CT-Guided vs. Navigational Bronchoscopic Biopsies for Solitary Pulmonary Nodules: A Single-Institution Retrospective Comparison.

OBJECTIVE: Lung cancer is the second most common cause of death by cancer. Multiple modalities can be used to obtain a tissue sample from a pulmonary nodule. We aimed to compare the yield and adverse events related to transthoracic needle aspiration (TTNA) and Electromagnetic Navigation Biopsy (ENB) at our institution. METHODS: This was a single-center retrospective study in which all patients referred for evaluation of a pulmonary lesion over 5 years (1 January 2013 to 31 December 2018) were identified. Our primary outcome was to compare the accuracy of TTNA to that of ENB in establishing the diagnosis of pulmonary lesions. Secondary outcomes included the evaluation of the adverse events and the sensitivity, specificity, positive, and negative predictive value of each modality. RESULTS: A total of 1006 patients were analyzed. The mean age of patients in the TTNA and the ENB group was 67.2 ± 11.2 years and 68.3 ± 9.2 years respectively. Local anesthesia was predominantly used for TTNA and moderate sedation was more commonly used in the ENB group. We found ENB to have an accuracy of 57.1%, with a sensitivity of 40.0%, a specificity of 100.0%, a positive predictive value of 100.0%, and a negative predictive value of 40.0%. As for the TTNA, the accuracy was 75.9%, with a sensitivity of 77.5%, a specificity of 61.5%, a positive predictive value of 95.0%, and a negative predictive value of 22.5%. The rate of clinically significant complications was higher in the TTNA group (8.2%) as compared to the ENB group (4.7%) with a p-value < 0.001. CONCLUSION: TTNA was superior to ENB-guided biopsy for the diagnostic evaluation of lung nodules. However, the complication rate was much higher in the TTNA group as compared to the ENB group.

TOMOGRAPHIC SARCOPENIA PREDICTS ANASTOMOTIC LEAKS AND LONG-TERM SURVIVAL IN GASTRIC CANCER PATIENTS OPERATED WITH CURATIVE INTENT.

BACKGROUND: The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field. AIMS: This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent. METHODS: This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted. RESULTS: We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15). CONCLUSIONS: Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

Folate administration ameliorates neurobehavioral effects of prenatal ethanol exposure.

Background: Prenatal ethanol exposure (PEE) induces heightened ethanol intake at adolescence in preclinical studies. Ethanol intake alters the absorption of folate, a methyl-group donor critical for numerous cellular functions. The prenatal administration of folate is, therefore, a promising approach to reduce the effects of PEE.Objectives: Experiment 1 determined if prenatal folate modulated the effects of PEE on ethanol intake, anxiety-like response, and exploratory behaviors (Experiment 1) in Wistar rats. Experiment 2 assessed, in rats not given PEE, if postnatal folate reversed effects of ethanol exposure at postnatal days 28-42. Experiment 3 assessed if folate altered blood ethanol levels (BELs).Methods: Experiment 1 involved 242 (125 male) adolescent Wistar rats derived from dams given folate (20 mg/kg, gestational days - GD- 13-20) + ethanol (2.0 g/kg, GD 17-20), ethanol, or vehicle only at pregnancy. Experiment 2 involved 29 male adolescents administered vehicle or ethanol doses co-administered or not with folate. In Experiment 3 twelve adult females were tested for BELs after folate administration. These tests were applied: intake tests, light dark box (LDB), elevated plus maze, open field and concentric square field.Results: PEE heightened ethanol intake (η2 ps = 0.06-07) and induced hyperactivity and a reduced latency to exit the white area of the LDB (η2 ps = 0.12-17). These effects were partially inhibited by folate (p > .05). Rats exposed to ethanol exposure at adolescence exhibited reduced motor activity (η2 p = .17), regardless of folate treatment. Folate did not affect BELs.Conclusion: Folate administration should be considered as a preventive or acute treatment to attenuate the neurobehavioral effects of PEE.

Tooth Loss and Caries Experience of Elderly Chileans in the Context of the COVID-19 Pandemic in Five Regions of Chile.

Risk factors associated with tooth loss have been studied; however, the current status of the epidemiological profiles and the impact of the pandemic on the oral health of the elderly is still unknown. This study aims to determine the experience of caries and tooth loss among elderly Chilean citizens in five regions and to identify the risk factors associated with tooth loss. The sample includes 135 participants over 60 years old assessed during COVID-19 lockdown. Sociodemographic variables such as education and RSH (Social Registry of Households) were obtained through a teledentistry platform called TEGO. The history of chronic diseases such as diabetes, obesity, depression and dental caries reported by DMFT index scores were incorporated. The statistical analysis included Adjusted Odds Ratios (ORs) to assess risk factors associated with the lack of functional dentition. Multivariate hypothesis testing was used to compare the mean equality of DMFT and its components between regions (p-value < 0.05). Individuals with RSH ≤ 40% were at higher risk of having no functional dentition with OR 4.56 (95% CI: 1.71, 12.17). The only mean difference between regions was the filled tooth component. Tooth loss was associated with multidimensional lower income, where the elderly belonging to the 40% most vulnerable population had a higher prevalence of non-functional dentition. This study highlights the importance of implementing a National Oral Health Policy that focuses on oral health promotion and minimally invasive dentistry for the most vulnerable population.

Tomographic sarcopenia predicts anastomotic leaks and long-term survival in gastric cancer patients operated with curative intent / Sarcopenia tomográfica prevê fístulas de anastomoses e sobrevida a longo prazo em pacientes com câncer gástrico operados com intenção curativa

ABSTRACT BACKGROUND: The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field. AIMS: This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent. METHODS: This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted. RESULTS: We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15). CONCLUSIONS: Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

RESUMO RACIONAL: O estado nutricional pré-operatório tem valor prognóstico pós-operatório. A densidade tomográfica e a área do músculo psoas é uma ferramenta validada para o estado nutricional. Existem poucos estudos avaliando a utilidade da tomografia de estadiamento em pacientes com câncer gástrico neste campo. OBJETIVOS: Determinar a influência da sarcopenia, medida por tomografia computadorizada de estadiamento pré-operatório, na morbimortalidade pós-operatória e sobrevida em longo prazo em pacientes operados de câncer gástrico com intenção curativa. MÉTODOS: Estudo retrospectivo de 2007 a 2013. A definição de sarcopenia radiológica foi pela medida da área (PA) e densidade do músculo psoas (PD) a nível de L3 (Terceira vertebra lombar), em um corte axial de tomografia computadorizada abdominopélvica (na seleção sem meio de contraste intravascular). O Software utilizado foi o OsirixX v 10.0.2, com a ferramenta "propagar segmentação", ajustando manualmente todos os músculos vistos na imagem. RESULTADOS: Foram incluídos 70 pacientes, 77% homens, PA média em L3: 16,6 cm2 (desvio padrão+6,1), PD média em L3: 36,1 mean muscle density (desvio padrão+7,1). Os cânceres avançados foram de 86, 28,6% tinham células em anel de sinete, 78,6% necessitaram de gastrectomia total, a morbidade e mortalidade cirúrgica pós-operatória foi de 22,8 e 2,8%, respectivamente, a sobrevida global de 5 anos a longo prazo (SV5) foi de 57,1%. Na análise multivariada, PA falhou em prever morbidade cirúrgica (p=0,4) e sobrevida global de 5 anos (p=0,34), enquanto PD foi capaz de prever fístulas anastomóticas (p=0,009; OR 0,86; IC95% 0,76-0,96) e SV5 (p=0,04; OR 2,9; IC95% 1,04-8,15). CONCLUSÕES: O diagnóstico tomográfico de sarcopenia por desvio padrão é capaz de predizer fístulas anastomóticas e sobrevida a longo prazo em pacientes com câncer gástrico tratados com intenção curativa.

Moderate ethanol exposure during early ontogeny of the rat alters respiratory plasticity, ultrasonic distress vocalizations, increases brain catalase activity, and acetaldehyde-mediated ethanol intake.

Early ontogeny of the rat (late gestation and postnatal first week) is a sensitive period to ethanol's positive reinforcing effects and its detrimental effects on respiratory plasticity. Recent studies show that acetaldehyde, the first ethanol metabolite, plays a key role in the modulation of ethanol motivational effects. Ethanol brain metabolization into acetaldehyde via the catalase system appears critical in modulating ethanol positive reinforcing consequences. Catalase system activity peak levels occur early in the ontogeny. Yet, the role of ethanol-derived acetaldehyde during the late gestational period on respiration response, ultrasonic vocalizations (USVs), and ethanol intake during the first week of the rat remains poorly explored. In the present study, pregnant rats were given a subcutaneous injection of an acetaldehyde-sequestering agent (D-penicillamine, 50 mg/kg) or saline (0.9% NaCl), 30 min prior to an intragastric administration of ethanol (2.0 g/kg) or water (vehicle) on gestational days 17-20. Respiration rates (breaths/min) and apneic episodes in a whole-body plethysmograph were registered on postnatal days (PDs) 2 and 4, while simultaneously pups received milk or ethanol infusions for 40-min in an artificial lactation test. Each intake test was followed by a 5-min long USVs emission record. On PD 8, immediately after pups completed a 15-min ethanol intake test, brain samples were collected and kept frozen for catalase activity determination. Results indicated that a moderate experience with ethanol during the late gestational period disrupted breathing plasticity, increased ethanol intake, as well brain catalase activity. Animals postnatally exposed to ethanol increased their ethanol intake and exerted differential affective reactions on USVs and apneic episodes depending on whether the experience with ethanol occur prenatal or postnatally. Under the present experimental conditions, we failed to observe, a clear role of acetaldehyde mediating ethanol's effects on respiratory plasticity or affective states, nevertheless gestational acetaldehyde was of crucial importance in determining subsequent ethanol intake affinity. As a whole, results emphasize the importance of considering the participation of acetaldehyde in fetal programming processes derived from a brief moderate ethanol experience early in development, which in turn, argues against "safe or harmless" ethanol levels of exposure.

Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients.

Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.

Copyright literacy and LIS education: analysis of its inclusion in the curricula of master's degree programs.

The close relationship between copyright laws and the development of library activities has become more intense and complex in recent years due to the impact of the digital setting. For this reason, librarians must have adequate knowledge about copyright, whether it be to carry out their own functions and tasks, or to help co-workers and users as efficiently as possible. The aim of the present paper is to determine the type of copyright instruction offered, plus its focus and depth, to students of master's programs in library and information studies at today's outstanding universities in this field. The results show that very few LIS programs provide the minimal training required for professionals to be copyright literate. Very few courses are dedicated specifically to copyright issues, as these subjects are usually studied in an excessively generic and superficial manner within broader courses dedicated to information policy, information ethics, or legal issues regarding information. If we also bear in mind that most of these courses are elective, not required, the conclusion is that very few LIS graduates attain the minimal instruction required. The best results are obtained by US and Canadian universities accredited by the American Library Association (ALA), since copyright issues are included in the list of core competences required to achieve accreditation. The solution to this problem may lie in two complementary approaches. One would be to follow the ALA model and the IFLA recommendation and include copyright contents in the LIS curricula worldwide, and the other would be to provide institutional support for those professionals interested in obtaining the required training.

Lung Cryobiopsy Outside of the Operating Room: A Safe Alternative to Surgical Biopsy.

OBJECTIVE: Transbronchial lung cryobiopsy (TBLC) is a promising technique that can provide a histologic diagnosis in interstitial lung diseases (ILD) and is an alternative to surgical lung biopsy. The main concerns with the procedure are safety and diagnostic accuracy. The technique is applicable in patients unable to undergo surgical biopsy due to severe comorbidities or when patient transport to the operating room is dangerous. This study reports the initial experience with TBLC on a thoracic surgical service as a first attempt at diagnosis in patients with diffuse parenchymal lung diseases (DPLD). METHODS: Between May 2018 and July 2020, 32 patients underwent TBLC using bedside flexible bronchoscopy for suspected ILD on a thoracic surgical endoscopy service. Retrospective evaluation of the procedure details, complications, and diagnostic yield were analyzed and reported. RESULTS: A total of 89 pathological samples were obtained (mean 2.8 per patient). Pneumothorax and minor bleeding occurred in 25% and 16.7% of patients, respectively. Sixty-seven percent of complications occurred with use of the 2.4 mm cryoprobe (P = 0.036). Concordance between the histologic diagnosis and final clinical diagnosis was observed in 62.5% of patients and the pathology guided the final treatment in 71% (P = 0.027) with Kappa-concordance of 0.60 (P < 0.001). CONCLUSIONS: Cryobiopsy is becoming part of the diagnostic evaluation in patients with indeterminate DPLD or hypoxemic respiratory failure. TBLC is easy to perform and has a favorable safety profile. Thoracic specialists should consider adding TBLC to their procedural armamentarium as a first option for patients with indeterminate PLD.

Operant conditioning with a stimulus discrimination: An alternative method for evaluating alcohol reinforcement in preweaning rats.

BACKGROUND: Ethanol exposure at early ontogeny promotes further predisposition to consume the drug. Operant conditioning allows motivational alcohol properties to be assessed. To date, the operant conditioning approach used during infancy consisted in paired subjects being trained to learn an operant response, using simultaneously a yoked partner, which received reinforcer solution as a result of a paired animal instrumental response (OYS). NEW METHOD: In our study, we attempted to evaluate ethanol reinforcing effects during PDs 15-18 in an operant conditioning schedule with a stimulus discrimination procedure (OSD), as an alternative control learning. This new proposal includes a single subject, who has to choose between an S+ nose-poke hole, which delivers the reinforcer into the mouth, or an S- nose-poke hole with no reinforcement effect. RESULTS: The OSD results seemed to be more reliable than those obtained using the OYS procedure, since some data appeared to be more robust when using a yoked nose-poke hole than when employing a yoked subject, such as in control learning. Consequently, OSD has the following advantages compared to the OYS procedure: a) the operant response learned is controlled by the overall behavior of the same subject, resulting in a relatively clearer data; b) a yoked animal is not necessary, thereby reducing the number of rats used in the operant conditioning procedure. COMPARISON WITH EXISTING METHODS AND CONCLUSIONS: A novel technique of operant conditioning adapted to infancy was developed by training animals to emit a particular response to gain access to alcohol solution as a reinforcer.

Balloon Dilation for Endosonographic Staging in Esophageal Cancer: A Phase 1 Clinical Trial.

BACKGROUND: Dilation in patients with malignant esophageal strictures precluding the passage of the endoscopic ultrasonography (EUS) scope allows complete evaluation; however, it may be associated with complications. This study evaluates the safety and clinical value of balloon dilation to complete EUS in patients with stenotic esophageal cancers. METHODS: This study consists of a phase I clinical trial. One-hundred-and fifty patients were recruited. Endoscopic balloon dilation was performed before EUS in patients with high-grade stenosis. The analysis was focused on the ability to complete an endosonographic examination after dilation, 30-day morbidity, and change in the final stage or definitive management based on the completed endosonographic examination. RESULTS: Dilation was required in 55 patients (36.7%), with a complication rate of 10.9% (n = 6). Dilation allowed completion of EUS in 53 patients (96.4%), leading to a modification of the clinical stage for 18 patients (34%) and a deviation in the treatment plan in 7 patients (13.2%). No differences were found in these variables when compared with the group that did not require dilation (26.3% and 14.7%, P = .33 and P = .79, respectively). Dilation was associated with more advanced disease on final pathology among patients who underwent surgical resection (P = .006). CONCLUSIONS: High-grade malignant esophageal strictures that preclude the passage of the ultrasound probe are associated with advanced stage disease. Owing to the high risk of perforation and the limited benefit in staging, balloon dilation to complete the EUS staging should be avoided. (Clinicaltrials.gov identifier: NCT01950442.).

LESSONS LEARNED ANALYZING COMPLICATIONS AFTER LAPAROSCOPIC TOTAL GASTRECTOMY FOR GASTRIC CANCER.

BACKGROUND: Laparoscopic surgery has been gradually accepted as an option for the surgical treatment ofgastric cancer. There are still points that are controversial or situations that are eventually associated with intra-operative difficulties or postoperative complications. AIM: To establish the relationship between the difficulties during the execution of total gastrectomy and the occurrence of eventual postoperative complications. METHOD: The operative protocols and postoperative evolution of 74 patients operated for gastriccancer, who were subjected to laparoscopic total gastrectomy (inclusion criteria) were reviewed. The intraoperative difficulties recorded in the operative protocol and postoperative complications of a surgical nature wereanalyzed (inclusion criteria). Postoperative medical complications were excluded (exclusion criteria). For the discussion, an extensive bibliographical review was carried out. RESULTS: Intra-operative difficulties or complications reported correspond to 33/74 and of these; 18 events (54.5%) were related to postoperative complications and six were absolutely unexpected. The more frequent were leaks of the anastomosis and leaks of the duodenal stump; however, other rare complications were observed. Seven were managed with conservative measures and 17 (22.9%) required surgical re-exploration, with a postoperative mortality of two patients (2.7%). CONCLUSION: We have learned that there are infrequent and unexpected complications; the treating team must be mindful of and, in front of suspicion of complications, anappropriate decision must be done which includes early re-exploration. Finally, after the experience reported, some complications should be avoided.

Whole blood for blood loss: hemostatic resuscitation in damage control / Sangre total: la nueva alternativa en la resucitación hemostática

Abstract Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

Resumen El choque hemorrágico y sus complicaciones son la principal causa de muerte en los pacientes con trauma. La resucitación en control de daños ha demostrado una disminución en la mortalidad y mejoría en el manejo del paciente. La resucitación hemostática consiste en la recuperación del volumen con hemoderivados como glóbulos rojos, plasma, crioprecipitado y plaquetas, en proporciones de 1:1:1:1. Sin embargo, esta demanda de hemo componentes podría no aplicarse para toda Latinoamérica u otros países de medianos y bajos ingresos. Las principales barreras para la implementación de esta estrategia serían la escasa disponibilidad de bancos de sangre y de hemoderivados insuficientes para contar con un protocolo de transfusión masiva. Una propuesta para superar estas barreras es el uso de sangre total fresca fría para la resucitación hemostática de los pacientes exsanguinados. Ecuador ha sido pionero en la implementación de esta estrategia con una experiencia ya de seis años, en que han demostrado que la sangre total tiene ventajas sobre la terapia de hemo componentes incluyendo, pero no limitando, la trasfusión de sangre con una razón fisiológica de componentes, fácil transporte y transfusión, menor volumen de anticoagulantes y aditivos trasfundidos al paciente, y menor exposición a donantes. La sangre total es una herramienta con un potencial reemergente que puede ser implementado en centros de trauma civil con óptimos resultados y menor demanda técnica.

REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients / El REBOA como nuevo actor en el control de daños del paciente hemodinámicamente inestable con hemorragia no compresible del torso

Abstract Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.

Resumen La hemorragia no compresible del torso es una de las principales causas de muerte prevenibles alrededor del mundo. Una evaluación eficiente y apropiada del paciente traumatizado con hemorragia activa es la esencia para evitar el desarrollo del rombo de la muerte (hipotermia, coagulopatía, hipocalcemia y acidosis). Actualmente, las estrategias de manejo inicial incluyen hipotensión permisiva, resucitación hemostática y cirugía de control de daños. Sin embargo, los recientes avances tecnológicos han abierto las puertas a una amplia variedad de técnicas endovasculares que logran esos objetivos con una morbilidad mínima y un acceso limitado. Un ejemplo de estos avances ha sido la introducción del balón de resucitación de oclusión aortica; REBOA ( Resuscitative Endovascular Balloon Occlusion of the Aorta , por sus sigla en inglés ), el cual, ha tenido gran provecho entre los cirujanos de trauma alrededor del mundo debido a su potencial y versatilidad en áreas como trauma, ginecología y obstetricia, y gastroenterología. El objetivo de este artículo es describir la experiencia lograda en el uso del REBOA en pacientes con hemorragia no compresible del torso. Nuestros resultados muestran que el REBOA puede usarse como un nuevo actor en la resucitación de control de daños del paciente con trauma severo, para este fin, nosotros proponemos dos nuevos algoritmos para el manejo de pacientes hemodinámicamente inestables: uno para trauma cerrado y otro para trauma penetrante. Se reconoce que el REBOA tiene sus limitaciones, las cuales incluye un periodo de aprendizaje, su costo inherente y la disponibilidad. A pesar de esto, para lograr los mejores resultados con esta nueva tecnología, el REBOA debe ser usado en el momento correcto, por el cirujano correcto con el entrenamiento y el paciente correcto.

Damage Control in Penetrating Liver Trauma: Fear of the Unknown / Control de Daños en Trauma Hepático Penetrante: El Miedo a Lo Desconocido

Abstract The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Resumen El hígado es el órgano solido más comúnmente lesionado en casos de trauma abdominal. El manejo del trauma penetrante hepático es un dilema para los cirujanos. Sin embargo, con la introducción del concepto de la cirugía de control de daños y los avances tecnológicos en imagenología y técnicas endovasculares han permitido que el enfoque del tratamiento cambie. La disponibilidad inmediata de la tomografía computarizada permite estadificar el grado de la lesión e incrementar la posibilidad de un manejo conservador en pacientes hemodinámicamente estables con trauma hepático. El trauma hepático severo que se asocia con inestabilidad hemodinámica tiene una alta mortalidad debido a la hemorragia activa. El objetivo de este artículo es proponer un algoritmo de manejo producto de un consenso de expertos acerca del abordaje de los pacientes hemodinámicamente inestables con trauma hepático penetrante. El manejo debe ser por parte de un equipo multidisciplinario que comienza desde la evaluación inicial de los pacientes, la activación temprana de protocolo de transfusión masiva y el control temprano de la hemorragia, siendo estos aspectos esenciales para disminuir la mortalidad. El miedo a lo desconocido es el dilema quirúrgico donde existen pocas opciones y es imperante decisiones rápidas y oportunas; por esta razón, se propone dar una luz de guía sobre lo desconocido respecto al manejo del paciente con trauma hepático severo.

Feasibility analysis for the development of a video-assisted thoracoscopic (VATS) lobectomy 23-hour recovery pathway.

Background: Video-assisted thoracoscopic (VATS) lobectomy has been demonstrated to offer several benefits over open surgery. The purpose of this study was to assess the feasibility and safety of an ultra-fast-track 23-hour recovery pathway for VATS lobectomy. Methods: A prospectively maintained institutional database was queried for patients who underwent VATS lobectomy from 2006 to 2016 at the McGill University Health Centre in Montreal, Quebec, and data were supplemented with focused chart review. Patients discharged with a length of stay (LOS) of 23 hours or less were compared with those with an LOS of 2 days or more. Logistic regression was performed to identify predictors of LOS of 23 hours or less. Results: Two hundred and five patients were included in the study. Perioperative 30-day mortality for our cohort was 0% and the major complication rate was 8.3%. The median LOS was 3 days (interquartile range [IQR] 2-4 d). Thirty-four patients were discharged within 23 hours and none of them required readmission; 171 patients were discharged on postoperative day 2 or later and 9 of them (5.3%) required readmission (p = 0.36). The proportion of patients discharged within 23 hours increased in 2016 compared with previous years (25.8% v. 12.0%, p = 0.05). Patients discharged within 23 hours had shorter chest tube duration (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.09-0.46, p < 0.001), lower clinical stage disease (stages II-III v. stage I OR 0.07, 95% CI 0.01-0.52, p = 0.011), lower pathologic stage lesions (stages II-III v. stage I OR 0.26, 95% CI 0.07-0.91, p = 0.035), fewer surgical complications (OR 0.04, 95% CI 0.01-0.30, p = 0.002) and shorter operative time (surgery duration > 120 min OR 0.42, 95% CI 0.18-0.95, p = 0.04). Our exploratory prediction modelling showed that chest tube duration, clinical stage and surgeon were the most influential predictors of discharge within 23 hours. Conclusion: The only preoperative factors that predicted shorter LOS in our cohort were clinical stage and surgeon. A significant proportion of patients can be discharged safely by adopting a VATS lobectomy 23-hour enhanced recovery pathway.

Contexte: Il a été démontré que la lobectomie par chirurgie thoracique vidéoassistée (CTVA) offre plusieurs avantages comparativement à la chirurgie ouverte. La présente étude avait pour but d'évaluer la faisabilité et la sûreté d'un protocole de récupération ultrarapide en 23 heures pour la lobectomie par CTVA. Méthodes: Nous avons extrait d'une base de données d'établissement maintenue de manière prospective des données sur les patients ayant subi une lobectomie par CTVA entre 2006 et 2016 au Centre universitaire de santé McGill à Montréal (Québec), complétées par un examen ciblé des dossiers. Les patients ayant reçu leur congé après une hospitalisation de 23 heures ou moins ont été comparés à ceux dont l'hospitalisation avait duré 2 jours ou plus. Nous avons ensuite mis en évidence les facteurs prédictifs d'une hospitalisation de 23 heures ou moins par une analyse de régression logistique. Résultats: Deux cent cinq patients ont été inclus dans l'étude. La mortalité périopératoire dans les 30 jours suivant l'intervention était de 0 % dans notre cohorte, et le taux de complications majeures était de 8,3 %. La durée d'hospitalisation médiane était de 3 jours (écart interquartile [EI] 2 à 4 jours). Trente-quatre patients ont reçu leur congé dans les 23 heures suivant l'intervention, et aucun n'a dû être réhospitalisé; comparativement, 171 patients ont reçu leur congé au deuxième jour ou après, et 9 d'entre eux (5,3 %) ont dû être réhospitalisés (p = 0,36). Le pourcentage de patients ayant reçu leur congé dans les 23 heures a augmenté en 2016 par rapport aux années précédentes (25,8 % c. 12,0 %, p = 0,05). Les patients au congé dans les 23 heures conservaient leur drain thoracique moins longtemps (rapport de cotes [RC] 0,20, intervalle de confiance [IC] de 95 % 0,09 à 0,46, p < 0,001); leur stade clinique était moins élevé (stades II à III c. stade I ­ RC 0,07, IC de 95 % 0,01 à 0,52, p = 0,011); le stade pathologique de leurs lésions était plus faible (stades II à III c. stade I ­ RC 0,26, IC de 95 % 0,07 à 0,91, p = 0,035); ils avaient moins de complications chirurgicales (RC 0,04, IC de 95 % 0,01 à 0,30, p = 0,002); et la durée de leur intervention était plus courte (durée de la chirurgie > 120 minutes ­ RC 0,42, IC de 95 % 0,18 à 0,95, p = 0,04). Notre modèle prédictif exploratoire a montré que le délai avant le retrait du drain thoracique, le stade clinique et le chirurgien était les facteurs prédictifs les plus importants du congé dans les 23 heures. Conclusion: Les seuls facteurs préopératoires permettant de prédire une hospitalisation plus courte dans notre cohorte étaient le stade clinique et le chirurgien. Un pourcentage important des patients peuvent recevoir leur congé sans danger si on suit un protocole de récupération optimisée en 23 heures après une lobectomie par CTVA.

Learning experiences comprising central ethanol exposure in rat neonates: Impact upon respiratory plasticity and the activity of brain catalase.

Fetal ethanol exposure represents a risk factor for sudden infant death syndrome, and the respiratory effects of fetal ethanol exposure promote hypoxic ischemic consequences. This study analyzes central ethanol's effects upon breathing plasticity during an ontogenetic stage equivalent to the human third gestational trimester. Ethanol's unconditioned breathing effects and their intervention in learning processes were examined. Since central ethanol is primarily metabolized via the catalase system, we also examined the effects of early history with the drug upon this system. During postnatal days 3, 5, and 7 (PDs 3-7), pups were intracisternally administered with vehicle or ethanol (300 mg%). They were tested in a plethysmograph scented or not scented with ethanol odor. The state of intoxication attenuated the onset of apneas, a phenomenon that is suggestive of ethanol's anxiolytic effects given the state of arousal caused by the novel environment and the stress of ethanol administration. At PD9, pups were evaluated when sober under sequential air conditions (initial-normoxia, hypoxia, and recovery-normoxia), with or without the presence of ethanol odor. Initial apneic episodes increased when ethanol intoxication was previously associated with the odor. Pups then ingested ethanol, and brain catalase activity was determined. Pre-exposure to ethanol intoxication paired with the odor of the drug resulted in heightened enzymatic activity. Central ethanol exposure appears to exert antianxiety effects that attenuate apneic disruptions. However, during withdrawal, the cues associated with such effects elicit an opposite reaction. The activity of the catalase system was also dependent upon learning processes that involved the association of environmental stimuli and ethanol intoxication.

Respiratory and emotional reactivity to ethanol odor in human neonates is dependent upon maternal drinking patterns during pregnancy.

BACKGROUND: Beyond the well-known deleterious effects of ethanol defining Fetal Alcohol Spectrum Disorders (FASD), the notion of fetal alcohol programming has gained scientific support. This phenomenon implies early neural plasticity relative to learning mechanisms comprising ethanol´s sensory cues and physiological effects of the drug; among others, its reinforcing properties and its depressant effects upon respiration. In this study, as a function of differential ethanol exposure during gestation, we analyzed neonatal physiological and behavioral responsiveness recruited by the odor of the drug. METHODS: A factorial design defined by maternal ethanol intake during pregnancy (Low, n = 38; Moderate, n = 18 or High, n = 19) and olfactory stimulation (ethanol odor and/or or a novel scent) served as the basis of the study. Neonatal respiratory and cardiac frequencies, oxygen saturation levels and appetitive or aversive facial expressions, served as dependent variables. RESULTS: Newborns of High drinkers exhibited significant physiological and behavioral signs indicative of alcohol odor recognition; specifically, respiratory depressions and exacerbated appetitive facial reactions coupled with diminished aversive expressions. Respiratory depressions were not accompanied by heart rate accelerations (cardiorespiratory dysautonomia). According to ROC curve analyses respiratory and behavioral reactivity were predictive of high maternal intake patterns. CONCLUSIONS: These results validate the notion of human fetal alcohol programming that is detected immediately after birth. The reported early functional signs indicative of relatively high alcohol gestational exposure should broaden our capability of diagnosing FASD and lead to appropriate primary or secondary clinical interventions (Registry of Health Research N.3201- RePIS, Córdoba, Argentina).

Fetal Alcohol Programming of Subsequent Alcohol Affinity: A Review Based on Preclinical, Clinical and Epidemiological Studies.

The anatomo-physiological disruptions inherent to different categories of the Fetal Alcohol Spectrum Disorder do not encompass all the negative consequences derived from intrauterine ethanol (EtOH) exposure. Preclinical, clinical and epidemiological studies show that prenatal EtOH exposure also results in early programming of alcohol affinity. This affinity has been addressed through the examination of how EtOH prenatally exposed organisms recognize and prefer the drug's chemosensory cues and their predisposition to exhibit heightened voluntary EtOH intake during infancy and adolescence. In altricial species these processes are determined by the interaction of at least three factors during stages equivalent to the 2nd and 3rd human gestational trimester: (i) fetal processing of the drug's olfactory and gustatory attributes present in the prenatal milieu; (ii) EtOH's recruitment of central reinforcing effects that also imply progressive sensitization to the drug's motivational properties; and (iii) an associative learning process involving the prior two factors. This Pavlovian learning phenomenon is dependent upon the recruitment of the opioid system and studies also indicate a significant role of EtOH's principal metabolite (acetaldehyde, ACD) which is rapidly generated in the brain via the catalase system. The central and rapid accumulation of this metabolite represents a major factor involved in the process of fetal alcohol programming. According to recent investigations, it appears that ACD exerts early positive reinforcing consequences and antianxiety effects (negative reinforcement). Finally, this review also acknowledges human clinical and epidemiological studies indicating that moderate and binge-like drinking episodes during gestation result in neonatal recognition of EtOH's chemosensory properties coupled with a preference towards these cues. As a whole, the studies under discussion emphasize the notion that even subteratogenic EtOH exposure during fetal life seizes early functional sensory and learning capabilities that pathologically shape subsequent physiological and behavioral reactivity towards the drug.