[How to manage risk in the surgical area. A Modal Analysis of Failures and Surgical Effects]. / Cómo gestionar el riesgo en el área quirúrgica. Análisis modal de fallos y efectos quirúrgicos.

OBJECTIVE: First to identify the areas of improvement in the surgical area before and during the performance of a surgical procedure in general surgery through the application of a Modal Analysis of Failures and Effects. Second to establish preventive measures to avoid adverse events in the surgical area. METHOD: A multidisciplinary working group was created in a university hospital for risk management in the General Surgery Operating Room Unit. The Modal Analysis of Faults and Effects was used. Potential risks for the patient in the ante-surgery and within the operating room were identified. The Risk Priority Index was calculated and preventive measures were established for all of them, with special interest when the Risk Priority Index was higher than 100. Preventive measures were developed based on the detected risks as well as those responsible for them. RESULTS: We identified a greater number of risks when the patient is in the operating room than in the ante-surgery room. Those with a higher risk priority index were: anticoagulated or antiaggregated patients, urinary tract infections, osteoarticular or neuropathic problems, patients not prepared for colon surgery, errors in laterality and leaving compresses in the operative field. CONCLUSIONS: A risk map has been developed in our organization, allowing the design of strategies to improve Patient Safety in the Surgical area. Training is a key aspect to improve Patient Safety.

[Creation and validation of a new in-house synthetic scale to measure patient safety culture]. / Creación y validación de una nueva escala para medir cultura de seguridad del paciente en el medio hispano hablante.

OBJECTIVE: Creation and validation of a new in-house synthetic scale to measure patient safety culture. MATERIAL AND METHOD: Cross-sectional and descriptive study in which the results of the assessment of the level of safety culture in health and non-health professionals of a university hospital are collected using a new in-house synthetic scale as a measurement tool. It is called 'Questionnaire on patient safety culture in a Spanish speaking environment'. The construction process was carried out in six phases: Bibliographic search; Validation of the structure and content of the questionnaire by a group of experts in patient safety using a nominal group technique; Assumptions verification and exploratory factor analysis; Pilot test to ensure its compression by a convenience sample of expert professionals; Modification of version 1.1 after the relevant analyses and analysis of the reliability of the questionnaire. RESULTS: The final version of the questionnaire had nine items, grouped into three factors a priori: Hospital Management support in patient safety, Perception of Safety, and Expectations and actions of the Managers/Supervisors that favour safety. The items were structured using a 5-point Likert scale. A general assessment item on patient safety at the Centre was also included, as well as five open questions to identify actions on patient safety undertaken by the Centre. Finally, the possibility of making observations in a section of free text was included. The comprehension analysis did not recommend, in any case, the revision of the wording or modification of the items. The Spearman and Pearson indices were similar, which allowed us to assume the linearity in the relationships proposed. The Kolmogorov-Smirnov test was satisfactory in all cases, which guaranteed the normal distribution of the variables. The sample was adequate to perform the factorial analysis. Both the Bartlett' sphericity test and the Kaiser-Meyer-Olkin (KMO) index showed sample quality to perform the analysis. The recommendation of the exploratory factor analysis that advised eliminating 1 item was followed. Specifically, item 9 was eliminated: 'It is only a matter of luck that in my Centre no more errors occur that affect patients'. The analysis of our scale has shown that all the factorial loads were greater than 0.5, which indicates good explanatory capacity of the item for the Dimension. In total, the scale manages to explain more than 60% of the perception by professionals in patient safety, considering an acceptable loss of information. CONCLUSIONS: A new and validated in-house scale has been created to measure patient safety culture in the Spanish speaking healthcare environment.

Technical aids for speech understanding in cochlear implanted adults using cell-phones.

OBJECTIVES: The present study sought to assess (1) phone use habits and awareness of listening aids in adult cochlear implant bearers, and (2) objective and subjective benefit of listening aids for cell-phone communication. MATERIAL AND METHODS: A questionnaire was sent to 17 cochlear (Cochlear(®)) implanted adults to assess phone use and awareness of available listening aids. Speech perception without lip-reading was assessed in silence and in noise using Fournier dissyllabic word lists recorded on an iPhone 5C(®), with and without listening aids. Subjective benefit was assessed according to listening aid system. RESULTS: Sixty-five percent of adult cochlear implant bearers regularly used a phone with all kinds of correspondent. Eighty-eight percent phoned only in quiet conditions; 53% did not answer unknown callers; 71% never used listening aids. Speech discrimination scores for disyllabic words recorded on the phone were respectively 69%, 63%, 45% and 16% in quiet and 50, 60 and 70dB SPL noise. Speech perception in quiet and noise was improved by listening aids; the Roger system was the most beneficial, followed by the FM system, then the inductive system. CONCLUSION: Listening aids are effective, but little known by adult cochlear implant bearers.

Evaluación y manejo de los insulinomas. Presentación de 4 casos y revisión de la literatura / Evaluation and management of the insulinomas. Report of four cases and review of the literature

Introducción: Los insulinomas son tumores neuroendocrinos poco frecuentes que habitualmente tienen buen pronóstico. El objetivo es la presentación y revisión de la literatura médica a propósito de 4 casos. Material y Métodos: Estudio descriptivo, observacional y retrospectivo de los pacientes diagnosticados e intervenidos en el Hospital Universitario de San Juan de Alicante de insulinomas, en un periodo de 18 años (1995-2013). Resultados: Nuestro grupo de estudio incluyó 4 pacientes, 1 caso en hombres (25%) y 3 en mujeres (75%), con una mediana de edad de años (rango 3; 72). La distribución de las lesiones fue : cuerpo (1 caso), proceso uncinado (1 caso), cabeza (1 caso), cola (1 caso). El diagnóstico preoperatorio se realizó mediante test del ayuno y Tac abdominal. La ecografía intraoperatoria se realizó en todos los casos. El procedimiento quirúrgico de elección fue la enucleación. Actualmente se encuentran libres de enfermedad en un seguimiento a 10 años. Conclusiones: Los insulinomas son tumores infrecuentes que presentan buen pronóstico a largo plazo. Su diagnóstico topográfico en ocasiones es complejo. El tratamiento de elección es la cirugía y el procedimiento quirúrgico empleado con mayor frecuencia es la enucleación

Background: Insulinomas are infrecuent neuroendocrine tumors that usually have a good prognosis. The goal is the presentation and review of the literature about 4 cases. Methods: A retrospective study of all patients diagnosed with insulinomas surgically managed at San Juan de Alicante Hospital during the period between 1995 and 2013 was performed. Results: We analyzed 4 patients, three females (75%) and one male (25%) with a range age (39 to 72 years). Distribution of the lesions were: body (1 case), uncinate process (1 case), head (1 case), tail (1 case). Preoperative diagnosis was made by fasting test and abdominal CT. In all cases, intraoperative ultraound was made. Surgical management of choice was enucleation. Currently, they are free of disease at 10 years of follow up. Conclusions: Insulinomas are infrecuent tumors with good long-term prognosis. Its topographic diagnosis is sometimes complex. The treatment of choice is surgery and the surgical procedure most often used is enucleation

[Cochlear implants in elderly: performance outcomes in the long term]. / L'implant cochléaire chez le sujet âgé: évolution des performances à long terme.

OBJECTIVES: To study and compare the evolving capacities of speech discrimination with cochlear implants in older patients compared to patients implanted at a younger age. METHODOLOGY: A retrospective study comparing a group of 52 patients aged over 65 with a control group of 58 patients aged between 30 and 50 years, followed for 5 years after implantation. We analyzed and compared the evolution of speech discrimination in silence (disyllabic words, sentences) and noise (sentences, S/N ratio: +10 dB) after implantation. RESULTS: In the group of elderly patients, the speech discrimination in silence remains stable over time (for disyllabic words, score at 6 months: 72.8 +/- 20.2%; score at 5 years: 73.7% +/- 19.7). Discrimination in noise tends to improve (mean score at 6 months: 70.5% +/- 21.5; score at 5 years: 76.9% +/- 16.9). The results obtained are in silence are comparable to the results of the group of patients aged between 30 and 50. In noise, their performance remains lower than the control group (mean differences between scores: -10.8; confidence interval at 95%: -17.9, -5.3). CONCLUSION: The cochlear implant is effective over the long term in elderly patients, for speech discrimination in quiet and in noise. In silence, their performance is comparable to younger patients with implants.

Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture.

OBJECTIVE: Retrospective evaluation of long term results after direct suture repair of chronic traumatic aneurysm of the aortic isthmus. METHODS: From March 1979 to June 1998, a total of 19 patients with chronic traumatic aneurysm of the aortic isthmus were operated on, among whom 12 (63%) underwent direct suture. These 12 patients (age ranging from 19 to 68 years; mean 34.2 years) constitute the subject of this study. All but one suffered traffic accidents. Mean delay between trauma and surgery was 4 years (range 3 months to 12 years). All patients underwent a left posterolateral thoracotomy through the fourth intercostal space. Extracorporeal circulation for spinal cord protection was installed in six patients (five ilio-iliac shunts, one atrio-iliac shunt). Aortic rupture was partial in five and circumferential in seven patients. The mean clamping time was 25 min. The absence of loss of aortic substance and a careful mobilization of the aorta made the repair by direct suture easier; this technique could thus be achieved in 63.2% of all 19 patients operated on of chronic traumatic aneurysm within the same period. RESULTS: There was no in-hospital death and no postoperative paraplegia. With a median follow-up of 15 years 3 months (ranging from 22 to 10 years), there were no late complications. Chest X-ray was normal in all patients; eight of them underwent a control angiography between 18 and 72 postoperative months; all these angiographies but one (20% stenosis without gradient) demonstrated a normal appearance of aortic isthmus. CONCLUSION: Direct suture for repair of chronic traumatic thoracic aneurysm is a safe procedure: long-term outcome was excellent and the complications observed with prosthetic grafts or with aortic endoprosthetic stent-grafts were avoided.

Synthesis and human leukocyte elastase inhibitory evaluation of phosphate triesters and acyl phosphates of penam sulfides and sulfones.

The synthesis of 6,6-dibromo-3alpha-(diphenylphosphate)oxymethyl-2,2-dimethyl penam sulfone (3a), 6alpha-chloro-3alpha-(diphenylphosphate)oxymethyl-2,2-dimethyl penam sulfone (3b), benzyl 6alpha-(diphenyl-phosphate)oxypenicillanate sulfone (4) and 6,6-dibromo-3alpha-(methylphosphate)carbonyl-2,2-dimethylpenam sulfone (12) are reported. When tested as inhibitors of human leukocyte elastase, the compound 4 proved to be the most active.

Surgical repair of an aneurysm of the innominate artery with fistulization into the trachea.

This report describes a 43-year-old patient presenting with an aneurysm located at the junction between the innominate artery and aorta, with spontaneous fistulization into the trachea. Emergency treatment of this unusually located lesion was undertaken to prevent intratracheal rupture. After ligation of the innominate artery, right common carotid artery, and right subclavian artery due to the risk of infection, the tracheal fistula was treated by direct closure and exclusion using an autologous pericardial flap. The procedure was performed under extracorporeal circulation and circulatory arrest with profound hypothermia.

The short- and mid-term results of bidirectional cavopulmonary shunt with additional source of pulmonary blood flow as definitive palliation for the functional single ventricular heart.

OBJECTIVE: The purpose of this study was to demonstrate the early and late outcomes of bidirectional cavopulmonary shunt (BCPS) as a definitive procedure for the functional single ventricular heart. METHOD: From September 1991 to December 1997, 34 patients underwent a BCPS procedure without a routine conversion to Fontan circulation. The additional source of pulmonary blood flow was left in all patients. Conversion was performed only when it was required for excessive cyanosis. RESULTS: The hospital mortality rate was 8.8% (3/34, 95% confidence limit; 1.9-23%) and the 5-year survival rate was 75% for a mean follow-up period of 33+/-22 months. Seven patients underwent a conversion procedure for remnant or recurrent cyanosis and deterioration of exercise tolerance. Four of these patients died after conversion to Fontan circulation. Twenty-five long-term survivors with BCPSs maintained an arterial oxygen saturation of 84+/-6.1%, and 52% of them had a normal exercise tolerance or mild limitation. No patients developed severe late complications other than recurrent cyanosis. CONCLUSION: Due to the high mortality after conversion to Fontan circulation in patients whose conditions had deteriorated, we could not demonstrate the clear superiority of long-term BCPS over the construction of Fontan circulation for management of the functional single ventricular heart. If deteriorated conditions were successfully managed in the late period, the outcome of long-term BCPS would have been better.

Benefits of cochlear implantation in elderly patients.

Cochlear implantation in elderly patients is a questionable subject. The purpose of this study was to evaluate the procedure and its outcome, the postoperative course, and the audiologic and social benefits of cochlear implantation in this population. Twenty-seven patients older than 60 years were compared with a control group of 15 adult patients. This retrospective study analyzed data concerning the outcome of the procedure, postoperative course, postoperative orthophonic test results, and answers of a questionnaire assessing the changes in communication, perception, and social outcomes. The procedure was uneventful in both groups. Minor complications were not more frequent in elderly patients. Orthophonic test results were comparable in both groups. At 12 months, 83% of the elderly patients had an open-set speech discrimination score above 60%. The benefits of cochlear implantation in terms of the quality of life are not statistically different with younger patients. Cost-utility analysis might support these findings.

Recent advances in the chemistry of beta-lactam compounds as selected active-site serine beta-lactamase inhibitors.

The b-lactamases catalyze the hydrolysis of the b-lactam bond of a variety of b-lactam antibiotics destroying their antibacterial activity. During the last decades, there has been an inexorable spread of b-lactamase genes into species that previously were not known to possess them. One approach to combat the action of the b-lactamase is to inhibit the enzyme. However, inhibition of b-lactamase alone is not sufficient. The ability to penetrate the external membrane of Gram-negative bacteria, chemical stability, pharmacokinetics and other factors are also important in determining whether an inhibitor is suitable or not for therapeutic use. This review takes recent examples of synthetic b-lactam compounds developed as active-site serine b-lactamase inhibitors, emphasizing information on their structures and their activity against Ambler classes A, C and D b-lactamases. In addition, examples based on rational design by computerized molecular modeling of crystal structure of the native enzyme and mechanism of the enzyme action are highlighted.

Moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion in ascending aorta and aortic arch surgery. Preliminary experience in twenty-two patients.

Deep hypothermic cardiocirculatory arrest is the commonest method of brain protection during transverse aortic arch surgery. Its principle drawbacks consist in the limited safe ischemic period and in the coagulative, renal and pulmonary complications related to low body temperatures and prolonged cardiopulmonary bypass time. Different selective cerebral perfusion techniques have recently raised the interest of some surgical teams in an effort to obviate these problems. The authors' initial experiences with 22 patients, ranging in age from 19 to 78 years (mean, 55 +/- 15 years), who underwent ascending aorta and/or aortic arch replacement using selective cerebral perfusion and moderately hypothermic cardiopulmonary bypass are reported here. Acute aortic dissection and atherosclerotic aneurysm were the commonest lesions observed: ascending aorta associated with partial or complete arch replacement was the most widely performed procedure. With regard to the perfusion technique, after regular cardiopulmonary bypass had been established through the iliac vessels, selective cerebral perfusion was started after aortic arch vessels cannulation (innominate artery, bilateral common carotid artery, innominate artery and left common carotid artery, or right common carotid artery) using a single roller pump separately from the systemic circulation, and brain perfusion was achieved by blood cooled at 30 degrees C, at a flow rate that ranged from 300 ml/min to 1500 ml/min, at a perfusion pressure of approximately 65 mmHg, with the patient maintained at moderate hypothermia (30 degrees C rectal). To perform distal aortic repair, if transverse aortic arch or proximal descending aorta cross-clamping was not feasible, cardiopulmonary bypass flow was lowered to 300-350 ml/min and an open anastomosis was performed, while independently assuring cerebral perfusion (six patients). There were three hospital deaths (mortality rate of 13.6%; s.d. 6.0-25.5%; 70% confidence limit), but none because of cerebral accident. No paraplegia occurred. One patient suffered from right hemiparesis, neither renal nor pulmonary complications were observed. Two chest reexplorations were necessary for bleeding, which were partially related to hemocoagulative disorders. In our experience, the technique of moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion in aortic surgery has provided good results with regard to cerebral protection and organ function preservation. Therefore, allowing a prolonged distal aortic reconstruction period, it may be considered as a safe alternative to profound hypothermia associated with cardiocirculatory arrest in aortic arch surgery.

[Conservation of residual hearing after cochlear implantation]. / Conservation de l'audition résiduelle après implantation cochléaire.

Indications for cochlear implantation have been expanded to include severely hearing impaired adults and may increase the number of patients presenting with preoperative residual hearing. Conservation of residual hearing may allow better performance with an implant. However, conventional thought is that implantation destroys auditory structures involved in residual hearing. This study was undertaken to assess if there are general or surgical factors intervening in the conservation of residual hearing in a sample of multichannel implant recipients. A retrospective study on 50 adult cochlear recipients with preoperative residual hearing has been undertaken. Sixteen of 50 implanted subjects (32%) were found to have conserved their residual hearing. Among them, seven patients have clinically non-significant changes of hearing. Age, side of implantation, gender and etiology did not influence the outcome of residual hearing. Round window ossification, ossification of the cochlea, length of insertion, approach and site of insertion (scala tympani vs.scala vestibuli) were not found to be statistically significant between the population having lost and the population having conserved residual hearing. This study emphasizes the need to undertake a larger multicenter longitudinal study to determine the existence of factors related to the conservation of residual hearing.

[Cochlear implants in the elderly]. / Implant cochléaire chez le sujet âgé.

The authors present a retrospective and multicenter study of 18 elderly patients aged above 60 years-old who underwent a cochlear implantation by comparing them with a population of adult patients. The purpose of this study is to evaluate the utility and benefits of cochlear implantation in the elderly by analyzing the clinical data and the results of a questionnaire assessing the use of the implant and the consequences of implantation on the quality of life. The results of this study indicate that the improvement of quality of life in the elderly is similar compared to a control group of adult patients.

[Early and long-term results of 233 heart transplant patients in University Bordeaux in France: quality of life following heart transplantations].

Between March 1986 and December 1993 we had 233 heart transplant patients who were 218 males and 15 females and had a mean age of 50.9 years (range, 2 to 65 years). We analyzed the actuarial survival for these patients and investigated the status of rehabilitation and return-to-work from the view point of quality of life after heart transplant. Actuarial survival (Kaplan-Meier) was 81.7% at 1 year, 76.3% at 3 years, and 72.2% at 5 years. In 57 dead patients 24 patients (42%) died in 1 month after heart transplant. In 176 living patients 165 patients (53%) returned to life. In 129 patients except 76 retired patients only 69 patients (53%) returned to work. In 60 patients, who didn't return to work, 38 patients (63%) were physically able to work.

Rupture of donor ascending aorta following heart transplantation.

Among 81 patients who underwent orthotopic heart transplantation between July 1986 and December 1990, we found rupture of the donor ascending aorta in three patients, all with severe ventricular dysfunction secondary to aortic valvular disease. The mechanism for this may be compliance mismatch between the recipient ascending aorta and the donor ascending aorta. This situation is a unique complication in heart transplantation for the recipients who have severe athero-sclerotic changes in the systemic aortic wall, especially for those with valvular diseases caused by calcification.

Synthesis and beta-lactamase inhibitory activity of 6-fluoropenicillanic acids.

The benzyl 6-fluoro-penicillanate sulfides 4a, 6a, 7a; and sulfones 6c, 7d were synthesized. The conversion to their free acids 4b, 6b, 6d, 7b, 7e and potassium salts 7c, 7f are described. These acids and salt 7c were evaluated as beta-lactamase inhibitors using beta-lactamase I from Bacillus cereus. The data indicate that substitution of the 6 alpha-hydrogen by a 6 alpha-fluorine atom on 6 beta-bromopenicillanic acid (1), leads to loss of beta-lactamase inhibitory activity. In the case of the isomers 6 beta- and 6 alpha-fluoropenicillanic acids the 6 beta-enantiomer proved to be considerably more potent. Potassium salts of 6 beta-fluoropenicillanate sulfide and sulfone were unstable in solid state and in water solution. The fragmentation of the sulfone in two parts in water solution is consistent with the hydrolytic behavior to the penicillanic acid sulfone (2) with 0.5 N NaOH.

Decreased resistance to antibiotics and plasmid loss in plasmid-carrying strains of Staphylococcus aureus treated with ascorbic acid.

The effect of ascorbic acid on plasmid-coded antibiotic resistance in Staphylococcus aureus was investigated. Several strains of S. aureus were cultured in the presence of 1 mM ascorbate for 6 h. This treatment induced an increased loss of resistance markers in 4 of 6 strains tested, and agarose gel electrophoresis showed this disappearance of plasmid DNA in ascorbate-induced susceptible colonies. The presence of ascorbate induced a 50-75% decrease in minimal inhibitory concentrations of different antibiotics for resistant strains. When ascorbate is added, formerly subinhibitory concentrations of penicillin or tetracycline have an increased inhibitory effect on resistant strains and even induced the death of 25-93% of the initial population. These results suggest that ascorbate can induce the loss of several plasmids of S. aureus, and that the levels of antibiotic resistance are also affected by the presence of this compound.