Maciel Hospital Research Articles

Rheumatoid arthritis: extra articular manifestations and comorbidities

IntroductionRheumatoid arthritis (RA) can present extra-articular manifestations (ExM) and comorbidities such as infections, cardiovascular events, and malignancies, which have been associated with increased morbidity and mortality. Methodologyanalytical, observational, retrospective, 2012−2019. Extra-articular manifestations and comorbidities were studied in patients with established RA, attended in the EAS service of Maciel Hospital, in Montevideo, Uruguay. Results83 cases, mean age 59.1±11, 87% female sex. RA overlapping 30%, 84% of cases with positive RF, 73% with positive anti-CCP, seronegative RA 10.8%. Extra-articular manifestations: 38%, ILD was the most frequent. A higher proportion of those who developed extra-articular manifestations had RF and positive anti-CCP. Infections: observed in 55.4%, 41.3% serious, 95.7% were non-opportunistic infections. The most frequent were urinary and respiratory. The most common causal microorganism was Escherichia Coli. Six patients with opportunistic infections were observed (pulmonary tuberculosis and Herpes Zoster). The use of corticosteroids was a risk factor for infections (p = 0.008), OR: 3,974 (CI: 1.39–11.36). SFZ was a protective factor (p = 0.033), OR: 0.313 (CI: 0.104–0.943). Cardiovascular events: evidenced in 6 patients, 50% had high activity. No increased risk was found with the drugs received. Neoplasms: 5 cases were found, there was no significant association between the risk of malignancy and the drugs used. ConclusionsExtra-articular manifestations and comorbidities are frequent in RA patients, adding great morbidity. The risk of infections is multifactorial, influencing glucocorticoids and disease activity. Suspicion is important to carry out a search and timely treatment

Artritis reumatoide: manifestaciones extraarticulares y comorbilidades

IntroductionRheumatoid arthritis (RA) can present extra-articular manifestations (ExM) and comorbidities such as infections, cardiovascular events, and malignancies, which have been associated with increased morbidity and mortality. MethodologyAnalytical, observational, retrospective, 2012-2019. Extra-articular manifestations and comorbidities were studied in patients with established RA, attended in the EAS service of Maciel Hospital, in Montevideo, Uruguay. Results83 cases, mean age 59.1±11, 87% female sex. RA overlapping 30%, 84% of cases with positive RF, 73% with positive anti-CCP, seronegative RA 10.8%. Extra-articular manifestations: 38%, ILD was the most frequent. A higher proportion of those who developed extra-articular manifestations had RF and positive anti-CCP. Infections: observed in 55.4%, 41.3% serious, 95.7% were non-opportunistic infections. The most frequent were urinary and respiratory. The most common causal microorganism was Escherichia coli. Six patients with opportunistic infections were observed (pulmonary tuberculosis and herpes zoster). The use of corticosteroids was a risk factor for infections (OR: 3,974; 95%CI: 1.39-11.36; P=.008). SFZ was a protective factor (OR: .313; 95%CI: 0.104-.943; P=.033). Cardiovascular events: evidenced in 6 patients, 50% had high activity. No increased risk was found with the drugs received. Neoplasms: 5 cases were found, there was no significant association between the risk of malignancy and the drugs used. ConclusionsExtra-articular manifestations and comorbidities are frequent in RA patients, adding great morbidity. The risk of infections is multifactorial, influencing glucocorticoids and disease activity. Suspicion is important to carry out a search and timely treatment.

Infections in systemic autoimmune diseases

IntroductionInfections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received. Material and methodsAn analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease. Results339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA. ConclusionsInfections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.

Infections in systemic autoimmune diseases.

Infections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received. An analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease. 339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA. Infections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.

COVID 19 en fase 2 sostenida. Experiencia quirúrgica inicial en el Hospital Macie

Introduction. In Uruguay, the start of the pandemic was decreed by Covid. 19 on March 13, 2020, In this context, the Maciel Hospital (HM) established guidelines and recommendations to face the disease that radically modified its usual benefits. The objective of this communication is to present the surgical experience developed in the care context of a sustained phase 2 of Covid infection.19 Material and methods The surgical activity of the HM is retrospectively analyzed from its record of Operative Descriptions, during the period between 13.3.2020 and 30.4.2020 (49 days) and performs a critical analysis from the governing documents of our surgical conduct. Results: 403 cases, 149 coordination and 254 emergency were operated. 287 patients with multiple etiologies, although predominantly oncological (27%) and infectious / inflammatory processes (19%), were operated by the general and specialty surgery services. Laparoscopy involved 62 cases, 43 of which were urgent, mostly due to infectious / inflammatory pathologies: appendicitis (35%), cholecystectomies (24%), and diagnostic laparoscopies (11%). 55% of the cases underwent surgery for cancer and the rest cholecystectomies and others. Conclusions: The HM operated three times more than the rest of the public system; Even so, with respect to its usual production, the number of surgeries decreased significantly (35%), especially coordination (59%). Covid.19 positive patients were not operated. A high number of justified operations were carried out in terms of quantity and type of pathology, using the protocol for maximum protection against Covid.19 rationally, within the established sanitary guidelines and without infectious impact by the coronavirus

¿ Estamos operando pacientes asintomáticos pero infectados por Covid19?:análisis retrospectivo de pacientes operados en el Hospital Maciel

Introduction: Since March 2020, COVID-19 infection was declared a pandemic with consequent impact on the health system. A particular case is the surgery service with the risk linked to transmission by microdrops or pneumoperitoneum. To reduce the risk of contagion, non-oncological coordination surgeries have been suspended. The objective of this study was to assess the proportion of asymptomatic patients at the time of surgery and who developed the disease after surgery. Materials and methods: This is an observational, descriptive and retrospective study. A search was made in the operative descriptions system of the Maciel Hospital, identifying the surgical procedures of all the specialties performed from March 16 to April 16, 2020. Demographic variables, variables related to surgery, complications and respiratory symptoms were recorded. Results: 128 patients were included, on which 165 procedures were performed. 42.2% of the coordination procedures, 52.1% of urgency and 5.5% of emergency were performed. It is highlighted that 73.4% of the patients did not present complications and a mortality of only 7.8% was found. 9 (7.0%) swabs were performed in the period, none of them was positive. Conclusions: COVID-19 infection is linked to an increase in postoperative mortality compared to pre-epidemic mortality, which requires strict triage to minimize risk. We highlight in our center the absence of surgery in asymptomatic patients with the infection.

COVID 19 en fase 2 sostenida. Experiencia quirúrgica inicial en el Hospital Maciel

Introducción. En el Uruguay se decretó el inicio de la pandemia por Covid.19 el 13 de marzo de 2020, En este contexto el Hospital Maciel (HM) estableció pautas y recomendaciones para enfrentar la enfermedad que modificaron radicalmente sus prestaciones habituales. El objetivo de esta comunicación es presentar la experiencia quirúrgica desarrollada en el contexto asistencial de una fase 2 sostenida de infección por Covid.19 Material y métodos Se analiza en forma retrospectiva la actividad quirúrgica del HM a partir de su registro de Descripciones Operatorias, durante el periodo entre el 13.3.2020 y el 30.4.2020 ( 49 días) y realiza un análisis crítico desde los documentos rectores de nuestra conducta quirúrgica. Resultados: Se operaron 403 casos, 149 de coordinación y 254 de urgencia .Los servicios de cirugía general y especialidades operaron 287 pacientes de múltiples etiologías,v aunque predominantemente oncológicos (27%) y procesos infecciosos /inflamatorios (19%). Por laparoscopia se intervinieron 62 casos, 43 de urgencia en su mayoría por patologías infeccioso/inflamatorias: apendicitis (35 %) , colecistectomias (24%) y laparoscopias diagnosticas ( 11 %) .De coordinación se operaron 55% de los casos por cáncer y el resto colecistectomías y otros. Conclusiones: El HM opero tres veces más que el resto del sistema público; aun así, respecto a su producción habitual descendió significativamente el número de cirugías (35%), especialmente de coordinación (59 %). No se operaron pacientes Covid.19 positivos. Se realizaron un alto número de operaciones justificadas en cantidad y tipo de patología, utilizando con racionalidad el protocolo de protección máxima contra el Covid.19, dentro de las pautas sanitarias establecidas y sin impacto infectológico por el coronavirus.

Estamos operando pacientes asintomáticos pero infectados por Covid19?:

Introducción: Desde marzo del 2020 la infección por COVID-19 fue declarada pandemia con consecuente impacto sobre el sistema de salud. Un caso particular es el servicio de cirugía con el riesgo vinculado a la trasmisión por microgotas o neumoperitoneo. Para disminuir el riesgo de contagio se han suspendido las cirugías de coordinación no oncológicas. El objetivo de este estudio fue valorar la proporción de pacientes asintomáticos al momento de la cirugía y que luego de la misma desarrollaron la enfermedad.
 Materiales y métodos: Se trata de un estudio observacional, descriptivo y retrospectivo. Se realizó una búsqueda en el sistema de descripciones operatorias del Hospital Maciel individuándose los procedimientos quirúrgicos de todas las especialidades realizados del 16 de marzo al 16 de abril del 2020. Se consignaron variables demográficas, variables vinculadas a la cirugía, complicaciones y sintomatología respiratoria.
 Resultados: Se incluyeron 128 pacientes sobre los cuales se realizaron 165 procedimientos. Se realizaron 42,2% de los procedimientos de coordinación, 52,1% de urgencia y 5,5% de emergencia. Se destaca que 73,4% de los pacientes no presentaron complicaciones y se halló una mortalidad de solo 7,8%. Se realizaron 9 (7,0%) hisopados en el período, ninguno de ellos fue positivo.
 Conclusiones: La infección por COVID-19 se vincula a un aumento de la mortalidad en el posoperatorio respecto a la mortalidad prepandemia lo que obliga a un estricto triage para minimizar el riesgo. Destacamos en nuestro centro la ausencia de cirugía en pacientes portadores asintomáticos de la infección.

Tratamiento de la litiasis coledociana por vía laparoscópica, serie de casos de la Clínica Quirúrgica 2 del Hospital Maciel

Introducción: La enfermedad litiásica es una patología con alta prevalencia en la población general siendo uno de los principales motivos de consulta de cirugía general tanto en policlínica como en emergencia. Dada su alta prevalencia y las potenciales complicaciones está indicado su tratamiento, siendo el ideal aún controvertido, pudiendo ser quirúrgico, endoscópico o percutáneo.
 El objetivo del trabajo consistió en la presentación del tratamiento de la litiasis coledociana realizado en la Clínica Quirúrgica 2 del Hospital Maciel, valorando su eficacia y las complicaciones halladas. 
 Materiales y métodos: Se realizó una búsqueda electrónica de todas las descripciones operatorias de colecistectomías realizadas entre el 1ro de enero y el 7 de octubre del 2018 seleccionándose las que presentaron confirmación colangiográfica de litiasis a nivel de la vía biliar principal. 
 Resultados: Se realizaron 115 colecistectomías, 113 laparoscópicas, 2 requirieron conversión hallándose litiasis a nivel de vía biliar principal en 20 casos. Los tratamientos de las mismas fueron mediante Dormia, balón de angioplastia, pinzas de Randall y lavado con suero fisiológico siendo exitoso en 18 casos.
 Discusión: El abordaje de la vía biliar principal tanto transcística como mediante coledocotomía permite la resolución integral de la patología litiásica en un solo acto. La colangiografía se realizó de forma exitosa en el 80% de los casos y mediante las modalidades utilizadas se logró la extracción de los litos en el 90%, no se halló diferencia respecto a otros trabajos publicados.
 Conclusiones: El tratamiento tanto transcístico como mediante coledocotomía puede ser realizado de forma segura y efectiva.

Evaluación de la producción quirúrgica de residentes de Cirugía General luego de la implementación del cuarto año curricular. Clínica Quirúrgica 3. Hospital Maciel (2011-2015)

The general surgeons training program is under the responsibility of the Surgical Clinics of the School of Medicine. The 3-year training program evidenced deficiencies in terms of the volume and complexity of the surgeries carried out by the different residents. Objective: to present the surgical outcome of the General Surgery residents after the implementation of the fourth year in the curriculum of graduate studies of the Surgical Clinic 3 at Maciel Hospital and to compare it to that of the residents trained in the previous 3-year studies plan. Method: observational, descriptive and retrospective study of the surgical outcome of residents of the Surgical Clinic 3 who studied in the 2011-2015 period. Below follow the variables considered: total number of surgeries carried out by all residents, average number of surgeries per year and per resident, maximum and minimum number of surgeries by a resident, total percentage of coordination and urgent surgeries and average number of surgeries by resident according to the classification into high complexity, complex, regular and minor. Data were taken from the ASSE surgery description system - Maciel Hospital. Conclusions: increasing one year the duration of the general surgery residence resulted in a higher number and complexity of surgeries carried out by the residents of Surgical Clinic 3 at Maciel Hospital, as well as an increase in the coordination surgeries when compared to urgency and emergency surgeries.

Two years experience on the use of molecular biology techniques in neuroinfections. Preliminary cohort at Maciel Hospital

Two years experience on the use of molecular biology techniques in neuroinfections. Preliminary cohort at Maciel Hospital

Esfinteroplastia anal en el tratamiento de la incontinencia fecal por trauma obstétrico


 Introducción:
 La incontinencia fecal tiene un impacto negativo en la calidad de vida de quienes la padecen. Cuando es de causa miogénica puede estar indicada la esfinteroplastia anal, cuyos resultados suelen ser poco alentadores.
 Técnica quirúrgica y casos clínicos:
 Se presenta la técnica quirúrgica utilizada en la Clínica Quirúrgica 2 del Hospital Maciel, junto con dos casos clínicos.
 Discusión:
 La esfinteroplastia anal anterior puede realizarse mediante afrontamiento simple o con técnica deoverlapping, no existiendo evidencia de que alguna de ellas sea superior en cuanto a resultados alejados.
 Conclusiones:
 Los resultados alejados de la esfinteroplastia anal son pobres, siendo la neuropatía pudenda asociada la que condiciona y puede predecir la mayoría de los fracasos terapéuticos.

Diagnosis of ventriculostomy-related infection: Is cerebrospinal fluid lactate measurement a useful tool?

ObjectiveTo evaluate the value of CSF lactate (LCSF) for the diagnosis of ventriculostomy related infections (VRI), and compare it with other CSF markers. MethodsProspective study of neurocritical patients admitted to Maciel Hospital and Clinicas Hospital ICUs in which an external ventricular drain (EVD) was inserted. In patients with clinical suspicion of VRI, a CSF sample was obtained through the EVD for CSF culture and markers analysis (glucose, protein, lactate and leukocytes). We defined proven VRI according to preset criteria as: fever, plus CSF alterations (glucose <50mg/dl or leukocytes >500/μl), plus positive CSF culture. CSF markers were plotted in a receiver operating curve (ROC) to evaluate their diagnostic accuracy. Results36 CSF samples were obtained: 14 corresponded to proven VRI and 22 to excluded VRI. Median LCSF was 9.90mmol/L (IQR: 4.7–12) for proven VRI versus 2.95mmol/L (IQR: 2.4–3.6) for excluded VRI (p<0.001). Both LCSF and CSF glucose showed a good diagnostic accuracy for VRI, with an AUC of 0.900 and 0.951 respectively. We found the following diagnostic values for LCSF: sensitivity of 86%, specificity of 86%, PPV of 80%, NPV of 91%, cut-off value of 4mM, positive likehood ratio of 6.1, negative likehood ratio of 0.16, Youden Index of 0.72 and Diagnostic Odds Ratio of 34. ConclusionsFor the studied population, LCSF represents a good marker for VRI. It could be used as a quick and specific test to identify the need for antimicrobial therapy in patients with clinical suspicion of VRI.

Restitución del procedimiento de Hartmann por vía laparoscópica. Análisis de nuestra experiencia en el Hospital Maciel de Montevideo, Uruguay, Clínicas Quirúrgicas 2 y 3 de la Facultad de Medicina de la Universidad de la República (UDELAR)

BackgroundDescribed almost 100 years ago, the Hartmann procedure is still valid, being the classical behavior adopted for the management of the left colon in the emergency room. The restitution of the intestinal transit provides an important improvement in the quality of life of the patients, nevertheless given the high morbimortality, only half is reconstructed. Laparoscopic Hartmann restitution offers all the advantages of minimally invasive procedures with morbidity and mortality comparable to conventional surgery. ObjectivesAnalyze surgical technique and the results of a series of patients in whom laparoscopic Hartmann restitution was performed. Material and methodsRetrospective review was conducted between March 2002 and January 2017. The population belongs to the Surgical Clinics of the Maciel Hospital (‘Q2’ and ‘Q3’), UDELAR Medical School, Montevideo, Uruguay. ResultsTwenty-nine patients were operated: 10 women and 19 men. The most frequent pathologies that determined the Hartmann were linked to diverticular pathology (37.93%) or oncological (34.48%). The minimum time elapsed between the Hartmann and the reconstruction was 4 months. The operative times ranged from 107 to 240min. The conversion rate was 24.1%. Major complications occurred in 6.90% and minor complications in 13.79%. There was no anastomotic leak. The hospital stay was 5.57 days. The mortality rate was 3.45%. ConclusionsOur results are consistent with the international literature, laparoscopic Hartmann restitution is a demanding but feasible, safe procedure that gives the patient the benefits of minimally invasive surgery.

Value of cerebrospinal fluid lactate for the diagnosis of bacterial meningitis in postoperative neurosurgical patients

To evaluate the diagnostic value of CSF lactate (L(CSF)) for the diagnosis of bacterial meningitis (BM) following neurosurgery, and compare it with other CSF markers. Prospective study of consecutive neurosurgical postoperative patients admitted to the Intensive Care Unit (ICU) at Maciel Hospital. Patients with clinical suspicion of BM were categorised, according to preset criteria, into 3 groups: (1) proven BM; (2) probable BM, and (3) excluded BM. CSF markers were plotted in a receiver operating curve (ROC) to evaluate their diagnostic accuracy. The study included 158 patients. We obtained 46 CSF samples from patients with clinical suspicion of BM by lumbar puncture (LP): 10 corresponded to proven BM, 4 to probable BM and 32 to excluded BM. Mean lactate in CSF (L(CSF)) was: 10.72±4.68mM for proven BM, 6.07±0.66mM for probable BM and 3.06±1.11mM for excluded BM (P<.001 for proven BM and probable BM vs excluded BM; P=NS for proven BM vs probable BM). L(CSF) displayed a better diagnostic accuracy for BM in the 2 scenarios studied: (1) positive bacterial CSF culture or Gram stain as positive control (gold standard) (sensitivity: 87%, specificity: 94%, cut-off value: 5.9mM), and (2) combination of proven BM and probable BM as positive control (sensitivity: 92%, specificity: 100%, cut-off value: 5.2mM). According to our results, determination of L(CSF) is a quick, sensitive and specific test to identify the need for antimicrobial therapy in neurosurgical postoperative patients with clinical suspicion of BM.

Lesiones Inadvertidas en Trauma Abdominal. Análisis del Trauma Abierto y Cerrado. 12 Casos en el Periodo 1999-2008

RESUMEN Antecedentes Analizar los factores determinantes de morbilidad y mortalidad en una serie de pacientes con LI (lesiones inadvertidas) clínicamente relevantes. Diseño del estudio Estudio retrospectivo, periodo 1999-2008, Hospital Maciel, Montevideo, Uruguay. Las variables analizadas fueron: Edad, sexo, mecanismo lesional, topografía, tiempo de retardo diagnostico, complicaciones, órganos comprometidos y mortalidad. Se realiza un análisis comparativo en el trauma abierto y contuso. Resultados Se reportaron 12 pacientes, todos del sexo masculino, edad media de 29 años con un tiempo de retardo diagnostico de 5,6 días para trauma contuso y de 3,5 para el penetrante. Los órganos comprometidos con mayor frecuencia fueron duodeno, páncreas y colon. Se asociaron mayor demora diagnostica y mortalidad para el trauma contuso de acuerdo al análisis estadístico utilizando el Test exacto de Fisher. Conclusiones En retardo diagnostico, el trauma con alta transferencia de energía así como la inadecuada exploración quirúrgica son los factores determinantes en la aparición de complicaciones y mortalidad en lesiones inadvertidas.

An approach to histologically diagnosed gallbladder carcinoma following cholecystectomy for presumed benign disease

Five cases of gallbladder adenocarcinoma treated at Surgical Department 2, Maciel Hospital, Montevideo, Uruguay, in a period ranging from 1985 to 1989 and follow-up to date are reported. All cases were first diagnosed by microscopic examination of the gallbladder, which had been removed for presumed benign disease; there were no intramucosal carcinomas, and 60% of the cases were classified as Nevin's stage II (submucosal and muscularis). Based on the pattern of spread (mainly direct hepatic infiltration, as well as venous and lymphatic involvement), our radical surgical treatment of gallbladder carcinoma includes cholecystectomy, extended lymphatic clearance (along the porta hepatis or R1, pre- and retroduodenopancreatic and hepatic artery R2, and celiac axis R3), and medial hepatectomy (segments, IV, V, and VIII according to Couinaud). Simple cholecystectomy is the treatment of choice in mucosal (T1) neoplasms; otherwise, histologically diagnosed gallbladder carcinoma following cholecystectomy for presumed benign disease calls for reoperation to achieve lymph node dissection and hepatic resection. Overall 2- and 3-year survival was 100% and 80%; mean survival was 50 months. Medial hepatectomy was selected according to gallbladder carcinoma patterns of spread and failures, and entails resection of the parenchyma most frequently involved without compromising liver function, in a quick and safe surgical procedure.