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Background Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The recommended treatment is the early laparoscopic cholecystectomy; however, the Tokyo Guidelines (TG) advocate for different initial treatments in some subgroups of patients without a strong evidence that all patients will benefit from them. There is no clear consensus in the literature about who is the unfit patient for surgical treatment. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. Methods Retrospective unicentric cohort study of patients emergently admitted with and ACC during 1 January 2011 to 31 December 2016. The study comprised 963 patients. Primary outcome was the mortality after the diagnosis. A propensity score method was used to avoid confounding factors comparing surgical treatment and non-surgical treatment. Results The overall mortality was 3.6%. Mortality was associated with older age (68 + IQR 27 vs. 83 + IQR 5.5; P = 0.001) and higher Charlson Comorbidity Index (3.5 + 5.3 vs. 0+2; P = 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.7–12.8 P = 0.001), dementia (OR 4.12; 95% CI 1.34–12.7, P = 0.001), age > 80 years (OR 1.12: 95% CI 1.02–1.21, P = 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.5–28.3, P = 0.001) which predicted the mortality in a 92% of the patients. The receiver operating characteristic curve yielded an area of 88% significantly higher that 68% (P = 0.003) from the TG classification. When comparing subgroups selected using propensity score matching with the same morbidity and severity of ACC, mortality was higher in the non-surgical treatment group. (26.2% vs. 10.5%). Conclusions Mortality was higher in ACC patients treated with non-surgical treatment. ACME identifies high-risk patients. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. Trial registration Retrospectively registered and recorded in Clinical Trials. NCT04744441

Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.

Antibiotic allergy labels (AAL) are related to worse therapeutic results. Strategies to improve the management of these patients, such as the implementation of antibiotic desensitization, are essential for Antimicrobial Stewardship Programs (ASP). The aim of our study is to evaluate the efficacy and safety of antibiotic desensitization procedures for the management of patients with AAL. A retrospective study from 2015 to 2022 was performed to describe all antibiotic desensitization conducted in our institution, within the framework of ASP. A systematic literature review using electronic databases, such as PubMed, was also done to identify studies describing antibiotic desensitization between 2000 and 2022. Sixteen antibiotic desensitization protocols were carried out in our institution. In fourteen cases, the desensitization was successfully completed, and the antibiotic could be used to treat the infection. In the systematic review, twenty-two studies were included, with a total of 202 desensitization episodes . In 97% of them, the desensitization was completed successfully. No desensitization-related mortality was observed neither in our cohort nor in literature review. Antibiotic desensitization strategies should be considered a safe and effective tool that can be included in ASP for patients with a high risk of or confirmed allergy to penicillin.

To challenge the risk factors described in Tokyo Guidelines in Acute Calculous Cholecystitis.Retrospective single center cohort study with 963 patients with Acute Cholecystitis during a period of 5 years. Some 725 patients with a "pure" Acute Calculous Cholecystitis were selected. The analysis included 166 variables encompassing all risk factors described in Tokyo Guidelines. The Propensity Score Matching method selected two subgroups of patients with equal comorbidities, to compare the severe complications rate according to the initial treatment (Surgical vs Non-Surgical). We analyzed the Failure-to-rescue as a quality indicator in the treatment of Acute Calculous Cholecystitis.the median age was 69 years (IQR 53-80). 85.1% of the patients were ASA II or III. The grade of the Acute Calculous Cholecystitis was mild in a 21%, moderate in 39% and severe in 40% of the patients. Cholecystectomy was performed in 95% of the patients. The overall complications rate was 43% and the mortality was 3.6%. The Logistic Regression model isolated 3 risk factor for severe complication: ASA II, cancer without metastases and moderate to severe renal disease. The Failure-to-Rescue (8%) was higher in patients with non-surgical treatment (32% vs. 7%; P = 0.002). After Propensity Score Matching, the number of severe complications was similar between Surgical and Non-Surgical treatment groups (48.5% vs 62.5%; P = 0.21).the recommended treatment for Acute Calculous Cholecystitis is the Laparoscopic Cholecystectomy. Only three risk factors from the Tokyo Guidelines list appeared as independent predictors of severe complications. The failure-to-rescue is higher in non-surgically treated patients.

Caecal volvulus represent the 20–40% of colonic volvulus, being the second most frequent localization. It causes intestinal occlusion symptomatology (nausea, vomiting, abdominal distension). We present a case of 45-year-old women with feeding jejunostomy tube due to connatal anoxia. She arrives at A&E after 12 h of vomits and abdominal pain. The CT scan shows a small intestine dilation that suggested a small intestine volvulus. A laparotomy is performed showing a caecal volvulus, so ileo-cequectomy with primary anastomosis is performed. After several complications, she was discharged after 60 days of hospital stay. Caecal volvulus can be challenging to diagnose by clinic, because it can be hardly differenced from other intestinal occlusion causes. CT scan can be useful to reach the diagnostic and see signs of tissue suffering. In contrast with sigma volvulus, endoscopic treatment has not shown any benefit to solve it.

BackgroundPrevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies. MethodsThis study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared. ResultsFrom an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62% vs. 43.2%; P=0.01) and operation due to a revision laparotomy (32.5% vs. 13%; P=0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P=0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR=2.47; 95% CI 1.318–4.624; P=0.05), contaminated surgery (HR=2.98; 95% CI 1.142–7.8; P=0.02), surgical site infection (SSI; HR=3.83; 95% CI 1.86–7.86; P=0.001), and no use of prophylactic mesh (HR=5.09; 95% CI 2.1–12.2; P=0.001). Conclusion Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and SSI benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate.

Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.

Background Postoperative adhesions represent 75% of all acute small bowel obstructions. Although open surgery is considered the standard approach for adhesiolysis, laparoscopic approach is gaining popularity. Methods A retrospective study with data from a prospectively maintained data base of all patients undergoing surgical treatment for adhesive small bowel obstruction (ASBO) from January 2007 to May 2016 was conducted. Postoperative outcomes comparing open vs laparoscopic approaches were analysed. An intention to treat analysis was performed. The aim of the study was to evaluate the potential benefits of the laparoscopic approach in the treatment of ASBO. Results 262 patients undergoing surgery for ASBO were included. 184 (70%) and 78 (30%) patients were operated by open and laparoscopic approach respectively. The conversion rate was 38.5%. Patients in the laparoscopic group were younger (p

Background This study was conducted to determine the efficacy and safety of the use of a partially absorbable large pore synthetic prophylactic mesh in emergent midline laparotomies for the prevention of evisceration and incisional hernia. Methods Retrospective analysis of all patients who underwent an emergency midline laparotomy between January of 2009 and July of 2010 was performed. Patients with complicated ventral hernia repair, postoperative death, and lack of follow-up were excluded. Results A total of 266 patients were included. Laparotomies were closed with a running suture of slow-reabsorbable material in 190 patients (Group S), and 50 patients within this group (26.3%) received additional retention sutures. In 76 patients (Group M), an additional partially absorbable lightweight mesh was placed in the Supra-aponeurotic space. Both groups presented similar complication rates (71.1% Group S vs 80.3% Group M, P = .97). There were no differences regarding surgical-site infection rates (17.9% Group S vs 26.3% Group M; P = .13) or postoperative mortality (13.7% Group S vs 18.3% Group M; P = .346). A total of 150 patients completed the follow-up (99 Group S; 51 Group M) at a mean time of 16.7 months. During follow-up, 36 cases of incisional hernia (24%) were diagnosed: 33 (33%) in Group S, whereas there were only three cases (5.9%) in Group M (P = .0001). Mesh removal for chronic infection was not required in any case. Conclusion The use of a partially absorbable, lightweight large pore prophylactic mesh in the closure of emergency midline laparotomies is feasible for the prevention of incisional hernia without adding a substantial rate of morbidity to the procedure, even if high contamination or infections are present.

Introduction Laparotomy is the standard approach for the surgical treatment of acute small bowel obstruction (ASBO). Patients and methods From February 2007 to May 2012 we prospectively recorded all patients operated by laparoscopy in our hospital because of ASBO due to adhesions (27 cases) and/or internal hernia (6 cases). A preoperative abdominal CT was performed in all cases. Patients suffering from peritonitis and/or sepsis were excluded from the laparoscopic approach. It was decided to convert to laparotomy if intestinal resection was required. Results The mean age of the 33 patients who underwent surgery was 61.1±17.6 years. 64% had previous history of abdominal surgery. 72% of the cases were operated by surgeons highly skilled in laparoscopy. Conversion rate was 21%. Operative time and postoperative length of stay were 83±44 min and 7.8±11.2 days, respectively. Operative time (72±30 vs 123±63 min.), tolerance to oral intake (1.8±0.9 vs 5.7±3.3 days) and length of postoperative stay (4.7±2.5 vs 19.4±21 days) were significantly lower in the laparoscopy group compared with the conversion group, although converted patients had greater clinical severity (2 bowel resections). There were two severe complications (Clavien-Dindo III and V) in the conversion group. Conclusions In selected cases of ASBO caused by adhesions and internal hernias and when performed by surgeons highly skilled in laparoscopy, a laparoscopic approach has a high probability of success (low conversion rate, short stay in hospital and low morbidity); its use would be fully justified in these cases.

Resumen Introduccion La laparotomia suele ser la via de abordaje de eleccion en los casos de intervencion quirurgica por obstruccion aguda de intestino delgado (OAID). Pacientes y metodos De febrero 2007 hasta mayo 2012 se registraron prospectivamente los pacientes intervenidos de urgencias en nuestro centro via laparoscopica por OAID por adherencias (27 casos) y/o hernia interna (6 casos). Todos disponian de una TC preoperatoria. Se excluyeron del abordaje laparoscopico aquellos con peritonitis y/o sepsis. En caso de requerir reseccion intestinal se convirtio a laparotomia. Resultados La edad media de los 33 pacientes operados fue de 61,1 ± 17,6 anos. El 64% tenian antecedentes de cirugia abdominal previa. El 72% de los casos fue operado por un cirujano experto en laparoscopia. La tasa de conversion fue del 21%. El tiempo operatorio y estancia postoperatoria medios fueron de 83 ± 44 min y 7,8 ± 11,2 dias, respectivamente. El tiempo operatorio (72 ± 30 vs 123 ± 63 min), dia de inicio de ingesta oral (1,8 ± 0,9 vs 5,7 ± 3,3 dia) y estancia postoperatoria (4,7 ± 2,5 vs 19,4 ± 21 dias) fueron significativamente menores en el grupo laparoscopia respecto al de conversion, si bien los pacientes convertidos presentaron mayor gravedad clinica (2 resecciones intestinales). Hubo 2 complicaciones graves (Clavien-Dindo III y V ) en el grupo de conversion. Conclusiones El abordaje laparoscopico, en casos seleccionados de OIDA por adherencias y hernias internas, cuando es realizado por cirujanos entrenados en laparoscopia, presenta una alta probabilidad de exito (baja tasa de conversion, corta estancia postoperatoria y baja morbilidad), por lo que su uso estaria plenamente justificado en estos casos.

Electrical shock can cause a direct myocardial damage and different types of arrhythmias, which are uncommon and occur more often when there is a high voltage exposure. We report a 19-year-old male that received a high voltage shock, falling thereafter from an altitude of four meters. On admission to the emergency room, he had second and third degree burns in the right hand and the left thigh. The electrocardiogram showed a nodal rhythm of 72 beats per minute. After four hours of monitoring, sinus rhythm returned spontaneously.

Introduction Observation is the gold standard for stable patients with stab wounds. The aim of the study was to analyze the value of the primary review and complementary examinations to predict the need for surgery in stab wound patients in order to decrease observation times. Methods A retrospective study of stab wound patients recorded in a database. Clinical and diagnostic workup parameters were analyzed. The main variable was the need for surgery. Results A total of 198 patients were included between 2006 and 2009, with a mean injury severity score (ISS) of 7.8±7, and 0.5% mortality. More than half (52%) of the patients suffered multiple wounds. Wound distribution was 23% neck, 46% thorax and 31% abdomen. Surgery was required in 73 (37%) patients (59% immediate, 27% delayed and 14% delayed). The need for surgery was associated with a lower revised trauma score (RTS), evisceration, active bleeding, and fascial penetration. Initial and control hemoglobin levels were significantly lower in patients who required surgery. A positive computerized tomography (CT) scan was associated with surgery. There were complications in 18% of patients, and they were more frequent in those who underwent surgery. There was no difference in complication rates between immediate and delayed (P=.72). Surgery was finally required in 10% of the patients with no abnormalities in the primary review and diagnostic workup, and 6% of those developed complications. Conclusion None of the parameters studied could individually assess the need for surgery. Primary and secondary reviews were the most important diagnostic tool, but CT scan should be used more often. An observation period of 24 h is recommended in torso penetrating wounds.

Resumen Introduccion La observacion es el patron oro del tratamiento de heridas de arma blanca en pacientes estables. El objetivo del estudio fue analizar el valor de la exploracion fisica inicial y de las exploraciones complementarias ante la necesidad de cirugia, para disminuir tiempos de observacion. Material y metodos Estudio retrospectivo de un registro prospectivo de pacientes politraumaticos, seleccionando heridas de arma blanca troncales. Se analizan parametros clinicos y diagnosticos. La variable principal es la necesidad de cirugia. Resultados Entre 2006 y 2009 se incluyo a 198 pacientes, con injury severity score medio de 7,8 ± 7 y mortalidad del 0,5%. El 52% sufrieron heridas multiples que se distribuyeron en cervicales 23%, toracicas 46% y abdominales 31%. Precisaron intervencion quirurgica 73 pacientes (37%), siendo el 59% inmediata, 27% precoz y 14% tardia. La necesidad de intervencion se asocio a un menor revised trauma score , evisceracion, hemorragia activa o constatacion de herida penetrante. Las hemoglobinas iniciales, a las 2 y 12 h fueron significativamente inferiores en pacientes quirurgicos. La tomografia computarizada (TC) positiva se asocio a intervencion. Un 18% de pacientes presentaron complicaciones, concentradas en los pacientes quirurgicos. Las intervenciones tardias no presentaron mas complicaciones que las inmediatas (p = 0,72). El 10% de los pacientes con exploracion fisica y complementarias normales precisaron cirugia y el 6% desarrollaron complicaciones. Conclusion Ningun parametro fisiologico o analitico guia de forma individual la necesidad de intervencion. La exploracion fisica seriada es la maniobra diagnostica mas importante para decidir intervencion, pero la TC puede usarse de forma liberal. Una observacion de 24 h es recomendable en pacientes con heridas penetrantes.

Resumen Objetivo Analizar los resultados del abordaje quirurgico laparoscopico frente al abierto en el tratamiento de las ulceras pepticas perforadas (UPP). Pacientes y metodos Estudio retrospectivo de todos los pacientes operados de una UPP durante el periodo enero de 2002-marzo de 2012. Se analizaron datos demograficos, tiempo operatorio, complicaciones y estancia hospitalaria. Resultados Se incluyo a 112 pacientes (mediana, 49 anos), 60 en el grupo laparoscopico y 52 en el grupo abierto. Los pacientes operados por via laparoscopica eran significativamente mas jovenes y tenian un mayor consumo de tabaco, alcohol y cannabis. La mediana de duracion de los sintomas agudos fue menor en los pacientes del grupo laparoscopico (6 h) en comparacion con los del grupo abierto (12 h). La mediana del tiempo operatorio fue significativamente mayor en los pacientes del grupo laparoscopico (104,5 vs. 76 min; p = 0,025). El porcentaje de conversion a cirugia abierta fue del 25%. La morbilidad fue similar en ambos grupos, pero 3 pacientes fallecieron en el grupo abierto. La mediana de estancia hospitalaria fue significativamente menor en el grupo laparoscopico (6 vs. 8 dias; p = 0,041). Conclusion El abordaje por via laparoscopica es una tecnica segura y comparable a la cirugia abierta en el tratamiento de la UPP, con la que el paciente se beneficia de una estancia hospitalaria mas corta.

To analyse the outcomes of laparoscopic versus open repair for perforated peptic ulcers (PPU).All patients undergoing PPU repair between January 2002 and March 2012 were included in the study. Demographic characteristics, operation time, complications, and length of hospital stay were evaluated.Two hundred and twelve patients (median age, 49 years) were included, 60 in the laparoscopic group and 52 in the open group. Patients operated laparoscopically were significantly younger and had a higher consumption of tobacco, alcohol and cannabis. Median acute symptoms time was shorter in the laparoscopic group (6h) compared to the open group (12h; P=.025) Symptoms time was shorter in the laparoscopic group. Median operating time was significantly longer in the laparoscopic group (104.5min vs. 76min, P=.025). The percentage of conversion to open repair was 25%. There was no difference in morbidity between 2 groups, but there were 3 deaths in the open group. Median hospital stay was significantly shorter in patients treated laparoscopically when compared with the open group (6 days vs. 8 days; P=.041).Laparoscopic and open repair are equally safe in the management of PPU. A shorter hospital stay can be achieved in the laparoscopic group.

Objective: To evaluate a multidisciplinary and multifocal intervention in order to reduce catheter related bloodstream infections (CRBI), based on previously identified risk factors in non-critical patients. Methods: A pre-post-intervention study, 2004-2006. Population: patients with a central venous catheter (CVC). The primary endpoint was the CRBI. Other studied variables were patient characteristics, insertion, maintenance and removal of the catheter. The intervention consisted of baseline knowledge and identifing risk factors. In a second period, there was specific training on these identified risk factors and communication of the results, monitoring and evaluation of the CVC inserted.

Resumen Introduccion La neoplasia intraepitelial anal es una lesion precursora del carcinoma escamoso anal. Se considera poblacion en riesgo de padecer esta lesion a los pacientes con condilomas anogenitales, historia previa de displasia de cervix, infeccion por VIH y en general los pacientes con infeccion por el VPH. El objetivo de este estudio es analizar los resultados de la aplicacion de un protocolo diagnostico de neoplasia intraepitelial anal en poblacion de riesgo mediante el empleo de citologia anal. Material y metodo El protocolo diagnostico de neoplasia intraepitelial anal consistio en realizar una anamnesis estructurada, exploracion fisica y citologia anal, la cual se interpreto mediante los criterios de Bethesda. En este estudio observacional de corte transversal se analizan los resultados de diagnostico de neoplasia intraepitelial anal y su asociacion con factores de riesgo. Resultados Se incluyo a 64 pacientes en los que se diagnosticaron 25 alteraciones citologicas: 9 alteraciones citologicas de significado incierto o ASCUS, 15 casos de neoplasia intraepitelial anal de bajo grado y 1 de alto grado. Al relacionar la presencia de alteraciones en la citologia anal con los factores de riesgo conocidos, no hubo asociacion estadisticamente significativa con la presencia de condilomas (p=0,22), infeccion por VPH de alto riesgo (p=0,84), infeccion por VIH (p=0,98) o tabaquismo (p=0,14). Conclusiones La aplicacion de un protocolo de deteccion de neoplasia intraepitelial anal en poblacion de riesgo ha permitido detectar un 25% de pacientes con lesiones precursoras de carcinoma anal.

Introduction Anal intraepithelial neoplasia is a precursor condition of squamous anal carcinoma. The groups at risk of this lesion are patients with anogenital condylomata, cervical dysplasia, human immunodeficiency virus infection and, in general, patients with HPV infection. The aim of this study was to analyse the results of a diagnostics protocol of anal intraepithelial neoplasia in high risk population using anal cytology. Patients and method The protocol is based on a visit in the outpatient department, clinical interview, physical examination, and anal cytology evaluated by Bethesda criteria. The cross-sectional observational study was designed to study the anal smear results and their relationship with risk factors. Results A total of 64 patients were included from January 2005 to December 2006. In the overall series, 25 patients have been diagnosed with abnormal anal cytology: 9 atypical squamous cells of undetermined significance (ASCUS), 15 low-grade, and 1 highgrade squamous intraepithelial lesions. There were no significant associations between abnormal cytology results and the presence of anal condyloma ( P = .22). Neither were there statistical associations found with high risk-HPV infection ( P = .84), HIV infection ( P = .98), or tobacco use ( P = .14). Conclusions Our diagnostic protocol of anal intraepithelial neoplasia revealed 25% of patients with pre-invasive lesions of squamous anal cancer.

La mastopatia diabetica es una entidad muy poco conocida y, por ello, poco descrita que puede confundirse facilmente con carcinoma mamario. Ha sido descrita principalmente en pacientes con diabetes mellitus tipo 1 y, en mucho menor medida, otras endocrinopatias. En este articulo se muestra un caso clinico en el que la mastopatia diabetica se encuentra asociada a diabetes mellitus tipo 2 y presenta una evolucion muy rapida en muy poco tiempo. El gran desconocimiento de esta entidad puede llevar a multitud de actuaciones clinicas equivocas. Al no reconocer histologicamente la lesion y carecer de datos clinicos de sospecha, es posible emitir un diagnostico negativo de neoplasia. se puede juzgar de erronea la toma de muestras y requerir una nueva prueba innecesaria. Unicamente sospechandola se puede llegar a un diagnostico correcto y a la actuacion clinica adecuada. Los resultados de las pruebas diagnosticas son inespecificos, y la biopsia con aguja gruesa es la clave diagnostica.

Sporadic primary hyperparathyroidism is due to single adenoma in over 90–95% of instances. Careful medical history and precise preoperative identification of the enlarged gland by parathyroid Tc-mibi scintigraphy and neck ultrasound allow selecting patients for minimally invasive parathyroidectomy, a focused intervention with minimal skin opening and tissue dissection. Small (

Resumen A pesar de que desde principios del siglo xx se conoce la alta mortalidad por infeccion entre los pacientes esplenectomizados, aun hoy las tasas de profilaxis antibacteriana en estos pacientes siguen siendo preocupantemente bajas. Por ello se planteo una busqueda sobre la situacion actual de la cuestion para elaborar unas recomendaciones aplicables a los pacientes esplenectomizados. Se expone la actitud profilactica ante este tipo de pacientes dependiendo de su edad y el motivo de la esplenectomia, tanto de vacunacion como de antibioterapia. El estado inmunitario del paciente es muy importante en la necesidad de profilaxis antibiotica, pues no seguiran la misma pauta un paciente sometido a esplenectomia tras un accidente de trafico y un paciente hematologico.

The usefulness of Tc-mibi parathyroid scintigraphy (Tc-PS) in planning parathyroidectomy for secondary hyperparathyroidism is not well known. The aim of this study was to review our experience with Tc-PS concerning: (1) the identification of hyperplastic glands, (2) detection of major ectopias and (3) prevention of recurrences.Thirty-three consecutive patients undergoing first-time subtotal parathyroidectomy for renal hyperparathyroidism had a dual-phase planar Tc-PS performed, and glands were classified as detected, weak, or not detected. The number and position of visualized glands were determined. Parathyroid weight, histology, and their relationship to Tc-PS were recorded after surgery.Of 132 potential glands, 48 (35%) were localized on the Tc-PS and 128 (96.9%) were identified intraoperatively. Tc-PS positive/weak glands were heavier than nonlocalized glands. Tc-PS contributed to successful surgery in four patients with a single difficult gland each (three retrieved from the neck and one--fifth gland--requiring mediastinotomy). There was one persistence (3%) because of a missed fourth undescended inferior parathyroid gland. Two recurrences 2 years after surgery were due to a fifth thoracic gland not shown in the preoperative Tc-PS.Preoperative Tc-PS helped in the intraoperative identification of moderate or major ectopias in 4/33 patients but was not useful to prevent recurrences from highly ectopic glands not visualized before first-time surgery.

Modifications of muscular contractile patterns by chronic low-frequency stimulation induce structural, physiological, and biochemical transformations in fast-twitch fibers that cause them to act like slow-twitch muscle. During this transformation many changes in protein pattern appear and the proteolytic system may be involved in those changes. The activities of cathepsin L, B, H, D, the level of cystatin, as well as the calpain activity in rabbit fast-twitch muscle have been compared with those of slow-twitch muscle. The results show that fast-twitch muscle has lower cathepsin activities and higher calpain activities than slow-twitch muscle. Chronic low-frequency stimulation was applied for 24 days to fast-twitch muscles and changes in proteases and protease inhibitors (cystatin and calpastatin) were studied. After 7-14 days of stimulation, lysosomal cathepsin L, B, and D and cytoplasm calpain and proteosome activities increased several-fold. Involvement of the phagocyte cells in the protein fiber turnover was minimal. Although the turnover of contractile proteins during muscle electrostimulation takes place in synchrony with changes in the muscle proteolytic system, the stimulation period used did not attain the total transformation from fast- to slow-twitch muscle proteolytic pattern.

Electrical shock can cause a direct myocardial damage and different types of arrhythmias, which are uncommon and occur more often when there is a high voltage exposure. We report a 19-year-old male that received a high voltage shock, falling thereafter from an altitude of four meters. On admission to the emergency room, he had second and third degree burns in the right hand and the left thigh. The electrocardiogram showed a nodal rhythm of 72 beats per minute. After four hours of monitoring, sinus rhythm returned spontaneously.

The authors report a case of an inguinal bubo in a young man caused by an anaerobe, Prevotella bivia, which was acquired during oral sexual intercourse. As far as the authors know, this is the first reported case of a sexually transmitted infection by Prevotella. Prevotella spp. inhabit the oral cavity and are highly prevalent in bacterial vaginosis, a polymicrobial syndrome resulting from replacement of the normal vaginal Lactobacillus spp. flora by high concentrations of anaerobic microorganisms such as Prevotella spp., Mobiluncus spp., Gardnerella vaginalis and other uncultivated anaerobes.

To evaluate a multidisciplinary and multifocal intervention in order to reduce catheter related bloodstream infections (CRBI), based on previously identified risk factors in non-critical patients.A pre-post-intervention study, 2004-2006.patients with a central venous catheter (CVC). The primary endpoint was the CRBI. Other studied variables were patient characteristics, insertion, maintenance and removal of the catheter. The intervention consisted of baseline knowledge and identifying risk factors. In a second period, there was specific training on these identified risk factors and communication of the results, monitoring and evaluation of the CVC inserted.We analysed 175 and 200 CVC, respectively. The incidence of CRBI was 15.4% during the pre-intervention and 4.0% in the post-intervention period (P.001). The incidence of BRC by CVC days in the first group was 8.8 infections 1.000 days of CVC and the second 2,3 (P=.0009). The multivariate analysis found an increased risk of CRBI during the first period (OR 4.32; 95% CI: 1.81-10.29) and the use of total parenteral nutrition (OR: 2.37; 95% CI: 1.10-5. 12).The application of specific measures directed at all non-critical patients in the entire hospital and involving a large number of professionals has achieved a decrease incidence of 73.9% of CRBI. An acceptable incidence of CRBI was obtained, and, with the completion of the project together with a new awareness, the situation will continue to improve.

The aim of this work was to analyze preoperative mortality risk factors after relaparotomy for abdominal surgery in a unit of General Surgery at a University Hospital.A total of 314 relaparotomies in 254 patients were performed between February 2004 and February 2008. We analyzed data about past medical history, first operation, as well as clinical and biochemical parameters previous to reoperation.Indications for relaparotomy were peritonitis, bleeding, abscess, exploratory laparotomy, and evisceration. Overall mortality was 22%. Mortality of the patients with a single relaparotomy was 20% vs. 44% if they were reoperated upon twice. Mortality was associated with age, past history of cardiovascular disease, active neoplasm, previous treatment with platelet anti-aggregant drugs, first surgery American Society of Anesthesia score, and the presence of an anastomosis. Preoperative data associated with mortality were the number of systemic inflammatory response syndrome criteria, suture dehiscense, ileus, positive blood cultures, mechanical ventilation, artificial nutrition, antibiotics or vasoactive drugs, tachycardia, and abnormal body temperature. High white blood cell count or bilirrubin levels and low albumin or prothrombin time were also associated with mortality. Multivariate logistic regression analysis isolated age (P = 0.02), abnormal body temperature (P = 0.02), and the need of mechanical ventilation (P = 0.004) as independent preoperative variables predictive for mortality after relaparotomy.Advanced age, the presence of either fever or hypothermia, and the need of mechanical ventilation are preoperative risk factors associated with mortality after relaparotomy and should be considered when planning reintervention.

Diabetic mastopathy is a little known entity and can easily be mistaken for breast carcinoma. This entity has mainly been described in patients with diabetes type 1 and, to a much lesser extent, in those with other endocrine disorders. We describe a case of diabetic mastopathy associated with diabetes mellitus type 2, which showed a rapid clinical course. Lack of awareness of this entity can lead to inappropriate management. Because there are no specific histological or clinical features for diabetic mastopathy, patients may receive an incorrect diagnosis or undergo unnecessary investigations. A high index of suspicion is required to reach a correct diagnosis and provide appropriate treatment. The results of diagnostic tests are non-specific and the key to diagnosis is core needle biopsy.

Although the high mortality rate from infectious causes in asplenic patients has been well known since the beginning of the twentieth century, rates of antibiotic prophylaxis in these patients continue to be worryingly low. Consequently, we reviewed the causes of these high mortality rates with a view to recommending preventive measures. The attitude to prophylaxis in these patients depends on age and the cause of splenectomy both in vaccination and antibiotic prophylaxis. The immune status of these patients is decisive in antibiotic prophylaxis, as this treatment will differ in patients splenectomized after a traffic accident and in those splenectomized for lymphoma.

Postoperative infections result from the interactions of bacteria, the surgical technique, and host defense mechanisms. Thus, identifying single determinant factors has proved difficult.In a recent survey of 2,809 colorectal resections, transfusion was the single most powerful risk factor for postoperative infection. In patients undergoing primary hip or knee prosthesis insertion, the transfusion of allogeneic blood increased the risk of a deep-seated infection by a factor of 12.Several host defense mechanisms are impaired by blood products. The initial hypothesis incriminated the transfused white blood cells, but this paradigm has since been challenged. The effects of free serum iron, the blood storage time, and the presence in stored blood of bioactive substances such as inhibitors of metalloproteinase-1 may also be important.It is worth pursuing efforts to emphasize autologous blood transfusion and the reinfusion of shed blood as blood conservation strategies, as these practices reduce the risk of infectious complications.