Postpartum Bilateral Tension Pneumothoraces.

We report the first case report of postpartum bilateral tension pneumothoraces. A 31-year-old primigravida presented with obstructive shock and respiratory failure five days following a normal spontaneous vaginal delivery. Bilateral surgical chest drains were inserted and following computed tomography suggestive of an underlying interstitial lung disease she was transferred to a tertiary cardiothoracic centre. Video-assisted thoracic surgery was carried out with left apicectomy and parietal pleurectomy. Histopathology supported a diagnosis of pulmonary lymphangioleiomyomatosis. We discuss the pathophysiology of labour-induced barotrauma and examine pertinent elements of the acute management of this case.

Effectiveness of high-flow nasal oxygen therapy in management of acute hypoxemic and hypercapnic respiratory failure.

BACKGROUND: High-flow nasal oxygen therapy (HFNOT) therapy has been increasingly used in patients with acute hypoxemic (Type I) respiratory failure (RF). Meanwhile indications and clinical effectiveness of HFNOT in patients with hypercapnic (Type II) RF remain controversial. The aim of our study was to evaluate the outcomes of primary HFTNOT in patients with hypoxemic and hypercapnic RF. MATERIALS AND METHODS: We conducted a retrospective observational study of patients diagnosed with severe community acquired pneumonia (CAP), who required HFNC oxygen therapy for hypoxemia. Primary end-point was intubation or escalation to NIV rate after HFNOT. The secondary endpoint was the 30-day mortality after an admission regardless of the cause. RESULTS: Analysis was conducted on all 51 (n = 51) patients. Of these, 32 (63%) were diagnosed with Type I RF and 19 (37%) with Type II RF. The partial pressure of arterial carbon dioxide (PaCO2) in Type I RF patients was 34.05 mmHg at admission and decreased to 33.07 mmHg after 1 hour of HFNOT. In patients with Type II RF PaCO2 decreased from 56.47 to 54.97 mmHg. In Type I RF successful outcome was achieved in 25 patients (78%) compared to 11 patients (58%) with Type II RF. Escalation was required in seven patients with Type I RF and eight patients in Type II group. There were no mortalities in our population group. CONCLUSIONS: Our data suggest that HFNOT can be effectively used in Type I and Type II RF. Clinicians should be cautious identifying patients at risk of escalation. A larger population group study is needed to identify predictors of HFNOT failure.

Metformin poisoning treated with high dose insulin dextrose therapy: a case series.

PURPOSE: We describe the compassionate use of high dose insulin dextrose (HID) for life threatening metformin associated lactic acidosis (MALA) in four patients admitted to intensive care. METHODS: Patients presenting with refractory lactic acidosis believed to be secondary to metformin poisoning were included.High dose insulin dextrose at 0.5units/kg/hour was infused in 50% dextrose. Frequent blood gas analysis allowed titration of therapy. All patients also received continuous veno-venous haemofiltration. RESULTS: All four patients recovered to normal or near normal lactate and pH between 10 and 24 hours of therapy. Two patients had significant separation in time between initiation of HID and haemofiltration to suggest an independent effect of HID on improving pH and lactate.All patients had at least one episode of hypoglycaemia below 4.0 mmol/L with the lowest glucose in any patient during therapy being 3.0 mmol/L. All episodes were corrected with a dextrose infusion without sequelae. CONCLUSIONS: Our study demonstrates that HID therapy appears to be safe in patients with suspected metformin poisoning. It also appears to work to drive down lactate, improve pH and patients' clinical condition. Further evidence is required to assess the effectiveness of HID therapy in the context of MALA.

Prevalencia de hiperandrogenismo y síndrome de ovario poliquístico en transexuales de mujer a hombre / Prevalence of hyperandrogenism and polycystic ovary syndrome in female to male transsexuals

INTRODUCCIÓN: La prevalencia de hiperandrogenismo (HA), que incluye el síndrome de ovario poliquístico (SOP), es alta en los pacientes transexuales de mujer a hombre (TMH). Este hecho se ha relacionado con el síndrome metabólico (SM), lo que parece aumentar la morbimortalidad cardiovascular a lo largo del tratamiento hormonal cruzado (THC). OBJETIVOS: Determinar la prevalencia de HA y SOP en pacientes TMH antes del inicio del THC, y su asociación con el SM y sus componentes, la insulinorresistencia (IR) y otros factores de riesgo cardiovascular (RCV). MATERIALES Y MÉTODOS: Setenta y siete TMH fueron valorados clínica y analíticamente para HA antes de iniciar el THC. También se determinaron los factores de RCV, la IR y otros parámetros del SM. RESULTADOS: La prevalencia de HA fue del 49,4% (el 73,7% de ellos con SOP [criterios de Rotterdam]), y del total de la muestra el 36,4% presentaron SOP. La prevalencia global de SM fue del 38,4 y 51,7% (criterios ATP-III e IDF, respectivamente). Los pacientes con HA frente a aquellos sin HA presentaban SM (criterios ATP-III e IDF, respectivamente) en el 36,8 y 57,9% frente al 25,6 y 41% (p < 0,0001 y p < 0,01, respectivamente). El 54,5% de los pacientes tenía normopeso (índice de masa corporal [IMC] 18,5-24,9 kg/m2), el 26% sobrepeso (IMC 25-29,9 kg/m2) y el 19,5% eran obesos (IMC ≥ 30 kg/m2). Al ajustar por el IMC la comparación de parámetros hormonales, metabólicos y antropométricos mostró diferencias estadísticamente significativas en los valores de glucemia, HOMA-IR y perímetro abdominal (p < 0,001), así como en los de colesterol-HDL (HDL) (p = 0,033), pero no en las concentraciones de testosterona total o de testosterona libre calculada. Del total de la muestra el 27,3% presentaron niveles de HDL por debajo de 50mg/dl. CONCLUSIONES: El HA y el SOP son muy prevalentes en la población TMH. HA y SOP se relacionan con el desarrollo temprano de SM, IR y otros factores de RCV, de consecuencias desconocidas en la edad adulta

INTRODUCTION: Prevalence of hyperandrogenism (HA), including the polycystic ovary syndrome (PCOS), in female-to-male transsexuals (FMT) is high. This has been related to metabolic syndrome (MS), which appears to increase cardiovascular morbidity and mortality throughout cross-sex hormone (CSH) therapy. OBJECTIVES: To assess the prevalence of HA and PCOS in FMT patients before the start of CSH therapy, and their association to MS and its components, insulin resistance (IR) and other cardiovascular risk (CVR) factors. MATERIALS AND METHODS: Seventy-seven FMTs underwent clinical and biochemical assessment for HA before the start of CSH therapy. CVR, IR, and other MS parameters were also assessed. RESULTS: Prevalence of HA was 49.4% (73.7% were cases of PCOS [Rotterdam criteria]), and prevalence of PCOS in the overall sample was 36.4%. Prevalence of MS was 38.4% and 51.7% according to ATP-III and IDF criteria respectively). MS (according to ATP-III and IDF criteria respectively) was found in 36.8% and 57.9% as compared to 25.6% and 41% of patients with and without HA respectively (p < 0.0001 and P < 0.01 respectively). Of total patients, 54.5% had normal weight (body mass index [BMI] 18.5-24.9 kg.m-2), 26% were overweight (BMI 25-29.9 kg.m-2), and 19.5% were obese (BMI ≥ 30 kg.m-2). After adjusting for BMI, the comparison of hormonal, metabolic, and anthropometric parameters showed statistically significant differences in plasma glucose, HOMA-IR, and abdominal circumference (P < 0.001 for all), as well as HDL cholesterol (HDL) (P = 0.033), but not in total testosterone or calculated free testosterone levels. In the total sample, 27.3% had HDL levels less than 50mg/dL. CONCLUSIONS: Overall HA, and PCOS in particular, are highly prevalent in FMTs. HA and PCOS are related to early development of SM, IR, and other CVR factors with unknown consequences in adulthood

Prevalence of hyperandrogenism and polycystic ovary syndrome in female to male transsexuals.

INTRODUCTION: Prevalence of hyperandrogenism (HA), including the polycystic ovary syndrome (PCOS), in female-to-male transsexuals (FMT) is high. This has been related to metabolic syndrome (MS), which appears to increase cardiovascular morbidity and mortality throughout cross-sex hormone (CSH) therapy. OBJECTIVES: To assess the prevalence of HA and PCOS in FMT patients before the start of CSH therapy, and their association to MS and its components, insulin resistance (IR) and other cardiovascular risk (CVR) factors. MATERIALS AND METHODS: Seventy-seven FMTs underwent clinical and biochemical assessment for HA before the start of CSH therapy. CVR, IR, and other MS parameters were also assessed. RESULTS: Prevalence of HA was 49.4% (73.7% were cases of PCOS [Rotterdam criteria]), and prevalence of PCOS in the overall sample was 36.4%. Prevalence of MS was 38.4% and 51.7% according to ATP-III and IDF criteria respectively). MS (according to ATP-III and IDF criteria respectively) was found in 36.8% and 57.9% as compared to 25.6% and 41% of patients with and without HA respectively (p<0.0001 and P<0.01 respectively). Of total patients, 54.5% had normal weight (body mass index [BMI] 18.5-24.9 kg.m(-2)), 26% were overweight (BMI 25-29.9 kg.m(-2)), and 19.5% were obese (BMI ≥ 30 kg.m(-2)). After adjusting for BMI, the comparison of hormonal, metabolic, and anthropometric parameters showed statistically significant differences in plasma glucose, HOMA-IR, and abdominal circumference (P<0.001 for all), as well as HDL cholesterol (HDL) (P=0.033), but not in total testosterone or calculated free testosterone levels. In the total sample, 27.3% had HDL levels less than 50mg/dL. CONCLUSIONS: Overall HA, and PCOS in particular, are highly prevalent in FMTs. HA and PCOS are related to early development of SM, IR, and other CVR factors with unknown consequences in adulthood.

Chronic pericardial effusion secondary to a influenza virus A (H1N1)/2009 infection.

We report, to our knowledge, the first successful treatment of novel Influenza A (H1N1)/2009 chronic pericardial effusion in an adult. This patient presented on admission respiratory failure and cardiac tamponade which required non invasive ventilation and drainage. Pericardial fluid polymerase chain reaction sequences were positive for Influenza A (H1N1)/2009 virus. Any other etiologies were discarded. Recidivating pericardial effusion after medical treatment, firstly with Oseltamivir, and afterwards, with colchicine and corticosteroids during six months, was solved with pericardiectomy.

Hepatopathy-thrombocytopenia syndrome after actinomycin-D therapy: treatment with defibrotide.

We report a case of administration compassionate use defibrotide in a 13-year-old girl with Sinusoidal Obstructive Syndrome and thrombocytopenia, also known as Hepatopathy--Thrombocytopenia Syndrome (HTS) during chemotherapy for Wilms' tumor.

The metabolic syndrome. Uncertain criteria.

The metabolic syndrome was defined with the aim of clustering several risk factors of cardiovascular disease present in some patients. Due to its high prevalence, different organizations have tried to simplify the diagnosis of this entity proposing practical, evidence based and applicable criteria. This effort of simplifying is being unworthy because of multiple errors published in recent articles (wrong cut-off points, incomplete figures, etc.). We remark with this editorial comment the challenge of universalising these criteria in order to prevent errors.