Factores relacionados con la cirugía secundaria en la reconstrucción mamaria autóloga con tejido libre abdominal / Secondary surgery related factors in autologous breast reconstruction using abdominal free tissue

La reconstrucción mamaria con colgajo libre abdominal se ha convertido en la opción terapéutica de elección en nuestro centro hospitalario cuando se necesita abundante cantidad de tejido. La culminación de este tipo de reconstrucción requiere un número variable de procedimientos auxiliares de retoque. Revisamos las historias de las pacientes sometidas en nuestro centro a reconstrucción mamaria con colgajo libre abdominal entre enero de 2010 y diciembre de 2013. El criterio de inclusión fue la reconstrucción del pezón como última cirugía. Las pacientes fueron estratificadas atendiendo a factores relacionados con la reconstrucción microquirúrgica y la existencia de radioterapia adyuvante. Analizamos el número y tipo de procedimientos y cirugías de retoque, así como el tiempo transcurrido hasta completar el proceso de reconstrucción. En total, recogimos 68 pacientes reconstruidas con colgajo libre abdominal. De ellas, 31 (45,6%) completaron la reconstrucción mamaria. La media de procedimientos fue de 3,2 por paciente, con una media de 2,4 tiempos quirúrgicos y un tiempo medio de 15,5 meses hasta la reconstrucción del pezón. El momento de la reconstrucción, la bilateralidad, el tratamiento con radioterapia y la presencia de complicaciones tempranas del colgajono se relacionaron con diferencias estadísticamente significativas en la tasa de cirugía secundaria. Los colgajos libres abdominales necesitan frecuentemente cirugías secundarias para mejorar el resultado y terminar la reconstrucción. Remarcamos la necesidad de planificar la reconstrucción desde el primer tiempo quirúrgico para disminuirla necesidad de cirugías de retoque y el tiempo hasta completarla reconstrucción mamaria (AU)

Breast reconstruction using abdominal free flaps has become the therapeutic choice at our center when a lot of tissueis needed, The completion of this reconstructive technique requires a variable number of ancillary procedures. Patients who underwent breast reconstruction with abdominal free flap at our center between January 2010 and December2013 were reviewed. The inclusion criterion was completion to nipple reconstruction. The patients were stratified attending to microsurgical reconstruction related factors and adjuvant radiotherapy. Number and sort of procedures and surgeries, and total elapsed time to complete the reconstruction were analyzed. Sixty-eight patients underwent reconstruction using abdominal free flap; 31 (45.6%) completed breast reconstruction. The average of procedures, surgical steps and elapsed time was3.2, 2.4 and 15.5 months respectively. Surgical time and bilateral procedures, treatment with radiotherapy and early flap complications were not related to statistically significant differences in secondary surgery rates. Abdominal free flaps often need secondary surgeries to improve the result and finish the reconstruction. We remark the necessity of planning the reconstruction since first surgical time to diminish the secondary surgeries and the elapsed time until completion of breast reconstruction (AU)

Diagnóstico histológico del tumor fibromixoide osificante: 2 casos en los últimos 20 años / Histologic diagnosis of ossifying fibromyxoid tumor: 2 cases in the past 20 Years

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Molecular markers and targeted therapy of skin rejection in composite tissue allotransplantation.

Skin rejection remains a major hurdle in reconstructive transplantation. We investigated molecular markers of skin rejection with particular attention to lymphocyte trafficking. Skin biopsies (n = 174) from five human hand transplant recipients were analyzed for rejection, characteristics of the infiltrate and lymphocytic adhesion markers. The cellular infiltrate predominantly comprised CD3+ T cells. CD68, Foxp3 and indoleamine 2, 3-dioxygenase expression and the CD4/CD8 increased with severity of rejection. Lymphocyte adhesion markers were upregulated upon rejection, intercellular adhesion molecule-1 and E-selectin correlated best with severity of rejection. Guided by the findings, a specific E- and P-selectin inhibitor was investigated for its effect on skin rejection in a rat hind limb allotransplant model. While efomycine M (weekly s.c. injection into the graft) alone had no effect, long-term allograft survival was achieved when combined with antithymocyte globulin and tacrolimus (control group without efomycine M rejected at postoperative day [POD] 61 +/- 1). Upregulation of lymphocyte trafficking markers correlates with severity of skin rejection and time after transplantation in human hand transplantation. Blocking E- and P-selectin in the skin holds potential to significantly prolong limb allograft survival.

Morphological and functional evaluation of visual disturbances in a bilateral hand allograft recipient.

Allograft recipients are exposed to risks owing to immunosuppression, and there is always the possibility that psychological issues interfere with the procedure's outcomes. An episode of blindness was suspected in a bilateral hand allograft recipient. The patient underwent a multidisciplinary evaluation, and clinical, electrophysiological, laboratory and a combination of functional and morphological magnetic resonance imaging (MRI) tests ruled out any visual process and revealed a secondary benefit, which turned out to be the use of privileges of the transplant support centre for several months. Composite tissue allograft recipients require a thorough psychological assessment before and after transplant procedures to prevent malingering.

Bilateral hand transplantation: result at 20 months.

On November 2006, a bilateral hand allotransplantation was performed for a 47-year-old female who had suffered radiocarpal amputations 28 years before. Technical aspects of the operation are detailed. Alemtuzumab induction, and triple therapy of tacrolimus, mycophenolate mofetil and prednisone were used to control rejection. The evolution of the result and functioning at 20 months are presented in detail. Two acute rejection episodes occurred and were successfully treated with steroids. In addition the patient developed a factitious visual disorder and a facial basal cell carcinoma. Functionally, at 20 months, the patient had a Hand Registry Functional Score of 69 (good), and a DASH score of 19.

Alemtuzumab: key for minimization of maintenance immunosuppression in reconstructive transplantation?

Minimization of immunosuppression has become the key effort in solid organ transplantation. Alemtuzumab, the humanized CD-52 monoclonal antibody, is an effective depleting agent increasingly used in transplantation trials. In this article, we summarize the current experience with alemtuzumab use in hand transplantation and discuss its role in current and future approaches toward minimization of maintenance immunosuppression in reconstructive transplantation.

The Banff 2007 working classification of skin-containing composite tissue allograft pathology.

Composite tissue allotransplantation (CTA) is a recently introduced option for limb replacement and reconstruction of tissue defects. As with other allografts, CTA can undergo immune-mediated rejection; therefore standardized criteria are required for characterizing and reporting severity and types of rejection. This article documents the conclusions of a symposium on CTA rejection held at the Ninth Banff Conference on Allograft Pathology in La-Coruna, Spain, on 26 June 2007, and proposes a working classification, the Banff CTA-07, for the categorization of CTA rejection. This classification was derived from a consensus discussion session attended by the first authors of three published classification systems, pathologists and researchers from international centers where clinical CTA has been performed. It was open to all attendees to the Banff conference. To the extent possible, the format followed the established National Institutes of Health (NIH) guidelines on Consensus Development Programs. By consensus, the defining features to diagnose acute skin rejection include inflammatory cell infiltration with involvement of epidermis and/or adnexal structures, epithelial apoptosis, dyskeratosis and necrosis. Five grades of severity of rejection are defined. This classification refines proposed schemas, represents international consensus on this topic, and establishes a working collective classification system for CTA reporting of rejection in skin-containing CTAs.

Infrared photodetectors in heterostructure nanowires.

We report on spectrally resolved photocurrent measurements on single self-assembled nanowire heterostructures. The wires, typically 3 microm long with an average diameter of 85 nm, consist of InAs with a 1 microm central part of InAsP. Two different sets of wires were prepared with phosphorus contents of 15+/-3% and 35+/-3%, respectively, as determined by energy-dispersive spectroscopy measurements made in transmission electron microscopy. Ohmic contacts are fabricated to the InAs ends of the wire using e-beam lithography. The conduction band offset between the InAs and InAsP regions virtually removes the dark current through the wires at low temperature. In the optical experiments, interband excitation in the phosphorus-rich part of the wires results in a photocurrent with threshold energies of about 0.65 and 0.82 eV, respectively, in qualitative agreement with the expected band gap of the two compositions. Furthermore, a strong polarization dependence is observed with an order of magnitude larger photocurrent for light polarized parallel to the wire than for light polarized perpendicular to the wire. We believe that these wires form promising candidates as nanoscale infrared polarization-sensitive photodetectors.

The effect of soybean soapstock on the quality parameters and fatty acid composition of the hen egg yolk.

The effects of increasing proportions of soybean soapstock (SSS) in laying hen diets on egg quality parameters and on the fatty acid (FA) composition of the yolk were studied. One hundred sixty Babcock B-300 x laying hens, 20 wk of age, were allotted to 5 dietary treatments comprising a control diet (D5) with soybean oil at 100% or SSS in proportions of 25% (D1), 50% (D2), 75% (D3), and 100% (D4) replacing the oil source in commercial-type diets throughout the 15-wk laying period. Egg quality parameters were recorded weekly. Four pooled yolks for each treatment were collected at 0, 9, and 15 wk, and their FA profiles were determined. Egg weight, shell thickness, shape index, and Haugh unit were not influenced by dietary treatment. The concentrations of saturated FA (SFA) in yolks were generally kept at a constant level, regardless of the percentage of SSS in the hen diets. Total monounsaturated FA (MUFA) content did not vary over the course of the experiment, except for C14:1. After 15 wk of feeding, the total polyunsaturated FA (PUFA) n-3 increased in yolks of all diets. Among the long-chain PUFA, the percentage of C20:4 (arachidonic acid) was less affected. Inclusion of 100% SSS allowed production of eggs with similar PUFA/SFA and n-6/n-3 ratios when compared with eggs from hens fed D5. As SSS represents one-third of the oil cost, its inclusion in layer diets could represent an important economic benefit.

Medicina basada en la evidencia y mastectomía profiláctica: nuevas perspectivas para un dilema clásico / Evidence based medicine and prophylactic mastectomy: a new viewpoint for a classic dilemma

El objetivo del presente artículo es interpretar en términos de “medicina basada en la evidencia” los riesgos y beneficios de una mastectomía profiláctica en mujeres con alto riesgo de padecer cáncer de mama. Llevamos a cabo una revisión no sistemática de resultados de mastectomía profiláctica. Calculamos el número de pacientes a los que es necesario realizar mastectomía para evitar un cáncer de mama (número-necesario-tratar) y el número de pacientes que es necesario someter a mastectomía para que se produzca un fallecimiento (número-necesario-dañar) a partir de datos publicados de reducción de riesgo de padecer cáncer de mama (90%) y el aumento del riesgo de fallecimiento (1,14%). Calculamos la probabilidad de ayudar a nuestro paciente frente a dañarles y la ajustamos a las preferencias del paciente mediante una escala visual. Se presentan ajustes aplicados a tres casos hipotéticos de preferencias de distintos pacientes. La probabilidad de evitar un cáncer de mama en pacientes con historia familiar de alto riesgo de cáncer de mama frente a fallecer a consecuencia de la intervención es en nuestro estudio de 30,5 frente a 1 (30,5:1). En conclusión las pacientes con historia familiar de alto riesgo de cáncer de mama pueden beneficiarse de una mastectomía profiláctica, si comparamos el riesgo de padecer cáncer de mama frente al riesgo de fallecer a consecuencia de la intervención (AU)

We try to interprete in “evidence based medicine” terms the prophylactic mastectomy benefits and risks in women at high risk of breast cancer, and we do a prophylactic mastectomy non-systematic review. We calculate the number needed to treat with mastectomy to prevent a breast cancer, and the number treated to see a death as a harmful effect (number needed to hurt), from published data of risk reduction of breast cancer (90%) and risk increase of death (1,14%). We then calculate the probability of aid versus harm our patient and adjust to the patients preferences measured by visual scale. We present three theoretical cases of patients with different preferences. Avoiding a breast cancer in high-risk women by prophylactic mastectomy is 30,5 times more feasible than dying because of surgery. As conclusion, women with high risk family history of breast cancer can benefit from a prophylactic mastectomy comparing the risk of developing cancer with the risk of dying from surgery (AU)

Organochlorine pesticide residues in cow's milk from a tropical region of Mexico.

A monitoring study was conducted to assess the magnitude of DDT [(1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane)] and HCH (hexachlorocyclohexane) contamination of bovine milk from the central tropical region of Mexico as the chemicals are extensively used in livestock and public-health programmes. Among pesticide residues analysed, the milk samples collected from Tlalixcoyan showed a mean level of gamma-HCH (0.128 mg x kg(-1)), which was significantly higher than residues in milk samples from Medellin (0.049 mg x kg(-1)) and Paso San Juan (0.022 mg x kg(-1)). The mean level of pp'-DDE in Medellin samples (0.039 mg x kg(-1)) was significantly higher than in Paso San Juan (0.018 mg x kg(-1)) and Tlalixcoyan (0.024 mg x kg(-1)) milk samples. The pp'-DDT mean level from Medellin milk samples (0.089 mg x kg(-1)) was significantly higher than the levels detected in the other two areas. The highest mean Sigma-DDT level detected in Medellin samples (0.146 mg x kg(-1)) was three times the FAO/WHO tolerance level. The highest acceptable daily intakes calculated for Sigma-DDT were 0.017 microg x kg(-1) bw day(-1) for adults and 0.530 microg x kg(-1) bw day(-1) for infants; for gamma-HCH residues, they were 0.021 microg x kg(-1) bw day(-1) for adults and 0.666 microg x kg(-1) bw day(-1) for infants, indicating that infants are more exposed to pesticide residues. Results indicate that cattle exposure to HCH and DDT results in high levels in dairy milk and a potential health risk for consumers.

El sistema de la proteína C en la sepsis / The protein C system in sepsis

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The effect of acidified soapstocks on feed conversion and broiler skin pigmentation.

The effect of different soapstocks (corn, sunflower, canola, and soybean) on productive performance and skin broiler pigmentation was investigated. Soapstock was added to reach 1.0% polyunsaturated fatty acids in the diet. The addition of soybean soapstock significantly improved live body weight gain of the birds from 1 to 7 wk of age. A live body weight gain of 1,736 g/bird was calculated for broilers fed with the soybean soapstock diet. Feed conversion was significantly higher for broilers fed with the soybean soapstock diet, and no negative effect was observed. Compared to broilers fed with Pixtafil (100.0% pigmentation), those fed soybean soapstock (when added as a supplement of 1.0% polyunsaturated fatty acids in the diet) reached 48.0% pigmentation, and those fed corn soapstock reached only 7.3%. When the diets were complemented with Pixtafil to reach 100% of calculated pigmentation, the soybean soapstock diet reached 100.8% pigmentation compared to a canola soapstock diet that reached 72.0% pigmentation. Acidified soybean soapstock could be a source of polyunsaturated fatty acids and of xantophyl pigments in broiler feeding.

Decreasing incidence of fractures in children: an epidemiological analysis of 1,673 fractures in Malmö, Sweden, 1993-1994.

The incidence of fractures in children in the city of Malmö, Sweden, almost doubled between 1950 and 1979. To see whether a further increase had occurred, we carried out an epidemiological analysis of fractures among children 0-16 years in Malmö 1993-1994. During the study period, 1,673 fractures occurred in 1,610 children. The commonest fracture location was the distal forearm (26%), followed by the phalanges of the hand (16%) and the clavicle (9%). The annual fracture incidence was 235/10(4) in boys, 149/10(4) in girls and 193/10(4) for both genders. This means a decrease in the annual fracture incidence by 9% since 1975-1979. The decrease was not associated with any specific type of fracture or etiological factor. Fractures of the distal forearm among girls were an exception to the general decline, having increased by one third since 1975-1979, which might be explained by the fact that today girls participate to a greater extent in the same sports as boys.

Optical studies of individual InAs quantum dots in GaAs: few-particle effects

Optical emission from individual strained indium arsenide (InAs) islands buried in gallium arsenide (GaAs) was studied. At low excitation power density, the spectra from these quantum dots consist of a single line. At higher excitation power density, additional emission lines appeared at both higher and lower energies, separated from the main line by about 1 millielectron volt. At even higher excitation power density, this set of lines was replaced by a broad emission peaking below the original line. The splittings were an order of magnitude smaller than the lowest single-electron or single-hole excited state energies, indicating that the fine structure results from few-particle interactions in the dot. Calculations of few-particle effects give splittings of the observed magnitude.

[Septic shock and nitric oxide]. / Shock séptico y óxido nítrico.

Refractory hypotension is the main cause of death of patients with septic shock. It has been shown that an excessive release of NO is responsible for the sepsis-induced hypotension and vascular hyporeactivity. Nitric oxide is produced under normal conditions by a constitutive enzyme present, among other cell types, in the endothelial cell, and is necessary for maintenance of normal organ perfusion. Under inflammatory or septic conditions, a new enzyme is expressed in phagocytic cells and vascular smooth muscle cells, giving rise to an uncontrolled NO production that is associated with cytotoxic effects and vasodilatation. Randomized clinical trials have shown that the administration of inhibitors of NO synthesis to patients with septic shock is associated with a greater incidence of shock resolution, without significant adverse effects. The recent discovery of the different biological functions of NO, both under normal and inflammatory conditions, has allowed the development of new concepts about the pathophysiology of septic shock, and has provided the bases to design novel therapeutic strategies for the treatment of septic shock, based on the inhibition of NO synthesis.

Epidemiology of children's fractures.

Fractures constitute 10% to 25% of all pediatric injuries and are more common in boys than in girls, and after age 13 or 14 years are twice as common. The results from an epidemiologic study in Malmö indicate that a child's risk of sustaining a fracture is 42% in boys and 27% in girls from birth to age 16 years. Fractures of the distal end of the radius are the most common injury, followed by fractures of the phalanges of the hand. From 1950 to 1979 there was a twofold increase in the risk of fracture, due to an increase in light-energy trauma, mainly sporting activities. Since the end of the 1970s there has been no further increase in the fracture risk. The data also indicate that preventive measures have been effective in decreasing severe accidents.