Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial.

BACKGROUND: Prehabilitation may reduce postoperative complications, but sustainability of its health benefits and impact on costs needs further evaluation. Our aim was to assess the midterm clinical impact and costs from a hospital perspective of an endurance-exercise-training-based prehabilitation programme in high-risk patients undergoing major digestive surgery. METHODS: A cost-consequence analysis was performed using secondary data from a randomised, blinded clinical trial. The main outcomes assessed were (i) 30-day hospital readmissions, (ii) endurance time (ET) during an exercise testing, and (iii) physical activity by the Yale Physical Activity Survey (YPAS). Healthcare use for the cost analysis included costs of the prehabilitation programme, hospitalisation, and 30-day emergency room visits and hospital readmissions. RESULTS: We included 125 patients in an intention-to-treat analysis. Prehabilitation showed a protective effect for 30-day hospital readmissions (relative risk: 6.4; 95% confidence interval [CI]: 1.4-30.0). Prehabilitation-induced enhancement of ET and YPAS remained statistically significant between groups at the end of the 3 and 6 month follow-up periods, respectively (ΔET 205 [151] s; P=0.048) (ΔYPAS 7 [2]; P=0.016). The mean cost of the programme was €389 per patient and did not increment the total costs of the surgical process (€812; CI: 95% -878 - 2642; P=0.365). CONCLUSIONS: Prehabilitation may result in health value generation. Moreover, it appears to be a protective intervention for 30-day hospital readmissions, and its effects on aerobic capacity and physical activity may show sustainability at midterm. CLINICAL TRIAL REGISTRATION: NCT02024776.

Simulation of Hypothermic Perfusion of Rabbit Livers for Cryopreservation Applications.

BACKGROUND: In cryopreservation of biological material, it is very important to precise control the perfusion of cryoprotectants (CPA) inside the sample. CPA concentration inside tissues and organs during the process was measured in a few studies. The simulation of the CPA perfusion inside the organ is still necessary to understand and optimize this complex process. OBJECTIVE: This study simulates the diffusion of Me2SO and PBS in a rabbit liver. MATERIALS AND METHODS: The software COMSOL for computational fluid-dynamics has been used. A hypothermic perfusion is simulated where temperature and pressure at the entrance of the organ are constant. RESULTS: The simulation shows that Me2SO concentration increases within the porous medium until saturation. The variation of perfusion speed and pressure inside the organ is almost null with time. CONCLUSION: Finite elements modelling shows that under hypothermic conditions it is possible a full and even loading of this organ with Me2SO, keeping constant the perfusion parameters.

Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva / Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: general and digestive surgery population characterization

Introducción. Una baja reserva cardiorrespiratoria, un bajo nivel de actividad física y la fragilidad se relacionan con una mayor morbimortalidad perioperatoria. Implementar medidas para optimizar estos aspectos es clave para mejorar el pronóstico. Es fundamental conocer la magnitud del problema para dimensionar los programas de optimización preoperatoria. Objetivo. Caracterizar la población quirúrgica de un hospital universitario de nivel terciario. Métodos. Se incluyeron prospectivamente todos los pacientes sometidos a evaluación preoperatoria para cirugía digestiva con ingreso durante 3 meses. Se evaluó el nivel de actividad física, la capacidad funcional, la fragilidad y el estado emocional, y se realizó un test de medición del estado físico (5 Times Sit-to-Stand Test). Se recogieron datos demográficos, clínicos y relacionados con la cirugía. Resultados. Se incluyeron 140 pacientes (60±15 años, 56% varones, 25% ASA III o IV). El 49% estaban propuestos para cirugía oncológica y un 13% había recibido neoadyuvancia. El 70% de los pacientes presentaban una capacidad funcional reducida y eran sedentarios. Un 18% fueron considerados frágiles y más de un 50% completaron el 5 Times Sit-to-Stand Test en un tiempo superior a los valores de referencia. La edad avanzada, el ASA III/IV, el sedentarismo, la fragilidad y un nivel de ansiedad/depresión elevado se relacionaron con una menor capacidad funcional. Conclusiones. La población quirúrgica de nuestro entorno tiene una baja reserva funcional y un elevado índice de sedentarismo y fragilidad, factores asociados a un peor pronóstico quirúrgico. Urge implementar medidas preoperatorias para identificar la población de riesgo y programas de prehabilitación considerados estrategias de optimización preoperatoria con gran potencial (AU)

Introduction. Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. Objective. To characterize surgical population in a university hospital. Methods. All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. Results. One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. Conclusions. The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome (AU)

Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization. / Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva.

INTRODUCTION: Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. OBJECTIVE: To characterize surgical population in a university hospital. METHODS: All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. RESULTS: One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. CONCLUSIONS: The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.

Afección laríngea obstructiva y síndrome de apnea obstructiva del sueño, una asociación con severo riesgo perioperatorio / Obstructive laryngeal disease and obstructive sleep apnoea syndrome, a combination with serious peri-operative risk

Presentamos el caso de una paciente con diagnósticos de bronquitis crónica, síndrome de apnea obstructiva del sueño y edemas laríngeos de gran tamaño que se intervino para resección mediante microcirugía transoral láser. En el postoperatorio inmediato desarrolló una insuficiencia respiratoria aguda por colapso faríngeo que requirió reintubación en condiciones de urgencia y traslado a UCI no prevista, en la que se mantuvo la ventilación mecánica durante 18 h, procediendo a continuación a la extubación. La evolución posterior fue normal. Se describe la asociación de varios factores de riesgo para el tratamiento anestésico y la importancia de detectar en el preoperatorio la gravedad de cada una de las alteraciones, especialmente la severidad del síndrome de apnea obstructiva del sueño (AU)

We present the case of a patient who was diagnosed with chronic bronchitis, obstructive sleep apnoea syndrome, and large Reinke laryngeal oedemas that were removed by transoral laser microsurgery. In the immediate post-operative period acute respiratory insufficiency occurred due to pharyngeal collapse that required emergency re-intubation, after which the patient was transferred to the ICU where mechanical ventilation was given for18 h. Subsequent progress was normal. We describe the combination of various risk-factors related to anaesthetic management and the importance of considering each one of them, especially the preoperative detection of the severity of obstructive sleep apnoea syndrome (AU)

[Obstructive laryngeal disease and obstructive sleep apnoea syndrome, a combination with serious peri-operative risk]. / Afección laríngea obstructiva y síndrome de apnea obstructiva del sueño, una asociación con severo riesgo perioperatorio.

We present the case of a patient who was diagnosed with chronic bronchitis, obstructive sleep apnoea syndrome, and large Reinke laryngeal oedemas that were removed by transoral laser microsurgery. In the immediate post-operative period acute respiratory insufficiency occurred due to pharyngeal collapse that required emergency re-intubation, after which the patient was transferred to the ICU where mechanical ventilation was given for 18h. Subsequent progress was normal. We describe the combination of various risk-factors related to anaesthetic management and the importance of considering each one of them, especially the preoperative detection of the severity of obstructive sleep apnoea syndrome.

Onychomadesis after a hand, foot, and mouth disease outbreak in Spain, 2009.

Few reports exist regarding the association between onychomadesis and an enterovirus infection presenting clinically as hand, foot, and mouth disease (HFMD). In February 2009, an outbreak of HFMD occurred in a Spanish nursery school, followed by onychomadesis 36-69 days later. Twelve of 17 children with HFMD developed nail shedding; enterovirus was detected in stool samples from eight (47%) of the 17. However, in only three of the children could an enterovirus serotype coxsackievirus B1 be identified. The epidemiological results of this study confirm onychomadesis as a complication in HFMD. In future outbreaks, molecular characterization of enterovirus from appropriate clinical samples should be studied.

Neumotórax recidivante en paciente con fibrosis quística / Recurrent pneumothorax in patients with cystic fibrosis

La fibrosis quística (FQ) es una enfermedad multisistémica que afecta a glándulas sudoríparas, aparatos respiratorio, digestivo y reproductor, siendo la afectación de las vías respiratorias la principal causa de morbi-mortalidad. La frecuencia de aparición de neumotórax va aumentando con la edad del paciente, siendo la edad media de presentación de 21,9 años. El principal factor de riesgo para la producción de neumotórax es la obstrucción bronquial, originándose el 75% de los neumotórax en pacientes con un FEV1 menor del 40%. Entre otros factores que aumentan la probabilidad de padecer un neumotórax se han descrito: la colonización crónica por Pseudomonas aeruginosa, Burkholderia cepacia y Aspergillus, la aspergilosis broncopulmonar alérgica (ABPA), el recibir alimentación enteral por desnutrición, la hemoptisis masiva, la insuficiencia pancreática y la terapia con tobramicina o DNasa inhalada. Presentamos el caso de un paciente que ha sufrido 10 neumotórax en el transcurso de un año (AU)

Cystic fibrosis (CF) is a multisystem disease that affects sweat glands, respiratory, digestive and reproductive systems. The respiratory disease is the leading cause of morbidity and mortality. The frequency of occurrence of pneumothorax increases depending on the age of the patient being the average age of onset of 21.9 years. The main risk factor for the production of pneumothorax is chronic bronchial obstruction occur 75% of patients with a spirometry with a value in FEV1 less than 40% of the expected value. Among other factors that increase the likelihood of suffering a pneumothorax include colonization of patients by Pseudomonas aeruginosa, Burkholderia cepacia or Aspergillus, allergic bronchopulmonary aspergillosis (ABPA), enteral feeding for malnutrition, massive hemoptysis, pancreatic insufficiency and the therapy with inhaled tobramycin or dornase. We present the case of a patient who has undergone 10 pneumothorax in one year (AU)

Gene therapy and intracytoplasmatic sperm injection (ICSI) - a review.

Human gene therapy (HGT), the treatment or prevention of disease by gene transfer is, regarded by many, as a potential revolution in medicine, because gene therapies target the causes of disease, whereas most current drugs treat the symptoms. Micro-assisted fertilization in the form of intracytoplasmatic sperm injection (ICSI) has truly revolutionized the treatment options for couples with impaired semen quality, and those with both obstructive and non-obstructive azoospermia. ICSI involves the injection of a single sperm directly into the cytoplasm of a mature egg (oocyte) using a glass needle (pipette). Fertilization with this technique occurs in 50%-80% of injected oocytes, but may damage a small percentage of them. With gene therapy, there are new and varied strategies for gene transfer and genome sequence manipulation with improved methodologies that use the technique of microinjection such as the intracytoplasmatic sperm injection-mediated transgenesis (ICSI-Tr), active transgenesis or the pronuclear microinjection technique. This review will look at these methods as well as their potential applications and limitations.

Selective targeting of pigmented retinal pigment epithelial (RPE) cells by a single pulsed laser irradiation: an in vitro study.

This work describes the selective targeting of pigmented retinal pigment epithelial (RPE) cells by a single pulsed laser irradiation. We observed: (1) single pulsed laser irradiation caused cellular damages on pigmented, and not on non-pigmented RPE cells at laser radiant exposure up to 2550 mJ/cm(2); (2) in the mixture of pigmented and non-pigmented RPE cells, single pulsed laser-induced damage was confined to pigmented RPE cells. This study demonstrates that the pigmented RPE cells can be selectively damaged, using a single pulsed laser irradiation, without thermal coagulation to adjacent non-pigmented RPE cells.

Breast cancer: metastatic patterns and their prognosis.

From 1969 to 1977, metastatic disease developed in 145 of the 558 patients treated for breast cancer at the University of Maryland Medical System. The most common first site of distant spread was bone (51%), followed by lung (17%), brain (16%), and liver (6%). The remaining 10% of patients had multiple metastatic sites. Fewer than 10% of the entire group received adjuvant chemotherapy after primary treatment. When metastatic disease appeared, most patients had palliative systemic chemotherapy and/or irradiation. In general, patients with initially negative axillary nodes had a longer median time until relapse (development of metastatic disease) and a longer survival time after diagnosis of metastases than patients with initially positive nodes. Liver was the least common initial metastatic site; while liver metastasis was seen only in patients with positive axillary nodes, it carried the worst prognosis. The overall median survival time after metastasis was 12 months for bone and lung lesions, three months for brain lesions, and only one month for liver metastasis. The median survival of patients with multiple metastatic sites was 7.5 months. No correlation was found between time until relapse and survival after metastasis. Patients in whom distant metastases developed relatively soon after the initial diagnosis had the same postmetastatic prognosis as patients whose disease metastasized later. No correlation was found between age at initial diagnosis and metastasis-free interval or survival after metastasis.