Importance of assessing biomarkers and physiological parameters of anemia-induced tissue hypoxia in the perioperative period

Abstract Anemia is associated with increased risk of Acute Kidney Injury (AKI), stroke and mortality in perioperative patients. We sought to understand the mechanism(s) by assessing the integrative physiological responses to anemia (kidney, brain), the degrees of anemia-induced tissue hypoxia, and associated biomarkers and physiological parameters. Experimental measurements demonstrate a linear relationship between blood Oxygen Content (CaO2) and renal microvascular PO2 (y = 0.30x + 6.9, r2= 0.75), demonstrating that renal hypoxia is proportional to the degree of anemia. This defines the kidney as a potential oxygen sensor during anemia. Further evidence of renal oxygen sensing is demonstrated by proportional increase in serum Erythropoietin (EPO) during anemia (y = 93.806*10−0.02, r2= 0.82). This data implicates systemic EPO levels as a biomarker of anemia-induced renal tissue hypoxia. By contrast, cerebral Oxygen Delivery (DO2) is defended by a profound proportional increase in Cerebral Blood Flow (CBF), minimizing tissue hypoxia in the brain, until more severe levels of anemia occur. We hypothesize that the kidney experiences profound early anemia-induced tissue hypoxia which contributes to adaptive mechanisms to preserve cerebral perfusion. At severe levels of anemia, renal hypoxia intensifies, and cerebral hypoxia occurs, possibly contributing to the mechanism(s) of AKI and stroke when adaptive mechanisms to preserve organ perfusion are overwhelmed. Clinical methods to detect renal tissue hypoxia (an early warning signal) and cerebral hypoxia (a later consequence of severe anemia) may inform clinical practice and support the assessment of clinical biomarkers (i.e., EPO) and physiological parameters (i.e., urinary PO2) of anemia-induced tissue hypoxia. This information may direct targeted treatment strategies to prevent adverse outcomes associated with anemia.

Inusual hallazgo en paciente cirrótico con anemia crónica e hipereosinofilia usando cápsula endoscópica: a propósito de un caso (video) / Unusual finding in cirrhotic patient with chronic anemia and hypereosinophilia using an endoscopic capsule: a case report (video)

We report a clinical case from a patient with alcoholic cirrhosis who had chronic anemia and carried out several endoscopic studies without evidence of active bleeding, a complementary study with endoscopic capsule was requested to search for a source of bleeding. In the analysis of laboratory data, the presence of hypereosinophilia stands out in parallel. The images obtained in the video capsule study show geoparasites helminth-type. After parasite treatment, anemia improves and the absolute eosinophil count is normalized.

Reportamos el caso de un paciente cirrótico por alcohol con anemia crónica quien se realizó varios estudios endoscópicos sin evidencia de sangrado activo, por tal motivo se solicitó estudio complementario con cápsula endoscópica para búsqueda de fuente de sangrado. En el análisis de los datos de laboratorio paralelamente destaca la presencia de hipereosinofilia. Las imágenes obtenidas en el estudio de la video cápsula muestran varios geoparásitos de tipo helmintos. Posterior al tratamiento antiparasitario mejora la anemia y se normaliza el recuento absoluto de eosinófilos.

Anemia en la enfermedad inflamatoria intestinal: un objetivo subestimado / Anemia in inflammatory bowel disease

Anemia is the most common extraintestinal manifestation of inflammatory bowel disease (IBD). Although there are several causes of anemia in IBD, the two most frequent etiologies are iron deficiency anemia and anemia of chronic disease. Despite the high prevalence of anemia in IBD and its significant impact on patient's quality of life, this complication is still underdiagnosed and undertreated by providers. Active screening for anemia, structured assessment, comprehensive management, and multidisciplinary collaboration are needed in IBD patients. The cornerstone of anemia management depends on the underlying etiology along with normalization of inflammatory activity. Although, oral iron is effective for the treatment of mild iron deficiency-related anemia, intravenous iron formulations have a good safety profile and can be used as first-line therapy in patients with active IBD, severe anemia and previous intolerance prior to oral iron. After proper treatment of anemia, careful monitoring is necessary to prevent its recurrence. Herein, we discuss the etiology, screening, diagnosis, therapy selection, and follow-up for anemia in IBD.

Morbilidad posoperatoria asociada a ferropenia y anemia no severa preoperatorias en cirugía cardíaca electiva / Postoperative morbidity associated with iron deficiency and preoperative non-severe anemia in elective cardiac surgery / Morbidade pós-operatória associada à deficiência de ferro e anemia pré-operatória não grave em cirurgia cardíaca eletiva

Introducción: la anemia y la ferropenia son frecuentes en candidatos a cirugía cardíaca y se asocian a peores resultados posoperatorios. Su manejo no está estandarizado. No existen datos locales sobre prevalencia y pronóstico. Objetivo: evaluar si la anemia no severa y la ferropenia se asocian en nuestro medio a peores resultados posoperatorios en cirugía cardíaca electiva. Método: estudio de cohorte prospectivo en dos centros. Se incluyeron pacientes mayores de 18 años sometidos a cirugía cardíaca electiva. Se conformaron tres grupos: 1) control, 2) ferropenia aislada y 3) anemia no severa. Se consignaron variables clínicas y paraclínicas preoperatorias, intraoperatorias y posoperatorias. Se realizaron análisis uni y multivariados para determinar significancia estadística (p < 0,05). Resultados: se incluyeron 167 pacientes, mediana y distancia IQ 68 años [60-74], 61,68% hombres. FEVI media 59% [45-60], EuroSCORE II 0,96 [0,76-1,35]. Se llevaron a cabo 96 revascularizaciones (57,49%), 39 sustituciones valvulares (23,35%) y 30 combinadas (17,96%), una trombectomía y un implante de tubo aórtico. La prevalencia de ferropenia aislada fue 15,57%, de anemia total 40,72% y de anemia y/o ferropenia 56,29%. El grupo control tuvo menos días de internación (p = 0,0018) y el grupo ferropenia necesitó más volúmenes de glóbulos rojos transfundidos (p = 0,045). En el análisis univariado los grupos 2 y 3 se asociaron a mayores eventos posoperatorios compuestos (OR 2,86, p = 0,03, y OR 2,11, p = 0,03, respectivamente). El grupo 3 se asoció a mayor probabilidad de infección posoperatoria (OR 8,63, 1,03-72,12, p = 0,049). En el análisis multivariado el hematocrito se asoció inversamente a insuficiencia renal (OR 0,61; IC 95% 0,38-0,99, p=0,04) y la edad en forma directa (OR 1,14; IC 95% 1,02-1,28, p=0,02). Conclusiones: la prevalencia de anemia no severa y ferropenia fue alta, se asoció a complicaciones en el posoperatorio y mayor estadía hospitalaria. Es necesario protocolizar su manejo.

Introduction: anemia and iron deficiency are frequent in candidates for cardiac surgery and are associated with poorer postoperative results. Its therapeutic approach is not standardized. There are no local data on prevalence and prognosis. Objective: to assess whether non-severe anemia and iron deficiency are associated with poorer postoperative results in elective cardiac surgery in our patients. Method: prospective cohort study in two centers. Patients > 18 years of age who underwent elective cardiac surgery were included. Three groups were formed: 1) control, 2) isolated iron deficiency and 3) non-severe anemia. Preoperative, intraoperative and postoperative clinical and paraclinical outcomes were recorded. Univariate and multivariate analyzes were performed to determine statistical significance (p < 0.05). Results: 167 patients were included, 68 years [60-74], 61.68% men. Mean LVEF 59% [45-60], EuroSCORE II 0.96 [0.76-1.35]. 96 revascularizations (57.49%), 39 valve replacements (23.35%) and 30 combined (17.96%), one thrombectomy and one aortic tube were carried out. The prevalence of isolated iron deficiency was 15.57%, total anemia 40.72% and anemia and/or iron deficiency 56.29%. The control group had fewer days of hospitalization (p = 0.0018) and the ferropenia group needed more red blood cells transfusions (p = 0.045). In the univariate analysis, groups 2 and 3 were associated with higher compound postoperative events (OR 2.86, p = 0.03, and OR 2.11, p = 0.03, respectively). Group 3 was associated with a higher probability of postoperative infection (OR 8.63, 1.03-72.12, p = 0.049). In the multivariate analysis, the hematocrit values ​​were associated with renal failure (OR 1.14, 95% CI 1.02-1.28, p = 0.02). Conclusions: the prevalence of non-severe anemia and iron deficiency was high, it was associated with greater complications in the postoperative period and a longer hospital stay. It is necessary to protocolize its therapeutic approach.

Introdução: a anemia e a deficiência de ferro são frequentes em candidatos à cirurgia cardíaca e estão associadas a maus resultados pós-operatórios. Sua abordagem terapêutica não é padronizada. Não existem dados locais sobre prevalência e prognóstico. Objetivo: avaliar se a anemia não grave e a deficiência de ferro estão associadas a maus resultados pós-operatórios em cirurgia cardíaca eletiva em nossos pacientes. Método: estudo de coorte prospectivo em dois centros. Pacientes > 18 anos de idade submetidos à cirurgia cardíaca eletiva foram incluídos. Foram formados três grupos: 1) controle, 2) deficiência de ferro isolada e 3) anemia não grave. Variáveis clínicas e paraclínicas pré-operatórias, intraoperatórias e pós-operatórias foram registradas. Análises univariadas e multivariadas foram realizadas para determinar a significância estatística (p < 0,05). Resultados: 167 pacientes foram incluídos, 68 anos [60-74], 61,68% homens. LVEF média 59% [45-60], EuroSCORE II 0,96 [0,76-1,35]. Foram realizadas 96 revascularizações (57,49%), 39 trocas valvares (23,35%), 30 combinadas (17,96%), uma trombectomia e um tubo aórtico. A prevalência de deficiência de ferro isolada foi de 15,57%, anemia total 40,72% e anemia e/ou deficiência de ferro 56,29%. O grupo controle teve menos dias de internação (p = 0,0018) e o grupo de deficiência de ferro necessitou de mais transfusão de volumes de hemácias (p = 0,045). Na análise univariada, os grupos 2 e 3 foram associados a eventos pós-operatórios compostos mais elevados (OR 2,86, p = 0,03 e OR 2,11, p = 0,03, respectivamente). O grupo 3 foi associado a uma maior probabilidade de infecção pós-operatória (OR 8,63, 1,03-72,12, p = 0,049). Na análise multivariada, o hematócrito foi associado à insuficiência renal (OR 1,14, IC 95% 1,02-1,28, p = 0,02). Conclusões: a prevalência de anemia não grave e deficiência de ferro foi elevada, associada a complicações pós-operatórias e maior tempo de internação. É necessário protocolar sua abordagem terapêutica.

Efectividad de las sesiones demostrativas para mejorar el conocimiento en la prevención de la anemia en gestantes, madres lactantes De niños menores de 3 años. Centro de salud Aparicio Pomares. Huánuco ­ perú / Effectiveness of demonstration sessions to improve knowledge in the prevention of anemia in pregnant women, nursing mothers of children under 3 years. Aparicio pomares health center. Huánuco ­ Peru

El problema de la anemia está muy relacionado a los índices de pobreza, falta de cuidado de la salud y educación de la población, pero principalmente a la falta de conocimientos sobre alimentación y nutrición infantil por parte de las madres. Objetivo: Determinar la efectividad de las sesiones demostrativas para mejorar el conocimiento en la prevención de la anemia en gestantes, madres lactantes de niños menores de 3 años. Materiales y Métodos: El estudio fue de tipo experimental, descriptivo y de nivel observacional, explicativo y analítico. La población de estudio estuvo conformada por 200 gestantes, obteniendo una muestra de 30 gestantes y 20 madres lactantes de niños menores de 3 años, haciendo un total de 50 pacientes, se utilizó el cuestionario para la recolección de datos, aplicado en dos momentos; antes y después de las sesiones demostrativas, con la finalidad de comparar los resultados. Resultados: El nivel de conocimiento teórico de las madres, luego de la aplicación de las sesiones demostrativas se incrementó su nivel a un conocimiento alto. Respecto a los conocimientos prácticos luego de la aplicación de las sesiones, se logró un conocimiento alto. Conclusiones: La técnica de sesiones demostrativas en el incremento de conocimientos es efectiva(AU)

The problem of anemia is closely related to the rates of poverty, lack of care of the health and education of the population, but mainly to the lack of knowledge about food and infant nutrition by mothers. Objective: To determine the effectiveness of the demonstration sessions to improve knowledge in the prevention of anemia in pregnant women, nursing mothers of minor children 3 years old Materials and methods: The study was of type, experimental, descriptive and observational level, explanatory and analytical. The study population consisted of 200 pregnant women, obtaining a sample of 30 pregnant women and 20 lactating mothers of children under 3 years of age, making a total of 50 patients, the questionnaire was used for data collection, applied in two moments; before and after demonstration sessions, in order to compare the results. Results: The level of theoretical knowledge of the mothers, after the application of the demonstrative sessions their level to high knowledge. Regarding the practical knowledge after the application of the sessions, high knowledge was achieved. Conclusions: The technique of demonstrative sessions in the increase of knowledge is effective(AU)

Pérdidas hemáticas en UCI: Breve estudio descriptivo / Blood loss in ICU: Brief descriptive study

Background: Anaemia and transfusions are frequent in critically ill patients and there are avoidable causes such as routine laboratory tests. Patients and methods: Descriptive study during one continuous week including patients over 18-years old in a medical-surgical ICU. Results: 18 patients were included during a week in 12 beds in our unit, median age 62,5 years, 50% male. Median daily blood loss was 35ml, 45% in laboratory samples and 27% related to renal replacement therapy. 3 patients required 1 transfusion of red blood cells. Conclusions: There is a pattern of continuous blood loss in critically ill patients, primarily in routine laboratory tests. (AU)

Anemia severa en adulto joven con infección por uncinarias / Severe anemia in a young adult with hookworm infection

La uncinariasis, anquilostomiasis o también conocida como anemia tropical, es una parasitosis intestinal de gran importancia mundial. Las uncinarias son parásitos nematodos transmitidas por el contacto de la piel con suelos contaminados. Una de las consecuencias más importantes de la infección masiva por estos parásitos es el sangrado intestinal crónico que conduce a disminución de la hemoglobina, y en casos inusuales, esta anemia puede llegar a ser severa. Con el objetivo de poner en discusión la importancia y morbilidad de esta enfermedad, presentamos el caso de un varón de 23 años, procedente de una zona tropical del Perú, quien ingresa por emergencia con un valor de hemoglobina de 2,3 mg/dL, alteración del nivel de conciencia e historia de rectorragia. Durante el proceso diagnóstico se encuentra en la colonoscopia múltiples parásitos con áreas de sangrado y colitis erosiva, mientras que en el examen parasitológico se observan huevos de Ancylostoma/Necator spp 2+. La sintomatología mejora posterior al tratamiento con albendazol. La uncinariasis debe siempre sospecharse en el proceso diagnóstico de pacientes con anemia crónica tanto en Perú como en zonas tropicales del mundo.(AU)

Uncinariasis or ancylostomiasis, a.k.a. tropical anemia, is an intestinal parasitosis of great importance worldwide. Hookworms are parasitic nematodes transmitted by skin contact with contaminated soils. One of the most important consequences of massive infection by these parasites is chronic intestinal bleeding, which leads to reduced hemoglobin. In unusual cases the resulting anemia may be severe. With the purpose of discussing the importance and morbidity of this disease, a case is presented of a male 23-year-old patient from a tropical area in Peru who was admitted for an emergency hemoglobin value of 2.3 mg/dL, altered mental status and a history of rectal bleeding. During diagnostic examination, colonoscopy revealed multiple parasites with bleeding areas and erosive colitis, whereas parasitological analysis found eggs of Ancylostoma/Necator spp 2+. Symptoms improved after treatment with albendazole. Uncinariasis should always be suspected in the process of diagnosis of patients with chronic anemia both in Peru and in tropical areas worldwide(AU)

Resultados de la implantación de un protocolo de corrección de anemia preoperatoria en la recuperación intensificada de cirugía colorrectal electiva / Results of the implantation of a protocol for correction of preoperative anemia in the intensified recovery of elective colorectal surgery

Resumen Introducción Los protocolo ERAS recomiendan la detección y optimización de la anemia preoperatoria. Objetivo Evaluar si la implantación de un protocolo de corrección de anemia preoperatoria en cirugía colorrectal electiva con un protocolo ERAS (grupo ERAS) reduce las transfusiones con respecto a un grupo de pacientes operado de la misma patología previo a su implantación (grupo preERAS). Objetivos secundarios Valorar estancia hospitalaria, complicaciones y reingresos a los 30 días tras el alta. Materiales y Método Comparamos los primeros 121 pacientes consecutivos que participaron en un protocolo ERAS con un protocolo corrección de anemia preoperatoria con los 135 previos a su implantación. Se consideraron resultados significativos p < 0,05. Resultados Se redujo el número de pacientes transfundidos en el grupo ERAS (31 (22,96%) vs 15 (12,4%), p = 0,028) y el número total de concentrados de hematíes transfundidos (3 ± 1,57 vs 1,8 ± 0,56, p < 0,001) con la aplicación del protocolo. No se encontraron diferencias estadísticamente significativas en los pacientes que recibieron hierro oral, pero sí en los que recibieron hierro intravenoso (3 vs 31, p < 0,001). Se redujo la estancia hospitalaria (11 ± 3,8 vs 9,8 ± 3,7, p = 0,018), sin aumentar la tasa de complicaciones ni los reingresos a los 30 días. Conclusión La aplicación de un protocolo de optimización de anemia preoperatoria en pacientes sometidos a cirugía colorrectal electiva siguiendo las guías ERAS redujo el número total de pacientes transfundidos, el número de concentrados de hematíes trasfundidos y la estancia hospitalaria.

Introduction An enhanced recovery after surgery (ERAS) protocol, recommends detection and optimization in treatment of preoperative anemia. Aim Evaluate if introducing a preoperative anemia correcting protocol in elective colorectal surgery, by means of an ERAS protocol (ERAS Group), reduces the need for transfusions with regards to a group of patients undergoing surgery for the same pathology before the protocol´s implementation (ERAS Group). Secondary objectives Evaluate length of stay, complications and readmission rates 30 days post discharge. Materials and Method We compared the first 121 consecutive patients who participated in an ERAS protocol with a preoperative correcting anemia protocol, with the previous 135 patients operated on before the protocol was introduced. A value of p < 0.05 was considered significant. Results The number of patients who needed a transfusion was reduced in the ERAS group (31 (22.96%) vs 15 (12.4%), p = 0.028) as was the total number of red blood cells transfused (3 ± 1.57 vs 1.8 ± 0.56, p < 0.001) with the use of the protocol. No statistical differences were noted in the patients who received oral iron although there was in those who received intravenous iron. (3 vs 31, p < 0.001). Overall length of stay was reduced (11 ± 3.8 vs 9.8 ± 3.7, p = 0.018), but no increase in complications or readmission rates at 30 days. Conclusions The implementation of an optimization in the treatment of preoperative anemia protocol in patients undergoing elective colorectal surgery following the ERAS guidelines, reduced the total number of patients who needed transfusions, the total concentrate of red blood cells transfused, and the length of stay.

Evaluation of adult celiac disease from a tertiary reference center: a retrospective analysis

SUMMARY OBJECTIVE It has been observed that celiac disease (CD) is not restricted to a single type characterized by diarrhea but also has atypical, asymptomatic (silent), and latent forms. The prevalence of this autoimmune disease, which affects approximately 1% of the world, is estimated to be around 3%, including atypical and asymptomatic cases. In our study, we aimed to evaluate adult celiac patients. METHODS Between December 2008-2015, patients diagnosed with CD over the age of 18 years old were included in the study. Patients' symptoms at admission, frequency and type of anemia, transaminase levels, and celiac antibody positivity, and autoimmune diseases diagnosed at follow up were evaluated retrospectively. RESULTS Of 195 patients, 151 (77.4%) were female. The mean age of the patients was 35.73 ± 12.19 years (range, 18-71 years). A hundred patients (51.3%) had gastrointestinal symptoms. At the time of admission, 118 patients (60.5%) had anemia, and 52 (26.7%) had hypertransaminasemia. During the mean follow-up period of 58 months (36-120 months), 84 (43.1%) of the patients presented at least one autoimmune disease, and this rate was 96.6% in individuals diagnosed above the age of 50 years. CONCLUSION In adult CD, resistant anemia, dyspepsia, and hypertransaminasemia are very common findings at the time of diagnosis, and the association with other autoimmune diseases, especially Hashimoto's thyroiditis, is high.

RESUMO OBJETIVOS Observou-se que a doença celíaca (DC) não se restringe a um único tipo caracterizado por diarreia, mas também tem formas atípicas, assintomáticas (silenciosas) e latentes. Estima-se que a prevalência desta doença autoimune, que afeta aproximadamente 1% da população do mundo, seja em torno de 3%, incluindo casos atípicos e assintomáticos. Em nosso estudo, objetivou-se avaliar pacientes celíacos adultos. MÉTODOS Entre dezembro de 2008 e 2015, pacientes diagnosticados como DC com idade acima de 18 anos foram incluídos no estudo. Os sintomas dos pacientes na admissão, frequência e tipo de anemia, níveis de transaminases e positividade de anticorpos celíacos e doenças autoimunes diagnosticadas no seguimento foram avaliados retrospectivamente. RESULTADOS Dos 195 pacientes, 151 (77,4%) eram do sexo feminino. A média de idade dos pacientes foi de 35,73±12,19 anos (variação de 18 a 71 anos). Cem pacientes (51,3%) foram encaminhados com sintomas gastrointestinais. No momento da internação, 118 pacientes (60,5%) apresentavam anemia e 52 (26,7%) apresentavam hipertransaminemia. Durante o período médio de acompanhamento de 58 meses (36-120 meses), 84 (43,1%) pacientes estavam acompanhados por pelo menos uma doença autoimune, e essa taxa foi de 96,6% em indivíduos diagnosticados acima dos 50 anos de idade. CONCLUSÃO No adulto DC, anemia resistente, dispepsia e hipertransaminasemia são achados muito comuns no momento do diagnóstico e a associação com outras doenças autoimunes, especialmente tireoidite de Hashimoto, é alta.

Survey of vector-borne and nematode parasites involved in the etiology of anemic syndrome in sheep from Southern Brazil / Pesquisa de hemoparasitos transmitidos por vetores e nematódeos envolvidos na etiologia de síndrome anêmica em ovinos no Sul do Brasil

Abstract Although anemia has been historically linked to Haemonchus contortus infection, other infectious agents, such as hemotropic mycoplasmas and tick-borne disease pathogens, may also lead to anemic crisis in sheep. This study has aimed to investigate infections related to anemia in a sheep herd from Bandeirantes City, Paraná State, southern Brazil. Seven out of forty-two (16.6%; 95% CI: 8.32-30.6%) sheep were positive for hemoplasmas by a PCR targeting the 16S rRNA gene and all tested negative for A. marginale/A. ovis and Babesia/Theileria spp. by PCR based on msp4 and 18S rRNA genes, respectively. Two (4.7%; 95% CI: 1.32-15.79%) animals were infested with Rhipicephalus microplus ticks. Fecal egg counting was performed in 38 sheep and 24 (63.15%; 95% CI: 47.2-76.6%) presented > 500 eggs per gram. Phylogenetic analysis of partial sequences of the detected hemotropic Mycoplasma sp. 16S and 23S rRNA genes confirmed that the animals were infected with Mycoplasma ovis. Polymorphism analysis of partial 16S rRNA sequences showed three different genotypes of M. ovis infecting sheep assessed in the present study. Mycoplasma ovis and gastrointestinal nematodes occurs in sheep from the northern region of Paraná State.

Resumo Embora a principal causa de anemia seja historicamente relacionada à infecção por Haemonchus contortus, outros agentes infecciosos, como micoplasmas hemotrópicos e patógenos transmitidos por carrapatos, também podem causar quadros anêmicos em ovinos. O presente estudo objetivou investigar infecções relacionadas à anemia em um rebanho de ovinos, na cidade de Bandeirantes, Estado do Paraná, sul do Brasil. Sete (16,6%; 95% CI: 8,32-30,6%) de 42 ovinos foram positivos para hemoplasmas pela PCR do gene 16S rRNA, enquanto todos foram negativos para A. marginale/A. ovis e Babesia/Theileria spp. por ensaios da PCR baseados nos genes msp4 e 18S rRNA, respectivamente. Dois (4,7%; 95% CI: 1,32-15,79%) animais estavam infestados por carrapatos Rhipicephalus microplus. Dos 38 animais nos quais foi realizada a contagem de ovos por grama de fezes (OPG), 24 (63,15%; 95% CI: 47,2-76,6%) apresentaram valores >500 para OPG. A análise filogenética das sequências parciais dos genes 16S rRNA e 23S rRNA de hemoplasmas confirmou a infecção por Mycoplasma ovis. A análise de polimorfismos de um fragmento do gene 16S rRNA mostrou a ocorrência de três genótipos diferentes de M. ovis nos animais. Mycoplasma ovis e nematódeos gastrointestinais ocorrem em ovinos da região nordeste do Estado do Paraná.

Tratamento endovascular da síndrome do quebra-nozes em adolescente: relato de caso / Endovascular treatment of a teenager with nutcracker syndrome: a case report

Resumo A síndrome do quebra-nozes (ou síndrome de nutcracker) é causada pela compressão da veia renal esquerda pela artéria mesentérica superior e aorta, e está associada a uma sintomatologia característica, como dor no baixo ventre, varicocele e hematúria. O diagnóstico é frequentemente difícil e, portanto, demorado. O tratamento invasivo é controverso, especialmente nos pacientes pediátricos; no entanto, em casos de hematúria severa associada a anemia, insuficiência renal funcional, severa dor pélvica ou ineficácia de tratamento conservador, ele é indicado. É relatado o caso de uma criança do sexo masculino, 12 anos, com quadro de hematúria maciça por 12 horas, sem evidências de alterações à investigação inicial, que evoluiu com anemia intensa e retenção urinária. Investigações futuras evidenciaram imagens sugestivas da síndrome de nutcracker e foi optado pelo tratamento endovascular por implante de stent smart control seguido de balonamento. Paciente cessou a hematúria após o procedimento e permanece assintomático há 5 anos.

Abstract The nutcracker syndrome is caused by compression of the left renal vein by the superior mesenteric artery and aorta and is associated with characteristic symptoms, such as lower abdominal pain, varicocele, and hematuria. Diagnosis is often difficult and, therefore, is often delayed. Invasive treatment is controversial, particularly in pediatric patients. However, it is indicated in cases of gross hematuria associated with anemia, renal function impairment, severe pelvic pain, or ineffective conservative treatment. We report the case of a 12-year-old boy presenting with severe hematuria for 12 hours, with no abnormal findings at a first evaluation, who progressed with severe anemia and urinary retention. Further investigation provided images suggestive of nutcracker syndrome, and endovascular stenting (smart control stent) followed by balloon dilatation was the treatment of choice. Hematuria ceased after the procedure, and the patient is still asymptomatic at 5-year follow-up.

Vasculitis asociada a anticuerpos anticitoplasma de neutrófilos: poliangeítis microscópica / Antineutrophil Cytoplasmic Antibody Associated Vasculitis: Microscopic Polyangiitis

La poliangeítis microscópica se define como una enfermedad autoinmune, multisistémica, de rara incidencia, asociada a anticuerpos anticitoplasma de neutrófilos. Se caracteriza por presentar vasculitis necrotizante de pequeños vasos, no granulomatosa y ausencia de depósito de inmunocomplejos, que afecta predominantemente el tejido renal, pulmonar y cutáneo. Se presenta un paciente masculino, 49 años, sin antecedentes patológicos. Presenta cuadro clínico de 30 días de evolución con tos seca de tipo irritativa, que evoluciona a tos productiva, hemoptisis, disnea de moderado esfuerzo, astenia y edema con fóvea en zonas en declive. Tenía anemia grave y los estudios imagenológicos de tórax evidenciaron infiltrados difusos con aspecto de vidrio deslustrado. Se inició terapia inmunosupresora con metilprednisolona y ciclofosfamida y profilaxis antibiótica. Se obtuvo una disminución en el puntaje de la escala de actividad vasculítica y la posterior remisión; sin embargo, debido al daño tisular renal, no hubo mejoría en la tasa de filtrado glomerular, por lo que el paciente se mantiene en terapia de sustitución renal permanente. Es trascendental el conocimiento de las manifestaciones clínicas, procedimiento diagnóstico y tratamiento de esta enfermedad, ya que, a pesar de su rara incidencia, posee una llamativa morbimortalidad que puede modificarse significativamente con un diagnóstico y tratamiento oportunos(AU)

Microscopic Polyangiitis is defined as an autoimmune, multisystemic, low prevalence disease, associated to antineutrophil cytoplasmic antibody. Characterized by necrotizing vasculitis of small vessels, with no granulomatous inflammation and absence of immune complex deposits, predominantly affecting renal, pulmonary and cutaneous tissue. 49-year old male patient with no past medical history. Refers symptomatology that started thirty days ago, characterized by dry cough, that evolves to productive cough, hemoptysis, exertional dyspnea, asthenia and pitting edema. Laboratory tests show severe anemia, glomerular filtration rate of 6.9 ml/min/1.73m2, hematuria, proteinuria, positive presence of antineutrophil cytoplasmic antibodies and anti-myeloperoxidase antibodies, additional thoracic imaging shows ground glass opacities consolidations. Immunosuppressive therapy is started with Methylprednisolone and Cyclophosphamide along with antibiotic prophylaxis, resulting in a decrease in the vasculitis activity score with subsequent remission; however due to renal tissue damage, there is no improvement in the glomerular filtration rate and the patient continues receiving renal replacement therapy. Due to its striking morbidity and mortality, we consider of great importance the knowledge of its clinical presentation, diagnostic procedures and treatment, in order to obtain a positive impact on the patient's quality of life and survival rate(AU)

Anemia no diabetes mellitus gestacional: implicações na instabilidade genômica / Anemia in gestational diabetes mellitus: implications for genomic instability

Introdução: Evidências têm mostrado uma associação entre anemia e Diabetes Mellitus. Contudo, a relação entre anemia e Diabetes Mellitus Gestacional (DMG) ainda não está bem estabelecida, bem como sua repercussão na instabilidade genômica. Portanto, objetivou-se verificar a associação entre anemia e instabilidade genômica em mulheres com DMG atendidas em um hospital universitário. Métodos: Estudo transversal com mulheres apresentando diagnóstico de DMG que realizaram pré-natal no Hospital Universitário de Santa Maria (RS). Informações referentes ao DMG, anemia e suplementação de ferro foram obtidas nos prontuários. A instabilidade genômica foi avaliada pelo ensaio de citoma em micronúcleos em células bucais (BMCyt). Resultados: Das 44 gestantes avaliadas, 28,6% apresentaram anemia e 79,5% foram suplementadas com ferro. Das gestantes que realizaram suplementação, 75,0% não apresentaram anemia gestacional. Níveis de hemoglobina não se associaram com a instabilidade genomica (p > 0,05), mas foi observada uma associação entre brotos nucleares e os níveis de glicemia (r = 0,977; p = 0,003). Conclusão: Não foi verificado associação entre anemia e instabilidade genômica em mulheres com DMG.(AU)

Introduction: There is evidence of an association between anemia and diabetes mellitus. However, the relationship between anemia and gestational diabetes mellitus (GDM) remains to be established, as well as its impact on genomic instability. Therefore, we aimed to examine the association between anemia and genomic instability in women with GDM treated at a university hospital. Methods: A cross-sectional study of women with a diagnosis of GDM who received prenatal care at the University Hospital of Santa Maria, southern Brazil. Data on GDM, anemia, and iron supplementation were obtained from medical records. Genomic instability was assessed by the buccal micronucleus cytome (BMCyt) assay. Results: Of 44 pregnant women evaluated, 28.6% had anemia and 79.5% received iron supplementation; of the latter, 75.0% did not have gestational anemia. Hemoglobin levels were not associated with genomic instability (p > 0.05), but an association was found between nuclear buds and blood glucose levels (r = 0.977; p = 0.003). Conclusion: There was no association between anemia and genomic instability in women with GDM.(AU)

Caracterización del paciente con anemia de células falciformes, Hospital Escuela Universitario, 2016-2017 / Characterization of the patient with Sickle Cell Anemia, University School Hospital, 2016­2017

La anemia de células falciformes es un trastorno autosómico recesivo, causado por una mutación genética que codifica la cadena ß de globina. Objetivo: caracterizar al paciente con diagnóstico de anemia de células falciformes atendidos en el Servicio de Hematología y salas de hospitalización del Hospital Escuela Universitario, período enero 2016 -junio 2017. Material y métodos: estudio retrospectivo, descriptivo transversal. Se incluyen 72 historias clínicas de pacientes con diagnóstico de anemia de células falciformes. Se definieron las variables sobre el último episodio documentado, aspectos sociodemográficos, antecedentes, presentación clínica y valores de laboratorio. Resultados: la media para la edad fue 29.7+/-13; hombres 42(58.3%) y mujeres 30(41.6%). De ellos 46(63.9%) procedían de Francisco Morazán.; 38(52.8%) presentaron trombocitosis y 32(44.4%) tuvieron hiperbilirrubinemia al ingreso; 30(41.7%) presentaron complicación relacionada con crisis vaso-oclusiva sin fallecimientos, 23(31.9%) pacientes fueron atendidos en consulta externa y 49(68.1%) fueron hospitalizados. Conclusión: la mayoría de los pacientes con diagnóstico de anemia de células falciformes eran adultos jóvenes, de predominio masculino, manejados con hidroxiurea, opioides y antibioticoterapia, presentándose como crisis vaso-oclusiva y/o crisis dolorosa, sin casos de mortalidad...(AU)

Ansiedad y calidad de sueño en estudiantes de medicina: ¿Existe una relación con la anemia? / Anxiety and poor sleep quality in medical students. Is there a relationship with anemia?

Introducción: Los estudiantes de medicina suelen ser vulnerables a sufrir trastornos de salud mental como la ansiedad y una mala calidad de sueño. Ambos pueden repercutir negativamente en su conducta alimentaria, lo cual podría generar problemas de anemia a mediano o largo plazo durante su carrera. Objetivo: Conocer la prevalencia de ansiedad y mala calidad de sueño y evaluar la asociación con la presencia de anemia en estudiantes de medicina de una universidad pública peruana. Material y Métodos: Estudio transversal analítico realizado en 80 estudiantes de medicina del primer al cuarto año. Usamos el Inventario de Ansiedad de Beck (BAI) y el Índice de Calidad de Sueño de Pittsburgh (ICSP) para evaluar síntomas de ansiedad y la calidad de sueño, respectivamente. Incluimos también data sociodemográfica, académica y conductual. Así mismo, determinamos la presencia de anemia a través de la obtención de hemoglobina, siguiendo los procedimientos estipulados por el Ministerio de Salud. Resultados: Encontramos que el porcentaje de ansiedad y mala calidad de sueño fueron de 62,5 por ciento y 63,7 por ciento, respectivamente. Ser mujer (RPa: 1,39; 95 por ciento CI: 1,01-1,91) y tener anemia moderada (RPa: 1,31; CI 95 por ciento: 1,06-1,64) se asociaron a tener ansiedad. Por su parte, los factores asociados a una mala calidad de sueño fueron estar en Clínicas (RPa: 1,54; CI 95 por ciento: 1,17-2,02) y tener anemia moderada (RPa: 1,52; CI 95 por ciento: 1,09-2,11). Conclusión: La ansiedad y la calidad de sueño fueron problemas frecuentes en los estudiantes de medicina evaluados. Tener anemia moderada fue un factor asociado para ambos casos(AU)

Introduction: Medical students are often vulnerable to mental health disorders such as anxiety and poor sleep quality. Both can have a negative impact on their eating behavior, which could generate middle- and long-term anemia-related problems during their studies. Objective: To identify the prevalence of anxiety and poor sleep quality and to evaluate the association with anemia in medical students of a Peruvian public university. Material and Methods: We conducted a cross-sectional analytical study in 80 medical students from the first to the fourth year. We used the Beck Anxiety Inventory (BAI) and the Pittsburgh Sleep Quality Index (PSQI) to assess anxiety symptoms and sleep quality, respectively. We also included sociodemographic, academic, and behavioral data. Likewise, we determined the presence of anemia by obtaining hemoglobin results, following the procedures stipulated by the Peruvian Ministry of Health. Results: We found a percentage of anxiety and poor sleep quality of 62.5 percent and 63,7 percent , respectively. To be female (RPa: 1,39; 95 percent CI: 1,01-1,91) and to have moderate anemia (PRa: 1,31; 95 percent CI: 1,06-1,64) were associated with anxiety. On the other hand, the factors associated with poor sleep quality were to be located in Clinics (PRa: 1,54, 95 percent CI: 1,17-2,02) and to have moderate anemia (PRa: 1,52, CI95 percent : 1,09-2,11). Conclusion: Anxiety and sleep quality were frequent problems in the medical students studied. Moderate anemia was an associated factor for both cases(AU)

Recuperação clínica e laboratorial dos pacientes submetidos à cirurgia combinada de lipoaspiração corporal e lipoabdominoplastia / Clinical and laboratory recovery of patients undergoing body liposuction associated with lipoabdominoplasty

Introdução: A lipoaspiração corporal e abdominoplastia são cirurgias muitas vezes realizadas em conjunto para obter melhores resultados na modelagem corporal. Cirurgias associadas sempre aumentam a espoliação, por isto conhecer o comportamento da hemoglobina (Hb) no pós-operatório e a recuperação do paciente submetido a estas cirurgias combinadas é importante para sua segurança. O objetivo deste trabalho foi estudar a queda da Hb e a recuperação clínica e laboratorial dos pacientes submetidos à cirurgia combinada de lipoaspiração corporal e lipoabdominoplastia. Métodos: Realizou-se um estudo prospectivo em pacientes submetidos à lipoaspiração corporal e lipoabdominoplastia, coletando-se hemogramas antes da indução anestésica, ao final da cirurgia, antes da alta hospitalar, após a 1ª, 2ª e 4ª semanas de pós-operatórios e também acompanhando suas evoluções clínicas. Resultados: A média da Hb ao final da cirurgia e na alta hospitalar foi de 10,4g/dl (desvio padrão (DP) 0,76) e 8,92g/dl (DP 0,86), respectivamente. A recuperação em média da Hb após 1ª, 2ª e 4ª semanas foi de 2,4% (DP 18,07), 41,6% (DP 18,4) e 74% (DP 15,2), respectivamente, em relação a redução que ocorreu entre a Hb inicial e a da alta hospitalar. Queixas de fraqueza e lipotimia foram frequentes até o segundo dia. Conclusão: A melhora clínica ocorreu até o segundo dia de pós-operatório (DPO) e a hemoglobina levou aproximadamente 1 mês para normalizar na maioria dos pacientes tratados apenas com reposição oral de ferro, sem necessidade de hemotransfusão.

Introduction: Body liposuction and abdominoplasty are surgeries often performed together to obtain superior results in body modeling. Since associated surgeries often increase spoliation, being aware of the evolution of hemoglobin (Hb) in the postoperative period and during the recovery of the patients undergoing these associated surgeries is important for their safety. This study aimed to analyze the decrease in Hb and the clinical and laboratory results throughout the recovery of patients undergoing body liposuction associated with lipoabdominoplasty. Methods: A prospective study was conducted with patients undergoing body liposuction and lipoabdominoplasty. CBCs were collected before anesthetic induction, at the end of the surgery, before hospital discharge, after the 1st, 2nd, and 4th postoperative weeks, and during their clinical follow-up period. Results: The average Hb values at the end of surgery and hospital discharge were 10.4 g/dL (standard deviation (SD) 0.76) and 8.92 g/dL (SD 0.86), respectively. The average values during the recovery of Hb after the 1st, 2nd, and 4th weeks were 2.4% (SD 18.07), 41.6% (SD 18.4), and 74% (SD 15.2), respectively. This is in relation to the reduction between the initial Hb and at hospital discharge. Complaints of weakness and lipothymia were frequent until the second day. Conclusion: Clinical improvement was observed until the second postoperative day (PO day). Hemoglobin required approximately 1 month to normalize in most patients. These patients were treated only with oral iron replacement and did not require blood transfusions.

Anemia en el paciente oncológico: un reto en medicina perioperatoria / Anemia in the oncological patient: a challenge in perioperative medicine

INTRODUCTION: Perioperative anemia in patients with cancer is frequent and is associated with potential adverse outcomes. In association studies it was established that anemia changes the prognosis in some cases, being associated with a possible increase in the risk of disease progression and death. On the other hand, it has been proposed that immunomodulation secondary to transfusions favors metastasis and the disease`s recurrence. OBJECTIVE: To describe the current evidence on anemia, transfusions and other perioperative strategies for the management of patients with anemia and cancer taken to surgery. MATERIALS AND METHODS: A non-systematic review of the literature that included articles on the perioperative management of anemic patients candidates for oncological surgery was performed. The main findings are described and the evidence is presented in favor of and against some strategies (other than red blood cell transfusion) to correct anemia. CONCLUSION: Optimization of the erythrocyte mass before surgery and the use of blood-sparing strategies should be considered in a comprehensive perioperative management.

INTRODUCCIÓN: La anemia perioperatoria en el paciente con cáncer es frecuente y se asocia a potenciales desenlaces adversos. En estudios de asociación se estableció que la anemia cambia el pronóstico en algunos casos, asociándose a un posible incremento del riesgo de progresión de la enfermedad y muerte. Por otra parte, se ha propuesto que la inmunomodulación secundaria a las transfusiones, favorece las metástasis y la recidiva de la enfermedad. OBJETIVOS: Describir la evidencia actual sobre la anemia, las transfusiones y otras estrategias perioperatorias para el manejo de los pacientes con anemia y cáncer llevados a cirugía. MATERIALES Y MÉTODOS: Se realizó una revisión no sistemática de la literatura que incluyó artículos sobre el manejo perioperatorio de pacientes anémicos candidatos a cirugía oncológica. Se describen los principales hallazgos y se presenta la evidencia a favor y en contra de algunas estrategias (diferentes a la transfusión de glóbulos rojos) para corregir la anemia. CONCLUSIÓN: La optimización de la masa eritrocitaria antes de la cirugía y el uso de estrategias ahorradoras de sangre deben ser consideradas en un manejo perioperatorio integral.

Asociación entre anemia y exacerbaciones de enfermedad pulmonar obstructiva crónica en Cartagena Colombia: estudio de cohorte prospectivo / Association between anemia and chronic obstructive pulmonary disease exacerbations in Cartagena Colombia: a prospective cohort study

INTRODUCCIÓN La presencia de anemia en la enfermedad pulmonar obstructiva crónica es un hecho frecuente. Las exacerbaciones de esta enfermedad se han asociado a un incremento de la mortalidad en estos pacientes. No es claro si la presencia de anemia se vincula al riesgo de exacerbaciones. OBJETIVO Establecer la asociación entre anemia e incidencia de desenlaces relacionados con las exacerbaciones de la enfermedad pulmonar obstructiva crónica. MÉTODOS Estudio analítico de una cohorte dinámica o abierta, prospectiva y concurrente de pacientes con diagnóstico de enfermedad pulmonar obstructiva crónica de dos instituciones de atención en salud de Cartagena, Colombia, entre julio de 2010 y julio de 2011. RESULTADOS De los casos revisados, 43,9% presentó anemia al inicio del seguimiento. La incidencia acumulada de exacerbaciones fue de 63% en el grupo de pacientes anémicos versus 55,5% en el grupo de no anémicos. La incidencia acumulada de recurrencia de exacerbaciones fue de 30,4% en el grupo de anémicos versus 38,8% en el grupo de no anémicos. La tasa de hospitalizaciones por exacerbaciones fue de 30,4% en el grupo de anémicos versus 33,3% en el grupo de no anémicos. CONCLUSIONES No se estableció asociación significativa entre la anemia y la incidencia de exacerbaciones de enfermedad pulmonar obstructiva crónica, la incidencia de recurrencia de la primera exacerbación, la tasa de hospitalizaciones por exacerbaciones de enfermedad pulmonar obstructiva crónica y el tiempo hasta la recurrencia de la primera exacerbación de enfermedad pulmonar obstructiva crónica.

BACKGROUND The presence of anemia in chronic obstructive pulmonary disease is not an infrequent event. Exacerbations of this disease have been associated with an increase in mortality in these patients. It is not clear if the presence of anemia is associated with the risk of exacerbations. OBJECTIVE To establish the association between anemia and the incidence of outcomes related to exacerbations of chronic obstructive pulmonary disease. METHODS Analytical study of a dynamic or open concurrent prospective cohort of patients diagnosed with chronic obstructive pulmonary disease at two health care institutions in Cartagena, Colombia, between July 2010 and July 2011. RESULTS 43.9% had anemia at the start of follow-up. The cumulative incidence of exacerbations was 63% in the anemic vs. 55.5% in the non-anemic group. The cumulative incidence of recurrence of exacerbations was 30.4% in the anemic vs. 38.8% in the non-anemic group. The rate of hospitalizations for exacerbations was 30.4% in the anemic vs. 33.3% in the non-anemic group. CONCLUSIONS No significant association was established between anemia and the incidence of exacerbations of chronic obstructive pulmonary disease, the incidence of recurrence of first exacerbation, the rate of hospitalizations for chronic obstructive pulmonary disease exacerbations and the recurrence time of the first exacerbation of chronic obstructive pulmonary disease.

Valor de la hemoglobina al ingreso como predictor de transfusión de sangre alogénica en fractura de cadera / Initial hemoglobin value as a predictor of allogeneic blood transfusion in hip fracture

Resumen: Introducción: La fractura de cadera es una causa de importante morbimortalidad y a menudo se asocia a una elevada tasa de transfusión sanguínea, terapia no exenta de complicaciones. El objetivo del estudio es evaluar los factores dependientes e independientes del acto transfusional, así como elaborar un algoritmo que nos permita realizar una toma de decisiones basada en un modelo estadístico racionalizando el empleo de sangre alogénica. Material y métodos: Estudio prospectivo sobre 100 pacientes mayores de 65 años intervenidos por fractura de cadera de forma consecutiva. Se analizaron datos demográficos, toma de fármacos, comorbilidad, analítica pre- y postoperatoria, tipo de fractura y los relativos a la cirugía valorando de forma uni- y bivariada los factores determinantes del acto transfusional para controlar el posible sesgo de confusión. Resultados: Tras la aplicación del modelo bivariante de regresión logística sólo la Hb al ingreso (p = 0.04, OR = 0.451) y el tipo de fractura (p = 0.003, OR = 5.479) se consideraron asociadas al acto transfusional. El valor de la Hb al ingreso genera una curva ROC con un área bajo la curva de 0.848, aceptable para valorar la probabilidad de transfusión. Un valor de Hb al ingreso inferior a 12.15 g/dl predeciría de forma correcta la transfusión con una sensibilidad de 80% y una especificidad de 85 %. Conclusiones: La presencia de anemia preoperatoria y la fractura extracapsular de cadera generan un alto riesgo de necesidad transfusional, mientras que es improbable en fracturas intracapsulares sin anemia al ingreso. En nuestra serie existe un valor analítico que predice de forma satisfactoria 80% de las transfusiones sanguíneas.

Abstract: Introduction: Hip fracture is a cause of major morbidity and mortality and is often associated with high blood transfusion rate, non-complication-free therapy. The objective of the study is to evaluate the factors dependent and independent of the transfusional act, as well as to elaborate an algorithm that allows us to make a decision making based on a statistical model rationalizing the use of blood. Material and methods: Prospective study on 100 patients older than 65 years intervened for hip fracture consecutively. We analyzed demographic data, drug taking, comorbidity, pre- and postoperative analytics, type of fracture and those related to surgery valuing uni- and bivariate determinants of the Transfusional Act to control the possible bias of confusion. Results: Following the application of the bivariate logistic regression model only the HB at the admission (p = 0.04, OR = 0.451) and the type of fracture (p = 0.003, OR = 5.479) were considered associated with the transfusion act. The value of initial HB generates a ROC curve with an area under the curve of 0.848, acceptable to assess the probability of transfusion. An initial HB value lower of 12.15 g/dl will predict the transfusion with a sensitivity of 80% and a specificity of 85%. Conclusion: The presence of preoperative anemia and extracapsular hip fractures generate a high risk of transfusion need, while it is unlikely in intracapsular fractures without anemia at admission. In our series there is an analytical value that predicts satisfactorily 80% of blood transfusions.