[The art of doing minimal harm in Mental Health]. / El arte de hacer el mínimo daño en Salud Mental.

There are socio-cultural and political-economic conditions that favor interventionism in mental health and iatrogenesis. However, the professional, in relationship with the patient, has the ability to reduce harm in clinical practice. This article, briefly, reviews the damage of work in mental health and arises, from the recognition of professional intellectual and personal conflicts, the foundation for a practice that causes the least harm to patients.

[THE ART OF DOING MINIMAL HARM IN MENTAL HEALTH]. / El arte de hacer el mínimo daño en Salud Mental.

There are socio-cultural and political-economic conditions that favor interventionism in mental health and iatrogenesis. However, the professional, in relationship with the patient, has the ability to reduce harm in clinical practice. This article, briefly, reviews the damage of work in mental health and arises, from the recognition of professional intellectual and personal conflicts, the foundation for a practice that causes the least harm to patients

Internal hernia after laparoscopic left colectomy: case series and review of the literature

Objective: Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods: We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results: The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management. (AU)

Double barreled wet colostomy. Case report and description of the surgical technique / Colostomia úmida em dupla-boca. Relato de caso e descrição da técnicacirúrgica

ABSTRACT Pelvic exenteration has showed to be beneficial therapeutically and palliatively in locally advanced colorectal cancer. Reconstruction of urinary transit posterior to a cystectomy has always been challenging with many associated complications. We present a 58-year-old male with locally advanced rectal cancer in which a pelvic exenteration and a double-barreled wet colostomy (DBWC) was created for urinary reconstitution. We present the surgical technique of DBWC. DBWC is a good alternative to other urinary reconstructions because fecal and urinary derivation occurs in only one stoma, the stoma output is easier to manage, and fewer complications are seen compared to other urinary reconstructions. Long-term surveillance is mandatory in patients with a DBWC because there is an increased risk of neoplasm in the reservoir.

RESUMO A exenteração pélvica mostrou-se benéfica, tanto terapêutica quanto paliativamente, em casos de câncer colorretal localmente avançado. A reconstrução do trânsito urinário após uma cistectomia sempre foi desafiadora, com muitas complicações associadas. Os autores apresentam o caso de um homem de 58 anos de idade com câncer retal localmente avançado, submetido a uma exenteração pélvica e uma colostomia úmida em dupla-boca (CUDB) para reconstituição urinária. Os autores apresentam a técnica cirúrgica da CUDB, uma boa alternativa para outras reconstruções urinárias, já que a derivação fecal e urinária ocorre em apenas um estoma, a saída do estoma é mais fácil de gerenciar e o método apresenta menos complicações em comparação com outras reconstruções urinárias. A vigilância a longo prazo é obrigatória em pacientes com CUDB, pois há um risco aumentado de neoplasia no reservatório.

[Iatrogenesis and quaternary prevention on mental health]. / Iatrogenia y prevención cuaternaria en salud mental.

Quaternary prevention avoids or mitigates the consequences of unnecessary or excessive activity of the health system. Iatrogenia produced by care systems activity is a serious public health problem and in mental health is poorly understood. The damage that can be inflicted to patients covers the entire episode of care, from prevention to treatment through the diagnostic process. We review the damage caused by preventive activities as the approach of mourning or debriefing, pharmacological and psychotherapeutic treatments, the iatrogenia produced in diagnosis and the deleterious effects of being under care in the psychiatric system especially related to stigma. Become aware of the seriousness of iatrogenic effects of our "well done" interventions allows foregrounding the importance of quaternary prevention and the need to work with the shared decision making model always considering alternatives and measures to ensure safety and rights of patients.

Treatment of a waste oil-in-water emulsion from a copper-rolling process by ultrafiltration and vacuum evaporation.

A process is proposed for the treatment of a waste oil-in-water (O/W) emulsion generated in an industrial copper-rolling operation. The use of demulsifier agents improves the subsequent treatment by techniques such as ultrafiltration (UF) or evaporation. The effluent COD is reduced up to 50% when the O/W emulsion is treated by UF using a flat 30 nm TiO(2) ceramic membrane (ΔP = 0.1 MPa) and up to 70% when it is treated by vacuum evaporation, after an emulsion destabilization pretreatment in both cases. Increases in the UF permeate flux and in the evaporation rate are observed when a chemical demulsifier is used in the pretreatment step. A combined process consisting of destabilization/settling, UF, and vacuum evaporation can yield a very high-quality aqueous effluent that could be used for process cooling or emulsion reformulation.

Conditions that do not reach the threshold for mental disorder in Spanish psychiatric outpatients: prevalence, treatment and management.

BACKGROUND: In recent years there has been controversy around the treatment demands of people who, without meeting diagnostic criteria for a mental disorder, have certain symptoms and are referred to mental health professionals. AIMS: To determine the prevalence of individuals assessed by mental health service, referred from primary care, who do not meet the diagnosis criteria of mental disorders according to ICD-10. To analyze the medical treatment given to these individuals, measured by the indication for discharge or follow-up and by the pharmacological intervention decided in the first interview, as well as the associated variables. DESIGN: descriptive study. SCOPE: urban area. POPULATION: all patients referred to the Salamanca mental health service during a year, without any exclusion (n = 1,187). VARIABLES: sociodemographics; clinical and health service utilization gathered through clinical interview, GHQ-28, SCL-90-R and an expectations scale. RESULTS: Of the 1,004 patients who attended interview, 24.4% (CI 95%: 21.6-27.0) did not present any diagnosable mental disorder (Z codes); they constitute the body of this study. 50.8% of these were referred from primary care with a psychotropic drug treatment already prescribed. Any drug intervention (addition, suspension or modification) was performed in 37.2% of the cases by the mental health service. Regardless of the treatment indicated, 52% were discharged after the first interview. CONCLUSIONS: The prevalence of patients who failed to reach diagnostic criteria for a mental disorder in this health service is similar to other studies, in spite of the filter provided by primary care. Many individuals without a diagnosable mental disorder received treatment both in primary care and in the mental health service.

Excesos y alternativas de la salud mental en atención primaria / Excessos e alternativas da saúde mental na atenção primária / Excesses and alternatives in mental health in primary care

La extraordinaria expansión de la psiquiatría y la psicología está propiciando el tratamiento de personas sanas que acaban siendo etiquetadas como trastornos mentales. El reduccionismo biológico del modelo médico centrado en los síntomas favorece la transformación de problemas sociales en conflictos individuales y la exposición de los ciudadanos a los efectos adversos de tratamientos excesivos e improcedentes. La prevención cuaternaria en salud mental contempla el empleo de narrativas y formulación de casos (más allá de la etiqueta diagnóstica), la indicación de no-tratamiento y un empleo de los psicofármacos prudente, que considere su deprescripción.

A extraordinária expansão da psiquiatria e da psicologia está proporcionando o tratamento de pessoas saudáveis que acabam sendo rotuladas como transtornos mentais. O reducionismo biológico do modelo médico centrado em sintomas favorece a transformação de problemas sociais em conflitos individuais e a exposição dos cidadãos aos efeitos adversos de tratamentos excessivos e inadequados. A prevenção quaternária em saúde mental contempla o uso de narrativas e formulação de casos (para além do rótulo diagnóstico), a indicação de não-tratamento e um uso prudente de drogas psicoativas, que leve em consideração sua desprescrição.

The extraordinary expansion of psychiatry and psychology is leading the treatment of healthy people who end up being labelled as mental disorders. The biological reductionism of the medical model centred on the symptoms favours both the transformation of social problems in individual conflicts and the exposure of citizens to the adverse effects of excessive and inappropriate treatments. Quaternary prevention in mental health contemplates the use of narratives and case formulation (beyond the diagnostic label), the indication of non-treatment, and prudent use of psychoactive drugs, taking into account its deprescription.

[Importance of parathyroid SPECT and 99mTc scintigraphy, and of clinical, laboratorial, ultrasonographic and citologic correlation in the pre-operative localization of the parathyroid adenoma - pictorial assay]. / Importância da complementação com SPECT e 99mTc na cintilografia das paratiroides e da correlação clínica, laboratorial, ultrassonográfica e citológica na localização pré-operatória do adenoma de paratiroide - ensaio pictórico.

OBJECTIVE: In patients with primary hyperparathyroidism, candidates for surgical intervention, the parathyroid pre-operative localization is of fundamental importance in planning the appropriate surgical approach. MATERIALS AND METHODS: The additional acquisition of SPECT and Technetium-99m images, during parathyroid scintigraphy with Sestamibi, is not common practice. Usually, only planar image acquisition, 15 minutes prior and 2 hours after radiopharmaceutical administration, is performed. RESULTS: In our experience, the complete protocol in parathyroid scintigraphy increases the accuracy of pre-operative parathyroid localization. CONCLUSION: The complete utilization of all available nuclear medicine methods (SPECT e 99mTc) and image interpretation in a multidisciplinary context can improve the accuracy of parathyroid scintigraphy.

[Mental health referrals of patients without diagnosable psychiatric pathology]. / La derivación a salud mental de pacientes sin un trastorno psíquico diagnosticable.

OBJECTIVE: To analyze the characteristics of referral from primary health care to mental health of patients with no diagnosable mental disorder. METHODS: Consecutively and without exemptions, all persons attending for first-time consultation a mental health centre in the course of a year were clinically examined. We measured the incidence of conditions not attributable to a mental disorder using ICD-10 (Z codes). Information was collected on whose idea it was that they attended, and who, how and with what treatment they were referred. In addition, data about their social, demographic and clinical characteristics were collected. RESULTS: Of the 1004 persons examined, 244 (24.4%) (95% CI, 21.6-27) did not meet the ICD-10 diagnosis criteria for mental disorders. They themselves or their family tended to request the Z codes (54.5%) (95% CI, 48.3-60.8]. Mental health referral was almost always through the PC doctor (95.5%) (95% CI, 92.1-97.7). Half the patients were already receiving drug therapy under their general practitioner before their visit and 20.9% (95% CI, 15.8-26) were referred as priority patients. CONCLUSIONS: Our study found that a large number of patients with no diagnosable mental disorder at the mental health centre, many of them with drug treatment prescribed, were referred. This places a question-mark over the function of primary care as a filter for these patients. The population s indiscriminate health care demand and the steady increase in treating mental health with drugs partially explain this phenomenon.

Importância da complementação com SPECT e 99mTc na cintilografia das paratiroides e da correlação clínica, laboratorial, ultrassonográfica e citológica na localização pré-operatória do adenoma de paratiroide - ensaio pictórico / Importance of parathyroid SPECT and 99mTc scintigraphy, and of clinical, laboratorial, ultrasonographic and citologic correlation in the pre-operative localization of the parathyroid adenoma - pictorial assay

OBJETIVO: Diante de um paciente portador de hiperparatiroidismo primário com indicação de tratamento cirúrgico, a localização pré-operatória da paratiroide é de fundamental importância para definir a melhor abordagem cirúrgica. MATERIAIS E MÉTODOS: A realização adicional de imagens SPECT e da cintilografia com 99mTc durante a cintilografia das paratiroides com Setamibi não é rotina em nosso meio, sendo comum a aquisição apenas das imagens planas − precoce (15 minutos) e tardia (2 horas). RESULTADOS: Na nossa experiência, tem-se percebido que a realização do protocolo completo contribui de maneira decisiva na sensibilidade da localização pré-operatória da paratiroide. CONCLUSÃO: A aplicação completa de todos os métodos cintilográficos disponíveis (SPECT e 99mTc) e a análise cuidadosa das imagens em um contexto multidisciplinar podem aumentar a acurácia da cintilografia das paratiroides.

OBJECTIVE: In patients with primary hyperparathyroidism, candidates for surgical intervention, the parathyroid pre-operative localization is of fundamental importance in planning the appropriate surgical approach. MATERIALS AND METHODS: The additional acquisition of SPECT and Technetium-99m images, during parathyroid scintigraphy with Sestamibi, is not common practice. Usually, only planar image acquisition, 15 minutes prior and 2 hours after radiopharmaceutical administration, is performed. RESULTS: In our experience, the complete protocol in parathyroid scintigraphy increases the accuracy of pre-operative parathyroid localization. CONCLUSION: The complete utilization of all available nuclear medicine methods (SPECT e 99mTc) and image interpretation in a multidisciplinary context can improve the accuracy of parathyroid scintigraphy.