Association between Complications and Death within 30 days after General Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) substudy.

OBJECTIVE: To determine the epidemiology of post-operative complications among general surgery patients, inform their relationships with 30-day mortality, and determine the attributable fraction of death of each postoperative complication. BACKGROUND: The contemporary causes of post-operative mortality among general surgery patients are not well characterized. METHODS: VISION is a prospective cohort study of adult non-cardiac surgery patients across 28 centres in 14 countries, who were followed for 30 days after surgery. For the subset of general surgery patients, a cox proportional hazards model was used to determine associations between various surgical complications and post-operative mortality. The analyses were adjusted for preoperative and surgical variables. Results were reported in adjusted hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: Among 7950 patients included in the study, 240 (3.0%) patients died within 30 days of surgery. Five post-operative complications (myocardial injury after non-cardiac surgery [MINS], major bleeding, sepsis, stroke, and acute kidney injury resulting in dialysis) were independently associated with death. Complications associated with the largest attributable fraction (AF) of post-operative mortality (i.e., percentage of deaths in the cohort that can be attributed to each complication, if causality were established) were major bleeding (n=1454, 18.3%, HR 2.49 95%CI 1.87-3.33, P<0.001, AF 21.2%), sepsis (n=783, 9.9%, HR 6.52, 95%CI 4.72-9.01, P<0.001, AF 15.6%), and MINS (n=980, 12.3%, HR 2.00, 95%CI 1.50-2.67, P<0.001, AF 14.4%). CONCLUSION: The complications most associated with 30-day mortality following general surgery are major bleeding, sepsis, and MINS. These findings may guide the development of mitigating strategies, including prophylaxis for perioperative bleeding.

Prognostic factors for deterioration of quality of life one year after admission to ICU for severe SARS-COV2 infection.

PURPOSE: Patients with COVID-19 present long-term symptoms collectively known as "post-COVID syndrome". Long-term manifestations are more frequent in patients requiring admission to Intensive Care Units (ICU), but the risk factors for their development are still unknown. This study explores the quality of life of patients with severe COVID-19 one year after their discharge from ICU. METHODS: Prospective observational study including 106 patients admitted to the ICU of a tertiary care hospital between March and August 2020. We analysed quality of life using the EuroQol-5D index (EQ-5D). We evaluated as possible risk factors associated with a worse value of the EQ-5D index the medical record, the clinical situation at hospital admission, the clinical situation at ICU admission and evolution in the ICU. As a secondary objective, we explored the presence of other frequent symptoms. RESULTS: Most patients (55.4%) reported that their quality of life worsened one year after admission. The mean perceived health status, on the EQ-VAS scale (0-100), was 70.4, with a median of 70 (RI 60-90). The median EQ-5D index was 0.91 (RI 0.76-1). The factors independently related to lower quality of life were female sex and duration of mechanical ventilation. Almost all (91%) of the patients had sequelae one year after discharge from the ICU. The most frequent manifestations were neuropsychiatric (71%). CONCLUSIONS: Critically ill COVID-19 patients worsen their quality of life more than one year after discharge. Female sex and duration of mechanical ventilation predict a lower quality of life assessed by the EQ-5D index.

[Fatigue, quality of life, and use of healthcare resources in children with complex chronic diseases].

BACKGROUND: The objective was to assess fatigue in children with complex chronic diseases (CCCDs) and analyze its relationship with clinical and sociodemographic characteristics, use of healthcare services, and quality of life (QoL). METHODS: Cross-sectional study carried out in CCCDs attended in a tertiary hospital during 2016. Fatigue (PedsFacit-F questionnaire) and quality of life (PedsQL) were determined, and the following variables were registered: use of health resources, disease group, time with disease, and educational level and type of employment of the parents. A multiple regression model was developed to predict the use of healthcare resources. RESULTS: Seventy children were included in this study; mean age 10.5 years (range: 8-17), 41.4% girls, and cancer was the most frequent group disease (28.6%). Annual use of healthcare resources (38.86; SD: 30.73) increased with fatigue (r=-0.292; p=0.015). Higher levels of fatigue were determined for children with cancer (24.9; SD: 10.7) in comparison to other pathologies, while lower levels were found for heart diseases (44.5; SD: 7.9). The QoL perceived by CCCDs (20.6; SD: 16.5) directly correlated (p<0.001) with that of their parents (22.8; SD: 16.8); a correlation with fatigue was seen in both cases (r=0.528 and r= 0.441; p<0.0001). The adjusted effect of higher levels of fatigue (lower scores), lower length of disease duration, and higher level of education of the mother, predicted greater use of healthcare resources. CONCLUSION: CCCDs with higher fatigue levels use healthcare resources more often and perceive a worse QoL. This should be considered when providing care to this population.

Fatiga, calidad de vida y utilización de recursos sanitarios en niñoscon enfermedades crónicas complejas / Fatigue, quality of life and health resource utilisation in children with complex chronic diseases

Fundamento: Nuestro objetivo fue determinar la fatiga en niños con enfermedades crónicas complejas (NECC) y analizar su asociación con características clínicas, sociodemográficas, utilización de servicios de salud y calidad de vida. Material y método: Estudio transversal realizado en NECC atendidos en un hospital terciario durante 2016. Se determinaron la fatiga (cuestionario PedsFacit-F) y la calidad de vida (cuestionario PedsQL), y se recogieron las variables uso de recursos sanitarios, grupo de enfermedad, tiempo con la enfermedad, y nivel de estudios y ocupación profesional de los progenitores. Se elaboró un modelo de regresión múltiple para predecir el uso de recursos. Resultados: Se incluyeron 70 niños, edad media 10,5 años (rango: 8-17), 41,4% niñas; la enfermedad oncológica fue la más frecuente (28,6%). El uso anual de recursos sanitarios (38,86; DE: 30,73) aumentó con la fatiga (r=-0,292; p=0,015). Las enfermedades oncológicas causaron más fatiga (24,9; DE: 10,7) que otras patologías y las cardiológicas menos (44,5; DE: 7,9). La calidad de vida percibida por NECC (20,6; DE: 16,5) correlacionó directa y significativamente (p<0,001) con la de sus progenitores (22,8; DE: 16,8); ambas se correlacionaron con la fatiga (r=0,528 y r=0,441; p<0,0001). El modelo de regresión lineal mostró que el efecto ajustado de mayor fatiga (menor puntuación), menor tiempo con la enfermedad y mayor nivel de estudios de la madre predijeron mayor uso de recursos de salud. Conclusión: Los NECC con mayor fatiga hacen mayor uso de los recursos sanitarios, y perciben una peor calidad de vida, aspectos que deberían tenerse en cuenta a la hora de prestar atención a esta población.(AU)

Background: The objective was to assess fatigue in children with complex chronic diseases (CCCDs) and analyze its relationship with clinical and sociodemographic characteristics, use of health care services, and quality of life (QoL). Methods.: Cross-sectional study carried out in CCCDs attended in atertiary hospital during 2016. Fatigue (PedsFacit-F questionnaire) and quality of life (PedsQL) were determined, and the following variables were registered: use of health resources, disease group, time with disease, and educational level and type of employment of the parents. A multiple regression model was developed to predict the use of healthcare resources. Results: Seventy children were included in this study; mean age 10.5 years (range: 8-17), 41.4% girls, and cancer was the most frequent group disease (28.6%). Annual use of healthcare resources (38.86; SD: 30.73) increased with fatigue (r= -0.292; p= 0.015). High-er levels of fatigue were determined for children with cancer (24.9; SD: 10.7) in comparison to other pathologies, while lower levels were found for heart diseases (44.5; SD: 7.9). The QoL perceived by CCCDs (20.6; SD: 16.5) directly correlated (p <0.001) with that of their parents (22.8; SD: 16.8); a correlation with fatigue was seen in both cases (r= 0.528 and r= 0.441; p <0.0001). The adjusted effect of higher levels of fatigue (lower scores), lower length of diseaseduration, and higher level of education of the mother, predicted greater use of healthcare resources. Conclusion: CCCDs with higher fatigue levels use healthcare resources more often and perceive a worse QoL. This should be con-sidered when providing care to this population.(AU)

Control de la vena cava inferior retrohepática por acceso anterior en el carcinoma de células renales con trombo tumoral nivel iiia: descripción paso a paso / Retrohepatic inferior vena cava control through an anterior approach in cases of renal cell carcinoma with level iiia tumor thrombus: Step-by-step description

Objetivo: Evaluar la seguridad y eficacia de la técnica de control de la vena cava inferior retrohepática por acceso anterior (RIVCA, por retrohepatic inferior vena cava control through an anterior approach) en el carcinoma de células renales (CCR) con trombo tumoral nivel iiia.Pacientes y métodosSerie inicial de 6 casos que presentan CCR con trombo tumoral nivel iiia intervenidos de nefrectomía radical y trombectomía tumoral mediante la técnica RIVCA entre 2018-2019. El objetivo de la técnica RIVCA es obtener un control completo de la vena cava inferior retrohepática por encima de la porción craneal del trombo tumoral, pero excluyendo las venas hepáticas mayores con el fin de preservar la circulación hepatocava natural. Se proporciona la descripción paso a paso del procedimiento. Se registraron prospectivamente los rasgos de la enfermedad, así como las características y los resultados quirúrgicos.ResultadosLa nefrectomía radical y la trombectomía tumoral se completaron en todos los casos. La técnica RIVCA no aumentó significativamente el tiempo quirúrgico (rango: 14-22min). La media de sangrado estimado fue de 325cc (rango: 250-400). No se requirió transfusión de sangre intraoperatoria en ningún caso. La media de unidades de concentrados de hematíes transfundidos por paciente en el período postoperatorio fue de 1,3 (rango: 0-2). No hubo casos de embolia pulmonar intraoperatoria ni se produjeron complicaciones mayores (Clavien-Dindo III-V) en el período postoperatorio a 30 días. La estancia hospitalaria postoperatoria (mediana) fue de 8 días (rango: 5-11). (AU)

Objective: To evaluate the safety and efficacy of the retrohepatic inferior vena cava control through an anterior approach (RIVCA) technique in renal cell carcinoma (RCC) with level iiia tumor thrombus.Patients and methodsInitial series of 6 cases presenting RCC and level iiia tumor thrombus who underwent radical nephrectomy and tumor thrombectomy using the RIVCA technique between 2018-2019. RIVCA technique aims to gain complete control of the retrohepatic inferior vena cava above the cranial end of the tumor thrombus, but excluding the major hepatic veins in order to preserve the natural hepato-caval shunt. A step-by-step description of the procedure is provided. Disease features, operative characteristics, and surgical outcomes were registered prospectively.ResultsRadical nephrectomy and tumor thrombectomy were completed in all cases. RIVCA technique did not increase operative time significantly (range: 14-22min). Mean estimated blood loss was 325cc (range: 250-400). Blood transfusion was not required intraoperatively in any of the cases. Mean postoperative transfusion rate was 1.3 red blood cells packed units (range: 0-2). There were no cases of intraoperative pulmonary embolism or major complications (Clavien-Dindo III-V) in the period of 30 days postoperatively. Median postoperative length of stay was 8 days (range: 5-11). (AU)

Retrohepatic inferior vena cava control through an anterior approach in cases of renal cell carcinoma with level IIIa tumor thrombus: Step-by-step description.

OBJECTIVE: To evaluate the safety and efficacy of the retrohepatic inferior vena cava control through an anterior approach (RIVCA) technique in renal cell carcinoma (RCC) with level IIIa tumor thrombus. PATIENTS AND METHODS: Initial series of 6 cases presenting RCC and level IIIa tumor thrombus who underwent radical nephrectomy and tumor thrombectomy using the RIVCA technique between 2018-2019. RIVCA technique aims to gain complete control of the retrohepatic inferior vena cava above the cranial end of the tumor thrombus, but excluding the major hepatic veins in order to preserve the natural hepato-caval shunt. A step-by-step description of the procedure is provided. Disease features, operative characteristics, and surgical outcomes were registered prospectively. RESULTS: Radical nephrectomy and tumor thrombectomy were completed in all cases. RIVCA technique did not increase operative time significantly (range: 14-22 min). Mean estimated blood loss was 325 cc (range: 250-400). Blood transfusion was not required intraoperatively in any of the cases. Mean postoperative transfusion rate was 1.3 red blood cells packed units (range: 0-2). There were no cases of intraoperative pulmonary embolism or major complications (Clavien-Dindo III-V) in the period of 30 days postoperatively. Median postoperative length of stay was 8 days (range: 5-11). CONCLUSIONS: The RIVCA technique applied to cases of RCC and level IIIa tumor thrombus provides complete control of the retrohepatic inferior vena cava above the tumor thrombus cranial end, while prevents intraoperative hemodynamic instability by maintaining cardiac preload through the porto-caval shunt. This technique may limit operative morbidity (intraoperative pulmonary embolism and massive hemorrhage), thus becoming a helpful adjunct to be used in cases of RCC with level IIIa tumor thrombus.

Retrohepatic inferior vena cava control through an anterior approach in cases of renal cell carcinoma with level iiia tumor thrombus: Step-by-step description. / Control de la vena cava inferior retrohepática por acceso anterior en el carcinoma de células renales con trombo tumoral nivel iiia: descripción paso a paso.

OBJECTIVE: To evaluate the safety and efficacy of the retrohepatic inferior vena cava control through an anterior approach (RIVCA) technique in renal cell carcinoma (RCC) with level iiia tumor thrombus. PATIENTS AND METHODS: Initial series of 6 cases presenting RCC and level iiia tumor thrombus who underwent radical nephrectomy and tumor thrombectomy using the RIVCA technique between 2018-2019. RIVCA technique aims to gain complete control of the retrohepatic inferior vena cava above the cranial end of the tumor thrombus, but excluding the major hepatic veins in order to preserve the natural hepato-caval shunt. A step-by-step description of the procedure is provided. Disease features, operative characteristics, and surgical outcomes were registered prospectively. RESULTS: Radical nephrectomy and tumor thrombectomy were completed in all cases. RIVCA technique did not increase operative time significantly (range: 14-22min). Mean estimated blood loss was 325cc (range: 250-400). Blood transfusion was not required intraoperatively in any of the cases. Mean postoperative transfusion rate was 1.3 red blood cells packed units (range: 0-2). There were no cases of intraoperative pulmonary embolism or major complications (Clavien-Dindo III-V) in the period of 30 days postoperatively. Median postoperative length of stay was 8 days (range: 5-11). CONCLUSIONS: The RIVCA technique applied to cases of RCC and level iiia tumor thrombus provides complete control of the retrohepatic inferior vena cava above the tumor thrombus cranial end, while prevents intraoperative hemodynamic instability by maintaining cardiac preload through the porto-caval shunt. This technique may limit operative morbidity (intraoperative pulmonary embolism and massive hemorrhage), thus becoming a helpful adjunct to be used in cases of RCC with level iiia tumor thrombus.

The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction.

INTRODUCTION: Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. METHODS: A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. RESULTS: Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. CONCLUSIONS: Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.

The sacral chordoma margin.

OBJECTIVE: Aim of the manuscript is to discuss how to improve margins in sacral chordoma. BACKGROUND: Chordoma is a rare neoplasm, arising in half cases from the sacrum, with reported local failure in >50% after surgery. METHODS: A multidisciplinary meeting of the "Chordoma Global Consensus Group" was held in Milan in 2017, focusing on challenges in defining and achieving optimal margins in chordoma with respect to surgery, definitive particle radiation therapy (RT) and medical therapies. This review aims to report on the outcome of the consensus meeting and to provide a summary of the most recent evidence in this field. Possible new ways forward, including on-going international clinical studies, are discussed. RESULTS: En-bloc tumor-sacrum resection is the cornerstone of treatment of primary sacral chordoma, aiming to achieve negative microscopic margins. Radical definitive particle therapy seems to offer a similar outcome compared to surgery, although confirmation in comparative trials is lacking; besides there is still a certain degree of technical variability across institutions, corresponding to different fields of treatment and different tumor coverage. To address some of these questions, a prospective, randomized international study comparing surgery versus definitive high-dose RT is ongoing. Available data do not support the routine use of any medical therapy as (neo)adjuvant/cytoreductive treatment. CONCLUSION: Given the significant influence of margins status on local control in patients with primary localized sacral chordoma, the clear definition of adequate margins and a standard local approach across institutions for both surgery and particle RT is vital for improving the management of these patients.

"Small-for-Flow" Syndrome: Concept Evolution.

BACKGROUND: The "Small-for-Size" syndrome is defined as a liver failure after a liver transplant with a reduced graft or after a major hepatectomy. The later coined "Small-for-Flow" syndrome describes the same situation in liver resections but based on hemodynamic intraoperative parameters (portal pressure > 20 mmHg and/or portal flow > 250 ml/min/100 g). This focuses on the damage caused by the portal hyperafflux related to the volume of the remnant. METHODS: Relevant studies were reviewed using Medline, PubMed, and Springer databases. RESULTS: Portal hypertension after partial hepatectomies also leads to a higher morbidity and mortality. There are plenty of experimental studies focusing on flow rather than size. Some of them also perform different techniques to modulate the portal inflow. The deleterious effect of high posthepatectomy portal venous pressure is known, and that is why the idea of portal flow modulation during major hepatectomies in humans is increasing in everyday clinical practice. CONCLUSIONS: Considering the extensive knowledge obtained with the experimental models and good results in clinical studies that analyze the "Small-for-Flow" syndrome, we believe that measuring portal flow and portal pressure during major liver resections should be performed routinely in extended liver resections. Applying these techniques, the knowledge of hepatic hemodynamics would be improved in order to advance against posthepatectomy liver failure.

Evaluation of Plasma Disappearance Rate Indocyanine Green Clearance as a Predictor of Liver Graft Rejection in Donor Brain Death.

INTRODUCTION: There currently exist no quantitative methods to assess graft viability before the donor procurement procedure. In Europe, around 20% of liver grafts evaluated "in situ" by an experienced surgeon are discarded. The aim of this study is to evaluate the use of the plasma disappearance rate indocyanine green (PDR-ICG) clearance in predicting liver graft rejection to avoid this 20% of futile surgeries. OBJECTIVES: To evaluate PDR-ICG as a predictor of liver graft rejection in death brain donors compared with the gold standard evaluation by an experienced surgeon. MATERIAL AND METHODS: Prospective observational single center study. From March 2017 to July 2019, 29 donors were included in the study, 17 were men and 12 women with a median age of 68 years ± 16.9 years. Donors had an intensive care unit stay of 2 days ± 4 days. PDR-ICG was measured with PICCO2 monitor. Indocyanine green clearance dose was 0.25 mg/kg injected intravenously in the operating room just before donor procurement procedure is initiated. The surgeon was unaware of the PDR-ICG measure until the decision of graft acceptance was taken. Data regarding the donors and biopsy results were included in a prospective database. RESULTS: PDR-ICG measure could be obtained in 10 minutes in all of the cases included. The median PDR-ICG obtained was 18%/min (range, 2.4-31%/min). Graft rejection took place in 15 out of the 29 donors. PDR-ICG value was less than 10%/min in 6 of these rejected grafts and less than 15%/min in 10 donors. All donor grafts with PDR-ICG <15% were discarded. The graft had been discarded in 5 donors with a PDR-ICG >15%. CONCLUSIONS: In our study a plasma disappearance rate <10 would have identified the grafts that would be rejected, thus avoiding the displacement work and expense of the surgical team. These results should be confirmed in a multicentric study.

Comprehensive Characterization of a Porcine Model of The "Small-for-Flow" Syndrome.

INTRODUCTION: The term "Small-for-Flow" reflects the pathogenetic relevance of hepatic hemodynamics for the "Small-For-Size" syndrome and posthepatectomy liver failure. We aimed to characterize a large-animal model for studying the "Small-for-Flow" syndrome. METHODS: We performed subtotal (90%) hepatectomies in 10 female MiniPigs using a simplified transection technique with a tourniquet. Blood tests, hepatic and systemic hemodynamics, and hepatic function and histology were assessed before (Bas), 15 min (t-15 min) and 24 h (t-24 h) after the operation. Some pigs underwent computed tomography (CT) scans for hepatic volumetry (n = 4) and intracranial pressure (ICP) monitoring (n = 3). Postoperative care was performed in an intensive care unit environment. RESULTS: All hepatectomies were successfully performed, and hepatic volumetry confirmed liver remnant volumes of 9.2% [6.2-11.2]. The hepatectomy resulted in characteristic hepatic hemodynamic alterations, including portal hyperperfusion, relative decrease of hepatic arterial blood flow, and increased portal pressure (PP) and portal-systemic pressure gradient. The model reproduced major diagnostic features including the development of cholestasis, coagulopathy, encephalopathy with increased ICP, ascites, and renal failure, hyperdynamic circulation, and hyperlactatemia. Two animals (20%) died before t-24 h. Histological liver damage was observed at t-15 min and at t-24 h. The degree of histological damage at t-24 h correlated with intraoperative PP (r = 0.689, p = 0.028), hepatic arterial blood flow (r = 0.655, p = 0.040), and hepatic arterial pulsatility index (r = 0.724, p = 0.066). All animals with intraoperative PP > 20 mmHg presented liver damage at t-24 h. CONCLUSION: The present 90% hepatectomy porcine experimental model is a feasible and reproducible model for investigating the "Small-for-Flow" syndrome.

Donor Risk Index Has an Impact in Intraoperative Measure of Hepatic Artery Flow and in Clearance of Indocyanine Green: An Observational Cohort Study.

BACKGROUND: The increase in indications for liver transplantation has led to acceptance of donors with expanded criteria. The donor risk index (DRI) was validated with the aim of being a predictive model of graft survival based on donor characteristics. Intraoperative arterial hepatic flow and indocyanine green clearance (plasma clearance rate of indocyanine green [ICG-PDR]) are easily measurable variables in the intraoperative period that may be influenced by graft quality. Our aim was to analyze the influence of DRI on intraoperative liver hemodynamic alterations and on intraoperative dynamic liver function testing (ICG-PDR). METHODS: This investigation was an observational study of a single-center cohort (n = 228) with prospective data collection and retrospective data analysis. Measurement of intraoperative flow was made with a VeriQ flowmeter based on measurement of transit time (MFTT). The ICG-PDR was obtained from all patients with a LiMON monitor (Pulsion Medical Systems AG, Munich, Germany). DRI was calculated using a previously validated formula. Normally distributed variables were compared using Student's t test. Otherwise, the Mann-Whitney U test or Kruskal-Wallis test was applied, depending on whether there were 2 or more comparable groups. The qualitative variables and risk measurements were analyzed using the chi-square test. P < .05 was considered statistically significant. RESULTS: DRI score (mean ± SD) was 1.58 ± 0.31. The group with DRI >1.7 (poor quality) had an intraoperative arterial flow of 234.2 ± 121.35 mL/min compared with the group having DRI < 1.7 (high quality), with an intraoperative arterial flow of 287.24 ± 156.84 mL/min (P = .02). The group with DRI >1.70 had an ICG-PDR of 14.75 ± 6.52%/min at 60 minutes after reperfusion compared to the group with DRI <1.70, with an ICG-PDR of 16.68 ± 6.47%/min at 60 minutes after reperfusion (P = .09). CONCLUSION: Poor quality grafts have greater susceptibility to ischemia-reperfusion damage. Decreased intraoperative hepatic arterial flow may represent an increase in intrahepatic resistance early in the intraoperative period.

Role of intraoperative radiotherapy in the treatment of sacral chordoma.

BACKGROUND CONTEXT: Sacral chordoma is a rare entity with high local recurrence rates when complete resection is not achieved. To date, there are no series available in literature combining surgery and intraoperative radiotherapy (IORT). PURPOSE: The objective of this study was to report the experience of our center in the management of sacral chordoma combining radical resection with both external radiotherapy and IORT. STUDY DESIGN: This is a retrospective case series. PATIENT SAMPLE: The patient sample included 15 patients with sacral chordoma resected in our center from 1998 to 2015. OUTCOME MEASURES: The outcome measures were overall survival (OS), disease-free survival (DFS), and rates of local and distant recurrences. METHODS: We retrospectively reviewed the records of all the patients with sacral chordoma resected in our center from 1998 to December 2015. Overall survival, DFS, and rates of local and distant recurrences were calculated. Results between patients treated with or without IORT were compared. RESULTS: A total of 15 patients were identified: 8 men and 7 women. The median age was 59 years (range 28-77). Intraoperative radiotherapy was applied in nine patients and six were treated with surgical resection without IORT. In 13 patients, we performed the treatment of the primary tumor, and in two patients, we performed the treatment of recurrence disease. A posterior approach was used in four patients. Wide surgical margins (zero residue) were achieved in six patients, marginal margins (microscopic residue) were achieved in seven patients, and there were no patients with intralesional (R2) margins. At a median follow-up of 38 months (range 11-209 months), the 5-year OS in the IORT group was 100% versus 53% in the group of non-IORT (p=.05). The median DFS in the IORT group was 85 months, and that in the non-IORT group was 41 months. In the group without IORT, two patients died and nobody died during the follow-up in the group treated with IORT. High-sacrectomy treated patients had a median survival of 41 months, and low-sacrectomy treated patients had a median survival of 90 months. Disease-free survival in patients without gluteal involvement was 100% at 5 years, and that in patients with gluteal involvement was 40%. All patients with a recurrence in our study had gluteal involvement. CONCLUSIONS: Multidisciplinary management of sacral chordoma seems to improve local control. The use of IORT, in our experience, is associated with an increase in OS and DFS. The level of resection and gluteal involvement seems to affect survival. The posterior approach is useful in selected cases. Multicenter studies should be performed to confirm the utility of IORT.

[Analysis of economic cost of missed outpatient appointments]. / Análisis del coste económico del absentismo de pacientes en consultas externas.

AIM: To estimate the economic costs of missed Outpatient appointments by the Costa del Sol Health Agency (ASCS). METHOD: An analysis was performed on the costs arising from missed outpatient appointments (first appointment and examinations) of each of the specialities in the Centres belonging to the ASCS. A formula was used to determine the unit cost per appointment and per centre and speciality. This involved the direct imputation of the controllable costs and the indirect imputation of the service costs, together with an estimated cost of re-appointments based on a previous case-control study. RESULTS: The cost of missed appointments per centre in the Costa del Sol Hospital was €2,475,640, with a failure rate of 14.2% (256,377 appointments). In the Benalmádena High Resolution Hospital it was €515,936, with an absence rate of 12.2% (44,848 appointments), and in the Mijas High Resolution Centre, a cost of €395,342 with an absence rate of the 13.5% (99,536 appointments). The mean extra cost of a re-appointment was €12.95. The specialities with a higher medium cost were Digestive Diseases, Internal Medicine, and Rehabilitation. CONCLUSIONS: The economic cost of patients not turning up for scheduled appointments in the ASCS was greater than 3 million Euros for a non-attendance rate of the 13.8%, with Mijas High Resolution Centre being the centre that showed the lowest mean unitary cost per medical appointment.

The dynamic experience of pain in burn patients: A phenomenological study.

Although pain is one of the main sources of suffering during the acute phase and rehabilitation in burn patients, it remains as a major challenge for burn care, and clinical management not always correlates with the experience felt by patients. The aim of this study was to understand the experience of pain from people who has suffered severe burns, to identify personal strategies used to cope with this challenging event. A qualitative phenomenological study with purposive sampling was carried out with severe burn patients admitted to a Burn Unit. Through individual in-depth interviews, verbatim transcription and content analysis, two main categories were isolated: a dynamic and changing experience of pain, from the onset to the hospital discharge, and diverse strategies developed by patients to cope with pain, being distraction the most frequently used. Pain experienced acquires its maximum intensity during wound care, and divergent patients' opinions about sedation are present. This study highlights how understanding subjective experiences is an invaluable aid to improve care in pain assessment and management. Furthermore, it points out the need to guarantee patient involvement in the organization and improvement of burn care, inasmuch as traditional professional centered approach is not ensuring an optimal management.

Using knowledge as the basis for evidence-based practice in primary care nurses.

AIM: The aim of this study was to explore the perception of primary care nurses regarding the need and use of knowledge from research, as a basis for evidence-based practice in their workplace. Additionally, the study aimed to determine which factors might hinder or enable implementation into daily practice. BACKGROUND: Evidence-based practice involves integrating best results in research with clinical experience, which enables us to provide a higher quality of care, as well as to optimize the care given. International studies show that nurses feel that there are still many barriers that hinder their doing research and incorporating new findings into clinical practice; although in the field of primary care, few studies have been carried out. METHODS: This descriptive qualitative study design used focus groups to collect data. This study was carried out in Spanish primary care centres. Forty-six registered nurses took part in this study and were divided into five focus groups. RESULTS: Three significant themes emerged: awareness of the need to use research, nurses as knowledge-generation agents and motivation to use research despite barriers. LIMITATIONS: A limited number of participants and a convenience sample were used. CONCLUSION: Nurses recognize that professional health care must be based on evidence obtained from daily work - both originated by their colleagues and by themselves - and they are willing to work on it although they perceive a lack of competence for this purpose and demand support from their institutions. IMPLICATIONS FOR NURSING POLICY: Primary care institutions should empower nursing coordinators as leaders of evidence-based practice and implicate clinical nurses from the beginning on the implementation of guidelines.

Effectiveness of Food-Based Fortification in Older People. A Systematic Review and Meta-Analysis.

BACKGROUND: Early intervention with nutritional support has been found to stop weight loss in older people malnourished or at risk of malnutrition. Enriched food could be a more attractive alternative to improve meals, than conventional oral nutritional supplements. AIMS: To determine the effectiveness of food-based fortification to prevent risk of malnutrition in elderly patients in community or institutionalized elderly patients. METHODS: A systematic review was conducted of randomized controlled trials, quasi-experimental, and interrupted time series including a longitudinal analysis. PARTICIPANTS: Elderly patients who are institutionalized, hospitalized or community-dwelling, with a minimum average age of 65 years. All type of patient groups, with the exception of people in critical care, or those who were recovering from cancer treatment, were included. INTERVENTION: Studies had to compare food-based fortification against alternatives. Studies that used oral nutritional supplementation such as commercial sip feeds, vitamin or mineral supplements were excluded. The search was conducted in Cochrane, CINAHL, PubMed, EMBASE, LILACS, and Cuiden. An independent peer review was carried out. RESULTS: From 1011 studies obtained, 7 were included for the systematic review, with 588 participants. It was possible to perform meta-analysis of four studies that provided results on caloric and protein intake. Food-based fortification yielded positive results in the total amount of ingested calories and protein. Nevertheless, due to the small number of participants and the poor quality of some studies, further high quality studies are required to provide reliable evidence. IMPLICATIONS FOR PRACTICE: Despite the limited evidence, due to their simplicity, low cost, and positive results in protein and calories intake, simple dietary interventions based on the food-based fortification or densification with protein or energy of the standard diet could be considered in patients at risk of malnutrition.

[Determinants and economic cost of patient absenteeism in outpatient departments of the Costa del Sol Health Agency]. / Factores determinantes y coste económico del absentismo de pacientes en consultas externas de la Agencia Sanitaria Costa del Sol.

BACKGROUND: To identify factors related to the people, the process and the context that determine patient compliance with their appointments in the ambulatory outpatient services in the Costa del Sol Health Care Agency; and to obtain the profile of patients who fail to keep their appointments, the reasons for this failure and an estimation of its economic cost. METHODS: Observational multicenter case-control study, through a survey carried out on patients with an appointment in the ambulatory outpatient services during 2013 and 2014, and analysis of the cost per appointment. RESULTS: In total, 882 patients participated in the study (294 cases and 588 controls). The main reasons for missing an appointment were forgetting about it (29, 6%; n=87), and failure in communication (16%; n=47). A shorter time period before the appointment and older age were significantly associated with fewer absences, as well as the fact of having attended more consultations in the past year. The economic cost was more than 3 million euros for a non-attendance rate of 13.8%. CONCLUSIONS: Young patients who usually do not visit outpatient clinics are at greatest risk of absence from scheduled appointments in our health area. The main reasons for absenteeism are preventable and interventions such as improved communication procedures or appointment reminder systems could be beneficial.