Tasa de afectación de los márgenes quirúrgicos tras la cirugía conservadora de mama y estimación de los costes directos

ObjectiveAssessment of the reoperation rate in patients with positive resection margins after initial breast-conserving surgery for breast cancer and estimation of the cost to the hospital.Method146 patients with diagnosis of invasive breast cancer were included, who were initially intervened with conservative surgery by the Gynecology and Obstetrics Service of Hospital Universitario de Tarragona Juan XXIII (HUTJ23) during the years 2018 and 2019. We calculated the rate of involvement of the surgical margins of the resection piece after initial conservative surgery, establishing in which cases it was necessary to carry out a second resection, estimating the added direct costs of the second surgical procedure, and comparing them with the costs established by the Catalan Health Service according to the level of the hospital and the Diagnosis-Related Groups (DRG) established by the National Health System.ResultsThe rate of positive margins after initial conservative surgery was 20.55% and 19.17% patients underwent reoperation, generating a total expense of € 129.696,89, € 82.654,34 in conservative surgeries (€ 3.757,01 on average per patient) and € 47.042,55 in mastectomies (€ 6.720,36 on average per patient).ConclusionsMargin involvement after breast-conserving surgery is synonymous for reoperation, this involves a series of direct costs. It is advisable to control the factors related to affected margins to minimize their impact.     

花宝金教授基于调气解毒法论治癌性疼痛

癌性疼痛是癌症患者的常见症状之一,其严重地摧残着患者的身心健康，影响着生命质量。中医药能够减轻疼痛，减少止痛药物的用量及减少不良反应，能够明显改善生命质量。花宝金教授指出正气不足为癌痛发作的内因，正气不足，脏腑功能失调，气血阴阳虚损，病邪乘虚而入，经脉不荣可发为疼痛。此外各种因素导致的气滞为癌痛发生的诱发因素，可导致形成血瘀、痰湿、热毒等积滞搏结发为癌肿，闭阻脉络，瘀塞不通，而致疼痛。病程日久所形成的癌毒为夙根，是癌痛反复发作的根本原因。“调气解毒法”是花宝金教授治疗癌性疼痛的主要方法之一，通过辨癌毒，从病机、治法、方药等方面论述调气解毒法在癌性疼痛中的应用。     

Cannabis and orofacial pain: a systematic review

The naturally occurring cannabis plant has played an established role in pain management throughout recorded history. However, in recent years, both natural and synthetic cannabis-based products for medicinal use (CBPM) have gained increasing worldwide attention due to growing evidence supporting their use in alleviating chronic inflammatory and neuropathic pain associated with an array of conditions. In view of these products’ growing popularity in both the medical and commercial fields, we carried out a systematic review to ascertain the effects of cannabis and its synthetically derived products on orofacial pain and inflammation. The application of topical dermal cannabidiol formulation has shown positive findings such as reducing pain and improving muscle function in patients suffering from myofascial pain. Conversely, two orally-administered synthetic cannabinoid receptor agonists (AZD1940 and GW842166) failed to demonstrate significant analgesic effects following surgical third molar removal. There is a paucity of literature pertaining to the effects of cannabis-based products in the orofacial region; however, there is a wealth of high-quality evidence supporting their use for treating chronic nociceptive and neuropathic pain conditions in other areas. Further research is warranted to explore and substantiate the therapeutic role of CBPMs in the context of orofacial pain and inflammation. As evidence supporting their use expands, healthcare professionals should pay close attention to outcomes and changes to legislation that may impact and potentially benefit their patients.     

Impact of abdominal imaging on the diagnosis of acute pancreatitis in patients with painless lipase elevation

Abdominal pain is considered a cardinal feature of acute pancreatitis (AP), and abdominal imaging is only required to diagnose AP when the pain is atypical, or serum enzyme elevation does not match the clinical picture. While painless lipase elevation is being increasingly associated with worse outcomes in various diseases, the diagnostic approach to such elevation is so-far unclear. We thus aimed to learn the impact of pain on the diagnosis of AP.MethodsAll patients presenting to the Mayo Clinic Arizona Hospital emergency department with a serum lipase ≥3x upper limit of normal between April 2016 and January 2020 were prospectively followed. Their charts were reviewed for the nature of pain, serum lipase levels on presentation, abdominal imaging, and whether a diagnosis of AP was made. Chronic pancreatitis was excluded.ResultsAmong 320 patients, 85 (26.5%) had painless lipase elevation. These patients had abdominal imaging less often (56/85, 66%) than in those with abdominal pain (201/235, 83%; p = 0.001). The diagnosis of AP increased overall from 31/63 (49%) without imaging to 198/257 (77%) with imaging (P < 0.001). Imaging increased the diagnosis of AP in patients with painless lipase elevation from 2/29 (7%) without imaging to 16/56 (29%; p = 0.025) among those who were imaged.ConclusionsPainless lipase elevation >3-fold the upper limit of normal is common in emergency department patients. 1/3 to 1/4 of these may have AP. Abdominal imaging increases the diagnosis of AP in patients with painless lipase elevation. Therefore, abdominal imaging in such patients may help detect AP that otherwise eludes diagnosis.     

Delivering end-of-life care for patients with cancer at home: Interviews exploring the views and experiences of general practitioners

Many patients with terminal cancer wish to die at home and general practitioners in the United Kingdom have a critical role in providing this care. However, it has been suggested general practitioners lack confidence in end-of-life care. It is important to explore with general practitioners their experience and perspectives including feelings of confidence delivering end-of-life care to people with cancer. The aim of this study was to explore general practitioners experiences of providing end-of-life care for people with cancer in the home setting and their perceptions of confidence in this role as well as understanding implications this has on policy design. A qualitative study design was employed using semi-structured interviews and analysed using thematic analysis. Nineteen general practitioners from London were purposively sampled from eight general practices and a primary care university department in 2018–2019, supplemented with snowballing methods. Five main themes were constructed: (a) the subjective nature of defining palliative and end-of-life care; (b) importance of communication and managing expectations; (c) complexity in prescribing; (d) challenging nature of delivering end-of-life care; (e) the unclear role of primary care in palliative care. General practitioners viewed end-of-life care as challenging; specific difficulties surrounded communication and prescribing. These challenges coupled with a poorly defined role created a spread in perceived confidence. Experience and exposure were seen as enabling confidence. Specialist palliative care service expansion had important implications on deskilling of essential competencies and reducing confidence levels in general practitioners. This feeds into a complex cycle of causation, leading to further delegation of care.     

The effect of heel-to-toe drop of running shoes on patellofemoral joint stress during running

BackgroundTraditional running shoes with heel-to-toe drops is thought to be a contributor to increased patellofemoral joint stress, which is proposed as a mechanism of patellofemoral pain.Research questionIs there an increase in patellofemoral joint stress when running in shoes with drops compared to running in shoes without a drop?MethodsLower limbs kinematics and ground reaction force were collected from eighteen healthy runners during over-ground running in shoes with 15 mm, 10 mm, 5 mm drops, and without a drop. Patellofemoral joint force and stress were calculated from the kinematic and kinetic data using a biomechanical model of the patellofemoral joint.ResultsThe peak patellofemoral joint stress was increased by more than 15% when running in shoes with 15 mm and 10 mm drops compared to running in shoes without a drop (p = 0.003, p = 0.001). The knee flexion angle was significantly increased when running in shoes with 15 mm, 10 mm and 5 mm drops (p = 0.014, p = 0.003, p = 0.002), the knee extension moment (p = 0.009, p = 0.002) and patellofemoral joint force (p = 0.003, p = 0.001) were increased when running in shoes with 15 mm and 10 mm drops, compared to running in shoes without a drop.SignificanceCompared to running in shoes without a drop, running in shoes with drops > 5 mm increase the peak patellofemoral joint stress significantly, which is mainly due to the increased knee extension moment.