El área de superficie corporal: un factor predictor de conversión en cirugía colorrectal laparoscópica

Antecedentes: El área de superficie corporal es una medida usada en el entorno clínico. Su impacto en la cirugía colorrectal laparoscópica no ha sido estudiado previamente. Objetivo: Evaluar el impacto de la superficie corporal sobre la tasa de conversión y el tiempo operatorio en cirugía laparoscópica. Diseño: Análisis retrospectivo de datos recogidos prospectivamente. Marco: Una sola institución de atención terciaria. Pacientes: Fueron identificados 916 pacientes consecutivos operados entre enero de 2004 y agosto de 2011, incluidos en una base de datos completada en forma prospectiva. Principales medidas de resultado: Se analizaron la tasa de conversión y el tiempo operatorio laparoscópico en relación a la edad, el género, la obesidad, la localización de la enfermedad (colon vs recto), el tipo de enfermedad (neoplásica vs no neoplásica), el antecedente de cirugías previas, y la superficie corporal; el área de superficie corporal se calculó mediante la fórmula de Mosteller. El área de superficie corporal se analizó utilizando la mediana, y cuartilos con valores de corte de 1.6; 1.8 y 2.0. Se utilizó la regresión logística para analizar la asociación entre el área de superficie corporal y la tasa de conversión, ajustada por diferentes factores. Se investigó la interacción entre la superficie corporal y el índice de masa corporal, pero no fue constatada. Resultados: La tasa de conversión global fue del 10%. La mediana del área de superficie corporal fue de 1.84 m² (rango: 1.14- 2.53). Las tasas de conversión de los cuartiles 1, 2, 3 y 4 fueron: 4.4%, 8.3%, 12.7% y 14.8%, respectivamente, p=0.001. Los pacientes con superficie corporal > 1.8 m²(N = 503) tuvieron una tasa de conversión más alta que los de superficie corporal < 1.8 m²(N=413) [13.8% vs 6.3%, respectivamente, OR: 2.35 (IC 95%: 1.45-3.86, p=0.0001)]. El análisis multivariado mostró que el área de superficie corporal > 1.8m² se asoció a la conversión (OR: 2, 95% Cl: 1.1-3.7, p=0.023) después de ajustar por sexo, edad, obesidad, localización de la patología (recto vs colon), tipo de abordaje laparoscópico y antecedente de cirugías previas. Limitación: se trata de un estudio retrospectivo realizado en una sola institución. Conclusión: El área de superficie corporal es un buen predictor de la conversión; debe ser incluido como parte de los futuros estudios sobre los resultados de la cirugía colorrectal laparoscópica, como información a los pacientes, cuando se seleccionan casos al inicio de la curva de aprendizaje, y al determinar el estándar de calidad de atención.(AU)

Background: Body surface área is a measurement used in clinical settings. Its impact on laparoscopic colorectal surgery has not been previously studied. Objective:To assess the impact of body surface área on conversión rate. Design: Retrospective analysis of prospectively collected data. Setting: Single tertiary care institution. Patients: 916 consecutive patients operated on between January 2004 and August 2011 were identified from a prospectively datábase. Main outcome measures: Conversión rate was analyzed related to age, gender, obesity, disease location (colon vs. rectum), type of disease (neoplastic vs. non-neoplastic), history of previous surgery, and body surface área; body surface área was calculated by Mosteller formula. Body surface área was analyzed using median and quartiles cut off valúes (1.6, 1.8 and 2.0). Logistic regression was used to analyze the association between body surface área and conversión, adjusting for different confounders. Interaction between body surface área and body mass Index was checked and not found. Results: Overall conversión rate was 10%. Median body surface área was 1.84 (range: 1.14-2.53).Conversión rates for quartiles 1, 2, 3 and 4 were: 4.4%, 8.3%, 12.7%, and 14.8%, respectively, p = 0.001. Patients with body surface área > 1.8 (N=503) had a higher conversión rate than those with body surface área < 1.8 (N=413) [13.8% vs 6.3%, respectively, OR: 2.35 (95% Cl: 1.45-3.86; p=0.0001)j. Multivariate analysis showed that body surface área > 1.8 was associated with conversión (OR: 2, 95% Cl: 1.1-3.7, p=0.023) after adjusting for gender, age, and previous surgery. ROC analysis of body surface área showed an área under the curve of 0.62. Body surface área > 1.8 had a sensitivity and specificity of 76% and 48% respectively. Limitation: This was a single institution retrospective study. Conclusión: Body surface área is a good predictor for conversión and should be included as part of future studies on outcomes for laparoscopic colorectal surgery.(AU)

El área de superficie corporal: un factor predictor de conversión en cirugía colorrectal laparoscópica

Antecedentes: El área de superficie corporal es una medida usada en el entorno clínico. Su impacto en la cirugía colorrectal laparoscópica no ha sido estudiado previamente. Objetivo: Evaluar el impacto de la superficie corporal sobre la tasa de conversión y el tiempo operatorio en cirugía laparoscópica. Diseño: Análisis retrospectivo de datos recogidos prospectivamente. Marco: Una sola institución de atención terciaria. Pacientes: Fueron identificados 916 pacientes consecutivos operados entre enero de 2004 y agosto de 2011, incluidos en una base de datos completada en forma prospectiva. Principales medidas de resultado: Se analizaron la tasa de conversión y el tiempo operatorio laparoscópico en relación a la edad, el género, la obesidad, la localización de la enfermedad (colon vs recto), el tipo de enfermedad (neoplásica vs no neoplásica), el antecedente de cirugías previas, y la superficie corporal; el área de superficie corporal se calculó mediante la fórmula de Mosteller. El área de superficie corporal se analizó utilizando la mediana, y cuartilos con valores de corte de 1.6; 1.8 y 2.0. Se utilizó la regresión logística para analizar la asociación entre el área de superficie corporal y la tasa de conversión, ajustada por diferentes factores. Se investigó la interacción entre la superficie corporal y el índice de masa corporal, pero no fue constatada. Resultados: La tasa de conversión global fue del 10%. La mediana del área de superficie corporal fue de 1.84 m² (rango: 1.14- 2.53). Las tasas de conversión de los cuartiles 1, 2, 3 y 4 fueron: 4.4%, 8.3%, 12.7% y 14.8%, respectivamente, p=0.001. Los pacientes con superficie corporal > 1.8 m²(N = 503) tuvieron una tasa de conversión más alta que los de superficie corporal < 1.8 m²(N=413) [13.8% vs 6.3%, respectivamente, OR: 2.35 (IC 95%: 1.45-3.86, p=0.0001)]. El análisis multivariado mostró que el área de superficie corporal > 1.8m² se asoció a la conversión (OR: 2, 95% Cl: 1.1-3.7, p=0.023) después de ajustar por sexo, edad, obesidad, localización de la patología (recto vs colon), tipo de abordaje laparoscópico y antecedente de cirugías previas. Limitación: se trata de un estudio retrospectivo realizado en una sola institución. Conclusión: El área de superficie corporal es un buen predictor de la conversión; debe ser incluido como parte de los futuros estudios sobre los resultados de la cirugía colorrectal laparoscópica, como información a los pacientes, cuando se seleccionan casos al inicio de la curva de aprendizaje, y al determinar el estándar de calidad de atención.

Background: Body surface área is a measurement used in clinical settings. Its impact on laparoscopic colorectal surgery has not been previously studied. Objective:To assess the impact of body surface área on conversión rate. Design: Retrospective analysis of prospectively collected data. Setting: Single tertiary care institution. Patients: 916 consecutive patients operated on between January 2004 and August 2011 were identified from a prospectively datábase. Main outcome measures: Conversión rate was analyzed related to age, gender, obesity, disease location (colon vs. rectum), type of disease (neoplastic vs. non-neoplastic), history of previous surgery, and body surface área; body surface área was calculated by Mosteller formula. Body surface área was analyzed using median and quartiles cut off valúes (1.6, 1.8 and 2.0). Logistic regression was used to analyze the association between body surface área and conversión, adjusting for different confounders. Interaction between body surface área and body mass Índex was checked and not found. Results: Overall conversión rate was 10%. Median body surface área was 1.84 (range: 1.14-2.53).Conversión rates for quartiles 1, 2, 3 and 4 were: 4.4%, 8.3%, 12.7%, and 14.8%, respectively, p = 0.001. Patients with body surface área > 1.8 (N=503) had a higher conversión rate than those with body surface área < 1.8 (N=413) [13.8% vs 6.3%, respectively, OR: 2.35 (95% Cl: 1.45-3.86; p=0.0001)j. Multivariate analysis showed that body surface área > 1.8 was associated with conversión (OR: 2, 95% Cl: 1.1-3.7, p=0.023) after adjusting for gender, age, and previous surgery. ROC analysis of body surface área showed an área under the curve of 0.62. Body surface área > 1.8 had a sensitivity and specificity of 76% and 48% respectively. Limitation: This was a single institution retrospective study. Conclusión: Body surface área is a good predictor for conversión and should be included as part of future studies on outcomes for laparoscopic colorectal surgery.

Fístulas enterocutáneas: manejo clínico y tratamiento sistema de vacío y compactación / Cutaneous Fistula: clinical management and treatment of compaction by vacuum

Antecedentes: las fístulas enterocutáneas se definen como una comunicación patológica entre la luz de una víscera y la piel, existiendo generalmente un trayecto fistulosode longitud variable. 1Entre el 75% y 85% de las fístulas digestivas adquiridas, son postoperatorias. 2El objetivo final en el tratamiento de esta patología es restablecer el tránsito intestinal. 2.4Objetivos: demostrar la aplicabilidad del sistema y analizar los resultados obtenidos con nuestra experiencia.Lugar de aplicación: Hospital público de alta complejidad.Diseño: Retrospectivo, descriptivo.Material y Método: 10 pacientes con fístulas enterocutáneas postoperatorias tratados con Sistema de Vacío y Compactación (SIVACO)Resultados: Todos los pacientes disminuyeron el débito luego de implementar el SIVACO, el 80% toleró satisfactoriamente la ingesta oral y mostró un incremento significativo en la curva de albuminemia, y el 100% de las lesiones dérmicas curaron. Todos lograron la movilización activa, y el 40% pudo completar la deambulación.Conclusiones: El SIVACO se asocia con una rápida reepitelización, aceleración del desarrollo del tejido de granulación, temprana curación de lesiones dérmicas perifístulosas y disminución del débito fístuloso entre otras cosas, situación que optimiza el estado general del paciente y lo prepara para la cirugía, u otorga confort y mejor calidad de vida a pacientes terminales. 3.5.

Síndrome de Hamman, revisión bibliográfica y presentación de un caso / Hamman syndrome, literature review and case report

Introducción: El neumomediastino se define como la presencia de aires en el espacio mediastinito. Desde su introducción en la literatura por Hamman se ha podido determinar su origen en la lesión alveolar por barotrauma. Generalmente tiene un curso benigno afectando a hombres entre los 20-30 años de edad.Objetivo: Revisión bibliográfica y presentación de caso.Lugar de aplicación: Hospital polivalente de alta complejidad.Caso Clínico: Varón de 22 años que consulta por dolor en hemotórax derecho, alteración del tono de vos y enfisema subcutáneo cervical. Al examen físico se constata signo de Hamman. Se solicita radiografía de tórax haciéndose diagnóstico de neumomediastino. Se instaura tratamiento médico con buena evolución sin requerir tratamiento quirúrgico.Discusión: El neumomediastino es una patología poco frecuente de curso generalmente benigno. Su diagnóstico obliga a descartar otras causas como la perforación esofágica o lesión del árbol traqueobronquial. Su tratamiento implica medidas de sostén y en algunos casos oxígeno a altas dosis, reservando el tratamiento quirúrgico a las complicaciones como el taponamiento cardíaco o neumotórax hipertensivo.

Baclofen treatment in Tourette syndrome: a double-blind, placebo-controlled, crossover trial.

OBJECTIVE: To investigate the effectiveness of baclofen for the treatment of tics in children with Tourette syndrome (TS). BACKGROUND: Baclofen, which contains both gamma-aminobutyric acid (GABA) and phenylethylamine moieties, was suggested in an open-label protocol to be an effective treatment for TS. This is a double-blind, placebo-controlled study to investigate this medication in children with TS. METHODS: Subjects received, in a randomized sequence, 4-week medication cycles of baclofen (20 mg three times daily) and placebo with a 2-week intervening washout period between the cycles. Outcome measures included the Clinical Global Impression (CGI) scale, and the Yale Global Tic Severity Scale (YGTSS), the latter including subscales for total tics and overall impairment. Measures were assessed at baseline and on days 28, 42, and 70 of the study. RESULTS: Ten children (seven boys and three girls, aged 8 to 14) with TS participated. Nine subjects completed the protocol; one dropped out for psychosocial reasons. No major side effects were reported. The mean change in CGI score (-0.9) after 4 weeks of baclofen treatment as compared with placebo treatment showed a significant improvement (95% CI, -1.7 to -0.1; p = 0.04). All subjects showed some amelioration in total YGTSS score during baclofen treatment. The mean change in total YGTSS score (-14.7) approached significance (95% CI, -30.3 to 0.9; p = 0.06). Examination of differences between baclofen and placebo treatment groups expressed as a percent change from baseline showed that baclofen had a statistically significant effect on both outcome measures. Subscales of the YGTSS showed that the reduction in total tic scores was primarily due to a reduction in the impairment score rather than a decrease in tics. CONCLUSIONS: Children with TS may benefit from treatment with baclofen, although improvements may be related to factors other than tics. Larger studies directly comparing baclofen against other tic-suppressing agents are recommended.

Subcortical volumes in girls with tourette syndrome: support for a gender effect.

OBJECTIVE: To test whether girls with Tourette syndrome (TS) show subcortical morphology that differentiates them from control subjects. METHODS: MRI-based subcortical assessment was completed on 19 girls with TS age 7 to 15 years, 11 with TS only, and 8 with TS plus attention deficit hyperactivity disorder (TS + ADHD), and on 21 age- and sex-matched controls. The structures measured were the caudate, putamen, globus pallidus, and lateral ventricle volumes. Whole-brain-corrected volumes and asymmetry indices were compared using two- and three-group designs (i.e., TS versus control; TS-only versus TS + ADHD versus control). RESULTS: Two-group comparisons demonstrated no robust significant differences between girls with TS and gender-matched controls. Three-group comparisons demonstrated that TS-only subjects had significantly small lateral ventricles compared with TS + ADHD and control subjects. Because the two-group comparisons of the current study differed from previous reports of putamen asymmetry index as a marker for TS, retrospective comparisons with data from boys were performed. These additional comparisons showed that girls with TS had putamen asymmetry indices similar to those of boys with TS; however, control girls also showed those same patterns. CONCLUSIONS: Basal ganglia volume and asymmetry differences do not distinguish the girls with TS from matched controls. Gender differences confound the association between putamen asymmetry and TS. Although the numbers are small and the clinical significance is unclear, this study further indicates that girls with TS-only have smaller lateral ventricular volumes than control subjects and those with TS + ADHD.

Infection: a stimulus for tic disorders.

The object of this study was to investigate the potential association of infections, especially group A hemolytic streptococcal infection, with the abrupt onset/exacerbation of tics or obsessive-compulsive behaviors. A structured clinical interview was used to evaluate 80 consecutive children, 5-17 years of age, with a diagnosis of tic disorder. Forty-two patients (53%) described a sudden, explosive onset or worsening of tic symptoms; 15 of these 42 had their exacerbation historically associated with an infection, nine of the 15 specifically with a streptococcal infection. Comparisons between those nine individuals and the remainder of the study population are presented. The results of this study reveal that descriptions of an abrupt tic onset or exacerbation are not uncommon in children with tic disorders; approximately 11% of children with tic disorders described abrupt changes of tic behavior within a 6-week period after a streptococcal infection.

Antibodies against a neuron-like (HTB-10 neuroblastoma) cell in children with Tourette syndrome.

BACKGROUND: Similar to the model for Sydenham's chorea, antineuronal antibodies (ANAb), which develop in response to a preceding streptococcal infection, have been speculated to have a role in the development of Tourette syndrome (TS). METHODS: Serum antibodies against the neuron-like HTB-10 neuroblastoma cell were assayed by ELISA methods and Western blot analysis on 41 children with TS (mean age 11.3 years) and 39 control subjects (mean age 12.1 years). RESULTS: Group comparisons of ELISA assay optical density (OD) showed that mean OD values for serum antibodies were not different [control (mean +/- SEM), .506 +/- .076; and TS, .584 +/- .053 (p = .38)]. In contrast, median values [.353 in control subjects and .477 in TS subjects (p = .012)] were significantly different. Western blots identified numerous bands in all TS and control sera with no difference in identified HTB-10 antigens. There was no relationship between the presence of ANAb and age of tic onset, family history, tic severity, attention deficit hyperactivity disorder, or obsessive compulsive disorder. No relationship existed between positive strep titers (ASO > or = 166 and/or antiDNAaseB > or = 170) and ANAb determinations or the severity of tics. CONCLUSIONS: Children with TS have higher median, but not mean, levels of ANAb, as measured by the HTB-10 neuroblastoma cell membrane assay. This assay system identified antibodies in both control and clinical groups and failed to identify a relationship between antibodies and clinical phenotype or one-time markers for streptococcal infection. Further studies are required to define a possible immune-mediated hypothesis for TS.

Antibodies against human putamen in children with Tourette syndrome.

BACKGROUND: Similar to the model for Sydenham's chorea, antineuronal antibodies, which develop in response to a preceding streptococcal infection, have been speculated to have a role in the development of Tourette syndrome (TS). METHODS: Serum antibodies against human caudate, putamen, and globus pallidus (interna and externa) were assayed by enzyme-linked immunosorbent assay (ELISA) and Western blot techniques and results were correlated with clinical characteristics and markers of streptococcal infection. SUBJECTS: A total of 41 children with TS (mean age, 11.3 years) and 39 controls (mean age, 12.1 years) were included. RESULTS: Compared with controls, TS subjects had a significant increase in the mean (p=0.006) and median (p=0.002) ELISA optical density (OD) levels of serum antibodies against putamen, but not caudate or globus pallidus. Western blots on 20 control and 20 TS serum samples showed that specific antibodies to caudate/putamen occurred more frequently in TS subjects at 83, 67, and 60 kDa; antigens were present in a synaptosomal fraction. TS subjects with a positive family history of tics had higher OD values (p < or = 0.04), but no association was shown with age of tic onset, tic severity, sudden onset of tics, or presence of attention-deficit hyperactivity disorder or obsessive-compulsive disorder. Risk ratio calculations in TS and control groups and in study subjects dichotomized for high and low putamen OD values were similar for titers of antistreptolysin O > or = 166 or antideoxyribonuclease B > or = 170. A subgroup analysis limited to subjects with elevated streptococcal titers, however, showed a significantly (p < or = 0.004) larger number of TS subjects with elevated OD levels. CONCLUSION: Children and adolescents with TS had significantly higher serum levels of antineuronal antibodies against putamen than did controls, but their relation to clinical characteristics and markers for streptococcal infection remains equivocal.

Antiphospholipid antibodies: an epiphenomenon in Tourette syndrome.

Antiphospholipids (aPLAs) have been previously identified in children with Tourette syndrome (TS), which has led to the speculation that these antibodies might have a pathophysiologic role in this disorder. Therefore, 21 healthy children and adolescents with TS, whose ages ranged from 7 to 17 years, underwent laboratory studies designed to diagnose the lupus anticoagulant, anticardiolipin (aCL) antibodies [immunoglobulin (Ig) G, IgA, and IgM], and antinuclear antibodies. Although five subjects had at least one value that differed from accepted laboratory standards, the changes were marginal in four of them. Lupus anticoagulant was identified in one patient, based on a minimal requirement of a prolonged dilute Russell viper venom time, clotting studies that did not correct after mixture with normal plasma, and an abnormal platelet neutralization procedure. A prolonged (but correctable) activated partial thromboplastin time was found in one individual, and aCL IgG was marginally increased in three subjects. Two (10%) of a control population of 20 same-age children also had low positive aCL IgG levels. There were no differences in tics (onset, type, frequency, severity, and family history) or comorbid features between children with normal or "abnormal" laboratory study results. Our data suggest that the presence of aPLAs in TS represents an epiphenomenon rather than a pathophysiologic mechanism.

Hypoxic sensitizer and cytotoxin for head and neck cancer.

Tumour hypoxia is well recognised as a major factor contributing to radioresistance. This article examines the role of hypoxia in influencing the treatment outcome following radiotherapy (RT), and reviews the rationale and results of clinical trials that utilise hypoxic sensitizers or cytotoxins in the treatment of head and neck carcinoma. Histologic evidence for tumour hypoxia in human neoplasms was first reported in 1955. Since then, direct measurement by microelectrodes has revealed heterogeneity in intratumoural oxygen concentrations, and low oxygen concentrations are associated with poor local-regional control by RT. These findings coupled with the result of nuclear imaging studies employing radiolabelled imidazoles, provide strong evidence for the existence of tumour hypoxia which influences RT treatment outcome. Hyperbaric oxygen (HBO) trials for head and neck cancer, conducted in the early 1970s, demonstrated that HBO improved local control and survival rates in patients with head and neck cancer receiving radiotherapy (RT). Since the mid-1970s, clinical research in overcoming tumour hypoxia was mainly centred on the use of nitro-imidazoles as hypoxic cell sensitizers. However, the results from several major clinical trials remain inconclusive. Specifically, the Radiation Therapy Oncology Group (RTOG) misonidazole head and neck trial (298 patients) showed no benefit. The Danish misonidazole trial (626 patients) showed no overall benefit, however positive results were observed in a subgroup (304 pharyngeal cancer patients). Although the European Organisation for Research and Teaching of Cancer (EORTC) misonidazole trial with hyperfractionated RT showed no benefit, the Danish nimorazole trial demonstrated an overall benefit in survival as well as local control. The European etanidazole (ETA) trial (374 patients) showed no advantage of adding the drug to RT. The RTOG ETA trial (504 patients) showed no global benefit. However, positive results were observed in a subset of patients with early nodal disease (197 patients). In addition, a recent meta-analysis by Overgaard, utilising pooled results in the literature demonstrated that modification of tumour hypoxia significantly improved local-regional control in head and neck cancers with an odds ratio of 1.23 (95% confidence limits 1.09 to 1.37). Hypoxic cytotoxins, such as tirapazamine, represent a novel approach in overcoming radioresistant hypoxic cells. Tirapazamine is a bioreductive agent which, by undergoing one electron reduction in hypoxic conditions, forms cytotoxic free radicals that produce DNA strand breaks causing cell death. In vitro and in vivo laboratory studies demonstrate that tirapazamine is 40 to 150 times more toxic to cells under hypoxic conditions as compared to oxygenated conditions and that tirapazamine is superior to ETA in enhancing fractionated irradiation in mouse SCCVII and other tumour types with an enhancement ratio of 1.5 to 3.0. Phase I studies demonstrated that therapeutic doses of tirapazamine can be given safely. A multi-institutional phase II trial using tirapazamine with concurrent RT for head and neck cancer is now in progress.

Nursing care of the patient with trismus.

This paper discusses trismus (mandibular hypomobility), addressing its etiologies, relevant anatomy and pathophysiology, with the medical and nursing care of trismic patients commonly seen in the otolaryngology setting. It aims to raise awareness among ORL nurses about the sometimes subtle presentation of trismus and about the important role ORL specialists can play in detecting and treating this debilitating disorder.

A peer education program to promote the use of conflict resolution skills among at-risk school age males.

Violence is devastating the lives of children in America's major cities. The problem of violence is particularly acute among disadvantaged young urban males. This program focuses on violence prevention in school-age boys using creative educational techniques and community partnership. The goal of this school-based program is to decrease the incidence of violent episodes in the school by teaching conflict resolution skills. Conflict resolution skills are taught in the health education component of the school health program. Skills are taught using a peer education model supervised by the school health nurse and planned in partnership with a Violence Prevention Advisory Board. Peer education teams consisting of fifth and sixth grade boys are trained and serve as peer educators for the boys in grades K-4. The violence prevention peer education program stresses primary prevention and targets at-risk school age males. The proposal uses a model that promotes the development of student leadership skills and self esteem. The proposal suggests ways to promote school and community involvement using an advisory board made up of student, community, and school leaders. The peer education program is cost effective and demonstrates how existing resources can be used creatively within the school setting.