Infiltration of Bupivacaine and Triamcinolone in Surgical Wounds of Milligan-Morgan Hemorrhoidectomy for Postoperative Pain Control: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Pain management after hemorrhoidectomy continues to be challenging. OBJECTIVE: The aim of this study was to evaluate the effectiveness of infiltration of bupivacaine hydrochloride and triamcinolone acetonide in surgical wounds of Milligan-Morgan hemorrhoidectomy for postoperative pain relief. DESIGN: A double-blind randomized controlled clinical trial was conducted between May 2015 and June 2019. SETTINGS: This study was carried out in a secondary referral hospital center in Spain. PATIENTS: Patients who underwent an elective Milligan-Morgan hemorrhoidectomy for grade III-IV hemorrhoids were included. INTERVENTIONS: Patients allocated in the intervention group received a single infiltration of bupivacaine and triamcinolone and patients allocated in the control group did not receive any intervention. MAIN OUTCOMES MEASURES: The primary end point was the median of maximum pain by visual analog scale during the 48 hours of hospital stay. Secondary end points were pain at follow-up, pain during defecation, analgesic requirements, wound healing rate, and complications. RESULTS: A total of 128 patients were randomly assigned (64 in each group). The median of maximum pain score at 48 hours was 3 points in the intervention group and 6 points in the control group, which was significantly different ( p < 0.05). No differences were observed regarding pain during defecation. Morphine requirements were significant lower in the intervention group (6.3% vs 21.9% patients; p = 0.01; 5 vs 23 cumulative doses; p = 0.01). Wound healing and complication rates were similar in both groups. LIMITATIONS: Use of placebo was not considered in the control group ("intervention group" vs "control group" clinical trial). Data regarding pain or other complications at 48 hours postoperatively were pooled and expressed as median of values. CONCLUSIONS: Infiltration of surgical wounds with bupivacaine and triamcinolone decreases postoperative pain and reduces morphine requirements in Milligan-Morgan hemorrhoidectomies. See Video Abstract at http://links.lww.com/DCR/B867 .Clinical trial registration: European Registry of Clinical Trials. EUDRACT 2014- 003043-35. INFILTRACIN DE BUPIVACANA Y TRIAMCINOLONA EN HERIDAS QUIRRGICAS DE HEMORROIDECTOMA DE MILLIGANMORGAN PARA EL CONTROL DEL DOLOR POSOPERATORIO ENSAYO CLNICO DOBLE CIEGO, ALEATORIZADO Y CONTROLADO: ANTECEDENTES:El manejo del dolor posterior a una hemorroidectomía sigue siendo un desafío.OBJETIVO:El objetivo de este estudio fue evaluar la efectividad de la infiltración de bupivacaína y triamcinolona en heridas quirúrgicas de hemorroidectomía de Milligan-Morgan para el alivio del dolor posoperatorio.DISEÑO:Se realizó un ensayo clínico controlado, aleatorizado, doble ciego entre mayo del 2015 y junio del 2019.ENTORNO CLINICO:Este estudio se llevó a cabo en un centro hospitalario de referencia secundaria en España.PACIENTES:Se incluyeron pacientes que se sometieron a una hemorroidectomía de Milligan-Morgan electiva por hemorroides de grado III-IV.INTERVENCIONES:Los pacientes asignados al grupo de intervención recibieron una única infiltración de bupivacaína y triamcinolona y los pacientes asignados al grupo de control no recibieron ninguna intervención.PRINCIPALES RESULTADOS RESULTADOS:El factor de valoración principal fue la mediana del dolor máximo según la escala análoga visual durante las 48 horas de estancia hospitalaria. Las variables secundarias fueron dolor durante el seguimiento, dolor durante la defecación, requerimientos de analgésicos, tasa de cicatrización de heridas y complicaciones.RESULTADOS:Se asignó aleatoriamente a un total de 128 pacientes (64 en cada grupo). La mediana de puntuación máxima de dolor a las 48 horas fue de 3 puntos en el grupo de intervención y de 6 puntos en el grupo de control con diferencias significativas (p < 0,05). No se observaron diferencias en cuanto al dolor durante la defecación. Las necesidades de morfina fueron significativamente menores en el grupo de intervención (6,3% versus 21,9% de los pacientes; p = 0,01; 5 versus 23 dosis acumuladas; p = 0,01). Las tasas de curación de heridas y complicaciones fueron similares en ambos grupos.LIMITACIONES:No se consideró el uso de placebo en el grupo de control (ensayo clínico: "grupo de intervención" versus "grupo control"). Los datos con respecto al dolor u otras complicaciones después de 48 horas postoperatorias se agruparon y expresaron como mediana de los valores.CONCLUSIONES:La infiltración de heridas quirúrgicas con bupivacaína y triamcinolona disminuye el dolor posoperatorio y reduce los requerimientos de morfina en la hemorroidectomía de Milligan-Morgan. Consulte Video Resumen en http://links.lww.com/DCR/B867 . (Traducción- Dr. Francisco M. Abarca-Rendon).Registro de ensayos clínicos: Registro europeo de ensayos clínicos. EUDRACT 2014- 003043-35.

Characterization and photocatalytic performance of cement mortars with incorporation of TiO2 and mineral admixtures.

As the main components of the building envelope, construction materials have a straight relation with air contaminants from anthropogenic origins. Titanium dioxide has been recently applied in construction industry products since its photocatalytic properties can be used for pollutant degradation purposes. This study evaluated the performance of cement-based mortars with the incorporation of TiO2 nanoparticles and mineral admixtures. Six mortar compositions were defined by considering two reference mixes (with and without TiO2 incorporation), two mineral admixtures (bentonite and metakaolin) as partial cement replacement and one waste from ornamental stone processing in two levels of partial substitution of natural sand. Consistency index, density, and entrained air content of mixtures were investigated at fresh state. Compressive strength, water absorption, sorptivity, and micrographs from scanning electron microscopy were used to characterize mortars at hardened state. It was observed that incorporation of TiO2 does not considerably change mortar's properties at fresh and hardened state, despite a denser microstructure and improved interfacial transition zone. In general, the relation between the water-to-cement ratio and porosity on the performances of TiO2-added mortars was shown, which is strongly related to their photocatalytic efficiency. Metakaolin mixtures were more efficient to NO conversion, and high selectivity was observed for the bentonite mortars.

Comparison of the Permeability of Potential Ballast Rocks from Northern Rio de Janeiro State under Different Fouling Rates after Sodium Sulfate Attack.

This paper aimed to analyze the reduction in the ballast layer permeability simulated in a laboratory in saturated conditions by the presence of rock dust as a contaminant of three types of rocks explored in different deposits in the northern region of the state of Rio de Janeiro, Brazil, through laboratory testing relating the physical properties of rock particles before and after sodium sulfate attack. Sodium sulfate attack is justified by the proximity of some sections of the planned EF-118 Vitória-Rio railway line to the coast and of the sulfated water table to the ballast bed, which could degrade the material used and compromise the railway track. Granulometry and permeability tests were performed to compare ballast samples with fouling rates of 0, 10, 20, and 40% rock dust by volume. A constant head permeameter was used to analyze hydraulic conductivity and establish correlations between the petrography and mercury intrusion porosimetry of the rocks, namely two types of metagranite (Mg1 and Mg3) and a gneisse (Gn2). Rocks, such as Mg1 and Mg3, with a larger composition of minerals susceptible to weathering according to petrography analyses, tend to be more sensitive to weathering tests. This, in conjunction with the climate in the region studied, with average annual temperature and rainfall of 27 °C and 1200 mm, could compromise track safety and user comfort. Additionally, the Mg1 and Mg3 samples showed greater percentage variation in wear after the Micro-Deval test, which could damage the ballast due to the considerable changeability of the material. The mass loss caused by abrasion due to the passage of rail vehicles was assessed by the Micro-Deval test, with Mg3 (intact rock) declining from 8.50 ± 1.5 to 11.04 ± 0.5% after chemical attack. However, Gn2, which exhibited the greatest mass loss among the samples, showed no significant variation in average wear, and its mineralogical characteristics remained almost unchanged after 60 sodium sulfate cycles. These aspects, combined with its satisfactory hydraulic conductivity rate, indicate that Gn2 is suitable for use as railway ballast in the EF-118 railway line.

Water reuse in industries: analysis of opportunities in the Paraíba do Sul river basin, a case study in Presidente Vargas Plant, Brazil.

In recent years, the demand for clean water has been growing all over the world despite the different threats posed, including increasing pollution, increasing deforestation and climate change. Industrial activity is the second largest consumer of water, so highly industrialized regions are more susceptible to water stress. In this sense, reuse strategies have been progressively discussed and used around the world; however, in Brazil there is still place for many advances, whether due to lack of incentives, cultural issues in society, or poor regulation of the subject. The objective of this work was to carry out a diagnosis of raw water uptake by industries in one Hydrographic Region of the state of Rio de Janeiro and to propose a discussion on the adoption of water reuse practices for non-potable purposes from the use of treated effluents. A survey of the theoretical framework on the subject was carried out, as well as an analysis of sustainability indicators and reports of the companies, including the current licensing processes of large undertakings consuming water resources. With this study, it was possible to obtain the average cost of implementing a water reuse unit for an industry in the state of Rio de Janeiro-Brazil, which, despite still being expensive, has a strong tendency to use due to world water shortages. Finally, it was concluded that the state of Rio de Janeiro has a threat of water scarcity that could be aggravated in the coming years, if measures and investments in supply alternatives are not adopted (water reuse), and improvement in all stages of water management water resources.

Effect of Granite Residue Incorporation on the Behavior of Mortars.

Civil construction is one of the most resource-consuming sectors in the world. For this reason, the last years have witnessed the study of reusing industrial residues in building materials. The ornamental stone processing industry has a considerable environmental liability related to residue generation during the cutting stages of granite blocks. The objective of this work is to analyze the viability of incorporating granite residues, up to 100%, to substitute sand in coating mortars for building construction. Mortars without residue, as control, and incorporated with 20, 40, 60, 80, and 100% of granite residue were subjected to consistency tests, incorporated air and water retention together with the rheological characterization using the squeeze-flow and the dropping-ball methods. The results show that mortars with 40% granite residues presented greater plastic deformation, helping their applicability by also presenting improved technological properties in the fresh state.

Is the severe pain after Milligan-Morgan hemorrhoidectomy still currently remaining a major postoperative problem despite being one of the oldest surgical techniques described? A case series of 117 consecutive patients.

INTRODUCTION: Surgery is the only curative method of hemorrhoidal disease. Currently the Milligan-Morgan hemorrhoidectomy is still considered the "gold standard", since it is the best performing technique. However, postoperative pain remains a major problem. We analize the postoperative analgesic requirements for this procedure in 117 patients. PRESENTATION OF CASES: Between 2012 and 2013, 117 consecutive patients undergoing Milligan-Morgan hemorroidectomy, with an analysis of sex, age, total vascular anal cushions removed, hospital stay, complications, and relation with postoperative analgesic requirements. Patients with documented allergy to NSAIDs or pyrazolones were excluded. Additionally 23 patients undergoing Milligan-Morgan hemorrhoidectomy associated to internal lateral sphincterotomy were also analyzed. RESULTS: The mean age of patients was 51.7 years. The 50.8% were women and 49.2% men. In 33.3% of cases, one vascular anal cushion was removed, 2 in 39.3%, and 3 in 27.4%. The average stay for the 3 groups was 2.0days. An analgesic dose average of 4.1 by day was given, with opioid requirements in 22.2% of cases. It was statistically significant that as more anal cushions were eliminated was higher the opioids need. No significant difference of opioids use was found regarding patients undergoing sphincterotomy as additional procedure. DISCUSSION: Postoperative pain after a Milligan-Morgan hemorrhoidectomy currently remains a problem for colorectal surgery teams. This involves the use of opioids comparable to other major surgeries, finally causing not negligible days of admission charge. A protocolized analgesic treatment, as we actually do in our center, should be implemented after a Milligan-Morgan hemorrhoidectomy for improving the postoperative period pain management.

[Mortality analysis as a tool for quality improvement in a general surgery service]. / Análisis de la mortalidad como herramienta de mejora de la calidad asistencial en un servicio de cirugía general.

OBJECTIVES: The present study aims to propose a method to improve healthcare quality based on systematic analysis of mortality and mortality-related adverse effects. PATIENTS AND METHODS: We analyzed all deaths in the surgery service between January, 1997 and December, 2003. There were 10,905 hospital admissions and 194 deaths. The mean number of deaths per year was 28 (range 24-36). The mean number of deaths/discharges per year was 1.77 (SD 0.2; range 1.5-2.13). The overall mean age was 80.5 years (SD 9.5; range 47-100). By sex there were 104 women (53.6%) and 90 men (46.6%). During the study period 9,437 patients underwent surgery. We defined the concept of death secondary to a hospital problem (DSHP): this easily objectified concept includes any hospital problem occurring from admission to death associated directly or indirectly with death, or simply precipitating a foreseeable death. RESULTS: We detected 33 DSHP. Of all deaths, 17% were DSHP. In these DSHP, 37 problems were detected (some deaths involved more than one problem). The most frequent types of problem were three nosocomial infections, 19 problems secondary to therapeutic or diagnostic techniques, seven insufficient evaluations or treatment omissions or delays, and eight harmful incidents. No deaths occurred because of organizational or structural problems. The number of DSHP in relation to discharges was 0.3%. CONCLUSIONS: We present a system of continuous self-evaluation, in which problems are recognized and a constructive attitude is adopted. The model can be extrapolated to other hospitals but the results must be evaluated in the specific context of each hospital. Nevertheless, the results can be used for monitoring within a single center over a period of years.