The Impact of a Computer-Based Interactive Informed Consent for Surgery on Decision Conflict.

PURPOSE: Informed consent for surgery can address the legal aspects of care while also being simple, informative, and empathic. We developed interactive informed consents and compared them with standard printed informed consents asking: (1) are there any factors associated with lower decision conflict or greater patient-rated clinician empathy including consent format? (2) Are there any factors associated with rating the consent process as informative, comfortable, and satisfying including consent format? METHODS: Ninety-four adult patients accepted an offer of surgery from one of three hand surgeons to address one of six common hand surgery diagnoses: carpal tunnel release, cubital tunnel release, trigger finger release, plate and screw fixation of a distal radius fracture, removal of a benign mass, including a ganglion cyst, and Dupuytren contracture release. Fifty-three patients were randomized to complete an interactive consent, and 41, a standard written consent. Symptoms of anxiety, depression, and unhelpful thoughts were measured. Patients completed the Decision Conflict Scale and the Jefferson Scale of Patient's Perceptions of Physician Empathy and rated the consent as informative, comfortable, and satisfactory on a scale of 0-10. RESULTS: Greater decisional conflict was slightly associated with greater patient unhelpful thoughts about symptoms and was not associated with consent format. A higher rating of comfort with the consent process was slightly associated with patient choice to proceed with surgical treatment, but not with consent format. Accounting for potential confounding in multivariable analysis, a higher rating of the consent process as informative was slightly associated with patient preference for surgical over nonsurgical treatment, CONCLUSIONS: The observation that an interactive consent form was not related to decision conflict or other aspects of patient experience suggests that such tools may not have much weight relative to the interaction between patient and clinician. CLINICAL RELEVANCE: Efforts to improve informed consent may need to focus on the dialog between patient and surgeon rather than how information is presented.

Factors Associated With Concerns the Day After Office Hand Surgery.

PURPOSE: Pain after minor hand surgery can be misinterpreted as a problem. The sense that something may be wrong intensifies the pain. Some surgeons anticipate these feelings and call patients the evening or day after surgery to guide them through the recovery process. A study of routine, next day, postoperative phone calls can help determine the frequency of concerns and associated factors. We asked: 1) What factors are associated with concern the day after office hand surgery? 2) What factors are associated with pain intensity, satisfaction with care, and patient's perceived recovery trajectory the day after office hand surgery? METHODS: In a cross-sectional study, 82 patients who had office hand and upper extremity surgery completed a survey recording age, gender, insurance, income level, measures of symptoms of depression and anxiety, a measure of catastrophic thinking regarding pain, 10-point ordinal ratings of pain intensity and satisfaction with care, whether the patient was concerned about their hand (yes or no) and whether they felt their recovery was on track (yes or no). RESULTS: Ten patients (12%) were concerned about their hand. In bivariate analysis, concern the day after surgery was associated with greater catastrophic thinking and male gender. Greater pain intensity was associated with greater catastrophic thinking. There was insufficient variation in satisfaction or a sense that recovery was on track for a meaningful analysis. CONCLUSIONS: The finding that concerns were common the day after minor office hand surgery supports the practice of contacting patients for support and helping to reorient unhelpful catastrophic thoughts. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Creating arteriovenous fistulas for children in Guatemala.

OBJECTIVE: The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. METHODS: Three surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions. RESULTS: AVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 ± 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 ± 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 ± 2.9 kg/m2). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications. CONCLUSIONS: Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months.

Nefrectomia en la edad pediátrica con técnica de cirugia minimamente invasiva: abordaje retroperitoneal como estándar de oro para el paciente sin o con enfermedad renal crónica (premio dr. efrain vargas año 2014) / Nephrectomy in pediatric age with minimally invasive surgery technique: retroperitoneal approach as a gold standard for patients without or with chronic kidney disease (Dr. Efrain Vargas Award 2014)

Existen múltiples patologías del tracto urinario, ya sea congénitas o adquiridas, que requieren de tratamiento quirúrgico de Nefrectomía total o parcial. En el siguiente estudio longitudinal prospectivo se incluyen 21 nefroureterectomías en pacientes pediátricos con patología del tracto urinario con o sin enfermedad renal crónica y algún tipo de terapia de reemplazo renal, realizados con la técnica de Cirugía Minimamente Invasiva (CMI) abordaje retroperitoneal o retroperitoneoscopía. (AU)

There are several urinary tract diseases, such as congenital or adquired, that require total or partial nephrectomy. This prospective longitudinal study included 21 total nephrectomies in pediatric patients with or without end stage renal disease and some kind of renal replacement therapy. All surgeries were done with retroperitoneal approach using minimally invasive surgery (MIS), retroperitoneoscopy. (AU)

Diagnóstico y tratamiento del quiste del colédoco neonatal. Reporte de casos / Diagnosis and treatment strategy of neonatal choledochal cyst: Cases Report

Se reportan 2 casos de quiste de colédoco neonatal sintomáticos, uno de ellos con diagnóstico prenatal, que fueron llevados a tratamiento quirúrgico, realizando la resección de quiste del colédoco, derivación bilioentérica tipo hepático-yeyuno anastomosis en Y de Roux y colocación de drenaje de Penrose. En seguimiento de 20 meses en promedio con adecuada evolución.

We report two cases of symptomatc neonatal choledochal cysts, one of them prenatally diagnosed, who had surgical treatment with choledochal cyst resecton and Roux en Y hepato-jejunal anastomosis and Penrose drain. Follow up at 20 months (average) with good outcomes.

Síndrome de Herlyn-Werner-Wunderlich. Síndrome OHVIRA. Reporte de Caso / Herlyn-Werner-Wunderlich Syndrome or OHVIRA Syndrome. Case Report

Paciente Femenina de 11 años con el síndrome de Herlyn-Werner-Wunderlich, manejado multdisciplinariamente y resuelto endoscópicamente con una septotomía y dilataciones vaginales.

This case is about a female patent, 11 years old, with Herlyn-Werner-Wunderlich Syndrome, who received multdisciplinary approach and was endoscopically resolved with septotomy and vaginal dilatatons.

Duplicación Uretral: Reporte de Caso / Urethral Duplication: Case Report

Preescolar, Masculino, 3 años 9 meses con antecedente quirúrgico de corrección de hipospadias 1er tiempo hace 2 años y que durante el 2do tiempo de corrección de hipospadias se encuentra incidentalmente una duplicación uretral tipo IB. Se confirma por medio de instilación de azul de metileno por uretra ventral y luego por medio de uretrocistoscopia. Se realiza la resección y cierre de uretra dorsal. Requiere de una dilatación uretral y está pendiente la corrección quirúrgica de una fistula uretrocútanea.

We report the case of a 3 year 9 month old boy who had a failed hypospadia correction two years prior to his second surgery when a IB urethral duplication was incidentally found. There are only 300 case reports of this published. The diagnosis was confirmed by instilling methylene blue through the ventral urethra, by urethero-cystoscopy. Resection and closure of the dorsourethra was performed. He required a urethral dilatation and developed aurethero-cutaneous fistula, which is pending surgical correction.

Embarazo y litiasis biliar. Especial referencia a la colecistectomía laparoscópica / Pregnancy and gall stones. Special reference to laparoscopic cholecistectomy

In this paper we review the indications of the laparoscopic cholecistectomy and other related methods in the diagnosis and treatment of cholelithiasis and choledocolithiasis during pregnancy. The epidemiology and ethiopathogenesis of biliary lithiasis during pregnancy are also reviewed.

Hipertensión portal / Portal hypertension

Esta revisión trata sobre los recientes conocimientos de la anatomía, fisiología, etiología, clínica, exámenes auxiliares y tratamiento del síndrome de hipertensión portal. En fisiopatología se destaca que además de los factores clásicos considerados en la hipertensión portal de origen cirrótico, habría otro, dado por el incremento en la sensibilidad de los receptores S2 de serotonina a nivel de la circulación portal. Se hace una actualización de los métodos diagnósticos no invasivos, y se comentan algunas pruebas de laboratorio de utilidad clínica. En relación al tratamiento se ha puesto énfasis en el uso de fármacos, especialmente vasodilatadores, que actúan modificando la magnitud de la presión portal

Enfermedad de Whipple:Un caso diagnosticado por Biopsia de Ganglio Linfático Periférico. / Whipple's disease: A case diagnosis by Peripheral Limph Node.

Presentamos un caso de enfermedad de Whipple diagnosticado con biopsia de ganglio linfático periférico,donde se encontró característicos macrófagos PAS-positivos.Al mismo tiempo,las muestras de biopsia de intestino delgado tanto a la microscopía óptica como electrónica no mostraron dichas alteraciones ni presencia de bacilos.Era un paciente peruano de 52 años de edad,cuyas manifestaciones clínicas más importantes fueron síndrome de malabsorción, artralgias,pigmentación cutánea,desnutrición y ascitis subclínica.El tratamiento con penicilina y tetraciclina dio excelentes resultados.Discutimos la importancia de realizar el diagnóstico en presencia de manifestaciones extraintestinales de la enfermedad y las razones por las cuales el estudio histológico del intestino puede ser negativo aun cuando haya malabsorción intestinal.El presente caso es el primero reportado en el Perú y probablemente en América Latina.