Trauma

Una entretenida página de internet dedicada al tema de trauma. Se pueden encontrar "escenarios" de trauma con opciones múltiples en la sección moulages en las cuales las decisiones tomadas determinan el destino del su paciente traumatizado. También, hay recursos bibliográficos y links a otros sitios dedicados al tema. Les recomiendo que la visiten en la siguiente dirección:

http://www.trauma.org/

Apendicitis Aguda en Niños

Does This Child Have Appendicitis?
David G. Bundy; Julie S. Byerley; E. Allen Liles; Eliana M. Perrin; Jessica Katznelson.
JAMA. 2007;298:438-451.

Context
Evaluation of abdominal pain in children can be difficult. Rapid, accurate diagnosis of appendicitis in children reduces the morbidity of this common cause of pediatric abdominal pain. Clinical evaluation may help identify (1) which children with abdominal pain and a likely diagnosis of appendicitis should undergo immediate surgical consultation for potential appendectomy and (2) which children with equivocal presentations of appendicitis should undergo further diagnostic evaluation.

Objective
To systematically assess the precision and accuracy of symptoms, signs, and basic laboratory test results for evaluating children with possible appendicitis.

Data Sources
We searched English-language articles in MEDLINE (January 1966–March 2007) and the Cochrane Database, as well as physical examination textbooks and bibliographies of retrieved articles, yielding 2521 potentially relevant articles.

Study Selection
Studies were included if they (1) provided primary data on children aged 18 years or younger in whom the diagnosis of appendicitis was considered; (2) presented medical history data, physical examination findings, or basic laboratory data; and (3) confirmed or excluded appendicitis by surgical pathologic findings, clinical observation, or follow-up. Of 256 full-text articles examined, 42 met inclusion criteria.

Data Extraction
Twenty-five of 42 studies were assigned a quality level of 3 or better. Data from these studies were independently extracted by 2 reviewers.
Results In children with abdominal pain, fever was the single most useful sign associated with appendicitis; a fever increases the likelihood of appendicitis (likelihood ratio [LR], 3.4; 95% confidence interval [CI], 2.4-4.8) and conversely, its absence decreases the chance of appendicitis (LR, 0.32; 95% CI, 0.16-0.64). In select groups of children, in whom the diagnosis of appendicitis is suspected and evaluation undertaken, rebound tenderness triples the odds of appendicitis (summary LR, 3.0; 95% CI, 2.3-3.9), while its absence reduces the likelihood (summary LR, 0.28; 95% CI, 0.14-0.55). Midabdominal pain migrating to the right lower quadrant (LR range, 1.9-3.1) increases the risk of appendicitis more than right lower quadrant pain itself (summary LR, 1.2; 95% CI, 1.0-1.5). A white blood cell count of less than 10 000/µL decreases the likelihood of appendicitis (summary LR, 0.22; 95% CI, 0.17-0.30), as does an absolute neutrophil count of 6750/µL or lower (LR, 0.06; 95% CI, 0.03-0.16). Symptoms and signs are most useful in combination, particularly for identifying children who do not require further evaluation or intervention.

Conclusions
Although the clinical examination does not establish a diagnosis of appendicitis with certainty, it is useful in determining which children with abdominal pain warrant immediate surgical evaluation for consideration of appendectomy and which children may warrant further diagnostic evaluation. More child-specific, age-stratified data are needed to improve the utility of the clinical examination for diagnosing appendicitis in children.

Prevención de TVP en Pacientes Hospitalizados

Preventing deep vein thrombosis in hospital inpatients
BMJ 2007;335:147-151
William E Cayley, Jr.

Summary points
• Appropriate use of prophylaxis against deep vein thrombosis (DVT) in hospital inpatients is important for reducing the risk of fatal and non-fatal pulmonary embolism and post-thrombotic complications
• For patients at low risk of DVT, ambulation is important, and mechanical methods of prophylaxis (such as graduated compression stockings and intermittent pneumatic compression devices) can provide added protection
• Patients at higher risk of DVT should be considered for guideline based anticoagulation with low molecular weight heparin, unfractionated heparin, or vitamin K antagonists unless clearly contraindicated
• Fondaparinux may provide additional prophylactic options
• The place of aspirin in DVT prophylaxis remains controversial
• To ensure adequate prophylaxis against DVT, doctors should be encouraged to follow appropriate guidelines

Riesgo de Diseminación por Perforación en Resección Endoscópica de Cáncer Gástrico

Gastric perforation during endoscopic resection for gastric carcinoma and the risk of peritoneal dissemination
Br J Surg 2007;94(8):992-5
H. Ikehara, T. Gotoda, H. Ono, I. Oda, D. Saito

Abstract
The potential risk of peritoneal seeding following perforation caused by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is unknown.

Between January 1991 and December 2003, 90 patients suffered gastric perforation during EMR or ESD at the National Cancer Centre Hospital, Tokyo. The clinical and pathological evidence for peritoneal dissemination in these patients was assessed retrospectively.

Eighty-four patients were followed up at this hospital for a median of 53·6 (range 7·0-136·6) months; the remaining six patients were followed up at other institutions. In 83 patients the perforation was repaired by endoscopic clip application and seven patients underwent emergency surgery. Gastrectomy was carried out in 33 patients who had non-curative endoscopic surgery. Among these, peritoneal fluid was sampled during operation in nine patients and was cytologically negative for malignancy. The other 24 patients who had a gastrectomy did not have ascites so cytology was not performed. No peritoneal dissemination was noted during follow-up.

This study suggests that perforation associated with EMR and ESD does not lead to peritoneal dissemination even in the long term.

Anticoagulantes y Antiagregantes en Enfermedad Arterial Oclusiva

Oral Anticoagulant and Antiplatelet Therapy and Peripheral Arterial Disease
N Engl J Med 2007;357(2):217-27
The Warfarin Antiplatelet Vascular Evaluation Trial Investigators

Background
Atherosclerotic peripheral arterial disease is associated with an increased risk of myocardial infarction, stroke, and death from cardiovascular causes. Antiplatelet drugs reduce this risk, but the role of oral anticoagulant agents in the prevention of cardiovascular complications in patients with peripheral arterial disease is unclear.

Methods
We assigned patients with peripheral arterial disease to combination therapy with an antiplatelet agent and an oral anticoagulant agent (target international normalized ratio [INR], 2.0 to 3.0) or to antiplatelet therapy alone. The first coprimary outcome was myocardial infarction, stroke, or death from cardiovascular causes; the second coprimary outcome was myocardial infarction, stroke, severe ischemia of the peripheral or coronary arteries leading to urgent intervention, or death from cardiovascular causes.

Results
A total of 2161 patients were randomly assigned to therapy. The mean follow-up time was 35 months. Myocardial infarction, stroke, or death from cardiovascular causes occurred in 132 of 1080 patients receiving combination therapy (12.2%) and in 144 of 1081 patients receiving antiplatelet therapy alone (13.3%) (relative risk, 0.92; 95% confidence interval [CI], 0.73 to 1.16; P=0.48). Myocardial infarction, stroke, severe ischemia, or death from cardiovascular causes occurred in 172 patients receiving combination therapy (15.9%) as compared with 188 patients receiving antiplatelet therapy alone (17.4%) (relative risk, 0.91; 95% CI, 0.74 to 1.12; P=0.37). Life-threatening bleeding occurred in 43 patients receiving combination therapy (4.0%) as compared with 13 patients receiving antiplatelet therapy alone (1.2%) (relative risk, 3.41; 95% CI, 1.84 to 6.35; P<0.001).

Conclusions
In patients with peripheral arterial disease, the combination of an oral anticoagulant and antiplatelet therapy was not more effective than antiplatelet therapy alone in preventing major cardiovascular complications and was associated with an increase in life-threatening bleeding.

Complicación Específica de Apendicectomía Laparocópica

Complicaciones sépticas intraabdominales tras apendicectomía laparoscópica: descripción de una posible nueva complicación específica de la apendicectomía laparoscópica
Cir Esp 2007; 82: 21 - 26
Guillermo Soler-Dorda, María José Fernández-Díaz, Ignacio Martín-Parra, José Luis Alonso-Gayón, Jose Luis Conty-Serrano, María Antonia de Andrés-Fuertes, José María Bárcena-Barros.

Para acceder al texto completo hacer click sobre el título de este entry.

Introducción.
Las controversias en torno a la apendicectomía laparoscópica (AL) se centran fundamentalmente en su índice de infecciones intraabdominales. Una complicación diferente y específica de la AL fue descrita por Serour et al en 2005 y denominada postlaparoscopic appendectomy complication (PLAC). Se trata de una infección intraabdominal, sin forma-ción de absceso, tras una apendicectomía laparoscó-pica por apendicitis no complicada (simple, flegmonosa o con apéndice normal), desarrollada en pacientes dados de alta tras un postoperatorio sin incidencias. Revisamos nuestra casuística para conocer nuestra incidencia de infección intraabdominal e identificar casos similares a esta recientemente descrita complicación.
Material y método.
Revisamos retrospectivamente 651 historias clínicas de apendicectomía realizadas tanto por vía laparoscópica (AL) como abierta (AA). Los criterios para el diagnóstico de PLAC fueron: a) clínica: apendicectomía no complicada (AA o AL), alta hospitalaria estando asintomático, aparición de dolor en cuadrante inferior derecho tras el alta, fiebre y leucocitosis; b) anatomía patológica: apendicitis no complicada (se excluye las gangrenosas o perforadas), y c) ecografía: imágenes características.

Resultados.
Fueron revisadas 432 apendicectomías laparoscópicas y 219 abiertas. El índice de conversión fue del 11,1%. Las principales complicaciones fueron (análisis por intención de tratar): infección de herida, el 6,3% en AL y el 7,8% en AA; infección intraabdominal, el 4,2% en AL y el 2,3% en AA. Hubo 4 casos de 18 infecciones intraabdominales tras AL que cumplieron los criterios de PLAC: el 1% de todas las AL y el 22% de las infecciones intraabdominales tras AL.

Conclusiones.
La AL parece estar asociada a una mayor incidencia de infección intraabdominal. Nuestros resultados indican la posible existencia de una forma diferente de infección intraabdominal específica de la apendicectomía laparoscópica.

¿Cirugía para Curar la Diabetes Mellitus Tipo 2?

How the hindgut can cure type 2 diabetes. Ileal transposition improves glucose metabolism and beta-cell function in Goto-kakizaki rats through an enhanced Proglucagon gene expression and L-cell number
Surgery Volume 142, Issue 1, July 2007, Pages 74-85
Alberto Patriti, Maria Cristina Aisa, Claudia Annetti MS, Angelo Sidoni, Francesco Galli, Ivana Ferri, Nino Gullà and Annibale Donini

Background
It has been hypothesized that glucagon-like peptide-1 (GLP-1), secreted by ileal L cells, plays a key-role in the resolution of type 2 diabetes after bariatric operations whose common feature is an expedite nutrient delivery to the hindgut. Ileal transposition (IT), an operation that permits L-cell stimulation by undigested food, was employed to verify this theory.

Methods
IT was carried out in Goto-Kakizaki (GK) type 2 diabetic rats and in euglycemic Sprague-Dawley (SD) rats. Glucose tolerance, insulin resistance, food-intake, body weight, pancreas morphology, and function were evaluated to track the effects of IT on diabetes. Intact GLP-1 secretion and gene expression pattern of the transposed ileum were investigated to verify the molecular bases of the hindgut action.

Results
In GK rats, IT significantly improved glucose tolerance, insulin sensitivity, and acute insulin response without affecting body weight and food intake. Immunohistochemistry revealed remodeled islets strictly resembling that of euglycemic rats and signs of β-cell neogenesis starting with exocrine structures. GLP-1 secretion in GK transposed rats was characterized by a more sustained response to oral glucose compared with nontreated rats. Gene expression of Proglucagon, Proconvertase 1/3 (PC1/3), and Chromogranin A in the transposed ileum significantly enhanced. Effects on glucose metabolism and pancreas morphology were not observed in the euglycemic rats as a consequence of the glucose-dependent action of GLP-1.

Conclusions
This study gives strong evidences for the crucial role of the hindgut in the resolution of diabetes after Roux-en-Y gastric bypass (GBP) and biliopancreatic diversion (BPD). Moreover, these findings confirm at the preclinical level that IT is a surgical procedure of possible relevance in the therapy of type 2 diabetes in non–overweight and mildly obese patients.

Factores de Riesgo de Resultado Adverso en Operación de Miles

Risk Factors for Adverse Outcome in Patients With Rectal Cancer Treated With an Abdominoperineal Resection in the Total Mesorectal Excision Trial.
Annals of Surgery. 246(1):83-90, July 2007.
den Dulk, Marcel; Marijnen, Corrie A. M.; Putter, Hein; Rutten, Harm J. T.; Beets, Geerard L.; Wiggers, Theo; Nagtegaal, Iris D.; van de Velde, Cornelis J. H.

Objective: This study was performed to identify tumor- and patient-related risk factors for distal rectal cancer in patients treated with an abdominoperineal resection (APR) associated with positive circumferential resection margin (CRM), local recurrence (LR), and overall survival (OS).

Background: The introduction of total mesorectal excision (TME) has improved the outcome of patients with rectal cancer. However, survival of patients treated with an APR improved less than of those treated with low anterior resections (LAR). Besides, an APR is associated with a higher LR rate.

Methods: Patients were selected from the TME trial, which is a randomized, multicenter trial, studying the effects of preoperative radiotherapy (RT) in 1861 patients. Of the Dutch patients, 455 underwent an APR. Location of the bulk of the tumor was scored with surgery, pathology, or other reports. CRM was available from pathology reports.

Result: A positive CRM was found in 29.6% of all patients, 44% for anterior, 21% for lateral, 23% for posterior, and 17% for (semi)circular tumor location (P < 0.0001). In a multivariate analysis, T-stage, N-stage, and tumor location were independent risk factors for CRM. If a (partial) resection of the vaginal wall was performed in women, 47.8% of patients still had a positive CRM. T-stage, N-stage, and CRM were risk factors for LR and age, T-stage, N-stage, CRM, and distance of the inferior tumor margin to the anal verge for OS.

Conclusion: Age, T-stage, N-stage, CRM, distance of the tumor to the anal verge, and tumor location were independent risk factors for adverse outcome in patients treated with an APR for low rectal cancer. Anterior location, specifically in women, more often requires downstaging and/or more extended resection to obtain free margins.

Metaánalisis Resultados Cirugía Antireflujo en Esofago de Barrett

The Effect of Antireflux Surgery on Esophageal Carcinogenesis in Patients With Barrett Esophagus: A Systematic Review.
Annals of Surgery. 246(1):11-21, July 2007.
Chang, Eugene Y. MD *; Morris, Cynthia D. PhD, MPH +; Seltman, Ann K. MD *; O'Rourke, Robert W. MD *; Chan, Benjamin K. MS +; Hunter, John G. MD *; Jobe, Blair A. MD *++

Objective: To determine whether patients with Barrett esophagus who undergo antireflux surgery differ from medically treated patients in incidence of esophageal adenocarcinoma and probability of disease regression/progression.

Summary Background Data: Barrett esophagus is a risk factor for the development of esophageal adenocarcinoma. A question exists as to whether antireflux surgery reduces this risk.

Methods: Query of PubMed (1966 through October 2005) using predetermined search terms revealed 2011 abstracts, of which 100 full-text articles were reviewed. Twenty-five articles met selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled adults with biopsy-proven Barrett esophagus, specified treatment-type rendered, followed up patients with endoscopic biopsies no less than12 months of instituting therapy, and provided adequate extractable data. The incidence of adenocarcinoma and the proportion of patients developing progression or regression of Barrett esophagus and/or dysplasia were extracted.

Results: In surgical and medical groups, 700 and 996 patients were followed for a total of 2939 and 3711 patient-years, respectively. The incidence rate of esophageal adenocarcinoma was 2.8 (95% confidence interval, 1.2-5.3) per 1000 patient-years among surgically treated patients and 6.3 (3.6-10.1) among medically treated patients (P = 0.034). Heterogeneity in incidence rates in surgically treated patients was observed between controlled studies and case series (P = 0.014). Among controlled studies, incidence rates were 4.8 (1.7-11.1) and 6.5 (2.6-13.8) per 1000 patient-years in surgical and medical patients, respectively (P = 0.320). Probability of progression was 2.9% (1.2-5.5) in surgical patients and 6.8% (2.6-12.1) in medical patients (P = 0.054). Probability of regression was 15.4% (6.1-31.4) in surgical patients and 1.9% (0.4-7.3) in medical patients (P = 0.004).

Conclusions: Antireflux surgery is associated with regression of Barrett esophagus and/or dysplasia. However, evidence suggesting that surgery reduces the incidence of adenocarcinoma is largely driven by uncontrolled studies.

Depresión Miocárdica y Shock Séptico

Revisión clínica: depresión miocárdica en sepsis y shock séptico
Drs. A González, M Boncompte, J F Vergara, M Andresen.
Servicio de Intensivo Médico, Departamento de Medicina Intensiva. Facultad de Medicina, Pontificia Universidad Católica de Chile.
Rev. Chilena de Medicina Intensiva 2007; 22(1)

Resumen
La sepsis y el shock séptico son patologías de gran mortalidad, cuyo evento final es la hipotensión refractaria, colapso cardiocirculatorio y falla multiorgánica. En los últimos años se han realizado importantes esfuerzos para entender la disfunción cardiaca asociada a este cuadro, que puede objetivarse hasta en el 50% de los pacientes con sepsis severa y shock séptico. A pesar de que hoy se acepta que la disfunción miocárdica juega un importante rol en la sepsis, aún no existe consenso respecto a la manera de evaluar la función cardiaca en este contexto, surgiendo nuevas propuestas como el uso de marcadores séricos. Por otra parte, el tratamiento más utilizado hasta hoy han sido los inótropos como la dobutamina, sin embargo con los nuevos estudios sobre la etiología de la disfunción miocárdica, se ha logrado el desarrollo de nuevas líneas experimentales de tratamiento.

Summary
The sepsis and the septic shock are pathologies of the great mortality, whose final event is the refractory hypotension, circulatory collapse and multiorganic failure. In the last years important efforts have been made to understand the associate cardiac dysfunction to this picture, which can appear until in 50% of the patients with severe sepsis and septic shock. Although today it is accepted that the myocardial dysfunction plays an important role in the sepsis. It does not yet exist consensus with respect to the way to evaluate the function cardiac. New proposals arising as the use from seric markers. On the other hand, the more used treatment until today has been the inotropic agent like the dobutamine. But with the new studies on the etiology of the myocardial dysfunction, has been obtained the development of experimental new line of treatment

Manejo de Cancer de Colon y sus Metastasis

A continuación encontrarán el link para un resumen de actualización publicado en Contemporary Surgery.

http://www.contemporarysurgery.com/pdf/6307/6307CS_Review.pdf

TAC Facial como Screening de Fracturas Faciales

Computed tomography of the head as a screening examination for facial fractures
Jon Marinaro,Cameron S. Crandall and David Doezema. Department of Surgery, University of New Mexico.

The American Journal of Emergency Medicine Volume 25, Issue 6, July 2007, Pages 616-619

Abstract
We hypothesized that head computed tomography (CT) is an accurate screening tool for detecting nonnasal midfacial fractures in trauma patients.

We retrospectively reviewed charts and official readings for all patients who underwent both head and facial CT scans for trauma at our trauma center between August 2002 and April 2003.

The ability of head CT to diagnose nonnasal bone midfacial fractures was compared with that of facial CT using sensitivity, specificity, accuracy, as well as positive and negative predictive values. Agreement was measured with κ statistics. Ninety-five percent confidence intervals (CIs) were used to assess precision.

Ninety-one patient records with head and facial CT scan reports were reviewed. Of the patients, 50 (55%) had nonnasal bone midfacial fractures. The sensitivity and specificity of head CT were 90% (95% CI = 79%-96%) and 95% (95% CI = 84%-99%), respectively; the positive and negative predictive values were 96% (95% CI = 86%-99%) and 89% (95% CI = 76%-95%), respectively. The rate of accuracy was 92%. The agreement was excellent (κ = 0.85, 95% CI = 0.74-0.96).

Head CT was sensitive and specific for identifying nonnasal bone midfacial fractures. An initial head CT alone may limit the need for a Waters view radiography or screening facial CT in detecting injuries.

Guías Clínicas GES 2007

Nos guste o no a partir del día de ayer se agregaron 16 nuevas patologías al sistema GES. Les doy el acceso a la página del Ministerio de Salud en donde podrán acceder a las guías clínicas de dichas enfermedades.

http://www.minsal.cl/ici/reforma_de_salud/guias_clinicas_ges_2007.html