Maternal Near Miss in Patients with Systemic Lupus Erythematosus / Near miss materno em pacientes com lupus eritematoso sistêmico

Abstract Objective Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity. Methods This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM). Results The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5-96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2-10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0-50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6-1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7-7.9 and p = 0.0009; OR: 17.68; 95%CI: 2-153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3-440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2-26.3]). Conclusion Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.

Resumo Objetivo Lúpus eritematoso sistêmico (LES) pode causar danos irreversíveis aos órgãos. A gravidez com LES pode ter riscos para condições ameaçadoras à vida. O presente estudo teve como objetivo determinar a prevalência de MMG em pacientes com LES e analisar os parâmetros que contribuíram para os casos de maior gravidade. Métodos Trata-se de um estudo transversal retrospectivo a partir da análise de dados obtidos de prontuários de gestantes com LES atendidas em um Hospital Universitário no Brasil. As gestantes foram divididas em grupo controle sem intercorrências, grupo com condições potencialmente ameaçadoras a vida (CPAV) e grupo com near miss materno (NMM). Resultados A taxa de NMM foi de 112,9 por 1.000 nascidos vivos. A maioria dos casos de CPAV (83,9%) e NMM (92,9%) teve partos prematuros com risco aumentado estatisticamente significativo em comparação com o grupo controle (p = 0,0042; odds ratio [OR]: 12,05; intervalo de confiança [IC]: 1,5-96,6 para o grupo NMM e p = 0,0001; OR: 4,84; IC95%: 2,2-10,8 para o grupo CPAV). MMG aumenta o risco de maior tempo de internação (p < 0,0001; OR: 18,8; IC95%: 7,0-50,6 e p < 0,0001; OR: 158,17; IC95%: 17,6-1424,2 para os grupos CPAV e NMM, respectivamente), recémnascidos com baixo peso (p = 0,0006; OR: 3,67; IC95%: 1,7-7,9 e p = 0,0009; OR: 17,68; IC95%: 2-153,6 para os grupos CPAV e NMM, respectivamente), bem como doenças renais (CPAV: 58,9%; 33/56; p = 0,0069 e NMM: 78,6%; 11/14; p = 0,0026)]. Os casos de NMM apresentaram risco aumentado para óbito neonatal (p = 0,0128; OR: 38,4; IC95%: 3,3-440,3), natimorto e aborto espontâneo (p = 0,0011; OR: 7,68; IC95%: 2,2-26,3). Conclusão Lúpus eritematoso sistêmico foi significativamente associado à morbidade materna grave, internações mais longas e risco aumentado de desfechos obstétricos e neonatais ruins.

Granulicatella adiacensinfective endocarditis

Infective endocarditis is an unconventional infectious disease nonetheless life-threatening. A roundabout of 3% to 5% cases of Streptococcalinfective endocarditis is caused by nutritionally variant Streptococci (NVS). Granulicatella species is one of the atypical causes of infective endocarditis. In this context, the authors are disclosing a case of infective endocarditis in an underlying rheumatic heart disease patient, caused by Granulicatella adiacens. The patient had breathlessness for the past four months, on and off fever for two months anew and mid-diastolic murmur with vegetation in aortic valve as appeared by echocardiogram. The blood cultures were tested positive for Granulicatella adiacens. The patient was successfully treated with intravenous vancomycin for a period of six weeks.

An Observational Study on Maternal Mortality and Maternal Near Miss in a Selected Facility of West Bengal

An observational study was performed at Purba Medinipur District Hospital, West Bengal, from April 1, 2018, to December 31, 2020, with an aim to find out the magnitude of maternal mortality and near miss cases and to assess the utilization of available maternal health care services by the deceased women and near miss cases. Result showed 4.5% women developed potentially life?threatening condition (PLTC) of which 21% women developed LTC. Maternal Near Miss (MNM) ratio was 9.46/1000 live birth and the MNM?to?Maternal Mortality ratio was 8.3:1 and the leading causes of MNM and maternal death were hemorrhage, pregnancy induced hypertension/eclampsia. The utilization of maternal health?care services revealed that there is a scope to increase the service delivery. Study finding indicates that health?care programs need to enhance the existing efforts to improve timely health seeking behavior of women

Meta-analysis of incidence and outcomes of life-threatening arrhythmias in takotsubo cardiomyopathy

Background: Takotsubo cardiomyopathy (TC) or stress-induced cardiomyopathy is a transient heart condition that clinically resembles an acute coronary syndrome. This study aims to assess the incidence of life-threatening arrhythmias in patients with Takotsubo cardiomyopathy and evaluate the outcomes of patients with life-threatening arrhythmias (LTAs) in Takotsubo cardiomyopathy compared with those without LTA. Methods: We comprehensively searched the PubMed, Google Scholar, and Embase databases from inception to February 2021. The primary aim of the study was to determine the incidence of LTAs in TC patients. Other outcomes of interest were the odds of in-hospital, long-term mortality, and cardiogenic shock (CS) in TC patients with LTAs versus those without LTAs. For all statistical analyses, ReviewManager and MedCalc were used. Results: Eighteen studies were included in this study involving 55,557 participants (2,185 with LTAs and 53,372 without LTAs). The pooled incidence of LTAs in the patients of TC was found to be 6.29% (CI: 4.70 e8.08%; I2 ¼ 94.67%). There was a statistically significant increased risk of in-hospital mortality (OR ¼ 4.74; CI: 2.24e10.04; I2 ¼ 77%, p < 0.0001) and cardiogenic shock (OR ¼ 5.60; CI: 3.51e8.95; I2 ¼ 0%, p < 0.00001) in the LTA group versus the non-LTA group. LTA was not associated with long-term mortality (OR ¼ 2.23; CI: 0.94e5.28; I2 ¼ 53%, p ¼ 0.07). Conclusion: The pooled incidence of life-threatening arrhythmias in the patients of TC was found to be 6.29%. In the group of TC patients with LTAs, the odds of in-hospital mortality and CS, was higher than in the TC patients without LTAs.

Anti pathogenic studies of new mixed ligand metal chelates

Drug discovery aimed at the methodical extermination of life-threatening bacterial infection, especially considering the emergence of multi-drug resistance of pathogenic bacteria has remained a challenge for medicinal inorganic chemistry. In this article, the mixed ligand complexes of Cu (II), Co (II), and Ni (II) containing heterocyclic ligands were synthesized and characterized by IR, LC-MS, UV, and TG-DTA. Complexes are screened for Anti-microbial activity against human pathogenic bacteria.

Guía práctica del traumatismo abdominal en la edad pediátrica

RESUMEN El traumatismo abdominal en la edad pediátrica se considera la segunda causa de muerte después del trauma craneoencefálico. Requiere para su diagnóstico un alto índice de sospecha y su riesgo vital está condicionado por la hemorragia y la peritonitis. Con el propósito de estandarizar en una guía la conducta en Cuba en el traumatismo abdominal pediátrico, se realiza una revisión bibliográfica sobre el tema y el estudio de diferentes casuísticas del hospital pediátrico "Juan Manuel Márquez", que es centro provincial de politrauma infantil de La Habana; la guía se aprueba por consenso en la Sociedad Cubana de Cirugía Pediátrica. Las causas más frecuentes de traumatismo abdominal son: en el niño mayor los accidentes de tránsito y en el niño menor las caídas de altura. En la anamnesis es importante la cinemática del trauma y la superficie de impacto. El examen físico debe ser evolutivo y en la evaluación inicial debe identificarse el riesgo vital. En el diagnóstico por imágenes se considera esencial la tomografía contrastada la que en nuestro centro se reserva para casos con dudas diagnósticas y de evolución no satisfactoria, la ecografía tiene gran utilidad. Se prioriza el tratamiento no quirúrgico en el trauma cerrado con ruptura de víscera maciza, siempre que exista estabilidad hemodinámica. Actualmente la cirugía de control de daños ha demostrado mejorar la sobrevida en pacientes con lesiones abdominales complejas y exanguinantes.

ABSTRACT Abdominal trauma in pediatric age is considered the second leading cause of death after traumatic brain injury. It requires for its diagnosis a high index of suspicion and its vital risk is conditioned by hemorrhage and peritonitis. With the purpose of standardizing in a guide the behavior in Cuba of pediatric abdominal trauma, a bibliographic review is carried out on the subject and the study of different casuistries of "Juan Manuel Márquez" Pediatric Hospital, which functions in turn as a provincial center of children's polytrauma of Havana; the guide is approved by consensus in the Cuban Society of Pediatric Surgery. The most frequent causes of abdominal trauma are: in the older children, traffic accidents and in the younger children falls from heights. In the anamnesis, the kinematics of the trauma and the impact surface are important. The physical examination should be evolutionary and the initial assessment should identify the life risk. In the diagnosis by images is considered essential the contrasted tomography which in our center is reserved for cases with diagnostic doubts and unsatisfactory evolution; ultrasound is very useful. Non-surgical treatment is prioritized in closed trauma with solid viscera rupture, provided that hemodynamic stability exists. Currently, damage control surgery has been shown to improve survival in patients with complex and exanguinating abdominal injuries.

Doença do refluxo gastroesofágico em lactentes que apresentaram Eventos Resolvidos Breves Não Explicados - Brief Resolved Unexplained Event (BRUE) / Gastroesophageal reflux disease in infants who presented brief resolved unexplained event (brue)

ABSTRACT BACKGROUND: The term brief resolved unexplained events (BRUE) is a description of the acute event occurring in infants less than 1-year-old that includes at least one of the following characteristics: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone or altered level of responsiveness. An investigative proceeding is required to identify the triggering phenomenon in those who are at high risk of complications. Prolonged esophageal pHmetry has been used as a tool in searching for gastroesophageal reflux disease (GERD) as one of the underlying etiologies. OBJECTIVE: The study aims to verify the frequency of GERD in infants up to 1-year-old, when pHmetry has been performed for investigating high-risk BRUE (HR-BRUE) and to analyze if clinical characteristics or any particular symptom related by caregivers during BRUE could be correlated to GERD. METHODS: It was performed a cross-sectional study. The data was collected retrospectively of patients less than 1-year-old, who had performed pHmetry in a tertiary hospital for investigating HR-BRUE between October 2008 and January 2018. For the analysis of medical records, a data collection protocol included: gender, age at the first HR-BRUE episode, age at the time of the pHmetry, gestational age, type of delivery (normal or caesarean) and birth weight and symptoms associated to HR-BRUE related by caregivers. Relation between variables were assessed using Fisher's exact test and Mann-Whitney test. The significance level was set at 0.05. RESULTS: A total of 54 infants were included (preterm 25, term 29), 62.9% males, median age at the HR-BRUE was 36 days, 53.7% HR-BRUE episodes had occurred during or right after feeding. According to pHmetry results: nine pHmetry results were considered inconclusive, physiological reflux (n=30) and GERD (n=15). The frequency of GERD diagnosed by pHmetry was 33%. GERD was not statistically related to gender (P-value=0.757), age at first HR-BRUE episode (P-value=0.960), age at the time of the pHmetry (P-value=0.720), prematurity (P-value=0.120) or type of delivery (P-value=0.738). GERD was statistically related to low birth weight (P-value=0.023). There was no association between symptoms reported by caregivers during HR-BRUE and GERD. CONCLUSION: GERD diagnosed by the pHmetry was found in one third of infants that experiencing a HR-BRUE, showing the importance of properly investigation. In half of infants BRUE occurred during or right after feeding. Besides low birth weight, it was not possible to select other data from the clinical history that suggest that these patients would be more likely to have GERD.

RESUMO CONTEXTO: O termo Eventos Resolvidos Breves Não Explicados (Brief Resolved Unexplained Event - BRUE) é uma descrição do evento agudo que ocorre em lactentes menores de 1 ano de idade que inclui pelo menos uma das seguintes características: cianose ou palidez; respiração ausente, diminuída ou irregular, alteração acentuada no tônus ou nível alterado de responsividade. É necessário um procedimento investigativo para identificar o fenômeno desencadeante naqueles que apresentam alto risco de complicações. A pHmetria esofágica prolongada tem sido usada como uma ferramenta na pesquisa de doença do refluxo gastroesofágico (DRGE) como uma das etiologias subjacentes. OBJETIVO: Este estudo tem como objetivo verificar a frequência da DRGE em lactentes de até 1 ano de idade, quando a pHmetria foi realizada para investigação da BRUE de alto risco, e analisar se alguma característica clínica ou sintoma particular relatado pelos cuidadores durante a BRUE poderia estar correlacionado a DRGE. MÉTODOS: Foi realizado um estudo observacional, transversal, cujos dados foram coletados retrospectivamente de pacientes menores de 1 ano de idade, que realizaram pHmetria em hospital terciário para investigação de BRUE de alto risco de outubro de 2008 e janeiro de 2018. Para a análise dos prontuários, um protocolo de coleta de dados incluiu: sexo, idade no primeiro episódio de BRUE de alto risco, idade no momento da pHmetria, idade gestacional, tipo de parto (normal ou cesárea), peso ao nascer e sintomas associados a alto risco-BRUE relatado por cuidadores. A relação entre as variáveis foi avaliada por meio do teste exato de Fisher, qui-quadrado e teste de Mann-Whitney. O nível de significância foi estabelecido em 0,05. RESULTADOS: Foram incluídos 54 lactentes (pré-termo 25, termo 29), 62,9% do sexo masculino, idade mediana na BRUE de alto risco foi de 36 dias. De acordo com o relatório do cuidador, 53,7% dos episódios de BRUE de alto risco ocorreram durante ou logo após a alimentação. Resultados da pHmetria: nove resultados da pHmetria foram considerados inconclusivos, refluxo fisiológico (n=30) e DRGE (n=15). A frequência de DRGE diagnosticada por pHmetria foi de 33%. A DRGE não foi estatisticamente relacionada ao sexo (P=0,757), idade no primeiro episódio de BRUE de alto risco (P=0,96), idade no momento da pHmetria (P=0,72) prematuridade (P=0,321) ou tipo de parto (P=0,738). A DRGE foi estatisticamente relacionada ao baixo peso ao nascer (P=0,023). Não houve associação entre os sintomas relatados pelos cuidadores durante BRUE de alto risco e o diagnóstico de DRGE. CONCLUSÃO: A DRGE diagnosticada pela pHmetria foi encontrada em um terço dos lactentes que vivenciaram BRUE de alto risco, mostrando a importância da investigação adequada. Em metade das crianças, o evento ocorreu durante ou logo após a alimentação. Além do baixo peso ao nascer, não foi possível selecionar outros dados da história clínica que sugiram que esses pacientes terão maior probabilidade de apresentar DRGE.

Tratamiento percutáneo de la hemoptisis. Anatomía, fisiopatología y metodología / Percutaneous treatment of hemoptysis. Anatomy, physiopathology and methodology

Resumen Se presentan los resultados de 105 pacientes con hemoptisis amenazante tratados mediante embolización arterial por cateterismo percutáneo por vía arterial sistémica y/o arterial pulmonar. Se describe la técnica del procedimiento y los hallazgos angiográficos. Se muestra la utilidad de la fibrobroncoscopía y de la radiografía de tórax para identificar la zona sangrante como diagnóstico previo al procedimiento. Entre mayo 2000 y septiembre 2015 se admitieron en el Servicio de Hemodinamia 105 pacientes con diagnóstico de hemoptisis amenazante, 76 masculinos (72.4%); edad media: 41 (±18.65 DS) años. El 93% (98/105) fue tratado con éxito. En el 90% (88/98) se efectuó embolización por arterias bronquiales y/o no bronquiales sistémicas y en el 10% (10/98) por vía arterial pulmonar. Cuando la afección era bilateral la angiografía sola no posibilitó identificar el sitio de sangrado. Al 60% (63/98) se le hizo fibrobroncoscopía flexible y se pudo ubicar el pulmón sangrante en el 84% (56/63). Cuando la afección era unilateral, la radiografía de tórax previa al procedimiento facilitó la ubicación del área de sangrado en el 47%. No se observaron complicaciones graves ni muertes vinculadas al procedimiento. El tratamiento de la hemoptisis masiva por vía percutánea tiene alto porcentaje de éxito primario con muy baja tasa de complicaciones. El tratamiento por vía arterial pulmonar es un abordaje alternativo. La fibrobroncoscopía flexible es un importante complemento en esta entidad.

Abstract We present the results of 105 patients with life-threatening hemoptysis who were treated with the systemic arterial and/or pulmonary artery routes. We also describe the procedure techniques and the angiographic findings. We show the usefulness of the flexible fiberoptic bronchoscopy and chest radiography to identify the bleeding zone previous to the procedure. From May 2000 to September 2015, a total of 105 patients were admitted to the Catheterization Laboratory with a diagnosis of life-threatening hemoptysis; 76 were male (72.4%) and mean age was 41 ± 18.65 years. Treatment was successful in 93% (98/105). In 90% (88/98) the approach was via the bronchial arteries and/or non-bronchial systemic arteries, and in 10% (10/98) the approach was via the pulmonary artery. In bilateral affection angiographic images alone could not identify accurately the site of the lung bleeding. Flexible fibrobronchoscopy was performed in 60% (63/98) and located the bleeding area in 84% (56/63). In unilateral affection, chest radiography previous to the procedure located the bleeding area in 47%. No complications or death were related to the procedure. The treatment of life threatening hemoptysis by a percutaneous way has a high percentage of primary success with a very low incidence of complications. Pulmonary arterial route treatment is an alternative approach. Flexible fibrobronchoscopy is an important complement to this entity.

Recomendación para disminuir el riesgo de colapso súbito e inesperado posnatal / Guidance to reduce the risk of Sudden and Unexpected Postnatal Collapse

El contacto piel a piel al nacer (COPAP) entre madres y recién nacidos a término sanos es fundamental en los estándares de la Iniciativa Hospital Amigo de la Madre y el Niño de Unicef. El COPAP inmediatamente después del nacimiento favorece la estabilidad cardiorrespiratoria, la prevalencia y duración de la lactancia materna y el vínculo madre-hijo, y disminuye el estrés materno. Existe preocupación por los casos de colapso súbito inesperado posnatal durante el COPAP con el bebé en decúbito prono sobre el torso desnudo materno. Si bien es infrecuente, evoluciona en el 50 % de los casos como evento grave de aparente amenaza a la vida y la otra mitad fallece (muerte súbita e inesperada neonatal temprana). Durante el COPAP y, al menos, las primeras 2 horas después del parto, el personal de Sala de Partos y recuperación debe observar y evaluar cualquier parámetro que implique una descompensación del bebé.

Early skin-to-skin contact (SSC) between mothers and healthy term newborns is a key part of the Unicef Baby Friendly Initiative Standards. SSC immediately after birth provides cardio-respiratory stability, improves prevalence and duration of breastfeeding, improves maternal-infant bonding and decreases maternal stress. There is a concern about cases of sudden unexpected postnatal collapse during a period of SSC with the infant prone on the mother ́s chest. Said collapse includes both severe apparent life-threatening event and sudden unexpected early neonatal death in the first week of life. Even if considered rare, consequences are serious with death in half of the cases and remaining disability in majority of the cases reported. For these reasons during SSC and for at least the first 2 hours after delivery, health care personnel in the delivery and recovery room should observe and assess for any sign of decompensation in the infant

Amoxicillin induced toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare life-threatening adverse drug reaction associated with mucocutaneous eruptions and peeling of skin (sloughing) mostly caused by drugs like sulphonamides, beta lactams, carbamazepine and non-steroidal anti-inflammatory drugs (NSAIDs). Amoxicillin is a broad spectrum, bactericidal, Beta-lactam antibiotic used in treatment of various infections. Here by we have reported the case of amoxicillin induced severe toxic epidermal necrolysis. A Patient admitted in the hospital with the symptoms of epidermal sloughing that resulted in bare dermis as he received Amoxicillin drug for his diagnosis of fever. After clear examination TEN was confirmed and suspected with the cause due to Amoxicillin. The drug was stopped and patient was treated with other drugs for symptomatic cure. The patient was recovered from his condition and improved significantly.

Study on Treatment and Outcome of Patients with Guillain–Barre Syndrome – A Prospective Study

Introduction: The history of Guillain–Barre syndrome (GBS) runs parallel with the discovery of the peripheral nervous system. Upto the second half of the 19th century, injury to the peripheral nervous system had not yet emerged as a possible cause of palsy.Aim: This study aims to study the treatment and outcome in patients with various subtypes of GBS.Materials and Methods: Patients who had been admitted with the diagnosis of GBS based on Asbury’s criteria which includedascending areflexic quadriparesis, with or without cranial nerve dysfunction, and evolving within a period of 4 weeks. We alsoincluded patients who presented with features of GBS subtypes without prominent weakness. A detailed history and physicalexamination as per a structured pro forma were taken and necessary laboratory investigations were done.Results: Twenty-five patients were admitted with disability grade of >3 in GBS disability scale (>5 in Medical Research Councildisability scale) and 18 were admitted below the score. Sixteen patients needed ventilator support and 10 patients expired.Among the 22 patients who were treated with intravenous immunoglobulin (IvIg), 14 patients (24.6%) had a good outcome and8 patients (14.0%) had a poor outcome. Among the nine patients who were treated with plasma exchange, six patients had agood outcome and three had a poor outcome. Among the 19 patients, who were treated with injection methylprednisolone, eightpatients had a good outcome and 11 patients had a poor outcome. The values obtained are not statistically significant (P = 0.076).Conclusion: The mean improvement in GBS disability scale from admission to the end of the 8th week is more for IvIg-treatedpatients when compared to methylprednisolone-treated group.

Efecto de un enfoque estandarizado para el manejo de lactantes hospitalizados por eventos aparentemente letales / Effect of a standardized approach on infants hospitalized for apparent life threatening events

Introducción. Los eventos aparentemente letales (Apparent Life-Threatening Event, ALTE) son causa frecuente de hospitalización en lactantes. Hay poca información sobre el enfoque estandarizado para establecer su etiología, a pesar de que un diagnóstico causal correcto puede afectar la evolución clínica, la duración de la hospitalización y los recursos sanitarios. Objetivo. Comparar los efectos del enfoque diagnóstico estandarizado en lactantes hospitalizados por este tipo de eventos. Materiales y métodos. Se hizo un estudio retrospectivo de cohorte con base en los datos recolectados de las historias clínicas de lactantes hospitalizados por esta causa en el servicio de pediatría entre el 2002 y el 2009. Se analizaron dos cohortes de pacientes agrupados según su manejo: la cohorte 1, con guías clínicas, y la cohorte 2, con guías clínicas, protocolo de estudio y seguimiento ambulatorio. Se compararon los grupos en cuanto a la etiología, el tiempo de hospitalización y la tasa de nuevas hospitalizaciones. Resultados. De los 255 lactantes hospitalizados por eventos aparentemente letales, el 57,6 % integró la cohorte 1 y, el 42,3 %, la cohorte 2. No se observaron diferencias en cuanto a la edad y el sexo. En la cohorte 2 se observó un mayor porcentaje de causas atribuidas (63,9 Vs. 87,0; p<0,0001), y un menor tiempo de hospitalización (8,0 Vs. 5,0 días; p=0,0001). No hubo diferencias en cuanto a nuevas hospitalizaciones (10,5 Vs. 8,3 días; p=0,7435). Conclusiones. El enfoque del manejo de lactantes afectados por eventos aparente letales basado en protocolos, se asoció con un mayor porcentaje de reconocimiento de las causas atribuidas y con un menor período de hospitalización. A partir de estos resultados es posible sugerir la implementación de este tipo de estandarización para el manejo de dichos pacientes.

Introduction: An apparent life-threatening event (ALTE) is a frequent cause of hospitalization in infants. However, there is little evidence about the existence of a standardized approach to discover the main etiology, although a correct causal diagnosis can affect clinical evolution, hospital stay, and health resources. Objective: To determine the effects of a standardized diagnostic approach in infants admitted with ALTE. Materials and methods: We conducted a retrospective cohort study with the data collected from clinical records of infants hospitalized for ALTE in the pediatric unit between 2002 and 2009. Two cohorts of patients were analyzed according to the procedures defined for these cases: Cohort 1 with clinical guidelines and cohort 2 with clinical guidelines, study protocol, and outpatient follow-up. Etiological causes, hospitalization periods and readmission rates were compared between both cohorts. Results: Of the 255 infants hospitalized for ALTE, 57.6% corresponded to cohort 1 and 42.3% to cohort 2. No differences were observed in age and gender between groups. The highest percentage of attributed causes (63.9 vs 87.0%; p<0.0001) and a shorter period of hospitalization (8.0 vs 5.0 days; p=0, 0001) were observed in cohort 2. No differences in hospital readmission were observed (10.5 vs 8.3 days; p=0.7435). Conclusions: The protocol-based approach for infants with EAL was associated with a higher percentage of recognition of attributed causes and a shorter hospitalization period. Therefore, our results allow recommending this type of standardization for the management of these patients.

Life-threatening Chlorhexidine Anaphylaxis: A Case Report

Chlorhexidine is a common antiseptic and disinfectant used in the medical field. Allergy to chlorhexidine has been reported in the literature but life-threatening anaphylactic shock is rare. We present a case of severe anaphylactic shock due to chlorhexidine occurring during surgery. Literatures suggest that profound anaphylactic shock to chlorhexidine is commonly preceded by milder, non-specific reactions. These mild symptoms are often dismissed by both the patient and physicians alike. Direct questioning of these symptoms is necessary as a part of the pre-operative assessment and the patient should be referred for further immunology testing if indicated.

Toxic epidermal necrolysis in a 5-year-old boy - case report / Necrólise epidérmica tóxica em um relato de caso de um menino de 5 anos de idade

Necrose epidérmica tóxica ( NET ) e síndrome de Stevens - Johnson ( SSJ ) são considerados um espectro de reação mucocutânea aguda com risco de vida , que diferem apenas em termos de gravidade, muitas vezes induzidos por drogas. Vírus varicelazoster tem sido raramente relatada como agente etiológico em casos de NET. O nosso relato de caso destaca a associação do vírus varicela- zoster e TEN em um menino de 5 anos de idade.

Toxic epidermal necrolysis (TEN) and StevensJohnson syndrome (SJS) are considered a spectrum of acute life-threatening mucocutaneous reaction that differ only in severity, often induced by drugs. Varicella-zoster virus has been rarely reported as an etiological agent in TEN. Our case report highlights the association of varicella-zoster virus and TEN in a 5-year-old boy.

Early intervention of life-threatening cardiac malformations in the newborn / 中国小儿急救医学

Objective To investigate the methods of early identification and early intervention for newborn with life-threatening congenital heart disease.Methods Between January 2010 and December 2010,223 neonates with serious congenital cardiac malformations were hospitalized in PICU of Fuwai Hospi-tal.Results The most type of cardiac lesions was complete transposition of the great arteries,accounting for 59%(131 cases),and the second was total anomalous pulmonary venous connection,17%(39 cases).For the primary clinical symptoms,the most common were any cyanosis,dyspnea and cardiac murmur,accounting for 91 %(204 cases),56%(125 cases)and 53%(1 18 cases),respectively.Fifty-nine cases developed into critical conditions such as severe hypoxia,metabolic acidosis and heart failure and were sent to PICU for emergency rescue.Early intervention included maintaining ductus arteriosus open,correcting internal environ-ment disturbances,treatment of heart failure,and surgical treatment as soon as possible.Four cases died before operation and 10 cases were abandoned to continue care,which all died within 12 days after discharge.In 209 cases who received operation,9 cases died.The total operation mortality was 4.3%.Within 3 to 63 month following-up,the late death was in 2 cases,2 cases received two-stage corrective operation,and three for reop-eration.The others all were in normal cardiac function and growth.Conclusion Most of neonatal life-threat-ening congenital cardiac malformations were ductus dependent such as transposition of the great arteries and total anomalous pulmonary venous connection,which the baby needs immediate diagnosis and management for survival.Early recognition,appropriate preoperative management and operation as soon as possible are the key to rescue.

Apparent life-threatening event in infancy / 소아과

An apparent life-threatening event (ALTE) is defined as the combination of clinical presentations such as apnea, marked change in skin and muscle tone, gagging, or choking. It is a frightening event, and it predominantly occurs during infancy at a mean age of 1–3 months. The causes of ALTE are categorized into problems that are: gastrointestinal (50%), neurological (30%), respiratory (20%), cardiovascular (5%), metabolic and endocrine (2%–5%), or others such as child abuse. Up to 50% of ALTEs are idiopathic, where the cause cannot be diagnosed. Infants with an ALTE are often asymptomatic at hospital and there is no standard workup protocol for ALTE. Therefore, a detailed initial history and physical examination are important to determine the extent of the medical evaluation and treatment. Regardless of the cause of an ALTE, all infants with an ALTE should require hospitalization and continuous cardiorespiratory monitoring and evaluation for at least 24 hours. The natural course of ALTEs has seemed benign, and the outcome is generally associated with the affected infants' underlying disease. In conclusion, systemic diagnostic evaluation and adequate treatment increases the survival and quality of life for most affected infants.

Caracterización de ALTE en neuropediatría. Hospital La Misericordia, Bogotá, Colombia, 2009-2013 / Characterization of ALTE in pediatric neurology. Hospital La Misericordia, Bogotá, Colombia, 2009-2013

Introducción: El síndrome de ALTE es una condición que amenaza la vida de los lactantes; requiere diagnóstico y manejo adecuado para evitar complicaciones o muerte, y sus causas son numerosas, entre ellas: gastrointestinales, respiratorias, neurológicas y otras; las patologías neurológicas representan la tercera causa en la mayoría de estudios. Objetivo: Describir las características de la población de pacientes que consultaron al Hospital de la Misericordia (HOMI) de Bogotá por un episodio de ALTE y que fueron valorados por la especialidad de neuropediatría en el período 2009 a 2013. Materiales y métodos: Se realizó un estudio descriptivo de corte transversal, en una población de 107 pacientes con diagnóstico de ALTE; se determinaron los datos sociodemográficos, características, causas y tratamientos de ALTE; se utilizó el programa SPSS 22. Resultados: La etiología neurológica de ALTE correspondió al 16,8%, correspondiente a crisis epilépticas, trastornos respiratorios de origen central y sangrados de sistema nervioso central. Ocupa el tercer lugar en etiologías, después de las causas gastrointestinales y respiratorias. Conclusión: Es importante definir el diagnóstico y tratamiento de los pacientes con ALTE, pues existe alto riesgo de morbimortalidad asociada. Deben evaluarse factores neurológicos, y no solo gastrointestinales o respiratorios, que ayuden a definir la etiología y evitar complicaciones.

Introduction: ALTE is a condition that threatens the lives of infants; requires diagnosis and appropriate management to avoid complications and / or death. There are numerous causes among which are gastrointestinal, respiratory, and neurological and others. Being the third cause, neurological pathologies in most studies. Objective: To describe the characteristics of the population of patients admitted to Hospital de la Misericord HOMI Bogota, for ALTE and were valued by the specialty of pediatric neurology in the period 2009-2013. Materials and methods: A descriptive cross-sectional study was conducted, with a population of 107 patients with a diagnosis of ALTE; sociodemographic data, characteristics, causes and treatments of ALTE were determined. SPSS 22 software was used. Results: The etiology of neurological ALTE corresponded to 16.8%, corresponding to seizures, respiratory disorders of central origin and CNS bleeds. Ranking as third in etiology below gastrointestinal and respiratory causes. Conclusion: It is important to define the diagnosis and treatment of patients with ALTE, as there is a high risk of morbidity and mortality associated. Factors not only neurological and gastrointestinal or respiratory, to help define the etiology and avoid complications should be evaluated.

articleIndicators of maternal ‘near miss’ morbidity at different levels of health care in North India: A pilot study.

Introduction: Maternal morbidity and mortality in India continues to remain high despite concerted efforts during the past decades. Objective of this study was to determine the prevalence and indicator of Potentially Life Threatening Conditions (PLTC) and ‘near miss’ obstetric cases at different tiers of health care. Material and Methods: A cross-sectional epidemiological study was carried out over a period of 12 months as per the WHO criteria for ‘near miss’. Probability sampling was done to systematically and randomly select health facilities i.e. two primary health centers (PHC), one community health centre (CHC) and a tertiary hospital all from Doiwala block of Dehradun, Uttarakhand, India. The study included all the women attending health-care facilities, who were pregnant, in labour, or who had delivered or aborted up to 42 days ago arriving at the facility. A convenient sampling was done (a hundred percent enumeration of eligible study subjects) for the audit. Result: A total of 937 pregnant women who accessed health care had 688 live births and 231 women had one or more of the Potentially Life Threatening Conditions (PLTC). Among them, 61 women had Severe Maternal Outcome (SMO) - 51 with maternal ‘near-miss’ and 10 maternal deaths. The Severe Maternal Outcome Ratio (per 1000 live births) was 88.66. The Maternal ‘near miss’ Mortality Ratio (MNM-MR) and Mortality Index (MI) were 5.1 and 16.39% respectively. Conclusion: The WHO ‘near miss’ approach has been found to be an effective measure to assess quality of care in maternal health across countries including India.

Ludwig’s angina by Salmonella Typhi: A clinical dilemma.

Salmonella Typhi has rarely been associated with focal abscesses; and in literature, there is no evidence of its association with abscesses in the neck spaces. Ability of Salmonella Typhi to invade and localise in the neck spaces not only poses a diagnostic challenge but also underscores the necessity to understand the mechanisms that facilitate Salmonella Typhi to establish infections at sites completely non-traditional to the organism.

Relationship between the Clinical Characteristics and Intervention Scores of Infants with Apparent Life-threatening Events

We investigated the clinical presentations, diagnostic and therapeutic modalities, and prognosis from follow-up of infants with apparent life-threatening events (ALTE). In addition, the relationship between the clinical characteristics of patients and significant intervention scores was analyzed. We enrolled patients younger than 12 months who were diagnosed with ALTE from January 2005 to December 2012. There were 29 ALTE infants with a peak incidence of age younger than 1 month (48.3%). The most common symptoms for ALTE diagnosis were apnea (69.0%) and color change (58.6%). Eleven patients appeared normal upon arrival at hospital but 2 patients required cardiopulmonary resuscitation during the initial ALTE. The most common ALTE cause was respiratory disease, including respiratory infection and upper airway anomalies (44.8%). There were 20 cases of repeat ALTE and 2 cases of death during hospitalization. Four patients (15.4%) experienced recurrence of ALTE after discharge and 4 patients (15.4%) showed developmental abnormalities during the follow-up period. The patients with ALTE during sleep had lower significant intervention scores (P=0.015) compared to patients with ALTE during wakefulness and patients with previous respiratory symptoms had higher significant intervention scores (P=0.013) than those without previous respiratory symptoms. Although not statistically significant, there was a weak positive correlation between the patient's total ALTE criteria and total significant intervention score (Fig. 2, r=0.330, P=0.080). We recommend that all ALTE infants undergo inpatient observation and evaluations with at least 24 hr of cardiorespiratory monitoring, and should follow up at least within a month after discharge.