Causas de ingresos no deseados tras la realización de procedimientos quirúrgicos de cirugía ortopédica y traumatología en cirugía mayor ambulatoria / Causes of unplanned admission after orthopedic procedures in ambulatory surgery

OBJETIVO: Los procedimientos de cirugía ortopédica y traumatología realizados en unidades de cirugía mayor ambulatoria ofrecen importantes ventajas que desaparecen cuando la recuperación postoperatoria no es la esperada y los pacientes precisan ingresar. El objetivo de este estudio es analizar las causas de ingresos no deseados tras intervenciones quirúrgicas de cirugía ortopédica y traumatología en una unidad de cirugía mayor ambulatoria en relación con variables como edad, riesgo anestésico, tipo de anestesia, procedimiento o duración. MÉTODOS: Estudio de cohorte ambispectivo sobre 5.085 pacientes intervenidos desde 1995 a 2017. Se analizaron 39 variables proporcionadas por la base de datos de la unidad que se abre al ingreso en la misma y se cierra el día 30 postoperatorio. RESULTADOS: El 98,2% de los pacientes fueron dados de alta de la unidad. Precisaron ingresar 74 (1,5%). Este porcentaje demostró diferencias significativas en relación con el tipo de procedimiento, el tipo de anestesia y la duración, que condicionaron el ingreso inmediato por mal control del dolor agudo postoperatorio, náuseas o alteraciones de la herida. Diecisiete pacientes (0,3%) precisaron un ingreso diferido por complicaciones surgidas en el domicilio, siendo la más frecuente la infección de la herida. CONCLUSIONES: Los ingresos no deseados se relacionan con mayor frecuencia con el empleo de anestesia general, con operaciones de mayor duración y con procedimientos como la cirugía artroscópica, las correcciones de hallux valgus o las retiradas de material de osteosíntesis, siendo las causas de ingreso más importantes el mal control del dolor agudo postoperatorio en los inmediatos y la infección de la herida en los diferidos

OBJECTIVE: Orthopaedic procedures performed in Day Surgery Units provide important advantages which disappear when patients require admission when postoperative recovery is not as expected. The aim of this study was to analyse the reasons for unplanned hospital admissions after orthopaedic procedures in a Day Surgery Unit and their relationship between variables such as patient age, anaesthetic risk and technique, procedure or duration. METHODS: Ambispective cohort study of 5,085 patients who underwent surgical orthopaedic procedures between 1995 and 2017. Thirty-nine variables provided by the Unit's database were analysed. The database was opened on the day of admission and closed the 30th postoperative day. RESULTS: Of the patients, 98.2% were discharged from the Unit. Seventy-four (1.5%) required overnight admission. This percentage showed significant differences in relation to the type of procedure, type of anaesthesia and duration, which conditioned overnight admission due to inadequate postoperative pain management, nausea or wound complications. Seventeen patients (0.3%) required readmission after discharge due to complications that arose at home, such as wound infection, which was the most common. CONCLUSIONS: Unplanned admissions are more frequently related to general anaesthesia, lengthy surgeries and procedures such as arthroscopy, hallux valgus corrections or removal of osteosynthesis material. The major reasons for unplanned admissions were inadequate postoperative pain management for overnight admissions and wound infection for admissions after discharge

Causes of unplanned admission after orthopedic procedures in ambulatory surgery. / Causas de ingresos no deseados tras la realización de procedimientos quirúrgicos de cirugía ortopédica y traumatología en cirugía mayor ambulatoria.

OBJECTIVE: Orthopaedic procedures performed in Day Surgery Units provide important advantages which disappear when patients require admission when postoperative recovery is not as expected. The aim of this study was to analyse the reasons for unplanned hospital admissions after orthopaedic procedures in a Day Surgery Unit and their relationship between variables such as patient age, anaesthetic risk and technique, procedure or duration. METHODS: Ambispective cohort study of 5,085 patients who underwent surgical orthopaedic procedures between 1995 and 2017. Thirty-nine variables provided by the Unit's database were analysed. The database was opened on the day of admission and closed the 30th postoperative day. RESULTS: Of the patients, 98.2% were discharged from the Unit. Seventy-four (1.5%) required overnight admission. This percentage showed significant differences in relation to the type of procedure, type of anaesthesia and duration, which conditioned overnight admission due to inadequate postoperative pain management, nausea or wound complications. Seventeen patients (0.3%) required readmission after discharge due to complications that arose at home, such as wound infection, which was the most common. CONCLUSIONS: Unplanned admissions are more frequently related to general anaesthesia, lengthy surgeries and procedures such as arthroscopy, hallux valgus corrections or removal of osteosynthesis material. The major reasons for unplanned admissions were inadequate postoperative pain management for overnight admissions and wound infection for admissions after discharge.

Gender- and site-related effects on lipolytic capacity of rat white adipose tissue.

Gender- and site-related differences in the lipolytic capacity, at the different steps of the adrenergic pathway, in gonadal and inguinal white adipose tissue (WAT), were assessed by studying alpha2A-adrenergic receptor (AR), beta3-AR and hormone-sensitive lipase (HSL) protein levels, and by determining the lipolytic response to different agents. Gonadal WAT showed a lower alpha2A/beta3-AR ratio, a greater lipolytic capacity in response to AR agonists, and higher HSL activity and protein levels than inguinal WAT. In female rats, we found greater alpha2A-AR protein levels and alpha2A/beta3-AR ratio compared to their male counterparts, but, on the other hand, a higher lipolytic response to beta-AR agonists and a greater lipolytic capacity at the postreceptor level, including a more activated HSL protein. Thus, the lipolytic capacity was clearly higher in gonadal than in inguinal WAT, at the different steps of the adrenergic pathway studied. Moreover, in both tissues, females showed a greater inhibition of lipolysis via alpha2-AR, which was counteracted by the higher lipolytic capacity at the postreceptor level.

The involvement of kallikrein-kinin system in diabetes type I (insulitis).

Islet inflammation or insulitis is followed by selective destruction of the insulin secreting B-cell. Animal models of insulin-dependent diabetes mellitus (IDDM) have been used to characterize more fully insulitis, and our results with C57/BL/Ks mdb with low doses of streptozotocin (STZ) confirmed the disease. B1 receptor antagonist [Leu8]des-Arg9-BK has shown a significant effect on diabetic glycemia and renal control parameters. Compared to insulin, the drug was effective to prevent the insulitis and the renal damage. On the other hand, B2 receptor antagonist (HOE 140) and ACE-I (captopril) were only able to control the urinary diabetic proteinuria.

Estrogens normalize the hypothalamic-pituitary-adrenal axis response to stress and increase glucocorticoid receptor immuno-reactivity in hippocampus of aging male rats.

Aging is associated with a disturbance in the regulation of the hypothalamic-pituitary-adrenal axis (HPA) and reduced levels of glucocorticoid receptors (GR) in the hippocampus. To compensate for these effects, we have investigated whether estrogen therapy normalized the HPA response to stress and GR in hippocampus and paraventricular (PVN) nucleus. Young (3-4 months) and old (20 months) male Sprague-Dawley rats were bled by tail cut in the basal state and following ether stress. While basal and ether-stimulated levels of plasma corticosterone (CORT) were similar in the two groups, old animals presented a delayed termination of the response to ether stress. A dexamethasone inhibition test carried out in old animals, showed a failure to completely block plasma CORT after ether stimulation. Furthermore, in old rats GR-immunoreactive levels were reduced in CA1-CA2 hippocampal subfields and subiculum, while normal levels were obtained in CA3-CA4 and PVN. We observed that prolonged estrogen treatment (6 weeks) of old rats normalized the termination of the stress response, restored dexamethasone inhibition of plasma CORT, and increased GR immunoreactivity in CA1 and CA2 hippocampal subfields and subiculum. The results suggest that estrogen treatment enhanced the glucocorticoid feedback signal by increasing GR in hippocampus, and corrected the disturbances in HPA axis regulation. These animal experiments may be important to elucidate the effects of estrogenic on the hippocampal and HPA dysfunction associated with aging and Alzheimer's disease in humans.

Constitutive nitric oxide synthase (cNOS) activity in Langerhans islets from streptozotocin diabetic rats.

Nitric oxide synthase activity was measured in Langerhans islets isolated from control and streptozotocin diabetic rats. The activity of the enzyme was linear up to 150 micrograms of protein from control rats and was optimal at 0.1 microM calcium, when it was measured after 45 min of incubation at 37 degrees C in the presence of 200 microM arginine. Specific activity of the enzyme was 25 x 10(-4) nmol [3H]citrulline 45 min-1 mg protein-1. Streptozotocin diabetic rats exhibited less enzyme activity both in total pancreas homogenate and in isolated Langerhans islets when compared to control animals. Nitric oxide synthase activity measured in control and diabetic rats 15 days after the last streptozotocin injection in the second group of animals corresponded only to a constitutive enzyme since it was not inhibited by aminoguanidine in any of the mentioned groups. Hyperglycemia in diabetic rats may be the consequence of impaired insulin release caused at least in part by reduced positive modulation mediated by constitutive nitric oxide synthase activity, which was dramatically reduced in islets severely damaged after streptozotocin treatment.

Constitutive nitric oxide synthase (cNOS) activity in Langerhans islets from streptozotocin diabetic rats

Nitric oxide synthase activity was measured in Langerhans islets isolated from control and streptozotocin diabetic rats. The activity of the enzyme was linear up to 150 mug of protein from control rats and was optimal at 0.1 muM calcium, when it was measured after 45 min of incubation at 37ºC in the presence of 200 muM arginine. Specific activity of the enzyme was 25 x 10(-4) nmol [3H] citrulline 45 min(-1) mg protein(-1). Streptozotocin diabetic rats exhibited less enzyme activity both in total pancreas homogenate and in isolated Langerhans islets when compared to control animals. Nitric oxide synthase activity measured in control and diabetic rats 15 days after the last streptozotocin injection in the second group of animals corresponded only to a constitutive enzyme since it was not inhibited by aminoguanidine in any of the mentioned groups. Hyperglycemia in diabetic rats may be the consequence of impaired insulin release caused at least in part by reduced positive modulation mediated by constitutive nitric oxide synthase activity, which was dramatically reduced in islets severely damaged after streptozotocin treatment.

Effects of aprotinin on the kallikrein-kinin system in type I diabetes (insulitis).

Sub-diabetogenic doses of streptozotocin (STZ) produce insulitis, beta cell destruction and diabetes in mice. Since kinin have been proposed as an inflammatory mediator in several diseases, we decided to evaluate the role of the kallikrein-kinin system in the evolution of insulitis. Male C 57 BL/KsJ mdb mice were injected with STZ (40 mg/kg) for 5 consecutive d. Aprotinin (4000 KIU/d) was injected simultaneously with STZ during 10 d. Plasma and urine samples collected on day 15 were assayed for glucose concentration and proteins, nitrites and kallikrein. Diabetic mice showed hyperglycemia and increased diuresis, marked proteinuria, nitrites and kallikrein. Administration of aprotinin, a potent tissue kallikrein inhibitor, to STZ mice, reduced the hyperglycemia and the altered renal function of the diabetic mice to level no different from normal mice. The present studies are consistent with the hypothesis that the over-production of tissue kallikrein in insulitis could be controlled by the effect of aprotinin.

Unexpected deaths in depressed medical inpatients treated with fluoxetine.

BACKGROUND: Depression in the medically ill is underdiagnosed and undertreated. Fluoxetine would appear promising in this population because of its efficacy and benign side effect profile, but it has not been systematically studied in the medically ill. METHOD: The authors report the cases of three seriously medically ill patients, seen in psychiatric consultation while patients on a general medical service, who were treated with fluoxetine for depression. Each was an elderly white female with pulmonary disease and atrial arrhythmias, including atrial fibrillation, and each was prescribed diuretics, nitrates, and other cardiac and/or pulmonary agents. RESULTS: Each patient died within 10 days of beginning fluoxetine treatment, from unexplained causes. CONCLUSIONS: The authors hypothesize that direct cardiac effects mediated by fluoxetine, or other factors, may have been contributory. The effects of fluoxetine on electrolytes, fluoxetine's possible effects on drug levels, and serotonin's effect on the pulmonary system are examined. Other antidepressant agents should be considered in this particular population until further data are available.

The onset of sperm production in pubertal boys. Relationship to gonadotropin excretion.

To determine the relationship of gonadotropin excretion to spermarche, 26 boys ranging in age from 10.3 to 17.5 years each provided ten overnight urine samples. Microscopic observation of sperm was found in 33 (13%) of the 260 samples, with 50% of the boys exhibiting sperm in at least one specimen. No further cumulative gain in detecting spermaturia occurred after the seventh urine collection. The median age of spermarche was computed by logistic regression analysis to be 14 years. Three urine collections from each boy were assessed for gonadotropin levels. At age 14 years mean follicule-stimulating hormone and luteinizing hormone excretion were, respectively, 857 and 503 mIU/h, into the reported adult daytime range. Spermarche is a midpubertal event associated with age-appropriate gonadotropin production.