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Currently, brachytherapy is the most commonly used therapeutic approach for uveal melanomas. Surgical resection by means of endoresection or exoresection is an alternative approach. The present report recounts our experience over 15 years in the treatment of uveal melanoma using a combined approach of resection surgery with brachytherapy. This is a single-center observational retrospective cohort study in which we describe clinical outcomes, complications and survival in 35 cases of melanoma of the iris or the ciliary body after a combination of surgery and brachytherapy or brachytherapy alone. Local treatment of the tumor was successful in all cases with surgery and brachytherapy. The most frequent complications were scleromalacia, bullous keratopathy, retinal toxicity, cataracts, hypotonia, and photophobia. There were three cases of recurrence, all of which were found in the group of patients who had received brachytherapy alone, and in one case we had to perform a secondary enucleation due to tumor growth after brachytherapy. At present, only one patient has died during follow-up due to liver metastases six years after the start of treatment. In carefully selected patients, this approach can be effective and safe, as long as a close follow-up is carried out after surgery.

La inmunoterapia está ganando importancia en el manejo de la patología oncológica, demostrando una gran eficacia aunque también presenta efectos secundarios hasta ahora desconocidos, como la colitis. Presentamos el primer caso de colitis por inmunoterapia(nivolumab + ipilimumab) corticorrefractaria que ha precisado tratamiento con infliximab en nuestro hospital.

We report a case of a regenerative nodular hyperplasia with a portal vein cavernomatosis with a subsequent progression to symptomatic, occlusive thrombosis of the superior mesenteric vein. A thorough investigation resulted in a final diagnosis of primary myelofibrosis associated with the V617F mutation in the JAK2 gene.

Epstein-Barr virus, a member of the Herpesviridae family, is responsible for the infectious mononucleosis clinical syndrome, which mainly includes the pharyngitis, fever, and lymphadenopathy triad after incubation for 30-50 days. The liver is involved in 80-90% of patients in a self-limiting transient manner, with jaundice being much more uncommon (5%). From a hematological standpoint it may manifest aplastic anemia, neutropenia, and thrombocytopenia. We report a case of infectious mononucleosis that included severe acute hepatitis and was associated with severe hemolytic anemia secondary to cold agglutinins. After exclusion of other etiologies, and given the clinical suspicion of the above association, which was later confirmed by lab tests, empiric therapy was initiated with antiviral agents (aciclovir + valganciclovir) and corticoids, which resulted in a progressive clinical improvement until complete remission. Therefore, we believe that this case report will reinforce the clinical evidence in support of the above combined therapy for serious infectious mononucleosis as a step prior to liver transplantation.

Background Colonic obstruction is a relatively common condition in emergency care, with a mortality rate of up to 20%. In 90% of cases it results from colonic or rectal adenocarcinoma, volvulus, or stenosis secondary to diverticular disease. When fecal impaction is the underlying cause, the condition is usually managed conservatively, but may on occasion become complicated and even require surgical intervention. Based on the proven efficacy of Coca-Cola® to dissolve gastric phytobezoars, we report a case of colonic obstruction secondary to sigmoid fecaloma. Case report A 58 years old woman arrived at the Emergency Room (ER) with persistent constipation for the last six days. An abdominal CT scan showed a large fecal mass at the sigmoid colon with retrograde dilated colonic loops. Cleansing enemas and oral lactulose were administered, which failed to resolve the clinical presentation, so we then proceeded to inject Coca-Cola® within the fecaloma using a sclerosing needle, and then washed the fecaloma surface also with Coca-Cola®. After a few minutes we started to fragment the fecalith, the consistency of which had been notably decreased. Discussion The use of Coca-Cola® for gastric washes in the management of phytobezoars is well established. Since fecaliths are partly composed of these same substances than phytobezoars, the use of Coca-Cola® might well be warranted against them as in our patient, without surgery. Our case report is the second one published in the literature, in which Coca-Cola® helped solve colonic obstruction secondary to fecaloma.

Introduccion. La reserva cognitiva resulta ser una variable de pronostico en la recuperacion cognitiva tras un dano cerebral. Pocos estudios han abordado su papel en el estado cognitivo tras un periodo sostenido de adiccion a sustancias. Objetivo. Analizar el papel modulador de la reserva cognitiva sobre la relacion entre el tiempo de abstinencia y el estado cognitivo de los pacientes con adiccion grave a sustancias. Pacientes y metodos. Se valora a un total de 26 pacientes en recuperacion tras una adiccion grave a sustancias con un protocolo de evaluacion neuropsicologica y cuestionarios de reserva cognitiva. Se emplea el analisis factorial exploratorio para conformar las variables y el analisis de regresion lineal para ver las relaciones predictivas. Resultados. Se obtienen tres factores de funcionamiento cognitivo: integridad de procesamiento, control inhibitorio y memoria verbal, asi como un factor global de reserva. En los modelos de regresion, solo se encuentran relaciones predictivas en un modelo de relacion directa entre la abstinencia y la memoria verbal, y en un modelo de relacion independiente entre la reserva cognitiva y el tiempo de abstinencia con la memoria verbal, pero no en la relacion de modulacion, ni en otras relaciones en el resto de los factores. Conclusion. Se debate el papel de la reserva cognitiva como mediadora en el estado cognitivo en los pacientes en periodo de abstinencia tras una adiccion grave a sustancias: muestra una relacion con la memoria, pero no una modulacion del papel del tiempo de abstinencia sobre ese estado cognitivo.

espanolIntroduccion: la hemorragia digestiva alta (HDA) es una entidad comun en gastroenterologia, pero las “Downhill varices” (DHV) son una causa infrecuente de HDA, con diferente etiologia de las varices esofagicas de tercio inferior y con diferentes implicaciones terapeuticas. Caso clinico: varon de 28 anos de edad, con antecedentes de insuficiencia renal cronica sometido a hemodialisis y sindrome de vena cava superior(SVCS) debido a multiples sustituciones cateter, acude a urgencias por hematemesis secundaria a ruptura de una variz en tercio proximal de esofago, que inicialmente se trata con etanolamina. El estudio diagnostico posterior demostro la circulacion colateral secundaria al SVCS. No se pudo realizar terapia endoscopica o endovascular y el paciente finalmente se sometera a un bypass quirurgico. Discusion: las DHV son una entidad infrecuente y la ligadura endoscopica con bandas se erige como el abordaje terapeutico apropiado para el evento hemorragico. La terapia definitiva sigue siendo la de la causa del SVCS. EnglishBackground: Upper gastrointestinal bleeding (UGIB) is a common condition in gastroenterology, but “Downhill varices” (DHV) or varices of the upper oesophagus are an uncommon cause of UGIB, with different aetiology from lower third oesophageal varices and different therapeutic implications. Case report: A 28-year-old male patient, with a history of chronic kidney failure secondary undergoing haemodialysis and superior vena cava syndrome (SCVS) due to multiple catheter replacements, was admitted to the Emergency Department with haematemesis secondary to a varicose vein rupture in the proximal third of oesophagus, treated initially with ethanolamine. Subsequent diagnostic studies showed the collateral circulation secondary to the SCVS. No further endoscopic or endovascular therapy could be performed and the patient will finally undergo a surgical bypass. Discussion: DHVs are a very uncommon condition and endoscopic band ligation emerges as the appropriate therapeutic approach for the bleeding event. The definitive therapy continues to be that for the cause of the SVCS.

BACKGROUND AND OBJECTIVES: Hypertrophic pyloric stenosis is a relatively common affection of gastrointestinal tract in childhood that results in symptoms, such as projectile vomiting and metabolic disorders that imply a high risk of aspiration during anesthetic induction. In this way, the carrying out of a technique with general anesthesia and intravenous rapid sequence induction, preoxygenation and cricoid pressure are recommended. After the correction of systemic metabolic alkalosis and pH normalization, cerebrospinal fluid can keep a state of metabolic alkalosis. This circumstance, in addition to the residual effect of neuromuscular blocking agents, inhalant anesthetics and opioids could increase the risk of postoperative apnea after a general anesthesia.CASE REPORT: We present the successful management in 3 neonates in those a pyloromyotomy was carried out because they had presented congenital hypertrophic pyloric stenosis. This procedure was done under general anesthesia with orotracheal intubation and rapid sequence induction. Then, ultrasound-guided paravertebral block was performed as analgesic method without the need for administrating opioids within intraoperative period and keeping an appropriate analgesic level.CONCLUSIONS: Local anesthesia has demonstrated to be safe and effective in pediatric practice. We consider the ultrasound-guided paravertebral block with one dose as a possible alternative for other local techniques described, avoiding the use of opioids and neuromuscular blocking agents during general anesthesia, and reducing the risk of central apnea within postoperative period. JUSTIFICATIVA E OBJETIVOS: A estenose hipertrófica do piloro é uma condição relativamente comum do trato gastrintestinal na infância, que causa um quadro de vômitos em jato e alterações metabólicas que envolvem um alto risco de aspiração durante a indução da anestesia. Assim, recomenda-se uma técnica sob anestesia geral e indução intravenosa de sequência rápida, pré-oxigenação e pressão cricoide. Após a correção da alcalose metabólica sistêmica e normalização do pH, o líquido cerebrospinal pode manter um estado de alcalose metabólica. Isso, juntamente com os efeitos residuais de agentes bloqueadores neuromusculares, anestésicos e opioides, pode aumentar o risco de apneia pós-operatória após anestesia geral.CASOS CLÍNICOS: Apresentamos o manejo bem-sucedido em três recém-nascidos que foram submetidos a piloroplastia por apresentar estenose hipertrófica do piloro congênita. O procedimento foi feito sob anestesia geral com intubação orotraqueal e indução de sequência rápida. Em seguida, fez-se um bloqueio paravertebral guiado por ultrassonografia como método analgésico sem a necessidade de administração de opioides durante o período intraoperatório e que mantém o nível analgésico adequado.CONCLUSÕES: A anestesia regional é comprovadamente segura e eficaz na prática pediátrica. Consideramos o bloqueio paravertebral guiado por ultrassom com dose única como uma possível opção a outras técnicas regionais descritas, evita o uso de opioides e bloqueadores neuromusculares durante a anestesia geral e reduz o risco de apneia central no pós-operatório. JUSTIFICACIÓN Y OBJETIVOS: La estenosis hipertrófica de píloro es una afección relativamente común del tracto gastrointestinal en la infancia, que conlleva un cuadro de vómitos en proyectil y alteraciones metabólicas que implican un elevado riesgo de aspiración durante la inducción anestésica. Así, se recomienda la realización de una técnica con anestesia general e inducción de secuencia rápida intravenosa, preoxigenación y presión cricoidea. Tras la corrección de la alcalosis metabólica sistémica y normalización del pH, el líquido cefalorraquídeo puede mantener un estado de alcalosis metabólica. Esta circunstancia, junto con el efecto residual de los bloqueantes neuromusculares, agentes anestésicos inhalatorios y opioides podrían incrementar el riesgo de apnea postoperatoria tras una anestesia general.CASOS CLÍNICOS: Presentamos el manejo exitoso en 3 neonatos a los que se les realizó una piloromiotomía por presentar una estenosis hipertrófica de píloro congénita. El procedimiento se realizó bajo anestesia general con intubación orotraqueal e inducción de secuencia rápida. A continuación se llevó a cabo un bloqueo paravertebral guiado por ecografía como método analgésico sin precisar administración de opioides durante el periodo intraoperatorio y manteniendo un adecuado nivel analgésico.CONCLUSIONES: La anestesia regional ha demostrado ser segura y efectiva en la práctica pediátrica. Consideramos el bloqueo paravertebral guiado con ecografía con dosis única como una posible alternativa a otras técnicas regionales descritas, evitando el empleo de opioides y bloqueantes neuromusculares durante la anestesia general y reduciendo el riesgo de apnea central en el periodo postoperatorio.

2 pages, 2 figures.-- PMID: 19036373 [PubMed].-- Available online Nov 25, 2008., Epignathus refers to a teratoma of the oropharyngeal region composed of cells from the ectodermal, mesodermal, and endodermal layers. When it arises from the palate or pharynx and protrudes from the mouth it may result in life-threatening airway obstruction after birth [K. Izadi, M. Smith, M. Askari, D. Hackam, A.A. Hameed and J.P. Bradley, A patient with an epignathus: management of a large oropharyngeal teratoma in a newborn, J Craniofac Surg 14 (4) (2003), pp. 468–472]. The ex utero intrapartum treatment (EXIT) procedure maintains fetoplacental circulation for sufficient oxygenation in a fetus at risk for airway obstruction.

Reference(s) [1] Khanna R, D’Haens G, Feagan BG, et al. Evaluation of the operating properties of candidate patient reported outcomes for use in randomized controlled trials in Crohn’s disease. Inflamm Bowel Dis 2013; abstract in press. [2] Feagan BG, Rochon J, Fedorak RN, et al. Methotrexate for the treatment of Crohn’s disease. The North American Crohn’s Study Group Investigators. N Engl J Med 1995; 332: 292 7.

The egg-recognition processes underlying egg rejection are assumed to be based on an imprinting-like process (a female learning the aspect of her own eggs during her first breeding attempt). The imprinting-like process and the misimprinting costs have been the objective of many theoretical models and frequently have a leading role in papers published on brood parasitism; however, an experiment has never been undertaken to test the existence of this imprinting-like process by manipulating egg appearance in first-time breeding females. Here, we present the first such experimental study using the house sparrow ( Passer domesticus ), which is a conspecific brood parasite and which has a good ability to reject conspecific eggs, as a model species. We found that contrary to what the hypothesis predicts first-time breeding females did not reject their own eggs in their second breeding attempt. This lack of response against unmanipulated eggs could indicate that females have an innate preference for their own eggs. However, in a second experimental group in which first-time breeding females were allowed to learn the aspect of their (unmanipulated) own eggs, none ejected manipulated eggs during their second clutch either—a finding that does not support the idea of recognition templates being inherited, but instead suggests that recognition templates could be acquired again at each new breeding attempt. Our results demonstrate that it is likely that egg discrimination is not influenced by egg appearance in the first breeding attempt.

ResumenJustificación y objetivosEl síndrome de Goldenhar es un cuadro polimalformativo consistente en una disostosis craneofacial que condiciona una vía aérea difícil hasta en el 40% de los casos. Describimos un caso de un neonato con síndrome de Goldenhar con atresia de esófago y fístula traqueoesofágica al que se practicó cirugía de reparación de la misma.Relato del casoPresentamos un caso de un neonato con síndrome de Goldenhar de 24 h de vida. Presentaba atresia esofágica con fístula traqueoesofágica distal. Se decidió una intervención quirúrgica urgente para la reparación de la misma. Se realizó bajo sedación, intubación con fibrobroncoscopio distal a la fístula, para limitar el paso de aire a esófago y la posible distensión abdominal. Tras la completa reparación de la atresia esofágica y la ligadura de la fístula, el paciente fue trasladado a la unidad de cuidados intensivos con sedoanalgesia e intubado.Conclusionesel hallazgo de un paciente con síndrome de Goldenhar y atresia de esófago supone una situación excepcional y un reto para los anestesiólogos, por lo que el manejo anestésico depende de la comorbilidad del paciente, del tipo de fístula traqueoesofágica, de la práctica hospitalaria habitual y de las habilidades del anestesiólogo responsable, siendo la principal particularidad el mantenimiento de una adecuada ventilación pulmonar en presencia de una comunicación entre la vía aérea y el esófago. La intubación con fibrobroncoscopio distal a la fístula solventa el manejo de la vía aérea probablemente difícil y limita el paso de aire al esófago a través de la fístula.AbstractBackground and objectivesGoldenhar's syndrome is a polymalformative condition consisting of a craniofacial dysostosis that determines difficult airway in up to 40% of cases. We described a case of a newborn with Goldenhar's syndrome with esophageal atresia and tracheoesophageal fistula who underwent repair surgery.Case reportWe report the case of a 24-hour-old newborn with Goldenhar's syndrome. He had esophageal atresia with distal tracheoesophageal fistula. It was decided that an emergency surgery would be performed for repairing it. It was carried out under sedation, intubation with fibrobronchoscope distal to the fistula, to limit the air flow into the esophagus, and possible abdominal distension. Following complete repair of the esophageal atresia and fistula ligation, the patient was transferred to the intensive care unit and intubated under sedation and analgesia.ConclusionsThe finding of a patient with Goldenhar's syndrome and esophageal atresia assumes an exceptional situation and a challenge for anesthesiologists, since the anesthetic management depends on the patient comorbidity, the type of tracheoesophageal fistula, the usual hospital practice and the skills of the anesthesiologist in charge, with the main peculiarity being maintenance of adequate pulmonary ventilation in the presence of a communication between the airway and the esophagus. Intubation with fibrobronchoscope distal to the fistula deals with the management of a probably difficult airway and limits the passage of air to the esophagus through the fistula.

Background: bioelectrical impedance analysis is a technique for the determination of the hydropic component. The hydropic component, determined by blood volume, could be a reflection of the hemodynamic situation. This study aimed to evaluate the usefulness of peripheral bioelectrical impedance analysis (BIA) for the prediction of hemodynamic changes in large-volume paracentesis and prognosis. Methods: this was a proof-of-concept prospective study of 14 patients with liver cirrhosis and refractory ascites. Peripheral bioimpedance was measured three times using a portable device, IVOL®, before and after large-volume paracentesis, at different frequencies (5, 10, 20, 50, 100 and 200 kHz). Consequently, resistance, reactance and phase angle were obtained, both pre- and post-paracentesis (the difference between them was defined as ¿). Results: the mean age of patients was 62.2 ± 9.6 years, the Child-Pugh was 8.4 ± 1.3 and the MELD score was 15.2 ± 3.9. A direct correlation between the extraction of ascitic fluid and ¿resistance (10 kHz [r = 0.722; n = 12; p = 0.008], 20 kHz [r = 0.658; n = 12; p = 0.020] and 50 kHz [r = 0.519; n = 14; p = 0.057]) was observed. The presence of edema was related to lower values of both pre-paracentesis resistance (10 Hz [23.9 ± 8 vs 32.2 ± 4; p = 0.043]) and phase angle (5 kHz [-1.9 ± 2.8 vs 5.9 ± 7.3; p = 0.032]). Pre-paracentesis phase angle was directly correlated with the decline in blood pressure after paracentesis at lower frequencies (5 kHz [r = 0.694; n = 13; p = 0.008] and 10 kHz [r = 0.661; n = 13; p = 0.014]). Lower frequencies of ¿phase-angle impacted on patient prognosis (5 kHz [-8.6 ± 5 vs -2.5 ± 2.7; p = 0.021]), patients with ¿phase-angle 5 kHz > -4 had a higher rate of mortality (83.3% [5/6] vs 0% [0/6]; logRank 7.306, p = 0.007). ¿resistance values were associated with overt HE at six months (10 kHz [4.9 ± 2.5 vs -0.4 ± 4.7; p = 0.046]). Conclusions: in conclusion, a significant correlation between peripheral impedance and hemodynamic changes was found. Impedance was also significantly related to prognosis and overt hepatic encephalopathy.