Eduardo Bracho-Blanchet

No Evidence of Porcine Endogenous Retrovirus in Patients With Type 1 Diabetes After Long-Term Porcine Islet Xenotransplantation

Xenotransplantation is a promising alternative for donor shortage to ameliorate physiologic and metabolic disorders. The major concern for xenotransplant is the risk of zoonosis mainly by the porcine endogenous retrovirus (PERV), presentation in the piglet genome. Twenty‐three patients with type 1 diabetes were transplanted with porcine islets using collagen‐generating devices which were implanted subcutaneously in the anterior wall of the abdomen. Clinical characteristics and metabolic tests were recorded in each visit. They were tested for PERV using PCR and RT‐PCR from blood pretransplantation and every 3 months during a 4.6‐ to 8‐year follow‐up after their first xenotransplant. Tests by PCR of every DNA sample (780 samples) revealed that there was no PERV infection in the DNA of white cells. No evidence of PERV activation was found in this group of patients with type 1 diabetes during clinical long‐term follow‐up. J. Med. Virol. 82:331–334, 2010.

Intestinal anastomosis in children: A comparative study between two different techniques☆

PURPOSE The aim of this study was to compare the incidence of surgical complications between two different surgical techniques for intestinal anastomosis in children. METHODS This was a clinically controlled, randomized study with blind follow-up from 18 to 36 months performed at the Reference Government Hospital in Mexico City. Eighty-six children required intestinal anastomosis, ages ranged between 1 month and 16 years, with emergency or elective surgery. Anastomoses of duodenum, rectum, with enteroplasty or protected with a proximal stoma were excluded. Two randomized groups were formed: (1) anastomosis with one layer of suture (Gambee stitches) and (2) with two layers of suture (first with Connel-Mayo stitches then with Lembert). Both groups were controlled in the principal variables without differences, and the follow-up concerning postoperative recovery was blind for the surgical team. RESULTS Forty-two cases in group 1 and 44 in group 2 were compared. Intestinal dehiscence was found in 5 of 86 (5.8%), two from group I and three from group II (P value, not significant). Surgical time for anastomosis with one layer was an average of 26 minutes versus 43 minutes with two layers (P<.001). There were no stenoses within the follow-up period. CONCLUSIONS This study proves that intestinal anastomosis with one layer of suture is as safe as anastomosis with two layers in children, and the time spent for completion of the procedure is significantly less with one plane of suture. For those reasons, it is the method of choice for intestinal anastomosis in children.

Unexpected Immunoresponse to Gal and APA Antigens in Diabetic Type 1 Patients Receiving Neonatal Pig Islets After 6 Years

Cotransplantation of porcine islets and Sertoli cells into preimplanted subcutaneous devices improve metabolic control in type 1 diabetic patients, and survive grafted for more than 4 years. We report here, further assessment of the endocrine and porcine nature of the surviving cells and the immune responses elicited toward Gal α(1,3)-Gal β(1,4)-GlcNAc (Gal) antigen in patients who received a second and third transplants. No immunosuppressive drugs were administered. We were able to immunostain insulin- and glucagon-positive cells in all biopsies of patients and Sertoli cell markers in 60.9% of biopsies. Additionally, all biopsies tested, amplified the porcine COII gene. Patients demonstrated an increase in antipig antibodies in response to the first transplant with a decreasing response toward the second and third transplants. In all transplants, the IgG levels promptly returned to basal values after 3–4 months. The long-term survival of porcine cells and the reduced humoral immune response to multiple transplants indicate a form of tolerance. We have not been able to find CD25-positive cells, indicating that it is probably an immune accommodation of the graft.

Assessment of the Mexican Board of Pediatric Surgery Certification System

OBJECTIVE To evaluate the quality of the Mexican Board of Pediatric Surgery (MBPS) certifying system, using contemporary international guidelines. DESIGN Retrospective assessment of evidence collected during the design and implementation processes of 2 consecutive applications of the MBPS certifying examination, using Cizeks checklist for evaluating credential-testing programs. It includes the relevant guidelines from the American Education Research Association, the American Psychological Association, the National Council on Measurement in Education, and the National Commission for Certifying Agencies. Four independent and previously trained raters used the checklist. They underwent a 2-week training using frame-of-reference and performance dimensions methodologies. SETTING Certification examinations of MBPS. POPULATION The 2013 and 2014 MBPS certification examinations, with 111 evidence items of the processes, followed for the assessment of 86 examinees. RESULTS The checklist internal consistency was 0.89. Absolute interrater agreement was 0.34 for the 2013 and 0.66 for the 2014 editions of the examination. The 2013 examination complied with 55 (64%) of the checklist 86 items, in 2014 with 72 (84%). CONCLUSION In 2014, the certifying system reached a quality of 84%. For optimal fulfillment of its social responsibility, the MBPS is required to maintain its level of quality and attempt to improve its performance.

Misdiagnosis and quality of management in paediatric surgical patients referred to a tertiary care hospital.

BACKGROUND The literature on diagnosis and management prior to transfer paediatric surgical patients to a tertiary care center is scarce. In referral centers, it is common to receive patients previously subjected to inadequate or inappropriate health care. AIM Analyze the prevalence of misdiagnosis and quality of management in patients before being referred and factors related to misdiagnosis and inadequate management. DESIGN Prospective, longitudinal, comparative study between patients with appropriate and inappropriate submission diagnosis and between patients with adequate or inadequate treatment. SETTING Third level care hospital, Mexico City. PARTICIPANTS Newborn to adolescents referred to Paediatric Surgery Department. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Misdiagnosis and quality of management prior to being referred. RESULT Two hundred patients were evaluated. Correlation between submission diagnosis and final diagnosis showed that 70% were correct and 30% incorrect; 48.5% were properly managed and 51.5% inappropriately managed. Incorrect diagnosis was more frequent when referred from first-or second-level hospitals and in inflammatory conditions. Patients referred by paediatricians had a higher rate of adequate management. CONCLUSION We present the frequency of incorrect diagnosis and inadequate patient management in a highly selected population. Sample size should be increased as well as performing these studies in other hospital settings in order to determine whether the results are reproducible.

Predictive value of procalcitonin for intestinal ischemia and/or necrosis in pediatric patients with adhesive small bowel obstruction (ASBO)

PURPOSE Evaluate serum procalcitonin (PCT) level as a predictor of intestinal ischemia or necrosis (IN) in patients with postoperative adhesive small bowel obstruction (ASBO). METHODS Prospective cohort of consecutive patients with ASBO. Patients previously treated with antibiotics or septic were excluded. PCT was measured at the diagnosis of ASBO and every 24 h afterwards. MAIN OUTCOME intestinal ischemia or necrosis (IN). RESULTS Fifty-nine patients were included, 12 of whom were excluded; 47 patients remained in the study; male-to-female ratio = 1.9:1. MANAGEMENT medical in 15 cases (32%) and surgical in 32 (68%). MAIN OUTCOME Intestinal necrosis (IN) in 10 patients (21.3%). Mean PCT level was higher in patients with IN (15.11 ng/ml vs. 0.183 ng/ml, p=0.002), the proportion of patients with elevated PCT (>0.5 ng/dl) was higher in patients with IN (70% vs. 8.1%, p=<0.001, RR=26.4 with a 95% CI of 4.39-159.5). Elevated PCT levels at diagnosis had a 70% positive predictive value (PPV) and 91.8% negative predictive value (NPV) for prediction of IN. With a PCT value at diagnosis of >1.0 ng/dl, PPV was 87.5% and NPV, 92.3%. CONCLUSIONS PCT levels are closely related to the presence of intestinal ischemia and necrosis in children with ASBO. LEVEL OF EVIDENCE Study of Diagnostic Test, Level II.

Laparoscopic treatment of nonpalpable testicle. Factors predictive for diminished size

PURPOSE The purposes of this study were to demonstrate the usefulness of laparoscopy in intraabdominal testicle (IAT) and to determine factors associated with diminished size during the final outcome after laparoscopic orchidopexy. METHODS This is a retrospective analysis of consecutive patients from 1999 to 2013 with a minimum follow-up of 1year. Patient and testicular factors were related to diminished size. RESULTS Sixty one patients, and 92 testicles were included. Median age at operation was 42months. Initially we found 66 normal sized testes (71.7%), 22 hypotrophic (23.9%) and four atrophic (4.3%). Eighty seven testes were brought down laparoscopically, 50 in one surgical stage and 37 in two stages. Mean follow-up was 40.2months and the final outcome was success: 73.5% and diminished size: 26.5%. Variables associated with diminished size were hypotrophy during initial evaluation, short spermatic vessels, section of spermatic vessels, two-stage surgery and tension to reach contralateral inguinal ring. Multivariate analysis showed that initial hypotrophy (odds ratio [OR] 4.96, confidence interval 95% [CI] 1.36-18.10) and tension to reach contralateral ring (OR 4.11, 95% CI 1.18-14.34) were associated with diminished size. CONCLUSIONS Laparoscopy is useful in treating IAT. Initial size and tension to reach contralateral ring are factors associated with diminished size.

A Gastroschisis bundle: effects of a quality improvement protocol on morbidity and mortality

OBJECTIVE Gastroschisis incidence is rising. Survival in developed countries is over 95%. However, in underdeveloped countries, mortality is higher than 15% often due to sepsis. The aim of this study was to evaluate the effect on morbidity and mortality of a Quality Improvement Protocol for out-born gastroschisis patients. METHODS The protocol consisted in facilitating transport, primary or staged reduction at the bedside and sutureless closure, without anesthesia, PICC lines and early feeding. Data was prospectively collected for the Protocol Group (PG) treated between June 2014 through March 2016 and compared to the last consecutive patients Historical Group (HG). Primary outcome was mortality. SECONDARY OUTCOMES need for and duration of mechanical ventilation (MV), time to first feed (TFF) after closure, parenteral nutrition (TPN), length of stay (LOS) and sepsis. Data were analyzed using χ2 and Mann-Whitney U tests. RESULTS 92 patients were included (46 HG and 46 PG). Demographic data were homogeneous. Mortality decreased from 22% to 2% (p = 0.007). Mechanical ventilation use decreased from 100% to 57% (p = <0.001), ventilator days from 14 to 3 median days (p = <0.0001), TPN days: 27 to 21 median days (p = 0.026), sepsis decreased from 70% to 37% (p = 0.003) and anesthesia from a 100% to 15% (p = <0.001), respectively. No difference was found in NPO or LOS. CONCLUSION A major improvement in the morbidity and mortality rates was achieved, with outcomes comparable to those reported in developed countries. It was suitable for all patients with gastroschisis. We believe this protocol can be implemented in other centers to reduce morbidity and mortality. LEVEL OF EVIDENCE III.