Benefica chirurgia. A global surgery project focusing on hernia surgery

BACKGROUND

The aim of international health cooperation projects is to alleviate the deficiencies in the area of health in low resource settings. Hernia surgery is a procedure that is well suited to these missions, due to its low morbidity, the fact that it can be performed on an outpatient basis, and the improvement in quality of life that it provides.

OBJECTIVE

To describe the results of Benefica Chirurgia (BC), a Spanish non-profit humanitarian association in hernia pathology.

METHODS

Five one-week surgical campaigns were carried out in Ecuador between 2015 and 2019, involving anesthetists, general and pediatric surgeons. Surgical and medical equipment was provided and transported by BC. ASA I/II patients underwent surgery.

RESULTS

Surgery was performed on 240 patients with hernia pathology on 27 days. Sixty-three per cent of patients were male and the mean age was 48.2 years (range: 1-83). Hernia location was inguinal in 113 patients, umbilical in 101, and other in 26. The anesthetic technique used was spinal in 185 patients (77.1%), local plus intravenous sedation in 31 (12.9%), and general in 24 (10%). The surgical technique used was hernioplasty in 191 patients, herniorrhaphy in 31, incisional hernia repair in 15 and herniotomy in three. Surgery was performed on an outpatient basis in 98.4% of cases. Morbidity was 2%. Long-term postoperative evaluation is very complex.

CONCLUSION

These campaigns make a significant contribution to health in low resource settings and provide great personal satisfaction for those involved. Standards achieved in the immediate postoperative period were similar to those obtained at the surgeons' centers in Europe. However, it is difficult to establish the rates of recurrence and chronic pain.

[How to organize a Fetal Medicine Unit in the context of COVID-19 pandemic. Safe measures for obstetric scans and equipment cleaning]

During a pandemic, the three basic principles are. to prioritize medical resources, ensure patients' lockdown in order to avoid community transmission and prevent healthcare collapse, and keep the number of visits to an absolute minimum to avoid patient exposure and safeguard healthcare workers. Antenatal care must be maintained during a health crisis, regardless of the COVID-19 state of alert. Routine and specialist obstetric ultrasound scans are essential for clinical decision-making during pregnancy, as it has a direct impact on the management of mothers and fetuses and on the perinatal outcome. In an attempt to minimize in-person visits, these will be organized according to the established ultrasound schedule. Based on scientific evidence, and on existing main national and international guidelines, this document has been prepared, in which proposals and options are provided for managing pregnant women in the context of the SARS-CoV-2 pandemic. It includes how a Fetal Medicine Unit facing this health crisis should be restructured, what safety measures should be followed in the performance of obstetric scans and invasive procedures, and how ultrasound rooms, equipment and transducers should be cleaned and disinfected. These recommendations should be adapted to different units based on their resources and infrastructure.

Effects of different cryopreservation methods on DNA integrity and sperm chromatin quality in men

BACKGROUND

Cryopreserved human sperm are used in assisted reproductive technology. However, the effect of cryopreservation on sperm DNA integrity is unclear.

OBJECTIVES

The objectives of this study were to: (i) determine the impact of semen cryopreservation on human sperm DNA integrity and chromatin structure; (ii) test if parameters obtained from TUNEL and SCSA® correlate; and (iii) verify correlation between sperm motility, morphology and viability with TUNEL and SCSA® parameters.

MATERIALS AND METHODS

Men attending a fertility clinic were recruited and grouped according to their sperm parameters (n = 9/group): normozoospermia, oligoasthenoteratozoospermia and teratozoospermia. Each semen sample was processed as follow: (i) directly frozen at -80 °C; (ii) diluted in Sperm Maintenance Medium, cooled for 30 min at 4 °C and frozen at -80 °C; (iii) diluted in Sperm Maintenance Medium; or (iv) in SpermFreeze. Each mixture from method (iii) and (iv) was then suspended for 30 min in liquid nitrogen vapor and plunged into liquid nitrogen. After at least two months of storage, samples were thawed at room temperature and analyzed for motility and viability, TUNEL and SCSA® assays.

RESULTS

Progressive motility and viability decreased after freeze-thawing. TUNEL scores increased significantly in all samples after freezing-thawing while no significant change in the DNA fragmentation index (DFI) from SCSA® was observed. No change in the percentage high DNA stainability (HDS) was observed in normozoospermic samples; however it was significantly increased in all the methods in oligoasthenoteratozoospermic and in the methods (ii)-(iv) in teratozoospermic samples. The DFI and TUNEL scores correlated significantly with each other and inversely with sperm motility, viability and morphology.

DISCUSSION AND CONCLUSION

Cryopreservation seems to be deleterious for the integrity of human sperm DNA and compaction. However, the sperm DFI was not affected during cryopreservation under the various methods of storage tested. Clinicians and investigators should take this information into consideration when using cryopreserved sperm for assisted reproduction.

[Study of pulmonary hypertension and long-term respiratory clinic in children with congenital diaphragmatic hernia]

INTRODUCTION AND OBJECTIVES

The aim of this study is to identify respiratory clinic and pulmonary arterial hypertension (PAH) in congenital diaphragmatic hernia (CDH) and whether these could be predicted by prenatal measures.

MATERIAL AND METHODS

We studied fetal ultrasound: Observed/expected Lung to Head Ratio (O/E LHR) and classified patients according to their outcome (group 1: O/E LHR <25%, group 2: 26-35%, group 3: 36-45%, group 4: >55%) as well as the severity of PAH (group 0: non-PAH, group 1: mild, group 2: moderate, group 3: severe) in echocardiograms at birth, 1st, 6th, 12th and 24 months of life. We also evaluated gestational age, weight, bronchodilator treatment and number of hospital admissions.

RESULTS

58 patients with CDH, 13 without prenatal diagnosis. 36 patients out of 45 had O/E LHR calculated at 22.4 ± 5.8 weeks. O/E LHR had significant association with the severity of PAH at birth and in the 1st, 6th, 12th and 24th months (p <0.05). At 6 months, only 30.4% had PAH without any association with a higher risk of hospital admission [OR 1.07 (0.11-10.1)] and only three patients (5.1%) required bronchodilator treatment.

CONCLUSION

In CDH, PAH and the respiratory clinic improve over time, being uncommon the need for treatment as of the 6th month. O/E LHR predicts the presence and severity of PAH in short and long term.

[The role of fetal magnetic resonance imaging in the study of congenital diaphragmatic hernia]

INTRODUCTION AND OBJECTIVES

Different echographic and fetal magnetic resonance (MRI) measurements have been described in the diagnosis of associated malformations and the prognosis of congenital diaphragmatic hernia (CDH). We have reviewed our experience searching for useful isolated or combined parameters and how MRI can complement ultrasound.

MATERIAL AND METHODS

We evaluated 29 fetuses with CDH. We examined ultrasonography: Lung to Head (LHR o/e) and in MRI: ipsilateral lung volume (IPV) and total expressed as percentage of observed / expected lung volume (VPT o/e) and percentage of herniated liver (PHH). We studied: survival, ECMO and associated malformations.

RESULTS

LHR o/e was the measure that best predicted survival (p< 0.05). VPT o/e did not predict survival or the need of ECMO (p> 0.05). PHH ≥19% was related to the need of ECMO. IPV < 2 cc required ECMO more frequently (p< 0.018) and when it was 0 cc in all cases. No combination of MR measurements was superior to LHR o/e in prediction of survival. MRI complemented the ultrasound in 4 cases: diaphragmatic eventration diagnosed with HDC, right HDC with fluid in the sac that suggested thoracic cyst, differentiation between spleen and lung that measured together overestimated the LHR and/or suspicion of Cornelia de Lange due to facial malformations.

CONCLUSIONS

Not a single or combined MRI measurement exceeds LHR o/e in survival prediction. MRI is related to prognosis and can be used to support ultrasound in making decisions. MRI occasionally provides complementary morphological information.

Dichorionic twin pregnancy discordant for anencephaly: two cases with different management

BACKGROUND

Prevalence ofanencephaly in dichorionic twins is higher than in singleton pregnancies. The authors report two cases with two different management strategies.

CASE 1

Spontaneous dichorionic diamniotic twin pregnancy with the second twin diagnosed with anencephaly at 12 weeks gestation. Selective feticide was performed at the age of 13.2 weeks. Vaginal delivery occurred at 39 weeks, and birth weight was 2,850 g.

CASE 2

Dichorionic diamniotic twin pregnancy discordant for anencephaly in the second twin was diagnosed at 13 weeks gestation. An expectant management was decided. Preterm delivery occurred at 35 weeks due to hydramnios of the affected fetus, delivering a healthy newborn weighing 2,300 g and an anencephalic neonate who died immediately after delivery.

CONCLUSION

Anencephaly should be diagnosed as soon as possible, idealistically at 11-13+6 weeks ultrasound (US) scan, in order to offer the most appropriate counselling to the parents, ranging from selective feticide or expectant management. This short series suggests that selective early feticide may increase gestational age and birth weight.

[Transformation of myelodysplastic syndrome to acute lymphoblastic leukemia: 2 new cases]

Myelodysplastic syndromes (MDS) are clonal disorders of hematopoietic stem cells, with a variable risk of transformation to acute myeloid leukemia. Progression into acute lymphoblastic leukemia (ALL) is an extremely rare event, with very few cases published in children. In this report, we describe two cases of myelodysplastic syndromes that progressed to ALL. Moreover, we review previously reported cases of MDS transformation to acute lymphoblastic leukemia in the pediatric population whose prognosis seems to be similar to that for adults.

Varicella zoster central nervous system vasculitis after allogeneic hematopoietic stem cell transplant successfully treated with cyclophosphamide

We report the first case of varicella zoster central nervous system vasculitis, to our knowledge, which responded to intravenous pulses of cyclophosphamide in an immunocompromised child with severe and progressive disease, without sequelae.

The value of comparative volumetric analysis of urinary and blood erythrocytes to localize the source of hematuria

PURPOSE

We evaluate comparative volumetric analysis of blood and urinary red blood cells (RBCs) to identify the source of hematuria. Comparative volumetric analysis is defined as the difference between mean corpuscular erythrocyte volume in peripheral blood (MCVB) diluted in urine supernatant after centrifugation and mean corpuscular volume of urinary erythrocytes (MCVU). The potential of MCVB-MCVU to distinguish the origin of hematuria is compared to MCVU alone. The fundamental hypothesis is that RBCs that can go through the glomerulus will be smaller than those from the collecting system or lower urinary tract, thus having a smaller MCVU and larger difference between MCVB and MCVU.

MATERIALS AND METHODS

A prospective detailed urological evaluation was performed on 210 patients with glomerular or nonglomerular hematuria detected by urinary sediment, clinical radiological evaluation, endoscopy, cytology and sometimes bladder or renal biopsy. After evaluation 24 cases with an uncertain source of hematuria were excluded from study. Specialized urinalysis, volumetric analysis and clinical investigation were performed in a blind fashion. MCVU and MCVB-MCVU were registered for every patient. The Technicon H-3 system with angle laser scattering dual system allowed measurement of mean corpuscular volume in a minimal number of RBCs, and resuspension of RBC pellets in the same urinary supinate avoided effects of osmolarity and pH on RBC size and shape. Reproducibility in assessing the index was tested in 50 cases in which comparative volumetric analysis was repeated on 2 consecutive days. Unpaired t test was performed, and a threshold value of MCVB-MCVU with maximum sensitivity and specificity to detect glomerular hematuria was identified. The potential of urinary and comparative volumetric analysis to distinguish the source of hematuria was evaluated and compared by receiver operating characteristics curve analysis.

RESULTS

Hematuria was nonglomerular in 53 (28.4%) and glomerular in 133 (71.6%) patients. Mean MCVB-MCVU was significantly different for nonglomerular (0.6 fl.) and glomerular (30.5 fl.) sources (p<0.0001). There was a correlation between repeat independent measures of MCVU and MCVB-MCVU. The highest positive predictive value to detect a glomerular origin is desirable so that unnecessary investigation can be obviated without the risk of missing a nonglomerular source. With a limit of 16 fl. specificity and positive predictive value were 98 and 99%, respectively. Receiver operating characteristics curve analysis to localize the source of hematuria revealed significant differences in favor of comparative volumetric analysis versus urinary volumetric analysis alone.

CONCLUSIONS

MCVB-MCVU using the Technicon H-3 system is a useful noninvasive and accurate method to locate the source of hematuria. A value of 16 fl. or greater practically rules out a nonglomerular origin and obviates further urological investigation. We have incorporated this investigation in our diagnostic algorithm for hematuria.

Prospective biochemical and scintigraphic evaluation of autografted normal parathyroid glands in patients undergoing thyroid operations

BACKGROUND

Parathyroid autotransplantation has been widely used in thyroid operations. Few studies have assessed the function of the autotransplanted glands. The aim of this study was to evaluate the success rate, pattern of biochemical function, and scintigraphic appearance of parathyroid autografts in patients undergoing thyroid operations.

METHODS

Twelve patients in whom 1 parathyroid gland was removed during thyroid operation were included. Glands were fragmented and autografted into individual pockets in the brachioradialis muscle of the nondominant forearm. Parathyroid hormone levels were measured in both arms the day of autotransplantation and 2 weeks and 1, 2, 3, and 6 months after operation. Serum calcium levels were also measured at each interval. Sestamibi scanning was performed 6 months after operation in 7 patients.

RESULTS

All patients were women with a mean age of 50 +/- 15 years. Serum calcium levels were normal during follow-up. A gradient of parathyroid hormone level of 1.5 or greater between the autotransplanted and nontransplanted arm was found in 10 patients. Isotope uptake at the site of the parathyroid autotransplant was demonstrated in the 7 patients evaluated.

CONCLUSIONS

Biochemical function of autotransplanted normal parathyroid tissue was documented in 83% of the patients. Sestamibi scintiscans were able to identify the autotransplanted tissue.

Myelodysplastic syndrome with erythroid hypoplasia/aplasia: a case report and review of the literature

Myelodysplastic syndrome (MDS) with erythroid hypoplasia/aplasia has not yet been clearly defined, and in most patients it is mistaken for acquired pure red cell aplasia (PRCA). We report a patient with severe transfusion-dependent anemia (Hb 6.9 g/dl) and reticulocytopenia. WBC and platelet counts were normal. Bone marrow examination showed a marked trilineage dysplasia and a low percentage of erythroid precursors (3%). A diagnosis of MDS (refractory anemia according to FAB classification) with erythroid hypoplasia/aplasia was made. Repeated cytogenetic analysis of bone marrow showed normal karyotypes. Moreover, serial IgM serology and DNA analysis of the patient's sera for B19 parvovirus were negative. Other conditions known to be associated with erythroid aplasia were also absent. The patient failed hematinics and prednisone therapy. He next received r-HuEPO (200 U/kg three times weekly). This form of therapy achieved a rapid and complete erythroid response. He has remained in complete erythroid response after a 7-month period on maintenance therapy of 100 U/kg three times weekly. A review of the literature revealed only 15 well-documented cases of MDS with erythroid hypoplasia/aplasia. All had morphological evidence of myelodysplasia. These patients were predominantly elderly males, all required regular packed red cell transfusions, and had an unfavorable prognosis, mainly because of a high rate of blastic transformation (frequently preceded by a myeloproliferative phase). The mechanism of erythroid hypoplasia in this subgroup of MDS remains uncertain. However, laboratory and clinical data suggest the existence of an intrinsic stem cell defect. None of the patients received hematopoietic growth factors. To our knowledge, our patient is the first case of MDS with erythroid hypoplasia where r-HuEPO was successfully attempted. The description of more cases is necessary to delineate the value of r-HuEPO therapy in this rare variant of MDS.

Weekly variation of fungal colonies in the atmosphere of Palencia (Spain) throughout the year 1992

We have carried out a qualitative and quantitative study of the fungal colonies developed in two different culture media: Czapecdox and Sabouraud, throughout the year 1992 in Palencia city. A volumetric trap was used. We collected daily samples of aerovagans spore from the atmosphere through a cellulose esther filter, half of which was cultivated on Petri dishes. The following genera were identified: 26 Deuteromycetes (54%), four Zygomycetes (28%), and three bacteria, which along with Actinomycetes, reached 18% of all the registered colonies. Fifty-two percent of the colonies were developed in Czapecdox culture medium and 48% in Sabouraud medium. Most of the bacteria were grown in Sabouraud medium. The highest number of colonies recorded belonged to the following three genera: Mucor (25%), Aspergillus (23%) and Penicillium (16%). Most colonies were grown in autumn (32%), while spring was the second most frequent season when 28% of the colonies were registered.

EBV-positive non-Hodgkin's lymphoma developing after phenytoin therapy

We report the first case of Epstein Barr virus (EBV) positive non-Hodgkin's lymphoma occurring 20 years after continuous phenytoin therapy for idiopathic epilepsy. This malignant lymphoproliferative disease was preceded by an phenytoin-associated benign reactive lymphadenopathy. Serological findings suggested a chronic active EBV infection. Immunohistochemistry showed that neoplastic cells expressed B antigens (CD20, lambda) and the bcl-2 protein. The presence of EBV-encoded latent membrane protein 1 (LMP 1) was also expressed on neoplastic cells. Cytotoxic chemotherapy (CHOP) reversed the non-Hodgkin's lymphoma.

[Preliminary analysis of the modifications of spinal curves, in extreme amplitudes, observed in rhythmic and athletic gymnastics]

Trained users of Rhythmic and Athletic Gymnastic, present kinetic spinal vast extents. Analysis, with pasted cutaneous markers, shows that, according to the codified movement, various segments of the vertebral column are requested and realized important displacements. Nevertheless, to have an homogeneous attitude, some subjects request more either lumbar or thoracic segments, of both. To prevent frequent spinal pain, it is important to realize a preliminary subject selection using their total spine and to improve protection by adapted gymnastic.

Adynamic bone lesion in renal transplant recipients with normal renal function

Adynamic bone lesion has been defined as low bone turnover, normal or low osteoid volume and decreased bone formation rate (BFR). A prospective cross-sectional study was performed in 16 asymptomatic post-transplant kidney patients with normal renal function, to evaluate low bone mineral density. The mean age of the nine women and seven men was 33.9 +/- 7.3 years, the mean serum creatinine was 1.1 +/- 0.2 mg/dl and the mean creatinine clearance 71.5 +/- 13.8 ml/min/1.73 m2. Six patients received triple immunosuppressive therapy for a period of 10.3 +/- 3.7 months and nine received double therapy. Eighty-four months after renal grafting, we carried out bone densitometry, biochemical markers and bone biopsy. Bone densitometry showed 78 +/- 8.7% and 80.4 +/- 8% for hip and lumbar spine, with a mean Z score of 1.79 +/- 0.72 and 1.88 +/- 0.78 (SD), significantly less than normal in the Hispanic young population for those two regions. Serum PTH (0.83 +/- 0.23 microgram/ml normal range 0.32-0.65), urine cAMP (4.1 +/- 1.3, normal range 0.5-4.7 nmol/mg Cr) and total and nephrogenic fraction (3.1 +/- 1.1, normal range 0.29-2.9 nmol/100 ml GFR) were significantly greater than normal (P < 0.01). The bone biopsy in 12/16 patients showed decreased percentage osteoid area (1.59 +/- 0.86% vs 3.19 +/- 0.82%), percentage mineralized area (13 +/- 4.7% vs 21.03 +/- 3.36%) and bone formation rate (505 +/- 237 vs 1275 +/- 168 microns2/mm2/day), with a P value < 0.05 compared with 10 normal bone biopsies. The remaining four patients exhibited low bone turnover image with normal bone formation rate (1442 +/- 206 microns2/mm2/ day). Iron deposits were demonstrated at the mineralization front in 10/16 patients. No aluminium or amyloid deposits were observed. The histomorphometric results showed the presence of adynamic bone lesion in 12 renal transplant recipients with normal renal function and osteopenia, which explains the low bone density. The long-term use of glucocorticoids and the presence of iron deposits may contribute to this bone lesion. The biochemical markers of bone remodelling showed abnormalities compatible with moderate increase in parathyroid function. The adynamic lesion in the presence of hyperparathyroid function may suggest down-regulation of PTH bone receptors, alterations of the bone microenvironment or both.