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Infantile hemangioma is a benign vascular tumor, the most common in childhood, whose natural evolution is the disappearance of the lesion in the pediatric age and which has effective and safe treatments that limit its growth and favor its disappearance at younger ages. Infantile hemangioma continues to be a reason for attention to complications, due to erroneous diagnoses, lack of knowledge of the condition, late referral or fear of the effects of the medications used for its treatment. Furthermore, its presence is normalized without taking into account that it can cause uncertainty, anxiety, feelings of guilt and, as a consequence, a significant impact on the quality of life, mainly in the parents or caregivers of the child. The need for a clinical practice guideline in our country arises from the high presentation of late-remitted complications in infantile hemangioma even with the availability of adequate treatments, the continuous evolution of medicine and the appearance of new evidence. Throughout the guide you will find recommendations regarding the diagnosis, treatment and follow-up of patients with infantile hemangioma, taking into account the paraclinical tests that can be performed, topical or systemic management options, as well as adjuvant therapies. For the first time, objective tools for patient follow-up are included in a guide for the management of infantile hemangioma, as well as to help the first contact doctor in timely referral.

El hemangioma infantil es un tumor vascular benigno, el más frecuente de la infancia, cuya evolución natural favorece la desaparición de la lesión en la misma edad pediátrica y que cuenta con tratamientos eficaces y seguros que limitan su crecimiento y favorecen su desaparición a edades más tempranas. Continúa siendo motivo de atención de complicaciones, debido a diagnósticos erróneos, desconocimiento del padecimiento, referencia tardía o temor de los efectos de los fármacos utilizados para su tratamiento. Además, se normaliza su presencia sin tomar en cuenta que puede llegar a causar incertidumbre, ansiedad, sentimientos de culpa y, como consecuencia, importante afectación de la calidad de vida, principalmente en los padres o cuidadores del niño. La necesidad de una guía de práctica clínica en nuestro país surge ante la alta presentación de complicaciones del hemangioma infantil referidas de manera tardía aun con la disponibilidad de tratamientos adecuados, la evolución continua de la medicina y la aparición de nueva evidencia. A lo largo de la guía se encontrarán recomendaciones en relación con el diagnóstico, el tratamiento y el seguimiento de los pacientes con hemangioma infantil, tomando en cuenta los paraclínicos que pueden realizarse, las opciones de manejo tópico o sistémico, y las terapias adyuvantes. Por primera vez se incluyen en una guía para el manejo del hemangioma infantil herramientas objetivas para el seguimiento de los pacientes, así como para ayudar al médico de primer contacto en su referencia oportuna.

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In this Letter, we provide analytical and numerical evidence that the single-layer quantum approximate optimization algorithm on universal Ising spin models produces thermal-like states. We find that these pseudo-Boltzmann states can not be efficiently simulated on classical computers according to the general state-of-the-art condition that ensures rapid mixing for Ising models. Moreover, we observe that the temperature depends on a hidden universal correlation between the energy of a state and the covariance of other energy levels and the Hamming distances of the state to those energies.

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INTRODUCTION AND OBJECTIVES: Outcomes of liver transplantation (LT) with donors after circulatory death (DCD) have been considered suboptimal due to higher rates of ischemic cholangiopathy, especially when the super-rapid recovery (SRR) technique is used. This study aimed to compare the incidence of complications between recipients receiving DCD vs those receiving donors after brain death (DBD) in a large-volume liver transplant centre. METHODS: We performed a retrospective cohort study (LT from January 2015 to December 2018) comparing recipients who underwent a LT with DCD vs. a control group of LT with DBD, matched 1:1 without replacement by propensity score matching that included the following variables: LT indication, recipient sex and age, donor age and MELD score. RESULTS: 51 recipients with DCD-LT (29 SRR, 22 normothermic regional perfusion [NRP]) were matched with 51 DBD-LT recipients. Biliary complications were more frequent in DCD, 10% (n=5), all with SRR technique, vs 2% (n=1) in the DBD group, p=0.2. Two patients (4%) suffered primary graft non-function in the DCD group (1 SRR and 1 NRP) versus zero in the DBD group (p=0.49). Postoperative bleeding and reinterventions were also higher in the DCD group: 7 (13.7%) vs 1 (1.95%) and 8 (15.7%) vs 2 (3.9%) respectively (p=0.06 and 0.09). On the 1st postoperative day AST/ALT peak was higher in DCD (p≤0001). The incidence of rejection, vascular complications, renal injury, hospital stay, and readmissions were similar in both groups. Cumulative 1-, 2-, 3- and 4-year graft and patient survival were also similar. CONCLUSIONS: DCD donors are an adequate option to increase the donor pool in LT, achieving similar graft and patient survival rates to those achieved with DBD donors, especially when the NRP technique is used.

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Even though the SARS-CoV-2 pandemic represents a historical challenge, science has had an exponential development, and the current vaccination campaigns are proof of this. Unfortunately, along came misinformation and myths regarding their production and their adverse effects. For this reason, we have considered of utter importance to review anaphylaxis, one of the most feared vaccine adverse events.Anaphylaxis can be defined as a life-threatening acute and systemic allergic reaction, with a wide clinical spectrum, which can be explained by many immunological mechanisms, and whose diagnostic complexity demands the fulfillment of strict criteria. Though infrequent, any vaccine has the potential to trigger anaphylaxis. In the United States, for the new SARS-CoV-2 vaccines, rates from 1:200 000 (Pfizer-BioNTech) to 1:360 000 doses (Moderna) have been estimated. Vaccine adverse events can be mediated by hypersensitivity reactions, either allergic or not. Unlike a typical drug allergy, rarely is the active ingredient responsible for the reaction. Therefore, excipients must be considered during the approach to this problem. Vaccine associated anaphylaxis has to be referred to an allergist so as to guarantee the maximum benefit for the patient and improve the vaccines' security profile.

A pesar de la difícil situación que se enfrenta con la actual pandemia de COVID-19, la ciencia ha tenido un desarrollo exponencial. Si bien la inmunización contra esa enfermedad ha sido posible gracias a ello, desafortunadamente se ha acompañado de desinformación y mitos en torno a su fabricación y reacciones adversas. Por tal razón, es importante revisar una de las reacciones adversas a vacunas más temidas para el personal de salud y la población general, la anafilaxia. La anafilaxia se define como una reacción alérgica aguda y sistémica que puede poner en riesgo la vida; se asocia con distintos mecanismos inmunológicos, factores desencadenantes y manifestaciones clínicas. Su diagnóstico puede ser confuso, por lo que se han establecido diferentes criterios. Todas las inmunizaciones tienen el potencial de desencadenar anafilaxia, aunque este evento es poco frecuente. Respecto de las vacunas contra el coronavirus SARS-CoV-2, en Estados Unidos se ha reportado una tasa de anafilaxia de 1:200 000 para la vacuna Pfizer-BioNTech, y de 1:360 000 para la vacuna de Moderna. Al igual que un fármaco, las vacunas pueden presentar efectos adversos mediados por mecanismos de hipersensibilidad, pero a diferencia de lo que sucede con los medicamentos, el principio activo rara vez es el responsable; es más frecuente que las reacciones indeseadas se deban a los excipientes. La sospecha de una anafilaxia secundaria a su aplicación obliga a una oportuna referencia y a un correcto diagnóstico, tanto para el beneficio del paciente como para mejorar el perfil de seguridad de la vacuna.

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INTRODUCTION: Microvascular free-flap reconstruction is one of the treatment options after large resection of head and neck neoplasms. The objectives of this study are to identify short-term outcomes and risk factors for flap complication in patients who underwent neoplasms resection of head and neck with microvascular free-flap reconstruction. METHODS: Retrospective study of patients who underwent surgery for head and neck neoplasm with microvascular free-flap reconstruction between January 2014-2020. Complications were studied at 30-days follow-up and divided into medical and flap complications. Factors independently associated with flap complication were analyzed. RESULTS: We included 31 patients (15 men). The mean age was 60 years. Reconstruction was performed with radial-forearm flap in 74% (n=23) and with free-fibula flap in 26% (n=8). Mean surgical time was 420 minutes. Median hospital length of stay was 7 days. Medical complications were of 23%. Minor complications were of 35% and major of 32%. There was no mortality in 30-days follow-up. Flap complications were of 35%. Reintervention was of 29%, surgical site infection of 9%, dehiscence of 29% and flap loss of 9.7%.  Surgical site infection was independently associated with prolonged surgical time (Odds ratio [OR]=1.03, IC95%=0.98-1.04, p=0.02) and body mass index equal to or greater than 30 (OR=1.38, IC95%=0.84-2.26, p=0.04) while flap loss was associated with prolonged surgical time (OR=1.02, IC95%=0.99-1.04, p=0.01). CONCLUSION: Microsurgical free-flap reconstruction should be considered in our population in patients with large head and neck neoplasms. Preoperative assessment of the risk of postoperative complications is essential before selecting patients for this surgery.

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OBJECTIVE: To develop a sheep autologous uterus transplantation (UT) program with an innovative surgical technique and assess long term uterus vitality and animal survival. METHODS: A novel surgical technique consisting of the procurement of the complete uterus and the two ovaries, back table vascular reconstruction, and subsequent implantation in the same animal, performing only two arterial and two venous anastomoses. RESULTS: Four autologous transplantations were performed; anesthesia and surgery were well tolerated by all the animals without complications. Direct observation and Doppler US performed a week after UT and laparoscopy performed three months later confirmed uterus vitality. All animals were alive more than a year after transplantation. CONCLUSIONS: Our study was the first to describe a novel surgical technique for sheep uterus autologous transplantation in Latin America, showing long-term survival and uterus vitality.

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PURPOSE: The aim was to evaluate if an abbreviated perioperative care bundle (APCB) is noninferior to the standard care, in terms of efficacy and safety, in pediatric patients undergoing bowel anastomoses. METHODS: A randomized, open, noninferiority trial with two parallel groups of equal size was carried out at the National Institute of Pediatrics in Mexico City, Mexico, from April 2016 to July 2018. The total number analyzed was 74 (37 per group). The APCB comprised same day admission, avoidance of mechanical bowel preparation, optimized antibiotic prophylaxis, and early feeding. Statistical analysis was done with Fisher's exact test or Chi2, and Student's T test. RESULTS: No significant differences were found for demographic variables and type of disease, either for the safety (anastomotic leakage, p 0.753; organ/space surgical site infection, p 0.500) or for some efficacy outcomes (ileus or bowel obstruction, p 0.693). Other efficacy outcomes were better in the study group, with shorter median times for feeding tolerance (19 h vs. 92 h, p < 0.001), for first bowel movement (15 h vs. 36 h, p < 0.001), and for discharge (1 vs. 6 days, p < 0.001). CONCLUSION: The abbreviated care bundle was proven to be as safe but more efficacious than the standard care. LEVEL OF EVIDENCE: I - randomized controlled trial with adequate statistical power.

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Objetivos: Determinar la viabilidad anatómica del aumento del continente del primer compartimento dorsal y comunicar la ex-periencia clínica de esta nueva técnica comparada con la liberación clásica. materiales y métodos: Estudio anatómico de 12 muñecas cadavéricas para comprobar el aumento del continente del primer compartimento y su relación con la rama sensitiva radial. Estudio clínico retrospectivo que incluyó a pacientes >18 años, sin cirugías previas, con tenosinovitis de De Quervain sin respuesta al tratamiento ortopédico, operados entre enero de 2014 y enero de 2019, y con un seguimiento mínimo de 12 meses. Veintidós pacientes fueron divididos en: grupo A (aumento) y grupo B(liberación simple). La edad promedio era 47 (grupo A) y 50 años (grupo B). La evaluación subjetiva incluyó la escala analógica visual para dolor, el puntaje QuickDASH y el cuestionario de satisfacción PSQ-18; el examen objetivo consistió en evaluaciones goniométrica y dinamométrica. Resultados: El estudio ana-tómico demostró un aumento del continente del primer compartimento dorsal y una íntima relación con la rama sensitiva radial. El seguimiento promedio del estudio clínico fue 24 y 50 meses, en los grupos A y B, respectivamente. El puntaje promedio de la escala analógica visual para dolor fue 0,5/10 (grupo A) y 1/10 (grupo B). El índice de satisfacción fue del 97% en ambos grupos. El puntaje QuickDASH, las evaluaciones goniométrica y dinamométrica no arrojaron diferencias significativas. Conclusión: La nueva plástica de aumento del continente del primer compartimento dorsal para tratar la tenosinovitis de De Quervain en este estudio anatomoclínico resultó eficaz y reproducible. Nivel de Evidencia: III

Objective: To establish the anatomical feasibility of the first dorsal compartment (FDC) enlargement and to report our clinical experience with this new technique compared with the traditional release. materials and methods: Anatomical study of 12 ca-daver wrists to corroborate first compartment enlargement and its relationship to the sensitive branch of the radial nerve. Clinical retrospective study of patients who had undergone surgery between 2014 and 2019 due to De Quervain tenosynovitis (DQT) refractory to nonsurgical management, over 18 years of age, with no previous surgical history and a 12-month minimum follow-up. The 22-patient series was divided into two groups: enlargement (Group A) and simple release (Group B). Average ages were 47 years (Group A) and 50 years (Group B). Subjective outcome was evaluated by the visual analogue scale (VAS) for pain, the Quick-DASH score, and the Patient Satisfaction Questionnaire Short Form (PSQ-18). Objective outcome was evaluated by goniometry and dynamometry tests. Results: The anatomical study proved the increase of the FDC laxity and its close relationship to the sensitive branch of the radial nerve. The clinical study follow-up periods were of 24 months in Group A and 50 months in Groups B. Average VAS scores were 0.5/10 in Group A and 1/10 in Group B). Satisfaction index was 97% in both groups. Quick-DASH scores, and goniometry and dynamometry tests yielded no significant differences. Conclusions: The new enlargement plasty of the FDC for the surgical treatment of DQT in this anatomical and clinical study proved to be a reproducible and effective technique. Level of Evidence: III

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This article reviews technical issues to improve surgical safety and avoid surgical errors in pediatric surgical oncology, particularly in the three most common extracranial solid tumors: neuroblastoma, hepatoblastoma and Wilms tumor. The use of adjuvant chemotherapy - when indicated - the use of tumor specific classifications, adequate surgical planning, that may include the use of 3D printable models, improved surgical instruments and technology, and following surgical guidelines, would result in avoiding error, increased safety, and therefore in improved surgical outcomes.

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Introduction: Evaluate the efficacy of an information system addressed to nursing staff to lower the blood culture contamination rate. Methods: A blind clinical trial was conducted at Internal Medicine and Emergency Departments during 2011. After following a reeducation program in BC extraction, participants were randomly selected in a 1:1 ratio. Every participant of the experimental group was informed of each worker's individual performance; whereas the control group was only informed of the global results. Results: A total of 977 blood extractions were performed in 12 months. Blood culture contamination rate was 7.5%. This rate was higher in the Emergency Department than in Internal Medicine (10% vs. 3.8%; p=0.001). Factors associated with the higher risk of contamination were, in the univariate analysis, the extraction through a recently implanted blood route and the time of professional experience, while those associated with a lower risk were the extraction in Internal Medicine and through a butterfly needle. On multivariate analysis, extraction through a recently placed access was an independent risk factor for an increased contamination rate (OR 2.29; 95%CI 1.18-4.44, p=0.014), while individual information about the blood culture results (OR 0.11; 95%CI 0.023-0.57; p=0.008), and more than 9 years of professional experience were asso-ciated with fewer contaminations (OR 0.30; 95%CI 0.12-0.77; p=0.012). In the intervention group the contamination rate diminished by a 26 %. Conclusions: Drawing blood cultures through a recently taken peripheral venous access increased their risk of contamination. The intervention informing the nurse staff of the contamination rate is effective to decrease it

Objetivos: Evaluar la eficacia de un sistema de información dirigido al personal de enfermería, en la reducción de la tasa de contaminación de los hemocultivos. Métodos: Durante el año 2011, se realizó un ensayo clínico en los servicios de Medicina Interna y de Urgencias. Después de seguir un programa de reeducación en la extracción de los hemocultivos, los participantes, fueron aleatorizados en una proporción de 1:1. En el grupo de intervención se informó del porcentaje de hemocultivos contaminados de cada profesional y en el grupo control se aportaba la información del porcentaje global de contaminaciones. Resultados: Durante un periodo de 12 meses se realizaron 977 extracciones. La tasa de contaminación de los hemocultivos fue del 7,5%. Esta tasa fue mayor en Urgencias que en Medicina Interna (10% versus 3,8%, p=0,001). Los factores asociados con mayor riesgo de contaminación fueron, en el análisis univariable: la extracción a través de una vía sanguínea recientemente implantada y el tiempo de experiencia profesional; mientras que los que se asociaron con menor riesgo fueron la extracción en Medicina Interna (versus en Urgencias) y a través de una palomilla. En el análisis multivariable, la extracción de los hemocultivos de una vía recientemente implantada se relacionó de forma independiente con un incremento de las contaminaciones (OR 2,29, IC 95% 1,18-4,44, p=0,014),mientras que la información individual sobre los resultados de los hemocultivos (OR 0.11; IC 95% 0,023-0,57; p=0,008) y la experiencia profesional mayor de 9 años, lo hizo con menos contaminaciones (OR 0,30, IC 95% 0,12-0,77, p=0,012). En el grupo de intervención la tasa de contaminaciones se redujo en un 26%. Conclusión: La extracción de hemocultivos a través de una vena periférica recientemente implantada aumentó el riesgo de contaminación de los mismos. La intervención informativa a los enfermeros de la tasa de contaminación de los hemocultivos, es eficaz para disminuirla

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In this article, we first review the development of clinical ethics in pediatrics in the United States. We report that, over the last 40 years, most children's hospitals have ethics committees but that those committees are rarely consulted. We speculate that the reasons for the paucity of ethics consults might be because ethical dilemmas are aired in other venues. The role of the ethics consultant, then, might be to shape the institutional climate and create safe spaces for the discussion of difficult and sometimes contentious issues. Finally, we report how pediatric clinical ethics has evolved differently in a number of other countries around the world.

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Introducción: Los bifosfonatos constituyen el tratamiento de primera elección de la enfermedad osteoporótica. Algunos efectos adversos ponen en duda su uso prolongado, como las fracturas atípicas de fémur proximal. Los objetivos de este estudio fueron determinar la relación entre consumo de bifosfonatos y fracturas atípicas de fémur, y mostrar la incidencia en nuestra institución. Materiales y Métodos: Estudio retrospectivo, observacional, análisis de caso-control no pareado. Se incluyeron pacientes >55 años, con fractura de fémur que ingresaron entre el 1 de enero de 2009 y el 31 de mayo de 2015. Las variables consideradas fueron: sexo, edad, tipo de fractura; uso, tipo y tiempo de consumo de bifosfonatos. Las fracturas se distribuyeron en típicas: pertrocantéricas, y cuello femoral, y atípicas: subtrocantéricas y diafisarias. Se consideraron como casos las fracturas atípicas y como controles, las pertrocantéricas. Resultados: Se incluyó a 517 pacientes que cumplieron los criterios de inclusión. Cuarenta y dos fracturas eran atípicas y 236, típicas. Hubo predominio del sexo femenino (81,4% en los casos y 83% en los controles). La edad promedio fue de 76 y 80 años, respectivamente. La asociación con bifosfonatos fue del 44,2% en los casos y 15,3% en los controles (11,6% y 0,8% en las fracturas pertrocantéricas, respectivamente). Conclusiones: El alendronato se asoció significativamente con fracturas atípicas de fémur. No se halló relación con el tiempo de consumo; sin embargo, la incidencia fue más alta luego de 4.5-5 años de consumo. Nivel de Evidencia: IV

Introduction: Bisphosphonates are currently considered a first-choice treatment for osteoporotic disease. A number of adverse effects call into question its long-term administration, such as proximal femoral pathological fractures. The purposes of this study were to determine the relationship between consumption of bisphosphonates and atypical femoral fractures, and to report the incidence in our institution. Methods: Retrospective, observational study, case-control unpaired analysis. Patients >55 years old with femoral fractures admitted from January 1, 2009 to May 31, 2015 were included. Considered variables were: sex, age, type of fracture, use, type and time of consumption of bisphosphonates. Fractures were divided into typical: pertrochanteric, and femoral neck, and atypical: subtrochanteric and diaphyseal. Atypical fractures were cases, and typical fractures functioned as controls. Results: A total of 517 patients met the inclusion criteria and were included in the study. Forty-two fractures were atypical and 236 were typical. Female sex predominated (81.4% of cases, and 83% of controls). Average age was 76 and 80 years, respectively. Association with bisphosphonates was observed in 44.2% of the cases, and 15.3% of controls (11.6% and 0.8% in pertrochanteric fractures, respectively). Conclusions: Alendronate was significantly associated with atypical femoral fractures. A relationship with length of consumption was not detected; however, incidence was higher after 4.5-5 years of use. Level of Evidence: IV

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PURPOSE: Constipation is present in 80% of children with corrected anorectal malformations, usually associated to rectal dilation and hypomotility. Osmotic laxatives are routinely used for idiopathic constipation. Senna is a stimulant laxative that produces contractions improving colonic motility without affecting the stool consistency. We designed this trial to study the effectiveness of Senna versus polyethylene glycol for the treatment of constipation in children with anorectal malformation. METHODS: A randomized controlled crossover design clinical trial, including a washout period, was conducted, including children with corrected anorectal malformations with fecal continence and constipation. The sample size was calculated for proportions (n=28) according to available data for Senna. Effectiveness of laxative therapy was measured with a three variable construct: 1) daily bowel movement, 2) fecal soiling, 3) a "clean" abdominal x-ray. Data analysis included descriptive statistics and a Fisher's exact test for the outcome variable (effectiveness). RESULTS: The study was terminated early because the interim analysis showed a clear benefit toward Senna (p = 0.026). The sample showed a normal statistical distribution for the variables age and presence of megarectum. The maximum daily dose of Senna (sennosides A and B) was 38.7mg and 17g for polyethylene glycol. No adverse effects were identified. CONCLUSION: Therapy with Senna should be the laxative treatment of choice as part of a bowel management program in children with repaired anorectal malformations and constipation, since the stimulation of colonic propulsion waves could lead to stool evacuation without modification of its consistency which can affect fecal continence. LEVEL OF EVIDENCE: I - randomized controlled trial with adequate statistical power.

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Background Osteoid osteoma of the wrist is rare and treatment is still in debate. Case Description We report on a patient with osteoid osteoma of the head of the ulna, as an unusual cause of pain on the ulnar side of the wrist. The diagnostic delay was 4 years. A previous ulna shortening surgery was performed because of misdiagnosis. The diagnosis was made with bone scan and computed tomography (CT). A surgical resection was performed. The symptoms disappeared, and full range of motion was recovered. Literature Review Osteoid osteoma on the head of the ulna had never been described before. Clinical Relevance This case demonstrates that osteoid osteoma can mimic ulnocarpal impingement syndrome.