ANESTHESIA FOR FETAL SURGERY - PRINCIPLES AND CONSIDERATIONS: A CONCISE REVIEW

Fetal surgery, an integral part of fetal therapy has undergone evolution since is conception, which was possible due to continuous refinements in surgical as well as anesthetic techniques The fetal surgery can be done in various stages of the gestation for corrective treatment. Time tested criteria have been laid down for patient selection which help improve the outcome of the whole exercise. The anesthesia concerns and considerations are unique as are the ethical issues involved in this treatment modality involving two patients with contrasting physiological needs. This article reviews salient aspects of fetal physiology in detail. Anesthesia for the fetal interventions is curated as per the invasive nature of surgical interventions. The type of fetal interventions are classified as minimally invasive procedures, Open mid gestation procedures and Ex-utero intrapartum treatment (EXIT) procedures. Preoperative evaluation is dictated by extent of gestation, and invasiveness of the surgical procedure apart from medical status of mother and fetus. This review also tries to enumerate number of clinically useful pharmacological agents in fetal anesthesia including essential tocolytic agents, in addition to management of common fetal complications with a separate section on fetal bradycardia

Heridas atípicas producidas por proyectil de arma de fuego Reporte de caso / Atypical wounds caused by firearm projectile Case report

Resumen Las heridas por proyectil de arma de fuego se definen como los efectos que producen sobre el organismo los disparos realizados con armas cargadas de proyectiles o diversos tipos de pólvora u otros explosivos. La valoración médico legal en estos casos, en personas vivas, se realiza en la Sección Clínica Médico Forense del Departamento de Medicina Legal del Organismo de Investigación Judicial, esta incluye la historia médico legal, el examen físico, el análisis de documentos médicos aportados, pericias conexas efectuadas y revisión de bibliografía, esto para tener todos los elementos de juicio que permitan realizar un análisis objetivo y basado en la evidencia científica, y así poder responder a las interrogantes de la Autoridad Judicial. El presente artículo abarca algunos de los aspectos principales a tomar en cuenta ante hallazgos atípicos de los orificios de entrada y salida de los proyectiles, mediante la presentación y abordaje de un caso clínico.

Abstract Firearm projectile injuries are defined as the effects produced on the body by shots fired with weapons loaded with projectiles or various types of gunpowder or other explosives. The legal medical assessment in these cases, in living persons, is carried out in the Forensic Medical Clinical Section of the Department of Legal Medicine of the Organismo de Investigación Judicial, this includes the legal medical history, physical examination, analysis of medical documents provided, expert carried out and bibliography review, this to have all the elements of judgment that allow an objective analysis based on scientific evidence, and thus be able to answer the questions of the Judicial Authority. This article covers some of the main aspects to be considered when faced with atypical findings of the entry and exit holes of the projectiles, through the presentation and approach of a clinical case. Ver bases de datos

Intubación endotraqueal intraparto en fetos con obstrucción de la vía aérea. Dos primeros casos de cirugía EXIT en el Hospital Rebagliati - EsSalud

Se presenta dos casos de gestantes en el tercer trimestre de gestación referidas para manejo de tumor cervical fetal con obstrucción de la vía respiratoria. Los casos fueron programados para cirugía fetal EXIT (ex-utero intrapartum treatment) que permitió la intubación orotraqueal intraparto controlada evitando el período de hipoxia y potencial asfixia que ocurrirían con el procedimiento neonatal convencional. Los recién nacidos fueron operados posteriormente por los cirujanos de cirugía de cabeza y cuello para la reducción de la masa cervical. Se sugiere plantear este procedimiento en los casos en que se sospeche obstrucción severa de la vía aérea y referirlos a centros que cuenten con una unidad de cirugía fetal con equipo médico multidisciplinario.

Two cases of pregnant women in the third trimester of gestation referred for management of fetal cervical tumor with airway obstruction are presented. The cases were scheduled for EXIT (ex-utero intrapartum treatment), fetal surgery which allowed controlled intrapartum orotracheal intubation avoiding the period of hypoxia and potential asphyxia that would occur with the conventional neonatal procedure. The neonates were subsequently operated on by head and neck surgeons for reduction of the cervical mass. It is suggested to consider this procedure in cases where severe airway obstruction is suspected and to refer them to centers that have a fetal surgery unit with a multidisciplinary medical team.

Mastering your fellowship: Part 3, 2022

The series, 'Mastering your Fellowship', provides examples of the question formats encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP SA) examination. The series is aimed at helping family medicine registrars (and their supervisors) prepare for this examination.Keywords: family physicians; FCFP (SA) examination; family medicine registrars; postgraduate training; national exit examination; infectious diseases.

Mastering Your Fellowship: Part 4, 2022

The 'Mastering Your Fellowship' series provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa examination. The series is aimed at helping family medicine registrars prepare for this examination.

Gastrosquisis / Gastroschisis

Introducción: La gastrosquisis es un defecto de la pared abdominal anterior, paraumbilical, habitualmente a la derecha con la protrusión de vísceras intraabdominales, las que flotan libremente en el líquido amniótico durante la vida intrauterina, solo recubiertas por su peritoneo visceral. Objetivo: Analizar la entidad a propósito de un caso portador de gastrosquisis compleja. . Caso clínico: Se describe una neonato de 4 días remitido al servicio de urgencias del Hospital Provincial de Cabinda, República de Angola, por presentar deshidratación severa y "evisceración". La paciente fallece 36 horas posteriores al ingreso. Conclusiones: Los neonatos con esta enfermedad se presentan como una emergencia quirúrgica que plantean un reto difícil para el cirujano tratante. Tiene una alta mortalidad aun con el tratamiento apropiado. Técnicas novedosas de tratamiento se acercan a las tasas de sobrevida esperadas para esta entidad(AU)

Introduction: Gastroschisis is a defect of the paraumbilical anterior abdominal wall, usually on the right with protrusion of intraabdominal viscera, which float freely in the amniotic fluid during intrauterine life, only covered by its visceral peritoneum. Objective: To analyze the entity apropos a case of complex gastroschisis. Clinical case: The case is described od a four-day-old neonate referred to the emergency service at Provincial Hospital of Cabinda, Republic of Angola, for presenting severe dehydration and "evisceration." The patient died 36 hours after admission. Conclusions: Neonates with this disease are presented as a surgical emergency that poses a difficult challenge for the treating surgeon. It has a high mortality even with the appropriate treatment. Novel treatment techniques are close to the expected survival rates for this entity(AU)

Protocolo para el manejo anestésico del binomio materno fetal en el proyecto EXIT para neonatos con hernia diafragmática / Protocol for the anesthetic management of the maternal-fetal binomial in the EXIT project for neonates with diaphragmatic hernia

Resumen: EXIT (tratamiento ex útero intraparto). El manejo anestésico para esta cirugía es significativamente diferente del manejo anestésico de una cesárea convencional, involucra anestesia general profunda con halogenados, administración de narcóticos, relajación uterina adecuada y preservación del flujo útero placentario hacia el feto durante la anestesia y al mismo tiempo tiene el beneficio de la anestesia general para que el producto obtenga anestesia y facilite el acceso a la vía aérea del neonato antes del pinzamiento del cordón umbilical. El fin de mantener la oxigenación a través de la placenta es efectuar la maniobra de intubación sin el riesgo de hipoxia. En el Hospital Infantil de México «Federico Gómez¼ se lleva a cabo este tipo de cirugías desde junio de 2007; sin embargo, aún no se cuenta con un manejo homogéneo. Material y métodos: A través de un reporte de casos se hizo una revisión perioperatoria de las pacientes embarazadas, a las cuales se les dio manejo anestésico para cirugía EXIT en el período comprendido entre junio de 2007 y mayo de 2018. Resultados: De los 43 casos manejados, la información anestésica perioperatoria obtenida permitió homologar el manejo anestésico del binomio materno fetal para poder realizar un protocolo intrahospitalario. Conclusión: El poder realizar un protocolo para el manejo anestésico del binomio materno fetal en el proyecto EXIT permite disminuir las complicaciones y la morbimortalidad ofreciendo mejor calidad en la atención.

Abstract: The anesthetic management for this procedure is quite different from the anesthetic management of a conventional caesarean section. It includes deep general anesthesia with halogenated and narcotic administration, to get adecuate uterine relaxation and preservation of best uteroplacental flow to the fetus during anesthesia and the benefit of general anesthesia to aim the neonate show effects of of anesthetic medication by this way facilitate airway access before umbilical cord clamping. The aim to mantain placental oxigenation to neonate is avoid hypoxia risk during intubation technique. In the Hospital Infantil de Mexico «Federico Gómez¼ this procedures have been carried out since June 2007, however, there is still no homogeneous management. Material and methods: Through a case report, a perioperative files review was made of pregnant patients who were given anesthetic management for EXIT procedure in June 2007 to May 2018 period. Results: Of the 43 cases, the perioperative anesthetic information obtained allowed to standardize the anesthetic management of the maternal fetal binomial in order to perform an intrahospital protocol. Conclusion: The ability to perform a protocol for the anesthetic management of the maternal fetal binomial in the exit project allows to reduce complications and morbidity and mortality in the binomial, offering better quality of care.

Teratoma oral: la importancia del diagnóstico prenatal y el trabajo interdisciplinario: un caso clínico / Epignathus, the importance of prenatal diagnosis and interdisciplinary work: A case report

Gracias al avance de la tecnología, es posible realizar el diagnóstico prenatal de distintas malformaciones congénitas que ponen en riesgo la vida del recién nacido. Entre estas, el teratoma oral o epignathus es una forma poco frecuente de teratoma congénito entre los que se localizan en cabeza y cuello. Suelen ser benignos y abarcan el 4 % de los teratomas neonatales.A partir del desarrollo de la técnica de tratamiento intraparto extraútero (EXIT, por su sigla en inglés), que se implementó en los años 90 para mantener la circulación fetal hasta asegurar la vía aérea del recién nacido, se logra planificar una estrategia de manejo multidisciplinario que permite el abordaje correcto de estas patologías. Se presenta un caso de teratoma oral gigante en una paciente de sexo femenino de 35 semanas de gestación, en quien se aplicó la técnica EXIT, y su evolución posterior.

Thanks to technological advances, it has been possible to carry out the prenatal diagnosis of different life-threatening congenital malformations. Among these, oral teratoma, or epignathus, is a rare form of congenital teratoma within those located in the head and neck. They are generally benign and comprise 4 % of neonatal teratomas. From the development of the EXIT technique (ex utero intrapartum treatment), which has been implemented since the 90's to support fetal circulation until the newborn's airway is secured, it is possible to plan a multidisciplinary management strategy that enables the correct approach of these pathologies.We present a case of giant epignathus in a 35-week gestation female patient, whose airway was secured using the EXIT technique, and follow up.

EXIT: Estado del arte y cómo lo hacemos

Resumen El protocolo EXIT (tratamiento ex-útero intraparto) es una técnica que permite establecer una vía aérea segura y estable, en un feto con obstrucción de esta o riesgo al momento del parto. Se basa en mantener la circulación uteroplacentaria con anestesia neonatal, logrando una hipotonía uterina controlada. Todo otorrinolaringólogo que se desempeñe en un hospital que cuente con un servicio de obstetricia de alta complejidad puede ser requerido en este tipo de casos y debe tener un protocolo establecido de cómo proceder. En nuestro medio se trata de un procedimiento poco frecuente que obliga a la revisión de la técnica. No existe un protocolo único en la literatura internacional, pero sí principios fundamentales. Se presenta caso clínico de un embarazo, en que se identifica una masa cervical fetal, realizándose el protocolo EXIT. Se realiza una revisión de la literatura, se describen los principios de esta técnica, así como también nuestro enfrentamiento y lecciones aprendidas.

Abstract The EXIT protocol (ex-utero intrapartum treatment) is a technique that allows establishing a safe and stable airway in a fetus with airway obstruction, or at risk of it, at the time of delivery. It is based on maintaining uteroplacental circulation with neonatal anesthesia, achieving controlled uterine hypotonia. Any otolaryngologist working in a hospital that has a highly complex gynecology and obstetric service may be required in this type of case and must have an established protocol of how to proceed. In our setting, it is an infrequent procedure, so it requires a revision of the surgical technique. There is no established protocol in the literature, but there are fundamental principles. We describe a clinical case of a pregnancy where a fetal cervical mass was identified, and an EXIT protocol was performed. A review of the literature is presented, the principles of this technique are described, as well as our procedure and lessons learned.

Técnica EXIT como manejo de la vía aérea en masas gigantes congénitas de cuello / Ex-Utero Intrapartum Treatment for airway management in congenital giant neck masses

Resumen: Introducción: Las masas congénitas de cabeza y cuello se asocian a asfixia perinatal e injuria cerebral con elevada mortalidad. La técnica EXIT (Ex Útero Intrapartum Treatment) consiste en asegurar la vía aérea del neonato, sin interrumpir la oxigenación y perfusión materno-fetal a través del soporte placentario. Esta técnica no ha sido estandarizada en países de medianos ingresos. Objetivo: Describir el caso clínico de 2 neonatos manejados mediante la técnica EXIT. Caso Clínico: Se reportan dos casos, uno con malformación linfática diagnosticada a la semana 20 gestación y el segundo con tiromegalia y polihidramnios diagnosticados a la semana 35 de gestación. En ambos casos, duran te la cesárea se realizó la técnica EXIT con un equipo conformado por neonatólogo, ginecólogo, anestesiólogo, cirujano pediatra, otorrinolaringólogo, enfermero y terapeuta respiratorio. En los dos pacientes se logró asegurar la vía aérea mediante intubación orotraqueal al primer intento. En el caso 1 se confirmó la malformación linfática y recibió escleroterapia, y en el caso 2 se diagnosticó hipotiroidismo congénito asociado a bocio, que fue manejado con levotiroxina. Los pacientes se mantuvieron 7 y 9 días con ventilación mecánica invasiva respectivamente y egresaron sin complicaciones respiratorias. Conclusiones: La técnica EXIT en estos casos fue un procedimiento seguro, llevado a cabo sin inconvenientes. Se necesita un equipo multidisciplinario y la disponibilidad de una unidad de cuidados intensivos neonatales, con el objetivo de reducir potenciales complica ciones y garantizar el manejo postnatal. Para lograr su ejecución, es indispensable el diagnóstico prenatal oportuno.

Abstract: Introduction: Congenital head and neck masses are associated with perinatal asphyxia and brain injury, increasing the risk of death. The EXIT (Ex Utero Intrapartum Treatment) technique con sists of ensuring the newborn's airway while is still receiving placental support. This technique has not been standardized in developing countries. Objective: To describe the clinical outcomes of two infants who underwent the EXIT technique. Clinical Case: We present two cases, one with lymphatic malformation diagnosed at 20 weeks of gestational age (WGE) and the second one, a preterm newborn with thyromegaly and polyhydramnios, diagnosed at 35 WGE. In both cases, during the C-section, the EXIT technique was performed with a team of a neonatologist, a gyne cologist, an anesthesiologist, a pediatric surgeon, an otolaryngologist, a nurse, and a respiratory therapist. In both patients, the neonatologist achieved to secure the airway through orotracheal intubation at the first attempt. In the first case, lymphatic malformation was confirmed and re ceived sclerotherapy, and the second one was diagnosed with congenital hypothyroidism which was managed with levothyroxine. The patients needed invasive mechanical ventilation for 7 and 9 days, respectively, and were discharged without respiratory complications. Conclusions: In these patients, the EXIT technique was a safe procedure, carried out without inconvenience. A multi disciplinary approach and the availability of a neonatal intensive care unit are needed to reduce potential complications and ensure postnatal management. Timely prenatal diagnosis is essential to perform this technique.

The multidisciplinary challenge of anesthesia for ex utero intrapartum treatment: a case report / O desafio multidisciplinar da anestesia para procedimento intraparto extra-uterino: relato de caso

Abstract The Ex Utero Intrapartum Treatment (EXIT) is a surgical procedure performed in cases of expected postpartum fetal airway obstruction, allowing the establishment of patent airway while maintaining placental circulation. Anesthesia for EXIT procedure has several specific features such as adequate uterine relaxation, maintenance of maternal blood pressure fetal anesthesia and fetal airway establishment. The anesthesiologist should be aware of these particularities in order to contribute to a favorable outcome. This is a case report of an EXIT procedure performed on a fetus with a cervical lymphangioma with prenatal evidence of partial obstruction of the trachea and risk of post-delivery airway compromise.

Resumo O procedimento Intraparto Extra-Uterino (EXIT) é procedimento cirúrgico realizado em casos de previsão de obstrução de via aérea fetal no pós-parto, que permite estabelecer via aérea patente enquanto a circulação placentária é mantida. A anestesia para o procedimento EXIT apresenta várias características específicas, tais como relaxamento uterino adequado, manutenção da pressão arterial materna, anestesia fetal e estabelecimento da via aérea fetal. O anestesiologista deve estar ciente dessas especificidades para contribuir para desfecho favorável. Trata-se de relato de caso de procedimento EXIT realizado em feto com linfangioma cervical e evidência pré-natal de obstrução parcial de traqueia e risco de comprometimento de via aérea pós-parto.

Percutaneous transforaminal endoscopic foraminoplasty for simple lumbar spinal lateral exit-zone stenosis / 中国骨伤

OBJECTIVE@#To evaluate the clinical effects of percutaneous endoscopic foraminoplasty for simple lumbar spinal lateral exit zone stenosis.@*METHODS@#A total of 36 patients with simple lumbar spinal lateral exit zone stenosis were admitted to our hospital from January 2013 to June 2018, and received selective nerve root canal radiography and radicular block. According to the symptoms and patients' personal wills, 22 cases underwent the one-stage percutaneous foraminal surgery(the one-stage operation group), and the other 14 patients were re-admitted to the hospital for operation(the delayed operation group) because of the recurrence of symptoms after discharge. The visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the clinical effects before therapy, 1 day after the radicular block, and 1 day, 3 months and 6 months after the operation.@*RESULTS@#VAS and ODI of all 36 cases were obviously improved (0.05), but when compared with its own pretherapy andbefore readmission results, the difference was significant (<0.05). There was no nerve injury in all cases. Only 2 cases were presented with the outlet root stimulation symptoms, and the symptoms relieved after short term conservative treatment.@*CONCLUSION@#The clinical effects of radicular block may be unsustainable for patients with simple lumbar spinal lateral exit zone stenosis. Instead, percutaneous endoscopic foraminoplasty was simple, safe and effective.

Exit (Ex Utero Intrapartum Treatment): relato do primeiro procedimento realizado em Santa Catarina / Exit (Ex Utero Intrapartum Treatment): the first procedure related in Santa Catarina

EXIT (Ex utero intrapartum treatment) é o tratamento perinatal mais recomentado para crianças com obstrução de vias aéreas, por permitir um prognóstico mais favorável. O procedimento consiste em garantir o acesso à via aérea do feto antes do clampeamento do cordão umbilical. Há poucos relatos na literatura mundial e brasileira sobre o procedimento, o que torna necessária a sua disseminação. Foi feito um relato de caso com base na análise de prontuário e revisão da literatura a partir do uso de palavras-chave em banco de dados. O atendimento envolveu os Serviços de Ginecologia e Obstetrícia do Hospital Universitário da Universidade Federal de Santa Catarina e da Maternidade Carmela Dutra e Serviço de Cirurgia Pediátrica e de Anestesiologia do Hospital Infantil Joana de Gusmão, em Florianópolis, Santa Catarina. Relato do caso: Gestante com identificação, por ultrassonografia, de massa cervical no feto, causando obstrução esofágica e da traqueia. Por esta razão foi encaminhada para realização de EXIT no centro cirúrgico do Hospital Infantil Joana de Gusmão. O estudo histopatológico da massa revelou teratoma imaturo, grau 3, com metástase em linfonodos. O primeiro EXIT do estado de Santa Catarina se assemelhou a relatos encontrados em revisão de literatura.

EXIT (Ex utero intrapartum treatment) procedure is the perinatal treatment of choice for airway obstruction with better prognosis where the fetal airway is accessed before umbilical cord clamping. Few case reports are registered in the international and national literature and its knowledge is usefull. This is a case report using the data register and literature available. The atendance envolved the Gynecology and Obstetrics of the Federal University Hospital of Santa Catarina and Carmela Dutra Maternity and Pediatric and Anestesiology Sectors of the Hospital Infantil Joana de Gusmão, in Florianópolis, Santa Catarina. Case Report: a fetal cervical tumor with esophageal and tracheal obstruction was identified by prenatal ultrasound. The expectant mother was sent to the operating room of the Hospital Infantil Joana de Gusmão and submitted to EXIT procedure. The hystopatologic diagnosis of the tumor was imature teratoma, grade 3 with linfonodal metastasis. Conclusion: The first EXIT procedure done in Santa Catarina, resembled literature findings.

Strenthening entry-exit supervision for protecting natural resources of traditional Chinese medicine / 中国中药杂志

China is highly rich of medicinal plants. Traditional Chinese medicine(TCM) has a long history and is important traditional resources in China. As one of the important strategic resources and the link among all the countries along the ancient "Silk Road", TCM has played important role in economy, politics, society and ecology. With the initiative of the "Belt and Road" in recent years, many natural resources of TCM now are facing the risk of extinction due to more and more frequent trade between China and other countries, also the increase of export has influenced to the stock of TCM. In order to prevent the loss of the resources, strengthen the protection and sustainable use of TCM, our study provided the strategies to the natural resources of TCM's entry-exit supervision from nine aspects, like law and regulation system, based on the analysis of current supervision status quo.

Cirugía fetal en teratoma sacrococcígeo

Sacrococcygeal teratoma is the most common neonatal tumor. In a large number of cases, fetuses are born at term and the teratoma can be resected without complications. However, in another group, prematurity, hydrops and cardiac failure do not allow pregnancy interruption without consequences for the fetus. Here is where fetal surgery has a place. We conducted a search of the literature related to sacrococcygeal teratoma and case reports where surgery was performed, including those with details on the patient's preparation, surgery, and the postoperative period. The average gestational age of presentation in ultrasound is 23 weeks. There is more literature on open surgery, and the main indication is hydrops or imminent cardiac failure. The reported cases with minimally invasive therapy are the least, with controversial results. Sacrococcygeal teratoma in the newborn is an entity with very good prognosis depending on the case, time of diagnosis, type of tumor, and malignancy potential. However, those of prenatal diagnosis are at high risk of complications and death. There are several reports of open surgery and EXIT procedure (special delivery technique where the sacrococcygeal teratoma is exposed through a limited incision in the uterus) with good surgical results but with high maternal and fetal comorbidity. Therefore, minimally invasive techniques have emerged to reduce the potential risks of open surgery; nevertheless, there are contradictory results.

El teratoma sacrococcígeo es el tumor neonatal más común. En un gran número de los casos los fetos llegan al término y pueden ser resecados sin complicaciones. Sin embargo, en otro grupo de pacientes, su prematuridad, el hidrops y la falla cardiaca no permiten interrumpir el embarazo sin consecuencias para el feto. Aquí es donde la cirugía fetal tiene cabida. Se realizó una búsqueda de la literatura relacionada al teratoma sacrococcígeo y reportes de casos donde se practicó cirugía. Se incluyeron también aquellos en donde se detallaba la preparación de la paciente, el transoperatorio y postoperatorio. La edad gestacional de la presentación usualmente fue durante la ecografía estructural, con una media de las 23 semanas. Se encuentra más literatura acerca de cirugías abiertas y la principal indicación es el hidrops y/o la falla cardiaca inminente. Los casos reportados realizados con mínima invasión son los menos, con resultados controversiales. El teratoma sacrococcígeo en el recién nacido es una entidad con muy buen pronóstico dependiendo del caso, tiempo del diagnóstico, tipo del tumor y potencial de malignidad del mismo. Sin embargo, el diagnosticado prenatalmente, cursa con alto riesgo de complicaciones y muerte. Hay varios casos reportados de cirugía abierta y procedimiento EXIT (técnica especial en la que el tumor es expuesto a través de una pequeña incisión) con buenos resultados quirúrgicos, pero con alta comorbilidad materna y fetal. Por ende, han surgido técnicas mínimamente invasivas para disminuir los riesgos potenciales de la cirugía abierta; a pesar de esto hay resultados contradictorios.

Infecciones asociadas a diálisis peritoneal en el paciente pediátrico: diagnóstico y tratamiento / Peritoneal dialysis-related infections in pediatric patients: diagnosis and treatment review

Resumen Las infecciones asociadas a diálisis peritoneal (DP), corresponden a la principal complicación de los pacientes pediátricos en esta terapia de reemplazo renal, disminuyendo la sobrevida de la membrana peritoneal y empeorando el pronóstico del paciente. El reconocimiento precoz y un tratamiento oportuno de éstas son fundamentales para preservar esta modalidad dialítica. Se presenta una revisión actualizada de la literatura científica, con el fin de entregar recomendaciones reproducibles en los distintos centros pediátricos que realizan diálisis peritoneal crónica en niños.

Peritoneal dialysis-related infections are the main complication in pediatric patients undergoing this renal replacement therapy, associating a high rate of morbidity, generating also a decreasing survival of the peritoneal membrane and worsening the patient outcome. We describe the recommended diagnostic and therapeutic modalities to treat dialysis-related in children.

Factors affecting the exit from farming of young farmers in Turkey: the case of Niğde province / Fatores que afetam a saída de jovens agricultores de propriedades rurais na Turquia: o caso da província de Niğde

ABSTRACT: This study has focused on the factor affecting the exit from farming of young farmers, since it is an important issue in many provinces of Turkey. Data obtained through face-to-face interview method with 85 selected young farmers (aged 15-40 years) engaged in agricultural activity in the Niğde province in 2017. Logistic regression model based upon the dependent variable decision to exit from farming was used to determine relevant factors. According to results, number of children, the presence of house in the city center and the monthly income level has effects to exit from farming. Young farmers have priorities to reach a better life conditions for their children such as better education and health care services. Rural investment support should be increased; entrepreneurship and innovation trainings should be expanded by encouraging training on agriculture. It would be beneficial to develop different applications such as distance learning modules and digital agriculture.

RESUMO: Este estudo centrou-se no fator que afeta a saída da agricultura de jovens agricultores, uma vez que é uma questão importante em muitas províncias da Turquia. Dados obtidos através do método de entrevista presencial com 85 jovens agricultores selecionados (com idade entre 15 e 40 anos) envolvidos na atividade agrícola na província de Niğde em 2017. Modelo de regressão logística baseado na variável dependente decisão de sair da agricultura foi usado para determinar fatores relevantes. De acordo com os resultados, o número de crianças, a presença de casa no centro da cidade e o nível de renda mensal tem efeitos para sair da agricultura de jovens agricultores na província de Niğde. Os jovens agricultores têm prioridades para alcançar melhores condições de vida para seus filhos, como melhor educação e serviços de saúde. O apoio ao investimento rural deve ser aumentado e os treinamentos de empreendedorismo e inovação devem ser expandidos, incentivando a capacitação em agricultura. Com isso, seria benéfico desenvolver diferentes aplicações, como módulos de ensino à distância e agricultura digital.

Executive dysfunction in patients with idiopathic epilepsy

Background: Idiopathic epilepsy is defined as disorder in which there is no underlying cause or structural pathology other than a possible hereditary predisposition for generating seizures which can be generalized or focal in nature. Objective: To study the occurrence of executive dysfunction in patients with idiopathic epilepsy and its association with age, gender, seizure type, duration of epilepsy, age at seizure onset, antiepileptic drug therapy and seizure control &the association of the interictal EEG pattern. Materials and methods: 100 cases of epileptic patients with normal CT scan brain / MRI brain were studied. Frontal Assessment Battery &The Executive Interview (EXIT) were used to assess the executive functions. Results: The FAB score were normal in 46% and abnormal in 54% of the cases. Executive dysfunction as per the FAB score was mild in 32% and moderately severe in 22% of the cases. Impairment in Executive function as per EXIT score was mild in 84% and moderate in 16 % of the cases. Executive Dysfunction was more in cases with either primary or secondarily generalized seizures, cases with a higher seizure frequency, longer duration of epilepsy, uncontrolled epilepsy and seen in 17.5% with normal and 10% cases with an abnormal EEG. Conclusion: Our study found a significant proportion of patients with idiopathic epilepsy have Executive Dysfunction, which adds to the seizure burden by reducing the capacity of an individual to successfully engage in self-care, social, academic and occupational pursuits.

Éxitus materno tras cesárea en gestante con anomalía de Taussig-Bing y síndrome de Eisenmenger / Maternal Exitus after Cesarean Section in Pregnant Women with Taussig-Bing Anomaly and Eisenmenger Syndrome

La anomalía de Taussig-Bing es una cardiopatía congénita cianosante caracterizada por la dextrotransposición de grandes vasos. Esta produce una doble salida arterial desde el ventrículo derecho, asociado a una comunicación interventricular. Este cuadro puede generar una hipertensión pulmonar secundaria al aumento de las resistencias vasculares y un flujo reverso cardiaco, conocido como síndrome de Eisenmenger. Normalmente, se presenta antes de la pubertad, aunque en ocasiones, puede debutar en la vida adulta, progresando durante dicha etapa. Clínicamente, se caracteriza por rasgos crónicos, como las acropaquias, la disnea, la sensación de cansancio o la cianosis. El diagnóstico de este tipo de cardiopatías se basa en la clínica y en las pruebas de imagen, preferentemente en el estudio ecocardiográfico fetal o durante la edad pediátrica. El tratamiento de elección es la corrección quirúrgica de las malformaciones cardiacas, siendo preferente la rectificación de la salida de la aorta y el cierre de la comunicación interventricular. El pronóstico depende del grado de hipertensión pulmonar, del momento del diagnóstico y de la corrección quirúrgica precoz. A edades tempranas se obtiene un mejor resultado, aunque las tasas de mortalidad alcanzan 50 % en algunos casos, incluso tras una corrección quirúrgica óptima. La gestación no está recomendada en pacientes que padecen dicha patología, la cual se ha contraindicado, según algunos estudios, en ausencia de tratamiento adecuado. Así pues, describimos un caso en el que una gestante con una anomalía Taussig-Bing sufre una atonía uterina y un posterior paro cardiorrespiratoria tras el parto, realizado mediante cesárea electiva, tras la que la paciente falleció(AU)

The Taussig-Bing anomaly is a congenital cyanosis characterized by the dextrotransposition of large vessels. It produces a double arterial exit from the right ventricle, associated with an interventricular communication. This may lead to pulmonary hypertension secondary to increased vascular resistance and a cardiac reverse flow, known as Eisenmenger syndrome. Generally, it occurs before puberty, although occasionally, it can debut in adults, progressing during that stage. It is clinically characterized by chronic features, such as acropachies, dyspnea, tiredness or cyanosis. The diagnosis of this type of heart disease is based on clinical exam and imaging tests, if at all possible in the fetal echocardiographic study or during the pediatric age. The surgical correction of cardiac malformations is the treatment of choice, modifying the aortic exit and closing of ventricular septal defect. The prognosis depends on the degree of pulmonary hypertension, the time of diagnosis, and the early surgical correction. Better outcome is obtained at early ages, although mortality rates reach 50% in some cases, even after optimal surgical correction. Pregnancy is not recommended in patients suffering from this disease. Some studies contraindicate pregnancy in absence of proper treatment. Thus, we describe a case of a pregnant woman with a Taussig-Bing anomaly, who suffered uterine atony and a subsequent cardiorespiratory arrest after delivery. Elective cesarean section was performed. This patient died(AU)