Impacto de la diabetes, la desnutrición y la sarcopenia en el pronóstico de los pacientes hospitalizados en Medicina Interna / Impact of diabetes, malnutrition and sarcopenia on the prognosis of patients admitted to Internal Medicine

Objetivo Describir los pacientes hospitalizados en medicina interna en términos de desnutrición y sarcopenia, en función de la presencia o no de diabetes mellitus tipo 2 (DM2), así como evaluar la mortalidad a corto y largo plazo relacionada con ambas. Métodos Estudio de cohortes, unicéntrico, que recoge pacientes consecutivos ingresados en Medicina Interna en mayo y octubre del 2021. La desnutrición se determinó mediante el Mini Nutritional Assessment-Short Form (MNA-SF) y la sarcopenia mediante SARC-F y dinamometría. Se excluyó a los pacientes hospitalizados más de 48 h. Resultados Se analiza a 511 pacientes, 49,1% varones, edad media de 75,2±15 años, 210 (41,1%) DM2. Se generan 6 grupos (diseño 2 × 3) en función de la presencia de DM2 y del estado nutricional acorde con el resultado del MNA-SF: 12-14 puntos, sin riesgo; MNA-SF 8-12 puntos, alto riesgo; MNA-SF 0-7 puntos, desnutridos. Los pacientes con DM2 y desnutridos tenían significativamente mayor sarcopenia, comorbilidad, inflamación y úlceras por presión. Los principales determinantes de mortalidad intrahospitalaria fueron la sarcopenia (OR 1,27, IC del 95%, 1,06-1,54, p=0,01), la comorbilidad (OR 1,27, IC del 95%, 1,08-1,49, p=0,003) y la inflamación (OR 1,01, IC del 95%, 1,00-1,02, p=0,02). El pronóstico a 120 días fue peor entre los pacientes desnutridos (p=0,042). Conclusión Los pacientes ingresados con DM2 presentan similar grado de desnutrición que el resto, pero con mayor sarcopenia. Esta sarcopenia, junto a la inflamación y la comorbilidad determinan un peor pronóstico. La identificación activa y temprana de la desnutrición y la sarcopenia, y su abordaje posterior podrían mejorar el pronóstico de los pacientes (AU)

Objective To describe patients hospitalized in internal medicine in terms of malnutrition and sarcopenia, depending on the presence or absence of type 2 diabetes mellitus (DM2), as well as to evaluate short- and long-term mortality related to both. Methods Cross-sectional, single-center study, which included consecutive patients admitted to internal medicine in May and October 2021. Malnutrition was determined using the Mini Nutritional Assessment-Short Form (MNA-SF) and sarcopenia using SARC-F and handgrip strength. Patients hospitalized for more than 48h are excluded. Results Five hundred and 11patients were analyzed, 49.1% male, mean age 75.2±15 years, 210 (41.1%) DM2. Six groups (2×3 design) are generated based on the presence of DM2 and the nutritional status according to the result of the MNA-SF: 12–14 points, without risk; MNA-SF 8–12 points, high risk; MNA-SF 0–7 points, malnourished. Malnourished patients with DM2 had significantly higher sarcopenia, comorbidity, inflammation, and pressure ulcers. The main determinants of in-hospital mortality were sarcopenia (OR 1.27, 95% CI: 1.06–1.54, p=0.01), comorbidity (OR 1.27, 95% CI: 1.08–1.49, p=0.003) and inflammation (OR 1.01, 95% CI: 1.00–1.02, p=0.02). The 120-day prognosis was worse among malnourished patients (p=0.042). Conclusion Patients admitted with DM2 have a similar degree of malnutrition than the rest, but with greater sarcopenia. This sarcopenia, together with inflammation and comorbidity determine a worse prognosis. The active and early identification of malnutrition and sarcopenia and their subsequent approach could improve the prognosis of patients (AU)

Impact of diabetes, malnutrition and sarcopenia on the prognosis of patients admitted to internal medicine.

OBJECTIVE: To describe patients hospitalized in internal medicine in terms of malnutrition and sarcopenia, depending on the presence or absence of type 2 diabetes mellitus (DM2), as well as to evaluate short- and long-term mortality related to both. METHODS: Cross-sectional, single-center study, which included consecutive patients admitted to internal medicine in May and October 2021. Malnutrition was determined using the Mini Nutritional Assessment-Short Form (MNA-SF) and sarcopenia using SARC-F and handgrip strength. Patients hospitalized for more than 48 h are excluded. RESULTS: 511 patients were analyzed, 49.1% male, mean age 75.2 +/- 15 years, 210 (41.1%) DM2. 6 groups (2 × 3 design) are generated based on the presence of DM2 and the nutritional status according to the result of the MNA-SF: 12-14 points, without risk; MNA-SF 8-12 points, high risk; MNA-SF 0-7 points, malnourished. Malnourished patients with DM2 had significantly higher sarcopenia, comorbidity, inflammation, and pressure ulcers. The main determinants of in-hospital mortality were sarcopenia (OR 1.27, 95%CI 1.06-1.54, p = 0.01), comorbidity (OR 1.27, 95%CI 1,08-1,49, p = 0.003) and inflammation (OR 1.01, 95%CI 1.00-1.02, p = 0.02). The 120-day prognosis was worse among malnourished patients (p = 0.042). CONCLUSION: Patients admitted with DM2 have a similar degree of malnutrition than the rest, but with greater sarcopenia. This sarcopenia, together with inflammation and comorbidity determine a worse prognosis. The active and early identification of malnutrition and sarcopenia and their subsequent approach could improve the prognosis of patients.

Asociación entre rigidez arterial y masa grasa en pacientes con obesidad / Association between arterial stiffness and fat mass in patients with obesity

Objetivo Comprobar si la composición corporal en los pacientes con obesidad de riesgo alto (índice de masa corporal>35 o entre 30 y 34,9kg/m2 con un perímetro abdominal mayor de 102cm en varones o mayor de 88cm en mujeres) se relaciona con la enfermedad vascular. Métodos Estudio transversal de pacientes con obesidad de riesgo alto. Se mide su masa grasa mediante bioimpedancia y la rigidez arterial mediante la velocidad de la onda de pulso (VOP). Se analizan los terciles de pacientes según la distribución de la VOP. Resultados Se ha estudiado a 59 pacientes. Con incrementos de la VOP, aumentan el IMC (p=0,02) y el contenido de masa grasa (p<0,00). Existe, además, un incremento significativo de los indicadores de inflamación. Conclusiones En pacientes con obesidad de riesgo alto existen diferencias relativas a su composición corporal que se asocian a modificaciones de su rigidez arterial y de su carga inflamatoria (AU)

Objective The aim is to observe whether body composition in patients with high-risk obesity (body mass index>35 or between 30 and 34.9kg/m2 with a waist circumference greater than 102cm in men or greater than 88cm in women) is related with vascular disease. Methods This is a cross-sectional study of patients with high-risk obesity. Their fat mass was measured through bioimpedance and arterial stiffness through pulse wave velocity (PWV). Tertiles of patients were analyzed according to PWV distribution. Results A total of 59 patients were analyzed. As PWV increased, BMI (p=0.02) and fat mass content (p<0.00) increased. There was also a significant increase in inflammation indicators. Conclusions In patients with high-risk obesity, there were differences in their body composition which were associated with changes in arterial stiffness and inflammatory burden (AU)

Association between arterial stiffness and fat mass in patients with obesity.

OBJECTIVE: The aim is to observe whether body composition in patients with high-risk obesity (body mass index >35 or between 30 and 34.9kg/m2 with a waist circumference greater than 102cm in men or greater than 88cm in women) is related with vascular disease. METHODS: This is a cross-sectional study of patients with high-risk obesity. Their fat mass was measured through bioimpedance and arterial stiffness through pulse wave velocity (PWV). Tertiles of patients were analyzed according to PWV distribution. RESULTS: A total of 59 patients were analyzed. As PWV increased, BMI (p=0.02) and fat mass content (p<0.00) increased. There was also a significant increase in inflammation indicators. CONCLUSIONS: In patients with high-risk obesity, there were differences in their body composition which were associated with changes in arterial stiffness and inflammatory burden.

Recomendaciones para el tratamiento oral de pacientes adultos con enfermedad de Gaucher tipo 1 / Recommendations for oral treatment for adult patients with type 1 Gaucher disease

Revisión de la evidencia científica sobre el tratamiento oral de pacientes adultos con enfermedad de Gaucher tipo 1 (EG1), con formato de guía clínica, según la normativa Agree II. Se describen las principales diferencias entre los 2 tratamientos orales disponibles actualmente para el tratamiento de esta entidad (miglustat y eliglustat).En esta revisión se recuerda que los criterios para iniciar el tratamiento oral en los pacientes con EG1 deben valorarse de forma individualizada. Si bien miglustat y eliglustat son inhibidores de la enzima glucosilceramida sintetasa, los 2 presentan diferentes mecanismos de acción y propiedades farmacológicas y nunca se deben considerar como equivalentes. Miglustat está indicado en pacientes con EG1 no grave que no pueden recibir otro tratamiento de primera línea, mientras que eliglustat está indicado en pacientes con EG1 con cualquier gravedad, en primera línea y sin necesidad de estabilización previa con tratamiento de reemplazo enzimático. Es importante enfatizar que para iniciar tratamiento con eliglustat debemos conocer el fenotipo metabólico CYP2D6 y que su asociación con fármacos metabolizados a través de los citocromos CYP2D6 y CYP3A4 –o bien que utilicen la glucoproteína P– se debe evaluar individualmente. Durante el embarazo se debe evitar el uso de eliglustat, pudiéndose emplear únicamente el tratamiento de reemplazo enzimático. A diferencia de miglustat, cuyos efectos adversos han limitado su utilización, eliglustat no solo ha demostrado una eficacia similar a la del tratamiento de reemplazo enzimático, sino que ha demostrado mejoría en la calidad de vida de los pacientes EG1. (AU)

This work is a review of the scientific evidence on the oral treatment of adult patients with Gaucher disease type 1 (GD1) with a clinical guideline format according to the Agree II regulations. It describes the main differences between the 2 oral treatments currently available for treating this disease (miglustat and eliglustat).This review reminds us that the criteria for starting oral treatment in patients with GD1 must be assessed individually. Although miglustat and eliglustat are both glucosylceramide synthase enzyme inhibitors, they have different mechanisms of action and pharmacological properties and should never be considered equivalent. Miglustat is indicated in patients with non-severe GD1 who cannot receive other first-line treatments, while eliglustat is indicated as first-line treatment for patients with GD1 of any severity without the need for prior stabilization with enzyme replacement therapy. It is important to emphasize that in order to start treatment with eliglustat, we must know the CYP2D6 metabolic phenotype and its association with drugs metabolized through the CYP2D6 and CYP3A4 cytochromes –or alternatively those that use P-Glycoprotein– must be evaluated on an individual basis. During pregnancy, the use of eliglustat should be avoided; only enzyme replacement therapy can be used. Unlike miglustat, whose adverse effects have limited its use, eliglustat has not only demonstrated similar efficacy to enzyme replacement therapy but has also been shown to improve the quality of life of patients with GD1. (AU)

Recommendations for oral treatment for adult patients with type 1 Gaucher disease.

This work is a review of the scientific evidence on the oral treatment of adult patients with Gaucher disease type 1 (GD1) with a clinical guideline format according to the Agree II regulations. It describes the main differences between the two oral treatments currently available for treating this disease (miglustat and eliglustat). This review reminds us that the criteria for starting oral treatment in patients with GD1 must be assessed individually. Although miglustat and eliglustat are both glucosylceramide synthase (GCS) enzyme inhibitors, they have different mechanisms of action and pharmacological properties and should never be considered equivalent. Miglustat is indicated in patients with non-severe GD1 who cannot receive other first-line treatments, while eliglustat is indicated as first-line treatment for patients with GD1 of any severity without the need for prior stabilization with enzyme replacement therapy (ERT). It is important to emphasize that in order to start treatment with eliglustat, we must know the CYP2D6 metabolic phenotype and its association with drugs metabolized through the CYP2D6 and CYP3A4 cytochromes-or alternatively those that use P-Glycoprotein must be evaluated on an individual basis. During pregnancy, the use of eliglustat should be avoided; only ERT can be used. Unlike miglustat, whose adverse effects have limited its use, eliglustat has not only demonstrated similar efficacy to ERT but has also been shown to improve the quality of life of patients with GD1.

Phase and amplitude reconstruction in single-pixel transmission microscopy: a comparison of Hadamard, cosine, and noiselet bases.

Hadamard, cosine, and noiselet bases are implemented into a digital holographic microscope based on single-pixel imaging with the capability to retrieve images of complex objects. The object is illuminated with coherent light modulated with different patterns deployed in a digital micromirror device, and the resulting fields are captured by single-pixel detection. For amplitude images, the experimental results of the three bases are evaluated with the peak SNR criteria. It is shown that the cosine basis recovers amplitude distributions with the best quality. Regarding phase images, the recovered ones compare well with those obtained with a CMOS camera.

Recommendations for the reopening and activity resumption of the neurogastroenterology units in the face of the COVID-19 pandemic. Position of the Sociedad Latinoamericana de Neurogastroenterología. / Recomendaciones para la reapertura y reinicio de actividades de las Unidades de Neurogastroenterología ante la pandemia por COVID-19. Posicionamiento de la Sociedad Latinoamericana de Neurogastroenterología.

The COVID-19 pandemic has forced the establishment of preventive measures against contagion during the performance of diagnostic and therapeutic tests in gastroenterology. Digestive tract motility tests involve an intermediate and elevated risk for the transmission of COVID-19 infection. Given their elective or non-urgent indication in the majority of cases, we recommend postponing those tests until significant control of the infection rate in each Latin American country has been achieved during the pandemic. When the health authorities allow the return to normality, and in the absence of an effective treatment for or preventive vaccine against COVID-19 infection, we recommend a strict protocol for classifying patients according to their infectious-contagious status through the appropriate use of tests for the detection of the virus and the immune response to it, and the following of protective measures by the healthcare personnel to prevent contagion during the performance of a gastrointestinal motility test.

Mean Airway Pressure As a Predictor of 90-Day Mortality in Mechanically Ventilated Patients.

OBJECTIVES: To determine the association between mean airway pressure and 90-day mortality in patients with acute respiratory failure requiring mechanical ventilation and to compare the predictive ability of mean airway pressure compared with inspiratory plateau pressure and driving pressure. DESIGN: Prospective observational cohort. SETTING: Five ICUs in Lima, Peru. SUBJECTS: Adults requiring invasive mechanical ventilation via endotracheal tube for acute respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of potentially eligible participants (n = 1,500), 65 (4%) were missing baseline mean airway pressure, while 352 (23.5%) were missing baseline plateau pressure and driving pressure. Ultimately, 1,429 participants were included in the analysis with an average age of 59 ± 19 years, 45% female, and a mean PaO2/FIO2 ratio of 248 ± 147 mm Hg at baseline. Overall, 90-day mortality was 50.4%. Median baseline mean airway pressure was 13 cm H2O (interquartile range, 10-16 cm H2O) in participants who died compared to a median mean airway pressure of 12 cm H2O (interquartile range, 10-14 cm H2O) in participants who survived greater than 90 days (p < 0.001). Mean airway pressure was independently associated with 90-day mortality (odds ratio, 1.38 for difference comparing the 75th to the 25th percentile for mean airway pressure; 95% CI, 1.10-1.74) after adjusting for age, sex, baseline Acute Physiology and Chronic Health Evaluation III, baseline PaO2/FIO2 (modeled with restricted cubic spline), baseline positive end-expiratory pressure, baseline tidal volume, and hospital site. In predicting 90-day mortality, baseline mean airway pressure demonstrated similar discriminative ability (adjusted area under the curve = 0.69) and calibration characteristics as baseline plateau pressure and driving pressure. CONCLUSIONS: In a multicenter prospective cohort, baseline mean airway pressure was independently associated with 90-day mortality in mechanically ventilated participants and predicts mortality similarly to plateau pressure and driving pressure. Because mean airway pressure is readily available on all mechanically ventilated patients and all ventilator modes, it is a potentially more useful predictor of mortality in acute respiratory failure.

Premature, Opportune, and Delayed Weaning in Mechanically Ventilated Patients: A Call for Implementation of Weaning Protocols in Low- and Middle-Income Countries.

OBJECTIVES: Weaning protocols establish readiness-to-wean criteria to determine the opportune moment to conduct a spontaneous breathing trial. Weaning protocols have not been widely adopted or evaluated in ICUs in low- and middle-income countries. We sought to compare clinical outcomes between participants whose weaning trials were retrospectively determined to have been premature, opportune, or delayed based on when they met readiness-to-wean criteria. DESIGN: Prospective, multicenter observational study. SETTING: Five medical ICUs in four public hospitals in Lima, Perú. SUBJECTS: Adults with acute respiratory failure and at least 24 hours of invasive mechanical ventilation (n = 1,657). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We established six readiness-to-wean criteria and retrospectively categorized our sample into three weaning groups: 1) premature: if the weaning trial took place before fulfilling all criteria, 2) opportune: if the weaning trial took place within 24 hours after fulfilling the criteria, and 3) delayed: if the weaning trial took place over 24 hours after fulfilling criteria. We compared 90-day mortality, ventilator-free days, ICU-free days, and hospital-free days between premature, opportune, and delayed weaning groups. In our sample, 761 participants (60.8%) were classified as having a premature weaning trial, 196 underwent opportune weaning (15.7%), and 295 experienced delayed weaning (23.6%). There was no significant difference in 90-day mortality between the groups. Both the premature and delayed weaning groups had poorer clinical outcomes with fewer ventilator-free days (-2.18, p = 0.008) and (-3.49, p < 0.001), ICU-free days (-2.25, p = 0.001) and (-3.72, p < 0.001), and hospital-free days (-2.76, p = 0.044) and (-4.53, p = 0.004), respectively, compared with the opportune weaning group. CONCLUSIONS: Better clinical outcomes occur with opportune weaning compared with premature and delayed weaning. If readiness-to-wean criteria can be applied in resource-limited settings, it may improve ICU outcomes associated with opportune weaning.

Risk factors for the development of acute respiratory distress syndrome in mechanically ventilated adults in Peru: a multicenter observational study.

BACKGROUND: Clinical and epidemiological differences between acute respiratory distress syndrome (ARDS) that presents at the initiation of mechanical ventilation [MV] (ARDS at MV onset) and that which develops during the course of MV (ARDS after MV onset) are not well understood. We conducted an observational study in five Peruvian ICUs to characterize differences between ARDS at MV onset and after MV onset and identify risk factors for the development of ARDS after MV onset. METHODS: We consecutively enrolled critically ill patients with acute respiratory failure requiring at least 24 h of mechanical ventilation and followed them prospectively during the first 28 days and compared baseline characteristics and clinical outcomes by ARDS status. RESULTS: We enrolled 1657 participants on MV (mean age 60.0 years, 55% males) of whom 334 (20.2%) had ARDS at MV onset and 180 (10.9%) developed ARDS after MV onset. Average tidal volume at the initiation of MV was 8.7 mL/kg of predicted body weight (PBW) for participants with ARDS at MV onset, 8.6 mL/kg PBW for those who developed ARDS after MV onset, and 8.5 mL/kg PBW for those who never developed ARDS (p = 0.23). Overall, 90-day mortality was 56% and 55% for ARDS after MV onset and ARDS at MV onset, respectively, as compared to 46% among those who never developed ARDS (p < 0.01). Adults with ARDS had a higher body mass index (BMI) than those without ARDS (27.3 vs 26.5 kg/m2, p < 0.01). Higher peak pressure (adjusted interquartile OR = 1.51, 95% CI 1.21-1.88), higher mean airway pressure (adjusted interquartile OR = 1.41, 95% CI 1.13-1.76), and higher positive end-expiratory pressure (adjusted interquartile OR = 1.29, 95% CI 1.10-1.50) at MV onset were associated with a higher odds of developing ARDS after MV onset. CONCLUSIONS: In this study of mechanically ventilated patients, 31% of study participants had ARDS at some point during their ICU stay. Optimal lung-protective ventilation was not used in a majority of patients. Patients with ARDS after MV onset had a similar 90-day mortality as those with ARDS at MV onset. Higher airway pressures at MV onset, higher PEEP, and higher BMI were associated with the development of ARDS after MV onset.

Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort.

OBJECTIVES: We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. DESIGN: A longitudinal study of critically ill participants on mechanical ventilation. SETTING: Five intensive care units (ICUs) in four public hospitals in Lima, Peru. PATIENTS: One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. RESULTS: After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001). CONCLUSIONS: Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.

Determinantes sociales de salud en los agricultores del resguardo indígena Zenú / Social determinants of health in indigenous farmers of shelter Zenú

Objetivo: Analizar los determinantes sociales de salud presentes entre los indígenas agricultores del Resguardo Zenú de San Andrés de Sotavento. Metodología: Estudio descriptivo de corte, con enfoque cuantitativo, participaron 64 indígenas agricultores de las comunidades Celeste Imperio y Santa Elena del Municipio de San Andrés de Sotavento en el año 2012, se seleccionaron bajo la técnica del muestreo aleatorio simple. La recolección de la información se efectuó a través de encuestas estructuradas diligenciadas mediante entrevista. Resultados: El rango de edad de la población sujeto osciló entre 18 a 70 años, existe 41% de analfabetismo absoluto, las familias son extensas con orientación endogámica, las condiciones de vida son precarias, hay ausencia de actividad recreativa y actividad física programada, 97% percibe menos de un salario mínimo mensual legal vigente producto del trabajo comunitario, 95.3% pertenece al regimen de salud subsidiado, todos carecen de afiliación a riesgos laborales y pensión, 77% admitió que tuvo algún accidente laboral en el último año, así mismo, 70% manifestó morbilidad sentida relacionada con la actividad laboral. Conclusiones: Los determinantes de carácter social que influyen negativamente en la salud identificados fueron: sociopolítico, circunstancias materiales, factores biológicos, conductuales y laborales; los cuales se reflejan en deficiencias en su calidad de vida, morbilidad sentida, accidentalidad laboral, fragilidades en el Sistema de Protección Social, altos índices de analfabetismo absoluto, pobreza y características que indiscutiblemente reafirman la relación perversa e interdependiente entre analfabetismo, pobreza y salud. Sin embargo, la cohesión social se identificó como determinante social de influencia positiva para la salud (94%).

Objective: To analyze the social determinants of health present among indigenous farmers of Zenú reservation of San Andrés de Sotavento. Methodology: Descriptive cutting with a quantitative approach, 64 indigenous farmers of communities Celeste Imperio and Santa Elena of the municipality of San Andrés de Sotavento participated in 2012; they were selected by simple random sampling technique. The data collection was conducted through structured surveys filled by interview. Results: The age range of the target population oscillated from 18 to 70 years, there is 41% of total illiteracy, families are large with inbred orientation, living conditions are poor, there are no recreational activity or physical activity programs, 97 % earn less than the monthly legal minimum wage of community work product, 95.3% belongs to the subsidized health regime, all lack of affiliation to occupational hazards and pension, 77% admitted that they had some accident in the last year also 70 % said they felt morbidity related to work activity. Conclusions: The identified social determinants that negatively affect health were: sociopolitical, material circumstances, biological, behavioral and occupational factors; which are reflected in deficiencies in their quality of life, perceived morbidity, occupational accidents, weaknesses in the social protection system, high levels of absolute illiteracy, poverty and characteristics that undoubtedly reinforce the perverse and interdependent relationship between illiteracy, poverty and health. However, social cohesion was identified as a positive influence of health (94%).

Adherencia, satisfacción al tratamiento y calidad de vida de pacientes con cáncer de mama en el Hospital Universitario del Caribe. (Cartagena, Colombia) / Adherence, treatment satisfaction and quality of life in patients with breast cancer at the Hospital Universitario del Caribe. (Cartagena, Colombia)

Objetivos: Determinar la adherencia, satisfacción al tratamiento y calidad de vida de pacientes con cáncer de mama. Materiales y métodos: Estudio descriptivo, prospectivo, trasversal, desarrollado en el Hospital Universitario del Caribe, entre agosto de 2014 y abril de 2015. La muestra fueron 23 pacientes, diagnosticadas de cáncer de mama. La adherencia, satisfacción al tratamiento y calidad de vida se determinaron con los instrumentos siguientes: Cuestionario simplified medication adherence questionnaire (SMAQ), registro de dispensación del hospital (RD), test de satisfacción ESTAR del Estudio ARPAS adaptado y el cuestionario WHOQOL BREF respectivamente. El cuestionario ESTAR fue validado por expertos y mediante alfa de Cronbach. Resultados: El 54,78% de las pacientes (según SMAQ), fueron no adherentes a quimioterápicos, la satisfacción fue de 3,94 (rango 0-6). La calidad de vida estuvo en un promedio de 3.2 (rango 1-5), con valores de 14,5% y 7,14% en el nivel 5 del rango. La mayoría de dimensiones del cuestionario de calidad de vida guardan una correlación directamente proporcional con el nivel total de satisfacción al tratamiento; arrojando un dato negativo (-0,3207) únicamente en la dimensión de satisfacción con la eficacia al tratamiento Conclusiones: La calidad de vida fue media y baja, la adherencia y satisfacción al tratamiento fueron bajas y se presentó una correlación inversa entre calidad de vida y la satisfacción al tratamiento, probablemente a causa de reacciones adversas indeseables que se constituyen en disminución de la calidad de vida

Objective: To determine the adherence, treatment satisfaction and quality of life of patients with breast cancer. Materials and methods: A descriptive, prospective, cross-sectional study, developed at the Hospital Universitario del Caribe, between August 2014 and April 2015. The sample consisted of 23 patients, diagnosed with breast cancer. Adherence, Treatment Satisfaction and quality of life were determined with the following instruments: Simplified Medication Adherence Questionnaire ( SMAQ ) , Dispensing Record (DR) , satisfaction test ESTAR of ARPAS Study adapted and WHOQOL BREF respectively. The ESTAR questionnaire was validated by experts using Cronbach’s alpha. Results: 54.78 % of patients (according SMAQ) were no adherent to chemotherapy, satisfaction was 3.94 (range 0-6) . Quality of life was on average 3.2 (range 1-5), with values of 14.5% at level 1 and 7.14% at level 5 range . Most dimensions of QoL questionnaire bear a direct correlation with the overall level of satisfaction to treatment; casting a negative figure (-0.3207 ***) only in the dimension of satisfaction with treatment effectiveness. Conclusions: The quality of life was medium and low, adherence and treatment satisfaction the decreased treatment and an inverse correlation between quality of life and treatment satisfaction, probably because of undesirable adverse reactions are in declining quality of life

Eculizumab Salvage Therapy for Antibody-Mediated Rejection in a Desensitization-Resistant Intestinal Re-Transplant Patient.

The presence of elevated calculated panel reactive antibody (cPRA) and anti-HLA donor specific antibodies (DSA) are high risk factors for acute antibody-mediated rejection (AAMR) in intestinal transplantation that may lead to graft loss. Eculizumab has been used for the treatment of AAMR in kidney transplantation of sensitized patients that do not respond to other treatment. Here, we report a case where eculizumab was used to treat AAMR in a desensitization-resistant intestinal re-transplant patient. A male patient lost his intestinal graft to AAMR 8.14 years after his primary transplant. He received a second intestinal graft that had to be explanted a month later due to refractory AAMR. The patient remained highly sensitized despite multiple treatments. He received a multivisceral graft and presented with severe AAMR on day 3 posttransplantation. The AAMR was successfully treated with eculizumab. The patient presently maintains an elevated cPRA level above 90% but his DSAs have decreased from 18 000 MFI (mean fluorescent intensity) to below the positive cut-off value of 3000 MFI and remains rejection free with a 2-year follow-up since his multivisceral transplant. Eculizumab offers an alternative to treat AAMR in intestinal transplantation in desensitization-resistant patients.

Establishment of a prospective cohort of mechanically ventilated patients in five intensive care units in Lima, Peru: protocol and organisational characteristics of participating centres.

INTRODUCTION: Mechanical ventilation is a cornerstone in the management of critically ill patients worldwide; however, less is known about the clinical management of mechanically ventilated patients in low and middle income countries where limitation of resources including equipment, staff and access to medical information may play an important role in defining patient-centred outcomes. We present the design of a prospective, longitudinal study of mechanically ventilated patients in Peru that aims to describe a large cohort of mechanically ventilated patients and identify practices that, if modified, could result in improved patient-centred outcomes and lower costs. METHODS AND ANALYSIS: Five Peruvian intensive care units (ICUs) and the Medical ICU at the Johns Hopkins Hospital were selected for this study. Eligible patients were those who underwent at least 24 h of invasive mechanical ventilation within the first 48 h of admission into the ICU. Information on ventilator settings, clinical management and treatment were collected daily for up to 28 days or until the patient was discharged from the unit. Vital status was assessed at 90 days post enrolment. A subset of participants who survived until hospital discharge were asked to participate in an ancillary study to assess vital status, and physical and mental health at 6, 12, 24 and 60 months after hospitalisation, Primary outcomes include 90-day mortality, time on mechanical ventilation, hospital and ICU lengths of stay, and prevalence of acute respiratory distress syndrome. In subsequent analyses, we aim to identify interventions and standardised care strategies that can be tailored to resource-limited settings and that result in improved patient-centred outcomes and lower costs. ETHICS AND DISSEMINATION: We obtained ethics approval from each of the four participating hospitals in Lima, Peru, and at the Johns Hopkins School of Medicine, Baltimore, USA. Results will be disseminated as several separate publications in different international journals.

Historia natural de la hernia de disco lumbar. ¿Tiene el realce con gadolinio valor pronóstico? / Natural history of lumbar disc hernias: does gadolinium enhancement have any prognostic value?

Objetivos. Evaluar qué porcentaje de hernias de disco desaparece tras un año de seguimiento y a qué ritmo; valorar si el uso del realce con gadolinio en RM tiene valor predictivo de la desaparición de la hernia; y estudiar si el patrón del realce ayuda a predecir la desaparición del fragmento. Material y métodos. Se incluyeron en este estudio prospectivo 118 pacientes con clínica de lumbociática aguda y que presentaban una hernia de disco diagnosticada mediante TC. A 72 pacientes se les realizó una RM con gadolinio cada 6 meses hasta el año o hasta que la hernia de disco desaparecía, y se relacionó la presencia de protrusión, extrusión y el patrón de realce con la desaparición o persistencia del material discal. Se realizó un estudio estadístico univariable y multivariable. Resultados. Un 59% de las hernias de disco desaparecieron tras un año de seguimiento, y de ellas el 66% lo hicieron en los primeros 8 meses. Un 83% de las hernias extruidas desaparecieron, y este dato tiene significación estadística en el análisis multivariable (p < 0,005). La ausencia de realce tiene asociación con la persistencia de la hernia, con significación estadística en el análisis univariable. El patrón de realce no ayuda a predecir la desaparición de la hernia. Hubo 5 hernias que desaparecieron muy pronto, dentro de los primeros 2 meses. Conclusiones. Un alto porcentaje de hernias de disco desaparecen, se ha encontrado la asociación estadísticamente significativa entre extrusión y desaparición, y falta de correlación entre el patrón de captación de gadolinio y la desaparición de la hernia(AU)

Objectives. To evaluate the percentage of disc hernias that have disappeared after one year of follow-up and the time to disappearance. To determine whether gadolinium enhancement is useful for predicting whether the hernia will disappear. To analyze whether the pattern of enhancement can help predict whether the fragment will disappear. Material and methods. This prospective study included 118 patients with acute symptoms of lumbosciatica and a herniated disc diagnosed by CT. In 72 patients, we performed gadolinium-enhanced MRI every 6 months for one year or until the herniation disappeared; we related the findings of protrusion, extrusion, and the enhancement pattern with the disappearance or persistence of herniated disc material. We analyzed the results with univariate and multivariate statistics. Results. The 59% of the hernias disappeared within 1 year of follow-up and 66% disappeared within the first 8 months of follow-up. The 83% of the extruded hernias disappeared, and this was significant in the multivariate analysis (P<.005). The absence of enhancement was significantly associated with the persistence of the hernia in the univariate analysis. The enhancement pattern was not useful for predicting whether the hernia would disappear. Five hernias disappeared within the first two months. Conclusions. A high percentage of disc hernias disappear. We found a significant association between extrusion and disappearance but no correlation between the pattern of gadolinium uptake and the disappearance of the herni(AU)

[Natural history of lumbar disc hernias: does gadolinium enhancement have any prognostic value?]. / Historia natural de la hernia de disco lumbar. ¿Tiene el realce con gadolinio valor pronóstico?

OBJECTIVES: To evaluate the percentage of disc hernias that have disappeared after one year of follow-up and the time to disappearance. To determine whether gadolinium enhancement is useful for predicting whether the hernia will disappear. To analyze whether the pattern of enhancement can help predict whether the fragment will disappear. MATERIAL AND METHODS: This prospective study included 118 patients with acute symptoms of lumbosciatica and a herniated disc diagnosed by CT. In 72 patients, we performed gadolinium-enhanced MRI every 6 months for one year or until the herniation disappeared; we related the findings of protrusion, extrusion, and the enhancement pattern with the disappearance or persistence of herniated disc material. We analyzed the results with univariate and multivariate statistics. RESULTS: The 59% of the hernias disappeared within 1 year of follow-up and 66% disappeared within the first 8 months of follow-up. The 83% of the extruded hernias disappeared, and this was significant in the multivariate analysis (P<.005). The absence of enhancement was significantly associated with the persistence of the hernia in the univariate analysis. The enhancement pattern was not useful for predicting whether the hernia would disappear. Five hernias disappeared within the first two months. CONCLUSIONS: A high percentage of disc hernias disappear. We found a significant association between extrusion and disappearance but no correlation between the pattern of gadolinium uptake and the disappearance of the hernia.

N-acethyl-cysteine reduces the occurrence of contrast-induced acute kidney injury in patients with renal dysfunction: a single-center randomized controlled trial.

BACKGROUND: The occurrence of contrast-induced acute kidney injury (CIAKI) has paralleled the increased number of diagnostic interventions requiring radiographic contrast media (CM). Several strategies aimed at preventing renal injury following iodine have been carried out over the last several years. The aim of this study was to evaluate the impact of three different strategies aimed at preventing CIAKI in patients with renal dysfunction (serum creatinine >1.25 mg/dl or estimated creatinine clearance <45 ml/min) receiving low osmolar CM for diagnostic-therapeutic procedures. METHODS: Candidates received 154 mmol NaHCO3 solution (B0) at a rate of 3 ml/kg/h from at least 2 h before the procedure and at 1 ml/kg/h during and for the next 6-12 h; the same schedule plus N-acethyl-cysteine (NAC) 600 mg twice daily the day before and the day of the procedure (BN) or NAC as above plus 154 mmol NaCl solution at a rate of 3 ml/kg/h from at least 2 h before the procedure and at 1 ml/kg/h during and for the next 6-12 h (SN). Serum creatinine (SCr) was measured at baseline and on days 2 or occasionally 3 after CM. The main outcome measure was the occurrence of CIAKI, defined as a ≥25% increase in SCr within 2-3 days of CM. RESULTS: The three groups were similar with regard to age, gender distribution, weight, baseline serum levels of creatinine, sodium, potassium, urate and estimated creatinine clearance. A larger proportion of individuals received ACEIs/ARAs in the BN group (p < 0.05), but in the SN group, more patients declared a past history of acute myocardial infarction or had high blood pressure, and few displayed mild-moderate left ventricular dysfunction (p < 0.05). CIAKI occurred in 24/123 (19.5%) assessable patients (15/42 in the B0 group, 3/43 in the BN group and 6/38 in the SN group; p < 0.01). Thus, 15/42 patients who did not receive NAC developed CIAKI in contrast to 9/81 who did (p < 0.01). Multivariate logistic regression models showed that the use of NAC was the unique factor associated with a statistically significant influence for the occurrence of CIAKI (OR: 0.18; 95% CI: 0.04-0.72; p = 0.016). CONCLUSIONS: The results from this study show that: (1) the occurrence of CIAKI after low-osmolar CM administration is similar to that reported worldwide. (2) NAC-based renoprotective measures are superior for the prevention of CIAKI in patients with previous renal dysfunction. (3) They also demonstrate that bicarbonate expansion alone has limited value in preventing CIAKI. For those individuals at risk, combination prophylaxis including volume expansion plus NAC should be recommended to reduce the chance of overt kidney injury following CM administration.

MicroRNA signature of intestinal acute cellular rejection in formalin-fixed paraffin-embedded mucosal biopsies.

Despite continuous improvement of immunosuppression, small bowel transplantation (SBT) is plagued by a high incidence of acute cellular rejection (ACR) that is frequently intractable. Therefore, there is a need to uncover novel insights that will lead to strategies to achieve better control of ACR. We hypothesized that particular miRNAs provide critical regulation of the intragraft immune response. The aim of our study was to identify miRNAs involved in intestinal ACR. We examined 26 small intestinal mucosal biopsies (AR/NR group; 15/11) obtained from recipients after SBT or multivisceral transplantation. We investigated the expression of 384 mature human miRNAs and 280 mRNAs associated with immune, inflammation and apoptosis processes. We identified differentially expressed 28 miRNAs and 58 mRNAs that characterized intestinal ACR. We found a strong positive correlation between the intragraft expression levels of three miRNAs (miR-142-3p, miR-886-3p and miR-132) and 17 mRNAs including CTLA4 and GZMB. We visualized these miRNAs within cells expressing CD3 and CD14 proteins in explanted intestinal allografts with severe ACR. Our data suggested that miRNAs have a critical role in the activation of infiltrating cells during intestinal ACR. These differences in miRNA expression patterns can be used to identify novel biomarkers and therapeutic targets for immunosuppressive agents.