Guidelines in the decision of surgical management in spine surgery

Introduction

The spine surgeon has knowledge and skills that allow him to make decisions when performing a surgical procedure, based on the evidence and ethical values and expectations of the patient. Any surgical procedure will be preceded by a diagnosis based on four fundamental pillars: traumatic, degenerative, vertebral destruction syndrome and deformities. Once the lesion is categorized, the surgeon will use his knowledge to identify instability or neurological compromise. When performing a surgical procedure, it should be kept in mind in the transoperative the four key objectives that will count, to achieve a satisfactory management: decompress, implement, merge and correct the sagittal balance.

Objective

To analyze the fundamental criteria in decision making, for conservative or surgical management in the spine.

Results

The assessment scales and the most frequent and best practices in relation to spine surgery will be analyzed, as well as the applications that will be applied and evaluated in each particular case, which will strengthen the diagnostic impression and the value forecast.

Conclusion

Implementing the culture of using patient outcome measurements as an assessment tool helps the spine surgeon to decide on a treatment plan that can be adapted to the patient's preferences and needs. We must base our clinical objective on the stability and the neurological commitment of the patient, there being four diagnostic possibilities; which will be corrected for four fundamental objectives.

State of endoscopic ultrasonography in Spain in 2017

AIM

To understand the current state of endoscopic ultrasonography (EUS) in Spain.

METHODS

Descriptive analysis from a national survey with 11 questions: 10 related to technique and 1 to the training and experience of the endoscopists.

RESULTS

Sixty endoscopists from 48 of the 97 (49.5%) hospitals that perform EUS in Spain responded to the survey. A total of 28,678 procedures (20,311 diagnostic, 7,446 with puncture and 921 therapeutic) were recorded over the course of one year. Approximately 64% of the hospitals perform between 300 and 999 tests per year. All have radial and sectorial echoendoscopes, with a median of 2 (2-8) scopes. For cytological diagnosis, the 22-gauge needle is the most commonly used (98%) and, for histological diagnosis, the Procore (72%). The study of the pancreas and bile duct is the most common indication for diagnostic EUS (60%), followed by the staging of digestive tract neoplasms (20%). Approximately 72% of the hospitals perform on-site cytopathology evaluations and sedation is administered in equal parts by both endoscopists and anaesthetists. In terms of experience, 45% of echoendoscopists perform fewer than 300 annual exams and the median training duration is 6months (0.5-36).

CONCLUSIONS

EUS is adequately implemented in Spain and good equipment is available. However, it is necessary to establish a standardised EUS training program since the one undertaken by many echoendoscopists could prove insufficient according to the standards established by Scientific Societies.

Guideline on cochlear implants

INTRODUCTION

In the last decade numerous hospitals have started to work with patients who are candidates for a cochlear implant (CI) and there have been numerous and relevant advances in the treatment of sensorineural hearing loss that extended the indications for cochlear implants.

OBJECTIVES

To provide a guideline on cochlear implants to specialists in otorhinolaryngology, other medical specialities, health authorities and society in general.

METHODS

The Scientific Committees of Otology, Otoneurology and Audiology from the Spanish Society of Otolaryngology and Head and Neck Surgery (SEORL-CCC), in a coordinated and agreed way, performed a review of the current state of CI based on the existing regulations and in the scientific publications referenced in the bibliography of the document drafted.

RESULTS

The clinical guideline on cochlear implants provides information on: a) Definition and description of Cochlear Implant; b) Indications for cochlear implants; c) Organizational requirements for a cochlear implant programme.

CONCLUSIONS

A clinical guideline on cochlear implants has been developed by a Committee of Experts of the SEORL-CCC, to help and guide all the health professionals involved in this field of CI in decision-making to treathearing impairment.

[Use of gastrostomies in patients over 75 years old]

OBJECTIVE

To describe the indications of insertion of a percutaneous gastrostomy (PG) in older patients in a university hospital, as well as patient characteristics, short and long term complications, and mortality.

METHODS

Retrospective descriptive study of all patients over 75 years who had a PG inserted during a three year period by the Interventional Radiology Department. The indication of the procedure was reviewed, and the incidence of complications and mortality during a 36 months follow-up period were assessed through electronic medical records.

RESULTS

The study included 74 patients, with a mean age of 84±6.1 years, and 57% were female. Furthermore, 40% lived in nursing homes and 80% had cognitive impairment. The main indications for PG insertion were dysphagia in severe dementia (56.8%), tumours of the oropharyngeal cavity (12.2%), Parkinson's disease (10.8%), and stroke (9.6%). PG was permanent in 90.5% of cases. The most common complication was aspiration pneumonia (32.4%). Overall mortality was 59.5% after a median follow-up of 18 months.

CONCLUSIONS

Dysphagia in severe dementia was the main indication for PG in patients over 75 years. This intervention did not prevent aspiration pneumonia, which was the most common complication. Mortality in patients who have a PG was high.

Radiology of external ear: indications, normal anatomy, and pathological processes

The external ear is accessible to direct examination; the clinical history and otoscopy are sufficient to diagnose and treat most diseases of the external ear. We aim to describe the normal anatomy of the external ear, specify the indications for imaging tests, and review the clinical and radiological manifestations of the most common diseases affecting the external ear. We classify these diseases according to their origin into congenital, inflammatory, infectious, or traumatic disease or benign bone tumors or malignant tumors. Imaging does not play an important role in diseases of the external ear, but in certain clinical scenarios it can be crucial for reaching a concrete diagnosis and establishing the best treatment. Computed tomography is the first-choice technique for most diseases. Magnetic resonance imaging complements computed tomography and makes it possible to differentiate among different tissue types and to evaluate the extension of disease accurately.

Miniperc and retrograde intrarenal surgery: when and how?

CONTEXT

Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) are consolidated procedures for the treatment of kidney stones; however, their primary weak points are the lower efficacy of ESWL, especially for lower calyx stones, and the morbidity of PCNL resulting from the creation and dilation of the percutaneous trajectory. The increasing miniaturization of percutaneous surgery instrumentation and the development of retrograde intrarenal surgery (RIRS) are recent innovations.

ACQUISITION OF EVIDENCE

A structured nonsystematic review was conducted through a literature search of articles published between 1997 and 2013, using the terms kidney stones, miniperc, mini-PCNL, RIRS and flexible ureteroscopy in the PubMed, Google Scholar and Scopus databases.

SUMMARY OF THE EVIDENCE

RIRS requires greater surgical time, several procedures for voluminous stones and higher hospital costs, due in part to the relative fragility of the instruments. On the other hand, miniperc requires a longer hospital stay, an increased need for postoperative analgesia and a greater reduction in hemoglobin levels, although these do not translate into an increased rate of transfusions.

CONCLUSIONS

The current treatment of kidney stones uses minimally invasive procedures such as miniperc and RIRS. The 2 procedures are equivalent in terms of efficacy (stone clearance) and are associated with minimal complications. Comparative prospective studies are necessary to determine the position of each of these techniques in the treatment of kidney stones. In our experience, the 2 techniques are complementary and should be part of the current urological therapeutic arsenal.

[Patients treated with micafungin during their stay in intensive care unit]

OBJECTIVES

To determine the reasons of prescription, the characteristics of patients and factors that affected the outcome of critically ill patients treated with micafungin (MCF) during their stay in Spanish ICUs.

MATERIAL AND METHODS

Observational, retrospective and multicenter study. Patients admitted to the ICU between March 2011 and October 2012 (20-month period) treated with MCF for any reason were included in the study. Severity of patients at the beginning of treatment was measured with the APACHE II, SOFA, Child-Pugh and MELD scores. Reasons for the use of MCF were classified as prophylaxis, preemptive treatment, empirical treatment and directed treatment. Continuous variables are expressed as mean and standard deviation or median, and categorical variables as percentages. A multivariate analysis was performed to identify variables related to intra-ICU mortality.

RESULTS

The study population included 139 patients admitted to 19 Spanish ICUs, with a mean age of 57.3 (17.1) years, 89 (64%) men, with surgical (53.2%) and/or medical (44.6%) conditions, APACHE II score of 20.6 (7.7) and SOFA score of 8.4 (4.3), with 84.2% of patients requiring mechanical ventilation, 59% parenteral nutrition, 37.4% extrarenal depuration procedures and 37.4% treatment with steroids. MCF was indicated as empirical treatment of a proven infection in 51 (36.7%) cases, pre-emptive treatment in 50 (36%) especially as a result of the application of the Candida score (32 cases), directed treatment of fungal infection in 23 (16.5%) and as prophylactic treatment in 15 (10.8%) cases. In 108 (77%) cases, a daily dose of 100mg was administered, with a loading dose in only 9 cases (6.5%). The mean duration of treatment was 13.1 (13) days. A total of 59 (42.4%) patients died during their stay in the ICU and 16 after ICU discharge (hospital mortality 53.9%). Independent risk factors for intra-ICU mortality were the Child-Pugh score (OR 1.45, 95% CI 1.162-1.813; P=.001) and the MELD score (OR 1.05, 95% CI 1.011-1.099; P=.014).

CONCLUSIONS

MCF is usually administered at a dose of 100mg/day, without loading dose and in 72.7% of cases as pre-emptive or empirical treatment. Factors that better predicted mortality were indicators of liver insufficiency at the time of starting treatment.