Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Epigenetic forest and flower morphogenesis.

This paper studies the epigenetic process that leads to Angiosperms' flower architecture (flowering plants). As a case study, we analyze the flower Arabidopsis thaliana's GRN obtained during cell fate determination in the early stages of the flower's development, which was constructed in a previous work using experimental data. We start by constructing and analyzing the Epigenetic Forest, a discrete representation of Waddington's Epigenetic Landscape, obtained as the transition graph of the discrete dynamical system associated with the GRN. Next, we propose an optimization problem to model morphogenesis by defining a biologically meaningful function that accounts for the work involved in cell specialization. Finally, the problem is solved using a genetic algorithm. The optimal solution found by the algorithm correctly recovers the flower's architecture, as observed in wild type flowers and recovered in other theoretical works. Even though the case study addresses this specific problem, the method is directly applicable to other GRN's with attractors consisting of equilibrium points only and could be extended to the situation where there are periodic attractors.

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation with minimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the main concern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patients aged between 4 and 18 years in Colombia. METHODS: A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a 5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment without FeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-related cases). Univariate 1-way sensitivity analyses were performed. RESULTS: In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and €480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for the routine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis. CONCLUSION: FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used by decision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries.

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective

Background: Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation withminimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the mainconcern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patientsaged between 4 and 18 years in Colombia.Methods: A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact wascalculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment withoutFeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-relatedcases). Univariate 1-way sensitivity analyses were performed.Results: In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and€480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for theroutine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis.Conclusion: FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used bydecision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries (AU)

Antecedentes: El óxido nítrico en aire exhalado es una medición simple y no invasiva de la inflamación de las vías respiratorias cuyosresultados están disponibles en pocos minutos. Para los responsables de la formulación de políticas sanitarias, la principal preocupaciónes el impacto económico que implica la adaptación de esta tecnología, muy especialmente en los países en desarrollo. Este estudiotiene como objetivo evaluar el impacto presupuestario, en el sistema Nacional de Salud de Colombia, del manejo del asma mediante lamonitorización de óxido nítrico exhalado en pacientes entre 4 y 18 años.Métodos: Se realizó un análisis de impacto presupuestario para evaluar el posible impacto financiero derivado de la implementación de lamonitorización óxido nítrico exhalado fraccionado en el asma. El análisis consideró un horizonte temporal de 5 años y la perspectiva delSistema Nacional de Salud de Colombia. El impacto presupuestario incremental se calculó restando el coste del nuevo tratamiento, en elque se reembolsa el FeNO, del coste del tratamiento convencional sin FeNO (manejo basado en síntomas clínicos (con o sin espirometría /flujo máximo) o guías de asma (o ambos), para los relacionados con el asma). Se realizaron análisis de sensibilidad univariantes de una vía.Resultados: En el análisis del caso base, los costos a 5 años asociados a FeNO y no FeNO se estimaron en 469.904.130 € y 480.485.149 €respectivamente, lo que indica un ahorro para la Salud Nacional de Colombia de 10.581.019 € si se adopta la monitorización de FeNOen el manejo rutinario de pacientes con asma persistente. La solidez de este resultado fue confirmada en el análisis de sensibilidadunivariante, unidireccional.Conclusión: El óxido nítrico exhalado fraccionado ahorró costos en los entornos de emergencia en población pediátrica con asma persistente.Esta evidencia puede ser utilizada por los tomadores de decisiones en nuestro país para mejorar las guías de práctica clínic

Reversion and non-reversion mechanisms of resistance to PARP inhibitor or platinum chemotherapy in BRCA1/2-mutant metastatic breast cancer.

BACKGROUND: Little is known about mechanisms of resistance to poly(adenosine diphosphate-ribose) polymerase inhibitors (PARPi) and platinum chemotherapy in patients with metastatic breast cancer and BRCA1/2 mutations. Further investigation of resistance in clinical cohorts may point to strategies to prevent or overcome treatment failure. PATIENTS AND METHODS: We obtained tumor biopsies from metastatic breast cancer patients with BRCA1/2 deficiency before and after acquired resistance to PARPi or platinum chemotherapy. Whole exome sequencing was carried out on each tumor, germline DNA, and circulating tumor DNA. Tumors underwent RNA sequencing, and immunohistochemical staining for RAD51 foci on tumor sections was carried out for functional assessment of intact homologous recombination (HR). RESULTS: Pre- and post-resistance tumor samples were sequenced from eight patients (four with BRCA1 and four with BRCA2 mutation; four treated with PARPi and four with platinum). Following disease progression on DNA-damaging therapy, four patients (50%) acquired at least one somatic reversion alteration likely to result in functional BRCA1/2 protein detected by tumor or circulating tumor DNA sequencing. Two patients with germline BRCA1 deficiency acquired genomic alterations anticipated to restore HR through increased DNA end resection: loss of TP53BP1 in one patient and amplification of MRE11A in another. RAD51 foci were acquired post-resistance in all patients with genomic reversion, consistent with reconstitution of HR. All patients whose tumors demonstrated RAD51 foci post-resistance were intrinsically resistant to subsequent lines of DNA-damaging therapy. CONCLUSIONS: Genomic reversion in BRCA1/2 was the most commonly observed mechanism of resistance, occurring in four of eight patients. Novel sequence alterations leading to increased DNA end resection were seen in two patients, and may be targetable for therapeutic benefit. The presence of RAD51 foci by immunohistochemistry was consistent with BRCA1/2 protein functional status from genomic data and predicted response to later DNA-damaging therapy, supporting RAD51 focus formation as a clinically useful biomarker.

Prevalence and mutational determinants of high tumor mutation burden in breast cancer.

BACKGROUND: High tumor mutation burden (TMB) can benefit immunotherapy for multiple tumor types, but the prevalence of hypermutated breast cancer is not well described. The aim of this study was to evaluate the frequency, mutational patterns, and genomic profile of hypermutated breast cancer. PATIENTS AND METHODS: We used de-identified data from individuals with primary or metastatic breast cancer from six different publicly available genomic studies. The prevalence of hypermutated breast cancer was determined among 3969 patients' samples that underwent whole exome sequencing or gene panel sequencing. The samples were classified as having high TMB if they had ≥10 mutations per megabase (mut/Mb). An additional eight patients were identified from a Dana-Farber Cancer Institute cohort for inclusion in the hypermutated cohort. Among the patients with high TMB, the mutational patterns and genomic profiles were determined. A subset of patients was treated with regimens containing PD-1 inhibitors. RESULTS: The median TMB was 2.63 mut/Mb. The median TMB significantly varied according to the tumor subtype (HR-/HER2- >HER2+ >HR+/HER2-, P < 0.05) and sample type (metastatic > primary, P = 2.2 × 10-16). Hypermutated tumors were found in 198 patients (5%), with enrichment in metastatic versus primary tumors (8.4% versus 2.9%, P = 6.5 × 10-14). APOBEC activity (59.2%), followed by mismatch repair deficiency (MMRd; 36.4%), were the most common mutational processes among hypermutated tumors. Three patients with hypermutated breast cancer-including two with a dominant APOBEC activity signature and one with a dominant MMRd signature-treated with pembrolizumab-based therapies derived an objective and durable response to therapy. CONCLUSION: Hypermutation occurs in 5% of all breast cancers with enrichment in metastatic tumors. Different mutational signatures are present in this population with APOBEC activity being the most common dominant process. Preliminary data suggest that hypermutated breast cancers are more likely to benefit from PD-1 inhibitors.

LAM study: Effects of lacosamide on behaviour and quality of life in patients with epilepsy. / Estudio LAM: conducta y calidad de vida en pacientes diagnosticados de epilepsia tratados con lacosamida.

INTRODUCTION: Psychiatric comorbidities are common in epileptic patients, and evaluating the impact of antiepileptic drugs on patients' moods is therefore essential. The aim of this study is to assess the effects of lacosamide on behaviour and quality of life in people with epilepsy. METHODS: We conducted a multicentre prospective observational study of poorly-controlled epileptic patients who received lacosamide as an adjuvant treatment. Patients were evaluated on 4 occasions during a 12-month period. The impact of lacosamide on patients' mood and quality of life was assessed with the Quality of Life in Epilepsy Inventory-10 (QOLIE-10), the Hospital Anxiety and Depression Scale (HADS), and the Barratt Impulsiveness Scale (BIS-11). As a secondary objective, we evaluated the effectiveness and safety of lacosamide. RESULTS: We included 55 patients with a mean age of 47.1±18.4 years. At baseline, 34.5% of the patients had psychiatric comorbidities; the mean number of crises in the previous month was 3.6±4.3. The QOLIE-10 and HADS scales revealed statistically significant improvements in patients with a poor baseline condition (anxiety, depression, and/or poor quality of life). The BIS-11 scale detected no impulsive behaviour during follow-up. After 12 months of treatment, 51.9% of the patients were seizure-free and 77.8% experienced a reduction of at least 50% in seizure frequency. Adverse effects were mild in most cases; lacosamide was discontinued in 10 patients (18.2%). CONCLUSIONS: Lacosamide is a safe and effective treatment option for patients with epilepsy and psychiatric comorbidities.

Meningioma en gestante afecta de endometriosis profunda. A propósito de un caso / Meningioma in pregnant women affected by deep endometriosis. About a case

RESUMEN El siguiente caso clínico trata de una paciente, gestante tras fecundación in vitro, afecta de endometriosis profunda. Dicha paciente debutó durante el embarazo con un síndrome del seno cavernoso con cefalea e hipoestesia facial, siendo diagnosticada tras una exploración neurológica detallada y las pruebas complementarias pertinentes de un meningioma. Por este motivo, tuvo que ser sometida a una cesárea previa al abordaje terapéutico del tumor, dado el empeoramiento clínico progresivo que se estaba produciendo. Dado que en la literatura científica la asociación entre la endometriosis y la aparición de meningiomas ya ha sido descrita, con este caso clínico intentaremos acercarnos a las posibles causas de dicha asociación, como podría ser el ambiente predominantemente estrogénico de las pacientes con endometriosis. De igual modo, abordaremos el manejo del meningioma tanto dentro como fuera del embarazo, sirviéndonos para ello de la bibliografía disponible.

ABSTRACT A pregnancy woman affected by deep endometriosis is presented in this clinical case. A cavernous sinus syndrome was diagnosed during her pregnancy. She started suffering from headache and facial hypoesthesia. After a detailed neurological examination and the relevant complementary tests the patient was diagnosed of a meningioma. Given the progressive clinical worsening that was taking place, she had to undergo a cesarean section prior to the therapeutic approach of the tumor. Through this clinical case we will try to approach the possible causes of the association between endometriosis and meningioma, such as the predominantly estrogenic environment of patients with endometriosis. Similarly, we will address the management of meningioma both inside and outside of pregnancy, using the related available literature.

Estudio del efecto de distintos tipos de nanocargas en el comportamiento mecánico y térmico de un cemento óseo / Study of the effect of different nanofillers on the thermal and mechanical behavior of a bone cement

Objetivo: Estudiar el efecto de la adición de diferentes nanocargas en la resistencia mecánica y en el proceso de curado de un cemento óseo. Material y método: Se preparó un cemento óseo de formulación similar a los cementos comerciales, al que se añadieron nanotubos de carbono (MWCNT), un modificador de la tenacidad basado en copolímeros en bloque (Nanostrength®). Para evaluar el efecto sobre el cemento base, se utilizaron diferentes cantidades de carga, en un rango de entre 0,1 y 1% p/p (MWCNT) y entre 1 y 10% p/p (Nanostrength®). Se efectuaron ensayos de flexión, compresión y fractura para determinar las propiedades mecánicas y las propiedades térmicas. Resultados: Encontramos una disminución en la temperatura máxima alcanzada durante el curado del cemento con la adición de los MWCNT, sin verse afectadas sus propiedades mecánicas. En el caso del Nanostrength®, los resultados obtenidos no presentaron mejoras significativas en sus propiedades mecánicas, fundamentalmente la tenacidad, pero si un ligero aumento en su temperatura de curado y una disminución en el tiempo de fijación. Conclusión: La adición de diferentes porcentajes de nanotubos de carbono a la formulación base de un cemento óseo mejora sus propiedades térmicas sin reducir las propiedades mecánicas. El Nanostrength®, por el contrario, no mejoró el comportamiento térmico ni mecánico del cemento óseo (AU)

Objective: To study the effect of the addition of different nanofillers on the mechanical properties and in the curing process of the bone cement. Methods: A bone cement of similar formulation to commercial cements was prepared in the laboratory. Two nanofillers were used: carbon nanotubes (MWCNT) and a toughness modifier based on block copolymers (Nanostrength®). To evaluate the effect on the cement, weigth loadings ranging from 0,1 to 1 wt% (MWCNT) from 1 to 10 wt% (Nanostrength®) were used. Bending, compressive and fracture test were achieved to determine their mechanical properties. In addition, thermal properties were studied. Results: The results show a significant decrease in the maximum curing temperature of the cement with the addition of MWCNT, without being affected its mechanical properties. In the case of Nanostrength®, significant improvements were not found in their mechanical properties, mainly tenacity, but a slight increase in temperature and a decrease of curing time of fixation were observed. Conclusions: The addition of carbon nanotubes to the basic formulation of a bone cement enhances the thermal properties without a reduction of the mechanical properties. Nanostrength® does not seem to improve the thermal and mechanical behavior of the bone cement (AU)

Atrial Fibrillation and Stroke Risk After Coronary Artery Bypass Grafting Surgery.

Background: The present multicentre study was aimed at determining the effect of preoperative atrial fibrillation (preop-AF) as stroke risk factor in coronary artery bypass graft surgery (CABG) during the perioperative period. Methods: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish centers. Baseline variables related with perioperative stroke risk were recorded and analysed. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) stroke risk schema was used to stratify stroke risk and compare predicted vs observed neurologic outcomes in this study. Results: 26347 patients were enrolled in the study. Prevalence of preop-AF was 4.2%, and was associated significantly with major cardiovascular comorbidities. The stroke rate was 1.38% (365 strokes), and it was slightly higher for patients with preop-AF vs non preop-AF, 1.82% vs 1.36%, p = 0.2. NNECVDSG schema showed good predictive ability calculating the area under the receiver operating characteristic curve (c-statistic 0.696; 95% CI 0.668 to 0.723). To investigate the associations of baseline preoperative variables with perioperative CABG-stroke a logistic regression model was performed. Preop-AF impact on perioperative stroke was lower that other variables. Preop-AF did not show an adverse impact in the quartiles groups according to NNECVDSG Stroke Risk Index. Conclusion: Risk of perioperative stroke in isolated CABG surgery patients is not significantly increased by preop-AF.

Influencia de cefazolina y vancomicina en la resistencia al desgaste del cemento óseo / Impact of cefazolin and vancomycin on resistance to bone cement wear

Objetivo: Evaluar experimentalmente la influencia de la mezcla de dos antibióticos, vancomicina y cefazolina, sobre la resistencia al desgaste del cemento óseo (PMMA). Material y métodos: Se definieron seis grupos de estudio en función del antibiótico y su dosis, realizando tres muestras por grupo, que fueron sometidas a desgaste de su superficie utilizando un tribómetro, según el estándar ASTM G99-05. Se midieron los coeficientes de rozamiento y se cuantificó el desgaste volumétrico de cada una de ellas. Obtuvimos imágenes de microscopía electrónica de barrido de cada muestra para observar las existencia de modificaciones en la superficie de las muestras. Resultados: Todos los grupos presentaron datos de desgaste por debajo de los máximos admitidos para uso comercial. No se demostraron diferencias significativas en el coeficiente de fricción o en el desgaste volumétrico, salvo el grupo 4 (vancomicina 2,5% + cefazolina 2,5%), que presentó un mayor desgaste frente al grupo 3 (vancomicina 2,5%) (p<0,05). Vimos una tendencia de mayor desgaste y menor homogeneidad en los grupos con cefazolina en su composición. Conclusiones: Los cementos óseos actuales pueden soportar mezclas con altas dosis de antibióticos sin modificar sus propiedades mecánicas. Además de la cantidad de antibiótico, es determinante su elección, puesto que no todos los antibióticos afectan por igual a las propiedades del PMMA (AU)

Objective: To evaluate experimentally the impact of the mixture of two antibiotics, vancomycin, and cefazolin, on resistance to bone cement wear (PMMA). Material and Methods: Six study groups were defined according to antibiotic and dose, performing three samples per group, which were subjected to wearing of the surface using a tribometer according to the ASTM G99-05 standard. The friction coefficients were measured and volumetric wear of each of them was quantified. We obtained electron scanning microscope images of each sample to observe the presence of changes in the surface of the samples. Results: All groups had wear data below the maximum admitted for commercial use. No significant differences were shown in friction coefficient or volumetric wear, except in group 4 (2.5% vancomycin + 2.5% cefazolin), which showed greater wear versus group 3 (2.5% vancomycin) (p<0.05). We saw a tendency towards greater wear and lower homogeneity in groups with cefazolin in its composition. Conclusions: Current bone cements can withstand mixtures with high doses of antibiotics without altering their mechanical properties. In addition to the amount of antibiotic, the choice is decisive, as not all antibiotics equally affect the properties of PMMA (AU)

Design, synthesis, and evaluation of 5'-diphenyl nucleoside analogues as inhibitors of the Plasmodium falciparum dUTPase.

Deoxyuridine 5'-triphosphate nucleotidohydrolase (dUTPase) is a potential drug target for malaria. We previously reported some 5'-tritylated deoxyuridine analogues (both cyclic and acyclic) as selective inhibitors of the Plasmodium falciparum dUTPase. Modelling studies indicated that it might be possible to replace the trityl group with a diphenyl moiety, as two of the phenyl groups are buried, whereas the third is exposed to solvent. Herein we report the synthesis and evaluation of some diphenyl analogues that have lower lipophilicity and molecular weight than the trityl lead compound. Co-crystal structures show that the diphenyl inhibitors bind in a similar manner to the corresponding trityl derivatives, with the two phenyl moieties occupying the predicted buried phenyl binding sites. The diphenyl compounds prepared show similar or slightly lower inhibition of PfdUTPase, and similar or weaker inhibition of parasite growth than the trityl compounds.

Personalidad y comportamiento suicida en adolescentes: el papel de la extraversión en la tentativa del suicidio / Personality and suicidal behaviour in young people: the role of extraversion in suicidal attempts

En este trabajo se estudia la relación entre la extraversión y el comportamiento suicida en una muestra de 282 adolescentes de población general con ideación suicida y tentativas de suicidio. Se analiza el papel de la impulsividad y se discuten los aspectos que diferencian entre sí a los adolescentes con ideación suicida, tentativa de suicidio instrumental y tentativa real de suicidio. Finalmente se discuten las implicaciones que los resultados tienen sobre la conceptualización del fenómeno suicida en adolescentes (AU)

[The kidney in mechanical ventilation]. / El riñón en la ventilación mecánica.

The negative effect of artificial ventilation with positive pressure on renal function, expresses itself as a decrease of water and sodium excretion, being directly related with the raise of intrathoracic pressure. Factors participating in this process are: lowering in cardiac output, arousal of sympathic nervous system, increase in vasopressin action, activation of renin-angiotensin-aldosterone system and decrease of atrial natriuretic peptide release. This disorder of hydromineral metabolism produces: Impairment of hemodynamic equilibrium, favors the increase of hypoxia and renal failure. The effects of mechanical ventilation on renal function can be attenuated with the adoption of the following measures: a) techniques (use of low levels of PEEP and early disconnection of respirator); b) therapeutic (dopamine 2-3 mcg/kg/min, rational use of diuretics and fluids); y c) monitoring of renal function and hydro-mineral equilibrium.

Prediccion de la madurez pulmonar fetal por la imagen ecografica de la placenta / Prediction of fetal pulmonary maturity by placental ecographic imaging

Se estudiaron 171 embarazadas que tenian indicacion de amniocentesis para diagnosticar madurez pulmonar fetal. Anexo de la misma se clasifico la placenta en inmadura, intermedia y madura, considerando la caracteristica que mas superficie ocupaba de la plasenta. De los 123 embarazos de termino, 44 (35.8%) presentaron plancentas ecograficamente maduras y estas se asociaron en el 98%, 96%, 93% con la presencia de fosfolipidos en el liquido amniotico en toda la muestra, en menores de 37 semanas y en menores de 35 semanas respectivamente. con los recien nacidos cuyos partos se produjeron dentro de los 7 dias del examen, se calculo la eficacia diagnostica de la imagen ecografica de la placenta para predecir en forma antenatal la enfermedad de la membrana hialina (EMH), encontrandose que la placenta madura predecia en un 100% la ausencia de EMH. El procentaje de imagenes ecograficas de placentas maduras a diferentes edades gestacionales, solo es superado por la relacion L/E mayor o igual a 2