ABSTRACT
BACKGROUND AND AIMS: Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures. METHODS: Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator. RESULTS: A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity. CONCLUSIONS: This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.
Subject(s)
General Surgery , Surgical Procedures, Operative , Adult , Aged , Benchmarking , Cohort Studies , Emergencies , Female , Hospital Mortality , Humans , Middle Aged , Postoperative Complications , Prospective Studies , Quality Improvement , Retrospective StudiesABSTRACT
BACKGROUND: Cytoreductive surgery with peritonectomy procedures and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) represents a radical therapeutic approach to achieve complete cytoreduction in ovarian peritoneal carcinomatosis. The aim of the present study was to analyze the outcomes obtained by the application of these procedures in a single center with extensive experience treating peritoneal carcinomatosis. PATIENTS AND METHODS: A series of 218 consecutive patients diagnosed with peritoneal carcinomatosis from primary or recurrent ovarian cancer (FIGO stage IIIC-IV) and treated with CRS + HIPEC between January 1996 and June 2012 were included in this observational study. RESULTS: Peritoneal carcinomatosis was treated primarily in 56% (124/218) of the cases and recurrently in 43% (94/218). A total of 42/218 patients (19%) presented with FIGO stage IV. Compared to recurrent cases, patients with primary ovarian carcinomatosis were older and presented higher Peritoneal Cancer Index (PCI) and percentage of FIGO stage IV; however, no significant differences in survival (5-year overall survival in patients with R0 cytoreduction, 63% and 56%, respectively) were observed. Cytoreduction score, PCI, lymphatic involvement and surgical morbidity ≥Grade III were statistically significant prognostic factors for survival in both univariate and multivariate analysis. CONCLUSIONS: CRS + HIPEC treating macroscopic and microscopic disease is currently an excellent surgical approach to achieve high rates of complete cytoreduction and improve survival in patients with peritoneal carcinomatosis from ovarian cancer. In order to minimize the high potential morbidity of these procedures, CRS + HIPEC should be performed in highly experienced centers.
Subject(s)
Carcinoma/therapy , Hyperthermia, Induced , Neoplasm Recurrence, Local/pathology , Ovarian Neoplasms/pathology , Peritoneal Neoplasms/therapy , Adult , Age Factors , Aged , Aged, 80 and over , Antineoplastic Agents/administration & dosage , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Carcinoma/mortality , Carcinoma/secondary , Cisplatin/administration & dosage , Cytoreduction Surgical Procedures , Female , Hospitals, High-Volume , Humans , Infusions, Parenteral , Middle Aged , Neoplasm Staging , Paclitaxel/administration & dosage , Peritoneal Neoplasms/mortality , Peritoneal Neoplasms/secondary , Survival Rate , Young AdultABSTRACT
BACKGROUND: The involvement of bone marrow hematopoietic stem cells (BMHSC) mobilization during liver regeneration from hepatectomized patients is under debate. The main aim of this study was to investigate the role of BMHSC mobilization after hepatic resection in 33 patients with liver disease. METHODS AND RESULTS: Mobilization of CD34(+) BMHSC after 72 h of surgery was found in peripheral blood of some, but not all, of the hepatectomized patients. These CD34(+) cells co-expressed other stem cells markers. The patients without BMHSC mobilization showed high levels of circulating and liver tissue BMHSC (CD34(+) cells) previous to surgery. Therefore, two types of patients: "mobilizers" and "non-mobilizers" were distinguished based on the values of CD34(+) cells before and after surgery. Changes in cytokines involved in the hepatic regeneration (HGF and TGF-ß), and in BMHSC mobilization process (SCF, SDF-1, IL-12, or MMP-2), were detected in both groups. In addition, a higher activation previous to surgery of the SDF-1/CXCR4 axis in liver tissue was observed in non mobilizers patients compared to mobilizer patients. CONCLUSION: BMHSC mobilization seems to be associated with variations in the levels of cytokines and proteolytic enzymes involved in hepatic regeneration and bone marrow matrix degradation. Hepatectomy may be an insufficient stimulus for BMSHC mobilization. The pre-hepatectomy higher levels CD34(+) cells in peripheral blood and liver, associated to the activation of hepatic SDF-1/CXCR4 axis, suggest a BMHSC mobilization process previous to surgery in non mobilizer patients.
Subject(s)
Antigens, CD34/metabolism , Hematopoietic Stem Cell Mobilization , Hematopoietic Stem Cells/metabolism , Liver Regeneration/physiology , Signal Transduction/physiology , Adolescent , Adult , Aged , Chemokine CXCL12/blood , Female , Hematopoietic Stem Cells/physiology , Hepatectomy , Hepatocyte Growth Factor/blood , Humans , Interleukin-12/blood , Ki-67 Antigen/metabolism , Liver/metabolism , Liver/pathology , Liver/surgery , Male , Matrix Metalloproteinase 2/blood , Middle Aged , Receptors, CXCR4/blood , Stem Cell Factor/blood , Transforming Growth Factor beta/bloodABSTRACT
La arteria cerebral media (ACM) es el más largo y complejo de todos los vasos intracerebrales, irrigando la mayor parte de los lóbulos frontales, parietales y temporales de ambos hemisferios cerebrales. Además de suplir el riego sanguíneo de una gran parte del cerebro, la ACM y sus ramas, están frecuentemente involucradas en enfermedades intracerebrales como hemorragias cerebrales, patología ateroesclerótica o degenerativa de la pared arterial, embolias y procesos inflamatorios. La alta frecuencia de patología y el amplio volumen cerebral irrigado por esta arteria hacen que el conocimiento de su anatomía sea fundamental en la descripción de los posibles mecanismos fisiopatológicos de las enfermedades que la involucran, así como para su estudio imagenológico y abordaje quirúrgico. El objetivo de este trabajo es comparar la anatomía macroscópica y microscópica de la ACM de sujetos chilenos con la publicada en series internacionales. Se estudiaron 10 hemisférios cadavéricos provenientes de 5 pacientes adultos de nacionalidad chilena cuya muerte no fue de causa encefálica, fijados con solución de formalina sometiendo a tinción los vasos arteriales. Se realizaron mediciones de la ACM y sus segmentos M1 y M2 comparando mediante análisis estadístico los resultados obtenidos con los publicados en la literatura. El análisis de éstos sugiere que las características anatómicas de la ACM de hemisferios provenientes de sujetos de nacionalidad chilena son similares a los reportados por estudios realizados con hemisferios cerebrales de sujetos de origen anglo-sajón.
Subject(s)
Adult , Humans , Middle Cerebral Artery/anatomy & histology , Middle Cerebral Artery/surgery , Middle Cerebral Artery/physiology , Microsurgery/methods , Telencephalon/physiology , Brain Diseases , Cadaver , Reference ValuesABSTRACT
La Encefalopatía de Wernicke (EW) es un síndrome neurológico reversible causado por un déficit de tiamina (vitamina B). Se le adjudica una frecuencia de 0,8 a 2,8 por ciento en la población general la que se eleva hasta un 12 por ciento si se considera sólo los pacientes alcohólicos. Su principal factor etiológico es el alcoholismo; sin embargo, se han descrito casos asociados a malnutrición de diversos orígenes. Clásicamente se caracteriza por la tríada de signos oculares, ataxia y confusión; pero esta asociación tiene una muy baja frecuencia (10 por ciento) por lo cual se han propuesto algunos criterios diagnósticos operacionales para reducir el subdiagnóstico. No existen en la actualidad métodos de laboratorio útiles para la confirmación de los casos, por lo cual es necesario mantener un elevado índice de sospecha clínica. El tratamiento y la profilaxis con tiamina están bien establecidos, sin embargo no existe evidencia actual que avale el empleo de un esquema en particular. No obstante se conoce la evolución natural de esta patología, la que de no medir un tratamiento oportuno conlleva una elevada proporción de pacientes desarrollen alteraciones neurológicas de carácter irreversible que dan origen a una psicosis de Korsakoff y en otros casos aislados incluso a la muerte.
Subject(s)
Male , Humans , Female , Thiamine Deficiency/complications , Wernicke Encephalopathy/diagnosis , Wernicke Encephalopathy/drug therapy , Thiamine/therapeutic use , Alcoholism/complications , Wernicke Encephalopathy/etiology , SyndromeABSTRACT
Amniotic band syndrome is a sporadic condition that may result in constriction bands, amputation and multiple craniofacial, visceral and body wall defects. It occurs in 1/1,200 to 1/15,000 live births. Most cases present with multiple congenital anomalies that are incompatible with life. A small group of fetuses shows isolated limb constrictions that may cause severe limb dysfunction or limb amputation if left untreated. Successful in utero surgical lyses of constriction rings have been reported. We report a case of constriction amniotic bands involving both legs and compromising blood flow to the distal extremity. The constriction ring was successfully released by a minimally invasive endoscopic surgical technique avoiding severe limb dysfunction or foot amputation.
Subject(s)
Amniotic Band Syndrome/surgery , Constriction, Pathologic/surgery , Fetal Diseases/surgery , Laparoscopy , Leg/embryology , Amniotic Band Syndrome/diagnostic imaging , Female , Gestational Age , Humans , Infant, Newborn , Leg/blood supply , Pregnancy , Pregnancy Outcome , UltrasonographyABSTRACT
La tricomonosis es una de las infecciones de transmisión sexual más frecuentes en el mundo. El Papanicolaou (PAP) no constituye el examen de elección para su diagnóstico, sin embargo, es frecuente el hallazgo del parásito en muestras obtenidas de población en control ginecológico. Para establecer la frecuencia de Tricomonas vaginalis en los PAP procedentes de los Servicios de Salud de Atacama, Metropolitano Norte, Oriente y Bío-Bío se realizó un análisis retrospectivo de 504.638 muestras entre los años 1997 y 2002. Los resultados demostraron la presencia del parásito en 20.270 muestras, (4,0 por ciento). En los 5 años estudiados se observó una tendencia a la disminución de la frecuencia de T. vaginalis de 4,96 por ciento a 3,31 por ciento en todos los Servicios de Salud. El grupo etario de 30-39 años fue el más afectado. Se discute la utilidad del PAP como método diagnóstico, los factores que pudieran incidir en la tendencia observada y las diferencias encontradas entre los servicios. Se concluye que la frecuencia de T. vaginalis disminuyó en los Servicios de Salud estudiados, y que la técnica de Papanicolaou permitió identificar a T. vaginalis, como también efectuar estudios de prevalencia y tratar los casos pesquisados.
Subject(s)
Adolescent , Adult , Humans , Female , Middle Aged , Trichomonas vaginalis/cytology , Trichomonas Vaginitis/diagnosis , Trichomonas Vaginitis/epidemiology , Candida/cytology , Chile/epidemiology , Vaginal SmearsABSTRACT
Macrophage Fcgamma receptors have an important role in host defense and the pathophysiology of immune mediated disorders. Alteration of splenic macrophage Fcgamma receptors expression predisposes to severe infection. Inhibition or blockade of splenic macrophage Fcgamma receptors is one of the mechanisms by which immune cytopenias improve. Dopaminergic drugs have clinically significant regulatory functions on the immune response. Using an experimental model in the guinea pig we assessed the effect of commonly used dopaminergic drugs on the expression of macrophage Fcgamma receptors. Three dopa-antagonists, bromocryptine, leuprolide, and pergolide, and seven dopa-antagonists, chlorpromazine, SCH 23390, metochlopramide, sulpiride, veralipride, alizapride, and cisapride, were studied. Following guinea pig treatment with dopaminergic drugs, the clearance of IgG-sensitized RBCs in vivo, the in vitro binding of IgG-sensitized RBCs by isolated splenic macrophages and flow cytometry with monoclonal antibodies were performed. Treatment with dopa-agonists enhanced the clearance of IgG-sensitized RBCs, the in vitro binding of IgG-sensitized RBCs by isolated splenic macrophages, and the cell surface expression of both macrophage Fcgamma receptors, and vice versa, dopa-antagonists impaired macrophage Fcgamma receptors expression. Macrophage FcgammaR1,2 was more sensitive than FcgammaR2 to such dopaminergic effect. These alterations of macrophage Fcgamma receptors expression are mediated by both D1 and D2 dopamine receptors, with a major participation of D2 receptors. Dopaminergic drugs alter the clearance of IgG-coated cells by an effect at the expression of splenic macrophage Fcgamma receptors.
Subject(s)
Dopamine Agents/pharmacology , Macrophages/drug effects , Receptors, IgG/biosynthesis , Spleen/cytology , Animals , Dose-Response Relationship, Drug , Guinea Pigs , Immune Complex Diseases/drug therapy , Immune Complex Diseases/immunology , Male , Neutropenia/drug therapy , Neutropenia/immunology , Receptors, Dopamine D1/metabolism , Receptors, Dopamine D2/metabolism , Receptors, IgG/classificationABSTRACT
Macrophage Fcgamma receptors (FcgammaRs) are critical for host defense against infection and have an important role in immune cytopenias. Modulation of macrophage FcgammaRs expression is a potential therapeutic approach to immune disorders. Glucocorticoids and synthetic progesterone analogues decrease macrophage FcgammaRs expression. We assessed the effect of treatment with commonly employed progestins on the expression of macrophage FcgammaRs using an experimental model in the guinea pig. Eight clinically available progesterones, medroxyprogesterone acetate (P3), megestrol acetate (P4), medrogestone (P5), alylestrenol (P6), linestrenol (P7), didrogesterone (P8), norethisterone (P9), and gestonorone caproate (P10) and two endogenous progesterones, progesterone (P1) and 17 alpha-hydroxyprogesterone (P2), were studied. Following in vivo treatment of guinea pigs, we determined the clearance of IgG-sensitized erythrocytes in vivo, the binding of IgG-sensitized erythrocytes by isolated splenic macrophages, and splenic macrophage Fcgamma receptor cell surface expression. All progesterones impaired the clearance of IgG-sensitized erythrocytes by decreasing splenic macrophage Fcgamma receptor expression. P5, P6, P7, and P8 were less effective. Flow cytometry and fluorescence microscopy with monoclonal antibodies demonstrated that progesterones decreased the cell surface expression of FcgammaR2 more than that of FcgammaR1,2. Clinically employed progestins impair the clearance of IgG-coated cells by decreasing splenic macrophage FcgammaRs expression. Thus, progesterones are candidate drugs for the treatment of immune disorders.
