Adult intussusception: still a challenging diagnosis for the surgeon.

INTRODUCTION AND AIM: Intussusception is rare in adults and can occur in the small bowel and colon. Its atypical presentation makes the diagnosis difficult. The aim of the present study was to evaluate the causes, clinical characteristics, and treatment outcomes of adult intussusception and to determine whether there was an association between etiology and clinical presentation. MATERIALS AND METHODS: A retrospective study was carried out on patients above 18 years of age that were treated for intussusception at a tertiary care hospital, between 2000 and 2020. The findings were summarized utilizing descriptive and inferential statistics. RESULTS: Twenty-eight cases were identified. Median patient age was 46 years (18-80) and median symptom duration was 18 days. Abdominal pain was the most frequent symptom (96.42%). The intussusceptions registered were enteroenteric (14), ileocecal (4), ileocolonic (4), colocolonic (5), and colorrectal (1). Intussusception etiology was benign in 15 cases, 9 were associated with malignancy, and 4 were idiopathic. Surgery was performed on 11 patients with enteroenteric intussusception and on all the cases of ileocecal, ileocolonic, colocolonic, and colorectal intussusception. There were 2 events of perioperative mortality (8%) and 8 of postoperative morbidity (32%). No significant differences were found regarding symptom duration or length of hospital stay, when the etiologic groups were compared. CONCLUSIONS: Intussusception is rare in adults. Diagnosis is a challenge because of the nonspecific signs and symptoms. Surgical resection should be considered in the definitive treatment and management should be individualized according to the patient's comorbidities, clinical presentation, and risk of malignancy.

Radiofrequency-assisted transection of the pancreas vs stapler in distal pancreatectomy: a propensity score matched cohort analysis.

To demonstrate the efficacy of radiofrequency for pancreatic stump closure in reducing the incidence of postoperative pancreatic fistula (POPF) in distal pancreatectomy (DP) compared with mechanical transection methods. Despite all the different techniques of pancreatic stump closure proposed for DP, best practice for avoiding POPF remains an unresolved issue, with an incidence of up to 30% regardless of center volume or surgical expertise. DP was performed in a cohort of patients by applying radiofrequency to stump closure (RF Group) and compared with mechanical closure (Control Group). A propensity score (PS) matched cohort study was carried out to minimize bias from nonrandomized treatment assignment. Cohorts were matched by PS accounting for factors significantly associated with either undergoing RF transection or mechanical closure through logistic regression analysis. The primary end-point was the incidence of clinically relevant POPF (CR-POPF). Of 89 patients included in the whole cohort, 13 case patients from the RF-Group were 1:1 matched to 13 control patients. In both the first independent analysis of unmatched data and subsequent adjustment to the overall propensity score-matched cohort, a higher rate of CR-POPF in the Control Group compared with the RF-Group was detected (25.4% vs 5.3%, p = 0.049 and 53.8% vs 0%; p = 0.016 respectively). The RF Group showed better outcomes in terms of readmission rate (46.2% vs 0%, p = 0.031). No significant differences were observed in terms of mortality, major complications (30.8% vs 0%, p = 0.063) or length of hospital stay (5.7 vs 5.2 days, p = 0.89). Findings suggest that the RF-assisted technique is more efficacious in reducing CR-POPF than mechanical pancreatic stump closure.

Evaluation of the learning curve for laparoscopic pancreatoduodenectomy by CUSUM analyses. Cohort study.

INTRODUCTION: Laparoscopic pancreatoduodenectomy (LPD) remains an extremely demanding surgery. The purpose of this study was to describe the learning curve required for its safe implementation. METHODS: Fifty consecutive patients undergoing LPD were retrospectively reviewed. The learning curve was clustered into 4 groups: A, B and C (initial phase, n = 10 each) and D (consolidation phase, n = 20). Cumulative Sum (CUSUM) analysis was applied to operative time, conversion rate and severe postoperative complications. RESULTS: No significant differences were observed among groups and phases concerning specific and general postoperative complications, oncological outcomes or mortality. The conversion rate significantly reduced from 90% (9) in Group A to 40% (4) in Group C (p < 0.01). Operative time was longer in the consolidation phase (median of 506 vs 437 min, p < 0.01). Conversely, hospital stays were shorter during the consolidation phase (8 vs 15 days, p < 0.01). CUSUM analysis identified 20-25cases as being enough to complete the learning curve if operative time and severe complications are analysed, while 40 cases would be needed for considering the conversion rate. CONCLUSIONS: The learning curve in LPD can be completed after 20-25 procedures. This information will help to design programmes for introducing new surgeons to this technique.

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.

Postoperative intra-abdominal infection is an independent prognostic factor of disease-free survival and disease-specific survival in patients with stage II colon cancer

Background: Recurrence occurs in up to 20% of patients with stage II colon cancer operated on for cure. Although postoperative intra-abdominal infection has been linked with an increased risk of recurrence, the association is controversial. The aim was to investigate the impact of postoperative intra-abdominal infection on disease-free survival and disease-specific survival in patients with stage II colon cancer. Methods: Patients undergoing elective surgery for colon cancer stage II, between 2003 and 2014, were included. Patients with anastomotic leak or intra-abdominal abscess were included in the infection group. We used the Kaplan-Meier method to represent the distribution of survival and the Cox proportional hazards model to estimate the contribution of relevant clinicopathological factors with prognosis. Results: Postoperative intra-abdominal infection was diagnosed in 37 of 363 (10.2%) patients. Perioperative blood transfusion was more frequent in patients with infection (p = 0.008). Overall 5-year disease-free survival rate was 85.1%. Disease-free survival at 5 years was lower in patients with postoperative intra-abdominal infection (52.8 vs 88.7%; p < 0.001), perineural invasion (p = 0.001), lymphovascular invasion (p = 0.001), pT4 (p = 0.013), and in patients with adjuvant chemotherapy (p = 0.013). Multivariate analysis showed that postoperative intra-abdominal infection (HR 4.275; p < 0.001), perineural invasion (HR 2.230; p = 0.007), and lymphovascular invasion (HR 2.052; p = 0.016) were all significant independent predictors of reduced disease-free survival. Regarding specific survival, independent significant prognostic factors were the number of lymph nodes, lymphovascular invasion, and postoperative intra-abdominal infection. Conclusion: In this series of patients with stage II colon cancer, postoperative intra-abdominal infection has an independent negative impact on disease-free survival and disease-specific survival

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Postoperative intra-abdominal infection is an independent prognostic factor of disease-free survival and disease-specific survival in patients with stage II colon cancer.

BACKGROUND: Recurrence occurs in up to 20% of patients with stage II colon cancer operated on for cure. Although postoperative intra-abdominal infection has been linked with an increased risk of recurrence, the association is controversial. The aim was to investigate the impact of postoperative intra-abdominal infection on disease-free survival and disease-specific survival in patients with stage II colon cancer. METHODS: Patients undergoing elective surgery for colon cancer stage II, between 2003 and 2014, were included. Patients with anastomotic leak or intra-abdominal abscess were included in the infection group. We used the Kaplan-Meier method to represent the distribution of survival and the Cox proportional hazards model to estimate the contribution of relevant clinicopathological factors with prognosis. RESULTS: Postoperative intra-abdominal infection was diagnosed in 37 of 363 (10.2%) patients. Perioperative blood transfusion was more frequent in patients with infection (p = 0.008). Overall 5-year disease-free survival rate was 85.1%. Disease-free survival at 5 years was lower in patients with postoperative intra-abdominal infection (52.8 vs 88.7%; p < 0.001), perineural invasion (p = 0.001), lymphovascular invasion (p = 0.001), pT4 (p = 0.013), and in patients with adjuvant chemotherapy (p = 0.013). Multivariate analysis showed that postoperative intra-abdominal infection (HR 4.275; p < 0.001), perineural invasion (HR 2.230; p = 0.007), and lymphovascular invasion (HR 2.052; p = 0.016) were all significant independent predictors of reduced disease-free survival. Regarding specific survival, independent significant prognostic factors were the number of lymph nodes, lymphovascular invasion, and postoperative intra-abdominal infection. CONCLUSION: In this series of patients with stage II colon cancer, postoperative intra-abdominal infection has an independent negative impact on disease-free survival and disease-specific survival.

Long-term effectiveness of irreversible electroporation in a murine model of colorectal liver metastasis.

Irreversible electroporation (IRE) has recently gained in popularity as an ablative technique, however little is known about its oncological long-term outcomes. To determine the long-time survival of animals treated with a high dose of IRE and which histological changes it induces in tumoral tissue, IRE ablation was performed in forty-six athymic-nude mice with KM12C tumors implanted in the liver by applying electric current with different voltages (2000 V/cm, 1000 V/cm). The tumors were allowed to continue to grow until the animals reached the end-point criteria. Histology was harvested and the extent of tumor necrosis was semi-quantitatively assessed. IRE treatment with the 2000 V/cm protocol significantly prolonged median mouse survival from 74.3 ± 6.9 days in the sham group to 112.5 ± 15.2 days in the 2000 V/cm group. No differences were observed between the mean survival of the 1000 V/cm and the sham group (83.2 ± 16.4 days, p = 0.62). Histology revealed 63.05% ± 23.12 of tumor necrosis in animals of the 2000 V/cm group as compared to 17.50% ± 2.50 in the 1000 V/cm group and 25.6% ± 22.1 in the Sham group (p = 0.001). IRE prolonged the survival of animals treated with the highest electric field (2000 V/cm). The animals in this group showed significantly higher rate of tumoral necrosis.

Irreversible electroporation of the liver: is there a safe limit to the ablation volume?

Irreversible electroporation is a fast-growing liver ablation technique. Although safety has been well documented in small ablations, our aim is to assess its safety and feasibility when a large portion of liver is ablated. Eighty-seven mice were subjected to high voltage pulses directly delivered across parallel plate electrodes comprising around 40% of mouse liver. One group consisted in 55 athymic-nude, in which a tumor from the KM12C cell line was grown and the other thirty-two C57-Bl6 non-tumoral mice. Both groups were subsequently divided into subsets according to the delivered field strength (1000 V/cm, 2000 V/cm) and whether or not they received anti-hyperkalemia therapy. Early mortality (less than 24 hours post-IRE) in the 2000 V/cm group was observed and revealed considerably higher mean potassium levels. In contrast, the animals subjected to a 2000 V/cm field treated with the anti-hyperkalemia therapy had higher survival rates (OR = 0.1, 95%CI = 0.02-0.32, p < 0.001). Early mortality also depended on the electric field magnitude of the IRE protocol, as mice given 1000 V/cm survived longer than those given 2000 V/cm (OR = 4.7, 95%CI = 1.8-11.8, p = 0.001). Our findings suggest that ionic disturbances, mainly due to potassium alterations, should be warned and envisioned when large volume ablations are performed by IRE.

Educación para la salud en pediatría a través de una aplicación para teléfonos móviles / Health education through a pediatric mobile phone application

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Bloqueo auriculoventricular transitorio de primer grado en paciente con poliintoxicación por drogas de abuso y etanol: the Holiday Heart Syndrome / Transitory first degree atrioventricular block in patient with poisoning for drug abuse and alcohol: the Holiday Heart Syndrome

Las intoxicaciones por alcohol y drogas de abuso son una causa frecuente de consulta en los Servicios de Urgencias. Las alteraciones electrocardiográficas y las arritmias debidas a la ingesta de alcohol se conocen como Holiday Heart Syndrome. Este síndrome se define como la presencia de alteraciones del ritmo o de la conducción cardiaca asociadas al consumo de alcohol que revierten tras la intoxicación y que se producen en una persona sin enfermedad cardiaca conocida. La alteración más común es la fibrilación auricular. Se presenta el caso de una paciente joven que ingresa en urgencias por intoxicación por alcohol y diferentes drogas y que presentaba un bloqueo auriculoventricular de primer grado transitorio. Se discute el posible efecto causal de las drogas y del alcohol en los cambios electrocardiográficos observados en esta paciente (AU)

Alcohol intoxication and drug abuse are a common cause of visits to emergency rooms. Arrhythmias and electrocardiographic changes due to alcohol intake is called Holiday Heart Syndrome. It is defined as a rhythm or cardiac conduction alterations associated to the consumption of alcohol, reversed after the poisoning, in a person without known heart disease. The most common alteration is atrial fibrillation. We report the case of a young patient that presented in the emergency room by poisoning with different drugs and alcohol who presented transitory first degree atrioventricular block. We discussed the possible causal effect of drugs and alcohol consumed in the electrocardiographic changes in this patient (AU)

Triaje de las urgencias pediátricas en Atención Primaria en España mediante telefonía móvil. Análisis de un modelo en una zona de salud / Paediatric emergency triage in Spanish primary care using mobile phones. Analysis of a model in a health area

Objetivos. Llevar a cabo un estudio piloto de consulta telefónica en la población pediátrica de un Centro de Salud urbano. Evaluar la consulta telefónica como un instrumento eficaz a la hora de ejercer un triaje previo de los pacientes que demandan atención urgente. Material y métodos. Se efectuó un trabajo piloto en 2 fases. En la primera de ellas se recogieron datos de todas las llamadas recibidas durante 6 meses. En una segunda fase se realizó un estudio de intervención telefónica para analizar en una muestra aleatoria de usuarios el recuerdo de la atención recibida. Se incluyeron como sujetos todos aquellos que solicitaron una demanda telefónica de consulta. En cada uno de ellos se monitorizan variables demográficas, sociosanitarias, epidemiológicas y clínicas. Se procesaron los datos mediante un paquete estadístico SPSS versión 17.0 para Windows. Resultados. En nuestro proyecto telefónico piloto se registraron 439 consultas telefónicas. El 35,1% fueron atendidas por residentes, 36% por pediatras y 28,9% por enfermeras dedicadas a pediatría. La consulta telefónica fue demandada de manera más frecuente en horario de tarde y en fin de semana. Los menores o iguales de 2 años supusieron el 57,9% de las consultas atendidas y no hubo diferencias entre sexos. Los motivos más frecuentes de consulta fueron síntomas gastrointestinales, fiebre y respiratorios. Se comprobó que el consejo fuese resolutivo en el 85,8%, precisando únicamente instrucciones de manejo domiciliario, y solo el 13,3% de los niños precisaron derivación a los servicios de urgencias. Se obtuvo una puntuación media de satisfacción de 9,2. Conclusiones. El proyecto piloto tuvo un alto nivel de satisfacción y capacidad resolutiva, demostrando un ahorro de costes de un 55% respecto a las consultas presenciales con un ahorro de 35,2 euros por consulta telefónica. El modelo de teleconsulta para la atención de las urgencias en Atención Primaria mediante teléfono sería asimilable a un consejo atendido por enfermeras pediátricas entrenadas(AU)

Objectives. To conduct a pilot study of telephone consultation in the paediatric population of an urban health centre. To evaluate the telephone consultation as an effective tool when it comes to exercising prior triage of patients requiring urgent attention. Material and methods. The study was conducted in two phases. In the first, data were collected from all calls received for six months. In a second phase, we conducted a telephone intervention study to analyse what a random sample of users remembered of the care provided. All those who requested a telephone consultation were included in the study. Demographic, social-welfare, epidemiological, and clinical features, of each patient were recorded. Data were processed using a statistical package SPSS version 17.0 for Windows. Results. There were 439 telephone inquiries in our pilot project, of which 35.1% were attended by residents, 36% by paediatricians, and 28.9% by paediatric nurses. There were more telephone calls in the afternoons and on weekends. Patients less than or equal to 2 years accounted for 57.9% of cases handled, and there were no differences between sexes. The most frequent reasons for consultation were gastrointestinal symptoms, fever and respiratory problems. The health problem was resolved in 85.8% of cases, requiring only home care instructions, and only 13.3% of children were referred to emergency services. We obtained a mean score of satisfaction of 9.2. Conclusions. The pilot project had a high level of satisfaction and resolution, demonstrating cost savings by reducing 55% of face to face visits, with a saving of 35.2 euros per telephone consultation. A teleconsultation model for dealing with emergencies in primary care by telephone would be comparable to a practice staffed by trained paediatric nurses(AU)

[Paediatric emergency triage in Spanish primary care using mobile phones. Analysis of a model in a health area]. / Triaje de las urgencias pediátricas en Atención Primaria en España mediante telefonía móvil. Análisis de un modelo en una zona de salud.

OBJECTIVES: To conduct a pilot study of telephone consultation in the paediatric population of an urban health centre. To evaluate the telephone consultation as an effective tool when it comes to exercising prior triage of patients requiring urgent attention. MATERIAL AND METHODS: The study was conducted in two phases. In the first, data were collected from all calls received for six months. In a second phase, we conducted a telephone intervention study to analyse what a random sample of users remembered of the care provided. All those who requested a telephone consultation were included in the study. Demographic, social-welfare, epidemiological, and clinical features, of each patient were recorded. Data were processed using a statistical package SPSS version 17.0 for Windows. RESULTS: There were 439 telephone inquiries in our pilot project, of which 35.1% were attended by residents, 36% by paediatricians, and 28.9% by paediatric nurses. There were more telephone calls in the afternoons and on weekends. Patients less than or equal to 2 years accounted for 57.9% of cases handled, and there were no differences between sexes. The most frequent reasons for consultation were gastrointestinal symptoms, fever and respiratory problems. The health problem was resolved in 85.8% of cases, requiring only home care instructions, and only 13.3% of children were referred to emergency services. We obtained a mean score of satisfaction of 9.2. CONCLUSIONS: The pilot project had a high level of satisfaction and resolution, demonstrating cost savings by reducing 55% of face to face visits, with a saving of 35.2 euros per telephone consultation. A teleconsultation model for dealing with emergencies in primary care by telephone would be comparable to a practice staffed by trained paediatric nurses.

SPE biosensor for cholesterol in serum samples based on electrochemiluminescent luminol copolymer.

A poly(luminol-3,3',5,5'-tetramethylbenzidine) copolymer manufactured by electropolymerization on screen-printed gold electrodes greatly improves the electrochemiluminescence of hydrogen peroxide. Cholesterol oxidase was immobilized on the surface of a poly(luminol-3,3',5,5'-tetramethylbenzidine) screen-printed cell modified with chitosan to prepare an ECL biosensor for cholesterol. Working under the optimized conditions, the linear dynamic range of cholesterol was 2.4 × 10(-5)-1.0 × 10(-3)M with a limit of detection of 7.3 × 10(-6)M and a precision of 10.3% (5.0 × 10(-4)M, n=5) expressed as relative standard deviation. This biosensor was applied to the determination of total cholesterol in serum samples obtaining satisfactory results with respect to the reference procedure. This cholesterol biosensor offers an alternative analytical method with low cost and high speed.

[Metabolic syndrome and its components in patients with sleep apnea syndrome]. / Síndrome metabólico y sus componentes en pacientes con síndrome de apnea-hipoapnea del sueño.

BACKGROUND: Sleep Apnea Syndrome (SAHS) represents a significant risk factor for the development of cardiovascular disease and evidence suggests a relation with Metabolic Syndrome (MS). The aim of this study was to determine the prevalence of individual components of MS and of MS as an entity, in patients with clinical suspicion of SAHS, and their relation to central obesity. METHODS: We examined the records of 486 consecutive patients, 359 (73.9%) men, with a mean age of 57.3 ± 13.5 years and a mean body mass index (BMI) of 32.1 ± 6.5 kg/m(2)), with clinical suspicion of SAHS. SAHS was diagnosed from the nocturnal register. An Apnea-Hipopnea Index (AHI) > 5 was considered SAHS. MS was evaluated according to the diagnostic criteria of the International Diabetes Federation. RESULTS: Three hundred and twenty-five (66.9%) of the entire group were moderate-severe SAHS. The mean of AHI was 30.2 ± 23.8. We had sufficient data available on 456 patients (93.8%) for MS diagnosis and its prevalence was 64.7% (295 patients). Multivariate analysis showed that age and abdominal perimeter were predictors of SAHS and MS (p<0.05). CONCLUSIONS: Patients with SAHS have a high prevalence of MS and their prevalence is greater in patients with major levels of SAHS. The rate of central obesity, measured by abdominal perimeter, predicts SAHS and MS.

Estudio piloto de consulta telefónica pediátrica / Pilot study of a telephone pediatric consultation

Introducción: Las urgencias pediátricas en Atención Primaria han aumentado enormemente en los últimos años. Los motivos de consulta suelen ser procesos banales, cuadros autolimitados que saturan las urgencias y obstaculizan la atención del niño críticamente enfermo. Presentamos un estudio piloto en población pediátrica de un centro de salud urbano, tras la implementación de consulta telefónica durante 6 meses. Material y métodos: Se realizó un estudio ambispectivo con una fase prospectiva a lo largo de seis meses y un análisis retrospectivo de la información generada. Se incluyeron como sujetos todos aquellos que solicitaban demanda telefónica de consulta. En cada uno de ellos se monitorizaron variables demográficas, socio-sanitarias, epidemiológicas y clínicas. Resultados: Se registraron 419 consultas telefónicas. El 37% fueron atendidas por residentes, 33% por pediatras y 30% por enfermeras dedicadas a pediatría. Los menores de 2 años supusieron el 48% de las consultas atendidas y no hubo diferencias entre sexos. Los motivos más frecuentes de consulta fueron síntomas gastrointestinales y fiebre. En las 24 horas siguientes se comprobó que el consejo fue resolutivo en el 56%, 27% acudió a su pediatra, 15% necesitaron acudir al servicio de urgencias y solo el 1% precisó ingreso. Se obtuvo una puntuación media de satisfacción de 9,24. Conclusiones: Destacamos que la consulta telefónica resuelve adecuadamente la mayoría de los problemas de salud planteados y que proporciona niveles muy altos de satisfacción de la población atendida(AU)

Histiocitosis X / Histiocytosis X

La histiocitosis X es una enfermedad pulmonar intersticial poco común que afecta a adultos jóvenes y se asocia en un elevado número de casos con antecedente de tabaquismo. Se describen 4 casos de histiocitosis X, revisando las características clínicas, diagnósticas y terapéuticas de la enfermedad (AU)

Histiocytosis X is an uncommon pulmonary interstitial disease that affects young adults and is associated to an elevated number of cases with a background of smoking. Four cases of histiocytosis X are described, reviewing the clinical, diagnostic and therapeutic characteristics of the disease (AU)