Complicaciones perinatales asociadas con la ganancia excesiva de peso durante el embarazo / Perinatal outcomes associated to overweight gain during pregnancy in women at a regional hospital in northwest of Mexico

Resumen OBJETIVO: evaluar la asociación entre la ganancia de peso durante el embarazo y las complicaciones perinatales: enfermedad hipertensiva del embarazo, diabetes gestacional, cesárea de urgencia y macrosomía fetal. MATERIALES Y MÉTODOS: estudio de casos y controles anidados en una cohorte de pacientes que recibieron control prenatal y atención del parto en el Hospital General Regional del Instituto Mexicano del Seguro Social de Ciudad Obregón, Sonora. Los momios se calcularon según las complicaciones perinatales, el índice de masa corporal pregestacional y la ganancia total de peso durante todo el embarazo. RESULTADOS: se seleccionó una cohorte de seguimiento de 714 pacientes de las que solo se estudió a 426 que, a su vez, se dividieron en dos grupos de 213 cada uno: de casos y controles. En el grupo de casos la frecuencia de obesidad fue de 17.6% (n = 55) y 40.3% (n=126) de sobrepeso. En el grupo control 6.7% (n=21) de obesidad y 50.8% (n=159) en los controles. En comparación con las pacientes con peso pregestacional normal, no se observó riesgo significativo de complicaciones perinatales en las pacientes con sobrepeso previo a la gestación (RM=0.79, IC 95%: 0.57-1.11, p=0.189). En las pacientes con obesidad pregestacional se observó un riesgo significativo (RM=2.63, IC 95%: 1.51- 4.60, p=.001). CONCLUSIONES: la ganancia de peso a lo largo del embarazo, superior a la recomendada, es un factor riesgo significativo de complicaciones perinatales, independiente del peso previo a la gestación.

Abstract OBJECTIVE: To evaluate the association between weight gain during pregnancy and perinatal complications: hypertensive pregnancy disease, gestational diabetes, emergency cesarean section and fetal macrosomia. MATERIALS AND METHODS: Nested case-control study in a cohort of patients who received prenatal care and delivery care at the Regional General Hospital of the Mexican Social Security Institute of Ciudad Obregon, Sonora. The odds were calculated according to perinatal complications, pregestational body mass index and total weight gain throughout pregnancy. RESULTS: A follow-up cohort of 714 patients was selected, of whom only 426 were studied, which in turn were divided into two groups of 213 each: cases and controls. In the group of cases the frequency of obesity was 17.6% (n=55) and 40.3% (n=126) of overweight. In the control group 6.7% (n=21) of obesity and 50.8% (n=159) in controls. Compared with patients with normal pregestational weight, no significant risk of perinatal complications was observed in pre-gestational overweight (OR=0.79, CI 95%: 0.57-1.11, p=0.189). A significant risk was observed in patients with pregestational obesity (OR=2.63, CI 95%: 1.51- 4.60, p=.001). CONCLUSIONS: Weight gain during pregnancy, higher than recommended, is a significant risk factor for perinatal complications, independent of pre-gestational weight.

The Dose Response Multicentre Investigation on Fluid Assessment (DoReMIFA) in critically ill patients.

BACKGROUND: The previously published "Dose Response Multicentre International Collaborative Initiative (DoReMi)" study concluded that the high mortality of critically ill patients with acute kidney injury (AKI) was unlikely to be related to an inadequate dose of renal replacement therapy (RRT) and other factors were contributing. This follow-up study aimed to investigate the impact of daily fluid balance and fluid accumulation on mortality of critically ill patients without AKI (N-AKI), with AKI (AKI) and with AKI on RRT (AKI-RRT) receiving an adequate dose of RRT. METHODS: We prospectively enrolled all consecutive patients admitted to 21 intensive care units (ICUs) from nine countries and collected baseline characteristics, comorbidities, severity of illness, presence of sepsis, daily physiologic parameters and fluid intake-output, AKI stage, need for RRT and survival status. Daily fluid balance was computed and fluid overload (FO) was defined as percentage of admission body weight (BW). Maximum fluid overload (MFO) was the peak value of FO. RESULTS: We analysed 1734 patients. A total of 991 (57 %) had N-AKI, 560 (32 %) had AKI but did not have RRT and 183 (11 %) had AKI-RRT. ICU mortality was 22.3 % in AKI patients and 5.6 % in those without AKI (p < 0.0001). Progressive fluid accumulation was seen in all three groups. Maximum fluid accumulation occurred on day 2 in N-AKI patients (2.8 % of BW), on day 3 in AKI patients not receiving RRT (4.3 % of BW) and on day 5 in AKI-RRT patients (7.9 % of BW). The main findings were: (1) the odds ratio (OR) for hospital mortality increased by 1.075 (95 % confidence interval 1.055-1.095) with every 1 % increase of MFO. When adjusting for severity of illness and AKI status, the OR changed to 1.044. This phenomenon was a continuum and independent of thresholds as previously reported. (2) Multivariate analysis confirmed that the speed of fluid accumulation was independently associated with ICU mortality. (3) Fluid accumulation increased significantly in the 3-day period prior to the diagnosis of AKI and peaked 3 days later. CONCLUSIONS: In critically ill patients, the severity and speed of fluid accumulation are independent risk factors for ICU mortality. Fluid balance abnormality precedes and follows the diagnosis of AKI.

A GIS-based methodology to quantitatively define an Adjacent Protected Area in a shallow karst cavity: the case of Altamira cave.

Different types of land use are usually present in the areas adjacent to many shallow karst cavities. Over time, the increasing amount of potentially harmful matter and energy, of mainly anthropic origin or influence, that reaches the interior of a shallow karst cavity can modify the hypogeal ecosystem and increase the risk of damage to the Palaeolithic rock art often preserved within the cavity. This study proposes a new Protected Area status based on the geological processes that control these matter and energy fluxes into the Altamira cave karst system. Analysis of the geological characteristics of the shallow karst system shows that direct and lateral infiltration, internal water circulation, ventilation, gas exchange and transmission of vibrations are the processes that control these matter and energy fluxes into the cave. This study applies a comprehensive methodological approach based on Geographic Information Systems (GIS) to establish the area of influence of each transfer process. The stratigraphic and structural characteristics of the interior of the cave were determined using 3D Laser Scanning topography combined with classical field work, data gathering, cartography and a porosity-permeability analysis of host rock samples. As a result, it was possible to determine the hydrogeological behavior of the cave. In addition, by mapping and modeling the surface parameters it was possible to identify the main features restricting hydrological behavior and hence direct and lateral infiltration into the cave. These surface parameters included the shape of the drainage network and a geomorphological and structural characterization via digital terrain models. Geological and geomorphological maps and models integrated into the GIS environment defined the areas involved in gas exchange and ventilation processes. Likewise, areas that could potentially transmit vibrations directly into the cave were identified. This study shows that it is possible to define a Protected Area by quantifying the area of influence related to each transfer process. The combined maximum area of influence of all the processes will result in the new Protected Area. This area will thus encompass all the processes that account for most of the matter and energy carried into the cave and will fulfill the criteria used to define the Protected Area. This methodology is based on the spatial quantification of processes and entities of geological origin and can therefore be applied to any shallow karst system that requires protection.

Climatology of salt transitions and implications for stone weathering.

This work introduces the notion of salt climatology. It shows how climate affects salt thermodynamic and the potential to relate long-term salt damage to climate types. It mainly focuses on specific sites in Western Europe, which include some cities in France and Peninsular Spain. Salt damage was parameterised using the number of dissolution-crystallisation events for unhydrated (sodium chloride) and hydrated (sodium sulphate) systems. These phase transitions have been calculated using daily temperature and relative humidity from observation meteorological data and Climate Change models' output (HadCM3 and ARPEGE). Comparing the number of transitions with meteorological seasonal data allowed us to develop techniques to estimate the frequency of salt transitions based on the local climatology. Results show that it is possible to associate the Köppen-Geiger climate types with potential salt weathering. Temperate fully humid climates seem to offer the highest potential for salt damage and possible higher number of transitions in summer. Climates with dry summers tend to show a lesser frequency of transitions in summer. The analysis of temperature, precipitation and relative output from Climate Change models suggests changes in the Köppen-Geiger climate types and changes in the patterns of salt damage. For instance, West Europe areas with a fully humid climate may change to a more Mediterranean like or dry climates, and consequently the seasonality of different salt transitions. The accuracy and reliability of the projections might be improved by simultaneously running multiple climate models (ensembles).

Tungiasis / Tungiasis

We present a ten years' old patient immune competent, with multiple lesions of tungiasis in both feet, that consult when she returned of her vacations in Paraguay. We make a brief description of the topic.

Se presenta una paciente de 10 años de edad inmunocompetente con lesiones múltiples de tungiasis en ambos pies, que consulta al regreso de sus vacaciones en Paraguay. Se efectúa una breve revisión del tema.

Alemtuzumab induction in kidney transplantation: clinical results and impact on T-regulatory cells.

Alemtuzumab (ALT), a humanized monoclonal anti-CD52 antibody, was introduced in solid organ transplantation as an induction agent. ALT associated with anticalcineurins has provided a low incidence of acute rejection episodes (ARE) and potential tolerogenic properties. We analyzed the clinical outcomes and effects on peripheral Treg of renal transplant recipients treated with ALT. Six-month data on kidney alone or kidney combined with pancreas or liver patients treated with ALT and tacrolimus (TAC) in standard doses were compared with those on renal transplant recipients of similar demography who were not treated with ALT. We evaluated patient and graft survivals, ARE incidence, hematological parameters, renal function, adverse events, and CD4+CD25+FoxP3+ T cells in peripheral blood. Demographics of recipients, donors, and transplants were similar in both groups. Mean HLA mismatch was slightly greater among ALT-treated patients (3.5 vs 2.5). No combined transplantation was performed in the ALT-untreated group. Patient and graft survivals were 100% without rejection or serious infections in both groups. ALT-treated recipients showed anemia and leukopenia in 3 patients as well as severe lymphopenia in 5 recipients, who partially recovered on day 90. Final mean plasma creatinine was 1.4 mg/dL, while calculated creatinine clearance was approximately 65 mL/min in both groups. Mean Treg cell percentage was higher among ALT-treated recipients than the comparative group or healthy controls (P < .05). In conclusion, renal transplantation results obtained using ALT with rigorous immunosuppressive therapy were excellent; serious adverse events and acute rejection were absent. The effect of the increased proportion of Treg cells must be evaluated with longer observation.

Conversion from a calcineurin inhibitor-based immunosuppressive regimen to everolimus in renal transplant recipients: effect on renal function and proteinuria.

New immunosuppressive agents are being actively researched to avoid complications of chronic allograft nephropathy (CAN), calcineurin inhibitor (CNI) nephrotoxicity, and posttransplantation cancer. The family of mTOR inhibitors offers a unique immunosuppressive opportunity to avoid CNI toxicity and reduce the incidence of malignancy. Nevertheless, increasing data have demonstrated that sirolimus (SRL), the first mTOR introduced in the treatment of solid organ transplant recipients, induces proteinuria, an adverse event that could produce deterioration of long-term renal function. In this short-term study of patients followed for 1 to 16 months, we examined changes in renal function and proteinuria among renal transplant recipients converted from a CNI-based regimen to an everolimus (EVL)-based one, a recently introduced mTOR inhibitor. Our data showed that renal function can be optimized after conversion to EVL by up to 42% in recipients showing CAN grade 1 or 2, or CNI nephrotoxicity. Importantly, patients who improved their creatinine clearance did not show increased proteinuria measured in a voided specimen as the ratio of urinary protein and creatinine concentration (P/C). These results, if confirmed with long-term follow-up and a larger number of patients, would allow us to consider EVL as a promising agent for maintenance immunosuppressive regimens in kidney transplantation.

Deterioration of building materials in Roman catacombs: the influence of visitors.

In the last decades, damages on building materials and mural paintings were observed in Roman catacombs. The damages were due to extensive formation of biofilms induced by artificial illumination and humidity. Microenvironmental data (temperature, CO(2) concentration, humidity, and atmospheric pressure) clearly showed the negative influence of visitors. Increasing heat, light and water vapour condensation into corridors and cubicles favoured biofilm development. The composition of biofilms was different and depended mainly on distance to illumination sources and humidity, thus denoting the influence of light on the growth of phototrophic microorganisms in the catacombs. In addition, biofilm distribution was governed by the type of material to be colonised. This study shows that countermeasures are needed to prevent deterioration of hypogean environments.

[Usefulness of thoracic radiography after insertion of transitory catheters for hemodialysis]. / Utilidad de la radiografía de tórax posterior a la instalación de catéteres transitorios para hemodiálisis.

A chest X-ray has been routinely used to evaluate possible complications of a catheter installed for hemodialysis. The objective of the present study was to evaluate the utility of routine chest X-ray to detect complications derived from the installation of temporary catheters through a jugular vein access. We studied prospectively 95 successive jugular catheters for hemodialysis. After installation the operator answered a questionnaire that asked for details of the procedure and his opinion of the utility of a chest X-ray to detect a complication in each particular case. A chest X-ray was done in every patient and analyzed blindly. There were 17 minor complications: 7 arterial punctures, 5 neck hamatomas and 5 malpositions of catheters. No major complications were found. Sixty per cent of the catheters that required three or more punctures had a complication vs only 10% of the ones that required two or less puncture (p < 0.05). In five occasions the catheters were malpositioned, in four of these cases a complication was suspected. The wire guide was twisted in all of these cases. The procedure was considered of medium or high difficulty in four of the five malpositioned catheters, in contrast a medium or highly difficult case was considered only in 13 of the 90 well positioned catheters (p < 0.05). The time employed for the catheters installation was significantly higher for the malpositioned catheters. In 29.5% of the cases the operator considered a chest X-ray necessary, 2/3 of the cases did not have a well founded clinical suspicion of complication. We conclude that routine chest X-ray after installation of a jugular catheter for hemodialysis has a low diagnostic value for the detection of complications derived from the procedure and should be ordered only when clinical features suggest a complication.

Utilidad de la radiografía de tórax posterior a la instalación de catéteres transitorios para hemodiálisis / Value of the chest radiograph after the insertion of temporary dialysis catheters

Para evaluar el valor de la radiografía de tórax de rutina posterior a la instalación de catéteres transitorios para hemodiálisis estudiamos prospectivamente 95 catéteres sucesivos. Una vez instalado cada catéter el operador contestó una encuesta sobre los detalles del procedimiento y manifestó su opinión sobre la utilidad de la radiografía para descartar alguna complicación en el caso en particular. En 95 catéteres hubo 17 complicaciones: 7 punciones arteriales, 5 hematomas y 5 malposiciones del catéter. No hubo hamotórax ni neumotórax. Presentaron alguna complicación el 60 % de los catéteres que requirieron 3 o más intentos antes de canular la vena y el 10% de los que requirieron menos intentos p < 0,05. En el 29,5% de los catéteres el operador consideró necesario realizar la radiografía de tórax, en el 65,4% de ellas sin una sospecha clínicamente fundada de complicación. En 5 ocasiones el catéter quedó mal posicionado, en 4 de estas se sospechó alguna complicación pero solo en 2 oportunidades se sospecho la mal posición, en las 5 oportunidades la guía de alambre salío acodada. En el 4 de 5 oportunidades en que el catéter quedó en mala posición y en 13 de las 90 en que el catéter quedó en buena posición el procedimiento fue considerado como alta o mediana dificultad por el operador p < 0,05. El tiempo necesario para la instalación fue mayor en los catéteres que quedaron en mala posición. En conclusión: La radiografía de tórax de rutina posterior a la instalación de catéteres para Hemodiálisis tiene poco rendimiento en el diagnóstico de complicaciones derivadas del procedimiento y debería ser practicada solo en presencia de hechos clínicos que sugieran una complicación

A chest X-ray has been routinely used to evaluate possible complications of a catheter installed for hemodialysis. The objetive of the present study was to evaluate the utility of routine chest X-ray to detect complications derived from the installation of temporary catheters through a jugular vein access. We studied prospectively 95 successive jugular catheters for hemodialysis. After installation the operator answered a questionnaire that asked for details of the procedure and his opinion of the utility of a chest X-ray to detect a complication in each particular case. A chest X-ray was done in every patient and analyzed blindly. There were 17 minor complications: 7 arterial punctures, 5 neck hamatomas and 5 malpositions of catheters. No major complications were found. Sixty per cent of the catheters that required three or more punctures had a complication vs only 10% of the ones that required two or less puncture (p < 0.05). In five occasions the catheters were malpositioned, in four of these cases a complication was suspected. The wire guide was twisted in all of these cases. The procedure was considered of medium or high difficulty in four of the five malpositioned catheters, in contrast a medium or highly difficult case was considered only in 13 of the 90 well positioned catheters (p < 0.05). The time employed for the catheters installation was significanthy higher for the malpositioned catheters. In 29.5% of the cases the operator considered a chest X-ray neccesary, 2/3 of the cases did not have a well founded clinical suspicion of complication. We conclude that routine chest X-ray after installation of a jugular catheter for hemodialysis has a low diagnostic value for the detection of complications derived from the procedure and should be ordered only when clinical features suggest a complication

[Angioplasty in acute myocardial infarction. Early and late results]. / Angioplastia en infarto agudo de miocardio. Resultado inicial y seguimiento alejado.

BACKGROUND: The usefulness of angioplasty in the first hours of an acute myocardial infarction is widely demonstrated. However, its long term effects are less well known. AIM: To report the effects of coronary angioplasty on early and late outcome of patients with acute myocardial infarction. PATIENTS AND METHODS: A non-randomized, consecutive and retrospective analysis of the hospital and late outcome of 70 patients, aged 35 to 85 years, subjected to coronary angioplasty during an acute myocardial infarction. Patients were followed during 12 to 60 months. RESULTS: Angioplasty was performed 5.3 +/- 5 hours after the initial symptoms. Anterior descendent artery was occluded in 63% of patients with a 99.5% luminal occlusion and TIMI 0-1 anterograde flow. An angiographic success was achieved in 83% of procedures with a residual stenosis of 32.3%. Recurrent ischemia was observed in 6% of patients, that were treated with a new revascularization procedure. Thirteen percent of patients died, all due to cardiogenic shock. Severe ventricular failure and failure of revascularization influenced mortality. During the first year of follow up there was a 3.3% mortality and 3.3% of patients required a new revascularization procedure. Eighty percent of patients were asymptomatic and event-free. CONCLUSION: Angioplasty was a useful therapeutic procedure in this group of patients.