Availability and use of resources for emergency fracture care of pelvic trauma associated with haemorrhagic shock in Latin America: A cross-sectional study.

Determining the true availability of resources and understanding the level of training of surgeons involved in the treatment of patients with pelvic fractures and haemorrhagic shock is critical. In the herein study, the availability of technical, technological, and human resources for the care of this injury in Latin America region was analysed, and the preferences of orthopaedic trauma surgeons when performing interventions for the diagnosis and treatment of patients with pelvic trauma and associated haemorrhagic shock was described. A cross sectional web-based survey containing questions on knowledge, attitudes, and practices with respect to imaging resources, emergency pelvic stabilization methods, and interventions used for bleeding control was sent to 948 Latin America orthopaedic trauma surgeons treating pelvic fractures in the emergency department. Differences between regional clusters, level of training, type of hospital, and pelvic surgery volume were assessed. 368 responses were obtained, with 37.5% of respondents reporting formal training in pelvic surgery and 36.0% having available protocol for managing these patients. The most frequently used interventions were the supra-acetabular pelvic external fixator and pelvic packing. Limited hospital and imaging resources are available for the care of patients with pelvic trauma and associated haemorrhagic shock throughout Latin America. In addition, the training of orthopaedic trauma surgeons dealing with this type of injury and the volume of pelvic surgeries per year is heterogeneous. It should be urgently considered to develop management protocols adapted to Latin America according to the availability of resources, as well as to promote training in this severe life-threatening traumatic condition.

An Overview of Genus Malachra L.-Ethnobotany, Phytochemistry, and Pharmacological Activity.

The genus Malachra L. belongs to the family Malvaceae. It includes herbs or subshrubs of nine accepted species with approximately thirty synonyms, and it has been widely used in community folk medicine to treat health problems including inflammation, nasal obstruction, leishmaniasis, malaria, childbirth, kidney disorders, fever, respiratory tract diseases, among others. From the genus Malachra L., flavonoids, steroids, triterpenes, anthocyanins, leucoanthocyanins, saponins, carbohydrates, phenols, glycosides, and alkaloids have been isolated and identified. Some pharmacological reports have indicated that the genus has antidiarrheal, antiepileptic, antiulcerogenic, antioxidant, anticonvulsant, antiviral, anticancer, antibacterial, anthelmintic, and hepatoprotective properties. However, there have been limited studies of bioactive molecules with pharmacological and biological activities associated with Malachra alceifolia Jacq., Malachra capitata (L.) L., Malachra fasciata Jacq., Malachra radiata (L.) L., Malachra ruderalis Gürke., Malachra rudis Benth., Malachra helodes Mart., Malachra urens Poit. ex Ledeb. & Alderstam., and Malachra officinalis Klotzsch. In this review, we consider the conservation of these species to save the ancestral knowledge of their traditional use in populations, and their pharmacological potential for future studies in search of alternatives for solutions to diseases in humans and animals and tools for the design and search of potential bioactive compounds against infectious and non-infectious agents.

Factores asociados con amputación de miembros inferiores de pacientes con pie diabético en una cohorte / Factors associated with lower limb amputation of patients with diabetic foot in a cohort

Introducción: El desarrollo de ulceraciones en el Pie Diabético (PD) puede derivar en amputación de miembros inferiores e incluso impactar la morbi mortalidad de los pacientes diabéticos. Por lo anterior, este estudio pretende evaluar las características de los pacientes con PD hospitalizados y manejados en un hospital regional. Materiales y métodos: 121 pacientes son incluidos en el estudio de cohorte retrospectiva entre amputados y no amputados, tomados de la base de datos del hospital entre enero de 2013 y enero de 2018. Los datos demográficos, así como factores relacionados fueron analizados con regresión logística bi y multivariada en relación con la amputación de miembro inferior como variable de desenlace, calculando razón de probabilidades (OR) con intervalos de confianza del 95%. Dicha información fue analizada con el programa estadístico STATA. Resultados: 81 pacientes requirieron amputación de miembros inferiores. En la regresión logística bivariada hay 3 factores relacionados con amputación [nivel de Wagner (p < 0.05 CI 95%), la presencia de leucocitosis (p <0.05 CI 95%) y el compromiso vascular en Doppler arterial (p < 0.05 CI 95%)], sin embargo, la regresión multivariada sólo relaciona el compromiso vascular del Doppler arterial como estadísticamente significativo con amputación de miembros inferiores (p < 0.05 CI 95%). Conclusión: Se muestran 3 factores estadísticamente significativos con la amputación de miembros inferiores en PD (Wagner, leucocitosis y compromiso vascular), reflejando la importancia de un diagnóstico temprano y un manejo adecuado como parte clave en el manejo de esta patología.

Introduction: The development of ulcerations in the Diabetic Foot (DP) can lead to lower limb amputation and even impact the morbidity and mortality of diabetic patients. Therefore, this study aims to evaluate the characteristics of patients with PD hospitalized and managed in a regional hospital. Materials and methods: 121 patients are included in the retrospective cohort study between amputees and non-amputees, taken from the hospital database between January 2013 and January 2018. Demographic data, as well as related factors, were analyzed with logistic regression. bi and multivariate in relation to lower limb amputation as an outcome variable, calculating odds ratio (OR) with 95% confidence intervals. This information was analyzed with the STATA statistical program. Results: 81 patients required lower limb amputation. In the bivariate logistic regression there are 3 factors related to amputation [Wagner level (p < 0.05 95% CI), the presence of leukocytosis (p < 0.05 95% CI) and vascular compromise on arterial Doppler (p < 0.05 95% CI). )], however, multivariate regression only relates vascular compromise on arterial Doppler as statistically significant to lower limb amputation (p < 0.05 95% CI). Conclusion: 3 statistically significant factors are shown with lower limb amputation in PD (Wagner, leukocytosis and vascular compromise), reflecting the importance of early diagnosis and adequate management as a key part in the management of this pathology.

Development and validation of a delirium risk prediction preoperative model for cardiac surgery patients (DELIPRECAS): An observational multicentre study.

STUDY OBJECTIVE: To develop and validate a delirium risk prediction preoperative model for patients undergoing cardiac surgery. DESIGN: Observational prospective multicentre study. SETTING: Six intensive care units in Spain. PATIENTS: 689 patients undergoing cardiac surgery consecutively, aged ≥18 years. MEASUREMENTS: The primary outcome measure was the development of delirium, diagnosed using the Confusion Assessment Method in Intensive Care Units (CAM-ICU), during the stay in the intensive care unit after cardiac surgery. MAIN RESULTS: The model was developed with 345 consecutive patients undergoing cardiac surgery at six hospitals and validated with another 344 patients from the same hospitals. The prediction model contained four preoperative risk factors: age over 65 years, Mini-Mental State Examination (MMSE) score of 25-26 points (possible impairment of cognitive function) or < 25 (impairment of cognitive function), insomnia needing medical treatment and low physical activity (walk less than 30 min a day). The model had an area under the receiver operating characteristics curve of 0.825 (95% confidence interval: 0.76-0.89). The validation resulted in an area under the curve of 0.79 (0.73-0.85) and the pooled area under the receiver operating characteristics curve (n = 689) was 0.81 (0.76-0.85). We stratified patients in groups of low (0%-20%), moderate (> 20%-40%), high (> 40%-60%) and very high (> 60%) risk of developing delirium, with a positive and negative predictive value for the very high risk group of 70.97% and 85.56%, respectively. CONCLUSION: The DELIPRECAS model (DELIrium PREvention CArdiac Surgery), consisting of four well-defined clinical risk factors, can predict in the preoperative period the risk of developing postoperative delirium in patients undergoing cardiac surgery. An automatic version of the risk calculator is available.

Poliartritis séptica y fascitis necrotizante en un paciente inmunocompetente. Reporte de caso / Septic polyarthritis and necrotizing fascitis in an immunocompetent patient. Case report

La presentación de poliartritis séptica en un paciente inmunocompetente es infrecuente, aún más lo es la presentación de la mencionada junto con fascitis necrotizante en el contexto de infección por Streptococcus Pyogenes (SP). Se presenta el caso de un paciente masculino de 54 años, recluido, sin antecedentes médicos relevantes, inmunocompetente, quien debuta con un cuadro clínico de poliartritis séptica en rodilla bilateral y tobillo izquierdo. Recibe manejo con múltiples lavados y desbridamientos quirúrgicos, desarrolla fascitis necrotizante de la cara posterior de la pierna izquierda, recibe a su vez manejo quirúrgico para dicha condición (incluyendo aplicación de terapia de vacío), al igual que antibioticoterapia enfocada al manejo del germen aislado (Penicilina + vancomicina). Sin embargo, tras un mes de manejo conjunto con servicios de Cirugía Plástica, Dermatología, Ortopedia, así como vigilancia en Unidad de Cuidados Intensivos, termina con un desenlace fatal tras presentar falla multiorgánica. La infección por el SP puede resultar en una elevada morbilidad para él paciente e incluso un desenlace mortal secundario a un compromiso sistémico de muy difícil manejo. El diagnóstico oportuno, así como un tratamiento médico y quirúrgico agresivo pueden no ser suficientes para el control de la infección, incluso en pacientes sin compromiso inmunológico previo. Asimismo, un enfoque multidisciplinario debe corresponder al estándar de manejo con el fin de controlar aquellas condiciones predisponentes de infección. Este es el primer caso reportado en la literatura nacional en relación con estas dos fatales condiciones. Finalmente se pretende resaltar que a pesar de que esta infección suele comprometer infantes y pacientes inmunocomprometidos, no se debe obviar su diagnóstico en pacientes previamente sanos, especialmente en casos de infecciones de rápida diseminación y poca respuesta al manejo adecuado.

Septic polyarthritis in an immunocompetent patient is highly rare, even more when it coexists with necrotizing fasciitis caused by Streptococcus Pyogenes (SP). A 54 year old, immunocompetent male patient is presented herein. The patient had no relevant previous illness, before the installation of a septic arthritis of both knees and he's left ankle. He receives treatment with sequential surgical debridement, then develops necrotizing fasciitis of the posterior aspect of the left leg requiring adequate treatment for such condition (including Vacuum Assisted Closure), as well as antibiotic therapy for the specific infecting microorganism (Penicillin + Vancomycin). Nonetheless, after a month of surgical management between Plastic Surgery, Dermatology, Orthopaedics as well as surveillance in the Intensive Care Unit, the patient dies after multi organic failure. Infection caused by SP might entail high morbidity for a patient and even end with death of the aforementioned caused by a hard to manage systemic organic failure. The adequate diagnosis, as well as aggressive medical and surgical management could not be enough for controlling the infection, even in patients without previous immunological compromise. At the same time, a multidisciplinary approach must be the standard of treatment, aiming to control predisposing infectious conditions. This is the first case reported in national literature related to these two fatal conditions. Finally, one of the purposes of this report is to highlight that despite reports of this microorganism infecting infants and immunocompromised patients, it must not be obviated in healthy patients, especially in cases of rapidly spreading infection and scarce response to adequate management.

Stability of a Parenteral Formulation of Betamethasone and Levobupivacaine.

Background: The therapeutic management of syndromes presenting simultaneously pain and inflammation often requires the administration of anesthetic and corticosteroid drugs by epidural administration. In this article, we studied a mixture that combines betamethasone and levobupivacaine, which demonstrates prolonged analgesic effects. To our knowledge, the stability of such a mixture in epidural solution has not been examined. Objective: To evaluate the chemical, physical, and microbiological stability of an extemporaneously prepared mixture. Methods: A solution of betamethasone acetate 1 mg/mL, betamethasone phosphate 1 mg/mL, and levobupivacaine hydrochloride 0.83 mg/mL was prepared in saline. The components were analyzed by high-performance liquid chromatography for up to 270 days of storage, protected and exposed to light, at room temperature, and stored in the refrigerator and at 45°C. In addition, sterility, organoleptic properties, and pH of the admixture were monitored. Results: There are no significant differences between drug concentrations obtained at room temperature and at refrigerated temperature. The accelerated conditions (45°C) demonstrated different results among the actives: betamethasone acetate and levobupivacaine hydrochloride are affected while betamethasone phosphate remains stable. The stability of the mixture does not depend on light exposure. The validity period of the different components in the mixture was estimated as 120 days for betamethasone phosphate and 163 days for levobupivacaine hydrochloride; betamethasone acetate remained unchanged during 155 days. Conclusion: Analgesic mixtures of betamethasone and levobupivacaine can be stored at ambient temperature in polypropylene vials for up to 120 days at the studied concentrations. These data enable the rationalization of the centralized preparation in the hospital pharmacy.

Supervised exercise for acute coronary patients in primary care: a randomized clinical trial.

BACKGROUND: Functional capacity is a prognostic factor for coronary patients; accordingly, they are recommended to walk. OBJECTIVE: To assess whether an exercise program supervised in primary care increases their functional capacity more than unsupervised walking. METHODS: A randomized clinical trial was carried out at eight primary care centres of the Spanish Health Service and involving 97 incident cases of low-risk acute coronary patients, <80 years old, randomly assigned to either an unsupervised walking program (UW group; n = 51) or a 6-month cycle ergometer exercise program with gradually increasing frequency and workload intensity supervised by primary care nurses (SE group; n = 46). The two groups received the same common components of secondary prevention care. Changes in functional capacity were assessed in terms of peak oxygen consumption (VO2peak) during exercise testing measured at baseline and at 7 months by cardiologists blinded to group assignment. RESULTS: Overall, 76% of participants completed the study, 30 in the SE and 44 in the UW. Both groups increased baseline-adjusted VO2peak: 5.56ml/kg per minute in the SE (95% confidence interval [CI] 3.38-7.74) and 1.64ml/kg per minute in the UW (95% CI -0.15 to 3.45). The multivariate-adjusted difference between groups was 4.30ml/kg per minute (95% CI 1.82-6.79; P = 0.001) when analyzing completers and 2.83ml/kg per minute (95% CI 0.61-5.05; P = 0.01) in the intention-to-treat analysis, including all participants with baseline values carried forward for those lost to follow-up. CONCLUSIONS: A cycle ergometer exercise program supervised by primary care nurses increased the functional capacity of coronary patients more than unsupervised walking with a clinically relevant difference.

Recombinant factor VIIa is an effective therapy for abdominal surgery and severe thrombocytopenia: a case report.

A 50-year-old woman was admitted to the emergency room. An appendectomy was done. On the sixth day the patient's general state deteriorated and she became somnolent with jaundice due to distal obstructive choledocholithiasis. The results of laboratory tests were platelets 12 x 10(9)/L, prothrombin time 13 seconds, international normalized ratio 1.19, activated partial thromboplastin time 31.8 seconds, and fibrinogen 8.78 g/L. There was no evidence of disseminated intravascular coagulation. In view of the patient's clinical condition, surgery was considered to be indicated. Because it was a life-threatening situation and at the time there was no platelet concentrate available for immediate transfusion, she was treated with a single dose of recombinant factor VIIa (rFVIIa) (60 microg/kg). The dose of 60 microg/kg was selected on the basis of experience with rFVIIa in the treatment of hemophilic patients. In this case, use of rFVIIa was a valid alternative to control the bleeding in a patient with thrombocytopenia. However, despite the efficacy of the treatment, it should not be forgotten that it was used because of the unavailability of platelets and that we were dealing with a life-threatening situation. Clinical trials should be carried out to verify the safety, effectiveness, and efficiency of rFVIIa in these cases.

Aplicaciones clínicas de la TAC con multidetectores / Multislice computed tomography

La tecnología multicorte de los equipos de tomografía axial computarizada (TAC) es un paso adelante que permite optimizar los estudios convencionales y que abre nuevas alternativas basadas en su mayor rapidez de adquisición y procesamiento, en la menor colimación y en la optimización de los recursos. Así, las reconstrucciones multiplanares y la generación de imágenes endoscópicas replantean los protocolos diagnósticos en múltiples procesos de tamizaje y evaluación patológica

Principales repercusiones socio-economicas y psicologicas en pacientes que presentaron cancer y que fueron internados en los servicios de clínica y cirugía del hospital Eugenio Espejo, en el período comprendido de febrero 20 a marzo 20 de 1986. Quito / Main repercussions partner-economicas and psicologicas in patients who presented/displayed to cancer and who were committed in the services of clinic and surgery of the hospital Eugene Mirror, in the period included/understood of February 20 to March

Cualquier médico o enfermera en el ejercicio de su profesión está familiarizado con mil preguntas, súplicas y anhelos con que acusan los pacientes o sus familiares y han vivido situaciones como las siguientes como: unas veces, llega el paciente al área hospitalaria a quejando dolor en está o aquella parte del cuerpo, manifiesta sus sospechas acerca del posible origen de su malestar y espera absolutamente concencido, que será tarea elemental para el Médico y la Enfermera el suprimir inmediatamente su sufrimiento: esto en el mejor de los casos, puesto que según el estudio que hemos realizado en su mayoría los pacientes afectados por el Cáncer ingresan en una etapa avanzada (III Grado), en cuyo caso el tratamieno de elección el Paleativo. El objetivo primordial de este trabajo es poder acercarnos a la comprensión de los problemas por los que atravieza la familia y en especial el paciente afectado por el cáncer: cuyos problemas se traducen en: Psicológicos, Socio-económicos y su deterioro físico. Es así como se inicia una larga carrera contra el tiempo para tratar de vencer los diferentes tratamientos mediante esquemas hace que el paciente y su familia se sumerga en el campo de la desesperación por tratar de obtener el dinero viendose obligados a vencer sus propiedades y bienes materiales, todos estos sacrificios banos puesto que al final del camino está la muerte...