Psaudoaneurisma de la arteria hipogástrica izquierda, una causa extremadamente rara de sangrado puerperal tardío / Pseudoaneurysm of the left hypogastric artery, an extremely rare cause of late puerperal late puerperal bleeding

Resumen ANTECEDENTES: La hemorragia puerperal tardía implica una importante morbilidad y mortalidad que requiere una actuación urgente. Su causa es muy variada y requiere una cuidadosa valoración que permita detenerla, sin complicaciones. CASO CLÍNICO: Paciente de 42 años que a las cinco semanas posteriores a una cesárea acudió a Urgencias debido a un sangrado puerperal abundante. Enseguida de un legrado y exhaustiva revisión en el quirófano en la ecografía se identificó un área parauterina anecogénica sugerente de dilatación aneurismática comunicada con la cavidad uterina. El diagnóstico se estableció con base en la angiografía y se confirmó luego de la embolización mediante radiología intervencionista, sin contratiempos, y resolución del cuadro. La paciente se dio de alta del hospital en los siguientes dos días, con posteriores revisiones que se reportaron normales. CONCLUSIONES: La patología vascular debe formar parte del diagnóstico diferencial del sangrado puerperal tardío y, si se diagnostica adecuadamente, puede facilitar el procedimiento terapéutico mediante radiología intervencionista y evitar, así, otros tratamientos más invasivos.

Abstract BACKGROUND: Late puerperal hemorrhage is a major morbidity and mortality that requires urgent action. Its cause is very varied and requires careful assessment to stop it without complications. CLINICAL CASE: A 42-year-old woman came to the emergency department five weeks after cesarean section for heavy puerperal bleeding. After curettage and thorough examination in the operating room, ultrasound identified an anechogenic parauterine area suggestive of aneurysmal dilatation in communication with the uterine cavity. The diagnosis was established based on angiography and confirmed after embolization by interventional radiology, without mishap, and resolution of the picture. The patient was discharged in two days, with subsequent revisions reported as normal. CONCLUSIONS: Vascular pathology should be part of the differential diagnosis of late puerperal hemorrhage and, if properly diagnosed, may facilitate the therapeutic procedure by interventional radiology and thus avoid other more invasive treatments.

Gut microbiota: A potential therapeutic target for management of diabetic retinopathy?

Diabetic Retinopathy (DR) is one of the main complications of Diabetes Mellitus (DM), drastically impacting individuals of working age over the years, being one of the main causes of blindness in the world. The existing therapies for its treatment consist of measures that aim only to alleviate the existing clinical signs, associated with the microvasculature. These treatments are limited only to the advanced stages and not to the preclinical ones. In response to a treatment with little resolution and limited for many patients with DM, investigations of alternative therapies that make possible the improvement of the glycemic parameters and the quality of life of subjects with DR, become extremely necessary. Recent evidence has shown that deregulation of the microbiota (dysbiosis) can lead to low-grade, local and systemic inflammation, directly impacting the development of DM and its microvascular complications, including DR, in an axis called the intestine-retina. In this regard, the present review seeks to comprehensively describe the biochemical pathways involved in DR as well as the association of the modulation of these mechanisms by the intestinal microbiota, since direct changes in the microbiota can have a drastic impact on various physiological processes. Finally, emphasize the strong potential for modulation of the gut-retina axis, as therapeutic and prophylactic target for the treatment of DR.

Cambiando el paradigma educativo: propuesta de una estrategia educativa para la enseñanza-aprendizaje en cirugía vascular. Prueba piloto / Changing the Educational Paradigm: Educational Strategy Proposal for Vascular Surgery Teaching-Learning. Pilot Test / Transformando o paradigma educativo: proposta de uma estratégia educativa para o ensino-aprendizagem em cirurgia vascular. Teste-piloto

Resumen: La preocupación por los escasos conocimientos en temas relacionados con la patología vascular en numerosos médicos generales ha llevado a cuestionar si el método tradicional de enseñanza en el área de cirugía vascular y angiología de la Universidad Militar Nueva Granada (UMNG) es el más apropiado y práctico para construir un conocimiento duradero, que pueda ser aplicado. En este trabajo analizamos los resultados de la implementación de tecnologías de la información y la comunicación (Tic) en la enseñanza-aprendizaje de los conocimientos que el médico general debe tener en cuanto a patologías vasculares, particularmente, las más frecuentes en la práctica clínica. Se trató de un modelo de aula virtual con módulos en que se presentaron los temas del currículo actual de la materia Patologías Vasculares y Angiología del Programa de Medicina de la UMNG, siguiendo el modelo de aula invertida (flipped classroom). Entre los resultados destaca una mejoría significativa de las notas en los estudiantes evaluados luego de que cursaron le módulo virtual, tanto en los casos en que ya habían llevado a cabo la rotación en el servicio de Cirugía Vascular, como en los que no lo habían hecho. La evaluación de esta prueba piloto se hizo con miras a determinar la efectividad de implementar en el futuro un módulo virtual aplicable a mayor escala en la formación básica del médico general en la Facultad de Medicina de la UMNG.

Abstract: The concern about numerous general practitioners' scarce knowledge of vascular pathology has led to questioning whether the traditional teaching method in the field of vascular surgery and angiology at the Universidad Militar Nueva Granada (UMNG) is the most appropriate and practical to build lasting and applicable knowledge. This paper discusses the results of implementing information and communication technologies (ICT) in the teaching-learning of knowledge of vascular pathologies, particularly the most frequent ones in clinical practice, that the general practitioner should have. It is a virtual classroom model with modules that present the current curriculum topics of the Vascular Pathologies and Angiology subject of the UMNG Medicine Program, following the flipped classroom model. The results include significant improvement in the marks of the students evaluated after completing the virtual module, whether they had already done a rotation in the Vascular Surgery service or not. The assessment of this pilot test was carried out to determine the effectiveness of implementing a virtual module applicable on a larger scale in the future to the basic training of general practitioners at the UMNG School of Medicine.

Resumo: A preocupação pelos escassos conhecimentos em temas relacionados com a patologia vascular em inúmeros clínicos gerais tem levado a questionar se o método tradicional de ensino na área de cirurgia vascular e angiologia da Universidad Militar Nueva Granada (UMNG) seja o mais apropriado e prático para construir um conhecimento duradouro, que possa ser aplicado. Neste trabalho, analisamos os resultados da implantação de tecnologias da informação e da comunicação no ensi-no-aprendizagem dos conhecimentos que o clínico geral deve ter quanto a patologias vasculares, em especial, as mais frequentes na prática clínica. Trata-se de um modelo de sala de aula virtual com módulos em que são apresentados os temas do currículo atual da matéria de Patologias Vasculares e Angiologia do programa de Medicina da UMNG, que segue o modelo de sala de aula invertida (flipped classroom). Entre os resultados, destaca-se uma melhora significativa das notas nos estudantes avaliados após cursarem o módulo virtual, tanto nos casos em que já tinham realizado o rodízio no serviço de cirurgia vascular quanto nos quais não tinham feito. A avaliação desse teste-piloto foi feita com vistas a determinar a efetividade de implantar, no futuro, um módulo virtual aplicável a maior escala na formação básica do clínico geral na faculdade de Medicina da UMNG.

Re-thinking the Etiological Framework of Neurodegeneration.

Neurodegenerative diseases are among the leading causes of disability and death worldwide. The disease-related socioeconomic burden is expected to increase with the steadily increasing life expectancy. In spite of decades of clinical and basic research, most strategies designed to manage degenerative brain diseases are palliative. This is not surprising as neurodegeneration progresses "silently" for decades before symptoms are noticed. Importantly, conceptual models with heuristic value used to study neurodegeneration have been constructed retrospectively, based on signs and symptoms already present in affected patients; a circumstance that may confound causes and consequences. Hence, innovative, paradigm-shifting views of the etiology of these diseases are necessary to enable their timely prevention and treatment. Here, we outline four alternative views, not mutually exclusive, on different etiological paths toward neurodegeneration. First, we propose neurodegeneration as being a secondary outcome of a primary cardiovascular cause with vascular pathology disrupting the vital homeostatic interactions between the vasculature and the brain, resulting in cognitive impairment, dementia, and cerebrovascular events such as stroke. Second, we suggest that the persistence of senescent cells in neuronal circuits may favor, together with systemic metabolic diseases, neurodegeneration to occur. Third, we argue that neurodegeneration may start in response to altered body and brain trophic interactions established via the hardwire that connects peripheral targets with central neuronal structures or by means of extracellular vesicle (EV)-mediated communication. Lastly, we elaborate on how lifespan body dysbiosis may be linked to the origin of neurodegeneration. We highlight the existence of bacterial products that modulate the gut-brain axis causing neuroinflammation and neuronal dysfunction. As a concluding section, we end by recommending research avenues to investigate these etiological paths in the future. We think that this requires an integrated, interdisciplinary conceptual research approach based on the investigation of the multimodal aspects of physiology and pathophysiology. It involves utilizing proper conceptual models, experimental animal units, and identifying currently unused opportunities derived from human data. Overall, the proposed etiological paths and experimental recommendations will be important guidelines for future cross-discipline research to overcome the translational roadblock and to develop causative treatments for neurodegenerative diseases.

Disfunção endotelial e hipertensão pulmonar / Endothelial dysfunction and pulmonary hypertension

Alterações no endotélio vascular pulmonar podem cursar mudanças abruptas no funcionamento harmônico do leito vascular pulmonar. Essas mudanças podem causar situações de aumento de resistência e de pressão da artéria pulmonar levando a uma condição de hipertensão pulmonar. Dessa forma, dosagens dos níveis de óxido nítrico pulmonar por meio do condensado do exalado pulmonar podem ser interessantes por contribuir para o ajuste da melhor terapêutica a ser empregada, e auxiliar no diagnóstico de hipertensão pulmonar. Algumas terapêuticas inalatórias podem auxiliar no tratamento da hipertensão pulmonar, destacando-se, entre elas, o óxido nítrico inalado, nitroprussiato de sódio, nitroglicerina e milrinone inalados na tentativa de reduzir a pressão elevada da artéria pulmonar. Cabe às equipes especializadas determinar qual o melhor tratamento a ser empregado para cada paciente, diante das diversas opções disponíveis. A presente revisão tem a finalidade de atualizar aspectos da disfunção endotelial na hipertensão pulmonar embasada em cinco tópicos: 1) O papel do óxido nítrico no sistema respiratório; 2) Alguns aspectos fisiopatológicos da hipertensão pulmonar; 3) O papel do óxido nítrico na hipertensão pulmonar; 4) O recurso da dosagem de nitrito no condensado pulmonar como expressão da microcirculação pulmonar e; 5) As opções terapêuticas inalatórias para o tratamento da hipertensão pulmonar.

Changes in pulmonary vascular endothelium may cause abrupt changes in the harmonious functioning of the pulmonary vascular circulation. These changes can lead to situations of increased resistance and pulmonary artery pressure leading to pulmonary hypertension condition. Thus, measurements of pulmonary nitric oxide levels by exhaled breath condensate may be an interesting contribution to the adjustment of treatment to be employed, and assist in the diagnosis of pulmonary hypertension. Some inhalation therapies can assist in the treatment of pulmonary hypertension, such as: inhaled nitric oxide, sodium nitroprusside, nitroglycerin and inhaled milrinone in an attempt to reduce the increased pulmonary artery pressure. This review aims to update aspects of endothelial dysfunction in pulmonary hypertension based on five topics: 1) The role of nitric oxide in the respiratory system; 2) Some pathophysiological aspects of pulmonary hypertension, 3) The role of nitric oxide in pulmonary hypertension and 4) The appeal of the determination of nitrite in the condensate and pulmonary expression of pulmonary microcirculation and 5) The inhalation therapeutic options for the pulmonary hypertension treatment.

Disfunção endotelial vasoplégica / The endothelial vasoplegic dysfunction

Embora a maioria dos estados de choque circulatório esteja associada com diminuição do débito cardíaco, uma situação distinta ocorre nos casos de choques por diminuição da capacitância vascular, na qual a situação de vasoplegia associa-se à elevação do débito cardíaco, configurando uma situação hiperdinâmica com hipotensão grave resistente a altas doses de catecolaminas. O mau prognóstico parece mais bem correlacionado com a baixa resistência vascular, levando à conclusão de que a vasoplegia é o fator prognóstico determinante. Dessa forma, o controle parácrino da capacitância vascular passa a ser um fator extremamente importante para investigações clínicas e experimentais na busca de novos conhecimentos fisiopatológicos e terapêuticos que possam contribuir para o tratamento e prognóstico da vasoplegia. Assim, a disfunção endotelial “vasoplégica” estaria presente nos estados de choque distributivo causada por ações de citocinas que estimulam liberação patológica de fatores relaxantes do endotélio, principalmente do óxido nítrico (sepse, anafilaxia, reações anafilactoides e vasoplegias relacionadas à circulação extracorpórea). Ressalte-se que a disfunção endotelial está associada a todos os tipos de estado de choque, disfunção essa abordada nessa revisão.

Although most circulatory shock conditions are associated with decreased cardiac output, a different situation occurs in cases of circulatory shock by decreasing vascular capacitance vasoplegia when the condition is associated with elevation of cardiac output by setting a hyperdynamic state with hypotension resistant to high doses of catecholamines. The poor prognosis appears better correlated with low vascular resistance, leading to the conclusion that the vasoplegia prognostic factor is decisive. Thus, the paracrine control of vascular capacitance becomes an extremely important factor for clinical and experimental investigations in research of new pathophysiological and therapeutic knowledge that may contribute to the treatment and prognosis of vasoplegia. Thus, endothelial "vasoplegic" dysfunction would be present in the distributive shock states caused by the actions of cytokines that stimulate pathological release of endothelial relaxing factors, mainly nitric oxide (sepsis, anaphylaxis, anaphylactic reactions and vasoplegias related to cardiopulmonary bypass). It is noteworthy that endothelial dysfunction is associated with all types of shocks and this impairment is discussed in this review.