TULUA Male High-Definition Abdominoplasty.

BACKGROUND: Abdominoplasty is a surgical technique for body contouring that has been shown to improve the patient's quality of life. It has become more common among male patients, so clear differences between procedures for men and women have to be stated. The authors present their experience with high-definition lipoabdominoplasty with transverse plication in men. METHODS: Records of male patients undergoing transverse plication full abdominoplasty in addition to high-definition liposculpture were analyzed. A total of 24 consecutive cases were found between January of 2017 and June of 2019. Patient ages ranged from 24 to 60 years. Patients aged 18 years or younger were excluded. Body mass index ranged from 25 to 33 kg/m2. Photographic records were taken before and during follow-up at 2 days and 1, 3, 6, and 12 months after surgery. RESULTS: Male TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) with high-definition lipoabdominoplasty was successfully achieved in 24 cases. No major complications were reported. Six minor complications were reported (25 percent). Rectus abdominis diastases are less common in men compared to women, as pregnancy is the most determining factor in its development. Fat distribution is also a key difference when performing lipoabdominoplasty for the male or the female patient. The authors recommend a transverse plication of the abdominal wall, instead of a vertical one, as flap viability is preserved and enhanced muscular definition can be accomplished. CONCLUSIONS: Combining transverse plication with high-definition lipoabdominoplasty (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar plus high-definition lipoabdominoplasty) is a safe and reproducible technique for the male patient. It offers higher aesthetic results in line with modern beauty ideals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Characterizing Breakthrough Cancer Pain Using Ecological Momentary Assessment with a Smartphone App: Feasibility and Clinical Findings.

BACKGROUND: mobile applications (apps) facilitate cancer pain ecological momentary assessment (EMA) and provide more reliable data than retrospective monitoring. The aims of this study are (a) to describe the status of persons with cancer pain when assessed ecologically, (b) to analyze the utility of clinical alarms integrated into the app, and (c) to test the feasibility of implementing an app for daily oncological pain monitoring. METHODS: in this feasibility study, 21 patients (mean age = 56.95 years, SD = 10.53, 81.0% men) responded to an app-based evaluation of physical status (baseline and breakthrough cancer pain (BTcP)) and mental health variables (fatigue, mood, and coping) daily during 30 days. RESULTS: cancer pain characterization with the app was similar to data from the literature using retrospective assessments in terms of BTcP duration and perceived medication effectiveness. However, BTcP was less frequent when evaluated ecologically. Pain, fatigue, and mood were comparable in the morning and evening. Passive coping strategies were the most employed daily. Clinical alarms appear to be useful to detect and address adverse events. App implementation was feasible and acceptable. CONCLUSION: apps reduce recall bias and facilitate a rapid response to adverse events in oncological care. Future efforts should be addressed to integrate EMA and ecological momentary interventions to facilitate pain self-management via apps.

TULUA Lipoabdominoplasty: No Supraumbilical Elevation Combined With Transverse Infraumbilical Plication, Video Description, and Experience With 164 Patients.

BACKGROUND: TULUA (transverse plication, undermining halted at umbilicus, liposuction [without restrictions], umbilicoplasty with a skin graft, and abdominoplasty with low transverse scar localization) is a fundamentally different lipoabdominoplasty technique intended to reduce the risk of vascular compromise, correct wall laxity through a unique plication, allow freedom in choosing the umbilical position, reduce tension on closure, and keep the final scar low. OBJECTIVES: The objectives of this article were to describe the TULUA technique and its variations, delineate the indications and contraindications, show the expected results, and determine its safety profile. METHODS: A series of 164 patients is presented. The technique's basic tenets were (1) infraumbilical wide transverse plication; (2) no undermining above the umbilicus; (3) unrestricted liposuction, including the supraumbilical tissues; (4) umbilical amputation and neoumbilicoplasty in the ideal position with a skin graft; and (5) low transverse scar placement. Complications were recorded and tabulated. Results were evaluated utilizing Salles' and the author's graded scales. RESULTS: Scores averaged 9.4 out of 10 on the Salles' scale and 5.6 out of 6 on the author's scale, demonstrating adequate correction of the abdominal contour and the wall and skin laxity, with properly placed scars and umbilici, and without compensatory epigastric bulging. Overall, 20% of the patients experienced a complication: 9.7% experienced a delay in either the healing or graft take of the umbilicus, 0.6% developed skin necrosis, 0.6% experienced a wound dehiscence, 2.4% had an infection, and 4.9% developed a seroma. CONCLUSIONS: The TULUA lipoabdominoplasty technique was found to improve abdominal wall laxity and aesthetics to a degree that is similar to traditional abdominoplasty, based on the evaluated parameters. The complications associated with the procedure are within the range of other abdominoplasty techniques, and the technique potentially has a reasonable safety profile with less risk of vascular compromise.

P2X7 receptor induces mitochondrial failure in monocytes and compromises NLRP3 inflammasome activation during sepsis.

Sepsis is characterized by a systemic inflammatory response followed by immunosuppression of the host. Metabolic defects and mitochondrial failure are common in immunocompromised patients with sepsis. The NLRP3 inflammasome is important for establishing an inflammatory response after activation by the purinergic P2X7 receptor. Here, we study a cohort of individuals with intra-abdominal origin sepsis and show that patient monocytes have impaired NLRP3 activation by the P2X7 receptor. Furthermore, most sepsis-related deaths are among patients whose NLRP3 activation is profoundly altered. In monocytes from sepsis patients, the P2X7 receptor is associated with mitochondrial dysfunction. Furthermore, activation of the P2X7 receptor results in mitochondrial damage, which in turn inhibits NLRP3 activation by HIF-1α. We show that mortality increases in a mouse model of sepsis when the P2X7 receptor is activated in vivo. These data reveal a molecular mechanism initiated by the P2X7 receptor that contributes to NLRP3 impairment during infection.

The importance of intra-hospital pharmacovigilance in the detection of medication errors / La importancia de la farmacovigilancia intrahospitalaria en la detección oportuna de los errores de medicación.

Introduction: Hospitalized patients are susceptible to medication errors, which represent between the fourth and the sixth cause of death. The department of intra-hospital pharmacovigilance intervenes in the entire process of medication with the purpose to prevent, repair and assess damages. Objective: To analyze medication errors reported by Mexican Fundación Clínica Médica Sur pharmacovigilance system and their impact on patients. Method: Prospective study carried out from 2012 to 2015, where medication prescriptions given to patients were recorded. Owing to heterogeneity, data were described as absolute numbers in a logarithmic scale. Results: 292 932 prescriptions of 56 368 patients were analyzed, and 8.9% of medication errors were identified. The treating physician was responsible of 83.32% of medication errors, residents of 6.71% and interns of 0.09%. No error caused permanent damage or death. Conclusion: This is the pharmacovigilance study with the largest sample size reported.

Introducción: Los pacientes hospitalizados son susceptibles a errores de medicación, que representan entre la cuarta y sexta causa de muerte. El servicio de farmacovigilancia intrahospitalaria interviene en todo el proceso de medicación con el fin prevenir, corregir y evaluar los daños. Objetivo: Analizar los errores de medicación reportados por el sistema de farmacovigilancia de la Fundación Clínica Médica Sur, México, y su impacto en los pacientes. Método: Estudio prospectivo efectuado de 2012 a 2015, en el que se registraron las prescripciones de medicamente a los pacientes. Los datos se describieron como número absoluto en escala logarítmica debido a la heterogeneidad. Resultados: Se analizaron 292 932 prescripciones de 56 368 pacientes, entre las cuales se identificó 8.9 % errores de medicación. El médico tratante fue responsable de 83.32 %, los residentes de 6.71 % y los internos de 0.09 %. Ningún error causó daño permanente o muerte. Conclusión: El estudio de farmacovigilancia que se presenta constituye el de mayor tamaño de muestra informado.

Phenomenological-narrative contributions to understand the narrative strategies that shape the autobiographical account throughout different moments of the therapeutic process.

Different studies suggest that the strategies and narrative styles that people use to construct their autobiographical accounts have repercussions on their self-organization, as well as on their identity experience and their conception of the world. Empirical evidence supports changes in different aspects related to process, structure, and content in the narrative of clients during the course of the therapeutic process; these, in turn, seem to condition the course and the results of the process. In this paper we will seek to show, based on a case study and through the application of a method of phenomenological-narrative analysis, what are the predominant narrative strategies that a client uses in order to shape her autobiographical narrative in the initial and final moments of her psychotherapeutic process. Our data suggest that the narrative strategies at the beginning and end of the therapy are qualitatively differentiable. Changes are observed in the plot of the respective accounts, as well as a differentiated mode in the use of narrative functions. More specifically toward the end of psychotherapy, the client makes a deeper characterization of herself and others, based on predicates of a subjectivating, interpretive, and evaluative-reflective kind. She also predominantly uses proconcluding metacomments, which could facilitate the integration of problematic experiences. In summary, our data suggest that after a successful therapeutic process the client uses more complex and integrated narrative strategies for the construction of her autobiographical account.

Evaluation and management of orofacial pain.

Challenging to diagnose and manage, orofacial pain is a common and costly problem with a profound effect on quality of life. Delayed diagnosis and management can lead to prolonged patient suffering and disability. This article describes the background, assessment, differential diagnosis, management, and referral of patients with orofacial pain.

Alteraciones de la hemostasia durante la cirugía con quimioterapia intraperitoneal hipertérmica en pacientes con carcinomatosis peritoneal / Alterations in hemostasis during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis

INTRODUCCIÓN: La cirugía citorreductora seguida de quimioterapia intraperitoneal hipertérmica (HIPEC) se asocia frecuentemente a alteraciones de la hemostasia y a elevados requerimientos transfusionales perioperatorios. El propósito de este estudio fue analizar los trastornos hemostáticos asociados a cada una de las fases de este procedimiento terapéutico mediante tromboelastometría rotacional (ROTEM), niveles de fibrinógeno y recuento plaquetario, así como su posible relación con las necesidades transfusionales. MÉTODOS: Se efectuó un estudio prospectivo longitudinal. Se registraron niveles de hemoglobina, recuento plaquetario, niveles de fibrinógeno y parámetros tromboelastométricos: tiempo de coagulación (CT), tiempo de formación del coágulo (CFT), firmeza máxima del coágulo (MCF), y ángulo α (EXTEM, INTEM, FIBTEM). Las mencionadas determinaciones se realizaron: antes del inicio de la cirugía; al finalizar la cirugía citorreductora y al concluir la HIPEC. Se utilizaron los test estadísticos apropiados. Los valores de p < 0,05 se consideraron estadísticamente significativos. RESULTADOS: Se incluyó en el estudio a 41 mujeres con una mediana de edad de 54 años (rango: 34-76). Tras la cirugía citorreductora se observó una caída de la tasa de hemoglobina desde 11,4 ± 1,5 a 10,6 ± 1,6 g/dl; un descenso del fibrinógeno sérico desde 269 ± 69 hasta 230 ± 48 mg/dl (p < 0,01) y una reducción de MCF en FIBTEM desde 20 ± 10 hasta 16 ± 8 mm (p < 0,01). La HIPEC no se asoció a alteraciones hemostáticas. Se observó una moderada relación negativa entre el número de concentrados de hematíes administrados y los niveles de fibrinógeno (ρ = −0,5; p = 0,002) y los valores de MCF EXTEM (ρ = −0,43; p = 0,006) registrados tras la HIPEC. CONCLUSIONES: Las alteraciones hemostáticas observadas aparecen tras la cirugía citorreductora, probablemente a consecuencia de la hemorragia quirúrgica. Se requieren más estudios para confirmar una correlación entre las necesidades transfusionales y las pruebas de coagulación postoperatorias

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is frequently associated with coagulation impairment and perioperative blood transfusion. Our aim was to investigate the impact of each procedure step on hemostasis, as measured by rotational thromboelastometry™ (ROTEM), fibrinogen level and platelet count as a primary outcome, along with its relationship with transfusion needs. METHODS: A prospective longitudinal study was performed. Hemoglobin level, fibrinogen level, platelet count and ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), α-angle (EXTEM, INTEM, FIBTEM) were measured before the procedure, at the end of cytoreductive surgery and after HIPEC. Appropriate statistical tests were used for comparison. A P<.05 was considered as significant. RESULTS: Forty-one women, with median age 54 (range 34-76) were recruited. Cytoreductive surgery was followed by a reduction of hemoglobin level from 11,4 ± 1,5 g/dl to 10,6 ± 1,6 g/dl, a reduction of serum fibrinogen level from 269 ± 69 mg/dl to 230 ± 48 mg/dl (P<.01) and MCF decline from 20 ± 10 to 16 ± 8 mm (P<.01), in the FIBTEM test. HIPEC was followed by no hemostatic impairment. The number of packed red blood cells administered during patients stay kept a mild significant relationship with both fibrinogen level (ρ = −0.5, P=.002), and MCF EXTEM values (ρ= -0.43, P=0.006), recorded after HIPEC. CONCLUSIONS: The mild observed hemostatic impairment appeared after cytoreductive surgery instead of HIPEC, involving surgical hemorrhage as the most likely responsible factor. Further studies are required to confirm a correlation between transfusion needs and postoperative hemostatic tests

Alterations in hemostasis during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is frequently associated with coagulation impairment and perioperative blood transfusion. Our aim was to investigate the impact of each procedure step on hemostasis, as measured by rotational thromboelastometry™ (ROTEM), fibrinogen level and platelet count as a primary outcome, along with its relationship with transfusion needs. METHODS: A prospective longitudinal study was performed. Hemoglobin level, fibrinogen level, platelet count and ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), α-angle (EXTEM, INTEM, FIBTEM) were measured before the procedure, at the end of cytoreductive surgery and after HIPEC. Appropriate statistical tests were used for comparison. A P<.05 was considered as significant. RESULTS: Forty-one women, with median age 54 (range 34-76) were recruited. Cytoreductive surgery was followed by a reduction of hemoglobin level from 11,4±1,5g/dl to 10,6±1,6g/dl, a reduction of serum fibrinogen level from 269±69mg/dl to 230±48mg/dl (P<.01) and MCF decline from 20±10 to 16±8mm (P<.01), in the FIBTEM test. HIPEC was followed by no hemostatic impairment. The number of packed red blood cells administered during patients stay kept a mild significant relationship with both fibrinogen level (ρ = -0.5, P=.002), and MCF EXTEM values (ρ= -0.43, P=0.006), recorded after HIPEC. CONCLUSIONS: The mild observed hemostatic impairment appeared after cytoreductive surgery instead of HIPEC, involving surgical hemorrhage as the most likely responsible factor. Further studies are required to confirm a correlation between transfusion needs and postoperative hemostatic tests.

In vitro correlation of the level of inferior alveolar canal with CBCT imaging.

PURPOSE: The aim was to correlate the level of the inferior alveolar canal on cadaver specimens and as evaluated with three-dimensional radiographic cone-beam computed tomography (CBCT) imaging. METHODS: Twenty-one skulls with intact mandibles (42 inferior alveolar canals) were imaged with an I-CAT Cone-Beam 3D Imaging System and multi-planar reformatted images obtained were scored to assess the level of the canal (Level I, Level II, and Level III). The mandibles were later dissected and level of the canal was directly visualized, scored, and further correlated with results from CBCT imaging. RESULTS: There was no difference in the level of the inferior alveolar canal between the dissected cadaver specimen and CBCT images. Also, there was no statistically significant difference in the level of the canal among the gender assigned to the specimens and corresponding CBCT images. There were no statistical differences in the level of the canal (cadaver specimen vs. CBCT) between the left and right sides of the specimens, as studied individually. CONCLUSION: Our study indicates that there is close correlation of the level of the inferior alveolar canal between cadaver specimens and CBCT images. Well-designed studies would be required to further validate the findings in this study.

A novel approach to abdominoplasty: TULUA modifications (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar).

BACKGROUND: Lipoabdominoplasty can be associated with complications, particularly tissue necrosis, wound dehiscence, epigastric bulging, high transverse scar, low positioning of the umbilicus, and seroma. METHODS: Modified abdominoplasty characterized by (1) transverse elliptical plication of the lower abdominal wall, (2) no undermining of the flap above the navel, (3) unrestricted liposuction, (4) umbilical amputation and neoumbilicoplasty by skin graft, and (5) low transversely placed abdominal scar (TULUA) was performed for 42 patients. These procedures were elective and performed primarily to remedy epigastric skin redundancy associated with obesity or when supraumbilical undermining was considered inappropriate. RESULTS: The results were objectively scored as excellent for 20 patients, good for 21 patients, and fair for 1 patient. A normal-appearing umbilicus was attained in all cases except one. The lower transverse scars were generally concealable (6.3 ± 1.4 cm from the anterior vulvar commissure), and epigastric bulging was avoided. Although four patients experienced seromas at the tail ends of incisions, no skin necrosis, wound dehiscence, or other major complications such as venothromboembolism occurred, and there were no fatalities. In four patients, postoperative magnetic resonance imaging demonstrated measurable and significant changes attributable to plicature compared with equivalent control points (p < 0.000001), which persisted over time. CONCLUSIONS: The TULUA procedure offers potential advantages in terms of vascular safety, sensory recovery, position and quality of the umbilicus, and transverse scar location, with aesthetic outcomes that generally eliminate epigastric bulging. A sizeable patient population stands to benefit from this approach, especially when obesity, smoking, secondary revisions, umbilical or hypogastric hernias, and massive weight loss are clinical considerations for abdominoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Hemicrania continua in a patient with concomitant dental disease.

BACKGROUND: There are nonodontogenic headache disorders that mimic dental pain. One such headache disorder is hemicrania continua (HC). HC is a primary headache syndrome characterized by a continuous, unilateral headache that is completely responsive to indomethacin. Patients may have signs and symptoms that the dentist should differentiate from odontogenic pain and temporomandibular disorders. These symptoms can make the diagnostic process a challenge for dentists if patients' pain has multiple causes. Dentists, thus, must have thorough knowledge of odontogenic and nonodontogenic causes of pain so they can make accurate diagnoses and prepare treatment plans. CASE DESCRIPTION: The authors describe the case of a 41-year-old woman with a six-year history of continuous headaches and a one-year history of temporomandibular dysfunction and odontogenic pain. She sought treatment from a number of dentists and received a diagnosis of right-side facial pain and headache on the basis of the results of clinical and radiologic examinations, which was followed by dental treatment. She did not experience any pain relief. Additional results of our examination led to a diagnosis of HC. CLINICAL IMPLICATIONS: Dentists must consider headache disorders in patients who have continuous headaches after undergoing dental treatment for odontogenic pain.

Topical pregabalin and diclofenac for the treatment of neuropathic orofacial pain in rats.

OBJECTIVE: The aim of this study was to evaluate the effect of topical treatment with pregabalin and diclofenac on neuropathic orofacial pain induced by infraorbital nerve injury in the rat. STUDY DESIGN: Sixty-four Sprague-Dawley rats underwent infraorbital nerve injury. Seven days after surgery, pain was verified and the rats randomly assigned to topical or systemic treatment with pregabalin or diclofenac, or to no treatment. Pain intensity and motor coordination were assessed at baseline, after surgery, and daily after treatment for 4 consecutive days. Medication plasma levels were assessed at the end of the study. RESULTS: Topical treatment with 10% pregabalin or 5% diclofenac reduced the pain significantly. A significant decrease in motor coordination was found in the systemic pregabalin. The medications' plasma levels were significantly higher in the systemic treatment compared with the topical. CONCLUSIONS: Topical treatment with pregabalin or diclofenac can reduce neuropathic orofacial pain induced by nerve injury.

Manejo de las náuseas y vómitos postoperatorios / Management of postoperative nausea and vomiting

Las nauseas y vómitos postoperatorios no han recibido el suficiente interés hasta la fecha. Se han considerado molestias inherentes e inevitables tras muchas intervenciones quirúrgicas. Sin embargo, esta desagradable complicación tiene un manejo que puede resultar eficaz. Para ello hay que valorar adecuadamente el riesgo y actuar en consecuencia. Existe una amplia variedad de opciones profilácticas disponibles relacionadas con la técnica anestésica, además del oportuno tratamiento antiemético. En este artículo se revisan los factores de riesgo y se efectúan una serie de recomendaciones operatorias y postoperatorias (AU)

There still appears to be insufficient interest in the management of postoperative nausea and vomiting. They are considered as inherent and inevitable discomforts after surgical operation. However, this disagreeable complication can be effectively managed. To do this, the risk must be suitably assessed and acted on accordingly. There are a wide variety of prophylactic options available associated with the anaesthetic technique, as well as appropriate anti-emetic treatment. In this article, the risk factors are reviewed and series of operative and postoperative recommendations are made (AU)

Origen anómalo de la arteria coronaria izquierda en la arteria coronaria derecha y curso ínter-arterial / Anomalous origin of the left coronary artery arising from the right coronary arter

El origen del tronco coronario principal izquierdo a partir de la arteria coronaria derecha o del seno de Valsava opuesto, es una anomalía extremadamente rara con un riesgo potencial de mortalidad. En este informe se describe el caso de una paciente con esta anomalía, inicialmente detectada por coronariografía y posteriormente confirmada mediante resonancia magnética cardiaca.

The left main coronary artery arising from the opposite sinus of Valsalva or from the right coronary artery is an extremely rare condition with a potential risk of mortality. This report describes the case of a female patient with this coronary artery anomaly, initially detected by coronariography and subsequently confirmed by cardiac magnetic resonance.

[Management of postoperative nausea and vomiting]. / Manejo de las náuseas y vómitos postoperatorios.

There still appears to be insufficient interest in the management of postoperative nausea and vomiting. They are considered as inherent and inevitable discomforts after surgical operation. However, this disagreeable complication can be effectively managed. To do this, the risk must be suitably assessed and acted on accordingly. There are a wide variety of prophylactic options available associated with the anaesthetic technique, as well as appropriate anti-emetic treatment. In this article, the risk factors are reviewed and series of operative and postoperative recommendations are made.

Uso rutinario del balón de contra-pulsación aórtica preoperatorio en pacientes con enfermedad del tronco común izquierdo sometidos a cirugía de revascularización coronaria / Routine use of preoperative intra-aortic balloon pump counterpulsation (IABP) implantation in patients with left main coronary artery disease undergoing coronary revascularization surgery

Generalidades: la enfermedad del tronco común izquierdo como único criterio para la colocación de balón de contra-pulsación aórtica, es una indicación cuya evidencia se limita a la recomendación de expertos y, por lo tanto, se requieren estudios que puedan aportar mayor nivel de evidencia al respecto. Por este motivo, en nuestra institución se desarrolló un estudio que evaluó la experiencia del uso de balón de contra-pulsación aórtica preoperatorio, en pacientes sometidos a cirugía de revascularización cardiaca electiva, con enfermedad del tronco común izquierdo.Objetivo: describir la letalidad, el tiempo de estancia y el porcentaje de infecciones y sepsis en la unidad de cuidados intensivos, así como el tiempo de ventilación mecánica, en los pacientes sometidos a cirugía de revascularización coronaria electiva con y sin el uso preoperatorio de balón de contra pulsación aórtica.Métodos: estudio descriptivo retrospectivo, que se llevó a cabo en la Clínica Cardiovascular Santa María, con los pacientes que se sometieron a revascularización coronaria quirúrgica electiva acompañados o no de balón de contra-pulsación aórtica preoperatorio entre 1999 y 2003, y en el que se observó el comportamiento post-operatorio de los pacientes con enfermedad severa del tronco común izquierdo (entendida como estenosis mayor de 50 porciento) sometidos a dicha intervención.Resultados: se analizaron en total 79 pacientes sometidos a revascularización quirúrgica electiva, a 46 de los cuales se les implantó balón preoperatorio y a 33 se les practicó intervención quirúrgica sin balón. El promedio de edad fue de 62 años. El 67,4 porciento de los pacientes tenía 60 años o más.