Bacteriemia oculta en niños atendidos en el Complejo Asistencial Dr. Sótero del Río: experiencia post vacuna neumocóccica conjugada / Occult bacteremia in Sótero del Río Hospital: experience after pneumococcal conjugated vaccine

Background: Occult bacteremia (OB) is one of the possible diagnoses of children younger than 3 years with fever without source in the emergency room. Objective: describe OB in the era after introduction of pneumococcal vaccine in Chile. Patients and Methods: Prospective descriptive review of data of children with possible OB diagnosis, referred from the emergency department between 2010-2013. Results: Possible OB was diagnosed on 391 patients. 233 had focus, mainly respiratory virus and urinary tract infection. On 158 patients, probable BO was diagnosed, 20 had proven OB from which 15 had positive blood culture for Streptococcus pneumoniae. From these, 7 were fully or partially vaccinated. The serotype was identified on 14 cases: 6 were PCV10 vaccine serotypes (none of them vaccinated), 2 were serotype related (both partially vaccinated) and 6 were non vaccine serotypes (partially or totally vaccinated). Discussion: It is necessary to improve diagnostic methods for respiratory viruses and urinary tract infections and try to expand coverage of pneumococcal conjugated vaccines in the pediatric population in order to reduce the risk of invasive pneumococcal disease in Chile.

Introducción: La bacteriemia oculta (BO) es uno de los diagnósticos que se plantean en los niños bajo 3 años de edad que se presentan con fiebre sin foco en el servicio de urgencia. Objetivo: Describir el diagnóstico de BO luego de la introducción de la vacunación universal para Streptococcus pneumoniae en Chile. Materiales y Métodos: Revisión descriptiva de seguimiento prospectivo de datos de niños con diagnóstico de BO posible derivados del SU entre 2010 y 2013. Resultados: Se diagnosticó BO posible en 391 pacientes. En 233 pacientes se encontró foco, siendo infecciones respiratorias virales e infección urinaria las más frecuentes. En 158 pacientes se diagnosticó BO probable, en 20 BO probada y 15 tuvieron hemocultivos positivos para S. pneumoniae. De estos últimos 7 estaban total o parcialmente vacunados. Se identificó serotipo en 14 casos: 6 serotipos vaccinales incluidos en PCV10 (ninguno vacunado), 2 serotipos relacionados (ambos parcialmente protegido) y 6 serotipos no vaccinales (parcial o totalmente vacunados). Discusión: Es necesario mejorar las técnicas diagnósticas de infecciones respiratorias virales e infección urinaria e intentar ampliar la cobertura de las vacunas neumocóccicas conjugadas en la población pediátrica, para reducir el riesgo de enfermedades neumocóccicas invasoras en Chile.

Utilidade da ecocardiografia transeofageana durante hipotensão arterial grave em cirurgia não cardíaca / Utility of transesophageal echocardiography during severe hypotension in non-cardiac surgery / Utilidad de la ecocardiografía transeofageana durante hipotensión arterial severa en cirugía no cardiaca

JUSTIFICATIVA E OBJETIVOS: Hipotensão arterial grave e refratária é uma ocorrência perioperatória rara em cirurgias não cardíacas, mas a determinação de sua etiologia é essencial para o tratamento bem-sucedido. MÉTODOS: Adultos submetidos a cirurgias não cardíacas foram incluídos prospectivamente neste estudo. Hipotensão arterial grave foi definida como uma queda de 30 por cento em relação à pressão arterial sistólica basal que não respondeu à administração adequada de fluidos e efedrina, de acordo com critérios do anestesiologista. Uma sonda multiplanar de ecocardiografia transesofageana (ETE) foi inserida antes de qualquer outro monitoramento hemodinâmico invasivo. RESULTADOS: Quarenta e dois adultos (68 ± 12 anos) foram incluídos neste estudo, 84 por cento durante a cirurgia não cardíaca eletiva. Cirurgias abdominais (abertas e laparoscópicas), torácicas e ortopédicas foram as mais frequentes. Em todos os pacientes, a ETE foi útil para a determinação da etiologia da hipotensão arterial grave. Hipovolemia foi diagnosticada em 18 pacientes (42 por cento). Baixa fração de ejeção (FE < 30 por cento) foi detectada em cinco casos, tendo sido tratada com sucesso pela administração de fármacos vasoativos. Obstrução dinâmica da via de saída do ventrículo esquerdo associada a movimento sistólico anterior (MAS) da válvula mitral foi diagnosticada em cinco pacientes; em outros seis, foi detectada embolia grave durante cirurgia dos quadris e joelhos. Isquemia miocárdica causando hipotensão arterial persistente foi detectada em cinco pacientes; em três pacientes, o tamponamento cardíaco foi a causa da hipotensão arterial grave. Dois pacientes morreram; ambos apresentavam isquemia miocárdica grave. CONCLUSÕES: Ecocardiografia transesofageana perioperatória foi realizada rapidamente e demonstrou ser uma técnica útil no contexto de hipotensão arterial durante cirurgia não cardíaca. O coração e os grandes vasos puderam ser observados diretamente e avaliados ...

BACKGROUND AND OBJECTIVES: Severe and refractory hypotension is an infrequent perioperative situation during non-cardiac surgery, but determining its etiology is essential for successful management and therapy. METHODS: Adults undergoing non-cardiac surgery were prospectively enrolled in this study. Severe hypotension was defined as a drop from 30 percent of baseline systolic arterial pressure unresponsive to adequate fluids administration and to ephedrine, according to the anasthesiologist criteria. A multiplanar transesophageal echocardiography (TEE) probe was inserted, prior to any other invasive hemodynamic monitor. RESULTS: Forty two adults (68 ± 12 years) were studied, 84 percent during elective non-cardiac surgery. Abdominal (open and laparoscopic), thoracic and orthopaedic surgeries were performed most frequently. In all patients, TEE was useful for determining the etiology of severe hypotension. Hypovolemia was diagnosed in 18 patients (42 percent). Low ejection fraction (EF < 30 percent) was detected in 5 cases and was successfully treated with vasoactive drugs. Dynamic left ventricular outflow tract obstruction, associated with systolic anterior motion of the mitral valve, was diagnosed in 5 patients; in another 6 patients severe embolism was detected during hip and knee surgery. Myocardial ischemia causing persistent hypotension was detected in 5 patients; in 3 patients, cardiac tamponade was the etiology of severe hypotension. Two patients died; both had severe myocardial ischemia. CONCLUSIONS: Perioperative TEE was performed quickly, proving to be a useful technique in the context of hypotension during non-cardiac surgery. The heart and great vessels could be observed directly and functionally evaluated. Thus, the etiology of severe hypotension could be easily determined and managed.

JUSTIFICATIVA Y OBJETIVOS: La hipotensión arterial severa y refractaria es una incidencia rara en Cirugías no cardiacas, pero determinar su etiología es esencial para el tratamiento exitoso. MÉTODOS: Adultos sometidos a cirugías no cardiacas que fueron incluidos prospectivamente en este estudio. La hipotensión arterial severa fue definida como una caída de un 30 por ciento con relación a la presión arterial sistólica basal que no respondió a la administración adecuada de fluidos y efedrina, de acuerdo con critérios del anestesiólogo. Una sonda multiplanar de ecocardiografía transesofageana (ETE) se insertó antes de cualqueir otro monitoreo hemodinámico invasivo. RESULTADOS: Cuarenta y dos adultos (68 ± 12 años) se incluyeron en este estudio, 84 por ciento durante la Cirugía no cardiaca electiva. Cirugías abdominales (abiertas y laparoscópicas), torácicas y ortopédicas fueron las más frecuentes. En todos los pacientes, la ETE fue útil para la determinación de la etiología de la hipotensión arterial severa. La Hipovolemia fue diagnosticada en 18 pacientes (42 por ciento). Una baja fracción de eyección (FE < 30 por ciento), fue detectada en cinco casos, y fue tratada exitosamente con la administración de fármacos vasoactivos. Se diagnosticó la obstrución dinámica de la vía de salida del ventrículo izquierdo asociada al movimento sistólico anterior (MAS), de la válvula mitral en cinco pacientes; en otros seis, fue detectada embolia severa durante cirugía de caderas y rodillas. La Isquemia miocárdica causando hipotensión arterial persistente se detectó en cinco pacientes; en tres pacientes, el taponamiento cardíaco fue la causa de la hipotensión arterial severa. Dos pacientes fallecieron y ambos presentaban isquemia miocárdica severa. CONCLUSIONES: La Ecocardiografia transesofageana perioperatoria fue realizada rápidamente y demostró ser una técnica útil en el contexto de la hipotensión arterial durante la cirugía no cardiaca. El corazón y ...

Consumo de sustancias ilícitas y psicotrópicos entre los estudiantes de medicina de la Pontificia Universidad Católica de Chile / Illicit and psychotropic drug use among medical students at the Pontificia Universidad Católica de Chile

Background: Illicit drug abuse is a public health problem, generally starting in adolescence. Medical students are not an exception. Aim: To assess the consumption of illicit drugs among medical students of the Pontificia Universidad Católica de Chile. Material and Methods: A questionnaire used by the National Council for the Control of Substance Abuse (CONACE) to evaluate substance use and the Goldberg Health Questionnaire (GHQ-12), were applied to medical students. The questionnaires were self administered under supervision. Results: The survey was completed by 569 of 775 students (74%). “Ever used” reached 33% for marijuana, 1.1% for cocaine, 2.1% for amphetamines without prescription, 6.9% for not prescribed benzodiazepines and 5.8% for not prescribed antidepressants. The use of these substances was only associated for ever used marijuana and level of career (p <0.01), with the highest rate in the seventh final year (51.4%). Benzodiazepine use was also associated with the level of career (p <0.01) withless than 6% prevalence from first to fourth and the highest in seventh year (32.4%). Non prescribed antidepessant use was significantly higher among women. Tobacco and alcohol use were associated with consumption of marijuana (p <0.0001) and benzodiazepines (p <0.0001). Conclusions: Our medical students have low marijuana consumption rates, only above Turkey. Cocaine and amphetamines use is low, benzodiazepine consumption is higher among final year students. Antidepressant use is higher among women.

Ecocardiografía transesofágica intraoperatoria y movimiento sistólico anterior de la válvula mitral / Intraoperative transesophageal echocardiography and systolic anterior motion of mitral valve

El fenómeno de movimiento sistólico anormal de la válvula mitral (SAM) es una entidad clínica poco reconocida como causa de hipotensión arterial sistémica aguda intraoperatoria durante cirugía no cardíaca. Con el advenimiento de la ecocardiografía transesofágica intraoperatoria (ETE), que permite obtener imágenes anatómicas y funcionales cardíacas en tiempo real, este fenómeno dinámico se ha hecho evidente. Su etiología aunque poco clara, se piensa se debe a cambios morfológicos y funcionales del ventrículo izquierdo que permiten el desplazamiento del anillo valvular mitral lo que facilita que uno o ambos velos sean arrastrados hacia el tracto de salida del ventrículo izquierdo, obstruyéndolo. La importancia que tiene su diagnóstico y reconocimiento como causa de hipotensión durante el intraoperatorio de una cirugía no cardíaca cardíaca es que su tratamiento se basa en el aporte de volumen y a la utilización preferencial de betabloqueadores. La ETE intraoperatoria permite la oportunidad única de visualizar los resultados de la terapia, ver cómo aumenta el tamaño del ventrículo izquierdo aportando volumen y evitando que éste se encuentre en un estado hiperdinámico utilizando betabloqueadores. Se presenta el siguiente caso clínico ocurrido durante una cirugía no cardíaca donde el manejo y la evolución dependieron de las imágenes diagnósticas de SAM aportadas por la ETE.

Systolic anterior motion of the mitral valve (SAM) is an under-recognized cause of acute severe perioperative hypotension during noncardiac surgery. With the introduction of transesophageal echocardiography (TEE) to the operating room real time 2D images permits to diagnose these specific dynamic entity. Obstruction of the left ventricular outflow tract can be explain because of morphologic and functional changes of mitral annulus and then the anterior mitral valve leaflet is swept towards the septum by the drag. Clinical importance of diagnosing acute intraoperative SAM causing hypotension is the change in therapy, which is based in volume and beta blockers. TEE permits to guide therapy and see how ventricular volumen change and hyperdynamic status ends with the use of beta blockers. In this case report ocurred during noncardiac surgery SAM was diagnosed and treated guided by the images of intraoperative TEE.