Gunshot Wounds Causing Distal Arterial Bullet Embolisms.

We report two cases involving small-caliber gunshot wounds to the chest with embolization of the bullet which complete occluding arterial circulation into the left lower extremity. A 30-years-old and 19-years-old men suffered gunshots wound to the thorax and abdomen with subsequent arterial embolisms into their left legs. Image studies revealed the left popliteal and femoral arteries occlusion by the missiles. Arteriotomies were auspiciously performed to retrieve the projectiles along with Fogarty catheters thrombectomies which conclude successful outcomes. At a 6 and 36 months' follow-up, the patients were doing well without any vascular associated complications. Bullet embolization of the arterial or venous systems is a rare complication of penetrating gunshot injuries with diagnostic and therapeutic challenges. This complication's suspicion should rise when there is a gunshot injury without an exit wound and with sudden pain or ischemia in an extremity. Individualized treatment should be urgently performed to avoid irreversible damage to the affected area.

Protecting Women's and Newborns' Rights in a Public Maternity Unit During the COVID-19 Outbreak: The Case of Dra. Eloísa Díaz - La Florida Hospital in Santiago, Chile.

The Maternity in Dra. Eloísa Díaz' hospital, located in the municipality of La Florida and city of Santiago, Chile, opened its doors in 2014, and has integrated a humanistic model of care called the "Safe Model of Personalized Childbirth" since 2016. With around 3,000 births per year, it has been recognized as an example of excellence in maternity care in the country. The COVID-19 outbreak presented a big challenge to this Maternity: to maintain its quality of care standards despite the health crisis. This article presents the Maternity's responses to the pandemic from March to July 2020, describing the strategies that were deployed and the obstetric outcomes achieved. Semi-structured interviews with midwives and OB-GYNs, and a retrospective review of the childbirth standards of care and outcomes of the 55 women who tested positive for SARS-CoV-2, were carried out. The results show how the Maternity's staff responded in order to avoid a significant negative impact on the rights of women and newborns. Protocols to reestablish the companion during labor and childbirth and skin-to-skin contact, which were suspended for almost three weeks at the beginning of the outbreak, and the creation of an Instagram account to communicate with the external community were some of the measures taken. After some initial weeks of adjustment, the standards of care for all women, included for those diagnosed with COVID-19, were reestablished almost to pre-pandemic levels. This case shows that quality of care can be maintained and the rights of women and newborns can be respected during health crisis such as the COVID-19 pandemic.

Dexmedetomidine pharmacokinetics in pediatric intensive care--a pooled analysis.

BACKGROUND: Published dexmedetomidine pharmacokinetic studies in children are limited by participant numbers and restricted pathology. Pooling the available studies allows investigation of covariate effects. METHODS: Data from four studies investigating dexmedetomidine pharmacokinetics after i.v. administration (n = 95) were combined to undertake a population pharmacokinetic analysis of dexmedetomidine time-concentration profiles (730 observations) using nonlinear mixed effects modeling (NONMEM). Estimates were standardized to a 70-kg adult using allometric size models. RESULTS: Children had a mean age of 3.8 (median 3 years, range 1 week-14 years) and weight of 16.0 kg (median 13.3 kg, range 3.1-58.9 kg). Population parameter estimates (between subject variability) for a two-compartment model were clearance (CL) 42.1 (CV 30.9%) lx h(-1) x 70 kg(-1), central volume of distribution (V1) 56.3 (61.3%) l.70 kg(-1), inter-compartment clearance (Q) 78.3 (37.0%) l x h(-1) x 70 kg(-1) and peripheral volume of distribution (V2) 69.0 (47.0%) l.70 kg(-1). Clearance maturation with age was described using the Hill equation. Clearance increases from 18.2 l x h(-1) x 70 kg(-1) at birth in a term neonate to reach 84.5% of the mature value by 1 year of age. Children given infusion after cardiac surgery had 27% reduced clearance compared to a population given bolus dose. Simulation of published infusion rates that provide adequate sedation for intensive care patients found a target therapeutic concentration of between 0.4 and 0.8 microg x l(-1). CONCLUSIONS: The sedation target concentration is similar to that described for adults. Immature clearance in the first year of life and a higher clearance (when expressed as l x h(-1) x kg(-1)) in small children dictate infusion rates that change with age. Extrapolation of dose from children given infusion in intensive care after cardiac surgery may not be applicable to those sedated for noninvasive procedures out of intensive care.

Pharmacokinetics of dexmedetomidine in postsurgical pediatric intensive care unit patients: preliminary study.

OBJECTIVE: To characterize the pharmacokinetics of dexmedetomidine and monitor any dexmedetomidine-related adverse events in postoperative pediatric patients requiring short-term mechanical ventilation, analgesia, and sedation in the pediatric intensive care unit (PICU). DESIGN: Prospective, case series. SETTING: Operating room and PICU in a large, urban children's hospital. Enrollment from February 14 to November 25, 2002. PATIENTS: Ten children (4 months to 7.9 yrs of age) who received postoperative infusions of dexmedetomidine. INTERVENTIONS: Toward the end of the operation, patients received dexmedetomidine at 1 microg/kg per hr for 10 mins. The anesthesiologist then titrated the infusion, as clinically indicated, to a rate of 0.2-0.7 microg/kg per hr. In the PICU, the infusion was titrated by the nursing staff based on assessment with a modified Ramsey Sedation Scale, while maintaining heart rate and blood pressure within normal limits for age. Dexmedetomidine was continued until the intensivist felt the patient no longer benefited, but for no longer than 24 hrs. MEASUREMENTS AND MAIN RESULTS: At specified times during the infusion and after discontinuation, dexmedetomidine plasma concentrations were determined. Pharmacokinetic parameters were calculated using a two-compartment model. Vital signs, sedation scores, adjunct sedative or analgesic medications, and adverse events were recorded. Average duration of infusion was 18.8 hrs (range, 8-24 hrs). Means (+/-sd) were calculated for the following: clearance, 0.57 (+/-0.14) L/hr per kg; volume of distribution at steady state, 1.53 (+/-0.37) L/kg; and terminal elimination half-life, 2.65 (+/-0.88 hrs)-all similar to published values in adults. There were no serious adverse events related to dexmedetomidine. CONCLUSIONS: Dexmedetomidine, administered as a continuous infusion, produces consistent, predictable concentrations in children and infants. Further evaluations of the safety, efficacy, and pharmacodynamics of dexmedetomidine are warranted.

Evaluation of the performance of 44 assays used in countries with limited resources for the detection of antibodies to hepatitis C virus.

BACKGROUND: This study was conducted by the International Consortium for Blood Safety (ICBS) and its Collaborating Center, the Paul Ehrlich Institute, to identify high-quality, affordable assays for the detection of hepatitis C virus (HCV) antibodies and make available information on their performance for the benefit of developing countries. STUDY DESIGN AND METHODS: Forty-four assays were evaluated for their sensitivity and specificity. The assays' sensitivity was evaluated on a characterized panel of 200 anti-HCV-positive samples comprising major HCV genotypes 1 through 6. Three seroconversion panels were used to estimate sensitivity in the early infectious phase. Specificity was evaluated with a characterized ICBS-negative panel of 181 verified negative samples. RESULTS: Sensitivity was 100 percent for 15 assays, 99.5 percent for 11 assays, 99.0 percent for 6 assays, and less than 99.0 percent for 12 assays. The false-negative results found were not linked to the genotype. Anti-HCV detection in the early infectious phase was, on average, 16.7 days later than for tests licensed in the European Union. Specificity in 25 tests was 100 percent, whereas 11 assays showed 1 false-positive result (99.45%) and the other assays were nonspecific in 2 or more samples. Two assays were not supplied in sufficient quantity to test for specificity. CONCLUSIONS: On applying criteria for highest sensitivity (100%) and high specificity (> or =99.5%), 11 tests met the criteria. An additional 19 tests reached a performance comparable to WHO's criteria for human immunodeficiency virus antibody assays. The genotype diversity of HCV was found not to influence sensitivity of the assays.

Detection of traumatic brain injury with magnetic resonance imaging and S-100B protein in children, despite normal computed tomography of the brain.

OBJECTIVE: The objective of this study was to obtain data to further define the extent of traumatic brain injury by using S-100B protein and standard noncontrast magnetic resonance imaging with added fluid-attenuated inversion recovery (FLAIR) and gradient echo sequence in children with normal head computed tomography. DESIGN: Pilot, single cohort, prospective, clinical diagnostic study. SETTING: Pediatric intensive care and intermediate care unit in a tertiary care children's hospital. PATIENTS: Children ages 5-18 yrs who sustained traumatic brain injury, had a negative computed tomography of the brain, and were admitted to hospital were eligible for enrollment. INTERVENTIONS: Two blood samples were drawn for S-100B protein analysis: the first (t-1) as soon as possible or close to 6 hrs of injury and the second (t-2) close to 12 hrs from the time of injury. A magnetic resonance image of the brain was obtained within 96 hrs of injury. MEASUREMENTS AND MAIN RESULTS: Seven of 17 patients (41%) had positive magnetic resonance image. Of the seven patients with positive magnetic resonance image, 100% (seven of seven) had a positive magnetic resonance image with FLAIR sequence, 85% (six of seven) with axial T2 sequence and 50% (three of six) with gradient echo sequence. There was no statistically significant difference in S-100B protein concentrations in patients with a positive magnetic resonance image (n = 7) and those with a negative magnetic resonance image (n = 10; p =.40 at t-1 and p =.13 at t-2). The concentration of S-100B protein was statistically significantly higher in patients with head and other bodily injury (n = 9) compared with isolated head injury (n = 6; p =.018 at t-1 and p =.025 at t-2). Patients with a positive magnetic resonance image had a lower Glasgow Coma Scale score and longer duration of hospital stay. CONCLUSIONS: Magnetic resonance imaging seems to be a useful modality to better define the spectrum of brain injury in children with mild head trauma. The addition of S-100B protein measurement does not seem to be useful in this setting.