Overdiagnosis of Septic Shock and Loss of Potential Donors of Corneal Tissue in the Hospital General de México Dr. Eduardo Liceaga.

At the Hospital General de México Dr. Eduardo Liceaga, a large number of potential donors of corneal tissue are discarded owing to various contraindications such as shock septic. The objective of this study is to determine the number of patients with postmortem diagnosis of septic shock and analyze whether there is an overdiagnosis of it. It is a cross-sectional and descriptive study in which 144 (n = 144) medical records were reviewed between January 2018 and May 2019 and where septic shock was identified within postmortem diagnoses. Exclusion criteria were age <2 or ≥75 years; infection due to human immunodeficiency virus, hepatitis B virus, or hepatitis C virus; active tuberculosis; neuroinfection; endocarditis; or cancer. The Sequential Organ Failure Assessment (SOFA) scale was calculated, and a descriptive analysis of the data was performed. According to the third international consensus for the definition of sepsis and septic shock (SEPSIS 3) using its SOFA diagnostic tool, 46 (32%) patients did not meet the criteria for septic shock because they did not require vasopressor nor had a lactate ≥ 18 mg/dL. These were potential donors of corneal tissue that were not considered as such; 35 of them met the diagnosis of sepsis with SOFA scores of ≥2 and the suspected or documented presence of infection. Eleven patients were not considered septic. It is important to train the hospital medical staff to properly diagnose septic shock, based on international consensus, and perform all the laboratory studies that allow doctors to calculate the SOFA to confirm or rule out the presence of septic shock.

Phenolics with Bactericidal Activity Alter Motility and Biofilm Formation in Enterotoxigenic, Enteropathogenic, and Enterohemorrhagic Escherichia coli.

Most Escherichia coli strains are innocuous to human beings; however, some strains can cause diarrhea and are grouped into pathotypes. Since current trends promote the use of natural-origin compounds to control bacteria, in this study, the effects of the phenolic compounds (PCs) tannic acid (TA), gallic acid (GA), methyl gallate (MG), and epigallocatechin gallate (EG) on the growth, swarming motility, biofilm formation, and expression of selected virulence genes of three E. coli pathotypes (enteropathogenic Escherichia coli [EPEC], enterohemorrhagic Escherichia coli [EHEC], and enterotoxigenic Escherichia coli [ETEC]) were evaluated. Minimum bactericidal concentrations (MBCs) were determined by using microtiter plates, and the effects of sublethal PC concentrations on swarming motility were evaluated on Luria-Bertani agar. Biofilm formation was assessed in microtiter plates via crystal violet staining, and the expression levels of genes involved in biofilm formation (flhC, fliA, fliC, and csgA) and swarming motility (csgD and cyaA) were evaluated via quantitative PCR. All PC were bactericidal with minimal bactericidal concentrations ranging from 0.07 to 2.1 mg/mL. At concentrations lower than the MBC, PCs decreased swarming motility (14.8-100%). GA reduced biofilm formation in all of the tested strains; however, TA, MG, and EG induced biofilm formation in some strains at specific concentrations. TA induced the overexpression of csgA, csgD, and cyaA, whereas the other PCs did not have any effects or reduced their expression levels. The PCs tested in this study showed potential to control E. coli strains belonging to the EHEC, ETEC, and EPEC pathotypes by affecting their growth, swarming motility, and virulence gene expression; however, proper concentrations must be used to avoid the induction of undesirable virulence factor genes.

Experiencia de una década en niños sometidos a esplenectomía en el Hospital Nacional de Niños / Experience on children's splenectomy: a ten year single center retrospective study

Resumen Objetivo: describir las características clínicas y la evolución de los pacientes sometidos a esplenectomía en el Hospital Nacional de Niños, de enero de 1996 a diciembre del 2006. Métodos: este es un estudio descriptivo retrospectivo que analiza un periodo de 10 años, de pacientes sometidos a esplenectomías en el Hospital Nacional se Niños. Se realizó una revisión de 107 expedientes con el diagnóstico en cuestión. De estos expedientes se obtuvieron: datos clínicos, epidemiológicos, indicaciones para el procedimiento y su respectiva evolución, complicaciones y mortalidad asociada. Se analiza además el seguimiento de las recomendaciones con respecto a profilaxis antibiótica y vacunación. Resultados: se analizó una muestra total de 107 casos. Entre los resultados se encontró que la edad promedio de intervención fue de 6,4 años. Los diagnósticos más comunes fueron hemoglobinopatías (59,8 %), púrpura trombocitopénica idiopática (16,8 %) y osteopetrosis maligna (8,4 %). Entre las indicaciones para esplenectomías predominaron el tratamiento de enfermedad de base (39,9%), hiperesplenismo (26,2 %) y ausencia de respuesta al tratamiento médico (22,4 %). El procedimiento quirúrgico más común fue la laparotomía en el 87,9 % de los casos. La complicación quirúrgica inmediata más frecuente fue la hemorragia persistente (3,7 %), mientras que la complicación quirúrgica tardía más común fue la sepsis (16,8 %). La respuesta terapéutica en la mayoría de los pacientes fue completa (66,7 %). Hubo 5 pacientes fallecidos, de los cuales en dos se relacionó su mortalidad con sepsis. La edad promedio al momento de fallecimiento fue de 6,7 años. Conclusiones: la esplenectomía es una alternativa para el tratamiento de las enfermedades médicas, tras la cual se evidenció una respuesta satisfactoria en la mayoría de los casos del estudio.

Abstract Aim: to describe clinical characteristics and evolution of patients who underwent splenectomy in Costa Rica's National Children's Hospital during January 1996 through December 2006. Methods: This is a chart review study in a 10 year period including children who underwent splenectomy. A hundred and seven charts of children with ages between 0 and 18 years old were reviewed to obtain their clinical presentation, characteristics, indications for splenectomy, follow up, complications and mortality. Also the antibiotic prophylaxis and immunization schedule was analyzed based on international recommendations. Results: A total of 107 patients were included. Results showed that the mean age at which splenectomy was performed was 6.4 years. Most of the patients had their splenectomy due to hemoglobinophaties (59.8%), followed by immune thrombocytopenic purpura (16.8%) and malignant osteopetrosis (8.4%). The most common indications for splenectomy were treatment of the disease (39.9%), hyperesplenism (26.2%) and lack of responde to medical treatment (22.4%). Laparotomy was the most performed surgery (87.9%). Mainly sepsis and hemorrhage were found as complications due to procedure. Overall, complete response to surgical treatment was observed (66.7%). Five patients died during follow up. Conclusions: Splenectomy is an alternative for treating medical disease with predominantly good outcomes observed in our study.

Reduced skeletal muscle phosphocreatine concentration in type 2 diabetic patients: a quantitative image-based phosphorus-31 MR spectroscopy study.

Mitochondrial function has been examined in insulin-resistant (IR) states including type 2 diabetes mellitus (T2DM). Previous studies using phosphorus-31 magnetic resonance spectroscopy (31P-MRS) in T2DM reported results as relative concentrations of metabolite ratios, which could obscure differences in phosphocreatine ([PCr]) and adenosine triphosphate concentrations ([ATP]) between T2DM and normal glucose tolerance (NGT) individuals. We used an image-guided 31P-MRS method to quantitate [PCr], inorganic phosphate [Pi], phosphodiester [PDE], and [ATP] in vastus lateralis (VL) muscle in 11 T2DM and 14 NGT subjects. Subjects also received oral glucose tolerance test, euglycemic insulin clamp, 1H-MRS to measure intramyocellular lipids [IMCL], and VL muscle biopsy to evaluate mitochondrial density. T2DM subjects had lower absolute [PCr] and [ATP] than NGT subjects (PCr 28.6 ± 3.2 vs. 24.6 ± 2.4, P < 0.002, and ATP 7.18 ± 0.6 vs. 6.37 ± 1.1, P < 0.02) while [PDE] was higher, but not significantly. [PCr], obtained using the traditional ratio method, showed no significant difference between groups. [PCr] was negatively correlated with HbA1c ( r = -0.63, P < 0.01) and fasting plasma glucose ( r = -0.51, P = 0.01). [PDE] was negatively correlated with Matsuda index ( r = -0.43, P = 0.03) and M/I ( r = -0.46, P = 0.04), but was positively correlated with [IMCL] ( r = 0.64, P < 0.005), HbA1c, and FPG ( r = 0.60, P = 0.001). To summarize, using a modified, in vivo quantitative 31P-MRS method, skeletal muscle [PCr] and [ATP] are reduced in T2DM, while this difference was not observed with the traditional ratio method. The strong inverse correlation between [PCr] vs. HbA1c, FPG, and insulin sensitivity supports the concept that lower baseline skeletal muscle [PCr] is related to key determinants of glucose homeostasis.

Free air on plain film: Do we need a computed tomography too?

CONTEXT: Standard teaching is that patients with pneumoperitoneum on plain X-ray and clinical signs of abdominal pathology should undergo urgent surgery. It is unknown if abdominal computed tomography (CT) provides additional useful information in this scenario. AIMS: The aim of this study is to determine whether or not CT scanning after identification of pneumoperitoneum on plain X-ray changes clinical management or outcomes. SETTINGS AND DESIGN: Retrospective study carried out over 4 years at a tertiary care academic medical center. All patients in our acute care surgery database with pneumoperitoneum on plain X-ray were included. Patients who underwent subsequent CT scanning (CT group) were compared with patients who did not (non-CT group). STATISTICAL ANALYSIS USED: The Wilcoxon rank-sum test, t-test and Fisher's exact test were used as appropriate to compare the groups. RESULTS: There were 25 patients in the non-CT group and 18 patients in the CT group. There were no differences between the groups at presentation. All patients in the non-CT group underwent surgery, compared with 83% (n = 15) of patients in the CT group (P = 0.066). 16 patients in the non-CT and 11 patients in the CT group presented with peritonitis and all underwent surgery regardless of group. For patients undergoing surgery, there were no differences in outcomes between the groups. After X-ray, patients undergoing CT required 328.0 min to arrive in the operating room compared with 136.0 min in the non-CT group (P = 0.007). CONCLUSIONS: In patients with pneumoperitoneum on X-ray and peritonitis on physical exam, CT delays surgery without providing any measurable benefit.

Central venous access by trainees: a systematic review and meta-analysis of the use of simulation to improve success rate on patients.

INTRODUCTION: Simulation training for invasive procedures may improve patient safety by enabling efficient training. This study is a meta-analysis with rigorous inclusion and exclusion criteria designed to assess the real patient procedural success of simulation training for central venous access. METHODS: Published randomized controlled trials and prospective 2-group cohort studies that used simulation for the training of procedures involving central venous access were identified. The quality of each study was assessed. The primary outcome was the proportion of trainees who demonstrated the ability to successfully complete the procedure. Secondary outcomes included the mean number of attempts to procedural success and periprocedural adverse events. Proportions were compared between groups using risk ratios (RRs), whereas continuous variables were compared using weighted mean differences. Random-effects analysis was used to determine pooled effect sizes. RESULTS: We identified 550 studies, of which 5 (3 randomized controlled trials, 2 prospective 2-group cohort studies) studies of central venous catheter (CVC) insertion were included in the meta-analysis, composed of 407 medical trainees. The simulation group had a significantly larger proportion of trainees who successfully placed CVCs (RR, 1.09; 95% confidence interval [CI], 1.03-1.16, P<0.01). In addition, the simulation group had significantly fewer mean attempts to CVC insertion (weighted mean difference, -1.42; 95% CI, -2.34 to -0.49, P<0.01). There was no significant difference in the rate of adverse events between the groups (RR, 0.50; 95% CI, 0.19-1.29; P=0.15). CONCLUSIONS: Training programs should consider adopting simulation training for CVC insertion to improve the real patient procedural success of trainees.

Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.

BACKGROUND: Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure. METHODS: The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity. RESULTS: Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries. CONCLUSION: The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda.

Excessively long hospital stays after trauma are not related to the severity of illness: let's aim to the right target!

IMPORTANCE: Reduction in length of hospital stay is a veritable target in reducing the overall costs of health care. However, many existing approaches are flawed because the assumptions of what cause excessive length of stay are incorrect; we methodically identified the right targets in this study. OBJECTIVE: To identify the causes of excessively prolonged hospitalization (ExProH) in trauma patients. DESIGN: The trauma registry, billing databases, and medical records of trauma admissions were reviewed. Excessively prolonged hospitalization was defined by the standard method used by insurers, which is a hospital stay that exceeds the Diagnosis Related Group-based trim point. The causes of ExProH were explored in a unique potentially avoidable days database, used by our hospital's case managers to track discharge delays. SETTING: Level I academic trauma center. PARTICIPANTS: Adult trauma patients admitted between January 1, 2006, and December 31, 2010. MAIN OUTCOMES AND MEASURES: Excessively prolonged hospitalization and hospital cost. RESULTS: Of 3237 patients, 155 (5%) had ExProH. The patients with ExProH compared with non-ExProH patients were older (mean [SD] age, 53 [21] vs 47 [22] years, respectively; P = .001), were more likely to have blunt trauma (92% vs 84%, respectively; P = .03), were more likely to be self-payers (16% vs 11%, respectively; P = .02) or covered by Medicare/Medicaid (41% vs 30%, respectively; P = .002), were more likely to be discharged to post-acute care facilities than home (65% vs 35%, respectively; P < .001), and had higher hospitalization cost (mean, $54 646 vs $18 444, respectively; P < .001). Both groups had similar Injury Severity Scores, Revised Trauma Scores, baseline comorbidities, and in-hospital complication rates. Independent predictors of mortality were discharge to a rehabilitation facility (odds ratio = 4.66; 95% CI, 2.71-8.00; P < .001) or other post-acute care facility (odds ratio = 5.04; 95% CI, 2.52-10.05; P < .001) as well as insurance type that was Medicare/Medicaid (odds ratio = 1.70; 95% CI, 1.06-2.72; P = .03) or self-pay (odds ratio = 2.43; 95% CI, 1.35-4.37; P = .003). The reasons for discharge delays were clinical in only 20% of the cases. The remaining discharges were excessively delayed because of difficulties in rehabilitation facility placement (47%), in-hospital operational delays (26%), or payer-related issues (7%). CONCLUSIONS AND RELEVANCE: System-related issues, not severity of illness, prolong hospital stay excessively. Cost-reduction efforts should target operational bottlenecks between acute and postacute care.

Nicaraguan surgical and anesthesia infrastructure: survey of Ministry of Health hospitals.

BACKGROUND: Developing countries have surgical and anesthesia needs that are unique and disparate compared to those of developed countries. However, the extent of these disparities and the specific country-based needs are, for the most part, unknown. The goal of this study was to assess the surgical capacity of Nicaragua's public hospitals as part of a multinational study. METHODS: A survey adapted from the World Health Organization Tool for Situational Analysis to Assess Emergency and Essential Surgical care was used to study 28 primary, departmental, regional, and national referral hospitals within the Ministry of Health system. Data were obtained at the national and hospital levels via interviews with administrators and surgical and anesthesia chiefs of services. RESULTS: There are 580 obstetrician/gynecologists (OB/GYN), 1,040 non-OB/GYN surgeons, and 250 anesthesiologists in Nicaragua. Primary, departmental, regional, and national referral hospitals perform an annual average of 374, 4,610, 7,270, and 7,776 surgeries, respectively. All but six primary hospitals were able to perform surgeries. Four hospitals reported routine water shortages. Routine medication shortages were reported in 11 hospitals. Eight primary hospitals lacked blood banks on site. Of 28 hospitals, 22 reported visits from short-term surgical brigades within the past 2 years. Measurement of surgical outcomes was inconsistent across hospitals. CONCLUSIONS: Surgical capacity varies by hospital type, with primary hospitals having the least surgical capacity and surgical volume. Departmental, regional, and national referral hospitals have adequate surgical capacity. Surgical subspecialty care appears to be insufficient, as evidenced by the large presence of NGOs and other surgical brigade teams filling this gap.

Hemorragia pulmonar y síndrome de insuficiencia respiratoria aguda secundaria a golpe de calor / Pulmonary hemorrhage and acute respiratory distress syndrome secondary to heat stroke

El golpe de calor es una entidad poco frecuente y subdiagnosticada. Se presenta relativamente más en los estados del norte del país, al exponerse los migrantes a condiciones climáticas extremas. La elevacion de la temperatura corporal es la que dispara las disfunciones metabólicas que pueden incluso llevar a la muerte. Se presenta el caso de un migrante chiapaneco que fue encontrado en el desierto de Altar, Sonora en malas condiciones generales; fue traído al Servicio de urgencias del Hospital General del Estado en Hermosillo, Sonora. La evolución inicial fue tórpida, con deterioro de la función respiratoria, infiltrados pulmonares, necesidad de ventilación mecánica, datos de falla renal y cifras muy elevadas de creatinincinasa; se establecieron los diagnósticos de golpe de calor, insuficiencia renal, rabdomiólisis, hemorragia pulmonar y SIRA. Se le dio manejo de sostén con buena evolución, egresó al 21° día de estancia hospitalaria por resolución del problema. El caso nos recuerda que la exposición a condiciones de calor por arriba de la temperatura corporal, lo cual es muy frecuente en las áreas desérticas del norte del país, deteriora los mecanismos de control de calor corporal y metabólico. Es necesario un diagnóstico rápido y un manejo de sostén para conseguir una evolución satisfactoria.

Heat stroke is a rare and underdiagnosed entity, it is more frequently seen in the northern states of Mexico after exposure to high environmental temperatures that induce elevation of the body temperature, triggering metabolic derangements that can result in death. We present the case of a 24 year old immigrant from the southeast state of Chiapas found in the Desert of Altar, in the northern state of Sonora; he was semiconscious, dehydrated and in poor general condition after attempting to cross the desert in his way to the border with the USA. He was brought to our hospital with labored breathing, hemoptysis, lung infiltrates and progressive deterioration of his blood gases. He was intubated and mechanically ventilated; the initial course was characterized by increased CPK levels suggestive of rabdomyolisis, acute renal failure, disseminated intravascular coagulation, lung hemorrhage and acute respiratory distress syndrome secondary to the heat stroke. He spent 14 days in the ICU receiving 4 courses of hemodyalisis, ventilatory support, iv fluids, antibiotics and monitoring of his respiratory, renal, cardiovascular, neurologic and metabolic parameters. He was discharged 21 days after admission. Heat stroke prevention is mandatory by public education; early diagnosis should avoid the full-blown systemic derangements; adequate support can reverse an otherwise potentially fatal course.

Secuencia de Potter con hipoplasia pulmonar y malformaciones craneofaciales: reporte de un caso / Potter`s Sequences with pulmonary hypoplasia and craniofacials malformation: report of a case

Paciente femenina de 15 horas, con control prenatal inadecuado, producto de un parto pretérmino secundario a sufrimiento fetal agudo por posición distónica y oligoaminios absoluto que cursa con insuficiencia respiratoria severa y Secuencia de Potter que por la gravedad de la patología fallece.

Síndrome de Corazón Izquierdo con hipoplasia severa de cavidades: reporte de un caso / Severe hipoplastic Left heart Syndrome of cavities: report of a case

Paciente femenina de 1 mes y 9 días de edad, con una historia perinatal adecuada que presentó un cuadro de cianosis peribucal y vómitos de contenido bilioso a los 15 días de nacida. Se diagnótico por un ecocardiograma un Síndrome de corazón izquierdo con hipoplasia severa de cavidades; que por la evolución natural y gravedad de la enfermedad terminó falleciendo.

Purification and molecular cloning of and immunization with Ancylostoma ceylanicum excretory-secretory protein 2, an immunoreactive protein produced by adult hookworms.

Hookworms remain major agents of global morbidity, and vaccination against these bloodfeeding parasites may be an attractive complement to conventional control methods. Here we describe the cloning of Ancylostoma ceylanicum excretory-secretory protein 2 (AceES-2), a novel immunoreactive protein produced by adult worms. Native AceES-2 was purified from excretory-secretory (ES) products by reverse-phase high-pressure liquid chromatography, subjected to amino-terminal sequencing, and cloned from adult worm RNA by using reverse transcription-PCR. The translated AceES-2 cDNA predicts that the mature protein consists of 102 amino acids and has a molecular mass of 11.66 kDa. Western immunoblot and enzyme-linked immunosorbent assay analyses demonstrated that recombinant AceES-2 (rAceES-2) reacted strongly with antibodies from A. ceylanicum-infected hamsters. Immunization of hamsters with native ES products adsorbed to alum induced antibodies that recognized rAceES-2, while rAceES-2-alum vaccination resulted in antibodies that reacted with a single protein band in ES products that closely approximated the size predicted for the native molecule. Infected hamsters that were passively immunized with hyperimmune rabbit anti-rAceES-2 serum exhibited more rapid and complete recovery from anemia than controls that received normal serum. Oral immunization with rAceES-2 was associated with significantly reduced anemia upon challenge, an outcome similar to the outcome observed in hamsters that were orally vaccinated with soluble hookworm extract (the latter animals were also resistant to weight loss). These data suggest that AceES-2 plays an important role in the host-parasite interaction and that vaccination against this protein may represent a useful strategy for controlling hookworm anemia.