Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo / Clinical practice guideline based on the evidence for the management of sedoanalgesia in the critically ill adult patient

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Carbazole biodegradation in gas oil/water biphasic media by a new isolated bacterium Burkholderia sp. strain IMP5GC.

AIM: To select carbazole-degrading bacteria able to survive and metabolize carbazole in biphasic organic-water media and to study the factors affecting carbazole degradation in such conditions. METHODS AND RESULTS: In this research a new carbazole-degrading strain was isolated from hot springs in Mexico. This bacterium was preliminary identified as Burkholderia sp. IMP5GC and was able to grow using carbazole as sole carbon and nitrogen source. Genetic analysis showed that this bacterium carries carA genes identical to those reported in Pseudomonas resinovorans CA10. Burkholderia IMP5GC efficiently degraded carbazole in aqueous media as well as in biphasic media with n-hexadecane. Furthermore, the strain IMPGC5 efficiently reduced the concentration of carbazole and monomethyl carbazole species in gas oil-water biphasic media. CONCLUSIONS: This study demonstrates the biodegradation of carbazole in biphasic gas oil/water media (1 : 1), regardless of the highly toxic effects of this petroleum distillate. SIGNIFICANCE AND IMPACT OF THE STUDY: Biodegradation of carbazole in biphasic media contributes to the understanding and design of bioprocesses for carbazole removal from petroleum-upgrading fractions and other carbazole-rich organic mixtures.

Nutrition and cataract in low-income Mexicans: experience in an Eye camp.

Surgical Eye-camps for cataract treatment of low-income adult Mexicans have been undertaken over the last 10 years. Despite the high prevalence of cataracts among these subjects, no assessment of their nutritional or health status has ever been made. We compare the results obtained for 81 adults (44 men and 37 women) who received treatment in May 1997 with those for a "control" group of age and sex-matched but affluent individuals in Mexico City. alpha-Tocopherol and beta-carotene were assessed and analysed by HPLC and colorimetric procedures, respectively. The plasma tocopherol to cholesterol ratio did not reveal deficiencies of this vitamin, and only 5 patients (2 men and 3 women) had low beta-carotene plasma levels. The patients had high BMI values, with 32% of men and 30% of women overweight, and 2% and 14%, respectively, obese, with higher glucose, cholesterol and triglyceride values reflecting enhanced insulin resistance and lipid abnormalities. The alkaline phosphatase values were elevated suggesting that many of these blind patients are osteomalacic because they now remain indoors. Although it has been suggested that an adequate intake of carotenes and tocopherol are associated with absence of cataract, this appears not to be the case in our study population. Surveys in Mexico have revealed, however, a highly prevalent deficiency of other vitamins such as niacin and riboflavin, both of which have been proved to be protective against cataract. It appears that nutritional deficiencies, obesity, incipient diabetes and lipid disorders co-exist in modern Mexico. We have identified a need for research to aid the design of preventive nutritional approaches at the population level that could be applied in parallel with ongoing surgical treatment.

[Ovulation induction with gonadotropins aided by cervix mucus analysis and echography]. / Inducción de la ovulación con gonadotropinas mediante evaluación del moco cervical y ecografía.

Induction of ovulation was performed in 148 cycles using human menopausal gonadotropins (HMG) in 52 patients, seven with hypothalamic-pituitary failure and 45 suffering dysfunction at this level. Several induction schemes were used beginning on the second day of the cycle, until one or more follicles larger than 14 mm were found, to administrate 10,000 UI of human chorionic gonadotropin (HCG). Clinical valuation of cervical mucus and ultrasound of the ovaries to assess follicular development were done, from day eight of the cycle. Twenty five pregnancies resulted in 23 patients (44%), three in patients with failure and 22 in the dysfunction group. A total of 19 healthy babies were taken home, however three neonatal deaths, four miscarriages and one ectopic pregnancy occurred. Multiple gestation was present in three patients (12%), one was quadruplet, one triplet and one twin. The ovarian hyperstimulation syndrome (OHS) was detected in seven patients (13.4%), three were mild, two moderate and two severe; two cases of OHS had multiple pregnancies. Although induction of ovulation with HMG in patients with anovulation is a complex procedure requiring strict clinical vigilance and advanced technological resources, in this clinical study it was possible to obtain similar results to other series, using high resolution ultrasound only, without daily measurements of hormones.

[The transfer of critically ill patients]. / El traslado de pacientes en estado crítico.

Critically ill patients admitted to an intensive care unit or an emergency ward, frequently need to be transported to different areas within the hospital in order to perform diagnostic procedures. An increased mortality and morbidity risk has been found associated with the transportation of these patients. In order to investigate the effect of the intra-hospitalary transport of our patients on their clinical status this study was conducted. We studied 12 patients admitted to the intensive care unit or the emergency ward; all were on mechanical-assisted ventilation and had been stable for at least six hours prior to transportation. Blood gas and hemodynamic measurements were obtained before, immediately after and thirty minutes after transportation. The most significant changes seen immediately in our patients were an increase in PaCO2 (30.8 +/- 7.35 vs 35.6 +/- 7.49, p less than 0.02) and a decrease in pH (7.36 +/- 0.08 vs 7.31 +/- 0.05, p less than 0.02). Patients with higher pH values prior to their transportation had the most significant change towards acidosis (r = -0.79). All changes reversed thirty minutes after reinstallation of the mechanical ventilation. There was no change in the hemodynamic measurements. We conclude that the transportation of critically ill patients within a hospital is fairly safe if patients are previously stabilized.

Trasplante de hígado en México: informe del primer caso exitoso / Human orthotopic liver transplantation: first case in Mexico

Se informa el primer caso exitoso de trasplante hepático en humanos en México. Se hace mención a los trabajos experimentales previos de este grupo. El caso corresponde a un hombre de 41 años de edad, con historia de hipertensión arterial y hepatitis en 1975 con cirrosis hepática postnecrótica corroborada por biopsia en 1985 y marcadores inmunológicos para hepatitis negativos, con una reserva funcional limitada (clasificación C Child-Pugh). El 2 de mayo de 1988, a través del Programa Nacional de Trasplantes, se obtuvo un injerto hepático, proveniente de un paciente con muerte cerebral posterior a un accidente cerebrovascular. Se efectuó trasplante hepático ortotópico utilizando un puente veno-venoso portosistémico. Desde entonces se ha manejado con triple esquema inmunosupresor a base de ciclosporina, azatioprina y prednisona. Su evolución postoperatoria inmediata cursó con colestasis idiopática, un episodio de rechazo agudo, hipertensión arterial, disfunción renal, herpes esofágico y linfocele inguinal, problemas que fueron resueltos satisfactoriamente. Actualmente a 28 meses postrasplante recibe dosis mínimas útiles de inmunosupresores, su función hepática es normal y su calidad de vida ha sido muy satisfactoria

[Liver transplantation in Mexico. Report of the first successful case]. / Trasplante de hígado en México. Informe del primer caso exitoso.

This article reports the first successful human orthotopic liver transplantation performed in Mexico. The recipient was a 41 year old white male, with a history of essential hypertension and hepatitis in 1975. The diagnosis of postnecrotic cirrhosis was made in 1985 by liver biopsy. The HBsAg was negative and the functional reserve of the liver was limited (Stage "C" of the Child-Pugh classification). A liver graft was obtained through the National Cadaver Organ Transplant Program on May 2, 1988 and an orthotopic liver transplantation was performed without incidents, using the portosystemic veno-venous bypass. Inmunosuppression was carried out with triple drug therapy, cyclosporine, azathioprine, and prednisone. His postoperative course was characterized by idiopathic cholestasis, one episode of acute rejerction, arterial hypertension, renal dysfunction, esophageal herpes and inguinal lymphocele, all of which resolved. Currently the patient is alive 22 months postransplantation with normal liver function and adequate quality of life.

Effects of electromagnetic extracorporeal shock wave lithotripsy on the fine structure of the liver and gallbladder of the rabbit.

The fine structure of the liver and gallbladder of rabbits submitted to lithotripsy was studied with transmission electron microscopy. Alterations found in both organs involved capilaries, venules and small veins as well as neighboring tissues. In the liver the most important alterations were seen in those areas located about central veins. These consisted in mitochondrial vacuolation, increase in the cytoplasmic electrondensity, and necrosis. In the gallbladder different stages of epithelial damage and regeneration (i.e. mitoses) were observed. Vascular damage was characterized by mitochondrial swollen and increase of nuclear and cytoplasmic electrondensities. The gallbladder's stroma displayed cell vacuolation, pyknosis, and edema. It is proposed that the damage produced by lithotripsy results from a direct colision of red blood cells upon blood vessels. Tissue damage was considered focal and in most cases reversible.

[Electromagnetic shock wave lithotripsy plus bile acids for the treatment of gallblader stones: results and perspectives from the first 57 patients]. / Litotricia electromagnética y acidos biliares para tratamiento de los cálculos de la vesícula biliar: resultados y perspectivas de los primeros 57 pacientes.

Fifty seven patients were selected from 620 cases with gallstones to be treated with an electromagnetic shock wave generator (Lithostar Plus). The machine has an overhead module with an electromagnetic generator able to produce 150-150 bar of pressure in the center of the focal zone (2 x 8 cms.) An in line ultrasound probe permits in vivo view of stone localization and fragmentations. The wide aperture of the device permits to treat patients with little pain in ambulatory basis. The mean age of the patients was 50 +/- 14 years, 57 were female and 20 were male. Stones were single in 35 cases and were multiple (2-4 gallstones) in the rest. The patients received a mean of 2620 +/- 371 shock waves. Intravenous analgesia (Fentanyl 87 +/- 40 ug p/session) was required in 26 cases. In 58.5% of the cases, fragmentation produced gallstone-rests of < 0.5 cm. Larger fragments (> 0.5 cm), were observed after an initial shock wave session in 33%. These patients underwent additional treatments sessions. Hence patients received 1.8 +/- 0.8 sessions. Minor fragmentation or no fragmentation after the first session was observed in the 14.5%. Mild biliary pain appeared in 17 patients and acute biliary colic in 2, one of these underwent emergency cholecystectomy. Overall gallstone disappearance after one year after lithotripsy, plus bile acid therapy (10-12 mg Kg day) was 72%. Patients with single gallstones were free of stones of fragments in 92% of the cases, after the same period of follow up.

[Extracorporeal shock waves lithotripsy during acute obstruction of the cystic duct]. / Litotricia extracorpórea en obstrucción aguda del conducto cístico.

Obstruction of the cystic duct after Biliary Shock Waves Lithotripsy in an uncommon complication. It occurs when a small fragment is hemming in the neck of the gallbladder. Usually, cholecystectomy is the indicated treatment, we challenged this concept and attempted early ESWL to treat this complication. In our clinic, 150 patients were treated with a Lithostar-Plus device between March 1, 1989 to April 30, 1990. Of these, 12 presented acute uncontrolled biliary colic, 28 presented mild abdominal pain and the rest, remained pain free. Of the 12, one presented biliary obstruction and cholecystectomy was performed in other hospital; one refused to be retreated and other presented sonographic gallbladder thickness and hence underwent surgery. Nine patients were re-treated and in all, fragments nested in the gallbladder neck were successfully pulverised and obstruction cleared. To date all patients are free of stones. In summary, we propose early re-treatment with ESWL as a non-surgical alternative approach for treating this complication.

Modulation of luteinizing hormone secretion by estrogens in patients with Reifenstein's syndrome.

The role of estrogens on gonadotropin secretion was assessed in two siblings with incomplete virilization syndrome type I due to partial androgen insensitivity (Reinfenstein's syndrome). Serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were measured before and after 100 micrograms LH-releasing hormone (RH) intravenous (IV) stimulation, as well as during long-term clomiphene citrate (CC) administration. Serum testosterone (T) and estrogens were determined before and during daily administration of human chronic gonadotropin (hCG) and also during the CC treatment. Basal levels of LH were elevated in both patients: 12.5 +/- 1.1 mIU in patient A and 19.8 +/- 1.8 mIU/ml in patient B. Conversely, FSH levels were within normal limits. Administration of LH-RH in both subjects induced a rise in LH levels, while FSH concentration showed no increase. The CC administration resulted in a significant (P less than 0.005) increment in serum LH levels without changes in FSH concentration. An important increase of serum T and estradiol (E2) levels was noted during CC administration; thus, in patient A those levels augmented from 20 to 48 ng/ml for T and from 78 to 220 pg/ml for E2; and patient B showed an increment from 20 to 35 ng/ml for T, and from 55 to 180 pg/ml for E2. The daily administration of hCG was followed by an increment in both T and E2 levels, which was of lesser degree for estrone concentration. These results suggest that endogenous estrogens, particularly E2, modulate LH secretion in patients with partial androgen insensitivity; however, it appears that estrogens had no physiologic effect on FSH secretion.

Cyclooxygenase blockade elevates leukotriene E4 production during acute anaphylaxis in sheep.

We examined changes in the levels of eicosanoids in blood and pulmonary lymph of anesthetized sheep undergoing acute anaphylaxis. Within 1-3 min of intravenous antigenic challenge of previously sensitized sheep, there were approximately 7-30-fold elevations in mean arterial plasma levels of thromboxane B2 and 6-ketoprostaglandin F1 alpha, respectively, as measured by RIA. Negligible changes in levels of these cyclooxygenase products were found in both nonsensitized sheep and in sensitized sheep treated with indomethacin before antigenic challenge. In contrast, no changes in levels of sulfidopeptide leukotrienes (SPLT) in pulmonary lymph were detectable by RIA during anaphylaxis in sensitized or nonsensitized sheep, but levels of SPLT in indomethacin-treated sensitized sheep increased more than fivefold above levels in lymph from both other groups of animals. The immunoreactive SPLT in lymph from indomethacin-treated sheep was accounted for as LTE4, as demonstrated by mobility on HPLC and absorbance at 280 nm. These results support the possibility that certain undesirable effects of nonsteroidal antiinflammatory drugs, such as cardiopulmonary reactions in aspirin-sensitive individuals, and impaired renal and cardiac function during therapy with these drugs, may be related in part to augmented synthesis of the 5-lipoxygenase pathway products, especially those of the sulfidopeptide class. Increased LT production could also limit the antiinflammatory effectiveness of these drugs in many disease states.

Venovenous bypass with a membrane lung to support bilateral lung lavage.

Partial venovenous cardiopulmonary bypass with a membrane oxygenator was used to exchange respiratory gases during and after bilateral lung lavage in a patient with severe hypoxemia caused by pulmonary alveolar proteinosis. The patient was unable to tolerate an attempt at lung lavage without bypass. Therefore, extracorporeal perfusion safely supported the patient's respiration for 32 hours, buying time to lavage each lung separately and to enable sufficient recovery of transpulmonary gas exchanging capacity.