Conjuntivitis cicatrizal recalcitrante: Tratamiento de nueve pacientes con rituximab / Recalcitrant cicatrizing conjunctivitis. Treatment of nine patients with rituximab

La conjuntivitis cicatrizal es la consecuencia de distintas enfermedades oculares. Entre ellas, las más graves son el penfigoide cicatrizal y el síndrome de Stevens-Johnson crónico. El tratamiento de estas enfermedades con corticoides e inmunosupresores es habitualmente exitoso, pero unos pocos pacientes siguen un curso recalcitrante. En los últimos años se introdujo el uso de rituximab, asociado o no a gammaglobulina endovenosa, en forma abierta, para el control de la inflamación conjuntival. Describimos aquí el tratamiento de siete pacientes con penfigoide y dos con Stevens-Johnson recalcitrante, con rituximab. Ocho recibieron también gammaglobulina y todos alcanzaron la remisión de la actividad. Tres recayeron y recibieron dos o tres nuevos cursos de la medicación con mejoría sintomática. El rituximab probó ser una droga efectiva para el tratamiento de la conjuntivitis cicatrizal crónica recalcitrante.

Cicatrizing conjunctivitis is the final consequence of several diseases. The most severe among them are cicatricial pemphigoid and chronic Stevens-Johnson syndrome. Systemic immunosuppressive drugs and steroids are usually an effective approach to these diseases. However, a few patients follow a recalcitrant course unremitting to usual therapy. We describe the treatment with rituximab of seven patients with cicatricial pemphigoid and two with chronic Stevens-Johnson syndrome. Eight of them also received gammaglobulin and all achieved clinical remission. Three relapsed and required two or three new courses of rituximab with good control of disease activity. Rituximab proved to be an efficacious drug for chronic recalcitrant cicatrizing conjunctivitis.

Isthmocele: an overview of diagnosis and treatment

SUMMARY An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

RESUMO A istmocele ou nicho uterino é representada por uma descontinuidade miometrial ou um defeito anecoico triangular na parede uterina anterior, com a base se comunicando com a cavidade uterina no local de uma cicatriz anterior de cesárea. O defeito pode ser classificado como pequeno ou grande, dependendo da espessura da parede miometrial deficiente. Embora geralmente assintomático, seu principal sintoma é o sangramento uterino anormal ou pós-menstrual; a dor pélvica crônica também pode ocorrer. Infertilidade, placenta acreta ou prévia, deiscência de cicatriz, ruptura uterina e gravidez ectópica em cicatriz de cesárea prévia também podem aparecer como complicações dessa condição. Os fatores de risco para desenvolvimento da istmocele comprovados até o momento incluem útero retroverso e múltiplas cesarianas. No entanto, fatores como localização mais inferior de uma cesárea prévia, fechamento incompleto da histerotomia, aderências precoces na parede uterina e predisposição genética também podem contribuir para o desenvolvimento de um nicho. Como não existem critérios definitivos para o diagnóstico de uma istmocele, vários métodos de imagem podem ser usados para avaliar a integridade da parede uterina e, assim, diagnosticar uma istmocele. Entretanto, ultrassonografia transvaginal e sono-histerografia com infusão salina surgem como métodos específicos, sensíveis e custo-efetivos para o diagnóstico de istmocele. O tratamento inclui manejo clínico ou cirúrgico, dependendo do tamanho do defeito, da presença de sintomas, da presença de infertilidade secundária e de planos de gravidez. O manejo cirúrgico inclui abordagens minimamente invasivas como histeroscopia, laparoscopia ou transvaginal, de acordo com o tamanho do defeito.

Acne scars in 18-year-old male adolescents: a population-based study of prevalence and associated factors

Abstract: Background: Acne vulgaris is a pilosebaceous follicle disorder affecting over 85% of adolescents to some degree. It frequently causes psychological distress that may persist into adulthood due to scarring. Little information about post-acne scarring epidemiology is available. Objectives: To describe prevalence, distribution patterns and associated factors of acne scarring in young males, drawing on a representative population sample from a southern Brazilian city. Methods: A cross-sectional study was undertaken during presentation for military service, which is compulsory for all 18-year-old males. A questionnaire was applied, covering topics like diet, smoking habits, ethnicity, family structure, socio-economic level, as well as specific questions about active acne and resulting scars. Dermatologists conducted the clinical examination. Results: A total of 2,201 male adolescents were interviewed and examined. The overall prevalence of acne scarring was 22%. The malar region was the most frequently involved, present in 80% of affected individuals, followed by the frontal region (31.5%), back (17%), anterior chest (8.2%) and mentonian region (6.4%). Correlation between the intensity of clinical acne and the presence of scars was found, but no association was observed with educational level, smoking, ethnicity, obesity or socio-economic status. Conclusions: There is a high prevalence of acne scars among this population. This is the first study to ascertain a correlation between acne scarring and factors such as socio-economic status and educational level. The direct relation between acne severity and scarring indicates that prompt and effective treatment is the best way to reduce scarring.

Epidemiología de las quemaduras en niños y adolescentes de Región Metropolitana de Chile / Epidemiology of burns in children and adolescents from Chile's Metropolitan Region

Objective: To determine demographic, clinical and health care factors associated to prevalence of burns in children less than 20 years of age in the districts of Cerro Navia, Lo Prado and Pudahuel, and their comparison with incidence in 2011. Patients and Method: Population survey based on probability and two-stage stratified complex sample of households, registering 4,968 households. In 302 of them randomly selected, the mother/adult present at the time of the injury took a survey. A questionnaire of 50 questions (20 minutes), created by 6 experts and previously validated, was conducted by 10 interviewers and 3 supervisors. People were contacted by telephone before visiting them at their homes. The non-response rate was 6%, after up to 3 home visits. Results: Regarding prevalence, the male-to-female ratio was 1.16:1. Main reasons were hot objects (42.4%) and liquids (41.5%). 84.1% of burns occurred inside the home and in the afternoon (50.7%). 93.3% of the burns took place with an adult present. Hands were the most affected areas (46.7%). 30.2% were left with scars the first time of the accident. 34.4% of the burn victims did not require health care and 8.4% of them required hospitalizations. Over 60% of respondents reported that they poured cold water on the burn as a first step. Conclusion: Relevant information was obtained to be used in burn prevention in children and adolescents. Recall bias is the main limitation of the study.

Objetivo: Determinar factores demográficos, clínicos y de atención de salud asociados a prevalencia de quemaduras en menores de 20 años residentes en comunas de Cerro Navia, Lo Prado y Pudahuel y su comparación con incidencia en 2011. Pacientes y Método: Encuesta poblacional, basada en muestra probabilística, estratificada y bietápica de hogares de tipo compleja, empadronándose 4.968 hogares. En 302 seleccionados aleatoriamente, se aplicó encuesta a madre/adulto presente en el momento de la lesión del menor. Cuestionario de 50 preguntas (20 min), realizado por 6 expertos, y validado previamente, fue aplicado por 10 encuestadores y 3 supervisores. Se contactó telefónicamente las personas antes de concurrir al domicilio. La tasa de no respuesta fue de 6%, luego de realizar hasta 3 visitas al domicilio. Resultados: En prevalencia, la razón masculina sobre femenina fue de 1,16:1. Agentes principales fueron objetos calientes (42,4%) y líquidos calientes (41,5%); 84,1% de las quemaduras ocurrieron dentro del hogar y a media tarde (50,7%); 93,3% de las quemaduras fue con adulto presente. La mano fue la localización más afectada (46,7%); 30,2% quedó con cicatriz la primera vez que se quemó. 34,4% de los quemados no demandó atención de salud y se declararon 8,4% de hospitalizaciones. Más de 60% de los encuestados relató echar agua fría a la quemadura como primera medida. Conclusión: Se obtiene información relevante para utilizar en prevención de quemaduras en niños y jóvenes. El sesgo de recuerdo es la limitante principal del estudio.

Sarcoidose em cicatrizes prévias / Sarcoidosis on previous scar

A sarcoidose é uma doença sistêmica de etiologia desconhecida, com apresentação clínica variável, onde 30 a 50% dos pacientes são assintomáticos ao diagnóstico. Afeta a pele, pulmões, sistema linfático, fígado e olhos. Outras áreas menos frequentemente afetadas são falanges ósseas, miocárdio, sistema nervoso central, fígado, baço e parótidas. A pele está envolvida em 25 a 35% dos casos, com diferentes formas de apresentação das lesões cutâneas. Relata-se caso de paciente de 26 anos cuja manifestação inicial da sarcoidose foram nódulos cutâneos em cicatrizes prévias e em que na investigação adicional mostrou-se haver acometimento pulmonar e mediastinal.

Sarcoidosis is a systemic disorder of unknown etiology and variable clinical presentation, where 30-50% of patients are asymptomatic at diagnosis. It affects the skin, lungs, lymphatic system, liver, and eyes. Less frequently affected areas are bone phalanxes, myocardium, central nervous system, liver, spleen and parotids. The skin is involved in 25-35% of the cases with different forms of presentation of skin lesions. Here the authors report the case of a 26-year-oldwhose initial manifestation of sarcoidosis were skin nodules on previous scars and which further investigation showed affected lung and mediastinum.

Impacto del Plan de Atención Básica en la Prevención de Leishmaniasis Cutánea en Zonas Rurales de Santander, Colombia / The Basic Health PlanÆs impact on preventing cutaneous leishmaniasis in rural areas of Santander, Colombia

Objetivo: Evaluar el impacto de los programas del Plan de Atención Básica en la prevención de leishmaniasis cutánea en tres municipios santandereanos. Materiales y Métodos: Estudio ecológico con unidad de análisis vivienda. Se seleccionaron aleatoriamente niños menores de diez años de las escuelas rurales, se aplicaron encuestas estructuradas por vivienda y se examinó la presencia de cicatriz/lesión. Se hizo un análisis de regresión binomial ajustando por conglomerados. Resultados: Se muestrearon un total de 18 veredas con 284 viviendas y 609 niños menores de diez años. La prevalencia general de niños con cicatriz/lesión fue de 19,1 por ciento distribuida en forma diferencial en los tres municipios. El 42,8 por ciento de las viviendas reportaron haber recibido algún tipo de información y el 39,9 por ciento algún tipo de intervención de leishmaniasis del Plan de Atención Básica. Las intervenciones del Plan de Atención Básica mostraron un efecto protector en el análisis bivariado, pero luego de ajustar por variables socioeconómicas y ambientales, su efecto no fue significativo (PR=1,39 IC95 por ciento 0,76-2,56) Conclusión: Las intervenciones del Plan de Atención Básica en leishmaniasis no tienen asociación significativa con la presencia de cicatriz/lesión en los niños menores de diez años, probablemente porque su efecto es superado por las condiciones socioeconómicas y ambientales de la zona, así como por las condiciones administrativas relacionadas con la baja cobertura de los programas.