Exploring the role of milk yield in the first week of lactation on the association between hyperketonemia and reproductive performance in dairy cattle.

The objective of this retrospective cohort study was to investigate whether the association of hyperketonemia (HYK) with reproductive performance differs based on milk production during the first week of lactation (wk 1). Data between calving and 150 d in milk (DIM) from 2,091 Holstein dairy cows from 5 commercial dairy herds in Minnesota were collected. The concentration of ß-hydroxybutyrate (BHB) was measured twice between 3 and 10 DIM in whole blood to diagnose HYK (defined as BHB ≥1.2 mmol/L). The average wk 1 milk yield was classified into 3 levels (low = lower 25th percentile; mid = 25th to 75th percentile; high = upper 75th percentile) according to parity and herd. Log-binomial regression, Cox-proportional hazard regression, and linear regression models were used to investigate the association of HYK with pregnancy to first insemination, pregnancy by 150 DIM, and calving-to-conception interval (CCI) between groups, respectively. To describe the differences in these estimates between each wk 1 milk yield level, an interaction term of HYK and stratified levels of wk 1 milk yield was added. The incidence of HYK between 3 to 10 DIM was 14.2% (4.6% in primiparous cows and 19.4% in multiparous cows). In the study population, the effect of HYK on reproduction was greater in cows with low milk yield. Among cows with low milk yield levels, HYK was associated with lower risk of pregnancy to first insemination [risk ratio = 0.62; 95% confidence interval (CI): 0.39-0.98], lower risk of pregnancy up to 150 DIM (hazard ratio = 0.70; 95% CI: 0.51-0.96), and extended days of CCI (mean difference = 13.0; 95% CI: 5.1-20.9). In contrast, among cows with mid and high wk 1 milk yield levels, hyperketonemic (HYK+) cows had a similar reproductive performance to non-HYK (HYK-) cows. Our results suggest that early-lactation milk yield plays a role in the association of hyperketonemia with reproductive performance. These results merit further investigation to determine the role that early milk yield has in the association of hyperketonemia with health and productivity outcomes.

Proteogenomic analysis in an early onset diffuse gastric cancer patient revealed alterations in PIK3R1, TP53, SMAD4 and a potential role of the PI3K-AKT and EGFR pathways: a case report.

Background: Early-onset gastric cancers (EOGC) are poor prognosis hard-to treat malignancies that affect young individuals (<45 years old). Case Description: Herein we describe the case of a 26-year-old female EOGC patient that initially displayed stable disease after first-line CAPOX plus immunotherapy. However, patient eventually developed progressive disease and was consecutively switched to paclitaxel plus ramucirumab, and palliative irinotecan. In search for therapeutic alternatives a proteo-genomic analysis was performed in a tissue biopsy taken after the first progression. Our analyses found a total of 18 somatic mutations, including TP53 and PIK3R1, and a previously unreported germline alteration in the tumor suppressor SMAD4. Also, our proteomic analysis found 62 proteins previously documented as "enriched in stomach cancer" and AKT/mTOR and EGFR as pathways with therapeutic potential. Unfortunately, the clinical utility of AKT/mTOR inhibitors or EGFR targeted therapies could not be assessed. Conclusions: As explained above EOGC is a growing health concern that affects young individuals. Furthermore, the reported case displayed a poor response to standard therapy including checkpoint inhibitors and chemotherapy despite the presence of biomarkers that predict a favorable outcome. Future studies should adopt alternative approaches to find novel, more effective therapies.

Assessment of milk yield and composition, early reproductive performance, and herd removal in multiparous dairy cattle based on the week of diagnosis of hyperketonemia in early lactation.

The purpose of this retrospective cohort study was to evaluate the effects of the timing of hyperketonemia (HYK) diagnosis during early lactation on milk yield and composition, reproductive performance, and herd removal. Plasma ß-hydroxybutyrate (BHB) was measured twice a week during the first 2 wk of lactation in 362 multiparous Holstein cows for the diagnosis of HYK. In each week, cows were diagnosed as HYK positive (HYK+) if the plasma BHB concentrations were ≥1.2 mmol/L in at least one of the tests for the week evaluated. Milk-related outcomes (first 10 monthly milk tests) included milk yield, milk fat and protein content, milk urea nitrogen (MUN), and linear score of somatic cell count. Other performance outcomes of interest included risk of pregnancy within 150 d in milk (DIM) and herd removal (i.e., culling or death) within 300 DIM. Statistical models were built separately for cows diagnosed with HYK during the first week of lactation (wk1) and for cows diagnosed during the second week of lactation (wk2). All models for wk2 were adjusted by HYK diagnosed in wk1, along with other potential confounder variables. The association between HYK in each week and milk-related outcomes was assessed using generalized estimated equation models that accounted for repeated measures. Time to pregnancy and time to herd removal were analyzed using Cox's proportional hazard regression models. Seventy-eight cows (21.5%) tested positive for HYK during wk1, 60 cows (16.6%) in wk2, and 29 cows (8.0%) in both weeks. Hyperketonemia during wk1 was associated with a milk yield reduction of 3.7 kg [95% confidence interval (CI): -6.67 to -0.76] per cow per day throughout the lactation. Meanwhile, we did not observe evidence of an association between HYK diagnosed during wk2 and milk yield. During the first 2 monthly milk tests, cows diagnosed as HYK+ in wk1 had greater fat (0.42%; 95% CI: 0.16 to 0.67) and MUN (0.75 mg/dL; 95% CI: 0.26 to 1.24) content in milk than HYK-negative (HYK-) cows. We did not detect any evidence of an association between HYK diagnosed in wk2 and these outcomes. The HYK+ cows in wk1 had a 30% [hazard ratio (HR) = 0.70; 95% CI: 0.48 to 1.01] lower risk of pregnancy within 150 DIM and 2.48 times (95% CI: 1.63 to 2.89) higher risk of herd removal within 300 DIM than HYK- cows. Conversely, no evidence of association was observed between HYK+ cows in wk2 and risk of pregnancy by 150 DIM (HR = 0.98; 95% CI: 0.64 to 1.51) or removal from the herd within 300 DIM (HR = 0.91; 95% CI: 0.52 to 1.60). Our findings indicate that HYK diagnosed during wk1 of lactation is associated with negative performance in terms of milk yield, reproduction, and herd removal. No evidence of association was found for the same outcomes when HYK was diagnosed in wk2. Our results suggest the need to consider the timing when HYK is diagnosed when investigating its association with performance outcomes.

Mutational Landscape and Actionable Target Rates on Advanced Stage Refractory Cancer Patients: A Multicenter Chilean Experience.

Major advances in sequencing technologies and targeted therapies have accelerated the incorporation of oncology into the era of precision medicine and "biomarker-driven" treatments. However, the impact of this approach on the everyday clinic has yet to be determined. Most precision oncology reports are based on developed countries and usually involve metastatic, hard-to-treat or incurable cancer patients. Moreover, in many cases race and ethnicity in these studies is commonly unreported and real-world evidence in this topic is scarce. Herein, we report data from a total of 202 Chilean advanced stage refractory cancer patients. Retrospectively, we collected patient data from NGS tests and IHC in order to determine the proportion of patients that would benefit from targeted treatments. Overall >20 tumor types were included in our cohort and 37% of patients (n = 74) displayed potentially actionable alterations, including on-label, off-label and immune checkpoint inhibitor recommendations. Our findings were in-line with previous reports such as the cancer genome atlas (TCGA). To our knowledge, this is the first report of its kind in Latin America delivering real-world evidence to estimate the percentage of refractory tumor patients that might benefit from precision oncology. Although this approach is still in its infancy in Chile, we strongly encourage the implementation of mutational tumor boards in our country in order to provide more therapeutic options for advanced stage refractory patients.

Characterization of Agfa Structurix series D4 and D3sc x-ray films in the 0.7-4.6 keV energy range.

X-ray films remain a key asset for high-resolution x-ray spectral imaging in high-energy-density experiments conducted at the National Ignition Facility (NIF). The soft x-ray Opacity Spectrometer (OpSpec) fielded at the NIF has an elliptically shaped crystal design that measures x rays in the 900-2100 eV range and currently uses an image plate as the detecting medium. However, Agfa D4 and D3sc x-ray films' higher spatial resolution provides increased spectral resolution to the data over the IP-TR image plates, driving the desire for regular use of x-ray film as a detecting medium. The calibration of Agfa D4 x-ray film for use in the OpSpec is communicated here. These calibration efforts are vital to the accuracy of the NIF opacity measurements and are conducted in a previously un-studied x-ray energy range under a new film development protocol required by NIF. The absolute response of Agfa D4 x-ray film from 705 to 4620 eV has been measured using the Nevada National Security Site Manson x-ray source. A broader range of energies was selected to compare results with previously published data. The measurements were taken using selected anodes, filters, and applied voltages to produce well-defined energy lines.

Atención en domicilio de pacientes NANEAS: experiencia del hospital de niños Dr. Roberto del Río / Home care of NANEAS patients: experience of the children's hospital Dr. Roberto del Río

El avance de las tecnologías de soporte vital ha aumentado la sobrevida de niños con patologías y secuelas graves, categorizados como NANEAS (Niños y Adolescentes con Necesidades Especiales de Atención en Salud) de mediana y alta complejidad. En el Hospital de Niños Dr. Roberto del Río se organizó un equipo de atención para NANEAS en 2014, que realiza visitas domiciliarias desde 2015 a pacientes médicamente complejos. OBJETIVO: Caracterizar la población atendida en domicilio y la modalidad de atención. PACIENTES Y MÉTODO: Estudio retrospectivo descriptivo mediante revisión de registro clínico electrónico y ficha clínica de NANEAS atendidos en domicilio del 2015 al 2018. RESULTADOS: Se analizaron 581 visitas a 81 pacientes, mediana 8 años, 78% hombres, 64% institucionalizados, 78% con patología neurológica de base, 75% de alta y mediana complejidad según clasificación SOCHIPE. De las visitas, 71% fue en comunas rurales, la mediana de tiempo de viaje 60 minutos y de atención 26 minutos. Un 60% de las visitas se realizó a pacientes con dispositivos médicos. En un 99% asistió pediatra, 33% enfermera y 68% otro profesional, que en 61% correspondió al neuropediatra. CONCLUSIONES: La mayor proporción de pacientes atendidos son de alta y mediana complejidad, usuarios de dispositivos médicos y la mayoría con patología neurológica de base, por lo que resulta fundamental contar con un neurólogo en el equipo interdisciplinario. Las visitas se realizan principalmente a comunas distantes por la dificultad de traslado de estos pacientes. Esta modalidad de atención promueve una mejor calidad de vida para niños y niñas médicamente complejos y para sus familias.

The advancement of life support technologies has increased the survival of children with serious pathologies and sequelae, categorized as NANEAS (Children and Adolescents with Special Health Care Needs) of medium and high complexity. At the Hospital de Niños Dr. Roberto del Río, a care team for NANEAS was organized in 2014, which has made home visits to medically complex patients since 2015. OBJECTIVE: To characterize the population attended at home and the care modality. PATIENTS AND METHOD: Retrospective descriptive study by reviewing the clinical file of NANEAS patients seen at home in this period. RESULTS: 581 visits were analyzed in 81 patients, median 8 years, 78% men, 63% institutionalized, 78% with neurological diseases. 75% were of high and medium complexity according to the SOCHIPE classification. Of the visits, 71% were in rural places, median travel time 60 minutes and direct attention 26 minutes. 60% of the visits were made to patients with medical devices, 99% attended by a pediatrician, 33% a nurse and 68% another professional, who in 61% corresponded to the child neurologist. CONCLUSIONS: The highest proportion of patients seen are of high and medium complexity with medical devices and with underlying neurological pathology, so it is important to have a neurologist in the interdisciplinary team. Many of the visits are made in places distant from the hospital center due to the difficulty of transferring these patients. This modality of care promotes a better quality of life for medically complex children and their families.

Diagnostic accuracy of a bovine specific electronic beta-hydroxybutyrate handheld meter in fresh blood and stored serum samples.

This study aims to evaluate the diagnostic accuracy of the bovine specific beta-hydroxybutyrate (BHB) meter Nova Vet (NVET). We evaluated the accuracy and agreement of the NVET in fresh blood and thawed serum with the reference laboratory assay; and the repeatability, the interference by anticoagulants, and the optimum slope calibration factor. Individual blood samples were collected from 200 Holstein and crossbred cows between 3 and 14 days post-calving from 13 dairy herds in Minnesota. Using a laboratory assay with a cut point of 1.2 BHB mmol/L hyperketonemia prevalence was 10.6% (95% CI: 6.7, 15.8). The sensitivity of NVET in blood and serum was 100.0% while the specificity was 98.3 and 97.7% respectively. The agreement between NVET and the laboratory assay was the highest using blood samples (concordance correlation coefficient -CCC = 96.2, 95% CI: 95.0, 97.1. The coefficient of variation including within day (intra-meter), between- days, and -batches was 13.4% when testing blood samples. Minimal interference was observed with the use of anticoagulants (K-EDTA and Li-Heparin, CCC 0.90 and 0.93 respectively) in reference to whole blood without anticoagulant. The best calibration slope factor in serum was 1.0 (Youden's index: 0.98). Results suggest that the NVET device maintained a high accuracy and precision to quantified BHB concentration when applied in fresh blood and thawed serum under field conditions using the default calibration slope (1.0), and with minimal anticoagulant interference when used in whole blood samples.

Association between hoof lesions and fertility in lactating Jersey cows.

The objectives of this study were to evaluate the association between hoof lesions and fertility in dairy cows. Lactating Jersey cows (n = 1,639) were enrolled at 20 ± 3 d in milk (D20), examined and treated for presence of hoof lesions (HL), and evaluated for body condition score (BCS). Afterward, they were managed according to standard farm procedures, including estrus detection and presynchronization and a 5 d Cosynch-72 protocol for cows that failed to show estrus. Ovaries were scanned at 27 and 41 ± 3 d in milk, and cows with a corpus luteum greater than 20 mm on at least 1 exam were considered cyclic. At 120 ± 3 d in milk (D120), cows were re-examined for HL and BCS. Cows were classified at D20 according to HL status as healthy (n = 1,197) or having HL (n = 429), and according to HL category as healthy (n = 1,197) or having a sole hemorrhage (n = 280), noninfectious HL (sole ulcer, toe ulcer, or white line disease; n = 113), or infectious HL (digital dermatitis and foot rot; n = 36). Cows with HL at D20 had reduced odds of being cyclic (38.3 vs. 51.9%) and a longer interval from calving to first service (58 vs. 51 d) compared with healthy cows. Cows with infectious HL at D20 had reduced odds of pregnancy to first service (16.7 vs. 38.3%) compared with healthy cows. Cows with sole hemorrhage at D20 were more likely to lose pregnancies between d 32 and 64 after the first service postpartum compared with healthy cows (10.5 vs. 5.2%). Cows with sole hemorrhage at D20 had a smaller hazard of pregnancy (67.9 vs. 75.5%) at 150 d in milk and more days open (88 vs. 77d) compared with healthy cows. To assess the relationship between the development of HL and fertility, cows were classified as healthy (no HL at D20 and D120; n = 308), cured (any HL at D20 and no HL at D120; n = 72), new HL (no HL at D20 and any HL at D120; n = 597), and chronic (any HL at D20 and D120; n = 226). Sole hemorrhage accounted for 93% of new HL. The proportions of cows with HL at D20 and D120 were 26.9 and 68.4%, respectively. We found no evidence for a difference in pregnancy hazard at 150 d in milk between cows that remained healthy (n = 308) and cows that developed new HL (n = 597). Hoof lesions at D20, but not new HL, were associated with decreased odds of cyclicity, longer interval from calving to first service postpartum, and reduced pregnancy hazard in Jersey cows. The effect of an HL diagnosis in early lactation and management to reduce chronic HL in dairy cows warrants further investigation.

Angioleiomiosarcoma de clítoris. Presentación de caso / Clitoral angio-leiomyosarcoma: Case report

El carcinoma vulvar es una entidad poco frecuente; representa el 3-5% de los tumores genitales malignos en la mujer. El 90% de ellos corresponden a carcinomas epidermoides, seguidos de los melanomas, enfermedad de Paget, enfermedad de Bowen, carcinomas basales y sarcomas. El leiomiosarcoma es la forma de presentación más frecuente de este último grupo. Se presenta un caso de una mujer adulta joven, 29 años, mestiza, que acude con una tumoración a nivel del clítoris, con el antecedente de exéresis de una tumoración benigna a nivel del labio mayor 3años antes. La lesión se mostraba móvil, ulcerada, muy dolorosa y sin adenopatías locales ni regionales. Se procede a la escisión total de la lesión y el estudio histológico informó un angioleiomiosarcoma de clítoris. Se envía el caso a Instituto de Oncología para confirmación diagnóstica y terapéutica, confirmándose el diagnóstico y la terapéutica. En 2años la paciente no ha tenido recidiva tumoral

Vulvar carcinoma is rare, and represents 3-5% of the all gynaecological cancers. Epidermoid carcinoma accounts for 90% of them, followed by melanoma, Paget́s disease, Boweńs disease illness, basal carcinoma and sarcomas. The leiomyosarcoma is the most frequent type of sarcoma. The case is presented of a 29 year-old woman that suffered from clitoral tumour. She was treated for a benign lesion in the labia majora 3years ago. In the current referral, she presented with pain and an ulcerated lesion, without local or regional adenopathies. The total excision was referred for a histological study, and the results showed an angio-leiomyosarcoma of the clitoris. Two years later, the patient showed no signs of residual lesion

Factores pronóstico de mortalidad asociados al síndrome deinsuficiencia respiratoria aguda por ventilación mecánica

RESUMEN: Se realizó una investigación descriptiva, de serie de casos, de 31 pacientes ingresados en la Unidad de Cuidados Intensivos del Hospital Provincial Docente Clinicoquirúrgico“Saturnino Lora Torres” de Santiago de Cuba, de enero de 2014 a igual mes de 2017,quienes presentaron el síndrome de insuficiencia respiratoria aguda, con vistas a describir los factores pronóstico de mortalidad por esta causa. En la serie predominaron el sexo masculino, la edad promedio de 57 años y la hipertensión arterial como enfermedad crónica asociada. La mayoría de los pacientes recibía ventilación mecánica previa al diagnóstico, en la modalidad controlada por volumen, y en un menor número se aplicaron maniobras de incorporación alveolar. La insuficiencia respiratoria moderada de causa extrapulmonar figuró en pacientes con ventilación prolongada, en tanto la complicación más frecuente fue la disfunción multiorgánica, que además resultó la principal causa de muerte. Finalmente, no se encontró relación directa entre la presencia de estos factores pronóstico de mortalidad y la probabilidad de fallecer.[AU]

Manejo anestésico en una mujer con malformación de Arnold-Chiari tipo II residual / Anesthetic management in a woman with residual Arnold-Chiari malformation Type II

Background: The Arnold-Chiari malformation (ACM) is a group of congenital abnormalities of the hindbrain and the spinal cord and is characterized by herniation of the cerebellum, kinking of the medulla oblongata and hydrocephalus, the anesthetic management Is complicated due to the anatomic and physiologic alterations. Case description: A 23 years old woman with Arnold-Chiari type II malformation, and perforated appendicitis. Conclusions: The present case demonstrates that patients with partially corrected ACM type II, restrictive lung disease due to scoliosis and perforated appendicitis delivery require an interdisciplinary team approach, diligent preparation, and skilled physicians.

Antecedentes: La malformación de Arnold-Chiari (ACM) es un grupo de anomalías congénitas del cerebro posterior y la médula espinal que se caracteriza por la herniación del cerebelo, retorcimiento del bulbo raquídeo e hidrocefalia, el manejo anestésico se complica debido a la anatomía y alteraciones fisiológicas. Descripción del caso: Una mujer de 23 años con Arnold-Chiari tipo II malformación y apendicitis perforada. Conclusiones: El presente caso demuestra que los pacientes con corregido parcialmente ACM tipo II, enfermedad pulmonar restrictiva debido a la escoliosis y la entrega apendicitis perforada requieren un enfoque multidisciplinario en equipo, preparación diligente, y los médicos cualificados.

Sirolimus (rapamicina) en pacientes con hemangioendotelioma kaposiforme: caso clínico / Sirolimus (rapamycin) in patients with kaposiform hemangioendothelioma: clinical case

Introducción: El hemangioendotelioma kaposiforme (HEK) es un tumor vascular poco frecuente, que se asocia a coagulopatía grave, conocida como fenómeno de Kasabach-Merritt (FKM). Puede ser letal en 20 por ciento de los casos. Se han descrito múltiples tratamientos, pero a pesar de las complicaciones potencialmente severas que pueden presentar estos pacientes, no hay hasta ahora un protocolo único. Existen experiencias internacionales, en modelos experimentales, con el uso de Sirolimus (SRL), macrólido, inhibidor de mTOR, con actividad antiangiogénica. Sin embargo, la experiencia de su uso en niños en el tratamiento de anomalías vasculares como el HEK es limitada. Objetivo: Reportar la evolución de dos pacientes con HEK y FKM tratados con SRL en centros oncológicos, después de múltiples fallas con otras terapias. Casos clínicos: Reportamos dos recién nacidos con HEK profundo asociado a FKM, refractarios a terapias habituales y que evolucionaron con complicaciones amenazantes de la vida, en quienes se inicio tratamiento con SRL. El uso de SRL permitió que los dos pacientes mostraran mejoría en su estado clínico, con normalización del recuento de plaquetas y de las pruebas de coagulación, disminución del tamaño de la lesión, del dolor asociado, desaparición del riesgo vital y sin efectos adversos. Conclusión: SRL parece ser efectivo y seguro en el tratamiento de HEK, representando una nueva opción terapéutica, disponible en nuestro medio.

Introduction: Kaposiform Hemangioendothelioma (KHE) is a rare vascular tumor, which is associated with the severe coagulopathy known as Kasabach-Merritt phenomenon (KMP). This condition has a mortality rate around 20 percent. Many treatments have been described, but despite the potentially severe complications that these patients may present, so far there is not a single protocol to follow. International experimental models have used Sirolimus (SRL), a macrolide mTOR inhibitor with antiangiogenic effect. However, its use in children against vascular anomalies, such as KHE, is limited. Objective: To report the development of two patients with KHE and KMP treated with SRL in cancer centers, after multiple failures with other therapies. Case reports: Two infants with severe KHE associated to FKM, resistant to standard therapies and who overcame life-threatening complications after treatment with SRL are presented. After SRL, the two patients showed normal platelet counts and coagulation tests, reduced lesion size and associated pain, no presence of life threatening conditions or side effects. Conclusion: SRL appears to be effective and safe in treating KHE, representing a new available therapeutic option.

Estimación de prevalencia de niños con enfermedades limitantes de la vida en un hospital pediátrico de alta complejidad / Prevalence of patients with life-limiting conditions in a high complexity pediatric hospital

En Chile fallecen aproximadamente 800 niños menores de 15 años por diversas causas, entre ellas, por enfermedades sin tratamiento curativo. La Sociedad Chilena de Pediatría creó el Comité de Niños y Adolescentes con Necesidades Especiales en Atención de Salud (NANEAS), que entregó las pautas para una atención integral de estos pacientes, incluyendo los cuidados paliativos (CP). Resulta indispensable conocer el número y características de los pacientes que padecen enfermedades limitantes de la vida (ELV) para elaborar programas de atención que prioricen por un cuidado ambulatorio bajo la supervisión de equipos multidisciplinarios. Objetivo: Estimar la prevalencia de pacientes con ELV en un hospital pediátrico de alta complejidad. Pacientes y método: Se revisaron los egresos de las Unidades de Pediatría General y Unidad de Paciente Crítico del Hospital Roberto del Río, durante el 2009 y 2010. Se seleccionaron los casos con diagnósticos de ELV según CIE-10, registrando datos demográficos y clasificándolos según los grupos de la ACT para ELV. Se excluyeron pacientes con cáncer avanzado. Resultados: De 6585 pacientes egresados, 190 tenían diagnóstico ELV (2.89 por ciento). Los lactantes fueron el grupo más numeroso (33 por ciento). El 51,6 por ciento de los pacientes pertenecían al grupo 4 (parálisis cerebral severa, genopatías complejas, TEC con secuelas graves) y todos fueron atendidos por 3 o más especialistas. Conclusión: Los niños con ELV constituyen un grupo emergente entre los pacientes pediátricos hospitalizados, demandando una atención de alta complejidad. Es un desafío implementar políticas públicas que optimicen su manejo y permitan planificar unidades especializadas para su atención, incluyendo los CP.

In Chile, approximately 800 children under the age of 15 years die from a variety of causes, including life-limiting conditions (LLC). The Chilean Society of Pediatrics established a Committee on Children and Adolescents with Special Health Care Needs (NANEAS), which established guidelines for comprehensive care of these patients, including palliative care (PC). It is essential to know the number and characteristics of patients with LLC, in order to develop programs for outpatient care under the supervision of multidisciplinary teams. Objective: To estimate the prevalence of patients with LLC in a high complexity pediatric hospital. Patients and methods: We reviewed the discharges from General Pediatric Units and the Critical Patient Unit at the Roberto del Rio Hospital during 2009 and 2010. We selected patients with LLC according to ICD-10. Their demographic characteristics were registered and classified into the four ACT groups. Patients with advanced cancer were excluded. Results: Of 6585 patients discharged, 190 were diagnosed as LLC (2.89 percent). Infants were the largest group (33 percent). 51.6 percent of patients belonged to group 4 (severe cerebral palsy, genopathies, serious sequelae of traumatic brain injury) and all were attended by at least three specialists. Conclusion: Children with LLC are an emerging group among hospitalized pediatric patients and they are demanding attention of high complexity. It is a challenge to design and implement public policies that can optimize health care for these patients, and facilitate the establishement of specialized units for this purpose, including PC.

Qué síntomas presentan los niños con cáncer avanzado en cuidados paliativos? / Symptoms in childrens with advanced cancer who were attended by the palliative care

El dolor es el síntoma más frecuente y que genera más temor en los pacientes y sus cuidadores en la etapa avanzada de la enfermedad oncológica. Estos niños también presentan otros síntomas que pueden provocar importante malestar y empeorar la sensación dolorosa. En nuestro medio no contamos con información en este ámbito, que permita optimizar el tratamiento de estos pacientes. Objetivo. Caracterizar síntomas distintos del dolor en pacientes con cáncer avanzado, controlados por el equipo de cuidado paliativo (CP) del Hospital Roberto del Río. Pacientes y método. Se revisaron 71 fichas clínicas de pacientes ingresados a CP entre abril de 2002 y diciembre de 2010. Se registraron las características demográficas y los diagnósticos fueron clasificados en leucemia aguda, tumores sólidos y tumores del sistema nervioso central (SNC). Se evaluó un listado de síntomas y sus frecuencias. Resultados. El síntoma más frecuente en los pacientes con leucemia aguda fue fiebre (15 por ciento), al igual que los pacientes con tumores sólidos (16 por ciento). En los pacientes con tumores SNC la alteración de conciencia fue el más frecuente (19 por ciento). Sobre el 70 por ciento de los pacientes tuvieron hasta cuatro síntomas y la evaluación de intensidad en la mayoría fue cualitativa. Conclusiones. Síntomas distintos del dolor son frecuentes y pueden producir gran incomodidad. Evaluarlos objetivamente permitiría un mejor manejo, favoreciendo con esto el control del dolor.

Pain is the most common symptom which generates most fear in patients and their caregivers in the advanced stage of cancer. These children also have other symptoms that can cause significant discomfort and exacerbate the sensation of pain. In Chile, there has been no evaluation of the intensity of these symptoms and their effect on pain, and relevant knowledge could improve patient treatment. Objective: Describe symptoms other than pain in patients with advanced cancer who were attended by the palliative care (PC) team at the Roberto del Rio Hospital. Patients and methods: We reviewed medical records of 71 patients admitted to PC between April 2002 and December 2010. We recorded demographic characteristics and diagnoses were classified into acute leukemia, solid tumors and tumors of the central nervous system (CNS). We evaluated a list of symptoms and their frequencies. Results: The most common symptom in patients with acute leukemia was fever (15 percent) as well as in patients with solid tumors (16 percent). In patients with CNS tumors alteration of consciousness was the most frequent (19 percent). Over 70 percent of patients had four or more symptoms and intensity assessment was mostly qualitative. Conclusions: Besides pain, other symptoms are common and can cause great discomfort. Objective assessment of these symptoms would allow better management of children and also optimize pain control.

Leucemia linfoblástica aguda en pacientes portadores de síndrome de Down / Acute lymphoblastic leukemia in children with Down's syndrome

Background: Children with Down's Syndrome (DS) present a higher incidence of Acute Lymphoblastic Leukemia (ALL) with more complications and shorter survival than healthy children. Objective: To describe clinical characteristics, laboratory and treatment results in patients with DS and ALL. Patients and Method: Retrospective analysis of 42 DS and ALL patients treated in three consecutive trials (1992,1996,2002) from the Pediatric National Cancer Program (PINDA). Clinical data, immunophenotype, cytogenetics and treatment results were analyzed. Results: There was no difference by age or gender, no patient presented LLA-T, t (9;22) o t (4;11). Of the 42 patients, 38 patients went into remission, 10 relapsed (26,3 percent, 11 died because of infection, none died from other toxicity. Survival at 5 years was 35 +/- 9 percent (median of follow-up was 50 mo), similar for all protocols (p = 0,61). Conclusion: The group of patients with ALL and DS evaluated was not associated with classic treatment resistance factors. The relapse rate was not increased, if compared with non DS ALL patients; in this group the infections were the determinant factor for a lower survival. These patients can be treated with the current trials but they require a detailed infection care.

Los niños con Síndrome de Down (SD) tienen mayor incidencia de leucemia linfoblástica aguda (LLA) con más complicaciones y menor sobrevida que los niños sin SD. Objetivo: Describir características clínicas, de laboratorio y resultados de tratamiento en niños con SD y LLA. Pacientes y Método: Análisis retrospectivo de 42 pacientes con LLA y SD tratados en 3 protocolos consecutivos (1992, 1996 y 2002) del Programa Nacional de Cáncer Infantil (PINDA). Se analizaron datos clínicos, de laboratorio, inmunofenotipo, citogenética y resultados de tratamiento. Resultados: La distribución por género o grupo etario no mostró diferencias, ningún paciente presentó LLA-T, t (9;22) o t (4;11). De los 38 pacientes que remitieron, 10 recayeron (26,3 por ciento), fallecieron por infección 11/42 (26,2 por ciento). Ninguno falleció por otra toxicidad. La sobrevida libre de eventos global a 5 años fue 35 +/- 9 por ciento (mediana de seguimiento 50 meses), siendo similar en los diferentes protocolos usados (p = 0,61). Conclusión: Los pacientes evaluados con SD y LLA no presentaron factores clásicos de resistencia a tratamiento. No se observó mayor frecuencia de recaída respecto a los pacientes con LLA sin SD y la menor sobrevida en este grupo fue determinada por infecciones. Estos pacientes pueden ser tratados con los protocolos actuales pero requieren un manejo precoz e intensivo de las infecciones.

Improved characterisation of aortic tortuosity.

Tortuosity can be described as the variation in blood vessel curvature. Abnormal tortuosity is an important clinical indicator of various conditions. Despite considerable research, there has been very little agreement on an accurate, unique measure of this phenomenon for clinical applications. It has been demonstrated that a single value is insufficient to describe vessel tortuosity. In this work, the fast Fourier transform of the vessel's curvature as a measure of tortuosity is introduced. Spectral analysis of a suite of computed-simulated vessels, a phantom and clinical data is carried out. Observation of the acquired spectra permits detection of the local curvature variations. Spectral analysis of curvature provides a compact and graphic representation of tortuosity. This paper also describes two new highly automated MATLAB algorithms for obtaining the vessel centrelines: a heuristic image processing algorithm, and an algorithm based on the probabilistic Hough transform. We demonstrate the accuracy of both algorithms comparing with a manual method to extract the vessel centreline. Both algorithms reduce potential errors and user time and only require the manual selection of one centroid.