Maniobras de reclutamiento en anestesia: ¿qué más excusas para no usarlas?

Pulmonary recruitment manoeuvres (RM) are intended to reopen collapsed lung areas. RMs are present in nature as a physiological mechanism to get a newborn to open their lungs for the first time at birth, and we also use them, in our usual anaesthesiological clinical practice, after induction or during general anaesthesia when a patient is desaturated. However, there is much confusion in clinical practice regarding their safety, the best way to perform them, when to do them, in which patients they are indicated, and in those where they are totally contraindicated. There are important differences between RM in the patient with adult respiratory distress syndrome, and in a healthy patient during general anaesthesia. Our intention is to review, from a clinical and practical point of view, the use of RM, specifically in anaesthesia.     

Intra-articular knee injuries in racquet sports

Summary Within the last decade, there has been a significant increase in racquet sport participation. The authors report that in a 5-year period, 17% of the injuries seen in a busy sports injuries clinic were associated with raquet sports, and over half of these were injuries to the knee. The findings are reported of those patients requiring knee arthroscopy, and the patterns of injury sustained are identified. Injuries to the knee in racquet sports are largely unavoidable and are inherent to the nature of the game.     

Adverse drug reactions

Adverse drug reactions (ADRs) are a response to a drug that is noxious and unintended. They are a frequent cause of hospitalization and mortality in the UK, resulting in a significant financial burden for the NHS. Between one-third to a half of ADRs are avoidable. To minimize their occurrence, each patient's susceptibility should be assessed by evaluating risk factors such as age, comorbidities and potential drug interactions before a medication is administered. Pharmacogenetics is an area of increasing interest which is likely to play a role in this assessment and enable clinicians to target drugs, with improved precision, to only the patients they are likely to benefit.Anaesthetists and intensivists hold a crucial role in managing ADRs. Firstly, we are responsible for patient safety throughout the perioperative period, during which we often administer multiple medications which could potentially cause an ADR. Fortunately, we also meticulously observe physiological changes during this period, increasing the likelihood of detecting such events. Secondly, several ‘atypical’ drug reactions, such as anaphylaxis and toxic epidermal necrolysis, are so severe that they often necessitate management in an intensive care environment. Therefore, we have a professional responsibility to ensure we are familiar with recognizing, managing, and reporting ADRs.     

Rapport sur la dialyse chronique en France en 2016

The report on dialysis in France in 2016 from the French Speaking Society of Nephrology Dialysis and Transplantation (SFNDT) provides an exhaustive and documented inventory on dialysis in France. It underlines the organizations that are important in 2016 to maintain a high quality dialysis. Several measures are proposed to maintain and improve the care of dialysis in France: (1) The regulation of dialysis treatment in France must be maintained; (2) a burden of care indicator is proposed to ensure that patients requiring the most care are treated in the centers. Proposals are also made to stimulate peritoneal dialysis offers, (3) to improve the calculation of the cost of dialysis and warn against lower reimbursement rates of dialysis, (4) to reduce transport costs by minimizing transport by ambulance (5). The SFNDT recalls recent recommendations concerning access to the renal transplant waiting list, are recalled; (6) as well as recommendations that require waiting until clinical signs are present to start dialysis (7). The SFNDT makes the proposal to set up advanced renal failure units. These units are expected to develop care that is not supported today: consultation with a nurse, a dietician, a social worker or psychologist, palliative care, and coordination (8). Finally, the financial and human resources for pediatric dialysis should be maintained.     

Inhalational anaesthesia

The use of inhalational agents for the induction and maintenance of anaesthesia in clinical practice has undergone significant advances in safety and effectiveness since its introduction in the 1800s. In the United Kingdom, desflurane, sevoflurane and isoflurane are the most commonly used agents. The ideal inhalational anaesthetic would have a low blood:gas solubility coefficient and a high oil:gas coefficient, which would generate a fast onset and high potency, respectively. Inhaled agents are delivered by vaporizers that are specific to each agent, and concentrations are closely measured to deliver safe anaesthesia. Expired concentrations of the volatile are used to monitor alveolar concentrations, which are used as a surrogate for the partial pressure in the brain, governing the effect of the agent. Unfortunately, inhaled anaesthesia is a cause of global warming, with inhalational agents representing 5% of the carbon footprint of the whole NHS. Consequently, their use needs to be tightly regulated.     

The untold story of the scorching sun—A wake up call for sun protection

Despite extensive warnings from health authorities regarding the dangers of direct sunlight exposure, most people still turn to sun bathing to get a golden tan. Unfortunately, that pleasant tan appearance is often lost because of over exposure to sunlight, resulting in painful red sunburns.In this paper we are reporting a case with significant sunburn injuries that required hospitalization and treatment in a burn center. Concurrently a pilot study was conducted to assess the knowledge about sun protection among the adult population and the results are discussed. The results obtained from the study revealed the lack of knowledge regarding sun protection and sun seeking behaviour among the responders.Deeper burns are rarely caused by direct sunlight exposure and are underreported in literature. Despite extensive health education and warnings, there are significant numbers of sunburn injuries reported annually. On most occasions, these are superficial and are in the form of erythema. Nonetheless, the public is unaware of the impending risks of developing deep sunburn injuries that can occur especially during protracted holiday exposures. Therefore, it is crucial to escalate public awareness and to implement preventive measures to reduce the short and long-term risks of sun exposure.     

Leadership and working in teams

Leadership and working in teams are core aspects of surgical training and practice. They are highlighted in the General Medical Council's ‘General Professional Capabilities’ framework, are a key part of the Intercollegiate Surgical Curriculum Programme, are included in Good Surgical Practice guidance published by the Royal College of Surgeons of England and are incorporated in the ‘Non-Technical Skills for Surgeons’ programme run by the Royal College of Surgeons of Edinburgh. Major healthcare failings, as detailed in a number of public inquiries, underline the importance of prioritizing leadership and teamworking in current undergraduate and postgraduate surgical training. A growing body of research has helped to identify the positive attributes and behaviours that are central to leading and working in the surgical team effectively. Evidence-based tools are increasingly being used for training and assessment as well as ongoing reflective practice for surgeons at all stages of their careers. Surgeons have a duty to promote a safe and positive working environment that enhances the performance of the team and leads to high quality patient care.     

Carcinoid tumor from the small bowel

Carcinoid tumors are non-pancreatic digestive neuroendocrine tumors well differentiated. Most of time they are developed from enterochromaffin cells of the digestive tract. Most of them are localized in ileum, rectum, stomach and appendix. Only bronchi are a frequent extra-digestive localization (20 to 25%). Most of these tumors are asymptomatic and discovered incidentally during a laparotomy or secondary to the exploration of a carcinoid syndrome. From a case report and a recent review of literature, diagnosis, histology and treatment of small bowel carcinoid tumors are summarized.     

Role of biofilms in neurosurgical device-related infections

Bacterial biofilms have recently been shown to be important in neurosurgical device-related infections. Because the concept of biofilms is novel to most practitioners, it is important to understand that both traditional pharmaceutical therapies and host defense mechanisms that are aimed at treating or overcoming free-swimming bacteria are largely ineffective against the sessile bacteria in a biofilm. Bacterial biofilms are complex surface-attached structures that are composed of an extruded extracellular matrix in which the individual bacteria are embedded. Superimposed on this physical architecture is a complex system of intercellular signaling, termed quorum sensing. These complex organizational features endow biofilms with numerous microenvironments and a concomitant number of distinct bacterial phenotypes. Each of the bacterial phenotypes within the biofilm displays a unique gene expression pattern tied to nutrient availability and waste transport. Such diversity provides the biofilm as a whole with an enormous survival advantage when compared to the individual component bacterial cells. Thus, it is appropriate to view the biofilm as a multicellular organism, akin to metazoan eukaryotic life. Bacterial biofilms are much hardier than free floating or planktonic bacteria and are primarily responsible for device-related infections. Now that basic research has demonstrated that the vast majority of bacteria exist in biofilms, the paradigm of biofilm-associated chronic infections is spreading to the clinical world. Understanding how these biofilm infections affect patients with neurosurgical devices is a prerequisite to developing strategies for their treatment and prevention.     

Technical requirements to become an osteopathic physician

A person must possess specific abilities in order to become an osteopathic physician. The acquisition of knowledge, the ability to apply the knowledge and the ability to perform appropriate treatment are necessary for students in training. A student needs to have the ability to develop a skill set to progress to the level necessary in both learning and skill acquisition before matriculating into an osteopathic training institution. The abilities necessary for a person to be able to progress to a practicing DO are discussed in this article, as well as the issues that led to the development of a recommended technical standards document. Potential issues are raised, and the currently accepted skills are also discussed.     

Intensive care outreach services

Intensive Care Outreach as a widespread, organized service was introduced throughout most of the United Kingdom in the later half of 2000 and early 2001. This followed recommendations in the report ‘Comprehensive Critical Care’. Many patients in British hospitals who die or require critical care admission are cared for in a ward setting for at least part of their hospital admission. During their ward stay management may be suboptimal and critical incidents that result in adverse outcomes are common. Intensive Care Outreach Services are a multidisciplinary approach to the identification and management of seriously ill patients on hospital wards outside of critical care areas. There are many different models for the delivery of this service. Most are nurse led, but they often include input from physicians and, less commonly, physiotherapists and other allied healthcare professionals. A single nurse may focus on education to improve early recognition of seriously ill patients. Other services are run 24h a day, 7 day a week, assisting in the management of the most seriously ill patients who require additional support. Almost all outreach services are involved in education. Many have worked with ward staff to improve monitoring and charting of physiological variables. These values may be used in an Early Warning Score to help identify those who are, or may become, critically ill. These services are an adjunct to critical care and should not be considered a substitute.     

Rare tumors of the lateral ventricle. Review of the literature

Metastases of lateral ventricle (LV) are attached to choroidal plexus. Primary source is cancer of kidney. Two thirds of patients are male. Oligodendrogliomas occur in young females. Signs of increased intracranial pressure are a constant feature. These tumors are found in anterior portion of the LV with severe enhancement and clumped calcifications. Treatment is surgical. Cavernomas have a preponderance of rapid growth with a bleeding revelation. Seizures are rare. Rebleeding is frequent and justifies a surgical treatment. Schwannomas are a rare entity in which the majority of patients are very young. MRI shows calcifications, cystic components and a strong enhancement. They are limited to sporadic cases, never associated with neurofibromatosis. Arachnoid cysts are located in the atrium and/or in the occipital horn. Patients are young (mean age < 40 years). MRI demonstrates an intracystic lesion with signal intensity similar to the CSF. Best treatment is an endoscopic fenestration. Epidermoid cysts occur in third decade. These pearly tumors appear isointense or a little hyperintense on T1-weighted imaging, very characteristic. They are enhanced after gadolinium injection and appear strongly hyperintense on T2-weighted imaging. An incomplete removal with a thorough long-term follow-up is necessary. Cavernomas of LV are hyperintense on T1- and T2-weighted imaging. They have a bleeding risk of 25 to 45%. Therefore, they must be operated.     

Prosthetic joint infectionsin the elderly

Total joint arthroplasty is among the most remarkable advances in orthopaedic surgery for the elderly, enabling themto regain physical function and be free of pain. Although uncommon, infection of the prosthetic joint causes serious morbidity leading to poor functional outcome with a mortality approaching 8% in the elderly. Most infections occur through inoculation of the prosthesis at the time of implantation and are due to Gram-positive cocci, although a third of the episodes are due to Gram-negative bacilli from a secondary focus. The management presents a major clinical and therapeutic challenge due to systemic and local comorbid conditions in the elderly. Medical and surgical treatment decisions for infected joint prosthesis are complex and should be individualized in each case. Optimal nutrition is essential for a successful outcome. Adverse reactions to medications are more common in the elderly due to end organ dysfunction and drug-drug interactions.     

The Effect of Hemofiltration on Fiber Platelet Concentration

Experimental methods and apparatus were developed to measure platelet concentration in an ultrafiltering hollow fiber with blood and ultrafiltrative flow rates that are characteristic of current hemofiltration practice. Values are presented for the adjusted local platelet concentration, which allows for the expected increase due to loss of ultrafiltrate volume. Platelet concentrations in fiber samples are of interest since ultrafiltration can create platelet polarization in a fashion similar to the concentration polarization that occurs for proteins. For many combinations of inlet flow rate, ultrafiltrative flow rate, and fiber dimension, there are significant elevations in adjusted fiber platelet concentration. The adjusted platelet concentrations of the outflow samples are nominally equal to those of the feed (reservoir) samples; thus, reaction and adhesion of platelets is not a significant source of fiber concentration. Experiments with fibers of different diameters indicate that, as expected in concentration polarization, the excess platelets are located near the wall. Data for the fiber platelet concentration depend in a complex fashion upon the inlet wall shear rate and ultrafiltrative velocity. For certain fixed ultrafiltrative velocities, a maximum fiber platelet concentration occurs at an intermediate inlet wall shear rate. The data are qualitatively explained by an extension of a published model involving diffusive, ultrafiltrative, and wall-induced fluxes of red cells and platelets.     

Fine structure of fetal rat calvarium; provisional identification of preosteoclasts

Summary This is a study of the fine structure of cells of the 20-day fetal rat calvarium. Special attention is given to identifying and characterizing preosteoclasts. These cells are relatively common and located largely, but not exclusively, at the endocranial bone surface. The preosteoclasts are characterized by abundant mitochondria, an incomplete perinuclear Golgi apparatus, and variable-shaped dense granules. The dense granules are unique in appearance in that they contain an internal dense matrix surrounded by a clear halo. Most granules are circular in shape but some are elongate or tubular in form. Granules with identical appearance are observed in osteoclasts. The preosteoclasts are mononucleate, or occasionally binucleate. It is suggested that because preosteoclasts are morphologically distinctive and relatively abundant, it should be feasible to separate these cells from a heterogeneous cell isolate.     

How to assess intestinal viability during surgery: A review of techniques

Objective and quantitative intraoperative methods of bowel viability assessment are essential in gastrointestinal surgery. Exact determination of the borderline of the viable bowel with the help of an objective test could result in a decrease of postoperative ischemic complications. An accurate, reproducible and cost effective method is desirable in every operating theater dealing with abdominal operations. Numerous techniques assessing various parameters of intestinal viability are described by the studies. However, there is no consensus about their clinical use. To evaluate the available methods, a systematic search of the English literature was performed. Virtues and drawbacks of the techniques and possibilities of clinical application are reviewed. Valuable parameters related to postoperative intestinal anastomotic or stoma complications are analyzed. Important issues in the measurement and interpretation of bowel viability are discussed. To date, only a few methods are applicable in surgical practice.Further studies are needed to determine the limiting values of intestinal tissue oxygenation and flow indicative of ischemic complications and to standardize the methods.     

Decision-Making Capacity and Disaster Research

The extent to which victims of a disaster are able to make capacitated and voluntary decisions to enroll in research is an important and virtually unexplored question. Although there are no compelling data to suggest that experiencing a severe trauma, in and of itself, renders all or even most individuals incapable of making autonomous decisions, the assessment of decision-making capacity (DMC) for research participation warrants serious consideration. This paper provides a framework for and procedural approach to the assessment of DMC in research with individuals exposed to disaster. Particular attention is paid to the implementation of additional safeguards to protect subjects who are vulnerable by virtue of impaired DMC. Recommendations are offered to clinical investigators, ethical review boards, and policymakers with regard to the design, review, and conduct of research in the aftermath of disaster.     

Technique of internal mammary-to-coronary artery bypass

Experience with 184 patients undergoing internal mammary artery bypass grafting has resulted in a reproducible, simplified, and organized surgical technique. Recatheterization study has been performed in 39 asymptomatic and 3 symptomatic patients at two weeks to one year postoperatively. Two distal stenoses and no closures have been found. The advantages of internal mammary arteries as bypass grafts are that the vessels are comparably sized, there is artery-to-artery anastomosis, only a single distal anastomosis per graft is needed, there is no subintimal hyperplasia, and no leg wound problems occur. Disadvantages are that a more tedious dissection of the relatively more friable internal mammary vessel is necessary, only two grafts are available whereas multiple bypasses are sometimes necessary, and the grafts are limited in length. Complications specific to the procedure are injury to the internal mammary artery during preparation (2 patients) and inadequate graft size (5 patients). Flow rates are adequate to relieve angina. Patients with subclavian bruits or differential blood pressure between the right and left arms are not considered candidates for internal mammary artery bypass grafting. The availability of a special 7-0 Prolene suture on a BV-1 needle and the use of optical magnification are especially important adjuncts to the procedure.     

Primary adenocarcinoma of the epididymis: Case report

Primary epididymal malignancies are uncommon and usually benign. Benign paratesticular tumors are most commonly adenomatoid, while the most common malignant paratesticular tumors are rhabdomyosarcomas. Approximately 25% of all epididymal tumors are malignant, and of the benign tumors, 60% to 78% are adenomatoid tumors. According to a recent MEDLINE search using epididymis and adenocarcinoma as key words, reports of a primary epididymal adenocarcinoma are extremely rare with only 23 cases in the literature. We report a case of epididymal adenocarcinoma with clinical follow up and metastatic natural history of this rare malignancy. This revised version was published online in August 2006 with corrections to the Cover Date.