Factores asociados a complicaciones post quirúrgicas en pacientes adultos con obstrucción intestinal mecánica en Bogotá, Colombia, período 2008 - 2014

Introducción: La obstrucción intestinal es una patología de alta prevalencia e impacto en los servicios de cirugía general a nivel mundial. El manejo de esta entidad puede ser médico o quirúrgico. Cuando se requiere intervención quirúrgica, se busca evitar el desarrollo de isquemia intestinal y resecciones intestinales; durante el postoperatorio, pueden existir complicaciones. El objetivo de este estudio es identificar los factores asociados al desarrollo de complicaciones post operatorias en un grupo de pacientes con obstrucción intestinal mecánica llevados a manejo quirúrgico. Metodología: Estudio analítico tipo casos y controles en un grupo de pacientes con diagnóstico de obstrucción intestinal mecánica llevados a manejo quirúrgico de su patología. Los casos corresponden a los pacientes con complicaciones postoperatorias y los controles aquellos que no presentaron complicaciones. Se identificaron factores asociados a complicación post operatoria mediante modelos estadísticos bivariados y multivariados de regresión logística para factores como edad, sexo, antecedente quirúrgico, presentación clínica, paraclínica y diagnóstico postoperatorio de malignidad, entre otras. Resultados: Se identificaron un total de 138 pacientes (54 casos y 129 controles). Los rangos de edad entre 55-66 años y mayor de 66 años fueron asociados con complicaciones postoperatorias (OR 3,87 IC95% 1,58-9,50 y OR 3,62 IC95% 1,45-9,08 respectivamente). El déficit de base inferior a 5 mEq/litro se relaciona con complicaciones postoperatorias (OR 2,64 IC95% 1.33-5,25) Otras pruebas de laboratorio, características radiológicas, hallazgos de malignidad en el postoperatorio y la evolución de los pacientes no fueron asociados con complicaciones. Conclusiones: Las disminución de las complicaciones durante el manejo quirúrgico de obstrucción intestinal mecánica continúa siendo un reto para la cirugía general. Factores no modificables como edad avanzada y modificables como el equilibrio ácido base deben ser tenidos en cuenta dada su correlación en el desarrollo de complicaciones postoperatorias.

Factores pronósticos al desarrollo de mutaciones relacionadas con resistencia antiretroviral secundaria en pacientes colombianos viviendo con VIH

Las mutaciones secundarias de resistencia al manejo antiretroviral es una realidad, y determina el éxito o fracaso del manejo del VIH. En Colombia, los casos de resistencia asociadas a mutaciones han aumentado. Para determinar esta condición en nuestra población, se realiza un estudio de tipo casos y controles, en pacientes VIH manejados en una IPS especializada en manejo y seguimiento de la enfermedad. Toman 71 pacientes con fracaso terapéutico por resistencia antiretroviral, y se documentaron las mutaciones confirmadas con Genotipo, pacientes que han manejado los diferentes esquemas antirretrovirales, y se comparan con pacientes controles que no desarrollaron resistencia a pesar de haber recibido un manejo antiretroviral similar e iniciado al mismo tiempo. Se busca evidenciar factores predictivos para controlar presencia de estas mutaciones a futuro. El estudio encontró que en ambos grupos, no existen diferencias significativas en cuanto a género, preferencia sexual, uso de psicoactivos, nivel social y las etapas de la enfermedad clasificadas según CDC. Observando que los pacientes con resistencia al tratamiento, eran más jóvenes que los controles (OR: 0,891; p> 0,001), y con una menor carga viral al momento del diagnóstico. La adecuada adherencia al tratamiento, se mostró como un factor protector al desarrollo de resistencia (OR: 0,030, p< 0,000). Se evidencia que existe mayor riesgo de generación de mutaciones en pacientes jóvenes. Respecto a los tipos de mutaciones evidenciadas por genotipos, se describen múltiples mutaciones, observando mutaciones para inhibidores de la transcriptasa reversa nucleosidos (33 mutaciones) y no nucleosidos (32 mutaciones), principalmente M184V en INTR (81%) y K103N en INNTR (40%), mutaciones para inhibidores de proteasa (57 mutaciones), principalmente L24I (40%); esta prevalencia de mutaciones son similares a estudios realizados y descritos en la literatura médica (1)

Lumbar estrecho: experiencia de 10 años en la fundación santa fé de Bogotá

El canal lumbar estrecho de tipo degenerativo, es una enfermedad que se presenta en pacientes entre la quinta y la sexta década de vida; es la causa más común de cirugía lumbar después de los 65 años. Este trabajo busca determinar cuáles son los factores asociados a la presentación de eventos adversos o re-intervención en cirugía de canal lumbar estrecho en la Fundación Santa Fe de Bogotá en los años comprendidos entre 2003 y 2013. Métodos: se realizó un estudio de prevalencia de tipo analítico, en donde se analizaron 249 pacientes sometidos a intervención quirúrgica por cirugía de canal lumbar estrecho.

Prevalencia de alteraciones audiométricas y su relación con exposición a ruido ocupacional y extra ocupacional, en una cohorte de trabajadores de Santander, Colombia, Años 2014-2015

La hipoacusia neurosensorial inducida por ruido (HNIR) definida como la pérdida de la capacidad auditiva secundaria a la exposición ocupacional continua o intermitente a ruido en el lugar de trabajo, es la cuarta enfermedad ocupacional en prevalencia en Colombia. Objetivo: Determinar la prevalencia de alteraciones audiométricas y su relación con exposición a ruido ocupacional y extra ocupacional, en un grupo de trabajadores que asistieron a una IPS de la ciudad de Bucaramanga en el periodo comprendido entre agosto de 2014 y agosto de 2015. Diseño: Se realizó un estudio de corte transversal con 2725 registros de las historias clínicas de fonoaudiología realizadas a los trabajadores con audiometría tonal como parte de los exámenes ocupacionales, entre el 1 de agosto de 2014 al 31 de agosto de 2015, en una Institución Prestadora de Salud (IPS) ocupacional, en la ciudad de Bucaramanga, Santander. Resultados: El 17.2% de los trabajadores presentaron alteraciones audiométricas, de estos el 33,1%, cumplió con los criterios definidos en el estudio para ser calificados como casos probables de hipoacusia neurosensorial inducida por ruido, de estos el 87,8% fueron clasificados como leves, 10,8% como moderados y el 1,2% como moderado severo, no se registraron casos de HNIR severa o profunda. El 62,7% se clasificaron como no HNIR y el 4% correspondió a hipoacusias con afectación de frecuencias conversacionales. Conclusiones: Al aplicar un modelo de regresión logística para controlar las variables de confusión, no se encontró asociación con ninguna de las variables anteriormente descritas. A pesar de esto, existe suficiente evidencia de la relación entre algunas ocupaciones y la HNIR.

Diferencia entre tratamientos en pacientes con angioma cavernoso del tallo cerebral en el instituto nacional de neurología y neurocirugía Manuel Velasco Suárez

Introducción: la historia natural de la hemorragia en el tallo cerebral secundaria a un angioma cavernoso es benigna. Sin embargo, el riesgo de recurrencia y de mayor discapacidad parece incrementarse con el tiempo a pesar del tratamiento recibido; hecho que plantea dudas acerca de si el manejo quirúrgico de estas lesiones ofrece mayor beneficio sobre el manejo médico después del primer evento hemorrágico. El objetivo del estudio fue evaluar el riesgo de resangrado y el grado de discapacidad final en los angiomas cavernosos del tallo cerebral según el tratamiento recibido. Métodos: estudio observacional, analítico tipo cohorte. Se incluyeron pacientes con un primer sangrado en el tallo cerebral secundario a angioma cavernoso que fueron tratados en el Instituto Nacional de Neurología y Neurocirugía (INNN) de Ciudad de México. Resultados: noventa y nueve (99) pacientes fueron incluidos en un periodo de 25 años (1990-2015). Treinta y siete (37) recibieron tratamiento quirúrgico y sesenta y dos (62) recibieron tratamiento médico tras su primer sangrado. El promedio de edad fue de 38 años (DS: 14,17) para el grupo que recibió tratamiento médico y 36 años (DS: 12,82) para los que recibieron tratamiento quirúrgico. La incidencia acumulada de resangrado para el tratamiento médico fue de 5,1 por 100 años/persona y para el tratamiento quirúrgico de 3,9 por 100 años/persona (p = 0,016). Se realizó un análisis estratificado donde no se encontró ninguna asociación entre resangrado y edad o sexo del paciente. Se evaluó la discapacidad final con la escala de Rankin (mRs) sin encontrar diferencias significativas entre tratamientos (p=0.77). Por último, se realizó un modelo explicativo de regresión logística binaria donde se encontró que la edad superior a 55 años (OR: 2.19 IC 95%: 1.67-47,6), el tamaño mayor a 15 mm (OR: 2,5 IC 95%: 3,8-45,9) y la recurrencia del sangrado (OR: 1,7 IC 95%: 1,63-18,7) son factores asociados a un desenlace desfavorable en cuanto a discapacidad final. Discusión y Conclusiones: en los pacientes con angioma cavernoso del tallo cerebral que han presentado un primer evento de sangrado no se encontró una diferencia estadísticamente significativa entre el tratamiento médico o quirúrgico al evaluar la discapacidad funcional con la escala de Rankin modificada, a pesar de evidenciar una diferencia significativa en la incidencia acumulada de resangrado por grupos de tratamiento. El tamaño de la lesión, la recurrencia del sangrado y la edad superior a 55 años son factores asociados a un desenlace desfavorable en este grupo de pacientes.

Post-polio syndrome: epidemiologic and prognostic aspects in Brazil

Objectives - To describe the clinical and epidemiological aspects of post-polio syndrome (PPS) and identify predictors of its severity. Materials and methods - 132 patients with PPS were selected at the Neuromuscular Disease Outpatient Clinic of the Federal University of Sao Paulo. Descriptive analysis was carried out and predictors of PPS severe forms were investigated using an unconditional logistic regression. Results - The average age at onset was 39.4 years. The most common symptoms were fatigue (87.1%), muscle pain (82.4%) and joint pain (72.0%); 50.4% of the cases were severe. The following were associated with PPS severity: a < 4-year period of neurological recovery (OR 2.8), permanent damage in two limbs (OR 3.6) and residence at the time of acute polio in a city with more advanced medical assistance (OR 2.5). Conclusions - Health professionals should carefully evaluate polio survivors for PPS and be aware of the implications of muscle overuse in the neurological recovery period.

Prediction of functional oucomes in stroke inpatients receiving rehabilitation

Background and Purpose: Early identification of predictive factors relevant to functional outcomes for stroke patients is important to the establishment of an effective continuing care program. The objective of this studywas to identify the predictive factors related to functional outcome at discharge after stroke rehabilitation therapy. Methods: 105 first-time stroke patients admitted to the inpatient rehabilitation department of a university-based medical center were recruited for this prospective study. The functional outcomes of the patients were assessed at admission and at discharge using the Functional Independence Measure (FIM). Severity of stroke was determined using the Canadian Neurological Scale (CNS). Age, gender, side of hemiplegia (SIDE), type of stroke (TYPE), onset to admission interval (OAI), and length of rehabilitation stay (LORS) were also included as predictor variables. Results: The mean (′SD) FIM score at discharge (76.6 ′ 26.4) correlated strongly (r = 0.78, p < 0.001) with the admission FIM score (56.3 ′ 24.1), moderately (r = 0.46, p < 0.001) with the admission CNS score (6.1 ′ 2.2), negatively (r = -0.38, p < 0.001) with age (63.2 ′ 12.3 years), negatively (r = -0.26, p = 0.009) with OAI (24.2 ′ 16.0 days), and negatively (r = -0.29, p = 0.002) with LORS (34.7 ′ 16.8 ays). Stepwise regression analyses indicated that admission FIM score, age, and admission CNS score were the stronge predictors of functional outcome and accounted for 66% of the total variation in discharge FIM total score. The admission FIM score was the best predictor and accounted for 61% of the variation. Conclusions: The findings of this study imply that the admission FIM scores for inpatients receiving stroke rehabilitation can be used to predict functional outcomes at discharge from hospital.

Validation and development of a clinical prediction rule in clinically suspected community-acquired pneumonia

To develop a mathematical model to predict the probability of having community-acquired pneumonia and to evaluate an already developed prediction rule that has not been validated in a clinical scenario.

Development and evaluation of a screening tool to identify people with diabetes at increased risk of medication problems relating to hypoglycaemia and medication non-adherence

Abstract Aims: To develop and evaluate a screening tool to identify people with diabetes at increased risk of medication problems relating to hypoglycaemia and medication non-adherence. Methods: A retrospective audit of attendances at a diabetes outpatient clinic at a public, teaching hospital over a 16-month period was conducted. Logistic regression was undertaken to examine risk factors associated with medication problems relating to hypoglycaemia and medication non-adherence and the most predictive set of factors comprise the Diabetes Medication Risk Screening Tool. Evaluating the tool involved assessing sensitivity and specificity, positive and negative predictive values, cut-off scores, inter-rater reliability, and content validity. Results: The Diabetes Medication Risk Screening Tool comprises seven predictive factors: age, living alone, English language, mental and behavioural problems, comorbidity index score, number of medications prescribed, and number of high-risk medications prescribed. The tool has 76.5% sensitivity, 59.5% specificity, and has a 65.1% positive predictive value, and a 71.8% negative predictive value. A score of 27 or more out of 62 was associated with high-risk of a medication problem. The inter-rater reliability of the tool was high (κ = 0.79, 95% CI 0.75 - 0.84) and the content validity index was 99.4%. Conclusion: The Diabetes Medication Risk Screening Tool has good psychometric properties and can proactively identify people with diabetes at greatest risk of medication problems relating to hypoglycaemia and medication non-adherence.

Fatores preditivos de dessaturação de oxigênio em pacientes submetidos à colangiopancreatografia endoscópica retrógrada sob sedação consciente

A hipoxemia pode ocorrer durante a Colangiopancreatografia Endoscópica Retrógrada (CPER) porque alguma analgesia e sedação precisam ser realizadas. O posicionamento do paciente em pronação dificulta a ventilação adequada. Um estudo transversal controlado foi utilizado para investigar possíveis fatores preditivos de dessaturação de oxigênio em pacientes submetidos à CPER sedados com midazolam associado à meperidina. No total, 186 pacientes foram monitorados continuamente com oxímetro de pulso. A regressão de Cox adaptada por Braslow foi utilizada para identificar fatores preditivos de dessaturação relacionados ao paciente e ao exame. As variáveis estudadas foram: idade, gênero, hematócrito e hemoglobina, uso de escopolamina, exame diagnóstico ou terapêutico, midazolam ( média 0,07mg/Kg) e meperidina (média 0,7mg/Kg), escores da Sociedade Americana de Anestesiologistas (ASA) e tempo de exame. Dos 186 pacientes, 113 não dessaturaram (60,8%), 22(11,8%) apresentaram dessaturação moderada (SpO2≤92%) e 51 (27,4%) apresentaram dessaturação grave (SpO2≤90%). As variáveis preditivas de dessaturação de oxigênio detectadas foram idade ≥60 anos (p=0,004; RR:1,5;IC:1,12-1,93) e escore ASA III (p=0,013) As variáveis idade (60 anos ou mais) e escore ASA III foram identificadas como de risco para dessaturação em pacientes que realizam CPER sob sedação consciente. Estes pacientes necessitam de maior monitoração para saturação e hipoventilação pela enfermagem, alertando para a depressão respiratória. A utilização do oxímetro de pulso e solicitação de respiração profunda durante o exame auxilia a diminuir estes riscos.

Hiperidrose compensatória após simpatectomia toracoscópica: características, incidência e influência na satisfação do paciente

Hyperhidrosis is an idiopathic condition characterized by excessive sweating. Symptoms generally begin in childhood or early adolescence, and rarely improve with age. The excessive localized sweating generally occurs either spontaneously, or in association with stressful or emotionally charged situations. This prospective study aimed to investigate predictive factors for compensatory hyperhidrosis after thoracoscopic sympathicotomy. From 2000 to 2002, 80 patients (53 female and 27 male) underwent hyperhidrosis surgery. The patients, ranging from 12 to 56 years old, were studied and followed-up for 42.51 ±5.98 months. A satisfaction grading using a visual analogue scale -VAS (0 = not at all satisfied, and 10 = fully satisfied) was used. The surgical procedure was performed bilaterally on the second ganglion (T2) for facial hyperhidrosis, on the third and fourth ganglia (T3 and T4) for axillary hyperhidrosis, and on the third ganglion (T3) for palmar hyperhidrosis. The results showed that, 68 patients (85%) presented with compensatory sweating (CS), which was classified as mild (33.8%), moderate (33.8%) and severe (32.4%). Considering the final surgical results, 70 patients (87.5%) were satisfied with the outcome of the operation, while 10 patients (12.5%) were dissatisfied. Degrees of satisfaction varied according to sex, age, BMI and extent of denervation. Moreover, the compensatory hyperhidrosis was more severe in abdomen and back than in legs. In conclusion, although CS is a frequent adverse effect of sympathicotomy, the degree of patient satisfaction was high. Some factors were related to the occurrence and severity of CS and the most adequate patients to be submitted to this operation are young adult women whose BMI is less than 24.9

O tratamento ortodôntico em uma perspectiva a longo prazo: avaliação da estabilidade oclusal e do grau de satisfação dos pacientes

This study aimed to evaluate factors associated to orthodontic treatment stability and patient satisfaction in the long-term. A total of 209 patients (88 class I and 121 class II) treated with straight wire fixed appliance were selected at least 5 years post treatment. Six hundred twenty seven dental casts were examined with the PAR Index at pretreatment (T1), end of treatment (T2), and at long-term follow up (T3, mean 8.5 years post treatment). At T3, a Dental Impact on Daily Living questionnaire was used to assess patient satisfaction with the dentition in the long-term. Friedman test and multiple regression analysis were used to evaluate changes among the time points and factors associated with stability and patient satisfaction. Predictive factors used to exam the occlusion were: PAR Index at T1 and T2, age at T1, the amount of time without retainer, length of Hawley retainer wear, length of follow-up, sex, extraction and third molar status. To assess patient satisfaction were considered: changes produced by the orthodontic treatment (PAR T2-T1), post treatment stability (PAR T3), age at the start of treatment (T1), length of treatment (T2-T1), gender, and extraction. Orthodontic treatment produced a significant improvement of 94.2% in the PAR Index (T2-T1), but this change was not associated with the level of satisfaction when the patient was questioned at T3. No significant change was observed between T2 and T3. However, when the sample was divided according to the level of finalization (PAR T2), it was observed that well-finished patients experienced some deterioration (P<.001), whereas the less well-finished ones showed some improvement (P<.05). Even with the deterioration, the well-finished patients still had a better PAR Index at T3 compared to the less well-finished ones (PAR T2- T3). Regression analysis showed that PAR Index at T1 and T2, age at T1, and length of retainer wear had a slight association with occlusal stability (R2 = 0.27). Patient satisfaction was significantly associated only with PAR Index at T3 (r2=0.125, P<.0001). We can conclude that, even thought orthodontic treatment is quite stable, not so well-finished treatments tend to show some improvement and well-finished ones deteriorate some in the long-term. Despite of that, well-finished patients still have better occlusal characteristics. Patient satisfaction is not related to the result of orthodontic treatment; nevertheless, there is a slight association with dentition in the long-term

Avaliação de lesões brancas de cáries: um estudo de prognóstico

Objective: The aim of the present study is to assess the current situation of white enamel lesions on vestibular surfaces of permanent upper incisors, diagnosed 6 years ago, without clinical intervention. Methods: A prospective study reassessed 53 students of both sexes, aged between 13 and 18 years old, all attending the public school system in Natal, Brazil. Data collection was performed by duly calibrated examiners, and a clinical chart consisting of demographic data on dental caries, oral hygiene, and gingival condition was prepared. A tactile-visual examination was conducted using a clinical mirror and periodontal probe. Data compilation and analysis were carried out using a SPSS software. In this analysis the chi-squared test was used for qualitative independent variables. To identify the net effect of treatment, multiple logistic analysis with forward stepwise model selection was performed. Results: The final sample was composed of 106 lesions in the 53 individuals, with mean age of 15.02 years, visible plaque index (VPI) of 23.34%, and gingival blood indices (GBI) of 25.92%. A statistically significant relationship (p = 0.003) was found between initial DMFS and prognosis of white enamel lesion. Conclusions: We observed that past caries experience and dental plaque were the main predictive factors for negative lesion outcomes, demonstrating the need for oral hygiene control through continuing preventive measures

Análise retrospectiva de fatores de risco e preditores de complicações intraoperatórias dos bloqueios do neuroeixo realizados na Faculdade de Medicina de Botucatu-UNESP

JUSTIFICATIVA E OBJETIVOS: As alterações cardiovasculares associadas aos bloqueios do neuroeixo apresentam interesse pela frequência com que ocorrem e porque algumas delas podem ser consideradas efeitos fisiológicos desencadeados pelo bloqueio do sistema nervoso simpático. O objetivo desta pesquisa foi avaliar as complicações cardiovasculares intraoperatórias e os fatores preditores associados aos bloqueios do neuroeixo em pacientes com idades > 18 anos submetidos a procedimentos não obstétricos, em um período de 18 anos, em hospital universitário de atendimento terciário-HCFMB-UNESP. MÉTODO: Foi realizada análise retrospectiva das seguintes complicações: hipertensão arterial, hipotensão arterial, bradicardia sinusal e taquicardia sinusal. Tais complicações foram correlacionadas com técnica anestésica, estado físico (ASA), idade, sexo e comorbidades pré-operatórias. Para a análise estatística, foram utilizadas o teste de Tukey para comparações entre proporções e regressão logística. RESULTADOS: Foram avaliados 32.554 pacientes submetidos a bloqueios do neuroeixo e houve 4.109 citações de hipotensão arterial, 1.107 de bradicardia sinusal, 601 de taquicardia sinusal e 466 de hipertensão arterial no período intraoperatório. Hipotensão foi mais frequente nos pacientes submetidos à anestesia subaracnoidea contínua (29,4%, OR = 2,39), com idades > 61 anos e do sexo feminino (OR = 1,27). CONCLUSÕES: Hipotensão e bradicardia intraoperatórias foram complicações mais frequentes, sendo que a hipotensão arterial esteve relacionada à técnica anestésica (ASC), faixa etária elevada e sexo feminino. Taquicardia e hipertensão arterial podem não ter sido diretamente relacionadas aos bloqueios do neuroeixo.

Relationship of upper-limb and thoracic muscle strength to 6-min walk distance in COPD patients

Study objectives: This study was developed to investigate the influence of thoracic and upperlimb muscle function on 6-min walk distance (6MWD) in patients with COPD.Design: A prospective, cross-sectional study.Setting: the pulmonary rehabilitation center of a university hospital.Patients: Thirty-eight patients with mild to very severe COPD were evaluated.Measurements and results: Pulmonary function and baseline dyspnea index (BDI) were assessed, handgrip strength, maximal inspiratory pressure (Pimax), and 6MWD were measured, and the one-repetition maximum (1RM) was determined for each of four exercises (bench press, lat pull down, leg extension, and leg press) performed on gymnasium equipment. Quality of life was assessed using the St. George Respiratory Questionnaire (SGRQ). We found statistically significant positive correlations between 6MWD and body weight (r = 0.32; p < 0.05), BDI (r = 0.50; p < 0.01), FEV, (r = 0.33; p < 0.05), PImax (r = 0.53; p < 0.01), and all values of 1RM. A statistically significant negative correlation was observed between 6MWD and dyspnea at the end of the 6-min walk test (r = -0.29; p < 0.05), as well as between 6MWD and the SGRQ activity domain (r = -0.45; p < 0.01) and impact domain (r = -0.34; p < 0.05) and total score (r = -0.40; p < 0.01). Multiple regression analysis selected body weight, BDI, Pimax, and lat pull down IRM as predictive factors for 6MWD (R-2 = 0.589).Conclusions: the results of this study showed the importance of the skeletal musculature of the thorax and upper limbs in submaximal exercise tolerance and could open new perspectives for training programs designed to improve functional activity in COPD patients.