Building a Culture of Support at a Pediatric Surgery Center Through Multidisciplinary Peer Support.

INTRODUCTION: Surgeons and perioperative staff experience high rates of burnout manifesting as exhaustion, depersonalization, and lack of achievement. Consequences include increases in errors and adverse patient events. Little data exist regarding the effectiveness of multidisciplinary peer support systems in combatting burnout. We sought to improve staff morale through establishment of a formally trained, multidisciplinary peer support team. METHODS: Selfselected surgeons, anesthesiologists, and nurses were formally trained as Peer Responders as part of an institutional peer support program. All perioperative staff at our pediatric surgery center (n = 120) were surveyed before initiation of the program and then 1-mo and 12-mo after initiation. Primary outcomes were unit morale, unit support, and peer approachability. Kruskal-Wallis tests and Chi-squared tests were used for comparison of primary outcomes among surveys and by position with an alpha value of 0.05 set for significance. Institutional review board approval was waived. RESULTS: The survey response rates were 57.5%, 32.5%, and 37.5% chronologically. After 1 year, there were statistically significant increases in unit support (P < 0.01) and peer approachability (P < 0.001), and a nonstatistically significant increase in unit morale (P = 0.22). On subgroup analysis by staff role, surgeons were least likely to utilize peer support. CONCLUSIONS: A multidisciplinary peer support team is an effective and easily reproducible means of building a culture of support and improving morale among perioperative staff. Surgeons were least likely to seek interprofessional peer support. Consequently, surgeon-specific strategies may be necessary. Further investigations are ongoing regarding secondary effects on staff burnout rates, patient safety, and quality of care.

[Food insecurity and its association with obesity and cardiometabolic risks in Mexican women]. / Inseguridad alimentaria y su asociación con la obesidad y los riesgos cardiometabólicos en mujeres mexicanas.

INTRODUCTION: Objective: we conducted a systematic review of the main scientific evidence that associates food insecurity with a higher frequency of obesity and cardiometabolic risks in Mexican women. Design: a systematic review. Data sources: MEDLINE, Embase, CINAHL Plus, Web of Science, CAB Abstracts and PAIS Index. Selection criteria: articles that met the journal quality criteria and integrated food status with health insecurity, in which the situation of vulnerability in the current statistics for cardiometabolic diseases and risks that are associated with food insecurity was shown in women and their homes. Data analysis: relevance and quality of the results regarding food security, the presence of overweight and obesity, and socio-environmental indicators in women. Results: households headed by women who are at higher risk of having some degree of food insecurity or food assistance associated with the presence of obesity and overweight (RR = 1.28 to 2.97; 95 % CI: 1.08-1.44 to 1.52-6.14) as well as the development of cardiometabolic diseases such as diabetes mellitus (with a history of pregnancy as risk factor for developing diabetes and hypertension) presenting premature labor, shorter stature in the adult stage, a deficiency in micronutrients such as iron and antioxidant vitamins. Conclusion: the evidence found shows an association of food insecurity as found in women and their homes with a greater risk of being overweight and obese, as well as the development of a cardiometabolic disease (diabetes, hypertension), in addition to anemia and vitamin deficiency.

INTRODUCCIÓN: Objetivo: realizar una revisión de la principal evidencia científica que asocie la inseguridad alimentaria con una mayor frecuencia de obesidad y riesgos cardiometabólicos en mujeres mexicanas. Diseño: revisión sistemática. Fuentes de datos: MEDLINE, Embase, CINAHL Plus, Web of Science, CAB Abstracts y PAIS Index. Selección de estudios: artículos que reunieran los criterios de calidad de las revistas e integraran la situación de inseguridad alimentaria y salud, en los que se viera la situación de vulnerabilidad en las estadísticas actuales de enfermedades y riesgos cardiometabólicos asociados con la situación de inseguridad alimentaria en mujeres y sus hogares. Extracción de datos: relevancia y calidad de los resultados respecto a la seguridad alimentaria, la presencia de sobrepeso y obesidad, e indicadores socioambientales en las mujeres. Resultados: los hogares encabezados por mujeres presentaron mayor riesgo de tener algún grado de inseguridad alimentaria o carencia alimentaria, asociándose esta con la presencia de obesidad y sobrepeso (RR = 1,28 a 2,97; IC 95 %: 1,08-1,44 a 1,52-6,14) así como con el desarrollo de enfermedades cardiometabólicas como la diabetes mellitus (siendo el embarazo, como antecedente, un factor de riesgo para desarrollar diabetes e hipertensión), presentar partos prematuros, tener menor estatura en la etapa adulta, una deficiencia de micronutrimentos como el hierro y de vitaminas antioxidantes. Conclusiones: la evidencia encontrada muestra una asociación de la inseguridad alimentaria encontrada en las mujeres y sus hogares con una mayor probabilidad de presentar sobrepeso y obesidad, así como el desarrollo de una enfermedad de índole cardiometabólica (diabetes, hipertensión), además de anemia y deficiencia de vitaminas.

Proposal for a clinicopathological prognostic score for resected gastric cancer patients.

BACKGROUND: Factors other than pTNM stage have been associated with gastric cancer (GC) prognosis, and several alternative prognostic scores have been constructed. Our aims are to identify prognostic factors in western GC patients and to build clinicopathological prognostic models for overall survival (OS) and disease-free survival (DFS). METHODS: A Retrospective study of 204 cases of GC resected during the years 2000 to 2014 was conducted in our hospital. Clinicopathological features were assessed, univariate and multivariate analysis were performed and prognostic scores were constructed. RESULTS: Most patients were diagnosed at pTNM stages II and III (36.9% and 48.1%, respectively). According to Laurén classification, tumors were intestinal (55.8%), diffuse (35.2%) and mixed (9%). During follow-up, 43.5% of patients had tumor recurrence, and 28.6% died due to tumor. Univariate analysis showed that patient age, Laurén subtype, signet-ring cell morphology, pTNM stage, tumor grade, perineural invasion, growth pattern, intratumoral inflammation, adjuvant therapy, and desmoplasia were significantly related to tumor progression or death. Multivariate analysis showed that Laurén subtype, pT stage, and lymph node ratio (LNR) were significantly and independently associated with GC recurrence. Laurén subtype and LNR were significantly related to patient survival. Prognostic scores for tumor progression and death were developed and patients were classified into four prognostic groups which showed good prognostic performance. CONCLUSION: A prognostic model comprising histological features such as Laurén subtype can be easily applied in clinical practice, and provides more prognostic information than pTNM stage alone. These models can further stratify resected GC patients and have the potential to aid in the individualization of patient management.

Update, validation and comparison of three different clinicopathological scores for patients with resected gastric cancer: A western experience.

INTRODUCTION: Gastric cancer (GC) is a multifactorial disease. Several prognostic scores have been proposed for refining the prognostic information provided by the TNM classification. Our aim is to validate and compare the prognostic performance of different clinicopathological scores in a western cohort of patients (Marubini, Haraguchi and Kologlu scores). MATERIAL AND METHODS: Retrospective study of all cases of GC resected in a western tertiary center (N = 377). Clinicopathological features were collected, scores were applied and statistical analyses were performed. RESULTS: 315 cases were finally included. According to Marubini, Haraguchi and Kologlu scores, patients were stage I (18.5%, 13.3% and 49%), II (29.3%, 47.2% and 29.5%) and III (52.2%, 39.5% and 21.5%, respectively). All classifications were significantly associated with lymphovascular invasion, perineural infiltration, lymph node involvement, patient progression and death due to GC. All scores showed good patient stratification by Kaplan-Meier analyses, but OS and DFS curves depending on Haraguchi score were less evenly spaced. Kologlu classification showed prognostic superiority over Haraguchi and Marubini classifications by ROC analysis. AUC values for OS and DFS were 0.654 and 0.647 (Marubini), 0.626 and 0.618 (Haraguchi) and 0.724 and 0.709 (Kologlu). Kologlu and Marubini classifications were independent factors for both OS and DFS, but Haraguchi classification was independently associated only with DFS. CONCLUSIONS: Clinicopathological scores can be easily validated and are cost-effective. Kologlu score is the most thorough classification, and it showed the best prognostic performance for both DFS and OS in our study. More studies are needed to validate its value in other populations.

Association between food insecurity and perinatal risk factors with hearing problems in preterm birth.

INTRODUCTION: Background: hearing disorders in the premature newborns impact on their development and language and therefore, on their quality of life. Several risk factors have been associated to these conditions, but little is known about socioeconomic, nutrition factors and food security. Objective: to analyze the association between food security and prenatal risk factors in newborns with hearing disorders. Material and methods: study of 35 cases and 105 controls in premature newborns from 30 to 37 weeks of gestation (WG) in a public hospital. The working tool was a questionnaire to collect data about the maternal medical record and the anthropometry of the newborn, as well as the risk factors for the auditory function, sociodemographic aspects, and food security with its respective classification and food habits. Results: the principal perinatal risk factor associated to hearing impairment was the use of gentamycin (ototoxic drug) in 18.1% of the total (OR: 5.61 [1.29-24.50]). Severe food insecurity was associated with auditory disfunctions in 27.2% of cases and in 2.8% of controls (OR: 12.75 [2.89-56.16]). There were differences between the groups regarding the education level (cases: 50% of the mothers finished or interrupted primary education level vs controls with 19%; Ji2 = 0.008). The anthropomorphic variables showed differences in weight, length and cephalic perimeter for the newborns (p < 0.000). Conclusion: severe food insecurity, exposure to gentamycin and low education level of the mother had a significant association with auditory impairments in preterm children. For these newborns, variables like weight, length and cephalic perimeter at the moment of birth were lower than in controls. These initial findings point to the important role that environmental risks, like food insecurity, have in auditory impairments in addition to those previously described.

INTRODUCCIÓN: Introducción: las alteraciones auditivas en el recién nacido prematuro impactan en su desarrollo y lenguaje y por ende a la calidad de vida. Se conocen varios factores de riesgo asociados a estas alteraciones, pero poco sobre los aspectos socioeconómicos, nutricionales y de inseguridad alimentaria. Objetivo: analizar la asociación con la inseguridad alimentaria y los factores de riesgo prenatales en prematuros con problemas de audición. Material y métodos: estudio de 35 casos y 105 controles, en prematuros de 30 a 37 SDG de un hospital público, realizado a través de una encuesta donde se recopilaron datos del expediente materno y del recién nacido (antropometría), así como factores de riesgo para alteración auditiva, aspectos sociodemográficos, seguridad alimentaria con sus respectivas clasificaciones y tipo de alimentación. Resultados: el principal factor de riego perinatal asociado a las alteraciones auditivas fue la administración de gentamicina (antibiótico ototóxico) en 18,1% de los casos (OR: 5,61 [IC = 1,29-24,50]). La inseguridad alimentaria severa se asoció con las alteraciones auditivas, en 27,2% de casos y en 2,8% de controles (OR: 12,75 [IC = 2,89-56,16]). Además, se encontraron diferencias entre los grupos para el nivel de escolaridad (casos: 50% de las madres tuvieron primaria terminada o incompleta vs. controles con 19%; Ji2 = 0,008) y Las variables antropométricas presentaron diferencias en peso, longitud y perímetro cefálico (p < 0,000). Conclusión: la inseguridad alimentaria severa, exposición a gentamicina, el nivel de escolaridad de la madre, tuvieron una asociación significativa con las alteraciones auditivas en el prematuro. Variables como el peso, longitud y perímetro cefálico al nacimiento presentaron valores inferiores en el grupo casos. Estos primeros hallazgos, reflejan riesgos ambientales como la inseguridad alimentaria en las alteraciones auditivas además de las ya conocidas.

Utilidad de la capilaroscopia para el diagnóstico de esclerosis sistémica / Usefulness of capillaroscopy for the diagnosis of systemic sclerosis

INTRODUCCIÓN: La capilaroscopia se emplea para la diferenciación del fenómeno de Raynaud puede ser primario o secundario, este último en una alta proporción es la manifestación más temprana de la Esclerosis Sistémica, entro otras enfermedades autoinmunes. Esta diferenciación se realiza, a través de la identificación de los patrones, considerando un patrón normal como FR primario y un patrón de esclerodermia como uno de los hallazgos para realizar el diagnóstico de ES ya sea temprana, activa o tardía. El diagnóstico de estos patrones modifica el pronóstico de la enfermedad. OBJETIVO: realizar una revisión, apreciación crítica y síntesis de la evidencia disponible sobre la validez y utilidad de la capilaroscopia para el diagnóstico de esclerosis sistémica. METODOLOGÍA: la evaluación fue realizada de acuerdo con un protocolo definido a priori por el grupo desarrollador. Se realizó una búsqueda sistemática en MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, LILACS y Google, sin restricciones de idioma, fecha de publicación y tipo de estudio. Las búsquedas electrónicas fueron hechas en octubre de 2014 y se complementaron mediante búsqueda manual en bola de nieve y una consulta con expertos temáticos. La tamización de referencias se realizó por dos revisores de forma independiente y los desacuerdos fueron resueltos por consenso. La selección de estudios fue realizada mediante la revisión en texto completo de las referencias preseleccionadas, verificando los criterios de elegibilidad predefinidos. Las características y hallazgos de los estudios fueron extraídos a partir de las publicaciones originales. RESULTADOS: se identificó evidencia proveniente de 5 estudios primarios (cohortes prospectivas y retrospectivas). En pacientes con fenómeno de Raynaud la capilaroscopia tiene un rango de sensibilidad de 0.85 a 0.95, y especificidad de 0.75 a 0.92, para la identificación del patrón de esclerosis. CONCLUSIONES: la capilaroscopia es útil para el diagnóstico de Esclerosis Sistémica en pacientes con fenómeno de Raynaud, y de manera relevante para el diagnóstico temprano de la enfermedad. De igual manera permite clasificar el tipo de ES. El riesgo global de sesgo de los estudios es bajo y sus resultados son consistentes con lo descrito en la literatura de manera general.(AU)

Efecto sobre la motilidad intestinal del extracto de alcaloides de semilla de Jatropha curcas L. / Effect of the alkaloid extract from Jatropha curcas L. seeds on the intestinal motility

Introducción: estudios preclínicos del extracto total de la raíz de Jatropha curcas L. (piñón blanco) demostraron su efecto antidiarreico, en contraste, ensayos de toxicidad crónica del extracto total de la semilla muestran efecto diarreico. Objetivo: determinar el efecto sobre la motilidad intestinal del extracto de alcaloides de semilla de Jatropha curcas L. Métodos: se utilizaron 50 ratones albinos con pesos medios de 25 g, se empleó el método de Arbós y otros; se administró carbón activado al 5 % vía oral, dosis de 0,1 mL/10 g, como marcador intestinal. Los grupos experimentales fueron: agua destilada 0,1 mL/10 g, atropina 1 mg/kg, extracto de alcaloides de semilla de Jatropha curcas 500 y 1 000 mg/kg, respectivamente, y neostigmina 1 g/kg. Para la validación estadística se usó la prueba de Kruskal-Wallis, ANOVA, Tukey, y Newman-Keuls. Resultados: el porcentaje de recorrido del carbón activado fue de 69,21; 36,37; 58,96; 49,65 y 74,17, respectivamente. La prueba de ANOVA demostró diferencias estadísticas (p< 0,05; IC 95 %), y la prueba de Tukey y Newman-Keuls, demostraron diferencias significativas entre el grupo que recibió agua destilada y la planta a 1 000 mg/kg. Conclusiones: se comprobó efecto de disminución de la motilidad intestinal por acción del extracto de alcaloides de Jatropha curcas, en dosis de 1 000 mg/kg.

Introduction: preclinical research studies of Jatropha curcas L. (piñón blanco) root extract proved its antidiarrheal activity; however the chronic toxicity test of the total seed extract demonstrated diarrheal effect. Objectives: to determine the effect of the alkaloid extract from Jatropha curcas L. seeds on the gastrointestinal motility. Methods: fifty albino mice with average weight of 25 g were used. The Arbos et al.´s method was applied. The intestinal marker was 5 % activated charcoal administered at a dose of 0.1 mL/10 g. The experimental groups included 0.1 mL/10 g of distilled water, 1.5 mg/kg of atropine, alkaloid extract of Jatropha curcas L. seeds at doses of 500 and 1 000 mg/kg respectively, and 1 g/kg of neostigmine The statistical validation was based on Kruskal-Wallis test, ANOVA, and Tukey and Newman-Keuls test. Results: the percentages of the charcoal run were 69.21, 36.37, 58.96, 49.65, and 74.17 respectively. The ANOVA test demonstrated statistical significance (p< 0.05, IC 95 %). Comparative Tukey and Newman-Keuls test showed statistical significance between distilled water and Jatropha curcas at a dose of 1 000 mg/kg. Conclusions: the decrease on the gastrointestinal motility resulting from the effect of the alkaloid extract of Jatropha curcas seeds was proved at a dose of 1 000 mg/kg.

Características de pacientes referidos para hospitalización a la Unidad de Emergencia del Instituto Nacional de Salud del Niño. Año 2011 / Patients' characteristics recounted for hospitalization to the Emergency unit of the National Institute of Health of the Child. Year 2011

Introducción: El sistema de referencia se define como derivación del paciente desde un establecimiento de menor capacidad resolutiva hacia otro de mayor complejidad de asistencia, debido a que los recursos propios y disponibles del primer nivel de atención no permiten dar respuesta a las necesidades del paciente. Materiales y métodos: Este estudio es de tipo observacional, descriptivo, retrospectivo. Se llevó a cabo en Instituto Nacional de Salud del Niño (INSN), Breña, seleccionándose todas las historias clínicas de aquellos pacientes menores de 18 años referidos de otras instituciones que hayan sido hospitalizados en la Unidad de Emergencia del INSN en el año 2011. Resultados: Se tabularon un total de 141 historias clínicas, pertenecientes a 141 niños que fueron mayormente menores de 5 años. Estos niños fueron predominantemente del sexo masculino, procedieron mayormente de Lima provincia o de Ancash. Los procedimientos que se realizaron con mayor frecuencia fueron Tomografías axiales y ecocardiografías. Las intervenciones más realizadas fueron cirugías y endoscopías terapéuticas...

Introduction: The reference system is defined as a patient referral from a less resolution hospital to another more complex, due to first level attention resources don´t satisfy patients requirements. Materials and Methods: This is an observational, retrospective and descriptive study. It was conducted at the Instituto Nacional de Salud de Niño, located in Breña, selecting all the medical histories from patients under 18 referred from other institutions who had been hospitalized in the Emergency Unit of the INSN in 2011. Results: We tabulated 141 medical histories, belonging to 141 children who were mostly under five. Most of them were male and came from Lima or Ancash. The procedures that were performed the most were CT´s and echocardiography. Surgery and therapeutic endoscopy were the most performed interventions. The most of the patients deserve the hospital reference...

Mitochondria and hypoxia-induced gene expression mediated by hypoxia-inducible factors.

The influence of mitochondrial activity on gene expression programs, particularly those involved in neuroprotection and repair, is likely to play an important role in the pathophysiology of neurodegenerative diseases. One such gene expression program is activated by the cellular pathway that senses a decrease in optimal oxygen levels and leads to activation of a family of transcriptional activators called hypoxia-inducible factors (HIFs). HIFs are members of the bHLH-PAS family of transcription factors and are heterodimers composed of HIF-alpha and HIF-beta (also known as aryl hydrocarbon receptor nuclear translocator) subunits that bind to canonical DNA sequences (hypoxia-regulated elements) in the promoters or enhancers of target genes. HIFs activate the expression of more than a hundred genes encoding proteins that regulate cell metabolism, survival, angiogenesis, vascular tone, hematopoiesis, and other functions. There is considerable evidence showing a bidirectional crosstalk between mitochondrial signals and HIF activity. For instance, mitochondrial reactive oxygen species and metabolic substrates from the tricarboxylic acid cycle are implicated in the regulation of the HIF pathway. Conversely, HIF activity leads to the expression of target genes that influence mitochondrial function. In this chapter we will review the complex interactions between mitochondria and the HIF pathway and we will discuss the relevance of this interaction for metabolic adaptation to hypoxia.

Relaciones anatómicas intraóseas en rama y cuerpo mandibular en la técnica de osteotomía sagital mandibular modificada / Intraosseous anatomical relations in ramus and mandibular body in modified sagittal mandibular osteotomy techniques

Se han realizado varias mofificaciones a la osteotomía digital mandibular (OSM) intraoral para disminuir sus complicaciones, que siguen presentándose posiblemente por desconocimiento de la anatomía.