Prospective, randomized comparative study of ultrasound-guided blocking of the lateral cutaneous branches of the intercostal nerves versus conventional analgesia in non-reconstructive breast surgery. / Estudio prospectivo, aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cutáneas laterales de los nervios intercostales frente a analgesia convencional en cirugía no reconstructiva de mama.

OBJECTIVE: The objective of this study is to determine whether the accomplishment of an interfascial blockade, the blocking of the cutaneous branches of the intercostal nerves in the axillary line (BRILMA) associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast. MATERIAL AND METHODS: A prospective, randomised and simple blind study was conducted on patients that underwent non-reconstructive breast surgery. The patients were randomly assigned to the blocking group, or to the standard post-operative analgesia group (paracetamol and dexketoprofen). The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol. RESULTS: Statistically significant differences were observed in the consumption of tramadol during the study period (10.5mg in the BRILMA group, compared to 34.3 in the control group, P=.0001). There were also differences in the pain assessment, with lower values found in the BRILMA group. CONCLUSIONS: In non-reconstructive breast surgery, performing a BRILMA block allows obtaining lower pain scores, which implies less need for rescue analgesics and a significant saving of tramadol in the study period.

The Patient's Comorbidity Burden Correlates with the Erectile Dysfunction Severity. / El peso de la comorbilidad del paciente se correlaciona con la gravedad de la disfunción eréctil.

OBJECTIVE: To explore the potential relationship between erectile dysfunction (ED), low testosterone levels, and the Charlson Comorbidity Index (CCI). MATERIAL AND METHODS: Cross-sectional study on patients referred to the andrology unit in 7 Spanish centers. The ED was diagnosed and graded using the International Index of Erectile Function (IIEF-5) score. Total testosterone, the prevalence of each comorbidity, and the CCI were compared between patients with different grades of ED. Besides, the correlation between total testosterone and the CCI score, the influence of each comorbidity, and the ED severity on the CCI was assessed in a multiple linear regression. RESULTS: The study included 430 men with a mean age of 61 years. The mean CCI was 3.5, and mean total testosterone 15.2 nmol/L; 389 (91%) subjects had some grade of ED: 97 (23%) mild, 149 (35%) mild-to-moderate, 86 (20%) moderate, and 57 (13%) severe. The increase in ED severity was significantly associated with a decrease in total testosterone (P=.002), and an increase in the CCI score (P<.001). Testosterone levels were significantly lower in patients with obesity, diabetes, hypercholesterolemia, and hypertriglyceridemia (P<.05). However, only the prevalence of diabetes and hypertension was significantly associated with the severity of ED. The multivariate analysis including variables related to all assessed comorbidities, total testosterone levels, and the DE severity significantly predicted the CCI score (P<.001, R2=.426). The severity of ED significantly contributed to this model (P=.011), but total testosterone did not (P=.204). CONCLUSIONS: The CCI is significantly associated with the ED severity, but it shows a weak correlation with the testosterone levels.

Factores etiológicos de la disnea al final de la vida / No disponible

Objetivos: analizar los factores etiológicos de la disnea en una población atendida por un Equipo de Cuidados Paliativos (ECP) de ámbito de actuación mixta (hospitalario y domiciliario). Metodología: estudio longitudinal retrospectivo de los pacientes seguidos por el ECP de Badajoz y que fueron éxitus en el año 2005. Se reclutaron 195 pacientes, y se registraron las siguientes variables: edad, sexo, presencia de disnea, enfermedad terminal, localización del cáncer, factores etiológicos de la disnea: a) cardiopulmonar: (directa/indirecta); b) enfermedad concomitante; y c) causas sistémicas, saturación basal de oxígeno (SatO2), niveles de hemoglobina (Hb), índice de Karnofsky. El análisis fue realizado con el paquete estadístico Stata9, empleándose modelos de regresión logística. Resultados: el 60% de los pacientes presentaron disnea. La edad media fue de 73 años, el 64% eran mujeres; la enfermedad oncológica representó el 88% de los casos, siendo el cáncer de pulmón (n = 39) la neoplasia más frecuente. El odds de presentar disnea en los pacientes con afectación cardiopulmonar directa (1) e indirecta (2), era superior a aquellos que no referían disnea (OR1 = 0,1 OR2 = 0,05, p = 0,0001). El odds de la etiología sistémica fue > al 50% en pacientes con disnea (p = 0,052). No se demostró una asociación significativa entre SatO2 baja y disnea (p = 0,12). Los niveles de Hb ( < 11 mg/dl) se asociaron con la presencia de disnea (OR = 0,09/p = 0,005). Conclusiones: la afectación cardiopulmonar fue el factor etiológico más frecuente. Parece existir una asociación entre la etiología sistémica y la disnea. Los pacientes con cifras inferiores de Hb, mostraron mayor probabilidad de padecer disnea

Objectives: to analyze the etiologic factors of dyspnea in a population treated by a palliative care support team with both in-hospital and home activities. Methodology: a retrospective longitudinal study of patients included in a palliative care program within Badajoz health area who died in 2005. In all, 195 patients were recruited and the following variables were studied: age, sex, % patients with dyspnea, type of terminal disease, cancer site, etiologic factors of dyspnea (1. Local heart and lung (direct/indirect). 2. Associated disease. 3. Systemic causes). Oxigen saturation, hemoglobin level, and Karnofsky index. The analysis was performed using the statistical Stata9 method and logistic regression models. Results: sixty percent of cases showed dyspnea. Mean age was 73 (64% women). Cancer represented 88% of all cases (lung cancer was most frequent). The “odds” of dyspnea in patients with cardiac and lung disease, both direct (1) and indirect (2), were higher than in patients without that etiology (OR1 = 0.1 OR2 = 0.05, p = 0.0001). The odds of systemic causes were > 50% in patients with dyspnea (p = 0.052). The association was not statistically significant between oxygen saturation and dyspnea (p = 0.12). Hemoglobin levels were statistically associated with dyspnea (OR: 0.09/p = 0.005). Conclusions: the presence of cardiac and lung disease was the most prevalent etiology. Systemic causes were also associated with dyspnea. Patients with lower hemoglobin levels were more likely to suffer from dyspnea

[Renal transplantation in patients with a vascular aortobifemoral prosthesis]. / Trasplante renal sobre prótesis aortobifemoral.

INTRODUCTION: Nowadays, it is much more common in end stage renal disease patients with vascular grafts, to be kidney transplant candidates. We expose our experience in five cases. MATERIAL AND METHODS: Of all 1,483 kidneys transplanted in our center, 5 recipients had a previous aortobifemoral bypass (2 due to abdominal aortic aneurysm, and 3 due to vascular occlusive disease). We review the clinical features, outcome and complications in these patients. RESULTS: The vascular surgery was done 6 months to 16 years prior to transplantation. The renal transplant was done in iliac fossa with arterial anastomosis to the vascular graft. Surgical complications were: 1 renal artery thrombosis that was treated with thrombectomy, and 1 stricture at the ureterovesical junction. 2 patients dead at 6 months and 7 years with a functioning allograft and 3 patients live with functional allograft at 7 months, 3 years and 7 years. CONCLUSION: Kidney transplantation may be successful in selected patients with aortobifemoral bypass.

[Testicular epidermoid cyst: uncommon lesion of difficult preoperative diagnosis]. / Quiste epidermoide testicular: una rara entidad de dificil diagnostico preoperatorio.

Intratesticular epidermoid cysts are rare tumours that constitute one percent of all testicular masses. They are bening lesions that make differential diagnosis from malignant testicular tumours difficult. The absence of serum markers elevation and ultrasound imaging could support these lesions being bening epidermoid cysts, and in that case, conservative surgery is adequate. We present the case of a 22 years old patient who complains of a left testicular mass. In this case ultrasound diagnosis was non-specific and a left radical inguinal orchiectomy was performed.

[Surgical aspects in the third and fourth kidney retransplant]. / Aspectos quirúrgicos en los terceros y cuartos retrasplantes renales.

INTRODUCTION AND OBJECTIVES: A quarter of patients waiting for kidney transplantation are patients with previous graft failure. Outcome of first and second renal transplant make these the gold standard for end renal stage disease, but this is not so clear in the case of third and further renal transplant, especially at the time of organ shortage. We revise our experience in patients with three or more kidney transplants focusing on surgical aspects and graft outcome. MATERIAL AND METHOD: 1364 renal transplants have been carried out in our centre since 1975 until December 2003. We have retrospectively revised the 34 patients with three renal transplants and the 5 with four. We analyse the surgical technique, surgical complications and graft outcome. RESULTS: Mean age was 42 years (21-65). Average mismatches between donor and recipient was 3.2. All kidneys, but one case of living donor, were harvested from cadaver donors, mostly in multiple organ-procurement. Average time from the last renal transplant was 5 years (3 days-17 years) and from the last transplant carried out in the iliac fossa reused until the new transplant was 9 years (3 days- 17.5 years). All implants were performed through an iterative lumboliliac incision (25 on the right side, 11 on the left one and in 3 cases where side was not registered). Mean average duration of the procedure was 166 minutes (100-300). Nephrectomy of previous graft at the moment of the implant was carried out in 13 patients (33%). Vascular anastomosis was made on the common iliac vessels (50%) or on the external ones (50%) in end to side way, Ureteroneocystostomy was performed in an extravesical way except in 1 patient with cutaneous diversion. Vascular complications were 4 haemorrages (1 patient died), 3 venous and 2 arterial thrombosis. We had an abscess secondary to intestinal fistulae. Other surgical complications were 4 lymphoceles, three of them needed surgical treatment, and one perirenal haematoma treated in a conservative way. No urological complications were seen. In total 6 grafts (15%) were lost due to surgical complications. Graft actuarial survival rate at 1 year was 65%, 40% at 5 and 28% at 10 years. CONCLUSIONS: Three and four renal transplant survival rates are shorter than first and second ones. Iterative access through lumboiliac incision is associated with a higher vascular complication rate, probably in these patients a transperitoneal access would be better. Multicentric studies with higher numbers of patients are needed to define more clearly which patients would benefit from multiple kidney retransplants.