Alejandro González-Ojeda

L-alanyl-L-glutamine-supplemented parenteral nutrition improves infectious morbidity in secondary peritonitis

BACKGROUND & AIMS A growing number of randomized clinical trials suggest that glutamine (Gln) supplementation may be beneficial in a selected group of patients and conditions. However, the effects of Gln-enriched total parenteral nutrition (TPN) on recovery from acute intra-abdominal infection have not been thoroughly investigated. Therefore, the aim of this study was to investigate whether the provision of Gln-enriched TPN after surgical and medical treatment of secondary peritonitis improves infectious morbidity. METHODS Thirty-three patients with secondary peritonitis were randomly assigned to receive either standard (n=16) TPN or L-alanyl-L-glutamine-supplemented (n=17) TPN, after medical and surgical treatment of the infectious focus. The two TPN formulae were isonitrogenous and isocaloric, which commenced the morning after surgery and ran continuously for 10 consecutive days. The control group received standard TPN, while the treatment group was given L-alanyl-L-glutamine, 0.40 g/kg/d (Dipeptiven, Fresenius Kabi, Bad Homburg, Germany). Infectious morbidity, nitrogen balance, leukocytes, lymphocytes, subpopulations CD(4) and CD(8), Immunoglobulin A (IgA), total proteins, albumin, hospital and intensive care unit (ICU) stays, and mortality were evaluated. Statistical analysis included one-way ANOVA, the unpaired Students t-test, the Mann-Whitney U-test, chi(2) test, or Fishers exact test. RESULTS Patients in both groups were comparable prior to the operation. Nitrogen balance and the levels of albumin and IgA were significantly better than those in the control group. Also, a significant reduction in the infectious morbidity was found in the Gln-treated group. Lymphocyte counts as well as subpopulations CD(4) and CD(8), and proteins showed a propensity to improvement and a tendency to reduced rates of mortality were observed when comparing the groups. Hospital and ICU stays were similar. CONCLUSION L-alanyl-L-glutamine-supplemented TPN improved the infectious morbidity of patients with secondary peritonitis. Gln supplementation to parenteral nutrition may be an alternative for enhancing host defenses and improving infectious morbidity.

Exogenous nitric oxide protects kidney from ischemia/reperfusion.

Blockade of NO production is followed by an increase in leukocyte rolling and adhesion resulting in some deleterious effects of ischemia. Preischemic administration of NO protects vascular integrity after reperfusion. Exogenous NO causes a direct reduction in leukocyte adhesion. This work was performed to test the hypothesis that exogenous NO administered during the preischemic period to the kidney alone, without coming into contact with the leukocytes, could also reduce leukocyte-endothelium adhesion. Adult rats were subjected to in situ isolation of the left kidney. Solutions were infused through the renal artery and drained through an incision in the renal vein, thus avoiding the systemic circulation. Group IC rats served as an ischemic control, and received 0.9% saline. Group NP received Na nitroprusside. Group S was a nonischemic control. Groups IC and NP were subjected to 75 min of renal ischemia. After this period, vascular structures were repaired and reperfusion allowed. A right nephrectomy was performed. Serum urea and creatinine, myeloperoxidase activity, and histopathological studies were carried out at different intervals after reperfusion. Survival at 15 days was 46%, 80%, and 100% in groups IC, NP, and S, respectively. Differences between groups for serum urea and creatinine were significant only during the first seven days. Myeloperoxidase values were significantly higher in group IC. All rats from group IC and only 20% from group NP showed histological evidence of necrosis. Thus, exogenous NO is protective and acts selectively upon the kidney, modulating its interactions with polymorphonuclear cells after ischemia/reperfusion.

Tension-free hernioplasty versus conventional hernioplasty for inguinal hernia repair.

PurposeTo show the effectiveness of tension-free hernioplasty for inguinal hernia repair.MethodsWe studied 106 patients who underwent inguinal hernia repair, as conventional hernioplasty in 52 and as tension-free hernioplasty in 54. We analyzed the operation time, postoperative complications, pain, time to resume daily activities, and frequency of recurrence in the short and long term.ResultsThe average age of the patients was 46.2 years. The operation time was significantly shorter in the tension-free group than in the conventional group, at 33 ± 11.1 versus 49 ± 8.8 min, respectively (P < 0.05). The overall complication rate was 10%, being 1.5% in the tension-free group and 13% in the conventional group (P = 0.4). The visual-analogue pain scores after surgery were lower in the tension-free group than in the conventional group (P = 0.01). Patients in the tension-free group returned to their normal activities sooner than those in the conventional group (P < 0.05).ConclusionsTension-free hernioplasty resulted in less pain and allowed patients to return to their daily activities sooner than conventional hernioplasty.

Impacto del manejo con cierre asistido al vacío en abscesos profundos de cuello

BACKGROUND The presence of deep neck abscesses is potentially serious; they can lead to death in a short period of time. The vacuum-assisted closure (V.A.C.) therapy has been used in many areas of surgery for complex wound healing. This treatment modality has recently been considered in the field of head and neck surgery. OBJECTIVE Evaluate the efficacy of healing therapy using V.A.C. therapy in deep neck abscesses. MATERIAL AND METHODS Open-label trial. Patients with deep neck abscesses were included using V.A.C. therapy versus conventional therapy. Cultures were taken before and during surgery, and prior to primary wound closure. The percentages of healing, viable tissue, wound healing time, and hospital stay were evaluated. RESULTS A total of 18 patients were included. Affected neck spaces: submaxilar 29%, parapharyngeal 22%, submental 21% and masticatory 13%. The final postsurgical culture was negative in 78%. Viable tissue of the wound for the V.A.C. group was 42%, and for the control group was 36% (p=0.025). Healing time was 22±6 days and 38±15.5, respectively (p = 0.01). The mean number of hospital stay was 12 days for both groups. CONCLUSIONS Therapy with V.A.C. is useful in the treatment of deep neck abscesses; it decreased healing time as a result of more viable tissue allowing suture closure of the wound in a shorter period.

Body weight changes after adjuvant chemotherapy of patients with breast cancer: results of a Mexican cohort study

&NA; Weight gain is observed in breast cancer patients receiving chemotherapy and is a well‐known complication. Several factors that contributing to weight gain have been identified. However, there is a lack of information about factors associated with weight changes following adjuvant chemotherapy. A retrospective cohort of 200 pre‐ and post‐menopausal Mexican patients treated for breast cancer was made. Anthropometric variables were measured before/after treatment. Biomarkers, cellular differentiation and chemotherapy were similar between groups. Weight gain occurred in 85.6% of pre‐menopausal and 72.6% of post‐menopausal women (p = .03). At the end of chemotherapy, weight and body mass index (BMI) did not differ significantly between pre‐menopausal (69.3 ± 12.6 kg; 26.6 ± 4.8 kg/m2) and post‐menopausal women (69.5 ± 10.9 kg; 27.3 ± 4.4 kg/m2) (p = .91 and 0.34). Dexamethasone doses were higher in pre‐menopausal (85.7 ± 39.1 g) than post‐menopausal patients (79.2 ± 22.5 g; p = .13). Weight loss was observed in 9.2% of pre‐menopausal and 20.2% of post‐menopausal patients (p = .04). A multivariate analysis revealed that age (OR = 2.7; 95% CI = 1.26‐5.79; p = .01), menopausal status (OR = 2.29; 95% CI = 1.09‐4.80; p = .03), dexamethasone dosage (OR = 2.1; 95% CI = 1.04‐4.23; p = .03) and daily caloric intake (OR = 2.3; 95% CI = 1.12‐5.10; p = .02) were independent variables that inducted weight gain. Pre‐ and post‐menopausal women gained weight, but more pre‐menopausal patients showed gain. An effort should be made to administer lower steroid doses to reduce weight gain.

Tratamiento de la tetralogía de Fallot con parche transanular. Seguimiento a 6 años

BACKGROUND Primary repair of Fallot tetralogy has been performed successfully for the last 45 years. It has low surgical mortality (< 5%), with excellent long-term results. However, there are delayed adverse effects: progressive right ventricular dilation and dysfunction, arrhythmia, and sudden death. In our centre, Fallot tetralogy is the most common form of cyanotic congenital heart disease (including transannular patch) and accounts for 7.5% of all cardiovascular surgical procedures. The mid-term follow-up results are reported. MATERIAL AND METHODS Case series. The study included patients who had complete repair of Fallot tetralogy with transannular patch from January 2000 to December 2009. An analysis was performed on the clinical variables, morbidity and mortality. RESULTS There were 52 patients in the study, with mean age 4 ± 2 years. Perioperative mortality in 6 patients, with 5 associated with residual right ventricular obstruction and, 1 associated with further surgery. The survival rate was 88% (46) patients, with a follow-up 75 ± 26 months. Late morbidity occurred in 14, due to right ventricular dysfunction in 11, recurrent distal obstruction in 2, and residual ventricular septal defect in 1. Associated risk factors were severe pulmonary insufficiency (p=0.001); QRS > 160 ms, p=0.001); cardiothoracic > 0.60 index, (p=0.048), and tricuspid regurgitation (p=0.001). CONCLUSIONS There was reasonable long-term survival and excellent quality of life after total correction of Fallot tetralogy; however, progressive right ventricular dysfunction requires continuous monitoring, as well as the choice of optimal timing of pulmonary valve replacement.

Manejo y administración de hemoderivados por personal de enfermería en un hospital de segundo nivel

Introduccion: El manejo y administracion de hemoderivados es una actividad que realiza el personal de enfermeria, por lo cual es de gran importancia tener presente que un uso inadecuado de estos puede tener consecuencias graves en los pacientes, siendo fundamental el buen desempeno del personal de enfermeria para la practica segura. Objetivo : Evaluar el desempeno de enfermeria en el manejo y administracion de hemoderivados en un hospital de segundo nivel. Metodos: Estudio de diseno transversal. Se incluyeron enfermeras durante el 1o Enero al 30 junio del 2013. Se utilizo un instrumento validado que consta de 4 criterios con 27 items de respuestas dicotomicas para identificar el desempeno en el manejo y ministracion de hemoderivados. La poblacion fue dividida por categoria contractual. Analisis estadistico: prueba Chi-cuadrada y/ exacta de Fisher. Resultados: Se incluyeron un total de 110 observaciones a personal de enfermeria que administro hemoderivados. Se obtuvo un indice de eficiencia global parcial (IEG) parcial a excelente de 64.5%. No se encontro asociacion en el turno (p=0.16), servicio (p=0.31) y/o categoria contractual (p=0.25). Los porcentajes de excelente en el IEF fueron bajos (por turno: matutino y nocturno de 10 y 13 respectivamente, medicina interna y cirugia general 5 y 7%, y conforme a la categoria contractual, la enfermera general obtuvo en excelente solo el 7.5%). Conclusiones: Nuestros resultados nos alertan para implantar programas de capacitacion a enfermeras, para otorgar atencion de calidad, disminuyendo los riesgos que comprometan la vida del paciente.