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PURPOSE OF REVIEW: The purpose of this review is to update the information about the different types of reconstruction after partial nephrectomy, with special emphasis on the new methods of suture-free hemostasis currently available. RECENT FINDINGS: The aim of renal reconstruction is to avoid bleeding and leakage of the collecting system, but now the renorrhaphy technique used is considered one of the modifiable determinants of renal function after surgery. In an attempt to avoid the loss of renal function implicit in classic reconstruction, new techniques have been described to control hemostasis and urinary leakage, which employ fewer suture layers, different suture materials and designs, and a wide range of commercially available hemostatic materials. Multiple suture characteristics have been studied as a potential factor influencing the renal function observed after partial nephrectomy. Single-plane suture techniques, the use of bearded sutures, and running sutures seem to be associated with less deterioration in postoperative renal function, and deep medullary sutures should be avoided to avoid affecting the arcuate arteries. Sutureless hemostasis systems could prevent the deterioration of renal function and complications derived from suturing, also reducing ischemia time and surgical time without increasing the risk of complications.

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INTRODUCTION: Muscle-infiltrating bladder tumor (MIBT) has a recurrence-free survival (RFS) of 50% at 5 years. Although neoadjuvant chemotherapy (NCT) has increased it by 8%, which group of patients benefits the most from this treatment remains unclear. OBJECTIVE: Evaluate the prognostic value of immune-nutritional status in patients with MIBT who are candidates for cystectomy, and to develop a score that allows identifying patients with a worse prognosis (pT3-4 and/or pN0-1). MATERIAL AND METHODS: A retrospective analysis was carried out on 284 patients with MIBT treated with radical cystectomy. Preoperative laboratory tests were analyzed and immune-nutritional indices were calculated. The Kaplan-Meier method was used to calculate the PFS. Cox regression was used for multivariate analysis. RESULTS: Univariate analysis showed a statistically significant relationship with leukocyte/lymphocyte index (p = 0.0001), neutrophil/lymphocyte index (p = 0.02), prognostic nutritional index (p = 0.002), and platelet/lymphocyte ratio (p = 0.002). In multivariate analysis, the leukocyte/lymphocyte ratio (p = 0.002) and PNI (p = 0.04) behaved as independent prognostic factors of decreased RFS. Based on these, a prognostic score was developed to classify patients into 3 prognostic groups. Eighty percent of patients with pT3-4 and/or pN0-1 tumors were in the intermediate-poor prognostic groups. CONCLUSION: The implementation of a precystectomy immune-nutritional score in clinical practice would help in the selection of a group of patients with a more unfavorable pathologic stage and worse PFS. We believe that these patients could benefit more from a NACT.

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Introducción El tumor vesical músculo-infiltrante (TVMI) tiene una supervivencia libre de recidiva (SLR) del 50% a los cinco años, la quimioterapia neoadyuvante (QTN) ha aumentado la misma un 8%, pero no está claro qué pacientes se pueden beneficiar en mayor grado de la misma. Objetivo Evaluar el valor pronóstico del estado inmunológico-nutricional en los pacientes con TVMI candidatos a cistectomía, y desarrollar un score que permita identificar precistectomía a los pacientes con peor pronóstico (pT3-4 y/o pN0-1). Material y método Se realizó un análisis retrospectivo de 284 pacientes con TVMI tratados con cistectomía radical. Se revisó la analítica preoperatoria y se calcularon índices inmunonutricionales. El método de Kaplan-Meier se utilizó para el cálculo de la SLR. Para el análisis multivariante se utilizó la regresión de Cox. Resultados Mediante análisis univariante se observó una relación estadísticamente significativa con el índice leucocito/linfocito (p = 0,0001), el índice neutrófilo/linfocito (p = 0,02) el índice pronóstico nutricional (p = 0,002), y el ratio plaqueta/linfocito (p = 0,002). En análisis multivariante, el ratio leucocito/linfocito (p = 0,002) y el IPN (p = 0,04) se comportaron como factores pronósticos independientes de disminución de SLR, y se elaboró con ello un score pronóstico que divide a los pacientes en tres grupos pronósticos. El 80% de los pacientes con tumores pT3-4 y/o pN0-1 se encontraban en los grupos de pronóstico medio-malo. Conclusión La incorporación en la práctica clínica de un score inmunonutricional precistectomía ayudaría a seleccionar a un grupo de pacientes con estadio patológico más desfavorable y peor SLR. Creemos que estos pacientes podrían beneficiarse en mayor medida de una QTN (AU)

Introduction Muscle-infiltrating bladder tumor (MIBT) has a recurrence-free survival (RFS) of 50% at 5 years. Although neoadjuvant chemotherapy (NCT) has increased it by 8%, which group of patients benefits the most from this treatment remains unclear. Objective Evaluate the prognostic value of immune-nutritional status in patients with MIBT who are candidates for cystectomy, and to develop a score that allows identifying patients with a worse prognosis (pT3-4 and/or pN0-1). Material and methods A retrospective analysis was carried out on 284 patients with MIBT treated with radical cystectomy. Preoperative laboratory tests were analyzed and immune-nutritional indices were calculated. The Kaplan–Meier method was used to calculate the PFS. Cox regression was used for multivariate analysis. Results Univariate analysis showed a statistically significant relationship with leukocyte/lymphocyte index (p = 0.0001), neutrophil/lymphocyte index (p = 0.02), prognostic nutritional index (p = 0.002), and platelet/lymphocyte ratio (p = 0.002). In multivariate analysis, the leukocyte/lymphocyte ratio (p = 0.002) and PNI (p = 0.04) behaved as independent prognostic factors of decreased RFS. Based on these, a prognostic score was developed to classify patients into 3 prognostic groups. Eighty percent of patients with pT3-4 and/or pN0-1 tumors were in the intermediate–poor prognostic groups. Conclusion The implementation of a precystectomy immune-nutritional score in clinical practice would help in the selection of a group of patients with a more unfavorable pathologic stage and worse PFS. We believe that these patients could benefit more from a NACT (AU)

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Given the importance of the management of sedation, analgesia and delirium in Intensive Care Units, and in order to update the previously published guidelines, a new clinical practice guide is presented, addressing the most relevant management and intervention aspects based on the recent literature. A group of 24 intensivists from 9 countries of the Pan-American and Iberian Federation of Societies of Critical Medicine and Intensive Therapy met to develop the guidelines. Assessment of evidence quality and recommendations was made according to the Grading of Recommendations Assessment, Development and Evaluation Working Group. A systematic search of the literature was carried out using MEDLINE, Cochrane Library databases such as the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects, the National Health Service Economic Evaluation Database and the database of Latin American and Caribbean Literature in Health Sciences (LILACS). A total of 438 references were selected. After consensus, 47 strong recommendations with high and moderate quality evidence, 14 conditional recommendations with moderate quality evidence, and 65 conditional recommendations with low quality evidence were established. Finally, the importance of initial and multimodal pain management was underscored. Emphasis was placed on decreasing sedation levels and the use of deep sedation only in specific cases. The evidence and recommendations for the use of drugs such as dexmedetomidine, remifentanil, ketamine and others were incremented.

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Se analiza uno de los requisitos de validez del consentimiento informado, en concreto, el tiempo o antelación con que ha de facilitarse la información al paciente para que pueda reflexionar y ejercer con plenitud su derecho kantiano de autodeterminación. Se aprecia cierta insuficiencia de la legislación estatal al tratar este requisito, que es subsanada por algunas legislaciones autonómicas. Concluimos señalando la necesidad de facilitar la información al paciente con la antelación suficiente para que pueda meditar adecuadamente su decisión (AU)

The analysis of one of the requisites of thevalidity of the informed consent, the notice period, during which the patient should be provided with information, so that he/she can reflect and fully exercise his/her Kantian right of self-determination. National legislation appears to be insufficient when dealing with this issue, which is compensated for in some regional legislations. We conclude by pointing the need to provide the patient with information with sufficient notice prior to operations, so that he/she can ponder over his/her decision (AU)

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The analysis of one of the requisites of the validity of the informed consent, the notice period, during which the patient should be provided with information, so that he/she can reflect and fully exercise his/her Kantian right of self-determination. National legislation appears to be insufficient when dealing with this issue, which is compensated for in some regional legislations. We conclude by pointing the need to provide the patient with information with sufficient notice prior to operations, so that he/she can ponder over his/her decision.

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Se analiza la controvertida aplicabilidad de la doctrina del daño desproporcionado en el acto anestésico, dado el elevado riesgo inherente al mismo, abstracción hecha de la gravedad y trascendencia del acto quirúrgico que lo motiva. La existencia de un resultado desproporcionado, esto es, no previsto ni explicable dentro de la esfera de la actuación profesional del anestesista, no determina por sí sola la existencia de responsabilidad del médico, sino la exigencia al mismo de una explicación coherente acerca del porqué de la importante disonancia existente entre el riesgo inicial que implicaba su actividad y la consecuencia finalmente producida (AU)

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INTRODUCTION: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes. OBJECTIVE: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium. METHODOLOGY: A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1=strong, or 2=weak, and quality of evidence as A=high, B=moderate, or C=low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines. RESULTS: Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition. CONCLUSIONS: This Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids.

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An analysis is made of the controversial application of the theory of disproportionate damage in the anaesthetic act, due to the high inherent risk, and regardless of the seriousness and importance of the surgery being performed. The existence of a disproportionate damage, that is, damage not foreseen nor accountable within the framework of the professional performance of the anaesthetist, does not by itself determine the existence of liability on the part of the anaesthetist, but the demand from the professionals themselves for a coherent explanation of the serious disagreement between the initial risk implied by their actions and the final consequence produced.

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Excess weight is fast becoming a serious health concern in the developed and developing world. The concern of the public health sector has lead to the development of public health campaigns, focusing on two-fold goals: to inform the public as to the health risks inherent in being overweight, and the benefits of a change in nutritional behaviour. Recent studies indicate that the effects of the average public health campaign on the target community is around 5%. In this study we aim to quantify the effect of different public health campaigns on lifestyle behaviour in the target populations in order to bring about weightloss in a significant number of people over the next few years. This study is based on recent works that consider excess weight as a consequence of the transmission of unhealthy lifestyles from one individual to another. Following this point of view, first a mathematical model is presented. Then, policies based on public health campaigns addressed to stop people gaining weight (prevention; this type of policy acts on individuals in order to maintain their weight and to stop an increase in weight) and, policies addressed to overweight individuals to reduce their weight (treatment; these campaigns act on overweight and/or obese individuals in order to reduce their weight) are simulated in order to evaluate their effectiveness. The study concludes that combination of preventive plus treatment campaigns are more effective than considering them separately.

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The authors study a recent Spanish High Court decision declaring liability on the Administration's part for the death of an inmate in a prison hospital. We analyse the Court's decision using legal, ethical, medical and social perspectives. The conclusions are that: 1. the Administration has no legitimate right to force a prisoner to take medical treatment, except in circumstances in which there is a grave and definite risk to the patient's life, or when the patient lacks capacity or when there is the risk of harm to the health of third parties; 2. That in the case of health decision making that might affect a patient, the Court has mounted a frontal attack on the autonomy of patients in prison; 3. That from a medical point of view the decision is discriminatory since it does not apply the same standards of measurement to all chronic illnesses that might be found in the prison context; 4. That it is inapplicable in daily practice due to the fact that its strictness of application would seriously affect the already highly fragile ordered coexistence that exists in a prison.

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Los autores estudian una reciente sentencia de la Sala 3ª del Tribunal Supremo en la que se declara la responsabilidad patrimonial de la Administración por la muerte de un paciente preso. Se analizan los argumentos de la Sala desde una perspectiva jurídica, ética, médica y social. Concluyen que: 1: la Administración no está legitimada para imponer tratamientos médicos a los reclusos, salvo que medie riesgo grave y cierto para su vida, incapacidad para decidir o riesgo para la salud de terceros; 2: que la sentencia supone un ataque frontal a la autonomía de los pacientes presos en la toma de decisiones sanitarias que les afecten; 3: que desde un punto de vista médico es discriminatoria, ya que no mide por el mismo rasero a todas las enfermedades crónicas que se pueden dar en prisión y 4: que resulta inasumible en la práctica diaria, porque su estricta aplicación alteraría considerablemente la ya de por sí frágil ordenada convivencia en un centro penitenciario

The authors study a recent Spanish High Court decision declaring liability on the Administration’s part for the death of an inmate in a prison hospital. We analyse the Court’s decision using legal, ethical, medical and social perspectives. The conclusions are that: 1. the Administration has no legitimate right to force a prisoner to take medical treatment, except in circumstances in which there is a grave and definite risk to the patient’s life, or when the patient lacks capacity or when there is the risk of harm to the health of third parties; 2. That in the case of health decision making that might affect a patient, the Court has mounted a frontal attack on the autonomy of patients in prison; 3. That from a medical point of view the decision is discriminatory since it does not apply the same standards of measurement to all chronic illnesses that might be found in the prison context; 4. That it is inapplicable in daily practice due to the fact that its strictness of application would seriously affect the already highly fragile ordered coexistence that exists in a prison

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Exposure to lead in children living on a former landfill in Vega Baja-Puerto Rico, a United States Environmental Protection Agency (USEPA) designated Superfund Site, is a major health concern. Direct contact with lead-contaminated soil is considered a major exposure source. However, there is a lack of information regarding the contribution of lead-contaminated house dust to children's blood lead concentrations. This study evaluated the relationship between lead contaminated-house dust and children's blood lead levels. Blood from 42 children, aged 6 years old or less, and dust from 29 houses were analyzed for lead, and face-to-face interviews were performed to gather information on potential risk factors for high blood lead levels. Blood lead levels ranged from 0.97 to 7.79 micrograms/dL. Lead values for floors fluctuated from 0.12 to 98.30 micrograms/ft2, with 17 per cent of houses surpassing the USEPA standard of 40 micrograms/ft2. Multiple regression analysis showed that lead in window sills, toy chewing and soil eating habits were significant predictors of blood lead levels. Further investigations aimed at assessing the long-term effects of constant exposure to environmental lead in these children are warranted.

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