Androgen treatment effects on neurocognition in female-to-male transgender adolescents. / Efectos del tratamiento con andrógenos sobre la neurocognición en adolescentes transgénero de mujer a hombre.

INTRODUCTION: It has been hypothesized that cognitive and memory-related brain function in transgender during cross-sex hormonal treatment might be activated towards that of the subjective gender. However, research on this topic has produced inconsistent results, and to the best of our knowledge no studies have investigated neurocognitive changes in androgen-treated female-to-male (FM) transgender adolescents. SUBJECTS AND METHODS: A total of 15 FM transgender adolescents (14-17 years) underwent neuropsychological testing in order to examine the effects of androgen on visuo-spacial abilities, verbal memory language, processing speed and executive functions. We used a longitudinal design in which 10 participants were tested twice, before and after receiving 12 months of testosterone treatment. This group was also compared with 5 FM transgender adolescents off-androgen treatment. RESULTS: Participants tested before and after 12 months of androgen treatment improved significantly on processing speed in a visuo-spatial (Rey-Osterrieth complex figure test) and in a visuo-oral task (Stroop), their performance on a verbal memory task (TAVEC) and on interference (Stroop) and they exhibited lower impulsivity control (CARAS-R). On-androgen treatment adolescents exhibited worse cognitive impulsivity control than off-androgen treatment adolescents. CONCLUSIONS: The results indicate that androgen has an influence on immediate verbal memory, cognitive interference, impulsivity control and processing speed.

TITLE: Efectos del tratamiento con andrógenos sobre la neurocognición en adolescentes transgénero de mujer a hombre.Introducción. Se ha planteado la hipótesis de que la neurocognición en personas transgénero durante el tratamiento hormonal cruzado podría aproximarse a la del género subjetivo. Sin embargo, la investigación sobre este tema ha producido resultados inconsistentes y, hasta donde sabemos, ningún estudio ha investigado los cambios neurocognitivos en adolescentes transgénero de mujer a hombre (FM) tratados con andrógenos. Sujetos y métodos. Quince adolescentes transgénero FM (14-17 años) se sometieron a pruebas neuropsicológicas para examinar los efectos de los andrógenos en sus habilidades visuoespaciales, memoria verbal, velocidad de procesamiento y funciones ejecutivas. Utilizamos un diseño longitudinal en el que se evaluó a 10 participantes dos veces, antes y después de recibir, durante 12 meses, tratamiento con testosterona. Este grupo también se comparó con cinco adolescentes transgénero FM sin tratamiento con andrógenos. Resultados. Los participantes evaluados antes y después de 12 meses de tratamiento con andrógenos mejoraron significativamente en velocidad de procesamiento en una tarea visuoespacial (prueba de la figura compleja de Rey-Osterrieth) y en una tarea visual (Stroop), en una tarea de memoria verbal (test de aprendizaje verbal España-Complutense) y en interferencia (Stroop), y exhibieron un menor control de la impulsividad (test de percepción de diferencias revisado). Los adolescentes que recibieron tratamiento con andrógenos mostraron un peor control de la impulsividad cognitiva que los adolescentes que no recibieron tratamiento con andrógenos. Conclusiones. Los resultados indican que los andrógenos influyen en la memoria verbal, la interferencia cognitiva, el control de la impulsividad y la velocidad de procesamiento.

Climate and health benefits of a transition from gas to electric cooking.

Household electrification is thought to be an important part of a carbon-neutral future and could also have additional benefits to adopting households such as improved air quality. However, the effectiveness of specific electrification policies in reducing total emissions and boosting household livelihoods remains a crucial open question in both developed and developing countries. We investigated a transition of more than 750,000 households from gas to electric cookstoves-one of the most popular residential electrification strategies-in Ecuador following a program that promoted induction stoves and assessed its impacts on electricity consumption, greenhouse gas emissions, and health. We estimate that the program resulted in a 5% increase in total residential electricity consumption between 2015 and 2021. By offsetting a commensurate amount of cooking gas combustion, we find that the program likely reduced national greenhouse gas emissions, thanks in part to the country's electricity grid being 80% hydropower in later parts of the time period. Increased induction stove uptake was also associated with declines in all-cause and respiratory-related hospitalizations nationwide. These findings suggest that, when the electricity grid is largely powered by renewables, gas-to-induction cooking transitions represent a promising way of amplifying the health and climate cobenefits of net-carbon-zero policies.

Cognitive outcomes following functional neurosurgery in refractory OCD patients: a systematic review.

Neurosurgery is a therapeutic option for patients with refractory obsessive-compulsive disorder who do not respond to previous treatments. Although its efficacy in reducing clinical symptomatology has been proven, few studies have analyzed its effects at the cognitive level. The aim of this systematic review was to describe the cognitive outcomes of functional neurosurgery in patients that went through capsulotomies or cingulotomies. PubMed, Medline, Scopus, PsycInfo, PsyArticles, and Web of Knowledge were searched for studies reporting cognitive outcomes in refractory obsessive-compulsive patients after capsulotomies and cingulotomies. The risk of bias was assessed with the Assessment Tool for Before-After (Pre-Post) Studies With No Control Group tool; 13 studies met inclusion criteria, including 205 refractory obsessive-compulsive disorder patients for both surgical procedures. Results showed a substantial number of studies that did report significant cognitive improvement after surgery, being this improvement specially related to memory and executive functions. The second-most frequent finding is the maintenance of cognitive performance (nor improvement or worsening). From a neuropsychological point of view, this outcome might be considered a success, given that it is accompanied by amelioration of obsessive-compulsive symptoms. Subtle cognitive adverse effects have also been reported. Neurosurgery procedures appear to be safe from a cognitive point of view. Methodological issues must be improved to draw clearer conclusions, but capsulotomies and cingulotomies constitute an effective alternative treatment for refractory obsessive-compulsive disorder patients.

Optimization of microfibrillated cellulose isolation from cocoa pod husk via mild oxalic acid hydrolysis: A response surface methodology approach.

Theobroma cacao L. species, cultivated worldwide for its valuable beans, generates up to 72% weight of the fruit as waste. The lack of reutilization technologies in the cocoa agroindustry has hindered the exploitation of valuable bio-components applicable to the generation of high value added bioproducts. One such bioproduct is microfibrillated cellulose (MFC), a biopolymer that stands out for its desirable mechanical properties and biocompatibility in biomedical, packing, 3D printing, and construction applications. In this study, we isolated microfibrillated cellulose (MFC) from cocoa pod husk (CPH) via oxalic acid hydrolysis combined with a steam explosion. MFC isolation started with the Solid/Liquid extraction via Soxhlet, followed by mild citric acid hydrolysis, diluted alkaline hydrolysis, and bleaching pre-treatments. A Response Surface Methodology (RSM) was used to optimize the hydrolysis reaction at levels between 110 and 125 °C, 30-90 min at 5-10% (w/v) oxalic acid concentration. The cellulose-rich fraction was characterized by Fourier-Transform Infrared Spectroscopy (FTIR), Thermogravimetric Analysis (TGA), Differential Scanning Calorimetry (DSC), X-Ray Diffraction (XRD), and Scanning Electron Microscopy (SEM) analyses. Characterization analyses revealed a cellulose-rich polymer with fibers ranging from 6 to 10 µm, a maximum thermal degradation temperature of 350 °C, and a crystallinity index of 63.4% (peak height method) and 29.0% (amorphous subtraction method). The optimized hydrolysis conditions were 125 °C, 30 min, at 5% w/v oxalic acid: with a 75.7% yield. These results compare with MFC obtained through highly concentrated inorganic acid hydrolysis from different biomass sources. Thus, we show a reliable and greener alternative chemical treatment for the obtention of MFC.

Resilient clean cooking: Maintaining household clean cooking in Ecuador during the COVID-19 pandemic.

Decades of government subsidies for LPG and electricity have facilitated near-universal clean cooking access and use in Ecuador, placing the nation ahead of most other peer low- and middle-income countries. The widespread socio-economic impacts of the COVID-19 pandemic has threatened the resilience of clean cooking systems globally, including by altering households' ability to purchase clean fuels and policymakers' considerations about continuing subsidy programs. As such, assessing the resilience of clean cooking in Ecuador during the pandemic can offer important lessons for the international community, especially other countries looking to ensure resilient transitions to clean cooking. We study household energy use patterns using interviews, newspaper reports, government data on household electricity and LPG consumption, and household surveys [N = 200 across two rounds]. The LPG and electricity distribution systems experienced occasional disruptions to cylinder refill delivery and meter reading processes, respectively, which were associated with pandemic-related mobility restrictions. However, for the most part, supply and distribution activities by private and public companies continued without fundamental change. Survey participants reported increases in unemployment and reductions in household income as well as increased use of polluting biomass as a secondary fuel. Ecuador's LPG and electricity distribution systems were resilient throughout the pandemic, with only minimal interruption of the widespread provision of low-cost clean cooking fuels. Our findings inform the global audience concerned about the resilience of clean household energy use on the potential for clean fuel subsidies to facilitate continued clean cooking even during the COVID-19 pandemic.

La prostatectomía radical retropúbica abierta es todavía una técnica quirúrgica bien establecida para el tratamiento del cáncer de próstata / Open retropubic radical prostatectomy: Still a well-established surgical technique for prostate cancer management

Introducción Las opciones de tratamiento quirúrgico del cáncer de próstata han experimentado cambios significativos gracias a la expansión de la robótica. Sin embargo, la prostatectomía radical retropúbica abierta (PRA) seguirá realizándose en aquellos entornos con limitaciones económicas o con escaso acceso a la robótica. El objetivo de este estudio fue determinar los resultados oncológicos a largo plazo, clasificar las tasas de complicaciones y examinar las tasas de recuperación temprana de la continencia en pacientes tratados con PRA. Métodos Identificamos a todos los pacientes sometidos a PRA en nuestra institución entre 2000 y 2020. Se utilizó un pad test (prueba de la compresa) estandarizado para determinar las tasas de continencia precoz tras la retirada del catéter; la continencia tardía, alrededor de un año después de la cirugía, se determinó mediante el número de compresas por día. Se utilizó la clasificación de Clavien-Dindo para informar las tasas de complicaciones. Las tasas de supervivencia libre de recidiva bioquímica (RB) y de supervivencia global (SG) se definieron mediante el método de Kaplan-Meier y el análisis log-rank. Se utilizaron modelos multivariantes de regresión de Cox para comprobar el efecto de los distintos factores sobre la recidiva bioquímica. Resultados Se analizaron los datos de 1.095 pacientes. La mediana de seguimiento fue de 93,4 meses. Se encontró una supervivencia global libre de RB a 10años y una SG del 73% y del 82%, respectivamente. Se observó una tasa de complicaciones de Clavien Dindo ≥3 en el 4,8% de los pacientes. La tasa de continencia precoz fue del 81,4% y la tasa de continencia tardía fue del 89,1%. El nivel de PSA preoperatorio, la suma de la puntuación de Gleason, el estadio pT, el estado de los ganglios linfáticos y el estado de los márgenes quirúrgicos fueron predictores independientes de RB (p<0,001). Entre las limitaciones del estudio están su diseño retrospectivo y unicéntrico (AU)

Introduction The surgical treatment options for prostate cancer have changed rapidly, given the expansion of robotics. However, open retropubic radical prostatectomy (ORP) will continue to be performed in areas with financial limitations or with limited access to robotics. The purpose of this study was to determine the long-term oncological outcomes, to categorize complication rates and to examine the early continence rates in patients treated with ORP. Methods We identified all patients who underwent ORP at our institution between 2000 and 2020. A standardized pad test was used to determine the early continence rates upon catheter removal, the late continence around a year after surgery was determined by the number of pads per day. The Clavien-Dindo classification was used to report the complication rates. The biochemical recurrence (BCR)-free survival and overall survival (OS) rates were defined using the Kaplan-Meier method and log-rank analysis. Multivariable Cox-regression models were used to test the effect of different factors on biochemical recurrence. Results We analyzed 1095 patients. The median follow-up was 93.4months. An overall 10-year BCR-free survival and OS of 73% and 82% respectively was found. A complication rate for Clavien Dindo ≥3 was seen in 4.8% of patients. The early continence rate was 81.4% and the late continence 89.1%. Preoperative PSA level, Gleason score sum, pT stage, lymph node status, and surgical margin status were independent predictors of BCR (P<.001). Limitations include retrospective and single centre study design. Conclusions ORP is a surgical procedure that provides excellent oncological- and early continence-rates (AU)

Widespread Clean Cooking Fuel Scale-Up and under-5 Lower Respiratory Infection Mortality: An Ecological Analysis in Ecuador, 1990-2019.

BACKGROUND: Nationwide household transitions to the use of clean-burning cooking fuels are a promising pathway to reducing under-5 lower respiratory infection (LRI) mortality, the leading cause of child mortality globally, but such transitions are rare and evidence supporting an association between increased clean fuel use and improved health is limited. OBJECTIVES: This study aimed to investigate the association between increased primary clean cooking fuel use and under-5 LRI mortality in Ecuador between 1990 and 2019. METHODS: We documented cooking fuel use and cause-coded child mortalities at the canton (county) level in Ecuador from 1990 to 2019 (in four periods, 1988-1992, 1999-2003, 2008-2012, and 2015-2019). We characterized the association between clean fuel use and the rate of under-5 LRI mortalities at the canton level using quasi-Poisson generalized linear and generalized additive models, accounting for potential confounding variables that characterize wealth, urbanization, and child health care and vaccination rates, as well as canton and period fixed effects. We estimated averted under-5 LRI mortalities accrued over 30 y by predicting a counterfactual count of canton-period under-5 LRI mortalities were clean fuel use to not have increased and comparing with predicted canton-period under-5 LRI mortalities from our model and observed data. RESULTS: From 1990 to 2019, the proportion of households primarily using a clean cooking fuel increased from 59% to 95%, and under-5 LRI mortality fell from 28 to 7 per 100,000 under-5 population. Canton-level clean fuel use was negatively associated with under-5 LRI mortalities in linear and nonlinear models. The nonlinear association suggested a threshold at approximately 60% clean fuel use, above which there was a negative association. Increases in clean fuel use between 1990 and 2019 were associated with an estimated 7,300 averted under-5 LRI mortalities (95% confidence interval: 2,600, 12,100), accounting for nearly 20% of the declines in under-5 LRI mortality observed in Ecuador over the study period. DISCUSSION: Our findings suggest that the widespread household transition from using biomass to clean-burning fuels for cooking reduced under-5 LRI mortalities in Ecuador over the last 30 y. https://doi.org/10.1289/EHP11016.

Open retropubic radical prostatectomy: Still a well-established surgical technique for prostate cancer management.

INTRODUCTION: The surgical treatment options for prostate cancer have changed rapidly, given the expansion of robotics. However, open retropubic radical prostatectomy (ORP) will continue to be performed in areas with financial limitations or with limited access to robotics. The purpose of this study was to determine the long-term oncological outcomes, to categorize complication rates and to examine the early continence rates in patients treated with ORP. METHODS: We identified all patients who underwent ORP at our institution between 2000 and 2020. A standardized pad test was used to determine the early continence rates upon catheter removal, the late continence around a year after surgery was determined by the number of pads per day. The Clavien-Dindo classification was used to report the complication rates. The biochemical recurrence (BCR)-free survival and overall survival (OS) rates were defined using the Kaplan-Meier method and log-rank analysis. Multivariable Cox-regression models were used to test the effect of different factors on biochemical recurrence. RESULTS: We analyzed 1095 patients. The median follow-up was 93.4 months. An overall 10-year BCR-free survival and OS of 73% and 82% respectively was found. A complication rate for Clavien Dindo≥3 was seen in 4.8% of patients. The early continence rate was 81.4% and the late continence 89,1%. Preoperative PSA level, Gleason score sum, pT stage, lymph node status, and surgical margin status were independent predictors of BCR (p<0.001, 95% CI). Limitations include retrospective and single center study design. CONCLUSIONS: ORP is a surgical procedure that provides excellent oncological- and early continence-rates.

Long-standing LPG subsidies, cooking fuel stacking, and personal exposure to air pollution in rural and peri-urban Ecuador.

Ecuador presents a unique case study for evaluating personal air pollution exposure in a middle-income country where a clean cooking fuel has been available at low cost for several decades. We measured personal PM2.5 exposure, stove use, and participant location during a 48-h monitoring period for 157 rural and peri-urban households in coastal and Andean Ecuador. While nearly all households owned a liquefied petroleum gas (LPG) stove and used it as their primary cooking fuel, one-quarter of households utilized firewood as a secondary fuel and 10% used induction stoves secondary to LPG. Stove use monitoring demonstrated clear within- and across-meal fuel stacking patterns. Firewood-owning participants had higher distributions of 48-h and 10-min PM2.5 exposure as compared with primary LPG and induction stove users, and this effect became more pronounced with firewood use during monitoring.Accounting for within-subject clustering, contemporaneous firewood stove use was associated with 101 µg/m3 higher 10-min PM2.5 exposure (95% CI: 94-108 µg/m3). LPG and induction cooking events were largely not associated with contemporaneous PM2.5 exposure. Our results suggest that firewood use is associated with average and short-term personal air pollution exposure above the WHO interim-I guideline, even when LPG is the primary cooking fuel.

Use of Sensory Analysis to Investigate the Influence of Climate Chambers and Other Process Variables in the Production of Sweet Wines.

In this study, a climate chamber, as an alternative method, has been used to dry raisins and the sensory profiles of the sweet sherry wines obtained have been evaluated. Other important factors, namely grape variety, vintage, vinification conditions, as well as the ageing method and its length of time, have also been considered. When heavy rainfall had been registered, the musts extracted from grapes dried under controlled conditions in a climate chamber showed a lower intensity of the musty off-odor compared to those elaborated with sun-dried grapes. The wine fermented at low temperature with Saccharomyces bayanus scored the highest in citric and floral notes, and this was preferred over all the other wines that were evaluated. The wines aged in oak barrels were preferred to both, wines aged in the presence of oak chips as well as those aged without any wood contact. The use of climate chambers to dry the grapes that are going to be used for the elaboration of sweet wines appears to be an advantageous alternative to the traditional method, since it allows a more precise control of the process and highly valued sweet wines from a sensory point of view are obtained thereby.

[Vascular anomalies in the neonatal period]. / Anomalías vasculares de presentación neonatal.

OBJECTIVE: Vascular anomalies in the neonatal period are a diagnostic challenge for the lack of evident signs, symptoms and follow-up, and the convenience of restricting aggressive diagnostic tests. The aim of this work is to review the characteristics of neonatal cases presented to our Vascular Anomalies Unit in the last 5 years. MATERIALS AND METHODS: All cases of suspected vascular anomaly presented to our unit before 1 month of age between 2010 and 2015 were reviewed, diagnostic tests and treatments carried out with chronology were analyzed. Presumptive diagnosis and final diagnosis (when available) were compared. RESULTS: Fifteen vascular tumors were found, 2 with visceral involvement: 6 infantile hemangiomas (IH), 3 NICH, 4 RICH, 1 tufted hemangioma, 1 unspecified liver vascular tumor, 3 venous malformations (2 equivocal MRI and a hyperkeratotic venous malformation), 4 lymphatic malformations, 3 of them macrocystic, and 2 vascular lesions that were diagnosed of fibrosarcoma and sclerema neonatorum and they were not vascular anomalies. Only 3 patients with macrocystic lymphatic malformations had prenatal diagnosis. CONCLUSION: Accurate diagnosis of vascular anomalies during the first month of life is difficult, even with MRI. Only in a few cases early treatment is needed, so it is worth taking time to follow-up. Different types of treatment (observation, propranolol, biopsy, laser, embolization, and resection) will depend on the condition to be treated. A continuous observation can avoid unnecessary procedures and risks.

OBJETIVOS: Las anomalías vasculares de presentación neonatal suponen un reto diagnóstico por la ausencia de semiología florida, de historia evolutiva y la conveniencia de restringir pruebas diagnósticas agresivas. El objetivo es revisar las características de los casos neonatales presentados a nuestra Unidad de Anomalías Vasculares en los últimos 5 años. MATERIAL Y METODOS: Se recogen todos los casos de sospecha de anomalía vascular presentados a nuestra Unidad antes de 1 mes de edad entre 2010 y 2015. Se revisa el momento del diagnóstico en relación con la anomalía, las pruebas diagnósticas y los tratamientos efectuados con su cronología. Se comparan el diagnóstico de presunción y el de certeza, cuando lo hay. RESULTADOS: Se incluyen 26 pacientes: 15 tumores vasculares, 2 de ellos con afectación visceral (6 hemangiomas infantiles (HI), 3 NICH, 4 RICH, 1 hemangioma en penacho, 1 tumor vascular hepático no especificado. 3 malformaciones venosas: 2 con RM equívoca y una malformación venosa hiperqueratótica. 4 malformaciones linfáticas: 3 macroquísticas y una microquística. 2 lesiones muy vasculares que se diagnosticaron posteriormente (fibrosarcoma y adiponecrosis) y no eran anomalías vasculares. Solo 3 pacientes tenían diagnóstico prenatal, las malformaciones linfáticas macroquísticas. CONCLUSION: El diagnóstico preciso de las anomalías vasculares durante el primer mes de vida es difícil, incluso con RM. En pocos casos se necesita un tratamiento precoz, por lo que conviene dar tiempo a la evolución, al menos durante unas semanas. Los diferentes tipos de tratamiento (observación, propranolol, biopsia, láser, embolización, exéresis) dependerán de la patología a tratar. Una observación continuada puede evitar procedimientos y riesgos innecesarios.

Anomalías vasculares de presentación neonatal / Vascular anomalies in the neonatal period

Objetivos. Las anomalías vasculares de presentación neonatal suponen un reto diagnóstico por la ausencia de semiología florida, de historia evolutiva y la conveniencia de restringir pruebas diagnósticas agresivas. El objetivo es revisar las características de los casos neo- natales presentados a nuestra Unidad de Anomalías Vasculares en los últimos 5 años. Material y métodos. Se recogen todos los casos de sospecha de anomalía vascular presentados a nuestra Unidad antes de 1 mes de edad entre 2010 y 2015. Se revisa el momento del diagnóstico en relación con la anomalía, las pruebas diagnósticas y los tratamientos efectuados con su cronología. Se comparan el diagnóstico de presunción y el de certeza, cuando lo hay. Resultados. Se incluyen 26 pacientes: 15 tumores vasculares, 2 de ellos con afectación visceral (6 hemangiomas infantiles (HI), 3 NICH, 4 RICH, 1 hemangioma en penacho, 1 tumor vascular hepático no especificado. 3 malformaciones venosas: 2 con RM equívoca y una malformación venosa hiperqueratótica. 4 malformaciones linfáticas: 3 macroquísticas y una microquística. 2 lesiones muy vasculares que se diagnosticaron posteriormente (fibrosarcoma y adiponecrosis) y no eran anomalías vasculares. Solo 3 pacientes tenían diagnóstico prenatal, las malformaciones linfáticas macroquísticas. Conclusión. El diagnóstico preciso de las anomalías vasculares durante el primer mes de vida es difícil, incluso con RM. En pocos casos se necesita un tratamiento precoz, por lo que conviene dar tiempo a la evolución, al menos durante unas semanas. Los diferentes tipos de tratamiento (observación, propranolol, biopsia, láser, embolización, exéresis) dependerán de la patología a tratar. Una observación continuada puede evitar procedimientos y riesgos innecesarios (AU)

Objective. Vascular anomalies in the neonatal period are a diagnostic challenge for the lack of evident signs, symptoms and follow-up, and the convenience of restricting aggressive diagnostic tests. The aim of this work is to review the characteristics of neonatal cases presented to our Vascular Anomalies Unit in the last 5 years. Materials and methods. All cases of suspected vascular anomaly presented to our unit before 1 month of age between 2010 and 2015 were reviewed, diagnostic tests and treatments carried out with chronology were analyzed. Presumptive diagnosis and final diagnosis (when available) were compared. Results. Fifteen vascular tumors were found, 2 with visceral involvement: 6 infantile hemangiomas (IH), 3 NICH, 4 RICH, 1 tufted hemangioma, 1 unspecified liver vascular tumor, 3 venous malformations (2 equivocal MRI and a hyperkeratotic venous malformation), 4 lymphatic malformations, 3 of them macrocystic, and 2 vascular lesions that were diagnosed of fibrosarcoma and sclerema neonatorum and they were not vascular anomalies. Only 3 patients with macrocystic lymphatic malformations had prenatal diagnosis. Conclusion. Accurate diagnosis of vascular anomalies during the first month of life is difficult, even with MRI. Only in a few cases early treatment is needed, so it is worth taking time to follow-up. Different types of treatment (observation, propranolol, biopsy, laser, embolization, and resection) will depend on the condition to be treated. A continuous observation can avoid unnecessary procedures and risks (AU)

Anal canal duplication and triplication: a rare entity with different presentations.

Anal canal duplication (ACD) is the rarest of gastrointestinal duplications. Few cases have been reported. Most cases present as an opening in the midline, posterior to the normal anus. The aim of our revision is to contribute with eight new cases, some of them with unusual presentations: five presented as the typical form, one with a perianal nodule, and two presented as two separate orifices (anal canal triplication). Complete excision was performed in all patients with no complications. ACD is the most distal and the least frequent digestive duplication. Its treatment should be surgical excision, to avoid complications such as abscess, fistulization, or malignization. Anal canal triplication has never been described before.

Colorectal liver metastases are more often super wild type. Toward treatment based on metastatic site genotyping?

Recent data showed that metastatic colorectal (mCRC) tumors exhibiting extended RAS-BRAF mutations were resistant to anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, making these drugs suitable for the so-called "super" wild-type (WT) patients only. This study aimed to compare the extended RAS-BRAF mutation frequency and characteristics according to location of tumor sampling. All consecutive mCRC specimens (N = 1659) referred to our institution from January 2008 till June 2014 were included in the analysis. Tumor genotyping (first for KRAS exon 2, then for BRAF exon 15, and later for KRAS exons 2, 3, and 4 and NRAS exons 2, 3, and 4) was performed with high-resolution melting analysis or allelic discrimination. The factors predicting for the presence of mutation were explored using multivariate binary logistic regression. Overall, the prevalence of KRAS exon 2 was 36.8%, and it was lower in liver metastases (N = 138/490; 28.2%) in comparison with primary tumors (N = 442/1086; 40.7%), lung metastases (16/32; 50%), or other metastatic sites (15/51; 29.4%; P < 0.0001). Similarly, in the 1428 samples analyzed, BRAF mutations were less often found in liver metastases (N = 9/396; 2.3%) as compared to primary tumors (N = 79/959; 8.2%), lung metastases (N = 2/29; 6.9%), or other metastatic locations (N = 2/44; 4.5%; P < 0.0002). Overall occurrence of extended RAS mutation was 51.7%. Of the 503 samples tested, the prevalence of extended RAS-BRAF mutations was twice as low in liver metastases (N = 53/151; 34.2 %) as compared to primary tumors (N = 191/322; 59.3%, P < 0.0001). Univariate analysis identified age ≤65 years, male gender, and liver localization as predictors of super WT status. At multivariate analysis, only liver metastases were retained (RR 2.85 [95% CI 1.91-4.30]). Colorectal liver metastases are twice as likely to exhibit a super WT genotype as compared to other tumor locations independently from other factors. This molecular feature has the potential to influence therapeutic strategy in mCRC patients.

Use of high-pressure balloon dilatation of the ureterovesical junction instead of ureteral reimplantation to treat primary obstructive megaureter: is it justified?

OBJECTIVE: To compare outcomes between high-pressure balloon dilatation of the ureterovesical junction (UVJ) and ureteral reimplantation with ureteral tapering to treat primary obstructive megaureter (POM). PATIENTS AND METHODS: Retrospective review of clinical data from patients who underwent surgical treatment of POM from 2005 to 2010. Patients were divided into two groups: endoscopic treatment (ET) with UVJ dilatation and ureteral reimplantation (UR) with Cohen's or Leadbetter-Politano neoureterocystostomy and Hendren's tapering. Preoperative studies included ultrasound scan (US), voiding cystourethrography, and diuretic isotopic renogram. Outcome parameters were US, differential renal function (DRF), presence of postoperative vesicoureteral reflux, need for secondary reimplantation and complications. RESULTS ET: 13 patients with a median age of 7 (4-24) months; UR: 12 patients with a median age of 14 (7-84) months, with no statistical differences in age and gender between groups. Preoperative US parameters were similar. ET: mean diameter of renal pelvis, calices and ureter was 23.5 mm, 13.46 mm and 15.77 mm respectively. UR: mean diameter of renal pelvis, calices and ureter was 22.25 mm, 11.75 mm, and 19.08 mm, respectively. Preoperative DRF was 45.62% and 39.33% for ET and UR, respectively (p > 0.05). Significant improvement of hydroureteronephrosis was observed in 11/13 patients of ET and 11/12 patients of UR (p > 0.05). Postoperative DRF was 42% and 48% for ET and UR, respectively (p > 0.05). Postoperative vesicoureteral reflux was observed in 2 patients of ET and 1 of UR (p > 0.05). Secondary ureteral reimplantation was needed in 3 patients of ET and 2 of UR (p > 0.05). CONCLUSION: Endoscopic treatment of POM is as effective as ureteral reimplantation but further randomized clinical trials are needed to support these results.

Oral lenalidomide with rituximab in relapsed or refractory diffuse large cell, follicular and transformed lymphoma: a phase II clinical trial.

Lenalidomide-rituximab therapy is effective in grade 1-2 follicular and mantle cell lymphoma, but its efficacy in diffuse large B-cell lymphoma (DLBCL), transformed large cell lymphoma (TL) and grade 3 follicular lymphoma (FLG3) is unknown. In this phase II trial, 45 patients with relapsed or refractory DLBCL (n=32), TL (n=9) or FLG3 (n=4) who had received 1-4 prior lines of treatment were given 20 mg oral lenalidomide on days 1-21 of each 28-day cycle, and intravenous rituximab (375 mg/m(2)) weekly during cycle 1. Grade 3/4 hematological toxicities included neutropenia (53%), lymphopenia (40%), thrombocytopenia (33%), leukopenia (27%) and anemia (18%), with a median follow-up time of 29.1 months (range 14.7-52.0 months). Overall response (OR) rate was 33%; median response duration was 10.2 months. Median progression-free survival (PFS) and overall survival (OS) were 3.7 and 10.7 months, respectively. Nine of the 15 responding patients (three partial response (PR), six complete response (CR)) proceeded with stem cell transplantation (SCT) and were censored at the time of transplantation. When data were analyzed without censoring, median PFS remained 3.7 months and response duration increased to 30.9 months. Rituximab plus oral lenalidomide is well tolerated and effective for patients with relapsed/refractory DLBCL and TL. SCT after lenalidomide-rituximab is associated with prolonged response duration.

Acute and delayed vesicoureteral obstruction after endoscopic treatment of primary vesicoureteral reflux with dextranomer/hyaluronic acid copolymer: why and how to manage.

OBJECTIVE: To present our cases of ureteral obstruction after endoscopic treatment of vesicoureteral reflux (VUR) with dextranomer/hyaluronic acid (Dx/HA). PATIENTS AND METHODS: We collected data from patients who had suffered ureteral obstruction after endoscopic treatment of VUR with Dx/HA in our institution. RESULTS: From April 2002 to April 2011 we treated endoscopically 475 ureters with VUR, and detected 5 ureteral obstructions. Median age at reflux treatment was 39 months. Reflux grade before treatment was III in one patient and IV in four. Three ureterovesical junctions (UVJ) were blocked after a second endoscopic treatment. The median of Dx/HA injected was 1 ml (0.6-1.1). In two patients ureteral obstruction presented acutely and was treated with a ureteral stent. In the other three, the ureteral obstruction appeared gradually and was detected by ultrasound scans and MAG3 diuretic renogram; one underwent nephrectomy because of poor renal function, and the other two were treated with endoscopic dilatation of the UVJ. In all these patients both reflux and obstructions have resolved. CONCLUSIONS: On preoperative cystography, three of the patients had a narrowed distal ureter, and probably had a refluxing and obstructive megaureter. Other causes are not clear, except for those patients with acute presentation in whom edema of the UVJ was found. Ureteral obstruction after endoscopic treatment of VUR is rare. Endoscopic intervention such as ureteral stent placement or high-pressure balloon dilatation of the UVJ has good results as a treatment of acute and delayed obstruction.

Sistema de Salud de Paraguay / Paraguayan health system

En este trabajo se describen las condiciones de salud de los paraguayos y, con mayor detalle, el Sistema Nacional de Salud del Paraguay, creado en virtud de la Ley 1032 de 1996. Se aborda en detalle su estructura y cobertura, sus fuentes de financiamiento, el monto y distribución del gasto en salud, los recursos físicos, materiales y humanos de los que dispone, y las actividades de rectoría que desarrolla el Ministerio de Salud Pública y Bienestar Social. También se discuten la descentralización y participación de los ciudadanos en la operación y evaluación del sistema de salud. Palabras clave: Sistema de salud paraguayo de salud, descentralización de los servicios de salud, Ley de Salud 1032/96

This paper discusses the health conditions in Paraguay and, in more detail, the characteristics of the Paraguayan health system, including its structure and coverage, its financial sources, the health and distribution of health expenditure, the physical, material and human resources available, and the stewardship functions developed by the Ministry of Public Health and Social Wellbeing. It also describes the participation of citizens in the operation and evaluation of the health system and the most recent health policy innovations implemented in Paraguay, including the approval of the Health Law (1032/96), which creates the National Health System, and the process of decentralization of health services. Keywords: Paraguayan health system, decentralization of health services, Health Law 1032/96

Optimizing the process of making sweet wines to minimize the content of ochratoxin A.

During the drying process of raisins, the grapes are subjected to climatic variations that can result in heavy infections of some fungal species that produce ochratoxin A (OTA), a powerful toxic metabolite, whose maximum permitted content is set by the European Union at 2.0 µg/L for grapes, wine and other drinks derived from the grape. The aim of this paper is to optimize the process of making sweet wines in order to minimize the content of ochratoxin A. The results reflect a reduction of the OTA content in grapes dried under controlled conditions in a climatic chamber up to 24% compared to those sunned in the traditional way. A decrease of the concentrations of OTA is also observed during the processes of vinification. Those wines with prefermentative maceration reached a higher OTA content than the wines without maceration, but unexpectedly were not those preferred from a sensorial point of view. In addition, the process of aging in oak casks has been shown to serve as a natural method for reducing the OTA content of these wines.