Vigencia de la cirugía biliar abierta / Validity of open biliary surger

En la actualidad, en la formación de los cirujanos en cirugía biliar se ha verticalizado el entrenamiento en colecistectomía laparoscópica, minimizando la formación en cirugía abierta, necesaria por la posibilidad de la conversión quirúrgica y por la presencia de casos complejos. El objetivo de este artículo es presentar una discusión científica sobre la importancia de la formación en cirugía biliar compleja, sobre la base de una situación clínica específica: una paciente con antecedentes de una cirugía compleja en el abdomen superior que consistió en la resección hepática y la reparación de la aorta abdominal, el duodeno y el estómago. La paciente presentó una litiasis biliar complicada, situación que obligó a la intervención abierta, con la cual se obtuvo un resultado satisfactorio. La colecistectomía videolaparoscópica es un procedimiento seguro y eficaz en las colecistopatías litiásicas y alitiásica, y la colecistectomía abierta o tradicional queda como alternativa de la primera, pero es indispensable un entrenamiento básico formativo en ella, no solo por una potencial conversión quirúrgica, sino por la posibilidad de encontrar situaciones como la aquí presentada(AU)

At present times, the formation of surgeons in the field of biliary surgery has increased training in laparoscopic cholecystectomy and reduced training in open surgery which is necessary for the surgical conversion possibilities and the presence of complex cases. The objective of this article was to present a scientific discussion about the importance of the formation of specialists in complex biliary surgery, on the basis of a specific clinical case. This is the case of a woman with a history of complex upper abdomen surgery comprising liver resection and repair of the abdominal aorta, the duodenum and the stomach. The patient presented with complicated biliary lithiasis that forced the physicians to perform open biliary surgery; the result was satisfactory. Laparoscopic cholecystectomy is a safe and effective procedure in lithiasis and alithiasis cholecystopathy whereas open or traditional cholecystectomy remains as an alternative to the former. However, it is indispensable to provide basic formative training in open cholecystectomy, not only because of potential surgical conversion but because of likelihood of situations similar to the one presented here(AU)

Vigencia de la cirugía biliar abierta / Validity of open biliary surgery

En la actualidad, en la formación de los cirujanos en cirugía biliar se ha verticalizado el entrenamiento en colecistectomía laparoscópica, minimizando la formación en cirugía abierta, necesaria por la posibilidad de la conversión quirúrgica y por la presencia de casos complejos. El objetivo de este artículo es presentar una discusión científica sobre la importancia de la formación en cirugía biliar compleja, sobre la base de una situación clínica específica: una paciente con antecedentes de una cirugía compleja en el abdomen superior que consistió en la resección hepática y la reparación de la aorta abdominal, el duodeno y el estómago. La paciente presentó una litiasis biliar complicada, situación que obligó a la intervención abierta, con la cual se obtuvo un resultado satisfactorio. La colecistectomía videolaparoscópica es un procedimiento seguro y eficaz en las colecistopatías litiásicas y alitiásica, y la colecistectomía abierta o tradicional queda como alternativa de la primera, pero es indispensable un entrenamiento básico formativo en ella, no solo por una potencial conversión quirúrgica, sino por la posibilidad de encontrar situaciones como la aquí presentada.

At present times, the formation of surgeons in the field of biliary surgery has increased training in laparoscopic cholecystectomy and reduced training in open surgery which is necessary for the surgical conversion possibilities and the presence of complex cases. The objective of this article was to present a scientific discussion about the importance of the formation of specialists in complex biliary surgery, on the basis of a specific clinical case. This is the case of a woman with a history of complex upper abdomen surgery comprising liver resection and repair of the abdominal aorta, the duodenum and the stomach. The patient presented with complicated biliary lithiasis that forced the physicians to perform open biliary surgery; the result was satisfactory. Laparoscopic cholecystectomy is a safe and effective procedure in lithiasis and alithiasis cholecystopathy whereas open or traditional cholecystectomy remains as an alternative to the former. However, it is indispensable to provide basic formative training in open cholecystectomy, not only because of potential surgical conversion but because of likelihood of situations similar to the one presented here.

Impact of telemonitoring home care patients with heart failure or chronic lung disease from primary care on healthcare resource use (the TELBIL study randomised controlled trial).

BACKGROUND: There is growing evidence that home telemonitoring can be advantageous in societies with increasing prevalence of chronic diseases.The main objective of this study is to evaluate the effect of a primary care-based telemonitoring intervention on the number and length of hospital admissions. METHODS: A randomised controlled trial was carried out across 20 health centres in Bilbao (Basque Country, Spain) to assess the impact of home telemonitoring on in-home chronic patients compared with standard care. The study lasted for one year. Fifty-eight in-home patients, diagnosed with heart failure (HF) and/or chronic lung disease (CLD), aged 14 or above and with two or more hospital admissions in the previous year were recruited. The intervention consisted of daily patient self-measurements of respiratory-rate, heart-rate, blood pressure, oxygen saturation, weight, body temperature and the completion of a health status questionnaire using PDAs. Alerts were generated when pre-established thresholds were crossed. The control group (CG) received usual care. The primary outcome measure was the number of hospital admissions that occurred at 12 months post-randomisation. The impact of telemonitoring on the length of hospital stay, use of other healthcare resources and mortality was also explored. RESULTS: The intervention group (IG) included 28 patients and the CG 30. Patient baseline characteristics were similar in both groups. Of the 21 intervention patients followed-up for a year, 12 had some admissions (57.1%), compared to 19 of 22 controls (86.4%), being the difference statistically significant (p = 0.033, RR 0.66; 95%CI 0.44 to 0.99). The mean hospital stay was overall 9 days (SD 4.3) in the IG versus 10.7 (SD 11.2) among controls, and for cause-specific admissions 9 (SD 4.5) vs. 11.2 (SD 11.8) days, both without statistical significance (p = 0.891 and 0.927, respectively). Four patients need to be telemonitored for a year to prevent one admission (NNT). There were more telephone contacts in the IG than in the CG (22.6 -SD 16.1- vs. 8.6 -SD 7.2-, p = 0.001), but fewer home nursing visits (15.3 -SD 11.6- vs. 25.4 -SD 26.3-, respectively), though the difference was not statistically significant (p = 0.3603). CONCLUSIONS: This study shows that telemonitoring of in-home patients with HF and/or CLD notably increases the percentage of patients with no hospital admissions and indicates a trend to reduce total and cause-specific hospitalisations and hospital stay. Home telemonitoring can constitute a beneficial alternative mode of healthcare provision for medically unstable elderly patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN89041993.

Staphylococcus aureus resistente a meticilina como causa de infección de piel y partes blandas / Methicillin-resistant Staphylococcus aureus as a cause of skin and soft tissue infections

Objetivo: presentar cinco casos y brindar información actualizada sobre el Staphylococcus aureus y su papel en la patogenia de lesiones de piel y partes blandas, así como en el mejor manejo de la antibioticoterapia utilizada en estos casos. Métodos: se realizó una revisión sobre el estado actual del conocimiento que existe en torno al S. aureus resistente a meticilina y su relación con la infección de piel y partes blandas, así como la antibioticoterapia propuesta en la actualidad. Se presentaron, a manera de ejemplo, cinco casos atendidos en los hospitales Manuel Fajardo, Dr. Luis Díaz Soto y Juan Manuel Márquez. Resultados: las infecciones de piel y partes blandas por este germen son frecuentes en nuestro medio, y afectan a uno y otro sexos y diferentes edades. Las lesiones van desde furunculosis hasta celulitis y abscesos. La identificación del S. aureus resistente a meticilina es posible mediante técnicas convencionales como el uso de discos de cefoxitina. No existe un buen conocimiento acerca del tratamiento antibiótico adecuado de estas infecciones. Los mejores resultados se consiguen con el uso del sulfaprim y las tetraciclinas. Conclusiones: existe un aumento importante del número de casos de infección de piel y partes blandas, tanto comunitarios como hospitalarios, en nuestro medio, provocados por cepas de S. aureus resistente a meticilina. El tratamiento más efectivo incluye el uso de sulfametoxazol-trimetoprim (sulfaprim) o doxiciclina, asociado al drenaje quirúrgico de la lesión(AU)

Objective: to present five cases and to provide updated information on Staphylococcus aureus and its role in skin and soft parts conditions, as well as on the best management to be used in these cases. Methods: areview of the existing state of knowledge on Methicillin-resistant Staphylococcus aureus and related to skin and soft tissues infection as well as its currently-proposed antibiotic treatment. As an example, five cases, treated in Manuel Fajardo Hospital, Dr. Luis Díaz Soto Hospital and Juan Manuel Marquez Hospital, were presented. Results: skin and soft tissues Infections by this organism are common in our environment, and affect both sexes and different ages. They range from furunculosis to cellulitis and abscesses. Identification of methicillin-resistant Staphylococcus aureus is possible through conventional techniques such as cefoxitin disks. There is no good knowledge about the appropriate antibiotic treatment on these infections. Best results are achieved with the use of sulfaprim and tetracyclines. Conclusions: there is a significant increase in the number of skin and soft tissue infections, in both community and inpatient cases in our environment, caused by strains of methicillin-resistant Staphylococcus aureus. The most effective treatment includes the use of sulfamethoxazole-trimethoprim (sulfaprim) or doxycycline, associated with surgical drainage of lesions(AU)

Staphylococcus aureus resistente a meticilina como causa de infección de piel y partes blandas / Methicillin-resistant Staphylococcus aureus as a cause of skin and soft tissue infections

Objetivo: presentar cinco casos y brindar información actualizada sobre el Staphylococcus aureus y su papel en la patogenia de lesiones de piel y partes blandas, así como en el mejor manejo de la antibioticoterapia utilizada en estos casos. Métodos: se realizó una revisión sobre el estado actual del conocimiento que existe en torno al S. aureus resistente a meticilina y su relación con la infección de piel y partes blandas, así como la antibioticoterapia propuesta en la actualidad. Se presentaron, a manera de ejemplo, cinco casos atendidos en los hospitales "Manuel Fajardo", "Dr. Luis Díaz Soto" y "Juan Manuel Márquez". Resultados: las infecciones de piel y partes blandas por este germen son frecuentes en nuestro medio, y afectan a uno y otro sexos y diferentes edades. Las lesiones van desde furunculosis hasta celulitis y abscesos. La identificación del S. aureus resistente a meticilina es posible mediante técnicas convencionales como el uso de discos de cefoxitina. No existe un buen conocimiento acerca del tratamiento antibiótico adecuado de estas infecciones. Los mejores resultados se consiguen con el uso del sulfaprim y las tetraciclinas. Conclusiones: existe un aumento importante del número de casos de infección de piel y partes blandas, tanto comunitarios como hospitalarios, en nuestro medio, provocados por cepas de S. aureus resistente a meticilina. El tratamiento más efectivo incluye el uso de sulfametoxazol-trimetoprim (sulfaprim) o doxiciclina, asociado al drenaje quirúrgico de la lesión.

Objective: to present five cases and to provide updated information on Staphylococcus aureus and its role in skin and soft parts conditions, as well as on the best management to be used in these cases. Methods: areview of the existing state of knowledge on Methicillin-resistant Staphylococcus aureus and related to skin and soft tissues infection as well as its currently-proposed antibiotic treatment. As an example, five cases, treated in "Manuel Fajardo" Hospital, "Dr. Luis Díaz Soto" Hospital and "Juan Manuel Marquez" Hospital, were presented. Results: skin and soft tissues Infections by this organism are common in our environment, and affect both sexes and different ages. They range from furunculosis to cellulitis and abscesses. Identification of methicillin-resistant Staphylococcus aureus is possible through conventional techniques such as cefoxitin disks. There is no good knowledge about the appropriate antibiotic treatment on these infections. Best results are achieved with the use of sulfaprim and tetracyclines. Conclusions: there is a significant increase in the number of skin and soft tissue infections, in both community and inpatient cases in our environment, caused by strains of methicillin-resistant Staphylococcus aureus. The most effective treatment includes the use of sulfamethoxazole-trimethoprim (sulfaprim) or doxycycline, associated with surgical drainage of lesions.

How do hatcheries influence embryonic development of sea turtle eggs? Experimental analysis and isolation of microorganisms in leatherback turtle eggs.

Many conservation programs consider translocation of turtle nests to hatcheries as a useful technique. The repeated use of the same incubation substrate over several seasons in these hatcheries could, however, be harmful to embryos if pathogens were able to accumulate or if the physical and chemical characteristics of the incubation environment were altered. However, this hypothesis has yet to be tested. We conducted two field experiments to evaluate the effects of hatchery sand and eggshell decay on the embryonic development of leatherback sea turtle eggs in Colombia. We identified the presence of both fungi and bacteria species on leatherback turtle eggs. Sea turtle eggs exposed to previously used hatchery substrates or to decaying eggshells during the first and middle third of the embryonic development produced hatchlings that were smaller and/or weighed less than control eggs. However, this did not negatively influence hatching success. The final third of embryonic development seems to be less susceptible to infection by microorganisms associated with decaying shells. We discuss the mechanisms that could be affecting sea turtle egg development when in contact with fungi. Further studies should seek to understand the infection process and the stages of development in which the fungi are more virulent to the eggs of this critically endangered species.

Assessment of a primary care-based telemonitoring intervention for home care patients with heart failure and chronic lung disease. The TELBIL study.

BACKGROUND: Telemonitoring technology offers one of the most promising alternatives for the provision of health care services at the patient's home. The primary aim of this study is to evaluate the impact of a primary care-based telemonitoring intervention on the frequency of hospital admissions. METHODS/DESIGN: A primary care-based randomised controlled trial will be carried out to assess the impact of a telemonitoring intervention aimed at home care patients with heart failure (HF) and/or chronic lung disease (CLD). The results will be compared with those obtained with standard health care practice. The duration of the study will be of one year. Sixty patients will be recruited for the study. In-home patients, diagnosed with HF and/or CLD, aged 14 or above and with two or more hospital admissions in the previous year will be eligible. For the intervention group, telemonitoring will consist of daily patient self-measurements of respiratory-rate, heart-rate, blood pressure, oxygen saturation, weight and body temperature. Additionally, the patients will complete a qualitative symptom questionnaire daily using the telemonitoring system. Routine telephone contacts will be conducted every fortnight and additional telephone contacts will be carried out if the data received at the primary care centre are out of the established limits. The control group will receive usual care. The primary outcome measure is the number of hospital admissions due to any cause that occurred in a period of 12 months post-randomisation. The secondary outcome measures are: duration of hospital stay, hospital admissions due to HF or CLD, mortality rate, use of health care resources, quality of life, cost-effectiveness, compliance and patient and health care professional satisfaction with the new technology. DISCUSSION: The results of this study will shed some light on the effects of telemonitoring for the follow-up and management of chronic patients from a primary care setting. The study may contribute to enhance the understanding of alternative modes of health care provision for medically unstable elderly patients, who bear a high degree of physical and functional deterioration.

Colecistectomía con anestesia local como recurso en el paciente anciano / Cholecystectomy with local anesthesia as a resource in the elderly

Ante un paciente con colecistitis aguda lo ideal es extirpar la vesícula biliar. A veces se presentan situaciones especiales en ancianos desnutridos, con deterioro de su estado general, en los que una intervención con anestesia prolongada, incluso con medios pocos invasivos como la videocirugía, pone en peligro la vida del enfermo. En tales casos la colecistectomía con anestesia local es una alternativa que se puede considerar(AU)

In the case of a patient presenting with acute cholescystectomy ideally is to remove the gallbladder. Sometimes there are special situations in malnourished elderlies with deterioration of its general status in whom a lengthy anesthesia intervention, even using not much invasive means as the videosurgery, put at risk the life of patient. In such cases the cholescystectomy with local anesthesia is an alternative that must to be taken into account(AU)