Consenso colombiano de la enfermedad inflamatoria intestinal pediátrica

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Introduction: Pediatric ulcerative colitis (CUP), pediatric Crohn's disease (PCD), and pediatric inflammatory bowel disease not classifiable (PIDNCID) have clinical and psychosocial particularities that differentiate them from those of adults and may condition different therapeutic approaches due to possible nutritional, growth and developmental repercussions, representing a challenge for the pediatrician and gastroenterologist. Objective: Develop expert consensus evidence-based recommendations for the timely and safe diagnosis and treatment of Pediatric Inflammatory Bowel Disease (PID) in children under 18 years of age for professionals caring for these patients and healthcare payers. Methodology: Through a panel of experts from the Colombian College of Pediatric Gastroenterology, Hepatology and Nutrition (COLGAHNP) and a multidisciplinary group, 35 questions were asked regarding the clinical picture, diagnosis, and treatment of PID. Through a critical review and analysis of the literature with particular emphasis on the main clinical practice guidelines (CPGs), randomized clinical trials (RCTs), and meta-analyses of the last ten years, from which the experts made 77 recommendations that responded to each of the research questions with their respective practical points. Subsequently, each of the statements was voted on within the developer group, including the statements that achieved > 80%. Results: All statements scored > 80%. PID has greater extension, severity, and evolution towards stenosis, perianal disease, extraintestinal manifestations, and growth retardation compared to adult patients, so its management should be performed by multidisciplinary groups led by pediatric gastroenterologists and prepare them for a transition to adulthood. Porto's criteria allow a practical classification of PID. In CPE, we should use the Paris classification and perform ileocolonoscopy and esophagogastroduodenoscopy, since 50% have upper involvement, using the SES-CD (UCEIS/Mayo in CUP) and taking multiple biopsies. Initial labs should include inflammatory markers and fecal calprotectin and rule out intestinal infections. Treatment, induction, and maintenance of PID should be individualized and decided according to risk stratification. Follow-up should use PCDAI and PUCAI for the last 48 hours. Immunologists and geneticists should evaluate patients with early and infantile PID. Conclusion: A consensus guideline is provided with evidence-based recommendations on timely and safe diagnosis and treatments in patients with ILD.

Manejo de hemorragia asociada a anticoagulantes orales directos: estado actual de las estrategias de reversión / Management of bleeding associated with direct oral anticoagulants: update on reversal strategies

Direct oral anticoagulants (DOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban have at least comparable efficacy as vitamin K antagonists along with a better safety profile, reflected by a lower incidence of intracranial hemorrhage. Specific reversal agents have been developed in recent years. Namely, idarucizumab, a specific antidote for dabigatran, is currently approved in most countries. Andexanet, which reverses factor Xa inhibitors, has been recently approved by the FDA, and ciraparantag, a universal antidote targeted to reverse all DOACs, is still under investigation. In this review we provide an update on the pharmacology of DOACs, the risk of hemorrhagic complications associated with their use, the measurement of their anticoagulant effect and the reversal strategies in case of DOAC-associated bleeding.

Feocromocitoma :presentación como síndrome coronario agudo: Reporte de un caso / Presentation of a pheochromocytoma as an acute coronary syndrome: Report of one case

The typical symptoms of pheochromocytoma are palpitations, sweating, headaches and hypertension. We report a 70-year-old female admitted to the hospital due to a sudden onset of precordial pain with electrocardiographic changes. After admission the patient evolved with recurrent chest pain accompanied by hypertensive paroxysms and a pheochromocytoma was suspected. Measurement of catecholamines and metanephrines confirmed the diagnosis and an abdominal magnetic resonance localized the tumor. The patient underwent surgery with successful removal of the pheochromocytoma and was discharged in good conditions.

Tormenta eléctrica en síndrome de Brugada tratada exitosamente con infusión de isoproterenol / Electrical storm in Brugada syndrome successfully treated with isoproterenol. Report of a case

We report a 22-year-old male who experienced several episodes of syncope within a timeframe of few hours. In the emergency room, multiple ventricular fibrillation episodes where documented along with a type 1 Brugada ECG pattern. Isoproterenol in continuous infusion was started, normalizing the ECG and avoiding further arrhythmia recurrences. The patient was implanted with an automated defibrillator and discharged 3 days after admission.

Terapia de resincronización en pacientes con insuficiencia cardiaca: experiencia acumulada de 10 años / Cardiac resynchronization therapy in patients with heart failure: A 10-year experience

Background: Multiple randomized trials support the clinical benefits of cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and ventricular dyssynchrony. Since the year 2000 this therapy has been increasingly used in Chile. Aim: To describe the clinical characteristics and follow-up of HF patients undergoing CRT in a single Chilean university hospital during the last 10 years. Patients and Methods: All patients undergoing CRT between 2000 and 2010 in our university hospital were included. Clinical and echocardiographic data were extracted from medical records and mortality causes were obtained from the National Identification Service. Results: A total of 252 patients underwent CRT during the study period. Seventy five percent were in New York Heart Associatin (NYHA) functional class III and mean ejection fraction was 29 ± 10%. Complete left bundle branch block was present in 55% and 20% had permanent atrial fibrillation (AF). Mean survival was 86% at 1 year and 82% of patients in NYHA class III-IV improved at least one functional class. Survival was poorer in patients with ischemic etiology (hazard ratio (HR) 1.48), functional class IV (HR 2.2), right bundle branch block (RBBB) (HR 3.1) and AF (HR 3.4). No survival differences were observed between patients with and without an implanted cardiodefibrillator. Conclusions: This series show good clinical outcomes, comparable to those reported in randomized trials. Predictors of worse survival included an ischemic etiology, functional class IV, RBBB and AF. Patients with a defibrillator had no better survival, which could be relevant in countries with limited health care resources.

Cambios en el pronóstico a largo plazo de la hipertensión arterial pulmonar / Changes long term prognosis of 17 patients with pulmonary artery hypertension

Background: Pulmonary artery hypertension (PAH) is a progressive disease with high mortality. Major advances had been made in the treatment of this condition during the last decade. Aim: To characterize the clinical evolution and mortality of a cohort of Chilean patients. Material and Methods: Seventeen patients with PAH diagnosed in the last 10 years in two Chilean hospitals were enrolled. Measurements at diagnosis included hemodynamic variables and 6-minute walk test. The patients were followed clinically for 3 years and the observed mortality was compared with that predicted by the prognostic equation proposed by the historic registry of the National Institutes of Health (NIH). Results: The mean age of patients was 45 years and 80 percent had an idiopathic PAH. The mean median pulmonary artery pressure was 57 ± 15 mmHg, the cardiac index was 2.4 ± 0.7 l/min/m² and the right atrial pressure was 12 ± 8 mmHg. The 6-minute walk distance was 348 ± 98 m. All patients received anticoagulants. Eighty two percent received ambrisentan, 12 percent received bosentan, 29 percent received iloprost and 24 percent sildenafil. At the end of follow-up only 3 patients had died, with an observed survival rate of88, 82 and 82 percent at 1, 2 and 3 years, respectively. In contrast, the survival calculated according to the predictive formula of the NIH was 67, 56 and 45 percent, respectively. Among surviving patients, an improvement in exercise capacity was observed after one year (p < 0.05). Conclusions: The observed survival rate was significantly better than that estimated according to historical data. Furthermore, therapy was associated with an improvement in functional capacity after one year. This prognostic improvement is consistent with data of other contemporary registries published after the NIH Registry.

Asociación entre strain y strain rate auricular izquierdo evaluado por speckle tracking y fibrilación auricular post cirugía de revascularización miocárdica / Speckle tracking derived left atrial strain and strain rate in patients with post myocardial revascularization atrial fibrillation

Introducción: La fibrilación auricular (FA) es la arritmia más común post cirugía de revascularización miocárdica (CRM) y está asociada a dilatación y disfunción auricular izquierda (AI). El strain y strain rate global longitudinal AI determinado por speckle tracking constituyen herramientas novedosas en la evaluación de la función AI. Objetivo: evaluar el strain y strain rate global longitudinal AI en pacientes con enfermedad coronaria con indicación de CRM y su relación con el desarrollo de FA post operatoria. Métodos: se incluyeron pacientes consecutivos con indicación de CRM, en ritmo sinusal con fracción de eyección > 50 por ciento. Se registraron características clínicas y ecocardiográficas con evaluación del strain AI: onda s (LASs) y strain rate: onda a (LASRa), onda s (LASRs) por speckle tracking (pre-cirugía). Se evaluó la ocurrencia de FA en el período post operatorio (una semana) mediante monitorización electrocardiografía continua. Se utilizó t-Student, chi-cuadrado y regresión logística múltiple. Resultados: Se incluyeron 70 pacientes, 26 por ciento presentaron FA. LASs, LASRr y LASRa estaban significativamente disminuidos en los pacientes que desarrollaron FA post CRM, LASs (10 +/- 1,1 vs 24 +/- 1,2 por ciento, p < 0,001), LASRa (- 0,6 +/- 0,1 vs - 1,8 +/- 0,12, p < 0,001) LASRs (0,6 +/- 0,007 vs 1,2 +/- 0,008, p < 0,001). Los pre-dictores independientes de FA fueron: LASRs OR: 6,1 IC 95 por ciento (1,3-15,2); LASRa OR: 2,4 IC 95 por ciento (1,1-19,6); volumen AI OR: 4,67 IC 95 por ciento (1,5-19,2) y edad > 65 años OR: 2,31 IC 95 por ciento (1,1-15,8). Conclusiones: LASs, LASRs y LASRa están disminudos en pacientes que desarrollan FA post CRM y LASRs, LASRa fueron predictores independientes de ésta.

Background: Atrial fibrillation (AF) is the commonest arrhythmia post coronary artery bypass grafting (CABG); it is associated to left atrial (LA) dilatation and dysfunction. Speckle tracking derived longitudinal strain and strain rate are novel techniques to evaluate LA function. Aim: to evaluate the relation of global longitudinal LA strain and strain rate with the development of AF in patients undergoing CABG. Methods: Consecutive patients undergoing CABG with LV ejection > 50 percent and sinus rhythm were included. Clinical characteristics were tabulated and LA echocar-diographic speckle tracking measurements, LASs, LAS-Ra, LARs, were used to determine LA strain and LA strain rate. Continuous ECG monitoring for 1 week was performed to assess the occurrence of AF. Student's t, chi square and multiple logistic regression were used for statistical analysis. Results. 70 patients were studied; 26 percent developed post-operative AF. Compared to patients remaining in sinus rhythm, patients developing post-operative AF had lower LASs (10 +/- 1,1 vs 24 +/- 1,2 percent, p < 0,001), LASRa (- 0,6 +/- 0,1 vs - 1,8 +/- 0,12, p < 0,001) and LASRs (0.6 +/- 0.007 vs 1.2 +/- 0.008, p < 0,001). Independent predictors of AF were LASRs (OR: 6.1, 95 percent CI 1.3-15.2); LASRa (OR: 2.4, 95 percent CI 1.1-19.6); LA volume (OR: 4,67, 95 percent CI 1.5-19.2) and age>65 years (OR: 2.31, 95 percent CI 1.1-15.8). Conclusion.: LASs , LASRs and LASRa are lower in patients who develop AF after CABG and LASRs and LASRa were independent predictors of post-operative AF. Thus, LA strain rate assessed by speckle tracking is useful for predicting AF after CABG in addition to classic risk factors such as age and LA volume.

Strain y strain rate auricular izquierdo evaluado por speckle tracking está relacionado a PCR ultrasensible en adolescentes obesos / Speckle tracking derived left atrial strain and strain rate are related to high sensitive C reactive protein in obese adolescents

Introducción: La obesidad y el síndrome metabólico están asociados a un tamaño auricular izquierdo (AI) aumentado y mayor riesgo cardiovascular. El strain y strain rate longitudinal determinado por speckle tracking son herramientas novedosas en la evaluación de la función AI. Objetivo: evaluar el strain y strain rate AI en adolescentes obesos y su relación con biomarcadores de riesgo cardiovascular. Métodos: se incluyeron adolescentes consecutivos con un z-índice de masa corporal (z-IMC) > 1 en ritmo sinusal sin otra comorbilidad y un grupo control pareado por edad y sexo. Se registraron las características clínicas y ecocardiográficas con evaluación del strain AI: onda s (LASs), onda a (LASa) y strain rate AI: onda s (LASRs), onda a (LASRa) por speckle tracking. Se midió adiponectina y PCR ultrasensible. Se utilizó t-Student, chi-cuadrado y correlación de Pearson. Resultados: Se incluyeron 15 sujetos por grupo de edad promedio de 13 años, 47 por ciento hombres sin diferencia entre ambos grupos. Los pacientes con sobrepeso presentaron significativamente mayores niveles de PCR us respecto del grupo control, 0,5 +/- 0,1 mg/L vs 1,4 +/- 0,3, p = 0,04 y menores de LASs (44 +/- 1,8 vs 32 +/-1,1 por ciento;p<0,01), LASa ( -1,7 +/- 0,3 vs -0,7 +/- 0,3 1/s; p<0,01), LASRs ( 1,7 +/- 0,07 vs 1,3 +/- 0,03 por ciento; p<0,01), LASRa (-1,8 +/- 0,1 vs -1,2 +/-0,08 1/s;p<0,01). En el grupo con sobrepeso se encontró una correlación negativa significativa entre LASs, LASRs y PCR ultrasensible (R: -0,62; p < 0,01 y R: -0,58: p = 0,02 respectivamente). Conclusiones: El strain y strain rate AI se encuentran reducidos en adolescentes obesos y estos parámetros de función AI se correlacionan con un estado inflamatorio aumentado. La importancia clínica de estos hallazgos requieren mayor investigación.

Background: Obesity is an emerging problem in children worldwide and a well-known risk factor for atrial fibrillation (AF) in adulthood. There is some evidence that functional and structural changes responsible for the development of AF may arise early in life. Left atrial (LA) strain and strain rate, assessed by speckle tracking, are indices of LA function and correlate with the development of AF. Objective: To evaluate LA strain and strain rate in obese adolescents and their correlation with plasma levels of high sensitive C reactive protein (hs-CRP) and adiponec-tin, two markers of cardiovascular risk. Methods: Fifteen obese adolescents, age 13 +/- 0.2 yr, body mass index (BMI)-z-score 1.9 +/- 0.16 and 15 lean controls were recruited. All patients underwent transtho-racic echocardiography with evaluation of LA strain and strain rate: a wave (LASa and LASRa) and s wave (LASs and LASRs). Plasma levels of hs-CRP was determined. Student's t test, chi-square and Pearson correlation were used for statistical analysis. Results: Obese patients had a lower LASs (44 +/- 1.8 vs 32 +/- 1.1 percent, p < 0.01), LASa (- 1.7 ± 0.3 vs - 0.7 +/- 0.1, p < 0.01), LASRs (1.7 +/- 0.07 vs 1.3 +/- 0.03, p < 0.01) and LASRa (- 1.8 +/- 0.1 vs - 1.2 +/- 0.08, p < 0.01). Plasma hs-CRP levels were significantly higher in the obese group and displayed a significant inverse correlation with LASs (r: - 0.62, p < 0.01) and LASRs (r: - 0.58, p = 0.02). Conclusion: Obese adolescents had an impaired LA function compared to age-matched lean subjects, which correlated with an increased inflammatory state. It is likely that LA dysfunction may predispose to AF later in life.