Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study.

BACKGROUND AND AIMS: Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures. METHODS: Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator. RESULTS: A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity. CONCLUSIONS: This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Laparoscopic aproach in post-traumatic chylous ascites.

Chylous ascites is a rare condition little reported in literature, with even more exceptional traumatic origin. Its production mechanism is not known exactly but has been attributed to hyperflexion or hyperextension of the spine leading to a rupture of lymph ducts. We present a case of post-traumatic chyloperitoneum in a young patient after abdominal blunt trauma. Conservative treatment should be the first therapeutic option, especially if the origin is traumatic, reserving more aggressive possibilities for cases that do not respond after 15 days, if debt is greater than 1.5 litres/day in adult patients or in those with metabolic complications. A laparoscopic approach is indicated to confirm the diagnosis and to rule out other associated injuries that may require other surgical procedures.

Breast cancer: determining the genetic profile from ultrasound-guided percutaneous biopsy specimens obtained during the diagnostic workups. / Cáncer de mama: determinación del perfil genético a partir de la biopsia percutánea ecoguiada diagnóstica.

OBJECTIVES: To evaluate the possibility of determining the genetic profile of primary malignant tumors of the breast from specimens obtained by ultrasound-guided percutaneous biopsies during the diagnostic imaging workup. MATERIAL AND METHODS: This is a retrospective study in 13 consecutive patients diagnosed with invasive breast cancer by B-mode ultrasound-guided 12 G core needle biopsy. After clinical indication, the pathologist decided whether the paraffin block specimens seemed suitable (on the basis of tumor size, validity of the sample, and percentage of tumor cells) before sending them for genetic analysis with the MammaPrint® platform. RESULTS: The size of the tumors on ultrasound ranged from 0.6cm to 5cm. In 11 patients the preserved specimen was considered valid and suitable for use in determining the genetic profile. In 1 patient (with a 1cm tumor) the pathologist decided that it was necessary to repeat the core biopsy to obtain additional samples. In 1 patient (with a 5cm tumor) the specimen was not considered valid by the genetic laboratory. The percentage of tumor cells in the samples ranged from 60% to 70%. In 11/13 cases (84.62%) it was possible to do the genetic analysis on the previously diagnosed samples. CONCLUSION: In most cases, regardless of tumor size, it is possible to obtain the genetic profile from tissue specimens obtained with ultrasound-guided 12 G core biopsy preserved in paraffin blocks.

El radiólogo invisible: ¿causa o efecto? / The invisible radiologist: Cause or effect?

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¿Cómo evitar problemas médico-legales en la radiología de la mama? / How can we avoid legal problems in breast imaging?

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Abnormal mammography and sonography associated with foreign-body giant-cell reaction after stereotactic vacuum-assisted breast biopsy with carbon marking.

BACKGROUND: Carbon marking of the biopsy site and needle track following stereotactic breast biopsy in nonpalpable mammography-detected lesions provides for safe and accurate localization for subsequent surgical excision. No significant complications of carbon marking have been reported to date. PURPOSE: To report follow-up imaging findings and histological changes (foreign-body giant-cell reaction) attributable to the use of carbon marking after vacuum breast biopsies. MATERIAL AND METHODS: This was a retrospective study of 130 patients in a mammographic screening program with nonpalpable suspicious breast lesions that were referred for stereotactic directional vacuum-assisted breast biopsy with carbon marking. Histological diagnosis was benign in all cases, but 1-year follow-up mammograms demonstrated suspect findings in four of them. RESULTS: For all four patients, the results of the initial stereotactic vacuum-assisted biopsy were benign, but mammographic follow-up and ultrasound findings revealed suspicious changes that, in all cases, were histologically shown to be foreign-body giant-cell reactions attributable to the use of carbon. CONCLUSION: In four of 130 lesions (3%) that were carbon marked following stereotactic vacuum-assisted breast biopsy, and in which surgical excision was not required, the mammographic and ultrasound follow-up appearance of the breast simulated malignancy. The abnormality was attributable to the use of carbon, which represents a potential source of misdiagnosis.

Benign adenomyoepithelioma of the breast: imaging findings mimicking malignancy and histopathological features.

Adenomyoepithelioma of the breast is a rare neoplasm. We present a case of a benign adenomyoepithelioma of the breast in an asymptomatic 60-year-old woman. This report illustrates the mammogram, ultrasound, and magnetic resonance appearances of this unusual lesion, with histopathological correlation.

Usefulness of MRI in detecting occult breast cancer associated with Paget's disease of the nipple-areolar complex.

MRI allows for the detection of mammographically and clinically occult breast neoplasms. We analysed the ability of MRI to detect occult breast cancer in three patients with Paget's disease of the nipple-areolar complex, proven histologically. In all three cases we observed differences in the morphological and dynamic features of healthy and pathological nipples, and we also found enhancement foci in breast tissue, with suspicious kinetic and morphological characteristics, which in the case of two patients corresponded to ductal carcinoma in situ. The detection and location with MRI of underlying neoplastic foci may be of help in choosing the most reasonable and conservative treatment in these patients.

[Bioenergetic radiographic absorptiometry in hemodialysis]. / Absorciometría radiográfica bienergética en hemodiálisis.

UNLABELLED: In order to assess bone loss in uremic renal osteodystrophy (URO), we have measured total and regional mineral bone density (TMBD and RMBD, respectively) by using bioenergetic radiographic absorptiometry (BRA) in a population of patients on hemodialysis (HD). Thirty one patients have been evaluated, with a mean age of 55 and a mean time on hemodialysis of 31 mo. (range 2-120 mo.). Bone absorptiometry consisted of measurement of total body (TMBD) and regional analysis of head, upper limb, lower limb, ribs, pelvis and spine (RMBD). TMBD inversely correlated with alkaline phosphatase and parathyroid hormone levels; it also correlated inversely with age, but only in females. TMBD showed significantly lower values in HD patients than in chronic renal failure patients and controls. All the regional parameters correlated inversely with alkaline phosphatase levels. CONCLUSION: BRA is a non invasive method which quantifies TMBD and RMBD with a very low radiologic exposure and correlates adequately with levels of alkaline phosphatase and parathyroid hormone in URO. TMBD measures total cortical bone of the skeleton with good accuracy, RMBD allows a selective analysis of regional bone changes and a evolutive control in these patients, given the nonuniform decrease of mineral density in the skeleton.

Bouveret's syndrome: new cause of double-arch-shadow sign in cholecystosonography.

A case of Bouveret's syndrome which later presented as a jejunal obstruction is reported. Special reference is made to the echographic findings. Bouveret's syndrome has a double-arch-shadow image in the zone of the gallbladder bed on ultrasound examination. So far, this sign has been considered specific for gallstones inside the gallbladder.