Quiste Vallecular: Caso clínico de estridor agudo / Vallecular cyst: clinical case of acute stridor

El enfrentamiento de estridor en el Servicio de Urgencias puede ser un desafío para el clínico. La mayoría de los pacientes responderán a medidas estándar de anafilaxia, no obstante, ante pacientes refractarios a tratamiento se deben sospechar otras patologías. Presentamos el caso clínico de una paciente refractaria a manejo de anafilaxia. Se realiza videolaringoscopía que identifica quiste de vallécula y se maneja mediante protección de vía aérea con intubación orotraqueal. Se decide escisión quirúrgica, en la cual se identifica estenosis subglótica que requiere instalación de traqueostomía. La paciente evoluciona favorablemente y es dada de alta.

Coping with stridor in the Emergency Department can challenge the clinician. Most patients respond to standard anaphylaxis measures. The clinician should suspect other differential diagnoses when patients are refractory to treatment. We present the clinical case of a patient refractory to standard anaphylaxis management. A video laryngoscopy was performed, identifying a vallecula cyst. We secured the airway through orotracheal intubation. The surgical team of our hospital performed a surgical excision of the cyst and identified subglottic stenosis, which required the installation of a tracheostomy. The patient evolved favorably in the postoperative period and was discharged.

Modelos de simulación para entrenamiento en cirugía de hueso temporal / Temporal bone surgery simulation-training models

El fresado de hueso temporal (HT) es un desafío para los otorrinolaringólogos. Este procedimiento requiere un conocimiento detallado de esta zona anatómicamente compleja y un dominio de la técnica quirúrgica. La exposición a una mastoidectomía simple o mastoidectomía radical varía entre residentes y distintos programas de especialidad y, frecuentemente, no se cumple el número requerido para la curva de aprendizaje durante la formación. Por lo anterior, surge la necesidad de realizar simulación quirúrgica de fresado de HT. El gold standard para su entrenamiento son los modelos cadavéricos, sin embargo, su costo y baja disponibilidad representan una limitación importante. Los modelos de simulación no cadavéricos podrían jugar un rol importante en el entrenamiento de esta cirugía. Se realizó una revisión exhaustiva de la literatura sobre los modelos de simulación disponibles en fresado de HT. Se encontraron estudios sobre modelos cadavéricos, basados en impresión 3D, realidad virtual y de bajo costo. Los modelos de impresión 3D y realidad virtual han sido evaluados favorablemente en cuanto a adquisición de habilidades, aprendizaje de anatomía, similitud con modelos cadavéricos y sensación táctil. Los modelos de impresión 3D presentan mayor fidelidad anatómica y física, pero tienen un mayor costo. En suma, se han desarrollado modelos de fresado de HT no cadavéricos que cuentan, principalmente, con validez de apariencia y contenido, y solo algunos con validez de constructo. Se necesitan más estudios para evaluar su validez predictiva y transferencia de habilidades al paciente real.

Temporal bone (TB) dissection is a challenging procedure for otolaryngologists. It requires a detailed knowledge of this anatomically complex area and mastery of the surgical technique. Exposure to a simple or radical mastoidectomy may vary among residents and specialty programs, frequently not complying with the required number of surgeries to complete the learning curve during residency. Hence, TB dissection simulation is of great importance. The gold standard for simulated training are cadaveric models, nevertheless, the associated high cost and low availability represent a major limitation for this modality. Non-cadaveric simulation models could play a key role in simulated training for this surgery. A comprehensive review of the literature regarding the available simulation models for TB dissection was conducted. Articles for cadaveric, 3D-printed, virtual reality and low-cost models were identified. 3D-printed and virtual reality models have been favorably evaluated in terms of skill acquisition, anatomy learning, similarity to cadaveric models, and tactile sensation. 3D-printed models present superior anatomic and physical fidelity, but are more expensive. In sum, the current non-cadaveric models for TB dissection mostly present face and content validity, while few models count with construct validity. Further studies are required to assess predictive validity and skill transfer to the real patient.

Implementación de un modelo porcino de trasplante hepático en Chile / Implementation of a porcine liver transplant model in Chile

Resumen Objetivo: Presentar la implementación del primer modelo porcino de trasplante hepático (TH) en Chile y sus resultados. Material y Método: Se implementó un protocolo quirúrgico y anestésico en el contexto de una investigación en perfusión normotérmica hepática financiada por un Fondo Nacional de Desarrollo Científico y Tecnológico. Los cerdos fueron seleccionados por peso (35-40 kilos), en cada experimento se utilizó dos, donante y receptor, sometidos a procura y trasplante respectivamente. El análisis se realizó con estadística descriptiva. Resultados: Se realizaron 26 experimentos (marzo de 2018-octubre de 2019). El protocolo consta de 7 etapas: Preparación, Instrumentalización, Procura o Hepatectomía, Tiempo Anhepático, Etapa de Isquemia-Reperfusión, Monitorización y Eutanasia. Las primeras tres son similares en ambos cerdos, y desde la cuarta en adelante corresponde sólo al receptor. La supervivencia a la cirugía fue de 92,3% (24/26) y al seguimiento de 76,9% (20/26). La mortalidad se produjo por inestabilidad cardiovascular postreperfusión portal. El tiempo quirúrgico promedio fue de 170 min, y el tiempo anhepático de 33 min. La PAM cursó una baja postreperfusión con recuperación al final de la monitorización (67,4 mmHg media) y la tendencia en ph fue a acidosis al final del seguimiento (7,21 media). Se requirió drogas vasoactivas en 12 casos. Discusión: Logramos implementar un modelo experimental simplificado y reproducible de TH sin necesidad de circulación extracorpórea ni puente veno-venoso gracias a la estandarización de la técnica quirúrgica y de los cuidados perioperatorios. Conclusiones: La consolidación de un modelo experimental significa el primer paso en investigación preclínica de nuevas tecnologías asociadas al TH en Chile.

Objective: To Present the implementation of the first porcine model of liver transplant in Chile and its results. Materials and Methods: In the context of an investigation based on normothermic perfusion that was subsidized by the National Fund for Scientific and Technological Development, surgical and anesthetic protocols were implemented. Two pigs were selected by weight (35-40 kg), in which one was a donor and the other a receptor; submitted to procure and as a transplant recipient, respectively. The analysis was executed with descriptive statistics. Results: 26 experiments (June 2018-October 2019) were performed. The protocol includes 7 stages: Preparation, Instrumentalization, Procure or Hepatectomy, Anhepatic Time, Phase of Ischemia-Reperfusion, Monitoring and Euthanasia. The first three stages are similar in both pigs; meanwhile the last four are exclusive to the receptor. 92.3% (24/26) survived the surgery and 76.9% (20/26) survived the follow up, including the pilots. Average surgical time was 170 minutes, and the anhepatic time was 33 minutes. The mean arterial pressure decreased after the reperfusion and it improved towards the end of the monitorization (67,4 mmHg average) In the follow up, pigs presented acidosis (7.21 average). Vasoactive drugs were necessary in 12 experiments. Discussion: We managed to implement a simple and reproducible model of porcine liver transplant without extracorporeal circulation or veno-venous by-pass. This was possible due to the standardization of surgical technique and perioperative cares. Conclusions: The consolidation of porcine liver transplant model is the first step in pre-clinical research for the development of new technologies in liver transplant in Chile.

SARS-CoV-2 screening of asymptomatic women admitted for delivery must be performed with a combination of microbiological techniques: an observational study.

OBJECTIVE: The aim of this study is to assess the value of systematic screening in asymptomatic women admitted for spontaneous delivery with a combination of reverse transcription polymerase chain reaction (RT-PCR) and cycle threshold (Ct) and serum antibodies. METHODS: Since May 6 all women admitted for spontaneous delivery underwent RT-PCR in nasopharyngeal swabs and specific antibodies IgG of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in serum that were performed as part of routine clinical care in our institution. Ct of the PCR was recorded. We analyzed the first 100 women consecutively admitted for spontaneous delivery at our institution. RESULTS: Nine women were positive for SARS-CoV-2 in nasopharyngeal samples (9%) and 13 (13%) presented positive specific antibodies of the coronavirus. Overall, SARS-CoV-2 prior exposure was 15%. The Ct determination (RT-PCR test) of our 9 positive patients ranged from 36 to 41 cycles with a median of 40. Vaginal delivery occurred in 94% of the cases and only 6% underwent a cesarean section, always for obstetric reasons. No fetal transmission was observed and maternal and neonatal prognosis was excellent. CONCLUSIONS: During epidemic episodes in asymptomatic women in labor, universal testing with RT-PCR (considering Ct determination), and the detection of antibodies, permits a better interpretation of the results and avoid unnecessary isolation procedures.

Oral myeloid cells uptake allergoids coupled to mannan driving Th1/Treg responses upon sublingual delivery in mice.

BACKGROUND: Polymerized allergoids coupled to nonoxidized mannan (PM-allergoids) may represent novel vaccines targeting dendritic cells (DCs). PM-allergoids are better captured by DCs than native allergens and favor Th1/Treg cell responses upon subcutaneous injection. Herein we have studied in mice the in vivo immunogenicity of PM-allergoids administered sublingually in comparison with native allergens. METHODS: Three immunization protocols (4-8 weeks long) were used in Balb/c mice. Serum antibody levels were tested by ELISA. Cell responses (proliferation, cytokines, and Tregs) were assayed by flow cytometry in spleen and lymph nodes (LNs). Allergen uptake was measured by flow cytometry in myeloid sublingual cells. RESULTS: A quick antibody response and higher IgG2a/IgE ratio were observed with PM-allergoids. Moreover, stronger specific proliferative responses were seen in both submandibular LNs and spleen cells assayed in vitro. This was accompanied by a higher IFNγ/IL-4 ratio with a quick IL-10 production by submandibular LN cells. An increase in CD4+ CD25high FOXP3+ Treg cells was detected in LNs and spleen of mice treated with PM-allergoids. These allergoids were better captured than native allergens by antigen-presenting (CD45+ MHC-II+ ) cells obtained from the sublingual mucosa, including DCs (CD11b+ ) and macrophages (CD64+ ). Importantly, all the differential effects induced by PM-allergoids were abolished when using oxidized instead of nonoxidized PM-allergoids. CONCLUSION: Our results demonstrate for the first time that PM-allergoids administered through the sublingual route promote the generation of Th1 and FOXP3+ Treg cells in a greater extent than native allergens by mechanisms that might well involve their better uptake by oral antigen-presenting cells.

Seguimiento a largo plazo de niños con síndrome urémico hemolítico con compromiso renal leve en la fase aguda / Long-term follow-up of children with hemolytic uremic syndrome with mild renal involvement in the acute phase

Introducción: 30-50% de los pacientes con síndrome urémico hemolítico asociado a diarrea (SUH D+) desarrollan secuela renal. La duración del período oligoánurico es el mejor predictor de secuela, sin embargo se comunicó daño renal en pacientes con formas leves. Objetivos: analizar la evolución de pacientes con SUH D+ que no dializaron y la asociación entre parámetros clínicos y de laboratorio del período agudo con la evolución final. Pacientes y métodos: revisamos 530 historias clínicas de pacientes internados en el Hospital Garrahan con SUH D+ entre 1987-2002. Criterios de exclusión: necesidad de diálisis y seguimiento menor a 6 meses. Se incluyeron 91 pacientes (48 varones). Definimos secuela a: hipertensión arterial (HTA) y/o proteinuria y/o insuficiencia renal crónica (IRC). Resultados: Mediana de edad al diagnóstico 1,5 años (0.3-10,75) y de seguimiento 9.1 años (0.9-18.5). 42.9% desarrolló proteinuria a los 2.85 años de evolución. Todos negativizaron la proteinuria (22 con dieta normoproteica normosódica y 17 con dieta y enalapril). Los pacientes con y sin secuela fueron omparables (p>0.05) en sexo, edad, glóbulos blancos, transfusiones, período oligoanúrico y creatinina máxima del período agudo, así como en el tiempo de seguimiento y peso de nacimiento. Conclusión: 42.9% de los pacientes con SUH D+ leve presentó proteinuria que remitió con dieta y/o enalapril en todos los casos. Ninguno presentó HTA ni IRC luego de 9 años de seguimiento. No encontramos factores predictivos de secuela por lo que recomendamos el seguimiento prolongado de todos los niños con SUH D+, aún de aquellos con formas leves (AU)

Introduction: 30-50% of patients with diarrhea-associated hemolytic uremic syndrome (D+ HUS) develop renal sequelae. The duration of the oligoanuric period is the best predictor of sequelae, but renal damage has been reported in patients with mild forms. Objectives: To analyze the evolution of patients with D+ HUS who did not undergo dialysis and the association of clinical and laboratory parameters during the acute phase and final outcome. Patients and Methods: We reviewed 530 clinical charts of D+ HUS patients hospitalized in the Garrahan Hospital between 1987 and 2002. Exclusion criteria: need for dialysis and a less than 6-month follow-up. Ninety-one patients (48 male) were included in the study. Sequelae were defined as: arterial hypertension (AHT) and/or proteinuria and/or chronic renal failure (CRF). Results: Median age at diagnosis 1.5 years (0.3-10.75) and follow-up 9.1 years (0.9-18.5). Of all patients, 42.9% developed proteinuria 2.85 years after the diagnosis. Proteinuria disappeared in all (in 22 with a normoproteic normosodic diet and in 17 with the diet and enalapril). The patients with and without sequelae were comparable (p>0.05) as to gender, age, white blood cell count, transfusions, oligoanuric period, and peak creatinine level in the acute phase, as well as time of follow-up and birth weight. Conclusion: 42.9% of patients with mild D+ HUS presented with proteinuria that disappeared with a diet and/or enalapril in all cases. None of the patients had AHT or CRF after 9 years of follow-up. No predictive factors for sequelae were found and thus long-term follow up is recommended for all children with D+ HUS, even for those with mild forms (AU)

Bevacizumab intravítreo en la neovascularización secundaria a degeneración macular asociada a la edad / No disponible

No disponible

Trends in mechanical ventilation and immediate extubation after liver transplantation in a single center in Chile.

INTRODUCTION: Some groups have reported early extubation post-liver transplantation in patients with previously defined criteria, in an attempt to shorten the ICU stay and decrease costs. We review our experience with trends in mechanical ventilation and resource utilization. METHODS: We retrospectively reviewed the length of mechanical ventilation, ICU stay, hospital stay, transfusions, and costs of liver transplants performed since the program's inception in 1993 and 2002 including 82 OLT in 71 patients. We also report our experience with immediate postoperative extubation, which we have done from October to December of 2002. We compare different periods: the early days (1993 to 1997), namely, fewer than 10 OLT per year, with the subsequent years assessed individually. RESULTS: There has been a progressive decrease over time in the length of mechanical ventilation, ICU stay, hospital stay, and costs. Since the program's inception actuarial adult patient 1- and 5-year survival rates were 88.7% and 78%, respectively. The 1-year survival rate increased to 97% during the period of 2000 to 2002 (n = 30). From October to the present, we extubated four of seven adult patients who met criteria with none of them requiring reintubation. CONCLUSIONS: We demonstrate improved results, decreased length of mechanical ventilation, ICU, and hospital stay, and costs. The immediate postoperative extubation may be feasible for patients who meet previously defined criteria.

[The elaboration, use and evaluation of eye-drops with autologous serum in corneal lesions]. / Elaboración, utilización y evaluación de un colirio con suero autólogo en las lesiones corneales.

OBJECTIVES: To expose the elaboration process, microbiological control and effectiveness of an eyewash prepared with the patient's serum, for the treatment of injure corneas of different etiology. METHOD: It was edited an elaboration protocol and microbiological control, following the norms of correct elaboration picked up in the real Ordinance 175/2001. The clinical answer was valued objectively and subjectively. RESULTS: The eyewashes got ready under sterile conditions, using the patient's serum diluted to 20% with physiologic. None of the containers conserved in the Service of Pharmacy were contaminated, while the contamination in those already used, varied according to the patient. Of the eleven evaluated cases, six experienced a total recovery of its corneal lesions, three improved partially, and in the remaining ones the treatment was not effective. CONCLUSIONS: The elaboration of the eyewash doesn't present technical problems if we have the appropriate equipment for the realization under sterile conditions. The contamination of the containers seems to be due to the inadecuate use by the patients. The results, in spite of the even scarce number of treated patients, justify the treatment in serious cases of dry eye and corneal ulceration.

Elaboración, utilización y evaluación de un colirio con suero autólogo en las lesiones corneales / The elaboration, use and evaluation of eye-drops with autologous serum in corneal lesion

Objetivos: Exponer el proceso de elaboración, control microbiológico y eficacia de un colirio preparado a partir de suero del paciente, para el tratamiento de lesiones cornéales de diferente etiología. Método: Se redactó un protocolo de elaboración y control microbiológico, siguiendo las normas de correcta elaboración recogidas en el real Decreto 175/2001.La respuesta clínica se valoró objetiva y subjetivamente. Resultados: Los colirios se prepararon en condiciones estériles, utilizando suero del paciente diluido al 20 per cent con fisiológico. Ninguno de los envases conservados en el Servicio de Farmacia se contaminó, mientras que la contaminación en los ya utiliza dos varió según el paciente. De los once casos evaluados, seis experimentaron una recuperación total de sus lesiones cornéales, tres mejoraron parcialmente y en los restantes el tratamiento no fue efectivo. Conclusiones: La elaboración del colirio no presenta problemas técnicos si se dispone del equipamiento adecuado para su realización en condiciones estériles. La contaminación de los envases parece deberse al uso inadecuado por los pacientes. Los resultados, pese al aún escaso número de pacientes tratados, justifican el tratamiento en casos graves de ojo seco con ulceración corneal (AU)

Identification of NPY-induced c-Fos expression in hypothalamic neurones projecting to the dorsal vagal complex and the lower thoracic spinal cord.

Neuropeptide Y exerts profound effects on body weight and glucose homeostasis. We have investigated the effect of centrally administered neuropeptide Y on the activity of descending neurones of the hypothalamic paraventricular nucleus by combining retrograde tract tracing with c-Fos immunocytochemistry. Male rats were injected with True Blue into the dorsal vagal complex and with FluoroGold into the intermediolateral column of the lower thoracic spinal cord. One week after the last surgical procedure, animals were injected centrally with an orexigenic dose of neuropeptide Y (5 microg) and sacrificed 60 to 240 minutes following this injection. Temporal analysis of NPY-induced c-Fos expression showed a peak at 90 minutes, which was nearly returned to basal levels between 120 and 240 minutes. Expression of c-Fos was prominent in several of the subnuclei of the paraventricular nucleus and in the adjacent perifornical nucleus. Neurones projecting to the spinal cord were prominent in the dorsal, lateral, and ventral portion of the medial parvicellular subnuclei of the PVN. About 15% of IML projecting neurones of the medial parvicellular subnucleus were Fos-positive, whereas less than 5% of IML projecting neurones from other subnuclei were Fos-positive. Hardly any PVN neurones projecting to the dorsal vagal complex were concomitantly Fos-positive. A considerably larger (>10%) proportion of perifornical neurones projecting to the nucleus of the solitary tract were c-Fos-immunopositive. In conclusion, NPY induces c-Fos in paraventricular neurones projecting to intermediolateral column of the spinal cord and in neurones of the perifornical nucleus projecting to the dorsal vagal complex.

Trasplante hepático: evaluación preoperatoria / Preoperative assessment of candidates for liver transplant

Candidates for hepatic transplant requiere a careful identification of risk factors present in the preoperative period. Child C patients have a higher incidence of renal function derangement, septic complications and mortality than Child A or B patients. Alterations in cardiovascular, renal respiratory and neurologic systems, that sometimes constitute clearly defined syndromes, have important prognostic implications. These alterations shed doubts on the moment and indications for transplantation and on the correct preoperative management of these patients

[Liver transplantation: preoperative assessment]. / Trasplante hepático: evaluación preoperatoria.

Candidates for hepatic transplant require a careful identification of risk factors present in the preoperative period. Child C patients have a higher incidence of renal function derangement, septic complications and mortality than Child A or B patients. Alterations in cardiovascular, renal, respiratory and neurologic systems, that sometimes constitute clearly defined syndromes, have important prognostic implications. These alterations shed doubts on the moment and indications for transplantation and on the correct preoperative management of these patients.