Spindle cell carcinoma: Two instances mistaken for vocal polyps

Spindle cell carcinoma is a variant of squamous carcinoma, with behavior that is apparently more aggressive than that of squamous carcinoma and that can produce distant lymphatic metastasis. It was first described by Virchow in 1864 [1], but the origin of the tumor is still not clear. The tumor is biphasic, with an epidermal component and a sarcomatous component involving spindle cells; transition zones between these components can be found [2–5]. In part due to this peculiar and complex nature, the tumor has accumulated various names since it was first described: sarcomatoid tumor, carci- nosarcoma, pleomorphic carcinoma, collision tumor, etc. [2,5,6]

Lacrimal Diversion Devices (Sinopsys Lacrimal Stent): Sharing our Experience with Patients with Chronic Rhinosinusitis without Polyposis

Introduction: Chronic rhinosinusitis (CRS) is a highly prevalent pathology in our society. Due to the prevalence of this condition and to the persisting symptoms despite an appropriate medical treatment, surgical techniques are often required. Lately, minimal invasive techniques have been described, such as lacrimal diversion devices (LDDs). This technique offers a fast and convenient choice for delivery of sinus irrigation and topical medication. Objective: We aimed to describe our experience with LDDs and evaluate the safety and effectiveness of the procedure in patients with moderate to severe CRS without nasal polyposis (CRSsNP) and persistent symptomatology despite medical therapy. Methods: A total of 7 patients underwent bilateral lacrimal stents placement in the operating room. A retrospective observational study was conducted. The Sino-Nasal Outcome Test-20 (SNOT-20) survey was performed and the score obtained was compared before and 1 month after the procedure. Results: The LDDs were used for an average of 80 days. During the follow-up, only three patients had a mild complication with the device (granuloma in the punctum, obstruction, and early extrusion). The mean baseline SNOT-20 score dropped significantly (p ¼ 0.015) from 25.85 to 11.57 (mean: - 14.29) 1 month after the procedure. Conclusion: According to our experience and results, the use of LDD is a novel, feasible, and less invasive technique to treat refractory CRS. It reduces the risk of mucosal stripping, provides short-term outcomes, and the surgical procedure does not require advanced training in endoscopic sinus surgery. Moreover, it can be performed in-office under local anesthesia or sedation

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Caracterización endoscópica y funcional de la disfonía por tensión muscular

El origen y los cimientos de los distintos trabajos y teorías que terminarían por definir lo que actualmente se conoce como Disfonía por Tensión Muscular (DTM) se inicia durante los primeros años de la década de los ochenta. En 1982 Koufman y Blalock (Koufman & Blalock, 1982), en un intento por definir y organizar mejor los desórdenes funcionales de la voz (Disfonías funcionales), propusieron una forma de clasificarlos que los dividía en cinco grandes grupos: Reacción de conversión (conversión reaction), ronquera crónica postviral (postviral chronic hoarseness), falseto inapropiado (inappropriate falsetto), disfonía postoperatoria (postoperative dysphonia) y los síndromes de mal uso/abuso vocal (vocal misuse/abuse syndromes)

Caracterización endoscópica y funcional de la disfonía por tensión muscular

El origen y los cimientos de los distintos trabajos y teorías que terminarían por definir lo que actualmente se conoce como Disfonía por Tensión Muscular (DTM) se inicia durante los primeros años de la década de los ochenta. En 1982 Koufman y Blalock (Koufman & Blalock, 1982), en un intento por definir y organizar mejor los desórdenes funcionales de la voz (Disfonías funcionales), propusieron una forma de clasificarlos que los dividía en cinco grandes grupos: Reacción de conversión (conversión reaction), ronquera crónica postviral (postviral chronic hoarseness), falseto inapropiado (inappropriate falsetto), disfonía postoperatoria (postoperative dysphonia) y los síndromes de mal uso/abuso vocal (vocal misuse/abuse syndromes)

Infecciones concurrentes por dos serotipos del virus dengue durante un brote en el noroeste de Perú, 2008

Objetives. To establish the existence of concurrent infections by different dengue virus (DENV) serotypes in an outbreak in the Northwestern in Peru during 2008. Material and methods. 73 serum samples from patients with dengue were analyzed during an outbreak that occurred in Northwestern in Peru between May and June 2008. Molecular biology techniques were used to serotype the DENV, thus, firstly the viral RNA viral was extracted using Viral QIAamp RNA mini kit (Qiagen, Valencia, California, USA), then the viral cDNA fragments were reverse transcripted and amplified by means of the Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) and the RT-Nested PCR region techniques and finally, genetic sequencing of the viral cDNA fragments were performed using the Big Dye Terminator v.3,1 kit. Results. The 73 dengue cases presented infections by different serotypes: 34 (46.6%) by DENV-3, 29 (39.7%) by DENV-1, 4 (5.5%) by DENV-4, and 6 (8.2%) concurrent infections by DENV-1 and DENV-3. The most frequent clinical manifestations observed among dengue patients were fever and headache (100%), myalgia (94.5%), ocular pain (83.6%), arthralgia (78.1%), shivers (63.0%), nausea/vomiting (38.4%), positive tourniquet test (30.1%), and rash (20.5%). All patients with concurrent infections presented light clinical course of dengue fever (Df) except one patient who had moderate hemorrhagic manifestations. Conclusion. This is the first Peruvian report of patients with concurrent infections of two DENV serotypes without severe clinical manifestations.Objetivo. Describir la existencia de infecciones concurrentes por diferentes serotipos del virus dengue (DENV) en un brote ocurrido en el noroeste de Perú durante el 2008. Materiales y métodos. Se analizó 73 muestras séricas de pacientes con dengue en un brote en el noroeste de Perú entre mayo y junio de 2008. Para la serotipificación del DENV se utilizó técnicas de biología molecular; así, primero se realizó la extracción del ARN con el kit QIAamp viral RNA Mini, luego se realizó la transcripción inversa y amplificación de los fragmentos de ADNc viral mediante las técnicas de reacción en cadena de la polimerasa con trans criptasa inversa (RT-PCR multiplex) y de RT-Anidada PCR (RT-Nested PCR), y finalmente de realizó el secuenciamiento genético de los fragmentos de ADNc viral utilizando el kit Big Dye Terminator v.3,1. Resultados. Los 73 casos de dengue presentaron infecciones por diferentes serotipos: 34 (46,6%) por DENV-3, 29 (39,7%) por DENV-1, 4 (5,5%) por DENV-4 y 6 casos (8,2%) por DENV-1 y DENV-3. Las manifestaciones clínicas más frecuentes fueron fiebre y cefalea (100%), mialgia (94,5%), dolor ocular (83,6%), artralgia (78,1%), escalofríos (63,0%), nauseas/vómitos (38,4%), prueba de lazo positiva (30,1%) y erupción cutánea (20,5%). Los pacientes con infecciones concurrentes presentaron cuadros leves, excepto una paciente que presentó prueba de lazo positivo y sangrado genital. Conclusión. Es el primer reporte de pacientes peruanos con infecciones concurrentes por dos serotipos del DENV sin formas graves de la enfermedad