Effects of preoperative dexamethasone on postoperative pain, nausea, vomiting and respiratory function in women undergoing conservative breast surgery for cancer: Results of a controlled clinical trial.

The objective was to evaluate whether preoperative administration of dexamethasone improved postoperative nausea and vomiting (PONV), pain and respiratory function tests in women undergoing conservative surgery for breast cancer. This was a controlled clinical trial conducted between June 2013 and October 2014. Eighty patients were evaluated. Patients received a preoperative dose of 8 mg of dexamethasone (n = 40) or placebo (n = 40). The data on PONV and pain intensity was obtained and forced spirometry tests were performed, 1 hr before and at 1, 6, 12 and 24 hr after surgery. Any use of additional analgesic/antiemetic drugs was recorded. Patients were followed until 30 days after surgery for any surgical or medical complications. The pain intensity was lower in the treatment group for all periods; PONV was lower at 6, 12 and 24 hr; Additional analgesics/antiemetics were required less frequently (all p < .05). Both groups exhibited a restrictive ventilatory pattern immediately after surgery, which was reversed in the following hours. However, spirometric values were higher in the dexamethasone group. There were no pulmonary or metabolic complications after surgery. Our conclusions were that dexamethasone significantly reduced the incidences of PONV, pain and improved respiratory parameters, and reduced the need for additional postoperative analgesic and antiemetic drugs.

Body weight changes after adjuvant chemotherapy of patients with breast cancer: results of a Mexican cohort study.

Weight gain is observed in breast cancer patients receiving chemotherapy and is a well-known complication. Several factors that contributing to weight gain have been identified. However, there is a lack of information about factors associated with weight changes following adjuvant chemotherapy. A retrospective cohort of 200 pre- and post-menopausal Mexican patients treated for breast cancer was made. Anthropometric variables were measured before/after treatment. Biomarkers, cellular differentiation and chemotherapy were similar between groups. Weight gain occurred in 85.6% of pre-menopausal and 72.6% of post-menopausal women (p = .03). At the end of chemotherapy, weight and body mass index (BMI) did not differ significantly between pre-menopausal (69.3 ± 12.6 kg; 26.6 ± 4.8 kg/m2 ) and post-menopausal women (69.5 ± 10.9 kg; 27.3 ± 4.4 kg/m2 ) (p = .91 and 0.34). Dexamethasone doses were higher in pre-menopausal (85.7 ± 39.1 g) than post-menopausal patients (79.2 ± 22.5 g; p = .13). Weight loss was observed in 9.2% of pre-menopausal and 20.2% of post-menopausal patients (p = .04). A multivariate analysis revealed that age (OR = 2.7; 95% CI = 1.26-5.79; p = .01), menopausal status (OR = 2.29; 95% CI = 1.09-4.80; p = .03), dexamethasone dosage (OR = 2.1; 95% CI = 1.04-4.23; p = .03) and daily caloric intake (OR = 2.3; 95% CI = 1.12-5.10; p = .02) were independent variables that inducted weight gain. Pre- and post-menopausal women gained weight, but more pre-menopausal patients showed gain. An effort should be made to administer lower steroid doses to reduce weight gain.

Platelet-Rich Plasma for the Treatment of Photodamage of the Skin of the Hands. / Plasma rico en plaquetas en el tratamiento del fotodaño cutáneo en las manos.

BACKGROUND: Platelet-rich plasma (PRP) provides growth factors that stimulate fibroblast activation and induce the synthesis of collagen and other components of the extracellular matrix. The objective of this study was to evaluate the effect of PRP in the treatment of photodamage of the skin of the hands. MATERIAL AND METHODS: Experimental study enrolling persons with photoaged skin on the dorsum of the hands (Glogau photoaging scale, type III, or Fitzpatrick wrinkle classification, type II) were included between August 2012 and January 2013. A histological comparison was made of skin biopsies taken before and after the application of PRP to the skin of the dorsum of the hands. RESULTS: The mean (SD) age of the 18 women enrolled was 47.9 (4.3) years. Histological analysis showed an increase in the number of fibroblasts (P<.001), number of vessels (P<.001), and collagen density (P=.27). These changes produced significant improvements in the Fitzpatrick wrinkle and elastosis scale (P<.001) and in the Glogau photoaging scale (P=.01). CONCLUSIONS: PRP induced a reduction in the manifestations of skin aging, including an improvement in wrinkles and elastosis.

External urology consultation quality at a third-level public hospital in Mexico.

INTRODUCTION: Patient satisfaction is the degree of conformity with the healthcare they receive. It is real evidence and one of the most important factors in determining the effectiveness and quality of healthcare systems. OBJECTIVE: To identify the quality of care in the Urology outpatient department of a third-level hospital. MATERIALS AND METHODS: The NHS (National Health Service) 2018 quality of care questionnaire with 11 sections, 133 items, and duration of approximately 25min was randomly administered to 250 patients attending Urology outpatients at a third-level public hospital in Mexico. RESULTS: According to responses, 92% (n=230) knew the reason for the consultation. 64.8% (n=162) had a consultation with the same physician by whom they were initially seen. The longest reported hospital wait time before being seen was more than 2h in 29.6% (n=74). As for consultation time, 212 patients responded and the duration was 11-20min in 52.8% (n=112). Finally, 33.2% (n=83) considered the quality of service to be good. CONCLUSIONS: The use of the NHS 2018 survey in the Urology service at a third-level public hospital in Mexico is feasible, since we managed to obtain a significant and continuous improvement in all its indicators which is satisfactory for all.

Prospective study of the modified Atkins diet in adult drug-resistant epilepsy: effectiveness, tolerability, and adherence.

INTRODUCTION: Drug-resistant epilepsy presents high worldwide prevalence and is difficult to control despite the wide variety of available antiepileptic drugs (AED). The modified Atkins diet (MAD) is an additional treatment alternative. Several studies have addressed the use of the ketogenic diet and MAD in children with drug-resistant epilepsy, but insufficient research has been conducted into adults with the same condition. OBJECTIVE: To evaluate the effectiveness and tolerability of, and adherence to, the MAD in adults with drug-resistant epilepsy. MATERIAL AND METHODS: We conducted a 6-month pre-post prospective study at a reference hospital. Patients were prescribed the MAD with limited carbohydrate intake and unlimited fat intake. We conducted clinical and electroencephalographic follow-up according to the relevant guidelines, and assessed adverse effects changes in laboratory findings, and adherence. RESULTS: Thirty-two patients with drug-resistant epilepsy were included in the study. Patients' mean age was 30 years, mean disease progression time was 22 years, and all patients had focal or multifocal epilepsy. Thirty-four percent of patients presented > 50% decreases in overall seizure frequency (P =  .001); seizure control was greater in the first month and subsequently declined. These patients presented weight loss (RR: 7.2; 95% CI, 1.3-39.5; P = .02), good to fair adherence only in the first and third months (RR: 9.4; 95% CI, 0.9-93.6; P = .04 and RR: 0.4; 95% CI, 0.30-0.69; P = .02, respectively). Tolerability data showed that the MAD is safe: adverse effects were minor and short-lived in most cases, with the exception of mild to moderate hyperlipidaemia in one-third of patients. The adherence rate was 50% at the end of the study. CONCLUSIONS: In adults with drug-resistant focal epilepsy, the MAD showed adequate tolerability and moderate but decreasing effectiveness and adherence, probably due to a preference for a carbohydrate-based diet.

Evaluation of the quality of life related to vision after penetrating keratoplasty. / Evaluación de la calidad de vida relacionada con la visión posterior a queratoplastia penetrante.

INTRODUCTION: Organ and tissue donation and transplantation represent the most important therapeutic advance of current times. The cornea is, by far, one of the most transplanted tissues worldwide due to the immune privilege of this tissue, as well as the advances in microsurgery, existence of cornea banks, preservation of corneas, and use of anti-rejection therapy. However, many patients with successful corneal transplants (with clear corneas) experience poor vision in the post-operative period due to irregular astigmatism, or other complications. OBJECTIVE: To evaluate the quality of life related to vision in patients undergoing penetrating keratoplasty. MATERIAL AND METHODS: A cross-analytical study including patients with a history of penetrating keratoplasty, over 18years of age, and at least 6months after surgery. The patients answered the Visual Function Questionnaire25 (VFQ-25) of visual function, a tool validated for use in Spanish, in which the higher the score, the better the quality of life. RESULTS: Thirty patients (20men and 10women), with a mean age of 61.2±18.7years, were included. The time of evolution after the transplant was 17.7±4months. The total quality of life score was 74.9±21.9, with significance in visual acuity (P<.001), and the presence of systemic comorbidities (P=.018). There was no significance between the transplant reason (P=.098) or ocular comorbidities (P=.119). CONCLUSION: The results suggest that visual acuity, as well as the presence of systemic comorbidities, has a significant impact on quality of life.

Double-balloon enteroscopy: Indications, approaches, diagnostic and therapeutic yield, and safety. Early experience at a single center. / Enteroscopia de doble balón: indicaciones, abordajes, eficacia diagnóstica y terapéutica y seguridad. Experiencia temprana de un solo centro.

INTRODUCTION AND AIMS: Double-balloon enteroscopy has been improving the visualization of the entire intestine for more than a decade. It is a complementary method in the study of intestinal diseases that enables biopsies to be taken and treatments to be administered. Our aim was to describe its main indications, insertion routes, diagnostic/therapeutic yield, and complications. MATERIALS AND METHODS: All patients referred to our unit with suspected small bowel pathology were included. The insertion route (oral/anal) was determined through diagnostic suspicion. The variables measured were: insertion route, small bowel examination extent, endoscopic diagnosis/treatment, biopsy/histopathology report, complications, and surgical findings. RESULTS: The study included 28 double-balloon enteroscopies performed on 23 patients, of which 10 were women and 13 were men (mean age of 52.95 years). The oral approach was the most widely used (n=21), the main indication was overt small bowel bleeding (n=16), and the general diagnostic yield was 65.21%. The therapeutic intervention rate was 39.1% and the procedure was effective in all the cases. The most widely used treatment was argon plasma therapy (n=7). The complication rate was 8.6%; one patient presented with low blood pressure due to active bleeding and another had deep mucosal laceration caused by the argon plasma. CONCLUSIONS: Double-balloon enteroscopy is a safe and efficacious method for the study and management of small bowel diseases, with an elevated diagnostic and therapeutic yield.

[Effect of the administration of rectal indomethacin on amylase serum levels after endoscopic retrograde cholangiopancreatography, and its impact on the development of secondary pancreatitis episodes]. / Efecto de la administración de indometacina rectal sobre los niveles séricos de amilasa posteriores a colangiopancreatografía retrógrada endoscópica y su impacto en la aparición de episodios de pancreatitis secundaria.

BACKGROUND: Hyperamylasemia and acute pancreatitis represent the most frequent major complication after endoscopic retrograde cholangiopancreatography (ERCP), developing in 1-30% of cases. OBJECTIVE: To determine the incidence of hyperamylasemia and acute pancreatitis after ERCP, and to assess the utility of rectal indomethacin to prevent these events. MATERIAL AND METHODS: A randomized clinical trial. During a 12-month period 150 patients were included. They were divided up into a study group (n = 75), where 100 mg of rectal indomethacin were administered 2 hours prior to the procedure, and a control group (n = 75), which received rectal glycerin. Two hours after ERCP serum amylase levels were measured and classified as follows: 0or=600 IU/L. Clinical pancreatitis episodes were quantified and classified according to Ranson's criteria. RESULTS: Gender distribution: 100 women and 50 men. Mean age: 55.37 +/- 18.0 for the study group, and 51.1 +/- 17.0 for the control group. A diagnosis of benign pathology was present in 56 (74.7%) cases in the study group, and 59 (78.7%) controls. After ERCP 13 (17.3%) patients in the study group and 28 (37.3%) in the control group developed hyperamylasemia (p (2) 0.05). Hyperamylasemia > 600 IU/L was found in 3 patients in the study group, and in 10 in the control group (p = 0.001). Mild pancreatitis was detected in 4 (5.3%) patients in the study group, and in 12 (16%) patients in the control group (p = 0.034). There were no deaths or adverse drug reactions. CONCLUSIONS: Rectal indomethacin before ERCP decreases the risk of hyperamylasemia and pancreatitis. Indomethacine is a feasible, low-cost drug with minimal or nil side effects.

Combined transurethral prostatectomy and mesh-based tension-free inguinal hernia repair.

Previous reports have recognized the benefits of combining prostatic resection and inguinal hernia repair. This study reports the surgical management of bladder-outlet obstruction with simultaneous transurethral prostatectomy and mesh-based tension-free inguinal hernia repair. A prospective study was undertaken of 31 consecutive patients seen from January 1993-December 1998 at the Western Medical Center. All surgery was performed electively under epidural anesthesia, and prophylactic antimicrobial agents were given routinely. Two hernia repair techniques were used: the mesh-plug technique and the Lichtenstein repair. Written informed consent was obtained from all patients. Over a 5-year period, in 31 consecutive patients without urinary tract infection, 36 groin hernias were diagnosed. The mean+/-SD age of patients was 65.9+/-6.3 years. Twenty-four (66.7%) hernias were direct, and 12 (33.3%) were indirect; 61.1% (22) were primary hernias, and 38.8% (14) were recurrent. The mesh-plug and Lichtenstein repair techniques were used to treat 22 (61.1%) and 14 (38.8%) hernias, respectively. Wound hematoma developed after three hernioplasties (8.3%) and wound infection in one (2.7%). Hospital stays ranged between 2 and 4 days. The mean follow-up period was 69 months. The recurrence rate was 2.7% (one hernia). Simultaneous mesh-based tension-free herniorrhaphy and transurethral prostatectomy is a reliable and safe alternative for patients with both prostate enlargement and groin hernia. Hospital stay is not affected by the combined procedure, and the infection rate is acceptably low.

[Abdominal complications after cardiopulmonary procedures]. / Complicaciones abdominales consecutivas a derivación cardiopulmonar.

OBJECTIVE: To know the frequency of intraabdominal complications and its impact on survival of patients submitted to cardiopulmonary bypass for common open-heart surgical procedures. BACKGROUND: The gastrointestinal complications after cardiac surgery with cardiopulmonary bypass (CPB) have an incidence of 0.3 to 3% but mortality can exceed 60%. Despite improvements in preoperative, operative and postoperative care it has been the general impression that abdominal complications remain a significant problem. TYPE OF STUDY: Retrospective case-control study. MATERIAL AND METHODS: Consecutive patients submitted to cardiac surgery with CPB between March 1995 to March 1997 were included. Any gastrointestinal complication was identified as well as its diagnosis, medical or surgical management and mortality. RESULTS: One thousand and three hundred fifty two patients were studied of which 516 (38%) were operated for coronary revascularization, 502 (37%) valvular replacement, 68 (5.2%) a combination of valvular replacement and revascularization, 144 (10.6%) correction of congenital defects and 122 (9.6%) treated of diverse problems. Forty-four patients developed complications (3.3%) and they were, postoperative intestinal ileus in 14 cases (32%), half of them had concomitant hyperamylasemia. Hepatobiliary complications represented 29.5% (13 cases). Ten patients (22.7%) developed peptic ulcer disease complicated with perforation or hemorrhage. Severe acute pancreatitis was observed in two patients as well as two with bowel necrosis. Three patients had complications considered not related to CPB as grade I liver trauma, acute appendicitis and amebic colitis. The mortality was 11/44 (25%). As a control group, 73 patients operated upon over the same time period and on the same days as the study patients were analyzed. The mortality in this group was 5/73 (6.8%). The medical history of peptic ulcer disease (< 0.01) and postoperative hemodynamic unstability (< 0.05), the use of intra-aortic balloon pump (< 0.05) and respiratory failure with prolonged ventilatory support (< 0.05) were separate statistical significant determinants for the development of postoperative abdominal complications. CONCLUSIONS: Factors indicative of or contributing to periods of decreased end-organ perfusion appear to be significantly related to abdominal complications. Also, medical history of peptic ulcer disease represented an individual determinant of severe surgical complications as ulcer perforation and massive bleeding.

Manejo y administración de hemoderivados por personal de enfermería en un hospital de segundo nivel / Handling and management of blood-derived products by the nursing staff in a second level hospital

Introducción: El manejo y administración de hemoderivados es una actividad que realiza el personal de enfermería, por lo cual es de gran importancia tener presente que un uso inadecuado de éstos puede tener consecuencias graves en los pacientes, siendo fundamental el buen desempeño del personal de enfermería para la práctica segura. Objetivo: Evaluar el desempeño de enfermería en el manejo y administración de hemoderivados en un hospital de segundo nivel. Métodos: Estudio de diseño transversal. Se incluyeron enfermeras durante el 1º Enero al 30 junio del 2013. Se utilizó un instrumento validado que consta de 4 criterios con 27 ítems de respuestas dicotómicas para identificar el desempeño en el manejo y ministración de hemoderivados. La población fue dividida por categoría contractual. Análisis estadístico: prueba Chi-cuadrada y/ exacta de Fisher. Resultados: Se incluyeron un total de 110 observaciones a personal de enfermería que administró hemoderivados. Se obtuvo un índice de eficiencia global parcial (IEG) parcial a excelente de 64.5%. No se encontró asociación en el turno (p=0.16), servicio (p=0.31) y/o categoría contractual (p=0.25). Los porcentajes de excelente en el IEF fueron bajos (por turno: matutino y nocturno de 10 y 13 respectivamente, medicina interna y cirugía general 5 y 7%, y conforme a la categoría contractual, la enfermera general obtuvo en excelente sólo el 7.5%). Conclusiones: Nuestros resultados nos alertan para implantar programas de capacitación a enfermeras, para otorgar atención de calidad, disminuyendo los riesgos que comprometan la vida del paciente.

Introduction: Handling and managing blood-derived products is a nursing staff activity and thus, it is very important to keep in mind that an inadequate handling of these products can have serious consequences on patients. Therefore, a safe practice from the nursing staff is fundamental. Objective: To assess the nursing performance related to the handling and management of blood-derived products in a second level hospital. Methods: A transversal study design. Nurses were observed from January 1 to June 30, of 2013. A validated instrument with 27 dichotomy-items, and based on 4 criteria, to assess the handling and management of blood-derived products was used. The population was divided by contractual category. Statistical analysis: Chi square and/or Fisher exact test. Results: A total of 110 observations to the nursing staff handling and managing blood-derived products were included. An index of global efficiency (IGE) of partial to excellent of 64.5% was obtained. No associations were found with shift (p=.16), service (p=.31) and/or contractual category (p=.25). The percentages of excellent in the IEF were low (per shift: morning and night of 10 and 13 respectively; per service: internal medicine and general surgery 5 and 7%, and according to the contractual category, overall excellent nurse obtained only 7.5%). Conclusions: Our results encourage us to foster training programs for nurses in order to enhance the quality of care and also decrease the life risks on the patients.

Fibrin glue as adjuvant treatment for gastrocutaneous fistula after gastrostomy tube removal.

Gastrocutaneous fistulas are infrequent after gastrostomy tube removal. However, if the fistulous tract remains permeable, even low-volume output can produce significant cutaneous burns. The use of biodegradable adhesives has been described, where fibrin glue is applied directly over the fistulous tract or under the guidance of procedures such as upper or lower gastrointestinal endoscopy or fistuloscopy. We studied the use of fibrin glue in five consecutive adult patients with gastrocutaneous fistulas after gastrostomy tube removal, with no complications that might impede spontaneous closure. A comparison group included seven patients treated during the preceding 2 years with conservative medical management, who were not treated with fibrin glue. There was no difference between the two groups with regard to age and gender, nor with regard to type of gastrostomy (surgical or endoscopic). The mean output volume from the fistulas was 151.4 +/- 146.1 ml/24 h in the study group and 115.0 +/- 42.7 ml/24 h in the control group, which was not significantly different ( P = 0.80). The duration of previous conservative treatment was 93.8 +/- 85.1 days for the study group and 95.8 +/- 80.7 days for the control group and this also did not differ significantly ( P = 0.93). The time to achieve total fistula closure was 7.0 +/- 3.1 days in the study group and 32.7 +/- 15.7 days in the control group. This difference was statistically significant ( P < 0.004). The time required before oral feeding could be recommenced after spontaneous or induced closure was similar in the two groups, at 2.8 +/- 1.3 days and 4.71 +/- 2.36 days, respectively. Endoscopic guidance allows direct instillation of fibrin glue via the external opening through the whole fistulous tract. This procedure reduces the time required for the closure of gastrocutaneous fistulas.