Association between obesity and mortality in adult patients receiving invasive mechanical ventilation: A systematic review and meta-analysis. / Asociación entre obesidad y mortalidad en pacientes adultos que reciben ventilación mecánica invasiva: una revisión sistemática y metaanálisis.

OBJECTIVE: To evaluate if there is an association between obesity and mortality in the Intensive Care Unit (ICU) in adult patients receiving invasive mechanical ventilation. DESIGN: Systematic review with meta-analysis. SCOPE: ICU. DATA SOURCE: A search was made in MEDLINE, Cochrane Library, CINAHL and Global Health databases without language restriction, until February 21, 2017. SELECTION OF STUDIES: Studies that reported mortality in the ICU in obese versus non-obese patients who received IMV were included. MAIN VARIABLES: Mortality in the ICU. RESULTS: 2163 articles were found, of which 14 studies were included. No statistically significant differences were found between obese and non-obese patients with respect to the variable mortality in the ICU (OR: 0.94, 95% CI: 0.81-1.10, P=.45). CONCLUSION: No relationship was found between the subgroup of obese adult patients receiving IMV and the mortality variable in the ICU.

Ventilación mecánica invasiva como tratamiento de la insuficiencia respiratoria aguda en pacientes infectados por el virus de la inmunodeficiencia humana / Invasive mechanical ventilation as a treatment of Severe respiratory insufficiency in patients infected by the immunodeficiency virus human

Objetivo: Conocer la prevalencia y las características epidemiológicas de los pacientes infectados por el virus de la inmunodeficiencia humana que requirieron ventilación mecánica invasiva más de 12 horas para tratar la insuficiencia respiratoria aguda en la Unidad de Cuidados Intensivos de un Hospital General de Agudos. Asimismo, se realizó un análisis comparativo entre los pacientes con el virus de la inmunodeficiencia humana y aquellos sin el virus. Materiales y Métodos: Estudio descriptivo, prospectivo y longitudinal llevado a cabo entre el 1 de agosto de 2012 y el 31 de julio de 2014. Se incluyeron adultos con ventilación mecánica invasiva por más de 12 horas debido a insuficiencia respiratoria aguda. Se realizó un análisis multivariado de regresión logística para identificar la asociación entre muerte en la Unidad de Cuidados Intensivos y virus de la inmunodeficiencia humana. Resultados: Ingresaron 344 pacientes en la Unidad, el 46,80% requirió ventilación mecánica invasiva por insuficiencia respiratoria aguda, con una prevalencia del virus de la inmunodeficiencia humana del 12,42%. Los pacientes infectados tenían una media de la edad de 39.42 ± 11.58 vs. 49.37 ± 20.54. En un análisis multivariado, se observó que los pacientes infectados corrían un mayor de riesgo de morir en la Unidad de Cuidados Intensivos que los no infectados (OR: 5,125; IC95% 1,725-15,226; p = 0,003). Conclusión: Los pacientes con el virus de la inmunodeficiencia humana que recibieron ventilación mecánica invasiva más de 12 horas para tratar la insuficiencia respiratoria aguda tuvieron un riesgo cinco veces más alto de morir en la Unidad de Cuidados Intensivos que los no infectados. (AU)

Objective: To know the prevalence and epidemiological characteristics of patients infected with human immunodeficiency virus requiring invasive mechanical ventilation for more than 12 hours as a treatment for acute respiratory failure at the Intensive Care Unit of a General Acute Care Hospital in Buenos Aires City. A comparative analysis was also performed between subjects with human immunodeficiency virus and those not infected. Materials and Methods: Descriptive, prospective and longitudinal study conducted between August 1st, 2012 and July 31st, 2014. Adults with invasive mechanical ventilation for more than 12 hours due to acute respiratory failure were included. A multivariate logistic regression analysis was performed to identify the association between mortality in the Intensive Care Unit and human immunodeficiency virus. Results: A total of 344 patients were admitted to the Intensive Care Unit, 46.80% of them required invasive mechanical ventilation for acute respiratory failure, with a prevalence of human immunodeficiency virus of 12.42%. The average age of infected patients was 39.42 ± 11.58 vs. 49.37 ± 20.54. In a multivariate analysis it was observed that patients with human immunodeficiency virus had more risk of death in the Intensive Care Unit than those not infected (OR: 5.12%, CI95% 1.72-15.22; P=0.003). Conclusion: The risk of death of subjects with human immunodeficiency virus who received invasive mechanical ventilation for more than 12 hours as a treatment for acute respiratory failure was five-fold higher than that of those uninfected patients.(AU)

Arteriovenous malformations of the uterus.

Arterial venous malformations (AVM) of the uterus are uncommon entities and should be considered in patients who present with profuse genital bleeding. There are two types of uterine AVM: acquired and congenital. Acquired uterine AVMs are conformed by communications between the uterine arteries and the myometrial veins, and are caused by an iatrogenic event or a pathological condition. Congenital AVMs are the result of abnormal development of primitive vessels that result in connections between pelvic arteries and veins in the uterus without an interconnecting capillary bed. Ultrasonography is a noninvasive diagnostic method able to demonstrate and characterize AVMs of the uterus. AVM in the pelvis may be noted incidentally by computed tomography (CT) of the pelvis, and magnetic resonance imaging (MRI) is frequently used to confirm and further characterize the sonographic findings of uterine AVM. Catheter angiography and embolization are very effective in defining the vascular anatomy and treating uterine vascular abnormalities.

Endovascular arterial interventions with embolic protection devices.

Endovascular treatment of atherosclerotic lesions can provide a clinical benefit, but arterial interventions are not exempt from complications. Embolization in the peripheral circulation may result in unfavorable outcomes. The purpose of this article is to review the technical applications, the clinical indications, and the risks and benefits of different protection devices, occlusions balloons, and filters commonly used during endovascular interventions in the carotid circulation, renal arteries, and lower extremities.

Role of magnetic resonance imaging in patient selection for uterine artery embolization.

Uterine fibroids are common tumors of the female pelvis. Uterine artery embolization (UAE) is an effective treatment of symptomatic uterine leiomyoma in the appropriate candidates, reducing or eliminating leiomyoma-related symptoms of bleeding, bulk, and/or pain. Magnetic resonance imaging (MRI) can be used to assess women with symptoms potentially attributable to uterine leiomyomas, and help to determine who is an appropriate candidate for UAE. Because of soft tissue characterization, multiplanar imaging capabilities, and enhancement, MR imaging not only accurately detects and characterizes uterine leiomyomas but also may predict who will benefit from the embolization. MRI ability to detect coexistent uterine or pelvic pathology may change the diagnosis and treatment management of patients being evaluated for UAE.

Inferior vena cava indices determine volume load in minimal lesion nephrotic syndrome.

The pathogenesis of edema in nephrotic syndrome has not been entirely understood. We investigated the value of the echographic parameters [inferior vena cava index (IVCI), inferior vena cava collapsibility index (IVCCI), and left atrium diameter (LAD)] to determine the volume load in children with minimal lesion nephrotic syndrome (MLNS). Twelve children with MLNS (seven boys, five girls) were included in this study. The patients were classified into three different stages (stage A: edematous; stage B: 50% decrease in weight gain; stage C: edema free) following measurement of their ideal weights. The ideal weight of patients in stage A was increased 13 +/- 7%. Serum total protein, albumin and urine sodium levels were found to be low in these patients. Plasma renin activity (PRA) and serum aldosterone levels in stage A were significantly different from those of the control group (P<0.05). PRA and serum aldosterone levels were not different from those of the control group in stage B (P>0.05). However, the increase in PRA was significant in stage C. Although a significant weight decrease was found in stages B and C, it had no effect on IVCI, LAD, and cardiothoracic index. We consider IVCI, IVCCI, and LAD measurements by echocardiography (ECHO) to be easy and reliable clinical methods for assessing the intravascular volume load in patients with MLNS.

Clinicopathologic correlations of Henoch-Schönlein nephritis in Turkish children.

BACKGROUND: In this study, 66 patients with Henoch-Schönlein nephritis (HSN) were investigated clinicopathologically. METHODS: The patients were classified according to their initial presentation, histologic findings, recurrences of purpura, type of treatment and clinical outcome. Logistic regression analysis was performed. RESULTS: Sixty-eight percent of patients were hospitalized with mild renal disease. Most patients were evaluated as class I and II according to light microscopy. In addition to IgA deposition alone, 33% of patients showed IgA + C3 and 27% had IgA + IgG + C3 depositions. After the follow-up period of 3.3 years, 15 patients had minor urinary findings, 4 had active renal disease and 1 had renal insufficiency. Recurrences occurred in 37.9% of patients and 37.1% of patients with recurrences had persistent pathologic findings. Symptomatic treatment was given to 51.5% of patients, while 27.2% were given corticotherapy. CONCLUSIONS: Clinical presentation was found to be correlated with outcome. Recurrence of the disease and the type of the treatment also affected the outcome. It was also thought that mesangial IgG and C3 depositions may have a role in the pathogenesis of renal damage in HSN.

Effect of enalapril on proteinuria, phosphaturia, and calciuria in insulin-dependent diabetes.

Elevated urinary calcium and phosphate excretion have been observed in children with insulin-dependent diabetes mellitus (IDDM). This may be related to a defect in tubular reabsorption. It is well known that converting enzyme inhibition decreases microalbuminuria and may prevent or retard diabetic nephropathy. We investigated whether enalapril also improves the defect in calcium and phosphate reabsorption. We studied 16 children and young adults (age 12-21 years) with IDDM and persistent microalbuminuria before and during 12 weeks of enalapril treatment. Before treatment microalbuminuria, urinary calcium excretion, and fractional tubular phosphorus reabsorption (TPR) were 153+/-53 microg/min, 5.5+/-0.9 mg/kg per day, and 71.4+/-3.6%, respectively. At the end of the 12th week, microalbuminuria had decreased to 20.3+/-7.9 microg/min and calcium excretion to 3.3+/-0.4 mg/kg per day (P<0.01), while the TPR increased to 80.1+/-3.8% (NS). The renal threshold phosphate concentration increased from 1.8+/-0.15 to 2.92+/-0.23 mg/dl (P<0.01). The fasting serum glucose and hemoglobin Alc levels did not change significantly during the study. Systolic and diastolic blood pressures were 120.4+/-2.2 / 79.3+/-1.4 mm Hg and 110.5+/-1.8 / 71.3+/-0.9 mm Hg before and after 12 weeks, respectively. We conclude that enalapril treatment improves not only microalbuminuria but also abnormal calcium and phosphate excretion in microalbuminuric children with IDDM.

The role of PAF and leukotrienes in bioincompatibility of cuprophane membranes in hemodialysis.

Inflammatory lipid mediators, PAF and leukotrienes (LTs), are thought to have an important role in biocompatibility in hemodialysis. PAF, LTB4 and LTC4 were studied both in controls (n: 12) and in 11 children on regular hemodialysis (150 minutes) with cuprophane dialyzers. Blood samples were collected initially (0'-precapillary), at first minute (1'-postcapillary) and at one hour after the hemodialysis sessions (210'-venous). Presence of LTs and high levels of PAF in 0' samples compared to levels in controls and significant increases in 1' samples suggested the alterations in PAF and LTs likely originated from the peripheral leukocyte activation. In 210' samples, PAF and LTs levels were decreased but still higher than the levels in 0' samples. This study suggested that PAF and LTB4 may be the control elements in biocompatibility in hemodialysis with cuprophane membranes, and demonstrated that the effects of activation last until the following session.

Plasma and urinary platelet activating factor concentrations and leukotriene releasing activity of leukocytes in steroid sensitive nephrotic syndrome of childhood.

Platelet activating factor (PAF) is synthesized and secreted by glomerular mesangial and endothelial cells. It increases glomerular basement membrane permeability and induces proteinuria. Leukotrienes (LT) are mediators released by either leukocytes or glomerular cells under the PAF effect. The possible role of PAF in steroid sensitive nephrotic syndrome (SSNS) of childhood was studied in 8 children with SSNS in the acute stage, 5 children in remission and 8 healthy controls. The PAF concentrations in urine and plasma were determined. Leukocytes were stimulated in vitro and the LT release in response to stimulation was determined. The urinary and plasma concentrations of PAF were significantly higher in the acute phase than in remission and in control patients. Children with SSNS were found to have peripheral leukocytes with increased LT releasing activity in vitro. These results are in accordance with clinical and experimental observations indicating that PAF originates in the kidney and plays a role in normal kidney physiology. Urinary PAF concentrations may be related to proteinuria because they were strongly correlated in the present study. Elevated plasma PAF concentrations in the acute stage of SSNS could result from either its secretion from the circulating leukocytes or decreased acetyl hidrolase activity needed for its hydrolysis in plasma. The increased LT release in vitro suggests that these cells might have been activated by PAF secreted from glomeruli. It is proposed that PAF and different LT in systemic and glomerular circulation are important mediators in childhood SSNS.

The adjustment of post-dialysis dry weight based on non-invasive measurements in children.

BACKGROUND: The clinical criteria to assess hydration status are not always reliable. Hence, the development of techniques to estimate more accurately post-dialysis dry weight (DW) remains a major challenge. The present study evaluates the value of the inferior vena cava (IVC) diameter, plasma concentration of atrial natriuretic peptide (ANP), and plasma renin activity (PRA) in determining the DW in chronic haemodialysis children. METHODS: Twelve overhydrated haemodialysis patients (4 girls, 8 boys) with a mean age of 12.8 were admitted to the study. Clinical, electrocardiographic, telecardiographic and echocardiographic findings, IVC and collapsibility indices and plasma concentrations of ANP and PRA were investigated before and after ultrafiltration (UF) therapy. Twelve age-matched normal children were studied as controls. Analysis of variance and Dunnett's test were applied for comparisons between patients and controls. RESULTS: Following UF therapy the patients' mean IVC collapsibility index was increased from 42.3 to 53.6% and IVC index was decreased from 1.08 to 0.81 cm/m2, both statistically significant. The pre-UF therapy collapsibility and IVC indices of the patient group were significantly different from those of the control group (56.9% and 0.70 cm/m2 respectively). The patients' mean plasma concentrations of ANP were 171 +/- 47.4 pg/ml before UF, 129 +/- 51.3 pg/ml after UF and 102 +/- 38.7 pg/ml in the control group. The ANP levels of the patients showed a significant decrease following the UF therapy. PRA was measured as 0.82 ng/ml/h before UF and 1.08 ng/ml/h after UF, but the increase was not statistically significant. CONCLUSIONS: Our findings revealed increased diameter of the IVC and plasma ANP concentrations and decreased collapsibility due to overhydration. Echography of IVC may be a promising non-invasive tool to estimate the DW in haemodialysis children. Further studies providing normative values for the IVC indices in both haemodialysis and normal children are required.

Severe acute thinner intoxication.

Thinner which contains aromatic hydrocarbons such as xylene, toluene and N-hexane is widely used in industrial plants manufacturing dyes, plastic, varnishes and glues. Chronic intoxication due to abuse of solvents, including thinner, by workers who inhale the solvent vapor is frequently encountered. Acute intoxication with ingestion of excessive amounts is relatively rare and usually fatal. It is reported that 45-50 ml of orally ingested thinner is enough to cause severe complications. The case reported here was forced to drink 200 ml of thinner by an older friend, and presented with severe complications such as rhabdomyolysis, polyneuropathy, chemical pneumonia and coma. To the best of our knowledge this is the first case reported in the literature to survive acute thinner intoxication with such complications.

Lymphocyte subpopulations in children with vitamin D deficient rickets.

Recent studies have shown 1,25(OH)2D3-mediated modulation of the immune system. We examined lymphocyte subpopulations of 16 children with nutritional rickets. Most of the patients suffered more frequent infection episodes than the control group of 15 healthy children and low serum levels of 25OHD and 1,25(OH)2D, such as 38.2 +/- 8.6 ng/mL and 15.7 +/- 2.6 pg/mL respectively. This decrease correlated with a significant decrease in total T lymphocytes and an increase in B lymphocytes expressing surface IgA, IgM, IgG molecules. These results suggest that vitamin D plays an important role in the impaired functions of T lymphocytes which may lead to frequent infection episodes in nutritional rickets.

Use of single voided urine samples to estimate quantitative proteinuria in children.

Quantitation of protein excretion in urine is used for diagnostic and prognostic purposes and also to assess the effects of therapy in children. The method in common use is to measure urinary protein in a 24-hour urine sample, which may be time consuming and is often inaccurate. The aim of this study was to determine if the urine protein/creatinine ratio in a single-void urine sample had a high correlation with the quantity of protein in a 24-hour urine specimen. We found that there was an excellent correlation between the protein content of a 24-hour urine excretion and the protein/creatinine ratios in single morning urine samples of 50 patients. We also discovered that a protein/creatinine ratio greater than 4.9 could signify "nephrotic-range" proteinuria, while a ratio less than 2.5 indicated nephritic syndrome or other renal diseases. We concluded that the determination of urinary protein/creatinine concentration ratios in a single morning urine sample under most clinical circumstances, especially in nephrotic syndrome, could replace the measurement of protein excretion in 24-hour urine specimens.

[Neonatal Chagas disease: laboratory diagnosis during the first year of life]. / Enfermedad de Chagas neonatal. Diagnóstico de laboratorio en el primer año de vida.

This paper describes the parasitologic and serologic studies carried out during the first year of life in 721 pediatric patients born to mothers serologically positive for Chagas disease. The search for circulating trypomastigotes was performed by Strout, blood culture and/or Xenodiagnosis. In some cases, amastigotes were also detected in placenta and umbilical cord. Complement fixation test, indirect hemagglutination and indirect immunofluorescence were used to detect Trypanosoma cruzi antibodies. The dosage of total Ig by single radial immunodiffusion was also carried out. The results obtained showed an absolute correlation between parasite detection and the persistence of antibodies after six months of life. In the first group (GI) formed by 8 children, the diagnosis of congenital infection could not be confirmed because the isolation of T. cruzi was obtained only in later studies. In another 8 children grouped in GIII, it was impossible to detect parasitemia, and the diagnosis was reached by the serological positivity after six months of life. Finally, in 684 patients with anti-T. cruzi antibodies at birth, the serology became negative at the age of 3 months (GIV) or 6 months (GV). The methodology employed in this work is accessible to laboratories of medium complexity, and permits the diagnosis of congenital or neonatal chagasic infection with a high degree of reliability. On the other hand, it avoids unnecessary administration of trypanomicide drugs in a number of newborn and infants who have only received maternal antibodies at birth and were not infected by T. cruzi.

Enfermedad de Chagas neonatal. Diagnóstico de laboratorio en el primer año de vida. / [Neonatal Chagas disease: laboratory diagnosis during the first year of life]

This paper describes the parasitologic and serologic studies carried out during the first year of life in 721 pediatric patients born to mothers serologically positive for Chagas disease. The search for circulating trypomastigotes was performed by Strout, blood culture and/or Xenodiagnosis. In some cases, amastigotes were also detected in placenta and umbilical cord. Complement fixation test, indirect hemagglutination and indirect immunofluorescence were used to detect Trypanosoma cruzi antibodies. The dosage of total Ig by single radial immunodiffusion was also carried out. The results obtained showed an absolute correlation between parasite detection and the persistence of antibodies after six months of life. In the first group (GI) formed by 8 children, the diagnosis of congenital infection could not be confirmed because the isolation of T. cruzi was obtained only in later studies. In another 8 children grouped in GIII, it was impossible to detect parasitemia, and the diagnosis was reached by the serological positivity after six months of life. Finally, in 684 patients with anti-T. cruzi antibodies at birth, the serology became negative at the age of 3 months (GIV) or 6 months (GV). The methodology employed in this work is accessible to laboratories of medium complexity, and permits the diagnosis of congenital or neonatal chagasic infection with a high degree of reliability. On the other hand, it avoids unnecessary administration of trypanomicide drugs in a number of newborn and infants who have only received maternal antibodies at birth and were not infected by T. cruzi.