Diagnostic accuracy of symptoms as a diagnostic tool for SARS-CoV 2 infection: a cross-sectional study in a cohort of 2,173 patients.

BACKGROUND: The SARS-CoV-2 pandemic continues to be a priority health problem; According to the World Health Organization data from October 13, 2020, 37,704,153 confirmed COVID-19 cases have been reported, including 1,079,029 deaths, since the outbreak. The identification of potential symptoms has been reported to be a useful tool for clinical decision-making in emergency departments to avoid overload and improve the quality of care. The aim of this study was to evaluate the performances of symptoms as a diagnostic tool for SARS -CoV-2 infection. METHODS: An observational, cross-sectional, prospective and analytical study was carried out, during the period of time from April 14 to July 21, 2020. Data (demographic variables, medical history, respiratory and non-respiratory symptoms) were collected by emergency physicians. The diagnosis of COVID-19 was made using SARS-CoV-2 RT-PCR. The diagnostic accuracy of these characteristics for COVID-19 was evaluated by calculating the positive and negative likelihood ratios. A Mantel-Haenszel and multivariate logistic regression analysis was performed to assess the association of symptoms with COVID-19. RESULTS: A prevalence of 53.72% of SARS-CoV-2 infection was observed. The symptom with the highest sensitivity was cough 71%, and a specificity of 52.68%. The symptomatological scale, constructed from 6 symptoms, obtained a sensitivity of 83.45% and a specificity of 32.86%, taking ≥2 symptoms as a cut-off point. The symptoms with the greatest association with SARS-CoV-2 were: anosmia odds ratio (OR) 3.2 (95% CI; 2.52-4.17), fever OR 2.98 (95% CI; 2.47-3.58), dyspnea OR 2.9 (95% CI; 2.39-3.51]) and cough OR 2.73 (95% CI: 2.27-3.28). CONCLUSION: The combination of ≥2 symptoms / signs (fever, cough, anosmia, dyspnea and oxygen saturation < 93%, and headache) results in a highly sensitivity model for a quick and accurate diagnosis of COVID-19, and should be used in the absence of ancillary diagnostic studies. Symptomatology, alone and in combination, may be an appropriate strategy to use in the emergency department to guide the behaviors to respond to the disease. TRIAL REGISTRATION: Institutional registration R-2020-3601-145, Federal Commission for the Protection against Sanitary Risks 17 CI-09-015-034, National Bioethics Commission: 09 CEI-023-2017082 .

Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico.

BACKGROUND: Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources. METHODS: A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question. RESULTS: From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made. CONCLUSIONS: This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

[Vaginal evisceration. Report of a case and a literature review]. / Evisceración vaginal. Informe de un caso y revisión de la bibliografía.

BACKGROUND: Vaginal evisceration is a rare event associated to be associated with several factors. In premenopausal women it is often associated with trauma during intercourse, rape, iatrogenic injury and introduction of foreign objects. In postmenopausal women 73% of cases are associated with previous vaginal surgery or hysterectomy. CASE REPORT: Here we present the case of a female patient who had a vaginal evisceration six days after an abdominal hysterectomy. The patient underwent an abdominal reduction of the small bowel, but due to irreversible vascular compromise it was resected. The vaginal cuff was closed with interrupted non-absorbable sutures. CONCLUSION: Vaginal evisceration is a rare disease associated with pelvic surgery. When it happens, it should be addressed as an emergency. The abdominal approach is the choice when there is trauma or intestinal ischemia, while the combined vaginal with laparoscopic approach is a good option in selected patients.

[Vitamin D and its positive effect on the PTH/vitamin D/calcium-FGF23/klotho/phosphorus axis in kidney transplant recipients]. / Vitamina D y su efecto positivo sobre el eje PTH/vitamina D/calcio-FGF23/klotho/fósforo en pacientes con trasplante renal.

Introduction: Background: hypovitaminosis D is frequent in kidney transplant recipient (KTR) patients and is associated with deleterious effects both at the bone and extraosseous levels. Treatment with cholecalciferol is effective for the normalization of 25(OH)D, demonstrating a beneficial effect on the calcium-tropic axis in other populations; however, its effect on the PTH/vitamin D/calcium and FGF23/klotho/phosphorus axis in RTR has not been reported. The aim of this study was to evaluate the effect of normalization of serum 25(OH)D concentrations on the PTH/vitamin D/calcium-FGF23/klotho/phosphorus axis in KTR treated with cholecalciferol, as well as the association between the components of this axis. Methods: a prospective study in 23 KTR with hypovitaminosis D, with evolution from 1 to 12 months post-transplantation, an estimated glomerular filtration rate > 60 mL/min/1.73 m2 and a history of primary nephropathy treated with cholecalciferol, in whom the PTH/vitamin D/calcium and FGF23/klotho/phosphorus axis was evaluated during the state of hypovitaminosis D and at normalization of 25(OH)D. Results: at the normalization of 25(OH)D, a reduction in PTH [103 (58.5-123.9) vs 45.6 (30.1-65.1) pg/mL; p = 0.002] and an increase in serum phosphorus [3.1 (2.3-3.5) vs 3.3 (3-3.6) mg/dL; p = 0.01] were evident, with no differences in calcium, klotho and FGF23 concentrations. The time to achieve normalization of 25(OH)D was 12 weeks (RIC, 4-12), with a dose of 5000 IU/day (RIC, 4000-6000). A positive association between klotho and PTH was corroborated (r = 0.54; p = 0.008; linear regression, ß = 0.421; B = 0.004; 95 % CI, 0.003-0.007; p = 0.045). Conclusions: treatment with cholecalciferol is effective for the normalization of 25(OH)D, with a beneficial effect on calcium-phosphotropic metabolism characterized by a reduction in PTH concentration, without significant changes in calcemia or calciuria, as well as an increase in phosphatemia, without modifications in FGF23 or klotho concentrations.

Introducción: Introducción: la hipovitaminosis D es frecuente en los receptores de trasplante renal (RTR) y se asocia con efectos deletéreos tanto a nivel óseo como extraóseo. El tratamiento con colecalciferol es eficaz para la normalización de la 25(OH)D, demostrándose un efecto benéfico sobre el eje calciotrópico; sin embargo, su efecto sobre el eje fosfotrópico no se ha reportado. El objetivo de este estudio fue evaluar el efecto de la normalización de las concentraciones séricas de 25(OH)D sobre el eje PTH/vitamina D/calcio-FGF23/klotho/fósforo en RTR tratados con colecalciferol, así como la asociación entre sus componentes. Métodos: estudio prospectivo en 23 RTR con hipovitaminosis D y antecedente de nefropatía primaria tratados con colecalciferol, en quienes se evaluó el eje PTH/vitamina D/calcio y FGF23/klotho/fósforo durante el estado de hipovitaminosis D y a la normalización de la 25(OH)D. Resultados: a la normalización de la 25(OH)D se evidenció una reducción de la PTH [103 (58,5-123,9) vs. 45,6 (30,1-65,1) pg/mL; p = 0,002] y un aumento del fósforo sérico [3,1 (2,3-3,5) vs. 3,3 (3-3,6) mg/dL; p = 0,01], sin diferencias en las concentraciones de calcio, klotho y FGF23. El tiempo para lograr la normalización de la 25(OH)D fue de 12 semanas (4-12), con una dosis de 5000 UI/día (4000-6000). Se corroboró una asociación positiva entre klotho y PTH (r = 0,54; p = 0,008; regresión lineal, ß = 0,421; IC 95 %: 0,003-0,007; p = 0,045). Conclusiones: el tratamiento con colecalciferol es eficaz para la normalización de la 25(OH)D con un efecto benéfico sobre el metabolismo calcio-fosfotrópico caracterizado por una reducción de la PTH y un incremento de la fosfatemia, sin modificaciones de calcemia, calciuria, FGF23 o klotho.

Evaluation of predictive value of olfactory dysfunction, as a screening tool for COVID-19.

OBJECTIVES: At the end of 2019, SARS-CoV-2 was identified, the one responsible for the COVID-19 disease. Between a 5.1% and a 98% of COVID-19 patients present some form of alteration in their sense of smell. The objective of this study is to determine the diagnostic yield of the smell dysfunction as screening tool for COVID-19. METHODS: Cross-sectional, observational, and pro-elective study was performed in a tertiary care hospital from May 25th to June 30th, 2020. One hundred and thirty-nine patients were included in the study. Demographic characteristics were collected from anamnesis. A Self-Perception Questionnaire and psychophysical olfactory test (POT) were applied to all participants. The presence of SARS-CoV2, was detected by RT-PCR methods. RESULTS: 51.7% of patients were SARS-CoV-2 positive. A sensitivity of 50% was obtained for the self-perception questionnaire as a screening tool for SARS-CoV2, with a specificity of 80.59%. The positive predictive value (PPV) was of 73.46%, the negative predictive value (NPV) was of 60%. The POT as a screening tool had a PPV of 82.35%, a NPV of 52.45%, a LR+ of 4.34, a LR- 0.84. The combination of anosmia (according to the POT) plus cough and asthenia got an OR of 8.25 for the SARS CoV-2 infection. CONCLUSION: There is a strong association between olfactory dysfunction and COVID-19. However, it is not really efficient in the screening of SARS-CoV-2 infection and thus, they should not be considered as a single diagnostic instrument. LEVEL OF EVIDENCE: 4.

High Serum Levels of High-Mobility Group Box 1 (HMGB1) and Low Levels of Heat Shock Protein 70 (Hsp70) are Associated with Poor Prognosis in Patients with Acute Pancreatitis.

INTRODUCTION: Cell damage in Acute Pancreatitis (AP) lead to release of cytokines and HMGB1 and Hsp70. While Hsp70 plays a role in cytoprotection, when released to extracellular milieu constitutes, as HMGB1, a danger signal and trigger pro-inflammatory responses. These molecules seem to be related to the clinical progression; but because no evidence exists about them as molecular network in AP development, we quantify HSP70, HMGB1, and cytokines in patients with AP and search for correlations with severity and prognosis. METHODS: Fifteen patients with AP were included. The average age was 52 years. Six patients had mild pancreatitis, 4 were moderately severe and 5 with a severe form. Blood samples were taken within the first 24 h, at 3d and 7d from the start. Serum HMGB1 and Hsp70 were determined using ELISA; TNF-α, IL-1ß, IL-6, IL-8, IL-10 and IL-12p70 were determined by bead based immuassay. RESULTS: Of all 15 patients recruited, 4 were women. Eight patients had APACHEII score higher than 8. Two patients died from AP related complications. Increase in serum HMGB1 and decrease of Hsp70 were associated with the severity and mortality. TNF-α, IL-6 and IL-8 were higher in patients that did not survive, in those with an APACHE II >8, and in those with severe AP. CONCLUSIONS: High HMGB1 and low Hsp70 were associated with poor prognosis. Hsp70 might play a protective role in AP. TNF-α, IL-6, IL-8, HMGB1 and Hsp70 during hospital admissions might serve to evaluate risk of death due to AP.

Vitamina D y su efecto positivo sobre el eje PTH/vitamina D/calcio-FGF23/klotho/fósforo en pacientes con trasplante renal / Vitamin D and its positive effect on the PTH/vitamin D/calcium-FGF23/klotho/phosphorus axis in kidney transplant recipients

Introducción: la hipovitaminosis D es frecuente en los receptores de trasplante renal (RTR) y se asocia con efectos deletéreos tanto a nivel óseo como extraóseo. El tratamiento con colecalciferol es eficaz para la normalización de la 25(OH)D, demostrándose un efecto benéfico sobre el eje calciotrópico; sin embargo, su efecto sobre el eje fosfotrópico no se ha reportado. El objetivo de este estudio fue evaluar el efecto de la normalización de las concentraciones séricas de 25(OH)D sobre el eje PTH/vitamina D/calcio-FGF23/klotho/fósforo en RTR tratados con colecalciferol, así como la asociación entre sus componentes. Métodos: estudio prospectivo en 23 RTR con hipovitaminosis D y antecedente de nefropatía primaria tratados con colecalciferol, en quienes se evaluó el eje PTH/vitamina D/calcio y FGF23/klotho/fósforo durante el estado de hipovitaminosis D y a la normalización de la 25(OH)D. Resultados: a la normalización de la 25(OH)D se evidenció una reducción de la PTH [103 (58,5-123,9) vs. 45,6 (30,1-65,1) pg/mL; p = 0,002] y un aumento del fósforo sérico [3,1 (2,3-3,5) vs. 3,3 (3-3,6) mg/dL; p = 0,01], sin diferencias en las concentraciones de calcio, klotho y FGF23. El tiempo para lograr la normalización de la 25(OH)D fue de 12 semanas (4-12), con una dosis de 5000 UI/día (4000-6000). Se corroboró una asociación positiva entre klotho y PTH (r = 0,54; p = 0,008; regresión lineal, β = 0,421; IC 95 %: 0,003-0,007; p = 0,045). (AU)

Background: hypovitaminosis D is frequent in kidney transplant recipient (KTR) patients and is associated with deleterious effects both at the bone and extraosseous levels. Treatment with cholecalciferol is effective for the normalization of 25(OH)D, demonstrating a beneficial effect on the calcium-tropic axis in other populations; however, its effect on the PTH/vitamin D/calcium and FGF23/klotho/phosphorus axis in RTR has not been reported. The aim of this study was to evaluate the effect of normalization of serum 25(OH)D concentrations on the PTH/vitamin D/calcium-FGF23/klotho/phosphorus axis in KTR treated with cholecalciferol, as well as the association between the components of this axis. Methods: a prospective study in 23 KTR with hypovitaminosis D, with evolution from 1 to 12 months post-transplantation, an estimated glomerular filtration rate > 60 mL/min/1.73 m2 and a history of primary nephropathy treated with cholecalciferol, in whom the PTH/vitamin D/calcium and FGF23/klotho/phosphorus axis was evaluated during the state of hypovitaminosis D and at normalization of 25(OH)D. Results: at the normalization of 25(OH)D, a reduction in PTH [103 (58.5-123.9) vs 45.6 (30.1-65.1) pg/mL; p = 0.002] and an increase in serum phosphorus [3.1 (2.3-3.5) vs 3.3 (3-3.6) mg/dL; p = 0.01] were evident, with no differences in calcium, klotho and FGF23 concentrations. The time to achieve normalization of 25(OH)D was 12 weeks (RIC, 4-12), with a dose of 5000 IU/day (RIC, 4000-6000). A positive association between klotho and PTH was corroborated (r = 0.54; p = 0.008; linear regression, β = 0.421; B = 0.004; 95 % CI, 0.003-0.007; p = 0.045). (AU)

[Lumbar hernia. Case report and literature review]. / Hernia lumbar. Informe de un caso y revisión de la literatura.

BACKGROUND: Lumbar hernia is a rare abdominal wall defect that usually presents spontaneously after trauma or lumbar surgery or, less frequently, during infancy (congenital). Few reports have been published in the literature describing congenital lumbar hernia. CASE REPORT: We present the case of a patient with congenital lumbar hernia and a review describing the regional anatomy, laparoscopic techniques as a surgical alternative, and the impact of modern imagenology in diagnosis, confirmation and demarcation of the aponeurotic defect, in order to update information and to provide the surgeon with the tools for optimal perioperative preparation and the best operative technique for this rare disease. We describe here the case of a 5-month-old Mexican female infant with a right lumbar bulging. Ultrasonographic findings showed an aponeurotic defect and an ipsilateral renal agenesia. Open surgical repair was carried out with identification of the defect in the superior or Grynfellt-Lesshaft's triangle and the inferior triangle as well, and a polypropylene mesh was placed below the posterior abdominal sheath. CONCLUSIONS: Congenital lumbar hernia usually originates in the superior triangle or Grynfellt-Lesshaft's triangle and is frequently associated with the lumbocostovertebral syndrome. Surgery is always indicated, with utilization of prosthetic material or muscular flaps as the best repair technique.

[Answer to comment on article "Acute appendicitis. Surgical and non surgical treatment"]. / Respuesta a comentario al artículo "Apendicitis aguda. Manejo quirúrgico y no quirúrgico".

No abstract.

Sin abstract.

Subclavian central venous catheter, complications at insertion / Catéter venoso central subclavio, complicaciones a la inserción

Background: Central Venous Catheters (CVC) are used as a tool in critically ill patients requiring hemodynamic monitoring and vasopressor support, as well as in stable patients requiring parenteral nutrition or chemotherapy. Placement of a CVC subclavian (CVCs) can present severe complications, even fatal. The aim of the present study was to determine the success of the placement of CVCs without ultrasonographic guidance and the number and type of complications associated with insertion. of these. Methods: In this retrospective cohort study we included all patient who were submitted to CVCs at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI. The variables studied were: medical indication for the placement, insertion site, duration, withdrawal motive and if there were complications type number and management of these. Results: 283 patients aged 16-95 years were studied. Fifty-five percent of the patients had already had a catheter placed during a previous hospitalization. In 45% of the patients was the first placement, the antecedent of a previous placement did not increase the complications. The indications for the CVCs were: NPT, preoperative use, severe patients, chemotherapy, inability to channel, and plasmapheresis. Conclusions: Placement of a subclavian central venous catheter by trained personnel in patients without risk factors and even without ultrasonographic support is safe and effective, with a success rate of close to 100% in placement, severe complications below 2%, and zero mortality. If the attempts are reduced to two punctures the morbidity can be reduced to almost zero.

Introducción: Los catéteres venosos centrales (CVC) son utilizados tanto en pacientes gravemente enfermos que ameritan monitorización hemodinámica y apoyo vasopresor, como en pacientes estables que requieren nutrición parenteral o quimioterapia. La colocación de un CVC subclavio (CVCs) puede presentar complicaciones severas incluso mortales. El objetivo del presente estudio fue determinar el éxito de la colocación de CVCs sin guía ultrasonográfica y el número y tipo de complicaciones asociadas a la inserción de estos. Métodos: Estudio de cohorte retrospectivo, que incluyó a todos los pacientes a los cuales se les colocó un CVCs en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI. Las variables estudiadas fueron: indicación médica para la colocación, sitio de inserción, duración, motivo de retiro y si se presentaron complicaciones. Resultados: Se estudió a un total de 283 pacientes de 16 a 95 años. En el 45% de los pacientes fue la primera colocación, el antecedente de una colocación previa no aumento las complicaciones. Las indicaciones para el CVCs fueron: nutrición parenteral, uso prequirúrgico, pacientes graves, quimioterapia, incapacidad para canalizar y plasmaféresis. Conclusiones: La colocación de un CVCs por personal capacitado en pacientes sin factores de riesgo y aun sin apoyo ultrasonográfico es segura y eficaz, con complicaciones graves menores al 2% y sin mortalidad. Si los intentos se reducen a dos punciones, la morbilidad puede reducirse aún más.

[Acute appendicitis. Surgical and non-surgical treatment]. / Apendicitis aguda. Manejo quirúrgico y no quirúrgico.

Appendicitis represents a common disease for the surgeon with a relative risk between 7-8%. It was thought that if more time passed between diagnosis and treatment, the risk for complications, such as perforation or abscess formation, was higher; nevertheless; the evolution is variable, making necessary the development of different strategies such as antibiotic use only, interval surgery or endoscopic treatment. The purpose of this study is to make a revision in the management of appendicitis comparing conservative and surgical treatment. It is known that traditional management of appendicitis is appendectomy with a complication rate of 2.5% to 48%. Nowadays, laparoscopy is the approach of choice by many surgeons and there have proposed new invasive techniques such as endoscopic treatment with the use of prosthesis and ambulatory surgery. Antibiotic use is essential in the management of appendicitis. Its use as the only strategy to treat this disease has the purpose of lowering costs and diminishing complications related to surgery or the resection of the organ. We conclude that the ideal management of appendicitis remains controversial and it will depend of the clinical characteristics of each patient and the resources available.

La apendicitis es una urgencia común para el cirujano. El riesgo estimado para presentarla es de 7-8%. Se pensaba que la apendicitis era un continuo donde, mientras más tiempo pasaba entre el inicio de síntomas y el tratamiento, el riesgo de complicaciones (necrosis, perforación y formación de abscesos) era mayor; sin embargo, la evolución es variable por lo que se han propuesto estrategias terapéuticas como el uso de antibióticos, cirugía de intervalo o tratamiento endoscópico. El objetivo de este estudio es hacer una revisión de la literatura acerca del manejo de apendicitis comparando manejo quirúrgico y conservador. Es sabido que el manejo tradicional para apendicitis es la apendicectomía, con tasa de complicación del 2.5 hasta el 48%. El abordaje ha cambiado de abierto a laparoscópico y han surgido nuevas técnicas invasivas como el manejo endoscópico con endoprótesis y la cirugía ambulatoria. El manejo antibiótico es esencial en apendicitis y su uso como terapia única en apendicitis tiene como objetivo disminuir la morbilidad asociada al evento quirúrgico, a la resección del órgano y a disminuir costos. Nuestra conclusión es que el manejo adecuado de la apendicitis es controversial y dependerá del estado clínico del paciente y de los recursos con que se dispongan.

[Persistent elevation of Ca 19-9 and an unexpected finding. A case report]. / Elevación persistente de Ca 19-9 y un hallazgo inesperado. Reporte de un caso.

BACKGROUND: Tumour markers are substances produced by the tumour itself, or by the host in response to a tumour. These markers could be measured either in the blood or in body secretions. One of the most common tumour markers used in gastrointestinal diseases is Ca 19-9. It is the marker most used for pancreatic cancer, but can be elevated in many benign processes. Thus, it is not a specific marker. CLINICAL CASE: The case is presented of a male patient with 4 years of moderate abdominal pain, weight loss, and persistent elevation of Ca 19-9. After an extensive work-up, renal and hepatic cysts were found, as well as steatosis and, apparently, a gallbladder polyp. With these findings and the persistent elevation of Ca 19-9, it was decided to operate the patient. An exploratory laparoscopy was performed showing multiple, yellowish nodular lesions all over the hepatic surface suggestive of metastases, as well as simple hepatic cysts. Pathology reported biliary hamartomas, steatosis, and chronic cholecystitis. After 2years of follow up, although there is no evidence of malignant neoplasia, there is still an elevation of Ca 19-9. CONCLUSION: The persistent elevation of Ca 19-9 is probably due to the presence of multiple benign diseases such as steatosis, urolithiasis, hepatic and renal cysts, and cholecystitis. An algorithm is needed for healthy patients with elevated levels of Ca 19-9 marker, in order to lower costs, avoid misdiagnoses, and improve management.

[Disseminated peritoneal hydatidosis manifested as intestinal ischaemia]. / Hidatidosis peritoneal diseminada manifestada como isquemia intestinal.

BACKGROUND: The hydatid disease, or echinococcosis, is endemic in Mediterranean countries, as well as in Australia, Asia, Africa, South America, and Canada. Among its complications is intraperitoneal rupture, a rare form of presentation, with highly variable symptoms. The treatment of choice is surgery plus adjuvant medical treatment in most patients. OBJECTIVE: A case is presented of a patient with disseminated peritoneal hydatidosis manifested as intestinal ischaemia. CLINICAL CASE: A 50-year-old male was admitted to the emergency room with a history of chronic abdominal pain that worsened in the last 24hours. He showed signs of sepsis in the physical examination and was subjected to surgery, in which intestinal ischaemia was found due to a disseminated peritoneal cystic disease, which had led to mesentery retraction. An intestinal resection with an end-ileostomy was performed. The results of the biopsy of the cystic lesions was disseminated peritoneal echinococcosis. Medical treatment was started with albendazole and praziquantel. CONCLUSION: This case shows a rare presentation of disseminated peritoneal hydatidosis, which led to intestinal ischaemia.

Management of acute bacterial skin and skin structure infections with a focus on patients at high risk of treatment failure.

Over the last 25 years, the terminology of skin and soft tissue infections, as well as their classification for optimal management of patients, has changed. The so-called and recently introduced term 'acute bacterial skin and skin structure infections' (ABSSSIs), a cluster of fairly common types of infection, including abscesses, cellulitis, and wound infections, require an immediate effective antibacterial treatment as part of a timely and cautious management. The extreme level of resistance globally to many antibiotic drugs in the prevalent causative pathogens, the presence of risk factors of treatment failure, and the high epidemic of comorbidities (e.g. diabetes and obesity) make the appropriate selection of the antibiotic for physicians highly challenging. The selection of antibiotics is primarily empirical for ABSSSI patients which subsequently can be adjusted based on culture results, although rarely available in outpatient management. There is substantial evidence suggesting that inappropriate antibiotic treatment is given to approximately 20-25% of patients, potentially prolonging their hospital stay and increasing the risk of morbidity and mortality. The current review paper discusses the concerns related to the management of ABSSSI and the patient types who are most vulnerable to poor outcomes. It also highlights the key management time-points that treating physicians and surgeons must be aware of in order to achieve clinical success and to discharge patients from the hospital as early as possible.

Effect of Oral ω3-Polyunsaturated Fatty Acids as a Complement Management to Control Fistula Output and Inflammation in Patients With Digestive Fistula.

BACKGROUND: The presence of digestive fistula involves chronic inflammation and fibrosis. It has been reported that ω3-polyunsaturated fatty acids stimulate the resolution of inflammation. AIM: Determine if the administration of oral ω3 reduces fistula output and the time required for fistula closure. METHODS: Forty-nine patients with postoperative fistula were randomly divided in two groups: 26 received conventional treatment and 23 received the conventional treatment supplemented with ω3 (540 mg eicosapentaenoic acid and 360 mg docosahexaenoic acid) for 35 days. Patients were monitored daily for fistula output and spontaneous closure. Additionally, serum pro-inflammatory cytokines and C-reactive protein were quantified in four patients with conventional and in seven patients with ω3 treatment. RESULTS: Patients with ω3 had significantly decreased fistula output from days 2 to 27, compared to control (p < 0.05). Spontaneous fistula closure was achieved in 15 patients (65%) in the ω3 group and in 14 (54%) in the control group. ω3-polyunsaturated fatty intake also decreased the serum concentrations of interleukin-6 and C-reactive protein (p < 0.05). CONCLUSIONS: Our results suggest that ω3 supplementation to conventional medical treatment decreases fistula output and reduces inflammation (interleukin-6 and C-reactive protein), and these effects may increase the efficiency of conventional medical treatment.

[Obscure gastrointestinal bleeding due to gastrointestinal stromal tumors]. / Hemorragia gastrointestinal de origen oscuro por tumores de estroma gastrointestinal.

BACKGROUND: The gastrointestinal stromal tumours (GIST) are the most common soft tissue sarcomas of the digestive tract. They are usually found in the stomach (60-70%) and small intestine (25-30%) and, less commonly, in the oesophagus, mesentery, colon, or rectum. The symptoms present at diagnosis are, gastrointestinal bleeding, abdominal pain, abdominal mass, or intestinal obstruction. The type of symptomatology will depend on the location and size of the tumour. The definitive diagnosis is histopathological, with 95% of the tumours being positive for CD117. CLINICAL CASES: This is an observational and descriptive study of 5cases of small intestinal GIST that presented with gastrointestinal bleeding as the main symptom. The period from the initial symptom to the diagnosis varied from 1 to 84 months. The endoscopy was inconclusive in all of the patients, and the diagnosis was made using computed tomography and angiography. Treatment included resection in all patients. The histopathological results are also described. CONCLUSION: GIST can have multiple clinical pictures and unusual symptoms, such as obscure gastrointestinal bleeding. The use of computed tomography and angiography has shown to be an important tool in the diagnosis with patients with small intestine GISTs.

[Surgical treatment of pancreatic pseudocysts]. / Tratamiento quirúrgico del seudoquiste de páncreas.

BACKGROUND: A pancreatic pseudocyst is the collection of pancreatic secretions surrounded by fibrous tissue caused by pancreatic disease that affects the pancreatic duct. Clinical presentation is variable. Management includes percutaneous, endoscopic or surgical drainage and resection. MATERIAL AND METHODS: Review of a cohort of patients with pancreatic pseudocyst in a third level hospital. An analysis was performed on the demographic data, aetiology, clinical presentation, radiological and laboratory findings, type of surgical procedure, complications, recurrence and mortality. The statistical analysis was performed using Chi squared and Student t tests, with a p<0.05. RESULTS: A total of 139 patients were included, of whom 58% were men and 42% were women, with median age of 44.5 years. Chronic pancreatitis was the most common aetiology, present in 74 patients (53%). The main complaint was abdominal pain in 73% of patients. Median size was 18cm (range 7-29) and the most frequent location was body and tail of the pancreas. Internal surgical drainage was selected in 111 (80%) patients, of whom 96 were cystojejunostomy, 20 (14%) had external surgical drainage, and 8 (6%) resection. Complications were, pancreatic fistula (12%), haemorrhage (4%), infection (4%), and other non-surgical complications (4%). Complication rate was higher if the cause was chronic pancreatitis or if the management was external surgical drainage. Recurrence rate was 6%, and a mortality rate of 1%. CONCLUSION: Surgical management is a viable option for the management of pancreatic pseudocyst with a low complication and recurrence rate.

[Choledochal cyst during pregnancy. Report of 3 cases and a literature review]. / Quiste de colédoco y embarazo. Reporte de 3 casos y revisión de la bibliografía.

BACKGROUND: Choledochal cysts are rare. They usually present during childhood in women, but it can also be seen during pregnancy. Clinical signs and symptoms are obscured during this time, thus it can complicate the diagnosis and represent a life threatening complication for both the mother and the child. OBJECTIVE: To communicate the case of 3 pregnant patients with choledochal cyst. CLINICAL CASES: Three pregnant women in which choledochal cyst were diagnosed. Two developed signs of cholangitis. The first one underwent a hepatic-jejunostomy, but had an abortion and died on postoperative day 10. The second one had a preterm caesarean operation due to foetal distress and underwent a hepatic-jejunostomy 4 weeks later; during her recovery she had a gastric perforation and died of septic complications. The third one did not develop cholangitis or jaundice. She had an uneventful pregnancy and had a hepatic-jejunostomy 4 weeks later with good results. CONCLUSIONS: Management of choledochal cysts during pregnancy is related to the presence of cholangitis. When they do not respond to medical treatment, decompression of the biliary tree is indicated. Definitive treatment should be performed after resolution of the pregnancy.

[Bariatric surgery for pseudotumor cerebri. Case report]. / Tratamiento del pseudotumor cerebri con cirugia bariátrica. Reporte de un caso.

INTRODUCTION: We report here a case of a patient with pseudotumor cerebri (PTC) associated with morbid obesity. PTC, also called benign intracranial hypertension, is a known complication of morbid obesity with resolution by reduction of obesity. CLINICAL CASE: A 42-year-old female with morbid obesity and secondary PTC underwent a modified jejunocolonostomy. RESULTS: The patient has lost 43% of excess body weight and the intracranial pressure is normal. CONCLUSIONS: PTC is a benign pathology, and the cause may be morbid obesity. Bariatric surgery is useful in the management of these patients for the resolution of this disease.

[Relaparotomy on demand: factors related to mortality]. / Relaparotomía a demanda. Factores asociados a mortalidad.

OBJECTIVE: To assess the mortality related factors of patients after relaparotomy on demand. BACKGROUND: In some patients, a relaparotomy after a primary laparotomy will be necessary, most due to acute complications. The relaparotomy can be planned or on demand based on the evolution of the patient. Which of these approaches is better is still a matter of debate. MATERIAL AND METHODS: Thirty three patients underwent relaparatomy on demand in a general surgery unit. RESULTS: Of 51 relaparotomies, 98% were positive. Nineteen of the 33 patients died, resulting in a mortality rate of 58%. The factors associated with mortality were development of an intestinal fistula (p < 0.02), wound infection (p < 0.03), generalized peritonitis in the primary surgery (p < 0.001), urgent primary laparotomy (p < 0.003), development of multiple organ failure (p < 0.005), and respiratory insufficiency (p < 0.01). CONCLUSIONS: Laparotomy on demand is useful in the treatment of patients with abdominal sepsis; however, the mortality is still very high.