Signo de McConnell en isquemia aguda de ventrículo derecho intraoperatoria: una etiología poco reconocida / McConnell's sign in intra-operative acute right ventricle ischaemia: an under-recognized aetiology

La ecocardiografía transesofágica (ETE) es parte de la monitorización en anestesia cardiotorácica y constituye una herramienta fundamental. Posee un papel indiscutible en cirugía valvular y de revascularización coronaria con deterioro severo de la función ventricular. Permite realizar diagnósticos que pueden optimizar la estrategia quirúrgica y monitorizar de manera dinámica y mínimamente invasiva la volemia y la función cardíaca durante el perioperatorio, detectando complicaciones no evidenciables por otros métodos. La ETE es beneficiosa en pacientes con inestabilidad hemodinámica intraoperatoria inexplicable. Numerosas publicaciones han reportado cambios en la estrategia quirúrgica como consecuencia del resultado del análisis perioperatorio de ETE, en un 27% antes de bypass, y en el periodo posterior a la salida de circulación extracorpórea, alteraciones en el plan quirúrgico que van de un 2,2% a un 14,7% de los pacientes. El signo de McConnell, visualizado mediante ETE como una acinesia de la pared libre del ventrículo derecho (VD), con una motilidad normal del ápex y agrandamiento de las cavidades derechas, es característico de disfunción del VD. El signo tiene 77% de sensibilidad y 94% de especificidad para el diagnóstico de embolia pulmonar aguda (EPA). Sin embargo, Casazza et al. demostraron que el signo de McConnell puede verse en caso de infarto, y de esta manera no es considerado un signo patognomónico de EPA. Presentamos el caso de un paciente de sexo masculino de 53 años, con antecedentes de estenosis aórtica severa y aneurisma de aorta ascendente con arterias coronarias normales, programado para cirugía de Bentall (reemplazo de aorta ascendente con injerto valvulado con válvula mecánica y reimplante de arterias coronarias), que tras el bypass presenta inestabilidad hemodinámica. La ETE mostró una imagen típica de signo de McConnell, sin hipertensión pulmonar, permitiendo un diagnóstico precoz de isquemia aguda de VD que originó cambios en el plan quirúrgico, la realización de una cirugía de revascularización coronaria. En consecuencia, el signo de McConnell, que describe características de disfunción del VD, obliga a un diagnóstico diferencial entre EPA, infarto de VD e isquemia miocárdica aguda (AU)

Transoesophageal echocardiography (TEE) has become a fundamental tool in modern cardiothoracic anaesthesia. It has an indisputable role in coronary valve surgery and revascularisations with severe impairment of ventricle function. It helps in making diagnoses that can optimise the surgical strategy and to minimal invasively dynamically monitor volaemia and cardiac function during the post-operative period, detecting complications unobservable by other methods. The McConnell sign, visualised using TEE as an akinesis of the right ventricular free wall, with a normal apex motility and enlargement of the right cavities, is characteristic of right ventricular (RV) dysfunction. This sign has a 77% sensitivity and 94% specificity for the diagnosis of acute pulmonary embolism (APE). The case is presented of a 53-year-old man scheduled for aortic valve and ascending aorta replacement surgery, with a history of severe valve aortic stenosis, aortic root and arch aneurysm, and with normal coronary arteries. Post-cardiopulmonary bypass (CBP), the patient presented with haemodynamic instability, with the TEE showing a typical image of the McConnell sign, with no pulmonary hypertension. This enabled making an early diagnosis of acute RV ischaemia, that led to a change in the surgical plan, the performing of coronary revascularisation surgery. As a result, the McConnell sign, which describes the characteristics of RV dysfunction, led to making a differential diagnosis between APE, RV infarction and acute myocardial ischaemia (AU)

McConnell's sign in intra-operative acute right ventricle ischaemia: An under-recognized aetiology. / Signo de McConnell en isquemia aguda de ventrículo derecho intraoperatoria: una etiología poco reconocida.

Transoesophageal echocardiography (TEE) has become a fundamental tool in modern cardiothoracic anaesthesia. It has an indisputable role in coronary valve surgery and revascularisations with severe impairment of ventricle function. It helps in making diagnoses that can optimise the surgical strategy and to minimal invasively dynamically monitor volaemia and cardiac function during the post-operative period, detecting complications unobservable by other methods. The McConnell sign, visualised using TEE as an akinesis of the right ventricular free wall, with a normal apex motility and enlargement of the right cavities, is characteristic of right ventricular (RV) dysfunction. This sign has a 77% sensitivity and 94% specificity for the diagnosis of acute pulmonary embolism (APE). The case is presented of a 53-year-old man scheduled for aortic valve and ascending aorta replacement surgery, with a history of severe valve aortic stenosis, aortic root and arch aneurysm, and with normal coronary arteries. Post-cardiopulmonary bypass (CBP), the patient presented with haemodynamic instability, with the TEE showing a typical image of the McConnell sign, with no pulmonary hypertension. This enabled making an early diagnosis of acute RV ischaemia, that led to a change in the surgical plan, the performing of coronary revascularisation surgery. As a result, the McConnell sign, which describes the characteristics of RV dysfunction, led to making a differential diagnosis between APE, RV infarction and acute myocardial ischaemia.

[Respiratory care in neonatal intensive care units. Situation in the year 2005]. / Asistencia respiratoria en las unidades de cuidados intensivos neonatales en España: situación en 2005.

AIM: To learn the characteristic of the neonatal intensive care units (NICUs) that offer neonatal respiratory assistance in Spain. MATERIAL AND METHOD: A structured survey was developed and sent to all Spanish neonatal units to learn about the respiratory care offered in 2005. RESULTS: A total of 96 Units answered the survey, with an estimated representatively of 63%, with a range from 3 to 92%, depending on the geographical area. Level IIIc Units were in the upper range. Answer the survey 26 units type IIb (27%), 16 IIIa (17%), 40 IIIb (42%) and 14 IIIc (14%). The total number of level III NICU beds was 541 (1.2 beds per 1000 livebirths; range, 0.7-1.7). The mean number of beds per NICU was 4.1 in level IIIa Units, 2.8 in those IIIb and 14.6 in type IIIc NICUs. In level III NICUs, the bed per physician ratio was 2.4 and that of beds per registered nurse was 2.8 (2.2 in level IIIc NICUs). There were a total 13,219 admissions, 54% of those needed mechanical ventilation (36% in IIIa and 65% in level IIIc NICUs). Oxygen blenders for resuscitation at birth were available in 42% of level IIIb and IIIc NICUs. NICUs had one neonatal ventilator per bed, and 63% of units had high frequency ventilation available. All units had nasal-CPAP systems, 25% of level IIIa Units, 58% IIIb and 64% of those type IIIc had systems for nasal ventilation. All level IIIc and 93% of level IIIb NICUs were able to provide inhaled nitric oxygen therapy. Four NICUS offered ECMO. CONCLUSIONS: The mean number of NICU beds per 1000 livebirths is within the lower limits of those been recommended, and there were wide variations among different geographical areas. A 54% of those babies admitted to NICUs required mechanical ventilation. The mean number of NICU beds per registered nurse was 2.8. There was an adequate number of neonatal ventilators (one per bed) and 63% were able to provide HFV. All NICUs hand n-CPAP systems.

Asistencia respiratoria en las unidades de cuidados intensivos neonatales en España: situación en 2005 / Respiratory care in neonatal intensive care units. Situation in the year 2005

Objetivo: conocer el tipo de unidades de cuidados intensivos neonatales (UCIN) que proporcionan asistencia respiratoria neonatal en España y sus características. Material y método: encuesta multicéntrica estructurada para conocer la actividad asistencial respiratoria prestada por las UCIN en 2005. Resultados: contestaron 96 unidades neonatales con una representatividad estimada en un 63%, con un intervalo entre el 3 y el 92%, según las áreas geográficas; las unidades IIIc se encuentran en el rango superior. Contestaron la encuesta 26 unidades tipo IIb (27%), 16 IIIa (17%), 40 IIIb (42%) y 14 IIIc (14%). Las camas totales de intensivos de nivel III fue de 541 (1,2 camas cada 1.000 recién nacidos vivos; intervalo, 0,7-1,7). La media de camas por unidad fue de 4,1 para las IIIa, 2,8 para las IIIb y 14,6 para las IIIc. En las unidades de nivel III, la relación camas/médicos fue de 2,4 camas/medico y la de camas/enfermeras 2,8 camas/enfermera (2,2 en nivel IIIc). Hubo un total de 13.219 ingresos, de los que el 54% precisó ventilación (el 36% en las IIIa y el 65% en las IIIc). La posibilidad de reanimación en el paritorio con mezcla de gases (aire y oxígeno) sólo la tiene el 42% de las IIIb y IIIc. La relación respirador/cama fue de 1/1; el 63% puede proporcionar ventilación de alta frecuencia (VAF). Todas disponen de sistemas de presión positiva continua nasal (CPAP-n). Sistemas para aplicar ventilación nasal intermitente están disponibles en el 25% de las IIIa, el 58% de las IIIb y el 64% de las IIIc. Todas las IIIc y el 93% de las IIIb pueden proporcionar oxido nítrico inhalado. Cuatro unidades disponían de ECMO. Conclusiones: la media de camas de UCIN de nivel III cada mil nacidos está en el límite bajo de lo recomendable, con notables diferencias regionales. La necesidad de ventilación mecánica fue del 54%. La relación de camas por enfermera fue de 2,8. Existe una buena dotación de respiradores (1 por cama) con alta disponibilidad de VAF (63%). Todas las unidades disponen de CPAP-n (AU)

Aim: To learn the characteristic of the neonatal intensive care units (NICUs) that offer neonatal respiratory assistance in Spain. Material and method: A structured survey was developed and sent to all Spanish neonatal units to learn about the respiratory care offered in 2005. Results: A total of 96 Units answered the survey, with an estimated representatively of 63%, with a range from 3 to 92%, depending on the geographical area. Level IIIc Units were in the upper range. Answer the survey 26 units type IIb (27%), 16 IIIa (17%), 40 IIIb (42%) and 14 IIIc (14%). The total number of level III NICU beds was 541 (1.2 beds per 1000 livebirths; range, 0.7–1.7). The mean number of beds per NICU was 4.1 in level IIIa Units, 2.8 in those IIIb and 14.6 in type IIIc NICUs. In level III NICUs, the bed per physician ratio was 2.4 and that of beds per registered nurse was 2.8 (2.2 in level IIIc NICUs). There were a total 13,219 admissions, 54% of those needed mechanical ventilation (36% in IIIa and 65% in level IIIc NICUs). Oxygen blenders for resuscitation at birth were available in 42% of level IIIb and IIIc NICUs. NICUs had one neonatal ventilator per bed, and 63% of units had high frequency ventilation available. All units had nasal-CPAP systems, 25% of level IIIa Units, 58% IIIb and 64% of those type IIIc had systems for nasal ventilation. All level IIIc and 93% of level IIIb NICUs were able to provide inhaled nitric oxygen therapy. Four NICUS offered ECMO. Conclusions: The mean number of NICU beds per 1000 livebirths is within the lower limits of those been recommended, and there were wide variations among different geographical areas. A 54% of those babies admitted to NICUs required mechanical ventilation. The mean number of NICU beds per registered nurse was 2.8. There was an adequate number of neonatal ventilators (one per bed) and 63% were able to provide HFV. All NICUs hand n-CPAP systems (AU)

[Do neonates have the same pharmacotherapeutic opportunities as adults?]. / Tienen los recién nacidos las mismas oportunidades farmacoterapéuticas que los adultos?

INTRODUCTION: The use of drugs in pediatrics, specially in neonates, poses two main problems: the legal conditions for their use in this population and the lack of commercial formulations suitable for pediatric dosing. PATIENTS AND METHODS: We reviewed the drug prescriptions of all patients admitted to our neonatal intensive care unit over 46 days, chosen at random between September and November 2005. RESULTS: A total of 2,558 drug prescriptions were issued, corresponding to 62 different drugs. Overall, 5.2 % of prescriptions were for drugs not authorized for use in pediatric patients. In neonates, this percentage increased to 8.4 %. A total of 22.6 % of the drugs were not authorized for use in neonates. Formulations prepared by the hospital pharmacists were required in 17.2 % of drug prescriptions. CONCLUSIONS: In the last few years, information on drugs in pediatric patients has increased. However, continued efforts are required in this field so that drugs with proven clinical efficacy in pediatric patients become authorized for use in this population. Because of the lack of suitable commercial formulations for use in pediatric patients, preparation of formulations by the hospital pharmacist and the use of drug dilutions at the bedside are mandatory, both of which are a source of possible preparation and administration errors.

[Medication prescription and transcription errors in a neonatal unit]. / Errores en la prescripción y transcripción de medicación en una unidad neonatal.

BACKGROUND: Medication errors occur because of pitfalls in one or more of the steps involved in the process of drug administration and should be considered as system errors. They should never be considered as human errors with assignment of responsibility. Rather, their causes should be analyzed to prevent repetition. The ultimate aim should be to improve working procedures to avoid these errors. PATIENTS AND METHODS: A total of 122 prescriptions were prospectively analyzed, along with their corresponding transcription to the nursing notes. Their legibility, dose, units, route of administration, and administration interval were evaluated. Units per kilogram of body weight and the use of generic names were also recorded. RESULTS: Prescription errors were detected in 35.2 % of the prescriptions reviewed. The most frequent errors were related to dosing (16.4 %). Analysis of the quality of the prescriptions revealed that 61.5 % of the drugs were prescribed by their generic name, but only 4.1 % specified the dose per kilogram of body weight. Errors were detected in 21.3 % of transcriptions, the most frequent being the absence of the administration route (7.4 %). The generic name was used in 57.4 % of the transcriptions. CONCLUSIONS: In the busy and complex environment of neonatal units, medication errors can be frequent. However, most of these errors are trivial and do not harm patients. Medication errors are indicators of the quality of the healthcare provided. Therefore, their detection and systematic analysis of their causes can contribute to their systematic prevention, thus improving the healthcare delivery process.

Errores en la prescripción y transcripción de medicación en una unidad neonatal / Prescription and transcription errors in a neonatal unit

Antecedentes: Los errores de medicación se producen por fallos en los procesos de utilización de los medicamentos y se deben analizar como errores de sistema. Nunca se deben considerar como errores humanos y asignar responsabilidades, sino analizar sus causas para prevenir que los errores se repitan. El objetivo final debe ser la mejora de los procedimientos de trabajo para evitar que vuelvan a suceder. Pacientes y métodos: Se revisaron prospectivamente 122 prescripciones de medicamentos y sus correspondientes transcripciones a la hoja de enfermería, de recién nacidos ingresados en la unidad neonatal. Se valoró la legibilidad, dosificación, unidades, vía e intervalos de administración. Se registraron también la especificación de las unidades por kilogramo de peso y el uso de genéricos. Resultados: Se detectaron errores de prescripción en el 35,2 % de las revisadas, siendo los más frecuentes los de dosificación (16,4 %). En cuanto a la calidad de las prescripciones, el 61,5 % de los fármacos estaban prescritos con su nombre genérico y sólo en el 4,1 % de los casos se especificó la dosis por kilogramo de peso. Se detectó el 21,3 % de errores en las transcripciones. El error más frecuente fue la ausencia de vía de administración (7,4 %). La denominación genérica en las transcripciones se utilizó en el 57,4 % de los casos. Conclusiones: En las unidades neonatales, con ambientes de mucha carga y complejidad asistencial, los errores de medicación pueden suceder frecuentemente. Sin embargo, destacamos que la mayoría de ellos fueron triviales y no causando daño alguno a los pacientes. Los errores de medicación son indicadores de la calidad de la asistencia sanitaria, por lo que su detección, y el análisis de sus causas, puede ayudar a su prevención sistemática, mejorando así la calidad del proceso asistencial

Background: Medication errors occur because of pitfalls in one or more of the steps involved in the process of drug administration and should be considered as system errors. They should never be considered as human errors with assignment of responsibility. Rather, their causes should be analyzed to prevent repetition. The ultimate aim should be to improve working procedures to avoid these errors. Patients and methods: A total of 122 prescriptions were prospectively analyzed, along with their corresponding transcription to the nursing notes. Their legibility, dose, units, route of administration, and administration interval were evaluated. Units per kilogram of body weight and the use of generic names were also recorded. Results: Prescription errors were detected in 35.2 % of the prescriptions reviewed. The most frequent errors were related to dosing (16.4 %). Analysis of the quality of the prescriptions revealed that 61.5 % of the drugs were prescribed by their generic name, but only 4.1 % specified the dose per kilogram of body weight. Errors were detected in 21.3 % of transcriptions, the most frequent being the absence of the administration route (7.4 %). The generic name was used in 57.4 % of the transcriptions. Conclusions: In the busy and complex environment of neonatal units, medication errors can be frequent. However, most of these errors are trivial and do not harm patients. Medication errors are indicators of the quality of the healthcare provided. Therefore, their detection and systematic analysis of their causes can contribute to their systematic prevention, thus improving the healthcare delivery process

The transient expression of C-C chemokine receptor 8 in thymus identifies a thymocyte subset committed to become CD4+ single-positive T cells.

Developing T cells journey through the different thymic microenvironments while receiving signals that eventually will allow some of them to become mature naive T cells exported to the periphery. This maturation can be visualized by the phenotype of the developing cells. CCR8 is a ss-chemokine receptor preferentially expressed in the thymus. We have developed 8F4, an anti-mouse CCR8 mAb that is able to neutralize the ligand-induced activation of CCR8, and used it to characterize the CCR8 protein expression in the different thymocyte subsets. Taking into account the intrathymic lineage relationships, our data showed that CCR8 expression in thymus followed two transient waves along T cell maturation. The first one took place in CD4(-) CD8(-) double-negative thymocytes, which showed a low CCR8 expression, and the second wave occurred after TCR activation by the Ag-dependent positive selection in CD4(+) CD8(+) double-positive cells. From that maturation stage, CCR8 expression gradually increased as the CD4(+) cell differentiation proceeded, reaching a maximum at the CD4(+) CD8(-) single-positive stage. These CD4(+) cells expressing CCR8 were also CD69(high) CD62L(low) thymocytes, suggesting that they still needed to undergo some differentiation step before becoming functionally competent naive T cells ready to be exported from the thymus. Interestingly, no significant amounts of CCR8 protein were detectable in CD4(-) CD8(+) thymocytes. Our data showing a clear regulation of the CCR8 protein in thymus suggest a relevant role for CCR8 in this lymphoid organ, and identify CCR8 as a possible marker of thymocyte subsets recently committed to the CD4(+) lineage.

Down-regulation of the beta-chemokine receptor CCR6 in dendritic cells mediated by TNF-alpha and IL-4.

Chemokines are involved in the control of dendritic cell (DC) trafficking, which is critical for the immune response. We have generated DC from human umbilical cord blood CD34+ progenitors cultured with granulocyte-macrophage colony-stimulating factor, tumor necrosis factor alpha (TNF-alpha), and stem cell factor. Using an anti-CCR6 monoclonal antibody, we observed that these cells showed maximum expression of this beta-chemokine receptor when they were immature, as determined by their relatively low expression of several DC maturation markers such as CD1a, CD11c, CD14, CD40, CD80, and CD83. Immature DC responded strongly to macrophage inflammatory protein-3alpha (MIP-3alpha), the CCR6 ligand, in migration and calcium mobilization assays. CCR6 expression decreased in parallel with the DC maturation induced by prolonged TNF-alphaq treatments. Interleukin-4 was also able to decrease CCR6 protein levels. Our findings suggest that the MIP-3alpha/CCR6 interaction plays an important role in the trafficking of immature DC to chemokine production sites such as injured or inflamed peripheral tissues, where DC undergo maturation on contact with antigens.

Identification of CCR8 as the specific receptor for the human beta-chemokine I-309: cloning and molecular characterization of murine CCR8 as the receptor for TCA-3.

Chemokine receptor-like 1 (CKR-L1) was described recently as a putative seven-transmembrane human receptor with many of the structural features of chemokine receptors. To identify the ligand of CKR-L1, we have studied chemokine-induced calcium mobilization in 293 cells transfected with CKR-L1. Of 20 different chemokines tested, only I-309 was able to elicit a significant calcium mobilization. In addition, I-309 induced the transfectants to migrate in vitro. As expected for chemokine receptor-mediated effects, pertussis toxin, but not cholera toxin, inhibited both the calcium flux and migration of the CKR-L1 transfectants in response to I-309. All of these data support the conclusion that I-309 is a functional ligand for CKR-L1. According to the current chemokine receptor nomenclature, we have designated this gene as CCR8. The murine CCR8 (mCCR8) gene was cloned, and its predicted amino acid sequence showed a 71% identity with that of human CCR8. As human CCR8, mCCR8 is expressed in thymus. Both I-309 and its murine homologue TCA-3 were able to induce calcium mobilization in transiently transfected 293-EBNA cells expressing mCCR8. The affinity of the binding of 125I-labeled TCA-3 to mCCR8 was high (Kd approximately 2 nM); the binding was prevented completely by an excess of cold TCA-3, and only partially competed (40%) by I-309. The identification of I-309 and TCA-3 as the functional ligands for CCR8 receptors will help to unravel the role of these proteins in physiologic and pathologic situations.

[Pulmonary mechanism in preterm neonates without respiratory problems]. / Estudio de la mecánica pulmonar en recién nacidos pretérmino sin problemas respiratorios.

Pulmonary function was measured by computerized pneumotacography in 26 preterm-newborn infants without respiratory problems. Mean (+/- SD) for birth weight, gestation and postnatal age were 2,034 +/- 412 g, 34.1 +/- 1.7 weeks, and 2.2 +/- 1.6 days, respectively. An esophageal balloon, a differential transducer and nasal prongs were used to measure pressure and flow. The following parameters were measured in each respiration by the mean squares method: Dynamic compliance (Cdyn), total respiratory resistance (RRt) and work (WRt), respiratory time constant (KTt), rate (f) and maximal inspiratory and expiratory flows (PIF, PEF). Replication of the method was found to be good, as the differences between two determinations were not significant (p less than 0.05). The mean differences were less than 6.26%. The mean (+/- SD) and the 3rd and 97th percentiles for each parameter were the following: f: 52 +/- 7 (39-66) r.p.m., Tv: 6.6 +/- 1.1 (4.5-8.7) ml/kg, Vmin: 342 +/- 82 (128-502) ml/min, Cdin: 3.7 +/- 1.1 (1.5-6) ml/cm, RRt: 83 +/- 47 (37-204) cm/L/sec, TRt: 27 +/- 15 (2-57.1) g/cm/kg, PIF: 2.2 +/- 0.5 (1.1-3.2) L/min and PEF: 1.9 +/- 0.6 (0.7-3) L/min.

Association between ocular pressure and certain health parameters.

Intraocular pressure (IOP) was measured in a mixed population of 12,803 apparently healthy employed people. Mean IOP was 13.5 +/- 3.3 mmHg, without sex difference. Frequency distribution demonstrated skewness towards high values. IOP weakly correlated with age (R = 0.06), and older subgroups showed more marked skewness, but further analysis showed this effect to be spurious. The correlations of IOP with heart rate and with systolic blood pressure were small, but stronger than with age (R = .16 and .15, respectively). Moreover, when corrected for heart rate, the effect of age was nullified. Other factors found to be correlated with IOP included blood glucose and hemoglobin concentration, smoking, and height. None of these factors significantly increased the correlation between IOP and heart rate or blood pressure, and the skewness was not fully explained by any of these factors or their combinations. The value of the epidemiologic approach to detection of factors responsible for ocular hypertension is stressed.