Effectiveness and Safety of Postoperative Hospital at Home for Surgical Patients: A Cohort Study.

OBJECTIVE: To determine the feasibility and effectiveness of a Hospital at Home (HaH) enabled early transfer pathways for surgical patients. BACKGROUND: HaH serves as a safe alternative to traditional hospitalization by providing acute care to patients in their homes through a comprehensive range of hospital-level interventions. To our knowledge, no studies have been published to date reporting a large cohort of early home-transferred patients after surgery through a HaH unit. METHODS: Cohort study enrolling every patient admitted to the HaH unit of a tertiary hospital who underwent any of 6 surgeries with a predefined early transfer pathway and fitting both general and surgery inclusion criteria (clinical and hemodynamic stability, uncomplicated surgery, presence of a caregiver, among others) from November 2021 to May 2023. Protocols were developed for each pathway between surgical services and HaH to deliver the usual postoperative care in the home setting. Discharge was decided according to protocol. An urgent escalation pathway was also established. RESULTS: During the study period, 325 patients were included: 141 were bariatric surgeries, 85 kidney transplants, 45 thoracic surgeries, 37 cystectomies, 10 appendicectomies, and 7 ventral hernia repairs. The overall escalation of care during HaH occurred in 7.3% of patients and 30-day readmissions in 7%. Most adverse events were managed at home and the overall mortality was zero. The total mean length of stay was 8 days (interquartile range 2-14), and patients with HaH were transferred home 3 days (interquartile range 1-6) earlier than the usual pathway; a total of 1551 bed-days were saved. CONCLUSIONS: The implementation of early home transfer pathways for surgical patients through HaH is feasible and effective, with favorable safety outcomes.

Emergence of carbapenem-resistant Pseudomonas aeruginosa ST179 producing both IMP-16 and KPC-2: a case study of introduction from Peru to Spain.

We describe four cases of a novel carbapenem-resistant Pseudomonas aeruginosa ST179 clone carrying the blaKPC-2 or blaKPC-35 gene together with blaIMP-16, imported from Peru to Spain and isolated from leukemia patients. All isolates were multidrug-resistant but remained susceptible to fosfomycin, cefiderocol, and colistin. Whole-genome sequencing revealed that blaKPC-2 and blaKPC-35 were located in an IncP6 plasmid, whereas blaIMP-16 was in a chromosomal type 1 integron. This study highlights the global threat of multidrug-resistant P. aeruginosa clones and underscores the importance of monitoring and early detection of emerging resistance mechanisms to guide appropriate treatment strategies. The importation and spread of such clones emphasize the urgent need to implement strict infection control measures to prevent the dissemination of carbapenem-resistant bacteria. IMPORTANCE: This is the first documented case of a Pseudomonas aeruginosa ST179 strain carrying the blaKPC-35 gene, and it represents the first report of a P. aeruginosa co-harboring blaIMP-16 and either blaKPC-2 or blaKPC-35, which wre imported from Peru to Spain, highlighting a threat due to the capacity of spreading carbapenem-resistance via plasmid conjugation.

Real-Life Comparison of Antivirals for SARS-CoV-2 Omicron Infection in Patients With Hematologic Malignancies.

BACKGROUND: We aimed to describe a cohort of hematologic patients with COVID-19 treated with antivirals early. METHODS: Non-interventional chart review study. Comparison of baseline characteristics and outcomes in high-risk hematologic patients treated with remdesivir between December 2021 and April 2022 versus those treated with nirmatrelvir/ritonavir between May and August 2022. RESULTS: Eighty-three patients were analyzed. Forty-two received remdesivir, and 41 nirmatrelvir/ritonavir. Patients with remdesivir were younger, vaccinated with lower number of doses, and received prior corticosteroids less frequently and sotrovimab, hyperimmune plasma and corticosteroids more often. Viral shedding median (IQR) duration was 18 (13-23) and 11 (8-21) days in the remdesivir and nirmatrelvir/ritonavir groups, respectively (p = 0.004). Median (IQR) Ct values before treatment were similar in both groups. Within 5 days of treatment, median (IQR) Ct values were 26 (23-29) and 33 (30-37) in the remdesivir and nirmatrelvir/ritonavir groups, respectively (p < 0.0001). All patients were hospitalized for remdesivir administration and only four (9.8%) in the nirmatrelvir/ritonavir group. The overall outcomes in this cohort of COVID-19 patients with Omicron variant was good, as no patient needed oxygen or ICU admission. One patient in remdesivir group died from septic shock. No severe adverse event was recorded in both treatment groups. CONCLUSIONS: Patients with hematologic malignancies and non-severe COVID-19 who received nirmatrelvir/ritonavir experienced faster decrease in viral load and shorter viral shedding. Furthermore, besides the advantage of oral administration, nirmatrelvir/ritonavir administration reduced the need of hospital admission.

K-Means Clustering Identifies Diverse Clinical Phenotypes in COVID-19 Patients: Implications for Mortality Risks and Remdesivir Impact.

INTRODUCTION: The impact of remdesivir on mortality in patients with COVID-19 is still controversial. We aimed to identify clinical phenotype clusters of COVID-19 hospitalized patients with highest benefit from remdesivir use and validate these findings in an external cohort. METHODS: We included consecutive patients hospitalized between February 2020 and February 2021 for COVID-19. The derivation cohort comprised subjects admitted to Hospital Clinic of Barcelona. The validation cohort included patients from Hospital Universitari Mutua de Terrassa (Terrassa) and Hospital Universitari La Fe (Valencia), all tertiary centers in Spain. We employed K-means clustering to group patients according to reverse transcription polymerase chain reaction (rRT-PCR) cycle threshold (Ct) values and lymphocyte counts at diagnosis, and pre-test symptom duration. The impact of remdesivir on 60-day mortality in each cluster was assessed. RESULTS: A total of 1160 patients (median age 66, interquartile range (IQR) 55-78) were included. We identified five clusters, with mortality rates ranging from 0 to 36.7%. Highest mortality rate was observed in the cluster including patients with shorter pre-test symptom duration, lower lymphocyte counts, and lower Ct values at diagnosis. The absence of remdesivir administration was associated with worse outcome in the high-mortality cluster (10.5% vs. 36.7%; p < 0.001), comprising subjects with higher viral loads. These results were validated in an external multicenter cohort of 981 patients. CONCLUSIONS: Patients with COVID-19 exhibit varying mortality rates across different clinical phenotypes. K-means clustering aids in identifying patients who derive the greatest mortality benefit from remdesivir use.

Safety and effectiveness of isavuconazole in real-life non-neutropenic patients.

OBJECTIVES: Information is scarce on clinical experiences with non-neutropenic patients with invasive fungal infection (IFI) receiving isavuconazole. We aimed to report the safety and effectiveness of this drug as a first-line treatment or rescue in real life. METHODS: A retrospective, observational multicentric study of non-neutropenic patients who received isavuconazole as an IFI treatment at 12 different university hospitals (January 2018-2022). All patients met criteria for proven, probable or possible IFI according to EORTC-MSG. RESULTS: A total of 238 IFIs were treated with isavuconazole during the study period. Combination therapy was administered in 27.7% of cases. The primary IFI was aspergillosis (217, 91.2%). Other IFIs treated with isavuconazole were candidemia (n = 10), mucormycosis (n = 8), histoplasmosis (n = 2), cryptococcosis (n = 2), and others (n = 4). Median time of isavuconazole treatment was 29 days. Only 5.9% (n = 14) of cases developed toxicity, mainly hepatic-related (10 patients, 4.2%). Nine patients (3.8%) had treatment withdrawn. Successful clinical response at 12 weeks was documented in 50.5% of patients. CONCLUSION: Isavuconazole is an adequate treatment for non-neutropenic patients with IFIs. Toxicity rates were low and its effectiveness was comparable to other antifungal therapies previously reported.

Intervenção multiprofissional melhora a aptidão física relacionada à saúde de adolescentes com maior efeito sobre as meninas em comparação aos meninos / Multiprofessional intervention improves health-related physical fitness in adolescents with greater effect on girls compared to boys

Resumo Este estudo teve como objetivo verificar as diferenças entre as respostas de meninos e meninas a um programa multiprofissional de tratamento da obesidade sobre a aptidão física relacionada à saúde. Fizeram parte do estudo 163 adolescentes com excesso de massa corporal e idade entre 10 e 18 anos. Foram avaliados parâmetros antropométricos, composição corporal, flexibilidade, força e resistência abdominal e aptidão cardiorrespiratória antes e após 16 semanas de intervenção multiprofissional. A intervenção multiprofissional contou com a participação de profissionais de educação física, nutrição, psicologia e pediatria e teve como foco principal o incentivo a mudanças nos hábitos alimentares e de atividade física que pudessem promover alterações positivas nos parâmetros analisados. A intervenção teve frequência semanal de três sessões, sendo uma hora de intervenções teóricas com os profissionais de educação física, nutrição e psicologia e a outra hora destinada à prática regular de exercícios físicos, com predominância de exercícios físicos resistidos, aeróbios e prática de basquetebol. Após a intervenção tanto as meninas quanto os meninos apresentaram melhoras significativas nas variáveis IMC, circunferência de cintura e quadril, massa gorda relativa e absoluta, massa magra, flexibilidade, força/resistência abdominal e aptidão cardiorrespiratória, porém com resultados mais expressivos para as meninas sobre a circunferência de cintura, gordura corporal (kg), VO2max e força/resistência abdominal.(AU)

Abstract This study aimed to verify the differences between both boys and girls responses to a multidisciplinary program of obesity treatment on health-related physical fitness. One hundred and sixty three adolescents with excess body weight and aged 10 to 18 years took part in the present study. It was assessed anthropometric parameters, body composition, flexibility, abdominal strength/resistance and cardiorespiratory fitness before and after 16 weeks of a multiprofessional intervention. The multiprofessional intervention was developed by physical educators, nutritionist, psychologist, pediatrician and was focused on motivate eating and exercise changes which could promote positive changes on the parameters analyzed. The intervention was conducted three times per week in which theoretical intervention lasted one hour with physical educators, nutritionist and psychologist and another hour designated to practical interventions of the physical educators in which predominated resistance and aerobic exercise as well as basketball practice. After the intervention, both girls and boys presented significant improvements in BMI, waist and hip circumference, relative and absolute body fat, lean mass, flexibility, strength and resistance in abdominal and cardiorespiratory fitness; however the results were more expressive for girls on waist circumference, body fat (kg), VO2max and abdominal strength/resistance.(AU)

Physical, clinical, and psychosocial parameters of adolescents with different degrees of excess weight / Parâmetros físicos, clínicos e psicossociais de adolescentes com diferentes graus de excesso de peso

OBJECTIVE: To compare body composition, hemodynamic parameters, health-related physical fitness, and health-related quality of life of adolescents with anthropometric diagnosis of overweight, obesity, and severe obesity. METHODS: 220 adolescents with excess body weight were enrolled. They were beginners in a intervention program that included patients based on age, availability, presence of excess body weight, place of residence, and agreement to participate in the study . This study collected anthropometric and hemodynamic variables, health-related physical fitness, and health-related quality of life of the adolescents. To compare the three groups according to nutritional status, parametric and non-parametric tests were applied. Significance level was set at p<0.05. RESULTS: There was no significant difference in resting heart rate, health-related physical fitness, relative body fat, absolute and relative lean mass, and health-related quality of life between overweight, obese, and severely obese adolescents (p>0.05). Body weight, body mass index, waist and hip circumference, and systolic blood pressure increased as degree of excess weightincreased (p<0.05). Dyastolic blood pressure of the severe obesity group was higher than the other groups (p<0.05). There was an association between the degree of excess weight and the prevalence of altered blood pressure (overweight: 12.1%; obesity: 28.1%; severe obesity: 45.5%; p<0.001). The results were similar when genders were analyzed separately. CONCLUSION: Results suggest that overweight adolescents presented similar results compared to obese and severely obese adolescents in most of the parameters analyzed...

OBJETIVO: Comparar composição corporal, parâmetros hemodinâmicos, aptidão física relacionada à saúde e qualidade de vida relacionada à saúde em adolescentes com o diagnóstico antropométrico de sobrepeso, obesidade e obesidade grave. MÉTODOS: Foram selecionados 220 adolescentes com excesso de peso, ingressantes em um programa de intervenção segundo os critérios de inclusão neste programa, baseados na idade, disponibilidade, presença de excesso de peso, local de residência e concordância na participação do estudo. Foram coletadas variáveis antropométricas, hemodinâmicas, aptidão física relacionada à saúde e qualidade de vida relacionada à saúde dos adolescentes. Para a análise de comparação entre os três grupos, foram utilizados testes paramétricos e não paramétricos quando apropriado. A significância foi pré-estabelecido em p<0,05. RESULTADOS: Não houve diferença significativa para a frequência cardíaca de repouso, aptidão física relacionada à saúde, gordura relativa, massa magra (relativa e absoluta) e qualidade de vida relacionada à saúde entre adolescentes com sobrepeso, obesos e obesos graves (p>0,05). O peso, índice de massa corporal, circunferência de cintura e de quadril e pressão arterial sistólica aumentaram conforme aumentou o grau de excesso de peso (p<0,05). A pressão arterial diastólica do grupo com obesidade grave foi maior que a dos demais grupos (p<0,05). Observou-se associação entre o aumento grau de excesso de peso e a prevalência de pressão arterial alterada (sobrepeso: 12,1%; obesidade: 28,1%; obesidade grave: 45,5%; p<0,001). Os resultados foram semelhantes quando os sexos foram analisados separadamente...

Segmentectomía hepática por laparoscopia / Laparoscopic hepatic segmentectomy

La primera resección anatómica hepática por laparoscopia la reportó Azagra en 1994. Este autor realizó una segmentectomía hepática lateral izquierda en un paciente con un adenoma sintomático (1). Desde entonces se ha reportado un número creciente de resecciones anatómicas tanto segmentarias como hemihepatectomías, para el manejo de enfermedades malignas y benignas de este órgano.El objetivo de este reporte es revisar la técnica quirúrgica de una segmentectomía hepática lateral izquierda por vía laparoscópica, como una opción mínimamente invasiva en un paciente con una litiasis intrahepática izquierda.

Lesiones de la vía biliar durante la colecistectomía laparoscópica. Factores técnicos, anatómicos y educacionales / Bile duct lesions during laparoscopic cholecystectomy. Technical, anatomic and educational factors

Hipótesis: El aprendizaje de la técnica de colecistectomía laparoscópica durante los programas de entrenamiento de cirugía general disminuye la incidencia de lesiones de la vía biliar, si se compara con la incidencia de estas lesiones en cirujanos que aprendieron dicha técnica luego de graduados.Materiales y métodos: Trabajo descriptivo, con una muestra de 64 cirujanos, miembros de la Asociación Colombiana de Cirugía, con título formal en Cirugía General, avalado por el ICFES con práctica corriente y permanente de la cirugía en el país.Criterios de exclusión: lesiones biliares menores: Se realizó una encuesta, diseñada por el Departamento de Epidemiología de la Universidad CES, acompañada de un instructivo para su diligenciamiento de carácter confidencial.Se separó al total de encuestados en dos: grupo A, cirujanos sin entrenamiento en laparoscopia durante la residencia; grupo B, cirujanos con entrenamiento durante la residencia. Se evaluaron otras variables como: edad, sexo, tiempo de práctica y lugar, número de colecistectomías realizadas al año y durante el tiempo de práctica, práctica o no de colangiografía intraoperatoria, número y tipo de lesiones mayores de la vía biliar, momento del diagnóstico, manejo inicial, definitivo, necesidad de remisión...

Estenosis de la anastomosis gastroyeyunal como complicación de la derivación gástrica en cirugía bariátrica por laparoscopia: reporte de tres casos y su manejo / Stricture of gastrojejunal anastomosis of the gastric bypass in laparoscopic bariatric surgery. Report of three cases and discussion of management

La obesidad se ha convertido en un problema de salud pública en muchos países. La cirugía bariátrica ha demostrado ser una terapia efectiva para la obesidad mórbida y cada día se realiza con más frecuencia este tipo de procedimientos. La estenosis de la gastroyeyunostomía es la complicación tardía más frecuente en la cirugía de derivación gástrica por laparoscopia. Presentamos el reporte de tres casos de estenosis de la anastomosis gastroyeyunal, su manejo y revisamos la literatura reciente sobre el tema...

Esplenectomía laparoscópica mano - asistida. Técnica quirúrgica en esplenomegalia masiva / Hand-assisted laparoscopic splenectomy. Surgical technique in massive splenomegaly

La esplenectomía laparoscópica se ha convertido en el procedimiento estándar para resecar el bazo. Algunas series descriptivas han sugerido que la esplenectomía laparoscópica mano-asistida facilita la realización de este procedimiento en casos de esplenomegalia masiva.Objetivo: Describir la técnica quirúrgica de la esplenectomía laparoscópica mano-asistida como una opción quirúrgica que se considera de invasión mínima.Caso: Paciente de sexo femenino de 65 años con esplenomegalia masiva. Técnica: Se inicio con una colecistectomía laparoscópica y luego se colocó el puerto de mano (Lap Disc® Johnson & Johnson) en incisión de Pfannestiel. Los puertos laparoscópicos se ubicaron en ombligo, y dos subcostales izquierdos a 5 centímetros del borde del bazo. Con la mano dentro de la cavidad, se suspendió el bazo hacia la línea media y arriba para ligar los vasos polares y liberar las adherencias laterales. Posteriormente se aislaron digitalmente los vasos del pedículo y se ligaron con una endograpadora. Se liberó el ligamento gastroesplénico con el bisturí armónico y se realizó hemostasia selectiva de los vasos cortos. El bazo se extrajo en una endobolsa y se realizó el cierre de los puertos...

Corrección laparoscópica de hernias diafragmáticas traumáticas: reporte de doce casos / Laparoscopic repair of diafragmatic herniae: report of twelve cases

Las lesiones del diafragma se presentan frecuentemente en pacientes con trauma toracoabdominal cerrado o penetrante. La herniación del contenido abdominal se asocia con una tasa de mortalidad elevada, por lo cual, la corrección temprana de estas lesiones disminuye la morbimortalidad en estos pacientes. Presentamos el informe de 12 casos de lesiones de diafragma. en 11 pacientes la corrección se realizó por vía laparoscópica y un paciente requirió conversión a cirugía abierta. Dos de los tres pacientes con hernias de presentación tardía requirieron una prótesis para cubrir el defecto. En los pacientes con hernias de presentación aguda se realizó un cierre primario del mismo. Sólo un paciente presentó trauma severo que requirió manejo en la unidad de cuidados intensivos. Este último desarrolló complicaciones postoperatorias y una estancia hospitalaria prolongada, ambas relacionadas con la magnitud del trauma. El resto de los pacientes no presentó complicaciones y el promedio de estancia hospitalaria en este grupo fue 3, 1 días. En conclusión, la corrección laparoscópica de las hernias diafragmáticas traumáticas es un método adecuado en pacientes hemodinámicamente estables y que no reuieren laparotomía o toracotomía por otras causas.

Antibioticoterapia en trauma de estómago e intestino delgado / Antibiotic therapy in abdominal and small bowel trauma

Desde el principio de la medicina moderna con Hipócrates se relatan casos de lesiones gástricas y de intestino delgado,(1) pero no es sino hasta 1.275, año en el cual un cirujano italiano, Guillaume de Salicet describe el primer reparo con material de sutura en una lesión intestinal. (2) En 1.767 Nolleston Fils reporta el primer reparo exitoso en un paciente con trauma de estómago. (36) Desde entonces hasta hoy los modelos de transporte de alta velocidad, el uso extendido del cinturón de seguridad y la exagerada violencia civil hacen del trauma abdominal una entidad epidémica. (3-6)...

Carcinoma tiroiedeo bien diferenciado en niños y adolescentes: revision del tema / Tiroiedeo well-differentiated carcinoma in children and adolescents: revision of item

El carcinoma bien diferenciado de tiroides en niños y adolescentes es una entidad poco común. Los pacientes menores de 16 años representan entre el 5% al 10% del total de pacientes con cánceres en el tiroides. Del 80% al 90% es de tipo papilar. Frecuentemente se presenta con metástasis ganglionares y es usual que sea la manifestación inicial. Es también más frecuente que presenten metástasis a pulmón. El tratamiento y la vigilancia postoperatoria sigue los mismos parámetros que en el adulto, sin embargo los niños presentan más complicaciones postoperatorias y posteriores a la terapia con iodo radioactivo. El pronóstico es muy favorable, con una tasa de sobrevida a largo plazo mayor que en la edad adulta.

Carcinoma papilar de tiroides, variante de células altas, reporte de un caso clínico / Papillary thyroid carcinoma, tall cell variant: One clinical case report

La variante de células altas (VCA) del carcinoma papilar de tiroides fue descrita por primera vez en 1976 por Hawk y Hazard. De comportamiento mas agresivo, con una incidencia de recurrencia y mortalidad mayor que la variante usual (VU). La VCA se define como un cáncer papilar de tiroides en el cual el 30 por ciento o mas de sus células tiene una altura de al menos el doble de su ancho. Pueden encontrarse frecuentemente figuras amitóticas, indicando un patrón de crecimiento más agresivo. Se diferencia de la variante columna por la ausencia de estratificación de sus núcleos.

Experiencia latinoamericana sobre manejo de residuos sólidos

Señala consideraciones económicas e institucionales para explicar la disminución o el estancamiento en la prestación del servicio de manejo y disposición de los desechos sólidos domésticos e industriales. Estima que la población de América Latina y el Caribe produce diariamente 220,000 toneladas de desechos sólidos, alcanzándose a recolectar el 70 por ciento de la producción urbana y a disponer sanitariamente sólo el 14 por ciento