Could trauma laparoscopy be the standard of care for hemodynamically stable patients? A retrospective analysis of 165 cases.

BACKGROUND: Trauma laparoscopy may provide a less invasive alternative to laparotomy by providing accurate diagnosis and minimally invasive management of selected trauma patients. The risk of missing injuries during the laparoscopic evaluation still refrains surgeons from using this approach. Our aim was to evaluate feasibility and safety of trauma laparoscopy in selected patients. METHODS: We performed a retrospective review of hemodynamically trauma patients who underwent laparoscopic management in a tertiary center in Brazil due to abdominal trauma. Patients were identified by searching through the institutional database. We collected demographic and clinical data, focusing on avoidance of exploratory laparotomy, and missed injury rate, morbidity, and length of stay. Categorical data were analyzed using Chi-square, while numerical comparisons were performed using Mann-Whitney and Kruskal-Wallis test. RESULTS: We evaluated 165 cases, of which 9.7% needed conversion to an exploratory laparotomy. One-hundred and twenty-one patients (73%) had at least one intrabdominal injury. Two missed injuries to retroperitoneal organs were identified (1.2%), of which only one was clinically relevant. Three patients died (1.8%), one of which was due to complications from an intestinal injury after conversion. No deaths were related to the laparoscopic approach. CONCLUSION: In selected hemodynamically stable trauma patients, the laparoscopic approach is feasible and safe, and reduces the need for exploratory laparotomy and its associated complications.

Out-of-equilibrium dynamics driven by photoinduced charge transfer in CsCoFe Prussian blue analogue nanocrystals.

In this paper we study the out-of-equilibrium dynamics associated with photoinduced charge-transfer (CT) in cyanide-bridged Co-Fe Prussian blue analogue nanocrystals. In these coordination networks, the structural trapping of the photoinduced CT polaron involves local electronic and structural reorganizations. Femtosecond X-ray and optical absorption spectroscopies show that the local structural trapping process occurs on similar timescale for particles with 11 nm and 70 nm sizes. The local photoinduced spin transition, elongating the Co-N bonds and driving the CoIIIFeII → CoIIFeIII CT, activates coherent lattice torsion modes. The elastic deformation waves, launched by these bond elongations, drive macroscopic volume expansion and breathing of the particles. The timescale of this macroscopic deformation depends strongly on the size of the particle, which is more evidence of the multiscale nature of photoinduced phenomena in molecular materials.

Which Model Is Better to Teach How to Perform Tube Thoracostomy: Synthetic, Cadaver, or Animal?

INTRODUCTION: The lack of standardized skill training reported by medical students in performing tube thoracostomies may be associated with higher complications. The ideal training model is yet to be determined. This study sought to evaluate three different models. METHODS: Between 2015 and 2017, 204 last-year medical students of Universidade de São Paulo with no prior training in tube thoracostomy were randomized into three groups: cadaver, pig, and synthetic models. All groups performed 1-d tube thoracostomy hands-on training and a 40-min theoretical class. The knowledge acquisition was measured by a comparison between a theoretical test before and 3 wk after the class, and the skills improvement was evaluated by a comparison between the skills test on the same day of the hands-on training and another after 24 wk (the retention skill test). A questionnaire was submitted to evaluate their satisfaction rate and self-reported confidence, as per a Likert scale. RESULTS: The theoretical post-test score was higher compared to the pretest score in all groups (P < 0.001). The retention skills test in the cadaver and synthetic groups decreased compared to the skills test (P = 0.01 and P = 0.007, respectively). There was no difference between the groups either in the theoretical test or in the skills test. Student satisfaction was higher in the cadaver and pig groups. The confidence perception increased in all groups after the training. CONCLUSIONS: The models used for tube thoracostomy training appear to have a similar impact on skills retention, knowledge acquisition, and confidence. Although the satisfaction rate is lower for the synthetic model, it has no biological risk or ethical issues and is more feasible.

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries.

BACKGROUND: Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. METHODS: Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. RESULTS: Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. CONCLUSION: Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

Photoselective MLCT to d-d pathways for light-induced excited spin state trapping.

We use femtosecond optical pump-probe spectroscopy to study the Light Induced Excited Spin State Trapping (LIESST) dynamics in an FeII spin-crossover material. In these systems, LIESST derives from fast molecular switching induced by light from low (LS, S = 0) to high spin (HS, S = 2) states, as reported for molecules in solution as well as in the solid state. Since the direct LS-to-HS conversion is forbidden by selection rules, the switching dynamics involves intermediate electronic states such as metal-to-ligand charge transfer (MLCT) or ligand-field excited states of singlet or triplet nature. In addition, the HS state is structurally trapped by the elongation of the metal-ligand bond, which is accompanied by the coherent activation and damping of the molecular breathing mode. The ultrafast LIESST dynamics was mainly investigated in FeN6 ligand field systems with almost octahedral symmetry, under MLCT excitation. Our recent study on the FeII(pap-5NO2)2 spin-crossover material, with a FeIIN4O2 ligand field of C2 symmetry, has shown that in addition to MLCT bands, optical excitation, through quite intense and low-energy shifted d-d bands, can also drive LIESST. Compared to MLCT, d-d excitation involves shorter-lived intermediates, drives faster LS-to-HS switching, and enhances the coherent structural dynamics. In this paper, we present an ultrafast study of the pump wavelength dependence of LIESST and we evidence a photoselective crossover from the MLCT to the d-d pathways.

Cooperative elastic switching vs. laser heating in [Fe(phen)2(NCS)2] spin-crossover crystals excited by a laser pulse.

Spin-crossover crystals show multi-step responses to femtosecond light excitation. The local molecular photo-switching from low to high spin states occurs on sub-picosecond timescale. It is followed by additional conversion due to elastic (ns) and thermal (µs) effects. In [Fe(phen)2(NCS)2] crystals discussed herein, the thermal switching can be made unobtrusive for the investigation of cooperative elastic switching. We evidence a cooperative transformation induced by lattice expansion through elastic coupling between molecules in the crystal, where up to 3 molecules are transformed per photon.

Surgical complications in the first and second semesters of the general surgery medical residence. A study of 14063 cases.

OBJECTIVE: To evaluate whether the rate of surgical complications is higher during the first semester of the General Surgery residency in the largest hospital complex in Latin America. During this period, students are expected to have less experience in carrying out procedures. METHODS: During a period of two years, all General Surgery resident doctors at the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo, made a notification of all the procedures they performed (n = 14.063), containing information such as name of the procedure, date, who participated, complications, among others. These data were analyzed with the purpose of evaluating the variation in the rate of complications throughout the year. RESULTS: There was a 52 % increase in the rate of complications in the first academic semester when compared to the second semester. This phenomenon was observed in resident doctors in the first and second years of residency. Furthermore, it was observed that second-year residents remain with high rates of complications, in some procedures, for a longer time than first-year residents. Furthermore, the first three months (March, April and May) seem to have the highest complication rates of the entire year. CONCLUSION: The impact of these complications can affect several health services and the increase in surgical complications in the first half of the year must be monitored by institutions, in order to control this phenomenon.

A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions.

BACKGROUND: Drug patch tests (PTs) can reproduce delayed hypersensitivity to drugs and entail a moderate re-exposure of patients to offending drugs. OBJECTIVES: To determine the value of PTs for identifying the responsible drug in severe cutaneous adverse drug reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). METHODS: In a multicentre study, PTs were conducted on patients referred for DRESS, AGEP or SJS/TEN within 1 year of their SCAR. All drugs administered in the 2 months prior to and the week following the onset of the SCAR were tested. RESULTS: Among the 134 patients included (48 male, 86 female; mean age 51·7 years), positive drug PTs were obtained for 24 different drugs. These included positive tests for 64% (46/72) of patients with DRESS, 58% (26/45) of those with AGEP and 24% (4/17) of those with SJS/TEN, with only one relapse of AGEP. The value of PTs depended on the type of drug and the type of SCAR (e.g. carbamazepine was positive in 11/13 DRESS cases but none of the five SJS/TEN cases). PTs were frequently positive for beta lactams (22 cases), pristinamycin (11 cases) and in DRESS with pump proton inhibitors (five cases), but were usually negative for allopurinol and salazopyrin. Of 18 patients with DRESS, eight had virus reactivation and positive PTs. In DRESS, multiple drug reactivity was frequent (18% of cases), with patients remaining sensitized many years later. CONCLUSIONS: PTs are useful and safe for identifying agents inducing SCAR.

Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil.

BACKGROUND: the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil. MATERIALS AND METHODS: retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. RESULTS: we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period. CONCLUSION: the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Aperiodic spin state ordering of bistable molecules and its photoinduced erasing.

We describe a novel type of ordering phenomenon associated with the incommensurate occupational modulation of bistable molecular magnetic state in a spin-crossover material. This unusual type of aperiodicity resulting from the ordering of multistable electronic states opens new possibilities for addressing such materials by light. Here we show that light can switch the crystal from four- to three-dimensional periodic structure. Mixing aperiodicity, multistability, and photoinduced phenomenà opens new perspectives for directing complex order and function in material science.

Strain wave pathway to semiconductor-to-metal transition revealed by time-resolved X-ray powder diffraction.

One of the main challenges in ultrafast material science is to trigger phase transitions with short pulses of light. Here we show how strain waves, launched by electronic and structural precursor phenomena, determine a coherent macroscopic transformation pathway for the semiconducting-to-metal transition in bistable Ti3O5 nanocrystals. Employing femtosecond powder X-ray diffraction, we measure the lattice deformation in the phase transition as a function of time. We monitor the early intra-cell distortion around the light absorbing metal dimer and the long range deformations governed by acoustic waves propagating from the laser-exposed Ti3O5 surface. We developed a simplified elastic model demonstrating that picosecond switching in nanocrystals happens concomitantly with the propagating acoustic wavefront, several decades faster than thermal processes governed by heat diffusion.

Ferromagnetically coupled Shastry-Sutherland quantum spin singlets in (CuCl)LaNb2O7.

A thorough crystal structure determination at very low temperature of (CuCl)LaNb2O7, originally proposed as a spin-1/2 square-lattice antiferromagnet, is reported thanks to the use of single-crystal x-ray diffraction and powder neutron diffraction. State-of-the-art calculations (maximum entropy method) reveal that (CuCl)LaNb2O7 is orthorhombic with Pbam symmetry. First-principles calculations demonstrate that the dominant magnetic interactions are antiferromagnetic between fourth nearest neighbors with a Cu-Cl-Cl-Cu exchange path, which lead to the formation of spin singlets. The two strongest interactions between the singlets are ferromagnetic, which makes (CuCl)LaNb2O7 the first system of ferromagnetically coupled Shastry-Sutherland quantum spin singlets.

Discovery of an intermediate phase in bis-thiourea pyridinium chloride inclusion compound.

This paper reports the occurrence of a new phase for bis-thiourea pyridinium chloride inclusion compound, which is intermediate to the high- and low-temperature ones already reported. The structure of the intermediate phase was determined by the x-ray diffraction and the following sequence of space groups was obtained: Cmcm-->(237 K)Cmc2(1)-->(206 K)Pbca. The triplication of the lattice a parameter in the intermediate phase was observed. Detailed investigations of its phase transitions were performed by differential scanning calorimetry, x-ray diffraction, and dielectric spectroscopy methods. The phase transition at T(1)=237 K is continuous while at T(2)=206 K is discontinuous. Both phase transitions have been classified as of order-disorder type. The high- and low-temperature phases are nonpolar in contrast to the intermediate phase, for which we could not found ferroelectric ordering.

[A 6-week-old infant with failure to thrive: insidious presentation of group B streptococcal ventriculitis]. / Stagnation pondérale chez un nourrisson de six semaines : présentation insidieuse d'une ventriculite à streptocoque du groupe B.

Failure to thrive is frequently seen in breastfed infants. The most common diagnosis is insufficiency of breast milk in an otherwise healthy child. However, several differential diagnoses need to be considered. Progressive feeding difficulties and failure to thrive can be the first manifestation of group B streptococcal ventriculitis. This rare disease does not present with acute symptoms of sepsis or meningitis but evolves insidiously with no fever. Diagnosis is therefore often delayed and made only when intracranial hypertension develops. Cerebrospinal fluid (CSF) culture confirming the group B streptococcal infection and cerebral imaging are the necessary investigations for diagnosis. To our knowledge, only 10 cases have been previously reported.

[Recommendations for patients to help prepare dermatology-allergology consultations]. / Préparation de la consultation de dermato-allergologie : recommandations aux malades.

This article provides an overview of the various suggestions and recommendations for patients to help them prepare for dermatology-allergology consultations and skin tests. This information is set out in a data sheet with practical advice.

[Codification procedures for medical acts and diagnostic procedures in dermatology and allergology]. / Comment coder les actes et les diagnostics en dermato-allergologie ?

For a number of years, the French health system has utilized an activity-based fee scale (T2A) with remuneration of technical acts based on a coding system (CCAM). In this article, we present the nomenclature of the various clinical and biological acts undertaken in dermatology and allergology.

[Total skin electron beam therapy for early-stage mycosis fungoides: immediate results and long-term follow-up in 68 patients]. / Electronthérapie corporelle totale du mycosis fongoïde aux stades précoces: 68 cas.

BACKGROUND: Our aim was to evaluate the efficacy of total skin electron beam therapy (TSEB) in the management of early-stage mycosis fungoides in order to assess its position in relation to other skin-directed therapies. PATIENTS AND METHODS: A retrospective study of 68 patients (30 in stage T1 and 38 in stage T2). RESULTS: The median treatment duration was 6 weeks. Three months after the end of TSEB, a complete clinical response occurred in 66 patients (97%). The most marked effects of acute toxicity included localized ulcerations in 13 patients (13.2%) not requiring hospitalization. Mean follow-up was 6.5 years (1.6 to 28.7). The overall survival rates at 5 and 10 years were 86% and 71%, respectively. Thirty-nine patients (57.4%) experienced relapse with a mean disease-free interval of 1.8 years. The disease-free survival rates at 5 and 10 years were 41% and 31%, respectively. This rate was higher when TSEB was performed early (p=0.031). Twenty-one years after TSEB, only one case of cutaneous malignancy (basal cell carcinoma) was noted. DISCUSSION: Because of its high response rates and rapidity of action, TSEB should be considered as first-line therapy in the management of early-stage mycosis fungoides.

Surgical complications in the first and second semesters of the general surgery medical residence. A study of 14063 cases

Abstract Objective: To evaluate whether the rate of surgical complications is higher during the first semester of the General Surgery residency in the largest hospital complex in Latin America. During this period, students are expected to have less experience in carrying out procedures. Methods: During a period of two years, all General Surgery resident doctors at the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo, made a notification of all the procedures they performed (n = 14.063), containing information such as name of the procedure, date, who participated, complications, among others. These data were analyzed with the purpose of evaluating the variation in the rate of complications throughout the year. Results: There was a 52 % increase in the rate of complications in the first academic semester when compared to the second semester. This phenomenon was observed in resident doctors in the first and second years of residency. Furthermore, it was observed that second-year residents remain with high rates of complications, in some procedures, for a longer time than first-year residents. Furthermore, the first three months (March, April and May) seem to have the highest complication rates of the entire year. Conclusion The impact of these complications can affect several health services and the increase in surgical complications in the first half of the year must be monitored by institutions, in order to control this phenomenon.