Uso de concentrados de fibrinógeno para el tratamiento de la hipofibrinogenemia adquirida / Use of Fibrinogen Concentrates for the Treatment of Acquired Hypofibrinogenemia

Resumen Introducción: Un adecuado manejo del sangrado debe incluir la correcta valoración y eventual reposición de fibrinógeno. Las fuentes tradicionales de este elemento hemostático incluyen el plasma fresco congelado y los crioprecipitados. Los concentrados liofilizados de fibrinógeno humano (CFH) son una alternativa terapéutica novedosa en el mercado chileno. Objetivo: Este estudio describe el curso clínico de los primeros pacientes en nuestra institución requirentes de CFH, dentro de un algoritmo de reposición hemostática por metas. Materiales y Método: Serie de pacientes con hipofibrinogenemia secundaria a sangrado perioperatorio severo, en los que se utilizó CFH como método de reposición de fibrinógeno. Se utilizó tromboelastometría para definir dosis. Se registraron variables demográficas, operatorias, complicaciones y seguimiento hasta los 3 meses. Resultados: Se utilizaron CFH en 18 pacientes. La mediana de edad fue 40,7 (56,5-63) años y dos tercios de los pacientes fueron de sexo masculino. Fallecieron 5 pacientes de la serie. Todos los pacientes requirieron manejo posoperatorio en una unidad de cuidados intensivos. Ocho pacientes fueron sometidos a cirugía cardiaca. El uso de hemocomponentes y concentrados liofilizados fue heterogéneo, pero en todos los casos su uso fue determinado por tromboelastometría. Ningún paciente fue reintervenido a causa de sangrado posoperatorio. Conclusión: El uso de concentrados de fibrinógeno humano dentro de un algoritmo de manejo de sangrado guiado por tromboelastometría, es un recurso hemostático factible en la realidad nacional. El impacto clínico de esta intervención requiere una subsiguiente evaluación basada en la evidencia.

Introduction: An adequate bleeding management should include a proper assessment of fibrinogen values and consequent replacement. Traditional sources for this hemostatic element include fresh frozen plasma and cryoprecipitates. Lyophilized human fibrinogen concentrates are a novel therapeutic alternative for the chilean market. Aim: This study aims to describe the clinical course of the first patients in our institution receiving fibrinogen concentrates, included in a goal directed hemostatic management algorithm. Materials and Method: Case series of patients with hypofibrinogenemia secondary to severe perioperative bleeding, in which fibrinogen concentrate was used for fibrinogen replacement. Thromboelastometry was used to define dose regimens. Demographic and surgical variables, complications and follow-up up to 3 months were registered. Results: Fibrinogen concentrate was used in 18 patients. Median age was 40.7 (56.5-63) years, and two thirds of the patients were male. Five patients died. All of the cases required postoperative intensive care. Eight patients underwent cardiac surgery. There was a heterogenic use of blood derived products and lyophilized concentrates, but in all cases its use was guided by thromboelastometry. No patients needed a secondary exploration due to bleeding. Conclusion: The use of human fibrinogen concentrate included in a bleeding management algorithm is a feasible hemostatic resource in the chilean current situation. The clinical impact of this intervention requires further evidence-based evaluation.

Ionic liquids as solvents for Cerenkov counting and the effect of a wavelength shifter.

We study the wavelength shift of the Cerenkov light - generated in the ionic liquid (BMIMCl) - caused by the addition of the highly fluorescent ionic liquid (BMIMHPTS). 18F and 32P efficiencies increases up to 124% and 14%, respectively, compared with the values obtained with pure BMIMCl. With this improvement, ionic liquid mixtures become a good alternative - when using the TDCR-Cherenkov technique - to standardize radionuclides having electron emissions energies close to the threshold energy in water (∼ 260keV). As an advantage compared with other solvents, the Ionic liquid mixture can be reused, in the case of short-lived radionuclides, by simply removing all water content in a vacuum oven.

Penectomía parcial y reconstrucción peneana. Manejo quirúrgico inicial del cáncer de pene localizado / Partial Penectomy and Penile Reconstruction. Initial Surgical Management of Localized Penile Cancer

Introducción: La cirugía para el cáncer de pene (CP) es mutilante y afecta significativamente la calidad de vida de los pacientes. Mostramos nuestra experiencia en reconstrucción peneana (RP) y proponemos el manejo reconstructivo simultáneamente con el oncológico. Materiales y métodos: Se registraron todos los pacientes llevados a RP en 4 hospitales universitarios de Colombia por el mismo cirujano (JPN), desde 2007 hasta abril de 2012. Las variables analizadas fueron: indicación de la reconstrucción, estado oncológico del paciente, técnica quirúrgica y seguimiento. Se documentó fotográficamente cada caso. Resultados: Se realizaron 15 RP, edad promedio 49 años y seguimiento promedio 15 meses. En 12 pacientes se hizo el procedimiento oncológico y la reconstrucción simultáneamente, 4 con desepitelización (resurfacing) del glande, 2 con glandectomía y 6 con penectomía parcial; los 3 restantes tenían penectomía previa. Todos los injertos fueron de piel de espesor parcial y el sitio donante la cara externa de la cadera. Hubo 2 complicaciones relacionadas con la reconstrucción, una estrechez del meato uretral y otro caso con isquemia en el 30% del injerto. En 3 pacientes se encontró enfermedad ganglionar desde el diagnóstico inicial y en 2 durante el seguimiento; ninguno ha tenido recaída local y uno murió por su enfermedad de base. Los demás han reportado calidad de vida adecuada con buenos resultados cosméticos y funcionales. Conclusiones: La reconstrucción del pene debe ser propuesta simultáneamente con la penectomía parcial y en un mismo tiempo quirúrgico

Introduction: Surgical management for penile carcinoma is mutilating and affects significantly quality of life. Hereby we present our experience on penile reconstruction (PR) immediately after oncologic resection. Materials and methods: We included all patients from January 2007 until April 2012 who underwent PR after partial penectomy (PP). Patients included in the study were seen at four different hospitals. All procedures were done by the same surgeon. Information included were: oncological status at the moment of surgery, surgical technique used for reconstruction. Each case was also registered photographically. On follow-up visits data about outcome and patient's satisfaction were registered. Results: During the study period 15 patients underwent PR. Average age at the moment of surgery was 49 years. Average follow-up was 15 months. In 12 patients PR was made at the same time as PP. Of those, four cases underwent glans resurfacing, 2 glandectomy, 6 partial penectomy, and the remaining 3 have had PP in a different time in the past. Every case underwent a split thickness graft procedure. Only 2 patients had postoperative complications. One of them presented urethral stricture and the other had graft ischemia. Three patients had positive nodes at the moment of PP and two during the follow-up. None of the cases have presented local recurrence and only one died. On follow-up the remaining patients refer a good quality of life and felt happy with esthetic results. Conclusions: Given the results presented hereby we propose that PR must be part of the same procedure as the PP

Partial penectomy and penile reconstruction. Initial surgical management of localized penile cancer.

INTRODUCTION: Surgical management for penile carcinoma is mutilating and affects significantly quality of life. Hereby we present our experience on penile reconstruction (PR) immediately after oncologic resection. MATERIALS AND METHODS: We included all patients from January 2007 until April 2012 who underwent PR after partial penectomy (PP). Patients included in the study were seen at four different hospitals. All procedures were done by the same surgeon. Information included were: oncological status at the moment of surgery, surgical technique used for reconstruction. Each case was also registered photographically. On follow-up visits data about outcome and patient's satisfaction were registered. RESULTS: During the study period 15 patients underwent PR. Average age at the moment of surgery was 49 years. Average follow-up was 15 months. In 12 patients PR was made at the same time as PP. Of those, four cases underwent glans resurfacing, 2 glandectomy, 6 partial penectomy, and the remaining 3 have had PP in a different time in the past. Every case underwent a split thickness graft procedure. Only 2 patients had postoperative complications. One of them presented urethral stricture and the other graft ischemia. Three patients had positive nodes at the moment of PP and two during the follow-up. None of the cases have presented local recurrence and only one died. On follow-up the remaining patients refer a good quality of life and felt happy with aesthetic results. CONCLUSIONS: Given the results presented hereby we propose that PR must be part of the same procedure as the PP.

Interfacial magnetic coupling between Fe nanoparticles in Fe­Ag granular alloys.

The role of the interface in mediating interparticle magnetic interactions has been analysed in Fe50Ag50 and Fe55Ag45 granular thin films deposited by the pulsed laser deposition technique (PLD). These samples are composed of crystalline bcc Fe (2­4 nm) nanoparticles and fcc Ag (10­12 nm) nanoparticles, separated by an amorphous Fe50Ag50 interface, occupying around 20% of the sample volume, as determined by x-ray diffraction (XRD), x-ray absorption spectroscopy (XAS), and high resolution transmission electron microscopy (HRTEM). Interfacial magnetic coupling between Fe nanoparticles is studied by dc magnetization and x-ray magnetic circular dichroism (XMCD) measurements at the Fe K and Ag L2,3 edges. This paper reveals that these thin films present two magnetic transitions, at low and high temperatures, which are strongly related to the magnetic state of the amorphous interface, which acts as a barrier for interparticle magnetic coupling.

Flegmasia cerulea dolens: reporte de un caso y revisión de la literatura / Flegmasia cerulea dolens: case report and literature review

Phlegmasia Caerulea Dolens is a rare complication of deep vein thrombosis. It presents with a sudden onset of pain, swelling, discoloration and arterial compromise of the affected limb. There’s usually history of prothrombotic events such as malignancy, femoral vein catheterism, antiphospholipid syndrome, recent surgery, pregnancy, etc. Left without treatment, it can evolvein to gangrene, septic shock and death. Diagnosis usually only requires clinical appreciation.Confirmation can be done with ultrasonographic studies with doppler. Treatment can be both medical and surgically based. Medical therapy can be done with heparin and elevation of the affected limb or the use of thrombolytic, whilst surgical therapy can be either venous thrombectomy or amputation. We present the case of a 57-year old smoker, diabetic, and with systemic lupus erythematosus history female patient, that goes to the emergency room with sudden left leg pain, with cyanosis and absence of distal pulses. Besides she presented with lower respiratory symptoms. Diagnosis was confirmed with ultrasound and CT pulmonary angiography was performed showing pulmonary embolism. Medical treatment was initiated with good response.

[Fatal necrotizing fasciitis due to Serratia marcescens]. / Fascitis necrosante grave por Serratia marcescens: Reporte de un caso clínico.

An 81 year old female patient with chronic heart failure and atrial fibrillation receiving anticoagulant therapy, was admitted with progressive pain on her right leg for the past 24 hours, associated to local erythema, edema and warmth. The lesion evolved at the same site where she presented a chronic ulcer for the previous 5 months managed only with local care. At admission a necrotic plaque on the affected site was perceived; there was no hypotension or mental confusion but signs of a deep venous thrombosis on the involved leg were found. She was febrile (37.8 degrees C) and with tachychardia (126 per minute). Laboratory evaluation revealed normal white blood cell count and a subtherapheutic anticoagulant INR value. A chest x-ray showed infiltrates on the left lower lung lobe. On the following hours the lesion evolved with increasing pain, haemorrhagic bullae and a purulent discharge through the ulcer, with the patient developing mental deterioration, hypotension, respiratory failure and shock. The patient received intravenous ciprofloxacin and clindamycin and was operated 15 hours after admission performing an over-the knee amputation. A cardiac catheterization demonstrated a low cardiac output (2.3 L/min), and both a high systemic vascular resistance (2888 din.s.cm(-5)) and pulmonary capillary wedge pressure (17 cm H(2)0), results compatible with cardiogenic shock. Evolution was progressively worse and she died of multiple organic failure 36 hours after admission. Two blood culture samples grew Serratia marcescens. No necropsy was performed and cultures taken from the leg remained negative.

Fascitis necrosante grave por Serratia marcescens: Reporte de un caso clínico / Fatal necrotizing fasciitis due to Serratia marcescens

Una paciente de 81 años con insuficiencia cardíaca crónica, fibrilación auricular y tratamiento anticoagulante, ingresó por un cuadro fulminante de dolor y celulitis en la extremidad inferior derecha de 24 horas de evolución. Sobre la zona existía una úlcera crónica de cinco meses de evolución, manejada con curaciones locales. Al ingreso, había una placa necrótica pero sin hipotensión o confusión mental. La paciente estaba febril y con taquicardia (126 por min). La evaluación reveló ausencia de leucocitosis, trombosis venosa profunda en la misma pierna e infiltrados radiológicos pulmonares en el lóbulo inferior izquierdo. En las horas siguientes aumentó el dolor, apareció secreción purulenta por la úlcera y la paciente presentó confusión, hipotensión, falla respiratoria y luego shock. La paciente recibió ciprofloxacino endovenoso y clindamicina y fue intervenida a las 15 horas de ingreso, efectuándose una amputación supracondílea. El sondeo cardíaco demostró un gasto bajo (2,3 L/min) y una resistencia vascular sistémica (2888 din.s.cm"5) y presión capilar pulmonar elevada (17 cm H(2)0), cifras compatibles con un shock cardiogénico. Evolucionó en malas condiciones y falleció de falla orgánica múltiple a las 36 horas de ingreso. Los hemocultivos demostraron crecimiento de Serratia marcescens en dos frascos. No se efectuó una necropsia y los cultivos de la secreción de la úlcera fueron negativos.

An 81 year old female patient with chronic heart failure and atrial fibrillation receiving anticoagulant therapy, was admitted with progressive pain on her right leg for the past 24 hours, associated to local erythema, edema and warmth. The lesion evolved at the same site where she presented a chronic ulcer for the previous 5 months managed only with local care. At admission a necrotic plaque on the affected site was perceived; there was no hypotension or mental confusion but signs of a deep venous thrombosis on the involved leg were found. She was febrile (37.8°C) and with tachychardia (126 per minute). Laboratory evaluation revealed normal white blood cell count and a subtherapheutic anticoagulant INR value. A chest x-ray showed infiltrates on the left lower lung lobe. On the following hours the lesion evolved with increasing pain, haemorrhagic bullae and a purulent discharge through the ulcer, with the patient developing mental deterioration, hypotension, respiratory failure and shock. The patient received intravenous ciprofloxacin and clindamycin and was operated 15 hours after admission performing an over-the knee amputation. A cardiac catheterization demonstrated a low cardiac output (2.3 L/min), and both a high systemic vascular resistance (2888 din.s.cm"5) and pulmonary capillary wedge pressure (17 cm H(2)0), results compatible with cardiogenic shock. Evolution was progressively worse and she died of multiple organic failure 36 hours after admission. Two blood culture samples grew Serratia marcescens. No necropsy was performed and cultures taken from the leg remained negative.

Breathers and thermal relaxation as a temporal process: a possible way to detect breathers in experimental situations.

Breather stability and longevity in thermally relaxing nonlinear arrays is investigated under the scrutiny of the analysis and tools employed for time series and state reconstruction of a dynamical system. We briefly review the methods used in the analysis and characterize a breather in terms of the results obtained with such methods. Our present work focuses on spontaneously appearing breathers in thermal Fermi-Pasta-Ulam arrays but we believe that the conclusions are general enough to describe many other related situations; the particular case described in detail is presented as another example of systems where three incommensurable frequencies dominate their chaotic dynamics (reminiscent of the Ruelle-Takens scenario for the appearance of chaotic behavior in nonlinear systems). This characterization may also be of great help for the discovery of breathers in experimental situations where the temporal evolution of a local variable (like the site energy) is the only available/measured data.

Consolidation of sanitary landfills

En el uso de los rellenos sanitarios pueden presentar incovenientes relacionados con diferentes factores (climatológicos, geológicos, hidrogeológicos, u operativos), que pueden predecirse, utilizando un modelo que también sea útil para el diseño de futuros rellenos. En este estudio se analizan los efectos que la construcción y operación de uno de ellos tiene sobre los residuos sólidos y el suelo

Trauma ureteral penetrante: revision de 6 años de 90 casos consecutivos / Penetrating urethreral trauma: 90 consecutive cases

Nosotros revisamos 90 casos consecutivos de Trauma Ureteral Penetrante tratados en el Hospital Universitario San Vicente de Paúl de Medellín, durante el período de enero de 1981 a diciembre de 1986.Todos los niveles del uréter fueron comprometidos prácticamente en igual frecuencia. En 11 paciente la injuria fue desapercibida en el acto quirúrgico inicial, requiriendo reintervención. Complicaciones se presentaron en el 45 por ciento, principalmente fístulas ureterocutáneas (53 por ciento) y absceso urinoso (20 por ciento). Nefrectomía como manejo de complicaciones en 11 pacientes (13 por ciento). Enfatizamos la importancia del pronto reconocimiento de la lesión y el tratamiento quirúrgico adecuado; realizando desbridamiento, espatulación y ureteroureterostomía tutorizada. Técnicas de reimplante ureteral o ureteroneocistomía en lesiones de tercio distal. Recomendamos el uso de drenes de polietileno. Esta serie tiene el mayor número de casos de trauma ureteral penetrante hasta ahora reportado