Interrelación entre enfisema y disfunción diastólica ventricular izquierda: nuestra experiencia en el Hospital Privado Centro Médico de Córdoba / Interrelation between emphysema and diastolic dysfunction left ventricular: our experience in the Hospital Private Medical Center of Córdoba

Introducción: Las consecuencias hemodinámicas de la hiperinflación y el enfisema se producen por compresión cardíaca debido a elevadas presiones intratorácicas, lo que produciría disfunción diastólica ventricular izquierda subclínica. Nuestro objetivo es correlacionar el porcentaje de enfisema con parámetros de función pulmonar y con el tamaño de las cámaras cardíacas, función sistólica ventricular global y función diastólica ventricular izquierda, en la enfermedad pulmonar obstructiva crónica. Materiales y Métodos: participaron pacientes con enfermedad pulmonar obstructiva crónica moderada y severa asistidos en un Servicio de Neumonología del Hospital Privado Centro Médico de Córdoba, desde el 01 de enero al 31 de octubre de 2014. Se cuantificó el volumen y porcentaje de enfisema por tomografía computada de alta resolución, se realizaron espirometría, prueba de marcha de seis minutos, determinación de volúmenes pulmonares y ecocardiograma Doppler color. Resultados: Se encontró correlación negativa y significativa del porcentaje de enfisema con el porcentaje del valor teórico del VEF1 postbroncodilatador (p = 0.005) y el cociente VEF1/CVF postbroncodilatador (p = 0.004) y; además, entre el cociente VEF1/CVF postbroncodilatador y el volumen del enfisema en cm3 (p = 0.000). De un subgrupo de 20 pacientes. Siete pacientes (35%) presentaron diagnóstico de disfunción diastólica ventricular izquierda de grado I. Se encontraron correlaciones negativas pero no significativas entre el porcentaje de enfisema con función sistólica ventricular global y el tamaño de las cámaras cardíacas. Conclusiones: Se destaca la utilidad del ecocardiograma para reducir el sub diagnóstico de disfunción diastólica ventricular izquierda. Se destaca la importancia que tendrían la hiperinflación y el enfisema en el deterioro del patrón de llenado diastólico ventricular izquierdo y en la reducción del tamaño de las cámaras cardíacas con disminución en la tolerancia al ejercicio.

Interrelationship between Emphysema and Left Ventricular Diastolic Dysfunction: our experience in the Hospital Privado Centro Médico de Córdoba

Introduction: The hemodynamic consequences of hyperinflation and emphysema are produced by cardiac compression due to high intrathoracic pressures, which could produce subclinical left ventricular diastolic dysfunction. Our purpose is to correlate the percentage of emphysema with lung function parameters and cardiac chamber sizes, the global ventricular systolic function and the left ventricular diastolic function, in cases of chronic obstructive pulmonary disease. Materials and Methods: The participants were patients with moderate and severe chronic obstructive pulmonary disease treated in the Pulmonology Service of the Hospital Privado Centro Médico de Córdoba from January 1st to October 13th, 2014. We quantified the volume and percentage of emphysema by high resolution computed tomography and carried out a spirometry, a Six Minute Walk Test, measurement of pulmonary volumes and color Doppler echocardiography. Results: We found a significant negative correlation between the percentage of emphysema and the percentage of the post-bronchodilator FEV1 theoretical value (p = 0.005) and the post-bronchodilator FEV1/FVC (Forced Expiratory Volume in First Second/Forced Vital Capacity) quotient (p = 0.004), and, also, between the post-bronchodilator FEV1/FVC quotient and the emphysema volume in cm3 (p = 0.000). Out of a sub-group of 20 patients, seven patients (35%) were diagnosed with grade I left ventricular diastolic dysfunction. We found negative, but not significant correlations between the percentage of emphysema and global ventricular systolic function and cardiac chamber sizes. Conclusions: We should emphasize the usefulness of the echocardiography in reducing sub-diagnoses of left ventricular diastolic dysfunction. We should also stress on the importance hyperinflation and emphysema would have in the impairment of the left ventricular diastolic filling pattern and in the decrease in cardiac chamber sizes, with a decrease in exercise tolerance.

Biosurfactant Production by Bacillus strains isolated from sugar cane mill wastewaters

Abstract Biosurfactants possess diverse chemical properties and provide important characteristics to the producing microorganisms, which can act as surface-actives and emulsifiers of hydrocarbon and others water insoluble substances. Most of them are lipopeptides synthetized by Bacillus. This study evaluated the biosurfactant production by strains of Bacillus previously obtained from liquid residues of sugar-alcohol industry. The bacterial isolates LBPMA: BSC, BSD, J1, J2 and L1 were cultivated in medium that induces production of biosurfactants (Landy medium). During 48 h of incubation, at intervals of 12 h, the total contents of proteins, reducing carbohydrates and surfactant activity of the filtrated growth media free of cells were evaluated. The results showed that these strains use glucose as a source of carbon, energy and for synthesis of surfactant. In this medium (24 h), the best producer of biosurfactant was the strain LBPMA-J2, molecularly identified as Bacillus thuringiensis. Once the supernatant free of cells of this microorganism disperses the oil phase in the water, this strain has potential for being utilized on bioremediation processes.

Encuesta sobre el uso de Ventilación no invasiva en instituciones públicas y privadas Argentinas: Conociendo la realidad de su aplicación / Survey on the Use of Noninvasive Ventilation in Public and Private Institutions in Argentina. Getting to know the Reality of its Application

Con el objetivo de explorar en nuestro país, la realidad de la aplicación de ventilación no invasiva (VNI), se realizó una encuesta electrónica entre los profesionales de la Asociación Argentina de Medicina Respiratoria y la Sociedad de Medicina Interna de Buenos Aires. Se determinaron las diferencias de utilización de ventilación no invasiva entre las instituciones públicas y privadas y se evaluó el rol de las distintas especialidades y ámbitos de cuidado en su indicación y monitoreo. Respondieron la encuesta 443 profesionales, se concluyó que en distintas instituciones públicas y privadas, la ventilación no invasiva es una terapéutica que se encuentra desarrollada uniformemente en Instituciones Privadas y Públicas. La indicación de ventilación mecánica no invasiva fue principalmente realizada por intensivistas y neumonólogos, y el manejo en Sala Común recayó con mayor frecuencia en los kinesiólogos. Su aplicación fue significativamente mayor cuando en los centros existía un programa de residencias, específicamente en Neumonología y Fisioterapia Respiratoria. Se atribuyeron como principales causas de no aplicación la carencia de equipos, de interfaces, falta de información y de entrenamiento de personal de enfermería, médicos y kinesiólogos. Poder conocer con qué recursos cuentan los profesionales de estas dos sociedades en el ambiente público y privado nos permitirá aplicar conductas para mejorar nuestra realidad y poder usar esta herramienta, tan valiosa, de soporte ventilatorio.

Survey on the Use of Noninvasive Ventilation in Public and Private Institutions in Argentina: Getting to know the Reality of its Application

With the purpose of exploring the reality of the application of noninvasive ventilation (NIV) in our country, we carried out an electronic survey among the professionals of the Argentinian Association of Respiratory Medicine and the Society of Internal Medicine of Buenos Aires. The differences in the use of noninvasive ventilation between public and private institutions were determined, and we evaluated the role of the different specialties and areas of care in its indication and monitoring. 443 professionals participated in the survey, and we concluded that the noninvasive ventilation treatment is uniformly developed in private and public entities. Noninvasive mechanical ventilation was mainly indicated by pulmonologists and intensive care physicians, and most frequently managed in the general ward by physiotherapists. It was most frequently applied in centers with residency programs, specifically in pulmonology and respiratory physical therapy. The reasons for which noninvasive ventilation was not applied were mainly the lack of equipment and interfaces, and the lack of information and training of nurses, physicians and physiotherapists. Knowing which resources are available to the professionals of these two societies in the public and private areas will let us apply behaviors to improve our reality and use this very valuable tool of ventilatory support.

Bloqueo supraclavicular ecoguiado por abordaje perivascular medial. Descripción anatómica, técnica de bloqueo y cambios de perfusión regionales / Ultrasound guided supraclavicular perivascular block. Anatomical, technical medial approach description and changes in regional perfusion

Abstract Introduction: Supraclavicular block is usually performed using a lateral to medial approach, although a medial to lateral approach is also feasible. Block onset may be evaluated through the sympathetic effect associated with the sensitive and motor blockade. Objective: To describe the ultrasound-guided supraclavicular block using a medial approach, evaluating the sensitive, motor, and sympathetic block onset. Materials and methods: An ultrasound-guided supraclavicular block was performed in a fresh cadaver with 20 ml volume (2 ml of iodine and 1 ml of methylene blue). A CT scan was performed and sagittal sections were obtained. The clinical phase included 10 patients undergoing a medial approach block; the onset of the block was evaluated based on a motor, sensory and sympathetic assessment (measuring flow changes in the humeral artery, the palmar temperature, and the perfusion index). Results: Adequate distribution of the contrast medium was observed in the cadaver, with complete spread through the brachial plexus, both in terms of the CT-reconstruction as in the anatomical cross sections. A significant change in all the sympathetic block parameters was observed 5 min after the bock: temperature (32.5 ± 1.8 °C to 33.4 ± 1.7 °C; p = 0.047), humeral arterial flow (105 ± 70ml/min to192 ± 97ml/min; p = 0.007), and thumb perfusion index (5 ± 3 to 10 ± 3%; p=0.002). The block was effective and uneventful in all patients. Conclusions: This supraclavicular approach achieves a homogeneous distribution throughout the brachial plexus, with high anesthetic efficacy. Regional changes secondary to the sympathetic block occur early after the block.

Resumen Introducción: El bloqueo supraclavicular habitualmente se realiza mediante abordaje lateral a medial, si bien puede realizarse de medial a lateral y su instauración puede evaluarse por el efecto simpático asociado al bloqueo sensitivo y motor. Objetivo: Describir el bloqueo supraclavicular ecoguiado por abordaje medial evaluando la instauración del bloqueo sensitivo, motor y simpático. Materiales y métodos: Se realizó el bloqueo supraclavicular ecoguiado en cadáver fresco con 20ml de volumen (con 2ml de yodo y 1ml de azul de metileno). Se realizó una tomografía computarizada y posteriormente cortes anatómicos sagitales. En la fase clínica se incluyeron 10 pacientes a quienes se les realizó el bloqueo y posteriormente se evaluó la instauración del bloqueo con valoración sensitiva, motora y simpática (cambios en flujo arterial humeral, temperatura palmar y el índice de perfusión). Resultados: En el cadáver se evidenció una adecuada distribución del medio de contraste bañando la totalidad del plexo braquial, tanto en la reconstrucción tomográfica como en los cortes seccionales anatómicos. Alos 5 min del bloqueo se observó un cambio significativo de todos los parámetros de bloqueo simpático: temperatura (32,5 ± 1,8 a 33,4 ± 1,7 。C; p = 0,047), flujo arterial humeral (105 ± 70 a 192 ± 97ml/min; p = 0,007) e índice de perfusión del pulgar (5 ± 3 a 10 ± 3%; p = 0,002). El bloqueo fue efectivo en todos los pacientes y sin complicaciones. Conclusiones: El abordaje supraclavicular propuesto logra una correcta distribución en el plexo braquial con elevada eficacia anestésica. Los cambios regionales secundarios al bloqueo simpático son precoces tras el bloqueo.

Physicochemical composition and antioxidant potential of bee pollen from different botanical sources in Alagoas, Brazil / Composição fisico-química e potencial antioxidante de pólen apícola de diferentes origens botânicas em Alagoas, Brasil

ABSTRACT Bee pollen results from the mixture of pollen and floral nectar with the salivary substances of bees and has increasingly been used as a food with therapeutic properties. In this study, 30 samples of bee pollen from Apis mellifera apiaries in three mesoregions of Alagoas (Brazil) - Mata Atlântica, South Coast and Caatinga, were collected during the dry season of 2008/09 and analysed. Mata Atlântica and Caatinga had good production of bee pollen. In the same season, Mata Atlântica contained a higher diversity of pollen types for feeding bees with a predominance of herbaceous pollen (63%), whereas the Caatinga samples contained monofloral pollen. Physicochemical data were analysed with the nonparametric Kruskal-Wallis statistical test. The Caatinga samples were analysed to determine their contents of total phenolic compounds (25.85 ± 10.80 mg gallic acid eq/g) and flavonoids (45.62 ± 32.19 mg quercetin eq/g) and their antioxidant activity (for instance, 70.62 ± 4.50% in the DPPH test), which were possibly affected by the environmental conditions of this biome.

RESUMO O pólen apícola resulta da mistura de pólen e néctar floral com substâncias salivares da abelha, e emerge como um alimento com propriedades terapêuticas. Neste trabalho foram analisadas 30 amostras desse material de apiários (Apis mellifera), coletadas durante a estação seca de 2008/09 em três mesorregiões de Alagoas - Mata Atlântica, Costa Sul e Caatinga. A Mata Atlântica e a Caatinga foram regiões boas produtoras de pólen apícola. Na mesma época, a Mata Atlântica apresentou a maior diversidade de tipos de pólen para alimentar abelhas, com predominância de herbáceas (63%), enquanto as amostras de Caatinga foram monoflorais. Os dados físico-químicos foram analisados pelo teste estatístico não paramétrico de Kruskal-Wallis. As amostras da Caatinga se destacaram quanto ao teor de fenóis (25,85 ± 10,80 eq. mg Ácido Gálico/g), flavonoides totais (45,62 ± 32,19 eq. mg Quercetin/g), e atividade antioxidante (através do teste do DPPH, por exemplo, 70,62 ± 4,50%), provavelmente devido à condição ambiental deste bioma.

Total carotenoids and antioxidant activity of fillets and shells (in natura or cooked) of "Vila Franca" shrimp (Litopenaeus Schmitti) in different intervals of storage under freezing / Carotenóides totais e atividade antioxidante dos filés e cascas (in natura ou cozida) do camarão "Vila Franca" (Litopenaeus schmitti) em diferentes intervalos de armazenamento sob congelamento

ABSTRACT Shrimps are sources of carotenoids, astaxanthin is the predominant, responsible for their special and desirable properties, as well as for their instability under heat treatment during the domestic preparation, industrial processing or storage under freezing. These can cause discoloration and reduce the beneficial health properties. This study aimed to evaluate the effect of heat treatment and storage under freezing (0, 45 and 90 days) on the levels of total carotenoids and stability of the antioxidant activity of ethanolic extracts of fillets and shells, raw and cooked, of the white shrimp ("Vila Franca") Litopenaeus schmitti (Burkenroad, 1938). The antioxidant ability of the extracts was evaluated using the radicals DPPH• (2,2-diphenyl-1-picryl-hydrazyl) and ABTS+• (2,2'-azino-bis (3-ethylbenzothiazoline-6 sulfonic acid), as well as by the iron reducing power (FRAP) test. The extracts of cooked or in natura shrimps (fillets and shells) represent dietary sources of carotenoids, displaying antioxidant activity through all the tested methods, after heat treatment and storage under freezing. The antioxidant activity of the extracts was superior to the one of ascorbic acid, mainly in the cooked fillet and shells. The samples of shrimp shells seemed a valuable source of carotenoids, whose antioxidant activity was verified even 90 days after freezing, and can be used in food products as functional natural supplement, adding value to this waste.

RESUMO Os camarões são fontes de carotenóides, sendo a astaxantina o predominante, responsáveis por suas propriedades especiais e desejáveis, e também a causa da sua instabilidade pelo tratamento térmico durante o preparo doméstico, processamento industrial ou armazenamento sob congelamento, que pode causar descoloração e redução de suas propriedades benéficas à saúde. Este trabalho visou avaliar o efeito do tratamento térmico e armazenamento sob congelamento (0, 45 e 90 dias) nos teores de carotenóides totais e na estabilidade da atividade antioxidante dos extratos etanólicos de filé e cascas, cruas ou cozidas, de camarão "Vila Franca" Litopenaeus schmitti (Burkenroad, 1938). A capacidade antioxidante dos extratos foi avaliada utilizando os radicais DPPH• (2,2-difenil-1-picril-hidrazila) e ABTS+• (2,2'-azino-bis-(3-etilbenzotiazolina-6- acido sulfônico), bem como pelo teste do poder redutor do ferro (FRAP). Os extratos do camarão cozido ou in natura (filé e cascas), representam fontes dietéticas de carotenóides, exibindo atividade antioxidante através de todos os métodos testados, após o tratamento térmico e armazenamento sob congelamento. A atividade antioxidante dos extratos foi superior a de ácido ascórbico, principalmente no filé e cascas cozidos. As amostras de cascas de camarão parecem uma valiosa fonte de carotenóides, cuja atividade antioxidante foi verificada até 90 dias após o congelamento, e pode ser utilizado nos produtos alimentares como suplemento natural funcional, agregando valor a esses resíduos.

Awake insertion of a Laryngeal Mask Airway-Proseal™ as alternative to awake fiberoptic intubation in management of anticipated difficult airway in ambulatory surgery / Inserção de máscara laríngea ProSeal™ em paciente acordado como opção para intubação por meio de fibra óptica para o manejo de via aérea difícil prevista em cirurgia ambulatorial

Abstract Background and objectives The decision whether to manage an ambulatory patient with a previously documented difficult airway with a supraglottic device remain controversial. We report an awake insertion of a Laryngeal Mask Airway Proseal™ in a patient with known difficult airway scheduled for ambulatory surgery. Case report A 46-yr-old woman was programmed as a day case surgery for breast nodule resection. Her anesthetic record included an impossible intubation with cancelation of surgery and subsequent awake fibroscopic intubation. She reported emotional distress with the previous experience and declined this approach. In view of the previous experience, an awake airway control with a Laryngeal Mask Airway Proseal™ was planned after explaining and reassuring the patient. After adequate topicalisation, a size 4 Laryngeal Mask Airway Proseal™ was successfully inserted after two attempts, and their patency was confirmed by capnography. Anesthesia was induced intravenously and the surgery was uneventful. Conclusion We describe a feasible alternative strategy to awake intubation in a patient with known difficult airway undergoing ambulatory surgery. In this specific clinical situation, if tracheal intubation is deemed unnecessary, awake supraglottic airway might allow adequate ventilation and their use should be considered.

Resumo Justificativa e objetivo A decisão quanto ao manejo de paciente ambulatorial com via aérea difícil previamente diagnosticada com o uso de dispositivo supraglótico permanece controversa. Relatamos o caso de inserção de máscara laríngea ProSeal™ em paciente acordado, com via aérea difícil prevista, agendado para cirurgia ambulatorial. Relato de caso Paciente do sexo feminino, 46 anos, programada para cirurgia de ressecção de nódulo de mama com alta hospitalar no mesmo dia. A história anestésica incluía uma intubação impossível, com o cancelamento da cirurgia e posterior intubação com o uso de fibroscópio, com a paciente acordada. A paciente relatou que ficou emocionalmente abalada com a experiência anterior e recusou essa abordagem. Considerando essa experiência anterior, uma abordagem das vias aéreas com a paciente acordada e o uso de uma máscara laríngea ProSeal™ foi planejada, após se explicar o procedimento para a paciente e tranquilizá-la. Após topicalização adequada, uma máscara laríngea (LMA ProSeal™) de tamanho 4 foi inserida com sucesso depois de duas tentativas e a permeabilidade foi confirmada por capnografia. A anestesia foi induzida por via intravenosa e a cirurgia foi feita sem intercorrências. Conclusão Descrevemos uma estratégia opcional viável para a intubação em uma paciente acordada com via aérea difícil previamente diagnosticada submetida a cirurgia ambulatorial. Nessa situação clínica específica, quando a intubação traqueal é considerada desnecessária, a via aérea supraglótica em paciente acordado pode permitir uma ventilação adequada e seu uso deve ser considerado.

Factors associated with infections in spinal surgery / Fatores associados a infecções em cirurgia da coluna vertebral / Factores asociados a las infecciones en cirugía de columna

ABSTRACT Objective: To identify the factors associated with postoperative infections in spinal surgery. Methods: Descriptive, retrospective, cross-sectional study conducted in the spine surgery department of the Medical Unit of High Specialty (UMAE) at the Hospital of Traumatology and Orthopedics Lomas Verdes, Mexican Institute of Social Security (IMSS) between January 01, 2013 and June 30, 2014 through medical records of the service and the records of clinical care. Data were gathered in accordance with the records of patients with infection after spinal surgery. The factors considered were age group, etiologic agent, surgical site, type of treatment, bleeding volume and pharmacotherapy. Frequency and descriptive statistic was conducted. The rank sum test with the Wilcoxon test for a single sample was performed in different measurements; Pearson's correlation was calculated and all p<0.05 values were considered significant. Results: The sample was composed of 14 patients of which 11 were female (78.6%) and 3 male (21.4%) with predominance of surgical area in the lumbar and dorsolumbar region. There was a significant correlation between the surgical time and the amount of bleeding with p<0.001. Conclusions: It was clear that the infections present in patients after spinal surgery are multifactorial. However, in this study the correlation between time of surgery and bleeding amount had the highest importance and relevance.

RESUMO Objetivo: Identificar os fatores associados a infecções pós-operatórias em cirurgia da coluna vertebral. Métodos: Estudo descritivo, retrospectivo, transversal, no serviço de cirurgia da coluna vertebral da Unidade Médica de Alta Especialidade (UMAE), Hospital de Traumatologia e Ortopedia Lomas Verdes, Instituto Mexicano de Seguro Social (IMSS), entre 1 de janeiro de 2013 e 30 de junho de 2014, por meio de registros de serviços e de registros do expediente clínico. Foram coletadas informações de acordo com os registros de pacientes com infecção pós-operatória em cirurgia da coluna vertebral. Os fatores considerados foram faixa etária, agente etiológico, local da cirurgia, tipo de tratamento, volume de sangramento e farmacoterapia. A estatística foi descritiva e de frequência. Realizou-se o teste de soma de postos com o teste de Wilcoxon para uma única amostra, em diferentes medições; a correlação de Pearson foi calculada e todos os valores de p < 0,05 foram considerados significantes. Resultados: Foram reunidos 14 pacientes, dos quais eram 11 do sexo feminino (78,6%) e 3 do sexo masculino (21,4%), com predominância de área cirúrgica na região lombar e dorsolombar. Verificou-se correlação significante entre o tempo de cirurgia e o volume de sangramento de p < 0,001. Conclusões: Ficou claro que as infecções presentes em pacientes depois da cirurgia de coluna vertebral são multifatoriais. No entanto, neste estudo a correlação entre tempo de cirurgia e volume de sangramento tem a maior importância e relevância.

RESUMEN Objetivo: Identificar los factores asociados a las infecciones postoperatorias en cirugía de columna. Métodos: Se realizó un estudio descriptivo, retrospectivo, transversal, en el servicio de cirugía de columna de la Unidad Médica de Alta Especialidad (UMAE), Hospital de Traumatología y Ortopedia Lomas Verdes, Instituto Mexicano del Seguro Social (IMSS) entre 01 de enero de 2013 y 30 de junio de 2014 utilizando los registros del servicio y los de expediente clínico. Se recabó información de acuerdo a los registros de pacientes con infección postoperatoria en cirugía de columna. Los factores que se tomaron en cuenta fueron grupo etario, agente etiológico, área quirúrgica, tipo de tratamiento, volumen de sangrado, tiempo quirúrgico, farmacoterapia utilizada. Se realizó estadística de frecuencia y descriptiva. Se realizó la prueba de suma de rangos con la prueba de Wilcoxon para una sola muestra en diferentes mediciones; se realizó la correlación de Pearson y se tomó como significativo todo valor de p < 0,05. Resultados: Fueron 14 pacientes de los cuales 11 del sexo femenino (78,6%) y 3 del sexo masculino (21,4%), con un predominio de área quirúrgica en la región lumbar y dorsolumbar. Se encontró una correlación significativa entre el tiempo quirúrgico y el volumen de sangrado de p < 0,001. Conclusiones: Es claro que las infecciones presentes en pacientes después de cirugía de columna son de origen multifactorial. Sin embargo, en este estudio se encuentran de mayor significancia y relevancia la correlación de volumen de sangrado y el tiempo quirúrgico.

Recomendaciones de vacunación en adultos con enfermedades respiratorias: Documento de la Asociación Argentina de Medicina Respiratoria para los neumonólogos / Recommendations on Vaccination for Adults with Respiratory Diseases. Document of the Argentina Association of Respiratory Medicine for Pulmonologists

El neumonólogo de adultos acostumbra a prescribir vacunas. Este documento hecho por expertos en aspectos de la especialidad que involucran vacunar a pacientes con enfermedades respiratorias, perteneciente a la Asociación Argentina de Medicina Respiratoria, resumió la información disponible proponiendo una participación activa en la vacunación contra influenza (VAG), neumococo (VAN), pertusis y zoster. El Ministerio de Salud (MSAL) en Argentina, como el CDC y su comité de consulta sobre inmunización (ACIP) en Estados Unidos, elaboran calendarios y recomendaciones para vacunación. La ACIP recomienda la VAG a mayores de 6 meses sin contraindicaciones; el MSAL a mayores de 65 años y a quienes tengan comorbilidades (incluye enfermedades respiratorias y tabaquismo) o contacto con personas vulnerables. La clásica VAN polisacárida de 23 serotipos es recomendada para adultos con riesgo de enfermedad invasiva, incluyendo a mayores de 65 años, revacunando a los inmunosuprimidos y una única vez a los mayores de 65 que hubieran sido vacunados 5 años antes o más; la ACIP recomienda dar la VAN conjugada de 13 serotipos, más inmunogénica, secuencialmente con la polisacárida de 23, en adultos con factores de riesgo y en mayores de 65 años. Sugerimos usarla en menores de 65 con comorbilidad respiratoria. El neumonólogo debe recordar al menos 2 vacunas más: dar el refuerzo decenal contra difteria y tétanos (DT) en mayores de 18, una vez con vacuna triple acelular (difteria, pertusis y tétanos) protegiendo contra pertusis y reduciendo su transmisión. El herpes zoster produce un rash cutáneo vesicular doloroso. Uno cada 2 mayores de 85 sufrirán al menos un ataque de herpes zoster. La vacuna reduce más del 50% la incidencia y más del 60% la neuralgia post herpética; el ACIP la recomienda en mayores de 60 años. Un gran número de los pacientes con afecciones pulmonares crónicas tienen esa edad.

The pulmonologist uses to prescribe vaccines to adult patients. Experts of the Argentina Association of Respiratory Medicine who are specialists in areas involving vaccination of patients with respiratory diseases prepared this document which summarizes the available information and proposes an active prescription of the infuenza, pneumococcus, pertussis and herpes zoster vaccinations. The Ministry of Health in Argentina as the CDC and its Advisory Committee on Immunization Practices (ACIP) in the USA, made recommendations on vaccination indications and schedules. The ACIP recommends influenza vaccination to persons older than 6 months of age without any contraindication. The Ministry of Health recommends this vaccination to persons over 65 years of age, to those with morbidities (including respiratory diseases and smoking habit) and to persons in contact with high risk people. The classic 23-valent polysaccharide pneumococcal vaccine is recommended for adults at risk of invasive disease, including persons over 65 years of age. Revaccination is recommended to immunosuppressed patients and persons over 65 years of age at 5-year intervals. The ACIP recommends vaccination with the 13-valent serotypes polysaccharide pneumococcal vaccine, which is more immunogenic, sequentially with the 23-valent vaccine in adults with risk factors and over 65 years of age. We suggest this practice in patients under 65 years of age with respiratory morbidities. The pulmonologist must remember at least two other vaccines: a booster vaccination every 10 years of diphtheria and tetanus vaccine to persons over 18 years of age, and once the triple acellular vaccine (diphtheria, pertussis and tetanus) to protect against pertussis and reduce transmission. Herpes zoster (shingles) causes a painful vesicular rash; 50% of persons over 85 years suffer at least one bout of herpes zoster. The vaccine reduces more than 50% incidence and more than 60% postherpetic neuralgia. This vaccine is recommended by ACIP for persons over 60 years. In this age group there are many patients with chronic lung conditions.

Acute pancreatitis: Reflections through the history of the Atlanta Consensus / Pancreatitis aguda: reflexiones a través de la historia del Consenso de Atlanta / Pancreatites aguda: reflexões através da história do Consenso de Atlanta

Acute pancreatitis is an inflammatory process with systemic and local repercussions. Most cases are mild with a low mortality rate, but 20% of patients have severe pancreatitis, with a mortality rate up to 30%. Throughout the years, the medical community has tried to reach a consensus about this disease to better understand, classify and treat it. The most important consensus is known as the Atlanta Consensus of 1992, which has been in use for many years. However, it has recently been the subject of various proposals for change and updating, which are discussed in this review.

La pancreatitis aguda es un proceso inflamatorio con repercusiones sistémicas y locales; la mayoría de los casos son leves con baja tasa de mortalidad, pero el 20% de los pacientes sufren pancreatitis grave cuya tasa de mortalidad puede llegar a ser hasta de un 30%. A lo largo de los años se ha intentado llegar a consensos acerca de esta enfermedad con el fin de orientar a la comunidad médica hacia su mejor entendimiento, clasificación y tratamiento. El más importante de estos ha sido conocido como el Consenso de Atlanta de 1992, vigente por muchos años, pero que está siendo objeto de diferentes propuestas de modificación y actualización, que se discuten en este artículo de revisión.

A pancreatites aguda é um processo inflamatório com repercussões sistémicas e locais; a maioria dos casos são leves com baixa taxa de mortalidade, mas 20% dos pacientes sofrem pancreatites grave cuja taxa de mortalidade pode chegar a ser até de um 30%. Ao longo dos anos se tentou chegar a consensos a respeito desta doença com o fim de orientar à comunidade médica para seu melhor entendimento, classificação e tratamento. O mais importante destes foi conhecido como o Consenso de Atlanta de 1992, vigente por muitos anos, mas que está sendo objeto de diferentes propostas de modificação e atualização, que se discutem neste artigo de revisão.

El desafío y la recompensa del enfoque multidisciplinario en las enfermedades intersticiales / The challenge and reward of focus multidisciplinary in diseases interstitial

En el último número de la RAMR (2014,2:171- 182) se presentó una paciente con Desorden bronquiolar primario de difícil diagnóstico, que fue discutido en el Ateneo del Hospital Angel C. Padilla de la Provincia de Tucumán. Considerando lo expuesto en la historia clínica, es de utilidad analizar tres aspectos: I. El amplio espectro clínico de fiebre e infiltrados pulmonares difusos, con sus posibles diagnósticos etiológicos en base a la integración de los hallazgos clínicos, de laboratorio e imágenes; definiendo en primer lugar si el cuadro es agudo, subagudo o crónico

Detección de compromiso respiratorio subdiagnosticado en transportistas de la ciudad de Córdoba / Detection of Underdiagnosed Respiratory Conditions Among Professional Drivers in Córdoba City

Los transportistas pueden constituir una población con características especiales: sedentarismo, tabaquismo y obesidad, que los predispone a numerosas enfermedades crónicas. Los objetivos de este trabajo fueron evaluar la prevalencia de compromiso respiratorio subdiagnosticado de tabaquismo y obesidad en transportistas de la Provincia de Córdoba. Material y métodos: Evaluación de 297 transportistas durante el examen médico para renovación de su licencia, en una clínica de la ciudad de Córdoba, a través de una encuesta anónima auto-administrada y espirometría. Resultados: La prevalencia de síntomas respiratorios fue de 81.1% y la de tabaquismo de 59.3%. El 46.1% fuma > 10 cigarrillos/día. De los sujetos con espirometría obstructiva, el 55.5% tiene historia de tabaquismo. La prevalencia de obesidad fue del 44.1% y de sobrepeso/obesidad 84.8%. No hubo correlación entre IMC aumentado y alteración espirométrica. El grupo de sobrepeso/obesidad tuvo mayor prevalencia de síntomas sugestivos de SAHOS ya sea en el análisis de síntomas individuales (ronquidos p = 0.0001, apneas p = 0.03 y somnolencia p = 0.05) como en forma conjunta (p = 0.016). Conclusiones: Se encontró patología obstructiva subdiagnosticada en el 10% de la población estudiada y un elevado porcentaje de sujetos con síntomas sugestivos de SAHOS. La prevalencia de tabaquismo fue doble de la media nacional y 30% superior a la media de la provincia de Córdoba. La prevalencia de obesidad fue 3 veces más elevada que la reportada en el país, con más del 80% de la muestra con IMC > 25 kg/m2.

Professional drivers may constitute a population with special features: sedentary lifestyle plus prevalence of smoking habit and obesity, which predispose them to several chronic diseases. The objectives of this study were to evaluate the prevalence of underdiagnosed respiratory conditions, smoking habit and obesity, among professional drivers of Cordoba province. Material and Methods: Evaluation of 297 professional drivers during the medical examination for driving license renewal, at a clinic in the city of Córdoba, through a self - administered anonymous questionnaire and spirometry. Results: The prevalence of respiratory symptoms was 81.1% and that of the smoking habit was 59.3%; 46.1% smoked >10 cigarettes/day. In the group of subjects with obstructive spirometry, 55.5% had a history of smoking. The prevalence of obesity was 44.1% and overweight/obesity 84.8%. There was no correlation between increased BMI and spirometric impairment. The group of overweight/obesity had a higher prevalence of symptoms suggestive of OSA, both in the analysis of individual symptoms (snoring p = 0.0001, apnea p = 0.03 and somnolence p = 0.05 ) and in the analysis of all the symptoms together (p = 0.016). Conclusions: Obstructive underdiagnosed pathology was found in 10% of the study population and in a high percentage of subjects with symptoms suggestive of OSA. Smoking habit prevalence was twice the national average and 30% higher than the average of the Cordoba province. The prevalence of obesity was 3 times higher than that reported in the country; over 80% of the sample had a BMI higher than 25 kg/m2.

Recomendaciones para la prevención, diagnóstico y tratamiento de LA EPOC en la Argentina / Guidelines for COPD prevention, diagnosis and treatment in Argentina

La enfermedad pulmonar obstructiva crónica (EPOC) está aumentando marcadamente su morbimortalidad, costos e indicadores epidemiológicos. Por ello la Asociación Argentina de Medicina Respiratoria (AAMR) convocó a un grupo de especialistas para actualizar conocimientos básicos y efectuar recomendaciones para su diagnóstico, prevención y tratamiento. Se revisan definición, avances en fisiopatología, presentación clínica, diagnóstico por imágenes y evaluación funcional. Se enfatiza su diagnóstico temprano mediante exploración funcional -esencialmente espirometría- y la prevención a través de la cesación del tabaquismo. Se describen estrategias para dejar de fumar, tratamiento farmacológico y no farmacológico. La administración de broncodilatadores, preferentemente de acción prolongada, es la primera opción de tratamiento farmacológico. Los corticoides inhalados se indican en combinación con los broncodilatadores en pacientes con obstrucción al flujo aéreo persistente asociada con exacerbaciones frecuentes, si bien se requieren estudios que confirmen su relación costo/beneficio. La vacuna antigripal es recomendada en todos los pacientes. Con respecto a las intervenciones no farmacológicas, la cirugía del enfisema solo se recomienda en circunstancias especiales. La rehabilitación respiratoria es una herramienta útil en pacientes con limitación en la actividad física habitual. La oxígenoterapia crónica domiciliaria mejora la supervivencia en pacientes con hipoxemia crónica grave. La ventilación no invasiva domiciliaria fuera de las exacerbaciones, tiene indicaciones en pacientes seleccionados. Las exacerbaciones agudas deben tratarse con broncodilatadores, oxígeno, corticoides, antibióticos y, bajo ciertas circunstancias, asistencia respiratoria mecánica tanto no invasiva como invasiva. El papel de la educación pública, del paciente y su familia, es considerada esencial en la prevención y tratamiento.

Since morbidity, mortality and socioeconomic costs from Chronic Obstructive Pulmonary Disease (COPD) are widely increasing, a group of respiratory medicine specialists was summoned by the AAMR to update basic knowledge on COPD and to issue recommendations for its prevention, diagnosis and treatment. The authors review the definition of COPD together with current knowledge on pathophysiology. Clinical presentation, functional evaluation and imaging are summarized. Early diagnosis through pulmonary function tests -mainly spirometry- and the role of smoking cessation are stressed. Smoking cessation strategies are described as well as pharmacological and non-pharmacological treatment. Long acting bronchodilators are considered the first pharmacological option for treatment due to its effectiveness and patient compliance. Inhaled corticosteroids are indicated in combination with long-acting bronchodilators in patients who present persistent airway obstruction associated with frequent exacerbations since they reduce their number although further studies are needed to confirm their cost/benefit. Annual influenza vaccination is recommended in all patients. In the non-pharmacological section, surgery for emphysema is suggested in very specific cases. Respiratory rehabilitation is a useful tool for patients with daily activities limitation. Long-term oxygen therapy at home improves survival in patients with severe chronic hypoxemia. Non-invasive home ventilation in chronic patients has limited indications in specific subgroups. Acute exacerbations should be aggressively treated with bronchodilators, oxygen, antibiotics, corticosteroids and eventually mechanical ventilation, as invasive as not invasive respiratory support. The importance of public education as well as of individual patients and their families is deemed essential in the prevention and treatment of the disease.

Procesos moleculares patogénicos de la aterosclerosis y alternativas terapéuticas para su control / Pathogenic molecular processes of atherosclerosis and therapeutic alternatives for control

La aterosclerosis es una enfermedad vascular crónica que afecta las bifurcaciones de las grandes arterias. Las enfermedades cardiovasculares asociadas a esta afección representan la primera causa de mortalidad en el mundo occidental. La fisiopatología de la aterosclerosis interrelaciona una serie de fenómenos moleculares y celulares complejos que aún no están del todo esclarecidos. Sin embargo, se han postulado algunas hipótesis para dar explicación a los procesos patogénicos que tienen lugar durante la aterogénesis. El objetivo del presente trabajo es ofrecer una actualización sobre los principales cambios moleculares que ocurren durante el inicio y progreso de esta enfermedad, así como las alternativas terapéuticas para su tratamiento y control. Para ello se realizó una revisión de publicaciones científicas en la base de datos MEDLINE durante los últimos 10 años. Se profundizó en la complejidad de dicha afección y se demostró que aún no existe una terapia totalmente eficaz para su tratamiento.

Atherosclerosis is a chronic vascular disease which affects bifurcations of major arteries. Atherosclerosis-associated cardiovascular diseases represent the first cause of mortality in the western world. The physiopathology of atherosclerosis associates a variety of molecular and cellular complex events, which are not completely understood. However, some hypothesis have been postulated to explain the pathogenic events during atherogenesis. The objective of the present article is to offer an updating on the principal molecular events during the atherosclerosis development and therapeutic alternatives for its treatment and control. To this end, a literature review was made in MEDLINE database, which covered the scientific publications of the last 10 years. The complexity of this illness was analyzed in depth and it was demonstrated that there was not any completely effective therapy to treat it.

Ação de Micoflora de efluentes agroindustriais sobre diferentes corantes e substratos lignocelulósicos / Action of mycoflora from agri-industrial effluents on different dyes and lignocellulosic substrates

Enzimas extracelulares de fungos são importantes para sua sobrevivência em ambientes inóspitos, sendo capazes de degradar compostos recalcitrantes. Fungos filamentosos secretam hidrolases e fenoloxidases capazes de degradar complexos de estruturas aromáticas, como de alguns xenobióticos. O propósito deste trabalho foi testar diferentes corantes (Azul de Metileno, Azure B, Verde Malaquita e Cristal Violeta), em substituição ao composto Poly R478, no método de seleção de microrganismos degradadores de fenóis em meio sólido, além de comparar tal atividade de Micoflora isolada de efluentes de indústria sucroalcooleira com a de outros fungos adquiridos em coleção oficial. Os corantes testados revelaram-se ótimos substitutos do Poly R478. O isolado que apresentou atividade descolorante mais intenso do que a do diâmetro de seu crescimento (Cladosporium sp.) foi testado, então, em meio líquido frente a dois substratos naturais e um sintético (bagaço de cana, serragem de madeira e azul de metileno). Este removeu altas concentrações de glicídios redutores, proteínas e fenóis totais, além de reduzir a DQO em meio com serragem de madeira como substrato fenólico natural. Tal fungo, portanto, mostrou-se promissor para compor consórcios visando cometabolismo e biorremediação de efluentes nos quais há presença de compostos fenólicos ou outros recalcitrantes com estrutura semelhante à de lignina.

Extracellular enzymes of fungi are important for survival in inhospitable environments, as they are able to degrade recalcitrant compounds. Filamentous fungi secrete hydrolases and phenoloxidases that are capable of degrading complexes of aromatic structures, such as certain xenobiotics. The purpose of this study was to test different dyes (methylene blue, Azure B, Malachite Green and Crystal Violet), replacing the compound Poly R478 in the method of selection of phenol decomposer microorganisms in solid medium, and compare this activity of the mycoflora of effluents from sugar-alcohol industry, to the ones of other fungi acquired in official collection. The tested dyes proved to be excellent substitutes for Poly R478. The isolate that showed more intense decolorant activity than the diameter of its growth (Cladosporium sp.) was then tested on two natural and one synthetic substrate (sugarcane bagasse, sawing wood, and methylene blue) in liquid medium. This isolate removed high concentrations of reducing sugars, proteins and total phenols, and reduced the COD in medium containing sawdust as natural substrate of phenols. This fungus, therefore, seems promising to form consortia for co-metabolism and bioremediation of effluents in which there is a presence of phenolic or other recalcitrant compounds with similar structure to lignin.

Efecto de nutrientes sobre la producción de biomasa del hongo medicinal Ganoderma lucidum / Effect of nutrients in the biomass production of the medicinal mushroom Ganoderma lucidum

El hongo Ganoderma lucidum, en los constituyentes de su biomasa, tiene compuestos con propiedades benéficas para la salud; es por esto que el conocimiento de las condiciones nutricionales adecuadas para su crecimiento permitirá su producción industrial y a bajo costo. En este trabajo se evaluó a nivel de matraz el efecto de la relación C/N, y la presencia de diferentes fuentes de carbono, nitrógeno y micronutrientes sobre la producción de biomasa. Empleando glucosa y peptona como fuentes de carbono y nitrógeno, respectivamente, se encontró una relación C/N óptima de 16,7:1 para la cual la máxima producción de biomasa fue de 25 g/L. Manteniendo esta relación C/N, y sustituyendo la glucosa por lactosa o harina de cebada y la peptona por extracto de levadura, la producción de biomasa se incrementó a 35 g/L. En presencia de harina de cebada la adición al medio de cultivo de sales de Mg y K, y de tiamina, no generó un mayor incremento en la producción de biomasa. La producción de biomasa de G. lucidum se ve favorecida por la presencia en el medio de cultivo de relaciones C/N cercanas a las reportadas conforme a la composición típica de los hongos, así como por la presencia de sustratos complejos como la harina de cebada que le aportan además de la fuente de carbono micronutrientes necesarios para su desarrollo.

Ganoderma lucidum fungus has some biomass components with beneficial health properties. The knowledge about its nutritionals requirements for growing will favor its industrial production at lower cost. In this work, the effect of C/N ratio, the presence of different carbon, nitrogen and micronutrients sources, on fungal biomass production, were evaluated. Using glucose and peptone as carbon and nitrogen sources, respectively, an optimal C/N ratio of 16,7:1 was found, for which the maximal biomass production was 25 g/L. Replacing glucose by lactose or barley flour and peptone by yeast extract at the same C/N ratio, the biomass production was enhanced to 35 g/L. With barley flour in the culture medium, the presence of Mg and K salts and thiamine did not turn out into a major increase of biomass. The G. lucidum biomass production is promoted by C/N ratios in the culture medium nearly equivalent to that found in the fungus, as well as the presence of complex substrates as barley flour which, additionally, contributes with important micronutrients along with the carbon source.

Colletotrichum isolates related to anthracnose of cashew trees in Brazil: morphological and molecular description using LSU rDNA sequences

Thirty six isolates of fungi obtained from anthracnose lesions of cashew and associated host plants in Brazil, were compared by their cultural, morphological and partial sequences of the 28S ribosomal DNA characters. They showed a high degree of cultural variability. The average mycelial growth rate on all tested media ranged from 10.2-13.3 mm/day between the isolates. Most of them produced perithecia (sterile and fertile) and some produced setae (sterile and fertile). All the isolates produced acervuli with predominantly cylindrical conidia (12.4-17.7 µmX 4.8-6.0 µm in width) with round ends, which became septate on germination, and produced unlobed or slightlylobed appressoria. Comparison of the D2 domain of the large subunit (LSU) rDNA sequences with those of other defined species of Colletotrichum and Glomerella grouped 35 of the isolates with known strains of C. gloeosporioides from different hosts (> 98.9 percent homology). The one exception (LARS 921) was identical to G. cingulata (LARS 238) from Vigna unguiculata.

Trinta e seis isolados de fungos obtidos de lesões de antracnose em cajueiros e outras plantas consorciadas no Brasil, foram comparados quanto a seus aspectos culturais, morfológicos e seqüências parciais do rDNA 28S. Os isolados apresentaram elevado grau de variabilidade cultural, com taxa de crescimento médio, em todos os meios testados, entre 10,2 e 13,3 mm/dia. A maioria deles produziu peritécios (estéreis e férteis), e alguns produziram setas (estéreis e férteis) nos diferentes meios. Todos apresentaram acérvulos com predominância de conídios cilíndricos (12,4-17,7 µm X 4,8-6,0 µm), de extremidades arredondadas, formando septos durante a germinação e produzindo apressórios ligeiramente lobados ou lisos. Comparando as seqüências do domínio D2 da larga subunidade (LSU) do rDNA dos isolados com aquelas já identificadas de espécies de Colletotrichum/ Glomerella, verificou-se que 35 deles correspondem a C. gloeosporioides (> 98,9 por cento de homologia), e um deles, o isolado 921, é idêntico a G. cingulata (LARS 238) de V. unguiculata.