Manejo nutricional de ascitis quilosa: Serie de casos y revisión de la literatura

RESUMEN Las ascitis quilosa (AQ) es una entidad poco común producida por el acúmulo de linfa en la cavidad peritoneal. Su incidencia se describe en aumento progresivo, asociándose a una mortalidad de 40-70%. Se incluyeron 3 pacientes con diagnóstico de AQ evaluados en la visita de asistencia nutricional del Hospital Clínico de la Universidad Católica (UC) durante el año 2019. Caso 1: Paciente mujer de 47 años, consulta por dolor abdominal agudo realizándose apendicectomía. Estudio de líquido peritoneal con triglicéridos (TG) de 1.362 mg/dL. Inicia Nutrición Parenteral Total (NPTC) progresando luego a régimen oral. Estudio no revela lesiones de vasos linfáticos ni otras causas. Caso 2: Paciente varón de 68 años con cirrosis por alcohol, Child Pugh B. Ingresa por disnea y ascitis refractaria. Estudio de líquido ascítico y pleural, con TG de 439 mg/dL y 592 mg/dL respectivamente. Se manejó con toracocentesis y paracentesis evacuadoras, tratamiento con régimen hipograso y aporte de triglicéridos de cadena media (MCT) vía oral. Evolución tórpida requiriendo apoyo con NPTC, realizándose drenajes sucesivos, por lo que se instala TIPS. Caso 3: Paciente mujer de 63 años consulta por dolor hipogástrico con masa palpable subcostal derecha. Estudio confirma masa pancreática por lo que se realiza Whipple. Reingresa por náuseas y vómitos profusos, evidenciándose líquido ascítico con TG de 251 mg/dl. Se inicia NPTC, escasos débitos del drenaje iniciándose realimentación progresiva por vía oral. El análisis del líquido tras la paracentesis establece el diagnóstico de AQ pues la clínica es inespecífica. Las principales complicaciones están dadas por la pérdida de quilo: desnutrición, infecciones y sepsis. Las opciones de tratamiento incluyen: medidas dietéticas, fármacos e intervenciones percutáneas o quirúrgicas; siempre orientadas al alivio sintomático, con foco en tratar la causa. Si la tolerancia oral es óptima la primera medida es la supresión de la grasa y la suplementación con MCT para evitar déficit energético. Con el empleo de estas medidas se ha reportado el cierre espontáneo de fístulas y/o defectos de vasos linfáticos en un 75%-80%. Se concluye que no hay guías de recomendación y los estudios se basan en series de pocos casos clínicos. La ascitis quilosa es una entidad patológica rara, que representa una situación clínica crítica con consecuencias inmunológicas y nutricionales; y el tratamiento debe ser etiológico y el paso clave inicial es optimizar el estado nutricional del paciente.

ABSTRACT Chylous ascites (CA) is an uncommon entity caused by the accumulation of lymph in the peritoneal cavity, its incidence has been gradually increasing; being associated with a mortality of 40-70%. This work includes 3 patients with CA diagnosis evaluated by the Nutritional Assistance team in the Hospital Clínico of the Universidad Católica, Chile during 2019. Case 1: 47-year-old female, with acute abdominal pain that resulted in an appendectomy. Peritoneal fluid study showed triglycerides (TG) of 1362 mg/dL. Total Parenteral Nutrition (TPN) was initiated with successive changes to an oral regimen. The case was negative for lymphatic vessel injuries or other causes of AQ. Case 2: 68-year-old male with alcoholic cirrhosis, Child-Pugh B. The patient was admitted for dyspnea and refractory ascites. Ascites and pleural fluid study showed TG of 439 mg/dL and 592 mg/dL, respectively, whichwas managed with thoracentesis and evacuating paracentesis, treatment with a low-fat regimen, and oral medium chain triglycerides (MCT). Case 2 had a poor evolution requiring TPN and successive evacuations, with TIPS installed. Case 3: A 63-year-old female patient with hypogastric pain and palpable right subcostal mass. Study confirmed a pancreatic tumor and Whipple Surgery was performed. Case 3 was readmitted for nausea and vomiting, showing ascitic fluid with TG of 251 mg/dl. TPN was started, with decrease in drainage fluids and successful progressive oral refeeding. The analysis of the paracentesis fluid established the diagnosis of CA since the symptoms were nonspecific. The main complications were due to the loss of chyle: malnutrition, infections and sepsis. Treatment options included: dietary measures, drugs, and percutaneous or surgical interventions; always oriented to symptomatic relief, focused on etiologic treatment. If oral tolerance is optimal, the first measure should be fat suppression and supplementation with MCT to avoid energy deficit. With the use of these measures, spontaneous closure of fistulas and / or lymphatic vessel defects has been reported in 75% -80% of patients. There are no recommendation guidelines for CA and studies are based on series of a few clinical cases. CA is a rare disease, representing a critical clinical situation with immunological and nutritional consequences. Etiologic treatment must be prioritized with a focus on optimization of the nutritional status of the patient

Machine Learning in Melanoma Diagnosis. Limitations About to be Overcome. / Uso del aprendizaje automático en el diagnóstico del melanoma. Limitaciones por superar.

BACKGROUND: Automated image classification is a promising branch of machine learning (ML) useful for skin cancer diagnosis, but little has been determined about its limitations for general usability in current clinical practice. OBJECTIVE: To determine limitations in the selection of skin cancer images for ML analysis, particularly in melanoma. METHODS: Retrospective cohort study design, including 2,849 consecutive high-quality dermoscopy images of skin tumors from 2010 to 2014, for evaluation by a ML system. Each dermoscopy image was assorted according to its eligibility for ML analysis. RESULTS: Of the 2,849 images chosen from our database, 968 (34%) met the inclusion criteria for analysis by the ML system. Only 64.7% of nevi and 36.6% of melanoma met the inclusion criteria. Of the 528 melanomas, 335 (63.4%) were excluded. An absence of normal surrounding skin (40.5% of all melanomas from our database) and absence of pigmentation (14.2%) were the most common reasons for exclusion from ML analysis. DISCUSSION: Only 36.6% of our melanomas were admissible for analysis by state-of-the-art ML systems. We conclude that future ML systems should be trained on larger datasets which include relevant non-ideal images from lesions evaluated in real clinical practice. Fortunately, many of these limitations are being overcome by the scientific community as recent works show.

CMOS based image cytometry for detection of phytoplankton in ballast water.

We introduce an image cytometer (I-CYT) for the analysis of phytoplankton in fresh and marine water environments. A linear quantification of cell numbers was observed covering several orders of magnitude using cultures of Tetraselmis and Nannochloropsis measured by autofluorescence in a laboratory environment. We assessed the functionality of the system outside the laboratory by phytoplankton quantification of samples taken from a marine water environment (Dutch Wadden Sea, The Netherlands) and a fresh water environment (Lake Ijssel, The Netherlands). The I-CYT was also employed to study the effects of two ballast water treatment systems (BWTS), based on chlorine electrolysis and UV sterilization, with the analysis including the vitality of the phytoplankton. For comparative study and benchmarking of the I-CYT, a standard flow cytometer was used. Our results prove a limit of detection (LOD) of 10 cells/ml with an accuracy between 0.7 and 0.5 log, and a correlation of 88.29% in quantification and 96.21% in vitality, with respect to the flow cytometry results.

An image cytometer based on angular spatial frequency processing and its validation for rapid detection and quantification of waterborne microorganisms.

We introduce a new image cytometer design for the detection of very small particulates and demonstrate its capability in water analysis. The device is a compact microscope composed of off-the-shelf components, such as a light emitting diode (LED) source, a complementary metal-oxide-semiconductor (CMOS) image sensor, and a specific combination of optical lenses that allow, through an appropriate software, Fourier transform processing of the sample volume. Waterborne microorganisms, such as Escherichia coli (E. coli), Legionella pneumophila (L. pneumophila) and phytoplankton, are detected by interrogating the volume sample either in a fluorescent or label-free mode, i.e. with or without fluorescein isothiocyanate (FITC) molecules attached to the micro-organisms, respectively. We achieve a sensitivity of 50 cells per ml, which can be further increased to 0.2 cells per ml by pre-concentrating an initial sample volume of 500 ml with an ad hoc fluidic system. We also prove the capability of the proposed image cytometer of differentiating microbiological populations by size with a resolution of 3 µm and operating in real contaminated water.

Ultra-fast quantum randomness generation by accelerated phase diffusion in a pulsed laser diode.

We demonstrate a high bit-rate quantum random number generator by interferometric detection of phase diffusion in a gain-switched DFB laser diode. Gain switching at few-GHz frequencies produces a train of bright pulses with nearly equal amplitudes and random phases. An unbalanced Mach-Zehnder interferometer is used to interfere subsequent pulses and thereby generate strong random-amplitude pulses, which are detected and digitized to produce a high-rate random bit string. Using established models of semiconductor laser field dynamics, we predict a regime of high visibility interference and nearly complete vacuum-fluctuation-induced phase diffusion between pulses. These are confirmed by measurement of pulse power statistics at the output of the interferometer. Using a 5.825 GHz excitation rate and 14-bit digitization, we observe 43 Gbps quantum randomness generation.

NMRbot: Python scripts enable high-throughput data collection on current Bruker BioSpin NMR spectrometers.

To facilitate the high-throughput acquisition of nuclear magnetic resonance (NMR) experimental data on large sets of samples, we have developed a simple and straightforward automated methodology that capitalizes on recent advances in Bruker BioSpin NMR spectrometer hardware and software. Given the daunting challenge for non-NMR experts to collect quality spectra, our goal was to increase user accessibility, provide customized functionality, and improve the consistency and reliability of resultant data. This methodology, NMRbot, is encoded in a set of scripts written in the Python programming language accessible within the Bruker BioSpin TopSpin™ software. NMRbot improves automated data acquisition and offers novel tools for use in optimizing experimental parameters on the fly. This automated procedure has been successfully implemented for investigations in metabolomics, small-molecule library profiling, and protein-ligand titrations on four Bruker BioSpin NMR spectrometers at the National Magnetic Resonance Facility at Madison. The investigators reported benefits from ease of setup, improved spectral quality, convenient customizations, and overall time savings.

Fast beam steering with full polarization control using a galvanometric optical scanner and polarization controller.

Optical beam steering is a key element in many industrial and scientific applications like in material processing, information technologies, medical imaging and laser display. Even though galvanometer-based scanners offer flexibility, speed and accuracy at a relatively low cost, they still lack the necessary control over the polarization required for certain applications. We report on the development of a polarization steerable system assembled with a fiber polarization controller and a galvanometric scanner, both controlled by a digital signal processor board. The system implements control of the polarization decoupled from the pointing direction through a feed-forward control scheme. This enables to direct optical beams to a desired direction without affecting its initial polarization state. When considering the full working field of view, we are able to compensate polarization angle errors larger than 0.2 rad, in a temporal window of less than ∼ 20 ms. Given the unification of components to fully control any polarization state while steering an optical beam, the proposed system is potentially integrable and robust.

True random numbers from amplified quantum vacuum.

Random numbers are essential for applications ranging from secure communications to numerical simulation and quantitative finance. Algorithms can rapidly produce pseudo-random outcomes, series of numbers that mimic most properties of true random numbers while quantum random number generators (QRNGs) exploit intrinsic quantum randomness to produce true random numbers. Single-photon QRNGs are conceptually simple but produce few random bits per detection. In contrast, vacuum fluctuations are a vast resource for QRNGs: they are broad-band and thus can encode many random bits per second. Direct recording of vacuum fluctuations is possible, but requires shot-noise-limited detectors, at the cost of bandwidth. We demonstrate efficient conversion of vacuum fluctuations to true random bits using optical amplification of vacuum and interferometry. Using commercially-available optical components we demonstrate a QRNG at a bit rate of 1.11 Gbps. The proposed scheme has the potential to be extended to 10 Gbps and even up to 100 Gbps by taking advantage of high speed modulation sources and detectors for optical fiber telecommunication devices.

Fast optical source for quantum key distribution based on semiconductor optical amplifiers.

A novel integrated optical source capable of emitting faint pulses with different polarization states and with different intensity levels at 100 MHz has been developed. The source relies on a single laser diode followed by four semiconductor optical amplifiers and thin film polarizers, connected through a fiber network. The use of a single laser ensures high level of indistinguishability in time and spectrum of the pulses for the four different polarizations and three different levels of intensity. The applicability of the source is demonstrated in the lab through a free space quantum key distribution experiment which makes use of the decoy state BB84 protocol. We achieved a lower bound secure key rate of the order of 3.64 Mbps and a quantum bit error ratio as low as 1.14×10⁻² while the lower bound secure key rate became 187 bps for an equivalent attenuation of 35 dB. To our knowledge, this is the fastest polarization encoded QKD system which has been reported so far. The performance, reduced size, low power consumption and the fact that the components used can be space qualified make the source particularly suitable for secure satellite communication.

Riesgo de complicaciones perinatales en embarazadas con periodontitis moderada y severa, en la ciudad de Córdoba. Argentina / Risk for adverse pregnancy outcome in a population with moderate and severe periodontal disease in Córdoba. Argentina

Objetivo: Evaluar en nuestro medio a las Periodontitis Moderadas a Severas (PM/S) en embarazadas como factores de riesgo de prematuridad (PP), ruptura prematura de membranas (RPM) y bajo peso al nacer (BPN). Método: Este estudio de cohorte, observacional y prospectivo involucró a 66 embarazadas en las semanas 24 a 30 de gestación, sin patologías sistémicas diagnosticadas, asistidas en dos hospitales universitarios de Maternidad y Neonatología de la ciudad de Córdoba, Argentina. Las pacientes fueron incorporadas al Grupo 1 ó de Cohorte expuesta al riesgo (CE) y Grupo 2 ó Cohorte no expuesta al riesgo (CNE) según presentaran o no PM/S en no menos de 4 sitios ubicados en diferentes cuadrantes de la boca. Fueron considerados los siguientes indicadores clínicos: índice de Placa Bacteriana (Pb); índice Gingival (IG); Profundidad de Sondaje (PS) y Nivel de Inserción Clínica (NIC) e"3 mm. Posteriormente, fueron recolectados los datos perinatales a partir de las historias clínicas de acuerdo con el sistema informático perinatal SIP (CLAP-OPS/OMS) y sometidos a los análisis estadísticos correspondientes. Resultados: Veintiún pacientes (n=21) conformaron el Grupo 1 ó CE; veintitrés mujeres (n=23) el Grupo 2 ó CNE y 22 embarazadas debieron ser excluidas por razones médicas. El 13.6 por ciento del total de pacientes, presentó su parto antes de las 37 semanas de gestación (PP). El Odds Ratio hallado para prematuridad fue de 6.06 (IC 95 por ciento; 5.86 - 7.76); para RPM, 2.8 (IC 95 por ciento; 1.81 - 4.39) y con respecto al BPN no se hallaron diferencias en la población estudiada. Conclusión: En la población analizada, las Periodontitis maternas moderadas a severas constituyen un verdadero factor de riesgo para PP y para RPM; por el contrario las mismas parecerían no tener influencia sobre los nacimientos de bajo peso.

Objectives: To evaluate moderate to severe Periodontitis (M/SP) in pregnant women as a risk factor for preterm birth (PTB), premature rupture of membranes (PROM) and low birth weight (LBW). Method: This observational and prospective cohort study involved 66 pregnant women between weeks 24 and 30 of gestation, without diagnosed systemic pathologies, attending at the Maternal and Neonatology University Hospital, Cordoba, Argentina. The patients were integrated into Group 1 or Cohort exposed to risk (CER) and Group 2 or Cohort not exposed to risk (CNER) according to whether they showed or not moderate to severe PD in no less than 4 points situated in different quadrants of the mouth. The following clinical indicators were considered: Dental Plaque Index (DP); Gingival index (GI); Periodontal Depth (PD) and Clinical Attachment Level (CALe"3 mm). Later, the perinatal data was collected from the medical records, according to the Perinatal informatic system, Latin American Center of Perinatology and Human Development-Panamerican Health Organization/WHO) and submitted to under proper statistical analyses. Results: Group 1 or CER comprised twenty-one patients (n=21); Group 2 or CNER comprised twenty-three women. 22 pregnant women had to be excluded due to medical reasons. 13.6 percent of the patients gave birth before the 37th week of gestation (PTB). The Odds Ratio for prematurity was 6.06 (CI 95 percent; 5.86 - 7.76); 2.8 for PROM (CI 95 percent; 1.81 - 4.39) and no differences were found concerning LBW among the population studied. Conclusion: In the population of patients studied, moderate to severe PD in pregnant women constitute a real risk factor for premature birth as well as for premature rupture of membranes; on the other hand, these diseases would not seem to affect low birth weight.

Influence of trial registration on reporting quality of randomized trials: study from highest ranked journals.

OBJECTIVE: To evaluate the reporting quality of key methodological items of randomized control trials (RCTs) in 55 of the highest ranked journals. STUDY DESIGN AND SETTING: A list of the highest top ranked journals was identified, and a search for detecting RCTs in those journals was made. Two hundred sixty four journals were screened and 55 of them were identified having at least one RCT. Three RCTs were randomly selected a priori from each journal; 148 RCTs were finally included. RCTs were assessed by two reviewers using the Consolidated Standards of Reporting Trials (CONSORT) statement. RESULTS: Only 11 (8%) RCTs had all items adequately reported. In addition, 36% of RCTs reported that the study was registered in any trial registry. We found a significant difference in the quality of reporting for baseline characteristics, recruitment, participant's flow, and randomization implementation between those studies having reported the registration of their RCT in a trial registry and those that have not. Adherence to key methodological items of the CONSORT statement was as follows: sample size determination (60%), sequence generation (49%), allocation concealment (40%), and blinding (25%). CONCLUSIONS: Reporting of varied CONSORT items remains suboptimal. Registration in a trial registry was associated with improved reporting. Further efforts to enhance RCT registration could contribute to this improvement.

Osteomalacia hipofosfatémica secundaria a sarcoma de muslo: caso clínico / Hypophosphatemic osteomalacia secondary to a sarcoma: report of one case

Tumor induced osteomalacia is uncommon and is characterized by an isolated and not PTH dependent reduction in tubular phosphate reabsorption. This alteration is produced by phosphaturic factors, such as fibroblast growth factor-23 (FGF-23) that are secreted by tumors. We report a 41 years old female presenting with joint pain and progressive loss of muscle strength in the lower limbs. Initial laboratory assessment showed hypophosphatemia, elevated alkaline phosphatases, normal intact parathormone levels, low levels of 25 hydroxy vitamin D and an elevated 24 h phosphaturia. Bone mineral density showed spine and femoral neck osteopenia. A positron emission tomography (PET) revealed a right thigh tumor with lung metastases. Its biopsy disclosed a fibrosarcoma. FGF-23 levels, measured by ELISA were markedly elevated. The patient was discharged with palliative measures.

[Animal mites transmissible to humans and associated zoonosis]. / Acarosis y zoonosis relacionadas.

Mites that affect animals (acariasis) can occasionally be transmitted to humans by incidental contact producing pruritus and dermatitis. Animals such as dogs, cats, mice, birds and reptiles, harbour several mite species. Hemophage mites and those that feed on lymph have the potential of transmitting important zoonotic agents (cuales??). The presence of lesions of unclear origin and a history of contact with pets or wild animals should alert towards the possibility of acariasis. Diagnosis is based on direct visualization of the mite,analysis of its morphology and obtaining information on the animal host. Awareness of these acarosis and the responsible care of pets and animals are the most relevant preventive measures.

Acarosis y zoonosis relacionadas / Animal mites transmissible to humans and associated zoonosis

Mites that affect animals (acariasis) can occasionally be transmitted to humans by incidental contact producing pruritus and dermatitis. Animals such as dogs, cats, mice, birds and reptiles, harbour several mite species. Hemophage mites and those that feed on lymph have the potential of transmitting important zoonotic agents (cuales??). The presence of lesions of unclear origin and a history of contact with pets or wild animals should alert towards the possibility of acariasis. Diagnosis is based on direct visualization of the mite,analysis of its morphology and obtaining information on the animal host. Awareness of these acarosis and the responsible care of pets and animals are the most relevant preventive measures.

Los ácaros de animales (acariasis) pueden transmitirse en forma accidental al hombre al estar en contacto con ellos, produciendo lesiones características (pápulas o vesículas) y ocasionando una dermatitis pruriginosa (acarosis). Existen diversas especies de ácaros, que se encuentran en perros, gatos, roedores, aves y reptiles. Los ácaros hematófagos o los que se alimentan de linfa tienen el potencial de transmitir importantes agentes zoonóticos. La presencia de lesiones sin una etiología clara y el antecedente de contacto con animales, tanto mascotas como animales silvestres, ayudan a plantear esta etiología. El diagnóstico se realiza con la visualización del acaro, morfología y tipo de hospedero animal. El conocimiento de estas acarosis y el control responsable de mascotas y animales, son las principales medidas de prevención.

Tratamiento y profilaxis de influenza estacional en niños / Treatment and prophylaxis of seasonal influenza in children

Influenza es una enfermedad respiratoria que produce una importante morbi-mortalidad. La prevención más importante es la vacuna anti-influenza. El tratamiento debe indicarse en las formas moderadas a graves, en niños con factores de riesgo e inmunosuprimidos. El tratamiento es efectivo si se inicia antes de las 48 horas del comienzo de los síntomas. Los inhibidores de la neuraminidasa como oseltamivir y zanamivir son efectivos e indicados para su uso en influenza en niños. Oseltamivir esta indicado a partir del año de edad y zanamivir en mayores de 7 años como tratamiento y mayores de 5 años como profilaxis. Ambos acortan los días de enfermedad, evitan la diseminación de la enfermedad y disminuyen complicaciones como la neumonía. En influenza B la eficacia es menor. La resistencia a estos agentes es baja.

Impacto de la infección por virus influenza en niños: costos, morbilidad y mortalidad asociada / The impact of influenza in children: costs, morbidity and mortality

La infección por virus influenza en niños tiene un alto impacto en términos de costos, morbilidad y mortalidad asociada. Las tasas más altas de infección se concentran en los niños menores de 2 años, especialmente en aquellos menores de 6 meses. Esta infección genera un importante número de consultas ambulatorias y es causa de frecuente de hospitalización en los menores 5 años durante cada temporada. Se reconoce, que los niños con factores de riesgo exhiben una mayor frecuencia de hospitalización y complicaciones respiratorias; mas aún, diversas publicaciones han sugerido que los niños son los principales transmisores de la enfermedad a otros grupos vulnerables. La infección por influenza traduce un ausentismo escolar y ausentismo laboral de sus padres o cuidadores, con importantes costos económicos.

Infección por Dipylidium caninum en un preescolar: presentación del caso y revisión de la literatura / Dipylidium caninum infection in a 2 year old infant: case report and literature review

Dipylidiasis is a zoonotic parasitic infection caused by the dog tapeworm Dipylidium caninum; it affects both feline and canine species and accidentally, humans. In Chile, as well as in other countries, it is an uncommon infection. A case of a 2 year old child from Casablanca, (a city located in the Valparaíso Región), with an infection by D. caninum, is presented. Clinical manifestations are reviewed, as well as epidemiology in domestic and wild animáis, cases among the published national literature and its treatment and prevention strategies.

La dipilidiasis es una zoonosis parasitaria provocada por Dipylidium caninum, teniasis que afecta a cánidos, félidos y, en forma accidental, al hombre. En Chile, al igual que en otros países, es una infección poco frecuente. Se presenta el caso de un preescolar con una infección por D. caninum, residente en la comuna de Casablanca, Región de Valparaíso. Se revisan las manifestaciones producidas por este agente, la epidemiología en animales domésticos y salvajes, los casos publicados en la literatura nacional, así como su tratamiento y las medidas de prevención.