Implementation of an Enhanced Recovery After Surgery (ERAS) protocol for acute complicated and uncomplicated appendicitis.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols are well-documented logistic programs in elective surgery but it is still uncertain whether ERAS can benefit emergency patients, because of significant challenges facing its application to emergency surgery. The aim of this study was to evaluate the implementation of an ERAS protocol for patients with acute appendicitis (AA), both complicated and uncomplicated. METHODS: A prospective observational study was performed at two university hospitals in Spain, between January 2012 and December 2019. Inclusion criteria were patients with diagnosis of AA, undergoing appendectomy following an ERAS protocol of perioperative care. The different items of the ERAS protocol were recorded and their implementation was separately evaluated. Analyzed variables also included postoperative complications, hospital stay and readmission rate. Levels of acute phase reactants were assessed as predictors of implementation for the ERAS protocol. RESULTS: Eight hundred fifty patients were included; 498 males (58.5%) and 302 females (41.5%), with a mean age of 34.95 ± 17 years. The implementation of all the items of the protocol was achieved in 770 patients (90.6%), 86.8% of patients with complicated AA and 93.1% of patients with uncomplicated AA (p = 0.02). Higher preoperative C-reactive protein (CRP) levels were significantly associated with the impossibility of implementing all the items of the ERAS protocol (p < 0.001), establishing a cut-off point at CRP = 13.5 mg/dl. CONCLUSIONS: The implementation of ERAS protocols is safe and feasible in patients with AA. Although the implementation rate of all the items is lower in patients with complicated AA, it can be completed in 86.8% of these patients. CRP levels over 13.5 mg/dl are predictors of difficulties in the implementation of all the items of ERAS protocols.

[Memory complaints: mental health, diseases, pain and loneliness. A population study in the city of Madrid]. / Quejas de memoria: salud mental, enfermedades, dolor y soledad. Estudio poblacional en la ciudad de Madrid.

INTRODUCTION: Subjective memory complaints (SMC) are considered predictor of cognitive impairment, but are also associated with other factors; social and lifestyle have been the least studied. AIM: To evaluate SMC and their association with epidemiological, health, social and lifestyle variables. SUBJECTS AND METHODS: Cross-sectional epidemiological study of the randomly selected population of Madrid. Telephone interview. TARGET POPULATION: 1,775 over 55 years of age. We asked about QSM, social, economic, health and lifestyle aspects. The Goldberg General Health Questionnaire (GHQ) and the COOP-Wonca Quality of Life Questionnaire were administered. RESULTS: We found statistically significant association of SMC with age, temporal orientation, all variables related to mental health (depression), anxiety, sleep, mental health/GHQ, and quality of life. Association was found with all pain variables and with loneliness. There was no association with specific diseases, except chronic allergy and those linked to pain. The predictors of the SMC were temporal orientation, multimorbidity, mental health/GHQ, anxiety, pain and feeling lonely. CONCLUSIONS: SMC is a multi-caused symptom. They are associated with lower memory performance, but also with variables related to health, social aspects and lifestyle. When faced with a patient with SMC, which may be due to cognitive impairment because of Alzheimer's disease, these associations should be taken into account to assess this risk and know when follow-up is most needed.

TITLE: Quejas de memoria: salud mental, enfermedades, dolor y soledad. Estudio poblacional en la ciudad de Madrid.Introducción. Las quejas subjetivas de memoria (QSM) se consideran predictoras del deterioro cognitivo, pero se asocian también a otros factores; los sociales y los hábitos de vida han sido los menos estudiados. Objetivo. Valorar las QSM y su asociación con variables epidemiológicas, de salud, sociales y hábitos de vida. Sujetos y métodos. Estudio epidemiológico trasversal de la población de Madrid elegida aleatoriamente según censo. Entrevista telefónica. Población diana: 1.775 mayores de 55 años. Se preguntó sobre QSM, aspectos sociales, económicos, de salud y hábitos de vida. Se administraron el cuestionario de salud general de Goldberg (GHQ) y el cuestionario de calidad de vida COOP-Wonca. Resultados. Encontramos asociación estadísticamente significativa de las QSM con la edad, la orientación temporal, todas las variables relacionadas con la salud mental (depresión), la ansiedad, el sueño, la salud mental/GHQ y la calidad de vida. Se halló asociación con todas las variables que miden el dolor y con sentir soledad. No hubo asociación con enfermedades específicas, excepto con la alergia crónica y las ligadas al dolor. Los predictores de las QSM fueron la orientación temporal, la multimorbilidad, la salud mental/GHQ, la ansiedad, el dolor y el sentir soledad. Conclusiones. Las QSM son un síntoma con múltiples causas. Se asocian a menor rendimiento de la memoria, pero también a variables relacionadas con la salud, los aspectos sociales y el tipo de vida. Ante un paciente con QSM, que pueden deberse al deterioro cognitivo por enfermedad de Alzheimer, deben considerarse estas asociaciones para valorar dicho riesgo y saber cuándo es más necesario un seguimiento.

Multifractal analysis to study break points in temperature data sets.

Since the last century, the air surface temperature has increased at a global scale, showing trends and inhomogeneities that vary from place to place. Many statistical methods can be used to analyze whether or not an inhomogeneity or break point exists in a meteorological data series, and even to detect the time of the break. Sometimes, there is no agreement in the year at which the inhomogeneity occurs detected by different tests. The scale invariance of a process can be studied through its multifractal properties that can be related to the existence of break points in it. In this work, the multifractal properties of monthly temperature data series are used to test what is the right break point year in those situations at which different dates are found by two different tests: the Pettitt and the Standard Normal Homogeneity tests. The comparison of the fractal dimension function Dq and the multifractal spectrum obtained by the box counting method for both the original data sets and for those obtained by splitting the original into two considering the break point years was made. When different multifractal functions and parameters were obtained, a break point was confirmed. Whereas, if equal values appeared, the break point year was discarded. These results let to select the most suitable test to be applied to detect inhomogeneities in a certain data set that will be very useful for climate change studies.

Multifractal analysis of diurnal temperature range over Southern Spain using validated datasets.

Multifractal properties of diurnal temperature range (DTR) have been analyzed in this work, using validated data of maximum and minimum temperature from 197 weather stations in Southern Spain (Andalusia region). DTR is a crucial factor to characterize the regional climate, providing more information than the average daily temperature. Apart from climate change studies, one of the most important applications of DTR in Agrometeorology is as an input variable in the solar radiation or reference evapotranspiration estimation models based on the temperature. With the aim of obtaining a detailed information for different time scales, different multifractal approaches have been applied. Different quality control methods such as range/limits or persistence tests were previously applied in order to detect incorrect and anomalous values, being discarded in the subsequent analysis. The DTR scaling of moments has been analyzed and the moment scaling exponent function K(q) has been obtained, finding some differences between weather stations. In addition, multifractal dimension (D1) and multifractal degree (MD) were also estimated, revealing differences at coastal and inland locations that show heterogeneity across the region, including its multifractal nature and its invariance for a range of scales. The nonlinear characterization carried out in this work improves the understanding of DTR as an indicator of climate changes, and it can have a very positive impact on the calibration of regional models for estimating solar radiation or reference evapotranspiration based on the temperature. This multifractal characterization can be used to group stations with similar nonlinear dynamics, regardless of their geographical features, in such a way that more accurate coefficients than conventional ones are used.

Effects of the application of vitamin E and silicone dressings vs conventional dressings on incisional surgical site infection in elective laparoscopic colorectal surgery: a prospective randomized clinical trial.

AIM: To compare the effect of conventional wound dressings (CD) with vitamin E and silicone (E-Sil) dressings on incisional surgical site infection (SSI) in patients undergoing elective colorectal laparoscopic surgery. PATIENTS AND METHODS: A prospective, randomized study was performed. Patients were assigned at random into two groups: an E-Sil group and a CD group. Incisional SSI, postoperative pain and acute phase reactants were investigated. RESULTS: In total, 120 patients were included in this study (60 in each group). The incisional SSI rate was 3.4% in the E-Sil group and 17.2% in the CD group (P = 0.013). Bacteroides fragilis alone grew in the cultures of infected wounds in the E-Sil group, while cultures for infected wounds in the CD group were polymicrobial. Mean postoperative pain 48 h after surgery was 27.1 [standard deviation (SD) 10.7] mm in the E-Sil group and 41.6 (SD 16.9) mm in the CD group (P < 0.001). White blood cell (WBC) count and C-reactive protein (CRP) level were lower in the E-Sil group, even after the exclusion of patients presenting with postoperative complications. CONCLUSION: Use of an E-sil dressing to cover the Pfannestiel wound after elective laparoscopic colorectal surgery leads to a reduction in the incisional SSI rate, lower postoperative pain, and a decrease in CRP level and WBC count.

Sub-Femto-g Free Fall for Space-Based Gravitational Wave Observatories: LISA Pathfinder Results.

We report the first results of the LISA Pathfinder in-flight experiment. The results demonstrate that two free-falling reference test masses, such as those needed for a space-based gravitational wave observatory like LISA, can be put in free fall with a relative acceleration noise with a square root of the power spectral density of 5.2±0.1 fm s^{-2}/sqrt[Hz], or (0.54±0.01)×10^{-15} g/sqrt[Hz], with g the standard gravity, for frequencies between 0.7 and 20 mHz. This value is lower than the LISA Pathfinder requirement by more than a factor 5 and within a factor 1.25 of the requirement for the LISA mission, and is compatible with Brownian noise from viscous damping due to the residual gas surrounding the test masses. Above 60 mHz the acceleration noise is dominated by interferometer displacement readout noise at a level of (34.8±0.3) fm/sqrt[Hz], about 2 orders of magnitude better than requirements. At f≤0.5 mHz we observe a low-frequency tail that stays below 12 fm s^{-2}/sqrt[Hz] down to 0.1 mHz. This performance would allow for a space-based gravitational wave observatory with a sensitivity close to what was originally foreseen for LISA.

Effects of hydroxylation and silanization on the surface properties of ZnO nanowires.

Silanization is commonly used to form bonds between inorganic materials and biomolecules as a step in the surface preparation of solid-state biosensors. This work investigates the effects of silanization with amino-propyldiethoxymethylsilane on hydroxylated sidewalls of zinc oxide (ZnO) nanowires (NWs). The surface properties and electrical characteristics of NWs are analyzed by different techniques after their hydroxylation and later silanization. Contact angle measurements reveal a stronger hydrophobic behavior after silanization, and X-ray photoelectron spectroscopy (XPS) results show a reduction of the surface dipole induced by the replacement of the hydroxyl group with the amine terminal group. The lower work function obtained after silanization in contact potential measurements corroborates the attenuation of the surface dipole observed in XPS. Furthermore, the surface band bending of NWs is determined from surface photovoltage measurements upon irradiation with UV light, yielding a 0.5 eV energy in hydroxylated NWs, and 0.18 eV, after silanization. From those results, a reduction in the surface state density of 3.1 × 10(11) cm(-2) is estimated after silanization. The current-voltage (I-V) characteristics measured in a silanized single NW device show a reduction of the resistance, due to the enhancement of the conductive volume inside the NW, which also improves the linearity of the I-V characteristic.

Evaluación y manejo de los insulinomas. Presentación de 4 casos y revisión de la literatura / Evaluation and management of the insulinomas. Report of four cases and review of the literature

Introducción: Los insulinomas son tumores neuroendocrinos poco frecuentes que habitualmente tienen buen pronóstico. El objetivo es la presentación y revisión de la literatura médica a propósito de 4 casos. Material y Métodos: Estudio descriptivo, observacional y retrospectivo de los pacientes diagnosticados e intervenidos en el Hospital Universitario de San Juan de Alicante de insulinomas, en un periodo de 18 años (1995-2013). Resultados: Nuestro grupo de estudio incluyó 4 pacientes, 1 caso en hombres (25%) y 3 en mujeres (75%), con una mediana de edad de años (rango 3; 72). La distribución de las lesiones fue : cuerpo (1 caso), proceso uncinado (1 caso), cabeza (1 caso), cola (1 caso). El diagnóstico preoperatorio se realizó mediante test del ayuno y Tac abdominal. La ecografía intraoperatoria se realizó en todos los casos. El procedimiento quirúrgico de elección fue la enucleación. Actualmente se encuentran libres de enfermedad en un seguimiento a 10 años. Conclusiones: Los insulinomas son tumores infrecuentes que presentan buen pronóstico a largo plazo. Su diagnóstico topográfico en ocasiones es complejo. El tratamiento de elección es la cirugía y el procedimiento quirúrgico empleado con mayor frecuencia es la enucleación

Background: Insulinomas are infrecuent neuroendocrine tumors that usually have a good prognosis. The goal is the presentation and review of the literature about 4 cases. Methods: A retrospective study of all patients diagnosed with insulinomas surgically managed at San Juan de Alicante Hospital during the period between 1995 and 2013 was performed. Results: We analyzed 4 patients, three females (75%) and one male (25%) with a range age (39 to 72 years). Distribution of the lesions were: body (1 case), uncinate process (1 case), head (1 case), tail (1 case). Preoperative diagnosis was made by fasting test and abdominal CT. In all cases, intraoperative ultraound was made. Surgical management of choice was enucleation. Currently, they are free of disease at 10 years of follow up. Conclusions: Insulinomas are infrecuent tumors with good long-term prognosis. Its topographic diagnosis is sometimes complex. The treatment of choice is surgery and the surgical procedure most often used is enucleation

[Gallstone ileus, an uncommon cause of bowel obstruction]. / Íleo biliar, causa poco frecuente de obstrucción intestinal.

Gallstone ileus is a rare complication of cholelithiasis. It is characterized by bowel obstruction secondary to gallstone impaction at some point of the gastrointestinal tract due to the existence of a bilioenteric fistula. The aim of this analysis was to evaluate our experience through a retrospective study, covering a 12-year period. It included 14 cases (10 women and 4 men) with a median age of 81 years; 11 of the patients had comorbidities. The main analytic alteration was an increase in urea (median 79mg/dl). Diagnosis was confirmed through abdominal computed tomography in 10 cases and plain abdominal x-ray in 4. The stone was located in the jejunum in 6 cases, the ileum in 6, and the sigmoid colon in one; the mean stone size was 3cm. There were 11 cases of cholecystoduodenal fistula, one case of cholecystocolonic fistula, and one idiopathic fistula. Two patients died, including the patient that did not undergo surgery.

Bullhorn and bullfighting injuries.

PURPOSE: Our purpose was to present our hospital experience with bullhorn injuries. METHODS: A retrospective analysis of patients in our Trauma Registry (1993-2012). RESULTS: Fifteen patients were included. All were hemodynamically stable on presentation, with a mean Glasgow Coma Scale (GCS) score and a Revised Trauma Score (RTS) of 15 and 11.9, respectively. The Injury Severity Score (ISS) and New Injury Severity Score were 13.6 ± 6 and 15.9 ± 9, respectively. Seven had an ISS > 15. Injuries resulted from an isolated blunt trauma (BT) in four, penetrating trauma (PT) in seven, with extensive soft tissue injuries (STI) in three, and a combined BT + PT mechanism in four patients, with extensive STI in all. Three patients had injuries to vessels in the groin, two with prehospital vein ligation. Five patients had abdominal visceral injuries, and another had a sheathed goring, with a traumatic abdominal wall hernia and retroperitoneal hematoma. Four patients had thoracic injuries, and one of them had a traumatic thoracoplasty with a large open thoracic wound, a flail chest, and extensive STI. Two patients had traumatic brain injury, and six had bone fractures. Two-thirds of patients required a surgical procedure under general anesthesia. Morbidity included three surgical site infections, one leg compartment syndrome, and one persistent lymph drainage. There was no mortality, and the mean length of hospital stay was 16 days. CONCLUSIONS: Bullhorn and bullfighting injuries frequently have a multimechanistic origin which goes beyond a pure penetrating trauma. Associated blunt and STI were common in our series, and the overall prognosis of patients admitted to hospital was good.

Conducting properties of nearly depleted ZnO nanowire UV sensors fabricated by dielectrophoresis.

ZnO nanowires (NWs) with different radii (rNW) have been aligned between pre-patterned electrodes using dielectrophoresis (DEP) for the fabrication of high gain UV sensors. The DEP conditions (voltage amplitude and frequency) and electrode material, geometry and size were optimized to enhance the efficiency during the DEP process. To understand the alignment mechanism of the ZnO NWs, the dielectrophoretic force (FDEP) was analyzed as a function of the DEP conditions and NW dimensions. These studies showed that the DEP alignment process tends to trap NWs with a smaller radius. The effects of NW size on device performance were analyzed by means of I-V measurements in darkness and under illumination (200 nm < λ < 600 nm). In darkness, the NW resistance increases as rNW decreases due to the reduction of the conduction volume, until saturation is reached for rNW < 65 nm. On the other hand, the NW spectral photoresponse shows high values around 10(8) A W(-1) (measured at 5 V and λ < 370 nm) and follows a linear trend as a function of the NW cross section. In addition, the cut-off wavelength depends on rNW, presenting a clear blue-shift for NWs with a lower radius (rNW < 50 nm). Transient photoresponse studies show that NWs with lower radii have longer rise times and shorter decay times mainly due to surface trapping effects. Regardless of NW size, passivation of the surface using a dielectric capping layer of SiO2 reduces the dynamic range of the photoresponse due to a strong increase of the dark current.

Multifractal analysis of validated wind speed time series.

Multifractal properties of 30 min wind data series recorded at six locations in Cadiz (Southern Spain) have been studied in this work with the aim of obtaining detailed information for a range of time scales. Wind speed records have been validated, applying various quality control tests as a pre-requisite before their use, improving the reliability of the results due to the identification of incorrect values which have been discarded in the analysis. The scaling of the wind speed moments has been analysed and empirical moments scaling exponent functions K(q) have been obtained. Although the same critical moment (qcrit) has been obtained for all the places, some differences appear in other multifractal parameters like γmax and the value of K(0). These differences have been related to the presence of extreme events and zero data values in the data series analysed, respectively.

Acute abdominal pain due to ruptured ovarian endometrioma with high CA125 and CA19- 9 levels

Una mujer de 47 años fue atendida en el servicio de urgencias por dolor abdominal de 72h de evolución con una elevación de los niveles plasmáticos de leucocitos, CA 19–9 y CA 125. La paciente fue intervenida encontrando un endometrioma roto en el ovario izquierdo. Los altos niveles de ambos marcadores tumorales nos obligaron a descartar una neoplasia de ovario en este caso (AU)

A 47-year-old woman presented to the emergency department complaining of abdominal pain for the last 3 days, with an increase in serum levels of white blood cells, CA19-9 and CA-125. Surgery revealed a ruptured left ovarian endometrioma. In this case, high levels of both antigens forced us to exclude an ovarian neoplasm (AU)

Functional outcome and quality of life in victims of terrorist explosions as compared to conventional trauma.

BACKGROUND: Following trauma, the number of preventable deaths is low. Outcome should also be measured in terms of quality of life (QoL). Studies analyzing QoL in trauma patients have been published, but little is known about the long term QoL of victims of terrorist attacks. METHODS: This is a case-control study of casualties of the March 11, 2004 attacks in Madrid. Patients treated for other trauma with similar age and Injury Severity Score (ISS), served as controls. Patients were assessed using the POLO-Chart (VAS, SF-36 and TOP). RESULTS: Fifty-eight patients were included, 32 casualties admitted following the March 11, 2004 attacks and 26 controls. Both groups were comparable in age (average = 37), ISS (average = 23) and time from trauma (average = 1,770 days). Subjects demonstrated lower scores for the VAS, and the SF-36 clusters social functioning, role emotional and mental health. There was a tendency towards higher prevalence of symptoms associated to posttraumatic stress disorder (PTSD) in subjects (p = 0.056). Subjects suffered from higher residual pain in the head region (p = 0.032). Strong association was found between the presence of symptoms associated to depression, anxiety and PTSD and worse QoL (p < 0.001). CONCLUSION: Subjects present more emotional distortions, residual pain in the head region and a tendency towards a worsened perception of their own health and wellness. They also present symptoms associated to PTSD more frequently. The presence of symptoms associated to PTSD, depression or anxiety was an independent variable related to lower QoL in both groups.

Fournier's gangrene: analysis of prognostic variables in 34 patients.

INTRODUCTION: Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area. The objective of this study was to assess risk factors for mortality. MATERIALS AND METHODS: We conducted an analytic and retrospective study of the patients with FG treated at our institution between 1998 and 2008. Statistical analysis was performed with the Statistical Package for Social Science for Windows, version 15.0, using the Mann-Whitney test for quantitative variables, and the chi-square and Fisher exact tests for qualitative variables, in univariate analyses. RESULTS: Of the 34 patients treated, 25 survived (74%) and 9 died (26%) with a median timing of 29 days (13, 60). Statistically significant differences were not found in age, sex and predisposing factors, except heart disease (p = 0.034). Admission laboratory parameters and severity criteria showed significant differences in serum urea (p = 0.007), potassium (p = 0.008), alkaline phosphatase (p = 0.014) and Fournier's gangrene severity index score (FGSIS) (p = 0.008). Others factors such as duration of symptoms before hospital admission, extent of body surface area, number of surgical debridements, additional surgical manoeuvers (supra-pubic catheterization or colostomy), microbiological cultures and ICU stay did not show significant differences. CONCLUSIONS: FG is a life-threatening necrotizing fasciitis with a high mortality rate. In our study, prognostic variables were heart disease, admission serum urea, potassium, alkaline phosphatase, and FGSIS. More studies are needed to validate these findings.

Anatomy-based surgical strategy of gastrointestinal fistula treatment.

Anatomic delineation of a gastrointestinal fistula is essential in assessing the likelihood of spontaneous closure or to plan the surgical management. Computed tomography (CT) enterography and/or fistulograms provide invaluable information. The surgical strategy should carefully consider the when and how, as well as the special clinical situations that may arise following radiotherapy, the inaccessible or "frozen abdomen", and enteroatmospheric fistulas (EAFs). New operations like those performed in bariatric surgery, and the wide acceptance of the damage-control philosophy in severe trauma, have given rise to new types of fistulas and increased the occurrence of others. When confronted with this difficult complication, the surgeon must always exercise patience and restraint, and be open-minded about the different surgical alternatives to solve the problem.

[Lower gastrointestinal bleeding secondary to rectal gastrointestinal stromal tumor]. / Hemorragia digestiva baja secundaria a tumor del estroma gastrointestinal rectal.

Gastrointestinal stromal tumors are the most frequent mesenchymal digestive tract neoplasms, but represent only 1 to3% of all GI tract neoplasms. We report an uncommon case of stromal rectal tumor because of its atypical location.

[Local resection and radiofrequency hepatic epithelioid hemangioendothelioma]. / Resección local y radiofrecuencia en hemangioendotelioma epitelioide hepático.

Epithelioid hemangioendothelioma is an uncommon tumor of vascular endothelial cell origin with a clinical course between hemangioma and angiosarcoma. Clinical manifestations and radiological findings are nonspecific, and histopathologic examination is required to establish a definitive diagnosis. Currently, hepatic resection or liver transplantation is the best therapeutic options. Because of its unknown biological behavior, local resection and radio-frequency ablation, although an uncommon treatment method, can be performed in the absence of extrahepatic or diffuse involvement.

[Low back pain as a manifestation of an intra-abdominal desmoplastic small round cell tumor]. / Dolor lumbar como manifestación de un tumor intra-abdominal desmoplásico de células pequeñas y redondas.

The desmoplastic small round cell tumor is infrequent.That mainly affects male youngsters and is normally located at the abdomino-pelvic cavity, being its clinic unspecific. The diagnosis is confirmed by the presence of a specific chromosomal translocation: t (11; 22), (p13; q12). As to its treatment, it is mostly recommended to follow a multimodal aggressive one. We present the case of a man, whose atypicality is due to his advanced age (63 years old) and the symptoms he presents (lumbar ache).