Hipotensión arterial postoperatoria: el enemigo inadvertido / Postoperative arterial hypotension: The unnoticed enemy

La hipotensión postoperatoria es un problema de salud frecuentemente subestimado, asociado a una elevada morbimortalidad y a un mayor uso de recursos sanitarios. También plantea importantes retos clínicos, tecnológicos y humanos para la asistencia sanitaria. Al tratarse de un factor de riesgo modificable y evitable, este documento pretende aumentar su visibilidad, definiendo su impacto clínico y los retos tecnológicos que conlleva la optimización de su manejo, teniendo en cuenta aspectos clínico-tecnológicos, humanísticos y económicos.(AU)

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.(AU)

Postoperative arterial hypotension: the unnoticed enemy.

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.

Obesity and female sexual dysfunctions: A systematic review of prevalence with meta-analysis.

Obesity represents a major global health challenge. Female sexual dysfunctions have a negative impact on quality of life and overall health balance. A higher rate of female sexual dysfunctions in obese women has been suggested. This systematic review summarized the literature on female sexual dysfunction prevalence in obese women. The review was registered (Open Science Framework OSF.IO/7CG95) and a literature search without language restrictions was conducted in PubMed, Embase and Web of Science, from January 1990 to December 2021. Cross-sectional and intervention studies were included, the latter if they provided female sexual dysfunction rate data in obese women prior to the intervention. For inclusion, studies should have used the female sexual function index or its simplified version. Study quality was assessed to evaluate if female sexual function index was properly applied using six items. Rates of female sexual dysfunctions examining for differences between obese vs class III obese and high vs low quality subgroups were summarized. Random effects meta-analysis was performed, calculating 95% confidence intervals (CI) and examining heterogeneity with I2 statistic. Publication bias was evaluated with funnel plot. There were 15 relevant studies (1720 women participants in total with 153 obese and 1567 class III obese women). Of these, 8 (53.3%) studies complied with >4 quality items. Overall prevalence of female sexual dysfunctions was 62% (95% CI 55-68%; I2 85.5%). Among obese women the prevalence was 69% (95% CI 55-80%; I2 73.8%) vs 59% (95% CI 52-66%; I2 87.5%) among those class III obese (subgroup difference p=0.15). Among high quality studies the prevalence was 54% (95% CI 50-60%; I2 46.8%) vs 72% (95% CI 61-81%; I2 88.0%) among low quality studies (subgroup difference p=0.002). There was no funnel asymmetry. We interpreted that the rate of sexual dysfunctions is high in obese and class III obese women. Obesity should be regarded as a risk factor for female sexual dysfunctions.

Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes.

OBJECTIVES: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS: Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

Protocolo de extubación ultra-fast track tras cirugía cardiovascular: predictores de fracaso y resultados / Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes

Objetivos: Identificar los factores predictores independientes de fracaso de la extubación ultra-fast track (UFT) y comparar los resultados hospitalarios de la extubación UFT frente a la extubación fast track en pacientes adultos sometidos a cirugía cardiovascular. Material y métodos: Análisis retrospectivo de 1.498 pacientes consecutivos mayores de 18 años sometidos a cirugía cardiovascular en un solo centro. Entre diciembre 2014 y diciembre 2016 se utilizó la extubación fast track (n=713), mientras que, entre diciembre 2016 y diciembre 2018 todos los pacientes fueron considerados preoperatoriamente aptos para extubación UFT (n=785). En este caso se empleó el mismo protocolo anestésico estandarizado en todos los pacientes. La decisión de extubar o no en quirófano se basó exclusivamente en parámetros hemodinámicos y ventilatorios. Resultados: La extubación en quirófano fue posible en 699 (89%) pacientes. Los factores predictores independientes de fracaso de la extubación UFT fueron: clase funcional preoperatoria iii-iv de la NYHA, infarto agudo de miocardio dentro de los 2 días previos a la cirugía, balón de contrapulsación intraaórtico preoperatorio, cirugía urgente o emergente, transfusión intraoperatoria de plaquetas y soporte intraoperatorio con fármacos inotrópicos y vasopresores. La extubación UFT se asoció con una menor tasa de complicaciones cardiovasculares, como insuficiencia cardiaca congestiva (OR: 1,57; IC 95%: 1,13-2,19; p=0,008) y fibrilación auricular postoperatoria de novo (OR: 1,40; IC 95%: 1,06-1,86; p=0,020). Los pacientes extubados en quirófanos presentaron un menor riesgo de complicaciones globales, menor estancia en la UCI y mayor supervivencia a corto plazo, aunque no se encontraron diferencias estadísticamente significativas al realizarse el ajuste multivariante. Conclusiones: La extubación inmediata rutinaria en quirófano tras cirugía cardiovascular en adultos es una...(AU)

Objectives: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. Material and methods: Retrospective analysis of 1,498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N=713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N=785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. Results: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; P=0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; P=0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. Conclusions: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.(AU)

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). / Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP).

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

[Design and validation of the second edition of the Women's Sexual Function Questionnaire, FSM-2]. / Diseño y validación de la segunda edición del Cuestionario de Función Sexual de la Mujer, FSM-2.

OBJECTIVE: To design and validate the second edition of the Female Sexual Function questionnaire (FSF-2). MATERIAL AND METHODS: A cross-sectional and multicentre study was conducted on 187 women (18-70 years) who completed a test (preliminary questionnaire FSF-2), and then answered a structured anamnesis on female sexual function. Four weeks later they completed a retest, which was equal to the test but with an additional question about possible influence of recent events in their sex life. RESULTS: The mean age of the women was 43.51 years. Internal consistency of the questionnaire: Cronbach's α of the 0.919 test, of structured anamnesis 0.921, of the 0.920 retest. Test-retest reliability: mean test scores 30.53 ± 8.605, retest 30.05 ± 8.770, without significant differences. Correlation between total test and retest scores (intraclass correlation coefficient) 0.960, significant (P<.01); between total test scores and structured anamnesis 0.977, significant (P<.01). Concordance between test questions and structured anamnesis (kappa index), minimum 0.706, maximum 0.915; between test and retest questions, minimum 0.630, maximum 0.802. Content validity by expert consensus. Criteria validity: specificity of the questionnaire exceeding 90% for all items/domains, sensitivity greater than 80%, except for items 5, 6, 9 (70-80%). Validity of the construct through factor analysis, grouping of items into 2 components (they explain 66.586% of variance). CONCLUSIONS: The FSF-2 questionnaire is reliable and valid. It evaluates the sexual response of women, describing important aspects of their sexual activity as a couple: anticipatory anxiety, initiative, confidence to communicate, preferences and events that may influence. It can detect sexual dysfunction in the couple.

[Design and validation of a Male Sexual Function Questionnaire]. / Diseño y validación del Cuestionario de Función Sexual del Hombre, FSH.

OBJECTIVE: The objective of this work was to design and validate a questionnaire on Male Sexual Function (MSF) in the Spanish language, following the criteria contemplated in the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, for the diagnosis of sexual dysfunctions. MATERIAL AND METHODS: A cross-sectional and multicentre study was conducted on 163 men (18-70 years) who self-completed a test (MSF questionnaire). They then answered questions on the Structured History of Male Sexual Function (AMSF). Four weeks later they completed a re-test, which was the same, but including a supplementary question about the possible influence of recent events. RESULTS: Internal consistency: Cronbach's α test 0.840, AMSF 0.835, retest 0.855. Test-retest reliability: mean test scores 33.13±6.566, retest 33.11±6.791; Student t 0.122, not significant (P=.903); correlation total test-retest scores (intraclass correlation coefficient) 0.979, significant correlation (P<.01); total correlations test-AMSF scores (intraclass correlation coefficient) 0.966, significant correlation (P<.01). Concordance: between questions of the AMSF test (Kappa index) minimum 0.749, maximum 0.934; between test-retest questions: 0.724, 0.844. Content validity using expert consensus. Criteria validity: specificity>90% for all items / domains, sensitivity>80% except item 4 (76%). Content validity: using factor analysis, grouping of items into 4 components (explain 75% variance); high correlation between "sexual desire" and "confidence in erection". CONCLUSIONS: The MSF questionnaire is reliable, stable and valid, with high specificity and sensitivity. It evaluates the sexual response of the male, describing aspects of interest: anticipatory anxiety, initiative, confidence to communicate preferences, events that may influence. Can detect sexual dysfunction in the couple.

[Pharmacological treatment of the premature ejaculation]. / Tratamiento farmacológico de la eyaculación precoz.

Biomedical approach to premature ejaculation (PE) has permited a better phisiopatologycal knowledge and so the use of pharmacological agents for the treatment of this sexual dysfuncion. Most of the studies to evaluate the eficacy of these drugs were not carried at all the parameters which actually define PE: intravaginal ejaculatory latencie time (IELT) tested with watch, ejaculation control self perception cuantification (questionaries) and cuantification of generated consequences in patient and partner, if it existes. For this reason, it is difficult to analyse the scientific evidence and we use medicines with no approved indication for PE ("off label"). This text is a review of pharmacologycal agents with no approved indication (PDE type 5 inhibitors, α-blockers, tramadol, SSRI, clomipramine), and pharmacologycal agents developed to be used in the treatment of PE and having got indication in this sexual dysfunction or "on label" drugs (topic anesthesics, dapoxetine).

La anamnesis en la historia clínica en salud sexual: habilidades y actitudes / The medical history taking in sexual health: skills and attitudes

Una vida sexual satisfactoria repercute de manera favorable en la calidad de vida, existiendo evidencia de que previene múltiples procesos orgánicos y de que las disfunciones sexuales constituyen a menudo un signo precoz de enfermedad orgánica oculta (cardiovascular, endocrinológica o neurológica). Existen dificultades para realizar la anamnesis sexual por parte del profesional, del paciente o del sistema de salud, sin embargo, dada su importancia, es necesario que el médico adopte una actitud de búsqueda activa, sobre todo entre la población de riesgo. Para realizarla es necesario que la situación sea propicia (sentido de la oportunidad), preservando la confidencialidad del encuentro, y se llevará a cabo con naturalidad, empatía, adoptando una actitud de escucha activa, cuidando el lenguaje no verbal, sin emitir juicios de valor y recurriendo a la asertividad para superar las resistencias. En esta publicación se propone una pauta para realizarla adecuadamente (AU)

A sexual satisfactory life favourably affects quality of life, there being evidence that shows there are multiple organic processes of which sexual dysfunction is often a precocious sign of underlying organic disease (cardiovascular, endocrinological or neurological). Difficulties exist in recording the sexual anamnesis on the part of the professional, the patient, or by the health system. Nevertheless, given its importance, it is necessary for the doctor to adopt an attitude of active search, especially among the population of risk. To do this, it is necessary that the situation is propitious (sense of the opportunity), preserving the confidentiality of the meeting, and it will be carried out naturally and with empathy, adopting a listening attitude, taking into account the non-verbal language, without issuing valued judgments, and resorting to assertivity to overcome the resistances. This article proposes guidelines to perform an anamnesis adequately (AU)

[The medical history taking in sexual health: skills and attitudes]. / La anamnesis en la historia clínica en salud sexual: habilidades y actitudes.

A sexual satisfactory life favourably affects quality of life, there being evidence that shows there are multiple organic processes of which sexual dysfunction is often a precocious sign of underlying organic disease (cardiovascular, endocrinological or neurological). Difficulties exist in recording the sexual anamnesis on the part of the professional, the patient, or by the health system. Nevertheless, given its importance, it is necessary for the doctor to adopt an attitude of active search, especially among the population of risk. To do this, it is necessary that the situation is propitious (sense of the opportunity), preserving the confidentiality of the meeting, and it will be carried out naturally and with empathy, adopting a listening attitude, taking into account the non-verbal language, without issuing valued judgments, and resorting to assertivity to overcome the resistances. This article proposes guidelines to perform an anamnesis adequately.

Weight loss induced by 6-month lifestyle intervention improves early endothelial activation and fibrinolysis in obese adolescents.

BACKGROUND: Adolescent obesity is associated with an increased risk of adult obesity and subsequent cardiovascular diseases. The present study aimed to assess the effect of weight loss after 6-month lifestyle intervention in obese adolescents on biomarkers of endothelial activation and fibrinolytic system. METHODS: Eighty-five obese adolescents aged 10 to 16 years were assigned to a 6-month lifestyle intervention and 61 completed the programme. We examined the effect of the intervention on adhesion molecules (selectin E, soluble intercellular adhesion molecule 1 and soluble vascular adhesion molecule 1) and fibrinolytic parameters [plasminogen activator inhibitor-1 (PAI-1) and fibrinogen]. Thirty-six lean adolescents were studied only at baseline as a comparison group. RESULTS: Compared with lean participants, obese adolescents at baseline demonstrated significantly higher levels of triglycerides, glucose, insulin, homeostasis model assessment, soluble intercellular adhesion molecule 1, PAI-1 and fibrinogen. After 6-month lifestyle intervention, those obese adolescents with decreased standard deviation score-body mass index (SDS-BMI) displayed significant decreases in insulin (19.2 ± 11.2 vs. 26.8 ± 13.2 mU/L, P≤ 0.01), homeostasis model assessment (4.24 ± 3.19 vs. 6.58 ± 4.08, P≤ 0.01), selectin E (100.2 ± 60.9 vs. 116.0 ± 69.0 ng/mL, P≤ 0.01) and PAI-1 (39.6 ± 38.0 vs. 51.8 ± 25.6 ng/mL, P≤ 0.05) with respect to the baseline levels. No changes in these parameters were observed in the obese adolescents with stable or increased SDS-BMI. The changes of triglycerides after intervention in subgroup with decreased SDS-BMI were significantly greater than those in subgroup with stable SDS-BMI. CONCLUSIONS: The present study demonstrated increased endothelial activation and impairment of the fibrinolytic system in early life, which is in part reversible by a 6-month lifestyle intervention.

A new generation of bio-derived ceramic materials for medical applications.

A new generation of bio-derived ceramics can be developed as a base material for medical implants. Specific plant species are used as templates on which innovative transformation processes can modify the chemical composition maintaining the original biostructure. Building on the outstanding mechanical properties of the starting lignocellulosic templates, it is possible to develop lightweight and high-strength scaffolds for bone substitution. In vitro and in vivo experiments demonstrate the excellent biocompatibility of this new silicon carbide material (bioSiC) and how it gets colonized by the hosting bone tissue because of its unique interconnected hierarchic porosity, which opens the door to new biomedical applications.

New biomorphic SiC ceramics coated with bioactive glass for biomedical applications.

A new generation of light, tough and high-strength material for medical implants for bone substitutions with a good biological response is presented. The innovative product that fulfills all these requirements is based on biomorphic silicon carbide ceramics coated with a bioactive glass layer. The combination of the excellent mechanical properties and low density of the biomorphic SiC ceramics, used as a base material for implants, with the osteoconducting properties of the bioactive glass materials opens new possibilities for the development of alternative dental and orthopedic implants with enhanced mechanical and biochemical properties that ensures optimum fixation to living tissue. Biomorphic SiC is fabricated by molten-Si infiltration of carbon templates obtained by controlled pyrolysis of wood. Through this process, the microstructure of the final SiC product mimics that of the starting wood, which has been perfected by natural evolution. The basic features of such microstructure are its porosity (ranging from 30% to 70%) and its anisotropy, which resembles the cellular microstructure and the mechanical characteristics of the bone. The SiC ceramics have been successfully coated with a uniform and adherent bioactive glass film by pulsed laser ablation using an excimer ArF laser. The excellent coverage of the SiC rough surface without film spallation or detachment is demonstrated. In order to assess the coating bioactivity, in vitro tests by soaking the samples in simulated body fluid have been carried out. After 72 h, the formation of a dense apatite layer has been observed even in interconnecting pores by SEM and energy dispersive X-ray spectroscopy analysis demonstrating the bioactive response of this product.

Determinación de triptófano en cerebro de ratas expuestas a ozono / Brain tryptophan levels in rats exposed to ozone

El objetivo del presente trabajo es cuantificar los niveles de triptófano por CLAR líquidos de alta resolución en 4 regiones del cerebro (cerebelo, corteza, hemisferio y tallo) en ratas machos de la cepa Wistar, de 50 días de edad con diferente condición nutricional expuestas a ozono o aire. Un grupo de animales fue alimentado con una dieta normal de bioterio (23 por ciento de proteína), y otro con una dieta deficiente en proteínas (7 por ciento de proteína). Ambos grupos fueron expuestos a 0.5 ppm de ozono o aire fresco, por 6 horas al día durante 30 días consecutivos. Los resultados muestran diferencias significativas en los niveles de triptófano en todas las regiones del estudio entre los grupos con diferente condición nutricional (p<0.05). Estos resultados sugieren que la alimentación deficiente en proteínas y la exposición a ozono, son condiciones que favorecen la formación de diversas reacciones que alteran los niveles de triptófano en el cerebro

[Basal cell carcinoma of the scrotum. A rare localization linked to a bad prognosis]. / Carcinoma basocelular del escroto. Una rara localización ligada a mal pronóstico.

OBJECTIVE: To present a case of basal cell carcinoma of the scrotum. METHODS: In a review of 56 scrotal tumors, we found 4 primary neoplasias, 3 benign mesenchymal tumors and one malignant tumor, the basal cell carcinoma of the scrotum described herein. RESULTS: A 52-year-old patient with no remarkable urological or dermatological history, complained of an excrescence in the right hemiscrotum that he had noted for several years. A clinical diagnosis of basal cell carcinoma of the scrotum was made and the lesion was surgically excised. Pathological analysis of the surgical specimen confirmed the diagnosis. CONCLUSIONS: Basal cell carcinoma is the most common type of skin cancer in the middle-aged and elderly, but localization to the scrotum is rare. It is a tumor that grows locally and rarely metastasizes, although scrotal tumors are much more aggressive and patients should therefore be followed very closely after resection of the tumor.

Differential regulation of p21waf-1/cip-1 and Mdm2 by etoposide: etoposide inhibits the p53-Mdm2 autoregulatory feedback loop.

The Mdm2 protein is frequently overexpressed in human non-seminomatous germ cell tumours and transitional carcinoma of the bladder where it may contribute to tolerance of wtp53. Mdm2 forms an autoregulatory feedback loop with p53; the Mdm2 gene is responsive to transactivation by p53 and once synthesized the Mdm2 protein terminates the p53 response. We show here that the topoisomerase poison etoposide, like ultra violet irradiation, inhibits Mdm2 synthesis. Cytotoxic concentrations of etoposide (IC90 for > 3 h) result in inhibition of Mdm2 induction at both the RNA and protein level. Rapid apoptosis ensues. Global transcription is not inhibited: p21waf-1/cip1 and GADD45 expression increase in a dose dependent manner. Inhibition of Mdm2 synthesis depends on the continuous presence of etoposide, suggesting the DNA damage may prevent transcription. Downregulation of Mdm2 transcript occurs in cells expressing HPV16-E6 suggesting that inhibition of Mdm2 transcription is p53-independent. When cells are -treated with a pulse (1 h) of etoposide and reincubated in drug free medium, Mdm2 synthesis commences immediately after damage is repaired (3 h) and the p53 response is attenuated. Induction of apoptosis and loss of clonogenicity are 3-5-fold lower under pulse treatment conditions. This is the first observation of inhibition of Mdm2 transcription following treatment with topoisomerase (topo II) poisons, a feature that may be useful in tumour types where p53 is tolerated by overexpression of Mdm2.