Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study.

BACKGROUND AND AIMS: Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures. METHODS: Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator. RESULTS: A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity. CONCLUSIONS: This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

The Châtelperronian Neanderthals of Cova Foradada (Calafell, Spain) used imperial eagle phalanges for symbolic purposes.

Evidence for the symbolic behavior of Neanderthals in the use of personal ornaments is relatively scarce. Among the few ornaments documented, eagle talons, which were presumably used as pendants, are the most frequently recorded. This phenomenon appears concentrated in a specific area of southern Europe during a span of 80 thousand years. Here, we present the analysis of one eagle pedal phalange recovered from the Châtelperronian layer of Foradada Cave (Spain). Our research broadens the known geographical and temporal range of this symbolic behavior, providing the first documentation of its use among the Iberian populations, as well as of its oldest use in the peninsula. The recurrent appearance of large raptor talons throughout the Middle Paleolithic time frame, including their presence among the last Neanderthal populations, raises the question of the survival of some cultural elements of the Middle Paleolithic into the transitional Middle to Upper Paleolithic assemblages and beyond.

Modern contaminants affecting microscopic residue analysis on stone tools: A word of caution.

Residue analysis is a method frequently used to infer the function of stone tools and it is very often applied in combination with use-wear analysis. Beyond its undeniable potential, the method itself has several intrinsic constraints. Apart from the exceptional circumstances necessary for residues to survive, the correct identification of the residue type is a very debatable topic. Before attempting to recognise ancient residues, a proper method should allow analysts to identify possible modern contaminants and exclude them from the final interpretation. Therefore, analysts should not underestimate the presence of modern contaminants and might learn how to discriminate the background noise due to handling. The main aim of this research is to provide some methodological improvements to residue analysis through the characterisation of some modern residues often present on the surface of stone tools (e.g. skin flakes, modelling clay). This characterisation was done by using both optical light microscopy (OLM) and scanning electron microscopy (SEM). Finally, a special care in the post-excavation treatment of stone tools is claimed in order to avoid major contamination of the samples.

Spontaneous pneumothorax and tuberculosis: long-term follow-up.

Though spontaneous pneumothorax (SP) is a well-known complication of pulmonary tuberculosis (TB), there are very few reports addressing this topic. For this reason, we retrospectively analysed the experience of SP in patients diagnosed with TB in our hospital between 1989 and 2010. Out of 872 patients treated for SP during this period, 47 (5.4%) had TB antecedents, 21 with active TB (0.95% of the 2,089 TB cases diagnosed during this period) and 26 with residual inactive TB. 46 cases were treated with pleural drainage (PD): 40 (85%) with only one PD, two with two, and four with three. The mean ± SD length of PD treatment was 12.9 ± 11.3 days. In 11 (23%) cases, a relapse of SP occurred, with no statistical relationship between the different studied variables. In 13 (28%) cases, it became necessary to carry out a resection (atypical segmentectomy in all cases) for persistent air leaks with PD. Survival statistics were unfavourable only in elderly patients and those infected with HIV. We conclude that the treatment of SP secondary to TB with PD is usually a sound response, with a good general prognosis and a low percentage of cases that require another PD and surgical treatment.

L-tryptophan administered orally at night modifies the melatonin plasma levels, phagocytosis and oxidative metabolism of ringdove (Streptopelia roseogrisea) heterophils.

The essential amino acid tryptophan is the precursor in the anabolic pathway of melatonin, a hormone with immunomodulatory properties. The present study shows the in vivo effect of tryptophan on the phagocytic function and oxidative metabolism of heterophils from Streptopelia roseogrisea of < 1 year of age, with a parallel evaluation of the plasma levels of melatonin. The L-tryptophan was administered orally (125 and 300 mg/kg b.w.) at 19:00, before the beginning of the period of darkness, for 7 days. At the end of the tryptophan treatment, determinations were made at 21:00 and 02:00 of the Phagocytosis Index, the Phagocytosis Percentage, the Phagocytic Efficiency and the superoxide anion levels in heterophils isolated from blood and of the plasma levels of melatonin. The results showed, for the determinations at 21:00 in the animals that had received 125 mg L-tryptophan/kg b.w., enhanced heterophil phagocytic function and raised levels of plasma melatonin, with no affect on the oxidative metabolism of the phagocytes. For the administration of the greater concentration of tryptophan (300 mg/kg b.w.), there were raised plasma melatonin levels together with increases in heterophil phagocytic capacity and phagocyte oxidative metabolism at 02:00. The results indicate that tryptophan administered orally at night to diurnal animals of less than 1 year in age affects the circulating levels of melatonin at the same time as inducing stimulation of the innate immune function.

Norepinephrine as mediator in the stimulation of phagocytosis induced by moderate exercise.

During intensive exercise the stimulation of phagocytosis is mediated by "stress hormones". During moderate exercise, however, such mediation is less clear. The influence of moderate exercise (45 min at 55% maximal oxygen uptake) on the phagocytic capacity of neutrophils was evaluated in sedentary men. The exercise stimulated phagocytosis of Candida albicans, and the stimulation was maintained for at least 24 h. The possible neuroendocrine mediators were then investigated. Stimulation of phagocytosis was found after incubating neutrophils from sedentary individuals, who were in a basal state, with plasma from exercised individuals. Immediately after exercise, there was a significant increase in the concentration of norepinephrine, but not of epinephrine or cortisol. Incubation of neutrophils with this post-exercise physiological concentration of norepinephrine also stimulated phagocytosis, and the effect was blocked by both propranolol and phentolamine. The norepinephrine-augmented phagocytosis was accompanied by an increase in intracellular levels of cAMP, but not of cGMP or calcium. In conclusion, moderate exercise performed by sedentary people stimulates the phagocytic capacity of neutrophils, and the stimulation lasts for at least 24 h. Norepinephrine mediates the stimulation, although other mechanisms could be involved during the recovery period.

Use of the preoperative levels of CEA in patients with colorectal cancer.

BACKGROUND/AIMS: Preoperative carcinoembryonic antigen has been considered useful as a prognostic factor and recurrence indicator of colorectal neoplasms. However, its diagnostic ability related to some parameters such as resectability or tumor staging has been less studied. The aim of this study was to evaluate the use of this marker as a diagnostic test for these parameters of colorectal cancer. METHODOLOGY: In a sample of 283 patients operated on for colorectal carcinoma data were retrospectively recorded corresponding to preoperative carcinoembryonic antigen, type of surgery performed (curative vs. non-curative), tumor intramural spread, lymph node involvement, distant metastasis, TNM stage, tumoral differentiation, survival time and survival time free of disease. Bivariate analysis between carcinoembryonic antigen and the rest of the parameters was performed. Also, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy (efficiency) of the marker considered as a diagnostic test, were analyzed in relation to the tumoral resectability and tumoral spread. RESULTS: Preoperative level of serum carcinoembryonic antigen was statistically significantly associated with type of surgery performed (p < 0.001); tumoral intramural spread (p = 0.001); lymph node involvement (p < 0.001); presence of distant metastasis (p < 0.001); TNM staging (p < 0.001); overall survival period (p < 0.001) and disease-free survival time (p = 0.04). There was no relation between carcinoembryonic antigen and the degree of tumoral differentiation. The carcinoembryonic antigen's greatest sensitivity corresponded with the prediction for the type of the surgery performed and with the existence of distant metastasis, 80% and 70.9%, respectively. The negative predictive value was also high (> 90% in both cases). When considering the intramural spread, the specificity was 82% and its positive predictive value 93.1%. CONCLUSIONS: Preoperative levels of serum carcinoembryonic antigen, considered as a diagnostic test, are useful as predictors of resectability and tumor spread in colorectal carcinoma.

Estudio evolutivo de las patologías de origen profesional en España (1989-1999) / Evolutionary study of pathologies of occupational accidents and disease in Spain (1989-1999)

En España se declaran cada año más de un millón de accidentes de trabajo, y en más de mil casos se produce la muerte del trabajador. Esto tiene importantes repercusiones sociales y económicas. La entrada en vigor de las nuevas normativas en materia de prevención de riesgos laborales no ha paliado dicha situación. En nuestro estudio realizamos un análisis descriptivo de los accidentes de trabajo y de las enfermedades profesionales declaradas en España entre 1/01/1989 y 31/12/1999. Se analiza la gravedad del caso y se especifica la Comunidad Autónoma en la que se produjo. Los datos fueron solicitados al Ministerio de Trabajo y al Instituto Nacional de Estadística. Los Accidentes de Trabajo (AT) se han incrementado en un 41,91 por ciento. De ellos, los graves han disminuido en un 12,09 por ciento y los mortales en un 23,45 por ciento. Un tercio de los AT mortales fueron AT "in itinere". Las Enfermedades Profesionales (EP) declaradas se han multiplicado por cuatro. Existen claras diferencias entre los casos declarados de AT y EP entre las diferentes Comunidades Autónomas (AU)

Melatonin and aging: in vitro effect of young and mature ring dove physiological concentrations of melatonin on the phagocytic function of heterophils from old ring dove.

We have studied the circadian rhythm of melatonin in the ring dove (Streptopelia risoria) for different age groups: young (1-1.5 years), mature (3-4 years) and old animals (>8 years). Melatonin levels were determined by radioimmunoassay. Results showed a significant decline in plasma melatonin levels in old animals when compared with the concentrations observed in the other two age groups, in which maximum (nocturnal) concentrations were 300 pg/ml and minimum (diurnal) concentrations were 50 pg/ml. We analyzed the in vitro effect of the physiological concentrations found in young and mature animals on the heterophils obtained from old animals, evaluating the capacity for ingestion and destruction of Candida albicans, and the oxidative metabolism associate to phagocytosis by determining the superoxide anion levels. Melatonin induced an increase in both the phagocytosis index and the candidicide capacity. This effect was dose-dependent. In relation with the oxidative metabolism, a decline in superoxide anion levels after incubation with both concentrations of the hormone was observed. Thus our results corroborate in this avian species the decline in plasma melatonin levels with advanced age, as well as the enhancing effect of physiological concentrations of melatonin on the phagocytic function.

Factores predictivos de la recidiva de cáncer colorrectal / Predictive factors for colorectal cancer recurrence

Introducción. El seguimiento estrecho y no selectivo de todos los pacientes intervenidos de cáncer colorrectal (CCR) supone un gran consumo de recursos y tiempo, cuya necesidad se ha cuestionado. Sería ideal conocer a priori a aquellos pacientes con mayor probabilidad de recidiva que serían los que verdaderamente se van a beneficiar de una estrecha vigilancia. Objetivos. Definir una población de alto riesgo de recidiva de CCR según parámetros comúnmente empleados en la clínica y laboratorio. Pacientes y método. Estudio retrospectivo, descriptivo y longitudinal de 398 pacientes intervenidos de CCR en nuestra institución entre 1988 y 1995. Se recogieron los datos correspondientes a filiación, antecedentes personales, síntomas clínicos relevantes (masa palpable, anemia, perforación, oclusión); datos de laboratorio; marcadores tumorales, localización del tumor, tipo y carácter de la intervención, estadio TNM, grado de diferenciación, presencia de mucina, transfusiones perioperatorias, complicaciones postoperatorias, infecciones, recidiva y supervivencia libre de enfermedad. El tiempo medio de seguimiento fue de 33,6 meses. Se analizó la relación de estas variables con la supervivencia libre de recidiva mediante el test de rangos logarítmicos. Posteriormente, se introdujeron las variables significativas en un modelo de regresión de Cox para determinar los factores pronósticos independientes que se relacionaban con la recidiva. Resultados. La muestra estudiada constaba de 398 pacientes, 204 varones (51,4 por ciento) y 194 mujeres (48,7 por ciento); edad media: 65,30 años (rango: 21-91) (DE: 13,46; IC del 95 por ciento: 63,98-66,63). Recidivaron 85 pacientes (21,4 por ciento), siendo la probabilidad de estar libre de recidiva a los 5 años del 63,47 por ciento. En el análisis bivariante se relacionaron con la recidiva de forma estadísticamente significativa los siguientes parámetros: edad (p = 0,007); clínica de complicación (perforación/oclusión) (p = 0,009); valores de GGT (p = 0,02); CEA alterado (p = 0,04); localización rectal (p = 0,03); cirugía urgente (p = 0,01); penetración transmural (p = 0,001); ganglios afectados (p = 0,0001) y absceso de pared (p = 0,0005). El resto de los parámetros no se relacionó con la recidiva. En el análisis multivariante permanecieron como factores predictivos independientes los siguientes: edad (p = 0,02; OR = 0,98); valores de GGT (p = 0,001; OR = 3,15); localización en recto (p = 0,04; OR = 2,03); absceso de pared (p = 0,04; OR = 1,9), y afecció ganglionar (p = 0,0001; OR = 4,72).Conclusiones. La identificación de una población de alto riesgo de recidiva tumoral podría permitir un seguimiento postoperatorio más selectivo con vistas a disminuir recursos y costes (AU)

Phagocytic function in cyclists: correlation with catecholamines and cortisol.

Flow cytometer measurements were made of the basal variations in peripheral blood functional monocytes and granulocytes over the course of a training season (January to November) of a cycling team. Parallel determinations were made of plasma concentration of catecholamines (chromatography) and cortisol (RIA) in a search for neuroendocrine markers. The results showed the greatest phagocytic capacity to occur in the central months (March, May, and July), coinciding with the greatest number and highest level of competitive events with good correlation with a peak in epinephrine during these months (r(2) = 0.998 for monocytes and r(2) = 0.674 for granulocytes). No good correlations were found between phagocytosis and norepinephrine or cortisol. The highest values for phagocytosis and epinephrine concentration were found in May. These results suggest that blood epinephrine concentration could be a good neuroendocrine marker of sportspeople's phagocytic response.

Anatomic characteristics of the infraorbital foramen: a cadaver study.

PURPOSE: The aim of this study was to document the variability in the position of the infraorbital foramen with relation to the facial midline, infraorbital rim, supraorbital notch, and maxillary teeth. MATERIALS AND METHODS: Forty-seven cadavers (94 sides) were dissected, exposing the infraorbital foramen, supraorbital foramen, and orbital floor bilaterally. Measurements made included (A) distance between the infraorbital foramen and inferior orbital rim; (B) distance of the infraorbital foramen from the facial midline; (C) distance of the supraorbital foramen from the facial midline; (D) distance between the infraorbital foramen and supraorbital foramen. Means, standard deviations, and ranges were determined, and statistical differences were calculated between the left and right orbits and sexes by use of an unpaired sample t-test (P < .05). RESULTS: In men, the mean distance between the infraorbital foramen and the inferior orbital rim was 8.5 +/- 2.2 mm. In women, this was 7.8 +/- 1.6 mm. The distance between the infraorbital foramen from the facial midline was 27.7 +/- 4.3 mm in males and 26.2 +/- 3.2 mm in females. The mean distance between the infraorbital foramen and supraorbital notch in males was 43.3 +/- 3.1 mm and in females was 42.2 +/- 2.4 mm. The average distance of the supraorbital notch from the midline was 26.5 +/- 3.5 mm in males and 26.3 +/- 3.3 mm in females. There were no statistically significant differences between the left and right sides or between sexes. The maxillary tooth most commonly found in the same vertical plane as the infraorbital foramen was the first premolar. Multiple ipsilateral foramina were found in 15% of cadavers. CONCLUSION: These anatomic characteristics may have important implications for surgical and local anesthetic planning.

Factores predictores del tiempo de estancia de los ancianos en un servicio de urgencias hospitalario / Predictive factors of the length of the stay of elderly patients in a hospital emergency department

Introducción: Los ancianos son uno de los sectores que demanda mayor asistencia sanitaria urgente. El proceso de atención a las urgencias presenta características diferenciales respecto al resto de la población. En general requieren mayor consumo de tiempo y de exploraciones complementarias lo que se correlaciona con un mayor número de problemas y gravedad de las patologías. Objetivo: Analizar los factores predictivos relacionados con el tiempo de estancia de la población anciana en un servicio de urgencias. Métodos: Estudio transversal de una muestra de 1002 pacientes obtenida mediante muestreo consecutivo a partir de la población mayor de 75 años que acudió durante 1995 al servicio de urgencias de un centro hospitalario de tercer nivel. Se recogieron de forma prospectiva una serie de variables independientes (filiación, procedencia, incapacidad, tipo de enfermedad, destino, exploraciones complementarias) que se relacionaron con el tiempo de estancia en horas mediante un análisis multivariante utilizando como modelo la regresión lineal. Resultados: El tiempo medio de estancia en el servicio de urgencias fue de 8,34 horas (DE:ñ9,36; IC95 por ciento:7,76-8,92 horas). Un 8,5 por ciento de los pacientes estuvieron más de 24 horas y el 16,6 por ciento precisó menos de una hora. Se revelaron como factores predictivos independientes del tiempo de estancia en el servicio de urgencias la incapacidad física (p=0,02); el padecer una enfermedad digestiva (p=0,04); el destino del paciente (p=0,001) y la realización de pruebas complementarias como un hemograma (p=0,03), una ecografía (p=0,001) o una tomografía computadorizada (p=0,001). Conclusiones: El tiempo asistencial que ocupan los ancianos en general es corto y depende fundamentalmente de las pruebas complementarias y de la espera de camas de hospitalización. Es de gran utilidad el conocimiento de los factores predictivos del tiempo de estancia en los servicios de urgencia para adecuar y planificar correctamente la asistencia (AU)

Suppression of both basal and antigen-induced lipid peroxidation in ring dove heterophils by melatonin.

There have been several findings recently concerning melatonin as a free radical scavenger and general antioxidant. For instance, in bird heterophils we found that 100 microM of melatonin decreases superoxide anion levels and modulates superoxide dismutase activity. This paper sought to study the effect of melatonin upon induced oxidative damage in heterophils of the ring dove (Streptopelia risoria). The concentration of malonaldehyde (MDA) as an index of induced oxidative damage to lipid membranes was tested by colorimetric assay. A heterophil suspension was co-incubated with and without inert particles (latex beads) as material to be phagocytosed, both alone and in combination with 100 microM of melatonin. Measurements were made at the basal time (0 min), as well as at 15, 30, 45, and 60 min. Protein concentrations were determined by a standardized method using bovine serum albumin as standard. Results are expressed as nmol MDA/mg prot. Melatonin clearly reduced the production of MDA, an index of lipid peroxidation. It also annulled the enhancement of MDA levels produced by latex beads. Both effects were observed at all the times studied. In conclusion, our findings again show that the neurohormone melatonin could be useful as an effective pharmacological antioxidant.

Correlation between the circadian rhythm of melatonin, phagocytosis, and superoxide anion levels in ring dove heterophils.

A functional role for melatonin is its relationship to circadian timing mechanisms. In addition, there has recently been assumed to be a functional connection between the pineal gland and the immune system in mammals and birds, with some findings showing melatonin to be a free radical scavenger and general antioxidant. The present study investigates the possible relationship between the circadian rhythm of melatonin and the ingestion capacity as well as superoxide anion levels of ring dove (Streptopelia risoria) heterophils. In birds, heterophils, with their ability to ingest and kill different antigens, play a central role in the host defence mechanism. All determinations were made during 24 hr periods at 2 hr intervals. Radioimmunoassay showed an increase of melatonin serum levels during the dark period (from 20:00 to 07:00 hr) with a maximum at 04:00 hr, and a significant decline during the hours of light with a minimum at 16:00 hr. Similarly, the phagocytic index was enhanced during the night, with the maximum at approximately 04:00 hr and the minimum at approximately 18:00 hr. The same was the case in relation to phagocytic percentage. However, the superoxide anion levels were lower during darkness (minimum at 04:00 hr) and higher during the light period (maximum at 14:00 hr). In conclusion, our findings show that one pineal-mediated effect on the immune system may be a direct action of melatonin on phagocytosis and the phagocytic biochemical process, and that this neurohormone might act as an antioxidant.

Neurosensory deficit and functional impairment after sagittal ramus osteotomy: a long-term follow-up study.

PURPOSE: This study evaluated persistent neurosensory deficit (NSD) and functional sensory deficit (FSD) after mandibular bilateral sagittal split osteotomies (BSSO) and their association with patient age at time of operation and eight additional variables. PATIENTS AND METHODS: Eighty-five patients more than 2 years post-BSSO were identified and stratified by age: group 1, 10 to 19 years (n=16); group 2, 20 to 29 years (n=24); group 3, 30 to 39 years (n=30); group 4, older than 40 years (n=15). Mean mandibular advancement, incidence of "bad split," excessive intraoperative bleeding, nerve manipulation, removal of third molars, use of rigid fixation, simultaneous mandibular procedures, and associated systemic disease were documented for each group. A questionnaire modified from Zuniga was used to document the presence of persistent (2 years or longer) NSD and FSD. Statistical analysis was performed to determine differences between groups. Logistic regression was used to evaluate each variable and determine its association with persistent NSD and FSD. RESULTS: Persistent NSD by age was: group 1, 81%; group 2, 46%; group 3, 73%; group 4, 87%. The trend of increasing persistence with increasing age was not significant (P=.248). However, persistent FSD with increasing age was highly significant (P=.003). The incidence of FSD in group 4 was statistically greater than in the other groups (P < .001; P < .001; P=.004, respectively). Logistic regression identified patient age and "bad splits" as associated with FSD (P=.003; P=.015, respectively). CONCLUSIONS: The incidence of persistent FSD more than 2 years post-BSSO increases with increasing age in a predictable and highly significant manner. Presurgical counseling should address this issue. FSD is also significantly associated with "bad splits." No other variables were found to be significant.

Sensory abnormalities associated with mandibular fractures: incidence and natural history.

PURPOSE: The aims of this study were to determine the incidence of inferior alveolar nerve (IAN) abnormalities in patients with mandibular fractures and to document the natural history and spontaneous recovery rate in patients with a sensory disturbance. PATIENTS AND METHODS: This was a retrospective evaluation of patients (n = 150) with mandibular fractures at risk for IAN injury admitted to the Oral and Maxillofacial Surgery Service between 1985 and 1995. The inclusion criteria were: 1) fractures between the mandibular and mental foramina, 2) availability of the results of a post-injury, preoperative sensory examination, and 3) at least 1 year follow-up. Fracture characteristics, physical examination findings, hospital course, operative treatment, and follow-up were documented. Patient interviews were conducted to determine the incidence of long-term sensory disturbance and associated morbidity. The results were evaluated with chi-square analysis. RESULTS: Fifty-six percent of patients (84 of 150) had a post-injury/pretreatment IAN abnormality. Patients with sensory disturbance had a significantly higher frequency of displaced fractures than those without sensory disturbance (P < .001). Sixteen of 24 patients (66.7%) with an abnormal post-injury/ pretreatment sensory examination reported a permanent sensory deficit (mean follow-up, 74.3 months); 55% of these patients complained of impairment. CONCLUSIONS: The incidence of postinjury IAN deficits in patients with mandibular fractures was greater than 50% and was related to fracture displacement. One third of these patients regained normal sensation; the remaining two thirds reported a persistent sensory deficit. A significant number of these patients complained of discomfort and impairment after a mean follow-up of greater than 6 years.