El deterioro renal postoperatorio puede ser útil para predecir el resultado y la supervivencia de la reparación de aneurismas de aorta abdominal, tanto abierta como endovascular / Postoperative renal impairment can predict outcomes and survival of open and endovascular abdominal aortic aneurysm repair

Introducción: El deterioro renal postoperatorio puede ser útil para predecir el resultado y la supervivencia de la reparación de aneurismas de aorta abdominal, tanto abierta como endovascular. Objetivo: Evaluar la función renal en cirugías de aorta abdominal, y analizar su capacidad predictiva de eventos adversos a corto y largo plazo. Pacientes: Trescientos diez pacientes con aneurisma de aorta abdominal intervenidos en nuestro centro (cirugía n = 150, reparación endovascular [EVAR] n = 160) entre 2003 y 2007, con seguimiento medio postoperatorio de 37,9 meses. Métodos: Recogida prospectiva de datos clínicos y función renal cada 12 horas hasta el tercer día posquirúrgico. Análisis univariante y multivariante, curvas COR y funciones de supervivencia de Kaplan-Meier. Resultados: La edad y el riesgo ASA fueron superiores en el grupo endovascular (p < 0,001). La mortalidad perioperatoria fue del 4 % (4 % cirugía, 4,4 % EVAR, p = 0,869), y la creatinina basal fue similar en ambas técnicas (cirugía 1,10 ± 0,21 mg/dl, EVAR 1,08 ± 0,25 mg/dl; p = 0,570). El fallo renal preoperatorio se asoció (p < 0,001) a mayor mortalidad perioperatoria, complicaciones y reintervención, pero no se comportó de forma independiente a otros factores. El fallo renal post-operatorio fue más frecuente en cirugías abiertas (39,8 % frente a 21,8 %, odds ratio [OR] = 1,82, p = 0,015) y predijo significativamente (p < 0,001) eventos adversos en cirugía y en EVAR, así como inferior supervivencia a 3 años (log rank p = 0,038). El análisis multivariante confirmó su excelente perfil predictivo para ambas técnicas (cirugía OR = 4,7, EVAR OR = 4,4). El riesgo fue máximo a partir de 1,40 mg/dl de creatinina máxima en los 3 días postoperatorios (COR AUC 0,919). Conclusiones: El deterioro postoperatorio de la función renal puede indicar qué grupos de pacientes sufrirán más eventos adversos a corto y largo plazo, de forma más precisa e independiente que otros marcadores de riesgo(AU)

Introduction: Postoperative renal impairment can predict outcomes and survival of open and endovascular abdominal aortic aneurysm repair. Objectives: To assess renal function in abdominal aortic surgery, and analysing its predictive power for both short and long-term adverse events. Patients: A total of 310 patients with abdominal aorta aneurysm who underwent surgery in our centre (open aortic repair [OAR] n = 150, endovascular aortic repair [EVAR] n = 160) from 2003 to 2007, with a mean postoperative follow-up of 37.9 months. Methods: Prospective collection of clinical data, serum creatinine determinations every 12 hours up to 3rd postoperative day. Uni- and multivariate analysis, ROC curves and Kaplan-Meier survival plots. Results: Mean age and ASA risk score were significantly higher in the endovascular group (p < 0.001). Perioperative mortality was 4.2 % (4 % open repair, 4.4 endovascular, p = 0.869), and preoperative creatinine levels were similar in both groups (OAR 1.10 ± 0.21 mg/dl, EVAR 1.08 ± 0.25 mg/dl, p = 0.570). Preoperative renal impairment (p < 0.001) was found to be associated with higher short-term mortality, complications and reintervention, but without showing independence to other risk factors. Postoperative renal dysfunction was more common in open repair group (39.8 % vs 21.8 %, odds ratio [OR] = 1.82, p = 0.015) and successfully predicted (p < 0.001) adverse events both in open and endovascular repair, and lower 3-year survival rate (log rank p = 0.038). The multivariate analysis confirmed this predictive power for both techniques (open repair OR = 4.7, endovascular OR = 4.4). Risk was higher for serum creatinine values over 1.4 mg/dl on any of the 3 postoperative days (ROC AUC 0.919). Conclusions: Postoperative renal impairment more precisely identifies groups of patients at increased risk for short and long-term adverse events, and independently of other risk factors or preoperative renal dysfunction(AU)

Experiencia preliminar con cirugía híbrida en el tratamiento de los aneurismas toracoabdominales / Initial experience with hybrid surgery in the treatment of thoracoabdominal aneurysms

Introducción. La cirugía convencional de los aneurismas toracoabdominales (ATA) todavía conlleva una elevada morbimortalidad, por lo que han surgido alternativas: endoprotesis con ramas y tratamiento híbrido. Objetivo. Se presenta la experiencia preliminar con tratamiento híbrido en ATA extensos. Material y métodos. Entre octubre de 2006 y septiembre de 2009 se trataron 5 pacientes con ATA extensos mediante cirugía híbrida, cuyas historias clínicas fueron retrospectivamente examinadas. Un caso se presentó con rotura, y fue el único tratado de manera urgente. Sólo dos procedimientos se realizaron durante una única intervención. En todos, excepto uno, se realizó revascularización renovisceral completa. La arteria subclavia izquierda fue ocluida intencionadamente en dos ocasiones, sin revascularización. Siempre se empleó un sistema de drenaje de líquido cefalorraquídeo. Para el seguimiento se empleó tomografía computarizada en el primer mes, a los 6 y 12 meses y anualmente. Resultados. La mortalidad inmediata fue nula. Ningún paciente presentó paraplejia. Dos pacientes sufrieron complicaciones respiratorias. En dos casos se registró un incremento de creatinina Ý 0,5 mg/dl, con recuperación. La permeabilidad inmediata fue del 100 %, sin endofugas en el primer control. El seguimiento oscila entre 4,9 y 37,4 meses (mediana 26,5 meses); se registraron dos exitus: hemorragia intracraneal a los 31 meses y sepsis a los 37,4 meses. Este último caso tenía una endofuga tipo I distal a los 6 meses, que no fue tratada. Conclusión. Los resultados del tratamiento híbrido en ATA extensos aparentan ser prometedores, aunque todavía no hay evidencia de que disminuya la morbimortalidad y cuál será su papel futuro (AU)

Introduction. Given that open repair of thoracoabdominal aortic aneurysms (TAA) is stillassociated with high mortality and morbidity, alternative techniques have arisen: branchedendografts and hybrid procedures (debranching plus endoprosthesis).Objective. To report our preliminary experience with hybrid procedures for extensive TAA.Materials and methods. Medical records of 5 patients with extensive TAA treated by abdominaldebranching plus endoprosthesis from October 2006 to September 2009 were retrospectivelyreviewed. Elective procedures were performed in all but one with rupture. Only in two patientswas treatment performed during a single intervention. Total debranching was performed in allcases but one. The subclavian artery was occluded without revascularisation in two patients.A cerebrospinal drainage was employed in all cases. Follow-up was assessed by computedtomography during the fi rst month, at 6, 12 months and annually thereafter.Results. There was no immediate mortality. No patient suffered paraplegia. Respiratorycomplications appeared in two patients, and worsening of renal function (creatinine increase¡Ý 0.5 mg/dl) appeared in other two cases, both with recovery. Immediate patency rate was100 %, without endoleaks during the fi rst assessment. Follow-up ranges from 4.9 to 37.4 months(median 26.5). Two patients died (intracerebral haemorrhage at 31 months and sepsis at37.4 months). The latter also developed a distal type I endoleak at 6 months, which was nottreated.Conclusion. Results of hybrid treatment for extensive TAA seem to be promising, although thereis still not enough evidence to demonstrate that it decreases mortality and morbidity, or whatwill be its role in the future(AU)

Síndrome del mentón entumecido. A propósito de un caso / The Numb Chin syndrome: a clinical case

El Síndrome del mentón entumecido o neuralgia mandibula maligna es un cuadro poco conocido por el odontólogo general pero con el que están bastante familiarizados los especialistas en Oncología. El paciente afecto presenta, dentro de un cuadro oncológico, un entumecimiento uni o bilateral de las áreas inervadas por los nervios mentonianos, sin relación, en muchos casos, con una tumoración a ese nivel. Presentamos un caso de un varón de 82 años que padecía, en noviembre de 2005, un cuadro febril leve y anestesia en el territorio inervado por el mentoniano derecho y un molar 46 con tratamiento de conductos obturados años atrás. Tras múltiples estudios, resultó padecer un cáncer pulmonar con diseminación ósea en el que, hasta su fallecimiento (mayo- 2008) no se puedo constatar masa tumoral en el territorio mandibular. Por otro lado, el tratamiento de los cánceres metastáticos o primitivamente óseos con bisfosfonatos I. V que pueden provocar osteonecrosis, aún pueden confundir más a la hora de llegar a un correcto diagnóstico del dolor o entumecimiento maxilar (AU)

The Numb Chin Syndrome o Malignat mentoniana neuropathy is a disease quite unknown by the general dentist but familiar to specialist in oncology. The patients present a uni-or-bilateral numbness of the areas innervated by the mentonian nerves, symptom which is not usually related with tumors in this area. We report a case of a man who suffered since he was 82 years old, in November of 2005, a mild fever and anesthesia in the area innervated by the right mentonian nerve. He also presented an endodontic treatment of the first lower right molar. After multiple studies the patient was diagnosed from a lung cancer which had spread to the bones, in which, until his death in May of 2008 we did not observe a tumor in the jaw area. On the other hand, the treatment of metastatic cancers with bisphosphonates I. V. can cause osteonecrosis, which can make difficult a correct diagnosis of jaw pain or numbness. In the case we find a combined presence of osteonecrosis for this reason and pain and numbness of the same area (AU)

[Medical liability in gynecology and obstetrics. Analysis of 25 cases]. / El arbitraje médico en ginecología y obstetricia. Análisis de 25 casos.

The authors studied 175 severe medical complaints which ended in Arbitration veredicts or expert opinions, handled by and Alternative Disputes Resolution Institution (CONAMED) between June 1996 and December 1999. The study was focused on 25 cases with complete medical records. Belonged to Gynecology area, 8 cases (32%), and 17 cases (68%) to Obstetrics. The physicians involved were ob/gyn specialists in 14 cases. Health public institutions were involved in 14 cases (56%), and private practitioners, 11 cases (44%). The main sources of unsatisfaction were injuries or technical failures during surgical procedures in 24% (6 cases) or diagnostic failures in 6 cases (24%). The outcomes were: deaths 8 (32%), amputation or another sequelae in three cases (12%), and fetus or newborns deaths or injuries in two cases (6%). The claimers asked for monetary benefits in 15 cases (60%), disclosure of medical responsibility in 8 cases (24%), and to probe murder or injuries in 3 cases (12%). The CONAMED conclusions were medical malpractice in 14 cases (56%), administrative failures in 14 cases (56%), and patient responsibility in 4 cases (16%).

[Resolution of medical complaints by arbitration. Analysis of 140 cases]. / Resolución de quejas médicas por arbitraje. Análisis de 140 casos.

The author studied 140 complex medical complaints handled by an Alternative Disputes Resolution Institution (CONAMED), between June 1996 and December 1999. There were 79 females and 61 males, cases originated in public hospitals 93 (66.4%) and private hospitals or practitioners 47 (33.6%). Several cases were treated sequentially in both types of institutions. The medical specialties involved were in frequency order: Neurosurgery, General Surgery, Gyn-Ob, Anesthesiology, Traumatology and Orthopedics, Oncology, Emergency, and 22 others. The causes of complaints were: Surgical treatment, Medical treatment, Diagnosis, Anesthesia, and mixed causes. There were 59 deaths, 43 anatomic or functional loses, disability or sequelae; and 34 recoveries. CONAMED delivered 27 arbitration verdicts, 94 expert opinions asked by prosecutors or human rights organizations, and 1 technical advice to medical authorities. Some resolutions included more than one case. More than half of physicians involved were found not guilty of malpractice. Even though the main CONAMED purpose is to improve the quality of Medical Care acting as The Health Ombudsman, its performance may be on behalf of medical practitioners.

Aneurismas de aorta abdominal. Evolución asistencial y quirúrgica en una comunidad durante 20 años

Objetivos: Estudio de la evolución asistencial, formas clínicas de presentación y resultados del tratamiento quirúrgico de los Aneurismas de Aorta Abdominal, durante un periodo de 20 años en la Comunidad Asturiana. Material y métodos: Análisis retrospectivo de 899 pacientes intervenidos de aneurismas, 203 (22,5 por ciento) urgentes y 696 electivos (77,5 por ciento) entre 1980-1998. Estudio evolutivo tanto en sus formas de presentación clínica como en su relación con el resto de la actividad quirúrgica. Resultados: El número de aneurismas operados anualmente de forma electiva ha aumentado un 256 por ciento en el periodo analizado. La cirugía urgente ha aumentado también un 34 por ciento, estabilizándose en los últimos 5 años. La mortalidad electiva ha descendido del 7,6 por ciento en el subperiodo 1980-1985 al 3,2 por ciento en los últimos 6 años. La de la urgente permanece por encima del 50 por ciento en ambos periodos. El número de aneurismas aórticos operados anualmente de forma urgente no ha disminuido en términos absolutos pero si de forma significativa en la relación urgentes/electivos, pasando del 33,7 por ciento (67/199) entre 1980-1990 al 19,5 por ciento (136/700) entre 1991-1998. La cirugía sobre los aneurismas ha pasado del 8 al 50 por ciento del total de cirugía aórtica y del 1,4 al 6,8 por ciento del total de intervenciones llevadas a cabo entre ambos períodos. Conclusiones: Se constata el aumento de la cirugía sobre los aneurismas aórticos en la Comunidad Asturiana en los últimos 20 años, muy especialmente en los operados de forma electiva. La cirugía urgente permanece estable en los últimos años. Es imprescindible llevar a cabo estrategias de salud con la colaboración de los médicos de Atención Primaria para el control de la enfermedad, cuya prevalencia aumentará en los próximos años en función del mantenido y previsible envejecimiento poblacional (AU)

[The reliability of the ankle/arm index for the study of chronic arteriopathy of the lower limbs in primary care]. / Fiabilidad del índice tobillo/brazo para el estudio de la arteriopatía crónica de los miembros inferiores en atención primaria.

OBJECTIVE: To validate the "ankle/arm" index (AAI) or "Yao index" for the primary care assessment of chronic arteriopathy in the lower limbs (CALL). DESIGN: A descriptive crossover study. SETTING: Primary care. PATIENTS: 21 with suspected or diagnosed CALL. MEASUREMENTS AND MAIN RESULTS: Four primary-care doctors made 164 examinations by means of palpation and determination of blood pressure with Doppler waves. The presence or absence of pulses was recorded and the AAI calculated. The interobserver Kappa ranged from 0.20 to 0.47 and the intraobserver from 0.52 to 0.76, according to the pulse examined. The intraclass interobserver correlation coefficient for the AAI was 0.80 and the intraobserver 0.79. Interobserver SD for the AAI was 0.14, and intraobserver SD 0.15. CONCLUSIONS: The ankle-arm index obtained by primary-care doctors using Doppler is a reliable method of studying CALL. However, due to its wide variability, it is advisable always to evaluate its evolution together with clinical data.

[Long-term course of arterial traumatisms in children. Analysis of 31 cases]. / Evolución a largo plazo de los traumatismos arteriales infantiles. Análisis de 31 casos.

Thirty children, 17 boys and 13 girls, with 31 arterial traumatisms, were studied. The follow-up period ranged from 4 to 166 months. The purpose of this study was to analyze the long term results. The etiology in 19 cases was accidental (61.3%) and iatrogenic in 12 (38.7%). Upper limbs were affected in 15 cases, lower limbs in 13. The arterial traumatism affected the supra-aortic truncus in 2 patients and the renal artery in one other. Arteriographies were carried out in 7 cases (22.6%). Twenty-three patients (74.2%) underwent surgical procedures. The rest of the patients were managed conservatively. No amputations were needed. Three patients died by no vascular causes. The long-term results were good in terms of permeability and absence of major sequels. We conclude that IAT (Infantile Arterial Traumatisms) are potentially graves; therefore an early diagnosis and a specialized care of patients, without rigid protocols of management, are needed. The uncertain prognosis of IAT obligate to a clinical follow-up.

[Improvement in the quality of medical care]. / Mejoría de la calidad de la atención médica.

UNLABELLED: The object of this research was investigating the existence of programs, as well as the patient's and healthy worker's opinions, concerning the quality of Medical Attention in the representative medical institutions in Mexico City (Distrito Federal). Eighteen directors of medical institutions were interviewed; as well as fifty university graduates, one hundred out patients from health centers and three hundred patients treated at general hospitals. A poll was applied to two hundred and fifty physicians and two hundred and fifty nurses from health centers and general hospitals. RESULTS: The eighteen institutions studied had permanent programs for Supervision and assemend. Other activities were also detected: sixteen had Technical Committees, five had a Department for Complaints, three had Quality Circles, two had programs for Evaluation of Educational Needs, two had Patients Polls, two had Worker's Polls, one had a Shadow Study and two had Quality Control Programs. The 86% of university graduates belonged to the social security system. Among these, 36% attended public services, 36% of them did this selectively and 28% did not use social security. 30% felt that public medical services were good, 14% less than good and 56% bad. 36% felt that public services were better than private ones, 36% said both were equally good and 28% judged the public system as worse than the private ones. The main deficiency reported was a lack of personal warmth. The patients from both the general practice and hospitalization graded the opportunity, warmth and process of medical attention as variables with figures of 80% or more. The frequency of diverse "complications" was 66% in out patients and 36% in the hospitalized ones. The physicians and nurses graded the infrastructure, teaching, laboral motivation and satisfaction, and continuity of services as variables with percentages of 50% to 60%; whereas the variables of warmth, control and supervision with values of 60% to 80%. Hospital nurses were less satisfied. These results show patients to have an acceptable satisfaction whereas the health personnel was unmotivated. Practical actions are suggested to improve the quality of medical attention.