Angioqueratoma solitario de lengua en una niña de 7 años / Solitary angiokeratoma of the tongue in a girl 7 years old

Los angioqueratomas son malformaciones vasculares, caracterizadas por ectasias vasculares en la dermis papilar con hiperplasia epitelial e hiperqueratosis reactiva, que pueden aparecer de manera aislada o como forma sistémica generalizada asociados a enfermedades metabólicas. El angioqueratoma solitario de mucosa oral es una lesión poco frecuente, que hasta la comunicación de Sipponen, en 2006, se creía siempre típica de las formas sistémicas y muy rara en las localizadas. Su aparición en la infancia es, asimismo, poco frecuente, habiéndose descrito hasta la fecha sólo 5 casos en menores de 18 años, aunque algunos autores señalan que puede tratarse de una enfermedad infradiagnosticada de ahí la importancia de su adecuado estudio y diagnóstico. Presentamos el caso de una paciente de 7 años de edad, con una lesión rojiza en el dorso de la lengua, no dolorosa, sin antecedente traumático, en cuyo examen físico se observó una lesión de 14 mm de diámetro en el borde derecho de la lengua, con múltiples pápulas eritematosas, sin apreciarse otros cambios en la mucosa oral. Se realizó una extirpación bajo anestesia general, y el diagnóstico se verificó por examen histopatológico de la pieza extirpada (AU)

Angiokeratomas are vascular malformations characterized by vascular ectasia in the papillary dermis with reactive epithelial hyperplasia and hyperkeratosis, which can occur in isolation or as widespread systemic form associated with metabolic diseases. The solitary angiokeratoma of the oral mucosa is a rare injury, which to Sipponen communication in 2006, always believed typical of systemic forms and very rare in localized. Its occurrence in childhood is likewise rare, having been described to date only 5 cases in children under 18, although some authors suggest that this may be an underdiagnosed disease, hence the importance of adequate study and diagnosis. We report a 7 years with a reddish lesion on the dorsum of the tongue, no pain, no history of trauma, in which physical examination showed a lesion of 14 mm in diameter in right right edge of the tongue with multiple erythematous papules, showing no other changes in the oral mucosa. Excision was performed under general anesthesia and the diagnosis was verified by histopathological examination of the resected specimen (AU)

[Analysis of the medical decision in abdominal pain suggestive of acute appendicitis]. / Análisis de la decisión médica en el dolor abdominal sugerente de apendicitis aguda.

OBJECTIVES: Application of the theorem of Bayes for the study of the usefulness of complementary quantitative and qualitative assessment of the effectiveness of ultrasound diagnosis in order to provide the clinician with a tool to accurately assess the effectiveness of these tests in diagnosing abdominal pain appendix subject box. METHODS: Retrospective cohort of 184 patients treated from January 2009 to June 2010 for abdominal pain suggestive of acute abdomen, of which 145 were operated. Were established as predictors of appendiceal disease abdominal exploration, ultrasonography and plasma levels of CRP and leukocytes. The statistical methodology developed by the systematic Bayesian prior determination of ROC curve and calculation of odds and post-test probability as pretest probability based on physical examination. RESULTS: The ROC analysis cut-points set of quantitative tests on the values of WBC >12,800 and CRP >1.8 mg/dl. Applying the model to the white cell count increased clinical certainty of this test in 11.3 points and 13.9 PCR. The combined use of both the index rose 32 points. The effectiveness of ultrasound method showed a statistically significant 94% and an increase in diagnostic certainty of 48 points. DISCUSSION: It is recommended to base the development of protocols and clinical guidelines in practice of test ultrasound as first, and joint determination of inflammatory markers, when that was questionable or negative. Further studies are proposed to increase the clinical certainty to reduce laparotomy white and diagnostic delays in this condition.

Análisis de la decisión médica en el dolor abdominal sugerente de apendicitis aguda / Analysis of the medical decision in abdominal pain suggestive of acute appendicitis

Objetivos. Aplicación del teorema de Bayes al estudio de la utilidad de las pruebas complementarias cuantitativas, y valoración cualitativa de la efi cacia del diagnóstico ecográfi co, con objeto de dotar al clínico de una herramienta para evaluar con exactitud la efectividad de dichas pruebas en el diagnóstico del dolor abdominal susceptible de cuadroapendicular. Método. Cohorte retrospectiva de 184 pacientes atendidos desde enero 2009 a junio 2010 por dolor abdominal sugestivo de abdomen agudo, de los que 145 fueron intervenidos. Se fijaron como variables predictoras de enfermedad apendicular la exploración abdominal, la ecografía y los valores plasmáticos de PCR y leucocitos. La metodología estadística se desarrolló según la sistemática bayesiana, previa determinación de curva ROC, y cálculo de momios y probabilidades postprueba, según la probabilidad preprueba basada en la exploración física. Resultados. El análisis ROC fi jó los puntos de corte de las pruebas cuantitativas en valores de leucocitos >12.800 y PCR >1,8 mg/dl. La aplicación del modelo al contaje leucocitario aumentó la certidumbre clínica de esta prueba en 11,3 puntos y de la PCR en 13,9. El uso combinado(..) (AU)

Objectives. Application of the theorem of Bayes for the study of the usefulness of complementary quantitative and qualitative assessment of the effectiveness of ultrasound diagnosis in order to provide the clinician with a tool to accurately assess the effectiveness of these tests in diagnosing abdominal pain appendix subject box. Methods. Retrospective cohort of 184 patients treated from January2009 to June 2010 for abdominal pain suggestive of acute abdomen, of which 145 were operated. Were established as predictors of appendice aldisease abdominal exploration, ultrasonography and plasma levels of CRP and leukocytes. The statistical methodology developed by the systematic Bayesian prior determination of ROC curve and calculation of odds and post-test probability as pretest probability based on physical examination. Results. The ROC analysis cut-points set of quantitative tests on the values of WBC >12,800 and CRP >1.8 mg/dl. Applying the model to the white cell count increased clinical certainty of this test in 11.3points and 13.9 PCR. The combined use of both the index rose 32 points. The effectiveness of ultrasound method showed a statistically significant (..) (AU)

Hormonal response to surgical stress in schoolchildren.

PURPOSE: To determine hormone concentrations (ACTH, cortisol, beta-endorphin) in children before and after surgery, to assess the correlation between any hormonal changes and to study the influence exercised on them by the severity of surgical stress and the elective/emergency nature of the surgery. PATIENTS AND METHODS: Prospective cohort of 78 children (age= 10+/-2.6 years, range 6-13 years) undergoing elective or emergency surgery. Preoperative and postoperative (1 and 24 hours postoperation) plasma concentrations of ACTH, cortisol and beta-endorphin were determined in all children. The severity of surgical stress was evaluated as low (< 6) or high (> 6) according to the Oxford scale. Student's t-test was used to analyse hormonal changes and the influence of degree of surgical stress and elective/emergency character of the surgery, and Pearson's coefficient for correlations between hormonal values. p < 0.05 was regarded as significant. RESULTS: We observed a significant increase in hormonal concentrations one hour after surgery. ACTH and cortisol values normalised 24 hours after surgery, but beta-endorphin concentrations remained increased. There was a correlation between ACTH and beta-endorphin values both before surgery and one hour after. Operations with high surgical stress significantly increased cortisol concentrations one hour after surgery and beta-endorphin concentrations 24 hours after surgery. Patients selected for emergency surgery showed significantly higher concentrations of cortisol and ACTH both before and after surgery. CONCLUSIONS: Postoperative hormonal response among children of school age is characterised by increases in ACTH, cortisol and beta-endorphin one hour after surgery, and by high concentrations of beta-endorphin 24 hours after surgery. Cortisol is an index of surgical stress. Emergency surgery is associated with significant increases in ACTH and cortisol.

Estrés quirúrgico y activación hipófiso-suprarrenal en edad pediátrica / Surgical stress and hipophysal-suprarrenal, activation in the paediatric age

Introducción. El estudio de las alteraciones fisiológicas secundarias a la agresión quirúrgica (estrés quirúrgico), ampliamente desarrollado en pacientes adultos, se halla aún por delimitar con precisión en la edad pediátrica. El objetivo del presente trabajo de investigación es la cuantificación del estrés quirúrgico en niños (evaluado según la escala de Oxford en bajolalto en valores inferiores o superiores a 6) mediante las modificaciones de los niveles plasmáticos de hormona adrenocorticotropa (ACTH),13-endorfina y cortisol en niños. Pacientes y métodos. Estudio observaeional analítico tipo cohorte prospectiva con comparación interna de grupos expuestos. Treinta y tres pacientes sometidos a intervención quirúrgica (edad 10 ñ 2,6; rango 514). Variables resultado: concentraciones plasmáticas de ACTH,13-endorfina y cortisol determinadas pre y postoperatoriamente (1 y 24 horas tras la intervención), mediante técnicas de radioinmunoanálisis. Resultados. Elevación significativa (p < 0,05) a la hora de la intervención de las tres hormonas consideradas con descenso a valores preoperatorios a las 24 horas de la intervención. Relación significativa de la concentración de la beta-endorrma (a la hora 24 postoperación) y del cortisol (una hora postoperación), con el grado de estrés quirúrgico. Conclusiones. La cirugía en el niño activa el eje hipófiso-suprarrenal, recuperando la normalidad precozmente a las 24 horas de la intervención. Existe un patrón específico de comportamiento de la f3-endorfina, pudiéndose afirmar que ésta es una 'hormona de estrés' en cuanto que refleja el impacto de la agresión quirúrgica. El cortisol se muestra como índice fiable de la cuantía del estrés quirúrgico (AU)

Absceso pulmonar en la infancia sobre malformación congénita subyacente / Childhood lung abscess associated with an underlying congenital malformation

En la actualidad el absceso pulmonar en la infancia constituye una entidad de baja frecuencia, debido a los avances producidos en el campo de la antibioticoterapia y a un tratamiento más precoz de sus factores predisponentes. El presente trabajo describe 3 casos diagnosticados en un periodo de 15 años, tratados con éxito mediante intervención quirúrgica (lobectomía de la zona afectada). Todos y cada uno de los casos asentaban sobre una patología malformativa congénita de base, como puso de manifiesto el examen histopatológico de la pieza resecada. Se pone énfasis en la necesidad de sospechar y tratar quirúrgicamente dicha patología malformativa pulmonar ante todo caso de absceso pulmonar recidivante y resistente a tratamiento médico (AU)

Metaanálisis cáncer-criptorquidia / Meta-analysis cancer-cryptorchidism

Introducción. La aparición de cáncer testicular en pacientes jóvenes o adultos afectos de criptorquidia (intervenidos o no) es un hecho clínicamente constatado, pero cuya importancia epidemiológica (en términos de profilaxis del cáncer y/o revisión terapéutica basados en datos cuantitativos poblacionales) no ha sido definida en la actualidad. Objetivo. Determinación mediante la técnica de metaanálisis cuantitativo de la fuerza de la asociación (cálculo de riesgo relativo = RR) cáncer-criptorquidia y mediante metaanálisis cualitativo de los factores de criptorquidia (posición anatómica del teste, edad intervención, biopsia) asociados a la aparición de cáncer. Resultados. Han sido incluidos para el cálculo del riesgo relativo los estudios de cohortes y caso-control extraídos de la literatura, habiéndose concluido que el riesgo relativo de padecer cáncer un paciente criptorquídico es 7,75 veces superior al control no criptorquídico (intervalo de confianza: 5,2-10,3). El metaanálisis cualitativo de los factores de criptorquidia estudiados arrojó una relación significativa entre la aparición de cáncer y la posición abdominal del teste, así como la intervención en edad posterior a los 10 años. Asimismo, la biopsia elevaba significativamente la potencial malignización del teste criptorquídico. Conclusiones. Se vuelve a constatar la asociación cáncer-criptorquidia por su RR superior a la población normal, aunque con cifras cuya escasa importancia epidemiológica no aconsejería cambio de actitud terapéutica, a la espera de resultados definitivos sobre los datos no ponderables, sobre todo en situaciones de teste intra-abdominal y diagnóstico posterior a los 10 años de edad. Se recomienda la no realización de biopsias, a menos que su indicación sea incuestionable, y se sugiere la realización de estudios amplios de carácter prospectivo, con estrategia de análisis multivariante que integrara todos los factores enumerados en esta aportación (AU)

[Cancer-cryptorchism meta-analysis]. / Metaanálisis cáncer-criptorquidia.

INTRODUCTION: Testicular cancer in adult and young patients with cryptorchidism (operated or not operated on) has been reported previously, but its epidemiological impact (as concept to profile cancer and/or therapeutical result of cryptorchidism based on quantitative dates) is not defined actually. OBJECTIVE: Determination by quantitative meta-analysis of the strength of relation (relative risk = RR) cancer and cryptorchidism and by qualitative meta-analysis of factors of cryptorchidism (anatomical position of teste, age of intervention, testicular biopsy) associated to cancer. RESULTS: Case-control and cohort studies of medical literature have been included in this report. Relative risk of develop cancer in the patient with cryptorchidism is 7.75 more than poblational control without cryptorchidism (interval of confiance: 5.2-10.3). Qualitative meta-analysis of factors concluded that there is a significative relation cancer and abdominal position of teste, and also age of intervention after 10 and testicular biopsy. CONCLUSIONS: Significative relation between cancer and cryptorchidism with relative risk above control population is constated again, although with dates without epidemiological importance. But significative relation among cancer with abdominal testes and intervention after 10 years would recommend prospective studies, with strategy of multivariant analysis. Authors recommend not to make testicular biopsy, except if its indication is not questionable.

[Surgical stress and hypophyseal-adrenal activation in childhood]. / Estrés quirúrgico y activación hipófiso-suprarrenal en edad pediátrica.

INTRODUCTION: The study on the physiological alterations due to surgical aggression (surgical stress), widely investigated in adults, is less known in paediatric age. THE OBJECTIVE: Of this work is to quantify surgical stress (evaluated by means of Oxford Scale as high or low depending on its value bigger or lower than 6), after determining changes of plasmatic concentrations of ACTH, beta-endorphin and cortisol in operated children. PATIENTS AND METHODS: Observational analytic design of a prospective cohort with internal comparison of the groups. SAMPLE SIZE: 33 (age 10 +/- 2.6 years; range 5 to 14 years). DEPENDENT VARIABLES: plasmatic concentrations of ACTH, beta-endorphin and cortisol determined before and after the intervention (1 and 24 hours after surgery), by radio-immune-analysis. RESULTS: Significative increase of the three considered hormones one hour after surgery, with decrease of them until preoperative levels 24 hours later. Significative correlation between beta-endorphin (24 hours after surgery), cortisol (1 hour after surgery) and surgical stress levels. CONCLUSIONS: Surgery in children provokes the activation of hipophysal-suprarrenal system. These levels early came back to normal ones, 24 hours after surgery. There is a specific change in beta-endorphin, that is why it is possible to assure that beta-endorphin is a "stress-hormone", since it is affected by surgical aggression. Cortisol seems to be a good index of level of surgical stress.

[Macrostomia secondary to transverse facial cleft of Tessier No.4]. / Macrostomía secundaria a hendidura facial transversa de Tessier n-0 4.

A case of bilateral macrostomia type transverse facial cleft of Tessier n. 4 is reported, which was operated on with good results when had ten months of age, repaired using suture of three planes of three embryonic folds. A treatment plain precocious is recommended and pathogenic theories about this uncommon entity are exposed.

[The usefulness of ultrasonography in the diagnosis of acute appendicitis in children]. / Utilidad de la ultrasonografía para el diagnóstico de apendicitis aguda en la infancia.

The main objective of the present report was the evaluation of the utility of echography as a diagnostic method in abdominal pain suspicious of acute appendicitis. A control-case study was performed in 165 children hospitalized for abdominal pain. Appendicitis histologically confirmed were considered cases (n = 110) while control (n = 55) were the not-operated patients (46 children) or the not-confirmed appendicitis after laparotomy (n = 9). The variables considered here were: the results of echography (Eco+ when echography showed signs of acute appendicitis: Eco- when not), the age of the patient (randomized at three groups; < 6, 6-9, > 9 years), and the conclusions of fisical exploration (conclusive or not as acute appendicitis). The results were analyzed statistically with the SPSS program, calculating the following predictive values; sensibility, specificity, positive predictive value, negative predictive value. Odds Radio before and after test and the global value of echography. Authors conclude that ultrasonography as method of support to abdominal exploration for diagnostic in acute appendicitis is manifest and present a global value of 70.90%.

Scrotal lymphangioma in children.

The intrascrotal localization of lymphangioma in children is uncommon, especially when the lymphangioma does not depend on testicular structures. We present the case of a 13-year-old male who started with a right intrascrotal mass unconnected with the testicle, clinically and ultrasonically compatible with cystic lymphangioma. The mass was excised because of progressive growth over the previous 5 months, and at surgery a scrotal lymphangioma was disclosed projecting towards the umbilical area through the subcutaneous cell tissue of the anterior abdominal wall. There have been no complications or recurrences to date, 6 months afterwards. Surgical removal is the only efficacious therapeutic approach and is the best way to achieve a definitive diagnosis in these patients.

[Deferred appendectomy in a case of appendiceal mass]. / Apendicectomía diferida en caso de plastrón apendicular.

The treatment of acute appendicitis when appendix is technically impossible to remove, remains controversial. The clinical case of a 12-years-old child diagnosed of acute appendicitis in which appendectomy was not initially performable is presently described. After treatment with antibiotics, he was submitted to appendectomy five months later. Operative and pathologic findings in this second laparotomy prove the predisposition of the patient to a second acute appendicitis, and uphold the preventive attitude, the interval appendectomy.

[Hormonal response and two special techniques of postoperative analgesia in pediatric surgery]. / Respuesta hormonal con dos técnicas distintas de analgesia postoperatoria en cirugía pediátrica.

AIMS: We studied neuroendocrine response in the postoperative pain relief in pediatric patients treated with two analgesic techniques (conventional intravenous analgesia and patient controlled analgesia). MATERIAL AND METHODS: A double blind study was made in 30 patients, 6-14 year-old children, under total intravenous anesthesia for programmed surgery. An intravenous analgesia dose of 0.5 mg/Kg was given 10 minutes before operation was finished. Postoperative analgesia was achieved by two techniques: A. Patient controlled analgesia (PCA), and B. Conventional intravenous analgesia every 6 hours. Hormones measurements were made (catecholamines, cortisol, ACTH and beta-endorphin), hemodynamic monitoring (blood pressure and heart rate), and pain measurement (Hannallah's score) in both pre and postoperative times (1, 6 and 24 hours after operation). RESULTS: Pain score was low and without significant differences in both groups (p > 0.05). beta-endorphin level decreased in both groups, and a cortisol and catecholamine level increase was noticed at 6 hours after operation; these changes were less significant in PCA group (p < 0.001). ACTH level did not change significantly in both groups. Hemodynamic monitoring measurements were not significantly different. CONCLUSIONS: Both analgesic techniques were appropriate to postoperative pain relief in pediatric patients. Low pain score shows better conditions to attend these patients. We suggest PCA technique is better to treat postoperative stress response following pediatric surgery.

[Analysis of regional anesthetic efficacy in pediatric postop pain]. / Análisis de la eficacia analgésica de la anestesia locorregional en cirugía infantil.

A randomized, double blind study was carried out in 76 paediatric surgical patients scheduled for herniography or circumcision. Patients were randomly assigned to receive ilioinguinal and iliohipogastric nerve block (group A), penile block (group B), caudal block (group C) or metamizol intravenously (group D). Postoperative pain was evaluated by Objective pain scale at the end of surgical process and at 15, 30, 60 minutes and 6 hours after surgery. Pain free time was also recorded. There was no difference between groups regarding demographic data. We find a significatively less pain scores in the children who received regional anaesthesia. In those groups the administration of any analgesic were not necessary. No side effects were recorded. We conclude that locorregional anaesthesia techniques are safe and effective for minor surgery in children, because they are easy to carry out, comfortable for the patient, and provide a good postoperative analgesia.

[Cerebral abscess secondary to esophageal dilatations]. / Absceso cerebral secundario a dilataciones esofágicas.

We report two cases of cerebral abscess secondary to esophageal dilations in children with caustic stenosis of the esophagus. High fever and neurological findings postdilation lead us to suspect this complication. Cranial C.T. confirmed the diagnosis. Clinical course was favourable in both patients, with antibioterapy on the first case and combined therapy with surgical drainage and parenteral antibiotics on the second patient. We remark the importance of suspect this complication on the basis of clinical and tomographic findings on the pediatric patients subjected to esophageal dilations. Pathogenic ways of bacterial dissemination from the esophagus to the brain are discussed and reviewed.

[Morgagni hernia in childhood]. / Hernias de Morgagni en la infancia.

We report six cases of Morgagni hernia diagnosed and operated on in our pediatric surgical unit during a 14-year period. Four children were younger than 1 year and two between 1 and 2 years. Predominance in males was found. Associated congenital pathology was present in 3 children (Down's syndrome, diaphragmatic relaxation, criptorquidia and pyelo-ureteral stenosis). Predominant clinical features were respiratory infections and vomiting. In only one patient clinical onset was with respiratory distress. Plain chest x-ray was the most used diagnostic procedure. In all cases barium enema was performed to confirm the clinical diagnosis. Most frequent surgical approach was a midline supra-umbilical laparotomy. Diaphragmatic defect was left sided in 3 children and right-sided in the other 3. Transverse colon and liver were the most frequent herniated viscera. Postoperative follow-up showed no complications or recidives.

[Surface microscopic patterns of an experimental model of surgically induced carcinogenesis]. / Patrones microscópicos de superficie de un modelo experimental de carcinogenesis inducido quirúrgicamente.

An experimental model of carcinogenesis is developed by authors, using internal urinary diversion in Wistar rats. Results show the transformation of normal digestive pattern, discovering proliferative-inflammatory changes at the first time which after go to an histiotypical tumorous pattern. They conclude at the carcinogenicity of the presented surgical model and is described the evolution of the superficial morphological pattern during the tumorigenic process.