Does Surgeon Fatigue Influence the Results of Liver Transplantation?

BACKGROUND: Recently, there has been an attempt to relate fatigue of the surgical team according to the start time of the transplant surgery and the surgeon's activity during the week, with the morbidity and mortality of liver transplant recipients. If this relationship could be demonstrated, it would be desirable to reconsider organization of transplant surgical teams. METHODS: We carried out a retrospective study of 439 successive cases of adult hepatic transplant from 2012 to 2016. We divided the patients into 2 groups, bearing in mind the interval between transplant procedures. Solitary liver transplantation was defined when >12 hours had elapsed since the last transplant, and consecutive liver transplant was defined when <12 hours had passed since the previous transplant. We analyzed the morbidity and mortality of the recipient (survival, vascular and biliary complications, early bleeding, and duration of surgery). Fatigue was measured as it related to the start time of the transplant, day of the week, and accumulation of daily and weekly activity of the surgical teams. RESULTS: No significant differences were found between the 2 groups with regard to donor or recipient characteristics. No variable related to the fatigue of the surgeons had an effect on the survival, biliary and vascular complications, early bleeding, or duration of the surgical intervention. CONCLUSION: We were unable to show that fatigue level of the surgical team influences the results of transplant procedures. Morbidity and mortality are likely related to other factors.

Role of imaging techniques in the diagnosis and follow-up of muscle-invasive bladder carcinoma. / Papel de las técnicas de imagen en el diagnóstico y seguimiento del carcinoma vesical músculo invasivo.

INTRODUCTION: Muscle-invasive bladder malignancies represent 20-30% of all bladder cancers. These patients require imaging tests to determine the regional and distant staging. OBJECTIVE: To describe the role of various imaging tests in the diagnosis, staging and follow-up of muscle-invasive bladder cancer. To assess recent developments in radiology aimed at improving the sensitivity and specificity of local staging and treatment response. ACQUISITION OF EVIDENCE: We conducted an updated literature review. SYNTHESIS OF THE EVIDENCE: Computed tomography and magnetic resonance imaging (MRI) are the tests of choice for performing proper staging prior to surgery. Computed tomography urography is currently the most widely used technique, although it has limitations in local staging. Ultrasonography still has a limited role. Recent developments in MRI have improved its capacity for local staging. MRI has been suggested as the test of choice for the follow-up, with promising results in assessing treatment response. Positron emission tomography could improve the detection of adenopathies and extrapelvic metastatic disease. CONCLUSIONS: Imaging tests are essential for the diagnosis, staging and follow-up of muscle-invasive bladder cancer. Recent technical developments represent important improvements in local staging and have opened the possibility of assessing treatment response.

[Primary biliary cirrhosis-autoimmune hepatitis overlap syndrome. Contribution of two new cases]. / Síndrome "overlap" hepatitis autoinmune-cirrosis biliar primaria. Aportación de dos nuevos casos.

The autoimmune hepatitis (AIH)-primary biliary cirrhosis (PBC) overlap syndrome is characterized for clinical, biochemical, immunological, and histological features overlapping those of AIH and PBC, whose pathogenesis and more appropriate treatment are unknown at present. We describe two new patients of this entity, which made debut with cholestasic acute hepatitis accompanied of hypergammaglobulinemia. In the first patient was demonstrated the presence of AMA, ASMA, and anti-LKM1 autoantibodies; and ANA in the second one. The histological findings showed changes suggestive of AIH and PBC. After the start of immunosuppressive treatment, associated to ursodeoxycholic acid in one patient, a successful outcome was observed.

Modifications of growth velocity and the insulin-like growth factor system in children with acute lymphoblastic leukemia: a longitudinal study.

The basis of impaired growth in children with acute lymphoblastic leukemia (ALL) is multifactorial, including the disease itself, infections, undernutrition, and adverse effects of therapy. Because growth is regulated by the GH-insulin-like growth factor (IGF) system, which may be altered in catabolic states, we studied serum IGF-I, free IGF-I, IGF-II, the IGF-binding proteins (IGFBP-1 to -3), and total and free acid-labile subunit (ALS) levels in 26 prepubertal children with ALL at diagnosis (n = 26) and 6 (n = 21), 12 (n = 21), 18 (n = 21), 24 (n = 20), 30 (n = 16), and 36 months (n = 16) after beginning treatment to investigate the effects of disease and therapy on this system and its relationship with growth in these patients. Intensive chemotherapy compromised growth, with a catch-up period beginning when maintenance therapy began and increased growth after stopping therapy. Weight increased 6 months after chemotherapy withdrawal, whereas the body mass index was increased both at 6 months after diagnosis and 6 months after therapy suppression. Serum IGF-I, IGF-II, IGFBP-3, and total and free ALS levels were significantly decreased at diagnosis. Normalization of IGF-II and IGFBP-3 occurred 6 months after diagnosis, and normalization of IGF-I and total and free ALS occurred 1 yr after terminating therapy. IGFBP-1 and IGFBP-2 levels were significantly increased at diagnosis and decreased after stopping therapy. Free IGF-I was elevated throughout the study. IGF and IGFBP-3 levels showed a close relationship to growth velocity at the end of chemotherapy, with this correlation remaining until at least 1 yr after therapy withdrawal. In conclusion, intensive chemotherapy compromises linear growth in prepubertal ALL patients, and this phenomenon is associated with alterations in the IGF system. However, when therapy is reduced or stopped, catch-up growth occurs, but various parameters of the GH-IGF axis remain impaired. This suggests the need for a longer period of follow-up to assess the long-term risks of therapy and disease on this system.

Anthropometric parameters and their relationship to serum growth hormone-binding protein and leptin levels in children with acute lymphoblastic leukemia: a prospective study.

OBJECTIVE: The aim of this study was to follow auxological parameters and their relationship to serum growth hormone-binding protein (GHBP) and leptin levels in children with acute lymphoblastic leukemia (ALL). DESIGN AND METHODS: In total, 26 prepubertal children with ALL were studied. We report these data at the time of the clinical diagnosis (n=26) and at 6 (n=21), 12 (n=21), 18 (n=21), 24 (n=20), 30 (n=16) and 36 months (n=16) after beginning treatment. RESULTS: Serum GHBP levels decreased during the first 18 months and returned to normal when therapy was withdrawn. Height SDS increased at 24 months after diagnosis. Weight and the upper arm circumference had increased 6 months after chemotherapy withdrawal, whereas tricipital and subscapular skinfolds had increased both at 6 months after diagnosis and 6 months after therapy had stopped. Therefore, the tendency to become overweight is both an early and a late side-effect of anti-leukemia therapy. A significant positive correlation was found between serum leptin levels and every nutritional anthropometric parameter, with body mass index having the best relationship. However, serum GHBP levels were only correlated with BMI at the end of the study. No correlation was found between leptin and GHBP. CONCLUSIONS: In children with ALL, linear growth is compromised during the acute phase of their illness and therapy; this is probably secondary to a state of partial and transient GH insensitivity. These patients tend to become obese after therapy withdrawal, with leptin being an excellent nutritional marker.

Cleaning and disinfection of gastrointestinal endoscopes. Comparative analysis of two disinfectants.

UNLABELLED: Gastrointestinal endoscopy can lead to infectious complications, and endoscopes must be disinfected to prevent them. AIM: to evaluate three methods of disinfection: 1) usual cleaning technique and immersion in glutaraldehyde phenolate (GP); 2) meticulous cleaning and immersion in GP, and 3) meticulous cleaning and immersion in hydrogen peroxide. METHOD: thirty endoscopes (15 gastroscopes and 15 colonoscopes) were disinfected with each method. Samples were taken following endoscopic exploration, after cleaning and after disinfection, and were cultured. The number of positive culture (cfu/ml > 1) was counted. RESULTS: the rate of contamination of endoscopes did not decrease significantly after cleaning with method 1 (66 vs 60%), but did decrease with method 2 (38 vs 16%) and method 3 (53 vs 17%). The contamination rate after cleaning was significantly lower with methods 2 and 3 (p < 0.005). This rate was also lower after disinfection (p < 0.025). Method 3 achieved 0% contamination following disinfection. CONCLUSIONS: the greatest decrease in contamination rate was achieved with conscientious cleaning followed by disinfection. Both disinfectants yielded similar results, although hydrogen peroxide produced a higher level of disinfection.

[Cerebral abscesses. The clinical and evolutionary aspects of 17 cases treated surgically]. / Abscesos cerebrales. Aspectos clínicos y evolutivos de 17 casos intervenidos quirúrgicamente.

Seventeen cases of cerebral abscesses undergoing surgery were reviewed, underlying the characteristics of predisposing factors, infectious sources, microbiological and radiological studies, as well as clinical and evolutive aspects. The average age of the patients was 34 years, with a higher incidence in the second (35%) and sixth (22%) decades. The young patients (< 40 years) showed a greater frequency of adjacent infectious sources (83%) and the older patients (> 40 years), distant infectious sources (75%). The average time gap between the onset of symptoms and the diagnosis was 7 +/- 13 days. CAT showed in all the patients typical hypodense images with a peripheral ring; three patients had multiple abscesses and the remainder, single abscesses. In 12 patients (70.5%), microbiological cultures were positive, 3 (25%) for aerobe germs, 7 (50.3%) for anaerobe germs, 1 (8.33%) for multiple germs and 1 (8.33%) for fungi. Eleven patients underwent surgical drainage, four of which required latter exeresis. Six other patients underwent exeresis as the only surgical treatment. One patient died and the remainder showed a positive evolution. The hospital length of stay was 42.3 +/- 52.3 days. The most frequent sequela was the epilepsia present in 23.5% of the patients. Our findings are similar to the results of recent works, although in our series, there is a higher frequency of anaerobe germs. No differences were observed between the surgical techniques used nor between the past and current antibiotherapy patterns.

[Cryofibrinogenemia: apropos of a case]. / Criofibrinogenemia: a propósito de un caso.

We describe the case of a 70-years-old woman with ischemic-hemorrhagic lesions in the cutaneous surface of both feet and analytical data of disseminated intravascular coagulation, in which the studies conducted were negative except for the presence of cryofibrinogen in plasma. We also review the clinical manifestations and the diseases associated to cryofibrinogenemia previously described in the literature.

[Infection by Salmonella typhi in the southern area of Ponteverde]. / Infección por Salmonella typhi en el área sur de Pontevedra.

A retrospective study of patients infected by Salmonella typhi (ST) was conducted in the southern area of Pontevedra during a 17-month period in order to assess the clinical and evolutive characteristics and the pattern of antibiotic susceptibility of the infection. ST was isolated from samples of 30 patients: 25 hemocultures, 7 coprocultores, 1 urine and 1 aortic aneurysm. Nineteen cases had consumed non-sanitary controlled water, 95% from rural areas. The clinical characteristics were similar to the ones traditionally described. Seven patients (23%) developed complications and their presence was associated to a poorer prognosis. We did not observe any resistance to the commonly used antibiotics. In summary, the infection by ST is still a health problem in our environment, probably associated to insufficient measures in the enloration of water for human consumption.

Prenatal mercury exposure in a multicenter cohort study in Spain.

BACKGROUND: Mercury is a ubiquitous heavy metal that may negatively affect human health. It is desirable to investigate mercury exposure in vulnerable populations. OBJECTIVE: To determine the concentrations of total mercury (T-Hg) in cord blood and to evaluate the role of maternal fish consumption in a Spanish mother and child cohort. METHODS: A total of 1883 mother and child pairs from a population-based cohort were included between 2004 and 2008. T-Hg concentrations were measured in whole cord blood and maternal seafood consumption was ascertained by means of a food-frequency questionnaire. Linear regression was used in stratified analyses, while a joint model was adjusted using a mixed-effects linear model. RESULTS: Maternal daily seafood consumption was 78g/d and the geometric mean for T-Hg was 8.2µg/L. Maternal fish intake during pregnancy, mother's age, country of origin, educational level, employment status and parity, as well as area of study and season of delivery, were associated with cord blood T-Hg levels. A doubling in consumption of large oily fish was associated with an increase of 11.4% (95%CI: 3.8 to 19.6%) in cord blood T-Hg levels, followed by an increase of 8.4% (95%CI: 5.7 to 11.2%) in the case of canned tuna and 8.3% (95%CI: 5.5 to 11.1%) in that of lean fish. CONCLUSION: A high proportion of newborns had elevated concentrations of cord blood T-Hg according to the current US-EPA reference dose (5.8µg/L for methylmercury). Mercury concentrations were related to maternal fish consumption, with large oily fish being the main contributor.

[Spinal epidural abscess without spondylodiscitis. Description of four cases]. / Absceso epidural espinal sin espondilodiscitis. Descripción de cuatro casos.

We performed a retrospective study about patients diagnosed of spinal epidural abscess without concurrent spondylodiscitis, collected in the last five years in our hospital. We describe four patients, all of them males, with ages ranged from 59 to 67 years old. All patients presented fever, elevated phase reactants and spinal pain, with cord compression in three of them. Two patients had risk factors: diabetes mellitus and non-Hodgkin lymphoma. S. aureus was isolated in three patients, and S. agalactiae in the other one. The posterior epidural space was the most frequently affected, with variable location along the spinal cord. Three patients required surgical operation, and the other one was treated only with antibiotics. All patients demonstrated a complete clinical, analytical and radiological resolution.

Neurosyphilis in HIV-infected patients.

To determine the prevalence and the clinical and serological findings of neurosyphilis in HIV-infected patients, Treponema pallidum hemagglutination (TPHA) tests, CD4+ lymphocyte counts and determination of rapid plasma reagin (RPR) titers were performed in 972 HIV-infected patients over a period of 3.5 years. Patients were scored according to the Centers for Disease Control's classification for HIV infection. Reactive serum syphilis tests and positive cerebrospinal fluid (CSF)-Venereal Disease Research Laboratory (VDRL) tests, with or without clinical symptoms, were used as the criteria for diagnosis of neurosyphilis. The TPHA test was positive in 31 patients, representing 3.1% of all HIV-infected patients included in the study. Of these, 13 were intravenous drug addicts, 14 were homosexuals and 4 were heterosexuals. Diagnosis of syphilis was concurrent with HIV infection in 19 patients, prior to HIV infection in 6 patients and after HIV infection in 6 patients. CSF examinations were performed in 28 of the 31 (90.3%) patients with serologically evident syphilis. Four patients had positive CSF-VDRL tests with pleocytosis (23.5% of untreated syphilis patients in whom CSF was examined), three of whom reported mild headache, which was considered a doubtful manifestation of neurosyphilis. Patients with syphilis diagnosed and treated prior to diagnosis of HIV infection did not have evidence of neurosyphilis. Seven patients had pleocytosis with a negative CSF-VDRL test, without any clinical manifestations of neurosyphilis. There was no significant difference in the mean CD4+ lymphocyte count between patients with and without neurosyphilis (p = 0.5). RPR titers in neurosyphilis patients were greater than those in patients previously treated for syphilis and in those with pleocytosis only (p = 0.046 and 0.036, respectively). All neurosyphilis patients had an RPR titer > 1:8. After therapy, neurosyphilis patients had negative CSF-VDRL tests with a lower level of pleocytosis. The prevalence of neurosyphilis was 0.4% in HIV-infected patients and 23.5% in HIV-infected patients with untreated syphilis. This high prevalence of neurosyphilis warrants CSF examination in HIV-infected patients with syphilis, regardless of the stage of syphilis.

[Lack of human herpesvirus type 6 DNA in CSF by nested PCR among patients with multiple sclerosis]. / Ausencia de ADN de herpesvirus humano 6 en LCR, mediante técnica de PCR anidada, en pacientes con esclerosis múltiple.

BACKGROUND: The etiology of multiple sclerosis (MS) is currently unknown. Different viruses have tentatively been involved as causative agents of MS that would trigger an autoimmune response leading to demyelination plaques. There is controversy regarding the role that the human herpesvirus 6 (HHV-6) might play in this condition, and high antibody titers have been detected to HHV-6. HHV-6 DNA has also been detected by PCR both in blood and cerebrospinal fluid by means of the Polymerase Chain Reaction (PCR). Immunohistochemistry studies were performed with histologic specimens from the white matters of patientes with MS. All this has led some authors to incriminate this virus as the triggering etiologic agent of this disease. PATIENTS AND METHODS: CSF specimens from 23 patients with Relapsing-Remitting MS were studied. The CSF specimens from 23 patients undergoing rachianesthesia were used as controls, and none of them had neurologic disorders. A nested PCR was performed in the collected specimens to detect specific DNA sequences of HHV-6. RESULTS: No DNA sequences of HHV-6, EBV, VZV, CMV and HSV were detected in the tested specimens. CONCLUSIONS: No HHV-6 DNA sequences were detected from CSF specimens of patients with MS. Further investigations on the association between HHV-6 and MS should be performed to elucidate the role of HHV-6 in the pathogenesis of this disease.

Ascites adenosine deaminase activity is decreased in tuberculous ascites with low protein content.

The value of adenosine deaminase activity (ADA) in ascitic fluid was examined in 12 patients with confirmed peritoneal tuberculosis and compared with that of 96 patients with ascites of other different etiologies as an age-matched control group, to determine the diagnostic value of the ADA activity in tuberculous ascites. The mean adenosine deaminase activity (ADA) value in ascitic fluid of the tuberculous peritonitis group was 47.9 +/- 21.9 IU/L and in the control group 9.6 +/- 5 U/L (mean +/- SD); p less than 0.01. A different method than that usually reported in tuberculous peritonitis was used for ascites ADA estimation. The best sensitivity and specificity was obtained when greater than 32 U/L was used as a cutoff point. The ascites ADA activity correlated with the ascites total protein concentration in the tuberculosis group (r = 0.842). Our findings confirm other results and support the ADA activity determination in ascitic fluid as a useful noninvasive screening test in the diagnosis of peritoneal tuberculosis in endemic areas or in high risk patients. However, false-negative results may occur in those patients in which ascites total protein concentration is low.