomized block design with a 2 × 2 factorial structure consisting of two levels of ZH for 26 d (0 and 0.20 mg/kg PV-1) and two levels of D3 for 7 d (0 and 1.5 × 106 IU/d-1). ZH improved (p ≤ 0.05) the average daily gain (ADG) and feed efficiency by 9.9% and 17.8%, respectively, as well as hot carcass weight (HCW) and dressing carcass by 4.3% and 2.6%, respectively. (p ≤ 0.03). However, ZH increased (p < 0.01) muscle pH and Warner-Bratzler shear force (WBSF) (2.5 and 23.0%, respectively). D3 supplementation negatively affected (p ≤ 0.02) dry matter intake (DMI) (last 7 d) and ADG by 15.7% and 18.1%. On the other hand, D3 improved the pH of the longissimus thoracis muscle by 1.7% (p = 0.03) without affecting WBSF. When D3 was supplemented in combination with ZH, it was observed that meat quality was improved by reducing muscle pH compared to lambs treated only with ZH. However, D3 did not improve the meat tenderness negatively affected by ZH supplementation.

In vitro ovicidal and larvicidal activity of a hydroalcoholic extract and its fractions from Cyrtocarpa procera fruits on Haemonchus contortus.

This study describes the in vitro anthelmintic effect of a hydroalcoholic extract (HA-E) and its fractions from Cyrtocarpa procera fruits against Haemonchus contortus eggs and infective larvae. The HA-E was subjected to bipartition using ethyl acetate, which resulted in an aqueous fraction (Aq-F) and an organic fraction (EtOAc-F). The HA-E and both fractions were tested using the egg hatching inhibition assay (EHIA) and the larval mortality test (LMT). Fractionation of the EtOAc-F was achieved using different chromatographic processes, i.e., open glass column and HPLC analysis. Fractionation of the EtOAc-F gave 18 subfractions (C1R1-C1R18), and those that showed the highest yields (C1R15, C1R16, C1R17 and C1R18) were subjected to anthelmintic assays. The HA-E and the EtOAc-F displayed 100% egg hatching inhibition at 3 and 1 mg/mL, respectively, whereas Aq-F exhibited 92.57% EHI at 3 mg/mL. All subfractions tested showed ovicidal effect. Regarding the larval mortality test, HA-E and EtOAc-F exhibited a larvicidal effect higher than 50% at 50 and 30 mg/mL, respectively. The subfractions that showed the highest larval mortality against H. contortus were C1R15 and C1R17, with larval mortalities of 53.57% and 60.23% at 10 mg/mL, respectively. Chemical analysis of these bioactive subfractions (C1R15 and C1R17) revealed the presence of gallic acid, protocatechuic acid, and ellagic acid. This study shows evidence about the ovicidal and larvicidal properties of C. procera fruits that could make these plant products to be considered as a natural potential anthelmintic agents for controlling haemonchosis in goats and sheep.

Extranodal Follicular Dendritic Cell Sarcoma Presenting on the Skin.

ABSTRACT: Follicular dendritic cell sarcoma is a rare intermediate-grade malignancy characterized by a proliferation of ovoid to spindle-shaped cells with morphologic and immunophenotypic features similar to normal follicular dendritic cells. It may develop in lymph nodes or extranodal sites. Its presentation in extranodal tissues is a diagnostic challenge. It requires a high index of suspicion because follicular dendritic cell markers are not included in the routine immunohistochemical panels used for differential diagnosis. In an extensive review of the English literature, we found 3 cases of follicular dendritic cell sarcoma developing on the skin. We report a case of a primary cutaneous follicular dendritic cell sarcoma in a 28-year-old man, which presented as a 6-mm skin-colored nodule on the right forearm. We describe the morphologic and immunohistochemical features and a review of the literature.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura / Pulmonary embolism in infective endocarditis associated with pacemaker: report of a case and review of the literature

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Genomic alterations in a cohort of pediatric acute myeloid leukemia patients at two cancer centers in Colombia.

Few studies identifying genomic aspects in pediatric acute myeloid leukemia patients in Latin American countries have been reported. The aim of this study was to identify genomic alterations, clinical characteristics and outcomes in a cohort of pediatric AML patients. This descriptive observational cohort study included patients with confirmed de novo acute myeloid leukemia up to 18 years of age. Cytogenetics and conventional FISH analysis, next-generation sequencing and PCR testing were performed. The correlation of genomic data with treatment response and outcomes were analyzed. Of the 51 patients analyzed, 67.4% had a cytogenetic abnormality and 74.5% had a genetic variant. FLT3 variants (ITD or TKD D835) were found in 27.4%, followed by NRAS (21.6%), KRAS (13.7%) and WT1 and KIT (11.8%). Patients were stratified by risk (66.6% high-risk) after the end of induction. FLT3-ITD was associated with relapse (OR 11.25; CI 1.89-66.72, p 0.006) and NRAS with death during induction (OR 16.71; CI 1.51-184.59, p 0.022). Our study highlights the importance of rapid incorporation of genetic testing in pediatric AML in Colombia, as it directly affects treatment decisions and outcomes. Incorporation of targeted therapies with conventional chemotherapy is an increasingly urgent need in pediatric patients.

Phenolic Acids and Flavonoids from Pithecellobium dulce (Robx.) Benth Leaves Exhibit Ovicidal Activity against Haemonchus contortus.

Pithecellobium dulce (Robx.) Benth is an arboreal legume used in traditional medicine for the treatment of several ailments, including a number of intestinal disorders, and as a natural deworming. The objective of this study was to evaluate the ovicidal activity of a hydroalcoholic extract (HA-E) and its fractions (aqueous, Aq-F and organic, EtOAc-F) from P. dulce leaves, as well as subfractions (C1F1-C17) obtained from EtOAc-F against Haemonchus contortus eggs. The HA-E, Aq-F, and EtOAc-F were assessed at 0.03-5.00 mg/mL and subfractions (C1F1-C17) were assessed at 0.06-1.00 mg/mL. The HA-E and Aq-F showed an ovicidal activity close to 100% at 2.5 mg/mL, and EtOAc-F displayed the highest anthelmintic effect (100% at 0.25 mg/mL). Meanwhile, the sub-fractions with the highest ovicidal effect were C1F6, C1F9, C1F10, C1F11, and CIF13. The main compounds identified in the most active fractions (C1F9, C1F11, and C1F13) were kaempferol (1), quercetin (2), coumaric acid (3), ferulic acid (4), luteolin 7-O-rhamnoside (5), quercetin 3-O-rhamnoside (6), and a caffeoyl derivate (NI). The results indicate that P. dulce leaves exhibit a potent anthelmintic activity and contain bioactive compounds able to inhibit egg hatching in H. contortus. Therefore, this plant could be used for the control of gastrointestinal nematodes in small ruminants.

Immune checkpoint inhibitors-associated thrombosis in patients with lung cancer and melanoma: a study of the Spanish society of medical oncology (SEOM) thrombosis and cancer group.

PURPOSE: Immune Checkpoint Inhibitors (ICI) can be associated with thrombotic events, both venous and arterial (VTE/AT). However, there is a paucity of information regarding patients in routine clinical practice. METHODS/PATIENTS: Retrospective, multicenter study promoted by the Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM). Patients with melanoma and lung cancer who initiated ICI between 01/01/2015 and 31/12/2019 were recruited. Minimum follow-up was 6 months (unless it was not possible because of death). The primary objective was to calculate the incidence of ICI-associated VTE/AT and the secondary objectives included to analyze its impact on survival and to identify predictor variables for VTE/AT. RESULTS: 665 patients with lung cancer were enrolled. The incidence of VTE/AT during follow-up was 8.4%. Median overall survival (OS) was lower in the VTE/AT group (12 months 95% CI 4.84-19.16 vs. 19 months 95% CI 16.11-21.9; p = 0.0049). Neutrophil/lymphocyte ratio (NLR) and anemia upon initiation of IT, as well as a history of thrombosis between cancer diagnosis and the start of ICI, were predictive variables for developing of VTE/AT (p < 0.05). 291 patients with melanoma were enrolled. There was a 5.8% incidence rate of VTE/AT during follow-up. Median OS was lower in the VTE/AT group (10 months 95% CI 0.0-20.27 vs. 29 months 95% CI 19.58-36.42; p = 0.034). NLR and lactate dehydrogenase (LDH) at the beginning of ICI were predictor variables for VTE/AT (p < 0.05). CONCLUSIONS: ICI increases the risk of VTE/AT in patients with lung cancer and melanoma, which impact OS.

Effect of soybean grain (Glycine max L.) supplementation on the production and fatty acid profile in milk of grazing cows in the dry tropics of Mexico.

Improving the lipid profile in milk of cows with the use of soybean grain (Glycine max L.) can be favored in the grazing systems in the dry tropics of Mexico. The objective was to evaluate the milk production, the chemical composition, and the fatty acids profile (FAs) of the milk of cows in continuous grazing and supplemented with and without ground roasted soybean in the dry tropics of Mexico. Ten cows randomly distributed in two equal groups were used. Daily during confinement for milking, the cows individually received the treatments on dry basis T0: supplement with 4.6 kg commercial concentrate® without soybean, T1: supplement with 3.7 kg commercial concentrate® with 380 g of soybean. During the 78 days of the experiment, milk production was measured in all cows, and samples were collected to determine the chemical composition and FAs profile. Milk production, protein, milk total fat, lactose, and non-fat solids did not vary with treatment (p >0.05). Linoleic acid content (C18: 2, cis, cis-∆9, ∆12) increased by 22% in milk fat of cows of the T1 (p ˂0.05). The sum of the mono- and polyunsaturated FAs 29.1%, the ratio of saturated-unsaturated FAs (1.65), and the atherogenicity index (1.71) also improved in the milk of cows supplemented with T1 (p ˂0.05). It was concluded that ground roasted soybean supplement in the diet of grazing dairy cows did not affect production and did improve the lipid profile in milk fat with favorable index to promote human health.

Ionizing Radiation Exposure in Children with Vesicoureteral Reflux: Should We Be Alarmed? / Exposición a radiacion ionizante en niños con reflujo vesicoureteral: Debemos preocuparnos?

Objectives Ionizing radiation imaging is commonly used for diagnosis and follow up in children with vesicoureteral reflux (VUR). We aim to measure the effective dose (mSv) in patients with VUR. Methods We reviewed our electronic database of patients under 8-years-old with VUR. Primary endpoint was to calculate the effective radiation dose (ED). Absolute frequencies and percentages were reported for global qualitative variables. This study conducted a logistic regression model to calculate the odds ratio for radiation exposure. Analysis was performed using STATA version 14.0 (StataCorp LLC, College Station, TX, EEUU). Results A total of 140 patients were found, 97 were assessed for eligibility. We included 59 patients in the final analysis. Mean age was 20 ± 17.9 months, 66% were females. Most cases of VUR were bilateral (44%) and high grade (93.4%). The lowest number of studies per patient was two, with a minimum radiation of 5.7 mSv. The highest radiation was estimated at 20.7 mSv corresponding to a total of five studies. Logistic regression showed that highest grades of VUR and age of first UTI episode were associated with higher ED (OR, 1.7; 95% CI, 0.87-3.31), (OR 1.02; 95% CI 0.97-1.07) respectively. A mean ED for children with VUR was estimated of 5.5 ± 3 mSv/year. Conclusion In our study, the children with VUR were exposed to 5.5 mSv/year without counting the natural background radiation, which is alarming, and we believe should raise awareness worldwide in how we are unnecessarily diagnosing indolent VUR cases and following patients.

Objetivos La imagenología por radiación ionizante es una herramienta usada frecuentemente para el diagnóstico y seguimiento de pacientes con reflujo vesicoureteral (RVU). El objetivo del presente trabajo es calcular la dosis estimada en milisieverts (mSv) de pacientes con RVU. Métodos Se realizó una revisión retrospectiva de todos los pacientes menores de 8 años con RVU. El objetivo principal fue calcular la dosis de radiación efectiva recibida por los pacientes con base en los estudios imagenológicos realizados hasta el momento de la revisión de la base de datos. Las frecuencias y porcentajes fueron reportados para las variables cualitativas. Se realizó una regresión logística para calcular la asociación de factores de riesgo con la exposición a radiación. El análisis estadístico fue realizado con el programa STATA versión 14.0 (StataCorp LLC, College Station, TX, EEUU). Resultados Se identificaron 140 patientes, de los cuales 97 fueron evaluados para coprobar su elegibilidad. En total, 59 pacientes fueron incluidos para el análisis final. La edad promedio de los pacientes fue de 20 ± 1,.9 meses, y 66% eran mujeres. La mayoría de casos fueron bilaterales (44%) y de alto grado (93,4%). El menor número de estudios realizados por paciente fue 2, con una dosis mínima de radiación acumulada de 5,7 mSv. La máxima radiación acumulada fue de 20,7 mSv, correspondiente a un total de 5 estudios. La regresión logística demostró que altos grados de reflujo y la edad a la cual tuvieron la primera infección se asociaban con mayores dosis de radiación efectiva (razón de probabilidades [RP]: 1.7; intervalo de confianza del 95% [IC95%]: 0,87­3,31), (RP: 1,02; IC95%: 0,97­1,07), respectivamente. Estimamos una dosis efectiva de radiación de 5,5 ± 3 mSv/año en nuestra población. Conclusión Nuestro estudio demuestra que pacientes con reflujo son expuestos a un promedio de 5,5 mSv/año sin contar la radiación de base a la que se exponen todos los humanos anualmente, lo cual resulta alarmante. Esto debe generar introspección al momento de evaluar pacientes con reflujo y evitar efectos a largo y mediano plazos.

Interpretación medicolegal para el abordaje de individuos con desórdenes del desarrollo sexual en Colombia / Interpretation of medical-legal Colombian legislation to treat individuals with disorders of sexual development

Objetivo Los desórdenes del desarrollo sexual (DDSs) son un grupo de condiciones médicas cuyo manejo implica un enfoque transdisciplinario. En la legislación colombiana, no existe una regulación específica en materia de intervenciones médicas en individuos con DDSs. La Corte Constitucional Colombiana se ha encargado de proferir sentencias, en las cuales se han establecido unos lineamientos y parámetros para el manejo jurídico de los casos de ambigüedad genital. Teniendo en cuenta lo anterior, nos proponemos en este artículo exponer y analizar, desde la visión de un grupo transdisciplinario, las sentencias más relevantes que han sido proferidas por la Corte Constitucional Colombiana. Métodos Se realizó una revisión narrativa en las bases de datos de la Corte Constitucional y de la literatura legal. Se recopilaron todas las sentencias disponibles, y se evaluaron lo casos clínicos identificados por el grupo transdisciplinario de DDSs del Hospital Universitario San Ignacio. Finalmente, los autores generaron por consenso un texto de discusión, como guía para los lectores, luego de analizar cada una de las sentencias y los casos presentados. Resultados Se identificaron 9 sentencias y los antecedentes que llevaron a la elaboración de cada una de ellas. Los nueve casos presentados contienen conceptos importantes para la articulación por parte del grupo transdisciplinario, tales como, autonomía, consentimiento sustituto y asistido, e indicación médica del tratamiento. Se excluyeron las sentencias T-692/99 y la T-918/2012, dado que daban información duplicada con referencia a sentencias incluidas en este documento. Conclusión La Corte Constitucional Colombiana ha proferido sentencias en las cuales no se ha contado con la participación de grupos de expertos. La terminología usada no describe apropiadamente el lenguaje técnico que se aplica al manejo de nuestros pacientes. Para el abordaje de individuos con DDSs, resulta muy importante conocer la relevancia de las sentencias basadas en un análisis individual de cada caso.

Objective Disorders of sexual development (DSDs) are a group of conditions that require a transdisciplinary approach. In the Colombian legislation, there are no specific regulations regarding medical interventions in individuals with DSDs. The Colombian Constitutional Court has issued sentences establishing some guidelines and parameters for the legal management of cases of genital ambiguity. Considering the aforementioned information, the present manuscript aims to describe and analyze, from the perspective of a transdisciplinary team, the most relevant sentences issued by the Colombian Constitutional Court. Methods We performed a narrative review of the database of the Colombian Constitutional Court and of the legal literature. We compiled all available court sentences and evaluated the clinical cases identified by the transdisciplinary team at Hospital Universitario San Ignacio. Lastly, the authors composed, through consensus, a text for discussion, as a guide to the readers, after the analysis of each of the sentences and cases presented. Results We identified nine sentences and the precedents that led to their development. The nine cases presented contain important concepts for the work of the transdisciplinary team, such as autonomy, substitute and assisted consent, and the medical indication of treatment. Sentences T-692/99 and T-918/2012 were excluded, as they provided duplicate information concerning sentences included in this document. Conclusion The Colombian Constitutional Court has issued sentences without the participation of a team of experts in DSDs. The terminology used does not properly describe the jargon that is applied in the management of our patients. In order to approach individuals with DSDs, awareness regarding the relevance of the sentences based on an individual analysis of each case is of great importance.

Gender Dysphoria in the Pediatric Population: Initial Experience of a Transdisciplinary Group / Disforia de género en la población pediátrica: experiencia inicial de un grupo transdisciplinario

Introduction Although there is an increasing experience in the management of transgender individuals, this has not been thoroughly explored in children. The need to establish a comprehensive and transdisciplinary management is of critical importance. In order to solve this issue, we want to report the results of a cohort of individuals with gender dysphoria (GD) seen by our transdisciplinary group from a social and clinical and health access perspective. Methods A 10-year retrospective case series of all patients that had been seen by our transdisciplinary team was reviewed. The main demographic characteristics were described, as well as impact variables in terms of diagnosis and treatment of these individuals. A social description of each individual was described. Frequency, distribution, and central tendency measures were evaluated for data presentation. IBM SPSS Statistics for Windows, version 24.0 (IBM Corp, Armonk, NY) software was used. Results Four cases of GD were included. Three had male to female dysphoria and one female to male. The median reported age of GD awareness was 6 years old (between 4 and 8 years old), and the median time between GD awareness and the 1st medical evaluation was 7 years for all individuals. The median age at gender role expression was 12 years old (between 10 and 14 years old). All patients had already assumed their experienced gender role before the 1st evaluation by our group. The median age at the 1st evaluation by our group was 13 years old (between 10 and 16 years old); three of the patients were evaluated after initiation of puberty. In the present study, individuals with GD demonstrated having health care access barriers for their transition process. Referral times are high, and individuals with GD are cared after pubertal development, which is related to suboptimal outcomes. The spectrum of GD is broad, and management must be individualized according to expectations. Conclusion Individuals with GD face multiple access barriers that limit their possibility of being seen by a transdisciplinary team. This reflects in longer waiting times that negatively impact medical management. Gender dysphoria is a wide spectrum, and individuals should be evaluated individually by a transdisciplinary team.

Introducción En las ultimas décadas se ha ganado más experiencia en el manejo de individuos con disforia de genero (DG). Sin embargo, en la población pediátrica esto aun no se ha explorado completamente. La necesidad de ofrecer un manejo cuidadoso y transdisciplinario es de gran importancia. El objetivo de este estudio es presentar la experiencia de nuestro grupo transdisciplinario (GT) en el abordaje de pacientes con DG desde el punto de vista medico y social. Materiales y métodos Se realizó un análisis descriptivo de los casos de DG en menores de 18 años tratados en los últimos 10 años por el GT de Desórdenes del Desarrollo e Identidad Sexual. Se usaron medidas de frecuencia y tendencia central para la presentación de datos mediante el programa SPSS, versión 24.0. Se realizó un análisis descriptivo de las variables: familia y dinámica social; evaluación psiquiátrica; expectativas; barreras de acceso; y abordaje del GT. Resultados Se presentan cuatro casos de DG, tres hombre-mujer y uno mujer-hombre. La edad a la primera sensación de disforia (PSD) fue en promedio 5,7 años, y el tiempo medio entre la PSD y la primera evaluación médica (PEM) fue de 6,25 años. La edad promedio a la primera evaluación por el grupo (PEG) fue de 13,25 años; 3 individuos tenían pubertad avanzada y 1, incipiente. Dos individuos habían recibido atención médica antes de la PEG. Se identificó que, al momento de la valoración por el grupo, los individuos contaban con el apoyo de sus familiares, y el entorno escolar era cada vez más incluyente; en ninguno se identificó enfermedad psiquiátrica, y a todos se indicó acompañamiento por psicoterapia. La expectativa con el proceso fue heterogénea con respecto a procedimientos quirúrgicos, manejos hormonales y rol de género, dependiendo de las características físicas que generaban disforia (caracteres sexuales secundarios, genitales). Las barreras de acceso fueron el desconocimiento de los especialistas en primeras valoraciones y las administrativas. La decisión del grupo con respecto al manejo hormonal y quirúrgico, así como acompañamiento psicológico se individualizó para cada paciente. Conclusiones Los individuos con DG presentan barreras de acceso a soporte médico para su proceso de transición. Los tiempos de atención son prolongados; por ende, son atendidos después de desarrollar la pubertad, lo cual se relaciona con desenlaces subóptimos. El espectro de la DG es amplio y se debe individualizar el manejo según las expectativas.

Surgical Technique of Supine Percutaneous Nephrolithotomy in Children / Técnica quirúrgica de la nefrolitotomía percutánea en supino en niños

Percutaneous nephrolithotomy (PCNL) in children has becomemore widely used due to its high efficacy and safety and to the development of miniaturized instruments. A supine approach is promising due to advantages such as better ventilation, reproducibility, and ergonomics. The purpose of the present study is to describe our surgical technique with special considerations in the pediatric population. We used an oblique supine position supported by one silicone gel positioning pad under the hip and another under the ipsilateral flank. The anatomical landmarks used to guide the puncture were the 11th and 12th ribs, the posterior axillary line, and the iliac crest. Initially, a ureteral catheter was introduced endoscopically. A retrograde pyelography was performed to guide the puncture, which was performed using a biplanar technique. A hydrophilic guide wire was then advanced through the needle. Dilation was performed with Alken telescopic dilators until 14 Ch. Fragmentation was performed either with a 13 Ch semirigid cystoscope or a flexible ureteroscope using a holmium: yttrium aluminum garnet (Ho:Yag) laser.We left a double J catheter. Supine PCNL in the pediatric population has comparable efficacy in terms of stone free rate to that of the prone approach as well as less complications. Certain considerations in children are careful padding and placement of the patient close to the edge of the table. Puncture should be guided by ultrasound to reduce radiation exposure. Miniaturized equipment is not widely available, so adaptation of adult equipment for the pediatric population is sometimes necessary.

La nefrolitotomía percutánea en niños se ha vuelto ampliamente utilizada por su alta efectividad, seguridad, y por la miniaturización de los instrumentos endoscópicos. El abordaje en supino es prometedor por sus ventajas, como mejor ventilación, reproducibilidad, y ergonomía. El propósito es describir nuestra técnica quirúrgica con las consideraciones especiales a tener en cuenta en la población pediátrica. Todos nuestros pacientes han sido intervenidos bajo la siguiente técnica quirúrgica: en una posición oblicua en supino, utilizando soportes de silicona ubicados debajo de la cadera y del flanco ipsilateral, se marcan los reparos anatómicos: las costillas once y doce, la línea axilar posterior y la cresta ilíaca. Inicialmente se introduce un cateter ureteral por vía endoscópica, con el cual se realiza una pielografía retrógrada para guiar la punción con una técnica biplanar. Se avanza una guía hidrofílica y, sobre esta, los dilatadores telescopados de Alken hasta un tracto de 14 Ch. Se realiza la fragmentación con un cistoscopio semirígido de 13 Ch o con un ureteroscopio flexible utilizando el láser Ho:Yag. Se deja un cateter JJ. La nefrolitotomía percutánea en la población pediátrica es comparable en términos de tasa libre de cálculos al abordaje en prono, con menos complicaciones. Una consideración importante en niños es una adecuada posición, cerca al eje de la mesa. La punción debe ser guiada por ultrasonido para disminuir la exposición a radiación. La disponibilidad de equipos miniaturizados es limitada, por lo cual usualmente es necesario adaptar los equipos de adultos.

Geometrical Model of Free Skin Graft for the Optimization of Glans Reconstruction after Partial Penectomy / Modelo geométrico de injerto de piel libre para la optimización de reconstrucción de glande tras penectomía parcial

Introduction and Objective The management of penile carcinoma is very disabling and mutilating, bur early treatment can be curative. Our group systematically performs oncological management with immediate penile reconstruction and preservation of the organ (partial penectomy, resurfacing, or glansectomy) when feasible. Due to the low incidence of penile carcinoma, it is difficult to achieve experience in penile reconstruction using free grafts in a standardized and reproducible way. Therefore, we herein present the results of the use of an inanimate model to identify the most efficient geometric way to procure and apply a free skin graft to reconstruct the penis. Methods A preclinical inanimate model of the penis was developed to simulate the surgical reconstruction using a free skin graft. Six different geometric skin-graft models were created and tested. For each of them, we measured graft's surface area as well as the discarded surface after placing the graft on the penis for reconstruction. We also measured the amount of suture lines required for reconstruction. All of these measurements in the six different models were compared. Results Based on the six models, we identified that the longitude of the graft must measure the same as the maximum perimeter of the glans in order to have a square that enables the complete coverage of the penile defect. The total graft area for the first 4 models was of 40 cm2; for models 5 and 6, it was of 60 cm2. The average discarded area of the graft was of 18.135 cm2 (range: 12 cm2 to 30 cm2). Models 4 years 6 were the ones with the least discarded tissue: 12 cm2. The average amount of suture lines to secure the different model grafts was 7.3 (range: 5 to 12). The models that required the least amount of suture lines were number 1 and 4, with a total of 5 suture lines. Conclusions The double trapezoid is the most efficient model to reconstruct the glans after organ-sparing oncological management. Our results contribute to establish a more standardized and predictable technique to reconstruct the penis.

Introducción y Objetivo El manejo del cáncer de pene es muy mutilante y discapacitante. Pero el manejo quirúrgico oportuno puede ser curativo. Nuestro grupo realiza de manera sistemática el manejo oncológico con reconstrucción inmediata del pene y preservación del órgano (penectomía parcial, desepitelización, o gladectomía) cuando sea viable. Como la incidencia de cancer de pene es baja, lograr obtener la experiencia en reconstrucción de pene con el uso de injertos libres de manera estandarizada y reproducible resulta difícil. Por lo tanto, presentamos en este artículo los resultados de un modelo inanimado para identificar la forma geométrica mas eficiente de obtener y aplicar un injerto de piel libre para reconstruir el pene. Materiales y Métodos Se desarrolló un modelo preclínico y inanimado del pene para que se simulara su reconstrucción quirúrgica con el uso de un ijerto de piel libre. Desarrollamos y evaluamos seis modelos geométricos de injerto de piel distintos. Para cada uno, medimos el area total del injerto y la del tejido desechado tras ponerlo en el pene para la recosntrucción. También medimos la cantidad de líneas de sutura necesarias para la recosntrucción. Comparamos todas las medidas entre los seis modelos distintos. Resultados De los 6 modelos diferentes, encontramos que la longitud del injerto debe tener la misma medida que el perímetro máximo del glande para que se tenga un cuadrado que nos permita cubrir todo el defecto del pene. El area total de los 4 modelos iniciales fue de 40 cm2, y el area de los modelos 5 y 6 fue de 60 cm2. El area promedio del tejido desechado en los injertos fue de 18,135 cm2 (rango: 12 cm2 a 30 cm2). Los modelos 4 y 6 fueron los que tuvieron la menor cantidad de tejido desechado: 12 cm2. El promedio de la cantidad de líneas de sutura para atar los distintos modelos de injerto fue de 7,3 (rango: 5 a 12). Los modelos con la menor cantidad de líneas de sutura fueron el 1 y el 4, con un total de 5 líneas. Conclusiones El modelo de doble trapezoide es el más eficiente para reconstruir el glande tras el majejo oncológico en que se preserva el órgano. Nuestros resultados contribuyen para establecer una técnica de reconstrucción del pene más estandarizada y previsible.

Complete corporeal preservation clitoroplasty: new insights into feminizing genitoplasty

ABSTRACT Introduction: 46,XX Congenital adrenal hyperplasia (CAH) remains the first cause of genital virilization and current surgical techniques aim to restore female aspect of genitalia while preserving dorsal neurovascular bundle but not at the expense of not preserving erectile tissue. We aim to report our experience with a new surgical technique for clitoroplasty, completely preserving corporeal bodies, neurovascular bundles without dismembering the clitoris, in four patients with over a year follow up. Materials and Methods: After IRB approval four patients with 46,XX CAH and Prader 5 and 3 external genitalia, underwent feminizing genitoplasty. Complete preservation of erectile tissue was accomplished without a need to dissect dorsal neurovascular bundle. Glans size allowed no need for glanular reduction and there was no need to dismember the corporeal bodies. Results: Four patients 12 to 24-months-old underwent complete corporeal preservation clitoroplasty (CCPC), mean age was 18.5 months, mean follow up was 10.25 months. Vaginoplasty was performed in all patients with partial urogenital mobilization (PUM) and Urogenital Sinus flap (UF), only one severely virilized patient required a parasagittal pre-rectal approach to mobilize the vagina. We had no complications until last follow up. Conclusion: To our knowledge, we are introducing the concept of CCPC without the need of disassembling the corporeal bodies, neurovascular bundle and glans. It stands as a new alternative for feminizing genitoplasty with complete preservation of erectile tissue and no dissection of neurovascular bundle. Although there is still lacking long-term follow-up, it represents a new step in conservative reconfiguration of the external virilized female genitalia.

Complete corporeal preservation clitoroplasty: new insights into feminizing genitoplasty.

INTRODUCTION: 46,XX Congenital adrenal hyperplasia (CAH) remains the first cause of genital virilization and current surgical techniques aim to restore female aspect of genitalia while preserving dorsal neurovascular bundle but not at the expense of not preserving erectile tissue. We aim to report our experience with a new surgical technique for clitoroplasty, completely preserving corporeal bodies, neurovascular bundles without dismembering the clitoris, in four patients with over a year follow up. MATERIALS AND METHODS: After IRB approval four patients with 46,XX CAH and Prader 5 and 3 external genitalia, underwent feminizing genitoplasty. Complete preservation of erectile tissue was accomplished without a need to dissect dorsal neurovascular bundle. Glans size allowed no need for glanular reduction and there was no need to dismember the corporeal bodies. RESULTS: Four patients 12 to 24-months-old underwent complete corporeal preservation clitoroplasty (CCPC), mean age was 18.5 months, mean follow up was 10.25 months. Vaginoplasty was performed in all patients with partial urogenital mobilization (PUM) and Urogenital Sinus flap (UF), only one severely virilized patient required a parasagittal pre-rectal approach to mobilize the vagina. We had no complications until last follow up. CONCLUSION: To our knowledge, we are introducing the concept of CCPC without the need of disassembling the corporeal bodies, neurovascular bundle and glans. It stands as a new alternative for feminizing genitoplasty with complete preservation of erectile tissue and no dissection of neurovascular bundle. Although there is still lacking long-term follow-up, it represents a new step in conservative reconfiguration of the external virilized female genitalia.