Navigating HER2-Low Testing in Invasive Breast Cancer: Update Recommendations for Pathologists.

The article discusses the importance of accurately distinguishing HER2-low from HER2-negative breast cancer, as novel ADCs have demonstrated activity in a large population of patients with HER2-low-expressing BC. While current guidelines recommend a dichotomous classification of HER2 as either positive or negative, the emergence of the HER2-low concept calls for standardization of HER2 testing in breast cancer, using currently available assays to better discriminate HER2 levels. This review covers the evolution and latest updates of the ASCO/CAP guidelines relevant to this important biomarker in breast cancer, including still-evolving concepts such as HER2 low, HER2 heterogeneity, and HER2 evolution. Our group presents the latest Mexican recommendations for HER2 status evaluation in breast cancer, considering the ASCO/CAP guidelines and introducing the HER2-low concept. In the era of personalized medicine, accurate HER2 status assessment remains one of the most important biomarkers in breast cancer, and the commitment of Mexican pathologists to theragnostic biomarker quality is crucial for providing the most efficient care in oncology.

Clinical practice guidelines for diagnostic and treatment of the chronic heart failure.

Chronic heart failure continues to be one of the main causes of impairment in the functioning and quality of life of people who suffer from it, as well as one of the main causes of mortality in our country and around the world. Mexico has a high prevalence of risk factors for developing heart failure, such as high blood pressure, diabetes, and obesity, which makes it essential to have an evidence-based document that provides recommendations to health professionals involved in the diagnosis and treatment of these patients. This document establishes the clinical practice guide (CPG) prepared at the initiative of the Mexican Society of Cardiology (SMC) in collaboration with the Iberic American Agency for the Development and Evaluation of Health Technologies, with the purpose of establishing recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. This document complies with international quality standards, such as those described by the US Institute of Medicine (IOM), the National Institute of Clinical Excellence (NICE), the Intercollegiate Network for Scottish Guideline Development (SIGN) and the Guidelines International Network (G-I-N). The Guideline Development Group was integrated in a multi-collaborative and interdisciplinary manner with the support of methodologists with experience in systematic literature reviews and the development of CPG. A modified Delphi panel methodology was developed and conducted to achieve an adequate level of consensus in each of the recommendations contained in this CPG. We hope that this document contributes to better clinical decision making and becomes a reference point for clinicians who manage patients with chronic heart failure in all their clinical stages and in this way, we improve the quality of clinical care, improve their quality of life and reducing its complications.

La insuficiencia cardiaca crónica sigue siendo unas de las principales causas de afectación en el funcionamiento y en la calidad de vida de las personas que la presentan, así como una de las primeras causas de mortalidad en nuestro país y en todo el mundo. México tiene una alta prevalencia de factores de riesgo para desarrollar insuficiencia cardiaca, tales como hipertensión arterial, diabetes y obesidad, lo que hace imprescindible contar con un documento basado en la evidencia que brinde recomendaciones a los profesionales de la salud involucrados en el diagnóstico y el tratamiento de estos pacientes. Este documento establece la guía de práctica clínica (GPC) elaborada por iniciativa de la Sociedad Mexicana de Cardiología (SMC) en colaboración con la Agencia Iberoamericana de Desarrollo y Evaluación de Tecnologías en Salud, con la finalidad de establecer recomendaciones basadas en la mejor evidencia disponible y consensuadas por un grupo interdisciplinario y multicolaborativo de expertos. Cumple con estándares internacionales de calidad, como los descritos por el Institute of Medicine de los Estados Unidos de América (IOM), el National Institute of Clinical Excellence (NICE) del Reino Unido, la Intercollegiate Network for Scottish Guideline Development (SIGN) de Escocia y la Guidelines International Network (G-I-N). El grupo de desarrollo de la guía se integró de manera interdisciplinaria con el apoyo de metodólogos con experiencia en revisiones sistemáticas de la literatura y en el desarrollo de GPC. Se llevó a cabo y se condujo metodología de panel Delphi modificado para lograr un nivel de consenso adecuado en cada una de las recomendaciones contenidas en esta GPC. Esperamos que este documento contribuya para la mejor toma de decisiones clínicas y se convierta en un punto de referencia para los clínicos que manejan pacientes con insuficiencia cardiaca crónica en todas sus etapas clínicas, y de esta manera logremos mejorar la calidad en la atención clínica, aumentar la calidad de vida de los pacientes y disminuir las complicaciones de la enfermedad.

Nonalcoholic Fatty Liver Disease Severity Is Related to Plasma Pro-Oxidative Biomarkers Rather Than Liver Tissue-Measured Nitrogen Metabolism Biomarkers in Population with Obesity and Metabolic Syndrome.

Background: The metabolic syndrome (MS) is associated with an increased production of nitrogen metabolites and elevated oxidative stress, which favors progression of nonalcoholic fatty liver disease (NAFLD). Subjects with the phenotype known as metabolically unhealthy obese (MUO) meet most of the MS cardiometabolic risk criteria and show a higher risk of advanced NAFLD severity, compared with the so-widely known metabolically healthy obese (MHO). Obese individuals with MS are more susceptible to abnormal lipid accumulation in different tissues, whereas oxidative stress and nitrogen metabolites are increased in MS and/or obesity. This study aimed to explore whether plasma- or liver tissue-determined biomarkers of nitrogen metabolism and oxidative stress relate to NAFLD severity and/or metabolic phenotype. Methods: This cross-sectional study included candidates for bariatric surgery with biopsy-proven NAFLD diagnosis and staging. For comparison, the study population was divided according to NAFLD damage (steatohepatitis F0-F1 vs. steatohepatitis F2-F4) and metabolic phenotype (MHO vs MUO, based on the MS criteria). Hepatic and plasma concentrations of nitrogen metabolites and oxidative stress biomarkers were determined by enzymatic kinetics assays, enzyme-linked immunosorbent assay, and Greiss reaction. Results: The study population (N = 45) was constituted by patients with obesity and higher prevalence of dyslipidemia, diabetes mellitus, and hypertension. According to plasma biomarkers, MUO phenotype was related to higher cardiometabolic risk; meanwhile, advanced NAFLD damage was related to higher glycated hemoglobin (HbA1c) and triglycerides. Elevated hepatic concentrations of ammonium, nitrites, arginine, and citrulline were found in MUO phenotype, but only higher plasma concentration of malondialdehyde was found as specifically related to advanced NAFLD damage. Conclusions: Circulating biomarkers of redox state were selectively related to advanced NAFLD damage, suggesting prognostic and therapeutic targets. Hepatic concentrations of nitrogen metabolism biomarkers may be more related to cardiometabolic risk.

The metabolic phenotype of the patient influences the reduction in carotid intima-media thickness achieved following metabolic surgery.

OBJECTIVES: To determine whether metabolic phenotype is associated with the change in carotid intima-media thickness (CIMT) in patients undergoing bariatric /metabolic surgery (BMS). METHODS: We performed a case-control study of BMS candidates who had metabolically unhealthy obesity (MUO) or metabolically healthy obesity (MHO). We measured the change in CIMT during the 9 months following BMS. The plasma tumor necrosis factor-α, interleukin-1ß, adiponectin, leptin, nitric oxide (NO), vascular endothelial growth factor A (VEGF-A), and malondialdehyde concentrations were determined, adipocyte area was measured histologically, and adipose tissue area was estimated using computed tomography. RESULTS: Fifty-six patients (mean age 44.5 years, mean body mass index 44.9 kg/m2, 53% women, and 53% had MUO) were studied. Nine months following BMS, the MUO phenotype was not associated with a significant reduction in CIMT, and that of the MHO group was larger. In addition, fewer participants achieved a 10% reduction in CIMT in the MUO group. A CIMT reduction was associated with lower VEGF-A and NO in the MUO group, while that in the MHO group was associated with a higher NO concentration. CONCLUSION: The metabolic phenotype of patients may influence their change in CIMT following BMS, probably through circulating vasodilatory and pro-inflammatory molecules.

Influence on Depression, Anxiety, and Satisfaction of the Relatives' Visit to Intensive Care Units prior to Hospital Admission for Elective Cardiac Surgery: A Randomized Clinical Trial.

Background: Intensive care units (ICUs) may produce stress on the relatives of patients that have long-term physiological and psychological implications. Objectives: This study aimed to evaluate the effects of the relatives´ visit prior to hospital admission(s) on the patient's scheduled cardiac surgery regarding depression, anxiety, and satisfaction of the patient's family in an ICU. Methods: A randomized clinical trial [NCT03605420] was carried out according to the CONSORT criteria. Thirty-eight relatives of ICU patients were recruited at an ICU and randomized into study groups. Experimental group participants (n = 19) consisted of relatives who received 1 ICU visit prior to the patient's admission. Control group participants (n = 19) consisted of patients' relatives who received standard care alone. A self-report test battery, including the Impact of Event Scale-Revised (IES-R) and the Hospital Anxiety and Depression Scale (HADS), was completed by the patient's relative prior to the patient's ICU admission and again three and 90 days after ICU discharge. Furthermore, the Family Satisfaction with Care in the Intensive Care Unit (FS-ICU) and Critical Care Family Needs Inventory (CCFNI) were administered to help determine the respondents' satisfaction three days after the patient's ICU discharge. Results: Statistically significant differences in FS-ICU results were found between control and experimental groups; no statistically significant differences were found in IES-R, HADS, and CCFNI results. Thus, members in the control group were more satisfied with the time elapsed to raise their concerns (p=0.005), emotional support provided (p=0.020), quality of care (p=0.035), opportunities to express concerns and ask questions (p=0.005), and general satisfaction with the ICU's decision-making (p=0.003). Conclusions: Relatives' satisfaction during patients' ICU admission may be impaired after their prior visit to the hospital admission. Relative's anxiety and depression scores did not seem to be significantly affected. Relatives´ visit prior to elective cardiac surgery hospital admission impaired their satisfaction in an ICU and may not be advisable for healthcare practice.

Identification of adipose tissue-related predictors of the reduction in cardiovascular risk induced by metabolic surgery.

OBJECTIVES: We aimed to determine whether parameters associated with adipose tissue (adipocyte density and the circulating concentrations of markers of adipose tissue pathology) predict cardiovascular risk (CVR) modification after metabolic surgery (MS). METHODS: We performed a case-control study of patients with morbid obesity who were candidates for MS. CVR was defined using flow-mediated dilation (FMD) and carotid intima media thickness (CIMT), which were measured during the 9 months following MS. Subgroups of CVR reduction were defined using the following cut-offs: CIMT 10% and/or a two-fold increase in FMD. RESULTS: We studied 40 patients with morbid obesity (mean age 44.5 years, 75% women, mean body mass index 46.4 kg/m2) and high prevalences of the metabolically unhealthy obesity phenotype, hypertension, and diabetes mellitus. A significant reduction in CVR was associated with lower vascular endothelial growth factor-A concentration (6.20 vs. 1.59 pg/mL, respectively), low adipocyte density in visceral adipose tissue (100 vs. 80 cells/field), low infiltration with CD68+ cells (18 vs. 8 cells/field) and higher concentrations of lipid peroxidation markers and malondialdehyde (313.7 vs. 405.7 ng/mL). CONCLUSION: The characteristics of adipose tissue and the circulating concentrations of markers of adipose pathology might represent useful predictors of the reduction in CVR following MS.Clinical trial registration number: NCT0356198 (https://clinicaltrials.gov).

Enlarged adipocytes from subcutaneous vs. visceral adipose tissue differentially contribute to metabolic dysfunction and atherogenic risk of patients with obesity.

Morphological characteristics and source of adipose tissue as well as adipokines may increase cardiometabolic risk. This study aimed to explore whether adipose tissue characteristics may impact metabolic and atherogenic risks. Subcutaneous Adipose Tissue (SAT), Visceral Adipose Tissue (VAT) and peripheral blood were obtained from obese patients submitted to bariatric surgery. Adipose tissue (morphometry), plasma adiponectin, TNF-α, resistin (multiplexing) and biochemical chemistry were analyzed; as well as endothelial dysfunction (Flow Mediated Dilation, FMD) and atherogenesis (Carotid Intima Media Thickness, CIMT). Subgroups divided by adipocyte size and source were compared; as well as correlation and multivariate analysis. Sixty patients 36.6% males, aged 44 years-old, BMI 46.7 kg/m2 were included. SAT's adipocytes showed a lower range of size expandability than VAT's adipocytes. Independent from their source, larger adipocytes were associated with higher glucose, lower adiponectin and higher CIMT. Particularly, larger adipocytes from SAT were associated with higher blood pressure, lower insulin and HDL-cholesterol; and showed positive correlation with glucose, HbA1c, systolic/diastolic values, and negatively correlated with insulin and adiponectin. VAT's larger adipocytes particularly associated with lower resistin and lower FMD values. Gender and Diabetes Mellitus significantly impacted the relation of adipocyte size/source with the metabolic and atherogenic risk. Multivariable analysis suggested hypertension-resistin-HbA1c interactions associated with SAT's larger adipocytes; whereas potential insulin-adiponectin associations were observed for VAT's larger adipocytes. Adipocyte morphology and source are differentially related with cardiometabolic and atherogenic risk in population with obesity, which are potentially affected by gender and Diabetes Mellitus.

Bi-allelic missense disease-causing variants in RPL3L associate neonatal dilated cardiomyopathy with muscle-specific ribosome biogenesis.

Dilated cardiomyopathy (DCM) belongs to the most frequent forms of cardiomyopathy mainly characterized by cardiac dilatation and reduced systolic function. Although most cases of DCM are classified as sporadic, 20-30% of cases show a heritable pattern. Familial forms of DCM are genetically heterogeneous, and mutations in several genes have been identified that most commonly play a role in cytoskeleton and sarcomere-associated processes. Still, a large number of familial cases remain unsolved. Here, we report five individuals from three independent families who presented with severe dilated cardiomyopathy during the neonatal period. Using whole-exome sequencing (WES), we identified causative, compound heterozygous missense variants in RPL3L (ribosomal protein L3-like) in all the affected individuals. The identified variants co-segregated with the disease in each of the three families and were absent or very rare in the human population, in line with an autosomal recessive inheritance pattern. They are located within the conserved RPL3 domain of the protein and were classified as deleterious by several in silico prediction software applications. RPL3L is one of the four non-canonical riboprotein genes and it encodes the 60S ribosomal protein L3-like protein that is highly expressed only in cardiac and skeletal muscle. Three-dimensional homology modeling and in silico analysis of the affected residues in RPL3L indicate that the identified changes specifically alter the interaction of RPL3L with the RNA components of the 60S ribosomal subunit and thus destabilize its binding to the 60S subunit. In conclusion, we report that bi-allelic pathogenic variants in RPL3L are causative of an early-onset, severe neonatal form of dilated cardiomyopathy, and we show for the first time that cytoplasmic ribosomal proteins are involved in the pathogenesis of non-syndromic cardiomyopathies.

Neutrophil-to-lymphocyte ratio and its relation with pro-inflammatory mediators, visceral adiposity and carotid intima-media thickness in population with obesity.

BACKGROUND: Atherosclerosis represents a cardiovascular risk. Chronic inflammation is a key factor for atherogenic progression. Neutrophil-to-lymphocyte ratio (NLR) has been proposed as a novel biomarker for cardiovascular risks. We aimed to explore whether NLR was related to surrogate pro-atherogenic promoters driving atherogenic progression, as measured by carotid intima-media thickness (CIMT). STUDY DESIGN: Thirty-one patients with obesity candidates for bariatric surgery were recruited from Centro Médico Nacional "20 de Noviembre", ISSSTE, Mexico City. The results are part of the "CROP" study (NCT03561987). NLR was calculated from routine complete blood count, and its relation with plasma pro-inflammatory mediators (hsCRP, TNF-α and IL-1ß), adipokines (adiponectin and leptin), adiposity markers (visceral adipose tissue [VAT] determined from CT scan image and VAT individual adipocyte area at histological sample) and CIMT were determined. RESULTS: Neutrophil-to-lymphocyte ratio correlated with hsCRP (Spearman's r = 0.70 [95% CI 0.46 to 0.85], P < 0.01), TNF-α (r = 0.69 [0.44 to 0.84], P < 0.0001) and adiponectin (r = -0.69 [-0.84 to -0.45], P < 0.03), as well as with VAT individual adipocyte area (r = 0.64 [0.37 to 0.81], P < 0.0001) and with VAT area (r = 0.43; [0.07 to 0.68], P < 0.01). Leptin and adiponectin showed further independent association with higher NLR (multivariate regression analysis OR 7.9 [95% CI 1.1 to 56.2] P = 0.03 and 0.1 [0.01 to 1.0] P = 0.05, respectively). Moreover, NLR distribution significantly varied between subgroups divided according to progressive CIMT (P = 0.05); whereas adiponectin and VAT adipocyte area associated with CIMT > 0.9 mm (univariate analysis OR 0.1 [0.01 to 1.0] P = 0.05 and 13.1 [1.4 to 126.3] P = 0.03, respectively). CONCLUSION: Neutrophil-to-lymphocyte ratio was related to pro-inflammatory, adiposity biomarkers and progressive subclinical atherogenesis.

Clinical Outcomes and Reduced Pulmonary Artery Pressure With Intra-Aortic Balloon Pump During Central Extracorporeal Life Support.

Patients supported with extracorporeal life support (ECLS) can experience severe complications from increased left ventricular afterload. The intra-aortic balloon pump (IABP) is thought to unload the left ventricle (LV) and is routinely used with ECLS despite conflicting evidence of its clinical benefit. This retrospective, single-center study examined the effect of the simultaneous use of IABP and centrally cannulated ECLS on patient outcomes and provides new insights into IABP-mediated LV unloading. Thirty patients supported with central ECLS and IABP (extracorporeal life support-IABP group, ECLS-I) were compared with 30 patients with central ECLS alone (ECLS) for cardiogenic shock. Rates of survival to 30 days (p = 0.06) and intensive care unit (ICU) discharge (p = 0.17), and clinical outcomes were not significantly different between the two groups. In patients with pulmonary artery pressure monitoring, mean pulmonary artery (PA) pressure was significantly reduced after 24 (p = 0.007) and 48 hours (p = 0.002) in the ECLS-I group. No significant difference in PA pressure was observed in the ECLS group after 24 or 48 hours. The IABP has the ability to reduce pulmonary artery pressure in patients supported by central ECLS. However, this did not translate into improved survival or clinical outcomes in our population.

Left Ventricular Unloading by Impella Device Versus Surgical Vent During Extracorporeal Life Support.

BACKGROUND: Patients supported with extracorporeal life support (ECLS) can experience severe complications from increased left ventricular (LV) afterload. The Impella (Abiomed, Danvers, MA) percutaneous ventricular assist device (PVAD) may offer an attractive option for unloading the LV in these patients. This study describes the efficacy and outcomes of PVAD use during ECLS compared with surgically placed LV vent. METHODS: In this retrospective study, we reviewed patients supported by ECLS with PVAD or surgical LV vent for cardiogenic shock between April 2010 and May 2016. Included were 23 patients with PVADs and 22 with surgical vents. Patients' baseline characteristics, hemodynamic data, and outcomes were collected immediately preceding combined support initiation, at 48 hours, intensive care unit discharge, and 30 days. RESULTS: After 48 hours, pulmonary artery diastolic pressure was significantly reduced in the PVAD (23.3 ± 8.4 vs 15.6 ± 4.2, p = 0.02) and surgical vent groups (20.1 ± 5.9 vs 15.6 ± 5.4, p = 0.01), and radiographic evidence of pulmonary edema was reduced or unchanged in 90% of PVAD patients and in 76% of surgical vent patients. The primary end points of survival to 30 days (43% vs 32%, p = 0.42) and intensive care unit discharge (35% vs 23%, p = 0.37) were not different between the two methods of support. The PVAD and surgical vent groups were also not significantly different in the rate of vascular complications or in the number decannulated from ECLS and transitioned to durable LV assist device. CONCLUSIONS: PVAD use in ECLS patients is an effective means of LV unloading and preventing worsened pulmonary edema, with outcomes and complications that are comparable to surgical LV vent.

Glicopéptidos, origen y desarrollo actual / Glycopeptids, origin and current development

Presidente del capítulo cubano de APUA-Cuba, Alianza para el Uso Prudente de los Antibióticos. Lejos estaba de pensar Mc Cormick, en 1955, cuando en tierras de Borneo, aislaba una cepa de Stretomyces orientalis productora de una sustancia con propiedades antimicrobianas, que nombró vancomicina y que 60 años después permanecería en la primera línea de tratamiento contra las infecciones por microorganismo grampositivos multirresistentes. La vancomicina, nombre proveniente de la palabra vanquish, que significa vencedor, recibió el sobrenombre de fango del Missipi, debido a su gran toxicidad, fue relegada a un segundo plano con la aparición, en 1958, de la primera penicilina antiestafilocócica (meticillina). Sin embargo, en fecha tan temprana como el comienzo de la década de los 60, hubo que retomar su uso, debido a la aparición de las primeras cepas de estafilococos meticillina resistente. Estas cepas, con el de cursar de los años, han aumento y diseminado por todo el planeta, robándose el protagonismo de las infecciones asociadas a la asistencia sanitaria.En la actualidad, más del 50 por ciento de las cepas de Stafilococcus aureus aisladas en el nosocomio son meticillina resistentes y alcanzan más del 70 por ciento en la mayoría de las unidades de cuidados intensivos. Debido al mecanismo de resistencia presente en estas, a través de una mutación genética (gen mecA), resisten la acción de todos los betalactámicos, incluso de los aminoglucósidos, quinolonas, rifampicina, macrólidos y otros antiestafilócicos, quedando pocos antimicrobianos disponibles para enfrentarlas, entre los que sobresalen, los glicopéptidos, encabezados por la vancomicina.1,2. El desarrollo de la familia de los glicopéptidos ha sido discreto, la aparición, en 1978, de la teicoplanina, aportó algunos avances como la aplicación intramuscular, vida media más prolongada...

Glicopéptidos, origen y desarrollo actual / Glycopeptids, origin and current development

Presidente del capítulo cubano de APUA-Cuba, Alianza para el Uso Prudente de los Antibióticos Lejos estaba de pensar Mc Cormick, en 1955, cuando en tierras de Borneo, aislaba una cepa de Stretomyces orientalis productora de una sustancia con propiedades antimicrobianas, que nombró vancomicina y que 60 años después permanecería en la primera línea de tratamiento contra las infecciones por microorganismo grampositivos multirresistentes. La vancomicina, nombre proveniente de la palabra vanquish, que significa vencedor, recibió el sobrenombre de fango del Missipi, debido a su gran toxicidad, fue relegada a un segundo plano con la aparición, en 1958, de la primera penicilina antiestafilocócica (meticillina). Sin embargo, en fecha tan temprana como el comienzo de la década de los 60, hubo que retomar su uso, debido a la aparición de las primeras cepas de estafilococos meticillina resistente. Estas cepas, con el de cursar de los años, han aumento y diseminado por todo el planeta, robándose el protagonismo de las infecciones asociadas a la asistencia sanitaria. En la actualidad, más del 50 por ciento de las cepas de Stafilococcus aureus aisladas en el nosocomio son meticillina resistentes y alcanzan más del 70 por ciento en la mayoría de las unidades de cuidados intensivos. Debido al mecanismo de resistencia presente en estas, a través de una mutación genética (gen mecA), resisten la acción de todos los betalactámicos, incluso de los aminoglucósidos, quinolonas, rifampicina, macrólidos y otros antiestafilócicos, quedando pocos antimicrobianos disponibles para enfrentarlas, entre los que sobresalen, los glicopéptidos, encabezados por la vancomicina.1,2 El desarrollo de la familia de los glicopéptidos ha sido discreto, la aparición, en 1978, de la teicoplanina, aportó algunos avances como la aplicación intramuscular, vida media más prolongada e incluso poder eliminar algunas cepas resistentes a vancomicina (vanB). Posteriormente, hubo que esperar hasta 2009 para que apareciera un nuevo componente de dicha familia, la telavancina, derivada de la vancomicina y con una potente acción sobre las cepas de estafilococos y enterococos resistentes a vancomicina.3,4 Tras más de 10 años de investigación, en el 2014, se introducen en la asistencia médica dos nuevos componentes de dicha familia la oritavancina (derivada de la vancomicina) y dalbavancina (derivada de la teicoplanina), ambas con características farmacológicas...(AU)

Eosinophilic gastroenteritis / Gastroenteritis eosinofílica

The eosinophilic gastroenteritis is a disease of unknown etiopathogenesis and rare presentation, with several clinical symptoms, ranging from mild episodes until nonspecific abdominal acute episodes of intestinal obstruction, which some times make it necessary urgent surgical treatment. This wide symptomatic range seems to be conditioned by the degree of eosinophilic infiltration of the intestinal wall and the number of layers involved. This paper reports the case of a patient who, due to the diagnosis difficulties, illustrates in a single patient the intestinal and respiratory anatomo-clinical diversity and the evolution of the eosinophilia both intestinal and peripheral. Patient was sent to our service with diagnoses of bronchial asthma, chronic allergic rhinitis and chronic anemia.

La gastroenteritis eosinofílica es una enfermedad de etiopatogenia no aclarada y manifestación poco frecuente, con síntomas clínicos diversos, abarca desde cuadros leves abdominales inespecíficos hasta episodios agudos de obstrucción intestinal que en ocasiones hacen preciso el tratamiento quirúrgico urgente. Este amplio abanico sintomático parece estar condicionado por el grado de infiltración eosinofílica de la pared intestinal y el número de capas afectadas. Comunicamos un caso que por la dificultad diagnóstica ilustra, en un solo paciente, la diversidad anatomoclínica del cuadro intestinal y respiratorio y la evolución de la eosinofilia intestinal y periférica. La paciente fue enviada a nuestro servicio con los diagnósticos de asma bronquial, rinitis crónica alérgica y anemia crónica persistente.

Indicación de nuevos antimicóticos en pacientes con candidiasis invasiva / Prescription of new antifungal drugs in patients with invasive candidiasis

Las infecciones micóticas invasivas han alcanzado tal importante diseminación en las unidades de cuidados intensivos, que hoy constituyen la cuarta causa de infecciones adquiridas en este servicio, con una mortalidad de hasta 50 por ciento. La inmunodepresión propia del paciente en estado crítico, unido a la aplicación de determinados procedimientos traumáticos -- catéteres, sondas, endoscopias, ventilación, intervenciones quirúrgicas abdominales, nutrición parenteral, entre otros --, predisponen a la infección. Al respecto, se está empleando una gama de nuevos antimicóticos (triazoles y equiniocandinas) en el tratamiento de pacientes con micosis invasivas, sobre la base de que la creación de protocolos terapéuticos puede disminuir el índice de mortalidad por dichas afecciones(AU)

The invasive fungal infections have reached such an important dissemination in the intensive care units that today they constitute the fourth cause of acquired infections in this service, with a mortality of up to 50 percent. The immunodepression characteristic of the patient in critical state, together to the application of certain traumatic procedures -- catheters, probes, endoscopies, ventilation, abdominal surgical interventions, parenteral nutrition, among other --, predispose to the infection. In this respect, a range of new antifungal drugs are being used (triazoles and equiniocandines) in the treatment of patients with invasive mycosis, on the base that the creation of therapeutic protocols can decrease the mortality index caused by these disorders(AU)

Frecuencia de aislamiento de Staphylococcus aureus resistente a meticillina en el Hospital Manuel Fajardo Rivero / Frequency of isolation of methicillin resistant Staphylococcus aureus in Manuel Fajardo Rivero hospital

Introducción: el Staphylococcus aureus constituye uno de los gérmenes patógenos más importantes desde el punto de vista clínico, tanto por el amplio espectro de infecciones que produce, como por la gran resistencia antimicrobiana que ha desarrollado, en especial las cepas resistentes a meticillina (MRSA), que además de portar resistencia a todos los betalactámicos, tienen genes de resistencia múltiples a otros antimicrobianos. Objetivo: caracterización epidemiológica de los aislamientos de MRSA realizados en pacientes ingresados en el Hospital Manuel Fajardo. Material y Métodos: se realizó un estudio retrospectivo en pacientes ingresados en el Hospital Comandante Manuel Fajardo, en el período comprendido entre el 1ro de junio y el 31 de diciembre de 2012. Resultados: a pesar de que en casi un cuarto de los aislamientos de S. aureus no se empleó el disco de cefoxitina como marcador de resistencia, se pudo comprobar una alta incidencia de MRSA en el tiempo estudiado. La gran mayoría de los aislamientos provino de heridas o abscesos, seguida a gran distancia por los hemocultivos. En correspondencia con esto, los servicios que mayores aislamientos reportaron fueron Dermatología y Angiología. Además de la vancomicina, los antimicrobianos a los que se halló mayor sensibilidad fueron amikacina, cloranfenicol, tetraciclina y ciprofloxacino. Conclusiones: las cepas MRSA son un problema internacional y una realidad en nuestro hospital, que deben ser identificadas para realizar un adecuado diagnóstico y tratamiento(AU)

Introduction: Staphylococcus aureus is one of the most important pathogens in the clinical setting, both for the broad spectrum of infections it causes and the increasing antibiotic resistance. Special attention is regarded to methicillin-resistant clones (MRSA), which provide not only resistance to all beta-lactamic agents, but carry multiple resistance genes. Objective: to characterize epidemiologically MRSA isolations in patients hospitalized in Comandante Manuel Fajardo hospital in the time period between the 1st of June and December 31st, 2012. Material and Methods: a retrospective study was performed between the 1st of June and December 31st, 2012, which included patients admitted in the hospital during that time in which at least 1 isolation of MRSA was made. Methillicin resistance was determined by using 30 µg cefoxitin discs. Results: although it was not possible to use cefoxitin discs as resistance marker in about a quarter of total S. aureus isolations, a high incidence of MRSA was found (64,2 percent). The vast majority of isolations came from skin and soft tissues infection. Angiology and Dermatology services had 60,0 percent of isolations. The greatest antimicrobial sensitivity was for vancomycin, amikacin, chloramphenicol, tetracycline and ciprofloxacin. Conclusions: MRSA clones are both an international problem and a reality in our hospital; they must be properly identified in order to start the right treatment(AU)

Absceso esplénico. Revisión del tema / Splenic abscess. Review of this subject

Los abscesos esplénicos son afecciones infrecuentes, pero con alta mortalidad. En la actualidad, los cuadros de inmunosupresión han aumentado su incidencia, provocados, generalmente, por metástasis sépticas a partir de infecciones sistémicas, muy frecuentemente endocarditis bacteriana. Se presentó un paciente, con antecedente de linfangitis crónica, que ingresó con un síndrome febril prolongado de causa no precisada. Se constató la existencia de esplenomegalia muy dolorosa a la palpación y se corroboró, por ultrasonido abdominal, la presencia de una lesión hipoecogénica en un bazo aumentado de tamaño. Se aplicó antibioticoterapia, pero no se obtuvo respuesta clínica satisfactoria y se decidió la esplenectomía con la cual se logró buena respuesta clínica y evolución favorable(AU)

Splenic abscesses are infrequent conditions but with high mortality. Currently,immunosuppression cases have increased their incidence, usually caused by septic metastases from systemic infections, very frequently by bacterial endocarditis. A patient with a history of chronic lymphangitis is presented here. This patiente showed a prolonged febrile syndrome of unknown etiology. During admission, painful splenomegaly on palpation was noted and abdominal ultrasound confirmed a hypoechoic injury in enlarged spleen. Antibiotic treatment was applied, but since no satisfactory clinical response was seen, splenectomy was decided to perform. Good and favorable clinical response was obtained(AU)

Absceso esplénico. Revisión del tema / Splenic abscess. Review of this subject

Los abscesos esplénicos son afecciones infrecuentes, pero con alta mortalidad. En la actualidad, los cuadros de inmunosupresión han aumentado su incidencia, provocados, generalmente, por metástasis sépticas a partir de infecciones sistémicas, muy frecuentemente endocarditis bacteriana. Se presentó un paciente, con antecedente de linfangitis crónica, que ingresó con un síndrome febril prolongado de causa no precisada. Se constató la existencia de esplenomegalia muy dolorosa a la palpación y se corroboró, por ultrasonido abdominal, la presencia de una lesión hipoecogénica en un bazo aumentado de tamaño. Se aplicó antibioticoterapia, pero no se obtuvo respuesta clínica satisfactoria y se decidió la esplenectomía con la cual se logró buena respuesta clínica y evolución favorable.

Splenic abscesses are infrequent conditions but with high mortality. Currently,immunosuppression cases have increased their incidence, usually caused by septic metastases from systemic infections, very frequently by bacterial endocarditis. A patient with a history of chronic lymphangitis is presented here. This patiente showed a prolonged febrile syndrome of unknown etiology. During admission, painful splenomegaly on palpation was noted and abdominal ultrasound confirmed a hypoechoic injury in enlarged spleen. Antibiotic treatment was applied, but since no satisfactory clinical response was seen, splenectomy was decided to perform. Good and favorable clinical response was obtained.

El uso de la farmacocinética y la farmacodinamia en el manejo clínico de antimicrobianos / Use of pharmacokinetics and pharmacodynamics in clinical management of antimicrobials

Existe elevado consenso en que el conocimiento y la utilización de las características farmacológicas de un antimicrobiano, permite optimizar el efecto terapéutico en términos de eficacia y seguridad. Para ello, es fundamental considerar que entre paciente y fármaco, se establece una relación farmacocinética (relación P-F) particularmente individualizada y determinada por los valores de volumen de distribución, constante de eliminación y aclaramiento que alcanza el fármaco en el paciente, en las condiciones fisiopatológicas de este en un instante determinado. Si esta relación es farmacológicamente manejada de modo adecuado, debe proporcionar el mejor escenario para que el fármaco pueda producir sus máximos efectos terapéuticos.1,2 El laboratorio clínico y sus técnicas actuales determinan con gran certeza la sensibilidad de un microorganismo a un antimicrobiano y la actividad bacteriostática o bactericida que este alcanza. Estas son características fundamentales en la eficacia de la terapia, pero no menos importantes son los procesos que tienen influencia y en definitiva, determinan sus concentraciones plasmáticas en el tiempo; las que deben centrarse en un rango efectivo y de máxima...(AU)