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Objetivos Evaluar la evolución de una población pediátrica con patrón de preexcitación ventricular, presencia de taquicardia supraventricular, fibrilación auricular, cardiopatías, mortalidad e intervención médica. Material y métodos Estudio descriptivo observacional. Se registraron pacientes con preexcitación ventricular en el electrocardiograma desde 1976 a 2011. Todos tenían ecocardiograma, 101 pacientes Holter (75,3%) y 69 (51,5%) ergometría. En pacientes seleccionados se realizó ablación por radiofrecuencia. Los datos se expresaron como media y desviación estándar. Resultados Se incluyeron en el estudio 134 pacientes, 80 varones (59,7%). Edad al diagnóstico: 2 días a 18 años, media 6,5 ± 5 años. Seguimiento clínico: 1 mes a 20 años, media 3,6 ± 3,9 años. Consultaron por taquicardia supraventricular 35 pacientes (26,1%), por preexcitación ventricular 16 pacientes (11,9%) y por otras causas 83 pacientes (61,9%); 76 pacientes (56,7%) evidenciaron vía izquierda, 3 pacientes doble vía; 16 pacientes (11,9%) presentaron taquicardia supraventricular durante el seguimiento. En total, 51 pacientes (38%) tuvieron taquicardia ortodrómica a los 6,3 ± 5,8 años, 10 pacientes en el período neonatal; 38 pacientes (28,3%) recibieron antiarrítmicos. No se observó fibrilación auricular. Veintiocho pacientes (20,9%) presentaron cardiopatía, 9 con taquicardia supraventricular. No hubo variables vinculadas con taquicardia supraventricular. En 43 pacientes (32,1%) se realizó ablación por radiofrecuencia. Un paciente murió súbitamente. Otro paciente falleció en el posoperatorio de cardiopatía. Conclusiones 1) Más del 60% de los pacientes permanecieron asintomáticos. 2) No se registró fibrilación auricular. 3) La tasa de muerte súbita fue del 0,75%. 4) Los pacientes con taquicardia supraventricular no sometidos a ablación evolucionaron bien. 5) No se asociaron variables con taquicardia supraventricular. 6) Las vías múltiples siempre desarrollaron taquicardia supraventricular.
Objectives The aim of the study was to evaluate the outcome of a pediatric population with ventricular preexcitation pattern, supraventricular tachycardia, atrial fibrillation, cardiomyopathies, mortality and medical treatment. Methods From 1976 to 2011, a descriptive observational study was conducted on patients with ventricular preexcitation in the electrocardiogram. All patients underwent an echocardiogram, 101 (75.3%) Holter monitoring, and 69 (51.5%) an ergometric test. Radiofrequency ablation was performed in selected patients. Data were expressed as mean and standard deviation. Results The study population consisted of 134 patients, 80 (59.7%) of whom were male. Age at diagnosis ranged from 2 days to 18 years, with a mean of 6.5±5 years. Clinical follow-up lasted 1 month to 20 years, with a mean of 3.6±3.9 years. Thirty five patients (26.1%) consulted for supraventricular tachycardia, 16 (11.9%) for ventricular preexcitation, and the remaining 83 patients (61.9%) for other abnormalities. Seventy-six patients (56.7%) evidenced left conduction pathway and 3 patients a double conduction pathway. Sixteen patients (11.9%) presented supraventricular tachycardia during follow-up. Overall, 51 patients (38%) had orthodromic tachycardia at 6.3±5.8 years, 10 patients during the neonatal period. Thirty-eight patients (28.3%) received antiarrhythmic drugs. No atrial fibrillation was observed. Twenty-eight patients (20.9%) presented cardiomyopathy, 9 with supraventricular tachycardia. No association was found between supraventricular tachycardia and another variable. Forty-three patients (32.1%) underwent radiofrequency ablation. A patient suffered sudden death and another patient died during the postoperative period of corrective surgery. Conclusions 1) More than 60% of patients remained asymptomatic. 2) No atrial fibrillation was recorded. 3) Sudden death rate was 0.75%. 4) Patients with supraventricular tachycardia not submitted to ablation had a favorable outcome. 5) Supraventricular fibrillation was not associated with any variable. 6) Multiple conduction pathways always developed supraventricular tachycardia.
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Introducción No obstante el progreso sostenido en cirugía cardiovascular neonatal en los últimos 30 años, los recién nacidos prematuros con cardiopatías congénitas presentan un desafío adicional al equipo multidisciplinario interviniente debido a la frecuente asociación de comorbilidades y bajo peso. A diferencia de las estrategias históricas diferidas de diferir la cirugía, desde 2007 llevamos a cabo cirugías correctoras sin importar el peso ni la edad en pacientes sintomáticos con el propósito de mejorar su estado cardíaco para que pudieran superar las comorbilidades asociadas. Objetivo Comunicar la experiencia inicial en cirugía cardiovascular (CCV) con circulación extracorpórea (CEC) en neonatos de menos de 2.500 gramos. Material y métodos De mayo de 2007 a mayo de 2009, 11 neonatos fueron intervenidos con CEC. La edad media fue de 24 días (4 a 90 días), la edad gestacional media fue de 34 semanas (32 a 37) y el peso medio, de 2,27 kg (1,7 a 2,5). Previo a la intervención, siete pacientes estaban con asistencia respiratoria mecánica (ARM) y nueve con inotrópicos. Los diagnósticos fueron comunicación interventricular (n = 4, uno con coartación de la aorta grave), anomalía total del retorno venoso pulmonar (n = 2), transposición de grandes arterias (n = 2), atresia pulmonar con septum íntegro (n = 1), atresia pulmonar con comunicación interventricular (n = 1) e hipoplasia del ventrículo izquierdo (n = 1). Se utilizó hipotermia profunda a 18 °C de temperatura rectal con paro circulatorio total intermitente (n = 8) o flujo completo a 28 °C de temperatura rectal (n = 3). En 10 pacientes se realizó cirugía correctora biventricular y en uno se efectuó cirugía de Norwood. Resultados En 8 pacientes se dejó el esternón abierto, con un tiempo medio al cierre de 3,5 días (3 a 5). Tres pacientes requirieron factor VII por presentar sangrado incoercible. El tiempo medio de ARM fue de 7,5 días (2 a 20). Las complicaciones más comunes fueron sangrado (n = 5), sepsis (n = 2) y quilotórax (n = 1). No hubo mortalidad inicial y sólo un paciente falleció alejadamente debido a sepsis por Candida albicans. Nueve sobrevivientes se encuentran en buen estado general libres de síntomas y uno con insuficiencia cardíaca compensada. Conclusiones La CCV con CEC en neonatos de bajo peso presenta resultados iniciales muy promisorios, pero con una morbilidad inicial significativa.
Background Despite the sustained progress in neonatal cardiovascular surgery in the last 30 years, premature newborns with congenital heart defects pose an additional challenge to the multidisciplinary team taking part in the intervention due to the frequent association with comorbidities and low weight. Unlike historical strategies, and imitating successful approaches reported in the last decade, we have been performing corrective surgeries in symptomatic patients since 2007, irrespective of weight and age, in order to improve their cardiac status and thus overcome the associated comorbidities. Objective To report the initial experience in cardiovascular surgery (CVC) with cardiopulmonary bypass (CPB) in newborns weighing less than 2500 grams. Material and Methods From May 2007 to May 2009, 11 newborns underwent CBP surgery. Mean age was 24 days (4 to 90 days), gestational age was 34 weeks (32 to 37) and mean weight was 2.27 kg (1.7 to 2.5). Before the intervention, 7 patients were under mechanical ventilation (MV) and 9 were receiving inotropic drugs. The diagnoses were ventricular septal defect (n = 4, one with severe coarctation of the aorta), total anomalous pulmonary venous drainage (n = 2), transposition of the great arteries (n = 2), pulmonary atresia with intact ventricular septum (n = 1), pulmonary atresia with ventricular septal defect (n = 1) and hypoplastic left heart syndrome (n = 1). Patients underwent either deep hypothermic circulatory arrest with a rectal temperature of 18 °C with intermittent flow perfusion (n = 8) or continuous flow perfusion with a rectal temperature of 28 °C (n = 3). Biventricular correction was performed in 10 patients and 1 patient underwent the Norwood procedure. Results The sternotomy remained opened in 8 patients; mean time to closure was 3.5 days (3 to 5). Three patients with unremitting bleeding required therapy with factor VII. Mean duration of MV was 7.5 days (2 to 20). Bleeding (n = 5), sepsis (n = 2) and chylothorax (n = 1) were the most frequent complications. There were no early deaths and only one patient died during late follow-up of sepsis due to Candida albicans. Nine survivors are in good general condition free from symptoms and one patient presents compensated heart failure. Conclusions The initial outcomes of cardiovascular surgery with CPB in newborns are promising, yet the initial morbidity is high.
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Clinical practice guidelines for community-acquired pneumonia (CAP) contribute to improve patient's management. CAP undergoes continuous changes in etiology, epidemiology and antimicrobial sensitivity, requiring periodic guidelines revisions. An inter-society committee designed this guidelines dividing it into several topics based on prior guidelines and recent clinical studies. CAP compromises annually more than 1 of the population; most of the cases only require outpatient care but others are severe cases, reaching the 6th cause of death in Argentina. The cases are distributed unevenly into ambulatory, admitted in the general ward or in the intensive care unit. There is no way to predict the etiology. Unfavorable outcome predictors include age, antecedents and physical, laboratory and radiography findings. Ten to 25 of inpatients need to be admitted to the intensive care unit at the onset or during the follow-up, for mechanical ventilation or hemodynamic support (severe CAP). Severe CAP is associated with high mortality and requires adequate and urgent therapy. Pregnant, COPD and nursing home patients require special recommendations. Diagnosis is clinical, while complementary methods are useful to define etiology and severity; chest X-ray is the only one universally recommended. Other studies, including microbiologic evaluation are particularly appropriate in the hospitalized patients. The initial therapy is empiric, it must begin early, using antimicrobials active against the target microorganisms, avoiding their inappropriate use which can lead to the development of resistance. Length of therapy must not be unnecessarily prolonged. Hydratation, nutrition, oxygen and therapy of complications must complement antibiotic treatment. Prevention is based on influenza prophylaxis, anti-pneumococcal vaccine, aspiration prevention and other general measures
Assuntos
Humanos , Masculino , Feminino , Gravidez , Idoso , Infecções Comunitárias Adquiridas , Pneumonia , Infecções Comunitárias Adquiridas , Pneumonia , Fatores de Risco , Sociedades MédicasRESUMO
Our objective was to describe incidence, clinical, radiographic and microbiological features of bacteremic pneumococcal pneumonia (BPP) in our environment. A total of 101 patients (7 were treated as outpatients), older than 18 years of age suffering BPP were prospectively evaluated. The incidence was 2.8 cases per 1000 admissions, 50 were males, mean age was 59.9 years (19-97), mortality was 11.8%. Eighty three percent of fatalities occurred within 3 days of admission. Mortality rate increased with advancing age. Fever, cough and chest pain were the commonest presenting symptoms and 44% of patients had extrapulmonary manifestations. Cigarette smoking, chronic obstructive lung disease, alcoholism and congestive heart failure (CHF) were the commonest underlying conditions. CHF was more frequent in non-survivors (p = 0.002). A lobar pattern at chest radiograph predominated in survivors and a diffuse pattern in non-survivors (p = 0.007). Pleural effusion (20.7%), empyema (7.9%) and respiratory failure (7.9%) were the main complications. Underlying diseases were present in 100% of non-survivors (p = 0.03). Ninety four percent of patients were treated with beta-lactam antibiotics. Streptococcus pneumoniae was isolated from sputum in 6 cases. Three out of 101 S. pneumoniae isolates recovered from blood samples (one from each patient) presented organisms resistant to penicillin. We observed an incidence of BPP that is similar to the observed in other countries. There are clinical and radiographic differences between survivors and non-survivors. Penicillin-resistant S. pneumoniae is still an unusual problem in our area
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Pneumonia Pneumocócica , Streptococcus pneumoniae , Idoso de 80 Anos ou mais , Argentina , Infecções Comunitárias Adquiridas , Incidência , Resistência às Penicilinas , Penicilinas , Pneumonia Pneumocócica , Estudos Prospectivos , Radiografia Torácica , Streptococcus pneumoniaeRESUMO
Enterococcus faecalis meningitis is an infrequent entity that accounts for less than 1 percent of all suppurative meningitis in the adult. Usually, this infection affects patients with compromised host defenses or those who have congenital or acquired CNS lesions mainly as intrahospitalary infections. An 85 year old woman from our community (Tandil county) without any predisposed condition, was admitted in the hospital in an unconscious state (grade 3 Glasgow's index), meningeal signs and purulent CSF, from which E. faecalis was isolated. The patient was treated with IV Ampicillin and Gentamycin (17 days), intrathecal Gentamycin (4 days) and ]V dexametasona (6 days). The clinical and bacteriological remission was achieved, without any sequel or relapse during 2 years follow up.