La cirugía en el tratamiento de la crisis tirotóxica / Surgery for the Treatment of Thyrotoxic Crisis

RESUMEN La crisis tirotóxica es una complicación de la tirotoxicosis mal tratada y se asocia con una elevada mortalidad. Requiere tratamiento médico urgente en unidades de cuidados intensivos. Mujer de 42 años, con antecedentes personales de hipertensión arterial y nódulo tiroideo hiperfuncionante desde hace 18 años, con abandono del tratamiento médico hace dos años, que acude a urgencias con disnea paroxística nocturna, taquicardia, hipertensión arterial, gran bocio y anasarca. Ingresa en la unidad de cuidados intensivos con diagnóstico de crisis tirotóxica e inicia el tratamiento médico con medidas de soporte precisas, la que incluye intubación orotraqueal. Debido a la dificultad de manejo clínico y respiratorio de la paciente, se decide realizar tratamiento quirúrgico urgente. Se practica una tiroidectomía total de bocio multinodular parcialmente intratorácico y una traqueostomía preventiva. El resultado de anatomía patológica fue: bocio multinodular tóxico. La paciente fue dada de alta con función tiroidea normal, cierre de traqueostomía y buena fonación, tras mes y medio de hospitalización. A pesar de que un tratamiento médico conservador es el adecuado de la tirotoxicosis, los síntomas y signos sistémicos de la crisis tirotóxica y sus manifestaciones órgano-específicas, asociados a una persistente dificultad respiratoria por síntomas compresivos derivados del gran bocio, se consideró que la tiroidectomía urgente en este caso estaba indicada, dato que se corroboró ante la buena evolución posoperatoria. El tratamiento de la tirotoxicosis es fundamentalmente clínico, sin embargo, la cirugía puede ser útil ante la dificultad en el manejo clínico(AU)

Abstract The thyrotoxic crisis is a complication of poorly treated thyrotoxicosis and is associated with high mortality. This condition requires urgent medical treatment in intensive care units. A 42-year-old woman, with a personal history of high blood pressure, hyperfunctioning thyroid nodule for 18 years, and abandonment of medical treatment since two years ago, presented to the emergency department with paroxysmal nocturnal dyspnea, tachycardia, high blood pressure, large goiter, and anasarca. She was admitted into the intensive care unit with a diagnosis of thyrotoxic crisis and started to receive medical treatment under precise support measures, including orotracheal intubation. Due to the patient's difficult clinical and respiratory management, it was decided to perform urgent surgical treatment. She was performed a total thyroidectomy of partial intrathoracic multinodular goiter and a preventive tracheostomy. The result of pathological anatomy was toxic multinodular goiter. The patient was discharged with normal thyroid function, tracheostomy closure, and good phonation, after a month and a half of hospitalization. Despite the fact that conservative medical treatment is the adequate one for thyrotoxicosis, the systemic symptoms and signs of the thyrotoxic crisis, and its organ-specific manifestations, associated with persistent respiratory distress due to compression symptoms derived from large goiter, urgent thyroidectomy needed to be indicated in this case, a fact corroborated after good postoperative evolution. The treatment of thyrotoxicosis is fundamentally clinical; however, surgery can be useful given the difficulty in clinical management(AU)

Pediatric appendicitis: age does make a difference / Apendicite em pediatria: a idade é importante

ABSTRACT Objective: To investigate the influence of patient age on the diagnosis and management of appendicitis, as well as to evaluate the rate of complications according to the age group. Methods: We undertook a retrospective analysis of 1,736 children who underwent laparoscopic appendectomy in our center between January 2000 and December 2013. Patients were divided in groups taken into account their age: group A were infants, group B were preschoolers, group C were those ones older than five years old, and group D were those ones younger than five years old. A p value of 0.05 was considered statistically significant. Results: We found higher incidence of misdiagnosis and atypical symptoms in the youngest patients. The rate of perforation was similar between group A and B (p=0.17). However, it was higher in group D than in group C (p<0.0001). The incidence of postoperative complications was higher in the youngest patients too (p=0.0002). Conclusions: The age does make a difference in acute appendicitis. Because of its unusual presentation in children younger than five years old, it is often misdiagnosed, which leads to an increased morbidity. Although clinical presentation varies between infants and preschoolers, no statistically significant differences were observed in the rate of perforated appendix or postoperative complications.

RESUMO Objetivo: Investigar a influência da idade do paciente no diagnóstico e tratamento de apendicite, bem como avaliar a frequência de complicações dependendo da faixa etária. Métodos: Análise retrospectiva dos 1.736 pacientes pediátricos que foram submetidos à apendicectomia laparoscópica em nosso hospital de janeiro de 2000 a dezembro de 2013. Os pacientes foram divididos em grupos de acordo com sua idade: grupo A eram crianças, grupo B eram pré-escolares, grupo C eram maiores de cinco anos de idade e grupo D eram menores de cinco anos de idade. Considerou-se estatisticamente significante p-valor <0,05. Resultados: Encontramos maior incidência de diagnóstico incorreto e sintomas atípicos em pacientes mais novos. A taxa de perfuração foi semelhante entre os grupos A e B (p=0.17); foi maior, porém, no grupo D que no grupo C (p<0.0001). A incidência de complicações no pós-operatório também foi maior em pacientes mais novos (p=0.0002). Conclusões: A idade faz diferença em casos de apendicite aguda. Por causa da sua apresentação rara em crianças menores de cinco anos, é frequentemente diagnosticada incorretamente, o que aumenta a morbidade. Apesar de sua apresentação clínica variar entre lactentes e pré-escolares, não foram observadas diferenças estatisticamente significativas na proporção de apêndices perfurados nem na de complicações pós-operatórias.

PEDIATRIC APPENDICITIS: AGE DOES MAKE A DIFFERENCE.

OBJECTIVE: To investigate the influence of patient age on the diagnosis and management of appendicitis, as well as to evaluate the rate of complications according to the age group. METHODS: We undertook a retrospective analysis of 1,736 children who underwent laparoscopic appendectomy in our center between January 2000 and December 2013. Patients were divided in groups taken into account their age: group A were infants, group B were preschoolers, group C were those ones older than five years old, and group D were those ones younger than five years old. A p value of 0.05 was considered statistically significant. RESULTS: We found higher incidence of misdiagnosis and atypical symptoms in the youngest patients. The rate of perforation was similar between group A and B (p=0.17). However, it was higher in group D than in group C (p<0.0001). The incidence of postoperative complications was higher in the youngest patients too (p=0.0002). CONCLUSIONS: The age does make a difference in acute appendicitis. Because of its unusual presentation in children younger than five years old, it is often misdiagnosed, which leads to an increased morbidity. Although clinical presentation varies between infants and preschoolers, no statistically significant differences were observed in the rate of perforated appendix or postoperative complications.

Uso de packing preperitoneal en paciente politraumatizado / Use of preperitoneal packing in politraumatized patient

Objetivo Reportar un caso de grave fractura pélvica y sangrado masivo tratado inicialmente con packing pélvico. Caso clínico Paciente precipitado hemodinámicamente debido a varias fracturas abiertas, entre las que se incluye fractura pélvica con importante diástasis púbica. Se decide intervención quirúrgica procediendo a fijación externa de la pelvis, y posteriormente se realiza un packing extraperitoneal dado el gran hematoma extraperitoneal con sangrado en sábana. Finalmente, se practica arteriografía donde se ve sangrado arterial activo dependiente del tronco pudendo obturador y de la arteria glútea superior izquierda que se embolizan, con posterior estabilización hemodinámica. Conclusión La arteriografía puede mejorar el control de la hemorragia en los pacientes con sangrado arterial y hemodinámicamente estables, pero el packing tiene prioridad en los pacientes con fracturas de pelvis e inestabilidad hemodinámica.

Aim To report a case of severe pelvic fracture and massive bleeding initially treated with pelvic packing. Clinical case Patient who falls off a high place, hemodynamically unstable due to several open fractures including a pelvic fracture with significant pubic diastasis. It is decided to operate on the patient, proceeding to external fixation of the pelvis and performing, afterwards, an extraperitoneal packing due to the large extraperitoneal hematoma with oozing hemorrhage. Lastly an arteriography is done, where active arterial bleeding is observed localized at the obturator pudendal trunk and the left superior gluteal artery, which are embolized with hemodynamic stabilization. Conclusion Arteriography can improve hemorrhage control in hemodynamically stable patients with arterial bleeding, but packing has the priority on patients with pelvic fractures and hemodynamic instability.

SIVEH: numerical computing simulation of wireless energy-harvesting sensor nodes.

The paper presents a numerical energy harvesting model for sensor nodes, SIVEH (Simulator I-V for EH), based on I-V hardware tracking. I-V tracking is demonstrated to be more accurate than traditional energy modeling techniques when some of the components present different power dissipation at either different operating voltages or drawn currents. SIVEH numerical computing allows fast simulation of long periods of time-days, weeks, months or years-using real solar radiation curves. Moreover, SIVEH modeling has been enhanced with sleep time rate dynamic adjustment, while seeking energy-neutral operation. This paper presents the model description, a functional verification and a critical comparison with the classic energy approach.

[Spleen injuries in Spain: at what point are we?]. / Traumatismo esplénico en España: ¿en qué punto estamos?

INTRODUCTION: Management of spleen trauma has changed over last decades, although there is no data on its treatment in Spain. The aim of this study is to determine the characteristics of spleen injuries in adults with severe abdominal injuries and how we manage them. METHODS: A prospective study using the databases of six Spanish hospitals: Gregorio Marañón Hospital, Virgen de la Vega Hospital, Torrevieja Hospital, Getafe Hospital, Doce de Octubre Hospital and Corporació Sanitària Parc Taulí. RESULTS: A total of 566 patients who had sustained spleen injuries were analyzed (448 males and 118 females), most of them were due to blunt trauma (94%), and the most frequent mechanism of injury was motor vehicle accident. The mean Injury Severity Score (ISS) was 25.2. The initial treatment was surgical in 56.6% of the patients (85.3% total splenectomy and 14.7% other conservative surgical procedures, of which 4.6% finally failed and required total splenectomy). The remaining 43.4% were initially managed conservatively, but 6.5% of them finally required surgical splenectomy, and in 8.8% angio-embolization was performed. CONCLUSION: In Spain, management of spleen trauma is mainly surgical (particularly splenectomy). Angio-embolization and conservative surgical procedures are now hardly used.

An ultra-low power and flexible acoustic modem design to develop energy-efficient underwater sensor networks.

This paper is focused on the description of the physical layer of a new acoustic modem called ITACA. The modem architecture includes as a major novelty an ultra-low power asynchronous wake-up system implementation for underwater acoustic transmission that is based on a low-cost off-the-shelf RFID peripheral integrated circuit. This feature enables a reduced power dissipation of 10 µW in stand-by mode and registers very low power values during reception and transmission. The modem also incorporates clear channel assessment (CCA) to support CSMA-based medium access control (MAC) layer protocols. The design is part of a compact platform for a long-life short/medium range underwater wireless sensor network.