Pars Planitis en la infancia / Pars Planitis in childhood

Objetivo: Evaluar la respuesta al tratamiento con corticoides e inmunomoduladores en niños con pars planitis. Materiales y método: Se realiza un estudio retrospectivo y observacional de nueve historias clínicas de pacientes con diagnóstico de pars planitis atendidos en el servicio de oftalmología del Hospital de Pediatría Juan P. Garrahan desde el año 2010. Resultados: De los nueve pacientes 6 eran niños y 3 niñas. El motivo de consulta principal fue disminución de la visión. La mayoría de los pacientes fueron derivados por otros oftalmólogos para tratamiento. El 100% sufrió afectación ocular bilateral. Las complicaciones fueron: catarata, queratopatía en banda, hipertensión ocular y edema macular cistoide. El 100% de los pacientes recibió tratamiento con corticoides por vía oral e inmunomoduladores. A algunos se les efectuó inyecciones de triamcinolona subtenoniana y criocoagulación. Conclusiones: con el tratamiento con prednisona e inmunomoduladores se logró mejoría en la agudeza visual en 15 ojos y 3 ojos mantuvieron igual agudeza visual. La pars planitis es una patología crónica con un pronóstico visual reservado que requiere de un seguimiento estrecho y tratamiento prolongado por parte de un equipo interdisciplinario (AU)

Objective: To assess response to steroid and immunomodulating treatment in children with pars planitis. Material and methods: A retrospective observational study was conducted reviewing nine clinical charts of children with a diagnosis of pars planitis seen at the Department of Ophthalmology of the Pediatric Hospital Juan P. Garrahan since 2010. Results: Of nine patients, six were boys and three were girls. Main complaint was loss of vision. The majority of patients were referred to our hospital by other ophthalmologists for treatment. All children had bilateral eye involvement. Complications observed were: cataracts, band keratopathy, ocular hypertension, and cystoid macular edema. All patients received oral steroids and immunomodulating treatment. In some subtenonian injection of triamcinolone and cryocoagulation was performed. Conclusions: Prednisone and immunomodulating treatment resulted in an improvement of visual acuity in 15 eyes and three eyes visual acuity remained unchanged. Pars planitis is a chronic disease with an uncertain visual prognosis that requires close follow-up and prolonged treatment by an interdisciplinary team (AU)

Síndrome del niño sacudido o Shaken Baby Syndrome: Lesiones oculares / Shaken Baby Syndrome: Eye lesions

Introducción: el síndrome del niño sacudido se incluye en la clasificación del maltrato físico. Las lesiones oculares se deben a la tracción producida sobre la retina a partir del vítreo del niño, fuertemente unido a ella, con desgarro de las capas retinales y colección de sangre en la cavidad resultante (retinosquisis hemorrágica). Objetivo: describir las manifestaciones oftalmológicas iniciales y la evolución del síndrome del bebé sacudido. Materiales y métodos: se realiza un estudio descriptivo y retrospectivo de cuatro pacientes con el síndrome del niño sacudido. Las variables analizadas son: sexo, edad, fondo de ojos, ecografía ocular, tratamiento y evolución visual. Resultados: los casos 1 y 2 eran gemelos, uno de ellos presentó manifestaciones a nivel del fondo de ojos y el segundo no, ambos requirieron intervención neuroquirúrgica. El tercero presentaba lesiones a nivel ocular con opacidad de medios por lo cual se le realizó en ambos ojos vitrectomía exploradora. El cuarto caso se trataba de una paciente de 6 meses con hemovítreo en ojo derecho y retinosquisis hemorrágica en ojo izquierdo, y requirió vitrectomía para la resolución del hemovítreo, aunque el resultado visual fue desfavorable. Conclusión: el examen oftalmológico contribuye al diagnóstico del síndrome del bebé sacudido por lo que es necesario en la evaluación de los niños pequeños que presenten lesiones sospechosas de abuso (AU)

Introduction: Shaken baby syndrome is included in the classification of physical abuse. Ocular lesions in the infant are due to traction to the retina from the adjacent vitreous causing with tears of the retinal layers and blood collection in the resulting cavity (hemorrhagic retinoschisis). Objective: To describe early ocular manifestations and outcome of shaken baby syndrome. Material and methods: A retrospective, descriptive study was conducted in four patients with shaken baby syndrome. Sex, age, ocular fundus, ultrasonography, treatment, and visual outcome were analyzed. Results: Cases 1 and 2 were twins, one of them presented with fundus manifestations, the other did not; both required neurosurgical intervention. The third infant had eye lesions with media opacities and therefore exploratory vitrectomy was performed in both eyes. The fourth was a 6-month-old baby girl with hemovitreous in the right and hemorrhagic retinoschisis in the left eye. She required vitrectomy to resolve the hemovitreous, but the result was poor. Conclusion: Ophthalmological examination was useful in the diagnosis of shaken baby syndrome and should therefore be performed in little children in whom child abuse is suspected (AU)

Aspectos epidemiológicos, diagnósticos y de tratamiento de la toxocariasis ocular / Epidemiological aspects, diagnosis, and treatment of ocular toxocariasis

Objetivo: Analizar la epidemiología, los métodos diagnósticos y los abordajes terapéuticos de la toxocariasis ocular en el Hospital de Pediatría Juan P. Garrahan. Materiales y métodos: Se realizó un estudio observacional y descriptivo en el Servicio de Oftalmología del Hospital de Pediatría J. P. Garrahan analizándose en forma retrospectiva los pacientes con ELISA positivo para IgG anti-Toxocara canis vistos en el laboratorio de Parasitología y evaluados en el servicio de Oftalmología entre enero 2006 a junio de 2013. Resultados: Se incluyeron en el estudio 301 pacientes de los cuales 95 (31,5%), presentaron diagnóstico de toxocariasis ocular (59 niños y 36 niñas) y 206 no tuvieron afección oftálmica por Toxocara canis. El 100% de los pacientes con afección ocular por el parásito presentó algún grado de alteración de la visión. Las formas de toxocariasis ocular que se registraron son: granuloma periférico aislado en 12 pacientes (12,6%), granuloma periférico con pliegue unido a papila en 36 (37,9%), granuloma de polo posterior en 7 (7,4%), endoftalmitis crónica en 3 (3,2%), neurorretinitis subaguda unilateral difusa en 2 (2,1%), desprendimiento de retina en 23 (24,2%) y en 12 (12,6%) forma indeterminada. Conclusiones: El diagnóstico de la toxocariasis ocular en la infancia tiende a hacerse en forma tardía ya que los niños pequeños no suelen manifestar a los padres la disminución visual de un ojo siendo el motivo de consulta más frecuente el estrabismo. El diagnóstico es clínico. La forma oftalmoscópica de presentación más frecuente en nuestro estudio fue el granuloma periférico con pliegue falciforme unido a papila. Oftalmoscopicamente la toxocariasis ocular puede presentarse de formas sumamente disímiles, lo cual hace dificultoso su diagnóstico y obliga a pensar siempre en éste en un niño que presenta inflamación intraocular unilateral. El uso de antiparasitarios en nuestros pacientes fue irregular (AU)

Objective: To assess the epidemiology, diagnostic methods, and treatment approach in ocular toxocariasis at the Pediatric Hospital Juan P. Garrahan. Material and methods: An observational descriptive study was conducted at the Department of Ophthalmology of the Pediatric Hospital Juan P. Garrahan. Patients with a positive ELISA for anti-Toxocara canis IgG seen at the laboratory of parasitology and evaluated at the Department of Ophthalmology between January 2006 and June 2013 were retrospectively analyzed. Results: 301 patients were included in the study of whom 95 (31.5%) had a diagnosis of ocular toxocariasis (59 boys and 36 girls) and in 206 the eyes were not affected by toxocariasis. All patients with ocular toxocariasis had some degree of visual impairment. The forms of ocular toxocariasis found were: isolated peripheral granuloma in 12 patients (12.6%), peripheral granuloma with the fold united to the papilla in 36 (37.9%), posterior pole granuloma in 7 (7.4%), chronic endophthalmitis 3 (3.2%), diffuse unilateral subacute neuroretinitis 2 (2.1%), retinal detachment in 23 (24.2%), and an indeterminate form in 12 (12.6%). Conclusions: The diagnosis of ocular toxocariasis in childhood is often late as children are not able to report vision loss to their parents. Strabism is the most common reason for consult. The diagnosis is clinical. The most frequent ophthalmoscopic presentation was peripheral granuloma with a falciform fold attached to the papilla. Ophthalmoscopically, ocular toxocariasis may present heterogeneously, resulting in a difficult diagnosis. The disease should always be suspected in a child with unilateral intraocular inflammation. The use of antiparasitic agents was variable in our patients (AU)

A rare case of necrotic thymoma.

The Authors report the case of a patient who underwent resection of a huge anterior mediastinal mass, revealing to be a necrotic thymoma. The patient had been previously submitted to surgical biopsies of the mass yielding non-diagnostic results due to extensive necrosis. A sternotomy was then performed to resect the mediastinal mass originating from the thymus, en-bloc with the mediastinal fat and the apparently infiltrated lung. Histopathology showed a possible cyst/thymoma in massive necrosis, not further definable; revision by a specialized experienced pathologist (J. Rosai) confirmed total mass necrosis and no lung infiltration, thus orientating diagnosis towards a necrotic thymoma and excluding a lymphoblastic lymphoma, with similar histopathological features but more frequent in children or characterized by neoplastic infiltration of surrounding lung. Total body computed tomography (CT) scan and fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/CT, show neither local recurrence, nor distant metastases two years after surgery. In case of anterior mediastinal mass with difficult histopathological diagnosis due to massive necrosis, the hypothesis of a necrotic thymoma should be considered. After radical removal prognosis is generally favourable and no adjuvant treatment is required.

Genital tract actinomycosis caused by Actimyces israëlii.

We report a case of actinomycosis caused by actinomyces israelii, related to the removal of intrauterine device (IUD). Diagnosing actinomycosis is difficult but should be considered in the event of any acute abdominal problems in a woman carrying an IUD. All abdominal organs may be affected. Even with a disseminated infection, the combination of appropriate antibiotic therapy (penicillin G) and surgery ensures a full recovery in most cases.

Cost analysis of fentanyl and remifentanil in coronary artery bypass graft surgery without cardiopulmonary bypass.

BACKGROUND: Opiates such as remifentanil have the potential to reduce time to extubation (TTE), shorten length of stay (LOS) and lower hospital costs, because of a short duration of action. However, the cost of remifentanil is approximately ten times higher than longer-acting opiates like fentanyl. OBJECTIVES: The objective of this analysis was to compare TTE, LOS and total hospital costs between patients who received remifentanil and fentanyl during off-pump bypass surgery. METHODS: The study was prospective and observational in design. Consecutive patients who underwent off-pump cardiac bypass surgery and received either remifentanil or fentanyl from September 1998 to August 1999 were screened for study entry. Patient bills and charges were converted to costs using hospital cost-to-charge ratios. The percent of patients' extubated in the operating room (OR), LOS and hospital costs were compared between the groups. RESULTS: The baseline demographics (age: 66 +/- 12 years mean +/- SD; female 36%) and intraoperative variables were similar between the remifentanil (n=39) and fentanyl (n=20) groups. Patients given remifentanil during surgery were significantly more likely to be extubated in the OR than patients given fentanyl (15 vs. 64%; P < 0.001). Mean LOS was similar in both groups (7.3 +/- 3.1 vs. 8.3 +/- 2.7 days; P=0.27). Patients who received remifentanil incurred lower pulmonary function testing ($0 +/- 0 vs. $34 +/- 103; P=0.045), recovery room ($31 +/- 40 vs. $65 +/- 33; P=0.002) and lower ward costs ($3973 +/- 1719 vs. $4808 +/- 1794; P=0.09) than patients who received fentanyl. Anesthesia costs were higher among patients who received remifentanil ($476 +/- 102 vs. $416 +/- 130; P=0.06). Medical and surgical supplies, OR, intensive care unit, laboratory, respiratory therapy, pharmacy, radiology and transfusion costs were similar between the two groups. The total cost was $15 272 +/- 5556 and $15 616 +/- 4169 in the remifentanil and fentanyl groups, respectively (P=0.81). CONCLUSION: Remifentanil, when used in off-pump bypass surgery, is associated with an increased likelihood of extubation in the OR. However, LOS and total hospital costs remain unchanged.

Pharmacokinetic comparison of omeprazole capsules and a simplified omeprazole suspension.

The pharmacokinetics of omeprazole delayed-release capsules and a simplified omeprazole suspension (SOS) were studied. Seven healthy volunteers randomly received either one 20-mg omeprazole delayed-release capsule or SOS (omeprazole 20 mg in 10 mL) for seven days before being crossed over to the opposite treatment for seven more days after a two-week washout period. On days 1 and 7, blood samples were drawn at intervals up to 360 minutes after drug administration. Plasma omeprazole concentrations were determined by a validated high-performance liquid chromatographic method, and pharmacokinetic values were determined. Area under the concentration-versus-time curve (AUC) from zero to six hours, AUC from time zero to infinity (AUC0-infinity), and maximum plasma concentration (Cmax) increased by 102%, 113%, and 85%, respectively, after seven days of treatment with the capsule. AUC0-infinity for SOS on day 1 was 58% of that for the capsule (p = 0.0141), and on day 7 it was 49% of that for the capsule (p = 0.0044). AUC0-infinity for SOS increased by 85% from day 1 to 7, but the difference was not significant. Cmax for SOS on day 1 was twice that for the capsule (p = 0.0014), but by day 7 the difference between the two formulations was negligible. Time to Cmax (tmax) for SOS on days 1 and 7 was shorter than for the capsule by 82% (p < 0.0001) and 70% (p < 0.0006), respectively. After one week of therapy, omeprazole absorption was faster and tmax was 70% shorter for SOS than for the capsule formulation, but AUC0-infinity was 49% lower for SOS.

Stability of extemporaneously prepared sterile testosterone solution in 0.9% sodium chloride solution large-volume parenterals in plastic bags.

The stability of extemporaneously compounded testosterone sterile solution in large-volume parenterals (LVPs) in plastic bags containing 0.9% sodium chloride solution was evaluated. Two LVPs were prepared; one remained at room temperature and the other was refrigerated. Samples were withdrawn and frozen at 0, 1, 3, 6, 9 and 24 hours. The concentrations of the samples at each time point were determined using a specific radioimmunoassay. Stability was defined as 90% or greater of the original concentration remaining. No color change was observed at any time during hte study. Inravenous testosterone solutions compounded extemporaneously in 0.9% sodium chloride solution containing LVPs in plastic bags were stable for nine hours at 5 deg C but were unstable at 24 deg C after only one hour.

Stability of omeprazole in an extemporaneously prepared oral liquid.

The stability of omeprazole 2 mg/mL. in an extemporaneously prepared oral liquid was studied. The contents of five 20-mg omeprazole capsules were mixed with 50 mL of 8.4% sodium bicarbonate solution in a Luer-Lok syringe. Three vials of this liquid were prepared for storage at 24, 5, and -20 degrees C. A 3-mL. sample of each was taken initially and on days 1, 2, 3, 4, 6, 8, 10, 12, 14, 18, 22, 26, and 30 and assayed by high-performance liquid chromatography. The liquids stored at 5 degrees C and at -20 degrees C did not change color during the study period, but the color of the liquid stored at 24 degrees C changed from white to brown. There were no significant changes in the omeprazole concentrations of the liquids stored at 5 and -20 degrees C during the study period, but the omeprazole concentration of the liquid stored at 24 degrees C was < 90% of the initial concentration on day 18. Omeprazole 2 mg/mL in an oral liquid compounded extemporaneously from capsules and sodium bicarbonate injection was stable for up to 14 days at 24 degrees C and for up to 30 days at 5 and -20 degrees C.

Stability of granisetron hydrochloride in an extemporaneously prepared oral liquid.

The stability of granisetron 0.2 mg/mL (as the hydrochloride salt) in an extemporaneously prepared oral liquid was studied. Twelve 1-mg granisetron tablets were pulverized and suspended in 30 mL of distilled water. This mixture was then diluted with cherry syrup to produce a 60-mL oral liquid with a granisetron concentration of 0.2 mg/mL. Half of the preparation was stored at 5 degrees C, and half was stored at 24 degrees C. Samples were taken on days 0, 1, 2, 3, 4, 6, 8, 10, 12, and 14 and assayed by high-performance liquid chromatography. There was no change in the liquid's color, consistency, or pH, and the concentrations of granisetron ranged from 97% to 104% of initial concentration during the 14 days at 5 and 24 degrees C. Granisetron 0.2 mg/mL (as the hydrochloride salt) in an extemporaneously prepared oral liquid was stable for up to 14 days.

Formulaic methods of estimating calorie requirements in mechanically ventilated obese patients: a reappraisal.

A variety of formulae are used by clinicians to estimate calorie requirements in hospitalized obese patients. Many of these formulae have been validated by determining their correlation to calorie requirements as determined by indirect calorimetry (IC). The use of correlation coefficients (CC) in this manner may be misleading. A more appropriate statistical methods, limits of agreement (LA), for comparing clinical measurements has recently been described by Bland and Altman. We obtained a total of 188 IC measurements on 113 obese (> 120% IBW), mechanically ventilated patients. These were compared by CC and LA to seven formulaic methods of determining calorie requirements. All formulae correlate significantly with IC. Analysis by LA indicated acceptable bias in several formulae (eg, 21 kcal/kg, Ireton-Jones obese patients (IJ), Ireton-Jones ventilatory patients, (VEE); however, the uniform lack of precision demonstrated by all formulae renders their clinical utility questionable.

Stability of famotidine in an extemporaneously prepared oral liquid.

The stability of famotidine in an extemporaneously prepared oral liquid stored at 4 and 24 degrees C for 30 days was studied. Famotidine liquid was prepared by pulverizing and suspending 12 40-mg tablets in distilled water. This mixture was diluted with cherry syrup to a total volume of 60 mL, resulting in a famotidine concentration of 8 mg/mL. The liquid was divided into two 30-mL amber glass bottles and stored at 4 degrees C and at room temperature (24 degrees C). Samples from each of the two bottles were assayed for famotidine content by high-performance liquid chromatography. Each sample was assayed in duplicate at time 0 and on days 2, 5, 10, 15, 20, 25 and 30. The concentration of famotidine remained above 90% of original concentration for 20 days at 4 degrees C and for 15 days at room temperature. After 30 days, famotidine concentration was reduced by 15% and 24% at 4 degrees C and room temperature respectively. Famotidine liquid 8 mg/mL compounded extemporaneously from tablets was stable for 20 days at 4 degrees C and for 15 days at 24 degrees C.

Strategy for developing a safe and cost-effective H2-receptor antagonist program.

The pharmacy staff of a community tertiary-care hospital evaluated efficacy and safety before addressing cost considerations in the transition to a capitation program with cimetidine as the preferred H2-receptor antagonist. Safety concerns were resolved by permitting the use of an alternative drug certain patients considered to be at high risk. Despite initial resistance to mandatory participation in the program, the physician and nursing staffs have grown supportive, and the annual cost savings, which include the costs of labor and supplies as well as acquisition, have been substantial.

A historical perspective and review of the safety of lipid emulsion in pregnancy.

Total parenteral nutrition for pregnant patients is essential to maintain or restore optimal nutritional status for both the mother and fetus when adequate protein and caloric intake by the oral or enteral route is not feasible. This report reviews the safety of intravenous lipid emulsions in total parenteral nutrition programs for pregnant patients. Controversy regarding the adverse effects of intravenous lipid emulsion when administered to pregnant patients is based on early reports of the use of cottonseed oil lipid emulsions. The adverse effects reported included infarction of the placenta, ketonemia, increased myometrial activity, and induction of labor. In 32 subsequent case reports in which soybean oil- or soybean/safflower oil-based emulsions were used in total parenteral nutrition programs for pregnant patients, there was no relationship apparent between onset of labor and harmful maternal or fetal effects associated with the administration of lipid emulsion. It appears that the currently available soybean and soybean/safflower lipid-based emulsions can be safely administered to pregnant patients.