Delay of surgical treatment of severe tricuspid regurgitation and outcomes in patients with left-sided heart valve disease.

INTRODUCTION AND OBJECTIVES: The influence of the delay between diagnosis and surgery in severe tricuspid regurgitation (TR) remains controversial. We aimed to analyze the association between delay to surgery and operative and mid-term mortality in patients with severe TR concomitant to left-valve surgery. METHODS: We conducted an observational retrospective study analyzing risk factors in patients undergoing left-valve surgery concomitant with severe TR. The clinical and demographic variables were prospectively collected. The time of first diagnosis of TR was retrospectively collected. RESULTS: A total of 253 patients were analyzed. TR was functional in 82.6%. The median latency between diagnosis and surgery was 24 months. Operative mortality was 12.2%. On multivariate analysis, higher operative mortality was associated with older age, worse preoperative NYHA functional class, triple valve surgery, hyponatremia, and anemia. The median follow-up was 35 months. Survival at 1 and 5 years was 85.2% and 73.7%, respectively. Mortality during follow-up was associated with male sex, preoperative massive TR, and longer latency between diagnosis and surgery. CONCLUSIONS: The variables related to worse preoperative functional class were associated with increased operative mortality. Lower mid-term survival was associated with longer latency between diagnosis of severe TR and surgery, massive preoperative TR, and older age.

[Impact of the pandemic on primary care. SESPAS Report 2022]. / Impacto de la pandemia en la atención primaria. Informe SESPAS 2022.

The COVID-19 pandemic, which last 2 years and still goes on, has pushed the primary health care (PC) to a current worrying situation of saturation and exhaustion. It is a community infectious disease, with a great amount of cases (around 10 million declared in January 2022) due to that, PC has made an extraordinary effort to pay attention on mild cases and on PC and to detect potentially serious cases early. Unfortunately, up to now, a global evaluation of the actions has not been carried out, in order to allow us to learn from this new experience. This article describes the different phases of the pandemic and its impact on PC. Finally, solutions are proposed to reinforce the central criteria that allow PC to be maintained as the foundation of the welfare state, longitudinality, resolution, accessibility, and care coordination and continuity, thanks to the contribution of resources and skills given to the PC. In conclusion, PC must still being the basis of the health system and it is mandatory to recover and claim those competencies and resources that should always have been a part of PC.

Neurological Complications in Active Left-Sided Infective Endocarditis Requiring Early Surgery.

Introduction: To determine whether preoperative symptomatic neurological complication (SNC) predicts a worse prognosis of patients with active left-sided infective endocarditis who required early surgery. Methods: We conducted a retrospective chart review and analyzed risk factors for SNCs and immediate, medium-term, and long-term mortality in patients with active left-sided infective endocarditis who required early surgery (median follow-up: 70.5 months). Results: Of 212 included patients, preoperative SNCs occurred in 22.1%. Independent risk factors for preoperative SNC included early hospital admission (<10 days after symptoms onset), duration of antibiotic therapy <7 days, vegetation diameter > 30 mm, preoperative chronic therapy with steroids, and peripheral embolism. A new postoperative SNC occurred in 12.7% of patients. No significant differences related to preoperative or postoperative SNCs were observed in postoperative mortality (29.8% vs. 31.5%) or during follow-up. No significant differences in postoperative mortality were observed between hemorrhagic or ischemic SNCs. There was a non-significant trend to increased mortality in patients who underwent surgery within 7 days of presenting with SNC (55.5%) compared to those who underwent surgery more than 7 days after SNC (33.3%) (P = 0.171). Concomitant risk of mortality or postoperative hemorrhagic transformation increased when surgery is required during the first week after preoperative SNC (77.5% vs. 25%) (P = 0.017). Conclusions: Patients with active left-sided infective endocarditis who need early hospital admission are at a higher risk of SNC. Mortality is higher in patients who underwent surgery within 7 days of SNC, but mortality of early surgery is acceptable after the first week of preoperative ischemic or hemorrhagic complication. We have not been able to demonstrate that preoperative nor postoperative SNCs predicted a reduced immediate, medium-term, or long-term survival in the population analyzed in this study.

Autoantibodies Against Ubiquitous and Confined Antigens in Patients With Ocular, Neuro-Ophthalmic and Congenital Cerebral Toxoplasmosis.

Toxoplasma gondii infection can trigger autoreactivity by different mechanisms. In the case of ocular toxoplasmosis, disruption of the blood-retinal barrier may cause exposure of confined retinal antigens such as recoverin. Besides, cross-reactivity can be induced by molecular mimicry of parasite antigens like HSP70, which shares 76% identity with the human ortholog. Autoreactivity can be a determining factor of clinical manifestations in the eye and in the central nervous system. We performed a prospective observational study to determine the presence of autoantibodies against recoverin and HSP70 by indirect ELISA in the serum of 65 patients with ocular, neuro-ophthalmic and congenital cerebral toxoplasmosis. We found systemic autoantibodies against recoverin and HSP70 in 33.8% and 15.6% of individuals, respectively. The presence of autoantibodies in cases of OT may be related to the severity of clinical manifestations, while in cases with CNS involvement they may have a protective role. Unexpectedly, anti-recoverin antibodies were found in patients with cerebral involvement, without ocular toxoplasmosis; therefore, we analyzed and proved cross-reactivity between recoverin and a brain antigen, hippocalcin, so the immunological phenomenon occurring in one immune-privileged organ (e.g. the central nervous system) could affect the environment of another (egg. the eye).

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents.

BACKGROUND: the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option. AIMS: the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks. METHODS: a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018. RESULTS: twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach. CONCLUSIONS: endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

The impact of frailty on the economic evaluation of geriatric surgery: hospital costs and opportunity costs based on meta-analysis.

Objectives: We used a systematic review and meta-analysis to analyze the difference in costs between surgery for frail and non-frail elderly patients. The opportunity cost of frailty in geriatric surgery is estimated using the results.Methodology: Two literature reviews were carried out between 2000 and 2019: (1) studies comparing total hospital costs of frail and non-frail surgical patients; (2) studies evaluating the length of hospital stay and cost for surgical geriatric patients. We performed a meta-analysis of the items selected in the first review. We subsequently calculated the opportunity cost of frail patients, based on the design of a cost/time variable.Results: Twelve articles in the first review were selected (272,717 non-frail and 16,461 frail). Fourteen articles were selected from the second review. Frail patients had higher hospital costs than non-frail patients (22,282.541 € and 16,388.844, p < .001) and a longer hospital stay (10.16 days and 8.4 (p < .001)). The estimated opportunity cost in frail patients is 1,019.56 € (cost/time unit factor of 579.30 €/day).Conclusions: Frail surgical geriatric patients generate a higher total hospital cost, and an opportunity cost arising from not operating in the best possible state of health. Preoperatively treating the frailty of elderly patients will improve the use of health resources.

Ethical aspects involving the use of information technology in new surgical aplications: telesurgery and surgical telementoring / Aspectos éticos relacionados con el uso de información tecnológica en nuevas aplicaciones quirúrgicas: tele-cirugía y tele-tutoría / Aspectos éticos envolvendo o uso de tecnologia da informação em novas aplicações cirúrgicas: telescirurgia e telemonitoria cirúrgica

Abstract: Background: The surgical telementoring is a technology that involves surgical procedures guided by an expert or mentor, performed by other surgeons from a distance, using information and knowledge technologies. This therapeutic innovation has generated new opportunities to improve the surgical attention and the training of the surgeons. However, their ethical implications should be analyzed to clarify their use, to check the patient's safety and eliminate uncertainties. The characteristics of surgical telementoring generate specific challenges and ethical dilemmas that must be identified, analyzed and solved. Results: In this paper the ethical challenges and dilemmas of surgical telementoring identified and analyzed cover multiple aspects such as patient safety, privacy and vulnerability, the surgeon-mentor-patient relationship and informed consent, professional responsibility, cost-effectiveness analysis and Solidarity and social justice regarding the use of healthcare resources, the systematic approach to validation of the proposed new technology and conflicts of interest. For many of these issues solutions are provided, but they are still to be solved. Conclusions: surgical telementoring potentially improves patient healing and surgeon education. It will have a rapid evolution in the next years. This rapid growth should not be anticipated to the solid implantation of ethical guarantees for its use due to the particular characteristics that this technology has in the field of telemedicine.

Resumen: Antecedentes: El uso de tele-tutoría en cirugía es una tecnología que incluye procedimientos quirúrgicos guiados por un experto o tutor, realizado por otros cirujanos a distancia usando tecnologías de información y conocimiento. Esta innovación terapéutica ha generado nuevas oportunidades para mejorar la práctica de cirugía y la formación de los cirujanos. Sin embargo, deberían de analizarse sus implicaciones éticas para clarificar su uso, comprobar la seguridad del paciente y eliminar incertidumbres. Las características de la tele-tutoría en cirugía generan desafíos específicos y dilemas éticos que deben identificarse, analizarse y resolverse. Resultados: En este artículo se identificaron y analizaron múltiples aspectos en cuanto a desafíos éticos y dilemas de tele-tutoría en cirugía tales como: seguridad del paciente, privacidad y vulnerabilidad, la relación cirujano-tutor-paciente y el consentimiento informado, la responsabilidad profesional, análisis de costo-efectividad, solidaridad y justicia social respecto al uso de recursos en el cuidado de la salud, la aproximación sistemática para la validación de la nueva tecnología propuesta y los conflictos de interés. Para muchos de estos temas se han proporcionado soluciones, pero todavía no han sido resueltas. Conclusiones: La tele-tutoría en cirugía mejora potencialmente la sanación del paciente y la educación del cirujano. Va a tener una rápida evolución en los próximos años. Este rápido crecimiento no debería anticiparse a la implantación sólida de garantías éticas para su uso debido a las características particulares que tiene esta tecnología en el campo de la tele-medicina.

Resumo: Fundo: A cirurgia teleguiada é uma tecnologia que envolve procedimentos cirúrgicos, guiados por um especialista ou mentor, executados por outros cirurgiões à distância, usando tecnologias da informação e do conhecimento. Esta inovação terapêutica tem gerado novas oportunidades para melhorar a atenção cirúrgica e a formação dos cirurgiões. No entanto, suas implicações éticas devem ser analisadas para esclarecer seu uso, para verificar a segurança do paciente e eliminar as incertezas. As características da cirurgia teleguiada geram desafios específicos e dilemas éticos que devem ser identificados, analisados e resolvidos. Resultados: Neste artigo os desafios éticos e dilemas da cirurgia teleguiada identificados e analisados vislumbram vários aspectos como a segurança do paciente, sua privacidade e vulnerabilidade, o relacionamento paciente-cirurgião-mentor e consentimento informado, responsabilidade profissional, análise custo-eficácia e solidariedade e justiça social em relação ao uso dos recursos de saúde, a abordagem sistemática para validação da tecnologia nova proposta e conflitos de interesse. Para muitas destas questões são fornecidas soluções, mas muitas ainda estão para serem resolvidas. Conclusões: a cirurgia teleguiada potencialmente melhora o atendimento do paciente e o ensino do cirurgião. Vai ter uma rápida evolução nos próximos anos. Este rápido crescimento não deve ser antecipado para a implantação contínua de garantias éticas para seu uso devido as características particulares que esta tecnologia tem no campo da telemedicina.

Gastric schwannoma presenting as a casual ultrasonographic findings.

We present the case of a patient under study due to ascites in which a mass located on the gastric wall was observed during ultrasonography. Further studies (upper endoscopy and computed tomography) confirmed this finding. After an ultrasound-guided percutaneous biopsy, diagnosis of gastric schwannoma was made as intense S-100 expression was found. Surgery was rejected due to the bad clinical situation of the patient and because the mass was an asymptomatic benign tumor.

A novel CD14(high) CD16(high) subset of peritoneal macrophages from cirrhotic patients is associated to an increased response to LPS.

The aim of this study was to characterize monocyte-derived macrophages (M-DM) from blood and ascites of cirrhotic patients comparatively with those obtained from blood of healthy controls. The phenotypic profile based on CD14/CD16 expression was analyzed by flow cytometry. Cells were isolated and stimulated in vitro with LPS and heat killed Candida albicans. Phosphorylation of ERK, c-Jun, p38 MAPK, and PKB/Akt was analyzed by Western blotting. A novel CD14(high)CD16(high) M-DM subpopulation is present in ascites (∼33%). The CD14(++)CD16(+) intermediate subset is increased in the blood of cirrhotic patients (∼from 4% to 11%) and is predominant in ascites (49%), while the classical CD14(++)CD16(-) subpopulation is notably reduced in ascites (18%). Basal hyperactivation of ERK and JNK/c-Jun pathways observed in ascites M-DM correlates with CD14/CD16 high expressing subsets, while PI3K/PKB does it with the CD16 low expressing cells. In vitro LPS treatment highly increases ERK1/2, PKB/Akt and c-Jun phosphorylation, while that of p38 MAPK is decreased in M-DM from ascites compared to control blood M-DM. Stimulation of healthy blood M-DM with LPS and C. albicans induced higher phosphorylation levels of p38 than those from ascites. Regarding cytokines secretion, in vitro activated M-DM from ascites of cirrhotic patients produced significantly higher amounts of IL-6, IL-10 and TNF-α, and lower levels of IL-1ß and IL-12 than control blood M-DM. In conclusion, a new subpopulation of CD14(high)CD16(high) peritoneal M-DM has been identified in ascites of cirrhotic patients, which is very sensitive to LPS stimulation.

Spontaneous retroperitoneal hematoma in a patient under anticoagulant agents presenting as upper gastrointestinal bleeding.

We present the case of a 44-year-old woman with past history of repeated miscarriage and Budd-Chiari syndrome secondary to primary myelofibrosis. Because of this she was under treatment with oral anticoagulant agents. The patient was admitted in hospital as she presented with gastrointestinal bleeding (melena), asthenia and progressive anemia. In an initial upper endoscopy an extrinsic duodenal compression associated with an ulcer on the posterior face of the first portion of duodenum and upper duodenal knee was observed. In the following days a huge spontaneous retroperitoneal hematoma due to anticoagulation was diagnosed by computed tomography. This was treated with a percutaneous drainage and withdrawal of the antithrombotic drugs. The evolution of the patient was initially satisfactory but she suffered subclavian and jugular vein thrombosis, and reintroduction of anticoagulant agents at the lowest therapeutic doses was required.

Opportunity cost in the economic evaluation of da Vinci robotic assisted surgery.

OBJECTIVE: This study aims to demonstrate the importance of the opportunity cost in using da Vinci robotic surgery, assisted by a comprehensive review of the literature to determine the differences in the total cost of surgery and operative time in traditional laparoscopic surgery and da Vinci robotic surgery. METHODOLOGY: We identified the studies comparing the use of traditional laparoscopic surgery with robotics during the period 2002-2012 in the electronic economic evaluation databases, and another electronic search was performed for publications by Spanish hospitals in the same period to calculate the opportunity cost. A meta-analysis of response variables considering the total cost of the intervention and surgical time was completed using the items selected in the first revision, and their differences were analyzed. We then calculated the opportunity cost represented by these time differences using the data obtained from the studies in the second review of the literature. RESULTS: Nine items were selected in the first review and three in the second. Traditional laparoscopic surgery has a lower cost than the da Vinci (p < 0.00001). Robotic surgery takes longer (8.0-65.5 min) than traditional surgery (p < 0.00001), and this difference represents an average opportunity cost for robot use of € 489.98, with a unit cost factor/time which varies according to the pathology dealt with, from € 8.2 to 18.7/min. CONCLUSIONS: The opportunity cost is a quantity that must be included in the total cost of using a surgical technology within an economic cost analysis in the context of an economic evaluation.

Desarrollo y validación psicométrica de la Escala de Privacidad en la Vivienda / Construction and Psychometric Validation of the Dwelling's Privacy Scale

El propósito de este estudio fue generar un instrumento que permita medir la privacidad en las viviendas urbanas de México de manera confiable y válida. Para lo cual se construyó una escala conformada por 20 reactivos con cinco opciones de respuesta; para realizar su validación psicométrica se aplicó a 200 habitantes de la Ciudad de México, de entre los 14 y 75 años de edad, 110 mujeres y 90 hombres con diferentes ocupaciones y grados de escolaridad. Se llevaron a cabo análisis para conocer el poder discriminativo de los reactivos; la confiabilidad y la estructura factorial válida para la población de la Ciudad de México. La escala final estuvo constituida por 11 reactivos, organizados en tres factores Control de Acceso a la Información, Control de Acceso a la Persona e Intimidad.

The main objective of this research was to generate a reliable and valid scale that assessed dwelling privacy in Mexico City's population. A scale was developed specifically for this purpose. The scale included 20 items with five options for answers (Never, few times, sometimes, frequently and always). The scale was applied to a sample of 200 Mexico City's inhabitants in order to obtain its psychometrical validation. The distribution of the participants was as follow: age between 14 to 75; 110 women and 90 men: diverse occupations and school levels. A proper analysis took place in order to learn about the items discriminative power, reliability and valid factorial structure. The final scale was conformed by 11 items organized by three factors as follow: 1) Information Access Control, 2) Person Access Control and 3) Intimacy it explains 68% of variance and has a reliability of Cronbach Alpha =0.89. Afterwards a Confirmatory Factor Analysis was conducted to verify if the structure obtained from the Principal Component Analysis was correct, and a good fit was achieved (df=39, x2= 48.07, p=.151; CFI= .987; RMSEA= .032).

Chest computed tomography findings in severe influenza pneumonia occurring in neutropenic cancer patients.

OBJECTIVE: To describe the chest computed tomography findings for severe influenza H1N1 infection in a series of hospitalized neutropenic cancer patients. METHODS: We performed a retrospective systematic analysis of chest computed tomography scans for eight hospitalized patients with fever, neutropenia, and confirmed diagnoses of influenza H1N1. The clinical data had been prospectively collected. RESULTS: Six of eight patients (75%) developed respiratory failure and required intensive care. Prolonged H1N1 shedding was observed in the three mechanically ventilated patients, and overall hospital mortality in our series was 25%. The most frequent computed tomography findings were ground-glass opacity (all patients), consolidation (7/8 cases), and airspace nodules (6/8 cases) that were frequently moderate or severe. Other parenchymal findings were not common. Five patients had features of pneumonia, two had computed tomography findings compatible with bronchitis and/or bronchiolitis, and one had tomographic signs of chronicity. CONCLUSION: In this series of neutropenic patients with severe influenza H1N1 infection, chest computed tomography demonstrated mainly moderate or severe parenchymatous disease, but bronchiolitis was not a common feature. These findings associated with febrile neutropenia should elicit a diagnosis of severe viral infection.

Chest computed tomography findings in severe influenza pneumonia occurring in neutropenic cancer patients

OBJECTIVE: To describe the chest computed tomography findings for severe influenza H1N1 infection in a series of hospitalized neutropenic cancer patients. METHODS: We performed a retrospective systematic analysis of chest computed tomography scans for eight hospitalized patients with fever, neutropenia, and confirmed diagnoses of influenza H1N1. The clinical data had been prospectively collected. RESULTS: Six of eight patients (75%) developed respiratory failure and required intensive care. Prolonged H1N1 shedding was observed in the three mechanically ventilated patients, and overall hospital mortality in our series was 25%. The most frequent computed tomography findings were ground-glass opacity (all patients), consolidation (7/8 cases), and airspace nodules (6/8 cases) that were frequently moderate or severe. Other parenchymal findings were not common. Five patients had features of pneumonia, two had computed tomography findings compatible with bronchitis and/or bronchiolitis, and one had tomographic signs of chronicity. CONCLUSION: In this series of neutropenic patients with severe influenza H1N1 infection, chest computed tomography demonstrated mainly moderate or severe parenchymatous disease, but bronchiolitis was not a common feature. These findings associated with febrile neutropenia should elicit a diagnosis of severe viral infection.