Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema.

OBJECTIVE: The aim of the study was to present our experience with the vertical musculocutaneous trapezius (VMCT) flap and highlight its utility in the thoracic wall reconstruction in patients with bronchopleural fistula (BPF). MATERIALS AND METHODS: We present a five case series of patients with long-standing cavities and BPF. The VMCT flap was used, and a direct pathway into the defect was made through a separate posterior thoracotomy shortening the distance between the flap and the defect. RESULTS: In 80% of the cases, the flap succeeded in solving the fistula and filling the defect, quality of life improved, and the need for oxygen decreased. CONCLUSIONS: Management of open window thoracostomy is challenging. Debridement, thoracoplasty, and flap coverage are the mainstream of their treatment, but these patients have scarce available muscle. The VMCT flap represents the major non-affected musculocutaneous unit in the thoracic area after lung surgery. Its dermal component offers a rigid matrix to form a seal over the bronchial stump. Its muscular component adds a good amount of vascularized tissue. No functional impairment has been described after its use.

OBJETIVO: Exponer nuestra experiencia con el colgajo vertical de trapecio y destacar su utilidad en la reconstrucción de la pared torácica en pacientes con fístulas broncopleurales. MATERIAL Y MÉTODOS: Presentamos una serie de cinco pacientes con cavidades y fístulas broncopleurales de larga evolución. Utilizamos el colgajo musculocutáneo vertical de Trapecio, con un redireccionamiento del mismo a través de una ventana costal que permite acortar la distancia entre el colgajo y el defecto. RESULTADOS: La fístula y el defecto fueron solucionados en el 80% de los casos. La calidad de vida mejoró y las necesidades de oxígeno disminuyeron. CONCLUSIONES: El manejo de las toracotomías es un reto. El desbridamiento, toracoplastia y cobertura con colgajo son los pilares de su tratamiento, pero estos pacientes tienen escasa disponibilidad muscular. El colgajo musculocutáneo vertical de Trapecio representa la mayor unidad intacta musculocutánea en el tórax tras cirugía pulmonar. Su componente dérmico ofrece una matriz rígida para sellar el muñón bronquial, su componente muscular añade una gran cantidad de tejido vascularizado. No se han descrito déficits funcionales tras su uso.

Shock index combined with age and the Glasgow Coma Scale during the initial care of polytraumatized patients as a predictor of mortality. / Shock Index asociado a la edad y al Glasgow Coma Score como predictor de mortalidad en la atención inicial del paciente politraumatizado.

OBJECTIVES: To study whether combining age and the Glasgow Coma Scale (GCS) with the shock index (SI) - SIA/G - during the initial care of polytraumatized patients can improve the ability of the SI alone to predict mortality. To compare the predictive performance of the SIA/G combination to other prognostic scales: the addition of points for the GCS, age and systolic blood pressure (GAP); the Revised Trauma Score (RTS); and the Injury Severity Score (ISS). MATERIAL AND METHODS: Observational cohort study of patients with severe trauma admitted to the intensive care unit of a tertiary care hospital between 2015 and 2020. We calculated the SI (heart rate/systolic blood pressure), the SI/G ratio, the product of the SI and age SIA, and the combined index: SIA/G. The areas under the receiver operating characteristic curves (AUROCs) for hospital mortality and 24-hour mortality were calculated for the SIA/G combination and compared to the AUROCs for the GAP, the RTS, and the ISS. RESULTS: We analyzed data for 433 patients, 47 of whom (10.9%) died. All the prognostic indexes were significantly related to mortality but the SIA/G was the best predictor of both hospital and 24-hour mortality, with AUROCs of 0.879 (95% CI, 0.83-0.93) and 0.875 (95% CI, 0.82-0.93), respectively. A score of 3.3 for the SIA/G showed 82% sensitivity and 80% specificity for hospital mortality (86% and 78%, respectively, for 24-hour mortality). The AUROCs for the GAP, RTS, and ISS indexes were lower for hospital mortality. CONCLUSION: The combined SIA/G score is a better predictor in hospital of mortality in patients with multiple injuries than the SI or the traditional GAP, RTS, and ISS indexes.

OBJETIVO: Estudiar si la edad y la puntuación Glasgow Coma Score (GCS) incrementan la predicción de mortalidad del Shock Index (SI) en la atención inicial del paciente politraumatizado y compararlo con las escalas pronósticas, GAP (Glasgow Coma Score-Age-Systolic Blood Pressure), RTS (Revised Trauma Score) e ISS (Injury Severity Score). METODO: Estudio observacional sobre una cohorte de pacientes de la unidad de cuidados críticos de un hospital de tercer nivel con diagnóstico de trauma grave entre 2015 y 2020. Se recogió el SI (FC/TAS) y el SI asociado al GCS (SI/G), a la edad (SIA) y a ambos (SIA/G). Se calculó el área bajo la curva (ABC) de la característica operativa del receptor (COR) para cada uno de ellos para la mortalidad hospitalaria (MH) y en las primeras 24 horas (M24). También se comparó el ABC COR del SIA/G con las de las escalas GAP, RTS e ISS. RESULTADOS: Se analizaron 433 pacientes de los cuales fallecieron 47 (10,9%). Todos los SI se relacionaron significativamente con la mortalidad, pero el SIA/G presentó la mayor ABC COR para MH (0,879, IC 95% 0,83-0,93) y para M24 (0,875, IC 95% 0,82-0,93). El valor SIA/G de 3,3 puntos mostró una sensibilidad del 82% y especificidad del 80% para MH y del 86% y 78% para M24. El ABC COR del SIA/G para la MH fue superior a las de las escalas GAP, RTS e ISS. CONCLUSIONES: SIA/G es superior al SI y a las escalas clásicas GAP, RTS e ISS como predictor de MH del paciente politraumatizado.

Angiotensin-Converting Enzyme 2 (SARS-CoV-2 receptor) expression in human skeletal muscle.

The study aimed to determine the levels of skeletal muscle angiotensin-converting enzyme 2 (ACE2, the SARS-CoV-2 receptor) protein expression in men and women and assess whether ACE2 expression in skeletal muscle is associated with cardiorespiratory fitness and adiposity. The level of ACE2 in vastus lateralis muscle biopsies collected in previous studies from 170 men (age: 19-65 years, weight: 56-137 kg, BMI: 23-44) and 69 women (age: 18-55 years, weight: 41-126 kg, BMI: 22-39) was analyzed in duplicate by western blot. VO2 max was determined by ergospirometry and body composition by DXA. ACE2 protein expression was 1.8-fold higher in women than men (p = 0.001, n = 239). This sex difference disappeared after accounting for the percentage of body fat (fat %), VO2 max per kg of legs lean mass (VO2 max-LLM) and age (p = 0.47). Multiple regression analysis showed that the fat % (ß = 0.47) is the main predictor of the variability in ACE2 protein expression in skeletal muscle, explaining 5.2% of the variance. VO2 max-LLM had also predictive value (ß = 0.09). There was a significant fat % by VO2 max-LLM interaction, such that for subjects with low fat %, VO2 max-LLM was positively associated with ACE2 expression while as fat % increased the slope of the positive association between VO2 max-LLM and ACE2 was reduced. In conclusion, women express higher amounts of ACE2 in their skeletal muscles than men. This sexual dimorphism is mainly explained by sex differences in fat % and cardiorespiratory fitness. The percentage of body fat is the main predictor of the variability in ACE2 protein expression in human skeletal muscle.

Efectos secundarios cardiorrespiratorios en la técnica del pinzamiento para el tratamiento de la hiperhidrosis palmar y axilar / Cardiorespiratory Side Effects in the Clipping Technique for the Treatment of Axillary and Palmar Hyperhidrosis

No disponible

Razonamiento clínico / Clinical reasoning

Todas las actuaciones médicas tienen una curva de aprendizaje, pero el razonamiento clínico se mantiene como un elemento clave en cualquiera de ellas. Los médicos experimentados manejan una gran cantidad de información en cualquier proceso clínico. Para conseguir la máxima eficiencia en la utilización de esta información, los clínicos emplean una serie de estrategias que les permiten combinar datos y sintetizarlos en un número reducido de hipótesis diagnósticas, evaluar los riesgos y los beneficios de realizar nuevos procedimientos diagnósticos y aplicar determinados tratamientos, y formular planes en el manejo del paciente. Uno de los objetivos principales de cualquier docente médico es promover el desarrollo de una forma de razonar experta en sus estudiantes. Sin embargo, enseñar estas habilidades cognitivas no es tarea sencilla porque no existe una teoría completa y ampliamente aceptada acerca de los procesos de razonamiento clínico, e incluso los médicos más experimentados a menudo no son conscientes de los métodos de razonamiento que utilizan para alcanzar un diagnóstico. Desde hace más de cuarenta años se ha investigado en este campo. En este artículo se revisan las bases científicas y las teorías propuestas a lo largo de este período acerca del modo de razonar de los clínicos. También se analiza la evolución de las estructuras del conocimiento y se examinan algunos errores frecuentes en razonamiento diagnóstico. Por último, se proponen algunas recomendaciones prácticas específicas para ayudar a los principiantes a fortalecer sus habilidades de razonamiento diagnóstico (AU)

There is a learning curve in almost everything doctors do, but judgment remains a key determinant of the value of any clinical intervention. Expert physicians manage huge amounts of information to ensure the quality of patient care by using a set of efficient reasoning strategies. These strategies allow them to combine and synthesize data into a few diagnostic hypotheses, assess benefits and risks of additional diagnostic procedures and treatments, and articulate plans for patient management. A major goal of the medical educators is to foster the development of expert clinical reasoning in apprentices. However, teaching these cognitive skills is a difficult task because there is no generally accepted inclusive theory of the clinical reasoning process and even the most seasoned clinicians are often unaware of the reasoning methods that lead them to achieve accurate diagnoses. Research in this field has been carried out for over 40 years. In this paper we review the scientific background and theories proposed throughout this time about how clinicians reason. We also analyze the evolution of knowledge structures and examine some common errors in diagnostic reasoning. Finally, we provide several practical and specific recommendations to help learners strengthen their diagnostic reasoning skills (AU)

Historia y realidad de los hospitales universitarios españoles / History and reality of the Spanish University hospitals

Existen muchos entornos asistenciales que pueden y deben participar activamente en la enseñanza práctica de la medicina, pero no se puede concebir una facultad de medicina sin un hospital docente con las características básicas que se describen en este documento. El sistema de comisiones mixtas se ha mostrado ineficaz y su funcionamiento es deficiente en la mayoría de las universidades. Desde hace años, la Conferencia de Decanos de Facultades de Medicina de España viene demandando la reforma del Real Decreto 1558/86 y el establecimiento de estándares claros en relación con el tipo de profesorado, los espacios físicos, la infraestructura y los recursos materiales necesarios para ejercer las labores docentes e investigadoras en los hospitales universitarios. También se requiere fijar unos criterios de calidad mínimos y el sistema que permita cuantificarlos. En definitiva, una evaluación por objetivos con auditorías rigurosas que conduzcan a la renovación o la revocación de la condición de "universitario" para todo hospital que opte al nivel de excelencia que esta denominación implica. En este artículo se proponen, con una óptica realista y pragmática, algunos de los criterios que deberían contemplarse

There are many clinical environments that might and should be used in the practical training of medical students, but it is inconceivable that a Medical School could exist without a teaching hospital with the basic features described in this document. The joint committee's system has proven to be inefficient in most universities. For years now, the RD 1558/86 reform has been an important item on the National Conference of Deans of the Spanish Medical Schools (CND) agenda. The CND has also been asking for clear policies and standards concerning clinical teachers, physical spaces, infrastructure, equipment and material resources which are necessary to carry out teaching and research activities at university hospitals. A set of minimum quality criteria and a system which makes it possible to check them is also required. In the end, a targeted evaluation and stringent audits that could imply the renewal or revocation of the "universitary" qualification of a hospital is mandatory. In this article, we propose some of the criteria that should be considered with a realistic and pragmatic view

Sumario ejecutivo de las recomendaciones SEPAR de diagnóstico y tratamiento del cáncer de pulmón de células no pequeñas / Executive summary of the SEPAR recommendations for the diagnosis and treatment of non-small cell lung cancer

La Sociedad Española de Neumología y Cirugía Torácica (SEPAR), a través de las áreas de Cirugía Torácica y de Oncología Torácica, ha promovido la realización de un manual de recomendaciones para el diagnóstico y el tratamiento del cáncer de pulmón de células no pequeñas. Las elevadas incidencia y mortalidad de esta patología hacen necesaria una constante actualización de las mejores evidencias científicas para su consulta por parte de los profesionales de la salud. Para su confección se ha contado con un amplio grupo de profesionales de distintas especialidades que han elaborado una revisión integral, que se ha concretado en 4 apartados principales. En el primero se ha estudiado la prevención y el cribado de la enfermedad, incluyendo los factores de riesgo, el papel de la deshabituación tabáquica y el diagnóstico precoz mediante programas de cribado. En un segundo apartado se ha analizado la presentación clínica, los estudios de imagen y el riesgo quirúrgico, incluyendo el cardiológico y la evaluación funcional respiratoria. Un tercero trata sobre los estudios de confirmación cito-histológica y de estadificación, con un análisis de las clasificaciones TNM e histológica, métodos no invasivos y mínimamente invasivos, así como las técnicas quirúrgicas para el diagnóstico y estadificación. En un cuarto y último capítulo se han abordado aspectos del tratamiento, como el papel de las técnicas quirúrgicas, la quimioterapia, la radioterapia, el abordaje multidisciplinar por estadios y otros tratamientos dirigidos frente a dianas específicas, terminando con recomendaciones acerca del seguimiento del cáncer de pulmón y los tratamientos paliativos quirúrgicos y endoscópicos en estadios avanzados

The Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals. To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages

Executive summary of the SEPAR recommendations for the diagnosis and treatment of non-small cell lung cancer. / Sumario ejecutivo de las recomendaciones SEPAR de diagnóstico y tratamiento del cáncer de pulmón de células no pequeñas.

The Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals. To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages.

Recomendaciones SEPAR de diagnostico y tratamiento del cancer de pulmón de celulas no pequeñas / Recommendations of the Spanish Society of Pneumology and Thoracic Surgery on the diagnosis and treatment of non-small-cell lung cancer

No disponible

Benchmarking en cirugía torácica. Tercera edición / Benchmarking in Thoracic Surgery. Third Edition

Introducción: Benchmarking hace referencia a la comparación continuada de la eficiencia y la calidad entre productos y actividades con el objetivo fundamental de alcanzar la excelencia. Objetivo: Analizar los resultados del benchmarking realizado en 2013 con la actividad asistencial de Cirugía Torácica en el año 2012 en 17 servicios de Cirugía Torácica españoles participantes. Métodos: La fuente de información para el estudio ha sido el conjunto mínimo básico de datos de hospitalización correspondiente al año 2012. Los datos han sido proporcionados por los centros participantes, a partir de los informes de alta hospitalaria, sin intervención de los responsables de los correspondientes servicios asistenciales. Los casos objeto del estudio han sido todas las altas de hospitalización registradas en los centros participantes. Los episodios incluidos han sido los de enfermedad quirúrgica respiratoria (CDM4-Q) y los del servicio de Cirugía Torácica. La identificación de estos casos se realizó usando los códigos de la novena edición de la Clasificación Internacional de Enfermedades, Modificación Clínica. Para valorar las diferencias en gravedad y complejidad de los casos se ha utilizado la clasificación de los grupos relacionados por el diagnóstico refinados. Resultados: Los diversos parámetros generales estudiados (casuística, estancia media, complicaciones, readmisiones, mortalidad y actividad) han tenido una gran variabilidad entre los participantes. El análisis concreto de intervenciones (lobectomía, neumonectomía, resecciones atípicas y neumotórax), también han oscilado considerablemente. Conclusiones: Se observa, al igual que en ediciones previas, una considerable variabilidad entre los grupos participantes. Existen áreas de mejora evidentes: estandarización de los procesos de admisión, evitando ingresos urgentes y mejorando la estancia preoperatoria; agilización de las altas hospitalarias y mejora de los informes de alta, reflejando toda la actividad y las complicaciones habidas. Algunas unidades de Cirugía Torácica deben hacer una revisión profunda de sus procesos porque pueden tener algunos parámetros con una desviación excesiva de la norma. También deben mejorarse los procesos de codificación de diagnósticos y comorbilidades

Introduction: Benchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence. Objective: To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units. Methods: Study data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labelled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases. Results: General parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely. Conclusions: As in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed

Benchmarking in Thoracic Surgery. Third Edition.

INTRODUCTION: Benchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence. OBJECTIVE: To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units. METHODS: Study data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labelled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases. RESULTS: General parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely. CONCLUSIONS: As in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed.

Morbilidad, mortalidad y supervivencia en las resecciones pulmonares en el carcinoma broncogénico / No disponible

No disponible

Compresión traqueal secundaria a una luxación esternoclavicular posterior / Tracheal Compression Secondary to Posterior Sternoclavicular Dislocation

No disponible