Evolución de la técnica «avance de colgajo frontal» en la ptosis congénita / Evolution of the «frontal flap advancement» in congenital ptosis

El tratamiento de la ptosis congénita con mala función del elevador se basa habitualmente en una suspensión del párpado superior al músculo frontal mediante diversos tipos de materiales autógenos o aloplásticos. Sin embargo, el empleo de dichos materiales conlleva una serie de complicaciones, lo cual dio lugar a la búsqueda de una técnica quirúrgica mediante la que, sin necesidad de ningún material adicional, se enlazaran músculo frontal y tarso; el avance de colgajo frontal. No obstante, es una técnica menos conocida y que todavía no está estandarizada, por lo que a lo largo del tiempo se han ido describiendo variaciones para mejorar los resultados estéticos y funcionales. El objetivo de esta revisión bibliográfica es repasar en detalle las distintas variaciones de la técnica quirúrgica y obtener la mejor opción con o sin la combinación de las diferentes versiones empleadas hasta el momento. Según los resultados observados, se podría deducir que la cirugía con mejores resultados estéticos y funcionales sería la siguiente; una única incisión en el surco palpebral para realizar una disección suborbicular hasta alcanzar reborde orbitario. Realización de lipectomía si lo precisa. A continuación, disección roma del músculo frontal y formación de colgajo en «U». Avance de la aponeurosis del elevador si se trata de una ptosis grave. Finalmente, sutura sin polea del colgajo frontal al tarso con tres puntos no reabsorbibles tratando de mantener el contorno simétrico al ojo contralateral y con una altura de 1,5mm por encima del limbo corneal (AU)

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improving the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determining which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a “U” shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5mm above the sclero-corneal limbus (AU)

Evaluación de la plataforma SEFAC e_XPERT® para la prestación del Servicio de Indicación Farmacéutica / Evaluation of the SEFAC e_XPERT® platform for the provision of the Pharmaceutical Indication Service

JUSTIFICACIÓN: la Indicación Farmacéutica es una de las actividades clínicas que se realizan habitualmente en la farmacia comunitaria. Foro de Atención Farmacéutica en Farmacia Comunitaria (FC) protocolizó hace años el Servicio de Indicación Farmacéutica (SIF) y SEFAC ha desarrollado una plataforma para registrar el SIF.OBJETIVOS: conocer la utilidad de la plataforma SEFAC e_XPERT® en la práctica diaria para realizar el SIF.METODOLOGÍA: estudio descriptivo, de corte transversal y multicéntrico realizado en farmacias comunitarias de Madrid, Guadalajara y Zaragoza por alumnos de Prácticas Tuteladas (PT) de la Universidad de Alcalá. Criterios de inclusión: farmacias con alumnos de PT, que tengan y utilicen SEFAC e_XPERT®. Se diseñó una encuesta a través de Google-Forms en la que se recogieron: quién realiza la encuesta, tipo de farmacia, utilidad de la plataforma, evaluación posterior del servicio, utilidad del uso de protocolos consensuados, detección de PRM/RNM, tiempo dedicado al servicio, recomendación de uso y fortalezas de la plataforma. Se ofreció una formación a los participantes sobre el manejo de la herramienta. Los datos se analizaron con EXCEL®.RESULTADOS: participaron 85 personas: 57 alumnos (67,1 %) y 28 tutores (32,9 %), que pertenecían a 57 farmacias: 75,3 % de barrio, 14 % próximas a un centro de salud, 5,2 % en un centro comercial y 3,5 % de paso. El 66,7 % de los alumnos y el 64,3 % de los tutores consideran útil la plataforma, frente al 26,3 % de alumnos y 25 % de tutores que creen que no tiene utilidad. La plataforma no es de utilidad en 33,3 % de las farmacias próximas a un centro de salud, 25 % de las ubicadas en centros comerciales. Y es de utilidad en el 67, 2% de las farmacias de barrio y en el 100 % de las de paso. 47,1 % manifiestan su utilidad para detectar PRM/RNM; 29, 4% utilizan otro programa y 23,5 % inútil. 56,5 % creen que enlentece el servicio y 37,6% que es el tiempo que se necesita para cada paciente. (AU)

Evolution of the «frontal flap advancement¼ in congenital ptosis.

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improve the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determine which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a "U" shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5 mm above the sclero-corneal limbus.

Brevibacterium casei endophthalmitis after intravitreal dexamethasone implant.

CLINICAL CASE: 49-year-old man with diabetic macular edema refractory to antiangiogenics, it is decided to perform therapy with intravitreal dexamethasone implant (Ozurdex; Allergan, California, United States of America). Seven days after treatment, he showed acute endophthalmitis suggestive signs. Despite the intravitreal injection of antibiotics, the patient got worse. Vitreous sampling was repeated for Gram and cultures, and vitrectomy was performed via pars plana. The culture suggested the development of Brevibacterium species. Through an additional test, the presence of Brevibacterium casei was confirmed. Despite the treatment adjusted by antibiogram, retinal ischemia and macular atrophy was evident. DISCUSSION: Brevibacterium casei is a Gram-positive bacterium, barely pathogenic, that mainly affects immunodepressed patients. Only two cases of endophthalmitis are described, one endogenous and the other one secondary to vegetal trauma. This is the first case of endophthalmitis, secondary to an ophthalmological procedure.

Vitamin D receptor (VDR) expression in different molecular subtypes of canine mammary carcinoma.

BACKGROUND: The molecular-based classification of canine mammary carcinomas (CMCs) has been the focus of much current research. Both in canines and humans, the triple-negative (TN) molecular subtype of mammary cancer is defined by a lack of expression of progesterone receptor (PR), oestrogen receptor (ER) and HER2. It has a poor prognosis; no effective targeted therapy is available. Vitamin D displays anticarcinogenic properties, and the expression of its receptor (VDR) has been found in different molecular subtypes, being about 30-40 % of TN breast cancer (TNBC) positive to it. We assessed the VDR expression in the different molecular subtypes of 58 CMCs from 45 female dogs using an immunohistochemical panel for the molecular classification of included: PR, ER, HER2, cytokeratin (CK) 5, CK14, and Ki67. In addition, we studied the relationship among the molecular subtypes of CMCs and clinicopathologic parameters. RESULTS: Investigation showed VDR positivity in 45.0 % of the triple-negative CMCs (TNCMCs), 27.3 % of luminal B and 19.0 % of luminal A. Luminal A was the most molecular subtype represented of the total tumours (36.2 %), followed of TNCMCs (34.5 %), luminal B (20.7 %) and HER2-overexpression (10.3 %). Both HER2-overexpression and TNCMC subtypes were positively related to lymphatic invasion (P = 0.028), simple histologic subtype (P = 0.007), a higher histological grade (P = 0.045) and a trend to higher proliferation index (P = 0.09). CONCLUSIONS: The highest VDR expression was observed in TNCMC, being almost half of them (45 %) positive to this receptor. VDR expression was absent in HER2-overexpression tumours and low in luminal A and B molecular subtypes.

Endoftalmitis aguda por Brevibacterium casei tras implante intravítreo de dexametasona / Brevibacterium casei endophthalmitis after intravitreal dexamethasone implant

Caso clínico Hombre de 49años, con edema macular diabético refractario a antiangiogénicos, en el que se realizó terapia intravítrea con implante de dexametasona (Ozurdex; Allergan, California, Estados Unidos). Tras 7días presentó signos sugerentes de endoftalmitis aguda. Pese a la inyección intravítrea de antibióticos, el paciente empeoró. Se repitió la toma de muestras en vítreo para Gram y cultivos, y se realizó vitrectomía vía pars plana. El cultivo sugirió el desarrollo de Brevibacterium species. Mediante una prueba adicional, se confirmó la presencia de Brevibacterium casei. Pese al tratamiento ajustado por antibiograma, se evidenció isquemia retiniana y atrofia macular. Discusión Brevibacterium casei es una bacteria grampositiva, escasamente patógena, que afecta principalmente a inmunodeprimidos. Se han descrito solo dos casos de endoftalmitis, una endógena y otra secundaria a trauma vegetal. Este es el primer caso de endoftalmitis por Brevibacterium casei secundaria a procedimiento oftalmológico (AU)

Clinical case A 49-year-old man with diabetic macular edema refractory to antiangiogenics was treated with intravitreal dexamethasone implant (Ozurdex; Allergan, California, USA). Seven days after treatment, he showed acute endophthalmitis suggestive signs. Despite the intravitreal injection of antibiotics, the patient got worse. Vitreous sampling was repeated for Gram and cultures, and vitrectomy was performed via pars plana. The culture suggested the development of Brevibacterium species. Through an additional test, the presence of Brevibacterium casei was confirmed. Despite the treatment adjusted by antibiogram, retinal ischemia and macular atrophy was evident. Discusion Brevibacterium casei is a Gram-positive bacterium, barely pathogenic, that mainly affects immunodepressed patients. Only two cases of endophthalmitis are described, one endogenous and the other one secondary to vegetal trauma. This is the first case of Brevibacterium casei endophthalmitis, secondary to an ophthalmological procedure (AU)

Brevibacterium casei endophthalmitis after intravitreal dexamethasone implant. / Endoftalmitis aguda por Brevibacterium casei tras implante intravítreo de dexametasona.

CLINICAL CASE: A 49-year-old man with diabetic macular edema refractory to antiangiogenics was treated with intravitreal dexamethasone implant (Ozurdex; Allergan, California, USA). Seven days after treatment, he showed acute endophthalmitis suggestive signs. Despite the intravitreal injection of antibiotics, the patient got worse. Vitreous sampling was repeated for Gram and cultures, and vitrectomy was performed via pars plana. The culture suggested the development of Brevibacterium species. Through an additional test, the presence of Brevibacterium casei was confirmed. Despite the treatment adjusted by antibiogram, retinal ischemia and macular atrophy was evident. DISCUSION: Brevibacterium casei is a Gram-positive bacterium, barely pathogenic, that mainly affects immunodepressed patients. Only two cases of endophthalmitis are described, one endogenous and the other one secondary to vegetal trauma. This is the first case of Brevibacterium casei endophthalmitis, secondary to an ophthalmological procedure.

Contribution of the Visante® OCT and B-scan ultrasound in the diagnosis and follow up of a topiramate-induced bilateral ciliochoroidal effusion syndrome. / Aportes de la tomografía de coherencia óptica Visante® y la ecografía ocular en el diagnóstico y seguimiento del síndrome de efusión ciliocoroideo bilateral secundario a topiramato.

A 45 year-old man with bilateral acute angle-closure and myopia after starting treatment with topiramate, secondary to alcohol and heroin dependence. Using Visante® OCT (Optical Coherence Tomography) and B-scan Ultrasound he was diagnosed with bilateral ciliochoroidal effusion as the pathophysiological mechanism. Topiramate was stopped and ocular hypotensive therapy with a topical cycloplegic and corticosteroids were started, resolving ciliochoroidal effusion syndrome. Visante® OCT and B-scan Ultrasound are useful tools for the diagnosis and follow-up of patients with acute angle-closure and myopia due to topiramate. As a result of broad spectrum of indications for topiramate, physicians and ophthalmologists should be aware of the possible ophthalmological manifestations attributable to this drug.

Vitamin D receptor expression in canine mammary gland and relationship with clinicopathological parameters and progesterone/oestrogen receptors.

The vitamin D receptor (VDR) belongs to the nuclear class II receptor family. VDR is a ligand transcription factor and mediates the actions of calcitriol, the active product of vitamin D synthesis. Nowadays, it is known that the biological actions of calcitriol include the capacity to modulate cancer features, such as proliferation and differentiation, apoptosis, angiogenesis, invasion and metastasis. VDR expression has been demonstrated in human breast cancer and vitamin D has emerged as a promising targeted therapy. We analyse the VDR expression in normal and neoplastic canine mammary tissue samples and its relationship with clinicopathological parameters and progesterone/oestrogens receptors (PR/ER). Expression of VDR, Ki67 (to evaluate the proliferation index, PI), PR and ER was assessed in 50 mammary gland tissue samples from 41 female dogs by immunohistochemistry. VDR-positive staining was found in the nuclei of both myoepithelial and luminal epithelial cell layers. VDR expression was higher in normal mammary tissue (37/37 cases, 100%) then followed by benign tumours (6/15 cases, 40%) and malignant tumours (9/34 cases, 26.5%) (P = .001). Female dogs aged ≥10 years had lower VDR expression compared with dogs younger (P = .017). Relationship between VDR and breed, number of tumours, tumour size, histologic subtype, histologic grade of malignancy, PI and PR and ER expression was not observed. Studies with more samples are necessary to further evaluate the possible role of VDR in the biological behaviour of canine mammary tumours, and to corroborate the possibility to use the dog as model for human breast cancer.

Prognostic impact of neoadjuvant aglepristone treatment in clinicopathological parameters of progesterone receptor-positive canine mammary carcinomas.

Neoadjuvant treatment of canine mammary carcinomas with the progesterone receptor (PR) antagonist aglepristone has a PR expression-related inhibiting effect on proliferation index (PI). The aim of this study was to evaluate the effect of the treatment in the disease-free period (DFP) and overall survival (OS) of canine mammary carcinomas. Fifty female dogs with mammary carcinomas were treated with aglepristone (n = 34) or oil vehicle (n = 16) before surgery (day 15). PR expression and PI were analysed by immunohistochemistry in samples taken at days 1 and 15. Epidemiological and clinicopathological data were assessed. DFP and OS data were retrieved every 4-6 months for at least 24 months after surgery. Aglepristone treatment increased DFP of animals bearing PR+ tumours with size smaller than 3 cm, complex and mixed tumours, with histologic grades I and II, and with PI ≤ 10%. Although further studies are necessary, current evidence points to treatment with aglepristone as useful for the management of canine mammary tumours.

Plateau iris secondary to iridociliary cysts.

CASE REPORT: We present a case of plateau iris and glaucoma due to multiple unilateral iridociliary cysts. The patient was treated with iridotomy Nd: YAG laser and 360° iridoplasty, without achieving pressure control. Phacoemulsification improved the hypertension. Dynamic gonioscopy and OCT of the anterior chamber was also performed before and after treatment. DISCUSSION: Iridociliary cysts are a benign condition that can cause iris plateau configuration, and can produce a difficult to treat ocular hypertension. Cystotomy, peripheral iridoplasty, and other treatments have been proposed.

Cow, sheep and llama manure at psychrophilic anaerobic co-digestion with low cost tubular digesters in cold climate and high altitude.

The aim of this research is to evaluate the co-digestion of cow and llama manure combined with sheep manure, in psychrophilic conditions and real field low cost tubular digesters adapted to cold climate. Four digesters were monitored in cold climate conditions; one fed with cow manure, a second one with llama manure, the third one with co-digestion of cow-sheep manure and the fourth one was fed with llama-sheep manure. The slurry had a mean temperature of 16.6 °C, the organic load rate was 0.44 kgvs m(-3) d(-1) and the hydraulic retention time was 80 days. After one hundred days biogas production was stable, as was the methane content and the pH of the effluent. The co-digestion of cow-sheep manure results in a biogas production increase of 100% compared to the mono-digestion of cow manure, while co-digestion of llama-sheep manure results in a decrease of 50% in biogas production with respect to mono-digestion of llama manure.

Improvement through low cost biofilm carrier in anaerobic tubular digestion in cold climate regions.

The aim of this research is to evaluate the increase of biogas production with low cost tubular digesters in cold climates using PET rings inside the reactor. Two similar digesters have been operated and monitored in cold weather conditions and have been fed with cow manure. Digester 1 was filled with PET - rings as a biofilm carrier, Digester 2 was kept as a reference. Through the PET - rings the functional surface could be increased by a factor 4.2. The results show that 44% more biogas per Kg SV has been produced with the biofilm carrier in use (0.33 m(3)/kg SV) (reference digester -0.23 m(3)/kg SV), at an organic load rate of 0.26 kg SV/m(3)/d. The thermal performance shows that with an adaptation of the low cost tubular digester the slurry temperature can be raised up to 16.6°C (average) by surrounding temperature of 6.1°C (average) without using any active heating system.

Progesterone receptor isoform analysis by quantitative real-time polymerase chain reaction in formalin-fixed, paraffin-embedded canine mammary dysplasias and tumors.

Cloning and sequencing of the progesterone receptor gene in dogs have revealed 2 isoforms, A and B, transcribed from a single gene. Distribution of isoforms A and B in canine mammary lesions has hitherto been investigated only by Western blot analysis. This study analyzed progesterone receptor and its isoforms in formalin-fixed, paraffin-embedded tissue samples from canine mammary lesions (4 dysplasias, 10 benign tumors, and 46 carcinomas) using 1-step SYBR Green quantitative real-time polymerase chain reaction (RT-qPCR). Progesterone receptor was expressed in 75% of dysplasias, all benign tumors, and 59% of carcinomas. Carcinomas, and particularly simple epithelial-type carcinomas, displayed the lowest levels of expression. A high rate of agreement was recorded between RT-qPCR and immunohistochemical labeling. Isoforms A and B were successfully amplified, with correlation coefficients of 0.99 and amplification efficiencies close to 2, and were expressed in all lesion types analyzed. Predominance of A over B expression was observed in carcinomas and complex adenomas. Low-grade tumors exhibited higher progesterone receptor messenger RNA (mRNA) levels, but no difference was observed in the expression of isoform A versus B. Analysis of progesterone receptor mRNA isoforms by RT-qPCR was successful in routinely formalin-fixed, paraffin-embedded tissue samples and enabled the distribution of isoforms A and B to be identified for the first time in dysplasias, benign tumors, and malignant tumors of the canine mammary gland. These findings will facilitate future research into the role of progesterone receptor isoforms in the progression of canine mammary tumors.

Isolation, purification, culture and characterisation of myoepithelial cells from normal and neoplastic canine mammary glands using a magnetic-activated cell sorting separation system.

Mammary gland tumours, the most common malignant neoplasm in bitches, often display myoepithelial (ME) cell proliferation. The aim of this study was to isolate, purify, culture and characterise ME cells from normal and neoplastic canine mammary glands. Monodispersed cells from three normal canine mammary glands and five canine mammary tumours were incubated with an anti-Thy1 antibody and isolated by magnetic-activated cell sorting (MACS). Cells isolated from two normal glands (cell lines CmME-N1 and CmME-N2) and four tumours (cell lines CmME-K1 from a complex carcinoma, CmME-K2 from a simple tubulopapillary carcinoma, and CmME-K3 and CmME-K4 from two carcinomas within benign tumours) were cultured in supplemented DMEM/F12 media for 40days. Cell purity was >90%. Tumour-derived ME cell lines exhibited heterogeneous morphology, growth patterns and immunocytochemical expression of cytokeratins, whereas cell lines from normal glands retained their morphology and levels of cytokeratin expression during culture. Cell lines from normal glands and carcinomas within benign tumours grew more slowly than those from simple and complex carcinomas. This methodology has the potential to be used for in vitro analysis of the role of ME cells in the growth and progression of canine mammary tumours.

Clasificación en subtipos moleculares de tumores de mama de pequeños animales mediante métodos inmunohistoquímicos / Classification in molecular subtypes of breast tumors of small animals through immunohistochemical methods

Antecedentes y Objetivos: Aplicar un panel de anticuerpos (anti -receptor de progesterona, -receptor de estrógenos, -receptor del factor de crecimiento epidérmico humano 2 y -citoqueratina 14) utilizando métodos inmunohistoquímicos en tumores mamarios de pequeños animales para analizar su clasificación en subtipos moleculares y su asociación con la invasión, el grado y el tipo histológico de las neoplasias. Material y Métodos: Muestras de tumores mamarios malignos, 10 de la especie canina y 3 de la felina. Control positivo interno: glándula mamaria no tumoral adyacente a las neoplasias. Resultados: El 23% (3/13) de los tumores fueron del subtipo luminal B, el 23% (3/13) fueron HER2 positivos, el 46% (6/13) fueron basales y el 7,6% (1/13) no se pudieron clasificar porque no expresaron ninguno de los marcadores tumorales analizados. Ningún caso fue del subtipo luminal A. Los 6 tumores basales fueron de grado II o III y presentaban o infiltración de solo el estroma o también invasión vascula Dos tercios de los tumores HER2 positivos presentaban infiltración del estroma y 1/2 tumores resultó ser de grado II. Los tumores luminal B, 2/3 fueron de grado II o III. Todos los controles internos fueron positivos. No se encontraron diferencias significativas en la distribución de los subtipos moleculares entre los diferentes grupos de las variables invasión (p-valor=0,26), ni grado de malignidad (p-valor=0,42). Sí hubo diferencias en el límite de la significación estadística en la distribución de los subtipos moleculares entre los diferentes grupos de la variable tipo histológico (p=0,08). Conclusiones: La aplicación del panel de anticuerpos ha permitido descubrir 4 (luminal B, HER2, basal y sin clasificar) de los 5 subtipos moleculares posibles (AU)

Antecedents and objectives: to apply an antibodies panel (anti-progesterone receptor -estrogen receptor, -human epi-dermal growth factor receptor 2 and cytokeratin 14) using immunohistochemical methods in mammary tumors of small animals to classify them in molecular subtypes and their association with the invasion, grade and histological type of the malignancies. Material and Methods: samples of malignant mammary tumors, 10 from canine species and 3 from feline ones. Internal positive control: non-tumoral mammary gland adjacent to the malignancy. Results: 23% (3/13) of the tumors were of the luminal B subtype, 23% (3/13) were HER2 positive, 46% (6/13) were basal types and 7,6% (1/13) were unclassifiable because they did not express any of the tested tumor markers. None of the cases belonged to the luminal A subtype. The 6 basal tumors were grade II or III and presented only stromal infiltration or vascular invasion as well. Two thirds of the HER2 positive tumors presented stromal infiltration and hal he tumors were grade II. Two thirds of luminal B tumors were grade II or III. All internal controls were positive. There were no signifi-cant differences in the distribution of the molecular subtypes among the different groups of the invasion (p-value=0.26) and malig-nancy grade variables (p-value=0.42). There were differences of borderline statistical significance in the distribution of the molecular subtypes among the different groups of the histological type variable (p-value=0.08). Conclusions: the application of the antibodies panel has allowed to find 4 (luminal B, HER2, basal and unclassified) out of 5 possible molecular subtypes (AU)