Variables biològiques i metabòliques preoperatories, tècniques, i d´evolució postoperatòria relacionades amb el buidament gàstric lent després de la duodenopancreatectomia cefàlica

[cat] La duodenopancreatectomia cefàlica és la tècnica d’elecció pel tractament dels tumors de cap de pàncrees i àrea periampul·lar. Una de les complicacions més freqüents és el buidament gàstric lent, que comporta una major estada hospitalària amb el conseqüent augment del cost i l’endarreriment de l’inici del tractament adjuvant. S’han descrit diverses modificacions en la tècnica quirúrgica per tal de disminuir l’aparició d’aquesta complicació. A més, s’han realitzat diversos estudis per poder establir altres factors que podrien predisposar a l’aparició de buidament gàstric lent. Les hipòtesis del treball han estat: ✔ La tècnica de Whipple clàssica amb antrectomia té menor incidència de buidament gàstric lent que la duodenopancreatectomia amb preservació pilòrica. ✔ La reconstrucció del trànsit intestinal amb gastroenteroanastomosi en dues nanses en Y de Roux té una menor incidència de buidament gàstric lent que la reconstrucció clàssica amb una nansa en Billroth II. L’objectiu principal de la tesi doctoral ha estat actualitzar l’evidència sobre la incidència de buidament gàstric lent relacionada amb les diferents modificacions de la tècnica quirúrgica i estudiar els factors implicats en l’aparició de la complicació. La realització de dos assaigs clínics aleatoritzats ha permès comparar tècniques quirúrgiques en relació a la incidència d’aquesta complicació i els resultats globals postoperatoris a més d’ampliar els coneixements sobre altres factors implicats en l’aparició de la complicació. Per últim, l’àmplia revisió bibliogràfica ens ha permès publicar una revisió actualitzada de les diferents variacions en la tècnica quirúrgica i la seva implicació en l’aparició de buidament gàstric lent. El primer assaig clínic aleatoritzat unicèntric inclou 84 pacients comparant els resultats postoperatoris de la intervenció clàssica de Whipple amb antrectomia amb la duodenopancreatectomia amb preservació pilòrica. En aquest estudi no es van evidenciar diferències entre els dos grups estudiats en relació a la incidència de buidament gàstric lent. Respecte a les complicacions globals, en el grup en que es va realitzar la duodenopancreatectomia amb preservació pilòrica van sorgir diversos problemes en relació a la realització de la tècnica, el maneig de tumors de gran tamany, isquèmia duodenal i afectació de marges. El segon assaig clínic aleatoritzat unicèntric no enmascarat inclou 80 pacients i compara la reconstrucció gastroentèrica en Y de Roux amb la reconstrucció gastroentèrica en Billroth II després de la duodenopancreatectomia cefàlica. Els resultats aporten evidència de que no hi ha diferències en relació a la incidència de buidament gàstric lent en comparar la reconstrucció amb nansa única en Billorth II amb la reconstrucció amb doble nansa en Y de Roux. Respecte a les complicacions globals, tampoc es van trobar diferències entre ambdós grups d’estudi. Respecte als factors relacionats amb el buidament gàstric lent es va evidenciar que la hipoalbuminemia i la hiperbilirrubinèmia preoperatòria es van associar a l’aparició de la complicació. Les conclusions de la tesi doctoral son: La incidència de buidament gàstric lent es similar entre la tècnica de Whipple clàssica i la duodenopancreatectomia amb preservació pilòrica. ✔ La tècnica de Whipple clàssica amb antrectomia no comporta diferències en la incidència de complicacions postoperatòries, estada hospitalària ni mortalitat postoperatòria respecte a la duodenopancreatectomia amb preservació pilòrica. ✔ La incidència de buidament gàstric lent es similar entre la reconstrucció en Y de Roux respecte a la reconstrucció en Billroth II de la gastroenteroanastomosi a la duodenopancreatectomia cefàlica. ✔ La reconstrucció en Y de Roux de la gastroenteroanastomosi a la duodenopancreatectomia cefàlica amb antrectomia no comporta diferències en la incidència de complicacions postoperatòries, estada hospitalària ni mortalitat postoperatòria respecte a la reconstrucció en Billroth II. ✔ La hipoalbuminèmia i la hiperbilirrubinèmia s’associen a buidament buidament gàstric lent en els pacients sotmesos a duodenopancreatectomia cefàlica.[eng] Pancreatoduodenectomy is the technique of choice for the treatment of tumors of the head of the pancreas and periampullary area. One of the most frequent complications is delayed gastric emptying, which leads to a longer hospital stay with the consequent increase in cost and delay in the start of adjuvant treatment. Over the years, different modifications in the surgical technique have been described to reduce the incidence of this complication, both in the resection phase and in the reconstruction phase. In addition, several studies have been carried out to establish other factors that could predispose to the appearance of delayed gastric emptying, including preoperative biological and metabolic factors or postoperative evolution. The main objective of this thesis has been to update the evidence on the incidence of slow gastric emptying related to the different modifications of the surgical technique and to study the factors involved in the appearance of delayed gastric emptying after pancreatoduodenectomy. The performance of two studies (randomized clinical trials) allowed to compare surgical techniques in relation to the incidence of this complication and the overall postoperative results. These two clinical trials, which include a large number of patients, have allowed us to expand our knowledge about other factors involved in the appearance of the complication (articles 1 and 2 of the thesis). Finally, the extensive review of the literature related to this specific complication has allowed us to publish an updated review of the different variations in the surgical technique and its implication in the appearance of delayed gastric emptying. In addition, a study of risk factors for delayed gastric emptying after pancreatoduodenectomy has been carried out (publications supporting the doctoral thesis)

Manual Borehole Drilling as a Cost-Effective Solution for Drinking Water Access in Low-Income Contexts

Water access remains a challenge in rural areas of low-income countries. Manual drilling technologies have the potential to enhance water access by providing a low cost drinking water alternative for communities in low and middle income countries. This paper provides an overview of the main successes and challenges experienced by manual boreholes in the last two decades. A review of the existing methods is provided, discussing their advantages and disadvantages and comparing their potential against alternatives such as excavated wells and mechanized boreholes. Manual boreholes are found to be a competitive solution in relatively soft rocks, such as unconsolidated sediments and weathered materials, as well as and in hydrogeological settings characterized by moderately shallow water tables. Ensuring professional workmanship, the development of regulatory frameworks, protection against groundwater pollution and standards for quality assurance rank among the main challenges for the future

Mapping the Viability, Time, and Cost of Manual Borehole Drilling in Developing Regions

While access to water remains an issue in arid and semiarid regions across the world, aquifers have the potential to help millions of people out of poverty by providing a reliable source of drinking and irrigation water. Manual boreholes are increasingly advocated as a safe and cost-effective substitute to mechanized drilling, as well as to traditional excavation methods. This research banks on the assumption that field and remote sensing data can be integrated within a geospatial database in order to map the viability of manual boreholes based on factors such as rock type, water table depth, landforms, or water quality. The approach presents three main novelties in relation to methodological precedents: (1) outcomes are not only expressed in terms of technical feasibility, but also as a function of drilling time and cost; (2) maps refer to a specific drilling technique; and (3) results take into account borehole diameter, as this constrains both drilling time and cost. The method provides univocal outcomes that can be immediately useful for non-experts, donors, planners, or practitioners and that can be readily exported to other catchment-scale settings. Results were validated against geophysical data

Streptomyces tsukubaensis as a new model for carbon repression: transcriptomic response to tacrolimus repressing carbon sources

[EN] In this work, we identified glucose and glycerol as tacrolimus repressing carbon sources in the important species Streptomyces tsukubaensis. A genome-wide analysis of the transcriptomic response to glucose and glycerol additions was performed using microarray technology. The transcriptional time series obtained allowed us to compare the transcriptomic profiling of S. tsukubaensis growing under tacrolimus producing and non-producing conditions. The analysis revealed important and different metabolic changes after the additions and a lack of transcriptional activation of the fkb cluster. In addition, we detected important differences in the transcriptional response to glucose between S. tsukubaensis and the model species Streptomyces coelicolor. A number of genes encoding key players of morphological and biochemical differentiation were strongly and permanently downregulated by the carbon sources. Finally, we identified several genes showing transcriptional profiles highly correlated to that of the tacrolimus biosynthetic pathway regulator FkbN that might be potential candidates for the improvement of tacrolimus productionSIThis study was funded by the Government of Spain (grant number PIM2010-EEI00677). María Ordóñez-Robles received a FPU grant from the Government of Spain (grant number AP2009-4508)

A survey of domestic wells and pit latrines in rural settlements of Mali: Implications of on-site sanitation on the quality of water supplies

On-site sanitation is generally advocated as a means to eradicate the health hazards associated with open defecation. While this has provided a welcome upgrade to the livelihoods of millions of people in low-income countries, improved sanitation facilities are increasingly becoming a threat to domestic groundwater-based supplies. Within this context, a survey of pit latrines, domestic wells and improved water sources was carried out in a large rural village of southern Mali. All households were surveyed for water, sanitation and hygiene habits. Domestic wells and improved water sources were georeferenced and sampled for water quality (pH, electric conductivity, temperature, turbidity, total dissolved solids, thermotolerant coliforms, chloride and nitrate) and groundwater level, while all latrines were inspected and georeferenced. A GIS database was then used to evaluate the proportion of water points within the influence area of latrines, as well as to underpin multiple regression models to establish the determinants for fecal contamination in drinking supplies. Moreover, an appraisal of domestic water treatment practices was carried out. This revealed that nearly two-thirds of the population uses bleach to purify drinking supplies, but also that domestic-scale treatment as currently implemented by the population is far from effective. It is thus concluded that existing habits could be enhanced as a means to make water supplies safer. Furthermore, population, well and latrine density were all identified as statistically significant predictors for fecal pollution at different spatial scales. These findings are policy-relevant in the context of groundwater-dependent human settlements, since many countries in the developing world currently pursue the objective of eliminating open defecation

Neocortical tissue recovery in severe congenital obstructive hydrocephalus after intraventricular administration of bone marrow-derived mesenchymal stem cells

BACKGROUND: In obstructive congenital hydrocephalus, cerebrospinal fluid accumulation is associated with high intracranial pressure and the presence of periventricular edema, ischemia/hypoxia, damage of the white matter, and glial reactions in the neocortex. The viability and short time effects of a therapy based on bone marrow-derived mesenchymal stem cells (BM-MSC) have been evaluated in such pathological conditions in the hyh mouse model. METHODS: BM-MSC obtained from mice expressing fluorescent mRFP1 protein were injected into the lateral ventricle of hydrocephalic hyh mice at the moment they present a very severe form of the disease. The effect of transplantation in the neocortex was compared with hydrocephalic hyh mice injected with the vehicle and non-hydrocephalic littermates. Neural cell populations and the possibility of transdifferentiation were analyzed. The possibility of a tissue recovering was investigated using 1H High-Resolution Magic Angle Spinning Nuclear Magnetic Resonance (1H HR-MAS NMR) spectroscopy, thus allowing the detection of metabolites/osmolytes related with hydrocephalus severity and outcome in the neocortex. An in vitro assay to simulate the periventricular astrocyte reaction conditions was performed using BM-MSC under high TNFα level condition. The secretome in the culture medium was analyzed in this assay. RESULTS: Four days after transplantation, BM-MSC were found undifferentiated and scattered into the astrocyte reaction present in the damaged neocortex white matter. Tissue rejection to the integrated BM-MSC was not detected 4 days after transplantation. Hyh mice transplanted with BM-MSC showed a reduction in the apoptosis in the periventricular neocortex walls, suggesting a neuroprotector effect of the BM-MSC in these conditions. A decrease in the levels of metabolites/osmolytes in the neocortex, such as taurine and neuroexcytotoxic glutamate, also indicated a tissue recovering. Under high TNFα level condition in vitro, BM-MSC showed an upregulation of cytokine and protein secretion that may explain homing, immunomodulation, and vascular permeability, and therefore the tissue recovering. CONCLUSIONS: BM-MSC treatment in severe congenital hydrocephalus is viable and leads to the recovery of the severe neurodegenerative conditions in the neocortex. NMR spectroscopy allows to follow-up the effects of stem cell therapy in hydrocephalus.España Instituto Carlos III , PI15/00619 (to AJJ), PI19/00778 (to AJJ and PPG), PI15/00796, and PI18/01557España Ministerio de Educación, Cultura y Deporte FPU13/02906España, Ministerio de Economía y Competitividad RYC-2014-16980España, FEDER Andalucía y Universidad de Málaga UMA18-FEDERJA-27

Hypoalbuminemia and advanced age are risk factors for delayed gastric emptying after pancreaticoduodenectomy

Background:delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. It could be related to some baseline patient-related characteristics. This study aims to assess the predictive factors associated to DGE in the cohort of patients included in the PAUDA clinical trial. Methods:this study was a retrospective analysis based on the 80 patients included in a randomized clinical trial conducted and published by our group. A descriptive analysis and a bivariate regression model were carried out. Some factors were further scrutinized for associations using the Pearson correlation coefficient and, finally, a multiple regression model using a stepwise selection of variables was conducted. Results:DGE was diagnosed in 36 (45 %) out of 80 patients (DGE group). The number of patients older than 60 years old in the DGE group was greater than in the group without DGE (32 vs 28 patients, p = 0.009]). Likewise, the number of patients with a preoperative albumin 200 & mu;mol/L (14 vs 8 patients, p = 0.039); postoperative haemorrhage (7 vs 1 patients, p = 0.011); postoperative intraabdominal abscess (12 vs 5 patients, p = 0.017); and postoperative biliary fistula (5 vs 0 patients, p = 0.011), was also greater in the DGE group. Two risk factors were associated with DGE: the patient's age at the time of surgery and preoperative hypoalbuminemia (serum albumin concentration & LE; 35g/L). Conclusions:the patient's age at the time of surgery and the preoperative nutritional status are independent risk factors to the development of DGE after pancreatoduodenectomy

Quality of ventilations during infant resuscitation: a simulation study comparing endotracheal tube with face mask

Background: There are few studies that analyze ventilation volume and pressure during CPR carried out on infants. The aim of this study was to evaluate the quality of the ventilations administered using a self-inflating bag with an endotracheal tube and a face mask in manikins. Methods: a quasi-experimental simulation study with a randomized case crossover design [endotracheal tube (ET) vs. face mask (FM)] was performed. Sixty participants who were previously trained nursing students participated in the study. The estimated air volumes breathed, and the pressure generated during each ventilation were assessed and the quality of the chest compressions was recorded. Results: the ET test presented a higher percentage of ventilations that reached the lungs (100% vs. 86%; p < 0.001), with adequate volume (60% vs. 28%; p < 0.001) in comparison to FM. Both tests presented peak pressures generated in the airway greater than 30 cm H2O (ET: 22% vs. FM: 31%; p = 0.03). Conclusions: performing quality CPR ventilations on an infant model is not an easy skill for trained nursing students. Both tests presented a significant incidence of excessive peak pressure during ventilations. Specific training, focused on quality of ventilations guided by a manometer attached to the self-inflating bag, must be considered in life support training for pediatric providers

Supuesto práctico profesional (ejercicio propuesto para el ingreso al Cuerpo Superior de Inspectores de Hacienda del Estado)

In the following report, we develop the professional practice proposed in the first part of the third exercise from the admission test for the Corps of Revenue Agents in Spain (Resolution of 27th June 2011, Spanish Official Journal of 11th July). Throughout the report, organized in eight sections, several cases on the Personal Income Tax, Corporate Tax, VAT, Transfer Tax and Stamp Duty, Customs Duty and Excise Taxes and Tax Procedures, Tax Inspection and Tax Collection are presented.Desarrollamos a continuación el supuesto práctico profesional correspondiente a la primera parte del tercer ejercicio de las pruebas de acceso al Cuerpo Superior de Inspectores de Hacienda del Estado. Convocatoria Resolución de 27 de junio de 2011 (BOE de 11 de julio). A lo largo del dictamen, estructurado en ocho partes, se plantean diferentes supuestos relativos a aspectos de IRPF, IS, IVA, ITP y AJD, Aduanas e Impuestos Especiales y Procedimientos de Gestión Tributaria, Inspección de los Tributos y Recaudación