Timely Access to Essential Surgery, Surgical Workforce, and Surgical Volume: Global Surgery Indicators in Mexico.

INTRODUCTION: The Lancet Commission on Global Surgery seeks to improve surgical care outcomes and equity for the world population through 6 indicators outlined in its 2030 Global Surgery Report. Our study aimed to estimate the percentage of the Mexican population with access to surgical care within the 2-hour distance range (indicator 1), the surgical workforce density (indicator 2), and the number of surgical procedures performed per 100,000 inhabitants (indicator 3) during the year 2020. Knowing these indicators can help to design and implement policies to increase surgical care access coverage and equity in our country. METHODS: Data related to population distribution, local referral hospitals, and surgical volume were obtained from the 2020 Mexican National Census. Information relating to hospital characteristics and surgical specialists was collected from the Secretariat of Health's public records. We calculated travel time between health care facilities and municipalities using the TrueWay Matrix API and R Studio. RESULTS: Taking into consideration the health care system affiliation, the proportion of the Mexican population with timely access to essential surgery was 81.7%, with 29.3 specialists per 100,000 inhabitants and 726.9 annual procedures performed per 100,000 inhabitants. We identified clusters of municipalities where a low proportion of the population has timely access to essential surgery. CONCLUSION: These findings illustrate that changes in Mexican policy are required to facilitate more equitable and timely access to essential surgical care among the population.

Intraoperative parathyroid hormone levels dynamics of cured patients with impaired renal function following parathyroidectomy for primary hyperparathyroidism.

BACKGROUND: Intraoperative parathyroid hormones have been used to establish operative success in patients with primary hyperparathyroidism. This study's aim was to assess the impact of estimated glomerular filtration rate and serum creatinine levels on the fulfillment of >50% drop and normalization of intraoperative parathyroid hormone levels. METHODS: Patients successfully treated for primary hyperparathyroidism were analyzed. The samples for parathyroid hormone were collected at baseline, 5-, 10-, and 30-minutes postexcision. The patients were classified as follows: (1) estimated glomerular filtration rate >60 mL/min, (2) estimated glomerular filtration rate <60 mL/min and serum creatinine levels <1.2 mg/dL, and (3) estimated glomerular filtration rate <60 mL/min and serum creatinine levels >1.2 mg/dL. Comparative analysis of patients achieving the >50% parathyroid hormone drop criterion and normalization of intraoperative parathyroid hormone was performed. RESULTS: One hundred-fourteen patients were distributed as follows: 88 patients (77.2%), 14 (12.3%), and 12 (10.5%) for groups 1, 2 and 3, respectively. No difference between groups in the proportion of patients fulfilling the >50% parathyroid hormone drop criterion was found. An abnormally elevated intraoperative parathyroid hormone level at 30-minute postexcision was observed in 0, 14.3, and 16.6% in groups 1, 2, and 3, respectively (P ≤ .0001). CONCLUSION: In the study, >50% parathyroid hormone drop criterion was equally achieved despite normal or reduced estimated glomerular filtration rate. When serum creatinine levels increased >1.2 mg/dL and estimated glomerular filtration rate declined <60 mL/min, the likelihood of reaching normal intraoperative parathyroid hormone levels postexcision was significantly lower.

LAW Trial - The Impact of Local Anesthetics Infiltration in Surgical Wound for Gastrointestinal Procedures (LAW): A Double-Blind, Randomized Controlled Trial.

INTRODUCTION AND AIMS: Prior studies have suggested that infiltration of local anesthetics reduce the rate of surgical site infections (SSIs). Opioid usage has become an epidemic. Some analgesic modalities, such as epidural analgesia and transversus abdominis plane block are associated with shorter length of stay and lower opioid use. The aim of our study was to assess the relationship between local infiltration of bupivacaine with rates of SSI and pain control. MATERIALS AND METHODS: We conducted a prospective, double-blinded randomized controlled trial in patients who underwent open major gastrointestinal procedures from July 2016 to June 2017. Patients were divided into two groups based on administration of 0.5% bupivacaine (n = 30) (group 1) or placebo (n = 30) (control group). Outcomes evaluated were SSI, postoperative opioid requirements and pain scores. RESULTS: Patients in the bupivacaine group required a lower dose of epidural analgesia during the first 24 h (5.3 mcg/kg/h vs. 6.4 mcg/kg/h; p = 0.05). Opioid requirement was shorter in the bupivacaine group (3.5 ± 2.3 days vs. 5.7 ± 2.9 days; p = 0.01). No difference was found between groups in terms of SSI rates (0% vs. 6.7%, p = 0.49). CONCLUSIONS: There is no clear association between bupivacaine infiltration and reduction of SSI rate according to our study. Wound bupivacaine infiltration is associated with a lower dose of epidural infusion and opioid requirements.

Computed tomography (CT) scan identified necrosis, but is it a reliable single parameter for discerning between malignant and benign adrenocortical tumors?

BACKGROUND: Adrenocortical carcinoma is a rare malignant tumor with a poor prognosis. Discernment of adrenocortical carcinoma in an adrenal mass through imaging studies is paramount for early surgical treatment. Recently, necrosis has been proposed as a single morphological parameter for adrenocortical carcinoma diagnosis. The aim of this study was to analyze the measures of diagnostic efficiency of necrosis and the different computed tomography-scan features related to adrenocortical carcinoma diagnosis. METHODS: We conducted a case-control study of patients surgically treated for an adrenal mass with histopathological report consistent with adrenocortical carcinoma (cases) and adrenocortical adenoma (control patients) between 1987 and 2019. Radiological features on computed tomography scan were collected. Bivariate and multivariate statistical analyses were performed for the different imaging features. The measures of diagnostic efficiency for each feature were calculated. Concordance analysis between image-detected and histopathological-identified necrosis was performed. RESULTS: Eighteen adrenocortical carcinoma and 41 adrenocortical adenomas were included. Differences between adrenocortical carcinoma and adrenocortical adenoma were found regarding heterogeneity (odds ratio 4.53, 95% confidence interval 2.3-8.9; P < .0001), tumor size ≥4 cm (odds ratio 3.5, 95% confidence interval 2.05-6.14; P < .0001), and attenuation index ≥10 Hounsfield units (odds ratio 1.9, 95% confidence interval 1.3-2.6; P = .001). Necrosis was the most important imaging feature significantly associated with adrenocortical carcinoma (odds ratio 35, 95% confidence interval 5.1-241.6; P < .0001), present in all adrenocortical carcinoma cases. After measures of diagnostic efficiency calculation, necrosis had the highest diagnostic accuracy (98%). Cohen's kappa for concordance between image-detected and histopathological-identified necrosis was 90.4% (P < .0001). CONCLUSION: Computed tomography scan-detected necrosis is a reliable radiological feature to discern adrenocortical carcinoma from adrenocortical adenomas.

Endocrine hypertension secondary to adrenal tumors: clinical course and predictive factors of clinical remission.

PURPOSE: Endocrinopathies constitute ~ 10% of secondary hypertension (SH) etiologies. Primary aldosteronism, pheochromocytoma (PHEO), and Cushing's syndrome are common causes. Early identification and treatment result in resolution/improvement of SH. The aim of this study was to characterize the clinical course, outcomes, and remission-associated prognostic factors of SH related to adrenal tumors. METHODS: Retrospective cohort study including patients with SH who underwent adrenalectomy from 2000 to 2019. Postoperative outcomes were analyzed. Remission was defined as normalization of blood pressure without drug use. RESULTS: Eighty-three patients with SH were included. Mean ± SD age was 38.8 ± 14.2 years and 75.9% were women. Diagnosis was PHEO in 35 patients (42.2%), aldosteronoma (APA) in 28 (33.7%), cortisol producing adenoma (CPA) in 16 (19.3%), and ACTH-dependent Cushing's in 4 (4.8%). Laparoscopic adrenalectomy was performed in 81 (97.6%) patients. Mean ± SD follow-up was 57.4 ± 49.6 months (range 1-232). Surgical morbidity occurred in 7.2% of patients and there was no mortality. Remission of SH occurred in 61(73.5%): 100% of ACTH-dependent Cushing's, 85.7% of PHEO, 68.8% of CPA, and 57.1% of APA. Biochemical phenotype and the combination of larger tumor size, number of antihypertensive drugs, male gender, older age, obesity, and preoperative SH for more than 5 years were associated with less likely clinical remission in patients with APA (p = 0.004), CPA (p < 0.0001), and PHEO (p < 0.0001). CONCLUSION: SH remission rates are 57-100% after adrenalectomy. Several prognostic factors could be used to predict SH control. Adrenalectomy provides good clinical outcome and must be considered a treatment option in all surgical candidates.

Thrombocytosis and Hyponatremia as Predictors of Complicated Acute Appendicitis: Predictors of Appendicitis.

BACKGROUND: Multiple serologic markers have been studied to predict complicated acute appendicitis (CAA) (C-reactive protein and procalcitonin); these increase health care costs and are not always available in medical centers in Mexico. There is a need for low-cost serologic markers to predict CAA and guide the preoperative management of patients. Our objective was to analyze the predictive value of hyponatremia and thrombocytosis for complicated acute appendicitis. METHODS: We analyzed 274 patients with AA surgically treated and divided them into two groups: the CAA group and the uncomplicated AA group. We compared the serum values of sodium and platelet blood counts on presentation in the emergency room between the two groups and the proportion of patients with hyponatremia and/or thrombocytosis. Receiver operating characteristic analysis was performed for the two biochemical markers. Sensitivity, specificity, and positive and negative predictive values were calculated for complicated appendicitis in the presence of hyponatremia and thrombocytosis. RESULTS: We found 87 patients with CAA and 187 with uncomplicated acute appendicitis. Patients with CAA presented with lower serum sodium values and higher platelet counts than uncomplicated patients. Hyponatremia was found in 54.8% of complicated patients and 29.2% in the uncomplicated group. Thrombocytosis was present in 11.6% of the complicated group and 3.2% in uncomplicated patients. We found a specificity and positive predictive value of 100% for complicated appendicitis in patients with hyponatremia and thrombocytosis. CONCLUSIONS: In patients with abdominal pain and suspected acute appendicitis, the presence of hyponatremia and thrombocytosis is a strong predictive tool for the complicated disease. This is the first study to analyze the association between thrombocytosis and complicated appendicitis.

Preoperative and Postoperative Risk Stratification of Thyroid Papillary Microcarcinoma: A Comparative Study Between Kuma Criteria and 2015 American Thyroid Association Guidelines Risk Stratification.

Background: The incidence of micropapillary thyroid carcinoma (mPTC) has increased in the last decade. Active surveillance (AS) has been proposed as an alternative management for low-risk mPTC based on preoperative Kuma criteria. Controversy still exists on how to appropriately manage this group of patients, as some low-risk mPTC may harbor some postoperative features associated with disease recurrence as described in the 2015 American Thyroid Association (ATA) guidelines. Methods: We retrospectively reviewed 108 patients with histopathologic diagnosis of mPTC after surgery at a third level hospital in Mexico City from 2000 to 2018. Demographic and clinicopathologic data were analyzed as predictors for disease recurrence and/or metastatic disease (lymph node or distant). Comparison between group stratification based on preoperative Kuma criteria and postoperative 2015 ATA guidelines risk criteria for disease recurrence was performed. Measures of diagnostic accuracy were obtained for preoperative risk features according to the Kuma criteria. Results: Of 108 patients, 79 (73%) were classified as preoperative high-risk mPTC and 29 (27%) as low risk based on the Kuma criteria. Of these 79 high-risk patients, 38 (48%) were reclassified as low risk for disease recurrence, 12 (15%) as intermediate risk, and 29 (37%) remained as high risk based on the 2015 ATA risk criteria. Of the 29 preoperative low-risk patients, 19 (65.5%) remained as postoperative low risk for disease recurrence, 2 (7%) as intermediate risk, and 8 (27.5%) as high risk. Higher accuracy of preoperative risk features was obtained for lymph node and distant metastases, 84.2% and 97.2%, respectively. After multivariate analysis, age <40 years and microscopic extrathyroidal extension (ETE) were associated with higher risk for metastatic disease (lymph node or distant) in our cohort. Conclusions: Patients with mPTC under 40 years old and microscopic ETE are more prone to develop metastatic disease (lymph node or distant). One-third of our patients stratified as low-risk mPTC according to the Kuma criteria for AS had histopathologic features associated with a more aggressive clinical behavior or structural recurrence. In addition, lymph node and distant metastases are the preoperative risk features with the highest diagnostic accuracy for preoperative risk stratification.

Transoral Endoscopic Thyroidectomy by Vestibular Approach-Initial Experience and Comparative Analysis in the First Reported Mexican Cohort.

Introduction: Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) is a relatively new technique for the surgical treatment of thyroid diseases. We present the initial experience of a reference hospital of Mexico with TOETVA. Materials and Methods: This is a comparative retrospective study of cases (TOETVA) and controls (open thyroidectomy) treated by the endocrine surgeons between July 2017 and April 2019. Cases were patients of any gender, older than 18 years of age, with malignant thyroid nodules <2 cm or undetermined <5 cm without extrathyroidal extension and no lymph node or distant metastasis. Demographic, operative, and postoperative data were obtained and analyzed. Results: Twenty patients were surgically treated by TOETVA during the study period. Controls were paired based on type of surgery and dominant thyroid nodule. Ninety percent of the patients had a definitive diagnosis of malignancy. No statistically significant differences were found in age, BMI, length of stay, thyroid lobes size, and complication rates. Operative time was longer in TOETVA (216.7 ± 62.5 vs. 153.9 ± 49.25 minutes; t test P < .0001) and intraoperative blood loss was lesser for the TOETVA group (38.25 ± 38.9 vs. 101.8 ± 126.6 mL; t test P < .04). Conclusions: TOETVA is a feasible and relatively safe surgical technique for patients with benign and malignant thyroid diseases. Complication rates seem to be comparable with conventional open technique with lesser intraoperative bleeding; nevertheless, it requires longer operative times.

Correction to: Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

In the original version of the article, the last three column headings in Table 3 were mislabeled. The original article has been corrected. Following is the corrected table.

Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

BACKGROUND: Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation. PATIENTS AND METHODS: We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05. RESULTS: Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02). CONCLUSIONS: Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).

Presentación clínica de la apendicitis aguda en pacientes inmunocomprometidos por diabetes o VIH/sida.

INTRODUCCIÓN: Los pacientes inmunocomprometidos presentan respuesta inflamatoria limitada que puede retrasar el diagnóstico de la apendicitis aguda (AA). OBJETIVO: Evaluar si el inmunocompromiso puede afectar el curso clínico y evolución de la AA. MÉTODO: Análisis retrospectivo, comparativo, de pacientes sometidos a apendicectomía por AA: con VIH, diabetes mellitus tipo 2 (DM2) y sin otra patología. RESULTADOS: Se revisaron 128 pacientes con AA intervenidos quirúrgicamente (53.6 % del sexo femenino), edad media de 42.5 años, 15 (11.7 %) tenían diagnóstico de VIH, 47 (36.7 %) de DM2 y 66 (51.6 %) no cursaban con otra enfermedad. La proporción de leucocitosis fue menor en el grupo con VIH (66.7 %; p = 0.007). En los pacientes con VIH y DM2 se registró mayor tiempo de evolución: 66.9 ± 61.2y 90.1 ± 144 horas (p ≤ 0.001), mayor tiempo de estancia hospitalaria: 11.1 ± 17.1 y 6.5 ± 4.1 días (p ≤ 0.0001), mayor tasa de complicaciones: 20 y 23.8 % (p = 0.036). La complicación más frecuente fue la infección del sitio quirúrgico superficial y profunda. La hemicolectomía derecha fue más frecuente en el grupo con VIH (20 %, p = 0.017). No se registró mortalidad. CONCLUSIONES: La inmunodepresión afecta el curso clínico y evolución de la AA. INTRODUCTION: Immunocompromised patients experience limited inflammatory response, which can delay acute appendicitis (AA) diagnosis. OBJECTIVE: To assess if immunosuppression can affect AA clinical course and evolution. METHOD: Comparative, retrospective analysis of patients with HIV or type 2 diabetes mellitus (DM2) or with no other pathology who underwent appendectomy for AA. RESULTS: A total of 128 patients with AA who were surgically intervened were assessed (53.6% were of the female gender); mean age was 42.5 years, 15 (11.7%) had been diagnosed with HIV infection, 47 (36.7%) with DM2 and 66 (51.6%) had no other disease. The proportion of leukocytosis was lower in the HIV group (66.7%; p = 0.007). Patients with HIV and DM2 had longer evolution time (HIV 66.9 ± 61.2, DM2 90.1 ± 144 hours; p ≤ 0.001), longer hospital length of stay (HIV 11.1 ± 17.1, DM2 6.5 ± 4.1 days; p ≤ 0.0001), and a higher rate of complications (HIV 20%, DM2 23.8%; p = 0.036). The most common complication was superficial and deep surgical site infection. Right hemicolectomy was more common in the HIV group (20%; p = 0.017). There was no mortality registered. CONCLUSIONS: Immunosuppression affects AA clinical course and evolution.

El pronóstico de la anemia refractaria / Prognosis of the refractory anemia

Se revisaron los expediantes de 85 pacientes con anemia refractaria, estudiados en el Laboratorio de Investigación en Hematología del Hospital, de abril de 1053 a julio de 1965. La condición se presentó con una frecuencia de 0.74 por cada 1000 egresos y predominió en los grupos avanzados de edad y en el sexo masculino en la proporción de 2 a 1. Su pronóstico se ha mejorado sensiblemente con la introducción de sangre fresca rica en plaquetas, eliminación de la administración preventiva de antibióticos y empleo de testosterona y dosis moderadas de corticoesteroides y en casos especiales el empleo de esplenectomía. La respuesta al tratamiento está condicionada por la situación hematologíca del paciente al ingreso, considerándose una situación favorable cuando el paciente tiene más de 2 por ciento de reticulocitos, más de 1 por ciento de reticulocitos coregidos, más de 500 neutrófilos por mm al cubo en sangres periférica y más de 10 por ciento de neutrófilos maduros en médula ósea

Ausentismo laboral en el personal médico Hospital Dr. Francisco Moscoso Puello / Work absence of the medical staff at the \"Francisco Moscoso Puello\" Hospital

Se realizó un estudio descriptivo con el objetivo de determinar la frecuencia y las causas del ausentismo laboral en 50 médicos escogidos al azar del Hospital Dr. Francisco M. Moscoso Puello durante el período enero-junio de 1996. Encontrándose que un 38// se ausentaban de su trabajo; el 52.6// los hicieron por enfermedad; las mujeres se ausentaron más que los hombres; el 89.5// de los ausentados no se encuentran satisfecho en la labor que desempeñan y el 57.9// señalaron que las condiciones de trabajo eran inadecuadas

Tumores de ovario: una modalidad combinada de tratamiento / Ovary tumors: a combined treatment

Se señala que este estudio abarcó 125 pacientes con tumor de ovario y se seleccionan los indicadores con el fin de obtener conclusiones. Se utilizó una modalidad combinada de tratamiento: cirugía, radiaciones ionizantes y quimioterapia (tiotepa más metrotexato en la cavidad abdominal y se continuó el tratamiento de mantenimiento con clorambucil (leukerán). Se informa que el resultado obtenido (12,5

) a los cinco años estuvo por debajo de las cifras de las series mayores y mejor estudaidas. Se señala que la gran deficiencia consistió en el número de pacientes ignorados (48,8

). Se recomienda la continuación de esta modalidad combinada de tratamiento, mediante la formulación de modelos tecnológicos terapéuticos y ensayos clínicos en que intervengan la inmunohormonoterapia y un estricto control de enfermos (AU)