Marco conceptual y diseño de un proyecto de desarrollo profesional continuo en Atención Primaria / Conceptual framework and design of a continuing professional development project in Primary Care

En países de nuestro entorno, fundamentalmente anglosajones, procesos de recertificación, relicencia, revalidación y desarrollo profesional continuo, están incluidos en la práctica y en la terminología cotidiana de los profesionales de la medicina.En nuestro país, la Sociedad Española de Médicos de Atención Primaria, consciente de la importancia para el médico de Atención Primaria (AP) de procesos como los mencionados, comenzó a desarrollar en el año 2006 un proyecto de desarrollo profesional continuo en AP. Para ello implicó a todas las estructuras de la sociedad, Junta Directiva, Juntas Autonómicas, grupos de trabajo y grupos de expertos.El proyecto se ofreció a todos los profesionales de AP en el Congreso Nacional de la sociedad celebrado en Valencia en octubre de 2008. Desde entonces más de 1.400 médicos se han dado de alta en este proyecto (AU)

In countries of our setting, basically the Anglo-Saxon ones, recertification, relicensing, revalidation and continuing professional development procedures are included within the daily practice and terminology of the medical professionals.In our country, in the year 2006, the Spanish Society of Primary Care Physicians, SEMERGEN, being aware of the importance of procedures such as those mentioned for the Primary Care (PC) physician, began to develop a project of Continuing Professional Development in PC. To do so, it involved all of the structures of the society, that is, the Board of Directors, Regional Boards, work groups, and expert groups.The project was offered to all of the PC professionals in the National Congress of the society held in Valencia in October 2008. Since then, more than 1400 physicians have registered in this project (AU)

[Rectal irrigation and bowel decontamination for the prevention of postoperative enterocolitis in Hirschsprung's disease]. / La irrigación rectal y descontaminación digestiva para la profilaxis de la enterocolitis postoperatoria en la enfermedad de Hirschsprung.

UNLABELLED: The object is to determine the utility of rectal irrigation (RI) and bowel decontamination for the prevention of postoperative enterocolitis in Hirschsprung's disease. MATERIAL AND METHODS: Between 1978 and 2005, 37 patients underwent surgical treatment for Hirschsprung's disease. Group 1 (1978-1993): 19 patients, 17 with rectosigmoid or long segment disease, and 2 total colonic aganglionosis (TCA). No postoperative prevention was used. Group II (1994-2005): 18 patients, 11 with rectosigmoid or long segment disease, and 7 TCA. Postoperative rectal irrigation (RI) and bowel decontamination was used. The RI volume was at least 10 ml/kg body weight. It was initiated on postoperative day 10, once a day for two months in the short segments, extending to 1 or more years in patients with iloeocoloplasty. Bowel decontamination, with a duration similar to the RI, was with metronidazol, gentamicin, or nistatin alternatingly. The incidence of enterocolitis, and the morbidity and mortality were evaluated in both groups. RESULTS: In Group I, 9 patients (47%) developed postoperative enterocolitis; 1 patient, with serious preoperative enterocolitis, required digestive rest for 10 days, with parenteral feeding and intravenous antibiotics. The 2 TCA patients, one treated by the L. Martin technique, and the other, with Down's syndrome, by the Kimura technique, suffered recurrent episodes of enterocolitis, with hospitalization, intravenous antibiotic therapy, and RI. In Group I, there were 2 deaths, one related to the postoperative enterocolitis. In Group II, each of 2 patients (11%) with TCA treated by Boley-type ileocoloplasty, with preoperative enterocolitis, had 1 episode of enterocolitis during treatment; one had a further episode after suspension of the treatment. Two patients of this group suffered enterocolitis before beginning the treatment. There was no mortality in this group. CONCLUSIONS: Rectal irrigation and bowel decontamination significantly decreased the incidence and severity of enterocolitis in Hirschsprung's disease by preventing faecal stasis and uncontrolled bacterial growth.

La irrigación rectal y desontaminación digestiva para la profilaxis de la enterocolitis postoperatoria en al enfermedad de Hirschsprung / Rectal irrigation and bowel decontamination for the prevention of postoperative enterocolitis in Hirschprung´s disease

El objeto es conocer la utilidad de las irrigaciones rectales y la descontaminación digestiva para la profilaxis de la enterocolitis postoperatoria en la enfermedad de Hirschsprung. Material y métodos. Entre los años 1978 a 2005 se trataron a 37 pacientes con enfermedad de Hirschsprung. Grupo I (1978-1993), 19 pacientes, 17 con extensión rectosigmoidea o más alta, y 2 aganglionismos cólicos totales (ACT). No se utilizó profilaxis postoperatoria. Grupo II (1994-2005), 18 pacientes, 11 con extensión rectosigmoidea o más alta, y 7 ACT. Se utilizó profilaxis postoperatoria mediante irrigaciones rectales y descontaminación digestiva. Las irrigaciones rectales se realizaron con suero fisiológico a 10 ml/kg, una vez al día, iniciándose al 10º día del postoperatorio, durante 2 meses en los segmentos cortos, y prolongándose durante 1 o más años en ACT con plastias ileocólicas. La descontaminación digestiva, con una duración similar a las IR, se realizó con metronidazol, gentamicina o nistatina de forma alternante. Se valora la incidencia de la enterocolitis en ambos grupos, su morbimortalidad y el tratamiento. Resultados. En el Grupo I, 9 pacientes (47,3%) presentaron enterocolitis postoperatoria; un paciente, con enterocolits preoperatoria grave, precisó reposo digestivo durante 10 días, alimentación parenteral y antibióticos intravenosos. Los dos pacientes con ACT, uno tratado mediante la técnica de L. Martín, y otro con síndrome de Down mediante la de Kimura, sufrieron múltiples episodios de enterocolitis, con hospitalizaciones y antibioticoterapia intravenosa e irrigaciones rectales. En el grupo I hubo 2 exitus, uno relacionado con la enterocolitis postoperatoria. En el grupo II, 2 pacientes (11,1%), con ACT tratados mediante ileocoloplastia tipo Boley, con enterocolitis preoperatoria, presentaron 1 episodio de enterocolitis cada uno durante el tratamiento; uno de ellos presentó nuevo episodio tras la suspensión del tratamiento. Dos pacientes de este grupo sufrieron enterocolitis antes de iniciarse el tratamiento. No hubo mortalidad en este grupo. Conclusiones. Las irrigaciones rectales y la descontaminación digestiva reducen de forma manifiesta la incidencia y la severidad de la enterocolitis postoperatoria en la enfermedad de Hirschsprung, al impedir el estasis fecal y controlar el sobrecrecimiento bacteriano (AU)

The object is to determine the utility of rectal irrigation (RI) and bowel decontamination for the prevention of postoperative enterocolitis in Hirschsprung's disease. MATERIAL AND METHODS: Between 1978 and 2005, 37 patients underwent surgical treatment for Hirschsprung's disease. Group 1 (1978-1993): 19 patients, 17 with rectosigmoid or long segment disease, and 2 total colonic aganglionosis (TCA). No postoperative prevention was used. Group II (1994-2005): 18 patients, 11 with rectosigmoid or long segment disease, and 7 TCA. Postoperative rectal irrigation (RI) and bowel decontamination was used. The RI volume was at least 10 ml/kg body weight. It was initiated on postoperative day 10, once a day for two months in the short segments, extending to 1 or more years in patients with iloeocoloplasty. Bowel decontamination, with a duration similar to the RI, was with metronidazol, gentamicin, or nistatin alternatingly. The incidence of enterocolitis, and the morbidity and mortality were evaluated in both groups. RESULTS: In Group I, 9 patients (47%) developed postoperative enterocolitis; 1 patient, with serious preoperative enterocolitis, required digestive rest for 10 days, with parenteral feeding and intravenous antibiotics. The 2 TCA patients, one treated by the L. Martin technique, and the other, with Down's syndrome, by the Kimura technique, suffered recurrent episodes of enterocolitis, with hospitalization, intravenous antibiotic therapy, and RI. In Group I, there were 2 deaths, one related to the postoperative enterocolitis. In Group II, each of 2 patients (11%) with TCA treated by Boley-type ileocoloplasty, with preoperative enterocolitis, had 1 episode of enterocolitis during treatment; one had a further episode after suspension of the treatment. Two patients of this group suffered enterocolitis before beginning the treatment. There was no mortality in this group. CONCLUSIONS: Rectal irrigation and bowel decontamination significantly decreased the incidence and severity of enterocolitis in Hirschsprung's disease by preventing faecal stasis and uncontrolled bacterial growth (AU)

[Severe caustic injuries of the esophagus: when to replace the esophagus]. / Causticaciones esofágicas graves: cuándo decidir prescindir del esófago.

From June 1985 to May 1998, 20 patients have been treated in our hospital by esophageal dilatations due to serious esophageal caustic stenosis. A retrospective analysis of these 20 patients was performed, evaluating age, sex, causative agent, number and time of dilatations, iatrogenic esophageal perforations, gastroesophageal reflux (GER) and psychological and social consequences. Follow-up has ranged from 1.5 to 14.5 years (mean = 8.07 years). The mean age at the time of accidental swallow was 42.2 months. The causative agent was dishwashing detergent in 11 patients and caustic soda in 9 patients. The mean of dilatations needed was 19.1 and the average duration of dilatations was 24.7 months. Seven patients had esophageal perforation during dilatation and none of them required surgical treatment. All patients had improvement of swallowing and an easier esophageal dilatation afterwards. Oral contrast studies demonstrated distortion of the esophago-gastric junction in the majority of patients. Ten patients were screened for GER with 24-hour esophageal pH monitoring in the first year postburn and it was pathological in 5. Antireflux surgery was carried out in 4 patients with a conspicuous improvement following surgery. Dilatations proved successful in 16 patients in less than two years, and in more than two years in 3 patients. The authors conclude that the majority of children with esophageal caustic stenosis can be managed successfully by esophageal dilatations, even with dilatation periods longer than two years or when an esophageal perforation occur during the procedure. The paramount importance of early diagnosis and treatment of GER is stressed.

Causticaciones esofágicas graves: Cuándo decidir prescindir del esófago / Severe aesophageal caustications: when to replace the esophagus

El tratamiento de las estenosis cáusticas (EC)graves incluye la posible sustitución del esófago par otro fragmento del tubo digestivo, cuando se considera que no se podrá conseguir su recuperación. En nuestra experiencia, todos los esófagos causticados pudieron ser recuperados.Entre junio de 1985 y mayo de 1998 hemos sometido a dilataciones esofágicas, por EC, a 20 pacientes. En todos el los hemos valorado distintas variables epidemiológicas y relacionadas con las dilataciones, reflujo gastroesofágico (RGE) y evolución.La edad media de los pacientes en el momento de la ingestión del caustico ha sido de 42,2 meses. El producto ingerido por f f fue lavavajillas industrial y sosa cáustica por 9, La media de dilataciones necesarias fue de 19,1 y la de su duración de 24,7 meses. fin -7 pacientes se produjo una perforación esofágica seguida en todos los casos de una mejoría llamativa de la disfagia y una mayor facilidad para las dilataciones posteriores. Los tránsitos esofágicas mostraron 'morfología refluyente, de la unión esófago gástrica en la mayoría de los pacientes. En 10 realizamos pHmetría esofágica durante el primer año de fa causticación, siendo patológica en seis. Sometimos a plastia antirreflujo a cuatro pacientes, con mejoría llamativamente rápida tras ella. Trece pacientes curaron tras menos de 2 años de dilataciones y tres tras 4 años y 2 meses, 6 años y 9 años, respectivamente.El límite de 1 a 2 años post-causticación, aceptado de forma amplia como tope para continuar los intentos de recuperación del esófago causticado, nos parece insuficiente, siempre que la luz esofágica mantenga algo de permeabilidad. Preferimos en el momento de mayor dificultad para dilatar, correr cl riesgo de perforar el esófago a dar lo por irrecuperable. El diagnóstico y tratamiento del RGE en estos pacientes nos parece fundamental para su buena evolución (AU)

[Study of intestinal motility in the child with acute appendicitis using phonoenterography]. / Estudio de la motilidad intestinal en el niño con apendicitis aguda mediante fonoenterografía.

Our experience in using the phonoenterographic procedure in measuring the sounds produced by the intestinal motility in 75 patients is reported: 30 underwent surgery, won acute appendicitis, 20 appendicular peritonitis and 25 underwent surgery without abdominal pathology. We performed in all patients a temporary record of 3 minutes of duration, one spectrogram and one sonogram before the surgery and after surgery in the following 6, 12 and 24 hours. We obtained the number of sounds recorded by our informatic program, and also its intensity measure in dB and frequency in Hz. The procedure we have used can distinguished the characteristics of the intestinal sound of each patient and allow to show a qualitative and quantitative activity, different in the three group of patients. The number of sounds is bigger in the patients with non digestive abdominal pathology and smaller in patients with peritonitis. In general, the lesser number of sounds the lesser intensity and a more grave tones.

[Ureteral valve associated with pyeloureteral stenosis]. / Válvula de ureter asociada a estenosis pieloureteral.

We report a case of ureteric valve associated with pyeloureteral obstruction, exhibited as fistula after pyeloplasty. We analyst different features of ureteric valves: anatomical, location, symptoms and associated congenital anomalies. The writer consider necessary to achieve the sounding of ureteral stretch during the operation of pyeloplasty.

[Esophageal atresia associated with cystic duplication of the esophagus]. / Atrésie oesophagienne associée à une duplication kystique d'oesophage.

A rare case of esophageal atresia associated with esophageal duplication cyst is reported. The cyst duplication was recognized and successfully resected at primary thoracotomy for repair of esophageal atresia. This case is believed to be the second reported instance where both lesions could be treated concomitantly at first thoracotomy.