Diabetes y cirugía II: Principios generales de tratamiento

El manejo terapéutico y de control metabólico del paciente diabético durante el acto quirúrgico posee una trascendencia esencial para reducir la posibilidad de desarrollo de complica- ciones. El mantenimiento de un adecuado estado de hidratación y la administración continua de insulina por vía intravenosa constituyen uno de los pilares básicos del tratamiento intraoperatorio. La posibilidad de variar las dosis de insulina a lo largo de la intervención justifica la necesidad de realizar controles frecuentes de glucemia. Algunas situaciones especiales como la cirugía urgente o la realización de un by pass aorto-coronario requieren esquemas terapéuticos específicos. En todos los casos la valoración entre cirujano, anestesista y endocrinólogo representa la base sobre la que se sustentan los protocolos ter- apéuticos del control de un paciente diabético antes, durante y después del acto quirúrgico. Se debe tener en cuenta que, pese a la realización de protocolos de actuación generales, el tratamiento siempre debe ser individualizado debido a la gran cantidad de factores que pueden influir en el control metabólico.The therapeutic management and metabolic control during surgery has an important significance in order to reduce the course of complications. Maintaining an appropriate hydration state and continuous insulin intravenous administration represents a basic mainstay of surgical management. The possibility of changing insulin doses all through the surgical operation justify the need of frequent blood glucose checking. Some types of surgery, such as emergency surgery or coronary by-pass require specific therapeutic schemes. As a whole the coordination among surgeon, anaesthesiologist and endocrinologist constitutes the basis of the perioperative diabetic management. It must be noticed that this management must be always individualized since multiple factors may influence glycemic control

Treatment of type 2 diabetes by patient profile in the clinical practice of endocrinology in Spain: Delphi study results from the think twice program

Introduction: The aim of this Delphi study is to unveil the management of patients with type 2 diabetes (T2D) and different levels of complexity in the clinical practice in Spain. Methods: Based on the common management practices of T2D profiles reported by Spanish endocrinologists, a Delphi questionnaire of 55 statements was developed and responded to by a national panel (n = 101). Results: A consensus was reached for 30 of the 55 statements. Regarding overweight patients inadequately controlled with metformin, treatment with a sodium-glucose transport protein 2 inhibitor (SGLT2-I) is preferred over treatment with a dipeptidyl peptidase-4 inhibitor (DPP4-I). If the patient is already being treated with a DPP4-I, an SGLT2-I is added on to the treatment regimen rather than replacing the DPP4-I. Conversely, if the treatment regimen includes a sulfonylurea, it is usually replaced by other antihyperglycemic agents. Current treatment trends in uncontrolled obese patients include the addition of an SGLT2-I or a glucagon-like peptide-1 receptor agonist (GLP1-RA) to background therapy. When the glycated hemoglobin target is not reached, triple therapy with metformin ? GLP1-RA ? SGLT2-I is initiated. Although SGLT2-Is are the treatment of choice in patients with T2D and heart failure or uncontrolled hypertension, no consensus was reached regarding the preferential use of SGLT2- Is or GLP1-RAs in patients with established cardiovascular disease. Conclusion: Consensus has been reached for a variety of statements regarding the management of several T2D profiles. Achieving a more homogeneous management of complex patients with T2D may require further evidence and a better understanding of the key drivers for treatment choice

N, P, K nutrition differentially affects the incidence and severity of the attack of pests and diseases in plants

Objective: To document and analyze relevant results reported on the relationships kept by the essential elements, nitrogen (N), phosphorus (P), and potassium (K) with biotic stress factors in higher plants. Design/methodology/approach: A bibliographic analysis was carried out using keywords related to the concepts of nutrient relationship with phytopathogens, plant fertilization and nutrition and biotic stress. Subsequently, the most relevant articles on N, P, and K and their relationship with pests and diseases were selected and analyzed. Results: The elements N, P, and K affect the development of pests on plants. Fertilization with N tend to increase the presence of pests, while fertilization with P and K decreases it. However, this cannot be generalized for all crops or pests. Limitations/implications of the study: Research on the effects of N, P, and K on the incidence of phytopathogens is limited and in most cases the mechanisms that determine such relashionship are not described. Findings/conclusions: Fertilization with N causes a higher incidence of pests and diseases in plants, while fertilization with P and K can contribute to reduce their incidence. However, due to the great diversity of responses, these statements are not applicable to all cases and depend on other factors such as the crop and the pest present in the agroecosystem. It is required to carry out studies that make it possible to clarify exactly how these essential elements influence the development of diseases in different crops, and thus be able to make nutrition recommendations in which limiting biotic factors are taken into account

Preliminary data on the ovarian histological structures observed in black hakes (M. polli and M. senegalensis) off Mauritania

The black hakes, Merluccius polli and M. senegalensis, are target species of a trawl Spanish fleet in Mauritanian waters. M. polli is a deep-water hake while M. senegalensis shows a shallower distribution. Both species are mixed in the landings, although the deeper hake totals a greater fraction (85%) of the catch due to the fishing strategy of the trawl fleet. The female gonads of both hakes were collected during an experimental survey carried out in the Mauritanian EEZ. Mature ovaries were examined from the start of the reproductive season in this area. Ovaries were processed by a standard histological technique. Histological characteristics of ovarian tissues and oocyte stages were studied by light microscopy. The ovaries of black hakes showed various stages of oocyte development from the small sized, chromatin nuclear and perinucleolar oocytes, and the medium sized, cortical alveoli and vitellogenic oocytes. This last stage presents yolk granules occupying the cytoplasm at different levels. In the case of M. senegalensis, the presence of large sized oocytes with early migration of the nucleus to the animal pole, as well as fusion of oil droplets indicate maturation and imminent spawning, thus, indicating an earlier spawning than M. polli. Furthermore, postovulatory follicles observed in M. senegalensis indicate a recent batch spawning episode. This result is concordant with the values of GSI obtained for both species in these waters. The reproductive period extends from October to Mars with a defined peak in December - January for females of both hakes, although the shallower species, M. senegalensis, shows an earlier spawning in this study. Atretic stages were observed, but their incidence was low because the sampling corresponds to the beginning of the spawning period. The species are multiple batch spawners as suggested by their oocyte size frequency distribution in the ovary. The present study is a first approach to ovarian histology of M. polli and M. senegalensis, and intended to provide basic knowledge for further detailed studies on the reproductive biology of these species, essential for an adequate assessment of this stock.Instituto Español de Oceanografía (IEO

TELMA: Technology enhanced learning environment for minimally invasive surgery

Background: Cognitive skills training for minimally invasive surgery has traditionally relied upon diverse tools, such as seminars or lectures. Web technologies for e-learning have been adopted to provide ubiquitous training and serve as structured repositories for the vast amount of laparoscopic video sources available. However, these technologies fail to offer such features as formative and summative evaluation, guided learning, or collaborative interaction between users. Methodology: The "TELMA" environment is presented as a new technology-enhanced learning platform that increases the user's experience using a four-pillared architecture: (1) an authoring tool for the creation of didactic contents; (2) a learning content and knowledge management system that incorporates a modular and scalable system to capture, catalogue, search, and retrieve multimedia content; (3) an evaluation module that provides learning feedback to users; and (4) a professional network for collaborative learning between users. Face validation of the environment and the authoring tool are presented. Results: Face validation of TELMA reveals the positive perception of surgeons regarding the implementation of TELMA and their willingness to use it as a cognitive skills training tool. Preliminary validation data also reflect the importance of providing an easy-to-use, functional authoring tool to create didactic content. Conclusion: The TELMA environment is currently installed and used at the Jesús Usón Minimally Invasive Surgery Centre and several other Spanish hospitals. Face validation results ascertain the acceptance and usefulness of this new minimally invasive surgery training environment

Learning curves of basic laparoscopic psychomotor skills in SINERGIA VR simulator

Purpose: Surgical simulators are currently essential within any laparoscopic training program because they provide a low-stakes, reproducible and reliable environment to acquire basic skills. The purpose of this study is to determine the training learning curve based on different metrics corresponding to five tasks included in SINERGIA laparoscopic virtual reality simulator. Methods: Thirty medical students without surgical experience participated in the study. Five tasks of SINERGIA were included: Coordination, Navigation, Navigation and touch, Accurate grasping and Coordinated pulling. Each participant was trained in SINERGIA. This training consisted of eight sessions (R1–R8) of the five mentioned tasks and was carried out in two consecutive days with four sessions per day. A statistical analysis was made, and the results of R1, R4 and R8 were pair-wise compared with Wilcoxon signed-rank test. Significance is considered at P value <0.005. Results: In total, 84.38% of the metrics provided by SINERGIA and included in this study show significant differences when comparing R1 and R8. Metrics are mostly improved in the first session of training (75.00% when R1 and R4 are compared vs. 37.50% when R4 and R8 are compared). In tasks Coordination and Navigation and touch, all metrics are improved. On the other hand, Navigation just improves 60% of the analyzed metrics. Most learning curves show an improvement with better results in the fulfillment of the different tasks. Conclusions: Learning curves of metrics that assess the basic psychomotor laparoscopic skills acquired in SINERGIA virtual reality simulator show a faster learning rate during the first part of the training. Nevertheless, eight repetitions of the tasks are not enough to acquire all psychomotor skills that can be trained in SINERGIA. Therefore, and based on these results together with previous works, SINERGIA could be used as training tool with a properly designed training program

Construct and face validity of SINERGIA laparoscopic virtual reality simulator

Purpose Laparoscopic techniques have nowadays become a gold standard in many surgical procedures, but they imply a more difficult learning skills process. Simulators have a fundamental role in the formative stage of new surgeons. This paper presents the construct and face validity of SINERGIA laparoscopic virtual reality simulator in order to decide whether it can be considered as an assessment tool. Methods Twenty people participated in this study, 14 were novices and 6 were experts. Five tasks of SINERGIA were included in the study: coordination, navigation, navigation and touch, precise grasping and coordinate traction. For each one of these tasks, a certain number of metrics are automatically recorded. All subjects accomplished each task only once and filled in two questionnaires. A statistical analysis was made and results from both groups were compared with the Mann–Whitney U-test, considering significant differences when P ≤ 0.05. Internal consistency of the system has been analyzed with the Cronbach’s alpha test. Results Novices and experts positively rated SINERGIA characteristics. At least one of the evaluated metrics of each exercise presented significant differences between both groups. Nevertheless, all metrics under study gave a better punctuation to the executions accomplished by experts (lower time, higher efficiency, fewer errors. . .) than to those made by novices. Conclusion SINERGIA laparoscopic virtual reality simulator is able to discriminate subjects according to their level of experience in laparoscopic surgery; therefore, it can be used within a training program as an assessment too

Study of Leading Hadrons in Gluon and Quark Fragmentation

The study of quark jets in e+e- reactions at LEP has demonstrated that the hadronisation process is reproduced well by the Lund string model. However, our understanding of gluon fragmentation is less complete. In this study enriched quark and gluon jet samples of different purities are selected in three-jet events from hadronic decays of the Z collected by the DELPHI experiment in the LEP runs during 1994 and 1995. The leading systems of the two kinds of jets are defined by requiring a rapidity gap and their sum of charges is studied. An excess of leading systems with total charge zero is found for gluon jets in all cases, when compared to Monte Carlo Simulations with JETSET (with and without Bose-Einstein correlations included) and ARIADNE. The corresponding leading systems of quark jets do not exhibit such an excess. The influence of the gap size and of the gluon purity on the effect is studied and a concentration of the excess of neutral leading systems at low invariant masses (<~ 2 GeV/c^2) is observed, indicating that gluon jets might have an additional hitherto undetected fragmentation mode via a two-gluon system. This could be an indication of a possible production of gluonic states as predicted by QCD.Comment: 19 pages, 6 figures, Accepted by Phys. Lett.

<i>Gaia</i> Data Release 1. Summary of the astrometric, photometric, and survey properties

Context. At about 1000 days after the launch of Gaia we present the first Gaia data release, Gaia DR1, consisting of astrometry and photometry for over 1 billion sources brighter than magnitude 20.7. Aims. A summary of Gaia DR1 is presented along with illustrations of the scientific quality of the data, followed by a discussion of the limitations due to the preliminary nature of this release. Methods. The raw data collected by Gaia during the first 14 months of the mission have been processed by the Gaia Data Processing and Analysis Consortium (DPAC) and turned into an astrometric and photometric catalogue. Results. Gaia DR1 consists of three components: a primary astrometric data set which contains the positions, parallaxes, and mean proper motions for about 2 million of the brightest stars in common with the HIPPARCOS and Tycho-2 catalogues – a realisation of the Tycho-Gaia Astrometric Solution (TGAS) – and a secondary astrometric data set containing the positions for an additional 1.1 billion sources. The second component is the photometric data set, consisting of mean G-band magnitudes for all sources. The G-band light curves and the characteristics of ∼3000 Cepheid and RR-Lyrae stars, observed at high cadence around the south ecliptic pole, form the third component. For the primary astrometric data set the typical uncertainty is about 0.3 mas for the positions and parallaxes, and about 1 mas yr−1 for the proper motions. A systematic component of ∼0.3 mas should be added to the parallax uncertainties. For the subset of ∼94 000 HIPPARCOS stars in the primary data set, the proper motions are much more precise at about 0.06 mas yr−1. For the secondary astrometric data set, the typical uncertainty of the positions is ∼10 mas. The median uncertainties on the mean G-band magnitudes range from the mmag level to ∼0.03 mag over the magnitude range 5 to 20.7. Conclusions. Gaia DR1 is an important milestone ahead of the next Gaia data release, which will feature five-parameter astrometry for all sources. Extensive validation shows that Gaia DR1 represents a major advance in the mapping of the heavens and the availability of basic stellar data that underpin observational astrophysics. Nevertheless, the very preliminary nature of this first Gaia data release does lead to a number of important limitations to the data quality which should be carefully considered before drawing conclusions from the data