Presión intraabdominal como Marcador de Severidad en Pancreatitis Aguda

Intra-abdominal pressure as a marker of severity in acute pancreatitis
Jose Manuel Hidalgo Rosas MDa, Salvador Navarro Soto MDa, , , Javier Serra Aracil MDa, Pere Rebasa Cladera MDa, Raquel Hernandez Borlan MDb, Antonia Vazquez Sanchez MDc, Felip Bory Ros MDc, d and Luis Grande Posa MD

Background
Acute pancreatitis is one of the main causes of intra-abdominal hypertension, which may lead to multiple physiologic alterations. The aim of this study was to determine the relationship between acute pancreatitis and intra-abdominal hypertension, and to evaluate the utility of intra-abdominal pressure (IAP) as a marker of severity in acute pancreatitis.

Methods
From July 2002 to July 2004, 45 patients admitted for acute pancreatitis were included in this prospective, observational study. The diagnostic criteria for acute pancreatitis were compatible clinical manifestations and a 3-fold increase in serum amylase levels. Severe pancreatitis was defined as Apache II score ≥8. IAP was determined every 12 hours, and the maximum and the mean values were used for analysis and correlated with prognostic factors of acute pancreatitis.

Results
A statistical relationship was observed between maximum IAP and the typical prognostic factors of acute pancreatitis. Maximum IAP had a significant relationship with the computed tomography severity index and the number of complementary tests required. The maximum IAP was significantly greater in patients who died and in patients requiring vasoactive drugs, total parenteral nutrition, or operative treatment related to complications. The maximum IAP was also greater in patients who developed systemic inflammatory response syndrome, multiorgan failure, increase in number and/or volume of intra-abdominal collections, those who required aspiration of the necrosis for suspected infection, those who demonstrated the presence of microorganisms, and those with positive blood cultures.

Conclusion
The maximum IAP is a useful, inexpensive, and easy method to measure prognostic marker of the evolution and complications of acute pancreatitis.

Reuniones Preoperatorias

Operating Room Briefings and Wrong-Site Surgery
Journal of the American College of Surgeons Feb 2007

Martin A. Makary MD, MPH, ‡, §, , , Arnab Mukherjee BA, #, , J. Bryan Sexton PhD†, , Dora Syin BS‡, #, Emmanuelle Goodrich MPH‡, Emily Hartmann MSS‡‡, Lisa Rowen RN, DScN¶, Drew C. Behrens#, ††, Michael Marohn DO, FACS, ‡ and Peter J. Pronovost MD, PhD,

Background
Wrong-site surgery can be a catastrophic event for a patient, caregiver, and institution. Although communication breakdowns have been identified as the leading cause of wrong-site surgery, the efficacy of preventive strategies remains unknown. This study evaluated the impact of operating room briefings on coordination of care and risk for wrong-site surgery.

Study Design
We administered a case-based version of the Safety Attitudes Questionnaire (SAQ) to operating room (OR) staff at an academic medical center, before and after initiation of an OR briefing program. Items questioned overall coordination and awareness of the surgical site. Response options ranged from 1 (disagree strongly) to 5 (agree strongly). MANOVA was used to compare caregiver assessments before and after the implementation of briefings, and the percentage of OR staff agreeing or disagreeing with each question was reported.

Results
The prebriefing response rate was 85% (306 of 360 respondents), and the postbriefing response rate was 75% (116 of 154). Respondents included surgeons (34.9%), anesthesiologists (14.0%), and nurses (44.4%). Briefings were associated with caregiver perceptions of reduced risk for wrong-site surgery and improved collaboration [F (6,390) = 10.15, p < 0.001]. Operating room caregiver assessments of briefing and wrong-site surgery issues improved for 5 of 6 items, eg, “Surgery and anesthesia worked together as a well-coordinated team” (67.9% agreed prebriefing, 91.5% agreed postbriefing, p < 0.0001), and “A preoperative discussion increased my awareness of the surgical site and side being operated on” (52.4% agreed prebriefing, 64.4% agreed postbriefing, p < 0.001).

Conclusions
OR briefings significantly reduce perceived risk for wrong-site surgery and improve perceived collaboration among OR personnel.

Embolización de la Arteria Uterina Vs Cirugía para el Manejo de Miomas Uterinos Sintomáticos

Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids
The REST Investigators
N Engl J Med 2007; 356 (4):360-70.

Background The efficacy and safety of uterine-artery embolization, as compared with standard surgical methods, for the treatment of symptomatic uterine fibroids remain uncertain.

Methods We conducted a randomized trial comparing uterine-artery embolization and surgery in women with symptomatic uterine fibroids. The primary outcome was quality of life at 1 year of follow-up, as measured by the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36).

Results Patients were randomly assigned in a 2:1 ratio to undergo either uterine-artery embolization or surgery, with 106 patients undergoing embolization and 51 undergoing surgery (43 hysterectomies and 8 myomectomies). There were no significant differences between groups in any of the eight components of the SF-36 scores at 1 year. The embolization group had a shorter median duration of hospitalization than the surgical group (1 day vs. 5 days, P<0.001) and a shorter time before returning to work (P<0.001). At 1 year, symptom scores were better in the surgical group (P=0.03). During the first year of follow-up, there were 13 major adverse events in the embolization group (12%) and 10 in the surgical group (20%) (P=0.22), mostly related to the intervention. Ten patients in the embolization group (9%) required repeated embolization or hysterectomy for inadequate symptom control. After the first year of follow-up, 14 women in the embolization group (13%) required hospitalization, 3 of them for major adverse events and 11 for reintervention for treatment failure.

Conclusions In women with symptomatic fibroids, the faster recovery after embolization must be weighed against the need for further treatment in a minority of patients

¿Un "Score de Apgar" para Cirugía?

An Apgar Score for Surgery
Journal of the American College of Surgeons feb 2007;204(2):201-8
Atul A. Gawande MD, MPH, FACS, †, , , Mary R. Kwaan MD, MPH, †, Scott E. Regenbogen MD, ‡, Stuart A. Lipsitz SCD† and Michael J. Zinner MD, FACS† †Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA‡Department of Surgery, Massachusetts General Hospital, Boston, MA.Department of Health Policy and Management, Harvard School of Public Health, Boston, MA

Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation. We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient’s condition and chances of major complications or death.

Study design
We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women’s Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation. We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution.

Results
A 10-point score based on a patient’s estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p < 0.0001; c-index = 0.72). Of 767 general and vascular surgery patients, 29 (3.8%) had a surgical score ≤ 4. Major complications or death occurred in 17 of these 29 patients (58.6%) within 30 days. By comparison, among 220 patients with scores of 9 or 10, only 8 (3.6%) experienced major complications or died (relative risk 16.1; 95% CI, 7.6–34.0; p < 0.0001).

Conclusions
A simple score based on blood loss, heart rate, and blood pressure can be useful in rating the condition of patients after general or vascular operations.

Resolución de Obstrucción Intestinal con un Tubo Largo Avanzado por Endoscopía

Rapid resolution of small-bowel obstruction with the long tube, endoscopically advanced into the jejunum
George F. Gowen M.D., a, aPennsylvania Hospital, Philadelphia, PA, USA, Thomas Jefferson University Hospital, Philadelphia, PA, USA, Pottstown Memorial Medical Center, 168 S. Sanatoga Rd., Pottstown, PA 19465,

Background
Long-tube decompression has achieved a 75% to 80% success rate in 5 studies, and the short tube had a 40% success rate in 3 studies.

Methods
From 1984 to 1991, an endoscope-advanced long intestinal tube was placed into the jejunum in 17 patients, and from 1992 to 2004 an improved long tube was used in 23 patients. Costs were calculated for each type of procedure.

Results
In the first group, decompression was successful in 12 of 17 patients (70%). In the second group, decompression was successful in 21 of 23 patients (90%). The average charges were as follows: for the short tube the average charge was $21,687, and for the long tube the average charge was $11,316.

Conclusions
First, by using the improved long tube, which was advanced endoscopically into the jejunum, the success rate was 90% with procedures that are standard in every hospital. Second, most patients who fail the short-tube procedure are candidates for the long tube. Third, the improved long tube, endoscopically advanced into the jejunum, is recommended strongly because it provides significant advantages, both clinically and economically, over the short-tube approach. A prospective randomized study comparing the short tube for 3 days versus the long tube for 3 days is recommended to prove the superiority of the long tube in patients with small-bowel obstruction.

Pancreaticoyeyunostomia vs Pancreaticogastrostomia: Meta-Ánalisis

Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis.
The American Journal of Surgery feb 2007; 193(2):171-83
Moritz N. Wente M.D., M.Sc.a, Shailesh V. Shrikhande M.D.a, b, Michael W. Müller M.D.a, Markus K. Diener M.D.a, Christoph M. Seiler M.D., M.Sc.a, Helmut Friess M.D.a and Markus W. Büchler M.D.a, , aDepartment of General, Visceral and Trauma Surgery, University of Heidelberg, Heidelberg, GermanybDepartment of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India

Objective
Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreaticoduodenectomy (PD). The ideal choice of anastomosis remains a matter of debate.

Data Sources
Articles published until end of March 2006 comparing PJ and PG after PD were searched.

Study Selection
Two reviewers independently assessed quality and eligibility of the studies and extracted data for further analysis. Meta-analysis was performed with a random-effects model by using weighted odds ratios.

Data Extraction and Synthesis
Sixteen articles were included; meta-analysis of 3 randomized controlled trials (RCT) revealed no significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, intra-abdominal fluid collection, or mortality. On the contrary, analysis of 13 nonrandomized observational clinical studies (OCSs) showed significant results in favor of PG for the outcome parameters with a reduction of pancreatic fistula and mortality in favor of PG.

Conclusions
All OCSs reported superiority of PG over PJ, most likely influenced by publication bias. In contrast, all RCTs failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally good results. This meta-analysis yet again highlights the singular importance of performing well-designed RCTs and the role of evidence-based medicine in guiding modern surgical practice.

Drenaje Biliar Selectivo o Total Para el Manejo de la Ictericia Obstructiva

Selective versus total biliary drainage for obstructive jaundice caused by a hepatobiliary malignancy
The American Journal Of Surgery 193(2):149-54
Takeaki Ishizawa M.D.a, Kiyoshi Hasegawa M.D., Ph.D.a, Keiji Sano M.D., Ph.D.a, Hiroshi Imamura M.D., Ph.D.a, Norihiro Kokudo M.D., Ph.D.a and Masatoshi Makuuchi M.D., Ph.D., a, aHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.

Background
Controversy exists regarding which approach is preferable among types of biliary drainage for obstructive jaundice before major hepatectomy: selective biliary drainage (SBD) only on the future remnant liver (FRL) or total biliary drainage (TBD).

Methods
There were 42 consecutive patients who underwent SBD (n = 15) or TBD (n = 27) for obstructive jaundice caused by a hepatobiliary malignancy, and subsequent portal vein embolization (PVE) before extended hemihepatectomy. The hypertrophy ratio, defined as the ratio of the FRL volume after PVE to that before PVE, was evaluated. The bilirubin clearance also was calculated.

Results
The hypertrophy ratio was higher in patients with SBD than in those with TBD (median, 128%; range, 111–152% vs median, 121%; range, 102–138%; P = .013). The bilirubin clearance of FRL with SBD was markedly improved after PVE compared with that in patients with TBD.

Conclusions
SBD is superior to TBD in promoting hypertrophy of the FRL induced by PVE and in guaranteeing good liver function before major hepatectomy

Uso de Estatinas para Prevenir Adherencia Abdominales Postoperatorias: Un Estudio Animal

Statins (HMG-CoA Reductase Inhibitors) Decrease Postoperative Adhesions by Increasing Peritoneal Fibrinolytic Activity.
Annals of Surgery. 245(2):176-184, February 2007.
Aarons, Cary B. MD *; Cohen, Philip A. MD *; Gower, Adam MS *; Reed, Karen L. PhD *; Leeman, Susan E. PhD +; Stucchi, Arthur F. PhD *; Becker, James M. MD, FACS *

Objectives: The aims of this study were to determine if statins reduce adhesion formation in vivo and to identify the mechanism of action in vitro.

Background: Intraperitoneal adhesions develop in up to 95% of patients following laparotomy. Adhesions are reduced by mechanisms that up-regulate fibrinolysis within the peritoneum. Statins promote fibrinolysis in the cardiovascular system and may play a role in the prevention of adhesions.

Methods: Adhesions were induced in rats (n = 102) using our previously described ischemic button model. Rats received vehicle (controls), lovastatin (30 mg/kg), or atorvastatin (30 mg/kg) as a single intraperitoneal dose at the time of laparotomy. Animals were killed and adhesions were quantified at day 7. Peritoneal fluid and tissue were collected at day 1 to measure tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) by real-time PCR and ELISA. To assess the effects of statins on wound healing, burst pressures were measured in anastomoses of the colon. The effects of lovastatin on tPA and PAI-1 production were measured in vitro in human mesothelial cells (HMC) in the presence or absence of mevalonate (MVA), geranylgeranyl-pyrophosphate (GGPP) and farnesyl-pyrophosphate (FPP), all intermediates in the cholesterol pathway downstream of HMG-CoA. The effect of a Rho protein inhibitor, exoenzyme C3 transferase, on tPA production was also determined.

Results: Lovastatin and atorvastatin reduced adhesion formation by 26% and 58%, respectively (P < 0.05), without affecting anastomotic burst pressure. At 24 hours, tPA mRNA levels in peritoneal tissue and tPA activity in peritoneal fluid from lovastatin-treated animals were increased by 57% and 379%, respectively (P < 0.05), while PAI-1 levels were unchanged. HMC incubated with either lovastatin or atorvastatin showed concentration-dependent increases in tPA production and decreases in PAI-1 production (P < 0.05). These lovastatin-induced changes in tPA and PAI-1 production were significantly reversed by the addition of MVA, GGPP, and FPP. The Rho protein inhibitor increased tPA production and rescued tPA production from the inhibitory effect of GGPP.

Conclusion: These data suggest that statins administered within the peritoneum can up-regulate local fibrinolysis, while the in vitro studies show that this effect may be mediated, in part, by intermediates of the cholesterol biosynthetic pathway that regulate Rho protein signaling.

Enterolitotomía Asistida por Laparoscopía o Técnica Tradicional Para el Manejo del Ileo Biliar

Laparoscopically assisted or open enterolithotomy for gallstone ileus British Journal of Surgery January 2007; 94(1):53-7
A.-C. Moberg, A. Montgomery

Gallstone ileus is associated with high morbidity and mortality rates. Enterolithotomy as a single procedure is recommended to minimize complications. The trauma could potentially be reduced further by using a laparoscopic technique.

Thirty-two consecutive patients with gallstone ileus operated by a laparoscopic or open approach between 1992 and 2004 were studied retrospectively. Demographic data, preoperative and postoperative hospital stay, duration of operation, complications and deaths were recorded.

Median follow-up after surgery was 36 months.Nineteen laparoscopic procedures, with two conversions, and 13 open operations were performed. The median duration of operation was 60 min in the laparoscopic group and 58 min in the open group (P = 0·675). The median hospital stay was 7 and 10 days, respectively (P = 0·383). There were five minor and one major complications in the laparoscopic group, compared with one and four, respectively, in the open group. There were no deaths within 30 days.The overall morbidity rate was low after both laparoscopic and open enterolithotomy for gallstone ileus, especially in terms of major complications in the laparoscopic group.

Laparoscopically assisted enterolithotomy can be recommended for both diagnosis and treatment

Lecciones Aprendidas por los Inhibidores Selectivos de COX-2

Un artículo publicado en la última edición de BMJ comenta sobre algunos aspectos importantes sobre los hechos que llevaron al retiro del mercado de Vioxx y similares por presentar efectos adversos severos luego de muchos años de haber sido casi la panacea para el manejo del dolor conpocos riesgos

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Laparoscopía "en el Box de Urgencia" para Descartar la Presencia de Herida Penetrantes Abdominales

“Awake” laparoscopy for the evaluation of equivocal penetrating abdominal wounds
Injury 2007; 38(1):60-64
Jordan A. Weinberga, Louis J. Magnottib, , , Norma M. Edwardsb, Jeffrey A. Claridgec, Gayle Minardb, Timothy C. Fabianb and Martin A. Croceb aDepartment of Surgery, University of Alabama at Birmingham

Background
Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic “awake” laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings.

Methods
Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared.

Results
Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7 h in the ALneg group versus 18 h in the DLneg group (p = 0.0003). Cost savings on hospital charges averaged US$ 2227 per patient in the ALneg group compared with the DLneg group.

Conclusions
AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.

Densidad Mamografica y Riesgo de Cáncer de Mama

Mammographic Density and the Risk and Detection of Breast Cancer
N Engl J Med 2007; 356:227-36

Background Extensive mammographic density is associated with an increased risk of breast cancer and makes the detection of cancer by mammography difficult, but the influence of density on risk according to method of cancer detection is unknown.

Methods We carried out three nested case–control studies in screened populations with 1112 matched case–control pairs. We examined the association of the measured percentage of density in the baseline mammogram with risk of breast cancer, according to method of cancer detection, time since the initiation of screening, and age.

Results As compared with women with density in less than 10% of the mammogram, women with density in 75% or more had an increased risk of breast cancer (odds ratio, 4.7; 95% confidence interval [CI], 3.0 to 7.4), whether detected by screening (odds ratio, 3.5; 95% CI, 2.0 to 6.2) or less than 12 months after a negative screening examination (odds ratio, 17.8; 95% CI, 4.8 to 65.9). Increased risk of breast cancer, whether detected by screening or other means, persisted for at least 8 years after study entry and was greater in younger than in older women. For women younger than the median age of 56 years, 26% of all breast cancers and 50% of cancers detected less than 12 months after a negative screening test were attributable to density in 50% or more of the mammogram.

Conclusions Extensive mammographic density is strongly associated with the risk of breast cancer detected by screening or between screening tests. A substantial fraction of breast cancers can be attributed to this risk factor.

Rol de la Radiografía de Tórax en la Evaluación Inicial del Trauma Estable

What is the Role of Chest X-Ray in the Initial Assessment of Stable Trauma Patients?

Journal of Trauma-Injury Infection & Critical Care. 62(1):74-79, January 2007.
Wisbach, Gordon G. MD; Sise, Michael J. MD; Sack, Daniel I. BA; Swanson, Sophia M. BA; Sundquist, Sanna M. BS; Paci, Gabrielle M. BA; Kingdon, Kenneth M. MD; Kaminski, Stephen S. MD

Background: The Advanced Trauma Life Support course advocates the liberal use of chest X-ray (CXR) during the initial evaluation of trauma patients. We reviewed CXR performed in the trauma resuscitation room (TR) to determine its usefulness.

Methods: A retrospective, registry-based review was conducted and included 1,000 consecutive trauma patients who underwent CXR in the TR at a Level I trauma center during a 7-month period.

Results: Patients receiving CXR comprised 91.5% of all patients evaluated in the TR during the study period. CXR followed by chest computed tomography (CCT) was performed in 820 (82.0%) patients. Subsequent CCT identified missed findings in 235 (35.6%) of the 660 patients with an initial negative CXR who went on to receive CCT. CXR alone was performed in 127 (26.1%) of the 487 patients who were stable, not intubated, and had a normal chest physical examination (CPE). Seven patients (5.5%) in this group had potentially significant findings but none required intervention beyond physiotherapy or antibiotics. Three hundred and sixty (73.9%) of the 487 patients who were hemodynamically stable with a normal CPE underwent both CXR and CCT. Fifty-four patients (15%) in this group had findings of significance, and two (0.6%) required intervention. One patient received bilateral chest tubes for large pre-existing pleural effusions found on CXR and CCT; another patient undergoing general anesthesia required a chest tube for a pneumothorax found only on CCT.

Conclusion: In stable trauma patients with a normal CPE, CXR appears to be unnecessary in their initial evaluation. CXR should be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination, and should be limited to use only for clear clinical indications.

¿Beta-bloqueadores son Factor Protector en el Trauma Adulto?

Beta-Blocker Use is Associated With Improved Outcomes in Adult Trauma Patients.
Journal of Trauma-Injury Infection & Critical Care. 62(1):56-62, January 2007.
Arbabi, Saman MD, MPH; Campion, Eric M. MD; Hemmila, Mark R. MD; Barker, Melissa RN; Dimo, Mary PharmD; Ahrns, Karla S. RN; Niederbichler, Andreas D. MD; Ipaktchi, Kyros MD; Wahl, Wendy L. MD

Background: Beta-adrenoreceptor blocker ([beta]-blocker) therapy may improve outcomes in surgical patients by decreasing cardiac oxygen consumption and hypermetabolism. Because [beta]-blockers can lower the systemic blood pressure and cerebral perfusion pressure, there is concern regarding their use in patients with head injury. However, [beta]-blockers may protect [beta]-receptor rich brain cells by attenuating cerebral oxygen consumption and metabolism. We hypothesized that [beta]-blockers are safe in trauma patients, even if they have suffered a significant head injury.

Methods: Using pharmacy and trauma registry data of a Level I trauma center, we identified a cohort of trauma patients who received [beta]-blockers during their hospital stay ([beta]-cohort). Trauma admissions who did not receive [beta]-blockers were in the control cohort. [beta]-blocker status, in combination with other variables associated with mortality, were placed in a stepwise multivariate logistic regression to identify independent predictors of fatal outcome.

Results: In all, 303 (7%) of 4,117 trauma patients received [beta]-blockers. In the [beta]-cohort, 45% of patients were on [beta]-blockers preinjury. The most common reason to initiate [beta]-blocker therapy was blood pressure (60%) and heart rate (20%) control. The overall mortality rate was 5.6% and head injury was considered to be the major cause of death. After adjusting for age, Injury Severity Scale score, blood pressure, Glasgow Coma Scale score, respiratory status, and mechanism of injury, the odds ratio for fatal outcome was 0.3 (p < 0.001) for [beta]-cohort as compared with control. Decreased risk of fatal outcome was more pronounced in patients with a significant head injury.

Conclusions: [beta]-blocker therapy is safe and may be beneficial in selected trauma patients with or without head injury. Further studies looking at [beta]-blocker therapy in trauma patients and their effect on cerebral metabolism are warranted

Alteraciones Genómicas Microambientales y Carcinoma Escamoso de Cabeza y Cuello

Microenvironmental Genomic Alterations and Clinicopathological Behavior in Head and Neck Squamous Cell Carcinoma
Frank Weber, MD; Yaomin Xu, MS; Li Zhang, PhD; Attila Patocs, MD, PhD; Lei Shen, PhD; Petra Platzer, PhD; Charis Eng, MD, PhD
JAMA. 2007;297:187-195.

Context Carcinogens associated with head and neck squamous cell carcinoma (SCC) genesis should inflict genomic alterations not only on the epithelium but also the mesenchyme of the aerodigestive tract. Therefore, the apparently nonmalignant stroma surrounding the tumor epithelium can acquire genomic alterations and contribute to cancer initiation and progression.

Objectives To determine compartment-specific loci of loss of heterozygosity or allelic imbalance (LOH/AI) and to identify which genomic alterations restricted to the stroma cell population contribute to aggressiveness of head and neck SCC disease.

Design, Setting, and Patients Tumor epithelium and surrounding stroma were isolated from 122 US patients with oral cavity and oropharyngeal or hypopharyngeal SCC and subjected to whole-genome LOH/AI analysis using 366 microsatellite markers. Samples, collected between 2001 and 2004, were pulled and transferred in batches of 10 to 30 between 2002 and 2005. Laser capture microdissection DNA extraction and technical genotyping occurred on a rolling model between 2002 and November 2005.

Main Outcome Measures Compartment-specific frequency and distribution of LOH/AI were determined, and hot spots of genomic alterations identified. Compartment-specific LOH/AI events were correlated with presenting clinicopathologic characteristics.

Results Tumor-associated stroma of head and neck SCC from smokers were found to have a high degree of genomic alterations. A correlation between tumor aggressiveness could be found for a specific set of 5 loci. Three stroma-specific loci (D4S2417, D3S360, and D19555) were associated with tumor size (pT) and regional nodal metastases (pN). Furthermore, 2 epithelial-specific LOH/AI hot spots were positively correlated with pN status and clinical stage.

Conclusions Stroma-specific genetic alterations are associated with smoking-related head and neck SCC genesis. These findings suggest novel prognostic or diagnostic biomarkers and identify potential new molecular targets for therapeutic and preventive intervention.

Colectomia Mano-Asistida

Un artículo de revisión publicado este mes en Contemporary Surgery trata el tema de la cirugía mano-asistida para colectomia. PDF en inglés

http://www.contemporarysurgery.com/pdf/6301/6301CS_Review.pdf

Manejo de la Inervación Durante Herniorrafia Abierta

Nerve management during open hernia repair.
British Journal Surgery January 2007 p.17-22
A. R. Wijsmuller, R. N. van Veen, J. L. Bosch, J. F. M. Lange, G. J. Kleinrensink, J. Jeekel, J. F. Lange

Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain.A systematic literature review was performed to identify studies investigating the influence of different types of nerve management.Based on three randomized studies the pooled mean percentage of patients with chronic pain after identification and division of the ilioinguinal nerve was similar to that after identification and preservation of the ilioinguinal nerve. Two cohort studies suggested that the incidence of chronic pain was significantly lower after identification of all inguinal nerves compared with no identification of any nerve. Another cohort study reported a significant difference in the incidence of chronic pain in favour of identification and facultative pragmatic division of the genital branch of the genitofemoral nerve compared with no identification at all.The nerves should probably be identified during open hernia repair. Division of and preservation of the ilioinguinal nerve show similar results.

Reinervación Laringea Mediante Implantación de Ansa Cervicalis

Laryngeal Reinnervation by Ansa Cervicalis Nerve Implantation for Unilateral Vocal Cord Paralysis in Humans
Journal of the American College of Surgeons January 2007 pages 64-72
Wan-Fu Su, MDa, Yaw-Don Hsu, MDb, Hsin-Chien Chen, MDa, Hwa Sheng, PhDc

Background
Ansa cervicalis (AC)–recurrent laryngeal nerve anastomosis (RLN) is usually not desirable for correction of paralytic dysphonia when it is difficult to find a viable distal stump of the recurrent laryngeal nerve. Nerve implantation of the thyroarytenoid muscle with the ansa cervicalis is a simple alternative method.

Study design
Ten patients with unilateral vocal cord paralysis were prospectively designed to receive nerve implantation. A minimum period of 12 months after onset of paralysis was allowed to elapse to permit possible spontaneous reinnervation or compensation. Patients were followed long enough (at least 2 years) to determine if the procedure was successful. All patients were subjected to preoperative and postoperative voice recording, acoustic analysis, and videolaryngoscopy. Some of them underwent laryngeal electromyography.

Results
Ten patients underwent nerve implantation of the thyroarytenoid muscles by using the ansa cervicalis, and 8 of 10 (80%) had improved phonatory quality. Laryngeal electromyography showed that the procedure produced satisfactory reinnervation of the thyroarytenoid muscle.

Conclusions
Nerve implantation of the thyroarytenoid muscle by the anso cervicalis is a simple and efficient alternative to nerve transfer if dense scarring at the cricothyroid articulation and lack of a viable distal stump of the recurrent laryngeal nerve preclude the procedure of nerve transfer. But careful selection of the appropriate candidate seems to be the earliest prerequisite for a successful procedure.

Monitorización del Paciente en Ventilación Mecánica

Un artículo publicado Medicina Intensiva (España) 2006; 30(9):440-8 trata sobre como monitorizar a pacientes, especialmente aquellos con SDRA, que se encuentran apoyados con ventilación mecánica.

Formato PDF en español

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Predictores de Bajo Riesgo de Meningitis en Niños con Líquido Cefalorraquideo con Pleostocitos

Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis
Lise E. Nigrovic, MD, MPH; Nathan Kuppermann, MD, MPH; Charles G. Macias, MD, MPH; Christopher R. Cannavino, MD; Donna M. Moro-Sutherland, MD; Robert D. Schremmer, MD; Sandra H. Schwab, MD; Dewesh Agrawal, MD; Karim M. Mansour, MD; Jonathan E. Bennett, MD; Yiannis L. Katsogridakis, MD, MPH; Michael M. Mohseni, MD; Blake Bulloch, MD; Dale W. Steele, MD; Ron L. Kaplan, MD; Martin I. Herman, MD; Subhankar Bandyopadhyay, MD; Peter Dayan, MD, MSc; Uyen T. Truong, MD; Vincent J. Wang, MD; Bema K. Bonsu, MD; Jennifer L. Chapman, MD; John T. Kanegaye, MD; Richard Malley, MD; for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics

JAMA. 2007;297:52-60.

Context Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/µL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10 000 cells/µL, and a history of seizure before or at the time of presentation.

Objective To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination.

Design, Setting, and Patients A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells 10 cells/µL) and who had not received antibiotic treatment before lumbar puncture.

Main Outcome Measure The sensitivity and negative predictive value of the Bacterial Meningitis Score.

Results Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized.

Conclusions This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.