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Introduction: Many HIV-positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced-prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4

Background In sub-Saharan Africa, individuals infected with HIV who are severely immunocompromised have high mortality (about 10%) shortly after starting antiretroviral therapy (ART). This group also has the greatest risk of morbidity and mortality associated with immune reconstitution inflammatory syndrome (IRIS), a paradoxical response to successful ART. Integrase inhibitors lead to significantly more rapid declines in HIV viral load (VL) than all other ART classes. We hypothesised that intensifying standard triple-drug ART with the integrase inhibitor, raltegravir, would reduce HIV VL faster and hence reduce early mortality, although this strategy could also risk more IRIS events. Methods and findings In a 2×2×2 factorial open-label parallel-group trial, treatment-naive adults, adolescents, and children >5 years old infected with HIV, with cluster of differentiation 4 (CD4) 0.7) and despite significantly greater VL suppression with raltegravir-intensified ART at 4 weeks (343/836 [41.0%] versus 113/841 [13.4%] with standard ART, p < 0.001) and 12 weeks (567/789 [71.9%] versus 415/803 [51.7%] with standard ART, p < 0.001). Through 48 weeks, there was no evidence of differences in mortality (aHR = 0.98 [95% CI 0.76–1.28], p = 0.91); in serious (aHR = 0.99 [0.81–1.21], p = 0.88), grade-4 (aHR = 0.88 [0.71–1.09], p = 0.29), or ART-modifying (aHR = 0.90 [0.63–1.27], p = 0.54) adverse events (the latter occurring in 59 [6.5%] participants with raltegravir-intensified ART versus 66 [7.3%] with standard ART); in events judged compatible with IRIS (occurring in 89 [9.9%] participants with raltegravir-intensified ART versus 86 [9.5%] with standard ART, p = 0.79) or in hospitalisations (aHR = 0.94 [95% CI 0.76–1.17], p = 0.59). At 12 weeks, one and two raltegravir-intensified participants had predicted intermediate-level and high-level raltegravir resistance, respectively. At 48 weeks, the nucleoside reverse transcriptase inhibitor (NRTI) mutation K219E/Q (p = 0.004) and the non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations K101E/P (p = 0.03) and P225H (p = 0.007) were less common in virus from participants with raltegravir-intensified ART, with weak evidence of less intermediate- or high-level resistance to tenofovir (p = 0.06), abacavir (p = 0.08), and rilpivirine (p = 0.07). Limitations of the study include limited clinical, radiological, and/or microbiological information for some participants, reflecting available services at the centres, and lack of baseline genotypes. Conclusions Although 12 weeks of raltegravir intensification was well tolerated and reduced HIV viraemia significantly faster than standard triple-drug ART during the time of greatest risk for early death, this strategy did not reduce mortality or clinical events in this group and is not warranted. There was no excess of IRIS-compatible events, suggesting that integrase inhibitors can be used safely as part of standard triple-drug first-line therapy in severely immunocompromised individuals. Trial registration ClinicalTrials.gov NCT01825031.

La medicina humanitaria tiene como objetivo mejorar el bienestar humano como acto de generosidad y solidaridad con los desfavorecidos, sin ninguna consideración de ganancia material. Va más allá del mero acto terapéutico, promueve, enseña, apoya y proporciona salud como un derecho humano. Presentamos de forma resumida el proyecto de Cirugía Plástica Infantil en campaña humanitaria en Guinea Ecuatorial, patrocinado por la organización Aldeas Infantiles SOS desde su origen hasta su situación actual, describiendo las principales acciones realizadas en el lugar de acogida y haciendo recomendaciones para mejorar la seguridad y eficacia en este tipo de campañas. Por último, recogemos algunas reflexiones sobre el impacto personal de campañas humanitarias como la que describimos. Humanitarian medicine aims to improve human welfare as an act of generosity and solidarity with the disadvantaged, without any consideration of material gain. It means more than a mere therapeutic act, it should promote, teach and provide health as a basic human right. In this paper, the authors summarize the project of humanitarian Pediatric Plastic Surgery mission developed in Equatorial Guinea and funded by the organization Aldeas Infantiles SOS, since its origin to its current state. The main actions performed in the host country are described, and recommendations are made to improve the safety and efficacy of these missions. Lastly some thoughts are outlined regarding the personal impact that such campaigns may bring about.

Las fístulas de paladar suponen una complicación frecuente en la cirugía de los pacientes fisurados. Las opciones de reconstrucción secundaria en fístulas de tamaño moderado-grande son limitadas por la escasez de tejido donante local y las cicatrices de la palatoplastia. Presentamos nuestra experiencia en el tratamiento de fístulas palatinas moderadas-grandes con colgajo músculomucoso basado en la arteria facial (colgajo FAMM: facial artery musculo-mucosal flap) y describimos algunos detalles técnicos que hemos incorporado para mejorar su seguridad. Revisamos 8 pacientes, 5 mujeres y 3 varones, con edades comprendidas entre los 5 y los 18 años, nacidos con fisura palatina que desarrollaron fístulas palatinas tras la palatoplastia primaria y que tras evaluación multidisciplinaria fueron sometidos a reconstrucción con colgajo FAMM. Los tamaños de las fístulas oscilaron entre los 0,5 y los 2,3 cm. de diámetro mayor. El seguimiento postoperatorio de los pacientes fue de 1 a 6 años. Obtuvimos cierre completo de las fístulas de paladar en el primer tiempo quirúrgico y sin complicaciones en 5 casos. Los 2 primeros sufrieron necrosis de los bordes distales del colgajo y precisaron revisión quirúrgica y una paciente sufrió necrosis total que requirió una nueva reconstrucción con colgajo FAMM contralateral. No hemos registrado complicaciones de la zona donante en ninguno de los casos. Consideramos que el colgajo FAMM es una excelente opción para la reparación de fístulas palatinas de tamaño moderadogrande secundarias a fisura palatina congénita, ya que permite aportar una gran cantidad de tejido vascularizado con un arco de rotación amplio, lo que posibilita obtener resultados de obturación satisfactorios. La tasa de complicaciones, tras una curva de aprendizaje relativamente breve, es baja. Palatal fistulas are a common complication of cleft surgery. Options for secondary reconstruction of moderate to large defects are limited due to the scarcity of local donor tissue as well as the scars from the primary cleft repair. We present our experience in the treatment of moderate to large palatal fistulas with facial artery musculo-mucosal flap (FAMM flap), and we describe some technical details that we have introduced to improve safety. We present 8 patients, 5 female and 3 male, aged 5 to 18 years, with congenital cleft palate who developed moderate to large fistulae that after multidisciplinary evaluation were reconstructed with FAMM flap. The sizes of the fistulae ranged from 0,5 to 2,3 cm. in largest diameter. The follow-up was 1-6 years. We obtained a complete correction of palatal fistula in 5 patients without complications. Marginal necrosis occurred in the first 2 cases and required revision. One patient suffered total flap necrosis and required reconstruction with a contralateral FAMM flap. We did not experience complications of the donor site. We consider this flap an excellent option in moderate to large palatal fistula repair because it allows providing a large amount of well vascularized tissue with a wide arc of rotation. After a relatively short learning curve, complications are rare.

Las anomalías vasculares son lesiones típicas de los pacientes pediátricos y se dividen en dos categorías: tumores vasculares y malformaciones vasculares de alto y bajo flujo. Estas últimas pueden tratarse de diversos modos: laserterapia, drenaje, aspiración, cirugía o escleroterapia, dependiendo del tipo de lesión y de su localización. Entre los agentes esclerosantes utilizados, la bleomicina ha demostrado tener buenos resultados en el tratamiento de estas lesiones. En este artículo presentamos nuestra experiencia en el tratamiento de las malformaciones vasculares de bajo flujo mediante escleroterapia con bleomicina intralesional. Desarrollamos un estudio descriptivo retrospectivo sobre 30 pacientes que presentaban malformación vascular de bajo flujo y fueron tratados con bleomicina intralesional. Los resultados fueron buenos o excelentes en 22 pacientes y regulares o malos en los 8 restantes. De acuerdo a nuestra casuística y a la literatura revisada, la escleroterapia con bleomicina es una alternativa terapéutica eficaz y segura en el tratamiento de las malformaciones vasculares de bajo flujo. Vascular anomalies are common in children and can be divided into two categories, vascular tumours and vascular malformations: high-flow or low-flow. The latter can be treated in different ways such as lasertherapy, drainage, aspiration, surgery or sclerotherapy depending on the type and location of the lesion. Among the accepted sclerosing agents, bleomycin has proven good results in the treatment of this condition. Herein we present our experience in the treatment of low-flow vascular malformations with intralesional bleomycin injection. This is a retrospective, descriptive study with 30 patients presenting a low-flow vascular malformation treated with intralesional bleomycin injection. Our results are good or excellent in 22 patients and poor in the other 8. According to our case series and the consulted literature, sclerotherapy with intralesional bleomycin injection is an effective and safe treatment for low-flow vascular malformations.

We discuss in detail top quark polarization in above-threshold (t \bar t)-production at a polarized linear e^+ e^- collider. We pay particular attention to the minimization and maximization of the polarization of the top quark by tuning the longitudinal polarization of the e^+ and e^- beams. The polarization of the top quark is calculated in full next-to-leading order QCD. We also discuss the beam polarization dependence of the longitudinal spin-spin correlations of the top and antitop quark spins., 50 pages, 20 figures

Conocemos poco sobre el Noma o Enfermedad Cancrum Oris. Esta entidad afecta a niños con malnutrición crónica, poca higiene oral, poco desarrollo sanitario y enfermedades concurrentes debilitantes. Existe un consenso general sobre que el Noma empieza como una gingivitis; en su fase aguda, puede haber respuesta al tratamiento antibiótico, no obstante, las secuelas tras su curación incluyen daños estéticos y funcionales variables, que pueden requerir cirugía reconstructiva. Presentamos 3 casos de anquilosis mandibular que en el examen preoperatorio presentaron dimorfismo mandibular, fusión de hueso maxilar y mandibular y anquilosis de la articulación témporomandibular. La ortopantografía y la Tomografía Axial Computerizada (TAC) fueron muy útiles en la planificación de la cirugía. El tratamiento quirúrgico consistió en todos los casos en la resección del hueso anquilótico y la reconstrucción con injerto condrocostal en uno de los casos. En el postoperatorio se siguió fisioterapia intensiva. Clínicamente todos los pacientes mostraron una gran mejoría en la masticación, la alimentación y el habla, obviamente debido a una buena oclusión. El problema más común fue la baja colaboración en la rehabilitación mandibular por parte de los pacientes. Little is known about Noma or Cancrum Oris Disease. This entity affects to children with chronic malnutrition, poor oral hygiene, poor environmental sanitation and debilitating concurrent illness. There is general consensus that noma starts as gingivitis. The acute stage responds readily to antibiotic treatment. The sequelae after healing include variable functional and aesthetic impairments, which require reconstructive surgery. We report 3 cases of mandibular ankylosis. Preoperative examination revealed mandibular dismorphism, fusion of maxilla and mandible and ankylosis of the temporomandibular joint. Orthopantography and Computed Thomography scan (TCS) were very useful in planning surgery. The surgical treatment performed consisted in ankylotic bone resection in all cases, accompanied with condrocostal graft reconstruction in one case. All patients continued postoperatively with an intensive physiotherapy. Clinically all patients showed an improvement in eating, chewing and speaking, obviously due to good occlusion. Low collaboration with the mandibular rehabilitation was the most common problem.