Single-operator cholangioscopy and electrohydraulic lithotripsy for the treatment of Mirizzi syndrome.

INTRODUCTION: Mirizzi syndrome is an infrequent complication of long-standing cholelithiasis. Extrinsic compression of the common hepatic duct is usually caused by an impacted stone in Hartmann's pouch or cystic duct resulting in the development of cholecystobiliary fistula. This syndrome is classified based on the presence and severity of cholecystobiliary fistula. Mirizzi syndrome is challenging to diagnose preoperatively and may require complex biliary surgical procedures for resolution. RESULTS: We present three patients with Mirizzi syndrome with different clinical presentations. All were successfully treated by cholangioscopy with electrohydraulic lithotripsy. Endoscopic treatment is a safe alternative with a high success rate. Single-operator cholangioscopy combined with lithotripsy has been shown to have a 90-100% success rate in the treatment of biliary stones. CONCLUSION: Herein, we present our experience treating Mirizzi syndrome with single-operator cholangioscopy guided electrohydraulic lithotripsy. Difficult management of Mirizzi syndrome has led to research of new treatment options to minimize the risk of high-rate complications. Single-operator cholangioscopy in combination with laser lithotripsy is an adequate and safe alternative for the treatment of this condition.

Percepciones de los profesores sobre de la deshonestidad en estudiantes de Medicina: prevalencia, motivaciones e implicaciones / Faculty perceptions of dishonesty on medical students: Prevalence, motivations and implications

INTRODUCCIÓN: La deshonestidad académica son actitudes y acciones que toma el estudiante con la finalidad de obtener beneficio. Poco se conoce sobre el efecto de los profesores en este fenómeno. El objetivo de esta investigación fue conocer la percepción de los docentes sobre la prevalencia, motivación e implicaciones de la deshonestidad académica, así como analizar su rol en la incidencia de estas conductas. Métodos y materiales: Fue un estudio cuantitativo, descriptivo y transversal para el que se aplicó un cuestionario de 39 ítems que valora el modelo que explica la deshonestidad en los factores de prevalencia, motivación e implicaciones. Se analizaron las medias considerando como factores para la prueba ANOVA los años de experiencia y la etapa de la carrera en la que participa. RESULTADOS: Los profesores indican que las conductas más frecuentes son que el alumno obtenga crédito en trabajos en los que no participó, y plagio en actividades y tareas, con una media de 2,13 y 2,18, respectivamente. De los motivadores, los más implicados son la obtención de mayores calificaciones y las facilidades que ofrecen las nuevas tecnologías, con una media de 3,91 y 3,82, respectivamente. Sobre las implicaciones, aunque los profesores aseguran que alguna vez han sido testigos de la deshonestidad, solo un 48,2% ha abierto la conversación con los estudiantes durante su clase. DISCUSIÓN: Es necesario fortalecer las políticas institucionales que faciliten los métodos de reporte y seguimiento a situaciones de riesgo. En particular, un punto de interés es el de desvincular de los profesores la documentación de evidencia y la responsabilidad del proceso

INTRODUCTION: Academic dishonesty are attitudes and actions taken by the student in order to obtain benefits. Little is known about the effect of teachers on this phenomenon. The objective of this research was to study the perception of teachers about the prevalence, motivation and implications of academic dishonesty on students, as well as to analyze their role in the incidence of these behaviors. METHODS AND MATERIALS: The study was quantitative, descriptive and cross-sectional. A questionnaire of 39 items that assesses the model that explains the dishonesty in the factors of prevalence, motivation and implications. The means were analyzed considering as factors for the ANOVA test: the years of experience and the stage of the career in which the faculty participates. RESULTS: The faculty members indicate that the most frequent behaviors are: the student that obtains credit for work where he / she did not participate, and plagiarism in activities and tasks, with an average of 2.13 and 2.18 respectively. Of the motivators, the most involved are: obtaining higher grades, and the easiness offered by new technologies, with an average of 3.91 and 3.82 respectively. On the implications, although the professors claim that they have witnessed dishonesty, only 48.2% have opened the conversation with the students during their class. DISCUSSION: It is necessary to strengthen the institutional policies that enable the methods of reporting and monitoring risk situations. Particularly, a point of interest is removing the responsibility of faculty about the documentation of evidence and the responsibility of the process itself

Effect of Surgical Expertise on Biomechanical Properties of Sutures After Abdominal Wall Closure.

BACKGROUND: Despite preventive methods and careful surgical technique, surgical site infection and incisional hernias are of main concern after the closure of surgical incisions and keep haunting abdominal wall wound healing. The aim of this study is to find how surgical expertise level modifies biomechanical properties of sutures commonly used in abdominal wall fascial closure (polypropylene, polyglactin 910, polydioxanone). MATERIALS AND METHODS: Surgery residents with different experience levels performed abdominal wall fascial closure in swine models with the previously mentioned suture materials. A standardized technique was used. Sutures were removed, and a tensile stress test was performed on the removed sutures. A total of 81 abdominal fascial closures were achieved. Time, extension, maximum tensile force (Ftmax), and maximum stress were measured and analyzed. RESULTS: The results of the polydioxanone stress test present a trend in three variables: extension, tensile force, and stress. The trend shows higher medians in the expert group and lower medians in the novice group. While using polypropylene sutures, medians in the expert group are the highest; however, a trend is not observed. Polyglactin 910 sutures have nonspecific behavior among the different experience groups and variables. Polypropylene is the material with the lowest Ftmax tested and fails at 42.64 (IQR 40.98-44.89) N. Regarding the elastic properties of the material, polyglactin demonstrates the least extension of all sutures tested, with a 14 (IQR 13.33-14.83) mm extension. This study demonstrates that polydioxanone has a superior Ftmax compared with polypropylene and has a superior extension at failure properties compared with polyglactin, confirming that polydioxanone could be the suture of choice used for abdominal wall fascial closure. CONCLUSIONS: Study results do not show statistically significant differences regarding the impact of the experience level of different general surgery residents in the biomechanical properties of sutures used in abdominal wall fascial closure.

Incremento de síndrome de burnout en estudiantes de Medicina tras su primer mes de rotación clínica / Increase in burnout syndrome in medical students during their first month of clinical rotation

INTRODUCCIÓN: Se ha demostrado que el desarrollo de burnout en los médicos se inicia desde su formación académica y puede repercutir en su vida personal. OBJETIVO: Evaluar la prevalencia de burnout al inicio y tras un mes de rotación clínica. MATERIAL Y MÉTODOS: Se empleó el Maslach Burnout Inventory-Human Services Survey de 22 reactivos. Se evaluaron al inicio de la rotación, después de un período vacacional, y después de un mes de rotación clínica. Se estableció la prevalencia y las diferencias entre las 2 mediciones. RESULTADOS: Veintiún (12,3%) alumnos presentaban síntomas de severidad al inicio del trimestre y 34 (19,8%) después del primer mes (p = 0,059). Tras eliminar la realización personal, 54 (31,6%) y 76 (44,2%) alumnos presentaron severidad en el resto de las dimensiones (p = 0,016), respectivamente. CONCLUSIÓN: Después de un mes de exposición clínica se presentó un incremento significativo en la presencia de cansancio emocional, despersonalización y burnout

INTRODUCTION: It has been demonstrated that the development of burnout in physicians begins during their academic training and it can affect their personal life. OBJECTIVE: To evaluate the prevalence of burnout in medical students at the beginning, and after one month of clinical rotation. MATERIALS AND METHODS: We evaluated students at the beginning of surgical clinical rotation and one month after using the Maslach Burnout Inventory-Human Services Survey. The prevalence and differences between the 2 measurements were calculated. RESULTS: Twenty-one (12.3%) students showed symptoms of severity at the beginning, and 34 (19.8%) after the first month (P = .059). After eliminating the personal accomplishment scale, 54 (31.6%) and 76 (44.2%) students had severity of symptoms in the rest of the dimensions at the beginning and after one month, respectively (P = .016). CONCLUSION: Medical students showed an increase in the presence of severe burnout, as well as emotional exhaustion and depersonalisation after one month of clinical rotation

Evaluación de la calidad de campos clínicos para la enseñanza en pregrado en México / Assessment of the quality of clinical fields for undergraduate medical education in Mexico

INTRODUCCIÓN: La formación del alumno de medicina es dinámica y multifactorial, requiere de entrenamiento constante con los recursos necesarios bajo la tutela de un profesor clínico que le guíe a desarrollar su máximo potencial. El objetivo de esta investigación fue diseñar y validar un instrumento que permita conocer la percepción de los alumnos sobre la calidad de los campos clínicos donde participan en sus rotaciones. MATERIAL Y MÉTODOS: Es un estudio de tipo cuantitativo, observacional, descriptivo, prospectivo y transversal. La población participante fueron los 148 alumnos del quinto año de la carrera de medicina de una universidad privada al norte de México. Se elaboró una herramienta de 30 ítems que evalúa la calidad de los campos clínicos en tres variables: estructura, tutoría, y proceso enseñanza-aprendizaje, en una escala Likert de 4 niveles que va desde 1, totalmente en desacuerdo, a 5, totalmente de acuerdo. Para el estudio se considera el análisis de ítem para evaluar la consistencia interna, así como la prueba ANOVA, prueba Tukey, y estadística descriptiva para estudiar las tendencias por factores y por servicio. RESULTADOS: Se obtuvo un alfa de Cronbach de 0,9549. La media del factor de estructura fue 3,64, la media de tutoría fue 4,03 y la de proceso enseñanza-aprendizaje, 4,18. El servicio que recibió una evaluación más favorable fue Pediatría, obteniendo una diferencia significativa en los elementos de estructura (p = 0,008) y tutoría (p = 0,003). DISCUSIÓN: Aunque la media observada en la percepción de los alumnos indica un nivel adecuado de la tutoría y el proceso de enseñanza aprendizaje, al hacer un análisis por sede se observa una amplia variación de la calidad de enseñanza ofrecida. Como instituciones educativas esto es un foco de atención porque significa que los alumnos no adquieren ni desarrollan sus competencias de igual manera en todos los campos clínicos

INTRODUCTION: Medical student training is dynamic and multifactorial. It requires continuing education and training under the tutelage of a clinic professor, who will guide the student to develop optimal potential. The objective of this study was to design and validate a tool to measure student perception on the learning quality of clinical rotations. MATERIAL AND METHODS: The study is quantitative, observational, descriptive, prospective, and cross-sectional. The study sample was consisted of 148 fifth-year medical students from a private university in northern Mexico. A 30 item questionnaire was developed to assess quality of clinical stewardships in three variables: structure, tutoring, and teaching-learning process. A five-level Likert scale from 1, absolutely disagree, to 5, absolutely agree, was used. The study used item analysis to estimate internal consistency, as well as ANOVA, Tukey and descriptive statistics to assess the tendencies by factors and stewardship. RESULTS: Cronbach alpha was 0.9549. The structure factor mean was 3.64, tutoring 4.03, and teaching-learning process 4.18. Paediatrics received the most favourable evaluation by obtaining a significant difference in the element structure (P=.008) and tutoring (P=.003). DISCUSSION: Even though the mean observed among tutoring and teaching-learning process indicates an adequate level of student perception, under the analysis per field, a significant variation was found in the quality of learning experience. As an academic institution, this is a concern because students are not acquiring or developing the same level of skills in all stewardships

Past, Present and Future of Surgical Meshes: A Review.

Surgical meshes, in particular those used to repair hernias, have been in use since 1891. Since then, research in the area has expanded, given the vast number of post-surgery complications such as infection, fibrosis, adhesions, mesh rejection, and hernia recurrence. Researchers have focused on the analysis and implementation of a wide range of materials: meshes with different fiber size and porosity, a variety of manufacturing methods, and certainly a variety of surgical and implantation procedures. Currently, surface modification methods and development of nanofiber based systems are actively being explored as areas of opportunity to retain material strength and increase biocompatibility of available meshes. This review summarizes the history of surgical meshes and presents an overview of commercial surgical meshes, their properties, manufacturing methods, and observed biological response, as well as the requirements for an ideal surgical mesh and potential manufacturing methods.

Surgical Site Infection Rate Drops to 0% Using a Vacuum-Assisted Closure in Contaminated/Dirty Infected Laparotomy Wounds.

Wound site infections increase costs, hospital stay, morbidity, and mortality. Techniques used for wounds management after laparotomy are primary, delayed primary, and vacuum-assisted closures. The objective of this study is to compare infection rates between those techniques in contaminated and dirty/infected wounds. Eighty-one laparotomized patients with Class III or IV surgical wounds were enrolled in a three-arm randomized prospective study. Patients were allocated to each group with the software Research Randomizer® (Urbaniak, G. C., & Plous, S., Version 4.0). Presence of infection was determined by a certified board physician according to Centers for Disease Control's Criteria for Defining a Surgical Site Infection. Twenty-seven patients received primary closure, 29 delayed primary closure, and 25 vacuum-assisted closure, with no exclusions for analysis. Surgical site infection was present in 10 (37%) patients treated with primary closure, 5 (17%) with primary delayed closure, and 0 (0%) patients receiving vacuum-assisted closure. Statistical significance was found between infection rates of the vacuum-assisted group and the other two groups. No significant difference was found between the primary and primary delayed closure groups. The infection rate in contaminated/dirty-infected laparotomy wounds decreases from 37 and 17 per cent with a primary and delayed primary closures, respectively, to 0 per cent with vacuum-assisted systems.

Aprendizaje centrado en las perspectivas del paciente: el caso de las escuelas de medicina en México / Perspectives on patient centred learning: A study in Mexican medical schools

INTRODUCCIÓN: La educación médica ha evolucionado en etapas. La más reciente de educación basada en sistemas implica un análisis desde perspectivas de alta complejidad para alinearlas a las necesidades del paciente. De esta forma surge el aprendizaje centrado en las perspectivas del paciente que incluye 4 dimensiones: humana, biomédica, gestión y emprendimiento. OBJETIVO: Describir el concepto de aprendizaje centrado en las perspectivas del paciente como estrategia didáctica y explorar su aplicación en las escuelas de medicina de México. MATERIAL Y MÉTODOS: El método fue exploratorio, descriptivo y transeccional. Se realizó una encuesta a 85 profesores y directivos pertenecientes a escuelas de medicina afiliadas a la Asociación Mexicana de Facultades de Escuelas de Medicina (AMFEM) para evaluar la implementación de las dimensiones del aprendizaje centrado en las perspectivas del paciente en escala Likert de 1 (Totalmente en desacuerdo) a 5 (Totalmente de acuerdo). RESULTADOS: La media por perspectiva fue: humana (3,76), biomédica (3,72), gestión (3,49) y emprendimiento (3,33). Destaca el mayor énfasis en ¿quién es el paciente? y el menor en ¿cómo puedo mejorar?. DISCUSIÓN: El modelo presentado evoluciona desde la educación basada en competencias implementadas en la educación a partir de contenidos aislados, a un enfoque en base a perspectivas que colocan en el centro al paciente para abordar desde un mismo caso múltiples competencias del médico

INTRODUCTION: Medical education has evolved through severel stages. The most recent one, systems-based learning, involves an analysis of complex perspectives an adapting them to patient needs. From this notion, the concept perspectives for patient centred learning emerges. It includes four dimensions: human, biomedical, managerial, and entrepreneurial. OBJECTIVE: The aim of this study was to define the perspectives for patient centred learning as a teaching strategy and examine its application in medical schools in Mexico. MATERIAL AND METHODS: The method was exploratory, descriptive and cross-sectional. A questionnaire was completed by 85 faculty members and deans from the Mexican Association of Schools and Faculties of Medicine (AMFEM for its initials in Spanish) to assess the implementation of perspectives for patient centred learning, using a Likert scale from 1 (Total disagreement) to 5 (Total agreement). RESULTS: The mean calculated by perspective was: human (3.76), biomedical (3.72), management (3.49), and entrepreneurship (3.33). Higher emphasis was placed on who is the patient?, and a lower focus on how the system should be improved?. DISCUSSION: The presented model evolves from a competency based framework implemented in education as isolated contents, to a perspective based focus that places the patient in the centre, analysing the same case from multiple medical skills

[Gallbladder agenesis. Case report]. / Agenesia de la vesícula biliar. Reporte de caso.

BACKGROUND: Gallbladder agenesis is a very rare congenital abnormality of the biliary tract. The diagnosis is made during surgery, because all preoperative studies have failed to identify this malformation. The purpose of this article is to present a case of gallbladder agenesis diagnosed during surgery, its management, and a review of the literature. CLINICAL CASE: The case involves a sixty-two year- old female, referring to repeated biliary colic symptoms. The abdominal ultrasound diagnosed cholelithiasis. It was impossible to identify the gallbladder during surgery. Diagnosis was confirmed by intra-operative cholangiography. DISCUSSION: Preoperative diagnostic workup has failed to recognise patients with gallbladder agenesis. It is currently recommended to abandon the surgery once this diagnosis is suspected and confirm it by a cholangio-magnetic resonance scan in order to avoid a bile duct injury. CONCLUSIONS: Agenesis of the gallbladder is a rare congenital abnormality of the biliary tree. Every surgeon must keep this rare entity in mind when a "difficult dissection" or an anatomic variant is identified during surgery, and make use of an intra-operative cholangiography, mainly to prevent a bile duct injury.

Incidental benign metastasizing leiomyoma in a patient with bone sarcoma: a case report.

Background. The benign metastasizing leiomyoma is an exceptionally rare entity; it presents with ectopic leiomyoma nodules with a benign pattern. Symptoms vary according to the anatomic location. The diagnosis is histopathological, usually in patients with history of hysterectomy. Case Presentation. A 36-year-old female with 2-month history of left knee pain was diagnosed with bone fibrosarcoma. A CT scan showed pulmonary nodules. The patient started neoadjuvant chemotherapy. Conservative surgery of pelvic limb was achieved. A new CT scan reported pulmonary nodules that remained in relation to the previous CT. A nodule resection by thoracotomy and TOB (transoperative biopsy) was performed. The final pathology report described benign proliferative lesions consistent with benign metastatic leiomyoma. Conclusions. Benign metastatic leiomyoma is a rare condition presenting with uterine and extrauterine nodules most commonly in the lung. The diagnosis is histopathological. The surgical procedure must be reserved for selected patients.

Evaluation of a surgical simulator as used by students with different experience levels.

BACKGROUND: Historically, the operating room has been the training setting for both surgeons and students. Nowadays, an alternative is represented by surgical simulators. In the same way a not-very-well-built mirror cannot reflect trustworthy images (distortion), a not well-built, calibrated or programmed simulator will be unable to reflect the training level of the operator. Our aim is to indirectly evaluate the Surgical SIM® simulator. METHODS: Twelve surgical residents were classified according to novices, intermediates and experts, and 15 tasks were applied with three dimensions of evaluation in each using the Surgical SIM® simulator. Pearson's correlation test was used to establish validity. RESULTS: In general, from the three dimensions evaluated, results showed a statistically significant difference for time (p = 0.001), trajectory (p = 0.01) and errors (p = 0.001). CONCLUSIONS: Effectiveness of Surgical SIM® was indirectly demonstrated.