[Relationship between crowding and community acquired skin and soft tissues infections]. / Relación entre hacinamiento e infecciones comunitarias de piel y partes blandas.

The association of the spread of community infections with poverty and overcrowding is well known. In our hospital, located in José C. Paz, we assist sporadic cases of post-cesarean infections caused by community acquired methicillin-resistant Staphylococcus aureus (CaMRSA). In a prospective study of families treated at our hospital, we investigated the relationship between a history of skin and soft tissue infections (SSTI) and extreme overcrowding defined as households with unsatisfied basic needs type 3 (NBI 3). A total of 264 households were included in the study; 109 (41.3%) had a history of SSTI and 59 (22.3%) were NBI 3. A total of 61.0% of the NBI 3 households and 35.6% of the non-NBI 3 households reported SSTI (p = 0.00047). Using Google Maps, we georeferenced households and identified them on a NBI map adapted from the 2010 demographic census. In neighborhoods with NBI > 9.7%, 51.2% of the households had a history of SSTI. When NBI was < 9.7%, the percentage fell to 31.1% (p = 0.0019). These results are suggestive of an association of SSTI acquired in the community with overcrowding and poverty. The presence of CaMRSA in community SSTIs should be suspected. Vancomycin or clindamycin prophylaxis could be considered when cesarean deliveries are performed in women from areas with high NBI or with a history of SSTI.

Common bile duct pressure in patients with and without cholelithiasis: A case-control study.

BACKGROUND: The reflux of pancreatic enzymes into the bile duct and the gallbladder is an abnormal phenomenon that plays a role in lithogenesis and carcinogenesis. Because the pressure of the common bile duct depends on the pressures of the sphincter of Oddi, its dysfunction would be reflected in an increase in the pressure of the common bile duct in patients with cholelithiasis. The objective of this study was to measure the pressures of the common bile duct in patients with and without cholelithiasis and to relate them to the presence of pancreatobiliary reflux. METHODS: A prospective case-control study was designed. The study universe was constituted by all patients undergoing total gastrectomy for gastric cancer stages I and II over 30 months. The primary outcome measure was to establish differences between common bile duct pressures in patients with and without cholelithiasis. RESULTS: Common bile duct pressures in patients with gallstones showed a significant elevation (16.9 mmHg) compared to patients without gallstones (3.3 mm Hg) (p < 0.0001). These pressures correlated with the levels of amylase and lipase in gallbladder bile; higher levels were found in patients with gallstones compared to patients without gallstones (P < 0.0001). CONCLUSIONS: Common bile duct pressure in patients with cholelithiasis was significantly higher compared to patients without cholelithiasis leading to pancreatobiliary reflux.

[Knowledge, attitudes, and practices about COVID-19 in Argentina. A cross-sectional study]. / Conocimientos, actitudes y prácticas sobre COVID-19 en Argentina. Estudio tranversal.

Our objective was to assess levels of knowledge, attitudes, and practices against COVID-19. A total of 3774 persons were surveyed between September 18 and October 16, 2020. Eighty% resided in Buenos Aires City or Buenos Aires Province: 58% had completed tertiary education; 72% worked either independently or as employees in the public or the private sector; 51% used a prepaid health care plan, 34% were covered by a trade union-based health system, and near 10% used the public health services. According to the socio-demographic variables analyzed, the population studied was representative of the middle class. A total of 7% had been diagnosed with COVID-19. There was a high level of knowledge about the disease, judging by the high proportion of correct answers (80-90%). Regarding the measures taken by the government, the answers varied widely ("correct", "inadequate", "harmful", "unnecessary", etc.). The medical staff was the preferred source of information; 44% of respondents felt protected by their health system; 28% would only seek healthcare when feeling very sick. There was a high degree of compliance with most protection measures, except for attendance to social events in poorly ventilated spaces (50%). The results of these studies contribute to establishing communication strategies for the prevention and control of COVID-19 and thus deal more efficiently with eventual outbreaks of the disease.

Nuestro objetivo fue evidenciar el nivel de conocimientos, actitudes y prácticas frente al COVID-19. Fueron encuestados 3774 individuos mayores de 16 años entre el 18/09/20 y el 16/10/20. El 80% residía en la ciudad de Buenos Aires o la Provincia de Buenos Aires. El 58% había completado estudio terciario. El 72% tenía actividad laboral independiente o en relación de dependencia pública o privada. Utilizaban el sistema de salud prepago el 51%, obra social laboral el 34%, y sistema público de salud cerca del 10%. De acuerdo a las variables socio-demográficas analizadas, la mayoría de la población fue representativa de la clase media. Del total de encuestados, el 7% tuvo diagnóstico de COVID-19. Observamos un alto nivel de conocimiento de la enfermedad, con 80 a 90% de respuestas correctas. En relación a las medidas adoptadas por las autoridades, los juicios emitidos variaron entre "correctas", "insuficientes", "perjudiciales", "innecesarias", etc. El 44% se sentía protegido por el sistema de salud. En cuanto a los referentes válidos para transmitir información, la respuesta preponderante fue el personal médico. En cuanto al momento deconsultar por síntomas, un porcentaje importante (28%) lo haría en forma tardía. Observamos un alto grado de cumplimiento de las medidas de protección, a excepción del ítem "Asistencia a reuniones" (50%). Los resultados de estos estudios contribuyen a establecer estrategias comunicacionales para la prevención y el control de la enfermedad y de ese modo enfrentar de forma más eficiente eventuales rebrotes de la enfermedad.

Pancreaticobiliary reflux in patients with and without cholelithiasis: is it a normal phenomenon?

BACKGROUND: Pancreaticobiliary reflux is a pathologic phenomenon occurring in patients with gallstones. However, the occurrence of pancreaticobiliary reflux has not been studied in patients without gallstones. The objective of the present study was to measure the bile levels of amylase and lipase in patients without gallstones submitted to cholecystectomy as part of another surgical procedure, and to compare these values with the bile levels of amylase and lipase of patients submitted to cholecystectomy for gallstone disease. PATIENTS AND METHODS: A prospective observational and comparative study was designed. A sample of 136 consecutive patients was included. Amylase and lipase levels were measured in bile. At our institution, normal plasma concentrations of amylase are 28-100 IU/l and lipase 13-60 IU/l. Normal values for pancreatic enzyme concentrations in bile have not been established. Therefore, bile amylase and lipase concentrations exceeding normal plasma concentrations were deemed to be elevated. RESULTS: Of the patients in the present study, 103 (76%) had gallstones and 33 (24%) had healthy gallbladders without gallstones. According to normal plasma levels for amylase and lipase, these enzymes in bile were elevated in 83.5% patients with gallstones, compared to elevated levels of amylase in 6% patients and lipase in 3% patients without gallstones (P < 0.0001). CONCLUSIONS: Pancreaticobiliary reflux is a common phenomenon in patients with gallstones and an uncommon phenomenon in patients with healthy gallbladders without gallstone disease.

Compression of the common femoral artery by a lymphangioma causing intermittent claudication.

External compression of the common femoral artery secondary to a lymphangioma has not been reported before. A female patient presented with intermittent claudication of the right lower extremity. She was examined with Doppler vascular ultrasound and computed tomography, which demonstrated a cystic mass that did not infiltrate the arterial wall. At operation we found a mass adjacent to and causing compression of the common femoral artery, which was completely resected. The histological report described a cystic cavernomatous lymphangioma. Surgical treatment of lymphangiomas includes complete resection of the lesion and arterial reconstruction or bypass if necessary. In our case, the lymphangioma did not infiltrate the arterial wall and was completely resected.

Raising concerns about the Sepsis-3 definitions.

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey.

BACKGROUND: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. METHODS: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. RESULTS: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). CONCLUSION: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Multiple gastrointestinal stromal tumors of the ileum and neurofibromatosis type 1.

Type 1 neurofibromatosis, also known as von Recklinghausen disease, is one of the most common genetic disorders. Gastrointestinal associations have been well described in these patients, but the true incidence of gastrointestinal tumors and the proportion of these becoming clinically significant are not known. The most common gastrointestinal tumors are stromal tumors, most of which are located in the stomach and jejunum. We discuss the case of a female patient with neurofibromatosis whose initial diagnosis was an ovarian mass. During surgery the diagnosis of an intestinal stromal tumor was made. Operative findings were a multilobulated tumor arising from the ileal wall 50 cm from the ileocecal valve. The tumor did not originate from the nervous myenteric plexus or muscular layer of the small bowel wall; it originated from within the stromal cells of the intestinal wall. Mitotic count showed 3 mitoses per 10 high-power fields. Immunohistochemical stains of the tumor showed positive staining for CD117 and CD34 and negative staining for S100, alpha-smooth muscle actin, and desmin. The intestinal myenteric plexus showed positive staining for chromegranin A and S100. The histologic characteristics of this patient's tumor are compatible with an undifferentiated stromal tumor of nonneural or nonmuscular origin.

The outcomes of open tension-free hernioplasty in elderly patients.

BACKGROUND: The outcomes of open tension-free hernioplasty have been evaluated for elderly patients and compared with other techniques without prosthesis or analyzed in elderly patients without a control group constituted by younger patients. Our aim was to compare the outcomes of open tension-free hernioplasty between elderly patients and younger patients applying the recently developed Quantitative and Qualitative Measurement Instrument (QQMI). METHODS: From January 1997 to December 2003, 731 male patients were electively operated on for inguinal hernia at our institution. We studied 688 patients (94%). Forty-three (6%) were excluded: 12 died of causes unrelated to inguinal surgery and 31 were lost to follow-up. The follow-up period ranged from 22 to 106 months, mean 87 +/- 8.5 months. RESULTS: Recurrence developed in seven patients (1%): six were patients younger than 70 years old. The final mean QQMI score for patients younger than 70 years old was 10.4, significantly higher than the score of 8.9 for elderly patients. CONCLUSION: The outcomes of open tension-free hernioplasty were better in patients younger than 70 years old than the outcomes for elderly patients.

Conocimientos, actitudes y prácticas sobre covid-19 en argentina. estudio tranversal / Knowledge, attitudes, and practices about COVID-19 in Argentina. A cross-sectional study

Resumen Nuestro objetivo fue evidenciar el nivel de conocimientos, actitudes y prácticas frente al COVID-19. Fueron encuestados 3774 individuos mayores de 16 años entre el 18/09/20 y el 16/10/20. El 80% residía en la ciudad de Buenos Aires o la Provincia de Buenos Aires. El 58% había completado estudio terciario. El 72% tenía actividad laboral independiente o en relación de dependencia pública o privada. Utilizaban el sistema de salud prepago el 51%, obra social laboral el 34%, y sistema público de salud cerca del 10%. De acuerdo a las variables socio-demográficas analizadas, la mayoría de la población fue representativa de la clase media. Del total de encuestados, el 7% tuvo diagnóstico de COVID-19. Observamos un alto nivel de conocimiento de la enfermedad, con 80 a 90% de respuestas correctas. En relación a las medidas adoptadas por las autoridades, los juicios emitidos variaron entre "correctas", "insuficientes", "perjudiciales", "innecesarias", etc. El 44% se sentía protegido por el sistema de salud. En cuanto a los referentes válidos para transmitir información, la respuesta preponderante fue el personal médico. En cuanto al momento deconsultar por síntomas, un porcentaje impor tante (28%) lo haría en forma tardía. Observamos un alto grado de cumplimiento de las medidas de protección, a excepción del ítem "Asistencia a reuniones" (50%). Los resultados de estos estudios contribuyen a establecer estrategias comunicacionales para la prevención y el control de la enfermedad y de ese modo enfrentar de forma más eficiente eventuales rebrotes de la enfermedad.

Abstract Our objective was to assess levels of knowledge, attitudes, and practices against COVID-19. A total of 3774 persons were surveyed between September 18 and October 16, 2020. Eighty% resided in Buenos Aires City or Buenos Aires Province: 58% had completed tertiary education; 72% worked either independently or as employees in the public or the private sector; 51% used a prepaid health care plan, 34% were covered by a trade union-based health system, and near 10% used the public health services. According to the socio-demographic variables analyzed, the population studied was representative of the middle class. A total of 7% had been diag nosed with COVID-19. There was a high level of knowledge about the disease, judging by the high proportion of correct answers (80-90%). Regarding the measures taken by the government, the answers varied widely ("correct", "inadequate", "harmful", "unnecessary", etc.). The medical staff was the preferred source of information; 44% of respondents felt protected by their health system; 28% would only seek healthcare when feeling very sick. There was a high degree of compliance with most protection measures, except for attendance to social events in poorly ventilated spaces (50%). The results of these studies contribute to establishing communication strategies for the prevention and control of COVID-19 and thus deal more efficiently with eventual outbreaks of the disease.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Mirizzi syndrome and gallstone ileus: an unusual presentation of gallstone disease.

We discuss the case of a man with an unusual complication of gallstone disease. An 85-year-old patient presented to the emergency department with a 3-week history of abdominal pain in the right upper abdominal quadrant. Thoracoabdominal radiography demonstrated that the whole extrahepatic biliary tree, including the common bile duct, common hepatic duct, gallbladder, and left and right hepatic ducts, were visibly delineated by air. The operative findings revealed a small shrunken gallbladder, a fistula between the gallbladder fundus and the gastric antrum, and a cholecystohepatic fistula, corresponding to Mirizzi syndrome, type II. A large gallstone was found impacted in the jejunum. This patient seems to have developed initially a cholecystohepatic fistula. Due to the acute inflammatory process, the stone eroded through the gallbladder wall and into the gastric antrum, passing from the antrum into the small bowel, where it became impacted. We suggest that the natural history of Mirizzi syndrome does not end with a cholecystobiliary fistula but that the continuous inflammation in the triangle of Calot may result in a complex fistula involving not only the biliary tract but also the adjacent viscera.

The Systemic Inflammatory Response in Patients with Appendicitis: a Progressive Phenomenon.

The systemic inflammatory response has been described in patients with appendicitis. However, its progression from onset of symptoms to diagnosis has not been characterized. The specific purpose of this study was to describe and characterize the systemic inflammatory response to appendicitis. A descriptive cross-sectional study was conducted. One hundred eighty-three patients were studied, divided into four groups from onset of symptoms to diagnosis. The primary outcome measure was to determine the systemic inflammatory response to appendicitis according to the established groups of time intervals. The secondary outcome measure was the analysis of C-reactive protein for the same purpose. The variables of the systemic inflammatory response, according to diagnostic intervals, showed non-significant differences in white blood cell count. The temperature rose constantly after 48 h, reaching its peak after 72 h (p = 0.001), and the respiratory rate rose after 73 h (p < 0.0001). After 73 h, most patients had three or four systemic inflammatory response criteria (p < 0.0001). C-reactive protein levels rose progressively, showing higher levels after 48 h (p = 0.005). The inflammatory response to appendicitis is progressive, being more marked along the timeline from onset of symptoms to diagnosis.

Solitary Fibrous Tumor of the Liver: a Review of the Current Knowledge and Report of a New Case.

INTRODUCTION: Solitary fibrous tumors of the liver (SFTL) are uncommon tumors; to the present day, less than 50 cases has been reported in the English scientific literature, most of which behaved as benign tumors. The present article reports a new case of SFTL and has the main purpose of updating the current knowledge of SFTL because due to its rarity, its clinical presentation, study, treatment, and prognosis are not well known. The clinical presentation, radiologic study, surgical treatment, immunohistochemical study, and prognosis are updated and comprehensively discussed. METHODS: Using the common search engines, a search of the English literature was conducted for "Solitary Fibrous Tumor of The Liver," and the relevant articles were retrieved, reviewed, and analyzed. RESULTS: All published articles reported anecdotal SFTLs, or SFTLs were included in large series analyzing solitary fibrous tumors on different sites. CONCLUSION: The SFTL is an uncommon neoplasm. The clinical presentation is habitually indolent and its behavior is uncertain. In some cases, the SFTL acts as an aggressive sarcoma with poor prognosis. Currently, only surgery offers a therapeutic opportunity for these patients. Due to the lack of current knowledge of long-term behavior of supposedly benign SFTLs and to the lack of specific therapies, methodical long-term follow-up is essential to ensure the survival of patients treated for SFTL.

The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper.

The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.

Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study).

BACKGROUND: To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression. METHODS: The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18-99) were enrolled in the WISS study. RESULTS: Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p < 0.0001). The multivariate logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4. CONCLUSIONS: WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.

[Clinical and epidemiological study of adult patients with positive blood cultures]. / Estudio clinico y epidemiológico de pacientes adultos con hemocultivo positivo.

A cohort evaluation of the microbiology, epidemiology and outcome of adult patients with positive blood cultures was performed on 336 patients, from July 1997 to March 2000. Data for mortality were obtained from 328 of these patients. The six most common pathogens were Staphylococcus aureus: 81 (23.5%), coagulase negative staphylococci: 50 (14.5%), Escherichia coli: 48 (14.0%), Streptococcus pneumoniae: 30 (8.7%), enterococci: 19 (5.5%) and Pseudomonas aeruginosa: 19 (5.5%). In 169 episodes infections were hospital-acquired and community-acquired in the remaining 159. Main infection foci included the respiratory and urinary tracts. Infection associated mortality was 33.2%; 29.6% of patients received inappropriate empiric antibiotic treatment. Univariate analysis showed that an age of 70 or more years, a systemic inflammatory response syndrome (SIRS) score higher than 2, a polimicrobial episode, certain foci (abdominal, respiratory or unknown), and an inappropriate empiric antibiotic treatment influenced outcome. By multivariate analysis the variables that influenced death by infectious cause were age of 70 or more years, a SIRS score higher than 2, certain foci (abdominal, respiratory or unknown), and an inappropriate empiric antibiotic treatment. SIRS score was useful to predict the positivity of the blood culture. No relation between outcome and presence of underlying disease, isolation of Gram negative microorganism and nosocomial vs. community acquired episode was observed (univariate analysis). In order to improve outcome in bacteremic patients, after performing cultures of blood and other relevant clinical foci, prompt and appropriate antibiotic treatment remains critical. Microbiologic, clinical and epidemiological information results crucial for the management of this critically ill population.

Multiple primary gastrointestinal stromal tumors presenting in jejunum and ileum.

Multiple primary gastrointestinal stromal tumors (GIST) are an infrequent finding. Benign and malignant tumors could coexist in the same patient. We discuss one case of a benign jejunal GIST and a malignant ileal GIST coexisting in the same patient and present their radiological characteristics.