The usefulness of the buffy coat smear and panbacterial polymerase chain reaction in early diagnosis of neonatal sepsis.

OBJECTIVE: In this study are evaluated the usefulness of the buffy coat smear and panbacterial polymerase chain reaction (PCR) as diagnostic tests in the early detection of neonatal sepsis. MATERIAL AND METHODS: It was studied 49 patients aged up to 28 days who were hospitalized in the Intensive Care Unit (ICUs) of the Neonatology, with a clinical diagnosis of neonatal sepsis and 49 umbilical cord samples of healthy newborns. Blood cultures and 50 microL of plasma were taken for the DNA and performance of the broad-range PCR primer system (panbacterial PCR). Simultaneously, were taken three capillaries with blood for the leukocyte layer (buffy coat) smear, we performed three stains: Gram; Löeffler blue methylene (LBM), and acridine orange (AO). Statistical analysis included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) against the clinical diagnosis. RESULTS: With respect to stains of buffy coat smear, they resulted very specific, from 90-97%, with 64-75% sensitivity, 87-94% PPV, and 77-82% NPV. In inverse fashion, PCR resulted very sensitive at 96%, with 91% specificity, 92% PPV, and 96% NPV. CONCLUSIONS: Buffy coat smear stains are easy, fast, and specific, while that of PCR was highly sensitive. Thus, both can be utilized as diagnostic tests.

[Predictors factors for the extubation failure in two or more times among preterm newborn]. / Factores predictores para falla en la extubación en dos o más ocasiones en el recién nacido de pretérmino.

INTRODUCTION: With the ventilatory mechanical attendance has been prolonged the life of the preterm newborn (PTNB) critically sick and during that lapse many occasions it is necessary reintubation to PTNB in two or more times with the subsequent damage that makes enter to the patient to a vicious circle with more damage during the same reintubated. The objective of this study was to determine the factors that predict the extubation failure among PTNB from 28 to 36 weeks of gestational age in two or more times. MATERIAL AND METHODS: It was considered extubation failure when in the first 72 hours of being had extubated the patient; there was reintubation necessity, independent of the cause that originated it. For the second extubation or more took the same approach. During the period of September to December of the 2004 were included in retrospective study to all PTNB that were interned in one hospital of third level that fulfilled the inclusion approaches (one study published where we take account the first extubation failure) and in retrolective study to the patients of the same hospital of January to October of the 2006. They were formed two groups, group A of cases (who failed in extubation two or more times) and the B of controls (who failed in extubation for the first time). The descriptive statistic and the inferential through of Student t test or Mann-Whitney U or rank sum test Wilcoxon, in suitable case; Chi-square or Fisher's exact test was used. Odds ratio (OR) and multivariate analysis for to study predictors factors for the extubation failure was employed. Statistical significance was considered at p < 0.05. RESULTS: The group A it was conformed by 21 patients and the group B for 20 patients. In the multivariate analysis it was association like predictive factor for fail of the second extubation to the presence of postextubation atelectasis with an OR 19.2 with IC to 95% of 3.1-117 (P = 0.001) and preextubation oxygenation index (IO2) >2, OR 5.3, IC to 95% of 1.3-21.4 (P = 0.02). In the bronchoscopy study they were some anatomical alterations that they explained the extubation failure in the second time. CONCLUSIONS: We conclude that it is important to plan an extubation in the PTNB, when there has already been a previous failure, and to avoid the well-known predictors factors for extubation failure as much as possible in the extubation in the PTNB, and that according to that found in this study non to extubate with an IO2 >2, and to manage the atelectasis postextubation intensively. Later to the pursuit of those limits and after a second extubation failure, be probably necessary to pass to bronchoscopy if the patient's conditions allow it.

[Risk factors associated to complications of the mechanical ventilatory assistance in the premature newborn]. / Factores de riesgo asociados a complicaciones de la asistencia mecánica ventilatoria en el recién nacido prematuro.

OBJECTIVE: To determine risk factors associated with the presence of complications with mechanical ventilatory support (MVS) in the preterm infants (PI). METHODS: One hundred thirty medical records of PI that had been discharged by amelioration or death were reviewed retrospectively. They were divided in two groups: group A, PI that had presented complications during MVS (cases) and B, PI with MVS, but that had not presented complications due to the procedure (controls). Statistical significance was considered at p < 0.05. RESULTS: The significative risk factors in the multivariate analysis reached significance for the associated of complications: gestational age (32 weeks or less), orotracheal reintubations three o more times, cycles of 60 per minute or more at the third day of being had initiate the MVS, and the symptomatic patent ductus arteriosus (PDA), all with p < 0.05. CONCLUSIONS: It will be necessary to impact more on the cycles level to diminish him below 60 per minute to the third day when it is feasible, to make the smallest reintubations number, to correct quickly the PDA when it is symptomatic, to avoid this way as much as possible, the complications of the MVS.

[Predictor factors for the production of bronchopulmonary dysplasia in the preterm newborn]. / Factores predictores para la producción de displasia broncopulmonar en el recién nacido de pretérmino.

INTRODUCTION: The bronchopulmonary dysplasia (BPD) is a lung illness chronicle that is developed in preterm newborn (PTNB) mainly, secondary to multiple factors of risk which have not been studied completely. OBJECTIVE: To determine the predictors factors (of risk factors) for the production of BPD in the PTNB of 28 at 36 weeks of gestational age. MATERIAL AND METHODS: Eighty medical records from January 2004 to May 2006 of PTNB that there was received mechanical attendance to the ventilation (MAV) at least 24 hrs were reviewed retrospectively. They were divided in two groups: group A, PTNB that had BPD, composed of 40 patients (cases) and group B, PTNB with MAV but that had not developed BPD due to the procedure of 40 patients too (controls). It was used descriptive and inferential statistic. Odds ratio (OR) and multivariate analysis were used to study predictors factors. Statistical significance was considered with P < 0.05. RESULTS: There was significant difference of the supply of the intravenous (i.v.) fluids the days 2, 3, 4 and 7 of extrauterine life (EUL), of the oxygen inspired fraction (FiO2) of in the day 7 of being had initiate the MAV, of the peak inspiratory pressure (PIP) in the day 1 and 3 of being had initiate the MAV everything to favor of the cases, with P < 0.05. In the multivariate analysis was significative in the intake of i.v. fluids > or = 140 mL x kg of weight x day to the fourth day of EUL, the oxygen arterial pressure (PaO2) > 70 mm Hg for > 4 days, reintubations number (two or more times) and the symptomatic patent ductus arteriosus (PDA), all with P < 0.05. CONCLUSIONS: We concluded that, in critically sick PTNB, they exist one series of well-known risk factors but more specified in this study that they should avoid as much as possible; the handling of the liquids i.v. should be cautious, not to spend of 139 mL x kg x day to the 4th day of EUL, not to be so permissive with the PaO2 maintaining it in values < or = 70 mm of Hg after four days, to avoid as much as possible the reintubations and to treat the but quick the symptomatic PDA still without that it is significant, to diminish this way, the risk of BPD.

[Comparison of oxygen saturation among newborns with bronchopulmonary dysplasia during and after feeding]. / Comparación de la saturación de oxígeno en lactantes con displasia broncopulmonar antes, durante y después de la alimentación.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is associated with frequent events of hypoxemia specially during feeding. OBJECTIVE: Determine peripheral oxygen saturation (SpO2) among infants with BPD before, during and after feeding. METHODS: Patients with diagnosis of BPD were prospectively studied between July-September, 2005. SpO2 was measured with a manual digital pulsioxymeter 5 times during feeding. Alpha levels were set at p<0.05. RESULTS: 67 events were studied in 18 patients. For each participant, oxygen saturation was measured five times yielding a total of 335 recordings. Frequent desaturation episodes were recorded during feeding, (SpO2<88%) in 16 of the 18 cases. SpO2 reached 80% for some recordings among 67% of participants (n=12), with p<0.001. CONCLUSION: Among BDP patients, SpO2 decreases during feeding, reaching severe desaturations (SpO2<80%) among in two thirds of the cases. Oxygen concentration must be sufficiently increased during feeding in order to rise the level of SpO2 to a minimum of 88%.

Comparación de la saturación de oxígeno en lactantes con displasia broncopulmonar antes, durante y después de la alimentación / Comparison of oxygen saturation among newborns with bronchopulmonary dysplasia during and after feeding

Antecedentes: La displasia broncopulmonar se relaciona con eventos frecuentes de hipoxemia, en especial durante la alimentación. El objetivo de este estudio fue determinar la saturación periférica de oxígeno (SpO2) en lactantes con displasia broncopulmonar, antes, durante y después de la alimentación. Métodos: Prospectivamente se estudiaron pacientes con displasia broncopulmonar del 1 de julio al 30 de septiembre de 2005, realizando mediciones de SpO2 a través de un pulsioxímetro digital de mano en cinco ocasiones con relación a la alimentación. Se consideró zona de significancia con p<0.05. Resultados: En 18 pacientes se estudiaron 67 eventos, midiendo en cada uno la SpO2 en cinco ocasiones, para un total de 335 mediciones; hubo momentos de desaturación frecuentes (SpO2 menor de 88%) en 16 pacientes de los 18, y SpO2 por debajo de 80% en alguna medición, en 67% de ellos (n=12), con p<0.001. Conclusiones: La SpO2 en pacientes con displasia broncopulmonar disminuye durante la alimentación llegando a niveles severos (menos de 80%) en las dos terceras partes de los casos, por lo que se sugiere que durante la misma se incremente la concentración de oxígeno lo suficiente como para llevarlos a una saturación de 88%, por lo menos.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is associated with frequent events of hypoxemia specially during feeding. OBJECTIVE: Determine peripheral oxygen saturation (SpO2) among infants with BPD before, during and after feeding. METHODS: Patients with diagnosis of BPD were prospectively studied between July-September, 2005. SpO2 was measured with a manual digital pulsioxymeter 5 times during feeding. Alpha levels were set at p<0.05. RESULTS: 67 events were studied in 18 patients. For each participant, oxygen saturation was measured five times yielding a total of 335 recordings. Frequent desaturation episodes were recorded during feeding, (SpO2<88%) in 16 of the 18 cases. SpO2 reached 80% for some recordings among 67% of participants (n=12), with p<0.001. CONCLUSION: Among BDP patients, SpO2 decreases during feeding, reaching severe desaturations (SpO2<80%) among in two thirds of the cases. Oxygen concentration must be sufficiently increased during feeding in order to rise the level of SpO2 to a minimum of 88%.

[Oxygen peripheral saturation using pulse oxymetry among healthy term newborns at Mexico's altitude (2240 m)]. / Saturación periférica de oxígeno por oximetría de pulso en recién nacidos clínicamente sanos a la altitud de la Ciudad de México (2240 m).

BACKGROUND: Oxygen peripheral saturation (SpO2) is crucial for an adequate management of critically-ill newborns infants (NB). The objective of the present study was to determine SpO2 by pulse oxymetry among healthy term and preterm NBs at an altitude of 2240 m above sea level. METHODS: Observational, cross-sectional and comparative. 218 NBs were prospectively studied between January to April 2004. Eighty nine were term and 128 were preterm. Alpha levels were set at p<0.05. RESULTS: The recorded lower value for SpO2 was 88%, and the maximum was 99%. We observed a significant SpO2 difference among the term NB (93.5+/-2%) and preterm NBs (92.9+/-2%), p=0.01. CONCLUSIONS: SpO2 in Mexico City's altitude is on average lower when compared to that observed at sea level. In general with a minimum and maximum values found in our study the SpO2 needed to maintain a critically sick NB with supplementary O2, is suggested. Values should be kept at between 88% and 94% to avoid hypoxemia and hyperoxemia.

Imiquimod enhances the systemic immunity attained by local cryosurgery destruction of melanoma lesions.

Melanoma lesions can be frozen in vivo, resulting in necrotic death of malignant cells and in tumor antigen release suitable for cross-presentation by professional antigen-presenting cells. Imiquimod is a small molecule with adjuvant pro-inflammatory effects that can be topically delivered as a cream. Local cryosurgery of B16/ovalbumin (OVA)-derived subcutaneous tumor nodules leads to curative destruction of the lesions. If imiquimod is repeatedly applied on the cryo-treated lesion, a conspicuous, leukocyte-rich inflammatory infiltrate appears during the days following treatment. Mice treated by cryosurgery plus imiquimod rejected rechallenges of B16/OVA in 90% of the cases, whereas cryosurgery alone failed to prevent tumor grafting in 70% of the cases. The combination treatment of B16/OVA tumors was also able to protect 60% of the mice against outgrowth of a lethal dose of non-transfected B16 tumor cells. Addition of imiquimod to cryosurgery results in increases of the cellular immune response against tumor antigens as measured by in vitro IFN-gamma production and T-cell proliferation in response to OVA. The potent memory response is not only directed against the OVA epitope, but also toward a broader range of B16 antigens. Our data indicate that these combined treatments turn the treated tumor lesion into an autologous tumor vaccine, which is even able to cause vitiligo in several cases. These preclinical data and the simplicity of the procedures warrant the design of a pilot clinical trial.

Incidental findings in negative sentinel lymph nodes of patients with malignant melanoma: report of three cases.

We present three cases of benign SLN that were clinically suspicious for involvement by metastatic melanoma and where found to be involved with other diseases or deposits previously unknown.

[Mucous membrane pemphigoid: clinical manifestations and treatment with corticosteroids, dapsone and cyclophosphamide in 5 patients]. / Penfigoide de mucosas: manifestaciones clínicas y tratamiento con corticoides, dapsona y ciclofosfamida en cinco pacientes.

INTRODUCTION: Cicatricial pemphigoid includes several processes which are characterized by the presence of subepidermal bullae, and which affect the mucous membranes and, more rarely, the skin. At present, the term mucous membrane pemphigoid (MMP) is more accepted than other names used in the past, as they do not clearly define the broad spectrum presented by this disease. MMP can cause significant dysfunctions, primarily in the mucous membranes. Therefore, it is necessary to diagnose the disease as soon as possible, in order to quickly initiate systemic immunosuppressive treatment. MATERIAL AND METHODS: We present our experience with 5 patients with MMP. We analyze the clinical manifestations and the response to immunosuppressive treatment during the evolution of the disease. RESULTS: The patients were aged 41 to 69 years. The most frequent location of the lesions was the oral mucosa (80 %) and the ocular mucosa (80 %), followed by the pharyngeal mucosa (60 %), laryngeal mucosa (40 %), skin, anal mucosa (20 %) and genital mucosa (20 %). Three patients received systemic corticosteroids, dapsone and cyclophosphamide, and several sessions of plasmapheresis were also associated in one patient. One patient was controlled with topical corticosteroids and dapsone. CONCLUSIONS: Many patients with MMP can present with severe secondary complications. For this reason, the diagnosis must be confirmed quickly and the appropriate treatment started as soon as possible. The association of corticosteroids, dapsone and cyclophosphamide is a combination that gives very good results.

[Mucous membrane pemphigoid: IgG and IgA antibodies against the BP180 antigen]. / Penfigoide de mucosas: anticuerpos IgG e IgA contra el antígeno BP180.

INTRODUCTION: Mucous membrane pemphigoid is a group of autoimmune bullous diseases, mediated by autoantibodies directed against different proteins in the dermoepidermal junction, including the BP180 antigen. PATIENTS, MATERIAL AND METHODS: We included five patients with MMP in this study. We studied the presence of circulating autoantibodies against the BP180 antigen and against recombinant extracellular fragments of this protein. RESULTS: We detected the presence of circulating antibodies against BP180 in all of the patients. Indirect immunofluorescence (IIF) studies were positive in 2 patients (20 %), as well as in 2 patients via salt-split studies. We found reactivity to the extracellular fragment of BP180 (LAD-1) in 3 patients, 2 of them via IgA and 1 with IgG. The serum of only 2 patients recognized the NC16A fragment, and 4 of the 5 patients had antibodies against the carboxy-terminal domain BP180 4575. CONCLUSIONS: Molecular biology techniques are very important to complement the diagnosis of MMP, especially when the results of hematoxylin-eosin or IF studies are not satisfactory for a diagnosis of MMP.

[The usefulness of isotopic lymphoscintigraphy in the study of lymphedemas]. / Utilidad de la linfogammagrafía isotópica en el estudio de linfedemas.

INTRODUCTION: Lymphedema is a process caused by the obstruction or destruction of the lymphatic vessels in the subcutaneous tissue. Early diagnosis and treatment can improve its clinical course, but this debilitating disease is often misdiagnosed. OBJECTIVE: To highlight the importance of isotopic lymphoscintigraphy as a simple, non-invasive technique for the assessment and diagnosis of lymphedemas. MATERIAL AND METHODS: We present 2 patients affected with genital edema, and another with edema in the right upper limb. All of these were secondary to chronic infections. An isotopic lymphoscintigraphy was performed on all three patients. RESULTS: In all three patients, the isotopic lymphoscintigraphy made it possible to confirm the diagnosis and the extent of the lymphedema. CONCLUSIONS: We believe that techniques such as phlebography, ultrasound/Doppler, CAT, magnetic resonance, cultures and biopsies should be used with all lymphedema patients in order to establish the cause of the disease. We propose that isotopic lymphoscintigraphy be added to these tests for appropriate lymphedema management.

Hormonas gastrointestinales en la estimulación enteral mínima en neonatos prematuros enfermos / Gastrointestinal hormone and minimal enteral feeding in sick premature infants

Objetivo. Medir la respuesta hormonal con estimulación enteral mínima (EEM) en prematuros enfermos. Metología. Fueron 41 pacientes, con peso al nacimiento <1800 g, distribuidos en: grupo I (temprano) con inicio del estímulo en menos de cinco días de edad (n=26), y grupo II (tardío) entre 10 y 14 días (n=15). Se hicieron mediciones basales de cuatro hormonas gastrointestinales (gastrina, PIG, motilina y neurotensina y se inició la estimulación con fórmula para prematuros diluida, comenzando un un mL cada dos horas e incrementando un mL diario hasta alcanzar aproximadamente 120 mL como volumen total, y se registraron las mediciones de las hormonas. Resultados. No hubo diferencia intergrupos en peso, edad gestacional, trofismo y estancia hospitalaria. Hubo diferencias intragrupos entre las mediciones basal y final en todas las hormonas en ambos grupos. Los resultados por subgrupos de edad gestacional (menores y mayores de 32 semanas) y eutróficos e hipotróficos mostraron diferencial basal-final. En relación con peso al nacer y volumen de leche de la EEM, los resultados fueron variables. No hubo complicaciones con el uso del EEM. Conclusiones. El EEM favorece la secreción hormonal gastrointestinal en prematuros enfermos aun administrado tardíamente. El EEM no incrementó las complicaciones abdominales. El peso, la edad gestacional, y el grado trofismo no se asocian a la magnitud de la secreción hormonal

Los derechos del niño y la responsabilidad del pediatra / The rights of children and responsability the pediatrician

Ante la dramática realidad que viven miles de niños en nuestro país, los médicos deben hacer conciencia del papel que desempeñamos como educadores y orientadores de la familia y de la comunidad. Conocer, difundir, aplicar los derechos de los niños, no es una obligación, sino una responsabilidad, tenemos que mejorar la salud y las condiciones de vida de nuestros niños, asegurarles así un crecimiento y desarrollo lo más sano y digno posible, en beneficio de nuestra sociedad. En este ensayo se discuten las transgresiones más frecuentes a estos derechos, en el ejercicio diario de la profesión

Indicadores de infección temprana en septicemia neonatal / Early diagnostic of neonatal septicemia

Se efectuó un estudio prospectivo en 58 neonatos con sospecha de septicemia, evaluándose al ingreso: proteína C rectiva, haptoglobina, fibrinógeno, velocidad de sedimentación globular, leucopenia o leucocitosis, neutropenia, trombocitopenia, bandas, relación bandas/neutrófilos e inmaduros/neutrófilos y hemoglobina. Catorce niños (21.4 por ciento) tuvieron hemocultivo positivo. La proteína C reactiva presentó la mayor sensibilidad (71 por ciento), pero también mayor número de falsos positivos (74 por ciento) y menor valor predictivo de índices positivos (26 por ciento). Más de cuatro índices positivos (4 puntos o más) dieron mayor sensibilidad y falsos positivos elevados (75 y 61.7 por ciento) con significancia estadística al aumentar el puntaje. La combinación de leucopenia con neutropenia elevó la sensibilidad; mejorando el valor predictivo y la eficiencia de la prueba (> 80 por ciento) al adicionar la trombocitopenia , la proteína C-reactiva o el fibrinógeno, con especificidad arriba del 90 por ciento. La ausencia de leucopenia y plaquetopenia, neutropenia e hipofibrinogenemia incrementan el valor de predicción de negatividad y la eficacia de los índices. Se concluye que las discrepancias de estos resultados ofrecen poca validez en la interpretación separada o conjunta de estos indicadores de infección, para establecer el diagnóstico temprano de septicemia neonatal

Ambroxol. Alternativas de uso en neonatología / Ambroxol. therapy use in newborn

El ambroxol es un medicamento útil en el tratamiento del síndrome de dificultad respiratoria neonatal, dada su capacidad de elevar la producción y liberación de surfactante y de mejorar los mecanismos pulmonares. Por otro lado, previene la atelectasia pulmonar postextubación, adicionándose a las características anteriores su efecto mucolítico y mucocinético. En el presente trabajo se hace una revisión para ofrecer al lector una visión amplia del medicamento y sus posibles aplicaciones en pediatría. No se pretende sugerir que el ambroxol desplace las otras posibilidades terapéuticas, sino presentarlo como un medicamento que ofrece nuevas alternativas

Los derechos del niño... ¿o las obligaciones del adulto? / The children rights... or adult responsabilities?

Se analizan y comentan los derechos de los niños en relación a las obligaciones del adulto

Riesgo de atelectasia postextubación en neonatos tratados con ambroxol / The effect of ambroxol in the newborn with post-extubation atelectasia

Se valora el efecto del ambroxol en recién nacidos con atelectasia postextubación. Se estudiaron 66 neonatos que requerían asistencia ventilatoria, divididos en dos grupos. El grupo I (n=36) tratado con ambroxol intravenoso, administrado desde inicio del destete hasta tres días después de la postextubación; el grupo II (control) fue integrado con 30 niños que recibieron tratamiento convencional. Ambos grupos fueron similares en semanas de edad gestacional, peso, Apgar y días de asistencia ventilatoria. Al valorar la evolución postextubación, al término del segundo día, la atelectasia postextubación fue menor frecuente en el grupo I (p<0.001); y al tercer día, la frecuencia de atelectasia fue de cero casos en el grupo I. Se concluye que el ambroxol facilita el drenaje de secreciones y disminuye el riesgo de presentación de atelectasia postextubación en el neonato que se recupera de patología pulmonar

Utilidad del ambroxol en el neonato con síndrome de dificultad respiratoria / The use of ambroxol in the treatment of neonatal respiratory distress sydrome

Se valora la utilidad del ambroxol en el tratamiento del recién nacido con síndrome de dificultad respiratoria (SDR). El grupo I (n=26) recibió ambroxol y el grupo II (n=22), fue el grupo control. Ambos grupos se sometieron a intubaciones y asistencia ventilatoria mecánica convencional. No hubo diferencia significativa en edad gestacional, peso y apgar al nacimiento. La edad de ingreso fue menor en forma significativa en el grupo I. Al evaluar el efecto sobre PaO2, se observó aumento significativo en los días 1 y 2 de tratamiento en el grupo I, así como también en el índice de oxigenación en el primer día. La extubación fue más precoz en el grupo I aunque no significativa. Hubo también niños con atelectasia pulmonar postextubación (APE). El ambroxol mejora la PaO2 y el índice de oxigenación en los primeros días de tratamiento, por lo que constituye una alternativa en el tratamiento integral de neonatos con síndrome de dificultad respiratoria