Physicians' Distress Related to Moral Issues and Mental Health In-Between Two Late Waves of COVID-19 Contagions.

In addition to the sanitary constrains implemented due to the pandemic, frontline physicians have faced increased workloads with insufficient resources, and the responsibility to make extraordinary clinical decisions. In 108 physicians who were at the forefront of care of patients with COVID-19 during the first two years of the pandemic, mental health, moral distress, and moral injury were assessed twice, in between two late waves of COVID-19 contagions, according to their adverse psychological reactions, in-hospital experience, sick leave due to COVID-19, quality of sleep, moral sensitivity, clinical empathy, resilience, and sense of coherence. Three months after the wave of contagions, the adverse emotional reactions and moral distress decreased, while moral injury persisted. Moral distress was related to clinical empathy, with influence from burnout and sick leave due to COVID-19, and moral injury was related to the sense of coherence, while recovery from moral distress was related to resilience. The results suggest that measures to prevent physician infection, as well as strengthening resilience and a sense of coherence, may be helpful to prevent persistent mental damage after exposure to a sanitary crisis.

Effect of single infusion of ketamine on depressive symptoms in elderly patients undergoing ophthalmological surgery: a randomized controlled trial / Efecto de una sola infusión de ketamina sobre síntomas depresivos en pacientes geriátricos sometidos a cirugía oftalmológica: ensayo controlado aleatorizado

Abstract: Introduction: Depressive symptoms are common in elderly surgical patients and are associated with negative outcomes. Although medication can relieve symptoms, only 50% of patients achieve remission using conventional treatments. Recently, ketamine has been shown to improve depression rapidly. However, its use and tolerability in elderly patients has not been widely studied. Material and methods: We conducted a randomized, double-blind, comparative study in patients aged 60 and over who required ophthalmological surgery. Experimental group received 0.5 mg/kg ketamine, whereas the control group received NaCl solution at 0.9%. Both groups received a standardized regimen of conscious sedation. Depressive symptom severity was assessed using the Geriatric Depression Scale-Short Form (GDS-SF) before and after exposure to ketamine infusion; tolerability was also evaluated. A repeated univariate analysis of variance (ANOVA) model examined the direction of changes in depressive symptom severity among groups. Results: 90 patients were randomized. A significant reduction in symptom severity was observed after ketamine infusion (mean change from baseline: -1.6 vs -0.3 in the control group; p = 0.003). No differences emerged between groups in the presence of adverse effects with ketamine infusion. Conclusions: A single infusion of ketamine in elderly patients undergoing ophthalmological surgery is associated with improved depressive symptoms in the first 24 hours of exposure to the drug with a good tolerability profile.

Resumen: Introducción: Los síntomas depresivos son comunes en pacientes quirúrgicos de edad avanzada y se asocian con resultados negativos. Aunque la medicación pueda aliviar los síntomas, sólo el 50% de los pacientes que están envejeciendo alcanzan la remisión usando tratamientos convencionales. Se ha demostrado que la ketamina mejora rápidamente la depresión, sin embargo, su uso y tolerabilidad en pacientes mayores no ha sido estudiada ampliamente. Material y métodos: Se realizó un estudio aleatorizado, doble ciego, comparativo en pacientes de 60 años o más que requirieron cirugía oftalmológica. Un grupo experimental recibió 0.5 mg/kg de ketamina, mientras que el grupo control recibió solución de NaCl al 0.9%. Ambos grupos recibieron un régimen estandarizado de sedación consciente. La severidad de los síntomas depresivos fue evaluada usando la versión acortada de la escala de depresión geriátrica (GDS-SF) antes y después de la exposición a la infusión de la ketamina, la tolerabilidad también fue evaluada. Un modelo de análisis de varianza univariada de medidas repetidas (ANOVA) examinó la dirección de los cambios en la gravedad de los síntomas depresivos entre los grupos. Resultados: 90 pacientes fueron aleatorizados. Se observó, una reducción significativa en la severidad de los síntomas después de la infusión de la ketamina (cambio de la media desde el valor basal: -1.6 versus -0.3 en el grupo de control; p = 0.003). No surgieron diferencias entre los grupos en la presencia de efectos adversos con la infusión de ketamina. Conclusiones: Una sola infusión de ketamina en pacientes geriátricos sometidos a cirugía oftalmológica se asocia con la mejoría de síntomas depresivos en las primeras 24 horas de exposición al fármaco con un buen perfil de tolerabilidad.

Towards Better Perioperative Pain Management in Mexico: A Study in a Network of Hospitals Using Quality Improvement Methods from PAIN OUT.

OBJECTIVE: This was a pre-post study in a network of hospitals in Mexico-City, Mexico. Participants developed and implemented Quality Improvement (QI) interventions addressing perioperative pain management. METHODS: PAIN OUT, an international QI and research network, provided tools for web-based auditing and feedback of pain management and patient-reported outcomes (PROs) in the clinical routine. Ward- and patient-level factors were evaluated with multi-level models. Change in proportion of patients reporting worst pain ≥6/10 between project phases was the primary outcome. RESULTS: Participants created locally adapted resources for teaching and pain management, available to providers in the form of a website and a special issue of a national anesthesia journal. They offered teaching to anesthesiologists, surgeons, including residents, and nurses. Information was offered to patients and families. A total of 2658 patients were audited in 9 hospitals, between July 2016 and December 2018. Participants reported that the project made them aware of the importance of: training in pain management; auditing one's own patients to learn about PROs and that QI requires collaboration between multi-disciplinary teams. Participants reported being unaware that their patients experienced severe pain and lacked information about pain treatment options. Worst pain decreased significantly between the two project phases, as did PROs related to pain interfering with movement, taking a deep breath/coughing or sleep. The opportunity of patients receiving information about their pain treatment options increased from 44% to 77%. CONCLUSIONS: Patients benefited from improved care and pain-related PROs. Clinicians appreciated gaining increased expertise in perioperative pain management and methods of QI.

Recomendaciones analgésicas en el perioperatorio del adulto mayor / Analgesic recommendations in the perioperative of the elderly adult

Resumen: El envejecimiento acelerado de la población representa un reto importante para el sector salud. En México, la pirámide poblacional tiene la proyección de modificarse hacia el año 2050 y el cambio ya ha comenzado. Las estimaciones del Consejo Nacional de Población indican que, para el año 2040, una de cada cuatro personas que vivan en nuestro país será mayor de 60 años. Además de la longevidad, los servicios quirúrgicos también se van incrementando y, en consecuencia, es necesario implementar esquemas de analgesia ajustados a este grupo etario que envejece. El siguiente escrito pretende resumir los cambios que ocurren con la edad y presenta los diversos grupos analgésicos y su indicación acordes a los niveles de evidencia de la National Health and Medical Research Council designation (NHMRC, 1999).

Abstract: The accelerated ageing of the population represents an important challenge for the health sector. In Mexico, the population pyramid has the projection to be modified by the year 2050 and the change has already begun. Estimates from the National Population Council indicate that by the year 2040, one in four people living in our country will be over 60 years. In addition to longevity, surgical services are also increasing therefore, it is necessary to implement analgesia schemes according to this age aging group. The following writing aims to summarize changes occurring with age and presents the analgesic groups with their indication according to the levels of evidence of the National Health and Medical Research Council designation (NHMRC, 1999).

Recomendaciones en la analgesia perioperatoria para la nefrectomía laparoscópica / Recommendations in perioperative analgesia for laparoscopic nephrectomy

Resumen: La nefrectomía laparoscópica se ha convertido en el enfoque quirúrgico estándar en muchos centros de tratamiento quirúrgico para los tumores renales, así como de otras patologías. Los estudios que comparan la nefrectomía abierta y laparoscópica reportaron que la nefrectomía laparoscópica facilitó una recuperación más rápida con una menor morbilidad perioperatoria, menor pérdida sanguínea y produjo menos dolor. Sin embargo, algunos pacientes sometidos a una nefrectomía laparoscópica todavía experimentan dolor postoperatorio que requiere el uso de opiáceos parenterales. Dado que el abordaje es frecuentemente lumboscópico, la distensión y el dolor interno en ese sitio quirúrgico, las incisiones de los puertos, la nocicepción de los órganos y los cólicos ureterales en conjunto con las molestias urinarias asociadas al catéter urinario contribuyen al dolor postoperatorio. A pesar de que esta cirugía ha llegado a ser menos invasiva, el dolor se reporta de moderado a intenso (visita http://www.painoutmexico.com para obtener la versión completa del artículo y el diagrama de recomendaciones).

Abstract: Lumboscopic nephrectomy has become the standard surgical approach in many surgical treatment centers for renal tumours as well as other pathologies. Studies comparing open and laparoscopic nephrectomy reported that laparoscopic technique facilitated a faster recovery with lower peri-operative morbidity, lower blood loss, and produced less pain. However, some patients undergoing laparoscopic nephrectomy still experienced postoperative pain requiring parenteral opioids. Due to the surgical approach is often lumboscopic, the distension and pain at the inner surgical site, laparoscopic port sites and incision, organ nociception, and ureteric colic together with urinary tract discomfort associated with urinary catheter contributed to the postoperative pain. So even though this surgery has become less invasive, pain is reported from moderate to intense (visit http://www.painoutmexico.com to see the full article and recommendations).

Analgesia preventiva en el dolor postoperatorio / Preventive analgesia in postoperative pain

Resumen: El término de analgesia preventiva no es un concepto nuevo, dado que fue descrito por primera vez en 1988. El concepto (al que podríamos llamar «tratamiento antinociceptivo¼) sostiene que el alivio del dolor antes de la cirugía puede mejorar el manejo del dolor agudo postoperatorio, mediante la planificación de una analgesia pretransoperatoria, y tiene como objetivo prevenir la sensibilización del sistema nervioso central; por lo tanto, el desarrollo del dolor patológico después de una lesión tisular. Por su propia definición, se fundamenta en la prevención de un proceso alterado de las aferencias sensitivas y el impacto que tiene sobre el control del dolor agudo postoperatorio, la transición de dolor agudo a dolor crónico y la amplificación del estímulo nociceptivo agudo. Este capitulo presenta un resumen de las intervenciones de analgesia preventiva con mayor grado de evidencia en la literatura para aminorar el dolor agudo postoperatorio.

Abstract: The term of preventive analgesia is not a new concept, since it was first described in 1988. This concept (that we could call «antinociceptive treatment¼) argues that pain relief before surgery may improve the management of postoperative acute pain, by planning a pre-trans-operative analgesia and aims to prevent the sensitization of the central nervous system, therefore the development of pathological pain after a tissue injury. By its own definition, it is based on the prevention of an altered process from some sensorial afferent pathways and the impact it has on the control of postoperative acute pain, the transition from acute pain to chronic pain and the amplification of acute nociceptive stimulation. This chapter presents a summary of the interventions of preventive analgesia with the highest level of evidence in literature to ameliorate postoperative acute pain.

Respondiendo a la interrogante: ¿el metamizol es o no un antiinflamatorio no esteroideo? / Answering the question: is metamizole a non-steroidal anti-inflammatory or not?

Resumen: El objetivo de este artículo es determinar la importancia del metamizol como analgésico en México, al conocer la frecuencia de su uso y los mecanismos de acción y así clasificar adecuadamente al medicamento dentro de la farmacopea de analgésicos. Pocos fármacos generan discusión sobre su filiación, pero el metamizol, desde que salió al mercado en 1922 hasta el día de hoy, se mantiene sin definirse claramente. Comúnmente cuando se busca una clasificación de los antiinflamatorios no esteroideos (AINE), se clasifica al metamizol dentro de los mismos como derivados de la pirazolona. Se debe comenzar entonces con los aspectos farmacológicos para relacionar las semejanzas y diferencias con otros AINEs y poder sacar conclusiones adecuadas. Aun así, el medicamento es de los más utilizados por los médicos en los hospitales de segundo y tercer nivel (82%), aunque la mayoría no sabe en realidad cuál es su mecanismo de acción (91%), por ello, la importancia de conocer el mecanismo de acción de este fármaco.

Abstract: The aim of this article is to know the importance of metamizol as analgesic in Mexico, knowing the frequency of their use and the mechanisms of action and to adequately classify the drug in the pharmacopoeia of painkillers. Few drugs generate discussion about their parentage but metamizol from that hits the market in 1922 until today, it has no clearly defined. Commonly when NSAIDs rated seeks to metamizol is classified within the same as pyrazolone derivatives. We then start with the pharmacological aspects and later to know the similarities and differences with other NSAIDs and can draw appropriate conclusions. Even so, the medicine is one of the most used by physicians in second and third level hospitals (82%), although most do not really know what their mechanism of action is (91%), so the importance of knowing the mechanism of action of this drug.

Gabapentine 300 mg vs. 450 mg as anesthetic premedication for reactive hypertension, anxiety and analgesia / Gabapentina a dosis de 300 vs. 450 mg como premedicación anestésica para hipertensión reactiva, ansiedad y analgesia.

Objective: Observe the behavior of gabapentin to reduce reactive hypertension secondary to anxiety and pain in patients undergoing ophthalmic surgery as well as opioid consumption between groups. Method: Clinical randomized double blind controlled trial that analyzed 125 patients divided into three groups: Group A, gabapentin 300 mg; Group B, gabapentin 450 mg; and Group C, amaranth dragees as a control 2 h before the surgical procedure. Chi-squared test was used in sociodemographic variables and one-way ANOVA for continuous numeric variables. It was considered as significant a p < 0.05 for a study of two tails with a power of 80% beta. Results: Anxiety and analgesia intraoperative and postoperative had significant differences between groups. Lower consumption of opioid was found in the groups that used gabapentin. Conclusions: Gabapentin orally 300 or 450 mg h prior to surgery reduces pain, anxiety and postoperative opioid consumption in patients undergoing ophthalmic surgery.

Objetivo: Observar el comportamiento de la gabapentina para aminorar la hipertensión reactiva secundaria a ansiedad y dolor en pacientes sometidos a cirugía oftálmica, así como el consumo de opiáceos entre los grupos. Método: Ensayo clínico controlado aleatorizado y doble ciego que analizó a 125 pacientes divididos en tres grupos: grupo A, gabapentina 300 mg; grupo B, gabapentina 450 mg; grupo C, amaranto en grageas como control 2 horas antes del procedimiento quirúrgico. Se utilizó la prueba de ji al cuadrado para variables sociodemográficas y ANOVA de un factor para variables numéricas continuas. Se consideró como significativo un valor de p < 0.05 para un estudio de dos colas con un poder beta del 80%. Resultados: La ansiedad y la analgesia transoperatoria y posoperatoria tuvieron diferencias significativas entre los grupos. Se encontró menor consumo de opiáceos en los grupos que usaron gabapentina. Conclusiones: La gabapentina por vía oral, 300 o 450 mg, 2 horas antes de la cirugía, reduce el dolor, la ansiedad y el consumo de opiáceos durante el posoperatorio en pacientes sometidos a cirugía oftalmológica.

[Assessment of amylase and lipase levels following puncture biopsy and fine needle aspiration guided by endoscopic ultrasound in pancreatic lesions]. / Evaluación de los niveles de amilasa y lipasa posterior a la realización de biopsia por aspiración con aguja fina guiada por ultrasonido endoscópico en lesiones del páncreas.

BACKGROUND: Puncture biopsy and fine needle aspiration guided by endoscopic ultrasound has been used as an effective technique and is quickly becoming the procedure of choice for diagnosis and staging in patients suspected of having pancreatic cancer. This procedure has replaced retrograde cholangiopancreatography and brush cytology due to its higher sensitivity for diagnosis, and lower risk of complications. OBJECTIVE: To assess the levels of pancreatic enzymes amylase and lipase, after the puncture biopsy and fine needle aspiration guided by endoscopic ultrasound in pancreatic lesions and the frequency of post-puncture acute pancreatitis. MATERIAL AND METHODS: A longitudinal and descriptive study of consecutive cases was performed on outpatients submitted to puncture biopsy and fine needle aspiration guided by endoscopic ultrasound in pancreatic lesions. Levels of pancreatic enzymes such as amylase and lipase were measured before and after the pancreatic puncture. Finally we documented post-puncture pancreatitis cases. RESULTS: A total of 100 patients who had been diagnosed with solid and cystic lesions were included in the study. Significant elevation was found at twice the reference value for lipase in 5 cases (5%) and for amylase in 2 cases (2%), none had clinical symptoms of acute pancreatitis. Eight (8%) of patients presented with mild nonspecific pain with no enzyme elevation compatible with pancreatitis. CONCLUSION: Pancreatic biopsy needle aspiration guided by endoscopic ultrasound was associated with a low rate of elevated pancreatic enzymes and there were no cases of post-puncture pancreatitis.

[Celiac block in paediatric patients using endoscopic ultrasound for management of severe pain due to chronic pancreatitis. Review of the technique in 2 cases]. / Bloqueo celiaco en Pediatría mediante ultrasonido endoscópico para el manejo de dolor por pancreatitis crónica. Revisión de la técnica en 2 casos.

BACKGROUND: Pancreatic diseases such as cancer, idiopathic recurrent pancreatitis, and chronic pancreatitis, can cause pain that is difficult to control. Pain is one of the most debilitating symptoms and demands increasing doses of analgesics and narcotics, as well as the number of hospital admissions, with a direct implication in the costs of medical treatments. OBJECTIVE: To describe the experience with 2 paediatric patients who were subjected to an ultrasound-guided endoscopic celiac ganglion block for difficult pain management, secondary to chronic pancreatitis disease. CLINICAL CASES: The first case concerns a 9-year-old male with a diagnosis of chronic pancreatitis, and the second case is a 12-year-old female who developed episodes of intermittent acute pancreatitis. Both cases suffered from chronic abdominal pain, which was difficult to control with stronger painkillers, such as opioids. The pain decreased after patients were subjected to an ultrasound-guided endoscopic celiac ganglion block. CONCLUSIONS: This technique showed that both patients obtained satisfactory pain relief, with significant improvements in general symptomatology and the stopping of almost all analgesic medication. The authors suggest that celiac ganglion block must be considered, and implemented early before the usual complications, such as a consumption syndrome that is frequent in paediatric patients with chronic pancreatitis.

The Per Oral Endoscopic Myotomy (POEM) technique: how many preclinical procedures are needed to master it?

BACKGROUND AND STUDY AIM: Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model. PATIENTS AND METHODS: This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1) = 30 ex vivo and Group 2 (G2) = 20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2. RESULTS: A total of 50 POEM were done in both groups (G1 = 30, G2 = 20). The mean times were 90.17 min (G1) and 89.50 min (G2) (P = 0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; P = 0.009) with a slightly slower tunnelization (40.35 vs 41.13 min; P = 0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; P = 0.26). VTM between the groups was similar (G1 = 0.159 vs G2 = 0.157 cm/min; P = 0.925). Complications were: mucosotomy (G1 = 18 %, G2 = 8 %; P = 0.430), mediastinal perforation (G1 = 12 %, G2 = 8 %; P = 1.0), and perforation at the gastroesophageal junction (GEJ) level (G1 = 16 %, G2 = 4 %; P = 0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases. CONCLUSIONS: We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.