Síndrome de Boerhaave: manejo diagnóstico y terapéutico en el Hospital Regional de Talca / Boerhaave Syndrome: diagnostic and therapeutic management at the Hospital Regional de Talca

Introduction: Boerhaave syndrome is a spontaneous rupture of the esophageal wall caused by a sudden increase in intraesophageal pressure. It represents an incidence of approximately 15% of all esophageal perforations, which do not exceed 3.1 per 1 million inhabitants per year. Objectives: To communicate the clinical presentation and management of patients with this syndrome, as well as to reveal the different options available in our service for its treatment. Methods: Search in the statistical data of the regional Hospital of Talca for patients with a diagnosis of Boerhaave syndrome. Five patients were found. Information was obtained from their clinical records and is presented as a clinical case report with a descriptive analysis of their management. Results: Of the 5 clinical cases presented, a classic clinical presentation can be observed, most of the patients presented with vomiting that later evolved with thoracic and/or epigastric pain, associated with imaging studies suggesting esophageal perforation. Management was surgical in 100% of the cases, applying different techniques described in the literature. Discussion and Conclusion: Boerhaave syndrome is a medical-surgical emergency that requires timely management. In spite of the variety of management and the consequences of each one of them, all the patients had an evolution that allowed them to preserve their lives until nowadays. Keeping a high index of suspicion and choosing the best management will have an impact on morbidity and mortality.

Drug utilization study in neonatal intensive care unit at tertiary care hospital

SUMMARY OBJECTIVE: Neonates are more susceptible to drug interactions and adverse effects, and special care should be taken when prescribing medication to them. This study aimed to investigate drug usage in the neonatal intensive care unit of a tertiary care hospital. METHODS: This prospective observational study was conducted on 98 patients at the Apollo tertiary care hospital (Bannerghatta, Bangalore, India) in a period of 6 months. The most common indications for neonatal intensive care unit admission, average number of drugs per patient, the most frequently used medication, distribution of patients based on the birth procedure, and possible drug interactions were collected from patient profiles. RESULTS: Among the patients, 52% were males and 48% were females. Notably, 38% of patients were preterm, 60% were term, and only 2% were post-term. Also, 80.6% were born by cesarean section and 19.4% were born by normal vaginal delivery. The highest mean of drug use was in the patient of 1,000-1,500 g (8.06 per patient). Preterm was the most frequent indication for admission in neonatal intensive care unit, followed by hyperbilirubinemia and then respiratory distress syndrome. The most frequently used medication was vitamin K (99%) and antibiotics followed by dextrose. In different types of antibiotics, amikacin (41%), cefoperazone+sulbactam (35%), cephalosporin (1%), ceftriaxone (0.7%), and amoxicillin (0.3%) were commonly administered. There were some possible interactions, such as aminoglycoside with furosemide and calcium gluconate. CONCLUSION: Premature birth and resulting low birth weight were the main reasons for drug prescription. High administration of antibiotics is probably an area of concern and should be seriously considered.

Análisis epidemiológico del cáncer de cérvix in situ e invasor, periodo 2015-2019 / Epidemilogical analysis of cérvix cancer in situ and invasor, period 2015-2019

El cáncer de cérvix sigue siendo un problema de salud pública a nivel mundial en las mujeres que se presenta mayormente en los países en desarrollo y en niveles de estrato socio económico bajo. Objetivo. Realizar un análisis epidemiológico del cáncer de cérvix in situ e invasor, atendidos en el hospital de SOLCA Guayaquil. Metodología. Estudio observacional, de diseño de investigación tipo corte transversal, descriptivo. Lugar: hospital SOLCA en Guayaquil, período 2015 a 2019. Los sujetos fueron las pacientes con cáncer de cérvix in situ e invasor. Aplicando estadísticas descriptivas como porcentaje y comparación entre variables. Resultados. Cáncer invasor tuvo un incremento entre 2015 al 2019 del 4% e in situ del 4,7%; corroborado al aplicar el modelo de tendencia polinomial. El invasor tuvo topográficamente de mayor frecuencia al Tumor maligno de cuello de útero sin otra especificación (79,59%), mientras en el cáncer in situ al Carcinoma in situ de otras partes especificadas del cuello del útero (53,13%); el invasor se observó en edades de 45 a 54 años e in situ de 30 a 39 años; morfológicamente el invasor tuvo al Carcinoma de células escamosas SAI (38,36%) e in situ al Carcinoma in situ de células escamosas SAI (83,07%). Conclusiones. El cáncer de cérvix presentado en este quinquenio se ha incrementado, siendo el cáncer invasor más frecuente en edades entre 45-54 años y el cáncer in situ en edades más tempranas, considerando que está patología se puede detectar oportunamente, se recomienda fortalecer las campañas de tamizaje para su prevención y control.

Cervical cancer continues being a public health problem worldwide in women, which occurs mainly in developing countries and at low socio-economic levels. Target. Carry out an epidemiological analysis of in situ and invasive cervical cancer treated at the SOLCA Guayaquil hospital. Methodology. Observational, descriptive, cross-sectional research design study. Place: SOLCA hospital in Guayaquil, period 2015 to 2019. The subjects were patients with in situ and invasive cervical cancer. Applying descriptive statistics as a percentage and comparison between variables. Results. Invasive cancer had an increase between 2015 and 2019 of 4% and in situ of 4,7%; corroborated by applying the polynomial trend model. The invader had a topographically higher frequency of malignant neoplasm of the cervix without other specification (79,59%), while in cancer in situ it had Carcinoma in situ of other specified parts of the cervix (53,13%); the invader was observed in ages 45 to 54 years and in situ from 30 to 39 years; Morphologically, the invader had squamous cell carcinoma NOS (38,36%) and in situ squamous cell carcinoma in situ NOS (83,07%). Conclusions. Cervical cancer presented in this five-year period has increased, being the most frequent invasive cancer in ages between 45-54 years and in situ cancer in younger ages, considering that this pathology can be detected in a timely manner, it is recommended to strengthen the campaigns of screening for its prevention and control.

Epidemiología de la Onicomicosis Pedis en adultos hospitalizados en un servicio de medicina en un hospital de tercer nivel en Chile / Epidemiology of Onychomycosis pedisinhospitalized adults at the internal medicine ward of a high complexity hospital in Chile

La prevalencia global de la onicomicosis pedis es de 4,3%, y en hospitalizados puede llegar hasta 8,9%. Aun así, se propone que está ampliamente subdiagnosticada. Personas añosas con comorbilidades presentan mayor riesgo de onicomicosis pedis y de sus complicaciones. Se examinaron aleatoriamente a 64 pacientes hospitalizados en el Servicio de Medicina del Hospital San José. A aquellos con signos clínicos de onicomicosis pedis se les realizó un examen micológico directo (MD) y estudio histopatológico de un corte de uña teñido con PAS (Bp/PAS). Muestra de 64 pacientes, un 78,1% presentó onicomicosis pedis clínica y en un 70,3% se confirmó el diagnóstico con MD y/o Bp/PAS positivo. De los pacientes con onicomicosis confirmada, el promedio de edad fue de 67,8 +/- 12,3 años. Un 44% correspondió al sexo femenino y un 56% al sexo masculino. La onicomicosis pedis en el servicio de medicina interna del Hospital San José es una condición frecuente. El conjunto de MD y Bp/PAS podría ser considerado como una buena alternativa diagnóstica. (AU)

Onychomycosis of the toenails has a global prevalence of 4,3% and can reach up to 8,9% in hospitalized patients. It has been hypothesized that it is widely under diagnosed. Aged patients with multiple diseases have an increased risk of Onychomycosis and its complications. 64 patients of the internal medicine ward were randomly selected. Those who had clinical signs of onychomycosis of the toenails were tested with direct microscopy and histological study of the nail plate with PAS staining. Of the 64 patients, 78,1% (50) had clinical signs of onychomycosis of the toenails and in 70,3% (45) the diagnosis was confirmed either by direct microscopy and/or by histological study of the nail plate with PAS staining. The mean age for the group with onychomycosis was 67,8 +/- 12,3 ages. 44% were female and 56% were male. Onychomycosis of the toenails is a frequent condition at the internal medicine ward of the San José Hospital. The direct microscopy together with the histological study of the nail plate with PAS staining seem to be a good diagnosis alternative. (AU)

Cambios en el patrón epidemiológico de la colitis ulcerosa crónica idiopática en México en un hospital de tercer nivel de atención / Changes in chronic idiopathic ulcerative colitis epidemiological pattern in Mexico in a tertiary care hospital

Resumen Antecedentes: La colitis ulcerosa crónica idiopática (CUCI) es una enfermedad con inflamación crónica de la mucosa del colon de origen multifactorial. El objetivo de este trabajo es identificar posibles cambios en el comportamiento de la CUCI en un hospital de referencia. Métodos: Se incluyeron nuevos casos de CUCI confirmados por histopatología de enero del 2007 a diciembre del 2014. Resultados: Se incluyeron un total de 189 pacientes. La media de nuevos casos anuales de CUCI fue de 23.6. Este estudio incorpora 95 pacientes de sexo masculino (50 %) y 94 de sexo femenino (50 %), con una edad promedio al diagnóstico de 44.6 años. La frecuencia de pancolitis fue del 77 %, en comparación con el 59 % en el periodo anterior. Las manifestaciones extraintestinales (MEI) estuvieron presentes en el 55.8 % y las colectomías en el 5.2 %. Conclusión: Algunas características de la enfermedad han cambiado con el tiempo: aumento de la frecuencia de pancolitis y MEI, así como disminución de la tasa de colectomías.

Abstract Background: Chronic idiopathic ulcerative colitis (CIUC) is a disease with multifactorial chronic inflammation of the colonic mucosa. In Mexico, there are studies that show an increase in the frequency of new cases. The purpose of this work was to identify possible changes in CIUC behavior in a referral hospital. Methods: New ulcerative colitis (UC) cases confirmed by histopathology from January 2007 to December 2014 were included. Results: A total of 189 patients were included. Mean number of UC annual new cases was 23.6. The study included 95 male patients (50 %) and 94 female patients (50 %), with an average age of 44.6 years at diagnosis. The frequency of pancolitis was 77 %, in comparison with 59 % in the previous period. Extra-intestinal manifestations (EIM) were present in 55.8 % and colectomies in 5.2 %. Conclusion: Some characteristics of the disease have changed over time: there is an increased frequency of pancolitis and EIM, as well as a decrease in the rate of colectomies.

Patent ductus arteriosus closure: experience from a tertiary referral center / Experiência de uma maternidade terciária no fechamento do canal arterial patente

ABSTRACT Objective: To characterize the number and methods of closure of Persistent Ductus Arteriosus (PDA) over a span of 16 years in a third level maternity hospital. Methods: Retrospective study of neonates born between January 2003 and Deccember 2018, who underwent ductus arteriosus closure by pharmacological, surgical and/or transcatheter methods. Gestational age, birth weight, number and methods of closures per year were evaluated. The success rate of the pharmacologic method was calculated, as well as the mortality rate. The association between mortality and birthweight, treatment used and treatment failure was explored. Results: There were 47,198 births, 5,156 were preterm, 325 presented PDA and 106 were eligible for closure (median gestational age - 27 weeks, birthweight <1000 g - 61%). Frequency of PDA closure decreased during the study period, especially starting in 2010. Success rate with pharmacologic treatment was 62% after the first cycle and 74% after the second. After drug failure, 12 underwent surgical ligation and two underwent transcatheter closure. Exclusive surgical ligation was indicated in four infants. Ibuprofen replaced indomethacin in 2010, and acetaminophen was used in three infants. Among the 106 infants, hospital mortality was 12% and it was associated with birthweight <1000 g (13/65 <1000 vs. 0/41 >1000 g; p=0.002) and with failure in the first pharmacologic treatment cycle (13/27 with failure, vs. 0/75 without failure; p<0.001). Conclusions: The national consensus published in 2010 for the diagnosis and treatment of PDA in preterm infants led to a decrease in the indication for closure. Pharmacological closure was the method of choice, followed by surgical ligation. Birthweight <1000 g and first cycle of pharmacologic treatment failure were associated with higher mortality.

RESUMO Objetivo: Caraterizar o número e métodos de fechamento de canal arterial durante 16 anos numa maternidade de nível terciário. Métodos: Estudo retrospetivo de nascidos entre 01 de janeiro de 2003 a 31 de dezembro de 2018 submetidos a fechamento do canal arterial por métodos farmacológico, cirúrgico e/ou percutâneo. Avaliaram-se idade gestacional, sexo, peso ao nascimento, número de fechamentos por ano e método utilizado. Aferiram-se as taxas de sucesso de método farmacológico e de mortalidade e sua associação com peso ao nascer, fármaco utilizado e insucesso do fechamento. Resultados: Verificaram-se 47.198 recém-nascidos, 5.156 prematuros, dos quais 325 com canal arterial patente, sendo 106 com indicação para fechamento (idade gestacional mediana 27 semanas, peso <1000 g em 61%). Verificou-se diminuição do número de fechamentos ao longo dos anos, sobretudo a partir de 2010. O fechamento ocorreu em 62% após primeiro ciclo de tratamento farmacológico e em 74% após segundo. Após insucesso farmacológico, 12 realizaram ligadura cirúrgica e dois, fechamento percutâneo. Houve indicação de ligadura cirúrgica exclusiva em quatro. O ibuprofeno substituiu a indometacina em 2010. O acetaminofen foi usado em três doentes. A mortalidade nos 106 pacientes foi de 12%, associando-se ao peso ao nascer (13/65 <1000 vs. 0/41 >1000 g; p=0,002) e à falha do primeiro ciclo de tratamento farmacológico (13/27 com falha vs. 0/75 com sucesso; p<0,001). Conclusões: Consenso nacional de 2010 para diagnóstico e tratamento do canal arterial nos prematuros levou à diminuição do número de fechamentos desse canal. O fechamento farmacológico foi o método mais utilizado, seguido da ligadura cirúrgica. Peso <1000 g e falha no primeiro ciclo de fechamento farmacológico se associaram à maior mortalidade.

A Ten-year Retrospective Study of Invasive Candidiasis in a Tertiary Hospital in Beijing / 生物医学与环境科学（英文）

Objective@#This study aimed to evaluate the epidemiological, clinical and mycological characteristics of invasive candidiasis (IC) in China.@*Methods@#A ten-year retrospective study including 183 IC episodes was conducted in a tertiary hospital in Beijing, China.@*Results@#The overall incidence of IC from 2010-2019 was 0.261 episodes per 1,000 discharges. Candidemia (71.0%) was the major infective pattern; 70.3% of the patients tested positive for @*Conclusion@#The incidence of IC has declined in the recent five years.

Clinical and epidemiological characteristics of patients diagnosed with covid-19 in a tertiary care center in Mexico City: a prospective cohort study

ABSTRACT Background: Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. Objective: The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). Methods: We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. Results: We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. Conclusions: Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.

Cutaneous sarcoidosis: clinico-epidemiological profile of 72 patients at a tertiary hospital in São Paulo, Brazil,

Abstract Background: Sarcoidosis is a multisystem disease of unknown cause that is characterized by the presence of granulomas in various organs. Cutaneous involvement is common and the reported incidence has varied from 9% to 37%. Studies on cutaneous sarcoidosis in Brazil are lacking. Objectives: To describe the clinical and epidemiological aspects of patients with cutaneous sarcoidosis diagnosed at the Department of Dermatology of the University of São Paulo, from May 1994 to March 2018. Methods: Clinical data of patients with confirmed cutaneous sarcoidosis were retrospectively reviewed and classified according to gender, ethnicity, age at diagnosis, cutaneous presentation, systemic involvement and treatment. Results: Cutaneous sarcoidosis was diagnosed in 72 patients with a female predominance (74%). The mean age at diagnosis was 49.6 years and most of the patients were white (61%). Papules and plaques were the most common lesions. Systemic sarcoidosis was detected in 81% of patients, affecting mainly the lungs and thoracic lymph nodes (97%). Typically, cutaneous lesions were the first manifestation (74%). Systemic therapy was necessary for 72% of patients; the dermatologist managed many of these cases. Oral glucocorticoids were the most commonly used systemic medication (92%). The mean number of systemic drugs used was 1.98 per patient. Limitations: Insufficient data in medical records. Conclusions: This series highlights the dermatologist role in recognizing and diagnosing cutaneous sarcoidosis, evaluating patients for systemic disease involvement and treating the skin manifestations. Cutaneous sarcoidosis was once considered exceedingly infrequent in Brazil in comparison to infectious granulomatous diseases; however, the present series seems to suggest that the disease is not so rare in this region.

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.

Which children account for repeated admissions within 1 year in a Brazilian pediatric intensive care unit? / Quais crianças representam as internações de repetição em um ano em uma unidade de terapia intensiva pediátrica brasileira?

Abstract Objective: While studies have focused on early readmissions or readmissions during the same hospitalization in a pediatric intensive care unit, little is known about the children with recurrent admissions. We sought to assess the characteristics of patients readmitted within 1 year in a Brazilian pediatric intensive care unit. Methods: This was a retrospective study carried out in a tertiary pediatric intensive care unit. The outcome was the maximum number of readmissions experienced by each child within any 365-day interval during a 5-year follow-up period. Results: Of the 758 total eligible admissions, 75 patients (9.8%) were readmissions. Those patients accounted for 33% of all pediatric intensive care unit bed care days. Median time to readmission was 73 days for all readmissions. Logistic regression showed that complex chronic conditions (odds ratio 1.07), severe to moderate cognitive disability (odds ratio 1.08), and use of technology assistance (odds ratio 1.17) were associated with readmissions. Multiple admissions had a significantly prolonged duration of mechanical ventilation (8 vs. 6 days), longer length of pediatric intensive care unit (7 vs 4 days) and hospital stays (20 vs 9 days), and higher mortality rate (21.3% vs 5.1%) compared with index admissions. Conclusion: The rate of pediatric intensive care unit readmissions within 1 year was low; however, it was associated with a relevant number of bed care days and worse outcomes. A 30-day index of readmission may be inadequate to mirror the burden of pediatric intensive care unit readmissions. Patients with complex chronic conditions, poor functional status or technology assistance are at higher risk for readmissions. Future studies should address the impact of qualitative interventions on healthcare and recurrent admissions.

Resumo: Objetivo: Apesar dos estudos terem focado em reinternações precoces ou reinternações durante a mesma internação na unidade de terapia intensiva pediátrica, pouco se sabe sobre essas crianças com internações recorrentes. Buscamos avaliar as características dos pacientes reinternados em 1 ano em uma unidade de terapia intensiva pediátrica brasileira. Métodos: Este foi um estudo retrospectivo realizado em uma unidade de terapia intensiva pediátrica terciária. O resultado foi o número máximo de reinternações por cada criança em qualquer período de 365 dias durante um período de acompanhamento de 5 anos. Resultados: Do total de 758 internações elegíveis, 75 pacientes (9,8%) foram de reinternações. Esses pacientes representaram 33% de todos os dias de cuidados com os internados na unidade de terapia intensiva pediátrica. O tempo mediano para a reinternação foi 73 dias para todas as reinternações. A regressão logística mostrou que as doenças crônicas complexas (razão de chance de 1,07), deficiência cognitiva grave a moderada (razão de chance de 1,08) e uso de suporte de aparelhos tecnológicos (razão de chance de 1,17) foram associados às reinternações. As múltiplas internações apresentaram duração significativamente prolongada na ventilação mecânica (8 em comparação a 6 dias), maior tempo de internação na unidade de terapia intensiva pediátrica (7 em comparação a 4 dias) e tempos de internação (20 em comparação a 9 dias) e maior taxa de mortalidade (21,3% em comparação a 5,1%), em comparação às internações iniciais. Conclusão: A taxa de reinternações na unidade de terapia intensiva pediátrica em 1 ano foi baixa, porém foi associada a um número relevante de cuidados durante internação e piores resultados. Um índice de reinternação de 30 dias pode ser inadequado para refletir a grande número de reinternações na unidade de terapia intensiva pediátrica. Os pacientes com doenças crônicas complexas, estado funcional ruim ou suporte de aparelhos tecnológicos correm maior risco de reinternações. Estudos futuros devem abordar o impacto das intervenções qualitativas sobre os serviços de saúde e as internações recorrentes.

Clinical and microbiological characteristics of community-acquired pneumonia associated with Streptococcus pneumoniae in adult patients in Mexico / Características clínicas y microbiológicas de la neumonía adquirida en la comunidad asociada con Streptococcus pneumoniae en pacientes adultos en México

The aim of this study was to assess the risk factors and clinical and microbiological characteristics of community-acquired pneumonia (CAP) in adult patients in Mexico. Streptococcus pneumoniae classified as the causative agent of CAP in adult patients and patients with invasive S. pneumoniae isolates presented to three tertiary teaching hospitals during the 15-year study period were selected. Serotyping and susceptibility testing were performed for all included isolates. Clinical and demographic data were recorded. A total of 96 patients infected with S. pneumoniae (71 with CAP, 25 with invasive disease) were included. The CAP group involved more males (74.6%) than the invasive disease group (p = 0.03). Head trauma was more common in the CAP group (21.1%) than in the invasive disease group (4.0%; p = 0.03). The most prevalent serotype was 19A, followed by serotypes 3 and 23F. After the introduction of the heptavalent conjugated pneumococcal vaccine (PCV7), the prevalence of included serotypes declined significantly; no such change was found after the introduction of the PCV13 vaccine, including in the prevalence of serotype 19A. Susceptibility to all antimicrobials tested except vancomycin declined over the study period. In conclusion, head trauma was the most common comorbidity in the CAP group. The most prevalent serotype was 19A. Decreased susceptibility to most antimicrobials tested was observed.

El objetivo de este estudio fue evaluar los factores de riesgo y las características clínicas y microbiológicas de la neumonía adquirida en la comunidad (NAC) en pacientes adultos en México. Se seleccionaron pacientes adultos con NAC con Streptococcus pneumoniae como agente causal y pacientes con aislamientos invasivos de S. pneumoniae que concurrieron a tres hospitales de enseñanza de tercer nivel durante el período de estudio de 15 anos (2000-2015). Se realizaron pruebas de serotipificación y sensibilidad con todos los aislados incluidos. Se colectaron los datos clínicos y demográficos. Se incluyeron en total 96 pacientes infectados con S. pneumoniae (71 con NAC y 25 con enfermedad invasiva). El grupo con NAC incluía más varones (74,6%) que el grupo de enfermedad invasiva (p = 0,03). El traumatismo craneoencefálico fue más frecuente en el grupo NAC (21,1%) queen el grupo con enfermedad invasiva (4,0%; p = 0,03). El serotipo más frecuente fue 19A, seguido de los serotipos 3 y 23F. Después de la introducción de la vacuna antineumocócica conjugada heptavalente (PCV7), la prevalencia de los serotipos incluidos en aquella disminuyó significativamente; no sucedió lo mismo después de la introducción de la PCV13, incluso en relación con la prevalencia del serotipo 19A. La sensibilidad a todos los antimicrobianos evaluados, excepto la vancomicina, disminuyó durante el período de estudio. En conclusión, el traumatismo craneoencefálico fue la comorbilidad más frecuente en el grupo con NAC. El serotipo más frecuente fue el 19A, y se observó disminución de la sensibilidad a la mayoría de los antimicrobianos probados a lo largo del período considerado.

Clinical and economic impact of generic versus brand name meropenem use in an intensive care unit in Colombia

Abstract Background: Recent studies suggest that sustained use of generic antibiotics may be associated with clinical failure and emergence of antibacterial resistance. The present study was designed to determine the clinical outcome between the use of generic meropenem (GM) and brand-name meropenem (BNM). Additionally, this study evaluated the economic impact of GM and BNM to determine if the former represents a cost-effective alternative to the latter. Methods: Patients treated between January 2011 and May 2014 received GM while patients treated between June 2014 and March 2017 received BNM. Mortality was compared between groups. Total infection cost was defined by the cost of antimicrobial consumption, length of stay, and laboratory and imaging exams until infection resolution. Findings: A total of 168 patients were included; survival rate for the 68 patients treated with GM was 38% compared to 59% in the patients treated with BNM. Multivariate analysis showed that the variables most strongly-associated with mortality were cardiovascular disease (OR 18.18, 95% CI 1.25-262.3, p = 0.033) and treatment with generic meropenem (OR 18.45, 95% CI 1.45-232.32, p = 0.024). On the other hand, total infection cost did not show a significant difference between groups (BNM $10,771 vs. GM $11,343; p = 0.91). Interpretation: The present study suggests that patients treated with GM have a risk of death 18 times higher compared to those treated with BNM. Furthermore, economic analysis shows that GM is not more cost effective than BNM. Summary: More studies measuring clinical outcomes are needed to confirm the clinical equivalence of brand-name versus generic antibiotics, not only for meropenem but also for other molecules.

Predictors of readmission and long length of stay in elders admitted with neurological disorders in a tertiary center: a real-world investigation / Preditores de readmissão hospitalar e de longo tempo de internação em idosos admitidos com doenças neurológicas em centro terciário: uma investigação no mundo real

ABSTRACT Hospital readmission and long length of stay (LOS) increase morbidity and hospital mortality and are associated with excessive costs to health systems. Objective: This study aimed to identify predictors of hospital readmission and long LOS among elders with neurological disorders (NDs). Methods: Patients ≥ 60 years of age admitted to the hospital between January 1, 2009, and December 31, 2010, with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic factors, NDs, and comorbidities as independent predictors of readmission and long LOS (≥ 9 days). Logistic regression was performed for multivariate analysis. Results: Overall, 1,154 NDs and 2,679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8 ± 9.1). Of the patients, 54.5% were female. Patient readmissions were 251(31%) and 409 patients (51%) had an LOS ≥ 9 days (95% confidence interval 48%-55%). We found no predictors for readmission. Low socioeconomic class (p = 0.001), respiratory disorder (p < 0.001), infection (p < 0.001), genitourinary disorder (p < 0.033), and arterial hypertension (p = 0.002) were predictors of long LOS. Identified risks of long LOS explained 22% of predictors. Conclusions: Identifying risk factors for patient readmission are challenges for neurology teams and health system stakeholders. As low socioeconomic class and four comorbidities, but no NDs, were identified as predictors for long LOS, we recommend studying patient multimorbidity as well as functional and cognitive scores to determine whether they improve the risk model of long LOS in this population.

RESUMO Readmissão hospitalar e tempo longo de internação aumentam a morbidade, a mortalidade hospitalar e estão associados a custos excessivos para os sistemas de saúde. Objetivo: Este estudo almejou identificar preditores de readmissões hospitalares e longo tempo de internação (TDI) entre idosos com doenças neurológicas (DN). Métodos: Pacientes de idade ≥ 60 anos admitidos no hospital entre 1 de janeiro de 2009 e 31 de dezembro de 2010 com DN aguda, DN crônica subjacente a transtorno clínico agudo e complicações neurológicas de outras doenças foram estudados. Nos analisamos fatores demográficos, DN e comorbidades como preditores independentes de readmissão hospitalar e TDI (≥ 9 dias). Utilizamos regressão logística para analise multivariada. Resultados: Um total de 1154 DN e 2679 comorbidades foram identificadas entre 798 pacientes com idade ≥ 60 anos (media 75.8 ± 9.1). Desses pacientes 54.5% foram mulheres. Foram 251(31%) readmissões de pacientes e 409 (51%) dos pacientes tiveram um TDI≥9 dias (intervalo de confiança 95%, 48%-55%). Não encontramos preditores para readmissões. Baixa classe social (p = 0,001), distúrbio respiratório (p < 0,001), infecção (p < 0,001), distúrbio genito-urinário (p = 0,033) e hipertensão arterial (p = 0,002) foram os preditores de longo tempo de internação. Esses fatores de risco compõem 22% dos preditores para longo TDI. Conclusões: A identificação de fatores de risco para readmissão hospitalar é um desafio para equipes neurológicas e gestores dos sistemas de saúde. Conquanto baixa classe social e 4 comorbidades, todavia nenhuma DN, foram identificadas como preditoras para longo TDI nós recomendamos investigar multimorbidade, escores funcionais e cognitivos para saber se eles melhoram o modelo de risco para longo TDI nesta população.

Malaria grave en mujeres gestantes hospitalizadas entre el 2010 y el 2014 en el departamento de Antioquia, Colombia / Severe malaria in pregnant women hospitalized between 2010 and 2014 in the Department of Antioquia (Colombia)

Resumen Introducción. La malaria (o paludismo) durante la gestación impacta negativamente la salud de la madre y del neonato, con alto riesgo de complicaciones clínicas y mortalidad. En las regiones de alta endemia se han caracterizado, especialmente, la anemia materna y el bajo peso al nacer, pero es poco conocido el espectro clínico en las zonas de baja endemia. Objetivo. Caracterizar clínica y epidemiológicamente los episodios de malaria en mujeres gestantes hospitalizadas en el departamento de Antioquia entre el 2010 y el 2014. Materiales y métodos. Se hizo un estudio descriptivo, transversal y retrospectivo, con historias clínicas de mujeres gestantes con malaria por Plasmodium falciparum y P. vivax. Se utilizaron los criterios diagnósticos de malaria complicada de la Organización Mundial de la Salud (OMS) y de la Guía para la atención clínica integral del paciente con malaria vigente en Colombia. Resultados. Se analizaron 111 casos; el 13,5 % se clasificó como complicación grave según los criterios de la OMS, porcentaje que ascendió a 23,4 % según los criterios de la guía colombiana. Las complicaciones detectadas fueron disfunción hepática, anemia, acidosis y trombocitopenia grave. No se observó diferencia en la frecuencia de las complicaciones según la especie de plasmodio. El 39,4 % de los casos presentó signos generales de peligro; la palidez y la ictericia fueron los más frecuentes. El 40,5 % presentó signos de peligro para la gestación como la cefalea persistente, el dolor abdominal y el sangrado vaginal. Conclusiones. La malaria grave se presenta con gran frecuencia en las mujeres gestantes, sin diferencia según la especie de plasmodio, y se manifiesta con signos de peligro precozmente reconocibles. Se encontró un subregistro hospitalario del 88 % de los casos graves y falta de exámenes de laboratorio para un diagnóstico más completo. Se requiere un protocolo para el diagnóstico clínico de las mujeres gestantes con malaria.

Abstract Introduction: Malaria during pregnancy has a negative impact on maternal-neonatal health, with a high risk of clinic complications and mortality. High endemic areas are specially characterized by maternal anaemia and low birth weight. The clinical spectrum is little known in low endemic areas. Objective: To clinically and epidemiologically characterize malaria episodes in hospitalized pregnant women in the Department of Antioquia (Colombia) in the period 2010-2014. Materials and methods: Retrospective, cross-sectional, descriptive study with medical records of pregnant women with P. falciparum and P. vivax malaria. The WHO severe malaria diagnostic criteria and the Colombian Guía para la atención clínica integral del paciente con malaria (guidelines for comprehensive malaria treatment) were used. Results: We analyzed 111 cases, out of which 13.5% were classified as severe malaria according to the WHO criteria. Following the Colombian Guidelines, the proportion increased to 23.4%. Identified complications included hepatic dysfunction, anaemia, acidosis, and severe thrombocytopenia. No difference in the frequency of complications by Plasmodium species was observed; 39.4% of the cases presented general danger signs, pallor and jaundice being the most frequent; 40.5% showed danger signs for pregnancy, such as persistent headache, abdominal pain, and vaginal bleeding. Conclusions: Severe malaria is a highly frequent event in pregnant women, without differences by Plasmodium species. It shows early recognizable dangers signs. Hospital under-reporting was identified in 88% of severe cases as well as a lack of laboratory tests for a more comprehensive diagnosis. A protocol for the clinical diagnosis of pregnant women with malaria is required.

Caracterización de los pacientes con bacteriemia por Staphylococcus aureus resistente a la meticilina en un hospital militar de alta complejidad / Characterization of patients with bacteremia by methicillin-resistant Staphylococcus aureus in a high-complexity military hospital

Resumen Introducción. En las Fuerzas Militares de Colombia, cerca de 500.000 de sus miembros asisten a consulta en los establecimientos sanitarios militares. En esta población, Staphylococcus aureus resistente a la meticilina (SAMR) se ha convertido en un agente patógeno de gran incidencia. Objetivo. Caracterizar los pacientes con diagnóstico de bacteriemia por SAMR en el Hospital Militar Central entre el 2012 y el 2015. Materiales y métodos. Se llevó a cabo un estudio observacional descriptivo de revisión retrospectiva de historias clínicas de pacientes mayores de 18 años, hospitalizados y con hemocultivos positivos para S. aureus resistente a la meticilina. Para la identificación de los pacientes se empleó el sistema Whonet, version 5.6. Resultados. De los 177 cultivos positivos para S. aureus, el 24,8 % (n=44) correspondió a SAMR, con mayor prevalencia en pacientes militares activos(n=20m 45,4 %). Se observó una frecuencia similar para la bacteriemia por SAMR adquirida en la comunidad y la adquirida en el hospital, siendo más frecuente (n=37, 84 %) el fenotipo de la comunidad en ambos grupos. El principal foco infeccioso fueron los tejidos blandos, seguidos por el tejido pulmonar. Se presentaron mayores tasas de complicaciones (61%, n=13) en la bacteriemia adquirida en el hospital; 34,9 % (n=15),de los pacientes tuvieron una estancia hospitalaria prolongada atribuible a las complicaciones desencadenadas por la bacteriemia. Conclusiones. La población más afectada por SAMR fueron los pacientes militares activos (n=20, 45,4 %), con una frecuencia similar de la bacteriemia adquirida en la comunidad (n=18, 43,2 %) y la adquirida en el hospital (n=25, 56,8 %), y el principal foco infeccioso fueron los tejidos blandos. Dados estos resultados, es necesario adelantar estudios para establecer la prevalencia de infecciones por SAMR en la piel.

Abstract Introduction: In Colombia, there are about 500,000 members in the national armed forces who consult military health institutions. In this population, methicillin-resistant Staphylococcus aureus (MRSA) has become a high-incidence pathogen. Objective: The aim of this study was to characterize patients with MRSA bacteremia in the Hospital Militar Central between 2012 and 2015. Materials and methods: This was an observational descriptive study with a retrospective review of clinical histories of hospitalized patients older than 18 years of age with positive blood cultures for methicillin-resistant S. aureus. The identification of the patients was made using the Whonet system, version 5.6. Results: From cultures positive for S. aureus, 24.8% were methicillin-resistant strains, with a higher prevalence in active military personnel. A similar frequency was observed for community-acquired MRSA bacteremias and those acquired at the hospital, with the community phenotype being the most frequent in both groups. The main infectious focus related to the development of bacteremia was soft tissue, followed by pulmonary tissue. There were higher complication rates in nosocomial bacteremias; 34.9% of the patients had prolonged stays attributable to complications triggered by the bacteremia. Conclusions: Active military personnel was the most affected population by MRSA, with a similar frequency in community-acquired and nosocomial bacteremias. The main infectious focus was soft tissue. Taking into account these data, studies that establish the prevalence of skin infections by MRSA should be carried out.

Epidemiology and clinical characteristics of herpes zoster in a tertiary care hospital in Brazil

ABSTRACT Background: There is little information on herpes zoster from hospital registries in South America. The aim of this study was to describe the epidemiological and clinical aspects of herpes zoster (HZ) in hospitalized patients.' Methods: We searched for hospital-based records during the period from March 2000 to January 2017 in a 700-bed tertiary-care hospital located in southern Brazil. The medical records of all eligible patients were reviewed, and data regarding demographics, medical history, clinical and laboratory characteristics, treatment regimens, and clinical outcomes were collected. Patients were also evaluated for mortality. Results: There were 801 records of herpes zoster according to the proposed criteria. Most patients with HZ presented a cutaneous clinical form of the disease with involvement of a single dermatome (n = 589, 73.5%). Additional clinical characteristics included postherpetic neuralgia (22.1%), ophthalmic HZ (7.6%) and meningoencephalitis (2.7%). Most patients presented immunocompromised conditions (64.9%) including HIV, administration of immunosuppressive agents, and malignant neoplasms. During this period, there were 105 (13.1%) deaths, which were mostly unrelated to HZ. Five deaths were related to HZ meningoencephalitis. Conclusion: The results of this study demonstrate a high burden of HZ disease in a Brazilian tertiary care hospital in the HZ vaccination era. Awareness of the incidence and comorbidity factors associated with HZ in Latin American countries such as Brazil contribute for adoption and implementation of strategies for immunization in this area.

Exploring obstetrical interventions and stratified cesarean section rates using the Robson classification in tertiary Care hospitals in the united arab emirates

Abstract Objective The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. Methods Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). Results The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS.The rate of vaginal birth after cesarean was 261(6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. Conclusion The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.

Complications After endoscopic balloon dilatation of esophageal strictures in children. Experience from a tertiary center in Shiraz - Iran (Nemazee Teaching Hospital) / Complicaciones posteriores a dilatación endoscópica con balón en niños con estenosis esofágica. Experiencia de un centro de referencia en Shiraz - Iran (Nemazee Teaching Hospital)

Background: Esophageal stricture is one of the most important complication of the caustic ingestion. Objective: The aim of this study was to evaluate complications of balloon dilatation among children with esophageal stenosis. Material and methods: In this retrospective study 82 children were included. Children who underwent balloon dilatation for esophageal stenosis were included in our study. Duration of study was 14 year starting from 2001. Mean age of the cases was 3.95±0.4 year (Min: 15 days, Max: 14 year). Chart review and telephone calling were the methods of data collection. Data was analyzed using SPSS. Results: In this study, 47% of the patients were male and 53% of the cases were female. Caustic ingestion (33.7%) was the most common etiology for the esophageal stricture. Vomiting (87.8%) was the most common presenting symptom. Among our cases, 76.8% had no compliant after esophageal dilatation. Chest pain was the most common compliant after esophageal dilatation. Response rate was similar among boys and girls. Toddler age had the best treatment response after esophageal dilatation. Conclusion: Among our cases, 76.8% had no post procedural compliant after esophageal dilatation. Esophageal perforation was seen in 4.9% of the cases. Chest pain was the most common post dilatation complication.

Antecedentes: La estenosis esofágica es una de las más importantes complicaciones de la ingesta de caústicos. Objetivo: El objetivo del estudio fue evaluar las complicaciones de la dilatación endoscópica con balón en niños con estenosis esofágica. Material y métodos: En este estudio retrospectivo se incluyeron 82 niños. Se incluyeron todos los niños que se sometieron a una dilatación endoscópica con balón por estenosis esofágica. La duración del estudio fue 14 años iniciando en el año 2001. La edad media de los pacientes fue 3,95 +/- 0,4 años (Min. 15 días, Máx. 14 años). La recolección de datos se realizó revisando las historias clínicas y con llamadas telefónicas. Los datos se analizaron con el Sistema SPSS. Resultados: En este estudio, 47% de los casos fueron varones y 53% fueron mujeres. La ingesta de caústicos fue la causa más frecuente de estenosis esofágica (33,7%). El síntoma más común fueron los vómitos (87,8%). Entre nuestros casos, 76,8% no presentaron molestias luego de la dilatación esofágica. El dolor torácico fue la molestia más común luego de la dilatación esofágica. La tasa de respuesta al tratamiento fue similar entre hombres y mujeres. Los niños pequeños tuvieron la mejor respuesta al tratamiento luego de la dilatación esofágica. Conclusiones: Entre nuestros casos, 76,8% no presentaron molestias luego de la dilatación esofágica. La perforación esofágica se presentó en 4,9% de los casos. El dolor torácico fue la complicación más común posterior a la dilatación.

Acidentes na infância: casuística de um serviço terciário em uma cidade de médio porte do Brasil / Accidents in childhood: casuistry of a tertiary service in a medium-sized city in Brazil

RESUMO Objetivo: investigar as principais causas e situações de risco mais comuns relacionadas aos acidentes na infância, em nossa realidade local. Métodos: estudo observacional, transversal, retrospectivo, descritivo e analítico, a partir dos prontuários médicos de pacientes atendidos nos serviços de urgências pediátricas do complexo hospitalar do Hospital das Clínicas da Faculdade de Medicina de Botucatu - UNESP, no ano de 2016. Foram incluídos os atendimentos de pacientes de zero a 15 anos de idade que haviam recebido atendimento médico relacionado a acidentes, determinando-se idade, sexo, tipo de acidente, período do dia e ambiente onde aconteceu o acidente e histórico de acidentes pregressos. Resultados: do total de atendimentos com registros adequados no prontuário, 936 (27,5%) estavam relacionados a acidentes: 588 (62,8%) em pacientes do sexo masculino e 348 (37,2%) em pacientes do sexo feminino. Quanto à idade, 490 (52,3%) acidentes ocorreram com crianças de zero a cinco anos, 245 (26,2%) com crianças de seis a dez anos e 201 (21,5%) com crianças com mais de dez anos de idade. Quedas e traumas locais foram os tipos de acidentes mais comuns em todas as faixas etárias analisadas. A maior parte dos acidentes ocorreu à tarde (46,1%), em casa (60,7%), e 26,6% dos pacientes apresentavam antecedentes de acidentes prévios. Conclusão: os acidentes foram responsáveis por grande parcela dos atendimentos de urgência. A elevada taxa de pacientes com registros de acidentes prévios indica a exposição repetida destas crianças às situações de risco.

ABSTRACT Objective: to investigate the main causes and most common risk situations related to childhood accidents, in our local reality. Methods: an observational, cross-sectional, retrospective, descriptive, and analytical study from the medical records of patients attended in the pediatric emergency services of the hospital complex of Hospital das Clínicas, Botucatu Medical School - UNESP, in 2016. We included patients from zero to 15 years old who had received medical care related to accidents, determining age, gender, type of accident, period of the day, accident place, and history of previous accidents. Results: considering all consultations with appropriate medical records, 936 (27.5%) were related to accidents: 588 (62.8%) in male patients and 348 (37.2%) in female patients. As to age, 490 (52.3%) happened with children from zero to five years, 245 (26.2%) with children from six to ten years, and 201 (21.5%) with children over ten years. Falls and local traumas were the most common types of accidents in all analyzed age groups. Most accidents occurred in the afternoon (46.1%), at home (60.7%), and 26.6% of the patients had a history of previous accidents. Conclusion: accidents were responsible for a large portion of urgent care. The high rate of patients with previous accident records indicated the repeated exposure of these children to risk situations.