Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the viable upstream pancreatic parenchyma and the gastrointestinal tract, generally caused by ductal necrosis after severe acute necrotizing pancreatitis. This compromised ductal integrity leads to extraductal leakage of pancreatic secretions, causing a prolonged disease course and complications. The existing literature is limited, with unclear therapeutic algorithms. We have performed a review of the literature on DPDS. Review in Pubmed and Scielo (2011-2021) of articles in English and Spanish using the terms “disconnected pancreatic duct syndrome”, “DPDS” and “disconnected pancreas” finding 16 relevant articles. Given the few citations, the references of these articles was reviewed. Finally, we found 21 articles. Among them, there is one meta-analysis, 4 prospective studies and no randomized trials.

Resumen El síndrome del ducto pancreático desconectado (SDPD) consiste en la disrupción del ducto pancreático principal con pérdida de continuidad entre el remanente pancreático distal viable y el tracto gastrointestinal, generalmente causado por necrosis ductal secundaria a pancreatitis aguda grave. Esto resulta en fuga de fluido pancreático, provocando un curso de enfermedad prolongado y complicaciones. La literatura sobre este tema es limitada, con algoritmos de tratamiento poco claros. Hemos realizado una revisión de la literatura sobre el tema. Revisión en Pubmed y Scielo (2011-2021) de artículos en inglés y español utilizando términos «síndrome del conducto pancreático desconectado», «DPDS» y «páncreas desconectado» encontrando 16 artículos relevantes. Dadas las pocas citas, se revisaron las referencias de estos artículos. Finalmente, revisamos un total de 21 artículos. Entre las referencias encontradas existe 1 metaanálisis, 4 estudios prospectivos y no existen ensayos aleatorizados.

The transition to and through college can affect the mental health of college students. The situation in medical students is particularly worrisome, considering that they have high rates of psychopathology. These mental health problems can be associated with worse academic and professional outcomes and worse patient care. In this scenario, it is relevant to look at how this problem can be addressed considering variables of both mental health and educational systems in medicine. Therefore, initiatives to promote well-being during the career are proposed. The importance of well-being at an institutional level should be defined. Also, the foundations of learning neurosciences from the point of view of well-being should be incorporated. Considering that well-being goes beyond the absence of discomfort, the role of educational environment both in learning and in mental health should be recognized. Proven effective interventions should be incorporated. It must be considered that not every initiative linked to well-being is necessarily positive and that discomfort to a certain extent can be exploited educatively as well. The well-being of medical students is a complex, dynamic and multidimensional issue. These principles are orientations for different actors of the educational process, to define how they will approach this problem in their contexts.

RESUMO RACIONAL: A fundoplicatura de Nissen laparoscópica falha em controlar o refluxo gastroesofágico em quase 15% dos pacientes e a maioria deles deve ser reoperada devido aos sintomas. Diferentes técnicas cirúrgicas têm sido sugeridas. OBJETIVOS: Apresentar os resultados pós-operatórios de pacientes submetidos a 3 procedimentos diferentes: Reoperação e fundoplicatura de Nissen laparoscópica apenas (Grupo A), reoperação e fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal (Grupo B) ou reoperação e conversão para Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux (Grupo C). MÉTODOS: estudo prospectivo incluindo 77 pacientes submetidos inicialmente a fundoplicatura de Nissen laparoscópica que apresentaram recidiva do refluxo gastroesofágico após a operação. Eles foram avaliados antes e após a reoperação com questionário clínico e estudos funcionais específicos. Reestabelecida a anatomia da junção esôfago-gástrica, procedeu-se às referidas cirurgias. Nenhum paciente perdeu seguimento. RESULTADOS: Os sintomas persistentes foram observados com maior frequência nos pacientes dos Grupos A ou B, associados à estenose da fundoplicatura, fundoplicatura intratorácico ou fundoplicatura torcida. No Grupo C, os sintomas recorrentes associados a essa alteração anatômica foram observados com pouca frequência. Esfincter esofágico inferior incompetente foi confirmado em 57,7% dos pacientes pertencentes ao Grupo A em comparação com 17,2% após fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal, e 26% após a Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux. Nesse grupo, apesar do alto percentual de pacientes com esfincter esofágico inferior incompetente, 8,7% apresentaram refluxo ácido anormal após a cirurgia. CONCLUSÕES: As técnicas de Nissen ou Toupet combinados com a gastrectomia distal em Y de Roux são seguras e eficazes para o manejo da falha da fundoplicatura a Nissen. A técnica de Toupet é preferível para pacientes que sofrem principalmente com disfagia e dor.

ABSTRACT BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Introduction: Various pathologies require oral anticoagulant treatment (TACO). Some of these patients present pathologies of surgical resolution. The perioperative management of these patients is variable depending on the center. Aim: To evaluate the morbidity and mortality of patients attended with hernia pathology and TACO, assisted in our hospital. Materials and Method: Prospective, descriptive study of 37 patients submmited to hernia surgery in TACO between 2008-2016. The data was obtained from the computer database of the Hernia Team, with a minimum follow-up of 1 month. Clinical, surgical characteristics and postoperative morbidity and mortality were evaluated. The treatment overlap from TACO to Low Molecular Weight Heparin (LMWH) in therapeutic doses, was initiated three days before surgery. LMWH was suspended 24 hours prior to surgery, and reinitiated 12 to 24 hours post operation. 48 to 72 hours TACO was resumed. The data was analyzed with Stata v14. Results: Twenty-six patients were men, the mean age was 67.3 years. 48.7% had atrial fibrillation. 100% consumed acenocoumarol as TACO. The mean time for resuming TACO after surgery was 1.4 days. The average INR at the time of discharge was 2.04. Two patients were discharged with dalteparin. One patient (2.7%) presented pain in the immediate postoperative period and one showed ecchymosis of the surgical site (2.7%). Conclusions: The work protocol used, proved to be safe, with minimal postoperative morbidity.

Resumen Introducción: Diversas patologías requieren de tratamiento anticoagulante oral (TACO). Algunos de estos pacientes requieren resolución quirúrgica. El manejo perioperatorio de estos pacientes es variable dependiendo del centro. Objetivos: Evaluar la morbilidad y mortalidad del protocolo de manejo de patología herniaria en TACO, atendidos en nuestro hospital. Material y Métodos: Estudio descriptivo prospectivo de 37 pacientes sometidos a cirugía herniaria en TACO entre 2008-2016. Los datos fueron obtenidos de la base de datos computacional del Equipo de Hernias, con un seguimiento mínimo de 1 mes. Se evaluaron las características clínicas, quirúrgicas y la morbimortalidad postoperatoria. El traslape consistió en hospitalizar al paciente tres días previos a la cirugía, suspendiéndose el TACO e iniciando heparina de bajo peso molecular (HBPM) en dosis terapéuticas, que se suspende 24 h previas a la cirugía. Se reinicia la HPBM a las 12 a 24 h postoperatorias, y se inicia el traslape a TACO a las 24-48 h. Los datos fueron analizados con Stata v14. Resultados: De los 37 pacientes estudiados, veintiséis pacientes fueron hombres (70,2%), la media de edad fue de 67,3 años. El 48,7% tenían fibrilación auricular. El 100% consumía acenocumarol como TACO. La media en el inicio del traslape a la anticoagulación oral fue de 1,4 días. El promedio de INR al momento del alta fue de 2,04. Dos pacientes fueron dados de alta con dalteparina. Un paciente (2,7%), presentó dolor en el postoperatorio inmediato y uno (2,7%), equimosis del sitio quirúrgico. Conclusiones: El protocolo de trabajo utilizado, demostró ser seguro, con una mínima morbilidad postoperatoria.

Introduction: The abdominoperineal resection (APR) was the standard treatment of middle-low rectal cancer, in the last 20 years the development of sparing techniques with sphincter preservation with adequate surgical and oncological results has allowed to offer the patient the sphincter apparatus preservation, avoiding the definitive colostomy, however, these techniques may present secondary incontinence to the loss of the rectum. Both surgical options can affect the quality of life of the patient and this element should be considered. Objective: To compare the change in quality of life of patients undergoing APR vs sphincter preserving techniques in patients operated for rectal cancer. Materials and Method: Cross-sectional cohort study with medium-low rectal cancer patients, operated in our hospital from 2009 to 2015. The instrument EuroQuol-5D2, validated in chilean spanish is used. Results: 39 patients were included (11 definitive colostomy and 28 sphincter preservation). In the analysis by domains, significant differences were observed favor to definitive colostomy in the Item of “Habitual Activities” and favor to sphincter preservation in the Item “Sexuality”. Conclusions: In patients with middle-low rectal cancer, the choice of surgical technique have a measurable impact on the patient's quality of life.

Resumen Introducción: La resección abdominoperineal (RAP) era el tratamiento estándar del cáncer de recto medio o bajo quedando el paciente sin ano y con una ostomía permanente. En los últimos 20 años el desarrollo de nuevas técnicas quirúrgicas, con adecuados resultados quirúrgicos y oncológicos, han permitido ofrecer al paciente la preservación del aparato esfinteriano, sin embargo, éstas pueden presentar problemas de tipo funcional lo que podría derivar en una alteración de la calidad de vida del paciente. Objetivo: Comparar la alteración en la calidad de vida en pacientes sometidos a RAP versus técnicas con preservación de esfínter anal en pacientes operados por cáncer de recto. Materiales y Método: Estudio de cohorte transversal con pacientes operados por cáncer de recto medio-bajo en nuestro hospital entre los años 2009 a 2015. Se utiliza el instrumento EuroQuol-5D2,3 validado en español chileno. Resultados: Se incluyen 39 pacientes, 11 corresponden a colostomía definitiva y 28 a preservación de esfínter. En el análisis por dominios se observaron diferencias significativas en el grupo con ostomía definitiva en el ítem de actividades habituales y a favor de la preservación de esfínter en el ítem sexualidad. Conclusiones: La técnica quirúrgica utilizada en pacientes con cáncer rectal medio-bajo altera la calidad de vida, razón por la cual debe ser adecuadamente seleccionada y además advertir al paciente de las consecuencias que dicha cirugía puede ocasionar.

Resumen Objetivo: Indagar cómo se entiende y aborda la salud mental en los modelos de atención de la población infantil infractora en los centros de detención de Argentina, Colombia, Estados Unidos y Canadá. Metodología: Se buscó literatura sobre el tema empleando las palabras clave adolescencia, salud mental, justicia juvenil, delincuencia juvenil, factores de riesgo e intervenciones. El buscador empleado para la consulta fue Pubmed. Adicionalmente, se utilizaron páginas de instituciones públicas de cada país. Conclusiones: La delincuencia juvenil se entiende ahora como un fenómeno multifactorial con múltiples áreas de intervención dentro de las cuales cobran relevancia las condiciones económicas, familiares y sociales puesto que propician la aparición de conductas delictivas. Se encontró una similitud entre los sistemas de Colombia y Argentina, pues ambos se basan en una justicia restaurativa que busca reparación y no castigo; por ende, no hay medidas punitivas. Al comparar Canadá y Estados Unidos se ve que Canadá es más parecido a los países latinoamericanos que al estadounidense, puesto que esta última usa medidas punitivas centradas en el victimario.

Abstract Objective: To investigate how mental health is understood and approached in the attention models of detention centers for the convicted underage population in Argentina, Colombia, United States and Canada. Methodology: A literature search was conducted using the following key words: adolescence, mental health, juvenile justice, juvenile delinquency, risk factors, and interventions. Searches were done through the search engine Pubmed. Additionally, public institution websites for each country were consulted. Conclusions: Juvenile delinquency is now understood as a multi-factorial phenomenon with multiple areas of intervention within which economic, domestic and social factors are considered relevant, since these favor the development of criminal behavior. A similarity was found between Colombian and Argentinian systems; both are based on restorative justice that seeks reparation and not punishment; which is why there are no punitive measures. When comparing Canada and the United States, it can be seen that Canada is more similar to Latin-American countries than to the United States, given that the latter uses punitive measures focused on the offender.

In recent years the relationship between Graves’ disease (GD), TSH, TRAb and thyroid carcinoma has been studied. Research studies show a higher prevalence and aggressiveness of thyroid carcinoma in patients with GD, however other researchers refute these findings suggesting it’s due to selection bias. Increasing evidence suggests a causal relationship between GD and the development of thyroid carcinoma, mainly because of the existence of TSI autoantibodies that could stimulate the focus of malignancy. It is believed that cytokines produced locally in patients with GD work alongside with TRAb regulating the aggressiveness of papillary thyroid carcinoma in these patients. Within the cells recruited by the tumor to elude the immune system we find Treg lymphocytes, which have been found to be increased in patients with GD, leading to a diminished immune response, creating a permissive environment for cell proliferation. Since this is a relatively new line of research, there is no consensus on the subject and its relevance for the treatment of patients with GD. The aim of this article is to show recent literature available on the subject.

Durante los últimos años se ha estudiado la relación entre enfermedad de Graves (EG), TSH, TRAb y cáncer de tiroides, existiendo estudios que demuestran mayor prevalencia y agresividad del cáncer de tiroides en pacientes con EG, mientras otros refutan estos hallazgos sugiriendo que serían producto del sesgo de selección. Aquellos estudios que plantean una relación causal entre EG y el desarrollo de cáncer de tiroides, la atribuyen a la presencia de autoanticuerpos TSI, que estimularían el foco de malignidad. Se cree que las citoquinas producidas localmente en pacientes con EG trabajarían en conjunto con los TRAb para determinar la agresividad del cáncer papilar de tiroides en estos pacientes. Dentro de las células reclutadas por el tumor para evadir la respuesta inmune se encuentran los linfocitos Treg, que estarían elevados en paciente con EG, llevando a la disminución de la respuesta inmune y creando un ambiente permisivo para la proliferación celular. Por tratarse de una línea de investigación reciente, no existe consenso sobre el tema y sus implicancias en el tratamiento de los pacientes con EG. La finalidad de este artículo es realizar una revisión de la literatura que exponga y contraste la información disponible a la fecha.

Introduction: Brucellosis is a zoonosis caused by Brucella spp. It may be acquired by consuming unpasteurized dairy products. Brucellosis has a low incidence in Chile, thus, we have a scarce data. Aim: To report and to characterize the first series of clinical cases of adult patients diagnosed with brucellosis in Chile. Methods: We describe a series of 13 clinical cases in patients diagnosed between 2000 and 2016 in three different centers in the Metropolitan Region, Chile. A retrospective analysis was performed on clinical presentation, laboratory, antibiotic treatment, morbidity and mortality. Results: The mean age was 50 years old. Eight cases had a record of consumption of unpasteurized dairy products. The most frequently reported complaints were fever. The most frequent focal point involved was the spine. Only one patient had a positive blood culture, while the diagnosis was made using serological techniques in the other part of the group. The most indicated antibiotic regimens were doxycycline-rifampicin and doxycycline-gentamicin. The hospital stay was 20 days approximately as an average. Clinical cure was achieved in all cases. Conclusions: Brucellosis is an infrequent zoonosis in Chile, and it produces a nonspecific clinical picture, so it is necessary to have high suspicion to make the diagnosis based in the antecedent of consumption of unpasteurized dairy or raw meat.

Introducción: La brucelosis es una zoonosis provocada por Brucella spp, cuyo principal mecanismo de transmisión es mediante el consumo de lácteos no pasteurizados. Es de baja ocurrencia en Chile, por lo que los datos locales son escasos. Objetivo: Reportar y caracterizar la primera serie de casos clínicos de pacientes adultos con diagnóstico de brucelosis en Chile. Material y Método: Se describe una serie de 13 casos clínicos en pacientes diagnosticados entre el año 2000 y el 2016 en tres centros de la Región Metropolitana, Chile. Se realizó un análisis retrospectivo acerca de la presentación clínica, laboratorio, tratamiento antimicrobiano y morbi-mortalidad. Resultados: El promedio de edad fue 50 años. Ocho casos tenían antecedente de consumo de lácteos no pasteurizados. El motivo de consulta más frecuente fue sensación febril. El compromiso focal más frecuente fue el de columna vertebral. Sólo en un paciente se encontró hemocultivo positivo; en el resto el diagnóstico se hizo mediante técnicas serológicas. Los esquemas antimicrobianos más indicados fueron doxiciclina-rifampicina y doxiciclina-gentamicina. La estadía hospitalaria fue en promedio de 20 días. En todos los casos se logró curación clínica. Conclusiones: La brucelosis es una zoonosis infrecuente en Chile, produce un cuadro clínico inespecífico, por lo que se debe tener una alta sospecha para realizar el diagnóstico, basada en el antecedente del consumo de productos lácteos no pasteurizados o de carne mal cocida.

RESUMO Investigar o padrão espacial das árvores, segundo suas classes de tamanho e segundo suas espécies mais abundantes pode fornecer evidências sobre a estrutura da comunidade vegetal, sendo que, o padrão espacial é uma questão-chave para estudos de ecologia florestal. O nível de organização espacial das árvores no ambiente depende de diversos processos ecológicos e características próprias de cada ambiente, de modo que a melhor compreensão deste quadro fornece subsídios importantes para o conhecimento sobre formações florestais. Neste trabalho objetivou-se estudar o padrão espacial das árvores, segundo suas classes de diâmetro e das quatro espécies mais abundantes em diferentes florestas, visando fornecer evidências sobre a ecologia de cada comunidade vegetal. A descrição do padrão espacial em cada formação florestal foi realizada segundo a Função K de Ripley. As formações florestais estudadas foram: Floresta Ombrófila, Cerradão, Floresta Estacional e Restinga. Instalou-se uma parcela de 10,24 ha em cada formação florestal, e todas as árvores com circunferência na altura do peito (CAP) a partir de 15 cm foram medidas, georreferenciadas e identificadas. Os resultados obtidos ressaltam o caráter agregado em florestas tropicais, como foi observado em todas as florestas estudadas. As árvores do Cerradão e da Restinga apresentaram padrões de agregação muito próximos. Para a Floresta Ombrófila, o padrão agregado foi significativo em toda a escala de distâncias estudada. Na Floresta Estacional, foi observada tendência à aleatoriedade, embora, uma agregação significativa tenha sido notada para curtas distâncias. O padrão espacial por classes de diâmetro foi, em linhas gerais, agregado para árvores menores que 10 cm de diâmetro, e entre 10 e 20 cm, e aleatório para as demais, evidenciando uma tendência de que árvores jovens são mais agregadas do que árvores adultas. O padrão espacial das espécies dominantes é sempre muito semelhante ao padrão geral de cada formação florestal. As diferenças entre o padrão espacial das espécies dominantes coincidentes entre as formações florestais indicam que seu padrão é influenciado por cada ambiente. Ressaltando-se assim, a importância da sua autoecologia e dos processos ecológicos intrínsecos a cada comunidade que podem explicar os padrões observados.

ABSTRACT Investigating tree's spatial patterns according to their size classes and according to their more abundant species can provide evidences about the structure of the vegetal community, since the spatial pattern is a key question for forestry ecology studies. The tree spatial organization patterns on the environment depend on several ecological processes and on the specific characteristics of each environment, so that the best understanding of this frame provides important elements for the knowledge on forestry formation. This paper aimed to study tree spatial patterns, according to the diameter classes and from four most abundant species in different forests, in order to provide evidences regarding to the ecology of each vegetal community. The spatial pattern description in each forestry formation was developed using Ripley's K function. The studied forestry formations were: Ombrophilous Forest, Cerradao, Seasonal Forest and Restinga Forest. In this work, a 10.24 ha plot was installed in each forestry formation, and every tree, with a circumference at breast height (CBH) larger than 15 cm were measured, georeferenced and identified. The obtained data highlights the aggregated character in tropical forests, as observed in every studied forest. The 'Cerradão' and 'Restinga' forest trees showed close aggregate patterns. In the Ombrophilous forest, for all distance scales, the aggregate pattern was meaningful. In the seasonal forest, a random tendency was observed, although a meaningful aggregation was observed in all short distances. The spatial pattern by diameter classes was generally aggregated for trees smaller than 10 cm of diameter and between 10 and 20 cm and random for the others, proving the existence of a tendency which in young trees is more aggregated than in old ones. The spatial pattern of the dominant species is always strongly similar to the general pattern of each forestry formation. The differences between the spatial patterns of two or three coincident species, among the forestry formations, indicate that its pattern is influenced by each different environment. This stands out the importance of its self-ecology and of its ecological processes, intrinsic of each community that can explain the observed patterns.