Is there a trend towards semi-extended knee positioning during intramedullary tibial nailing in Latin America? A survey among 990 orthopaedic surgeons.

OBJECTIVE: The aim of this study was to evaluate the Latin American orthopaedic trauma surgeons preference regarding knee positioning and entry portals for IM nailing and identify the reasons of these preferences. METHODS: Using the AO Trauma database, 22.285 surveys were distributed by email to Latin American orthopaedic surgeons. Demographic data and practice patterns, especially regarding knee positioning and approach for tibial nailing, were then evaluated and statistically treated. RESULTS: amongst one thousand five hundred fourteen responses, 990 orthopaedic surgeons (4.4% of response rate) fully responded to the survey. Transpatellar tendon approach (613 / 61.9%,) with the knee in flexion (518 / 52.3%) on a radiolucent table remains the standard practice for intramedullary tibial nailing. Even for proximal and distal tibial nailing, the transpatellar tendon approach (455 / 46%) with the knee in flexion (562 / 56.8%) hold on the most used method. Only 55 (9.36%) orthopaedic surgeons reported that they have migrated to the supra-patellar tibial nailing in the recent years. The main reasons for a low rate of migration were lack of knowledge about the technique and unavailability of specific gigs and cartilage protectors for a safe suprapatellar nailing. CONCLUSION: Even with the potential benefits of the semi-extended knee positioning for tibial nailing, the Latin American orthopaedic community remains using the transpatellar tendon approach with the knee in flexion as the standard technique. Lack of surgical training for suprapatellar and parapatellar approaches with the knee in semi-extension, added by the unavailability of suprapatellar jigs and soft outer protection sleeves contribute to counter the trend towards the semi-extended techniques.

Availability and use of resources for emergency fracture care of pelvic trauma associated with haemorrhagic shock in Latin America: A cross-sectional study.

Determining the true availability of resources and understanding the level of training of surgeons involved in the treatment of patients with pelvic fractures and haemorrhagic shock is critical. In the herein study, the availability of technical, technological, and human resources for the care of this injury in Latin America region was analysed, and the preferences of orthopaedic trauma surgeons when performing interventions for the diagnosis and treatment of patients with pelvic trauma and associated haemorrhagic shock was described. A cross sectional web-based survey containing questions on knowledge, attitudes, and practices with respect to imaging resources, emergency pelvic stabilization methods, and interventions used for bleeding control was sent to 948 Latin America orthopaedic trauma surgeons treating pelvic fractures in the emergency department. Differences between regional clusters, level of training, type of hospital, and pelvic surgery volume were assessed. 368 responses were obtained, with 37.5% of respondents reporting formal training in pelvic surgery and 36.0% having available protocol for managing these patients. The most frequently used interventions were the supra-acetabular pelvic external fixator and pelvic packing. Limited hospital and imaging resources are available for the care of patients with pelvic trauma and associated haemorrhagic shock throughout Latin America. In addition, the training of orthopaedic trauma surgeons dealing with this type of injury and the volume of pelvic surgeries per year is heterogeneous. It should be urgently considered to develop management protocols adapted to Latin America according to the availability of resources, as well as to promote training in this severe life-threatening traumatic condition.

Treatment of fracture-related infection in Latin America (FRILA). Proposal for a multicentre regional registry.

Postoperative bone infection is a severe complication in the treatment of fractures. The management of this pathology is challenging, but recent advances have been made to achieve standardization that can help diagnosis and decision-making. However, we are unaware of studies validating these models in Latin America. Therefore, this study aims to collect data from patients with fracture-related infections treated in different institutions in Latin America to create a registry that will assist in future clinical decision-making regarding the diagnostic process and the surgical and medical treatment of these patients.

An Overview of Genus Malachra L.-Ethnobotany, Phytochemistry, and Pharmacological Activity.

The genus Malachra L. belongs to the family Malvaceae. It includes herbs or subshrubs of nine accepted species with approximately thirty synonyms, and it has been widely used in community folk medicine to treat health problems including inflammation, nasal obstruction, leishmaniasis, malaria, childbirth, kidney disorders, fever, respiratory tract diseases, among others. From the genus Malachra L., flavonoids, steroids, triterpenes, anthocyanins, leucoanthocyanins, saponins, carbohydrates, phenols, glycosides, and alkaloids have been isolated and identified. Some pharmacological reports have indicated that the genus has antidiarrheal, antiepileptic, antiulcerogenic, antioxidant, anticonvulsant, antiviral, anticancer, antibacterial, anthelmintic, and hepatoprotective properties. However, there have been limited studies of bioactive molecules with pharmacological and biological activities associated with Malachra alceifolia Jacq., Malachra capitata (L.) L., Malachra fasciata Jacq., Malachra radiata (L.) L., Malachra ruderalis Gürke., Malachra rudis Benth., Malachra helodes Mart., Malachra urens Poit. ex Ledeb. & Alderstam., and Malachra officinalis Klotzsch. In this review, we consider the conservation of these species to save the ancestral knowledge of their traditional use in populations, and their pharmacological potential for future studies in search of alternatives for solutions to diseases in humans and animals and tools for the design and search of potential bioactive compounds against infectious and non-infectious agents.

Fragility fracture systems, Latin America perspective.

Osteoporosis is a worldwide epidemic, affecting an average of 30% to 50% of those over 50 years of age in Latin America. Resulting from it is another epidemic, that of fragility fractures, which adversely affects morbidity and mortality of this population. Increasing in their incidence, fragility fractures are expected to occur in 1 in 3 women and 1 in 5 men over 50years of age during their lifetimes. Currently, there are diagnostic and management guidelines for fragility fractures in Latin American countries, especially those for hip and spine fractures. In general, in Latin America, the quality indicators and standards for the care of these fractures vary greatly according to the health system, being suboptimal in many situations. The organization of health services is different in the different countries throughout Latin America. Common underlying characteristics, however, include the distinctions that exist in care between public and private medicine and the lack of economic resources directed to public healthcare systems from the national levels. Several important changes have been implemented in recent years, with the collaboration between national organizations and international associations such as the Fragility Fracture Network and the International Osteoporosis Foundation, aimed at improving quality standards in care and rates of morbidity and mortality in patients treated thorough fragility fracture programs. The underregistration in these programs and absence of formal national registries also contribute to a lack of recognition of the size, scope, and severity of the problem.

Factores asociados con amputación de miembros inferiores de pacientes con pie diabético en una cohorte / Factors associated with lower limb amputation of patients with diabetic foot in a cohort

Introducción: El desarrollo de ulceraciones en el Pie Diabético (PD) puede derivar en amputación de miembros inferiores e incluso impactar la morbi mortalidad de los pacientes diabéticos. Por lo anterior, este estudio pretende evaluar las características de los pacientes con PD hospitalizados y manejados en un hospital regional. Materiales y métodos: 121 pacientes son incluidos en el estudio de cohorte retrospectiva entre amputados y no amputados, tomados de la base de datos del hospital entre enero de 2013 y enero de 2018. Los datos demográficos, así como factores relacionados fueron analizados con regresión logística bi y multivariada en relación con la amputación de miembro inferior como variable de desenlace, calculando razón de probabilidades (OR) con intervalos de confianza del 95%. Dicha información fue analizada con el programa estadístico STATA. Resultados: 81 pacientes requirieron amputación de miembros inferiores. En la regresión logística bivariada hay 3 factores relacionados con amputación [nivel de Wagner (p < 0.05 CI 95%), la presencia de leucocitosis (p <0.05 CI 95%) y el compromiso vascular en Doppler arterial (p < 0.05 CI 95%)], sin embargo, la regresión multivariada sólo relaciona el compromiso vascular del Doppler arterial como estadísticamente significativo con amputación de miembros inferiores (p < 0.05 CI 95%). Conclusión: Se muestran 3 factores estadísticamente significativos con la amputación de miembros inferiores en PD (Wagner, leucocitosis y compromiso vascular), reflejando la importancia de un diagnóstico temprano y un manejo adecuado como parte clave en el manejo de esta patología.

Introduction: The development of ulcerations in the Diabetic Foot (DP) can lead to lower limb amputation and even impact the morbidity and mortality of diabetic patients. Therefore, this study aims to evaluate the characteristics of patients with PD hospitalized and managed in a regional hospital. Materials and methods: 121 patients are included in the retrospective cohort study between amputees and non-amputees, taken from the hospital database between January 2013 and January 2018. Demographic data, as well as related factors, were analyzed with logistic regression. bi and multivariate in relation to lower limb amputation as an outcome variable, calculating odds ratio (OR) with 95% confidence intervals. This information was analyzed with the STATA statistical program. Results: 81 patients required lower limb amputation. In the bivariate logistic regression there are 3 factors related to amputation [Wagner level (p < 0.05 95% CI), the presence of leukocytosis (p < 0.05 95% CI) and vascular compromise on arterial Doppler (p < 0.05 95% CI). )], however, multivariate regression only relates vascular compromise on arterial Doppler as statistically significant to lower limb amputation (p < 0.05 95% CI). Conclusion: 3 statistically significant factors are shown with lower limb amputation in PD (Wagner, leukocytosis and vascular compromise), reflecting the importance of early diagnosis and adequate management as a key part in the management of this pathology.

Development and validation of a delirium risk prediction preoperative model for cardiac surgery patients (DELIPRECAS): An observational multicentre study.

STUDY OBJECTIVE: To develop and validate a delirium risk prediction preoperative model for patients undergoing cardiac surgery. DESIGN: Observational prospective multicentre study. SETTING: Six intensive care units in Spain. PATIENTS: 689 patients undergoing cardiac surgery consecutively, aged ≥18 years. MEASUREMENTS: The primary outcome measure was the development of delirium, diagnosed using the Confusion Assessment Method in Intensive Care Units (CAM-ICU), during the stay in the intensive care unit after cardiac surgery. MAIN RESULTS: The model was developed with 345 consecutive patients undergoing cardiac surgery at six hospitals and validated with another 344 patients from the same hospitals. The prediction model contained four preoperative risk factors: age over 65 years, Mini-Mental State Examination (MMSE) score of 25-26 points (possible impairment of cognitive function) or < 25 (impairment of cognitive function), insomnia needing medical treatment and low physical activity (walk less than 30 min a day). The model had an area under the receiver operating characteristics curve of 0.825 (95% confidence interval: 0.76-0.89). The validation resulted in an area under the curve of 0.79 (0.73-0.85) and the pooled area under the receiver operating characteristics curve (n = 689) was 0.81 (0.76-0.85). We stratified patients in groups of low (0%-20%), moderate (> 20%-40%), high (> 40%-60%) and very high (> 60%) risk of developing delirium, with a positive and negative predictive value for the very high risk group of 70.97% and 85.56%, respectively. CONCLUSION: The DELIPRECAS model (DELIrium PREvention CArdiac Surgery), consisting of four well-defined clinical risk factors, can predict in the preoperative period the risk of developing postoperative delirium in patients undergoing cardiac surgery. An automatic version of the risk calculator is available.

Poliartritis séptica y fascitis necrotizante en un paciente inmunocompetente. Reporte de caso / Septic polyarthritis and necrotizing fascitis in an immunocompetent patient. Case report

La presentación de poliartritis séptica en un paciente inmunocompetente es infrecuente, aún más lo es la presentación de la mencionada junto con fascitis necrotizante en el contexto de infección por Streptococcus Pyogenes (SP). Se presenta el caso de un paciente masculino de 54 años, recluido, sin antecedentes médicos relevantes, inmunocompetente, quien debuta con un cuadro clínico de poliartritis séptica en rodilla bilateral y tobillo izquierdo. Recibe manejo con múltiples lavados y desbridamientos quirúrgicos, desarrolla fascitis necrotizante de la cara posterior de la pierna izquierda, recibe a su vez manejo quirúrgico para dicha condición (incluyendo aplicación de terapia de vacío), al igual que antibioticoterapia enfocada al manejo del germen aislado (Penicilina + vancomicina). Sin embargo, tras un mes de manejo conjunto con servicios de Cirugía Plástica, Dermatología, Ortopedia, así como vigilancia en Unidad de Cuidados Intensivos, termina con un desenlace fatal tras presentar falla multiorgánica. La infección por el SP puede resultar en una elevada morbilidad para él paciente e incluso un desenlace mortal secundario a un compromiso sistémico de muy difícil manejo. El diagnóstico oportuno, así como un tratamiento médico y quirúrgico agresivo pueden no ser suficientes para el control de la infección, incluso en pacientes sin compromiso inmunológico previo. Asimismo, un enfoque multidisciplinario debe corresponder al estándar de manejo con el fin de controlar aquellas condiciones predisponentes de infección. Este es el primer caso reportado en la literatura nacional en relación con estas dos fatales condiciones. Finalmente se pretende resaltar que a pesar de que esta infección suele comprometer infantes y pacientes inmunocomprometidos, no se debe obviar su diagnóstico en pacientes previamente sanos, especialmente en casos de infecciones de rápida diseminación y poca respuesta al manejo adecuado.

Septic polyarthritis in an immunocompetent patient is highly rare, even more when it coexists with necrotizing fasciitis caused by Streptococcus Pyogenes (SP). A 54 year old, immunocompetent male patient is presented herein. The patient had no relevant previous illness, before the installation of a septic arthritis of both knees and he's left ankle. He receives treatment with sequential surgical debridement, then develops necrotizing fasciitis of the posterior aspect of the left leg requiring adequate treatment for such condition (including Vacuum Assisted Closure), as well as antibiotic therapy for the specific infecting microorganism (Penicillin + Vancomycin). Nonetheless, after a month of surgical management between Plastic Surgery, Dermatology, Orthopaedics as well as surveillance in the Intensive Care Unit, the patient dies after multi organic failure. Infection caused by SP might entail high morbidity for a patient and even end with death of the aforementioned caused by a hard to manage systemic organic failure. The adequate diagnosis, as well as aggressive medical and surgical management could not be enough for controlling the infection, even in patients without previous immunological compromise. At the same time, a multidisciplinary approach must be the standard of treatment, aiming to control predisposing infectious conditions. This is the first case reported in national literature related to these two fatal conditions. Finally, one of the purposes of this report is to highlight that despite reports of this microorganism infecting infants and immunocompromised patients, it must not be obviated in healthy patients, especially in cases of rapidly spreading infection and scarce response to adequate management.

Corrigendum to: Impact of reference change value (RCV) based autoverification on turnaround time and physician satisfaction.

[This corrects the article DOI: 10.11613/BM.2017.037.].

Impact of reference change value (RCV) based autoverification on turnaround time and physician satisfaction.

BACKGROUND: For a quicker delivery of laboratory test results to the hospital emergency department (ED), we implemented an autoverification system based on the reference change value (RCV). The aim of this study was to assess how the RCV based autoverification reflected on turnaround time (TAT) and on physician satisfaction. MATERIALS AND METHODS: The laboratory information system (LIS) was programmed to autoverify the results as long as they were within the range settled by RCV, so that the autoverified results were reported to the physician as soon as the tests were carried out, without any further intervention. We analyzed the same three-month periods' TAT and verification time (VFT) from the years prior to and following the implementation of RCV autoverification. The change in physicians' satisfaction levels was assessed using the hospital's Annual Physician Satisfaction Survey (APSS). Over sixty percent of physicians completed the questionnaire, and the amount of daily ED test requests (nearly three hundred) did not vary throughout the duration of this study. RESULTS: Mann-Whitney U test showed that the VFT was significantly reduced in all the test but troponin I. There were substantial reductions in TAT medians (haemogram, 75%; fibrinogen, 41%; prothrombin time, 40%; sodium, 27%). The percentage of physicians satisfied with the haematological and biochemical tests´ TAT increased from 84% to 93% and from 86% to 91% respectively. CONCLUSIONS: Our results reveal that VFT and TAT were severely reduced in most emergency tests, greatly improving physicians' satisfaction with TAT.

Stability of a Parenteral Formulation of Betamethasone and Levobupivacaine.

Background: The therapeutic management of syndromes presenting simultaneously pain and inflammation often requires the administration of anesthetic and corticosteroid drugs by epidural administration. In this article, we studied a mixture that combines betamethasone and levobupivacaine, which demonstrates prolonged analgesic effects. To our knowledge, the stability of such a mixture in epidural solution has not been examined. Objective: To evaluate the chemical, physical, and microbiological stability of an extemporaneously prepared mixture. Methods: A solution of betamethasone acetate 1 mg/mL, betamethasone phosphate 1 mg/mL, and levobupivacaine hydrochloride 0.83 mg/mL was prepared in saline. The components were analyzed by high-performance liquid chromatography for up to 270 days of storage, protected and exposed to light, at room temperature, and stored in the refrigerator and at 45°C. In addition, sterility, organoleptic properties, and pH of the admixture were monitored. Results: There are no significant differences between drug concentrations obtained at room temperature and at refrigerated temperature. The accelerated conditions (45°C) demonstrated different results among the actives: betamethasone acetate and levobupivacaine hydrochloride are affected while betamethasone phosphate remains stable. The stability of the mixture does not depend on light exposure. The validity period of the different components in the mixture was estimated as 120 days for betamethasone phosphate and 163 days for levobupivacaine hydrochloride; betamethasone acetate remained unchanged during 155 days. Conclusion: Analgesic mixtures of betamethasone and levobupivacaine can be stored at ambient temperature in polypropylene vials for up to 120 days at the studied concentrations. These data enable the rationalization of the centralized preparation in the hospital pharmacy.

[Boundaries and integrity in the "Social Contract for Spanish Science", 1907-1939]. / Frontera e integridad en el "contrato social para la ciencia española", 1907-1939.

This article analyzes the relationship between science and politics in Spain in the early 20th century from the perspective of the Social Contract for Science. The article shows that a genuine social contract for science was instituted in Spain during this period, although some boundary and integrity problems emerged. These problems are analyzed, showing that the boundary problems were a product of the conservative viewpoint on the relationship between science and politics, while the integrity problems involved the activation of networks of influence in the awarding of scholarships to study abroad. Finally, the analysis reveals that these problems did not invalidate the Spanish social contract for science.

[Boundaries and integrity in the "Social Contract for Spanish Science", 1907-1939]. / Frontera e integridad en el "contrato social para la ciencia española", 1907-1939.

This article analyzes the relationship between science and politics in Spain in the early 20th century from the perspective of the Social Contract for Science. The article shows that a genuine social contract for science was instituted in Spain during this period, although some boundary and integrity problems emerged. These problems are analyzed, showing that the boundary problems were a product of the conservative viewpoint on the relationship between science and politics, while the integrity problems involved the activation of networks of influence in the awarding of scholarships to study abroad. Finally, the analysis reveals that these problems did not invalidate the Spanish social contract for science.

Supervised exercise for acute coronary patients in primary care: a randomized clinical trial.

BACKGROUND: Functional capacity is a prognostic factor for coronary patients; accordingly, they are recommended to walk. OBJECTIVE: To assess whether an exercise program supervised in primary care increases their functional capacity more than unsupervised walking. METHODS: A randomized clinical trial was carried out at eight primary care centres of the Spanish Health Service and involving 97 incident cases of low-risk acute coronary patients, <80 years old, randomly assigned to either an unsupervised walking program (UW group; n = 51) or a 6-month cycle ergometer exercise program with gradually increasing frequency and workload intensity supervised by primary care nurses (SE group; n = 46). The two groups received the same common components of secondary prevention care. Changes in functional capacity were assessed in terms of peak oxygen consumption (VO2peak) during exercise testing measured at baseline and at 7 months by cardiologists blinded to group assignment. RESULTS: Overall, 76% of participants completed the study, 30 in the SE and 44 in the UW. Both groups increased baseline-adjusted VO2peak: 5.56ml/kg per minute in the SE (95% confidence interval [CI] 3.38-7.74) and 1.64ml/kg per minute in the UW (95% CI -0.15 to 3.45). The multivariate-adjusted difference between groups was 4.30ml/kg per minute (95% CI 1.82-6.79; P = 0.001) when analyzing completers and 2.83ml/kg per minute (95% CI 0.61-5.05; P = 0.01) in the intention-to-treat analysis, including all participants with baseline values carried forward for those lost to follow-up. CONCLUSIONS: A cycle ergometer exercise program supervised by primary care nurses increased the functional capacity of coronary patients more than unsupervised walking with a clinically relevant difference.

Frontera and integrity in the 'social contract for the Spanish science', 1907-1939 / Boundaries and integrity in the 'Social Contract for Spanish Science', 1907-1939

En este artículo se analizan las relaciones entre ciencia y política en el primer tercio del siglo XX español desde la perspectiva del Contrato Social para la Ciencia. En él se muestra que en dicho periodo se instituyó un auténtico contrato social para la ciencia en España, aunque surgieron algunos problemas de frontera e integridad. Dichos problemas son analizados y se defiende que los problemas de frontera fueron resultado de la concepción de las relaciones entre ciencia y política de los gobiernos conservadores, mientras que los problemas de integridad tuvieron que ver con la activación de redes de influencia en la concesión de las becas para la formación en el extranjero. Finalmente, el análisis revela que estos problemas no invalidaron el contrato social para la ciencia en España (AU)

This article analyzes the relationship between science and politics in Spain in the early 20th century from the perspective of the Social Contract for Science. The article shows that a genuine social contract for science was instituted in Spain during this period, although some boundary and integrity problems emerged. These problems are analyzed, showing that the boundary problems were a product of the conservative viewpoint on the relationship between science and politics, while the integrity problems involved the activation of networks of influence in the awarding of scholarships to study abroad. Finally, the analysis reveals that these problems did not invalidate the Spanish social contract for science (AU)

La medicina tradicional china en el ámbito médico legal y ético / Traditional Chinese medicine in the medical, legal and ethical field

La Medicina Tradicional China es una de las prácticas más antiguas de sanación a las que ha acudido el ser humano y en donde se encuentra el inicio de la llamada relación médico paciente, en la que se complementan mutuamente para encontrar la cura de la enfermedad que padezca. A diferencia de la medicina occidental trata únicamente las patologías dejando de lado a la persona que tiene la enfermedad. Es de gran importancia que todos los médicos que deseen practicar esta medicina estén realmente informados y formados en esta práctica, ya que deberán tener todas las herramientas necesarias para la atención integral del paciente a tratar; todo esto enmarcado en el ámbito legal, normativo y ético que corresponde a un Estado de derecho. Se hace necesario el conocimiento de la normativa que rige en Colombia en cuanto a la medicina tradicional china, a partir de la reglamentación que efectúa al respecto la OMS. Pues hay que entender las bases a partir de las cuales esta práctica debe calificarse como una especialización del campo médico y por tanto de exclusiva práctica por profesionales médicos, debidamente capacitados, no solo para darle a esta medicina la importancia que tiene sino para bienestar y seguridad de los pacientes, que es el mensaje que ella lleva, ínsito desde tiempos inmemoriales.

Recombinant factor VIIa is an effective therapy for abdominal surgery and severe thrombocytopenia: a case report.

A 50-year-old woman was admitted to the emergency room. An appendectomy was done. On the sixth day the patient's general state deteriorated and she became somnolent with jaundice due to distal obstructive choledocholithiasis. The results of laboratory tests were platelets 12 x 10(9)/L, prothrombin time 13 seconds, international normalized ratio 1.19, activated partial thromboplastin time 31.8 seconds, and fibrinogen 8.78 g/L. There was no evidence of disseminated intravascular coagulation. In view of the patient's clinical condition, surgery was considered to be indicated. Because it was a life-threatening situation and at the time there was no platelet concentrate available for immediate transfusion, she was treated with a single dose of recombinant factor VIIa (rFVIIa) (60 microg/kg). The dose of 60 microg/kg was selected on the basis of experience with rFVIIa in the treatment of hemophilic patients. In this case, use of rFVIIa was a valid alternative to control the bleeding in a patient with thrombocytopenia. However, despite the efficacy of the treatment, it should not be forgotten that it was used because of the unavailability of platelets and that we were dealing with a life-threatening situation. Clinical trials should be carried out to verify the safety, effectiveness, and efficiency of rFVIIa in these cases.