Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study.

BACKGROUND: All health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were the following: (1) to analyze the association between IHA and the development of subsequent AEs; (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions. METHODS: An observational cross-sectional study was conducted on hospitalized patients in May 2019 in a high-complexity hospital in Madrid, Spain. The Appropriateness Evaluation Protocol was used to measure IHA, and the methodologies of the Harvard Medical Practice Study and the European Point Prevalence Survey of Healthcare-associated Infections were used to detect and characterize AEs. The association between IHA and the subsequent. RESULTS: A total of 558 patients in the hospital ward were studied. IHA increased the risk of subsequent occurrence of AEs (OR [95% CI]: 3.54 [1.87 to 6.69], versus appropriate) and doubled the mean AEs per patient (coefficient [95% CI]: 0.19 [0.08 to 0.30] increase, versus appropriate) after adjusting for confounders. IHA was a predictive variable of subsequent AEs and the number of AEs per patient. AEs developed after IHA were associated with scheduled admissions (78.9% of AEs, versus 27.9% after appropriate admissions; p < 0.001). Compared with AEs developed after appropriate admissions, AEs after IHA added 2.4 additional days of stay in the intensive care unit and incurred an extra cost of €166,324.9 for the studied sample. CONCLUSIONS: Patients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns.

Evaluation of functional warm ischemia time during controlled donation after circulatory determination of death using normothermic regional perfusion (ECMO-TT): A prospective multicenter cohort study.

BACKGROUND: Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. METHODS: We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. RESULTS: A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal of life-sustaining therapy (61%), followed by anoxic encephalopathy (21%). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. CONCLUSIONS: Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.

Adverse events: an expensive and avoidable hospital problem.

INTRODUCTION: Adverse healthcare-related events (AE) entail reduced patient safety. Estimating their frequency, characteristics, avoidability and impact is a means to identify targets for improvement in the quality of care. METHODS: This was a descriptive observational study conducted within the Patient Safety Incident Study in Hospitals in the Community of Madrid (ESHMAD). The study was conducted in a high-complexity hospital in May 2019 through a two-phase electronic medical record review: (1) AE screening and epidemiological and clinical data collection and (2) AE review and classification and analysis of their impact, avoidability, and associated costs. RESULTS: A total of 636 patients were studied. The prevalence of AE was 12.4%. Death during the stay was associated with the presence of AE (OR [CI95%]: 2.15 [1.07 to 4.52]) versus absence and emergency admission (OR [CI95%]: 17.11[6.63 to 46.26]) versus scheduled. A total of 70.2% of the AEs were avoidable. Avoidable AEs were associated with the presence of pressure ulcers (OR [CI95%]: 2.77 [1.39 to 5.51]), central venous catheter (OR [CI95%]: 2.58 [1.33 to 5.00]) and impaired mobility (OR [CI95%]: 2.24[1.35 to 3.71]), versus absences. They were associated too with the stays in the intensive care unit (OR [CI95%]: 2.75 [1.07 to 7.06]) versus medical service. AEs were responsible for additional costs of €909,716.8 for extra days of stay and €12,461.9 per patient with AE. CONCLUSIONS: The prevalence of AEs was similar to that found in other studies. AEs led to worse patient outcomes and were associated with the patient's death. Although avoidable AEs were less severe, their higher frequency produced a greater impact on the patient and healthcare system.Key messagesAdverse events are one of the main problems in healthcare delivery and patients who suffer from at least one AE are double as likely to die during hospitalization.Avoidable adverse events are the most frequent in health care and they are a good target where achieve improvement areas that allow getting optimal patient safety and quality of care levels.Patients hospitalized in the ICU, with the previous presence of pressure ulcers, central venous catheter, or impaired mobility were associated with the development of avoidable AE, so optimal management of these patients would reduce the impact of AE.

How Does Vaccination against SARS-CoV-2 Affect Hospitalized Patients with COVID-19?

(1) Background: The development of effective COVID-19 vaccines has reduced the impact of COVID-19 on the general population. Our study aims to analyze how vaccination modifies the likelihood of death and length of stay in hospitalized patients with COVID-19; (2) Methods: A retrospective cohort study of 1927 hospitalized patients infected with COVID-19 was conducted. Information was gathered on vaccination status, hospitalization episode, and clinical profile of the patients. The effect of vaccination on mortality was analyzed using a multiple logistic regression model, and length of stay was analyzed using linear regression. The performance and fit of the models were evaluated; (3) Results: In hospitalized patients with COVID-19, the risk of dying during admission in vaccinated patients was half that of non-vaccinated (OR: 0.45; CI 95%: 0.25 to 0.84). In patients who were discharged due to improvement, the reduction in hospital stay in vaccinated patients was 3.17 days (CI 95%: 5.88 to 0.47); (4) Conclusions: Patients who, despite having been vaccinated, acquire the infection by SARS-CoV-2, have a significant reduction of the risk of death during admission and a reduction of hospital stay compared with unvaccinated patients.

Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018.

OBJECTIVES: Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system. METHODS: A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index. RESULTS: There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was €56,338,247 (an average of €17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024). CONCLUSIONS: Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.

Surgery Is in Itself a Risk Factor for the Patient.

(1) Background: Adverse events (AE) affect about 1 in 10 hospitalised patients, and almost half are related to surgical care. The aim of this study is to determine the prevalence of AE in operated and non-operated patients in surgical departments in order to determine whether surgical treatment is a risk factor for AE. (2) Methods: A cross-sectional design that included 3123 patients of 34 public hospitals in the Community of Madrid determining the prevalence of AEs in operated and non-operated patients in surgical departments. (3) Results: The prevalence of AE in non-operated patients was 8.7% and in those operated was 15.8%. The frequency of AE was higher in emergency surgery (20.6% vs. 12.4%). The 48.3% of AEs led to an increase in hospital stay, and surgery was involved in 92.4% of cases. The most frequent AEs were related to hospital-acquired infection (42.63%), followed by those related to a procedure (37.72%). In the multivariate analysis, being operated on represented 2.3 times the risk of developing an AE. (4) Conclusions: Surgical sites are particularly vulnerable to AE. Surgical intervention alone is a risk factor for AE, and we must continue to work to improve the safety of both patient care and the working environment of surgical professionals.

[Apropriateness of hospital admissions due to COVID-19 in the 2nd and 5th phase of the pandemic.] / Adecuación de ingresos hospitalarios por COVID-19 en la 2ª y 5ª fase de la pandemia.

OBJECTIVE: The increase in the demand for healthcare caused by COVID-19 implies a lower availability of health resources and influences the appropriateness of their use. Due to the variability of demand during the pandemic, the study aimed to compare the appropriateness of hospital admissions between the 2nd and 5th phases of the pandemic according to the criteria of the Hospital Emergency Service (CiHRyC). These results were compared with those obtained according to the Pneumonity Severity Index (FINE) and the Appropriateness Evaluation Protocol (AEP). As a secondary objective, the clinical and sociodemographic characteristics of the patients studied were described. METHODS: 80 patients hospitalized from the Emergency Department were randomly selected in two study periods (2nd and 5th pandemic phase) obtained from the registry of hospitalizations of the Preventive Medicine service of Hospital Ramon y Cajal. Prevalences of inappropriateness were estimated according to the CiHRyC, FINE and AEP and an analysis was performed using univariate logistic regression between epidemiological variables of both periods collected through the electronical medical records. RESULTS: Inappropriateness of admissions were 35% and 45% in the 2nd and 5th phase of the pandemic according with CiHRyC, 25% and 5/% according with FINE and 0% and 5% according with AEP. Median age was 71.4 and 50.0 years in 2nd and 5th phase (p=0.02). 72.5% and 17.5% of the patients in the 2nd and 5th phases had at least one risk factor for COVID-19 severe illness (p<0.01). CONCLUSIONS: The measurement tools used identified more inappropriately cases in the 5th phase of the pandemic than in the 2nd one. CiHRyC coincided with FINE and AEP in the result of their evaluation.

OBJETIVO: El aumento de la demanda asistencial hospitalaria producida por la COVID-19 supone una menor disponibilidad de recursos sanitarios e influye en la adecuación de su utilización. Debido a la variabilidad de la demanda durante la pandemia, el objetivo del estudio fue comparar la adecuación de los ingresos hospitalarios entre la 2ª y 5ª fase de la pandemia según los criterios del servicio de Urgencias del Hospital (CiHRyC). Se compararon estos resultados con los obtenidos según el Pneumonity Severity Index (FINE) y el Appropriateness Evaluation Protocol (AEP). Como objetivo secundario se describieron las características clínicas y sociodemográficas de los pacientes estudiados. METODOS: Se seleccionaron aleatoriamente 80 pacientes hospitalizados desde Urgencias en dos periodos de estudio (2ª y 5ª fase pandémica) obtenidos del registro de hospitalizaciones del servicio de Medicina Preventiva del Hospital Ramón y Cajal. Se estimaron las prevalencias de inadecuación según los CiHRyC, el FINE y el AEP para admisiones y se realizó un análisis mediante regresión logística univariante entre las variables epidemiológicas de ambos periodos recogidas mediante la Historia Clínica Electrónica (HCE). RESULTADOS: La inadecuación de la hospitalización fue del 35% y 45% en la 2ª y 5ª fase de la pandemia con los CiHRyC, del 25% y 57% con el FINE y del 0% y 5% con el AEP. La mediana de edad fue de 71,4 y 50 años en la 2ª y 5ª fase (p=0,02). El 72,5% y el 17,5% de los pacientes de la 2ª y 5ª fase tuvieron al menos un factor de riesgo de complicaciones de COVID-19 (p<0,01). CONCLUSIONES: Los instrumentos de medida empleados (CiHRyC, el FINE y el AEP) identificaron más casos inadecuadamente ingresados en la 5ª fase de la pandemia que en la 2ª, coincidiendo el CiHRyC con el FINE y el AEP en el resultado de su evaluación.

Adecuación de ingresos hospitalarios por COVID-19 en la 2ª y 5ª fase de la pandemia / Apropriateness of hospital admissions due to COVID-19 in the 2nd and 5th phase of the pandemic

Fundamentos: El aumento de la demanda asistencial hospitalaria producida por la COVID-19 supone una menor disponibilidad de recursos sanitarios e influye en la adecuación de su utilización. Debido a la variabilidad de la demanda durante la pandemia, el objetivo del estudio fue comparar la adecuación de los ingresos hospitalarios entre la 2ª y 5ª fase de la pandemia según los criterios del servicio de Urgencias del Hospital (CiHRyC). Se compararon estos resultados con los obtenidos según el Pneumonity Severity Index (FINE) y el Appropriateness Evaluation Protocol (AEP). Como objetivo secundario se describieron las características clínicas y sociodemográficas de los pacientes estudiados. Métodos: Se seleccionaron aleatoriamente 80 pacientes hospitalizados desde Urgencias en dos periodos de estudio (2ª y 5ª fase pandémica) obtenidos del registro de hospitalizaciones del servicio de Medicina Preventiva del Hospital Ramón y Cajal. Se estimaron las prevalencias de inadecuación según los CiHRyC, el FINE y el AEP para admisiones y se realizó un análisis mediante regresión logística univariante entre las variables epidemiológicas de ambos periodos recogidas mediante la Historia Clínica Electrónica (HCE). Resultados: La inadecuación de la hospitalización fue del 35% y 45% en la 2ª y 5ª fase de la pandemia con los CiHRyC, del 25% y 57% con el FINE y del 0% y 5% con el AEP. La mediana de edad fue de 71,4 y 50 años en la 2ª y 5ª fase (p=0,02). El 72,5% y el 17,5% de los pacientes de la 2ª y 5ª fase tuvieron al menos un factor de riesgo de complicaciones de COVID-19 (p<0,01). Conclusiones: Los instrumentos de medida empleados (CiHRyC, el FINE y el AEP) identificaron más casos inadecuadamente ingresados en la 5ª fase de la pandemia que en la 2ª, coincidiendo el CiHRyC con el FINE y el AEP en el resultado de su evaluación.(AU)

Background: The increase in the demand for healthcare caused by COVID-19 implies a lower availability of health resources and influences the appropriateness of their use. Due to the variability of demand during the pandemic, the study aimed to compare the appropriateness of hospital admissions between the 2nd and 5th phases of the pandemic according to the criteria of the Hospital Emergency Service (CiHRyC). These results were compared with those obtained according to the Pneumonity Severity Index (FINE) and the Appropriateness Evaluation Protocol (AEP). As a secondary objective, the clinical and sociodemographic characteristics of the patients studied were described. Methods: 80 patients hospitalized from the Emergency Department were randomly selected in two study periods (2nd and 5th pandemic phase) obtained from the registry of hospitalizations of the Preventive Medicine service of Hospital Ramon y Cajal. Prevalences of inappropriateness were estimated according to the CiHRyC, FINE and AEP and an analysis was performed using univariate logistic regression between epidemiological variables of both periods collected through the electronical medical records. Results: Inappropriateness of admissions were 35% and 45% in the 2nd and 5th phase of the pandemic according with CiHRyC, 25% and 5/% according with FINE and 0% and 5% according with AEP. Median age was 71.4 and 50.0 years in 2nd and 5th phase (p=0.02). 72.5% and 17.5% of the patients in the 2nd and 5 th phases had at least one risk factor for COVID-19 severe illness (p<0.01). Conclusions: The measurement tools used identified more inappropriately cases in the 5th phase of the pandemic than in the 2 nd one. CiHRyC coincided with FINE and AEP in the result of their evaluation.(AU)

Selective T3-T4 sympathicotomy versus gray ramicotomy on outcome and quality of life in hyperhidrosis patients: a randomized clinical trial.

Compensatory hyperhidrosis is the leading cause of patients' dissatisfaction after thoracic sympathicotomy. The study aimed to reduce compensatory hyperhidrosis to increase patients' satisfaction. A prospective randomized study on palmar hyperhidrosis, May 2016-September 2019. Twenty-one patients T3-T4 sympathicotomy and 21 T3-T4 gray ramicotomy. Data prospectively collected. Analysis at study's end. Focus on the sweating, temperature, quality of life baseline and postoperatively, compensatory hyperhidrosis, hand dryness, patients' satisfaction, and if they would undergo the procedure again and recommend it. No baseline differences between groups. Hyperhidrosis was controlled postoperatively in all patients. No mortality, serious complications, or recurrences. Sympathicotomy worse postoperative quality of life (49.05 (SD: 15.66, IR: 35.50-63.00) versus ramicotomy 24.30 (SD: 6.02, IR: 19.75-27.25). After ramicotomy, some residual sweating on the face, hands, and axillae. Compensatory sweating worse with sympathicotomy. Satisfaction higher with ramicotomy. Better results with ramicotomy than sympathicotomy regarding hand dryness, how many times a day the patients had to shower or change clothes, intention to undergo the procedure again or recommend it to somebody else, and how bothersome compensatory hyperhidrosis was. T3-T4 gray ramicotomy had better results than T3-T4 sympathicotomy, with less compensatory sweating and higher patients' satisfaction.

Serum cholesterol predicts transplant-free survival in cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt.

BACKGROUND: Malnutrition is frequent in patients with cirrhosis and has been associated with poor prognosis. The Model for End-stage Liver Disease (MELD) score was created to predict survival after Transjugular Intrahepatic Porto-systemic Shunt (TIPS) but lacks a nutritional parameter. AIMS: To evaluate the prognostic value of serum cholesterol in patients with cirrhosis undergoing TIPS and to develop a prognostic score to predict survival. METHODS: An explorative cross-sectional study was conducted of cirrhotic patients undergoing TIPS from 2008 until 2019. Exclusion criteria were liver transplantation or hepatocellular carcinoma before TIPS. Risk analysis was used to compare survival according to clinical and analytical data. The diagnostic performance of serum cholesterol added to MELD was evaluated and confirmed in an external validation cohort. RESULTS: The final cohort of 100 patients had a mean MELD score of 14±5 and cholesterol of 122±51 mg/dL. MELD (p < 0,05) and both cholesterol (p < 0,05) and low-density lipoprotein levels (LDL-C) (p < 0,05) were independent predictors of post-TIPS transplant-free survival with an optimal cut-off of 106 mg/dL for serum cholesterol. The combined MELD-cholesterol risk score improved diagnostic accuracy of each parameter separately, and this was confirmed in the external cohort. CONCLUSION: Serum cholesterol and LDL-C are independent predictors of transplant-free survival in cirrhotic patients undergoing TIPS. The MELD-cholesterol score slightly improved prognostic accuracy. LAY SUMMARY: As an objective and easily measured indicator of both nutritional status and hepatic function, serum cholesterol could be useful to predict transplant-free survival in patients with cirrhosis undergoing TIPS. It can enable health care providers to identify high-risk patients and to optimize nutritional status before TIPS.

Nasopharyngeal Panbio COVID-19 Antigen Performed at Point-of-Care Has a High Sensitivity in Symptomatic and Asymptomatic Patients With Higher Risk for Transmission and Older Age.

BACKGROUND: Performance of point-of-care tests in different clinical scenarios and on different samples remains undetermined. We comprehensively evaluated the performance of the nasopharyngeal Panbio COVID-19 Ag Rapid Test Device. METHODS: This is a prospective study that includes consecutive patients attending 3 primary care centers (PCCs) and an emergency department. The antigen test was performed at point-of-care in nasopharyngeal and nasal swabs and in saliva. Positive percent agreement (PPA) and negative percent agreement (NPA) were calculated with the reverse-transcription polymerase chain reaction (RT-PCR) assay as reference standard. RESULTS: Of 913 patients included, 296 (32.3%) were asymptomatic and 690 (75.6%) came from the PCC. Nasopharyngeal swabs were collected from 913 patients, nasal swabs were collected from 659 patients, and saliva was collected from 611 patients. The RT-PCR was positive in 196 (21.5%) nasopharyngeal samples (NPS). Overall, PPA (95% CI) in NPS was 60.5% (53.3-67.4), and it was lower in nasal swabs (44.7%) and saliva (23.1%). Test performance in NPS was largely dependent on the cycle threshold (Ct) in RT-PCR, with PPA of 94% for Ct ≤25 and 80% for Ct <30. In symptomatic patients, the PPA was 95% for Ct ≤25, 85% for Ct <30, and 89% for the symptom triad of fever, cough, and malaise. Performance was also dependent on age, with a PPA of 100% in symptomatic patients >50 years with Ct <25. In asymptomatic patients, the PPA was 86% for Ct <25. In all cases, NPA was 100%. CONCLUSIONS: The nasopharyngeal Panbio COVID-19 Ag test performed at point-of-care has a good sensitivity in symptomatic patients with Ct <30 and older age. The test was useful to identify asymptomatic patients with lower Ct values.

Transjugular intrahepatic portosystemic shunt reduces hospital care burden in patients with decompensated cirrhosis.

BACKGROUND AND AIMS: Patients with decompensated cirrhosis frequently require hospital admissions, which are associated with worse prognosis. The aim of this study was to analyze the effect of TIPS on the need for hospital care. Secondary objectives were to assess the clinical and biological impact of TIPS and to identify predictors of post-TIPS hospital care. METHODS: An observational, retrospective study of patients with decompensated cirrhosis treated with TIPS from January 2008 until March 2019. Exclusion criteria were TIPS placed for non-cirrhotic portal hypertension (PH) and patients referred from another hospital without prior or subsequent follow-up at our Unit. Hospital care, PH-related complications, and laboratory data were compared before and after TIPS. RESULTS: The final cohort comprised 104 patients (72% male) with a mean age of 60 (± 10) years. Follow-up from first decompensation until TIPS and that from procedure to study completion were 7 (4.2-9.8) and 20 (4.6-35.4) months, respectively. TIPS was indicated mainly for refractory ascites (50%) and variceal bleeding (39%). Hemodynamic and clinical success rates were 97% and 92%, respectively. The number of emergency department visits and hospital admissions decreased after the procedure (p < 0.001). Improvement was seen in MELD and Child-Pugh scores, renal function, hyponatremia, and anemia after TIPS. Variceal bleeding as the indication for TIPS (OR 0.047; 95 CI 0.006-0,39; p < 0.05) together with early creation of the shunt (stage 3 vs 5; p < 0.05) were associated with a reduction in risk of post-TIPS hospital care. CONCLUSION: TIPS is a safe and effective procedure that reduces hospital care burden by improving PH-related complications, hepatic, renal function, hyponatremia, and anemia. Variceal bleeding as the indication and early placement of the device were associated with a reduction in post-TIPS hospital care. These findings support a role for this treatment, predominantly in the early stages of cirrhosis.

Estimation of the Overuse of Preoperative Chest X-rays According to "Choosing Wisely", "No Hacer", and "Essencial" Initiatives: Are They Equally Applicable and Comparable?

BACKGROUND: Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice. METHODS: This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to "Choosing Wisely", "No Hacer" and "Essencial" initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units. RESULTS: A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the "No Hacer" recommendation and 73.3% according to "Choosing Wisely" and "Essencial" criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to "Choosing Wisely" and "Essencial"; 4.1% according to "No Hacer"). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to "No Hacer" and EUR 3895.29 (2276.1 Relative Value Units) according to "Choosing Wisely" or "Essencial" criteria. CONCLUSIONS: There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.

Neoadjuvant treatment for locally advanced unresectable and borderline resectable pancreatic cancer: oncological outcomes at a single academic centre.

INTRODUCTION: Pancreatic cancer (PC), even in the absence of metastatic disease, has a dismal prognosis. One-third of them are borderline resectable (BRPC) or locally advanced unresectable PC (LAUPC) at diagnosis. There are limited prospective data supporting the best approach on these tumours. Neoadjuvant chemotherapy (ChT) is being increasingly used in this setting. METHODS: This is a retrospective series of consecutive patients staged as BRPC or LAUPC after discussion in the multidisciplinary board (MDB) at an academic centre. All received neoadjuvant ChT, followed by chemoradiation (ChRT) in some cases, and those achieving enough downstaging had a curative-intent surgery. Descriptive data about patient's characteristics, neoadjuvant treatments, toxicities, curative resections, postoperative complications, pathology reports and adjuvant treatment were collected. Overall survival (OS) and progression-free survival was calculated with Kaplan-Meier method and log-rank test. RESULTS: Between August 2011 and July 2019, 49 patients fulfilled the inclusion criteria, and all of them received neoadjuvant ChT. Fluorouracil+folinic acid, irinotecan and oxaliplatin was the most frequently used scheme (77%). The most prevalent grade 3 or 4 toxicities were neutropenia (26.5%), neurotoxicity (12.2%), diarrhoea (8.2%) and nausea (8.2%). 18 patients (36.7%) received ChRT thereafter. In total, 22 patients (44,9%) became potentially resectable and 19 of them had an R0 or R1 pancreatic resection. One was found to be unresectable at surgery and two refused surgery. A vascular resection was required in 7 (35%). No postoperative deaths were observed. Postoperative ChT was given to 12 (66.7%) of resected patients. Median OS of the whole cohort was 24,9 months (95% CI 14.1 to 35.7), with 30.6 months for resected and 13.1 months for non-resected patients, respectively (p<0.001). CONCLUSION: A neoadjuvant approach in BRPC and LAUPC was well tolerated and allowed a curative resection in 38.8% of them with a potential improvement on OS.

Mascarillas como equipo de protección individual durante la pandemia de COVID-19: cómo, cuándo y cuáles deben utilizarse / Masks as personal protective equipment in the COVID-19 pandemic: How, when and which should be used

ANTECEDENTES Y OBJETIVO: Durante la pandemia COVID-19 se ha producido un aumento de la demanda de mascarillas por parte de profesionales sanitarios y de la población general. En este contexto, se hace necesario sintetizar las características y las indicaciones de uso de los distintos tipos de mascarillas existentes. MATERIAL Y MÉTODOS: Se consultaron y recopilaron las diferentes recomendaciones difundidas por instituciones de reconocido prestigio, como la Organización Mundial de la Salud, The European Centre for Disease Prevention, The Centre for Evidence-Based Medicine o el Ministerio de Sanidad del Gobierno de España. RESULTADOS: Las instituciones consultadas aconsejan reservar las mascarillas filtering face piece (FFP) para el personal sanitario, especialmente en la realización de procedimientos generadores de aerosoles (PGA) (protección mínima de FFP2), y plantean posibles sistemas de reutilización durante épocas de escasez. Asimismo, se recomienda el uso de mascarillas quirúrgicas en profesionales que no realicen PGA y en población sintomática, existiendo variación en las indicaciones de uso para población general sana. CONCLUSIÓN: En situaciones de escasez de equipos de protección individual por pandemia de COVID-19 se debe establecer una priorización y racionalización de uso de cada tipo de mascarilla en función del usuario y de la actividad a realizar

BACKGROUND AND OBJECTIVE: In the COVID-19 pandemic, the demand of masks has been increased by health professionals and the general population. In this context, it is necessary to summarize the features and indications of the different types of masks. MATERIAL AND METHODS: To consult and to compile the different recommendations disseminated by prestigious institutions such as the World Health Organization, the European Center for Disease Prevention, the Center for Evidence-Based Medicine, or the Ministry of Health of the Government of Spain has been reviewed. RESULTS: The institutions consulted recommend reserving FFP respirators for healthcare workers, especially when carrying out aerosol-generating procedures (AGPs) (minimum FFP2 protection) and consider some reutilization systems during times of scarcity. The use of surgical masks is recommended to professionals who do not perform AGPs and to the symptomatic population but exist variations in its indications intended for the general healthy population. CONCLUSION: In the context of shortage of personal protective equipment due to the COVID-19 pandemic, a prioritization and rationalization of the use of each type of mask should be established according to the user and the activity performed

[Masks as personal protective equipment in the COVID-19 pandemic: How, when and which should be used]. / Mascarillas como equipo de protección individual durante la pandemia de COVID-19: cómo, cuándo y cuáles deben utilizarse.

BACKGROUND AND OBJECTIVE: In the COVID-19 pandemic, the demand of masks has been increased by health professionals and the general population. In this context, it is necessary to summarize the features and indications of the different types of masks. MATERIAL AND METHODS: To consult and to compile the different recommendations disseminated by prestigious institutions such as the World Health Organization, the European Center for Disease Prevention, the Center for Evidence-Based Medicine, or the Ministry of Health of the Government of Spain has been reviewed. RESULTS: The institutions consulted recommend reserving FFP respirators for healthcare workers, especially when carrying out aerosol-generating procedures (AGPs) (minimum FFP2 protection) and consider some reutilization systems during times of scarcity. The use of surgical masks is recommended to professionals who do not perform AGPs and to the symptomatic population but exist variations in its indications intended for the general healthy population. CONCLUSION: In the context of shortage of personal protective equipment due to the COVID-19 pandemic, a prioritization and rationalization of the use of each type of mask should be established according to the user and the activity performed.

Low-Value Clinical Practices: Knowledge and Beliefs of Spanish Surgeons and Anesthetists.

OBJECTIVES: To know the frequency and causes of low value surgical practices, according to the opinion of surgeons and anesthetists, and to determine their degree of knowledge about the Spanish "Choosing wisely" initiative. METHODS: Cross-sectional observational study, based on a self-administered online questionnaire through an opportunistic sample of 370 surgeons and anesthetists from three Spanish regions, contacted through Scientific Societies. The survey took part between July and December 2017. RESULTS: A patient profile requesting unnecessary practices was identified (female, 51-65 years old and unaffiliated disease). The frequency of requests was weekly or daily for 50.0% of the professionals, of whom 15.1% acknowledged succumbing to these pressures. To dissuade the patient, clinical reasons (47%) were considered the most effective. To increase control and safety in the case was the main reason to indicate them. The greatest responsibility for overuse was attributed to physicians, defensive medicine and mass media. Assessing professionals' knowledge on unnecessary practices, an average of 5 correct answers out of 7 was obtained. Some 64.1% of the respondents were unaware of the Spanish "Choosing wisely" initiative. CONCLUSIONS: Low value surgical practices are perceived as a frequent problem, which requires an approach entailing intervention with patients and the media as well as professionals. Increase awareness on unnecessary surgical practices, and how to avoid them remain essential.

Selective block of grey communicantes in upper thoracic sympathectomy. A feasibility study on human cadaveric specimens.

Background: Sympathetic chain interruption is the gold standard treatment for essential hyperhidrosis. Postoperative compensatory hyperhidrosis, the main reason for patients' dissatisfaction, is reduced by selectively lesioning white and grey rami communicantes (ramicotomy).Objective: To develop an endoscopic surgical technique that interrupts only T3 and T4 grey rami communicantes to minimize compensatory hyperhidrosis.Material and Methods: T3 and T4 grey rami communicantes ramicotomy in fifteen cold-preserved cadavers through a uniportal axillary endoscopic approach. The sympathetic chain, its ganglia, and white rami communicantes were left intact. On opening the chest, the sympathetic chain, rami communicantes and ganglia were dissected, photographed, measured and excised for histological examination.Results: Dissecting the grey rami communicantes is feasible as they consistently lie between the intercostal nerve and the homonymous sympathetic ganglion. At some levels, Kuntz nerves, as well as more than one grey ramus communicans, can be found. White rami communicantes are more medial, therefore damaging them can be avoided. Intercostal veins can be obstructive, but these can be controlled via coagulation or clipping if necessary.Conclusion: Uniportal endoscopic selective excision of the T3 and T4 grey rami communicantes is feasible without damaging the white rami communicantes, the sympathetic chain or its ganglia. Clipping the grey rami communicantes is technically possible but not reliable due to their thin diameter. This study confirms that T3 and T4 grey rami sympathetic block is technically feasible. Its application might reduce compensatory hyperhidrosis, but clinical studies are needed.

Tratamiento quirúrgico de la recidiva supraclavicular y a nivel de la mamaria interna por un carcinoma de mama / Surgical Treatment of Supraclavicular and Internal Mammary Recurrence of Breast Cancer

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