[Filnut-scale: rationale and use in screening for malnutrition risk within the infornut process]. / Filnut-escala: justificación y utilidad en el cribaje de riesgo por desnutrición dentro del proceso infornut.

OBJECTIVES: To offer a rationale for assigning a minimum score for risk of malnutrition for total proteins lower than 5g/dl and a scoring scale for our filter (FILNUT-Scale); and to analyse results of the MUST screening test performed on positive scores in the FILNUT nutritional filter and assess usefulness of said test in this population. METHODS: We searched the laboratory database for laboratory test orders (dated between 2004 and 2007) for which total proteins and albumin or cholesterol levels were determined, and we identified those with results for the above three parameters plus lymphocyte count. A limit (less than 5g/dl) was placed on the total protein level and the results for other parameters were not limited. Distribution curves for albumin and cholesterol were analysed. The same protocol was followed after establishing the CONUT score for each sample with the necessary parameters. From September 2007 to January 2008, the MUST test was performed on all FILNUT positives and we analysed how the degrees of risk corresponded. RESULTS: In 95% of the cases in which total proteins are lower than 5g/dl (n=1,176), albumin values are between 0.98 and 2.94g/dl, resulting in CONUT scores of 4 or 6 for albumin. Regarding total cholesterol, (n=761) 89.1% of the samples are lower than 180mg/dl, which accounts for one or two points in the score. In 98.79 % of the cases (n=490) that presented all four parameters, CONUT score was >/=5, which could be classified as medium or high risk. During the study period, 100% of the patients identified as medium or high risk by the FILNUT-Scale (n=568) tested as at-risk by MUST: of these, 421 (74.1%) were at high risk and 147 (25.9%) were at medium risk. CONCLUSIONS: Total proteins lower than 5g/dl determine a medium or high risk of malnutrition where a complete nutritional screening profile is lacking. This is why it should be included in the FILNUT-Scale with a score of five points. Performing the MUST test on patients with five or more points is efficient and provides clinical data needed for a complete assessment.

[INFORNUT process: validation of the filter phase-FILNUT--and comparison with other methods for the detection of early hospital hyponutrition]. / Proceso INFORNUT: validación dela fase de filtro-FILNUT--y comparación con otros métodos de detección precoz de desnutrición hospitalaria.

INTRODUCTION: According to several series, hospital hyponutrition involves 30-50% of hospitalized patients. The high prevalence justifies the need for early detection from admission. There several classical screening tools that show important limitations in their systematic application in daily clinical practice. OBJECTIVES: To analyze the relationship between hyponutrition, detected by our screening method, and mortality, hospital stay, or re-admissions. To analyze, as well, the relationship between hyponutrition and prescription of nutritional support. To compare different nutritional screening methods at admission on a random sample of hospitalized patients. Validation of the INFORNUT method for nutritional screening. MATERIAL AND METHODS: In a previous phase from the study design, a retrospective analysis with data from the year 2003 was carried out in order to know the situation of hyponutrition in Virgen de la Victoria Hospital, at Malaga, gathering data from the MBDS (Minimal Basic Data Set), laboratory analysis of nutritional risk (FILNUT filter), and prescription of nutritional support. In the experimental phase, a cross-sectional cohort study was done with a random sample of 255 patients, on May of 2004. Anthropometrical study, Subjective Global Assessment (SGA), Mini-Nutritional Assessment (MNA), Nutritional Risk Screening (NRS), Gassull's method, CONUT and INFORNUT were done. The settings of the INFORNUT filter were: albumin < 3.5 g/dL, and/or total proteins <5 g/dL, and/or prealbumin <18 mg/dL, with or without total lymphocyte count < 1.600 cells/mm3 and/or total cholesterol <180 mg/dL. In order to compare the different methods, a gold standard is created based on the recommendations of the SENPE on anthropometrical and laboratory data. The statistical association analysis was done by the chi-squared test (a: 0.05) and agreement by the k index. RESULTS: In the study performed in the previous phase, it is observed that the prevalence of hospital hyponutrition is 53.9%. One thousand six hundred and forty four patients received nutritional support, of which 66.9% suffered from hyponutrition. We also observed that hyponutrition is one of the factors favoring the increase in mortality (hyponourished patients 15.19% vs. non-hyponourished 2.58%), hospital stay (hyponourished patients 20.95 days vs. non-hyponourished 8.75 days), and re-admissions (hyponourished patients 14.30% vs. non-hyponourished 6%). The results from the experimental study are as follows: the prevalence of hyponutrition obtained by the gold standard was 61%, INFORNUT 60%. Agreement levels between INFORNUT, CONUT, and GASSULL are good or very good between them (k: 0.67 INFORNUT with CONUT, and k: 0.94 INFORNUT and GASSULL) and wit the gold standard (k: 0.83; k: 0.64 CONUT; k: 0.89 GASSULL). However, structured tests (SGA, MNA, NRS) show low agreement indexes with the gold standard and laboratory or mixed tests (Gassull), although they show a low to intermediate level of agreement when compared one to each other (k: 0.489 NRS with SGA). INFORNUT shows sensitivity of 92.3%, a positive predictive value of 94.1%, and specificity of 91.2%. After the filer phase, a preliminary report is sent, on which anthropometrical and intake data are added and a Nutritional Risk Report is done. CONCLUSIONS: Hyponutrition prevalence in our study (60%) is similar to that found by other authors. Hyponutrition is associated to increased mortality, hospital stay, and re-admission rate. There are no tools that have proven to be effective to show early hyponutrition at the hospital setting without important applicability limitations. FILNUT, as the first phase of the filter process of INFORNUT represents a valid tool: it has sensitivity and specificity for nutritional screening at admission. The main advantages of the process would be early detection of patients with risk for hyponutrition, having a teaching and sensitization function to health care staff implicating them in nutritional assessment of their patients, and doing a hyponutrition diagnosis and nutritional support need in the discharge report that would be registered by the Clinical Documentation Department. Therefore, INFORNUT would be a universal screening method with a good cost-effectiveness ratio.

[Inguinal hernia: what is the optimal size of prosthetic patch?]. / Hernies inguinales: quelle est la dimension optimale de la prothèse?

The use of prosthetic material for hernia repair is steadily increasing although some surgeons consider this excessive. This shift in surgical practice seems inevitable given the advantages of mesh prosthetic repair, but one may wonder about the amount of prosthetic material left in place which varies widely from one technique to another. While it may be impossible to determine the ideal size of a mesh, it is nevertheless useful to evaluate the relative advantages and drawbacks of techniques using meshes of different sizes. This study provides some elements of reflection based on anatomical, technical, and clinical data. The myo-pectineal orifice of Fruchaud is divided in two parts by the ilio-pubic tract. While the lower part is occupied by the femoral nerve and vessels and the lacunar ligament, the upper part contains the zone of weakness through which most groin hernias protrude. This area is small in size and can be covered by a mesh 8-9 cm long and 5-6 cm wide. There is no difference in the rate of recurrence of repairs using a wide preperitoneal mesh and those using a smaller onlay mesh. The theoretical advantage of a wide preperitoneal mesh is to prevent the possible occurrence of a femoral hernia. Given the rarity of femoral hernia, this advantage must be balanced against the drawbacks of this technique which include the need for general anesthesia, a higher incidence of early postoperative complications, and particularly a higher risk of late complications due to adhesion of the mesh to bladder and iliac vessels. Small onlay mesh prostheses are preferrable in most cases; the use of a wide preperitoneal mesh should be reserved for those cases of inguinal hernia at high risk of recurrence, particularly if bilateral.

[Treatment of inguinal hernia in the adult: results of tension-free procedures]. / Traitement de la hernie inguinale de l'adulte: résultats des réparations sans tension.

OBJECTIVES: The aim of this study was to verify, by a prospective multicenter evaluation, if the results attributed to tension-free procedures were obtained in current practice. PATIENTS AND METHODS: From 1994 to 1997, 398 patients were operated on by three surgical teams. There were 357 men and 4 women (mean age: 58.5 years, range: 25-90). The hernia was bilateral in 37 patients and 435 hernias were treated by Perfix plug (n = 322), Gilbert plug (n = 76) or by Lichtenstein procedure (n = 37), according to the choice of the surgeon. In tension-free procedures, sutures under tension were replaced by a mesh or a plug without any approximation of the margins of the hernial orifice. The procedure was performed under local (n = 316), epidural (n = 94), or general (n = 25) anesthesia. RESULTS: There were no postoperative deaths. There were 19 postoperative benign complications (4.4%). The duration of analgesics consumption, postoperative hospital stay, cessation of normal activities and work (mean [SD] [range]) were 3.3 days ([3.9] [0-60]), 1.3 day ([1.1] [0-16]), 4.5 days ([3.1] [0-34]) and 15.4 days ([10.2] [0-60]) respectively. With a mean follow-up of 36 months ([14] [6-67]), 423 hernias (97.2%) were assessed. Two (0.5%) recurrences occurred. Twenty three patients had secondarily troubles (5.8%): 21 patients complained of chronic pain, one had testis atrophy and one plug had to be removed. CONCLUSION: These results confirm that tension-free procedures are minimally invasive, induce few benign postoperative complications and low pain, allow early return to normal activity, and are followed by few recurrences.

Inguinal hernia: a patch covering only the myopectineal orifice is effective.

A large mesh in the preperitoneal space, spread on iliac vessels and bladder, can cause future difficulties in a case of urogenital or vascular disease. Since all recurrences are located in the area of the myopectineal orifice, a mesh covering only this area, as in the Rives procedure, is effective and avoids these drawbacks. However, the Rives procedure is demanding, which is why we tried to simplify the technique. A mesh 8-10 cm long and 6-7 cm wide was spread in the preperitoneal space using the inguinal approach, without any fixation or with only a few stitches; the fascia was then simply approximated over the mesh without tension. A total of 161 hernias (99% Nyhus type III and IV) were repaired using this technique. Only six benign complications (3.7%) occurred. With a median follow-up of 63 months (range, 18-94 months), only one recurrence occurred (0.7%), due to misplacement of the mesh, eight patients complained of mild pain, and no late complications were observed. In conclusion, placement of a small mesh covering only the myopectineal orifice using the inguinal approach is effective and is associated with a low risk of drawbacks and complications.

[Tension-free procedures: progress in the treatment of inguinal hernia]. / Les procédés sans tension: un progrès dans le traitement de la hernie inguinale.

OBJECTIVE: Tension-free procedures are aimed to minimize post-operative pain and rate of recurrence, by replacing sutures under tension by a mesh without any approximation of the margins of the hernial orifice. Moreover they offer the advantage of being performed under local or epidural anesthesia. The aim of this study was to verify, by a prospective multicentre evaluation, if the results attributed to these procedures are obtained in current practice. RESULTS: Evaluation involved 435 hernias, treated by Lichtenstein procedure, Gilbert plug and Perfix plug. There were 19 postoperative benign complications (4.4%). The durations of analgesics consumption, post-operative hospital stay, cessation of normal activities and time off work [mean, [(SD), (extremes)]] were 3.3 days [(3.9) (0-60)], 1.3 days [(1.1) (0-16)], 4.5 days [(3.1) (0-34)] and 15.4 days [(10.2) (0.60)] respectively. With a mean follow-up of 36 months [(14) (6-67)], 423 hernias (97.2%) were assessed. Two (0.5%) recurrences occurred. Twenty three patients had secondary troubles (5.8%): 21 patients complained of chronic pain, one had atrophy of the testis and one plug had to be removed. CONCLUSION: Our results confirm that tension-free procedures are minimally invasive, induce few benign postoperative complications, low pain and allow early return to normal activity.

[Progress in the treatment of inguinal hernia]. / Progrès dans le traitement de la hernie inguinale.

The aim of surgical treatment of inguinal hernia is to a) reduce post-operative pain and discomfort to a minimum allowing patients to return to the activities as rapidly as possible, and b) hold the recurrence rate under 1%. The Shouldice technique remains the gold standard; its real recurrence rate is about 5%. Applying a mesh in the retroperitoneal space by laparoscopy is a good approach and can theoretically reach both aims. In current practice however, laparoscopy is not always favorable: general anesthesia is mandatory, technical pitfalls lead to morbidity and later to recurrences. Tension-free procedures would provide the best compromise for achieving the two advantages of: a) reducing pain, discomfort and recurrence risks by eliminating tension and, b) local and or loco-regional anesthesia.