Resultados de un programa de recuperación mejorada (PRM) en cirugía colorrectal: efectos en la estadía hospitalaria / Shortening of hospital length of stay after the implementation of an Enhanced Recovery Program for elective colorectal surgery

Resumen Introducción Los Programas de Recuperación Mejorada (PRM) en cirugía colorrectal disminuyen las complicaciones y acortan la estadía hospitalaria. La implementación de un PRM representa un desafío en nuestro sistema de salud público, dado la alta demanda y recursos limitados. Objetivo Evaluar el efecto en la estadía hospitalaria (EH) posterior a la implementación de un PRM en cirugía colorrectal electiva en un hospital público. Materiales y Método Estudio retrospectivo, que incluyó pacientes entre 15 y 85 años operados electivamente de resecciones colorrectales en un hospital público entre 1 de enero de 2015 y 31 de diciembre de 2016. Se compararon dos grupos: 1) total de pacientes operados electivamente 1 año posterior a la implementación del PRM (post-PRM) y 2) total de pacientes operados electivamente un año previo a la implementación de PRM (pre-PRM), en términos de EH, reingresos, complicaciones y mortalidad a 30 días. Se realizó análisis de tiempo a evento para comparar la EH entre ambos grupos. Resultados Un total de 144 pacientes fueron incluidos: 92 en el grupo post-PRM y 52 en el grupo pre-PRM. No hubo diferencias clínicas entre ambos grupos. La mediana de EH en el grupo post-PRM fue 2 días menor que en el grupo control (5 vs 7 días, test de log-rank, p = 0,03). No hubo diferencia en complicaciones, reingresos ni mortalidad. Conclusión La implementación de un PRM en cirugía colorrectal electiva en un hospital público se asocia a una disminución de la EH sin aumento de morbimortalidad.

Background Enhanced Recovery Programs (ERP) in colorectal surgery has proved to decrease complications and shorten hospital stay. The implementation of an ERP could be a difficult task in a high-demanding public health system with limited resources. Aim Evaluate the effect on length of stay (LOS) after the implantation of an ERP for colorectal surgery in a resource-limited public hospital. Materials and Method This retrospective study included patients aged 15-85 years who underwent elective colorectal surgery at a resource-limited public hospital in Chile between January 1, 2015 and December 31, 2016. We compared two groups: (1) total number of patients operated electively after 1-year of ERP implementation (post-ERP group) and (2) total number of patients electively operated 1-year previous ERP (pre-ERP group) in terms of LOS, readmissions, complications, and 30-day mortality. A time to event analysis was performed to evaluate differences in LOS. Results A total of 144 patients were included in this study: 92 in the post-ERP group and 52 in the pre-ERP group. There were no clinical differences between groups. The median LOS in the post-ERP group was 2 days lower than that in the control group (5 vs 7 days, log-rank test p = 0.03). There were no differences in complications, readmissions, and 30-day mortality. Conclusions The implementation of an ERP for colorectal surgery in a resource-limited hospital was associated with decreased LOS without increasing morbidity.

Miotomía endoscópica por vía oral (POEM) para el tratamiento de la acalasia: experiencia clínica inicial y resultados a corto plazo / Per-oral endoscopic myotomy (POEM) for the treatment of achalasia: initial clinical experience and short term results

Resumen Introducción: La acalasia es el trastorno motor primario más frecuente del esófago. El estándar de tratamiento actual es la miotomía de Heller laparoscópica. En los últimos años, el desarrollo de técnicas endoscópicas avanzadas ha permitido el posicionamiento de la técnica POEM (del inglés: per-oral endoscopic myotomy) como una nueva alternativa terapéutica con resultados promisorios. Objetivo: Presentar nuestra experiencia clínica, con descripción de la técnica utilizada, resultados perioperatorios y seguimiento a corto plazo en el desarrollo de esta alternativa terapéutica. Materiales y métodos: Se realizó un análisis retrospectivo de datos obtenidos en forma prospectiva de 15 pacientes intervenidos mediante POEM en 3 hospitales docentes asociados. Se recopilaron variables demográficas preoperatorias, detalle del intraoperatorio y registro de morbimortalidad operatoria. Se realizó un seguimiento clínico dirigido registrando el puntaje de Eckardt y la presencia de síntomas de reflujo gastroesofágico. Resultados: Entre agosto de 2015 y noviembre de 2016 se realizaron 15 POEM. Seis de estos pacientes eran mujeres, y la edad promedio fue de 49 años. El tiempo operatorio promedio fue de 110 min; no hubo morbimortalidad operatoria. La estadía hospitalaria promedio fue de 2,8 días. El seguimiento fue de entre 1 y 15 meses. El puntaje de Eckardt promedio en el preoperatorio y en el postoperatorio fue de 10,5 y 0,4 puntos, respectivamente. Tres pacientes presentaban síntomas de reflujo gastroesofágico al momento del seguimiento. Conclusión: Los resultados obtenidos en nuestra serie apoyan la efectividad y seguridad del POEM a corto plazo. Se requiere de un seguimiento mayor para determinar el rol definitivo de esta técnica.

Abstract Introduction: Achalasia is the most common primary motor disorder of the esophagus. The current standard of treatment is laparoscopic Heller's myotomy. Recently the development of advanced endoscopic techniques has allowed the positioning of the POEM (per-oral endoscopic myotomy) technique as a new therapeutic alternative with promising results. Objective: To present our clinical experience in POEM, with description of the technique used, peri-operative results and short-term follow-up in the development of this therapeutic alternative. Materials and methods: We performed a retrospective analysis of data obtained prospectively from 15 patients undergoing POEM in three clinical centers in our country. Preoperative demographic variables, intraoperative detail, and operative morbidity and mortality were collected. Clinical follow-up was performed with controls recording Eckardt score and presence of gastroesophageal reflux symptoms. Results: Between August 2015 and November 2016, 15 POEM were performed, six of these patients were women, average age was 49 years. The average operative time was 110 min, we did not have any perioperative morbimortality. Hospital stay was 2.8 days. Follow-up was between 1 and 15 months, Eckardt's preoperative and postoperative score was on average 10.5 and 0.4 points, respectively. Three patients had gastroesophageal reflux symptoms at the time of follow-up. Conclusion: Our results support the effectiveness and security of POEM in short-term follow up. Further monitoring is required to determine the definitive role of this technique.

[Cryptogenic organizing non-resolving pneumonia. Report of one case]. / Neumonía criptogénica organizada como diagnóstico diferencial de neumonía que no responde a tratamiento.

Non-resolving pneumonia is a common clinical problem that prolongs morbidity and increases hospitalization costs. We report an 82 year-old non-smoking female who was admitted with chronic diarrhea and later developed nosocomial pneumonia. Lung infiltrates did not resolve despite sequential antibiotic treatments. Infectious causes such as resistant nosocomial pathogens, respiratory viruses, tuberculosis, Legionellosis, cytomegalovirus or agents associated with HIV infection were discarded. Non-infectious causes such as thromboembolic lung disease, neoplasms and rheumatic disorders were also ruled out. An exudative pleural effusion was detected, but the study was unremarkable. Fiberoptic bronchoscopy and a transbronchial biopsy, revealed nonspecific findings. The patient persisted febrile, required non-invasive mechanical ventilation and displayed a migratory pattern of lung infiltrates that motivated a second biopsy, this time by open thoracotomy, showing a cryptogenic organizing pneumonia. The patient's conditions improved after treatment with adrenal steroids. In patients with non-resolving pneumonia, a dedicated and comprehensive study should be done using invasive procedures and considering both infectious and non-infectious causes. Cryptogenic organizing pneumonia is one of the alternatives that is potentially treatable, but often underdiagnosed.

Neumonía criptogénica organizada como diagnóstico diferencial de neumonía que no responde a tratamiento / Cryptogenic organizing non-resolving pneumonia.Report of one case

Non-resolving pneumonia is a common clinical problem that prolongs morbidity and increases hospitalization costs. We report an 82 year-old non-smoking female who was admitted with chronic diarrhea and later developed nosocomial pneumonia. Lung infiltrates did not resolve despite sequential antibiotic treatments. Infectious causes such as resistant nosocomial pathogens, respiratory viruses, tuberculosis, Legionellosis, cytomegalovirus or agents associated with HIV infection were discarded. Non-infectious causes such as thromboembolic lung disease, neoplasms and rheumatic disorders were also ruled out. An exudative pleural effusion was detected, but the study was unremarkable. Fiberoptic bronchoscopy and a transbronchial biopsy, revealed nonspecific findings. The patient persisted febrile, required non-invasive mechanical ventilation and displayed a migratory pattern of lung infiltrates that motivated a second biopsy, this time by open thoracotomy, showing a cryptogenic organizing pneumonia. The patient's conditions improved after treatment with adrenal steroids. In patients with non-resolving pneumonia, a dedicated and comprehensive study should be done using invasive procedures and considering both infectious and non-infectious causes. Cryptogenic organizing pneumonia is one of the alternatives that is potentially treatable, but often underdiagnosed.

Linfoma intravascular tratado con anticuerpos monoclonales anti CD20: descripción de un caso clínico / Intravascular lymphoma treated with anti CD20 monoclonal antibodies: report of one case

We report a 78 year old male with prostatism, that was subjected to a prostate biopsy. The pathological study showed a microvascular lymphocytic infiltration. Four months later, the patients presentd with reduced alertness, cough, dyspnea, fever and elevation of lactic dehydrogenase and erythrocyte sedimentation rate. Chest and abdominal CAT scans, bone marrow aspirate, protein electrophoresis and prostate specific antigen were normal. A re-evaluation of prostate biopsy showed an intravascular lymphoid infiltration, positive for CD45 and CD20, compatible with the diagnosis of intravascular lymphoma. Chemotherapy was started, but it was not tolerated by the patient and the response was partial. Therefore, treatment with monoclonal antibodies anti CD20 (Rituximab) was started. The tumor had a complete and prolonged (24 months) remission after the treatment.

[Ten years of ENT surgery in the Toledo's outpatient surgery unit]. / Diez años de cirugía otorrinolaringológica en la unidad de cirugía mayor ambulatoria de Toledo.

One of the Spain's pioneer out patient surgery units is the Toledo's one. We have realized a retrospective study of the 10th first years of its functioning. During this period, 4733 patients were operated, on tonsills and adenoids, laryngeal microsurgeries, septoplasties, miringotomies, and miringoplasties. We obtained a 91.8% of discharge from hospital in the same day and few complications (5.5% without hospitalization and 0.7% with). Thanks to a questionary we know that the degree of satisfaction of the patients is high, and so, added to our good statistic results, stimulate us to follow in this working line.

Diez años de cirugía otorrinolaringológica en la unidad de cirugía mayor ambulatoria de Toledo / Ten years of ent surgery in the Toledo's out patient surgery unit

Una de las unidades de cirugía mayor ambulatoria pioneras de Espala, es la de Toledo. Hemos realizado un estudio retrospectivo de los 10 primeros años de su funcionamiento. En este lapso, se han intervenido 4733 pacientes, realizándose cirugías de amígdalas y adenoides, microcirugías laringeas, septoplastias, miringotomías y miringoplastias. Hemos obtenido un 91,8 por ciento de altas en el día y escasas complicaciones (5,5 por ciento sin hospitalización, 0,7 por ciento con ingreso). Gracias a una encuesta, sabemos que el grado de satisfacción del usuario es alto, lo que, sumado a nuestros buenos resultados estadísticos, nos estimulan a seguir en esta línea de trabajo (AU)

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[Actinomycosis sub-masseter abscess, simulating a parotiditis. Review of case and revision of literature]. / Absceso submaseterino por actinomicosis, simulando parotiditis. Descripción del caso y revisión de la literatura.

We present one case of a pluripathologic female patient who has developed an submaseterin abscess secondary to an actinomyces mandibular osteomielitis. The initial presentation seems an acute supurative parothiditis. We describe its presentation, evolution, special tests done for its diagnostic, as also the discussion of the type and duration of the treatment. And we include also a differential diagnosis between the two diseases, with a similar form. We do also a bibliographic revision of the few similar cases published.

Absceso submaseterino por actinomicosis, simulando parotiditis descripción del caso y revisión de la literatura / Actinomycosis submaseterin absces, simulating a parothiditis, description of the case and revision of the literatur

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Variation in specific needle area of old-growth Douglas-fir in relation to needle age, within-crown position and epicormic shoot production.

Variation in specific needle area (SNA; cm2 projected fresh needle area g-1 oven-dried needle weight) was investigated in relation to needle age, within-crown position and epicormic shoot production in 450-year-old Douglas-fir (Pseudotsuga menziesii Mirb. (Franco) var. menziesii) trees. Specific needle area decreased with increasing needle age. The magnitude and rate of change in SNA with needle age were greatest for lower-crown branches, and decreased toward the middle- and upper-crown branches. For all branches, there was no difference between regular and epicormic shoots in the relationship between SNA and needle age. Specific needle area decreased with increasing distance from branch base, and this relationship was significant for the majority of needle age classes of the upper- and middle-crown branches. In the lowercrown branches, SNA did not vary with distance from branch base for the majority of needle age classes. For all branches, there was no difference between regular and epicormic shoots in the relationship between SNA and distance from branch base for the majority of needle age classes. These results indicate that renewal of foliage by epicormic shoot production maintains needle quality. Branch SNA increased linearly with decreasing height in the crown at a mean rate of 0.951 +/- 0.110 cm2 g-1 per vertical meter. Total needle area of branches was estimated from total needle dry weight taking into account within-branch variation in SNA. Analyses of allometric relationships between branch size and foliage amount (needle area and needle dry weight) showed that branch length was a better predictor of foliage amount than branch diameter for old Douglas-fir trees. Total needle dry weight and needle area of the sample trees, estimated from branch length and branch height and taking into account vertical within-crown variation in branch SNA, ranged from 42.4 to 154.2 kg and from 246.2 to 816.0 m2 per tree, respectively.

Biopsia de mama guiada por ultrasonido: cirugía mínimamente invasiva / Breast biopsy with ultrasound guide: minimally invasive surgery

Se presentan los resultados de biopsias de mama guiadas con ultrasonido utilizando el sistema percutáneo Mammotome en 50 pacientes con 55 lesiones. Los hallazgos histológicos correspondieron a fibroadenoma en el 65,4 por ciento, cambios fibroquísticos en el 20 por ciento, y papiloma en el 3,7 por ciento. En cinco pacientes se encontró una lesión maligna. El seguimiento con ecografía a los 6 meses se ha hecho hasta ahora en 14 pacientes sin cambio con respecto al diagnóstico histológico. Complicaciones no hubo, excepto un hematoma en paciente con daño hepático grave, que no fue necesario drenar. Las principales indicaciones para este tipo de biopsia son nódulos sólidos cuya etiología se requiera precisar, microcalcificaciones sospechosas visibles en ecografía, adenopatía axilar y sospecha ecográfica de recidiva local

Selectivity of IMAC columns in trypsin inhibitor purification.

The properties of an adsorbent and the parameters in an adsorption process affect the resolution of chromatographic purifications. This is reflected in the elution profile, which shows the relative affinity of different proteins for a specific adsorbent. In the work presented here, elution profiles for trypsin inhibitor were used to study the effects of the concentration of trypsin inhibitor, ionic strength of the protein solution, slope of the elution gradient, and the regeneration treatment of the chromatography column on the selectivity of the adsorbent Cellufine Chelate-Cu(II)(ida). Cytochrome c was used as a reference protein. Variations in the concentrations of trypsin inhibitor and in the ionic strength of the buffered solution did not have any effects on the elution profile. On the other hand, changes in the slope of the pH gradient used for elution caused shifting of the elution peaks toward lower values of the elution volume, resulting in the best strategy to modify the elution profile of the system. Finally, using a constant slope pH gradient of elution, the variation of the selectivity of the adsorbent for trypsin inhibitor when subjected to cleaning treatments with 0.5 N NaOH was studied. Appropriate cleaning practices used in industry were followed. The adsorbent showed only a slight tendency for resolution loss in the order of 2 x 10(-4) days(-1). The results presented here show a good stability of the adsorbent when compared to other biospecific adsorbents commonly used.

Treatment of children suffering from severe malnutrition in an area of Santiago, Chile.

PIP: Despite marked progress in recent years, infant and young child malnutrition remains a serious health problem in Chile. To help define the nature of that problem better, researchers working in the Southeastern Metropolitan Area of Santiago conducted a survey of infants classified as having grade 2 protein-calorie malnutrition (PCM) and children under age 2 classified as having grade 3 PCM during the period March 31-October 1, 1980. The survey, based on a review of health facility records for all children in the area receiving care during the study period, found a total of 388 infants with grade 2 PCM and 102 subjects under 2 with grade 3 PCM. The study also found that the subjects who received comprehensive professional outpatient care at the area's Infant Nutrition Center fared significantly better than those cared for at outpatient health centers. The authors therefore recommend that the treatment of such children should be referred to or coordinated with centers that are diagnostically and therapeutically more sophisticated than the outpatient health centers. In this vein, it appears that the style of treatment provided by the Infant Nutrition Center could be developed more broadly throughout Chile and could be effectively employed in other countries with similar situations. It also appears, however, that malnourished children cannot be treated effectively as outpatients because they have very unsatisfactory home environments. One alternative approach is such cases is to admit the child as an inpatient to a special nutritional recovery center. Hospitalization, which typically occurs when the child is suffering from 1 or more pathologic conditions besides malnutrition, constitutes another alternative. However, the present survey found that the nutritional status of hospitalized study children did not improve, on the average, and some subjects experienced a marked nutritional deterioration. Another important point is that over 1/4 of the malnourished study children had low birthweights or had been premature. This underscores the importance of avoiding low birthweights as much as possible, and then giving low birthweight infants adequate care and treatment. In addition, clear standards should be established for the feeding of low birthweight children and for determining their nutritional status.^ieng

Recuperacion de ninos desnutridos graves en un area de Santiago, Chile DE. / Recovery of severe undernourished children in an area of Santiago, Chile

Se estudiaron 490 lactantes que constituyeron el total de ninos desnutridos graves diagnosticados en el Area Sur Oriente de Santiago, entre marzo y octubre de 1980.Se evaluo la adecuacion del diagnostico del estado nutricional segun los niveles de atencion y se encontraron algunas deficiencias por no haberse considerado en forma adecuada el peso y la edad gestacional al nacer. El antecedente de bajo peso al nacer se presento en 26% de los ninos desnutridos, la mitad de ellos, aproximadamente, de pretermino y la otra mitad constituida por recien nacidos pequenos para su edad gestacional. La hospitalizacion aparecio como factor de importancia en el agravamiento de la desnutricion primaria en los ninos que precisaron internarse. La respuesta al tratamiento ambulatorio de la desnutricion fue significativamente mejor en los lactantes atendidos en el Consultorio de Nutricion Infantil (73%) que en los Consultorios Perifericos (31%)