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Resumen: Introducción: La pruebas de Evaluación Clínica Objetiva Estructurada (ECOE) son cada vez más utilizadas para evaluar a los estudiantes de medicina. Suelen emplearse al finalizar los estudios y no se valora la opinión de los estudiantes. Objetivo: Evaluar la utilidad de la ECOE, desde el punto de vista del estudiante de medicina, en su primer año de prácticas clínicas.Material y métodos Se diseñó una ECOE reducida que incluyó tres estaciones clínicas con actores y evaluadores estandarizados. Posteriormente fue evaluada mediante una encuesta con 5 preguntas previamente validadas. Resultados: Participaron 104 estudiantes y se obtuvieron 97 (92,3%) respuestas. El 89,7% consideró que la prueba fue muy útil para su formación. El 92,8% opinó que sería muy positivo incluir ECOE en sus prácticas clínicas y que ayudaría a adquirir competencias clínicas. Conclusiones: La prueba ECOE es una herramienta útil de evaluación y aprendizaje en los primeros años de prácticas clínicas. Abstract: Background: The Objective Structured Clinical Examination (OSCE) is commonly used for the evaluation of medical students. OSCE is normally used at the end of their training and there is no feed-back with the students. Aim: To evaluate the utility of OSCE, from the student point of view, at their first clinical year. Material and methods: A reduced OSCE with three clinical stations was designed. The participants and evaluators were previously standardised. The students then evaluated the OSCE using a previously validated survey. Results: Of the 104 medical students that participated, 97 (92.3%) completed the questionnaire. The OSCE was considered a useful tool by 89.7%, and 92.8% thought that it would be really positive to include OSCEs in their clinical practice in order to achieve clinical competence. Conclusion: The OSCE is a useful tool for evaluation and learning by students in their first clinical years. Palabras clave: Educación médica, ECOE, Grado en medicina, Prácticas clínicas, Keywords: Medical education, OSCE, Grade in medicine degree, Clinical practice

Aim To determine predictive factors of axillary lymph node dissection (ALND) results in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), and subsequent staging using Targeted Axillary Dissection (TAD). Material and method Case-control study between January 2016 and August 2019. Patients with BC, cN1 staging, marked with a metallic clip prior to NACT, and subsequently staged with TAD and ALND were included. They were divided into 2 groups: ALND patients with or without metastatic involvement (group 1 and group 2, respectively). We carried out a univariate analysis comparing clinical, radiological, surgical and pathological variables, and a logistic regression, (dependent variable: positive result of ALND; independent variables: number of suspicious lymph nodes in diagnostic ultrasound, positive hormone receptors, HER2 positive, complete clinical-radiological response to NACT, positive TAD, and biopsy of ≤2 nodes in TAD). A score for prediction of a metastatic ALND was proposed, with an internal validation study. Results 60 patients were included: Group 1: 33 (55.0%); Group 2: 27 (45.0%). Tumor size (Odds Ratio (OR) = 1.67; 95%CI 1.02–2.74), number of suspected nodes in ultrasound (OR = 2.20; 95%CI 1.01–4, 77), HER2 positive (OR 0.04; 95%CI 0.003–0.54), clinical-radiological response to NACT (OR = 0.07; 95%CI 0.01–0.75), and positive TAD (OR 15.48; 95%CI 1.68–142.78) were independent predictors of a positive result in ALND. We developed a “positive ALND predictive score”, with good calibration (Hosmer-Lemeshow test: p = 0.65), and discrimination (AUC = 0.93; 95% CI 0, 87–0.99), with highest Youden index (0.7) at cut-off point of 17% risk of positive ALND (sensitivity = 100%; specificity = 70%). Conclusion Tumor size, number of suspected nodes, positive HER2, response to NACT, and metastatic TAD are independent predictors of ALND. The predictive score for positive ALND would be a good indicator to safely omit ALND.

The possibility of avoiding axillary lymphadenectomy (AL) in patients with breast cancer (BC) after positive sentinel lymph node biopsy (SLNB) and low metastatic burden (ó = 2 positive lymph nodes) has put into question the role of axillary ultrasound due to the risk of overtreatment after positive axillary lymph node biopsy with low metastatic burden. Our aim was to identify clinical and ultrasound features to detect low and high metastatic burden.A retrospective study of 405 BC patients with primary surgical treatment with axillary ultrasound examination and subsequent AL after positive fine needle aspiration (FNA) or SLNB. The low and high tumor burdens after AL were correlated with clinical and ultrasound variables: lymph node morphology (UN1 to UN5), number of suspicious lymph nodes, and Berg level.Positive FNA, lymph node morphology UN4 (focal thickening with displacement of the fatty hilum) or UN5 (complete replacement of the fatty hilum) and2 suspicious lymph nodes were significantly associated with "high metastatic burden". Lymph node morphology UN2 and UN3, even after FNA+, lymph node morphology UN4 after FNA-, and suspicious lymph nodes at Berg level I were low metastatic burden criteria. Lymph node morphology UN5, lymph node morphology UN4 after FNA+, two nodes or more with UN4/UN5 morphology, and suspicious lymph nodes at Berg levels II and III with FNA+ were associated with high metastatic burden.Axillary lymph node ultrasound data for patients with early BC allows predicting the axillary metastatic burden, guiding the optimal clinical management of the axilla.

To analyse factors that may predict the appearance of rib fracture complications during the first days of evolution and determine whether the number of fractures is related to these complications. Retrospective case–control study of patients admitted with a diagnosis of rib fractures between 2010 and 2014. Two groups were established depending on the appearance or not of pleuropulmonary complications in the first 72 h, and the following were compared: age, sex, Charlson comorbidity index (CCI), number and uni- or bilateral involvement, mechanism of trauma, days of hospital stay, haemoglobin on discharge minus haemoglobin on admission, pleuropulmonary complications during admission (pneumothorax, haemothorax or pulmonary contusion) and placement of pleural drainage. One hundred and forty-one cases of rib fractures were admitted in the period mentioned. There were no differences in the patients’ baseline characteristics (age, sex and Charlson Comorbidity Index) between the two groups. Differences were found in the number of fractures (2.98 ± 1.19 in the group without complications vs 3.55 ± 1.33 in the group with complications, p = 0.05) and in the drop in the level of haemoglobin (0.52 ± 0.91 mg/dl vs 1.22 ± 1.29 mg/dl, p = 0.01). The length of hospital stay varied considerably in each group (5.35 ± 4.05 days vs 7.86 ± 6.96 days), but without statistical significance (p = 0.11). The number of fractured ribs that best predicted the appearance of complications (delayed pleuropulmonary complications and greater bleeding) was 3 or more.

In previous studies, there seems to be a relationship between different genetic polymorphisms and postoperative nausea and vomiting (PONV). We perform a systematic review of the current literature about the relationship between genetic polymorphisms and the presence of PONV. Two bibliographic searches were carried out in three databases (PubMed, Web of Science, and Scopus) of studies, preferably prospective, about PONV following abdominal surgery. It was completed with a backward citation searching. A total of 73 articles were found of which 6 were selected after their critical lecture using CASPe network criteria. Relative frequency and relative risk were taken in each study according to the polymorphism. Studies about 5-HT3B gene receptor polymorphisms, ABCB1 transporter, and dopamine D2 receptor showed a significant association with the presence of PONV (p = 0.02, 0.01, and 0.034 respectively). In relation to cytochrome P-450 2D6 (CYP2D6) polymorphisms, two of the three analysed articles showed a significant association with postoperative vomiting (p = 0.007). Genetic polymorphisms could play an important role in PONV. The AAG deletion in both alleles of the 5-HT3B receptor gene, the Taq IA polymorphism of the dopamine D2 receptor, and the presence of three or more functional alleles of CYP2D6 seem to be related with a higher incidence of PONV, especially in the first 24 h after surgery. The 2677TT and 3435TT genotypes of the ABCB1 transporter could reduce the PONV due to their association with a greater effectiveness of ondansetron. However, new quality studies are needed to consider this relationship.

Aim to study the feasibility and value of “Targeted Axillary Dissection” (TAD) in cN1 breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), in order to avoid unnecessary axillary lymph node dissection (ALND). Materials and methods Design: Prospective observational study. Inclusion criteria: Patients with histologically confirmed cN1 staging BC and treated with NACT between January 2016 and August 2019 who accomplished clinical response. Method: Fine-Needle Aspiration (FNA) positive axillary nodes were marked with a metallic clip prior to neoadjuvant treatment. All patients were summited to TAD and ALND. Analysis of data: We performed [1]: a feasibility analysis of clinical, radiological and pathological variables, as well as difficulties and complications of the TAD [2]; a diagnostic test study of the sentinel lymph node biopsy (SLNB), clipped lymph node biopsy (BCLIP) and their combination (TAD), using ALND as the Gold Standard. Results 60 patients were included. 43 patients (71.7%) had a complete clinical lymph node response to NACT. Neither limitations nor complications in clip placement were found. Intraoperative location of the clipped node was problematic in 7 cases (11.7%). The pathological complete response rate (pCR) was 30.5% (18 patients) and ypN0 staging rate was 38.3% (23 patients). Sensitivity values of each technique were: SLNB: 80.9% (95%CI: 61.8–100); BCLIP: 80.8% (95%CI: 63.7–97.8); TAD: 92.6% (95%CI: 80.9–100) with negative predictive values of: SLNB: 84.6% (95%CI: 68.8–100); BCLIP: 81.0% (95%CI: 63.7–97.8); TAD: 91.3% (95%CI: 77.6–100). Conclusion TAD is feasible and valid to rule out axillary metastatic involvement in cN1 breast cancer patients who respond to NACT.

Resumen Introduccion Describir las principales caracteristicas clinicas, anatomopatologicas, terapeuticas y evolutivas de una serie amplia de tumores estromales gastrointestinales (GIST). Metodos Estudio observacional de una serie de 66 casos de GIST tratados en nuestro hospital de 2002 a 2015. Seleccionamos variables relacionadas con los antecedentes personales, las manifestaciones clinicas, el tratamiento medico y quirurgico, la anatomia patologica y la morbimortalidad. Anadimos una revision de la literatura para correlacionarla con nuestros resultados. Resultados La localizacion mas frecuente fue el estomago (65,2%), en el que destaco como region predominante el fondo. La manifestacion clinica mas habitual fue la hemorragia digestiva (45,5%), seguida del hallazgo casual tras la realizacion de alguna prueba de imagen o procedimiento invasivo (33,3%). Recibieron cirugia 58 pacientes (90,6%), el 15,5% de caracter urgente. El 69% de los GIST tenian un tamano entre 2 y 10 cm. La mortalidad al ano debida al tumor fue de un 7,9% (5 casos), todos ellos relacionados con extension local o a distancia, o complicacion quirurgica. Conclusiones La variabilidad clinica de los GIST es muy amplia. El tratamiento de primera eleccion es la cirugia, que es factible en la mayoria de los casos y debe ser lo mas conservadora posible. El pronostico es variable, dependiendo del tamano y del indice de proliferacion, por lo que debe realizarse un seguimiento estrecho. No existe un marcador tumoral claramente asociado a un peor pronostico, por lo que se necesitan nuevos estudios de biologia molecular con el objetivo de encontrar dianas terapeuticas.

Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence.

Introduction: Currently, the Doctor-Patient relationship of all cultures and societies is in crisis due to the distrust that has arisen in this social contract. This distrust origins from various changes that have occurred worldwide. We, as doctors, can contribute to solving this crisis, reaffirming the values that integrate medical professionalism. In the absence of specific studies and programmes on medical professionalism in Spanish universities, we consider knowing the perception of medical professionalism by medical students at the University of Murcia essential to see if there is a need to introduce educational improvements in our faculty. Methods: A professionalism questionnaire from the Penn State University School of Medicine (PSCOM) was provided online, voluntarily and anonymously to all students of the Medicine degree of the University of Murcia. Results: The perception of professionalism in students was high, since all categories have more than 75% positive responses on average. The categories of Respect and Altruism were the best rated. On the other hand, there is a slight increase in negative responses as students progress through the degree. Between sexes, however, there were no differences in the criteria. Conclusions: Although the perception of professionalism is good, it is still a perception, so it should reach values closer to 100%. Therefore, the faculty is encouraged to carry out specific programmes to promote medical professionalism in the degree courses.

Background: The present study analyzes the evaluation of communication skills by standardized patients (SPs) and medical evaluators (Es) in an OSCE setting. Methods: The OSCE involved 189 sixth-year medical students, as well as 34 SPs and 63 Es. Communications skills were evaluated in 8 stations, simultaneously by SPs and Es. The SPs were actors who had been trained in the clinical case and who acted in accordance with a standardized script in a simulated clinical situation. The evaluators, also standardized, were Resident Doctors or staff Doctors from the Hospital Services involved. Results: The global scores awarded to students for communication skills were very similar in both groups, although the score awarded by Es was significantly higher, and a direct relationship was also observed between the mean scores awarded by both groups. Evaluators awarded significantly higher scores than SPs in 7 out of the 10 items on the checklist. Female medical students also scored significantly higher than their male counterparts in many items, including external appearance, listening, cordiality, optimism, interest, expression and empathy. Conclusions: Our data indicate that SPs and Es evaluated communication skills in a similar manner in an OSCE setting, a finding which suggests that health-related professionals can be used as an alternative to SPs, thus helping to lower economic costs. Our study also confirms a gender difference (in favor of women) in the evaluation of communications skills by both groups.Our data indicate that SPs and Es evaluated communication skills in a similar manner in an OSCE setting, a finding which suggests that health-related professionals can be used as an alternative to SPs, thus helping to lower economic costs. Our study also confirms a gender difference (in favor of women) in the evaluation of communications skills by both groups.

Resumen El ileo paralitico es una de las principales complicaciones del postoperatorio. Con la introduccion de los protocolos fast-track para acelerar la recuperacion, han aparecido nuevas medidas, como la toma temprana de cafe, mascar chicle y el gastrografin. Para conocer mejor estas actuaciones, se ha realizado un resumen de la evidencia actual, utilizando las bases de datos de MEDLINE, Cochrane Database of Systematic Reviews, Web of Science y SCOPUS. Los terminos empleados fueron «postoperative ileus» AND («definition» OR «epidemiology» OR «risk factors» OR «management»). Se han seleccionado 44 articulos, de los cuales 9 son revisiones sistematicas, 11 revisiones narrativas, 13 ensayos clinicos aleatorizados, 6 estudios observacionales y los 5 restantes cartas cientificas, hipotesis, etc. Se ha visto que existe poca literatura acerca del tema, que los estudios son heterogeneos (con disparidad en los resultados) y se centran en cirugia colorrectal y ginecologica. Se necesitan nuevos estudios, preferentemente ensayos clinicos aleatorizados, que esclarezcan la utilidad de estas medidas.

Postoperative ileus is one of the main complications in the postoperative period. New measures appeared with the introduction of «fast-track surgery» to accelerate recovery: coffee, chewing gum and gastrograffin. We performed a summary of current evidence, reviewing articles from MEDLINE, Cochrane Database of Systematic Reviews, ISI Web of Science, and SCOPUS databases. Employed search terms were «postoperative ileus» AND («definition» OR «epidemiology» OR «risk factors» OR «Management»). We selected 44 articles: 9 systematic reviews 11 narrative reviews, 13 randomized clinical trials, 6 observational studies, and the remaining 5 scientific letters, assumptions, etc. There is little literature about this topic, studies are heterogeneous, with disparity in the results. In addition, they only focus on colorectal and gynecological surgery. New high-quality studies are needed, preferably randomized clinical trials, in order to clarify the usefulness of these measures.

Aim. To study the feasibility and validity of ultrasound-guided pre-chemotherapy marking of metastatic axillary lymph nodes followed by targeted axillary dissection (TAD), in breast cancer patients undergoing neoadjuvant chemotherapy (NACT). Material and method Prospective diagnostic test study conducted between January 2016 and March 2018. Patients with breast cancer and indication for NACT, cN1 or cN2 axillary staging, were included. A clip was placed in the affected lymph node prior to NACT. A sentinel lymph-node biopsy (SLNB) and a clipped lymph-node biopsy (BCLIP) were conducted, followed by axillary lymph node dissection (ALND). Location rate (LR) and negative predictive value (NPV) were evaluated, taking SLNB, BCLIP and their combination (TAD) as evaluated tests and metastatic involvement in the ALND specimen as the gold standard. Results Twenty-three patients were included in the study. Sentinel lymph node could only be detected in 19 cases (LR = 80.61%), whereas BCLIP was successful in 22 (LR = 95.65%). The sentinel lymph node coincided with the marked lymph node in 14 patients (60.9%). We found a NPV for the SLNB of 0.85 (95%CI: 0.61–1.0), whereas for TAD it was 1.00 (95%CI: 0.74–1.0). Conclusion TAD is a feasible test for axillary restaging after NACT, with a higher success rate than SLNB.

Introduction This study was aimed to assess the main clinical, pathological and therapeutic characteristics of a cohort of gastrointestinal stromal tumors (GIST). Methods Observational study including 66 patients diagnosed with GIST admitted to our hospital between 2002 and 2015. Parameters related to medical history, clinical manifestations, medical and surgical treatment, histopathology, and morbi-mortality were studied. A review of the literature was included to correlate with the results. Results The most frequent location of GIST in our patients was the stomach (65.2%), in which the gastric fondo was the predominant region. The most common clinical manifestation was gastrointestinal hemorrhage (45.5%), followed by incidental finding after imaging or invasive procedures (33.3%). 58 patients underwent surgery (90.6%), 15.5% were urgent. A total of 69% of the GISTs had a size between 2 and 10 cm. The one-year mortality was 7.9%, all cases related to local or remote extension, or surgical complications. Conclusion There is a large clinical variability among GIST cases. The first choice of treatment is surgery, which is feasible in most cases and should be as conservative as possible. The prognosis varies depending on the size and proliferation index, thus close follow-up should be performed. No tumor marker is clearly associated with a poor prognosis. New molecular biology studies are needed in order to find therapeutic targets.

Introducción: La hernia de Spiegel supone un 1-2 % de todas las hernias de la pared abdominal. Existen factores de riesgo que predisponen a su aparición, entre los cuales se encuentran las cirugías abdominales previas.Caso clínico: Presentamos un caso clínico de una paciente con una incisión de Pfannestiel previa por histerectomía, que terminó desarrollando una hernia de Spiegel al año siguiente de la cirugía.Discusión: Se comenta su etiopatogenia, planteando la hipótesis del estiramiento y cizallamiento de la pared abdominal debido a la retracción producida por incisiones abdominales previas, embarazo y obesidad.

espanolIntroduccion y objetivos: actualmente no existe consenso entre colecistectomia o colecistostomia percutanea como eleccion terapeutica en la colecistitis aguda alitiasica. El objetivo de nuestro trabajo es revisar la evidencia cientifica acerca del tratamiento en estos pacientes segun los hallazgos clinicos y radiologicos. Metodos: revision sistematica de la literatura desde 2000 hasta 2016. La busqueda se realizo usando PubMed, Indice Medico Espanol, Cochrane Library y Embase, siguiendo nuestros criterios de inclusion: idioma de publicacion (ingles o espanol), pacientes adultos, etiologia alitiasica y apropiado diseno de estudio. Resultados: se han identificado 1.013 articulos; finalmente, se han seleccionado para la revision diez articulos que describian los resultados de pacientes tratados con colecistostomia percutanea y colecistectomia urgente, incluyendo cinco estudios observacionales controlados y cinco series de casos. No se han identificado estudios prospectivos o randomizados con los criterios de busqueda. Los datos de la literatura y el examen de los resultados indicaron que, para la colecistitis aguda alitiasica, la colecistostomia percutanea puede ser un tratamiento definitivo sin requerir una colecistectomia electiva posterior. Conclusiones: la colecistostomia percutanea puede ser la primera opcion de tratamiento en pacientes con colecistitis aguda alitiasica salvo en los casos que presenten perforacion o gangrena vesicular. Los pacientes con bajo riesgo quirurgico podrian beneficiarse de una colecistectomia, aunque ambas opciones de tratamiento pueden ser efectivas. La colecistostomia percutanea en pacientes con colecistitis aguda alitiasica puede ser un tratamiento definitivo sin necesidad de una colecistectomia electiva posterior. No obstante, la calidad de los estudios es, en general, baja y hace necesario tomar con cautela las recomendaciones finales EnglishBackground and objectives: There is currently no consensus with regard to the use of cholecystectomy or percutaneous cholecystostomy as the therapy of choice for acute acalculous cholecystitis. The goal of this study was to review the scientific evidence on the management of these patients according to clinical and radiographic findings. Methods: A systematic review of the literature from 2000 to 2016 was performed. The databases of PubMed, Indice Medico Espanol, Cochrane Library and Embase were searched according to the following inclusion criteria: publication language (English or Spanish), adult patients, acalculous etiology and appropriate study design. Results: A total of 1,013 articles were identified and ten articles were selected for review. These included five observational controlled studies and five case series which described the outcome of patients treated with percutaneous cholecystostomy and emergency cholecystectomy. No prospective or randomized studies were identified using the search criteria. The data from the literature and analysis of results suggested that percutaneous cholecystostomy may be a definitive therapy for acute acalculous cholecystitis with no need for subsequent elective cholecystectomy. Conclusions: Percutaneous cholecystostomy may be the first treatment option for patients with acute acalculous cholecystitis except in cases with a perforation or gallbladder gangrene. Patients at low surgical risk may benefit from cholecystectomy but both treatment options may be effective. Percutaneous cholecystostomy in patients with acute acalculous cholecystitis may be a definitive therapy with no need for a subsequent elective cholecystectomy. However, the overall quality of studies is low and the final recommendations should be considered with caution.