Economic Impact of the Implementation of an Enhanced Recovery after Surgery (ERAS) Protocol in a Bariatric Patient Undergoing a Roux-En-Y Gastric Bypass.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) protocols have proven to be cost-effective in various surgical procedures, mainly in colorectal surgeries. However, there is still little scientific evidence evaluating the economic impact of their application in bariatric surgery. The present study aimed to compare the economic cost of performing a laparoscopic Roux-en-Y gastric bypass following an ERAS protocol, with the costs of following a standard-of-care protocol. PATIENTS AND METHODS: A prospective non-randomized study of patients undergoing Roux-en-Y gastric bypass was performed. Patients were divided into two groups: patients following an ERAS protocol and patients following a standard-of-care protocol. The total costs of the procedure were subdivided into pharmacological expenditures, surgical material, and time expenses, the price of complementary tests performed during the hospital stay, and costs related to the hospital stay. RESULTS: The 84 patients included 58 women (69%) and 26 men (31%) with a mean age of 44.3 ± 11.6 years. There were no significant differences in age, gender, and distribution of comorbidities between groups. Postoperative pain, nausea or vomiting, and hospital stay were significantly lower within the ERAS group. The pharmacological expenditures, the price of complementary tests performed during the hospital stay, and the costs related to the hospital stay, were significantly lower in the ERAS group. There were no significant differences in the surgical material and surgical time costs between groups. Globally, the total cost of the procedure was significantly lower in the ERAS group with a mean saving of 1458.62$ per patient. The implementation of an ERAS protocol implied a mean saving of 21.25% of the total cost of the procedure. CONCLUSIONS: The implementation of an ERAS protocol significantly reduces the perioperative cost of Roux-en-Y gastric bypass.

Study of cutaneous melanoma recurrences after sentinel node biopsy: Patterns of dissemination and use of complementary test in follow-up.

OBJECTIVES: To investigate the patterns of melanoma recurrence in the local population, including factors that may influence in this event and timing of relapse, and to determine the mode of detection of them. METHODS: This is a retrospective cohort study of patients with melanoma who underwent sentinel lymph node biopsy at the Complejo Hospitalario de Navarra (Spain) from 2002 to 2012. The following data were collected of each patient: age, gender, date of diagnosis, location of melanoma, histological subtype, Breslow thickness, ulceration, mitosis, sentinel node status, AJCC 8th edition stage, site of first diagnosed metastasis, mode of relapse, date of first relapse and time of death. RESULTS: Of 308 patients, 30% people suffered metastasis. The mean follow-up time was 68.63 months. 51.1% of relapses were locoregional and 48.9% haemato-visceral. Sentinel node status was the only variable associated with higher risk of haemato-visceral metastasis (p < 0.001). The mean time between diagnosis of melanoma and recurrence was 2.7 years. Most recurrences were detected by the patient himself or had any type of symptoms and were consequently selected for a complementary test. CONCLUSION: It is important to follow-up all patients with diagnosis of cutaneous melanoma, essentially during the first 5 years after diagnosis.

How and when to refer patients diagnosed with primary headache and craniofacial neuralgia in the Emergency department or Primary Care: Recommendations of the Spanish Society of Neurology's Headache Study Group. / Cómo y cuándo derivar un paciente con cefalea primaria y neuralgia craneofacial desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología.

INTRODUCTION: When a patient is diagnosed with primary headache or craniofacial neuralgia in the emergency department or in primary care, and is referred to a neurologist due to the complexity of the case, it is useful to know whether additional examination should be sought and the priority (urgent, preferential or normal) with which the patient should be seen. This will avoid unnecessary delays in patients with disabling headache and where organic causes are suspected. In order to issue recommendations on this matter, the Spanish Society of Neurology's Headache Study Group has decided to create a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgia. DEVELOPMENT: Young neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with Spanish Society of Neurology's Headache Study Group Executive Committee. For practical reasons, the document was divided into 2 articles: this first article focuses on primary headaches and craniofacial neuralgias and the second on secondary headaches. In order for the recommendations to be helpful for daily practice they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. CONCLUSIONS: We hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment.

Anterolateral talar palpation: A complementary test for ankle instability.

BACKGROUND: The anterior drawer test is traditionally used to assess ankle instability, but we believe that there is room for a small but effective improvement by adding digital palpation of the talus. We aimed to determine the accuracy of anterolateral talar palpation (ATP) in the diagnosis of ankle instability by comparing it with the traditional anterior drawer test. METHODS: Fourteen symptomatic and 10 asymptomatic patients were examined for excessive mobility through comparison of both ankles by two blinded orthopedic surgeons, each one using one of the above-mentioned tests. Symptomatic patients were also referred for stress radiography and magnetic resonance imaging (MRI). RESULTS: ATP was the most sensitive test, but also the least specific, yielding more positive results than the other tests, including tests with negative MRI. ATP and radiography had the highest accuracy and highest level of agreement with MRI. CONCLUSIONS: ATP significantly improved diagnostic accuracy in detecting ankle instability. LEVEL OF EVIDENCE: IV: cross-sectional study.

Utilização de diferentes volumes de sêmen na realização do teste hiposmótico em touros adultos da raça nelore / Use of different semen volumes in hypoosmotic test of adult nelore bulls / El uso de diferentes volúmenes de semen en el test hiposmótico en toros adultos de la raza nelore

O objetivo deste estudo foi avaliar diferentes proporções de sêmen: solução hiposmótica na realização do teste hiposmótico e suas relações com a congelabilidade do sêmen de touros zebuínos. Utilizaram-se 15 ejaculados de três touros adultos da raça Nelore. No sêmen in natura realizou-se a avaliação física e morfológica, a coloração supravital e o teste hiposmótico. No teste hiposmótico foi utilizada uma solução com osmolaridade de 100 mOsm/Kg com 15 minutos de período de incubação a 37 ºC, tanto no sêmen in natura quanto no congelado/descongelado. Foram utilizados quatro volumes de sêmen em 1mL de solução hiposmótica: 10, 20, 50 e 100 µL. As amostras criopreservadas foram descongeladas e foram realizados os testes hiposmótico, coloração supravital, teste de termo-resistência lento e a coloração fluorescente. Os valores médios e desvios padrão do percentual de espermatozoides reativos ao teste hiposmótico em sêmen in natura e congelado/descongelado foram 69,3 ± 11,8 e 20,5 ± 6,8; respectivamente. Não houve correlação do teste hiposmótico com os aspectos físicos e morfológicos e os testes complementares realizados em sêmen in natura e congelado/descongelado. Nenhum teste de integridade de membrana plasmática dos espermatozoides foi capaz de classificar os touros quanto a sua congelabilidade do sêmen. Conclui-se que o teste hiposmótico pode ser realizado com 20 a 100 µL de sêmen in natura, e 10 a 100 µL de sêmen congelado/descongelado em 1 mL de solução hiposmótica, sem interferir em seus resultados, mas deve-se optar por 100 µL tanto para sêmen in natura e congelado/descongelado, porque melhora consideravelmente a leitura das lâminas.(AU)

The objective of this study was to evaluate different proportions of semen: hypoosmotic solution in the hypoosmotic swelling test and their relationship with semen freezability in Zebu bulls. A total of 15 ejaculates from three adult Nelore bulls were used. Physical and morphological features were analyzed in fresh semen, as well as supravital staining and hypoosmotic swelling test. In the hypoosmotic test, a hypoosmotic solution with 100 mOsm/kg osmolality using 15 minutes incubation at 37 °C was used both in fresh and frozen/thawed semen. Four semen volumes in 1-ml hyposmotic solution were used: 10, 20, 50 and 100 µL. Cryopreserved samples were thawed and submitted to hypoosmotic tests, supravital staining, slow thermo-resistance test and fluorescent staining. Mean values and standard deviations of the percentage of reactive sperm cells in the hypoosmotic test in fresh and frozen/thawed semen were 69.3 ± 11.8 and 20.5 ± 6.8, respectively. There was no correlation between the hypoosmotic test and physical and morphological features and the complementary tests performed on fresh and frozen/thawed semen. None of the plasma membrane integrity tests was able to predict bull semen freezability. It can be concluded that the hypoosmotic test can be performed with 20 to 100 µL fresh semen, and 10 to 100 µL of frozen/thawed semen in 1 mL of hypoosmotic solution without interfering with their results, but 100 µL should be used in both, because it considerably improves the view of the slides.(AU)

El objetivo de este estudio ha sido evaluar diferentes proporciones de semen: solución hiposmótica en la realización del test hiposmótico y sus relaciones con la congelabilidad del semen de toros cebú. Se utilizaron 15 eyaculados de tres toros adultos de la raza Nelore. En el semen fresco se realizó evaluación física y morfológica, la tinción supravital y test hiposmótico. En el test hiposmótico se ha utilizado una solución con osmolaridad de 100 mOsm/kg con un período de incubación de 15 minutos a 37 ºC, tanto en el semen fresco cuanto en el congelado/descongelado. Fueron utilizados cuatro volúmenes de 1 mL de solución hiposmótica: 10, 20, 50, y 100 µL. Las muestras criopreservadas fueron descongeladas y realizados los tests hiposmótico, tinción supravital, test de resistencia al fuego lento y la tinción fluorescente. Los valores medios y desvío estándar del porcentaje de espermatozoides reactivos al test hiposmótico en l semen fresco y congelado/descongelado fueron 69,3 ± 11,8 y 20,5 ± 6,8; respectivamente. No hubo correlación del test hiposmótico con las características físicas y morfológicas y pruebas adicionales en el semen fresco y congelado/descongelado. Ningún test de integridad de la membrana plasmática de los espermatozoides han sido capaz de clasificar a los toros cuanto su congelabilidad del semen. Se puede concluir que el test hiposmótico puede ser realizado con 20 a 100 µL de semen fresco, y de 10 a 100 µL de semen congelado/descongelado en 1 mL de solución hiposmótica, sin interferir en sus resultados, pero se debe optar por 100 µL para el semen fresco y congelado/descongelado, porque mejora significativamente la lectura de las láminas.(AU)