Navigating between two figured worlds: A constructivist grounded theory study on residents' workplace experiences with health care management tasks.

INTRODUCTION: Medical residents may be required to handle health care management (HCM) tasks alongside their clinical duties, despite not having received training to perform them. However, little research has been done on how medical residents acquire HCM skills at the workplace and how these experiences impact their learning. METHODS: We completed a qualitative research study using the Constructivist Grounded Theory approach inform by the Figured World theory. To gather data, we held focus groups and conducted semi-structured interviews with 22 medical residents from various disciplines and learning levels at Pontificia Universidad Javeriana. We utilised iterative data collection and analysis, constant comparison methods and theoretical sampling to construct our findings. RESULTS: We constructed two different worlds to represent how residents acquire HCM skills: the non-managing physician and the physician-as-manager. The former was characterised by a discourse that underplayed the role of the HCM tasks as part of residents' training, was full of negative interactions with the health care team and limited residents' agency. In the latter, residents collaborated and learned from health care team members, had supervisors who modelled how to incorporate HCM tasks into daily activities and expanded residents' agency. Residents developed their professional identity according to the world they were introduced into. DISCUSSION: Educational leaders must understand that the non-managing physician figured world gives residents a feeling of uprooting and discomfort when carrying out this type of tasks. To transform this world into the physician-as-manager, it is necessary to reconfigure some workplace hierarchies, consolidate interprofessional collaborations and change the discourse perpetuated by influential role models. Supervisors must also strengthen their knowledge of HCM and improve its integration into clinical practice. Any effort to train residents on HCM competencies could be lost if the workplace underscores their value in patient care.

Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn.

BACKGROUND: Heartburn that persists despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with reflux-reducing medication (e.g., baclofen) or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators (e.g., desipramine). METHODS: Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20 mg of omeprazole twice daily for 2 weeks, and those with persistent heartburn underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the Gastroesophageal Reflux Disease (GERD)-Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at 1 year. RESULTS: A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomization procedures excluded 288 patients: 42 had relief of their heartburn during the 2-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had non-GERD esophageal disorders, and 99 had functional heartburn (not due to GERD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomization. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to that with active medical treatment (7 of 25 patients, 28%; P = 0.007) or control medical treatment (3 of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and the control medical group was 16 percentage points (95% confidence interval, -5 to 38; P = 0.17). CONCLUSIONS: Among patients referred to VA gastroenterology clinics for PPI-refractory heartburn, systematic workup revealed truly PPI-refractory and reflux-related heartburn in a minority of patients. For that highly selected subgroup, surgery was superior to medical treatment. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT01265550.).

Caracterización del estado nutricional de pacientes posoperados con complicaciones en una unidad de cuidados intensivos / Characterization of the status of postoperative patients with complications in an intensive care unite

Introducción: Las unidades de atención al paciente gravemente enfermo informan numerosos casos con desnutrición. Para poder estimarlo es necesario utilizar indicadores dietéticos, antropométricos, bioquímicos e inmunológicos. Objetivo: Caracterizar el estado nutricional de los pacientes posoperados ingresados en una unidad de cuidados intensivos. Métodos: Se realizó un estudio descriptivo, prospectivo de corte transversal. Los valores se obtuvieron de los indicadores antropométricos (circunferencia media del brazo y circunferencia de la pantorrilla), bioquímicos (albúmina, colesterol, triglicéridos y creatinina) e inmunológicos (conteo total de linfocitos) de 98 pacientes ingresados en dicha unidad. El estado nutricional fue evaluado mediante variables independientes. Resultados: Predominaron los pacientes con estadía entre 1-7 días (71,4 por ciento), la ventilación mecánica se utilizó en 33,6 por ciento, fallecieron 19,3 por ciento de los pacientes, y predominó el grupo de afecciones intraabdominales 38,8 por ciento. La linfopenia (68,3 por ciento) y la hipoalbuminemia (62,2 por ciento) fueron más significativas, seguida de la circunferencia media del brazo (CMB) en rango de desnutrición (47,9 por ciento). No se demostró asociación de las variables nutricionales con la estadía, ni la necesidad de ventilación mecánica. Todas las variables se asociaron con el estado al egreso. Conclusiones: Predominó la estadía alrededor de una semana, la tercera parte de la muestra requirió apoyo ventilatorio, y la mortalidad fue baja. De las variables nutricionales estudiadas no se encontró asociación de estas con la estadía ni el uso de ventilación mecánica pero sí con el estado al egreso(AU)

Introduction: Critically ill care units report numerous cases of malnutrition. In order to estimate such statistics, it is necessary to use dietary, anthropometric, biochemical and immunological indicators. Objective: To characterize the nutritional status of postoperative patients admitted to an intensive care unit. Methods: A descriptive, prospective, cross-sectional study was carried out. The values ;were obtained from the indicators of the type anthropometric (average arm and calf circumference), biochemical (albumin, cholesterol, triglycerides and creatinine) and immunological (total lymphocyte count) of 98 patients admitted to the unit. The nutritional status was evaluated by independent variables. Results: Patients with 1-7 days of stay predominated (71.4 percent), mechanical ventilation was used in 33.6 percent, 19.3 percent of patients died, and the group of intra-abdominal conditions predominated (38.8 percent). Lymphopenia (68.3 percent) and hypoalbuminemia (62.2 percent) were more significant, followed by average arm circumference (AAC) in the malnutrition range (47.9 percent). There was no association of nutritional variables with the stay, nor the need for mechanical ventilation. All the variables were associated with the state at the time of discharge. Conclusions: A stay of about one week predominated, one third of the sample required ventilatory support, and mortality was low. Among all the nutritional variables studied, no association was found with the stay or the use of mechanical ventilation, but instead with the state at discharge(AU)

Implementation of an Intraoperative Instructional Timeout Just Prior to Stapler Use Improves Proficiency of Surgical Stapler Usage by Surgery Residents.

INTRODUCTION: With the fragmented rotational structure of training, exposure to surgical staplers is not uniform across surgical residents. Traditionally, educational sessions dedicated to instruction in surgical staplers have taken place outside the operating room. This study implemented and evaluated an intraoperative timeout immediately prior to stapler use in cases with surgical residents. METHODS: During general surgery cases from June 1, 2017 until December 31, 2017, surgical teams, including the surgical attending, surgical resident, and scrub nurse participated in an intraoperative instructional timeout, during which proper use of linear or circular staplers was reviewed. At the conclusion of the timeout, residents were required to demonstrate proper stapler assembly and verbalize all technical steps involved in stapler use. Duration of each timeout was recorded. Immediately following the case, a pre-post survey was administered to each participating junior (R1-R2) or senior (R4-R5) surgical resident. The primary outcome was change in stapler use knowledge by surgical residents. Survey questions with Likert scale responses were analyzed using paired ttests, and responses from junior residents were compared to those from senior residents with independent t tests. RESULTS: Forty-three general surgery cases involved stapler use during the study period and implemented an intraoperative instructional timeout. The educational intervention increased stapler use knowledge significantly in all surgical residents. Prior to the timeout, junior residents reported significantly higher anxiety related to stapler usage compared to their senior counterparts; anxiety scores in junior residents decreased significantly for use of both linear and circular staplers. The mean timeout duration was 2.9 minutes (standard deviation 0.9 minutes, range 1.2-4.6 minutes). All participating surgical residents recommended routine implementation of an instructional timeout prior to intraoperative stapler use. CONCLUSIONS: An intraoperative timeout dedicated to stapler teaching is effective in increasing proficiency and easing anxiety in all levels of surgical residents. Further research is warranted to determine whether this educational intervention would translate into fewer stapler use errors and decreased intraoperative complications.

Playing the Surgical Technologist Role by Surgery Residents Improves Their Technical and Nontechnical Skills.

BACKGROUND: The present study was designed to implement and evaluate an interprofessional surgical technologist-to-surgical resident training program for junior general surgery residents aimed at enhancing their operating room skills. This program would be incorporated into the general surgery educational curriculum. MATERIAL AND METHODS: Under the guidance and supervision of a surgical technologist, first-year and second-year general surgery residents performed the perioperative and intraoperative tasks that are the responsibilities of the surgical technologist for 16 inguinal/umbilical hernia and 15 laparoscopic appendectomy/cholecystectomy operations performed by attending surgeons assisted by other surgical residents from June 01, 2017 until December 31, 2017. A pretraining and post-training survey comprised 25 ranked questions (using a four-point Likert scale), and four Yes/No questions were administered to volunteer general surgery residents. RESULTS: Paired t-test analysis showed that playing the role of the surgical technologist by the junior surgery residents significantly improved (P < 0.0001) their assessment of operating room technical skills (knowledge and skills to prepare for the case and maintain a sterile field, understanding of the operative steps, knowledge of surgical instruments and their handling) as well as their nontechnical skills (situational awareness, understanding the importance of collaboration, teamwork, and communication). The answers to the binary Yes/No questions showed that all participating residents expect to use the experience gained from this training, would recommend this training session to a colleague, and support including this training session in their educational curriculum. CONCLUSIONS: The findings of this study suggest a significant educational benefit of incorporating interprofessional, surgical technologist-to-surgical resident training into the educational curriculum of the junior general surgery residents.

Surgical management of obesity.

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.

Prescripción de antimicrobianos y su relación con la resistencia bacteriana en un hospital general municipal / Antimicrobians prpescription and their relationship with the bacterial resistance in a municipal general hospital

Se realizó un estudio descriptivo y transversal, de utilización de medicamentos de tipo prescripción-indicación, de los 303 adultos que recibieron tratamiento antimicrobiano, ingresados en los servicios de Cuidados Intensivos, Medicina Interna y Cirugía del Hospital General Orlando Pantoja Tamayo del municipio de Contramaestre, desde enero hasta junio de 2015, con vistas a evaluar la prescripción de estos medicamentos y su relación con la resistencia bacteriana. En la serie, de un total de 568 prescripciones evaluadas predominaron las inadecuadas (82,3 por ciento); asimismo, los antimicrobianos más prescriptos resultaron ser la cefuroxima y la ceftriaxona, que también presentaron el mayor número de cepas resistentes y el Staphylococcus aureus resultó ser el germen con mayor resistencia

A descriptive and cross-sectional study on the use of prescription-indication medications of the 303 adults that received antimicrobian treatment was carried out. They were admitted to the Intensive Care, Internal Medicine and Surgery services of Orlando Pantoja Tamayo General Hospital in Contramaestre, from January to June, 2015, aimed at evaluating the prescription of these medications and their relationship with the bacterial resistance. In the series, there was a prevalence of inadequate prescriptions (82.3 percent) from a total of 568 that were evaluated; also, the most prescribed antimicrobians were the cefuroxime and the ceftriaxone that also presented the highest number of resistant stumps and the Staphylococcus aureus was the germ with higher resistance

Factors Associated With Long-term Outcomes of Umbilical Hernia Repair.

Importance: Umbilical hernia repair is one of the most commonly performed general surgical procedures. However, there is little consensus about the factors that lead to umbilical hernia recurrence. Objective: To better understand the factors associated with long-term umbilical hernia recurrence. Design, Setting, and Participants: A retrospective cohort of 332 military veteran patients who underwent umbilical hernia repair was studied between January 1, 1998, and December 31, 2008, at the VA Boston Healthcare System. Recurrence and mortality outcomes were tracked from that period until June 1, 2014. Data were collected on patient characteristics, operative, and postoperative factors and univariate and multivariable analyses were used to assess which factors were significantly associated with umbilical hernia recurrence and mortality. All patients with primary umbilical hernia repair, with or without a concurrent unrelated procedure, were included in the study. Patients excluded were those who underwent umbilical hernia repair as a part of another major planned procedure with abdominal incisions. Data were collected from June 1, 2014, to November 1, 2015. Statistical analysis was performed from November 2, 2015, to April 1, 2016. Main Outcomes and Measures: The primary study outcomes were umbilical hernia recurrence and death. Results: Of the 332 patients in this study, 321 (96.7%) were male, mean age was 58.4 years, and mean (SD) time of follow-up was 8.5 (4.1) years. The hernia recurrence rate was 6.0% (n = 20) at a mean 3.1 years after index repair (median, 1.0-year; range, 0.33-13 years). The primary suture repair recurrence rate was 9.8% (16 of 163 patients), and the mesh repair recurrence rate was 2.4% (4 of 169 patients). On univariate analysis, ascites (P = .02), liver disease (P = .02), diabetes (P = .04), and primary suture (nonmesh) repairs (P = .04) were significantly associated with increased recurrence rates. Patients who had a history of hernias (125 [39%]) were less likely to have umbilical hernia recurrences (χ21 = 4.65, P = .03). On multivariable regression analysis, obesity and ascites were associated with significantly increased odds ratios of recurrence of 3.3 (95% CI, 1.0-10.1) and 8.0 (95% CI, 1.8-34.4), respectively. Mesh repair was seen to decrease recurrence with odds of 0.28 (95% CI, 0.08-0.95). There was no significant difference in complication rates between mesh repair and primary suture repair. The survival rate was 73% (n = 242) at the end of the study. Factors associated with mortality were older age, smoking, liver disease, ascites, emergency or semiurgent repair, and need for intraoperative bowel resection. Conclusions and Relevance: Ascites, liver disease, diabetes, obesity, and primary suture repair without mesh are associated with increased umbilical hernia recurrence rates. Elective umbilical hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.

Efectividad del tratamiento homeopático en pacientes con trastorno del sueño / Effectiveness of the homeopathic treatment in patients with sleeping disorder

Se realizó un estudio experimental, de tipo intervención terapéutica, en 48 pacientes con trastorno del sueño, atendidos en el Centro de Salud Mental del municipio de Contramaestre, de la provincia de Santiago de Cuba, desde enero hasta junio de 2015, con vistas evaluar la respuesta al tratamiento con homeopatía. Se conformaron 2 grupos de 24 integrantes cada uno: el primero recibió los beneficios de los remedios homeopáticos y el segundo, tratamiento convencional. Entre los resultados principales predominaron el trastorno ansioso (50,0 %) y el uso de la pasiflora (45,0 %). El tratamiento homeopático resultó ser tan efectivo como el convencional, la evolución clínica fue más rápida y no produjo reacciones adversas.

An experimental, of therapeutic intervention study type was carried out, in 48 patients with sleeping disorder, assisted in the Mental Health Center of Contramaestre, in Santiago de Cuba, from January to June, 2015, aimed at evaluating the response to the treatment with homeopathy. Two groups of 24 members each were formed: the first one received the benefits of the homeopathic remedies and the second, conventional treatment. Among the main results the anxious disorder (50.0%) and the use of passiflora (45.0%) prevailed. The homeopathic treatment was as effective as the conventional one, the clinical course was faster and it didn't produce adverse reactions.

Surgeons' Disclosures of Clinical Adverse Events.

Importance: Surgeons are frequently faced with clinical adverse events owing to the nature of their specialty, yet not all surgeons disclose these events to patients. To sustain open disclosure programs, it is essential to understand how surgeons are disclosing adverse events, factors that are associated with reporting such events, and the effect of disclosure on surgeons. Objective: To quantitatively assess surgeons' reports of disclosure of adverse events and aspects of their experiences with the disclosure process. Design, Setting, and Participants: An observational study was conducted from January 1, 2011, to December 31, 2013, involving a 21-item baseline questionnaire administered to 67 of 75 surgeons (89%) representing 12 specialties at 3 Veterans Affairs medical centers. Sixty-two surveys of their communication about adverse events and experiences with disclosing such events were completed by 35 of these 67 surgeons (52%). Data were analyzed using mixed linear random-effects and logistic regression models. Main Outcomes and Measures: Self-reports of disclosure assessed by 8 items from guidelines and pilot research, surgeons' perceptions of the adverse event, reported personal effects from disclosure, and baseline attitudes toward disclosure. Results: Most of the surgeons completing the web-based surveys (41 responses from men and 21 responses from women) used 5 of the 8 recommended disclosure items: explained why the event happened (55 of 60 surveys [92%]), expressed regret for what happened (52 of 60 [87%]), expressed concern for the patient's welfare (57 of 60 [95%]), disclosed the adverse event within 24 hours (58 of 60 [97%]), and discussed steps taken to treat any subsequent problems (59 of 60 [98%]). Fewer surgeons apologized to patients (33 of 60 [55%]), discussed whether the event was preventable (33 of 60 [55%]), or how recurrences could be prevented (19 of 59 [32%]). Surgeons who were less likely to have discussed prevention (33 of 60 [55%]), those who stated the event was very or extremely serious (40 of 61 surveys [66%]), or reported very or somewhat difficult experiences discussing the event (16 of 61 [26%]) were more likely to have been negatively affected by the event. Surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patients' surgical outcomes or events following disclosure (odds ratio, 1.54; 95% CI, 1.16-2.06). Conclusions and Relevance: Surgeons who reported they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences, were more negatively affected by disclosure than others. Quality improvement efforts focused on recognizing the association between disclosure and surgeons' well-being may help sustain open disclosure policies.

Metodología para implementar la Medicina Natural y Tradicional en la enseñanza de la Química / Methodology to implement the Herbal and Folk Medicine in the teaching of Chemistry

Fundamento: la instrumentación del enfoque interdisciplinario implica una forma de trabajo metodológico diferente de las utilizadas tradicionalmente, encaminada a lograr aprendizajes significativos en los estudiantes. Objetivo: diseñar una metodología para la implementación de la Medicina Natural y Tradicional en los contenidos de la asignatura Química, en Tecnología de la Salud. Métodos: se realizó una investigación de desarrollo desde septiembre 2012 a julio 2013 en la Facultad de Tecnología de la Salud "Juan Manuel Páez Inchausti" de Santiago de Cuba. El universo de estudio estuvo conformado por la totalidad de estudiantes (215) que recibieron la asignatura Química y 12 profesores con vasta experiencia en la docencia, másteres en Medicina Natural y Tradicional y categoría docente principal. Se utilizaron métodos teóricos, empíricos y estadísticos que permitieron conformar la metodología propuesta. Resultados: se constató que existen algunas insuficiencias para relacionar los contenidos entre MNT y Química: la mayoría de los alumnos refieren que en las clases solo reciben conocimientos de la mencionada asignatura, existen deficiencias en la preparación metodológica de los docentes para integrar ambas ciencias y desconocimiento acerca de las diferentes modalidades de la MNT; por lo que se elaboró una metodología que permite la integración y consolidación de ambos contenidos en el proceso enseñanza aprendizaje. Conclusiones: la implementación de la metodología fue valorada como adecuada por criterio de especialistas por su pertinencia, asequibilidad y tratamiento científico y metodológico. Cumple con una estructura apropiada según las exigencias del modelo de formación del tecnólogo y dinamiza el proceso enseñanza aprendizaje de la Química.

Background: the instrumentation of the interdisciplinary approach implies a form of methodological work that requires to differ from those traditionally used, guided to achieve a meaningful learning in the students. Objective: to design a methodology for the implementation of the Herbal and Folk Medicine (HFM) in the contents of the Chemistry subject, in Health Technology. Methods: it was carried out a development investigation from September 2012 to July 2013 in "Juan Manuel Páez Inchausti" Health Technology faculty of Santiago de Cuba. The study universe comprised all the students who received the Chemistry subject (215) and 12 professors with vast teaching experience, masters in Herbal and Folk Medicine and high teaching ranks. Theoretical, empiric and statistical methods were used which allowed to conform the proposed methodology. Results: it was verified that there are some deficiencies to relate the contents between Herbal and Folk Medicine and Chemistry: most of the students refer that in the classes they only receive knowledge of the mentioned subject, deficiencies exist in the methodological preparation of the professors to integrate both sciences and lack of knowledge about the different modalities of (HFM); That is why a methodology was elaborated that allows the integration and consolidation of both contents in the teaching-learning process. Conclusions: the implementation of the methodology was valued as pertinent by the specialists' criteria for its relevancy, accessibility and scientific and methodological treatment. It fulfills an appropriate structure according to the demands of the model of the technologist's formation and it revitalizes the Chemistry subject teaching-learning process.

Hiperentorno de enseñanza-aprendizaje de la asignatura Análisis de Datos / Hyperentorno for the teaching-learning of the subject Data Analysis

En este trabajo se presenta el diseño de un hiperentorno educativo sobre la asignatura Análisis de Datos, el cual constituye una herramienta para la formación de estudiantes de las facultades de tecnología de la salud. La elaboración de dicho hiperentorno de enseñanza-aprendizaje, compuesto por un tutorial y un entrenador, surgió a partir de la insuficiencia en el aprendizaje, debido a la escasez de bibliografías actualizadas sobre dicho contenido y el difícil acceso a estas por parte de alumnos y profesores, y tuvo como objetivo elevar y perfeccionar el nivel de conocimientos al respecto. El hiperentorno fue estructurado en diferentes módulos: Temario, Ejercicios, Glosario, Mediateca, Complementos, Juegos y Ayuda, con interrelaciones entre sí, que facilitan el desarrollo del aprendizaje; y para ello se emplearon diferentes aplicaciones: Chreasoft 2.2, ProShow Producer v 4.0.2442, Format Factory y Microsoft Office Picture Manager.

In this work the design of a teaching hyperentorno on the subject Data Analysis is presented, which constitutes a tool for the training of students of the health technology faculties. The implementation of this teaching-learning hyperentorno, composed by a tutorial and a trainer, arose from the inadequacy in learning, due to the scarcity in updated literature on this topic and the difficult access to it by students and professors, and its objective was to rise and to improve the knowledge level on this respect. The hyperentorno was structured in different modules: Topics, Exercises, Glossary, Mediateca, Complements, Games and Help, with interrelations between them which facilitates the development of learning; and for this, different tools were used: Chreasoft 2.2, ProShow Producer v 4.0.2442, Format Factory and Microsoft Office Picture Manager.

Blended Infant Massage-Parenting Enhancement Program on Recovering Substance-Abusing Mothers' Parenting Stress, Self-Esteem, Depression, Maternal Attachment, and Mother-Infant Interaction.

PURPOSE: This study aimed to determine whether a blended Infant Massage-Parenting Enhancement Program (IMPEP) improved maternal psychosocial health outcomes (parenting stress, depressive symptoms, self-esteem, maternal attachment) and maternal-infant interaction among substance-addicted mothers (SAMs) actively engaged in outpatient rehabilitation. METHODS: Designed as a randomized, three-group controlled trial testing two levels of psychoeducational intervention (IMPEP vs. PEP) and a control group (standard care parenting resources), the study was conducted in two substance abuse centers in southeast Florida on a convenience sample of 138 recovering SAM-infant pairs. IMPEP or PEP classes were held weekly on Weeks 2-5, with data collected at baseline (Week 1), Week 6, and Week 12 via structured interviews, observation (Observation Checklist on Maternal-Infant Interaction), and self-administered questionnaires (Abidin Parenting Stress Index, Beck Depression Inventory, Rosenberg Self-Esteem Scale, Muller's Maternal Attachment Inventory), analyzed descriptively and inferentially using Kruskall-Wallis analysis of variance and post hoc Wilcoxon rank sum and Mann-Whitney U tests. RESULTS: Both IMPEP and PEP groups had significantly increased Parenting Stress Index scores (decreased parenting stress) and decreased Beck Depression Inventory scores (decreased depressive symptoms) compared to controls at Week 12, whereas there were no clinically meaningful differences among study groups in Rosenberg Self-Esteem Scale, Muller's Maternal Attachment Inventory, or Observation Checklist on Maternal-Infant Interaction scores. Only the IMPEP group showed significant improvements in both psychological and physical (waist-hip ratio) measures of parenting stress over time. CONCLUSIONS: The findings suggest that infant massage blended into a structured parenting program has value-added effects in decreasing parenting stress and maternal depressive symptoms, but not on SAM's self-esteem, attachment, or maternal-infant interaction.

Complicaciones severas por el uso parenteral del Kerosene en intento de autólisis: a propósito de tres casos / Severe complications due to the parenteral use ofKerosene in autolysis intends: a propose of three cases

El suicidio o intento suicida es un proceder muy antiguo, realizado por el ser humano en contra de sí mismo. Se presentó un estudio descriptivo de tres pacientes, que en intento suicida se auto inocularon kerosene, combustible doméstico, lo que desencadenó severa necrosis tisular y lesión pulmonar aguda en uno de ellos. La falta de previsión desde su inicio en el personal facultativo sobre la envergadura de las complicaciones que posteriormente aparecieron, se puso de manifiesto en el estudio. Se realizaron sugerencias para futuros afectados por esta causa.

Suicide or suicidal intend is a very old procedure, carried out by the human being against himself. We presented the descriptive study of three patients who inoculated themselves kerosene, a domestic combustible, in a suicidal intend, unleashing severe tissue necrosis and acute pulmonary lesion in one of them. In the study it was clear the lack of prevision on the reach of the complications that lately appeared, from the part of the medical staff. We made suggestions for the persons injured for this cause in the future.

Caracterización clínico epidemiológica de pacientes con infarto agudo del miocardio no trombolizados en el Hospital General Orlando Pantoja Tamayo, del municipio Contramaestre / Clinical-epidemiologic characterization of non thrombolyzed patients with acute myocardium infarct at the General Hospital Orlando Tamayo Pantoja, municipality of Contramaestre

La cardiopatía isquémica tiene una alta morbimortalidad en todo el mundo. Se realizó un estudio descriptivo transversal con el objetivo de caracterizar clínica y epidemiológicamente a 43 pacientes con diagnóstico de infarto agudo del miocardio que no recibieron tratamiento trombolítico en el Hospital General Orlando Pantoja Tamayo, del municipio Contramaestre, provincia Santiago de Cuba, desde enero a diciembre de 2012, donde predominó el sexo masculino y el grupo de edades de 61 a 70 años, con 2 o más factores de riesgo coronario. Fue significativa la dislipemia, obesidad y la hipertensión arterial. El tiempo de demora mayor de 12 horas fue la causa fundamental que inhabilitó la aplicación de la trombolisis, teniendo como génesis principal el desconocimiento por parte del enfermo de las señales de alarma que lo motivaron acudir al facultativo. Predominó el infarto de la cara inferior y la estadía hospitalaria superior a los 12 días como promedio.

The ischemic cardiopathy has a high morbimortality all around the world. A cross-sectional descriptive study was carried out with the objective of clinically and epidemiologically characterizing 43 patients diagnosed with acute myocardial infarct who did not received thrombolytic treatment in the General Hospital Orlando Pantoja Tamayo of the municipality of Contramaestre, from January to December 2012, with a predominance of the male sex and the age group from 61 to 70 years old, with 2 or more coronary risk facts, being significant dyslipidemia, obesity and arterial hypertension. The arrival time delayed more than 12 hours was the main cause disqualifying thrombolysis application, mainly caused by the ignorance of the alarm signs motivating the visit to the doctor from the part of the patient. There was a predominance of the lower side infarct and an average hospital staying of more than 12 days.

Morbilidad y mortalidad en pacientes egresados de la unidad de cuidados intensivos de Contramaestre durante un bienio / Morbidity and mortality in patients discharged from the intensive care unit in Contramaestre during a biennium i:en

Se realizó un estudio observacional, descriptivo y transversal de 550 pacientes en estado crítico, ingresados en la Unidad de Cuidados Intensivos del Hospital General Docente "Orlando Pantoja Tamayo" de Contramaestre en la provincia de Santiago de Cuba, durante el bienio 2010-2011, con vistas a determinar la morbilidad y mortalidad en ellos mediante algunas variables clinicoepidemiológicas de interés: edad, sexo, estado al egreso, aplicación de ventilación mecánica, estadía, diagnósticos principales, entre otras. En la casuística se obtuvo predominio de los hombres, la ancianidad y el infarto agudo del miocardio. En general, la mortalidad no fue elevada, excepto en los afectados por enfermedades cerebrovasculares, con estadía prolongada, y en los que recibieron ventilación mecánica invasiva, aunque el índice de ventilación fue relativamente bajo.

An observational, descriptive and cross-sectional study was carried out in 550 patients in critical condition, admitted to the Intensive Care Unit of "Orlando Pantoja Tamayo" General Teaching Hospital of Contramaestre in Santiago de Cuba province during 2010-2011, in order to determine the morbidity and mortality in them by means of some clinical and epidemiological variates of interest: age, sex, status at discharge, mechanical ventilation, hospital stay, main diagnoses, among others. There were prevalence of males, old age and acute myocardial infarction in the case material. Overall, the mortality was not high, except for those affected by cerebrovascular diseases with long stay, and for those receiving invasive mechanical ventilation, although the ventilation rate was relatively low.

Uso de la ventilación mecánica no invasiva en la Unidad de Cuidados Intensivos de Contramestre / Use of noninvasive mechanical ventilation in the Intensive Care Unit of Contramaestre municipality

Se realizó un estudio observacional, descriptivo y transversal de 52 pacientes con insuficiencia respiratoria aguda, admitidos en la Unidad de Cuidados Intensivos del Hospital General Docente "Orlando Pantoja Tamayo" del municipio de Contramaestre en Santiago de Cuba, de enero del 2010 a diciembre del 2011, quienes requirieron de ventilación mecánica no invasiva (con la postergación o evitación de la ventilación mecánica invasiva), a fin de demostrar la eficacia de esta modalidad terapéutica. En la serie se observó un predominio de los afectados mayores de 70 años de edad y del sexo femenino, así como una frecuencia superior de la enfermedad pulmonar obstructiva crónica, la insuficiencia cardiaca y las infecciones respiratorias. La aplicación de dicha técnica disminuyó la estadía en este servicio hospitalario y aumentó la calidad de vida de los pacientes.

An observational, descriptive and cross-sectional study was conducted in 52 patients with acute respiratory failure admitted to the Intensive Care Unit of "Orlando Pantoja Tamayo" General Teaching Hospital of Contramaestre municipality in Santiago de Cuba, from January 2010 to December 2011, who required noninvasive mechanical ventilation (with the delay or avoidance of invasive mechanical ventilation) in order to demonstrate the efficacy of this therapeutic modality. In the series a prevalence of people affected over 70 years and the female sex was observed, as well as a high frequency of chronic obstructive lung disease, heart failure and respiratory infections. The application of this technique decreased hospital stay in this service and increased the quality of patients' life.

Revisiting percutaneous cholecystostomy for acute cholecystitis based on a 10-year experience.

OBJECTIVES: To identify patient characteristics leading to percutaneous cholecystostomy (PC) and to compare outcomes between PC and cholecystectomy (CCY) in patients with acute cholecystitis (AC). DESIGN: Retrospective cohort study. SETTING Veterans Affairs Boston Healthcare System. PATIENTS: All consecutive patients with AC per the Tokyo criteria who underwent PC or CCY from January 1, 2001, through December 31, 2010. MAIN OUTCOME MEASURES: Differences in baseline characteristics and outcomes between PC and CCY patients, odds of PC vs CCY use, and odds of death after PC or CCY. RESULTS: Of 480 CCY and 92 PC procedures, 150 CCY and 51 PC procedures were performed for AC. The PC patients were older (70.4 vs 65.0 years, P = .01) and had higher leukocyte counts (16 500 vs 14 700/µL [to convert to × 109/L, multiply by 0.001], P = .046), alkaline phosphatase levels (198.2 vs 140.1 U/L [to convert to microkatals per liter, multiply by 0.0167], P = .02), Charlson comorbidity index scores (3.0 vs 1.0, P < .001), and American Society of Anesthesiologists class (P = .006) compared with CCY patients. The PC patients had longer intensive care unit stays (5.9 vs 2.3 days, P = .008), longer hospital stays (20.7 vs 12.1 days, P < .001), more complications per patient (2.9 vs 1.9, P = .01), and higher readmission rates (31.4% vs 13.3%, P = .006). On multivariate analysis, a Charlson comorbidity index score of 4 or higher was the only independent predictor of treatment with PC vs CCY (odds ratio, 1.226; 95% CI, 1.032-1.457) and was the only independent predictor of death after PC or CCY (odds ratio, 1.318; 95% CI, 1.143-1.521). No differences in survival were found between the PC and CCY groups (P = .14). CONCLUSION: Compared with CCY, PC is associated with higher morbidity rates and should be reserved for patients with prohibitive risks for surgery.

Tumor size and depth predict rate of lymph node metastasis in colon carcinoids and can be used to select patients for endoscopic resection.

BACKGROUND: Regional lymphadenectomy is recommended for all colon carcinoids, whereas resection without lymphadenectomy is accepted for selected appendiceal and rectal carcinoids. We examined the relation of tumor size and depth to lymph node metastasis in order to determine whether colon carcinoids could be selected for endoscopic resection. METHODS: Patients were identified from the Surveillance Epidemiology and End Results Registry. The Pearson chi-square and the log rank tests were used. P < 0.05 was considered significant. RESULTS: We identified 929 patients who underwent resection of localized colon carcinoids without distant metastasis diagnosed from 1973 to 2006. The diagnosis of small and superficial tumors increased over time (p < 0.001). The presence of lymph node metastasis was adversely associated with survival (p < 0.001); however, there was only a trend toward independence on multivariate analysis (p = 0.054). Tumor size and depth were associated with lymph node metastasis (p < 0.001, p < 0.001). Tumors were subgrouped by size and depth to find cases with a low risk of lymph node metastasis. Intramucosal tumors < 1 cm had a 4% rate of lymph node metastasis, while all other subgroups had rates ≥ 14%. CONCLUSION: Tumor size and depth predict lymph node metastasis for colon carcinoids. Endoscopic resection may be appropriate for intramucosal tumors <1 cm.

Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment.

BACKGROUND: Prosthetic mesh infection is a catastrophic complication of ventral incisional hernia (VIH) repair. METHODS: The current surgical literature was reviewed to determine the incidence, microbiology, risk factors, and treatment of mesh infections. RESULTS: Mesh infections tend to present late. Diagnosis depends on high clinical suspicion and relies on culture of the fluid surrounding the mesh or of the mesh itself. Risk factors may include a high body mass index (obesity); chronic obstructive pulmonary disease; abdominal aortic aneurysm repair; prior surgical site infection; use of larger, microporous, or expanded polytetrafluoroethylene mesh; performance of other procedures via the same incision at the time of repair; longer operative time; lack of tissue coverage of the mesh; enterotomy; and enterocutaneous fistula. The best treatment is prevention. Treatment of mesh infection is evolving on a case-by-case basis from explantation toward mesh salvage, to prevent complications such as hernia recurrence. CONCLUSION: Higher-quality reporting on mesh infection in VIH repair must be achieved through better classification and quantification of these infections. Tactics to avoid mesh infection should be based on best evidence and high-quality prospective trials and observational studies.