Analysis of outcomes of emergency general and gastrointestinal surgery during the COVID-19 pandemic.

BACKGROUND: Few surgical studies have provided adjusted comparative postoperative outcome data among contemporary patients with and without COVID-19 infection and patients treated before the pandemic. The aim of this study was to determine the impact of performing emergency surgery in patients with concomitant COVID-19 infection. METHODS: Patients who underwent emergency general and gastrointestinal surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective study (COVID-CIR). The main outcome was 30-day mortality. Secondary outcomes included postoperative complications and failure to rescue (mortality among patients who developed complications). Propensity score-matched comparisons were performed between patients who were positive and those who were negative for COVID-19; and between COVID-19-negative cohorts before and during the pandemic. RESULTS: Some 5307 patients were included in the study (183 COVID-19-positive and 2132 COVID-19-negative during pandemic; 2992 treated before pandemic). During the pandemic, patients with COVID-19 infection had greater 30-day mortality than those without (12.6 versus 4.6 per cent), but this difference was not statistically significant after propensity score matching (odds ratio (OR) 1.58, 95 per cent c.i. 0.88 to 2.74). Those positive for COVID-19 had more complications (41.5 versus 23.9 per cent; OR 1.61, 1.11 to 2.33) and a higher likelihood of failure to rescue (30.3 versus 19.3 per cent; OR 1.10, 0.57 to 2.12). Patients who were negative for COVID-19 during the pandemic had similar rates of 30-day mortality (4.6 versus 3.2 per cent; OR 1.35, 0.98 to 1.86) and complications (23.9 versus 25.2 per cent; OR 0.89, 0.77 to 1.02), but a greater likelihood of failure to rescue (19.3 versus 12.9 per cent; OR 1.56, 95 per cent 1.10 to 2.19) than prepandemic controls. CONCLUSION: Patients with COVID-19 infection undergoing emergency general and gastrointestinal surgery had worse postoperative outcomes than contemporary patients without COVID-19. COVID-19-negative patients operated on during the COVID-19 pandemic had a likelihood of greater failure-to-rescue than prepandemic controls.

Fructooligosaccharides metabolism and effect on bacteriocin production in Lactobacillus strains isolated from ensiled corn and molasses.

Fructo- (FOS) and galacto-oligosaccharides have been used to promote the growth of probiotics, mainly those from Lactobacillus genus. However, only few reports have evaluated the effect of prebiotics on bacteriocins activity and production. In this work, we characterized the effect of FOS supplementation on the growth, lactic and acetic acids production, and antimicrobial activity of crude extracts obtained from Lactobacillus strains isolated from ensiled corn and molasses. Seven out of 28 isolated Lactobacillus, belonging to Lactobacillus casei, Lactobacillus plantarum, and Lactobacillus brevis, showed antimicrobial activity against Listeria innocua. Among them, the strain L. plantarum LE5 showed antimicrobial activity against Listeria monocytogenes and Enteroccocus faecalis; while the L. plantarum LE27 strain showed antimicrobial effect against L. monocytogenes, E. faecalis, Escherichia coli and Salmonella enteritidis. This antimicrobial activity in most of the cases was obtained only after FOS supplementation. In summary, these results show the feasibility to increase the antimicrobial activity of Lactobacillus bacteriocins by supplementing the growth medium with FOS.

Solvent extraction of organic acids from stillage for its re-use in ethanol production process.

Stillage re-use in the fermentation stage in ethanol production is a technique used for the reduction of water and fermentation nutrients consumption. However, the inhibitory effect on yeast growth of the by-products and feed components that remains in stillage increases with re-use and reduces the number of possible recycles. Several methods such as ultrafiltration, electrodialysis and advanced oxidation processes have been used in stillage treatment prior its re-use in the fermentation stage. Nevertheless, few studies evaluating the effect of solvent extraction as a stillage treatment option have been performed. In this work, the inhibitory effect of serial stillage recycling over ethanol and biomass production was determined, using acetic acid as a monitoring compound during the fermentation and solvent extraction process. Raw palm oil methyl ester showed the highest acetic acid extraction from the aqueous phase, presenting a distribution coefficient of 3.10 for a 1:1 aqueous phase mixture:solvent ratio. Re-using stillage without treatment allowed up to three recycles with an ethanol production of 53.7 +/- 2.0 g L(-1), which was reduced 25% in the fifth recycle. Alternatively, treated stillage allowed up to five recycles with an ethanol final concentration of 54.7 +/- 1.3 g L(- 1). These results show that reduction of acetic acid concentration by an extraction process with raw palm oil methyl ester before re-using stillage improves the number of recycles without a major effect on ethanol production. The proposed process generates a palm oil methyl ester that contains organic acids, among other by-products, that could be used for product recovery and as an alternative fuel.

The role of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal carcinomatosis in recurrent ovarian cancer

BACKGROUND AND OBJECTIVES: Peritoneal carcinomatosis in women frequently has an ovarian origin. Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) along with radical surgery/peritonectomy could present a new therapeutic approach with curative intention. The purpose of this research is to evaluate the role of the administration of HIPEC. METHODS: A series of patients (N=26) diagnosed with peritoneal carcinomatosis for recurrent epithelial ovarian cancer (stage III) from January 1997 to December 2004 submitted to radical surgery/peritonectomy with optimal cytoreduction (R0-R1) were included in this study, 14 treated with HIPEC and 12 without HIPEC. RESULTS: The variables age, histologic type, peritonectomy procedures, peritoneal cancer index (PCI) and lymph node affectation were similar in both groups. The 5-year global survival was 58% and 17% (p=0.046), and 67% and 29% in patients with maximal cytoreduction (R0) (p=0.264), in the HIPEC- and non-HIPEC-treated patients, respectively. In patients with optimal cytoreduction and partial peritonectomy, 5-year global survival was also superior in the HIPEC group (75% vs. 11%, p=0.011). Average time free of disease was superior in the HIPEC group (48+/-42 vs. 24+/-21 months), with less reinterventions due to a new reappearance during the first three evolutionary years (2/14 vs. 4/12). Postoperative morbidity did not show substantial differences in both groups and there was no surgical mortality. CONCLUSIONS: HIPEC is a complement to radical surgery/ peritonectomy, which has been shown to be a surgical procedure with high tolerability, low morbimortality, enhanced survival and prolonged disease-free interval in patients with peritoneal carcinomatosis for recurrent ovarian cancer (AU)

No disponible

Trigeminal neurinomas in infants: report of two cases.

Two cases of trigeminal neurinoma in two infant girls aged 3 and 6 months are reported. Both presented with temporal cranial vault bulging at birth. The 6-month-old patient suffered onset of focal fits 1 month before admission and her neurological examination revealed no abnormalities. The 3-month-old patient had right exophthalmus and a subcutaneous fronto-orbital plexiform neurofibroma at birth. Neurological examination disclosed a sensory deficit of the first trigeminal nerve division. She also had a family medical history of von Reckling-hausen's disease. The incidence of trigeminal neurinomas in children is reviewed. The patients in these two cases are the youngest recorded; the cases are the only ones reported in infants. Clinical, radiological, and therapeutic aspects are discussed.

[Correlations between respiratory function tests and hemodynamic studies in the decision of pneumonectomy]. / Correlación entre las pruebas de función respiratoria y el estudio hemodinámico para la decisión de neumonectomía.

We report a prospective study of 50 patients with chronic pulmonary pathology of diverse etiology and various grades of abnormality in Pulmonary mechanics and blood gases. In all patients we performed pulmonary function test and hemodynamic study with a Dotter-Lucas catheter with and without unilateral occlusion of pulmonary artery, at rest and during exercise. Our objective was to define if one or more parameters of routine pulmonary function test could allow us to predict the condition of pulmonary circulation, and therefore identify those patients at risk of pulmonary hypertension in whom pneumonectomy could be contraindicated and in this way avoid cardiac catheterization. We did not find any correlation between the grade of abnormality in pulmonary mechanics and the severity of pulmonary hypertension. On the other hand, all patients with severe pulmonary hypertension, that precluded pneumonectomy, had severe hypoxemia (PaO2 less than 50 mmHg); patients with moderate hypoxemia (PaO2 50-57 mmHg) had pulmonary hypertension of diverse grade, that could preclude or not, pneumonectomy. We conclude that this group of patients need to be catheterized to evaluate the indication of pneumonectomy.

[Pulmonary thromboembolism in children]. / Tromboembolia pulmonar en niños.

We report our experience with five children with pulmonary embolism and infarction. Two with congenital heart disease, one with rheumatic cardiopathy and two with a previously healthy cardiopulmonary system. The risk factors, clinical behavior and ECG were similar to those in adults. In chest roentgenogram we found pulmonary infarction with cavitations in three patients because of a delayed diagnosis. All patients had hypoxemia and hypocapnia, and diagnosis was made on the basis of segmentary or larger defects in perfusion gammagraphy. In just one case we obtained V/Q gammagraphy and pulmonary angiography. In one case we confirmed the clinical diagnosis by autopsy. We conclude that it is very important to keep this diagnosis in mind in all children with respiratory failure.

[Silent myocardial ischemia: a problem in diagnosis and treatment]. / Isquemia miocárdica silenciosa: un problema de diagnóstico y tratamiento.

We tried to establish the incidence of silent myocardial ischemia (SMI) in the general population and also in patients with recognised ischemic heart disease. For this, purpose 2, 375 stress tests (ST) with Bruce protocol were reviewed, 364 were positive and those patients were divided in two groups: group I with SMI during the ST and group II with myocardial ischemia and angina during the ST. Coronary risk factors ergometric behaviour and angiographic factors were analysed. Group I had 263 patients with SMI (71%). Group II had 111 patients with ischemia and angina (29%) P less than 0.05; 90 patients had diabetes mellitus in group I and 19 in group II P less than 0.05. A previous myocardial infarction was registered in 157 patients from group I and 55 from group II P less than 0.05. The remaining coronary risks factors, ergometrics variables and significance and number of diseased coronary vessels were similar in both groups. We conclude that SMI is a frequent event in patients with ischemic heart disease. It represents probably the most frequent event in this disease. Previous myocardial infarction and diabetes mellitus may play an important role in the pathogenesis of SMI. The ST and Holter monitoring are dependable procedures for the identification of SMI and should be always performed specially in patients with high coronary risk factors. Once detecting SMI a therapeutic plan should be considered for medical, angioplastic or surgical procedures even in asymptomatic patients.

[Early tracheal intubation and mechanical ventilation in the treatment of pulmonary edema secondary to ischemic heart disease]. / Intubación traqueal temprana y ventilación mecánica para el tratamiento del edema pulmonar secundario a cardiopatía isquémica.

Forty patients with overt pulmonary edema secondary to ischemic heart disease were treated in the emergency room with iv ouabain and furosemide; 20 patients in Group A received sublingual nifedipine before undergoing early tracheal intubation and mechanical ventilation with 100% FiO2 during 15 min. and then 50% FiO2; 20 patients in Group B received iv aminophylline, rotating tourniquets and IPPB by mask with 60% FiO2. All patients in Group A were extubated after 66 +/- 10.8 min. in the emergency room; 7 in Group B improved but 13 had to undergo tracheal intubation and mechanical ventilation. Upon arrival at the ICCU all had a Swan-Ganz catheter installed and received comparable therapy for ischemic heart disease. Statistically significant differences in favor of patients in Group A as compared to the 7 improved in B were seen in heart rate, arrhythmias, diastolic blood pressure, mean and wedge pulmonary pressures, systemic resistances, arterial pH and PaO2; when compared to the 13 patients undergoing late tracheal intubation and mechanical ventilation, parameters were more or less similar but improvement appeared later and extubation took place after 1.94 +/- 1.24 days (P less than 0.05). Three patients in Group B died in the emergency room, 3 in Group A and 4 in B died in the ICCU (P less than 0.01). Early tracheal intubation and mechanical ventilation in patients with overt pulmonary edema secondary to ischemic heart disease produce better results due to early improvement in pulmonary and systemic hemodynamics and should be considered in all such patients arriving at the emergency room.

[Radiologic characteristics of cardiogenic pulmonary edema in the elderly]. / Características radiológicas del edema pulmonar cardiogénico en el anciano.

The radiologic appearance of atypical cardiogenic pulmonary edema (ACPE) is presented in 10 cases admitted from 1983 to 1985, with age ranges from 74 to 89, and with diagnosis of ischemic heart disease, with myocardial infarction in 50% of them. Clinically they had asthenia, adynamia and anorexia in 80%, cough and weight loss in 50%. All of them had tachycardia, pulmonary rales and 50% pericardial rub. ECG showed in 80% anterior subepicardial ischemia, 60% posteroinferior subepicardial ischemia, 60% bifascicular block, and 50% left anterior fascicular block. Chest films were interpreted at first as pulmonary fibrosis in 90% of the cases with superior lobe involvement in 50%. Heart enlargement was present in 50%. A chronic lung disease was disclosed on clinical and pulmonary physiological grounds. It is concluded that asthenia, adynamia and anorexia were atypical manifestations of heart failure in the elderly. Silent myocardial infarction was observed in half of our patients and it was complicated with pericardial involvement in 50%. Irregular distribution of fluids in pulmonary edema was attributed to anatomic changes in elder lung. These atypical behaviour of pulmonary edema, has been misinterpreted on radiologic basis with pulmonary infection, tumours, metastasis or fibrosis. Those radiologic changes disappeared or improved in 72 hrs. with treatment of left ventricular failure.

[Electric cardioversion in the emergency service. Experience in 1000 cases]. / Cardioversión eléctrica en el servicio de urgencias. Experiencia de 1000 casos.

We describe our experience with 1000 electric cardioversions performed at the emergency ward in the Hospital of Cardiology y Neumology, National Medical Center I.M.S.S. The objectives are: 1. Report our experience. 2. Investigate if digitalis treatment should be discontinued before the procedure. 3. Determine if all patients should be on anticoagulant therapy for elective cardioversion. 4. Indicate the optimal anesthetic drug with minimal side effects. A therapeutic procedure was performed in 73% of our cases and an elective one in the remaining 27%. Patients were grouped as ischemic heart disease 26%, rheumatic heart disease 24%, chronic obstructive pulmonary disease 14%, systemic hypertensive heart disease 13%, without clinical heart disease 6%, preexcitation syndrome 6%, adult congenital heart disease 4%, with implanted pacemaker 2%, pregnancy 2% and diverse myocardial diseases 2%. As a cardiac arrhythmias atrial fibrillation was the main cause 45%. Atrial flutter represented 25%, atrial paroxysmal tachycardia was 21% and ventricular tachycardia 9%. A cardioversion was performed in 43% of patients under digitalis treatment at therapeutic levels, without complications. Atrial flutter reverted to sinus rhythm in 98% of the procedures, and atrial fibrillation in 97%. Elective cardioversion in patients with atrial fibrillation was achieved with energies of 200 joules in 82% of the procedures (P less than 0.001) and in atrial flutter with 100 joules in 89% of the cases (P less than 0.001). The most frequent complications were atrial and junctional premature beats in 41% of the cases. We consider this procedure a safe one, effective at the energy levels described, with no need for discontinuation of digitalis therapy, with no mandatory previous anticoagulant therapy, and with no contraindications on pregnancy or implanted pacemakers.

[Massive pulmonary thromboembolism with left axis deviation and low voltage]. / Tromboembolia pulmonar masiva con desviación del eje eléctrico a la izquierda y bajo voltaje.

The classic electrocardiographic abnormalities observed in massive or submassive thromboembolism in the absence of preexistent cardiac or pulmonary disease are: S1Q3T3 pattern, right axis deviation, "pulmonary" P wave, ST segment depression or elevation, subepicardic ischemia and transient right bundle branch block. Left axis deviation due to pulmonary embolism was first described in 1949; this same finding and the presence of low voltage of the frontal plane owed to pulmonary embolism has been reported occasionally in the last decades, but it has had little diffusion. We report on a patient with no prior cardiac or pulmonary disease who suffered massive pulmonary thromboembolism. Electrocardiographically left axis deviation and low voltage of the horizontal plane attributed to pulmonary thromboembolism was observed. The mechanisms that originate this electrocardiographic changes in pulmonary embolism are unknown. Since the electrocardiogram is aspecific method for the diagnosis of this disorder, and the presence of the mentioned changes originate a greater difficulty in the diagnosis; we consider is important to publish it.