[Early detection of WHIM symdrome. A case report]

BACKGROUND

WHIM syndrome corresponds to an inborn error of innate and intrinsic immunity, characterized by: warts (Warts), Hypogammaglobulinemia, Infections and Myelocathexis, for its acronym in English.

CASE REPORT

4-year-old male, with severe neutropenia and B-cell lymphopenia from birth, without severe infections or warts; the panel genetic sequencing study of primary immunodeficiencies with the CXCR4 c.1000C>T (p.Arg334*) variant, which is associated with WHIM syndrome.

CONCLUSIONS

The diagnosis of severe neutropenia from birth should include the search for inborn errors of immunity, through genetic sequencing studies, especially in asymptomatic or oligosymptomatic patients.

Diminished cortical bone density of long bones among children with haemophilic arthropathy

INTRODUCTION

Children with haemophilia (CwH) have lower bone mineral density in the spine (trabecular bone) than healthy children. There are few studies focusing on bone mineral density in long bones (cortical bone).

AIM

To evaluate bi-laterally the distal third of radius and midshaft tibias using quantitative ultrasound (QUS) and assess the speed of sound (SoS).

METHODS

A cross-sectional study where 91 CwH and 91 age-matched healthy boys were included. Joint evaluation was determined with the Haemophilia Joint Health Score 2.1 and SoS values. The Z scores were measured with the Sunlight Omnisense 8000 S equipment.

RESULTS

Ninety-one CwH (haemophilia A) were evaluated (26 mild form, 26 moderate, and 39 severe). Most patients were treated with on-demand factor replacement and had higher total HJHS scores according to severity (4.8, 14.8 and 14.1, respectively). Patients with moderate and severe disease showed a statistical difference in SoS values for both radius and tibias compared to controls. QUS Z-scores ≥-2 were more frequent in radius and tibias in CwH, but were statistically significant only in tibias when compared to controls (in 30% mild, 46% moderate, 28% severe, respectively).

CONCLUSIONS

There was diminished cortical bone density in radius and tibias of CwH compared to healthy controls. Changes predominated in tibias, more frequently affected according to the severity of haemophilia. Early intervention with factor replacement combined with physical activity are key aspects to promote bone health.

COVID-19 in the pediatric population of the state of Jalisco: spatiotemporal analysis of 1,515 cases

BACKGROUND

Initial publications of COVID-19 (2019 coronavirus disease) focused on the adult population until March 2020, when the first series in children was reported. Our objective was to analyze the spatiotemporal behavior of the pediatric population with COVID-19 in the state of Jalisco.

METHODS

We conducted a cross-sectional study including subjects < 18 years of age with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection confirmed by reverse transcription-polymerase chain reaction, registered in the RADAR platform. We investigated the prevalence, incidence rate, age, sex, outpatient or inpatient status, distribution of cases by time, municipality of residence, and geographical region. Descriptive statistics were used for data analysis.

RESULTS

Of 58,231 subjects studied, 1,515 were children (3%): 768 males (51%) and 747 females (49%). The mean age was 12 ± 5 years; outpatients predominated (94%). The Central region concentrated the largest cases with 1,257 (82%) and was the second-highest incidence rate, behind the Occidental Coastal-Mountain region. The most affected municipality was Guadalajara. The distribution of new cases increased proportionally to mobility: after the holiday weekend in May, it rose from 28 to 161 cases; after the opening of beaches and recreational sites in June and July, to 539; and after the opening of movie theaters in August, to 673 cases.

CONCLUSIONS

Although with a lower incidence, the pediatric population is not exempt from SARS-CoV-2 infection. We observed an increase in cases as restrictions on social activities diminished.

Psoriasiform skin reaction due to Brazilian keratin treatment: A clinical-dermatoscopic study of 43 patients

Introduction:

Hair straightening products like the Brazilian Keratin Treatment (BKT) contain high concentrations of formaldehyde, and its use is associated with adverse effects. In 2016, seven cases of eczema-like psoriasiform skin reaction secondary to BKT were described for the first time. We aim to investigate the clinical characteristics and dermatoscopic findings of patients with psoriasiform skin reactions due to BKT.

Materials and Methods:

A cross-sectional study was performed from October 2017 to June 2020. Patients who developed erythema and scales on the scalp following the use of BKT were included. Age, sex, number of BKTs, time elapsed between BKT and the skin reaction, pull test, and dermatoscopic findings were investigated. Descriptive and inferential statistics were used.

Results:

We found 43 patients with a mean age of 35 ± 10 years, predominantly females in 42 (98%) cases. The mean number of BKTs was 2 ± 2. The mean length of time elapsed to present the reaction was 12 ± 17 months and this was related to the number of BKTs (P = 0.01). The pull test was positive in 37 (86%) patients. The most frequent dermatoscopic findings were perifollicular scales in 42 (98%), red patches in 35 (81%), and peripilar desquamation resembling the outer skin of an onion bulb in 32 (74%).

Conclusion:

Hair straightening products are widely used and the psoriasiform skin reaction that develops afterward might be underdiagnosed. It is important to investigate the background of BKT in conjunction with the clinical and dermatoscopic findings suggestive of this cutaneous reaction.

Parental satisfaction with health care during child hospitalization at a social security facility in Mexico

BACKGROUND

The Service Quality in Hospital (SERVQHOS) assesses quality and satisfaction with hospital care received. This study aimed to determine the quality and satisfaction of parents in a tertiary-level pediatric public facility in Mexico.

METHODS

We conducted a cross-sectional study in which 425 anonymous surveys were distributed during the discharge of children. The questionnaire evaluates the individual (subjective) and organizational (objective) quality of service: reliability, tangibles, assurance, responsiveness, and empathy, as well as satisfaction on a 5-point scale from 1 (much worse) to 5 (much better).

RESULTS

A total of 401 questionnaires were returned (94%). The mean quality score was 3.6 ± 0.7. The best-rated aspects were the medical equipment technology (3.6 + 0.8), the confidence that the staff transmits to patients (3.6 ± 0.8), and the friendliness of the staff when attending patients (3.6 ± 0.8). The worst-rated aspects were the condition of the rooms (3.4 ± 0.8), the waiting time to be attended by a physician (3.3 ± 0.8), and the timeliness of internal consultations (3.3 ± 0.8). The overall population rated as satisfied in 97% of cases.

CONCLUSIONS

A high rate of satisfaction was observed concerning both objective and subjective factors. However, the negative aspects of objective quality, such as reliability, should be addressed organizationally without implying economic investment in their resolution.

Lymphocytoma cutis (cutaneous B-cell pseudolymphoma): study of 102 cases with emphasis on the histological characteristics and immunohistochemistry of the miliarial type

BACKGROUND

Lymphocytoma cutis (LC) is a benign reactive lymphoproliferative B-cell process. It has two variants: localized type with solitary lesions and miliarial type with numerous lesions. The objective was to investigate the characteristics of LC with emphasis on the miliarial type.

METHODS

Retrospective study, patients with clinical and histopathological diagnosis of LC were included. Age, sex, evolution time, affected site, and type of treatment were investigated. In miliarial-type LC, the histological and immunohistochemical characteristics were also investigated.

RESULTS

In an 18-year period, there were 102 patients found with LC: 72 (71%) corresponded to females, the median age was 45 years, the median evolution time was 4 months, and the face was the most predominant affected area in 81 (79%) cases. Localized-type LC corresponded to 88 (86%) cases, and miliarial type in 14 (14%). The most common treatment was surgery, which was used in 32 (31%) patients, all of whom had localized type (P < 0.01). The most frequent treatment for miliarial-type LC was corticosteroids in five (36%, P = 0.32), the predominant histopathological pattern was nodular in 10 (71%) specimens, and immunohistochemistry was performed in 11 (79%), where all were positive for CD20 with polyclonality to kappa and lambda light chains.

CONCLUSIONS

The importance of LC lies in that it can be clinically and histopathologically confused with cutaneous lymphoma and that it is a rare entity, with its miliarial variant being rarer still. This study provides information on the clinical-histological characteristics of LC and its immunohistochemistry.

Psoriatic arthritis in patients with psoriasis: A clinical-epidemiological study at a dermatology center in western Mexico

BACKGROUND/OBJECTIVE

Psoriatic arthritis (PsA) is a chronic inflammatory illness. Approximately, 15% of psoriasis patients have undiagnosed PsA. In Mexico, we found no related studies. Our objective was to investigate the clinical-epidemiological characteristics of PsA in psoriasis patients in western Mexico.

METHODS

A cross-sectional study including Mexican patients with clinical and histopathological diagnosis of psoriasis. Physical examination, rheumatoid factor analysis and radiographies of axial and peripheral skeleton were performed. The prevalence of PsA using the CASPAR criteria, age, sex; clinical variants of PsA, psoriasis type and the Psoriasis Area and Severity Index (PASI), were assessed. Descriptive and inferential statistics were used.

RESULTS

Of 90 patients with psoriasis, 48 met the criteria for PsA, with a prevalence of 53%, and average age of 50 ± 15 years. Predominating were, the female sex in 29 (60%), the axial variant of PsA in 24 (50%), and psoriasis plaques in 40 (83%). The average PASI was 12 ± 11. All cases were rheumatoid factor negative. These variables were not significantly different when comparing subjects with and without PsA, except for the female sex (60% vs. 7%; P < 0.001).

CONCLUSIONS

Patients with psoriasis should intentionally be evaluated jointly Dermatologists and Rheumatologists searching joint involvement given the high prevalence of PsA previously undiagnosed.

Basal cell carcinoma, blue-white variant: Dermatoscopic findings in 32 cases

BACKGROUND

The diagnosis of basal cell carcinoma is histopathological, but there are dermatoscopic criteria that confer high sensitivity and specificity to help the clinician improve its identification. However, the basal cell carcinoma blue-white variant does not totally meet these dermatoscopic criteria, and thus can be confused with other pigmented tumors. In the literature reviewed, we found only five cases of this variant.

AIMS

The present objective is to describe the dermatoscopic characteristics of the blue-white variant of basal cell carcinoma observed in a tertiary dermatology institute.

METHODS

The dermatoscopy files of patients with a histopathological diagnosis of basal cell carcinoma between January 1, 2006 and December 31, 2015 were reviewed.

RESULTS

A total of 32 cases with blue-white variant of basal cell carcinoma were observed over a period of 10 years. Of these cases, 97% presented dermatoscopic findings not included in the aforementioned criteria, such as whitish septa, structureless white areas, homogenous blue pigmentation and shiny white structures.

LIMITATIONS

The small sample size and the retrospective nature of the design.

CONCLUSION

We consider it important for dermatologists to know this rare variant of basal cell carcinoma and to familiarize themselves with their dermatoscopic findings, in order to prevent erroneous diagnoses or inadequate treatments.

[Clinical characteristics of primary immunodeficiencies in children from a tertiary hospital]

BACKGROUND

Primary immunodeficiencies are diseases that are caused by one or more defects in the immune system.

OBJECTIVE

The purpose of the article is to describe the characteristics of the immunodeficiencies that were diagnosed in a pediatric hospital, which forms a reference center in the West of Mexico.

METHODS

A cross-sectional study of pediatric patients with primary immunodeficiency in a pediatric hospital in Guadalajara, Jalisco.

RESULTS

60 patients were registered, of which 21% were female, and 78% were male. Predominant immunodeficiencies of antibodies formed the largest group (46% of patients). X-linked agammaglobulinemia was the most frequent immunodeficiency (21%); other frequent diagnoses were common variable immunodeficiency, and IgG subclass deficiency. The average age of the patients that were diagnosed was of 6.3 years. The most common initial manifestations were infectious processes (46%), and pneumonia was the frequent diagnosis (30%). Autoimmune manifestations were observed in 13% of patients; 67% of the patients were found with immunoglobulin replacement therapy, with which a decrease in hospitalizations from 3.2 times to 0.13 times was observed. There were two deceased patients due to surgical complications of cardiac correction and intestinal reconnection.

CONCLUSION

Knowing the behavior of primary immune deficiencies in our environment allows the opening of areas of opportunity in order to improve the survival and quality of life of our patients.

Lung Function in Adolescents Exposed to Environmental Contamination and Brickworks in Guadalajara, Mexico

OBJECTIVE

To compare the pulmonary function in adolescents exposed to different concentrations of air pollutants in two different zones.

METHODS

Two zones based on monitoring of environmental pollutant concentration as high (zone 1) and low (zone 2) were chosen. The lung functions of apparently healthy adolescents (12-15 years) residing in two zones were measured for forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC ratio, and forced expiratory flow (FEF)25-75.

RESULTS

A total of 302 adolescents (142, zone 1 and 160, zone 2) resided in the study area, with higher than permissible concentrations of PM10 and ozone at both places. Abnormal lung functions were seen in a higher proportion of adolescents in zone 1 than zone 2 (23% and 14%; P=0.04). A significantly lower mean (SD) FEV1 was seen in adolescents in zone 1 than zone 2 [2.9 (0.5) vs. 3.2 (0.4) L, P = 0.04]. A higher proportion of abnormal FEV1/FVC ratio% was seen in zone 1 than 2 (12% vs. 6%, P=0.04), suggestive of an obstructive pattern on spirometry. Higher risk (b 95% CI) for abnormal lung functions was seen with the zone [2.2 (1.1-4.2)], diagnosis of asthma [5.74 (2.4-13.2)], and living within 500 meters from a brickwork [1.8 (1.0-2.5)].

CONCLUSION

High exposure to PM10, ozone and living near brickwork were associated with reduced lung function in adolescents.

Haplotypes of (-794(CATT)5-8/-173G>C) MIF gene polymorphisms and its soluble levels in basal cell carcinoma in western Mexican population

Basal cell carcinoma (BCC) is the most common dermatological neoplasms in Caucasian populations. In Mexico, a prevalence of 3.9 per 1000 habitants is estimated. Recently, the macrophage migration inhibitory factor (MIF) has been related to different types of cancer. Therefore, this study aimed to investigate the genetic association of haplotypes of [-794(CATT)5-8/-173G>C]MIF gene polymorphisms and its soluble levels in BCC. A total of 360 individuals were recruited for the study, that is, 180 of the total amounts were patients with BCC histologically confirmed and the remaining 180 individuals were identified as control subjects (CS). Both polymorphisms were genotyped by PCR and PCR-RFLP (restriction fragment length polymorphism), and MIF serum levels were measured by ELISA kit. A borderline difference was found between the 55 genotype and the susceptibility to BCC (5.6% vs 1.7% in BCC and CS, respectively, OR=3.7 and p=0.04). Furthermore, the haplotype 7G showed a significant association with BCC (p=0.02, OR=1.99). Concerning MIF soluble levels, patients with BCC showed a media of 2.1 ng/mL and CS showed 4.4 ng/mL, the comparison between groups was significant (p<0.01). Our findings suggest that the 55 genotype and the haplotype 7G are associated with the susceptibility to BCC; furthermore, a significant difference was found between MIF soluble levels in both study groups.

Nevoid acanthosis nigricans: Report of four cases localized to the umbilicus

Nevoid acanthosis nigricans is a rare, benign form of acanthosis nigricans. Of the 24 cases documented in the literature, only two are exclusively localized to the umbilicus. We present four cases of nevoid acanthosis nigricans localized to the umbilicus; in patients less than 25 years of age, with no known co-morbidities, three of whom were females. Two of the cases received, with good response, treatment based on topical calcipotriol, a medication not previously reported to be used for this indication. Contrary to other types of acanthosis nigricans, the nevoid acanthosis nigricans is not associated with any syndrome, endocrinopathy, obesity, medication, or neoplasia and it can be confused with other pathologies such as epidermal nevus or dermatosis neglecta.

Genetic biomarkers related to hemarthrosis, inflammation, and cartilage structure in pediatric patients with hemophilic arthropathy

Background

The pathophysiology of hemophilic arthropathy is complex and not completely understood. In this study, we aimed to identify biomarkers that can affect the hemophilic arthropathy severity.

Methods

Fifty patients were analyzed for biomarker frequencies; in 37 patients, articular symptoms were evaluated based on the physical joint examination score, and in 18, it was based on magnetic resonance imaging. Eight polymorphisms, namely FV 1691G>A, FII 20210G>A, MTHFR 677C>T and 1298A>C, TNFα‐308G>A and ‐238G>A, ACAN VNTR, and IL1RN*2‐VNTR were identified.

Results

Patients with the MTHFR 677TT genotype showed a higher number of affected joints (1.83 ± 0.9 vs. 0.55 ± 0.7 for CC; p = .023), whereas those with the MTHFR 1298AC genotype exhibited higher effusion according to two radiologists (0.90 ± 0.31/1.20 ± 0.63 vs. 0.38 ± 0.52/0.50 ± 0.53 for AA genotype; p = .043/0.036, respectively). In addition, patients with the TNFα‐308GA genotype had more subchondral cysts (0.75 ± 0.95 vs. 0.07 ± 0.26 for GG genotype; p = .041).

Conclusions

The distribution of risk genotypes for MTHFR and TNFα‐308GA suggests their association with clinical parameters of hemophilic arthropathy. Cohort studies are essential to verify these associations.

Cutaneous melanoma in patients from western Mexico: Clinical pathology characteristics and their relationship to prognosis

BACKGROUND/OBJECTIVE

Melanoma is the third most frequent malignant neoplasm in skin. The majority of information available comes from studies performed in Caucasian populations. Our objective was to investigate the clinico-pathological characteristics in Mexican patients with cutaneous melanoma and the relationship these characteristics had to prognosis.

METHODS

A retrospective study included patients with a histopathological diagnosis of melanoma who were attended at a tertiary level Dermatology Institute over a 10-year period. Age, gender, anatomical location; histopathological subtype, Breslow thickness, Clark level; presence of ulceration, metastasis, anatomical-pathological stage and survival were investigated. To assess the data, descriptive statistics, chi-squared or the Fisher exact test and Kaplan-Meier curves were used.

RESULTS

There were 323 patients included. The overall survival rate was 77% with an average follow-up of 7 years. The lowest survival was statistically related to the following: higher age (>65 years), localisation in palms/soles, histopathological nodular subtype, presence of ulceration, Breslow thickness >4.0 mm, Clark level V, the presence of metastasis and stage IV disease.

CONCLUSIONS

Our results relay the characteristics and prognosis of patients with the diagnosis of cutaneous melanoma in western Mexico.

Giant basal cell carcinoma: clinical-histological characteristics of 115 cases

INTRODUCTION

Giant basal cell carcinoma (GBCC) is a tumor ≥5 cm in size, with aggressive biological behavior, that represents 1% of basal cell carcinomas (BCC), and studies regarding it are scarce. Our objective was to investigate the clinical-histopathological characteristics of GBCC and the risk factors associated with its development.

METHODS

A retrospective study over 8 years included patients with the clinical and histopathological diagnosis of GBCC. Age, sex, localization, size, evolution time, risk factors, and histological variants were compared to conventional BCC. Descriptive and inferential statistics were used, and a value of P < 0.05 was considered statistically significant.

RESULTS

Of 5958 patients with BCC, 115 (2%) of them corresponded to GBCC. The average patient age was 73 ± 11 years, and the male sex (52%) and localization on the head and neck (63%) predominated. Average tumor size was 6.6 ± 2.2 cm, evolution time was 96 ± 86 months, and high-grade histological variants (51%) predominated. The group with GBCC had higher age (P < 0.01), greater frequency in the male sex (P = 0.01), longer evolution time (P < 0.01); a greater prevalence of risk factors (24% vs. 16%, P = 0.01), antecedents of other types of cancer (P = 0.03), and of burns (P = 0.03); and a greater frequency of high-grade histological variants (51% vs. 29%, P < 0.01).

CONCLUSIONS

This is the largest series of GBCC published to date. Findings are similar to those previously reported, although the prevalence found here was greater.

[Riesgo de recurrencia y de nuevas neoplasias cutáneas malignas en sujetos mexicanos con carcinoma basocelular]

Introducción

El carcinoma basocelular (CBC) es la neoplasia cutánea maligna más común.

Objetivo

se investigó el riesgo de recurrencia y de nueva neoplasia cutánea maligna después del tratamiento de CBC.

Método

Estudio retrospectivo. Fueron identificados los pacientes con diagnóstico histopatológico de CBC primario, de enero de 2007 a diciembre de 2009, y se revisaron los expedientes para investigar el número de recurrencias, la localización, el tipo de tratamiento y la variante histopatológica, determinando nuevas neoplasias cutáneas malignas. El análisis incluyó estadística descriptiva e inferencial, considerando significativa una p < 0.05.

Resultados

Se incluyeron 397 pacientes, con un seguimiento promedio de 4 ± 1.5 años. La recurrencia se presentó en el 4% y se relacionó con un mayor tiempo de evolución (36 vs. 32 meses; p = 0.04) y haber sido tratado mediante técnicas destructivas (electrofulguración, criocirugía o imiquimod; 31 vs. 4%; p = 0.0004). No hubo relación con la localización ni con la variante histopatológica. El riesgo de desarrollar una nueva neoplasia maligna fue del 25%, y de ellas el 66% correspondió a un nuevo CBC y el 30% a carcinoma espinocelular.

Conclusiones

Es importante el seguimiento de los pacientes con CBC para identificar tanto las recurrencias como las nuevas neoplasias malignas, independientemente de la localización y de la variante histopatológica del primario. El tratamiento con técnicas quirúrgicas condiciona una menor recaída que las técnicas destructivas.

Introduction

Basal cell carcinoma (BCC) is the most common skin malignant neoplasm.

Objective.

Investigate the risk of recurrence and of new skin malignant neoplasms, after treatment of BCC.

Method

Retrospective study. We examined the files of patients with histopathological diagnosis of primary BCC, between January 2007 and December 2009, and we investigate number of recurrences and their relationship with localization, treatment type, and histopathological variant, and the number of new skin malignant neoplasms. For analysis, we employed descriptive and inferential statistics; p < 0.05 was considered significant.

Results

A total of 397 patients, with an average follow-up of 4 ± 1.5 years. Recurrences presented in 4%. Recurrences were related with longer time of evolution (36 vs. 32 months; p = 0.04) and treatment with destructive techniques (electrofulguration, cryosurgery or imiquimod; 31 vs. 4%; p < 0.001). There was no relationship with localization, or the histopathological variant. The risk of developing a new malignant neoplasm was 25%; 66% corresponded to a new BCC and 30% to squamous cell carcinoma.

Conclusions

Follow-up of patients with BCC should be conducted independently of their localization and histopathological variant, especially in patients with greater evolution time, principally with surgical techniques.

[Seguridad y eficacia del modelo de atención fast-track vs. atención convencional en apendicitis no complicada del paciente pediátrico]

Objetivo

Comparar la seguridad y la eficacia de la atención fast-track vs. atención convencional en apendicitis no complicada en un hospital pediátrico.

Método

Ensayo clínico controlado, aleatorizado, con dos grupos de 30 pacientes cada uno: A) fast-track, apendicitis no complicada que cumplieron el programa; y B) atención convencional, apendicitis no complicada con atención habitual. Variables de seguridad y eficacia: proporción de complicaciones y tiempo de estancia hospitalaria.

Resultados

Se incluyeron 60 pacientes, sin diferencia entre grupos: sexo masculino (53 vs. 60%), edad (8 ± 3 vs. 8 ± 2 años), tiempo de evolución (23 ± 21 vs. 24 ± 20 horas), tiempo desde ingreso a urgencias hasta inicio de cirugía (6 ± 4 vs. 8 ± 6 horas), y tipo de apendicitis edematosa (27 vs. 24%) o supurada (73 vs. 76%). La estancia hospitalaria promedio del grupo fast-track fue de 13 ± 5 vs. 72 ± 40 horas del grupo de atención convencional (p = 0.001). Hubo complicaciones en el 3 y el 6%, respectivamente (p = 1.0). La estancia hospitalaria disminuyó 2.45 días por paciente con el protocolo fast-track, lo que representa un ahorro de $ 6,731 pesos/día/paciente/hospitalización (US$ 373), sin un aumento de las complicaciones.

Conclusión

El protocolo fast-track en los niños con apendicitis no complicada es seguro y efectivo en un hospital universitario. El programa fast-track aportó beneficios clínicos y económicos, ahorrando en total $ 403,860 en los 30 pacientes.

Objective

To compare safety and efficacy of fast-track program vs. conventional attention in non-complicated appendicitis attending a pediatric university hospital.

Method

Randomized clinical trial, comparing two groups with 30 patients each: (A) fast-track group, appendicitis agreeing the treatment protocol; and (B) conventional attention group, appendicitis following habitual surgical care. The efficacy and safety measures were length of hospital stay and proportion of complications.

Results

We included 60 patients, there were no significant difference between groups with regard: male gender (53 vs. 60%), age (8 ± 3 vs. 8 ± 2 years-old), time of evolution (23 ± 21 vs. 24 ± 20 h), time since admittance to emergency and beginning of surgery (6 ± 4 vs. 8 ± 6 h), and type of appendicitis edematous (27 vs. 24%) or suppurate (73 vs. 76%). Mean length of hospital stay in fast-track group was 13 ± 5 vs. 72 ± 40 h in conventional attention (p = 0.001). The complications were 3 and 6%, respectively (p = 1.0). Fast-track program diminished length of hospital stay in 2.45 days per patient, representing a mean cost saving of 6,731 Mexican pesos per day, per patient hospitalized (US$ 373), without increased complications.

Conclusion

Fast-track program in children with non-complicated appendicitis is safe and effective in pediatric university hospital; there was cost-minimization without carelessness of safety. This program support clinical and economic benefits, a total saving of 403,860 Mexican pesos for the 30 patients in the fast-track group.

Geographical Distribution and Cluster Detection of Childhood Leukemia in the Metropolitan Area of Guadalajara, Mexico

BACKGROUND

Acute leukemia is the most common cancer in childhood. Analyzing the spatial distribution of acute leukemia may generate the identification of risk factors.

OBJECTIVE

To study the incidence rate of acute leukemia, its geographic distribution, and cluster detection in the metropolitan area of Guadalajara, Mexico.

METHODS

We included children under 15 years of age diagnosed with acute leukemia during the period 2010-2014 in the metropolitan area of Guadalajara. Each case was geo-referenced to street level to latitude and longitude coordinates using Quantum Geographic Information System (QGIS). Spatial clusters were found in the location of the acute leukemia cases applying the Density-Based Spatial Clustering of Applications with Noise (DBSCAN) algorithm with R statistical software.

RESULTS

A total of 269 cases of leukemia were registered, 227 (84%) were acute lymphoblastic leukemia and 42 (16%) acute myeloblastic leukemia. The mean age was 6 ± 4 years. The mean incidence of acute leukemia was 6.44 cases/100,000 inhabitants: El Salto 10.12/100,000, Guadalajara 7.55/100,000, and Tlaquepaque 6.74/100,000. The DBSCAN found three clusters, all located within the municipality of Guadalajara.

CONCLUSIONS

The incidence of acute leukemia in our population is higher than that in Canada and the USA. We found three spatial clusters of childhood acute lymphoblastic leukemia in the municipality of Guadalajara, suggesting the presence of local predisposing factors.

Psoriasis in Children and Adolescents: Epidemiological Study of 280 Patients from Mexico

BACKGROUND

Psoriasis in children and adolescents has not been well studied in Mexico.

OBJECTIVE

To study the epidemiological characteristics of psoriasis in this age group.

METHODS

This is a retrospective study in an academic, tertiary care dermatology center from January 1999 to December 2014. We included patients ≤ 18 years of age, with clinical and histopathological diagnosis of psoriasis. We recorded the following information: gender, age, disease duration, clinical variant, nail involvement, treatment, and family history. Descriptive and inferential statistics were used for analysis.

RESULTS

Of 2,491 patients with psoriasis, 280 were ≤ 18 years of age, resulting in a prevalence of 11%. There was female predominance and the mean age was 11.5 years. Disease duration was 18 ± 34 months. Plaque psoriasis was the most common form, comprising 191 cases (68%). Nail involvement occurred in only 15 patients (5%). Topical treatment was given to 177 patients (63%). Only 14 cases (5%) had a family history of psoriasis. These variables did not differ when children were compared with adolescents, except in those with a shorter disease duration (13 ± 19 vs. 24 ± 29 months; p = 0.0004).

CONCLUSIONS

We found a higher prevalence of psoriasis than previously published studies in this age group and a lower frequency of nail involvement and family history of psoriasis.

Models Predictive of Metabolic Syndrome Components in Obese Pediatric Patients

BACKGROUND AND AIMS

Components of metabolic syndrome (MetS) are complications caused by abdominal obesity and insulin resistance (IR). Diagnosis of MetS by clinical indicators could help to identify patients at risk of cardiovascular disease and type 2 diabetes. We undertook this study to propose predictive indicators of MetS in obese children and adolescents.

METHODS

A cross-sectional study was carried out. After obtaining informed consent and the registration of the study with an institutional research committee, 172 obese patients from an Obesity Clinic, aged 6-15 years, were included. Variables included were waist circumference (WC), glucose, high-density lipoprotein (HDL), triglycerides (TGL), blood pressure, insulin resistance (by homeostatic model assessment HOMA-index), acanthosis nigricans (AN), uric acid, serum glutamic oxaloacetic transaminase (GOT) and alanine transaminase, and hepatic sonogram. International standards for age and sex variables were used. Multivariate analysis was applied.

RESULTS

Variables predicted components of MetS in children: HOMA-IR (insulin resistance by HOMA index) was increased by 2.4 in hepatic steatosis, by 0.6 for each unit of SUA (serum uric acid), and by 0.009 for every mg/dL of triglycerides. In adolescents, every cm of waist circumference increased systolic blood pressure by 0.6 mmHg, and each unit of SUA increased it by 2.9 mmHg.

CONCLUSIONS

Serum uric acid and waist circumference are useful and accessible variables that can predict an increased risk of cardiovascular disease in obese pediatric patients.

[Adverse events during diagnostic and therapeutic pediatric cardiac catheterization]

BACKGROUND

The aim of this paper is to determine the frequency of adverse events during heart catheterization, in both categories diagnostic and therapeutic procedures in children.

METHODS

We review the clinical charts of those patients undergoing heart catheterization during the period from May 1 to October 31, 2014, in order to determine the frequency of adverse events presented within the first 24 hours after the procedure.

RESULTS

During the six month period, 143 procedures were performed, of which 126 met the inclusion criteria. According to the type of procedure we divide it in: diagnostic 68 (54%) and therapeutic 58 (46%). Adverse effects were developed in 16 patients (13%), 11.7% during diagnostic and 14% within the therapeutic procedures. The adverse events were classified as serious in 7 (5.5%), endangering the live in 5 (3.9%) and catastrophic in only one (0.79%). Those factors associated with the development of an adverse event were: age less than one year-old (OR = 5.45), unscheduled admission to the procedure (OR = 1.2) and use of inotropic drugs (OR = 7).

CONCLUSIONS

Cardiac catheterization performed in our facility is a safe procedure, with a percentage of adverse events similar to that reported worldwide. It is essential to make a proper and comprehensive assessment of the patient before the procedure, considering stratification according to risk categories and assessing the state of gravity of the children.

Safety and efficacy of cetirizine versus cetirizine plus ranitidine in chronic urticaria: Double-blind randomized placebo-controlled study

BACKGROUND

First-line treatment for chronic urticaria is H1 non-sedating antihistamines. When these fail, guidelines recommend combination with H2 antihistamines.

AIM

We conducted a randomized, double-blind, placebo-controlled trial.

METHODS

Thirty-two patients with chronic urticaria were included. Group A (16 subjects) treated with cetirizine plus ranitidine and Group B (16 subjects) with cetirizine plus placebo, both for 30 days. Efficacy measures were Urticaria Activity Score (UAS), Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) and time of symptom remission, safety measures were clinical and laboratory effects.

RESULTS

Complete remission was obtained in ten patients (62.5%) from Group A and seven patients (44%) from Group B (p = 0.28). The UAS in Group A was 1.53 ± 2.09 versus Group B 2.06 ± 1.34 (p = 0.20). The CU-Q2oL in Group A was 12.93 ± 19.20 versus Group B 12.68 ± 10.30 (p = 0.20). At the end of treatment, 13 patients (81%) from Group A and 14 patients (87.5%) from Group B had some type of adverse effect (p = 1.0).

CONCLUSIONS

Combination of cetirizine with ranitidine was not more effective than cetirizine alone in chronic urticaria. Both treatments resulted equally safe; however, our main limitation is the small sample size.

Pirfenidone gel in patients with localized scleroderma: a phase II study

Introduction

Localized scleroderma is an inflammatory disease in its first stages and a fibrotic process in later stages, principally mediated by the transforming growth factor β. To date, there is no standard treatment. The objective of this study was to determine the effectiveness and safety of 8% pirfenidone gel in patients with localized scleroderma.

Methods

This was an open phase II clinical trial that included 12 patients. Treatment with pirfenidone was indicated, three times daily for 6 months. Patients were evaluated clinically with the modified Localized Scleroderma Skin Severity Index (mLoSSI), as well with a durometer and histologically using hematoxylin and eosin stain and Masson’s trichrome stain.

Results

The baseline mLoSSI average scores were 5.83 ± 4.80 vs. 0.83 ± 1.75 (P = 0.002) at 6 months. The initial durometer induration of the scleroderma plaques was 35.79 ± 9.10 vs. 32.47 ± 8.97 at 6 months (P = 0.05). We observed histopathological improvement with respect to epidermal atrophy, inflammation, dermal or adipose tissue fibrosis and annex atrophy from 12.25 ± 3.25 to 9.75 ± 4.35 (P = 0.032). The 8% pirfenidone gel application was well tolerated, and no side effects were detected.

Conclusions

This is the first study on the therapeutic use of pirfenidone gel in localized scleroderma. It acts on both the inflammatory and the fibrotic phases. Considering its effectiveness, good safety profile and the advantage of topical application, pirfenidone is a treatment option in this condition.

Visuoperceptual sequelae in children with hemophilia and intracranial hemorrhage

BACKGROUND

The goal of this study was to examine the impact of focal brain injuries on the outcomes of visual perception and visuospatial abilities in Mexican children with hemophilia who have experienced intracranial hemorrhages.

METHODS

We assessed ten boys who had hemophilia with intracranial hemorrhage (HIC), six boys who had hemophilia without intracranial hemorrhage (HH), and ten boys without hemophilia (CTL). The Verbal (VIQ), Performance IQs (PIQ), and Full Scale IQs (FSIQ) from the Wechsler Intelligence Scale for Children-Mexican Revision, Visual Perception, and Visuospatial Abilities domains, which are from a neuropsychological assessment battery for Spanish-speaking children (ENI), were employed for our analysis.

RESULTS

The results showed that the HIC group performed in the low-average range on the PIQ and FSIQ, which was lower than the HH group. The HIC group showed low performance on visual perception tests, such as line orientation, fragmented objects, and overlapping figures, compared with their matched controls.

CONCLUSIONS

The results suggest that it is not the ability to recognize objects that is impaired in the HIC group, but the ability to identify objects under less favorable conditions. Our findings may have therapeutic and rehabilitative implications for the management of children with hemophilia and early focal brain lesions.

[Costs of appendicitis treatment by diagnosis-related groups in a third-level pediatric hospital]

BACKGROUND

Diagnosis-related groups (DRGs) are widely used in Europe. They allow performing comparisons in hospitals and incurrent hospital payment systems, defining the payment categories. We undertook this study to classify children who underwent appendectomy according to DRGs.

METHODS

Cross-sectional study. Comorbidities, length of hospitalization, histopathologic classification, and DRG classifications were analyzed.

RESULTS

We included 313 patients, 62% males, with an average age of 8 ± 3 years; 91% were referred by another hospital and 67% were treated at night. Average length of hospitalization was 4 ± 3 days. There were comorbidities in 8% and surgical complications in 11%. According to histopathology, appendicitis was edematous (11%), suppurative (36%), gangrenous (22%), perforated (29%), and abscessed (2%). At discharge, 97% of the patients were healthy. Total cost for DRG 343 was $10,470,173.00 (Mexican pesos), DRG 342 was $1,227,592.00 and DRG 340 was $511,521.00. The global amount was $12,209,286.00 (Mexican pesos).

CONCLUSION

The unitary cost for treatment of appendectomy for DRG 343 was $37,935.00, for DRG 342 was $49,103.00 and for DRG 340 was $42,626.00 (Mexican pesos). Because 88% of the cases of appendicitis were uncomplicated, this amount of money could be spent to treat these patients in a second-level hospital, using reimbursement 343 without generating additional expenses.

Odontogenic cutaneous fistulas: clinical and epidemiologic characteristics of 75 cases

BACKGROUND

Odontogenic cutaneous fistulas arise as a sequel of bacterial invasion of the dental pulp, become necrotic, and infection spreads into the periradicular area resulting in dissection and breakthrough to form sinus tracts that drain towards the skin. The objective of this study was to investigate the clinical and epidemiologic characteristics of patients diagnosed with odontogenic cutaneous fistulas.

METHODS

A retrospective study was done between January 2001 and December 2011. Cases were included with a clinical and radiological diagnosis of odontogenic cutaneous fistulas. The variables investigated were frequency, gender, age, localization, morphology, time of evolution, and referral clinical diagnosis. Data were analyzed using descriptive statistical methods.

RESULTS

During an 11-year period, 75 cases were found. Female gender predominated with 53% of the cases, and the mean age was 45 ± 26 years. The most frequent location was the mandible angle, in 36% of the cases, and the most common morphology was a nodule, in 52%. The mean time of evolution was 8 ± 11 months. The referral clinical diagnosis was odontogenic cutaneous fistulas in 51% of the cases.

CONCLUSIONS

Our results are similar to those previously published-the diagnosis was suspected in only half of the cases. We consider it important that odontogenic cutaneous fistulas be included among the differential diagnosis of cutaneous facial lesions to avoid delaying appropriate treatment.

Is executive function intact after pediatric intracranial hemorrhage? A sample of Mexican children with hemophilia

The goal of this study was to examine executive functioning outcomes in children with hemophilia who have suffered intracranial hemorrhage. We assessed 10 boys with hemophilia with intracranial hemorrhage; 6 boys with hemophilia without intracranial hemorrhage; and 10 healthy boys as controls. Intellectual functioning was assessed with subscales from the Wechsler Intelligence Scale for Children-Mexican Revision. Concept formation and reasoning, cognitive flexibility, and planning and organization domains from a neuropsychological assessment battery for Spanish-speaking children were employed for our analysis. Results indicated that children with intracranial hemorrhage demonstrated significant impairment on some measures of executive function compared with the control groups. All differences reflected poorer performance by the intracranial hemorrhage group. These results may reflect the impact of disruption to immature brain circuits and the deficiency of functional specificity within the immature brain. This is the only known study examining neuropsychological functioning in Mexican youth with hemophilia.

Functional independence score in hemophilia: a cross-sectional study assessment of Mexican children

BACKGROUND

The Functional Independence Score in Hemophilia (FISH) is a performance-based assessment tool used to measure the patients functional ability so far only used in patients with severe hemophilia. Its aim is to determine if FISH is useful in patients with mild and moderate disease.

PROCEDURE

In a cross-sectional study 90 children 60 hemophilic and 30 sex-, race-, and age-matched healthy males were assessed. Patients between 5 and 16 years of age were selected each patient was evaluated in seven activities under three categories: self-care (grooming and eating, bathing, and dressing), transfers (chair and squat), and locomotion (walking and step climbing). Each activity was graded from 1 to 4 according to the amount of assistance required to perform the activity with total scores ranging from 7 to 28.

RESULTS

As a whole, the mean age of the patients was 10.0 +/- 3.4 years with a mean FISH of 25.8 +/- 3.6 (range 15-28). There were no differences in the FISH between healthy males and patients with mild hemophilia; however, the score was significantly higher in patients with mild hemophilia (28 +/- 0) than patients with moderate (26.2 +/- 2.5; P = 0.004) or severe hemophilia (24.0 +/- 4.7; P = 0.0006). The most affected activities were squatting, walking, and step climbing.

CONCLUSIONS

A significant decrease in functional ability was demonstrated according to the severity of hemophilia, especially for those activities involving weight-bearing demands like locomotion and step climbing. Of seven activities evaluated, changes were observed in the group with moderate and severe hemophilia, but no changes detected in patients with mild disease.

Acute generalized exanthematous pustulosis: report of 12 cases and literature review

BACKGROUND

Acute generalized exanthematous pustulosis is an acute pustular eruption occurring after infection and/or drug ingestion, with spontaneous cure after a single eruption.

AIM

To communicate a series of cases of acute generalized exanthematous pustulosis.

METHODS

A retrospective analysis was performed on cases of acute generalized exanthematous pustulosis, observed between 1993 and 2006 at the Dermatology Department, Hospital General de Occidente, Jalisco, Mexico.

RESULTS

Twelve patients were included, with a predominance of male patients and a mean age of 28 years. The most common cause was drugs, detected in 83% of cases, and most of these were a result of anticonvulsants and antimicobials. The most frequent symptoms were itching, present in all cases, and fever, present in 92% of cases.

CONCLUSIONS

Acute generalized exanthematous pustulosis is considered to be a distinct clinical and histopathologic entity. Because of its self-resolving character, early recognition can help to avoid unnecessary diagnostic studies and treatments.

Use of complementary and alternative medicine in children with cancer in Occidental, Mexico

PURPOSE

To describe the types of complementary and alternative medicine (CAM) used by pediatric cancer patients attending a tertiary care hospital in Western Mexico.

PATIENTS AND METHODS

In a cross-sectional survey, parents were interviewed and types of CAM employed as well as factors related to their use and their perceived effectiveness were determined.

RESULTS

One hundred ten parents of pediatric cancer patients completed the survey. Seventy-seven patients (70%) received CAM. Of CAM used, herbal remedies (69%) and orally administered products (26%) were most common. Mean number of therapies was 2 +/- 1.1 (95% CI 1.59-2.12). Prior CAM use by the family was associated with use in patients (P = 0.006) (OR 4.6, CI 95% 1.7-12.9). Perceived usefulness was reported in 79% of CAM users.

CONCLUSION

CAM use in Mexican children is common, most frequently with herbal therapies. The majority perceived benefits with its usage but in most cases, the treating physician was not informed about this practice.

Pimecrolimus 1% cream for the treatment of discoid lupus erythematosus

OBJECTIVES

To determine the safety and efficacy of pimecrolimus cream on lesions of discoid lupus erythematosus.

METHODS

In an open-label phase II trial, patients with discoid lupus were treated with pimecrolimus 1% cream twice daily for 8 weeks. We assessed skin involvement with a clinical severity score, quality of life, patient improvement and toxicity. The changes were documented by skin biopsy at baseline and at the end of treatment.

RESULTS

Ten patients with a mean age of 34 +/- 17 yr and disease duration of 3 yr (range 1-8) were studied; 90% were female and 40% had received prior topical or systemic therapy without response. In all patients, improvement of skin damage was observed after therapy. A significant decrease of 52% was observed in the mean +/- s.d. clinical severity score, from 6.1 +/- 1.4 before treatment to 2.9 +/- 1.5 after treatment (P = 0.005). Quality of life score (0 = no effect, 100 = maximum effect on quality of life) showed a mean improvement of 46%, from 42.8 +/- 23.1 before to 23 +/- 16.5 after treatment (P = 0.008). According to the patients' assessment of the response to treatment, 50% qualified as marked improvement, 40% moderate and 10% slight improvement. The treatment was well tolerated; adverse reactions consisted of minimal erythema and pruritus, which resolved without any further action.

CONCLUSIONS

Our data suggest that pimecrolimus cream for discoid lupus erythematosus seems to be a safe and clinically effective option. However, this was an open and uncontrolled study, and double-blind, placebo-controlled studies are needed.

Onychomycosis in systemic lupus erythematosus: a case control study

OBJECTIVE

Immunosuppressed patients are prone to develop onychomycosis. In systemic lupus erythematosus (SLE) there are no previous studies. We aimed to establish the prevalence, clinical characteristics, and organisms causing onychomycosis in SLE patients compared with controls.

METHODS

Fifty consecutive patients with SLE seen on an outpatient basis and 50 sex and age matched controls. Samples were obtained when abnormal nails were found: distal and lateral subungual onychomycosis (DLSO), white superficial, proximal subungual (PSO), endonyx, and total dystrophic (TDO). The nail specimens were evaluated in a blinded fashion, by mycologic examination and culture.

RESULTS

Of the SLE patients, there were 12 (24%) with onychomycosis confirmed. The distribution of the clinical forms were TDO 6/12 (50%), DLSO 4/12 (33%), and PSO 2/12 (17%). The causative organisms were isolated in 6 cases: Trichophyton rubrum 3/6 (50%), Trichophyton mentagrophytes 2/6 (33%), Microsporum canis 1/6 (17%). Direct microscopy examination revealed fungal elements in the other 6 cases. Of the 50 controls, 4 (8%) presented onychomycosis [p = 0.029; OR 3.63 (95% CI 1.04-14.68)]: DLSO 2/4 (50%), and TDO 2/4 (50%). Trichophyton rubrum was isolated in 1 and Trichophyton mentagrophytes in 1 (50%).

CONCLUSION

These data suggest a higher prevalence of onychomycosis in SLE versus controls, the predominant organism was Trichophyton rubrum, an anthropophilic dermatophyte. Toenails were more frequently affected and the most common clinical presentation was TDO. PSO, a rare pattern in immunocompetent subjects, was exclusively found in the lupus group.

Proximal white subungual onychomycosis caused by Microsporum canis in systemic lupus erythematosus

We report the case of a Mexican lupus patient who developed proximal white subungual onychomycosis on multiple toenails. Microsporum canis was the causative agent. Both nail invasion by M. canis and proximal white subungual onychomycosis are rare conditions indicative of an underlying immunodeficiency.

Minor Salivary Gland Punch Biopsy for Evaluation of Sjögren’s Syndrome

Incisional biopsy of labial salivary glands has been a valuable technique for diagnosis of Sjögren's syndrome. This report describes a new technique using punch biopsies that requires fewer resources and appears to be equally effective. Fifty patients evaluated by punch biopsy all yielded adequate pieces averaging 6 glands per specimen. Two patients had transient numbness of the lip. There were no other complications. Classical findings of Sjögren's histopathology were demonstrable with these specimens. This technique is safe, less expensive, and is proposed as a reliable alternative to incisional biopsy.