Face Mask and Tear Film Stability: A Pilot Study of the Objective Measurement of Tear Break-Up Time.

(1) Background: Mask-associated dry eye (MADE) has been associated with increased dry eye symptoms, apparently due to reduced tear break-up time (TBUT). This study aimed to determine the short-term impact of surgical face mask (FM) on tear film stability by measuring non-invasive tear break-up time (NIBUT). (2) Methods: Twenty-six healthy participants had NIBUT evaluated without FM, with surgical FM and with a surgical FM secured to the skin with adhesive tape (TFM). NIBUT-first was measured with Keratograph 5M (K5M, Oculus, Wetzlar, Germany). Each participant had NIBUT measured in four sessions on four consecutive days. Session 1: without FM vs. with FM. Session 2: with FM vs. without FM. Session 3: without FM vs. with TFM. Session 4: with TFM vs. without FM (3). The time between each measured setting was 2 min. Results: The mean ± SD NIBUT without FM was 8.9 ± 3.7, with FM 10.2 ± 4.1, and with TFM 8.4 ± 3.8 s. No significant differences were observed in NIBUT in any of the evaluated settings: without FM vs. with FM (p = 0.247), without FM vs. with TFM (p = 0.915), and with FM vs. with TFM (p = 0.11). (4) Conclusions: This study did not find a significant short-term effect of FM on NIBUT. Other variables or longer periods of exposure might trigger the symptoms and ocular surface alterations in MADE.

Reduced corneal endothelial cell density after toxic anterior segment syndrome (TASS) caused by inadvertent intraocular ointment migration: A case report.

INTRODUCTION AND IMPORTANCE: Toxic anterior segment syndrome (TASS) is an acute sterile inflammation of the anterior segment which may occur after surgery. This case presents endothelial cell density (ECD) loss due to months of TASS caused by intraocular migration of ocular ointment. The chronicity of this case and the clinical consequences are rare in the literature. CASE PRESENTATION: A Colombian 71-year-old man developed TASS secondary to intraocular ointment migration after uneventful cataract surgery with phacoemulsification and intraocular lens placement in the capsular bag. The main complaint for the patient was a chronic red eye, no pain or visual disturbance were reported, rheumatologic diseases were discarded. It was documented the presence of intraocular ointment in the anterior chamber, over the iris and in the anterior chamber angle. The ECD was reduced secondary to TASS and the long-term presence of ointment moving in the anterior chamber, so it had to be removed. CLINICAL DISCUSSION: It is important to avoid using ocular ointment after intraocular surgeries to avoid the risk of ointment migration into the anterior chamber. Intraocular ointments should be removed promptly to reduce ECD loss as documented in the present case report in which after ointment elimination ECD remains stable for 7 years. CONCLUSION: Topical ointments should not be used after routine cataract surgery because of the risk of intraocular ointment migration and subsequent risk of developing TASS and reduced ECD.

Relationship of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratio With Visual Acuity After Surgical Repair of Open Globe Injury.

Purpose: To assess the relationship and prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with poor final best-corrected visual acuity (BCVA) after surgical repair of open globe injuries (OGI) in adults. Design: Retrospective analysis of data from an ongoing prospective cohort of consecutive patients. Methods: In a tertiary university hospital, 197 eyes of 197 patients were included between 2013 and 2017. NLR and PLR were obtained from pre-operative blood tests to analyze its relationship with poor final BCVA. Results: Severe visual impairment (SVI) was defined as ≤20/200, and was observed in 96 (48.7%) patients after surgical repair of OGI. SVI patients had higher NLR (7.4 ± 6.6 vs. 4.0 ± 3.2, p < 0.001), and PLR (167 ± 92 vs. 139 ± 64; p = 0.021) than non-SVI. NLR ≥ 3.47 and PLR ≥ 112.2 were the best cut-off values for SVI, were univariate risk factors for SVI, and had sensitivity: 69.0, 71.4, and specificity: 63.6, 44.8, respectively. In multivariate analysis, only OTS, athalamia, and hyphema remained as risk factors. NLR had significant correlation with ocular trauma score (OTS) (r = -0.389, p < 0.001) and final BCVA (r = 0.345, p < 0.001). Limitations: Simultaneous trauma in other parts of the body that could influence the laboratory findings. Conclusion: Patients with SVI after a repaired OGI had increased pre-operative NLR and PLR levels. High NLR and PLR are risk factors for SVI in univariate analysis. It is confirmed that low OTS is a risk factor for SVI. High NLR and PLR could be used as a prognostic tool to identify patients at higher risk for SVI after repair of OGI.

Split unilateral del nervio femoral a nivel del músculo psoas mayor: reporte de caso / Unilateral femoral nerve split at the psoas major muscle: case report

RESUMEN: El nervio femoral (NF) es el mayor o ramo del plexo lumbar. Normalmente se origina de las divisiones posteriores del segundo al cuarto ramo anterior del plexo lumbar (L2-L4). El músculo psoas mayor tiene su origen a nivel de las vértebras T12 a L5, se fusiona con el músculo ilíaco para luego insertarse en el trocánter menor del fémur. Normalmente, a nivel de la pelvis menor el NF se encuentra entre los músculos ilíaco y psoas mayor. En este trabajo presentamos un caso donde el músculo psoas mayor se relaciona con divisiones o split del NF, esta es una rara variación en la división y curso del NF con relación al músculo psoas mayor. Se observó que el NF se dividía en dos ramos por sobre el plano del ligamento inguinal después de su origen en el plexo lumbar. El NF del lado izquierdo se formó por las ramas ventrales de L2 a L4, a nivel de L5 el nervio es perforado por fascículos del músculo psoas mayor. La división inferior del NF pasaba profundamente a las fibras del músculo iliopsoas y la división superior pasaba superficialmente al músculo psoas mayor y profundo a la fascia ilíaca. Después de un trayecto de 60,21 mm ambas divisiones se unieron, después de atrapar fibras músculo iliopsoas justo inmediatamente proximal al ligamento inguinal para formar el tronco del NF. Si bien las causas embriológicas de las variaciones de los nervios periféricos se remontan a la quinta y sexta semana de vida intrauterina, la expresión clínica de disfunciones neuromusculares aparecerá varios decenios después. De modo que los médicos de las áreas de la traumatología y neurología deben estar al tanto de tales variantes anatómicas para entender mejor el dolor y los síndromes asociados a la compresión nerviosa y durante las maniobras quirúrgicas en esta región.

SUMMARY: AbstractThe femoral nerve (NF) is the major branch (or ramus) of the lumbar plexus. It normally originates from the posterior divisions of the second to fourth anterior branches of the lumbar plexus (L2-L4). The psoas major muscle originates at the level of the T12 to L5 vertebrae, fuses with the iliacus muscle and then inserts into the lesser trochanter of the femur. Normally, at the level of the lesser pelvis, the NF is found between the iliacus and psoas major muscles. In this paper we present a case where the psoas major muscle is related to divisions or splitting of the NF, this is a rare variation in the division and course of the NF in relation to the psoas major muscle. The NF was observed to divide into two branches above the plane of the inguinal ligament after its origin in the lumbar plexus. The NF on the left side was formed by ventral branches from L2 to L4, at the level of L5 the nerve is perforated by fascicles of the psoas major muscle. The lower division of the NF passed deep to the fibers of the iliopsoas muscle and the upper division passed superficial to the psoas major muscle and deep to the iliac fascia. After a path of 60.21 mm both divisions joined, after trapping iliopsoas muscle fibers just immediately proximal to the inguinal ligament to form the NF trunk. While the embryological causes of peripheral nerve variations date back to the fifth and sixth week of intrauterine life, the clinical expression of neuromuscular dysfunctions will appear several decades later. Thus, physicians in the areas of traumatology and neurology should be aware of such anatomical variants to better understand pain and syndromes associated with nerve compression and during surgical maneuvers in this region.

Determinación de la morfología del canal incisivo mandibular mediante tomografía computarizada de haz cónico (CBCT) en población de Valdivia, Chile / Determination of mandibular incisor canal morphology by cone beam computed tomography (CBCT) in a population of Valdivia, Chile

RESUMEN: El canal incisivo mandibular (MIC) es un canal neural que contiene una de las ramas inferiores del nervio alveolar inferior, llamado nervio incisivo mandibular, que puede resultar dañado durante intervenciones quirúrgicas y causar complicaciones postoperatorias. Estudio descriptivo de corte transversal. Se identificó el MIC en la imagen transversal del canino en 83 hemiarcadas. Se registró edad, sexo, hemiarcada, longitudes desde reborde alveolar vestibular de canino a MIC, cortical lingual y vestibular de canino a MIC, base mandibular de canino a MIC y ubicación del MIC (tercio lingual, medio, vestibular). Medidas se registraron en milímetros. Se aplicó test T-student para muestras independientes para variables de longitud y Chi-cuadrado para ubicación espacial del MIC, en relación con grupo etario y sexo. Se evaluó el MIC en todas las muestras (100 %). El MIC fue encontrado mayormente en el tercio medio mandibular (p <0,05). La media desde el MIC a la cortical lingual es de 5,25 mm ? 1,42 mm (derecho) y 5,24 mm ? 1,18 mm (izquierdo). La media desde el MIC a la cortical vestibular fue de 4,42 mm ? 1,29 mm (derecho) y 4,53 mm ? 1,24mm (izquierdo). La media entre centro del canal y reborde alveolar vestibular fue 18,89 mm ? 2,68mm (derecho) y 18,20 mm ? 3,06 mm (izquierdo), media desde centro del MIC al margen basal fue de 9,77 mm ? 1,93 (derecho) y 10,12 mm ? 1,92 mm (izquierdo). Se encontró mayor distribución del MIC en el tercio medio mandibular. Se identificó el MIC en el 100 % de las muestras a través de CBCT por lo que su uso como examen complementario debe ser considerado al planificar cirugías en el sector anterior mandibular.

SUMMARY: The objective of the study was to determine the morphology of the mandibular incisive canal (MIC) and its location using cone beam computed tomography (CBCT) in the population of Valdivia, Chile. Descriptive cross-sectional study. MIC was identified in the canine cross image in 83 quadrants. Age, gender, quadrants, length from buccal alveolar ridge of canine to MIC, lingual and buccal cortical of canine to MIC, mandibular base of canine to MIC, and location of MIC (lingual, middle and buccal third) were recorded. Measurements were recorded in millimeters. Independent sample Student-T test was performed to determine length variables and Chi-square test was performed to determine spatial location of MIC, in relation to age group and gender. MIC was evaluated in all samples (100 %). MIC was found mainly in the mandibular third quadrant (p < 0.05). The mean from the MIC to the lingual cortex is 5.25 mm ? 1.42 mm (right) and 5.24 mm ? 1.18 mm (left). The mean from the MIC to the buccal cortex was 4.42 ? 1.29 mm (right) and 4.53 mm ? 1.24 mm (left). The mean between the center of the canal and the buccal alveolar ridge was 18.89 mm ? 2.68mm (right) and 18.20 mm ? 3.06 mm (left), the mean from the center of the MIC to the basal edge was 9.77 mm ? 1.93 (right) and 10.12 mm ? 1.92 mm (left). A greater distribution of MIC was found in the mandibular third quadrant. MIC was identified in 100 % of the samples through CBCT, therefore, its use as a complementary examination should be considered when planning surgeries in the anterior mandibular area.

Multirresistencia, resistencia extendida y panresistencia a antibacterianos en el norte de México.

OBJETIVO: Describir el perfil de multirresistencia (MDR), resistencia extendida (XDR) y panresistencia (PDR) a antibacterianos en aislados de muestras de pacientes de un hospital privado de tercer nivel en el norte de México. MÉTODO: Se realizó un estudio retrospectivo durante el periodo comprendido de febrero de 2016 a abril de 2019. A partir de 156 muestras clínicas de orina, heridas, sangre, expectoración y otros fluidos se aislaron 166 bacterias; 10 de las muestras incluyeron dos microorganismos. Los microrganismos aislados se clasificaron en MDR, XDR o PDR. RESULTADOS: El 78% de los aislados gramnegativos y el 69% de los aislados grampositivos mostraron MDR, XDR o PDR. Staphylococcus epidermidis fue la bacteria grampositiva con multirresistencia más frecuentemente aislada. Escherichia coli y Klebsiella sp. se encontraron entre los gramnegativos MDR más frecuentes. En dos casos, los aislados clínicos de Pseudomonas aeruginosa procedentes de la unidad de cuidados intensivos neonatales mostraron PDR. CONCLUSIÓN: Los servicios de terapia intensiva, cirugía y unidad de cuidados intensivos neonatales merecen especial atención por la alta proporción de aislados MDR y la presencia de PDR a causa de P. aeruginosa. OBJECTIVE: To describe the profile of multidrug-resistance (MDR), extensively resistance (XDR) and pandrug-resistance (PDR) to antibacterial drugs in isolates from patient samples from a third level private hospital in the North of Mexico. METHOD: A retrospective study was carried out during the period from February 2016 to April 2019. From 156 clinical samples of urine, wounds, blood, expectoration and other fluids, 166 bacteria were isolated; 10 samples included two microorganisms. Isolated microorganisms were classified into MDR, XDR or PDR. RESULTS: 78% of the Gram negative and 69% of the Gram positive isolates showed MDR, XDR or PDR. Staphylococcus epidermidis was the most frequently isolated MDR Gram positive bacteria. Escherichia coli and Klebsiella sp. were among the most frequent MDR Gram negative. In two cases, the clinical isolates of Pseudomonas aeruginosa from the neonatal intensive care unit showed PDR. CONCLUSIONS: The intensive care, surgery and neonatal intensive care unit services deserve special attention due to the high proportion of MDR isolates and the presence of PDR due to P. aeruginosa.

Natural genetic transformation of Vibrio parahaemolyticus via pVA1 plasmid acquisition as a potential mechanism causing AHPND.

Vibrio parahaemolyticus is the causative bacterium of acute hepatopancreatic necrosis disease (AHPND) in white shrimp Litopenaeus vannamei. This bacterium secretes protein toxins whose genes are encoded in an auto-transmissible plasmid called pVA1. The presence of this plasmid in V. parahaemolyticus is determinant for disease development. Its propagation is not only linked to bacterial colonisation capacity but also to horizontal gene transfer mechanisms. Nevertheless, the active uptake of plasmid, which is known as natural genetic transformation (NGT), has not yet been proposed as a possible acquisition mechanism of the pVA1 plasmid among Vibrio species. Previous studies suggest that some Vibrio species have the ability to undergo NGT in the presence of chitin. Therefore, the objective of this study was to evaluate the induction of NGT mediated by chitin in V. parahaemolyticus (ATCC-17802) through its ability to incorporate and express the pVA1 plasmid. The results showed that a reference strain that does not initially contain the plasmid can incorporate the plasmid under the appropriate transformation conditions, and cause mortality in white shrimp similar to that observed for pathogenic strains isolated from infectious outbreaks. Given the management and conditions of a shrimp farm with large amounts of chitinous exoskeletons, it is feasible that NGT could be a possible acquisition mechanism of plasmid pVA1 among Vibrio species, turning a non-causative strain of V. parahaemolyticus into a causative strain. With this study, we have expanded the knowledge of the pathogenesis process mediated by NGT and the understanding of the possible propagation mechanisms of emerging diseases in the aquaculture sector.

Arteria subclavia derecha retroesofágica: reporte de caso / Right retroesophageal subclavian artery: case report

RESUMEN: Durante el desarrollo embrionario suelen ocurrir anomalías a nivel del arco aórtico primordial. Una de estas es la arteria subclavia retroesofágica derecha (ASDR) la cual es un defecto frecuente de los arcos aórticos embriológicos y se debe a la interrupción del cuarto arco aórtico (AO) derecho entre las depresiones para la arteria carótida común y la arteria subclavia. Las variaciones anatómicas y morfológicas del AO y sus ramas son significativas para los procedimientos diagnósticos y quirúrgicos en el tórax y el cuello. Reportar una ASDR encontrada durante disección, correlacionando esta con sus implicancias clínicas. De un cadáver de sexo femenino, de edad y causa de muerte desconocida, fijado con formaldehído al 10 % y aguada destilada. Se realizó disección del corazón y los grandes vasos, en especial el AO, desarrollado según la técnica convencional, para remover el órgano luego de disecar el pericardio y disecar la arteria aorta ascendente y el AO, preservando plenamente su configuración externa y sus ramas colaterales, donde se encontró la ASDR. La ASDR presentó un diámetro en su origen de 12,13 mm. La longitud existente entre la ASDR y la Arteria carótida común Derecha (ACCD) fue de 43,84 mm. El diámetro del esófago a nivel cefálico y caudal de la ASDR alcanzó valores de 17,59 mm y 13,82 mm respectivamente. Por su parte los diámetros de la tráquea a nivel cefálico y caudal a la ASDR, fueron respectivamente 22,12 mm y 13,30 mm. El conocimiento de esta variante anatómica resulta de gran interés a la hora de interpretar y orientar el diagnóstico de las posibles causas de una disfagia asociada a una arteria subclavia retroesofágica y fundamenta aún más la importancia del estudio mediante disección.

SUMMARY: During embryonic development, anomalies usually occur at the primordial aortic arch (AA) level. One of these is the right retroesophageal subclavian artery (RSA). The anatomical and morphological variations of AA and its branches are significant for diagnostic and surgical procedures in the thorax and neck. The objective of the study was to report an RSA found during the dissection, correlating this with the corresponding clinical implications. A human female cadaver of unknown age and cause of death was used and conserved in 10 % formaldehyde and distilled wash. The dissection of the heart and large vessels was performed. There was particular emphasis one the AA, and development according to conventional techniques, removing the organ after dissecting the pericardium and dissecting the ascending aorta and the AA. External function and its collateral branches were fully preserved, where the RSA was located. The RSA presented a diameter at its origin of 12.13 mm. The length between the RSA and the common right carotid artery (CRCA) was 43.84 mm. The diameter of the esophagus at the cephalic and caudal level of the RSA has values of 17.59 mm and 13.82 mm respectively. Furthermore, the diameters of the trachea at cephalic and caudal level to the RSA, respectively, were 22.12 mm and 13.30 mm. Knowledge of this anatomical variant is of great interest when interpreting and guiding the diagnosis of potential causes of a dysphagia associated with a retroesophageal subclavian artery, and is even more important during dissection studies.

Proactive measurements in the search of aortic aneurysms have an impact in the prevalence.

An abdominal aortic aneurysm is defined as a focal dilation greater than 50% of the normal diameter of the vessel. The prevalence in individuals older than 65 years is estimated between the 2 and 8% with a risk of rupture when the diameter >5.5 cm in men and 5 cm in women. The risk increases exponentially with the expansion of this aneurysmal sac, and if the rupture occurs, its mortality can achieve 80%. The pathogenesis and factors associated to the development and progression of this disease remain not fully understood and isolating the aneurysm from the circulation is the main therapeutic goal to eliminate the risk of rupture. Over the last decades, ultrasonographic screening programs have been implemented for its detection. In this article, we review the epidemiology, natural history of aneurysms and the relevance of ultrasonographic screening programs.

Un aneurisma aórtico abdominal se define como una dilatación focal mayor del 50% del diámetro normal del vaso. La prevalencia en los adultos mayores de 65 años se estima entre el 2 y el 8%, con un riesgo de rotura elevado cuando su diámetro es mayor de 5.5 cm en el sexo masculino y de 5 cm en el femenino. Este riesgo aumenta linealmente con el crecimiento del aneurisma, y de manifestarse la rotura, la mortalidad puede alcanzar hasta el 80%. La patogénesis y otros factores asociados al crecimiento y la progresión de esta enfermedad no se conocen con certeza, por lo que aislar el aneurisma de la circulación mediante cirugía abierta o endovascular es el objetivo terapéutico para el eliminar el riesgo de rotura. En las últimas décadas se han implementado programas de escrutinio ultrasonográfico para la detección. En el presente artículo hacemos una revisión de la literatura sobre la epidemiología, la evolución natural de los aneurismas y la relevancia de estos programas de escrutinio ultrasonográfico.

[Valor predictivo de la procalcitonina para la necesidad de cirugía y la presencia de isquemia y necrosis en pacientes con obstrucción del intestino delgado]. / Predictive value of procalcitonin for the need of surgery and the presence of ischemia and necrosis in patients with small bowel obstruction.

INTRODUCTION: The purpose of this prospective cohort study was to evaluate whether serum procalcitonin (PCT) levels predict the need for surgery and the presence of ischemia and/or necrosis (I/N) in small bowel obstruction. METHOD: Of 54 patients included, conservative management was performed in 31 (non-surgical group) and an exploratory laparotomy in 23 (surgical group). The reference value of the PCT was between 0.10 and 0.50 ng/mL. RESULTS: PCT levels were higher in the surgical group (7.05 ± 7.03 ng/mL) than in the non-surgical (0.37 ± 0.63 ng/mL), and in patients with I/N (10.06 ± 7.07 ng/mL) than without I/N (1.52 ± 1.45 ng/mL). In the ROC curve, the area under the curve was 0.91 for the need for surgery and 0.93 for I/N. PCT ≥ 0.80 ng/mL had the best sensitivity and specificity for surgery and ≥ 1.95 ng/mL for I/N. PCT was also an independent predictor for these events. CONCLUSIONS: The levels of PCT can recognize the need for surgery and the presence of I/N in small bowel obstruction. Additional studies are needed to affirm or invalidate our findings.

OBJETIVO: El propósito de este estudio de cohorte prospectivo fue evaluar si las concentraciones séricas de procalcitonina (PCT) predicen la necesidad de cirugía y la presencia de isquemia o necrosis (I/N) en la obstrucción del intestino delgado. MÉTODO: De 54 pacientes incluidos, se realizó manejo conservador en 31 (grupo no quirúrgico) y laparotomía exploradora en 23 (grupo quirúrgico). El valor de referencia de la PCT fue entre 0.10 y 0.50 ng/ml. RESULTADOS: Los valores de PCT fueron mayores en el grupo quirúrgico (7.05 ± 7.03 ng/ml) que en el no quirúrgico (0.37 ± 0.63 ng/ml), y en los pacientes con I/N (10.06 ± 7.07 ng/ml) que en aquellos sin I/N (1.52 ± 1.45 ng/ml). En la curva COR (Característica Operativa del Receptor), el área bajo la curva fue 0.91 para la necesidad de cirugía y 0.93 para la I/N. La PCT ≥ 0.80 ng/ml obtuvo las mejores sensibilidad y especificidad para una cirugía, y ≥ 1.95 ng/ml para I/N. La PCT también fue un predictor independiente para estos eventos. CONCLUSIONES: Los valores de PCT permiten reconocer la necesidad de cirugía y la presencia de I/N en la obstrucción del intestino delgado. Son necesarios estudios adicionales para reafirmar o invalidar nuestros hallazgos.

[Primary posterior perineal hernia associated with dolichocolon]. / Hernia perineal posterior primaria asociada a dolicocolon.

BACKGROUND: Primary posterior perineal hernias in men are rare. We report a case of this type of hernia associated with dolichocolon, a condition which, to our knowledge, has not been reported previously. CLINICAL CASE: A 71-year old male presenting with a perineal tumour of 40 years evolution. He had no history of perineal surgery or trauma. On physical examination, a lump of 4×3cm was observed in the right para-anal region, which increased in volume during the Valsalva manoeuvre. Computed tomography showed a defect in the pelvic floor, which was reconstructed using a roll of polypropylene mesh in the hernia defect. DISCUSSION: The case described is of interest, not only because a perineal hernia is a rare clinical entity, but also because repair using a roll of mesh has not been reported associated with a dolichocolon, which can be considered a factor risk for development. CONCLUSIONS: The surgical approach and repair technique of the pelvic floor for perineal hernias should be individualised. The use of mesh for reconstruction should always be considered. The presence of dolichocolon can contribute to the gradual development of a perineal hernia.

[Complicated diverticular disease debuting as necrotising fasciitis of pelvic limb. A case report]. / Enfermedad diverticular complicada iniciada como fascitis necrosante de miembro pélvico. Reporte de caso.

BACKGROUND: Diverticular disease, and the diverticulitis, the main complication of it, are widely studied diseases with multiple chronic cases reported in the literature, but there are no atypical presentations with extra-abdominal symptoms coupled with seemingly unrelated entities, such as necrotising fasciitis. CLINICAL CASE: Female 52 years old, was admitted to the emergency department with back pain of 22 days duration. History of importance: Chronic use of benzodiazepines intramuscularly. Physical examination revealed the presence of a gluteal abscess in right pelvic limb with discoloration, as well as peri-lesional cellulitis and crepitus that stretches across the back of the limb. Fasciotomy was performed with debridement of necrotic tissue. Progression was torpid with crackling in abdomen. Computed tomography showed free air in the cavity, and on being surgically explored was found to be complicated diverticular disease. DISCUSSION: It is unusual for complicated diverticular disease to present with symptoms extra-peritoneal (< 2%) and even more so that a diverticulitis is due to necrotising fasciitis (< 1%). The absence of peritoneal manifestations delayed the timely diagnosis, which was evident with the crackling of the abdomen and abdominal computed tomography scan showing the parietal gaseous process. CONCLUSION: All necrotising fasciitis needs an abdominal computed tomography scan to look for abdominal diseases (in this case diverticulitis), as their overlapping presentation delays the diagnosis and consequently the treatment, making a fatal outcome inevitable.

[Risk factors for nosocomial pneumonia in patients with abdominal surgery]. / Factores de riesgo para neumonía nosocomial en pacientes con cirugía abdominal.

BACKGROUND: The risk of post-operative pneumonia is a latent complication. A study was conducted to determine its risk factors in abdominal surgery. MATERIAL AND METHODS: A cross-sectional study was performed that included analysing the variables of age and gender, chronic obstructive pulmonary disease and smoking, serum albumin, type of surgery and anaesthesia, emergency or elective surgery, incision site, duration of surgery, length of hospital stay, length of stay in the intensive care unit, and time on mechanical ventilation. The adjusted odds ratio for risk factors was obtained using multivariate logistic regression. RESULTS: The study included 91 (9.6%) patients with pneumonia and 851 (90.4%) without pneumonia. Age 60 years or over (OR=2.34), smoking (OR=9.48), chronic obstructive pulmonary disease (OR=3.52), emergency surgery (OR=2.48), general anaesthesia (OR=3.18), surgical time 120 minutes or over (OR=5.79), time in intensive care unit 7 days or over (OR=1.23), time on mechanical ventilation greater than or equal to 4 days (OR=5.93) and length of post-operative hospital stay of 15 days or over (OR=1.20), were observed as independent predictors for the development of postoperative pneumonia. CONCLUSIONS: Identifying risk factors for post-operative pneumonia may prevent their occurrence. The length in the intensive care unit of greater than or equal to 7 days (OR=1.23; 95% CI 1.07 - 1.42) and a length postoperative hospital stay of 15 days or more (OR=1.20; 95% CI 1.07 - 1.34) were the predictive factors most strongly associated with lung infection in this study.

[Sigmoido-buttock fistula by diverticulitis: report of a rare complication]. / Fístula sigmoideo-glútea por diverticulitis. Reporte de una rara complicación.

INTRODUCTION: The complicated diverticulitis of the colon is characterized by its association with abscesses, bleeding, stenosis, perforation, obstruction or fistula. We report a case of spontaneous sigmoido-cutaneous fistula from diverticulitis to an unusual place in the gluteal region. CLINICAL CASE: A 59-year-old male patient presented an inflammatory wound in left buttock without response to the conservative medical treatment. The fistulography, colonoscopy, barium enema and computed tomography showed a sigmoido-cutaneous fistula to the left buttock from diverticulitis. The biopsy of the lesion ruled out malignancy. We performed an elective sigmoid resection with primary colorectal anastomosis, partial fistulectomy and injection of a fibrin sealant in the residual tract. DISCUSSION: The colon-cutaneous fistulas from diverticulitis are relatively rare. We report a spontaneous fistula with origin in a single diverticulum in the sigmoid colon and that drained through the piriform fossa of the pelvic floor to the skin of the left buttock. CONCLUSIONS: A high index of suspiscion is necessary to not confuse the colo-buttock fistula with local abscesses.

[Analgesic efficacy of the incisional infiltration of ropivacaine vs ropivacaine with dexamethasone in the elective laparoscopic cholecystectomy]. / Eficacia analgésica de la infiltración incisional de ropivacaína vs ropivacaína con dexametasona en la colecistectomía laparoscópica electiva.

BACKGROUND: Incisional pain is the main obstacle for elective laparoscopic cholecystectomy as an outpatient. We evaluated the analgesic efficacy of local infiltration of ropivacaine with dexamethasone (Rop/Dx), compared with ropivacaine (Rop) alone, during the first 24 hours postoperative of this surgery. Our hypothesis is that incisional pain intensity will be lower in patients of the group Rop/Dx. METHODS: In a randomized, controlled, double-blind trial clinical, 80 patients were divided into two groups. Group Rop (n= 40) received pre and post-incisional infiltration with 150 mg of ropivacaine in 8 mL of 0.9% saline, while group Rop/Dx (n= 40) received 150 mg of ropivacaine with 8 mg of dexamethasone in 6 mL of 0.9% saline. The intensity of pain at rest and movement was assessed at 2, 4, 8, 12 and 24 hours postoperatively by a numerical rating scale of 11 points. RESULTS: Incisional pain scores in group Rop/Dx were significantly lower, compared to the group Rop, at 12 hours (p= 0.05) and 24 hours (p= 0.01) at rest and at 12 hours (p= 0.04) and 24 hours (p= 0.01) during movement postoperatively. CONCLUSIONS: We found initial evidence that ropivacaine with dexamethasone for local infiltration decreased incisional pain intensity after 12 hours post-elective laparoscopic cholecystectomy with a good safety profile.

Antecedentes: el dolor incisional es el principal obstáculo para la colecistectomía laparoscópica electiva ambulatoria. Objetivo: evaluar la eficacia analgésica de la infiltración local de ropivacaína con dexametasona (Rop/Dx) en comparación con ropivacaína (Rop) sola, durante las primeras 24 horas del postoperatorio de esta cirugía. Material y métodos: ensayo clínico aleatorizado, controlado y doble ciego, efectuado en 80 pacientes que para fines de estudio se dividieron en dos grupos. El grupo Rop (n= 40) recibió infiltración pre y post-incisional con 150 mg de ropivacaína en 8 mL de solución salina 0.9%, mientras que el grupo Rop/Dx (n= 40) recibió 150 mg de ropivacaína con 8 mg de dexametasona en 6 mL de solución salina 0.9%. La intensidad del dolor durante el reposo y el movimiento se evaluó a las 2, 4, 8, 12 y 24 horas del postoperatorio con una escala de clasificación numérica de 11 puntos. La hipótesis es que la intensidad del dolor incisional será menor en los pacientes del grupo Rop/Dx. Resultados: las puntuaciones del dolor incisional en el grupo Rop/Dx fueron significativamente menores, comparadas con el grupo Rop, a las 12 horas (p= 0.05) y 24 horas (p= 0.01) durante el reposo y a las 12 horas (p= 0.04) y 24 horas (p= 0.01) durante el movimiento postoperatorio. Conclusiones: la evidencia inicial es que la ropivacaína con dexametasona, por infiltración local, disminuye la intensidad del dolor incisional a partir de las 12 horas post-colecistectomía laparoscópica electiva con un buen perfil de seguridad.

[Treatment of open abdomen in patients with abdominal sepsis using the vacuum pack system]. / Tratamiento de abdomen abierto con el sistema de vacuum pack en pacientes con sepsis abdominal.

BACKGROUND: In abdominal sepsis, when the initial surgery fails to control infection, a good choice may be to leave the abdomen open. This is a descriptive study of a series of cases using the vacuum pack system for temporary abdominal closure. METHODS: We studied 19 patients. Demographic data were obtained, as well as those related to the vacuum pack, and the final fascial closure. We describe the technique of temporary abdominal closure. Values are presented as mean ± standard deviation (SD). RESULTS: The average length of the hospital stay was 24.7 days. Fourteen (73.7%) patients survived and five patients (26.3%) died. The mean treatment time with the vacuum pack was 12.7 days, with an average of 3.9 changes. Early fascial closing was achieved in seven patients with an average of 14.6 days. In seven patients a planned ventral hernia formed, which was repaired by separation of components on an average of 261 days or by polypropylene mesh on an average of 228 days. CONCLUSIONS: In our series, early fascial closing was achieved using the vacuum pack at a lower frequency than reported by other authors. Other parameters analyzed were similar to those reported in the literature. The vacuum pack system demonstrated to be effective, although the final selection for temporary abdominal closure will depend on the experience of the institution as well as surgeon preference. The vacuum pack system for temporary abdominal closure of the open abdomen is an effective alternative in patients with abdominal sepsis.

Síndrome hepatopulmonar / Hepatopulmonary syndrome

El Síndrome hepatopulmonar (SHP) es una entidad clínica reconocida por vez primera en 1884 por Flückiger, sin embargo fue hasta 1977 cuando Kennedy y Knudson la consideraron como un síndrome, el cual se caracteriza por una tríada conformada por insuficiencia hepática, vasodilatación pulmonar e hipoxemia. Entre las causas de esta entidad clínica se encuentra la insuficeincia hepatica, ya sea aguda o crónica. El factor relajante del endotelio es aparentemente la principal causa de las alteraciones vasculares pulmonares. La sintomatología es la producida por la insuficiencia hepática per se como ascitis, ictericia, eritema palmar, varices esofágicas, hemorragia del tubo digestivo, y por el componente pulmonar como son, ortodeoxia, hipocratismo digital y cianosis. Los mecanismos de hipoxemia en el SHP son alteraciones de la ventilación perfusión, cortos circuitos y trastornos de la difusión. El diagnóstico se realiza con base en diferentes estudios, como son la radiografía de tórax, el gammagrama perfusorio, la ecocardiografía contrastada bidimensional y la angiografía. Hasta el momento, no hay un tratamiento conocido que sea totalmente efectivo, no obstante el trasplante hepático ha sido considerado como la mejor opción, aunque otros como la embolización y terapia farmacológica pueden ser utilizados

Agentes antituberculosos. Nuevas alternativas farmacológicas / Antituberculous drugs. New alternatives

La principal indicación de los fármacos antituberculosos de segunda línea es la presencia de tuberculosis resistente a drogas primarias. Comparados con los antituberculosos de primera línea, estos fármacos tienen una menor actividad antimicrobiana, más efectos colaterales, algunos son más caros y varios regímenes en los que se incluyen estas drogas son administradas por un mayor tiempo. Los principales fármacos son: ácido paraaminosalicílico (PAS), tiacetazona, clofazimina, etionamida, cicloserina, capreomicina, amikacina y kanamicina. Sus mecanismos de acción y de resistencia, así como su absorción, eliminación y efectos colaterales son diferentes para cada droga. Para el PAS y la tiacetazona los efectos colaterales más importantes son a nivel gastrointestinal; la clofazimina puede producir hiperpigmentación de la piel; la ciloserina puede originar síntomas neurológicos; los aminoglucósidos y la capreomicina generalmente causan trastornos vestibulococleares. Las contraindicaciones y las dosis de cada fármaco, de acuerdo a las posibles enfermedades concomitantes, son quizás de los aspectos a considerar más importantes cuando estas drogas son administradas