User perspectives of digital manufacturing for lower-limb prosthetic sockets

BACKGROUND

There is growing interest to use digital technology (DT) for manufacturing lower-limb prosthetic sockets to improve efficiency and clinical outcomes. However, little is known about how lower-limb prosthesis users perceive DTs, such as 3D scanning and 3D printing.

OBJECTIVES

This study aimed to provide an understanding of perceptions and experiences with DT for prosthetic socket manufacturing from the perspective of prosthesis users.

STUDY DESIGN

A qualitative descriptive research study.

METHODS

Nine lower-limb prosthesis users (mean age 56; 5 female; 4 male) participated in one-on-one semistructured telephone interviews. Inductive thematic analysis was performed to identify a codebook and emerging themes from the interview transcripts.

RESULTS

Two major themes were identified: (1) expectations and prioritization of 3D printed socket usability and (2) facilitators and barriers to uptake of DT among patients.

CONCLUSION

DT methods were found to be acceptable and feasible from a patient perspective, although technological advancements are still required, and real-time communication about the process may be vital for ensuring patient engagement. Consideration of these findings may improve patient satisfaction to emerging prosthesis treatment plans and ultimately support widespread adoption of DT as an additional tool for fabricating prosthetic sockets.

A qualitative study exploring healthcare professionals' perceptions of lower limb 3D printed sockets

PURPOSE

The purpose of this study was to explore healthcare professionals' (HCPs) perceptions and experiences related to 3D scanning and 3D printing for fabricating lower limb prosthetic sockets.

MATERIALS AND METHODS

This study used a qualitative descriptive approach. Participants were recruited through HCPs' professional associations, social media posts, and snowball sampling. Purposive sampling was used to attain variation in provider type. One-on-one telephone interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was performed to identify the main themes.

RESULTS

Three themes were identified: (1) 3D scanning of the residual limb for designing prosthetic sockets is perceived as clean, quick, and convenient; (2) concerns about the strength and safety of 3D printed sockets for long-term use; (3) Adoption of 3D scanning and 3D printing technology for fabricating prosthetic sockets.

CONCLUSION

We identified perceived benefits and challenges with digital technologies for fabricating prosthetic sockets. To increase adoption, more research demonstrating its efficacy compared to conventional methods, increasing 3D printing material quality, and improving software training programs are needed.Implications for Rehabilitation3D printing and 3D scanning are emerging digital technologies that can be used as alternative methods for prosthetic socket manufacturing in the field of rehabilitation.Our research identified perceived benefits of using digital technologies for fabricating prosthetics sockets (3D scanning is perceived as clean, quick, and convenient) and perceived challenges (concerns about the strength and safety of 3D printed sockets for long-term use and a prolonged learning curve).To increase adoption of these digital technologies, more training should be provided to prosthetists and support provided to integrate new processes into staff workloads.

7 Pregnancy from a vitrified-warmed alpaca pre-implantation embryo

The alpaca (Vicugna pacos) is a ruminant livestock species in the South American camelid family. There are more than 9 million South American camelids globally that make important contributions to the livelihoods of rural farmers through conversion of low quality roughages to high quality food and fibre. Reproductive biotechnologies for alpacas are not well developed compared with those for other ruminant livestock species. In particular, embryo cryopreservation technologies are lacking. The objective of this study was to evaluate under field conditions a vitrification protocol originally developed for old world camels that we adapted for use in alpacas. Potential donors were evaluated for follicular development using a 7.5-MHz ultrasound probe. Hembras (sexually mature female alpacas) with ovarian follicles 7-10mm in diameter were behaviour tested to determine sexual receptivity, and receptive females were naturally mated to a proven herd sire. At the time of breeding, non-superovulated donors (n=4) received 30μg gonadorelin. Embryos were nonsurgically collected 7 days after breeding and handled at 20°C. Diameter of harvested embryos (n=4 quality grade 1 hatched expanded blastocysts) was measured using an eyepiece reticle. All recovered embryos were placed individually into 0.5-mL drops of vitrification solution (VS1: 1.4M glycerol) for 5min, 0.5-mL drops of VS2 (1.4 M glycerol + 3.6M ethylene glycol) for 5min, 0.05-mL drops of VS3 (3.4 M glycerol + 4.6M ethylene glycol) for 20s, and 0.05-mL drops of VS3 for 20s while loading into open-pulled straws (OPS). Each OPS was plunged directly into liquid nitrogen for storage for 29 days. At warming, each OPS was submerged into a 1-mL drop of warming solution 1 (WS1: 0.5M galactose) for 1min followed by 1min in WS2 (0.25 M galactose) for 5min before being incubated at 37°C in 5% CO2 in humidified air for 21h in 1mL of Syngro holding medium supplemented with 10% (vol/vol) alpaca serum. Embryos that grew during culture (n=2) were transferred individually into synchronous recipients, and embryos that did not appear to grow (n=2) were transferred together as a pair. Prior to embryo transfer, potential recipients were evaluated ultrasonographically as described previously. Hembras with ovarian follicles 7-10mm in diameter were behaviour tested, and sexually receptive females received 30μg gonadorelin 6 days before embryo transfer. Final selection of recipients (n=3) was based on presence of a corpus luteum and nonreceptive behaviour to a herd sire 24h before transfer. Pregnancy was detected ultrasonographically, and fetal heartbeat was detected 29 days post-transfer in one of the three recipients. Ultrasound at 177 days post-transfer revealed that the pregnancy, generated from a 400μm×375μm vitrified-warmed embryo that had grown in culture, was still ongoing. If this pregnancy results in the birth of a live cria (newborn alpaca), it would represent-to the best of our knowledge-the world's first cria born from a cryopreserved alpaca pre-implantation embryo. It would also demonstrate the potential utility of this protocol under field conditions.

New designs in early clinical drug development

The availability of an unprecedented massive amount of data has provided a magnificent window of opportunity for the development of new drugs. There are currently more drugs in development targeting cancer than any other disease. While this has brought us new waves of drugs, the counterpart is that with these new molecules we have different mechanisms of action, drug kinetics and dynamics, response types and toxicity profiles, which impair classical early clinical trial designs from being effective and efficient. What we once treated as a 'one-size-fits-all' homogeneous disease, has now been uncovered to be a rather heterogeneous condition with multiple targetable mutations. As this generates endless scenarios, it will be impossible to design single 'me-too' trials for every different disease, target, biomarker and agent. To overcome this, we must focus on improving early phase studies, undoubtedly the most critical step from bench to bedside. Goals include decreasing clinical development times, lowering research and development costs and optimizing decisions in advancing through the several phases with a higher degree of certainty in exchange for less failed attempts. We need more informative and, really, transformative early phase designs that seek to obtain the typical late phase objectives in a time continuum and to allow for more robust and efficient go/no-go decisions. With this in mind, different classes of drugs seem to fit with different designs, which present solutions to the different challenges that they pose after finding the maximum tolerated dose/optimum biological dose. This article reviews these concepts and designs and how they can adapt to this new reality in early phase investigation.

[Arterial sinus pericranii. First case report]

INTRODUCTION

Sinus pericranii (SP) is a rare vascular anomaly consisting in an abnormal intradiploic communication between intra and extra cranial venous systems. It usually presents as a congenital soft mass in the cranial midline with progressive growth, which enlarges significantly with Valsalva maneuver. A similar congenital vascular anomaly involving intra and extra cranial arterial systems has not been previously described in the medical literature.

CLINICAL CASE

A 6-year-old boy with suspected midline capillary malformation of the frontal bone was referred to our Vascular Anomalies Unit for progressive increase in size. A conclusive ultrasound of high flow malformation was performed. Angio-TAC confirmed the arterial nature of the lesion and its communication with the middle meningeal artery. Embolization of the distal portion of the middle meningeal artery was performed prior to surgery. Previous to exeresis of the malformation, skin expanders were placed to cover the subsequent defect. The histopathological result was an arteriovenous malformation. Currently the patient is 10 years old and is asymptomatic, with no recurrence of the lesion.

CONCLUSIONS

Since its first description, SP has been classified and described in the literature as a venous malformation. Although morphologically may resemble a SP, histologically and immunohistochemically it corresponds to an arteriovenous malformation with intracranial arterial connection. It is especially important to know how to diagnose this type of cranial malformations because their long-term evolution will depend on correct management and initial follow-up.

Motility and recovery of alpaca (Vicugna pacos) spermatozoa after centrifugation in a density gradient solution

BACKGROUND

One of the factors limiting successful processing of alpaca (Vicugna pacos) semen is the viscosity of seminal plasma. The viscous nature of the collected ejaculate has hindered sperm cryopreservation as well as artificial insemination (AI) under field conditions.

AIMS

The objective of this investigation was to evaluate recovery, motility, and plasma membrane integrity of alpaca spermatozoa after centrifugation in one of two different solutions at one of three different combinations of speed and time.

METHODS

A total of 24 ejaculates was recovered from seven reproductively sound Huacaya males using a modified artificial vagina (AV) after training the animals for semen collection. A 2 × 3 factorial treatment arrangement was utilized for this study. Ejaculates were divided into fractions for centrifugation in one of two solutions (Tris extender or PureSperm^®80 density gradient solution) at one of three combinations of speed and time (492 × g for 15 min, 1968 × g for 10 min, or 4448 × g for 7 min). The experiment was replicated eight times.

RESULTS

Analysis revealed that centrifugation at 4448 × g for 7 min in PureSperm^®80 provided a high recovery rate of spermatozoa with the highest sperm motility and functional integrity of plasma membrane post-centrifugation. Conclusion: Results suggest that adoption of this procedure (centrifugation at 4448 × g for 7 min in PureSperm^®80) in the initial processing of alpaca ejaculates may enhance subsequent ability to use semen for AI and other assisted reproductive biotechnologies in this species.

Pepsin egg white hydrolysate ameliorates metabolic syndrome in high-fat/high-dextrose fed rats

The aim of this study was to examine the effect of a pepsin egg white hydrolysate (EWH) on metabolic complications using a high-fat/high-dextrose diet-induced Metabolic Syndrome (MetS) experimental model. Male Wistar rats were divided into 4 groups which received: standard diet and water (C), standard diet and a solution with 1 g kg^-1 day^-1 of EWH (CH), high-fat/high-dextrose diet and water (MS), and high-fat/high-dextrose diet and a solution with 1 g kg^-1 day^-1 of EWH (MSH). EWH consumption normalized body weight gain; abdominal obesity and peripheral neuropathy developed in MetS animals, and adipose tissue and liver weight, as well as plasma glucose were reduced. Oxidative stress and inflammation biomarkers were normalized in MSH animals. In conclusion, the oral administration of EWH could be used as a functional food ingredient to improve some complications associated with MetS induced by unhealthy diets.

Expression enhancement in brown adipose tissue of genes related to thermogenesis and mitochondrial dynamics after administration of pepsin egg white hydrolysate

Pepsin egg white hydrolysate enhanced mitochondria proliferation on brown adipose tissue and thermogenesis. Reduced body weight and adiposity were observed.

Pepsin Egg White Hydrolysate Ameliorates Obesity-Related Oxidative Stress, Inflammation and Steatosis in Zucker Fatty Rats

The aim of this work was to evaluate the effect of the administration of egg white hydrolysates on obesity-related disorders, with a focus on lipid metabolism, inflammation and oxidative stress, in Zucker fatty rats. Obese Zucker rats received water, pepsin egg white hydrolysate (750 mg/kg/day) or Rhizopus aminopeptidase egg white hydrolysate (750 mg/kg/day) for 12 weeks. Lean Zucker rats received water. Body weight, solid and liquid intakes were weekly measured. At the end of the study, urine, faeces, different organs and blood samples were collected. The consumption of egg white hydrolysed with pepsin significantly decreased the epididymal adipose tissue, improved hepatic steatosis, and lowered plasmatic concentration of free fatty acids in the obese animals. It also decreased plasma levels of tumor necrosis factor-alpha and reduced oxidative stress. Pepsin egg white hydrolysate could be used as a tool to improve obesity-related complications.

Dietary fiber and blood pressure control

In the past few years, new strategies as dietary fiber to control blood pressure levels are emerging by developing new bioactive components of foods. The implicated mechanisms are under research.

164 EMBRYO SURVIVAL TO CALVING ACCORDING TO TYPE OF EMBRYO AND EMBRYO TRANSFER METHOD IN ALPACAS

The objective of the study was to determine the embryo survival up to calving of fresh and cryopreserved (frozen and vitrified) alpaca embryos transferred into alpaca recipients by nonsurgical transcervical embryo transfer and by surgical laparoscopically aided embryo transfer. For this report we have compiled the information from 127 embryo transfers in alpacas done by our group at Mallkini, Puno, Peru, at 4200 m elevation. The embryos have been collected from superovulated donor alpacas flushed at 6.5 days post mating, some were transferred as fresh and some were cryopreserved; the recipients (3 to 7 years old) were selected based on presence of functional corpora lutea at ecosonographic examination and subjected to ovarian cycle synchronization and ovulation induction as per Vivanco (2013). From a total of 133 alpacas selected, 127 were used, from which 82 received fresh, 32 frozen, and 13 vitrified embryos. All embryos were classed as A-class expanded blastocysts at time of transfer. By nonsurgical transcervical embryo transfer, 33 embryos were transferred fresh, 22 were frozen/thawed embryos, and 13 were vitrified/warmed embryos. By surgical laparoscopically aided method, 49 embryos were transferred fresh and 10 embryos were frozen/thawed; no vitrified embryos were transferred by this method. Results are detailed in Table 1. Pregnancy losses occured at up to 9 weeks (63 days) of gestation, the heaviest loss occurs in the first 3 weeks. After 9 weeks of gestation, no losses were registered. In average, 22% of fresh embryos transferred were represented as crias born. None of the cryopreserved embryos survived up to 11 weeks post-transfer. There is no difference in percentage of crias born between nonsurgical transcervical embryo transfers and surgical laparoscopically aided embryo transfers.The heavy embryo losses could be related to nutrition and high-altitude limitations; however, it is difficult to make comparisons with others because reports to date lack information on the actual crias born from embryo transfers in alpacas; most of the reports are based on pregnancy reports up to 30 to 60 days post-transfers. To date, no births from cryopreserved alpaca embryos have been reported. Furher studies on causes of embryo/fetal losses are necessary. Table 1.Results of embryo transfer This study was financed by the Peruvian Fund for Innovation, Science and Technology (FINCYT).

CD34+ circulating progenitor cells after different training programs

Circulating progenitor cells (CPC) are bone marrow-derived cells that are mobilized into the circulation. While exercise is a powerful mediator of hematopoiesis, CPC levels increase, and reports of their activation after different types of exercise are contradictory. Moreover, few studies have compared the possible effects of different training programs on CPC concentrations. 43 physically active healthy male subjects (age 22±2.4 years) were assigned to 4 different training groups: aerobic, resistance, mixed and control. Except for the control group, all participants trained for 6 weeks. Peripheral blood samples were collected through an antecubital vein, and CPC CD34(+) was analyzed on different days: pre-training, post-training, and 3 weeks after finishing the training period. While no significant differences in CPC were observed either within or between the different training groups, there was a tendency towards higher values post-training and large intra- and intergroup dispersion. We detected an inverse linear relationship between pre-training values and % of CPC changes post-training (p<0.001). In the CPC values 3 weeks after training this inverse relationship was maintained, though to a lower extent (p<0.001). No changes in CPC CD34(+) were detected after 6 weeks of different training groups, or after 3 weeks of follow-up.

[Cervico-sternotomy for thoracic inlet conditions in children]

BACKGROUND/AIM

Neither cervicotomy nor postero-lateral thoracotomy allow safe surgical access to the lower cervical spine and high posterior mediastinum with full control of the vascular and neural structures involved. We report our favorable experience with cervico-sternotomy for accessing this region.

PATIENTS AND METHODS

Six patients were operated upon between 1998 and 2011 for either removal of huge cervico-thoracic neural ganglioneuromas (n = 2) or anterior arthrodesis for congenital (n = 2), neuropathic (n = 1) or osteolytic scoliosis (n = 1). In all cases, cervicotomy was followed by sternotomy, thymectomy, division of the innominate vein and dissection of jugular veins, carotid arteries and vagus nerves.

RESULTS

The tumors measured 10.9 x 3.9 x 8.7 cm and 8 x 6 x 5 cm, and involved the paravertebral chain from the aortic arch to the base of the skull and from the left lung hilus to the thyroid region respectively. In the scoliosis patients, anterior vertebral fixation between C5 and T5 was readily feasible. Blood transfusion was avoided. Horner's syndrome and transient lymphedema were the only complications. Median operative time was 210 minutes (range 180-240 minutes) and median estimated blood loss was 2.7 cc/kg (0-13.8 cc/kg). Median hospital stay was 7 days (range 5-18 days).

CONCLUSIONS

Cervico-sternotomy is an optimal approach for this anatomical region in children. It offers better exposure of the anterior cervico-thoracic spine and the thoracic inlet than cervicotomy or thoracotomy. Control of the nervous and vascular structures was safely achieved in all cases and postoperative discomfort was surprisingly limited.

Warthin tumor in an unusual site: a case report

Warthin tumor (papillary cystadenoma lymphomatosum, adenolymphoma) is a benign neoplasm from salivary glands and is almost restricted to the parotid gland and the periparotid lymph nodes. Its etiopathogenesis has been associated with tobacco smoke. Several authors believe that the tumor develops from heterotopic salivary gland tissues or through the attraction of a heavy lymphoid reaction. Most cases involve the lower pole or the tail of the parotid. Since its description, a few cases have been reported in other sites, like the submandibular salivary gland. This study aimed to describe a rare presentation of a Warthin tumor and discuss its etiology and differential diagnosis. A 72-year-old male patient presented an asymptomatic, nodular mass adjacent to the submandibular salivary gland. Based on clinical diagnosis of cervical lymphadenopathy, the patient underwent a surgical excision of the lesion. Histopathological exam revealed a benign neoplasm from salivary glands composed of two components: epithelial and lymphoid. The findings were consistent with Warthin tumor. Warthin tumor from submandibular salivary gland is a rare lesion. Professionals should not misinterpret their site of origin, as if they were from the lower pole or the tail of the parotid.

Long-term bladder function, fertility and sexual function in patients with posterior urethral valves treated in infancy

OBJECTIVE

To address the issue of sexual function and fertility in PUV patients.

PATIENTS AND METHODS

Of 47 patients (age > 18 years) treated for PUV in infancy 28 were contactable. They were sent a standard questionnaire requesting details on voiding dysfunction symptoms, and experience of erection, orgasm and ejaculation.

RESULTS

Of the 28, 16 (mean age 24 years) returned the questionnaire. Voiding frequency ranged from 3 to 10 times per day (mean = 5). Two patients had occasional mild diurnal incontinence but none had symptoms of overactivity. Three patients had a weak urinary stream. Renal function was normal in 9, 4 had a glomerular filtration rate <80 ml/min/1.73 m(2), and 3 had undergone renal transplant. Erections and orgasm were experienced by the 15 patients who responded to these questions, with 4 reporting mild or medium erectile dysfunction and 1, on dialysis, reporting slow ejaculation. Post-masturbation samples of semen and urine were collected from 6 patients. One had an alkaline pH, high percentage of immotile sperm and low sperm count. Another had a high concentration of abnormal forms, and seminal fluid was present in the urine of 3 patients.

CONCLUSIONS

In long-term follow-up, 44% of PUV patients develop chronic renal failure or end-stage renal disease, but bladder dysfunction symptoms are infrequent. Sexual function is mostly normal. Total semen counts and motility are compatible with paternity in most patients.

Nitric oxide mediates the antihypertensive and vascular relaxing effects of a soluble cocoa fiber product in spontaneously hypertensive rats

The involvement of endothelial-relaxing factors on the vascular and antihypertensive effects of a cocoa fiber product (CFP) obtained from cocoa husks was studied. We carried out in vitro experiments with aorta rings from untreated spontaneously hypertensive rats (SHR) and in vivo experiments with SHR. CFP did not relax the endothelium denuded aorta rings and N(W)-nitro-l-arginine methyl ester (l-NAME) partially blocked the vascular relaxing and antihypertensive effects of CFP. Nevertheless, indomethacin did not modify these effects. Nitric oxide mediates therefore the antihypertensive and aorta relaxing effects of CFP in SHR.

[The polyphenols, naturally occurring compounds with beneficial effects on cardiovascular disease]

In recent years, a number of studies have endorsed the beneficial effects of polyphenols intake on health, especially on the cardiovascular system. This is important since cardiovascular diseases are the main death cause worldwide. The effects of polyphenols are mainly due to their antioxidant properties. These compounds present vasodilating effects, and they can improve the lipid profile and lessen the oxidation of low-density lipoproteins (LDL). They show clear antiinflammatory effects and they can modulate the apoptotic pathways in the vascular endothelium. This review defines from the structural viewpoint the different groups of polyphenols that may occur in vegetables, and updates the knowledge on their bioavailability. Some of the recent studies establishing their beneficial properties at a cardiovascular level are also included.

Brain perfusion SPECT in patients with PHACES syndrome under propranolol treatment

INTRODUCTION

Children with PHACES syndrome (PS) and visual impairment or stridor show a dramatic and immediate response to propranolol. However, this beta-blocking drug could be responsible for an eventually increased risk of ischemic stroke due to the underlying cerebral vascular disease. To more accurately understand the effects of propranolol on brain vascularization, we examined PS patients treated with this drug for airway or visual complications using brain perfusion SPECT (Single Photon Emission Computed Tomography). In the past, this examination has been shown to be useful in the management of patients with different neurovascular disorders.

METHODS

Clinical records and imaging studies were reviewed in 7 patients with a diagnosis of PS. All patients underwent magnetic resonance angiography (MRA), echocardiography, chest X-ray and ophthalmologic, neurological, and cardiologic assessments. They received 2-3 mg/kg/day propranolol in an attempt to treat stridor or avoid ophthalmologic occlusion. We performed SPECT after 3-6 months of treatment.

RESULTS

SPECT showed a normal uptake in the frontal and temporal regions despite vascular abnormalities found with MRA imaging. Significant improvements of symptoms and in the volume of the hemangioma were noted in all cases without signs of a reduction of brain blood perfusion.

CONCLUSIONS

Propranolol treatment was safe in our patients who did not show signs of perfusion changes. The high sensitivity for detecting functional impairment makes brain perfusion SPECT useful in the diagnosis and follow-up of patients with PS considered at risk of neurovascular impairment. Accurate knowledge of its pathophysiological basis, together with the appropriate technique and careful interpretation of reporting, will enhance the clinical use of brain SPECT in those patients.

Liver transplantation in children with cystic fibrosis: experience in our centre and preliminary results with a combined en bloc liver-pancreas graft

AIM OF THE STUDY

Cystic fibrosis (CF) is a multisystemic disease, with some patients developing end-stage liver disease (ESLD), requiring liver transplantation (LT). These children usually present with severe mutations of the CFTR gene. Almost 100% of patients with severe mutations develop exocrine pancreatic insufficiency, leading later to endocrine insufficiency. Immunosuppression accelerates the development of insulin-dependent diabetes (IDD) in transplanted children with CF. Our aims were: (1) to analyze our experience with CF-related ESLD children who received LT, and the relationship to the development of IDD; (2) to report our preliminary results with en bloc liver-pancreas transplantation (CLPT).

METHODS

9 children (6M/3F) with CF and ESLD underwent LT between 1993 and 2010; median age and weight were 12.3 years (range: 5.4-17.0) and 36.7 kg (range: 14.2-58.5), respectively. 4 patients received a whole graft, 4 had reduced grafts (1 split) and 1 underwent CLPT. Immunosuppression followed the protocols at the time of transplantation.

RESULTS

Liver function was restored in all patients and none of them needed re-transplantation. Median follow-up was 105 months (range: 4-206). 1 child died of respiratory failure at 23 months after transplantation while awaiting pulmonary transplantation. Survival (Kaplan-Meier) at 105 months was 87.5%. 4 children already had IDD before transplantation and 3 developed diabetes immediately after transplantation. 2 had not developed IDD at the end of the study: the youngest at the time of LT (5.4 years, follow-up 7.1 years) and the girl who had had CLPT and who recovered normal exocrine and endocrine pancreatic function after transplantation.

CONCLUSIONS

LT is a realistic option to treat CF-related ESLD children. IDD is common in these patients. En bloc liver-pancreas transplantation is an appealing option, since it simultaneously restores exocrine function and prevents IDD. This procedure has clear technical advantages over simultaneous isolated liver and pancreas transplantation.

[Noninvasive positive pressure ventilation in postoperative period of tracheal surgery]

OBJECTIVES

Reconstructive surgery of the airway often means prolonged periods of intubation during the post-operatory period, increasing the needs for drugs and favoring the appearance of infectious complications. We present an original system of ventilatory support with non-invasive positive pressure ventilation (NIPPV) using in patients subjected to reconstructive surgery of the airway.

PATIENTS AND METHODS

A retrospective study in patients undergoing reconstructive procedures of the airway in the year 2009 was carried out. We exclude those treated endoscopically and those who had vascular rings. The positive pressure mechanism used in the Surgery Critical Care Unit was a design made by the unit based on the circuit devised by Mapleson that provides optimum levels of ventilation without need for connection to a respiratory. We analyze the results, postoperatory intubation time, time dependent on NIPPV and medical treatment received.

RESULTS

A total of 7 patients (1 Female and 6 Males) with median age of 1.6 (0.1-7.5) years were included. The diagnoses were: 4 subglottic stenosis, 2 had tracheal stenosis and 1 subcarinal stenosis with involvement of both principal bronchioles. The techniques used were: laryngotracheoplasty with costal cartilage graft (4), tracheoplasty with costal cartilage (1) and sliding tracheoplasty (2) with bilateral bronchoplasty in one of them. The mean time of nasotracheal intubation was 3 days, and mean time of NIPPV was 2.3. No patient required reintubation and none had infectious complications.

CONCLUSIONS

Ventilatory support by VPPNI allows effective extubation in these patients, it being possible to maintain a safe airway. Infectious complications, frequent in prolonged intubations, were not observed in any of the cases.

[Correction of the complicated pectus excavatum with extracorporeal circulation (ECC) support]

INTRODUCTION

The most serious complication in surgery of the pectus excavatum is the possible cardiac perforation. After its resolution, it is very likely that the relapse of the excavatum will be more severe due to the intense retrosternal fibrosis generated, involving cardiac structures and fixing them to the sternum. Reintervention requires modifications of the usual techniques and special monitoring due to the increased risk of cardiac and large vessel lesions. We present the case of 2 patients with severe pectus excavatum with a previous attempt for correction with cardiac perforation.

CLINICAL CASES

Case 1. A 16 year old male with Haller index 9.9, diagnosed of Ehlers-Danlos syndrome and operated on in neonatal period of cardiac disease, with previous attempt for correction using the Ravitch technique that relapsed and cardiac perforation during it. Case 2. An 11 year old girl, with background of diaphragmatic hernia and cardiac perforation on introducing the Nuss bar at 5 years of age, with Haller index 5.5. Both were operated on under ECC with the collaboration of the Cardiac Surgery Service and cardiac adherences were released after median sternotomy. After it, the Nuss bar was introduced and then sternal closure was performed with reinforced steel wires with titanium plates in the anterior and posterior part.

DISCUSSION

The backgrounds of the cardiac approach complicate the intervention for the correction of the pectus excavatum, with a high risk of cardiac trauma. Counting on the support of the cardiac surgery and the ECC, we achieve an adequate control and prediction of the complications

Late surgery for spinal deformities in children previously treated for neural tumors

BACKGROUND/AIM

Surgery for neural tumors occasionally involves opening of the neural canal and/or costovertebral resection that may be followed by radiotherapy. Spinal deformities (SD) may occur in these cases. This study investigated the incidence, surgical indications and results of repair of late SD in a large series of patients with neural tumors.

METHODS

A retrospective review of neural tumors treated between 1991 and 2009 at our institution identified children with SD who subsequently required spinal surgery. SD was meaÂ-sured using Cobb's angle. Instrumentation of the spine was indicated in patients with a Cobb's angle of more than 60° or rapidly progressing SD. The operation was adapted to the location, type and degree of SD. Patients were followed up and the remaining deviations were measured annually.

RESULTS

Out of a series of 188 patients with neural tumors, 5 of 173 patients with neuroblastomas/ganglioneuromas (NB/GN) and 3 of 15 patients with PNET/Askin tumors developed SD over time. NB/GN children had intraspinal tumors requiring laminotomy (n=3) or laminectomy (n=2). PNET/Askin tumor patients had undergone largescale rib and partial vertebral body resection and radiotherapy. Scoliosis or kyphosis were located in the thoracic spine in 4, in the thoracolumbar spine in 3 and in the cervicothoracic spine in 1. The median preoperative Cobb's angle was 65° (50°-90°) prior to spinal surgery performed 2.9 (0.4-11) years after tumor removal. 3 growth bars, 2 vertical expandable prosthetic titanium ribs, 1 pediatric ISOLA device and anterior instrumentation were used. Arthrodesis was necessary in 3 patients. Median post-instrumentation deformity after 3.1 (0.2-12.2) years was 40° (20°-50°), giving an improvement of 38.4%.

CONCLUSIONS

With increasing numbers of children surviving cancer, attention must focus on sequelae. A sizeable number of survivors of NB/GN and PNET/Askin tumors develop serious SD requiring surgical correction. Pediatric surgeons, patients and relatives must be aware of these possible sequelae.

High-risk hepatoblastoma: results in a pediatric liver transplantation center

AIM

Aim of the study was assess the results of the treatment of High-Risk Hepatoblastoma (HRH) in a tertiary center where all liver surgery facilities, including pediatric transplantation (LT), are available.

METHODS

91 primary liver tumors treated between 1991 and 2009 were retrospectively reviewed. HRHs as defined by the SIOP criteria (PRETEXT IV or any stage with venous involvement, extrahepatic disease, tumor rupture and <100 ng/ml serum AFP) were identified and imaging and biopsies were reviewed. The treatment consisted of total removal of the tumor, involving extended hepatectomies and LT if necessary, together with SIOPEL-guided chemotherapy.

RESULTS

23/57 hepatoblastomas were HRH (11F/12M). 17 were considered unresectable by standard techniques, 3 had extrahepatic disease, and 3 fulfilled both criteria. Mean age at diagnosis was 2.3 ± 2.4 years. 3 children (referred after chemotherapy) died without surgery. 4 had resections (2 left and 2 right trisegmentectomies). Primary LT was required in 15 children (7 cadaveric donors and 8 living related donor transplantations (LRDT), 2 of them with retrohepatic vena cava replacement), and 1 patient had rescue LT after recurrence. Mean follow-up was 4.8 ± 2.9 years. 2 children who had undergone liver resection developed pulmonary metastases at 1.7 and 1.6 years postoperatively and survived after surgical treatment. 2 children with LT developed EBV-related lymphoma and leukemia respectively but survived. Event-free survival (EFS) at 1, 5, and 10 years was 78.3 ± 8.6%, 63.1 ± 10.5%, and 63.1 ± 10.5%, respectively. 6 children died (3 without surgery, 1 after liver resection, 1 after primary LT and 1 after rescue LT). Overall survival at 1, 5 and 10 years was 78.3 ± 21.7%, 73.2 ± 26.8% and 73.2 ± 26.8%. Of those with primary LT, survival at 1, 5 and 10 years was 93.3 ± 6.4%, 93.3 ± 6.4% and 93.3 ± 6.4%.

CONCLUSIONS

Outstanding results in the treatment of HRH are possible in tertiary centers when referral is early (preferably at diagnosis) and specialized liver surgery and transplantation facilities are available.

[Traumatic diaphragmatic hernia: a vital need for an early diagnosis]

INTRODUCTION

Traumatic diaphragmatic hernia (HDT) is exceptional in children. Its diagnosis is usually delayed for appearing in the context of severe polytrauma. The aim is to analyze our series in relation to the severity scores.

PATIENTS AND METHODS

Five patients with HDT are presented. Age, biomechanics, clinical, ISS (injury severity score), ITP (pediatric trauma index), GCS (Glasgow coma scale), RTS (Revised Trauma Score) and treatment were studied. The probability of survival (Ps) was calculated with the TRISS method, Ps = 1/(1 + eb), b = b0 + bl (RTS) + b2 (ISS) + B3 (age).

RESULTS

There were two males and three females, mean age was six years old (range = 3-10). Traffic accident was the mechanism of the thoracoabdominal trauma in 80% and one was crushed by garage door. The affected side was right in two cases and left in three. Mean ISS was 41 (range = 32-57), ITP 6 (range = 2-9) and RTS 6.1 (range = 5.1 to 6.9). The main symptom was respiratory. Plain chest radiography was diagnostic in three patients, one by CT scann, and another was a finding at laparotomy. Two had liver herniation, one had tension gastrothorax and two had gastric perforations. All patients underwent surgery through the abdomen. Estimated survival by the TRISS method was respectively 86.6%, 78.2%, 57.2%, 84.7% and 57.1%, while the actual was 100%. One has a severe disability.

DISCUSSION

To study the biomechanics and semiology is essential in the early diagnosis of TDH in pediatric polytrauma and suspect it is mandatory prior to realize percutaneous chest procedures. The TRISS method has a great importance to assess the adult polytrauma, but specific scores are needed for children.

Arterial blood pressure and aortic responses in obese, age-grouped Zucker rats

Endothelial dysfunction is one of the many proposed mechanisms of hypertension and it may justify, at least in part, the increased blood pressure of hypertensive subjects. Nevertheless, the exact mechanisms involved in the hypertensive condition of obese Zucker rats are unclear. In this study, we measured the arterial blood pressure (tail cuff method) of four groups of seven, female, obese Zucker rats each. The rats of groups 1-4 were 9-12, 15-18, 21-24 and 27-30 weeks old respectively. We also evaluated the responses of aortic rings to KCl, methoxamine and acetylcholine, in these animals. Aortic rings were successively exposed to 80 mM KCl and to methoxamine (10(-8)-10(-5) M). The endothelium-dependent relaxation to acetylcholine (10(-9)-10(-5) M) was also established in the methoxamine-precontracted tissue (precontraction close to 80% of the maximum effect of methoxamine). A clear increase in the arterial blood pressure was observed when the age of these animals increased. The contractile responses to KCl and methoxamine were lower in the aortic rings of rats with increased arterial blood pressure. The response to acetylcholine was lower in the rings from 15-18, 21-24 and 27-30 weeks old rats, than in the younger groups. In conclusion, obese Zucker rats develop hypertension and endothelial dysfunction. Nevertheless, the arterial contractions elicited by depolarization or by α(1)-adrenoceptor stimulation decrease in aged, obese Zucker rats.

[Bean or blue rubber blue nevus syndrome. Presentation of 6 patients]

INTRODUCTION/AIMS

Bean or Blue Rubber Bleb Nevus Syndrome (BRBNS) is an uncommon disease characterized by multifocal venous malformations that predominantly affect the skin, soft tissues and gastrointestinal tract. Our objective is to familiarize the pediatric surgeon with this condition, promoting early diagnosis and seriated surgical treatment as therapeutic options. We have reviewed the diagnosis and treatment of 6 patients treated from 1993 to 2009.

MATERIAL AND METHODS

All the patients had a venous malformation (> 10 cm) that acted as a marker. After, characteristic skin lesions appeared as well as chronic anemia due to digestive bleeding associated to hypofibrinogenemia. Age of appearance of the anemic picture varied from 6 months to 7 years, it being more aggressive the earlier its appearance. The diagnosis of the disease was made by endoscopically. All the patients required transfusion with blood derivatives 5 to 25 times a year. Treatment was multidisciplinary: periodic transfusions in every case, endoscopic sclerosis in lesions that affect the colon or stomach and surgical treatment for lesions of the jejunum and ileum. In two of these patients, 23 and 46 lesions were excised, respectively. In the last year, the tendency has been to use enterotomy and fulguration with Argon.

RESULTS

The patients who have undergone excision of the digestive malformations have experienced a significant decrease in their transfusion needs. One female patient with miliary dissemination died.

CONCLUSIONS

BRBNS is a difficult to diagnose due to its low frequency. Treatment of gastrointestinal tract lesions is multidisciplinary, combining endoscopic and surgical techniques that decrease transfusions and improve the quality of life of the patients.

[Chronic idiopathic intestinal pseudoobstruction and Berdon syndrome: still a diagnostic and therapeutic challenge for the pediatric surgeon]

AIM/BACKGROUND

Chronic Intestinal Pseudo Obstruction (CIPO) and Berdon Syndrome (BS) are motility disorders with still unclear pathophysiology, and challenging diagnosis and management. Patient and methods. 26 patients (8M/18F) treated of CIPO (21) or BS (5) at our institution between 1982-2009 were retrospectively reviewed and clinical, diagnostic, therapeutic and follow-up data were analyzed.

RESULTS

77% had a neonatal onset by the 3rd month of life (5 had a prenatal diagnosis of megacystis). Abdominal distension (87%), recurrent suboclusive episodes (70%) and malnourishment (60%) were the main symptoms followed by vomits, chronic diarrhea, constipation and dysfagia. The urinary tract was involved in 12 patients (46%): 8 had megacystis, 8 had vesicoureteral reflux. Arrythmias were seen in 2, deafness in 1, hydrocephalia in 1 and malrotation in 5. Radiological studies were consistent for CIPO in all of them: the disease was limited to the esophagus in 1, 3 had segmentary involvement of the small bowel, 6 had microcolon, and the rest had all the digestive tract involved. Anorectal manometry ruled out aganglionosis in 12, esophageal manometry showed aperistalsis in 9 and antro-duodenal manometry confirmed the diagnosis in 9 (visceral myopathy in 4 y neuropathy in 5). Rectal biopsies (16) and muscular biopsies (5) were normal in all of them. Full thickness biopsies (in 18, after surgery) showed myopathy in 12 and neuropathy in 6. Prokinetics and antibiotics for bacterial overgrowth were employed in 100%, 17 required long-time parenteral nutrition (PN), 21 required surgery and 7 were transplanted (4 isolated small bowel, 3 multivisceral). Symptoms improved in 9/15 with an ileostomy. 19 weaned from PN. After a median follow-up of 7.9 years (range 5m-17a), 3 were lost, 17/23 patients are alive and only 2 on home PN. Six died, 3 after being transplanted.

CONCLUSIONS

CIPO and/or BS have a wide clinical spectrum and a complex diagnosis; however, the knowledge of the disease and an appropriate treatment, generally aggressive, allows the patients with CIPO to enjoy a long-term acceptable quality of life.

[Need of hepatic bipartition or split in the transplant in children]

AIM

To analyze the benefits of Split (for adult and for child) in liver transplantation.

PATIENT/METHODS

1) Analysis of the waiting list mortality estimated on 228 inclusions for transplant since January 2004 to December 2008.2) Impact of the variant techniques (living-related donor and split) on the waiting list mortality in our patients. 3) Analysis of the outcome of 33 split livers which allowed to perform 66 transplants (1994-2008).

RESULTS

Estimated as number of patients by 1,000 candidates by year of exposure, the waiting list mortality was 110 in children older than 5 year old, 180 in children from 2 to 5 year-old, 90 in children between 1 and 2 year-old and 510 in younger than 1 year (p<0.05 for the last group). 36/66 split grafts were implanted by our group. Five grafts were lost, 3 due to retransplantation and 2 due to death. Overall patient/graft survival alter 10 years of follow-up was 94.5% and 85.1%, respectively. The rest of the grafts (n=30), were used in other hospitals, and 4 were lost in the early postoperative period. Since the beginning of the study, 85.4% of children between 1 and 2 years, received a living-donor or a split graft, as only 59.9% in the younger than 1 year-old group.

CONCLUSION

Our results absolutely justify the ethics of split liver transplantation for an adult and a child. Despite other factors, the benefits of the variant techniques in the 1-2 year-old group are obvious. Up to 60% optimization with these techniques in children younger than 1 year would not be yet enough in order to decrease the mortality waiting list down to that of the rest of the groups.

[Pneumonectomy in children]

BACKGROUND/AIM

Pneumonectomy is seldom indicated in children and its long-term effects are not well known. The aim of the present study was to examine retrospectively the indications and the long-term sequelae in a relatively large cohort of patients treated at our institution.

MATERIAL AND METHODS

We reviewed the charts of children undergoing pneumonectomy between 1969 and 2009 with particular attention to indications, techniques, complications, survival, pulmonary function and spine deformities

RESULTS

Ten patients (M:F=6/4) aged 102 +/- 66 months underwent pneumonectomy for bronchiectasis (4, one with cystic fibrosis), tumors (4, 1 myofibroblastic inflammatory pseudotumor, 1 bronchial carcinoid, 1 primary pulmonary PNET and 1 massive metastasis of osteosarcoma) and malformations (2, 1 pulmonary sequestration and 1 congenital bilobar emphysema). Overall survival was 90% at 5.6 (0.3-23) years. Patients with bronchiectasis improved markedly except the one with cystic fibrosis who died. All children with tumors cured. Four have some degree of scoliosis which is severe in one with malformative costal fusion. All survivors live unrestristricted normal lives. Postoperative respiratory function is well preserved with FVC of 58% (40-70%), FEV1 of 60% (47-84%) and FEV1/FVC of 92% (87-98%) of the theoretical value for their height and weight.

CONCLUSIONS

Pneumonectomy does not affect by itself to the overall survival, and the respiratory function is good and there is no impairment of the quality of life.

[The risk of necrotizing enterocolitis in newborns with congenital heart disease. a single institution-cohort study]

BACKGROUND/AIM

Necrotizing enterocolitis (NEC) is the most common gastrointestinal surgical disease among neonates. Congenital heart disease (CHD) is also a significant cause of infant morbidity and mortality and it is usually associated with prematurity, low birth weight, pulmonary and gastrointestinal disease, conditions that also account for the development of NEC. Our aim is to analyze the incidence and the risk factors for NEC in neonates with CDH admitted to the Neonatal Intensive Care Unit (NICU) in a 6 years period.

METHODS

All patients admitted in the NICU for any type of CDH from January 2003 to December 2008 comprised the cohort of this study. The primary outcome measure was the development of NEC in any stage. Sixteen independent variables were selected to include those factors previously correlated with NEC. Uni and multivariate statistical analysis were performed with SPSS 15.0 for Windows. Relative Risks (RR) are presented with 95% confidence intervals.

RESULTS

935 out of the 7803 neonates admitted during this period, 935 (11.9%) presented a CHD. Among them, 70 also had NEC (RR 8.4-17.8), 31 requiring surgical treatment (Bell stages III and IV). The risk for NEC was specially increased if CHD needed surgical correction (2.1-5.1) and among babies with very low birth weight (VLBW, <1,500 g) (2-4.8). After multivariate analysis the only independent variables associated with an increased risk of NEC were birth weight less than 1,500 g (2.2-7.4), the need of surgical correction of CHD (2.2-7.1) and a clinical picture of septicaemia (1.1-3.9).

CONCLUSIONS

The incidence of NEC is greater in neonates with CDH than in the normal newborn population. Early recognition of NEC should be warranted among CHD patients, specially in those with VLBW, surgical treatment of CHD and sepsis. In this sub-cohort of patients an increased risk of NEC should be suspected.

Changes in arterial blood pressure of a soluble cocoa fiber product in spontaneously hypertensive rats

The effect produced by long-term intake of a soluble cocoa fiber product (SCFP) on the development of hypertension of spontaneously hypertensive rats (SHR) was evaluated. Twenty male 3-week-old SHR were divided into two groups of 10 animals that drank either tap water (control) or a solution of SCFP (0.75 g/day SCFP) until the 20th week of life. Five 20-week-old rats of each group were sacrificed. Tap water as drinking fluid was given to all the animals from the 20th to 24th week of life. The 24-week-old rats were also sacrificed. Body weight, liquid and dry food intake, and arterial blood pressure (tail cuff) were recorded weekly. Malondialdehyde (MDA), glucose and angiotensin converting enzyme (ACE) activity in the plasma from the sacrificed rats were also obtained, and we evaluated the relaxation caused by acetylcholine in the aorta from these animals. SCFP attenuated the development of hypertension in SHR; however, the withdrawal of SCFP caused an increase in blood pressure in the rats. Body weight gain was slower in the group treated with SCFP. SCFP increased liquid intake but decreased dry food intake in the rats. SCFP decreased plasma MDA concentrations and slightly decreased plasma ACE activity, but no differences were observed in plasma glucose and in the aorta responses to acetylcholine in both groups of 20-week-old SHR. We have demonstrated the antihypertensive and antioxidant properties of SCFP. The control of body weight and the control of increased angiotensin II may be involved in the antihypertensive effect of this product.

The role of cyclooxygenase (COX)-2 derived prostanoids on vasoconstrictor responses to phenylephrine is increased by exposure to low mercury concentration

We have previously demonstrated that chronic exposure to low-dose of mercury induced endothelial dysfunction and increased vasoconstrictor responses. The aim of this work was to investigate if mercury exposure alters contractile prostanoids production from cyclooxygenase-2 (COX-2) and its contribution to phenylephrine responses. For this, aortic segments from 3-month old Wistar rats daily treated with HgCl(2) (1(st) dose 4.6 microg/kg, subsequent dose 0.07 microg/kg/day, i.m.) or vehicle for 30 days were used. Mercury treatment did not affect systolic blood pressure but increased phenylephrine-induced vasoconstriction. The non selective COX inhibitor, indomethacin (10 micromol/l) reduced the response to phenylephrine more in aortic segments from mercury-treated than control rats. The selective COX-2 inhibitor NS 398 (1 micromol/l), the thromboxane A(2)/prostaglandin H(2) receptor (TP) antagonist SQ 29,548 (1 micromol/l), the TXA(2) synthase inhibitor furegrelate (1 micromol/l), the EP(1) receptor antagonist SC 19220 (1 micromol/l) and the AT(1) receptor antagonist losartan (10 micromol/l) reduced phenylephrine response only in vessels from mercury-treated rats. TXA(2) and PGE(2) levels were greater in the incubation medium of vessels from treated than untreated rats; NS 398 decreased these levels only in the mercury group. COX-2 protein was localized in adventitial and endothelial cells. Aortic COX-2 mRNA expression and plasma angiotensin converting enzyme activity were greater in mercury-treated rats. These results suggest that treatment with low doses of mercury increases the release of COX-2-derived vasoconstrictor prostanoids and its participation in phenylephrine responses. The increased activation of the renin-angiotensin system after mercury treatment might be associated to this increased COX-2 activity.

Low mercury concentrations cause oxidative stress and endothelial dysfunction in conductance and resistance arteries

Increased cardiovascular risk after mercury exposure has been described, but the underlying mechanisms are not well explored. We analyzed the effects of chronic exposure to low mercury concentrations on endothelium-dependent responses in aorta and mesenteric resistance arteries (MRA). Wistar rats were treated with mercury chloride (1st dose 4.6 μg/kg, subsequent dose 0.07 μg·kg−1·day−1im, 30 days) or vehicle. Blood levels at the end of treatment were 7.97 ± 0.59 ng/ml. Mercury treatment: 1) did not affect systolic blood pressure; 2) increased phenylephrine-induced vasoconstriction; 3) reduced acetylcholine-induced vasodilatation; and 4) reduced in aorta and abolished in MRA the increased phenylephrine responses induced by either endothelium removal or the nitric oxide synthase (NOS) inhibitor NG-nitro-l-arginine methyl ester (l-NAME, 100 μM). Superoxide dismutase (SOD, 150 U/ml) and the NADPH oxidase inhibitor apocynin (0.3 mM) decreased the phenylephrine-induced contraction in aorta more in mercury-treated rats than controls. In MRA, SOD did not affect phenylephrine responses; however, when coincubated with l-NAME, the l-NAME effect on phenylephrine response was restored in mercury-treated rats. Both apocynin and SOD restored the impaired acetylcholine-induced vasodilatation in vessels from treated rats. Endothelial NOS expression did not change in aorta but was increased in MRA from mercury-treated rats. Vascular O2−production, plasmatic malondialdehyde levels, and total antioxidant status increased with the mercury treatment. In conclusion, chronic exposure to low concentrations of mercury promotes endothelial dysfunction as a result of the decreased NO bioavailability induced by increases in oxidative stress. These findings offer further evidence that mercury, even at low concentrations, is an environmental risk factor for cardiovascular disease.

[Peptides with antihypertensive activity from milk and egg proteins]

Antihypertensive hydrolysates and peptides have been isolated from food proteins. Among them, there are of particular interest the antihypertensive casein hydrolysates, and some antihypertensive products obtained when milk was fermented by Lactobacillus helveticus. The sequences Val-Pro-Pro (VPP) and Ile-Pro-Pro (IPP), with angiotensin-converting enzyme (ACE) inhibitory activity, have been isolated from these fermented products. Selected Enterococcus faecalis strains can also produce milk derived peptides with ACE inhibitory and antihypertensive activities. The main of them is the sequence LHLPLP. Some studies also describe the production of antihypertensive hydrolysates and peptides from egg proteins. The sequences FRADHPFL (ovokinin) and RADHPFL (ovokinin 2-7), that have shown endothelium-dependent vasodilator activity, were obtained at first. Some egg white hydrolysates with ACE inhibitory activity have also been described. The idea of including the above-mentioned products as functional food ingredients is particularly attractive. Some of them have already proved their safety and effectiveness in hypertensive patients.