Treatment Outcomes With Licensed and Unlicensed Stimulant Doses for Adults With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis.

Importance: Stimulants (methylphenidate and amphetamines) are often prescribed at unlicensed doses for adults with attention-deficit/hyperactivity disorder (ADHD). Whether dose escalation beyond US Food and Drug Administration recommendations is associated with positive risk benefits is unclear. Objective: To investigate the impact, based on averages, of stimulant doses on treatment outcomes in adults with ADHD and to determine, based on averages, whether unlicensed doses are associated with positive risk benefits compared with licensed doses. Data Sources: Twelve databases, including published (PubMed, Cochrane Library, Embase, Web of Sciences) and unpublished (ClinicalTrials.gov) literature, up to February 22, 2023, without language restrictions. Study Selection: Two researchers independently screened records to identify double-blinded randomized clinical trials of stimulants against placebo in adults (18 years and older) with ADHD. Data Extraction and Synthesis: Aggregate data were extracted and synthesized in random-effects dose-response meta-analyses and network meta-analyses. Main Outcome Measures: Change in ADHD symptoms and discontinuations due to adverse events. Results: A total of 47 randomized clinical trials (7714 participants; mean age, 35 (SD, 11) years; 4204 male [56%]) were included. For methylphenidate, dose-response curves indicated additional reductions of symptoms with increments in doses, but the gains were progressively smaller and accompanied by continued additional risk of adverse events dropouts. Network meta-analyses showed that unlicensed doses were associated with greater reductions of symptoms compared with licensed doses (standardized mean difference [SMD], -0.23; 95% CI, -0.44 to -0.02; very low certainty of evidence), but the additional gain was small and accompanied by increased risk of adverse event dropouts (odds ratio, 2.02; 95% CI, 1.19-3.43; moderate certainty of evidence). For amphetamines, the dose-response curve approached a plateau and increments in doses did not indicate additional reductions of symptoms, but there were continued increments in the risk of adverse event dropouts. Network meta-analysis did not identify differences between unlicensed and licensed doses for reductions of symptoms (SMD, -0.08; 95% CI, -0.24 to 0.08; very low certainty of evidence). Conclusions and Relevance: Based on group averages, unlicensed doses of stimulants may not have positive risk benefits compared with licensed doses for adults with ADHD. In general, practitioners should consider unlicensed doses cautiously. Practitioners may trial unlicensed doses if needed and tolerated but should be aware that there may not be large gains in the response to the medication with those further increments in dose. However, the findings are averages and will not generalize to every patient.

Environmental risk management: A participatory diagnosis from a rural school in Colombia.

The rural population is potentially exposed to several environmental risks. Environmental risk management is a recurring challenge in rural educational communities that are far from large urban areas. Assessing and identifying the knowledge on prevention and response to environmental risks and natural disasters is fundamental for planning and designing educational programs for communities to face disasters. This article presented the practical application of a participatory methodology to obtain information about the knowledge and experience in the prevention and attention of environmental threats and natural disasters in the rural school Las Huacas, village of Quintana, municipality of Popayán, in the region of Cauca, Colombia. The diagnosis methodology consisted of three phases: preparatory, fieldwork and analytical. The participatory diagnosis allowed the construction of instruments and tools for social interaction, the conduction of dynamic workshops and the systematisation of the collected information. The results evidenced the lack of knowledge on environmental disasters and how parents and children must face them. The absence of communication facilities implied a high degree of vulnerability, which was compensated with the awareness, commitment and participation in the processes led by the educational community. The next challenge is the participatory construction of a scholar environmental risk-management plan supported on appropriated information and communication technologies. Contribution: This article presents the practical application of a participatory methodology to obtain information about the rural context and the knowledge and experience in the prevention and attention of environmental threats and natural disasters in a rural school in Cauca, Colombia.

[Efficacy and safety of atorvastatin in major cardiovascular events: Meta-analysis]. / Eficacia y seguridad de la atorvastatina en eventos cardiovasculares mayores: metaanálisis.

Introduction: Atorvastatin has been used in the management of dyslipidemia and little is known about the efficacy and safety of high-dose atorvastatin administration for secondary prevention of Major Cardiovascular Events (MACE). Objective: To evaluate the impact of high-dose atorvastatin on secondary prevention of MACE and adverse events. Material and methods: A systematic review and meta-analysis of Pubmed, Embase, Bireme and Cochrane Library Plus databases was performed, with a time scope from 1990 to July 2022. Six randomized clinical trials were included with a total of 29,333 patients who were treated with 80 mg, 10 mg or placebo doses of Atorvastatin where the main outcomes evaluated were Major Cardiovascular Events (MACE), mortality and treatment safety. Results: In the comparative study between the use of Atorvastatin 80 mg and other therapies, a relative risk (RR) of 0.8 (95%CI 0.69-0.92) was found, representing a 20% reduction in risk (RRR) and a number needed to treat (NNT) of 30-55. In the analysis of adverse effects, an RR of 2.37 (95% CI 0.86-6.53) and a number needed to harm (NNH) of 14-19 were observed. The use of 80 mg atorvastatin is associated with similar adverse events at lower doses. Conclusions: The use of atorvastatin 80 mg is effective in the secondary prevention of Major Cardiovascular Event (MACE). The drug has adverse events that should be taken into account in secondary prevention.

Introducción: la atorvastatina ha sido usada en el manejo de la dislipidemia y se conoce poco sobre la eficacia y seguridad de la administración de atorvastatina en altas dosis para la prevención secundaria de eventos cardiovasculares mayores (MACE). Objetivo: evaluar el impacto de altas dosis de atorvastatina en la prevención secundaria de MACE y eventos adversos. Material y métodos: se realizó una revisión sistemática y un metaanálisis de las bases de datos Pubmed, Embase, Bireme y Cochrane Library Plus, con un alcance temporal de 1990 a julio de 2022. Se incluyeron seis ensayos clínicos aleatorios con un total de 29,333 pacientes que fueron tratados con dosis de 80 mg, 10 mg o placebo de Atorvastatina donde los resultados principales evaluados fueron los eventos cardiovasculares mayores (MACE), la mortalidad y la seguridad del tratamiento. Resultados: en el estudio comparativo entre el uso de Atorvastatina de 80 mg y otras terapias, se encontró un riesgo relativo (RR) de 0.8 (IC95%: 0.69-0.92), lo que representa una reducción del 20% en el riesgo (RRR) y un número necesario a tratar (NNT) de 30 a 55. En el análisis de los efectos adversos, se observó un RR de 2.37 (IC95%: 0.86-6.53) y un número necesario a dañar (NNH) de 14 a 19. El uso de atorvastatina de 80 mg se asocia con eventos adversos similares a dosis menores. Conclusiones: el uso de atorvastatina de 80 mg es efectivo en la prevención secundaria de evento cardiovascular mayor (MACE). El medicamento tiene eventos adversos que deben de tomarse en cuenta en la prevención secundaria.

Does the SDMQ-9 Predict Changes in HbA1c Levels? An Ecuadorian Cohort.

Background and Objectives: Diabetes mellitus affects 422 million people around the world, positioning it as a major health problem. According to the WHO(World Health Organization), 90% corresponds to type 2. The shared-decision making (SDM) is a method used to facilitate patient control, medication, maintenance, and assessment of health status according to their priorities and preferences. With the application of SDM in patients with diabetes, it is expected there will be an increase in treatment adherence and a reduction in HbA1c levels. The aim of this study is to determine the predictors of the change in HbA1c. Material and Methods: A sample of 76 participants attending as endocrinology outpatients was obtained. Data collected within the sample included: sex, age, educational level, body mass index, and the level of SDM using the SDMQ-9. In addition, HbA1c levels were measured twice: at baseline and three months after the first measurement. Results: The linear regression indicates that the level of SDM is a significant predictor of the change in HbA1c, specifically in men. However, the direction of the relationship was a somewhat opposite trend than we expected. Higher levels of SDM imply an increase in HbA1c rather than a reduction. Conclusions: Contrary to the literature, our results shows that elevated levels of perceived SDM may be associated with worse diabetic control. However, more investigation is needed as these results are not generalizable, due to the specific population used and the sample size. Furthermore, to better understand the effect of SDM on the change in HbA1c in patients with poorly controlled diabetes.

The effects of stimulant dose and dosing strategy on treatment outcomes in attention-deficit/hyperactivity disorder in children and adolescents: a meta-analysis.

Clinical guidelines currently recommend practitioners titrate stimulant medications, i.e., methylphenidate (MPH) and amphetamines (AMP), to the dose that maximizes symptom control without eliciting intolerable adverse events (AEs) when treating attention-deficit/hyperactivity disorder (ADHD) in school-aged children/adolescents. However, robust evidence-base regarding the effects of doses and dosing strategies of stimulants on clinical outcomes in the treatment of children/adolescents with ADHD is currently lacking and stimulants are often underdosed in clinical practice. To address this gap and provide rigorous evidence-base in relation to the dose and dosing strategy of stimulants, we conducted the largest systematic review and dose-response meta-analysis examining change in ADHD symptoms (efficacy), and treatment discontinuations due to AEs (tolerability) and any reason (acceptability). We conducted one-stage random-effects dose-response meta-analyses examining MPH and AMP separately, stratifying trials based on fixed-dose and flexible-dose design. Daily doses of stimulants were converted to MPH- and AMP-equivalent doses by adjusting for different pharmacokinetics across formulations. We also conducted pairwise meta-analyses to provide indirect comparisons between flexible-dose versus fixed-dose trials. Our study included 65 RCTs involving 7 877 children/adolescents. Meta-analyses of fixed-dose trials for both MPH and AMP demonstrated increased efficacy and increased likelihood of discontinuation due to AEs with increasing doses of stimulants. The incremental benefits of stimulants in terms of efficacy decreased beyond 30 mg of MPH or 20 mg of AMP in fixed-dosed trials. In contrast, meta-analyses of flexible-dose trials for both MPH and AMP demonstrated increased efficacy and reduced likelihood of discontinuations for any reason with increasing stimulant doses. The incremental benefits of stimulants in terms of efficacy remained constant across the FDA-licensed dose range for MPH and AMP in flexible-dose trials. Our results suggest that flexible titration as needed, i.e., considering the presence of ADHD symptoms, and tolerated, i.e., considering the presence of dose-limiting AEs, to higher doses of stimulants is associated with both improved efficacy and acceptability because practitioners can increase/reduce doses based on control of ADHD symptoms/dose-limiting AEs. Although fixed-dose trials that are required by the FDA are valuable to characterize dose-dependency, they may underestimate the true potential benefit of trialing dose-increases of stimulants in clinical practice by not allowing dose adjustment based on response and tolerability. Additional research is required to investigate potential long-term effects of using high doses of stimulants in clinical practice.

Beyond Single Discrete Responses: An Integrative and Multidimensional Analysis of Behavioral Dynamics Assisted by Machine Learning.

Understanding behavioral systems as emergent systems comprising the environment and organism subsystems, include spatial dynamics as a primary dimension in natural settings. Nevertheless, under the standard approaches, the experimental analysis of behavior is based on the single response paradigm and the temporal distribution of discrete responses. Thus, the continuous analysis of spatial behavioral dynamics is a scarcely studied field. The technological advancements in computer vision have opened new methodological perspectives for the continuous sensing of spatial behavior. With the application of such advancements, recent studies suggest that there are multiple features embedded in the spatial dynamics of behavior, such as entropy, and that they are affected by programmed stimuli (e.g., schedules of reinforcement) at least as much as features related to discrete responses. Despite the progress, the characterization of behavioral systems is still segmented, and integrated data analysis and representations between discrete responses and continuous spatial behavior are exiguous in the experimental analysis of behavior. Machine learning advancements, such as t-distributed stochastic neighbor embedding and variable ranking, provide invaluable tools to crystallize an integrated approach for analyzing and representing multidimensional behavioral data. Under this rationale, the present work (1) proposes a multidisciplinary approach for the integrative and multilevel analysis of behavioral systems, (2) provides sensitive behavioral measures based on spatial dynamics and helpful data representations to study behavioral systems, and (3) reveals behavioral aspects usually ignored under the standard approaches in the experimental analysis of behavior. To exemplify and evaluate our approach, the spatial dynamics embedded in phenomena relevant to behavioral science, namely, water-seeking behavior and motivational operations, are examined, showing aspects of behavioral systems hidden until now.

Plant Organellar DNA Polymerases Evolved Multifunctionality through the Acquisition of Novel Amino Acid Insertions.

The majority of DNA polymerases (DNAPs) are specialized enzymes with specific roles in DNA replication, translesion DNA synthesis (TLS), or DNA repair. The enzymatic characteristics to perform accurate DNA replication are in apparent contradiction with TLS or DNA repair abilities. For instance, replicative DNAPs incorporate nucleotides with high fidelity and processivity, whereas TLS DNAPs are low-fidelity polymerases with distributive nucleotide incorporation. Plant organelles (mitochondria and chloroplast) are replicated by family-A DNA polymerases that are both replicative and TLS DNAPs. Furthermore, plant organellar DNA polymerases from the plant model Arabidopsis thaliana (AtPOLIs) execute repair of double-stranded breaks by microhomology-mediated end-joining and perform Base Excision Repair (BER) using lyase and strand-displacement activities. AtPOLIs harbor three unique insertions in their polymerization domain that are associated with TLS, microhomology-mediated end-joining (MMEJ), strand-displacement, and lyase activities. We postulate that AtPOLIs are able to execute those different functions through the acquisition of these novel amino acid insertions, making them multifunctional enzymes able to participate in DNA replication and DNA repair.

Plant organellar DNA polymerases bypass thymine glycol using two conserved lysine residues.

Plant organelles cope with endogenous DNA damaging agents, byproducts of respiration and photosynthesis, and exogenous agents like ultraviolet light. Plant organellar DNA polymerases (DNAPs) are not phylogenetically related to yeast and metazoan DNAPs and they harbor three insertions not present in any other DNAPs. Plant organellar DNAPs from Arabidopsis thaliana (AtPolIA and AtPolIB) are translesion synthesis (TLS) DNAPs able to bypass abasic sites, a lesion that poses a strong block to replicative polymerases. Besides abasic sites, reactive oxidative species and ionizing radiation react with thymine resulting in thymine glycol (Tg), a DNA adduct that is also a strong block to replication. Here, we report that AtPolIA and AtPolIB bypass Tg by inserting an adenine opposite the lesion and efficiently extend from a Tg-A base pair. The TLS ability of AtPolIB is mapped to two conserved lysine residues: K593 and K866. Residue K593 is situated in insertion 1 and K866 is in insertion 3. With basis on the location of both insertions on a structural model of AtPolIIB, we hypothesize that the two positively charged residues interact to form a clamp around the primer-template. In contrast with nuclear and bacterial replication, where lesion bypass involves an interplay between TLS and replicative DNA polymerases, we postulate that plant organellar DNAPs evolved to exert replicative and TLS activities.

Evaluación molecular del aguacate criollo (Persea americana Mill) en Nuevo León, México / Molecular evaluation of the wild avocado (Persea americana Mill) in Nuevo León, México

RESUMEN México es centro de origen del aguacate (Persea americana Mill), la mayoría de los miembros reconocidos del género Persea ocurren primariamente desde la parte central de México hasta Centroamérica. En este estudio se realizó la evaluación molecular de germoplasma de aguacate criollo del Estado de Nuevo León, México, utilizando la técnica del DNA Polimórfico Amplificado al Azar (RAPD's). Se colectaron 27 materiales de aguacate criollo en la región sur y 16 en la región norte de Nuevo León. El nivel de diversidad genética detectado fue del 84%, el cual se considera como alto. Se observaron fragmentos específicos o únicos tipo RAPD's, presentes en un solo individuo, este tipo de fragmentos son de particular interés ya que pueden estar ligados a un genotipo en particular y servir en el diagnóstico para diferenciar un genotipo o una región específica del genoma. Lo anterior es de particular interés para el aguacate criollo del Estado de Nuevo León, cuyo problema para su comercialización es la corta vida de anaquel que presenta, por lo tanto, encontrar gran variación genética como la detectada en este trabajo incrementa la posibilidad de generar nuevos materiales cuya vida de anaquel sea más prolongada, potenciando su valor comercial.

ABSTRACT México is the center of origin of the avocado (Persea americana Mill), most of the recognized members of the genus Persea occur primarily from the central part of México to Central América. In this study, the molecular evaluation of germplasm of wild avocado from the State of Nuevo León, México, was performed using Random Amplified Polymorphic DNA (RAPD's) technique. A total of 27 wild avocado materials were collected in the southern region and 16 in the northern region of Nuevo León. The level of gen et-ic diversity detected was 84%, which is considered high. Specific fragments or only RAPD's type, present in a single individual, were observed, this type of fragments are of particular interest since they can be linked to a particular genotype and serve in the diagnosis to differentiate a genotype or a specific region of the genome. The above is of particular interest for the creole avocado of the State of Nuevo León, whose problem for marketing is the short shelf life that presents, therefore, finding great genetic variation as detected in this work increases the possibility of generating new materials whose shelf life is longer, enhancing its commercial value.

Validación externa del modelo HUSI para la predicción de coledocolitiasis en pacientes con colelitiasis-colecistitis / External validation of the HUSI model for prediction of choledocholithiasis in patients with cholelithiasis-cholecystitis

Introducción. La probabilidad de que los pacientes con colelitiasis cursen con coledocolitiasis y determinar si realmente el cálculo se encuentra en la vía biliar, siguen siendo un reto para el cirujano. La toma de decisiones puede generar costos elevados, por lo que se requiere evaluar con exactitud la probabilidad de cálculos en la vía biliar y la utilidad de las escalas de probabilidad. Objetivo. Validar externamente el modelo de predicción de coledocolitiasis desarrollado por Domínguez, et al., en el Hospital Universitario de San Ignacio, haciendo una evaluación preoperatoria de la coledocolitiasis en pacientes con colelitiasis-colecistitis en Medellín. Material y métodos. Se revisaron de manera retrospectiva 2.122 historias clínicas de pacientes con diagnóstico de colelitiasis-colecistitis en el Hospital Pablo Tobón Uribe, de las cuales 201 fueron incluidas en este estudio. Se usó la escala propuesta de predicción de coledocolitiasis, evaluando los costos directos del modelo de uso de recursos diagnósticos. Resultados. Se incluyeron 201 pacientes (117 mujeres y 84 hombres), con edad media de 54 años. El riesgo de coledocolitiasis en la población evaluada fue de 19,9 %, distribuido por grupos, así: población normal, 0 %; con bajo riesgo, 5,26 %; con riesgo intermedio, 52,6 %, y con riesgo alto, 93,7 %. El área bajo la curva ROC para el modelo predictivo fue de 0,95 (IC95% 0,92-0,98). Según el análisis de los costos por grupos de riesgo, en los pacientes con riesgo normal, se obtuvo un sobrecosto de COP$ 7'010.000 y, en aquellos con riesgo bajo, uno de COP$ 44'013.500; en el grupo con riesgo medio, contrario a los demás grupos, se obtuvo una disminución de COP$ 26'829.000, mientras en el grupo de riesgo alto el sobrecosto fue de COP$ 977.500. Conclusiones. El modelo ofrece un buen rendimiento para predecir el riesgo de coledocolitiasis en la población estudiada. Si la escala se usa correctamente y se sigue el protocolo establecido con los pacientes, se disminuyen los estudios innecesarios y los costos, y se hace un uso racional de los recursos

Introduction. To determine the probability of choledocholithiasis in patients with cholelithiasis and to predict if the biliary stones are located at the common bile duct is a challenge for surgeons. Decision making can increase costs, so it is necessary to define the utility of predictive scores in these cases. Objective. To validate the score to predict coledocolitiasis in patients with cholelithiasis developed by Domínguez, et al., in an external cohort in Medellín. Material y methods. 2122 clinical records of patients with diagnosis of cholecystitis/ cholelithiasis were reviewed at the Hospital Pablo Tobón Uribe. The Dominguez score was used to predict probability of choledocholithiasis and we calculated the use of resources and costs. Area under ROC curve was calculated. Results. 201 patients (117 women and 84 men), with a mean age of 54 years were included. The frequency of choledocholithiasis was 19,9 %, distributed by risk groups: no risk, 0 %; low risk, 5,26 %; intermediate risk, 52,6 %, and high risk, 93,7 %. Area under ROC curve was 0,95 (IC95% 0,92-0,98). Regarding costs, overrun was: COP$ 7'010.000 in patients without risk, COP$ 44'013.500 in those with low risk and COP$ 977.500 in the high-risk group. In the intermediate risk group there was a saving of COP$ 26'829.000. Conclusions. The Dominguez score offer good performance to predict choledocholithiasis. If the score is used according to recommendations, unnecessary costs decrease and more rational use of resources is achieved

A new allele of γ-kafirin gene coding for a protein with high lysine content in Mexican white sorghum germplasm.

BACKGROUND: Low protein digestibility and lysine content of white sorghum grain limit its use as a foodstuff. The increase in γ-kafirin cross-linking, has an important role in the reduction of protein digestibility. The objective of this study was to characterize the γ-kafirin gene in 12 Mexican tannin-free white sorghum genotypes and its relationship with protein digestibility and lysine content. RESULTS: Two alleles of γ-kafirin gene were identified: alleles 1 and 7. The predicted amino acid sequence of allele 7 showed seven point mutations; six were silent, and one missense (C235G), causing the substitution P79A in the deduced amino acid sequence. In silico analysis showed that γ-kafirin codified by allele 1 has five α-helixes without disulfide bonds, while γ-kafirin coding by allele 7 has four α-helixes and three disulfide bonds. Genotypes with allele 7 had higher lysine content than those with allele 1, showing no differences in the kafirin electrophoretic profile, neither a correlation with the protein content nor the in vitro pepsin digestibility. CONCLUSIONS: Mexican tannin-free white sorghum genotypes showed two γ-kafirin alleles, 1 and 7. Allele 7 was associated with higher lysine content; in silico analysis showed that the substitution of P79A in this allele could modify γ-kafirin secondary structure. © 2015 Society of Chemical Industry.

Manejo no quirúrgico de pacientes sintomáticos con cápsula endoscópica retenida en enfermedad de Crohn / Non operative management of symptomatic patients with retained endoscopic capsule in Crohn's disease

Introducción. La enfermedad de Crohn es una enfermedad crónica del sistema gastrointestinal, que produce múltiples complicaciones a lo largo de su presentación clínica, lo cual hace difícil su diagnóstico y abordaje terapéutico. Objetivo. El objetivo del estudio fue describir las opciones diagnósticas y terapéuticas en la enfermedad de Crohn, en casos que cursan con cápsula endoscópica retenida; se presentan dos casos y el resultado de su manejo no operatorio. Materiales y métodos. Se tomaron los datos de la historia clínica de dos pacientes y se analizaron los datos clínicos y las ayudas diagnósticas utilizadas. Se describieron los hallazgos y el enfoque terapéutico, y se hizo una revisión de la literatura científica sobre el tema. Resultados. Dos pacientes con enfermedad de Crohn presentaron retención sintomática de la cápsula endoscópica. Se manejaron con éxito, sin tenerse que practicar ninguna intervención quirúrgica, como indica la mayoría de los informes en presencia de síntomas y signos de obstrucción gastrointestinal. Conclusiones. La retención de la cápsula endoscópica es poco frecuente y su manejo a lo largo de la historia ha sido la cirugía como primera elección, en aquellos pacientes que presentan signos y síntomas de obstrucción intestinal. Sin embargo, con el pasar de los años se han practicado diferentes técnicas terapéuticas, como las endoscópicas y médicas, las cuales han sido exitosas y con pocas complicaciones, en comparación con el tratamiento quirúrgico tradicional.

Introduction: Crohn's disease is a chronic disease of the gastrointestinal tract associated with multiple complications throughout the clinical course, which makes it difficult to diagnose and treat. Objective: To describe the diagnostic and therapeutic options in Crohn's disease presenting with retained endoscopic capsule, and to present two patients who developed symptomatic retention of the endoscopic capsule and its outcome with expectant management. Materials and Methods: Data from the medical records of the two patients were analyzed prior informed consent. Clinical data and diagnostic aids were analyzed. The findings and the therapeutic approach were described, and a review o the literature was conducted. . Results: Two patients with Crohn´s disease presented symptomatic retained endocopic capsule. They were successfully managed without surgical intervention, as indicated by the majority of reports in patients with symptoms and signs of intestinal obstruction, Conclusions: Retention of the endoscopic capsule is rare and its management throughout history has been surgical, especially in those patients with signs and symptoms of intestinal obstruction. However, with the passing of years appeared different therapeutic options, such as endoscopic or medical approaches, which have been successful and exhibit few complications as compared with the traditional surgical management.

A vital signs telemonitoring system - interoperability supported by a personal health record systema and a cloud service.

This article presents the development process of an acquisition and data storage system managing clinical variables through a cloud storage service and a Personal Health Record (PHR) System. First, the paper explains how a Wireless Body Area Network (WBAN) that captures data from two sensors corresponding to arterial pressure and heart rate is designed. Second, this paper illustrates how data collected by the WBAN are transmitted to a cloud storage service. It is worth mentioning that this cloud service allows the data to be stored in a persistent way on an online database system. Finally, the paper describes, how the data stored in the cloud service are sent to the Indivo PHR System, where they are registered and charted for future revision by health professionals. The research demonstrated the feasibility of implementing WBAN networks for the acquisition of clinical data, and particularly for the use of Web technologies and standards to provide interoperability with PHR Systems at technical and syntactic levels.

Physicochemical, morphological, and rheological characterization of Xanthosoma robustum Lego-like starch.

This work presents the physicochemical and pasting characterization of isolated mafafa starch and mafafa flour (Xanthosoma robustum). According to SEM images of mafafa starches in the tuber, these starches form Lego-like shaped structures with diameters between 8 and 35 µm conformed by several starch granules of wedge shape that range from 2 to 7 µm. The isolated mafafa starch is characterized by its low contents of protein, fat, and ash. The starch content in isolated starch was found to be 88.58% while the amylose content obtained was 35.43%. X-ray diffraction studies confirm that isolated starch is composed mainly by amylopectin. These results were confirmed by differential scanning calorimetry and thermo gravimetric analysis. This is the first report of the molecular parameters for mafafa starch: molar mass that ranged between 2×10(8) and 4×10(8) g/mol, size (Rg) value between 279 and 295 nm, and molecular density value between 9.2 and 9.7 g/(mol nm(3)). This study indicates that mafafa starch shows long chains of amylopectin this fact contributes to higher viscosity development and higher gel stability. The obtained gel phase is transparent in the UV-vis region. The viscosity, gel stability and optical properties suggest that there is potential for mafafa starch applications in the food industry.

Evaluación del manejo interdisciplinario de una serie de 53 pacientes con hepatolitiasis / Evaluation of interdisciplinary care of a series of 53 patients with hepatholithiasis

Objetivos: Evaluar, en una serie de enfermos con hepatolitiasis, el resultado del manejo interdisciplinario. Pacientes y métodos: Durante 8 años se valoraron, en un estudio retrospectivo, 53 pacientes con diagnóstico de hepatolitiasis. Resultados: Se estudiaron 23 hombres (43%) y 30 mujeres con una edad promedio de 50 ± 15 años (25 a 83 años). Predominó el dolor (94%), seguido de ictericia (68%) y fiebre (57%). Según la clasificación de Tsunoda, 6 pacientes eran Tsunoda I, 12 Tsunoda II, 4 Tsunoda III y 5 Tsunoda IV. El compromiso más frecuente fue del lóbulo izquierdo (36%) o bilateral (34%). La colangiografía endoscópica tuvo éxito en el 64% y solo se manejaron 4 pacientes por la vía transparietohepática (2 éxitos). Se operaron 35 pacientes (66%) y lo más frecuente fue la hepatectomía izquierda en 40% (7 con asa subcutánea) seguida por hepaticoyeyunostomía con asa subcutánea (26%). Se realizaron cuatro trasplantes ortotópicos de hígado que evolucionan asintomáticos en pacientes con complicaciones por cirrosis. Las complicaciones postoperatorias tempranas fueron del 40%, la más frecuente la infección del sitio operatorio (14%) y cálculos residuales (9%). La complicación tardía más usual fue la litiasis residual (23%). El 80% de los pacientes operados están asintomáticos comparados con el 72% de los no operados. No hubo mortalidad quirúrgica. Conclusiones: La hepatolitiasis es una entidad con manejos no bien estandarizados, entre ellos, la opción quirúrgica cursa con buenos resultados, mejoría clínica y poca morbimortalidad; con el apoyo interdisciplinario dado la radiología intervencionista y la endoscopia biliar.

Objectives: Evaluate the results of interdisciplinary care in a series of patients with hepatolithiasis. Patients and Methods: A retrospective study of 53 patients with hepatolithiasis who were evaluated over an eight year period. Results: 23 men (43%) and 30 women were studied. The average age was 50 ± 15 years (range: 25-83 years). Pain was the predominant symptom (94%), followed by jaundice (68%) and fever (57%). According to the Tsunoda classification, 6 patients were Tsunoda I, 12 were Tsunoda II, 4 were Tsunoda III, and 5 were Tsunoda IV. Left lobe hepatolithiasis was most frequent (36%), followed by bilateral hepatolithiasis (34%). Endoscopic cholangiography was successful in 64% of patients. Only 4 patients were treated by percutaneous cholangiography, with 2 successes. 35 patients (66%) were operated on. The most frequent surgery was left hepatectomy with subcutaneous loop in 7 patients (40%), followed by hepatojejunostomy with subcutaneous loop (26%). Four orthotopic liver transplantations with good evolution were performed in patients with cirrhotic complications. 40% had early complications. Most frequent were infection of the operative site (14%) and residual stones (9%). The most frequent delayed complication was residual lithiasis (23%). 80% of the patients who underwent surgery were asymptomatic compared with 72% of those who did not undergo surgery. There were no mortalities resulting from surgery. Conclusions: Hepatolithiasis is a disease which does not have a well standardized treatment. Surgery is an alternative with good results, clinical improvement and low morbidity and mortality rates when there is interdisciplinary including interventionist radiology and biliary endoscopy.

Lesión quirúrgica de la vía biliar: experiencia en la Unidad de Cirugía Hepatobiliar y Pancreática del Hospital Pablo Tobón Uribe de Medellín / Iatrogenic lesions of the biliary ducts: experience at the Hepatobiliary and Pancreatic Unit of Pablo Tobón Uribe Hospital (Medelín, Colombia)

Introducción. Las lesiones operatorias de la vía biliar son alteraciones de baja frecuencia y alta complejidad, que requieren manejo interdisciplinario para lograr resultados adecuados y evitar complicaciones devastadoras en el futuro.Objetivo. Describir una serie de pacientes referidos por esta complicación y manejados en la Unidad de Cirugía Hepatobiliar y Pancreática del Hospital Pablo Tobón Uribe, los resultados y las complicaciones de su manejo.Pacientes y métodos. Se recolectó de manera prospectiva una serie de pacientes referidos entre el 1º de agosto de 2003 y el 30 de abril de 2008, con diagnóstico postoperatorio de lesión de vías biliares en un hospital de referencia. En total fueron 33 pacientes con lesión posquirúrgica de vías biliares, 73% fueron mujeres y 27% hombres, con una edad promedio de 42 años. Todos fueron remitidos de otras instituciones de la ciudad.Resultados. La cirugía inicial fue por laparoscopia en 48% y cirugía abierta en 52%. Las manifestaciones clínicas fueron ictericia (91%), dolor (70%) y colangitis (42%). El 52% de los pacientes presentó peritonitis biliar por la lesión. Se hizo colangiorresonancia en el 67%, seguida por colangiografía retrógrada endoscópica en el 61%. Los procedimientos quirúrgicos realizados fueron: derivación bilio-digestiva, 27 pacientes (82%), trasplante hepático, 2 casos (6%) y sólo laparotomía exploradora en 2 pacientes (6%). El promedio de días de estancia fue de 6,8 días. Se presentaron complicaciones posquirúrgicas en 21% y no hubo casos de filtración biliar. El seguimiento promedio fue de 14,9 meses. 1 a 56 meses el 78% de los pacientes con derivación bilio-digestiva están asintomáticos, 14% presentaron colestasis y el 4%, estenosis. Sólo hubo un caso de mortalidad por sepsis.Conclusión. Las lesiones iatrogénicas de la vía biliar son alteraciones complejas que requieren un centro de referencia y un manejo interdisciplinario experto para mejorar su pronóstico a largo plazo.

Long-term results of the Spanish Protocol SO-95 for the treatment of non-metastatic high-grade osteosarcoma of the extremities in children.

INTRODUCTION: The long-term results of the Spanish Study Protocol SEOP-SO-95 for treatment of localised osteosarcoma of the extremities in children were evaluated. PATIENTS AND METHODS: One hundred consecutive patients under 18 years of age from 22 institutions were enrolled from January 1995 to December 2000. Immunohistochemical expression of p53, HER/erbB-2 and P-glycoprotein were retrospectively studied in 27 patients. Treatment consisted of: preoperative chemotherapy with doxorubicin, cisplatin, high-dose methotrexate with leucovorin rescue and ifosfamide for 14 weeks; surgery of primary tumour in week 16; postoperative chemotherapy with the above-mentioned drugs for 25 weeks. RESULTS: With a median follow-up of 124 months (range 84-158 months), 69 patients (69%) were continuously event-free survivors; the 10-year probability of event-free survival (EFS) was 62%. Conservative surgery was performed in 85% of patients. Twenty-six patients had local recurrence or distant relapse. The median time to recurrence/ relapse was 27 months (range 17-93 months). The local recurrence rate was 7% (7 of the 100 patients); 4 had wide surgical margins, 2 marginal and 1 intralesional. Four patients died as a result of chemotherapy-related toxicity and 1 developed a second neoplasia (acute myeloid leukaemia). p53 expression and HER2/erbB-2 expression showed no effect on survival or EFS. CONCLUSIONS: This therapeutic protocol achieved good oncologic and orthopaedic results. We observed a significant treatment-related toxicity.

¿La episiotomía debe ser un procedimiento de rutina? / ¿The Episiotomy have to a rutine procedure?

Introducción: La episiotomía como procedimiento obstétrico tuvo sus inicios en el siglo XVIII y desde 1920 hasta hoy es usada como procedimiento de rutina en primigestantes. Objetivo: Identificar algunas complicaciones obstétricas en mujeres nulíparas después de practicar o no la episiotomía mediolateral.Metodología: El trabajo se realizó en el Hospital Carlos Holmes Trujillo en el suroriente de Cali. Se utilizó un diseño experimental con selección aleatoria de dos grupos de gestantes. La muestra estuvo conformada por 34 pacientes para el grupo control (quienes recibieron el manejo rutinario de realizar episiotomía) y 30 pacientes para el grupo experimental (a quienes no se les realizó episiotomía de rutina). Resultados y discusión: La percepción dolorosa fue más intensa en el grupo control con diferencias estadísticamente significativas; el nivel del dolor se calificó con la escala visual análoga . En ninguno de los grupos se presentaron desgarros severos; sin embargo, se presentaron desgarros grado I y II en el grupo experimental ocurridos en su mayoría en los partos atendidos por el personal menos experimentado. Las molestias asociadas con la episiotomía valorada a los 10 días postparto fueron hasta cuatro veces mayores mayores en el grupo control sobre el grupo experimental, sobre todo dificultad para sentarse y temor para reiniciar la actividad sexual, circunstancias que pueden afectar el proceso de cicatrización y la relación de pareja. Al evaluar la presencia de dispareunia en ambos grupos a los 60 días postparto se observó en el grupo control molestias como ardor, dolor y sangrado con el inicio de la actividad sexual; en el grupo experimental el inicio de la actividad sexual fue más precoz (15 días postparto). La fortaleza del presente estudio radica precisamente en estos aspectos relativos a la experiencia de la mujer a quien se le realizó episiorrafia; es de vital importancia conocer la forma de realización del procedimiento y cómo afecta su vida después del egreso hospitalario. Conclusiones: Existe un grupo de pacientes que se benefician en forma importante de la episiotomía, motivo por el cual no se puede abolir completamente este procedimiento; pero la literatura y el presente estudio coinciden en sugerir que cuando se usa de manera selectiva con inminencia de desgarro o compromiso de la vitalidad fetal produce mayores beneficios a la gestante