[Detection of adverse events in thyroid and parathyroid surgery using trigger tool and Minimum Basic Data Set (MBDS)]. / Detección de eventos adversos en la cirugía tiroidea y paratiroidea utilizando la herramienta trigger y el Conjunto Mínimo de Datos Básicos (CMBD).

OBJECTIVES: To compare the ability of the trigger tool) and the Minimum Basic Data Set (MBDS) in detecting adverse events (AE) in hospitalized surgical patients with thyroid and parathyroid disease. METHODS: A descriptive, cross-sectional observational study, retrospective and cross-sectional study was conducted from May 2014 to April 2015 analysing retrospectively data on of patients submitted to thyroidectomy and parathyroidectomy in order to detect AE through the identification of triggers (an event often associated to an AE) and the MBDS. triggers and AE were located by systematic review of clinical documentation. The MBDS was got from the data base. Once an AE was detected, it was characterized. RESULTS: 203 AE were identified in 251 patients, being the 90.04% detected by trigger tool and 10.34% by MBDS. 126 patients had at least one AE (50.2%). Without the cases in which uncontrolled pain was the only AE, the percentage of patients that suffering AE was 38.65%. 187 AE were considered preventable and 16 AE were considered unpreventable. The trigger tool and the MBDS demonstrated a sensitivity of 91.27 and 13.49%, a specificity of 4.8 and 100%, a positive predictive value of 49,15 and 100%, and a negative predictive value of 35.29 and 53.42%, respectively. The triggers with more predictive power in AE detection were «antiemetic administration¼ and «calcium administration¼. CONCLUSIONS: Trigger tool shows higher sensitivity for detecting AE than the MBDS. All the detected AE were considered low severity and most of them were preventable.

Does a 6-point scale approach to post-treatment 18F-FDG PET-CT allow to improve response assessment in head and neck squamous cell carcinoma? A multicenter study.

PURPOSE: Response assessment to definitive non-surgical treatment for head and neck squamous cell carcinoma (HNSCC) is centered on the role of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET-CT) 12 weeks after treatment. The 5-point Hopkins score is the only qualitative system available for standardized reporting, albeit limited by suboptimal positive predictive value (PPV). The aim of our study was to explore the feasibility and assess the diagnostic accuracy of an experimental 6-point scale ("Cuneo score"). METHODS: We performed a retrospective, multicenter study on HNSCC patients who received a curatively-intended, radiation-based treatment. A centralized, independent qualitative evaluation of post-treatment FDG-PET/CT scans was undertaken by 3 experienced nuclear medicine physicians who were blinded to patients' information, clinical data, and all other imaging examinations. Response to treatment was evaluated according to Hopkins, Cuneo, and Deauville criteria. The primary endpoint of the study was to evaluate the PPV of Cuneo score in assessing locoregional control (LRC). We also correlated semi-quantitative metabolic factors as included in PERCIST and EORTC criteria with disease outcome. RESULTS: Out of a total sample of 350 patients from 11 centers, 119 subjects (oropharynx, 57.1%; HPV negative, 73.1%) had baseline and post-treatment FDG-PET/CT scans fully compliant with EANM 1.0 guidelines and were therefore included in our analysis. At a median follow-up of 42 months (range 5-98), the median locoregional control was 35 months (95% CI, 32-43), with a 74.5% 3-year rate. Cuneo score had the highest diagnostic accuracy (76.5%), with a positive predictive value for primary tumor (Tref), nodal disease (Nref), and composite TNref of 42.9%, 100%, and 50%, respectively. A Cuneo score of 5-6 (indicative of residual disease) was associated with poor overall survival at multivariate analysis (HR 6.0; 95% CI, 1.88-19.18; p = 0.002). In addition, nodal progressive disease according to PERCIST criteria was associated with worse LRC (OR for LR failure, 5.65; 95% CI, 1.26-25.46; p = 0.024) and overall survival (OR for death, 4.81; 1.07-21.53; p = 0.04). CONCLUSIONS: In the frame of a strictly blinded methodology for response assessment, the feasibility of Cuneo score was preliminarily validated. Prospective investigations are warranted to further evaluate its reproducibility and diagnostic accuracy.

Organs at risk's tolerance and dose limits for head and neck cancer re-irradiation: A literature review.

Re-irradiation is becoming an established treatment option for recurrent or second primary head and neck cancer(HNC). However, acute and long-term RT-related toxicities could dramatically impact patients' quality of life. Due to the sparse literature regarding HNC re-irradiation, data on tolerance doses for various organs at risk (OARs) are scarce. Our aim was to systematically review the clinical literature regarding HNC re-irradiation, focusing on treatment toxicity, OARs tolerance, and dose limit recommendations. Thirty-nine studies (three randomized, five prospective, 31 retrospective) including 3766 patients were selected. The median interval time between the first course and re-irradiation was 28  months (range, 6-90). In 1043 (27.6%) patients, postoperative re-irradiation was performed. Re-irradiation doses ranged from 30 Gy in 3 fractions using stereotactic technique to 72 Gy in conventional fractionation using intensity-modulated radiotherapy. Pooled acute and late toxicityrates ≥G3 were 32% and 29.3%, respectively. The most common grade 3-4 toxic effects were radionecrosis, dysphagia requiring feeding tube placement and trismus. In 156 (4.1%) patients, carotid blowout was reported. Recommendations for limiting toxicity included the time interval between radiation treatments, the fractionation schedules, and the re-irradiation treatment volumes. Cumulative dose limit suggestions were found and discussed for the carotid arteries, temporal lobes, and mandible.

Bariatric Surgery Waiting Lists in Spain.

Bariatric surgery is one of the most common general surgery procedures in countries that, like Spain, have public healthcare systems, but is also one of the procedures for which patients have to wait the longest. The Spanish Society of Obesity Surgery (SECO) conducted a survey to estimate the situation of bariatric surgery waiting lists in Spain's public hospitals and to gather information on a number of related aspects. METHODS: An online survey was sent to the members of the SECO. The survey received 137 visits, all via the click-through link provided, from 52 health centers (47 public and 5 private). The data collected were included in a database and later analyzed using the SPSS18.0 statistical software package. RESULTS: A total of 4724 patients were on bariatric surgery waiting lists (BWLs), at an average of 100 per public hospital. Sixty-eight percent had been waiting for more than 6 months. The mean delay per patient was 397 days, and the longest wait was 1661 days. A further 46.2% of respondents were able to recall cases of patients who in the past 5 years had suffered cardiovascular events with sequelae while awaiting surgery, and 21.2% recalled at least one fatal cardiovascular event in that time. CONCLUSION: Our data revealed an unacceptably long wait for obesity surgery. Notwithstanding the limitations and potential biases of our research, the long wait for surgery in our context inevitably has serious consequences for a potentially significant number of patients.

[Impact of imaging tests on the negative appendectomy rate]. / Impacto de los métodos de diagnóstico por imagen en la apendicectomía de urgencia.

INTRODUCTION: Negative appendectomies and perforated appendectomies have traditionally been quality indicators in surgery. The aim of this study is to analyze the emergency appendectomies in our hospital regarding the use of imaging tests and a review of the literature to analyze the quality of diagnosis in acute appendicitis. MATERIAL AND METHODS: Retrospective study including all patients operated on for suspected acute appendicitis at a single institution for one year (2007). Data gathered from histology and imaging tests reports. Analysis of the histology results, imaging test used and its diagnostic accuracy. Comparison with quality levels published in the international literature. RESULTS: A total of 394 patients were included in the study, the overall rate of negative appendectomy was 9.6%. Abdominal ultrasound (AU) was performed on 54.6% of patients and abdominal CT-scan on 10.2% of them, and 4.2% of the patients had both tests. AU positive predictive value was 82%. CT-scan positive predictive value was 97%. CONCLUSION: The negative appendectomy rate (9.6%) in our centre shows values lower than the published ones in historical series but superior to the one published recently in the USA. The use of imaging tests in our hospital is lower than the one published in the USA, although similar to data reported in other European countries.

Chronic intestinal pseudo-obstruction: a diagnosis to be considered.

Chronic intestinal pseudoobstruction (CIPO) is a rare entity characterized by recurrent clinical episodes of intestinal obstruction in which no mechanical cause is identified. There are multiple causes for this syndrome but two main groups can be distinguished: a) secondary to a systemic non-gastrointestinal disease; and b) primary or idiopathic originated from alterations in the components of the intestinal wall. The latter forms are the most uncommon and their diagnosis is generally difficult. In the present article, we describe nine patients with CIPO that were diagnosed in our center over the last six years. Four of them were diagnosed with primary or idiopathic form of CIPO and another four were clearly secondary to a systemic disease. The ninth case, which was initially diagnosed as secondary, is probably also a primary form of the disease. The number of patients diagnosed in our center, even thought small, makes us to hypothesize that the prevalence of CIPO is probably greater than is generally believed and that the reasons of its rarity are the incomplete understanding of its physiopathology and the difficulties to achieve a correct diagnosis.

Roles of NCX and PMCA in basolateral calcium export associated with mineralization cycles and cold acclimation in crayfish.

Basolateral Na+/Ca2+ exchanger (NCX) and plasma membrane Ca2+ ATPase (PMCA) are the primary transmembrane proteins that export calcium (Ca2+) from cells. In our lab we use a nonmammalian animal model, the freshwater crayfish, to study cellular Ca2+ regulation. Two experimental conditions are employed to effect Ca2+ dyshomeostasis: (a) in the postmolt stage of the crustacean molting cycle increased unidirectional Ca2+ influx associated with cuticular mineralization is accompanied by elevated basolateral Ca2+ export (compared with intermolt Ca balance); and (b) exposure of the poikilothermic crayfish to cold acclimation (4 degrees C) causes influx of Ca2+ into cells, which is compensated by increased basolateral Ca2+ export (compared with exposure to 23 degrees C). This study compares expression of both NCX and PMCA mRNA (real-time PCR) and protein (Western) in both epithelial (kidney) and nonepithelial tissue (tail muscle) during elevated basolateral Ca2+ export. Both experimental treatments produced increases in NCX and PMCA expression (mRNA and protein) in both tissues. Mineralization produced greater upregulation of mRNA in kidney than in tail, whereas cold acclimation yielded comparable increases in both tissues. Protein expression patterns were generally confirmatory of real-time PCR data although expression changes were less pronounced. Both experimental treatments appear to increase basolateral Ca2+ export.

Marjolin's ulcer arising from a laparostomy scar.

Marjolin's ulcer is the malignant transformation of a scar, usually as a squamous cell carcinoma. An uncommon presentation form is from a laparostomy scar. A 49-year-old patient that had a laparostomy during the treatment of a necrohemorrhagic pancreatitis in 1987 complained 13 years later of a 20-cm ulcer on the laparostomy scar. A resection of the abdominal wall including the ulcer and a segmental transverse colectomy were performed because of infiltration by an invasive squamous cell carcinoma. Ten months later, axillary lymphadenectomy was performed because of lymph node metastasis. Currently, the patient is free of disease. Lymph node infiltration is frequent in squamous cell carcinoma on Marjolin's ulcer and survival is not good. Prophylaxis of this disease includes meticulous care of wounds, with early skin grafts when required and treatment of infections.

[Intraoperative serum parathyroid hormone measurement in the surgical treatment of hyperparathyroidism]. / Utilidad de las determinaciones intraoperatorias de la parathormona plasmática en la cirugía del hiperparatiroidismo.

BACKGROUND: PTH(1-84) short half life permits us to monitor parathyroidectomy efficacy, confirming complete resection after unilateral surgical approach in some cases of primary hyperparathyroidism. Nevertheless, this utility has been tested in controlled clinical trials and there is no agreement regarding the extraction of samples, their processing and interpretation of results. PATIENTS AND METHODS: In 18 consecutive patients operated on for primary or secondary hyperparathyroidism, serum PTH(1-84) concentrations were assessed at different times before, during and after partial (in 11 patients with multiglandular illness) and total resections. RESULTS: Initial PTH(1-84) concentrations very largely in different pre-resection samples, and these variations significantly affect post-resection percentage reduction. Plasmatic clearance of PTH(1-84) after incomplete resection follows a decreasing exponential curve towards new equilibrium concentrations. The difference is significant comparing with concentrations following complete resection only 5 minutes after, but the 95% intervals with a confidence level of 90% of confidence are exclusive only for determinations after 120 minutes. CONCLUSIONS: The decrement of serum PTH(1-84) concentrations to 20% of the preresection levels 120 minutes after an adenomectomy confirms the complete removal of all pathologic parathyroid tissue. A less sharp decrement must be investigated and may justify an early surgical revision.

Pathologic intrathyroidal parathyroid glands.

BACKGROUND: Parathyroid glands originate from the third and fourth branchial pouches and migrate caudally to their final positions. Aberrations during migration result in anomalous locations. Intrathyroidal location is not common. METHODS: We reviewed cervical explorations performed from 1974 to 1993 in hyperparathyroidism patients. RESULTS: We found pathological intrathyroidal glands in six patients. Three patients had adenomas (left superior, left inferior and right inferior glands). The hyperplastic glands were left inferior in one patient and right inferior in the remaining two. Intraoperative diagnosis was made in three cases in which palpation of the thyroid gland showed a nodule that was suspected to be the parathyroid missing gland. In three patients it was a finding in thyroidectomy or hemithyroidectomy specimens, two of them with associated thyroid nodular disease. CONCLUSIONS: Ipsilateral thyroidotomy on the side of a palpable thyroid mass or blind hemithyroidectomy are justified if a presumably pathological intrathyroidal gland is suspected, when all other sites in the neck have been excluded.

Phase transitions in nuclei and chromatin. Is nuclear volume controlled by the chromatin or by the nuclear matrix?

Changes in the volume of rat liver nuclei have been monitored as a function of modifications in ionic environment (from 0 to 20 mM), temperature (from 4 to 37 degrees C), and pH (from 1 to 8). An abrupt reduction of nuclear volume occurred with increasing ion concentration, this contraction being more pronounced with bivalent (either Ca2+ or Mg2+) than with monovalent (either Na+ or K+) cations. The lowering of pH produced a similar effect. Parallel changes in chromatin structure took place at the same time as phase-like transitions. Atomic absorption spectroscopy allowed determination of free and nuclei-bound ions, pointing to the presence of a sizeable number of free binding sites for chromatin-DNA even within intact nuclei. DNA-phosphate sites appear to be neutralized by ions strictly according to the size of the electric charge and polyelectrolyte theory. Partial digestion (by micrococcal nuclease) or simple breaks (by chemical carcinogens) of the chromatin-DNA fiber caused respectively elimination or reduction of the abrupt volume changes in the intact nuclei. The apparent role of chromatin structure versus nuclear matrix in determining the shape and volume of intact nuclei is briefly discussed.