Ventilación controlada por flujo y gafas nasales de alto flujo en cirugía láser de estenosis subglótica grado III / Flow-controlled ventilation and hi-flow nasal oxygen in laser surgery for a grade III subglottic stenosis patient

Paciente de 49 años (IMC 29,4 kg/m2 y ASA III) con estenosis subglótica (ES) de más de 70% (grado III) intervenida mediante resección láser y posterior dilatación. Durante la resección láser se empleó ventilación controlada por flujo utilizando el respirador Evone®, que permite controlar todo el ciclo respiratorio regulando tanto el flujo inspiratorio como el espiratorio sin comprometer el intercambio gaseoso a pesar de administrar FIO2 máxima de 0,3 por riesgo de ignición. Antes de proceder a la dilatación endoscópica, se retiró el tubo endotraqueal láser de 4,5 mm de diámetro interno y se inició terapia con gafas nasales de alto flujo (GNAF) para prolongar la oxigenación apneica. El tiempo total de apnea fue de 11 minutos, manteniendo en todo momento SpO2 > 98% y End Tidal de CO2 máximo de 60 mmHg.(AU)

A 49-year old patient (BMI 29.4 kg/m2 and ASA III) with grade III subglottic stenosis (> ventilator in flow controlled ventilation mode, which allowed us to regulate both inspiratory and expiratory flow without compromising gas exchange despite maintaining peak FIO2 at 0.3 due to the risk of ignition. Before proceeding with endoscopic dilation, the 4.5 mm laser endotracheal tube was withdrawn and high flow nasal cannula oxygenation was started in order to prolong apnoeic oxygenation. Total apnoea time was 11 minutes, maintaining SpO2 > 70%) underwent laser resection followed by dilation. During resection he was ventilated by the Evone > ventilator; high flow nasal cannula therapy; apnoeic oxygenation-98% and peak EtCO2 60 mmHg throughout the procedure.(AU)

Flow-controlled ventilation and hi-flow nasal oxygen in laser surgery for a grade III subglottic stenosis patient.

A 49-year old patient (BMI 29.4kg/m2 and ASA III) with grade III subglottic stenosis (> ventilator in flow controlled ventilation mode, which allowed us to regulate both inspiratory and expiratory flow without compromising gas exchange despite maintaining peak FIO2 at 0.3 due to the risk of ignition. Before proceeding with endoscopic dilation, the 4.5mm laser endotracheal tube was withdrawn and high flow nasal cannula oxygenation was started in order to prolong apnoeic oxygenation. Total apnoea time was 11min, maintaining SpO2>70%) underwent laser resection followed by dilation. During resection he was ventilated by the Evone>ventilator; high flow nasal cannula therapy; apnoeic oxygenation-98% and peak EtCO2 60mmHg throughout the procedure.

Textbook outcome in colon carcinoma: implications for overall survival and disease-free survival.

BACKGROUND: Textbook outcome (TO) is a multidimensional quality management tool that uses a set of traditional surgical measures to reflect an "ideal" surgical result for a particular pathology. The aim of the present study is to record the rate of TO in patients undergoing elective surgery for colon cancer (CC). MATERIAL AND METHODS: Retrospective study of all patients undergoing scheduled CC surgery at a Spanish university hospital from September 2012 to August 2016. Patients with rectal cancer were excluded. The variables included in the definition of TO were: R0 resection, number of isolated nodes ≥ 12, no Clavien-Dindo ≥ IIIa complications, no prolonged stay, no readmissions, and no mortality in the first 30 days. The main objective of this study is to analyse the achievement of TO in these patients and to assess the relationship between TO and overall and disease-free survival. RESULTS: Five hundred and sixty-four patients were included in the study. TO was achieved in 49.8%. The sample had a mean age of 69 ± 11 years, and 60% were male. Female sex (OR 1.61; 95% CI 2.30-1.13), T3 and T4 classification (OR 2.50, 95% CI 4.59-1.36, and OR 2.55, 95% CI 5.21-1.24 respectively) and laparoscopic approach (OR 1.53, 95% CI 2.33-1.00) were independent factors that were significantly associated with achieving a TO. Patients who achieved TO had higher overall survival (p = 0.008) than those who did not. However, with regard to disease-free survival, no statistically significant differences were found (p = 0.303). CONCLUSION: TO is a useful, easy-to-interpret management tool for measuring oncological results and for predicting patient survival.

Geographic distribution, evolution, and disease importance of species within the Neotropical Anopheles albitarsis Group (Diptera, Culicidae).

The Anopheles albitarsis group of mosquitoes comprises eight recognized species and one mitochondrial lineage. Our knowledge of malaria vectorial importance and the distribution and evolution of these taxa is incomplete. We constructed ecological niche models (ENMs) for these taxa and used hypothesized phylogenetic relationships and ENMs to investigate environmental and ecological divergence associated with speciation events. Two major clades were identified, one north (Clade 1) and one south (Clade 2) of the Amazon River that likely is or was a barrier to mosquito movement. Clade 1 species occur more often in higher average temperature locations than Clade 2 species, and taxon splits within Clade 1 corresponded with a greater divergence of variables related to precipitation than was the case within Clade 2. Comparison of the ecological profiles of sympatric species and sister species support the idea that phylogenetic proximity is related to ecological similarity. Anopheles albitarsis I, An. janconnae, and An. marajoara ENMs had the highest percentage of their predicted suitable habitat overlapping distribution models of Plasmodium falciparum and P. vivax, and warrant additional studies of the transmission potential of these species. Phylogenetic proximity may be related to malaria vectorial importance within the Albitarsis Group.

Comparison of continuous infusion with intermittent bolus administration of cefotaxime on blood and cavity fluid drug concentrations in neonatal foals.

Healthy neonatal foals were treated with cefotaxime by bolus (40 mg/kg i.v. q6h for 12 doses; n=10) or by infusion (loading dose of 40 mg/kg i.v. followed by continuous infusion of a total daily dose of 160 mg/kg per 24 h for 3 days; n=5). Population pharmacokinetics was determined, and concentrations in cavity fluids were measured at steady state (72 h). Highest measured serum drug concentration in the bolus group was 88.09 µg/mL and minimum drug concentration (C(min)) was 0.78 µg/mL at 6-h postadministration (immediately before each next dose), whereas infusion resulted in a steady-state concentration of 16.10 µg/mL in the infusion group. Mean cefotaxime concentration in joint fluid at 72 h was higher (P=0.051) in the infusion group (5.02 µg/mL) compared to the bolus group (0.78 µg/mL). Drug concentration in CSF at 72 h was not different between groups (P=0.243) and was substantially lower than serum concentrations in either group. Insufficient data on pulmonary epithelial lining fluid were available to compare the methods of administration for cefotaxime in this cavity fluid. Results support continuous drug infusion over bolus dosing in the treatment for neonatal foal septicemia to optimize time that cefotaxime concentration exceeds the minimum inhibitory concentration of common equine pathogens.

[Analysis of prescriptions given on discharge from the emergencies department. Economic impact]. / Análisis de la prescripción al alta en urgencias. Impacto económico.

OBJECTIVE: To analyse the characteristics and cost of medical prescriptions given upon discharge from the casualty department, as well as the savings made by making substitutions with generic drugs or other equivalent pharmaceutical products in a third level hospital. METHODS: 669 patients were chosen using a cluster sample with a sub-sample. The following variables were considered: a) analysis of the prescription (medication quantification, active ingredients and most prescribed therapeutic groups, and possibility of prescribing generic drugs); b) calculation of cost and saving estimate (price to public and equivalent products); c) prescription quality (adherence to the guide and percentage of products of high therapeutic use.) RESULTS: 370 of the 669 patients received medication when they were discharged, with an average of 1.7 per patient. 629 products were prescribed, 16 % due to their active ingredient, with 37.53 % generic products available. The main active ingredients prescribed were paracetamol, ibuprofen and omeprazole amounting to 26.70 % of the total prescribed and the therapeutic groups that were highlighted were locomotor apparatus, the nervous system, the digestive apparatus and metabolism with 69.39 % of the total. 92.84 % of the prescriptions adhered to the pharmaco-therapeutic guide and 98.41 % were of high therapeutic use. The annual cost of prescribed medication was 1,013,778 Euro and the saving made by generic product substitution and a programme of therapeutic equivalents was 145,971 Euro. CONCLUSIONS: A prescription based on its active ingredients and a therapeutic and generic substitution produce a significant saving both for the patient and for the hospital.

Análisis de la prescripción al alta en urgencias. Impacto económico / Analysis of prescriptions given on discharge from the emergencies department. Economic impact

Objetivo: Analizar las características y coste de la prescripción medicamentosa al alta en urgencias, así como el ahorro que supondría la sustitución por su EFG u otra especialidad farmacéutica equivalente, en un hospital de nivel terciario. Métodos: Se seleccionó a 669 pacientes mediante un muestreo de conglomerados con submuestreo. Las variables recogidas fueron: a) análisis de la prescripción (cuantificación de la medicación, principios activos y grupos terapéuticos más prescritos, y posibilidad de prescripción por especialidades farmacéuticas genéricas); b) cálculo de coste y estimación de ahorro (precio de venta al público y de especialidades equivalentes); c) calidad de la prescripción (adherencia a la guía y porcentaje de especialidades de utilidad terapéutica alta). Resultados: De los 669 pacientes, 370 recibieron medicación al alta, con una media de 1,7 por paciente. Se prescribieron 629 especialidades y un 16 % fue por principio activo, habiendo disponibilidad de genéricos en un 37,53 %. Los principios activos más prescritos fueron paracetamol, ibuprofeno y omeprazol, con un 26,7 % del total y los grupos terapéuticos destacados fueron aparato locomotor, sistema nervioso, y aparato digestivo y metabolismo con 69,39 % del total. Un 92,84 % de las prescripciones perteneció a la guía farmacoterapéutica y un 98,41 % fue de utilidad terapéutica alta. El coste anual de la medicación prescrita fue de 1.013.778 ¿ y el ahorro con la sustitución genérica y un programa de equivalentes terapéuticos sería de 145.971 ¿. Conclusiones: Una prescripción por principio activo y una sustitución terapéutica y genérica producen un ahorro significativo tanto para el paciente como para el hospital (AU)

Objective: To analyse the characteristics and cost of medical prescriptions given upon discharge from the casualty department, as well as the savings made by making substitutions with generic drugs or other equivalent pharmaceutical products in a third level hospital. Methods: 669 patients were chosen using a cluster sample with a sub-sample. The following variables were considered: a) analysis of the prescription (medication quantification, active ingredients and most prescribed therapeutic groups, and possibility of prescribing generic drugs); b) calculation of cost and saving estimate (price to public and equivalent products); c) prescription quality (adherence to the guide and percentage of products of high therapeutic use.) Results: 370 of the 669 patients received medication when they were discharged, with an average of 1.7 per patient. 629 products were prescribed, 16 % due to their active ingredient, with 37.53 % generic products available. The main active ingredients prescribed were paracetamol, ibuprofen and omeprazole amounting to 26.70 % of the total prescribed and the therapeutic groups that were highlighted were locomotor apparatus, the nervous system, the digestive apparatus and metabolism with 69.39 % of the total. 92.84 % of the prescriptions adhered to the pharmaco-therapeutic guide and 98.41 % were of high therapeutic use. The annual cost of prescribed medication was ¿1,013,778 and the saving made by generic product substitution and a programme of therapeutic equivalents was ¿145,971. Conclusions: A prescription based on its active ingredients and a therapeutic and generic substitution produce a significant saving both for the patient and for the hospital (AU)

Pseudotrombocitopenia EDTA dependiente / No disponible

No disponible

Manejo del trauma grave en la Comunidad Valenciana / Management of severe trauma patients in the Valencia Community

Objetivo: La lesión traumática representa hoy en nuestro país la principal causa de muerte en las primeras cuatro décadas de la vida. Sin menoscabo de la importancia de una política eficaz de prevención, es preciso garantizar el manejo y tratamiento adecuado de estos pacientes. Se investiga la atención que se dispensa al paciente crítico y se estudia la capacidad de mejora cuando sea necesario y donde sea posible. Métodos: Estudio multicéntrico entre todos los hospitales de la Comunidad Valenciana. Se elaboró una encuesta de preguntas cerradas en relación con la atención al paciente crítico que se remitió por correo a los diferentes servicios de urgencias hospitalarias. La recogida y el procesamiento de los datos se realizó mediante modelos estadísticos con valoración de los resultados obtenidos. Resultados: Un 61% de los servicios de urgencias de la Comunidad Valenciana dispone de un registro de la recepción del trauma grave. El mayor número de politraumatizados son por accidente de tráfico (40%). La responsabilidad en la observación y control evolutivo corre a cargo del médico de urgencias en el 61% de los centros encuestados. Un 33% de los servicios responde no disponer, dentro de su propia unidad estructural, de capacidad de atención a múltiples víctimas con riesgo vital. Sobre la disponibilidad de material, el 23,8% de los SUH no dispone, en el momento de cumplimentar la encuesta, de collarín tipo Philadelphia. En el 85% de los servicios encuestados se solicita, de manera habitual, hemograma, bioquímica y coagulación, mientras que sólo una cuarta parte solicita pruebas toxicológicas de manera protocolarizada (con una positividad de las mismas entre un 25-50%). Las exploraciones radiográficas se encuentran protocolarizadas en más del 90% de los servicios encuestados. Respecto a la planificación en la formación de los profesionales en los servicios de urgencias, aunque el 90% de los centros hospitalarios encuestados se encuentran acreditados para la docencia por parte del Ministerio de Sanidad y Consumo en el momento actual aunque sólo en un 15% de los centros se realizan cursos de formación o reciclaje de una manera frecuente. Conclusiones: Si bien resulta evidente el papel a desempeñar por parte de los servicios de urgencias hospitalarias en el plan integral de la atención del paciente politraumatizado, el estudio detecta una apreciable descoordinación en la recepción hospitalaria del paciente politraumatizado, observándose una falta de uniformidad asistencial en la valoración inicial y tratamiento en la comparativa de los diferentes centros participantes en el mismo (AU)

Background and aims: Traumatisms represent in our times the leading cause of death during the first four decades of life. Without belittling the importance of an effective prevention policy, there is a need to guarantee the adequate management and therapy of these patients. We review the current management of the critical patient and study the possibilities of improvement whenever needed and wherever possible. Methods: Multicenter study encompassing all the hospitals in the Valencia Community. A closed-question survey questionnaire was prepared regarding the attention to critical patients, which was mailed to the various hospitalary Emergency Departments. Data acquisition and processing was carried out using statistical models with assessment of the results. Results: An admission registry for severe trauma cases is available in 61% of the Emergency Departments in the Valencia Community. The greatest number of polytraumatism cases corresponds to traffic accidents (40%). In 61% of the centres surveyed it is the Emergency Physician who is responsible for the observation and evolutive control of the cases. Among the Emergency Departments surveyed 33% did not have, within their own sutructural unit, a capability for attending to multiple victims at risk of death. As regards material and equipment availability, 23.8% of the hospital Emergency Departments did not have available, at the time of the survey, a Philadelphia neck support. In 85% of the surveyed Departments blood counts, blood biochemistries and coagulation tests are routinely requested on admission, while only one-quarter does request toxicologic tests per protocol (with a positivity rate of 25- 50%). X-ray examinations are protocolised in over 90% of the surveyed Departments. As for the planification of training for the professionals in the Emergency Departments, frequent training and/or update courses are carried out in 15% of the centres, while 90% of all hospitalary centres surveyed are accredited for docency by the Ministry of Health and Consumer Affairs at the present time. Conclusions: Even though the role of the hospital Emergency Departments in the integrated plan for care to the polytraumatised patient is evident, our study has detected an appreciable lack of coordination in the hospital admission of the polytraumatised patient, with a lack of assistential uniformity in the initial assessment and management when the various participating centres are compared (AU)

[Capillary hemoglobin as a predictor of the response to the oral intake of iron in children with iron deficiency]. / La hemoglobina capilar como predictor de la respuesta al hierro oral en niños con deficiencia de hierro.

A study was made to determine the prevalence of anemia in apparently healthy children of both sexes aged 6 to 24 months attending the preventive medicine service in a general hospital of the Mexican Social Security Institute in the city of Tapachula, State of Chiapas. One hundred children were studied with a capillary hemoglobin (Hb) determination: 91 had anemia (Hb less than or equal to 11 g/dL). Sixty eight of the anemic children received oral iron for 3 months (3 mg/kg/day): their Hb before and after iron therapy were compared. Considering as responders those with an increment in Hb greater than 1 g/dL, sixty four children (94%) showed a mean increment of 2.6 g/dL. Four were considered as non-responders: in 3 the iron supplementation was stopped due to infectious diseases; the fourth case had a Hb increment below 1 g/dL. The use of capillary Hb as a criterium for treating anemic children proved to be a good predictor of response in a population where the prevalence of iron deficiency is high.

[Elective appendectomy associated with cesarean section]. / Apendicectomía electiva asociada a cesárea.

A prospective study was conducted in 90 patients divided in two different groups: the first group included 45 labor patients operated of cesarean section and elective appendectomy, the second group included 45 labor patients operated of cesarean section without appendectomy (control group). The purpose was to evaluate if the elective removal of the appendix increase the postoperative morbidity. The most common indication of cesarean section was the mother-fetus disproportion (55.5%). The main type of uterine incision was the segmental transverse (over 90% of the cases). Appendectomy added 11.2 minutes to the operation time, as compared with the control group (p less than 0.01). There were 4 cases (8.8%) of decidual infection in the appendectomy group and 2 cases (4.4%) of decidual infection (one of these complicated with wound dehiscence) in the control group. Nevertheless there was not difference statistically significative in comparing the morbidity between the groups (p = 0.33). There were no complications directly attributable to elective appendectomy. It is concluded that the elective appendectomy does not increase the postoperative morbidity in labor patients undergoing cesarean section and it requires a good selection of patients to be appendectomized.