Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters.

INTRODUCTION AND AIMS: The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes. MATERIALS AND METHODS: A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion. RESULTS: The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%. CONCLUSIONS: Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

Pancreatic ductal adenocarcinoma: Eleven years of experience at a tertiary care hospital center. / Adenocarcinoma ductal de páncreas. Experiencia de 11 años en un centro de tercer nivel.

INTRODUCTION AND AIM: Pancreatic cancer is considered one of the most aggressive solid tumors. In Mexico, it is the twelfth cause of cancer, with 4,489 cases diagnosed annually, and accounts for 4.9% of oncologic deaths. The aim of our study was to describe the clinical and epidemiologic characteristics of the patients diagnosed with pancreatic cancer spanning an 11-year period at the Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". METHODS: A retrospective, cross-sectional study was conducted that included 479 patients diagnosed with pancreatic cancer, within the time frame of 2003-2013. The documented findings were summarized through descriptive statistics. RESULTS: Of the patients with pancreatic ductal adenocarcinoma, 50.9% were women, and the mean patient age at diagnosis was 61.5 years. A total of 48.4% of the cases were diagnosed at clinical stage IV, 12.9% presented with clinical stage III, and 25.0% had localized disease. Surgery was performed on 37.5% of the patients, the most frequent of which was pancreatoduodenectomy. The surgical mortality rate was 5.5%. CONCLUSION: The clinical characteristics in our study group were similar to those described in the literature. However, the number of candidates for surgical treatment was higher than that reported in other hospitals and the percentage of borderline tumors was lower. Those differences, respectively, are possibly associated with the nature of our referral center and the prolonged intervals between diagnosis and treatment that result in the loss of potential surgical patients.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters. / Conversión de colecistectomía laparoscópica a abierta: análisis de factores de riesgo con base en parámetros clínicos, de laboratorio y de ultrasonido.

INTRODUCTION AND AIMS: The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes. MATERIALS AND METHODS: A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion. RESULTS: The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%. CONCLUSIONS: Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

Laparoscopic Roux-en-Y gastric bypass in the treatment of obesity: evidence based update through randomized clinical trials and meta-analyses.

Bariatric surgery was introduced in 1953, but during the last 20 years its popularity has increased after the development of significant Romaevidenced based breakthroughs in the field. Currently, approximately 150 long-term randomized clinical trials and 40 meta-analyses support and give credibility to the surgical approaches for the treatment of obesity and its related metabolic disturbances. Bariatric surgery has demonstrated improved outcomes compared to medical treatment, conduct therapy, and endoscopic procedures. Roux-en-Y gastrojejunostomy (RYGB) and Sleeve gastrectomy (SG) are the surgical procedures most frequently performed, due to their satisfactory results and security profile. There is sufficient evidence in medical literature to perform these procedures when indicated; however, there are still several controversies regarding technical aspects that need to be further explored.

Contrast-enhanced swallow study sensitivity for detecting esophagojejunostomy leakage. / Sensibilidad del trago de contraste hidrosoluble para la detección de fugas de anastomosis esofagoyeyunal.

INTRODUCTION AND AIM: Sixty percent of the patients with gastric carcinomas are candidates for surgical resection through total gastrectomy and esophagojejunostomy, the latter of which is associated with leaks in up to 12.3% of cases. There is no standardized procedure for diagnosing anastomotic leaks. The aim of the present study was to establish the diagnostic sensitivity of the contrast-enhanced swallow study for detecting esophagojejunostomy leakage after total gastrectomy. MATERIALS AND METHODS: A retrospective analysis was conducted on patients that underwent total gastrectomy due to gastric adenocarcinoma, within the time frame of 2002 and 2017. Demographic, clinical, and laboratory factors were identified, emphasizing the clinical and radiologic detection of anastomotic leaks. Descriptive statistics were carried out and the sensitivity of the contrast-enhanced swallow study for diagnosing leakage was calculated. RESULTS: Fifty-eight patients were included in the study. Their mean age was 61.5 years. A total of 55.2% of the patients were men and 44.8% were women. Gastric adenocarcinoma was the indication for gastrectomy in 100% of the cases. Anastomotic leak presented in 31.01% of the patients. Diagnostic sensitivity of the contrast-enhanced swallow study for detecting leaks was 66%. CONCLUSIONS: According to our analysis, the contrast-enhanced swallow study had limited diagnostic efficiency for detecting anastomotic leaks, with a sensitivity of 66%. We suggest maintaining high diagnostic suspicion in patients with studies that are initially negative and basing decisions on a more extensive approach.

Percutaneous cholecystostomy as treatment for acute cholecystitis: What has happened over the last five years? A literature review. / Colecistostomía percutánea como tratamiento de colecistitis aguda: ¿qué ha pasado en los últimos 5 años? Revisión de la literatura.

Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with.

Myths and realities in the management of the open abdomen with negative pressure systems. A case report and literature review.

INTRODUCTION: The open abdomen is a useful resource for treating patients with abdominal hypertension and abdominal compartment syndrome. Currently, early closure assisted with negative pressure devices is considered standard of treatment, and its use has demonstrated favorable outcomes and a decreased rate of complications. PRESENTATION OF A CASE: We present a case of a 32-year-old male patient with diagnosis of non-seminomatous germinal testicular tumor (Stage IIIB (T3-N3-M1), which was summited to surgery, as a complication he presented massive bleeding, that culminated in acute compartment syndrome. With the aforementioned findings the patient re entered the operating room and was managed with open abdomen combined with a medial retraction technique of the abdominal fascia. Currently, the patient has not presented recurrence or late complications after a year. DISCUSSION: The use of negative pressure techniques for open abdomen management began to be generalized in 1995. Subsequently, this technique evolved to V.A.C therapy (Vacuum-assisted closure therapy). Currently, these negative pressure techniques have become the most used method for the temporary closure and management of open abdomen. Controversies continue to limit its widespread use and effectiveness. CONCLUSION: Adequate application of negative pressure therapy in combination with techniques of medial retraction of the abdominal fascia, have proved to be useful in management for patients with open abdomen.

Recurrent giant Brunner's gland adenoma.

Benign duodenal tumours are extremely rare, with an incidence of 0.008% among general population; those originating from Brunner's Gland represent 11% of this neoplasms. Most cases remain asymptomatic and are often diagnosed during routine endoscopic procedures, however their clinical presentation may be variable making resection treatment of choice in order to prevent complications. Recurrence has not been reported previously on literature. 59-year-old male presented to the emergency department nine months following endoscopic resection of a 2x1.5cm Brunner's gland adenoma complaining of bloating, weight loss and gastro intestinal bleeding, diagnostic approach revealed a 10x4cm mass occupying the duodenum. Tumour size did not allow for endoscopic resection and surgical removal was performed with excellent outcome and no further recurrence at 30 months.

Cytological screening for cervical cancer and associated factors in the penitentiary population of Peru.

OBJECTIVE: To determine the prevalence and factors associated with the screening of cervical cancer by Papanicolaou in the penitentiary population of Peru. METHOD: A cross-sectional study was conducted using data from the 2016 National Penitentiary Population Census of Peru. The dependent variable was the cytological screening of cervical cancer during the last year. The independent variables were classified as facilitators, sociodemographic predisposers, and generators of need for the use of health services.The multivariate association was estimated through adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI), using Poisson regression and using the variables with p <0.05 in the bivariate. RESULTS: A total of 4515 women incarcerated in the 67 prisons of Peru entered the study. 69% (95% CI: 67.81-70.5) performed cytological screening during the last year and this is associated with having public health insurance (aPR 1.28 , 95% CI: 1.21-1.36), go to prison health services (aPR 1.18 , 95% CI: 1.12-1.24) and have a history of cancer (aPR 1.14, 95% CI: 1.02-1.26). Age, number of children, sports activities and the type of prison were also associated with cytological screening. DISCUSSION: There is an association between cytological screening and access to health services, sociodemographic predispositions and pathological backgrounds of women incarcerated in Peru. More research should be promoted on health prevention behaviors in this population.

A stress tensor and QTAIM perspective on the substituent effects of biphenyl subjected to torsion.

The Quantum Theory of Atoms in Molecules (QTAIM) defines quantities in 3D space that can be easily obtained from routine quantum chemical calculations. The present investigation shows that local properties can be related quantitatively to measures traditionally connected to experimental data, such as Hammett constants. We consider the specific case of substituted biphenyl to quantify the effects of a torsion φ, 0.0° ≤ φ ≤ 180.0°, of the C-C bond linking the two phenyl rings for C12 H9 -x, where x = N(CH3 )2 , NH2 , CH3 , CHO, CN, NO2, on the entire molecule. QTAIM interpreted Hammett constants, aΔH(rb ) are introduced and constructed using the difference between the H(rb ) value of C12 H9 -x and the C12 H9 -H, biphenyl which is the reference molecule, with a constant of proportionality a. This investigation unexpectedly yields very good or good agreement for the x groups with the Hammett para-, meta-, and ortho-substituent constants and is checked against para-substituted benzene. We then proceed to present the interpreted substituent constants of seven new biphenyl substituent groups, where tabulated Hammett substituent constant values are not available; y = SiH3 , ZnCl, COOCH3 , SO2 NH2 , SO2 OH, COCl, CB3 . Consistency is found for the QTAIM interpreted biphenyl substituent constants of the seven new groups y independently using the stress tensor polarizability Pσ . In addition, a selection of future applications is discussed that highlight the usefulness of this approach. © 2016 Wiley Periodicals, Inc.

Estimación de la fracción de eyección intraoperatoria: comparación entre método de Simpson y Doppler tisular / Intraoperative ejection fraction: estimation with Simpson’s rule vs tissue

Introducción: La ecocardiografía transesofágica permite una adecuada monitorización de la hemodinamia intraoperatoria. Un parámetro frecuentemente utilizado es la fracción de eyección medido con método de Simpson. Con el advenimiento de Doppler tisular y la medición de onda s’, que corresponde a la velocidad de la perfusión del tejido miocárdico durante la sístole, podría estimarse la fracción de eyección de manera más rápida y fácil durante una cirugía. Objetivos: Comparar la fracción de eyección calculada con método de Simpson con las mediciones intraoperatorias de la velocidad de la onda s’ medida con Doppler tisular. Material y método: Se estudiaron pacientes afectos de patología cardiovascular crónica sometidos a cirugía cardiaca y no cardiaca electiva. Se excluyeron pacientes en ritmo no sinusal y con enfermedad mitral. Se midió en 4 y 2 cámaras volumen de fin de diástole y volumen de fin de sístole para calcular la fracción de eyección con método de Simpson. Este grupo fue dividido en aquéllos con fracción de eyección normal (> 50%) y un segundo grupo con fracción de eyección disminuida (< 49%) Luego se utilizó Doppler tisular de anillo mitral para medir la velocidad de la onda s’. Para estimar la fracción de eyección con s’ se utilizó la fórmula: FE = 5,5 x s’ + 8. Resultados: Fueron estudiados 92 pacientes, 51 (55%) casos con fracción de eyección normal y 41 (45%) disminuida. El grupo con fracción de eyección < 49% tuvo una buena correlación con la calculada mediante la velocidad de la onda s’ del Doppler tisular (r = 0,91, p < 0,01). En cambio en el grupo con fracción de eyección normal esta correlación fue menor (r = 0,61, p > 0,5). Conclusión: La estimación de la fracción de eyección con Doppler tisular es una técnica fácil y reproducible. Su utilidad podría ser mayor especialmente en aquellos pacientes que tienen un ventrículo izquierdo alterado(AU)

Background: Transesophageal echocardiography is appropriate for intraoperative monitoring of hemodynamics. The parameter often estimated is ejection fraction (EF) by means of Simpson’s rule. With the advent of tissue Doppler imaging and measurement of the systolic (S) wave, corresponding to the rate of myocardial perfusion during the systole, it is possible to estimate the EF more easily and rapidly during surgery. Objective: To compare EF estimates obtained by Simpson’s rule to those based on intraoperative tissue Doppler measurements of S-wave velocity (S'). Material and methods: Patients with chronic cardiovascular disease undergoing scheduled cardiac and noncardiac surgery were studied. Patients in nonsinus rhythm and with mitral valve disease were excluded. To apply Simpson's rule for calculating the EF, we measured end-diastolic volume in 4- and 2-chamber views. The group was divided into patients with normal ( 50%) and diminished ( 49%) ejection fraction. Tissue Doppler imaging of the mitral annulus was then used to measure S'. Ejection fraction was calculated according to the formula EF = 5.5 x S' + 8. Results: Ninety-two patients were studied; in 51 (55%) the EF was normal and in 41 (45%) it was reduced. In patients whose EF was 49% according to Simpson’s rule, the correlation between that measurement and EF based on tissue Doppler estimate of S' was good. The correlation was lower, however, in the group with normal EF (r=0.61; P>0.5). Conclusions: EF is easy to estimate with tissue Doppler imaging and the procedure is reproducible. This approach is probably more useful in patients with left ventricular dysfunction(AU)

[Intraoperative ejection fraction: estimation with Simpson's rule vs tissue Doppler imaging]. / Estimación de la fracción de eyección intraoperatoria: comparación entre método de Simpson y Doppler tisular.

BACKGROUND: Transesophageal echocardiography is appropriate for intraoperative monitoring of hemodynamics. The parameter often estimated is ejection fraction (EF) by means of Simpson's rule. With the advent of tissue Doppler imaging and measurement of the systolic (S) wave, corresponding to the rate of myocardial perfusion during the systole, it is possible to estimate the EF more easily and rapidly during surgery. OBJECTIVE: To compare EF estimates obtained by Simpson's rule to those based on intraoperative tissue Doppler measurements of S-wave velocity (S'). MATERIAL AND METHODS: Patients with chronic cardiovascular disease undergoing scheduled cardiac and noncardiac surgery were studied. Patients in nonsinus rhythm and with mitral valve disease were excluded. To apply Simpson's rule for calculating the EF, we measured end-diastolic volume in 4- and 2-chamber views. The group was divided into patients with normal (> or = 50%) and diminished (< or = 49%) ejection fraction. Tissue Doppler imaging of the mitral annulus was then used to measure S'. Ejection fraction was calculated according to the formula EF = 5.5 x S' + 8. RESULTS: Ninety-two patients were studied; in 51 (55%) the EF was normal and in 41 (45%) it was reduced. In patients whose EF was < or = 49% according to Simpson's rule, the correlation between that measurement and EF based on tissue Doppler estimate of S' was good. The correlation was lower, however, in the group with normal EF (r=0.61; P>0.5). CONCLUSIONS: EF is easy to estimate with tissue Doppler imaging and the procedure is reproducible. This approach is probably more useful in patients with left ventricular dysfunction.

[Spinal anesthesia may diminish left ventricular function: a study by means of intraoperative transthoracic echocardiography]. / La anestesia subaracnoidea (espinal) podría disminuir la función ventricular izquierda: estudio con ecocardiografía transtorácica intraoperatoria.

BACKGROUND: Spinal anesthesia reduces arterial blood pressure mainly because of vasodilation secondary to blocking preganglionic fibers in the sympathetic nervous system. It is hypothesized, however, that spinal anesthesia may also be a direct cause of some degree of myocardial depression. These factors may be studied by means of transthoracic echocardiography to detect changes in left ventricular function following start of spinal anesthesia. MATERIAL AND METHODS: Left ventricular function was assessed in ASA 1 patients before spinal anesthesia, by means of measurements of left ventricular systolic and diastolic volumes, ejection fraction, the Doppler transmitral (E and A) and tissue (E', A', and Sm) inflow velocities, and the left ventricular outflow tract velocity. The measurements were repeated after the start of spinal anesthesia. RESULTS: Fifty-five patients (58% men; mean [SD] age, 46.9 [15.7] years) were studied. The spinal block caused a significant reduction in systolic and diastolic arterial blood pressures (P < .0009). Diastolic function also decreased (the E wave from 69.52 [11.24] to 61.59 [10.82] cm x s(-1) and the A wave from 50.18 [10.69] to 43.67 [13.75] cm x s(-1); P < .0001). Also reduced was the left ventricular outflow tract velocity, from 18.77 (4.89) to 15.64 (4.75) cm x s(-1) (P < .00001). There were no significant changes in systolic and diastolic volumes or ejection fraction. There was no correlation between the level of spinal block and the magnitude of changes. CONCLUSIONS: Left ventricular function was compromised after spinal anesthesia without significant changes in left ventricular volumes. We can infer that the reduction in arterial blood pressure after a spinal block might be due to some degree of direct ventricular depression.

La anestesia subaracnoidea (espinal) podría disminuir la función ventricular izquierda: Estudio con ecocardiografía transtorácica intraoperatoria / Spinal anesthesia may diminish left ventricular function: a study by means of intraoperative transthoracic echocardiography

INTRODUCCIÓN: La anestesia subaracnoidea (espinal)produce disminución de la presión arterial y su principalcausa sería la vasodilatación secundaria al bloqueo defibras preganglionares simpáticas. Se postula, sinembargo, que también podría producir algún grado dedepresión miocárdica directa. Para determinar estos factoresse pueden estudiar con ecocardiografía transtorácica(ETT) los cambios en la función del ventrículoizquierdo (VI) de una anestesia espinal.MATERIAL Y MÉTODOS: Se evaluó la función ventricular depacientes ASAI previa a la anestesia espinal. Se midió el volumensistólico del ventrículo izquierdo (VSFVI), volumen diastólico(VDFVI), fracción de eyección (FE), Doppler llenadotransmitral (E, A), Doppler tisular (E’, A’ y Sm) e integral develocidad del tracto de salida del VI (ITV). Este mismo examense repitió después de instaurarse la anestesia espinal.RESULTADOS: Se estudiaron 55 pacientes, 58% hombres,edad 46,9 ± 15,7 años. El bloqueo espinal produjouna disminución significativa de presión arterial sistólicay diastólica (p < 0,0009), de la función diastólica, dondela onda E disminuyó desde 69,52 ± 11,24 a 61,59 ±10,82 cm seg–1 y la onda A desde 50,18 ± 10,69 a 43,67 ±13,75 cm seg–1 (p < 0,0001) y de ITV desde 18,77 ± 4,89a 15,64 ± 4,75 cm seg–1 (p < 0,00001) sin cambios significativosen el VDF, VSF y FE. No existió correlación entreel nivel del bloqueo con la magnitud de estos cambios.CONCLUSIÓN: Los resultados demostraron que tras laanestesia espinal se comprometió la función ventricularizquierda, sin que cambiaran los volúmenes del VI enforma significativa. A partir de estos resultados puedeinferirse que la disminución de la presión arterial luegode un bloqueo espinal podría deberse también a algúngrado directo de depresión ventricular(AU)

BACKGROUND: Spinal anesthesia reduces arterialblood pressure mainly because of vasodilation secondaryto blocking preganglionic fibers in the sympatheticnervous system. It is hypothesized, however, that spinalanesthesia may also be a direct cause of some degree ofmyocardial depression. These factors may be studied bymeans of transthoracic echocardiography to detectchanges in left ventricular function following start ofspinal anesthesia.MATERIAL AND METHODS: Left ventricular functionwas assessed in ASA 1 patients before spinal anesthesia,by means of measurements of left ventricular systolicand diastolic volumes, ejection fraction, the Dopplertransmitral (E and A) and tissue (E', A', and Sm) inflowvelocities, and the left ventricular outflow tract velocity.The measurements were repeated after the start ofspinal anesthesia.RESULTS: Fifty-five patients (58% men; mean [SD]age, 46.9 [15.7] years) were studied. The spinal blockcaused a significant reduction in systolic and diastolicarterial blood pressures (P<.0009). Diastolic functionalso decreased (the E wave from 69.52 [11.24] to 61.59[10.82] cm·s–1 and the A wave from 50.18 [10.69] to 43.67[13.75] cm·s–1; P<.0001). Also reduced was the leftventricular outflow tract velocity, from 18.77 (4.89) to15.64 (4.75) cm·s–1 (P<.00001). There were no significantchanges in systolic and diastolic volumes or ejectionfraction. There was no correlation between the level ofspinal block and the magnitude of changes.CONCLUSIONS: Left ventricular function wascompromised after spinal anesthesia without significantchanges in left ventricular volumes. We can infer that thereduction in arterial blood pressure after a spinal blockmight be due to some degree of direct ventricular depression(AU)

[Echocardiography-derived Tei index during surgery, a predictor of postoperative cardiovascular complications]. / Indice ecocardiográfico de Tei durante cirugía no cardiaca como predictor de complicaciones cardiovasculares postoperatorias.

BACKGROUND AND OBJECTIVE: The Tei index is a Doppler echocardiographic parameter that reflects both systolic and diastolic myocardial function. Our aim was to monitor the Tei index by transesophageal echocardiography during noncardiac surgery to explore the correlation between this parameter and the incidence of postoperative cardiovascular complications. MATERIAL AND METHODS: Patients at risk of cardiovascular complications were enrolled. The Tei index was derived from the pattern of pulsed Doppler transmitral filling and aortic outflow, by dividing the sum of isovolumetric contraction and relaxation intervals by ejection time in milliseconds. RESULTS: Seventy-three patients (58% men) were enrolled. The mean (SD) age was 68 (12) years. Two groups were identified based on myocardial function. A Tei index over 0.35 defined group 2 (n = 25) and correlated with a larger number of postoperative cardiovascular events. In patients with a normal Tei index less than 0.35 (group 1, n = 48), the incidence of cardiovascular complications was lower. Hypotension occurred in 60% of patients in group 2 and 21% of those in group 1, hypertension in 24% of group 2 and 4.1% of group 1, and pulmonary edema in 8% of group 2 and 2.1% of group 1 (P < .05 for all comparisons). CONCLUSIONS: This pilot study found that patients with a high Tei index were more likely to develop postoperative cardiovascular complications. This index may provide a useful indicator to take into consideration in planning hemodynamic management when patients have a history of cardiovascular disease.

Índice ecocardiográfico de Tei durante cirugía no cardiaca comopredictor de complicaciones cardiovasculares postoperatorias / Echocardiography-derived Tei index during surgery, a predictor of postoperative cardiovascular complications

OBJETIVOS: El índice de función miocárdica (índice deTei) es un parámetro obtenido con ecocardiografíamediante Doppler, que estudia en forma conjunta e integradala sístole y la diástole. El objetivo del presenteestudio es evaluar si el índice de Tei medido con ecocardiografíatransesofágica (ETE) durante cirugía no cardiacase correlaciona con una mayor incidencia de eventoscardiovasculares postoperatorios.MATERIAL Y MÉTODOS: Se estudiaron pacientes conriesgo cardiovascular. El índice de Tei se midió con ETEdesde la curva de Doppler pulsado de llenado transmitraly de flujo aórtico, dividiendo la suma del tiempo decontracción y relajación isovolumétrica por el tiempo deeyección en milisegundos.RESULTADOS: Se incluyeron 73 pacientes, el 58% varones,con una edad promedio de 68 ± 12 años. Se determinódos grupos según el índice de función miocárdica. Uníndice de función miocárdica mayor de 0,35 (grupo 2, n= 25 pacientes) se correlacionó con un mayor número deeventos cardiovasculares postoperatorios. El grupo 1 (n= 48 pacientes) con índice de función miocárdica< 0,35 (normal) presentó una menor incidencia de eventos.Destacó la hipotensión en 60% de enfermos del grupo2 frente a 21% del grupo 1 (p < 0,05), hipertensión en24% de los casos del grupo 2 frente a 4,1% del grupo 1(p < 0,05) y congestión pulmonar 8% en el grupo 2 y2,1% del grupo 1 (p < 0,05).CONCLUSIONES: En este estudio preliminar se observóque pacientes con un índice de Tei patológico podríantener una mayor incidencia de complicaciones cardiovascularespostoperatorias. Este índice podría ser un factormás a considerar en el tratamiento hemodinámico depacientes con antecedentes de patología cardiovascular (AU)

BACKGROUND AND OBJECTIVE: The Tei index is aDoppler echocardiographic parameter that reflects bothsystolic and diastolic myocardial function. Our aim wasto monitor the Tei index by transesophagealechocardiography during noncardiac surgery to explorethe correlation between this parameter and theincidence of postoperative cardiovascular complications.MATERIAL AND METHODS: Patients at risk ofcardiovascular complications were enrolled. The Teiindex was derived from the pattern of pulsed Dopplertransmitral filling and aortic outflow, by dividing thesum of isovolumetric contraction and relaxationintervals by ejection time in milliseconds.RESULTS: Seventy-three patients (58% men) wereenrolled. The mean (SD) age was 68 (12) years. Twogroups were identified based on myocardial function. ATei index over 0.35 defined group 2 (n=25) andcorrelated with a larger number of postoperativecardiovascular events. In patients with a normal Teiindex less than 0.35 (group 1, n=48), the incidence ofcardiovascular complications was lower. Hypotensionoccurred in 60% of patients in group 2 and 21% of thosein group 1, hypertension in 24% of group 2 and 4.1% ofgroup 1, and pulmonary edema in 8% of group 2 and2.1% of group 1 (P<.05 for all comparisons).CONCLUSIONS: This pilot study found that patientswith a high Tei index were more likely to developpostoperative cardiovascular complications. This indexmay provide a useful indicator to take into considerationin planning hemodynamic management when patientshave a history of cardiovascular disease (AU)

Linfangioma quístico sin otras anomalías asociadas / Cystic lymphangioma without associated anomalies

El higroma, o linfangioma quístico, se debe a una anomalía del sistema linfático producida por la obstrucción del drenaje de los sacos linfáticos cervicales al sistema venoso yugular. Habitualmente se localiza en la región cervical posterior o posterolateral y contiene múltiples tabiques. Entre el 20 y el 40% de los casos se asocia a normalidad cromosómica; el resto de los casos se asocia a diversas aneuplodías o malformaciones. El diagnóstico diferencial incluye edema nucal, meningocele, encefalocele, teratoma cervical, seudomembranas, hemangioma y quiste placentario subcorial.Su incidencia es de uno cada 1.775 a 6.000 nacidos vivos. La tasa de aneuploidía asociada al linfangioma quístico diagnosticado prenatalmente es del 45 al 60% (principalmente síndrome de Turner y síndrome de Down). También se ha observado asociación a otros síndromes polimalformativos. El resultado fetal es incierto y varía según los estudios revisados.A continuación se presenta el caso de un linfangioma quístico inusual por varios motivos: su gran tamaño, la ausencia de otras anomalías morfológicas y de aneuploidías, la joven edad de la madre y el desarrollo morfológico posnatal normal (AU)

Hygroma or cystic lymphangioma is due to an obstruction of jugular lymph sac drainage to the jugular venous system. The most common localization is the posterolateral neck region. These lesions are usually multiseptated. Between 20% and 40% of affected individuals have a normal karyotype and the remainder show diverse aneuploidies and/or malformations. The differential diagnosis includes nuchal edema, meningocele, encephalocele, cervical teratoma, pseudomembranes, hemangioma and subchorial placental cyst.The incidence of cystic lymphangioma has been reported to be 1/6,000–1,775 live-newborns. The rate of aneuploidy associated with prenatally diagnosed cases are between 45% and 60% (mainly Turner and Down syndromes). Some cases are associated with other polymalformation syndromes. Fetal outcome is uncertain and differs among studies.We present the case of a fetal cystic lymphangioma that is unusual for several reasons: its huge size, the absence of any other morphological abnormalities and aneuploidies, the young age of the mother, and the normal morphological postnatal growth (AU)

Whole Saliva has a Dual Role on the Adherence of Candida albicans to Polymethylmetacrylate.

Adhesion of Candida albicans to acrylic of dental prostheses or to salivary macromolecules adsorbed on their surface is believed to be a critical event in the development of denture stomatitis. In previous studies our group has shown that adhesion of C. albicans germ tubes to polystyrene is decreased by saliva whereas C. albicans yeast cells adhesion to the same material is enhanced. The results presented in this study confirm this dual role played by whole saliva, since it decreased the adhesion of germ tubes but increased the adhesion of yeast cells to polymethylmetacrylate (PMMA). These effects mediated by whole saliva do not seem to be related to an inhibition of the germination of C. albicans, since similar levels of filamentation were observed in presence and absence of saliva. These results may give new insights into the conflicting role of saliva in the adhesion of C. albicans to acrylic resins of dental prostheses.

[Intraoperative transesophageal echocardiography and systolic anterior motion of the mitral valve: findings during noncardiac surgery]. / Ecocardiografía transesofágica intraoperatoria y movimiento sistólico anterior de válvula mitral: hallazgo intraoperatorio durante cirugía no cardíaca.

Systolic anterior motion is an under-recognized cause of acute systemic hypotension during noncardiac surgery. This dynamic event has come to light with the introduction of intraoperative transesophageal echocardiography, which provides anatomic and functional images in real time. The cause of this abnormal motion is still uncertain, although it is thought that changes in the shape and function of the left ventricle allow displacement of the mitral valve annulus so that 1 or more leaflets can be pulled toward the outflow tract and obstruct it during the systole. It is important to recognize and diagnose this phenomenon as a cause of hypotension during noncardiac surgery because it can be treated with volume replacement and beta-blockers. The results of such measures can be monitored on intraoperative echocardiographic images. Volume replacement should increase the size of the ventricle and the beta-blockers should decrease the hyperdynamic state. We report a case of abnormal systolic motion during noncardiac surgery that was managed with the help of echocardiography.

Ecocardiografía transesofágica intraoperatoria y movimiento sistólico anterior de válvula mitral: hallazgo intraoperatorio durante cirugía no cardíaca / Intraoperative transesophageal echocardiography and systolic anterior motion of the mitral valve: findings during noncardiac surgery

El fenómeno de movimiento sistólico anormal de la válvulamitral es una entidad clínica poco reconocida comocausa de hipotensión arterial sistémica aguda intraoperatoriadurante cirugía no cardíaca. Con el advenimiento dela ecocardiografía transesofágica intraoperatoria que permiteobtener imágenes anatómicas y funcionales cardíacasen tiempo real, este fenómeno dinámico se ha hecho evidente.Su etiología aunque poco clara, se piensa que sedebe a cambios morfológicos y funcionales del ventrículoizquierdo que permiten el desplazamiento del anillo valvularmitral lo que facilita que uno o ambos velos sean arrastradosdurante la sístole hacia el tracto de salida del ventrículoizquierdo, obstruyéndolo. La importancia que tienesu diagnóstico y reconocimiento como causa de hipotensióndurante el intraoperatorio de una cirugía no cardíacaes que su tratamiento se basa en el aporte de volumen y ala utilización preferente de betabloqueantes. La ecocardiografíaintraoperatoria permite la monitorización y visualizaciónde los resultados de esta terapia. Con el aporte devolumen aumenta el tamaño ventricular y con el uso debetabloqueantes se logra disminuir el estado hiperdinámico.Se presenta el siguiente caso clínico ocurrido duranteuna cirugía no cardíaca donde el manejo y la evolucióndependieron de las imágenes diagnósticas de movimientosistólico anormal realizadas con ecocardiografía

Systolic anterior motion is an under-recognized cause of acute systemic hypotension during noncardiac surgery. This dynamic event has come to light with the introduction of intraoperative transesophageal echocardiography, which provides anatomic and functional images in real time. The ;;cause of this abnormal motion is still uncertain, although it ;;is thought that changes in the shape and function of the left ;;ventricle allow displacement of the mitral valve annulus so ;;that 1 or more leaflets can be pulled toward the outflow ;;tract and obstruct it during the systole. It is important to ;;recognize and diagnose this phenomenon as a cause of ;;hypotension during noncardiac surgery because it can be ;;treated with volume replacement and Beta-blockers. The ;;results of such measures can be monitored on intraoperative ;;echocardiographic images. Volume replacement should ;;increase the size of the ventricle and the Beta-blockers should ;;decrease the hyperdynamic state. We report a case of ;;abnormal systolic motion during noncardiac surgery that ;;was managed with the help of echocardiography