Delay of surgical treatment of severe tricuspid regurgitation and outcomes in patients with left-sided heart valve disease.

INTRODUCTION AND OBJECTIVES: The influence of the delay between diagnosis and surgery in severe tricuspid regurgitation (TR) remains controversial. We aimed to analyze the association between delay to surgery and operative and mid-term mortality in patients with severe TR concomitant to left-valve surgery. METHODS: We conducted an observational retrospective study analyzing risk factors in patients undergoing left-valve surgery concomitant with severe TR. The clinical and demographic variables were prospectively collected. The time of first diagnosis of TR was retrospectively collected. RESULTS: A total of 253 patients were analyzed. TR was functional in 82.6%. The median latency between diagnosis and surgery was 24 months. Operative mortality was 12.2%. On multivariate analysis, higher operative mortality was associated with older age, worse preoperative NYHA functional class, triple valve surgery, hyponatremia, and anemia. The median follow-up was 35 months. Survival at 1 and 5 years was 85.2% and 73.7%, respectively. Mortality during follow-up was associated with male sex, preoperative massive TR, and longer latency between diagnosis and surgery. CONCLUSIONS: The variables related to worse preoperative functional class were associated with increased operative mortality. Lower mid-term survival was associated with longer latency between diagnosis of severe TR and surgery, massive preoperative TR, and older age.

[Prospective observational study of the impact of problems accessing treatment such as risk factors for adherence and persistence. Pilot study]. / Estudio observacional prospectivo del impacto de los problemas de acceso al tratamiento como factores de riesgo de la adherencia y persistencia. Estudio piloto.

Introduction: Some preliminary studies that reveal the onset of risk factors not investigated previously in regard to the health system were performed. They can reduce adherence and/or persistence of pharmacological treatments. Knowledge about them can lead to possible solutions. Aim: To estimate the incidence of risk factors in regard to the health system that can reduce adherence/persistence with treatments associated with problems accessing these in the community pharmacy. Method: Transversal, randomized, prospective study in community pharmacies in Asturias and Aragón regions. The primary endpoint was the incidence of new risk factors that means that the prescription is inadequate for its dispensing. Different subgroups were analyzed according to type of risk factor, population and prescription. Results: The typical patient is a vulnerable person according to his age (65.4 years), multipathology and polypharmacy (6.8 drugs). After the evaluation of 138,697 cases of dispensing in 98 community pharmacies a total of 2009 patients were detected with 2221 cases of dispensing with risk factors in terms of adherence and/or persistence (1.6% of the total dispensing). The type of incidence most commonly observed was expiry of the prescription (54.7%; 95%CI=52.6-56.8), followed by no prescription record (18.7%; 95%CI: 17.1-20.3). For its part supply problems stood at 10.2% (95%CI= 10.6%-10.9%). The most compromised therapeutic groups were groups N Nervous System (27.6%), C Cardiovascular System (20.3%) and A Gastrointestinal System (15.3%). Conclusions: The results obtained suggest that the current incidence of risk factors in regard to the health system in terms of adherence and/or persistence may comprise a health problem with a clinical, quality of life and financial impact. As these risk factors are modifiable, a greater capacity for community pharmaceutical action by means of exceptional dispensing to authorize the treatment's continuity would be an acceptable solution.

[Project on exceptional dispensation in the Principality of Asturias]. / Proyecto sobre dispensación excepcional en el Principado de Asturias.

Community pharmacy (CF) is daily confronted with situations that prevent the proper dispensing of medication, putting at risk the continuity of treatment by patients, which causes medication-related problems (DRPs). In this pilot study, carried out in the Principality of Asturias, the aim was to quantify the number of incidents of this type related to those aspects of the prescription that could be easily corrected by the community pharmacist through simple interventions at the time of dispensing. It was carried out in ten pharmacies in this autonomous community during normal opening hours over fifteen working days. The sample included a total of 32,331 containers dispensed. A total of 406 incidences of exceptional dispensing were recorded. The total incidence rate reached 1.26% of the dispensations, which extrapolating to the total number of dispensations made in Asturias during the month of October 2020 would give us a figure of 27,030 total dispensations susceptible to exceptional dispensing.The total incidence rate was lower in urban pharmacies (1.03%) compared to semi-urban and rural pharmacies (1.37% and 1.39%). Most of the cases (59.4 %) involved patients with an individual contribution to the Health System corresponding to 10 % (TSI2) and the mean age of the patient was 60.8 years. Regarding the level of care, 79% of the cases corresponded to Primary Care (PC) prescriptions. The most common type of incidence is "potential interruption due to prescription not active at the time of dispensing (exceeding the 10-day margin)" with an incidence rate of 0.61 % of the dispensations, which would mean a total of 13,181 prescriptions susceptible to exceptional dispensing due to this type of incidence.In terms of economic savings, it was found that 63 of the 406 cases would have necessarily required a medical consultation and 30% of them would have been for active patients. Therefore, the remaining 343 cases, which could be resolved through exceptional dispensing by the community pharmacist, would mean a saving of more than 4,000 consultations and nearly 200,000 euros in direct and indirect costs if the pharmacist were allowed to intervene.

[Impact of the pandemic on primary care. SESPAS Report 2022]. / Impacto de la pandemia en la atención primaria. Informe SESPAS 2022.

The COVID-19 pandemic, which last 2 years and still goes on, has pushed the primary health care (PC) to a current worrying situation of saturation and exhaustion. It is a community infectious disease, with a great amount of cases (around 10 million declared in January 2022) due to that, PC has made an extraordinary effort to pay attention on mild cases and on PC and to detect potentially serious cases early. Unfortunately, up to now, a global evaluation of the actions has not been carried out, in order to allow us to learn from this new experience. This article describes the different phases of the pandemic and its impact on PC. Finally, solutions are proposed to reinforce the central criteria that allow PC to be maintained as the foundation of the welfare state, longitudinality, resolution, accessibility, and care coordination and continuity, thanks to the contribution of resources and skills given to the PC. In conclusion, PC must still being the basis of the health system and it is mandatory to recover and claim those competencies and resources that should always have been a part of PC.

Neurological Complications in Active Left-Sided Infective Endocarditis Requiring Early Surgery.

Introduction: To determine whether preoperative symptomatic neurological complication (SNC) predicts a worse prognosis of patients with active left-sided infective endocarditis who required early surgery. Methods: We conducted a retrospective chart review and analyzed risk factors for SNCs and immediate, medium-term, and long-term mortality in patients with active left-sided infective endocarditis who required early surgery (median follow-up: 70.5 months). Results: Of 212 included patients, preoperative SNCs occurred in 22.1%. Independent risk factors for preoperative SNC included early hospital admission (<10 days after symptoms onset), duration of antibiotic therapy <7 days, vegetation diameter > 30 mm, preoperative chronic therapy with steroids, and peripheral embolism. A new postoperative SNC occurred in 12.7% of patients. No significant differences related to preoperative or postoperative SNCs were observed in postoperative mortality (29.8% vs. 31.5%) or during follow-up. No significant differences in postoperative mortality were observed between hemorrhagic or ischemic SNCs. There was a non-significant trend to increased mortality in patients who underwent surgery within 7 days of presenting with SNC (55.5%) compared to those who underwent surgery more than 7 days after SNC (33.3%) (P = 0.171). Concomitant risk of mortality or postoperative hemorrhagic transformation increased when surgery is required during the first week after preoperative SNC (77.5% vs. 25%) (P = 0.017). Conclusions: Patients with active left-sided infective endocarditis who need early hospital admission are at a higher risk of SNC. Mortality is higher in patients who underwent surgery within 7 days of SNC, but mortality of early surgery is acceptable after the first week of preoperative ischemic or hemorrhagic complication. We have not been able to demonstrate that preoperative nor postoperative SNCs predicted a reduced immediate, medium-term, or long-term survival in the population analyzed in this study.

Autoantibodies Against Ubiquitous and Confined Antigens in Patients With Ocular, Neuro-Ophthalmic and Congenital Cerebral Toxoplasmosis.

Toxoplasma gondii infection can trigger autoreactivity by different mechanisms. In the case of ocular toxoplasmosis, disruption of the blood-retinal barrier may cause exposure of confined retinal antigens such as recoverin. Besides, cross-reactivity can be induced by molecular mimicry of parasite antigens like HSP70, which shares 76% identity with the human ortholog. Autoreactivity can be a determining factor of clinical manifestations in the eye and in the central nervous system. We performed a prospective observational study to determine the presence of autoantibodies against recoverin and HSP70 by indirect ELISA in the serum of 65 patients with ocular, neuro-ophthalmic and congenital cerebral toxoplasmosis. We found systemic autoantibodies against recoverin and HSP70 in 33.8% and 15.6% of individuals, respectively. The presence of autoantibodies in cases of OT may be related to the severity of clinical manifestations, while in cases with CNS involvement they may have a protective role. Unexpectedly, anti-recoverin antibodies were found in patients with cerebral involvement, without ocular toxoplasmosis; therefore, we analyzed and proved cross-reactivity between recoverin and a brain antigen, hippocalcin, so the immunological phenomenon occurring in one immune-privileged organ (e.g. the central nervous system) could affect the environment of another (egg. the eye).

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents

BACKGROUND: the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option. AIMS: the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks. METHODS: a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018. RESULTS: twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach. CONCLUSIONS: endoscopic treatment with fully covered selfexpandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center

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Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents.

BACKGROUND: the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option. AIMS: the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks. METHODS: a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018. RESULTS: twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach. CONCLUSIONS: endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

The impact of frailty on the economic evaluation of geriatric surgery: hospital costs and opportunity costs based on meta-analysis.

Objectives: We used a systematic review and meta-analysis to analyze the difference in costs between surgery for frail and non-frail elderly patients. The opportunity cost of frailty in geriatric surgery is estimated using the results.Methodology: Two literature reviews were carried out between 2000 and 2019: (1) studies comparing total hospital costs of frail and non-frail surgical patients; (2) studies evaluating the length of hospital stay and cost for surgical geriatric patients. We performed a meta-analysis of the items selected in the first review. We subsequently calculated the opportunity cost of frail patients, based on the design of a cost/time variable.Results: Twelve articles in the first review were selected (272,717 non-frail and 16,461 frail). Fourteen articles were selected from the second review. Frail patients had higher hospital costs than non-frail patients (22,282.541 € and 16,388.844, p < .001) and a longer hospital stay (10.16 days and 8.4 (p < .001)). The estimated opportunity cost in frail patients is 1,019.56 € (cost/time unit factor of 579.30 €/day).Conclusions: Frail surgical geriatric patients generate a higher total hospital cost, and an opportunity cost arising from not operating in the best possible state of health. Preoperatively treating the frailty of elderly patients will improve the use of health resources.

Validación psicométrica de la Escala de gravedad de fatiga en médicos residentes mexicanos / Psychometric validation of the Fatigue Severity Scale in Mexican medical residents

Los médicos residentes están continuamente expuestos a la fatiga, que puede ocasionarles problemas laborales, académicos y personales, por consiguiente, es importante contar con instrumentos confiables y válidos para medirla. Una de las escalas más utilizadas es la Escala de gravedad de fatiga, sin embargo, hay versiones con una y distinto número de reactivos en distintas poblaciones. Por lo que el propósito de este trabajo fue traducir, adaptar de manera culturalmente relevante y comparar las versiones con distinto número de reactivos de la escala, para identificar la más adecuada en médicos residentes mexicanos. Se trabajó con tres grupos diferentes de participantes; el primero para la traducción y adaptación conformado por siete jueces expertos en el idioma, el segundo para la validación psicométrica con 100 médicos residentes y, el tercero, para el análisis factorial confirmatorio y prueba de invarianza por tipo de programa (especialidad y alta especialidad) con 182 médicos residentes. Se probó la distribución, discriminación, confiabilidad y estructura de la escala, en un análisis exploratorio y confirmatorio, quedando una escala final de 6 reactivos con buen ajuste (X2[9] = 9,39, p = 0,40; CFI = 0,99; RMSEA = 0,02), con una confiabilidad = 0,91 e invarianza factorial estricta por tipo de programa de residencia

Resident physicians are continually exposed to fatigue, which can lead to work, academic and personal problems, so it is important to have reliable and valid instruments to measure it. One of the most used is Fatigue Severity Scale, but, there are versions with different number of items in different populations. Therefore, the purpose of this work was to translate, adapt culturally relevant and compare versions with different numbers of items, to identify the most appropriate in Mexican resident physicians. With three different groups of participants; first one for translation by seven expert judges in the language, second for psychometric validation with 100 resident physicians, and third for confirmatory factor analysis and invariance test by type of program (specialty and high specialty) with 182 resident physicians. Distribution, discrimination, reliability and factor structure of the scale were tested in an exploratory and confirmatory analysis, leaving a final scale of 6 items with good fit (X2[9] = 9,39, p = 0,40; CFI = 0,99; RMSEA = 0,02), with a reliability = 0,91 and strict factorial invariance by type of residence program

Ethical aspects involving the use of information technology in new surgical aplications: telesurgery and surgical telementoring / Aspectos éticos relacionados con el uso de información tecnológica en nuevas aplicaciones quirúrgicas: tele-cirugía y tele-tutoría / Aspectos éticos envolvendo o uso de tecnologia da informação em novas aplicações cirúrgicas: telescirurgia e telemonitoria cirúrgica

Abstract: Background: The surgical telementoring is a technology that involves surgical procedures guided by an expert or mentor, performed by other surgeons from a distance, using information and knowledge technologies. This therapeutic innovation has generated new opportunities to improve the surgical attention and the training of the surgeons. However, their ethical implications should be analyzed to clarify their use, to check the patient's safety and eliminate uncertainties. The characteristics of surgical telementoring generate specific challenges and ethical dilemmas that must be identified, analyzed and solved. Results: In this paper the ethical challenges and dilemmas of surgical telementoring identified and analyzed cover multiple aspects such as patient safety, privacy and vulnerability, the surgeon-mentor-patient relationship and informed consent, professional responsibility, cost-effectiveness analysis and Solidarity and social justice regarding the use of healthcare resources, the systematic approach to validation of the proposed new technology and conflicts of interest. For many of these issues solutions are provided, but they are still to be solved. Conclusions: surgical telementoring potentially improves patient healing and surgeon education. It will have a rapid evolution in the next years. This rapid growth should not be anticipated to the solid implantation of ethical guarantees for its use due to the particular characteristics that this technology has in the field of telemedicine.

Resumen: Antecedentes: El uso de tele-tutoría en cirugía es una tecnología que incluye procedimientos quirúrgicos guiados por un experto o tutor, realizado por otros cirujanos a distancia usando tecnologías de información y conocimiento. Esta innovación terapéutica ha generado nuevas oportunidades para mejorar la práctica de cirugía y la formación de los cirujanos. Sin embargo, deberían de analizarse sus implicaciones éticas para clarificar su uso, comprobar la seguridad del paciente y eliminar incertidumbres. Las características de la tele-tutoría en cirugía generan desafíos específicos y dilemas éticos que deben identificarse, analizarse y resolverse. Resultados: En este artículo se identificaron y analizaron múltiples aspectos en cuanto a desafíos éticos y dilemas de tele-tutoría en cirugía tales como: seguridad del paciente, privacidad y vulnerabilidad, la relación cirujano-tutor-paciente y el consentimiento informado, la responsabilidad profesional, análisis de costo-efectividad, solidaridad y justicia social respecto al uso de recursos en el cuidado de la salud, la aproximación sistemática para la validación de la nueva tecnología propuesta y los conflictos de interés. Para muchos de estos temas se han proporcionado soluciones, pero todavía no han sido resueltas. Conclusiones: La tele-tutoría en cirugía mejora potencialmente la sanación del paciente y la educación del cirujano. Va a tener una rápida evolución en los próximos años. Este rápido crecimiento no debería anticiparse a la implantación sólida de garantías éticas para su uso debido a las características particulares que tiene esta tecnología en el campo de la tele-medicina.

Resumo: Fundo: A cirurgia teleguiada é uma tecnologia que envolve procedimentos cirúrgicos, guiados por um especialista ou mentor, executados por outros cirurgiões à distância, usando tecnologias da informação e do conhecimento. Esta inovação terapêutica tem gerado novas oportunidades para melhorar a atenção cirúrgica e a formação dos cirurgiões. No entanto, suas implicações éticas devem ser analisadas para esclarecer seu uso, para verificar a segurança do paciente e eliminar as incertezas. As características da cirurgia teleguiada geram desafios específicos e dilemas éticos que devem ser identificados, analisados e resolvidos. Resultados: Neste artigo os desafios éticos e dilemas da cirurgia teleguiada identificados e analisados vislumbram vários aspectos como a segurança do paciente, sua privacidade e vulnerabilidade, o relacionamento paciente-cirurgião-mentor e consentimento informado, responsabilidade profissional, análise custo-eficácia e solidariedade e justiça social em relação ao uso dos recursos de saúde, a abordagem sistemática para validação da tecnologia nova proposta e conflitos de interesse. Para muitas destas questões são fornecidas soluções, mas muitas ainda estão para serem resolvidas. Conclusões: a cirurgia teleguiada potencialmente melhora o atendimento do paciente e o ensino do cirurgião. Vai ter uma rápida evolução nos próximos anos. Este rápido crescimento não deve ser antecipado para a implantação contínua de garantias éticas para seu uso devido as características particulares que esta tecnologia tem no campo da telemedicina.

Uso transitorio de sistemas personalizados de dosificación (SPD): más allá de la polimedicación / Transient use of personalized dosing systems (PDS): beyond polypharmacy

Los pacientes diana del Servicio Personalizado de Dosificación (SPD) han sido habitualmente las personas con enfermedades crónicas polimedicadas con dificultades físicas o cognitivas para manejar adecuadamente su medicación. Sin embargo, existen otros grupos susceptible de beneficiarse igualmente de esta herramienta, como son los pacientes sin deficiencias ni dependencias pero que debido a la complejidad de la pauta del tratamiento a administrar pueden aprovechar este servicio de forma puntual. En este caso veremos una paciente habituada a manejar no sólo su medicación sino también la de su marido pero que debido a una pauta cambiante de medicamentos ansiolíticos y antidepresivos prefiere confiar en la farmacia comunitaria para su correcta administración

The target patients of the Personalized Dosing Service (PDS) have usually been people with chronic polymedicated diseases with physical or cognitive difficulties to properly manage their medication. However, there are other groups likely to equally benefit from this tool, such as patients without deficiencies or dependencies but due to the complexity of the treatment regimen to be administered, they can occasionally take advantage of this service. In this case, we will see a patient used to handling not only her own medication but also that of her husband but due to a changing pattern of anxiolytic and antidepressant medications, she prefers to rely on the community pharmacy for proper administration

Medicamentos innovadores: hacia un modelo colaborativo / No disponible

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Gastric schwannoma presenting as a casual ultrasonographic findings.

We present the case of a patient under study due to ascites in which a mass located on the gastric wall was observed during ultrasonography. Further studies (upper endoscopy and computed tomography) confirmed this finding. After an ultrasound-guided percutaneous biopsy, diagnosis of gastric schwannoma was made as intense S-100 expression was found. Surgery was rejected due to the bad clinical situation of the patient and because the mass was an asymptomatic benign tumor.

Hemorragia digestiva alta como forma de presentación de hematoma retroperitoneal espontáneo gigante secundario a anticoagulación en una mujer con reordenación del gen JAK2 / Spontaneous retroperitoneal hematoma in a patient under anticoagulant agents presenting as upper gastrointestinal bleeding

Presentamos el caso de una mujer de 44 años de edad con antecedentes de abortos de repetición y síndrome de Budd-Chiari secundario a una mielofibrosis primaria en tratamiento anticoagulante. Consulta por melenas y astenia, presentando anemización progresiva. En una gastroscopia inicial se aprecia una compresión extrínseca a nivel supraampular de segunda porción duodenal, con una úlcera asociada en cara posterior de bulbo y primera rodilla. Posteriormente se diagnostica mediante una tomografía computarizada de un hematoma retroperitoneal espontáneo secundario a anticoagulación. Se trata con drenaje percutáneo y retirada de anticoagulación con buena respuesta inicial. No obstante, presenta complicaciones trombóticas (trombosis subclavia y yugular) y se reintroducen los anticoagulantes con dosis en el límite bajo del rango terapéutico (AU)

We present the case of a 44-year-old woman with past history of repeated miscarriage and Budd-Chiari syndrome secondary to primary myelofibrosis. Because of this she was under treatment with oral anticoagulant agents. The patient was admitted in hospital as she presented with gastrointestinal bleeding (melena), asthenia and progressive anemia. In an initial upper endoscopy an extrinsic duodenal compression associated with an ulcer on the posterior face of the first portion of duodenum and upper duodenal knee was observed. In the following days a huge spontaneous retroperitoneal hematoma due to anticoagulation was diagnosed by computed tomography. This was treated with a percutaneous drainage and withdrawal of the antithrombotic drugs. The evolution of the patient was initially satisfactory but she suffered subclavian and jugular vein thrombosis, and reintroduction of anticoagulant agents at the lowest therapeutic doses was required (AU)

Schwannoma gástrico como hallazgo ecográfico casual / Gastric schwannoma presenting as a casual ultrasonographic findings

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