The present study aims to assess the results obtained after surgical treatment of cholangiocarcinoma (CC) recurrences.
We carried out a single-center retrospective study, including all patients with ...recurrence of CC. The primary outcome was patient survival after surgical treatment compared with chemotherapy or best supportive care. A multivariate analysis of variables affecting mortality after CC recurrence was performed.
Eighteen patients were indicated surgery to treat CC recurrence. Severe postoperative complication rate was 27.8% with a 30-day mortality rate of 16.7%. Median survival after surgery was 15 months (range 0-50) with 1- and 3-year patient survival rates of 55.6% and 16.6%, respectively. Patient survival after surgery or CHT alone, was significantly better than receiving supportive care (p< 0.001). We found no significant difference in survival when comparing CHT alone and surgical treatment (p=0.113). Time to recurrence of <1 year, adjuvant CHT after resection of the primary tumor and undergoing surgery or CHT alone versus best supportive care were independent factors affecting mortality after CC recurrence in the multivariate analysis.
Surgery or CHT alone improved patient survival after CC recurrence compared to best supportive care. Surgical treatment did not improve patient survival compared to CHT alone.
Background & Aims There is an increasing discrepancy between the number of potential liver graft recipients and the number of organs available. Organ allocation should follow the concept of benefit ...of survival, avoiding human-innate subjectivity. The aim of this study is to use artificial-neural-networks (ANNs) for donor-recipient (D-R) matching in liver transplantation (LT) and to compare its accuracy with validated scores (MELD, D-MELD, DRI, P-SOFT, SOFT, and BAR) of graft survival. Methods 64 donor and recipient variables from a set of 1003 LTs from a multicenter study including 11 Spanish centres were included. For each D-R pair, common statistics (simple and multiple regression models) and ANN formulae for two non-complementary probability-models of 3-month graft-survival and -loss were calculated: a positive-survival (NN-CCR) and a negative-loss (NN-MS) model. The NN models were obtained by using the Neural Net Evolutionary Programming (NNEP) algorithm. Additionally, receiver-operating-curves (ROC) were performed to validate ANNs against other scores. Results Optimal results for NN-CCR and NN-MS models were obtained, with the best performance in predicting the probability of graft-survival (90.79%) and -loss (71.42%) for each D-R pair, significantly improving results from multiple regressions. ROC curves for 3-months graft-survival and –loss predictions were significantly more accurate for ANN than for other scores in both NN-CCR (AUROC-ANN = 0.80 vs. –MELD = 0.50; -D-MELD = 0.54; -P-SOFT = 0.54; -SOFT = 0.55; –BAR = 0.67 and -DRI = 0.42) and NN-MS (AUROC-ANN = 0.82 vs. –MELD = 0.41; -D-MELD = 0.47; -P-SOFT = 0.43; -SOFT = 0.57, -BAR = 0.61 and -DRI = 0.48). Conclusions ANNs may be considered a powerful decision-making technology for this dataset, optimizing the principles of justice, efficiency and equity. This may be a useful tool for predicting the 3-month outcome and a potential research area for future D-R matching models.
The relief of the impediment to urinary flow is the treatment of acute kidney failure due to urinary tract obstruction. However, there is a risk of inducing massive polyuria, which can be ...self-limited or produce severe contraction of the intravascular volume with pre-renal acute kidney failure and alterations in the internal environment. Polyuria, urine output > 3 L/d or > 200 mL/min for more than 2 hours, can have multiple causes, and can be classified as osmotic, aqueous or mixed. Post-obstructive polyuria obeys different pathogenic mechanisms, which overlap and vary during a patient's evolution. Initially, there is a decrease in vasoconstrictor factors and an increase in renal blood flow, which, added to the excess of urea accumulated, will cause intense osmotic diuresis (osmotic polyuria due to urea). Added to these factors are the positive sodium and water balance during acute renal failure, plus the contributions of crystalloid solutions to replace diuresis (ionic osmotic polyuria). Finally, there may be tubular dysfunction and decreased solutes in the renal medullary interstitium, adding resistance to the action of vasopressin. The latter causes a loss of free water (mixed polyuria). We present the case of a patient with post-obstructive polyuria where, by analyzing the clinical symptoms and laboratory alterations, it was possible to interpret the mechanisms of polyuria and administer appropriate treatment for the pathogenic mechanism.
Species are being lost at an unprecedented rate due to human-driven environmental changes. The cases in which species declared extinct can be revived are rare. However, here we report that a remote ...volcano in the Galápagos Islands hosts many giant tortoises with high ancestry from a species previously declared as extinct: Chelonoidis elephantopus or the Floreana tortoise. Of 150 individuals with distinctive morphology sampled from the volcano, genetic analyses revealed that 65 had C. elephantopus ancestry and thirty-two were translocated from the volcano's slopes to a captive breeding center. A genetically informed captive breeding program now being initiated will, over the next decades, return C. elephantopus tortoises to Floreana Island to serve as engineers of the island's ecosystems. Ironically, it was the haphazard translocations by mariners killing tortoises for food centuries ago that created the unique opportunity to revive this "lost" species today.
Introduction
Transplantation-mediated alloimmune thrombocytopenia (TMAT) is a rare complication affecting the recipient of an organ from a donor with immune thrombocytopenia (ITP).
Methods
We present ...a case of TMAT following liver transplantation successfully treated by retransplantation, along with a review of previously published cases.
Clinical presentation: The liver donor had lupus and ITP and died from an intracranial hemorrhage. The recipient’s platelet count fell to 2x109/L on postoperative day 2. Due to the lack of response to medical treatment, emergency retransplantation was undertaken with a steady recovery of the platelet count within a few days.
Discussion
Six additional cases of transplantation-mediated alloimmune thrombocytopenia after liver transplantation have been reported. In all cases, severe thrombocytopenia ensued within 3 days after liver transplantation. Four patients suffered hemorrhagic complications. Three patients died. Early retransplantation was needed in three out of four patients receiving a graft from a donor with ITP and splenectomy. All recovered shortly after the new graft was in place.
Conclusion
Severe refractory transplantation-mediated alloimmune thrombocytopenia can develop in liver recipients from donors with ITP, especially those with previous splenectomy. Early retransplantation should be considered if there is no rapid response to medical therapy.
Abstract
Species are being lost at an unprecedented rate due to human-driven environmental changes. The cases in which species declared extinct can be revived are rare. However, here we report that a ...remote volcano in the Galápagos Islands hosts many giant tortoises with high ancestry from a species previously declared as extinct:
Chelonoidis elephantopus
or the Floreana tortoise. Of 150 individuals with distinctive morphology sampled from the volcano, genetic analyses revealed that 65 had
C. elephantopus
ancestry and thirty-two were translocated from the volcano’s slopes to a captive breeding center. A genetically informed captive breeding program now being initiated will, over the next decades, return
C. elephantopu
s tortoises to Floreana Island to serve as engineers of the island’s ecosystems. Ironically, it was the haphazard translocations by mariners killing tortoises for food centuries ago that created the unique opportunity to revive this “lost” species today.
Introduction: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten ...years later we sent a questionnaire to check the current situation. Methods: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. Results: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. Conclusions: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country.
Es imperiosa la necesidad de inserción en hogares adecuados de aquellos niños que se hallan en centros de acogida o en situación riesgosa en sus hogares, con el fin de precautelar la integridad de ...aquellos y su correcto desarrollo. Esta decisión de acogimiento reviste una gran importancia en la vida del menor que claramente afectará a su desarrollo de una manera positiva o negativa. Por ello, el presente trabajo tiene por objeto analizar la medida del Acogimiento Familiar de niños o adolescentes desde un punto de vista doctrinario y legislativo, así como su aplicación en el Ecuador. Para ello se usó metodología cualitativa con método de investigación analítico sintético. La estructura del artículo, luego de la introducción, inicia con la conceptualización del acogimiento familiar, resaltando sus características, finalidad así al menor de edad que es sujeto de esta medida; luego se examina las modalidades de acogimiento familiar haciendo énfasis en aquel que se lo realiza en familia extensa; luego se analizan las condiciones requeridas, para finalizar los derechos y responsabilidades del menor acogido. El trabajo concluye, principalmente, que a pesar del desconocimiento aún existente en nuestro país sobre esta medida, el acogimiento familiar aplicado correctamente beneficiará a un sinnúmero de menores que se encuentran en riesgo precautelando su integridad física y mental.
Background
The aim of the study is to analyze the feasibility, the safety and short- and medium-term survival of totally laparoscopic simultaneous resections (LSR) of colorectal cancer (CRC) and ...synchronous liver metastases (LM).
Methods
This is a retrospective study of a single-center series. Patients ASA IV, ECOG ≥ 2, major hepatectomies (≥ 3 segments), symptomatic CRC as well as low rectal tumors were excluded from indication. The difficulty level of all liver resections was classified as low or intermediate according to the Iwate Criteria. Dindo–Clavien classification for postoperative complications evaluation was used.
Results
15 Patients with 21 liver lesions were included. Laparoscopic liver surgery was performed first in every case. Median size of the lesions was 20 mm (r 8–69). Major complications (Dindo–Clavien ≥ 3) occurred in 3 patients (20%); median hospital stay was 7 days (r 4–35), and only one patient (6.6%) was readmitted upon the first month from the surgery. 90-day mortality rate was 0%. After a median follow-up of 24 months (r 7–121), disease-free survival at 1, 2 and 3 years was 58%, 36% and 24%, respectively; overall survival at 1, 2 and 3 years was 92.3%.
Conclusions
In selected patients, LSR of CRC and LM is technically feasible and has an acceptable morbidity rate and mid-term survival.
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