RESUMEN
A 69-year-old man with rectal adenocarcinoma and no relevant medical history was scheduled for anterior resection of the tumor under combined anesthesia. The epidural catheter was removed 48 h after surgery. A clinical picture consistent with a diagnosis of epidural hematoma developed gradually and was confirmed by magnetic resonance imaging. The last dose of low molecular weight heparin had been administered 8 h before catheter removal and blood analyses were normal. Recovery was complete following laminectomy and evacuation of the hematoma 31 h after the onset of symptoms. Our analysis of the literature on conditions leading to epidural hematoma after catheter insertion revealed that complications may appear for unknown reasons even when catheter management and thrombolytic prophylaxis are appropriate. Nevertheless, the maneuver for removing an epidural catheter is clearly not risk-free and can cause complications. Monitoring after removal is therefore important if complications are to be detected early.
Asunto(s)
Anestesia Epidural , Anticoagulantes/efectos adversos , Hematoma Epidural Craneal/etiología , Heparina de Bajo-Peso-Molecular/efectos adversos , Punciones/efectos adversos , Adenocarcinoma/cirugía , Anciano , Anestesia Epidural/instrumentación , Cateterismo , Hematoma Epidural Craneal/complicaciones , Hematoma Epidural Craneal/cirugía , Humanos , Laminectomía , Imagen por Resonancia Magnética , Masculino , Paresia/etiología , Complicaciones Posoperatorias/prevención & control , Neoplasias del Recto/cirugía , Trombosis/prevención & controlRESUMEN
Un varón de 69 años, sin antecedentes patológicos de interés, diagnosticado de adenocarcinoma de recto, fue intervenido de resección anterior bajo anestesia combinada. El catéter epidural se retiró a las 48 h, apareciendo de forma progresiva un cuadro compatible con hematoma epidural que se confirmó por resonancia magnética. La última dosis de heparina de bajo peso molecular había sido administrada 8 h antes de la retirada del catéter y la analítica completa fue normal. El paciente se sometió a laminectomía y evacuación del hematoma 31 h después de iniciada la clínica y la recuperación fue ad integrum. Analizamos las circunstancias que pueden llevar a la aparición de un hematoma epidural tras el uso de un catéter, y vemos que incluso con un manejo correcto del catéter y administración de la pauta de profilaxis tromboembólica adecuada pueden aparecer complicaciones, sin poder establecerse las causas. Al mismo tiempo, destaca que la maniobra de retirada del catéter epidural no está exenta de riesgos, por lo que el seguimiento posterior del paciente es muy importante para poder detectar de forma precoz posibles complicaciones (AU)
Objectives: To determine the opinion of primary healthcare managers on the importance and legitimacy of different sources of influence in medical practice, and to compare the results with the opinions of physicians in healthcare teams. Material and methods: Design: cross-sectional study. Population: primary healthcare managers in the Spanish public health system (area managers, medical and nursing directors) and in the Andalusian health service (district director, nursing coordinators and epidemiology and program coordinators). The sample comprised the total population of 302. As dependent variables, a series of questions was designed to gather the interviewees' opinions on different strategies, institutions and/or collectives that exert some kind of influence on medical practice. The degree of «importance» of each factor was summarized into a set of 9 items. The subjects were asked to score each item from 1 (most important) to 9 (least important). To assess the «legitimacy» of these scores, 16 items were presented measured using a Likert-type 7-point scale (1: not at all legitimate; 7: very legitimate). A self-administered questionnaire was used, sent by mail. Non-parametric tests (Friedman and Kruskall-Wallis) were used for statistical analysis of the data. Results: The response rate was 79.8%. Using the Friedman test for an ordinal 9-point scale, analysis of the mean ranges for each item revealed that the most important sources of influence for the primary healthcare managers interviewed were: the devising of management protocols by the doctors themselves; discussion with colleagues; feedback from patients, and attending training courses, and reading articles and scientific journals. The institutions or groups with the greatest legitimacy to influence medical practice were: users or citizens; internal audits; peers; scientific associations, and the managers themselves. Conclusions: The sources of influence considered to have the greatest importance and legitimacy in influencing medical practice concern the «professional medical system» (self-defined protocols, discussion with colleagues, etc.). Managers accept the use of business managerial tools as well as the influence of social actors to a greater extent than do physicians. This finding could indicate differences in the value systems between primary healthcare physicians and managers (AU)
Asunto(s)
Anciano , Masculino , Humanos , Anestesia Epidural , Trombosis , Paresia , Complicaciones Posoperatorias , Punciones , Anticoagulantes , Cateterismo , Adenocarcinoma , Imagen por Resonancia Magnética , Heparina de Bajo-Peso-Molecular , Laminectomía , Neoplasias del Recto , Hematoma Epidural CranealAsunto(s)
Astrocitoma/diagnóstico , Astrocitoma/cirugía , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/cirugía , Imagen Eco-Planar/métodos , Corteza Motora/cirugía , Astrocitoma/complicaciones , Mapeo Encefálico/métodos , Neoplasias Encefálicas/fisiopatología , Humanos , Cuidados Intraoperatorios , Corteza Motora/fisiología , Reproducibilidad de los ResultadosRESUMEN
OBJECT: The authors sought to evaluate the advantages and limitations of functional magnetic resonance (fMR) imaging when it was used regularly in the clinical context to identify the central sulcus. METHODS: A 1.5-tesla MR system comprising a spoiled gradient recalled acquisition in the steady-state functional sequence and a cross-hand cancellation analysis method were used to evaluate 50 surgical candidates with centrally located space-occupying lesions in the brain. Three-dimensional (3-D) models of the patient's head and brain showing the relative position of the tumor and the eloquent cortex were obtained in each case. A selective and reproducible focal activation was found, indicating the probable central sulcus position in 41 patients (82%). Direct cortical stimulation confirmed the fMR findings in 100% of 22 intraoperatively assessed patients. Failure to identify the central sulcus occurred in 18% of cases and was mainly a consequence of intrinsic damage in the primary sensorimotor region that resulted in severe hand paresis. CONCLUSIONS: Although specific factors were identified that contributed to reduced sensitivity of fMR imaging in the clinical context, the present study supports functional assessment and 3-D representation of specific surgical situations as generally feasible in common practice.
Asunto(s)
Neoplasias Encefálicas/cirugía , Encéfalo/patología , Imagen por Resonancia Magnética , Adolescente , Adulto , Factores de Edad , Anciano , Encéfalo/cirugía , Mapeo Encefálico , Neoplasias Encefálicas/complicaciones , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/fisiopatología , Corteza Cerebral/patología , Corteza Cerebral/fisiopatología , Distribución de Chi-Cuadrado , Estudios de Factibilidad , Femenino , Mano/fisiopatología , Cabeza/anatomía & histología , Humanos , Procesamiento de Imagen Asistido por Computador , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Corteza Motora/patología , Corteza Motora/fisiopatología , Parálisis/etiología , Parálisis/fisiopatología , Planificación de Atención al Paciente , Cuidados Preoperatorios , Radiología Intervencionista , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Corteza Somatosensorial/patología , Corteza Somatosensorial/fisiopatologíaRESUMEN
Calbindin D-28K and parvalbumin immunocytochemistry were used in the study of central ganglionic cell tumors. Most neurons in the ganglioglioma were immunoreactive to calbindin D-28K, but a few cells were labeled with antibodies against parvalbumin. In contrast, most cells in dysplastic gangliocytoma of the cerebellum were parvalbumin immunoreactive, but fewer reacted with anti-calbindin antibodies. These latter cells had two or three dendrites with claw-shaped terminals and axons with recurrent collateral branches and varicose terminals filled with strings and buttons. These observations suggest that central ganglionic cell tumors, including dysplastic gangliocytoma of the cerebellum, are composed of neurons which, on the basis of their calcium-binding protein content, have particular metabolic and electrophysiological properties.